Shailesh Shah

Use of Intralipid in an infant with impending cardiovascular collapse due to local anesthetic toxicity.

Local anesthetic-associated cardiac toxicity following caudal epidural blockade is, fortunately, a rare event. Prompt recognition and early treatment is the key to successful resuscitation. Early use of the lipid emulsion Intralipid in bupivacaine-induced cardiac toxicity may lead to a good outcome.

Combination of oral ketamine and midazolam as a premedication for a severely autistic and combative patient

Patients with impaired ability to understand and communicate can be difficult to manage perioperatively. They frequently require lateral thinking on the part of the anesthesiologists to make the induction process as smooth as possible. We present a case of a severely autistic and violent patient scheduled for dental rehabilitation under general anesthesia. A combination of oral ketamine and midazolam was mixed in the beverage Dr Pepper to mask the taste and the appearance of the drugs. The unique flavor of Dr Pepper is well suited to increase the palatibility and the acceptability of medications in children and patients with developmental delay.

Severe hypertension and bradycardia after dexmedetomidine for radiology sedation in a patient with acute transverse myelitis

Med 2004; 30: 302–308. 3 Britto J, Nadel S, Maconochie I et al. Morbidity and severity of illness during interhospital transfer: impact of a specialised paediatric retrieval team. BMJ 1995; 311: 836–839. 4 Bull C. Current and potential impact of fetal diagnosis on prevalence and spectrum of serious congenital heart disease at term in the UK. British Paediatric Cardiac Association. Lancet 1999; 354: 1242–1247. 5 Randolph GR, Hagler DJ, Khandheria BK et al. Remote telemedical interpretation of neonatal echocardiograms: impact on clinical management in a primary care setting. J Am Coll Cardiol 1999; 34: 241–245. 6 Browning Carmo KA, Barr P, West M et al. Transporting newborn infants with suspected duct dependent congenital heart disease on low-dose prostaglandin E1 without routine mechanical ventilation. Arch Dis Child Fetal Neonatal Ed 2007; 92: F117–F119.

Tension pneumothorax and subcutaneous emphysema during retrieval of an ingested lithium button battery

We present a case of a child with an ingested lithium battery causing esophageal perforation with mediastinal injury extending to the pleural cavity. During the endoscopic retrieval of the battery, the child developed the rare complication of subcutaneous emphysema, tension pneumothorax, and pneumomediastinum from excessive iatrogenic air insufflation. The patient developed mediastinitis and had a complicated postoperative course.

Atypical presentation of an impacted radiolucent esophageal foreign body

Patients with impacted esophageal foreign bodies usually present with gastrointestinal and rarely with respiratory symptoms. Impacted esophageal foreign bodies may be identified by radiologic studies. Ingested radiolucent foreign bodies may be more difficult to diagnose, especially if the patient presents with minimal symptoms. We report a rare case of a child who presented with stridor and obstructive sleep apnea. The cause of respiratory symptoms was thought to be due to enlarged tonsils and adenoids, and the patient was scheduled for tonsillectomy and adenoidectomy. On re-evaluation by the surgeon on the day of surgery, the procedure was changed to diagnostic microlaryngoscopy and bronchoscopy to rule out any other cause. The patient’s respiratory symptoms were resolved when an incidental discovery and retrieval of the radiolucent esophageal foreign body was made. The diagnosis of radiolucent esophageal foreign body can be difficult and can be easily missed without reasonable clinical suspicion.

