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Anesthetic
Management for the
Pediatric Airway
Advanced Approaches
and Techniques
Diego Preciado
Susan Verghese
Editors
123
Anesthetic Management for the
Pediatric Airway
Diego Preciado · Susan Verghese
Editors
Anesthetic
Management for the
Pediatric Airway
Advanced Approaches and
Techniques
Editors
Diego Preciado Susan Verghese
School of Medicine Department of Anesthesiology
George Washington University School Children’s National Health System
of Medicine Washington, DC
Washington, DC USA
USA
ISBN 978-3-030-04599-9 ISBN 978-3-030-04600-2 (eBook)

https://doi.org/10.1007/978-3-030-04600-2
Library of Congress Control Number: 2019932798
© Springer Nature Switzerland AG 2019

This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or
part of the material is concerned, specifically the rights of translation, reprinting, reuse of
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and transmission or information storage and retrieval, electronic adaptation, computer software,
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The use of general descriptive names, registered names, trademarks, service marks, etc. in this
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exempt from the relevant protective laws and regulations and therefore free for general use.
The publisher, the authors, and the editors are safe to assume that the advice and information in
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The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland
This book is dedicated to all of our former and current
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enriching our lives!
Preface
The management of pediatric airway disorders has seen tremendous progress

in surgical techniques and advancements over the past 30 years. From the
introduction of novel endoscopic instrumentation, to improved open airway
reconstructive techniques, the evolution of surgical approaches to improve
outcomes in children with airway pathology has been substantial.
Undoubtedly, many of these advances in surgical techniques have been fueled
by dramatic refinements in optimal anesthetic management of children under-
going surgery in their airway. The textbook intends to be of great interest to
both the pediatric anesthesiologist as well as the pediatric otolaryngology
surgeon as it aims to combine the salient aspects of both specialties and
describe the ideal and safe management of the pediatric patient undergoing
anesthesia. Difficult airway scenarios; including subglottic stenosis, pharyn-
geal airway obstruction, laryngeal airway obstruction, obesity and sleep
apnea, thoracic airway obstruction, among others will be covered in detail. To
date there is no other leading textbook focusing primarily on the anesthetic
management of children with these pathologies, yet often the anesthesiolo-
gist’s level of expertise in these scenarios is as critical (if not more important
than) the surgeon’s. Chapters are by experts from both pediatric anesthesia
and pediatric otolaryngology; focusing on scenarios where the skills and
expertise of both specialists are being continually tested. This book will
hopefully serve as a state of the art compendium of the anesthetic manage-
ment of pediatric airway patients.
Washington, DC, USA Susan T. Verghese

Diego A. Preciado
vii
Contents
1 Evolution of Anesthesia for Pediatric Airway Surgery:

From Ether to TIVA and Current Controversies�� 1
Susan T. Verghese
2 Preop Considerations in the Evaluation of Children
with Airway Pathologies�� 15
Janish Jay Patel, Susan T. Verghese, and Diego A. Preciado
3 Airway Pathologies Requiring Specialized Pediatric
Anesthesia �� 21
Diego A. Preciado
4 Preferred Anesthesia for Routine Otolaryngologic
Procedures�� 29
Monica Shah and Mofya S. Diallo
5 Anesthesia Methods for Airway Endoscopy�� 43
Benjamin Kloesel and Kumar Belani
6 Neonatal Laryngoscopy and Bronchoscopy�� 59
Claude Abdallah, Jennifer R. White, and Brian Kip Reilly
7 Difficult Airway Management of Neonates, Infants,
and Children with Syndromes Involving the Airway �� 67
Grace Hsu and John E. Fiadjoe
8 Anesthesia Maintenance During Endoscopic Airway
Surgery�� 77
Sharon H. Gnagi, Michel J. Sabbagh, and David R. White
9 Anesthesia Maintenance During Open Airway
Reconstruction�� 91
Bobby Das and Catherine K. Hart
10 Optimal Sedation Protocol After Single-Stage Open Airway
Reconstruction�� 97
Hoyon Lee and Sophie R. Pestieau
ix
x Contents
11 Anesthetic Management in Emergent Pediatric

Foreign Bodies�� 105
Suresh Thomas and Nikhil Patel
12 Anesthetic and Reconstructive Considerations
in Major Head and Neck Trauma�� 113
Sean W. Gallagher and Andrew R. Scott
13 Anesthetic Management of Morbidly Obese Patients
Undergoing Airway Surgery �� 127
Songyos Valairucha and Raafat S. Hannallah
14 Extracorporeal Membrane Oxygenation (ECMO)
Considerations in Fulminant Airway Obstruction �� 153
Andrew J. Matisoff and Mark M. Nuszkowski
15 Prevention Airway Complications During Aerodigestive
Surgery�� 161
Nina Rawtani and Yewande Johnson
16 Management of Immediate Postoperative Airway Events
in Children�� 169
Domiciano Jerry Santos and Evonne Greenidge
17 Opioid Metabolism, Variability, and Overdose Management
in Pediatric Airway Patients�� 181
Sean-Patrick Alexander, Senthil Packiasabapathy,
and Senthilkumar Sadhasivam
18 ENT Surgery and Anesthesia Neurotoxicity in Children �� 191
Susan Lei and Lena S. Sun
Index�� 199
Contributors
Claude Abdallah, MD, MSc Department of Anesthesia, George Washington

University, Washington, DC, USA
Sean-Patrick Alexander, MD Anesthesia and Pain Medicine, Children’s
National Medical Center, George Washington University, Washington, DC,
USA
Kumar Belani, MBBS, MS Department of Anesthesiology, Masonic
Children’s Hospital, University of Minnesota, Minneapolis, MN, USA
Bobby Das, MD Department of Pediatric Anesthesiology, Cincinnati
Children’s Hospital Medical Center, Cincinnati, OH, USA
Mofya S. Diallo, MD, MPH Division of Anesthesiology, Sedation and
Perioperative Medicine, Children’s National Health System, The George
Washington University, Washington, DC, USA
John E. Fiadjoe, MD Children’s Hospital of Philadelphia/University of
Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
Sean W. Gallagher, MD Division of Pediatric and Cardiac Anesthesiology,
Floating Hospital for Children at Tufts Medical Center, Boston, MA, USA
Sharon H. Gnagi, MD Division of Otolaryngology – Head and Neck
Surgery, Phoenix Children’s Hospital, Phoenix, AZ, USA
Evonne Greenidge, MD Anesthesiology, Pain, and Perioperative Medicine,
Children’s National Health System, George Washington University School of
Medicine, Washington, DC, USA
Raafat S. Hannallah, MD, FAAP Anesthesiology and Pediatrics, Children’s
National Health System/George Washington University School of Medicine
and Health Sciences, Washington, DC, USA
Catherine K. Hart, MD Division of Pediatric Otolaryngology-Head and
Neck Surgery, Cincinnati Children’s Hospital Medical Center, Cincinnati,
OH, USA
Department of Otolaryngology-Head and Neck Surgery, University of
Cincinnati College of Medicine, Cincinnati, OH, USA
xi
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xii Contributors
Grace Hsu, MD Department of Anesthesiology and Critical Care Medicine,

The Children’s Hospital of Philadelphia/Perelman School of Medicine at the
University of Pennsylvania, Philadelphia, PA, USA
Yewande Johnson, MD Anesthesiology, Pain, and Perioperative Medicine,
Children’s National Health System, Washington, DC, USA
Benjamin Kloesel, MD, MSBS, FAAP Department of Anesthesiology,
Masonic Children’s Hospital, University of Minnesota, Minneapolis, MN,
USA
Hoyon Lee, MD Division of Anesthesiology, Pain and Perioperative
Medicine, Children’s National Health System, Washington, DC, USA
Susan Lei, MD Department of Anesthesiology, Columbia University
Medical Center, New York, NY, USA
Andrew J. Matisoff, MD Division of Cardiac Anesthesia, Children’s
National Health System/George Washington University, Washington, DC,
USA
Mark M. Nuszkowski, MPS, CCP Perfusion Clinical Manager, CV
Surgery, Children’s National Medical Center, Washington, DC, USA
Senthil Packiasabapathy, MBBS, MD Department of Anesthesia, Riley
Hospital for Children at Indiana University Health, Indianapolis, IN, USA
Janish Jay Patel, MD, MBA Division of Anesthesiology and Pain Medicine,
Children’s National Health System, George Washington University, Washington,
DC, USA
Nikhil Patel, MD Department of Anesthesiology, Pain and Perioperative
Medicine, Children’s National Medical Center/George Washington
Sophie R. Pestieau, MD Division of Anesthesiology, Pain and Perioperative
Medicine, Children’s National Health System, Washington, DC, USA
Diego A. Preciado, MD, PhD Division of Pediatric Otolaryngology,
Children’s National Health System, George Washington University School of
Nina Rawtani, MD Department of Anesthesiology, Children’s National
Health System, George Washington University, Washington, DC, USA
Brian Kip Reilly, MD, FACS, FAAP Department of Otolaryngology,
George Washington University Medical Center, Children’s National Hospital,
Washington, DC, USA
Michel J. Sabbagh, MD, MBA Department of Anesthesia and Perioperative
Medicine, Division of Pediatric Anesthesia, Medical University of South
Carolina, Charleston, SC, USA
Senthilkumar Sadhasivam, MD, MPH Department of Anesthesia, Riley
Hospital for Children at Indiana University Health, Indianapolis, IN, USA
Contributors xiii
Domiciano Jerry Santos, MD Anesthesiology, Pain and Perioperative

Andrew R. Scott, MD Division of Pediatric Otolaryngology and Facial
Plastic Surgery, Floating Hospital for Children at Tufts Medical Center,
Boston, MA, USA
Monica Shah, MD Division of Anesthesiology, Sedation and Perioperative
Medicine, Children’s National Health System, The George Washington
Lena S. Sun, MD Department of Anesthesiology, Columbia University
Medical Center, New York, NY, USA
Suresh Thomas, MD Department of Anesthesiology, George Washington
University School of Medicine, Washington, DC, USA
Pediatric Anesthesiology, Children’s National Medical Center, Washington,
DC, USA
Songyos Valairucha, MD Anesthesiology, Pain and Perioperative Medicine,
Children’s National Health System/George Washington University School of
Medicine and Health Sciences, Washington, DC, USA
Susan T. Verghese, MD Division of Anesthesiology and Pain Medicine,
Children’s National Health System, George Washington University,
Washington, DC, USA
David R. White, MD Department of Pediatric Otolaryngology – Head and
Neck Surgery, Medical University of South Carolina Children’s Hospital,
Charleston, SC, USA
Jennifer R. White, MD Department of Otolaryngology, Medstar
Georgetown University Hospital, Washington, DC, USA
Editor’s Biography
Susan Thomas Verghese is a professor of Anesthesia and Pediatrics at

