Protocol-driven early tracheal extubation in patients with flaccid neuromuscular scoliosis and pre-existing lung disease.

PURPOSE: To review the results of a postoperative respiratory pathway for patients with muscular dystrophy (MD) and spinal muscular atrophy (SMA) undergoing spinal surgery. METHODS: With IRB approval, a retrospective review was done on all patients with SMA and MD undergoing spinal surgery on a neuromuscular protocol. Baseline demographics, perioperative results, and long-term outcomes were collected. Per the protocol, patients remained intubated after surgery and were transported to the intensive care unit (ICU) for extubation. We present the results of protocol implementation and compare patients with MD to those with SMA. RESULTS: Twenty-four patients were treated using the protocol. Average age was 13.1 years. Severe restrictive lung disease was present in 75% of patients. Nocturnal BiPAP was required in 68% of patients. Average number of instrumented levels was 17. All patients were immediately extubated upon entering the ICU. There were three respiratory complications and only was patient was re-intubated. Average ICU stay was 1.8 days and average hospital length of stay was 6.7 days. No differences in postoperative inspiratory or expiratory positive airway pressures were observed between the MD and SMA groups. CONCLUSION: Through a multidisciplinary neuromuscular protocol, excellent clinical outcomes were achieved in patients with neuromuscular scoliosis and restrictive lung disease, with complication rates and length of stay significantly lower than previously published data. LEVEL OF EVIDENCE: IV.

Immune Function following Major Spinal Surgery and General Anesthesia.

There are reported differences in the effects that general anesthetics may have on immune function after minor surgery. To date, there are no prospective trials comparing total intravenous anesthesia (TIVA) with a volatile agent-based technique and its effects on immune function after major spinal surgery in adolescents. Twenty-six adolescents undergoing spinal fusion were randomized to receive TIVA with propofol-remifentanil or a volatile agent-based technique with desflurane-remifentanil. Immune function measures were based on the antigen-presenting and cytokine production capacity, and relative proportions of cell populations. Overall characteristics of the two groups did not differ in terms of perioperative times, hemodynamics, or fluid shifts, but those treated with propofol had lower bispectral index values. Experimental groups had relatively high baseline interleukin-10 values, but both showed a significant inflammatory response with similar changes in their respective immune functions. This included a shift toward a granulocytic predominance; a transient reduction in monocyte markers with significant decrease in antigen-presenting capacity and cytokine production capacity. Anesthetic choice does not appear to differentially impact immune function, but exposure to anesthetics and surgical trauma results in reproducibly measurable suppression of both innate and adaptive immunity in adolescents undergoing posterior spinal fusion. The magnitude of this suppression was modest when compared with pediatric and adult patients with critical illnesses. This study highlighted the need to evaluate immune function in a broader population of surgical patients with higher severity of illness.

Evolving Surgical Management for Early-Onset Scoliosis in Spinal Muscular Atrophy Type 1 Given Improvements in Survival.

CASE: We present a case of an 18-month-old child with early-onset scoliosis in the setting of spinal muscular atrophy (SMA) type 1 whose rapidly progressive scoliosis is successfully managed with magnetic growing rods, the youngest age of implantation in a patient with SMA we are currently aware of. Technical challenges, complications, and outcome are described in this case presentation. CONCLUSION: Patients with SMA type 1 and early-onset scoliosis can be managed with growing-rod constructs given dramatic improvements in medical care that have expanded life expectancy.

Impact of Intraoperative Fluid Management on Electrolyte and Acid-Base Variables During Posterior Spinal Fusion in Adolescents.

INTRODUCTION: Various isotonic fluids may be used to maintain intravascular homeostasis during major surgical procedures. Variations in the electrolyte and buffer concentrations between these solutions may result in differential changes in electrolyte and acid-base status during fluid resuscitation. This study evaluates these changes during posterior spinal fusion in adolescents. METHODS: Patients were randomized to receive lactated Ringers (LR), normal saline (NS) or Normosol-R® (NR) during posterior spinal fusion (N=19, 20, and 20, respectively). The specific fluid was used for maintenance fluids as well as fluid replacement of deficits, third space losses, and blood loss. RESULTS: Patients who received NS had a greater base deficit (NS: -2.0 ± 2.2 vs NR -0.6 ± 1.8, p=0.031 or LR: -0.2 ± 1.7, p=0.007) and were more likely to have a ≥2 point change in the base deficit (60% with NS compared to 30% with NR and 47% with LR). Patients receiving NS also had a lower pH (NS: 7.37 ± 0.03 vs NR: 7.39 ± 0.04, p=0.013) and a greater change in pH (NS: -0.03 ± 0.04 vs NR: 0.01 ± 0.06). CONCLUSION: The use of NS for intraoperative resuscitation during posterior spinal fusion in adolescents resulted in a greater base deficit and a lower pH than the use of LR or NR. Although these changes had limited clinical significance in our patient population, future studies are indicated to further investigate the potential clinical impact of these changes.

