Transfusion targets and adverse events in pediatric perioperative acute Anemia.

STUDY OBJECTIVE: To evaluate the association between pretransfusion and posttransfusion hemoglobin concentrations and the outcomes of children undergoing noncardiac surgery. DESIGN: Retrospective review of patient records. We focused on initial postoperative hemoglobin concentrations, which may provide a more useful representation of transfusion adequacy than pretransfusion hemoglobin triggers (the latter often cannot be obtained during acute surgical hemorrhage). SETTING: Single-center, observational cohort study. PATIENTS: We evaluated all pediatric patients undergoing noncardiac surgery who received intraoperative red blood cell transfusions from January 1, 2008, through December 31, 2018. INTERVENTIONS: None. MEASUREMENTS: Associations between pre- and posttransfusion hemoglobin concentrations (g/dL), hospital-free days, intensive care unit admission, postoperative mechanical ventilation, and infectious complications were evaluated with multivariable regression modeling. MAIN RESULTS: In total, 113,713 unique noncardiac surgical procedures in pediatric patients were evaluated, and 741 procedures met inclusion criteria (median [range] age, 7 [1-14] years). Four hundred ninety-eight patients (68%) with a known preoperative hemoglobin level had anemia; of these, 14% had a preexisting diagnosis of anemia in their health record. Median (IQR) pretransfusion hemoglobin concentration was 8.1 (7.4-9.2) g/dL and median (IQR) initial postoperative hemoglobin concentration was 10.4 (9.3-11.6) g/dL. Each decrease of 1 g/dL in the initial postoperative hemoglobin concentration was associated with increased odds of transfusion within the first 24 postoperative hours (odds ratio [95% CI], 1.62 [1.37-1.93]; P < .001). No significant relationships were observed between postoperative hemoglobin concentrations and hospital-free days (P = .56), intensive care unit admission (P = .71), postoperative mechanical ventilation (P = .63), or infectious complications (P = .74). CONCLUSIONS: In transfused patients, there was no association between postoperative hemoglobin values and clinical outcomes, except the need for subsequent transfusion. Most transfused patients presented to the operating room with anemia, which suggests a potential opportunity for perioperative optimization of health before surgery.

Dexmedetomidine Levels in Breast Milk: Analysis of Breast Milk Expressed During and After Awake Craniotomy.

Background: Dexmedetomidine is an α2-adrenoreceptor agonist with utility in sedation and analgesia for the perioperative or intensive care patient. The literature regarding the safety of dexmedetomidine in lactating patients is very limited. Methods: We present a case of a lactating patient who received dexmedetomidine bolus and infusion as part of her intraoperative sedation during an awake craniotomy. Breast milk samples were expressed by the patient twice intraoperatively and twice postoperatively. All samples collected were analyzed using liquid chromatography mass spectrometry. Results: Dexmedetomidine concentrations in the breast milk were measured at various intervals and were 88 and 50 pg/mL intraoperatively, and 89 and 15 pg/mL postoperatively. Conclusion: Levels of dexmedetomidine in breast milk were exceedingly low. Interruption of breastfeeding and/or discarding expressed breast milk may not be necessary after dexmedetomidine in breastfeeding mothers. Further investigation with a larger sample size is warranted to describe safety profile of dexmedetomidine in breastfeeding infants.

Racial Disparities in Diagnosis of Attention-Deficit/Hyperactivity Disorder in a US National Birth Cohort.

Importance: There are limited data on the racial disparities in the incidence of attention-deficit/hyperactivity disorder (ADHD) diagnosis in children at the national level. Objective: To explore differences in rates of diagnosis of ADHD and use of treatment among children by race and ethnicity. Design, Setting, and Participants: This retrospective cohort study assessed insurance claims data of children born in the US between January 1, 2006, and December 31, 2012, who had continuous insurance coverage for at least 4 years. The last date of follow-up included in the cohort was June 30, 2019. Race/ethnicity designations were based on self-report and included non-Hispanic White, Black, Hispanic, and Asian. Data were analyzed between October 2019 and December 2020. Exposures: Race and ethnicity. Main Outcomes and Measures: ADHD diagnosis as defined by International Classification of Diseases codes (ninth or tenth editions) and treatment within 1 year of diagnosis, including medication and behavior therapy as defined by billing codes. Data on ADHD diagnosis and treatment were adjusted for sex, region, and household income in a multivariate Cox regression model. Results: Among 238 011 children in the cohort (116 093 [48.8%] girls; 15 183 [6.7%] Asian, 14 792 [6.2%] Black, 23 358 [9.8%] Hispanic, and 173 082 [72.7%] White children), 11 401 (4.8%) were diagnosed with ADHD. The cumulative incidence at age 12 was 13.12% (95% CI, 12.79%-13.46%). In multivariate Cox regression adjusting for sex, region, and household income, the hazard ratio for Asian children was 0.48 (95% CI, 0.43-0.53); Black children, 0.83 (95% CI, 0.77-0.90); and Hispanic children, 0.77 (95% CI, 0.72, 0.82) compared with White children. In the first year after diagnosis, 516 preschool children (19.4%) received behavioral therapy only, 860 (32.4%) had medications only, 505 (19.0%) had both, and 774 (29.2%) had no claims associated with either option. A higher percentage of school-aged children (2904 [65.6%]) were prescribed medications, and fewer had therapy only (639 [14.4%]) or no treatment at all (884 [20.0%]). Compared with other groups, White children were more likely to receive some kind of treatment. Asian children had the highest odds of receiving no treatment (odds ratio compared with White children, 0.54; 95% CI, 0.42-0.70). Conclusions and Relevance: Racial and ethnic disparities in the diagnosis and treatment of ADHD are evident. Future study is needed to elucidate the mechanism behind these disparities, with special attention to Asian children. Clinicians should provide racially sensitive care in the evaluation and treatment of ADHD.

Whole-lung lavage in a patient with pulmonary alveolar proteinosis.

Pulmonary alveolar proteinosis (PAP) is a rare syndrome in which phospholipoproteinaceous matter accumulates in the alveoli leading to compromised gas exchange. Whole-lung lavage is considered the gold standard for severe autoimmune PAP and offers favorable long-term outcomes. In this case report, we describe the perioperative management and procedural specifics of a patient undergoing WLL for PAP in which an anesthesiologist serves as the proceduralist and a separate anesthesiologist provides anesthesia care for the patient.