Anaesthesiology Intensive Therapy, 2010,XLII,3; 160-166 AAA

Guidelines for safe paediatric anaesthesia of the Committee on Quality and Safety in Anaesthesia, Polish Society of Anaesthesiology and Intensive Therapy
*Andrzej Piotrowski

• Fig. 1. Algorithm of anaesthesia maintenance with sevoflurane after volatile or intravenous induction in children

• Table 1. Assessment of post-anaesthesia recovery according to Steward classification The safety of procedures has always been a priority in anaesthesiology. Relevance of this issue is emphasized in the document announced recently during the latest congress of the European Society of Anaesthesiology called Helsinki Declaration on Patient Safety in Anaesthesiology [1]. For paediatric anaesthesia the fundamental question is whether it can be safely performed in general hospitals or rather in specialist paediatric hospitals. The answer is simple – each anaesthesia and surgery in a child under 16 years of age should be administered in paediatric centres, with recovery and postoperative surveillance rooms, optimally with ITUs. Unfortunately, such requirements are not feasible to be met and many children >10 years of age, even >6 years are anaesthetized in general hospitals. The Act issued by the Minister of Health on November 10, 2006 (law gazette no 06.213.1568, later changed into 08.30.187), states that children should always stay in separate wards (those <3 years separated from older children) and in rooms with suitable equipment. In many cases, these are small wards of multi-profile hospitals; therefore, it is essential that all anaesthesiologists have appropriate trainings in anaesthesia for developmental age patients. According to the Federation of European Societies of Paediatric Anaesthesia (FEAPA), currently the European Society for Paediatric Anaesthesia (ESPA), such trainings, lasting about 3 months, should be carried out in a multi-profile paediatric hospital [2]. During the trainings, anaesthesiologists should anaesthetize unaided at least 10 infants <1 year, 20 aged 1-3 years and 60 aged 3-10 years. Poland still lacks such requirements although the training in paediatric anaesthesia, compulsory to specialize, is to be lengthened. Moreover, supplementary trainings in paediatric anaesthesia, every several years (preferably every 5 years) are considered. In the majority of cases, surgical procedures in children are performed under general anaesthesia. The preparation for anaesthesia and surgery includes first contacts of a child and parents with an anaesthesiologist, whose role at this stage is extremely important and goes well beyond assessing the

• kidney diseases. The advances in this field are associated with the introduction of “one-day surgery” (80% of procedures in children in the United States). tachycardia). which is related to physiological anaemia in children and better monitoring during anaesthesia. During the visit. The anaesthesia-related risk of death in children was not completely eliminated. preferably in the ambulatory setting at the clinic of anaesthesiology. Furthermore. laboratory tests can be completely abandoned [4]. the “anaesthetic questionnaire” is useful. • history of anaemia or polycytheamia. For this purpose. the anaesthetic visit is necessary before anaesthesia. searching for symptoms such as fatigue. easy fatigue. Its relevant element is the conversation with parents to obtain information concerning past diseases. such events are usually associated with insufficient blood saturation resulting from improper lung ventilation. state of nutrition. Additional data are provided by the inspection of the throat. • symptoms suggestive of anaemia (dyspnoea. checking test results or prescribing premedication. once informed about the type of . PREPARATIONS FOR ANAESTHESIA Hospital stay is associated with great stress and can adversely affect the development of a child regressing it even by several “steps”. Children often sustain critical events during relatively simple procedures. its incidence for scheduled procedures is 1:20 000 – 1:40 000 of anaesthesias [5]. cyanosis. the child is mainly inspected. Moreover. the plans regarding the child should not be concealed from him/her. cough.58 mmol L-1. procedures or intraoperative deaths in the family (possible cause –malignant hyperthermia). chemotherapy or radiation therapy. malnutrition. In order not to miss any important existing disease or risk. 5. additionally. dyspnoea. The information gathered and knowledge about the type of surgery justify ordering additional tests. with negative medical history. parental presence. The current indications for preoperative haemoglobin determinations are as follows: • surgery with anticipated high or medium blood loss. etc. • history of blood neoplasm. and exclusively oral premedication. blood re-sampling is not necessary. lower safe values of haemoglobin are permissible. The degree of risk is mainly assessed according to the ASA classification of physical status. The anaesthesia risk increases in cases of additional conditions and in emergent procedures. and anaesthesia induced in the presence of parents [3]. the majority of information can be obtained without palpation. mental and pharmacological preparation before anaesthesia as well as postoperative pain management. liver failure. In children in good general status aged >6 months. hypertension. if necessary.physical status. If haemoglobin or haemotocrit was determined within the last 3 months and the general state of a child has not changed. toys ought to be available. to humanize the hospital stay. behaviour and physical efficiency. auscultation of the heart and lungs. a limited number of laboratory tests. i. The essential factors reducing this stress include shortening the stay to a minimum. compared to the recommendations of the late 20th century. Parents. The basic activities include getting to know the body structure. who should also be present as soon as possible after surgery.e. the EMLA cream before catheterization of vessels.

