Mao Ping Luo

Measures to facilitate the classic laryngeal mask airway guided fiberoptic intubation in children with a difficult airway

0.2 mcgÆkgh and infusing an additional 15 ccÆkg of normal saline. At the end of surgery, hydromorphone 0.02 mgÆkg was administered and the patient was extubated in the operating room. At that time, he was awake and denied having any pain. Five minutes later, blood pressure abruptly increased to 230 ⁄ 120 mmHg, and heart rate to 84 ⁄ min. Sodium nitroprusside infusion was begun at 1 mcgÆkgÆmin and blood pressure was maintained within preoperative range. Patient-controlled analgesia was initiated using intravenous hydromorphone and the patient was transferred to ICU in a stable condition. Sodium nitroprusside was continued until the second postoperative day, when all of his oral antihypertensive medications were restarted. Patients with FD frequently experience paroxysmal dysautonomic crises characterized by severe hypertension, vomiting, rash, and sweating. These are triggered by emotional upset, pain, and other physiological factors that result in increase in levels of circulating catecholamines. In patients older than 15 years of age, supine hypertension and orthostatic hypotension are more commonly seen. One of the most important goals of our anesthetic management was to maintain hemodynamic stability and to prevent dysautonomic crises. We used dexmedetomidine as an anesthetic adjunct based on it’s alpha2-agonist effects, to inhibit central sympathetic discharge. There are reports of perioperative cardiac arrest as a result of severe hypotension in these patients. Various methods for improving cardiovascular stability have been described, including invasive monitoring and the use of vasopressors to treat the hypotension (2). In FD patients with supine hypertension, maintenance of appropriate intravascular volume through adequate volume resuscitation is the key to avoid episodes of severe hypotension. Our patient was admitted overnight to ensure proper hydration and CVP monitoring was used to guide our fluid infusions. Our patient was extubated smoothly at the end of the case. However, we were unable to prevent the abrupt onset of severe hypertension upon greater arousal. It is possible that a higher dose of dexmedetomidine may have been more effective. Axelrod et al. (3) reviewed 81 patients with FD undergoing 727 surgical procedures. They concluded that there is a frequent requirement for postoperative ventilatory support after abdominal surgery when opioids are used for postoperative pain control. Our case illustrates that with the careful titration of short-acting anesthetic agents, use of dexmedetomidine, and the modest doses of opioids, we could provide hemodynamic stability without the need for postoperative ventilatory support. Geeta Gurbuxani Saraiya Neeta Sun Lena Department of Anesthesiology Columbia University 622 West 168th street BHN 4-440 New York NY 10032 USA (email: gg2289@columbia.edu)

Different small-dose sufentanil blunting cardiovascular responses to laryngoscopy and intubation in children: a randomized, double-blind comparison

BACKGROUND Sufentanil is a potent opioid analgesic frequently used in clinical anaesthesia. This prospective, randomized, double-blind study was designed to assess the efficacy of different small-dose sufentanil attenuating the cardiovascular intubation response in healthy children, aiming at determining the optimal dose of sufentanil for this purpose. METHODS A total of 165 children aged 3-9 yr were randomized to one of four groups to receive the following in a double-blind manner: normal saline (Group 1), sufentanil 0.1 microg kg(-1) (Group 2), sufentanil 0.2 microg kg(-1) (Group 3), and sufentanil 0.3 microg kg(-1) (Group 4). Anaesthesia was induced with propofol 2.5 mg kg(-1) and vecuronium 0.1 mg kg(-1). Non-invasive blood pressure (BP) and heart rate (HR) were recorded before induction of anaesthesia (baseline value), at immediately before intubation (post-induction values), at intubation, and at 1 min intervals for 5 min after intubation. The per cent changes of systolic blood pressure (SBP) and HR during the observation were calculated. RESULTS Except for Group 4, tracheal intubation caused significant increases in BP and HR in Groups 1, 2, and 3 compared with baseline values. BP and HR at intubation and their maximum values during the observation were significantly different among the four groups. The maximum per cent increases of SBP and HR during the observation were 20 and 28% of baseline values, respectively, in Group 2, 13 and 13% in Group 3, and 0 and 4% in Group 4 compared with 24 and 37% in Group 1. Except for the Group 3 vs Group 4 comparison, the incidences of SBP and HR per cent increases >30% of baseline values were also significantly different among the four groups. CONCLUSIONS In combination with propofol for induction of anaesthesia in children, the bolus administration of sufentanil can produce a dose-related attenuation of the cardiovascular intubation response and sufentanil 0.3 microg kg(-1) can completely abolish the cardiovascular intubation response.

