Low-pressure CSF shunt malfunction without preceding lumbar puncture treated by epidural blood patch: report of 2 cases.

Low-pressure CSF shunt malfunction is a poorly understood complication of hydrocephalus affecting patients of all ages. Treatment commonly requires external drainage of CSF to subatmospheric pressures for days to weeks in an intensive care setting. The current communication describes the repurposing of an established therapeutic technique, epidural blood patch, for successful initial management in 2 cases of low-pressure shunt malfunction in the absence of a recognized spinal CSF fistula. This technique may shorten length of stay and obviate potential morbidity in the management of what is otherwise a vexatious clinical problem.

The impact of the COVID-19 pandemic on the education and wellness of U.S. Pediatric Anesthesiology Fellows.

BACKGROUND: The global coronavirus disease 2019 (COVID-19) pandemic caused state-wide shutdowns of elective surgical activities in March and April of 2020 forcing graduate medical education program directors and their trainees in the United States to quickly adapt to new rules and circumstances. AIM: The aim of this study was to determine the effect of the current pandemic on pediatric anesthesiology fellow education and wellness nationally in order to guide creation of optimal support systems for fellows during the ongoing pandemic. METHODS: In July 2020, an electronically distributed survey was sent to all United States-based pediatric anesthesiology fellowship program directors who were asked to distribute the survey to all current/graduating fellows. RESULTS: A total of 75 out of 184 pediatric anesthesiology fellows (41%) responded to the survey. Major domains identified include reduction of clinical time, financial impact, mental health/wellness effects, and concerns about the overall quality of the fellowship educational experience. Respondents indicated that the pandemic has led to personal quarantine (and/or illness) leave time (21.3%), changes in finances (42.7%) and career opportunities (37.3%), decreased clinical education/experience (28%), and a dissatisfaction with the modified didactic experience (22.7%). In addition, a majority of respondents (97.3%) experienced increased stressors during this pandemic, including worry for family members (80%), stress due to changes in certifying examinations (76%), and fear of contracting COVID-19 from a patient (72%). CONCLUSION: While the results of this survey are only one snapshot in time during an evolving pandemic, these results highlight important domains where program directors and other departmental leaders might focus limited resources to maximize the educational experiences and overall wellness for pediatric anesthesiology fellows.

Preoperative Blood Transfusions and Morbidity in Neonates Undergoing Surgery.

BACKGROUND: Blood transfusions in the neonatal patient population are common, but there are no established guidelines regarding transfusion thresholds. Little is known about postoperative outcomes in neonates who receive preoperative blood transfusions (PBTs). METHODS: Using the American College of Surgeons National Surgical Quality Improvement Program-Pediatric Participant Use Data Files from 2012 to 2015, we identified all neonates who underwent surgery. Mortality and composite morbidity (defined as any postoperative complication) in neonates who received a PBT within 48 hours of surgery were compared with that in neonates who did not receive a transfusion. RESULTS: A total of 12 184 neonates were identified, of whom 1209 (9.9%) received a PBT. Neonates who received a PBT had higher rates of preoperative comorbidities and worse postoperative outcomes when compared with those who did not receive a transfusion (composite morbidity: 46.2% vs 16.2%; P < .01). On multivariable regression analysis, PBTs were independently associated with increased 30-day morbidity (odds ratio [OR] = 1.90; 95% confidence interval [CI]: 1.63-2.22; P < .01) and mortality (OR = 1.98; 95% CI: 1.55-2.55; P < .01). In a propensity score-matched analysis, PBTs continued to be associated with increased 30-day morbidity (OR = 1.53; 95% CI: 1.29-1.81; P < .01) and mortality (OR = 1.58; 95% CI: 1.24-2.01; P = .01). CONCLUSIONS: In a propensity score-matched model, PBTs are independently associated with increased morbidity and mortality in neonates who undergo surgery. Prospective data are needed to better understand the potential effects of a red blood cell transfusion in this patient population.

An Advanced Boot Camp for Pediatric Anesthesiology Fellows.

BACKGROUND: Managing pediatric crises necessitates the acquisition of unique skills and confidence in its execution. Our aim was to develop and assess a curriculum based on the constructivist learning environment to enhance learning, orientation, and preparation of graduating pediatric anesthesiology fellows. METHODS: Fifty pediatric anesthesiology fellows from 9 academic institutions in the United States were recruited for an advanced boot camp over a 2-year period. Training stations were developed using high-fidelity simulation, standardized patients, self-reflection modules, and facilitated discussions. The curriculum was evaluated using an anonymous survey that assessed knowledge, self-confidence, appropriateness of case-scenario complexity, and usefulness for transitioning into an independent practitioner on a Likert scale (1 = strongly disagree to 5 = strongly agree). Data points were expressed as the median and interquartile range (IQR). RESULTS: Ninety-eight percent of the fellows completed a survey. Fellow perceptions of the advanced boot camp was positive. The median scores (IQR) for knowledge, self-confidence, appropriateness of case complexity, and usefulness for transition in 2017 were 5 (3,5), 4.5 (3,5), 5 (3,5), and 5 (3,5), respectively, and 5 (3,5), 4.5 (3,5), 5 (4,5), and 5 (3,5), respectively, in 2018. The IQR in the assessment for an appropriate level of complexity for their level of training, narrowed in 2018 (4,5), when compared with 2017 (3,5). CONCLUSIONS: Fellow responses support the idea that the advanced boot camp provided tools and strategies for their transition. A narrowed IQR regarding the appropriate level of complexity of scenarios in 2018, when compared with 2017, might suggest an improvement in the curriculum.

