Awake laryngeal mask insertion followed by induction of anesthesia in infants with the Pierre Robin sequence

Abstract

Recalling some fundamental concepts would be interesting for the discussion. The basic concept of measuring CVP intraoperatively by inserting a CVC is still a hypothesis. 2 Some published studies to date show an appealing association between a low CVP, a low blood loss and a better outcome in patients undergoing elective liver resection. 2 This finding was contradicted in some other studies in which CVP monitoring did not appear to reduce blood loss in elective liver resection. 3 Globally, the intraoperative clinical value of CVP is questionable. 4 Intraoperative changes of transthoracic pressure by both mechanical ventilation and the pressure of surgical retractors on the thorax and right atrium are likely to alter the CVP interpretation. 4 Ascites in a cirrhotic patient is also likely to increase transthoracic pressure hence altering CVP. 4 Furthermore, liver resection has become safer and associated with low intraoperative bleeding mainly because of improved surgical skill and techniques. 5 The evidence that lowering CVP per se decreases blood loss and therefore improves outcome is strong but still circumstantial. 2,6 To our knowledge, blood loss was demonstrated to be reduced by a low CVP in only one prospective, randomized study of 50 patients. 6 In this study, mean intraoperative blood loss was 2329 ml, a value far above usual blood loss recorded in recent similar series, thus questioning the relevance for the present practice. 6 Furthermore, the causal link between reduced blood loss and improved outcome remains speculative in liver resection similarly as in other surgical fields. 7 Finally, pharmacologic intervention likely to decrease CVP may result in relative hypovolemia, decrease in weak organ vascularization, which has never been convincingly demonstrated to be safe. Many patients undergoing liver resection are old, have coexisting diseases and are likely to have pre-existing organ dysfunction. 7 In this respect, assessing the safety of such practices remains mandatory.In conclusion, a CVC was not contributive in most patients undergoing liver resection in Stephan's series. 1 However, the clinical contributive value of a low CVP in patients undergoing elective liver resection remains unanswered. N. Mansour C. Lentschener Y. Ozier References 1. Stephan F, Bezaiguia-Delclaux S. Usefulness of central venous catheter during hepatic surgery. Acta Anesthesiol Scand 2008; 52: 388-96. 2. Melendez J, Arslan V, Fische ME, Wuest D, Jarnagin WR, Fong Y, Blumgart LH. Perioperative outcomes of major hepatic resections under low central venous pressure anesthesia: blood loss, blood transfusion, and the risk of postoperative renal dysfunction. J Am Coll Surg 1998; 187: 620-5. 3. Niemann CU, Feiner J, Behrends M, Eilers H, Ascher NL, Roberts JP. Central venous pressure monitoring during living right donor hepatectomy. Liver Transpl 2007; 13: 266-71. 4. Gelman S. Venous function and central venous pressure. A physiologic story. Anesthesiology 2008; 108: 735-48. 5. Franco D. Liver surgery has become simpler. Eur J Anae...

Airway management for intubation in newborns with pierre robin sequence

“…The remaining 22 of 35 (63%) who failed direct laryngoscopy were successfully intubated over a flexible fiberoptic bronchoscope. Stricker et al11 found a similar percentage of PRS newborns were successfully intubated with direct laryngoscopy. Four of 14 (29%) were intubated with direct laryngoscopy, and 10 of 14 (71%) were fiberoptically intubated.…”

“…The device can be used for both ventilatory purposes and to aid in endotracheal tube placement. Stricker et al11 described LMA placement followed by inhaled induction of anesthesia. LMA placement can help reduce the risk of upper airway obstruction following anesthesia induction, and the authors determined it to be an effective ventilatory device for PRS newborns.…”

Anesthesia Challenges for the Difficult and Critical Neonatal Airway

“…This device allows for the ability to oxygenate and ventilate a patient while using a fi beroptic bronchoscope. The LMA has also been proven to be useful as a way to perform an inhalation induction in a neonate when it is diffi cult to get a mask fi t such as in patients with Goldenhar syndrome [ 7 ]. A topical local anesthetic can be applied to the oropharynx of the patient to reduce airway activation when the LMA is placed awake; however, this is not necessary in most neonates.…”

Airway Management in Neonates with Pierre Robin Syndrome along with Mobius Syndrome and Platoglossal Fusion

“…Antenatal history was essentially unremarkable except for family history of cerebral palsy and prematurity in a sibling. Physical exam by the otolaryngologist demonstrated palatoglossal fusion in the midline with possible underlying bilateral cleft palate, retrognathia and microcanthia with a patent right nasal cavity, but narrowed left nasal cavity (Figure 1) [12][13][14]. An echocardiogram showed him to have a small patent ductus arterioles (PDA) with a small right to left shunt and bilateral talipes equinovarus.…”