• David M Polaner, Jeannie Zuk, Kristi Luong, and Zhaoxing Pan.
• Department of Anesthesia, The Children's Hospital, 13123 East 16th Ave., B090, Aurora, CO 80045, USA. polaner.david@tchden.org
• Anesth. Analg. 2010 Jan 1;110(1):41-5.

BackgroundThe 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.MethodsWe 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.ResultsAll 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.ConclusionsA 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.

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