If you wish to respond to a paper or other item already published in the BJA, please go to the abstract/full text version of that item and click on the link "E-Letters: Submit a response to the article".
Electronic Letters to:
|
|
E-letters: Electronic letters published:
-
![[Read E-letter]](/icons/misc/sectionDOWN.gif)
Vigilant Maintenance of Lateral Wall Pressures During Paediatric Anaesthesia
- John George George Cherian (11 October 2007)
-
Reply to Drs Norton and Cave
- MARY CUNLIFFE, DR N SOUNDARARAJAN (5 October 2007)
-
Neuromonitoring plays a major role in anaesthetic requirements for spinal surgery in children
- Jonathan A Norton, Dominic Cave (20 September 2007)
|
|
|||
|
John George George Cherian Fellow, Malaysian Institute of Medical Laboratory Sciences
Send letter to journal:
|
Sirs, Seegobin's study on the effect of endotracheal tube cuff pressures on arterioles in the posterior tracheal submucosa should be referenced when attempting to effect a clinical tracheal seal and especially so in paediatric anaesthesia. In this regard, the advent of the microcuff and the LMA should be greeted with as much enthusiasm and utility due to its association with decreased morbidity and need for tube exchange. It is hoped that this helps to draw renewed interest in excercising extraordinary care and vigilance in maintaining homeostatic microcirculatory pressures especially in paediatric anaesthesia. John George Fellow - Malaysian Institute of Medical Laboratory Sciences Correspondence: 4 Lrg 4/48 F, PJ, Selangor, Malaysia Conflict of Interest:None declared |
|||
|
|
|||
|
MARY CUNLIFFE, CONSULTANT PAEDIATRIC ANAESTHETIST ROYAL LIVERPOOL CHILDREN'S HOSPITAL, LIVERPOOL, UK, DR N SOUNDARARAJAN
Send letter to journal:
|
Sir, We would like to thank Drs Norton and Cave for their comments on our article - Anaesthesia for spinal surgery in children. As they quite rightly point out, it is difficult within the confines of a word limited review to sometimes put in as much information as you would like on a particular aspect of care. I hope we did stress the importance of spinal cord monitoring in patients undergoing this type of surgery, which is now a standard of care for these patients. We would also like to fully endorse the view that spinal cord monitoring is a team event which involves the neurophysiologist, the anaesthetist and the surgeon. The choice of which type of monitoring to use has also increased, and we must choose the technique which will be most sensitive and accurate within the context of the surgery being performed. Conflict of Interest:None declared |
|||
|
|
|||
|
Jonathan A Norton, Neurophysiologist University of Alberta Hospital, Dominic Cave
Send letter to journal:
|
Sir, Soundarajan & Cunliffe have produced an admirable summary of the conditions requiring spinal surgery in children and the major anesthestic considerations surrounding this type of surgery. Any such review of such a challenging and diverse subject matter must, by necessity, give only cursory attention to certain aspects of anesthetic care. The authors briefly describe the use of spinal cord monitoring towards the end of their review. We would like to elaborate on the issues surrounding monitoring of spinal cord function intra-operatively, as this is both of rapidly increasing importance in the field and of great impact to the anesthetic technique. Following the publication of guidelines in 1991 (Dawson EG and others) 1, monitoring of spinal cord function has become the standard of care in scoliosis surgery and is increasingly utilized in other spinal surgeries. With the approval by regulatory bodies of appropriate stimulators, and the publication of workable guidelines, TcMEPS (Motor Evoked Potentials) are increasingly used in addition to SSEPs (MacDonald DB) 2. This type of monitoring presents an additional challenge to the anaesthetist. In the majority of centres the motor evoked potentials are recorded from the muscles, especially in scoliosis surgery, to avoid the need of placing electrodes on the spinal cord. This necessitates the entire anesthetic management be tailored to the requirements of this monitor. The anesthetic can not include ongoing neuromuscular blockade, and particularly in children reliable recordings of MEPs are best obtained in the absence of many of the halogenated agents. This makes a TIVA approach utilizing propofol and a short acting opioid infusion preferable (Pajewski TN, Arlet V and Phillips LH) 3, (Sloan TB and Heyer EJ) 4. In our experience, in children in particular, motor evoked potentials recorded using EMG needle electrodes elicited with multipulse transcranial electrical stimulation are poorly recorded and reproducible if the mean arterial pressure is less than 60mmHg. There are benefits. When monitoring is taking place the neurophysiology technician will frequently record EEG, allowing the anaesthetist to determine depth of anesthesia with increased accuracy. This is important in the face of the significant impact that depth of anesthesia has on spinal cord monitoring. Whilst burst suppression allows for easy recording of SSEPs, it can lead to difficulty obtaining TcMEPs due to loss of the oscillatory activity in the motor cortex which is crucial for generation of TcMEPs. Preserving neural function, especially in children, is of critical importance. In many instances scoliosis surgery is at least semi-elective yet presents a significant risk of neural damage. Appropriate and comprehensive neuromonitoring is therefore crucial and the anesthetic considerations of that monitoring is of major importance to the safe completion of surgery. As can be clearly seen from this description this is an area which requires experience and communication. As spinal surgery increasingly becomes a team activity with the involvement of the surgeon, anaesthetist and neurophysiologist, it is important that we recognize that we may need to alter our choices away from our preferred anesthetic in order to provide for improved global patient safety (Raw DA, Beattie JK and Hunter JM)5. We would like to thank Soundarajan and Cunliffe for drawing renewed attention to this important and developing area of pediatric anesthetic care. Table of References 1. Dawson EG, Sherman JE, Kanim LEA, Nuwer MR. Spinal Cord Monitoring: Results of the Scoliosis Research Society and the European Spinal Deformity Society Survey. Spine 1991; 16: S361-S364 2. MacDonald DB. Intraoperative Motor Evoked Potential Monitoring: Overview and Update. Journal of Clinical Monitoring and Computing 2006; 20: 347-77 3. Pajewski TN, Arlet V, Phillips LH. Current Approach on Spinal Cord Monitoring: The Point of View of the Neurologist, the Anesthesiologist and the Spine Surgeon. European Spine Journal 2007; In Press 4. Sloan TB, Heyer EJ. Anesthesia for Intraoperative Neurophysiologic Monitoring of the Spinal Cord. Journal of Clinical Neurophysiology 2002; 19: 430-43 5. Raw DA, Beattie JK, Hunter JM. Anesthesia for Spinal Surgery in Adults. British Journal of Anaesthsia 2003; 91: 886-904 Conflict of Interest:None declared |
|||