Cardiocirculatory intraoperative assessment during single-shot caudal anaesthesia in children: comparison between levobupivacaine and ropivacaine.

BACKGROUND: Caudal block with levobupivacaine or ropivacaine is the most commonly used regional anaesthesia in children. METHODS: The aim of study was to compare the cardiocirculatory profile induced in two matched groups of young patients, submitted to caudal anaesthesia with levobupivacaine or ropivacaine for an elective subumbilical surgery. Sixty children were enrolled: thirty received levopubivacaine 0.25% and thirty ropivacaine 0.2%. Intraoperative heart rate (HR), systolic blood pressure (SBP), diastolic blood pressure (DBP) were monitored at following times: Ta0 (after anaesthesia induction), Tal (after caudal anaesthesia), Ta2 (five minutes later), Ta3 (ten minutes later), Ts1 (at surgical incision), Ts2, Ts3, Ts4, Ts5 (every 10 minutes during surgery), Taw (at the awakening). RESULTS: In both groups the cardiocirculatory trend remained within normal ranges at all times considered, demonstrating the safety of the method with both drugs. Both groups showed a similar trend at the different monitoring times: low decrease in HR, SBP and DBP after caudal block, slight increase in parameters after skin incision, slight decrease during surgery, increase at awakening. Regarding SBP and DBP, the levobupivacaine group children generally showed higher levels compared to the ropivacaine group, especially for DBP. CONCLUSIONS: Paediatric caudal anaesthesia is an effective method with an very infrequent complication rate. Possible hypotheses for differing haemodynamic behaviour could include a stronger vasoconstriction reflex of innervated areas during caudal anaesthesia with levobupivacaine and a lower levobupivacaine induced block of the sympathetic fibers, related to different pharmacokinetic profile of low concentrations of the local anaesthetics used in paediatric epidural space.

Combined left pulmonary artery sling transposition and tracheal lobe resection through a median sternotomy: a case report.

INTRODUCTION: The aim of this paper was to report the management of a very rare malformative association of Left Pulmonary Artery (LPA) sling and Tracheal Lobe which is not still reported in scientific literature. MATERIALS AND METHODS: The Authors describe the clinical case of a 6 years old girl that was admitted for chronic respiratory symptoms associated with recurrent upper respiratory infections. The CT-scan with virtual bronchoscopy showed an ectopic bronchus arising from the right side of the upper third of the trachea and ending in an accessory pulmonary lobe, covered by normal pleura, located in the upper mediastinum. The tracheo-broncoscopy showed a stenotic tracheal lumen with complete cartilaginous ring with an evident vascular pulsation in the middle of stenotic tract. An angio-CT confirmed the vascular anomalies with the LPA which passes between the lower trachea and the accessory tracheal bronchus and the coexistence of a persistent left superior vena cava. The surgical approach, after the thoracoscopic exploration, was a double procedure through a median sternotomy with cardiopulmonary bypass has permitted to excise completely the tracheal lobe and to reimplant the left pulmonary artery into the main pulmonary artery. RESULTS: No more upper respiratory symptoms or pulmonary infections have been observed during the clinical and instrumental follow up. CONCLUSIONS: Current controversy in the management of Pulmonary Artery sling include surgical approach (median sternotomy versus left thoracotomy), use or non-use of cardiopulmonary bypass, and reimplantation versus translocation with distal tracheal resection. In our experience LPA reimplantation and tracheal lobe resection have been made easily and safely by the same sternotomy utilized for the cardio-pulmonary by-pass.

Acute liver failure associated with a prolonged course of acetaminophen at recommended dosages in paediatric age.

Acetaminophen is considered as a safe analgesic and antipyretic drug in paediatric age. The main problem in the use of acetaminophen is acute liver failure after an overdose or an acute intoxication. We report a case of fulminant liver failure and spontaneous recovery in a patient treated with a prolonged course of acetaminophen at recommended dosages.

Protocols to manage postoperative pain in neonates and children hospitalized in a surgical ward. Methodological issues and cultural background.

The authors describe the cultural background and methods they adopted to construct protocols for analgesia in newborns and children hospitalized in a surgical ward. Drugs and dosages are reported in the Appendix, whereas scales for pain measurement and cut off ratings for rescue doses (or otherwise relevant) are described respectively in Tables 2 and 3. Genetics and cognitive structures play a crucial role in pain and analgesia. Protocols have a critical role, however their application must be tailored to the single child.

