SEVOFLURANE AS A CAUSE OF TORSADE DE POINTES IN PATIENT WITH THE LONG QT SYNDROME: Case Report.

Long QT syndrome (LQTS) is a rare condition that in certain circumstances can lead to severe and potentially lethal cardiac arrhythmia known as Torsade de Pointes (TdP). Inhalational anesthetics are among many medications and conditions known to prolong QT and thus potentially predispose the patient to TdP. Although studies have shown that sevoflurane should be safe for the healthy patients, the situation is unclear in patients with LQTS. We present a case of 14-year-old Caucasian female with the diagnosis of LQTS who developed TdP during sevoflurane inhalational induction. At the end, an anesthetic plan for patients with LQTS will be suggested.

STRAIGHT TO VIDEO: TONSILLAR INJURY DURING ELECTIVE GLIDESCOPE(ò)-ASSISTED PEDIATRIC INTUBATION.

Airway management in pediatric patients presenting for tonsillectomy and adenoidectomy may prove challenging given the enlarged upper airway structures. Video Laryngoscopy (VL) can be very helpful but it does not come without risks. In this case report, we report an unfavorable outcome of VL in a pediatric patient with adenotonsillar hypertrophy.

Aprotinin and transfusion requirements in pediatric craniofacial surgery.

OBJECTIVE: To evaluate transfusion requirements in children receiving aprotinin during craniofacial surgery. BACKGROUND: Pediatric craniofacial procedures may involve massive blood loss. Aprotinin may decrease perioperative blood loss and transfusion requirements. METHODS: Patients (aged 1 month to 3 years) who had major reconstructive craniofacial surgery received intraoperative aprotinin (13 patients) or placebo (13 patients). Administered colloids and blood products were recorded. RESULTS: Patients in the aprotinin and placebo groups had similar mean age, body weight, body surface area, operative time, and length of hospital stay. Mean volumes of total colloids (aprotinin group: 70 ± 40 ml; and placebo group: 120 ± 80 ml; P ≤ 0.05) and packed red blood cells (aprotinin group: 380 ± 90 ml; and placebo group: 550 ± 200 ml; P ≤ 0.004) were less in the aprotinin group than in the placebo group. Mean urine output during surgery was greater in the aprotinin group than in the placebo group (320 ± 200 ml vs 150 ± 70 ml, respectively; P ≤ 0.003). Mean blood urea nitrogen and serum creatinine values after surgery were similar between the groups. Complications of aprotinin included anaphylaxis (one patient) and rash (one patient); no deaths occurred. CONCLUSIONS: Aprotinin was associated with decreased packed red blood cell transfusion requirements in children undergoing craniofacial surgery, with no renal toxicity or death. Aprotinin is no longer available for clinical use in the USA because of adverse effects in adults; re-evaluation of aprotinin is warranted for children scheduled to undergo surgery involving potentially high blood loss.

Cerebral "hyperoxygenation" with inhalational induction of anesthesia in children: a retrospective comparison between vasoparalytic sevoflurane vs. vasoneutral fentanyl.

BACKGROUND: The higher levels of oxygen in cerebrum may contribute to neuro-apoptosis, analogous to direct tissue injury induced by toxic levels of oxygen. Earlier report highlighted the possibility of cerebral "hyperoxygenation" secondary to inhalational induction of anesthesia with sevoflurane in small number of children. OBJECTIVE: The aim of this retrospective review was whether similar cerebral "hyperoxygenation" trends can be seen in larger and retrospective patients' database. METHODS: Data of patients who had undergone cardiac surgeries at Children's Hospital during the two-year period (2010-2011) was retrieved during this retrospective review: (a) stored computer data from INVOS Cerebral/Somatic Oximeter for oximetry numbers and total duration of oximetry monitoring, (b) paper chart perfusion records of the cardiac surgeries for age and sex of the patient, urgency of the surgery, type of induction (inhalational or intravenous), and total duration of cardiopulmonary bypass, (c) general medical records for inpatient setting vs. outpatient setting of the patient, and (d) anesthesia medical records for name of the medications used during induction of anesthesia to segregate the patients who had fentanyl as a lone induction agent and sevoflurane as a lone induction agent, for final statistical calculations and analysis. For the two-year period (2010-2011), data of 358 patients who had cardiac surgeries at Children's Hospital were reviewed. However, after deletions of various patients' data due to various reasons, only 69 patients (0-4 years of age) who had sevoflurane induction were analyzed for final statistical comparisons to 14 patients (0-4 years of age) who had fentanyl induction. RESULTS: Cerebral and renal "hyperoxygenation" occurred during the first 127 minutes with sevoflurane as compared to fentanyl though the percentage changes from pre-induction values in oximetry during this time did not reach level of significance. However, only cerebral "hyperoxygenation" persisted in the last 127 minutes when patients had been induced with sevoflurane as compared to fentanyl. CONCLUSION: Cerebral "hyperoxygenation" occurs with inhalational induction of anesthesia with vasoparalytic sevoflurane in children 0 to 4 years of age when compared to anesthesia induction with vasoneutral fentanyl.

