Objectives/Aim: To determine whether sedation/analgesia drugs used before, during, and after infa... more Objectives/Aim: To determine whether sedation/analgesia drugs used before, during, and after infant cardiac surgery are associated with neurocognitive and functional outcomes. Background: Some animal models suggest neurotoxic effects of anesthetic drugs on the developing brain; however, potential human effects are unknown. Whether these results can be extrapolated to humans is unknown. Methods/Materials: Prospective follow-up project of all infants ≤6 weeks old having surgery for congenital heart disease between 04/03 and 12/06. Demographic, perioperative, and sedation/analgesia variables were collected. Outcomes at kindergarten age were Wechsler Preschool and Primary Scale of Intelligence-III, Beery-Buktenica Developmental Test of Visual Motor Integration (VMI-V), and General Adaptive Composite (GAC) of the Adaptive Behavior Assessment System-II. Multivariable linear regression was used to identify predictor variables. Results: From 135 infants who underwent heart surgery, 19 died, 17 were excluded, 8 were lost to follow-up, leaving 91 children for analysis. Multiple linear regression found days on chloral hydrate [3.5 (3.7) days] was associated with lower performance intelligence quotient (PIQ) (Effect size À1.03; 95% CI À1.96, À0.10; P = 0.03), and cumulative dose [54.2 (60.3) mgÁkg À1 ] of benzodiazepines was associated with lower VMI scores (Effect size À0.07; 95% CI À0.12, À0.01; P = 0.026). No other associations were found between sedation/analgesia variables and full-scale IQ, PIQ, Verbal IQ, VMI, or GAC. Conclusion: Assessment of this cohort at kindergarten age found a small statistically significant association between days on chloral hydrate and PIQ, and benzodiazepine cumulative dose and lower VMI. No other association between sedation/analgesia drugs and outcomes was found.
To report our experience of providing anesthesia for noncardiac procedures in children with in si... more To report our experience of providing anesthesia for noncardiac procedures in children with in situ Berlin Heart EXCOR Pediatric ventricular assist devices and to suggest principles of anesthetic management. With the initiation of the first North American training and support center for Berlin Heart at our institution in 2006, we have been asked to provide anesthesia for noncardiac procedures to these children. No current anesthetic approach to these children has been reported. Anesthetic records for all noncardiac procedures for children with Berlin Heart between August 2006 and February 2009 in a tertiary care pediatric hospital were retrospectively reviewed. Charts were reviewed for demographic and clinical data, perioperative management, and occurrence of hypotension. Twenty-nine procedures were performed on 11 patients. Hypotension was a common occurrence with all anesthetic induction and maintenance agents even at low doses. Ketamine induction, however, was less likely to produce hypotension, odds ratio for hypotension 0.1333 (95% confidence range 0.021-0.856). Hypotension was responsive to fluid bolus (60%) and alpha-receptor agonists (100%). Preoperative stability and presence of biventricular ventricular assist device (BiVAD) did not predict intraoperative hemodynamic course. Unlike patients with other ventricular assist devices, these children do not tolerate reductions in systemic vascular resistance (SVR) because of the relatively fixed cardiac output of this device. Agents that reduce SVR should be avoided where possible. Preoperative stability is not predictive. Fluids and alpha-agonists should be first-line response to hypotension in this population. Further study of this unusual population is warranted to further delineate best anesthetic practice.
OBJECTIVES/AIM: To determine whether sedation/analgesia drugs used before, during, and after infa... more OBJECTIVES/AIM: To determine whether sedation/analgesia drugs used before, during, and after infant cardiac surgery are associated with neurodevelopmental outcome.
Extracorporeal membrane oxygenation (ECMO) is a life-saving treatment for pediatric patients with... more Extracorporeal membrane oxygenation (ECMO) is a life-saving treatment for pediatric patients with respiratory and/or cardiac failure. The ECMO circuit oxygenates and sometimes pumps the blood, effectively replacing lung and/or heart function temporarily. ECMO patients are clinically very complex not only because of their underlying, life-threatening pathology, but also because of the many physiological parameters that must be monitored and adjusted to maintain adequate tissue perfusion and oxygenation. Drainage and reinfusion cannulae connecting the patient to the ECMO circuit are visible on radiograph. These cannulae have different functions, different configurations, different radiographic appearances, and different positions that should be familiar to the interpreting pediatric radiologist. The primary complications of ECMO include hemorrhage, thrombosis and ischemia, as well as equipment failure and cannula malpositioning, all of which may be detected on imaging. In this pictorial essay, we discuss the basics of ECMO function and clinical management, ECMO cannula features and configurations, and the many complications of ECMO from an imaging perspective. Our goal is to educate pediatric radiologists about ECMO imaging, equipping them to properly interpret these studies and to become a useful consultant in ECMO patient care.
This case report describes the occurrence of massive upper gastrointestinal hemorrhage immediatel... more This case report describes the occurrence of massive upper gastrointestinal hemorrhage immediately after cross-clamping of the inferior vena cava and hepatic portal vein. This case suggests that acute intraoperative hemorrhage from a varix should always be a consideration before liver transplantation in patients who have a history of upper gastrointestinal bleeding.
