Perioperative Intravenous Fluid in Children Undergoing Brain Tumor Resection: Balancing the Threats to Homeostasis

No abstract available

https://ift.tt/2B9Ie6b

Epidemiology and Resource Utilization of Simple Febrile Seizure-associated Hospitalizations in the United States, 2003-2012

Background: Simple febrile seizure (SFS) affects 2% to 4% of children under 6 years of age. The purpose of this study is to examine the epidemiologic patterns and resource utilization of SFS-associated hospitalizations in children aged younger than 6 years of age in the United States. Materials and Methods: This study is a serial, retrospective analysis of the Healthcare Cost and Utilization Project Kids' Inpatient Databases for the years 2003, 2006, 2009, and 2012. SFS-associated hospitalizations were identified based on International Classification of Diseases, Ninth Revision, Clinical Modification, diagnosis code 780.31. We calculated the proportion of hospitalizations in pediatric patients under 6 years of age due to SFS and all other nonbirth causes, the rate of SFS-associated hospitalizations per 100,000 population, the mean length of stay and inflation-adjusted hospital costs of SFS-associated hospitalizations, as well as patient demographics and hospital characteristics. Results: From 2003 to 2012, the weighted proportion of hospitalizations due to SFS declined from 0.83% to 0.41% (P

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Developmental Neurotoxicity: An Update

In the section of "Developmental Neurotoxicity: An Update" of the Pediatric Anesthesia Neurodevelopmental Assessment (PANDA) symposium 2018 the speakers presented the current literature in translational and clinical research. Dr. Brambrink spoke about translational research in anesthetic neurotoxicity, beginning with discovery in the rodent model, then focusing on evidence from nonhuman primates. Dr. Waspe applied the methodology of Adverse Outcome Pathways from the field of toxicology to developmental neurotoxicity of anesthetics. Dr. O'Leary presented relevant clinical studies that were published in 2017 divided by a focus on academic performance, clinical outcomes or diagnoses, or neuropsychological testing.

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Introduction to “Anesthesia and Neurodevelopment in Children”: A Supplement from the Sixth Pediatric Anesthesia Neurodevelopmental Assessment (PANDA) Symposium

No abstract available

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Anesthesia and Neurodevelopment in Children: Many Important Questions Remain Unanswered

No abstract available

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Engaging Stakeholders to Promote Safe Anesthesia and Sedation Care in Young Children

An important aspect of any research endeavor is engaging various stakeholders to work toward the common goal of pushing knowledge forward about the question at hand. Research into pediatric anesthetic neurotoxicity could benefit greatly from interventions designed to improve the efforts and dedication of government agencies, pharmaceutical companies, research communities, and most importantly, patients. The Pediatric Anesthesia Neurodevelopment Assessment (PANDA) symposium is a biennial meeting where updates in research in the field are presented, and issues relevant to the community are discussed in round table discussions. Here, we summarize a discussion that took place at the 2018 meeting regarding new methods of engaging various stakeholders, as well as perspectives from other stakeholders. Topics discussed included an online portal to better reach patients, experiences with a public-private partnership, steps by the National Institutes of Health to improve engagement with research and improve the dissemination of results, and the experiences of the United States Food and Drug Administration attempting to improve stakeholder engagement following the passage of a new law to promote drug development. The round table discussion provided interesting insights into a critical research topic, and shared first-hand experience of attempts to improve engagement with a variety of stakeholders.

https://ift.tt/2Uvl7M2

Phenytoin-induced Excessive Sedation During Awake Craniotomy: An Unusual Observation

No abstract available

https://ift.tt/2UCbDyP

Using Neuroimaging to Study the Effects of Pain, Analgesia, and Anesthesia on Brain Development

Neuroimaging has been increasingly used as a modality to study the impact of pain, analgesia, and anesthetics on pediatric neurodevelopment. The sixth biennial Pediatric Anesthesia Neurodevelopmental Assessment (PANDA) Symposium addressed the 2016 US Food and Drug Administration drug safety warning regarding the potential neurotoxic effects of commonly used anesthetic and sedative medications in children, and included a session discussing the use of various neuroimaging techniques, to detect structural, metabolic, and functional brain changes that can occur with exposure to pain and to anesthetic medications. The presenters concluded that advanced multimodal magnetic resonance imaging techniques are useful in detecting the aforementioned changes, which were found to be pain-specific and anesthetic agent-specific.

