Awake fibreoptic intubation for airway burns

Gastroschisis is an uncommon condition which is now being detected at an earlier stage due to the use of routine antenatal ultrasound scanning. The presence of intestinal atresia secondary to impairment of the vascular supply is well recognised and is associated with a poorer outcome because of the potential for loss of bowel length. We report a case of gastroschisis in which there was resorption of the bowel and closure of the abdominal wall defect. At laparotomy there was total intestinal atresia.     

Retrograde fibreoptic intubation in a child with Nager's syndrome

PURPOSE: The authors describe a retrograde fibreoptic technique for tracheal intubation in a micrognathic child with a tracheo-cutaneous fistula. CLINICAL FEATURES: A four-year-old child with Nager's syndrome presented for surgical closure of a tracheocutaneous fistula. A tracheostomy tube had been placed in the neonatal period for management of upper airway obstruction due to severe micrognathia. At 2 1/2 yr of age, after a successful mandibular advancement procedure, the tracheostomy was removed and the child allowed to breathe through the natural airway. Preoperative physical examination revealed an uncooperative child, unable to open her mouth due to limited temporo-mandibular motion. The child was first anaesthetized with ketamine, 70 mg im, then halothane by mask. The authors were unable to open the child's mouth sufficiently to allow rigid laryngoscopy. Attempts at oral and nasal fibreoptic intubation were unsuccessful. Ultimately, the authors were able to intubate nasally by passing an ultrathin Olympus LF-P laryngoscope under direct vision through the tracheocutaneous fistula in a cephalad direction, through the larynx and nasopharynx, then out the nares. An endotracheal tube was then advanced over the fibreoptic scope and positioned distal to the tracheocutaneous fistula. The surgical procedure was successfully accomplished and the trachea was extubated postoperatively without difficulty. CONCLUSION: Retrograde fibreoptic intubation may be an option for airway management of a select group of children who cannot be intubated by traditional techniques.     

Nasal fibreoptic tracheal intubation in anaesthetised patients breathing via a modified laryngeal mask airway

A modified laryngeal mask airway was used to facilitate nasotracheal intubation with a fibreoptic laryngoscope. A size 4 laryngeal mask airway was modified by creating a defect at the base of the stem and removing the bars to allow passage of the fibreoptic laryngoscope from the nasopharynx to the larynx. The laryngeal mask airway cuff was split and the cut edges were sealed with silicone. This design allowed the cuff to function normally and allowed removal of the split laryngeal mask airway after the tracheal tube had been 'railroaded' into place. Thirty-four patients were studied. The split laryngeal mask airway was easily inserted with satisfactory airway maintenance in 32 patients. Nasal airway endoscopy and laryngoscopy were successfully achieved with the split laryngeal mask airway in place in 31 of 32 patients. Railroading the tracheal tube over the fibreoptic laryngoscope with the split laryngeal mask airway in place was successful in all 31 of these patients. This prototype split laryngeal mask airway allows good airway maintenance while fibreoptic nasotracheal intubation is performed.     

The cuffed oropharyngeal airway as an aid to fibreoptic intubation

OBJECTIVE: To determine if a structured encounter form for well-child care improves documentation of well-child care. DESIGN: Retrospective medical record review of a before-and-after trial. SETTING: Family practice residency clinic serving a primarily low-socioeconomic urban population. PATIENTS: Children younger than 6 years receiving well-child care visits. INTERVENTION: Detailed checklists were developed and implemented in 1994 for each of 12 well-child examinations for the assessment of children aged 2 weeks to 5 years based on recommendations from the American Academy of Pediatrics and the US Preventive Services Task Force. MAIN OUTCOME MEASURES: Documentation of multiple aspects of well-child care, including developmental assessment, safety and nutrition counseling, and laboratory tests for 6-month periods in 1993 and 1994, before and after implementation of the structured encounter form. RESULTS: A total of 842 well-child visits were reviewed. Documentation improved significantly with the use of the encounter form for 19 of the 23 aspects of well-child care that were studied. Screening test rates were less than optimal despite the encounter form. CONCLUSIONS: The structured encounter form was very effective in improving documentation of almost all aspects of well-child care. However, effective communication is needed among physicians, nurses, and parents to ensure optimal screening test rates.     

