Improved Quality of Life Among Chronic Pancreatitis Patients Undergoing Total Pancreatectomy With Islet Autotransplantation-Single Center Experience With Large Cohort of Patients.

Total pancreatectomy with islet autotransplantation (TPIAT) is the treatment of choice to preserve pancreatic endocrine function, alleviate pain, and improve quality of life (QoL) when other strategies are ineffective for chronic pancreatitis (CP) patients. This study utilized pancreatic disease-specific surveys developed by the European Organisation for Research and Treatment of Cancer (EORTC) to conduct a comprehensive, single-center examination of a large cohort of patients to gain understanding of QoL post-TPIAT. Two validated QoL surveys of the EORTC-QLQ-C30 and QLQ-PAN26-were administered in a prospective cohort of CP patients during pre-and post-operative scheduled visits. A total of 116 patients responded to the preoperative survey and were included in this study. The global health scale of QLQ-C30 was significantly improved after TPIAT when compared to baseline with delta scores of 24.26, 20.54, and 26.7 at 1, 2, and 3 years post-TPIAT (p < 0.001). The EORTC-PAN26 revealed significant improvements in symptom scales for pancreatic pain, bloating, digestive symptoms, taste, indigestion, weight loss, body image, and future worries. The comprehensive surveys in such a large cohort expands the QoL criterion in CP patients and indicates significant improvement in QoL post-TPIAT, further validating TPIAT as a treatment option for refractory CP.

Bearing Fault Diagnosis Using Lightweight and Robust One-Dimensional Convolution Neural Network in the Frequency Domain.

The massive environmental noise interference and insufficient effective sample degradation data of the intelligent fault diagnosis performance methods pose an extremely concerning issue. Realising the challenge of developing a facile and straightforward model that resolves these problems, this study proposed the One-Dimensional Convolutional Neural Network (1D-CNN) based on frequency-domain signal processing. The Fast Fourier Transform (FFT) analysis is initially utilised to transform the signals from the time domain to the frequency domain; the data was represented using a phasor notation, which separates magnitude and phase and then fed to the 1D-CNN. Subsequently, the model is trained with White Gaussian Noise (WGN) to improve its robustness and resilience to noise. Based on the findings, the proposed model successfully achieved 100% classification accuracy from clean signals and simultaneously achieved considerable robustness to noise and exceptional domain adaptation ability. The diagnosis accuracy retained up to 97.37%, which was higher than the accuracy of the CNN without training under noisy conditions at only 43.75%. Furthermore, the model achieved an accuracy of up to 98.1% under different working conditions, which was superior to other reported models. In addition, the proposed model outperformed the state-of-art methods as the Signal-to-Noise Ratio (SNR) was lowered to -10 dB achieving 97.37% accuracy. In short, the proposed 1D-CNN model is a promising effective rolling bearing fault diagnosis.

Comparison of the Fitbit® charge and polysomnography for measuring sleep quality in children with sleep disordered breathing.

BACKGROUND: Due to the cost and inconvenience of polysomnography (PSG), wrist-worn accelerometers have been explored as an alternative method to measure sleep efficacy in children with obstructive sleep apnea (OSA) or sleep-disordered breathing (SDB). We compared the measurement of sleep quality with the Fitbit® charge (Fitbit Inc., San Francisco, CA, USA) compared to PSG in children presenting for sleep studies. METHODS: Children ages 3 to 18 years presenting for PSG with persistent SDB symptoms were enrolled. During PSG, the Fitbit® charge (Fitbit Inc.) was placed on the wrist and time-synchronized with sleep laboratory devices, which were worn while a single-night PSG was performed. Bias and concordance in measurements of total sleep time (TST), total wake time (TWT), and number of awakenings were assessed using paired t-tests, sign-rank tests, and Lin's concordance coefficient. RESULTS: The study cohort included 22 patients (9 boys and 13 girls; 9±3 years). TST was significantly overestimated using the Fitbit® charge (Fitbit Inc.) (difference in means: 30 min; 95% confidence interval [CI] of difference: 3-58; P=0.031), while TWT was underestimated (difference: 23 min; 95% CI: 4-42; P=0.018). All measures showed a lack of concordance between the Fitbit® charge (Fitbit Inc.) and PSG. CONCLUSIONS: The current prospective study confirms that the Fitbit® charge (Fitbit Inc.) overestimates time spent asleep compared to PSG in children with OSA/SDB symptoms, limiting the validity of sleep monitoring with wearable activity trackers appears in these patients.