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Cognitive Aids for the Diagnosis and Treatment of Neuroanesthetic Emergencies: Consensus Guidelines on Behalf of the Society for Neuroscience in Anesthesiology and Critical Care (SNACC) Education Committee

Cognitive aids and evidence-based checklists are frequently utilized in complex situations across many disciplines and sectors. The purpose of such aids is not simply to provide instruction so as to fulfill a task, but rather to ensure that all contingencies related to the emergency are considered and accounted for and that the task at hand is completed fully, despite possible distractions. Furthermore, utilization of a checklist enhances communication to all team members by allowing all stakeholders to know and understand exactly what is occurring, what has been accomplished, and what remains to be done. Here we present a set of evidence-based critical event cognitive aids for neuroanesthesia emergencies developed by the Society for Neuroscience in Anesthesiology and Critical Care (SNACC) Education Committee.

https://ift.tt/2BeABvk

Protecting the Brain With Xenon Anesthesia for Neurosurgical Procedures

Xenon possesses some, but not all, of the clinical features of an ideal anesthetic agent. Besides well-known advantages of rapid awakening, stable hemodynamics and lack of biotransformation, preclinical data lead to the expectation of xenon's advantageous use for settings of acute ongoing brain injury; a single randomized clinical trial using an imaging biomarker for assessing brain injury corroborated xenon's preclinical efficacy in protecting the brain from further injury. In this review, we discuss the mechanisms and hence the putative applications of xenon for brain protection in neurosurgery. Although the expense of this rare monoatomic gas will likely prevent its widespread penetration into routine clinical neurosurgical practice, we draw attention to the theoretical benefits of xenon anesthesia over other anesthetic regimens for awake craniotomy and for neurosurgery in older, high-risk, and sicker patients.

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The Best of the Old With Promise of the New: The Format of the Annual Meeting of the Society for Neuroscience in Anesthesiology and Critical Care is Changing

No abstract available

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Balanced Crystalloids Versus Saline for Perioperative Intravenous Fluid Administration in Children Undergoing Neurosurgery: A Randomized Clinical Trial

Background: Balanced crystalloid solutions induce less hyperchloremia than normal saline, but their role as primary fluid replacement for children undergoing surgery is unestablished. We hypothesized that balanced crystalloids induce less chloride and metabolic derangements than 0.9% saline solutions in children undergoing brain tumor resection. Methods: In total, 53 patients (age range, 6 mo to 12 y) were randomized to receive balanced crystalloid (balanced group) or 0.9% saline solution (saline group) during and after (for 24 h) brain tumor resection. Serum electrolyte and arterial blood gas analyses were performed at the beginning of surgery (baseline), after surgery, and at postoperative day 1. The primary trial outcome was the absolute difference in serum chloride concentrations (post-preopΔCl−) measured after surgery and at baseline. Secondary outcomes included the post-preopΔ of other electrolytes and base excess (BE); hyperchloremic acidosis incidence; and the brain relaxation score, a 4-point scale evaluated by the surgeon for assessing brain edema. Results: Saline infusion increased post-preopΔCl (6 [3.5; 8.5] mmol/L) compared with balanced crystalloid (0 [−1.0; 3.0] mmol/L; P

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The Effects of Leukocyte Filtration on Cell Salvaged Autologous Blood Transfusion on Lung Function and Lung Inflammatory and Oxidative Stress Reactions in Elderly Patients Undergoing Lumbar Spinal Surgery