A prospective observational case series of children receiving light general anesthesia for magnet... more A prospective observational case series of children receiving light general anesthesia for magnetic resonance imaging (MRI) was performed. Our purpose was to examine the merit of anesthesia and recovery/discharge times of combined remifentanil and propofol total intravenous anesthesia (TIVA) in spontaneously breathing children. After IRB approval and informed consent, 56 patients receiving Remi/Propofol TIVA (Remifentanil 10 microg.ml(-1) Propofol 10 mg.ml(-1)) were observed. Blood pressure, respiratory rate, endtidal CO(2) (P(E)CO(2)), oxygen saturation and temperature were recorded at the start and finish of anesthesia. In addition, induction and recovery times were noted. Recovery time was from scan completion until discharge from the initial recovery area. Discharge time was from scan completion to discharge home. Fifty-six patients received Remi/Propofol TIVA. The mean Remi/Propofol recovery and discharge times were 8.9 and 28.2 min, respectively. There was a statistically significant decrease in respiratory rate and increase in CO(2) from the start to the end of the procedure. During the scan, seven patients moved. One patient experienced postprocedure nausea and or vomiting. The combination of remifentanil and propofol for TIVA may be an effective method of light general anesthesia in pediatric patients undergoing MRI.
Background: Despite the fact that almost all critically ill children experience some degree of pa... more Background: Despite the fact that almost all critically ill children experience some degree of pain or anxiety, there is a lack of highquality evidence to inform preferred approaches to sedation, analgesia, and comfort measures in this environment. We conducted this survey to better understand current comfort and sedation practices among Canadian pediatric intensivists. Methods: The survey was conducted after a literature review and initial focus groups. The survey was then pretested and validated. The final survey was distributed by email to 134 intensivists from 17 PICUs across Canada using the Research Electronic Data Capture system. Results: The response rate was 73% (98/134). The most commonly used sedation scores are Face, Legs, Activity, Cry, and Consolability (42%) and COMFORT (41%). Withdrawal scores are commonly used (65%). In contrast, delirium scores are used by only 16% of the respondents. Only 36% of respondents have routinely used sedation protocols. The majority (66%) do not use noise reduction methods, whereas only 23% of respondents have a protocol to promote day/night cycles. Comfort measures including music, swaddling, soother, television, and sucrose solutions are frequently used. The drugs most commonly used to provide analgesia are morphine and acetaminophen. Midazolam and chloral hydrate were the most frequent sedatives. Conclusion: Our survey demonstrates great variation in practice in the management of pain and anxiety in Canadian PICUs. Standardized strategies for sedation, delirium and withdrawal, and sleep promotion are lacking. There is a need for research in this field and the development of evidence-based, pediatric sedation and analgesia guidelines.
BACKGROUND In pediatrics, foreign body ingestion poses unique challenges. Each case is unique giv... more BACKGROUND In pediatrics, foreign body ingestion poses unique challenges. Each case is unique given variability in timing, type, and size of object, compounded by underlying comorbidities and age. In the mid-1990s, mortality and morbidity associated with button battery (BB) ingestion (BBI) emerged corresponding to modification in battery fabrication towards higher voltage, large-diameter lithium cells. AIMS To describe the case and management of a BBI in a pediatric patient necessitating the use of cardiopulmonary bypass and deep hypothermic circulatory arrest (DHCA). MATERIALS AND METHODS A 17-month-old female presented with the sudden loss of consciousness at home. Chest X-ray revealed an esophageal foreign body suspicious for BBI. A massive upper gastrointestinal bleeding was temporized with packing. The patient was urgently taken to the operating room for sternotomy, establishment of cardiopulmonary bypass (CPB) with deep hypothermic circulatory arrest (DHCA), removal of BB, repair of the left common carotid artery, esophageal, and tracheal injuries. DISCUSSION Successful management of BBI requires coordinated care and a multidisciplinary approach. A high degree of clinical suspicion for BBI is imperative to facilitate early aggressive interventions. Lateral and anteroposterior chest films should be obtained in any suspected BBI. CONCLUSION This case demonstrates the utility of CPB and DHCA where control of bleeding secondary to BBI is not otherwise possible.
Brain blood flow tests with diffusible radiopharmaceuticals are often done as an ancillary test i... more Brain blood flow tests with diffusible radiopharmaceuticals are often done as an ancillary test in brain death (BD). We report a case of an infant with absent brain blood flow on an anterior planar image despite persistent breathing and extensor posturing. We reviewed the literature from 1980 to 2008 using MEDLINE and PubMed to determine the sensitivity and specificity of these tests in the diagnosis of BD. Search terms were any combination of: brain death; and single photon emission computed tomography (SPECT), radiopharmaceuticals, technetium Tc 99m exametazime, or organotechnetium compounds. The sensitivity of absent brain blood flow on planar imaging for clinically confirmed BD is 119/153 = 77.8% [95% CI 70.5%—83.7%]; and the specificity is 41/41 (100%) [95% CI 92.6%—100%]. For clinically confirmed BD, the sensitivity of SPECT is 107/121 (88.4%) [95% CI 81.4%—93.1%], and specificity is 12/12 (100%) [95% CI 78.4%—100%]. For contrast angiography confirmed BD, the sensitivity of SPECT is 34/34 (100%) [95% CI 91.2%—100%]; the specificity could not be estimated as there were no patients without clinical BD having both tests. Case reports emphasized the possibility of isolated posterior-fossa blood flow, which would not be detectable using non-diffusible radiopharmaceuticals, or without a lateral view using diffusible agents. We conclude that patients having an ancillary radiopharmaceutical brain blood flow test for BD should have anterior and lateral views without exception. Larger numbers of patients both with and without BD (but with severe brain injury) must be studied to determine the sensitivity and specificity of these tests.
