A bronchoscopic, computer-assisted examination of the changes in dimension of the infant tracheal lumen with changes in head position: implications for emergency airway management.

BACKGROUND: Resuscitation guidelines caution against extreme extension or flexion of an infant's head because tracheal obstruction may occur. No data support this recommendation. The authors therefore examined the dimensions of the tracheal lumen in neutral, extended, and flexed head positions in infants undergoing general endotracheal anesthesia for elective surgery. METHODS: Eighteen healthy full-term infants were studied. A flexible fiberoptic bronchoscope was passed through a previously inserted endotracheal tube and positioned above the cricoid cartilage. Video recordings were taken in each of three head positions. Recordings were analyzed by an investigator blinded to head position. A computer-digitized technique was used to measure anterior-posterior and lateral dimensions and cross-sectional area. Data were analyzed using paired t tests and sign tests. RESULTS: No significant differences in mean tracheal dimensions with changes in head position were found. No infant had complete tracheal obstruction. Infants were equally as likely to have a small increase as they were to have a small decrease in tracheal dimension with changes in head position. CONCLUSIONS: Despite the belief that infants and neonates have obstruction at the level of the trachea with extreme positions of the head, the authors were unable to demonstrate this phenomenon.

Comparison of a rigid laryngoscope with the ultrathin fibreoptic laryngoscope for tracheal intubation in infants.

The flexible ultrathin fibreoptic laryngoscope allows placement of endotracheal tubes as small as 2.5 mm internal diameter. The purpose of this study was to document the safety and efficacy of intubation using an ultrathin fibreoptic laryngoscope. Proved safety and efficacy would justify the routine use of fibreoptic laryngoscopy in normal infants to maintain skills needed for management of the difficult infant airway. In this prospective study, 40 infants < 24 mo of age scheduled for elective surgery were randomly divided into two equal groups. After inhalation induction of anaesthesia, in 20 infants the trachea was intubated using direct rigid laryngoscopy, and in 20 using the ultrathin fibreoptic laryngoscope (size 1.8 mm OD) Olympus LFP. Time to successful intubation was recorded, as well as blood pressure, heart rate, end-tidal CO2 and oxygen saturation. Airway trauma in the operating room, the post-anaesthesia care unit, and on the first postoperative day was recorded. The intubation times using rigid laryngoscopy were less than those using fibreoptic laryngoscopy (13.6 +/- 0.9 sec (mean +/- SEM) vs 22.8 +/- 1.7 sec; P < 0.01). Oxygen saturation and end-tidal CO2 readings were not different between the two groups. After intubation, blood pressure and heart rate increased equally in both groups, returning to normal within one to two minutes. There was no difference in the airway trauma between groups. We conclude that the ultrathin fibreoptic laryngoscope is a safe and effective method for tracheal intubation in infants and may be used routinely in order to maintain fibreoptic airway skills.

Use of fluorescein to predict survival of a free jejunal transfer after disruption of the arterial pedicle on postoperative day 12.

The arterial pedicle to a free jejunal transfer was inadvertently disrupted on the 12th postoperative day. Intravenous fluorescein indicated viability of the entire jejunal transfer except for a 2 cm diameter area on the antimesenteric border midway between the upper and lower enteric anastomoses. The entire jejunum survived except for the small area which failed to fluoresce; this area was converted to a controlled pharyngocutaneous fistula. Neovascularisation from surrounding, unirradiated tissue can allow survival of a free vascularised jejunal transfer after disruption of arterial inflow as early as 12 days postoperatively.

The cervicopectoral rotation flap--a valuable technique for facial reconstruction.

Four cases of lower cheek reconstruction using the cervicopectoral rotation-advancement flap are reported. This fasciocutaneous flap can be raised quickly, provides excellent colour and texture match for the tissues of the face, and donor site morbidity is minimal. It is an especially useful method for lower cheek reconstruction following wide excision of melanomas of the cheek and for advanced parotid tumours where skin replacement is required following resection.

A retrospective cohort evaluation of preventive resin restorations.

This study measured the longevity and clinical success of preventive resin restorations (PRRs) placed in permanent teeth by multiple operators in the Pediatric Dentistry Clinic at the University of Minnesota. A retrospective chart audit identified patients who had one or more PRRs placed. Only restorations of the occlusal surfaces of the first or second permanent molars were included. Each patient was given a dental examination. On completion, the patient's chronological record of treatment was reviewed for the following information: experience of the operator, type of isolation used, bonding material, liner type, composite resin, and sealant type. Teeth were examined with a front surface dental mirror and a sharp No. 23 dental explorer. Evaluations were made according to criteria developed by Cvar and Ryge, but modified to include a sealant evaluation. Independent measurements were made by each of the two examiners and a consensus was obtained. One hundred restorations were examined in 64 patients. The mean duration of service was 27 +/- 13 months. Sealant was evaluated as alfa (complete) 26 per cent, bravo (incomplete/adequate) 48 per cent, charlie (incomplete/inadequate) 21 per cent and delta (lost) five per cent. Cavosurface discoloration was evaluated as alfa (none) 87 per cent, bravo (margin only) 12 per cent, and charlie (margin/proceeding toward pulp) one per cent. Anatomical form was evaluated as alfa (well contoured) 89 per cent, bravo (under contoured/dentin not exposed) 11 per cent. Marginal adaptation was evaluated as alfa (no visible crevice) 85 per cent, bravo (visible crevice/no dentin exposed) 12 per cent, charlie (visible crevice/dentin exposed) two per cent and delta (restoration missing) one per cent.(ABSTRACT TRUNCATED AT 250 WORDS)

Augmentation of skin flap survival by parenteral pentoxifylline.

One prime factor implicated in flap necrosis is diminished blood flow. A known corollary of morbid ischaemia is an energy-dependent reduction in red blood cell deformability associated with an increase in whole blood viscosity. The newly available drug pentoxifylline is alleged to improve this red cell membrane defect in the low flow state, thereby improving the rheologic characteristics of blood. We studied its effect in a flap model with an ischaemic component and also measured changes in blood viscosity. A caudally-based dorsal flap in a rat model was used. Control (saline-treated) animals exhibited 74.8 +/- 9.8% flap survival. Three groups of animals were treated at different times with pentoxifylline with respect to date of surgery; all groups showed a statistically significant increase in flap survival compared to controls, ranging from 92.3 to 94.3% (p less than .01). Simultaneous viscometric measurements with a cone-plate viscometer were performed. The observed increase in flap survival did not, as suggested by other investigators, correlate dependably with viscosity reduction. Reasons for this are discussed.