The effect of labor epidural analgesia on labor, delivery, and neonatal outcomes: a propensity score-matched analysis in a single Japanese institute.

PURPOSE: Lumbar epidural analgesia (LEA) is the most widely used method in reducing labor pain. Previous RCTs have shown that LEA does not increase cesarean section rates; however, the results are inconsistent and may vary depending on the different backgrounds. Therefore, we aimed to study whether LEA would affect the course of labor in our institute. METHODS: Delivery records from October 2013 to April 2016 were collected. Deliveries at gestational age < 36 weeks and multiple pregnancies were excluded. All cases were divided into the non-epidural labor (NEL) group or the epidural labor (EL) group. We performed a propensity score matching analysis to balance intergroup differences. Our primary outcome was a mode of delivery (spontaneous, assisted vaginal, cesarean). Secondary outcomes were lengths of labor and outcomes of the neonates. RESULTS: During the study period, 2632 cases met the inclusion criteria. All analyses were performed after propensity score matching (218 pairs). The percentage of assisted vaginal delivery increased by the use of LEA (11.5% in NEL group vs 25.7% in EL group; p < 0.001), but the rate of cesarean section was similar (12.8% vs 17.0%; p = 0.23). The durations of the first and second stages of labor were prolonged by the use of LEA in both primipara and multipara women. Outcomes of the neonates were similar in both groups. CONCLUSION: Use of LEA did not increase the rate of cesarean section when analyzed by propensity score-matched analysis in our institute.

Life-Sustaining Treatment Status at the Time of Death in a Japanese Pediatric Intensive Care Unit.

BACKGROUND: Substantial variability exists among countries regarding the modes of death in pediatric intensive care units (PICUs). However, there is limited information on end-of-life care in Japanese PICUs. Thus, this study aimed to elucidate the characteristics of end-of-life care practice for children in a Japanese PICU. METHODS: We examined life-sustaining treatment (LST) status at the time of death based on medical chart reviews from 2010 to 2014. All deaths were classified into 3 groups: limitation of LST (limitation group, death after withholding or withdrawal of LST or a do not attempt resuscitation order), no limitation of LST (no-limitation group, death following failed resuscitation attempts), or brain death (brain death group). RESULTS: Of the 62 patients who died, 44 (71%) had limitation of LST, 18 (29%) had no limitation of LST, and none had brain death. In the limitation group, the length of PICU stay was longer than that in the no-limitation group (13.5 vs 2.5 days; P = .01). The median time to death after the decision to limit LST was 2 days (interquartile range: 1-5.5 days), and 94% of the patients were on mechanical ventilation at the time of death in the limitation group. CONCLUSIONS: Although limiting LST was a common practice in end-of-life care in a Japanese PICU, a severe limitation of LST such as withdrawal from the ventilator was hardly practiced, and a considerable LST was still provided at the time of death.

[Ultrasound-guided Rectus Sheath Block vs Transversus Abdominis Plane Block in Children Undergoing Umbilical Hernia Repair].

BACKGROUND: Although many reports describe the usefulness of the rectus sheath block (RSB) in the umbilical hernia repair, the efficacy of the transversus abdominis plane block (TAPB) is rarely reported. The purpose of this study was to compare the efficacy and technique of ultrasound-guided RSB and TAPB in children undergoing umbilical hernia repair. METHODS: Thirty-four children younger than 12 years of age scheduled for umbilical hernia repair were enrolled in this prospective observer-blinded randomized clinical trial. They were randomly assigned either to RSB group (median age, 3.7 years) or TAPB group (median age, 3.8 years). After the induction of general anesthesia with sevoflurane, nitrous oxide, and oxygen children in both groups received regional anesthesia with 0.3 ml x kg(-1) of 0.25% ropivacaine on each side under ultrasound guidance. Hemodynamic changes at the skin incision, postoperative pain scores and parental satisfaction were recorded. Anesthesiologists rated the quality of ultrasound images and easiness of the block performance. RESULTS: The patients' demographics of the two groups were similar. There were no significant differences in the time needed for the block procedure, quality of ultrasound images and the change of the heart rate and blood pressure at the skin incision between the two groups. Postoperative pain score (immediately, 2 and 4 hours after the operation), need for rescue analgesia and satisfaction of the parents also did not differ. There were no major complications in the patients. CONCLUSION: TAPB provided comparable perioperative analgesia and easiness of block performance to RSB in the pediatric umbilical hernia repair.