Interventions to prevent hypothermia in extremely preterm low-weight infants undergoing cardiac catheterisation.

BACKGROUND: In January 2019, a new device called the Amplatzer Piccolo Occluder was approved by the US Food and Drug Administration for percutaneous closure of patent ductus arteriosus in infants weighing more than 700 g and of postnatal age more than 3 days. Premature low-weight infants are predisposed to hypothermia when transported outside of the thermo-neutral environment. At our institution, 90% of extremely preterm low-weight infants developed transient moderate hypothermia in the cardiac catheterisation suite. METHODS: We conducted a study testing multiple hypotheses aimed at preventing hypothermia in the cardiac catheterisation suite. Interventions included increasing ambient room temperature, reducing exposure to cold environment and reducing overall time spent in the remote location. The primary outcome was the proportion of patients who developed transient hypothermia at the start of the procedure in the cardiac catheterisation suite. The secondary measures included mean core body temperature at four different instances, as well as anaesthesia time, procedure time and radiation exposure. RESULTS: During the study period, 10 patients were enrolled in each group. The postintervention group saw a reduction in transient hypothermia from 90% to 40% (absolute risk reduction 50%, p=0.02). Data analysis showed an improvement in mean core body temperature (35.4°C vs 36.4°C, p<0.01) as well as a smaller percentage drop in temperature (4% vs 1.3%, p<0.01) between the two groups, both of which were statistically significant. The anaesthesia time, procedure time and radiation exposure reduced between the two groups. CONCLUSION: The application of the interventions reduced hypothermia in this high-risk population. The implementation of a protocol with collaboration of a multidisciplinary team is indispensable in providing optimal care to extremely preterm infants.

Anesthetic management of children with Rubinstein-Taybi syndrome--case reports.

A limited number of cases of anesthetic management of Rubinstein-Taybi Syndrome (RTS) have been reported since this syndrome was first diagnosed in 1963. After some well-publicized complications following anesthesia for patients with RTS, there has been great interest in avoiding all precipitant factors and careful monitoring during intraoperative and postoperative periods. This case series examines the cases of three pediatric patients with RTS who presented to the Children's Hospital of Michigan for different surgeries. We aim in this study to share information about this rare syndrome and to emphasize how this case series allowed us to improve our anesthetic management. In each case, we adjusted our techniques using information from preceding cases to avoid complications in the following encounter.

Pediatric laryngospasm: prevention and treatment.

PURPOSE OF REVIEW: The purpose of this review is to discuss the risk factors associated with laryngospasm and the techniques used for prevention and treatment. We also summarize the prevention and treatment modalities in organized algorithms. RECENT FINDINGS: According to recent endoscopic studies, laryngospasm is always complete, thus airway management and intravenous therapy are indicated. Parental history of children having upper respiratory infection is associated with increased risk of laryngospasm. Anesthesia administered by a pediatric anesthesiologist is associated with lower incidence of laryngospasm. Intravenous anesthesia is associated with lower incidence of laryngospasm than inhalational anesthesia. In tracheal intubation, the use of muscle relaxants decreases laryngospasm. Deep laryngeal mask airway removal is associated with lower incidence of laryngospasm in sevoflurane or isoflurane anesthesia. In no intravenous line situation, laryngospasm can be treated with succinylcholine administration by intramuscular, intraosseous and intralingual routes. SUMMARY: Identifying the risk factors and taking the necessary precautions are the key points in prevention of laryngospasm. An experienced anesthesiologist is associated with lower incidence of laryngospasm. Airway management is the most essential part of treatment of laryngospasm. Drugs can be used as an adjunct in treatment of laryngospasm, especially when anesthesia is administered by beginners.

Electrocautery-induced fire during adenotonsillectomy: report of two cases.

We describe two cases of flash fires in the oropharynx, secondary to electrocautery during adenotonsillectomies. We believe that in both cases, the leak around the uncuffed endotracheal tubes raised the oxygen concentration in the oropharynx. Cuffed endotracheal tubes provide many advantages, and their use should strongly be considered during adenotonsillectomy in children when electrocautery is to be used.

