What Is the Role of Developmental Disability in Patient Selection for Pediatric Solid Organ Transplantation?

The National Organ Transplant Act stipulates that deceased donor organs should be justly and wisely allocated based on sound medical criteria. Allocation schemes are consistent across the country, and specific policies are publicly vetted. Patient selection criteria are largely in the hands of individual organ transplant programs, and consistent standards are less evident. This has been particularly apparent for patients with developmental disabilities (DDs). In response to concerns regarding the fairness of transplant evaluations for patients with DDs, we developed a transplant centerwide policy using a multidisciplinary, community-based approach. This publication details the particular policy of our center. All patients should receive individualized assessments using consistent standards; disability should be neither a relative nor an absolute contraindication to transplantation. External review can increase trust in the selection process. Patients in persistent vegetative states should not be listed for transplantation.

Human papillomavirus-related high-grade squamous intraepithelial lesions of the esophagus, skin, and cervix in an adolescent lung transplant recipient: a case report and literature review.

High-risk (carcinogenic) genotype human papillomavirus (HPV) infections can be associated with significant morbidity in the immunocompromised solid organ transplant (SOT) recipient. Immunosuppression-associated persistent infection can predispose to the development of rapidly progressive high-grade squamous intraepithelial lesions (HSIL) in this population. We present a case report of an adolescent bilateral lung transplant recipient who developed HSIL of the esophagus, cervix, and skin secondary to HPV. This review highlights the unique developmental needs of the sexually active adolescent SOT recipient and reviews guidelines for HPV-related screening and education of this population.

Prophylactic antiemetics for laparoscopic cholecystectomy: a comparison of perphenazine, droperidol plus ondansetron, and droperidol plus metoclopramide.

STUDY OBJECTIVE: To compare the prophylactic administration of ondansetron plus droperidol, droperidol plus metoclopramide, and perphenazine to determine effects on postoperative nausea, vomiting, and sedation after laparoscopic cholecystectomy. DESIGN: Prospective, randomized, double-blind study. SETTING: University medical center. PATIENTS: 212 ASA physical status I and II adults presenting for laparoscopic cholecystectomy. INTERVENTIONS: Patients were randomly assigned to receive one of three prophylactic antiemetic drug combinations: ondansetron 4 mg plus droperidol 0.625 mg (Group OD), droperidol 0.625 mg plus metoclopramide 10 mg (Group DM), or perphenazine 5 mg (Group P). Study drugs were administered intravenously after induction of general anesthesia. MEASUREMENTS AND MAIN RESULTS: The groups were similar with respect to gender, age, weight, duration of surgery, numbers of patients receiving intraoperative atropine or ephedrine, number admitted overnight, and time to discharge home. Patients in Group P used lower total doses of opioids than did patients in Group OD. There were no significant differences in postoperative nausea, pain, or sedation scores, in numbers of patients requiring antiemetics (Group OD, 13 of 66; Group DM, 15 of 66; Group P, 14 of 68), or in numbers of patients vomiting, either in hospital or during the first postoperative day. CONCLUSIONS: These three drug regimens are equivalent for antiemetic prophylaxis before laparoscopic cholecystectomy.

Transcutaneous PCO2 monitoring during laparoscopic cholecystectomy in pregnancy.

PURPOSE: Respiratory acidosis during carbon dioxide (CO2) insufflation has been suggested as a cause of spontaneous abortion and preterm labour following laparoscopic cholecystectomy during pregnancy. Capnography may not be adequate as a guide to adjust pulmonary ventilation during laparoscopic surgery and hence arterial carbon dioxide (PaCO2) monitoring has been recommended. We report the feasibility and benefits of transcutaneous carbon dioxide monitoring (PtcCO2) as an approach to optimise ventilation during laparoscopic surgery in pregnancy. METHOD: A healthy parturient received general anaesthesia for laparoscopic cholecystectomy. Pulmonary ventilation was adjusted to maintain end-tidal carbon dioxide (conventional PETCO2) at 32 mmHg during CO2 insufflation. A PtcCO2 monitor was used to trend PaCO2 throughout the procedure. Mechanical ventilation was interrupted every five minutes to obtain an end-tidal PCO2 value at large tidal volume (squeeze PETCO2). RESULTS: The PtcCO2 increased from 39 mmHg before induction to 45 mmHg after CO2 insufflation. This corresponds to an estimated maximum PaCO2 of 39-40 mmHg during insufflation. The PtcCO2 gradually returned to pre-induction baseline values one hour after the termination of CO2 insufflation. Squeeze PETCO2 values approximated PtcCO2 more closely than did conventional PETCO2 values (P < 0.01). CONCLUSION: Continuous PtcCO2 measurements as well as squeeze PETCO2 may be of clinical value in trending and preventing hypercarbia during laparoscopic surgery.

Prophylactic antiemetics for laparoscopic cholecystectomy: ondansetron versus droperidol plus metoclopramide.