... Regional Anesthesia Dominic A. Cave and Barry A. Finegan 211 ... 32. Schurg R, Biscoping J,Ba... more ... Regional Anesthesia Dominic A. Cave and Barry A. Finegan 211 ... 32. Schurg R, Biscoping J,Bachmann-M B, Hempelmann G. Intravenous regional anesthesia of the foot using prilocaine. Clinical aspects, pharmacokinetic and pharmacodynamic studies. ...
While policy changes toward early extubation in the operating room (OR) have been commonly seen i... more While policy changes toward early extubation in the operating room (OR) have been commonly seen in palliative surgeries in single ventricle anatomy, no systematic assessment of their impact on patient outcome has been reported. All patients aged 0-17 years admitted to a PICU in a quaternary children's hospital for post-operative management following a primary Fontan procedure between 2005 and 2011 were included. Patients for revision of Fontan or patients admitted to adult Cardiovascular Intensive Care Unit were excluded. Practice policy was changed from routine extubation in the PICU to early extubation in OR in January 2008. Data were compared between the pre-policy-change era (2005-2007) and the post-policy-change era (2008-2011) to assess the impact of the change on patient outcomes. Generalized linear regression (GLM) and interrupted time series (ITS) analysis were used to access the effect of policy change on PICU length of stay and post-operative fluid balance, adjusting for potential confounders using propensity scores. Root cause analysis (RCA) was conducted to describe causes of failed extubation and challenges of this policy change. One hundred twenty-seven children met inclusion criteria. Average body weight was 14.7 kg [standard deviation (SD) 3.9], and age was 3.5 years (SD 1.9). A clear change in extubation practice occurred between the pre- versus post-policy-change eras: 97.5 % were extubated in the PICU in the pre-policy-change era, as compared to 15.0 % in the post-policy-change era. The average PICU length of stay was shortened by 4.1 days from the pre-policy-change era to the post-policy-change era [95 % CI -1.2 to -6.9, p < 0.01] in the GLM, whereas the ITS analysis did not show a statistically significant difference [95 % CI 1.8 to -2.5] (p = 0.23). No statistically significant difference was observed in the fluid balance in the 24 h post-operation in both analyses. Sixteen patients (16/127, 12.6 %) were reintubated mainly for hemodynamic instability in the pre-policy-change era (6/39, 15.4 %) and excessive bleeding or respiratory etiologies in the post-policy-change era (10/88, 11.4 %). Significant reduction of PICU length of stay was achieved without any evidence of worsening of patient outcomes. RCA suggests watchful observations with respect to bleeding and respiratory etiologies are the key to prevent failure of extubation in the current practice.
In Reply:-We appreciate the interest of Drs. Saidman and Eger in the safety of sevoflurane and th... more In Reply:-We appreciate the interest of Drs. Saidman and Eger in the safety of sevoflurane and the protection of human research participants. Although we disagree with their contentions, we completely share their safety concerns. Indeed, our own concern for patient safety is why we performed the investigation. We assessed the renal effects of low-flow (Յ l/min) sevoflurane in patients at greatest risk for postoperative renal dysfunction: those with preexisting renal insufficiency. Even in such susceptible patients, the renal effects of low-flow sevoflurane and isoflurane were the same. 1 Our conclusions were specific: "Low-flow sevoflurane is as safe as low-flow isoflurane and does not alter renal function in patients with preexisting renal disease." These results amplify previous studies in patients with renal insufficiency, conducted at higher flow rates, which showed no significant differences in the renal effects of sevoflurane and other volatile anesthetics. 2-6 This investigation helps to resolve any outstanding questions about the renal effects of sevoflurane. These have concerned sevoflurane defluorination, patients with renal insufficiency, low flows and compound A formation, and low-flows in renal insufficiency patients. What has emerged from prospective studies and from postapproval pharmacovigilance is a remarkably consistent picture. Postoperative sevoflurane renal effects are not different from those of other anesthetics. After more than 120 million sevoflurane anesthetics given, there is not a single case report of sevoflurane-related renal dysfunction. Considering together all of the studies published to date in patients or volunteers, and even using proteinuria as a so-called "sensitive" (albeit unvalidated and experimental) marker of renal dysfunction, there is no difference between the renal effects of low-flow sevoflurane and other anesthetics (Fig. 1). Drs. Saidman and Eger assert that the compound A exposure in our investigation was "too small." The patients received the compound A exposure they did because the average low-flow duration was 3.2 h, and compound A concentrations typically average 10-15 ppm. Clinical research is captive to the patient population at hand. Nevertheless, we
contributed to conception and design of the study, interpretation of data and revision of the man... more contributed to conception and design of the study, interpretation of data and revision of the manuscript critically for intellectual content, and have read and approved the version to be published; Moez EK contributed to interpretation of data, confirmation of statistical analyses and revision of the manuscript critically for intellectual content, and has read and approved the version to be published; Joffe AR contributed to acquisition and interpretation of data, wrote the first draft of the manuscript, and had final approval of the version to be published; Alobaidi R contributed to acquisition and interpretation of data and revision of the manuscript critically for intellectual content, and had final approval of the version to be published; Joffe AR, Alobaidi R and Moez EK had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis; all authors participated sufficiently in the work to take public responsibility for the manuscript content.
