Swati Patel

Airway evaluation of conjoined twins.

Case reports in the literature on conjoined twins discuss the difficulties with anesthesia and surgical separation; however, the role of airway endoscopy as a means of evaluating the respiratory tract has not been described. This case of thoraco-omphaloischiopagus laterally conjoined twins demonstrates the importance of videoendoscopic airway evaluation in the management of conjoined twins. Direct laryngoscopy and bronchoscopy was used to evaluate ventilator dependence and demonstrated tracheal anomalies that were partially responsible for difficulties with weaning and endotracheal tube placement. Knowledge of the airway anomalies assisted in ventilator management of the twins, and the neonatalogists were able to proceed with greater confidence because no surgically correctable airway obstruction was found. Direct laryngoscopy and bronchoscopy offer valuable information about thoracopagus conjoined twins and should be included in the preoperative evaluation of planned separation of conjoined twins, as well as being used for conjoined twins who are ventilator-dependent.

Radiation therapy in children.

With the growing role of radiotherapy (XRT) in treatment of pediatric malignancies, and its improved precision requiring a reproducible, immobile position for daily treatment, the demand for sedation and anesthesia in radiation therapy suites is increasing. Malignancies commonly treated with radiation therapy include those that require whole body irradiation such as leukemia, before bone marrow transplant, and those that may require a very specific focus of radiation to avoid normal tissue damage such as medulloblastoma and retinoblastoma. For these types of tumors (and the many other solid tumors treated with radiation therapy) even a small amount of patient movement may undermine techniques for sparing vital, normal tissue function and diminishes therapeutic efficacy. In this chapter, we will briefly describe the most common types of radiotherapy and the anesthetic implications of caring for these patients.

CMR in pediatric patients with congenital heart disease: comparison at 1.5T and at 3.0T

Author(s): Nguyen, Kim-Lien; Khan, Sarah; Moriarty, John; Mohajer, Kiyarash; Renella, Pierangelo; Satou, Gary; Ayad, Ihab; Patel, Swati; Boechat, Ines; Finn, J

Contrast enhanced magnetic resonance angiography in children: initial experience at 3.0 Tesla

Background To assess the role of contrast enhanced magnetic resonance angiography (CEMRA) at 3.0T in pediatric patients referred for vascular evaluation, and to compare the technical and diagnostic performance of a clinically similar control group at 1.5T. Methods Fifty pediatric patients referred for vascular evaluation and without evidence of congenital heart disease, were evaluated with CEMRA. Thirty-five patients received 37 studies at 3.0T (age 0.4 -16.5 years, mean 5.8 ± 4.7 years. Fifteen patients received 16 studies at 1.5T (age 0.1 - 17.5 years, mean 5.8 ± 6.4 years). CEMRA was performed in three phases: arterial, early venous and late venous. Two independent observers analyzed the studies for image quality, artifacts and vessel definition. Results Overall image quality and vessel definition scores were higher at 3.0T than 1.5T in the arterial and early venous phase, however not the late venous phase. Overall

CEMRA in neonatal and pediatric congenital vascular diseases at 1.5T and 3.0T: comparison of an intravascular contrast agent (Gadofosveset) with an extracellular agent (Gadopentetate Dimeglumine)

