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OBJECTIVES: To determine if bolus administration of calcium increases pulmonary artery pressures after unifocalization procedures or pulmonary artery reconstruction surgery. DESIGN: Retrospective cohort study using Stanford University's data warehouse. SETTING: A large pediatric heart center within an academic quaternary care facility. PARTICIPANTS: All patients undergoing pulmonary artery reconstruction or unifocalization procedures identifiable in the data warehouse. INTERVENTIONS: Data were collected from Stanford University's data repository and formatted and analyzed using RStudio (v 2023.06.1+524). MEASUREMENTS AND MAIN RESULTS: The primary outcome was the change in pulmonary artery systolic pressure (PASP) after a bolus administration of calcium. Secondary endpoints include changes in pulmonary arterial-to-systemic arterial pressure ratio, mean arterial pressure, right-sided filling pressure, and left atrial pressure. The Friedman test was used to assess differences and the Durbin-Conover rank-sum for pairwise comparisons. A difference in PASP after a bolus dose of calcium was found (Friedman X2 = 13.67, p = 0.003), with a higher PASP 5 minutes after calcium administration compared with 2 minutes before administration (35 mmHg v 33 mmHg, p = 0.01), and a higher PASP 10 minutes after calcium administration compared with2 minutes before administration (35 mmHg v 33 mmHg, p = 0.008). CONCLUSIONS: Calcium bolus administration led to an increase in pulmonary arterial pressure in patients after pulmonary artery reconstruction or unifocalization surgeries. It may be prudent to avoid bolus administration in this patient population immediately after repair or in patients with right ventricular dysfunction.
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Background: The current approach to increasing diversity in medical education fails to consider local community demographics when determining medical school matriculation. Purpose: We propose that medical schools better reflect their surrounding community, both because racially/ethnically concordant physicians have been shown to provide better care and to repair the historical and current racist impacts of these institutions that have criminalized, displaced, and excluded local Black and Brown communities. Methods and Results: In this study, we used geospatial analysis to determine that medical school enrollments generally fail to reflect their surrounding community, represented as their core-based statistical area, within which the individual medical schools reside.
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Anesthetic induction in children can have significant psychological and behavioral impacts. Strategies like premedication or parental presence for induction may reduce distress. In children who require ongoing procedural care into adulthood, like those who receive heart transplants, transitioning from these strategies toward independence may require intermediate steps. The use of parental presence by video may aid in this transition. It might also be a reasonable approach for those children who have adverse reactions to medications commonly used for anxiolysis before procedures.
Assuntos
Anestesia , Ansiedade , Criança , Humanos , Ansiedade/prevenção & controle , Anestesia/efeitos adversos , Pré-Medicação , Pais/psicologia , Comunicação por VideoconferênciaAssuntos
Aorta Torácica/cirurgia , Circulação Colateral/fisiologia , Transplante de Coração-Pulmão/métodos , Procedimentos de Cirurgia Plástica/métodos , Artéria Pulmonar/cirurgia , Tetralogia de Fallot/cirurgia , Procedimentos Cirúrgicos Vasculares/métodos , Aorta Torácica/fisiopatologia , Criança , Angiografia Coronária , Humanos , Masculino , Artéria Pulmonar/fisiopatologia , Tetralogia de Fallot/diagnósticoRESUMO
BACKGROUND: Surgical repair of tetralogy of Fallot and major aortopulmonary collaterals (TOF/MAPCAs) involves unifocalization of MAPCAs and reconstruction of the pulmonary arterial circulation. Surgical and cardiopulmonary bypass (CPB) times are long and suture lines are extensive. Maintaining patency of the newly anastomosed vessels while achieving hemostasis is important, and assessment of transfusion practices is critical to successful outcomes. METHODS: Clinical, surgical, and transfusion data in patients with TOF/MAPCAs repaired at our institution (2013-2018) were reviewed. Types and volumes of blood products used in the perioperative period, in addition to the use of antifibrinolytics and/or procoagulants (factor VIII inhibitor bypassing activity [FEIBA]; anti-inhibitor coagulant complex), were assessed. Outcome measures included days on mechanical ventilation (DOMV), postoperative intensive care unit and hospital length of stay (LoS), and incidence of thrombosis. RESULTS: Perioperative transfusion data from 279 patients were analyzed. Surgical (879 ± 175 minutes vs 684 ± 257 minutes) and CPB times (376 ± 124 minutes vs 234 ± 122 minutes) were longer in patients who received FEIBA than those who did not. Although the indexed volume of packed red blood cells (128.4 ± 82.2 mL/kg) and fresh frozen plasma (64.2 ± 41.1 mL/kg) was similar in patients who did and did not receive FEIBA, the amounts of cryoprecipitate (5.5 ± 5.2 mL/kg vs 5.8 ± 4.8 mL/kg) and platelets (19.5 ± 20.7 mL/kg vs 20.8 ± 13 mL/kg) transfused were more in those who did receive FEIBA. CONCLUSION: Perioperative transfusion is an important component in the overall surgical and anesthetic management of patients with TOF/MAPCAs. The intraoperative use of FEIBA was not associated with a decrease in the amount of blood products transfused, DOMV, or LoS or with an increase in thrombotic complications.
