A survey of blood transfusion practice in French-speaking pediatric anesthesiologists

Background: There are so far no existing consensus guidelines regarding red blood cell transfusion during pediatric surgery, and there is a little information regarding red blood cell transfusion policy among pediatric anesthesiologists. Objectives: To determine the transfusion threshold and the volumes of packed red blood cell (PRBC) transfusion among French‐speaking pediatric anesthesiologists. Materials and methods: A questionnaire of case scenarios was sent to active members of the French Language Society of Pediatrics Anesthesiologists (ADARPEF). Results: Of the 324 active members of the ADARPEF, 175 (54%) completed the questionnaire. The threshold for blood transfusion varied from 6 to 12 g·dl^?1 depending on the scenario. The hemoglobin threshold for blood transfusion and the volume of blood transfused vary among ADARPEF physicians, for the same class of patients. The median [95% CI] hemoglobin threshold for starting blood transfusion was 7.9 [6.9–8.9], 7.3 [6.4–8.2], and 8.1 [7.0–9.2] g·dl^?1 in the pre‐, intra‐, and postoperative phase, respectively. The median [95% CI] PRBC volume transfused was 11.7 [6.6–16.8] ml·kg^?1, and the median hemoglobin target was 11.3 [9.8–12.8] g·dl^?1. Physicians ranked age (79%), clinical tolerance of anemia (99%), underlying medical conditions (95%), hemodynamic instability (89%), hemostasis disorder (86%), and sepsis (79%) as the most significant factors affecting their transfusion decisions. Most pediatric anesthesiologists (89%) measure the hemoglobin level before PRBC transfusion. Conclusions: This survey identifies significant differences in transfusion practice patterns among pediatric anesthesiologists with a median transfusion threshold of 7.6 [6.6–8.6] g·dl^?1 and a median PRBC volume transfusion of 11.7 [16.8–6.6] ml·kg^?1.     

Reduction of blood loss using aprotonin during spinal surgery in children for non-idiopathic scoliosis.

Background Aprotinin, a serine protease inhibitor, reduces surgical blood loss by mechanisms including antifibrinolysis and preservation of platelet function. Its effectiveness has been reported in adult patients undergoing cardiac, major orthopaedic surgery (1) and liver surgery, as well as in paediatric cardiac surgery. Spinal surgery in children with scoliotic deformities involves major blood loss. This may often be more than one circulatory blood volume and therefore results in exposure to blood products and the accompanying risks and problems. Patients with Duchenne muscular dystrophy or other neuromuscular conditions presenting for correction of a spinal deformity pose a particular problem because of their propensity to bleed during surgery. Aprotinin was introduced into the RMCH for the purpose of reducing blood loss in this group of patients in 1999. Administration of aprotinin carries the risk of the formation of aprotinin specific antibodies and anaphylaxis. Re‐exposure carries a greater risk. The aim of this study was to investigate the effect of aprotinin on blood loss during corrective spinal surgery in the neuromuscular patients. Methods We have performed a retrospective review of 33 ASA III cases operated on in period June 1998–September 2000. All notes were studied and data recorded on the intraoperative blood loss and the length of surgical procedure. Aprotinin was used only in children where it was felt that they would be unlikely to be re‐exposed because of their initial presenting diagnosis. Our regimen for aprotinin administration was: test dose 5 ml (50 000 KIU) over 20 min, loading dose 2 ml·kg^?1 (20 000 KIU·kg^?1) infused over 30 min, then maintenance at 0.5 ml·kg^?1·hr^?1 (5 000 KIU·kg^?1·h^?1). Results In the group that had not received aprotinin were 15 patients aged 7–17 years (mean age 13 ± 2 years), measured blood loss was 2849 ± 1802 ml, length of surgery 343 ± 78 min. In the aprotinin group we had 18 patients aged 7–15 years (mean age 12 ± 2 years) with recorded mean blood loss of 1380 ± 1000 ml and duration of procedure 389 ± 142 min. The blood loss in the group that had received aprotinin was significantly reduced (P < 0.01). Discussion Our two groups of patients were similar regarding the age of patients, pathology and clinical presentation. We believe that the use of aprotinin resulted in significant reduction of blood loss and requirements for blood products.     