Endotracheal tube obstruction by unexpected blood clot in anesthetized children: a report of three cases

McGaw, IL, USA) returned a small amount of clear-yellow secretions. ETCO2 and tidal volumes returned to normal. The patient was disconnected from the anesthesia circuit and positioned prone for the procedure. His face was placed on a foam pad (Pediatric Gentletouch 4; Orthopedic Systems, Inc., Union City, CA, USA), and the circuit was reconnected. Shortly after reconnecting the circuit, ETCO2 and tidal volumes decreased to zero, and breath sounds were absent. Positive-pressure ventilation by bag was ineffective. A kink in the tube was suspected, and the patient’s head was repositioned, with no improvement in ventilation. An 8F soft suction catheter was again inserted and upon withdrawal of the catheter, a white foreign body was noted in the endotracheal tube. The foreign body migrated distally with attempts at ventilation, and could not be withdrawn with the 8F catheter. A 10F soft suction catheter was passed, and the foreign body was retrieved. The patient’s oxygen saturation remained above 96% and his heart rate above 100 throughout this time. Tidal volumes and ETCO2 returned to normal, and the rest of the case was uneventful. The foreign body was a 12 · 4 · 5 mm piece of white foam. Upon further inspection, a small gouge in the foam face pad, near the premade passage for the endotracheal tube, was noted and was equal in shape and size to the foreign body. There are numerous case reports of foreign bodies recovered from airways and anesthesia circuits. There are fewer reports of anesthesia equipment obstructing the endotracheal tube. There may be a higher risk with smaller pediatric tubes, as demonstrated by this incident and those cited above. The step of disconnecting and reconnecting the endotracheal tube to the circuit always entails the risk of subsequent complications as the integrity of the circuit is temporarily disrupted. Visual inspection of the circuit should always be undertaken after any disconnection. However, in our situation, only the connector piece of the endotracheal tube was readily visible. The foreign body was initially thought to be a mucus plug, because our patient did have a recent URI and mild ventilatory difficulty at the beginning of the case. Fortunately, positive-pressure ventilation did not push the foam into the bronchial tree, which could have caused more serious complications and required bronchoscopy for retrieval. We are not aware of another instance of this specific complication, despite foam pads being used commonly for surgery in the prone position. Benjamin J . Walker Sally E. Rampersad Department of Anesthesiology and Pain Medicine, University of Washington School of Medicine, Seattle Children’s Hospital, Seattle, WA 98105, USA (email: benjamin.walker@seattlechildrens.org)

Airway anesthesia for awake fiberoptic intubation in management of pediatric difficult airways

1 Brett CM, Davis PJ, Bikhazi G. Anesthesia for neonates and premature infants. In: Motoyama EK, Davis PJ, eds. Smith’s Anesthesia for Infants and Children, 7th edn. St. Louis, USA: C.V. Mosby, 2006: 521–570. 2 Cote CJ. Pediatric anesthesia. In: Miller RD, ed. Miller’s Anesthesia, 6th edn. Philadelphia: Churchill Livingstone Inc., 2005: 2367–2407. 3 Boloker J, Bateman DA, Wung JT et al. Congenital diaphragmatic hernia in 120 infants treated consecutively with permissive hypercapnea ⁄ spontaneous respiration ⁄ elective repair. J Pediatr Surg 2002; 37: 357–366. 4 Paul O, Mely L, Viard L et al. Acute presentation of congenital diaphragmatic hernia past the neonatal period: a life threatening emergency. Can J Anaesth 1996; 43: 621–625. 5 Wilson WC, Benumof JL. Respiratory physiology and respiratory function during anesthesia. In: Miller RD, ed. Miller’s Anesthesia, 6th edn. Philadelphia: Churchill Livingstone Inc., 2004: 679–722.

