Do pediatric patients undergoing cardiac surgeries require larger-size cuffed endotracheal tubes? A prospective study

Accuracy of Age-Based Formula to Predict the Size and Depth of Cuffed Oral Preformed Endotracheal Tubes in Children Undergoing Tonsillectomy

OBJECTIVES

To retrospectively investigate the reliability of the age-based formula, year/4 + 3.5 mm in predicting size and year/2 + 12 cm in predicting insertion depth of preformed endotracheal tubes in children and correlate these data with the body mass index.

PATIENTS AND METHODS

Patients were classified into 4 groups according to their nutritional status: thinness, normal weight, overweight, and obesity; we then retrospectively compared the actual size of endotracheal tube and insertion depth to the predicting age-based formula and to the respective bend-to-tip distance of the used preformed tubes.

RESULTS

Altogether, 300 patients were included. The actual endotracheal tube size corresponded with the Motoyama formula (64.7%, 90% CI: 60.0-69.1), except for thin patients, where the calculated size was too large (0.5 mm). The insertion depth could be predicted within the range of the bend-to-tip distance and age-based formula in 85.0% (90% CI: 81.3-88.0) of patients.

CONCLUSION

Prediction of the size of cuffed preformed endotracheal tubes using the formula of Motoyama was accurate in most patients, except in thin patients (body mass index < -2 SD). The insertion depth of the tubes was mostly in the range of the age-based-formula to the bend-to-tip distance.

Effect of hyperglycemia treatment on complications rate after pediatric cardiac surgery

Introduction: The goal of this study was to elucidate harmful complications of intraoperative hyperglycemia following children cardiac surgery and benefits of insulin administration for accurate blood sugar controlling.

Methods: this study is a Randomized clinical trial. We conducted this study in the operating room of shahid madani hospital. Fifty patients who were children under 12 years old undergone cardiac surgery using cardiopulmonary bypass (CPB). Intraoperative insulin infusion was administered intravenously targeting blood sugar levels of 110-140 mg/dL. Blood sugar and arterial blood gas (ABG) were measured every 30 min during operation.

Results: Inotropes were used less in the study than the placebo group during surgery. The means of hospitalization and extubation time were more in the placebo group than the study group(P =0.03) and (P =0.005), respectively. However, the mean time of hospitalization in the ICU ward did not differ significantly between the two groups.

Conclusion: Hyperglycemia has a relation with long time of intubation and hospitalization in ICU. These findings suggest the positive effect of accurate blood sugar control on reducing complication and hospitalization time in children undergoing cardiac surgery.

Airway ultrasound: Point of care in children-The time is now

BACKGROUND

Point-of-care ultrasonography of the airway is becoming a first-line noninvasive adjunct assessment tool of the pediatric airway. It is defined as a focused and goal-directed portable ultrasonography brought to the patient and performed and interpreted on the spot by the provider. Successful use requires a thorough understanding of airway anatomy and ultrasound experience.

AIMS

To outline the many benefits, and some limitations, of airway ultrasonography in the clinical and perioperative setting.

MATERIALS AND METHODS

Expert review of the recent literature.

RESULTS

Ultrasound assessment of the airway may provide the clinician with valuable information that is specific to the individual airway static and dynamic anatomy of the patient. Ultrasound can help identify vocal cord dysfunction and pathology, assess airway size, predict the appropriate diameter of endotracheal and tracheostomy tubes, differentiate tracheal from esophageal intubation, localize the cricothyroid membrane for emergency airway access and identify tracheal rings for US-guided tracheostomy. Ultrasonography is also a great tool for the intraoperative diagnosis of a pneumothorax, the visualization of the movement of the diaphragms, and quantifying the amount of gastric content. Ultrasonography signs, tips, and pearls that allow these diagnoses are highlighted. The major disadvantage of ultrasonography remains interobserver variability, and operator dependence, as it requires specific training and experience.

CONCLUSION

Although it is not standard of care yet, there is significant potential for the integration of ultrasound technology into the routine care of the airway.

