Jesus Apuya

Use of Intralipid in an infant with impending cardiovascular collapse due to local anesthetic toxicity.

Local anesthetic-associated cardiac toxicity following caudal epidural blockade is, fortunately, a rare event. Prompt recognition and early treatment is the key to successful resuscitation. Early use of the lipid emulsion Intralipid in bupivacaine-induced cardiac toxicity may lead to a good outcome.

Combination of oral ketamine and midazolam as a premedication for a severely autistic and combative patient

Patients with impaired ability to understand and communicate can be difficult to manage perioperatively. They frequently require lateral thinking on the part of the anesthesiologists to make the induction process as smooth as possible. We present a case of a severely autistic and violent patient scheduled for dental rehabilitation under general anesthesia. A combination of oral ketamine and midazolam was mixed in the beverage Dr Pepper to mask the taste and the appearance of the drugs. The unique flavor of Dr Pepper is well suited to increase the palatibility and the acceptability of medications in children and patients with developmental delay.

Intravenous versus epidural analgesia after surgical repair of pectus excavatum.

Surgical repair of pectus excavatum can be associated with significant postoperative pain. Various analgesic modalities have been suggested including thoracic epidural analgesia and intravenous patient-controlled analgesia (IV PCA). The current study compares the efficacy and adverse efficacy profile of these 2 analgesic modalities. The charts of 18 adolescents who had undergone pectus excavatum repair were retrospectively reviewed and divided into 2 groups: thoracic epidural analgesia (E) or IV PCA (I). Demographic data included age, weight, sex, and anesthesia/surgical times. Treatment days (defined as the number of days the patients received intravenous or epidural analgesia), time to oral intake, and time to discharge from the hospital were also recorded. Pain scores using a visual analogue scale ranging from 0 (no pain) to 10 (worst imaginable pain) and sedation scores were recorded in the postanesthesia care unit and at 6, 12, 24, 36, 48, and 60 hours postoperatively. The charts were also reviewed for side effects including nausea and/or vomiting, pruritus, oxygen desaturation, and respiratory depression. The study cohort included 18 patients divided equally into group E (epidural analgesia) (n = 9) and group I (IV PCA). There were no statistically significant differences between the 2 groups with regard to demographic data, time to oral intake, and time to hospital discharge. Anesthesia to surgery times were longer in group E compared with group I (43 ± 11 versus 25 ± 11 minutes, P = 0.004), but there was no difference in overall surgery and anesthesia times. The number of treatment days (days that the patients received intravenous or epidural medications) was decreased in group E versus group I (2.3 ± 0.7 versus 3.3 ± 1.0 days, P = 0.027). There was no difference between the 2 groups in regard to the onset of oral intake or hospital discharge time. Pain scores were initially higher in the postanesthesia care unit in group E versus group I (6.78 ± 2.17 versus 5.78 ± 3.77); however, after that point, pain scores were lower in group E than in group I. There was no difference between the 2 groups in regard to sedation scores or adverse effect profile. Epidural analgesia provided better pain control than the intravenous route for the management of patients after pectus excavatum repair. No adverse effects related to epidural analgesia were noted. The only issue identified with thoracic epidural anesthesia was a mean increase of 18 minutes for anesthesia time required for catheter placement before the start of the case.

Is it worth the risk

the two patterns of congenital deformity; quoted incidences for their coexistence vary from as low as 1.3% to as high as 51% (3,4). The diagnosis of congenital heart disease in the newborn is complicated by the physiologic changes that occur in the postnatal period. Even with a detailed cardiac antenatal scan and clinical examination up to 30% of cases can be missed. As many as half of these missed cases can be severe, presenting with heart failure or sudden death (5, 6). The most common cause of low saturations in the perioperatve child is respiratory insufficiency. Exclusion of respiratory causes, in a patient with persistently low saturations, must raise concerns about the presence of an intracardiac or cardiopulmonary shunt (7). Our patient displayed low saturations despite being intubated and ventilated with 50% oxygen. This case identifies some important points: The normal saturation of an anesthetized child on 30% oxygen should be >96%. If this cannot be achieved then an explanation must be sought. The preoperative assessor of a child with a cleft defect must maintain a high index of suspicion of associated congenital heart disease even in the face of unremarkable scans. This makes the measurement and documenting of preoperative saturations necessary in patients with cleft defects presenting for surgery. M. Taylor* C. Persad* S. Jones† *University Hospitals Birmingham and †Birmingham Children’s Hospital, Birmingham, UK (email: persadcindy@hotmail.com)

Atypical presentation of an impacted radiolucent esophageal foreign body

Patients with impacted esophageal foreign bodies usually present with gastrointestinal and rarely with respiratory symptoms. Impacted esophageal foreign bodies may be identified by radiologic studies. Ingested radiolucent foreign bodies may be more difficult to diagnose, especially if the patient presents with minimal symptoms. We report a rare case of a child who presented with stridor and obstructive sleep apnea. The cause of respiratory symptoms was thought to be due to enlarged tonsils and adenoids, and the patient was scheduled for tonsillectomy and adenoidectomy. On re-evaluation by the surgeon on the day of surgery, the procedure was changed to diagnostic microlaryngoscopy and bronchoscopy to rule out any other cause. The patient’s respiratory symptoms were resolved when an incidental discovery and retrieval of the radiolucent esophageal foreign body was made. The diagnosis of radiolucent esophageal foreign body can be difficult and can be easily missed without reasonable clinical suspicion.

Stridor accompanying red man's syndrome following perioperative administration of vancomycin

A neonate developed red mans syndrome and stridor following perioperative administration of vancomycin. The medical management of stridor and red mans syndrome are presented.

Anesthetic management of a patient with idiopathic arterial calcification of infancy and fused cervical spine

Authors do not have any conflict of interest nor financial support. Daniele De Luca* Domenico Pietrini* Marco Piastra* Eloisa Tiberi† Anita Romiti Tommaso Bernardini Giorgio Conti* Susanna Zecca§ Enrico Zecca† *Pediatric Intensive Care Unit, Department of Anaesthesiology and Intensive Care †Division of Neonatology, Department of Pediatrics ‡Division of Obstetrical Pathology, Department of Obstetrics and Gynecology University Hospital ‘‘A. Gemelli’’ – Catholic University of the Sacred Heart, Rome, Italy §Department of Pediatrics, 2nd University of Rome ‘‘Tor Vergata’’, Rome, Italy (email: dm.deluca@fastwebnet.it)