Anesthesia in a pediatric patient with ROHADD syndrome. / Anestesia en paciente pediátrico con síndrome de Rohhad.

Rapid-onset obesity with hypothalamic dysfunction, hypoventilation, and autonomic dysregulation (ROHHAD) syndrome is a rare entity that is characterised by its onset in healthy children at 2-4 years of age. It is a complex syndrome that includes, among other symptoms, rapid weight gain with hyperphagia, hypothalamic dysfunction, central hypoventilation, and autonomic dysregulation. The case is presented of a 10-year-old boy with a diagnosis of ROHHAD syndrome undergoing insertion of a port-a-cath under general anaesthesia, who developed complications during the anaesthetic procedure related to his illness. The peri-operative management of these patients represents a challenge for the anaesthetist, given the involvement of multiple systems and the frequent respiratory comorbidities associated with them. A summary is presented of some of the implications and anaesthetic considerations that must be taken into account in the management of these patients.

[Migration of a stent implanted in the pulmonary artery of a patient with tetralogy of Fallot]. / Migración de stent implantado en la arteria pulmonar en un paciente con tetralogía de Fallot.

Tetralogy of Fallot is a congenital heart disease that accounts for 11-13% of the congenital cardiomyopathies. Stenosis and hyperplasia of the pulmonary arteries occur in a high proportion of them as this disease causes a native stenosis of the pulmonary branch, which can be surgically repaired with a stent. The use of balloon expandable intravascular stents is an alternative technique to further surgery in patients with congenital heart diseases. However, despite the gradual increase in their use, the limited number of procedures, combined with the wide anatomical variability and different characteristics of these patients, even in expert hands, stent implants are associated with a not inconsiderable incidence of complications. These are not always obvious and often require performing surgery in patients who have already had multiple interventions, thus increasing the complexity and the risk.

[Relationship between arginase activity and the storage time of packed red blood cells]. / Relación entre la actividad arginasa y el tiempo de conservación de los concentrados de hematíes.

OBJECTIVES: Given the increasing evidence regarding a relationship between packed red blood cells storage time and post-transfusion complications, we decided to determine the relationship between the arginase enzyme levels, biochemical parameters and haemolysis, with the storage time of transfused packed red blood cells. MATERIAL AND METHODS: We designed a prospective study that included 24 units of packed cells that had been consecutively transfused to patients of our hospital. After recording the storage time of each bag, 15 ml of blood was removed to determine arginase activity, biochemical parameters and haemolysis. A univariate analysis was performed on all the recorded parameters, and included those that were significant in the multiple regression model (P<.05). RESULTS: The mean storage time was 18.6±6.1 days (range: 6-31 days), with a haematocrit of 59.8%±0.05%, a haemoglobin of 20.3±1.8 g/dl, a pH of 6.5±0.1, and an arginase activity of 140.1±124.0 mU/ml. A linear relationship was observed in the univariate analysis between the storage time and the pH (P=.001), the actual HCO(3) (P=.001), the haemolysis index (P=.035) and the SpO(2) (P=.01). Once adjusted for the confounding variables of the univariate model, a linear relationship was observed between the arginase activity and the storage time (P=.031). CONCLUSIONS: Our study shows a directly proportional linear relationship between the storage time of packed red blood cells and their arginase activity. We suggest that these findings could be associated with the high incidence of complications after transfusion that may be directly proportional to their storage time.

[Inhaled anesthesia through a device for noninvasive continuous positive airway pressure ventilation for upper digestive endoscopy in pediatric patients]. / Anestesia inhalatoria mediante un dispositivo de ventilación no invasiva tipo "CPAP sin respirador" para endoscopia digestiva alta en pacientes pediátricos.

