The prone position is associated with a decrease in respiratory system compliance in healthy anaesthetized infants.

Ten healthy (ASA I or II) anaesthetized infants undergoing clubfoot surgery were studied. General anaesthesia included rocuronium, nitrous oxide and isoflurane. Volume controlled ventilation (12 ml.kg-1) was delivered via a coaxial Mapleson-D (Bain) system and a Datex AS/3 ventilator. Pulmonary mechanics were measured sequentially in the supine and prone positions using a Bicore CP-100 pulmonary function monitor. Subjects had a mean age of 6 (+/- 2) months and a mean weight of 8.3 (+/- 1.4) kg. Dynamic compliance (CDYN) and static compliance (CSTAT) were both significantly lower in the prone position than in the supine position (P < 0.0005). Mean CDYN decreased from 14.9 +/- 4.9 ml.cmH2O-1 (supine) to 11.6 +/- 3.5 ml.cmH2O-1 (prone). Mean CSTAT decreased from 10.2 +/- 2.8 ml.cmH2O-1 (supine) to 8.9 +/- 2.3 ml.cmH2O-1 (prone). No clinically significant differences in gas exchange were noted, however, on repositioning.

Retropharyngeal haematoma leading to airway obstruction in a child with closed head trauma.

Retropharyngeal haematoma is a rare complication of head trauma that has been chiefly reported in adults, particularly in the elderly. A case is presented of retropharyngeal haematoma in a 13-year-old child following closed head trauma. Acute upper airway obstruction resulted, requiring tracheal intubation. Surgical drainage of the haematoma was not required and the trachea was successfully extubated on the third day. The case presented serves to remind practitioners that this complication of closed head injury may occur in children and strategies for airway management are discussed.

Laryngeal mask insertion with a laryngoscope in paediatric patients.

PURPOSE: To assess epiglottic position after laryngeal mask airway (LMA) insertion with or without the use of a laryngoscope. METHODS: A double-blind randomized study. In 48 children an LMA (#2 for 6-20 kg, #2.5 for 20-30 kg) was inserted either blindly or with the help of a laryngoscope and its position assessed using fibreoptic endoscopy. RESULTS: An unobstructed view of the glottis, as assessed by fibrescope, was observed in 10 of 25 patients in the laryngoscope group, but only in 1 of 22 patients in the blind insertion group (P = 0.005). CONCLUSION: This technique offers an alternative when the standard technique has failed, or when LMA insertion precedes bronchoscopy or intubation via the laryngeal mask.

Hypoxaemia and hypotension after intravenous codeine phosphate.

This report describes a case of accidental intravenous administration of codeine phosphate (1 mg.kg-1) to a previously healthy five-year-old boy, who was undergoing strabismus surgery. Hypoxaemia (SpO2 85% with FIO2 of 1) and hypotension (systolic BP 65 mmHg) resulted, which responded to resuscitation with lactated Ringers' (20 ml.kg-1) and phenylephrine (2 micrograms.kg-1). The degree of hypoxaemia observed in this case was severe, but was not associated with clinical evidence of bronchospasm. Possible mechanisms for this reaction might have included direct myocardial depression and histamine release. This case adds further support to the recommendation that codeine phosphate should never be administered intravenously.

Efficacy, results, and complications of mechanical ventilation in children with status asthmaticus.

We have conducted a retrospective survey of 79 children out of a total hospital asthmatic patient population of 2,412, admitted over a 32 month period to the ICU for the management of severe status asthmaticus. All patients were in severe respiratory distress with CO2 retention; 19 required mechanical ventilation due to increasing fatigue and worsening bronchospasm, having failed to respond to either inhaled or IV bronchodilator therapy. All patients were ventilated at slow rates (less than 12 min) and their airway pressure (Paw) was deliberately kept below 45 cmH2O, while accepting a PaCO2 in the 45-60 mmHg range, as long as the pH was compensated. Although two patients developed pneumothoraces while on positive pressure ventilation, these were resolved without incidents. Five patients who had mediastinal or subcutaneous air leaks prior to intubation did not develop pneumothoraces. Following the initiation of mechanical ventilation, IV beta-agonist therapy was increased in order to reverse the bronchospasm and reduce the duration of mechanical ventilation. Mean duration of intubation was 42 hours. Fourteen of the 19 patients were weaned and extubated within 48 hours. All patients survived without sequelae. We conclude that a degree of controlled "hypoventilation" by deliberately choosing Paw less than 45 cmH2O can be successfully used to ventilate children with severe status asthmaticus with a reduced rate of pressure-related complications.

