Correspondence
Key learning points
Source of funding
1. Extraoral kinking of PVC tracheal tube can take place during surgery in supine position especially if an uncut tube is used in presence of warming device. 2. Reinforced tubes or precut PVC tubes should be used wherever possible. 3. External splinting using another tube shall be tried to correct any kinking instead of cutting or replacing the tube in situ.
No funding was received for this letter. Conflict of interest No conflict of interests declared. Prakash K. Dubey & Neeraj Kumar Department of Anesthesiology & Critical Care Medicine, Indira Gandhi Institute of Medical Sciences, Patna, India Email: [email protected]
Acknowledgment
doi:10.1111/pan.12345
Written informed consent for publication obtained from the parent. References 1 Hubler M, Petrasch F. Intraoperative kinking of polyvinyl endotracheal tubes. Anesth Analg 2006; 103: 1601–1602. 2 Ayala JL, Coe A. Thermal softening of tracheal tubes: an unrecognized hazard of
the Bair Hugger active patient warming system. Br J Anaesth 1997; 79: 543–545. 3 Yamashita M, Motokawa K. A simple method for preventing kinking of 2.5-mm ID endotracheal tubes. Anesth Analg 1987; 66: 803–804.
4 Sivapurapu V, Subramani Y, Vasudevan A. “Externally reinforced endotracheal tube” in a pediatric neurosurgical patient. J Neurosurg Anesthesiol 2012; 24: 82–83.
Ultrasound-guided rectus sheath blocks for open pyloromyotomy: a chance to turn down the gas SIR—We read with much interest the article by Breschen et al. (1) ‘Ultrasound-guided rectus sheath block for pyloromyotomy in infants: a retrospective analysis of a case series’ and congratulate the authors on their informative study. In our institution, we carried out a similar retrospective review of 26 consecutive neonates undergoing open pyloromyotomy where preincisional ultrasound-guided rectus sheath blocks were performed (2). Like Breschen et al., the requirement for opiate supplementation was low with only one patient requiring intravenous fentanyl in the postanesthetic care unit and none in theater. The mean time to patient discharge was 46 h, which was comparable with that of local anesthetic infiltration techniques reported in a recent meta-analysis (3). Similar to Breschen et al., no complications were identified from the rectus sheath blocks. The vulnerability of neonates to apnea postoperatively makes opiate-sparing techniques of great value, and ultrasound-guided rectus sheath block provides a simpler alternative to central neuraxial blockade during pyloromyotomy. When performed prior to skin incision, 356
this can reduce or even obviate the need for intraoperative opiates and should also allow for a reduced MAC of inhalational agents. Although these data were not recorded in our review, it is our experience anecdotally that 0.5 MAC of sevoflurane usually suffices. A reduction in MAC may have further significance given the association of early exposure to anesthetic agents and adverse neurodevelopmental outcomes. More recently, we have used remifentanil infusions in combination with bilateral rectus sheath blocks following intubation and have achieved a further reduction in MAC. With no visceral analgesia provided by the block, remifentanil is useful during surgical manipulation of the stomach and pylorus. The need for amnesia in neonates has been the subject of some debate recently (4); however the benefit of adequate analgesia has been shown to improve outcomes. As concern exists over the effect of some inhalational anesthetics on neurological development, a combination of rectus sheath block and remifentanil in appropriate situations might aid in minimizing neonatal exposure to these agents. © 2014 John Wiley & Sons Ltd Pediatric Anesthesia 24 (2014) 339–357
Correspondence
2
Conflict of interest The authors declare no conflicts of interest. Keith Bailie1, Aidan Cullen2 & Andrew Eggleton3 1 Department of Anaesthesia, Royal Belfast Hospital for Sick Children, Belfast, UK
Craigavon Area Hospital, Portadown, UK 3 Belfast City Hospital, Belfast, UK Email: [email protected] doi:10.1111/pan.12349
References 1 Breschan C, Jost R, Stettner H et al. Ultrasound-guided rectus sheath block for pyloromyotomy in infants: a retrospective analysis of a case series. Pediatr Anesth 2013; 23: 1199–1204. 2 Eggleton A, Cullen A, Bailie K. Bilateral Rectus Sheath Blocks: an effective analgesic
© 2014 John Wiley & Sons Ltd Pediatric Anesthesia 24 (2014) 339–357
option for open pyloromyotomy. Poster session presented at: 40th Association of Paediatric Anaesthetists Annual Scientific Meeting and AGM 2013 June 19–21st, Cambridge, UK. 3 Oomen MWN, Hoekstra LT, Bakx R et al. Open versus laparoscopic pyloromyotomy for
hypertrophic pyloric stenosis: a systematic review and meta-analysis focusing on major complications. Surg Endosc 2012; 26: 2104–2110. 4 Davidson AJ. Neurotoxicity and the need for Anesthesia in the Newborn. Anesthesiology 2012; 116: 507–509.
