Samuel J. Ajizian

Safety profile of multilevel chemical denervation procedures using phenol or botulinum toxin or both in a pediatric population.

Kolaski K, Ajizian SJ, Passmore L, Pasutharnchat N, Koman LA, Smith BP: Safety profile of multilevel chemical denervation procedures using phenol or botulinum toxin or both in a pediatric population. Am J Phys Med Rehabil 2008;87:556–566. Objective:To investigate the safety of single and repeated multilevel injections of botulinum toxin (BoNT) alone or a combination of phenol and BoNT performed under general anesthesia in children with chronic muscle spasticity. Design:Retrospective cohort study. Data from 336 children who received a total of 764 treatments were analyzed. Mean age was 7.4 yrs, and 90% had diagnoses of cerebral palsy. Results:The overall complication rate was 6.8%, similar to rates reported in comparable studies of BoNT alone and combined BoNT and phenol. Of the total number of injection sessions with complications, 1.2% were anesthesia related and 6.3% were injection related; none resulted in any deaths or long-term morbidity. Injection-related complications were most frequently local symptoms of short duration. These were comparable with those reported previously, except that in this series there was a rare occurrence of dysesthesias (0.4%) with phenol injections. Complications occurred more frequently in patients injected with a combination of phenol and BoNT vs. BoNT alone, but no single causal factor can be implicated. No increase in complications with repeat injections was observed, and there was no correlation of complication rates with dosage of either agent. Conclusions:Although these procedures are not without adverse effects, this series suggests that the potential benefits outweigh the risks.

Developing a standard method for apnea testing in the determination of brain death for patients on venoarterial extracorporeal membrane oxygenation: a pediatric case series.

Objective: The revised guidelines for the determination of brain death in infants and children stress that apnea testing is an integral component in determining brain death based on clinical criteria. Unfortunately, these guidelines provide no process for apnea testing during the determination of brain death in patients supported on venoarterial extracorporeal membrane oxygenation. We review three pediatric patients supported on venoarterial extracorporeal membrane oxygenation who underwent apnea testing during their brain death evaluation. This is the only published report to elucidate a reliable, successful method for apnea testing in pediatric patients supported on venoarterial extracorporeal membrane oxygenation. Design: Retrospective case series. Setting: Two tertiary care PICUs in university teaching hospitals. Patients: Three pediatric patients supported by venoarterial extracorporeal membrane oxygenation after cardiopulmonary arrest. Interventions: After neurologic examinations demonstrated cessation of brain function in accordance with current pediatric brain death guidelines, apnea testing was performed on each child while supported on venoarterial extracorporeal membrane oxygenation. Measurements and Main Results: In two of the three cases, the patients remained hemodynamically stable with normal oxygen saturations as venoarterial extracorporeal membrane oxygenation sweep gas was weaned and apnea testing was undertaken. Apnea testing demonstrating no respiratory effort was successfully completed in these two cases. The third patient became hemodynamically unstable, invalidating the apnea test. Conclusions: Apnea testing on venoarterial extracorporeal membrane oxygenation can be successfully undertaken in the evaluation of brain death. We provide a suggested protocol for apnea testing while on venoarterial extracorporeal membrane oxygenation that is consistent with the updated pediatric brain death guidelines. This is the only published report to elucidate a reliable, successful method for apnea testing in pediatric patients supported on venoarterial extracorporeal membrane oxygenation.

Atypical presentation of a mediastinal mass in an adolescent: Critical care considerations.

Objective: To describe the clinical course and treatment of a large mediastinal mass with unusual presentation and critical lower airway compression in an adolescent. Design: Case report. Setting: Pediatric intensive care unit in a tertiary care, academic childrens hospital. Patients: A previously well 15-yr-old boy presented to an outside physician with a 2-mo history of widening of his fingernail beds, progressing within a month of admission to fatigue, weight loss, progressive cough, and dyspnea on exertion. One week before admission, he developed facial swelling, headache, and large neck, chest, and abdomen veins. At the time of admission, he was hypoxic and had a large mediastinal mass with severe lower airway compromise, right-sided atelectasis and pleural effusion, as well as significant right atrial compression on chest computed tomography. Intervention: The patient was placed in the pediatric intensive care unit and underwent emergent tube thoracostomy and drainage of the pleural effusion in the upright position, using a local anesthetic. Results: The patient developed mild reexpansion pulmonary edema with worsening hypoxia, which was managed using bilevel positive airway pressure. Pleural fluid was nondiagnostic, as was bone marrow aspirate and biopsy done in similar fashion on day 2. The patient then underwent a fine-needle biopsy in the operating room, also nonintubated and upright, which diagnosed non-Hodgkins lymphoma, nodular sclerosing type. Treatment for tumor lysis syndrome and chemotherapy were initiated, and he progressively improved. Conclusions: Mediastinal mass with true critical airway and vascular compromise is often discussed but infrequently seen in the pediatric intensive care unit. This case shows not only unusual associated signs of lymphoma (clubbing and caput medusae) but more importantly the rapid identification and thoughtful management of the patients respiratory compromise. This case serves to remind the pediatric intensivist of alternative ways to provide analgesia safely in such patients for lifesaving as well as diagnostic invasive procedures.

Disseminated Mucormycosis in an Adolescent with Newly Diagnosed Diabetes Mellitus

We report a 16-year-old, previously healthy female who presented with disseminated mucormycosis leading to multiorgan failure and death with newly diagnosed type 1 diabetes mellitus and ketoacidosis. We review previous reported cases of mucormycosis in children with diabetes to demonstrate that this uncommon invasive infection may cause significant morbidity and mortality in this population.