Timothy W. Martin

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.

Moyamoya disease: a review of the disease and anesthetic management.

Moyamoya disease is a rare chronic cerebrovascular disease seen both in children and adults. It has a progressive course, but may have a variable clinical presentation. The disease causes ischemic stroke, intracranial hemorrhage, headache, seizures, and transient ischemia attack in children and in adults. Although the pathogenesis of the disease remains unknown, research suggests a genetic predisposition. There are also undefined systemic processes involved in this vasculopathy. Better noninvasive diagnostic techniques for diagnosis of the Moyamoya disease have been developed, but medical treatment can still be challenging. However, various surgical revascularization procedures have shown to provide symptomatic benefit in a majority of these patients. In addition, the anesthetic management of these patients has evolved over the years with an increased understanding of the disease. These have specifically resulted from the identification of risk factors for perioperative complications and outcomes related to the use of anesthetic agents. Finally, research in the last 3 decades has led to the recognition of the importance of pain control, the increased use of regional anesthesia, and better monitoring techniques in providing high quality and safe patient care to patients with Moyamoya disease. This article will provide a comprehensive review of the disease and its anesthetic management.

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.

Acute-recurrent subcutaneous emphysema after ventriculopleural shunt placement.

Ventriculopleural shunts are one of the alternatives to ventriculoperitoneal shunts for draining cerebrospinal fluid. They are used in patients who have failed multiple ventriculoperitoneal shunts because of peritonitis, loculated ascites, or pseudocyst formation, or those who are not optimal candidates for vascular shunts. A case of acute recurrent subcutaneous emphysema around the incision of a ventriculopleural shunt is presented.

The "other tube" in the airway: what do we know about it?

• Volume 118 • Number 3 www.anesthesia-analgesia.org 501 Copyright

Successful anesthetic management of a child with an extensive facial hemangioma and high output cardiac failure for placement of a central venous catheter.

A two‐and‐a‐half‐year‐old female with an extensive facial and lingual hemangioma, associated high output cardiac failure, and a history of difficult intubation presented for central venous catheter (CVC) placement for vincristine chemotherapy. Anesthetic management of this complex case is presented and the complicating medical conditions are discussed.

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.

Assessing Caudal Block Concentrations of Bupivacaine With and Without the Addition of Intravenous Fentanyl on Postoperative Outcomes in Pediatric Patients: A Retrospective Review.

Caudal blocks are a significant and efficacious aspect of pediatric anesthesia, especially in urologic and many general surgery cases. This type of regional anesthesia is common because it has a high success rate and provides between 6 and 8 hours of postoperative pain control. The aim of this study was to determine whether the concentration of bupivacaine or the addition of intravascular (i.v.) fentanyl affected the postanesthesia care unit (PACU) discharge time. A retrospective cohort study comparing the outcomes in pediatric patients who have received varying caudal concentrations with and without the addition of i.v. fentanyl was performed. A total of 849 consecutive patients undergoing hypospadias repairs or circumcisions were reviewed and placed in one of the following 3 groups: 0.125% bupivacaine (group 1), 0.25% bupivacaine (group 2), or one of these concentrations of bupivacaine + i.v. fentanyl intraoperatively (group 3). Total PACU time for each group was 46.1 minutes (group 1), 48.9 minutes (group 2), and 49.7 minutes (group 3). Our results revealed that there is no statistically significant difference between concentrations of bupivacaine administered in a caudal block with or without i.v. fentanyl with regard to the outcome of PACU duration (P = 0.16). Overall, based on the retrospective cohort design, there is no difference in primary and secondary outcomes based on the concentration of bupivacaine, when administered at a volume of 1 mL/kg.

How will we ever know if our machine is adequately flushed

• Volume 119 • Number 1 www.anesthesia-analgesia.org 9 Standard anesthesia practice includes a detailed preanesthetic check and preparation of the anesthesia workstation (the “anesthesia machine”) before the first patient of the day and an abbreviated check before subsequent patients, according to guidelines established by the American Society of Anesthesiologists,a United States Food and Drug Administration,b and other professional societies.1 This “machine check” serves to verify that all components of the anesthesia workstation (including the patient breathing circuit) are present and functional, and that any leaks within the highor low-pressure portions of the system are within acceptable limits, with the ultimate goal of assuring that the workstation is safe for patient use. In the case of patients with known or suspected malignant hyperthermia susceptibility (MHS), and perhaps more commonly in some patients with apparent neuromuscular dysfunction of uncertain etiology but in whom MHS is a possibility, such as unexplained hypotonia, there are additional considerations in the preparation of the anesthesia workstation.2,3 If the decision is made to provide the patient a “nontriggering” anesthetic that does not expose the patient to any of the potent inhalational anesthetics (or succinylcholine), there are several alternatives as indicated by the Malignant Hyperthermia Association of the United States (MHAUS).c The first of these alternatives directs the anesthesia provider to “flush and prepare workstation according to manufacturer’s recommendations or published studies.” In this issue of Anesthesia & Analgesia, Cottron et al.4 report an in vitro bench test evaluation of the sevoflurane washout profiles of 7 different modern anesthesia workstations, including 4 that have not been previously tested. Following a standard priming procedure with 3% sevoflurane that was applied to all 7 of the workstations (subject to some minor device-specific limitations), the workstations were then prepared with preoperative “flushing” according to the current recommendations of the MHAUS on its website. The flush procedure was standardized with a test lung and controlled mechanical ventilation until a sevoflurane concentration of <5 ppm was obtained at the “Y-piece” of the breathing circuit. Following this flush period, the simulation of 2 clinical scenarios was undertaken. In the first, the fresh gas flow was decreased to 10 L/min, while minute ventilation of the test lung was maintained the same as during the flush period. In the second, the minute ventilation was substantially reduced to simulate the mechanical ventilation of an infant. In both scenarios, sevoflurane concentration was measured to detect any “rebound” increase in breathing circuit concentration after these changes and the amount of time required for the sevoflurane concentration to again fall below 5 ppm. In all but 2 of the workstations that were studied, the sevoflurane concentration increased when the fresh gas flow was decreased after the initial flush period. In all but one of the workstations, the sevoflurane concentration increased during the simulated mechanical ventilation of an infant. This report is novel in that not only have 4 of the machines not been previously tested, but it is also the first to simulate mechanical ventilation of small patients in whom the anesthesia workstation and breathing circuit gas flow characteristics, and therefore, potent inhaled anesthetic agent elimination, may be different. So what is one to make of the increasing evidence that the traditional practice of providing a 20-minute flush of the anesthesia machine at a fresh gas flow rate of at least 10 L/min after removing the carbon dioxide absorbent and vaporizers is insufficient, perhaps markedly so, in preparing a machine that is “safe” for the MHS patient? How should one respond to the apparent wide variation in inhaled anesthetic agent elimination times among different models of modern anesthesia workstations? Indeed, it is possible and perhaps even likely that there would be variation in the elimination time for inhalation agents among different How Will We Ever Know if Our Machine Is Adequately Flushed?