Usefulness of ultrasound-guided measurement of minimal transverse diameter of subglottic airway in determining the endotracheal tube size in children with congenital heart disease: A prospective observational study

Introduction

The search for an accurate and predictable method to estimate the endotracheal tube (ETT) size in pediatric population had led to derivation of many formulae. Of this, age-based formulae are the most commonly used. Studies have shown that minimal transverse diameter of subglottic airway (MTDSA) measurements using a high-frequency probe improves the success rate of predicting the airway diameter to about 90%. We did a prospective observational study using MTDSA as the criteria to select the size of ETT in children with congenital heart disease.

Methods

In this prospective observational study, 51 children aged from 1 day to 5 years, scheduled for cardiac surgery, were enrolled for this study. The ETT size was guided solely based on the MTDSA. Leak test was used to determine the best-fit ETT size.

Results

Data from 49 patients were analyzed. Agreement between the ETT determined by MTDSA and that predicted by Cole's age-based formulas with the best-fit ETT size was analyzed using a Bland-Altman plot.

Conclusion

Age-based formula showed poor correlation (27.5%) compared to MTDSA (87.8%) in predicting the best-fit ETT. We observed that pediatric patients with congenital heart disease need a larger sized ETT as compared to what was predicted by age-based formula. Using ultrasound MTDSA measurements to guide selection of ETT size is a safe and accurate method in pediatric cardiac population.

Selection of cuffed endotracheal tube for children with congenital heart disease based on an ultrasound-based linear regression formula

It remains to be discovered whether a formula predicting the subglottic transverse diameter measured by ultrasound (SGD_formula) for the selection of an appropriate endotracheal tube (ETT) for children without congenital heart disease (CHD) is useful for children with CHD. A formula for predicting SGD was established after assessing 60 children ≤ 8 years without CHD and validated on 60 children with CHD. We selected the cuffed ETT size based on the SGD by ultrasound (SGD_ultra). Subsequently, the fit of the ETT cuff in 60 children with CHD was examined via air-leak test. The maximum allowed difference between the SGD_formula and the ETT size that fit was 0.2 mm. The agreement among and accuracy of SGD_ultra, SGD_formula, and the ETT used in children was analyzed. For children without CHD, we adopted a linear formula, given by SGD_formula (mm) = 0.4 × age + 5.3. For children with CHD, allometric formula was adopted, given by SGD_formula (mm) = 5.4 × age^0.18. A stronger agreement exists between SGD_ultra and ETT size compared to that between SGD_formula and ETT size. And the mean bias (SGD_formula-ETT size and SGD_ultra-ETT size) was 0.21 mm (95% confidence interval, - 0.59 to 1.01 mm) and 0.00 mm (- 0.79 to 0.84 mm). For the CHD group, the ultrasound-based method yielded a 78% success rate of ETT size choice, while the formula-based method permitted an appropriate ETT size in only 32% of subjects (P < 0.001). Our analysis showed that measuring the SGD_ultra was more accurate in predicting the correct OD of the ETT in children with CHD undergoing cardiovascular surgery, based on the correlation and agreement with ETT OD.

The role of ultrasound in appropriate endotracheal tube size selection in pediatric patients

BACKGROUND

The aim of this prospective study was to investigate the success of ultrasound in pediatric patients in determining the appropriate sized cuffed endotracheal tube and to compare the results with conventional height-based (Broselow) tape and age-based formula tube size.

METHODS

One hundred and fifty-two children of 1-10 years of age, who received general anesthesia for adenotonsillectomy were enrolled to the study. In all participants, the transverse diameter of the subglottis was measured with ultrasound during apnea. An endotracheal tube was chosen with the outer diameter matched to the measured subglottic airway diameter. An age-based (Motoyama-Khine) and height-based (Broselow) endotracheal tube size was calculated. If there was resistance to passage of the tube into the trachea or an airway pressure >25 cmH₂ 0 was required to detect an audible leak, the endotracheal tube was replaced with internal diameter of 0.5 mm smaller. If there was an audible leak at airway pressure <10 cmH₂ O, or peak pressure >25 cmH₂ 0 or a cuff pressure > 25 cmH₂ O was required to seal, the tube was changed to the 0.5 mm larger internal diameter. Best-fit tube internal diameter was the resultant tube internal diameter that met the previously stated conditions. The need for endotracheal tube replacement and peak airway pressure were recorded.

