An audit of anesthetic management and complications of tracheo-esophageal fistula and esophageal atresia repair

BACKGROUND

Many different anesthetic techniques have been suggested for the management of tracheo-oesophageal fistula/oesophageal atresia (TOF/OA) although the incidence of ventilation difficulty is not well known and it is unclear which technique is best in managing this. The aim of our audit was to determine the incidence of ventilation difficulty during repair of TOF/OA. We also recorded the current practice for anesthesia and analgesia in these children as well as the incidence of comorbidities and surgical complications.

METHODS

We retrospectively audited cases of TOF/OA repair over a 3-year period in four hospitals, recording demographics, comorbidities, surgical data, postoperative complications, and anesthetic technique, including ventilation difficulty and management strategy.

RESULTS

A total of 111 patients were identified with TOF/OA, and 106 patient notes and 101 anesthetic records were found. 42% of patients were premature, and 57.5% had significant comorbidities. Death was most likely in infants with low birth weight and low gestational age at birth and in those with major cardiac comorbidity. A range of techniques were used for induction, maintenance, extubation, and pain control. There were ventilation difficulties recorded at induction in seven patients, and significant desaturations were recorded in 15 patients intraoperatively.

CONCLUSIONS

This audit adds to the data already published about incidences of complications and comorbidities associated with TOF/OA repair. Defining anesthetic practice with regard to ventilation and analgesic strategies is important in comparing the adequacy and risk of techniques used. Our audit shows that a range of differing anesthetic techniques are still employed by different anesthetists and institutions and details some of the techniques being used for managing difficult ventilation.

MAC-awake of sevoflurane in children

INTRODUCTION

Age influences the potency of anesthetic agents, but there is little information on how age influences MAC-awake. MAC-awake may be an important aspect of anesthesia potency for the prevention of awareness during anesthesia. The aim of this study was to measure MAC-awake in a range of ages in children.

METHODS

After institutional ethics approval and informed parental consent 60 children were enrolled; 20 in each of three age groups (2 to <5, 5 to <8 and 8-12 years). Children were excluded if they had opioids, sedative premedication or a procedure likely to cause any residual discomfort. All children had sevoflurane anesthesia. At the end of the procedure the sevoflurane was decreased to the target concentration. Once the target endtidal concentration was achieved it was maintained for 10 min before a standard stimulus was applied and an observer determined if the child was awake. The Dixon up-down method was used to determine progression of subsequent concentrations and MAC-awake (ED50) for the three age groups were obtained using the probit model.

RESULTS

This study found evidence for a difference in ED50 between age groups (P = 0.008). The MAC-awake was highest in the youngest group (0.66%) and similar in the older groups (0.45% and 0.43%).

CONCLUSION

Although MAC-awake changes with age, in the ages where awareness has been reported, MAC-awake was found to be relatively low, and therefore it seems unlikely that age-specific changes to MAC-awake are a cause for awareness in children aged 5-12 years.

The optimum initial pediatric epidural bolus: a comparison of four local anesthetic solutions

BACKGROUND

There is no consensus on the concentration or type of local anesthetic used for initiation of epidural anesthesia. The aim of this randomized, double-blind, controlled trial was to compare the clinical effectiveness of epidural administration of both levobupivacaine and bupivacaine in 0.2% and 0.25% concentrations in pediatric patients undergoing abdominal and urological surgery.

METHODS

One hundred and forty-one children scheduled for lower abdominal and urological surgery were randomized to receive 0.4-0.6 ml.kg(-1) epidural, 0.25% bupivacaine, 0.2% bupivacaine, 0.25% levobupivacaine or 0.2% levobupivacaine. Initial epidural volumes, onset times; hemodynamic consequences, postoperative pain scores and degree of residual postoperative motor block were all recorded.

RESULTS

There were no significant differences in the proportion of children with effective analgesia after incision [0.20% bupivacaine 97%, 0.25% bupivacaine 94%, 0.20% levobupivacaine 91%, 0.25% levobupivacaine 92% (P=0.73)] when a median volume of 0.55 ml.kg(-1) was used. There was no association between the volume used for thoracic, lumbar, or sacral epidural anesthesia and the effectiveness of the agents used. There was a significantly greater incidence of pain on awakening with the 0.2% solutions compared with the 0.25% solutions, but no differences in the incidence of residual motor block between groups.

CONCLUSIONS

While there is no difference in the proportion of effective surgical anesthesia, the lower incidence of pain and distress with the 0.25% solutions suggests that this concentration has clinical advantages over the 0.2% solutions for pediatric epidural anesthesia.

Evaluation of the revised laryngeal tube suction: the laryngeal tube suction II in 100 patients

BACKGROUND

We prospectively assessed the performance of the laryngeal tube suction mark II (LTS II).

METHODS

LTS II was assessed during controlled and spontaneous ventilation during total i.v. anaesthesia. Ventilation adequacy, functional and anatomical positioning and airway seal were evaluated.

RESULTS

One hundred healthy patients (30F:70M) aged 18-85-yr-old were studied. Insertion of the LTS II was successful in 71 at first attempt, in 24 at second attempt and in five at third/fourth attempt. Median insertion time was 15 s (range 5-120 s). Temporary obstruction occurred in six patients. A median of one manipulation per patient was required to establish an airway (range 0-5). During maintenance, temporary airway obstruction occurred in eight patients. Use of the device was abandoned once during insertion, once during maintenance and once because of complications unrelated to the study. The airway was clear in 89 of 97 patients during maintenance and partially obstructed in eight. Median seal pressure was 29.5 (range 15-85) cm H2O. A gastric tube was passed via the posterior channel in 97 of 99 patients. The glottis was visible using a fibrescope passed via the device in 51% of patients. Via the drain tube the upper oesophagus was visible in 22% and this was open in 50%. Blood was visible on the device after removal in 12 patients. After the operation 14 patients reported mild sore throat.

DISCUSSION

The LTS II appears to be an improvement on its predecessor and merits further investigation comparing it with its competitors during use for anaesthesia and emergency airway management.