Scott D. Cook-Sather

Lighted Stylet Tracheal Intubation: A Review

Tracheal intubation is older than the recognized his-tory of general anesthesia itself. In the late 18th cen-tury, The Royal Humane Society of London used tra-cheal intubation for resuscitating the near-drowned.Approximately 100 years later, MacEwan (1) per-formed a digital tracheal intubation in an awake pa-tient before a chloroform and air general endotrachealanesthetic for the resection of a tongue tumor, and in1928, Magill (2) incorporated blind nasal tracheal in-tubation as a part of a general anesthetic. Althoughlaryngoscopes were invented in the 19th century, tra-cheal intubation under direct visualization was greatlyenhanced by the development of a special laryngo-scope blade by Macintosh (3) in 1943.The first reported use of a lighted stylet used tofacilitate intubation came in 1957 when (by now SirRobert) Macintosh (4) described an 18-inch illumi-nated tracheal tube introducer, which was designed tostiffen the tube and better illuminate the cords bysupplementing the light of the laryngoscope. Berman(5) described a similar device in 1959 and said it wasuseful “when the fickle light of the laryngoscope hasgone out at the most inopportune time.” In the sameyear, Yamamura et al. (6) described a light bulb-tippedwire that was inserted into the tracheal tube beforeblind nasal intubation in awake patients. The tubeposition was then determined by the medial transillu-mination of the external throat and neck.In 1977, Foster (7) used a transilluminating fiberop-tic bundle to facilitate tracheal intubation in a youngchild with trismus, and Ducrow (8), in the followingyear, used a flexible surgical light (Flexi-lum™, Con-cept Corporation, Clearwater, FL) to achieve the sameend by first passing a guide (two plastic suction cath-eters connected end-to-end) into the trachea followedby passage of the tracheal tube over the guide. In acorrespondence to the latter article, Rayburn (9) com-mented that the Flexi-lum™ could be positioned in-side the tracheal tube, thereby shortening the intuba-tion sequence and claimed that the technique,nicknamed “lightwand intubation,” had been used forsome years at the Brooke Army Medical Center.

A comparison of awake versus paralyzed tracheal intubation for infants with pyloric stenosis

This prospective, nonrandomized, observational study of 76 infants with pyloric stenosis was conducted at an academic childrens hospital and compared awake versus paralyzed tracheal intubation in terms of successful first attempt rate, intubation time, heart rate (HR) and arterial hemoglobin oxygen saturation (SpO2) changes, and complications.Three groups were determined by intubation method: awake (A) with an oxygen-insufflating laryngoscope, after rapid-sequence induction (R), or after modified rapid-sequence induction (M) including ventilation through cricoid pressure. Successful first attempt intubation rate was 64% for Group A versus 87% for paralyzed Groups R and M (P = 0.028). Median intubation time was 63 s in Group A versus 34 s in Groups R and M (P = 0.004). Transient, mild decreases in mean HR and SpO2 and incidences of significant bradycardia and decreased SpO2 did not vary by group. Complications, including bronchial or esophageal intubation, emesis, and oropharyngeal trauma, were few. Senior anesthesiologists intervened in four tracheal intubations. We advocate anesthetized, paralyzed tracheal intubation because struggling with conscious infants takes longer, often requires multiple attempts, and prevents neither bradycardia nor decreased SpO2. After induction, additional mask ventilation with O2 confers no advantage over immediate tracheal intubation in preserving SpO2. Implications: In our childrens hospital, awake tracheal intubation was not superior to anesthetized, paralyzed intubation in maintaining adequate oxygenation and heart rate or in reducing complications, and should be abandoned in favor of the latter technique for routine anesthetic management of otherwise healthy infants with pyloric stenosis. (Anesth Analg 1998;86:945-51)

Gastric fluid measurement by blind aspiration in paediatric patients: A gastroscopic evaluation