Hemostatic consequences of a non-fresh or reconstituted whole blood small volume cardiopulmonary bypass prime in neonates and infants

Objectives: Despite aggressive measures to miniaturize the cardiopulmonary bypass (CPB) circuit in neonates and infants, the CPB prime volume is often at least as large as the patients’ blood volume. We conducted an observational study to characterize the hemostatic consequences of a CPB prime consisting of either non‐fresh or reconstituted whole blood. Methods: Hematocrit, fibrinogen, platelet count, plasminogen, anti‐thrombin III (AT‐III), and factors (F) II, V, VII, IX, and X of 30 neonates and infants undergoing cardiac surgery with CPB utilizing either a non‐fresh or reconstituted whole blood prime were prospectively evaluated at eight time points. Following protamine administration, microvascular bleeding was treated by protocol. Results: The hemostatic composition of the CPB prime was the same following the use of either non‐fresh or reconstituted whole blood. The CPB prime platelet count (mean ± sd ) was 5.87 ± 2.84 × 10³ μl^?1 when compared to a preoperative platelet count of 298 ± 142 × 10³ μl^?1 (P < 0.0001). Twenty patients received 17.3 ± 9.2 ml·kg^?1 (0.86 ± 0.46 units·kg^?1) of platelets with significant improvement in platelet count. Nine patients received 16.7 ± 13.4 ml·kg^?1 (0.84 ± 0.67 units·kg^?1) of cryoprecipitate with significant improvements in FVIII and fibrinogen. Conclusions: Non‐fresh or reconstituted whole blood as a component of a small volume CPB prime in neonates and infants induces clinically significant dilutional thrombocytopenia in conjunction with less significant reductions in fibrinogen, FII, FV, FVII, FVIII, FIX, FX, plasminogen, and AT‐III.     

Four different fluid regimes during and after minor paediatric surgery—a study of blood glucose concentrations

In order to evaluate the efficiency of glucose homeostatic mechanisms in otherwise healthy infants and children during and after anaesthesia and surgery four different fluid regimes were studied in 40 patients, 6–24 months old. The four regimes all resulted in a total fluid volume of 10 ml·kg^?1·h^?1 intraoperatively and 3 ml·kg^?1 h^?1 postoperatively. One group received a combination of glucose 300 mg·kg^?1h^?1 and Ringer acetate intraoperatively and glucose postoperatively, a second group was given the same intraoperative fluid followed by glucose free Ringer acetate postoperatively. A third group received Ringer acetate both intra- and postoperatively and a fourth group was given Ringer acetate intraoperatively and glucose postoperatively. Blood glucose concentrations were measured after induction (Preop.), immediately after surgery (Postop.) and after 30, 60 and 120 min. Increased blood glucose concentrations were found in all children immediately after surgery. The concentrations were highest among children given glucose. Postoperatively blood glucose remained elevated in children receiving glucose after surgery. In patients without postoperative glucose supply blood glucose concentrations declined. Hypoglycaemia was not seen on any occasion. The differences in blood glucose concentrations with different regimes were significant but small. We conclude that the studied group of healthy children appeared to be capable of regulating blood glucose levels within normal limits with or without intraoperative glucose and also if the intraoperative glucose supply was interrupted postoperatively.     

Measuring circulating blood volume in newborn infants using pulse dye densitometry and indocyanine green

Background: Circulating blood volume (BV) is an important, but often unconsidered, variable in newborn infants undergoing intensive care. The data on validation and repeatability of BV measurement are limited. Aim: To validate and test the repeatability of measuring BV in newborn infants using indocyanine green (ICG) and pulse dye densitometry (PDD). Methods: Validation– Paired measurements of BV were made using the fetal hemoglobin (HbF) dilution and the PDD method. Repeatability– The BV was measured twice at an interval of 30–40 min in a second group of infants. Results: Validation– Data from three of 13 infants studied were excluded because of probe dislodgement or ICG injection error. The median (range) birth weight of the 10 infants whose data were analyzed was 1032 g (740–2384 g) and seven (70%) were receiving either mechanical ventilation or nasal CPAP. The median BV measured by HbF dilution was 66.2 ml·kg^?1 (43.7–81.0 ml·kg^?1) and by the PDD method was 68.9 ml·kg^?1 (49.3–101.0 ml·kg^?1). The mean difference was 5.92 ml·kg^?1 (sd 17.33 ml·kg^?1). Repeatability– Twelve infants were studied and three excluded because of probe dislodgement/motion artifact or ICG injection error. The median weight of the nine infants whose data were analyzed was 1208 g (795–2600 g). The median (range) BV1 and BV2 were 70.5 ml·kg^?1 (53.1–160 ml·kg^?1) and 87.5 ml·kg^?1 (38.0–248.0 ml·kg^?1), respectively. Mean difference of the two BV estimates (BV1–BV2) was ?24.6 ml·kg^?1 (sd 33.3 ml·kg^?1) and coefficient of repeatability was 66.5 ml·kg^?1. Conclusion: Pulse dye densitometry can be used to measure BV in the newborn infant at the cotside but the repeatability measurements suggest that its use is limited.     

