Anesthetic complications during general anesthesia without intravenous access in pediatric ophthalmologic clinic: assessment of 5216 cases.

BACKGROUND: General anesthesia utilizing inhalational agents without intravenous (IV) access for minor procedures is controversial. Eliminating IV access increases efficiency and patient satisfaction; however, the ability to introduce rapid acting medications into the circulation during an unanticipated emergency becomes challenging. The objective of this study was to examine complication risk following pediatric ophthalmologic examinations under anesthesia (EUA) without IV placement. METHODS: A retrospective review of consecutive pediatric patients who underwent EUA for retinoblastoma management was performed from 2004 to 2014. The total number of anesthetics and elective IV placement were identified. Patient characteristics, length of the procedure, laryngeal mask airway (LMA) placement, and complications were also recorded. A survey of specialized ophthalmology institutions was performed in order to ascertain the state of standard practices. RESULTS: Over 10 years, 5216 anesthetics were identified. The mean age and weight of the patients were 2.7±2.0 years and 14.4±6.6 kg, respectively. In all, 298 elective IVs were placed (6%) and 4918 cases (94%) were performed without IV access. A total of 1687 (32%) anesthetics were administered with a laryngeal mask airway (LMA), of which 1389 (82%) did not have IV access. There were no deaths and no unplanned admissions. There were 8/5216 complications (0.153%) which all resolved safely. CONCLUSIONS: The current study shows that it is safe to perform EUA and procedures for the diagnosis and treatment of retinoblastoma in pediatric patients without securing IV access. All emergency post-complication IV placements were successful and no long-term sequelae were seen.

Buprenorphine/naloxone therapy for opioid refractory neuropathic pain following traumatic amputation: a case series.

Phantom limb pain is a common consequence of limb amputation and is prevalent among the service members sustaining traumatic battlefield limb injuries during the conflicts in Iraq and Afghanistan. Current treatment to relieve phantom limb pain consists of physical, behavioral, and medical modalities including opioids and adjunct medications. Treatment failure resulting in persistent pain and disability may result. This case series describes four previously healthy service members who developed phantom limb pain following traumatic amputation successfully treated with buprenorphine/naloxone after failing traditional treatment. This is the first reported case series of patients expressing improved pain control with decreased frequency of phantom limb pain with the use of buprenorphine/naloxone instead of traditional opioid agonists.

Circulating angiogenic precursors in idiopathic pulmonary arterial hypertension.

Vascular remodeling in idiopathic pulmonary arterial hypertension (IPAH) involves hyperproliferative and apoptosis-resistant pulmonary artery endothelial cells. In this study, we evaluated the relative contribution of bone marrow-derived proangiogenic precursors and tissue-resident endothelial progenitors to vascular remodeling in IPAH. Levels of circulating CD34+ CD133+ bone marrow-derived proangiogenic precursors were higher in peripheral blood from IPAH patients than in healthy controls and correlated with pulmonary artery pressure, whereas levels of resident endothelial progenitors in IPAH pulmonary arteries were comparable to those of healthy controls. Colony-forming units of endothelial-like cells (CFU-ECs) derived from CD34+ CD133+ bone marrow precursors of IPAH patients secreted high levels of matrix metalloproteinase-2, had greater affinity for angiogenic tubes, and spontaneously formed disorganized cell clusters that increased in size in the presence of transforming growth factor-beta or bone morphogenetic protein-2. Subcutaneous injection of NOD SCID mice with IPAH CFU-ECs within Matrigel plugs, but not with control CFU-ECs, produced cell clusters in the Matrigel and proliferative lesions in surrounding murine tissues. Thus, mobilization of high levels of proliferative bone marrow-derived proangiogenic precursors is a characteristic of IPAH and may participate in the pulmonary vascular remodeling process.

Pulmonary gas transfer related to markers of angiogenesis during the menstrual cycle.

Gas transfer in the female lung varies over the menstrual cycle in parallel with the cyclic angiogenesis that occurs in the uterine endometrium. Given that vessels form and regress in the uterus under the control of hormones, angiogenic factors, and proangiogenic circulating bone marrow-derived progenitor cells, we tested the possibility that variation in pulmonary gas transfer over the menstrual cycle is related to a systemic cyclic proangiogenic state that influences lung vascularity. Women were evaluated over the menstrual cycle with weekly measures of lung diffusing capacity and its components, the pulmonary vascular capillary bed and membrane diffusing capacity, and their relation to circulating CD34(+)CD133(+) progenitor cells, hemoglobin, factors affecting hemoglobin binding affinity, and proangiogenic factors. Lung diffusing capacity varied over the menstrual cycle, reaching a nadir during the follicular phase following menses. The decline in lung diffusing capacity was accounted for by approximately 25% decrease in pulmonary capillary blood volume. In parallel, circulating CD34(+)CD133(+) progenitor cells decreased by approximately 24% and were directly related to angiogenic factors and to lung diffusing capacity and pulmonary capillary blood volume. The finding of a greater number of lung microvessels in ovariectomized female mice receiving estrogen compared with placebo verified that pulmonary vascularity is influenced by hormonal changes. These findings suggest that angiogenesis in the lungs may participate in the cyclic changes in gas transfer that occur over the menstrual cycle.