Assessment of Common Criteria for Awake Extubation in Infants and Young Children.

BACKGROUND: Practice patterns surrounding awake extubation of pediatric surgical patients remain largely undocumented. This study assessed the value of commonly used predictors of fitness for extubation to determine which were most salient in predicting successful extubation following emergence from general anesthesia with a volatile anesthetic in young children. METHODS: This prospective, observational study was performed in 600 children from 0 to 7 yr of age. The presence or absence of nine commonly used extubation criteria in children were recorded at the time of extubation including: facial grimace, eye opening, low end-tidal anesthetic concentration, spontaneous tidal volume greater than 5 ml/kg, conjugate gaze, purposeful movement, movement other than coughing, laryngeal stimulation test, and oxygen saturation. Extubations were graded as Successful, Intervention Required, or Major Intervention Required using a standard set of criteria. The Intervention Required and Major Intervention Required outcomes were combined as a single outcome for analysis of predictors of success. RESULTS: Successful extubation occurred in 92.7% (556 of 600) of cases. Facial grimace odds ratio, 1.93 (95% CI, 1.03 to 3.60; P = 0.039), purposeful movement odds ratio, 2.42 (95% CI, 1.14 to 5.12; P = 0.022), conjugate gaze odds ratio, 2.10 (95% CI, 1.14 to 4.01; P = 0.031), eye opening odds ratio, 4.44 (95% CI, 1.06 to 18.64; P= 0.042), and tidal volume greater than 5 ml/kg odds ratio, 2.66 (95% CI, 1.21 to 5.86; P = 0.015) were univariately associated with the Successful group. A stepwise increase in any one, in any order, of these five predictors being present, from one out of five and up to five out of five yielded an increasing positive predictive value for successful extubation of 88.3% (95% CI, 82.4 to 94.3), 88.4% (95% CI, 83.5 to 93.3), 96.3% (95% CI, 93.4 to 99.2), 97.4% (95% CI, 94.4 to 100), and 100% (95% CI, 90 to 100). CONCLUSIONS: Conjugate gaze, facial grimace, eye opening, purposeful movement, and tidal volume greater than 5 ml/kg were each individually associated with extubation success in pediatric surgical patients after volatile anesthetic. Further, the use of a multifactorial approach using these predictors, may lead to a more rational and robust approach to successful awake extubation.

Mass-independent Dunham analysis of the known electronic states of platinum sulfide, PtS, and analysis of the electronic field-shift effect.

Several new vibrational bands of the [12.5] Ω = 0+-X3Σ- Ω=0+ and the [15.9] B Ω = 0+-X3Σ- Ω=0+ transitions have been observed in high resolution absorption measurements recorded using Intracavity Laser Spectroscopy (ILS). These new bands have been rotationally analyzed and incorporated into a comprehensive PtS dataset that was fit to a mass-independent Dunham expression using PGOPHER. The comprehensive dataset included all reported field-free, gas phase spectroscopic data for PtS, including 32 Fourier transform microwave transitions (estimated accuracy: 1 kHz), 9 microwave/optical double resonance transitions (25 kHz), 51 millimeter and submillimeter transitions (25-50 kHz), 469 molecular beam-laser induced fluorescence transitions (0.003 cm-1), and 4870 ILS transitions (0.005 cm-1). The determined equilibrium constants have been used with the Rydberg-Klein-Rees method to produce potential energy curves for the four known electronic states of PtS. Isotopic shifts in electronic transition energy beyond expectations from the Born-Oppenheimer approximation were observed and treated as electronic field-shift effects due to the difference in the nuclear charge radius between Pt isotopes. The magnitude and sign of the determined field-shift parameters are rationalized through the analysis of the previously reported ab initio calculations.

The spin-forbidden a 4Σ--X 2Π1/2 transition of GeH detected in absorption using intracavity laser spectroscopy.

