Anesthetic challenges in patients with multicompartmental lymphatic failure after Fontan palliation undergoing transcatheter thoracic duct decompression.

Lymphatic flow abnormalities are central to the development of protein losing enteropathy, plastic bronchitis, ascites and pleural effusions in patients palliated to the Fontan circulation. These complications can occur in isolation or multicompartmental (two or more). The treatment of multicompartmental lymphatic failure aims at improving thoracic duct drainage.

Lymphatic imaging and intervention in a pediatric population: Anesthetic considerations.

The recent adoption of an improved lymphatic access technique coupled with Dynamic Contrast-enhanced Magnetic Resonance Lymphangiography has introduced the ability to diagnose and treat severe lymphatic disorders unresponsive to other therapies. All pediatric patients presenting for lymphatic procedures require general anesthesia presenting challenges in managing highly morbid and comorbid conditions both from logistical as well as medical aspects. General anesthesia is used because of the procedural requirement for immobility to accurately place needles and catheters, treat pain secondary to contrast and glue injections, and to accommodate additional procedures.

Reduced transfusion requirement with use of fresh whole blood in pediatric cardiac surgical procedures.

Background: Pediatric patients undergoing cardiac operations are at high risk for blood loss and transfusion. A practice intended to reduce transfusion using a standard order of 2 units fresh whole blood (< 48 hours from donation) for elective cardiac operations in patients younger than 2 years of age was in place from 1995 to 2010. The objective of this study was to describe blood use in this population and to compare the results with those in published reports describing the use of blood components exclusively for transfusion.

Evaluation of central venous pressure monitoring in children undergoing craniofacial reconstruction surgery.

Background: Massive hemorrhage during craniofacial surgery is common and often results in hypovolemia and hypotension. We conducted this study to assess the effect of the addition of routine central venous pressure (CVP) monitoring on the incidence of intraoperative hypotension and to evaluate the relationship between CVP and hypotension in this population.

Methods: Data from our prospective craniofacial perioperative registry for children 6 to 24 months of age undergoing cranial vault reconstruction with CVP monitoring were compared with data from a historical cohort without CVP monitoring.

Absence of tachycardia during hypotension in children undergoing craniofacial reconstruction surgery.

Background: Tachycardia is a baroreceptor-mediated response to hypotension. Heart rate (HR) behavior in the setting of hypotension in anesthetized children is not well characterized. We conducted this study to assess the relationship between HR and hypotension in a population of anesthetized children experiencing massive blood loss.

Implications of anesthesia in children with long QT syndrome.

Background: Patients with congenital long QT syndrome (LQTS) are susceptible to an episodic malignant ventricular tachyarrhythmia known as torsade de pointes, which can result in a cardiac arrest and death. Patients can suffer severe cardiac events resulting in syncope, seizures, and sudden cardiac death during times of physical and emotional stress and when exposed to certain drugs including anesthetics. We describe the occurrence of perioperative adverse events (AEs) related to arrhythmias in children with congenital LQTS exposed to volatile general anesthesia and describe associated risk factors.

Reconstituted blood reduces blood donor exposures in children undergoing craniofacial reconstruction surgery.

Objective/aims: To assess the effect of prophylactic administration of fresh-frozen plasma (FFP) in the form of reconstituted blood in children undergoing craniofacial reconstruction. The outcomes of interest included immediate postoperative coagulation laboratory test results, postoperative surgical drain output, and the number of unique blood donor exposures incurred.

Background: We recently changed our intraoperative transfusion strategy in children undergoing craniofacial reconstruction surgery to one in which blood loss is replaced with donor-matched reconstituted blood rather than traditional blood component therapy.

A comparison of the efficacy and safety of chloral hydrate versus inhaled anesthesia for sedating infants and toddlers for transthoracic echocardiograms.

Background: Pediatric patients may need sedation for a transthoracic echocardiogram. Due to the unpredictability and safety concerns with chloral hydrate, we offered mask anesthesia as an alternate strategy.

Methods: A retrospective chart review of 507 pediatric patients sedated for transthoracic echocardiography was conducted to compare the use of oral chloral hydrate (n = 297) with the face mask administration of sevoflurane anesthesia (n = 210).

Blood loss, replacement, and associated morbidity in infants and children undergoing craniofacial surgery.

Background: Pediatric craniofacial reconstruction (CFR) procedures involve wide scalp dissections with multiple osteotomies and have been associated with significant morbidity. The aim of this study was to document the incidence of clinically important problems, particularly related to blood loss, and perform a risk factor analysis.

Methods: Records of all patients who underwent craniofacial surgery at the Children's Hospital of Philadelphia between December 1, 2001 and January 1, 2006 were reviewed.

The Fontan patient.

