Jackson Wong

Cardiovascular effects of dexmedetomidine sedation in children.

BACKGROUNDnDexmedetomidine (DEX) affects heart rate (HR), mean arterial blood pressure, cardiac index (CI), stroke index (SI), and systemic vascular resistance index (SVRI) in adults. In this study we sought to determine whether similar effects occur in children undergoing DEX sedation.nnnMETHODSnHemodynamic changes in children were followed during IV DEX sedation for radiological procedures. One group of 8 patients (DEX-brief) received a bolus (2 mcg/kg bolus over 10 minutes) and completed the procedure within 10 minutes. The second group of 9 patients (DEX-prolong) received the bolus plus additional DEX as needed to maintain sedation for procedures lasting longer than 10 minutes (additional 1 mcg/kg/hr infusion with second bolus if needed). CI, SI, and SVRI were measured using a continuous noninvasive cardiac output monitor. Changes in hemodynamic variables at minutes 10, 20, and discharge (time at which patient achieved Aldrete Score ≥9) were compared to baseline by repeated measures ANOVA with effect sizes reported as mean [95% confidence interval].nnnRESULTSnData were obtained during 8 DEX-brief and 9 DEX-prolong procedures. In DEX-brief, HR and CI decreased (18.9 [2.3 to 35.5] bpm and 0.74 [0.15 to 1.33] L/min/m(2); respectively) at T1. There was no change in any other hemodynamic variables and all hemodynamic variables returned to baseline at recovery. In DEX-prolong, both HR and CI remained decreased (24.0 [8.3 to 39.6] bpm, 1.51 [0.95 to 2.06] L/min/m(2); respectively) at recovery. In addition, SI was decreased (8.01 [1.71 to 14.31] mL/m(2)) and SVRI was increased (776.0 [271.9 to 1280.4] dynes-sec/cm(5)/m(2)) at recovery in the DEX-prolong group. There were no significant changes in mean arterial blood pressure in either group.nnnCONCLUSIONnDEX decreases CI in children and has a cumulative effect. For patients undergoing prolonged procedures HR and CI remained decreased at the time of discharge together with a decrease in SI and an increase in SVRI.

Cardiac parameters in children recovered from acute illness as measured by electrical cardiometry and comparisons to the literature.

Electrical cardiometry (EC) is a non-invasive cardiac output method that can assess cardiac index (CI) and stroke index (SI) but there are no reference values for children per se. The primary aim of this study was to develop reference values for clinical application. The secondary aim was to compare the EC measurements to published values. We performed a prospective observational study in patients (<21xa0years of age) without structural heart disease who had recovered from an acute illness. EC recordings in children that had normal heart rate and mean arterial blood pressure at discharge were eligible for analysis. The relationship of CI or SI and age in children was performed by regression analysis. Similar analysis was performed comparing measurements by EC to cardiac parameters values compiled from reference sources to assess bias in EC. Eighty-three children (2xa0weeks–21xa0years of age) were studied. There was a significant curvilinear relationship between CI or SI and age by EC (F-test, pxa0<xa00.05). Regression curves of cardiac parameters reported in the literature using 6 Fick’s method, thermodilution, echocardiography and cardiac MRI were the same or higher than (0–19.6xa0%) values obtained with EC, with higher values being statistically significant (pxa0<xa00.05 all). There is a curvilinear relationship of CI or SI and age by EC in normal children. Cardiac parameters reported in the literature using alternative methods are different from those obtained with EC but are within acceptable ranges, with EC biased to underestimate CI. Adjustment of target value is required for EC goal-directed therapies.

Non-invasive cardiac output and oxygen delivery measurement in an infant with critical anemia.