Anesthetic Care During Posterior Spinal Fusion in an Adolescent With Ebstein's Anomaly.

Ebstein's anomaly is a rare form of cyanotic congenital heart disease (CHD) that involves malformation and dysfunction of the tricuspid valve and right ventricle (RV). The severity of the defect impacts clinical presentation, survival, and treatment options. Presentation during the neonatal period with hypoxemia and cyanosis is noted in patients with severe tricuspid valve malformation, a hypoplastic RV, or RV outflow tract obstruction. However, presentation later in infancy is more common when there is a moderate tricuspid valve malformation and no associated RV outflow tract obstruction. Although Ebstein's anomaly is not generally associated with other congenital defects, patients may occasionally require surgery for other comorbid conditions. We describe the perioperative anesthetic management of an adolescent with Ebstein's anomaly for posterior spinal fusion. Previous reports of anesthetic care in this clinical scenario are reviewed, anesthetic considerations discussed, and options for intraoperative monitoring and anesthetic care presented.

The Utility of Preoperative Neuromonitoring for Adolescent Idiopathic Scoliosis.

BACKGROUND: Intraoperative neuromonitoring is well established and widely used to assist in completing corrective surgery for adolescent idiopathic scoliosis (AIS) safely. The role of preoperative measurement of somatosensory evoked potentials (SSEPs) and/or transcranial magnetic stimulation (TMS) to determine if there is transpinal pathology, however, is not clear. We sought to determine if preoperative SSEP and/or TMS measurement provided clinical benefit to patients with AIS. METHODS: A review of medical charts between 2010 and 2012 was conducted for patients undergoing surgery for scoliosis. Patients with diagnoses other than AIS were excluded. Patients with incomplete preoperative or intraoperative data were also excluded. Relevant clinical information such as age, sex, number of levels fused, and major Cobb angle were recorded. Preoperative neuromonitoring measurements and intraoperative neuromonitoring results were reviewed by an attending neurologist. Any instance in which an intraoperative surgical plan or neuromonitoring result interpretation was influenced by preoperative results was recorded. Further imaging obtained based on preoperative results was noted. Any acute neurologic complication such as paralysis was noted. RESULTS: Eighty-one patients met inclusion criteria (64 female, 17 male). Average age was 15 years (± 1.92). Major Cobb angle at preoperative evaluation averaged 57.5 degrees (± 10.81 degrees). Ten patients had abnormal preoperative SSEP/TMS results. There were no changes in protocol during intraoperative neuromonitoring based upon preoperative neuromonitoring findings. No additional imaging was required for patients with abnormal preoperative neuromonitoring results. There was no statistically significant difference in preoperative Cobb angle between the group of patients with abnormal preoperative neuromonitoring and those with normal baseline testing. CONCLUSION: Preoperative SSEP/TMS measurement prior to corrective surgery for AIS has limited utility. There were no instances in which a patient's clinical course was improved by testing. We recommend against routine use of preoperative SSEP/TMS testing for AIS patients requiring corrective surgery.

Analgesic effects of methadone and magnesium following posterior spinal fusion for idiopathic scoliosis in adolescents: a randomized controlled trial.

