bENT-Department "Otto Körner", Rostock University, Rostock, Germany
Abstract
At present, the modern short-acting anaesthetic combination, such as propofol/remifentanil or desflurane/remifentanil combined with mivacurium, are the best narcotic drugs for brief ENT operations in children.
We tried to find out which procedure was the best for administering ENT anaesthesia to children in a teaching hospital. In the study, 681 case notes of administering anaesthesia for ENT in children (3 months–18-years-old) in 2001 were reviewed retrospectively. For premedication, children received EMLA creme on the back of their hands, midazolam (0.3–0.5 mg/kg), atropine (0.01 mg/kg), and paracetamol (125–500 mg) via the rectal or oral route. We noted that for younger ages (till 4 years), inhalational induction of anaesthesia with sevoflurane via facemask was the preferred method. Anaesthesia was maintained with volatiles in this age group. For analgesia, the continuous application of remifentanil was preferred. TIVA with propofol/remifenanil was more commonly used with children older than 4 years. Most of the children were intubated with muscle relaxants (altogether 91%). For children up to 7 years, the favourite relaxant was mivacurium. A laryngeal mask was never used.
E-mail address: [email protected]
doi:10.1016/S0531-5131(03)01102-6
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Contents
1. Background
The induction of anaesthesia for ENT surgery in paediatric patients is aimed to be without stress.
The ideal drugs to be used should have a rapid onset, rapid recovery, and long-lasting postoperative analgesic effect.
The purpose of this study was to evaluate which modern anaesthetics were commonly used at paediatric ENT surgery, and which procedure was the best for administering anaesthesia to children of different ages in a teaching hospital.
2. Methods
In the study, case notes of administering anaesthesia for ENT in children in 2001 were reviewed retrospectively. Surgical procedures in these patients were adenotomy, tonsillectomy, neck-, ear- and nose operations. Children were assigned to 5 groups, depending on their age: 3 month–1 year, 2–4 years, 5–7 years, 13–18 years.
3. Results
Demographic data: 681 cases were reviewed. Peaks are seen for children at 2–4 years old (29.5%) and 13–18 years old (31.1%). Adenotomies were performed most frequently in children aged 2–4 years old, and tonsillectomies, neck operations, ear operations, and nose operations in children aged 13–18 years, respectively.
Anaesthetic management: For premedication, children received an eutetic mixture of local anaesthetics (EMLA creme) on the back of their hands. Midazolam (0.3–0.5 mg/kg), atropine (0.01 mg/kg), and paracetamol (125–500 mg) were given via the rectal or oral route.
For younger ages (till 4 years), inhalational induction of anaesthesia was the preferred method. Anaesthesia was maintained with volatiles (94.5%) in this age group.
Sevofluran was the volatile used most frequently (83%) for anaesthesia. Most of the older children accepted to be pricked before starting anaesthesia. In these cases, it was common to use thiopentone for i. v. induction (43.2%). Then, anaesthesia was maintained with volatiles. For analgesia, the continuous application of remifentanil was preferred, and the number of children receiving alfentanil or fentanyl was negligible. TIVA with propofol and remifentanil became more common for children 5–7 years old (52%), and was the technique that was primarily used for children between 12 and 18 years (92%). All children who were undergoing adenotomy, tonsillectomy, or longer lasting operations received muscle relaxants, their trachea was intubated (altogether 91%) and their lungs were mechanically ventilated.
Children below 8 years predominantly received mivacurium for muscle relaxation (90%), children 8–18 years received rocuronium or cis atracurium (54.7%) or mivacurium (43.3%). A laryngeal mask was never used. If severe pain was expected postoperatively, piritramid was given additionally during the operation, especially for school children (60%).
ENT anaesthesia was performed by residents-in-training at an average of 67% of surgeries.
4. Discussion
At present, the modern short-acting anaesthetic combinations, such as propofol/remifentanil or desflurane/remifentanil combined with mivacurium, are the best narcotic drugs for brief ENT operations in children [2]. We noted that at younger ages (till 4 years), inhalational induction with sevoflurane via facemask is mainly used for induction of anaesthesia [4]. We assumed that the premedication with midazolam [1] and EMLA creme is not always sufficient to reduce anxiety regarding operations, venous cannula, and temporal separation from parents. Sevoflurane is the preferred volatile anaesthetic because desflurane is not suitable for inhalational induction of anaesthesia due to its pungent odour. The main disadvantage of propofol is its pain on injection, especially in small veins. TIVA with propofol/remifenatil was more commonly used with children older than 4 years.
Remifentanil is associated with higher postoperative pain score if severe pain was expected postoperatively. For example with a tonsillectomy, piritramid as a long-lasting opioid was given via i. v. at the end of the operation.
By far, the most common interventions of preschool children were adenotomies. In these cases, it is possible to use the laryngeal mask [5]. In our hospital, residents-in-training executed ENT operations and administered anaesthesia, and the safer way is the general anaesthesia with tracheal intubation. For children up to 7 years, the favourite relaxant was mivacurium, as this induced a very short duration of neuromuscular block [3]. For the longer lasting operations in older children, it is less expensive to use relaxants with a longer duration of neuromuscular block than to use repetitive doses of mivacurium.