The a 4Σ--X 2Π1/2 transition of GeH has been recorded in absorption for the first time using Intracavity Laser Spectroscopy (ILS). The GeH molecules were produced in a 0.40-0.60 A DC plasma discharge inside an aluminum hollow cathode, using 500 mTorr of Ar, 100 mTorr of H2, and 200 mTorr of GeH4. This cathode is located within the resonator cavity of a Coherent Verdi™ V-10 pumped dye laser. Effective path lengths for this series of measurements using the ILS method ranged from 2 to 7 km. Spectra were calibrated using the absorption spectrum of I2 collected from an extracavity cell, the I2 transmission spectrum from Salami and Ross, J. Mol. Spectrosc. 223(1), 157 (2005) and PGOPHER's [C. M. Western, J. Quant. Spectrosc. Radiat. Transfer 186, 221-242 (2016)] calibration feature. Differences in peak positions between calibrated experimental spectra and the reference data were on average less than ±0.002 cm-1. All eight branches expected to have appreciable intensity for the transition have been identified, and isotopologue splitting was observed in features of 5 of the 8 identified rotational branches. Molecular constants have been obtained for the a 4Σ- states of 70GeH (20.84% abundant), 72GeH (27.54% abundant), and 74GeH (36.28% abundant). The transitions were fit using PGOPHER, holding the ground state constants fixed to the values reported by Towle and Brown [Mol. Phys. 78(2), 249 (1993)]. The constants for the a 4Σ- state of 74GeH determined by the fit are T0 = 16 751.5524(13) cm-1, B0 = 6.764 912(33) cm-1, D0 = 0.459 60(17) × 10-3 cm-1, λSS = 9.7453(12) cm-1, λD = 0.468(14) × 10-3 cm-1, γ = 0.077 878(84), and γS = -0.361(77) × 10-3 cm-1.

High resolution electronic spectroscopy of the A (2)Σ- - X (2)Π1/2 transition of PtN.

The (2,0) vibrational band of the A (2)Σ(-) - X (2)Π1/2 transition of platinum nitride, PtN, was recorded at Doppler-limited resolution using intracavity laser absorption spectroscopy (ILS) and at sub-Doppler resolution using molecular beam laser induced fluorescence (LIF) spectroscopy. Isotopologue structure for (194)PtN, (195)PtN, and (196)PtN, magnetic hyperfine splitting due to (195)Pt (I = ½), and nuclear quadrupole splitting due to (14)N (I = 1) were observed in the spectrum. Molecular constants for the ground and excited states are derived. The hyperfine interactions are used to illuminate the nature of the A (2)Σ(-) excited electronic state.

The Pt2 (1,0) band of System VI in the near infrared by intracavity laser absorption spectroscopy.

Intracavity laser absorption spectroscopy has been used to record rotationally resolved electronic spectra of Pt(2) in the near infrared. The metal dimers were created using a 50 mm-long, platinum-lined hollow cathode plasma discharge. The observed transition at 12 937 cm(-1) is identified as the (1,0) band of System VI, with state symmetries Ω = 0 - X Ω = 0.

Video-assisted ductal ligation in premature infants.

BACKGROUND: Video-assisted thoracic surgery has been shown to be a safe and effective method of closing the patent ductus arteriosus in infants and children. We have applied this technique in low birth weight premature infants and now report our experience. METHODS: Since 1996, we have used video-assisted thoracic surgery ligation as the treatment of choice for all patent ductus arteriosus, including 100 performed on premature infants (23 to 31 weeks' gestation, mean 25.6 weeks; 0.420 to 1.5 kg, mean 0.859 kg). A modification of our previously described technique was used with a three-port approach. All patients had some degree of symptoms of congestive failure with failure to wean from ventilatory support or oxygen dependency. Five infants had associated patent foramen, and 1 had a small ventricular septal defect. RESULTS: All 100 procedures were performed in the operating room. One infant was found to have a coarctation, and the procedure was aborted. The remaining 99 were successfully ligated, although three were converted to an open procedure (3%) because of coagulopathy, poor pulmonary compliance, or hemodynamic instability. There were no procedure-related deaths; however, 15 infants subsequently died of complications of prematurity, including enterocolitis, sepsis, and late respiratory failure. Six infants had chest tubes left in place for coagulopathy, effusions, suspected air leak, and existing empyema. There were six residual pneumothoraces, four requiring treatment. CONCLUSIONS: Video-assisted thoracic surgery is a safe and effective technique for patent ductus arteriosus ligation in premature infants, including those with very low and extremely low birth weight.