357
Key learning points
Source of funding
1. Extraoral kinking of PVC tracheal tube can take place during surgery in supine position especially if an uncut tube is used in presence of warming device. 2. Reinforced tubes or precut PVC tubes should be used wherever possible. 3. External splinting using another tube shall be tried to correct any kinking instead of cutting or replacing the tube in situ.
No funding was received for this letter. Conflict of interest No conflict of interests declared. Prakash K. Dubey & Neeraj Kumar Department of Anesthesiology & Critical Care Medicine, Indira Gandhi Institute of Medical Sciences, Patna, India Email: [email protected]
Acknowledgment
doi:10.1111/pan.12345
Written informed consent for publication obtained from the parent. References 1 Hubler M, Petrasch F. Intraoperative kinking of polyvinyl endotracheal tubes. Anesth Analg 2006; 103: 1601–1602. 2 Ayala JL, Coe A. Thermal softening of tracheal tubes: an unrecognized hazard of
the Bair Hugger active patient warming system. Br J Anaesth 1997; 79: 543–545. 3 Yamashita M, Motokawa K. A simple method for preventing kinking of 2.5-mm ID endotracheal tubes. Anesth Analg 1987; 66: 803–804.
4 Sivapurapu V, Subramani Y, Vasudevan A. “Externally reinforced endotracheal tube” in a pediatric neurosurgical patient. J Neurosurg Anesthesiol 2012; 24: 82–83.
Ultrasound-guided rectus sheath blocks for open pyloromyotomy: a chance to turn down the gas SIR—We read with much interest the article by Breschen et al. (1) ‘Ultrasound-guided rectus sheath block for pyloromyotomy in infants: a retrospective analysis of a case series’ and congratulate the authors on their informative study. In our institution, we carried out a similar retrospective review of 26 consecutive neonates undergoing open pyloromyotomy where preincisional ultrasound-guided rectus sheath blocks were performed (2). Like Breschen et al., the requirement for opiate supplementation was low with only one patient requiring intravenous fentanyl in the postanesthetic care unit and none in theater. The mean time to patient discharge was 46 h, which was comparable with that of local anesthetic infiltration techniques reported in a recent meta-analysis (3). Similar to Breschen et al., no complications were identified from the rectus sheath blocks. The vulnerability of neonates to apnea postoperatively makes opiate-sparing techniques of great value, and ultrasound-guided rectus sheath block provides a simpler alternative to central neuraxial blockade during pyloromyotomy. When performed prior to skin incision, 356
this can reduce or even obviate the need for intraoperative opiates and should also allow for a reduced MAC of inhalational agents. Although these data were not recorded in our review, it is our experience anecdotally that 0.5 MAC of sevoflurane usually suffices. A reduction in MAC may have further significance given the association of early exposure to anesthetic agents and adverse neurodevelopmental outcomes. More recently, we have used remifentanil infusions in combination with bilateral rectus sheath blocks following intubation and have achieved a further reduction in MAC. With no visceral analgesia provided by the block, remifentanil is useful during surgical manipulation of the stomach and pylorus. The need for amnesia in neonates has been the subject of some debate recently (4); however the benefit of adequate analgesia has been shown to improve outcomes. As concern exists over the effect of some inhalational anesthetics on neurological development, a combination of rectus sheath block and remifentanil in appropriate situations might aid in minimizing neonatal exposure to these agents. © 2014 John Wiley & Sons Ltd Pediatric Anesthesia 24 (2014) 339–357
Correspondence
2
Conflict of interest The authors declare no conflicts of interest. Keith Bailie1, Aidan Cullen2 & Andrew Eggleton3 1 Department of Anaesthesia, Royal Belfast Hospital for Sick Children, Belfast, UK
Craigavon Area Hospital, Portadown, UK 3 Belfast City Hospital, Belfast, UK Email: [email protected] doi:10.1111/pan.12349
References 1 Breschan C, Jost R, Stettner H et al. Ultrasound-guided rectus sheath block for pyloromyotomy in infants: a retrospective analysis of a case series. Pediatr Anesth 2013; 23: 1199–1204. 2 Eggleton A, Cullen A, Bailie K. Bilateral Rectus Sheath Blocks: an effective analgesic
© 2014 John Wiley & Sons Ltd Pediatric Anesthesia 24 (2014) 339–357
option for open pyloromyotomy. Poster session presented at: 40th Association of Paediatric Anaesthetists Annual Scientific Meeting and AGM 2013 June 19–21st, Cambridge, UK. 3 Oomen MWN, Hoekstra LT, Bakx R et al. Open versus laparoscopic pyloromyotomy for
hypertrophic pyloric stenosis: a systematic review and meta-analysis focusing on major complications. Surg Endosc 2012; 26: 2104–2110. 4 Davidson AJ. Neurotoxicity and the need for Anesthesia in the Newborn. Anesthesiology 2012; 116: 507–509.
357
