Hybrid Left Heart Bypass Circuit for Repair of the Descending Aorta in an 8-kg Williams Syndrome Patient.

A 1-year old male patient with Williams syndrome and multiple prior interventions presented for surgical repair of his descending aorta (DA) through a left thoracotomy. Concerns for significant bleeding and spinal cord protection led the care team to consider a left heart bypass (LHB) circuit with options for pump sucker use, heat exchange capacity, and the possibility of converting to traditional cardiopulmonary bypass (CPB). A traditional CPB circuit with a roller-head arterial pump was assembled with a bypass line around the cardiotomy venous reservoir (CVR). Excluding the CVR with this line allowed for a closed LHB circuit. A second pump head was integrated to both recirculate the CVR volume and to serve as a means for controlled volume administration to the closed LHB circuit. Pump sucker return directed to the CVR could easily be transfused back to the patient. The patient was placed on the hybrid LHB circuit and cooled to 32°C. DA clamps were placed. Upper body dynamic blood pressure was managed for a target mean of 50 mmHg, the left atrial pressure (LAP) was maintained in the 5-7 mmHg range, and the nonpulsatile lower body blood pressure was targeted at 40-50 mmHg. Cerebral near-infrared spectroscopy (NIRS) helped guide volume and pressure management. The surgeons placed two long-segment patches on the DA, moving clamps as needed. The patient was rewarmed and separated from the hybrid LHB circuit after 82 minutes. Closed circuit LHB can be provided with a roller-head hybrid circuit incorporating an oxygenator for gas exchange, central cooling and warming, and arterial line filtration along with a CVR for pump sucker use and controlled transfusion to the patient.

Anesthesia for high-risk procedures in the catheterization laboratory.

Recent advances in catheterization and imaging technology allow for more complex procedures to be performed in the catheterization laboratory. A number of lesions are now amenable to a percutaneous procedure, eliminating or at least postponing the need for a surgical intervention. Due to the increase in the complexity of the procedures performed, the involvement of anesthesiologists and their close collaboration with the interventional cardiologists have increased. It is important to understand the physiology and pathophysiology of the patients and to anticipate the plans and the potential complications in order to manage them. We are witnessing a rise in the number of complex interventions in newborns and infants, such as balloon valvotomy (critical aortic stenosis, pulmonary stenosis), radio frequency perforation (of pulmonary atresia and intact ventricular septum), right ventricular outflow tract stenting (in Tetralogy of Fallot), ductal stenting (in some ductus-dependent pulmonary circulation), and combined with a surgical procedure (hybrid procedure for hypoplastic left heart syndrome). Multiple registries have been created in order to understand and improve outcomes of patients with congenital heart disease undergoing catheterization procedures and to develop performance and quality metrics, from which data regarding anesthetic-related risks can be extrapolated. Experienced personnel and a multidisciplinary team approach with direct communication among the team members is a must to ensure anticipation and management of critical events when they occur.

Impact of the endoscopic teaching process on colonic adenoma detection.

BACKGROUND: There has been little reported experience in the Latin American hospital setting in relation to the impact of the endoscopic training process on colonoscopy quality. AIMS: To determine the effect that training in the technique of colonoscopy has on adenoma detection in an Argentinian teaching hospital. MATERIAL AND METHOD: Within the time frame of July 2012 and July 2013, 3 physicians received training in colonoscopy from 4 experienced endoscopists. The colonoscopies performed by the supervised trainees were compared with those carried out by the experienced endoscopists. RESULTS: A total of 318 colonoscopies performed by any one of the 3 supervised trainees and 367 carried out by any one of the experienced endoscopists were included. The univariate analysis showed a non-significant difference in the detection rate of adenomas (30.4 vs. 24.7%, P=.09). In the multivariate analysis, the detection rate of adenomas was significantly higher in the colonoscopies performed by one of the 3 trainees (odds ratio = 1.72 [1.19-2.48]). CONCLUSIONS: The supervised involvement of endoscopic trainees has a positive effect on adenoma detection.

Primary school teacher's knowledge and attitudes toward children with epilepsy.

