Anesthetic Management for Pediatric Liver Transplantation in a Patient With Propionic Acidemia: A Case Report.

Propionic acidemia is an inborn error of metabolism characterized by accumulation of propionic acid due to deficiency of propionyl-CoA carboxylase. Main stay of treatment focuses on reducing dietary protein. However, orthotropic liver transplantation decreases the frequency of metabolic decompensations and improves life expectancy. We report a case of a 4-year-old boy undergoing orthotropic liver transplantation to treat propionic acidemia. This case highlights the use of intraoperative monitoring of metabolic markers like urine ketones, arterial ammonia, and lactate levels as these patients are at risk for hyperammonemia and metabolic acidosis. Also, the relevance in outcomes when performing early extubation in fast-tracking recovery.

Decline of Pediatric Ambulatory Surgery Cases Performed at Florida General Hospitals Between 2010 and 2018: An Historical Cohort Study.

BACKGROUND: In the province of Ontario, nonphysiologically complex surgical procedures have increased at 4 pediatric hospitals with a reciprocal decline among the other (general) hospitals performing pediatric surgery. Given the differences between the Canadian and US health systems, we studied whether a similar shift occurred in the state of Florida and examined the age dependence of the shift. METHODS: We used outpatient pediatric surgery data from all nonfederal hospitals, hospital-owned facilities, and independent ambulatory surgery centers in Florida, 2010-2018. Inferential analyses were performed comparing 2010-2011 with 2017-2018. Annual caseloads are reported as cases per workday by dividing by 250 workdays per year. RESULTS: Statewide, comparing 2010-2011 with 2017-2018, among children 1-17 years, pediatric hospitals' caseload increased overall by 50.7 cases per workday, overall meaning collectively among all hospitals combined. The caseload at general hospitals and ambulatory surgery centers, combined, decreased by 97.7 cases per workday. The general hospitals performed 54.7 fewer cases per workday. Among the 112 general hospitals, the mean pairwise decline was -0.49 cases per workday (99% confidence interval, -0.87 to -0.10; P < .0001). The changes were due to multiple categories of procedures, not just a few. Comparing 2010-2011 with 2017-2018, among 3 age cohorts (1-5, 6-12, and 13-17 years), the pediatric hospitals, statewide, performed overall 16.2, 15.1, and 19.3 more cases per workday, respectively. The general hospitals and ambulatory surgery centers, combined, performed fewer cases per workday for each cohort: 49.4, 21.4, and 26.9, respectively. The general hospitals overall performed fewer cases per workday for each cohort: 27.3, 12.1, and 15.4, respectively. Among general hospitals, the mean pairwise difference in the declines between patients 1-5 years vs 6-17 years was 0.00 cases per workday (99% confidence interval, -0.13 to +0.14). CONCLUSIONS: The decline across all age groups was inconsistent with multiple general hospitals increasing their minimum age threshold for surgical patients because, otherwise, the younger patients would have accounted for a larger share of the decreases in caseload. Pediatric hospitals and their anesthesiologists have greater surgical growth than expected from population demographics. Many general hospitals can expect either needing fewer pediatric anesthesiologists or that their pediatric anesthesiologists, who also care for adults, will have smaller proportions of pediatric patients in their practices.

Perioperative Temperature Measurement Considerations Relevant to Reporting Requirements for National Quality Programs Using Data From Anesthesia Information Management Systems.

BACKGROUND: Perioperative hypothermia may increase the incidences of wound infection, blood loss, transfusion, and cardiac morbidity. US national quality programs for perioperative normothermia specify the presence of at least 1 "body temperature" ≥35.5°C during the interval from 30 minutes before to 15 minutes after the anesthesia end time. Using data from 4 academic hospitals, we evaluated timing and measurement considerations relevant to the current requirements to guide hospitals wishing to report perioperative temperature measures using electronic data sources. METHODS: Anesthesia information management system databases from 4 hospitals were queried to obtain intraoperative temperatures and intervals to the anesthesia end time from discontinuation of temperature monitoring, end of surgery, and extubation. Inclusion criteria included age >16 years, use of a tracheal tube or supraglottic airway, and case duration ≥60 minutes. The end-of-case temperature was determined as the maximum intraoperative temperature recorded within 30 minutes before the anesthesia end time (ie, the temperature that would be used for reporting purposes). The fractions of cases with intervals >30 minutes between the last intraoperative temperature and the anesthesia end time were determined. RESULTS: Among the hospitals, averages (binned by quarters) of 34.5% to 59.5% of cases had intraoperative temperature monitoring discontinued >30 minutes before the anesthesia end time. Even if temperature measurement had been continued until extubation, averages of 5.9% to 20.8% of cases would have exceeded the allowed 30-minute window. Averages of 8.9% to 21.3% of cases had end-of-case intraoperative temperatures <35.5°C (ie, a quality measure failure). CONCLUSIONS: Because of timing considerations, a substantial fraction of cases would have been ineligible to use the end-of-case intraoperative temperature for national quality program reporting. Thus, retrieval of postanesthesia care unit temperatures would have been necessary. A substantive percentage of cases had end-of-case intraoperative temperatures below the 35.5°C threshold, also requiring postoperative measurement to determine whether the quality measure was satisfied. Institutions considering reporting national quality measures for perioperative normothermia should consider the technical and logistical issues identified to achieve a high level of compliance based on the specified regulatory language.

