Accuracy of oscillometric noninvasive blood pressure compared with intra-arterial blood pressure in infants and small children during neurosurgical procedures: An observational study.

BACKGROUND: General anaesthesia in children results in a significant decrease of arterial pressure. Hypotension in neonates and infants reduces cerebral perfusion; therefore, an accurate arterial pressure measurement is of utmost importance. Although arterial pressure measured via an arterial catheter is considered to be the gold standard, in most children undergoing anaesthesia, arterial pressure is monitored by an upper arm cuff using an oscillometric technique. Data on the accuracy of these devices in such young patients are rare. OBJECTIVE: The aim of this study was to assess the accuracy of oscillometric blood pressure measurement compared with intra-arterial measurement. DESIGN: An observational comparison study. SETTING: A single-centre study, conducted in a German university hospital from November 2015 to January 2018. PATIENTS: Twenty-five children of 2 years old or less (median age 6 [IQR, 5 to 11]) months undergoing neurosurgical procedures requiring invasive arterial pressure determination. MAIN OUTCOME MEASURES: Arterial pressure was measured invasively and also oscillometrically by an upper arm cuff every 10 min. Simultaneously measured pairs of mean arterial pressures were analysed by the Bland-Altman method; the correlation coefficient, percentage error and concordance were calculated. RESULTS: Data from 21 children were analysed. Mean, (standard deviation) and [range] of invasive and noninvasive mean arterial pressures were 54 (8) [30 to 94] and 57 (8) [40 to 108] mmHg, respectively. The overall bias between invasive and noninvasive arterial pressure was -3 (7) mmHg, with 95% limits of agreement from -17 to +10 mmHg. The correlation coefficient, percentage error and concordance were 0.65, 25% and 0.77, respectively. For hypotensive invasive arterial pressure values below 45 mmHg, the mean bias (invasive arterial pressure - noninvasive arterial pressure) was -9 (5) mmHg. CONCLUSION: Arterial pressure derived by the oscillometric device showed acceptable levels of agreement. However, during hypotension, a clinically relevant overestimation of arterial pressure occurred when measured by an upper arm cuff.

Falsely low values of oxygen saturation measured by pulse oximetry in a boy treated with Chinese herb tea.

An 8-year-old boy suffering from progressive glioblastoma was scheduled for neurosurgery. Prior to induction of anaesthesia pulse oximetry measured 64 % saturation of oxygen (SpO2). Arterial blood gas analysis revealed normal oxygen saturation and normal oxygen partial pressure. After having ruled out technical problems of pulse oximetry the neurosurgical procedure was halted. Meticulous examination of the child's history and medication did not explain a possible interaction of drugs with pulse oximetry. A Chinese herb tea had been given to the child, but was then stopped on the day of admission. The surgical procedure took place the next day without any complications. During the subsequent inpatient stay, repeated blood gas analyses showed normal oxygenation, but pulse oximetry measured initially SpO2 values of 64 %, gradually increasing over 7 days up to 91 % by the time of discharge from hospital. Blood samples were taken and analysed. Absorption spectroscopy from the patient's blood showed an uncommon absorption maximum at 684 nm besides the normal maxima. The normalisation of SpO2 values after stopping Chinese herb tea administration leads to the conclusion that one of its ingredients caused the distorted pulse oximetry measurement.

Laparoscopic anterior hemifundoplication and hiatoplasty for the treatment of upside-down stomach: mid- and long-term results after 40 patients.

BACKGROUND: Treatment of type 4 hiatal hernia using a minimally invasive approach is challenging and requires good familiarity with this technique. METHODS: From October 1992 to August 2010, 40 patients with a median age of 68 years underwent laparoscopic anterior hemifundoplication surgery for upside-down stomach and were included in our prospective study. The median symptoms duration was 5 years. The leading clinical symptoms were postprandial, epigastric, or retrosternal pain (80%), heartburn (78%), regurgitation (80%), dysphagia (53%), and anemia (48%). Preoperative evaluation included blood test, chest X-ray, upper endoscopy, and barium swallow. In some patients an esophageal 24-h pH study and esophageal manometry were performed. The median follow-up was 46 months using a standardized questionnaire, including Smiley score, modified Visick score, gastrointestinal quality-of-life index (GQLI), and specific reflux symptoms score. RESULTS: Surgery was finished laparoscopically in 39 patients (97%). One patient had to be converted to an open procedure because of severe adhesions. Mesh hiatoplasty had to be performed in one patient due to a large hiatal defect. Median operative time was 160 min (range=90-275) and median blood loss was 5 ml (range=0-300). Seven patients (18%) presented with acute symptoms. Intraoperative technical complications occurred in four patients (10%) and nontechnical complications in two cases (5%). Median postoperative hospital stay was 5 days (range=2-17). Postoperative complications occurred in two patients (5%): one pleural effusion and one surgical emphysema. There was no mortality or symptomatic recurrence. All scores showed significant improvement and patient satisfaction. CONCLUSION: Laparoscopic treatment of type 4 hiatal hernia is safe. With respect to the quality of life, anterior hemifundoplication is highly effective.

Esophageal leiomyomatosis combined with intrathoracic stomach and gastric volvulus.

CASE REPORT: A 42-year-old female presented with long-standing symptoms suggestive of gastroesophageal reflux disease improved after proton pump inhibitor treatment. An upper endoscopy revealed an intrathoracic position of the stomach (type 4 hiatal hernia) with no mucosal abnormality. Barium swallow demonstrated gastric herniation with gastric volvulus without stenosis. A computed tomographic scan confirmed the intrathoracic location of the stomach associated with thickening and edema of the gastric wall due to gastric volvulus, but no evidence of malignancy. The patient was scheduled for laparoscopic gastric repositioning with anterior hemifundoplication. Due to the incidental intraoperative finding of a large distal esophageal tumor (frozen section: esophageal leiomyomatosis), the operation was converted to conventional distal esophagectomy and proximal gastrectomy with reconstruction using a Merendino procedure. Final histology revealed extensive circumferential leiomyomatosis of the distal esophagus with a diameter of 10 cm. Esophageal leiomyomatosis is an extremely rare pathological finding with <100 cases reported in the literature. CONCLUSION: Any surgeon performing laparoscopic fundoplication has to be ready to deal with such unexpected findings, ie, converting the procedure and doing reconstruction with minimal morbidity. The Merendino procedure is a well-established reconstructive surgical option in cases of tumor formation at the gastroesophageal region with fewer postoperative morbidities like reflux symptoms.