TIVA in paediatric day surgery in a DGH (a decade of experience)

S Vijayaraghavan,  Bishop Auckland Hospital

Introduction

Children require higher infusion rates than adults to maintain a steady state of 3µg/ml and have longer context sensitive half time¹.  Remifentanil provides a more rapid recovery and adequate postop analgesia after TIVA for paediatric abdominal surgery². TIVA patients suffer less incidence of PONV³.  My hospital is a treatment centre for joint replacement and day surgery.  I have been doing TIVA since 1997 and these are my observations from the children I anaesthetised for various diagnostic and treatment procedures.

Materials and methods

All of the children had a local anaesthetic cream to facilitate IV cannulation.  Gaseous induction was used if two attempts at IV cannulation were unsuccessful.  The children were induced with bolus of propofol (3-5 mg/kg) or TCI to a target of 6-8 µg/ml and remifentanil 1 µg/kg over 30 seconds.  Maintenance with propofol 2-3µg/ml and remifentanil 0.25-0.5µg/kg/min, oxygen enriched air.  Appropriate opiate, NSAID and local anaesthetic nerve block/infiltration were administered and an airway maintained with a mask, LMA or ETT. Routine monitoring included ECG, SPO₂, NIBP, ETCO₂ and in later years BIS.

The duration of anaesthesia, amount of drugs used ant the time taken to open their eyes, tell their date of birth / obey simple commands, stand up and discharge noted. The amount of pain, PONV and analgesic and treatment given in both recovery and the ward was recorded. Reason for admission was also noted.

Results

A total of 304 children were anaesthetised of which 68 % were boys, 63 % ASA I, 36% ASA II and 1%ASA III . These children underwent the following procedures, conservative dental surgery 43 %, surgery 38 %, endoscopy 8 %, orthopaedics 8 % and gynaecology 3%.  VIMA was used in 5 children (1.6 %) because of failed IV insertion. The mean age was 9.25 yrs (range 2-17) and the mean weight 36 kg (range 12-96).  Airway maintained with LMA 82 %, ETT 14% and face mask 4 %.  Only 55 % of ETT group had muscle relaxants for intubation and 42 % of the children had BIS monitoring as well as routine monitoring.

 Post operative pain experienced: mild 6 %, moderate 1.3 %, severe 0.6 % and none 92 %.  Only one child needed an opiate to control the pain in the ward. Only two children (0.6 %) suffered PONV and one needed anti emetic treatment.

Four children needed admission (1.3 %) for various reasons:

·          Control of postoperative pain.

·          Persistent PONV needing IV fluid.

·          For observation because child had bronchospasm at the end operation.

·          Abdominal distention and died 12 hours later. Cause unknown (Cornelia De Lange syndrome).

Discussion

·          Postoperative pain following TIVA in children is not a major problem.

·          Incidence of PONV is minimal.

·          Complication/admission rate is less.

·          BIS monitored children seem clinically recover quicker than the non monitored group.

References

1. Mc Farlan et al: Use of propofol infusions in paediatric anaesthesia a practical guide: Paediatric anaesthesia: 1999:9 209-216.

2. Ganidagli et al: remifentanil provides a more rapid recovery and adequate postop analgesia after TIVA for paediatric abdominal surgery, compared with Alfentanil: Paediatric anaesthesia: 2003:13 695-700.

3. Sneyd et al: A Meta analysis of nausea and vomiting following maintenance with propofol or inhalational agents, Eur.J.Anaesthesiol: 1998:15 433-445.