Surgical management of bronchopulmonary malformations.

BACKGROUND: Bronchopulmonary malformations (BPM) are rare conditions, which typically arise below the carina and can result in significant morbidity (infection and/or hemorrhage) and mortality (respiratory failure). MATERIALS AND METHODS: All children with BPM surgically treated from 2001-2014 at a tertiary care children's hospital were identified. Patient demographics, surgical indications, procedure type, estimated blood loss, pathology, perioperative complications, length of stay, and outcomes were analyzed. RESULTS: A total of 41 BPM patients underwent surgery with 98% overall survival (one abdominal BPM expired) but 100% for thoracic lesions. Resections were performed thoracoscopically (37%), thoracoscopy converted to open (22%), and via thoracotomy (37%). Poor visualization (67%) or inability to tolerate single lung ventilation (33%) led to conversions. No conversions resulted from hemorrhage or received blood transfusions. Patients with prenatally diagnosed BPM were more likely to undergo thoracoscopic surgery (odds ratio [OR], 18.2) versus nonprenatally diagnosed, P = 0.002. Open/converted patients had longer chest tube days (6.2) versus thoracoscopic (2.9), P = 0.048. Additionally, respiratory distress was a more common indication in patients aged <4 mo (OR, 28.0) versus ≥4 mo and <6 kg (OR, 40.5) versus ≥6 kg, P < 0.001. Open resections were more common in patients aged <4 mo (OR, 26.3) versus ≥4 mo, P = 0.002. Operative time was shorter and estimated blood loss (mL/kg) was greater for <6 versus ≥6 kg, P < 0.05. CONCLUSIONS: BPM resections have high overall survival. Chest tube days are shorter among thoracoscopic patients, but conversion to thoracotomy can avoid hemorrhage and need for transfusion. Size and respiratory distress limit use of thoracoscopy in young infants with BPM.

General anesthesia in the pediatric population.

PURPOSE OF REVIEW: This article reviews the pertinent perioperative, intraoperative, and short- and long-term postoperative risks associated with general anesthesia in children undergoing ocular surgery. RECENT FINDINGS: Animal studies suggest an association between general anesthesia and neurodevelopmental delay; however, animal pharmacodynamics and pharmacokinetics do not directly correlate with human metrics. Retrospective human studies present conflicting data. Further, prospective studies in humans are underway, with projected results available within the next 3-5 years. SUMMARY: All surgeons should be aware of current practices in pediatric anesthetic care, as well as the immediate- and long-term risks of general anesthesia. Ophthalmologists with pediatric patients should be aware of the potentially life-threatening conditions associated with general anesthesia. Additionally, the relative lifelong risks and benefits of general anesthetic exposure should be considered when recommending surgery, especially in light of the child's age, health status, and necessity of multiple anesthetic events.

Use of a warming catheter to achieve normothermia in large burns.

Maintaining burn patients' body temperature during surgery is a significant challenge. Although increasing the ambient operating room (OR) temperature and other passive rewarming methods help, such measures have limited effectiveness and prove taxing on OR personnel. Initial studies indicate that an intravascular warming catheter may improve and sustain burn patient body temperatures. The authors hypothesize that the warming catheter is similarly effective at maintaining normothermia despite a lower OR temperature than in a cohort of matched control burn patients. This is a retrospective case-control study involving patients with major burns treated between January 2006 and June 2011. Cases received an intravascular warming catheter, whereas controls receive traditional temperature conserving interventions. As the catheters maintained body temperature, the room temperature was gradually lowered to normal. Twenty-three patients were involved in 31 cases using the catheter, compared with 39 controls in 62 surgeries. The mean temperature deviation for each catheter group was -0.76 ± 1°C and -0.80 ± 0.9°C for the control group. Given 20-minute intervals throughout the operations, the mean patient temperature for cases and controls never deviated by more than 1°C. OR staff satisfaction has improved with decreased room temperatures. An intravenous warming catheter reliably maintained patient core body temperature during surgery. To date, this is the largest cohort study of such a catheter among burn patients. This system may be more effective than current warming techniques, with the potential to decrease the total number of procedures and the time to complete wound closure.