Children’s National Health System and George Washington University. She
is a pediatric anesthesiologist who works at Children’s National Medical
Center in Washington, DC after completing her fellowship in pediatric
Anesthesia in 1981. She earned her Bachelor of Medicine at Christian
Medical College, Vellore, in Tamilnadu, India and her internship and resi-
dency in anesthesia at the Peter Bent Brigham Hospital in Boston,
Massachusetts.
Dr. Verghese has authored numerous book chapters and contributed many
scientific papers in anesthesia journals as well as served as a reviewer of
manuscripts for many academic journals including Pediatric Anesthesia,
Anesthesiology, Anesthesia and Analgesia, Critical Care Medicine and
Urology. She is a member of the Editorial Advisory Board for Anesthesiology
News.
She has been an invited speaker to many scientific pediatric anesthesia
meetings held internationally in different parts of the world. For the last two
decades, she was invited regularly to serve as a moderator and facilitator of
the pediatric Anesthesia scientific sessions at the annual American Society of
Anesthesiologists (ASA) and the International Anesthesia Research Society–
(IARS) meetings in different cities USA and Canada. Her interest in creating
and being a lead discussant in Problem Based Learning Discussion–( PBLD)
sessions allowed her to help mentor junior staff to create and facilitate many
such academic sessions at the ASA and the Society of Pediatric Anesthesia
(SPA). Dr. Verghese has served at the ASA national leadership level as the
Chair of the Scientific Abstract Review subcommittee on Pediatric Anesthesia
from 2012 to 2014.
She has been active in the District of Columbia Society of Anesthesiologists
(DCSA ) in different capacities – serving as its president for 2 years (2006–
2008) its delegate and alternate director to the ASA for a 3 year term and
currently as its treasurer.
Above all, Dr. Verghese is grateful to God for the opportunity to serve as a
caring pediatric anesthesiologist at CNMC in Washington, DC – a place she
calls her “home” for the last 37 years.
Diego A. Preciado is a Professor with tenure at Children’s National Health

System and George Washington University. He serves as Vice-Chief of the
Division of Pediatric Otolaryngology as well as Program Director of the
xv
xvi Editor’s Biography
ACGME accredited pediatric otolaryngology fellowship at Children’s

National. His clinical practice is focused on pediatric airway reconstruction,
childhood hearing loss/cochlear implants, and velopharyngeal insufficiency.
He has authored over 100 vpeer-reviewed manuscripts, 10 book chapters and
2 edited books. An active basic science researcher, Dr. Preciado runs an otitis
media translational laboratory funded through numerous intramural and
extramural awards including R01, U01, and R21 grants from the NIH. Finally,
he has served on numerous national committees including the American
Society of Pediatric Otolaryngology Board of Directors and the Executive
Committee for the Section of Otolaryngology of the American Academy of
Pediatrics.
Evolution of Anesthesia
for Pediatric Airway Surgery: 1
From Ether to TIVA and Current
Controversies
Susan T. Verghese
volution of Anesthetic Agents

E laugh. After experiencing the euphoric effect of
in Pediatric Anesthesia this exhilarating gas firsthand, he named it
“laughing gas.” Although nitrous oxide had been
General anesthesia revolutionized the practice of used in dentistry since 1844, it lacked the anes-
surgery in adults and children. The history of thetic potency of diethyl ether in causing insensi-
anesthesia from its humble origin to its present- bility. On December 11, 1844, Horace Wells
day specialty is an incredible story of fearless (1815–1848) a dentist and a pioneer in dental
pioneers and heroes who discovered new drugs anesthesia tried to demonstrate for the first time
and invented ingenious devices and novel routes albeit unconvincingly that the use of nitrous
to facilitate their delivery. oxide could produce insensitivity to pain during a
Surgery before the advent of anesthesia was a wisdom tooth extraction. This failed demonstra-
barbaric torture inflicted by bold speedy surgeons tion humiliated Wells, and he did not venture fur-
on hapless patients writhing in agonizing pain ther to prove the effectiveness of other drugs in
while being restrained by strong men. public even though he was experimenting with
The dawn of modern anesthesia begins with ether [4, 6]. However, this failure spurred him
the discovery of two powerful inhalational and others to search for a better agent. A fellow
agents: ether and chloroform – gases discovered dentist William T. G. Morton (1819–1868) who
within a year of each other [1–13]. was in attendance during the demonstration
In 1772, an English scientist and clergyman began investigating the effect of ether inhalation
Joseph Priestley (1733–1804) discovered nitrous to produce insensibility for surgery. A knowl-
oxide, a year after he had discovered oxygen. The edgeable chemist, Dr. Charles Thomas Jackson
anesthetic and analgesic properties of nitrous (1819–1868) who was a Harvard lecturer and a
oxide were not discovered until 1799 by an mentor, was able to guide him during his experi-
English scientist, Humphry Davy. He inhaled ments with ether to produce a purified vapor of
nitrous oxide gas as an experiment and to his sur- sulfuric ether [6].
prise found that it made his body relax while On October 16, 1846, William T. G. Morton
making him giddy and cheerful forcing him to induced anesthesia with ether enabling John
Collins Warren (1778–1856), a renowned sur-
S. T. Verghese (*) geon and chief of surgery at Massachusetts
Division of Anesthesiology and Pain Medicine, General Hospital (MGH), to remove a vascular
Children’s National Health System, George tumor from the neck of his patient, Edward
Washington University, Washington, DC, USA Gilbert Abbott. This was the first public
e-mail: [email protected]
© Springer Nature Switzerland AG 2019 1

