Prophylactic versus reactive transfusion of thawed plasma in patients undergoing surgical repair of craniosynostosis: a randomized clinical trial.

BACKGROUND: Surgical repair of craniosynostosis in young children is associated with copious bleeding and often coagulopathy. Typically, a reactive transfusion strategy is used to treat coagulopathy whereby fresh frozen plasma (FFP) is given only after clinical manifestation of clotting abnormality. This prospective, randomized clinical trial was designed to test the hypothesis that prophylactic FFP during craniofacial surgery reduces blood loss and blood transfusion requirements compared to a reactive FFP transfusion strategy. METHODS: Eighty-one patients less than 2 years of age requiring primary repair of craniosynostosis were randomized to receive FFP using either a prophylactic or reactive strategy. Laboratory values were measured at four standardized time points. The volume of blood products transfused, length of stay in the pediatric intensive care unit (PICU), hospital length of stay, and number of donor exposures were recorded for each patient. RESULTS: The prophylactic FFP group received a significantly greater average volume of FFP compared to the reactive group (29.7 ml·kg(-1) vs 16.1 ml·kg(-1) ; P < 0.001), which was associated with improvement in coagulation values at multiple time points. However, there was no difference in blood transfusion requirements or blood loss between the two groups. The two transfusion strategies resulted in similar median donor exposures. There was no difference in PICU or hospital length of stay. CONCLUSION: A reactive FFP transfusion strategy required less plasma transfusion and was associated with similar rates of blood loss and PRBC transfusion as prophylactic FFP despite improvement in coagulation values in the prophylactic FFP group.

Emergence delirium and postoperative pain in children undergoing adenotonsillectomy: a comparison of propofol vs sevoflurane anesthesia.

BACKGROUND: Emergence delirium (ED) is a frequent postoperative complication in young children undergoing ENT procedures and it may be exacerbated by sevoflurane anesthesia whereas propofol maintenance has been suggested to decrease the incidence of ED. The aim of this randomized, prospective, double-blind study was to evaluate the effect of sevoflurane vs propofol anesthesia on the quality of recovery after adenotonsillectomy. METHODS: Forty-two patients were randomized to maintenance with either propofol or sevoflurane for adenotonsillectomy. At the conclusion of surgery, patients were extubated awake. ED and pain were assessed using the Pediatric Anesthesia Emergence Delirium (PAED) and the Children's Hospital of Eastern Ontario Scale (CHEOPS), respectively. Higher PAED scores (0-20) indicate greater severity of ED. Nursing and parental satisfaction, hospital length of stay, postoperative nausea and vomiting (PONV), anesthetic complications, and subsequent emergency room admissions were also assessed. RESULTS: Median PAED score was 14 in the propofol group and 17 in the sevoflurane group (NS). Propofol was associated with less pain medication required during recovery and a lower incidence of PONV (5.3% vs 36.8%, P < 0.05). Nursing and parental satisfaction as well as time spent in recovery room was similar for the two groups. CONCLUSION: Propofol anesthesia does not influence agitation after adenotonsillectomy, as measured by the PAED score. A PAED score of ≥ 10 was not useful in identifying patients with ED. However, propofol maintenance is associated with less need for pain medication in the recovery room and a lower incidence of PONV compared to sevoflurane anesthesia.

Front teeth-to-carina distance in children undergoing cardiac catheterization.

BACKGROUND: Knowledge of normal front teeth-to-carina distance (FT-C) might prevent accidental bronchial intubation. The aim of the current study was to measure FT-C and to examine whether the Morgan formula for oral intubation depth, i.e., endotracheal tube (ETT) position at front teeth (cm) = 0.10 x height (cm) + 5, gives appropriate guidance when intubating children of different ages. METHODS: FT-C was measured in 170 infants and children, aged 1 day to 19 yr, undergoing cardiac catheterization. FT-C was obtained as the sum of the ETT length at the upper front teeth/dental ridge and the distance from the ETT tip to the carina. The latter measure was taken from an anterior-posterior chest x-ray. RESULTS: There was close linear correlation between FT-C and height: FT-C (cm) = 0.12 x height (cm) + 5.2, R = 0.98. The linear correlation coefficients (R) for FT-C versus weight and age were 0.78 and 0.91, respectively. If the Morgan formula had been used for intubation, the ETT tip would have been at 90 +/- 4% of FT-C. No patient would have been bronchially intubated, but the ETT tip would have been less than 0.5 cm from the carina in 13 infants. CONCLUSIONS: FT-C can be well predicted from the height/length of the child. The Morgan formula provides good guidance for intubation in children but can result in a distal ETT tip position in small infants. Careful auscultation is necessary to ensure correct tube position.

