David G. Nichols

Life-threatening airway obstruction as a complication to the management of mediastinal masses in children

Life-threatening airway obstruction from large mediastinal masses in children poses a difficult diagnostic and therapeutic dilemma, requiring the close coordination of a pediatric surgeon, anesthesiologist, radiologist, and oncologist. To focus on this problem, the anesthetic and surgical management of 50 consecutive children with mediastinal masses treated between 1978 and 1984 were reviewed. Thirty children presented with respiratory symptoms; nine had life-threatening respiratory compromise with dyspnea, orthopnea, and stridor. Thirteen of these symptomatic children had marked compression of the trachea and/or mainstem bronchi on radiographic studies. The tracheal cross-sectional area which was measured by computed tomography was decreased by 35% to 93% of the normal tracheal dimensions in these children. Nonresectable malignant neoplasms including lymphoma, Hodgkins disease, rhabdomyosarcoma, and neuroblastoma were the eventual diagnoses in 10 of these patients. The other 3 patients were less than 4 years old and had benign lesions. General anesthesia was judged to be prohibitively risky in 5 of 13 patients. The diagnosis was established by node or needle biopsy under local anesthesia, and general anesthesia was deferred until the compromised airway was alleviated by radiation and chemotherapy. General anesthesia with endotracheal intubation was administered to 8 patients, 5 of whom developed total airway obstruction. Using a variety of maneuvers, ventilation was reestablished in all 5 patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Predictors of outcome in severely head-injured children

ObjectiveDetermine variables in the acute care period associated with survival and pediatric intensive care unit (PICU) length of stay (LOS) for children with severe traumatic brain injury. DesignRetrospective cohort. SettingLevel 1 pediatric trauma center. PatientsChildren (0–17 yrs) admitted 1991 to 1995 with nonpenetrating traumatic brain injury and admission Glasgow Coma Scale score of ≤8. InterventionsNone. Measurements and Main Results The first 72 hrs of hospitalization were analyzed in detail for 136 patients. The primary end point was survival; secondary end points were PICU LOS, cost, and day at which Glasgow Coma Scale score was ≥14. Predictors of outcome were abstracted, including Pediatric Trauma Score, Glasgow Coma Scale score, Pediatric Risk of Mortality, physiologic variables, computed tomography evidence of brain injury, and neuroresuscitative medications. The fatality rate was 24%. Age and gender were similar between groups (p ≥ .1). Survival was independently predicted by 6-hr Glasgow Coma Scale score (odds ratio [OR] 4.6; 95% confidence interval [CI] 2.06–11.9;p < .001) and maximum systolic blood pressure (OR 1.05; 95% CI 1.01–1.09;p < .02). Odds of survival increased 19-fold when maximum systolic blood pressure was ≥135 mm Hg (OR 18.8; 95% CI 2.0–178.0;p < .01). By discharge, 67% of patients had an age-appropriate Glasgow Coma Scale score. Median hospital costs were

Preinduction of Anesthesia in Children with Rectally Administered Midazolam

8,798 for survivors: only mannitol use independently predicted high cost (odds ratio 4.9; 95% CI 1.2–19.1;p < .01). For survivors, median PICU LOS was 2 days, although 25% had LOS >6 days. Six-hour Glasgow Coma Scale score (OR 0.62; 95% CI 0.48–0.80;p < .001) and mannitol (OR 7.9; 95% CI 2.3–27.3;p < .001) were each independently associated with a prolonged LOS among survivors. ConclusionsPatients with higher 6-hr Glasgow Coma Scale scores were more likely to survive. Adjusting for severity of injury, survival was associated with maximum systolic blood pressure ≥135 mm Hg, suggesting that supranormal blood pressures are associated with improved outcome. Mannitol administration was associated with prolonged LOS, yet conferred no survival advantage. We suggest reevaluation of blood pressure targets and mannitol use in children with severe traumatic brain injury.

Polysomnography after adenotonsillectomy in mild pediatric obstructive sleep apnea

The authors evaluated the efficacy of rectally administered midazolam for preinduction (i.e., premedication/induction) of anesthesia in 67 pediatric patients, ASA physical status 1 or 2, undergoing a variety of elective surgical procedures. In phase 1, 41 children weighing 12 +/- 3 kg (range 7-20 kg) and 31 +/- 16 months (range 8-67 months) of age (mean +/- SD) received midazolam, 0.4-5.0 mg.kg-1, in an attempt to produce unconsciousness. Only one child lost consciousness (4.5 mg.kg-1). However, at all doses, inhalational induction of anesthesia was facilitated because children were tranquil and calmly separated from their parent(s). There were no clinically significant changes in arterial blood pressure, heart rate, oxyhemoglobin saturation, and end-tidal carbon dioxide concentration, 10 min after drug administration. In phase 2, 26 children weighing 17 +/- 4 kg (range 10-26 kg) and 44 +/- 19 months (range 17-84 months) months of age undergoing tonsil and/or adenoid surgery were studied to determine the optimal sedative dose of rectally administered midazolam. Patients received 0.3, 1.0, 2.0, or 3.0 mg.kg-1 of midazolam in a randomized, double-blind fashion. One third (3 of 9) of patients receiving 0.3 mg.kg-1 struggled during mask induction. All patients receiving greater than or equal to 1.0 mg.kg-1 were adequately sedated (P less than 0.008). Discharge from the postanesthesia care unit (PACU), however, was delayed (greater than 60 min) in children receiving greater than or equal to 2.0 mg.kg-1 (P less than 0.03).(ABSTRACT TRUNCATED AT 250 WORDS)