Sleep apnea syndrome in acromegalic patients]

Hippocampal slices prepared from adult rats were loaded with fura-2 and the intracellular free Ca2+ concentration ([Ca2+]i) in the CA1 pyramidal cell layer was measured. Hypoxia (oxygen-glucose deprivation) elicited a gradual increase in [Ca2+]i in normal Krebs solution. At high extracellular sodium concentrations ([Na+]o), the hypoxia-induced response was attenuated. In contrast, hypoxia in low [Na+]o elicited a significantly enhanced response. This exaggerated response to hypoxia at a low [Na+]o was reversed by pre-incubation of the slice at a low [Na+]o prior to the hypoxic insult. The attenuation of the response to hypoxia by high [Na+]o was no longer observed in the presence of antagonist to glutamate transporter. However, antagonist to Na+-Ca2+ exchanger only slightly influenced the effects of high [Na+]o. These observations suggest that disturbance of the transmembrane gradient of Na+ concentrations is an important factor in hypoxia-induced neuronal damage and corroborates the participation of the glutamate transporter in hypoxia-induced neuronal injury. In addition, the excess release of glutamate during hypoxia is due to a reversal of Na+-dependent glutamate transporter rather than an exocytotic process.     

Changes in oxygen saturation and transcutaneous carbon dioxide and oxygen levels in patients undergoing fibreoptic bronchoscopy

Though women have a lower absolute risk of disease than men at all ages, almost all the risk factors for cardiovascular disease carry the same or higher relative risk for women as for men. Moreover, the attributable risk is higher in older women than in men. Epidemiologic studies show that recent decreases in coronary heart disease mortality are in some cases greater among women than men. Interventional studies show that women appear to have as good or better a response than men to cholesterol-lowering in secondary prevention. Antihypertensive drug therapy is effective in preventing clinical endpoints in elderly women. These observations imply that an overall estimation of cardiovascular risk in women needs careful consideration. Because established therapies appear to be effective in high risk women, postmenopausal and probably also elderly women are important target groups for preventive efforts. The value of prevention for premenopausal women should not be underestimated, but should on the whole be approached through population-based strategies.     

Clinical presentations and results of therapy of 63 acromegalic patients Chang Gung Memorial Hospital

The role of nitric oxide in inflammatory responses to substance P and other mediators of inflammation was examined in rat skin microvasculature in a blister base raised on the hind footpad. Superfusion of substance P (1 microM) over the blister base caused an increase in plasma extravasation and a vasodilator response which was not maintained. N(G)-Nitro-L-arginine (100 microM), an inhibitor of nitric oxide biosynthesis, attenuated vasodilatation and plasma extravasation due to substance P. The inactive isomer N(G)-nitro-D-arginine was without effect. Neurokinin A (1 microM), 5-hydroxytryptamine (1 microM), ATP (50 microM) and vasoactive intestinal polypeptide (1 microM) elicited vasodilation, which for vasoactive intestinal polypeptide was maintained even after washout. 5-Hydroxytryptamine and neurokinin A, but not ATP or vasoactive intestinal polypeptide, significantly increased plasma extravasation. Vasodilatation to neurokinin A, 5-hydroxytryptamine and ATP, and the increase in plasma extravasation due to neurokinin A and 5-hydroxytryptamine were unaffected by N(G)-nitro-L-arginine (100 microM), whereas vasodilation due to vasoactive intestinal polypeptide was significantly attenuated. These findings suggest that in rat skin microvasculature in vivo, nitric oxide is involved in vasodilator responses due to substance P and vasoactive intestinal polypeptide, and plasma extravasation due to substance P, but does not contribute significantly to vasodilatation induced by neurokinin A, 5-hydroxytryptamine or ATP, or the plasma extravasation induced by neurokinin A or 5-hydroxytryptamine.     

