Difficulty In Extubation Research Articles

Aneurisma aórtico roto associado com salmonelose difusa: Um relato de caso

Case report: A 63-year-old female patient, hypertensive and diabetic, reported a sudden onset of chest pain at night, which persisted continuously for 20 days. According to CT scans and computed tomography angiography, the diagnostic hypothesis of ruptured thoracic aortic aneurysm was considered. During the postoperative evolution, the patient presented difficulty in extubation and persistence of infectious symptoms, because of this, new tests were performed, which indicated a possible fistula with subsequent upper digestive endoscopy. During this period, the patient persisted with infectious symptoms and lack of improvement. Bronchoalveolar lavage fluid culture was performed at the same time, which identified bacterial growth of Salmonella spp. Discussion: A study that analyzed 129 cases of Salmonella in a hospital in Massachusetts showed that DM is one of the most common risk factors for Salmonella spp in adults. In a study carried out in China, it was evident that 28.9% of the cases were considered asymptomatic, that is: presence of the bacteria, but absence of diarrhea. In the scientific society, there is concern about the antimicrobial resistance of Salmonella spp. Because of this, treatment with antibiotics is indicated, especially in cases with a higher risk of complications. It is considered that the consequences of the bacterium on the body can lead the patient to septic shock and death. Final considerations: Thus, having knowledge about triggering factors, main symptoms, and appropriate treatment becomes essential for the best evolution of the clinical condition of infected patients.

Identification of key genes affecting ventilator-induced diaphragmatic dysfunction in diabetic mice.

Mechanical ventilation (MV) is often required in critically ill patients. However, prolonged mechanical ventilation can lead to Ventilator-induced diaphragmatic dysfunction (VIDD), resulting in difficulty in extubation after tracheal intubation, prolonged ICU stay, and increased mortality. At present, the incidence of diabetes is high in the world, and the prognosis of diabetic patients with mechanical ventilation is generally poor. Therefore, the role of diabetes in the development of VIDD needs to be discovered. MV modeling was performed on C57 mice and DB mice, and the control group was set up in each group. After 12h of mechanical ventilation, the muscle strength of the diaphragm was measured, and the muscle fiber immunofluorescence staining was used to verify the successful establishment of the MV model. RNA sequencing (RNA-seq) method was used to detect mRNA expression levels of the diaphragms of each group, and then differential expressed gene analysis, Heatmap analysis, WGCNA analysis, Venn analysis, GO and KEGG enrichment analysis were performed. qRT-PCR was used to verify the expression of the selected mRNAs. Our results showed that, compared with C57 control mice, the muscle strength and muscle fiber cross-sectional area of mice after mechanical ventilation decreased, and DB mice showed more obvious in this respect. RNA-seq showed that these differential expressed (DE) mRNAs were mainly related to genes such as extracellular matrix, collagen, elastic fiber and Fbxo32. GO and KEGG enrichment analysis showed that the signaling pathways associated with diabetes were mainly as follows: extracellular matrix (ECM), protein digestion and absorption, PI3K-Akt signaling pathway, calcium signaling pathway, MAPK signaling pathway and AGE-RAGE signaling pathway in diabetic complications, etc. ECM has the closest relationship with VIDD in diabetic mice. The key genes determined by WGCNA and Venn analysis were validated by quantitative real-time polymerase chain reaction (qRT-PCR), which exhibited trends similar to those observed by RNA-seq. VIDD can be aggravated in diabetic environment. This study provides new evidence for mRNA changes after mechanical ventilation in diabetic mice, suggesting that ECM and collagen may play an important role in the pathophysiological mechanism and progression of VIDD in diabetic mice, and provides some clues for the research, diagnosis, and treatment of VIDD in diabetic context.

The current status and challenges of perioperative management of patients with a BMI of greater than or equal to 50kg/m 2 undergoing bariatric surgery in China: a multicenter cross-sectional study.

