Endoscopic diathermy obliteration of recurrent tracheoesophageal fistulae.

Recurrence of tracheoesophageal fistula after surgical repair for esophageal atresia occurs in approximately 5% to 15% of cases. Further surgery may be hazardous and mortality rates of up to 50% have been reported. We report two patients in whom successful obliteration of a recurrent fistula has been achieved by diathermy at bronchoscopy. This experience is compared to previous reports of fistula obliteration using tissue adhesives.

The management of the retained tracheostomy tube.

A tracheostomy tube that has to be retained despite attempts to remove it, must de defined as a retained tube. The previous literature is reviewed. The consequences of establishing a tracheostomy are described and, based on these considerations, recommendations are made for a regime to allow decannulation to be performed.

Anaesthesia and progressive muscular dystrophy.

The presentation and features of Duchenne's progressive muscular dystrophy (Duchenne's PMD) are described and the increased risks associated with anaesthesia are considered. Hazards associated with induction of anaesthesia and immediate postoperative recovery have been stressed in recent case reports, and these are summarized. Features of a hyperpyrexia-like response including cardiac arrest, increased serum creatine phosphokinase concentration, myoglobinuria and metabolic acidosis following suxamethonium or halothane, or both, have been described in patients with Duchenne's PMD. Subsequent in vitro muscle tests have suggested that it is possible that a malignant hyperpyrexia response to general anaesthesia may occur. Six children known to have Duchenne's PMD who developed delayed respiratory insufficiency following anaesthesia and required controlled pulmonary ventilation are reported. In five of the children, cardiac arrest occurred despite apparently adequate respiratory support. Suxamethonium was common to the anaesthetic received by all six patients. In one of these patients subsequent anaesthetics, without suxamethonium, were uneventful and delayed muscle weakness did not occur.

Prolonged neuromuscular blockade following suxamethonium in a patient with a normal genotype.

A patient is described who developed prolonged apnoea following a single normal dose of suxamethonium which was shown by nerve stimulation to be due to persistent neuromuscular blockade. The plasma cholinesterase profile demonstrated a normal genotype.

Can persistent cerebral damage be caused by hyperglycaemia?

An eight-year-old girl demonstrated severe and persistent neurological damage following an uneventful anaesthetic for a planned appendicectomy. The perioperative period was remarkable only in that the patient experienced very severe hyperglycaemia and an epileptiform convulsion. A possible mechanism for neurological damage as a result of severe hyperglycaemia is described.

Tracheal compression as a cause of respiratory symptoms after repair of oesophageal atresia.

A case of tracheal compression in an infant after repair of a tracheo-oesophageal fistula and oesophageal atresia is reported. Tracheopexy completely relieved the symptoms of apnoeic attacks, cyanosis, and convulsions. We suggest that tracheal compression in infants and children with repaired oesophgeal atresia can not only cause life-threatening attacks but also be responsible for recurrent chest infections. All infants and children with signs and symptoms of tracheal compression as shown by the presence of a barking type of cough, recurrent chest infections, or persistent mild respiratory symptoms should be referred for thorough investigation of the tracheobronchial tree.

Ventilatory support for children with whooping cough. Experience with children admitted to a paediatric intensive care unit.

Twenty-four patients with pertussis admitted to a paediatric Intensive Care Unit over a period of 42 months are reviewed. It is concluded that pertussis affects the young baby most severely, the majority of the children admitted were under the age of 3 months. Many required long term intubation and pulmonary supportive therapy and the percentage of those admitted to the Intensive Care Unit who have needed mechanical ventilation has steadily increased over the period reviewed from 25 to 71%. The youngest infant died from overwhelming respiratory infection. The other 23 patients recovered but three children developed neurological complications and their recovery is still being assessed. The importance of maintenance of the immunisation programme is stressed in view of the evidence of the severity of the disease in the very young infant.

Plasma potassium after halothane--suxamethonium induction in children.

The changes in plasma potassium following inhalation induction of anaesthesia with halothane followed by suxamethonium were studied in 48 normal children aged 1 to 10 years. Highly significant increases were found in both age groups studied (5 years and under, and 6 to 10 years). The mean percentage increase in plasma potassium and the proportion of children in whom an increase of 0.4 mmol/litre or greater was found, were both greater than in an earlier study on children after thiopentone induction and suxamethonium.

Pain-free injection in infants. Use of a lignocaine-prilocaine cream to prevent pain at intravenous induction of general anaesthesia in 1-5-year-old children.