Improved surgical and medical management has led to an increase in survival after staged univentricular palliative procedures. Subsequently, this improved survival has led to an increase in the number of patients who will present for noncardiac surgical interventions with Fontan physiology. A comprehensive understanding of normal Fontan physiology and the perturbations that the proposed surgical procedure will likely have is necessary to care for and design a comprehensive anesthetic plan that takes into account the effects of anesthetic agents, ventilation strategies, cardiovascular drugs, and various other perioperative factors.

Early tracheal extubation in adults undergoing single-lung transplantation for chronic obstructive pulmonary disease: pilot evaluation of perioperative outcome.

The objective of this pilot study was to evaluate the safety and success of early tracheal extubation (ETE) as compared to delayed tracheal extubation (DTE) in single-lung transplantation (SLT) for chronic obstructive pulmonary disease (COPD). This retrospective observational study was undertaken at a university hospital. Fifty-seven adult patients who underwent SLT for COPD (1998-2003) were enrolled.

Bleeding and blood product utilization in adults undergoing elective aortic root replacement: the impact of antifibrinolytic exposure and aortic root prosthesis.

A retrospective observational study was carried out to test the hypothesis that bleeding and blood component utilization are significantly associated with aortic root replacement (ARR). The aims of the study were as follows. (1) To determine antifibrinolytic exposure (AFE) in ARR; (2) To determine mediastinal drainage within the first 24 hours after ARR; (3) To determine blood component transfusion within the first 24 hours after ARR; (4) To determine whether AFE affects bleeding and blood component transfusion for ARR; and, (5) To determine whether type of aortic root prosthesis affects bleeding and/or blood component transfusion after ARR.

Cardiopulmonary bypass for lung transplantation in cystic fibrosis: pilot evaluation of perioperative outcome.

Objective: The purpose of this study was to determine whether cardiopulmonary bypass (CPB) reduces the incidence of perioperative graft infection after lung transplantation in adults with cystic fibrosis (CF).

Design: Retrospective and observational.

Setting: University hospital.

Female gender increases the risk of death during hospitalization for pediatric cardiac surgery.

Objectives: The study objective was to determine whether gender is a determinant of in-hospital mortality after surgery to repair congenital heart disease in patients aged 20 years or less. Secondary objectives were to determine other factors associated with increased risk of death and whether female gender is associated with increased length of stay or total charges.

Methods: The study included a retrospective cohort consisting of all records indicating cardiac operations within the Healthcare Cost and Utilization Project Kids' Inpatient Database for the year 2000.

Renal dysfunction after thoracic aortic surgery requiring deep hypothermic circulatory arrest: definition, incidence, and clinical predictors.

Objective: The purpose of this study was to evaluate renal dysfunction (RD) after thoracic aortic surgery (TAS) requiring deep hypothermic circulatory arrest (DHCA), to determine the influence of definition on RD after TAS-DHCA, to determine univariate predictors of RD after TAS-DHCA, and to determine multivariate predictors for RD TAS-DHCA. RD was defined in 3 ways: (1) >25% reduction in creatinine clearance, (2) >50% increase in serum creatinine, and (3) >50% increase in serum creatinine with an abnormal peak serum creatinine (>1.3 mg/dL for men and >1.

Evaluation of tissue saturation as a noninvasive measure of mixed venous saturation in children.

Background: Mixed venous saturation (S & OV0456;o2) is an important measurement that helps guide the care of critically ill patients. Invasive S & OV0456;o2 assessment in infants and children is often avoided because of the inherent risks. A noninvasive tissue saturation (S to 2) monitor has recently been developed that uses near-infrared spectroscopy to measure oxyhemoglobin saturation in muscle.

A randomized controlled clinical trial of real-time needle-guided ultrasound for internal jugular venous cannulation in a large university anesthesia department.

Objective: The purpose of this study was to evaluate needle-guided ultrasound for internal jugular venous cannulation in a large university anesthesia department, to determine cumulative cannulation success by method, to determine first-pass cannulation success by method and operator, and to determine arterial puncture by method and operator.

Study Design: Prospective, observational, and randomized. Blinding was not possible.

Major clinical outcomes in adults undergoing thoracic aortic surgery requiring deep hypothermic circulatory arrest: quantification of organ-based perioperative outcome and detection of opportunities for perioperative intervention.

Objective: The purpose of this study was to describe clinical outcome after adult thoracic aortic surgery requiring standardized deep hypothermic circulatory arrest (DHCA), to determine mortality and length of stay, neurologic outcome, cardiorespiratory outcome, and hemostatic and renal outcome after DHCA.

Design: Retrospective and observational.

Setting: Cardiothoracic operating rooms and intensive care unit (ICU).