Background: This study was designed to investigate the effects of leukocyte filtration of autologous salvaged blood on lung function, lung inflammatory reaction, and oxidative stress reaction in elderly patients undergoing lumbar spinal surgery. Materials and Methods: Sixty elderly patients undergoing lumbar spinal surgery were randomly divided into 2 groups: Leukocyte Filter group and Control group. Serum levels of inflammatory markers including white blood cell and polymorphonuclear count, neutrophil elastase, serum surfactant protein A, methane dicarboxylic aldehyde, superoxide dismutase, interleukin (IL)-6, IL-8, tumor necrosis factor-α, and respiratory function markers including dynamic respiratory system compliance, oxygenation index, and respiratory index were measured immediately before induction of anesthesia (T0), immediately before blood transfusion (T1), and 1 (T2), 6 (T3), and 12 hours (T4) after end of blood transfusion. Results: The Leukocyte Filter group had higher dynamic respiratory system compliance at T2, oxygenation index at T2 and T3, respiratory index and superoxide dismutase at T2, T3, and T4 than those in the Control group (P

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Outcomes of Anesthesia Selection in Endovascular Treatment of Acute Ischemic Stroke

Background: The association between anesthesia type and outcomes in patients with acute ischemic stroke undergoing endovascular treatment (EVT) remains a subject of ongoing debate. Methods: This prospective nonrandomized controlled trial included 149 consecutive patients with acute anterior circulation stroke who underwent EVT. The primary outcome was functional independence assessed by the modified Rankin Scale (mRS) after 3 months. Results: A total of 105 (70.5%) and 44 (29.5%) patients undergoing EVT who received conscious sedation (CS) and general anesthesia (GA), respectively. The patients who received GA had similar demographics and basic National Institute of Health Stroke Scale scores (17 vs. 16, P>0.05) as the patients who received CS. The recanalization time (304 vs. 311 min, P=0.940) and the recanalization rate (86.4% vs. 84.1%, P=0.170) did not differ between the patients receiving the different types of anesthesia. The National Institute of Health Stroke Scale at 24 hours was lower in the patients who received CS than in those who received GA (β=−2.26, 95% confidence interval, −5.30 to 0.79). The independence (modified Rankin Scale score 0 to 2) at 3 months was equal between patients who received GA and those who received CS (odds ratio=0.73, 95% confidence interval, 0.32-1.68). The mortality and the morbidity rates did not differ. Conclusions: The data indicated that the selection of GA or CS during EVT had no impact on the independent outcomes of patients with anterior circulation occlusion.

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Prolonged Anesthetic Exposure in Children and Factors Associated With Exposure Duration

Introduction: Anesthetic exposure duration has come under scrutiny because of a Food and Drug Administration warning against prolonged use of anesthesia in children, defined as exposures longer than 3 hours. Methods: Data for 2,613,344 pediatric anesthetic records from the American Society of Anesthesiologist's National Anesthesia Clinical Outcomes Registry from 2010 to 2015 were analyzed to describe anesthetic duration and the prevalence of prolonged exposures in children. Common pediatric inpatient procedures were independently assessed to determine factors associated with exposure duration. Results: The overall mean pediatric anesthetic duration was 83.3±107.4 minutes (median, 57 min). Prolonged exposures comprised 7% of pediatric anesthetic records, and 15% of anesthetic records in infants. After restricting to common pediatric inpatient procedures (n=96,603) and adjusting for procedure type using a Poisson model, compared with children 10 years or older, exposures in infants were 20.5% longer (anesthetic duration ratio [ADR], 1.205; 95% confidence interval [CI], 1.202–1.208). Longer exposures were also seen with a variety of other patient and hospital factors including ASA 4 patients versus ASA 1 patients, (ADR, 1.381; 95% CI, 1.376-1.386), and university hospitals versus surgery centers (ADR, 1.241; 95% CI, 1.236-1.246). Conclusions: Most pediatric anesthetic exposures last

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Radiographic Predictors of Difficult Laryngoscopy in Acromegaly Patients