[Thoracoscopic treatment of oesophageal atresia]. / Correzione toracoscopica dell'atresia esofagea.

BACKGROUND: Advancements in minimally invasive surgery in newborns have allowed even the most complex neonatal procedures to be approached using these techniques. Other authors have demonstrated its efficacy in the treatment of the esophageal atresia with distal fistula. METHODS: We report our experience based on the thoracoscopic repair of esophageal atresia with distal fistula in two newborns. Birth weights were 2.800 g and 2.300 g respectively. The patients were intubated endotracheally and placed in a left prone position. Four trocars were inserted: the first one of 5 mm was positioned in the fifth intercostal space for the camera, the other two of 3 mm were positioned in the fourth intercostal space on the anterior and posterior axillary line respectively for the operative instruments. The last trocar of 3 mm was inserted in the third intercostal space on the anterior axillary line for the lung retractor. CO2 was insufflated at a pressure of 8 mm Hg and a flow of 0.5 L/min. The fistula was first isolated then ligated and cut with scissors. The proximal esophagus was opened and an anastomosis was made over a 6F or 8F nasogastric tube with interrupted 4-0 Vicryl sutures. A tube chest was placed through the lower trocar site with the tip near the anastomosis. RESULTS: These two procedures were free of neither intraoperative nor post-operative complications. Feeding by nasogastric tube was started after a mean of 4 days. Barium swallow made on day 7 demonstrated no leakage and no stenosis of the anastomosis. Total oral feeding was possible after 8 days. Mean hospitalization was 14 days. CONCLUSION: This initial report shows, as demonstrated by the experience since 1999 by other authors, that the thoracoscopic esophageal repair in the newborns is technically feasible and, thanks to a magnified vision, it allows to abtain a good isolation of the esophagus and of the tracheo-esophageal fistula respecting the anatomical structures. Moreover the advantages are in terms of exposure and esophageal length, avoiding the significant short and long-term morbidity associated with thoracotomy.

Secondary prevention of latex allergy in children: analysis of results.

OBJECTIVE: Latex allergy has become an increasing and clinically important problem. Several recommendation for secondary preventive measures have been advised. The aims of the study were to illustrate the results of the latex-safe protocol and to evaluate in allergic patients the role of risk factors for the development of latex allergy. METHODS: Latex-safe treatment was divided into the following phases: anamnestic identification, allergologic assessment, patient selection, intervention programme, preventive medication, operating room equipment, postoperative management, patient and family training, follow-up. RESULTS: Between 1998 and 2004, 6.832 patients underwent 7.333 operations. Anamnestic and diagnostic tests showed that 26 patients had latex allergy. 44 secondary perioperative latex-safe management have been accomplished in 26 children. No allergic event or complications linked to the procedure occurred. Atopy, congenital malformations frequently associated with latex allergy and the presence of 5 or more surgical procedures were the major risk factors recognized. Six out of the 26 patients (23%) had only one risk factor (atopy). Twenty out of 26 children (77%) had several associated risk factors: 8 of them had simultaneously 9 of the 10 analysed risk factors. Our data shows that, the higher their number, the higher the gravity of the allergy. CONCLUSIONS: Although latex allergy is a limited phenomenon, it is nevertheless quite frequent within risk groups. Most patients have simultaneously many risk factors for the development of such an allergy, and the occurrence of several risk factors increases severity of the allergy. Latex-safe perioperative management offers guarantees of safety against latex allergy phenomena.

A pain educational program for pediatric nurses: topics and key points.

The undertreatment of pain in children may lead to severe consequences. Basic knowledge about pain in this category of patients may improve pain assessment and its management. In line with the Project established by the Italian Ministry of Health, authors planned an educational program devoted to the pediatric nurses. The concept of brain and of cognitive development, the methodological bases of the pain measurement and the cognition of long-term consequences on pain have been the key points of the program. The course was efficacious and highly appreciated by nurses. The improvement of practice standards will be the true indicator of its efficacy.

Predictive outcome indexes in neonatal Congenital Diaphragmatic Hernia.

