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Letter to the Editor



AN ALTERNATIVE APPROACH FOR CONTINUOUS MONITORING OF HEART AND BREATH SOUNDS IN PEDIATRIC PATIENTS. A LETTER TO EDITOR

Dileep Kumar, Summaiya Ali, Fauzia Anis Khan, Mohammad Suleman.

Abstract
Anesthesic management in neonates, infants and young children is always a challenge. Both esophageal and precordial stethoscopes are used for continuous monitoring of heart and breath sounds in this age group. Recent (2018) publication of Standards by World Health Organization-World Federation of Societies of Anesthesiologists (WHO-WFSA) for Safe Practice of Anesthesia have also recommended monitoring with a precordial or esophageal stethoscope2. By using an esophageal stethoscope both heart and breath sounds can be continuously monitored and endotracheal tube (ETT) obstruction can be readily detected. However, the detection of one lung ventilation due to incidental endobronchial ETT placement during surgical positioning and tissue handling may be difficult. Complications of esophageal stethoscope placement have been reported e.g. incidental tracheal and bronchial insertion resulting in hypoxia, hoarseness, oropharyngeal trauma or bleeding3.
Precordial stethoscope on the other hand is a relatively safe, non-invasive and inexpensive alternative to esophageal stethoscope. It also circumvents the esophageal stethoscope induced complications. It is usually fixed on the chest wall to the left of lower part of sternum in order to ausculate both the heart and breath sounds. However, itís applicability is limited since it is easily displaced and its contact with the skin loosens quickly and it may require frequent refixing during surgery which may interfere with sterlity. The current practice for the fixation of precordial stethoscope varies among anesthesiologists as there is no standard recomendation.
We have used Self Adhesive Fabric Tape (Mefix) in our pediatric patients for the fixation of precordial stethoscope as shown in figure-I. We suggest the following approach to fix the precordial stethoscope. Hold stethoscope on confirmed (heart and breath sound loudly audible) site and apply one piece of Mefix of 10Ôāī10 cm to secure the stehoscope. Mefix fixes the edges of precordial stethoscope precisely and ensures firm contact with the patientís skin. The usual position for the stethoscope is the 5th intercostal space (fig-I) medial to the left nipple however, position of the precordial stethoscope can be changed (fig-I) according to nature of surgery and clear audibility of heart and breath sounds. Mefix is gentle to the skin and it is relatively cheap and readily available in the operating room.
This approach is easy to use and it will reassure the patientís safety in limited resource countries by providing uninterrupted and reliable monitoring of heart and breath sounds during surgical anesthesia and transportation.

Key words: Stethoscope, Paediatric, Cardiorespiratory, Breath sound, Anaesthesia



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