Lightwand guided nasotracheal intubation in children with difficult airways

was maintained with oxygen, air and isoflurane (1.5–2%) and intermittent positive pressure ventilation. Analgesia was supplemented with fentanyl 4 lg and morphine 0.1 mgÆkg in incremental doses. A slight head up tilt, intravenous inj.mannitol 0.25 gÆkg and inj. lasix 1 mg were used to decrease the intracranial pressure. The surgery lasted for 9 h and the patient’s temperature was maintained between 36 and 37 C with an underbody forced air warmer and IV fluid warmer. The intraoperative blood loss was approximately 800 ml, which was replaced with 600 ml of whole blood and 200 ml of fresh frozen plasma. Urine output was 10–20 mlÆkgÆh, which was replaced along with a maintenance fluid (normal saline and ringer lactate). A CVP of 8–10 mm of mercury was maintained during surgery. At the end of the craniofacial surgery, arterial blood gas, coagulation profiles, PCV and serum electrolytes were checked and found to be normal, except for a low serum potassium (2.8 meqÆl), which was treated with potassium supplementation. A subcutaneous drain connected to a small container (Romsons, Nunhai, Agra, India, Minivac Figure 1) was placed and the cranial incision was sutured. The child was re-draped and the ophthalmic surgeon proceeded with enucleation of the left eye. Initially the child was stable but the systolic blood pressure started drifting down over 20 min. Then he had a bradycardia (HR 55 per minute) which was treated with atropine. The heart rate and blood pressure went up followed by severe bradycardia and hypotension. The drapes were removed and it was found that the surgical drain receptacle was full and further drainage was not possible leading to a ‘shiny and tense distended head’ with a marked increase in intracranial pressure. Immediately the scalp sutures were reopened and the venous bleeding controlled. During this period the child lost about 300 ml of blood, which was immediately replaced with intravenous tetra starch 20 mlÆkg, (Voluven, Fresenius Kabi, Pune, India) and blood when it was obtained 30 min later. A repeat coagulation profile was deranged and more Fresh Frozen Plasma was required for correction. Because of this acute episode and the deranged parameters, it was decided not to extubate and the child was shifted to pediatric intensive care unit. Blood loss following craniofacial reconstruction is a known complication (1). In this particular case, blood loss during the surgery was replaced adequately but during the period of enucleation of the eye, blood loss in the surgical drain was not visible externally as it was covered under the surgical drapes (2). The size of the drain chamber was small (50 ml) and inadequate. Once full it could not accommodate the excess blood from the venous ooze. The tight closure of scalp and the full drainage container led the blood to collect extradurally resulting in intracranial hypertension, bradycardia and hyper tension [Cushing’s reflex (3)] followed by severe hypotension and near cardiac arrest. Rebecca Jacob Kamal Kumar Amar Nandhakumar Department of Anaesthesia, Christian Medical College, Vellore, Tamilnadu, India (email: rebeccajacob@hotmail.com)

An intraoral fixation method of endotracheal tube using the surgical suture in pediatric patients

tion of anaesthesia mask for fibreoptic intubation in children. Paediatr Anaesth 1999; 9: 119–122. 5 Holm-Knudsen R, Eriksen K, Rasmussen LS. Using a nasopharyngeal airway during fiberoptic intubation in small children with a difficult airway. Pediatr Anesth 2005; 15: 839– 845. 6 Paterson NA. Management of an unusual pediatric difficult airway using ketamine as a sole agent. Pediatr Anesth 2008; 18: 785–788. 7 Bryan Y, Chwals W, Ovassapian A. Sedation and fiberoptic intubation of a neonate with a cystic hygroma. Acta Anaesthesiol Scand 2005; 49: 122–123. 8 Smith JA, Santer LJ. Respiratory arrest following intramuscular ketamine injection in a 4-year-old child. Ann Emerg Med 1993; 22: 613–615. 9 Antila H, Laitio T, Aantaa R et al. Difficult airway in a patient with Marshall-Smith syndrome. Paediatr Anaesth 1998; 8: 429– 432. 10 Hostetler MA, Barnard JA. Removal of esophageal foreign bodies in the pediatric ED: is ketamine an option? Am J Emerg Med 2002; 20: 96–98.

Intra‐oral stabilisation of the reinforced tracheal tubes using the surgical suture

1 Fanning RM. Monitoring during sedation given by non-anaesthetic doctors. Anaesthesia 2008; 63: 370–4. 2 Association of Anaesthetists of Great Britain and Ireland. Recommendations for Standards of Monitoring During Anaesthesia and Recovery. Guidelines of the Association of Anaesthetists of Great Britain and Ireland. London: AABGI, March 2007. 3 National Confidential Enquiry into Patient Outcome and Death. Scoping our Practice: The 2004 Report of the National Confidential Enquiry Into Patient Outcome and Death. London: NCEPOD, 2004. 4 Williams EJ, Taylor S, Fairclough P, et al. Are we meeting the standards set for endoscopy? Results of a large-scale prospective survey of endoscopic retrograde cholangio-pancreatograph practice. Gut 2007; 56: 821–9. 5 UK Academy of Medical Royal Colleges and their Faculties. Implementing and Ensuring Safe Sedation Practice for Healthcare Procedures in Adults. Report of an Intercollegiate Working Party Chaired by the Royal College of Anaesthetists. London: Royal College of Anaesthetists, 2001.

