Peter Stoddart | University Hospitals Bristol NHS Foundation Trust (original) (raw)

Papers by Peter Stoddart

Core Topics in Paediatric Anaesthesia, 2013

Pediatric Anesthesia, 2013

Myotonic dystrophy type 1 (MD1) is the commonest muscular dystrophy found in adults; however, it ... more Myotonic dystrophy type 1 (MD1) is the commonest muscular dystrophy found in adults; however, it may present in the neonatal period with hypotonia, talipes, poor feeding, and respiratory failure. Inheritance is autosomal dominant with a defect in the DMPK gene found on the long arm of chromosome 19 with variable expansion of the cytosine-thymine-guanine (CTG) triplet repeat. A 14-month-old boy with congenital MD type 1 was scheduled for percutaneous endoscopic gastrostomy (PEG) insertion, orchidopexy, and division of tongue-tie. Following induction of anesthesia, acceleromyography was used to monitor neuromuscular function. This revealed a very rapid onset of profound neuromuscular block which lasted significantly longer than would be expected in a child without MD1. Sugammadex reversed the block rapidly. The anesthetic management of children with MD1 has been well described but not the acceleromyographic monitored use of rocuronium and its subsequent reversal with the new cyclodextrin sugammadex.

Pediatric Anesthesia, 1998

In a blinded randomized study intubating conditions were compared at one min following intravenou... more In a blinded randomized study intubating conditions were compared at one min following intravenous induction with propofol and either suxamethonium 1.0 mg.kg-1, or rocuronium 0.6 mg.kg-1. Onset time to maximal twitch depression, % block at one minute and clinical duration (time to 25% recovery) were measured. Sixty children undergoing elective tonsillectomy were recruited. Onset time [42s (SD 11s)] and clinical duration [3.3 min (SD 1.0 min)] in the suxamethonium group was significantly (P < 0.001) less than in the rocuronium group [92s (41s)] and [24.2 min (6.6 min)] respectively. The median twitch height at one minute for suxamethonium was 0% (range 0-8%) and significantly greater (P < 0.001) at 5% (range 0-22%) for rocuronium. Despite this there was no difference in the intubating conditions at one minute with 25 excellent/5 good in the suxamethonium group and 27 excellent/3 good in the rocuronium group. We conclude that rocuronium 0.6 mg.kg-1 gives optimal intubating conditions at one minute in children.

Acta Paediatrica, 2009

Seventy-two hours of therapeutic hypothermia (HT) with a core temperature of 33.5-34.5°C commence... more Seventy-two hours of therapeutic hypothermia (HT) with a core temperature of 33.5-34.5°C commenced within 6 h of life is becoming the standard of care aiming to reduce death ⁄ disability after neonatal encephalopathy (NE) (1-3). As a result of concerns about maintaining haemodynamic stability and normal clotting during surgery, and post-operative wound healing (4), infants with NE born with major congenital abnormalities requiring surgery were excluded in the HT trials. In the UK, infants undergoing HT since the end of total body hypothermia (TOBY) trial are registered into the TOBY registry and managed using a standardized protocol (5). There is no previous report of undertaking surgery in an encephalopathic infant during therapeutic HT. We report our first infant with NE and oesophageal atresia and tracheoesophageal fistula (TEF) who underwent surgery while undergoing therapeutic HT.

Pediatric Anesthesia, 2009

Background. Formerly premature infants having inguinal herniotomy have been at a high risk of pos... more Background. Formerly premature infants having inguinal herniotomy have been at a high risk of postoperative apnoea, newer less soluble anaesthetic agents may reduce this risk.