Ultrasound assessment of the inferior vena cava in children: A comparison of sub-xiphoid and right lateral coronal views.

OBJECTIVES: The inferior vena cava collapsibility index (IVCCI) has been used to assess the respiratory variation of the inferior vena cava (IVC) diameter and hence intravascular volume. The sub-xiphoid view (SXV) is the standard view to evaluate the IVC. The right lateral transabdominal view (RLV) has been shown in adults to be an alternative view to evaluate the IVC when the SXV is not feasible. The aim of the study was to compare IVC dimensions from these two views and thus determine whether the RLV view can be used instead of the SXV in pediatric patients. METHODS: We conducted a single-center prospective observational crossover study. Study subjects were ASA physical status 1-2 children, 1-12 years of age scheduled for elective surgery under general anesthesia. Anesthesia was maintained by mask with spontaneous ventilation with end-tidal sevoflurane at 2%-5% after the induction of anesthesia. IVCCI was measured using M-mode in both the SXV and RLV. RESULTS: The study cohort included 50 children with a mean age of 5.1 years. The median value for the IVCCI-sx was 0.45 (IQR: 0.28-0.70) while the IVCCI-rl was 0.30 (0.19-0.5). The mean difference between the two groups was 0.12 (95% CI: 0.177-0.066, p < .001, two-tailed paired t-test). Spearman's rank correlation coefficient was 0.66. The univariate linear regression model was IVCCIsx = 0.21 + 0.77 × IVCCIrl. CONCLUSIONS: IVCCIrl was lower than IVCCIsx. IVCCI measured from the right lateral view tended to overestimate the patient's fluid-responsiveness and therefore these two values are not interchangeable.

Peripheral Nerve Stimulation for Treatment of Headaches: An Evidence-Based Review.

Headaches are one of the most common medical complaints worldwide, and treatment is often made difficult because of misclassification. Peripheral nerve stimulation has emerged as a novel treatment for the treatment of intractable headaches in recent years. While high-quality evidence does exist regarding its use, efficacy is generally limited to specific nerves and headache types. While much research remains to bring this technology to the mainstream, clinicians are increasingly able to provide safe yet efficacious pain control.

Prophylactic hyperthermic intraperitoneal chemotherapy (HIPEC) for the prevention and control of peritoneal metastasis in patients with gastrointestinal malignancies: a systematic review of randomized controlled trials.

Peritoneal metastasis is associated with poor prognosis, with studies in the literature reporting the survival of peritoneal metastasis without treatment to be three to six months. Hyperthermic intraperitoneal chemotherapy (HIPEC) has shown positive outcomes by improving the prognosis in patients with gastrointestinal malignancies. This systematic review of randomized controlled trials was done to determine the prophylactic role of hyperthermic intraperitoneal chemotherapy in preventing and controlling peritoneal metastasis gastrointestinal origin. Randomized controlled trials published between January 2019 to June 2021 were included. The databases used were MEDLINE (PubMed), EMBASE (Ovid), and the Cochrane library. Cochrane handbook for systematic review of intervention was used to assess the risk of bias in included trials. The results were reported using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. A total of five trials met the inclusion criteria. Two studies were on patients with gastric cancer, and the other three studies were on patients with colorectal cancer. HIPEC was given to a total of 116 gastric cancer patients and 308 colorectal cancer patients. In all the included studies on patients with gastric cancer, the peritoneal recurrence-free survival was significantly higher in the group that received HIPEC. There was no significant improvement in peritoneal-free survival in patients with colorectal cancer who received HIPEC. HIPEC appears to be effective in preventing peritoneal metastasis in patients with locally advanced gastric cancer without minimal postoperative complications. However, in patients with advanced colorectal malignancy, HIPEC does not seem to play a crucial role in preventing and controlling peritoneal metastasis.

