Comparison of intranasal midazolam-fentanyl with dexmedetomidine-fentanyl as pre-medication in the paediatric age group.

Background & objectives: Intranasal midazolam-fentanyl is commonly used as pre-medication in paediatric patients, but there is a risk of respiratory depression with this combination. Dexmedetomidine is a drug that preserves respiratory function. The objective of this study was to compare the efficacy of intranasal midazolam-fentanyl and dexmedetomidine-fentanyl in paediatric patients undergoing elective surgeries. Methods: Hundred children in the age group of 3-8 yr of American Society of Anaesthesiologists physical status grade 1 were randomized into two groups- group A received intranasal midazolam (0.2 mg/kg)-fentanyl (2 µg/kg) and group B received intranasal dexmedetomidine (1 µg/kg)-fentanyl (2 µg/kg) 20 min before induction of general anaesthesia. Heart rate and SpO2 were monitored. Sedation score, parental separation and response to intravenous cannulation were seen after 20 min. Children were monitored for 2 h for post-operative analgesia by Oucher's Facial Pain Scale. Results: Sedation scores were satisfactory in both groups, although children in group A were more sedated than in group B. Parental separation and response to intravenous cannulation were comparable in both the groups. The two groups were also haemodynamically comparable intraoperatively. Post-operative heart rate was also comparable at all-time intervals in both the groups except for heart rate at 100 and 120 min which were more in group A. Group A experienced more post-operative pain as assessed by Oucher's Facial Pain Scale as compared to group B. Children receiving intranasal dexmedetomidine-fentanyl had better post-operative analgesia as compared to those who received intranasal midazolam-fentanyl. Interpretation & conclusions: Both intranasal midazolam with fentanyl and intranasal dexmedetomidine with fentanyl provided satisfactory sedation. Both groups were comparable in separation reaction and response to intravenous cannulation with better post-operative analgesia in children receiving intranasal dexmedetomidine-fentanyl.

Determinants of electrocardiographic abnormalities in patients with pectus excavatum.

BACKGROUND: Electrocardiographic abnormalities such as cardiac axis deviation, conduction abnormalities and ST-segment, and T &P wave abnormalities have been reported in patients with pectus excavatum. The precise determinants of these electrocardiographic abnormalities have however not been systematically evaluated. We therefore carried out this exploratory study to assess the electrocardiographic abnormalities and their determinants in children and young adults with pectus excavatum. METHODS: Patients aged between 6 and 22 years with unrepaired pectus excavatum were eligible for enrollment in this preliminary hypothesis generating study, if they were seen at University of Chicago Medical Center between Jan 1, 2017 to Nov 30, 2020, and underwent an electrocardiogram during comprehensive evaluation for pectus excavatum. Pertinent data was collected from the medical charts. Unadjusted and adjusted logistic regression models were used to determine the effect of variables including age, BMI, inspiratory Haller's index, gender, right ventricular geometric distortion and FEV1/FVC (% predicted) on odds of electrocardiographic abnormalities (primary outcome variable). P-values of <0.05 were considered significant. RESULTS: The study group (16.6 ± 2.9 years, 80% symptomatic) consisted of 28 patients [Caucasian, male (n = 24, 86% each)]. A high proportion (86%) of these patients had geometric distortion of the right ventricle on noninvasive imaging and these patients had a higher Haller's index (4.4 ± 0.95 vs 3.3 ± 0.2, p = 0.03). Approximately 60% of the patients had an abnormal electrocardiogram. Unadjusted and adjusted logistic regression models were utilized to study the determinants of these electrocardiographic abnormalities. Haller's index, BMI, age, gender, geometric distortion of the right ventricle and lung function parameters [FEV1/FEV (% predicted)] were not associated with increased odds of electrocardiographic abnormalities. CONCLUSIONS: Electrocardiographic abnormalities, particularly deviation of cardiac axis, are common in patients with pectus excavatum. In this exploratory hypothesis generating study, Haller's index and geometric distortion of the right ventricle were not associated with these abnormalities. However, systematic multicentric efforts are needed to better define electrocardiographic abnormalities in patients with pectus excavatum and elucidate their precise determinants.

Extreme hyperthermia-induced arrhythmogenesis.

Hyperthermia is defined as an elevated body temperature above the normal range due to a failure of heat regulatory mechanisms. In addition to its effects on other organ systems, hyperthermia is associated with profound cardiovascular effects. We report the sentinel case of a 6-year-old girl with structurally and electrically normal heart, who presented with life-threatening hyperpyrexia-induced ventricular tachycardia, which was refractory to cardioversion and anti-arrhythmics but responded promptly to cooling. We emphasise the lifesaving role of immediate and aggressive cooling in such patients.

Cardiovascular Phenotypic Spectrum of 1p36 Deletion Syndrome.

Chromosome 1p36 deletion syndrome is a common genetic anomaly (prevalence: 1 in 5,000-1 in 10,000). Despite reports of cardiovascular involvement, the cardiovascular phenotypic spectrum of patients with 1p36 deletion syndrome is not well characterized. In this article, we reported the clinical course of a full-term African American boy with chromosome 1p36 deletion syndrome and neonatal onset of severe cardiac disease with moderate-to-severe biventricular dysfunction and severe pulmonary hypertension. Early neonatal onset presentation of 1p36 deletion syndrome is rare and might be associated with a more guarded prognosis. This case based study is supplemented by a comprehensive review of cardiovascular involvement in this relatively common genetic syndrome.