Background: Nerve stimulation guidance (Tsui test) has been reported to be an effective alternati... more Background: Nerve stimulation guidance (Tsui test) has been reported to be an effective alternative to radiographic imaging for proper catheter placement. The purpose of this study was to examine the success rate and complications of continuous caudal epidural analgesia since the implementation of routine use of the Tsui test at the authors' institution. Methods: The authors examined prospectively collected data in their pediatric pain service database from 289 children who had attempted caudal placement of a lumbar or thoracic catheter between 1999 and 2002. Results: In five patients (aged 5 months-1.6 yr), the catheter did not thread to the desired level and was abandoned in the operating room (technical success rate, 98.2%). Of the remaining 284 patients, the overall analgesic success rate of all caudal route epidural analgesia procedures was 84.9%. There was no significant difference in adequate pain control (success) in infants (aged 1 day-1 yr) versus older children (aged younger than 1 yr). The most common adverse effects were pruritus (26.1%) and nausea and vomiting (16.9%). Of the patients in our study, 57.7% had urinary catheters in situ; of those who did not have a catheter placed, 20.8% experienced urinary retention. The incidence of respiratory depression was 4.2%, but the administration of naloxone for severe respiratory depression was never necessary. Three percent of catheters were removed because of suspected contamination, but no epidural abscesses or systemic infection were noted. Conclusions: The results of this study suggest that epidural catheter placement via the caudal approach using the Tsui test is an effective and reasonable alternative to direct lumbar and thoracic epidural analgesia in pediatric patients.
We designed this study to determine the threshold current for nerve stimulation of an insulated n... more We designed this study to determine the threshold current for nerve stimulation of an insulated needle in the epidural space. The intended dermatome was identified using the bony landmarks of the spine. An 18-gauge insulated Tuohy needle was inserted perpendicularly to the skin and advanced until "loss of resistance" was felt. A nerve stimulator was then connected to the insulated needle. Twenty patients were studied using an insulated Tuohy needle and one patient was studied using a noninsulated Tuohy needle. Muscle twitch was elicited with a current of 11.1 Ϯ 3.1 mA (mean Ϯ sd) in all patients in which an insulated needle was used. Muscle twitches were within 2 myotomes of the intended level (based on Address correspondence and reprint requests to Ban C
BACKGROUND In pediatrics, foreign body ingestion poses unique challenges. Each case is unique giv... more BACKGROUND In pediatrics, foreign body ingestion poses unique challenges. Each case is unique given variability in timing, type, and size of object, compounded by underlying comorbidities and age. In the mid-1990s, mortality and morbidity associated with button battery (BB) ingestion (BBI) emerged corresponding to modification in battery fabrication towards higher voltage, large-diameter lithium cells. AIMS To describe the case and management of a BBI in a pediatric patient necessitating the use of cardiopulmonary bypass and deep hypothermic circulatory arrest (DHCA). MATERIALS AND METHODS A 17-month-old female presented with the sudden loss of consciousness at home. Chest X-ray revealed an esophageal foreign body suspicious for BBI. A massive upper gastrointestinal bleeding was temporized with packing. The patient was urgently taken to the operating room for sternotomy, establishment of cardiopulmonary bypass (CPB) with deep hypothermic circulatory arrest (DHCA), removal of BB, repair of the left common carotid artery, esophageal, and tracheal injuries. DISCUSSION Successful management of BBI requires coordinated care and a multidisciplinary approach. A high degree of clinical suspicion for BBI is imperative to facilitate early aggressive interventions. Lateral and anteroposterior chest films should be obtained in any suspected BBI. CONCLUSION This case demonstrates the utility of CPB and DHCA where control of bleeding secondary to BBI is not otherwise possible.
Pediatric critical care medicine : a journal of the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies, 2018
To determine the clinical benefit of using colloids versus crystalloids for volume resuscitation ... more To determine the clinical benefit of using colloids versus crystalloids for volume resuscitation in children admitted after cardiac surgery. Retrospective pre-/postintervention cohort study. Stollery Children's Hospital tertiary care pediatric cardiac ICU. Children admitted to the pediatric cardiac ICU after cardiac surgery. Fluid resuscitation policy change in which crystalloids replaced albumin 5% as the primary fluid strategy for resuscitation after cardiac surgery. Children who underwent cardiac surgery in the 6 months prior to the policy change (5% albumin group) were compared with children admitted during the 6 months after (crystalloid group). Demographic, perioperative, and outcome variables (fluid intake days 1-4 postoperative, vasoactive therapy, blood products, time to negative fluid balance, renal replacement therapies, mechanical ventilation, pediatric cardiac ICU, and length of stay) were collected. Data were analyzed using linear and logistic multivariate analysis...
