T.C.K. Brown

Anaesthesia for children with osteogenesis imperfecta – a review covering 30 years and 266 anaesthetics

Osteogenesis imperfecta is an uncommon condition which presents in a variety of forms which are reviewed. Many of the problems, particularly in the more severe cases, are related to fractures and deformities which require anaesthesia for correction. This paper reviews 266 anaesthetics for 63 patients. The concept that malignant hyperpyrexia is an associated condition is refuted although these patients may have an increased metabolic rate and a tendency to pyrexia. The care of these patients during anaesthesia is discussed particularly in relation to transfer, positioning, temperature and airway problems.

History of pediatric regional anesthesia

The history of local and regional anesthesia began with the discovery of the local anesthetic properties of cocaine in 1884. Shortly afterwards nerve blocks were being attempted for surgical anesthesia. Bier introduced spinal anesthesia in 1898, two of his first six patients being children. Spinal anesthesia became more widely used with the advent of better local anesthetics, stovaine and procaine in 1904–1905. Caudals and epidurals came into use in children much later. In the early years these blocks were performed by surgeons but as other doctors began to give anaesthetics the specialty of anesthesia evolved and these practitioners gradually took over this role. Specific reports of their use in children have increased as pediatric anesthesia has developed. Spinals and other local techniques had periods of greater and lesser use and have not been universally employed. Initial loss of popularity seemed to relate to improvements in general anaesthesia. The advent of lignocaine (1943) and longer acting bupivacaine (1963) and increasing concern about postoperative analgesia in the 1970–1980s, contributed to the increased use of blocks.

Arthrogryposis multiplex congenita (AMC). A review of 32 years’ experience

Arthrogryposis multiplex congenita (AMC) is an uncommon condition with multiple congenital joint contractures of variable severity that is present in 1:3000 to 1:10 000 newborns. This abnormality results from a neuropathic or occasionally a myopathic lesion present in utero. Surgery is required for the correction of skeletal deformities and associated visceral anomalies. A retrospective study of the Royal Childrens Hospital experience with AMC patients over the last 32 years is presented. The anaesthetic drugs and techniques used, complications, surgical procedures and mortality in 143 patients are reviewed. Thirteen patients were severely affected and died during their first week of life. One hundred and twenty‐eight patients underwent 928 procedures, the majority of them orthopaedic. Seventy complications were reported. Ten patients had a moderate increase in temperature (less than 2°C) out of 43 in whom it was recorded. There were 27 difficult intubations in 9 patients who had a total of 81 anaesthetics. Patients with AMC require careful preoperative assessment of their airway. Skill in gaining intravenous access and at intubation is essential. Monitoring of temperature, neuromuscular function and careful assessment of ventilation at the end of the anaesthetic is necessary.

Type IV laryngotracheoesophageal cleft in a neonate

The peri‐operative management of a neonate with type IV laryngotracheoesophageal cleft, microgastria and pulmonary hypoplasia is described. Bronchoscopy was necessary to delineate the extent of the defect and was useful for performing selective endobronchial intubation. Chronic aspiration and atelectasis complicated the post‐operative management. Endobronchial intubation is compared with the use of a double lumen tube and tracheostomy for intra‐operative ventilation.

Early experiences of vasodilators and hypotensive anesthesia in children.

The physiological application of OHMS LAW explains the basis of hypotensive anesthesia.

Bardet-Biedl syndrome: review of anaesthetic problems

Bardet‐Biedl syndrome is a rare syndrome characterized by obesity, mental retardation, polydactyly, retinitis pigmentosa and hypogenitalism. These children frequently require multiple anaesthetics for diagnostic and therapeutic measures. The anaesthetic management of a child with the syndrome is described. Eight cases presenting between 1974 and 1990 at the Royal Childrens Hospital in Melbourne are reviewed. The anaesthetic problems associated with this syndrome include obesity with consequent difficulty with venous access, placement of local anaesthetic blocks and induction of anaesthesia due to behavioural activity.