Performing bariatric surgery on patients with a BMI of over 50kg/m 2 is challenging. This study aimed to explore the status and challenges related to the perioperative management of such patients in China. A prospective survey was designed to investigate the perioperative management of patients with a BMI of greater than or equal to 50kg/m 2 undergoing bariatric surgery in China. The questionnaire of our survey included general information, preoperative management measures, surgical procedures performed, technical details regarding anaesthesia, and postoperative management measures. A response from only one attending physician per bariatric centre was accepted. Physicians from a total of 101 hospitals responded to the questionnaire, and the questionnaire data from 98 hospitals were complete. These centres had completed a total of 44702 bariatric surgeries since the launch of such surgery to December 2021. A total of 3280 patients had a BMI exceeding 50kg/m 2 . The preferred surgical procedures for patients with super obesity were sleeve gastrectomy by 62 centres, Roux-en-Y gastric bypass by 11 centres, sleeve gastrectomy plus jejunojejunal bypass by 19 centres, one anastomosis gastric bypass by 1 centre, and duodenal switch by 1 centre. The most worrying issues were cardiopulmonary failure and difficulty in extubation. 91 centres believed that preoperative weight loss was beneficial. A low-calorie diet was the specific measure mainly implemented, only three centres considered using intragastric balloon placement. Postoperative management measures varied greatly. Bariatric surgery has seen rapid development. Chinese physicians show significant differences regarding the perioperative management for patients with a BMI of over 50kg/m 2 . The perioperative risks of these patients remain relatively high, making further development of clinical pathways is necessary.

Challenging management of a baby with congenital multiple intestinal atresia, trisomy 18 and extremely low birth weight: a case report

BackgroundExtremely low birth weight (< 1000 g) still influences postsurgical prognosis in the neonatal and infantile periods. Additionally, the life expectancy of neonates with trisomy 18 is extremely poor owing to various comorbidities. Therefore, it takes courage to perform laparotomy for the purpose of treatment of congenital multiple intestinal atresia in a baby with an unpredictable life prognosis.Case presentationFetal ultrasonography revealed cardiac malformation, intestinal dilation, and physical characteristics suggestive of a chromosomal abnormality in this case. The patient was diagnosed with trisomy 18 after birth, with an extremely low birth weight. An atrial septal defect, ventricular septal defect, dilated jejunum, and a very thin collapsed small intestine were found on ultrasonography. With a diagnosis of congenital small intestinal atresia, a challenging laparotomy was done at 3 days of age, with jejunal atresia and multiple distal small intestinal atresia were observed. The jejunal end and distal small intestinal stump were separated into stomas at the wound edge. Hypertrophic pyloric stenosis developed at the age of 3 months and resolved with medication. The patient gained weight (2 kg) by daily stool injection into anal side of the intestine and decompression against poor peritonitis of dilated jejunum using enteral feeding tube for the long period. Finally, we could perform intestinal reconstruction safely and successfully at the age of 9 months.Tracheotomy was performed due to difficulty in extubation associated with chronic lung disease. The patient was discharged at the age of 1 year and 3 months, and no major problems were noted at the age of 2 years.ConclusionsWe treat congenital intestinal atresia in extremely low birth weight infants with severe chromosomal abnormalities and severe cardiac malformations as follows: Stoma creation is performed quickly to avoid deterioration of the patient's hemodynamics. After that, while continuing enteric management, palliative cardiovascular surgery is performed as necessary, and the patient's body weight and intestinal tract status are determined to allow safe intestinal reconstruction.

Difficulty in tracheal extubation due to vocal cord edema

Difficulty in tracheal extubation due to vocal cord edema - IJCA- Print ISSN No: - 2394-4781 Online ISSN No:- 2394-4994 Article DOI No:- 10.18231/j.ijca.2023.023, Indian Journal of Clinical Anaesthesia-Indian J Clin Anaesth

GENETICALLY CONFIRMED TYPE I LEUKOCYTE ADHESION DEFICIENCY IN A TWO-YEAR-OLD MALE

<h3>Introduction</h3> Leukocyte adhesion deficiency (LAD) type 1 affects about one in a million people world-wide. Presentation typically includes delayed separation of the umbilical cord, neutrophilia, and repeated bacterial infections soon after birth. Here we present a case of a 2-year-old male who presented in respiratory failure later found to have genetically confirmed type 1 LAD. <h3>Case Description</h3> A 2-year-old male in state custody presented to an outside hospital with fever and respiratory distress secondary to croup. Hospital course was complicated by right vocal cord avulsion likely secondary to trauma, difficulty in extubation requiring steroids and tracheostomy, persistent leukocytosis with neutrophilia, and reccuring fevers. He was transferred to our hospital after CD18/CDb11 expression was found to be 0%. We sent primary immunodeficiency genetic testing confirming a pathogenic variant in ITGB2 and 22q22.3 pathogenic deletion which included ITGB2, AIRE and ICOSLG. <h3>Discussion</h3> When given an unclassical and convoluted history, relying on more objective data like laboratory results and physical exam is crucial. Our case was challenging due to a complex social situation making obtaining a good history difficult and inability to examine the patient on initial consultation. History revealed insignificant infection history and no delayed separation of the umbilical cord. Therefore, before being able to examine the patient and obtain genetic testing there was some skepticism of the diagnosis despite supporting flow cytometry. Once the patient arrived at our facility, physical exam revealed wound healing characteristic of LAD, increasing suspicion of the disease. Genetic testing confirmed LAD, as he was hemizygous for a pathogenic variant in ITGB2.

