Irina Milojevic

The effects of different anesthesia techniques on free radical production after tourniquet-induced ischemia-reperfusion injury at children's age.

BACKGROUND/AIM Reperfusion of previously ischemic tissue leads to injuries mediated by reactive oxygen species. The aim of the study was to investigate the effects of different anesthesia techniques on oxidative stress caused by tourniquet-induced ischemia-reperfusion (IR) injury during extremity operations at childrens age. METHODS The study included 45 patients American Society of Anesthesiologists (ASA) classification I or II, 8 to 17 years of age, undergoing orthopedic procedures that required bloodless limb surgery. The children were randomized into three groups of 15 patients each: general inhalational anesthesia with sevoflurane (group S), total intravenous anesthesia with propofol (group T) and regional anesthesia (group R). Venous blood samples were obtained at four time points: before peripheral nerve block and induction of general anesthesia (baseline), 1 min before tourniquet release (BTR), 5 and 20 min after tourniquet release (ATR). Postischemic reperfusion injury was estimated by measurement of concentration of malondialdehyde (MDA) in plasma and erythrocytes as well as catalase (CAT) activity. RESULTS Plasma MDA concentration in the group S was significantly higher at 20 min ATR in comparison with the groups T and R (6.78 +/- 0.33 micromolL-1(-1) vs. 4.07 +/- 1.53 and 3.22 +/- 0.9. micromolL-1(-1), respectively). There was a significant difference in MDA concentration in erytrocythes between the groups S and T after 5 min of reperfusion (5.88 +/- 0.88 vs. 4.27 +/- 1.04 nmol/mlEr, p < 0.05). Although not statistically significant, CAT activity was slightly increased as compared to baseline in both groups S and R. In the group T, CAT activity decreased at all time points when compared with baseline, but the observed decrease was only statistically significant at BTR (34.70 +/- 9.27 vs. 39.69 +/- 12.91 UL-1, p < 0.05). CONCLUSION Continuous propofol infusion and regional anesthesia techniques attenuate lipid peroxidation and IR injury connected with tourniquet application in pediatric extremity surgery.

Unpredictable drug reaction in a child with Cornelia de Lange syndrome

Case descriptionPreoperative use of midazolam sedation is mandatory during induction of anesthesia in noncooperative and hyperactive children to prevent possible obstacles. Unusual drug reactions rarely occur in patients undergoing anesthesia or in intensive care unit. This report describes an unpredictable drug reaction after a routine midazolam premedication in a patient with no history of allergy. There has been no literature data yet to show that midazolam can provoke respiratory problems in patients with Cornelia de Lange Syndrome.ConclusionIn our opinion midazolam should be avoided in patients with Cornelia de Lange Syndrome, which we enforced after first unpredictable reaction.

Intraoperative use of hydroxyethyl starch 130/0.4 in neonates

ation of DMD and true MH is available and describe alternative pathophysiological mechanisms for these ‘MHlike’ reactions during anaesthesia in DMD patients. They group these reactions into three categories based on clinical presentation. We like to comment on two of them. In the first group they reviewed reports between 1970 and 2005 of 13 patients with Duchenne or Becker muscular dystrophy who had sudden hyperkalemic cardiac arrest without hypermetabolism during or after anesthesia using volatile agents without succinylcholine. We realize how difficult it is to analyse the information (presented or unavailable) from these sometimes anecdotal case reports, and we would also like to emphasize that the lack of specific clinical signs or symptoms is the main reason for the limited use of the MH Clinical Grading Scale (3). It is well-known, as the authors state, that patients with Duchenne or Becker muscular dystrophy are susceptible to perioperative respiratory and cardiac complications. with or without ‘triggering’ anesthetics. However, it is not clear from the review whether these children had preexisting cardiomyopathy, nor what concentrations of volatile anesthetics were used. Furthermore, two case reports describe intraoperative cardiac arrest In DMD children during spinal surgery under propofol-sufentanyl anesthesia without succinylcholine or volatile anesthetics (4,5). The third group comprises six patients with postoperative rhabdomyolysis without cardiac signs or symptoms. Most patients with DMD have already greatly increased creatine kinase levels preoperatively possibly as the hallmark symptom of ongoing rhabdomyolysis. These levels may increase during surgery proportionally with the duration of surgery and other factors (positioning, obesity etc.). So, in our view it is not reasonable to blame only volatile anesthetics for the rhabdomyolysis. Fortunately, the authors recommend the use of volatile anesthetics for short periods when a total intravenous technique is not an option e.g. for difficult airway management. However, the authors fail to mention a specific agent for such a TIVA technique. Propofol has been regularly proposed as an alternative anesthetic for patients with DMD and other myopathies although this drug is well known to trigger rhabdomyolysis and MH-like reactions in susceptible patients (6). Shouldn’t the conclusion of the review better be that DMD patients are prone to develop serious problems during surgery and anesthesia irrespective of the type of anesthetic agents used? We belief this topic deserves special attention in an international working group. Jacques Driessen* Marc Snoeck† *Department of Anesthesiology, Radboud University, Nijmegen, the Netherlands †MH investigation unit, Canisius-Wilhelmina Hospital, Nijmegen, the Netherlands (email: JJ.Driessen@anes.umcn.nl) References

