Simonetta Baroncini

Blunt Abdominal Trauma: Diagnostic Performance of Contrast-enhanced US in Children—Initial Experience

PURPOSE To prospectively compare the sensitivity and specificity of ultrasonography (US) with those of contrast material-enhanced US in the depiction of solid organ injuries in children with blunt abdominal trauma, with contrast-enhanced computed tomography (CT) as the reference standard. MATERIALS AND METHODS The study protocol was approved by the ethics board, and written informed consent was obtained from parents. US, contrast-enhanced US, and contrast-enhanced CT were performed in 27 consecutive children (19 boys, eight girls; mean age, 8.9 years +/- 2.8 [standard deviation]) with blunt abdominal trauma to determine if solid abdominal organ injuries were present. Sensitivity, specificity, agreement, accuracy, number of lesions correctly identified, and positive and negative predictive values were determined for US and contrast-enhanced US, as compared with contrast-enhanced CT. RESULTS In 15 patients, contrast-enhanced CT findings were negative. Contrast-enhanced CT depicted 14 solid organ injuries in 12 patients. Lesions were in the spleen (n = 7), liver (n = 4), right kidney (n = 1), right adrenal gland (n = 1), and pancreas (n = 1). Contrast-enhanced US depicted 13 of the 14 lesions in 12 patients with positive contrast-enhanced CT findings and no lesions in the patients with negative contrast-enhanced CT findings. Unenhanced US depicted free fluid in two of 15 patients with negative contrast-enhanced CT findings and free fluid, parenchymal lesions, or both in eight of 12 patients with positive contrast-enhanced CT findings. Overall, the diagnostic performance of contrast-enhanced US was better than that of US, as sensitivity, specificity, and positive and negative predictive values were 92.2%, 100%, 100%, and 93.8%, respectively. CONCLUSION Contrast-enhanced US was almost as accurate as contrast-enhanced CT in depicting solid organ injuries in children.

Cardiocirculatory changes during videolaparoscopy in children: an echocardiographic study.

We examined cardiovascular changes associated with intra‐abdominal insufflation in 20 children (mean age 6.1 ± 4.7 years, ASA physical status I or II) undergoing laparoscopic surgery with general anaesthesia using echocardiography with a transthoracic approach. Intra‐abdominal pressure never exceeded 10 mmHg. Systolic blood pressure, diastolic blood pressure, endtidal CO2, peak, and mean airway pressure increased during intra‐abdominal insufflation (P < 0.001). Pneumoperitoneum was associated with increases (P < 0.001) in left ventricular enddiastolic volume, left ventricular end‐systolic volume and left ventricular endsystolic meridional wall stress. In addition, before, during and after intra‐abdominal insufflation, left ventricular fractional shortening and left ventricular ejection fraction, underwent slight, insignificant changes. Pneumoperitoneum in children has a major impact on cardiac volumes and function, mainly through the effect on ventricular load conditions. The sharp increase in intra‐abdominal pressure affects both preload and afterload, while systolic cardiac performance remains unchanged.

A uterine wall defect after uterine artery embolization for symptomatic myomas

Fourteen months after the embolization, she presented with metrorrhagia; a CO2 diagnostic hysteroscopy demonstrated a defect 2 cm wide and 2 cm deep with regular, well-defined borders in the right uterine wall, covered by smooth irregular yellow tissue containing hard yellowish fibroid remnants covered by a film of clear secretion (Figs. 1, 2, 3). The defect was limited to the internal myometrium and did not lead to the peritoneal cavity. It opened into the uterine cavity through a 1.5-cm fistula of endometrium and myometrium. The uterine cavity was regular elsewhere and had a regular mucosa.

