Claude Abdallah

Perioperative chlorhexidine allergy: Is it serious?

Chlorhexidine is an antiseptic agent, commonly used, in many different preparations, and for multiple purposes. Despite its superior antimicrobial properties, chlorhexidine is a potentially allergenic substance. The following is a review of the current evidence-based knowledge of allergic reactions to chlorhexidine associated with surgical and interventional procedures.

Considerations in perioperative assessment of valproic acid coagulopathy

Valproic acid (VPA) is one of the widely prescribed antiepileptic drugs in children with multiple indications. VPA-induced coagulopathy may occur and constitute a pharmacological and practical challenge affecting pre-operative evaluation and management of patients receiving VPA therapy. This review summarizes the different studies documenting the incidence, severity and available recommendations related to this adverse effect.

Acute epiglottitis: Trends, diagnosis and management

Acute epiglottitis is a life-threatening disorder with serious implications to the anesthesiologist because of the potential for laryngospasm and irrevocable loss of the airway. Acute epiglottitis can occur at any age. Early diagnosis with careful and rapid intervention of this serious condition is necessary in order to avoid life-threatening complications.

Valproic acid and acquired coagulopathy.

1 Kaufmann J, Laschat M, Hellmich M et al. A randomized controlled comparison of the Bonfils fiberscope and the GlideScope Cobalt AVL video laryngoscope for visualization of the larynx and intubation of the trachea in infants and small children with normal airways. Pediatr Anesth 2013; doi:10.1111/ pan.12137. 2 Fiadjoe JE, Gurnaney H, Dalesio N et al. A prospective randomized equivalence trial of the GlideScope Cobalt video laryngoscope to traditional direct laryngoscopy in neonates and infants. Anesthesiology 2012; 116: 622–628.

Anesthesia for fucosidosis.

Fucosidosis is an extremely rare, autosomal recessive lysosomal storage disease, characterized by a deficiency of the lysosomal hydrolase alpha fucosidase. We report a case of a 6‐year‐old child, diagnosed with fucosidosis type 2, who presented for dental rehabilitation under general anesthesia. Anesthesia was uneventful. Features of fucosidosis are discussed

Dystonic reaction after Botox injection under nitrous oxide/oxygen and sevoflurane anesthesia.

old baby. The patient underwent a minor elective surgical procedure. Postoperatively they were completely anuric despite multiple i.v. fluid boluses. At 36 h postoperation a blood sample was sent for urea and electrolyte analysis. This revealed sodium 126 mM, potassium 7.2 mM, urea 11.2 mM, and creatinine 163 mM. An ultrasound scan at this time demonstrated bilateral hydronephrosis and dilated ureters. The bladder was not visualized. The patient was admitted to the PICU where conservative treatment for hyperkalemia consisted of nebulised salbutamol, bicarbonate infusion and i.v. calcium gluconate. The patient was listed for an emergency cystoscopy and insertion of nephrostomies. When we assessed the patient, who was now 48 h postoperation, serum potassium had risen to 7.7 mM. Clinical examination revealed them to be edematous but otherwise comfortable. The parents reported ‘jerky’ movements. The electrocardiogram (ECG) was normal. We were concerned that this acute hyperkalemia, secondary to an obstructive picture, had been unresponsive to what we considered sub-optimal medical management. The patient was at risk of cardiac arrhythmias especially if surgery resulted in a direct increase in the serum potassium. After consultation with the intensive care and renal physicians we decided to postpone surgery for 2 h while the patient was commenced on an insulin ⁄ dextrose infusion, salbutamol infusion, calcium resonium enema, and i.v. magnesium. This resulted in serum potassium of 7.1 mM. Peritoneal dialysis was not considered practical at this time. The patient was taken to theatre and anesthetized uneventfully with sevoflurane, fentanyl, and atracurium. The infusions were continued perioperatively. Despite this, the serum potassium increased to 7.7 mM. Within 2 h of completion of the surgery the serum potassium was within normal range. Over the next 6 h this was accompanied by a massive diuresis of 13 mlÆkgÆh. The patient’s renal function has now fully recovered. We share the observation that conservative treatment of hyperkalemia was disappointing but nevertheless needed to be optimized. This was important given that surgery appeared to contribute to a rise in the serum potassium. Bruce Neary Vesna Colovic Department of Paediatric Anaesthesia, Royal Manchester Children’s Hospital, Hospital Road, Pendlebury, Manchester M27 4HA, UK (email: docbruceter@hotmail.com)

Use of modified rapid sequence tracheal intubation in pediatric patients

Background: Rapid sequence intubation (RSI) has been an established practice, but is not without risks to patient. In different situations, a modification of the standard RSI technique may be more appropriate. The definition of a modified rapid sequence intubation (MRSI) is not well-documented. The purpose of this survey was to determine the working definition of MRSI as well as the modality of its use. Materials and Methods: This descriptive study consisted of a survey of pediatric anesthesiologists and included basic questions related to the anesthesiologists experience, practice setting and use of MRSI. Responses were compiled and analyzed to identify the working definition, technique, perceived indications/complications as well as hands-on performance of tracheal intubation during use of MRSI in children. Results: The mean ± SD years in practice of the 228 respondents were 14.9 ± 8.16 years, with pediatric patients comprising 77 ± 33% of their practice. 76.8% completed a fellowship in pediatric anesthesia. 60% of the respondents’ practice setting was at a Childrens Hospital. Different respondents agreed with different techniques of MRSI with the majority (65%) defining a MRSI as equivalent to a RSI, but with mask ventilation. The major indication of use of a MRSI was a concern about apnea time tolerance with traditional RSI (74%). Conclusion: Technique of a MRSI varies among pediatric care providers.

MR-compatible pumps versus manual titration of propofol for pediatric sedation

This study aimed to review the use of two methods of propofol infusion: a metred burette system where propofol is diluted in Lactated Ringer using the rule of six [[1]] or an infusion pump: Medrad Continuum Magnetic resonance (MR) compatible Infusion System (Medrad Inc. Indianola, PA) and to determine the difference, if any, between the total amount of drug delivered, the impact on vital signs, sedation status and discharge time of the patients. With Institutional Review Board (IRB) approval, 140 children aged 0 to 18 years, American Society of Anesthesiologists (ASA) physical status I or II requiring sedation for elective outpatient brain Magnetic Resonance Imaging (MRI) examination were included in the study. A total of 70 patients in each group were studied. The (Mean ± S.D.) total amount of propofol infused was significantly less in the infusion pump group (12.47 ± 7.67 mg/kg) than the metred burette system (15.84 ± 16.13 mg/kg, p = 0.003). There were also significant mean differences in awakening times (26.63 ± 16.35 vs. 37.06 ± 20.98 min, p = 0.006), and discharge times (53.46 ± 21.12 vs. 67.89 ± 26.84 min, p = 0.008) in the infusion pump group versus the buretrol infusion group. This study demonstrates that both infusion techniques preserve haemodynamic stability and are associated with minimal complications. The use of an infusion pump, which consistently maintains accurate dosing, reduces the amount of propofol judged adequate by the anaesthesiologist to achieve sedation in MRI. This leads to a more consistently faster emergence and early discharge after sedation in children undergoing MRI studies.