Jacob Katz

Premedication with midazolam in young children: a comparison of four routes of administration

Summary Background: We undertook a study to determine the effects of four routes of administation on the efficacy of midazolam for premedication.

Chlorhexidine-impregnated dressing for prevention of colonization of central venous catheters in infants and children: a randomized controlled study.

Background: Infections of short term, nontunneled, intravascular catheters are often caused by migration of organisms from the insertion site. The aim of this study was to evaluate the effectiveness and safety of a chlorhexidine gluconate-impregnated dressing for the reduction of central venous catheter (CVC) colonization and CVC-associated bloodstream infections in infants and children after cardiac surgery. Methods: This prospective, randomized, controlled study was conducted in the pediatric cardiac intensive care unit of a tertiary care pediatric medical center. Patients 0–18 years of age who were admitted to the pediatric cardiac intensive care unit during a 14-month period and required a CVC for >48 hours were randomized to receive a transparent polyurethane insertion site dressing (control group) or a chlorhexidine gluconate-impregnated sponge (Biopatch) dressing covered by a transparent polyurethane dressing (study group). The main outcome measures were rates of bacterial colonization, rates of CVC-associated bloodstream infections and adverse events. Results: Seventy-one patients were randomized to the control group and 74 to the study group. There were no significant between group differences in age, sex, Pediatric Risk of Mortality score or cardiac severity score. CVC colonization occurred in 21 control patients (29%) and 11 (14.8%) study patients (P = 0.0446; relative risk, 0.6166; 95% confidence interval, 0.3716–1.023). Bloodstream infection occurred in 3 patients (4.2%) in the control group and 4 patients (5.4%) in the study group. Local redness was noted in 1 control patient and 4 study group patients. Conclusions: The chlorhexidine gluconate-impregnated sponge is safe and significantly reduces the rates of CVC colonization in infants and children after cardiac surgery.

Recombinant factor VIIa (NovoSeven®) as a hemostatic agent after surgery for congenital heart disease

Background :u2002Postoperative bleeding and blood product requirements can be substantial in children undergoing open‐heart surgery, and reexploration is required in 1% of cases. Recombinant activated factor VII (rFVIIa, NovoSeven®, NovoNordisk, Denmark) is a hemostatic agent approved for the treatment of hemophilic patients with inhibitors to factor VIII or factor IX. It has also been used with success in other conditions. We present our experience with rFVIIa treatment for uncontrolled bleeding after open‐heart surgery in five pediatric patients.

Infectious complications of peripherally inserted central venous catheters in children.

Background: Peripherally inserted central venous catheters (PICCs) are frequently used in infants and children. However, only limited data are available on current infectious and noninfectious complications of PICCs in this patient population. The aim of the study is to define the current rate of infectious and noninfectious complications of PICCs, the causative agents, and to define possible risk factors associated with these complications. Methods: A prospective surveillance study was conducted at the Schneider Children Medical Center of Israel. All patients in whom a PICC was inserted between August 2004 and October 2006 were included. Demographic, clinical, and microbiologic data were collected by a questionnaire completed by the anesthesiologist at the time of insertion and removal of each catheter. Items covered epidemiologic, clinical, and microbiologic data. Results: A total of 279 PICCs were inserted in 221 patients. There were no complications at insertion. Mean dwell time was 30 days. One hundred seventy-seven (63%) of all PICC placements were free of complications. Twenty-six catheters (9.3%) were dislodged accidentally; 38 (13.6%) were removed for mechanical problems: tears in 5, leaks in 12, and obstructions in 21; 38 (13.6%) were removed for an infectious complication: phlebitis in 13 (4.6%, 1.5/1000 PICC days), exit-site infection in 10 (3.5%, 1.1/1000 PICC days), PICC-associated bloodstream infection in 12 (4.3%, 1.4/1000 PICC days), and PICC-related bloodstream infection in 4 (1.4%, 0.4/1000 PICC days); 15 more were removed for presumed infection (5.3%, 1.7/1000 PICC days). On multivariate analysis, composite indication for PICC use and older patient age were significantly associated with infectious complications. Conclusions: PICCs are safe and may be used for prolonged periods. In our center, the rates of infectious complications are lower than for tunneled central venous catheters. Accidental dislodgement is not uncommon and may be prevented by use of sutures, occlusive dressing, and education of patients, families, and medical staff.

