Coagulation Profile of Patients with Adolescent Idiopathic Scoliosis Undergoing Posterior Spinal Fusion.

BACKGROUND: Blood loss and transfusion requirements during posterior spinal fusion for adolescent idiopathic scoliosis remain a concern. The mechanism of bleeding in these patients is poorly characterized. Thromboelastography is a comprehensive test of a patient's coagulation system commonly used in cardiac surgical procedures. It has not been well studied for use in patients with adolescent idiopathic scoliosis. METHODS: A prospective, observational study of the coagulation profile of patients with adolescent idiopathic scoliosis undergoing posterior spinal fusion is presented. Healthy patients with adolescent idiopathic scoliosis without a bleeding abnormality were analyzed during posterior spinal fusion. Standard coagulation laboratory and thromboelastogram measures were obtained at the time of the incision and at 1-hour intervals during the surgical procedure. Laboratory values were analyzed in relation to outcomes such as bleeding, transfusion, and a fibrinolysis score. RESULTS: Fifty-eight patients were observed. Eighty-one percent of patients were female, the mean age was 13.5 years, a mean of 11.1 levels were fused, the median estimated blood loss was 645 mL, and 47% of patients received blood products. Overall, laboratory values remained stable throughout the surgical procedure. Mild increases in prothrombin time and partial thromboplastin time were observed, and platelets remained stable. From thromboelastogram analysis, an acceleration of clot formation (decreased reaction time) and a slight increase in clot lysis (increased lysis percentage at 30 minutes) were observed. A fibrinolysis score compiled from the presence of fibrin degradation products, the presence of D-dimers, and increased prothrombin time rose steadily over surgical time. The fibrinolysis score was predictive of both transfusion and greater estimated blood loss per level. CONCLUSIONS: The stress of posterior spinal fusion induces a hypercoagulable state in patients with adolescent idiopathic scoliosis. Over the first 2 hours of a surgical procedure, varying degrees of fibrinolysis develop. Platelets and coagulation factors are not depleted. Our data support the use of antifibrinolytic therapy for patients with adolescent idiopathic scoliosis.

Dexmedetomidine-related polyuria in a pediatric patient.

Polyuria related to pharmacologic α2-adrenoreceptor agonism has been well described in vitro and in animal models and is thought to be the result of functional antagonism of arginine vasopressin. Despite its widespread use as a sedative and anesthetic adjunct, very few reports of dexmedetomidine-related polyuria in humans exist in the literature. We present the first description of a pediatric patient manifesting polyuria and hypernatremia in association with dexmedetomidine infusion for posterior spinal fusion.

Bilateral Paravertebral Blockade (T7-10) Versus Incisional Local Anesthetic Administration for Pediatric Laparoscopic Cholecystectomy: A Prospective, Randomized Clinical Study.

BACKGROUND: Single-injection paravertebral nerve blocks (PVBs) provide effective postoperative analgesia after adult laparoscopic cholecystectomy (LC). We sought to compare PVBs with local anesthetic injections at laparoscopic port sites in a pediatric population. METHODS: Eighty-three patients (8-17 years old) scheduled for LC were randomized prospectively to 2 treatment groups: the PVB group received ropivacaine 0.5% injected in the paravertebral space and normal saline injections at laparoscopic instrument sites, and the port infiltration group received normal saline in the paravertebral space and ropivacaine 0.5% at instrument sites. Postoperative analgesia was provided with hydromorphone via patient-controlled analgesia for up to 12 hours, followed by oxycodone and hydromorphone. The total amount of analgesic, serial visual analog scale scores for pain and subject pain control satisfaction, type and characteristics of pain, and complications were recorded for 24 hours. RESULTS: The intraoperative fentanyl requirement (ng/kg/min) was lower in the PVB group than in the port infiltration group (12.81 vs 16.57, P = 0.007). Total postoperative analgesic consumption and mean visual analog scale scores were not different between the groups. Baseline pain recorded before surgery correlated with self-reported postoperative pain scores only in the port infiltration group. The rate of complications was low and similar between groups. There was no difference in incidence of patient-reported incisional, visceral, or gas pain. Shoulder pain, however, was 49% less (95% confidence interval, 0.269-0.893) in the port infiltration group. CONCLUSIONS: PVBs did not reduce postoperative pain associated with pediatric LC but decreased intraoperative fentanyl requirements.

Postoperative analgesia via transversus abdominis plane (TAP) catheter for small weight children-our initial experience.

Pain management in small infants and children is challenging. We report the use of unilateral transversus abdominis plane (TAP) catheters for analgesia following single-sided open lower abdominal surgery when epidural analgesia was undesirable in a series of six low-weight children. Data collection was done via a retrospective chart review. All catheters attempted were successfully placed with resultant low pain scores and the minimal use of rescue analgesic medications. No complications were reported related to these catheters. TAP catheters, although technically challenging, are feasible for the provision of analgesia for surgeries involving the lower abdominal wall in very small patients.