Anuradha Patel

Distraction with a hand-held video game reduces pediatric preoperative anxiety

Background : Video games have received widespread application in health care for distraction and behavior modification therapy. Studies on the effect of cognitive distraction during the preoperative period are lacking. We evaluated the efficacy of an interactive distraction, a hand‐held video game (VG) in reducing preoperative anxiety in children.

Dexmedetomidine Infusion for Analgesia and Prevention of Emergence Agitation in Children with Obstructive Sleep Apnea Syndrome Undergoing Tonsillectomy and Adenoidectomy

BACKGROUND:Dexmedetomidine, a specific &agr;2 agonist, has an analgesic-sparing effect and reduces emergence agitation. We compared an intraoperative dexmedetomidine infusion with bolus fentanyl to reduce perioperative opioid use and decrease emergence agitation in children with obstructive sleep apnea syndrome undergoing adenotonsillectomy (T&A). METHODS:One hundred twenty-two patients with obstructive sleep apnea syndrome undergoing T&A, ages 2 to 10 years, completed this prospective, randomized, U.S. Food and Drug Administration–approved study. After mask induction with sevoflurane, group D received IV dexmedetomidine 2 &mgr;g · kg−1 over 10 minutes, followed by 0.7 &mgr;g · kg−1 · h–1, and group F received IV fentanyl bolus 1 &mgr;g · kg−1. Anesthesia was maintained with sevoflurane, oxygen, and nitrous oxide. Fentanyl 0.5 to 1 &mgr;g · kg−1 was given to subjects in both groups for an increase in heart rate or systolic blood pressure 30% above preincision values that continued for 5 minutes. Observers in the postanesthesia care unit (PACU) were blinded to treatment groups. Pain was evaluated using the objective pain score in the PACU on arrival, at 5 minutes, at 15 minutes, then every 15 minutes for 120 minutes. Emergence agitation was evaluated at the same intervals by 2 scales: the Pediatric Anesthesia Emergence Delirium scale and a 5-point scale described by Cole. Morphine (0.05 to 0.1 mg · kg−1) was given for pain (score >4) or severe agitation (score 4 or 5) lasting more than 5 minutes. RESULTS:In group D, 9.8% patients needed intraoperative rescue fentanyl in comparison with 36% in group F (P = 0.001). Mean systolic blood pressure and heart rate were significantly lower in group D (P < 0.05). Minimum alveolar concentration values were significantly different between the 2 groups (P = 0.015). The median objective pain score was 3 for group D and 5 for group F (P = 0.001). In group D, 10 (16.3%) patients required rescue morphine, in comparison with 29 (47.5%) in group F (P = 0.002). The frequency of severe emergence agitation on arrival in the PACU was 18% in group D and 45.9% in group F (P = 0.004); at 5 minutes and at 15 minutes, it was lower in group D (P = 0.028). The duration of agitation on the Cole scale was statistically lower in group D (P = 0.004). In group D, 18% of patients and 40.9% in group F had an episode of SPO2 below 95% (P = 0.01). CONCLUSIONS:An intraoperative infusion of dexmedetomidine combined with inhalation anesthetics provided satisfactory intraoperative conditions for T&A without adverse hemodynamic effects. Postoperative opioid requirements were significantly reduced, and the incidence and duration of severe emergence agitation was lower with fewer patients having desaturation episodes.

Open gastrostomy for noninvasive ventilation users with neuromuscular disease.

