Massive fatal ventricular septal defect due to nonpenetrating chest trauma in a six-year-old boy: the role of early invasive monitoring in an evolving lesion.

Isolated ventricular septal defects due to nonpenetrating chest trauma are unusual lesions in adults and very rare in children. A review of the literature and of the natural course of traumatic ventricular septal defects is discussed, with emphasis on the evolving course and frequent late appearance of this lesion. Surgical closure is the treatment of choice, most often performed electively following medical treatment. Defects resulting in progressive severe congestive heart failure must be repaired emergently. The key to successful outcome is early suspicion of such a defect in the presence of heart failure following a period of relative cardiovascular stability. Anticipation of evolving myocardial dysfunction in the presence of seemingly minor chest wall injury and nonspecific electrocardiographic changes is emphasized. A case of a fatal traumatic ventricular septal defect is presented. The importance of early invasive monitoring with proper interpretation of hemodynamic data is discussed.

The safety of continuous epidural infusion for postoperative analgesia in pediatric spine surgery.

Epidural analgesia and anesthesia are standard regional techniques in orthopaedic surgery of the lower extremities. Benefits of epidural anesthetic infusions include excellent analgesia, minimal respiratory depression, no somnolence, and decreased need for blood transfusion. Adverse effects include pruritus, nausea, and urinary retention, but standard methods have evolved to counter each adverse effect. A continuous epidural infusion of opioid and bupivacaine was used as the principal postoperative analgesic for 71 young patients undergoing surgery for the correction of spinal deformity. The infusion was titrated to a point at which each patient denied having any pain and was maintained for an average of 2.9 days. Sixty-four patients experienced satisfactory analgesia with minimal adverse effects. The technique worked despite multiple laminotomies for segmental fixation and did not compromise neurologic assessment. We conclude that epidural analgesia is as safe and effective after spinal-deformity surgery as it is after other types of surgery.