Letters to the Editor: Letters & Announcements
I have shared the letter with my co-author, and here are our comments:
1. The letter writers feel that we should not have proceeded with the magnetic resonance imaging using just the laryngeal masks despite the fact that the laryngeal mask airways were functioning perfectly, enabled positive pressure ventilation, and the children did not have any absolute indications for endotracheal intubation such as “full stomachs” or history of gastroesophageal reflux. They present a valid point of view for any general anesthetic in an magnetic resonance imaging scanner (i.e., difficult environment to intubate children because of the magnet, difficult access when they are in the scanner, often suboptimal monitoring): that airway control is desirable. However, most pediatric anesthetic procedures in the magnetic resonance imaging scanner are not done with endotracheal intubation at our institution nor at other regional pediatric centers I inquired of in response to this letter.
2. After recognizing the difficulty with endotracheal intubation and the laryngospasm was reported, we were prepared to intubate these children fiberoptically (as the letter writer suggests), and we had a pediatric surgeon and tracheotomy kit at the ready. However, the children were easily ventilated with the laryngeal mask airways, and this was a modality we had much experience with for “typical” children having magnetic resonance imaging under general anesthesia.
3. In retrospect (i.e., if called to manage a second set of thoracopagus twins in the magnetic resonance imaging scanner), we would agree with fiberoptic-assisted intubation as the initial airway management. At the time of this case, there were no reports in the literature identifying the difficulty in intubation that thoracopagus twins present.
We feel the purpose of this case report was to identify the challenges—including difficult airway management—that these twins may present. We believe this was accomplished.
Erik S. Shank, MD
Ulrich Schmidt, MD
Department of Anesthesia and Critical Care
Massachusetts General Hospital