The intraoperative use of recombinant FVIIa in child with hemophilia A with antibodies

Patients with hemophilia A that developed inhibitors to FVIII represent a problem for bleeding control especially during surgical procedures. We report the use of bolus injections of rFVIIa during one intervention that included synoviectomy on the right knee, cholecystectomy and appendicectomy in a child with high titer of inhibitors to FVIII. rFVIIa was administered at the start (120 μg·kg−1) and then every 2 h (90 μg·kg−1) during the procedure. ε‐aminocapronic acid was also administered as an antifibrinolytic every 3 h. We monitored aPTT (activated partial thromboplastin time) and PT (prothrombin time) and they were within reference values. Surgery lasted 7 h without significant hemorrhage. Postoperatively the dose of rFVIIa was slowly reduced and after ten days the patient was discharged home in good condition. In our case rFVIIa helped a child with hemophilia A with antibodies to undergo major surgery but each case should be treated individually and the cost of rFVIIa has also to be taken into account.

Acute myocarditis during anesthesia after rubella infection

Electrophysiological studies revealed partial axonal injury on the lateral division of right sciatic nerve consistent with a partial sciatic nerve injury. Then he was immediately started on gabapentin 100 mg three times daily introduced over a 3-day period to avoid possible side effects. At the same time, tramadol was given in a dose of five drops (12.5 mg) as a rescue medication. One week after his first evaluation, his pain intensity was 5 on NRS with gabapentin 300 mg three times daily and tramadol 37.5 mg per day. However, he still had allodynia and foot drop. He reported a decrease in pain intenstiy especially during the first 5 h after medication intake. No side effects were seen. Thereupon, gabapentin dose was increased to 400 mg three times daily and tramadol was given five drops as a rescue medication. At the end of 2 weeks, his pain intensity was 2 on NRS. He continued this medical treatment for 2 months and at 2 months follow-up he used no rescue medications and his pain described as burning, stabbing and shooting was completely controlled with gabapentin 400 mg three times daily. He felt only the cold and heat allodynia (he said that he felt his foot painful only during taking shower). Thereafter, gabapentin doses were decreased gradually to 300 mg three times daily and offered to continue for 1 month. Nerve conduction studies and EMG performed 3 months after injury showed partial axonal injury on the peroneal division of right sciatic nerve with sign of reinnervation. The regeneration potentials could not reach the right extensor digitorum brevis muscle yet. At 3 months follow-up he had no pain but still had cold and heat allodynia on his right foot then he was advised to continue gabapentin 100 mg three times daily. Nerve conduction studies and EMG 6 months after the sciatic nerve injury showed reinnervation of the right extensor digitorum brevis muscle. He had still no neuropathic pain but had allodynia on his right toe so that the treatment continued with gabapentin 100 mg three times daily. At 8 months follow-up, he had no neuropathic pain and allodynia so that gabapentin treatment was stopped. New nerve conduction studies and EMG were not needed. In the literature there is no detailed information about drugs used in medical treatment of postinjection sciatic nerve injury pain. Our child suffered from neuropathic pain due to sciatic nerve injury with burning and stabbing in quality. So that we started gabapentin in a dosage of 300–400 mg three times daily in our child that was the first line and standard treatment of neuropathic pain (3). In the literature, there are also several reports reporting that gabapentin is used safely in dosage of 200–500 mg three times daily in children without side effects (4,5). In our child gabapentin reduced his burning and stabbing pain sensation in big toe and at the bottom of right foot and shooting pain going down his right leg for several months, while postinjection sciatic nerve injury resolved spontaneously in several months. In conclusion, gabapentin was able to control neuropathic pain symptoms in this pediatric case of sciatic nerve injury following i.m. injection without any side effects and can be recommended for the safe and effective treatment of neuropathic pain in pediatric ages of 8 years. Kader Keskinbora* Is ik Aydinli† *Anesthesiology Department, Cerrahpasa Medical Faculty, Algology Clinic, Istanbul University, Istanbul, Turkey and †Anesthesiology Department, Cerrahpasa Medical School, Algology Clinic, Istanbul University, Istanbul, Turkey (email: kader@istanbul.edu.tr)

