Kiyoshi Katori

Subglottic Jet Ventilation for Pediatric Microlaryngosurgery: A Case Report

A 6-year-old girl with laryngeal papillomatosis underwent ablation of the tumors with Nd-YAG laser under microlaryngosurgery. During the surgery, she was managed with subglottic high-frequency jet ventilation using a stainless steel cannula made from a nerve block needle. It was passed through the light channel of the suspension laryngoscope and firmly affixed to it. There was no hypoxia or barotrauma to the lungs during the surgery. The postoperative course was uneventful.

Acceleromyography at the Flexor Hallucis Brevis Muscle Underestimates Residual Neuromuscular Blockade

Purpose: Recovery of the train-of-four ratio (TOFR) to > 0.9 in the upper limb is commonly used to determine that neuromuscular function has returned to the preoperative level. It is not known whether recovery of neuromuscular function can be determined in the same way using lower limb acceleromyography. We compared measurements of recov- ery from neuromuscular blockade using upper limb electromyography and lower limb acceleromyography. Methods: Twenty-nine patients who were scheduled for elective surgery were enrolled in this study. Patients were ex- cluded if they had neuromuscular disease or contraindications to neuromuscular blockade. General anesthesia was induced and maintained with propofol and fentanyl. Patients were monitored using electromyography at the first dorsal interosse- ous muscle of the upper limb and acceleromyography at the flexor hallucis brevis muscle of the lower limb. Vecuronium 0.1 mg/kg was administered for neuromuscular blockade, and the profile of the blockade was recorded, including onset time and recovery times to TOFR 0.7 and 0.9. Results were compared between the upper and lower limbs. Results: The first dorsal interosseous muscle of the upper limb was slower to recover to TOFR 0.7 and 0.9 than the flexor hallucis brevis muscle. When the TOFR at the flexor hallucis brevis muscle had recovered to 0.9, the TOFR at the first dorsal interosseous muscle was 0.44 ± 0.23. Conclusion: Monitoring the flexor hallucis brevis muscle using acceleromyography underestimates the residual neuro- muscular blockade.

Sevoflurane Induction Shortens the Onset of Vecuronium at the Corrugator Supercilii Muscles: A Randomized Comparison with Propofol Induction

We evaluated if induction with sevoflurane shortened the onset of vecuronium-induced neuromuscular blockade at the corrugator supercilii muscles (which have a similar time course of neuromuscular blockade with laryngeal muscles). Thirty-two patients were randomly allocated to a sevoflurane or propofol group. Anesthesia was induced with 5% sevoflurane in oxygen (sevoflurane group, 𝑛=16) or with propofol 2–2.5u2009mgu2009kg−1(propofol group, 𝑛=16), and vecuronium (0.1u2009mgu2009kg−1) was given in both groups. Evoked responses to train-of-four stimuli were measured by acceleromyography at the corrugator supercilii and adductor pollicis muscles. Sevoflurane induction, as compared with propofol, significantly shortened the onset time at the corrugator supercilii muscles from 138 ± 34u2009s to 107 ± 28u2009s (𝑃<0.01). Onset time at the corrugator supercilii was significantly shorter than at the adductor pollicis for both groups (𝑃<0.01). Our results suggest that induction with sevoflurane, as compared with propofol, shortened the onset time of vecuronium at laryngeal muscles.

