Gennadiy Fuzaylov

Inhalation burn injury in children.

With advances in burn care, many children are surviving severe burn injuries. Inhalation injury remains a predictor of morbidity and mortality in burn injury. Inhalation of smoke and toxic gases leads to pulmonary complications, including airway obstruction from bronchial casts, pulmonary edema, decreased pulmonary compliance, and ventilation–perfusion mismatch, as well as systemic toxicity from carbon monoxide poisoning and cyanide toxicity. The diagnosis of inhalation injury is suggested by the history and physical exam and can be confirmed by bronchoscopy. Management consists of supportive measures, pulmonary toilet, treatment of pulmonary infection and ventilatory support as needed. This review details the pathophysiology, diagnosis, and management options for inhalation injury.

Anesthetic considerations for major burn injury in pediatric patients

Major burn injury remains a significant cause of morbidity and mortality in pediatric patients. With advances in burn care and with the development of experienced multi‐disciplinary teams at regionalized burn centers, many children are surviving severe burn injury. As members of the multi‐disciplinary care team, anesthesia providers are called upon to care for these critically ill children. These children provide several anesthetic challenges, such as difficult airways, difficult vascular access, fluid and electrolyte imbalances, altered temperature regulation, sepsis, cardiovascular instability, and increased requirements of muscle relaxants and opioids. The anesthesia provider must understand the physiologic derangements that occur with severe burn injury as well as the subsequent anesthetic implications.

Continuous noninvasive cardiac output in children: is this the next generation of operating room monitors? Initial experience in 402 pediatric patients.

Electrical Cardiometry™ (EC) estimates cardiac parameters by measuring changes in thoracic electrical bioimpedance during the cardiac cycle. The ICON®, using four electrocardiogram electrodes (EKG), estimates the maximum rate of change of impedance to peak aortic blood acceleration (based on the premise that red blood cells change from random orientation during diastole (high impedance) to an aligned state during systole (low impedance)).

Case 5-2008: An 18-Month-Old Girl with an Advanced Neck Contracture after a Burn

While the patient was in the hospital breathing ambient air, grunting respirations were noted intermittently as she slept, with oxygen saturations as low as 55% and bradycardia, with the heartbeat as low as 40 beats per minute. These episodes were alleviated by stimulation and prone positioning. A pediatric otolaryngologist was consulted, but endoscopic evaluation of the airway could not be performed because

Successful resuscitation after inadvertent intravenous injection of bupivacaine in an adolescent

