Eric A. Harris

Endotracheal tube malposition within the pediatric population: a common event despite clinical evidence of correct placement.

Purpose: To ensure that the endotracheal tube (ETT) is ideally placed for proper ventilation, radiographic confirmation of ETT placement is frequently used to supplement clinical examination in the intensive care unit setting. However, fluoroscopy rarely serves the same role during surgery, despite the fact that portable units are often present in the operating room. The purpose of this study was to ascertain the value of fluoroscopy in determining ETT malposition among the pediatric surgical population.Methods: Chest radiographs from 257 children (age 12 days- 12 yr), who presented for a total of 446 individual procedures in the fluoroscopy suite, were studied to determine the incidence of ETTs placed too shallow (above the inferior clavicular border) or too deep (at or below the carina). A logistic regression with outcomes of correct and incorrect was used to analyze the data points.Results: Eighteen percent of all the radiographs showed initial improper ETT placement, despite clinical evidence suggesting the contrary. The peak incidence of malposition, which occurred in patients under one year old, reached 35%. Incidence decreased with advancing age, but remained over 10% until the age of ten. A second attempt at positioning the tube, based on information from the chest radiograph, was successful in 95% of the cases. The remaining 5% required placement of the ETT under continuous fluoroscopic guidance.Conclusion: Fluoroscopy, when readily available in the operating room, is a safe and useful technique to ensure proper ETT placement among the pediatric population.RésuméObjectif: Lorsqu’on veut s’assurer que le tube endotrachéal est adéquatement placée pour une bonne ventilation, la confirmation radiographique du positionnement du tube est souvent utilisée pour complémenter l’examen clinique dans l’unité des soins intensifs. Cependant, il est rare que la fluoroscopie joue le même rôle pendant la chirurgie, malgré le fait que des unités portables soient souvent à disposition dans la salle d’opération. L’objectif de cette étude était de confirmer la valeur de la fluoroscopie pour détecter le mauvais positionnement du tube endotrachéal chez des patients de chirurgie pédiatriques.Méthode: Les radiographies du thorax de 257 enfants (âgés de 12 jours à 12 ans) qui ont subi un total de 446 interventions individuelles dans la salle de fluoroscopie, ont été étudiées afin de déterminer l’incidence de tubes endotrachéaux positionnées au dessus de la ligne claviculaire (pas assez profond) ou à ou au dessous de la carène (trop profond). Une analyse par régression logistique avec le binôme correct / incorrect a été utilisée pour évaluer les points de données.Résultats: Au total, 18 % des radiographie ont montré un positionnement initialement inadéquat du tube endotrachéal, malgré le fait que les données cliniques suggéraient le contraire. L’incidence maximale de mauvais positionnement, qui a été observée chez les patients de moins d’un an, a atteint 35 %. L’incidence diminuait avec l’âge, mais demeurait au dessus de 10 % jusqu’à dix ans. Une deuxième tentative de positionnement de la sonde sur la base des informations tirées de la radiographie du thorax, a été réussie dans 95 % des cas. Les 5 % restants ont nécessité un positionnement de la sonde endotrachéale sous monitorage fluoroscopique continu.Conclusion: Lorsqu’elle est à portée de main dans la salle d’opération, la fluoroscopie est une technique sécuritaire et utile pour s’assurer du positionnement correct du tube endotrachéal dans une population pédiatrique.

Sedation and Anesthesia Options for Pediatric Patients in the Radiation Oncology Suite

External beam radiation therapy (XRT) has become one of the cornerstones in the management of pediatric oncology cases. While the procedure itself is painless, the anxiety it causes may necessitate the provision of sedation or anesthesia for the patient. This review paper will briefly review the XRT procedure itself so that the anesthesia provider has an understanding of what is occurring during the simulation and treatment phases. We will then examine several currently used regimens for the provision of pediatric sedation in the XRT suite as well as a discussion of when and how general anesthesia should be performed if deemed necessary. Standards of care with respect to patient monitoring will be addressed. We will conclude with a survey of the developing field of radiation-based therapy administered outside of the XRT suite.

