ABO-incompatible blood transfusion and invasive therapeutic approaches during pediatric cardiopulmonary bypass.

Human error has been identified as a major source of ABO-incompatible blood transfusion which most often results from blood being given to the wrong patient. We present a case of inadvertent administration of ABO-incompatible blood to a 6-mo-old child who underwent congenital heart surgery and discuss the use of invasive therapeutic approaches. Invasive techniques included total circulatory arrest and large-volume exchange transfusion, along with conventional ultrafiltration and plasmapheresis, which could all be performed rapidly and effectively. The combination of standard pharmacologic therapies and alternative invasive techniques after a massive ABO-incompatible blood transfusion led to a favorable outcome in our patient.

Methemoglobin levels during epidural anesthesia for renal transplantation--comparison of prilocaine with bupivacaine.

BACKGROUND AND OBJECTIVE: One goal of anesthesia for renal transplantation is to avoid an excess load to be imposed on the newly functioning kidney, by using appropriate agents and dosages in the perioperative management. The purpose of this study was to investigate the effect of prilocaine on serum methemoglobin levels when used as the local anesthetic in epidural anesthesia for renal transplantation, and to compare its effects with that of bupivacaine, which is the standard local anesthetic used. METHODS: 26 adult renal recipients were randomized into 2 equal groups according to the local anesthetic used for epidural anesthesia during the operation. Patients in group P (n = 13) were given prilocaine and those in group B (control, n = 13) received bupivacaine. The methemoglobin measurement intervals were at: baseline before administration of local anesthetic, and then at 2 hours, 5 hours, and 12 hours of local anesthetic administration. RESULTS: Methemoglobin levels in the prilocaine group were above the normal range in all measurements other than baseline. In the bupivacaine group, methemoglobin levels increased only at 5 hours of local anesthetic administration. However, methemoglobin concentrations and hemoglobin levels were comparable between the two groups at all time intervals, and none of the patients demonstrated clinical symptoms. CONCLUSION: The use of prilocaine in epidural anesthesia for renal transplantation surgery resulted in an increase in methemoglobin levels, which did not cause any clinical symptoms and was similar to those of bupivacaine at all time measurements.

Fluid resuscitation of acute hemorrhage in uninephrectomized rabbits--effects on the early function of the remnant kidney.

The aim of this study was to determine the effects of fluid resuscitation of acute hemorrhage on the early function and histopathology of the remnant kidney in uninephrectomized rabbits. Thirty-nine adult rabbits were studied in four groups. Group 1 (n = 8) included healthy controls; Group 2 (n = 10) healthy, bled animals; Group 3 (n = 10) uninephrectomized, non-bled animals; and Group 4 (n = 11) uninephrectomized, bled animals. In the hemorrhage groups, 8 mL kg(-1) of blood was drawn, and replaced with lactated Ringer's solution three times the volume of shed blood. Urine and blood samples were collected after 120-minutes of observation. None of the animals experienced hypotension during the study period. Serum and urinary electrolytes were similar between the Groups (p > 0.05). Urine output was lower in Groups 3 and 4 than in Group 1 (p = 0.001, both). Urinary microalbumin, NAG, fractional sodium excretion and creatinine clearance were similar in all four Groups. Light microscopic evaluation revealed only slight enlargement of the proximal tubule lumen in the renal medulla of the rabbits that were both uninephrectomized and bled. We observed no deleterious effects of well resuscitated hemorrhage on early function and histopathology of the remnant kidney in uninephrectomized rabbits.

Knowledge of basic life support: a pilot study of the Turkish population by Baskent University in Ankara.