e. Diazepam. Extremely anxious and uncooperative children may receive midazolam sublingually 0. this time is 6-8 h. anxiety. Children (similarly to adults) react to operative stress with hyperglycaemia. can also be used 0.05 mg kg-1. for liquids (including milk) – 6 h (4 h for breast milk). the interval from the latest feeding to the procedure can be that long [6].02-0. such as glucose or tea.2-0. This route can also be used for ketamine. yet this is associated with higher incidences of dizziness. To reduce the incidence of these unpleasant incidents. The blood glucose level ought to be checked. nausea and vomiting.8 mL kg-1 [6]. pain or severe general state of a child can markedly and unpredictably delay gastric emptying. the morning dose of insulin is omitted and during anaesthesia. every 3 h.9% NaCl.25-0. Diazepam is available in tablets and as a suspension. FASTING TIME An important element of safe anaesthesia is the appropriately long fasting period. hydrocortisone 1 mg kg-1 is administered on induction of anaesthesia and every 6 h until drugs can be taken orally [15]. 9] and incidence of complications after anaesthesia [10].anaesthesia and its typical course. After surgery.g. e. have the chance to ask questions and then are obliged to sign their written consent for anaesthesia. characterized by longer action.g. are administered. Surgeries in diabetic children should be performed first in a series of scheduled procedures. preferably as “one-day surgeries”. The time from the latest meal should correspond to the time of gastric emptying. This anxiety should be prevented by administering drugs.3 mg kg-1 or ketamine 3 mg kg-1 [12.g. 60 min before surgery [14]. neutral fluids. 13]. in steroid hormone therapy. Premedication is administered orally and includes mainly benzodiazepines – midazolam 0. Patients above 16 years of age additionally sign such consents.4 mg kg-1 [11]. This drug should also be used in children <4 years of age undergoing volatile induction of anaesthesia and when muscle relaxation is provided with suxamethonium. 0. a typical protocol of insulin therapy and oral food supply should be returned to. During extensive procedures in children with unstable diabetes. Nasal supply is also possible although less pleasant [9]. if an infant receives natural food regularly. which also decreases the requirements for anaesthetics [8. For clear liquids. 0. Midazolam or diazepam can be supplemented with oral morphine 0.5 mg kg-1 used 30 min before wheeling to the operating room. Chewing gum and its effects on gastric emptying have not been fully elucidated yet it is generally known that this habit can increase the volume of residual gastric fluid and increase pH [7]. Before anaesthesia. The regularity of feeding is also considered – e. In such cases. the volume of gastric fluid should not exceed 0. Postoperative vomiting occurs in about 20% of all anaesthetized children. according to more recent studies.4 mL kg-1. in premedication for children <1 year. On the other hand. if their extent permits. For solid foods. antiemetic drugs are recommended in premedication. midazolam is administered in tablets or as a liquid directly from an ampoule or mixed with juice or syrup. ondansetron. the infusion of glucose and short-acting .4 mg kg-1 (which is not beneficial in cases of early discharge). the interval from drinking (50 mL) to the procedure should be 2 h. SPECIAL SITUATIONS Children with asthma should receive routine oral and volatile drugs in the morning before the procedure. Additionally. oral atropine is needed 0. PREMEDICATION Some children seem to be brave during the preoperative visit yet are extremely anxious on the day of surgery.