Background: Patients with acromegaly have a high risk of difficult laryngoscopy. However, clinical predictors, such as upper lip bite test or modified Mallampati class, show limited predictive performance for difficult laryngoscopy in such patients. In this retrospective study, we evaluated radiographic indices obtained from skull lateral x-ray and ostiomeatal unit computed tomography images to predict difficult laryngoscopy in acromegaly patients. Materials and Methods: Data on demographics, preoperative serum levels of pituitary hormones, and radiographic indices were collected from 90 acromegaly patients that underwent transsphenoidal removal for pituitary tumor from January 2010 to December 2016. Difficult laryngoscopy was defined as Cormack-Lehane grade ≥III. Results: Difficult laryngoscopy occurred in 21 (23%) patients. In univariate analysis, age and radiographic indices indicating tongue size, such as tongue area (TA) on ostiomeatal unit computed tomography, linear distance from the alveolar line of the mandible to the hyoid bone, and linear distance from the interior border of the mandible to the hyoid bone on skull lateral x-ray, were associated with difficult laryngoscopy. In multivariate analysis, age (odds ratio [95% confidence interval], 1.084 [1.037-1.190]; P=0.002) and TA (1.002 [1.000-1.003], P=0.014) were independent risk factors for difficult laryngoscopy. The area under the curve of the combined model of age and TA was 0.80. Conclusions: Old age and radiographic predictors indicating large tongue size (large TA, long alveolar line of the mandible to the hyoid bone and mandible to the hyoid bone) were associated with an increased rate of difficult laryngoscopy in acromegaly patients. Preoperative radiographic measurements of tongue size can be helpful for safe airway management in such patients.

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A Summary of Preclinical Poster Presentations at the Sixth Biennial Pediatric Anesthesia Neurodevelopment Assessment (PANDA) Symposium

The potential for long-term neurotoxic effects of anesthetics on the developing human brain has led to intensified research in this area. To date, the human evidence has been inconclusive, but a large body of animal evidence continues to demonstrate cause for concern. On April 14 and 15, 2018 the sixth biennial Pediatric Anesthesia and Neurodevelopmental Assessment (PANDA) study symposium was held at Morgan Stanley Children's Hospital of New York. This symposium brought together clinicians and researchers and served as a platform to review preclinical and clinical data related to anesthesia and neurotoxicity in developing brains. The program participants included many active investigators in the field of anesthesia neurotoxicity as well as stakeholders from different backgrounds with the common interest of potential anesthetic neurotoxicity in children. The moderated poster session included presentations of preclinical animal research studies. These studies focused on defining the anesthetic-induced neurotoxicity phenotype, understanding the mechanism of injury and discovering potential inhibitors of neurotoxic effects.

https://ift.tt/2UyZcDK

Analgesia Nociception Index Monitoring During Supratentorial Craniotomy

Background: Objective monitoring of pain during and after surgery has been elusive. Recently, Analgesia Nociception Index (ANI) monitor based on the high frequency component of heart rate variability has been launched into clinical practice. We monitored analgesia during craniotomy using ANI monitor and compared it with cardiovascular parameters and response entropy (RE) of entropy monitor. Materials and Methods: In 21 patients undergoing a craniotomy for a supratentorial lesion, we monitored ANI, heart rate (HR), mean arterial pressure (MAP), state entropy, and RE throughout the surgery. Also, ANI, hemodynamic variables and spectral entropy values were noted at the times of maximal stimulation, such as induction, intubation, head pin fixation, skin incision, craniotomy, durotomy, and skin closure. We also compared ANI with RE during administration of bolus doses of fentanyl. Results: There was an inverse correlation between ANI values and the hemodynamic changes. When the HR and MAP increased, ANI decreased suggesting a good correlation between hemodynamics and ANI values during the times of maximal stimulation. State entropy and RE did not change significantly in response to bolus doses of fentanyl administered during the course of surgery, while ANI increased significantly. Conclusion: In neurosurgical patients undergoing elective supratentorial craniotomy, ANI measures response to noxious stimuli with at least as much reliability as hemodynamic variables and changes in ANI parallel the changes in HR and MAP. ANI is superior to RE for measurement of response to noxious stimuli.

