Correspondence

Prevention of postoperative vomiting withgranisetron in paediatric patients with andwithout a history of motion sicknessSIRIRÐWe would welcome the opportunity to comment on

the study `Prevention of postoperative vomiting with

granisetron in paediatric patients with and without a

history of motion sickness' by doctors Fujii et al. (1).

We appreciate that this study was designed primarily to

examine the merits of prophylactic antiemesis in children

predisposed to motion sickness, and therefore where

possible it was necessary to eradicate certain predisposing

factors that have been previously shown to accentuate

PONV, e.g. opioid analgesics.

We were, however, unclear as to whether the decision

to omit all types of pre- and intraoperative analgesics is the

standard practice in the authors' institute or whether they

chose, in particular, to omit an opioid analgesic from their

study technique because it is known to increase the

incidence of PONV.

We would have been interested to know what pain scoring

tool was used, particularly as the authors comment that pain

itself is a well-recognized cause of postoperative vomiting.

We were also unsure as to whether any of the children

who required postoperative opioid had also received

paracetamol or whether there was no overlap between

the groups, which would make the numbers of children in

each group requiring some form of analgesia quite

different (24±25 out of 30 versus 28±29 out of 30). Either

way, it appears that the number of children requiring

rescue analgesia postoperatively was greater than 80%,

reinforcing the fact that tonsillectomy is considered by

many anaesthetists, ENT surgeons and ward nurses to be a

very uncomfortable surgical procedure. The authors, in

their discussion, acknowledge that postoperative pain

increases the incidence of postoperative emesis.

We are unaware of any published studies to show that

the pre- or intraoperative administration of paracetamol

and/or a nonsteroidal anti-in¯ammatory analgesic drug

(NSAID) increases the incidence of PONV in children.

We are, however, aware of studies that have shown that

the perioperative administration of paracetamol and

NSAIDs does reduce opioid requirements in children

undergoing this and other types of surgery (2±4).

It is worth noting the work of Anderson et al. (3) and

Birmingham et al. (5), who have independently concluded

that when paracetamol is administered rectally a loading dose

of at least 30 mg á kg)1 and probably 40 mg á kg)1 should be

given, these doses being somewhat greater than administered

in this study. We also would question the ef®cacy of the rectal

route when used for rescue therapy because studies have

shown subtherapeutic serum paracetamol concentrations in

the ®rst 40 min after administration (6).

From our own clinical practice, we have observed that

children having undergone tonsillectomy do sometimes

retch or vomit a little blood-stained saliva once or twice

either on emergence from anaesthesia or immediately

postoperatively. They then seem to settle without the need

for further treatment. Our surgical colleagues have ex-

pressed their concerns that giving antiemetic prophylaxis

routinely to younger children can conceal ongoing bleed-

ing from the tonsillar bed postoperatively, thereby delay-

ing its diagnosis and management.

We hope the authors ®nd these comments useful.

JUDITHUDITH NOLANOLAN

DYLANYLAN PARRYARRY PROSSERROSSER

Department of AnaesthesiaRoyal Hospital for Sick Children

Bristol BS2 8EG, UK

References

1 Fujii Y, Saitoh Y, Tanaka H et al. Prevention of postoperativevomiting with granisetron in paediatric patients with andwithout a history of motion sickness. Paed Anaesth 1999; 9:527±530.

2 Korpela R, Korvenoja P, Meretoja O. Morphine-sparing effect ofacetaminophen in pediatric day-case surgery. Anesthesiology1999; 91: 442±447.

3 Anderson B, Kanagasundarum S, Woollard G. Analgesic ef®-cacy of paracetamol in children using tonsillectomy as a painmodel. Anaesth Intens Care 1996; 24: 669±673.

4 Mather SJ, Peutrell JM. Postoperative morphine requirements,nausea and vomiting following anaesthesia for tonsillectomy.Comparison of intravenous morphine and non-opioid analgesictechniques. Paed Anaesth 1995; 5: 185±188.

5 Birmingham PK, Toblin MJ, Henthorn TK et al. Twenty-four hourpharmacokinetics of rectal acetaminophen in children: an olddrug with new recommendations. Anesthesiology 1997; 87: 244±252.

6 Rusy LM, Houck CS, Sullivan LJ et al. A double-blind evalu-ation of ketorolac tromethamine versus acetaminophen inpediatric tonsillectomy: analgesia and bleeding. Anesth Analg1995; 80: 226±229.

Author's reply

SIRIRÐThank you for an opportunity of answering the

questions by readers in Paediatric Anaesthesia. As previ-

Paediatric Anaesthesia 2000 10: 451±455

Ó 2000 Blackwell Science Ltd 451

ously described in the ®rst report by us (1), we evaluated

the ef®cacy and safety of granisetron, a selective 5-

hydroxytryptamine type 3 (5-HT3) receptor antagonist,

for preventing postoperative vomiting (POV) in children

undergoing general anaesthesia for tonsillectomy, and we

used acetaminophen 100±300 mg rectally depending on

patient weight and/or pentazocin 0.3 mg á kg)1 intrave-

nously as an analgesic for the control of pain after

operation. This is the routine technique of postoperative

pain relief in our institution. Consequently, in this clinical

trial, the number of patient requiring these two analgesics

were not different among the groups.