Bach JR, Gonzalez M, Sharma A, Swan K, Patel A: Open gastrostomy for noninvasive ventilation users with neuromuscular disease. Objective:To report open gastrostomy for ventilator-assisted or -supported patients with altered nutritional status as a result of severe dysphagia and without tracheostomy, translaryngeal intubation, or general anesthesia. Avoiding intubation and general anesthesia decreases the risk of respiratory complications and can prolong noninvasive respiratory management. Design:The procedure was performed for 62 noninvasive intermittent positive-pressure ventilation users: 44 with amyotrophic lateral sclerosis, 10 with muscular dystrophy including 6 with Duchenne muscular dystrophy, and 8 with other conditions. All had vital capacities <40% of predicted normal. Noninvasive intermittent positive-pressure ventilation was provided in ambient air before, during, and after the procedure. Oxyhemoglobin saturation was maintained at 95% or greater and end-tidal CO2 <40 cm H2O by noninvasive intermittent positive-pressure ventilation and mechanically assisted coughing. Results:There were no complications of the procedure. All patients gained weight subsequently. Mean postgastrostomy survival was 38.8 ± 6.2 mos with 26 of the patients still alive. Eighteen of the 62 patients had no ventilator-free breathing ability before, during, or after the gastrostomy. Fifty-one patients eventually lost all ventilator-free breathing abilities without tracheostomy. Conclusions:Open gastrostomy can be performed safely without airway intubation or general anesthesia for patients with little or no autonomous breathing ability. It permitted continued survival without tracheostomy despite loss of all ventilator-free breathing abilities for 51 patients.

Propofol Exposure in Pregnant Rats Induces Neurotoxicity and Persistent Learning Deficit in the Offspring

Propofol is a general anesthetic widely used in surgical procedures, including those in pregnant women. Preclinical studies suggest that propofol may cause neuronal injury to the offspring of primates if it is administered during pregnancy. However, it is unknown whether those neuronal changes would lead to long-term behavioral deficits in the offspring. In this study, propofol (0.4 mg/kg/min, IV, 2 h), saline, or intralipid solution was administered to pregnant rats on gestational day 18. We detected increased levels of cleaved caspase-3 in fetal brain at 6 h after propofol exposure. The neuronal density of the hippocampus of offspring was reduced significantly on postnatal day 10 (P10) and P28. Synaptophysin levels were also significantly reduced on P28. Furthermore, exploratory and learning behaviors of offspring rats (started at P28) were assessed in open-field trial and eight-arm radial maze. The offspring from propofol-treated dams showed significantly less exploratory activity in the open-field test and less spatial learning in the eight-arm radial maze. Thus, this study suggested that propofol exposure during pregnancy in rat increased cleaved caspsase-3 levels in fetal brain, deletion of neurons, reduced synaptophysin levels in the hippocampal region, and persistent learning deficits in the offspring.

Blood loss during posterior spinal fusion for adolescent idiopathic scoliosis.

Study Design. Retrospective uncontrolled case series. Objective. The purpose of this study was to determine the association, if any, between intraoperative blood loss and need for transfusion with the use of periapical (Ponte) osteotomies, as well as other patient and surgical variables among patients with adolescent idiopathic scoliosis (AIS) undergoing posterior spinal instrumentation and fusion. Summary of Background Data. Blood loss during posterior spinal fusion for AIS can be substantial. Numerous techniques are used to minimize intraoperative blood loss and the need for allogeneic transfusion. However, it is unclear which patient and surgeon variables affect blood loss most significantly. Methods. A review was conducted on consecutive patients with AIS who had undergone posterior spinal fusion from July 1997 to February 2013 by a single primary surgeon at 1 institution. The relationship of estimated blood loss, normalized blood loss (normalized blood loss = estimated blood loss/number of levels fused/patients weight in kilograms), autologous blood retrieved, and allogeneic transfusion received with various patient- and procedure-related variables were analyzed. Results. Estimated blood loss, normalized blood loss, and autologous blood retrieved were higher in patients who underwent periapical Ponte osteotomies (n = 38) (P < 0.0001, P < 0.001, P < 0.01, respectively). The mean major curve correction was 64% in patients without osteotomies, and 65% in patients with osteotomies (P = 0.81). All patients who underwent osteotomies (38/38) received allogeneic transfusion versus 26% (19/73) of those without osteotomies (P < 0.001). The likelihood of transfusion correlated with increasing number of osteotomies and a lower preoperative hemoglobin level (odds ratio, 3.34; P = 0.003; and odds ratio, 0.51; P = 0.02, respectively). Conclusion. In patients with AIS undergoing posterior spinal fusion with instrumentation, performing periapical osteotomies increased all measures of intraoperative blood loss and need for transfusion without substantially improving major curve correction. As expected, a lower preoperative hemoglobin level was observed in patients who received a blood transfusion after posterior instrumentation and fusion. Level of Evidence: 4

