A&A practice
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"Cannot intubate, cannot oxygenate" situations in healthy children are uncommon but are often associated with poor outcomes. Clinical assessment, anticipatory planning, and the use of algorithms can lessen the likelihood of untoward outcomes, but the common final pathway of many algorithms for a difficult pediatric airway involves obtaining emergency tracheal access. The airway practitioner must have the know-how and training needed to invasively secure the airway when confronted with this rare but potentially devastating emergency. We provide practitioners with an overview of pediatric emergency front-of-the-neck access strategies and a structure for their management.
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Case Reports
Cardiac Arrest due to Failed Pacemaker Capture After Peripheral Nerve Blockade With Levobupivacaine: A Case Report.
We describe a patient with a pacemaker who developed cardiac arrest shortly after ultrasound-guided rectus sheath block for postoperative analgesia. The cause of cardiac arrest was capture failure due to an increased pacing threshold, and the patient was promptly treated by increasing the pacing amplitude. Local anesthetics used for rectus sheath block might have affected the pacing threshold and caused pacing capture failure, since local anesthetics can block cardiac sodium channels. Anesthesiologists should recognize the risk of pacemaker capture failure when a large amount of local anesthetic is given to patients with a cardiac pacemaker.
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Flecainide is a first-line antiarrhythmic drug used to treat atrial arrhythmias and/or supraventricular tachycardia in those without coronary artery disease or structural heart disease. Even though it is an older antiarrhythmic, flecainide accounted for 1.6 million prescriptions in the United States in 2016, and its utilization is generally increasing. Despite its popularity, flecainide may predispose patients to rapid atrial flutter with resultant hemodynamic compromise, particularly in the physiologically stressful perioperative period. This article reviews the pharmacology of flecainide, describes problematic arrhythmias that may arise specifically during flecainide use, and offers recommendations for perioperative flecainide management.