PURPOSE: Primary school teacher's knowledge and attitudes toward epilepsy can have significant impact on the performance and psycho-social development of the child with epilepsy. Our objectives were to study teacher's knowledge and attitudes and identify areas in which further teacher training and education are required. METHODS: A stratified random sample survey involving a group of primary school teachers in Jeddah, Saudi Arabia included private/public schools designated for male and female students. A structured 37-item questionnaire was used to examine their demographics, knowledge, attitudes, and experience with epilepsy. RESULTS: Six hundred and twenty primary school teachers working in public (58%) or private (42%) schools were included with ages ranging between 21 and 59 years (mean 36). Most teachers (79%) were of Saudi Arabian nationality and 66% had a college or university degree. Their years of experience ranged from 1 to 35 (mean 13.5). Only 17% of the teachers felt very well informed about epilepsy. Teachers with higher education were more likely to have good knowledge (p=0.009). Teachers of Saudi nationality were also more likely to report good knowledge, independent of their educational level (p=0.013). Overall, teachers with good knowledge were less likely to have negative attitudes including minding to have an epileptic child in their class (p=0.028) or thinking that they should be placed in a special classroom (p=0.029). CONCLUSIONS: Primary school teacher's knowledge about epilepsy needs improvements. Their attitudes correlated highly with their knowledge. Educational campaigns about epilepsy are needed to develop a well informed and tolerant community.

Comparison of abdominal bloating severity between Irritable Bowel Syndrome patients with high and low levels of breath hydrogen excretion in a lactulose breath test.

BACKGROUND: There is growing evidence that gut flora plays a role in the development of Irritable Bowel Syndrome (IBS). Abdominal bloating is a common symptom in these patients and the severity of this symptom could be related to the variations in their fermentative profiles, obtained by measuring the levels of breath hydrogen excretion after lactulose ingestion. AIMS: Our objective was to determine the difference in abdominal bloating severity between IBS patients with high vs low levels of breath hydrogen excretion after lactulose administration. METHODS: Lactulose breath tests were carried out on IBS patients in our institution between July 2009 and August 2010. Patients were requested to fill out a validated questionnaire to assess the severity of their symptoms. Abdominal bloating severity score was compared among patients with high and low breath hydrogen levels. RESULTS: A total of 234 patients were enrolled. There was a statistically significant difference in the abdominal bloating severity score between groups: 7.0 (5.7-8.0) vs 6.5 (5.0-7.5), p=0.001. The comparison among IBS patients with constipation (IBS-C) in both groups also showed a statistically significant difference: 7.5 (6.0-8.5) vs 5.8 (3.5-7.2), p=0.0051. CONCLUSIONS: Those patients with a low level of breath hydrogen excretion after lactulose ingestion presented with significantly greater abdominal bloating than those with a high level of breath hydrogen excretion.

Retrograde intubation during laryngeal cleft repair on cardiopulmonary bypass.

Retrograde intubation is part of the difficult airway algorithm in the American Society of Anesthesiologists, but its usage is rare in small pediatric patients with the advent of new intubation techniques. We present our experience of retrograde intubation for a 4-month-old patient who presented for laryngeal cleft repair on cardiopulmonary bypass. This case highlights the unique place for retrograde intubation in small patients in the current era.

Postoperative maladaptive behavioral changes in children.

Induction of anesthesia can be a very stressful period for a child and his family and can be associated with increased risk of psychological disturbances. These disturbances are categorized as preoperative anxiety, emergence delirium and postoperative behavioral changes. Several tools have been developed to measure these psychological manifestations as well as the baseline personality traits of these patients. Postoperative negative behavioral changes, such as sleep and eating disorders, separation anxiety, temper tantrum, aggression toward authorities, may occur in up to 60% of all children undergoing general anesthesia. Several studies found a strong association between these postoperative behavioral changes, the distress of the child on induction and his individual personality characteristics, although a cause-effect relationship could not be determined. Understanding the risk factors for behavior changes helps us determine the best way for prevention and treatment of these changes in the perioperative period.

Anesthetic and cardiopulmonary bypass considerations for cardiac surgery in unique pediatric patient populations: sickle cell disease and cold agglutinin disease.

