A case of unusual evisceration through laparoscopic port site.

Drain site eviscerations have been reported as a rare complication following abdominal surgery. An 82-year-old women was diagnosed with carcinoma stomach and underwent laparoscopic subtotal gastrectomy. A few hours following removal of the duodenal stump drain, she developed small bowel evisceration through the drain site. It was successfully managed with immediate bedside release of fascial constriction followed by definitive repair later. Although herniations and eviscerations via larger drain sites have been reported, eviscerations from small laparoscopic port sites used for drains are rare. Here, we report the first case of small bowel evisceration with strangulation through a 5-mm port site.

Genomic resources for the study of neuropsychiatric disorders.

The National Institute of Mental Health (NIMH) has made sustained investments in the development of genomic resources over the last two decades. These investments have led to the development of the largest biorepository for psychiatric genetics as a centralized national resource. In the realm of genomic resources, NIMH has been supporting large team science (TS) consortia focused on gene discovery, fine mapping of loci, and functional genomics using state-of-the-art technologies. The scientific output from these efforts has not only begun to transform our understanding of the genetic architecture of neuropsychiatric disorders, but it has also led to a broader cultural change among the investigator community towards deeper collaborations and broad pre-publication sharing of data and resources. The NIMH supported efforts have led to a vast increase in the amount of genetic and genomic resources available to the mental health research community. Here we provide an account of the existing resources and estimates of the scale and scope of what will be available in the near future. All biosamples and data described are intended for broad sharing with researchers worldwide, as allowed by the subject consent and applicable laws.

The Effect of Transesophageal Echocardiography Probe Placement on Intracuff Pressure of an Endotracheal Tube in Infants and Children.

OBJECTIVES: To evaluate the effects of transesophageal echocardiography (TEE) probe insertion on the endotracheal cuff pressure (CP). DESIGN: Prospective observational study. SETTING: Single standing, not-for-profit pediatric hospital. PARTICIPANTS: A total of 80 pediatric patients (aged 6 days to 18.4 years) who underwent cardiac surgery and intraoperative TEE. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Following anesthesia induction and endotracheal intubation, the CP was recorded at 4 points: before the insertion of the TEE (P1), at TEE insertion (P2), during TEE examination (P3), and after the probe was advanced into the stomach (P4). Twenty patients were enrolled in each of the following age groups:<1 year of age; 1-4 years of age; 5-8 years of age; and 9-18 years of age. CP was compared between pairs of time points using paired t-tests, and differences in CP over time were compared among age groups using repeated-measures analysis of variance. CP at P1, P2, P3, and P4 was 18.7±11.6, 26.7±14.4, 22.3±12.4, and 20.6±12.6 cmH2O, respectively. Although CP significantly increased from P1 to P2 (p<0.001), there was no significant difference between P1 and P4 (95% CI; -0.3 to 4.1; p = 0.083). There was no significant difference in CP change based on the age of the patient. CONCLUSION: Following a transient increase in CP with TEE probe insertion, the CP returned to baseline after the tip of the TEE probe was advanced into the stomach. There was no variation among age groups in the magnitude of the CP change during the study.

Cuffed endotracheal tubes in children: the effect of the size of the cuffed endotracheal tube on intracuff pressure.

