Timothy E. Smith

Surgical advancement influences perioperative care: A comparison of two surgical techniques for sagittal craniosynostosis repair

Methods for surgical correction of sagittal craniosynostosis have progressed. The hypothesis is that advances in surgical interventions for craniosynostosis affect perioperative anesthetic care. We reviewed the records of eight children who underwent cranial vault reconstruction (CVR) and nine who underwent spring-mediated cranial expansion (SME) for sagittal craniosynostosis. We compared the data from the CVR procedure to data from the combined procedures for SME (insertion and removal of springs). Anesthesia times were similar between the CVR (4 h 24 min) and the combined SME (4 h 27 min) groups, whereas surgical times were different between the CVR (3 h 25 min) and combined SME groups (2 h 21 min) (P = 0.002). Length of stay was 4.1 days for the CVR group (confidence interval [CI], 3.8–4.4 days) versus 3.1 days (CI, 2.9–3.4 days) in the combined SME group (P = 0.0001). Blood loss was significantly less in the combined SME group at 48 mL (CI, 29–83 mL) compared with the CVR group at 291 mL (CI, 230–352 mL). All eight patients in the CVR group received blood with a mean of 1.4 U (range, 1–2 U). No SME patient received any blood products. The reduction in blood loss with this new surgical treatment is significant for the patient in reducing blood transfusion and for the anesthesiologist in reducing concerns of volume resuscitation.

Better for some, maybe not for all: a response to preemptive transfusion and infusion strategy in children during craniofacial reconstruction.

SIR—We read with interest the presentation by Cortellazzi et al. on an early preemptive transfusion (hemoglobin independent) and infusion (EPTI) strategy (1). Their attempts at trying to evaluate quality of patient outcome and anesthetic and surgical management in the pediatric population undergoing craniofacial reconstructive surgery is laudable. Management of anesthetic care of small children during procedures with the possibility of large volume blood loss is difficult and complex. Determination of the amount and rate of blood loss at any given moment is difficult and further complicated by the amount and type of fluid replacement to maintain adequate circulatory volume and hematocrit simultaneously as discussed by Cortellazi. Certainly, one method is to replace all volume loss with appropriate proportions of blood and crystalloid and colloid to maintain hematocrit. This is a reasonable strategy, commonly employed in circumstances where the exposure to blood products is inevitable. However, the stated EPTI strategy was developed from a ‘group of earlier cranioplasties’ and based on the fact that 50% of patients had intraoperative blood loss of >20% of estimated red cell volume (ERCV). The strategy as explained automatically proceeds with transfusion of 20% ERCV at the beginning of the surgery. If 50% of the cases had intraoperative losses of >20% ERCV, then 50% of the cases had blood loss of <20% ERCV. In addition, this strategy was implemented and followed without any stated regard for the starting hematocrit in these children. In fact, in the control (CONT) group, only 22 out of 25 children received blood transfusion. This suggests that 12% of the 34 cases (four children) in the EPTI strategy would not have received blood product transfusion had they not been in the EPTI group. Our concern about this blanket approach is that exposure to blood products is not without risk. Many different complications can occur related to blood product transfusion including exposure to infectious agents and ranging from mild to life-threatening transfusion reactions (2). Great efforts have been made throughout the craniofacial team community to reduce the risks of the procedures through both development of novel surgical techniques as well as blood conservation or sparing interventions (3–5). Efforts to reduce blood exposure in craniofacial reconstructive procedures in children have ranged from preoperative erythropoietin and autologous donation to cell saver and use of antifibrinolytic agents. Surgical advancement has resulted in less invasive surgeries to avoid cranial vault remodeling for scaphocephaly (6,7). The majority of the cases reported in the series by Cortellazzi et al. were for correction of scaphocephaly. Through less invasive procedures, the impact of the anesthetic management has been drastically altered from the traditional cranial vault reconstruction procedure (4). This includes less blood loss, less invasive monitoring requirement, and reduced hospital times. We currently have provided anesthesia for over 100 cases of scaphocephaly (sagittal suture synostosis) correction using the spring-mediated expansion technique. At present, none of the patients required intraoperative transfusion as a result of blood loss during the procedure. Additionally, the children have no need for intensive care unit management postoperatively with an average hospital stay of 36 h. Using a blanket transfusion protocol may have resulted in all of these children being exposed to blood products and the inherent risks. We feel it is critical to continue to provide safe and optimal anesthetic care to all children undergoing craniofacial reconstruction. Adequate oxygencarrying capacity through adequate red cell mass, despite ongoing surgical blood loss, is imperative to assure adequate oxygen delivery and reduce complications. This is eloquently addressed in the quality improvement study by Cortellazzi et al., whereby maintaining adequate red cell mass improved postoperative recovery. However, we feel that caution is to be used in use of protocols that may expose patients to risks that would otherwise not be incurred. Furthermore, continued efforts at reducing blood and blood product exposure in children are mandatory to reduce or prevent life-long effects from exposure to blood products. Differences in the patient, the procedure, the surgeon and even the anesthesiologist should be taken into consideration when deciding the best approach to blood loss and transfusion. D O U G L A S G. R I R I E* T I M O T H Y E. S M I T H* L I S A R. D A V I D† L O U I S C. A R G E N T A† *Department of Anesthesiology †Department of Plastic and Reconstructive Surgery, Wake Forest University School of Medicine and Brenner Children’s Hospital, Winston-Salem, NC, USA (email: dririe@wfubmc.edu) Pediatric Anesthesia 2010 20: 574–583