[Comparison of Sedative and Analgesic Requirements in Children with and without Down Syndrome following Pediatric Cardiac Surgery].

BACKGROUND: Conflicting results have been reported on postoperative analgesia in pediatric patients with Down syndrome. We compared sedative and analgesic requirements following cardiac surgery between pediatric patients with and without Down syndrome. METHODS: Patients who underwent atrial septal defect closure, ventricular septal defect closure and repair of atrioventricular septal defect at the age between one month and 24 months in our institution for 2 years from 2011 to 2012 were recruited into the study. Patient's background and perioperative managements were investigated. Data collected included preoperative cardiac catheterization data, postoperative sedative and analgesic dosage, postoperative sedation scores and duration of mechanical ventilation. RESULTS: Eight Down syndrome (mean : weight 5.6 kg, age 7.9 months) and twelve non-Down syndrome (mean : weight 5.6 kg, age 5.6 months) patients were enrolled into the study. Pulmonary-systemic artery pressure ratio after cardiac repair and intraoperative anesthetic doses did not differ. Postoperative sedation score, duration of mechanical ventilation and stay in intensive care unit were equivalent. Maintenance and cumulative dose of midazolam, dexmedetomidine and fentanyl, and times of rescue administration did not differ between the groups. CONCLUSIONS: In our study, all enrolled patients received adequate sedation and analgesia after pediatric cardiac surgery. Sedative and analgesic doses following pediatric cardiac surgery were not different between the groups of Down syndrome and non-Down syndrome.

[Spontaneous Respiration Technique for Pediatric Microlaryngeal Surgery without Endotracheal Intubation].

We report the anesthetic management of microlaryngeal surgery in children using tubeless total intravenous anesthesia (TIVA) without endotracheal intubation under spontaneous breathing. In 9 patients (median age : 4.9 yr. range 1 months-14 years, body weight : 17 kg, range 3-61 kg), 19 procedures were performed with TIVA using propofol and remifentanil. The median time from the start of TIVA to rigid laryngoscope insertion was 11 minutes. Propofol 15.7 mg x kg(-1) x hr(-1) and remifentanil 0.05 µg x kg(-1) x min(-1) was infused in this interval. Laryngospasm was observed in two cases, but it responded to a bolus of propofol (0.5-1.0 mg x kg(-1)) and additional topical anesthesia with 1% lidocaine. Three children were found apneic after a bolus administration of remifentanil or after increasing the rate of remifentanil infusion accompanied with desaturation and their tracheae were intubated. The spontaneous respiration technique using TIVA without intubation provides an excellent view of the operative field while allowing stable anesthesia. Further studies are required to establish the optimal dose of propofol and remifentanil and the timing of rigid laryngoscope insertion.

[Outcome of the Pediatric Patients Who Required Repeated Cardiopulmonary Bypass during the Repair of Congenital Heart Disease].

BACKGROUND: We occasionally encounter clinical deterioration after discontinuation of cardiopulmonary bypass (CPB) and are forced to reinstitute CPB during cardiac surgery. Some reports describe such cases occurring in adults, but few in infants and children. We retrospectively investigated the causes and outcomes of children requiring repeated CPB during the repair of congenital heart anomalies. METHODS: Patients who required repeated CPB during the repair of congenital heart anomalies in our institution from 2007 to 2012 were recruited into the study. Patient's background, diagnosis, surgical procedures, durations of total CPB and aortic cross-clamping, indications for re-CPB, procedures or treatment added after reinstitution of CPB and outcomes were collected. RESULTS: Out of 600 pediatric patients who underwent the repair of congenital heart disease during the study period, 34 required repeated CPB and were enrolled into the study. Mean age was 2 years and mean body weight was 9.9 kg. Twenty-six patients of 34 were weaned from the CPB after additional surgical repair with re-bypass, one of whom died in the ICU. The remaining 8 patients were weaned from the CPB after medical treatment. One of 8 patients died in the ICU and 2 died after discharge from ICU. CONCLUSIONS: In cardiac surgery of congenital heart disease, pediatric patients who required repeated CPB showed high mortality but patients who received additional surgical repair to be weaned from CPB had better outcome compared with those who received medical treatment.

[Bupivacaine-induced Anaphylaxis in a Parturient Undergoing Cesarean Section].