Exposure of personnel to sevoflurane during paediatric anaesthesia: influence of professional role and anaesthetic procedure

Background and objective: This study was performed to determine the individual exposure of paediatric operating theatre personnel to sevoflurane and to evaluate the impact of inhalation induction and various airway approaches on exposure to airborne sevoflurane. Methods: Mean individual environmental (workplace air) exposure to sevoflurane and a biomarker of exposure (urinary sevoflurane) were monitored in 36 subjects (10 anaesthetists, 10 surgeons, 12 nurses and 4 auxiliary personnel) working in two paediatric operating rooms. Results: Environmental and urinary values were significantly greater in anaesthetists compared with other groups, with median values of 0.65 ppm (interquartile range 1.36; 95th percentile 4.36) for breathing zone sevoflurane and 2.1 μgL−1 urine (interquartile range 2.6; 95th percentile 7.6) for urinary sevoflurane. Anaesthetists exceeded the 2 ppm maximum allowed environmental concentration recommended by the National Institute for Occupational Safety and Health in 4 of 22 cases (18.1%). A positive correlation was found between the number of patients undergoing inhalational induction each day and mean values of breathing zone and urinary sevoflurane. An increase in the number of daily laryngeal mask insertions, or the use of rigid bronchoscopy, are statistically related to higher environmental and urinary values (P < 0.01 and <0.00001 for breathing zone sevoflurane, P < 0.05 and <0.01 for urinary sevoflurane, respectively). Conclusions: Anaesthesia with sevoflurane can pose a hazard of chronic exposure with anaesthetists having the highest risk. Endotracheal intubation offers considerable protection against exposure. Routine anaesthesia using a standard facemask, a laryngeal mask or rigid bronchoscopy are risk factors for increased anaesthetic exposure.

Latex allergy in children with oesophageal atresia

Background: Latex allergy is frequently found in children and patients with spina bifida and urogenital abnormalities and have been considered at risk for latex sensitization. The aim of the study was to evaluate the incidence of latex sensitization in patients with oesophageal atresia and undergoing three or more surgical procedures and to identify possible risk factors in the process of latex sensitization.

Neurally adjusted ventilatory assist in weaning of neonates affected by congenital diaphragmatic hernia

Objective: The aim of the study is to evaluate the application of neurally adjusted ventilatory assist (NAVA) in the respiratory weaning of patients affected by congenital diaphragmatic hernia (CDH). Methods: We analyzed the NAVA weaning in 12 neonates affected by CDH, relating the effectiveness of the electrical activation of the diaphragm (EAdi) signal to the type of CDH repair (with or without patch), the size of the patch, the stomach and His angle position, and the trend evaluation of some cardiorespiratory parameters with NAVA compared to pressure-support-ventilation (PSV). Results: 5 neonates submitted to primary repair showed a regular EAdi signal and were successfully weaned with NAVA. Of the seven patients submitted to patch repair, five operated with patch limited to the diaphragmatic postero-lateral area had an active EAdi signal that permitted weaning with NAVA. Only in two neonates with hemidiaphragm agenesis was NAVA not feasible due to the impossibility to capture the EAdi signal. Compared to PSV, NAVA allows a significant improvement of oxygenation-linked indexes and paCO2, while PIP is reduced. Conclusion: Neonatal CDH with a postero-lateral diaphragmatic defect allows the NAVA catheter to obtain a correct EAdi signal and develop a viable NAVA ventilation. The lower risk of lung injury in NAVA appears compatible with current ventilatory strategies considered useful in CDH.

Effects of sympathetic blockade on the efficiency of forced-air warming during combined spinal-epidural anesthesia for total hip arthroplasty.