From arrow poison to neuromuscular blockers

Peter Martyr D’ Anghera first described the paralyzing arrow poison used in South America in 1516. Walter Raleigh recounted tales of arrow poison used by South American Indians in 1596. It is uncertain whether it caused paralysis. Charles Waterton, the Squire of Walton Hall near Wakefield in Yorkshire, was an unusual man. At the age of 32, he went to Guyana in South America where he looked after family sugar plantations for 7 years before undertaking his first trip into the wilds in 1812. One of his main aims was to obtain samples of Wourali arrow poison. He made three more exploration trips in 1816, 1820, and 1824, which he described in his famous book, Wanderings in South America published in 1825 (1). He was a great naturalist – he turned the estate at Walton Hall, after he inherited it, into a nature park with a three mile wall around it to keep out vermin. During these trips, he became a wildlife collector and developed his special taxidermy methods using poisonous bichloride of mercury to cure and preserve the skins before molding them into life-like models, which still form a major collection of animals and birds after nearly 200 years. He also made some other weird creations such as his Nondescript (Figure 1). He returned from Guyana with a block of the Indian arrow poison – wourali (see pot in Figure 2). He describes in his book some experiments conducted in London in 1814 where two donkeys were injected with wourali. They collapsed and died in 12 and 10 min. A tourniquet was applied to the leg of a third donkey, and the wourali was injected beyond it. It continued to walk around for an hour until the tourniquet was removed. Within minutes, the donkey collapsed, paralyzed. Its windpipe was opened immediately, and a bellows was inserted into the trachea to ventilate it. After 2 hours, ventilation was stopped, the donkey roused, and then collapsed into a stupor. Ventilation was begun again before the animal died, and after another two hours, the donkey recovered and walked around. This remarkable experiment was performed 127 years before purified D-tubocurarine was introduced into clinical anesthesia by Harold Griffiths (First President of the World Federation of Societies of Anesthesiologists) and Enid Johnson in Montreal in January 1942 (2). This was even before anesthesia began that makes it all the more remarkable. Similar experiments more recently showed that the effects of snake bite could be delayed by application of a tourniquet over or proximal to the bite. The author was taken to Walton Hall in 1977 by Dennis Smith, one of Britain’s leading anesthesia historians and author of a comprehensive series of articles on nitrous oxide. (3). The mansion was beside a lake (Figure 3) with a most intriguing sundial outside, which could tell the time in several places around the world. It was used as a maternity hospital for some years but more recently became a country club. Waterton died in 1865, aged 83, and is buried on the estate. Three years before the donkey experiments, Benjamin Brodie (later Sir and President of the Royal College of Surgeons in 1844) had rubbed wourara into a wound in a guinea pig. It stopped breathing and looked dead, but when the chest was opened, the heart was still beating. After being ventilated, it recovered. Derivatives of wourali were tried, with only occasional survivors, from the mid 1800s, for the treatment of tetanus and strychnine poisoning, both of which cause severe muscle spasms. Tetanus is now treated with magnesium sulfate because a high plasma magnesium reduces the release of acetyl choline at both the neuromuscular junction and at ganglia. In 1963, before intensive care had become widely established, the author successfully treated a 16 years old with strychnine poisoning, who had severe

Farewell! Some halogenated inhalation anesthetics: chloroform, trichlorethylene, halothane and methoxyflurane

CHLOROFORM (CHCl3) was the first halogenated compound used in anesthesia. James Young Simpson and some friends tried inhaling it and several other drugs first. When it was found to prevent pain, Simpson used it to relieve labor pain. It was pungent but more pleasant to inhale than ether and soon gained in popularity and, in some places, particularly Scotland replaced ether. A few months later, 15-year-old Hannah Greener died during induction (1). It would be a long time before the mechanism was understood. It was after the development of electrocardiography by Levy in 1911 that it was realized that sudden death during induction was due to ventricular fibrillation, caused by chloroform sensitizing the heart to catecholamines. In 1899, eightythree cases of death under chloroform anesthesia were reported in England. 68 occurred before the operation had started (2). Hundreds of experiments were performed by a number of researchers to find out the primary cause of death. Two scientifically unsound Hyderabad Commissions in India concluded that it was due to respiratory failure but E.H. Embley in Melbourne, in a series of 284 experiments on dogs, correctly concluded that the heart failed before respiration. Without an ECG, he could not show the cause during induction although that is what stimulated his research. His report occupied 20 pages of the British Medical Journal in 1902 so it must have been a topic of major interest at the time (2). Soon after its introduction in Edinburgh, John Snow in London became a proponent. He reported 3000 cases without a death. He was careful to keep the concentration low (up to 2%) but his success must also have indicated that he was able to reassure his patients so that they were not anxious. His administration to Queen Victoria for the birth of Prince Leopold in 1853 sealed its approval for use during labor, in an otherwise hostile environment. Carbon tetrachloride frequently caused jaundice and liver failure when inhaled so it is not surprising that the closely related chemical, chloroform, might do the same although it was much less toxic. It was a well-recognized occasional serious complication that eventually contributed to the demise of chloroform. Chloroform, like halothane, relaxed the uterus which made it useful for turning babies before delivery so that they came head first. The only time the author used it was for such a case in 1963. TRICHLORETHYLENE (Trilene) (CHCl=CCl2) was used as a de-greasing agent and dry cleaning fluid. It was noted to give relief to patients with trigeminal neuralgia. There was a report of 284 cases of intoxication with 25 fatalities before it became an unlikely agent for use in anesthesia. It was first tried in USA in 1934 but was abandoned in 1936 because the American Medical Association Council of Pharmacy and Chemistry decided ‘the case for its use had not been completely made out’ (3). Langton Hewer in London undertook a preliminary clinical trial in 1941 following an unusual request by a Mr C. Chalmers for information about trilene’s

Endotracheal tubes and intubation.