OBJECTIVE: We examined the reliability of the main prenatal and postnatal prognosis-related indexes that can be used to evaluate congenital diaphragmatic hernia (CDH) outcome. METHODS: Seventy-seven neonates with CDH were analyzed according to CDH prognosis-related factors, divided into prenatal findings, postnatal clinical values and postnatal predictive outcome scores applied at birth and within the first 12-24 h. The data are compared between two groups: survivors and non-survivors. RESULTS: During prenatal age, major associated anomalies, intrathoracic stomach, diagnosis prior to 25 weeks of gestational age and lung-to-head ratio < 0.6 were statistically significant, demonstrating their greater incidence in non-survivors. The majority of postnatal values at PICU admission were found to be reliable in identifying the CDH outcome: paO2/FiO2, oxygenation index, alveolar-arterial-O2 gradient, arterial-alveolar-O2 tension ratio, pH, mean blood pressure, body temperature. All the postnatal predictive outcome scores (Apgar 1' and 5', CDH-Study-Group equation, Score for Neonatal-Acute-Physiology II, SNAP-Perinatal-Extension II, Pediatric Risk of Mortality III and Wilford-Hall/Santa-Rosa formula) were statistically significant with more favorable values for prognosis in the survivors group. CONCLUSION: The chances of predicting CDH outcome are fairly high. During prenatal age, only a few findings may be obtained. Conversely, many postnatal indexes and scores can reliably predict such outcome.

Salvage and reinfusion of chyle in closed chest injury.

The aim of this study was to describe a system of salvaging and reinfusing chyle which accumulated in the right pleural cavity of a patient after a thoracic duct lesion caused by a closed chest injury associated with amyelic fracture of the dorsal spine D10-D11. The chyle was collected in a reservoir (BT 844 Dideco), transferred by an electronic pump (BT 797 recovery Dideco) to a storage bag, microfiltered and then reinfused to the patient A solution was needed to prevent the patient with severe chylothorax, from having immunological and metabolic imbalance. The long period of conservative treatment with our system was imposed by the onset of acute post-traumatic myocardic infarction which delayed surgery. From experience gained, we can say that using total parenteral nutrition, chyle can not only be salvaged but also reinfused, respecting the strict rules of hygiene.

Effects of sympathetic blockade on the efficiency of forced-air warming during combined spinal-epidural anesthesia for total hip arthroplasty.

STUDY OBJECTIVE: To evaluate if active cutaneous warming of the two upper limbs with reflex vasoconstriction is less effective in maintaining intraoperative normothermia than warming the vasodilated unoperated lower limb during combined spinal-epidural anesthesia (CSE). DESIGN: Prospective, randomized study. SETTING: Inpatient anesthesia at university departments of orthopedic surgery. PATIENTS: 48 ASA physical status I, II, and III patients, who were scheduled for elective total hip arthroplasty. INTERVENTIONS: Patients received CSE with intrathecal injection of 15 mg of 0.5% hyperbaric bupivacaine. All procedures started 8 to 10 AM, and operating room temperature was maintained between 21 degrees and 23 degrees C, with relative humidity ranging between 40% and 45%. For warming therapy, patients received active forced-air warming of either the two upper limbs (Group Upper body, n = 24), or the unoperated lower limb (Group Lower extremity, n = 24). Core temperature was measured before CSE placement (baseline), and then every 30 minutes until completion of surgery. Time for fulfillment of clinical discharging criteria from the recovery area was evaluated by a blinded observer. MEASUREMENTS AND MAIN RESULTS: Demographic data, duration of surgery, intraoperative blood losses, crystalloid infusion, and hemodynamic variables were similar in the two groups. Core temperature slightly decreased in both groups, but at the end of surgery the mean core temperature was 36.2 degrees +/- 0.5 degree C in Group Upper body and 36.3 +/- 0.5 in Group Lower extremity (NS). At recovery room arrival, seven patients in Group Upper body (29%) and three patients in Group Lower extremity (12.5%) had a core temperature less than 36 degrees C (NS). Shivering was observed in one patient in Group Upper body and in two patients in Group Lower extremity (NS). Clinical discharging criteria were fulfilled after 37 +/- 16 minutes in Group Upper body and 30 +/- 32 minutes in Group Lower extremity (NS). CONCLUSIONS: Forced-air cutaneous warming allows the anesthesiologist to maintain normothermia during CSE for total hip replacement even if the convective blanket is placed on a relatively small skin surface with reflex vasoconstriction. Placing the forced-air warming system on the vasodilated unoperated lower limb may be troublesome to the surgeons and does not offer clinically relevant advantages in warming efficiency.

[Postoperative duodeno-cutaneous fistula in an infant: conservative treatment, total parenteral nutrition]. / Fistola duodeno-cutanea post-operatoria in lattante: trattamento conservativo, N.P.T.