We describe a case of anaphylaxis that occurred in a 33-year-old gravida 1, para 1 term woman scheduled for cesarean delivery for breech presentation. Her past history was unremarkable except for orciprenaline allergy. Spinal anesthesia was performed at L3-4 using 2.5 ml of 0.5% hyperbaric bupivacaine and 0.1 mg morphine. Seven minutes after spinal anesthesia, she complained of hoarseness and difficulty in breathing and 3 minutes later, blood pressure decreased to 76/51 mmHg, and oxygen saturation to 87% with supplemental oxygen. Skin flushing was noted in the face and trunk of the body and anaphylaxis was diagnosed. She was treated with a rapid intravenous infusion and iv administration of phenylephrine (total dose 0.4 mg), ephedrine (total dose 25 mg), hydrocortisone and famotidine. Cesarean section was started 23 minutes after spinal anesthesia when blood pressure and oxygen saturation recovered. A male infant was delivered (18 minutes after the onset of anaphylactic event) with Apgar scores of 2 and 5 at 1 and 5 min, respectively and resuscitated with mask ventilation. Umbilical artery blood gas analysis revealed pH 6.85, base excess -20.3 mmol x l (-1) and lactate 109 mg x dl (-1). The mother was discharged from the hospital on the 6th postoperative day. The baby's electroencephalogram, however, demonstrated a pattern consistent with mild hypoxic-ischemic encephalopathy. Lymphocyte stimulation test revealed that she was allergic to bupivacaine. If maternal hypotension persists, i.m. or i.v. adrenaline should be administered immediately because maternal hypotension and hypoxemia may cause significant fetal morbidity and mortality and prompt cesarean section should be considered.

Perioperative management of 19 infants undergoing glossopexy (tongue-lip adhesion) procedure: a retrospective study.

BACKGROUND: Glossopexy (tongue-lip adhesion) is a procedure in which the tongue is anchored to the lower lip and mandible to relieve the upper airway obstruction mainly in infants with Pierre Robin sequence. Infants suffering from severe upper airway obstruction and feeding difficulties due to glossoptosis are the candidates for this procedure and are predicted to demonstrate difficult airway and difficult intubation. METHODS: We retrospectively examined the perioperative management of 19 infants undergoing glossopexy procedure at our institution from 1992 to 2010. RESULTS: Out of 19 patients, Pierre Robin sequence was diagnosed in 17, Treacher Collins syndrome in 1, and Stickler syndrome in 1. In all of them, inhalation anesthesia was induced with a nasopharyngeal tube in place. Nine patients underwent fiberoptic intubation. After surgery, 12 patients were extubated in the operating room and 11 of them required a nasopharyngeal tube to keep the airway open. Seven patients left the operating room with the trachea intubated. Two patients received tracheostomy at the age of 2 months. Seventeen patients underwent release of tongue-lip adhesion coincidentally with the palate repair at 7-14 months of age. For this surgery, no one required fiberoptic intubation. CONCLUSIONS: The airway of these patients should be managed carefully not only before but also after the operation. A nasopharyngeal tube was effective in maintaining the upper airway patency during anesthesia induction and before and after operation.

Successful use of recombinant activated factor VII (eptacog alfa, Novoseven®) in a refractory bleeding during pediatric cardiac surgery: a case report.

A 2-year-and-7-month-old boy underwent an emergent reconstruction surgery of the right ventricle-pulmonary artery (RV-PA) conduit. Although he was successfully weaned from cardiopulmonary bypass (CPB) after reconstruction of the RV-PA conduit, the bleeding continued despite the massive transfusion of red blood cell (RBC), fresh frozen plasma (FFP), and platelets. Because of persistent bleeding and abnormal coagulation laboratory results, we administered the recombinant activated factor VII (rFVIIa), which was not approved for use in the treatment of post-CPB coagulopathy. After administration of rFVIIa, his coagulation data dramatically improved, the bleeding decreased, and the operation was able to be finished.

[Successful perioperative use of noninvasive positive pressure ventilation in a pregnant woman with acute pulmonary edema].