Plasma volume replacement with HES 130/0.42 obviates negative side effects of pneumoperitoneum in piglets

Background: Evidence‐based guidelines on optimal perioperative fluid management in infants have not been established. Recent randomized trials in major abdominal surgery in adults suggest that large volumes of fluid may increase morbidity and hospital stay. Our own clinical experience in infants undergoing laparoscopic surgery is different. So the aim of this study was to compare a crystalloid vs a plasma volume stabilizing fluid management regime during prolonged pneumoperitoneum (PP) in an experimental setting. Methods: Fifteen German landrace piglets were randomized to one of the following treatment groups: control (no PP, 5 ml·kg^?1·h^?1 electrolyte solution); crystalloid (180 min of PP, 5 ml·kg^?1·h^?1 electrolyte solution); colloid (180 min of PP, single bolus of 5 ml·kg^?1 followed by 5 ml·kg^?1·h^?1 hydroxyethyl starch 130/0.42/6:2). After decompression, monitoring was continued for a further 120 min. During the investigation, the hemodynamic situation including transpulmonary thermodilution and blood gases was monitored periodically. Results: During the study, mean arterial pressure remained within the normal range in colloid‐treated animals and controls, but was significantly lower in crystalloid‐treated animals after decompression of PP. Cardiac output remained within the normal range in the colloid and control groups, but decreased in the crystalloid‐treated animals. In the crystalloid group, the lactate concentrations were higher and base excess was lower than in the colloid and control groups at 240 and 300 min (study end). Conclusion: This study shows that the negative effects of prolonged PP on hemodynamics and acid–base balance can be obviated by a liberal plasma volume stabilization regimen with colloids.     

Perioperative course of FXIII in children undergoing major surgery

Background: Acquired deficiency of FXIII because of perioperative hemodilution has been described several times in adults; however, data in children are scarce. We performed a prospective observational trial to evaluate the intraoperative course of FXIII in children undergoing elective major surgery. Methods: Blood samples were repeatedly taken from 46 children aged 0.3–16 years undergoing major surgery. Concentrations of FXIII and fibrinogen, thrombelastometry by ROTEM^®, and cell count were assessed intraoperatively. Results: A significant decrease in FXIII concentration (median 60%; IQR 49–69%) was already noted at beginning of surgical procedures, while most ROTEM^® traces remain unchanged. FXIII levels further deteriorated intraoperatively to minimal levels of 33% (15–61%). Lowest intraoperative clot strength (ExTEM) was 44 mm (34–50 mm), and fibrinogen plasma levels decreased to minimal levels of 130 mg·dl^?1 (95–160 mg·dl^?1). In 43 of 46 children, transfusion therapy was necessary. Despite of transfusion of fresh frozen plasma (cumulative total dose 22 ml·kg^?1 [11–32 ml·kg^?1]) in 21 of 46 children, FXIII level remains low in all children till the end of surgery at levels of 39% (20–46%). Conclusions: Coagulation factor XIII decreased early during major surgery owing to hemodilution. Overall intraoperative FXIII levels remain low despite of transfusion of fresh frozen plasma.     

Adequacy of caudal analgesia in children after penoscrotal and inguinal surgery using 0.5 or 1.0 ml·kg−1 bupivacaine 0.125%

To determine the optimal volume of bupivacaine 0.125% for postoperative caudal analgesia, we compared the effectiveness of 0.5 ml·kg^?1 and 1 ml·kg^?1 of bupivacaine 0.125% with 1:200,000 epinephrine in 80 children undergoing penoscrotal and inguinal surgery. The adequacy of caudal analgesia and supplemental analgesic requirements did not differ between the two groups at any time during the first 12 hr after surgery. We conclude that 0.5 ml·kg^?1 of bupivacaine 0.125% with 1:200,000 epinephrine is as effective as 1 ml·kg^?1 of the same solution and recommend its use for penoscrotal surgery. The evidence for ss of 0.5 ml·kg^?1 of bupivacaine 0.125% for inguinal owever, is inconclusive because of an insufficient patients studied.     

