Mario Patino

Accuracy of acoustic respiration rate monitoring in pediatric patients

Rainbow acoustic monitoring (RRa) utilizes acoustic technology to continuously and noninvasively determine respiratory rate from an adhesive sensor located on the neck.

Trending and Accuracy of Noninvasive Hemoglobin Monitoring in Pediatric Perioperative Patients

BACKGROUND:Rainbow Pulse CO-Oximetry technology® (Masimo Corporation, Irvine, CA) provides continuous and noninvasive measurement of arterial hemoglobin concentration (SpHb). We assessed the trending and accuracy of SpHb by this innovative monitoring compared with Hb concentration obtained with conventional laboratory techniques (Hb) in children undergoing surgical procedures with potential for substantial blood loss. METHODS:Hb concentrations were recorded from Pulse CO-Oximetry and a conventional hematology analyzer. Regression analysis and 4-quadrant plot were used to evaluate the trending for changes in SpHb and Hb measurements (&Dgr;SpHb and &Dgr;Hb). Bias, precision, and limits of agreement of SpHb and of in vivo adjusted SpHb (SpHb − first bias to HB) compared with Hb were calculated. RESULTS:One hundred fifty-eight SpHb–Hb data pairs and 105 delta pairs (&Dgr;SpHb and &Dgr;Hb) from 46 patients aged 2 months to 17 years with Hb ranging from 16.7 to 7.9 g/dL were collected. To evaluate trending, the delta pairs (&Dgr;SpHb and &Dgr;Hb) were plotted, which revealed a positive correlation (&Dgr;SpHb = 0.022 + 0.76&Dgr;Hb) with correlation coefficient r = 0.76, 95% CI [confidence interval] = 0.57–0.86. The bias and precision of SpHb to Hb and in vivo adjusted SpHb were 0.4 ± 1.3 g/dL and 0.1 ± 1.2 g/dL, respectively; the limits of agreement were −2.0 to 3.2 g/dL before in vivo adjustment and −2.4 to 2.2 g/dL after in vivo adjustment (P value = 0.04). The mean percent bias (from the reference Hb concentration) decreased from 4.1% ± 11.9% to 0.7% ± 11.3% (P value = 0.01). No drift in bias over time was observed during the study procedure. Of patient demographic and physiological factors tested for correlation with the SpHb, only perfusion index at sensor site showed a weak correlation. CONCLUSIONS:The accuracy of SpHb in children with normal Hb and mild anemia is similar to that previously reported in adults and is independent of patient demographic and physiological states except for a weak correlation with perfusion index. The trending of SpHb and Hb in children with normal Hb and mild anemia showed a positive correlation. Further studies are necessary in children with moderate and severe anemia.

Arytenoid prolapse and inability to ventilate.

Syndrome of inappropriate antidiuretic hormone secretion (SIADH) is a relatively common complication of major spine surgery. Appropriate clinical management hinges on early diagnosis and prompt treatment to avoid neurologic complications. Postoperatively, a standard order set including daily laboratories, scheduled non-narcotic pain medications with additional opioids as needed, and isotonic isonatremic maintenance IV fluids are important means of assuring patient safety after spine fusion surgery.

To Pretreat or Not to Pretreat: Prophylactic Anticholinergic Administration Before Dexmedetomidine in Pediatric Imaging.

BACKGROUND:Dexmedetomidine (Dex) appears to be very effective as a sole sedative for pediatric imaging when used at high doses, but at an increased risk of transient hypertension, hypotension, and bradycardia. There are no clinical evidence/guidelines to guide anesthesia providers as to whether patients should be pretreated with an anticholinergic. The aim of this study was to demonstrate the changes in hemodynamic parameters after Dex sedation attributed to receiving or not receiving an anticholinergic pretreatment and compare for any differences or similarities. A subgroups analysis was performed in children with Down syndrome (DS). METHODS:In this retrospective descriptive study, we reviewed the records of 163 children receiving Dex anesthesia during MRI studies. Data analyzed included demographics, history of DS, and hemodynamics (heart rate [HR], systolic blood pressure [SBP], and diastolic blood pressure [DBP]) following Dex loading and infusion and the administration of an anticholinergic (atropine or glycopyrrolate). RESULTS:The mean age was 94.5 months, and 52 (32%) patients had DS. The generalized linear mixed-effects regression model showed a significant reduction in HR and SBP in all patients when no anticholinergic was administered compared with when it was administered. There was no significant change with DBP. During the scan period, the HR of the no-anticholinergic group decreased 26.6%, whereas that of the anticholinergic group decreased by only 16.7% from baseline (P < 0.01). The maximal SBP increased by a significantly greater percentage, compared with baseline, in the anticholinergic group in comparison with the no-anticholinergic group (20.2% vs 10.4%, respectively; P = 0.02). In the DS group, the difference in the maximal SBP change during the scan period was exaggerated, with a percentage increase that was 36 times larger in the anticholinergic group compared with the no-anticholinergic group (22% vs 0.6%, respectively; P< 0.01). CONCLUSIONS:Administration of a prophylactic anticholinergic with Dex shows no advantage other than a transient clinically insignificant increase in HR and SBP, and it may precipitate transient exaggerated SBP in more patients compared with not using a prophylactic anticholinergic.

