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Summary Background: We describe 7 years experience of providing anesthesia for children undergoing lithotripsy in a hospital without pediatric inpatient facilities. A pediatric team, including anesthetist, pediatric nurse along with the equipment travel across the city with the patient from the children's hospital. As a high incidence of postoperative vomiting and discomfort was observed, the effect of increasing intraoperative analgesia and the use of antiemetic medication was examined., Methods: From 1998 to 2004, 69 children (49 boys and 20 girls) were anesthetized for 120 procedures: 67 extracorporeal shock wave lithotripsy (ESWL) and 53 endosurgical procedures, consisting of percutaneous nephrolithotomy (29), ureteroscopic laser lithotripsy (17) and percutaneous bladder litholapaxy (7). The mean age was 5.4 years (10 months to 13 years) and weight 23.7 kg (7.1-59 kg). ESWL was performed initially with a Wolf Piezolith 2300, and after 1999, a Dornier Compact Delta., Results: Increased administration of intraoperative analgesia resulted in reduced postoperative analgesia requirements in all the groups, with a significant reduction (P < 0.05) in the endosurgical group. Those who required more postoperative analgesia had more vomiting significantly (P < 0.05)., Conclusions: For ESWL postoperative pain is dependent on the type of lithotriptor and the resultant stone fragment size created. This study suggests that postoperative vomiting could be reduced more effectively by the increased administration of intraoperative analgesia, than by a single intraoperative dose of an antiemetic drug.

Objective: To determine the benefits of nephrectomy in children performed via a retroperitoneoscopic approach compared to the laparoscopic route., Materials and Methods: We reviewed all endoscopic nephrectomies performed at our institution from August 1998 to February 2003., Results: A total of 32 endoscopic nephrectomies were undertaken: 22 laparoscopic nephrectomies with 5 conversions to open surgery, and 10 retroperitoneoscopic. The main indication for surgery was poor function secondary to either reflux or obstructive nephropathy. Intraoperative heart rate changes were less marked in patients undergoing retroperitoneoscopic nephrectomy. The median operative time for retroperitoneoscopic nephrectomy was 65 minutes and 95 minutes for laparoscopy. Epidural analgesia was not required in successful endoscopic nephrectomies. The median postoperative morphine requirement in the retroperitoneoscopic group was 110mcg/kg compared to 280mcg/kg in the laparoscopic group. The majority of patients who had successful endoscopic nephrectomies were discharged to home within 2 days of surgery., Conclusion: Retroperitoneoscopic nephrectomy appears to be a safe technique in children, with reduced intraoperative physiological effects compared to the laparoscopic approach. Operative time was generally shorter than the laparoscopic approach and there appeared to be an additional benefit of reduced postoperative pain.

We report the anaesthetic management and outcomes of our first 51 laparoscopic fundoplications. Case records of the 50 patients (one redo), median age 6 years (5 months to 20 years), were reviewed. Median duration of anaesthesia was 120 (60-300) min. During the procedure, the heart rate and blood pressure increased by more than 20% over baseline in 18% and 12% cases, respectively. Median increase in PECO2 was 1.0 (0.3-2.3) kPa [7.6 (2.3-18) mmHg]. After surgery, all but one of the patients were managed on a normal surgical ward. Postoperative analgesia requirement was oral or rectal analgesics in 89% of patients and ceased within 48 h of surgery in 95% patients. Median time to discharge home from day of operation was 2 (1-9) days. We conclude that laparoscopic fundoplication in children is well tolerated, there is no requirement for routine postoperative high dependency care and analgesic requirements are minimal.

Forty boys aged from one to five years undergoing orchidopexy were randomly allocated to receive one of two solutions for caudal epidural injection. Group A received 1 ml.kg-1 of 0.125% bupivacaine with ketamine 0.5 mg.kg-1 and Group B received 1 ml.kg-1 of bupivacaine 0.25% with ketamine 0.5 mg.kg-1. Postoperative pain was assessed by means of a modified Objective Pain Score and analgesia was administered if this score exceeded four. The median duration of caudal analgesia was 8 h in Group A compared with 9.5 h in Group B (P<0.05). The time taken to recover the ability to walk was a median of two h in Group A and three h in Group B (P<0.05). There were no differences between the groups in the incidence of urinary retention or postoperative sedation.

We undertook a double-blind study to evaluate equianalgesic doses of intramuscular morphine sulphate (0.15 mg.kg-1) and codeine phosphate (1.5 mg.kg-1) in 40 healthy children undergoing adenotonsillectomy. There were no significant differences in pain scores, analgesic requirements or sedation scores between the two groups over the following 24 h. More children vomited in the morphine group (60%) than the codeine group (30%) between one and six h after the procedure (P < 0.05). Codeine phosphate is associated with less postoperative vomiting than morphine sulphate while providing comparable postoperative analgesia for adenotonsillectomy.

