Correspondence
Oluwaseun A. Adetayo1 & Devin Midura2 Division of Plastic Surgery, Section of Pediatric Plastic & Craniofacial Surgery, Albany, NY, USA 2 Albany Medical College,Albany, NY, USA Email: [email protected]
Acknowledgments
1
None. Conflict of interest
doi:10.1111/pan.12666
The authors report no conflict of interest. References 1 Spencer R, Chang P, Guimaraes A et al. The use of Google Glass for airway assessment and management. Pediatr Anesth 2014; 24: 1009–1011.
2 Muensterer OJ, Lacher M, Zoeller C et al. Google Glass in pediatric surgery: an exploratory study. Int J Surg 2014; 12: 281–289.
3 Albrecht U-V, von Jan U, Kuebler J et al. Google Glass for documentation of medical findings: evaluation in forensic medicine. J Med Internet Res 2014; 16: e53.
Total intravenous anesthesia with dexmedetomidine and ketamine in children SIR—I want to add the drug combination of dexmedetomidine and ketamine to the armamentarium of pediatric total intravenous anesthesia (TIVA) agents described in the recent review article by Lauder (1). ‘Ketadex’ (earlier called as ketodex; revised in view of the name already existing in drug pharmacopoeia for another drug) (2) is a useful and practical alternative to the standard drugs used for TIVA. The drug combination provides good sedation along with preservation of spontaneous breathing and maintenance of hemodynamic stability (cardiovascular effects of dexmedetomidine are negated by that of ketamine). Ketamine activates the sympathetic nervous system and causes an increase in the heart rate and blood pressure. Dexmedetomidine, on the other hand has a biphasic action with initial hypertension followed by a more sustained dose-dependent hypotension and bradycardia (2). In a study in 22 children (ages 5–17 years) undergoing electrophysiologic study and ablation for supraventricular tachycardia, Char et al. (3) showed that the concurrent use of ketamine may mitigate the negative chronotropic effects of dexmedetomidine. Ketamine is a good analgesic and a bronchodilator, and some of its side effects like delirium and increased salivation are prevented or minimized by the concurrent use of dexmedetomidine. There are several reports and a few preliminary studies that indicate effective analgesia and sedation by this drug combination. Its successful use has been reported for children undergoing cardiac catheterization, upper gastrointestinal
756
endoscopy, extracorporeal shock wave lithotripsy, muscle biopsy, and mediastinal mass excision (4). However, most studies have shown that though the adverse effects were less, the recovery time was more with dexmedetomidine–ketamine as compared to other drugs like midazolam, propofol, and opioids. Further studies are required that can solve the arithmetic of the dosages and the rate of the individual infusion of the two drugs which is effective, safe, and easy to deliver in children. I would say that Altman and Bland are correct in saying that absence of evidence is not evidence of absence (1). Ethics approval Not applicable. Funding The study received no external funding. Conflict of interest The authors report no conflict of interest. Rakhee Goyal Department of Anesthesia and Critical Care, Armed Forces Medical College, Pune, India Email: [email protected] doi:10.1111/pan.12658
© 2015 John Wiley & Sons Ltd Pediatric Anesthesia 25 (2015) 753–760
Correspondence
References 1 Lauder GR. Total intravenous anesthesia will supercede inhalational anesthesia in pediatric anesthetic practice. Pediatr Anesth 2015; 25: 52–64. 2 Goyal R, Singh S, Shukla RN et al. Ketodex, a combination of dexmedetomidine and ketamine for upper gastrointestinal endoscopy in
children: a preliminary report. J Anesth 2013; 27: 461–463. 3 Char D, Drover DR, Motonaga KS et al. The effects of ketamine on dexmedetomidineinduced electrophysiologic changes in children. Pediatr Anesth 2013; 23: 898–905.
4 Tobias JD. Dexmedetomidine and ketamine: an effective alternative for procedural sedation? Pediatr Crit Care Med 2012; 13: 423–427.