A vein entry indicator device for facilitating peripheral intravenous cannulation in children: a prospective, randomized, controlled trial.

BACKGROUND: Vascular access is often technically difficult in children because of the small caliber and impalpability of the veins. In this study, we sought to determine if use of the Vein Entry Indicator Device (VEID™) in children facilitates peripheral venous access. METHODS: Two-hundred-two healthy (ASA grade I and II) children scheduled for same-day surgery at a major tertiary hospital in Israel were randomly allocated to undergo VEID-assisted or standard peripheral venous cannulation. All cases involved the insertion of a 22-gauge cannula into an upper limb vein. Primary outcome measures were number of attempts to successful cannulation, rate of success at first attempt, and time required for insertion. The data were presented as mean (sd). Analyses of variance and Pearson &khgr;2 test or Fisher’s exact test were used to compare the groups; forward stepwise logistic regression was used to identify the three variables (age, vein assessment category, use of the VEID) significantly associated with a successful first attempt. A P value of ≤0.05 was considered significant. RESULTS: Successful cannulation was achieved at the first attempt in the majority of patients in both groups. Two attempts were needed in 8% of the VEID group and 28% of the control group, and 3 attempts were needed in 1% and 3%, respectively (P < 0.01). Analysis by vein assessment category yielded a similar rate of successful first-attempt cannulations in the two groups for easy veins. However, for the difficult and intermediate categories, the rate was 89.7% in the VEID group compared to 23.3% in the control group (P < 0.001). The fewer number of attempts in the study group was associated with a shorter time from the start of the search for an appropriate vein to successful cannulation (9.1 s versus 22.5 s in the control group). CONCLUSIONS: The VEID facilitates the insertion of peripheral venous cannulas in healthy children with intermediate/difficult veins undergoing same-day surgery, reducing the number of attempts and the overall time required.

Spinal anesthesia in infants with ventriculoperitoneal shunt: report of five cases and review of literature

We describe five cases of children with ventriculoperitoneal shunt who underwent abdominal and perineal procedures under spinal anesthesia. Four of them had been born prematurely, and all had suffered from severe neonatal complications. All of our patients suffered from severe respiratory impairment, that had required mechanical ventilation, and three of them suffered additionally from apnea of prematurity. Four patients had ventriculoperitoneal shunt inserted because of obstructive hydrocephalus and one because of congenital central nervous system anomalies. Two underwent subsequently shunt revision. The benefits of spinal anesthesia in this high‐risk population are described. The risks of spinal anesthesia in the presence of a ventricular shunt device, especially infection and dural leakage, are discussed, and the literature about this topic briefly reviewed.

Anomalous origin of the pulmonary artery from the aorta: early diagnosis and repair leading to immediate physiological correction.

INTRODUCTIONnAnomalous origin of one pulmonary artery from the ascending aorta is a rare cardiac anomaly in which the pulmonary artery abnormally arises from the ascending aorta. Physiologically, most patients develop signs of cardiac failure due to high flow to both lungs, with systemic or supra-systemic pressures in the normally connected lung. The purpose of this study is to present our experience with this rare anomaly, in which early anatomic repair lead to rapid physiologic correction.nnnMATERIALS AND METHODSnRetrospective case review of all patients with anomalous origin of one pulmonary artery from the ascending aorta at Schneider Childrens Medical center of Israel between 1986 and 2007. All clinical operative and echocardiographic charts were analysed.nnnRESULTSnTwelve patients were diagnosed as anomalous origin of one pulmonary artery from the ascending aorta. In 10 patients, the right pulmonary artery rose from the ascending aorta, while in two an anomalous origin of the left pulmonary artery was associated with a right aortic arch. Initial diagnoses was made with two-dimensional echocardiography in all patients. In six patients, diagnostic cardiac catheterisation was performed in order to confirm the diagnosis. Age at diagnosis ranged from 5 to 180 days with a median of 15 days, and patient weight ranged from 780 grams to 5 kilograms, with a median of 3 kilograms. Initial echocardiographic evaluation showed systemic (four patients) or supra-systemic (seven patients) pressures in the right ventricle and normally connected lung. All underwent surgical repair. There was no operative mortality. All reconstructed patients achieved normal right ventricular pressures within days after surgery. The flow pattern in both pulmonary arteries was normalised.nnnCONCLUSIONSnEarly surgical repair of anomalous origin of one pulmonary artery from the ascending aorta is feasible and safe even in newborn and premature babies with complete resolution of the pulmonary hypertension and normalisation of pulmonary vascular resistance.