Is Single-Dose Antimicrobial Prophylaxis Sufficient to Control Infections in Gastrointestinal Oncological Surgeries?

Surgical site infections (SSIs) represent one of the most important complications occurring postoperatively following surgical procedures. The SSI incidence is higher following gastrointestinal (GI) surgeries compared to any other surgery. It contributes to the majority of morbidity and mortality in patients undergoing GI surgeries. The accepted practice worldwide for the prevention and control of SSIs is providing antimicrobial prophylaxis. The appropriate antimicrobial and dose are chosen depending on the microbial flora, complications, and patient risk factors. The objective of this review was to determine the sufficient number of prophylactic antimicrobial doses that would be efficacious and safe in controlling the SSIs following GI oncological surgeries. Single-dose antimicrobial prophylaxis has shown the same efficacy as the multiple-dose antimicrobial regimen in controlling SSIs in esophageal, gastric, and colorectal surgeries. The advantages of a single-dose regimen include less chance of emergence of resistance, less chance for allergies or toxicity, and less cost. The addition of metronidazole with single-dose antimicrobial prophylaxis in colorectal surgery should be considered due to its beneficial effect in further reducing infections. Further randomized controlled trials are needed for the literature to determine the efficacy and safety of single-dose antimicrobial prophylaxis in patients undergoing esophageal and colorectal surgeries. In addition, studies are required to determine the individual effectiveness of metronidazole in controlling SSIs in colorectal surgeries.

Clinical Outcomes of a Modified Laryngeal Mask Airway (LMA® Gastro™ Airway) During Esophagogastroduodenoscopy in Children and Adolescents: A Randomized Study.

INTRODUCTION: During esophagogastroduodenoscopy (EGD), general anesthesia (GA) may be provided using a laryngeal mask airway (LMA) with the endoscope inserted behind the cuff of the LMA into the esophagus. Passage of the endoscope may increase the intracuff of the LMA. We evaluated a newly designed LMA (LMA® Gastro™ Airway) which has an internal channel exiting from its distal end to facilitate EGD. The current study compared the change of LMA cuff pressure between this new LMA and a standard clinical LMA (Ambu® AuraOnce™) during EGD. METHODS: Patients less than 21 years of age and weighing more than 30 kg were randomized to receive airway management with one of the two LMAs during EGD. After anesthetic induction and successful LMA placement, the intracuff pressure of the LMAs was continuously monitored during the procedure. The primary outcome was the change of intracuff pressure of the LMAs. RESULTS: The study cohort included 200 patients (mean age 13.6 years and weight 56.6 kg) who were randomized to the LMA® Gastro™ Airway (n=100) or the Ambu® AuraOnce™ LMA (n=100). Average intracuff pressures during the study period (before and after endoscope insertion) were not different between the two LMAs. Ease of the procedure was slightly improved with the LMA® Gastro™ Airway (p<0.001). DISCUSSION: The LMA® Gastro™ Airway blunted, but did not prevent an increase in intracuff pressure during EGD when compared to the Ambu® AuraOnce™ LMA. Throat soreness was generally low, and complications were infrequent in both groups. The ease of the procedure was slightly improved with the LMA® Gastro™ Airway compared to the Ambu® AuraOnce™ LMA.

A Survey to Define and Predict Difficult Vascular Access in the Pediatric Perioperative Population.