Monitored anesthesia care (MAC) sedation: clinical utility of fospropofol

Fospropofol, a phosphorylated prodrug version of the popular induction agent propofol, is hydrolyzed in vivo to release active propofol, formaldehyde, and phosphate. Pharmacodynamic studies show fospropofol provides clinically useful sedation and EEG/bispectral index suppression while causing significantly less respiratory depression than propofol. Pain at the injection site, a common complaint with propofol, was not reported with fospropofol; the major patient complaint was transitory perianal itching during the drug’s administration. Although many clinicians believe fospropofol can safely be given by a registered nurse, the FDA mandated that fospropofol, like propofol, must be used only in the presence of a trained anesthesia provider.

Does the Site of Anterior Tracheal Puncture Affect the Success Rate of Retrograde Intubation? A Prospective, Manikin-Based Study

Background. Retrograde intubation is useful for obtaining endotracheal access when direct laryngoscopy proves difficult. The technique is a practical option in the “cannot intubate / can ventilate” scenario. However, it is equally useful as an elective technique in awake patients with anticipated difficult airways. Many practitioners report difficulty successfully advancing the endotracheal tube due to anatomical obstructions and the acute angle of the anterograde guide. The purpose of this study was to test whether a more caudal tracheal puncture would increase the success rate. Methods. Twenty-four anesthesiology residents were randomly assigned to either a cricothyroid or a cricotracheal puncture group. Each was instructed how to perform the technique and then attempted it on a manikin at their assigned site. Data collection included whether the trachea was intubated, the number of attempts required, and the total time. Results. Both groups displayed a high degree of success. While the group assigned to the cricotracheal site required significantly more time to perform the procedure, they accomplished it in fewer attempts than the cricothyroid group. Conclusion. Retrograde intubation performed via a cricotracheal puncture site, while more time consuming, resulted in fewer attempts to advance the endotracheal tube and may reduce in vivo laryngeal trauma.

A matrix model for valuing anesthesia service with the resource-based relative value system

Background The purpose of this study was to propose a new crosswalk using the resource-based relative value system (RBRVS) that preserves the time unit component of the anesthesia service and disaggregates anesthesia billing into component parts (preoperative evaluation, intraoperative management, and postoperative evaluation). The study was designed as an observational chart and billing data review of current and proposed payments, in the setting of a preoperative holing area, intraoperative suite, and post anesthesia care unit. In total, 1,195 charts of American Society of Anesthesiology (ASA) physical status 1 through 5 patients were reviewed. No direct patient interventions were undertaken. Results Spearman correlations between the proposed RBRVS billing matrix payments and the current ASA relative value guide methodology payments were strong (r=0.94–0.96, P<0.001 for training, test, and overall). The proposed RBRVS-based billing matrix yielded payments that were 3.0%±1.34% less than would have been expected from commercial insurers, using standard rates for commercial ASA relative value units and RBRVS relative value units. Compared with current Medicare reimbursement under the ASA relative value guide, reimbursement would almost double when converting to an RBRVS billing model. The greatest increases in Medicare reimbursement between the current system and proposed billing model occurred as anesthetic management complexity increased. Conclusion The new crosswalk correlates with existing evaluation and management and intensive care medicine codes in an essentially revenue neutral manner when applied to the market-based rates of commercial insurers. The new system more highly values delivery of care to more complex patients undergoing more complex surgery and better represents the true value of anesthetic case management.

Letter to the Editor regarding 'Autonomic cardio-respiratory reflex reactions and superselective ophthalmic arterial chemotherapy for retinoblastoma' by Phillips, McGuirk, Chahal, et al.