Physiological disturbances induced by cardiopulmonary bypass (CPB) and hypothermia during cardiac surgery are particularly pronounced in certain unique patient populations, such as patients with sickle cell disease (SCD) and cold agglutinin disease. Red blood cells containing hemoglobin S (HbS) are at increased risk of sickling under conditions encountered during cardiac surgery, leading to SCD-related complications such as vaso-occlusive events. While a target level of HbS has not been determined for patients with SCD undergoing CPB, a safe practice includes increasing the Hb level to 10 g/dL and reducing the proportion of HbS to approximately 30%. This can be accomplished through simple or exchange transfusion prior to surgery or via the modification of the CPB circuit prime. There is no clear consensus on the formulation or the delivery temperature of the cardioplegia solution necessary to prevent sickling and microvascular occlusion. The presence of cold agglutinins is another entity requiring extra vigilance for the conduct of CPB, where hypothermia can lead to activation of cold agglutinins inducing massive hemagglutination, hemolysis, microvascular thrombosis, and possibly intracoronary thrombosis. Determination of thermal amplitude is important to provide a safe reference range of temperature during surgery. High-volume plasmapheresis may be warranted to reduce cold agglutinin titers. Both warm blood cardioplegia and cold crystalloid cardioplegia above the thermal amplitude have been utilized with success.

Blood utilization in neonates and infants undergoing cardiac surgery requiring cardiopulmonary bypass.

Neonates and infants undergoing cardiac surgery with cardiopulmonary bypass are exposed to multiple blood products from different donors. The volume of the bypass circuit is often as large as the patient's total blood volume and asanguineous bypass primes are unusual. As a result, blood products are required for the cardiopulmonary bypass prime and are often used to treat the postbypass dilutional coagulopathy. We review clot formation and strength, cardiopulmonary bypass prime considerations, assessment of postbypass coagulopathy, component therapy use, ultrafiltration techniques, and use of antifibrinolytic medications. A combined approach including techniques to minimize the prime volume, utilization of ultrafiltration, administration of antifibrinolytics during surgery, and the proper treatment of the dilutional coagulopathy can limit the transfusion requirements.

Influencia de la enfermedad periodontal en la evaluación de los trastornos funcionales digestivos / The influence of periodontal disease in the evaluation of functional digestive disorders

Introducción: existe evidencia de una asociación entre las alteraciones de la flora bacteriana intestinal y el síndromde intestino irritable (SII). Dichas alteraciones pueden ser medidas en forma indirecta mediante el test de hidrógeno en aire espirado con lactulosa (THAEL). La flora bacteriana puede verse también alterada en sujetos con enfermedad periodontal (EP). Objetivo: evaluar la influencia de la EP sobre los resultados del THAEL. Materiales y métodos: se incluyeron pacientes con diagnóstico de SII, alo que se les realizó un THAEL. Se evaluó la presencia de EP según la clasificación de la American Dental Association. Se compararon los resultados del THAEL, medidos como área bajo la curva de concentración de hidrógeno/tiempo (ABC) entre aquellos con y sin EP. Resultados: fueron incluidos 51 pacientes, en su mayoría mujeres. El grupo con EP presentó mayor edad. Encontramos un valor basal de hidrógeno significativamente mayor en aquellos con EP que en el grupo sin EP [4 (2-6) vs 1 (1-3.5), p=0.04], pero con el valor de ABC similar entre ambos grupos [2232 (162-5184) vs 2088 (216-6071), p=0.5]. Conclusión: la salud bucal parece ser relevante en el estudio de las alteraciones de la flora bacteriana intestinal, llevando a cambios en los resultados del THAEL.