RESULTS

The internal diameter of ultrasound determined tube was the same as best-fit tube in 88% of children. Endotracheal tube was replaced in 15 patients with a one size larger, and in three patients with one size smaller tube. Using Bland-Altman analysis, a better agreement was observed with ultrasound measurement rather than height-based estimation and age-based formulas.

CONCLUSION

Our findings show that subglottic diameter measured by ultrasound appears to be a reliable predictor for the assessment of the subglottic diameter of the airway in estimating appropriate size pediatric endotracheal tube.

Impact and Challenges of a Policy Change to Early Track Extubation in the Operating Room for Fontan

While policy changes toward early extubation in the operating room (OR) have been commonly seen in palliative surgeries in single ventricle anatomy, no systematic assessment of their impact on patient outcome has been reported. All patients aged 0-17 years admitted to a PICU in a quaternary children's hospital for post-operative management following a primary Fontan procedure between 2005 and 2011 were included. Patients for revision of Fontan or patients admitted to adult Cardiovascular Intensive Care Unit were excluded. Practice policy was changed from routine extubation in the PICU to early extubation in OR in January 2008. Data were compared between the pre-policy-change era (2005-2007) and the post-policy-change era (2008-2011) to assess the impact of the change on patient outcomes. Generalized linear regression (GLM) and interrupted time series (ITS) analysis were used to access the effect of policy change on PICU length of stay and post-operative fluid balance, adjusting for potential confounders using propensity scores. Root cause analysis (RCA) was conducted to describe causes of failed extubation and challenges of this policy change. One hundred twenty-seven children met inclusion criteria. Average body weight was 14.7 kg [standard deviation (SD) 3.9], and age was 3.5 years (SD 1.9). A clear change in extubation practice occurred between the pre- versus post-policy-change eras: 97.5 % were extubated in the PICU in the pre-policy-change era, as compared to 15.0 % in the post-policy-change era. The average PICU length of stay was shortened by 4.1 days from the pre-policy-change era to the post-policy-change era [95 % CI -1.2 to -6.9, p < 0.01] in the GLM, whereas the ITS analysis did not show a statistically significant difference [95 % CI 1.8 to -2.5] (p = 0.23). No statistically significant difference was observed in the fluid balance in the 24 h post-operation in both analyses. Sixteen patients (16/127, 12.6 %) were reintubated mainly for hemodynamic instability in the pre-policy-change era (6/39, 15.4 %) and excessive bleeding or respiratory etiologies in the post-policy-change era (10/88, 11.4 %). Significant reduction of PICU length of stay was achieved without any evidence of worsening of patient outcomes. RCA suggests watchful observations with respect to bleeding and respiratory etiologies are the key to prevent failure of extubation in the current practice.

Cuffed endotracheal tubes in neonates and infants undergoing cardiac surgery are not associated with airway complications

STUDY OBJECTIVE

To determine the incidence of postoperative airway complications in infants <5kg in weight undergoing cardiac surgery intubated with Microcuff (Kimberley-Clark, Roswell, GA) endotracheal tubes (ETTs).

DESIGN

Retrospective review of infants weighing <5.0 kg with congenital heart disease (CHD) presenting for cardiac surgery.

SETTING

Single-center, tertiary pediatric cardiac critical care unit at a university hospital.

PATIENTS

A total of 208 infants weighing <5 kg underwent cardiac surgery for CHD from 2008 to 2013.

INTERVENTION

Intubation with Microcuff (Kimberley-Clark) ETTs.

STUDY DESIGN

Retrospective review of infants weighing <5.0 kg with CHD presenting for cardiac surgery to a single-center tertiary care university hospital.

MEASUREMENTS

Perioperative data were collected. Primary outcome was development of tracheal stenosis and/or reintubation for stridor. Stridor was defined as mild (≤2 doses of racemic epinephrine), moderate (>2 doses of racemic epinephrine), or severe (requiring reintubation). Secondary outcomes were variables possibly contributing to postextubation stridor. Infants with a tracheostomy, airway anomalies, and death prior to initial extubation were excluded. Logistic regression analysis was performed to evaluate the association between clinical risk factors and the incidence of postextubation stridor.