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Chemical Eye Injury in a Case of Cervical Spine Surgery

No abstract available

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The Impact of Intraoperative Magnetic Resonance Imaging on Patient Safety Management During Awake Craniotomy

Background: Awake craniotomy paired with intraoperative magnetic resonance imaging (iMRI) is now the established technique for maximizing surgical resection, while preserving neurological function. However, leaving an unsecured airway patient in the iMRI gantry represents considerable risk. Our study aimed at identifying the incidence of critical adverse events in unsecured airway patients during iMRI as part of awake craniotomy. Materials and Methods: We conducted a clinical chart review of consecutive awake craniotomies performed between November 1999 and December 2015. Sequences of iMRI performed without invasive airway management were selected for assessment and the incidence of critical adverse events, including general convulsive seizure, respiratory arrest, nausea/vomiting and agitation, was identified. Results: Critical adverse events occurred in 21 of 356 unsecured airway patients within 24 of the 579 iMRI sequences. In cases using the low-field strength open MRI scanner, emergency termination of scans due to patient decline was recorded in only 4 cases: no cases of cardiac arrest, accidental death, or thermal injury were recorded. Compared with cardiovascular monitoring, patient respiratory status was poorly recorded. Conclusions: In terms of anesthesia, concurrent use of iMRI for awake craniotomy is clinically acceptable providing potential intraoperative complications can be controlled. Further, the configuration of the iMRI scanner as well as the reduced exposure from the lower magnetic field strength was found to impact patient safety management. Therefore when a conscious patient is left in the gantry without airway support, it is advisable that levels of oxygenation and ventilation should be monitored at all times.

https://ift.tt/2Bc9DV2

Epithelioid cell granuloma with caseating necrosis possibly caused by periapical periodontitis: a case report

Epithelioid cell granuloma with caseating necrosis is a typical pathological finding in tuberculosis. While specific inflammation, including that related to tuberculosis, can induce caseating granuloma formati...

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Ocular Complications from Retained Intraocular Ointment Discovered 33 Months after Cataract Surgery

Topical antibiotic and steroid ointments are sometimes used topically at the conclusion of intraocular surgery, and inadvertent entry into the eye has been reported. Dispersed ointment droplets or consolidated globules in the anterior chamber (AC) can sometimes be visualized on exam. Occasionally, intraocular ointment is found incidentally without apparent toxic effect, but retained ointment usually presents with early or delayed intraocular inflammation, pressure rise, macular edema, or corneal edema. The usual treatment for toxicity from retained ointment is removal of the ointment. While the complication of ointment-induced cystoid macular edema has been reported, there is paucity of literature on the anatomical response and eventual visual outcome of patients who have been treated for long-standing edema from retained ointment. We present a case of a patient who presented with history of poor vision since the time of cataract surgery 33 months prior, who had cystoid macular edema, reduced endothelial cell count, and apparent Maxitrol ointment (neomycin, polymyxin B sulfate, and dexamethasone in paraffin vehicle; Novartis Pharmaceuticals UK) floating in the AC. The patient was treated with AC washout and sub-Tenon injection of triamcinolone. His vision, retinal architecture by optical coherence tomography, endothelial cell count, and pachymetry has been followed for 9 months following this treatment.
Case Rep Ophthalmol 2018;9:493–498

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Extensive Paneth cell metaplasia in an ovarian Krukenberg tumor: report of an unusual case and literature review

