A 24-year-old male patient was posted for spinal instrumentation for listhesis of the first and second dorsal spine. He had a history of road traffic accident with associated cervical spine injury. Prior to surgery, the patient had an elective tracheostomy in view of anticipated prolonged mechanical ventilation. The patient underwent the surgery using a standard anesthetic technique of propofol, rocuronium, fentanyl, sevoflurane, oxygen, and air under recommended patient monitoring. After induction of anesthesia, invasive arterial monitoring was initiated and the patient was placed in prone position properly. The surgery went well for next 3 hours, and after that, we observed a ventilator alarm indicating inadequate tidal volume being delivered to the patient. We immediately started manually ventilating the patient's lungs with 100% oxygen and tried to figure out the source of gas leak. After a thorough investigation, we figured out the tracheostomy tube cuff leak to be the reason for the air leak in the circuit. We tried to inflate the cuff with air but failed to maintain the cuff inflation due to fault in the pilot balloon.Because the surgery was at a crucial stage, it was not possible to make the patient supine. Hence, to tide over this airway crisis, we inflated the pilot balloon again and clamped the inflation tube with artery forceps. This maneuver contained the air leak only for a brief duration. Therefore, we again inflated the pilot balloon, clamped the inflation tube, and cut the inflation tube near the pilot balloon. A 22-gauge intravenous cannula was then carefully inserted inside the inflation tubing; the needle was removed and the sheath was left in situ; and then the artery forceps were removed. Thereafter, a three-way stopcock was attached to the cannula, tracheal cuff was inflated through the cannula, and the stopcock was closed to block the deflation of the cuff (►Fig.
Background: Direct measurement of intracranial pressure (ICP) is an invasive technique with potential complications, which has prompted the development of alternative, noninvasive, methods of ICP assessment. The aim of this study was to determine the relationship between noninvasive ultrasound-based measurement of optic nerve sheath diameter (ONSD), transcranial Doppler-derived pulsatility index (PI), and invasive ICP measurements in children with traumatic brain injury (TBI). Methods: Children aged 1 to 18 years undergoing invasive ICP monitoring following TBI were included in the study. Noninvasive ONSD and PI measurements were compared with simultaneous invasive ICP. Results: In all, 406 measurements of ONSD and PI were obtained in 18 patients. ONSD and PI correlated with ICP (r=0.76 and 0.79, respectively), combining ONSD and PI resulted in an even stronger correlation with ICP (r=0.99). Formulas were derived from mixed-effect models that best fitted the data for noninvasive ICP estimation. A combination of ONSD and PI had the highest ability to detect ICP >20 mm Hg (area under the receiver operating characteristic curve=0.99, 95% confidence interval: 0.99-1.00). Optimal cutoff values for the prediction of intracranial hypertension were 5.95 mm for ONSD (sensitivity, 92%; specificity, 76%) and 1.065 for PI (sensitivity, 92%; specificity, 87%). Conclusions: In children with TBI, a combination of ONSD and PI strongly correlates with invasive ICP and has potential to screen for intracranial hypertension noninvasively. ONSD and PI may be useful tools for assessing ICP where invasive monitoring is unavailable or contraindicated.
Background Pediatric traumatic brain injury (TBI) has distinctive pathophysiology and characteristics that differ from adults. These can be attributed to age-related anatomical and physiological differences and distinct patterns of injuries seen in children. Our aim was to identify the patient characteristics, clinical variables during intensive care and intraoperative management associated with poor functional outcome in a cohort of pediatric TBI patients. Methods Retrospective chart review of pediatric TBI patients admitted to neurotrauma intensive care unit (NICU) over a period of 1 year. Results A total of 105 children (< 12 years) with head injury were admitted in the NICU during the study period. The most common mechanism of injury was fall in 78% cases. Fifty-four patients (51.4%) presented with a severe head injury (Glasgow coma scale [GCS] ≤ 8), while 31 (29.5%) and 20 (19.1%) had a mild and moderate head injury. The most common finding was skull fractures (59%), contusions (36.2%), and subdural hematoma (SDH) (30.4%). Forty nine patients (46.7%) required surgical management. The median duration of anesthesia was 205 (interquartile range [IQR] 65, 375) minutes, and median blood loss during the surgery was 16.7 mL/kg body weight with 41% requiring intraoperative blood transfusions. Median duration of ICU and hospital stay was 5 (IQR 1, 47) and 8 (IQR 1, 123) days, respectively. GOS at discharge ≤ 3 representing poor outcome was present in 35 patients (33.3%). Mortality was seen in 15 (14.3%) patients. Multivariate analysis identified postresuscitation GCS ≤ 8 on admission as independent predictor of mortality, and postresuscitation GCS ≤ 8 on admission and NICU stay of > 7 days as independent predictor of poor outcome. Conclusion Despite advances in neurointensive care, mortality and morbidity remains high in pediatric head trauma and is mainly dependent on postresuscitation GCS and NICU stay of more than 7 days. Multidimensional approach is required for its prevention and management.
Neonatal progeroid syndrome is a unique condition wherein features of aging are apparent in a newborn at birth. It is a very rare genetic disorder. The first case in India was reported in December 2011. The anesthetic management of any infant with this condition could not be found in the medical literature. Independently described by Rautenstrauch and Wiedemann, neonatal progeroid syndrome poses significant challenges to the anesthesiologist for a variety of anatomic and physiologic reasons. Coronary and cerebrovascular atherosclerosis pose significant concerns in such children. Here, we present the successful anesthetic management of a 6-month-old male infant with neonatal progeroid syndrome operated on for bilateral inguinoscrotal swellings.
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