D. Preciado, S. Verghese (eds.), Anesthetic Management for the Pediatric Airway,
https://doi.org/10.1007/978-3-030-04600-2_1
2 S. T. Verghese
d emonstration of a painless surgery performed and poet and a brilliant scientific leader, and he
and witnessed by many scientific minds of that proposed naming this insensible painless state
day in the surgical amphitheater now known as “anesthesia” and the procedure an “anesthetic,”
the Ether Dome. Morton wears the mantle of thus ushering the genesis of the new specialty –
fame as the discoverer of ether because it was he anesthesiology – into the practice of surgical
who first proved to the world its efficacy and medicine [2, 6, 7].
safety as an anesthetic agent on that day marked Now let us digress from the discovery of ether
as Ether Day in the history of medicine [1, 9]. to a few other forgotten pioneers who did dis-
This momentous milestone of ether producing cover its anesthetic properties earlier but did not
a state of insensibility ushered the new era in publish their findings in time.
medicine where pain could be eliminated during Crawford Williamson Long (1815–1878), a
surgical trauma. News of this inhalational agent rural physician from Jefferson, Georgia, is actu-
spread abroad and soon found its use into operat- ally the first person to have administered the first
ing rooms in many countries. Robert Liston, documented and witnessed ether anesthetic in his
another famous surgeon in London, performed office to a child, an 8-year-old boy for the ampu-
the first limb amputation under ether anesthesia tation of a toe on July 3, 1842. He anesthetized
on December 21, 1846. Despite its popularity, other patients with ether for painless removal of
ether had some undesirable properties of being digits, cysts, and neck masses in his medical
flammable and unpleasant to inhale due to its practice. His caution and delay in publishing
strong odor. In addition to the need for a pro- these astounding findings however prevented him
longed induction period, ether often caused sig- from being given the recognition for discovering
nificant nausea and vomiting in most patients ether in abolishing pain during surgery [8–13].
who inhaled it [1]. In addition to Crawford Long, there were two
These disadvantages prompted the search for other physicians mentioned earlier – Charles
a better inhalational anesthetic. James Young Thomas Jackson and Horace Wells – who were
Simpson (1811–1870) an obstetrician from Morton’s close mentors who claimed that they
Edinburgh, Scotland, introduced chloroform in too had used ether before Morton or with him,
1847. He believed it to be an agent superior to and this led to “The Ether Controversy,” a histori-
ether because of its pleasant smell and fast induc- cal event brought about by their claims stemming
tion, requiring only a handkerchief to administer. from a desire for fame and recognition. It was
Chloroform was used for decades, but the safety precipitated upon publishing the article describ-
of the drug became questionable after several ing the incredulous events of October 16, 1846,
reports of hepatotoxicity were reported in patients by a surgeon Henry Jacob Bigelow (1818–1890)
anesthetized with this agent. When a demonstra- who was present at the ether demonstration at
tion showing the combined use of light chloro- MGH. His article proclaimed that Jackson and
form anesthesia and adrenalin resulted in the Morton had discovered a way to render patients
patient’s demise from ventricular fibrillation, insensible to pain. When Horace Wells, Morton’s
interest in chloroform as an anesthetic slowly former teacher in dentistry and work partner in
began to wane. It is unfortunate to note that the Hartford, Connecticut, read this article, he wrote
first pediatric anesthetic death reported was with a rebuttal explaining that he had discovered this
Hannah Greener, a 15-year-old girl who under- anesthetic property of ether 2 years earlier. Soon
went chloroform anesthetic for the removal of an the assertion by Morton that he alone had discov-
ingrown toenail [1, 2, 4, 6]. ered the use of ether as an anesthetic led to the
The term “anesthesia” was coined by Oliver feud between Jackson and Morton [8–13].
Wendell Holmes (1809–1894) from the Greek Pinckney Webster Ellsworth (1814–1896), a
words “an” (without) and “esthesia” (sensibil- prominent Hartford surgeon and a staunch sup-
ity) after witnessing a painless surgery under porter of Wells, then wrote an article in support
ether. Holmes was a famous physician, writer, of Wells’ assertion that appeared in the Boston
1 Evolution of Anesthesia for Pediatric Airway Surgery: From Ether to TIVA and Current Controversies 3
Medical Surgical Journal, and these articles was the first to use this mask and to specialize
started the ether controversy which is still in the field of anesthesia. He is considered one
debated by different supporters of these different of the fathers of modern epidemiology, in part
physicians. because of his work in tracing the source of a
The Ether Monument erected in Boston’s cholera outbreak in Soho, London, in 1854. He
Public Garden commemorates the first public ether is also the first physician who attempted to alle-
anesthetic demonstration at the Massachusetts viate the pain of childbirth in women despite
General Hospital but does not give specific claim the existing belief that “labor pain” was to be
to any individual – choosing to focus only on the endured and not treated. His choice of a royal
event in 1846, leaving Morton’s name conspicu- subject Queen Victoria to be anesthetized for
ously absent [2, 4]. the delivery of Prince Leopold in 1853 paved
Morton, Wells, and Jackson bitterly contended the way for the future of the field of anesthesia
to be recognized for the discovery of ether and in obstetrics [6, 7].
endured tremendous turmoil and encountered The Schimmelbusch mask was invented by
personal tragedies. Crawford Long alone contin- Curt T. Schimmelbusch (1860–1895), a German
ued his work unaffected by this denial of recogni- physician and pathologist in 1890, and was used
tion, living a peaceful life, busy with his practice to deliver the anesthetic until the 1950s [14].
and his family until he died at the age of 62. He The wire frame of the mask was covered with
was not a publicist, avid for fame or glory, and his layers of gauze, and the drops of highly volatile
own words that his career was defined as a minis- anesthetic diethyl ether or chloroform could be
try given to him by God is etched on his tomb- applied over it repeatedly when placed against
stone. It was on March 30, 1842, that Crawford the patient’s face and nose. This original open
Long had successfully used ether to anesthetize anesthetic system allowed a mixture of air and
James Venable and then proceeded to excise a evaporated anesthetic to produce anesthesia.
tumor from his neck painlessly. It was believed Semi-open, semi-closed, and closed anesthetic
that he charged 25 cents for ether anesthesia and systems developed after this simple open anes-
$2 for performing the surgical procedure. This thetic system.
day was the first time ether was safely used in a There were other illustrious names that were
patient, and the delay in telling the whole world instrumental in producing the endotracheal tubes
about it cost Dr. Long the honor of being known and laryngoscopes, which allowed the birth of
as the discoverer of ether anesthesia. It is only airway anesthesia and surgery. It is interesting to
fitting that we celebrate “Doctors’ Day” each note that the first endotracheal tube was created
year in March 30, to recognize this caring physi- by a caring pediatrician, Joseph O’Dwyer (1841–
cian’s original contribution to medicine, which 1898), in order to overcome airway obstruction in
remained forgotten for a long time [8–13]. his young pediatric patients who were suffering
from diphtheria. He was able to pass these metal
“O′ Dwyer tubes” blindly into their tracheas to
irst the Mask, Then the Tracheal
F allow them to breathe [3, 7, 15].
Tube, and Then the Laryngoscope The first physician to perform an oral endo-
tracheal intubation without a laryngoscope was
The “Morton mask” originally used by William Sir William Macewen (1848–1924). He used
Morton was soon discarded, and several types blind oral intubation to administer chloroform
of wired masks were used instead of towels and anesthesia for oral surgery to prevent blood
sponges. The prototype of modern face mask from entering the larynx, and the concept of
came from Francis Sibson (1814–1876), and it “securing the airway from contamination” was
covered the nose and mouth. John Snow (1813– born. Ivan W. Magill (1888–1986) and Edgar
1858) an English physician and a leader in the S. Rowbotham (1890–1979) were the anesthesi-
adoption of anesthesia and medical hygiene ologists who developed the mineralized red rub-
4 S. T. Verghese
ber endotracheal tube to provide endotracheal scopic technique required less sedation and
anesthesia for surgery around the mouth. The caused fewer problems with laryngospasm.
technique they used for nasal intubation was to Macintosh successfully popularized his blade as
position the patients in such a way chin up that the “gold standard” despite the fact that many
they looked as if they were “sniffing the morning question even now the blade’s superior ability to
air” [1, 7, 16]. view the larynx when compared to the Miller
In 1932, Arthur Guedel (1883–1956) and blade. Macintosh’s contribution was not so
Ralph M. Waters (1883–1979) added an inflat- much the shape of the blade as much as the tech-
able cuff to the existing endotracheal tubes which nique of laryngoscopy [15, 16, 17].
further enabled the anesthesiologist to provide The results of a study comparing the effective-
positive-pressure ventilation. ness of Bullard laryngoscope and the short-
Tracheal intubation techniques were achieved handled Macintosh laryngoscope for orotracheal
by blind or tactile (digital) means since the only intubation in pediatric patients with simulated
possible way to visualize the larynx was by indi- restriction of cervical spine movements showed
rect laryngoscopy utilizing small mirrors at the the Mac blade to be superior to pediatric Bullard
end of specially angled instruments [2, 7, 15]. laryngoscope with a faster laryngoscopy time
The technique of using a laryngoscope for and a higher success rate [18].
direct visualization of the larynx to insert an
endotracheal tube was first described in 1911 by
Chevalier L. Jackson (1865–1958), an American irst the Needle, Then the Syringe,
F
pioneer in laryngology, who is known as the Then Intravenous Anesthetics,
father of bronchoscopy and laryngoscopy. His and Finally the Amazing Amazonian
direct laryngoscope was U shaped with no curve Arrow Poison
at the tip but had a light for better visualization.
In 1941, Robert A. Miller designed the Miller The first recorded subcutaneous injection took
blade with a slight curve at the end to retract the place in 1844 by the Irish physician Francis Rynd
epiglottis. (1801–1861) who had invented the hollow needle
However, it was Sir Robert Reynolds to inject a sedative subcutaneously to treat neu-
Macintosh (1897–1989), the Nuffield professor ralgia. In 1853, Charles Pravaz and Alexander
of anesthetics at the University of Oxford, who Wood manufactured a syringe with a fine hypo-
is credited with the first description of direct dermic needle that could pierce the skin [19]. The
laryngoscopy to intubate the trachea – thus development of these devices – syringes and later
enabling the anesthesiologist a secure method of mechanical pumps – to deliver precise amounts
administering the anesthetic. During the admin- of drugs intravenously continuously per minute
istration of anesthesia for a tonsillectomy, he based on patient’s weight enabled physicians to
discovered that by indirectly elevating the epi- administer total intravenous anesthesia (TIVA).
glottis, he could have a “perfect display” of the Pierre-Cyprien Ore’ (1828–1891) was the first
cords. He described the method of routinely physician to attempt intravenous anesthesia by
placing the tip of the laryngoscope in the epi- administering chloral hydrate in a patient in
glottic vallecula, which is attached to the base of 1872, believing that this method was superior to
the tongue, and gently lifting to expose the inhaling chloroform. The combination of intrave-
entire larynx. Macintosh argued against the tra- nous morphine and scopolamine produced a state
ditional way of lifting the epiglottis in order to of “twilight sleep” which was popular in obstetric
avoid bradycardia and laryngospasm that could anesthesia and was widely used throughout the
result from vagal stimulation. It was soon evi- WW1 era [1, 6, 7, 8, 15].
dent that the use of the shorter more curved One of the intravenous drugs that made sig-
blade which bears his name (although slightly nificant impact on the anesthetic management of
altered as McIntosh) and his modified laryngo- the patient was sodium thiopental, a barbiturate
which was introduced in 1932. It was John traumatic complications of electroshock therapy
Lundy (1894–1973) who popularized its use in psychiatry.
while he was at the Mayo Clinic, but its popular- In 1857, Claude Bernard (1813–1878) pre-
ity waned because of cardiovascular depression sented his experimental findings that the site of
when administered. Lundy also introduced the action of curare was at the neuromuscular junc-
initial concept of “balanced anesthesia” where a tion, thus ushering the use of muscle relaxants
combination of different drugs could be used into anesthesia and surgery.
synergistically for general anesthesia to decrease “Balanced anesthesia” in its true modern
the side effects of each when used alone in large sense was described by T. Cecil Gray in 1946,
amounts [1]. 100 years after the discovery of anesthesia. He
Etomidate was discovered in 1973, and introduced the “Liverpool technique,” the prac-
because of its ability to maintain hemodynamic tice of intravenous induction, muscle relaxation,
stability, it continues to be used successfully in light general anesthesia, controlled ventilation,
patients with marginal cardiac reserve. Ketamine and reversal of muscle relaxation with a cholines-
was another interesting drug synthesized in 1962, terase inhibitor [20].
which could be given intravenously as well as After curare, other drugs were synthesized and
intramuscularly. Despite its hallucinogenic used but discarded because of unwanted side
effects when given alone and in large amounts, it effects. Steroid-based intravenous muscle relaxants
gained popularity in providing analgesia and car- such as pancuronium (1966), vecuronium (1980),
diovascular stability when used in combination and rocuronium (1991) have remained in the clini-
with other anesthetic agents as in balanced anes- cal use having replaced the older drugs [6, 7].
thesia as suggested by Dr. Lundy earlier [6, 7]. Sigmund Freud (1956–1939) and Carl Koller
Anesthesia was practiced without the use of (1858–1944) discovered the numbing effect of
muscle relaxants until the discovery of curare, an cocaine when applied topically, and regional
alkaloid extract from the plant Chondrodendron anesthesia soon became an invaluable addition to
tomentosum. It was used as an “arrow poison” or general anesthesia. Newer drugs were soon dis-
“flying death” to paralyze the prey by the South covered, and novel methods of applying them to
American indigenous people. The tips of the produce sensory block expanded the scope of
arrows or blow gun darts which were shot from anesthesia far beyond human imagination and
hollow bamboo “tubes” were first dipped in this improved the safety and ease of administering
paralyzing agent called curare – a word derived anesthetics and analgesics to alleviate the pain
from the word “wurari” from the Carib language during surgery [1, 2, 3].
of the Macushi Indians of Guyana. Propofol arrived in 1977 and revolutionized
When curare was purified, the main toxin the scope of intravenous anesthesia by providing
obtained was called D-tubocurarine to denote its smooth anesthetic induction, maintenance, and
origins of being packed in hollow bamboo tubes. rapid emergence, thus becoming increasingly
It functions by competitively and reversibly useful in adult and pediatric anesthesia. It has
inhibiting the nicotinic acetylcholine receptor antiemetic properties, has a short recovery period,
(nAChR), which is a subtype of acetylcholine and is superior in suppressing laryngeal reflexes
receptor found at the neuromuscular junction [1, 2, 3, 7]. Propofol has become the most com-
[20]. This causes weakness of the skeletal mus- monly used intravenous drug in providing seda-
cles and, when administered in a sufficient dose, tion and general anesthesia alone or in
eventual death by asphyxiation due to paralysis combination with a short-acting narcotic like
of the diaphragm. If the respiration was sup- remifentanil in TIVA during many surgeries
ported by artificial means, then the animal would where inhalational agent is undesirable. TIVA
wake up as if nothing had happened during the has gained popularity in providing anesthesia in
time of paralysis. It was used as an “interrupter” suspension laryngoscopy and airway visualiza-
of the neuromuscular junction mainly to prevent tion for endoscopic surgery.
6 S. T. Verghese
Dexmedetomidine (Precedex®) is the dextro cardial depression and the potential for hepatic
optical isomer of medetomidine, a pharmacologi- damage [7]. Halothane is no longer available in
cally potent selective alpha-2 adrenoceptor ago- the United States, but is still used in developing
nist with sedative, sympatholytic, anxiolytic, and countries, particularly in pediatric patients.
analgesic-sparing properties. It is similar to Methoxyflurane – another inhalational agent –
clonidine but differs in its eightfold greater affin- was also removed because of nephrotoxicity
ity for alpha-2 receptors than alpha-1 receptors resulting from high fluoride concentration during
compared to clonidine. Dexmedetomidine pro- its metabolism. All halogenated methyl ethyl
duces its hypnotic action by activation of central ethers can also cause myocardial depression as
pre- and postsynaptic alpha-2 receptors in the well as depress the respiratory response to carbon
locus coeruleus. The quality of sedation and dioxide and to hypoxia [6, 7].
unconsciousness is similar to natural sleep in The search for an ideal inhalational anesthetic
patients who appear cooperative and easily arous- agent still continues slowly. Xenon, one of the
able. Dexmedetomidine can produce transient noble gases, which has been studied because of
hypertension, bradycardia, and hypotension its inertness, has limited use in clinical practice
when given as a bolus because of peripheral because of its prohibitive cost, which is about
vasoconstriction and sympatholysis. Since its 2000 times the cost of nitrous oxide [23].
approval for procedural sedation by the Food and Xenon has anesthetic and analgesic properties
Drug Administration in 2003, it has been used in and is devoid of toxicity and side effects. It dis-
pediatric sedation, premedication by novel plays the characteristics of an ideal anesthetic
routes – buccal and intranasal – and for preven- agent by providing exceptional hemodynamic
tion and treatment of emergence delirium in chil- stability and rapid emergence from anesthesia, as
dren especially if there is no intravenous line. well as the ability to protect against ischemic
One of the major advantages of dexmedetomi- damage to vital organs like the heart and the
dine over other sedatives is its minimal respira- brain. Closed-circuit xenon delivery has been
tory depression in adults and children [21]. achieved clinically in study patients by utilizing
The use of dexmedetomidine in children with an efficient gas delivery protocol, which elimi-
OSA has been extremely useful in decreasing nated wastage, and recovered xenon from exhaled
narcotic use significantly in the postoperative gas by simple breathing hose alterations. These
period. An intraoperative infusion of dexmedeto- special delivery techniques may make its use
midine combined with inhalation anesthetics dur- clinically possible (despite the high cost) in
ing T&A provided satisfactory intraoperative selective patients where neuro- and cardioprotec-
conditions without any adverse hemodynamic tion may be at risk with conventional drugs [24].
effects. The authors also reported a decrease in Another noble gas, somewhat like xenon, is
the incidence and duration of severe emergence helium. Helium is less dense than air or oxygen,
agitation with fewer patients having desaturation and so it can travel past airway obstruction pro-
episodes [22]. viding a laminar airflow. The use of heliox is
Current inhaled agents are ether-based anes- believed to reduce work of breathing, respiratory
thetics with either a methyl ether (enflurane, iso- distress, and postextubation stridor [25]. Short-
flurane, and desflurane) or a methyl isopropyl term benefit of heliox inhalation has been
(sevoflurane) polyhalogenated ether skeleton –all reported in children with moderate to severe
of which are more stable and potent than its par- croup [26].
ent compound, diethyl ether. Halothane – a fluo- Anesthesia induction has evolved from open
rinated alkane – was synthesized by a British drop ether and chloroform to semi-closed non-
chemist Charles Walker Suckling (1920–2013) in rebreathing and to circle systems. The newer sys-
1954 and introduced clinically in 1956. Halothane tems with disconnect alarms and interlocks to
enjoyed some years of popularity in pediatric prevent delivery of hypoxic mixtures enhance
anesthesia before being shelved because of myo- safety while reducing both the cost and
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environmental pollution. Inhaled anesthetics adult and pediatric anesthesia. However, the
have become much safer compared to the older question whether the frequent use of LMA may
agents with fewer side effects. Currently the most have lessened the ability of the anesthesia trainee
common inhalational agents used in pediatric to master the technique of the proper bag and
anesthesia include sevoflurane, which is less pun- mask ventilation during inhalational induction
gent and thus easy to use as induction agent and remains controversial.
desflurane, which is strictly used for maintenance The LMA has become an important tool in the
of anesthesia in intubated patients. Desflurane is management of the difficult airway algorithm.
never used as an induction agent because of its Both older and newer supraglottic airway devices
pungency and airway irritability. It is an ideal have been studied in children and have become
agent for maintenance in prolonged surgeries invaluable in managing difficult airway [29].
especially in obese patients because of its lack of A recent technological update on EADs high-
tissue accumulation and speed of emergence. lights the improvements in their design, safety,
Anesthesia delivery systems have come a long and functionality. These innovations include the
way from their modest origins, and the modern shape of the mask, number of cuffs, and quality
anesthesia ventilators are capable of multimodal of the construction material used. In order to
functions and pressure waveform integration. increase flexibility of the device, phthalates were
used initially but eliminated later because of the
adverse effect on reproductive function. The for-
Extraglottic Airway Devices (EAD) mation of the Airway Device Evaluation Project
Team (ADEPT) by the Difficulty Airway Society
Dr. Archie Brain, a brilliant anesthesiologist in (DAS) was initiated by the arrival of numerous
East End of London in 1981, created a new type airway devices with different designs into the air-
of airway which could be inserted easily as an way market to improve the safety of the patient
alternative to the endotracheal tube or the face [30].
mask [27]. This extra- or supraglottic airway was EADs have been used safely over 200 million
called the laryngeal mask airway (LMA) and times in the last 3 decades, and its introduction is
marketed in late 1987 after undergoing some considered as the most important development in
years of material and design modification. The airway management over the last 50 years [31].
pediatric classic LMA (cLMA) arrived into the
clinical arena first followed by flexible and
ProSeal LMAs with additional features and later Intraoperative Ventilation
the reusable and disposable forms. The advanced Techniques During Airway Surgery
models soon followed: LMA supreme and i-gel
with gastric drain port as well as the Air-Q and The field of airway management is continuously
Ambu Aura-i, the first intubating airway devices evolving. Pediatric anesthesiologists who work
in pediatric sizes. These newer LMAs were daily with ENT surgeons intuitively know the
designed to decrease gastric insufflation, protect usual intra-op ventilation strategy in healthy chil-
the airway, and allow effective ventilation as well dren with ASA status 1 or 2 scheduled for EUA,
as provide a secure definitive airway in difficult bilateral myringotomies and tube placement, and
intubation scenarios [28]. routine tonsillectomy and adenoidectomy as
The LMA became the rapidly accepted form detailed in the chapter included in this book.
of airway management globally, thus revolution- However, if patients with ASA status 3 or 4 with
izing anesthetic practice in adults and children. unusual preoperative systemic issues are sched-
The easy insertion of LMA without the aid of a uled even for routine surgery, they will need spe-
laryngoscope enabled anesthesiologists to pro- cial preparation and planning. These can include
vide hand-free anesthesia for the first time. This children who present with morbid obesity
was a definite game changer in the practice of (BMI > 40), severe OSA, critical airway
8 S. T. Verghese
narrowing, lung parenchymal loss, and global depression or airway collapse and with minimal
developmental delay with swallowing difficulty hemodynamic effect. DISE is usually reserved for
causing micro-aspiration, as well as children with those children with persistent OSA after tonsillec-
severe systemic diseases who are unable to main- tomy, those with OSA without enlarged tonsils, or
tain normal ventilation because of hypotonia, in a child in whom you suspect the occurrence of
loss of FRC from abdominal masses, and central laryngomalacia when asleep. DISE is also used to
apnea when anesthetized. These patients are usu- determine surgical therapy for OSA.
ally intubated, and their ventilation controlled Intravenous infusion of propofol is the most
intraoperatively with or without paralysis, and if commonly used agent for DISE in adults. A com-
extubation is expected to be difficult in the imme- prehensive review of literature regarding pediat-
diate postoperative period, they are observed in ric DISE concluded that the protocol using
the intensive care unit overnight. Significant mor- dexmedetomidine (DEX) and ketamine appeared
bidity and mortality can result from poorly to be safe, and they were the drugs most com-
planned and therefore sub-optimally managed monly used. The authors recommended this com-
pediatric airway. Ventilation techniques and air- bination of DEX and ketamine due to the lower
way management of neonatal, obese children and risk of respiratory depression and upper airway
those with known airway problems and syn- obstruction as compared with other agents. It is
dromes scheduled for routine and endoscopic also recommended to discontinue the inhala-
surgery are detailed in several of the following tional anesthetics if used for induction to insert
chapters in this book. an intravenous (IV) line as soon as intravenous
The use of intravenous dexmedetomidine and sedation starts [33]. Inhalational anesthetics
ketamine as bolus and as infusion has enabled the have been shown to decrease upper airway mus-
anesthesiologist to produce sedation without cle activity and therefore need to be eliminated to
causing respiratory depression. The use of prevent compromising the findings during DISE.
ultrashort-acting narcotics like remifentanil, as an Good communication between the anesthesia
infusion during airway surgery in combination providers and airway surgeon is crucial as chil-
with intravenous propofol, has been very effective dren with OSA are at greater risk for airway
in producing an optimal surgical environment obstruction and oxygen desaturation when
during endoscopic laser excision of papillomas or sedated, and oversedation can result in airway
extraction of foreign bodies from the airway in a compromise and/or central apnea.
spontaneously breathing patient [32]. Although DISE is an objective method to
observe dynamic airway obstruction, the assess-
ment and classification of the findings can
rug-Induced Sleep Endoscopy
D become subjective and biased because of the
(DISE) above reasons [33].
Another review on the effects of anesthesia
It is sometimes necessary to create a pharmaco- and opioids on the upper airway described the
logically induced sleeplike state or drug-induced dose-dependent effects of propofol on the upper
sleep endoscopy (DISE) to evaluate the dynamic airway as causing uniform narrowing throughout
upper airway collapse in children with obstructive the pharyngeal airway in infants and at the level of
sleep apnea (OSA) using a flexible endoscope. It the epiglottis in older children. Dexmedetomidine
was pioneered at Royal National Throat, Nose and did not show these dose-dependent effects when
Ear Hospital, London, in 1990 and initially intro- evaluated by cine magnetic resonance imaging
duced as sleep nasendoscopy. The choice of ideal when compared to sevoflurane, isoflurane, and
drugs during DISE is crucial for obtaining accu- propofol, and it caused less dynamic airway col-
rate results. These drugs should be able to produce lapse than propofol [34].
analgesia while simulating a natural sleep in the In a retrospective review of the records of 59
patient without producing excessive respiratory children presenting for DISE, another group of
authors concluded that propofol when used alone For example, an infant with no history or symp-
or combined with sevoflurane produced more tom of stridor is suggestive of clinical airway
oxygen desaturations and a lower rate of success- obstruction when awake but becomes completely
ful completion than a combination of dexmedeto- obstructed during anesthetic induction due to a
midine and ketamine during DISE in children pre-existing subglottic hemangioma – a scenario
with OSA [35]. that can be challenging for even the most experi-
A third review in children to compare the enced pediatric anesthesiologist. High incidence
agents for DISE based on agent-specific neuro- of airway hemangiomas in infants diagnosed with
pharmacology concluded that compared to pro- PHACE (posterior fossa anomalies, hemangio-
pofol and midazolam, dexmedetomidine’ s mas, arterial lesions, coarctation of aorta, and eye
mechanism of action appeared to simulate natu- anomalies) syndrome can present with or without
ral sleep pathways [36]. stridor. Early detection of airway involvement is
critical by performing direct laryngoscopy and
bronchoscopy in all of these patients. An airway
Controversies in Airway evaluation is recommended in infants with PHACE
Management in Children even if they are asymptomatic [38]. Anesthetizing
an infant with PHACE syndrome without stridor
In a comprehensive review of the current rel- in a remote location like the MRI suite and encoun-
evant literature using Google Scholar, PubMed, tering an occluding subglottic hemangioma during
MEDLINE (OVID SP), and DynaMed, and the study can be a critically challenging situation
the keywords Airway(s), Children, Pediatric, for the anesthesiologist and may need termination
Difficult Airways, and Controversies, the of the imaging study and emergent evaluation by
authors identified several controversies in pedi- the ENT specialist [39]. Airway difficulty in
atric anesthesia: difficult airway prediction, asymptomatic children scheduled for non-airway
difficult airway management, cuffed versus surgery can and do occur, and the preoperative
uncuffed endotracheal tubes for securing pediat- evaluation by history and physical examination
ric airways, rapid sequence induction (RSI), use should be undertaken in a systematic manner to
of laryngeal mask versus endotracheal tube, and prevent its possible occurrence in every patient.
extubation timing. Availability of an appropriate-sized LMA for the
The data collected showed that the proce- patient in the room is an important part of dealing
dural steps in airway management in pediatric with any child who unexpectedly appears to be
anesthesia are currently based on adult airway difficult to intubate [40].
management protocols due to lack of strong evi- A Cochrane review which included seven tri-
dence-based medicine data in children [37]. als involving a total of 794 infants showed that
LMA can achieve effective ventilation during
newborn resuscitation in a time frame consistent
Highlights with current neonatal resuscitation guidelines.
LMA was found to be more effective than bag
hould One Anticipate Unexpected
S and mask ventilation in terms of shorter
Airway Loss in Every Patient resuscitation and ventilation times and less need
Scheduled for Surgery and Have for endotracheal intubation [41].
an LMA as a Backup Plan, Even
in a Newborn?
ho Should Anesthetize These
W
A patient with a known difficult airway is eas- Children? Where?
ier to manage than an airway that suddenly
becomes difficult because of unexpected airway Another controversy regarding the performance of
obstruction. these complex airway surgeries is the question as
10 S. T. Verghese
to who should ideally be assigned to manage the born. The popularity could be due to the fact that
pediatric airway. An anesthesiologist with some newer low-pressure high-volume cuffed tubes
pediatric experience who manages an occasional has enabled its use in neonates and small infants.
pediatric patient in an adult hospital setting vs a New cuffed endotracheal tubes (Microcuff pedi-
fellowship trained pediatric anesthesiologist with atric tracheal tube, Microcuff GmbH, Weinheim,
airway skills in a specialized pediatric hospital. Germany, and Microcuff® PET, Kimberly Clark,
In children with anatomical upper airway Health Care, Atlanta, GA, USA) with improved
obstruction from tonsillar and adenoidal hyper- tracheal sealing characteristics and a recommen-
trophy or upper airway collapse, mask ventilation dation chart for tube size selection have been
can become difficult, and the use of high airway introduced in the market [44]. The Microcuff
pressure can lead to gastric inflation and transient tube consists of an ultrathin polyurethane cuff
hypoxia due to acute reduction of functional (10 μm), which does not form folds and channels
residual capacity (FRC). Insertion of an oral air- between the cuff and the tracheal wall. The elimi-
way during insufficient depth of anesthesia in a nation of the Murphy eye has allowed the cuff to
child with a partially obstructed upper airway can be moved more distally on the cuffed endotra-
also lead to laryngospasm and/or bronchospasm. cheal tube shaft. The cuff is short, and when
In the absence of an established intravenous line, inflated, it expands below the subglottis, provid-
early recognition and treatment of these func- ing a seal with cuff pressure less than 10 cm
tional airway problems are essential to prevent H2O. It has correctly placed depth markings and
morbidity and mortality. As a rule it is good to has low tube exchange rate. A recent meta-
have another trained person who can place an analysis showed that cuffed endotracheal tube
intravenous line to administer anesthetics or reduced the need for tube changes and did not
relaxants as needed as the anesthesia provider is show a higher incidence of post-extubation stri-
managing the airway. A review of the current dor when compared with uncuffed endotracheal
concepts in approaching a child with a difficult tubes [45]. Another study showed that the use of
airway stated that although a normal pediatric cuffed tubes in small children provides a reliably
airway that becomes “impaired” on induction sealed airway at cuff pressures of 20 cm H2O,
may be managed by anesthetists experienced reduces the need for tube exchanges, and does
with children, the anticipated difficult pediatric not increase the risk for post-extubation stridor
airway should be managed by a dedicated pediat- compared with uncuffed endotracheal tubes.
ric anesthesia specialist in specialized centers However, the cost of pediatric endotracheal tube
[42]. The airway in infants and children can with Microcuff is several times more than those
become challenging due to [1] the difficulty in in routine use without cuff [46]. Measuring cuff
obtaining a mask seal [2], difficulty in visualizing pressure is important because of potential for
the vocal cords, and the rare scenario where the increase in cuff pressure which can damage
larynx is visualized, but the difficulty lies at or underlying tracheal mucosa. Periodical monitor-
beyond that level in the form of bronchomalacia ing of cuff pressure is recommended in children
or extrinsic airway compression [43]. especially during long surgery [47].
se of Cuffed Endotracheal Tube