Experience with a propofol-ketamine mixture for sedation during pediatric orthopedic surgery

Background: Various combinations of propofol and ketofol have been described for the provision of procedural sedation in both adults and children. Utilization of ‘ketofol’ for deep sedation during prolonged pediatric orthopedic procedures has not previously been described. Methods: During an orthopedic aid trip, a 1:1 mixture of propofol and ketamine (200 mg of each drawn up to 22 ml) was utilized to provide deep sedation or general anesthesia as an adjunct to regional analgesia for lower limb surgery. Details for 18 patients having a total of 19 procedures were recorded with a record of intraoperative and postoperative parameters including initial bolus doses and infusion rates of ketofol required to produce deep sedation. Results: Mean operating time was 153.7 min (range 64–241 min). The mean initial bolus dose of ketofol was 0.19 ml·kg^?1 (range 0.1–0.5 ml·kg^?1) or 1.7 mg·kg^?1 each of propofol and ketamine (range 0.9–4.5 mg·kg^?1). The mean upper limit of the infusion rate required to maintain deep sedation was 0.19 ml·kg^?1·h^?1 (range 0.07–0.26 ml·kg^?1·h^?1) or 1.7 mg·kg^?1·h^?1 (range 0.6–2.4 mg·kg^?1·h^?1) and the mean lower limit of the infusion rate was 0.08 ml·kg^?1·h^?1 (range 0.02–0.13 ml·kg^?1·h^?1) or 0.7 mg·kg^?1·h^?1 (range 0.2–1.2 mg·kg^?1·h^?1). The mean initial bolus dose of ketofol was 0.19 ml·kg^?1 (range 0.1–0.5 ml·kg^?1). There were no episodes of hypo‐ or hypertension or of desaturation. Mean time to eye opening after infusion cessation was 5.1 min (median 2 min; range 0–17 min). Conclusion: Ketofol successfully produced deep sedation for prolonged pediatric orthopedic procedures in conjunction with regional analgesia. Further research to confirm its safety and applicability to a wider range of settings is required.     

Unusual presentation of postdural puncture headache requiring repeat epidural blood patch in a 4‐year‐old child

We present the case of a 4‐year‐old child who required two epidural blood patches (EBPs) to treat a delayed onset postdural puncture headache (PDPH) caused by lumbar cerebrospinal fluid drain. The first EBP was unsuccessful with 0.41 ml·kg^?1 of blood injected. A second EBP with 0.76 ml·kg^?1 of blood was performed 2 days later with the complete resolution of symptoms. The volume of blood necessary for effective treatment for symptomatic cerebrospinal fluid leaks in children remains controversial, and a repeat EBP may be required for resolution of symptoms.     

The effect of volume of local anesthetic on the anatomic spread of caudal block in children aged 1-7 years

Objectives: To examine the anatomic spread of caudal local anesthetic solution in children aged 1–7 years. Aim: To determine whether incremental increases in the volume of caudal injections of 0.5, 0.75, and 1.0 ml·kg^?1 result in reliable (>90%) and potentially clinically significant increases in the number of vertebral segments reached. Background: Caudal block is one of the most frequently performed pediatric regional analgesic techniques. Traditional formulae suggest that changes in the volume of caudal injectate in the range 0.5–1.0 ml·kg^?1 would have clinically useful effects. Methods: In a single blind design, 45 children aged 1–7 years undergoing caudal block received one of the three predetermined volumes (0.5, 0.75, and 1 ml·kg^?1) of local anesthetic solution containing radio‐opaque contrast under controlled conditions. Following X‐ray examination, the anatomic spread of the block was reported by a radiologist blinded to the volume of solution received. Results: There were 15 children in each group, and they were similar in terms of age, height, and weight. Spread was observed between the 5th lumbar (L5) and 12th thoracic (T12) vertebral levels. A volume of 1 ml·kg^?1 results in a small but significantly greater spread of solution than 0.5 ml·kg^?1 (P < 0.05), but there was no difference between 0.5 and 0.75 ml or between 0.75 and 1.0 ml. No volume reliably reached a level higher than the second lumbar vertebra (L2). Conclusions: Incrementally increasing the volume of injectate between 0.5 and 1.0 results in a modest increase in the spread of the caudal solution. It is unlikely that volumes of <1 ml will reliably reach a vertebral level that is higher than L2.     

