Edmond C. Bloch

The Case for Immediate Pyeloplasty in the Neonate with Ureteropelvic Junction Obstruction

The 99mtechnetium-diethylenetriaminepentaacetic acid renal scan allows differentiation of ureteropelvic junction obstruction from multicystic kidney in most instances. Although renal function usually will improve at least a little after relief of obstruction, the young infant is privileged and more improvement can be expected than occurs usually in older children. Since an operation is as safe and results of pyeloplasty are as good in the neonate as in older infants or children early correction of ureteropelvic junction obstruction is advocated in otherwise healthy infants as soon as the diagnosis is established.

Limb tourniquets and central temperature in anesthetized children.

We have observed an association between the use of tourniquets for limb surgery and a progressive increase in body temperature in pediatric patients. Consequently, we evaluated the effect of leg tourniquet(s) on intraoperative nasopharyngeal temperature in pediatric patients. We measured central temperature in three groups of children anesthetized with halothane and nitrous oxide: those with unilateral tourniquets (n = 15), those with bilateral tourniquets (n = 8), and a control group not requiring tourniquets (n = 24). Intraoperative ambient temperatures were maintained near 23 degrees C, respiratory gases were actively heated and humidified, and skin was warmed using a circulating water blanket set at 38 degrees C. The control patients remained normothermic during anesthesia and surgery. In contrast, central temperature increased 1.0 +/- 0.6 degrees C in 90 min in those with one tourniquet and 1.7 +/- 0.6 degrees C in those with bilateral tourniquets. The tourniquet-induced hyperthermia appeared to result from decreased effective heat loss from distal skin and from constraint of metabolic heat to the central thermal compartment. These data suggest that pediatric patients requiring intraoperative tourniquets should not be aggressively warmed during surgery.

Tracheal intubation in children: a new method for assuring correct depth of tube placement

Airway mismanagement is a major factor responsible for morbidity and mortality in pediatric anesthesia. One of the most feared complications is accidental intraoperative tracheal extubation in a paralyzed patient receiving controlled ventilation. Less potentially catastrophic, but nevertheless undesirable, is unrecognized bronchial intubation. Accurate placement of the endotracheal tube (ETT) to a predetermined depth is thus of prime importance. After the head has been positioned for the operation, the tip of the ETT should, in our opinion, be located 2.0 cm above the carina in the neonate, infant, and young child. In children approaching 5 to 6 years of age, this distance may be increased to 3.0 cm. We want to be as sure as possible that the tip of the ETT lies a safe distance above the carina and well below the vocal cords. We describe a simple and effective clinical method for achieving this in pediatric patients.

A thin fiberoptic bronchoscope as an aid to occlusion of the fistula in infants with tracheoesophageal fistula

The survival rate of otherwise healthy term neonates with esophageal atresia and distal tracheoesophageal fistula (EA/TEF) now approaches loo%, but morbidity and mortality remain high when there are associated major congenital anomalies, especially those related to the heart, or when pulmonary complications ensue (1). We (2) and others (3) have reported the use of a Fogarty balloon catheter for temporary occlusion of the fistula to allow recovery from respiratory insufficiency before any surgical correction of the EA/TEF is undertaken. We describe an illustrative case in which we found a new thin fiberoptic bronchoscope (diameter 2.0 mm) helpful in placing the Fogarty balloon catheter in the fistula via the stomach at the time of gastrostomy.

The esophageal temperature gradient in anesthetized children

Objective. Our objective was to study the effect of the temperature of the anesthetic gas mixture (AGM) on esophageal temperature measurements made in children whose tracheas had been intubated for anesthesia. We also sought to establish the optimal site for the temperature sensor in the esophagus and to find a way to accurately place the sensor.Methods. Special esophageal temperature probes with thermistors located at 1-cm intervals were used for data collection on a multiplex system. Esophageal temperature measurements were made every 15 minutes for a period of 120 minutes in anesthetized children receiving heated (n=30) and unheated (n=30) anesthetic gases.Results. The temperature of the AGM (p<0.001), the site of measurement (p<0.001), and the interaction between AGM temperature and site of measurement (p<0.007) all had a significant effect on esophageal temperature measurements. This effect was greatest at a point 3 cm distal to the level of the tip of the endotracheal tube when AGMs were not heated.Conclusion. We conclude that best results are obtained when care is taken to place the thermistor in the lower quarter of the esophagus. (We provide a simple formula for calculating this placement in pediatric patients of varying ages.) Placing the probe by acoustic criteria cannot consistently be relied on to provide good thermometry.Objective. Our objective was to study the effect of the temperature of the anesthetic gas mixture (AGM) on esophageal temperature measurements made in children whose tracheas had been intubated for anesthesia. We also sought to establish the optimal site for the temperature sensor in the esophagus and to find a way to accurately place the sensor.Methods. Special esophageal temperature probes with thermistors located at 1-cm intervals were used for data collection on a multiplex system. Esophageal temperature measurements were made every 15 minutes for a period of 120 minutes in anesthetized children receiving heated (n=30) and unheated (n=30) anesthetic gases.Results. The temperature of the AGM (p<0.001), the site of measurement (p<0.001), and the interaction between AGM temperature and site of measurement (p<0.007) all had a significant effect on esophageal temperature measurements. This effect was greatest at a point 3 cm distal to the level of the tip of the endotracheal tube when AGMs were not heated.Conclusion. We conclude that best results are obtained when care is taken to place the thermistor in the lower quarter of the esophagus. (We provide a simple formula for calculating this placement in pediatric patients of varying ages.) Placing the probe by acoustic criteria cannot consistently be relied on to provide good thermometry.

Anaesthesia and the Kearns‐Sayre syndrome

A six‐month‐old infant presented for anaesthesia with, unbeknown to us, some of the manifestations of the Kearns‐Sayre Syndrome. This syndrome is one of the clinical presentations in patients with mitochondral myopathy. The anaesthetic related events and aspects of mitochondral myopathy are described and caveats are suggested for the management of anaesthesia for patients with this type of myopathy.

Update on anesthesia management for infants and children.

This review aims at providing the pediatric surgeon with an update on the most important issues in pediatric anesthesia and the changes that have taken place over the last few years. Many practices, entrenched in tradition, are being modified in the light of research that has provided new knowledge, drugs, and techniques. Pediatric anesthesia requires dedication, a sense of anticipation, meticulous attention to detail, and an individual who derives enormous satisfaction from the pleasure to be had from dealing with these small patients and their families.

The Esophageal Temperature Gradient in Anesthetized Children

OBJECTIVE Our objective was to study the effect of the temperature of the anesthetic gas mixture (AGM) on esophageal temperature measurements made in children whose tracheas had been intubated for anesthesia. We also sought to establish the optimal site for the temperature sensor in the esophagus and to find a way to accurately place the sensor. METHODS Special esophageal temperature probes with thermistors located at 1-cm intervals were used for data collection on a multiplex system. Esophageal temperature measurements were made every 15 minutes for a period of 120 minutes in anesthetized children receiving heated (n = 30) and unheated (n = 30) anesthetic gases. RESULTS The temperature of the AGM (p < 0.001), the site of measurement (p < 0.001), and the interaction between AGM temperature and site of measurement (p < 0.007) all had a significant effect on esophageal temperature measurements. This effect was greatest at a point 3 cm distal to the level of the tip of the endotracheal tube when AGMs were not heated. CONCLUSION We conclude that best results are obtained when care is taken to place the thermistor in the lower quarter of the esophagus. (We provide a simple formula for calculating this placement in pediatric patients of varying ages.) Placing the probe by acoustic criteria cannot consistently be relied on to provide good thermometry.