BACKGROUND: Various criteria exist for defining difficult peripheral intravenous (DPIV) cannulation in infants and children. With the help of a survey tool, the characteristics perceived to increase the likelihood of DPIV cannulation amongst anesthesia providers were assessed. METHODS: An individualized survey regarding DPIV which included pediatric anesthesiology faculty and certified registered nurse anesthetists at Nationwide Children's Hospital and anesthesiology faculty members of Wake-up Safe was conducted. Anesthesia provider, patient, and procedural characteristics were expressed as a count and percentage, and compared according to group (faculty, certified registered nurse anesthetists, Wake-up Safe faculty) using analysis of variance. RESULTS: Of the 48 local respondents, 33 (69%) reported age as a contributing factor to DPIV, and 32 (67%) reported weight as a factor. Of the 22 Wake-up Safe respondents, 14 (63%) reported age, and 16 (73%) reported weight as a factor. Patient and procedural characteristics perceived to increased likelihood of DPIV cannulation did not differ by respondent role. The factors most commonly mentioned by local respondents as contributing to DPIV included trisomy 21, neuromuscular disorders, and history of many prior IV cannulations. Among the Wake-up Safe faculty respondents, the most commonly mentioned factors were neuromuscular disorders, trisomy 21, and skin injuries or conditions. CONCLUSION: Age and weight were the two most commonly reported factors from both groups of respondents. Other factors contributing to DPIV included prior history of DPIV, neuromuscular disorders, trisomy 21 and American Society of Anesthesiology status ≥4. Patient and procedural characteristics were perceived to increase the likelihood of DPIV cannulation with no difference among respondents.

Heart Rate Changes Following the Administration of Sugammadex to Infants and Children With Comorbid Cardiac, Cardiovascular, and Congenital Heart Diseases.

BACKGROUND: Sugammadex is a novel, rapidly-acting pharmacologic agent to reverse steroidal neuromuscular blocking agents with demonstrated advantages over acetylcholinesterase inhibitors. However, anecdotal reports have noted rare instances of bradycardia and even cardiac arrest. The current study examined heart rate (HR) changes in infants and children with comorbid cardiac, cardiovascular, and congenital heart diseases. METHODS: Patients less than 18 years of age, who had a comorbid cardiac, cardiovascular, or congenital heart disease and were to receive sugammadex, were included in this prospective observational study. After sugammadex administration, HR was continuously monitored and recorded every minute for the first 15 min, and then every 5 min for the next 15 min or until the patient was transferred from the operating room. The primary outcome, bradycardia, was defined as HR below the fifth percentile for age. Secondary outcomes included greatest decrease in HR from baseline for each patient and interventions required for bradycardia. RESULTS: The study cohort included 99 patients (58 male and 41 female) with a median age of 3 years. Bradycardia was noted in 20 of 99 patients (20%); however, six of these patients were bradycardic prior to the administration of sugammadex. Older patients, male patients, and patients with higher body weight were the most likely to experience bradycardia. None of the patients required treatment for bradycardia. CONCLUSIONS: The incidence of bradycardia following the administration of sugammadex was low, even in patients with congenital heart disease. Bradycardia was not associated with clinically significant hemodynamic changes and no treatment was required.

Neuroimaging in Dementia: A Brief Review.

Dementia is a clinical syndrome that manifests itself with impairment in cognitive functions owing to various neurodegenerative etiologies causing severe disability in the older population. Although the diagnosis is largely dependent on clinical examination, biomarkers can significantly aid in early diagnosis of dementia, especially in those without any clinical evidence of neurocognitive impairment. These biomarkers can be discovered in cerebrospinal fluid (CSF) or can be assessed by neuroimaging. Our goal was to discuss and assess the role of different neuroimaging techniques in the early diagnosis of relatively common etiologies of dementia. We used PubMed as search engines to look for helpful articles; most of the sources used were peer reviewed. We discussed the utility of various neuroimaging techniques, such CT, MRI, positron emission tomography (PET) scan, and single-photon emission computed tomography (SPECT), in the diagnosis of dementia. We concluded that various modern neuroimaging techniques prove to be very helpful in early identification, diagnosis, and differentiation between subtypes. However, the actual clinical utility of these tests in terms of their cost-effectivity and availability remains to be seen. Ongoing research is required to further develop biomarkers for early identification and monitor the progression of different etiologies of dementia.

Parkinsonism: A Rare Adverse Effect of Valproic Acid.