El incremento del hidrógeno en el aire espirado no predice la intolerancia a la fibra en la dieta en el síndrome del intestino irritable con constipación: estudio piloto / Breath hydrogen levels do not predict fiber intolerance in irritable bowel syndrome with constipation

BACKGROUND: Irritable Bowel Syndrome (IBS) is characterized by the worsening of symptoms with a high fiber diet. This intolerance could be related to an increase in colonic bacterial fermentation. The hydrogen breath test (HBT) is a marker of the intestinal micro flora fermentative capacity. AIM: To assess if there is an association between hydrogen (H2) levels and clinical changes between diets with and without bran. PATIENTS AND METHODS: 10 women with predominantly constipated irritable bowel syndrome (Rome II criteria) received a lowfiber diet during one week. This phase was followed by a second 7 day period with the same diet but supplemented with 12 g of crude dietary fiber. At the end of both periods, patients completed a symptom scale (Lickert type) and performed a HBT. RESULTS: Comparing both periods with a different diet the median difference in the clinical scale score (-2.5) shows a tendency favorable to the diet without bran, p = 0.048. In the fiber period the median increase of 2 ppm in H2 values was not significant deferent. Neither was possible to establish an association between breath H2 and the clinical response to a fiber diet. CONCLUSIONS: In this pilot study we could not detect ary association between breath H2 levels and the clinical response to dietary fiber.(AU)

Introducción: Los pacientes con síndrome del intestino irritable (SII) frecuentemente agravan sus síntomas cuando incorporan fibra insoluble en su dieta. Esta intolerancia podría estar relacionada con una incrementada fermentación colónica. El nivel de hidrógeno en el aire espirado es una variable dependiente de la capacidad fermentativa del contenido bacteriano del intestino por lo que podría representar un recurso capaz de predecir el grado de intolerancia a la fibra dietética. Objetivo: El objetivo de este estudio piloto fue investigar si existe una asociación entre los niveles de hidrógeno (H2) en el aire espirado y la respuesta clínica a las dietas con y sin fibra. Pacientes y métodos: En este estudio piloto se incluyeron diez mujeres afectadas de síndrome de intestino irritable con constipación (Criterios Roma II). Siguieron una dieta poco fermentable durante 14 días. En la primera semana las pacientes se sujetaron a la dieta sin ningún agregado, en la segunda semana incorporaron 12 gr diarios de fibra dietaria cruda. Al finalizar ambos períodos las pacientes completaron una escala de Lickert de 7 ítems donde se valoró la respuesta clínica a la dieta administrada y se midió la excreción de H2 en el aire espirado. Resultados: Comparando ambas dietas, se observó que la mediana de las diferencias de los puntajes clínicos (-2,5) indicaba una tendencia favorable a la dieta poco fermentable sin fibra, p=0,048. El incremento de la mediana de la concentración de H2 en el aire espirado fue de 2 ppm para la dieta con fibra, pero el mismo no fue significativo. Tampoco se pudo demostrar una tendencia que permitiera relacionar los valores de H2 con la respuesta clínica a la fibra dietética. Conclusión: Los resultados de este estudio no lograron demostrar una asociación entre los niveles de hidrógeno en el aire espirado y la respuesta clínica a la dieta con fibra.(AU)

El incremento del hidrógeno en el aire espirado no predice la intolerancia a la fibra en la dieta en el síndrome del intestino irritable con constipación: estudio piloto / Breath hydrogen levels do not predict fiber intolerance in irritable bowel syndrome with constipation

BACKGROUND: Irritable Bowel Syndrome (IBS) is characterized by the worsening of symptoms with a high fiber diet. This intolerance could be related to an increase in colonic bacterial fermentation. The hydrogen breath test (HBT) is a marker of the intestinal micro flora fermentative capacity. AIM: To assess if there is an association between hydrogen (H2) levels and clinical changes between diets with and without bran. PATIENTS AND METHODS: 10 women with predominantly constipated irritable bowel syndrome (Rome II criteria) received a lowfiber diet during one week. This phase was followed by a second 7 day period with the same diet but supplemented with 12 g of crude dietary fiber. At the end of both periods, patients completed a symptom scale (Lickert type) and performed a HBT. RESULTS: Comparing both periods with a different diet the median difference in the clinical scale score (-2.5) shows a tendency favorable to the diet without bran, p = 0.048. In the fiber period the median increase of 2 ppm in H2 values was not significant deferent. Neither was possible to establish an association between breath H2 and the clinical response to a fiber diet. CONCLUSIONS: In this pilot study we could not detect ary association between breath H2 levels and the clinical response to dietary fiber.

