Conservative management of posterior tracheal wall injury by endoscopic stent placement in children: Preliminary data of three cases.

The management of tracheal wall lacerations is debated. Current treatments are mainly derived by the experience on adults and include conservative or surgical treatments depending on the clinical condition of the patient. We report our preliminary data with removable tracheal stents in 3 children with tracheal tears and respiratory failure. If performed in specialized centers with appropriate endoscopic and clinical follow-up, airway stents can be considered a valid and safe conservative treatment for tracheal tears and an alternative to intubation or tracheostomy. Further studies are needed to compare different therapeutic options and better define the management and duration of stent treatment.

The role of endoscopy in the treatment of IV type laryngotracheal cleft complications after surgical repair.

Laryngotracheal cleft (LTC) is a rare congenital anomaly. Severe forms of LTC are usually treated surgically using extracorporeal circulation. Despite tremendous improvement of surgical techniques, postoperative complications are still frequent. We report a comprehensive description of an endoscopic approach to diagnosis, surgical repair and endoscopic treatment of complications after correction in a type IV LTC.

Endoscopic anterior cricoid split and balloon dilation in pediatric subglottic stenosis.

OBJECTIVES: To analyze the outcome of a new endoscopic approach for the treatment of pediatric subglottic stenosis. STUDY DESIGN: Case series. SETTING: Tertiary care center. MATERIAL AND METHODS: Eighteen pediatric cases of grade II to IV subglottic stenosis (8 congenital and 10 acquired) consecutively treated at our institutions by Endoscopic Anterior Cricoid Split (EACS) and balloon dilation between 2006 and 2010. Treatment protocol encompassed systematic postoperative laryngeal stenting (7 days of intubation or 1 month of Montgomery T-tube in previously tracheotomized patients) and endoscopic controls with possible additional balloon dilation every 15 days for at least 2 months. RESULTS: Patients' ages ranged from 1 to 101 months. Postoperative follow-up ranged from 4 to 45 months (median value±SD: 15.3±11.9). The mean duration of the endoscopic procedure was 35.2±13.2 min. The number of days spent in PICU during the perioperative period varied between 2 and 15. Four patients (22.2%) needed one and 14 patients (77.7%) required several (from 4 to 7) additional balloon dilations during the postoperative endoscopic controls. No incident was observed during or immediately after EACS. Treatment was efficient in 83% of cases (n=15), with no residual respiratory symptoms and grade 0 to 1 SGS at the end of follow-up. CONCLUSION: EACS is a safe and efficient technique to treat pediatric subglottic stenosis, regardless of their grade and length, provided to associate it with postoperative laryngeal stenting and regular endoscopic follow-up with possible additional balloon dilations. In our teams, it has become the first line treatment for most grades II to IV SGS. Its indications can be extended to congenital stenosis with cartilaginous involvement and to long-lasting acquired stenosis with firm fibrosis.

Plasma levels of lignocaine during tumescent local anaesthesia in children with burns.

The aim of the study was to assess the changes in plasma lignocaine concentrations over time when the tumescent solution is injected into subcutaneous tissue of children undergoing surgical treatment of burns. Sixteen consecutive children with burns were studied using a prospective study design. After induction of general anesthesia, tumescent lignocaine solution 0.1% with adrenaline in nine patients (adrenaline group) for the treatment of postburn sequelae, or without adrenaline in seven patients (no-adrenaline group) for the treatment of acute burns, was injected into the subcutaneous tissue of burned and donor areas. The maximum dose of lignocaine was 7 mg/kg. Blood samples were collected before the start of the injection as well as at 5, 10, 20, 30, 45, 60, 90 minutes and 2, 4, 8, 12, 24 hours after the infiltration was completed. The course of lignocaine plasma levels was chaotic in the adrenaline group and biphasic during the first hour in the no-adrenaline group. The maximum plasma concentration of lignocaine was 2.09 microg/ml in the adrenaline group and 1.98 microg/ml in the no-adrenaline group. No adverse reactions were noted. Tumescent injection in burned children resulted in lignocaine plasma concentrations that were always lower than the often quoted value of 5 microg/ml, considered to be the toxic plasma threshold in adults. These data lend support to the use of lignocaine using the tumescent technique in burned paediatric patients.

Lipid peroxidation, circulating cytokine and endothelin 1 levels in healthy volunteers undergoing hyperbaric oxygenation.

BACKGROUND: The aim of the present study was to evaluate the effects of hyperbaric oxygenation on lipid peroxidation, on the release of circulating cytokines (TNFa, IL6, IL1b) and endothelin-1 (ET1). EXPERIMENTAL DESIGN: single arm, prospective study. SETTING: ICU hyperbaric division of a University Hospital. PATIENTS: fifteen healthy volunteers (10 male and 5 female, mean age 32+/-7 years) studied during hyperbaric oxygenation divided at random into two groups: group A (7 subjects) and group B (8 subjects). INTERVENTIONS: Both groups were consecutively pressurized at 2 atmospheres (2 atm abs) and 2.8 atm abs, with a constant descending rate of 1 m/min; in accordance with the experimental design, group A breathed pure oxygen continuously through facial masks and group B breathed chamber air during pressurization. MEASURES: Twenty millilitres of blood were drawn from all individuals at the following times: 1) basal, before HBO; 2) after 10 min at 2 atm abs; 3) after 10 min at 2.8 atm abs; 4) 30 min after the end of HBO. In all collected samples thiobarbituric reacting substances were evaluated, using the spectrophotometric technique, IL1 TNF and IL6 serum levels by ELISA and endothelin 1 plasma levels by radioimmunoassay. RESULTS: In both groups, TBARS levels showed a twofold increase (p<0.05) in relation to the baseline, during and after hyperbaric oxygenation. Serum IL6 and IL1b values did not significantly change over the study in any of the volunteers. TNFa amounts significantly increased (p<0.05) during HBO, at 2 atm abs and 2.8 atm abs in both groups, with almost twofold increments. ET1 plasma values increased (p<0.05) in all volunteers during and after HBO: at 2 atm abs (range 7 to 24 pg/ml), 2.8 atm abs (range 7 to 19 pg/ml) and 30 min after (range 8 to 17 pg/ml) in relation to baseline (range 4 to 12 pg/ml). All the studied compounds had a similar trend in the two groups. CONCLUSIONS: Hyperbaric oxygenation in healthy volunteers can induce not only lipid peroxidation, but also liberation of compounds such as TNFa and endothelins, no matter whether pure oxygen is breathed or not. These results suggest that the phenomenon behind this release might be leukocyte activation as induced by HBO. The possible role of ET1 in determining vasoconstriction occurring during HBO is also suggested.