BACKGROUND: In children, the size of the cuffed endotracheal tube is based on various age-based formulas. However, such formulas may over or underestimate the size of the cuffed endotracheal tube. There are no data on the impact of different-sized cuffed endotracheal tubes (ETT) on the intracuff pressure in children. AIM: The current study measures intracuff pressure with different-sized cuffed ETT. METHOD: The study was conducted in an in vitro and in vivo phase. For the in vitro phase, 10 cuffed ETT of size 4.0, 4.5, and 5 mm internal diameter (ID) each were randomly placed inside a 1.0 cm ID plastic tube (mimicking the trachea), which was in turn connected to a 1 l test lung. After inflation of the cuff using the air leak test at a continuous positive airway pressure of 20 cmH2 O, the intracuff pressure was measured. The in vivo phase was conducted in 100 children (4-8 years) and were randomly divided into two groups to receive either a cuffed endotracheal tube based on the Khine formula (Group R) or a cuffed endotracheal tube that was a half-size (0.5 mm ID) smaller (Group S). Following the inflation of the cuff to seal the trachea, the intracuff pressure was measured. RESULTS: In the in vitro phase, the intracuff pressure was 45 ± 6, 23 ± 1, and 14 ± 6 cmH2 O with size 4.0, 4.5, and 5 mm ID cuffed ETT, respectively (F-test P < 0.001 for difference among three groups). In the in vivo phase, the mean intracuff pressure in Group R was 25 ± 19 cmH2 O vs 37 ± 35 cmH2 O in Group S (95% CI of difference: 1, 23; P = 0.039). CONCLUSION: If the cuffed endotracheal tube is too small, the trachea can still be sealed by inflating the cuff with additional air. However, this transforms the cuff from the intended high-volume, low-pressure cuff to an undesirable high-volume, high-pressure cuff.

Oropharyngeal oxygen and volatile anesthetic agent concentration during the use of laryngeal mask airway in children.

BACKGROUND: The laryngeal mask airway is increasingly used as an airway adjunct during general anesthesia. Although placement is generally simpler than an endotracheal tube, complete sealing of the airway may not occur, resulting in contamination of the oropharynx with anesthetic gases. Oropharyngeal oxygen enrichment may be one of the contributing factors predisposing to an airway fire during adenotonsillectomy. The current study prospectively assesses the oropharyngeal oxygen and volatile anesthetic agent concentration during laryngeal mask airway use in infants and children. METHODS: Following the induction of general anesthesia and placement of a laryngeal mask airway, the oropharyngeal gas sample was obtained by placing a 14-gauge catheter attached to the gas sampling tube into the oropharynx above the laryngeal mask airway. The oropharyngeal concentration of the oxygen and the anesthetic agent were recorded for five breaths during both spontaneous ventilation (SV) and positive pressure ventilation (PPV). RESULTS: The study included 238 patients. The oropharyngeal concentration of sevoflurane was >50% of the inspired sevoflurane concentration during SV in 10 of 238 (4.2%) patients and during PPV in 135 of 238 (56.7%) patients. Similarly, during SV and PPV, the oropharyngeal oxygen concentration was >21% in 30 of 238 (12.6%) patients and in 188 of 238 (79%) patients, respectively. Significantly, we also noticed that the oropharyngeal oxygen concentration exceeded 50% in 5 of 238 (2.1%) patients during SV and in 139 of 238 patients (58.4%) patients during PPV. CONCLUSIONS: With the use of a laryngeal mask airway and the administration of 100% oxygen, there was significant contamination of the oropharynx during both PPV and SV. The oropharyngeal concentration of oxygen was high enough to support combustion in a significant number of patients. The use of a laryngeal mask airway does not ensure sealing of the airway and may be one risk factor for an airway fire during adenotonsillectomy.

Changes in intracuff pressure of cuffed endotracheal tubes while positioning for adenotonsillectomy in children.