Introducción: Los pacientes con síndrome del intestino irritable (SII) frecuentemente agravan sus síntomas cuando incorporan fibra insoluble en su dieta. Esta intolerancia podría estar relacionada con una incrementada fermentación colónica. El nivel de hidrógeno en el aire espirado es una variable dependiente de la capacidad fermentativa del contenido bacteriano del intestino por lo que podría representar un recurso capaz de predecir el grado de intolerancia a la fibra dietética. Objetivo: El objetivo de este estudio piloto fue investigar si existe una asociación entre los niveles de hidrógeno (H2) en el aire espirado y la respuesta clínica a las dietas con y sin fibra. Pacientes y métodos: En este estudio piloto se incluyeron diez mujeres afectadas de síndrome de intestino irritable con constipación (Criterios Roma II). Siguieron una dieta poco fermentable durante 14 días. En la primera semana las pacientes se sujetaron a la dieta sin ningún agregado, en la segunda semana incorporaron 12 gr diarios de fibra dietaria cruda. Al finalizar ambos períodos las pacientes completaron una escala de Lickert de 7 ítems donde se valoró la respuesta clínica a la dieta administrada y se midió la excreción de H2 en el aire espirado. Resultados: Comparando ambas dietas, se observó que la mediana de las diferencias de los puntajes clínicos (-2,5) indicaba una tendencia favorable a la dieta poco fermentable sin fibra, p=0,048. El incremento de la mediana de la concentración de H2 en el aire espirado fue de 2 ppm para la dieta con fibra, pero el mismo no fue significativo. Tampoco se pudo demostrar una tendencia que permitiera relacionar los valores de H2 con la respuesta clínica a la fibra dietética. Conclusión: Los resultados de este estudio no lograron demostrar una asociación entre los niveles de hidrógeno en el aire espirado y la respuesta clínica a la dieta con fibra.

The effect of injection of two vs 10 mL saline on the subsequent spread and quality of epidural analgesia in parturients.

OBJECTIVE: To determine whether two vs 10 mL of saline injected into the epidural space affects the subsequent spread and quality of epidural analgesia in parturients. DESIGN: Randomized, double-blinded, placebo-controlled study. SETTING: Delivery room. PATIENTS: 105 ASA physical status I and II parturients requesting epidural analgesia. INTERVENTIONS: After identification of the epidural space by the loss-of-resistance technique using normal saline, two mL of saline was then injected into the epidural space in the 2-mL group (n = 53) and 10 mL in the 10-mL group (n = 52). Five minutes after the test dose, patients received 10 mL of bupivacaine (0.1%) with fentanyl two microg mL(-1). MEASUREMENTS: 25 minutes after the initial bolus of bupivacaine and fentanyl, spread of block, subsequent pain relief, and influence of the volume of the injected saline on the ease of epidural catheter insertion and on the incidence of blood vessel trauma and paresthesia were evaluated. RESULTS: The total number of dermatomes blocked for cold and pinprick sensation in the 10-mL group was significantly more than in the 2-mL group (19 [6-29] vs 15 [4-27] for cold sensation, P = 0.000; and 15 [3-29] vs 11.5 [3-26] for pinprick sensation, P = 0.001). However, the visual analog pain scale and need for supplemental analgesia were similar between the two groups. The epidural catheter was easily inserted in 94.2% of the 2-mL group and 100% of the 10-mL group. The incidence of blood vessel trauma was low and the incidence of paresthesia was high without any significant difference between the two groups. CONCLUSIONS: 10 mL saline was associated with a higher total number of dermatomes blocked for both cold and pinprick sensation than the two mL saline. However, the pain relief was adequate in both groups, and two mL saline was as effective as the 10 mL in the ease of catheter insertion and prevention of intravascular cannulation.

A comparison of sevoflurane-propofol versus sevoflurane or propofol for laryngeal mask airway insertion in adults.