PURPOSE: To provide optimal conditions for neurophysiological monitoring and rapid awakening, remifentanil is commonly used during pediatric spinal surgery. However, remifentanil may induce hyperalgesia and increase postoperative opioid requirements. We evaluated the potential of methadone or magnesium to prevent remifentanil-induced hyperalgesia. METHODS: Using a prospective, randomized, blinded design, adolescents presenting for posterior spinal fusion to treat idiopathic scoliosis were assigned to receive desflurane with remifentanil alone (REMI), remifentanil + methadone (MET) (0.1 mg/kg IV over 15 min), or remifentanil + magnesium (MAG) (50 mg/kg bolus over 30 min followed by 10 mg/kg/h). Primary outcomes were opioid requirements and postoperative pain scores. Secondary outcomes included intraoperative anesthetic requirements, neurophysiological monitoring conditions, and emergence times. RESULTS: Data analysis included 60 patients. Total opioid requirement (hydromorphone) in the REMI group (received perioperatively and on the inpatient ward) was 0.34 ± 0.11 mg/kg compared to 0.26 ± 0.10 mg/kg in the MET group (95% confidence interval (CI) of difference: - 0.14, - 0.01; p = 0.035). The difference in opioid requirements between the REMI and MET group was related to intraoperative dosing (0.04 ± 0.02 mg/kg vs. 0.02 ± 0.01 mg/kg; 95% CI of difference: - 0.01, - 0.02; p = 0.003). No difference was noted in pain scores, and no differences were noted when comparing the REMI and MAG groups. CONCLUSION: With the dosing regimens in the current study, the only benefit noted with methadone was a decrease in perioperative opioid requirements. However, given the potential for hyperalgesia with the intraoperative use of remifentanil, adjunctive use of methadone appears warranted.

Changes in cerebral oxygenation based on intraoperative ventilation strategy.

INTRODUCTION: Cerebral oxygenation can be monitored clinically by cerebral oximetry (regional oxygen saturation, rSO2) using near-infrared spectroscopy (NIRS). Changes in rSO2 have been shown to precede changes in pulse oximetry, providing an early detection of clinical deterioration. Cerebral oximetry values may be affected by various factors, including changes in ventilation. The aim of this study was to evaluate the changes in rSO2 during intraoperative changes in mechanical ventilation. PATIENTS AND METHODS: Following the approval of the institutional review board (IRB), tissue and cerebral oxygenation were monitored intraoperatively using NIRS. Prior to anesthetic induction, the NIRS monitor was placed on the forehead and over the deltoid muscle to obtain baseline values. NIRS measurements were recorded each minute over a 5-min period during general anesthesia at four phases of ventilation: 1) normocarbia (35-40 mmHg) with a low fraction of inspired oxygen (FiO2) of 0.3; 2) hypocarbia (25-30 mmHg) and low FiO2 of 0.3; 3) hypocarbia and a high FiO2 of 0.6; and 4) normocarbia and a high FiO2. NIRS measurements during each phase were compared with sequential phases using paired t-tests. RESULTS: The study cohort included 30 adolescents. Baseline cerebral and tissue oxygenation were 81% ± 9% and 87% ± 5%, respectively. During phase 1, cerebral rSO2 was 83% ± 8%, which decreased to 79% ± 8% in phase 2 (hypocarbia and low FiO2). Cerebral oxygenation partially recovered during phase 3 (81% ± 9%) with the increase in FiO2 and then returned to baseline during phase 4 (83% ± 8%). Each sequential change (e.g., phase 1 to phase 2) in cerebral oxygenation was statistically significant (p < 0.01). Tissue oxygenation remained at 87%-88% throughout the study. CONCLUSION: Cerebral oxygenation declined slightly during general anesthesia with the transition from normocarbia to hypocarbic conditions. The rSO2 decrease related to hypocarbia was easily reversed with a return to baseline values by the administration of supplemental oxygen (60% vs. 30%).

Changes in Cerebral Oxygenation during Transfusion Therapy.