Objectives/Aim: To determine whether sedation/analgesia drugs used before, during, and after infa... more Objectives/Aim: To determine whether sedation/analgesia drugs used before, during, and after infant cardiac surgery are associated with neurocognitive and functional outcomes. Background: Some animal models suggest neurotoxic effects of anesthetic drugs on the developing brain; however, potential human effects are unknown. Whether these results can be extrapolated to humans is unknown. Methods/Materials: Prospective follow-up project of all infants ≤6 weeks old having surgery for congenital heart disease between 04/03 and 12/06. Demographic, perioperative, and sedation/analgesia variables were collected. Outcomes at kindergarten age were Wechsler Preschool and Primary Scale of Intelligence-III, Beery-Buktenica Developmental Test of Visual Motor Integration (VMI-V), and General Adaptive Composite (GAC) of the Adaptive Behavior Assessment System-II. Multivariable linear regression was used to identify predictor variables. Results: From 135 infants who underwent heart surgery, 19 died, 17 were excluded, 8 were lost to follow-up, leaving 91 children for analysis. Multiple linear regression found days on chloral hydrate [3.5 (3.7) days] was associated with lower performance intelligence quotient (PIQ) (Effect size À1.03; 95% CI À1.96, À0.10; P = 0.03), and cumulative dose [54.2 (60.3) mgÁkg À1 ] of benzodiazepines was associated with lower VMI scores (Effect size À0.07; 95% CI À0.12, À0.01; P = 0.026). No other associations were found between sedation/analgesia variables and full-scale IQ, PIQ, Verbal IQ, VMI, or GAC. Conclusion: Assessment of this cohort at kindergarten age found a small statistically significant association between days on chloral hydrate and PIQ, and benzodiazepine cumulative dose and lower VMI. No other association between sedation/analgesia drugs and outcomes was found.
To report our experience of providing anesthesia for noncardiac procedures in children with in si... more To report our experience of providing anesthesia for noncardiac procedures in children with in situ Berlin Heart EXCOR Pediatric ventricular assist devices and to suggest principles of anesthetic management. With the initiation of the first North American training and support center for Berlin Heart at our institution in 2006, we have been asked to provide anesthesia for noncardiac procedures to these children. No current anesthetic approach to these children has been reported. Anesthetic records for all noncardiac procedures for children with Berlin Heart between August 2006 and February 2009 in a tertiary care pediatric hospital were retrospectively reviewed. Charts were reviewed for demographic and clinical data, perioperative management, and occurrence of hypotension. Twenty-nine procedures were performed on 11 patients. Hypotension was a common occurrence with all anesthetic induction and maintenance agents even at low doses. Ketamine induction, however, was less likely to produce hypotension, odds ratio for hypotension 0.1333 (95% confidence range 0.021-0.856). Hypotension was responsive to fluid bolus (60%) and alpha-receptor agonists (100%). Preoperative stability and presence of biventricular ventricular assist device (BiVAD) did not predict intraoperative hemodynamic course. Unlike patients with other ventricular assist devices, these children do not tolerate reductions in systemic vascular resistance (SVR) because of the relatively fixed cardiac output of this device. Agents that reduce SVR should be avoided where possible. Preoperative stability is not predictive. Fluids and alpha-agonists should be first-line response to hypotension in this population. Further study of this unusual population is warranted to further delineate best anesthetic practice.
OBJECTIVES/AIM: To determine whether sedation/analgesia drugs used before, during, and after infa... more OBJECTIVES/AIM: To determine whether sedation/analgesia drugs used before, during, and after infant cardiac surgery are associated with neurodevelopmental outcome.
Extracorporeal membrane oxygenation (ECMO) is a life-saving treatment for pediatric patients with... more Extracorporeal membrane oxygenation (ECMO) is a life-saving treatment for pediatric patients with respiratory and/or cardiac failure. The ECMO circuit oxygenates and sometimes pumps the blood, effectively replacing lung and/or heart function temporarily. ECMO patients are clinically very complex not only because of their underlying, life-threatening pathology, but also because of the many physiological parameters that must be monitored and adjusted to maintain adequate tissue perfusion and oxygenation. Drainage and reinfusion cannulae connecting the patient to the ECMO circuit are visible on radiograph. These cannulae have different functions, different configurations, different radiographic appearances, and different positions that should be familiar to the interpreting pediatric radiologist. The primary complications of ECMO include hemorrhage, thrombosis and ischemia, as well as equipment failure and cannula malpositioning, all of which may be detected on imaging. In this pictorial essay, we discuss the basics of ECMO function and clinical management, ECMO cannula features and configurations, and the many complications of ECMO from an imaging perspective. Our goal is to educate pediatric radiologists about ECMO imaging, equipping them to properly interpret these studies and to become a useful consultant in ECMO patient care.
This case report describes the occurrence of massive upper gastrointestinal hemorrhage immediatel... more This case report describes the occurrence of massive upper gastrointestinal hemorrhage immediately after cross-clamping of the inferior vena cava and hepatic portal vein. This case suggests that acute intraoperative hemorrhage from a varix should always be a consideration before liver transplantation in patients who have a history of upper gastrointestinal bleeding.