PurposeNumerous investigators have estimated gastric fluid volume using blind aspiration through multi-onficed catheters, but none have confirmed the validity of this technique in infants and children. We sought to validate the accuracy of this technique in a fasted paediatric population by using gastroscopy. Data from several studies were then combined to generate a gastric fluid volume frequency distribution for healthy paediatric patients fasted for surgery.MethodsThis is a prospective study of 17 patients aged six months to 11 yr who underwent elective upper endoscopy at a paediatric teaching hospital. Gastric contents were aspirated blindly with a syringe and a 16 or 18F multi-orificed orogastric tube, and the volume of gastric contents removed in the supine and decubitus positions was measured. Residual gastric fluid was aspirated using an endoscope. Data from 611 infants and children enrolled in previously published stuthes utilizing the same blind aspiration technique were pooled and a gastric fluid volume frequency distribution was created.ResultsBlind aspiration removed 97 ± 8% of the total gastric fluid volume. In 661 children presenting for elective surgery, the gastnc fluid volume was 0.40 ± 0.45 ml·kg−1. Median volume was 0.27 ml · kg−1, with the 95%ile at 1.25 ml · kg−1 and an upper limit of 4.1 ml-kg−1.ConclusionBlind aspiration of gastric contents accurately estimates gastric fluid volume for paediatric patients fasted for surgery. Population estimates for gastric fluid volume in otherwise healthy fasted paediatric patients are shown.RésuméObjectifPlusieurs investigateurs évaluent à l’aveugle le volume du liquide gastrique à l’aide de cathéters à orifice multiples, mais aucun n’a jamais prouvé la validité de cette technique chez les nourrissons et les enfants. Cette étude visait à valider l’exactitude de cette technique avec la gastroscopie chez des enfants gardés à jeun pour la chirurgie. Les données compilées de plusieurs études ont été réunies pour créer une pente de distribution de fréquence du volume de liquide gastrique chez des jeunes patients non tarés gardés à jeun pour la chirurgie.MéthodesCette étude prospective, réalisée dans une hôpital pour enfants à vocation éducative, réunissait 17 jeunes patients de six mois à 11 ans programmés pour une endoscopie digestive supérieure. Avec le patient en position de décubitus, le liquide gastrique était aspiré à l’aveugle à l’aide d’une seringue aboutée à un tube nasogastnque 16 ou 18F à orifices multiples et mesuré. Le liquide résiduel était par la suite aspiré par endoscopie. Les données de 611 nourrissons et enfants recueillies à partir d’études antérieures sur la même technique d’aspiration étaient compilées et une distribution de fréquence établie pour le volume de liquide gastrique.RésultatsL’aspiration à l’aveugle a permis de retirer 97 ± 8% du volume gastrique total. Chez 661 enfants programmés pour une chirurgie élective, le volume du contenu gastrique était de 0,40 ± 0.45 ml·kg−1. La médiane du volume était de 0,27 ml·kg−1. avec un 95e centile à 1,25 ml·kg−1 et une limite supérieure à 4,1 ml·kg−1.ConclusionL’aspiration à l’aveugle du contenu gastrique évalue avec exactitude le volume du liquide gastrique chez des enfants gardés à jeun pour la chirurgie. Après validation, cette technique permet d’évaluer le volume du contenu gastrique chez des enfants non tarés à jeun.