This study assesses the effects of transfusion of autologous or allogeneic blood on cerebral and tissue oxygenation during spinal surgery. Packed red blood cell transfusions are indicated to improve oxygen delivery to tissues. There are limited data demonstrating changes in tissue oxygenation with blood administration. Tissue (deltoid) and cerebral oxygenation were monitored using near-infrared spectroscopy during spinal surgery in patients. As indicated, cell saver or allogeneic blood was administered. Tissue and cerebral oxygenation were recorded before and after transfusion. The study enrolled 50 patients, 33 of whom (17 males and 16 females) received allogeneic blood (n = 8) or autologous blood (n = 25). Patients ranged in age from 9 to 19 years (14.0 ± 2.3 years) and in weight from 16.8 to 122.7 kg (54.6 ± 25.7 kg). Tissue oxygenation increased from 83 ± 9 (pretransfusion) to 86 ± 7 at the end of transfusion (p = .002) and remained at the same level (86 ± 7) in the post-transfusion period. Cerebral oxygenation increased from 76 ± 8 (pretransfusion) to 84 ± 8 at the end of transfusion (p < .001) and remained at 84 ± 8 in the post-transfusion period. Changes in tissue and cerebral oxygenation were similar between cell saver and allogeneic blood and between starting hemoglobin value <8 gm/dL and starting hemoglobin ≥8 gm/dL. In conclusion, although both cerebral and tissue oxygenation increased during the administration of either allogeneic or autologous blood, the clinical impact was likely limited given the high initial tissue and cerebral oxygenation values. No differences were noted between autologous (cell saver) and allogeneic blood or based on the starting hemoglobin value.

Intraoperative Anaphylactic Reaction: Is it the Floseal?

When hemodynamic or respiratory instability occurs intraoperatively, the inciting event must be determined so that a therapeutic plan can be provided to ensure patient safety. Although generally uncommon, one cause of cardiorespiratory instability is anaphylactic reactions. During anesthetic care, these most commonly involve neuromuscular blocking agents, antibiotics, or latex. Floseal is a topical hemostatic agent that is frequently used during orthopedic surgical procedures to augment local coagulation function and limit intraoperative blood loss. As these products are derived from human thrombin, animal collagen, and animal gelatin, allergic phenomenon may occur following their administration. We present 2 pediatric patients undergoing posterior spinal fusion who developed intraoperative hemodynamic and respiratory instability following use of the topical hemostatic agent, Floseal. Previous reports of such reactions are reviewed, and the perioperative care of patients with intraoperative anaphylaxis is discussed.

A prospective, open-label trial of clevidipine for controlled hypotension during posterior spinal fusion.

OBJECTIVES: Controlled hypotension is one means to limit or avoid the need for allogeneic blood products. Clevidipine is a short-acting, intravenous calcium channel antagonist with a half-life of 1 to 3 minutes due to rapid metabolism by non-specific blood and tissue esterases. To date, there are no prospective evaluations with clevidipine in the pediatric population. We prospectively evaluated the dosing requirements, efficacy, and safety of clevidipine for ontrolled hypotension during spinal surgery for neuromuscular scoliosis in the pediatric population. METHODS: Patients undergoing posterior spinal fusion for neuromuscular scoliosis were eligible for inclusion. The study was an open label, observational study. Maintenance anesthesia included desflurane titrated to maintain a bispectral index at 40 to 60 and a remifentanil infusion. Motor and somatosensory evoked potentials were monitored intraoperatively. When the mean arterial pressure (MAP) was ≥ 65 mmHg despite remifentanil at 0.3 mcg/kg/min, clevidipine was added to maintain the MAP at 55 to 65 mmHg. Clevidipine was initiated at 0.25 to 1 mcg/kg/min and titrated up in increments of 0.25 to 1 mcg/kg/min every 3 to 5 minutes to achieve the desired MAP. RESULTS: The study cohort included 45 patients. Fifteen patients (33.3%) did not require a clevidipine infusion to maintain the desired MAP range, leaving 30 patients including 13 males and 17 females for analysis. These patients ranged in age from 7.9 to 17.4 years (mean ± SD: 13.7 ± 2.2 years) and in weight from 18.9 to 78.1 kg (mean ± SD: 43.4 ± 14.2 kg). Intraoperatively, the clevidipine infusion was stopped in 6 patients as the surgeon expressed concerns regarding spinal cord perfusion and requested a higher MAP than the study protocol allowed. The data until that point were included for analysis. The target MAP was initially achieved at a mean time of 8.9 minutes. Sixteen of the 30 patients (53.3%) achieved the target MAP within 5 minutes. Heart rate (HR) increased from a baseline of 83 ± 16 to 86 ± 15 beats per minute (mean ± SD) (p=0.04) with the administration of clevidipine. No patient had a HR increase ≥ 20 beats per minute or required the administration of a ß-adrenergic antagonist. The duration of the clevidipine administration varied from 8 to 527 minutes (mean ± SD: 160 ± 123 minutes). The maintenance infusion rate of clevidipine varied from 0.25 to 5.0 mcg/kg/min (mean ± SD: 1.4 ± 1.1 mcg/kg/min). Clevidipine was paused a total of 43 times in the 30 cases. In 18 of the 30 patients (60%), the clevidipine infusion was temporarily paused more than once due to a MAP < 55 mmHg. A fluid bolus was administered to only 1 patient to treat the low MAP. No patient required the administration of a vasoactive agent for hypotension. When the clevidipine infusion was discontinued as controlled hypotension was no longer required, the MAP returned to baseline or ≥ 65 mmHg within 10 minutes in 12 of the 30 patients (40%). CONCLUSIONS: Clevidipine can be used to provide controlled hypotension during posterior spinal fusion. The response of the MAP, both the onset and duration of action, were rapid. Although titration of the infusion with occasional pauses of administration may be needed, excessive hypotension was not noted.

