SEVOFLURANE AS A CAUSE OF TORSADE DE POINTES IN PATIENT WITH THE LONG QT SYNDROME: Case Report.

Long QT syndrome (LQTS) is a rare condition that in certain circumstances can lead to severe and potentially lethal cardiac arrhythmia known as Torsade de Pointes (TdP). Inhalational anesthetics are among many medications and conditions known to prolong QT and thus potentially predispose the patient to TdP. Although studies have shown that sevoflurane should be safe for the healthy patients, the situation is unclear in patients with LQTS. We present a case of 14-year-old Caucasian female with the diagnosis of LQTS who developed TdP during sevoflurane inhalational induction. At the end, an anesthetic plan for patients with LQTS will be suggested.

Spatial-temporal patterns of electrocorticographic spectral changes during midazolam sedation.

OBJECTIVE: To better understand 'when' and 'where' wideband electrophysiological signals are altered by sedation. METHODS: We generated animation movies showing electrocorticography (ECoG) amplitudes at eight spectral frequency bands across 1.0-116 Hz, every 0.1s, on three-dimensional surface images of 10 children who underwent epilepsy surgery. We measured the onset, intensity, and variance of each band amplitude change at given nonepileptic regions separately from those at affected regions. We also determined the presence of differential ECoG changes depending on the brain anatomy. RESULTS: Within 20s following injection of midazolam, beta (16-31.5 Hz) and sigma (12-15.5 Hz) activities began to be multifocally augmented with increased variance in amplitude at each site. Beta-sigma augmentation was most prominent within the association neocortex. Augmentation of low-delta activity (1.0-1.5 Hz) was relatively modest and confined to the somatosensory-motor region. Conversely, injection of midazolam induced attenuation of theta (4.0-7.5 Hz) and high-gamma (64-116 Hz) activities. CONCLUSIONS: Our observations support the notion that augmentation beta-sigma and delta activities reflects cortical deactivation or inactivation, whereas theta and high-gamma activities contribute to maintenance of consciousness. The effects of midazolam on the dynamics of cortical oscillations differed across regions. SIGNIFICANCE: Sedation, at least partially, reflects a multi-local phenomenon at the cortical level rather than global brain alteration homogeneously driven by the common central control structure.

Airway management for rigid bronchoscopy via a freshly performed tracheostomy in a child with Goldenhar syndrome.

A case of tooth aspiration in a 6 year old boy with Goldenhar syndrome and known difficult intubation is presented. A fresh tracheostomy was performed after a failed fiberoptic intubation and dental aspiration. The patient was transferred to our tertiary-care children's hospital for emergency bronchoscopy through the fresh tracheostomy for removal of an aspirated tooth. Rigid bronchoscopy performed via a fresh tracheostomy presents several challenges. The major complications associated with bronchoscopy performed via a fresh tracheostomy, as well as management of airway emergencies are discussed.

A novel rescue technique for difficult intubation and difficult ventilation.

We describe a novel non surgical technique to maintain oxygenation and ventilation in a case of difficult intubation and difficult ventilation, which works especially well with poor mask fit. Can not intubate, can not ventilate" (CICV) is a potentially life threatening situation. In this video we present a simulation of the technique we used in a case of CICV where oxygenation and ventilation were maintained by inserting an endotracheal tube (ETT) nasally down to the level of the naso-pharynx while sealing the mouth and nares for successful positive pressure ventilation. A 13 year old patient was taken to the operating room for incision and drainage of a neck abscess and direct laryngobronchoscopy. After preoxygenation, anesthesia was induced intravenously. Mask ventilation was found to be extremely difficult because of the swelling of the soft tissue. The face mask could not fit properly on the face due to significant facial swelling as well. A direct laryngoscopy was attempted with no visualization of the larynx. Oxygen saturation was difficult to maintain, with saturations falling to 80%. In order to oxygenate and ventilate the patient, an endotracheal tube was then inserted nasally after nasal spray with nasal decongestant and lubricant. The tube was pushed gently and blindly into the hypopharynx. The mouth and nose of the patient were sealed by hand and positive pressure ventilation was possible with 100% O2 with good oxygen saturation during that period of time. Once the patient was stable and well sedated, a rigid bronchoscope was introduced by the otolaryngologist showing extensive subglottic and epiglottic edema, and a mass effect from the abscess, contributing to the airway compromise. The airway was secured with an ETT tube by the otolaryngologist.This video will show a simulation of the technique on a patient undergoing general anesthesia for dental restorations.

