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Background: Early negative postoperative behavior (e-PONB) is common in children and manifests itself as emergence agitation (EA), emergence delirium (ED), and pain. The objective of this prospective double blind, randomized, placebo-controlled trial was to determine whether IV clonidine or IV fentanyl prior to surgery modifies e-PONB in children., Methods: Ninety children scheduled for subumbilical surgery under sevoflurane anesthesia supplemented with regional anesthesia were randomized to either receive IV clonidine 2 mcg·kg(-1) , IV fentanyl 2 mcg·kg(-1) or placebo (IV saline) before surgery. Primary outcome measures were the incidence of EA, ED and pain during the first hour after awakening. Secondary outcome measures were side effects such as nausea and vomiting and delayed discharge from PACU., Results: Eighty-seven children (n = 29 per group) completed the study. EA was present in 10 children (six clonidine, none fentanyl, and four placebo, P = 0.04) whereas ED was observed in 20 children (nine clonidine, three fentanyl, and eight placebo P = 0.13). Sixteen children who received placebo had a CHIPPS score of ≥4 compared with nine children in fentanyl group and 18 children receiving clonidine (P = 0.04). Ten children receiving fentanyl vomited during the first postoperative day, compared with six children in placebo group and none in clonidine group (P = 0.003). Discharge from PACU was not affected., Conclusions: IV fentanyl before surgery but not IV clonidine modifies e-PONB in children undergoing lower abdominal surgery under general anesthesia supplemented with regional anesthesia. The use of fentanyl in this population was also associated with reduced pain scores after awakening but with significantly greater incidence of PONV., (© 2014 John Wiley & Sons Ltd.)

Background: The preoperative assessment involves the process of evaluating the patient's clinical condition, which is intended to define the physical status classification, eligibility for anesthesia and the risks associated with it, thus providing elements to select the most appropriate and individualized anesthetic plan. The aim of this recommendation was provide a framework reference for the preoperative evaluation assessment of pediatric patients undergoing elective surgery or diagnostic/therapeutic procedures., Methods: We obtained evidence concerning pediatric preoperative evaluation from a systematic search of the electronic databases MEDLINE and Embase between January 1998 and February 2012. We used the format developed by the Italian Center for Evaluation of the Effectiveness of Health Care's scoring system for assessing the level of evidence and strength of recommendations., Results: We produce a set of consensus guidelines on the preoperative assessment and on the request for preoperative tests. A review of the existing literature supporting these recommendations is provided. In reaching consensus, emphasis was placed on the level of evidence, clinical relevance and the risk/benefit ratio., Conclusion: Preoperative evaluation is mandatory before any diagnostic or therapeutic procedure that requires the use of anesthesia or sedation. The systematic prescription of complementary tests in children should be abandoned, and replaced by a selective and rational prescription, based on the patient history and clinical examination performed during the preoperative evaluation.

Background: This randomized, double-blind controlled trial was conducted to determine whether the association of sevoflurane for induction and isoflurane for anesthesia maintenance resulted in a lower incidence of postoperative agitation compared with sevoflurane as single agent., Methods: After Institute Ethics Committee's approval and parental written informed consent, 128 unpremedicated children (1-6 years), ASA I-II, scheduled for elective subumbilical surgery were enrolled. After induction with 8% sevoflurane, patients were randomly allocated to receive sevoflurane or isoflurane 1-1.5 MAC as maintenance agent. The primary endpoint of the study was the incidence of postoperative agitation defined as a screaming and crying child and/or a child that required physical restraint during emergence., Results: Eighteen children were excluded because they received sedatives, analgesia or anesthesia or because of ineffective regional analgesia before randomization. Fifty-four patients receiving sevoflurane and 56 receiving isoflurane completed the study. Twenty-eight children (95% CI 38-66%) in the sevoflurane group presented with postoperative agitation compared with 18 (95% CI 20-46%) patients receiving isoflurane (P = 0.028). Fifteen minutes after awakening, 11/54 children receiving sevoflurane were agitated compared with 4/56 receiving isoflurane (P = 0.03). Thereafter, there was a gradual reduction in the incidence of postoperative agitation over time., Conclusions: The association of sevoflurane for induction and isoflurane for maintenance produced significant less postoperative agitation in preschool children receiving regional anesthesia during subumbilical surgery compared with sevoflurane for induction and maintenance.