Utilization of Orthopaedic Trauma Surgical Time: An Evaluation of Three Different Models at a Level I Pediatric Trauma Center.

OBJECTIVE: Over the past decade, our institution has instituted three different scheduling models in an attempt to care for pediatric trauma at our Level I Trauma Center. This has been in response to a number of factors, including a limited number of physicians covering the call schedule, increasing competition for operating room (OR) time after hours (pediatric surgery, urology, neurosurgery), an attempt to fully utilize OR time during the daytime, fully staffed hours, and optimizing patients' timeliness to surgery. We examined the three on-call systems in place at our institution to determine whether a more flexible approach to pediatric trauma call resulted in delays in treatment. METHODS: We retrospectively reviewed patient records for three distinct 1-year periods with three different surgical call schedules: (i) a traditional call schedule in which the call physician was responsible for patients who presented to our emergency room; (ii) a half-day trauma block OR reserved the morning following call; and (iii) a full-day trauma block. Variables included date of injury, time of admission, admission diagnosis, cause of injury, and OR procedure and start time. RESULTS: We reviewed 951 cases over the entire study, 268 during the traditional call schedule, 282 during the half-call block and 401 over the time period of the full-day block. Mechanisms of injury were similar among the three groups, with falls and motor vehicle accidents being the leading causes. The average delay time was 17:40 for the traditional call group, 15:10 for the half-block call group, and 15:09 for the full-day block group. Our findings suggest that there was a high incidence of cases performed on weekdays after peak staffing hours with a traditional call model (59%). In contrast, half-day and full-day block models saw only 4% and 1% of the cases performed after peak staffing hours, respectively. There was a statistically significant difference in the number of patients admitted to the OR among the three groups (χ(2) = 488.8449, P < 0.0001). The number of patients seen during Monday through Friday was also statistically significant among the three groups (χ(2) = 382.0576, P < 0.0001). CONCLUSIONS: The institution of more flexible and physician-directed half-call and full-day blocks did result in delays in treatment. However, it also has demonstrated benefits to patients in reducing the number of operative cases performed after weekday peak staffing hours; helped our institution better manage its staffing and financial resources; and provided the treating surgeon flexibility in determining the timing of operative care.

A preliminary study of volatile agents or total intravenous anesthesia for neurophysiological monitoring during posterior spinal fusion in adolescents with idiopathic scoliosis.

STUDY DESIGN: A prospective randomized controlled trial. OBJECTIVE: The purpose of this study was to prospectively compare the efficacy of neurophysiological monitoring during general anesthesia with either a total intravenous technique or with the volatile anesthetic agent, desflurane. SUMMARY OF BACKGROUND DATA: A total intravenous anesthetic technique is generally chosen when neurophysiological monitoring is used as it has been shown to facilitate such monitoring. Despite this, with prolonged infusions of propofol, prolonged awakening times may be seen, which may impact the time required for postoperative neurological assessment or more importantly result in significant delays, should a wake-up test become necessary. To date, there are no prospective trials comparing intravenous techniques with a volatile agent-based anesthetic technique and its effects on neurophysiological monitoring. METHODS: This prospective study compares somatosensory evoked potential and motor evoked potential monitoring during posterior spinal fusion in 30 adolescents. The patients were randomized to receive a total intravenous technique with propofol-remifentanil or a volatile agent-based technique with desflurane-remifentanil. RESULTS: The groups were similar with regard to age, weight, height, body mass index, Cobb angle, and distribution of Lenke classifications. No differences were noted in anesthesia time, surgery time, intraoperative fluids, or estimated blood loss between the 2 groups. Time to eye opening, time to following commands, and time to tracheal extubation were shorter in the volatile anesthesia group than the total intravenous anesthesia group. No clinically significant difference was noted in the amplitude or latency of somatosensory evoked potential monitoring. Although statistically significantly greater voltage amplitude was required to generate a motor evoked potential, the voltage amount was within a clinically acceptable range. CONCLUSION: Our data demonstrate that a volatile agent-based anesthetic regimen is feasible even during neurophysiological monitoring. Advantages include a more rapid awakening and the feasibility of a rapid wake-up test (<5 min) in the event that irreversible changes in neurophysiological monitoring are noted. LEVEL OF EVIDENCE: 2.

