Marco Caruselli

Difficult intubation in a small for gestational age newborn by bonfils fiberscope

The neonate has the anatomic and physiologic peculiarities that completely diversify it from an adult although they are externally alike. In fact, the newborn has a prominent occiput, a proportionally larger tongue, a large and omega shaped epiglottis, an aditus of larynx in higher position (C3–C4 vertebral level). The airway has a very narrow caliber so that the presence of an edema can easily obstruct them and typically the larynx gets narrower in the subglottic region having a shape approximately like a cone (1). Those special marks can make the endotracheal intubation in a newborn more difficult than in an adult, especially if the operator is not used to treat the pediatric patients. Today the anesthetist has many tools to help him largely in case of difficult intubation: • the laringeal mask (2) • kit for retrograde tracheal intubation (3) • fiberoptic endoscopy (4) • rigid bronchoscope • rigid fiberscope for intubation Bonfils (5) Other useful tools for adults like the Fastrach laringeal mask; there are not in sizes that fit the neonates. The Bonfils fiberscope is a rigid fiberoptic device used in difficult intubating conditions. It is a rigid stylet with a 40 curved tip and it has to be inserted inside the endotracheal tube and positioned just proximal to the tip of it. It is possible to connect the eyepiece placed on the stylet handle to a video and a cold light source or a small battery can be attached to the same handle. There is also a lock to fix the endotracheal tube and a connector that permits oxygen insufflation inside the tube during intubation (Figure 1). We relate a case of a difficult intubation in a small for gestational age newborn in whom the Bonfils fiberscope was successfully used. A male neonate was born at 37 wk of gestation, 1520 g weight, in respiratory failure with an Apgar score 2-4-4. A during the pregnancy echography showed the fetal size <5 percentile, right cerebral borderline ventriculomegaly, possible hypoplasia of jaw bone, the tetralogy of Fallot. Since the beginning, the tracheal intubation appeared extremely difficult for the presence of the mandibular hypoplasia (Figure S1) and the enormous size of the tongue made it impossible to visualize the aditus of larynx. After the failure of some attempts, we decided to go on by video-assisted intubation. A 2.5-mm-uncuffed tube was chosen and applied on rigid Bonfils fiberscope; the fiberoptic laryngoscopy permitted us to put in evidence the aditus of larynx, otherwise impossible to visualize by a classic laryngoscopy, and to intubate the patient by oral endotracheal intubation. The intubation was confirmed by capnographic curve and thoracic auscultation. The Bonfils rigid fiberscope showed to be a useful tool for a difficult intubation of the low-weight premature infant. It is recommended to prepare in advance this tool when it is expected a difficult intubation, because repeated attempts of intubation can cause in the neonate dangerous accidents (laryngospasm or hemorrhage) because of delicacy of the airway’s mucosa. Marco Caruselli Rita Zannini Roberto Giretti Giovanni Rocchi Gianfranco Camilletti Patrizia Bechi Francesco Ventrella Roberta Pallotto Raffaella Pagni Anesthesia and Intensive Care Unit, Children’s Hospital ‘‘G. Salesi’’, Ancona, Italy (email: camr@libero.it)

The pinch-off syndrome in a pediatric patient

Recombinant activated coagulation factor VII was developed for treatment of hemophilia with antibodies (inhibitors) to coagulation factors VIII or IX (2). The usage indications are extended for the therapy of congenital deficiency of coagulation factor VII and Glanzmann’s thrombasthenia. It has been recently employed with benefit for the management of hemorrhages in other non-hemophilic congenital and acquired hemostatic abnormalities. A number of reports describe usage of rFVIIa in DIC associated with various conditions (4). In all these reports, the response to treatment was very good, although the mechanism by which the bleeding was stopped remains unknown. The prime mechanism by which abnormalities of the hemostasis develop in KMS is platelets trapping and activation (5). As activated platelets play major role in therapeutic efficacy of rFVIIa, there is a reasonable concern that in KMS side effects of rFVIIa might be more pronounced than in DIC associated with other conditions. However, we decided that in a child with persistently low platelet count, facing major surgery, all therapeutic options should be used. Careful clinical monitoring in our patient revealed no side effects of rFVIIa. The role of rFVIIa in controlling hemostasis during this procedure is difficult to access. We measured prothrombine time, which was as expected shortened, after rFVIIa administration. Hematoma was partially resected and hematological disturbances characteristic of KMS persisted trough out the operation. Although blood loss during the operation was extensive, we speculate that this procedure might not be possible at all without addition of rFVIIa. Medline search using key words: Kasabach-Merritt syndrome and rFVIIa, did not reveil any matching article. Therefore, our report on a successful use of rFVIIa in a child with full-blown KMS suggests that rFVIIa might be an useful addition to the existing therapeutical strategies. Dragana Janic* Dimitri je Brasanac† Nada Krstovski* Lidija Dokmanovic* Jelena Lazic* Zoran Krstic* *Department for Hematology and Oncology, University Children‘s Hospital, Belgrade, Serbia †Institute of pathology, Medical school, University of Belgrade, Belgrade, Serbia

Optimal Position of a Long-Term Central Venous Catheter Tip in a Pediatric Patient with Congenital Diseases

Progress in medical and scientific research has increased the chances of survival for young patients with congenital diseases, children who, in the past, would not have had any chance of survival. Nowadays, congenital diseases can be treated with appropriate replacement therapies. These treatments can be difficult to administer in young patients because of the high frequency of administration (sometimes more than a dose per week), the use of intravenous infusion and the long-term or life-term requirement.