ObjectiveTo assess the combination of a non-invasive blood oxygen content (CaO2) monitor and a non-invasive cardiac output (CO) monitor to continuously measure oxygen delivery (DO2; DO2xa0=xa0CaO2 × CO).MethodsDO2 was assessed during blood transfusions in an infant with acute hemolytic anemia following admission (~48xa0h). CaO2 was measured by Pulse Co-Oximetry, which also provides estimates of hemoglobin (Hgb) concentration and percent oxygen saturation. CO was measured by Electrical Velocimetry, which also provides an estimate of stroke volume (SV). Lactate levels, an indirect measure of adequate DO2, were assessed during the initial 8xa0h following admission.ResultsIncremental blood transfusions during the first 36xa0h increased Hgb from 2.7 to 9.5xa0g/dL during which time heart rate (HR) normalized from 156 to 115 beats/min. Lactate levels decreased from 20 to 0.8xa0mmol/L in the first 7xa0h. Non-invasive Hgb and CaO2 measurements were well correlated with invasive Hgb and CaO2 measures (r2xa0=xa00.88; Pxa0=xa00.019; r2xa0=xa00.86; Pxa0=xa00.0074, respectively). CO decreased from 2.47 ± 0.06 to 1.28 ± 0.02xa0L/min and SV decreased from 15.9 ± 0.4 to 11.1 ± 0.2xa0mL/beat. Mean arterial blood pressure was stable throughout the admission with systemic vascular resistance increasing from 407.6 ± 15.2 to 887.7 ± 30.1xa0dynes-s/cm5. DO2 was estimated to increase from 120.2 ± 18.9 to 182.4 ± 5.6xa0mLxa0O2/min.ConclusionsNon-invasive contin- uous CO and CaO2 monitors are shown in this single case to provide continuous DO2 measurement. The ability to assess DO2 may improve hemodynamic monitoring during goal directed therapies.

Cardiac output assessed by non-invasive monitoring is associated with ECG changes in children with critical asthma

The primary aim of this study was to determine changes in CI and SI, if any, in children hospitalized with status asthmatics during the course of treatment as measured by non-invasive EC monitoring. The secondary aim was to determine if there is an association between Abnormal CI (defined as <5 or >95xa0% tile adjusted for age) and Abnormal ECG (defined as ST waves changes) Non-invasive cardiac output (CO) recordings were obtained daily from admission (Initial) to discharge (Final). Changes in CI and SI measurements were compared using paired t tests or 1-way ANOVA. The association between Abnormal CI on Initial CO recording and Abnormal ECG was analyzed by Fischer’s exact test. Data are presented as meanxa0±xa0SEM with mean differences reported with 95xa0% confidence interval; pxa0<xa00.05 was considered significant. Thirty-five children with critical asthma were analyzed. CI decreased from 6.2xa0±xa00.2 to 4.5xa0±xa00.1 [−1.6 (−0.04 to −0.37)] L/min/m2 during hospitalization. There was no change in SI. There was a significant association between Abnormal Initial CI and Abnormal ECG (pxa0=xa00.02). In 11 children requiring prolonged hospitalization CI significantly decreased from 7.2xa0±xa00.5 to 4.0xa0±xa00.2 [−3.2 (−4.0 to −2.3)] L/min/m2 and SI decreased from 51.2xa0±xa03.8 to 40.3xa0±xa02.0 [−11.0 (−17.6 to −4.4)] ml/beat/m2 There was a significant decrease in CI in all children treated for critical asthma. In children that required a prolonged course of treatment, there was also a significant decrease in SI. Abnormal CI at Initial CO recording was associated with ST waves changes on ECG during hospitalization. Future studies are required to determine whether non-invasive CO monitoring can predict which patients are at risk for developing abnormal ECG.

Changes in cardiac output and stroke volume as measured by non-invasive CO monitoring in infants with RSV bronchiolitis

Objectives: The primary aim of the study was to determine the changes, if any, in cardiac output (CO) and stroke volume (SV) in normal infants with RSV bronchiolitis. The secondary aim was to determine whether changes in CO (ΔCO) and SV (ΔSV) are associated with changes in respiratory rate (ΔRR). Methods: Non-invasive CO recordings were obtained within 24xa0h of admission and discharge. Changes in CO, SV, and HR measurements were compared using paired t-tests. The effect of fluid boluses during the first 24xa0h (<60 or ≥60xa0cc/kg) on CO was assessed by 2 way ANOVA with time and group as main effect. The relationship between ΔRR and ΔCO or ΔSV was assessed by linear regression. Data is presented as Meanxa0±xa0SEM and mean differences with 95xa0% confidence interval (pxa0<xa00.05 considered significant). Results: 15 infants with RSV bronchiolitis were studied. CO (1.31xa0±xa00.13 to 1.11xa0±xa00.11xa0l/min (0.21 [0.04–0.37]) and SV (9.42xa0±xa01.10 to 7.75xa0±xa00.83xa0ml/beat (1.67 [0.21–3.12]) decreased significantly while HR (142.1xa0±xa04.0 to 145.2xa0±xa03.1 beats/min 3.0 [−5.3 to 11.3]) was unchanged. SV (pxa0=xa00.02) and CO (pxa0=xa00.04) significantly decreased only in the 7 infants that received ≥60xa0cc/kg. ΔRR correlated significantly with ΔCO (r2xa0=xa00.28, pxa0=xa00.04); but not with ΔSV (r2xa0=xa00.20, pxa0=xa00.09). Conclusions: ∆CO was related to ΔSV and not Δ HR. The ∆CO and ΔSV were affected by fluid boluses. ΔRR correlated with ΔCO. Non-invasive CO monitoring can trend CO and SV in infants with bronchiolitis during hospitalization.