Comparison of high flow oxygen therapy versus noninvasive mechanical ventilation for successful weaning from invasive ventilation in children: An observational study.

Post-extubation respiratory failure is associated with a poor prognosis due to increased ventilator-associated pneumonia, and longer length of stay in the ICU and hospital. In this study, we aimed to evaluate the efficacy of high-flow nasal cannula (HFNC) and noninvasive mechanical ventilation (NIMV) on extubation success in children. A total of 48 patients, aged between 1 month and 18 years, who were weaned to either NIMV or HFNC were included. Patients who had tracheostomy or were not weaned and underwent unplanned extubation were excluded. Age, gender, anthropometric parameters, Pediatric Risk of Mortality and Pediatric Logistic Organ Dysfunction scores, oxygenation index, mechanical ventilation length of stay (LOS), HFNC/NIMV LOS, Modified Downes-Silverman score (MDS), and venous blood gas parameters, pediatric intensive care unit (PICU) LOS were recorded. 24 patients were extubated to NIMV, and 24 patients to HFNC. HFNC LOS and NIMV LOS were similar (P = .621). The failure rates at the 48th hour of HFNC and NIMV were 33% (n = 8), and 33% respectively (n = 8) (P = 1.0). PICU LOS and mortality rate was also similar (P = .06, P = .312 respectively). MDS decreased significantly in both groups (P < .001, P = .02 respectively). Changes in blood gas parameters and MDS within the first 48-hour of device application were similar between the 2 groups. HFNC is not inferior to NIMV in patients with extubation difficulty or those expected to have such difficulty in terms of treatment success, PICU LOS, and mortality. Therefore, HFNC appears to be a weaning technique alternative to NIMV after extubation.

A Case of Gas in the Stomach Wall and Portal Venous System After Percutaneous Endoscopic Gastrostomy

Question: An 86-year-old man was diagnosed with glioblastoma and was receiving bevacizumab after radiation therapy. He had hypertension and diabetes and had undergone chemoradiotherapy for esophageal cancer in the past. He developed aspiration pneumonia and was intubated due to decreased respiratory function, and tracheotomy was performed due to extubation difficulty. After that, bevacizumab was resumed. He was clearly conscious, but he gradually developed difficulty in swallowing. Percutaneous endoscopic gastrostomy (PEG) was performed with an expectation of improvement of nutritional status, although there was a risk of delayed wound healing due to bevacizumab, which was administered 13 days before PEG.

Intermittent extubation nursing care of a patient with PICC asymptomatic thrombosis and difficult extubation

Objective To discuss and summarize the nursing care of a patient with difficult extubation due to asymptomatic thrombosis of PICC. Methods By observing the local and global conditions, psychological tests, chest X-ray localization and vascular ultrasound, using critical thinking, the causes of difficult extubation were analyzed; after active anticoagulation and thrombolytic therapy, intermittent extubation of PICC; after extubation, continuous nursing was done. Results After the above nursing measures were implemented, PICC was removed intermittently within 24 hours, and after 3 months vascular ultrasound was showing that the thrombus in the blood vessel had been completely organized. Conclusion When we encounter difficulties in PICC removal, it is not necessary to extubate the PICC forcibly. It is necessary to analyze the causes and implement correct nursing measures to improve the success rate of extubation. Key words: Catheterization, central vein; Asymptomatic thrombosis; Difficulty in extubation; Nursing care

AB096. Cause analysis of double J tube retention and the study of endoscopic minimally invasive management

