James F. Mayhew

Anesthetic management in a child with Glycogen Storage Disease IV.

1 Sigaut S, Skhiri A, Stany I et al. Ultrasound guided internal jugular vein access in children and infant: a metaanalysis of published studies. Paediatr Anaesth 2009; 19: 1199–1206. 2 Verghese ST, McGill WA, Patel RI et al. Ultrasound-guided internal jugular venous cannulation in infants: a prospective comparison with the traditional palpation method. Anesthesiology 1999; 91: 71–77. 3 Verghese ST, McGill WA, Patel RI et al. Comparison of three techniques for internal jugular vein cannulation in infants. Paediatr Anaesth 2000; 10: 505–511. 4 National Institute for Clinical Excellence. Guidance on the use of Ultrasound locating devices for placing central venous catheters. Technology Appraisal Guidance No. 49, September 2002, http://www.nice.org.uk

Anesthetic management in a child with Angelman syndrome

1 Jagannathan N, Roth AG, Sohn LE et al. The new air-Q intubating laryngeal airway for tracheal intubation in children with anticipated difficult airway: a case series. Pediatr Anesth 2009; 19: 618–622. 2 Peiris K, Traynor M, Whyte S. Intubation via the intubating laryngeal airway in two pediatric patients with predicted difficult airways. Pediatr Anesth 2010; 20: 202–204. 3 Yang D, Deng XM, Tong SY et al. Fibreoptic intubation throughCookgas intubating laryngeal airway in two children. Anaesthesia 2009; 64: 1148–1149. 4 Jagannathan N, Wong DT. Successful tracheal intubation through the intubating laryngeal airway in pediatric patients with airway hemorrhage. J Emerg Med. Accepted for publication.

Anesthsia in neonates with large encephaloceles

1 Allegaert K, Naulaers G. Procedural sedation of neonates with chloral hydrate: a sedation procedure does not end at the end of the acquisition of images. Paediatr Anaesth 2008; 18: 1270– 1271. 2 Beauve B, Dearlove O. Sedation of children under 4 weeks of age for MRI examination. Paediatr Anaesth 2008; 18: 892–3. 3 Allegaert K, Daniels H, Naulaers G et al. Pharmacodynamics of chloral hydrate in former preterm infants. Eur J Pediatr 2005; 164: 403–7. 4 Cote C, Zaslavsky X, Downes JJ et al. Postoperative apnea, airway obstruction in former preterm infants after inguinal herniorraphy. Anesthesiology 1995; 82: 809–22.

Use of caudal morphine in pediatric burn patients

Shinya Sugahara† Takao Motosuneya– Hiroki Wada Isao Fukuda† Eiichiro Umeda† Tomiei Kazama§ *Research Fellow of the Graduate Course of Medicine, Department of Anesthesiology, National Defense Medical College, Saitama, Japan, †Associate Professor, Department of Anesthesiology, National Defense Medical College, Saitama, Japan, Department of Anesthesiology, National Hospital Organization Saitama National Hospital, Saitama, Japan, §Clinical Professor, Department of Anesthesiology, National Defense Medical College, Saitama, Japan, –Department of Orthopedics, Saitama medical center, Saitama, Japan (email: tutuu@ca3.so-net.ne.jp)

