Addition of Local Anesthetic Epidural Infusion Catheter to Intravenous Opioid Analgesia for Postoperative Pain Control in Children Undergoing Video Assisted Thoracoscopic Surgery (VATS).

PURPOSE: Postoperative analgesia following minimally invasive video assisted thoracoscopic surgery (VATS) in pediatric patients may involve intravenous opioid analgesics and continuous local anesthetic infusions via an epidural infusion catheter. The use of epidural catheters may avoid systemic side effects of intravenous opioids in this vulnerable population. DESIGN: Our primary aim was to compare total morphine equivalents (MEQ) required, and pain scores between local anesthetic epidural infusion catheters combined with intravenous opioids, versus intravenous opioids alone in pediatric patients following VATS procedure. METHODS: Following Institutional Review Board approval, we performed a retrospective chart review of children (ages 1 month to 18 years) who underwent VATS procedure for noncardiac thoracic surgery. Based on the postoperative analgesic technique used, the study population was divided into two groups that is, epidural group and nonepidural group. Both groups received intravenous systemic opioids. The primary outcome variables were total MEQ required and pain scores in the perioperative period. FINDINGS: Ninety-two patients were included in the study. Of these, 22 patients belonged to the epidural group versus 70 patients to the nonepidural group. There was no statistical difference in MEQ requirements or pain scores between the groups intraoperatively (P = .304), in the postanesthesia care unit (P = .166), or at postoperative time intervals of 24 hours (P = .805) and 48 hours (P = .844). The presence of infection or empyema was a significant factor for the avoidance of epidural placement by providers (P = .003). CONCLUSIONS: There was no significant difference in the perioperative MEQ or postoperative pain scores between the epidural catheter group and the nonepidural group. More research is necessary to determine if this could be due to epidural catheter malposition and/or inadequate dermatomal coverage of surgical chest tubes.

Emergent airway management in a case of fibrodysplasia ossificans progressiva.

Fibrodysplasia ossificans progressiva (FOP), or Stone man syndrome, is rare and one of the most disabling genetic conditions of the connective tissue due to progressive extraskeletal ossification. It usually presents in the first decade of life as painful inflammatory swellings, either spontaneously or in response to trauma, which later ossify and lead to severe disability. Progressive spinal deformity including thoracolumbar kyphoscoliosis leads to thoracic insufficiency syndrome, increasing the risk for pneumonia and right sided heart failure. We present the airway management in a 22-year-old male, diagnosed with FOP with severe disability, who required urgent airway intervention as a result of respiratory failure from pnuemonia. Tracheostomy triggers ossification and consequent airway obstruction at the tracheostomy site and laryngoscopy triggers temporomandibular joint ankylosis. Therefore, awake fiber-optic endotracheal intubation is recommended in these patients. Use of an airway endoscopy mask enabled us to simultaneously maintain non-invasive ventilation and intubate the patient in a situation where tracheostomy needed to be avoided.

Intra-Arterial Lidocaine Blunts the Trigeminocardiac Reflex during Endovascular Treatment of a Carotid-Cavernous Fistula.

Carotid-cavernous fistulas (CCFs) are vascular shunts that allow blood to flow from the carotid artery or its branches into the cavernous sinus. Endovascular embolization is the treatment modality of choice. The trigeminocardiac reflex (TCR) is a vagally mediated reflex that can lead to hemodynamic instability. It can be activated during embolization procedures due to the proximity of vagal efferent neurovascular structures within the cavernous sinus. This case report describes the intraoperative management of recurrent, profound bradycardia due to TCR during endovascular CCF embolization.

Bedside ultrasound assessment of gastric content in children noncompliant with preoperative fasting guidelines: Is it time to include this in our practice?

Ultrasound assessment of gastric contents and volume is gaining popularity in adults and children. At present, a preoperative verbal check is used to determine the fasting status. Due to fear of delay or cancellation of surgery, parents may not disclose noncompliance with fasting guidelines. Pulmonary aspiration of gastric contents is a potential cause of morbidity and mortality. Ultrasound assessment of gastric contents is noninvasive and easy to learn. We present a series of three cases to demonstrate how the use of ultrasound to assess gastric contents in children can provide an objective means for decision-making and impact anesthetic management when preoperative fasting status is uncertain.