LETTERSTOTHEEDITOR 665 hypoxemiaundercertainconditions.However,the
relation-shipbetweenpulmonaryanestheticadministrationandHPV remainscontroversial.
Inconclusion,globaleffectsofinhalationinductionwith sevofluraneathighconcentrationsmaycauseoxygen desat-uration in lungs that are normally ventilated with 100% oxygen, potentially resulting in global inhibition of HPV. However,theseconditionsmaybeaconsequenceofglobal HPV and associated 100% shunt fractions. Thus, despite thehighlevel evidenceofnodifferencesin outcomes fol-lowingpulmonaryandintravenousanesthesia, thehypoxic consequencesofinhalationanesthesiarequirefurther clar-ification.
Consent
Writteninformedconsentwasobtainedfromthepatientfor publicationofthiscasereport.Acopyofthewrittenconsent isavailableforreviewbytheEditorofthisjournal.
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
References
1.Bindslev L, Jolin A, Hedenstierna G, et al. Hypoxic pul-monaryvasoconstrictioninthehumanlung:effectofrepeated hypoxicchallengesduringanesthesia.Anesthesiology.1985;62: 621---5.
2.MarshallC,LindgrenL,MarshallBE.Effectsofhalothane, enflu-rane,andisofluraneonhypoxicpulmonaryvasoconstrictioninrat lungsinvitro.Anesthesiology.1984;60:304---8.
3.Domino KB, Borowec L, Alexander CM, et al. Influence of isofluraneonhypoxicpulmonaryvasoconstrictionindogs. Anes-thesiology.1986;64:423---9.
4.IshibeY,GuiX,UnoH,et al.Effectofsevoflurane onhypoxic pulmonary vasoconstrictioninthe perfusedrabbitlung. Anes-thesiology.1993;79:1348---53.
5.LoerSA,ScheerenTW,TarnowJ.Desfluraneinhibitshypoxic pul-monaryvasoconstrictioninisolatedrabbitlungs.Anesthesiology. 1995;83:552---6.
6.KerbaulF,BellezzaM,GuidonC,etal.Effectsofsevofluraneon hypoxicpulmonaryvasoconstrictioninanaesthetizedpiglets.Br JAnaesth.2000;85:440---5.
7.Liu R, Ueda M,Okazaki N, et al. Roleof potassiumchannels in isoflurane- and sevoflurane-induced attenuation ofhypoxic pulmonary vasoconstriction in isolated perfused rabbit lungs. Anesthesiology.2001;95:939---46.
MenekseOksar∗,OnurKoyuncu,SelimTurhanoglu
MustafaKemalUniversityFacultyofMedicine,Department ofAnesthesiologyandReanimation,Hatay,Turkey
∗Correspondingauthor.
E-mail:menekseoksar@gmail.com(M.Oksar).
http://dx.doi.org/10.1016/j.bjane.2016.02.003
0104-0014/
©2016SociedadeBrasileiradeAnestesiologia.Publishedby ElsevierEditoraLtda.ThisisanopenaccessarticleundertheCC BY-NC-NDlicense( http://creativecommons.org/licenses/by-nc-nd/4.0/).
Anesthesia
in
a
newborn
with
Klippel---Feil
syndrome
Anestesia
em
recém-nascido
com
síndrome
de
Klippel-Feil
DearEditor,
IreadthecasereportofAltayetal.1aboutanesthesia
man-agementofanewbornwithKlippel---Feilsyndrome(KFS)with interest.Theauthorspresentedtheircaseas‘‘theyoungest child withKFS onwhomoral intubation wasperformed’’. I appreciate the colleagues for their management of this challengingcase,buttherearesomepointsthathavetobe discussed.
Altay et al. performed a successful intubation at first attemptwithDirectLaryngoscopy (DL),which was consis-tent with the literature. According tothe literature, KFS alonemaynotbeapredictorofdifficultairwaymanagement in infants. Naguib et al.2 had reported a three-week-old
boy diagnosed with KFS successfully intubated with DL.
DOIofreferstoarticle:
http://dx.doi.org/10.1016/j.bjane.2014.03.006
Creightonetal.3hadreported8infantswithKFS(6ofthem
had alsocleft palate, most probablysome of them were newborns)onwhomoralornasalintubationwasperformed withDLusingregularlaryngoscope.Theyperformedawake DLsuccessfully, despite theother present conditionsthat complicateintubationlikecleftpalateandlateralposition inadditiontoKFS.