A 32-year-old woman (148 cm, 59 kg, gravida 2, para 2) with quadruplet pregnancy was admitted to our hospital for the threatened preterm labor at 23 weeks and 2 days of gestation. She was treated with ritodrine, magnesium sulfate and nifedipine to maintain tocolysis. Betamethasone was administered to accelerate fetal lung maturity. After ritodrine dose was increased at 23 weeks and 5 days of gestation, she developed dyspnea with desaturation. Acute pulmonary edema was revealed on chest X-ray. The decision was made to proceed with emergency cesarean delivery. On arrival at the operating room, the blood pressure was 123/53 mmHg, heart rate 111 beats x min(-1), and oxygen saturation (SpO2) 84% with supplemental oxygen 15 l x min(-1) via a reserved face mask. Noninvasive positive pressure ventilation (NPPV) was initiated with S/T mode (FIO2 1.0, inspiratory positive airway pressure 10 cmH2O, expiratory positive airway pressure 6 cmH2O). The dyspnea was improved with her SpO2 100%. Spinal anesthesia was performed at L 34 using 2.5 ml of 0.5% bupivacaine and 100 microg morphine. Throughout the operation (operation time 44 minutes), she did not develop dyspnea under NPPV. NPPV was discontinued after the operation. Her SpO2 declined, and pulmonary edema on chest X-ray was exacerbated. She was transferred to the intensive care unit and NPPV was continued for 22 hours after the operation. She was discharged from the intensive care unit on the next day and was discharged from the hospital on the 6th postoperative day.

[Refractory headache after epidural catheter placement in a girl in whom epidural blood patches were ineffective].

A 12-year-old girl who had received epidural catheter placement for an orthopedic surgery developed postural headache on postoperative day (POD) 1 which resolved in 24 hours. She was discharged on POD 6 but readmitted on POD 16 for headache accompanied by nausea and photophobia. On POD 17 and 35 she received epidural blood patches (EBPs) with 15 ml and 20 ml of autologous blood, respectively and her headache disappeared shortly after the second EBP. Laboratory data were normal and cranial CT on POD 16 and MR imaging on POD 33 demonstrated no abnormalities. She was discharged on POD 47. On POD 80 she was readmitted for a recurrent headache. She was referred to a doctor specializing in headache in another institution and advised to lead her usual daily life. She went back to school on POD 100. Headache gradually and completely disappeared on the POD 200. It took more than 100 days for her to regain her usual life. In conclusion, in adolescents whose symptoms and atypical, psychosomatic disorder should be taken into consideration as a differential diagnosis and a referral to a specialist is important.

[Ultrasound guided transversus abdominis plane block in early infancy].

We retrospectively examined the transversus abdominis plane (TAP) block performed in 8 infants (range, 1-115 days) from July 2010 to March 2011. Ultrasound images clearly visualized the fascial plane between the transversus abdominis and the internal oblique muscle and it was possible to confirm proper administration of local anesthetics into the plane in all patients. Complications resulting from opioid overdose were noted in two cases. One infant required reintubation. Another infant developed delayed emergence from anesthesia. We should tailor the dose of systemic opioid, considering the fact that the simultaneous administration of nerve block and systemic opioids may cause sedation and respiratory depression in young infants.

[Management of a child with Swyer-James syndrome who underwent flexible bronchoscopy under general anesthesia].

Swyer-James syndrome (SJS) is a rare syndrome characterized by hyperlucency of one or more lobes of the unilateral lung and decreased pulmonary vascularity which is considered to be secondary to the childhood obliterative bronchiolitis. We report anesthetic management of a girl with SJS who underwent flexible bronchoscopy. A 15-year-old girl weighing 47 kg was referred to our hospital with suspected SJS. She had a history of bronchiolitis in early childhood. On admission, chest radiograph showed a hyperlucent lung with diminished pulmonary vasculature on the left lung. Pulmonary function test revealed slightly restrictive pattern (%VC 69.3%, %FEVa1.0 77.9%). Ventilation and perfusion scanning demonstrated the markedly decreased ventilation (left : right, 33 : 67) and perfusion (left : right, 10 : 90) of the left lung. To rule out the foreign body and bronchial stenosis, flexible bronchoscopy under general anesthesia was planned. Anesthesia was induced with propofol and maintained with propofol and remifentanil. Spontaneous respiration was maintained by using laryngeal mask airway to prevent the pressure alveolar damage by positive pressure ventilation. Flexible bronchoscopy was performed safely by using topical laryngeal lidocaine administration and additional bolus of propofol. Her postoperative course was uncomplicated and she was discharged on the following day.