Cerebral Vasoconstriction Triggered By Sympathomimetic Drugs During Intra-atrerial Chemotherapy

Reversible cerebral vasoconstriction syndrome is a rare cause of headache and stroke in the pediatric population. Reversible vasoconstriction is reported in a 19-month-old girl with retinoblastoma who underwent selective ophthalmic artery infusion chemotherapy with melphalan. Procedure-related cerebral vasoconstriction was specifically triggered during coadministration of adjunctive medications, which included mydriatic eye drops containing phenylephrine, intranasal oxymetazoline, nebulized albuterol, intravenous hydrocortisone, and intravenous diphenhydramine. The course of cerebral vasospasm, which began with a severe hypertensive surge and resolved spontaneously within hours of blood pressure normalization, was documented by angiography in real time. Subsequent brain magnetic resonance imaging showed no evidence of perfusion abnormality, cerebral infarction, or cerebral hemorrhage, and the patient was discharged home without any neurologic sequelae. In this report, we highlight the potential risk of reversible cerebral vasoconstriction in children administered vasoactive drugs and discuss its relevance during treatment of retinoblastoma by intraarterial chemotherapy.

A comparison of inhalational inductions for children in the operating room vs the induction room.

Background:  There has been debate about the use of an induction room (IR) compared with an operating room (OR) for inhalational induction in children. The quality of the anesthesia induction between these two physical environments has not been studied previously. We sought to compare child distress, OR utilization and efficiency, and parental satisfaction and safety, between an IR and an OR.

Intraoperative Neuromonitoring in Pediatric Surgery

The use of intraoperative neurophysiological monitoring (IONM) in children was first described in 1979 (Neurosurgery 4(2):146–51, 1979), just 2 years after the first descriptions of the use of somatosensory evoked potentials (SSEPs) in adult spine surgery (Clin Orthop Rel Res 126:100–5, 1977). Since then, surgeons from many countries have integrated the use of IONM into the surgical care of pediatric patients. The modalities used and the types of procedures for which IONM is utilized have expanded greatly since 1979.

Obstructive sleep apnea syndrome: anesthetic concerns.

OSA is increasingly recognized as a common disorder in children with substantial morbidity. As a condition that results from decreased upper airway patency during sleep compared with wakefulness, OSA belongs to the spectrum of anomalies known as sleep-related breathing disorders in which the airway is completely (apnea) or partially (hypopnea) occluded despite continued respiratory efforts. These abnormalities lead to abnormal gas exchange resulting in hypoxemia, hypercapnia, and sleep fragmentation. Common clinical manifestations include loud and episodic snoring with pauses in breathing, disrupted and restless sleep, daytime drowsiness, and inattention. Systemic manifestations in the cardiovascular, pulmonary, metabolic, and neurological systems occur secondary to the

Morfologia das vias aéreas superiores em pacientes com síndrome de Down sob sedação com dexmedetomidina.

BACKGROUND AND OBJECTIVES Children with Down Syndrome are vulnerable to significant upper airway obstruction due to relative macroglossia and dynamic airway collapse. The objective of this study was to compare the upper airway dimensions of children with Down Syndrome and obstructive sleep apnea with normal airway under dexmedetomidine sedation. METHODS IRB approval was obtained. In this retrospective study, clinically indicated dynamic sagittal midline magnetic resonance images of the upper airway were obtained under low (1mcg/kg/h) and high (3mcg/kg/h) dose dexmedetomidine. Airway anteroposterior diameters and sectional areas were measured as minimum and maximum dimensions by two independent observers at soft palate (nasopharyngeal airway) and at base of the tongue (retroglossal airway). RESULTS AND CONCLUSIONS Minimum anteroposterior diameter and minimum sectional area at nasopharynx and retroglossal airway were significantly reduced in Down Syndrome compared to normal airway at both low and high dose dexmedetomidine. However, there were no significant differences between low and high dose dexmedetomidine in both Down Syndrome and normal airway. The mean apnea hypopnea index in Down Syndrome was 16±11. Under dexmedetomidine sedation, children with Down Syndrome and obstructive sleep apnea when compared to normal airway children show significant reductions in airway dimensions most pronounced at the narrowest points in the nasopharyngeal and retroglossal airways.

Upper airway morphology in Down Syndrome patients under dexmedetomidine sedation

BACKGROUND AND OBJECTIVES Children with Down Syndrome are vulnerable to significant upper airway obstruction due to relative macroglossia and dynamic airway collapse. The objective of this study was to compare the upper airway dimensions of children with Down Syndrome and obstructive sleep apnea with normal airway under dexmedetomidine sedation. METHODS IRB approval was obtained. In this retrospective study, clinically indicated dynamic sagittal midline magnetic resonance images of the upper airway were obtained under low (1mcg/kg/h) and high (3mcg/kg/h) dose dexmedetomidine. Airway anteroposterior diameters and sectional areas were measured as minimum and maximum dimensions by two independent observers at soft palate (nasopharyngeal airway) and at base of the tongue (retroglossal airway). RESULTS AND CONCLUSIONS Minimum anteroposterior diameter and minimum sectional area at nasopharynx and retroglossal airway were significantly reduced in Down Syndrome compared to normal airway at both low and high dose dexmedetomidine. However, there were no significant differences between low and high dose dexmedetomidine in both Down Syndrome and normal airway. The mean apnea hypopnea index in Down Syndrome was 16±11. Under dexmedetomidine sedation, children with Down Syndrome and obstructive sleep apnea when compared to normal airway children show significant reductions in airway dimensions most pronounced at the narrowest points in the nasopharyngeal and retroglossal airways.