Kimmo Murto

A Randomized Trial of Tranexamic Acid to Reduce Blood Transfusion for Scoliosis Surgery

Pediatric patients who undergo posterior spinal fusion surgery to correct scoliosis often require multiple blood transfusions. Tranexamic acid is a synthetic antifibrinolytic drug that reduces transfusion requirements in cardiac surgery and total knee arthroplasty. We evaluated the efficacy of prophylactic tranexamic acid to reduce perioperative blood transfusion requirements in a prospective, double-blinded, placebo control study. Forty patients, 9–18 yr of age, were randomized to either tranexamic acid (initial dose of 10 mg/kg and infusion of 1 mg · kg−1 · h−1) or placebo (isotonic saline). Perioperative management was standardized. A uniform transfusion threshold for noncell saved red blood cells was 7.0 g/dL. The total amount of blood transfused in the perioperative period was significantly reduced in the Tranexamic group (P = 0.045). No thrombotic complications were detected in either group. The administration of prophylactic tranexamic acid in patients with scoliosis undergoing posterior spinal fusion surgery has the potential to reduce perioperative blood transfusion requirements.

Perioperative autologous blood donation in children.

Autologous blood donation in children has become a standard of care. Children have to live with the life-time complications associated with allogeneic blood including the transmission of known and unknown pathogens, and the impact of alloimmunization on future blood transfusions, organ transplants and pregnancies. Donor reaction, allogeneic exposure and utilization rates in pediatric preoperative autologous donation (PAD) programs are as good if not better than reported in adult literature. Children are very resilient when undergoing extreme isovolemic hemodilution (IHD). PAD, IHD and intraoperative blood recovery appear to be useful components of a pediatric blood conservation program. Prospective, randomized studies addressing the specific needs of children are required to properly define their perioperative role.

Intra- and inter-observer reliability using a noninvasive ultrasound cardiac output monitor in healthy anesthetized children

Background:  Accurate and reliable evaluation of cardiac index (CI) in critically ill pediatric patients can optimize their management. Although validated, noninvasive ultrasound measurement techniques have been previously shown to be unreliable because of observer variability.

Neck circumference percentile: A screening tool for pediatric obstructive sleep apnea

Large neck circumference (NC) is associated with obstructive sleep apnea (OSA) in adults, especially males. Since NC changes with age and sex, a lack of reference ranges makes neck size difficult to assess as a screening tool in children.

Skin temperature over the carotid artery provides an accurate noninvasive estimation of core temperature in infants and young children during general anesthesia

The accurate measurement of core temperature is an essential aspect of intraoperative management in children. Invasive measurement sites are accurate but carry some health risks and cannot be used in certain patients. An accurate form of noninvasive thermometry is therefore needed. Our aim was to develop, and subsequently validate, separate models for estimating core temperature using different skin temperatures with an individualized correction factor.

Cerebral microembolization during pediatric scoliosis surgery: a transcranial doppler study.

The goal of this study was to identify cerebral microemboli during scoliosis surgery and their potential relationship with visual alterations. Transcranial Doppler identified high-intensity transient signals (HITS) during surgery in both middle cerebral arteries, and ophthalmologic examination assessed their potential effects on the visual system. Thirteen children (age 13–17 years) undergoing surgery for scoliosis or kyphosis with spine curvature >45° were studied. HITS were identified in 92%. Eleven patients had a total count of <15 HITS, but in the remaining two the count was unexpectedly high (63 and 265 HITS). Echocardiography in these two patients indicated the presence of an atrial right-to-left shunt. Uneventful preoperative and postoperative visual function was found in 11 patients. One patient had preoperative blindness and in another ophthalmologic complications developed not related to microembolization. Scoliosis surgery is frequently associated with low counts of cerebral microemboli. It appears that such low embolic counts have no effects on postoperative visual function as determined clinically. Some patients may show high rates of microemboli, which may be related to the presence of right-to-left cardiac shunts. The impact of these signals on brain function remains to be investigated.

Does Neck-to-Waist Ratio Predict Obstructive Sleep Apnea in Children?

OBJECTIVES Central adiposity and large neck circumference are associated with obstructive sleep apnea (OSA) in adults but have not been evaluated in children as predictors of OSA. Study objectives were to determine whether (1) anthropometric measures including neck-to-waist ratio are associated with OSA in older children; (2) body fat distribution, measured by neck-to-waist ratio, is predictive of OSA in overweight/obese children. METHODS Cross-sectional study involving children 7-18 years scheduled to undergo polysomnography at a tertiary care childrens hospital. OSA was defined as total apnea-hypopnea index > 5 events/h and/or obstructive apnea index > 1 event/h. Recursive partitioning was used to select candidate predictors of OSA from: age, sex, height and weight percentile, body mass index (BMI) z-score, neck-to-waist ratio, tonsil size, and Mallampati score. These were then evaluated using log binomial models and receiver operator characteristic analysis. RESULTS Two hundred twenty-two participants were included; 133 (60%) were overweight/obese, 121 (55%) male,47 (21%) had OSA. Neck-to-waist ratio (relative risk [RR] 1.97 per 0.1 units, 95% CI 1.48 to 2.84) and BMI z-score (RR 1.63 per unit, 95% CI 1.30 to 2.05) were identified as independent predictors of OSA. Considering only overweight/obese children, neck-to-waist ratio (RR 2.16 per 0.1 units, 95% CI 1.79 to 2.59) and BMI z-score (RR 2.02 per unit, 95% CI 1.25 to 3.26) also independently predicted OSA. However, in children not overweight/obese, these variables were not predictive of OSA. CONCLUSIONS Neck-to-waist ratio, an index of body fat distribution, predicts OSA in older children and youth, especially in those who were overweight/obese.