Use of GlideScope in airway management of a patient with osteogenesis imperfecta

To the Editor: Patients with osteogenesis imperfecta (OI) have multiple factors that impact airway management, including megalocephaly, macroglossia, and a short neck, which may be complicated by the potential risk of cervical spine injury during neck extension. We present the first reported case of the use of the GlideScope for endotracheal intubation in a patient with severe OI. A 65-year-old woman (86 cm tall, 18.6 kg) with OI congenita was admitted for umbilical hernia repair. She had a history of multiple extremity fractures and contractures, fractures with coughing, and scoliosis (Fig. 1). Airway examination showed mild macroglossia, Mallampati grade II, 3-cm mouth opening, and neck fixed in 20 extension. Planned anesthetic management included local anesthesia and sedation with midazolam 2 mg and fentanyl 125 lg IV. The incision site was infiltrated with local anesthetic. The patient tolerated the procedure until intraperitoneal stimulation caused herniation of abdominal contents, so general anesthesia was induced with propofol 2 mg/kg and rocuronium 1 mg/kg IV. A mask airway was easily obtained. Succinylcholine was avoided because of the risk of fasciculation-induced fractures. Placement of a #3 laryngeal mask airway (LMA) was attempted, but the distorted oral anatomy would not allow it to advance into the hypopharynx. The patient was easily intubated using a GlideScope #3 and cuffed endotracheal tube size 5.5 with in-line stabilization. Direct laryngoscopy was avoided to prevent facial, dental, or spinal trauma. Anesthesia was maintained with O2 and propofol, avoiding volatile triggers for malignant hyperthermia [1]. Blood pressure was measured with a pediatric cuff, set at child inflation limits, every 15 min. The patient was extubated after reversal of muscle relaxation with no coughing. Postoperatively, the patient had a mild sore throat, but no injuries or nausea. She was discharged home on postoperative day 3. Osteogenesis imperfecta is an autosomal dominant disorder characterized by defective synthesis of collagen type I (abnormal mineralization) and a triad of skeletal fragility, blue sclera, and conductive hearing loss [2]. Preoperative evaluation should include an echocardiogram, pulmonary function tests, and assessment of platelet function. Airway management can be complicated by macroglossia, cervical spine problems, micrognathia, and dental fractures with minimal manipulation. The GlideScope uses less force as compared to conventional laryngoscopy. It has an antifogging mechanism and unique angulation permitting a better view of the anterior glottis and can be used with inline stabilization. The distortion of anterior airway anatomy is reduced with use of GlideScope as compared to a Macintosh blade. Cervical extension between the occiput and C4 as well as anterior deviations of the vertebral bodies from baseline are significantly less with the GlideScope [3]. Previous reports illustrate the use of nasal fiberoptic intubation in patients with OI and dental anomalies presenting for maxillary surgery. LMA and intubating LMA F. A. Khan (&) S. Shah S. Shah V. Mandoff W. Brooks Gentry Department of Anesthesiology, University of Arkansas for Medical Sciences, 4301 West Markham Street, # 515, Little Rock, AR 72205, USA e-mail: fakhan@uams.edu

Incidental finding of a metallic nasal foreign body during MRI

mitochondrial deficiency leads to an impaired production and conversion of adenosine triphosphate in the mitochondria and results clinically in a progressive multipleorgan dysfunction (1). The main target organs are the muscle and encephalon, which require a large amount of energy metabolism. The heart, liver, and the pancreas can also be involved. We saw a patient (1.35 m, 25 kg) with serious psychomotoric retardation suffering from complex multifocal seizures resulting in convulsions, tonic muscle spasms and apnoeas for about 20 s, which was treated with clobazam, clonazepam, desmethylclobazam, and lamotrigine. Because of the refractory nature of the epileptic seizures, under medication, he was included in the study protocol for vagal nerve stimulation at the department of neurosurgery of our hospital. The child is wheelchair bound, calm in nature but continuously moving with arms and legs and increasingly unable to make contact with his environment. Further testing revealed no heart disease and no deviations in blood and biochemical markers. Patients with mitochondrial cytopathy are known to have an increased susceptibility to malignant hyperthermia (2). Although the relationship between mitochondrial complex II deficiency and malignant hyperthermia has not been clarified, we decided to give a trigger substance free general anaesthesia. To avoid any contact with vapors, we used a transportable intensive care respirator. In a patient with muscle weakness and usage of numerous anticonvulsant drugs, the effect of neuromuscular blockers is difficult to predict. Therefore, we decided to avoid those as well. We administered 7.5 mg midazolam rectally as premedication. The boy reached the operating room relatively calm, accompanied by his mother. We could easily find intravenous access. We applied an ECG, pulse oxymetry, and blood pressure monitoring. It was possible to preoxygenate by putting the mask close to his face for about 3 min. We induced anesthesia with 20 lgÆkg alfentanil and 5 mgÆkg propofol. Mask ventilation was easily to perform. After 2 min, we performed laryngoscopy, sprayed 2 ml lidocaine 4% on the vocal cords and smoothly intubated with an oral tube 6. We maintained anesthesia with 1–1.5 lgÆkgÆmin alfentanil and 10 mgÆkgÆh propofol. The anesthesia was uneventful. Successfully, the surgeon placed a pacemaker device under the left clavicle and a stimulation electrode in the neck region. At the end of the 50 min lasting operation, the wound was locally infiltrated with 4 ml bupivacaine 0.5%. The awakening was fast and smooth. There were no drops in saturation. We kept the patient 3 h in the recovery room where he received in total 4 mg Piritamide intravenous in a state of unrest interpreted as pain before he was transferred back to the ward where he was further monitored with pulse oximetry. As postoperative pain medication, he received 3 · 500 mg paracetamol and 2 · 25 mg diclofenac rectally. In conclusion, we report the safe anesthetic management with a total intravenous technique and under avoidance of muscle relaxants in a child with a mitochondrial complex II deficiency. Ronny M. Schnabel Marco A. E. Marcus Henricus M. S. Theunissen Maurice M. L. Janssens Academisch Ziekenhuis Maastricht, Department of Anesthesiology P. Debyelaan 25, 6202 AZ Maastrich, The Netherlands (email: hmth@sane.azm.nl ⁄ r.m.schnabel@t-online.de)