Isovolaemic hemodilution with gelatin and hydroxyethylstarch 130/0.42: effects on hemostasis in piglets

Objectives: Artificial colloids, frequently used to prevent hemorrhagic shock in children, impair blood coagulation. To determine the impact of acute isovolaemic hemodilution with artificial colloids on clot formation, we conducted an experimental study in a pediatric animal model. Methods: Fifteen piglets underwent hemorrhage by withdrawing 40 ml·kg^?1 of blood volume in steps of 10 ml·kg^?1 each within 1 hour. After each withdrawal, the blood loss was randomly compensated by administering 4% gelatin (GEL) or hydroxylethyl starch 130/0.42 (HES) in a ratio of 1 : 1, or isotonic crystalloid solution (ICS) in a ratio of 1 : 4 for isovolaemic hemodilution. Quality of clot formation and platelet function was measured using Thrombelastometry (ROTEM^®) and Multiple electrode impedance aggregometry (Multiplate^®) after 10, 20, and 40 ml·kg^?1 blood replacement. Results: Moderate hemodilution (10–20 ml·kg^?1 blood replacement) caused no significant differences among groups (e.g. INTEM^®‐MCF after 20 ml·kg^?1 blood replacement (ICS vs GEL vs HES, P > 0.05). Profound hemodilution with 40 ml·kg^?1 blood replacement showed a significant difference between ICS and both colloids (P < 0.05), but no significant differences between GEL and HES. Conclusions: Impairment of clot formation by moderate isovolaemic hemodilution did not significantly differ between ICS, GEL, and HES. Profound hemodilution of more than 50% of the estimated blood volume with GEL and HES caused significant impairment of clot formation in comparison to ICS and has to be considered when using high amounts of these synthetic colloids.     

Effect of minimizing preoperative fasting on perioperative blood glucose homeostasis in children

Two hundred healthy, unpremedicated children, ages 1–10 years, scheduled for elective outpatient surgery were studied in order to examine the effect of minimizing preoperative fasting on perioperative blood glucose concentrations in paediatric patients. None of the patients ingested solids after midnight. On the day of surgery, the children were assigned to one of two groups. Group A children (n= 113) were not allowed any liquids for at least 6 h prior to surgery (NPO). Children in Group B (n= 87) ingested 10 ml·kg^?1 of apple juice 2–4 h prior to the induction of anaesthesia. All patients received lactated Ringer's solution intraoperatively, unless BG at induction was < 50 mg·dl^?1 (2.8 m·mol·l^?1) in which case dextrose 2.5% in lactated Ringer's solution was administered. None of the patients who received apple juice was hypoglycaemic during induction of anaesthesia. However, two children in the NPO group had blood glucose values ± 50 mg·dl^?1 (2.8 m·mol·l^?1) at the time of induction of anaesthesia. Thirteen (11%) patients in Group A and 6 (7%) patients in Group B showed either no change or a further decrease in their postoperative BG concentration as compared with their induction values. Two of 43 patients in Group A and 2 of 41 patients in Group B had gastric fluid volumes > 0.4 ml/kg. All patients in both groups had gastric pH < 2.5. This study shows that gastric fluid volume and pH following a 2–4 h fast are not different from the values measured in children who were subjected to a traditional fasting period of 6 h or longer. Moreover, apple juice consumed 2–4 h prior to surgery neither buffers gastric pH nor does it modify intraoperative glucose homeostasis in children.     

血管内临时性球囊阻断技术用于减少异体输血的进展

背景血管内临时性球囊阻断（temporary balloon occlusion of aorta, TBOA ）可减少异体输血（autologous bloodtransfusion, ABT）。目的TBOA可减少术中出血及ABT并取得理想效果,总结其优势、局限性及并发症。内容减少围术期出血、ABT一直是术者及麻醉医师共同面临的问题,手术辅助技术改进、血液制品替代治疗、自体血回输等被应用于围术期。对于一些特殊群体,如肿瘤、产妇、严重创伤休克患者,术中出血量大,传统止血方式难以达到理想效果。TBOA阻断供血动脉,起到暂时止血作用,有效减少术中出血保持术野清晰,缓解了ABT的紧张程度。趋向TBOA经过改进,被用于减少术中出血和减少ABT。     

The effects of caudal or intravenous clonidine on postoperative analgesia produced by caudal levobupivacaine in children