RESULTS

A total of 208 infants weighing <5 kg underwent cardiac surgery for CHD from 2008 to 2013; 12 subjects were excluded for death prior to initial extubation. No infant developed tracheal stenosis. The incidence of any stridor was 20.9% (95% confidence interval, 15.8%-27.1%) with severe stridor in 2 cases (1%). Age at surgery, weight, duration of intubation, dexamethasone use, and ETT size were not significantly associated with postextubation stridor. Presence of a comorbidity was significantly associated with stridor (P=.01).

CONCLUSIONS

Microcuff ETTs in infants <5.0 kg in weight undergoing cardiac surgery are associated with a low incidence of severe postextubation stridor. Because cuffed ETTs allow for improved control of ventilation/oxygenation and decreased risk of aspiration, they should be considered for use in this high-risk population. Larger studies are needed to confirm these results.

Management of difficult airway with laryngeal mask in a child with mucopolysaccharidosis and mitral regurgitation: a case report

INTRODUCTION

Mucopolysaccharidoses (MPSs) are a group of heredity storage diseases, transmitted in an autosomal recessive manner, associated with the accumulation of glycosaminoglycans (GAGs) in various tissues and organs. The concerned patients have multiple concomitant hereditary anomalies. Considering the craniofacial abnormality in these patients, airway management may be difficult for anesthesiologists. In these patients, preanesthetic assessment is necessary and performed with the accurate assessment of airways, consisting of the physical exam and radiography, MRI or CT of head and neck. An anesthesiologist should set up a "difficult intubation set" with a flexible fiber-optic bronchoscope and also, it may be necessary to discuss with an ear-nose and throat (ENT) specialist if required, for unpredicted emergency situations.

CASE PRESENTATION

In this case-report we presented a 2-year-old boy with known MPSs with psychomotor retardation, bilateral corneal opacities, impaired hearing and vision, inguinal hernia, severe mitral regurgitation, micrognathia, coarse facial feature, stiff and short neck and restricted mouth opening. He scheduled for left inguinal hernia repair surgery.

DISCUSSION

The patient's difficult airway was managed successfully and the anesthesia of his surgical procedure had an uneventful course.

Laryngeal ultrasonography versus cuff leak test in predicting postextubation stridor

Introduction: Although cuff leak test has been proposed as a simple method of predicting the occurrence of postextubation stridor, cut-off point of cuff-leak volume substantially differs between previous studies. In addition, laryngeal ultrasonography including measurement of air column width could predict postextubation stridor. The aim of the present study was to evaluate the value of laryngeal ultrasonography versus cuff leak test in predicting postextubation stridor.

Methods: In a prospective study, all patients intubated for a minimum of 24 h for acute respiratory failure, airway protection and other causes were included. Patients were evaluated for postextubation stridor and need for reintubation after extubation. The cuff leak volume was defined as a difference between expiratory tidal volumes with the cuff inflated and deflated. Laryngeal air column width was defined as the width of air passed through the vocal cords as determined by laryngeal ultrasonography. The air-column width difference was the width difference between balloon-cuff inflation and deflation.

Results: Forty one intubated patients with the mean age of 57.16±20.07 years were included. Postextubation stridor was observed in 4 patients (9.75%). Cuff leak test (cut off point: 249 mL) showed sensitivity and specificity of 75% and 59%, respectively. In addition, laryngeal ultrasonography (cut off point for air column width: 10.95 mm) resulted in sensitivity and specificity of 50% and 54%, respectively. Positive predictive value of both methods were <20%.

Conclusion: Both cuff leak test and laryngeal ultrasonography have low positive predictive value and sensitivity in predicting postextubation stridor and should be used with caution in this regard.

Warming Endotracheal Tube in Blind Nasotracheal Intubation throughout Maxillofacial Surgeries

INTRODUCTION

Blind nasotracheal intubation is an intubation method without observation of glottis that is used when the orotracheal intubation is difficult or impossible. One of the methods to minimize trauma to the nasal cavity is to soften the endotracheal tube through warming. Our aim in this study was to evaluate endotracheal intubation using endotracheal tubes softened by hot water at 50 °C and to compare the patients in terms of success rate and complications.

