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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

physical status, checking test results or prescribing premedication. 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. The essential factors reducing this stress include shortening the stay to a minimum, parental presence, mental and pharmacological preparation before anaesthesia as well as postoperative pain management. Furthermore, to humanize the hospital stay, the plans regarding the child should not be concealed from him/her, and anaesthesia induced in the presence of parents [3], who should also be present as soon as possible after surgery; additionally, toys ought to be available. The advances in this field are associated with the introduction of one-day surgery (80% of procedures in children in the United States), the EMLA cream before catheterization of vessels, a limited number of laboratory tests, and exclusively oral premedication. In children in good general status aged >6 months, with negative medical history, laboratory tests can be completely abandoned [4]. The current indications for preoperative haemoglobin determinations are as follows: surgery with anticipated high or medium blood loss, history of blood neoplasm, chemotherapy or radiation therapy, symptoms suggestive of anaemia (dyspnoea, easy fatigue, tachycardia), history of anaemia or polycytheamia, kidney diseases, hypertension, liver failure, malnutrition. If haemoglobin or haemotocrit was determined within the last 3 months and the general state of a child has not changed, blood re-sampling is not necessary. Moreover, compared to the recommendations of the late 20th century, lower safe values of haemoglobin are permissible, i.e. 5.58 mmol L-1, which is related to physiological anaemia in children and better monitoring during anaesthesia. The anaesthesia-related risk of death in children was not completely eliminated; its incidence for scheduled procedures is 1:20 000 1:40 000 of anaesthesias [5]. Children often sustain critical events during relatively simple procedures; such events are usually associated with insufficient blood saturation resulting from improper lung ventilation. The anaesthesia risk increases in cases of additional conditions and in emergent procedures. The degree of risk is mainly assessed according to the ASA classification of physical status. In order not to miss any important existing disease or risk, the anaesthetic visit is necessary before anaesthesia, preferably in the ambulatory setting at the clinic of anaesthesiology. Its relevant element is the conversation with parents to obtain information concerning past diseases, procedures or intraoperative deaths in the family (possible cause malignant hyperthermia). For this purpose, the anaesthetic questionnaire is useful. During the visit, the child is mainly inspected; the majority of information can be obtained without palpation. The basic activities include getting to know the body structure, state of nutrition, behaviour and physical efficiency, searching for symptoms such as fatigue, cough, cyanosis, dyspnoea, etc. Additional data are provided by the inspection of the throat, auscultation of the heart and lungs. The information gathered and knowledge about the type of surgery justify ordering additional tests, if necessary. Parents, once informed about the type of

anaesthesia and its typical course, have the chance to ask questions and then are obliged to sign their written consent for anaesthesia. Patients above 16 years of age additionally sign such consents. FASTING TIME An important element of safe anaesthesia is the appropriately long fasting period. Before anaesthesia, the volume of gastric fluid should not exceed 0.4 mL kg-1; according to more recent studies, 0.8 mL kg-1 [6]. The time from the latest meal should correspond to the time of gastric emptying. For solid foods, this time is 6-8 h, for liquids (including milk) 6 h (4 h for breast milk). For clear liquids, such as glucose or tea, the interval from drinking (50 mL) to the procedure should be 2 h. The regularity of feeding is also considered e.g. if an infant receives natural food regularly, every 3 h, the interval from the latest feeding to the procedure can be that long [6]. On the other hand, anxiety, pain or severe general state of a child can markedly and unpredictably delay gastric emptying. 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]. PREMEDICATION Some children seem to be brave during the preoperative visit yet are extremely anxious on the day of surgery. This anxiety should be prevented by administering drugs, which also decreases the requirements for anaesthetics [8, 9] and incidence of complications after anaesthesia [10]. Premedication is administered orally and includes mainly benzodiazepines midazolam 0.5 mg kg-1 used 30 min before wheeling to the operating room. Diazepam, characterized by longer action, can also be used 0.25-0.4 mg kg-1 (which is not beneficial in cases of early discharge). Diazepam is available in tablets and as a suspension; midazolam is administered in tablets or as a liquid directly from an ampoule or mixed with juice or syrup. Extremely anxious and uncooperative children may receive midazolam sublingually 0.2-0.4 mg kg-1 [11]. Nasal supply is also possible although less pleasant [9]. This route can also be used for ketamine. Additionally, in premedication for children <1 year, oral atropine is needed 0.02-0.05 mg kg-1. 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. Midazolam or diazepam can be supplemented with oral morphine 0.3 mg kg-1 or ketamine 3 mg kg-1 [12, 13], yet this is associated with higher incidences of dizziness, nausea and vomiting. Postoperative vomiting occurs in about 20% of all anaesthetized children. To reduce the incidence of these unpleasant incidents, antiemetic drugs are recommended in premedication, e.g. ondansetron, 60 min before surgery [14]. SPECIAL SITUATIONS Children with asthma should receive routine oral and volatile drugs in the morning before the procedure; in steroid hormone therapy, hydrocortisone 1 mg kg-1 is administered on induction of anaesthesia and every 6 h until drugs can be taken orally [15]. Surgeries in diabetic children should be performed first in a series of scheduled procedures, preferably as one-day surgeries, if their extent permits. In such cases, the morning dose of insulin is omitted and during anaesthesia, neutral fluids, e.g. 0.9% NaCl, are administered. The blood glucose level ought to be checked. Children (similarly to adults) react to operative stress with hyperglycaemia. After surgery, a typical protocol of insulin therapy and oral food supply should be returned to. During extensive procedures in children with unstable diabetes, the infusion of glucose and short-acting

