Developing an Extubation strategy for the difficult pediatric airway-Who, when, why, where, and how?

Comprehensive airway management of the pediatric patient with a difficult airway requires a plan for the transition back to a patent and protected airway. Multiple techniques are available to manage the periextubation period. Equally important is performing a comprehensive risk assessment and developing a strategy that optimizes the likelihood of safe extubation. This includes team-focused communication of the desired goals, critical steps in the process, and potential responses in the case of failed extubation. This review summarizes extubation of pediatric patients with difficult airways along with one suggested framework to manage this challenging period.

A Novel 3-Dimensional Printing Fabrication Approach for the Production of Pediatric Airway Models.

BACKGROUND: Pediatric airway models currently available for use in education or simulation do not replicate anatomy or tissue responses to procedures. Emphasis on mass production with sturdy but homogeneous materials and low-fidelity casting techniques diminishes these models' abilities to realistically represent the unique characteristics of the pediatric airway, particularly in the infant and younger age ranges. Newer fabrication technologies, including 3-dimensional (3D) printing and castable tissue-like silicones, open new approaches to the simulation of pediatric airways with greater anatomical fidelity and utility for procedure training. METHODS: After ethics approval, available/archived computerized tomography data sets of patients under the age of 2 years were reviewed to identify those suitable for designing new models. A single 21-month-old subject was selected for 3D reconstruction. Manual thresholding was then performed to produce 3D models of selected regions and tissue types within the dataset, which were either directly 3D-printed or later cast in 3D-printed molds with a variety of tissue-like silicones. A series of testing mannequins derived using this multimodal approach were then further refined following direct clinician feedback to develop a series of pediatric airway model prototypes. RESULTS: The initial prototype consisted of separate skeletal (skull, mandible, vertebrae) and soft-tissue (nasal mucosa, pharynx, larynx, gingivae, tongue, functional temporomandibular joint [TMJ] "sleeve," skin) modules. The first iterations of these modules were generated using both single-material and multimaterial 3D printing techniques to achieve the haptic properties of real human tissues. After direct clinical feedback, subsequent prototypes relied on a combination of 3D printing for osseous elements and casting of soft-tissue components from 3D-printed molds, which refined the haptic properties of the nasal, oropharyngeal, laryngeal, and airway tissues, and improved the range of movement required for airway management procedures. This approach of modification based on clinical feedback resulted in superior functional performance. CONCLUSIONS: Our hybrid manufacturing approach, merging 3D-printed components and 3D-printed molds for silicone casting, allows a more accurate representation of both the anatomy and functional characteristics of the pediatric airway for model production. Further, it allows for the direct translation of anatomy derived from real patient medical imaging into a functional airway management simulator, and our modular design allows for modification of individual elements to easily vary anatomical configurations, haptic qualities of components or exchange components to replicate pathology.

The origins and development of physician anaesthesiology training in Papua New Guinea: From colonial days to the current era.

Papua New Guinea is a Pacific country that remains an enigma to the world at large. Despite massive geographical challenges due to mountainous terrain, remote islands, poverty, and with 80% of the population of over eight million living in rural villages, Papua New Guinea has managed to develop national medical and postgraduate specialty training. The first recorded anaesthetic was administered in Papua New Guinea in 1880 and the first anaesthetist trained in 1968. The University of Papua New Guinea graduated its first diploma in anaesthesia candidate in 1986 and its first master of medicine candidate in anaesthesiology in 1991. As of December 2021, there have been 82 diplomas and 40 masters of medicine awarded. We review the factors and influences bearing on the development of physician anaesthesia training in Papua New Guinea over this period. Many of the people involved have contributed information used in this article.

A New Scope of Practice: Adult Pulmonary Aspiration Managed With a Pediatric Gastroscope: A Case Report.

Pulmonary aspiration continues to be a major cause of anesthesia-related mortality. Anesthesiologists are encouraged to perform bronchoscopy to manage aspiration of particulate matter; however, they have limited training and experience in clearing luminal obstructions endoscopically. In our report, an adult with achalasia aspirated during induction for a per-oral endoscopic myotomy (POEM), resulting in desaturation and high airway pressures. Bronchoscopy by the anesthesiologist was ineffective. However, bronchoscopy by the gastroenterologist using a pediatric gastroscope cleared the bronchi of debris and led to immediate clinical improvement. Anesthesiologists, faced with particulate matter aspiration, could consider assistance from a gastrointestinal endoscopist.

Charles and Emma Darwin: Under the 'influence' of chloroform anaesthesia.

A number of Charles Darwin's biographies record the administration of chloroform by Darwin to his wife Emma, during her labour and delivery of her eighth child, Leonard. This occurred on 15 January 1850, a little over two years after James Young Simpson in Edinburgh described the analgesic action of inhaled chloroform. An online search of more than 9000 items of Darwin's correspondence at Cambridge University and other sources revealed that he was an active proponent and user of chloroform in midwifery, for euthanising animals he studied, as well as in botanical studies of carnivorous plants. He also discovered that the concurrent inhalation of chloroform, during its administration to his wife, alleviated his distressing anxiety which he suffered when present at her earlier confinements.

History of non-physician anaesthesia providers in Papua New Guinea: from heil tultuls to Anaesthetic Scientific Officers.