In case of duodeno-cutaneous fistula conservative treatment is advisable. Its successful results, also due to fundamental T.P.N. support and continuous naso gastric suction, has been obtained in an infant with nesidioblastosis, treated by staged pancreatectomy.

Bronchoscopy in newborns with esophageal atresia.

The aim was to evaluate the influence of rigid laryngotracheo-bronchoscopy in newborns with oesophageal atresia (OA) and tracheoesophageal fistula (TOF) in preventing complications, improving diagnosis and surgical treatment. Among 76 consecutive newborns, received in the Paediatric Intensive Care Unit (PICU) from January 1990 to September 2001 with prenatal o perinatal suspected OA, forty-five had one or more other congenital anomalies. They were divided in I Montreal's risk group for 73.7% (56) and in the II one for 26.3% (20). Endoscopic procedure was performed in the operating room with Storz's rigid ventilating bronchoscope just before surgery, in all babies. With bronchoscopic examination we were able to identify the level, number and size of TOF and to visualise anatomical variants in 76 children. 15 children with OA had a gasless abdomen, but an upper pouch fistula was found only in three cases. In another four cases bronchoscopy confirmed the diagnosis of an "H" fistula and cervical surgical approach was established. One case had only oesophageal stenosis. 56 patients had fistula in lower pouch and in the last 38 cases we proceeded with selective transtracheal fistula incannulation and then we provided gastric drainage. One quadriforcation, 2 triforcations, 3 aberrant right upper lobe bronchi, 1 congential subglottic stenosis and 1 associated with a congenital subglottic stenosis and 1 left main bronchus agenesia were detected. No complications were correlated to the procedure and no babies had early pneumonia. Continuous feeding was achieved in 70 out of 76 patients: 46 primary anastomosis with 12 staged repairs (OA I and II type long gap), 4 resections of TEF, 8 oesophagocoloplasty. Nine babies (11.8%) did not survive. Clinical follow-up was possible in all the survivors. Mortality rate in the high-risk patients with OA remains high because of the many complications that may occur. Tracheal endoscopy is useful in improving the diagnostic approach and to prevent pulmonary complications. Fistula incannulation minimizes the risk of gastric distension and its detrimental effect on ventilation, helping the surgeon to identify TEF easily and quickly. Moreover, the endoscopic approach offers obvious advantages for the anaesthesiologist and the surgeon and has proven, in our experience, to be effective.

Gastric perforation in a newborn.

Gastric perforation in neonates is an uncommon condition. In most cases, it is attributed to peptic ulceration and/or hemorrhagic gastritis. The high mortality rate in such patients can be improved by early diagnosis and prompt resuscitation, followed by surgery. We report a full-term female newborn, who developed a gastric perforation in the first day of life. The possible aetiology and the perioperative management are discussed.

[Malignant primary tumors of the liver in childhood]. / I tumori maligni primitivi del fegato in età pediatrica. Esperienza di un singolo centro.

Twenty-one children (16 males, 5 females) with malignant primary hepatic tumors were admitted to the Pediatric Clinic of the University of Bologna between June 1973 and July 2001. The diagnosis was hepatoblastoma (HBL) in 16 cases; hepatocellular carcinoma (HCA) in 3 cases; undifferentiated sarcoma in 1, malignant rhabdoid tumour of the liver in 1. Median age at diagnosis was 1.8 year (1 mounth-13 years). As to intrahepatic tumor's extension, patients were classified in groups (from I to IV) according to International Society of Pediatric Oncology staging. 2 patients were ascribed to group I; 9 to group II; 9 to group III and I to group IV. At diagnosis 3 pts presented lung metastases. Seventeen patients (81%) were treated with surgery, in 11 cases as first approach to the tumor. In 10 patients, initially with unresesectable tumor, chemotherapy was started first. Drugs used were mostly Cisplatinum or Carboplatinum with Doxorubicin. Sussequently 6 patients were submitted to surgery. At a median follow up of 12.5 years, 52.3% of patients is alive without disease. This percentage rises to 58% taking into consideration only HBL and HCA cases (alive 11/19). We conclude that excluding metastases at diagnosis (3 deaths), the main prognostic factor is resectability and radical surgery: in our experience 4 patients with unresectable tumor died, as 2 patients with microscopical residual after surgery.

[In-hospital pediatric cardiopulmonary resuscitation]. / Emergenze intraospedaliere pediatriche.

