Robert F. Seal

Comparison of esophageal, rectal, axillary, bladder, tympanic, and pulmonary artery temperatures in children☆☆☆★★★

Our objective was to determine the most reliable site for temperature measurement in children. In anesthetized children esophageal temperature readings were closest to those in the pulmonary artery (mean difference 0.1 degree C +/- 0.5 degree C compared with Genius tympanic thermometer (mean difference 0.6 degree C +/- 1.0 degree C), IVAC tympanic thermometer (mean difference 0.8 degree C +/- 1.0 degree C), rectal probe (mean difference 0.7 degree C +/- 1.7 degrees C), bladder probe (mean difference 0.9 degree C +/- 1.4 degrees C), and axillary probe (mean difference 1.3 degrees C +/- 1.3 degrees C).

Oesophageal, rectal, axillary, tympanic and pulmonary artery temperatures during cardiac surgery

PurposeThe gradient between temperatures measured at different body sites is not constant; one factor which will change this gradient is rapid changes in body temperature. Measurement of this gradient was done in patients undergoing rapid changes in body temperature to establish the best site to measure temperature and to compare two brands of commercial tympanic thermometers.MethodA total of 228 sets of temperatures were measured from probes in the oesophagus, rectum, and axilla and from two brands of tympanic thermometer and compared with pulmonary artery (PA) temperature in 18 adults during cardiac surgery.ResultsMeasurements from the oesophageal site was closest to PA readings (mean difference 0.0 ± 0.5°C) compared with IVAC tympanic thermometer (mean difference −0.3 ± 0.5°C), Genius tympanic thermometer (mean difference −0.4 ± 0.5°C), axillary (mean difference 0.2 ± 1.0dgC) and rectal (mean difference −0.4 ± 1,0°C) readings. When data during cooling were analysed separately, all sites had similar gradients from PA except for rectal, which was larger. On rewarming, oesophageal readings were closest to PA readings; tympanic readings were closer to PA than were rectal or axillary readings. Readings from the two brands of tympanic thermometer were equivalent.ConclusionOesophageal temperature is more accurate and will reflect rapid changes in body temperature better than tympanic, axillary, or rectal temperature. When oesophageal temperature cannot be measured, tympanic temperature done by a trained operator should become the reading of choice.RésuméObjectifLe gradient entre les mesures de température réalisées à différents endroits du corps n’est pas constant; les changements rapides de la température corporelle représentent un des facteurs modifiant ce gradient. Ce dernier a été mesuré chez des patients subissant des changements rapides de la température corporelle dans le but d’identifier le meilleur endroit où mesurer la température et dans le but de comparer deux marques de thermomètre tympanique sur le marché.MéthodeUn total de 228 groupes de mesures de la température ont été obtenues à partir des sites oesophagien, rectal, axillaire et tympaniqué (deux marques de thermomètre) et ont été comparés aux mesures réalisées dans l’artère pulmonaire chez 18 adultes subissant une chirurgie cardiaque.RésultatsLes mesures oesophagiennes étaient les plus proches de celles de l’artère pulmonaire (différence moyenne (0,0 ± 0,5°C), comparativement aux mesures tympaniques par thermomètre IVAC(−0,3 ± 0,5°C) et Genius (−0,4 ± 0,5°C), aux mesures axillaires (0,2 ± 1°C) et aux mesures rectales (−0,4 ± 1°C). Lorsque les mesures durant le refroidissement étaient analysées séparément, tous les sites démontraient des gradients analogues par rapport à l’artère pulmonaire, sauf le rectum qui démontrait un gradient plus considérable. Lors du réchauffement, les mesures oesophagiennes étaient plus proches de celles de l’artère pulmonaire, suivies des mesures tympaniques, avant les mesures axillaires ou rectales. Les lectures obtenues avec les deux marques de thermomètre tympaniqué se sont avérées équivalentes.ConclusionLa température oesophagienne est plus précise et reflète mieux les changements rapides de température corporelle que les sites tympaniqué, axillaire ou rectal. Lorsqu’on ne peut mesurer la température oesophagienne, la mesure tympaniqué réalisée par un opérateur entraîné devrait être la mesure de choix.