A prospective observational case series of children receiving light general anesthesia for magnet... more A prospective observational case series of children receiving light general anesthesia for magnetic resonance imaging (MRI) was performed. Our purpose was to examine the merit of anesthesia and recovery/discharge times of combined remifentanil and propofol total intravenous anesthesia (TIVA) in spontaneously breathing children. After IRB approval and informed consent, 56 patients receiving Remi/Propofol TIVA (Remifentanil 10 microg.ml(-1) Propofol 10 mg.ml(-1)) were observed. Blood pressure, respiratory rate, endtidal CO(2) (P(E)CO(2)), oxygen saturation and temperature were recorded at the start and finish of anesthesia. In addition, induction and recovery times were noted. Recovery time was from scan completion until discharge from the initial recovery area. Discharge time was from scan completion to discharge home. Fifty-six patients received Remi/Propofol TIVA. The mean Remi/Propofol recovery and discharge times were 8.9 and 28.2 min, respectively. There was a statistically significant decrease in respiratory rate and increase in CO(2) from the start to the end of the procedure. During the scan, seven patients moved. One patient experienced postprocedure nausea and or vomiting. The combination of remifentanil and propofol for TIVA may be an effective method of light general anesthesia in pediatric patients undergoing MRI.
Background: Despite the fact that almost all critically ill children experience some degree of pa... more Background: Despite the fact that almost all critically ill children experience some degree of pain or anxiety, there is a lack of highquality evidence to inform preferred approaches to sedation, analgesia, and comfort measures in this environment. We conducted this survey to better understand current comfort and sedation practices among Canadian pediatric intensivists. Methods: The survey was conducted after a literature review and initial focus groups. The survey was then pretested and validated. The final survey was distributed by email to 134 intensivists from 17 PICUs across Canada using the Research Electronic Data Capture system. Results: The response rate was 73% (98/134). The most commonly used sedation scores are Face, Legs, Activity, Cry, and Consolability (42%) and COMFORT (41%). Withdrawal scores are commonly used (65%). In contrast, delirium scores are used by only 16% of the respondents. Only 36% of respondents have routinely used sedation protocols. The majority (66%) do not use noise reduction methods, whereas only 23% of respondents have a protocol to promote day/night cycles. Comfort measures including music, swaddling, soother, television, and sucrose solutions are frequently used. The drugs most commonly used to provide analgesia are morphine and acetaminophen. Midazolam and chloral hydrate were the most frequent sedatives. Conclusion: Our survey demonstrates great variation in practice in the management of pain and anxiety in Canadian PICUs. Standardized strategies for sedation, delirium and withdrawal, and sleep promotion are lacking. There is a need for research in this field and the development of evidence-based, pediatric sedation and analgesia guidelines.
BACKGROUND In pediatrics, foreign body ingestion poses unique challenges. Each case is unique giv... more BACKGROUND In pediatrics, foreign body ingestion poses unique challenges. Each case is unique given variability in timing, type, and size of object, compounded by underlying comorbidities and age. In the mid-1990s, mortality and morbidity associated with button battery (BB) ingestion (BBI) emerged corresponding to modification in battery fabrication towards higher voltage, large-diameter lithium cells. AIMS To describe the case and management of a BBI in a pediatric patient necessitating the use of cardiopulmonary bypass and deep hypothermic circulatory arrest (DHCA). MATERIALS AND METHODS A 17-month-old female presented with the sudden loss of consciousness at home. Chest X-ray revealed an esophageal foreign body suspicious for BBI. A massive upper gastrointestinal bleeding was temporized with packing. The patient was urgently taken to the operating room for sternotomy, establishment of cardiopulmonary bypass (CPB) with deep hypothermic circulatory arrest (DHCA), removal of BB, repair of the left common carotid artery, esophageal, and tracheal injuries. DISCUSSION Successful management of BBI requires coordinated care and a multidisciplinary approach. A high degree of clinical suspicion for BBI is imperative to facilitate early aggressive interventions. Lateral and anteroposterior chest films should be obtained in any suspected BBI. CONCLUSION This case demonstrates the utility of CPB and DHCA where control of bleeding secondary to BBI is not otherwise possible.
Brain blood flow tests with diffusible radiopharmaceuticals are often done as an ancillary test i... more Brain blood flow tests with diffusible radiopharmaceuticals are often done as an ancillary test in brain death (BD). We report a case of an infant with absent brain blood flow on an anterior planar image despite persistent breathing and extensor posturing. We reviewed the literature from 1980 to 2008 using MEDLINE and PubMed to determine the sensitivity and specificity of these tests in the diagnosis of BD. Search terms were any combination of: brain death; and single photon emission computed tomography (SPECT), radiopharmaceuticals, technetium Tc 99m exametazime, or organotechnetium compounds. The sensitivity of absent brain blood flow on planar imaging for clinically confirmed BD is 119/153 = 77.8% [95% CI 70.5%—83.7%]; and the specificity is 41/41 (100%) [95% CI 92.6%—100%]. For clinically confirmed BD, the sensitivity of SPECT is 107/121 (88.4%) [95% CI 81.4%—93.1%], and specificity is 12/12 (100%) [95% CI 78.4%—100%]. For contrast angiography confirmed BD, the sensitivity of SPECT is 34/34 (100%) [95% CI 91.2%—100%]; the specificity could not be estimated as there were no patients without clinical BD having both tests. Case reports emphasized the possibility of isolated posterior-fossa blood flow, which would not be detectable using non-diffusible radiopharmaceuticals, or without a lateral view using diffusible agents. We conclude that patients having an ancillary radiopharmaceutical brain blood flow test for BD should have anterior and lateral views without exception. Larger numbers of patients both with and without BD (but with severe brain injury) must be studied to determine the sensitivity and specificity of these tests.