OBJECTIVE: The demand for sedation for pediatric diagnostic procedures performed outside operating rooms has increased considerably, but the ideal method to choose has been the subject of debate. The aim of this study was to assess the efficacy of using a device for continuous positive airway pressure, connected to a Mapleson D circuit and a nasopharyngeal tube as the interface, in order to ventilate and administer sevoflurane for upper digestive tract endoscopy in children. MATERIAL AND METHODS: Prospective cohort study of children undergoing upper digestive tract endoscopy. We recorded epidemiologic variables, heart rate, mean arterial pressure, arterial oxygen saturation and procedure-related adverse events before, during and 10 minutes after the procedure. Time spent in the recovery room was also recorded. The endoscopist asked the patients about their level of satisfaction and whether they had noticed any irritating smell or gas smell. RESULTS: Data was collected on 29 patients (17 boys, 12 girls) with a mean (SD) age of 4.2 (3.9) years. The mean duration of endoscopy was 15 (7) minutes. Arterial oxygen saturation below 92% during the procedure did not occur and the endoscopic exploration was completed satisfactorily with this technique in 28 patients (96%). All were discharged from the recovery room within 30 minutes. The endoscopist reported that the technique was considered satisfactory in all cases, although 2 children noted an anesthetic "gas" smell. CONCLUSIONS: A modified Mapleson D circuit and nasopharyngeal tube can be used effectively as an interface for noninvasive ventilation and administration of sevoflurane during upper digestive endoscopy in pediatric patients.

Thoracic epidural anesthesia decreases C-reactive protein levels in patients undergoing elective coronary artery bypass graft surgery with cardiopulmonary bypass.

BACKGROUND: Coronary artery bypass graft surgery with cardiopulmonary bypass induces a systemic inflammatory response. However, when thoracic epidural anaesthesia is administered as part of a combined anesthetic technique, the stress response associated with the cardiopulmonary bypass (CPB) may be attenuated. METHODS: Twenty-two patients undergoing elective coronary artery bypass graft surgery were randomized to receive either balanced general anesthesia with 7-20 microg/kg fentanyl (GA group) or combined anesthesia with 3-6 microg/kg fentanyl and an epidural bolus of 0.33% bupivacaine followed by a continuous perfusion of 0.175% bupivacaine, which was continued up to 48 hours after surgery (TEA group). The hemodynamic levels, troponin I, C-reactive protein (CRP), fibrinogen, leukocyte and platelet counts were recorded preoperatively, and 5 h, 16 h, 24 h, and 36 h after termination of the cardiopulmonary bypass. The time to tracheal extubation and cardiopulmonary complication rate were measured postoperatively. Data were analyzed with the Student's t and Mann Whitney tests, as appropriate. Differences were considered significant at P<0.05. RESULTS: All parameters significantly increased following CPB. The increase in CRP levels were lower in the TEA group at 16 hours (P=0.048). The increase of fibrinogen levels were lower in the TEA group at 24 hours (P=0.047). No differences were found in troponin levels between groups during the study. No significant differences were observed in extubation times (GA group 750+/-144 min; TEA group 702+/-451 min). CONCLUSION: Thoracic epidural anaesthesia, as a part of a combined anesthetic technique, attenuated the inflammatory response (CRP and fibrinogen levels) to cardiac surgery with cardiopulmonary bypass. However, this effect was not reflected in a decrease of troponin I levels, reduced incidence of complications, or in an earlier extubation time.

[Evaluation of a continuous positive airway pressure system without a ventilator to treat acute respiratory failure in children]. / Evaluación de un dispositivo de CPAP sin respirador en la insuficiencia respiratoria aguda en pediatría.

OBJECTIVE: Noninvasive continuous positive airway pressure (CPAP) is widely used in pediatric patients with acute respiratory failure. However, the lack of specific interfaces and appropriate ventilators and poor tolerance of the technique by these patients can lead to failure of the application. The aim of this study was to analyze the efficacy of a CPAP system using a modified Mapleson breathing circuit during acute respiratory failure in pediatric patients. MATERIAL AND METHODS: We performed a prospective observational study in children with acute respiratory failure in whom noninvasive ventilation was indicated. CPAP was applied through a Mapleson D circuit fitted with a manometer and a nasopharyngeal tube as the interface. Heart rate, respiratory rate, inspired oxygen fraction (FiO2), PaO2, PaCO2, and pulse oximetry were measured before treatment and after 2 hours of treatment. RESULTS: Sixteen patients with a mean age of 3.8 years were studied for a period of 18 months. We observed a mean (SD) change in PaCO2 from 66.8 (18.08) mm Hg to 46.48 (5.9) mm Hg after CPAP (P=.16) and a mean change in the PaO2/FiO2 ratio from 201 (111) to 262 (115) after CPAP (P=.30). The mean heart rate fell from 156 (22) beats/min to 127 (18) beats/min (P=.05) and the mean respiratory rate from 53 (15) breaths/min to 33 (13) breaths/min (P<.05). No severe complications were recorded and tolerance was satisfactory. The technique was considered a success in 12 patients (75%). CONCLUSIONS: CPAP without a ventilator, through a Mapleson D circuit, can be used with a high success rate to provide noninvasive ventilation for pediatric patients with acute respiratory failure.