Gastric fluid volume in infants for pyloromyotomy

PurposeTo quantify gastric fluid volumes in infants with pylonc stenosis presenting for pyloromyotomy and to demonstrate endoscopically the efficacy of blind aspiration for gastric fluid recovery. We hypothesized that previous diagnostic contrast studies, preoperative nasogastric suction, and fasting interval would not affect these volumes.MethodsSeventy-five infants scheduled for pyloromyotomy were given atropine before induction of anaesthesia. For those who had undergone preoperative nasogastric suction, the nasogastric tube was aspirated and removed. A 14 F multionficed orogastric catheter was blindly passed to aspirate gastric fluid for measurement. Following tracheal intubation. I 5/75 subjects underwent gastroscopy to measure residual gastric fluid.ResultsGastric fluid volume removed by blind aspiration averaged 4.8 ± 4.3 ml·kg−1 with 83% of patients having > 1.25 ml·kg−1. Although 14 of the 15 patients evaluated by endoscope had ≤ 1 ml residual gastric fluid, one had 1.8 ml·kg−1. Recovery of total gastric fluid volume by blind aspiration averaged 96 ± 7%. The large gastric fluid volumes were independent of a history of banum study, preoperative nasogastric suction, and fasting interval.ConclusionInfants with pylonc stenosis have large gastric fluid volumes which are not substantially reduced by preoperative nasogastric suction. Blind aspiration of gastric contents prior to induction of anaesthesia provides a reliable estimate of total gastric fluid for most of these infants, although the occasional infant may retain a small amount of gastric fluid. The clinical importance of such a residual volume is uncertain.RésuméObjectifQuantifier le volume de liquide gastrique chez des enfants porteurs de sténose du pylore se présentant pour une pylorotomie et démontrer par endoscopie l’efficacité de l’aspiration à l’aveugle pour le recueillir. Nous avons supposé que les examens en contraste antérieurs, les aspirations nasogastriques préopératoires et les intervalles de jeûne n’affectaient pas le volume gastrique.MéthodesSoixante-quinze enfants programmés pour un pylorotomie ont reçu de l’atropine avant l’induction de l’anesthésie Si une sonde nasogastrique étart déjà en place, celle-ci était aspirée et retirée. Une sonde orogastrique 14 F à orifices multiples était introduite à l’aveugle dans l’estomac dans le but d’aspirer le liquide et de le mesurer Après l’intubation de la trachée, 15 des sujets sur 75 ont subi un gastroscopie pour évaluer le liquide gastrique résiduel.RésultatsLe volume moyen de liquide gastrique retiré par l’aspiration à l’aveugle était 4,8± 4.3 ml·kg−1 et dépassait 1,25 ml·kg−1 chez 83% des patients. Par endoscopie, chez 14 des 15 sujets évalués, le volume résiduel était ≤ 1 ml: toutefois, il était de 1.8 ml·kg−1 chez un des patients. Le volume de liquide gastrique recueilli par aspiration à l’aveugle était de 96 ± 7% du total. Les volumes importants n’étaient pas en relation avec des examens barytés préalables, la succion nasogastrique préopératoire et l’intervalle de jeûne.ConclusionLes enfants souffrant de sténose du pylore ont de grands volumes de liquide gastrique qui ne sont pas substantiellement diminués par la succion nasogastrique préopératoire. L’aspiration à l’aveugle du contenu gastrique avant l’induction procure une estimation valide du contenu total de liquide chez la plupart des enfants, bien qu’à l’occasion un enfant puisse en retenir une petite quantité. L’importance clinique de ce volume résiduel demeure indéterminée.

Overweight/obesity and gastric fluid characteristics in pediatric day surgery: implications for fasting guidelines and pulmonary aspiration risk.

BACKGROUND:The safety of 2-h preoperative clear liquid fasts has not been established for overweight/obese pediatric day surgical patients. Healthy children and obese adults who fasted 2 h have small residual gastric fluid volumes (GFVs), which are thought to reflect low pulmonary aspiration risk. We sought to measure the prevalence of overweight/obesity in our day surgery population. We hypothesized that neither body mass index (BMI) percentile nor fasting duration would significantly affect GFV or gastric fluid pH. In children who were allowed clear liquids up until 2 h before surgery, we hypothesized that overweight/obese subjects would not have increased GFV over lean/normal subjects and that emesis/pulmonary aspiration events would be rare. METHODS:Demographics, medical history, height, and weight were recorded for 1000 consecutive day surgery patients aged 2–12 yr. In addition, 1000 day surgery patients (age 2–12 yr) undergoing general endotracheal anesthesia were enrolled. After tracheal intubation, a 14–18F orogastric tube was inserted and gastric contents evacuated. Medications, fasting interval, GFV, pH, and emetic episodes were documented. Age- and gender-specific Center for Disease Control and Prevention growth charts (2000) were used to determine ideal body weight (IBW = 50th percentile) and to classify patients as lean/normal (BMI 25th–75th percentile), overweight (BMI ≥85th to <95th percentile), or obese (BMI ≥ 95th percentile). RESULTS:Of all day surgery patients, 14.0% were overweight and 13.3% were obese. Obese children had lower GFV per total body weight (P < 0.001). When corrected for IBW, however, volumes GFV(IBW) were identical across all BMI categories (mean 0.96 mL/kg, sd 0.71; median 0.86 mL/kg, IQR 0.96). Preoperative acetaminophen and midazolam contributed to increased GFV(IBW) (P = 0.025 and P = 0.001). Lower GFV(IBW) was associated with ASA physical status III (P = 0.024), male gender (P = 0.012), gastroesophageal reflux disease (P = 0.049), and proton pump inhibitor administration (P = 0.018). GFV(IBW) did not correlate with fasting duration or age. Decreased gastric fluid acidity was associated with younger age (P = 0.005), increased BMI percentile (P = 0.036), and African American race (P = 0.033). Emesis on induction occurred in eight patients (50% of whom were obese, P = 0.052, and 75% of whom had obstructive sleep apnea, P = 0.061). Emesis was associated with increased ASA physical status (P = 0.006) but not with fasting duration. There were no pulmonary aspiration events. CONCLUSIONS:Twenty-seven percent of pediatric day surgery patients are overweight/obese. These children may be allowed clear liquids 2 h before surgery as GFV(IBW) averages 1 mL/kg regardless of BMI and fasting interval. Rare emetic episodes were not associated with shortened fasting intervals in this population.