Guidelines for elective pediatric fiberoptic intubation.

Fiberoptic intubation in pediatric patients is often required especially in difficult airways of syndromic patients i.e. Pierre Robin Syndrome. Small babies will desaturate very quickly if ventilation is interrupted mainly to high metabolic rate. We describe guidelines to perform a safe fiberoptic intubation while maintaining spontaneous breathing throughout the procedure. Steps requiring the use of propofol pump, fentanyl, glycopyrrolate, red rubber catheter, metal insuflation hook, afrin, lubricant and lidocaine spray are shown.

Electrocautery-induced fire during adenotonsillectomy: report of two cases.

We describe two cases of flash fires in the oropharynx, secondary to electrocautery during adenotonsillectomies. We believe that in both cases, the leak around the uncuffed endotracheal tubes raised the oxygen concentration in the oropharynx. Cuffed endotracheal tubes provide many advantages, and their use should strongly be considered during adenotonsillectomy in children when electrocautery is to be used.

Parental satisfaction with anesthesia without intravenous access for myringotomy.

OBJECTIVE: To evaluate the effect of intravenous (i.v.) access in children undergoing bilateral myringotomy with pressure-equalizing tube placement. DESIGN: One hundred healthy children were enrolled in this randomized controlled study. One group received i.v. access; the other group did not. Anesthesia in both groups was induced through a mask and maintained with oxygen, nitrous oxide, and sevoflurane. Spontaneous ventilation was maintained. All children received fentanyl, 1 microg/kg intramuscularly. Children with i.v. access received 20 mL/kg of lactated Ringer's solution. Parents were telephoned the day after surgery to report on pain and vomiting, as well as their satisfaction with anesthesia. SETTING: Tertiary care children's hospital with all procedures performed by attending pediatric otolaryngologists and otolaryngology residents. Anesthesia was administered by a pediatric anesthesiologist and a trainee. RESULTS: The groups were similar in age, weight, and incidence of vomiting. Children with i.v. access spent more time than those without (mean +/- SD minutes) in the operating room (21 +/- 8 vs 17 +/- 7; P =.02), in phase 2 recovery (75 +/- 67 vs 51 +/- 24; P =.02), and in the hospital (119 +/- 67 vs 88 +/- 30; P =.005). These children also required more pain medication (31% vs 2%; P<.001) and had a lower parental satisfaction rate (28% vs 95%; P<.001). CONCLUSIONS: Intravenous access in otherwise healthy children undergoing myringotomy provided no added benefit. Children without i.v. access had reduced pain requirement and spent less time in the operating room, in phase 2 recovery, and in the hospital. Parental satisfaction, a clinically relevant outcome, was significantly greater for parents of children without i.v. access.

Propofol decreases waste anesthetic gas exposure during pediatric bronchoscopy.

OBJECTIVE: This study compared the anesthetic gas exposure and operating conditions during insufflation anesthesia with halothane-alone versus halothane-propofol in children undergoing direct laryngobronchoscopy. STUDY DESIGN: Forty-six children were enrolled in this randomized prospective study, with institutional review board approval and informed consent. METHODS: All children were anesthetized by halothane mask induction and anesthesia was maintained using spontaneous ventilation with insufflation. No muscle relaxants or opioids were used. In the halothane group, halothane was titrated as needed. In the propofol group, halothane was decreased to 1% inspired concentration and the propofol was titrated as needed to maintain spontaneous ventilation and a still patient. Trace anesthetic gases, hemodynamic stability, and operating conditions were measured. RESULTS: The groups were similar in age, weight, and bronchoscopy time. There was significantly less gas exposure in the propofol group (25 +/- 33 parts per million) versus the halothane group (66 +/- 97 ppm; P <.02). There was a trend toward earlier emergence in the halothane group (33 +/- 13 minutes) versus the propofol group (41 +/- 17 minutes). Postoperative stridor was common, occurring in 30% of children. CONCLUSIONS: Insufflation anesthesia with spontaneous respiration provides excellent surgical conditions for laryngobronchoscopy. The addition of propofol resulted in fewer airway complications (P =.047). Although the addition of propofol significantly decreased anesthetic gas exposure in the operating room, both techniques resulted in operating room pollution that exceeded the maximum levels of 2 ppm per hour recommended by the US National Institute for Occupational Safety and Health (NIOSH).