PAEDIATRICS
Anaesthesia for elective ear,
nose and throat surgery in
children
Zo€
e Brown
Simon Whyte
Abstract
This review is an update of anaesthesia for elective ear, nose and throat
procedures commonly performed in the paediatric population. Increas-
ingly these often-complex procedures are being undertaken as day
cases and so preoperative assessment needs to be tailored accordingly
to identify those children requiring closer postoperative monitoring.
Assessment of co-morbidities, consequences of the child’s presenting
pathology (e.g. obstructive sleep apnoea (OSA)), bleeding risk and the
presence of any concurrent upper respiratory tract infections needs to
be the focus of the preoperative visit. Day case procedures involve careful
patient selection and good communication with families regarding the
post-operative phase and potential complications. Adenotonsillectomy
is most commonly performed to relieve the symptoms of OSA. The main
anaesthetic concerns include co-morbidities (e.g. obesity), analgesia
including the potential use of non-opioids like dexmedetomidine, post-
operative nausea and vomiting (PONV), risk of postoperative haemorrhage,
postoperative respiratory complications and postoperative disposition.
Children undergoing middle ear surgery need careful consideration to
prevent problems associated with bleeding, hypothermia and PONV, and
staff need to be aware of any hearing deficit that the child may have. Use
of lasers is common in airway surgery with children often having repeated
laser procedures; associated risks include airway fire and injury to the eyes
of the patient and theatre staff.
Keywords Adenotonsillectomy; day care; elective; obstructive sleep
apnoea; otolaryngology; paediatrics
Introduction
The majority of paediatric ear, nose and throat (ENT) surgeries
are performed as elective day case procedures. This provides the
anaesthetist with numerous challenges, such as: high-turnover
lists; shared airways; co-morbidities with anaesthetic signifi-
cance, including syndromic associations; an increasing incidence
€ Brown MB ChB FRCA is a Specialist Registrar in Anaesthesia under-
Zoe
taking a fellowship in Paediatric Anaesthesia at the British Columbia
Children’s Hospital in Vancouver, Canada. Conflicting interests: none
declared.
Simon Whyte MBBS FRCA is a Clinical Assistant Professor in Paediatric
Anaesthesia at the British Columbia Children’s Hospital in Vancouver,
Canada. Conflicting interests: none declared.
ANAESTHESIA AND INTENSIVE CARE MEDICINE 13:5
Learning objectives
After reading this article you should:
C have an awareness of the pertinent points of preoperative
assessment of children for common ENT procedures, particu-
larly regarding day case adenotonsillectomy
C understand the implications of obstructive sleep apnoea in
children on perioperative management
C comprehend the anaesthetic considerations for common ENT
procedures, including laser surgery
of obesity and its clinical sequelae; increased risks of perioper-
ative respiratory adverse events (PRAE) and post-operative
nausea and vomiting (PONV).
Preoperative assessment
In addition to standard enquiries, preoperative assessment of
children undergoing ENT procedures should specifically include
a focus upon several commonly-encountered issues in more
detail: upper respiratory tract infection (URTI), obesity, sleep-
disordered breathing (SDB), bleeding disorders and common
congenital syndromes.
Upper respiratory tract infections
Postponement of a child with an active or recently resolved
upper respiratory tract infection (URTI) is a difficult decision. It
is accepted that an active or recent infection within the last
4 weeks, with a moist cough, green runny nose or fever increases
the risk of perioperative respiratory adverse events (PRAE) such
as desaturation, bronchospasm, cough, laryngospasm or airway
obstruction.1 With milder active URTI symptoms, in non-body-
cavity, non-airway surgery, and with strategies to mitigate the
risks of PRAE (e.g. salbutamol pre-medication, avoidance of
airway instrumentation, minimization or avoidance of irritant
volatile anaesthetics), many experienced anaesthetists would feel
comfortable in proceeding. The anaesthetist does need to be
mindful that adverse events associated with a URTI are particu-
larly common with airway surgery or if the child is intubated.
Therefore, the risk/benefit decision to operate or not should be
guided by the child’s symptoms and co-morbidities, comfort of
the anaesthetist in managing children with URTI and type of
surgery planned.
Obesity
About 35% of children in the USA are overweight or obese and
the incidence is increasing. Body mass index (BMI) is used for
children over 2 years old and is calculated and compared to an
age- and gender-specific reference range. Overweight is defined
as a BMI in the 85th percentile or higher; obesity is defined as
a BMI at least in the 95th percentile (Table 1). Younger than 2
years, length-for-age and weight-for age or head circumference-
for-age and weight-for-length are plotted on a growth chart.
Obesity has an association with specific co-morbidities:
asthma, hypertension, obstructive sleep apnoea (OSA) and dia-
betes. Obese children have a higher incidence of difficult mask
ventilation and adverse perioperative respiratory events are
234 Ó 2012 Elsevier Ltd. All rights reserved.
 PAEDIATRICS