STUDY OBJECTIVE To evaluate if active cutaneous warming of the two upper limbs with reflex vasoconstriction is less effective in maintaining intraoperative normothermia than warming the vasodilated unoperated lower limb during combined spinal-epidural anesthesia (CSE). DESIGN Prospective, randomized study. SETTING Inpatient anesthesia at university departments of orthopedic surgery. PATIENTS 48 ASA physical status I, II, and III patients, who were scheduled for elective total hip arthroplasty. INTERVENTIONS Patients received CSE with intrathecal injection of 15 mg of 0.5% hyperbaric bupivacaine. All procedures started 8 to 10 AM, and operating room temperature was maintained between 21 degrees and 23 degrees C, with relative humidity ranging between 40% and 45%. For warming therapy, patients received active forced-air warming of either the two upper limbs (Group Upper body, n = 24), or the unoperated lower limb (Group Lower extremity, n = 24). Core temperature was measured before CSE placement (baseline), and then every 30 minutes until completion of surgery. Time for fulfillment of clinical discharging criteria from the recovery area was evaluated by a blinded observer. MEASUREMENTS AND MAIN RESULTS Demographic data, duration of surgery, intraoperative blood losses, crystalloid infusion, and hemodynamic variables were similar in the two groups. Core temperature slightly decreased in both groups, but at the end of surgery the mean core temperature was 36.2 degrees +/- 0.5 degree C in Group Upper body and 36.3 +/- 0.5 in Group Lower extremity (NS). At recovery room arrival, seven patients in Group Upper body (29%) and three patients in Group Lower extremity (12.5%) had a core temperature less than 36 degrees C (NS). Shivering was observed in one patient in Group Upper body and in two patients in Group Lower extremity (NS). Clinical discharging criteria were fulfilled after 37 +/- 16 minutes in Group Upper body and 30 +/- 32 minutes in Group Lower extremity (NS). CONCLUSIONS Forced-air cutaneous warming allows the anesthesiologist to maintain normothermia during CSE for total hip replacement even if the convective blanket is placed on a relatively small skin surface with reflex vasoconstriction. Placing the forced-air warming system on the vasodilated unoperated lower limb may be troublesome to the surgeons and does not offer clinically relevant advantages in warming efficiency.

Diagnosis of congenital myasthenic syndrome with mutation of the RAPSN gene after general anaesthesia.

Editor, In congenital myasthenia syndrome (CMS), a genetic defect causes a disruption of the neuromuscular transmission. Symptoms start perinatally or in the first years of life and consist mainly of bilateral ptosis, dysarthria, weak cry, feeding difficulties and muscle weakness accentuated by exertion. Diaphragmatic involvement may eventually lead to respiratory failure. Reflexes and sensibility are generally unchanged.

Complex double-outlet right ventricle repair in a neonate with complete tracheal agenesis

underline the relative greater frequency of this complication in heterotaxy syndrome when associated with anomalous pulmonary and systemic venous connections, which can make surgical repair complicated with the need to create a tortuous and potentially obstructive pathway. Despite this concern, a recent report from our institution 5 has shown excellent outcome with cavopulmonary connection in patients with heterotaxy syndrome and anomalous pulmonary venous return. This is likely due to improved surgical technique and use of extracardiac conduit in cases with complex atrial and venous anatomy (18%). None of the 3 patients had evidence of obstruction at the pulmonary venous pathway early after the Fontan procedure, as determined by 2-dimensional echocardiography. Pulmonary venous obstruction developed slowly through a period of several months to years. In patient 2, pulmonary venous obstruction developed 4 months after device closure of the fenestration, suggesting that the additional scarring from device implantation contributed to the obstruction. The obstruction was due to fibrotic tissue at either the interatrial septum or in the interatrial course of the pulmonary veins (patient 2). To prevent this complication, and to ensure a wide open pulmonary venous outflow, particularly in patients with mitral atresia or stenosis, we currently enlarge the communication between the pulmonary veins and the right atrium by unroofing the coronary sinus posteriorly into the left atrium, in addition to resection of the interatrial septum. In conclusion, late onset obstruction of pulmonary venous pathway after lateral tunnel cavopulmonary connection is a rare but serious complication that may be prevented by unroofing the coronary sinus at the time of Fontan procedure.

Severe withdrawal syndrome in three newborns subjected to continuous opioid infusion and seizure activity dependent on brain hypoxia--ischemia. A possible link.

Background : The aim of this investigation was to verify whether brain hypoxia represented a risk factor for the occurrence and severity of opioid abstinence syndrome.