METHODS

60 patients with ASA Class I and II scheduled to undergo elective jaw and mouth surgeries under general anesthesia were recruited.

RESULTS

success rate for Blind nasotracheal intubation in the control group was 70% vs. 83.3% in the study group. Although the success rate in the study group was higher than the control group, this difference was not statistically significant. The most frequent position of nasotracheal intubation tube was tracheal followed by esophageal and anterior positions, respectively.

CONCLUSION

In conclusion, our study showed that using an endotracheal tube softened by warm water could reduce the incidence and severity of epistaxis during blind nasotracheal intubation; however it could not facilitate blind nasotracheal intubation.

Does adenotonsillectomy alter IGF-1 and ghrelin serum levels in children with adenotonsillar hypertrophy and failure to thrive? A prospective study

OBJECTIVES

Adenotonsillar hypertrophy (ATH) contributes to upper airway obstruction and recurrent tonsillitis in children. The aim of this study was to evaluate the effect of adenotonsillectomy on serum IGF-1 and ghrelin levels in children with ATH failure to thrive.

METHODS

Forty pre-pubertal children with more than 5 years of age (6.57 ± 1.284 years) suffering from ATH, sleep disorder breathing, snoring, open mouth breathing and growth retardation were studied. Blood samples were taken eight hours after fasting and weight and height were measured by SECA instrument. Blood samples were centrifuged immediately and the extracted sera were stored at -70 °C in Eppendorf vials. IGF-1 and ghrelin were measured by ELISA kit. Patients with adenotonsillectomy indication underwent adenotonsillectomy and serum levels of IGF-1 and ghrelin were measured 12 months after operation.

RESULTS

Weight, height and BMI were increased significantly after operation (P < 0.001). Serum IGF-1 and ghrelin levels increased significantly after operation compared to before operation (P < 0.001).

CONCLUSION

Growth retardation in children with adenotonsillar hypertrophy is related to lower serum IGF-1 levels. Ghrelin levels increase before the meals and ghrelin increases hunger and food intake. The results obtained from our study confirmed that weight, height and BMI increase significantly following adenotonsillectomy; this could in turns prevent undesirable and irreversible physiological changes that occur due to adenotonsillar hypertrophy. Adenotonsillectomy in children with adenotonsillar hypertrophy and failure to thrive increases IGF-1 and Ghrelin serum levels which might contribute to the improvement in the growth pattern of the children.

Hemodynamic Stability during Induction of Anesthesia in ElderlyPatients: Propofol + Ketamine versus Propofol + Etomidate

INTRODUCTION

Various methods have been recommended to prevent hemodynamic instability caused by propofol induction. Current study evaluates hemodynamic effects of ketamine and propofol in comparison to etomidate and propofol during anesthesia induction.

METHODS

Sixty-two patients over 50 years old undergoing elective surgeries were randomly assigned to ketamine + propofol (ketofol) (n=30) and etomidate + propofol (etofol) (n=32) groups. Patients in ketofol group were induced with ketamine 0.75 mg/kg and propofol 1 mg/kg. In etofol group, induction was performed with etomidate 0.2 mg/kg and propofol 1 mg/kg. Hemodynamic states before and after induction, first, third and sixth minutes after intubation were measured and compared between groups.

RESULTS

There was no difference between groups in systolic (SAP), diastolic (DAP) and mean arterial pressure (MAP), heart rate (HR) and blood oxygen saturation (SaO2). There was significant decrease in SAP, DAP and MAP after induction and 6 minutes after intubation and in HR after induction than values before induction. There was significant increase in SaO2 in all evaluated periods than before induction in etofol group; however, the difference in ketofol group was not significant.

CONCLUSION

Both methods of induction -ketamine + propofol and etomidate + propofol- are effective in maintaining hemodynamic stability and preventing hemodynamic changes due to propofol administration.