Does exposure to inhalation anesthesia gases change the ratio of X-bearing sperms and Y-bearing Sperms? A worth exploring project into an uncharted domain.

According to recent surveys performed in United States and India, anesthesia care providers were observed to have sired female offspring in a higher proportion than male offspring as their firstborn progeny; however, the reasons for the skew are not clear. Our hypothesis is that the underlying biological evidence may be elucidated by unraveling differences (if any) between the concentrations of X-bearing sperms and Y-bearing sperms in the semen samples obtained from males exposed to varied levels of anesthetics in their lifetimes. Therefore, the objectives of the envisaged study would be to conduct a three-stage investigative study on in-vitro human semen samples to determine (a) X-bearing sperms and Y-bearing sperms concentrations' ratio in male pediatric anesthesia care providers' semen samples, (b) changes in X-bearing sperms and Y-bearing sperms concentrations' ratios between the pre-rotation and post-rotation semen samples of male medical student volunteers/observers, and (c) changes in X-bearing sperms and Y-bearing sperms concentrations' ratios between the pre-operative and post-operative day-3 semen samples of male patients presenting for outpatient procedures under inhalational anesthesia. The expected outcomes would be (a) linear and positive correlation of the anesthetic gas usage (exposure) with increased X-bearing sperms/Y-bearing sperms ratio in post-anesthesia day 3 sample as compared to the baseline preoperative sample, (b) linear and positive correlation of the anesthetic gas usage (exposure) with increased X-bearing sperms/Y-bearing sperms ratio in post-rotation sample as compared to the baseline sample, and (c) observation of high X-bearing sperms/Y-bearing sperms ratio in the pediatric anesthesia care providers. In summary, effects (if any) of occupational or personal exposure to inhalational anesthetic gases on the X-bearing sperms and Y-bearing sperms ratio is a worthy project wherein lots of questions that have arisen over decades could find the path to their definitive answers, based on envisaged laboratory investigations into this uncharted domain.

Spatial-temporal patterns of electrocorticographic spectral changes during midazolam sedation.

OBJECTIVE: To better understand 'when' and 'where' wideband electrophysiological signals are altered by sedation. METHODS: We generated animation movies showing electrocorticography (ECoG) amplitudes at eight spectral frequency bands across 1.0-116 Hz, every 0.1s, on three-dimensional surface images of 10 children who underwent epilepsy surgery. We measured the onset, intensity, and variance of each band amplitude change at given nonepileptic regions separately from those at affected regions. We also determined the presence of differential ECoG changes depending on the brain anatomy. RESULTS: Within 20s following injection of midazolam, beta (16-31.5 Hz) and sigma (12-15.5 Hz) activities began to be multifocally augmented with increased variance in amplitude at each site. Beta-sigma augmentation was most prominent within the association neocortex. Augmentation of low-delta activity (1.0-1.5 Hz) was relatively modest and confined to the somatosensory-motor region. Conversely, injection of midazolam induced attenuation of theta (4.0-7.5 Hz) and high-gamma (64-116 Hz) activities. CONCLUSIONS: Our observations support the notion that augmentation beta-sigma and delta activities reflects cortical deactivation or inactivation, whereas theta and high-gamma activities contribute to maintenance of consciousness. The effects of midazolam on the dynamics of cortical oscillations differed across regions. SIGNIFICANCE: Sedation, at least partially, reflects a multi-local phenomenon at the cortical level rather than global brain alteration homogeneously driven by the common central control structure.

Propofol decreases waste anesthetic gas exposure during pediatric bronchoscopy.

OBJECTIVE: This study compared the anesthetic gas exposure and operating conditions during insufflation anesthesia with halothane-alone versus halothane-propofol in children undergoing direct laryngobronchoscopy. STUDY DESIGN: Forty-six children were enrolled in this randomized prospective study, with institutional review board approval and informed consent. METHODS: All children were anesthetized by halothane mask induction and anesthesia was maintained using spontaneous ventilation with insufflation. No muscle relaxants or opioids were used. In the halothane group, halothane was titrated as needed. In the propofol group, halothane was decreased to 1% inspired concentration and the propofol was titrated as needed to maintain spontaneous ventilation and a still patient. Trace anesthetic gases, hemodynamic stability, and operating conditions were measured. RESULTS: The groups were similar in age, weight, and bronchoscopy time. There was significantly less gas exposure in the propofol group (25 +/- 33 parts per million) versus the halothane group (66 +/- 97 ppm; P <.02). There was a trend toward earlier emergence in the halothane group (33 +/- 13 minutes) versus the propofol group (41 +/- 17 minutes). Postoperative stridor was common, occurring in 30% of children. CONCLUSIONS: Insufflation anesthesia with spontaneous respiration provides excellent surgical conditions for laryngobronchoscopy. The addition of propofol resulted in fewer airway complications (P =.047). Although the addition of propofol significantly decreased anesthetic gas exposure in the operating room, both techniques resulted in operating room pollution that exceeded the maximum levels of 2 ppm per hour recommended by the US National Institute for Occupational Safety and Health (NIOSH).