U I s There a Role for True Rapid
Versus Uncuffed Endotracheal Tubes Sequence Induction (RSI) in Children?
in Neonates, Infants, and Very Young Should We Use Rocuronium Instead
Children: Should We Check Cuff of Succinylcholine Now that We Have
Pressure Frequently? Sugammadex?
Currently almost all pediatric anesthesia centers The use of true RSI is controversial on two
routinely use cuffed tubes in children and new- accounts: the application of cricoid pressure also
known as Sellick’s maneuver (SM) to prevent overcome this desaturation while providing mus-
gastric aspiration and the need for succinylcho- cle relaxation and adequate depth of anesthesia.
line – the fastest-acting depolarizing muscle
relaxant. Although the cricoid pressure is often
applied in pediatric patients with full stomach, it xtubation in Children: Deep Versus
E
can worsen intubating conditions and also led to Awake
a lower esophageal sphincter tone. This lowering
of esophageal sphincter tone by cricoid pressure If ventilation was easily maintained with a mask
is not attenuated by metoclopramide [48]. The airway on induction of anesthesia and endotra-
other problem with true RSI is the use of succi- cheal intubation was established without any dif-
nylcholine in children with full stomach scenar- ficulty and if there is no risk of aspiration in a
ios after recommendations from the Food and spontaneously breathing healthy patient, then
Drug Administration (FDA) to reserve the drug deep extubation can be undertaken to minimize
only for emergency situations. Currently the use coughing and cardiovascular stimulation.
of this drug falls into the category of drugs “one
should always have but seldom use.” There are iming and Positioning for Extubation
T
situations where RSI with succinylcholine may Most experienced anesthesiologists time this
be needed as in a child with post-tonsillectomy extubation after suctioning the mouth and at the
bleed with a full stomach or a child with a bowel moment of end inspiration to decrease incidence
obstruction. Although we do not have a neuro- of laryngospasm. Placing children in the lateral
muscular blocker with the same fast onset as suc- position and suctioning the mouth also help
cinylcholine, rocuronium can now be used at a decrease this complication. The upper airway of
higher dose to enable intubation in 60 s, and its a sedated, spontaneously breathing child has
action can be reversed with the newly approved been shown to be wider in the lateral position in
reversal agent sugammadex – a chelating agent an MRI study in children. The region between the
with high specificity for rocuronium reversal. tip of the epiglottis and the vocal cords demon-
This is especially important if rocuronium was strated the greatest relative percent increase in
used in a child for the removal of a foreign body, size [50]. Despite the evidence of airway diame-
and the procedure is completed in less than ter being wider in the lateral or recovery position
10 min. A dose of 2 mg/ kg of sugammadex has in children, it is unfortunate that this particular
been used successfully to reverse a profound position is not universally accepted as a safer
block due to rocuronium use in a child [49]. This position to transport children after deep extuba-
can also be helpful in difficult airway scenarios to tion following T&As. Recovery position allows
re-establish spontaneous ventilation if the airway for blood and secretions to pool on the dependent
was lost after paralysis with rocuronium. side of the mouth instead of dripping back into an
Many pediatric anesthesiologists prefer a unprotected airway after extubation. One study
“modified RSI” instead of a classical RSI because looked at the incidence of laryngospasm after a
they find the strict no manual hand bag ventila- carefully defined awake extubation in children
tion rule during classic RSI difficult to follow in after elective tonsillectomy. The technique
clinical scenarios in children. This is mainly due involved turning anesthetized children into the
to the rapid fall in oxygen saturation in most recovery position and then turning the inhala-
young children as soon as you administer a drug tional agents off. No further stimulation was
to cause apnea. Neonates and young infants have allowed till the child awoke on his/her own. This
reduced lung capacity, but higher oxygen con- “no-touch” technique in children placed in the
sumption and oxygen desaturation are inevitable lateral or recovery position prevented any cough-
even if they are well preoxygenated prior to RSI. ing, desaturation, or incidence of laryngospasm
The “modified RSI technique” allows gentle [51]. Most experienced pediatric anesthesiolo-
intermittent face mask ventilation with oxygen to gists currently use deep extubation technique
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conceptos más graves, publicólo, con una
continuación, Cervantes de Salazar en 1546;
tradújolo al italiano Alonso de Ulloa y lo publicó en
Venecia, 1563. Compuso además: De las Potencias
del alma y buen uso de ellas. Muestra de la Lengua
Castellana en el nacimiento de Hércules ó Comedia
de Amphitryon, tomado el argumento de la Latina de
Plauto. Hécuba triste, de Eurípides. Razonamiento
que hizo en el ayuntamiento de la Ciudad de
Córdova sobre la navegación del Río Guadalquivir.
Razonamiento que hizo en Salamanca el día de la
lición de oposición de la cátedra de Philosophía
moral. Títulos ó inscripciones en latín para las aulas
de la Universidad Salmanticense. Enigmas en verso
de arte mayor (octavas). Lamentación al saqueo de
Roma, año 1527, en coplas de pie quebrado. Todas
estas obras fueron juntamente publicadas por
Ambrosio de Morales, su sobrino, en Córdoba, 1586:
Las obras con otras cosas, Córdoba (comenzóse á
escribir en Salamanca). Dejó sin acabar un Discurso
en latín sobre la piedra imán, donde trató de "cómo
se pudiesen hablar dos absentes", que no es más
que el telégrafo moderno.
16. Hernán Pérez de Oliva, Obras, Madrid, 1787, 2 vols. Diálogo de
la dignidad del hombre, Bibl. de Aut. Esp., t. LXV. Consúltese: M.
Menéndez y Pelayo, Páginas de un libro inédito, en La Ilustración
Española y Americana (1875), t. XIX, págs. 154-155 y 174-175;
sobre todo en el Razonamiento que hizo (Pérez de Oliva) en
Salamanca el día de la lición de oposición de la cátedra de
Philosophía moral, donde nos da noticias de su vida.
17. Año 1518. Mateo Adriano publicó Introductiones in linguam

