Time-dependent perioperative anesthetic management and outcomes of the first 100 consecutive cases of spring-assisted surgery for sagittal craniosynostosis.

BACKGROUND: The anesthetic risks and outcomes of the first 100 consecutive spring-assisted surgeries (SAS) for cranial expansion from a single institution are reported. The effect of number of procedures was also tested on hematocrit postoperative day 1 (POD1), anesthesia time, and surgery time of the first procedure. METHODS: The records of 100 consecutive patients undergoing SAS were reviewed. Anesthesia management and related complications are presented. Time series linear regression analysis was performed on hematocrit POD1, anesthesia time, and surgery time of the first procedure. RESULTS: The average age of the first insertion procedure was 4.4 and 9.0 months for the second removal procedure. Two patients were inadvertently extubated during positioning. Thirty-eight children had a decrease in blood pressure >20% from baseline. No child was admitted to the intensive care unit. No patient received any blood or blood product transfusion. Anesthesia time, surgery time, and hematocrit POD1 were correlated with procedure number or experience. CONCLUSIONS: Changes in anesthetic management resulted from changing the procedure. The reduction in volume resuscitation reduces the need for invasive monitoring. Facility and comfort with the surgical procedure increase with time and number of procedures performed. This experience further reduces blood loss and risk of transfusion.

Video-assisted ductal ligation in premature infants.

BACKGROUND: Video-assisted thoracic surgery has been shown to be a safe and effective method of closing the patent ductus arteriosus in infants and children. We have applied this technique in low birth weight premature infants and now report our experience. METHODS: Since 1996, we have used video-assisted thoracic surgery ligation as the treatment of choice for all patent ductus arteriosus, including 100 performed on premature infants (23 to 31 weeks' gestation, mean 25.6 weeks; 0.420 to 1.5 kg, mean 0.859 kg). A modification of our previously described technique was used with a three-port approach. All patients had some degree of symptoms of congestive failure with failure to wean from ventilatory support or oxygen dependency. Five infants had associated patent foramen, and 1 had a small ventricular septal defect. RESULTS: All 100 procedures were performed in the operating room. One infant was found to have a coarctation, and the procedure was aborted. The remaining 99 were successfully ligated, although three were converted to an open procedure (3%) because of coagulopathy, poor pulmonary compliance, or hemodynamic instability. There were no procedure-related deaths; however, 15 infants subsequently died of complications of prematurity, including enterocolitis, sepsis, and late respiratory failure. Six infants had chest tubes left in place for coagulopathy, effusions, suspected air leak, and existing empyema. There were six residual pneumothoraces, four requiring treatment. CONCLUSIONS: Video-assisted thoracic surgery is a safe and effective technique for patent ductus arteriosus ligation in premature infants, including those with very low and extremely low birth weight.

Surgical advancement influences perioperative care: a comparison of two surgical techniques for sagittal craniosynostosis repair.

Methods for surgical correction of sagittal craniosynostosis have progressed. The hypothesis is that advances in surgical interventions for craniosynostosis affect perioperative anesthetic care. We reviewed the records of eight children who underwent cranial vault reconstruction (CVR) and nine who underwent spring-mediated cranial expansion (SME) for sagittal craniosynostosis. We compared the data from the CVR procedure to data from the combined procedures for SME (insertion and removal of springs). Anesthesia times were similar between the CVR (4 h 24 min) and the combined SME (4 h 27 min) groups, whereas surgical times were different between the CVR (3 h 25 min) and combined SME groups (2 h 21 min) (P = 0.002). Length of stay was 4.1 days for the CVR group (confidence interval [CI], 3.8-4.4 days) versus 3.1 days (CI, 2.9-3.4 days) in the combined SME group (P = 0.0001). Blood loss was significantly less in the combined SME group at 48 mL (CI, 29-83 mL) compared with the CVR group at 291 mL (CI, 230-352 mL). All eight patients in the CVR group received blood with a mean of 1.4 U (range, 1-2 U). No SME patient received any blood products. The reduction in blood loss with this new surgical treatment is significant for the patient in reducing blood transfusion and for the anesthesiologist in reducing concerns of volume resuscitation.