per hour (apnoeaehypopnea index (AHI)) and the lowest oxy-

Body mass index for a range of ages and both sexes haemoglobin saturation level. This enables classification of OSA
as mild, moderate or severe. An AHI greater than 1 is consistent
Body mass index
with a diagnosis of childhood OSA:
(kg/m2) percentile
 mild OSA: AHI 1e5
Age (years) 50th 85th 95th  moderate OSA: AHI 6e10
 severe OSA: AHI greater than 10.5
Boys 2 16.6 18.2 19.4 The consequences of significant OSA that may affect anaesthetic
5 15.4 16.8 18.0 management include:
10 16.6 19.4 22.2  Cardiovascular complications e classically right ventric-
Girls 2 16.4 18.0 19.1 ular dysfunction, causing pulmonary hypertension and cor
5 15.2 16.2 18.2 pulmonale at its worst. Potentially additional left ventric-
10 16.8 20.0 23.0 ular dysfunction and systemic hypertension. Cardiac
changes have been documented in children with mild OSA.
Table 1  Increased risk of postoperative respiratory complications.
This has been attributed to two reasons:
more likely to be severe, requiring intervention, for example re-  Children with OSA have a reduced ventilatory response
intubation for airway obstruction.2 to increased arterial carbon dioxide tensions, which is
exacerbated by general anaesthesia. These children are
Sleep-disordered breathing and obstructive sleep apnoea less able to ‘rescue themselves’ from an obstructive
SDB is the commonest indication for adenotonsillectomy in episode postoperatively.
children. Preoperative assessment of SDB severity informs deci-  Increased pharmacodynamic sensitivity to opioids.
sions of suitability for day case surgery. Children with severe OSA require half the standard
SDB due to upper airway obstruction presents with a clinical opioid dose to achieve adequate postoperative
spectrum of disease that ranges from primary snoring, through analgesia.
upper airways resistance syndrome and obstructive alveolar  Neurological complications including behavioural prob-
hypoventilation, to OSA in its severest form. Up to one in five lems and learning difficulties, which may make for
children within the general population have been diagnosed with a turbulent pre- and postoperative experience.
primary snoring. OSA affects approximately 1e3% of children, Unfortunately, the true severity of SDB in a child labelled with
with a peak incidence between 3 and 6 years old. a diagnosis of OSA and listed for adenotonsillectomy is often
Childhood OSA is currently classified into types I (tonsillar undetermined, as PSG is a resource-intensive investigation that
hyperplasia without obesity) and II (concurrent obesity, resem- requires an overnight stay in hospital. ‘OSA’ is instead often
bling the adult form). About 50% of children with OSA have type diagnosed clinically from history and examination (Table 2).
II.3 Risk factors for developing childhood OSA are listed in Box 1. Preoperative assessment may therefore involve the anaes-
Polysomnography (PSG) is the gold standard for OSA diag- thetist making an educated guess on the severity of SDB, to
nosis. The concept is to measure the number of SDB episodes establish: (i) whether these children can be anaesthetized as
a day case procedure and (ii) whether they warrant further
cardio-respiratory evaluation preoperatively.
The American Academy of Pediatrics has identified risk
Risk factors for developing childhood OSA4 factors that contraindicate day case adenotonsillectomy (Box 2).
These children should be admitted overnight for monitoring with
C Tonsillar and adenoid hypertrophy continuous pulse oximetry.6
C Afro-Caribbean ethnicity
C Respiratory disease Bleeding
 Asthma The use of universal preoperative screening of coagulation
 Sinus problems disorders in children is controversial, but the anaesthetist
C Obesity should be aware that there is a population of healthy children
C Former prematurity with undiagnosed coagulation disorders. The anaesthetist may
C Craniofacial disorders identify at risk individuals through preoperative screening
C Neuromuscular disorders questions regarding a history of increased bleeding tendency,
 Cerebral palsy although it has been reported that children with undiagnosed
bleeding disorders have undergone previously straightforward
C Chromosomal abnormalities surgery.
 Down syndrome
 PradereWilli syndrome Other co-morbidities
C Family history of OSA Any congenital, chromosomal or syndromic abnormalities
should be specifically identified. Commonly encountered exam-
ples include children with Down syndrome, who often require
Box 1 middle ear surgery (which is more challenging as they have

