Incidents and complications during pediatric cardiac catheterization

BACKGROUND: Cardiac catheterization has revolutionized the management of pediatric cardiac disease. There has been little information on adverse events during these cases from an anesthesia viewpoint. The aim of this audit was to determine the incident rate during pediatric cardiac catheterization as contemporaneously reported by the anesthetist and to identify both the types of events and which procedures had the highest risk. METHODS: Since 1993, data have been collected prospectively on an audit form for every anesthetic given in our institution, and in-theatre events were recorded on this form. We have reviewed the data collected on pediatric cardiac catheterizations over a period of 9 years. RESULTS: A total of 4454 cardiac catheterizations were recorded. The overall incidence of events was 9.3%. Cardiac catheterization with occlusion of a patent ductus arteriosus (PDA) or a secundum atrial septal defect (ASD) had the lowest event rate at 4.2%. The figure for cardiac catheterization with other therapeutic interventions was 11.6 and 9.3% for solely diagnostic cardiac catheterization. The event rate in infants under the age of 1 year was 13.9% compared with 6.7% for those children over the age of 1 year. Of the 253 reports from cardiac catheterizations that could be analyzed further, there were 91 major complications including four deaths, 72 minor complications and 90 other incidents. CONCLUSIONS: Adverse events occur more commonly during cardiac catheterization than during pediatric anesthesia in general. Cases with highest risk are those in the under 1 year olds and those including a therapeutic intervention other than PDA or ASD occlusion.     

Endoscopic management of anastomotic hemorrhage from pancreatogastrostomy

Background  Hemorrhage from pancreatic-enteric anastomosis after pancreaticoduodenectomy (PD) is a critical condition due to its difficult accessibility and delicate condition, and therefore remains a major challenge for the surgeon in charge. Objective  This study analyzed presentation and management of pancreatogastrostomy hemorrhage (PGH) after PD to determine the respective roles of endoscopy and surgery. Patients and methods  Patients who underwent PD with pancreatogastrostomy between 1989 and January 2008 were identified from a pancreatic resection database and analyzed with regards to PGH, treatment strategy and outcome, and incidence of postoperative complications. Results  Out of 265 consecutive patients with PD, 10 patients (3.7%) experienced an episode of PGH, detected on average on postoperative day 5. No patient with PGH died during hospital stay as opposed to a mortality rate of 2.7% in patients without PGH. Morbidity rates were 50% versus 48% and length of hospital stay was 23 versus 21 days for patients with and without PGH, respectively, with no statistical differences between the groups. Endoscopic approach to control PGH was successful in nine patients. Pancreatogastrostomies were not compromised regarding procedure or air insufflations and no concomitant development of pancreatic fistula was observed. Open surgery was inevitable in one patient with recurrent PGH in order to achieve hemostasis, but resulted in pancreatic fistula and protracted hospital stay. Conclusions  The present study demonstrates a feasible endoscopic approach for the management of PGH with high success rate and no concomitant procedure-related morbidity. Medical illustrations: Lothar Knorn, Bonn.     

Pancreas after living donor kidney transplants in diabetic patients: impact on long-term kidney graft function

Abstract:  In this single-institution study, we compared outcomes in diabetic recipients of living donor (LD) kidney transplants that did vs. did not undergo a subsequent pancreas transplant. Of 307 diabetic recipients who underwent LD kidney transplants from January 1, 1995, through December 31, 2003, a total of 175 underwent a subsequent pancreas after kidney (PAK) transplant; 75 were deemed eligible (E) for, but did not receive (for personal or financial reasons), a PAK, and thus had a kidney transplant alone (KTA); and 57 deemed ineligible (I) for a PAK because of comorbidity also had just a KTA. We analyzed the three groups (PAK, KTA-E, KTA-I) for differences in patient characteristics, glycemic control, renal function, patient and kidney graft survival rates, and causes of death. Kidney graft survival rates (actuarial) were similar in the PAK vs. KTA-E groups at one, five, and 10 yr post-transplant: 98%, 82%, and 67% (PAK) vs. 100%, 84%, and 62% (KTA-E) (p = 0.9). The long-term (greater than four yr post-transplant) estimated glomerular filtration rate (GFR) was higher in the PAK than in the KTA-E group: 53 ± 20 mL/min (PAK) vs. 43 ± 16 mL/min (KTA-E) (p = 0.016). The patient survival rates were also similar for the PAK and KTA-E groups. We conclude that the subsequent transplant of a pancreas after an LD kidney transplant does not adversely affect patient or kidney graft survival rates; in fact, it is associated with better long-term kidney graft function.     