Valproic acid (VPA) is an anti-epileptic drug (AED) used as a first-choice agent for most forms of epilepsy. It is used in the treatment of manic episodes, bipolar disorder, migraine prevention, and impulse control. Hence it is one of the most commonly prescribed drugs by physicians nowadays. VPA acts by increasing gama amino butyric acid (GABA) levels, and also reduces neuronal activation by blocking voltage-gated sodium, potassium, and calcium channels. VPA has various adverse effects like thrombocytopenia, hyperammonemia, teratogenicity causing spina bifida in newborns when exposed in utero. The focus of this review is to research one such easily overlooked adverse effect of VPA, which is VPA-induced Parkinsonism. We carried out a review of literature and gathered all comprehensive peer-reviewed articles from PubMed. The data for this research were collected ethically and legally after a thorough examination of the literature. Data obtained from the studies have suggested that Parkinsonism is an adverse effect of VPA. Chronic usage of VPA causes Parkinsonism. It occurs equally in males and females, more common in older people usually above the age of 55 years and not dose-dependent. According to the data obtained, all patients who developed Parkinsonism had serum levels in the therapeutic range (50-100 mcg/mL). Thus the chronic intake of maintenance dose of VPA seems to be the leading cause. The symptoms usually improve over a few weeks and fully resolve in a few months after stopping the drug. When the patient's symptoms do not improve, it means VPA has unmasked the underlying potential for developing Parkinson's disease. Such patients benefit from levodopa therapy. However, the mechanism of how VPA causes Parkinsonism remains unknown. Based on the articles reviewed, we hypothesize that VPA's mechanism of neuronal inactivation by blocking membrane channels across the neuronal membrane, primarily when used chronically could be the mechanism by which it causes Parkinsonism. VPA causes down regulation of sodium and potassium channels on neuronal membrane in order to stop the neurons from firing. Thereby a decrease in action potential across the neurons causes a temporary physiological inactivation of the neuron. When multiple neurons are inactivated in the basal ganglia of the brain, the patient develops symptoms of Parkinsonism. As the neurons are only temporarily inactivated physiologically, when the drug is stopped the membrane receptors are reactivated on the neuronal membranes. This leads to neuronal activation and neuronal membrane potential becomes the same as before. The above mechanism clarifies why the symptoms settle down when the medication is stopped.

Fluorescence Imaging Using Indocyanine Green Dye in the Pediatric Population.

OBJECTIVES: Fluorescence imaging using indocyanine green (ICG) allows for the intraoperative mapping of the vascular supply of various tissue beds. Although generally safe and effective, rare adverse effects have been reported including anaphylactoid reactions. The current study retrospectively reviewed our experience the intraoperative administration of ICG to pediatric patients. METHODS: The anesthetic records of patients who received ICG over a 2-year time period were retrospectively reviewed and demographic, surgical, and medication data retrieved. Objective intraoperative data before and after the administration of ICG were also recorded. These included heart rate, systolic and diastolic blood pressures, oxygen saturation, and peak inflating pressure. RESULTS: The study cohort included 100 patients with a median age of 12 years (9.5 ± 7.4 years) and the median weight being 44.5 kg (45.9 ± 36.9 kg). ICG was administered intravenously to all patients. In all cases, 2.5 mg/mL ICG solution was used, with a median dose of 1.1 mL (1.79 ± 1.8 mL). Eight patients received more than 1 dose of ICG, with no adverse respiratory or hemodynamic effects related to its use. CONCLUSIONS: ICG fluorescence is an important imaging modality that can be safely used as an intraoperative adjunct to various surgical procedures in the pediatric population.

Choosing endotracheal tube size in children: Which formula is best?

OBJECTIVES: Various formulae have been suggested to calculate the appropriate sized endotracheal tube in children. The current study prospectively compares three commonly used formulae for selection of cuffed endotracheal tubes in children. METHODS: Patients were randomized to one of three formulae (Duracher, Cole, or Khine) to determine the size of the cuffed endotracheal tube for endotracheal intubation. The fit of the tube was noted and intracuff pressure was measured using a manometer. The postoperative incidence of stridor, throat pain/soreness, and hoarseness was noted in the post-anesthesia care unit at 2, 4 and 24 h after the procedure. RESULTS: The study cohort included 135 patients less than or equal to 8 years, equally divided into three groups based on age, weight, and gender. There was no difference in the intracuff pressure, the volume required to seal the airway, or the number of times in which the intracuff pressure was greater than or equal to 20 or 30 cm H2O among the three groups. Six tube changes were required in the Cole group while no tube changes were required in the Duracher group (p < 0.05). The postoperative incidence of adverse events (throat pain, hoarseness, and stridor) at 0-2 h, 2-4 h, and 24 h was higher in the Cole group when compared to the Duracher group. CONCLUSION: When using an endotracheal tube with a polyurethane cuff, the Duracher formula provided the best estimate for choosing the correct size.

