Preoperative Iron Supplementation in Pediatric Cardiac Surgical Patients: A Preliminary Single-Center Experience.

OBJECTIVE: To assess preoperative hemoglobin and perioperative red blood cell transfusion in children undergoing cardiac surgery after the implementation of a preoperative patient blood management (PBM) clinic with oral iron supplementation. DESIGN: A retrospective analysis. SETTING: A single tertiary hospital. PARTICIPANTS: Patients who underwent cardiac surgery with cardiopulmonary bypass at the Hospital for Sick Children (Toronto, Canada) during a 12-month period before and following the implementation of a preoperative PBM clinic. Patients younger than 3 months of age, or who were admitted to the cardiac intensive care unit preoperatively, were excluded because they were not systematically assessed by the PBM clinic. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: A total of 296 patients were included in the authors' analysis. After adjustment for confounding factors (age at surgery, preoperative oxygen saturation, type of congenital heart disease, surgery type), they found that preoperative hemoglobin levels were significantly higher in children treated with iron supplementation (n = 201) compared to historic controls (n = 95) (13.9 [12.8-15.1] g/dL v 12.9 [11.7-15.0] g/dL, adjusted p = 0.001). The exposure rate to red blood cell transfusion (50% v 61%, adjusted p = 0.930) was not significantly different between groups. However, the volumes of allogeneic red blood cells (1.4 (0.0-14.0) mL/kg v 12.5 (0.0-23.0) mL/kg, adjusted p = 0.004) and autologous blood (11.0 (6.8-17.0) v 17.0 (11.0-31.0), adjusted p < 0.001) transfused were significantly reduced in children treated with iron supplementation. CONCLUSIONS: Preoperative iron supplementation led to an increase in preoperative hemoglobin levels. The exact prevalence of iron deficiency and the effect of iron supplementation on perioperative allogeneic blood transfusion and long-term outcomes should be studied in a prospective randomized study.

Perioperative management of Fontan operation for the child with panhypopituitarism: a case report.

With the surgical improvement of congenital heart disease, Fontan operation has been applied to many complicated patients in recent years. This is the first report of a child with panhypopituitarism who underwent Fontan operation. A 5-year-old boy was scheduled for Fontan operation. He previously underwent Blalock-Taussig shunt and bidirectional Glenn operations for univentricular heart with double-outlet right ventricle and pulmonary atresia. He was receiving hydrocortisone and 1-desamino-8-D-arginine vasopressin (DDAVP) for panhypopituitarism secondary to removal of craniopharyngioma performed at the age of three years. Although urine output and serum sodium concentration were adequately controlled by adjustment of vasopressin infusion rate during surgery, massive pleural effusions and ascites developed postoperatively, which required several days for control by adjusting the dose of oral DDAVP and normalize the serum sodium level. Intraoperative management of Fontan operation for a patient with panhypopituitarism was controllable by appropriate hormone replacement. However, postoperative fluid management was complicated by the clinical features of panhypopituitarism and Fontan physiology.

[GlideScope Cobalt: assessment of performance in 50 children].

BACKGROUND: GlideScope Cobalt video laryngoscope is a new type of GlideScope series. A reusable camera baton is inserted into a disposable plastic curved blade. The blade has 5 choices of size and can be used from infants to adults. The aim of the current study was to evaluate the efficacy of GlideScope Cobalt in children. METHODS: Endotracheal intubation was performed in 50 surgical children undergoing general anesthesia. The length of time in intubation, percentage of glottic opening (POGO) score and optimizing procedures were recorded. RESULTS: 100% POGO score was obtained in 42 cases. Successful endotracheal intubation was performed in 47 cases and 37 patients were intubated within 1 minute. It took over 1 minute to intubate in 13 cases, because of the difficulty of tracheal tube maneuver. Particular children, mostly aged 6-8, had difficulty in matching the size of the blade because of the large difference between the sizes of blade 2 and that of blade 3. CONCLUSIONS: GlideScope Cobalt is a useful tool in chidlren's airway management but it necessitates getting used to the tracheal tube maneuver and lacks the suitable blade size for 6-8 years old children.

[GlideScope Ranger: clinical assessment of the performance in 100 patients].

To evaluate the suitability of GlideScope Ranger, endotracheal intubation was performed in 100 surgical patients undergoing general anesthesia. The time to complete intubation, percentage of glottic opening score and optimizing procedures were recorded. GlideScope Ranger allowed visualization of the glottis and successful intubation in all 100 patients, including two patients with difficult airway. Endotracheal intubation was performed within one minute in 81 cases, and percentage of glottic opening score of 75% or more was obtained in 75 cases. It was easily handled not only by experienced anesthetists but also by novice personnel. GlideScope Ranger could be an effective aid to airway management in surgical patients.