[The effect of nitroglycerin 200 microg on uterine relaxation during cesarean delivery].

BACKGROUND: Rapid and transient uterine relaxation is sometimes required for fetal distress or difficult delivery due to uterine hyperactivity during cesarean section. For its rapid onset and short duration, intravenous nitroglycerin (NTG) is commonly used for this purpose. But its suitable dose is unclear. METHODS: We evaluated the effect of NTG 200 microg on uterine relaxation in 14 parturients who required rapid uterine relaxation during cesarean delivery from October 2010 to March 2011. We assessed the softness of the uterus, maternal hemodynamic changes after NTG administration, blood loss, uterine contraction after delivery, and Apgar scores. RESULTS: Obstetricians graded the uterus as "moderately soft" in 9, and "very soft" in 5 patients, respectively. Uterine contraction after delivery was good with intravenous oxytocin or dinoprost. Blood loss was acceptable. Six patients exhibited moderate but transient hypotension, and in two of which blood pressure was immediately restored with phenylephrine 100 microg. Four patients complained of nausea and 1 patient complained of headache, but all of which were transient. Median Apgar scores at 1 and 5 minutes were 8.0 and 8.5, respectively. CONCLUSIONS: This study indicated that an intravenous administration of NTG 200 microg was effective for rapid uterine relaxation during cesarean delivery.

[Ultrasound guided nerve block in infants undergoing pyloromyotomy].

BACKGROUND: Ultrasound guided nerve block has become popular in pediatric practice. We applied this technique to infants undergoing pyloromyotomy. METHODS: We retrospectively reviewed the hospital records of infants who underwent pyloromyotomy with the aid of the ultrasound guided nerve block from July 2010 to March 2011. RESULTS: Rectus sheath block was performed in 4 infants. In one infant ilioinguinal/hypogastric nerve block was also placed for simultaneous repair of inguinal hernia. There were no complications attributable to the ultrasound guided nerve block. CONCLUSIONS: We performed ultrasound guided nerve block safely in infants undergoing pyloromyotomy.

[Perioperative management of tongue reduction surgery for macroglossia associated with Beckwith-Wiedemann syndrome -A retrospective evaluation of 14 patients--].

BACKGROUND: Macroglossia is the commonest symptom of Beckwith-Wiedemann syndrome (BWS) and sometimes requires surgical tongue reduction for cosmetic, feeding, drooling and speech problems. METHODS: We retrospectively reviewed the perioperative course of 14 BWS patients. The subjects were children who underwent tongue reduction surgery or glossopexy between 1994 and 2008 at Osaka Medical Center for Maternal & Child Health. RESULTS: The median age was 18 months, and the median weight was 12.2 kg at the time of surgery. One patient had the trachea intubated and another had tracheostomy to keep airway patency. Other 12 patients had no artificial airway and were premedicated with midazolam or diazepam and had the trachea intubated after induction with sevoflurane and nitrous oxide in oxygen. Only one patient developed difficult mask ventilation for which a nasal airway was applied. No patients demonstrated difficult intubation. All without preoperative artificial airway were extubated in the OR after the surgery. One patient demonstrated hypoglycemia. Airway compromise in the two patients who was intubated or had tracheostomy prior to surgery was not alleviated by the surgery. CONCLUSIONS: Airway disorder was not alleviated by tongue reduction surgery or glossopexy.

[Perioperative management of a child with central diabetes insipidus who underwent two surgeries before and after desmopressin administration].

A 14-year-old girl weighing 32 kg was diagnosed with suprasellar tumor causing hydrocephalus, hypothyroidism, adrenal dysfunction and central diabetes insipidus. She was treated with levothyroxine and hydrocortisone and urged to take fluid to replace urine. She was scheduled to undergo ventricular drainage to relieve hydrocephalus prior to tumor resection. For the first surgery, desmopressin was not started and urine output reached 4,000 to 6,000 ml x day(-1), urine osmolality 64 mOsm x l(-1) and urine specific gravity 1.002. Anesthesia was induced with sevoflurane and maintained with propofol and remifentanil. Maintenance fluid was with acetated Ringer's solution and urine loss was replaced with 5% dextrose. Bradycardia and hypotension occurred after intubation, which was treated with volume load. Infusion volume was 750 ml and urine output was 1100 ml during 133 min of anesthesia. Postoperative day 1 nasal desmopressin was started. Ten days later, partial tumor resection was performed. Anesthesia was induced with propofol and fentanyl and maintained with sevoflurane and remifentanil. Infusion volume was 610 ml, urine output 380 ml, and blood loss 151 ml during 344 min of anesthesia. Hemodynamic parameters were stable throughout the procedure. Pathology of the tumor was revealed to be germinoma. Bradycardia and hypotension experienced during the first surgery was suspected to be caused by preoperative hypovolemia brought by polyuria. Desmopressin was proved to be effective to treat excessive urine output and to maintain good perioperative water balance.

