Review of electrical impedance tomography in the pediatric patient.

Electrical impedance tomography (EIT) is a new method of monitoring non-invasive mechanical ventilation, at the bedside and useful in critically ill patients. It allows lung monitoring of ventilation and perfusion, obtaining images that provide information on lung function. It is based on the physical principle of impedanciometry or the body's ability to conduct an electrical current. Various studies have shown its usefulness both in adults and in pediatrics in respiratory distress syndrome, pneumonia and atelectasis in addition to pulmonary thromboembolism and pulmonary hypertension by also providing information on pulmonary perfusion, and may be very useful in perioperative medicine; especially in pediatrics avoiding repetitive imaging tests with ionizing radiation.

Perioperative management of patients with arrhythmogenic syndromes refractory to medical treatment: A clinical case report.

Family heart diseases related to sudden death are a group of cardiovascular diseases (cardiomyopathies, channelopathies, aortic diseases …) that require familiarity of the anesthesiologist with the perioperative treatment of complex hemodynamic disorders, as well as their surgical treatment.1 We present the case of a 12-year-old man diagnosed with non-obstructive hypertrophic cardiomyopathy (MHNO), after cardiorespiratory arrest (PCR), who underwent video-guided thoracoscopy-guided left sympathectomy (VATS) for frequent syncope, despite pharmacological treatment and implantation of an implantable automatic defibrillator (ICD). Whenever arrhythmic syncope occurs in the setting of familial heart disease, left heart denervation should be considered as the next step in the treatment plan.2.

Perioperative management of patients with arrhythmogenic syndromes refractory to medical treatment: A clinical case report. / Valoración y tratamiento perioperatorio de los pacientes con síndromes arritmogénicos refractarios a tratamiento médico: a propósito de un caso clínico.

Family heart diseases related to sudden death are a group of cardiovascular diseases (cardiomyopathies, channelopathies, aortic diseases...) that require familiarity of the anesthesiologist with the perioperative treatment of complex hemodynamic disorders, as well as their surgical treatment1. We present the case of a 12-year-old man diagnosed with non-obstructive hypertrophic cardiomyopathy, after cardiorespiratory arrest, who underwent video-guided thoracoscopy-guided left sympathectomy for frequent syncope, despite pharmacological treatment and implantation of an implantable automatic defibrillator. Whenever arrhythmic syncope occurs in the setting of familial heart disease, left heart denervation should be considered as the next step in the treatment plan2.

Original and minimally invasive approach to a left-lung refractory atelectasis after reparation of an aortic recoarctation in a lactant: Selective endobronchial CPAP.

Atelectasis is one of the most common respiratory complications in pediatric patients after open-heart surgery, and may lead to weaning failure and increased morbidity. We report the use of an original, minimally invasive approach to refractory left lung atelectasis after repair of an aortic coarctation in a 2 month-old infant, in which a CPAP system connected to a flexible endobronchial tube resolved the atelectasis.

[Inhaled anesthesia through a device for noninvasive continuous positive airway pressure ventilation for upper digestive endoscopy in pediatric patients]. / Anestesia inhalatoria mediante un dispositivo de ventilación no invasiva tipo "CPAP sin respirador" para endoscopia digestiva alta en pacientes pediátricos.