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 PAEDIATRICS

Signs and symptoms suggestive of sleep-disordered breathing in children

Night-time symptoms Daytime symptoms Signs

Snoring Daytime sleepiness (rare in children with OSA) Obesity

Apnoea Hyperactivity Tonsillar hypertrophy
Arousals or wakening Poor concentration Mouth-breathing
Restless sleep Lethargy Failure to thrive
Night sweats Social withdrawal
Difficult to rouse in the morning Poor school performance

OSA, obstructive sleep apnoea.

Table 2

narrow external auditory canals) and adenotonsillectomy for
OSA; patients with branchial arch abnormalities, who present for
reconstructive ear surgery and may be extremely difficult to
intubate; infants with cleft lips and/or palates, which may be
isolated anomalies but may also be part of syndromes whose
other features (particularly cardiac) may have an impact on the
anaesthesia management.
Common ENT operations
Myringotomy and tympanostomy tubes
Anaesthetic considerations: this is usually a quick procedure
performed as a day case. Emphasis should be on appropriate
analgesia and quick recovery.
Preoperatively: many children have had this procedure before,
resulting in anxiety surrounding repeat anaesthetics. Analgesia
with oral paracetamol (acetaminophen) with or without a non-
steroidal anti-inflammatory drug (NSAID) is appropriate. Iden-
tify those with active or recent URTI, common in children
undergoing this operation.
Intraoperatively: the airway can be maintained either with
a facemask or a laryngeal mask airway (LMA) whilst the child
breathes spontaneously. Ondansetron 0.15 mg/kg intravenously
can be considered for anti-emesis.
Risk factors for postoperative respiratory
complications in children with OSA undergoing
adenotonsillectomy
C Age younger than 3 years
C Failure to thrive
C Obesity
C History of prematurity
C Upper respiratory tract infection within last 4 weeks
C Craniofacial anomalies
C Neuromuscular disorders
C Cor pulmonale
C Systemic hypertension
Box 2
Postoperatively: analgesic requirements are highly variable
between children. Intravenous opioids are rarely required.
Adenotonsillectomy
Adenotonsillectomy (T&A) is commonly performed to treat OSA
in younger children and recurrent infection in older children.
Surgery is often as a day case and anaesthetic management needs
to be tailored to this. Identification of those at higher risk of
complications postoperatively (Box 1) is a key part of the pre-
operative assessment; those with risk factors for postoperative
respiratory complications (Box 2) should be considered for
overnight admission.
Anaesthetic considerations: OSA and its sequelae; shared
airway; potential difficult airway (obstruction, bleeding); chal-
lenge of balancing postoperative pain management and risk of
postoperative airway complications; PONV and postoperative
bleeding.
Preoperative assessment: enquire about a bleeding diathesis.
Identify pre-existing risk factors for PONV. See Box 3 specifically
for OSA.
Premedication in all children for T&A should include para-
cetamol and an NSAID unless contraindicated. There has been
concern that NSAIDs were associated with an increased risk of
bleeding. A Cochrane report updated in 2010 found that the use
of NSAIDs did not cause an increase in postoperative bleeding.
The report focused on ketorolac, as previously it had been
avoided intraoperatively because it potentially increased the risk
of bleeding. No evidence was found for it causing increased
bleeding, but many anaesthetists would use ibuprofen or diclo-
fenac in preference. NSAIDs have the added benefit of reducing
PONV, which may either be due to improved pain control or
a reduction in opioid use.7
Intraoperative management (See Box 3): T&A is a painful
procedure and opioids are usually required, but care should be
taken with children with OSA. Use of adjuncts, for example
ketamine or dexmedetomidine may reduce opioid requirement.
Dexmedetomidine is a potent and highly selective a2-adre-
noceptor agonist with sedative and analgesic properties.8 It is
commonly used as a sedative agent on the intensive care units in
North America. It has the advantages being short acting, rela-
tively cardiovascularly stable and does not produce respiratory