Anesthetic management of an infant with Perlman syndrome

SIR—Perlman syndrome is a rare disorder characterized by fetal overgrowth, multiple facial anomalies, and visceromegaly. Searching Medline from 1966 to 2005 revealed only 23 subjects with this syndrome (1–10); however, there were no reports of anesthesia management of patients with Perlman syndrome in the English language literature. We report here the anesthesia management of an infant with Perlman syndrome who underwent an exchange of nephrostomy catheters. A 43-day-old girl, weighing 3700 g, with Perlman syndrome was scheduled for an exchange of nephrostomy catheters. The parents had a consanguineous marriage (first cousins). The mother did not have diabetes mellitus. Abdominal ultrasound study at the 25th week of gestation revealed the fetus had polyhydramnios and hydronephrosis. Because of fetal distress, delivery by cesarean section was undertaken at the 34th week of gestation; and the infant weighed 3797 g with an Apgar score of 1 point at 1 and 9 at 5 min. She had multiple facial anomalies (prominent forehead, depressed nasal bridge, and everted upper lip), but no micrognathia. Abdominal distension and cyanosis were also noted. Moist rales were heard over both lung fields. SpO2 was 80%, despite oxygen administration. The trachea was intubated and bronchial secretions were suctioned. SpO2 increased to 100% (FIO2 0.6). Abdominal ultrasound study showed a normal left kidney, but a hydronephrotic right kidney (4 · 9 cm). A nephrostomy catheter was inserted into the right kidney under ultrasound guidance on the day of delivery. Abdominal circumference decreased from 41 to 38 cm. Blood urea nitrogen was 4.6 mmolÆl (13 mgÆdl) creatinine 71 lmolÆl (0.8 mgÆdl) and potassium 4.2 mmolÆl. The trachea was extubated 7 days after birth. SpO2 did not decrease below 96% (FIO2 0.4), and was more than 98% while breathing room air from 18 days after birth. Because the nephrostomy catheter was occluded, an exchange of catheters under general anesthesia was scheduled for 43 days of age. Premedication was not administered, and anesthesia was induced with sevoflurane (5%) in oxygen (50%) and nitrous oxide. Anesthesia was maintained with sevoflurane (2%) in oxygen (50%) and nitrous oxide. She received assisted manual ventilation with a bag and mask; ventilation was easily assisted and SpO2 was more than 98% during the exchange of nephrostomy catheters, a procedure that lasted 20 min. Emergence from anesthesia was uneventful and there was no postoperative hypoxemia. Reexchange of the nephrostomy catheters was scheduled at 76 days of age because the nephrostomy catheter was accidentally removed. Anesthesia was induced with sevoflurane (5%) in oxygen (30%) and nitrous oxide, and vecuronium (0.5 mg) was given intravenously. Ventilation with a bag and mask was easily implemented. The vocal cords were clearly visualized by direct laryngoscopy and a tracheal tube (I.D. 3.5 mm) was inserted into the trachea with ease. She was positioned in the prone position. Anesthesia was maintained with sevoflurane (1.5–3.0%) in oxygen (50%) and nitrous oxide. SpO2 was 100% during the procedure, which lasted 45 min. There were no cardiorespiratory complications after anesthesia and surgery, and she was discharged 8 days after the procedure. Perlman syndrome, which was first reported by Liban and Kozenitzky in 1970, is a rare disorder and is assumed to have an autosomal recessive inheritance (10); however, the exact chromosome anomaly has not been demonstrated. Perlman syndrome shows a high neonatal mortality. Searching Medline from 1966 to 2005 revealed only 23 subjects with this syndrome. Among the 23 subjects, two were stillborn (1,6), and 18 died before 2 years of age (12 dying in the first month after birth). The main cause of death was respiratory failure because of visceromegaly (3,4,6–10). Potential problems for anesthesia management of subjects with Perlman syndrome mainly involve respiratory and renal problems because respiratory failure as a result of visceromegaly is the leading cause of death in such cases and some have renal dysfunction caused by a renal tumor and/or hydronephrosis (6,8). In addition, some patients have hypoglycemia because of hyperplasia of the pancreatic islet cells (2,8). Respiratory condition in our infant improved after insertion of the nephrostomy catheter into the hydronephrotic right kidney, but renal function was not impaired. Although our patient did not have hypoglycemia, blood glucose levels should be measured during anesthesia and surgery in subjects with Perlman syndrome. Some of these infants have micrognathia (2,7–9) and tracheal intubation may be difficult in such patients. However, as this infant did not have micrognathia, tracheal intubation was not difficult.