Pediatric Anesthesia, 2003

Pediatric Anesthesia, 2007

Background: Rapid sequence induction (RSI) is the 'gold standard' technique for preventing aspira... more Background: Rapid sequence induction (RSI) is the 'gold standard' technique for preventing aspiration of gastric contents during induction of anesthesia in unfasted patients. We conducted a survey to discover whether the conduct of RSI in children varies amongst anesthetists and if practice alters in relation to the time since training or degree of ongoing experience. Methods: Six hundred and fifteen questionnaires were sent to anesthetists in the south-west of England. Results: The response rate was 61%. Preoxygenation was utilized by 83% of anesthetists for infants whereas 94% preoxygenated schoolchildren, P < 0.001. Only 59% of respondents used cricoid pressure in infants, compared with 96% in schoolchildren, P < 0.001. Propofol was the induction agent of choice for all anesthetists, although thiopentone was used more in infants (35%) than schoolchildren (9%), P < 0.001. Suxamethonium was widely used in all children. All anesthetists intubated patients for pyloromyotomy, 50% using cricoid pressure. RSI was performed by 86% of anesthetists for appendicectomy, with consultants most likely to deviate from a standard RSI. Sixty percent of anesthetists intubated for manipulation of forearm, 72% performing an RSI, 53% intubated for scrotal exploration, but only 42% performed an RSI. Conclusions: Classical RSI is used for children by most anesthetists in south-west England. RSI is modified for infants especially by more recently trained consultants. Suxamethonium is used less by consultant anesthetists. Whilst RSI is performed for appendicectomy there is a large variation in techniques for anesthetizing children for MUA and scrotal exploration which is independent of the grade of anesthetist.

Pediatric Anesthesia, 2011

We aimed to review the pain management in 100 episodes of severe mucositis in children and determ... more We aimed to review the pain management in 100 episodes of severe mucositis in children and determine the incidence of associated side effects. Mucositis is a painful, debilitating condition affecting the alimentary mucosa and occurs following many anticancer treatments. Severe pain associated with mucositis may necessitate reductions, delays or termination of anticancer therapy and so intravenous morphine, preferably by patient-controlled analgesia (PCA) is the treatment of choice. Retrospective review of consecutive episodes of mucositis in children requiring intravenous opioid analgesia over a 3-year period (May 2006-April 2009). In 24/92 (26%) of cases, morphine PCA provided insufficient pain relief and children required adjuvant ketamine therapy. These children had rapidly increasing morphine requirements approaching 1000 mcg/kg/day by day 2 (more than double compared with children on morphine alone), were more likely to be female, and tended to be older (median [IQR] age 12 [6-12] years vs 7 [3-14] years). The addition of ketamine to the morphine PCA appears to be associated with reduced morphine consumption, improved pain scores, causing minimal side effects and no hallucinations. Children with severe mucositis who have escalating morphine requirements may benefit from the addition of ketamine to their morphine PCA.

Pediatric Anesthesia, 2004

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European Journal of Anaesthesiology, 2001

British Journal of Anaesthesia, 2002

Background. The analgesics used for paediatric tonsillectomy may be associated with sideeffects s... more Background. The analgesics used for paediatric tonsillectomy may be associated with sideeffects such as sedation, respiratory depression and vomiting (opioids) or increased bleeding [non-steroidal anti-in¯ammatory drugs (NSAIDs)]. In our institution, we employ a combination of paracetamol, NSAID and opioid, although there is no published evidence of analgesic bene®t from adding NSAIDs to paracetamol in children.

British Journal of Anaesthesia, 2006

Background. We hypothesized that increasing duration of inhalation anaesthesia is associated with... more Background. We hypothesized that increasing duration of inhalation anaesthesia is associated with slower emergence and recovery in children, and that this effect would be less marked with desflurane in comparison with isoflurane.

