Roland N. Kaddoum

A randomized controlled trial comparing the AccuVein AV300 device to standard insertion technique for intravenous cannulation of anesthetized children

Objectives and Aims:  To evaluate the efficacy of the AccuVein AV300 device in improving the first‐time success rate of intravenous cannulation of anesthetized pediatric patients.

The effect of adjuvant drugs on the quality of tracheal intubation without muscle relaxants in children: a systematic review of randomized trials

Intubation without prior administration of muscle relaxants is a common practice in children. However, succinylcholine may be considered as the golden standard for optimizing intubating conditions. We conducted a systematic review of the literature to identify drug combinations that included induction of anesthesia with sevoflurane or propofol. Our aim was to select drug combinations that yield excellent intubating conditions ≥80%; we identified six combinations in children aged 1–9 years. Sevoflurane with remifentanil (1 or 2 μg·kg−1), lidocaine (2 mg·kg−1), or propofol (2 mg·kg−1) as the adjuvant shared the following characteristics: premedication with midazolam and/or ketamine, long sevoflurane exposure time, high inspired and endtidal sevoflurane concentration, and assisted ventilation. One combination using sevoflurane with propofol (3 mg·kg−1) without premedication, with shorter sevoflurane exposure time, and spontaneous breathing indicated that propofol may be the adjuvant of choice for a rapid sevoflurane induction. The only adjuvant identified in propofol induction was remifentanil (4 μg·kg−1). No serious adverse events were reported with these combinations.

Prophylactic methylene blue in a patient with congenital methemoglobinemia.

PurposeTo report the beneficial effect of prophylactic methylene blue administration before induction of anesthesia in a patient with congenital methemoglobinemia.Clinical featuresA 26-yr-old male patient known to have congenital methemoglobinemia was scheduled forturbinectomy under general anesthesia. The patient was clinically cyanotic with a pulse oximetry of 91 %. Arterial blood gas analysis showed a partial pressure of oxygen (PaO2) of 81.3 mmHg associated with a fractional oxyhemoglobin of 80.7%, and a methemoglobin fraction of 0.159. Preoperativeiv administration of 1 mg·kg-1 of methylene blue resulted, within five minutes, in a decrease of methemoglobin fraction down to 0.05 associated with an increase of the fractional oxyhemoglobin saturation up to 94.7%. After two hours, the methemoglobin fraction decreased to 0.01 and the fractional oxyhemoglobin concentration increased to 97.7%. Induction of anesthesia as well as intraoperative and postoperative course were uneventful without any episode of hypoxemia. Postoperatively, the methemoglobin fractions remained low for 24 hr, to be followed by a gradual increase up to 0.02 on the second day to reach 0.094 on the fifth day.ConclusionThe prophylactic preoperative methylene blue administration in a patient with congenital methemoglobinemia significantly decreased the methemoglobin level and increased the fractional oxygen saturation with a consequent increase of the safety margin against perioperative hypoxemia.RésuméObjectifSignaler l’effet bénéfique de l’administration prophylactique de bleu de méthylène avant l’induction de l’anesthésie chez un patient atteint de méthémoglobinémie congénitale.Éléments cliniquesUn homme de 26 ans atteint de méthémoglobinémie congénitale devait subir une turbinectomie sous anesthésie générale. Le patient était cyanosé et présentait une sphygmo- oxymétrie de 91 %. L’analyse des gaz artériels a montré une pression partielle d’oxygène (PaO2) de 81,3 mmHg associée à une oxyhémo- globine fractionnelle de 80,7 % et à une fraction de méthémoglobine de 0,159. L’administration iv préopératoire de 1 mg·kg-1 de bleu de méthylène a donné, en moins de cinq minutes, une baisse de la frac- tion de méthémoglobine jusqu’à 0,05, et une hausse de la saturation d’oxyhémoglobine fractionnelle jusqu’à 94,7 %. Après deux heures, la fraction de méthémoglobine a baissé à 0,01 et la concentration d’oxy- hémoglobine fractionnelle a augmenté à 97,7 %. L’induction de l’anesthésie et l’évolution peropératoire et postopératoire ont été sans incident et sans épisode d’hypoxémie. Après l’opération, les fractions de méthémoglobine sont demeurées basses pendant 24 h et ont été suivies d’une hausse graduelle jusqu’à 0,02 le deuxième jour et 0,094 le cinquième jour.Conclusion : L’administrationprophylactique préopératoire de bleu de méthylène chez un patient atteint de méthémoglobinémie con-génitale a significativement réduit le niveau de méthémoglobine et augmenté la saturation en oxygène fractionnée, ce qui a augmenté la marge de sécurité contre l’hypoxémie périopératoire.PURPOSE To report the beneficial effect of prophylactic methylene blue administration before induction of anesthesia in a patient with congenital methemoglobinemia. CLINICAL FEATURES A 26-yr-old male patient known to have congenital methemoglobinemia was scheduled for turbinectomy under general anesthesia. The patient was clinically cyanotic with a pulse oximetry of 91%. Arterial blood gas analysis showed a partial pressure of oxygen (PaO(2)) of 81.3 mmHg associated with a fractional oxyhemoglobin of 80.7%, and a methemoglobin fraction of 0.159. Preoperative iv administration of 1 mg.kg(-1) of methylene blue resulted, within five minutes, in a decrease of methemoglobin fraction down to 0.05 associated with an increase of the fractional oxyhemoglobin saturation up to 94.7%. After two hours, the methemoglobin fraction decreased to 0.01 and the fractional oxyhemoglobin concentration increased to 97.7%. Induction of anesthesia as well as intraoperative and postoperative course were uneventful without any episode of hypoxemia. Postoperatively, the methemoglobin fractions remained low for 24 hr, to be followed by a gradual increase up to 0.02 on the second day to reach 0.094 on the fifth day. CONCLUSION The prophylactic preoperative methylene blue administration in a patient with congenital methemoglobinemia significantly decreased the methemoglobin level and increased the fractional oxygen saturation with a consequent increase of the safety margin against perioperative hypoxemia.

