Paediatric Anaesthesia 1997 7: 87–88

Correspondence

Difficulty with a preformed tube in a References1 Black AE, Mackersie AM. Accidental bronchial intubation withneonate

RAE tubes. Anaesthesia 1991; 46: 42–43.SIR—We would like to report a complication with the useof a preformed south facing (Portex, Polar) tracheal tubewith a Murphy eye in a neonatal patient requiringanaesthesia on two occasions for congenital cataracts. Shepresented at 13 days of age following an elective Caesarean Jet ventilation via the suction port duringSection at 38 weeks for breech presentation. She was fibreoptic bronchoscopy in a childan otherwise well Asian baby who weighed 2.96 kg.

SIR—Flexible fibreoptic bronchoscopy in children is usuallyFollowing premedication with intramuscular atropineperformed under general anaesthesia, which involves the(100 lg) she was induced with oxygen, nitrous oxide andintroduction of the fibreoptic bronchoscope (FOB) throughsevoflurane for examination under anaesthetic anda tracheal tube, and hence the relationship of the internalsyringing and probing of nasolacrimal ducts. Atracuriumdiameter of the tube to the external diameter of the1.5 mg was given but on intubation with a south facingbronchoscope is critical. We have recently shown that theoral tracheal tube (size 3 Portex, Polar) ventilation waspaediatric laryngeal mask airway (LMA) may be a betterfound to be difficult and a bronchial intubation was noted.alternative to tracheal intubation in children undergoingOn repositioning of the tube there was a large leak, despitefibreoptic bronchoscopy, because the LMA has a larger IDa snug fit as the tube passed the cricoid cartilage. Attemptedthan the equivalent tracheal tube that would be used inrepositioning of the tube resulted in either bronchialthe same age group, and hence can provide adequateintubation or a leak too large to allow adequate ventilation.ventilation, facilitate passive exhalation and minimize airIt was therefore changed to a size 3 Portex plain tubetrapping (1).(without a Murphy eye) after which anaesthesia proceeded

The present case report shows that intermittent oxygenuneventfully, with adequate ventilation and no leak. Twojet ventilation via the suction port of the bronchoscopedays later the patient returned for right lensectomy.can provide adequate oxygenation in young childrenFollowing induction as above and paralysis with 2 mgundergoing fibreoptic bronchoscopy, without the need foratracurium, attempts to pass a size 3 preformed tube weretracheal intubation or laryngeal mask insertion. Themade, which again either produced a large leak aroundtechnique has been previously evaluated experimentallythe tube or bronchial intubation. On direct laryngoscopyin animals, as well as clinically in adult patients (2).the Murphy eye could not be seen in the larynx but the

A two-year-old child who had atelectasis and pneumonicsituation was again resolved with the use of a plain tube.infiltration of both lungs was scheduled for diagnosticIntubation with a size 3.5 tube was not attempted due tofibreoptic bronchoscopy. The child was premedicated withthe snug fit through the cricoid cartilage of the size 3 tube.atropine 0.2mg. Anaesthesia was induced by propofolDespite not being able to visualize the Murphy eye we2mg·kg−1 and suxamethonium 2mg·kg−1, and wasassume this was the cause of the very large leak whichmaintained by intermittent doses of the same agents. Theappeared with minimal movement of the tube. A chestchild was monitored continuously by EKG and pulseradiograph showed no abnormality and the tracheaoximetry. The trachea was intubated with a tube no. 4.0mm,appeared to be of normal length and calibre.but the paediatric bronchoscope (3.4mm OD) could not beThe incidence of bronchial intubation with preformedeasily introduced via the tube. The trachea was extubatedRAE tubes was 20% in a group of 40 patients aged threeand a LMA size 2 (ID 7.0mm) with a swivel connector wasmonths to 16 years (1). The tube was at the carina in 12.5%inserted and its cuff was inflated. The FOB could be easilyand too short (T1 or T2) in 17.5%. Ventilation of theintroduced via the LMA; however, because of the badleft lung during bronchial intubation may occur via thelung compliance, intermittent positive pressure ventilationMurphy eye. This case further illustrates problems withusing a T-piece circuit was inadequate and excessive airthe use of preformed tubes especially in neonatal patients,leak was observed. The SpO2 decreased from a controlin whom accurate placement may be difficult to achievevalue of 95% to 85%. Intermittent oxygen jets of 25 psi viabecause of the small distances involved.the suction port of the bronchoscope were used to ventilateD. S. MCDONALD