Is there still a place for cast wedging in pediatric forearm fractures?

BACKGROUND: Forearm fractures are common skeletal injuries in childhood and can usually be treated nonoperatively with closed reduction and casting. Trends toward increasing operative treatment of these fractures have emerged. We aim to demonstrate the safety and efficacy of cast wedging for treatment of pediatric forearm fractures. METHODS: We performed a prospective chart review of patients with forearm fractures, including distal radius (DR) fractures, treated with cast wedging at a single large pediatric hospital from June 2011 to September 2012. Inclusion criteria specified open distal radial physis, closed injury, loss of acceptable reduction, and availability of clinical and radiographic data from injury to cast removal. Exclusion criteria included pathologic fractures, neurovascular injury, fracture dislocations, open fractures, and closed DR physis. Reductions were performed and patients followed according to standard protocol at our institution, including placement into long-arm casts, initial follow-up visit within 5 to 10 days postinjury, and weekly visits for 2 weeks thereafter. If alignment were deemed unacceptable within 3 weeks of injury, cast wedging was utilized. Radiographic measurements of alignment included both radius and ulna on the injury film, postreduction, prewedge, postwedge, and final films. Radiographic technique was standardized, with repeatability testing demonstrating a precision of ±2 degrees. RESULTS: Over 15 months, our hospital treated 2124 forearm or DR fractures with closed reduction and casting. There were 60 fractures treated either with percutaneous fixation (36) or open treatment (24). A total of 79 forearm or DR fractures were treated with cast wedging secondary to loss of reduction, of which 70 patients had complete clinical and radiographic data. Average age was 8.4 years (range, 3 to 14 y), with 25 females and 45 males. Significant improvement in angulation for both-bone forearm fracture from prewedge to final films was seen in 69 children, with no major complications. One patient failed wedging and required surgical reduction and fixation. CONCLUSIONS: Cast wedging is a simple, safe, noninvasive, and effective method for treatment of excessive angulation in pediatric forearm fractures. LEVEL OF EVIDENCE: Level IV.

Perioperative management of a patient with Rett syndrome.

Rett syndrome is a neurodevelopmental disorder that results from mutations in the genes encoding methyl-cytosine-guanosine binding protein 2 located on the X chromosome. Clinical features of central nervous system involvement include regression of developmental milestones in the late infant and early toddler stages, mental retardation, seizures and other electroencephalographic abnormalities. Given the invariable association of this degenerative disorder with orthopedic deformities including scoliosis, patients with Rett syndrome may present for anesthetic care during various surgical procedures. The complexity of the end-organ involvement, specifically the progressive nature of respiratory and cardiac involvement, makes the anesthetic care of such patients challenging. Specific perioperative concerns include potential difficulties with airway management, an underlying seizure disorder, an increased sensitivity to anesthetic agents, prolonged QT syndrome, and diabetes mellitus. We present an 11-year-old girl with Rett syndrome who required anesthetic care for posterior spinal fusion. Previous reports of anesthetic care for these patients are reviewed, the end-organ involvement discussed, and options for anesthetic care presented.

Accuracy of the CNAP monitor, a noninvasive continuous blood pressure device, in providing beat-to-beat blood pressure readings in the prone position.