Two hundred adults undergoing laparoscopic cholecystectomy were enrolled in a prospectively randomized, double-blind investigation comparing ondansetron, 4 mg (Group O) with the combination of droperidol, 0.625 mg, and metoclopramide, 10 mg (Group DM). Antiemetic drugs were administered intravenously (IV) after induction of general anesthesia (propofol, desflurane). Moderate or severe nausea in the postanesthesia care unit was treated with the cross-over drug, i.e., ondansetron for patients in Group DM or droperidol plus metoclopramide for patients in Group O. Data were analyzed using t-tests and chi 2 analyses, with P < 0.05 considered statistically significant. The groups were similar with respect to gender, age, weight, duration of surgery, number receiving intraoperative atropine or ephedrine, number admitted over-night, and time to discharge home. Of 102 patients in Group O, 44 required antiemetics in the postanesthesia care unit, compared with 24 of 98 patients in Group DM (P < 0.01). One patient (in Group DM) was admitted for persistent nausea. In conclusion, droperidol 0.625 mg IV in combination with metoclopramide 10 mg IV was more effective in preventing postoperative nausea than was ondansetron 4 mg IV in patients undergoing laparoscopic cholecystectomy, with no difference in the time to discharge.

The effects of different central venous line dressing changes on bacterial growth in a pediatric oncology population.

Central venous lines are now common in children who need a permanent form of intravenous access. These lines frequently become infected. This study compared the effects of different antiseptics (Hibiclens [chlorhexadine 4%; Stuart Pharmaceutical, Wilmington, DE] and Betadine [povidone-iodine, Clini Pad Corp, Guilford, CT]) used to clean the skin as well as the dressings used to cover the exit site (Tegaderm [3-M Medical-Surgical Division, St Paul, MN] and gauze) on microorganism growth on the skin in a pediatric oncology population. Sixty subjects were recruited from the oncology and bone marrow transplant units of Children's Hospital in Boston, MA. The subjects were randomly assigned to one of four dressing groups. These included: 1, Betadine and Tegaderm; 2, Betadine and gauze; 3, Hibiclens and Tegaderm; and 4, Hibiclens and gauze. Dressings were done on a Monday-Wednesday-Friday basis. Quantitative cultures were obtained before the first and after the fifth dressing changes. There were no significant differences in incidence of bacterial growth between dressing groups (F = 1.05, P = .377). Redness (F = 3.01, P = .037) and swelling (F = 2.75, P = .051) were more frequently seen in Betadine groups. Boys were more often infected than girls. (Chi 2 = 4.075, P = .044).

Butorphanol compared with fentanyl in general anaesthesia for ambulatory laparoscopy.

Butorphanol was compared with fentanyl as the narcotic component of general anaesthesia for ambulatory laparoscopic surgery. This double-blind, randomized study enrolled 60 healthy women who received equianalgesic doses of fentanyl 1 microgram.kg-1 (F, n = 30) or butorphanol 20 micrograms.kg-1 (B, n = 30) prior to induction of anaesthesia. Tracheal anaesthesia was maintained with nitrous oxide/oxygen, isoflurane, and succinylcholine by infusion. Intraoperatively, patients who received B demonstrated lower pulse rate before and after intubation (P less than 0.05, P less than 0.01) and lower diastolic blood pressure after intubation (P less than 0.01). Anesthesiologists judged the maintenance phase as satisfactory more often with B (P less than 0.05). Postoperatively, there were no differences in analgesic need. No major side-effects occurred in either group. Among minor side-effects, patients who received B reported postoperative sedation more often, 77% vs 37% (P less than 0.01), which occurred during the first 45 min of recovery (P less than 0.05). Discharge times were not different. On the first postoperative day, more subjects who received B were satisfied with their anaesthesia experience (P less than 0.05). Butorphanol 20 micrograms.kg-1 is an acceptable alternative analgesic in general anaesthesia for ambulatory laparoscopy.

Differential spread of blockade of touch, cold, and pinprick during spinal anesthesia.

The differential levels of sensory blockade of pinprick, cold, and touch were monitored throughout the course of spinal anesthesia administered to 50 patients to determine variations in the degree of spread during onset, plateau, and regression, and to establish the effects of epinephrine and the effect of posture during injection. A significant difference was observed between the dermatomal level of sensory loss of touch and the dermatomal level of loss of either pinprick or cold during onset, at 5 min in patients given tetracaine with epinephrine, at time of maximum spread in patients given tetracaine with epinephrine or in the sitting position, and in all groups during regression. Loss of touch began later, never extended as far cephalad, and regressed sooner. The extent of this difference was greatest during regression, when the anesthetic was given to patients in the sitting position, after epinephrine. The level at which the sense of touch was lost seemed to mark the limits of the zone of solid spinal anesthesia; these limits could not be assessed effectively using pinprick. We propose that loss of touch sensation be used to assess whether anesthesia is adequate to avoid tourniquet pain. If there is loss of touch sensation above the L1 dermatome, it is unlikely that tourniquet pain will occur.

A clinical sign to predict difficult tracheal intubation: a prospective study.

It has been suggested that the size of the base of the tongue is an important factor determining the degree of difficulty of direct laryngoscopy. A relatively simple grading system which involves preoperative ability to visualize the faucial pillars, soft palate and base of uvula was designed as a means of predicting the degree of difficulty in laryngeal exposure. The system was evaluated in 210 patients. The degree of difficulty in visualizing these three structures was an accurate predictor of difficulty with direct laryngoscopy (p less than 0.001).