the child using an inspiratory:expiratory time ratio ofA. MCCORMICK

1:3, to allow passive exhalation around the bronchoscope.A. M. MACKERSIE

Throughout bronchoscopy, the SpO2 was always aboveAnaesthetic Department,97% suggesting that intermittent oxygen jet ventilation viaGreat Ormond Hospital NHS Trust,

Great Ormond Street, London WC1N 3JH, UK the suction port can ensure adequate oxygenation in

87 1997 Arnette Blackwell SA

88 CORRESPONDENCE

young children undergoing fibreoptic bronchoscopy. The Blood glucose and ionized calcium were within normallimits. Further neurological workup was normal and thetechnique may be particularly advantageous in children

with low lung compliance. clonic movements did not recur.The child was breathing spontaneously during theANIS BARAKA

Professor & Chairman procedure and there was no drop in the arterial oxygensaturation.Department of Anesthesiology

American University of Beirut The use of propofol in small infants is controversial buthas been previously reported without major side effects inBeirut-Lebanona limited number of cases (6). To our best knowledge it isthe first case of propofol-related convulsions reported ininfants.References

O. GELBER MD1 Baraka A, Choueiry P, Medawwar A. The laryngeal mask airway

M. GAL MDfor fibreoptic bronchoscopy in children. Paediatr Anaesth 1995;Y. KATZ MD5: 197–198.

Schneider Children’s Medical Centre of Israel2 Satyanarayana T, Capan L, Ramanathan S, et al. Bronchofiber-scopic jet ventilation. Anesth Analges 1980; 59: 350–354. Petah-Tiqwa

IsraelCorrespondence to: O. Gelber, Department of Anaes-thesiology, Schneider Children’s Medical Centre of Israel,Petah-Tiqwa, Israel.Clonic convulsions in a neonate after

propofol anaesthesiaReferencesSIR—Excitatory phenomena in patients receiving propofol1 Dorrington KL. Asystole with convulsions following aanaesthesia have been reported (1,2), and related to

subanesthetic dose of propofol plus fentanyl. Anesthesia 1989;enhancement of the motor manifestations of excitatory44: 658–659 (8).amino acid agonists (3).

2 Wittenstein UL, Lyle DJR. Fits after alfentanil and propofol.Subanaesthetic doses consistent with induction andAnaesthesia 1989; 44: 532–533 (6).

emergence have usually been incriminated (4,5). The child 3 Bansinath M, Kumar V, Turndorf H. Propofol modulates thereported here is a 14-day-old otherwise healthy baby effects of chemoconvulsants acting at GABergic, clycinergic andweighing 3.5kg admitted for breast abscess incision under glutumate receptor subtypes. Anesthesiology 1995; 83: 809–815

(4).general anaesthesia. Due to the expected short duration of4 Herrma IH. A 10-second convulsion during propofol injection.the procedure (under one min), a propofol-based technique

Anesthesia 1989; 44: 700 (8).was selected.5 Bevan JC. Propofol-related convulsions. Can J Anaesth 1993; 40:

Eight mg of propofol were sufficient for induction and 805–809 (9).no further doses were necessary. During recovery clonic 6 Dubois MC, Troje C., Martin C et al. Anesthesia in theconvulsion of the four limbs appeared. The convulsions management of pyloric stenosis. Ann Franc d’Anesth et de Rean

1993; 12: 566–570 (6).persisted for about ten min and spontaneously subsided.

1997 Arnette Blackwell SA, Paediatric Anaesthesia, 7, 87–88