BACKGROUND: When using cuffed endotracheal tubes (cETTs), changes in head and neck position can lead to changes in intracuff pressure. AIM: The aim of this study was to assess the combined effect of neck extension, shoulder roll placement, and Crowe-Davis retractor use during adenotonsillectomy on the intracuff pressure of cETTs in children. METHODS: Patients <18 years of age undergoing adenotonsillectomy under general anesthesia following the placement of a cETT were included in the study. After inflation of the cuff to seal the trachea, using the leak test, baseline intracuff pressure was recorded and then continuously monitored. After neck extension, placement of a shoulder roll, insertion of the Crow-Davis retractor, suspension from a Mayo stand, and positioning for surgery, the intracuff pressure was recorded again. RESULTS: The study cohort included 84 patients, ranging in age from 0.9 to 17 years (5.7 ± 3.9 years). In 46 patients (54.8%), the intracuff pressure increased from baseline after positioning for adenotonsillectomy. In 12 of these patients (14.3%), the intracuff pressure was >30 cm H2O. The intracuff pressure decreased in 28 patients (33.3%), while no change was noted in 10 patients (11.9%). Overall, the general trend was an increase in intracuff pressure from 15.9 ± 7.8 cm H2O to 18.9 ± 11.6 cm H2O. CONCLUSION: Both increases and decreases in the intracuff pressure may occur following positioning of the pediatric patient for adenotonsillectomy. An increase in intracuff pressure may result in a higher risk of damage to the tracheal mucosa. A decrease in the intracuff pressure can result in an air leak resulting in inadequate ventilation, increased risk of aspiration, and even predispose to airway fire if oxygen-enriched gases are used. Continuous intracuff pressure monitoring or rechecking the intracuff pressure after positioning for adenotonsillectomy may be indicated.

Changes in intracuff pressure of a cuffed endotracheal tube during surgery for congenital heart disease using cardiopulmonary bypass.

BACKGROUND: With the development of newer polyurethane cuffed endotracheal tubes (cETTs), there has been a shift in clinical practice among pediatric anesthesiologists. Despite improvements in design, excessive inflation of the cuff can still compromise tracheal mucosal perfusion. Several perioperative factors can affect the intracuff pressure (CP), and there is no consensus on safe CP in pediatric patients undergoing repair of congenital cardiac disease (CHD) utilizing cardiopulmonary bypass (CPB). In the current study, the CP was continuously monitored in pediatric patients undergoing surgery for CHD. METHODS: After IRB approval, this observational study was conducted on pediatric patients who underwent repair of CHD using CPB with a cETT in place. After anesthetic induction and endotracheal intubation, the cuff was inflated using the air leak technique while maintaining a continuous positive airway pressure of 20 cmH2 O. After inflation, the CP was continuously monitored throughout the procedure. In addition, temperature and mean arterial pressure (MAP) were also recorded. RESULTS: The study included 33 patients who ranged in age from 1 month to 15.3 years. Their weight ranged from 4.0 to 83.6 kg. Six patients were excluded from the analysis due to the need to add or remove air from the cuff, leaving 27 patients for data analysis for cuff pressure over time. The baseline CP at the time of inflation was 16.1 ± 7.6 cmH2 O. With the use of CPB and initiation of hypothermia, when compared to the baseline, the CP decreased by -0.7 ± 5.8 cmH2 O at 35-37°C, -9.1 ± 8.4 cmH2 O at 31-33°C, -7.8 ± 6.2 cmH2 O at 27-29°C, and -11.1 ± 6.0 cmH2 O at <27°C. With rewarming, the CP increased back to the baseline level (-3.5 ± 7.0 cmH2 O). CONCLUSION: There was a significant decrease in the CP during CPB and associated hypothermia. This may offer some protection for mucosal perfusion during CPB which is usually associated with lower than normal MAP. However, the decrease in the CP may compromise the tracheal seal which may not offer the intended protection for the airway from aspiration.

Effect of dexmedetomidine on the QT interval in pediatric patients undergoing general anesthesia.