[Rapid sequence induction in pediatric patients--a questionnaire survey to the children's hospitals in Japan].

BACKGROUND: Details of the rapid sequence induction in children with full stomach in Japanese children's hospitals are not known. METHODS: We sent the questionnaire to the 27 pediatric anesthesia departments in Japanese children's hospitals and asked the practice of two scenarios of full stomach cases; an infant (4-week-old) presenting with pyloric stenosis and a child (3-year-old) with full stomach due to ileus. RESULTS: We obtained replies from 17 of 27 (63%) facilities. Nasogastric tube was inserted and suctioned thoroughly before the induction of anesthesia in all institutions. Atropine prior to the induction of anesthesia was more often used in infant cases (53%). Awake intubation was not performed in any facilities regardless of the age. Gentle mask ventilation between induction and tracheal intubation were more frequently performed in infant cases (53%). The maneuver of cricoid pressure was utilized in infants in only 24% of all institutions. CONCLUSIONS: We clarified details of rapid sequence induction in infants and children in Japanese children's hospitals. The practical method of rapid sequence induction was different in 2 scenarios probably due to the consideration of the age, diseases and conditions.

[Decision to avoid general anesthesia on 3 cases with anterior mediastinal masses].

We report 3 cases of anterior mediastinal masses in which we avoided providing general anesthesia for a biopsy and a central venous catheter placement. In all cases, chest X-rays on admission showed mediastinal mass ratio (MMR) greater than 44% and thoracic computed tomographic scans demonstrated cross sectional area (CSA) of the trachea 60% less than expected and the main stem bronchi narrowing. We made a decision not to provide general anesthesia, considering the risk of airway obstruction after induction of general anesthesia. In case 1, a 6-year-old boy, preoperative corticosteroid therapy relieved respiratory complaints without improvement of MMR and %CSA. On hospital day 3 the patient developed airway obstruction during induction of anesthesia and the surgery was postponed. After 3 days of additional chemotherapy MMR decreased to 34% and %CSA increased to 94%. On day 6 surgery under general anesthesia was performed safely. In case 2, a 15-year-old boy presented with MMR 44% and %CSA 48% and left bronchial stenosis and underwent surgery under local anesthesia. In case 3, a 3-year-old boy, preoperative corticosteroids and chemotherapy improved MMR 67% to 34% and %CSA 60% to 95%. On day 8 of admission a biopsy was performed under general anesthesia uneventfully. We emphasize not only clinical signs but also radiological signs are important to evaluate the safety in induction of general anesthesia for the management of the cases of anterior mediastinal masses.

[Anesthetic considerations for a boy with non-bullous ichthyosiform erythroderma].

We administered anesthesia for a 20-month-old boy with non-bullous ichthyosiform erythroderma who underwent orthopedic syndactyly repair on two occasions. Anesthetic considerations include the difficult fixation of the tracheal tube and iv cannulas and the risk of hypothermia. Intravenous access placement was also difficult due to the hyperkeratosis and the deformity of extremities. In the first surgery, pharyngeal temperature fell to 34.4 degrees C despite the use of the 37 degrees C circulating water mattress and room temperature set to 26 degrees C. It gradually returned to 36 degrees C during the surgery. We applied Steri-Strip compound benzoin tincture to the skin to increase adhesiveness before taping the tracheal tube. It resulted in a good fixation but difficult removal. In the second surgery, we fixed the tracheal tube with a tube holder which enabled the fixation without the use of adhesive tapes to the skin. To maintain body temperature we used forced air warming device Bair Huggar, which was very useful to avoid hypothermia but resulting in a rather high body temperature. In conclusion, a tube holder was an effective device to fix the tracheal tube in this patient. Forced air warming device was useful to prevent hypothermia.