Noriko Miyazawa

Nasal intubation with Bullard laryngoscope : a useful approach for difficult airways

Since the original technique using the Bullard laryngoscope requires considerable practice to be reliable, we have developed an easier method with a directional-tip endotracheal tube through the nostril. We first examined the feasibility of our method in patients with or without difficult airways. All 26 patients with difficult airways were successfully tracheally intubated with our method, and times for visualization and intubation were not different from those in 10 patients with normal airways. We further examined the direction of the tips of endotracheal tubes through the nostril in 128 patients with normal airways using four combinations of two kinds of both laryngoscopes (Bullard and Macintosh) and endotracheal tubes (directional-tip tube: EndotrolTM Mallinckrodt Laboratories, Athlone, Ireland; or straight distal-end tube: Blue LineTM, Portex Ltd., Hythe Kent, United Kingdom). We found that a combination of the Bullard laryngoscope and the EndotrolTM tube had a higher probability of accessing the center of the glottis than the others. In conclusion, nasal insertion of a directional-tip tube assisted by the Bullard laryngoscope is an assured and prompt procedure for intubating the tracheas of patients with difficult airways.

Epidural anesthesia during upper abdominal surgery provides better postoperative analgesia

Since repeated noxious stimuli may sensitize neuropathic pain receptors of the spinal cord, we tested the hypothesis that the appropriate blockade of surgical stimuli with epidural anesthesia during upper abdominal surgery would be beneficial for postoperative analgesia. Thirty-six adult patients undergoing either elective gastrectomy or open cholecystectomy were randomly allocated to receive either inhalational general anesthesia alone (group G) or epidural anesthesia along with light general anesthesia (group E) throughout the surgery. Postoperative pain management consisted of patient-controlled analgesia (PCA) with bupivacaine accompanied by the continuous infusion of buprenorphine. To assess postoperative pain, a visual analogue scale (VAS) was employed at 2, 24, and 48 h postoperatively. While there was no significant difference in the bupivacaine dose, more patients undergoing gastrectomy in group G required supplemental analgesics than those in group E, and the VAS scores in group E demonstrated significantly better postoperative analgesia compared to group G after both types of surgery. Thus, an appropriate epidural blockade during upper abdominal surgery likely provides better postoperative pain relief.

A Case of General Anesthesia for a Young Infant in Whom Intubation Was Suspected to Be Difficult Because of a Thyrolingual Cyst

This is a case report of an infant who underwent thyrolingual cystectomy under general anesthesia. Two tracheal tubes were used: 1 for nasopharyngeal airway and the other for fiberoptic intubation. With this method, nasal intubation was successfully performed without hypoxia and hypercapnia even in a 3-month-old infant. We concluded this is a useful intubation method for infants who are predicted to be a difficult intubation.

Distribution of sciatic nerve division in children: a prospective observational study using an ultrasound device

in addition to a lack of an appreciation for the consequences of their requests. Moreover, the challenges of conveying that to a family and patient as well as building trust with them. Finally, it attests to the sequela when a potential error in the literature is open to misinterpretation and then used as dogma. We write to share our experience as well as see if others have faced similar challenges.

A Pediatric Case With Takotsubo Cardiomyopathy and Neurogenic Pulmonary Edema Due to an Epidural Hemorrhage

To JNA Readers: Type 1 Chiari malformation was diagnosed in a 14-year-old girl. She underwent a foramen magnum decompression and cervical laminectomy. The operation was completed without event but on the fourth postoperative day, the patient experienced loss of consciousness and magnetic resonance imaging of the brain revealed an epidural hemorrhage compressing the right cerebellum. An emergency hematoma removal in the prone position was scheduled. During the hematoma removal, sudden circulatory collapse occurred with the electrocardiogram (ECG) showing more ST segment depressions in II/III/aVF than in the preoperative state. Besides, the inspiratory pressure increased gradually. Frothy, bloody fluid pooling in the endotracheal tube flowed toward the heat and moisture exchanger, requiring frequently removal by suction. The postoperative transthoracic echocardiogram showed apical ballooning and moderate-to-severe mitral regurgitation (MR) (Fig. 1). Chest computed tomography showed obvious bilateral consolidation (Fig. 2). Takotsubo cardiomyopathy (TC), which is also called stressinduced cardiomyopathy, is a transient, regional, systolic dysfunction of the left ventricle with symptoms of chest pain and often, shortness of breath triggered by an emotionally, or physically stressful event.1 A central neurological insult can also lead to neurogenic pulmonary edema (NPE), defined as acute pulmonary edema occurring shortly after a central neurologic insult. In the pediatric population, the occurrence of both TC and NPE at the same time is rare. Although the overall incidence of ECG changes resulting from head injuries in adults is 12%, the figure for children is not known. Some pediatric cases of acute ECG change suggesting myocardial damage following a severe head injury have been documented.2 In our patient, acute hemodynamic fluctuations with ECG changes indicative of neuronal disease suggested the diagnosis of TC intraoperatively. Postoperative transthoracic echocardiogram showed ballooning of the apex region. The cardiac dysfunction remitted within a few days which was consistent with the typical time course for TC. This case met 2 of the 4 Mayo Clinic criteria, namely, wall motion and new ECG abnormalities. Normally all 4 criteria should be met for the diagnosis of TC.3 As for the 2 remaining criteria, namely, the absence of obstructive coronary disease and the absence of pheochromocytoma or myocarditis, we did not perform a coronary angiography because we considered that the probability of a coronary arterial event in this young girl was low enough while the risk posed by a coronary angiography outweighted any benefit to diagnosis. Pheochromocytoma and myocarditis were negative based on her clinical course. FIGURE 1. Transthoracic echocardiogram showing left ventricular apical ballooning and moderate-to-severe mitral regurgitation.