A relevant element of safety of this management is to preserve the child’s spontaneous breathing during induction without imposing control ventilation. INDUCTION OF ANAESTHESIA A. Thanks to that. In the period of 3-7 days after vaccination. For this purpose. During total volatile anaesthesia. • a precordial stethoscope. determinations of the level of volatile anaesthetics in the inhaled and exhaled air are strongly recommended. the risk of undetected circulatory depression is avoided. During induction and maintenance of inhalation anaesthesia. • ECG and the respiration curve. In children with upper respiratory tract infections. if the child’s spontaneous breathing is preserved. anaesthesias and scheduled procedures should be withheld due to possible post-vaccination reactions. especially when surgery is performed urgently or emergently. an efficient pulse oximeter with the plethysmographic curve is essential. depression which is always preceded by markedly shallow breathing followed by apnoea. it is advised to postpone scheduled procedures for about 7 days [15]. the circle breathing system should be replaced with the paediatric one. the remaining elements of monitoring are necessary in the immediate postoperative period. The device provides reliable readings of saturation even in fidgety children. This last . various respiratory disturbances are likely to develop – cough. is higher. Except for capnometry. • non–invasive arterial blood pressure. semi-closed systems with absorbers and transparent facial masks are currently used. Volatile induction. shallow respiration (decreased tidal volume) or even apnoea. children suffering from a common cold without fever >38o C.insulin should be started simultaneously with the induction of anaesthesia and continued monitoring the level of glucose. Such an induction and maintenance of anaesthesia belong to the oldest anaesthetic methods. the incidence of anaesthesia-related complications. On the other hand. • capnometry. without auscultatory changes over the lung fields and in good general state should not be disqualified. even up to 4 weeks after the disease. However. acid-base balance and electrolytes in blood. such as laryngospasm. In paediatric anaesthesia. • body temperature. At body weight <20 kg. monitoring can be limited to ECG and pulse oximetry. bronchospasm or apnoea with decreased blood saturation. MONITORING The basic monitoring includes: • Pulse oximetry and concentration of oxygen supplied (oximetry).

also in infusions [17]. • using transparent masks.5 mg kg-1. propofol is used. is a relatively simple and convenient method. if patents are calm). ketamine is also extremely useful. yet its action can be substantially prolonged by administering opioids or barbiturates. Propofol. changes of dressings in patients with burns. respiratory failure) and for short procedures. • making the mask smelling nice by applying a suitable oil or cooking essence (e. To relieve the pain during administration. Ketamine acts about 15-30 min. The complications discussed are relatively common in infants. not only due to its lack of depressive circulatory effects but also possible intramuscular. the concentration of sevoflurane should not exceed 6% and it should be administered in the respiratory gas mixture of the flow: O2 – 2 L min-1 and N2O – 4 L min-1. Unlike barbiturates. the agent containing medium-chain triglyceryde (MCT) failed in reducing injection-related pain [16]. it is recommended to precede it with atropine. e. reduces the blood pressure and slows down the heart rate. Intravenous induction. B. Inhalation induction of general anaesthesia may also be carried out before the intravenous access has been prepared. the child’s breathing should be meticulously observed.g. strawberryor lemon-scented). which may be additionally facilitated by: • leaving the child dressed (for many small children undressing is extremely stressful). like thiopentone. if possible. lidocaine should be added. Therefore. it is an excellent agent preparing for regional anaesthesia. Propofol is a short acting anaesthetic used in the dose of 2. if performed by an experienced anaesthesiologist. In younger children the flow of fresh gases ought to be suitably lower.5 – 2 mg kg-1 in older children.5 – 3.g. The routine intravenous dose is 2 mg kg-1. However. for postoperative pain management. Inhalation induction cannot be performed with desflurane and isoflurane due to their irritating smell causing cough and choking. Moreover. in children aged >3 years. due to increased saliva secretion. or abandoning their use in favour of free gas flow over the child’s face or using a hand as a funnel. bone marrow biopsy or abscess incision. overlapping of . After the loss of ciliary reflex. airway patency disorders can be easily eliminated by the placement of the oropharyngeal tube. Thiopentone is most useful for such an induction (in the average dose of 5 mg kg-1. Two techniques of volatile induction are used – slowly increasing the concentration of an anaesthetic – every 2 breaths by 1% or rapid-sequence induction using high concentrations and only a few breaths (even one). maximum sterility has to be provided and the open ampoule should be used within the period <6 h. Since the solution does not contain the bacteriostatic agent and microorganisms are likely to develop in the lipid environment. and obviously because of minimal depression of breathing (unless administered too quickly). in infants – 7 mg kg-1). and sounds warning about the development of airway obstruction listened to (snoring. Propofol-Lipuro. It may be additionally facilitated when the EMLA cream is applied 45-60 min before the procedure over one or two most likely places of intravenous access. Ketamine is particularly useful in children in severe conditions (shock. In paediatric anaesthesia. Moreover. or O2 – 3 L min-1 and air – 3 L min-1. Intravenous induction in children is safe and convenient. it has some antiemetic properties. Inhalation induction. it prevents sudden pressure increases during intubation and enables smooth placement of the laryngeal mask. however. oral or rectal administration. • parental presence during induction (holding a child on his/her lap. Gradual induction is safer. whizzes). in children below 10 years of age and 1.phenomenon is associated not only with depression of the respiratory centre but also with relaxation of pharyngeal and laryngeal muscles (obstructive apnoea).