... Regional Anesthesia Dominic A. Cave and Barry A. Finegan 211 ... 32. Schurg R, Biscoping J,Ba... more ... Regional Anesthesia Dominic A. Cave and Barry A. Finegan 211 ... 32. Schurg R, Biscoping J,Bachmann-M B, Hempelmann G. Intravenous regional anesthesia of the foot using prilocaine. Clinical aspects, pharmacokinetic and pharmacodynamic studies. ...
While policy changes toward early extubation in the operating room (OR) have been commonly seen i... more While policy changes toward early extubation in the operating room (OR) have been commonly seen in palliative surgeries in single ventricle anatomy, no systematic assessment of their impact on patient outcome has been reported. All patients aged 0-17 years admitted to a PICU in a quaternary children's hospital for post-operative management following a primary Fontan procedure between 2005 and 2011 were included. Patients for revision of Fontan or patients admitted to adult Cardiovascular Intensive Care Unit were excluded. Practice policy was changed from routine extubation in the PICU to early extubation in OR in January 2008. Data were compared between the pre-policy-change era (2005-2007) and the post-policy-change era (2008-2011) to assess the impact of the change on patient outcomes. Generalized linear regression (GLM) and interrupted time series (ITS) analysis were used to access the effect of policy change on PICU length of stay and post-operative fluid balance, adjusting for potential confounders using propensity scores. Root cause analysis (RCA) was conducted to describe causes of failed extubation and challenges of this policy change. One hundred twenty-seven children met inclusion criteria. Average body weight was 14.7 kg [standard deviation (SD) 3.9], and age was 3.5 years (SD 1.9). A clear change in extubation practice occurred between the pre- versus post-policy-change eras: 97.5 % were extubated in the PICU in the pre-policy-change era, as compared to 15.0 % in the post-policy-change era. The average PICU length of stay was shortened by 4.1 days from the pre-policy-change era to the post-policy-change era [95 % CI -1.2 to -6.9, p < 0.01] in the GLM, whereas the ITS analysis did not show a statistically significant difference [95 % CI 1.8 to -2.5] (p = 0.23). No statistically significant difference was observed in the fluid balance in the 24 h post-operation in both analyses. Sixteen patients (16/127, 12.6 %) were reintubated mainly for hemodynamic instability in the pre-policy-change era (6/39, 15.4 %) and excessive bleeding or respiratory etiologies in the post-policy-change era (10/88, 11.4 %). Significant reduction of PICU length of stay was achieved without any evidence of worsening of patient outcomes. RCA suggests watchful observations with respect to bleeding and respiratory etiologies are the key to prevent failure of extubation in the current practice.
In Reply:-We appreciate the interest of Drs. Saidman and Eger in the safety of sevoflurane and th... more In Reply:-We appreciate the interest of Drs. Saidman and Eger in the safety of sevoflurane and the protection of human research participants. Although we disagree with their contentions, we completely share their safety concerns. Indeed, our own concern for patient safety is why we performed the investigation. We assessed the renal effects of low-flow (Յ l/min) sevoflurane in patients at greatest risk for postoperative renal dysfunction: those with preexisting renal insufficiency. Even in such susceptible patients, the renal effects of low-flow sevoflurane and isoflurane were the same. 1 Our conclusions were specific: "Low-flow sevoflurane is as safe as low-flow isoflurane and does not alter renal function in patients with preexisting renal disease." These results amplify previous studies in patients with renal insufficiency, conducted at higher flow rates, which showed no significant differences in the renal effects of sevoflurane and other volatile anesthetics. 2-6 This investigation helps to resolve any outstanding questions about the renal effects of sevoflurane. These have concerned sevoflurane defluorination, patients with renal insufficiency, low flows and compound A formation, and low-flows in renal insufficiency patients. What has emerged from prospective studies and from postapproval pharmacovigilance is a remarkably consistent picture. Postoperative sevoflurane renal effects are not different from those of other anesthetics. After more than 120 million sevoflurane anesthetics given, there is not a single case report of sevoflurane-related renal dysfunction. Considering together all of the studies published to date in patients or volunteers, and even using proteinuria as a so-called "sensitive" (albeit unvalidated and experimental) marker of renal dysfunction, there is no difference between the renal effects of low-flow sevoflurane and other anesthetics (Fig. 1). Drs. Saidman and Eger assert that the compound A exposure in our investigation was "too small." The patients received the compound A exposure they did because the average low-flow duration was 3.2 h, and compound A concentrations typically average 10-15 ppm. Clinical research is captive to the patient population at hand. Nevertheless, we
contributed to conception and design of the study, interpretation of data and revision of the man... more contributed to conception and design of the study, interpretation of data and revision of the manuscript critically for intellectual content, and have read and approved the version to be published; Moez EK contributed to interpretation of data, confirmation of statistical analyses and revision of the manuscript critically for intellectual content, and has read and approved the version to be published; Joffe AR contributed to acquisition and interpretation of data, wrote the first draft of the manuscript, and had final approval of the version to be published; Alobaidi R contributed to acquisition and interpretation of data and revision of the manuscript critically for intellectual content, and had final approval of the version to be published; Joffe AR, Alobaidi R and Moez EK had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis; all authors participated sufficiently in the work to take public responsibility for the manuscript content.