Hamid et al. (2) have demonstrated that antiemetics

may mask the presence of blood in the stomach by

preventing POV, and the effect of these drugs should be

appreciated when adenotonsillectomy is performed on an

outpatient basis. However, in our clinical study, all

patients were admitted to the hospital and were observed

for 24 h postoperatively by nurses. Sometimes POV may

result in a prolonged stay in the recovery room and ¯uid

and electrolyte imbalance. Therefore, prophylactic antie-

metic may avoid these unanticipated adverse effects.

YOSHITAKAOSHITAKA FUJIIUJII

Department of AnaesthesiologyUniversity of Tsukuba Institute of Clinical Medicine

2-1-1, Amakubo, Tsukuba CityIbaraki 305, Japan

References

1 Fujii Y, Saitoh Y, Tanaka H et al. Prevention of postoperativevomiting with granisetron in paediatric patients with andwithout a history of motion sickness. Paed Anaesth 1999; 9:527±530.

2 Hamid SK, Selby IR, Sikich N et al. Vomiting after adenoton-sillectomy in children: a comparison of ondansetron, dimen-hydrinate, and placebo. Anesth Analg 1998; 86: 496±500.

Blind intubation via the laryngeal mask:a word of cautionSIRIRÐWe read with interest the paper by Osses et al.regarding intubation using the laryngeal mask airway

(LMA) in infants (1). We have twice copied their innova-

tive use of an tracheal tube stylet to maintain position of

the tracheal tube (TT) while removing the laryngeal mask.

The technique works well and quickly, and requires no

special preparation. However, we must urge caution.

Osses et al. recommend blind passage of the TT through

the LMA. Critical ®breoptic examination of LMA place-

ment has revealed that position is not always perfect. The

epiglottis may partially obstruct the distal aperture of the

LMA in 25±50% of infants, but this is rarely apparent

clinically (2,3). This was the case in one of our two

patients, a 2.4-kg 14-day-old neonate with Miller syn-

drome (airway similar to that seen in Treacher±Collins

Syndrome) (4). Blind advancement of the TT in such a case

could injure the epiglottis. Instead, it is preferable to

sheath a ®breoptic endoscope with the TT (5,6) and

advance through the LMA and into the trachea with

®breoptic guidance. If a small enough scope is not

available, a larger scope should be used to con®rm proper

LMA placement before blind passage of a TT.

STEVETEVE M. AUDENUDEN

GUYUY M. LERNERERNER

Pediatric Anesthesiology, N-65Kosair Children's Hospital

231 East Chestnut StreetLouisville, KY 40202, USA

References

1 Osses H, Poblete M, Asenjo F. Laryngeal mask for dif®cultintubation in children. Paed Anaesth 1999; 9: 399±401.

2 Dubreuil M, Laffon M, Plaud B et al. Complications and®beroptic assessment of size 1 laryngeal mask airway AnesthAnalg 1993; 76: 527±529.

3 Mizushima A, Wardall GJ, Simpson DL. The laryngeal maskairway in infants. Anaesthesia 1992; 47: 849±851.

4 Miller M, Fineman R, Smith DW. Postaxial acrofacial dysostosissyndrome. J Pediatr 1979; 95: 970±975.

5 Auden SM. Flexible ®beroptic laryngoscopy in the pediatricpatient. In: Riazi J, ed. The Dif®cult Pediatric Airway. Anesthe-siology Clinics of North America, 1998: 763±793.

6 Ellis DS, Potluri PK, O'Flaherty JE et al. Dif®cult airwaymanagement in the neonate: a simple method of intubatingthrough a laryngeal mask airway. Paed Anaesth 1999; 9: 460±462.

A pragmatic approach to fastingin paediatric trauma?SIRIRÐIt is widely thought that all acute paediatric trauma

should be regarded as unfasted regardless of the fasting

interval, but the evidence is inconclusive. A large retro-

spective study demonstrated a ®ve-fold increase in risk of

aspiration during emergency compared with elective

surgery (1). Another showed that in paediatric emergency

surgery, the volume of gastric residue is > 0.4 mlákg)1 in

50% of cases whilst older children and those with

super®cial injuries have a lower risk of exceeding this

volume (2). Bricker et al. (3) found that whilst there is

some correlation between starvation time and gastric

aspirate volume in acute paediatric trauma, a clearer

relationship exists between gastric volume and food-

452 CORRESPONDENCE

Ó 2000 Blackwell Science Ltd, Paediatric Anaesthesia, 10, 451±455