Anesthesia for a neonate with persistent buccopharyngeal membrane and unilateral choanal atresia.

We report our anesthetic management of a neonate who presented with complete persistent buccopharyngeal membrane and unilateral choanal atresia, and underwent examination under anesthesia. Maintaining airway patency and spontaneous respiration were our priority. Intravenous propofol was used to maintain adequate anesthetic depth for flexible laryngotracheoscopy and nasotracheal intubation through the only patent passage. We encountered problems of bradycardia and hypotension. Tracheostomy was performed. Definitive management of the persistent buccopharyngeal membrane was carried out on day 14.

The intubation depth marker: the confusion of the black line.

BACKGROUND: Estimation of the correct depth of insertion of a tracheal tube (TT) in children is extremely important. Insertion of an excessive length may result in endobronchial intubation while an inadequate length of insertion may lead to accidental extubation. METHODS: We reviewed TTs commonly used in paediatric practice and also reviewed recommended guidelines for correct depth of insertion. RESULTS: Amongst the different brands of TTs used, there was a wide discrepancy in the placement of the intubation depth marker. This is important as the intubation depth marker is often used as a guideline for intubation. CONCLUSIONS: For optimal placement we can rely on various formulae and manufacturers' markings on the TTs. Clinical judgement, however, remains the cornerstone of optimal placement.

Ilioinguinal and iliohypogastric nerve block revisited: single shot versus double shot technique for hernia repair in children.

BACKGROUND: We attempted to determine the efficacy of a one plane ilioinguinal and iliohypogastric nerve block with a single shot and double shot techniques. METHODS: In a randomized single blind study, 90 children, aged 2-12 years, received a single shot (SS) or a double shot (DS) technique for ilioinguinal and iliohypogastric (IG-IH) nerve block for inguinal hernia repair. In the SS group, 0.25 ml x kg(-1) of 0.25% bupivacaine was given one fingerbreadth medial to the anterior superior iliac spine under the external oblique aponeurosis. In the DS group, one-third of the total dose of bupivacaine was given as for the SS group. The remaining two-thirds was deposited 0.5 cm above and lateral to the mid-inguinal point deep to the external oblique aponeurosis. RESULTS: The success rates of both techniques were similar, at 72%, although the presence of local anaesthetic in the inguinal canal was significantly higher with the DS technique. The incidence of femoral nerve block was 4.5% with the SS and 9% with the DS technique (P > 0.05). Parental satisfaction with postoperative pain relief was high, at 94%. CONCLUSIONS: The DS technique, while technically more difficult, does not improve the success rate of the IG-IH nerve block compared with the SS technique.

Infusion technology: a cause for alarm.

BACKGROUND: [corrected] Volumetric infusion pumps are widely used in paediatric practice. Tissue extravasation is a hazard. The occlusion pressure limit alarm, although not intended to detect extravasation, is the only warning sign present to indicate flow faults in the infusion systems. METHODS: Extravasations were created in the subcutaneous plane of 20 limbs of five piglets with normal saline via an infusion pump. Five flow rates were used with each piglet allocated to one: 100 ml.h-1, 200 ml.h-1, 300 ml.h-1, 400 ml.h-1, 500 ml.h-1. The occlusion pressure limit was first set at low and adjusted to medium, then to high, upon alarm activation. Line pressure at 5-min intervals and upon alarm activation and volume of infusate given were measured. Limb diameters before and after infusion were measured. RESULTS: Six out of 20 cases failed to activate any alarm. The low, medium and high occlusion pressure limit alarms were activated in 14, 1 and 0 instances, respectively. The incidence of alarm activation is higher in the forelimb compared with the hindlimb (P=0.001). The tissue compliance and volume infused at alarm activation are significantly lower in the former (P < 0.05). Line pressure increases with increase in flow rates for the same limb (P=0.013 Fore, P=0.005 Hind). CONCLUSIONS: Occlusion pressure limit alarm cannot reliably detect extravasation especially at sites with high compliance, low flow rates, even at low occlusion limit. Line pressure depends on interplay of site (compliance) and flow rate and is independent of volume extravasated. Users must be aware of the set occlusion pressure limit. Repeated clinical assessment remains vital.