Anesthetic Management of an Infant With Postnatally Diagnosed Tracheal Agenesis Undergoing Tracheal Reconstruction: A Case Report.

A term infant born cyanotic failed multiple intubation attempts and tracheostomy placement. After esophageal intubation resulted in the ability to ventilate, he was presumed to have tracheal agenesis and distal bronchoesophageal fistula. He was transferred to our institution where he was diagnosed with Floyd Type II tracheal agenesis. He underwent staged tracheal reconstruction. He was discharged to home at 4 months of age with a tracheostomy collar, cervical spit fistula, and gastrostomy tube. He represents the sole survivor-to-discharge of tracheal agenesis in the United States. We describe the anesthetic considerations for a patient with tracheal agenesis undergoing reconstruction.

Hepatic Calcified Tumor-like Mass Complicating Umbilical Vein Catheterization in a Neonate.

Presented is a case of a hepatic calcified mass complicating umbilical vein catheterization in a neonate and diagnosed by wedge biopsy. Wedge biopsy of the hepatic mass, situated in proximity to the falciform ligament, revealed expansion of portal tracts by fibrosis and calcification. Some aggregates of calcified material appeared in ectatic vascular spaces. The biopsy findings accounted for the radiographic appearance of the mass and the constellation of features were deemed indicative of calcification secondary to umbilical vein catheterization. Umbilical vein catheterization in neonates may be complicated by a calcified mass that requires histologic evaluation for distinction from other space-occupying lesions. Such a calcified pseudotumor may develop after an umbilical catheter has been in place for only 5 days.

Redistribution of Kv2.1 ion channels on spinal motoneurons following peripheral nerve injury.

Pathophysiological responses to peripheral nerve injury include alterations in the activity, intrinsic membrane properties and excitability of spinal neurons. The intrinsic excitability of α-motoneurons is controlled in part by the expression, regulation, and distribution of membrane-bound ion channels. Ion channels, such as Kv2.1 and SK, which underlie delayed rectifier potassium currents and afterhyperpolarization respectively, are localized in high-density clusters at specific postsynaptic sites (Deardorff et al., 2013; Muennich and Fyffe, 2004). Previous work has indicated that Kv2.1 channel clustering and kinetics are regulated by a variety of stimuli including ischemia, hypoxia, neuromodulator action and increased activity. Regulation occurs via channel dephosphorylation leading to both declustering and alterations in channel kinetics, thus normalizing activity (Misonou et al., 2004; Misonou et al., 2005; Misonou et al., 2008; Mohapatra et al., 2009; Park et al., 2006). Here we demonstrate using immunohistochemistry that peripheral nerve injury is also sufficient to alter the surface distribution of Kv2.1 channels on motoneurons. The dynamic changes in channel localization include a rapid progressive decline in cluster size, beginning immediately after axotomy, and reaching maximum within one week. With reinnervation, the organization and size of Kv2.1 clusters do not fully recover. However, in the absence of reinnervation Kv2.1 cluster sizes fully recover. Moreover, unilateral peripheral nerve injury evokes parallel, but smaller effects bilaterally. These results suggest that homeostatic regulation of motoneuron Kv2.1 membrane distribution after axon injury is largely independent of axon reinnervation.

Is routine tube thoracostomy necessary after prehospital needle decompression for tension pneumothorax?

BACKGROUND: Thoracic needle decompression is lifesaving in tension pneumothorax. However, performance of subsequent tube thoracostomy is questioned. The needle may not enter the chest, or the diagnosis may be wrong. The aim of this study was to test the hypothesis that routine tube thoracostomy is not required. METHODS: A prospective 2-year study of patients aged ≥18 years with thoracic trauma was conducted at a level 1 trauma center. RESULTS: Forty-one patients with chest trauma, 12 penetrating and 29 blunt, had 47 needled hemithoraces for evaluation; 85% of hemithoraces required tube thoracostomy after needle decompression of the chest (34 of 41 patients [83%]). CONCLUSIONS: Patients undergoing needle decompression who do not require placement of thoracostomy for clinical indications may be assessed using chest radiography, but thoracic computed tomography is more accurate. Air or blood on chest radiography or computed tomography of the chest is an indication for tube thoracostomy.

Necrotizing enterocolitis.

Necrotizing enterocolitis (NEC) is the most common acquired gastrointestinal disease of premature neonates and is a serious cause of morbidity and mortality. NEC is one of the leading causes of death in neonatal intensive care units. Surgical treatment is necessary in patients whose disease progresses despite medical therapy. Surgical options include peritoneal drainage and laparotomy, with studies showing no difference in outcome related to approach. Survivors, particularly those requiring surgery, face serious sequelae.

Comparison of hemodynamic measurements from invasive and noninvasive monitoring during early resuscitation.