Early onset ACS: An age based clinico-epidemiologic and angiographic comparison.

BACKGROUND AND AIMS: Acute coronary syndrome (ACS) in the very young is a rare entity, with limited data. We aimed to study patterns and profile of ACS in patients aged 20-30 years in comparison with those above 30 years. METHODS: In this retrospective record-based study, the demographic and clinical profile of all patients with ACS in the last 12 years (n = 35259) was analysed: group I (20-30 years) and group II (above 30 years). Patients in group II were selected by systematic sampling. Age, gender, domicile, body mass index (BMI), serum cholesterol, smoking, alcohol use, drug abuse, diabetes, hypertension, family history, type of ACS, angiographic findings and management strategies were recorded. Chi-square test and Fischer's exact test were used for data analysis. RESULTS: Of 35,259 patients, 0.32% (n = 114) were from the younger age group, with a rising trend of prevalence over 12 years. Obesity, overweight, urban living, smoking, alcohol and drug abuse were significantly higher in group I (p < 0.05). Diabetes mellitus and hypertension were more prevalent in group II (p = 0.001). STEMI in group I (76.3%) and NSTEMI in group II (47.1%) were the common modes of presentation (p = 0.001). 42.1% of group I patients had recanalized coronaries with conservative management in comparison to 3% in group II (p = 0.001). CONCLUSIONS: There is a rising trend in prevalence of ACS in very young patients. Overweight, obesity, urbanization and drug abuse are potential risk factors. The younger subset of ACS patients is different from the older population due to their thrombotic milieu, which could be more amenable to intensive pharmacologic management.

Comparison of Intubating Conditions using Fentanyl plus Propofol Versus Fentanyl plus Midazolam during Fiberoptic Laryngoscopy.

INTRODUCTION: Awake nasal or oral flexible fiberoptic intubation is the airway management technique of choice in known or anticipated difficult airway, unstable cervical fracture, limited mouth opening (as in temporomandibular joint disease), mandibular-maxillary fixation and severe facial burns. Both optimal intubating condition and patient comfort are important for fiberoptic intubation. Optimal intubating conditions provided by an ideal sedation regimen would ensure haemodynamic stability, patient comfort, attenuation of airway reflexes and amnesia. AIM: To compare the intubating conditions using fentanyl plus propofol versus fentanyl plus midazolam during fiberoptic laryngoscopy. MATERIALS AND METHODS: A prospective, comparative and randomized study was conducted on 60 patients of either gender aged between 18 and 60 years belonging to the American Society of Anaesthesiologists (ASA) grade-I or II scheduled for elective surgery. Patients were randomly allocated into two groups of 30 each. In group I, patients received i.v. fentanyl 1 µg/kg+ propofol 1 mg/kg to achieve an adequate level of sedation that is Ramsay Sedation Scale (RSS) score of 3. In group II, patients received i.v. fentanyl 1 µg/kg + midazolam 0.03 mg/kg to achieve RSS= score of 3. Haemodynamic parameters (heart rate, systolic and diastolic blood pressure, mean arterial pressure), SpO2, EtCO2, total comfort scale values and patient's tolerance were assessed during preoxygenation, fiberscope insertion and endotracheal intubation. RESULTS: Fentanyl plus midazolam group showed better patient comfort and maintenance of oxygen saturation than fentanyl plus propofol group during fiberoptic intubation. CONCLUSION: Both fentanyl plus midazolam and fentanyl plus propofol regimes are suitable for fiberoptic intubation. Fentanyl plus midazolam appeared to offer better tolerance, preservation of an airway and spontaneous ventilation, while maintaining haemodynamic stability.

Gender bias in cardiovascular healthcare of a tertiary care centre of North India.

OBJECTIVES: To analyse the gender bias in paediatric patients referred for free cardiac treatment as part of School Health Programme at a tertiary care centre in North India. METHODS: A total of 537 children were referred for further management of congenital heart disease or rheumatic heart disease. Of these, 519 underwent cardiac intervention, and the data from their records were analysed retrospectively to determine any gender disparity in the utilisation of cardiac surgery. RESULTS: Of the 519 children studied, only 195 (37.6%) were girls, while the remaining 324 (62.4%) were boys (male-to-female ratio of 1.66:1, p<0.0001), indicating a large gender divide. Gender bias was found to be prevalent across all the age groups irrespective of the type of cardiac ailment. Moreover, no statistically significant difference was found between the urban and rural populations (male-to-female ratio of 1.64:1 in rural and 1.71:1 in urban populations; p=0.823) in terms of gender disparity. CONCLUSIONS: Significant gender discrepancies exist in healthcare-seeking behaviour of patients in North India despite the provision of free cardiac treatment. An equal prevalence of gender bias in urban and rural communities points towards deep-rooted social norms beyond just the economic constraints. Healthcare policies ensuring equal treatment of male and female children should be promulgated to ensure a complete eradication of this social evil.