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

phenomenon is associated not only with depression of the respiratory centre but also with relaxation of pharyngeal and laryngeal muscles (obstructive apnoea). Therefore, the childs breathing should be meticulously observed, and sounds warning about the development of airway obstruction listened to (snoring, whizzes). The complications discussed are relatively common in infants. After the loss of ciliary reflex, airway patency disorders can be easily eliminated by the placement of the oropharyngeal tube. 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). Gradual induction is safer; if possible, 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, or O2 3 L min-1 and air 3 L min-1. In younger children the flow of fresh gases ought to be suitably lower. Inhalation induction cannot be performed with desflurane and isoflurane due to their irritating smell causing cough and choking. Inhalation induction, if performed by an experienced anaesthesiologist, is a relatively simple and convenient method, which may be additionally facilitated by: leaving the child dressed (for many small children undressing is extremely stressful), parental presence during induction (holding a child on his/her lap, if patents are calm), using transparent masks, or abandoning their use in favour of free gas flow over the childs face or using a hand as a funnel, making the mask smelling nice by applying a suitable oil or cooking essence (e.g. strawberryor lemon-scented). Inhalation induction of general anaesthesia may also be carried out before the intravenous access has been prepared. B. Intravenous induction. Intravenous induction in children is safe and convenient. 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. Thiopentone is most useful for such an induction (in the average dose of 5 mg kg-1, in infants 7 mg kg-1), in children aged >3 years, propofol is used. Propofol is a short acting anaesthetic used in the dose of 2.5 3.5 mg kg-1, in children below 10 years of age and 1.5 2 mg kg-1 in older children. To relieve the pain during administration, lidocaine should be added. Propofol-Lipuro, the agent containing medium-chain triglyceryde (MCT) failed in reducing injection-related pain [16]. Propofol, like thiopentone, reduces the blood pressure and slows down the heart rate. Unlike barbiturates, however, it prevents sudden pressure increases during intubation and enables smooth placement of the laryngeal mask. Moreover, it has some antiemetic properties. Since the solution does not contain the bacteriostatic agent and microorganisms are likely to develop in the lipid environment, maximum sterility has to be provided and the open ampoule should be used within the period <6 h. In paediatric anaesthesia, ketamine is also extremely useful, not only due to its lack of depressive circulatory effects but also possible intramuscular, oral or rectal administration, and obviously because of minimal depression of breathing (unless administered too quickly). The routine intravenous dose is 2 mg kg-1; due to increased saliva secretion, it is recommended to precede it with atropine. Ketamine is particularly useful in children in severe conditions (shock, respiratory failure) and for short procedures, e.g. changes of dressings in patients with burns, bone marrow biopsy or abscess incision. Moreover, it is an excellent agent preparing for regional anaesthesia, for postoperative pain management, also in infusions [17]. Ketamine acts about 15-30 min, yet its action can be substantially prolonged by administering opioids or barbiturates. However, overlapping of

