Hee-Soo Kim

Head rotation, flexion, and extension alter endotracheal tube position in adults and children

PurposeThe purpose of this study was to evaluate the effect of head rotation in adults and children on endotracheal tube (ETT) position and to confirm previous results regarding the influence of head flexion and extension on ETT position.MethodsAfter inducing anesthesia in 24 young adults and 22 children (aged 1–9xa0yr), ETTs were secured on the right corner of each of their mouths. Using a fiberoptic bronchoscope, the distance from the carina to the tip of the ETT was measured with each patient’s head and neck placed in a neutral position, flexed, extended, rotated to the right, and rotated to the left.ResultsIn all patients, flexing the head resulted in the ETT moving towards the carina, and extension resulted in the tube being displaced in the opposite direction. In adults, head rotation to the right resulted in withdrawal of the ETT in all but one patient; displacement was 0.8xa0±xa00.5xa0cm (meanxa0±xa0SD) (Pxa0<xa00.001). Head rotation to the left resulted in the endotracheal tube being displaced in an unpredictable direction by 0.1xa0±xa00.6xa0cm. In children, head rotation to the right resulted in withdrawal of the ETT in all patients; displacement was 1.1xa0±xa00.6xa0cm (Pxa0<xa00.001). Head rotation to the left also resulted in partial withdrawal in all patients; displacement measured 0.6xa0±xa00.4xa0cm (Pxa0<xa00.001).ConclusionsIn adult patients under general anesthesia, head rotation towards the side of ETT fixation resulted in partial withdrawal of the tube tip away from the carina, whereas head rotation to the opposite side displaced the tube in an unpredictable manner. In children, head rotation to either side resulted in withdrawal of the ETT away from the carina.RésuméObjectifL’objectif de cette étude était d’évaluer l’effet de la rotation de la tête chez l’adulte et l’enfant sur le positionnement de la sonde endotrachéale et de confirmer les résultats précédents concernant l’influence de la flexion et de l’extension de la tête.MéthodeAprèsxa0l’induction de l’anesthésie chez 24 jeunes adultes et 22 enfants (âgés de 1 à 9 ans), les sondes endotrachéales ont été fixées au coin droit de leurs bouches. À l’aide d’un bronchoscope à fibre optique, la distance entre la carène et le bout de la sonde a été mesurée avec la tête et le cou de chaque patient positionnés de façon neutre, en flexion, en extension, tournés vers la droite et tournés vers la gauche.RésultatsChez tous les patients, la flexion de la tête a provoqué le mouvement de la sonde endotrachéale vers la carène, et l’extension a provoqué le déplacement de la sonde dans la direction opposée. La rotation de la tête vers la droite a provoqué le retrait de la sonde chez tous les patients adultes, sauf un; le déplacement était de 0,8xa0±xa00,5xa0cm (moyennexa0±xa0ET) (Pxa0<xa00,001). La rotation de la tête vers la gauche a provoqué un déplacement de la sonde de 0,1xa0±xa00,6xa0cm dans une direction imprévisible. Chez les enfants, la rotation de la tête vers la droite a provoqué le retrait de la sonde chez tous les patients; le déplacement était de 1,1xa0±xa00,6xa0cm (Pxa0<xa00,001). La rotation de la tête vers la gauche a également provoqué un retrait partiel de la sonde chez tous les patients; le déplacement était de 0,6xa0±xa00,4xa0cm (Pxa0<xa00,001).ConclusionChez les patients adultes sous anesthésie générale, la rotation de la tête vers le côté où la sonde était fixée a provoqué un retrait partiel de la pointe de la sonde par rapport à la carène, alors que la rotation dans la direction opposée a provoqué un déplacement de la sonde dans une direction imprévisible. Chez les enfants, la rotation de la tête de part et d’autre a provoqué un retrait de la sonde endotrachéale par rapport à la carène.