21]. providing good conditions for intubation already after 50 sec in infants and 60 sec in children. in patients with normal function of this enzyme.5 mg kg-1 for older children. Compared to the intubation tube.25 mg kg-1 (its action starts after 90 sec. the laryngeal mask may be sufficient (lower risk of laryngeal oedema and stridor). and in those with full stomach.2 mg kg-1 enables intubation within 40 sec since the injection of the agent [19]. for short intravenous anaesthesias in otolaryngology. malignant hyperthermia and hyperkalemia.). Remifentanil in children is safe if administered in infusions (e. Volatile agents alone – mainly sevoflurane at the concentration of at least 2. which is likely to manifest as skin redness and reduced arterial pressure.g. respectively) seems beneficial. Rocuronium administered in the dose of 0. In children. the use of this anaesthetic does not ensure 100% safety! The combination of ketamine and propofol (0. Prior to endotracheal intubation. moreover. spontaneous breathing returns quickly – after 4 min. Mivacurium releases histamine similarly to atracurium. The block induced with rocuronium or vecuronium may be reversed using sugammadex 4 – 16 mg kg-1 depending on the interval from the administration of a relaxant. For children >6 years of age or younger and for oropharyngeal procedures. The dose of 1. after burns. those bedridden for a long time. Complete muscle relaxation is achieved most quickly – already after 40 sec. cis-atracurium or rocuronium are more useful for muscle relaxation. mivacurium is most useful. . In neonates. the patient should be suitably oxygenated to reach the blood saturation of at least 96-98%. 0. intubation tubes with sealing cuffs should be used. The intubation tube diameter is tailored according to the formula: (mm) = (age in years/4) + 4 mm. For longer procedures (30-60 min). the laryngeal mask may also be placed at light anaesthesia. the relaxing effect maintains for 10-14 min. 0. Thus. This agent is broken down by plasma cholinesterase. e. Due to the risk of bradycardia. suxamethonium is successfully used – 2 mg kg-1 for children <2 years and 1-1. It is also beneficial in procedures lasting >1 h.action of several agents in the immediate postoperative period may be dangerous. In other cases. cardiology and paediatric orthopaedic surgery.g.5-1 mg kg-1 and 1-2 mg kg-1. atropine premedication is important. decreased saturation develops much quickly than in adults. In general. Suxamethonium should not be administered to patients with neuromuscular diseases (dystrophies).6 mg kg-1 produces neuromuscular blockage for about 40 min. For short procedures. The use of suxamethonium is associated with the risk of cluster seizures with subsequent muscle pains (not occurring in children <6 years of age). neostigmine to reverse the block is not required. Endotracheal intubation in children can also be performed with propofol 3-4 mg kg-1 in combination with remifentanil 3 µg kg-1 [20. the procedure is performed after the administration of a muscle relaxant.2 µg kg-1 min-1) and not in a single dose. oeosophagoscopy or gastroscopy. which may induce bradycardia and thoracic rigidity [20]. and with crushing syndromes. when difficult intubation is anticipated.7%. those in lateral recumbent and prone positions as well as in neck and nasopharyngeal procedures. The depth of intubation through the mouth is usually: (cm) = tube diameter (mm) x 3. The supply of opioids before intubation should be generally limited due to frequent difficulties in artificial lung ventilation caused by the thoracic rigidity mentioned. atracurium. ENDOTRACHEAL INTUBATION Endotracheal intubation is particularly recommended in children <1 year of age due to higher risks of upper airway obstruction. may be used for endotracheal intubation [18]. vecuronium.