Time-dependent perioperative anesthetic management and outcomes of the first 100 consecutive cases of spring-assisted surgery for sagittal craniosynostosis.

Background:  The anesthetic risks and outcomes of the first 100 consecutive spring‐assisted surgeries (SAS) for cranial expansion from a single institution are reported. The effect of number of procedures was also tested on hematocrit postoperative day 1 (POD1), anesthesia time, and surgery time of the first procedure.

Routine inhaled induction in adults: a safe practice?

7. European Medicines Evaluation Agency public statement on parecoxib sodium (dynastat, rayzon, xapit): risk of serious hypersensitivity and skin reactions. EMEA/ 25175/02, October 22, 2002. Available at http://www.emea.eu.int/pdfs/human/ press/pus/2517502en.pdf. 8. European Medicines Evaluation Agency public statement on valdecoxib (bextra/ valdyn) and parecoxib sodium (dynastat/rayzon). EMEA/204802/04, December 15, 2004. Available at http://www.emea.eu.int/pdfs/human/press/pus/20480204en. pdf. 9. Rudic RD, Brinster D, Cheng Y, et al. COX-2 derived prostacyclin modulates vascular remodeling. Circ Res 2005 May 19 [Epub ahead of print]. 10. Stiller CO, Hjemdahl P. Endothelial COX-2 inhibition: possible relevance for hypertension and cardiovascular risk? J Hypertension 2003;21:1615–8. 11. Egan KM, Lawson JA, Fries S, et al. Cyclooxygenase-2-derived prostacyclin confers atheroprotection on female mice. Obstet Gynecol Surv 2005;60:309–10.

Pulmonary Vein Widening Plasty for Pulmonary Vein Stenosis and Occlusion After Catheter Ablation

We successfully performed a pulmonary vein widening plasty in a patient with pulmonary vein stenosis and occlusion after multiple catheter ablations for paroxysmal atrial fibrillation.

Thoracoscopic left atrial appendage clipping as novel treatment option for peri-device leakage

Athin a M. Kougioumtzoglou, Tim Smith, Martin J. Swaans, Lucas V.A. Boersma, and Bart P. van Putte* Department of Cardiothoracic Surgery, St. Antonius Hospital, PO Box 2500, 3435 CM Nieuwegein, The Netherlands; Department of Cardiology, St. Antonius Hospital, PO Box 2500, 3435 CM Nieuwegein, The Netherlands; and Department of Cardiothoracic Surgery, Academic Medical Center, PO Box 22660, 1100 DD Amsterdam, The Netherlands * Corresponding author. Tel: 131 088 320 11 80; fax: 131 088 320 11 96. E-mail address: b.van.putte@antoniusziekenhuis.nl

Transapical paravalvular leakage closure in high surgical risk patients: procedural outcomes and mortality