An unusual complication following laparoscopic pyloromyotomy and a classic pediatric anesthesia dilemma.

manifestations of hyperkalemia. Am J Emerg Med 2000; 18: 721–729. 5 Martinez-Vea A, Bardaji A, Garcia C et al. Severe hyperkalemia with minimal electrocardiographic manifestations: a report of seven cases. J Electrocardiol 1999; 32: 45–49. 6 Littmann L, Brearley WD Jr, Taylor L 3rd et al. Double counting of heart rate by interpretation software: a new electrocardiographic sign of severe hyperkalemia. Am J Emerg Med 2007; 25: 584–586. 7 Seefelder C, Tucker MS, Lillehei CW. Subtle hyperkalemia detected through monitor ‘‘artifact’’. Anesthesiology 2002; 96: 779. 8 Bhananker SM, Ramamoorthy C, Geiduschek JM et al. Anesthesia-related cardiac arrest in children: update from the Pediatric Perioperative Cardiac Arrest Registry. Anesth Analg 2007; 105: 344–350. 9 Brown KA, Bissonnette B, MacDonald M et al. Hyperkalaemia during massive blood transfusion in paediatric craniofacial surgery. Can J Anaesth 1990; 37: 401–408. 10 Swindell CG, Barker TA, McGuirk SP et al. Washing of irradiated red blood cells prevents hyperkalaemia during cardiopulmonary bypass in neonates and infants undergoing surgery for complex congenital heart disease. Eur J Cardiothorac Surg 2007; 31: 659–664. 11 Weiskopf RB, Schnapp S, Rouine-Rapp K et al. Extracellular potassium concentrations in red blood cell suspensions after irradiation and washing. Transfusion 2005; 45: 1295–1301. 12 Vohra HA, Adluri K, Willets R et al. Changes in potassium concentration and haematocrit associated with cardiopulmonary bypass in paediatric cardiac surgery. Perfusion 2007; 22: 87–92.

An unforeseen complication of orotracheal suctioning.

1 Papile LA, Burstein J, Burstein R et al. Incidence and evolution of subependymal and intraventricular hemorrhage: a study of infants with birth weights less than 1,500 gm. J Pediatr 1978; 92: 529–534. 2 Whitelaw A. Intraventricular haemorrhage and posthaemorrhagic hydrocephalus: pathogenesis, prevention and future interventions. Semin Neonatol 2001; 6: 135–146. 3 Liu L, Cote CJ, Goudsouzian NG et al. Life-threatening apnea in infants recovering from anesthesia. Anesthesiology 1983; 59: 506– 510. 4 Hanlo PW, Cinalli G, Vandertop WP et al. Treatment of hydrocephalus determined by the European Orbis Sigma Valve II survey: a multicenter prospective 5-year shunt survival study in children and adults in whom a flow-regulating shunt was used. J Neurosurg 2003; 99: 52–57. 5 Tuli S, Drake J, Lawless J et al. Risk factors for repeated cerebrospinal shunt failures in pediatric patients with hydrocephalus. J Neurosurg 2000; 92: 31–38. 6 Suresh S, Voronov P. Head and neck blocks in children: an anatomical and procedural review. Paediatr Anesth 2006; 16: 910–918.

A lost art: casualty of deep tracheal extubation

vation, steroid injection, Nd:YAG laser ablation, excision and reconstruction, or a combination of the above. Difficult airway management may result from several variables acting alone or in concert, and this case was no exception. First, she was a child. Fear and anxiety precluded a full airway examination. Second, she could have blood and secretions obscuring her upper airway. Third, she was distinctly anemic and hypovolemic. Fourth, we had to secure her airway while maintaining pressure on the nose. Removing pressure on the nose for even a few seconds produced 5–10 ml blood loss and increased the risk of blood soiling her airway. Fifth, she had a full stomach, placing her at high risk for aspiration under anesthesia. Lastly, she had no venous access when she presented for the procedure. One option would be to secure venous access prior to induction, but we decided against it as she was already vasoconstricted and uncooperative. More importantly, intravenous induction has greater potential to produce apnea. We feared we would then be forced to use positive pressure ventilation by mask, and increase the risk of blowing blood and secretions down her airway, or insufflating the stomach with gases. A good mask fit was difficult if not impossible, because of the concurrent need to maintain hemostasis on her nose. We elected to maintain spontaneous mask ventilation until a secure airway was established based on these. We devised a way to deliver the gases using a smaller-thanusual mask to cover just the mouth, while occluding the nostrils to maintain a good seal. Sitting position and cricoid pressure by a trained assistant were our best defense against aspiration of stomach contents following loss of the airway reflexes. We managed this challenging airway and anesthetic in a slightly unconventional manner, within the constraints of time and patient factors, and obtained a successful outcome (Figure 4). We submit that while the conventional rapid-sequence airway access approach fits many fullstomach situations, modification and adaptation to individual airway issues are essential to safe airway control.