A simple homemade lighted stylet for neonates and infants: a description and case report of its use in an infant with the Pierre Robin anomalad

The glossoptosis and micrognathia associated with Pierre Robin anomalad can make tracheal intubation by conventional laryngoscopy quite difficult. Lighted stylets may be helpful in the successful intubation of infants with this anomalad, but those currently available that are small enough to accommodate 3.0 mm ID tracheal tubes have two major drawbacks limiting their utility: an insufficiently rigid stylet component and a nonadjustable, overly bright light. We describe a lighted stylet that can be easily assembled in the operating room which overcomes these problems and allowed us to successfully intubate a six‐day‐old with severe Pierre Robin anomalad.

Fascia iliaca block for an infant with arthrogryposis multiplex congenita undergoing muscle biopsy.

Children with arthrogryposis multiplex congenita often require multiple surgical procedures. We present a case of a neonate with arthrogryposis multiplex congenita in which intubation was judged to be technically difficult and in which peripheral regional anesthesia allowed us to obtain a satisfactory muscle biopsy without risking the complications of general anesthesia.

Cisapride does not prevent postoperative vomiting in children.

UNLABELLED The peripherally acting prokinetic drug cisapride can overcome opioid-induced gastrointestinal paresis and may thereby eliminate a stimulus for postoperative vomiting. We conducted a prospective, randomized, double-blinded, controlled trial of 96 children undergoing inguinal surgery to determine whether cisapride would reduce the incidence of postoperative vomiting after general anesthesia supplemented with morphine. Group C1 patients (n = 38) received cisapride 0.3 mg/kg orally 1 h before surgery and placebo 6 h later, Group C2 (n = 28) received cisapride both before and after surgery, and Group P (n = 30) received placebo. Mean age (5.0 +/- 2.7 yr) and weight (21.0 +/- 8.6 kg), median pain scores and parent satisfaction scores, and incidence of rescue analgesic administration were similar across groups. Contrary to our hypothesis, incidences of postoperative vomiting in the hospital (32% vs 20%, P = 0.33) and at home (53% vs 46%, P = 0.33) did not vary by treatment group (with [C1 and C2] and without [P] cisapride, respectively). There was a trend toward more severe postoperative vomiting (three or more episodes) in children who received cisapride versus those who did not, both in hospital (6% vs 0%, P = 0.3) and at home (22% vs 8%) (P = 0.13). We conclude that cisapride does not prevent postoperative vomiting in this patient population and speculate that factors other than reduced gastrointestinal motility associated with general anesthesia and opioids are more important determinants of postoperative vomiting. IMPLICATIONS Cisapride does not prevent postoperative vomiting in children and may increase its severity.

Inadvertent Extra-Epidural Catheter Placement in an Infant

We report the inadvertent passage of an epidural catheter threaded from the caudal space out of a lumbar intervertebral foramen and into the lower thoracic paravertebral space in an infant. We identified the errant catheter by radiography and removed it without sequelae.

Endoscopic findings in hypertrophic pyloric stenosis : appearance in classic and evolving disease

BACKGROUND Hypertrophic pyloric stenosis (HPS) is the most common abdominal surgical disorder in infants. Although the majority of cases are diagnosed by ultrasound, equivocal cases may require endoscopy. This study was performed to assess the various endoscopic appearances of HPS in infants. METHODS A prospective study comparing the endoscopic appearance of the antrum and pylorus of 18 children with HPS to 21 children in a normal control group. RESULTS Antral or pyloric mucosal hypertrophy was visualized endoscopically in all 18 study patients. The degree of mucosal thickening varied depending on the age of presentation and duration of symptoms. Antral fold hypertrophy was first noted at 10 days of age, and in the oldest patient (4 months of age) a pyloric mass was noted. By comparison, 21 control infants had no evidence of antral or pyloric narrowing or mucosal thickening. CONCLUSIONS Upper endoscopy can be a valuable adjunctive diagnostic tool in select cases of HPS when imaging tests are inconclusive or when infants present with clinical symptoms outside the typical age-time frame for HPS. Because HPS may evolve over time, it is important that the endoscopist recognize the different appearances of HPS.