SIR—We describe a case of accidental intravenous injection of bupivacaine and immediate circulatory arrest in an anesthetized adolescent during an overseas medical mission trip. The patient was successfully resuscitated with cardiopulmonary resuscitation (CPR) and possibly with early administration of intralipid emulsion (ILE) with complete recovery. A 13-year-old, 50 kg, 143 cm tall and ASA I physical status healthy adolescent girl was scheduled for an elective cleft lip and palate repair. General anesthesia was induced with intravenous propofol 3 mgÆkg, fentanyl 3 mcgÆkg, isoflurane in 100% oxygen and 0.1 mgÆkg of atracurium to facilitate trachea intubation. Anesthesia was maintained with 1% isoflurane in 50% nitrous oxide and oxygen. Five minutes after securing the endotracheal tube, the circulating nurse (one of only three English speaking individuals in the room) administered the pre-incision antibiotic and mistakenly administered 10 ml of an unlabeled syringe of bupivacaine 0.25% (0.5 mgÆkg without epinephrine) over approximately 20 s. Immediately after completion of the injection, the surgeon asked if we had given the antibiotic, and the nurse stated she had, but I was holding the antibiotic syringe. The error was recognized; help was summoned, crash cart and ILE 20% solution were brought into the room and 100 ml (2 mgÆkg) ILE was administered within 3–4 min after local anesthetic injection. Soon after injection of bupivacaine, sinus tachycardia of 134 bÆmin developed and within 90 s the systolic blood pressure markedly decreased from 90 to 60 mmHg without significant reduction in oxygen saturation (SpO2 94%) or in end-tidal carbon dioxide (30 mmHg). Hypotension was treated with rapid administration of normal saline 500 ml and intravenous boluses 10 mcg of epinephrine twice. Despite these boluses, blood pressure only responded transiently, and QRS complex morphology rapidly progressed to slow broad complex with ST segment depression immediately followed by unstable ventricular tachycardia. Standard external chest compressions were started. The external defibrillator was malfunctioning. Ventricular tachycardia self-converted to stable sinus tachycardia 1.5–2 min after completion of ILE injection to a rate of 146–156 bÆmin, but was associated with a low perfusion state at blood pressure of 60 ⁄ 35. Dopamine infusion was started at 10 mcgÆkgÆmin through a peripheral venous access. As soon central venous access via the femoral was established epinephrine at 0.1 mcgÆkgÆmin infusion were started. Patient was transferred to intensive care unit after stabilization of blood pressure. We did not follow the initial bolus of ILE with an infusion because we had only one 100 ml-bag of ILE supply on this medical mission. The pulmonary edema that had developed one hour after the event per the chest x-ray, resolved over the next 2 days, the dopamine infusion was gradually tapered off and trachea was extubated 2 days after the incident. The patient recovered uneventfully and was discharged home on fourth post-incident day. In this case scenario, unstable ventricular rhythm occurred within minutes after a rapid unintentional intravenous injection of a large dose of bupivacaine. It produced immediate severe cardiac toxicity and hemodynamic instability. Institution of effective CPR in a well-ventilated patient and early use of ILE may have rapidly reversed the cardiotoxicity. In anticipation of a high plasma level of bupivacaine, the potential for intractable cardiac arrest and unavailability of a defibrillator device, the decision was made to administer ILE earlier in the course of resuscitation (1). Rapid intravenous injection of bupivacaine, as was the case in our patient, can result in high-unbound fraction of bupivacaine that can reach the CNS and myocardium in high concentrations to produce potentially acute life threatening events. There are several reports of cardiac arrest from bupivacaine, levobupivacaine, ropivacaine and lidocaine systemic toxicity during the conduct of regional anesthesia (2). The role of lipid emulsion in reversing local anesthetic toxicity has been questioned when lipid emulsion therapy was instituted prior to performing standard resuscitation measures. While the precise mechanism by which ILE reverses the cardiac toxicity of bupivacaine is not completely elucidated, animal data suggest several possible mechanisms such as sequestration of bupivacaine (lipid sink), reversal of bupivacaine-induced inhibition thereby improving cardiac mitochondrial oxidative phosphorylation (metabolic), augmentation of intra-myocytes calcium concentration or some combination of these mechanisms (3,4). Our case represents among few pediatric reports that used ILE early in the course of bupivacaine toxicity and the first with a known toxic dose of intravenous local anesthetic injection. This case demonstrates a series of events that although individually would not lead to grave results, together led to highly adverse results and Pediatric Anesthesia 2010 20: 958–976

Case 5-2008

While the patient was in the hospital breathing ambient air, grunting respirations were noted intermittently as she slept, with oxygen saturations as low as 55% and bradycardia, with the heartbeat as low as 40 beats per minute. These episodes were alleviated by stimulation and prone positioning. A pediatric otolaryngologist was consulted, but endoscopic evaluation of the airway could not be performed because

Global health: burn outreach program.

The objective of this article is to outline the elements of an international burn care outreach program in a resource-constrained country. The program has grown from a collaborative effort with Ukrainian physicians and healthcare officials. With this collaboration, a multipronged approach has been developed to address the gaps in burn care as discovered by years of interaction with the medical community in Ukraine. Contact was initiated with the burn unit of a single municipal hospital in Lviv, Ukraine. Patients with burn injuries were screened and selected patients were comanaged over a 3-year period by American and Ukrainian physicians. This comanagement included repeated evaluation both by telemedicine conferencing as well as annual trips with physicians from Boston, Massachusetts, traveling to Ukraine to assess patients in an outreach clinic and perform surgical procedures. In our first trip in 2011 we assessed 22 patients and operated on 5. In 2012, 38 patients were evaluated and 12 had combined surgical intervention. In our 2013 trip, 63 patients were evaluated and we operated on 22 of these patients. Multiple clinical research projects related to burn prevention and improving perioperative care have been initiated, presented at national meetings, and submitted for publication in peer-reviewed journals. Our outreach program in Lviv, Ukraine, strives to improve overall burn care by a multilayered approach. These elements can serve as a possible template for additional international burn outreach plans as they can be customized for both large and small interventions.