However.015 mg kg-1 and neostigmine 0. fentanyl should not be administered within the final 30 min of anaesthesia and aminophylline or theophylline (5 mg kg-1) ought to be used to stimulate the respiratory centre [24]. After the mask placement. In the majority of cases. fentanyl 1-5 µg kg-1 or sufentanil 1 µg kg-1 is used. at the expense of analgesic effects. MAINTENANCE OF ANAESTHESIA General anaesthesia can be successfully maintained with halogenated volatile agents: isoflurane (12%). their placement is possible under light (compared to intubation) anaesthesia.g. Furthermore. They are particularly recommended for procedures <1 h.5 µg kg-1 min-1 should be applied.06 mg kg-1. rather permits to limit its concentration. The symptoms of agitation can be treated with iv midazolam or ketamine [22. which is associated with low values of blood-gas solubility coefficients. except for those within the thorax. neostigmine is routine management. they do not fully protect against aspiration of gastric contents to the lungs. BLOCK ANAESTHESIA . despite the mentioned activities and subsidence of relaxant effects. optimally pre-emptive one. After the completion of procedure.LARYNGEAL MASKS In children with ASA I and II physical status. block analgesia or supply of opioids) and by avoiding the sevoflurane concentrations >6 %. due to compliance of the respiratory system and dead space. The use of volatile anaesthetics is also connected with lower risk of postoperative respiratory depression compared to opioids. The addition of N2O in the concentration of 50-70% facilitates anaesthesia and ensures smoother recovery. cranial or oral cavity. alfentanil in the initial dose of 7-20 µg kg-1 or remifentanil in infusion 0. isoflurane and sevoflurane is associated with higher incidences of agitation in the postoperative period compared to already historic halothane. Good local analgesia should be provided or early. laryngeal masks are the basic devices during unanticipated difficult intubation and can be used for cardio-pulmonary resuscitation. capnographic monitoring is necessary). the supply of opioids does not exclude the use of a volatile agent. Muscle relaxants are not required. Agitation may be partially prevented by providing effective analgesia by the end of the procedure and in the postoperative period (e. control mode of ventilation is carried out with the frequency according to the child’s age and tidal volume of about 6 mL kg-1 (or higher. sevoflurane (2-3%) or desflurane (5-9%). They offer good control of anaesthesia as their brain concentration can be quickly increased or decreased. neuromuscular blockage subsides spontaneously by the end of anaesthesia. especially by physicians with short-term experience in intubation. Opioids are indispensible elements of anaesthesia for painful procedures. To avoid such a situation. the commonly met problem is the return of efficient breathing of the patient. During the procedure. it is recommended to provide control/assist ventilation of the lungs and to avoid leaving the spontaneously breathing patients.03-0. abdomen. The block should be reversed using atropine 0. if not. In most cases. This is particularly relevant when the procedure duration is difficult to anticipate. 23]. For shorter procedures. laryngeal masks are safe and easy to apply devices securing patent airways during some surgeries and diagnostic procedures. volatile agents should be early withdrawn. Generally. The use of desflurane. Naloxone should be given to children whose breathing does not return. The ProSeal mask provides better tightness of airways compared to classical masks.