[Effect of tranexamic acid on postoperative bleeding in pediatric heart surgery]. / Efecto del ácido tranexáimico en el sangrado postoperatorio de cirugía cardiaca en pediatría.

OBJECTIVE: To assess the effects of a single dose of tranexamic acid on bleeding and requirement for blood product transfusion in children undergoing cardiac surgery with cardiopulmonary bypass. PATIENTS AND METHODS: A prospective study of closed cohorts undergoing pediatric heart surgery was carried out. The children weighed between 4 and 10 kg. Reoperated and cyanotic patients were included in the sample. The treatment group received 50 mg x kg(-1) of tranexamic acid before surgery. Analyzed data collected during the first 24 hours after surgery were biochemical parameters, bleeding, use of blood products, and D-dimer levels. RESULTS: Fifty-three patients, 25 in the treatment group, were enrolled. Patients on treatment had 24.8% less bleeding in the first 24 hours after surgery (P = .02). The transfusion of blood products was 20% less in the treatment group, although the difference was not significant except in the subgroup of patients who were reoperated. In that group the amount of blood products transfused was 72% less than in the control group (P = .05). D-dimer levels were also lower in the treatment group (P = .003). No adverse effects attributable to the treatment were observed. CONCLUSIONS: A single preoperative dose of tranexamic acid to inhibit fibrinolysis reduces bleeding 24.8% in pediatric patients undergoing heart surgery with cardiopulmonary bypass. The effect is greater in reoperated patients, leading to a reduction in their requirement for transfusion. The use of this therapy in these patients is therefore highly justified.

[Electroconvulsive therapy in the third trimester of pregnancy: a case report]. / Terapia electroconvulsiva en el tercer trimestre de la gestación. A propósito de un caso.

Electroconvulsive or electroshock therapy is an effective psychiatric treatment. The need for effective psychotherapy in the pregnant patient and the need to limit application of psychotropic drugs have encouraged the use of electroshock therapy in the past 50 years. We report the case of a 35-year-old woman at 30 weeks' gestation who was hospitalized with severe depression. When her condition worsened after initiation of medical treatment, electroshock therapy was considered. She received a total of 9 sessions (3 per week). During treatments the patient received general anesthesia with propofol and succinylcholine with insertion of a tracheal tube. Significant variations in the hemodynamic variables of mother and fetus were not observed; nor were there signs of fetal distress. The patient experienced clear improvement and 2 days after the last treatment spontaneous labor commenced. A healthy boy was born by vaginal delivery.

[Upper respiratory tract infections in children: impact on surgical scheduling at a pediatric hospital]. / Repercusión de la infección de vía respiratoria alta en niños sobre la programación quirúrgica en un hospital infantil.

OBJECTIVE: To determine the rate of cancelation of scheduled surgical procedures attributable to upper respiratory tract infection (URTI) in our university pediatric hospital in Madrid and to analyze the effect that literature reviews and appropriate counseling of parents would have on cancelations. MATERIAL AND METHODS: We carried out a retrospective study of the reasons for canceling scheduled pediatric ear, nose, or throat operations in 2001, 2002, 2003, and 2004. Statistical comparisons were performed with the chi2 test. RESULTS: In 2001, 24% of the 641 procedures scheduled were canceled, 12.9% of them because of URTIs. After applying criteria based on a review of the literature, 15% of the 751 procedures were canceled in 2002, 4.9% of them because of URTIs (P<0.0001 in comparison with 2001). In 2003 14.3% of the 760 scheduled procedures were canceled, 6.5% because of URTIs (P<0.0001 in the comparison with 2001). In 2004 12.2% of the 692 scheduled procedures were canceled, 7.2% because of URTIs (P<0.0001 in comparison with 2001). Cancelations in autumn-winter or in spring-summer seasons amounted to 28.2% vs 19.8% in 2001, 17.1% vs 12.7% in 2002, 16.6% vs 11.8% in 2003, and 13.8% vs 11.1% in 2004. CONCLUSIONS: URTIs are responsible for a high rate of cancelations of scheduled operations, particularly in colder seasons of the year. To obtain optimal results, criteria based on up-to-date literature reviews should be put into effect and parents should be given appropriate information.