[Distortion of the anterior airway anatomy and cervical spine motion during laryngoscopy with GlideScope videolaryngoscope: a comparison of mid-size blade vs large blade].

BACKGROUND: GlideScope videolaryngoscope (GVL) is a novel indirect laryngogoscope for tracheal intubation. Both mid-size and large blades of the GVL are available for adult patients. The distortion of the anterior airway anatomy and cervical spine motion using the mid-size GVL is unknown. We compare the degree of anterior airway distortion and cervical spine movement during the use of the mid-size GVL compared with the large GVL. METHODS: Twenty patients requiring general anesthesia and tracheal intubation were studied. Each patient underwent laryngoscopy with both mid-size and large GVLs. During each laryngoscopy, a radiograph for the lateral view of the head and neck was taken when the best view of the larynx was obtained. Based on the radiographs, independent radiologists evaluated anterior airway movement and cervical spine movement. RESULTS: The tip of the mid-size GVL was anteriorly positioned during laryngoscopy, compared with large GVL. The distance between epiglottis and posterior laryngeal wall was longer with the mid-size GVL than with the large GVL. Both the mid-size and large GVL caused a significant anterior movement in the cervical spine during laryngoscope. The difference in the movement in the atlas and C2 was small, but statistically significant. No difference was found in the anterior movement with C3 and C4. During laryngoscopy, cervical spinal extension occurred with both GVLs, while there was no difference in the cervical spinal extension between the mid-size and large GVL. CONCLUSIONS: The tip of the mid-size GVL during laryngoscopy is anteriorly positioned and the distortion of the anterior airway was greater with the mid-size GVL than with the large GVL.

Rudimentary right ventricle to pulmonary artery shunt in the Norwood procedure.

We describe here successful palliative repair of tricuspid atresia, hypoplastic right ventricle, transposition of the great arteries, and hypoplastic aortic arch in a neonate. The repair consisted of the Norwood procedure with a rudimentary right ventricle to pulmonary artery shunt, which was located on the right side of a neo-aorta. This procedure could be a useful adjunct to avoid left ventriculotomy and its subsequent dysfunction.

[A case report of successful treatment of a child with respiratory distress using non-invasive continuous positive airway pressure via helmet].

Helmet is a new device of non-invasive continuous positive airway pressure (CPAP). Few cases have been described about usage of the helmet in children. We describe successful treatment of a child with respiratory distress using the helmet-delivered non-invasive CPAP. A 2-month-old male infant (3.1 kg) with multiple anomalies (cardiovascular, facial, and vertebral) developed respiratory distress after extubation. The helmet was well tolerated regardless of facial anomaly. Helmet CPAP started at initial settings of CPAP 8 cm H2O and FI(O2) 0.7, improved oxygenation. Pa(O2)/FI(O2) ratio increased from 106 to 316, and chest X-rays showed a marked improvement (15 hour after NPPV initiation). The helmet offers important advantage: the possibility of fitting to any children, regardless of any facial or external anomalies.

Radial incision for ventricular septal defect with membranous septal aneurysm.

Surgical exposure and accurate closure of a ventricular septal defect with a membranous septal aneurysm beneath the septal tricuspid leaflet carries a risk of tricuspid valve dehiscence and conduction disturbances when the septal leaflet is detached along the tricuspid annulus. To avoid these problems, we use a radial incision to expose and close perimembranous ventricular septal defects. We reviewed recent cases to determine the risks and benefits of this technique. From January 2005 through September 2008, 30 patients underwent closure of a perimembranous ventricular septal defect through a right atrial approach at our institution. The operation included radial incision of the membranous septal aneurysm to improve visualization of the perimembranous ventricular septal defect in 9 patients. There was no perioperative or late death. The operative and postoperative courses were uneventful in all cases. A residual leak was detected in only one patient. No patient had more than mild postoperative tricuspid valve insufficiency, none underwent reoperation, and no new arrhythmia or conduction disturbance was detected during follow-up. The radial incision for closure of a ventricular septal defect with a membranous septal aneurysm provides satisfactory exposure of the defect through the right atriotomy, for safe and accurate closure.

[Use of the GlideScope video laryngoscope in 50 pediatric patients].

BACKGROUND: The GlideScope video laryngoscope (Verathon Inc. Bothell, Washington, USA) is a relatively new device for tracheal intubation, which provides a excellent glottic visualization. We here report the clinical experience of the GlideScope (small) in 50 pediatric patients. METHODS: Tracheal intubation with GlideScope (small) was performed in 50 consecutive pediatric patients requiring orotracheal intubation for surgery. The view of glottic opening was scored according to the classification of Cormack-Lehane. The time required to intubate and the number of intubation attempts were recorded. RESULTS: In all, 50 children included 4 neonates, 8 infants under 1 year and 38 children between 1 year and 9 years. Cormack-Lehane classification 1 or 2 was obtained in 74% and 22%, respectively, and successful intubation was achieved in 48 of 50 children (96%). In remaining two babies, GlideScope failed to intubate the trachea. The mean +/- SD time for instrumentation in successful intubation at first attempt was 56.6 +/- 34.2 seconds. CONCLUSIONS: GlideScope seemed to be a novel device in pediatric patients. Further studies are required to evaluate the usefulness in neonates, small infants and children with a difficult airway.