Background The comparison of gadofosveset (Ablavar, Lantheus Medical) at a dose of 0.06 mmol /kg with gadopentetate dimeglumine (Magnevist, Bayer-Schering Inc.) at a dose of 0.2 mmol /kg for CEMRA in pediatric patients with complex congenital heart disease (CCHD) at 1.5T and 3.0T. Methods Twenty-eight pediatric patients with CCHD underwent CEMRA at 3.0T (n=16) or at 1.5T (n=12). Sixteen patients were imaged with gadofosveset; 9 at 3.0T (age 1.00 ± 1.58 months; weight 2.38 ± 1.13 kg) and 7 at 1.5T (age 8.00 ± 7.83 months; weight 5.06 ± 3.09 kg). Twelve patients were imaged with gadopentetate; 7 at 3.0T (age 1.00 ± 1.41 months; weight 3.02 ± 1.59 kg) and 5 at 1.5T (age 6.60 ± 8.62 months; weight 5.23 ± 2.93 kg). High resolution CEMRA was performed in two phases with strictly comparable imaging parameters, acquisition times and contrast agent infusion periods. Two independent observers scored the studies blindly on a four point scale for image quality, artifacts and vessel definition. Results At 3.0T, overall image quality (IQ) was good to excellent (3<=IQ<=4) in all patients and similar for gadofosveset and gadopentate. At 1.5T, IQ was also good to excellent, but higher for gadofosveset than gadopentetate. Cardiac motion or pulsation artifact was found in all studies at both field strengths but appeared more severe at 3.0T than 1.5T. Parallel acquisition artifact was noted in all studies at 3.0T, but in no studies at 1.5T. Vessel definition scores were higher for gadofosveset at both field strengths and both contrast phases, but lower for gadopentetate in the venous phase at 3.0T and in both phases at 1.5T. SNR and CNR was higher at 3.0T than 1.5T in the aortic arch, pulmonary artery, inferior vena cava and superior vena cava. SNR and CNR was higher for gadofosveset than gadopentetate during the arterial phase in the aortic arch and pulmonary artery. Conclusions

Cardiac MR imaging and MR angiography in pediatric congenital heart disease: a comparison between 1.5T and 3.0T

Author(s): Nguyen, KL; Khan, SN; Moriarty, J; Mohajer, K; Renella, P; Satou, G; Ayad, I; Patel, S; Boechat, I; Finn, P

Changing Health Care Providers’ Behavior During Pediatric Inductions With an Empirically Based Intervention

COMMENT Advances in medical technology and drug development have revolutionized the practice of anesthesiology during the last 30 years. The importance of pulse oximetry, modern anesthesia machines, and drugs with predictable pharmacology is sometimes overlooked as we enter the next phase of pharmacogenomics and applied pharmacology. In the current era, we administer drugs based on total body weight, although lean body LBM may represent a more accurate means of drug dosing. The current authors previously published methods for deriving LBM from height and weight using elegantly simple formulas (from Boer). Here, Peters et al estimate LBM based on theoretical formulas (eLBM = 3.8 eECVe and eECV = 0.0215 W0.6469 H0.7236) and compare results to empirical data obtained from children and adults. The authors conclude that the theoretical formulas agree with the empirical data for both adults and children (mean ratio of 1.04 for children with an SD of 0.18). The authors have validated a simple method for calculating LBM from height and weight. However, these calculations assume that the linear relationship between ECV and LBM for adults holds true for children. This is quite a big step, if not a leap. Although these relationships may hold true for young children and adolescents, they may prove challenging in neonatal populations with unusual relationships between ECV, weight, and height. The current study provides a simple means for calculating LBM from height and weight that should be studied in neonatal and young infant populations.

Setting up for pediatric offsite anesthesiology.

The role of anesthesiologists is ever evolving to include an increasing presence in intensive care and a greater demand for our services in nonoperating-room settings. Improved diagnostic imaging technology and a trend toward minimally invasive therapies have pulled pediatric anesthesiologists to many corners of the hospital not ventured into before. These unfamiliar ‘‘offsite’’ areas lend themselves to unique challenges to the anesthesiologist, and proper preparation is key in safely caring for these patients. Although in some hospitals critical care and emergency room physicians provide sedation services for many of these procedures, as demand increases anesthesiologists are asked to provide sedation more frequently. Furthermore, several years ago the Joint Commission of Accreditation of Health Care Organization (JCAHO) reviewed hospital sedation practices in response to increasing adverse events, and mandated practice standards that were to be made uniform throughout the hospital. Some institutions met these standards by asking anesthesiologists to provide all sedations, whereas others continue to have intensivists and emergency room physicians provide sedation with practice standards in review by anesthesiology. Most institutions are a hybrid of these, and as such it is important for all physicians providing sedation to be aware of the latest practice guidelines and to ensure compliance.