Pediatric Anesthesia would report a similar spread of names and characteristics initially described in the syndrome by Pierre Robin in 1934 (3,4). We contend that Treacher Collins syndrome is a distinct group of infants with phenotypically consistent features including mandibular hypoplasia and, in some individuals, upper airway obstruction. In contrast to the other syndromes in our series, where the body of the mandible was markedly hypoplastic, the mandible of patients with TCS is well documented to be morphologically different in shape and configuration. This premise is supported by a number of recent publications (5) and has implications for the long-term anesthetic and surgical management of these challenging patients. The mandibular deformity in Treacher Collins syndrome is characterized as hypoplastic with a deep antegonial notch (6). The ramus is short with a consequently steep mandibular and occlusal plane, usually resulting in an anterior open bite deformity. Chung used 3D CT reconstructions and found that the mandibular body length was significantly shorter in children with Pierre Robin sequence, whereas ramus height was relatively reduced in height for children with Treacher Collins syndrome (7). The surgical implication is that both ramal and mandibular body bony structures must be increased when attempting to normalize the Treacher Collins syndrome morphology in the pursuit of the best esthetic and functional outcome. Drs Breugems and deGraaff noted ‘that even in the Robin sequence with or without a syndrome, different causes might influence the airway obstruction, including glossoptosis, skull base anomalies, pharyngeal hypotonia, nasal constriction, or central nervous system impairment’. We concur with these comments, however, that the multiple airway anomalies and multilevel origin in Treacher Collins syndrome (TCS) have been well recognized, and this impacts on their management and reinforces the need to distinguish TCS from Pierre Robin sequence (8).

Trigeminocardiac Reflex after Direct Infusion of Chemotherapy into the Ophthalmic Artery for Retinoblastoma

Introduction: Direct intra-ophthalmic artery infusion of chemotherapy has emerged as a front-line treatment modality for both early and advanced forms of retinoblastoma. The procedure has become common practice for neurointerventionalists at institutions with major ophthalmology centers. We present a case series of patients who manifest an autonomic reaction of acute hypoxemia, hypocapnia, hypotension, and bronchospasm consistent with trigeminocardiac reflex. We report our experience with this reaction, which is commonly seen during pediatric strabismus surgery but until now, rarely seen in the neuroangiography suite. Methods: We retrospectively reviewed our 5-year experience with intra-ophthalmic artery chemotherapy infusion for retinoblastoma. Procedure notes, anesthetic records, patient characteristics, and chemotherapeutic agents used were reviewed. Results: Over a 5-year period, 199 treatment sessions were performed in 49 patients. Twenty-eight TCR events were observed in 18 patients. Twenty-seven of these were quickly terminated following interruption of chemotherapy infusion, ventilatory support, and administration of pressor agents. In one case the procedure was aborted due to the prolonged duration of the reflex. There were no permanent sequelae. Conclusions: We found an appreciable incidence of trigeminocardiac reflex to intra-ophthalmic artery infusion of chemotherapy in patients with retinoblastoma. Both interventionalists and anesthesiologists should be aware of this potential event and be prepared to provide immediate resuscitative measures.

Fospropofol Disodium Injection: A Review of its Use as a Sedative-hypnotic Agent for Monitored Anesthesia Care (MAC) Sedation in Adult Patients Undergoing Diagnostic or Therapeutic Procedures

Fospropofol, a phosphorylated prodrug version of the popular induction agent propofol, is hydrolyzed in vivo to release active propofol, formaldehyde, and phosphate. Pharmacodynamic studies show fospropofol provides clinically useful sedation and EEG/BIS suppression while causing significantly less respiratory depression than propofol. Pain at the injection site, a common complaint with propofol, was not reported with fospropofol; the major patient complaint was transitory perianal itching during the drug’s administration. Although many clinicians believe fospropofol can safely be given by a registered nurse, the FDA mandated that fospropofol, like propofol, must be used only in the presence of a trained anesthesia provider.