BACKGROUND: Recent years have seen an increase in the use of dexmedetomidine in pediatric patients presenting for surgical procedures. However, only a limited number of studies have evaluated its effects on the QT interval in this patient group. To address this lack of knowledge, we have evaluated the effects of dexmedetomidine on the QT interval in children receiving sevoflurane anesthesia. METHODS: This study was a prospective case-control study in which pediatric patients presenting for anesthetic care were divided into two groups--the dexmedetomidine (D) and control (C) groups. Three electrocardiograms (ECGs) were obtained on each patient, including a baseline ECG (T1) prior to anesthetic induction and an ECG after the induction of anesthesia with sevoflurane (T2). In group D, the third ECG was obtained 2 min after the administration of dexmedetomidine, which in turn was started immediately after the T2 ECG reading (T3D); in group C, it was obtained 2 min after the T2 reading (T3C). Statistical analysis was performed using analysis of variance to compare the QT intervals at the three time points outlined above. RESULTS: A total of 50 patients were recruited to the study, ranging in age from 1 to 16 [mean 7.9 ± 4.1 (SD) years]. There were 25 patients in group C and 25 in group D. There were no statistical differences in the demographics between the 2 groups. In group C, the QTc was noted to increase progressively with the administration of sevoflurane (T3C vs. T1; P = 0.006). In group D, following the administration of dexmedetomidine, there was a significant decrease in the QTc relative to the post-induction value [436 ± 25 (T2) vs. 418 ± 17 ms (T3D); P < 0.01]. CONCLUSION: A progressive lengthening of the QTc interval following the administration of sevoflurane was observed in the control group. In the dexmedetomidine group, there was a significant shortening of the QTc interval following the administration of dexmedetomidine compared to the length of the post-induction QTc interval and when compared to the control group.

SUBMUCOSAL DISSECTION OF THE RETROPHARYNGEAL SPACE DURING NASAL INTUBATION.

Various complications have been reported with nasal endotracheal intubation including bleeding, epistaxis, bacteremia, damage to intranasal structures, and even intracranial penetration. We present two cases that required general anesthesia for dental surgery. Submucosal dissection of the retropharyngeal tissues occurred during attempted nasal endotracheal intubation. Previous reports of this complication are reviewed, treatment strategies presented, and potential maneuvers to prevent this complication suggested.

An in vitro and in vivo validation of a novel monitor for intracuff pressure in cuffed endotracheal tubes.

BACKGROUND: The clinical practice of pediatric anesthesiology has changed with increasing use of cuffed endotracheal tubes (cETTs) in infants and children. To limit the risk of tracheal mucosal damage, regular monitoring of intracuff pressure (CP) is necessary. This study evaluates the efficacy and accuracy of a novel syringe device that provides a digital readout of the CP. METHODS: The study was conducted in two phases. In phase 1, an in vitro study, cETTs of sizes 4.0, 5.0, and 6.0 mm ID were placed into polyvinylchloride tubing of appropriate sizes. The cuffs were then inflated, and the CP was measured simultaneously using the syringe device and a manometer. In phase 2, an in vivo study on 200 pediatric patients, the syringe device and the manometer were simultaneously attached to the pilot balloon to measure the CP following endotracheal intubation. Statistical analysis included linear regression analysis and Bland-Altman comparison. RESULTS: Linear regression analysis of the in vitro study demonstrated an R2 value of 0.9989. Bias and precision were -1.92 ± 0.62 with 95% level of agreement (LOA) ranging from -3.13 to -0.72. For the in vivo study, the linear regression analysis demonstrated an R2 value of 0.9943. The bias and precision were -0.53 ± 0.68 with 95% LOA ranging from -1.86 to 0.81. CONCLUSION: The study has demonstrated clinically acceptable correlation between the CPs obtained from the standard manometer and the syringe device both in vitro and in vivo. This device is a simple, reliable, portable, and affordable method to monitor CP.

The relationship between head and neck position and endotracheal tube intracuff pressure in the pediatric population.