BackgroundTo analyze the common causes of double J tube retention and to explore the safety and effectiveness of endoscopic minimally invasive management of double J tube retention.MethodsThe clinical data of 34 patients with difficult extubation of double J tube under conventional cystoscope from November 2012 to March 2018 in our center were retrospectively analyzed, including 22 cases of double J tube indwelling in the operation of upper urinary calculi and 12 cases due to ureteral stenosis and obstruction. Patients were diagnosed as double J tube retention according to the medical history, combined with abdominal plain tablets (KUB) plain film, total abdominal CT and other imaging findings. Among them, double J tube was located in the left side of ureter in 15 cases, right side in 15 cases, bilateral in 4 cases, with an average retention time of 10.64 months (0.5 to 72 months). The minimally invasive endoscopic technique was performed alone or in combination with cystoscopy, ureteroscopy and percutaneous nephrolithotomy.ResultsSeventeen cases with peri-tube stone formation and 10 cases of double J tube displacement resulting in retention and difficulty in extubation. Four patients had forgotten extubation after discharge. Two patients with severe urinary tract infection underwent stents replacement after anti infection treatment. One case of severe hematuria accompanied by bladder spasm led to failure of extubation. All stranded double J tubes were successfully removed, of which 14 cases were removed by ureteroscopy, 12 by cystoscopy or ureteroscopic lithotripsy, and 8 cases were removed by the combination of cystoscopy, ureteroscopy and percutaneous nephroscope. The average operation time was 68.5 minutes (14 to 275 minutes). No case was transferred to open surgery. Except for a small amount of hematuria, there were no severe complications such as ureteral perforation, laceration and nephrectomy. Two patients developed hyperthermia after operation and the body temperature returned to normal with active anti-infection treatment. Residual stones were found in 4 patients after operation. The average postoperative hospital stay was 2.7 days (1 to 12 days).ConclusionsThe peri-tube stone formation and displacement of double J tube after long term indwelling are the main reasons for the retention of double J tube. According to the patient’s condition, it is safe and effective to remove the stranded double J tube through minimally invasive endoscopic technique alone or in combination with cystoscopy, ureteroscopy and percutaneous nephroscopy. Moreover, it is necessary to strengthen the management of patients with double J tube indwelling, so as to avoid double J tube being left behind.

Clinical analysis of difficulty in removing peripherally inserted central catheters

Objective To analyze the relevant materials of cases found with difficulty in removing peripherally inserted central catheters (PICC) and to preliminarily explore its causes and risk factors. Methods The medical history of totally 26 patients with difficulty in removing PICC in the Department of Vascular Surgery of Tianjin Medical University General Hospital between May 2012 and December 2016 was retrospectively analyzed with descriptive statistical analysis. Results Among these patients, 13 received PICC radiography plus perspective PICC extubation; 7 received PICC extubation through venotomy with general or local anesthesia; and 1 received PICC extubation by precava and right ventricular angiography and right intracardiac insertion through femoral vein. The suspected risk factors to difficulty in removing PICC included age, hematological malignancy, chemotherapy, discharge with PICC, infection, transfusion history, duration of PICC and level of D-double polymer. The causes of difficulty in extubation mainly were phlebothrombosis, catheter fracture, adhesion between catheters and vessel wall, local fibrous tissue package in catheters, catheter deformation and circuity in venous vein. Conclusions During the period with catheters, catheter maintenance and management shall be strictly performed with regular check over D-double polymer and routine ultrasonic testing before extubation. When removing the catheter, nurses should pay attention to psychological nursing for patients to reduce the incidence of extubation difficulty and improve patients' satisfaction. Key words: Peripherally inserted central catheter; Extubation difficulty; Influencing factors

P.123 - Scoliosis is an inescapable comorbidity in SMA type II. A single center experience

Scoliosis is the most debilitating and unresolved problem in SMA type II patients. We present data of progression of scoliosis and treatment in a cohort of 20 SMA type II patients followed in the last fifteen years (2002–2017) in our Neuromuscular Unit. Medical records were collected prospectively. In all patients brace was prescribed since Cobb angle in sitting position was ≥20°or in case of marked kyphosis. All patients underwent systematical X-Ray, functional and pulmonary assessments. Seventeen of 20 patients (age range 2–20 y) have scoliotic curve. Mean age at scoliosis development was 3,4 y (range 2–7 y) and Cobb angle at diagnosis varied from 5° to 35°. Nine patients underwent scoliosis surgery. Six patients had Growing-rods or VEPTR at mean age of 8,1 y (range 6,2- 10y). Five patients (two of them received at first growing-rods) underwent definitive spine fusion at a mean age of 12.2 y (range 10-14y). Postoperative complications were observed in 3 patients: urinary infection, difficulty in extubation and weaning from mechanical ventilation and infective complication of the surgical wound. Despite the use of brace, scoliosis progressed in all cases and, as observed in our series, since the age of 6 years patients develop severe rotoscoliosis that, following the current standards of care, requires surgery. These findings have to be carefully considered in the developing of potentially effective therapy intrathecally administered.

