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Gupta A, Gupta N, Kamal G, Girdhar KK. Videolaryngoscopy Bails us out of Difficult Intubation Scenarios in Syndromic Children: A Case Series. Turk J Anaesthesiol Reanim 2020; 49:78-82. [PMID: 33718912 PMCID: PMC7932707 DOI: 10.5152/tjar.2020.00947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Accepted: 08/18/2019] [Indexed: 11/22/2022] Open
Abstract
Airway management in children with craniofacial anomalies can be complicated and may require multiple attempts with conventional direct laryngoscopy (DL). Videolaryngoscopes (VLs) have a well-established role in difficult airway management in adults; however, their role remains to be fully elucidated in paediatric age group. There is a relative paucity in the literature regarding the role of VLs in cases of syndromic children, and it is not clear whether they should be used as an initial option or as a rescue device. Herein, we report a series of cases of children with Pierre Robin sequence, Beckwith–Wiedemann syndrome, and Hurler’s syndrome wherein VLs proved beneficial after multiple failed DL attempts. Following initial failed attempts to intubate using DL, these children were subsequently intubated using VLs. Therefore, VLs should be used for initial intubation attempts in syndromic children with potential difficult airways.
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Affiliation(s)
- Anju Gupta
- Department of Anaesthesiology, Pain Medicine and Critical Care, AIIMS, New Delhi, India
| | - Nishkarsh Gupta
- Department of Onco-Anaesthesiology and Palliative Medicine, DRBRAIRCH, AIIMS, New Delhi, India
| | - Geeta Kamal
- Department of Anaesthesiology, Chacha Nehru Bal Chikitsalya, New Delhi, India
| | - Kiran Kumar Girdhar
- Department of Anaesthesiology, Pain Medicine and Critical Care, AIIMS, New Delhi, India
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2
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Dohrmann T, Muschol NM, Sehner S, Punke MA, Haas SA, Roeher K, Breyer S, Koehn AF, Ullrich K, Zöllner C, Petzoldt M. Airway management and perioperative adverse events in children with mucopolysaccharidoses and mucolipidoses: A retrospective cohort study. Paediatr Anaesth 2020; 30:181-190. [PMID: 31834659 DOI: 10.1111/pan.13787] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Revised: 12/01/2019] [Accepted: 12/08/2019] [Indexed: 12/25/2022]
Abstract
BACKGROUND Children suffering from mucopolysaccharidoses (subtypes I, II, III, IV, VI, and VII) or mucolipidoses often require anesthesia, but are at high risk for perioperative adverse events. However, the impact of the disease subtype and the standard of care for airway management are still unclear. AIMS This study aimed to assess independent risk factors for perioperative adverse events in individuals with mucopolysaccharidoses/mucolipidoses and to analyze the interaction with the primary airway technique implemented. METHODS This retrospective study included individuals with mucopolysaccharidoses/mucolipidoses who underwent anesthesia at two high-volume centers from 2002 to 2016. The data were analyzed in a multivariate hierarchical model, accounting for repeated anesthesia procedures within the same patient and for multiple events within a single anesthesia. RESULTS Of 141 identified inpatients, 67 (63 mucopolysaccharidoses and 4 mucolipidoses) underwent 269 anesthesia procedures (study cases) for 353 surgical or diagnostic interventions. At least one perioperative adverse event occurred in 25.6% of the cases. The risk for perioperative adverse events was higher in mucopolysaccharidoses type I (OR 8.0 [1.5-42.7]; P = .014) or type II (OR 8.8 [1.3-58.6]; P = .025) than in type III. Fiberoptic intubation through a supraglottic airway was associated with the lowest risk for perioperative adverse events and lowest conversion rate. Direct laryngoscopy was associated with a significantly higher risk for airway management problems than indirect techniques (estimated event rates 47.8% vs 10.1%, OR 24.05 [5.20-111.24]; P < .001). The risk for respiratory adverse events was significantly higher for supraglottic airway (22.6%; OR 31.53 [2.79-355.88]; P = .001) and direct laryngoscopy (14.8%; OR 14.70 [1.32-163.44]; P = .029) than for fiberoptic intubation through a supraglottic airway (2.1%). CONCLUSIONS The disease subtype and primary airway technique were the most important independent risk factors for perioperative adverse events. Our findings indicate that in MPS/ML children with predicted difficult airway indirect techniques should be favored for the first tracheal intubation attempt.