A total of 494 participants who were scheduled to take Baskent University's basic life support (BLS) training programme in 2001-02 were asked to complete a 25-item questionnaire prior to the course. The questionnaire investigated the demographic characteristics of the subjects, their knowledge of the theoretical and practical aspects of BLS, and personal experience and attitudes related to BLS. The 'non-medical group' included 179 laypersons, and the 'medical group' was composed of medical students (n=220), residents (n=69) and clinical nurses (n=26). One-hundred and twenty-six (25.5%) of the participants had an encounter with some form of medical emergency event in their past and 207 (41.9%) had taken a BLS course previously. The most commonly cited anxiety about performing BLS was the fear of further harming the victim (56.9%). Nine of the participants said they would not perform mouth-to-mouth ventilation (1.8%). Compared to the other participants, individuals with previous emergency experience, and those who had previous BLS training answered significantly more of the theoretical questions correctly. However, neither of these groups performed significantly better than the other participants in the practical questions (P>0.05 for both comparisons). Based on our findings, we recommend that BLS training for medical undergraduates, other medical personnel and laypersons be improved and standardized throughout Turkey.

Tracheoesophageal fistula and associated congenital heart disease: implications for anesthetic management and survival.

BACKGROUND: Infants with tracheoesophageal fistula (TEF) and/or esophageal atresia (EA) frequently have other associated congenital anomalies which can have a significant impact on their anesthetic care and survival to discharge. METHODS: A medical record review and retrospective data analysis were performed in a university affiliated children's hospital of all infants undergoing TEF/EA repair between January 1998 and July 2004. The incidence of intraoperative complications during the TEF repair and overall survival to hospital discharge was compared in two groups of infants: 26 patients with TEF/EA and coexisting congenital heart disease (CHD), and 27 patients with TEF/EA and no CHD. RESULTS: The overall incidence of intraoperative critical events during repair of TEF/EA was significantly higher in infants with associated cardiac pathology (P = 0.003). Six of 53 infants died during hospitalization (overall mortality, 11.3%) and all had associated cardiac pathology. In comparison with nonductal-dependent lesions, the presence of a ductal-dependent cardiac lesion appeared to significantly increase patient mortality (57% vs. 10%, P = 0.028). CONCLUSIONS: Low birth weight (<1500 g) and associated cardiac pathology were found to be independent predictors of mortality in infants undergoing surgery for TEF/EA repair. The presence of a ductal-dependent cardiac lesion further increased the risk of morbidity and mortality, in addition to necessitating special anesthesia considerations.

Remifentanil use in children undergoing congenital heart surgery for left-to-right shunt lesions.

OBJECTIVE: The authors compared the effects of remifentanil with fentanyl on the hemodynamic and respiratory variables in children with left-to-right shunting and pulmonary hypertension. DESIGN: A prospective, randomized, and controlled design. SETTING: University hospital. PARTICIPANTS: Children aged between 3 months and 6 years undergoing pediatric cardiac surgery for correction of left-to-right intracardiac shunting. INTERVENTIONS: Children were assigned to 1 of the 2 opioids for intraoperative use. Fentanyl was given as a 20 microg/kg intravenous bolus followed by infusion at a rate of 20 microg/kg/h in group 1 (control, n=15), and remifentanil was given as a 2 microg/kg intravenous bolus followed by infusion at a rate of 2 microg/kg/min in group 2 (n=18). MEASUREMENTS AND MAIN RESULTS: Mean arterial pressures at 30 to 40 minutes postbypass and the first 2 hours postsurgery were higher in the remifentanil group (p<0.05). Heart rates, pulmonary artery pressures, and airway pressures did not differ at any time between groups. Peripheral oxygen saturation values were lower at 30 and 45 minutes in the prebypass period and higher at 1 to 4 hours in the intensive care unit in the remifentanil group (p<0.05). After protamine administration, transient peripheral oxygen desaturation was observed with 10 children in the remifentanil group and with 3 children in the fentanyl group without any hemodynamic deterioration (p=0.029). CONCLUSION: There were no clinically important differences in hemodynamic and respiratory measurements intraoperatively and during the initial 24 hours postoperatively between fentanyl and remifentanil in pediatric patients undergoing surgical repair of defects with left-to-right shunts.

Anesthetic management and outcome of complex late arterial-switch operations for patients with transposition of the great arteries and a systemic right ventricle.