Phantom limb pain in young cancer-related amputees: recent experience at St Jude children's research hospital.

Objectives:This study in children and young adults having cancer-related amputation aimed to examine the incidence of phantom limb pain (PLP) in the first year after amputation and also the proportion of patients who had preamputation pain. Methods:A retrospective review of medical records was undertaken. The proportion of patients with PLP was reported. Fisher exact test was used to examine the association between PLP and the presence of preamputation pain and between PLP and age (⩽18 y vs. >18 y). Results:Twenty-six amputations were performed on 25 patients. During the year after amputation, 76% of patients had experienced PLP at some time. After 1 year, though, only 10% still had PLP. Preamputation pain was present in 64% of patients. Although both of our patients with PLP at 1 year were young adults (older than or equal to 18 y) and both had preamputation pain, we found no statistically significant associations between age or the presence of preamputation pain with PLP. Discussion:PLP after cancer-related amputation in children and young adults seems to be common but generally short lived in most patients.

The effect of adjuvant drugs on the quality of tracheal intubation without muscle relaxants in children: A systematic review of randomized trials

Intubation without prior administration of muscle relaxants is a common practice in children. However, succinylcholine may be considered as the golden standard for optimizing intubating conditions. We conducted a systematic review of the literature to identify drug combinations that included induction of anesthesia with sevoflurane or propofol. Our aim was to select drug combinations that yield excellent intubating conditions ≥80%; we identified six combinations in children aged 1–9 years. Sevoflurane with remifentanil (1 or 2 μg·kg−1), lidocaine (2 mg·kg−1), or propofol (2 mg·kg−1) as the adjuvant shared the following characteristics: premedication with midazolam and/or ketamine, long sevoflurane exposure time, high inspired and endtidal sevoflurane concentration, and assisted ventilation. One combination using sevoflurane with propofol (3 mg·kg−1) without premedication, with shorter sevoflurane exposure time, and spontaneous breathing indicated that propofol may be the adjuvant of choice for a rapid sevoflurane induction. The only adjuvant identified in propofol induction was remifentanil (4 μg·kg−1). No serious adverse events were reported with these combinations.

Improving Hospital Discharge Time: A successful Implementation of Six Sigma Methodology

AbstractDelays in discharging patients can impact hospital and emergency department (ED) throughput. The discharge process is complex and involves setting specific challenges that limit generalizability of solutions.The aim of this study was to assess the effectiveness of using Six Sigma methods to improve the patient discharge process.This is a quantitative pre and post-intervention study.Three hundred and eighty-six bed tertiary care hospital.A series of Six Sigma driven interventions over a 10-month period.The primary outcome was discharge time (time from discharge order to patient leaving the room). Secondary outcome measures included percent of patients whose discharge order was written before noon, percent of patients leaving the room by noon, hospital length of stay (LOS), and LOS of admitted ED patients.Discharge time decreased by 22.7% from 2.2 hours during the preintervention period to 1.7 hours post-intervention (P < 0.001). A greater proportion of patients left their room before noon in the postintervention period (P < 0.001), though there was no statistical difference in before noon discharge. Hospital LOS dropped from 3.4 to 3.1 days postintervention (P < 0.001). ED mean LOS of patients admitted to the hospital was significantly lower in the postintervention period (6.9 ± 7.8 vs 5.9 ± 7.7 hours; P < 0.001).Six Sigma methodology can be an effective change management tool to improve discharge time. The focus of institutions aspiring to tackle delays in the discharge process should be on adopting the core principles of Six Sigma rather than specific interventions that may be institution-specific.

Methemoglobinemia after a Blast Injury

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Femoral arterial cannulation performed by residents: a comparison between ultrasound-guided and palpation technique in infants and children undergoing cardiac surgery

Percutaneous cannulation of the femoral artery in the pediatric age group can be technically challenging, especially when performed by residents in training.

Acute Opioid Withdrawal Precipitated by Blood Transfusion in a 21-Year-Old Male

relationship between the night fall in PaO2 and night fall in SaO2 was such that, across a range of values of PaO2, the change in SaO2 was generally greater for the group with nocturnal hypoxemia, which had lower day SaO2 levels (Fig. 1b). In conclusion, a sleep-related reduction in ventilation could be sufficient to explain the falls in night PaO2 and SaO2 seen in patients with cancer, with those with a lower day SaO2 level more likely to experience a degree of nocturnal hypoxemia associated with impaired mental functioning. Further work, including more detailed sleep studies, is required to confirm our findings.