Hebraicam, 1518.—Fray Alberto de Aguayo, de la Orden de
Predicadores, publicó el Libro de Boecio Severino, intitulado De la
Consolación de la Filosofía, agora nuevamente traducido de latín en
castellano por estilo nunca visto en España, Sevilla, 1518; ibid.,
1521.—Gonzalo Arredondo y Alvarado († 1518), benedictino en
Arlanza y su abad, burgalés, de cerca de Belorado, escribió la
Crónica Arlantina de los famosos y grandes hechos de los
bienaventurados cavalleros sanctos conde Fernán Gonçález y Cid
Ruy Díez... (Ms. Escorial, con permiso para la impresión de 1522).
El Castillo inexpugnable y defensorio de la fe, Burgos, 1528,
póstumo. Historia del Monasterio de Arlanza (ms.). Arlantina, poema
en redondillas (ms. Acad. Historia).—Ordenanzas reales de Castilla.
Burgos, 1518; Toledo, 1549; Salamanca, 1560; Alcalá, 1565.—Don
Francisco de Castilla, palentino, gobernador en 1518 de Baza,
Guadix, Almería, etc., publicó, en natural y elegante estilo, la Teórica
de virtudes en coplas de arte humilde con comento... Práctica de las
virtudes de los buenos reyes de España en coplas de arte mayor.
Murcia, 1518; Zaragoza, 1552; Alcalá, 1554, 1564. De los tratados
de filosofía moral en coplas, de don Francisco de Castilla, los
siguientes: El Proemio de su Teórica de virtudes. Los Proverbios.
Inquisición de la felicidad en metáfora. La satírica lamentación de
humanidad. Otras cosas de devoción trovadas y algunas en latín,
Sevilla, 1546: es la misma obra anterior, Zaragoza, 1552; Alcalá,
1554, 1564; Zaragoza, 1570.—Juan Dolz, de Castellar (Teruel),
catedrático en París, publicó Cunabula omnium fere scientiarum et
precipue physicalium difficultatum in proportionibus proportionalibus,
Montalbán de Francia, 1518.—Pedro Cándido Dezimbre publicó,
traducido, Quinto Curcio. Historia de Alexandro magno, Sevilla,
1518.—El licenciado Alonso Espina publicó Tratado contra toda
pestilencia y ayre corrupto, Valladolid, 1518.—Jerónimo López
publicó Libro primero del esforçado Cavallero don Clarián de
Landanis, Toledo, 1518; Sevilla, 1527; Medina, 1542. Libro II de la
Historia de don Clarián de Landanis, traducido en castellano por
Albaro físico, Sevilla, 1550; Toledo, 1522. Libro III de la Historia
de..., Toledo, 1524. La quarta parte de don clarián, en la qual se
trata de... Lidaman de Ganayl, Toledo, 1528.
18. Año 1519. El capitán Gonzalo Hernández de