Pseudo-spectral methods and linear instabilities in reaction-diffusion fronts.

We explore the application of a pseudo-spectral Fourier method to a set of reaction-diffusion equations and compare it with a second-order finite difference method. The prototype cubic autocatalytic reaction-diffusion model as discussed by Gray and Scott [Chem. Eng. Sci. 42, 307 (1987)] with a nonequilibrium constraint is adopted. In a spatial resolution study we find that the phase speeds of one-dimensional finite amplitude waves converge more rapidly for the spectral method than for the finite difference method. Furthermore, in two dimensions the symmetry preserving properties of the spectral method are shown to be superior to those of the finite difference method. In studies of plane/axisymmetric nonlinear waves a symmetry breaking linear instability is shown to occur and is one possible route for the formation of patterns from infinitesimal perturbations to finite amplitude waves in this set of reaction-diffusion equations. (c) 1996 American Institute of Physics.

Molecular Constants for the v=0, b(1)Sigma(g)(+) Excited State of O(2): Improved Values Derived from Measurements of the Oxygen A-Band Using Intracavity Laser Spectroscopy.

High-resolution intracavity laser spectroscopy (ILS) absorption measurements have been made on the b-X oxygen electronic transition (the A-band) which has bandheads occurring in the region of 13 165 cm(-1). The positions of the lines were determined to an accuracy that is based on calibration with I(2) absorption lines using the Laboratoire Aimé Cotton (Orsay) Atlas as reference. Based on the ILS measurements and the more accurately determined positions given by L. R. Brown and C. Plymate (J. Mol. Spectrosc. 199, 166-179 (2000)) and with the (3)Sigma(g)(-) ground state molecular constants fixed at the values determined by G. Rouillé et al. (J. Mol. Spectrosc. 154, 372-382 (1992)), the following values (in cm(-1)) were found for the molecular constants: T(0)=13122.2524(1); B(0)=1.391244(2); D(0)=5.352(4)x10(-6); and H(0)=-1.2(2)x10(-11). These results are compared with values derived from fits of the line positions listed in several other studies of this transition. Copyright 2001 Academic Press.

The pharmacokinetics of epsilon-aminocaproic acid in children undergoing surgical repair of congenital heart defects.

UNLABELLED: epsilon-Aminocaproic acid (epsilonACA) is often administered to children undergoing cardiac surgery by using empiric dosing techniques. We hypothesized that children would have different pharmacokinetic variables and require a dosing scheme different from adults to maintain stable and effective serum epsilonACA concentrations. Eight patients were enrolled in our study. epsilonACA 50 mg/kg was administered three times IV: before, during, and after cardiopulmonary bypass (CPB). Nine serum samples were obtained. epsilonACA plasma concentrations were measured by using high-performance liquid chromatography, and pharmacokinetic modeling was done by using NONMEM. The best fit was seen with a two-compartment model with volume of distribution (V(1)) adjusted for weight and CPB. Compared with published results in adults, modeling suggests that weight-adjusted V(1) is larger in children than in adults before, during, and after CPB. Clearance from the central compartment (k(10)) was also greater in children than adults, and declined during CPB. Redistribution rates from the central compartment, k(12) and k(21), were greater in children and not affected by CPB. We modeled several different dosing regimens for epsilonACA based on the larger V(1), and higher redistribution and clearance variables. We conclude that, because of the developmental differences in pharmacokinetic variables of epsilonACA, when compared with adult patients, a larger initial dose and faster infusion rate as well as an addi-tional dose on CPB are needed to maintain similar concentrations. IMPLICATIONS: Pharmacokinetic modeling of epsilon-aminocaproic acid in children undergoing cardiac surgery suggests that there are developmental differences in pharmacokinetic variables. Based on these data, a dosing modification in children is suggested which may better maintain serum concentrations in children when compared with adults.