Recentlywehavereviewedtheairwaymanagementand the success of DL in children with KFS4 and found that
thereis no report describing difficult mask ventilation or unsuccessfulLaryngeal MaskAirway(LMA)insertion inthe literature. Also,there is no report of an unsuccessful DL ininfantswithKFS.Wethinkthatthesuccessrateof tra-cheal intubation with DL in early ages (probably before adolescence)seemstobeincreasedwhenotherpredictors ofdifficult intubationdoes not accompany.Thesefindings mayencourage usfor attemptingDL in children withKFS alone,butaccompanying airwayanomalies arenotrarein KFSandhavetobeinvestigatedbeforeanesthesiainduction. Also,a previous successfulDL does not ensure successful intubation because cervical fusion may become progres-sivelyworsenovertimeandDLmaybechallenginginolder ages.
666 LETTERSTOTHEEDITOR anesthesiatoablate the rise in pulmonary vascular
resis-tanceassociatedwithsurgicalstimuliisoneoftheprimary goalsinanesthesiamanagementofthesepatients,whatwas thereasontousesevofluraneasasoleanestheticagentina cardiacpatientwithpersistentpulmonary hypertension,if earlypostoperativeextubationwasnotplanned?
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
References
1.Altay N, Yuce HH, Aydogan H, et al. Airway management in newborn with Klippel---Feil syndrome. Braz J Anesthesiol. 2016;66:551---3.
2.NaguibM,FaragH,IbrahimAel-W.Anaestheticconsiderationsin Klippel---Feilsyndrome.CanAnaesthSocJ.1986;33:66---70.
3.Creighton RE,Relton JE, Meridy HW. Anesthesia for occipital encephalocoele.CanAnaesthSocJ.1974;21:403---6.
4.BakanM,Umutoglu T,ZenginSU,et al.Thesuccess ofdirect laryngoscopy in childrenwith Klippel---Feil syndrome. Minerva Anestesiol.2015;81:1384---6.
MefkurBakan
BezmialemVakifUniversity,FacultyofMedicine,
DepartmentofAnesthesiologyandReanimation,Istanbul, Turkey
E-mail:mefkur@yahoo.com
http://dx.doi.org/10.1016/j.bjane.2017.04.003
0104-0014/
©2017PublishedbyElsevierEditoraLtda.onbehalfofSociedade BrasileiradeAnestesiologia.Thisisanopenaccessarticleunder theCCBY-NC-NDlicense(http://creativecommons.org/licenses/ by-nc-nd/4.0/).
Effects
of
lidocaine
and
magnesium
sulfate
in
attenuating
hemodynamic
response
to
orotracheal
intubation:
a
single-center,
prospective,
double
blind,
randomized
study
Os
efeitos
da
lidocaína
e
do
sulfato
de
magnésio
na
atenuac
¸ão
da
resposta
hemodinâmica
à
intubac
¸ão
orotraqueal:
estudo
unicêntrico,
prospectivo,
duplamente
encoberto
e
aleatorizado
DearEditor,
ItwaswithgreatpleasurethatIreadthearticle‘‘Effects oflidocaineandmagnesiumsulfateinattenuating hemody-namicresponsetoorotrachealintubation:asingle-center, prospective,doubleblind,randomizedstudy’’.1Concerned
to clarify some points related to the statistical analy-sis and conclusion; here are some considerations to the authors:
1. The authorsreportadiscretestatisticaldifferenceand thisdoesnotallowthearticle’sreadertocometo conclu-sions: ‘‘Therewasastatistically significantincrease in SBP (p=0.018) and DBP (p=0.0467) values measured post-TI(Fig.2),butof littleclinicalimportance’’. The valuesshouldhavebeendemonstratedintextbecause, as shown in Fig. 2, it is not possible to capture its
DOIofreferstoarticle:
http://dx.doi.org/10.1016/j.bjane.2015.08.004
magnitude,sothatthelackofclinicalimportancedoes notrepresentabsenceofbiologicalrelevance;
2. The data werepartiallyor totallyanalyzed over time, and the patients were also submitted to anesthetics in addition to the medications tested, which may be in addition or not. It is known that magnesium sul-fate has a prolonged clinical effect after venous use, whereas lidocaine has a short protective effect com-paredtomagnesium. Thus, therearetwofactors that mustbeconsideredinthisstatisticalanalysis:timeand treatment. The beststatistical test toperform in this situation is two-way ANOVA.2 The results analyzed as
they are in the text may be erroneously positive and thepossibilityofatypeIerrorinthisresearchisclearly perceived;
3. Ifthe authors considerthe use ofthe Student’s ttest as correct, or more appropriately in some cases the Mann---WhitneyUtest,accordingtothetext,theyshould havecorrectedthepvaluewiththeprocedurefor multi-plecorrectionofhypothesistests,insteadofconsidering only5%asthelevelofsignificanceinallanalyzes.The possibilityof having a positive resultin the statistical analysisoccurringat randomis5%.Thep-value correc-tion would have reduced the probability of a random occurrenceofthestatisticalresult.Thus,thepossibility oftypeIerrorinthisresearchisclear;