Heart rate changes following the administration of sugammadex in children: a prospective, observational study.

INTRODUCTION: Sugammadex is a novel agent to reverse steroidal neuromuscular blocking agents (NMBA) with potential clinical advantages over acetylcholinesterase inhibitors such as neostigmine. However, rare instances of bradycardia were reported during its initial clinical trials. To better define this issue, its incidence and mitigating factors, we prospectively evaluated heart rate changes after sugammadex administration in pediatric-aged patients. METHODS: Patients less than 18 years of age who were to receive sugammadex were included. After sugammadex administration, heart rate (HR) was recorded every minute for 15 min and then every 5 min for the next 15 min or until the patient was transferred from the operating room. Bradycardia was defined as HR below the 5th percentile for age. RESULTS: The study cohort included 221 children. Bradycardia was noted in 18 cases (8%; 95% confidence interval 5%, 13%), occurring at a median of 2 min (IQR: 1, 6) after sugammadex administration. Among patients developing bradycardia, 7 of 18 (38%) had comorbid cardiac conditions (congenital heart disease). No patient required treatment for bradycardia and no clinically significant blood pressure (BP) changes were noted. On bivariate analysis, initial sugammadex dose was not associated with bradycardia onset. In multivariable analysis, cardiac comorbid conditions and male gender were associated with an increased incidence of bradycardia. CONCLUSIONS: The incidence of bradycardia following the administration of sugammadex is low, is not associated with BP changes or other clinically significant effects, and did not require treatment. A higher incidence of bradycardia was noted in patients with cardiac comorbid conditions.

Decrease in heart rate following the administration of sugammadex in adults.

BACKGROUND AND AIMS: Sugammadex is a novel agent for reversal of steroidal neuromuscular blocking agents (NMBAs) with potential advantages over acetylcholinesterase inhibitors. In preclinical trials, there have been rare instances of bradycardia with progression to cardiac arrest. To better define this issue, its incidence and mitigating factors, we prospectively evaluated the incidence of bradycardia after sugammadex administration in adults. MATERIAL AND METHODS: Patients ≥ 18 years of age who received sugammadex were included in this prospective, open label trial. After administration, heart rate (HR) was continuously monitored. HR was recorded every minute for 15 minutes and then every five minutes for the next 15 minutes or until patient was transferred out of the operating room. Bradycardia was defined as HR less than 60 beats/minute (bpm) or decrease in HR by ≥ 10 beats per minute (bpm) if the baseline HR was <70 bpm. RESULTS: The study cohort included 200 patients. Bradycardia was observed in 13 cases (7%; 95% confidence interval: 4, 11), occurring a median of 4 minutes after sugammadex administration (IQR: 4, 9, range: 2-25). Among patients developing bradycardia, two (15%) had cardiac comorbid conditions. One patient received treatment for bradycardia with ephedrine. No clinically significant blood pressure changes were noted. On bivariate analysis, patients receiving a higher initial sugammadex dose were more likely to develop bradycardia. On multivariable logistic regression, initial sugammadex dose was not associated with the risk of bradycardia. CONCLUSION: The incidence of bradycardia after administration of sugammadex in our study was low and not associated with significant hemodynamic changes.

Changes in cerebral and renal oxygenation during laparoscopic pyloromyotomy.