Forty boys weighing less than 25 kg undergoing unilateral orchidopexy were randomly allocated to receive one of two analgesic regimens. Group C received a caudal epidural block with 0.25% bupivacaine 1 ml.kg-1 and preservative-free ketamine 0.5 mg.kg-1; Group L received an ilioinguinal nerve block with 0.25% bupivacaine 0.5 ml.kg-1 and infiltration of the wound with 0.25% bupivacaine 0.5 ml.kg-1. All subjects received diclofenac sodium 1-2 mg.kg-1 as a rectal suppository. Postoperative pain was assessed by means of a modified Objective Pain Score and analgesia was administered if this exceeded a value of 4. The median duration of analgesia was 10 h (range 2.6 to > 24 h) in Group C and 2.9 h (range 0.7 to > 24 h) in Group L (p < 0.05). There were no differences between groups in the incidence of motor block, urinary retention, postoperative vomiting or postoperative sedation. Subjects in Group L required significantly more doses of postoperative analgesia than those in Group C (p < 0.05).

Sixty boys aged up to 9 years undergoing orchidopexy were randomly allocated to receive one of three solutions for caudal epidural injection: group A received 1 ml.kg-1 of 0.25% bupivacaine with 0.25 mg.kg-1 of preservative-free ketamine, group B received 1 ml.kg-1 of 0.25% bupivacaine with ketamine 0.5 mg.kg-1 and group C received 1 ml.kg-1 of 0.25% bupivacaine with 1 mg.kg-1 of ketamine. Postoperative pain was assessed by means of a modified Objective Pain Score and analgesia was administered if this score exceeded four. The median duration of caudal analgesia was 7.9 h in group A, 11 h in group B and 16.5 h in group C. There were no differences between the groups in the incidence of motor block, urinary retention, postoperative vomiting or postoperative sedation. Group C had a significantly higher incidence of behavioural side effects, including slightly odd behaviour, vacant stares and abnormal effect than groups A and B.

Using a specific RIA, we have investigated in patients and volunteers whether fasting, diminished hepatic clearance, hemoconcentration, or within-day biological variation might be responsible for the transient increases in plasma glutathione S-transferase (GST) concentration observed after anesthesia. GST concentration was measured in 44 healthy volunteers after an overnight fast and at 3, 6, and 24 h after the fasting sample. The concentration was significantly lower at 3 and 6 h after than in the fasting sample (P = 0.0019 and P = 0.015, respectively). The change in GST concentration caused by fasting was examined in 30 subjects by comparing pre- and postfasting values. Fasting had no significant effect on GST concentration overall (P = 0.4721), but two individuals showed a marked increase in GST concentration after fasting overnight. In a separate study of 10 patients, plasma amylase activity and plasma concentrations of GST and albumin were measured immediately before and 3 h after induction of halothane anesthesia. Although GST concentration was increased at 3 h in each of the 10 patients, plasma amylase activity and plasma albumin concentration were significantly decreased in all patients (P = 0.002). Apparently, increases in GST concentration after anesthesia do not result from incidental factors.

A previously undiagnosed case of myotonic dystrophy presenting with apnoea of 2.5 h duration following thiopentone is described. A review of the anaesthetic outcome from 49 operations in 17 patients with myotonic dystrophy in the Aberdeen area is presented. The type of operation and intra- and postoperative problems are analysed. The results reveal a 52% complication rate in previously diagnosed cases and a 35% complication rate in undiagnosed cases. In the series, 29% of the anaesthetics were administered to symptomatic patients before formal diagnosis. To avoid potential hazards it behoves the anaesthetist to remain alert to the possibility of the undiagnosed disease. The symptomatology and associated findings of the 17 patients at initial diagnosis are presented. The literature has been reviewed and anaesthetic implications noted.

The outcome of 175 pregnancies during which nitrous oxide was administered has been evaluated. All anaesthetics were of short duration (20-30 min) and 97% were administered during the second trimester. No adverse effects were identified. The mechanism of potential toxicity and the implications of the use of nitrous oxide during the first and second trimesters of pregnancy are discussed.

The plasma concentration of hepatic glutathione S-transferase (GST) was measured in matched groups of patients who received halothane, enflurane or isoflurane anaesthesia for elective minor surgery. The GST concentrations increased significantly at 3 h after anaesthesia in patients who received halothane or enflurane, but not in patients who were given isoflurane. A secondary increase in GST concentration, at 24 h, was seen in a small number of individuals who received halothane or enflurane. Abnormal GST concentrations were found in 50% of patients following halothane anaesthesia, 20% following enflurane and 11% after isoflurane. The small but significant increases in GST concentrations in patients receiving halothane or enflurane suggests an impairment of hepatocellular integrity following the administration of these anaesthetics. In contrast, isoflurane anaesthesia did not appear to be associated with this effect.