Prediction of successful primary closure of congenital abdominal wall defects using intraoperative measurements

OBJECTIVES a) To determine the need for intensive monitoring on the first operative night of surgery in children undergoing adenotonsillectomy for mild obstructive sleep apnea; b) to examine the effect of narcotics on postoperative obstructive sleep apnea. DESIGN Randomized, prospective study. SETTING University hospital. PATIENTS Children, ranging in age between 1 and 18 yrs, presented to the Pediatric Otolaryngology Clinic for adenotonsillectomy for mild obstructive sleep apnea defined as from one to 15 obstructive apnea events per hour on preoperative polysomnogram. INTERVENTIONS Patients were assigned to receive either a narcotic- or a halothane-based anesthetic for adenotonsillectomy. A postoperative polysomnogram was performed in the pediatric intensive care unit on the first operative night. MEASUREMENTS AND MAIN RESULTS Eighteen patients were recruited, 15 of whom met inclusion criteria: nine patients received a halothane-based anesthetic and six patients received a fentanyl-based anesthetic. When the data were analyzed by pooling both groups, the differences between pre- and postoperative sleep studies demonstrated a reduction in the number of obstructive events and less severe oxygen desaturations on the operative night. Total sleep time between the two sleep studies decreased from 371 +/- 13 to 304 +/- 14 mins. The number of obstructive apnea events/hr decreased as well. The lowest oxygen saturation measured during rapid eye movement sleep was 78 +/- 5% preoperatively and 92 +/- 1% postoperatively. CONCLUSIONS Our data suggest that children without underlying medical conditions, neuromotor diseases, or carniofacial abnormalities, 1 to 18 yrs of age, who suffer from mild obstructive sleep apnea, have improvements documented by polysomnography on the night of surgery following adenotonsillectomy and do not necessarily need to be monitored intensively. These findings were not significantly affected by the choice of intraoperative anesthetic.

The critically ill child with novel H1N1 influenza A: A case series

To determine whether intragastric pressure (IGP) and central venous pressure (CVP) would reliably predict successful primary closure of congenital abdominal wall defects (omphalocele/gastroschisis) in newborn infants, we developed the following prospective intraoperative management protocol. Following a temporary trial of fascial closure, infants who had an IGP less than 20 mm Hg or an increase in CVP of less than 4 mm Hg were primarily closed. If IGP was greater than 20 mm Hg or if CVP increased by more than 4 mm Hg, the temporary closure of the abdomen was reopened and a prosthetic silo was placed. Ten infants who were less than 24 hours old and averaged 2.7 kg (range, 1.4 to 4.2 kg) and 37-weeks gestation (range, 32 to 41 weeks) were studied. Eight infants met criteria for primary closure. Their IGP averaged 14 +/- 4 mm Hg (+/- SD) (range, 8 to 19 mm Hg), and their increase in CVP averaged 1 +/- 2 mm Hg (range, -2 to 3 mm Hg). In the two infants who required staged repair, IGP averaged 25 +/- 1 mm Hg (+/- SD) (range, 24 to 25 mm Hg), and the increase in CVP averaged 7 +/- 1 mm Hg (range, 6 to 8 mm Hg). All patients were anesthetized with fentanyl (12.5 micrograms/kg) and paralyzed with metocurine (0.3 mg/kg) intraoperatively. There were no postoperative complications in either group of patients related to increased intraabdominal pressure, and all patients were extubated within 48 hours of the initial surgery. We conclude that the intraoperative measurement of changes in IGP and CVP can serve as a guide to the operative management of congenital abdominal wall defects and can reliably predict successful outcome following repair.

Assessing Pediatric Anesthesia Practices for Volunteer Medical Services Abroad

Objective: To describe the presentation, course, and outcome of critically ill children with novel H1N1 influenza disease. Design: Retrospective case series. Setting: Pediatric intensive care unit in an urban tertiary academic center. Patients: Thirteen consecutive patients admitted between June 2009 and August 2009 and known or subsequently found to be infected with novel H1N1 influenza A. Interventions: None. Measurements and Main Results: Clinical, laboratory, and radiographic data were reviewed. The patients were predominantly male (62%), aged 5 months to 21 yrs, and most (92%) had known risk factors for severe disease. Direct fluorescent antibody testing had a high false-negative rate (62%) and delayed treatment in some cases. The respiratory illness presented clinically with both bronchoconstriction and alveolar consolidation to varying degrees. Bacterial superinfection occurred frequently (23%). Forty-six percent of patients required mechanical ventilation and 23% required inotropic support for hypotension. None of the patients in this series required extracorporeal membrane oxygenation. Intensive care unit length of stay did not differ between an early (within 48 hrs) oseltamivir treatment group (length of stay, 4.2 ± 4.4 days) vs. a late treatment group (length of stay, 6.8 ± 8.8 days). All patients survived to hospital discharge. Conclusions: Underlying chronic illness (especially respiratory illness) seems associated with critical novel H1N1 influenza disease in children. Respiratory manifestations are highly variable among patients and within a single patient involving both bronchoconstriction and alveolar disease. Therapies must be individualized and rapidly adjusted. The duration of critical illness was not different between early and late treatment groups. Whether this is reflective of sample size or indicative of the importance of therapeutic intervention at any time early during infection in critically ill patients is unclear. Bacterial superinfection was more common than previously reported for seasonal influenza A. Moderate novel H1N1 influenza disease, including respiratory failure and hypotension, had 100% survival in our series.