Shunt Dependency in Shunted Arachnoid Cyst: A Reason to Avoid Shunting

Cystoperitoneal (CP) shunting is minimally invasive and achieves a high rate of resolution on neuroimaging. However, in the absence of definite symptoms, shunting should be reconsidered, because some patients can experience shunt dependency after CP shunting. In this study, the risk of shunt dependency in patients with arachnoid cysts treated with CP shunting and the management of these patients are described. Eight patients (7 boys and 1 girl) were diagnosed as shunt dependent following CP shunting. At the time of the first operation (mean age at first shunting 6.1 years, range 1–11 years), a causal relationship between symptoms and the arachnoid cyst was evident in only 2 cases. Clinical manifestations, neuroimaging (computed tomography and/or magnetic resonance imaging) and intracranial pressure (ICP) data were reviewed retrospectively. The mean age of the patients at the time of shunt dependency was 9.8 years (range 6–13 years), and the mean time between the first shunt operation and shunt dependency was 41 months (range 17–80 months). Although neuroimaging demonstrated a collapsed cyst and small ventricles in most patients, ICP monitoring revealed significant intracranial hypertension. The release of shunt ligation, revision or additional shunting, such as ventriculoperitoneal shunting or lumboperitoneal shunting, resulted in the complete resolution of symptoms except in one patient who lost vision. This study shows that shunt dependency after CP shunting is a real problem and requires more attention. ICP monitoring can demonstrate the presence of intracranial hypertension when clinical and radiological analyses do not.

Encephaloduroarteriosynangiosis with bifrontal encephalogaleo(periosteal)synangiosis in the pediatric moyamoya disease: the surgical technique and its outcomes

MethodsTo increase the blood flow of the anterior cerebral artery (ACA) and the middle cerebral artery (MCA) territories, we modified the ribbon procedure in combination with encephaloduroarteriosynangiosis (EDAS). This is referred to as EDAS with bifrontal encephalogaleo(periosteal)synangiosis (EGS). The surgical technique, clinical outcomes, complications, extent of revascularization, and changes in CBF in 67 pediatric MMD patients were retrospectively reviewed.ResultsThe excellent and good clinical recovery rates were 57% and 31%. The rate for complete disappearance of TIA was 63%. All the bifrontal EGS made abundant collateral vessels in the ACA territory. When the EDAS with bifrontal EGS was performed in the first operation, collaterals of EGS sites developed more on the contralateral side of the EDAS. The arachnoid opening of the medial frontal lobe in the EGS site had no effect on the results. There was a positive correlation between the clinical outcome and the extent of angiographic revascularization. Improvements in the CBF and the reserve in ACA territory were observed in 57%.ConclusionsEDAS with bifrontal EGS resulted in excellent revascularization in both the MCA and ACA territories. The clinical and hemodynamic results were also excellent. This procedure may be an effective and safe surgical modality for the prevention of ischemia in the whole territory of the anterior circulation of the brain in pediatric MMD.

The Effect of Cardioplegic Solution-Induced Sodium Concentration Fluctuation on Postoperative Seizure in Pediatric Cardiac Patients

BACKGROUNDnDespite potential benefits of histidine-tryptophan-ketoglutarate (HTK) solution as a cardioplegic solution, it can cause hyponatremia, especially in pediatric patients. Fluctuations in the sodium concentration during cardiopulmonary bypass (CPB) can adversely affect the central nervous system. We evaluated the relationship between the cardioplegic solution, the fluctuation of sodium concentration, and the incidence of postoperative seizure in pediatric cardiac patients.nnnMETHODSnThe medical records of 628 patients were reviewed for the occurrence of a postoperative seizure, type of cardioplegic solution (HTK or del Nido solution), and intraoperative data. A change of sodium concentration exceeding 15 mmol/L (ΔNa>15) during CPB was defined as a significant fluctuation of sodium concentration.nnnRESULTSnPostoperative seizures were detected in 18 patients (2.9%). The ΔNa>15 was detected in 63 of 189 patients (33.3%) who received the HTK solution and in 14 of 439 patients (3.2%) who received the del Nido solution (p<0.001). The incidence of ΔNa>15 was strongly associated with postoperative seizure (odds ratio, 6.3; 95% confidence interval, 2.4 to 16.4, p=0.001). After adjusting for potential confounders, the ΔNa>15 remained significantly associated with postoperative seizure (odds ratio, 3.9; 95% confidence interval, 1.3 to 12.3, p=0.018).nnnCONCLUSIONSnHistidine-tryptophan-ketoglutarate solution during CPB frequently causes fluctuations of sodium concentration, usually combined with hyponatremia, which is associated with postoperative seizure. Special attention to sodium concentration is required, particularly when HTK solution is used in pediatric cardiac patients.