action of several agents in the immediate postoperative period may be dangerous. Thus, the use of this anaesthetic does not ensure 100% safety! The combination of ketamine and propofol (0.5-1 mg kg-1 and 1-2 mg kg-1, respectively) seems beneficial, e.g. for short intravenous anaesthesias in otolaryngology, cardiology and paediatric orthopaedic surgery. ENDOTRACHEAL INTUBATION Endotracheal intubation is particularly recommended in children <1 year of age due to higher risks of upper airway obstruction. It is also beneficial in procedures lasting >1 h, those in lateral recumbent and prone positions as well as in neck and nasopharyngeal procedures, oeosophagoscopy or gastroscopy. In other cases, the laryngeal mask may be sufficient (lower risk of laryngeal oedema and stridor). Compared to the intubation tube, the laryngeal mask may also be placed at light anaesthesia. Volatile agents alone mainly sevoflurane at the concentration of at least 2.7%, may be used for endotracheal intubation [18]. In general, the procedure is performed after the administration of a muscle relaxant. For short procedures, mivacurium is most useful, 0.25 mg kg-1 (its action starts after 90 sec.), the relaxing effect maintains for 10-14 min. This agent is broken down by plasma cholinesterase; in patients with normal function of this enzyme, neostigmine to reverse the block is not required. Mivacurium releases histamine similarly to atracurium, which is likely to manifest as skin redness and reduced arterial pressure. For longer procedures (30-60 min), vecuronium, atracurium, cis-atracurium or rocuronium are more useful for muscle relaxation. Rocuronium administered in the dose of 0.6 mg kg-1 produces neuromuscular blockage for about 40 min, providing good conditions for intubation already after 50 sec in infants and 60 sec in children. The dose of 1.2 mg kg-1 enables intubation within 40 sec since the injection of the agent [19]. 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. In neonates, when difficult intubation is anticipated, and in those with full stomach, suxamethonium is successfully used 2 mg kg-1 for children <2 years and 1-1.5 mg kg-1 for older children. Complete muscle relaxation is achieved most quickly already after 40 sec; moreover, spontaneous breathing returns quickly after 4 min. Due to the risk of bradycardia, atropine premedication is important. The use of suxamethonium is associated with the risk of cluster seizures with subsequent muscle pains (not occurring in children <6 years of age), malignant hyperthermia and hyperkalemia. Suxamethonium should not be administered to patients with neuromuscular diseases (dystrophies), those bedridden for a long time, after burns, and with crushing syndromes. Endotracheal intubation in children can also be performed with propofol 3-4 mg kg-1 in combination with remifentanil 3 g kg-1 [20, 21]. Remifentanil in children is safe if administered in infusions (e.g. 0.2 g kg-1 min-1) and not in a single dose, which may induce bradycardia and thoracic rigidity [20]. The supply of opioids before intubation should be generally limited due to frequent difficulties in artificial lung ventilation caused by the thoracic rigidity mentioned. Prior to endotracheal intubation, the patient should be suitably oxygenated to reach the blood saturation of at least 96-98%. In children, decreased saturation develops much quickly than in adults. For children >6 years of age or younger and for oropharyngeal procedures, 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. The depth of intubation through the mouth is usually: (cm) = tube diameter (mm) x 3.

LARYNGEAL MASKS In children with ASA I and II physical status, laryngeal masks are safe and easy to apply devices securing patent airways during some surgeries and diagnostic procedures, except for those within the thorax, abdomen, cranial or oral cavity. They are particularly recommended for procedures <1 h. However, they do not fully protect against aspiration of gastric contents to the lungs. Muscle relaxants are not required; their placement is possible under light (compared to intubation) anaesthesia. The ProSeal mask provides better tightness of airways compared to classical masks. Furthermore, laryngeal masks are the basic devices during unanticipated difficult intubation and can be used for cardio-pulmonary resuscitation, especially by physicians with short-term experience in intubation. After the mask placement, it is recommended to provide control/assist ventilation of the lungs and to avoid leaving the spontaneously breathing patients. MAINTENANCE OF ANAESTHESIA General anaesthesia can be successfully maintained with halogenated volatile agents: isoflurane (12%), sevoflurane (2-3%) or desflurane (5-9%). They offer good control of anaesthesia as their brain concentration can be quickly increased or decreased, which is associated with low values of blood-gas solubility coefficients. This is particularly relevant when the procedure duration is difficult to anticipate. The use of volatile anaesthetics is also connected with lower risk of postoperative respiratory depression compared to opioids, at the expense of analgesic effects. Good local analgesia should be provided or early, optimally pre-emptive one. The addition of N2O in the concentration of 50-70% facilitates anaesthesia and ensures smoother recovery. During the procedure, control mode of ventilation is carried out with the frequency according to the childs age and tidal volume of about 6 mL kg-1 (or higher; due to compliance of the respiratory system and dead space, capnographic monitoring is necessary). The use of desflurane, isoflurane and sevoflurane is associated with higher incidences of agitation in the postoperative period compared to already historic halothane. Agitation may be partially prevented by providing effective analgesia by the end of the procedure and in the postoperative period (e.g. block analgesia or supply of opioids) and by avoiding the sevoflurane concentrations >6 %. The symptoms of agitation can be treated with iv midazolam or ketamine [22, 23]. Opioids are indispensible elements of anaesthesia for painful procedures. In most cases, fentanyl 1-5 g kg-1 or sufentanil 1 g kg-1 is used. For shorter procedures, alfentanil in the initial dose of 7-20 g kg-1 or remifentanil in infusion 0.03-0.5 g kg-1 min-1 should be applied. Generally, the supply of opioids does not exclude the use of a volatile agent, rather permits to limit its concentration. After the completion of procedure, the commonly met problem is the return of efficient breathing of the patient. To avoid such a situation, volatile agents should be early withdrawn, 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]. Naloxone should be given to children whose breathing does not return, despite the mentioned activities and subsidence of relaxant effects. In the majority of cases, neuromuscular blockage subsides spontaneously by the end of anaesthesia; if not, neostigmine is routine management. The block should be reversed using atropine 0.015 mg kg-1 and neostigmine 0.06 mg kg-1. BLOCK ANAESTHESIA