[GlideScope video laryngoscope].

Increasing evidence indicates that the GlideScope" video laryngoscope (GVL) has an established role in endotracheal intubation. The GVL has been on the market in Japan. In this report, we introduced the clinical performance of the GVL. The GVL has been reported to provide a better glottic exposure compared with the direct laryngoscope in normal and difficult airways. In addition, the GVL has been reported to have superior performance, compared with direct laryngoscope when used for nasotracheal intubation. The GVL is a novel indirect rigid laryngoscope for routine endotracheal intubation.

[Work load of anesthesiologists at the Central Surgical Unit of the Jichi Medical University Hospital].

BACKGROUND: Since the diagnosis procedure combination (DPC) for health insurance plans in Japan was started in medical practice, the number of surgical procedures is increasing at teaching hospitals. METHODS: We retrospectively surveyed 8,672 surgical procedures performed at the central surgical unit of the Jichi Medical University Hospital from April 1, 2007 to March 31, 2008. RESULTS: Of the 8,672 surgical procedures, 6,922 operations were performed under the management of anesthesia staffs, and 1,904 procedures (27.5%) were done in emergency situation. Central surgical unit has 14 operating rooms and an estimated maximum number of surgical procedures is 7,700. CONCLUSIONS: This survey revealed that the present status of manpower of anesthesiologists at our hospital was insufficient for the work. In particular, the demands for anesthesiologists have increased in emergency operations including major cardiovascular surgery, neurosurgery and liver transplantations.

GlideScope videolaryngoscope reduces the incidence of erroneous esophageal intubation by novice laryngoscopists.

The purpose of this study was to evaluate the performance of the GlideScope videolaryngoscope for tracheal intubation by novice laryngoscopists compared with that of the Macintosh laryngoscope. Under supervision by staff anesthetists, non-anesthesia residents performed tracheal intubation using either the GlideScope videolaryngoscope (n = 100) or Macintosh laryngoscope (n = 100). The time required for airway instrumentation, the number of attempts required until successful intubation, and erroneous esophageal intubation were investigated. There were no significant differences in the time needed to secure the airway between the GlideScope videolaryngoscope and the Macintosh laryngoscope. Fewer attempts until successful intubation were made with the GlideScope videolaryngoscope than with the Macintosh laryngoscope (p < 0.05). Erroneous esophageal intubation with the GlideScope videolaryngoscope was less frequent than with the Macintosh laryngoscope (p < 0.05). Compared to the Macintosh laryngoscope, the GlideScope videolaryngoscope reduces the incidence of erroneous esophageal intubation by less experienced laryngoscopists.

[Crisis management in pediatric anesthesia].

We describe the risk management of pediatric anesthesia. The most important risk management of pediatric anesthesia is airway and temperature management. Neonates and infants easily become hypoxic due to their insufficient functional residual capacity. Therefore airway management is most important not only during induction of anesthesia but also during maintenance of anesthesia and extubation. The management of patients' temperature, including control of room temperature should be taken into consideration. In addition, careful attention should be paid not to introduce air bubbles in any lines, especially in patients with congenital heart diseases.

[Airtraq optical laryngoscope].

BACKGROUND: We described an early experience of Airtraq laryngoscope in 20 patients receiving general anesthesia. METHODS: In all, 2 staff anesthesiologists, 3 anesthesia residents and 10 non-anesthesia residents performed endotracheal intubation with 14 polyvinyl chloride tubes with inside diameter of 7-8 mm, 5 double lumen 37-F tubes and 1 preformed nasotracheal tube. RESULTS: Every endotracheal intubation was achieved at the first trial, and the mean time to secure the airway was 46 +/- 18 seconds. CONCLUSIONS: Airtraq laryngoscope is a useful novel device for tracheal intubation.

[Use of the airway scope for difficult airway].

The Airway Scope (AWS) is a new videolaryngoscope which consists of an optical system and a single-use blade. The blade of the device is designed according with the pharyngeal anatomy, and thus the AWS is expected to have a role in the management of difficult airway. We here report 15 patients with difficult airway in whom the AWS provided in successful intubation. The AWS provides a view of the glottis with Cormack-Lehane grade 1 and resulted in successful intubation in the 15 patients. The AWS is useful for the management of difficult airway.