ANAESTHESIA AND INTENSIVE CARE MEDICINE 13:5 236 Ó 2012 Elsevier Ltd. All rights reserved.
 PAEDIATRICS
Key points for anaesthetizing a child with possible OSA
Preoperative management
C Assess in preoperative assessment clinic
C Identify OSA on history and examination and assess
severity
C Decide if child requires further investigation or cardio-
respiratory assessment
C Consideration of suitability for day case procedure
Intraoperative management
C No evidence for the use or avoidance of sedation
premedication
C Inhalational induction may be more problematic with
risk of upper airway obstruction
C No evidence regarding use of laryngeal mask airway
rather than endotracheal tube
C Awake extubation, possibly using a nasal airway
C Reduced dose of intraoperative opioids as sensitive,
due to chronic hypoxia
Postoperative management
C Increased risk of postoperative respiratory complications
Box 3
depression. For these reasons it has theoretical advantages for
intraoperative use in children undergoing T&A, particularly those
with a history of OSA. Early studies have suggested that infusions
or boluses of dexmedetomidine increase the time to first opioid
dose in recovery, reduce the risk of emergence delirium in all
children undergoing T&A, decrease intraoperative opioid
requirement, but possibly increase time in the post-anaesthesia
care unit. The role of dexmedetomidine in anaesthetic manage-
ment of T&A will be an area of ongoing active research.
T&A is a high-risk procedure for PONV. The Association of
Paediatric Anaesthetists of Great Britain and Ireland recommends
all children undergoing T&A receiving intravenous (IV) ondan-
setron 50 mg/kg and IV dexamethasone 150 mg/kg.
Postoperative management: need for postoperative opioids may
be reduced with regular paracetamol and NSAIDs. Eating and
drinking should occur on a voluntary basis postoperatively, to
reduce the incidence of emesis.
About 9% of children less than 4 years old have an unplanned
admission after T&A, more commonly due to vomiting (5.2%)
than for surgical (1.7%) reasons. Postoperative primary hae-
morrhage (within 6 hours) is an uncommon but serious
complication.
It should be noted that any child who has a respiratory
complication in the immediate postoperative period is at greater
risk of having a further event within the following 24-hour period.
Middle ear surgery
Mastoidectomy, myringoplasty and cochlear implantation:
Anaesthetic considerations e presence of a co-existing
syndrome; potentially long procedure with minimal stimula-
tion; maintain a ‘bloodless field’; PONV prophylaxis; difficult
ANAESTHESIA AND INTENSIVE CARE MEDICINE 13:5
airway access; facial nerve monitoring; increasingly done as
a day case procedure.
Preoperatively e premedication with paracetamol with or
without an NSAID. Assess for bleeding diatheses and risk factors
for PONV. Awareness of hearing deficit and assess for URTI or
otitis media as these children are at risk of bacterial meningitis.
All children with a sensorineural hearing deficit should have an
electrocardiograph to exclude long QT syndrome as part of
JervelleLange-Nielsen syndrome.
Intraoperatively e these operations can be prolonged, often
not stimulating, and access to the airway can be difficult.
Topicalizing the vocal cords with local anaesthetic may help to
prevent coughing on extubation. Total intravenous anaesthesia
(TIVA) is one option to allow tolerance of an endotracheal tube if
used, reducing the risk of PONV and avoiding large fluctuations
in blood pressure. By avoiding hypertension and hypercarbia, the
anaesthetist can aid the surgeon by reducing the amount of
bleeding within the operative field. Hypotensive anaesthesia may
additionally aid microscopic visualization of the operative field.
Middle ear surgery is associated with a higher risk of PONV.
Single-agent prophylaxis with ondansetron 150 mg/kg is indi-
cated and dual therapy (dexamethasone 150 mg/kg and ondan-