Background: Clonidine is used increasingly in pediatric anesthesia practice to prolong the duration of action of caudal block with a local anesthetic agent. Which route of administration of clonidine is the most beneficial remains unknown. We compared the effects of caudal and intravenous clonidine on postoperative analgesia produced by caudal levobupivacaine. Methods: Sixty ASA I and II children, aged 2–8 undergoing inguinal hernia repair or orchidopexy surgery received standardized premedication with midazolam and general anesthesia. The children were randomized in a double‐blind fashion to three groups. Group L (n = 20) patients received 0.75 ml·kg^?1 of caudal 0.25% levobupivacaine and i.v. 5 ml saline, Group L‐Ccau (n = 20) patients received 0.75 ml·kg^?1 of caudal 0.25% levobupivacaine + 2 μg·kg^?1 clonidine and i.v. 5 ml saline, Group L‐Civ (n = 20) patients received 0.75 ml·kg^?1 of caudal 0.25% levobupivacaine and i.v. 2 μg·kg^?1 clonidine in 5 ml of saline. Mean arterial blood pressure, heart rate, peripheral oxygen saturation, and end‐tidal carbon dioxide values were recorded. Postoperative pain [Children and Infants Postoperative Pain Scale (CHIPPS) score], sedation (Ramsay Sedation Scale) and motor blockade (Modified Bromage Scale) were assessed at predetermined time points during the first 24 h after surgery. Results: Caudal clonidine significantly delayed the time to first rescue analgesic and fewer patients required rescue analgesia in the 24 h after surgery. No motor block was observed in any of the three groups on awakening or during the study period. In Group L‐Ccau, the CHIPPS score was lower than in Group L at all times through 240 min (P < 0.05), while the pain scores were lower in Group L‐Civ only at extubation and at 240 min (P < 0.05). Conclusions: Caudal clonidine prolongs the duration of analgesia produced by caudal levobupivacaine without causing significant side effects and this is because of a spinal mode of action.     

Allogeneic blood transfusion reduction by risk-based protocol in total joint arthroplasty

Purpose

To evaluate the effect of a preoperative protocol that triages patients awaiting total joint arthroplasty to one of four strategies designed to mitigate the risk of allogeneic blood transfusion (ABT) based on a priori transfusion risk on perioperative exposure to allogeneic blood.

Methods

We compared the transfusion experiences of a historical control series of 160 subjects with a study group of 160 subjects treated by protocol. Protocol subjects with hemoglobin (Hb) 100-129 g·L^?1 were given erythropoietin, dosed by weight. Subjects with Hb 130-139 g·L^?1 underwent preoperative autologous blood harvest and perioperative re-infusion as deemed clinically necessary. Subjects with Hb >139 g·L^?1 received no special intervention, unless they were aged >70 yr and weighed < 70 kg, in which case they received oral iron and folate supplementation.

Results

The relative risk of ABT in the Study group was 0.68 (95% confidence interval 0.54-0.85). The Control group received 104 units of allogeneic blood and the Study group received 35 units (P = 0.0007). These differences cannot be explained by differences in transfusion risk or autologous units transfused. There was no worsening of anemia or its consequences in the Study group.

Conclusion

A simple protocol based on easily obtained preoperative clinical indices effectively targets interventions that mitigate the risk of ABT.     

Hyperkalaemia during massive blood transfusion in paediatric craniofacial surgery

Children undergoing major craniofacial surgery (MCFS) often require transfusion in excess of one blood volume. Therefore they were the subject of a retrospective review which looked at the longitudinal trend of plasma potassium concentration [K⁺] during surgery. Ten of eleven children had a statistically significant increase in plasma potassium concentration during their intraoperative course and in five the potassium concentration exceeded 5.5 mmol · L^?1. This was in contrast to the stable intraoperative plasma [K⁺] observed in a control group which did not receive blood transfusion. All MCFS children received a blood transfusion with red blood cell concentrates (RBCconc). The age of the units of RBCconc which had been transfused was 16.1 ± 8.4 days. The amount of extracellular potassium in 28 units of RBCconc was determined in order to estimate the amount of free potassium (K_dose) which the MCFS group received. The plasma [K⁺] in units of RBCconc < 1 week of age was < 20 mmol · L^?1, whereas in units aged > 2 weeks it was > 40 mmol · L^?1. The estimated K_dose was 0.2–1.6 mmol · kg^?1. We concluded that the amount of extracellular potassium in units of RBCconc was clinically important and may give rise to hyperkalaemia during massive blood transfusion.     