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Affiliation(s)
- Thorsten Dohrmann
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Nicole M Muschol
- Department of Pediatrics, Center for Obstetrics and Pediatrics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,International Center for Lysosomal Disorders (ICLD) and Martin Zeitz Centre for Rare Diseases, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Susanne Sehner
- Department of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Mark A Punke
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Sebastian A Haas
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medicine Rostock, Rostock, Germany
| | - Katharina Roeher
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Sandra Breyer
- Department of Pediatric Orthopedics, AKK Altona Children's Hospital, Hamburg, Germany.,Department of Orthopedics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Anja F Koehn
- Department of Pediatrics, Center for Obstetrics and Pediatrics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,International Center for Lysosomal Disorders (ICLD) and Martin Zeitz Centre for Rare Diseases, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Kurt Ullrich
- International Center for Lysosomal Disorders (ICLD) and Martin Zeitz Centre for Rare Diseases, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Christian Zöllner
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Martin Petzoldt
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,International Center for Lysosomal Disorders (ICLD) and Martin Zeitz Centre for Rare Diseases, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
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Madoff LU, Kordun A, Cravero JP. Airway management in patients with mucopolysaccharidoses: The progression toward difficult intubation. Paediatr Anaesth 2019; 29:620-627. [PMID: 30929289 DOI: 10.1111/pan.13640] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Revised: 02/27/2019] [Accepted: 03/10/2019] [Indexed: 12/27/2022]
Abstract
BACKGROUND Patients with mucopolysaccharidoses (MPS) have physical changes to their airways over time. Due to the natural progression of their disease, these patients become more difficult to intubate as they get older. AIMS The aims of this study were to evaluate the difficulty of airway management in MPS patients over time, and to evaluate the effect of bone marrow transplant and/or enzyme replacement therapy on airway difficulty. METHODS A retrospective review of MPS patients presenting for surgery from January 2012 to May 2018 was performed. Patients were assigned to groups based on their ages at the time of surgery, number of intubation attempts, equipment used for intubation, difficulty of mask ventilation, and difficulty of laryngeal mask airway placement. The same designations were applied to patients with a history of a bone marrow transplant (BMT) and/or enzyme replacement therapy, and they were compared to patients of similar ages who had received no treatment. Logistic regression was used to determine the odds of difficult intubation. RESULTS One hundred and twenty-eight anesthetic records were reviewed. In 27 cases, the patient had a BMT and in 54 cases, the patient had received enzyme replacement therapy. Adults (18 years and older) had the highest likelihood of difficult intubation (OR 13.44, CI 1.45-124.86, P = 0.022). Mask ventilation and laryngeal mask airway placement were not significantly more difficult in any age groups. Bone marrow transplant did not improve airway management. A history of enzyme replacement therapy was associated with an increased risk of difficult intubation in patients under the age of 12. CONCLUSIONS As patients with MPS get older, there is a progression toward difficult intubation. Mask ventilation and laryngeal mask airway placement does not become more difficult with age. Bone marrow transplantation did not affect airway difficulty in our population, while enzyme replacement therapy was associated with difficult intubations in younger patients.
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Affiliation(s)
- Lauren U Madoff
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Anna Kordun
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Joseph P Cravero
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts
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Abstract
Background Patients suffering from mucopolysaccharidosis are among the most complex from the anesthesiological point of view, especially regarding the management of the airway. The evidence base for anesthesia management is often limited to case reports and small case series. Aims To identify useful information about experience with each subtype of mucopolysaccharidosis reported in the literature and propose a guide on the best options for airway management to the anesthesiologists who take care of these patients. Methods A query of the PubMed database specific for “anesthesia” and “mucopolysaccharidosis” and a further query specific for “mucopolysaccharidosis and difficult airway management” was conducted. We looked for those items that offered practical guidance to anesthesiological management. We did not exclude case reports, especially those that reported a specific technique, because of their practical suggestions. Results We identified 15 reviews, 17 retrospective case series, 5 prospective studies, and 28 case reports that focused on airway managements in anesthesia or had practical suggestions for preoperative evaluation and risk assessment. An accurate preoperative evaluation and the need for an experienced team are emphasized in all the reviewed articles and for each type of mucopolysaccharidosis. Many suggestions on how to plan the perioperative period have been highlighted. Insertion of a laryngeal mask airway generally improves ventilation and facilitates intubation with a fiberoptic bronchoscope. Furthermore, the videolaryngoscope is very useful in making intubation easier and facilitating bronchoscope passage. Conclusions Patients with mucopolysaccharidosis are at high risk for anesthesia-related complications and require a high level of attention. However, a multidisciplinary approach, combined with expertise in the use of new techniques and new devices for airway management, makes anesthesiological management safer. Further research with prospective studies would be useful. Electronic supplementary material The online version of this article (10.1186/s13052-018-0554-1) contains supplementary material, which is available to authorized users.