STUDY OBJECTIVE: To assess the accuracy of a noninvasive continuous arterial pressure (CNAP) monitor in patients who are positioned prone in the operating room. DESIGN: Prospective study. SETTING: Operating room at a children's hospital. PATIENTS: 20 pediatric patients, aged 13.8 ± 2 years, and weight 63.7 ± 18.8 kg, scheduled for surgery in the prone position, and for which arterial catheter placement was planned. INTERVENTIONS: Measurements were recorded with an arterial line (AL) and a new noninvasive continuous blood pressure (BP) monitor. MEASUREMENTS: Systolic (SBP), diastolic (DBP), and mean arterial (MAP) pressure readings were captured from an arterial cannula and the CNAP device every minute during anesthesia. MAIN RESULTS: The study cohort consisted of analysis of 4104 pairs of SBP, DBP, and MAP values, which showed an absolute difference between the AL and CNAP device readings of 7.9 ± 6.3 mmHg for SBP, 5.3 ± 4.3 mmHg for DBP, and 4.6 ± 3.9 mmHg for MAP. Bland-Altman analysis of MAP values showed a bias of 0.26 mmHg, with upper and lower limits of agreement of 12.18 mmHg and -11.67 mmHg, respectively. CNAP readings deviated from arterial values by ≤ 5 mmHg in 67% of MAP values, 59% of DBP values, and 43% of SBP readings. The difference was ≤ 10 mmHg for 94% of MAP readings, 90% of DBP values, and 73% of SBP readings. CONCLUSIONS: During prone positioning, the CNAP monitor provided clinically acceptable accuracy for MAP values, similar to those reported in adults in the supine position.

Phenylephrine to Treat Hypoxemia during One-Lung Ventilation in a Pediatric Patient.

To improve surgical visualization and facilitate the procedure, one-lung ventilation (OLV) is frequently used during thoracic surgery. Although generally well tolerated, the ventilation-perfusion inequality induced by OLV may lead to a decrease in oxygenation and, at times, hypoxemia. Effective treatment algorithms and strategies are necessary for the treatment of hypoxemia during OLV to ensure that the technique can be continued without interruption and allow for completion of the surgical procedure. Treatment strategies may include applying positive end expiratory pressure to the nonoperative lung, continuous positive airway pressure or low flow oxygen insufflation to the operative lung, decreasing anesthetic agents that interfere with hypoxic pulmonary vasoconstriction (HPV), or switching to total intravenous anesthesia. Although less commonly employed, α-adrenergic agonists may also improve oxygenation during OLV by augmenting HPV. We present a 12-year-old girl who developed hypoxemia during OLV, which was not corrected by the usual maneuvers. Hypoxemia was successfully treated with a phenylephrine infusion. The potential applications of α-adrenergic agonists such as phenylephrine in the treatment of hypoxemia during OLV are discussed and its physiologic basis reviewed.

A retrospective quality improvement study of ketorolac use following spinal fusion in pediatric patients.

BACKGROUND: There are studies and literature that support the claim that ketorolac use after spinal fusion in the adult population can increase the risk of pseudarthrosis, instrumentation failure, and/or nonunion. There is limited research when using ketorolac in the pediatric population, especially short-term use. METHODS: Chart review of 46 pediatric patients who had prior spinal fusions for scoliosis between July 2003 and August 2005. Twenty-five of the patients received ketorolac and 21 did not. The lengths of stay, incidence of curve progression, and/or incidence of nonunion or instrumentation failure were compared in the 2 groups. RESULTS: At the 1-year follow-up, 95% of the patients returned and at the 3-year follow-up, 52% of the patients returned and there was no clinical or radiographic evidence of curve progression, nonunion, or instrumentation failure. LEVEL OF EVIDENCE: This is a retrospective study looking at results of 2 patient groups. This is a level III study.

Multifocal epithelioid hemangioendothelioma in a 16-year-old boy.

We report on a 16-year-old white male presenting with a 4-month history of syncopal episodes and occasional headaches. The CT and MRI studies revealed numerous lytic lesions of the skull base and cervical spine; subsequently, similar lesions were demonstrated in all areas of the skeleton, and CT showed numerous lesions in the lungs, liver, and kidneys. Excisional biopsy from several sites confirmed the diagnosis of epithelioid hemangioendothelioma. We conclude that epithelioid hemangioendothelioma should be added to the differential diagnosis for lytic lesions of bone that are clustered in the same anatomic region and that might also present with visceral involvement.