Laryngeal mask airway (LMA) artefact resulting in MRI misdiagnosis

We report a 7-year-old child who underwent brain MRI for a known seizure disorder. The technique used for general anesthesia included inhalation induction followed by placement of a laryngeal mask airway (LMA) for airway maintenance. Because the reviewing radiologist was unfamiliar with the use of an LMA during anesthesia, and because the attending anesthesiologist did not communicate his technique to the radiologist, an MRI misdiagnosis was reported because of artefact created by the in situ LMA. As a result of this misdiagnosis the child was subjected to unnecessary subsequent testing to rule out a reported anatomic abnormality induced by the LMA. Our case illustrates the need for coordination of patient care among hospital services.

Novel intra-operative pulse oximetry monitoring for gastroschisis: a noninvasive monitor of intra-abdominal pressure.

levels and D-dimers may confirm a fibrinolytic effect is present. D-dimers were 0.85 mgÆl 4 days after discontinuation of alteplase in our patient. The incidence of thrombosis of the SVC after a Glenn procedure is not known. However it may have devastating consequences and therefore central venous lines in the Glenn circuit should be avoided. Noninvasive imaginary methods may not be adequate to either establish the diagnosis or follow-up its progress. Angiography seems to be the most reliable method to ascertain the effectiveness of the treatment. Ignacio Malagon* Fabiola C M Evens† Mathias W Freund‡ *Department of Anaesthesia †Department of Cardiac Surgery ‡Department of Cardiology, Wilhelmina Children’s Hospital, PO Box 85090, 3508 AB Utrecht, The Netherlands (email: imalagon@umcutrecht.nl)

Statins as Potentially Neuroprotective Agents: A Review

The aim of this literature review is to assess the experimental and clinical evidence regarding potential neuroprotective effects of statins and their possible perioperative benefit. Statins are drugs used to control cholesterol disorders and prevent cardiovascular diseases by four mechanisms: improvement of endothelial function, modulation of inflammatory responses, maintenance of plaque stability, and prevention of thrombus formation. It is possible that these various effects may also be neuroprotective. The anti-inflammatory effects of statins on endothelial cell mechanisms are better understood than their role in neuroprotection or tumoral apoptosis and evidence is only just emerging that statins may be beneficial. Data regarding perioperative use of statins in neurosurgery is scarce, controversial and inconclusive since there is a lack of convincing randomized, prospective clinical trials. More trials in humans are needed to determine whether statins could contribute to the current management of neurosurgical diseases. Not much is known about utilizing statins as a prophylactic treatment and some would probably advocate that we should be treating ‘at risk’ patients with statins perioperatively or at least it is important to try to put this into a clinical perspective.

Acute Hyperkalemia and Hyponatremia Following Intraoperative Mannitol Administration

Intravenous mannitol may lead to electrolyte disturbances involving sodium and potassium and resulting in cardiac dysfunction. This report demonstrates that when mannitol is given during intracranial surgery it can cause large increase potassium ion concentration and decrease in sodium ion concentration in the absence of any other possible causes. Intraoperative checks of serum electrolyte levels, arterial blood gas analysis and electrocardiogram monitoring could be recommended to be done routinely when using mannitol.

Pediatric-compatible train-of-four monitoring.

accounted for when calculating the test-dose volume. We chose a test-dose volume of 1 ml. Assuming a catheter dead space of 0.2 ml, this resulted in an actual test-dose volume of approximately 0.22 mlÆkg containing 1.1 lgÆkg epinephrine. This large dose of epinephrine containing local anesthetic allowed to unmistakably identify intravascular catheter position by immediate and dramatic but brief T-wave elevation in a neonate.