Low-Dose Versus High-Dose Postoperative Naloxone Infusion Combined With Patient-Controlled Analgesia for Adolescent Idiopathic Scoliosis Surgery: A Randomized Controlled Trial.

STUDY DESIGN: Randomized controlled trial. OBJECTIVES: The aim of this prospective randomized clinical trial was to compare low (0.5 µg/kg/h) and high (2.5 µg/kg/h) dose naloxone infusion on the time to tolerate liquids and meals after surgery, patient-controlled analgesia (PCA) opioid requirements, nausea and pruritus ratings, and hospital length of stay. SUMMARY OF BACKGROUND DATA: Adolescents undergoing posterior spinal fusion often receive PCA after surgery and may experience common opioid-associated side effects, including nausea and pruritus. Low-dose naloxone infusion has been shown to reduce the incidence of pruritus and nausea while preserving analgesia, although an ideal dose has not been determined. Less is known about the potential for naloxone to improve bowel function after surgery. METHODS: Eighty-four patients (age 10-21 years) were randomly allocated to receive low- or high-dose naloxone infusion postoperatively. Surgical anesthetic consisted of propofol and opioid infusion with intrathecal morphine (10-15 µg/kg) at the conclusion of surgery. A visual analog scale (VAS) was used to rate nausea and pruritus. RESULTS: The groups had similar time to oral liquid intake after surgery and transition from PCA to oral pain medication. The VAS scores for pruritus and nausea were also similar, as was the need to treat these side effects. Morphine equivalents were similar between groups on postoperative day (POD) 0 and 1. On POD 2, the high-dose infusion group had significantly greater PCA bolus use (1.41±0.9 vs. 1.04±0.6; p<.05), although pain scores did not differ significantly. Hospital length of stay was similar for the two groups. CONCLUSION: High-dose naloxone infusion was associated with similar rates of opioid side effects as low-dose. Increased PCA use noted on POD 2 may represent partial reversal of opioid analgesia in the high-dose naloxone group. LEVEL OF EVIDENCE: Level 1.

Overnight observation in former premature infants undergoing inguinal hernia repair.

BACKGROUND: Overnight observation for apneic events is standard practice in former preterm infants. However, the literature supporting current protocols is dated. Therefore, we retrospectively evaluated the post-anesthetic risks in these patients. METHODS: A retrospective review was conducted on former preterm infants admitted after an inguinal herniorrhaphy between 1/00 and 10/09. The protocol for overnight admission was for patients born before 37 weeks gestation who are less than 60 weeks post-conceptional age (PCA). RESULTS: There were 363 patients, of which 23 were <40 weeks PCA (group 1), 244 were 40 to 49.9 weeks PCA (group 2), and 96 were 50 to 60 weeks PCA (group 3). Events registered by alarms occurred in 4 patients (1.1%), 2 from group 1 and 2 from group 2. In Group 1, one occurred during nasogastric tube placement and resolved spontaneously. In group 2, one was apnea-induced bradycardia that resolved spontaneously, and one was in a patient on home monitors with an event similar to home reports. There were no events in group 3. CONCLUSION: Conservative guidelines for overnight observation after inguinal hernia repair could be set for patients born before 37 weeks gestation who are under 50 weeks PCA.

Inhaled Anesthetics Promote Albumin Dimerization through Reciprocal Exchange of Subdomains.

Inhaled anesthetics affect protein-protein interaction, but the mechanisms underlying these effects are still poorly understood. We examined the impact of sevoflurane and isoflurane on the dimerization of human serum albumin (HSA), a protein with anesthetic binding sites that are well characterized. Intrinsic fluorescence emission was analyzed for spectral shifting and self-quenching, and control first derivatives (spectral responses to changes in HSA concentration) were compared against those obtained from samples treated with sevoflurane or isoflurane. Sevoflurane increased dimer-dependent self-quenching and both decreased oligomer-dependent spectral shifting, suggesting that inhaled anesthetics promoted HSA dimerization. Size exclusion chromatography and polarization data were consistent with these observations. The data support the proposed model of a reciprocal exchange of subdomains to form an HSA dimer. The open-ended exchange of subdomains, which we propose occuring in HSA oligomers, was inhibited by sevoflurane and isoflurane.