A devised strategy for tracheal extubation for predicted difficult airway in a child with unilateral vocal cord paralysis: a case report

BackgroundExtubation is a more challenging medical practice than intubation, and countermeasures against it are similar to those described in the Difficult Intubation Guidelines, but problems cannot be overcome by completely the same methods. We predicted difficult extubation in a pediatric patient with left recurrent laryngeal nerve paralysis and devised an extubation method.Case presentationThe patient was a 2-year-and-8-month-old boy scheduled for cleft palate repair. Concomitant cardiac anomaly and first and second branchial arch syndrome-associated facial malformations, such as mandibular micrognathia and auricular malformation, were observed. He had a past medical history of difficult intubation and respiratory arrest on a catheter test under intravenous sedation at 4 months old. Left recurrent laryngeal nerve paralysis was discovered on preoperative examination of the cleft palate, based on which difficulty in postoperative extubation was predicted. A catheter for tracheal tube exchange proposed by the extubation guidelines of the Difficult Airway Society (DAS) was placed, endoscopic examination was performed while inducing spontaneous breathing and swallowing reflex by an otolaryngologist, and the tube was removed while movement of the tissue around the glottis was visually evaluated. The patient was managed in an ICU after extubation, and both the systemic and respiratory conditions were favorable.ConclusionsExtubation and airway management could be safely performed by devising extubation while conforming to the DAS guidelines.

Factors affecting difficulty in extubation after initial successful resuscitation in cardiopulmonary arrest patients.

Factors affecting difficulty in extubation after initial successful resuscitation in cardiopulmonary arrest patients.

Efficacy of shock wave lithotripsy in treating patients with double J stent extubation difficulties due to the stone scales surface

Objective To evaluate clinical efficacy of extracorporeal shock wave lithotripsy (ESWL) for treating patients with double J (DJ) stent extubation difficulties.Methods A retrospective analysis were conducted from July 1999 to December 2013,total 30 cases (18 male and 12 female) were accepted the ESWL therapy for treating the DJ extubation difficult due to the stone scales surface.The average age in those patients was 46 years (range 24 to 83 years).The average duration of DJ stents indwelling was 8.3 months (range 1.5 to 36.0 months).There were 10 cases with single stone and 20 cases with multiple stones.The distribution of stone location included left kidney in 14 cases,right kidney in 6 cases,left ureter in 3 cases and right ureter in 7 cases.The ureteral stone scales around the DJ stent showed tubular distribution.The distribution of imaging characteristic included kidney stones around the DJ stent joint in 20 cases and surface coarse in 10 cases.The diameter of the stone ranged from 0.7 to 3.2 cm (mean 1.8 cm).All the 30 cases were treated by ESWL with the 2 000-3 300 times frequency (mean 2 800 times).Treatment voltage was 4-8 KV.Results Gravel time ranged from 40 to 70 min (mean 45 min).No intraoperative and postoperative complications occurred.Their DJ stents were easily extubated immediately after ESWL.One week after ESWL,all the patients reported the flushing of the stone.Conclusion ESWL is a simple,convenient and efficacy way to solve the DJ stent extubation difficulties due to the scales surface. Key words: Double J stent; Stone scale; Extubation difficulty; Extracorporeal shock wave lithotripsy