Parental satisfaction with anesthesia without intravenous access for myringotomy.

OBJECTIVE: To evaluate the effect of intravenous (i.v.) access in children undergoing bilateral myringotomy with pressure-equalizing tube placement. DESIGN: One hundred healthy children were enrolled in this randomized controlled study. One group received i.v. access; the other group did not. Anesthesia in both groups was induced through a mask and maintained with oxygen, nitrous oxide, and sevoflurane. Spontaneous ventilation was maintained. All children received fentanyl, 1 microg/kg intramuscularly. Children with i.v. access received 20 mL/kg of lactated Ringer's solution. Parents were telephoned the day after surgery to report on pain and vomiting, as well as their satisfaction with anesthesia. SETTING: Tertiary care children's hospital with all procedures performed by attending pediatric otolaryngologists and otolaryngology residents. Anesthesia was administered by a pediatric anesthesiologist and a trainee. RESULTS: The groups were similar in age, weight, and incidence of vomiting. Children with i.v. access spent more time than those without (mean +/- SD minutes) in the operating room (21 +/- 8 vs 17 +/- 7; P =.02), in phase 2 recovery (75 +/- 67 vs 51 +/- 24; P =.02), and in the hospital (119 +/- 67 vs 88 +/- 30; P =.005). These children also required more pain medication (31% vs 2%; P<.001) and had a lower parental satisfaction rate (28% vs 95%; P<.001). CONCLUSIONS: Intravenous access in otherwise healthy children undergoing myringotomy provided no added benefit. Children without i.v. access had reduced pain requirement and spent less time in the operating room, in phase 2 recovery, and in the hospital. Parental satisfaction, a clinically relevant outcome, was significantly greater for parents of children without i.v. access.

Airway management for rigid bronchoscopy via a freshly performed tracheostomy in a child with Goldenhar syndrome.

A case of tooth aspiration in a 6 year old boy with Goldenhar syndrome and known difficult intubation is presented. A fresh tracheostomy was performed after a failed fiberoptic intubation and dental aspiration. The patient was transferred to our tertiary-care children's hospital for emergency bronchoscopy through the fresh tracheostomy for removal of an aspirated tooth. Rigid bronchoscopy performed via a fresh tracheostomy presents several challenges. The major complications associated with bronchoscopy performed via a fresh tracheostomy, as well as management of airway emergencies are discussed.

Airway and ventilation management during repair of a large acquired tracheoesophageal fistula: the novel use of a readily available tool.

Acquired tracheoesophageal fistula (TEF) is a life-threatening disorder of the airway that requires early diagnosis and treatment. The case of an infant who had delayed development of a TEF following endoscopic removal of a disc battery lodged in the midesophagus is reported. A repeat bronchoscopy, performed for respiratory distress 4 days later, showed a large defect in the posterior wall of the distal trachea, including the carina. A Foley catheter was used for airway management in the repair of the acquired TEF.

A novel rescue technique for difficult intubation and difficult ventilation.

We describe a novel non surgical technique to maintain oxygenation and ventilation in a case of difficult intubation and difficult ventilation, which works especially well with poor mask fit. Can not intubate, can not ventilate" (CICV) is a potentially life threatening situation. In this video we present a simulation of the technique we used in a case of CICV where oxygenation and ventilation were maintained by inserting an endotracheal tube (ETT) nasally down to the level of the naso-pharynx while sealing the mouth and nares for successful positive pressure ventilation. A 13 year old patient was taken to the operating room for incision and drainage of a neck abscess and direct laryngobronchoscopy. After preoxygenation, anesthesia was induced intravenously. Mask ventilation was found to be extremely difficult because of the swelling of the soft tissue. The face mask could not fit properly on the face due to significant facial swelling as well. A direct laryngoscopy was attempted with no visualization of the larynx. Oxygen saturation was difficult to maintain, with saturations falling to 80%. In order to oxygenate and ventilate the patient, an endotracheal tube was then inserted nasally after nasal spray with nasal decongestant and lubricant. The tube was pushed gently and blindly into the hypopharynx. The mouth and nose of the patient were sealed by hand and positive pressure ventilation was possible with 100% O2 with good oxygen saturation during that period of time. Once the patient was stable and well sedated, a rigid bronchoscope was introduced by the otolaryngologist showing extensive subglottic and epiglottic edema, and a mass effect from the abscess, contributing to the airway compromise. The airway was secured with an ETT tube by the otolaryngologist.This video will show a simulation of the technique on a patient undergoing general anesthesia for dental restorations.