OBJECTIVE: The demand for sedation for pediatric diagnostic procedures performed outside operating rooms has increased considerably, but the ideal method to choose has been the subject of debate. The aim of this study was to assess the efficacy of using a device for continuous positive airway pressure, connected to a Mapleson D circuit and a nasopharyngeal tube as the interface, in order to ventilate and administer sevoflurane for upper digestive tract endoscopy in children. MATERIAL AND METHODS: Prospective cohort study of children undergoing upper digestive tract endoscopy. We recorded epidemiologic variables, heart rate, mean arterial pressure, arterial oxygen saturation and procedure-related adverse events before, during and 10 minutes after the procedure. Time spent in the recovery room was also recorded. The endoscopist asked the patients about their level of satisfaction and whether they had noticed any irritating smell or gas smell. RESULTS: Data was collected on 29 patients (17 boys, 12 girls) with a mean (SD) age of 4.2 (3.9) years. The mean duration of endoscopy was 15 (7) minutes. Arterial oxygen saturation below 92% during the procedure did not occur and the endoscopic exploration was completed satisfactorily with this technique in 28 patients (96%). All were discharged from the recovery room within 30 minutes. The endoscopist reported that the technique was considered satisfactory in all cases, although 2 children noted an anesthetic "gas" smell. CONCLUSIONS: A modified Mapleson D circuit and nasopharyngeal tube can be used effectively as an interface for noninvasive ventilation and administration of sevoflurane during upper digestive endoscopy in pediatric patients.

[Anesthetic induction with nitrous-oxide-free sevoflurane in pediatric patients]. / Inducción anestésica con sevoflurano libre de óxido nitroso en pediatría.

OBJECTIVE: To evaluate the pediatric use of inhaled nitrous oxide (N2O)-free induction with sevoflurane for the purpose of protecting staff from exposure to workplace air pollution. PATIENTS AND METHODS: Prospective, randomized trial in ASA class 1-2 children in whom a tidal breathing technique was used for anesthetic induction in a variety of surgical procedures. Patients were allocated to 2 groups. The sevo-N2O group inhaled 8% sevoflurane in a 60/40% mixture of oxygen and N2O. The sevo-air group received 8% sevoflurane in a mixture of oxygen and air (inspired oxygen fraction, 40%). We recorded mean arterial pressure (MAP), heart rate, oxygen saturation by pulse oximetry (SpO2), limb response to venous puncture, alveolar concentration of sevoflurane, and incidence of adverse events. RESULTS: Twenty-two patients were assigned to each group. The vein was catheterized in all patients without a pain reflex in the limb, and there were no statistically significant differences in MAP, heart rate, SpO2, or incidence of adverse events. Mean (SD) alveolar concentration of sevoflurane, however, differed between the 2 groups: 53% (0.51%) in the sevo-N2O group and 4.91% (0.41%) in the sevo-air group (P = .028). CONCLUSIONS: N2O-free anesthetic induction by tidal breathing of 8% sevoflurane provides similar anesthetic conditions (efficacy, safety, and rapid onset) without a higher incidence of adverse events. The use of N2O can therefore be avoided.

[Evaluation of a continuous positive airway pressure system without a ventilator to treat acute respiratory failure in children]. / Evaluación de un dispositivo de CPAP sin respirador en la insuficiencia respiratoria aguda en pediatría.

OBJECTIVE: Noninvasive continuous positive airway pressure (CPAP) is widely used in pediatric patients with acute respiratory failure. However, the lack of specific interfaces and appropriate ventilators and poor tolerance of the technique by these patients can lead to failure of the application. The aim of this study was to analyze the efficacy of a CPAP system using a modified Mapleson breathing circuit during acute respiratory failure in pediatric patients. MATERIAL AND METHODS: We performed a prospective observational study in children with acute respiratory failure in whom noninvasive ventilation was indicated. CPAP was applied through a Mapleson D circuit fitted with a manometer and a nasopharyngeal tube as the interface. Heart rate, respiratory rate, inspired oxygen fraction (FiO2), PaO2, PaCO2, and pulse oximetry were measured before treatment and after 2 hours of treatment. RESULTS: Sixteen patients with a mean age of 3.8 years were studied for a period of 18 months. We observed a mean (SD) change in PaCO2 from 66.8 (18.08) mm Hg to 46.48 (5.9) mm Hg after CPAP (P=.16) and a mean change in the PaO2/FiO2 ratio from 201 (111) to 262 (115) after CPAP (P=.30). The mean heart rate fell from 156 (22) beats/min to 127 (18) beats/min (P=.05) and the mean respiratory rate from 53 (15) breaths/min to 33 (13) breaths/min (P<.05). No severe complications were recorded and tolerance was satisfactory. The technique was considered a success in 12 patients (75%). CONCLUSIONS: CPAP without a ventilator, through a Mapleson D circuit, can be used with a high success rate to provide noninvasive ventilation for pediatric patients with acute respiratory failure.