Survival rate changes with transfusion of blood products during liver transplantation

PurposeTo determine whether red blood cell (RBC) or plasma transfusion is associated with the one-year survival rate variation previously detected in liver transplantation.MethodsA retrospective study of 206 consecutive liver transplantations was undertaken. Intraoperative transfusions of blood products were identified. Twenty-seven variables were studied using univariate and multivariate analyses to identify factors that were associated significantly with survival rate. For analysis of one-year survival, the cases were studied according to the transfused blood products. Patients were stratified according to the degree of RBC and plasma transfusion into four groups: more than four units of RBC, one to four units of RBC, plasma transfusion only, and no plasma or RBC transfusions.ResultsPatients received an average of 2.8 ± 3.5 units of RBC and 4.1 ± 4.1 units of plasma. Thirty-two percent of the patients did not receive any RBC transfusion and 19.4% did not receive any blood products. The one-year survival rate was 81.9% for all patients and 97.4% for patients without any transfusions. Of the 27 variables evaluated, only RBC and plasma transfusions were associated with significant decrease in the one-year survival rate, which was seen in the group who received only plasma (76.9%, P = 0.014) and the group who received more than four units of RBC (62.5%, P < 0.0001).ConclusionAlthough we cannot demonstrate causality, our analysis shows that our one-year survival rate following liver transplantation decreased significantly with the intraoperative transfusion of any amount of plasma or more than four units of RBC.RésuméObjectifDéterminer si la transfusion de globules rouges (GR) ou de plasma est associée à la variation du taux de survie d’un an déjà détectée pour une transplantation hépatique.MéthodeUne étude rétrospective de 206 transplantations hépatiques consécutives a été menée. Les transfusions peropératoires de produits sanguins ont été recensées. Nous avons étudié 27 variables par des d’analyses à une ou plusieurs variables pour repérer les facteurs associés de façon significative au taux de survie. Pour l’analyse du taux de survie d’un an a été faite selon les produits sanguins transfusés. Les patients ont été stratifiés en quatre groupes d’après le degré de transfusion de GR et de plasma: plus de quatre unités de GR, de une à quatre unités, transfusion de plasma seulement et aucune transfusion.RésultatsLes patients ont reçu en moyenne 2,8 ± 3,5 unités de GR et 4,1 ± 4,1 unités de plasma. Trente-deux pour cent n’ont reçu aucune transfusion de GRet 19,4% aucun produit sanguin. Le taux de survie d’un an a été de 81,9% pour tous les patients et de 97,4% pour ceux qui n’ont eu aucune transfusion. Des 27 variables évaluées, seules les transfusions de Gr et de plasma ont été associées à une baisse significative du taux de survie d’un an, notée chez les patients qui ont reçu du plasma seulement (76,9%, P = 0,014) ou plus de quatre unités de GR (62,5%, P < 0,0001).ConclusionSans pouvoir établir de causalité, notre analyse montre que le taux de survie d’un an après une transplantation hépatique diminue significativement avec la transfusion peropératoire de toute quantité de plasma ou de plus de quatre unités de GR.

Thoracic Epidural Analgesia Via the Caudal Approach in Pediatric Patients Undergoing Fundoplication Using Nerve Stimulation Guidance

IMPLICATIONS Epidural catheter placement using electrical stimulation guidance is an alternative approach for positioning the catheter into the thoracic region via the caudal space. This easily performed clinical assessment provides optimization of catheter tip positioning for achieving effective pain control.

Swine influenza (H3N2) infection in a child and possible community transmission, Canada

Seropositivity to the same strain was demonstrated in the child and in multiple other community members.

A Comparison of Intrathecal Morphine/fentanyl and Patient-controlled Analgesia with Patient-controlled Analgesia Alone for Analgesia After Liver Resection

Continuous epidural anesthesia and analgesia may be considered in liver resection, but is often avoided because of the potential development of coagulopathies and the risk of epidural hematoma. In this prospective, randomized, double-blind study we compared postoperative morphine consumption via patient-controlled analgesia after liver surgery between two groups of patients: patients receiving a preoperative dose of intrathecal morphine (0.5 mg) and fentanyl (15 &mgr;g) (treatment group) and patients receiving a sham intrathecal injection (placebo group). Forty patients scheduled for major liver resection (≥two segments) were enrolled. The primary outcome measure was patient-controlled analgesia morphine consumption. Secondary outcomes were evaluation of pain at rest and with movement, scored on a visual analog scale with assessment of sedation, nausea, pruritus, and respiratory frequency. Outcome measures were recorded at 6, 12, 18, 24, and 48 h postspinal anesthesia or simulation. Patients in the placebo group consumed approximately three times more morphine during each time interval than patients in the treatment group (at 48 h: 124 ± 30 vs 47 ± 21 mg, P < 0.0001). Pain evaluation on the visual analog scale was lower for the first 18 h in the treatment group. There was no difference in the incidence of side effects in both groups. Intrathecal morphine (0.5 mg) and fentanyl (15 &mgr;g) given before liver surgery significantly decreased postoperative morphine consumption compared to placebo without any increase in side effects.

