Anesthesia for a child with Menkes disease

(PPV)? This is a somewhat controversial topic. It is common knowledge that instrumentation of the larynx, trachea or bronchi is a powerful stimulus and may easily elicit coughing, bucking, laryngospasm, gagging, dysrthythmias or hypertensive responses which may have serious consequences. All these can be avoided with general anaesthesia using muscle relaxation and PPV. However, on literature review, Vane et al. (1) prefer spontaneous ventilation because they consider that PPV can potentially force the foreign body deeper into the small airways. This may make retrieval of foreign body more difficult or potentially create a ball valve obstruction. On the contrary, Kosloske (2) advocated muscle paralysis and PPV. Litman et al. (3) in their analysis of 94 cases for foreign body removal in children found that, in some cases in which spontaneous breathing techniques were used initially, the switch was made during the procedure to PPV. Causes for change in ventilatory management were inadequate ventilation, patient movement and laryngospasm. Consequently, each technique can be argued for; so, the anesthetic should be tailored to each specific case and what is deemed the most advantageous method for each individual child at that time. The point worth noting in this case is that the child did not have any recollection of actually inhaling the nail, consequently presenting only with an irritating cough, leading to a delayed diagnosis. Thus, one must have a very high index of suspicion for foreign body inhalation in pediatric patients, particularly in the younger age groups where the history can be more unreliable. Susan Calderbank Howard Wakeling Department of Anaesthesia, Worthing Hospital, Sussex (email: susiecalderbank@hotmail.com)