Lafora Disease With Novel Autopsy Findings: A Case Report With Endocrine Involvement and Literature Review

BACKGROUNDnLafora disease is a rare, autosomal recessive, progressive myoclonic epilepsy with onset typically in the second decade of life and uniformly fatal outcome. Most of the current literature focuses on diagnosis, genetic basis, neurological signs, and possible treatment of this currently incurable disease. On literature review of over 50 articles including over 300 patients, there were no comments on or pathologic description of endocrinologic issues in relation to Lafora disease.nnnPATIENT DESCRIPTIONnWe describe a patient with Lafora disease with severe neurological deterioration. During hospitalization for urosepsis, he exhibited thyrotoxicosis with a free thyroxine (T4) level greater than 7.77 ng/dL. On autopsy, he had lymphocytic thyroiditis and Lafora bodies throughout his organs including the anterior pituitary, hypothalamus, and pancreas.nnnCONCLUSIONSnThis is the first report of the pathologic findings of Lafora bodies in endocrine organs. Although this patients thyrotoxic state was likely not a direct result of his Lafora disease, given the diffuse deposition of Lafora bodies, endocrinologic abnormalities should be considered in patients with Lafora disease. Furthermore, acute decompensation in these individuals may arise not from a declining neurological status but from a coincidental disease process.

Sublingual desensitization for buprenorphine hypersensitivity

Lisa M. Stutius, MD1,2, Itai Pessach, MD, PhD1,2, Joanne Lee, PharmD, BCPS3, Mindy S. Lo, MD, PhD1,2, Sharon Levy, MD, MPH2,4, Patricia Schram, MD2,4, Miriam Schizer, MD2,4, Jackson Wong, MD5, Wanda Phipatanakul, MD, MS1,2, and Dale T. Umetsu, MD, PhD1,2 1 Division of Immunology, Children’s Hospital Boston, Boston, MA 2 Harvard Medical School, Boston, MA 3 Department of Pharmacy, Children’s Hospital Boston, Boston, MA 4 Adolescent Substance Abuse Program, Children’s Hospital Boston, Boston, MA 5 Medicine Critical Care Program, Children’s Hospital Boston, Boston, MA

A Critical Asthma Standardized Clinical and Management Plan Reduces Duration of Critical Asthma Therapy

BACKGROUND AND OBJECTIVEnReduction of critical asthma management time can reduce intensive care utilization. The goal of this study was to determine whether a Critical Asthma Standardized Clinical Assessment and Management Plan (SCAMP) can decrease length of critical asthma management time.nnnMETHODSnThis retrospective study compared critical asthma management times in children managed before and after implementation of a Critical Asthma SCAMP. The SCAMP used an asthma severity score management scheme to guide stepwise escalation and weaning of therapies. The SCAMP guided therapy until continuous albuterol nebulization (CAN) was weaned to intermittent albuterol every 2 hours (q2h). Because the SCAMP was part of a quality improvement initiative in which all patients received a standardized therapy, informed consent was waived. The study was conducted in Medicine ICU and Intermediate Care Units in a tertiary care freestanding childrens hospital. Children ≥2 years of age who had CAN initiated in the emergency department and were admitted to the Division of Medicine Critical Care with status asthmaticus were included. The time to q2h dosing from initiation of CAN was compared between the baseline and SCAMP cohorts. Adverse events were compared. The Mann-Whitney test was used for analysis; P values <.05 were considered statistically significant.nnnRESULTSnThere were 150 baseline and 123 SCAMP patients eligible for analysis. There was a decrease in median time to q2h dosing after the SCAMP (baseline, 21.6 hours [interquartile range, 3.2-32.3 hours]; SCAMP, 14.2 hours [interquartile range, 9.0-23.1 hours]; P < .01). There were no differences in adverse events or readmissions.nnnCONCLUSIONSnA Critical Asthma SCAMP was effective in decreasing time on continuous albuterol.