Between 0,7-3% of pediatric patients may require resuscitation during hospital stay. The physicians of the Pediatric Intensive Care Unit of the C.O.U. Anesthesia and Intensive Care-Baroncini developed a plan for the management of pediatric emergencies inside the Department of Pediatric Medical and Surgical Sciences. The plan consisted of: the drawing up of a PI 34-Procedure; the preparation and implementation of a training course for doctors and nurses; the purchase of 12 emergency-trolleys according to the Broselow Pediatric Resuscitation Measuring Tape and the implementation of a specific system for the emergency-call. Precise duty for anesthesiologists and intensivists is the emergency- planning and management, in order to diffuse the medical knowledge needed to assist patients requiring vital functions support. The management of the intra-hospital pediatric emergencies is strictly dependent on the training of the staff, based on a specific support algorithm, and specific equipment for the different ages.

Update of recommendations for Analgosedation in pediatric intensive care unit.

Effective and adequate therapy to control pain and stress are essential in managing children in Pediatric Intensive Care Unit (PICU) undergoing painful invasive procedures, this should be, but is not yet, one of our main aims. Aware that this difficult mission must be pursued in a systematic, multimodal and multitasking way, the Studying Group on Analgosedation in PICU from the Italian Society of Neonatal and Paediatric Anesthesia and Intensive Care (SARNePI) is providing its recommendations.

Preoperative evaluation in infants and children: recommendations of the Italian Society of Pediatric and Neonatal Anesthesia and Intensive Care (SARNePI).

BACKGROUND: The preoperative assessment involves the process of evaluating the patient's clinical condition, which is intended to define the physical status classification, eligibility for anesthesia and the risks associated with it, thus providing elements to select the most appropriate and individualized anesthetic plan. The aim of this recommendation was provide a framework reference for the preoperative evaluation assessment of pediatric patients undergoing elective surgery or diagnostic/therapeutic procedures. METHODS: We obtained evidence concerning pediatric preoperative evaluation from a systematic search of the electronic databases MEDLINE and Embase between January 1998 and February 2012. We used the format developed by the Italian Center for Evaluation of the Effectiveness of Health Care's scoring system for assessing the level of evidence and strength of recommendations. RESULTS: We produce a set of consensus guidelines on the preoperative assessment and on the request for preoperative tests. A review of the existing literature supporting these recommendations is provided. In reaching consensus, emphasis was placed on the level of evidence, clinical relevance and the risk/benefit ratio. CONCLUSION: Preoperative evaluation is mandatory before any diagnostic or therapeutic procedure that requires the use of anesthesia or sedation. The systematic prescription of complementary tests in children should be abandoned, and replaced by a selective and rational prescription, based on the patient history and clinical examination performed during the preoperative evaluation.

Neonatal congenital diaphragmatic hernia: respiratory and blood-gas derived indices in choosing surgical timing.

BACKGROUND: Congenital diaphragmatic hernia (CDH) still has a high mortality despite advanced assistance techniques. The aim of this study is to verify the validity of five respiratory and blood-gas-derived indices in defining presurgical stabilization: the oxygenation index (OI), the alveolar-arterial O(2) gradient (A-aDO(2)), the arterial-alveolar O(2) tension ratio (a/AO(2)), the arterial pH and the PaCO(2). METHODS: The study involved 73 neonates with CDH where the accuracy of stabilization was assessed through the survival percentage and the contemporary behaviour of mean arterial pressure (MAP), ductal shunting, urine output and lactate levels. The trend of the indices was compared in two groups (stable/fit for surgery vs unstable/unfit for surgery) at five times (PICU admission, 6, 12, 24 hours after admission, assessment of clinical stabilization). RESULTS: Fifty-five neonates were defined stabilized on the basis of the indices and underwent surgery with a 100% survival rate; 18 patients died before surgery, having never achieved clinical stabilization. MAP, ductal shunting, urine output and lactate levels were normal in the stabilized patients and altered in the non stabilized. Of the five parameters considered, all three oxygenation-linked indices (OI, A-aDO(2), a/AO(2)) are very powerful, whereas pH and PaCO(2) appears valid but more tardive. Their progressive improvement (OI<10, A-aDO(2)<250 mmHg, a/AO(2)>0.50, PaCO(2)<55 mmHg, pH>7.35) defined presurgical stabilization, thus allowing CDH surgical correction. CONCLUSION: The study confirms the validity of these indices as a guide to the treatment of neonates with CDH, showing a good reliability in identifying presurgical stabilization.