Comparison of ventral corpectomy and plate-screw-instrumented fusion with dorsal laminectomy and rod-screw-instrumented fusion for treatment of at least two vertebral-level spondylotic cervical myelopathy

The objective of the article is to verify the hypothesis that the dorsal multilevel laminectomy and rod-screw-instrumented fusion (DLF) for multilevel spondylotic cervical myelopathy (MSCM) is less strenuous for patients, and less prone to perioperative complications, than ventral multilevel corpectomy and plate-screw-instrumented fusion (VCF), while clinical outcome is comparable. One hundred and three successive patients were treated for at least two vertebral-level MSCM, 42 of them by VCF and 61 by DLF. The two patients groups were retrospectively compared. VCF patients were slightly younger than DLF patients (62.5 ± 10.61 years versus 66 ± 12.4 years, P = 0.012). In VCF patients, a median of 2 (2–3) corpectomies and in DLF patients a median of 3 (2–5) laminectomies were performed. In VCF patients, surgery lasted longer than in DLF patients (229 ± 60 min versus 183 ± 46 min, P ≤ 0.001). Between the VCF and the DLF patients groups, no significant difference was found in perioperative complications (e.g. hardware failure rates of 16.7% in VCF and of 6.6% in the DLF patients) and mortality rates. The postoperative outcome, as assessed by the postoperative change of the Nurick scores, the change of neck pain, the patients’ satisfaction, and the change of the subaxial Cobb angle of the spine did not differ between the two patients groups. However, when comparing the postoperative Nurick scores directly, VCF patients fared somewhat better than DLF patients [median of 2 (0–5) versus 3 (1–5), P = 0.003]. The hypothesized advantages of DLF over VCF in the surgical treatment of at least two vertebral-level MSCM could not be confirmed in this retrospective study. A prospective randomized study is warranted to clarify this issue.     

Establishing a regional pediatric surgical service in the setting of universal health care: a glimpse into the future

Purpose

Increasing health care expense and rising numbers of uninsured Americans have led many to propose a national health insurance. This study describes the process, rationale, and requirements in creating a regional pediatric surgical service in the setting of a single-payer system.

Methods

Our health care system consists of 10 medical centers providing comprehensive care to more than 3 million members. All services are provided by salaried physicians/practitioners to prepaid members. Before July 2004, pediatric surgical care was performed at multiple medical centers with many services contracted out. Starting July 2004, a multidisciplinary, comprehensive pediatric perioperative plan was established. Implementation has occurred in steps; current status and preliminary results are reviewed.

Results

Strict guidelines for pediatric anesthesia and requirements for support services, personnel, and equipment were defined. Pediatric surgery is now performed at 3 community medical centers and 1 tertiary, teaching hospital. Operative cases were assigned to each center based on age, complexity, level of postoperative care, and location. A single high-volume, center for complex care has been established. Access to care was excellent; more than 90% of outpatient consultations were seen within 2 weeks. Utilization of services was 94% in 2006 and 98% in 2007. Physician and patient satisfaction were high. Additional pediatric surgeons have been hired and nearly all care has been internalized. Given the proximity to a major children's hospital, specialty services have not been duplicated.

Conclusion

Establishing a multidisciplinary, comprehensive pediatric perioperative plan provided standards for supporting pediatric surgical services at community hospitals. This regional service may be a model for the future of specialty care, especially in the setting of a single-payer system.     

Muscle function during gait is invariant to age when walking speed is controlled

Older adults walk more slowly, take shorter steps, and spend more time with both legs on the ground compared to young adults. Although many studies have investigated the effects of aging on the kinematics and kinetics of gait, little is known about the corresponding changes in muscle function. The aim of this study was to describe and compare the actions of the lower-limb muscles in accelerating the body's center of mass (COM) in healthy young and older adults. Three-dimensional gait analysis and subject-specific musculoskeletal modeling were used to calculate lower-limb muscle forces and muscle contributions to COM accelerations when both groups walked at the same speed. The orientations of all body segments during walking, except that of the pelvis, were invariant to age when these quantities were expressed in a global reference frame. The older subjects tilted their pelves more anteriorly during the stance phase. The mean contributions of the gluteus maximus, gluteus medius, vasti, gastrocnemius and soleus to the vertical, fore-aft and mediolateral COM accelerations (support, progression and balance, respectively) were similar in the two groups. However, the gluteus medius contributed significantly less to support (p < 0.05) while the gluteus maximus and contralateral erector spinae contributed significantly more to balance (p < 0.05) during early stance in the older subjects. These results provide insight into the functional roles of the individual leg muscles during gait in older adults, and highlight the importance of the hip and back muscles in controlling mediolateral balance.     