Skeletal involvement in female acromegalic subjects: the effects of growth hormone excess in amenorrheal and menstruating patients

Bone involvement is a common clinical feature in acromegalic patients, though previous studies gave divergent results possibly because of the different gonadal status of the patients studied. To study the influence of estrogen milieu in these patients, we evaluated 23 acromegalic patients with active disease, subdivided into two groups: menstruating and amenorrheal patients, comparable for duration and activity of disease. Forty-two matched women served as controls. Skeletal involvement was studied by measuring: (a) the main biomarkers of bone turnover: serum alkaline phosphatase total activity (AP), bone GLA protein (BGP), serum carboxy-terminal propeptide of type I collagen (PICP), serum type I cross-linked N-telopeptide (ICTP), and urinary pyridinoline and deoxypyridinoline corrected for creatinine (Pyr/Cr, D-Pyr/Cr) and urinary calcium/creatinine ratio (Ca/Cr); (b) bone mineral density (BMD), as measured by quantitative computed tomography both at lumbar spine and distal radius, and by dual X-ray absorptiometry both at lumbar spine and at three femoral sites (Ward's triangle, femoral neck, and great trochanter). AP, BGP, ICTP, Pyr/Cr, D-Pyr/Cr were significantly higher in patients than in controls, independent of the menstrual pattern. Higher PICP levels were found in the whole group and in menstruating acromegalics when compared with control women; no difference was found in amenorrheal patients, who in turn showed higher urinary Ca/Cr values. When patients were considered all together, BMD at spine, femoral neck, and trochanter was higher than in controls. In contrast, when the gonadal status was taking into account and, menstruating and amenorrheal subjects were considered separately, BMD at spine, but not in other sites, was significantly higher in menstruating patients than in controls. In contrast, no difference of BMD values at any site was observed between amenorrheal patients and controls. The mean BMD Z scores allowed us to detect an unequal involvement of different skeletal sites. Our results show that bone turnover is increased in acromegalic women and suggest that GH anabolic effect on bone is more evident in the presence of estrogens and that different skeletal sites may be affected differently by hormone excess.     

Circulatory changes in patients with coronary artery disease following thiamylal-succinylcholine and tracheal intubation

After introductory remarks concerning the Posner-Schlossman-syndrome (syndrome of glaucomatocyclitic crises) a case is reviewed. The concurrence with Addison's disease in this patient gives rise to speculations as to possible connections between the two conditions, but the conclusion is that the simultaneous occurrence of the two diseases at present must be regarded as coincidental.     

Palliative intubation of esophageal prosthesis in two patients with lung cancer

PURPOSE: Severe eye burns often result in extensive necrosis of the conjunctiva and episcleral tissue. Video fluorescein angiography was performed to reveal the perfusion of the anterior eye segment after severe eye burns. METHODS: A scanning laser ophthalmoscope was used for anterior segment fluorescein angiography in 12 patients (14 eyes) with severe burns grade III-IV and in 7 healthy volunteers. RESULTS: Necrotic tissues occurred as non perfused areas and remained dark throughout the whole angiogram. In general, the borders from healthy to necrotic conjunctival tissue were sharply demarcated. Thus, the extent of scleral and limbal ischemia could be determined exactly. Injured vessels showed hyperfluorescence with late leakage. Damage of the subconjunctival tissue appeared as a deep weak fluorescence in the early angiography and exhibited patchy leakage in the late angiogram. CONCLUSIONS: Anterior segment angiography provides a basis for deciding the extent of surgical debridement of necrotic tissue in the acute phase of the burn. The determination of the extent of limbal and scleral ischemia may give useful information for early plastic-reconstructive procedures.     

The ethics of practicing intubation on recently deceased patients

We performed special psychological investigations in 120 patients with neurosensory hypoacusis (NSHA) and emotional somatovegetative disorders. These patients were found to have neurosis and neurosis-like conditions. To elucidate the involvement of the exogenic factor on the onset of neurotic reactions in NSHA, we performed a questionnaire survey reflecting the attitude of the family, coworkers, strangers to people with hearing problems. It was found that neuroses and neurosis-like conditions in NSHA patients are provoked not only by premorbid personality traits but also by exogenic psychotraumatic factors.     