BACKGROUND: Over the past few years, there has been a change in clinical practice with a transition to the use of cuffed instead of uncuffed endotracheal tubes (ETTs) in pediatric patients. These changes have led to concerns regarding unsafe intracuff pressures in pediatric patients, which may result in postoperative morbidity. To avoid these issues, it is generally suggested that the intracuff pressure be maintained at ≤30 cmH2 O. The current study prospectively assesses the changes in intracuff pressure related to alterations in head and neck position in pediatric patients. METHODS: Patients less than 18 years of age, undergoing surgery, requiring endotracheal intubation with a cuffed ETT were eligible for inclusion. No alteration in the technique of anesthetic induction or maintenance was required for the study. Following endotracheal intubation and inflation of the cuff with the head and neck in a neutral position, the intracuff pressure was measured. The intracuff pressure was then subsequently measured with the head turned to the right, head turned to the left, head and neck flexed, and head and neck extended. RESULTS: A total of 200 patients were included in the study resulting in a total of 1000 intracuff pressure readings. When compared to the neutral position, the intracuff pressure increased in 545 instances (68.1%) with changes in position of the head and neck. An increase in intracuff pressure was noted more frequently and to the greatest degree with head and neck flexion. The pressure decreased in 153 instances (19.1%), most frequently with neck extension. CONCLUSION: Significant changes in the intracuff pressure occur with changes in head and neck position. In several cases, this resulted in a significant increase in the intracuff pressure. For prolonged cases with the head and neck turned from the neutral position, the intracuff pressure should be measured following patient positioning to ensure that the intracuff pressure is within the clinically recommended range.

A technique to measure the intracuff pressure continuously: an in vivo demonstration of its accuracy.

OBJECTIVE: A major concern with the use of cuffed endotracheal tubes (cETT) in children is hyperinflation of the cuff which may compromise tracheal mucosal perfusion. To measure the intracuff pressure (CP), we devised a method using the transducer of an invasive pressure monitoring device. The objective of the study was to test the accuracy and validity of this device for instantaneous and continuous CP monitoring. METHODS: The study was conducted in 2 phases. In Phase 1 (200 pediatric patients), after inflation of the cuff, the CP was measured using the standard manometer and the transducer simultaneously. In Phase 2 (20 pediatric patients), the transducer was left connected to the pilot balloon of the ETT to obtain a continuous CP reading and the standard manometer was used to measure the CP at 5-min intervals. Statistical analysis included a Bland-Altman comparison and linear regression analysis. RESULTS: In Phase 1, linear regression analysis demonstrated an R2 value of 0.9956. The bias was 0.30 cmH2O, the precision was 0.75 cmH2O, and the 95% level of agreement (LOA) ranged from -1.16 to 1.77 cmH2O. In Phase 2, the linear regression analysis revealed an R2 value of 0.9846. The bias was 0.28 cmH2O, the precision was 0.7 cmH2O, and the 95% LOA ranged from -1.1 to 1.66 cmH2O. CONCLUSION: Our study demonstrates that when cETTs are used in the pediatric population, the transducer of the invasive pressure monitoring device can be used reliably to measure the CP at the time of inflation and continuously thereafter.

Isolation and molecular characterization of Chikungunya virus from the Andaman and Nicobar archipelago, India: evidence of an East, Central, and South African genotype.

Chikungunya virus (CHIKV) is an Alphavirus belonging to the family Togaviridae. In 2006, CHIKV infection struck the Andaman and Nicobar archipelago, with an attack rate of 60%. There were more than 10 cases with acute flaccid paralysis simulating the Guillian Barre Syndrome. The majority of the patients presented severe joint pain. The cause for such an explosive nature of the outbreak with increased morbidity was not known. The isolation of CHIKV was attempted and succeeded from nine subjects presenting clinical symptoms of Chikungunya fever. The cDNA of all the isolates was sequenced for partial E1 and nsP1 genes. Sequences were aligned based on the double locus sequence typing concept. The phylogenetic analysis shows that sequences of Andaman isolates grouped with the East, Central, and South African genotype of virus isolates from India, Sri Lanka, and Réunion. The genetic distance between Andaman isolates and the Réunion isolates was very small. The phylogenetic analysis confirmed the origin of the isolates responsible for the first ever confirmed CHIKV outbreak in these islands to be the East, Central, and South African genotype. In this manuscript, we discuss the involvement of the East, Central, and South African strain with the Chikungunya fever outbreak in this archipelago and double locus sequence typing as a first time approach.