This kind of analgesia is increasingly common in children, also under ambulatory conditions. The most widely used blocks include: block of the ilioinguinal and iliohypogastric nerve using 0.5% bupivacaine 2 mg kg-1, administered medially from the anterior superior iliac spine particularly useful for inguinal hernia repairs or retained testis procedures; block of the dorsal nerve of the penis e.g. by circular injections of the penis base (circular block) using 0.25% bupivacaine, especially recommended for phimosis procedures (adrenaline should be avoided due to the risk of ischaemia and necrosis); subarachnoid block, especially that reduced arterial pressure and headaches are less common in children than in adults. This method is recommended in infants with bronchopulmonary dysplasia to avoid intubation. The typical dose of 0.5% bupivacaine for urological procedures is 0.4-0.5 mg kg-1. Another dosage formula is 0.1 mL kg-1 + 0.1 mL (dead space of the needle); epidural block from the sacral access using 0.25% bupivacaine 1 mL kg-1, ideal for anaesthesia for all procedures performed in the region innervated by the branches originating from Th10 S5. Ilioinguinal and iliohypogastric blocks can be performed by the surgeon before wound suturing during hernia repairs and retained testis surgeries. Injections of the wound with 0.25% bupivacaine in the dose 0.5 1 mg kg-1 by the end of the procedure is also an effective way to provide postoperative analgesia. FLUID SUPPLY In procedures lasting >30 min and those in children at risk of high blood loss or postoperative vomiting (retained testis surgery, strabotomy, tonsillectomy), fluids must be transfused. Fluids should not contain glucose to avoid the risk of hyperglycaemia, which is likely to cause higher number of intra- and postoperative complications. The optimal fluid is the preparation containing sodium ions in the concentration of at least 130 mmol L-1, e.g. 0.9% NaCl solution, Ringers solution or Ringers lactate. 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; during next hours 6 mL kg-1 h-1 for minor, 8 mL kg-1 h-1 for moderate and 10 mL kg-1 h1 for major surgical trauma. POSTOPERATIVE CARE In the postoperative period, the range of monitoring of vital functions must be the same as during anaesthesia. The child should be continuously observed, heart rate, respiration and saturation monitored. Vital parameters should be recorded every 15 min. During this period, apnoea, vomiting, bleeding from the wound and pain are likely to develop. The anaesthesiologist should be within reach (the recovery room must be adjacent to the operative theatre or ITU).

Pain after less extensive procedures is usually managed with paracetamol 20 mg kg-1, tramadol 2 mg kg-1 (beware of vomiting !), and in children >3 years of age metamizol 4 mg kg-1. Morphine 0.10.2 mg kg-1 at 2-4 h intervals is recommended for surgeries that are more painful. DISCHARGE FROM A RECOVERY ROOM The relevant factors, 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; efficient breathing of the frequency typical of a given age, SpO2 >95% without oxygen therapy. The physician should decide about discharge personally after inspecting the patient. After ambulatory procedures, the child may be discharged once the following is fulfilled: stability and full normalization of basic vital parameters; consciousness and contact in the range similar to that before anaesthesia; ability to move suitably to the age; no nausea and vomiting. The general status of the patient after anaesthesia is assessed according to the Steward classification; children scored 6 are candidates for hospital discharge. .............................................................................................................................................................. REFERENCES 1. Helsinki Declaration on patent safety in anaesthesiology, htpp://www.euroanaesthesia.ogr/sitecore/content/Publications/Helsinki%20Declaration.aspx. 2. De Lange S: The European Union of Medical Specialists and specialty training. Eur J Anaesthesiol 2001; 18: 561-562. 3. Kain Z Mayes LC, Caramico LA, Lisa A, Silver D, Spieker M, Nygren M, Anderson G, Rimar S: Parental presence during induction of anesthesia. A randomized controlled trial. Anesthesiology 1996; 84: 1060-1067. 4. Meneghini L, Zadra N, Zanette G, Baiocchi M, Giusti F : The usefulness of routine preoperative laboratory tests for one-day surgery in healthy children. Paediatr Anaesth 1998; 8: 11-15. 5. Eichhorn JH: Effect of monitoring standards on anesthesia outcome. Int Anesthesiol Clinics 1993; 31: 181-196. 6. Raidoo DM, Marszaek A, Brock-Utne JG: Acid aspiration in primates: a surprising experimental

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