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Aorta/cirurgia , Fatores de Coagulação Sanguínea/uso terapêutico , Transfusão de Sangue/estatística & dados numéricos , Coagulantes/uso terapêutico , Circulação Colateral , Assistência Perioperatória/métodos , Artéria Pulmonar/cirurgia , Tetralogia de Fallot/cirurgia , Trombose/epidemiologia , Aorta/anormalidades , Perda Sanguínea Cirúrgica , Procedimentos Cirúrgicos Cardíacos , Ponte Cardiopulmonar , Pré-Escolar , Transfusão de Eritrócitos , Oxigenação por Membrana Extracorpórea , Fator VIII/uso terapêutico , Feminino , Fibrinogênio/uso terapêutico , Cardiopatias Congênitas/cirurgia , Humanos , Lactente , Unidades de Terapia Intensiva , Tempo de Internação , Masculino , Duração da Cirurgia , Plasma , Transfusão de Plaquetas , Artéria Pulmonar/anormalidades , Circulação Pulmonar , Estudos Retrospectivos , Trombose/induzido quimicamenteRESUMO
Tetralogy of Fallot with pulmonary atresia and major aortopulmonary collaterals (TOF/PA/MAPCAs) is a heterogeneous disease with varying degrees of severity, requiring complex anesthetic management. Our institution has adopted the approach of early complete repair with incorporation of all lung segments, extensive lobar and branch segmental pulmonary artery reconstruction, and ventricular septal defect closure. While the surgical management of TOF/PA/MAPCAs has been extensively described and varies depending on the institution, there is a paucity of literature on the anesthetic management for such procedures. Herein, we describe our anesthetic management based on our own institution's surgical approach at Lucile Packard Children's Hospital/Stanford University.
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Anormalidades Múltiplas/cirurgia , Anestesia/métodos , Circulação Colateral , Defeitos dos Septos Cardíacos/cirurgia , Atresia Pulmonar/cirurgia , Tetralogia de Fallot/cirurgia , Ponte Cardiopulmonar/métodos , Humanos , Assistência Perioperatória/métodos , Estudos RetrospectivosAssuntos
Anestesia em Procedimentos Cardíacos/métodos , Procedimentos Cirúrgicos Cardíacos/métodos , Cardiopatias Congênitas/cirurgia , Monitorização Neurofisiológica Intraoperatória/métodos , Anestesia em Procedimentos Cardíacos/tendências , Anestesiologistas/educação , Anestesiologistas/tendências , Procedimentos Cirúrgicos Cardíacos/tendências , Cardiopatias Congênitas/fisiopatologia , Humanos , Monitorização Neurofisiológica Intraoperatória/tendênciasRESUMO
Anesthetic neurotoxicity has been a hot topic in anesthesia for the past decade. It is of special interest to pediatric anesthesiologists. A subgroup of children potentially at greater risk for anesthetic neurotoxicity, based on a prolonged anesthetic exposure early in development, are those children receiving anesthesia for surgical repair of congenital heart disease. These children have a known risk of neurologic deficit after cardiopulmonary bypass for surgical repair of congenital heart disease. Yet, the type of anesthesia used has not been considered as a potential etiology for their neurologic deficits. These children not only receive prolonged anesthetic exposure during surgical repair, but also receive repeated anesthetic exposures during a critical period of brain development. Their propensity to abnormal brain development, as a result of congenital heart disease, may modify their risk of anesthetic neurotoxicity. This review article provides an overview of anesthetic neurotoxicity from the perspective of a pediatric cardiac anesthesiologist and provides insight into basic science and clinical investigations as it relates to this unique group of children who have been studied over several decades for their risk of neurologic injury.
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We report the case of a 10-month old girl with a significant past medical history who presented for elective surgery with a new-onset fixed, dilated pupil. We briefly review the diagnostic approach to such patients and provide guidelines for managing these patients in the immediate preoperative setting.