setron 50 mg/kg) should be considered if risk factors for PONV
are present. Intravenous hydration, the use of TIVA and avoid-
ance of long-acting opioids further reduce the risk of PONV.
With intraoperative facial nerve monitoring, the use of muscle
relaxant is precluded during the case. If neuromuscular block is
needed for intubation, choose a dose and an agent that ensures
rapid return of function.
Long duration of surgery means that hypothermia can be
a risk. Temperature monitoring is important to avoid iatrogenic
hyperthermia.
Avoiding the use of nitrous oxide (N2O) in middle ear surgery
is preferential. These children are at higher risk of PONV, and
whether or not N2O does increase the risk, it is particularly best
to avoid in myringoplasty to prevent negative middle ear pres-
sure being applied to grafts.
Postoperatively e pain and PONV are the commonest prob-
lems with bleeding a rare occurrence. Pre-emptive analgesia and
anti-emesis is desirable. In the case of children having cochlear
implants, the PACU should have the skills to manage these
children with a hearing deficit. Activation of the cochlear implant
does not occur for a couple of weeks postoperatively and so their
hearing deficit will be unchanged.
Surgery for congenital ear defects
Anaesthetic considerations: congenital ear defects can be
microtia (external ear deformity) and or atresia (absent ear
canal), often associated with severe hearing loss in the affected
ear. They can be idiopathic or associated with a congenital
syndrome that has affected in-utero development of the first or
second branchial arch (Box 4).
These children should be assessed for co-morbidities and
likelihood of difficult intubation. They present for single or multi-
stage reconstructive ear surgery, and for insertion of temporal
screws to enable attachment of bone-anchored hearing aids.
Preoperatively: focused evaluation of the affected organ systems
should be based on syndrome components. Standard airway
237 Ó 2012 Elsevier Ltd. All rights reserved.
 PAEDIATRICS
Syndromes associated with congenital ear defects
C Goldenhar syndrome
C Treacher Collins syndrome
C Auriculocondylar syndrome
C Pierre Robin sequence
C Mo€bius syndrome
C Crouzon syndrome
C Klippel-Feil syndrome
C Fanconi syndrome
C Velocardiofacial syndrome
C VATER syndrome
C CHARGE syndrome
Box 4
assessment to evaluate potential difficulty with bage
valveemask ventilation (severe mandibular hypoplasia can
make this very difficult), laryngoscopy and LMA insertion.
Review the previous anaesthetic records where available, and
formulate airway management plans accordingly. Anticholin-
ergic agents can be administered at this time to reduce airway
secretions.
Intraoperatively: for long operations involving ear reconstruc-
tion, endotracheal intubation should be the first choice for
securing the airway. If using an LMA in shorter cases, the
anaesthetist should be prepared in case a problem arises with the
airway. These longer operations require attention to normo-
thermia, pressure areas and fluid management. Invasive moni-
toring is at the discretion of the individual anaesthetist.
Postoperatively: pain management in these cases can be difficult
to assess in children with deafness and/or learning difficulties as
an association with the syndromes. Otherwise, pain manage-
ment, PONV prevention and fluid requirements are routine.
Laser surgery of the larynx
Laser is used for:
 laryngeal papillomata treatment
 supraglottoplasty or epiglottopexy for laryngomalacia
 tracheo-oesophageal fistula remnant marsupialization
 haemangiomata
 oral lesions.
The human papillomavirus causes laryngeal papillomata. Chil-
dren affected are commonly younger than 10 years old with
a peak at 4 years old. Severe laryngeal obstruction can occur.
There is no curative treatment for this condition and recurrent
surgical removal of recurrent tumour is usually necessary every
6e12 weeks. Surgery can involve laser or endoscopic micro-