Background: The laryngeal tube (LT) is a supraglottic ventilatory device used in adults. However, there is limited information about LT use in pediatric patients. This randomized controlled study compares LT with laryngeal mask (LMA) for airway management during spontaneous or assisted ventilation and during fiberoptic laryngoscopy in children., Methods: Thirty children under 10-years old, ASA I-II, scheduled for minor general surgery, Mallampati score I-II, fasted and premedicated were included. Patients with upper respiratory infection, craniofacial malformation, intracranial hypertension, emergency surgery were excluded. The primary outcome measure was the proportion of patients in whom effective spontaneous or assisted ventilation [Vt > or = 4 ml.kg(-1), SpO2 > or = 95% with FiO2 0.4, P(E)CO2 < or = 7.2 kPa (55 mmHg)] was achieved after 3 min of LT or LMA cuff inflation. The secondary endpoint was the proportion of patients in whom fiberoptic laryngoscopy resulted in identification of the vocal cords., Results: Eleven children with LMA and two children in LT group had adequate spontaneous or assisted ventilation after initial positioning (P < 0.01). After head extension or device repositioning 15 of 15 patients in LMA group had adequate ventilation compared with 11 of 15 patients in LT group (P < 0.05). The vocal cords could be observed with fiberoptic laryngoscopy in 11 LMA group patients compared with no patients in the LT group (P < 0.001)., Conclusions: The LT is less effective than the LMA to allow adequate spontaneous or assisted ventilation and for fiberoptic evaluation of the airway in children under 10 years old.

Background: Nitrous oxide (N2O) has been associated with postoperative nausea and vomiting (PONV), but some studies show conflicting data. The aim of this study was to assess whether the combination of N2O/sevoflurane, in paediatric general anaesthesia, increases the incidence of vomiting in the 24 h following surgery compared with sevoflurane alone., Methods: One hundred and fourteen children, aged 1-10 years, who underwent testicle and inguinal hernia surgery, were randomized to receive one of the following two anaesthetic regimens: sevoflurane with 70% N2O (group A) or sevoflurane alone (group B)., Results: No significant differences were observed in the incidence of postoperative vomiting between the two groups. The overall incidence of postoperative vomiting was 14.9%; 14.3% in group A and 15.5% in group B (P=0.9)., Conclusions: Nitrous oxide used in combination with sevoflurane is not associated with an increase in the incidence of emesis in children who undergo testicle and inguinal hernia procedures.

40% to 60% of children undergoing surgery under general anaesthesia develop anxiety in the preoperative period. Multiple factors contribute to the genesis of this disorder. Preoperative anxiety may complicate the induction of anaesthesia and can cause behavioural modifications in children even long after surgical procedures have been completed. It is important to focus on prevention of such problems. A preparation program, premedication and parental presence during induction of anaesthesia are valid tools for achieving this goal. We are herewith presenting a play preparation program carried out by play specialists and offered to all children prior to surgery. This approach proved effective in reducing preoperative anxiety in children and their mothers.

Studies have been made on the possible involvement of malondialdehyde (MDA) and (E)-4-hydroxynon-2-enal (HNE), two terminal compounds of lipid peroxidation, in modifying xanthine oxidoreductase activity through interaction with the oxidase (XO) and/or dehydrogenase (XDH) forms. The effect of the two aldehydes on XO (reversible, XO(rev), and irreversible, XO(irr)) and XDH was studied using xanthine oxidase from milk and xanthine oxidoreductase partially purified from rat liver. The incubation of milk xanthine oxidase with these aldehydes resulted in the inactivation of the enzyme following pseudo-first-order kinetics: enzyme activity was completely abolished by MDA (0.5-4 mM), while residual activity (5% of the starting value) associated with an XO(irr) form was always observed when the enzyme was incubated in the presence of HNE (0.5-4 mM). The addition of glutathione to the incubation mixtures prevented enzyme inactivation by HNE. The study on the xanthine oxidoreductase partially purified from rat liver showed that MDA decreases the total enzyme activity, acting only with the XO forms. On the contrary HNE leaves the same level of total activity but causes the conversion of XDH into an XO(irr) form., (Copyright 2001 Academic Press.)

