Anesthetic challenges in managing a case of type III laryngo-tracheo-esophageal cleft.

Laryngo-tracheo-esophageal cleft (LTEC) is a rare congenital anomaly characterized by failure of fusion of the cricoid cartilage posteriorly and incomplete development of the tracheo-esophageal septum. Securing the airway during anesthesia in patients with LTEC, especially in the severe forms is a challenge. We describe the anesthetic management and the airway challenges in a neonate with type III LTEC who underwent bronchoscopy and repair of LTEC.

Interpreting positive cultures of endotracheal aspirates: factors associated with treatment decisions in ventilated neonates.

AIMS: Diagnosis of ventilator-associated pneumonia in newborns is challenging because of ease of colonisation, non-specific chest radiograph changes and lack of a consensus definition. The aims of this study were to review treatment decisions in neonates with culture-positive endotracheal aspirate and to assess impact on respiratory outcomes using blinded review of radiological studies. METHODS: Charts from all very low birthweight neonates ventilated for >48 h and with positive culture were assessed. Chest radiographs were reviewed by a radiologist masked to the grouping of the episode (treated/not treated). Clinical, investigational and radiological features used in practice were assessed on impact on treatment decisions. Association between treatment and outcomes was assessed. RESULTS: Seventy-four episodes of culture-positive endotracheal aspirate were analysed in 38 babies. Fifty-eight episodes were treated with antibiotics. Gestational age at birth and birthweight in both groups (treated vs. non-treated) were statistically comparable (25.5 ± 3.1 vs. 27.2 ± 2.3 weeks and 809 ± 302 vs. 870 ± 262 g). Comparative chest radiographs were available in 51 of 58 treated episodes; deterioration was noted in 42 (82.3%). Ventilatory parameters were significantly higher in the treatment group and showed a significant improvement after antibiotics. Twenty-three babies developed chronic lung disease. Odds ratio (of having chronic lung disease when treatment is initiated) was 4.5 (95% confidence interval = 0.97-20.8, P= 0.06). CONCLUSIONS: Treated culture-positive aspirate episodes were accompanied by higher ventilatory requirements, increased symptoms and elevated septic markers. Need for treatment was associated with greater likelihood of developing chronic lung disease.

Use of milrinone in the management of haemodynamic instability following duct ligation.

Haemodynamic instability affects 22% to 29% of very low birth weight infants in the acute period following ligation of the ductus arteriosus and contributes to the mortality seen in this group. Since the sudden elevation of systemic vascular resistance has been recognised to be one of the factors contributing to this instability, milrinone, an afterload reducing agent, might potentially be of significant therapeutic benefit. This report presents the clinical course of an infant born at 26 weeks gestation who required surgical ligation of a haemodynamically significant patent ductus arteriosus after two unsuccessful 6-day courses of intravenous indomethacin. The post-operative period was characterized by oxygenation failure, rising blood pressure and echocardiographic signs indicative of diastolic dysfunction. The infant was successfully managed with milrinone, a phosphodiesterase inhibitor, which acts both as an "inodilator" and has lusitropy properties. Post-duct ligation haemodynamic instability in a preterm infant was successfully managed with milrinone. The role of afterload-reducing agents such as milrinone in this setting should, therefore, be systematically analyzed.