Abstract

Paneth cells are classified as secretory cells which are normally found in the cecum and ascending colon. Their presence in other parts of the gastrointestinal tract is regarded as abnormal and indicates metaplasia. Paneth cells may also be rarely found in gastrointestinal, biliary and prostatic tumors. The presence of Paneth cells in ovarian Krukenberg tumors is rare and to the best of our knowledge is restricted to metastatic appendiceal goblet cells tumors. We report a rare case of unilateral metastatic gastric carcinoma to the ovary in a 23-year-old female. This tumor showed unusual extensive Paneth cells metaplasia with classical signet ring cell morphology.

https://ift.tt/2C52Ttu

A case series on the conservative management of the bony skull in patients with aggressive skin carcinomas of the scalp

Abstract

Few studies examine techniques of surgical resection for scalp malignancies to ensure clear margins. We present a case series utilizing outer cortex removal in patients without evidence of bony or pericranial invasion. A retrospective casenote review is presented of three cases treated in a tertiary Head and Neck Cancer Centre. An outer table removal approach was utilized based on the absence of bony involvement either on pre-operative imaging or from intra-operative findings. All cases underwent an outer table drilldown procedure. Tumour histology included high grade carcinoma of unknown origin, malignant cylindroma and squamous cell carcinoma. Complete excisions with adequate deep margins were achieved in 100% cases. Overall disease-free survival was 66.6% and local control rate was 100%. This technique allows a high degree of local control, notably at the deep margin. There is little morbidity and it avoids the complications associated with full thickness calvarial resection.

https://ift.tt/2LcRtqw

Internal hernia through the foramen of Winslow

Abstract

Foramen of Winslow hernias are one of the most uncommon types of internal hernias that a surgeon will encounter. They are often initially indolent with vague symptoms that present over an extended period of time. Unfortunately, these hernias are not often diagnosed prior to requiring emergent operative intervention. This case report describes a patient who had a long history of vague abdominal pain and radiographic evidence of a foramen of Winslow hernia 4 years prior to presenting with acute obstructive symptoms. This raises the question: Should foramen of Winslow hernias, if diagnosed early, be repaired on an elective basis?

https://ift.tt/2LaM6Z4

Perioperative Care of the Trauma Patient: New Concepts Since Wartime Learning

Publication date: Available online 10 December 2018

Source: Anesthesiology Clinics

Author(s): Lee A. Fleisher

https://ift.tt/2L8z3aJ

Modern Day Trauma Care for the Anesthesiologist

Publication date: Available online 10 December 2018

Source: Anesthesiology Clinics

Author(s): Maureen McCunn, Mohammed Iqbal Ahmed, Catherine M. Kuza

https://ift.tt/2C3uOKD

Surface contamination in the operating room: use of adenosine triphosphate monitoring

Abstract

Purpose

We prospectively investigated contamination of high-contact surfaces in the operating room (OR) using adenosine triphosphate (ATP) monitoring. We tested whether contamination would increase from morning (AM) to afternoon (PM), despite cleaning between cases. Second, we compared the degree of OR contamination to non-OR control sites.

Methods

ORs with high case volumes were selected for the study. Ten sites in each OR were swabbed using the AccuPoint^® HC ATP Sanitation Monitoring device, which provided a numerical measure of contamination (relative light units, RLUs). According to the manufacturer, surfaces are considered clean at ≤ 400 RLUs. AM measurements were taken before the start of surgical cases and PM measurements were taken after cases were completed.

Results

Eighty morning and 70 afternoon samples were obtained from 8 ORs. Apart from the OR floor, laryngoscope handles had the highest level of morning contamination (1204 RLUs, interquartile range 345, 2603), with 75% of AM samples and 100% of PM samples exceeding 400 RLUs. This contamination was comparable to hospital toilet seats (87% of samples exceeding 400 RLUs). No sites showed statistically significant increases in contamination from AM to PM.

Conclusion

Apart from the OR floors, laryngoscope handles emerged as a key OR site where improved cleaning practices may reduce cross-contamination risk. While some sites showed increased contamination over the course of the day, none of these met statistical significance thereby offering tentative evidence that current cleaning practices during case turnover are effective for most sites.

https://ift.tt/2zROhwq