The optimal fluid is the preparation containing sodium ions in the concentration of at least 130 mmol L-1.This kind of analgesia is increasingly common in children. e. .9% NaCl solution. heart rate. administered medially from the anterior superior iliac spine – particularly useful for inguinal hernia repairs or retained testis procedures. • epidural block from the sacral access using 0. FLUID SUPPLY In procedures lasting >30 min and those in children at risk of high blood loss or postoperative vomiting (retained testis surgery. • subarachnoid block. The typical dose of 0. • during next hours – 6 mL kg-1 h-1 for minor.4-0. vomiting. especially recommended for phimosis procedures (adrenaline should be avoided due to the risk of ischaemia and necrosis).25% bupivacaine in the dose ≤0. the range of monitoring of vital functions must be the same as during anaesthesia.5 mg kg-1. respiration and saturation monitored. apnoea. especially that reduced arterial pressure and headaches are less common in children than in adults. Ringer’s solution or Ringer’s lactate. strabotomy. Vital parameters should be recorded every 15 min. Ilioinguinal and iliohypogastric blocks can be performed by the surgeon before wound suturing during hernia repairs and retained testis surgeries.25% bupivacaine. bleeding from the wound and pain are likely to develop.and postoperative complications. • block of the dorsal nerve of the penis – e. Another dosage formula is 0. The anaesthesiologist should be within reach (the recovery room must be adjacent to the operative theatre or ITU). by circular injections of the penis base (circular block) using 0. Injections of the wound with 0. tonsillectomy). POSTOPERATIVE CARE In the postoperative period. The most widely used blocks include: • block of the ilioinguinal and iliohypogastric nerve using 0.5 – 1 mg kg-1 by the end of the procedure is also an effective way to provide postoperative analgesia. Fluids should not contain glucose to avoid the risk of hyperglycaemia.25% bupivacaine 1 mL kg-1. ideal for anaesthesia for all procedures performed in the region innervated by the branches originating from Th10 – S5. also under ambulatory conditions. During this period.5% bupivacaine 2 mg kg-1.1 mL kg-1 + 0. 8 mL kg-1 h-1 for moderate and 10 mL kg-1 h1 for major surgical trauma.1 mL (dead space of the needle). which is likely to cause higher number of intra. This method is recommended in infants with bronchopulmonary dysplasia to avoid intubation. 0.5% bupivacaine for urological procedures is 0. The child should be continuously observed.g.g. Fluids should be transfused according to the following principle: • during the first hour of procedure – supplementation of fluids in the amount of 25 mL kg-1 in children ≤3 years and 15 mL kg-1 in children >4 years. fluids must be transfused.

. Morphine 0..... The general status of the patient after anaesthesia is assessed according to the Steward classification.. A randomized controlled trial... Kain Z Mayes LC. Lisa A. • ability to move suitably to the age. children scored 6 are candidates for hospital discharge. htpp://www. 3... Marszałek A.. Brock-Utne JG: Acid aspiration in primates: a surprising experimental ... De Lange S: The European Union of Medical Specialists and specialty training.2 mg kg-1 at 2-4 h intervals is recommended for surgeries that are more painful........... DISCHARGE FROM A RECOVERY ROOM The relevant factors. Paediatr Anaesth 1998......euroanaesthesia. 31: 181-196..... Rimar S: Parental presence during induction of anesthesia.......10... 8: 11-15..... Caramico LA.... Meneghini L.. Int Anesthesiol Clinics 1993.. REFERENCES 1.......Pain after less extensive procedures is usually managed with paracetamol 20 mg kg-1... The physician should decide about discharge personally after inspecting the patient.....ogr/sitecore/content/Publications/Helsinki%20Declaration... After ambulatory procedures... ... Zadra N............. Baiocchi M.... • efficient breathing of the frequency typical of a given age. tramadol 2 mg kg-1 (beware of vomiting !).... Giusti F : The usefulness of routine preoperative laboratory tests for one-day surgery in healthy children.................... Nygren M... Helsinki Declaration on patent safety in anaesthesiology.. Anesthesiology 1996..aspx. 2. Spieker M.... 6........ the child may be discharged once the following is fulfilled: • stability and full normalization of basic vital parameters... 18: 561-562.. Silver D.... Eichhorn JH: Effect of monitoring standards on anesthesia outcome. Anderson G.. 5...... Eur J Anaesthesiol 2001.. 84: 1060-1067... SpO2 >95% without oxygen therapy.. 4..... • consciousness and contact in the range similar to that before anaesthesia.. which should be considered while taking the decision about discharge to the setting where monitoring is not accessible include: • return of consciousness and stabilization of basic vital functions... and in children >3 years of age – metamizol 4 mg kg-1.... • no nausea and vomiting... Zanette G........... Raidoo DM..

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. Chowdary K: Ketamine is effective in decreasing the incidence of emergence agitation in children undergoing dental repair under sevoflurane general anesthesia..... Abu-Shahwan I........................ Johnson CM: Postoperative apnoea in infants. Anaesth Intensive Care 1994....pl .23.......... Paediatr Anaesth 2007......... 24.................................... ................ 22: 40-45............17:846-850.............. 91-738 Łódź tel.....: 42-617 77 40 fax: 42-617 79 89 e-mail: andrzej-oiom@wp............ Address: *Andrzej Piotrowski Oddział Kliniczny Intensywnej Terapii i Anestezjologii II Katedra Pediatrii Uniwerystet Medyczny w Łodzi ul.... Sims C. Sporna 36/50..................