Licuefacción caaalítica directa de carbones. efecto de la temperatura / Direct catlytic liquefaction of coals. effect of the temperatree / Liquefaçã catalíítica directa de carvão. efeito da temperatura

Un carbón bituminoso alto volátil del departamento de Cundinamarca (Colombia), se licuó en presencia de un catalizador polimetálico en un reactor discontinuo de 500 mL a 370, 410 y 450 °C, en atmósfera de hidrógeno, usando tetralina como solvente dador de hidrógeno y tiempo de residencia de 1 h. El uso del catalizador incrementó la conversión del carbón y el rendimiento hacia la fracción de aceites a medida que aumentó la temperatura. El máximo rendimiento a aceites obtenido fue del 67% a 450 °C.

A high volatile bituminous coal from the Department of Cundinamarca (Colombia), was liquefied in the presence of a polymetallic catalyst in a 500 mL batch reactor at 370, 410 and 450 °C under hydrogen atmosphere, using tetralin as hydrogen donor solvent and residence time of 1 h. When the catalyst was used and the temperature increased, the coal conversion and the oil yield increased too. The maximum oil yield obtained was 67% at 450 °C.

Um carvão betuminoso alto volátil do Departamento de Cundinamarca foi liquefeito na presença de um catalisador polimetálico num reactor de 500 mL a 370,410 e 450 °C em atmosfera de hidrogênio, usando tetralina como doador de hidrogênio do solvente e tempo de residencia de 1 h. O uso do catalisador aumentou a conversão do carvão e rendimento de óleo com o aumento da temperatura. O rendimento máximo de óleo obtido foi de 67% a 450 °C.

CATALIZADORES DE Co, Fe Y Ni SOPORTADOS SOBRE COQUE PARA LA LICUEFACCIÓN DIRECTA DE CARBÓN / Co, Fe AND Ni CATALYSTS SUPPORTED ON COKE FOR DIRECT COAL LIQUEFACTION / CATALISADORES DE Co, Fe E Ni NUM SUPORTE DE COQUE PARA A LIQUEFAÇÃO DIRECTA DE CARVÃO

Se prepararon catalizadores de metales de transición soportados en coque por impregnación con una solución del complejo de metal-tiourea, obtenido a partir de las sales precursoras de cloruro de cobalto, cloruro de níquel o sulfato de hierro y amonio. La formación del sulfuro sobre la superficie del soporte se realizó mediante la descomposición del complejo. Los catalizadores producidos se usaron en la licuefacción directa de un carbón bituminoso medio volátil (Yerbabuena No 1) de Cundinamarca en un reactor Parr discontinuo de 250 mL a 723 K y una presión de hidrógeno de 8,0 MPa en presencia de tetralina como solvente donor de hidrógeno, con un tiempo de residencia de una hora. Los resultados de los ensayos catalíticos muestran, para todos los catalizadores, una buena conversión del carbón y rendimientos significativos en la fracción de aceites e indican que el método de preparación propuesto del catalizador es efectivo y, eventualmente, permitiría remplazar los procesos convencionales de sulfuración con H2S.

Transition metal catalysts supported on coke were prepared by impregnation with a solution of complex of metal-thiourea, that is produced from salt precursors of cobalt chloride, nickel chloride or iron sulfate and ammonium. Sulphide formation on the support surface was generated by decomposition of the metal complex. The catalysts obtained were used in direct coal liquefaction of a medium volatile bituminous coal (Yerbabuena No 1) from Cundinamarca using a 250 mL Parr reactor at 723 K, and a hydrogen pressure of 8.0 MPa, with a reaction time of 1 h and using tetralin as hydrogen-donor solvent. The catalytic results show, for all samples, both a good coal conversion and an enhancement of the yield of oils, this indicates that the proposed preparation method of catalyst is effective and, that eventually, the H2S sulphidation conventional process could be replaced.