Triplet pregnancy after pulsatile gonadotrophin-releasing hormone treatment in an acromegalic woman

A triplet pregnancy is reported in an acromegalic woman with hypothalamic amenorrhoea treated with pulsatile gonadotrophin-releasing hormone (GnRH). The patient was on bromocriptine medication and had slightly elevated growth hormone (GH) and somatomedin-C (Sm-C) levels. This probably accounted for the conception of triplets in the first stimulation cycle.     

Endobronchial intubation causes an immediate increase in peak inflation pressure in pediatric patients

Our purpose was to determine whether endobronchial intubation always causes an immediate increase in peak inflation pressure and, if so, the magnitude of the increase. Fourteen children scheduled for central line placement for prolonged antibiotic administration comprised the study group. After routine premedication and induction of anesthesia (halothane in oxygen), an endotracheal tube was inserted, and its position was verified by auscultation and fluoroscopy. Children were mechanically ventilated using a preset volume pressure-limited ventilator with a 5-L fresh gas flow. All children received a constant tidal volume using a similar circuit, similar tubing, and a similar compression volume. The lowest peak inflation pressure to deliver a tidal volume of 15 mL/kg was used. After adjusting the respiratory rate (end-tidal CO2 30 mm Hg) and anesthetic level (halothane end-tidal 1.2%), the peak inflation pressure at this endotracheal position was recorded. The endotracheal tube was advanced into a bronchus, the position was verified as above, and peak inflation pressure was recorded. The endobronchial tube was then pulled back into the trachea, and placement of the central line proceeded. The peak inflation pressure at the endobronchial position was significantly greater than the peak inflation pressure at the endotracheal position (P < 0.0001). The increase was instantaneous at the endobronchial position. Monitoring peak inflation pressure while inserting an endotracheal tube and during anesthesia can help to diagnose endobronchial intubation. Implications: Monitoring peak inflation pressure while inserting an endotracheal tube and during anesthesia can help to diagnose endobronchial intubation.     

Tracheal intubation in infants

BACKGROUND: So far only a few cases of carcinoma in situ of the fallopian tube have been reported, but its detailed clinical and pathologic findings, including cytology, have not been fully described. CASE: A 70-year-old female was admitted to our hospital because of irregular genital bleeding. Endometrial smear revealed a small number of atypical cells with a clear background. Hysterectomy, bilateral salpingo-oophorectomy and omentectomy were performed. Grossly, a grayish white papillary tumor, measuring 1.5 x 1.0 cm, was observed within the lumen of the left fallopian tube. Microscopically, the diagnosis of papillary adenocarcinoma in situ of the left fallopian tube was made according to 1992 International Federation of Gynecologists and Obstetricians fallopian tube staging. CONCLUSION: Although endometrial brush cytology is not sensitive enough to detect a primary carcinoma of the fallopian tube, our case indicates that it may contribute useful information on extrauterine diseases and can detect a stage 0 cancer of the fallopian tube. Clinicians, as well as pathologists, should consider the possibility of fallopian tube cancer if cervical or endometrial cytology shows atypical cells with papillary patterns with a clear background but endometrial curettage cannot prove malignancy.     

Nasotracheal intubation in calves

Nasotracheal intubation can be accomplished in calves by use of a silicone nasotracheal tube of a Murphy design. For intubation, the calf's head and neck should be extended to facilitate tube passage through the naris into the ventral meatus and then through the larynx into the trachea. Preanesthetic medication may assist in tube passage by decreasing the alertness of the calf and decreasing the ability of the calf to swallow the tube into the esophagus. Nasotracheal intubation allows the inhalant anesthetic agent to be delivered with minimal room pollution and less stress to the calf. It would be useful for oral surgery when an orotracheal tube would obstruct the surgical site.