Background: Oxidative stress is present in cardiovascular diseases (CVDs), and hyperhomocysteinemia, an independent risk factor for these diseases, may play a role by inducing production of oxygen free radicals., Methods: To evaluate the possible role of homocysteine (Hcy) in inducing oxidative stress in coronary artery disease (CAD), plasma Hcy was measured in 68 consecutive cardiovascular patients, and plasma malondialdehyde (MDA), both free and total (free + bound), was measured in 40 patients with CAD (18 with chronic stable angina and 22 with unstable angina). As controls, we tested 70 healthy volunteers. Hcy was measured by an immunoenzymatic method and MDA, an index of lipid peroxidation, by gas chromatography-mass spectrometry., Results: Plasma Hcy concentrations were significantly higher in cardiovascular patients than in controls (10.2 vs 8.9 micromol/L; P <0.0002), with no significant difference between values in the stable and unstable angina subgroups. Similarly, total MDA was significantly higher in the CAD group than in the controls (2.6 vs 1.3 micromol/L; P <0.00001), again with no significant difference between stable and unstable angina patients. By contrast, free MDA, which was significantly higher in the CAD patients than the controls (0.4 vs 0.2 micromol/L; P < 0.00001), was also significantly higher in the unstable than in the stable angina group (0.5 vs 0.3 micromol/L; P <0.03). However, no correlation was observed among Hcy and free and total MDA., Conclusions: Our findings show that a moderate increase of Hcy is associated with CVD but that Hcy at the detected values cannot be considered completely responsible for oxidative damage. That lipid peroxidation is involved in CAD is shown by our observation of significantly increased plasma free and total MDA concentrations compared with controls. Moreover, free MDA values discriminated between unstable and chronic stable angina, and could thus represent a new diagnostic tool.

The aim of the present study was to investigate the relationship between physical abstinence and changes in dopamine release in the nucleus accumbens and in the medial prefrontal cortex induced by mecamylamine and naloxone in rats chronically exposed to nicotine. The rats were implanted with osmotic minipumps (Alzet) delivering nicotine tartrate at a rate of 9 mg/kg/day (3.16 mg of free base) and 8 days later with a dialysis probe in the nucleus accumbens or in the medial prefrontal cortex. Steady-state dopamine output from the nucleus accumbens of the rats implanted with nicotine minipumps was higher than that of sham implanted rats; no differences were observed in the prefrontal cortex. In nicotine but not in sham implanted rats mecamylamine (1 mg/kg s.c.) precipitated a physical abstinence syndrome and brought dopamine output back to control values in the nucleus accumbens. In contrast mecamylamine (1 mg/kg s.c.) increased dopamine output in the medial prefrontal cortex of nicotine but not sham-implanted rats. Naloxone (2 mg/kg) precipitated a physical abstinence syndrome qualitatively similar to that produced by mecamylamine but failed to modify extracellular dopamine in the nucleus accumbens or in the prefrontal cortex of nicotine-implanted and sham-implanted rats. The results indicate that the mesolimbic and mesocortical dopamine system undergo opposite changes during mecamylamine-precipitated abstinence in rats chronically exposed to nicotine and that physical abstinence signs can be dissociated from changes in dopamine transmission.

The recovery time after Propofol-Tiva (P) or Isoflurane-anesthesia (I) for elective plastic surgery was studied by the Authors in two series of patients: 60 in group P, 60 in group I. All patients received a standard premedication and induction-anesthesia (premedication: Atropine 0.005 mg/kg i.m.; induction: Fentanyl 2.1 micrograms/kg+Propofol 2.5 mg/kg i.m. and Succinylcholine 1 mg/kg i.v. for tracheal intubation) and a different maintenance (group P received an infusion of 12 mg/kg/h for 10 min, 9 mg/kg/h for the next 10 min and 6 mg/kg/h thereafter+Fentanyl 1.4 micrograms/kg/h, group I clinically appropriate inspired concentration of Isoflurane and both Fentanyl-bolus at demand). They were ventilated mechanically with air and oxygen mixture (FiO2 = 0.3) to maintain normal blood-oxygen tension and normocarbia. The results showed that the recovery time was significantly shorter in the group P than in the group I and that Propofol-Tiva is accompanied by a more rapid recovery than Isoflurane-anesthesia.

Impairment of the state of consciousness is an important contributing factor in the onset of respiratory tract infections; in this study the data were collected prospectively to investigate the incidence and clinical implications of pneumonia in a population of head injured patients. The study was conducted on all patients treated at our centre throughout 1990. The incidence of pneumonia in the head injured was 10.8% versus 7.3% in the rest of the patients. Mortality in the group with pneumonia was not significantly different from the group without pneumonia. The average time of onset was on the fifth day from admission. The lung injury score (LIS) on the sixth day, the time on artificial ventilation and the length of stay in intensive care were significantly greater in those with pneumonia (1.18, 14.6 days and 21.9 days versus 0.8, 4.2 days and 12.9 days respectively). Staphylococcus was the single most frequently isolated germ. Our study concludes that pneumonia represents a relatively frequent and early complication in patients with head injury, and it is associated with prolonged artificial ventilation and longer staying in ICU.