Anaesthetic management in a case of a type IV laryngotracheo-oesophageal cleft

Remifentanil in neonatal intensive care and anaesthesia practice

Remifentanil is a relatively new ultrashort action synthetic opioid. Studies on the use of remifentanil in neonatology have emerged demonstrating its effectiveness and safety in neonates. The present study describes the use of remifentanil in both full-term and premature newborns, highlighting the theoretical benefits for this population in terms of both neonatal intensive care and anaesthesia. A Medline search was undertaken of all reviews and reports about the use of remifentanil in neonates published between 1996 and 2009 using MeSH search terms 'remifentanil', 'analgesia', 'anaesthesia', 'newborn' and 'neonate'. The review points that remifentanil has been used with advantages in newborns including preterm neonates and even for foetal anaesthesia. It proved to be a good option to attenuate the hemodynamic/endocrine markers of stress related to surgery. Owing to its unique pharmacokinetic profile, shorter extubation times can be achieved what makes the drug also a good option for short duration invasive procedures in NICUs (InSurE). A concern on its use is that the hemodynamic response (hypotension) may become significant when the drug is associated to other drugs like sevoflurane.

CONCLUSION

Remifentanil seems to be an effective and safely used opioid for neonatal intensive care and anaesthesia practice.

Emergency use of a size 1 laryngeal mask airway in a ventilated neonate with an undiagnosed type IV laryngotracheo-oesophageal cleft

The perioperative management of a neonate with a type IV laryngotracheo-oesophageal cleft and exomphalos major is described. Following an otherwise uncomplicated exomphalos repair, this baby became increasingly and inexplicably difficult to ventilate through an endotracheal tube. The emergency use of a laryngeal mask airway as a rescue maneuver allowed positive pressure ventilation, and subsequent diagnosis of the airway abnormality. The difficulties in management of the two co-existing conditions are discussed.

Remifentanil: an update

PURPOSE OF REVIEW

Remifentanil has now reached maturity, as reflected by the increasing number of clinical papers relating to its use. Its position among anaesthetic drugs is now better understood, and this review will attempt to place it in the context of current clinical practice.

RECENT FINDINGS AND SUMMARY

Propofol reduces the initial distribution of remifentanil, leading to higher concentrations during induction. Propofol and remifentanil administered together at sedative doses display a major synergistic interaction on the respiratory drive. Remifentanil accelerates the penetration of sevoflurane to its site of effect. The risk of intraoperative awareness seems to be low when remifentanil is associated to very low concentrations of hypnotic drugs, but this field warrants further investigation. Acute tolerance to opioids and its prevention remain controversial.

SUMMARY

Remifentanil is the opioid of choice for tracheal intubation without muscle relaxants. It provides an alternative to regional anaesthesia in labour pain control. Target-controlled infusion may further improve the administration of remifentanil.