Drowning eye sign—massive hydrocephalus SIR—Hydrocephalus occurs as a result of excessive accumulation of cerebrospinal fluid (CSF) during impaired circulation and/or absorption of CSF (1). As the hydrocephalus progresses, the eyes are displaced downward by pressure on thinned orbital roof. This displacement of eyes causes the sclera to be visible above the iris, or the ‘sunset eye’ sign which is a valuable early sign of hydrocephalus requiring prompt neuroimaging and urgent surgical intervention. This clinical phenomenon is encountered in infants and young children with raised intracranial pressures (seen in up to 40% of children with obstructive hydrocephalus) that may initially be intermittent, and later become continuous due to increasing intracranial pressure and loss of upward conjugate gaze (2). A 6-month-old male baby weighing 8 kg was admitted to our hospital with hydrocephalus and was scheduled for ventriculo-peritoneal (VP) shunt surgery under general anesthesia. The chief complaints were increase in head circumference for 1 month and vomiting and decreased intake for 5 days. There was no history of seizures or focal neurological deficit. Antenatal history was unremarkable. On examination, the baby was drowsy, with heart rate of 116 bmin 1, and respiratory rate 28 breaths per minute. The head circumference was 50 cm, (a)
and dilated scalp veins and bulging anterior fontanel was present. The eyes appeared to be placed deep in the lower part of orbit. These unusual deep-seated, downward looking eyes, out of the orbital socket with massive hydrocephalus may be termed the ‘drowning eye’ sign (Figure 1a). Other system examination and blood investigations were unremarkable. The noncontrast computed tomography scans of head showed massive enlargement of all the ventricles with periventricular ooze (Figure 1b). Emergency VP shunt surgery under general anesthesia was done with low pressure, Chhabra shunt system (G. Surgiwear Ltd., Shahjahanpur, India) in view of the raised intracranial tension and deteriorating neurological conditioning. During follow-up, the patient’s head circumference was 48 cm at 1 month and 40 cm at 6 months. However, this reduction in head circumference was not associated with clinical neurological improvement. Discussion The sunset sign manifests as a result of pressure on the supra-pineal recess of mid-brain with excessive CSF. No classification or grading exists either for severity of sunset sign or the rate of increase in head circumference. (b)
Figure 1 (a) Drowning eye sign and (b) Computed tomography head showing enlarged ventricles. © 2015 John Wiley & Sons Ltd Pediatric Anesthesia 25 (2015) 753–760
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Oluwaseun A. Adetayo1 & Devin Midura2 Division of Plastic Surgery, Section of Pediatric Plastic & Craniofacial Surgery, Albany, NY, USA 2 Albany Medical College,Albany, NY, USA Email: [email protected]
Acknowledgments
1
None. Conflict of interest
doi:10.1111/pan.12666
The authors report no conflict of interest. References 1 Spencer R, Chang P, Guimaraes A et al. The use of Google Glass for airway assessment and management. Pediatr Anesth 2014; 24: 1009–1011.
2 Muensterer OJ, Lacher M, Zoeller C et al. Google Glass in pediatric surgery: an exploratory study. Int J Surg 2014; 12: 281–289.
3 Albrecht U-V, von Jan U, Kuebler J et al. Google Glass for documentation of medical findings: evaluation in forensic medicine. J Med Internet Res 2014; 16: e53.