Management of heparin resistance during cardiopulmonary bypass: the effect of five different anticoagulation strategies on hemostatic activation

OBJECTIVE: Attenuation of hemostatic activation is a central goal during CPB. However, this poses a problem in patients insensitive to heparin. The present investigation was performed to assess different strategies of managing patients with heparin resistance during CPB. DESIGN: A randomized, prospective clinical investigation. SETTING: A major European heart center. PARTICIPANTS: Five groups with 20 patients each were investigated. INTERVENTIONS: The groups were handled as follows: (1). maintenance of a target ACT, (2). maintenance of the target unfractionated heparin (UFH) level and supplementation of a UFH level-based strategy with (3). AT III, (4). the direct thrombin inhibitor r-hirudin, or (5). the short-acting platelet glycoprotein (GP) IIb/IIIa antagonist tirofiban. Platelet count and generation of contact factor XIIa, thrombin, and soluble fibrin were assessed. Samples were obtained before CPB and after CPB before protamine infusion. MEASUREMENTS AND MAIN RESULTS: There were no differences observed in the generation of factor XIIa. The UFH-based strategy and supplementation with AT III, r-hirudin, and tirofiban resulted in significantly reduced (p < 0.05) thrombin generation compared with ACT management. A significant reduction of fibrin formation was seen only in patients who received AT III, r-hirudin, or tirofiban supplementation to the UFH. The administration of tirofiban resulted in a significant preservation of the platelet count compared with the other groups. There were no significant differences in the postoperative blood loss. CONCLUSIONS: Activation of hemostasis during CPB in heparin-resistant patients most likely has to be attributed to stimulation of the tissue factor pathway. Even the sole use of high concentrations of UFH does not effectively inhibit this activation. Therefore, in these patients anticoagulation during CPB with UFH should be supplemented with either AT III, a short-acting direct thrombin inhibitor, or a short-acting platelet glycoprotein IIb/IIIa antagonist.     

Management of acute calvarial burns in children

BACKGROUND: Although rare, head burns involving the calvarium are a serious complication of burns and electrical injury, and present therapeutic challenges to the surgical burn care team. We evaluated our experiences and compared available strategies to address this challenge. METHODS: Records of all burned children between January 1986 and December 2000 were reviewed. Twenty-seven children (15 boys and 12 girls) with scalp burns extending at least into the outer table of bone were identified and compared with a matched group of 30 patients admitted for acute thermal burns without skull injury. RESULTS: Flame burn was the injury mechanism in 78% of these patients and electrical injury was the injury mechanism in 22%. The incidence of calvarial burns in our patient population was 1.2% for thermal burns and 5.6% for electrical injuries during the study period. The age distribution was biphasic, with maximums in infancy for thermal burns and in puberty for electrical injuries. Eight of 27 patients (29.6%) developed full-thickness calvarial bone defects. In 23 patients, calvarial burn wound coverage was achieved with bone debridement and immediate or delayed placement of autograft skin. In four patients (all with electrical injury), local scalp flaps were required for closure. The length of hospital stay and overall number of acute operative procedures significantly increased for patients with calvarial burns. CONCLUSION: Acute calvarial burns are safely managed by bone debridement in combination with staged autografting or early flap coverage. Although flap coverage reduces the number of required procedures, the extensive wound size in thermal burns restricts acute flap procedures primarily to electrical injuries. Compared with patients without skull injury, length of hospital stay and the number of acute operative procedures are tremendously increased in patients with calvarial burns.     

MRI thermometry: Fast mapping of RF‐induced heating along conductive wires

Conductive implants are in most cases a strict contraindication for MRI examinations, as RF pulses applied during the MRI measurement can lead to severe heating of the surrounding tissue. Understanding and mapping of these heating effects is therefore crucial for determining the circumstances under which patient examinations are safe. The use of fluoroptic probes is the standard procedure for monitoring these heating effects. However, the observed temperature increase is highly dependent on the positioning of such a probe, as it can only determine the temperature locally. Temperature mapping with MRI after RF heating can be used, but cooling effects during imaging lead to a significant underestimation of the heating effect. In this work, an MRI thermometry method was combined with an MRI heating sequence, allowing for temperature mapping during RF heating. This technique may provide new opportunities for implant safety investigations. Magn Reson Med, 2008. © 2008 Wiley‐Liss, Inc.     

Complement activation following optic nerve crush in the adult rat

Activation of the complement cascade following peripheral nerve axotomy and following traumatic brain injury has been demonstrated in previous studies. This study investigates the temporal pattern of microglia/macrophages and complement activation following axotomy of sensory CNS neurons, using a standardized experimental crush injury of the optic nerve in adult rats. Numerous ED1-labeled macrophages were found at the lesion site and distal to the injury at 7 days post injury (dpi). Complement C3-mRNA was upregulated 2-28 days post lesion, indicating local synthesis of complement in the optic nerve. Furthermore, increased immunoreactivity (IR) for the end product of the complement cascade, the membrane attack complex (MAC), was detected along disintegrating axons co-labeled with anti-neurofilament distal to the injury. Double-labeling for microglia show MAC-immunoreactivity expressed in their immediate vicinity, indicating a key role of microglia/macrophages in complement activation. The complement regulator Clusterin was upregulated in astrocytes at the lesion site as well as in the distal portion of the injured optic nerve, suggesting activation of a defense response to endogenous complement attack. A crush injury of the optic nerve leads to complement activation at the site of lesion and along the distal portion of the nerve, as well as upregulation of the complement inhibitor Clusterin at least in astrocytes. Reactive microglial cells seem to have a key role in complement activation as a local source of C3. We suggest that the balance between complement activation and their regulators may have impact on axonal degeneration following optic nerve injury.