Complex regional pain syndrome type I after infliximab infusion

narrow forehead, microphthalmia, large floppy ears and micrognathia. They may have deformities of the extremities such as arachnodactyly. Ovarian agenesis has been reported in one patient (5). Our patient exhibited all the classic features of the disease. In addition, the femoral vessels were abnormal bilaterally. This has not been previously reported as an association of the disease. The rapid progression of the renal failure prompted a difficult decision on the part of the parents to move forward to dialysis. The facies of the patient made us anticipate the need for other airway maneuvers to intubate him. Interestingly, much of the abnormality of the face was excess soft tissue of the lower face compounded by microcephaly which made it look as though it might be technically difficult. In reality, mask ventilation and intubation proved easy. In summary, we present a case of a child with GMS whose renal failure required insertion of dialysis catheters and who also required a Nissen fundoplication for control of reflux. The major anesthesia implications were renal failure, severe neurologic delay and a potentially difficult airway. Ann Bailey* Linda Georges† *Department of Anesthesiology and Pediatrics, University of North Carolina, NC, USA and †Department of Anesthesiology, University of North Carolina, NC, USA (email: abailey@alms.unc.edu)

Direct innominate artery cannulation for antegrade cerebral perfusion in neonates undergoing arch reconstruction.

BACKGROUNDnAntegrade cerebral perfusion (ACP) is performed in neonates either by direct cannulation (DC) or indirect cannulation (IC) of the innominate artery. IC is achieved by a graft sutured to the innominate artery or advancement of a cannula through the ascending aorta into the innominate artery, whereas DC is performed by directly cannulating the innominate artery. These techniques may be limited by technical problems that can compromise perfusion. The purpose of the present study was to evaluate the flow measurements and safety of DC when compared with IC.nnnMETHODSnThis was a retrospective chart review of consecutive neonates who underwent ACP from January 2007 to December 2010. Patient characteristics, surgical and hemodynamic measurements, and postoperative neurologic findings were recorded.nnnRESULTSnSeventy neonates underwent ACP during the study period (46 using DC and 24 using IC). The groups were similar in age and weight. Operative variables were similar regarding cardiopulmonary bypass (CPB), cross-clamp times, maximal flow at full CPB, minimal temperature, ACP time, flow and flow index, and upper extremity blood pressure and proximal cannula pressure during ACP. There was a significantly higher flow index at full CPB in the DC group (217 ± 40 mL/kg/min versus 190 ± 46 mL/kg/min; p = 0.013), which correlated with higher proximal cannula pressures at full CPB (172 ± 27 mm Hg versus 158 ± 26 mm Hg; p = 0.04). Sixty-two of the 65 survivors (95%) had normal neurologic evaluations on discharge.nnnCONCLUSIONSnACP using DC is comparable to that using IC, with appropriate pressures in the proximal aortic line at full CPB and adequate upper extremity pressures during ACP, reflecting suitable flows in the cerebral circulation.

Anesthesia management for the child with Sanjad–Sakati syndrome

Sanjad–Sakati syndrome (SSS) is a rare genetic disorder characterized by congenital hypoparathyroidism, hypocalcemia and hyperphosphatemia, seizures, severe intrauterine and postnatal growth failure, dwarfism, mental retardation, dysmorphic features including retromicrognathia and abnormal dentition and increased susceptibility to infection. It is mainly confined to children in the Middle‐East countries. We report the anesthesia management of a 12‐year‐old boy with SSS for dental treatment, and discuss the anesthesia implications of this disorder.