Dominic Sanfilippo

Blood management in pediatric spinal deformity surgery: review of a 2‐year experience

BACKGROUND: Pediatric scoliosis surgery is associated with considerable blood loss and allogenic transfusions. Transfusions contribute to morbidities and cost. A perioperative pediatric blood management program was implemented at our institution. Patients received preoperative evaluation, cell salvage, topical hemostasis, antifibrinolytics, and hypotensive anesthesia.

Heliox improves ventilation during high-frequency oscillatory ventilation in pediatric patients.

Objective To describe improved ventilation during high-frequency oscillatory ventilation when a nitrogen-oxygen gas mixture is replaced by a helium-oxygen gas mixture. Design Case series. Setting A tertiary pediatric intensive care unit. Patients Five patients with hypoxemic respiratory failure who developed persistent respiratory acidosis during treatment with high-frequency oscillatory ventilation. Interventions Introduction of helium-oxygen into a conventional high-frequency oscillatory ventilation circuit. Measurements and Main Results Blood gas values (pH, Pco2, and Po2) were compared in these patients during treatment with high-frequency oscillatory ventilation with nitrogen-oxygen gas flow and then for several hours after a change in treatment to helium-oxygen gas flow. An initial 24% decrease in Pco2 was documented, and an ultimate 43% decrease in Pco2 was observed. The mechanism for this improved ventilation may be related to improved gas flow properties as well as increased CO2 diffusion resulting from helium’s low-mass density. Oxygenation was not adversely affected in any way. Conclusion In patients with hypoxemic respiratory failure and in whom respiratory acidosis develops during high-frequency oscillatory ventilation, the use of helium-oxygen rather than nitrogen-oxygen may improve ventilation and decrease ventilator-related trauma. Further investigation is needed to validate these findings and to elucidate the mechanisms of improved ventilation.

Prediction of neurobehavioral outcome 1-5 years post pediatric traumatic head injury

OBJECTIVE To examine the neurobehavioral status of children with traumatic head injury (THI) and to identify variables that predict outcome. DESIGN Retrospective chart review, with follow-up 1-5 years after injury. Outcome predictor variables were identified through stepwise regression analysis. SETTING Level one trauma center and pediatric rehabilitation program. PATIENTS 71 Children with THI, selected from a four-year series of consecutive admissions. MEASURE Vineland Adaptive Behavior Scales-Survey Edition. RESULTS Significant predictors of better neurobehavioral status at follow-up included absence of a premorbid learning problem (p <.01), older age at injury (p <.01), and normal pupillary response (p <.001) and higher cerebral perfusion pressure (p <.0001) during critical care management. CONCLUSIONS Neurobehavioral outcome after THI is influenced by premorbid psychosocial variables as well as by critical care management.

The safety of propofol sedation for elective nonintubated esophagogastroduodenoscopy in pediatric patients.

Objectives: To evaluate the safety of deep sedation provided by pediatric intensivists for elective nonintubated esophagogastroduodenoscopy. Design: Retrospective observational study. Setting: The sedation program at the Helen DeVos Children’s Hospital. Patients: A 4-year retrospective analysis was done on all outpatient elective pediatric esophagogastroduodenoscopy procedures performed in an intensivist run sedation program. Safety was examined by reviewing the occurrence of minor and major adverse effects during esophagogastroduodenoscopy sedation. Interventions were studied and reported. Interventions: None. Measurements and Main results: During the study period, 12,447 sedations were performed by the pediatric sedation program for various procedures. Two thousand one hundred forty-seven patients received 2,325 sedations (18.6%) for esophagogastroduodenoscopies performed for various indications. During the same time period, 53 (one for every 40 esophagogastroduodenoscopy sedations) were screened, found unsuitable for nonintubated sedation, and referred for general anesthesia. There were 2,254 sedations with propofol, 65 methohexital, five ketamine, and one fentanyl/midazolam sedation. Propofol sedation proved safe with a 2.1% prevalence of minor adverse events and no major events. Methohexital, on the other hand, had higher rate (p < 0.001) of minor events and one patient developed an anaphylactic reaction to its use. Regression analysis showed that other sedative agents were 8.6 times more likely to be associated with complications than propofol (odds ratio, 8.6; 95% CI, 4.1–18.2; p < 0.001). Conclusions: This study demonstrates that deep sedation for elective esophagogastroduodenoscopies can be provided safely in the appropriately screened patient by nonanesthesiologist physicians in a sedation program. These data suggest that propofol is a safe and effective agent for esophagogastroduodenoscopy sedation.

Randomized controlled trial for intermittent versus continuous propofol sedation for pediatric brain and spine magnetic resonance imaging studies.