Correlation of bispectral index (BIS) monitoring and end-tidal sevoflurane concentration in a patient with lobar holoprosencephaly

OBJECTIVE The bispectral index (BIS) is a parameter derived by electroencephalography (EEG) which provides a direct measurement of the effects of sedatives and anesthetics on the brain and offers guidance on the adequacy of anesthesia. The literature lacks studies on BIS monitoring in pediatric patients with congenital brain disease undergoing general anesthesia. CLINICAL FEATURES A 13-year-old child weighing 32kg, suffering from lobar holoprosencephaly, underwent surgery in which the bispectral index (BIS) monitoring the depth of anesthesia showed an abnormal response. Detailed analysis of the trends of BIS values in the different observation times demonstrated sudden falls and repetitive values of BIS likely related to repetitive epileptiform electrical activity caused by sevoflurane. CONCLUSION The BIS is a very useful monitoring tool for assessing the degree of depth of anesthesia and to analyze the electroencephalographic variations of anesthetics. Particular attention should be given to patients with congenital disorders of the central nervous system in which the BIS may give abnormal responses that do not reflect an accurate assessment of the depth of anesthesia.

Correlação entre monitoração do índice bispectral (BIS) e concentração expirada de sevoflurano em paciente com holoprosencefalia lobar

OBJECTIVE The bispectral index (BIS) is a parameter derived by electroencephalography (EEG) which provides a direct measurement of the effects of sedatives and anesthetics on the brain and offers guidance on the adequacy of anesthesia. The literature lacks studies on BIS monitoring in pediatric patients with congenital brain disease undergoing general anesthesia. CLINICAL FEATURES A 13-year-old child weighing 32kg, suffering from lobar holoprosencephaly, underwent surgery in which the bispectral index (BIS) monitoring the depth of anesthesia showed an abnormal response. Detailed analysis of the trends of BIS values in the different observation times demonstrated sudden falls and repetitive values of BIS likely related to repetitive epileptiform electrical activity caused by sevoflurane. CONCLUSION The BIS is a very useful monitoring tool for assessing the degree of depth of anesthesia and to analyze the electroencephalographic variations of anesthetics. Particular attention should be given to patients with congenital disorders of the central nervous system in which the BIS may give abnormal responses that do not reflect an accurate assessment of the depth of anesthesia.

Cuffed and Uncuffed Tubes and the Geometric Correlation with Pediatric Airway

To the Editor: We read with great interest the article by Litman1 concerning the problems surrounding the choice of cuffed and uncuffed tracheal tubes in anesthesia and pediatric intensive care. Although the issue has been on debate for many years and now there is a general belief that cuffed tubes can also be safely used in children, I think it is important to make some reflections on the strict geometrical relationship between tracheal tubes and the anatomy of the cricoid and trachea. Both Litman and Weiss2,3 have frequently reported and demonstrated that the cricoid lumen is not circular but rather of an ellipsoidal shape. By performing investigations with nuclear magnetic resonance, Litman has shown that the cricoid ring in its cross section is narrower than the anteroposterior section. This finding is, in our opinion, of considerable clinical importance and should not be overlooked. Considering that the orotracheal tubes have a perfectly circular shape, they are ill-adapted within an ellipsoidal structure. If we try to draw a circle inside an ellipse, imagining that the circle represents the tube and the ellipse is the cricoid, we can easily demonstrate that the tracheal tube, even if the proper size, can apply excessive pressure on cricoid structures along the minor axis of its elliptical shape. At the same time, the tube would not adhere well to the lateral areas of the cricoid corresponding to the major axis of the ellipse. This circumstance, in the presence of uncuffed tubes, creates the condition for an imperfect seal in the tube airway system with an increased risk of microinhalation, loss of gas, requiring repeated adjustments of mechanical ventilation parameters. Another risk present is the excessive movement of the tube and its tip with In Reply: We thank Dr. Eisenkraft for taking the time to write regarding our recent article1 and describe to us a detailed alternative scheme by which expiratory limb ventilation can be provided. The suggestion is valid and not the one that we thought of in this emergency. We were unaware of the Kummar et al. description, which does not explain how the Bain circuit was pressurized on his Aisys machine (GE Healthcare, Madison, WI). Dr. Eisenkraft’s alternative demands mental preparation for such emergencies, just as we taught our option in previous simulations, and would require that the clinician recall the alternate common gas outlet circuitry immediately within a crisis situation. Although we admire his technically accurate methods of scavenging the volatile agent, we believe that such connections would not be available or clinically necessary in a brief emergency situation. From a technical perspective, we would like to raise three issues with his alternative.

