Donald Schwartz

An unusual cause of respiratory distress in a neonate.

* Abbreviations: PICU = : pediatric intensive care unit • MRI = : magnetic resonance imaging • OR = : operating room Congenital nasolacrimal duct obstruction with cystic extension into the nasopharynx (dacryocystocele) is a rare cause of respiratory distress in the neonate. We describe the pediatric intensive care unit (PICU) course of a newborn with this disorder who had severe distress and in whom the diagnosis was originally missed. A 20-day-old female infant was admitted to the PICU after several cyanotic episodes at home. The mother stated that the child was a noisy breather since birth but that over the past 3 days labored breathing, retractions, and “dusky spells” had developed. She denied episodes of apnea. The child was a full-term infant with Apgar scores of 4 and 9 who was noted in the delivery room to have snorting respirations and retractions. Physical examination was normal except for a 3-mm ecchymotic mass noted in the left medial canthus adjacent to the lacrimal duct. The child was observed in the neonatal intensive care unit where a direct laryngoscopy was normal. Her obstructive symptoms improved and she was discharged home on day 3. On admission to the PICU, her temperature was 99.3°F, her heart rate was 138 beats per …

Anesthetic management of the exit (ex utero intrapartum treatment) procedure

The EXIT (ex utero intrapartum treatment) procedure is used to maintain fetal-placental circulation during partial delivery of a fetus with a potentially life-threatening upper airway obstruction. We performed the EXIT procedure on a fetus with a large intra-oral cyst. Sevoflurane was used as the anesthetic because of its rapid titratability. Sevoflurane provided excellent maternal and fetal anesthesia. Modifications to previously described monitoring techniques for the EXIT procedure were also used.

Determining the accuracy of caudal needle placement in children: a comparison of the swoosh test and ultrasonography

Background:  The aim of the present study was to compare two confirmatory tests ‐ the ‘swoosh’ test (auscultation during caudal injection) and real time ultrasound imaging (both transverse 2D imaging and color flow Doppler imaging) in pediatric patients receiving a caudal epidural block.

Ultrasonography and Pediatric Caudals

Ultrasound is an important tool for performing pediatric regional blocks, including caudal blocks. We present a case in which the availability of ultrasound allowed us to proceed with a successful caudal block which we otherwise might have abandoned in an infant with difficult anatomy.

Early intravenous cannulation in children during sevoflurane induction.

Background : It has been shown that early placement of an intravenous line in children anesthetized with halothane is equally safe compared with later placement. Whether this is true of sevoflurane is not known.

Ultrasound and caudal blocks in children

SIR—We read, with much interest, the recent article by Roberts et al. (1), describing their experience using ultrasound to confirm proper placement of caudal blocks in children. We too have used ultrasound for caudal blocks and have found it to be particularly useful for teaching inexperienced resident anesthesiologists. We utilize the SonoSite TITAN ultrasound system (SonoSite Inc., Bothell, MA, USA) to teach caudals in the following way: after the induction of general anesthesia, the child is turned in the lateral position. The resident is asked to place a mark where they think a caudal puncture should be performed. The instructing anesthesiologist then performs an ultrasound examination, first in the transverse plane, starting at the tip of the coccyx and working up to the sacrum, pointing out landmarks. This is then repeated using the probe in the longitudinal plane. The resident then performs their own ultrasound examination and can determine how close to the sacral hiatus and cornua their original mark actually was. The patient then undergoes a sterile prep. Once the needle is advanced (we use 21 G regional needles or 20 G angiocaths) the ultrasound probe (after being placed in a sterile sheath) is positioned cephalad to the injection site in the transverse plane, at the approximate tip of the needle or angiocath. While an assistant listens for heart rate changes and notes ECG morphology, the caudal solution is injected in small increments. Dilatation of the caudal space and localized turbulence is noted on the ultrasound screen, confirming successful placement. We have also used the color mode to indicate the flow of fluid in the caudal space. Repeated ultrasound examinations have allowed us to recognize (and teach to our residents) relevant sacrococcygeal anatomy in children. Images over the coccyx (indicating too caudad a position) as well as the sacral cornua and hiatus (which we instruct should be the entry point of the caudal needle) are illustrated in Figures 1–3. Turbulence during injection can best be seen when the

Hyperkalemia and pyloric stenosis.

Children presenting with pyloric stenosis have hypochloremic metabolic alkalosis and their serum potassium levels are thought to be low or normal. We reviewed potassium levels in infants with pyloric stenosis. Thirty-six percent of patients with pyloric stenosis had increased serum potassium levels. We conclude that hyperkalemia may be more common in children with pyloric stenosis than previously thought.

Caudal block in a child with a sacral dimple utilizing ultrasonography

SIR—A dimple over the sacrum is considered a relative contraindication to a caudal block (1). While the defect may be an isolated finding, it might signal an underlying spinal abnormality. Spina bifida occulta is a common disorder of the spine, and complications from neuraxial anesthesia have been reported (2–4). These have involved spinal and epidural blocks, but there is little written about this condition and caudal blocks. We describe our management of a child with a sacral dimple in whom we placed a caudal block as an adjunct for penile surgery.

Analgesia for paediatric tonsillectomy and adenoidectomy with intramuscular clonidine.

Summary Background: After undergoing tonsillectomy and adenoidectomy (T&A), children may experience significant pain. Clonidine, an α2 agonist, exhibits significant analgesic properties. The current investigation sought to determine whether intramuscular (I.M.) clonidine would decrease pain in paediatric patients undergoing T&A.

A comparison of two concentrations of bupivacaine and adrenaline with and without fentanyl in paediatric inguinal herniorrhaphy.

This study was designed to determine whether administration of caudal bupivacaine with fentanyl would have any effect on analgesia in paediatric patients undergoing inguinal herniorrhaphy repair. Fifty‐six outpatient paediatric patients undergoing inguinal hernia repair were evaluated. Patients received, in a randomized manner, 1 ml·kg−1 of either bupivacaine 0.25% or 0.125% with or without fentanyl 1 μg·kg−1. There was no difference in pain scores in the hospital, the night of surgery, or 24 h postoperatively nor was there a difference in the oral analgesics administered between any of the groups. There was a higher incidence of vomiting at home in both 0.25% bupivacaine groups irrespective of the use of fentanyl. The 0.125% bupivacaine group had significantly more patients who received intravenous fentanyl in the PACU than did the other three groups (P<0.001). Increasing the concentration of bupivacaine from 0.125% to 0.25% increased the incidence of postoperative vomiting. We recommend that clinicians utilize bupivacaine 0.125% with 1 μg·kg−1 fentanyl as the caudal injectate in paediatric patients undergiong inguinal hernia repair.