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Background: We aimed to evaluate if two-handed mask airway is superior to one-handed mask airway during inhalational induction of anesthesia in children., Methods: A randomized, two period, crossover study was performed on 60 children aged 1-8 years, with obstructive sleep apnea due to adenotonsillar hypertrophy, scheduled for adenotonsillectomy. Children were assigned to two study sequences and one control sequence of 20 subjects each. A control sequence was added to evaluate the effect of anesthetic depth. Sequence 1: One-handed followed by two-handed airway, 30 seconds each; Sequence 2: two-handed followed by one-handed airway, 30 seconds each and Sequence 3: two-handed airway, for 60 seconds. The work of breathing indices, phase angle, and labored breathing index were recorded using respiratory inductance plethysmography. Additional outcome measures were tidal volume, minute ventilation, and respiratory rate. A straight comparison and a crossover analysis was performed., Results: The initial comparison revealed that one-handed airway had greater phase angle (mean diff. 17.4; 95% confidence interval [CI] 1.07-33.68; P = .034), greater labored breathing index (mean diff. 0.56; 95% CI 0.16-1.04; P = .004),lower minute ventilation (mean diff. -1567; 95% CI -2695 to -5.4; P = .004),and lower tidal volume (mean diff. -39; 95% CI -2.7 to -5.4; P = .02) than two-handed airway. On crossover analysis, within-subject difference in the phase angle was greater during one-handed than two-handed airway (34.3; 95% CI 8.46-60.14; P = .01) as was labored breathing index (mean diff. 1.2; 95% CI 0.39-2.00; P < .0046).Minute ventilation was lower during one-handed than two-handed airway (mean diff. -3359; 95% CI -4363 to -2355, P < 0.0001) as was tidal volume(mean diff. -78; 95% CI -110.4 to -45.8; P < .0001)., Conclusion: In children with obstructive sleep apnea due to adenotonsillar hypertrophy, two-handed airway provides superior airway patency that was not influenced by the anesthetic depth., (© 2020 John Wiley & Sons Ltd.)

Background: Resistance to the passage of the endotracheal tube (ETT) is frequently encountered in children as it is advanced over the fiberoptic scope for placement into the trachea because it gets hung up at the laryngeal inlet. Literature in adults indicates that a 90° counterclockwise rotation (CCR) of the ETT before advancing results in smooth passage. We found no literature in children., Objectives: Our aim was to study if a 90° counterclockwise rotation (CCR) of the ETT before advancement leads to smooth passage of the ETT into the larynx in children., Methods: Following IRB approval, we performed this study in two parts: Part 1: An unblinded, observational, pilot study on 20 children scheduled for oral rehabilitation where we concurrently used a fiberoptic scope nasally and GlideScope orally. We visualized the ETT path and observed that 90° CCR allowed smooth passage without hang up. Part 2: A blinded and randomized study on 40 children to confirm if 90° CCR from the outset would improve passage of the ETT during nasal intubation with a fiberoptic scope in children. All children were divided into two groups: group S, ETT bevel facing left; group R, ETT bevel facing down., Results: In Part 1, we observed that the ETT got hung up in 57% of children with standard bevel direction (facing left) and in 0% of children when prerotated. In Part 2, efficacy of prerotation was confirmed; the ETT got hung up in 50% of children in group S but in only 10.5% of children in group R., Conclusion: A change in ETT tip orientation from bevel facing left to facing down by 90° CCR, leads to a significantly higher first-attempt success rate by nasal approach in children. We believe the ETT should be rotated before insertion into the nostril to ensure that full 90° CCR of the tip has been accomplished., (© 2016 John Wiley & Sons Ltd.)

Objectives: Intramuscular injection is a commonly used route of parenteral drug administration. We studied the fat vs muscle location, the depth of calcified buttock granulomas, and the thickness of subcutaneous fat. Data were assessed with respect to the length of a needle commonly used in intramuscular buttock injections., Design: Three hundred thirty-eight sequential pelvic computed tomographic scans were studied. Subcutaneous fat thickness was measured for each patient at the upper outer quadrant of the buttock. The location and depth of each calcified granuloma were also recorded., Setting: Tertiary care academic teaching hospital., Results: One hundred sixty-four calcified granulomas were found in 67 patients. One hundred fifty-two of these granulomas were in fat and 12 were in muscle; this was statistically significant using a single-sample binomial distribution (P < .001;95% confidence interval, 0.04 to 0.13). The mean (+/- SD) subcutaneous fat thickness at the upper outer quadrant of the buttock was 5.0 +/- 1.9 cm, with female patients having a mean subcutaneous fat thickness of 5.7 +/- 1.8 cm vs 4.4 +/- 1.7 cm for male patients., Conclusions: The finding that buttock subcutaneous fat thickness exceeds the length of the most commonly used needle for intramuscular buttock injection (3.8 cm), together with the preponderance of calcified granulomas found in the fat of female patients, suggests that the currently used injection technique may not be therapeutically optimal. We suggest that longer needles be used for intramuscular buttock injections in adults.