Horseradish peroxidase labeling of the central pathways in the medulla of the ampullary nerves in the chicken, Gallus gallus.

The purpose of the present study was to place horseradish peroxidase on the distal processes of the three ampullary nerves in 6-8-week-old chickens so that we could identify the ganglion cells associated with each nerve and trace the specific central pathways taken by each nerve in the brainstem. We are especially interested in the pathways of the colossal vestibular fibers, which may play a role in a fast reflex pathway as suggested by their large caliber and electrotonic mode of transmission in the tangential vestibular nucleus. The cells of origin of each ampullary nerve occupy discrete portions of the vestibular ganglion. Those vestibular ganglion cells giving rise to the posterior ampullary nerve (PAN) occupy the posterior portion of Scarpa's ganglion; the ganglion cells producing the anterior (AAN) and lateral (LAN) ampullary nerves occupy the anterior ganglion, within the dorsal and ventral portions, respectively. Centrally the vestibular fibers occupy discrete portions of the tangential vestibular nucleus before bifurcating into ascending and descending tracts. The tangential nucleus receives afferents from the colossal fibers, which form spoon endings, and also from the fine vestibular fibers, which form small terminals. The ascending fibers of the posterior ampullary nerve are associated with the nucleus piriformis; the ascending fibers of the anterior and lateral ampullary nerves occupy discrete cell groups of the vestibulo-cerebellar nucleus. All three ampullary nerves have descending branches that course through the retrotangential nucleus into the descending vestibular nucleus (DVN). Within the descending vestibular nucleus, the descending fibers of the posterior ampullary nerve run dorsally and centrally, whereas fibers of the anterior ampullary nerve course ventromedially, and the lateral ampullary nerve fibers take a ventrolateral course until all three fiber bundles converge in the posterior tip of the descending vestibular nucleus. The ascending and descending fibers of each ampullary nerve form collaterals that pass to the ventrolateral and dorsomedial parts of the medial vestibular nucleus. These collaterals are derived exclusively from the fine and medium diameter vestibular fibers. Some of these ascending fibers form a distinctive tract that courses posteriorly within medial regions of the dorsomedial part of the medial vestibular nucleus. The colossal vestibular fibers, which are found within all three ampullary nerves, conform to the ampullary pathways as described, excluding the innervation of the medial vestibular nucleus.

Horseradish peroxidase labeling of the efferent and afferent pathways of the avian tangential vestibular nucleus.

The efferent and afferent pathways of the chick tangential nucleus were studied by using horseradish peroxidase (HRP: Sigma type VI) to label nerve cell bodies and fibers. Depositions of HRP into the tangential nucleus, as well as into the second cervical level of the spinal cord, show that the axons of tangential neurons on leaving the nucleus form an anteriorly coursing tract that passes through the ventrolateral vestibular nucleus without branching and then to the contralateral medial longitudinal fasciculus (MLF). Within the MLF, the tangential axons course posteriorly, forming collaterals that innervate the abducens nucleus, and then proceed to the cervical spinal cord. This pathway was demonstrated for the axons of the two main neurons, the principal and elongate cells, in 1-day, 1-week, and 7-week-old animals. In addition, we propose the existence of an unidentified, ipsilateral pathway to the spinal cord for the tangential axons, since HRP injections into one side of the spinal cord resulted in the bilateral labeling of tangential neurons. No labeled cells were found in the tangential nucleus following HRP depositions into the uvula, flocculus, pontine reticular formation, nucleus piriformis, nucleus jumeaux, vestibulocerebellar nucleus, retrotangential nucleus, or the dorsomedial part of the medial vestibular nucleus. The tangential nucleus receives afferents from the colossal vestibular fibers (spoon endings), small collaterals of fine vestibular ampullary fibers, flocculus, and high cervical levels of the spinal cord. From our small sample, it appears that the spinal cord fibers form most of the afferent terminals in the tangential nucleus in 1-day, 1-week, and 7-week-old animals.

The role of anaesthetic management in enhancing peripheral blood flow in patients undergoing free flap transfer.

An anaesthetic protocol is described that is designed to promote peripheral blood flow and prevent vascular spasm in patients undergoing free flap transfer. The technique has been used successfully over a period of 3 years at St Thomas' Hospital, London, and since its introduction vascular spasm has ceased to be a major intraoperative problem.