John J. McCloskey

Comparison of cuffed and uncuffed endotracheal tubes in young children during general anesthesia

Background Uncuffed endotracheal tubes are routinely used in young children. This study tests a formula for selecting appropriately sized cuffed endotracheal tubes and compares the use of cuffed versus uncuffed endotracheal tubes for patients whose lungs are mechanically ventilated during anesthesia. Methods Full‐term newborns and children (n = 488) through 8 yr of age who required general anesthesia and tracheal intubation were assigned randomly to receive either a cuffed tube sized by a new formula [size(mm internal diameter) = (age/4) + 3], or an uncuffed tube sized by the modified Coles formula [size(mm internal diameter) = (age/4) + 4]. The number of intubations required to achieve an appropriately sized tube, the need to use more than 21 [center dot] min sup ‐1 fresh gas flow, the concentration of nitrous oxide in the operating room, and the incidence of croup were compared. Results Cuffed tubes selected by our formula were appropriate for 99% of patients. Uncuffed tubes selected by Coles formula were appropriate for 77% of patients (P < 0.001). The lungs of patients with cuffed tubes were adequately ventilated with 2 1 [center dot] min sup ‐1 fresh gas flow, whereas 11% of those with uncuffed tubes needed greater fresh gas flow (P < 0.001). Ambient nitrous oxide concentration exceeded 25 parts per million in 37% of cases with uncuffed tubes and in 0% of cases with cuffed tubes (P < 0.001). Three patients in each group were treated for croup symptoms (1.2% cuffed; 1.3% uncuffed). Conclusions Our formula for cuffed tube selection is appropriate for young children. Advantages of cuffed endotracheal tubes include avoidance of repeated laryngoscopy, use of low fresh gas flow, and reduction of the concentration of anesthetics detectable in the operating room. We conclude that cuffed endotracheal tubes may be used routinely during controlled ventilation in full‐term newborns and children during anesthesia.

Bupivacaine toxicity secondary to continuous caudal epidural infusion in children

egional anesthesia has become an integral part of the intraoperative anesthetic management R of children (1,2). The success of nerve blocks and “kiddie caudals” in managing surgical stress has also led to the use of these techniques in alleviating postoperative pain (2-5). In many instances, bupivacaine is the local anesthetic chosen for these techniques because of its longer duration of action and greater sensory versus motor blockade at a given therapeutic dose (6,7). A safe and effective bolus dose for caudal injection, based on pharmacokinetic and pharmacodynamic studies, has been determined for infants and children (8-10); however, the pharmacokinetic and pharmacodynamic properties of prolonged continuous caudal epidural bupivacaine infusions in children have not been investigated. We present three case reports to illustrate that prolonged infusions of bupivacaine by the caudal route can lead to systemic toxicity.

A multi-institutional high-fidelity simulation "boot camp" orientation and training program for first year pediatric critical care fellows.

Objective: Simulation training has been used to integrate didactic knowledge, technical skills, and crisis resource management for effective orientation and patient safety. We hypothesize multi-institutional simulation-based training for first year pediatric critical care (PCC) fellows is feasible and effective. Design: Descriptive, educational intervention study. Setting: The simulation facility at the host institution. Interventions: A multicentered simulation-based orientation training “boot camp” for first year PCC fellows was held at a large simulation center. Immediate posttraining evaluation and 6-month follow-up surveys were distributed to participants. Measurements and Main Results: A novel simulation-based orientation training for first year PCC fellows was facilitated by volunteer faculty from seven institutions. The two and a half day course was organized to cover common PCC crises. High-fidelity simulation was integrated into each session (airway management, vascular access, resuscitation, sepsis, trauma/traumatic brain injury, delivering bad news). Twenty-two first year PCC fellows from nine fellowship programs attended, and 13 faculty facilitated, for a total of 15.5 hours (369 person-hours) of training. This consisted of 2.75 hours for whole group didactic sessions (17.7%), 1.08 hours for a small group interactive session (7.0%), 4.67 hours for task training (30.1%), and 7 hours for training (45.2%) with high-fidelity simulation and crisis resource management. A “train to success” approach with repetitive practice of critical assessment and interventional skills yielded higher scores in training effectiveness in the end-of-course evaluation. A follow-up survey revealed this training was highly effective in improving clinical performance and self-confidence. Conclusions: The first PCC orientation training integrated with simulation was effective and logistically feasible. The train to success concept with repetitive practice was highly valued by participants. Continuation and expansion of this novel multi-institutional training is planned.