Cardiac arrest related to anaesthesia in Williams-Beuren syndrome. / Parada cardíaca relacionada con la anestesia en el síndrome Williams-Beuren.

Williams-Beuren syndrome is the clinical manifestation of a congenital genetic disorder in the elastin gene, among others. There is a history of cardiac arrest refractory to resuscitation manoeuvres in anaesthesia. The incidence of myocardial ischaemia is high during anaesthetic induction, but there are patients who do not have this condition yet also have had very serious cardiac events, and issues that are still to be resolved. Case descriptions will enable the common pathophysiological factors to be defined, and decrease morbidity and mortality. We report the case of a 3-year-old boy with cardiac arrest at induction, rescued with circulatory assistance with extracorporeal membrane oxygenation and hypothermia induced for cerebral protection.

The importance of bilateral monitoring of cerebral oxygenation (NIRS): Clinical case of asymmetry during cardiopulmonary bypass secondary to previous cerebral infarction. / Importancia de la monitorización bilateral de la oxigenación cerebral: caso clínico de asimetría durante el bypass cardiopulmonar secundaria a infarto cerebral previo.

Cerebral oximetry based on near infrared spectroscopy (NIRS) technology is used to determine cerebral tissue oxygenation. We hereby present the clinical case of a 12-month old child with right hemiparesis secondary to prior left middle cerebral artery stroke 8 months ago. The child underwent surgical enlargement of the right ventricular outflow tract (RVOT) with cardiopulmonary bypass. During cardiopulmonary bypass, asymmetric NIRS results were detected between both hemispheres. The utilization of multimodal neuromonitoring (NIRS-BIS) allowed acting on both perfusion pressure and anesthetic depth to balance out the supply and demand of cerebral oxygen consumption. No new neurological sequelae were observed postoperatively. We consider bilateral NIRS monitoring necessary in order to detect asymmetries between cerebral hemispheres. Although asymmetries were not present at baseline, they can arise intraoperatively and its monitoring thus allows the detection and treatment of cerebral ischemia-hypoxia in the healthy hemisphere, which if undetected and untreated would lead to additional neurological damage.

Cerebral oximetry monitoring in the management of severe hypoxaemia associated with transposition of the great arteries with balloon atrial septostomy. / Monitorización de la oximetría cerebral en el manejo de la hipoxemia severa asociada a la transposición de grandes arterias mediante atrioseptostomía con balón.

Transposition of the great arteries (D-TGA) is one of the most common congenital heart diseases requiring neonatal surgical intervention. In the desperately ill neonate with TGA and the resultant hypoxaemia, acidemia, and congestive heart failure, improvement is often obtained with balloon atrial septostomy (BAS). Current methods employed to evaluate oxygen delivery and tissue consumption are frequently nonspecific. Near infrared spectroscopy (NIRS) allows a continuous non-invasive measurement of tissue oxygenation which reflects perfusion status in real time. Because little is known about the direct effect of BAS on the neonatal brain and on cerebral oxygenation, we measured the effectiveness of BAS in two patients with D-TGA using NIRS before and after BAS. We concluded BAS improves cerebral oxygen saturation in neonates with D-TGA.

[Effect of tranexamic acid on postoperative bleeding in pediatric heart surgery]. / Efecto del ácido tranexáimico en el sangrado postoperatorio de cirugía cardiaca en pediatría.