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Scaravilli V, Zanella A, Ciceri V, Bosatra M, Flandoli C, La Bruna A, Sosio S, Parini R, Gasperini S, Pesenti A, Moretto A. Safety of anesthesia for children with mucopolysaccharidoses: A retrospective analysis of 54 patients. Paediatr Anaesth 2018; 28:436-442. [PMID: 29687523 DOI: 10.1111/pan.13379] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/15/2018] [Indexed: 01/01/2023]
Abstract
BACKGROUND Complications are common during anesthesia for patients with mucopolysaccharidoses. San Gerardo Hospital (Italy) is a reference center for mucopolysaccharidoses with a dedicated pediatric anesthesia service. AIMS This study aims to evaluate the safety of anesthesia for mucopolysaccharidoses patients, describe their anesthetic management at our institution, and assess risk factors for complications. METHODS The anesthetic charts of mucopolysaccharidoses patients admitted from January 1999 to December 2014 were retrospectively analyzed. We retrieved patients' demographics; location and type of the procedure; anesthetic approach airway management and occurrence of difficult intubation and complications and outcome at hospital discharge. A generalized linear mixed model was performed to assess risk factors for complications and difficult intubation. RESULTS Fifty-four consecutive children were included. The anesthetic charts of 232 procedures (52% radio-diagnostics, 15% orthopedics, 15% ear-nose-throat surgery, 10% neurosurgery, and 8% general surgery) were analyzed. Each patient underwent a median of 4 (1-6) procedures. The median age at the first procedure was 2 (1-5), and overall age was 5 (2-8) years old. One hundred and twenty-five (54%) procedures were performed in remote locations. General anesthesia was utilized for 100 (43%) procedures. No death was recorded. Twenty-one (9%) procedures had respiratory complications. Remote location anesthesia was associated with increased risk for complications (odds ratio 5.405 [1.355-28.571], P = .016). All planned intubations (n = 65) were successful. Nineteen (29%) of those were defined difficult. All emergency intubations (n = 3) failed and were rescued by laryngeal mask airways. Older age was associated with an increased risk of difficult intubation (OR 1.200 [1.019-1.436], P = .028). CONCLUSION Patients with mucopolysaccharidoses are at high risk for anesthesia-related complications. Remote location anesthesia is associated with increased risk for complications, and older age is associated with increased risk for difficult intubation.