Guidelines for elective pediatric fiberoptic intubation.

Fiberoptic intubation in pediatric patients is often required especially in difficult airways of syndromic patients i.e. Pierre Robin Syndrome. Small babies will desaturate very quickly if ventilation is interrupted mainly to high metabolic rate. We describe guidelines to perform a safe fiberoptic intubation while maintaining spontaneous breathing throughout the procedure. Steps requiring the use of propofol pump, fentanyl, glycopyrrolate, red rubber catheter, metal insuflation hook, afrin, lubricant and lidocaine spray are shown.

Comparison of phenoxybenzamine to sodium nitroprusside in infants undergoing surgery.

OBJECTIVES: The purpose of this study was to compare the effects of a direct-acting arterial dilator, sodium nitroprusside, to an alpha-adrenergic receptor blocker, phenoxybenzamine, in infants with congenital heart defects undergoing cardiac repairs on cardiopulmonary bypass. DESIGN: A prospective, multicenter, observational study. SETTING: Tertiary care center. PARTICIPANTS: Sixty infants scheduled for elective congenital cardiac surgery repair requiring cardiopulmonary bypass. INTERVENTIONS: Patients received either sodium nitroprusside 2 to 5 microg/kg/min infusion intraoperatively and in the intensive care unit (n=30 patients) or received phenoxybenzamine 1 mg/kg slowly intravenously at the onset of cardiopulmonary bypass (n=30 patients). MEASUREMENT AND MAIN RESULTS: Despite similar mean arterial pressures during cardiopulmonary bypass in both groups, infants who received phenoxybenzamine had a significantly higher flow compared with those who received sodium nitroprusside (180+/-4.8 v 73+/-5.12 mL/kg/min, p<0.0001). Base deficit was significantly larger in the sodium nitroprusside group compared with the phenoxybenzamine group intraoperatively and postoperatively (3.4+/-0.5 v 1.3+/-0.5 mEq/L, p<0.05). The core-to-peripheral temperature gradient was significantly larger in the sodium nitroprusside group compared with the phenoxybenzamine group intra- and postoperatively at all points studied. In the intensive care unit, the left atrial pressure was significantly higher in the sodium nitroprusside group compared with the phenoxybenzamine group (9+/-0.4 v 7+/-0.4 mmHg, p

A Workshop in Physician-Patient Communication for Anesthesiology Trainees.

BACKGROUND: Although abundant literature demonstrates the importance of effective physician-patient communication, most research and teaching models in this area are based on a primary care setting, and may not apply to procedural specialties. Some research demonstrates that patients perceive their surgeons' and anesthesiologists' communication skills to be less effective than those of primary care specialists. In order to improve the effectiveness of anesthesiology trainee communication skills and simultaneously address the new ACGME general competency requirements pertaining to such skills, faculty from the Departments of Anesthesiology and Internal Medicine collaborated in the development of a workshop tailored to the needs of this group. METHODS: After reviewing the literature on physician-patient communication in primary care and in procedural specialties, we created and delivered a workshop. RESULTS: The literature review revealed that although the essential communication skills are the same in primary care and procedural specialties, the anesthesia-patient interaction is unique because it is inherently brief, its function is to prepare for a procedure, not to diagnose and treat, and patient anxiety is generally high due to the imminent surgical procedure. We created a workshop by adapting the Bayer Institute for Health Communication's 4E Model to the anesthesia setting. This teaching model was chosen because it is based on literature that reflects both primary care and procedural settings, because it has been widely and successfully used in brief workshops to physicians, and because it achieves the overall goals of the course. They were 1) to teach the skills related to the essential elements for physician-patient communication and the functions of the pre-operative anesthesiologist-patient interaction and 2) to partially fulfill the ACGME general competency objectives. In addition to teaching the basic skills of the 4Es (Engage, Empathize, Educate and Enlist), specific examples, video cases, and role plays from the anesthesia setting were used to illustrate common problems in physician-patient communication. CONCLUSIONS: Non-primary care specialties may need to tailor current physician-patient communication models to their setting in order to train residents in interpersonal and communication skills. Our proposal for a physician-patient communication workshop for anesthesiology trainees illustrates one way in which an existing teaching model can be adapted to meet the specific needs of a procedural specialty.