Anesthesiology, 2003

Levobupivacaine, the levo-enantiomer of bupivacaine, is as potent as bupivacaine but less toxic. ... more Levobupivacaine, the levo-enantiomer of bupivacaine, is as potent as bupivacaine but less toxic. Therefore, the authors investigated the efficacy, safety, and pharmacokinetics of perioperative epidural levobupivacaine with and without fentanyl in children. After Research Ethics Board approval and informed written consent, 120 healthy children aged 6 months to 12 yr who were scheduled to undergo urologic or abdominal surgery were randomized in a double-blinded and concealed manner to receive one of four epidural solutions as a continuous infusion for 24 h: 0.125% levobupivacaine; 0.0625% levobupivacaine; 1 mug/ml fentanyl; or the combination, 0.0625 levobupivacaine and 1 mug/ml fentanyl. After induction of anesthesia and tracheal intubation, a lumbar epidural catheter was sited, a loading dose was administered (0.75 ml/kg levobupivacaine, 0.175%), and the epidural infusion was commenced. The primary endpoint was the need for rescue analgesia (morphine) in the first 10 h after surgery. Pain, motor strength, and side effects were recorded for 24 h. Venous blood was collected from 18 children to determine the plasma concentrations of levobupivacaine and/or fentanyl before and 2, 4, 8, 16, 24, and 26 or 30 h after the start of the epidural infusion. Of the 114 children who were analyzed for intention to treat, a similar number of children in each group reached the 10-h mark. The time to the first dose of morphine in the first 10 h was less in the plain fentanyl group (P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.044). All other effects were similar among the four groups. The plasma concentration of levobupivacaine increased during the infusion period, reaching a maximum of 0.76 +/- 0.11 mug/ml in the 0.125% group and 0.48 +/- 0.12 mug/ml in the 0.0625% group by 24 h. The plasma concentration of fentanyl also increased steadily, reaching a maximum concentration of 0.37 +/- 0.11 ng/ml by 24 h. We conclude that 0.0625% levobupivacaine without fentanyl is an effective perioperative epidural solution in children when infused at a rate of 0.3 ml. kg-1. h-1. The plasma concentrations of 0.125% and 0.0625% levobupivacaine and fentanyl (1 mug/ml) at the end of a 24-h infusion are low.

Anesthesia & Analgesia, 1995

The purpose of this study was to measure the serum fluoride concentration after enflurane or sevo... more The purpose of this study was to measure the serum fluoride concentration after enflurane or sevoflurane anesthesia and to compare the effects of prolonged anesthesia with these drugs on renal concentrating function in male volunteers. The study was subdivided into three stages; an ascending dose study of 3.0 and 6.0 minimum alveolar anesthetic concentration (MAC) hours of sevoflurane alone, a 6.0-MAC-hour comparison of enflurane and sevoflurane, and a 9.0-MAC-hour comparison of enflurane and sevoflurane. Renal concentrating function was assessed by an 18-h period of fluid deprivation and the serum fluoride concentration was measured at intervals until 60 h postanesthesia. The maximum serum fluoride concentration was greater in the volunteers exposed to sevoflurane and reached a peak in the 9-MAC-hour sevoflurane group of 36.6 microM (SD 4.3) compared with 27.5 microM (SD 2.6) in the 9-MAC-hour enflurane group. However, the rapid decrease in the serum fluoride concentration after sevoflurane was such that there was no difference between the areas under the fluoride concentration-time curves. There were no significant differences between the median maximum urine osmolalities after enflurane or sevoflurane anesthesia. Prolonged anesthesia with enflurane or sevoflurane is not associated with impaired renal concentrating function despite an increase in the serum fluoride concentration.

Anesthesia & Analgesia, 2007

Background: Sugammadex reverses neuromuscular blockade by chemical encapsulation of rocuronium. T... more Background: Sugammadex reverses neuromuscular blockade by chemical encapsulation of rocuronium. This phase IIIA study explored efficacy and safety of sugammadex in infants (28 days to 23 months), children (2-11 yr), adolescents (12-17 yr), and adults (18 -65 yr).

Anaesthesia, 2007

In a randomised study of analgesia following Caesarean section, we compared the eficacy and side ... more In a randomised study of analgesia following Caesarean section, we compared the eficacy and side effects of on-demand epidural diamorphine 2.5 mg with intravenous patient-controlled analgesia using diamorphine from the Baxter in fusor system. Pain scores fell more rapidly in the epidural group, but by the fourth hour, and thereafter, both techniques had a similar analgesic effect. The patient-controlled analgesia group used significantly more diamorphine ( p < 0.001). median 62 mg (range 18-120 mg) compared to the epidural group, median 10 mg (range 2.5-20 m g ) , over a significantly longer time period ( p < 0.001) ~ median