Robert Steelman

Analgesia for pediatric thoracostomy tube removal

Eutectic mixture of local anesthetics (EMLA®; Astra Pharmaceuticals, Wayne, PA) has been shown to reduce the pain of blood draws in children. We investigated the use of EMLA® versus IV morphine for providing analgesia during chest tube removal (CTR) in children. One hundred twenty pediatric cardiothoracic surgery patients were enrolled. Patients were randomly assigned to receive either morphine (0.1 mg/kg up to 10 mg IV 30 min before CTR) or EMLA® cream (5 g per chest tube cutaneously 3 h before CTR). A single, trained observer rated the patient’s pain before, during, and after CTR using a 10-cm visual analog scale. The sites were evaluated for adverse effect. Methylhe-moglobin levels were monitored in infants. Before CTR, the pain scores of the children who received morphine were rated lower than those who received EMLA® (P < 0.01). During CTR, there was no difference in the pain score between the morphine or EMLA® group. The change from baseline pain score in the morphine group was significantly larger than in the EMLA® group (P < 0.01). We conclude that EMLA® is safe and useful for blunting the pain of CTR. Implications Chest tube removal is one of the most painful parts of the cardiothoracic surgical experience. This study compared EMLA® (Astra Pharmaceuticals, Wayne, PA) >

Nalmefene to Prevent Epidural Narcotic Side Effects in Pediatric Patients: A Pharmacokinetic and Safety Study

Study Objective. To determine the pharmacokinetics and preliminary efficacy of nalmefene in children in preventing epidural‐induced narcotic side effects.

Rapid Physical Assessment of the Injured Child

Traumatic injuries that involve the dentition and maxillofacial region may occur as isolated events in pediatric patients but are often associated with multisystem injuries and traumatic brain injuries. The primary trauma survey serves to identify and treat life-threatening injuries. The secondary trauma survey is a complete examination of the patient after the stabilization of physiological parameters. Frequent neurologic and physical assessments of the injured child are crucial to preventing deterioration. The role of the dental professional is to identify and refer for medical evaluation patients who present with concerning neurologic signs and symptoms after traumatic injuries to the maxillofacial region.

Aspiration of a Tooth in a Patient with a Tracheostomy

To the editor: Tympanocentesis is the standard diagnostic procedure for evaluating the efficacy of antibiotic therapy for otitis media. It provides a sample for identification of the pathogen and for measurement of antibiotic concentration in the middle-ear effusion. Tympanocentesis is also therapeutic. The aspiration of infected material assists the middle ear in clearing purulent exudate and facilitates antibiotic efficacy by reducing the sheer number of microorganisms in the effusion. Studies of otitis media therapy do not routinely compare children who have tympanocentesis with children who do not undergo this procedure. The standard care of treatment for otitis media is antibiotic therapy and not tympanocentesis. Studies in which tympanocentesis is routinely performed create artificial results not truly representing the results in general practice where tympanocentesis is not performed. Some pediatric practitioners routinely perform tympanocentesis. However, even though most of us have performed tympanocentesis in residency or fellowship, we do not routinely perform this procedure in general practice. This is because of the potential complications that may occur and it may be more the standard of care for the otolaryngologist to perform this procedure. Depending on the medical community, otolaryngologists may not be eager to perform the procedure in their office, but rather in outpatient surgery, making it less likely tympanocentesis would be performed away from an academic setting. In the environment of managed health care even fewer diagnostic and therapeutic tympanocenteses will be performed.

The Dicrotic Pulse: A Common, Non-Ominous Finding After the Ross Operation

We noted a dicrotic pulse in several patients following a Ross operation. Although the etiology of this unique arterial waveform is not completely understood, it has been reported as a sign of low cardiac output and a poor prognosis. We reviewed preoperative echocardiograms and postoperative radial arterial pressure tracings in 33 patients who underwent a Ross procedure between 2000 and 2004. We found a dicrotic pulse to occur commonly (20/33; 61%) following a Ross operation. Moderate to severe preoperative aortic insufficiency was present in 19/20 patients (95%) in whom a dicrotic pulse was noted and in only 3/13 (23%) who did not exhibit a postoperative dicrotic pulse (p < 0.001). A dicrotic pulse was not associated with an increased use of vasoactive infusions or longer hospitalization following the Ross operation. The dicrotic pulse should be recognized as a common postoperative finding in Ross patients that does not herald a delayed postoperative convalescence. The mechanism for a dicrotic pulse in these patients is speculative but may result from changes in vascular compliance secondary to chronic aortic insufficiency.

INABILITY TO ALKALINIZE URINE IN A PATIENT AT RISK FOR TUMOR LYSIS SYNDROME: A Case Report

This report provides a description and discussion of a 19-year-old, 65-kg male, with a large mediastinal mass, right pleural effusion, and pericardial effusion, requiring urine alkalinization during a propofol infusion. The patient required NaHCO3 boluses, urine pH, electrolyte, arterial blood gas and lactate monitoring, and discontinuation of the propofol. The authors suggest that caution be used when prescribing a propofol infusion for patients who are at risk of tumor lysis syndrome and the need for urine alkalinization.