Aprotinin in children undergoing repair of congenital heart defects

BACKGROUND Aprotinin use in adults is increasing, and its use in children has recently been reported. METHODS The efficacy of aprotinin in children was tested in 80 children. Patients were in four groups: reoperations (59), neonates (8), extremely cyanotic children (6), and other complex repairs (7). The results were compared with those of 55 control infants and children: reoperations (25), neonates (10), cyanotic (10) and complex (10). Treatment groups were identical in age, sex ratio, cross-clamp time, and bypass time. RESULTS Patients treated with aprotinin had a significant reduction in chest tube drainage (16.5 +/- 9.8 versus 33.4 +/- 22.1 mL.kg-1.h-1; p < 0.001) and time to skin closure (64.2 +/- 23.7 versus 80.1 +/- 24.6 minutes; p < 0.001). Transfusion requirements were decreased in aprotinin-treated patients 4.2 +/- 3.4 versus 6.7 +/- 5.2 donors; p < 0.001). All of the control patients were exposed to at least one donor, whereas 10/80 (12.5%) of the aprotinin-treated group had no blood use (p < 0.006). There were no cases of renal insufficiency or allergic reactions in children receiving aprotinin. Three patients had thrombotic episodes: 2 superior vena caval problems and a lower extremity deep venous thrombosis. There were 3 cases of mediastinitis in the aprotinin group versus none in control patients (p < 0.05). CONCLUSIONS We conclude aprotinin is an effective means of reducing bleeding, operating time, and donor exposure in infants and children. An increased rate of thrombosis and possibly mediastinitis are potential problems.

Threshold Current of an Insulated Needle in the Intrathecal Space in Pediatric Patients

A threshold current of <1 mA has been suggested to be sufficient to produce a motor response to electrical stimulation in the intrathecal space. We designed this study to determine the threshold current needed to elicit motor activity for an insulated needle in the intrathecal space. Twenty pediatric patients aged 7.3 ± 3.9 yr scheduled for lumbar puncture were recruited. After sedation with propofol, patients were turned to the lateral position and an 18-gauge or 20-gauge introducer needle was placed at the L4-5 level through which an insulated 24-gauge Pajunck unipolar needle (with a Sprotte tip and stylet) was inserted. The needle was advanced into the intrathecal space as suggested by the presence of a “pop.” At this point, a nerve stimulator was attached to the insulated needle and the current was gradually increased until motor activity was evident. The needle hub was checked for cerebrospinal fluid. If cerebrospinal fluid was not present, the needle was advanced further until cerebrospinal fluid was present. The threshold current was retested. The mean current in the intrathecal space required to elicit a motor response was 0.6 ± 0.3 mA (range, 0.1–1 mA). In 19 patients, the twitches were observed at the L4-5 myotomes and 1 patient had twitches at L2. Twitches were observed unilaterally in 19 children and bilaterally in one child. This confirms the hypothesis that the threshold current in the intrathecal space is <1 mA and that it differs significantly from the threshold currents reported for electrical stimulation in the epidural space.

Adult congenital heart disease

For a decade now, it has been recognized that optimal management of adult congenital heart disease (ACHD) requires a skilled multidisciplinary team. The size and complexity of the population of adults with congenital heart disease (CHD) are increasing. This article reviews the general considerations for giving an anesthetic to an adult with CHD for cardiac or noncardiac surgery and provides further elaboration for a variety of complex patient types. Lastly, the advantages of an organized multidisciplinary approach to patients with ACHD are discussed.

Randomized trial of success of pediatric anesthesiologists learning to use two video laryngoscopes.

The primary purpose of this study was to establish the ability of pediatric anesthesiologists to learn to use two video laryngoscopes ‐ the GlideScope® system (GS) and the Karl Storz Direct Coupled Interface, DCI®, (KS).