Anesthesia in pyruvate dehydrogenase deficiency

45 min before the anesthesia. In the operating room nasal oxymetazolin spray and 0.25 mg atropine intravenously were used for vasoconstriction and dryness. Sedation was induced with 2 mgÆkg propofol and maintained with 3 mgÆkgÆmin propofol. The patient was ventilated with 100% O2 via face mask. When SpO2 was 100% and spontaneous ventilation was resumed, a fibreoptic bronchoscope (Olympus LF-DP; Olympus Winter&Ibe GmbH, Hamburg, Germany) that had been passed through an 5.0 ID tracheal tube was inserted through the nose. During fiberoscopy jaw thrust was used to improve visualization. After visualization of carina as the last landmark the tube was easily advanced over the fibreoptic bronchoscope into the trachea at the first attempt. 0.1 mgÆkg vecuronium was injected and propofol infusion was ceased. Desflurane in 50% O2 ⁄ air mixture was used for maintenance of anesthesia during the operation. Fentanyl was given when hypertension and tachycardia were observed. Electrocardiography, heart rate, invasive blood pressure, oxygen saturation, end-tidal gases, temperature and urine output were monitored during the anesthesia. Anesthesia lasted 240 min uneventfully in the prone position. He was observed for 30 min in the recovery room and then transferred to the postoperative intensive care unit. In conclusion, in addition to importance of preanesthetic preparation, intubation with FOB under propofol anesthesia and maintenance with desflurane anesthesia is very convenient anesthetic technique for a patient with Goldenhar syndrome and other patients with airway difficulty.

Management of Anesthesia in a Child with a Large Neck Rhabdoid Tumor.

Objective: The aim of this paper was to report the management of anesthesia of a child with a large neck rhabdoid tumor. Clinical Presentation and Intervention: A 9-month- old female patient underwent urgent neck tumor excision due to intratumoral bleeding from a large tumor that compressed and dislocated the trachea; therefore, intubation was expected to be difficult. Sevoflurane inhalation induction was utilized to maintain spontaneous respiration. Oral laryngoscopy revealed Cormack-Lehane grade 3 laryngeal view. The trachea was intubated using a reinforced tube on the third attempt. Fiberoptic bronchoscope-assisted intubation was planned as an alternative in case of conventional intubation failure. Anticipation of massive blood loss necessitated central venous catheterization. Conclusion: Establishing a safe airway, intubation during spontaneous breathing and invasive hemodynamic monitoring are crucial factors in the anesthetic management of pediatric patients with a large neck tumor.

Anesthesia in a child with Mulvihill–Smith syndrome

To the Editor: Mulvihill–Smith syndrome (MSS) is a very rare disease with important anesthetic implications [1]. It is characterized by a short stature, senile face, small mouth opening, prognatio mandible, and atherosclerosis. This case illustrates the potential difficulties in airway management during major surgery in a child with MSS. We report a case of a 10-year-old female child with MSS and diabetes mellitus type 2 who underwent general anesthesia for hepatic tumor extraction. Mallampaty score was III with Cormarck–Lehane gradus 3. Neck extension was limited, and she had a small mouth opening. After premedication with atropine and midazolam, induction in anesthesia was performed with fentanyl, propofol, and vecuronium. We had some difficulties with mask ventilation, but we intubated the patient with a no. 1 Macintosh blade and orotracheal tube no. 4, 5, after the third attempt. A fiberoptic laryngoscope was available in the operating room. There are not many papers that discuss anesthetic management in patients with progeria. Establishing the airway is one of the problems, including a difficult airway with small mouth opening [2]. The anesthetic management and positioning of these patients may be difficult because of atherosclerosis, bone deformities, and arthritic changes of the joints [3, 4]. The anesthetic management was planned as if this patient were a geriatric case because these patients have physiological changes suggestive of old age despite being chronologically and psychologically young [3]. Although there were no complications in establishing the airway in our case, it is important to evaluate the airway before the induction of anesthesia and to be prepared for difficult airway management.