Intubation using a "bonfils fiberscope" in a patient with pfeiffer syndrome.

To the Editor: Pfeiffer syndrome is an autosomal dominant disorder characterized by craniosynostosis, brachicephaly, midface hypoplasia, low nasal bridge, flat occiput, severe ocular proptosis, over-sized tongue, and cerebral ventriculomegaly (Fig. 1). Providing general anesthesia in such patients could lead to complications in terms of airway management, due to potential difficulties in ventilation using the facial mask or tracheal intubation. A Bonfils fiberscope is a handy device to overcome difficulties of intubation, both in pediatric patients and in neonates. It is a rigid telescopic stylet with a 40-degree curved tip, which is inserted inside the endotracheal tube, keeping its distal end positioned just proximal to tip of the tube. The proximal eyepiece end of the device allows connections for a video monitor and a fixed or battery-operated light source. The instrument can be easily locked onto an endotracheal tube, while a special connector allows administration of the gases during intubation. The instrument is available in various sizes and its design makes intubation easy under direct visualization. The main limiting factor for its use is the rigidity, which may increase the risk of airway trauma. Obviously, it cannot be used for nasal intubation. We encountered the case of a 6-year-old patient, weighing 21 kg, who had Pfeiffer and Arnold Chiari syndromes, with caudal migration of cerebral tonsils to the level of the second cervical vertebra. Due to the presence of loud snoring and oxygen desaturation during sleep, the patient was required to undergo adenoidectomy under general anesthesia. The endotracheal intubation was found to be very challenging in this particular case. The induction was carried out with an intravenous administration of fentanyl 60mcg and propofol 60mg. At this stage, the anesthesiologist performed upward traction of the patient’s mandible by holding it between the left hand thumb and the forefinger (Fig. 1B) without using the laryngoscope. The Bonfils fiberscope, held in the right hand, was inserted through the oral cavity, the scope preloaded with size 5.5mm, and the intubation was performed without any difficulty. Our case illustrates that the Bonfils fiberscope allows easy intubation in cases with a complicated upper airway anatomy without requiring a laryngoscope. Some authors do believe, however, that the use of a laryngoscope may be necessary when the Bonfils fiberscope is used in adult patients. We recommend that the operator practice the intubation on a mannequin, according to the aforementioned method before the actual procedure. In summary, we find the rigid Bonfils fiberscope a useful device for difficult intubation in pediatric patients with a complex upper airway anatomy. We recommend that this instrument be made available in operatory rooms where pediatric patients undergo general anesthesia.

Central venous catheters in neonates: From simple monolumen to port catheter

The use of Central Venous Catheters (CVCs) represents an important step in the management of the surgical, onco-hematology and critically ill patients. CVCs in neonates, like in adult patients, are mainly used to infuse hyperosmolar solutions, to take blood samples and for hemodynamic monitoring. The need for CVCs is higher in neonates than in adults. Poor peripheral access and the high demand for IV access and blood samples are already valuable indications for a CVC.

Epidural analgesia during labor and incidence of cesarian section: prospective study

For many years the opportunity of reducing the pain of birth through the administering of drugs (e.g. local anesthetics and opioids) into the epidural space has been known. Numerous studies have been conducted throughout the years to clarify whether the use of the epidural has resulted in a higher incidence of cesarean sections but it appears that this is due more to maternal–fetal factors than it is to the epidural. In this study, we have outlined the experience of the Anesthesia and Intensive Care Unit of an Italian Childrens Hospital in which approximately-2500 births take place every year and in which there is an active birth analgesia service which requires the presence of a dedicated anesthetist.

Bilateral ultrasound transversus abdominis plane block in a patient affected from Menkes disease

This case report demonstrates the utility and safety of ultrasound transversus abdominis plane (TAP) block in a paediatric patient suffering from Menkes disease. Anaesthetists, and particularly paediatric and neonatal anaesthetists, have to make a careful assessment of these patients, who are subjected to frequent surgeries, despite their tender years. These operations are often necessary in order to improve the patients quality of life as much as possible. The choice of anaesthetic technique must take the particular nature of the disease and the patients medical history into consideration, while careful preparation and preoperative evaluations make it possible to administer the general or local anaesthetic safely. Official literature on the subject does not provide sufficient information about the use of local anaesthetic techniques. Moreover, the use of ultrasound TAP block in patients affected by Menkes disease has never been published in literature. In our experience, ultrasound TAP block has provided positive results, although the rarity of this childhood disease makes a detailed study difficult.