Peripherally inserted central catheters: a randomized, controlled, prospective trial in pediatric surgical patients.

Background Anesthetic techniques and problems in volunteer medical services abroad are different from those of either the developed countries from which volunteers originate or the host country in which they serve because of differences in patient population, facilities, and goals for elective surgery. Assessing outcomes is hampered by the transience of medical teams and the global dispersion of providers. We studied general anesthesia techniques and outcomes in a large international voluntary surgical program. Methods Anesthesia providers and nurses participating in care of patients undergoing reconstructive plastic and orthopedic surgery by Operation Smile over an 18-month period were asked to complete a quality assurance data record for each case. Incomplete data were supplemented by reviewing the original patient records. Results General anesthesia was used in 87.1% of the 6,037 cases reviewed. The median age was 5 yr (25th–75th percentiles: 2–9 yr). Orofacial clefts accounted for more than 80% of procedures. Halothane mask induction was performed in 85.6% of patients; 96.3% of patients had tracheal intubation, which was facilitated with a muscle relaxant in 19.3%. Respiratory complications occurred during anesthesia in 5.0% of patients and during recovery (postanesthesia care unit) in 3.3%. Arrhythmias requiring therapy occurred in 1.5%, including three patients to whom cardiopulmonary resuscitation was administered. Prolonged ventilatory support was required in seven patients. There was one death. Inadvertent extubation during surgery occurred in 38 patients. Cancellation of surgery after induction of anesthesia occurred in 25 patients. Overall, complications were more common in younger children. Conclusions Our study showed that in this setting it is feasible to track anesthesia practice patterns and adverse perioperative events. We identified issues for further examination.

Pilot study of antibiotic cycling in a pediatric intensive care unit.

Peripherally-inserted central catheters (PICCs) are long-term IV catheters used for drug and fluid administration, blood sampling, or hyperalimentation. The short-term use of PICCs in postoperative patients has not been studied. In this randomized, controlled trial, patients received either a PICC or peripheral IV catheter (PIV). Our outcome measures were patient and parent satisfaction with care, complications of the venous access devices, number of postoperative venipunctures, and cost-effectiveness of use. Satisfaction was significantly more frequent in the PICC group (P < 0.05), and there were significantly fewer postoperative needle punctures in the PICC group compared with the PIV group (P < 0.05). Minor complications were common in the PIV group; major complications were uncommon in both groups. PICCs are more expensive, but better satisfaction can make them a cost-effective option. Additionally, insertion during surgical preparation time in the operating room (OR) means that cost is not increased by adding anesthesiologist and OR time. Anesthesiologists should consider placing PICCs in patients requiring more than 4 days of in-hospital postoperative care, especially if frequent blood sampling or IV access is required.

A qualitative study of expert and team cognition on complex patients in the pediatric intensive care unit.

ObjectiveThis pilot study was performed to determine the safety and size of effect of antibiotic cycling to reduce colonization and infection with antibiotic-resistant bacteria. DesignOpen, observational study. SettingThe study was performed in a 16-bed pediatric medical-surgical intensive care unit. PatientsCritically ill children requiring antibiotic therapy. InterventionsThree antibiotic classes were systematically cycled for 3-month intervals over 18 months. Antibiotic regimens were used for all empirical therapy and continued if the bacterial isolate was susceptible. MeasurementsThe primary outcome was colonization with antibiotic-resistant bacteria, determined by surveillance cultures obtained twice monthly from all patients in the unit. Rates of antibiotic-resistant, nosocomial blood stream infections, and risks of colonization over calendar time in the intensive care unit were also evaluated. Main resultsThe cycling of broad-spectrum, empirical antibiotics was safe and did not generate increased antibiotic resistance nor select for new organisms. Over the study period, the trend in prevalence of children colonized with antibiotic-resistant bacteria was from 29% to 24% (p = .41). The effect on prevalence of resistant blood stream infections was similar (p = .29). Changes in individual risks of colonization with resistant bacteria over calendar time were consistent with the ecologic effect in size and direction. ConclusionsResults of this pilot intervention suggest that cycling antibiotics may be a safe and viable strategy to minimize the emergence of antibiotic resistance in intensive care units. A definitive study will require a randomized and controlled trial of only four pediatric intensive care units over an 18-month period.