Lawrence M. Borland

Pulmonary Aspiration in Pediatric Patients During General Anesthesia: Incidence and Outcome

STUDY OBJECTIVES To determine the incidence of, outcome of, and risk factors for anesthesia-related pulmonary aspiration in the predominantly pediatric population receiving anesthesia care. DESIGN Using a clinical concurrent quality assessment system we developed, we used data stored in a custom-designed computerized database to initiate a retrospective review. Statistical relationships were analyzed by Fishers exact test and binary logistic regression with commercially available software. SETTING University-affiliated pediatric hospital. PATIENTS All patients receiving anesthesia (n = 50,880) between April 1, 1988, and March 31, 1993. MEASUREMENTS AND MAIN RESULTS Aspiration occurred in 52 (0.10% or 10.2 per 10,000) of the 50,880 general anesthesia cases. Aspirate was food or gastric contents in 25 cases (0.049% or 4.9 per 10,000), blood in 13 (0.026% or 2.6 per 10,000), and unknown material in 14 (0.0275% or 2.76 per 10,000). There were no deaths attributable to aspiration. Morbidity was confined to unanticipated hospital admission (n = 12), cancellation of the surgical procedure (n = 4), and intubation, with or without ventilation (n = 15). Aspiration occurred significantly more often in patients with greater severity of underlying illness (ASA physical status III or IV) (p = 0.0015), intravenous induction (p = 0.0054), and age equal to or greater than 6.0 years and less than 11.0 years (p = 0.0029). Emergency procedures had a marginally significant increased aspiration risk (p = 0.0527). CONCLUSIONS The overall incidence of anesthesia-related aspiration in our series (0.10%) was twice that reported in studies of adults, and four times (0.25%) higher for those at highest risk (ASA physical status III or IV vs. physical status I or II). Anesthesia-related pulmonary aspiration was proven to be a rare event in this tertiary pediatric center and its consequences relatively mild. Because of the very low frequency and the lack of serious outcome after aspiration in ASA physical status I and II pediatric patients, it appears that routine prophylactic administration of histamine blockers or propulsive drugs in healthy pediatric patients is unwarranted.

Frequency of anesthesia-related complications in children with Down syndrome under general anesthesia for noncardiac procedures

Background : Craniofacial and cardiac anomalies of Down syndrome (DS; trisomy 21) would seem to place these patients at higher risk of anesthesia‐related complications (ARCs), but to date no comprehensive large‐scale study has quantified this risk.

Liver transplantation for arteriohepatic dysplasia (Alagille's syndrome).

Abstract. Thirteen out of 268 children (18 years old) underwent hepatic transplantation (OLT) for end‐stage liver disease (ESLD) associated with arteriohepatic dysplasia (AHD). Seven children are alive and well with normal liver function. Six children died, four within 11 days of the operation and the other two at 4 and 10 months after the OLT. Vascular complications with associated septicemia were responsible for the deaths of three children. Two died of heart failure and circulatory collapse, secondary to pulmonary hypertension and congenital heart disease. The remaining patient died of overwhelming sepsis not associated with technical complications. Seven patients had a portoenterostomy or portocholecystostomy early in life; five of these died after the OLT. Severe cardiovascular abnormalities in some of our patients suggest that complete hemodynamic monitoring with invasive studies should be performed in all patients with AHD, especially in cases of documented hypertrophy of the right ventricl. The improved quality of life in our surviving patients confirms the validity of OLT as a treatment of choice in cases of ESLD due to AHD.

Intraoperative Coagulation Changes in Children Undergoing Liver Transplantation

Intraoperative changes in blood coagulation were observed in eight children undergoing liver transplantation using a simplified coagulation profile (prothrombin time [PT], activated partial thromboplastin time [aPTT], and platelet count) and thrombelastography. Preoperatively, PT and aPTT were moderately prolonged (1.5 times control), and platelet count was greater than 100,000/mm3 in all patients but one (91,000/mm3). During the preanhepatic and anhepatic stages, PT, aPTT, reaction time, and coagulation time improved toward normal values, but platelet count and maximum amplitude did not change. Significant changes in coagulation occurred on reperfusion of the grafted liver: PT, aPTT, reaction time, and coagulation time were prolonged, and platelet count, maximum amplitude, and clot formation rate decreased. A heparin effect, which did not require treatment, was seen on reperfusion in four patients. Fibrinolysis occurred during the operation in five patients and was treated with Epsilon-aminocaproic acid (EACA) in one. Blood coagulation improved slowly, and values were close to baseline 90 min after reperfusion. In general, the coagulation changes seen in these children are similar to those in adults but less severe, possibly because of the preponderance of cholestatic disease in children compared with the more common hepatocellular disease in adults.

Jet ventilation for laser laryngeal surgery in children. Modification of the Saunders jet ventilation technique.

In our clinical series, 40-50% O2 and 50-60% N2O (regulated by a blender and delivered by manual jet ventilation (MJV] and residual halothane from induction provided satisfactory supralaryngeal anesthesia. Fentanyl, N2O, atracurium, and lidocaine administered i.v. effectively blunted laryngeal stimulation, allowed control of respiration, and minimized vocal cord motion. Wide unobstructed surgical access to the entire endolarynx is provided. Atracurium (an intermediate-acting non-depolarizing muscle relaxant administered in a single bolus or by constant infusion) achieves the needed level of blockade and permits the anesthesiologist to focus on the pattern of respiration rather than the degree of neuromuscular blockade. Its duration of action seems to be well matched to the average duration of this surgical procedure. Because its reversal is prompt (35-45 min from i.v. injection to 25% recovery by neuromuscular transmission monitor) (Brandom et al., Clinical pharmacology of atracurium in paediatric patients, Br. J. Anaesth., 55 (1983) 117S-121S) children can be discharged safely from the recovery room to home after an appropriate period of observation in the short-stay unit. Our report confirms and extends another recent report supporting supraglottic jet ventilation (Scamman, F.L. and McCabe, B.F., Supraglottic jet ventilation for laser surgery of the larynx in children, Ann. Otol. Rhinol. Laryngol., 95 (1986) 142-145). We believe that the MJV technique is advantageous in children, particularly for outpatient surgery. Attention to detail and careful communication between a skilled anesthesiologist and surgeon are essential. Dangerous barotrauma can occur and skill and monitoring are essential.

Outcomes Studies of Epiglottic and Base of Tongue Prolapse in Children

Objectives: The purpose of this study was to compare previously reported flexible fiberoptic laryngoscopy (FFL) findings of a grading system for children with epiglottic and base of tongue (EBT) prolapse with findings at follow‐up FFL. Surgical outcomes and tracheotomy decannulation are also reported.