Assessment of Mini-dose Succinylcholine Effect on FacilitatingLaryngeal Mask Airway Insertion

INTRODUCTION

Laryngeal Mask Airway (LMA) has gained wide acceptance for routine airway management and with increasing emphasis on day care surgery it is widely used. The aim of this study was to assess the effects of mini dose succinylcholine (0.1mg/kg) with semi-inflated cuff on facilitation of laryngeal mask airway insertion in order to achieve more satisfaction yet less complications .

METHODS

In a randomized double-blinded study, sixty ASA 1, 2 and 3 patients aged 20-60 years scheduled for urologic surgical procedures were included. Thirty patients received succinylcholine (Group S), and thirty received 0.9% sodium choride as a placebo (Group C).

RESULTS

Coughing occured in 33.3% of patients in the control group and there was no incidence in succ group (P=0.002). Head or limb movement occurred in 70% of the patients in the control group vs. 10% in succ group (P<0.001). Laryngospasm occurred in 36.6 % of the patients in the control group but there was no incidence in succ group (P=0.004). Additional propofol was required in 53% of the patients in control group vs. 10% for succ group (P=0.001). Ease of insertion and first successfull attempt of LMA were achieved in 93.3% and 90% of the patients respectively in group S (P<0.05). Myalgia and sore throat occurred in 66.7 % of patients in the group C in comparison with 33.3% in group S (P=0.06).

CONCLUSION

The combination of propofol with mini dose succinylcholine, provided a significantly better method for LMA insertion, while reduced propofol doses were needed and number of attempts decreased.

The Role of Esophagogastric Anastomotic Technique in DecreasingBenign Stricture Formation in the Surgery of Esophageal Carcinoma

INTRODUCTION

Postoperative stenosis and dysphagia after esophageal carcinoma resection is the major problem. The aim of this study is to compare two types cervical esophagogastric anastomosis in reduction of stricture formation in esophageal cancer surgery.

METHODS

The subjects of this study were 223 patients undergoing esophageal carcinoma resection during 1998 to 2007. Twenty two patients were excluded from the study because of recurrent malignancy of anastomosis, mortality and losing in follow up period. Two hundred and one patients remained by the end of study were classified into two groups: 98 patients were treated by routinely transverse hand-sewn cervical esophagogastric anastomosis (group 1); and 103 patients were treated by the proposed oblique hand-sewn esophagogastric anastomotic technique (group 2). All the operations were with high abdominal and left cervical incisions (Transhiatal esophagectomy). All patients of both groups were followed up at least 6-month for detection of anastomotic strictures.

RESULTS

Postoperative dysphagia occurred in 20 patients of group 1 versus 5 patients of group 2. In working up by rigid esophagoscopy, two patients of group 2 and four patients of group 1 had not true strictures. Anastomotic strictures occurred in 16 cases of group 1, versus 3 cases of group 2. Statistical comparative analysis results of two groups about stricture formation were significant (3% versus 16% P= 0.003).

CONCLUSION

The oblique hand-sewn esophagogastric anastomostic techniques reduce markedly the rate of stricture formation after esophagectomy.

Effect of Intravenous Hydrocortisone on Preventing Postoperative Sore Throat Followed by Laryngeal Mask Airway Use in patients Undergoing Urogenital Surgeries

INTRODUCTION

Postoperative sore throat is a common complication which can lead to discomfort after operation and delay in patients' returning to normal daily activities. The present study was carried out to evaluate the influence of intravenous hydrocortisone on preventing postoperative sore throat followed by laryngeal mask airway use.

METHODS

Sixty patients who were scheduled to undergo urogenital surgery were divided into two groups. Five minutes before anesthesia induction, 100 mg of intravenous hydrocortisone or placebo with the same volume were given to the patients randomly. At the end of the operation and after LMAs were removed, patients were asked about having sore throat at hours 2, 4 and 24 after operation.

RESULTS

There were three and six cases of sore throat after operation in hydrocortisone and in placebo groups respectively which showed no significant statistical difference (P=0.472). No cases of moderate or severe pain were reported in any of the patients in both groups and no statistically significant difference was observed regarding pain severity in recovery, hours 2, 4 or 24 after operation.

CONCLUSION

Based on the statistical data obtained from this research, administrating intravenous hydrocortisone five minutes before anesthesia induction has no effect on postoperative sore throat severity and degree in urogenital surgeries.