Targeting burn prevention in Ukraine: evaluation of base knowledge in burn prevention and first aid treatment.

Burn prevention has been identified by the World Health Organization (WHO) as a topic in need of further investigation and education throughout the world, with an increased need in low-income countries. It has been noted that implementing educational programs for prevention in high income countries has aided in lowering the rate of burn injuries. The purpose of this study is to evaluate the current education level of knowledge of prevention and first aid treatment of scald burns. A prevention campaign will target these educational needs as a part of an outreach program to improve burn care in Ukraine. The research team evaluated the current health structure in Ukraine and how it could benefit from the increased knowledge of burn prevention and first aid. A test was designed to assess the baseline level of knowledge with regard to first aid and scald prevention in parents, pregnant woman, and healthcare and daycare providers. A total of 14,456 tests were sent to pediatric clinics, obstetrician clinics, and daycare facilities to test respondents. A total of 6,120 completed tests were returned. Doctors presented with the highest level of knowledge averaging 77.0% on prevention and 67.5% on first aid while daycare workers presented the largest gap in knowledge at 65.0% in prevention and 54.3% in first aid. Interest in further educational materials was reported by 92% of respondents. The results of this study clearly show a lack of knowledge in first aid and prevention of scald burn injury in all the populations tested.

Use of telemedicine to improve burn care in Ukraine.

Global burn injuries have been described as the “forgotten public health crises” by the World Health Organization. Nearly 11 million people a year suffer burns severe enough to require medical attention; more people are burned each year than are infected with human immunodeficiency virus/acquired immunodeficiency syndrome and tuberculosis combined. Telemedicine has the potential to link experts in specialized fields, such as burn care, to regions of the world that have limited or no access to such specialized care. A multilevel telemedicine program was developed between Massachusetts General Hospital/Shriners Hospital in Boston, Massachusetts, and City Hospital #8 in Lviv, Ukraine. The program should lead to a sustainable improvement in the care of burn victims in Ukraine. The authors helped establish a Learning Center at City Hospital #8 in Lviv, Ukraine, through which they were able to consult from Shriners Hospital in Boston, on a total of 14 acute burn patients in Ukraine. This article discusses two case reports with the use of telemedicine and how it has allowed the authors to provide not only acute care consultation on an international scale, but also to arrange for direct expert examination and international transport to their specialized burn center in the United States. The authors have established a program through doctors from Massachusetts General Hospital/Shriner’s Hospital in Boston, which works with a hospital in Ukraine and has provided acute consultation, as well as patient transportation to the United States for treatment and direct assessment.