Purpose: Significant periprosthetic paravalvular leak (PVL) can have serious clinical consequences. Initially, reoperation was the only solution with a high mortality rate. Recently, efforts for transcatheter closure have been made. We evaluate the feasibility and safety of transcatheter device PVL closure using a transapical approach in a consecutive series of high-risk surgical patients. Methods: All consecutive patients who underwent transcatheter PVL closure in our centre from October 2009 to December 2012, were included. All procedures were carried out in the catheterization laboratory under general anesthesia, using a small anterolateral thoracotomy to expose the apex. Access was provided with a 9-French sheath. Three-dimensional transesophageal echocardiography was used to guide the operator and evaluate the severity of regurgitation immediate after implantation. Procedural success was defined according to the valve academic research consortium-2 consensus document. Mortality was registered at 6 and 12 months. Results: In total, 36 consecutive patients (mean age 67,2±12,1 years, 69,4% male) with severe symptomatic PVL in mitral (n = 28) or aortic (n = 8) position, underwent transapical PVL closure. NYHA functional class was ≥ 3 in 100%. Preprocedural median logistic EuroSCORE was 25,8% (IQR 31,4) and STS score was 24,7% (IQR 19,7). Procedural success was achieved in 88,9% of the patients. Mean procedure time was 94,0±33,0 minutes with a fluoroscopic time of 25,1±12,6 minutes. There were 2 procedural deaths. Rethoracotomy was performed in 11.1% because of bleeding complications. The survival rates at 6 and 12 months after PVL closure were 79,3% (n = 29) and 60,9% (n = 23), respectively. Conclusions: Transapical paravalvular leakage closure in high-risk patients is safe and technically feasible, and might be an attractive alternative for re-do surgery.

Late diagnosis of H-Type tracheoesophageal fistula

Additional Supporting Information may be found in the online version of this article: Table S1. Patient data. Table S2. OR time and time to clinical outcomes in patients on inhaled nitric oxide (iNO) and without iNO. Please note: Wiley-Blackwell are not responsible for the content or functionality of any supporting materials supplied by the authors. Any queries (other than missing material) should be directed to the corresponding author for the article.

Overcoming dose-counting mechanisms on metered-dose inhalers for urgent treatment in the operating room.

To the Editor: We report difficulty encountered when using the newly packaged Ventolin hydrofluoroalkane (HFA) metered dose inhaler (MDI; GlaxoSmithKline, Philadelphia, PA) for the treatment of acute intraoperative bronchospasm. A 14mo-old girl with achondroplasia, weighing 8 kg, presented for decompression of occipital cervical stenosis. This patient’s medical history was complicated by severe obstructive sleep apnea and chronic pulmonary congestion requiring continuous supplemental oxygen by nasal cannula. An IM injection of ketamine and glycopyrrolate was given preoperatively. After an uneventful inhalation induction and establishment of IV access, a 4.0 uncuffed endotracheal tube was placed with fiberoptic guidance via a laryngeal mask airway. Marked expiratory wheezes were heard bilaterally. An albuterol MDI was removed from the emergency medicine drawer of the Ploss cart. However, we were surprised to find that the hospital pharmacy had changed albuterol products to incorporate use of a product with an MDI dosecounting mechanism. There had been no effective method of drug delivery to pediatric patients before adopting this device and including it in all of our pediatric anesthesia carts. The bronchospasm continued and an “old” Proair HFA (Teva Pharmaceuticals USA, North Wales, PA) was found and used to manage the event. The Proair HFA was placed in a 60-mL BD syringe (Becton Dickinson, Franklin Lakes, NJ), which was connected to the circuit via the ETco2 port, an old method that is well known to most. The albuterol was then delivered via the circuit. This change in pharmacy stock resulted in delayed treatment of intraoperative bronchospasm. Several anesthesiologists and respiratory therapists worked together to develop a means to deliver albuterol by MDI with a dose-counting mechanism to a patient whose lungs were mechanically ventilated intraoperatively. A 3.0 Mallinckrodt (Glens Falls, NY) endotracheal tube adaptor fit the Ventolin HFA “cap” quite snugly and also connected with a standard end-tidal CO2 detector tubing port at the anesthesia circuit (Fig. 1). This allows for adequate delivery of the albuterol to the patient. It should be noted that the dose-counting mechanism that we encountered cannot be removed without significant physical force and a makeshift tool. The published outpatient dose for all patients is 2 puffs/delivery every 4 – 6 h to a maximum of 12 puffs per day. However, treatment of intraoperative bronchospasm in a patient with full monitors frequently exceeds this dose. In the operative setting, patients are monitored for excessive -2 stimulation, namely, tachycardia. In March 2003, the U.S. Department of Health and Human Services Food and Drug Administration Center for Drug Evaluation and Research released a “Guidance for Industry” regarding the integration of dosecounting mechanisms into MDI drug products. Before the integration of dose-counting mechanisms, patients needed to guess how many doses were left in their MDI devices. This left patients with the option of either discarding MDIs with remaining active drug or using MDIs devoid of active drug. Thus, the Agency recommended that manufacturers integrate dose-counting devices into all newly developed MDI devices. It is important to note that because of the international ban on chlorofluorocarbon propellants, all MDIs are being reformulated to HFA propellants, making them “newly developed devices.”