OBJECTIVE: For patients with transposition of the great arteries and a systemic right ventricle, complex late arterial-switch operations (double switch, switch conversion, Senning-Rastelli) after the newborn period have been described recently to restore the morphologic left ventricle to the systemic circulation. The purpose of this study was to describe the anesthetic management and perioperative outcome of this group of patients and to compare them with a control group of patients who had primary arterial-switch operations in the neonatal period. DESIGN: Retrospective database and medical record review with 3:1 control:case ratio. SETTING: Tertiary care academic children's hospital. PARTICIPANTS: Patients undergoing complex late-arterial switch operations after the newborn period. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Thirteen patients were identified in the complex late-switch group and 43 in neonatal arterial-switch group. There were no perioperative deaths, no new gross neurologic deficits, and all patients were discharged home in both groups. Anesthetic and bypass times were significantly longer in the late-switch group (745 v 558 minutes, p < 0.001, and 382 v 243 minutes, p < 0.001, respectively). Transfusion requirements were similar between the groups. The incidence of arrhythmia (92% v 9%, p < 0.001), use of pacing systems (69% v 9%, p < 0.001), cardioversion (15% v 0%, p = 0.05), and pharmacologic treatment of arrhythmias (69% v 0%, p < 0.01) intraoperatively were significantly higher in the complex late-switch group. CONCLUSIONS: Patients presenting for complex late corrective operations for transposition of the great arteries require long and complex anesthetics. Despite these challenges, perioperative outcomes are excellent.

Difficult intubation in pediatric cardiac anesthesia.

OBJECTIVE: The aim of this study was to investigate cases of difficult intubation in pediatric cardiac surgical patients and to evaluate the importance of associated congenital abnormalities. DESIGN: Retrospective analysis. SETTING: Departments of Anesthesiology and Pediatric Cardiovascular Surgery of a tertiary university hospital. PARTICIPANTS: All children undergoing congenital heart surgery. INTERVENTIONS: Patients who had difficult intubations according to their anesthetic charts were further evaluated from hospital files for demographic characteristics, associated congenital abnormalities, and perioperative airway and/or respiratory complications. MEASUREMENTS AND MAIN RESULTS: A total of 1,278 pediatric patients with congenital heart disease were operated on from January 1999 to July 2002. Difficult intubation was encountered in 16 cases (1.25%). Two of these were newborns, 11 were infants, and 3 were in the pediatric age group. Anterior larynx was the most common reason for difficult intubation (7 cases, 43.7%). There were associated syndromes and/or other congenital abnormalities in 8 children (50%). CONCLUSION: The likelihood of difficult intubation during pediatric cardiac surgery, especially in cases with other congenital pathologies should be kept in mind, and the anesthetic approach must be planned accordingly.

Anesthetic risks for donors in living-related liver transplantation: analysis of 30 cases.

Liver transplantation involving living-related donors has been adopted in many centers as a way of relieving organ shortage. This study reviewed the anesthetic considerations for donor operations at our institution in relation to intraoperative blood transfusion, complications, and postoperative liver function test results. From January 1990 to May 2001, 30 living-related liver transplantations were performed at Baskent University Hospital, Ankara. The donor data used for analysis were retrospectively obtained through chart review, anesthesia records, and the computerized hospital database. Left lobectomy was performed in 19 cases, and left lateral segmentectomy in 11 cases. Intraoperatively, the average volume of intravenous fluids used was 6431+/-468 ml, and the average amount of blood transfused was 2.1+/-0.4 units. The mean postoperative hospital stay was 11.5+/-1.3 days. The only intraoperative complication observed in these 30 donors was severe bleeding during retrohepatic vena cava dissection in one of the cases. The postoperative complications related to anesthesia were one case each of shoulder pain, neuropraxia, and compartment syndrome. The levels of total and direct bilirubin, aspartate aminotransferase, and alanine aminotransferase peaked within the first 2 postoperative days (2.19+/-0.36 mg/dl, 1.02+/-0.18 mg/dl, 245.7+/-26.6 U/l, 313.5+/-51.9 U/l, respectively). In all 30 donors, these levels had normalized by 1 month after surgery. Maximal efforts must be applied in the anesthetic approach to minimize donor complications in living-related liver transplantation; however, this will not completely eliminate some risks to the donor.