More maneuvers to facilitate endotracheal intubation using the Bonfils fiberscope in children with difficult airways

SIR—We were interested to read the case of a difficult intubation in a small for gestation age newborn using a retromolar intubation endoscope (1). We have found the Brambrink retromolar intubation endoscope (Karl Storz, Tuttlingen, Germany) (Figure 1, above) useful for difficult diagnostic laryngoscopy and intubation in neonates. The Brambrink has a very fine 22 cm optical rod of outside diameter (OD) 2.0 mm, suitable for endotracheal tubes (ETTs) 2.5–3.5 mm. In our experience, the Brambrink’s distal curve of 40 , has also provided good conditions for glottic visualization in infants where direct laryngoscopy and rigid laryngoscopy with Hopkins rods of 0 and 30 have failed. The ability to insufflate oxygen via the tube holder prolongs the diagnostic time.

Anesthesia and airway management for children with tonsillar hypertrophy

SIR—We read with interest the recent letter of Sabapathi and Macneil (1) regarding tonsillar hypertrophy in a young infant. We congratulate the authors on a safe airway management using the facemask ventilation and laryngoscopic intubation in this rare case. Because lifethreatening upper airway obstruction and difficulty with intubation may occur after anesthesia induction (2), anesthetic management of children with tonsillar hypertrophy is really centered around the preservation and control of the upper airway, especially for children with associated craniofacial anomalies, adenoidal hypertrophy and obstructive sleep apnea (OSA) syndrome (3). Therefore, we would like to offer a few suggestions that can improve anesthetic safety and facilitate airway management in children with tonsillar hypertrophy according to our practice. Tonsillar hyperplasia is a physiologic phenomenon of childhood. The volume of tonsillar tissue in the upper airway increases from about 6 months of age up to puberty (2). Hypertrophic tonsils can significantly narrow oral and pharyngeal airways and plays a major role in the pathogenesis of OSA syndrome in children. During the preoperative visiting, therefore, awareness of the clinical features of OSA syndrome in children with tonsillar hypertrophy is important as the diagnosis may previously have been missed (3). The anesthetist should enquire specifically about sleeping habit and snoring in all children presenting for anesthesia. If a child is thought to have OSA syndrome, a full preoperative assessment is necessary. If possible, a corrective otolaryngological surgery should be firstly undertaken. For children with a known severely bilateral tonsillar hypertrophy, we prefer inhalational induction with maintenance of spontaneous ventilation because it can produce a smooth transition from spontaneous to assisted ventilation which may ease the management of a difficult airway. Also the effects of anesthesia are reversible if difficulties in maintaining an airway occur. Sevoflurane has smoother and more rapid inhalational induction characteristics with faster emergence compared with halothane, which may be advantageous (4). If the upper airway becomes obstructed during induction, this can usually be relieved by the jaw thrust, use of an oral or nasal pharyngeal airway or use of continuous positive airway pressure (CPAP). In children with tonsillar hypertrophy, moreover, lateral positioning combined with jaw thrust may significantly improve airway patency compared with the jaw thrust alone in the supine position and can avoid airway complications of an airway insertion under light anesthesia, such as laryngospasm, coughing, breath-holding, etc. (5). When visualization of the glottis during direct laryngoscopy is difficult because of hypertrophic tonsils, multiple intubation attempts must be avoided to decrease the risks of the upper airway trauma. Bleeding and edema of the upper airway may not only make the task even more difficult, but also can put the child at greater risk of loss of airway control and make the child more susceptible to postoperative airway obstruction. When the laryngoscopic intubation fails, therefore, we often use the lightwand guided intubation under laryngoscopy as rescue option. After the tongue is completely displaced to the left side of the mouth by the flange of the laryngoscope blade, the lightwand with the endotracheal tube is inserted between the bilateral hypertrophic tonsils. If the tip of the lightwand is placed at the glottic opening, a well-defined circumscribed glow can be seen in the anterior neck slightly below the laryngeal prominence (Figure 1). If a glow is not seen, the lightwand should be repositioned. A main advantage of this technique is that under the guide of laryngoscopy, the lightwand may easily be positioned at the laryngeal aperture according to transillumination of soft tissues of the anterior neck, without risk of trauma to the hypertrophic tonsils. For children with a known difficult airway because of combined craniofacial anomalies and tonsillar hypertrophy, we frequently use a laryngeal mask airway (LMA) to maintain airway patency during induction. To prevent

Airway topical anesthesia using a rigid fiberoptic stylet in children with difficult airways.

Overall CP is Useful 82% Harmful 7.1% Both 3.2% Blank 7.1% Do you use succinylcholine when performing rapid sequence intubation? In Females 1.3% In both males and females 68% Never 29% No response 1.9% Do you always premedicate for aspiration prophylaxis? Yes 9.1% No 91% Do you use Succinylcholine when performance rapid sequence intubation? Females only 1.3% Both males and females 68% Never 29% Blank 1.9% Do you ever use bimanual CP? Yes 18.2% No 80% Blank 1.9% Table S-5 Contraindication of cricoid pressure as described by the respondents