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Affiliation(s)
- Vittorio Scaravilli
- Department of Anesthesia and Critical Care, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Alberto Zanella
- Department of Anesthesia and Critical Care, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy.,Department of Medical Physiopathology and Transplants, University of Milan, Milan, Italy
| | - Valentina Ciceri
- School of Medicine and Surgery, University of Milan-Bicocca, Milan, Italy
| | - Mariagrazia Bosatra
- Department of Perioperative Medicine and Intensive Care, San Gerardo Hospital, Monza, Italy
| | - Claudia Flandoli
- Department of Perioperative Medicine and Intensive Care, San Gerardo Hospital, Monza, Italy
| | - Alessia La Bruna
- Department of Anesthesia and Intensive Care, Ospedale San Raffaele, Milan, Italy
| | - Simone Sosio
- School of Medicine and Surgery, University of Milan-Bicocca, Milan, Italy
| | - Rossella Parini
- Pediatric Unit, Fondazione MBBM, San Gerardo Hospital, Monza, Italy
| | - Serena Gasperini
- Pediatric Unit, Fondazione MBBM, San Gerardo Hospital, Monza, Italy
| | - Antonio Pesenti
- Department of Anesthesia and Critical Care, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy.,Department of Medical Physiopathology and Transplants, University of Milan, Milan, Italy
| | - Alessandra Moretto
- Department of Perioperative Medicine and Intensive Care, San Gerardo Hospital, Monza, Italy
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Clark BM, Sprung J, Weingarten TN, Warner ME. Anesthesia for patients with mucopolysaccharidoses: Comprehensive review of the literature with emphasis on airway management. Bosn J Basic Med Sci 2018; 18:1-7. [PMID: 28590232 DOI: 10.17305/bjbms.2017.2201] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Accepted: 06/01/2017] [Indexed: 11/16/2022] Open
Abstract
Mucopolysaccharidoses (MPS) are rare, inherited, lysosomal storage diseases that cause accumulation of glycosaminoglycans, resulting in anatomic abnormalities and organ dysfunction that can increase the risk of anesthesia complications. We conducted a systematic review of the literature in order to describe the anesthetic management and perioperative outcomes in patients with MPS. We reviewed English-language literature search using an OVID-based search strategy of the following databases: 1) PubMed (1946-present), 2) Medline (1946-present), 3) EMBASE (1946-present), and 4) Web of Science (1946-present), using the following search terms: mucopolysaccharidosis, Hurler, Scheie, Sanfilippo, Morquio, Maroteaux, anesthesia, perioperative, intubation, respiratory insufficiency, and airway. The review of the literature revealed nine case series and 27 case reports. A substantial number of patients have facial and oral abnormalities posing various challenges for airway management, however, evolving new technologies that include videolaryngoscopy appears to substantially facilitate airway management in these patients. The only type of MPS that appears to have less difficulty with airway management are MPS III patients, as the primary site of glycosaminoglycan deposition is in the central nervous system. All other MPS types have facial and oral characteristics that increase the risk of airway management. To mitigate these risks, anesthesia should be conducted by experienced anesthesiologists with expertise in using of advanced airway intubating devices.
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Affiliation(s)
- Brittney M Clark
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA.
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Hack HA, Walker RWM, Gardiner P. Anaesthetic Implications of the Changing Management of Patients with Mucopolysaccharidosis. Anaesth Intensive Care 2016; 44:660-668. [DOI: 10.1177/0310057x1604400612] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The mucopolysaccharidoses are a group of inherited metabolic disorders that are renowned for presenting clinical problems, particularly related to cardiac, airway, and skeletal abnormalities, in children during anaesthesia. The changing clinical management of the mucopolysaccharidoses can be described in three phases. An initial phase of accumulation and dissemination of knowledge about the management of this rare disease with a growing recognition that untreated Hurler syndrome and more severe forms of other phenotypes such as Hunter syndrome and Maroteaux–Lamy syndrome were associated with severe complications under anaesthesia. This was followed by a second phase reflecting the beneficial results of new treatments such as haemopoietic stem cell transplantation and enzyme replacement therapy. Early and successful transplantation has dramatically improved long-term outcome and reduced anaesthetic complications in children with Hurler syndrome. Enzyme replacement therapy is available for many forms of mucopolysaccharidosis. If commenced at an early age improvement in many organ systems may be observed with an improved quality of life. However, these current treatment regimens do not appear to improve neurocognitive dysfunction, or cardiac valvular or skeletal abnormalities. We are now entering a third phase where the partial benefits of these treatment regimens are resulting in an increasing number of older patients with partially corrected abnormalities, including difficult airways, presenting for ongoing treatment to a new and potentially unsuspecting group of clinicians. Major airway abnormalities may be encountered and current adult guidelines may need to be adapted. A multidisciplinary team approach involving paediatric and adult anaesthetists is recommended to optimise future management.