Delayed awakening from general anesthesia in a hypovolemic infant

SIR—Delayed awakening from anesthesia is defined as failure to regain consciousness within 20–30 min after surgical procedure. While usually benign, it may be the result of serious and potentially treatable conditions that should be considered in the immediate postoperative period. Sometimes, no obvious cause can be found. This report presents the case of a previously dehydrated, but resuscitated 1-month-old patient who demonstrated markedly delayed emergence from general anesthesia. The likely metabolic and neurologic causes were systematically ruled out. Left with no alternative explanation, we present some of the evidence that supports hypovolemia as a possible etiology. A one-month-old, full-term baby boy with pyloric stenosis was scheduled for an urgent pyloromyotomy under general anesthesia. He presented with a 1-week history of nonbloody, nonbilious emesis after feedings. Over the following week he became increasingly lethargic with significant weight loss of approximately 0.75 kg from his baseline weight of 4.35 kg. He was lethargic but normothermic (36.7 C.), with a sunken fontanel and cool extremities. Laboratory tests were consistent with protracted emesis and dehydration with a contraction alkalosis: sodium 136 mmolÆl, potassium 3.0 mmolÆl, chloride 90 mmolÆl, HCO3 25.7 mmolÆl , Ca 10.5 mgÆdl, Mg 14 mgÆdl, BUN 14 mgÆdl, creatinine 0.3 mgÆdl, and glucose 94 mgÆdl. Venous blood gases showed a pH of 7.5, PvCO2 5 kPa (38 mmHg), and PvO2 3.6 kPa (28 mmHg) while the patient was breathing room air. He was admitted to the hospital and received a total of 600 ml normal saline and 100 ml of D10 in preparation for surgery during 11 h. On the morning of surgery the baby was awake, and had wet diapers. He had moist mucous membranes, but had muscle hypotonia and reacted to tactile stimuli with a weak cry. Lab results after fluid resuscitation were: sodium 140 mmolÆl, potassium 3.0 mmolÆl, HCO3 25 mmolÆl, chloride 106 mmolÆl, glucose 4.1 mmolÆl (96 mgÆdl), BUN 2.1 mmolÆl (6 mgÆdl), and creatinine 26 lmolÆl (0.3 mgÆdl) Venous blood gasses (room air) now showed a pH of 7.41, PvCO2 5.3 kPa (41 mmHg), and PvO2 2.7 kPa (21 mmHg). The patient had an uneventful rapid sequence induction and intubation with sodium thiopental 8.5 mgÆkg i.v. and succinylcholine 1 mgÆkg i.v. He received 15 mgÆkg of acetaminophen p.r. following induction. Anesthesia was maintained with isoflurane (1.5%), oxygen, and air. No additional hypnotics, muscle relaxants, or narcotics were administered. After induction and during the procedure the baby was hemodynamically stable and normothermic. The pyloromyotomy was completed in <30 min, and isoflurane was discontinued. For 45 min after the procedure the patient remained on the ventilator, did not react to the tracheal tube, and was completely unarousable. Stimulation of the ulnar nerve showed a normal train-of-four and sustained tetany. By 60 min postoperatively, he was still unresponsive to voice or touch but started reacting to manipulation of the tracheal tube by moving all extremities. Spontaneous ventilation began, and he maintained an endtidal carbon dioxide of 5.2 kPa (40 mmHg). Fifteen minutes later, the baby unexpectedly dislodged the tracheal tube. The decision was made to watch him rather than reintubate immediately. With oxygen via face mask he maintained a respiratory rate of 40 and oxygen saturation of 100%. At 4 h postoperatively, the patient remained somnolent and responded to pain by grimacing and moving his extremities. Sodium was 139.3 mmolÆl, potassium 3 mmolÆl, chloride 108 mmolÆl, HCO3 17.5 mmolÆl, BUN 5 mgÆdl, creatinine 0.3 mgÆdl, and glucose 90 mgÆdl. Venous pH was 7.49, PvCO2 26 mmHg, PvO2 212 mmHg in 40% oxygen, and hematocrit 32%. Over the following 18 h, the patient gradually became more vigorous and awakened. He began feeding by the next morning. There was no evidence of focal neurologic deficit, seizure activity, or significant abnormality in laboratory tests. In any case of delayed emergence, it is important to rule out metabolic and neurologic causes, but no such abnormality could be found in our patient. There was no indication of hypoxia or hypercarbia, the patient was warm, and serum electrolytes and glucose were normal. There was no evidence for renal or hepatic dysfunction. Neurologic complications such as cerebral hypoxia, hemorrhage, embolism, thrombosis, or seizure activity were unlikely given the patient’s nonfocal motor examination, lack of previous neuropathology, and subsequent complete recovery. It is much more likely that the patient had a prolonged anesthetic effect, and this must be from either to (i) excessive dose, (ii) delayed clearance, or (iii) increased sensitivity. Investigations of thiopental requirements for fast and reliable induction of anesthesia in healthy infants (1) suggest that 5–8 mgÆkg is required, a dose lower than that required for neonates, children (2), or adults (3). The patient had no other medications preoperatively. The duration of exposure to isoflurane was <30 min, and it was discontinued in a timely fashion. A twitch monitor revealed complete recovery from succinylcholine. Hypovolemia is well known to affect the pharmacokinetics of many drugs, but this has not been specifically CORRESPONDENCE 435