debridement. Treatment frequency usually lengthens with age,
as the children tend to grow out of the disease in later
adolescence.
Anaesthetic considerations: preparation for these cases is key.
Discussion prior to each case with the surgeons and nursing staff
ANAESTHESIA AND INTENSIVE CARE MEDICINE 13:5
to plan how the case will be managed is important. Potential
complete airway obstruction is a possibility. Laser safety proto-
cols should be followed. Postoperative care and level of moni-
toring should be arranged preoperatively.
Preoperatively: a thorough history and examination of the child,
with surgical and radiological input to assess the anatomical
location of the lesion, degree of airway obstruction and its nature
(e.g. fixed, dynamic or both). Access to records of previous
surgery can help. This information will help determine the
anticipated degree of difficulty in maintaining an airway during
anaesthesia, whether the child can or should be intubated, and
whether a spontaneously ventilating technique is required.
Sedative pre-medication should be avoided.
Intraoperatively: the method of anaesthesia depends on the
child, the degree of airway obstruction, and surgical and anaes-
thesia preference. Prior to induction, the surgeon should be
within the operating room, with equipment ready, in case the
airway becomes compromised. Classically a gas inhalational
induction has been used in children with a potentially obstruct-
ing airway lesion. A TIVA technique using propofol and remi-
fentanil titrated to maintain spontaneous ventilation is a possible
alternative in experienced hands. Anaesthetizing the airway with
topical local anaesthetic and maintaining an adequate depth of
anaesthesia is essential.
Endotracheal tubes specifically designed for use with laser are
not available in smaller sizes and there is a risk of airway fire
with standard tubes. Standard endotracheal tubes can be inserted
for laser surgery, removed prior to starting to use the laser and
then re-inserted. Some anaesthetists and surgeons prefer tech-
niques where the child is not intubated, but the airway is
insufflated with oxygen using the surgical laryngoscope.
Spontaneous ventilation is often preferred as high frequency jet
ventilation may cause seeding of papillomata within the airway,
or barotrauma. A child with severe obstruction is likely to need
initial intubation with a standard endotracheal tube, although
downsized to fit in the airway with the obstruction. A range of
endotracheal tube sizes and difficult airway equipment should be
available.9
Other standard laser precautions should be observed: the
child’s eyes should be taped shut and covered with moist gauze
pads. Any exposed facial hair on the child (e.g. eyebrows) should
be coated with aqueous lubricating jelly to make it non-
combustible. The operating theatre should be designated
a ‘laser-controlled area’ and warning signs placed at all entry
points. While the laser is in use, windows should be covered and
doors secured to prevent injury to passers by. All personnel in
the theatre should wear appropriate eye protection.
Extubation of these children should only occur once they
are awake, obeying commands and spontaneously ventilating.
Re-examination of the oropharynx to exclude further bleeding
and clearance of secretions can be undertaken prior to
extubation.
Postoperatively: the location and level of postoperative care
should have been determined preoperatively. Bleeding and
oedema are typically minimal after laser surgery and obstructive
symptoms often show immediate improvement. Children who
238 Ó 2012 Elsevier Ltd. All rights reserved.
 PAEDIATRICS

have had topical local anaesthetic to their airway should be kept
nil by mouth for 2 hours postoperatively. A perioperative management of patients with obstructive sleep apnea:
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ANAESTHESIA AND INTENSIVE CARE MEDICINE 13:5 239 Ó 2012 Elsevier Ltd. All rights reserved.