Low dose methylprednisolone prophylaxis to reduce inflammation during one-lung ventilation.

BACKGROUND: The specific aim of this study was to examine the efficacy of a low dose of methylprednisolone in minimizing inflammatory response in juvenile piglets when given 45-60 min prior to onset of one-lung ventilation. METHODS: Twenty piglets aged 3 weeks were assigned to either the control group (n = 10) or methylprednisolone group (n = 10). The animals were anesthetized and after 30 min of ventilation, they had their left lung blocked. Ventilation was continued via right lung for 3 h. The left lung was then unblocked. Following another 30 min of bilateral ventilation, the animals were euthanized and both lungs were harvested. The methylprednisolone group had a single dose (2 mg x kg(-1)) of methylprednisolone given i.v. 45-60 min prior to onset of one-lung ventilation. Physiological parameters (PaO2, resistance, and compliance) and markers of inflammation (tumor necrosis factor [TNF]-alpha, interleukin [IL]-1beta, IL-6, and IL-8) were measured at baseline and every 30 min thereafter. Lung tissue homogenates from both collapsed and ventilated lungs were analyzed for TNF-alpha, IL-1beta, IL-6, and IL-8. RESULTS: The methylprednisolone group had higher partial pressure of oxygen (P = 0.01), lower plasma levels of TNF-alpha (P = 0.03) and IL-6 (P = 0.001) when compared with control group. Lung tissue homogenate in the methylprednisolone group had lower levels of TNF-alpha (P < 0.05), IL-1beta (P < 0.05), and IL-8 (P < 0.05) in both the collapsed and the ventilated lungs. CONCLUSIONS: In a piglet model of one-lung ventilation, use of prophylactic methylprednisolone prior to collapse of the lung improves lung function and decreases systemic pro-inflammatory response. In addition, in the piglets who received methylprednisolone, there were reduced levels of inflammatory mediators in both the collapsed and ventilated lungs.

Hypothyroxinemia in mechanically ventilated term infants is associated with increased use of rescue therapies.

OBJECTIVE: Although common in preterm infants, transient hypothyroxinemia (TH) has not been investigated extensively in ill term infants. The objectives of this study were to investigate serum thyroxine (T4) and thyroid-stimulating hormone (TSH) in sick term infants and to determine whether there is any association between measures of thyroid function and short-term outcome in term infants who receive mechanical ventilation. METHODS: The investigation consisted of both a prospective observational study and a retrospective cohort study. In the prospective study, T4 and TSH were measured after birth in a group of sick term infants (n = 38) and compared with a group of well term infants (n = 18). Infants in the sick group received mechanical ventilation or continuous positive airway pressure and/or had neonatal seizures. Illness severity was quantified using the Score for Neonatal Acute Physiology. The retrospective cohort study included term infants who required mechanical ventilation and were born over a 5-year period (n = 347). Routine T4 screening was collected on the fifth day of life. TH was diagnosed in infants with a T4 <10%, with a TSH <25 microIU/mL. Clinical outcomes in infants with TH were compared with infants without TH. RESULTS: In the prospective study, infants in the sick group had lower T4 on the fifth day of life as compared with infants in the well group (11.7 +/- 4.9 vs 18.9 +/- 5.4 microg/dL), and 34% of infants in the sick group had a T4 <10th percentile compared with 6% of infants in the well group. T4 on day of life 5 was inversely correlated with Score for Neonatal Acute Physiology (R = -0.52). In the retrospective study, 21% of mechanically ventilated infants developed TH and were given statistically more inhaled nitric oxide, high-frequency ventilation, vasopressors, and pharmacologic paralysis when compared with infants without TH. Moreover, infants with TH were statistically more likely to die or require transfer to an extracorporeal membrane oxygenation center compared with infants without TH. CONCLUSION: Our data show that, similar to preterm infants, ill term infants develop TH. Term infants with TH required more intensive rescue interventions, including inhaled nitric oxide and transfer to an extracorporeal membrane oxygenation center. However, whether T4 levels are a marker or a mediator of clinical outcome remains to be determined.