Parents are reluctant to use technological means of communication in pediatric day care

Purpose: We hypothesized that advanced information and communication technology (ICT) would be acceptable to parents in a pediatric surgical, and diagnostic imaging day care setting.Methods: After Ethics Committee approval, we distributed surveys, over a one-month period, to parents of children arriving for day care surgery or diagnostic imaging. Parents indicated their acceptance of various proposed modes of postoperative discussion of healthcare i.e.; face-to-face, videophone, or telephone. Parents were also asked to describe their receptiveness to scheduling non-emergency hospital appointments online and to receiving electronic media describing their child’s surgery and postoperative management. Parental education, income, and familiarity with the Internet were also assessed.Results: A total of 451 surveys (84% response rate) were returned. Most parents (95%) had access to the Internet and 70% did their banking online. Forty-two percent of the parents had at least a university education and 63% had an annual family income >

Cerebral blood flow velocity during occlusive manipulation of patent ductus arteriosus in children.

50,000 Canadian. The majority of parents (98%) accepted face-to-face interaction, while only 35% and 37% of parents were receptive to videophone and telephone interviews, respectively. Computer availability (P=0.001) and online banking (P=0.011) were the only variables that predicted those parents who were in favour of using videophone technology. Parents were receptive to instruction electronic media (80%) and booking appointments online (61%).Conclusions: A well-educated and technologically sophisticated parent population does not favour advanced communication technologies over simple, face-to-face interaction in an in-hospital setting. These parents are prepared to receive technology-based information about their child’s surgery and to schedule non-emergency hospital appointments online.RésuméObjectif: Nous avons émis l’hypothse que des technologies d’information et de communication (TIC) avancées seraient considérées comme acceptables par les parents dans le contexte des soins de jour en pédiatrie chirurgie, et en imagerie diagnostique.Méthode: Après avoir obtenu l’aval du comité d’éthique, nous avons distribué des questionnaires pendant un mois aux parents d’enfants admis pour des chirurgies ou des imageries diagnostiques aux soins de jour. Les parents ont indiqué leur acceptation de diverses méthodes proposées de discussion postopératoire des soins de santé, nommément : face à face, visiophone, ou téléphone. Nous avons également demandé aux parents de décrire leur réceptivité face à la prise de rendez-vous hospitaliers non urgents en ligne et à la réception de documents électroniques décrivant la chirurgie de leur enfant et la prise en charge postopératoire. La formation des parents, leurs revenus et leur aisance sur Internet ont aussi été évalués.Résultats: Au total, 451 questionnaires (taux de réponse de 84%) ont été retournés. La plupart des parents (95%) bénéficiaient d’un accès Internet et 70% effectuaient leurs transactions bancaires en ligne. Quarante-deux pour cent des parents avaient au moins une formation universitaire et 63% affichaient un revenu familial annuel τ 50 000 dollars canadiens. La majorité des parents (98%) consentaient à une interaction face à face, alors que seulement 35% et 37% des parents considéraient, respectivement, le visiophone et les entrevues téléphoniques comme moyens de communication appropriés. L’accès à un ordinateur (P=0,001) et les transactions bancaires en ligne (P=0,011) constituaient les seules variables prédisant quels parents seraient réceptifs à l’utilisation d’un visiophone. Les parents jugeaient appropriés l’envoi électronique de documents éducatifs (80%) et la prise de rendez-vous en ligne (61%).Conclusions: Une population de parents bien éduquée et à l’aise avec les technologies avancées ne préfère pas les moyens de communications à la fine pointe de la technologie en remplacement des interactions simples, face à face, dans un contexte hospitalier. Ces parents sont cependant prêts à recevoir des renseignements électroniques concernant la chirurgie de leur enfant et àprendre des rendez-vous hospitaliers non urgents en ligne.

Adrenal insufficiency and thyroid replacement therapy

Patent ductus arteriosus (PDA) with left‐to‐right shunting modifies the Doppler flow pattern of the intracranial circulation. The ability of increases in cerebral blood flow velocity (CBFV) to predict shunt resolution during PDA occlusion was evaluated. A 2 MHz transcranial Doppler (TCD) monitored diastolic and mean CBFV, plus the systolidmean CBFV ratio in the middle cerebral artery from before (baseline) to immediately after PDA occlusion. Shunt resolution was verified by echocardiography and/or angiography. A minimum of 40% increase in diastolic‐CBFV from baseline was considered successful resolution. Patients were age‐stratified into group I (<15 months; n=23) and group II (> 15 months; n=10). Thirty‐three children were studied (age, 0.1 to 109 months) during surgical (n=22) or coil occlusions (n=11 ). Transcranial Doppler successfully identified shunt resolution in 78% of cases in group I, as compared to 0% in group II (p<0.01). Identification rate decreased from 79% in cases of minimum ductal diameter of 3 mm (n=19) to 21% in smaller ductuses (n=14) (p<0.01). Body weight and left‐atrium size (p=0.004) in group I and PDA diameter in group II (p=0.02), were the only preoperative ductal parameters associated with diastolic‐CBFV changes after ductus occlusion. Transcranial Doppler detects shunt resolution in infants with moderate to large PDAs.