Cavernous sinus thrombosis complicating sinusitis.

Background Septic cavernous sinus thrombosis is a rare complication of paranasal sinusitis. Objective To familiarize the clinician with the pathogenesis, diagnosis, and appropriate management of septic cavernous sinus thrombosis. Design Case report and literature review. Setting Pediatric intensive care unit in a university hospital. Patient We present a 12-yr-old female with a 1 wk history of an upper respiratory tract infection with worsening dyspnea, cough, and swelling of the left eye progressing to adult respiratory distress syndrome. Secondary to the need for significant mechanical ventilatory support, venovenous extracorporeal membrane oxygenation was initiated. Computed tomography scan of the head and neck with contrast revealed bilateral cavernous sinus thrombosis. After broad-spectrum intravenous antibiotics and aggressive supportive care in conjunction with surgical intervention (maxillary sinus lavage and right orbital exploration) and anticoagulation therapy, the patient recovered. Blood cultures were positive for Viridans streptococcus. At discharge 3 wks later, the patient had improved, but had right-eye blindness. Conclusions The diagnosis of septic cavernous sinus thrombosis requires a high index of suspicion and confirmation by imaging; early diagnosis and surgical drainage of the underlying primary source of infection in conjunction with long-term intravenous antibiotic therapy are critical for an optimal clinical outcome.

Battery ingestion resulting in an aortoesophageal fistula.

1354 December 2012 A 4-YR-OLD, 13-kg girl presented to the emergency department in cardiopulmonary arrest after acute episodes of bright red hematemesis. The patient had no witnessed foreign body ingestion or past medical history. Once stabilized, the patient was transferred to the pediatric intensive care unit. Chest radiograph (fig. A) revealed a 23-mm, round foreign body with a peripheral rim (suggesting the presence of a battery) in the central mediastinum within the distal esophagus posterior to the heart. She was taken to the operating room for emergency thoracotomy. Upon transfer to the operating room table, the patient experienced cardiopulmonary arrest. The surgeons cross clamped the aorta and initiated open-chest cardiopulmonary resuscitation. Despite ongoing resuscitation, the patient never regained a sustainable cardiac rhythm and expired. Postmortem examination confirmed the presence of a battery-induced aortoesophageal fistula (fig. B). Battery ingestion is an increasing hazard with potentially fatal clinical implications. Public awareness is essential in preventing complications because early recognition of battery ingestion and removal is key to therapeutic management. If battery ingestion is suspected, a chest radiograph should be obtained immediately. Patients with ingested batteries larger than 12 mm should go to the operating room within 2 h for endoscopic removal and inspection of the esophageal mucosa. Even if the battery is smaller than 12 mm, patients are still at risk for injury or death. It is essential to make a decision based on symptoms and clinical judgment. Failure to remove batteries within 2 h can lead to esophageal necrosis and aortoesophageal fistulas. After removal of the battery, patients with mucosal injuries should be observed for delayed complications such as abscesses, perforations, mediastinitis, and strictures for up to several months. Images In anesthesIology

Endotracheal Intubation in Awake Versus Sedated Premature Infants: A Randomized, Double Blind, Placebo-Controlled Trial

Endotracheal Intubation in Awake Versus Sedated Premature Infants: A Randomized, Double Blind, Placebo-Controlled Trial

Does Pediatric ICU (PICU) Residency Curriculum Match General Pediatric Practice (GP) Needs

Does Pediatric ICU (PICU) Residency Curriculum Match General Pediatric Practice (GP) Needs?