Oviedo y Valdés (1478-1557) nació en Madrid,
entró desde su niñez al servicio de don Alfonso de
Aragón, segundo Duque de Villahermosa, á los trece
de su edad, como mozo de Cámara del príncipe don
Juan, que tenía los mismos años que él, y á su
muerte (1497) partióse á Italia de soldado, siendo
luego familiar del rey don Fadrique, secretario en
España del Gran Capitán. Fué á América como
veedor de las fundiciones del oro (1514), luego
regidor y teniente del Darien en Tierra Firme y
gobernador electo de la provincia de Cartagena.
Nombróle Carlos V cronista de Indias, alcaide de la
fortaleza y regidor de Santo Domingo, y vuelto á
España, falleció en Valladolid, cumplidos los setenta
y nueve años. Ni la confianza de los españoles en el
Nuevo Mundo ni la predilección de la Corte fueron
bastantes á engendrar en su pecho bastardas
ambiciones, contento siempre con la medianía que le
había tocado en suerte, trabajando sin cesar por la
justicia en aquellas partes. Doce veces cruzó el
Océano, yendo á América los años 1514, 1520,
1526, 1532, 1536 y 1549. Las ciudades del Darien,
Panamá y Santo Domingo, mirándole como su
libertador, acudieron constantemente á su lealtad
para que les sacase de los mayores apuros. La Real
Chancillería de la Isla Española no se desdeñó de
investirle con su representación y poderes,
sucediéndole siempre bien y en provecho de sus
representados. Y entre tantos y tan espinosos
negocios y correrías tantas, tuvo tiempo para escribir
todos los acontecimientos de su tiempo, á los cuales
había asistido ó conocido á los principales
personajes y aun tratádoles con familiaridad y
amistad, á Colón, al rey don Fernando, al Gran
Capitán, á Las Casas, á los Conquistadores, á
Carlos V. Pero su obra de mayor momento fué la que
enseñó á España y á Europa entera las maravillas
de la naturaleza de América, la historia de la
Conquista, los intentos é intereses de los que la
llevaron al cabo. No tienen precio sus infinitas
noticias sobre las hazañas y sobre las torpezas
mismas cometidas por los españoles en América,
sobre las costumbres de los indios, naturaleza de
plantas, animales y muchedumbre de cosas, que
describe como quien las ha visto, en estilo llano y sin
pretensiones, con aquella fresca naturalidad del
historiador imparcial y grande observador de las
cosas, de los hombres y de sus acciones. Es el
Plinio americano y el más transparente historiador de
aquella época, la más importante de la vida de la
nación española, de los Reyes Católicos y del
emperador Carlos V, mayormente en lo tocante á las
primeras conquistas del Nuevo Mundo. No abarca
como filósofo en conjunto los grandes
acontecimientos; pero en cambio se detiene en
pormenores, que otros menospreciarían,
pintándonos con mayor viveza los hechos, los
hombres y los objetos, sin faltarle de vez en cuando
el calor que le comunica la visión de cosas tan
maravillosas, de tan grandiosos acaecimientos y de
tan pasmosas empresas.
(Toledo, 1526).
19. Batall.: "Yo nací año de 1478". Era oriundo del valle de Valdés,
en las Asturias de Oviedo. Bat.: "Porque la villa de Cortes en
Navarra era en essa saçón de doña Leonor de Soto, duquesa de
Villahermosa, mi señora, madre de don Alonso de Aragón, duque de
Villahermosa, mi señor, que me crió, al qual yo serví antes que
sirviesse al príncipe don Juan". Á la muerte de éste es cuando se
partió á Italia: "Mi descontento me llevó fuera de España á
peregrinar por el mundo, habiendo passado por mí muchos trabaxos
y nescessidades, en diversas partes discurriendo, como mancebo, á
veçes al sueldo de la guerra y otras vagando de unas partes y
reynos en otras regiones". "Discurrí por toda Italia, donde me di todo
lo que yo pude saber é leer y entender la lengua toscana y
buscando libros en ella de los quales tengo algunos que ha más de
cincuenta y cinco años (escribía en 1555) que están en mi
compañía, deseando por su medio no perder de todo punto mi
tiempo". "En el mes de mayo de 1502, en otra armada, tornó á
navegar la Reina, mi señora y dentro de ocho días fuymos á
España, en Valencia del Cid, donde estaba su madre, y pocos
meses después que ove dado cuenta de la cámara, con licencia de
la reina, mi señora, fuy á Madrid, mi patria". Casó con Margarita de
Vergara, "más mancebo y con menos hacienda que fuera
menester", á los veinticuatro de su edad; murió ella á los pocos
meses, de sobreparto. Estuvo en la guerra y victoria del Rosellón
(1503). Volvió á casarse, y en 1509 tuvo un hijo. "Para volver á Italia
el Gran Capitán, el qual quiso servirse de mí de secretario..., me
volví á la Corte". Partióse á América con Pedrarias Dávila, con el
oficio de Veedor de las fundiciones del oro y de Secretario general,
en 1514, á los treinta y seis de su edad; pero volvióse á dar cuenta
de la tiranía del Gobernador al Rey, el cual falleció entonces; Carlos
V le despachó bien, fué nombrado teniente del Gobernador de
Darien; perdió á su mujer; trataron de asesinarle, y embarcóse
secretamente para España, donde acusó á Pedrarias, y obtuvo la
gobernación de Cartagena, de donde pasó á Nicaragua. Nombrado
procurador por las ciudades de Panamá y Santo Domingo, vino de
nuevo á España, nombróle Carlos V cronista de Indias, adonde
volvió, siendo elegido alcaide de la fortaleza de Santo Domingo.
Tornó, con nueva procuración, á España en 1534, y el año siguiente
publicó la primera parte de la Historia general y natural de las Indias,
en que había trabajado cuarenta y tres años, siendo recibida con tan
general aceptación, que "estaba ya en lengua toscana y francesa é
alemana é latina é griega é turca é arábiga". Por quinta vez volvió á
América en 1536, y por última vez, en 1549, y en 1556 estaba en
España, donde, á poco, murió, impidiéndose así la impresión del
resto de su obra principal. Obras de Oviedo. El libro del muy
esforçado et invencible caballero de la Fortuna propiamente llamado
don Claribalte, Valencia, 1519: obra que hizo después de la primera
vuelta de América, cuando todavía los hechos militares y su primera
visión americana le llenaban el alma de las ficciones caballerescas
tan en boga á la sazón. La Respuesta á la Epístola moral del
Almirante, 1524 (Ms. Bibl. Nac), del almirante don Fadrique
Enríquez. Relacion de lo subçedido en la prision del Rey Francisco
de Francia desde que fué traydo á España..., 1525, pinta la Corte de
la época. Sumario de la natural y general istoria de las Indias ó
Historia de Indias, Toledo, 1526; Sevilla, 1535; traducida al latín y
reimpresa por Andrés González Barcia en el t. I de los Historiadores
primitivos de las Indias occidentales. Cathalogo Real de Castilla y de
todos los Reyes de las Españas é de Nápoles y Secilia, é de los
Reyes y señores de las casas de Francia, Austria, Holanda y
Borgoña..., 1535 ó Historia general de Emperadores, Pontífices,
Reyes, etc. (Ms., Bibl. Escor.), 450 folios, con las fábulas consabidas
en los orígenes; pero de valor desde la Edad Media, por haber
depurado los hechos y cotejado muchas crónicas. Libro de la
Cámara Real del Príncipe don Juan y offiçios de su casa é serviçio
ordinario, 1546 y 1548 (Ms. Bibl. Esc. y Real), publicado en Madrid,
1870 (Bibl. Españ.), precioso arsenal de noticias sobre este asunto.
Reglas de la vida espiritual y secreta theologia, Sevilla, 1548,
traducción del italiano. Batallas y Quinquagenas, escritas en 1550,
obra de genealogista, con muchas noticias del tiempo de los Reyes
Católicos y anécdotas (Ms. Bibl. Nac., Real y de la Acad.). Tractado
general de todas las armas é diferencias dellas é de los escudos...,
1550 ó 1551, obra de blasón, curiosa (Acad. Hist.). Libro de linages
y armas, 1551 ó 1552 (Acad. Hist.). Las Quinquagenas de los
generosos é illustres é no menos famosos reyes, prínçipes, duques,
marqueses y condes é caballeros é personas notables de España,
escritas en Santo Domingo de 1555 á 1556 y publicadas en Madrid,
1880; en 7.500 versos de arte menor, en tres Quinquagenas de á 50
estanzas, y cada estanza de 50 versos; tienen muchas noticias,
además de las sentencias ó proverbios morales. Historia General y
Natural de las Indias, Islas y Tierra Firme del mar Océano, los
primeros 20 libros impresos en Sevilla-Salamanca, 1535-1537; con
los restantes hasta 50, en Madrid, 1851-1855, 4 vols., por la
Academia de la Historia. Es la principal obra de Oviedo, monumento
imperecedero. Véase Prescott, Historia de los Reyes Católicos, t. I,
pág. 112. La Vida y Obras de Oviedo, por José Amador de los Ríos,
en la edición de la Academia de la Historia general y natural de las
Indias, Madrid, 1851-1855, 4 vols.; Las Quinquagenas, ed. V. de la
Fuente (Academia de la Historia), Madrid, 1880 (ed. sin acabar).
Consúltese: A. Morel-Fatio, en Revue Historique (1883), t. XXI,
págs. 179-190. La Historia del Estrecho de Magallanes, 1557, se
extractó de la obra grande.
20. Año 1519. Cristóbal de Arcos, sevillano, capellán del

