The effect of intraoperative methadone during pediatric cardiac surgery on postoperative opioid requirements.

BACKGROUND: Pain control in pediatric patients undergoing cardiac surgery presents a unique challenge. Postoperatively, many of these patients require long-term opioid infusions and sedation leading to need for prolonged weaning from opioids and longer hospital stays. We hypothesized that intravenous methadone as the sole opioid in children having cardiac surgery with cardiopulmonary bypass would improve perioperative pain control and decrease overall perioperative use of opioid analgesics and sedatives. METHODS: We instituted a practice change involving pediatric patients aged <18 years who underwent cardiac surgery with cardiopulmonary bypass over a 14-month period, comparing the patient population who had surgery prior to the institution of intraoperative methadone usage to patients who had surgery in the months following. We then separated patients into two groups: neonatal (aged < 30 days) and non-neonatal (aged > 30 days to 18 years). Our primary outcome was intraoperative and postoperative opioid requirements measured in morphine equivalents intraoperatively, during the first 24 hours postoperatively, and up to postoperative day 7. Secondary outcomes included extubation rates in the OR, pain and sedation scores, sedation requirements, and time to start of oxycodone. RESULTS: Patients in both groups had similar demographics. In neonatal patients, the postintervention group required significantly lower doses of intraoperative opioids. There was no statistically significant difference in postoperative opioid use. In non-neonatal patients, the postintervention group required significantly less intraoperative opioids. Postoperatively, those in the postintervention group required significantly less opioids in the first 24 hours. CONCLUSION: The use of intraoperative methadone appears to be a reasonable alternative to the use of fentanyl with potential other benefits both intra- and postoperatively of decreased total dose of opioids and other sedatives. Future studies will assess for any improvement in total postoperative opioid requirements during the total hospital stay, and potential use of methadone by the ICU team.

Cardiopulmonary Bypass Strategy for a Cyanotic Child With Hemoglobin SC Disease.

Hemoglobin SC (HbSC) disease is a hemoglobinopathy that may produce sickling under conditions of hypoxemia, dehydration, and acidosis. We present a case of HbSC disease and tricuspid atresia, type IB. We describe management by cardiopulmonary bypass CPB using exchange transfusion at initiation of bypass and fractionation of collected blood, allowing platelet and plasma apheresis, as an option for patients unable to undergo this procedure off pump.

A no-laminectomy spinal cord compression injury model in mice.

The purpose of this study was to develop a minimally invasive recovery model of spinal cord injury in the C57Bl/6J mouse. Without laminectomy, the epidural space was exposed by disruption of the T10-T11 interspinous ligament. Perpendicular to the rostral-caudal axis of the spine, a 1.5-mm silicone tube (O.D. 0.047 in.) was placed in the T11 epidural space. Prior to placement, a suture was passed through the tube allowing withdrawal of the tube after discontinuation of anesthesia. After 1, 30, 60, or 120 min (n = 5-8) of spinal cord compression (SCC), the tube was withdrawn. Neurological function was measured at 1, 3, 7, and 14 days after injury followed by histologic analysis. BBB locomotor score, rotarod latency, and screen grasping were worsened in a SCC duration-dependent manner (p < 0.0001). With increasing SCC duration, the number of histologically normal neurons in the ventral horns decreased (p < 0.0001) while the cross-sectional area of spinal cord with pancellular necrosis increased (p < 0.0001). Increased duration of SCC caused progressive rostral-caudal spread of histologic damage. The results indicate that this is a simple, reliable model with neurologic and histologic injury highly dependent on SCC duration. This model may be useful for study of spinal cord injury in genetically modified mice in the absence of anesthetic confounds while leaving the vertebral column intact.

Changes in superoxide dismutase and catalase activities of rat brain regions during early global transient ischemia/reperfusion.

It has been widely recognized that the hippocampus and striatum are clearly more susceptible to oxidative stress than the remaining brain regions. However, the mechanism involved is not known. The activities of the antioxidant enzymes CuZn-superoxide dismutase (SOD), Mn-SOD and catalase were measured in the hippocampus and striatum and the results were compared to cortex and cerebellum (less susceptible to oxidative stress) after 3 h of a global transient ischemia/reperfusion. CuZn-SOD activities were reduced in all brain regions, but mainly in the hippocampus and striatum. Mn-SOD activity was lowered in the striatum, whereas catalase activity was reduced in the hippocampus and striatum. Our findings indicate that in the earlier phase of ischemia/reperfusion the decay in activities of catalase and SOD may be related with the high susceptibility of the hippocampus and striatum to oxidative damage.