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Affiliation(s)
- H. A. Hack
- Department of Paediatric Anaesthesia, Starship Children's Hospital, Auckland, New Zealand
| | - R. W. M. Walker
- Department of Paediatric Anaesthesia, Royal Manchester Children's Hospital, Manchester, UK
| | - P. Gardiner
- Department of Anaesthesia, Auckland City Hospital, Auckland, New Zealand
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8
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Kerai S, Saith V, Kumar R, Tewari S. Airway management in Hurler's syndrome: A persistent challenge for anaesthesiologists. Indian J Anaesth 2016; 60:599-601. [PMID: 27601746 PMCID: PMC4989814 DOI: 10.4103/0019-5049.187811] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Affiliation(s)
- Sukhyanti Kerai
- Department of Anaesthesiology and Critical Care, Maulana Azad Medical College and Associated Lok Nayak Hospital, New Delhi, India
| | - Vandana Saith
- Department of Anaesthesiology and Critical Care, Maulana Azad Medical College and Associated Lok Nayak Hospital, New Delhi, India
| | - Rakesh Kumar
- Department of Anaesthesiology and Critical Care, Maulana Azad Medical College and Associated Lok Nayak Hospital, New Delhi, India
| | - Saipriya Tewari
- Department of Anaesthesiology and Critical Care, Maulana Azad Medical College and Associated Lok Nayak Hospital, New Delhi, India
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Megens JHAM, de Wit M, van Hasselt PM, Boelens JJ, van der Werff DBM, de Graaff JC. Perioperative complications in patients diagnosed with mucopolysaccharidosis and the impact of enzyme replacement therapy followed by hematopoietic stem cell transplantation at early age. Paediatr Anaesth 2014; 24:521-7. [PMID: 24612129 DOI: 10.1111/pan.12370] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/22/2014] [Indexed: 11/29/2022]
Abstract
BACKGROUND Mucopolysaccharidoses (MPS) are hereditary storage diseases; airway management typically worsens in these patients with the progression of the disease. OBJECTIVE(S) To assess the incidence of perioperative complications in children with MPS and the impact of enzyme replacement therapy (ERT) followed by hematopoietic stem cell transplantation (HSCT). METHODS The records of patients with MPS treated with ERT followed by HSCT, who received anesthesia at the Wilhelmina Children's Hospital between 2003 and 2012, were reviewed. Data were collected on incidence of perioperative respiratory and cardiovascular complications and the impact of treatment and age. RESULTS Nineteen children with MPS were identified (including 17 Hurler patients), who received ERT treatment followed by HSCT. Median age at start of treatment was 14 (range: 7-43) months. Patients were anesthetized 136 times. The incidence of respiratory and cardiovascular complications was 24% and 4%, respectively. Airway management by face mask was difficult in 7%. There were no problems with the laryngeal mask airway. Tracheal intubation was difficult in 25% and failed in 10%; using a video laryngoscope was most successful (89%), followed by classic laryngoscope (67%) and fiber-optic scope (20%). Multivariate logistic regression analyses showed that the incidence of perioperative respiratory problems did not increase with age or decrease after start of treatment. CONCLUSION Perioperative airway management was most successful using a laryngeal mask airway or video laryngoscope. Treatment with ERT followed by HSCT and patient age did not influence the incidence of perioperative respiratory problems.
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Affiliation(s)
- Johanna H A M Megens
- Department of Anesthesiology, Intensive Care and Emergency Medicine, Wilhelmina Children's Hospital, University Medical Centre Utrecht, Utrecht, The Netherlands
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Guerrero-Domínguez R, García-Santigosa M, Ontanilla A. [Difficult airway in a pediatric patient with mucopolysaccharidosis type I (Hurler syndrome)]. ACTA ACUST UNITED AC 2013; 61:115-6. [PMID: 23477891 DOI: 10.1016/j.redar.2012.12.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2012] [Revised: 12/09/2012] [Accepted: 12/13/2012] [Indexed: 10/27/2022]
Affiliation(s)
- R Guerrero-Domínguez
- Unidad de Gestión Clínica de Anestesiología y Reanimación, Hospital Infantil, Hospitales Universitarios Virgen del Rocío, Sevilla, España.
| | - M García-Santigosa
- Unidad de Gestión Clínica de Anestesiología y Reanimación, Hospital Infantil, Hospitales Universitarios Virgen del Rocío, Sevilla, España
| | - A Ontanilla
- Unidad de Gestión Clínica de Anestesiología y Reanimación, Hospital Infantil, Hospitales Universitarios Virgen del Rocío, Sevilla, España
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Abstract
The 'new' challenging pediatric patients are those who could be called 'the survivors' and neonates undergoing birth under materno-fetal circulation. Their anesthetic management is complex because their initial pathology was previously lethal: the physiologic, pharmacologic, and or technical aspect of their management is presently unknown or hypothetical. Some examples are described. Communication with the pediatrician in charge of the child is the key to safe and effective anesthetic care of these cases.
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