Page Kidney in a Child with Severe Pelviureteric Junction Obstruction.

There are various causes of Reno Vascular Hypertension in children reported in the literature. Amongst these, Page kidney gets a rare mention. This phenomenon is a result of the accumulation of blood or urine in the perinephric or subcapsular space, resulting in compression of renal parenchyma, microvascular ischemia, alteration in the renin-angiotensin apparatus, and high renin hypertension. It has been well documented and studied in adults. Only a few cases are reported in the paediatric population. We report a rare presentation of Page kidney in a 5 year 8 months old girl. She initially presented with Dietl's crisis secondary to left Pelviureteric Junction obstruction (PUJO) causing massive hydronephrosis. She developed Page kidney phenomenon after spontaneous rupture of the pelvicalyceal system formed a tight compressive urinoma. She was managed successfully with internal JJ stenting and ultrasound-guided aspiration of the urinoma followed by elective delayed Pyeloplasty. To our knowledge, this is the first documented case of Page kidney in a child with severe PUJO.

Co-immunization with an optimized plasmid-encoded immune stimulatory interleukin, high-mobility group box 1 protein, results in enhanced interferon-gamma secretion by antigen-specific CD8 T cells.

DNA vaccination is a novel immunization strategy that has great potential for the development of vaccines and immune therapeutics. This strategy has been highly effective in mice, but is less immunogenic in non-human primates and in humans. Enhancing DNA vaccine potency remains a challenge. It is likely that antigen-presenting cells (APCs), and especially dendritic cells (DCs), play a significant role in the presentation of the vaccine antigen to the immune system. A new study reports the synergistic recruitment, expansion and activation of DCs in vivo by high-mobility group box 1 (HMGB1) protein. Such combinational strategies for delivering vaccine in a single, simple platform will hypothetically bolster the cellular immunity in vivo. Here, we combined plasmid encoding human immunodeficiency virus-1 (HIV-1) Gag and Env with an HMGB1 plasmid as a DNA adjuvant in BALB/c mice (by intramuscular immunization via electroporation), and humoral and cellular responses were measured. Co-administration of this potent immunostimulatory adjuvant strongly enhanced the cellular interferon-gamma (IFN-gamma) and humoral immune response compared with that obtained in mice immunized with vaccine only. Our results show that co-immunization with HMGB1 can have a strong adjuvant activity, driving strong cellular and humoral immunity that may be an effective immunological adjuvant in DNA vaccination against HIV-1.

Human immunodeficiency virus type 1 Nef induces programmed death 1 expression through a p38 mitogen-activated protein kinase-dependent mechanism.

Chronic viral infection is characterized by the functional impairment of virus-specific T-cell responses. Recent evidence has suggested that the inhibitory receptor programmed death 1 (PD-1) is specifically upregulated on antigen-specific T cells during various chronic viral infections. Indeed, it has been reported that human immunodeficiency virus (HIV)-specific T cells express elevated levels of PD-1 and that this expression correlates with the viral load and inversely with CD4(+) T-cell counts. More importantly, antibody blockade of the PD-1/PD-L1 pathway was sufficient to both increase and stimulate virus-specific T-cell proliferation and cytokine production. However, the mechanisms that mediate HIV-induced PD-1 upregulation are not known. Here, we provide evidence that the HIV type 1 (HIV-1) accessory protein Nef can transcriptionally induce the expression of PD-1 during infection in vitro. Nef-induced PD-1 upregulation requires its proline-rich motif and the activation of the downstream kinase p38. Further, inhibition of Nef activity by p38 MAPK inhibitor effectively blocked PD-1 upregulation, suggesting that p38 MAPK activation is an important initiating event in Nef-mediated PD-1 expression in HIV-1-infected cells. These data demonstrate an important signaling event of Nef in HIV-1 pathogenesis.