Background: Nerve stimulation guidance (Tsui test) has been reported to be an effective alternati... more Background: Nerve stimulation guidance (Tsui test) has been reported to be an effective alternative to radiographic imaging for proper catheter placement. The purpose of this study was to examine the success rate and complications of continuous caudal epidural analgesia since the implementation of routine use of the Tsui test at the authors' institution. Methods: The authors examined prospectively collected data in their pediatric pain service database from 289 children who had attempted caudal placement of a lumbar or thoracic catheter between 1999 and 2002. Results: In five patients (aged 5 months-1.6 yr), the catheter did not thread to the desired level and was abandoned in the operating room (technical success rate, 98.2%). Of the remaining 284 patients, the overall analgesic success rate of all caudal route epidural analgesia procedures was 84.9%. There was no significant difference in adequate pain control (success) in infants (aged 1 day-1 yr) versus older children (aged younger than 1 yr). The most common adverse effects were pruritus (26.1%) and nausea and vomiting (16.9%). Of the patients in our study, 57.7% had urinary catheters in situ; of those who did not have a catheter placed, 20.8% experienced urinary retention. The incidence of respiratory depression was 4.2%, but the administration of naloxone for severe respiratory depression was never necessary. Three percent of catheters were removed because of suspected contamination, but no epidural abscesses or systemic infection were noted. Conclusions: The results of this study suggest that epidural catheter placement via the caudal approach using the Tsui test is an effective and reasonable alternative to direct lumbar and thoracic epidural analgesia in pediatric patients.
We designed this study to determine the threshold current for nerve stimulation of an insulated n... more We designed this study to determine the threshold current for nerve stimulation of an insulated needle in the epidural space. The intended dermatome was identified using the bony landmarks of the spine. An 18-gauge insulated Tuohy needle was inserted perpendicularly to the skin and advanced until "loss of resistance" was felt. A nerve stimulator was then connected to the insulated needle. Twenty patients were studied using an insulated Tuohy needle and one patient was studied using a noninsulated Tuohy needle. Muscle twitch was elicited with a current of 11.1 Ϯ 3.1 mA (mean Ϯ sd) in all patients in which an insulated needle was used. Muscle twitches were within 2 myotomes of the intended level (based on Address correspondence and reprint requests to Ban C
BACKGROUND In pediatrics, foreign body ingestion poses unique challenges. Each case is unique giv... more BACKGROUND In pediatrics, foreign body ingestion poses unique challenges. Each case is unique given variability in timing, type, and size of object, compounded by underlying comorbidities and age. In the mid-1990s, mortality and morbidity associated with button battery (BB) ingestion (BBI) emerged corresponding to modification in battery fabrication towards higher voltage, large-diameter lithium cells. AIMS To describe the case and management of a BBI in a pediatric patient necessitating the use of cardiopulmonary bypass and deep hypothermic circulatory arrest (DHCA). MATERIALS AND METHODS A 17-month-old female presented with the sudden loss of consciousness at home. Chest X-ray revealed an esophageal foreign body suspicious for BBI. A massive upper gastrointestinal bleeding was temporized with packing. The patient was urgently taken to the operating room for sternotomy, establishment of cardiopulmonary bypass (CPB) with deep hypothermic circulatory arrest (DHCA), removal of BB, repair of the left common carotid artery, esophageal, and tracheal injuries. DISCUSSION Successful management of BBI requires coordinated care and a multidisciplinary approach. A high degree of clinical suspicion for BBI is imperative to facilitate early aggressive interventions. Lateral and anteroposterior chest films should be obtained in any suspected BBI. CONCLUSION This case demonstrates the utility of CPB and DHCA where control of bleeding secondary to BBI is not otherwise possible.
Pediatric critical care medicine : a journal of the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies, 2018
To determine the clinical benefit of using colloids versus crystalloids for volume resuscitation ... more To determine the clinical benefit of using colloids versus crystalloids for volume resuscitation in children admitted after cardiac surgery. Retrospective pre-/postintervention cohort study. Stollery Children's Hospital tertiary care pediatric cardiac ICU. Children admitted to the pediatric cardiac ICU after cardiac surgery. Fluid resuscitation policy change in which crystalloids replaced albumin 5% as the primary fluid strategy for resuscitation after cardiac surgery. Children who underwent cardiac surgery in the 6 months prior to the policy change (5% albumin group) were compared with children admitted during the 6 months after (crystalloid group). Demographic, perioperative, and outcome variables (fluid intake days 1-4 postoperative, vasoactive therapy, blood products, time to negative fluid balance, renal replacement therapies, mechanical ventilation, pediatric cardiac ICU, and length of stay) were collected. Data were analyzed using linear and logistic multivariate analysis...
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