Newborn With Multiple Congenital Anomalies

He was transferred to our facility for evaluation of multiple congenital anomalies (Figure 1).Neural tube defect, split vertebral column, imperforate anus, double descending thoracic aorta, and absent spleen in a term infant.The actual diagnosis was split notochord syndrome. Meningocele was repaired and physical therapy ordered. Due to absent sacrum and coccyx, parents were informed about the prognosis of their child not being able to ambulate. Colostomy was performed for an imperforate anus. Intestinal duplication cyst was excised. Absent spleen noted during the surgery and decision was made to observe. No invasive cardiac procedures were necessary. Bilateral scrotal hernia was repaired. Post operatively, he faced extubation difficulty, remained on oxygen for weeks, and eventually needed tracheostomy. He developed feeding difficulties after colostomy and needed a g tube. Chromosome analysis revealed 46 XY. Posterior phallic structure is still being evaluated. He was discharged home with tracheostomy, g tube, and endocrinology follow-up for ambiguous genitalia. Anterior micropenis may require testosterone around puberty.Split notochord syndrome is a rare congenital malformation of nervous system involving brain, spinal cord, and vertebral column. Less than 40 cases have been reported in the United States. Vertebral column clefting gives a picture of butterfly vertebra. The cleft usually occurs in the thoracic or lumbar region. It is associated with dorsal neuroenteric fistula in 50% of the cases and imperforate anus in one-third of the cases. Split notochord syndrome occurs due to failure of fusion of the lateral ossifications centers of the vertebrae. The defect appears before the embryo is 63 mm. The terminal, dorsal part of the enteric fistula, which is produced between the endoderm and the ectoderm through a partially duplicated notochord, remains after obliteration of the fistula. Consequently, the mucosa of the enteric remnant is inverted and projects through the skin on the back.Because it is a rare syndrome and not very many cases have been reported, not much information is available. Management consists of supportive treatment. A multidisciplinary approach is recommended involving a neonatologist, surgeon, neurosurgeon, geneticist, endocrinologist, cardiologist, and physical-therapist for the management of disabilities. Answering parents’ questions about the syndrome and giving them realistic expectations about the functioning capacity of their infant is an important role of a neonatologist.JoDee M. Anderson, MD, MEd, Assistant Editor, Visual Diagnosis, Video Corner; Associate Professor, Oregon Health & Science University, Portland, OR.

Extubation difficulty after transphenoidal pituitary surgery in an acromegalic patient

Extubation difficulty after transphenoidal pituitary surgery in an acromegalic patient

Nasal packing and transseptal suturing techniques: surgical and anaesthetic perspectives

The objective of this study is to compare the nasal packing and the transseptal suturing techniques regarding the extubation difficulty evaluation scores, follow-up times in post-anaesthesia care unit (PACU), pain scores, and postoperative complications. Two hundred patients who underwent septoplasty from January 2009 to October 2009 were randomly assigned either to have nasal packs (n: 100) or transeptal sutures (n: 100). In the transseptal suture group, extubation was easier and PACU follow-up times were shorter, when compared to the nasal packing group (p < 0.001). Patients with nasal packing had significantly higher pain scores (p < 0.001). Minor bleeding was significantly higher in the transseptal group with seven cases, compared to the nasal packing group without any bleeding cases (p = 0.014). There were two patients who had postoperative major bleeding, and two patients who had septal hematoma in the transseptal suture group. One patient with nasal packing had postoperative infection. Septal perforation was not seen in any of the cases. While patients in both groups experienced postoperative crusting, patients in the transseptal suture group also complained about foreign body sensation. Extubation was more comfortable; post-anaesthesia monitorization duration was shorter, and postoperative pain was less, but minor bleeding was seen more with transseptal sutures. There was no significant difference in terms of major bleeding, hematoma, infection or perforation. Foreign body sensation was the main cause of postoperative discomfort in the transseptal suture group. Transseptal suturing might be a significantly comfortable, cost-effective and reliable alternative to nasal packing.

Patología neuromuscular del paciente crítico en pediatría

To describe and provide diagnosis guidelines for the neuromuscular pathology of the pediatric critical patients, manifested as extubation difficulty, based in our experience. A retrospective study has been performed on three patients in the Pediatric Intensive Care Unit that were diagnosed by using clinical, analytical and electromyographical findings. In the three patients the presence of the disorder was suspected due to the extubation difficulty and the hypotony. All them received vecuronium as neuromuscular blockage while dexamethasone was provided to one of them due to a nodal tachycardia. Myopathic causes were discarded in view of the normally of the muscular enzymes. The electromyography showed an axonal disorder in all three child. Neither lumbar puncture nor muscular biopsy were performed in any of them. The three patients were diagnosed for a drug neuropathy (neuromuscular blocked and/or corticotheraphy). There were described another causes of the critical patient polyneuropathy in the literature, but we didn't find any of them.

The anterior cricoid split. Clinical experience with extended indications.

A recommended approach to postextubation infant subglottic stenosis secondary to subglottic edema employs the recently described anterior cricoid split (ACS) procedure. This technique provides an expanded subglottic airway with minimal paratracheal dissection and does not require concomitant tracheotomy. We applied this procedure in managing extubation difficulty in pediatric as well as neonatal patients. Five of ten patients in our series did not fulfill the traditional criteria for ACS. Relief of stridor and avoidance of tracheotomy were accomplished in nine of ten patients. One patient in whom mechanical ventilation was reinstituted developed an interesting complication. In properly selected infants with subglottic airway compromise, the ACS appears to be an effective adjunct in facilitating extubation.