Pediatric pheochromocytoma. A 36-year review.

Fourteen children (10 boys and 4 girls, aged 8 to 17 years) had 20 pheochromocytomas treated over a 36-year period from 1959 to 1995 inclusive. Nine patients had 11 tumors before 1980; 5 children had 9 tumors up to 1987. There were no new children with pheochromocytomas at our hospital from 1988 to 1995. Hypertension, sweating, headache, and visual blurring were the most common symptoms and signs (average 5 months). The most reliable biochemical investigations were the urinary catecholamines and norepinephrine. Before 1980, intravenous pyelography and angiography were most successful in localizing the tumor, but since then ultrasonography and computerized tomography have been the radiological investigations of choice. Early involvement of the anesthesiologist in the preoperative control of the hypertension is essential; blood pressure (BP) control was achieved with phenoxybenzamine. The main anesthetic drugs used were: sodium thiopental, fentanyl, methoxyflurane, isoflurane, nitrous oxide, and metocurine. Sixteen tumors were adrenal and 4 were extra-adrenal (1 intrathoracic and 1 extradural). All except 2 tumors were completely resected; they ranged in size from 1.3 to 14 cm. Ligation of the tumor's venous drainage was usually associated with a sudden, temporary fall in systemic BP. There were 2 children with malignant tumors. Four patients had five recurrences (second pheochromocytoma) within 6 years, and all were heralded by a return of their original symptoms and signs. One girl was left with no adrenal tissue. The only complication was in a boy with a large, partly-resected malignant right adrenal tumor who had a subphrenic abscess drained and was left with a temporary bile fistula, cirrhosis, and chronic pain. All children were normotensive when discharged from hospital and remain alive and well with a follow-up of 7 to 36 years. There were no deaths. Long-term follow-up is essential. Key word Pheochromocytoma

Pediatric neuraxial blockade.

Regional anesthetic techniques for children have recently enjoyed a justified resurgence in popularity. Intraoperative blockade of the neuraxis, whether by the spinal or epidural route, provides excellent analgesia with minimal physiologic alteration and, with an indwelling catheter, can provide continuous pain relief for many days postoperatively. As a supplement to general anesthesia, local anesthetic blockade of the neuraxis decreases the total amount of general anesthetic required for surgery, hastens emergence, and allows for a better postoperative experience by providing a pain-free emergence from general anesthesia. Although some practitioners contend that a regional block on an already anesthetized child adds to the risk of the general anesthetic itself, in experienced hands the risks are negligible and the benefits dramatic. In this review of caudal and lumbar epidural and subarachnoid blockade in infants and children, anatomy, physiologic alterations, and pharmacology pertinent to the three types of neuraxial blockade are described, with the aim of providing the practicing anesthesiologist with the foundation needed to perform these blocks with relative confidence.

Anaesthesia and the child with HIV infection.

The frequency of AIDS in the paediatric population is growing rapidly and is expected to get worse. The anaesthetist will participate in the care of these children in the operating room and the intensive care unit with increasing frequency and must therefore have an understanding of the many manifestations of this syndrome. Children become infected with HIV by transplacental transmission from mother to fetus in over 80% of cases. Early diagnosis in infants can be very difficult. Clinical manifestations of HIV infection in children result from damage to almost every organ system. Considerations for the anaesthetist include: the effects of medications, cardiovascular dysfunction, pulmonary disease, altered metabolism, equipment preparation, choice of anaesthetic, modes of viral transmission and psycho-social issues.

Anaesthesia for patients with mediastinal masses.

Anaesthesia for patients with mediastinal masses may be associated with significant respiratory and cardiovascular complications. In this review, we discuss the anatomical and pathological considerations in these adult and paediatric patients and the three types of intra-thoracic compromise that may be found: compression of the tracheobronchial tree, compression of the pulmonary artery and heart and the superior vena caval syndrome. Patient evaluation by symptom history, computerized tomography and flow-volume loops is emphasized. Preoperative thoracic radiation therapy in severely symptomatic patients is associated with a decrease in postoperative respiratory complications and an improvement in risk. During radiation therapy a small window can be created to spare some tissue for adequate histological diagnosis. Anaesthetic management techniques for these patients are discussed. Life-threatening complications can occur at any point during anaesthesia for patients with mediastinal masses. Anaesthetists should have a high degree of awareness of the underlying anatomy, pathophysiology and anaesthetic alternatives when caring for these patients.

Arterial desaturation in healthy children during transfer to the recovery room.

The oxygen saturation in 71 healthy paediatric patients (3.5 months to 16.7 years) was measured by pulse oximetry during transfer from the operating room to the recovery room. These measurements were recorded continuously while the patients breathed room air. Of the patients studied, 28.1 per cent exhibited significant arterial desaturation of less than or equal to 90 per cent. The corresponding PO2 for this saturation level is less than or equal to 58 mmHg. In only 45 per cent of these desaturated patients was the desaturation recognized clinically by the presence of cyanosis. Age, type of anaesthetic, the use or avoidance of narcotics, and the use of controlled or spontaneous respiration had no significant relationship to the incidence of desaturation. Since more than a one quarter of all patients studied desaturated significantly, and since cyanosis can be difficult to detect clinically during the transfer period, the use of supplemental oxygen during transfer should be considered by the anaesthetist at the end of every paediatric general anaesthetic.

Airway management in craniofacial surgery: experience in 542 patients.

Five hundred and forty-two patients undergoing 579 craniofacial surgical procedures were admitted to the Intensive Care Unit of the Hospital for Sick Children, Toronto, during the 13-year period of 1972 to 1984. Ninety-eight of these patients underwent tracheotomies; 12 significant complications were documented. Two hundred and seventy-eight patients were managed with nasal endotracheal intubation for greater than 24 hours postoperatively; 42 related complications were documented. Good communication among the craniofacial surgeon, otolaryngologist, anesthetist and intensivist is crucial for the safe management of the various airway problems observed in patients with major craniofacial anomalies undergoing corrective surgery.