arzobispo Deza, publicó Itinerario de... micer Luis Patricio Romano:
en el qual cuenta mucha parte de la ethiopía Egypto y entrambas
Arabias: Siria y la Yndia. Buelto de latín (de Luis Varthema
Bolognese), Sevilla, 1519; ibid., 1523, 1570. La cruenta conquista y
lamentable batalla de Rodas, del latín, de Jacome Fontano, Sevilla,
1526; Valladolid, 1549, 1564; Medina, 1571. Reprobación... contra la
falsa pronosticación del diluvio... Compuesta por el excellente
filósofo Augustino Nifa, saesano. Vuelta de latín en vulgar
castellano, Sevilla.—Cancionero de obras de burlas provocantes á
risa, Valencia, 1519, del cual sólo se conoce el ejemplar del Museo
Británico. Editólo Luis Usoz y Río en Londres, 1841 (con falsa
portada de Madrid). Es uno de los libros más deshonestos
españoles, y en Valencia se había de publicar, donde la licencia y el
escándalo llegaban al colmo (véase M. Pelayo, Oríg. novela, t. III,
CLXXIII).—Fray Alonso de Córdoba († 1542), agustino, publicó
Principia Dialectices, Salamanca, 1519. In Libros Aristotelis
Ethicorum, Oeconomicorum et Politicorum.—Don Gonzalo de
Córdoba publicó Historia de Ávila, Salamanca, 1519.—Martín
Fernández de Enciso, sevillano, alguacil mayor de Castillo del Oro,
hoy istmo de Darien, publicó el primer libro que trató de cosas de
América: Suma de geographia que trata de todas las partidas &
provincias del mundo: en especial de las indias..., Sevilla, 1519;
ibid., 1530, 1546.—Enrique de Hamusco publicó Compendium
totius scripturae divinum Apiarium nuncupatum, Toledo, 1519.—
Hexamerón theologal sobre el regimiento Medicinal contra la
pestilencia, Alcalá, 1519.—Don Diego López de Stúñiga († 1530),
gran humanista, escribió Annotationes contra Jacobum Fabrum
Stapulem, Alcalá, 1519; París, 1522. Annotationes contra Des.
Erasmum in defensionem translationis Novi Testamenti, Alcalá,
1520. Itinerarium ab Hispania usque ad urbem Romam, Roma,
1521. Erasmi Roter. Blasphemiae et impietates, Roma, 1522.
Libellus trium illorum voluminum praecursor quibus Erasmicas
impietates ac blasphemias redarguit, Roma, 1522. Sobre esta
controversia, M. Pelayo, Heterod., II, pág. 48.—Historia de la linda
Magalona, Burgos, 1519; Sevilla, 1519; Burgos, 1521; Toledo, 1526;
Sevilla, 1533, 1542, 1689; Barcelona, 1600 (en lemosín); Zaragoza,
1602; Baeza, 1628; Barcelona, 1650; Sevilla, 1689. Tradújose del
francés de Bernardo Treviez, canónigo de Maguelonne, antigua
ciudad junto á Montpellier.—Libro de medicina llamado macer que
trata de los mantenimientos, Assi mesmo todas las virtudes del
Romero. Fechas por Arnaldo de villanova. Segunda vez Imprimido:
é puesto en buen romance, Granada, 1519.—El bachiller Juan de
Molina, de Ciudad Real, publicó Confesionario de Juan Gerson,
Alcalá, 1519. Epístolas de San Gerónimo, con una narración de la
guerra de las Germanías, Valencia, 1520, 1522, 1526; Sevilla, 1532,
1541, 1548. Gamaliel traducido in lingua castellana; cum septem
tractatibus, atribuido á San Pedro Pascual, Valencia, 1522, 1525;
Toledo, 1525, 1527; Sevilla, 1534. Chronica de los Reyes de
Aragón, de Marineo Sículo, Valencia, 1523. Vita b. marie en español
(de la publicada en valenciano por Miguel Pérez en Barcelona,
1494); Toledo, 1525; ó De la Vida y excelencias de Nuestra Señora,
Sevilla, 1531; Toledo, 1537; Sevilla, 1542; Toledo, 1549. Antonio
Panormita (Ant. Beccatelli) de los dichos y hechos del Rey don
Alonso de Nápoles, el V de Aragón, Valencia, 1527; Burgos, 1530;
Zaragoza, 1552, 1554; Amberes, 1554. Lucio Marineo Sículo, de las
cosas memorables de España, Alcalá, 1539. Homiliario de Alcuino,
Valencia, 1552. Gayangos le atribuye las Guerras civiles, de Apiano,
Valencia, 1522.—Don Jerónimo de Villegas, prior de Covarrubias
y canónigo de Burgos (1504?), publicó la Sexta Sátira de Juvenal,
Valladolid, 1519. Sátira dezena de juvenal..., Valladolid, 1519; del
ital., de Fr.co Patricio publicó De Reyno y de la institución del que
ha de Reynar, París, 1519; Madrid, 1591.—Nicolao de Pax,
mallorquín introductor del lulismo, publicó Vita Raimundi Lulli, Alcalá,
1519. Commentaria super artem divi R. Lulli. Traducción del
Desconort, 1540. Publicó el Ars inventiva Veritatis y otras obras
lulianas.
21. Año 1520. Micael de Carvajal, clérigo, natural

de Plasencia, teniendo de treinta y cinco á cuarenta
años, publicó hacia 1520 la Tragedia llamada
Josephina, obra eclesiástico-simbólica, tan acabada
como un auto del siglo xvii; aunque mucho más
natural en la expresión de los sentimientos, en los
caracteres bien dibujados y en el dialogado. Es pieza
del teatro religioso, de las que se representaban en
las festividades; además con el elemento humano
que siempre tuvieron, aunque sin las chocarrerías y
los bajos personajes de otras. Sobre lo humano,
cristiano y popular ha soplado el aire del
Renacimiento tan sólo para prestarle delicadeza y
elegancia. Compuso también el Auto de las Cortes
de la Muerte; pero sin acabarlo, lo cual hizo Luiz
Hurtado (véase año 1547).
El bachiller Hernán López de Yanguas publicó la

Farsa sacramental en coplas; otra edición Farsa del
mundo y moral... La qual declara como el mundo con
sus cautelas engaña á cada uno de nosotros. Y en
fin relata la Assumpcion de nuestra señora, 1520,
1528, 1551; Madrid, 1555, 1913 (Biblióf. Madril.).
Triunfos de la locura, 1542. Los dichos ó sentencias
de los siete sabios de Grecia: hechos en metros...
"Estos bocadillos de oro | me plugo screvir en ternos
| porque los niños más tiernos | los puedan saber de
coro", Zaragoza, 1549 (Biblioteca Nacional);
Salamanca, 1587; Madrid, Sevilla. Cincuenta
preguntas con otras tantas respuestas, Valencia,
1550; en otra edición: Aqui, lector, veras juntas | por
Hernán López compuestas | cincuenta vivas
preguntas | con otras tantas respuestas. Y otra obra
al mismo Yanguas. Obra nuevamente compuesta por
el B. Hernán López de Yanguas, llamada Problemas
que quiere decir Preguntas con sus respuestas: la
cual, por no estar ocioso, compuso á imitación de
Aristotiles e de Plutarco y de Alexandro Afrodiseo.
Farsa nuevamente compuesta sobre la felice nueva
de la concordia y paz y concierto de nuestro
felicisimo emperador semper augusto y del
cristianisimo rey de Francia, Madrid, 1913 (Biblióf.
Madril.): el ms. en la Biblioteca Nacional. En el
Registro de Colón, hay: Farsa de genealogía. Farsa
de Natividad. Drama. Farsa turquesca. Jornada de
tres peregrinos, en coplas, 1500.
22. Carvajal: "Después de otros filosóficos estudios, me pasé á la
Sagrada Escritura"; parece, pues, que fué clérigo. En el Registro de
Colón hay ejemplar de la Josephina, Salamanca, 1535; en la Bibl.
Imper. de Viena otro de Toledo, 1546, estudiado por Wolf y reeditado
en Madrid, 1870 (Biblióf. Españ.). Pero debió de haber otra edición
anterior á la de 1315, pues está dirigida la obra á don Álvar Pérez de
Osorio, el cual heredó en 1505 á su padre Pedro Álvarez Osorio,
que murió hacia el 1523. De modo que debió de escribirse y
publicarse hacia 1520. Hízose para la fiesta del Corpus, y se
representó en la plaza. "Es materia que en figura contiene la causa
que hoy causa esta sancta fiesta". Cañete, en su edic, XLIII: "No hay
comedia (de aquel tiempo) profana en que se pinten pasiones y
caracteres con mayor elevación y verdad, ni en que esté mejor
expresada la poesía del sentimiento y de la naturaleza... ¿Hay en el
famoso y popularísimo teatro español del siglo xvii una sola
comedia profana donde las pasiones que aquí agitan el corazón del
hombre estén puestas en relieve con más verdad y naturalidad que
en la tragedia Josefina, escrita expresamente para una fiesta
religiosa?" Id.: "Carvajal es elocuente prosador, discreto filósofo,
sano moralista, conocedor del mundo y de los hombres y muy
versado en letras divinas y humanas". Tragedia llamada "Josefina",
ed. M. Cañete (Soc. de biblióf. españoles), Madrid, 1870; Las Cortes
de la Muerte, Bibl. de Aut. Esp., t. XXXV. Consúltese: W. E. Purser,
Palmerin of England, Dublin-London, 1904.
Hern. López de Yanguas, Égloga nuevamente trovada... en loor de