Tubes are placed in the trachea to overcome an obstruction, to facilitate ventilation, especially when controlled, and to allow the anesthetist access to the airway while distanced from the operative site. They are necessary in intrathoracic surgery where intermittent positive pressure is applied to overcome the problem of collapsing lungs when the chest is open. Tracheostomy has been described for relieving upper airway obstruction since Asclepiades in 100 BC. It was used for the treatment of quinsy (Cornelius Celsus AD 14, Pedro Virgili C18). Chevalier Jackson, who also designed a laryngoscope, popularized tracheotomy for the relief of obstruction (1909) (1). In 1780, Chaussier introduced the concept of laryngeal intubation for asphyxia of the newborn. Diphtheria was a rampant killer during epidemics. Between 1879 and 1884, Joseph O’Dwyer, a physician at the New York Foundling Hospital developed a set of metal laryngeal tubes and special forceps to insert them into the larynx in cases of diphtheria. Many children died from this disease, particularly when a membrane developed over the larynx resulting in suffocation. His aim was to use a laryngeal tube to replace the need for a tracheostomy which was often a bloody procedure performed without anesthesia. He began experimenting with his ideas in 1879 and took some years to perfect the tubes. They had to fit through the larynx, not prevent epiglottic closure, and allow free passage of air and coughing up of secretions. Initially, they were too short and could be coughed out so he lengthened them and made a widening which prevented their easy expulsion (Figure 1). Diphtheria was a dangerous disease. In 1880, 1969 of 5022 patients (39%) with diphtheria in New York and Boston died. In a compilation of 21 853 cases of obstructive diphtheritic croup reported before 1887 from UK, USA, France, and Germany who had tracheostomy, the recovery rates were 24–32 percent. The results depended on the expertise of the operator and the death rate was higher in children under three years old. The introduction of diphtheria antitoxin in 1895 was one of the great advances in preventative medicine, initially reducing the mortality to one-third of the previous figure. Progressively, the mortality decreased, so that survival was over 90 percent. In 1927, F. Scholes, at Fairfield Infectious Diseases Hospital in Melbourne, reported a series of 1275 cases where these tubes were used with great success. Tracheotomy continued to be used in children until polyvinyl chloride (PVC) tubes were introduced about 1960. The introduction of prolonged nasotracheal intubation (1962) contributed to the evolution of pediatric intensive care. Various tubes have been used for anesthesia in children. The red rubber tube was widely used but caused irritation if left in for too long. One variant, developed by Dicky Salt, the technician in the Nuffield Department in Oxford, was the Oxford tube which was bent at a right angle at the back of the pharynx at the appropriate distance from the larynx so that it would lie correctly in the larynx. The tube was slightly thicker to prevent kinking but narrowed slightly as it approached the end where it passed through the larynx. This could create a hazard from pressure on the mucosa if it was inadvertently inserted too far. Small babies have a narrow larynx. The Cole tube had a wide lumen to allow free flow of gas but it narrowed for the last 2–3 cms so that it could fit a narrow larynx. The reason for this relates to Pouisseuille’s Pediatric Anesthesia ISSN 1155-5645

Toivo Suutarinen – Father of Finnish Pediatric Anesthesia

Toivo Suutarinen (Figure 1) was born in 1918. He qualified in medicine in 1948. He trained initially as a surgeon for 4 years but realized that there was a need for good anesthesia, so he switched. Training in anesthesia was unsatisfactory in Finland, so he went to the United States in 1955 and worked for a year in Chicago and then for another year at the Massachusetts General Hospital. He became a specialist in anesthesia in 1956. Not long after his return to Helsinki, an opening for an anesthesiologist became available at the Childrens Hospital, and he was appointed. He became the father of Finnish pediatric anesthesia. In 1962– 1963, he spent a further year in USA working at the Clinical Center, National Institute of Health in Maryland. He obtained his doctorate by thesis in 1966. I met him in Madrid in 1974 and then visited Helsinki in 1977. In 1979, he came with John Inkster to Melbourne as Guest Speakers for one of our weekend pediatric anesthetic meetings that were held every 3– 4 years. I drove them round the coast to Adelaide with their wives for the Australian Society Annual meeting. Traveling with them by VW kombi led to us all becoming very good friends. This was the seed for future pediatric anesthetist tours in various parts of the world. In 1981, shortly before he retired, Toivo Suutarinen organized a joint Finnish Society/APA meeting in Helsinki and Turku. He was one of the early overseas members of the APA. We visited his country house on the way back from Turku, and before we left, he lowered the Finnish flag in company of Jackson Rees (Liverpool) and Sheila Anderson (long-time senior anesthetist at Great Ormond Street in London) (Figure 2). Following this meeting, he organized a tour for about 20 of the visitors, who could stay, to spend a week in East Finland. This proved to be an important initiative in our specialty because it was the first of several such ventures, which have since taken place in Australia, Canada, South Africa, and France. These trips brought pediatric anesthetists from all over the world together, so that they could become well acquainted. The bonds of friendship made contributed