In a prospective, randomized study, we investigated the incidence of successful insertion of laryngeal mask airway (LMA) at the first attempt and the incidence of side effects after LMA insertion using the combination of sevoflurane and propofol as compared with either sevoflurane or propofol alone for induction of anesthesia. Eighty-three unpremedicated ASA physical status I-II patients were anesthetized with a single vital capacity breath (VCB) of sevoflurane 8% supplemented with IV propofol 1.5 mg/kg, a single VCB of sevoflurane 8%, or IV propofol 3 mg/kg. The coinduction technique was associated with the most frequent incidence of successful LMA insertion at the first attempt (93.5%) than either sevoflurane alone (46%) or propofol alone (61.5%) (P < 0.001). Propofol-induced induction of anesthesia allowed the fastest insertion of LMA and was associated with the least frequent incidence of postoperative nausea and vomiting. However, this advantage of propofol was offset by a frequent incidence of pain on injection (69%) and the occurrence of movements during insertion of the LMA (50% in the propofol group versus 19% and 26% in the sevoflurane and sevoflurane-propofol groups, respectively; P < 0.05), as well as a more frequent incidence of apnea (84% in the propofol group versus 7% and 16% in the sevoflurane and sevoflurane-propofol groups, respectively; P < 0.001). The report shows that induction of anesthesia with sevoflurane-propofol combined provides a frequent incidence of successful LMA insertion at the first attempt that is associated with an infrequent incidence of apnea.

Oxygenation using tidal volume breathing after maximal exhalation.

UNLABELLED: We compared, in volunteers, the oxygenation achieved by tidal volume breathing (TVB) over a 3-min period after maximal exhalation with that achieved by TVB alone. Twenty-three healthy volunteers underwent the two breathing techniques in a randomized order. A circle absorber system with an oxygen flow of 10 L/min was used. The end-expiratory oxygen concentration (EEO(2)) was monitored at 15-s intervals up to 3 min. TVB after maximal exhalation produced EEO(2) values of 68% +/- 5%, 75% +/- 5%, and 79% +/- 4% at 30, 45, and 60 s, respectively, which were significantly larger (P < 0.05) than the corresponding values obtained with TVB alone (58% +/- 5%, 66% +/- 6%, and 71% +/- 5%, respectively). In both techniques, the EEO(2) increased exponentially, with time constants of 35 s during TVB after maximal exhalation versus 58 s during TVB without prior maximal exhalation. In conclusion, maximal exhalation before TVB can hasten preoxygenation by decreasing the nitrogen content of the functional residual capacity, with a consequent increase of EEO(2) to approximately 70% in 30 s and 80% in 60 s. IMPLICATIONS: Oxygenation by using maximal exhalation before tidal volume breathing produced a significantly faster increase in end-expiratory oxygen concentration than oxygenation with tidal volume breathing alone.

Hypothermia and excessive sweating following intrathecal morphine in a parturient undergoing cesarean delivery.

OBJECTIVE: Intrathecal morphine has been used for the relief of postoperative pain following cesarean delivery. We report a case of postoperative hypothermia down to 33.6 degrees C associated with excessive sweating in patient undergoing elective cesarean delivery under spinal bupivacaine anesthesia who received intrathecal morphine for postoperative pain management. CASE REPORT: A healthy 31-year-old multigravida presented for elective cesarean delivery. Following prehydration with 500 mL hemaccel, she had a subarachnoid block, using hyperbaric bupivacaine 12 mg and morphine 200 microgram, via a 25-gauge Whitacre needle. In the recovery room, 3 hours after induction of spinal anesthesia, the patient's sublingual temperature was 33.6 degrees C and she was noted to be sedated and sweating excessively. During the next 2 hours, the patient was still hypothermic despite active warming. She also complained of severe nausea, vomiting, and moderate pruritus. Following administration of naloxone 400 microgram sedation, vomiting, and pruritus were relieved. Also, the patient experienced excessive shivering, and her body temperature started to increase in association with a concurrent decrease of sweating. The postoperative hypothermia and excessive sweating in our patient may be related to the cephalad spread of the intrathecal morphine within the cerebrospinal fluid (CSF) to reach the level of opioid receptors in the hypothalamus, causing a perturbation of the thermoregulatory center. This effect could be counteracted by administration of naloxone. CONCLUSIONS: Intrathecal morphine may cause disruption of thermoregulation resulting in hypothermia associated with excessive sweating.