la Natividad de N. S., en Sieben spanische dramatische Eklogen, ed.
E. Köhler, Dresden, 1911, págs. 192-209. Consúltense: Fernando
Wolf, Ein spanisches Frohnleichnamspiel von Todtentanz, Viena,
1852; E. Cotarelo y Mori, El primer auto sacramental y noticia de su
autor el Bach. H. L. de Y., en Revista de Archivos (1902), t. VII,
págs. 251-272.
23. Año 1520. Alfonso Álvarez Guerrero († 1577) publicó Las

docientas del Castillo de la Fama, Valencia, 1520. Palacio de la
Fama y Historia de las Guerras de Italia con la Coronación de su
Magestad (Carlos V), Bolonia, 1530. De Bello iusto et iniusto,
Nápoles, 1543. De modo et ordine Generalis Concilii, ibid., 1545. De
administratione Justitiae. Thesaurus Christianae Religionis et
Speadum Sacr. Sum. Pontificum, Imperatorum ac Regum et S.
Episcoporum, Venecia, 1559.—Fernán Díaz Paterniano, de
Toledo, publicó Grammatica Caldea, 1520.—Hernando Díaz
publicó la Vida y excelentes dichos de los más sabios philosophos
que hubo en este mundo, Sevilla, 1520; Toledo, 1527; Sevilla, 1535,
1538, 1541. Parece extracto de la compilación mucho más vasta de
Gualtero Burley, Liber de vita et moribus philosophorum
poetarumque veterum, traducida y muy leída en el siglo xv con el
título de La vida y las costumbres de los viejos filósofos ("Crónica de
las fazañas de los filósofos" la llamó Amador de los Ríos). Hermann
Knust publicó juntos el texto latino y la traducción castellana en el
tomo CLXXVII de la Bibliotek des litterarischen vereins, de Stuttgart
(Tübingen, 1886). Historia de los honestos amores de Peregrino y
Ginebra (Fern. Colón, sin lugar ni fecha), Sevilla, 1520?, 1527, 1548;
Salamanca, 1548, dos sin lugar ni año: es traducción de Il
Peregrino, de Jacopo Caviceo (1508). Véase su estudio en Adolfo
Albertazzi, Romanzieri é Romanzi del Cinquecento é del Seicento,
Bolonia, 1891, pág. 7.—Juan de Espinosa, racionero de la sancta
yglesia de Toledo, publicó el Tractado de principios de música
práctica é theórica, Toledo, 1520.—Antón Francés, vecino de
Borja, publicó El Doctrinal de Motazafes ó fieles, Zaragoza, 1520.—
La institución de la muy estrecha y no menos observante orden de la
cartuxa y de la vida del excelente doctor San Bruno, primero
cartuxano, buelta de latín en romance según el verdadero original d'
la ystoria cartuxana, Sevilla, 1520.—La Historia de Leoneo de
Ungría y de Vitoriano de Pannonia, su hijo, Toledo, 1520.—La
fundación y destruyción de la cibdad de Monvedro antiguamente
llamada Sagunto, Valencia, 1520.—Diego de Segura, jurisconsulto
sevillano, publicó Repetitiones, Salamanca, 1520. Tratatus de bonis
per maritum haereticum constante matrimonio quaesitis, Colonia,
1580.—Juan Viñao publicó su Cancionero, Valencia, 1520. Son
notables las obras burlescas, provocantes á risa y hasta "nefandas y
bestiales" (M. Pelayo).—Vocabulario para aprender francés, español
y flamenco, 1520, anónimo.
24. Año 1521. Publicóse en 1521: Síguese la

comedia llamada Thebayda nuevamente compuesta,
dirigida al muy illustre señor Duque de Candia.—
Síguese la comedia llamada: Ipólita, nuevamente
compuesta en metro. (Portada aparte).—Comedia
nuevamente compuesta llamada: Seraphina, en que
se introducen nueve personas, las quales en estilo
cómico y á vezes en metro, van razonando...,
Valencia, ibid., 1524; sin la Hipólita, Sevilla, 1546
(Bibl. Imper. de Viena). La Thebayda y la Serafina
parecen más ser de un mismo autor que no la
Hipólita, la cual es una pieza dramática en verso,
calcada sobre La Celestina, aunque difiere en el
personaje principal y en el desenlace. La Serafina es
más obscena, pero más ingeniosa que la Hipólita y
la Thebayda, de excelente prosa, aunque
deslustrada por la afectación y la pedantería de citas
clásicas, á imitación de La Celestina. Su argumento
son las aventuras amorosas de un hombre
disfrazado de mujer. Encierra muchos proverbios é
idiotismos familiares; tiene dicción pura, natural
gracejo y, sobre todo, observación realista en la
pintura de costumbres. Como en La Celestina, hay
lenguaje renacentista y culto muy afectado, junto con
el popular, entrambos más extremados que en su
modelo. No es menos extremada la obscenidad. El
autor subióla de punto, creyendo en ello imitar á La
Celestina, sin tomar de ella el intento moral, bien
patente en el desastrado desenlace de los amantes
y de la misma tercerona. Inferior, aunque bastante
parecida á la Serafina, es la Comedia llamada
Thebayda, de prolija y fastidiosa lectura, en 15
escenas, con largos razonamientos y episodios,
mezcla de retórica y de escolástica, y no pocos
latinismos y citas mitológicas é históricas á granel.
En suma: la Serafina y la Tebaida no desdirían de
Proaza, pues tienen los mismos defectos que lo que
éste añadió á la primitiva Celestina, no habiendo
tenido talento más que para exagerar las faltas que
en ella apuntaban y convertir en defectos sus
virtudes. Son más útiles al filólogo por la riqueza de
refranes y frases castizas populares. Algunas voces
y alusiones muestran haberse compuesto en
Valencia; pero no había por aquel tiempo autor
valenciano que así conociese nuestro romance. Todo
lo cual induce á sospechar si sería Proaza su autor,
como lo fué de los actos que añadió en sus
ediciones de La Celestina.
25. Alonso de Proaza, que escribió una Farsa, que editó La
Celestina, añadiéndole nuevos actos, y probablemente hizo la
edición de 1514 en Valencia, hombre trabajador, que andaba metido
en cien cosas á la vez, no debió ser ajeno á la composición de estas
tres comedias valencianas, remedadoras de La Celestina, y más de
los defectos, esto es, remedadoras de lo añadido por el mismo
Proaza. No carece de misterio el que estas primeras imitaciones de
La Celestina, mejor dicho, de lo á La Celestina añadido por Proaza,
se hiciesen en Valencia, donde él vivía. Ejemplar de la primera
edición sólo se conoce el del Museo Británico; de la segunda los hay
en las Bibliotecas Nacionales de Madrid, París y Viena.
Reimprimióse la Serafina con la Selvagia en la Colecc. de libros
españ. raros y curiosos, t. V, Madrid, 1873, y la Tebaida en la
misma, Madrid, 1894.—La Hipólita está en verso y "plagia
servilmente la fábula de La Celestina, salvo el personaje principal y
el desenlace, que no es trágico, sino festivo y placentero, y, por
consiguiente, inmoralísimo; su corta extensión, que no es mayor que
la de las farsas de Jaime Huete y Agustín Ortiz, su versificación en
coplas de pie quebrado á estilo de Torres Naharro y todas las
condiciones externas, en suma, hacen de ella una pieza dramática y
de ningún modo novelesca". (M. Pelayo, Oríg. novel., t. III,
CLXXVIII). Timoneda (prólogo) dice de la Thebayda que es de "muy
apacible estilo cómico, propio para pintar los vicios y las virtudes".
No la prohibió la Inquisición, á pesar del parecer contrario de Zurita.
Los mejores escritores valencianos del tiempo de Carlos V

escribieron en latín y algunos en catalán; hasta fines del siglo xvi no
hubo en Valencia prosistas castellanos que pudiesen escribir estas
comedias, propias de quien ha mamado el castellano con la leche.
Además, el autor parece andaluz, como dice M. Pelayo. En la
Seraphina (pág. 379) se menciona "el lienzo sevillano y el lino de
Guadalcanal, que cuesta á moneda de oro la vara"; Galterio, en la

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The management of pediatric airway disorders has seen tremendous progress

Washington, DC, USA Susan T. Verghese

1 Evolution of Anesthesia for Pediatric Airway Surgery:

11 Anesthetic Management in Emergent Pediatric

Claude Abdallah, MD, MSc Department of Anesthesia, George Washington

Grace Hsu, MD Department of Anesthesiology and Critical Care Medicine,

Domiciano Jerry Santos, MD Anesthesiology, Pain and Perioperative

Susan Thomas Verghese is a professor of Anesthesia and Pediatrics at

Diego A. Preciado is a Professor with tenure at Children’s National Health

ACGME accredited pediatric otolaryngology fellowship at Children’s

 volution of Anesthetic Agents

© Springer Nature Switzerland AG 2019 1

 se of Cuffed Endotracheal Tube

15. Año 1518. El M. Hernán Pérez de Oliva (1494?

17. Año 1518. Mateo Adriano publicó Introductiones in linguam

18. Año 1519. El capitán Gonzalo Hernández de

20. Año 1519. Cristóbal de Arcos, sevillano, capellán del

21. Año 1520. Micael de Carvajal, clérigo, natural

El bachiller Hernán López de Yanguas publicó la

Hern. López de Yanguas, Égloga nuevamente trovada... en loor de

23. Año 1520. Alfonso Álvarez Guerrero († 1577) publicó Las

24. Año 1521. Publicóse en 1521: Síguese la

Los mejores escritores valencianos del tiempo de Carlos V

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