Total intravenous anesthesia with dexmedetomidine and ketamine in children SIR—I want to add the drug combination of dexmedetomidine and ketamine to the armamentarium of pediatric total intravenous anesthesia (TIVA) agents described in the recent review article by Lauder (1). ‘Ketadex’ (earlier called as ketodex; revised in view of the name already existing in drug pharmacopoeia for another drug) (2) is a useful and practical alternative to the standard drugs used for TIVA. The drug combination provides good sedation along with preservation of spontaneous breathing and maintenance of hemodynamic stability (cardiovascular effects of dexmedetomidine are negated by that of ketamine). Ketamine activates the sympathetic nervous system and causes an increase in the heart rate and blood pressure. Dexmedetomidine, on the other hand has a biphasic action with initial hypertension followed by a more sustained dose-dependent hypotension and bradycardia (2). In a study in 22 children (ages 5–17 years) undergoing electrophysiologic study and ablation for supraventricular tachycardia, Char et al. (3) showed that the concurrent use of ketamine may mitigate the negative chronotropic effects of dexmedetomidine. Ketamine is a good analgesic and a bronchodilator, and some of its side effects like delirium and increased salivation are prevented or minimized by the concurrent use of dexmedetomidine. There are several reports and a few preliminary studies that indicate effective analgesia and sedation by this drug combination. Its successful use has been reported for children undergoing cardiac catheterization, upper gastrointestinal
756
endoscopy, extracorporeal shock wave lithotripsy, muscle biopsy, and mediastinal mass excision (4). However, most studies have shown that though the adverse effects were less, the recovery time was more with dexmedetomidine–ketamine as compared to other drugs like midazolam, propofol, and opioids. Further studies are required that can solve the arithmetic of the dosages and the rate of the individual infusion of the two drugs which is effective, safe, and easy to deliver in children. I would say that Altman and Bland are correct in saying that absence of evidence is not evidence of absence (1). Ethics approval Not applicable. Funding The study received no external funding. Conflict of interest The authors report no conflict of interest. Rakhee Goyal Department of Anesthesia and Critical Care, Armed Forces Medical College, Pune, India Email: [email protected] doi:10.1111/pan.12658
© 2015 John Wiley & Sons Ltd Pediatric Anesthesia 25 (2015) 753–760
Correspondence
References 1 Lauder GR. Total intravenous anesthesia will supercede inhalational anesthesia in pediatric anesthetic practice. Pediatr Anesth 2015; 25: 52–64. 2 Goyal R, Singh S, Shukla RN et al. Ketodex, a combination of dexmedetomidine and ketamine for upper gastrointestinal endoscopy in
children: a preliminary report. J Anesth 2013; 27: 461–463. 3 Char D, Drover DR, Motonaga KS et al. The effects of ketamine on dexmedetomidineinduced electrophysiologic changes in children. Pediatr Anesth 2013; 23: 898–905.
4 Tobias JD. Dexmedetomidine and ketamine: an effective alternative for procedural sedation? Pediatr Crit Care Med 2012; 13: 423–427.
Drowning eye sign—massive hydrocephalus SIR—Hydrocephalus occurs as a result of excessive accumulation of cerebrospinal fluid (CSF) during impaired circulation and/or absorption of CSF (1). As the hydrocephalus progresses, the eyes are displaced downward by pressure on thinned orbital roof. This displacement of eyes causes the sclera to be visible above the iris, or the ‘sunset eye’ sign which is a valuable early sign of hydrocephalus requiring prompt neuroimaging and urgent surgical intervention. This clinical phenomenon is encountered in infants and young children with raised intracranial pressures (seen in up to 40% of children with obstructive hydrocephalus) that may initially be intermittent, and later become continuous due to increasing intracranial pressure and loss of upward conjugate gaze (2). A 6-month-old male baby weighing 8 kg was admitted to our hospital with hydrocephalus and was scheduled for ventriculo-peritoneal (VP) shunt surgery under general anesthesia. The chief complaints were increase in head circumference for 1 month and vomiting and decreased intake for 5 days. There was no history of seizures or focal neurological deficit. Antenatal history was unremarkable. On examination, the baby was drowsy, with heart rate of 116 bmin 1, and respiratory rate 28 breaths per minute. The head circumference was 50 cm, (a)
and dilated scalp veins and bulging anterior fontanel was present. The eyes appeared to be placed deep in the lower part of orbit. These unusual deep-seated, downward looking eyes, out of the orbital socket with massive hydrocephalus may be termed the ‘drowning eye’ sign (Figure 1a). Other system examination and blood investigations were unremarkable. The noncontrast computed tomography scans of head showed massive enlargement of all the ventricles with periventricular ooze (Figure 1b). Emergency VP shunt surgery under general anesthesia was done with low pressure, Chhabra shunt system (G. Surgiwear Ltd., Shahjahanpur, India) in view of the raised intracranial tension and deteriorating neurological conditioning. During follow-up, the patient’s head circumference was 48 cm at 1 month and 40 cm at 6 months. However, this reduction in head circumference was not associated with clinical neurological improvement. Discussion The sunset sign manifests as a result of pressure on the supra-pineal recess of mid-brain with excessive CSF. No classification or grading exists either for severity of sunset sign or the rate of increase in head circumference. (b)
Figure 1 (a) Drowning eye sign and (b) Computed tomography head showing enlarged ventricles. © 2015 John Wiley & Sons Ltd Pediatric Anesthesia 25 (2015) 753–760
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