BACKGROUND: Measurements obtained from the insertion of a pulmonary artery catheter (PAC) in critically ill and/or injured patients have traditionally assisted with resuscitation efforts. However, with the recent utilization of ultrasound in the intensive care unit setting, transthoracic echocardiography (TTE) has gained popularity. The purpose of this study is to compare serial PAC and TTE measurements and document levels of serum biomarkers during resuscitation. METHODS: Over a 25-month period, critically ill and/or injured patients admitted to a Level I adult trauma center were enrolled in this 48-hour intensive care unit study. Serial PAC and TTE measurements were obtained every 12 hours (total = 5 points/patient). Serial levels of lactate, Δ base, troponin-1, and B-type natriuretic peptide were obtained. Pearson correlation coefficient and intraclass correlation (ICC) assessed relationship and agreement, respectively, between PAC and TTE measures of cardiac output (CO) and stroke volume (SV). Analysis of variance with post hoc pairwise determined differences over time. RESULTS: Of the 29 patients, 69% were male, with a mean age of 47.4 years ± 19.5 years and 79.3% survival. Of these, 25 of 29 were trauma with a mean Injury Severity Score of 23.5 ± 10.7. CO from PAC and TTE was significantly related (Pearson correlations, 0.57-0.64) and agreed with moderate strength (ICC, 0.66-0.70). SV from PAC and TTE was significantly related (Pearson correlations, 0.40-0.58) and agreed at a weaker level (ICC, 0.41-0.62). Tricuspid regurgitation was noted in 80% and mitral regurgitation in 50% to 60% of patients. CONCLUSION: Measurements of CO and SV were moderately strong in correlation and agreement which may suggest PAC measurements overestimate actual values. The significance of tricuspid regurgitation and mitral regurgitation during early resuscitation is unknown.

Circulating cellular and humoral elements of immune function following splenic arterial embolisation or splenectomy in trauma patients.

BACKGROUND: Splenectomy impairs the ability to combat infection, especially with encapsulated organisms. However, there is limited understanding of the impact of splenic arterial embolisation on immune function. Our hypothesis was that embolisation would not impair systemic immune function. This study examines elements of cellular and humoral immunity in patients undergoing splenic embolisation or splenectomy for trauma. PATIENTS AND METHODS: Splenic embolisation (SE) and splenectomy patients (S) were compared to blunt trauma patients without splenic injury (NS). Lymphocyte counts, natural-killer cells, serum complement (C3, C4), and properdin levels were assayed. RESULTS: No significant differences in total, helper, or suppressor T-lymphocytes, complement (C3, C4), or properdin were found. B-lymphocyte counts were higher in S (602±445cells/mm(3)) than SE (238±114cells/mm(3)) or NS (293±153cells/mm(3)) (p=.003 for pairwise comparisons). S also had more natural killer T-cells than NS (325±170cells/mm(3) vs. 174±116cells/mm(3), p=.004). CONCLUSION: Splenic embolisation does not alter the measured immunologic parameters. The absence of sensitive markers for splenic immune function limits the ability to assess the impact of embolisation for trauma.

Incidence and risk factors for deep venous thrombosis after moderate and severe brain injury.

BACKGROUND: Patients with traumatic injuries possess a high risk of developing deep venous thrombosis (DVT), thus the need for appropriate prophylaxis. Patients with head injuries pose a unique challenge due to contraindication to the use of anticoagulation. We sought to determine the incidence of DVT and identify specific risk factors for its development in patients with head injuries. METHODS: All head injury admissions between January 1, 2000, and July 31, 2006, with a length of stay >or=7 days were identified. Patient data including age, sex, injuries, Glasgow Coma Scale, Injury Severity Score (ISS), and venous duplex scan results were collected. Mechanical methods were routinely used for prophylaxis; heparin was not used in this population. Weekly duplex screening was commenced at 7 days to 10 days after admission. RESULTS: There were 939 patients who met criteria for review, however, duplex scans were performed in only 677, which was the population studied. Overall, DVT was present in 31.6%. There were fewer DVTs in patients with isolated head injuries (25.8%) compared with patients with those with head and extracranial injuries (34.3%)--p = 0.026. Independent predictors for DVT identified included male gender (p = 0.04), age >or=55 (p < 0.001), ISS >or=15 (p = 0.014), subarachnoid hemorrhage (p = 0.006), and lower extremity injury (p = 0.001). CONCLUSIONS: DVT occurs in one third of moderately to severely brain injured patients. Isolated head injuries have a lower incidence. Older age, male gender, higher ISS, and the presence of a lower extremity injury are strong predictors for developing DVT. Regular screening and the use of prophylactic inferior vena cava filters in patients with risk factors should be strongly considered.