RANKL Gene Polymorphism as a Potential Biomarker to Identify Acute Charcot Foot Among Indian Population With Type 2 Diabetes: A Preliminary Report.

Studies addressing the link between gene polymorphism and Charcot neuropathic osteoarthopathy (CN) have been limited to analyse osteoprotegerin gene. Aim is to understand the association of RANKL gene variants on the susceptibility of diabetic neuropathy and CN and to measure the serum levels of sRANKL among Indian population with type 2 diabetes. 77 subjects (48 males: 29 females) were recruited and divided into 3 groups. Group 1 Control: normal glucose tolerance (NGT). Group 2: Type 2 diabetes mellitus and neuropathy (DPN). Group 3: Established type 2 diabetes mellitus, DPN, and CN. Subjects were genotyped for RANKL SNP 693 C/G and 643 C/T using polymerase chain reaction-restriction fragment length polymorphism. sRANKL levels were measured using ELISA (enzyme-linked immunosorbent assay). The serum levels of sRANKL were significantly different between the 3 groups. In RANKL -643 C/T the frequency of "CT" genotype and the minor allele "T" was greater among the DPN and CN group compared with the NGT. Further statistical analysis found a significant difference in genotypic frequencies between DPN and NGT subjects with CT genotype. In RANK L -693 C/G the frequency of homozygote mutant "GG" and the minor allele "G" was greater among the DPN and CN group compared with the NGT. Significant differences in genomic frequencies were observed among "GG" genotype. RANKL -643 C/T was significantly associated with DPN alone while -693 C/G was significantly associated with both DPN and CN. Thus, the study suggests RANKL polymorphism might be considered as an independent risk factor for the development of CN.

Intracuff pressure during one-lung ventilation in infants and children.

OBJECTIVE: We prospectively evaluated intracuff pressure (IP) during one-lung ventilation (OLV) to characterize potential risk associated with overinflation of the cuff used for OLV. DESIGN: Prospective observational study over a 2-year period, in infants and children undergoing thoracic surgery. The IPs of the tracheal and bronchial balloon were measured using a manometer and compared to a previously recommended threshold of 30 cmH2O. Data were compared by the device type used to achieve OLV. SETTING: Freestanding tertiary-care pediatric hospital. PARTICIPANTS: Patients ≤18 years of age undergoing thoracic procedures requiring OLV. INTERVENTIONS: Measurement of IP. MEASUREMENTS AND MAIN RESULTS: Thirty patients were enrolled (age 5 months-18 years) with a median weight of 28 kg. Median tracheal and bronchial IPs were 32 cmH2O (range: 11, 90) and 44 cmH2O (range: 10, 100), respectively. The tracheal and bronchial IPs exceeded 30 cmH2O in 13 of 20 patients (65%) and 21 of 30 patients (70%), respectively. CONCLUSIONS: IP was high and in excess of recommended levels in most children undergoing OLV. Continuous monitoring of IP may be indicated during OLV to address the risks involved and ensure the prevention of complications related to high IP. TYPE OF STUDY: Prospective comparative study. LEVEL OF EVIDENCE: Level II.

Management of the Difficult Airway in the Pediatric Patient.

Loss of airway control in children, if not resolved quickly, will lead to devastating consequences. Successful management of the pediatric difficult airway, both anticipated and unanticipated, is facilitated by preprocedure assessment and preparation. Accessibility of and continued hands-on training with modern airway instruments, familiarization with difficult airway guidelines, and collaboration with multidisciplinary airway teams can aid in the management of the difficult pediatric airway. This review outlines the importance of airway assessment and advanced airway equipment for children. It also discusses difficult airway management techniques and algorithms for the management and rescue of the pediatric difficult airway.