Although a laparoscopic approach may be preferred over open procedures for abdominal surgery, there are limited data on the effect of laparoscopic procedures on cerebral and renal oxygenation in neonates and young infants. Here, we evaluated the effect in neonates and infants. In this two-center prospective observational study, we evaluated changes in cerebral and renal regional oxygen saturation (rSO2) in infants during laparoscopic pyloromyotomy. Intraoperative hemodynamic and respiratory parameters and rSO2 were recorded. For the primary outcome, these parameters were compared at incision and at the end of pneumoperitoneum. The study cohort included 25 infants with a mean age of 40 ± 10 days and weight of 4.0 ± 0.6 kg. IAP at the beginning of laparoscopy was 10 ± 2 mmHg (range 7-15 mmHg). Although both cerebral and renal rSO2 decreased from incision compared to the end of laparoscopy, the decrease reached statistical significance only for cerebral rSO2 (81 ± 12 to 76 ± 16, p = 0.033). Similarly, the increase in fractional tissue oxygen extraction (FTOE) was only statistically significant for cerebral FTOE (0.18 ± 0.12 to 0.23 ± 0.16, p = 0.037). No change in hemodynamic or respiratory parameters was found. Although there was a decrease in cerebral rSO2 and increase in cerebral FTOE during pneumoperitoneum, the values did not decrease below those noted before anesthetic induction.

Perioperative Administration of Emend® (Aprepitant) at a Tertiary Care Children's Hospital: A 12-Month Survey.

INTRODUCTION: Aprepitant (Emend®) is a novel antiemetic agent that works through antagonism of neurokinin-1 (NK-1) receptors. To date, there are limited data regarding its use to prevent postoperative nausea and vomiting (PONV) in children. We retrospectively reviewed our initial 12-months experience with aprepitant after it was made available for perioperative use. METHODS: The anesthetic records of patients who received aprepitant were retrospectively reviewed and demographic, surgical, and medication data retrieved. RESULTS: The study cohort included 31 patients (15 male and 16 female) ranging in age from 4 to 27 years (15.7 ± 7.4 years) and in weight from 14.4 to 175.7 kilograms (59.3 ± 30.2 kgs). Most of the patients (30 of 31) received the capsule form and 1 received the liquid. The average dose of aprepitant administered was 0.9 ± 0.6 mg/kg; however, only one patient received dosing expressed as mg/kg, and the majority received a 40 mg capsule. All of the patients in the cohort had either a previous history of PONV or risk factors for PONV. PONV occurred in the PACU in 1 patient and during the first 24 postoperative hours in 3 additional patients. No adverse effects related to aprepitant use were noted. CONCLUSION: Aprepitant was easily added to the preoperative regimen for pediatric patients who may require it. Our approach limited overuse and subsequent cost concerns. Future studies with a comparator group and a greater sample size are needed to demonstrate its efficacy, especially in comparison to time-honored agents such as ondansetron. No adverse effects were noted in our limited study cohort.

Comparison of blood pressure measurements in the upper and lower extremities versus arterial blood pressure readings in children under general anesthesia.

PURPOSE: To compare invasive blood pressure (IBP) readings obtained from an arterial cannula with non-invasive blood pressure (NIBP) measurements from oscillometric cuffs on the upper and lower extremities of infants and children under general anesthesia. PATIENTS AND METHODS: Patients under 10 years of age were enrolled in our study if they were to receive general anesthesia with planned placement of a radial arterial cannula. At 5 mins intervals, IBP was measured using a fluid-coupled pressure transducer and NIBP was measured with two oscillometers with appropriately sized cuffs placed on the upper arm and lower leg, for 10 readings per patient. RESULTS: The study enrolled 18 boys and 12 girls, ranging in age from 0 to 8 years. Across 300 data points, the absolute difference between the arm and invasive mean arterial pressure (MAP) measurements was 7±7 mmHg (range: 0-52 mmHg). The absolute difference between the leg and invasive MAP measurements was 8±8 mmHg (range: 0-52 mmHg). Although both non-invasive measurement sites demonstrated frequent deviation from invasive measurement, large deviations were more common when BP was measured at the leg (81 of 298 observations (27%) deviating by >10 mmHg) compared to the arm (60 of 300 observations (20%) deviating by >10 mmHg). CONCLUSION: The frequency of clinically significant NIBP deviation in children under general anesthesia supports the importance of IBP monitoring when hemodynamic fluctuations are likely and would be particularly detrimental. NIBP measured at the lower leg is more likely to result in clinically significant deviation from invasively measured MAP than NIBP values obtained from an upper arm.