Monica Botero

Effects of trendelenburg position and positive intrathoracic pressure on internal jugular vein cross-sectional area in anesthetized children

STUDY OBJECTIVE To compare the cross-sectional area (in cm(2)) of the left internal jugular vein (LIJV) and right internal jugular vein (RIJV) in anesthetized children, and measure the response to the Trendelenburg tilt position (TBRG) and a positive inspiratory pressure hold. DESIGN Prospective, nonrandomized study. SETTING University medical center. PATIENTS 45 ASA physical status I and II children, ages 6 months to 8 years, undergoing general anesthesia and mechanical ventilation. INTERVENTIONS The cross-sectional area of both internal jugular veins was measured with a 5-MHz, two-dimensional surface transducer, at the level of the cricoid cartilage. Three measurements were obtained: 1) with the patient supine, 2) during a 10-second breath-hold with a positive inspiratory pressure (PIP) of 20 cm H(2)O, and 3) with the patient at 20 degrees TBRG. Data were analyzed with two-way analysis of variance (ANOVA) and Student-Newman-Keuls test, with a p < 0.05 considered significant. MEASUREMENTS AND MAIN RESULTS In supine patients, the cross-sectional area of the RIJV was larger than the LIJV in 31 patients (69%), and equal or smaller in 14 patients (31%) (0.80 +/- 0.38 vs. 0.59 +/- 0.22; p = 0.002). A PIP hold, but not TBRG, significantly dilated the RIJV (0.8 +/- 0.38 at baseline vs. 0.93 +/- 0.42 with TBRG; p = not significant vs. 1.1 +/- 0.46 with PIP; p < 0.05), whereas neither maneuver was effective with the LIJV. CONCLUSION The cross-sectional area of the RIJV is often greater than the LIJV; the TBRG was not effective to increase the cross-sectional area of the internal jugular veins, and only a PIP hold increased significantly the cross-sectional area of the RIJV. In this study, the LIJV appeared of smaller size and less compliant compared with the RIJV.

Carcinoid heart disease: A case report and literature review

We report a patient who presented for elective exploratory laparotomy, and resection of a pelvic mass, which was thought to be ovarian carcinoma. Intraoperative transesophageal echocardiography demonstrated right-sided valvular heart lesions, which suggested the diagnosis of carcinoid syndrome before a pathologic confirmation was obtained. This article discusses the classical presentation and anesthetic management of patients with carcinoid syndrome and emphasizes the importance of proper preoperative diagnosis and careful planning if the incidence and severity of the symptoms that this condition can provoke are to be reduced.

Diagnosis and Management of Arrhythmias in Children After Cardiac Surgery

Arrhythmias that lead to hemodynamic deterioration and sudden death are one of the most challenging problems in children after cardiac surgery. In infants with congenital heart disease, disorders of impulse conduction are more frequent than those of impulse generation. Various factors that include anatomic or physiologic abnormalities of the conduction system, damage as a result of hemodynamic stress or chronic hypoxia, and injury occurring at the time of surgery interact to produce dysrhythmias. During the post operative period, supraventricular tachycardia rarely causes sudden death in children. However, junctional ectopic tachy cardia and Wolff-Parkinson-White syndrome are 2 that have been associated with a high mortality rate. In general, ven tricular tachycardia carries a more serious prognosis than supraventricular tachycardia because it typically occurs in abnormal myocardium with suboptimal function, which may also be vulnerable to degeneration into ventricular fi brillation. A practical approach to the most common intra operative and postoperative arrhythmias in pediatric cardiac patients is discussed. Patients at risk, the types of arrhyth mias likely to occur after specific cardiac operations, and the most effective current therapies are reviewed.