Objectives: Intermittent bolus propofol is an effective agent for pediatric magnetic resonance imaging sedation but requires constant vigilance and dose titration. Magnetic resonance imaging-compatible infusion pumps may make it possible to continuously infuse propofol, achieving a steady level of sedation at a lower total dose. This study investigates total propofol dose, recovery time, and magnetic resonance image quality in children receiving intermittent vs. continuously infused propofol sedation in children undergoing brain and spine magnetic resonance imaging studies. Design: An open-label, prospective, randomized, controlled study. A single-blinded radiologist rated the quality of magnetic resonance images. Setting: Childrens hospital pediatric radiology sedation center. Patients: One hundred seventy children age 1 month to 18 yrs undergoing deep sedation for brain, spine, or both brain and spine magnetic resonance imaging. Interventions: After informed consent, patients were randomly assigned to two groups: group 1 (intermittent) received a propofol bolus of 2–4 mg/kg, followed by repeat boluses of 0.5–2 mg/kg/dose as needed. Group C (continuous) received a bolus of propofol 2–4 mg/kg, followed by a continuous infusion of 100 &mgr;g/kg/min with 1-mg/kg/dose boluses with drip titration to effect. Measurements and Main Results: Patient demographics, sedation risk assessment, propofol dose, sedation recovery times, incidence of complications, and quality of the magnetic resonance imaging studies were measured. A total of 170 children were enrolled in the study, with 75 in group C and 95 in group I. Both groups were similar with regard to age, weight, gender, and magnetic resonance imaging study type. Group C required a lesser dose of propofol (132 ± 54 &mgr;g/kg/min) compared to (162 ± 74 &mgr;g/kg/min) in that required in group I (p = .018). There were no differences between the two groups with regard to quality of the imaging study, recovery time, or incidence of complications. Conclusions: Compared to intermittent bolus dosing, continuous propofol infusion provides lesser dose exposure without impacting recovery time or quality of the magnetic resonance imaging study.

Respiratory Impairment after Early Red Cell Transfusion in Pediatric Patients with ALI/ARDS

Introduction. In the first 48 hours of ventilating patients with acute lung injury (ALI)/acute respiratory distress syndrome (ARDS), a multipronged approach including packed red blood cell (PRBC) transfusion is undertaken to maintain oxygen delivery. Hypothesis. We hypothesized children with ALI/ARDS transfused within 48 hours of initiating mechanical ventilation would have worse outcome. The course of 34 transfused patients was retrospectively compared to 45 nontransfused control patients admitted to the PICU at Helen DeVos Childrens Hospital between January 1st 2008 and December 31st 2009. Results. Mean hemoglobin (Hb) prior to transfusion was 8.2 g/dl compared to 10.1 g/dl in control. P/F ratio decreased from 135.4 ± 7.5 to 116.5 ± 8.8 in transfused but increased from 148.0 ± 8.0 to 190.4 ± 17.8 (P < 0.001) in control. OI increased in the transfused from 11.7 ± 0.9 to 18.7 ± 1.6 but not in control. Ventilator days in the transfused were 15.6 ± 1.7 versus 9.5 ± 0.6 days in control (P < 0.001). There was a trend towards higher rates of MODS in transfused patients; 29.4% versus 17.7%, odds ratio 1.92, 95% CI; 0.6–5.6 Fisher exact P < 0.282. Conclusion. This study suggests that early transfusions of patients with ALI/ARDS were associated with increased ventilatory needs.

Cost and safety of pediatric intensive care physician-placed broviac catheters.

Objective: To compare the cost and safety of placement of Broviac catheters in children by pediatric intensivists in a sedation suite versus placement by pediatric surgeons in the operating room. Design: Single-center retrospective analysis. Setting: Pediatric sedation suite and operating rooms in a tertiary care children’s hospital. Patients: All pediatric patients with Broviac catheters placed (n = 253) at this institution over a 3-year period from 2007 to 2009. Interventions: None. Measurements and Main Results: We reviewed the charts of all pediatric patients with Broviac catheters placed, either by intensivists or surgeons, and compared cost and outcomes. Procedure safety was assessed and categorized into immediate, short-term (within 2 wk of procedure), and long-term outcomes. Anesthetic safety and billing data for the procedure were also collected. Among similar patient populations, immediate complications, such as pneumothorax, procedure failure (p > 0.999), and anesthetic complications (p = 0.60), were not significantly different. Short-term outcomes, including infection (p = 0.27) and catheter malfunction (p > 0.999), were not different. Long-term outcomes, including mean indwelling catheter days (p = 0.60) and removal due to catheter infection (p = 0.09), were not different between the groups. Overall cost of the procedure was significantly different:

Implementing an Oxygen Supplementation and Monitoring Protocol on Inpatient Pediatric Bronchiolitis: An Exercise in Deimplementation

7,031 (±

Survival and functional outcome in pediatric traumatic brain injury: a retrospective review and analysis of predictive factors.

784) when performed by surgeons and

Intravenous Methohexital for Brief Sedation of Pediatric Oncology Outpatients: Physiologic and Behavioral Responses

3,565 (±