title: Positive intravascular test dose criteria in children during total intravenous anesthesia with propofol and remifentanil are different than during inhaled anesthesia.
abstract: BACKGROUND
  The use of local anesthetic test doses is standard practice when performing regional anesthesia. When an intravascular test dose is administered during inhaled anesthesia, the heart rate does not increase in about 25% of children; altered T-wave amplitude is a better indicator. No studies have examined the criteria for a positive result during total i.v. anesthesia (TIVA) in children.
  
  
  METHODS
  We studied the effect of a simulated positive test dose on heart rate, arterial blood pressure, and T-wave amplitude in 17 ASA physical status I or II children receiving TIVA with propofol and remifentanil. Bupivacaine 0.25% 0.1 mL/kg with epinephrine 1:200,000 was injected i.v., and vital signs and electrocardiogram were continuously monitored. Increases of heart rate and arterial blood pressure >10% and T-wave amplitude >25% of baseline were considered clinically significant changes.
  
  
  RESULTS
  All subjects had increased systolic and diastolic blood pressure (30.3% +/- 11.7% and 49.3% +/- 16.7%), which peaked within 120 s. Heart rate increases >10% of baseline occurred in 73% of subjects. T-wave amplitude increased in 33.3%, was unchanged in 25%, and decreased in 41.7% of subjects.
  
  
  CONCLUSIONS
  A positive test dose during TIVA is best detected by increased arterial blood pressure. Twenty-seven percent of intravascular injections were missed using heart rate criteria. T-wave amplitude is not a reliable indicator of intravascular injection during TIVA. This is in marked distinction to what is seen during inhaled anesthesia.
authors.affiliation: Department of Anesthesia, The Children's Hospital, 13123 East 16th Ave., B090, Aurora, CO 80045, USA. polaner.david@tchden.org
authors.forename: David M
authors.initials: DM
authors.lastname: Polaner
authors.forename: Jeannie
authors.initials: J
authors.lastname: Zuk
authors.forename: Kristi
authors.initials: K
authors.lastname: Luong
authors.forename: Zhaoxing
authors.initials: Z
authors.lastname: Pan
mesh_terms: D000769:Anesthesia, Inhalation; D000771:Anesthesia, Intravenous / Q000379:methods*; D018686:Anesthetics, Intravenous / Q000008:administration & dosage*; D000779:Anesthetics, Local / Q000008:administration & dosage* / Q000009:adverse effects*; D001794:Blood Pressure / Q000187:drug effects; D002045:Bupivacaine / Q000008:administration & dosage* / Q000009:adverse effects*; D002648:Child; D002675:Child, Preschool; D004562:Electrocardiography / Q000187:drug effects; D004837:Epinephrine / Q000494:pharmacology; D005260:Female; D006321:Heart / Q000187:drug effects; D006801:Humans; D007223:Infant; D008297:Male; D010880:Piperidines / Q000008:administration & dosage*; D015742:Propofol / Q000008:administration & dosage*; D000077208:Remifentanil; D015203:Reproducibility of Results; D014662:Vasoconstrictor Agents / Q000494:pharmacology
chemical_list: D018686:Anesthetics, Intravenous; D000779:Anesthetics, Local; D010880:Piperidines; D014662:Vasoconstrictor Agents; D000077208:Remifentanil; D002045:Bupivacaine; D015742:Propofol; D004837:Epinephrine