A randomised, placebo-controlled, double-blind study was undertaken in 111 children between the ages of 1 and 5 years to assess the efficacy of EMLA 5% cream in the alleviation of venepuncture pain at intravenous induction of general anaesthesia using 27-gauge needles. Pain assessment was made by an operating department assistant using both verbal rating scale and visual analogue scale methods. Seventy-five children, of whom 24 were premedicated, were treated with EMLA cream and 36 with placebo, 14 of whom were premedicated. Significantly lower pain scores were recorded in the children treated with EMLA cream (verbal rating scale: premedicated p less than 0.05, unpremedicated p less than 0.001; visual analogue scale: premedicated p less than 0.0005, unpremedicated p less than 0.0002). No variation in analgesia was found for application times between 30 and 300 minutes and there were no serious side effects.

Peri-operative dreaming and awareness in children.

Dreaming under anaesthesia was investigated in a prospective study of 120 day case paediatric patients, aged 5-17 years, who underwent a variety of surgical procedures. Patients were anaesthetised using the 'Liverpool technique' of paediatric anaesthesia (nitrous oxide-oxygen-relaxant). No patient reported awareness, but 23 of 120 patients (19%) reported dreams. Analysis of the data revealed that the choice of muscle relaxant, (nondepolarising or depolarising) had a statistically significant effect on the incidence of dreaming (p less than 0.05). It is suggested that the technique of intermittent intravenous suxamethonium may result in increased muscle spindle discharge and cause cerebral arousal and an increased incidence of dreaming.

Peri-operative dreaming in paediatric patients who receive suxamethonium.

A prospective study is described of peri-operative dreaming in 144 paediatric patients aged 5-14 years who received suxamethonium for day case surgery. No case of awareness was elicited. One group received pretreatment with 80 micrograms/kg [corrected] tubocurarine. The incidence of dreaming in the 72 patients who were not pretreated was 16.7% compared with 2.8% in the patients pretreated with tubocurarine. This difference is statistically significant. The use of an intermittent suxamethonium technique gives a high incidence of dreaming which may be caused by muscle spindle discharge that produces cerebral arousal. Pretreatment with a non-depolarizing agent decreases this risk of dreaming.

A study of glycopyrrolate and atropine in the suppression of the oculocardiac reflex during strabismus surgery in children.

Glycopyrrolate 5 and 7.5 micrograms kg-1 and atropine 10 and 15 micrograms kg-1 were studied in 80 paediatric patients to assess more fully the dose of glycopyrrolate required for adequate prevention of the oculocardiac reflex. A dose-related improvement in protection from this reflex was seen with both drugs, but neither drug prevented reductions in heart rate in every patient. A nodal rhythm was the most common arrhythmia observed with both drugs. In the doses used, no adverse effects were noted and no further anticholinergic treatment was required during muscle traction. Higher doses may be associated with an increase in side-effects with more pronounced dryness of the mouth and tachycardia and, with atropine, a greater likelihood of the production of the "central anticholinergic syndrome".

Congenital diaphragmatic hernia in the older child.

Five children aged between 9 months and 7 years were admitted to hospital each with an unsuspected congenital diaphragmatic hernia. In 4 the diagnosis was pneumonia with a secondary pleural effusion or lung abscess. Initial investigations were unhelpful to the admitting physician; two of the children had had a previous chest x-ray which was normal. For 3 children the correct diagnosis was only made at necropsy. It is suggested that the possibility of a congenital diaphragmatic hernia be considered in any patient who has an indefinable diaphragm and cystic lesion on his chest x-ray film. Barium studies with the patient in Trendelenburg's position are of value in excluding the presence of bowel in the chest.

All that wheezes is not asthma.

A case is presented in which the inhalation of a foreign body caused a respiratory arrest and was subsequently diagnosed and treated as an attack of acute asthma. The presentation, diagnosis, investigation and treatment of this condition is discussed and a review of the literature is presented.

Deaths in children with a diagnosis of acute appendicitis in England and Wales 1980-4.

Thirty five children died of acute appendicitis in England and Wales in 1980-4 compared with 204 in 1963-7. Thirteen of the 35 deaths in 1980-4 took place at home or on the day of admission to hospital before operation and a further 18 on the day of operation or the first day after it. Thirty one of the children had peritonitis. A third of the deaths were in children aged 0-4 years, and the hospital fatality rate in this age group was one death in 320 cases compared with one death in 4760 cases in children aged 5-14 years. The fall in the number of deaths between the 1960s and the 1980s was due to improvements in medical care, a reduction in the incidence of appendicitis, and changes in the age structure of the child population. Difficulty and delay in diagnosis and inadequate intravenous therapy are now the main factors contributing to death.