Anesthetic Management in Mitochondrial Encephalomyopathy: A Case Report

We report on a morbidly obese 16-year-old boy (weight, 116 kg; height, 176 cm; body mass index, 35.5 kg/m2) with mitochondrial encephalomyopathy and a history of cerebral infarction, epilepsy, and severe mental retardation. The patient was scheduled for elective surgery under general anesthesia for multiple dental caries and entropion of the left eye. Preoperative examination results, including an electrocardiogram, were normal. No obvious cardiac function abnormalities were observed on echocardiography. Midazolam (10 mg) was administered orally as premedication 30 minutes before transfer to the operating room; however, the patient was uncooperative, and his body movements were difficult to control upon entering the operating room. This complicated our attempts to establish a peripheral intravenous line and necessitated volatile inhalational induction, followed by maintenance using total intravenous anesthesia. General anesthesia was used to minimize metabolic system stress. We did not use an infusion solution containing sodium lactate. The operation and subsequent clinical course until discharge were uneventful. Because aerobic metabolism is already compromised in patients with mitochondrial encephalomyopathy, anesthetic management should be designed to avoid placing additional stress on the metabolic system.

External reinforcement of tracheal tube by using polyvinyl chloride tube.

little risk of harm. Our results demonstrate that there is still great variation in the aseptic technique employed by pediatric anesthetists in performing caudal anesthesia, despite national guidelines on the subject (2). Given the poor availability of evidence to guide decision-making, and the rarity of neuraxial infection after these procedures (4,5) preventing adequate controlled studies, it seems likely that disagreement on the best way to provide asepsis will continue.

Muscle injury following laparoscopic appendectomy

To the Editor: We describe a rare case of position-related muscle injury in a previously healthy 13-year-old boy (height 155 cm; weight 45 kg) undergoing laparoscopic appendectomy. The surgery was performed in supine position with the patient under general anesthesia and thoracic epidural analgesia. Duration of the laparoscopic procedure was 78 min. Patient positioning was in a head-down position as great as 30 . We carefully monitored the patient’s position to avoid compressing his body. After emerging from anesthesia, he did not complain of surgical site pain or hip pain. However, he complained of severe left hip pain after 6 h. The hip appeared to be swollen and tender. On postoperative day 3, magnetic resonance imaging did not indicate other serious diseases, such as necrotizing fasciitis or rhabdomyolysis (Supplementary Fig. 1). The muscle pain was improved by conservative therapy. Despite full-scale preparations for minimizing risk, position-related muscle injury occurred in a healthy pediatric patient. When a patient is in the head-down position, maintenance of limb perfusion is important to avoid position-related soft tissue injury [1]. Estimating from a simple model in a head-down position of 30 (Supplementary Fig. 2), blood pressure around the hip drops about 1/5.44 9 (height, cm) mmHg compared to that of the head. In pediatric cases, this pressure gradient could have a bad influence on limb perfusion because the normal blood pressure in children is lower than in adults. Additional intermittent measurement of blood pressure at the lower extremity could be effective for monitoring limb perfusion. If blood pressure in the lower extremity cannot be maintained, the anesthesiologist should consider intermittent reversal of the head-down position or limiting the duration of that position.

Comment on an article by Ahuja et al.

To the Editor: The case reported by Ahuja et al. [1] entitled ‘‘Infant feeding tube as rescue endotracheal tube in an infant with an aerodigestive foreign body’’ is very interesting. They used an 8 Fr infant feeding tube (IFT, outer diameter of 2.4 mm) as a rescue endotracheal tube (ETT) for a 1-yearold boy undergoing a procedure for the retrieval of a small button battery, which resulted in avoidance of emergency tracheostomy. We agree that it is beneficial to use an alternative airway apparatus on a case-by-case basis for performing safe pediatric anesthesia. We would like to know the details of the intraoperative respiratory management including the ventilator setting, EtCO2 waveform, and expiratory pressure. The author did not mention the inner diameter (ID) of the IFT. We assume that the IFT used was approximately 2.0 mm ID, if the estimated IFT wall thickness was approximately 0.2 mm. According to Hagen-Poiseuille’s law, airway resistance of an IFT would be 16 times as high as that of an ETT with an ID of 4.0 mm, which is generally said to be the ideal size for a healthy 1-year-old boy. High airway resistance could be a problem during the expiratory phase, causing hypercapnia and auto-positive end-expiratory pressure. Airway complications could arise because of mechanical compression during endoscopic removal of the foreign bodies, even though ventilation was initially secured. As the author mentioned, it is important to make ready various types of equipment to facilitate intubation. In addition, we suggest that the preparation of emergency invasive airway access should be continued even after intubation in a case of compromised airway.