OBJECTIVE: To assess the effects of a single dose of tranexamic acid on bleeding and requirement for blood product transfusion in children undergoing cardiac surgery with cardiopulmonary bypass. PATIENTS AND METHODS: A prospective study of closed cohorts undergoing pediatric heart surgery was carried out. The children weighed between 4 and 10 kg. Reoperated and cyanotic patients were included in the sample. The treatment group received 50 mg x kg(-1) of tranexamic acid before surgery. Analyzed data collected during the first 24 hours after surgery were biochemical parameters, bleeding, use of blood products, and D-dimer levels. RESULTS: Fifty-three patients, 25 in the treatment group, were enrolled. Patients on treatment had 24.8% less bleeding in the first 24 hours after surgery (P = .02). The transfusion of blood products was 20% less in the treatment group, although the difference was not significant except in the subgroup of patients who were reoperated. In that group the amount of blood products transfused was 72% less than in the control group (P = .05). D-dimer levels were also lower in the treatment group (P = .003). No adverse effects attributable to the treatment were observed. CONCLUSIONS: A single preoperative dose of tranexamic acid to inhibit fibrinolysis reduces bleeding 24.8% in pediatric patients undergoing heart surgery with cardiopulmonary bypass. The effect is greater in reoperated patients, leading to a reduction in their requirement for transfusion. The use of this therapy in these patients is therefore highly justified.

[Occupational exposure to nitrous oxide and sevoflurane during pediatric anesthesia: evaluation of an anesthetic gas extractor]. / Exposición laboral al óxido nitroso y sevoflurano durante la anestesia en pediatráa: evaluación de un dispositivo de extracción de gases anestésicos.

OBJECTIVES: To determine the level of occupational exposure to anesthetic gases in the absence of an extractor during pediatric anesthesia and to assess the efficacy of a purpose-built extraction system. METHODS: The patients were 24 children undergoing tonsillectomy and adenoidectomy. Gases were extracted from the room for 1 group and were not extracted for the other group (n=12 in each group). Induction was with 8% sevoflurane, 60% nitrous oxide (N2O), 40% oxygen at a flow rate of 8 L x min(-1) through a Mapleson C circuit. Maintenance was with 2% sevoflurane at the same flow rate and gas mixture under spontaneous ventilation with an endotracheal tube and a Mapleson D circuit. The circuits were equipped with an airway pressure-limiting valve to allow connection to an anesthetic gas extractor. Ambient levels of sevoflurane and N2O were measured in the breathing area around the anesthesiologist. The surgeon and the nurse were asked about symptoms related to occupational exposure. RESULTS: The mean (SD) exposure to N2O and sevoflurane in the group without an extractor was 423 (290) and 12 (10.9) parts per million (ppm), respectively. In the group working with the extractor, exposure was 94% and 91% lower: 24.7 (26) and 1.1 (1) ppm (P<.001). A higher incidence of noticing a "smell of gas" was registered for the group without an extractor (87% vs 11% in the extractor group, P=.003). Higher rates were also found for general discomfort (62% vs 11%, P=.05), nausea (62% vs 0%, P=.009), and headache (62% vs 0%, P=.009) in the absence of the extractor. CONCLUSIONS: Gas extraction decreased the level of exposure by up to 94%, achieving levels that were below the recommended limits and greatly reducing occupational risk.

[Upper respiratory tract infections in children: impact on surgical scheduling at a pediatric hospital]. / Repercusión de la infección de vía respiratoria alta en niños sobre la programación quirúrgica en un hospital infantil.

OBJECTIVE: To determine the rate of cancelation of scheduled surgical procedures attributable to upper respiratory tract infection (URTI) in our university pediatric hospital in Madrid and to analyze the effect that literature reviews and appropriate counseling of parents would have on cancelations. MATERIAL AND METHODS: We carried out a retrospective study of the reasons for canceling scheduled pediatric ear, nose, or throat operations in 2001, 2002, 2003, and 2004. Statistical comparisons were performed with the chi2 test. RESULTS: In 2001, 24% of the 641 procedures scheduled were canceled, 12.9% of them because of URTIs. After applying criteria based on a review of the literature, 15% of the 751 procedures were canceled in 2002, 4.9% of them because of URTIs (P<0.0001 in comparison with 2001). In 2003 14.3% of the 760 scheduled procedures were canceled, 6.5% because of URTIs (P<0.0001 in the comparison with 2001). In 2004 12.2% of the 692 scheduled procedures were canceled, 7.2% because of URTIs (P<0.0001 in comparison with 2001). Cancelations in autumn-winter or in spring-summer seasons amounted to 28.2% vs 19.8% in 2001, 17.1% vs 12.7% in 2002, 16.6% vs 11.8% in 2003, and 13.8% vs 11.1% in 2004. CONCLUSIONS: URTIs are responsible for a high rate of cancelations of scheduled operations, particularly in colder seasons of the year. To obtain optimal results, criteria based on up-to-date literature reviews should be put into effect and parents should be given appropriate information.