Nothing new under the sun

glottis (Figure 1a). Also, a keyhole-shaped outlet of airway tube is designed to limit excessive upward angle of the TT tip and direct the TT tip toward the glottis (3). When a TT is reversely inserted into the airQ-ILA, however, the TT tip emerged from outlet of airway tube will move along the bottom of the cuff, pass above the distal end of the cuff (Figure 1b) and enter upper esophagus under the larynx, resulting in a failed intubation. This problem may be more possible to occur in the infants and young children with an anterior larynx. 3. In the available literature, there is no clinical study with enough sample size to assess availability and safety of the blind intubation through the air-Q-ILA in pediatric patients with a difficult airway. We think that in the infants and young children, small laryngeal aperture may decrease the possibility of successful blind intubation through the air-Q-ILA. Also, the repeated blind intubation attempts can cause the damage to the airway structures. In view of above concerns, we strongly recommend that when the air-Q-ILA is used as a conduit for tracheal intubation in pediatric patients with a difficult airway, a fiberoptic technique is best combined (Figure 1c), as described in previous case reports (4–6). By our practice, the fiberoptic intubation through the air-Q-ILA has a high success rate and a low incidence of complication. However, it must be pointed out that the glottis can be well visualized in all pediatric patients with the FOB passing the air-Q-ILA, but some degree of epiglottic downfolding is a common problem on fiberoptic examination in most cases. The ‘Klein maneuver’ is a useful measure to address this issue. It includes jaw lift and withdrawal of the air-Q-ILA, followed by reinsertion (3). If a FOB is unavailable, a pediatric version gum elastic bougie can be passed through the TT placed within the airQ-ILA and into the trachea. By gently placing the fingers of the left hand over the cricoid cartilage, the gum elastic bougie may be felt as it passes through the cricoid ring. When the gum elastic bougie passes into the trachea, the TT is simply advanced over the gum elastic bougie, through the laryngeal inlet, and into the trachea, using the gum elastic bougie as a guide. F U S H A N X U E J U N X I O N G Y U J I N G Y U A N Q I A N G W A N G X U L I A O Department of Anesthesiology, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China (email: fruitxue@yahoo.com.cn) Acknowledgements

Fibreoptic intubation through the LMA in children.

SIR—I read with interest the review article ‘Management of difficult intubation in children’ by Walker and Ellwood (1). I would like to call to the authors’ attention two reports, which I was involved with using fiberoptic intubation through the LMA in children (2,3). This technique is so easy and straightforward and with a little experience can be performed without loss of the airway or desaturations. I have taught it to multiple residents and staff. Respectfully, J A M E S M A Y H E W University of Oklahoma Medical Center – Anesthesiology 750 N.E 13th Street, Suite 200 Oklahoma City, OK 73102, USA (email: rejfm@hotmail.com)

Tracheal intubation without neuromuscular blocking drugs

I read with great interest the editorial by Dr. Morton (1) on tracheal intubation without neuromuscular blocking drugs in children. As he mentioned, because of our newer agents and techniques have been developed to avoid routine use of muscle relaxants. However, Dr. Morton did not mention intubation without the use of adjuvant agents which all require intravenous access prior to their use. A few years ago, a practitioner inquired about instrumentation the airway without intravenous access. Dr. S. Muhiddin and I (2,3) replied that we teach our residents and fellows how to intubate our pediatric patients safely without intravenous access. The old Guedal signs of depth of anesthesia first describe with either can be applied both halothane and sevoflurane. The use of topical lidocaine to the pharynx is also useful with this technique (4). As experienced pediatric anestheiologists are aware there is the occasional patient who presents with a difficult problem of easy intravenous access. However, once the airway is safely secured, if need be drugs can to given through the endotracheal tube. James F. Mayhew Professor of Anesthesiology and Pediatrics, Department of Anesthesiology, University of Oklahoma Medical Center, Oklahoma City, OK, USA (email: rejfm@hotmail.com)

Changing an oral endotracheal tube to a nasal tube in Pierre–Robin sequence

1 Wall JJ. Axillary nerve blocks. Am Fam Physician 1975; 11: 135–142. 2 Louahem DM, Nebunescu A, Canavese F et al. Neurovascular complications and severe displacement in supracondylar humerus fractures in children: defensive or offensive strategy? J Pediatr Orthop B 2006; 15: 51–57. 3 Blakemore LC, Cooperman DR, Thompson GH et al. Compartment syndrome in ipsilateral humerus and forearm fractures in children. Clin Orthop Relat Res 2000; 1: 32–38. 4 Spanos S, Booth R, Koenig H et al. Jet Injection of 1% buffered lidocaine versus topical ELA-Max for anesthesia before peripheral intravenous catheterization in children: a randomized controlled trial. Pediatr Emerg Care 2008; 24: 511–515.