A comparison of GlideScope(®) videolaryngoscopy and direct laryngoscopy for nasotracheal intubation in children.

Background:u2002 The relative effectiveness of GlideScope® videolaryngoscopy (GV) for nasotracheal intubation in pediatric patients is unclear. The purpose of this study is to evaluate the usefulness of GV for nasotracheal intubation compared with direct laryngoscopy (DL) in pediatric patients.

Flexion compromises ventilation with the laryngeal tube suction II in children

Background:u2002 There are insufficient data as to the influence of the head and neck flexion, extension, and rotation on the ventilation with laryngeal tube suction II® (LTS II). The purpose of this study was to investigate the influence of the head and neck position on oropharyngeal sealing pressure (primary outcome) and ventilation score (secondary outcome) during ventilation with the LTS II in children.

Ultrasonographic Investigation of the Effect of Inguinal Compression on the Cross-sectional Area of the Femoral Vein

OBJECTIVESnThe reverse Trendelenburg position increases the cross-sectional area (CSA) of the femoral vein, making it easier to cannulate, although this position is potentially harmful in hypovolemic patients. The authors hypothesized that compression above the femoral vein increases the CSA of the femoral vein during emergency cannulation.nnnMETHODSnUltrasound was used to measure the CSA of the femoral vein of 20 healthy volunteers. The following five measurements were made inferior to the inguinal crease: 1) in the horizontal supine position (control), 2) with inguinal compression 2 cm above the inguinal crease (at the point of arterial pulsation and its medial side), 3) in the Trendelenburg position 15 degrees, 4) in the Trendelenburg position 15 degrees plus inguinal compression, and 5) in the reverse Trendelenburg position 15 degrees.nnnRESULTSnFemoral vein CSA was increased by 35% by inguinal compression in the horizontal supine position (p < 0.001) and was decreased by the Trendelenburg position (p < 0.001). However, inguinal compression increased the CSA by 66% in the Trendelenburg position (p < 0.001). The reverse Trendelenburg position also increased the CSA of the femoral vein by 50% (p < 0.001).nnnCONCLUSIONSnInguinal compression presents an alternative method for increasing the CSA of the femoral vein for venous catheterization in normal patients.

The effect of sevoflurane and ondansetron on QT interval and transmural dispersion of repolarization in children.

This study evaluated the prolongation of QT interval by the combination of sevoflurane and ondansetron in pediatric patients. Additionally, transmural dispersion of repolarization as interval between the peak and end of the T wave (Tp‐e) and Tp‐e/QT ratio was also measured to assess the risk of ventricular arrhythmia.

Critical incidents, including cardiac arrest, associated with pediatric anesthesia at a tertiary teaching children's hospital.

Analysis of critical incidents provides valuable information to improve the quality and safety of patient care. This study identified and analyzed pediatric anesthesia‐related critical incidents including cardiac arrests in a tertiary teaching childrens hospital.

Transthoracic echocardiographic guidance for obtaining an optimal insertion length of internal jugular venous catheters in infants

There are multiple methods of determining the optimal position of central venous catheter (CVC) tips. The purpose of this study was to assess the feasibility of transthoracic echocardiography (TTE), and compare TTE and height‐based method for correct positioning of CVCs in infants undergoing cardiac surgery.