[Resuscitation of the burned child in critical condition]. / Reanimación del niño quemado en estado crítico.

Recent advances in surgical techniques, control of infection and nutritional support have dramatically increased the survival rates of burned children. The characteristics of severely burned pediatric patients dictate that management be different from that required for adults in the intensive care unit. The formulas for fluid replacement should be based on body surface rather than weight in children and adjusted for degree of stress and age, with appropriate monitoring and treatment of hypothermia, pain and associated psychological disorders. Early assessment and treatment of airway obstruction and gas and smoke inhalation syndromes with high FiO2 is necessary; prophylactic endotracheal intubation may be required.

[Sevoflurane anesthesia for magnetic resonance procedures in pediatrics]. / Anestesia con sevoflurano para exploraciones de resonancia magnética en pediatría.

OBJECTIVE: To assess the efficacy and safety of sevoflurane anesthesia in children during magnetic resonance imaging procedures. MATERIAL AND METHODS: The patients were 105 ASA-I-II children, mean weight 13 +/- 10 Kg and mean age 2.9 years (range 1 day-10 years), twenty (20%) of whom were under 3 months old. Induction was gradual with 6% sevoflurane in a mixture of nitrous oxide and oxygen, followed by maintenance with 1-2% sevoflurane in the same mixture through a face mask or nasal tubes while the patient breathed spontaneously. All procedures were performed satisfactorily. Ten minutes after anesthesia, 88% of the patients were fully awake. None suffered prolonged sedation and no serious complications occurred during the study period. The most common side effects were transient decreases in oxygen saturation in 15 patients (14%), although none reached the critical level (SpO2 < 90%). Six of those patients were under 3 months old. After recovering from sedation, 13 patients (12%) suffered transient episodes of excessive agitation, usually 5 minutes after awakening. Five patients (4.8%) vomited in the recovery room. CONCLUSIONS: This study indicates that sevoflurane is safe and effective for sedating children, including newborn infants, who must undergo magnetic resonance imaging.

[Anesthesia for a pediatric multivisceral transplant]. / Anestesia en el trasplante multivisceral en pediatría.

A 15-year-old female with short intestine syndrome due to chronic intestinal pseudo-obstruction associated with kidney failure underwent a multivisceral (stomach-duodenum-jejunum-ileum-pancreas-liver) and kidney transplant. She had required parenteral nutrition for the last 5 years, with numerous complications such as sepsis from the central catheter, deep venous thrombosis, severe liver dysfunction, pancytopenia due to bone marrow failure, and severe malnutrition. Surgery lasted 15 hours and was free of complications other than hypothermia, which worsened after revascularization of the grafts. Replacement of 6 units of blood products and crystalloids was required. Biochemical and hemodynamic variables were stable, apart from the development of hypernatremia, hyperglycemia, and lactic acidosis. The anesthetic approach included preoperative assessment of problems related to chronic parenteral nutrition (liver dysfunction, coagulopathy, and restricted venous access), the prevention of hypothermia, correction of electrolyte imbalance and the acid-base status, treatment of reperfusion syndrome, and the replacement of fluids and blood products to maintain circulatory homeostasis and assure sufficient splanchnic perfusion.