The most recent estimates, published in 2016, have indicated that around 70% of anaesthesia providers in Papua New Guinea are non-physician anaesthetic providers and that they administer over 90% of anaesthetics, with a significant number unsupervised by a physician anaesthetist. Papua New Guinea has a physician anaesthetist ratio estimated to be 0.25 per 100,000 population, while Australia and New Zealand have a ratio of 19 physician anaesthetists per 100,000, which is 75 times that of Papua New Guinea. To reach a ratio of seven per 100,000, recommended as the minimum acceptable by the Lancet Commission in 2016, there will need to be over 35 practitioners trained per annum until 2030, at a time when the average annual numbers of recent years are less than three physicians and less than five non-physician anaesthetic providers. We review the development of anaesthesia administered by non-physician indigenous staff and the stages of development from heil tultuls, dokta bois, liklik doktas, native medical assistants, aid post orderlies, and Anaesthetic Technical Officers up to the current Anaesthetic Scientific Officers having attained the Diploma in Anaesthetic Science from the University of Papua New Guinea.

The East-Freeman Automatic Vent: An interesting footnote in the history of mechanical ventilation.

An example of the East-Freeman Automatic Vent from Oxford was found in the early anaesthesia equipment collection at St George Hospital, Sydney. It weighs less than 200 g and is representative of a group of miniature ventilators that were described in the 1960s, including the Minivent from South Africa and the Microvent from Canada. All relied on a pressure-operated inflating valve that was described in 1966 by Mitchell and Epstein from Oxford. The ventilators were compact, portable and were powered by the gas supply from the anaesthesia machine or other driving source that distended a reservoir bag. The main problem was that they could stick in the inspiratory phase. This led to pressure in the lungs rising towards the driving pressure. There was a risk of barotrauma to the patient if the system was not promptly disconnected. While theyhad provided an alternative to hand bagging, they were superseded, as more sophisticated and safer ventilators became widely available.

Limited excision of a right atrial lipoma.

A 67-year-old female presented with a 1-year history of exertional dyspnoea. Echocardiography showed a mass in the right atrium. Surgery revealed a lipoma on the interatrial septum, near the superior cavoatrial junction. This was excised leaving the atrial septum intact. Histopathology confirmed a benign lipoma. The patient improved symptomatically after surgery and no recurrence was seen after 1 year. These rare masses are the accumulation of mature adipose tissue, arising from the subepicardial layer. Due to benign pathology and slow growth, right atrial lipomas may be resected without interatrial septum resection, avoiding the potential complications of more radical surgery.

A Forgotten Contribution to Early Anesthesia Literature: The Chloroform Problem: A Textbook Unrepresentative of Contemporary Opinion.

Dr. Richard Gill published a textbook in London in 1906 titled The CHCl3 - Problem. Gill was the Chief Chloroformist at St Bartholomew's Hospital, London, and was recognized as an excellent clinical anesthetist and was of an intelligent but reclusive and eccentric personality. This textbook is rarely found and has not been appreciated in the history of anesthesia for several reasons including that it was generally ignored at publication and few copies exist in libraries around the world. The CHCl3Problem is written in a verbose, archaic, and convoluted fashion and is rarely quoted. It has no references whatsoever. Gill was extensively quoted by one of his students who returned to Australia, Dr. John W Bean, which brought the book to the authors' attention. It was found on the Internet, and a copy from the Boston Medical Library had been scanned and was available as a print-on-demand.

Treatment of Intravenous Leiomyomatosis with Cardiac Extension following Incomplete Resection.

Aim. Intravenous leiomyomatosis (IVL) with cardiac extension (CE) is a rare variant of benign uterine leiomyoma. Incomplete resection has a recurrence rate of over 30%. Different hormonal treatments have been described following incomplete resection; however no standard therapy currently exists. We review the literature for medical treatments options following incomplete resection of IVL with CE. Methods. Electronic databases were searched for all studies reporting IVL with CE. These studies were then searched for reports of patients with inoperable or incomplete resection and any further medical treatments. Our database was searched for patients with medical therapy following incomplete resection of IVL with CE and their results were included. Results. All studies were either case reports or case series. Five literature reviews confirm that surgery is the only treatment to achieve cure. The uses of progesterone, estrogen modulation, gonadotropin-releasing hormone antagonism, and aromatase inhibition have been described following incomplete resection. Currently no studies have reviewed the outcomes of these treatments. Conclusions. Complete surgical resection is the only means of cure for IVL with CE, while multiple hormonal therapies have been used with varying results following incomplete resection. Aromatase inhibitors are the only reported treatment to prevent tumor progression or recurrence in patients with incompletely resected IVL with CE.

Gastroschisis management: an experience in Angau Memorial Hospital.

This paper is the report of a 2 kg baby girl born with a large gastroschisis at the Angau Memorial Hospital. She is the first long-term survivor in Papua New Guinea with this major ventral abdominal wall defect as far as we are aware. In the report important steps in the management of this major congenital defect are highlighted from both the surgical and anaesthetic perspectives. It is imperative that a large gastroschisis be managed by a reduction carried out over two or more stages to prevent catastrophic abdominal compartment syndrome. Postoperative ventilation via an endotracheal tube was required due to respiratory compromise from the raised intra-abdominal pressure. Deflation of the dilated small bowel was shown to be an important step to allow full return of the small bowel into the abdominal cavity. A percutaneous jejunostomy feeding tube was inserted for feeding postoperatively as total parenteral nutrition was not available, and this was crucial for the nutritional management and ultimate survival of the baby. Gastroschisis is a very significant congenital defect with major challenges in its management in a developing country, but if important principles of management are followed, the prognosis can be remarkably improved.