Radiological and clinical distribution of thoracic paravertebral blockade in infants and children

The radiological distribution of thoracic paravertebral blockade was studied by chest radiographs with radio-opaque dye injection in 18 paediatric patients. Two distinct patterns of distribution were found: longitudinal and cloudlike. Linear regression analysis found a strong correlation between the relative injected volume of radio-opaque dye and the number of covered segments for the longitudinal group (r= 0.92; number of segments = 3.19 + 14.49 × ml·kg^?1) whereas a moderate correlation was found for the cloudlike group (r= 0.47; number of segments = 3.27 + 3.21 × ml·kg^?1). An injected volume of 0.25 (SD 0.12) ml·kg^?1 of radio-opaque dye was found to cover 5.7 (SD 1.6) segments. In no case could spread to the extradural space be found. The clinical distribution of the blocks was examined in a small number of patients and was found to extend from dematome Th 3/4 to Th 12. An initial bolus dose of 0.5 ml·kg^?1 of the local anaesthetic solution is advocated in order to cover reliably at least five segments which would be sufficient in most clinical situations.     

Open-heart surgery without homologous blood transfusion in infants and children under simple deep hypothermia

Purpose To investigate the hematological changes during the perioperative period of open-heart surgery without homologous blood transfusion under simple deep hypothermia in infants and small children, and to define the limits of body weight for open-heart surgery without homologous blood transfusion under simple deep hypothermia. Methods We performed open-heart surgery without homologous blood transfusion under simple deep hypothermia on eight children, four infants, and a neonate with diagnoses of atrial septal defect, ventricular septal defect, on total anomalous pulmonary venous return (TATVR). All patients except for one with TAPVR were surface-cooled with ice water under deep ether anesthesia. Hematological examinations were performed seven times during the perioperative period. Results The body weight of the patients ranged from 2.5 to 15.0 kg (mean±SD, 9.5±3.5 kg) and the blood loss from 0.7 to 7.1g·kg⁻¹ (4.6±2.0g·kg⁻¹) The lowest values of the hematological findings in each case after surgery were as follows: Hb ranged from 7.6 to 10.9g·dl⁻¹ (8.8±1.0g·dl⁻¹), blood platelet count from 158×10³ to 337×10³ cells·μℓ⁻¹-agonist (271±88 ×10³ cells·μℓ⁻¹-agonist, and total protein from 4.3 to 5.5 g·dl⁻¹ (5.0±0.4g·dl⁻¹) Conclusion Severe anemia and hypoproteinemia were not detected in any case, and, in particular, the reduction of the platelet count was slight. No events occurred as a result of decreased Hb concentration, serum protein, or both.     

Clonidine does not improve quality of ropivacaine axillary brachial plexus block in children

Background: The addition of clonidine to peripheral nerve blocks is controversial in children. Objective: The aim of our study was to evaluate the effect of clonidine added to ropivacaine in pediatric axillary brachial plexus block (ABPB). Methods: Children aged 1–6 years, scheduled to undergo forearm or hand surgery, were recruited into this prospective, double‐blind controlled trial. Patients were randomly allocated to receive an ABPB either with ropivacaine 0.2% 0.4 ml·kg^?1 plus saline in 1 ml (RS) or ropivacaine 0.2% 0.4 ml·kg^?1 plus clonidine 1 μg·kg^?1 in 1 ml (RC). Primary endpoints were quality of postoperative analgesia as assessed by pain scores and total 24‐h postoperative analgesia requirements. Secondary outcomes were time to first analgesia request and duration of motor blockade. Results: Sixty patients were recruited (n = 30 per group) into the study. Pain scores were comparable throughout the first 24 h between the two groups. Ten children in the (RS) and six in (RC) groups required supplementary analgesia during the first 24 h (P = 0.24). Children who required further analgesia did so after 288 ± 94 min in the (RS) and 437 ± 204 min in the (RC) group (P = 0.06). There was no difference in the duration of motor block [186 ± 71 and 154 ± 56 min, P = 0.12 for (RS) and (RC), respectively]. Conclusion: Ropivacaine (0.2% 0.4 ml·kg^?1) for ABPB provides sufficient postoperative analgesia in children scheduled for forearm or hand surgery. The addition of clonidine to ABPB does not improve overall postoperative analgesia but may increase the time to first analgesia request.