[Anesthesia-related cardiac arrest in children. Data from a tertiary referral hospital registry]. / Parada cardiaca relacionada con la anestesia en pediatría. Registro en un hospital infantil terciario.

OBJECTIVES: The aim of this study is to analyze the cardiac arrests related to anesthesia in a tertiary children's hospital, in order to identify risk factors that would lead to opportunities for improvement. METHODS: A 5-year retrospective study was conducted on anesthesia related cardiac arrest occurring in pediatric patients. All urgent and elective anesthetic procedures performed by anesthesiologists were included. Data collected included patient characteristics, the procedure, the probable cause, and outcome of the cardiac arrest. Odds ratio was calculated by univariate analysis to determine the clinical factors associated with cardiac arrest and mortality. RESULTS: There were a total of 15 cardiac arrests related to anesthesia in 43,391 anesthetic procedures (3.4 per 10,000), with an incidence in children with ASA I-II versus ASA≥III of 0.28 and 19.27 per 10,000, respectively. The main risk factors were children ASA≥III (P<.001), less than one month old (P<.001), less than one year old (P<.001), emergency procedures (P<.01), cardiac procedures (P<.001) and procedures performed in the catheterization laboratory (P<.05). The main causes of cardiac arrest were cardiovascular (53.3%), mainly due to hypovolemia, and cardiovascular depression associated with induction of anesthesia, followed by respiratory causes (20%), and medication causes (20%). The incidence of mortality and neurological injury within the first 24h after the cardiac arrest was 0.92 and 1.38 per 10,000, respectively. The mortality in the first 3 months was 1.6 per 10,000. The main causes of death were ASA≥III, age under one year, pulmonary arterial hypertension, cardiac arrest in areas remote from the surgery area, a duration of cardiopulmonary resuscitation over 20min, and when hypothermia was not applied after cardiac arrest. CONCLUSION: The main risk factors for cardiac arrest were ASA≥III, age under one year, emergency procedures, cardiology procedures and procedures performed in the catheterization laboratory. The main cause of the cardiac arrest was due mainly to cardiovascular hypovolemia. All patients who died or had neurological injury were ASA≥III. Pulmonary arterial hypertension is a risk of anesthesia-related mortality.

Valoración y tratamiento perioperatorio de los pacientes con síndromes arritmogénicos refractarios a tratamiento médico: a propósito de un caso clínico / Perioperative management of patients with arrhythmogenic syndromes refractory to medical treatment: A clinical case report

Las cardiopatías familiares relacionadas con la muerte súbita son un grupo de enfermedades cardiovasculares (miocardiopatías, canalopatías, enfermedades aórticas…) que requieren familiaridad del anestesiólogo con el tratamiento perioperatorio de los trastornos hemodinámicos complejos, así como con el tratamiento quirúrgico de los mismos1. Presentamos el caso de un varón de 12 años diagnosticado de miocardiopatía hipertrófica no obstructiva, tras una parada cardiorrespiratoria, al que se le practicó una simpatectomía izquierda guiada por videotoracoscopia por síncopes frecuentes, a pesar de tratamiento farmacológico e implantación de un desfibrilador automático implantable. Siempre que se produzca un síncope arrítmico en el contexto de enfermedades cardiacas familiares, la denervación cardiaca izquierda debe considerarse como el siguiente paso en el plan de tratamiento2.(AU)

Family heart diseases related to sudden death are a group of cardiovascular diseases (cardiomyopathies, channelopathies, aortic diseases...) that require familiarity of the anesthesiologist with the perioperative treatment of complex hemodynamic disorders, as well as their surgical treatment1. We present the case of a 12-year-old man diagnosed with non-obstructive hypertrophic cardiomyopathy, after cardiorespiratory arrest, who underwent video-guided thoracoscopy-guided left sympathectomy for frequent syncope, despite pharmacological treatment and implantation of an implantable automatic defibrillator. Whenever arrhythmic syncope occurs in the setting of familial heart disease, left heart denervation should be considered as the next step in the treatment plan2.(AU)