Foram preparados catalisadores de metais de transição num suporte de coque por impregnação com uma solução do complexo de metal-tioureia, obtidos a partir dos sais precursores de cloreto de cobalto, cloreto de níquel ou sulfao de ferro y amônia. A formação de enxofre sobre a superfície do suporte foi realizado mediante a descomposição do complexo. Os catalisadores produzidos foram usados na liquefação directa de um carvão betuminoso meio volátil (Yerbabuena No1) de Cundinamarca num reactor Parr descontinuo de 250 ml a 723 K y uma pressão de hidrogênio de 8,0 MPa na presença de tetralina como solvente doador de hidrogênio, com um tempo de residência de 1 hora. Os resultados dos ensaios catalíticos mostram, para todos os catalisadores, uma boa conversão do carvão e rendimentos significativos na fracção orgânica e indicam que o método de preparação proposto do catalisador é efectivo e, eventualmente, permitiria substituir os processos convencionais de sulfuração com H2S.

Efecto del carbnnato de potasio en la evoluciónde los grupos funcionales de loos biocrudos de conversión hidrotérmica de biomasa lignocelulósica alrededor del punto crítico del agua / Potassium arbonaate effect on biocrude funtional groups evolving from liggnocellulosic biomass undergoing hydrothermal conversion close to the critical point o water / Efeio do carbonaato de potássio na formação dos grups funcionais doos biopetróleos obtidos por conversão hidrotérmica de biomassa lenhocelulósica próximo do ponto crítico da água

Un tipo de biomasa pobre en lignina, del género Pennisetum, fue sometida al proceso de conversión hidrotérmica en presencia de carbonato de potasio como catalizador. Las reacciones se llevaron a cabo en ambientes cercanos al punto crítico del agua. Los productos de reacción no acuosos (biocrudo) se separaron por decantación y se analizaron por espectrometría infrarroja. Los biocrudos obtenidos contienen compuestos con funcionalidades aromáticas, olefínicas, hidroxiladas, éteres, y para el caso del biocrudo obtenido bajo la condición subcrítica funciones carbonilo. La fracción gaseosa y el biocrudo aumentan en presencia del carbonato de potasio.

A type of poor-lignin biomass (Pennisetum sp.) was hydrothermally converted in the presence of potassium carbonate as catalyst. The reactions were carried out close to the critical point of the water. The non-aqueous (biocrude) reaction products were separated by decantation and were analyzed by infrared spectrometry. The biocrude products so obtained contained compounds having aromatic, olephinic, hydroxylated and ether functionalities; sub-critical biocrude had carbonyl functions. The gaseous and biocrude fractions increased in the presence of potassium carbonate.

Um tipo de biomassa pobre em lenhina, do género Pennisetum, foi submetido ao processo de conversão hidrotérmica na presença de carbonato de potássio como catalisador. As reacções foram conduzidas em condições próximas do ponto crítico da água. Os produtos de reacção não aquosos (biopetróleo) foram separados por decantação e analisados por espectroscopia de infravermelho. Os biopetróleos obtidos contêm compostos com funcionalidades aromáticas, olefínicas, hidroxiladas, éteres e, no caso do biopetróleo obtido sob condição subcrítica, funções carbonilo. A fracção gasosa e a quantidade de biopetróleo aumentam na presença de carbonato de potássio.

The use of an anesthesia information system to identify and trend gender disparities in outpatient medical management of patients with coronary artery disease.

BACKGROUND: Previous anesthesia information management systems-based studies have focused on intraoperative data analysis. Reviewing preoperative data could provide insight into the outpatient treatment of patients presenting for surgical procedures. As gender-based disparities have been demonstrated in the treatment of patients with cardiac disease, we hypothesized that there would be gender disparities in the outpatient pharmacologic management of patients with coronary artery disease (CAD) scheduled for elective noncardiac surgery. METHODS: We analyzed electronic medical records of ambulatory patients with CAD (prior myocardial infarction [MI], coronary artery bypass surgery, and angioplasty with or without stenting, angina) presenting for elective noncardiac surgery between 1/2004 and 6/2006 (30 mo) at an inner city hospital. RESULTS: Of 21,039 ambulatory patients seen in the preanesthesia clinic, 6.4% (1346) had CAD. Patients with CAD: Men were more likely to be taking beta-blockers (P < 0.002), statins (P < 0.0001), aspirin (P < 0.0001), and antiplatelet medications (P < 0.04), although there was a trend of increased use of aspirin (P < 0.01) by women over the course of the study. Patients with history of prior MI: Men with a prior MI were more likely to be taking beta-blockers (P < 0.0001) and statins (P < 0.02), although there was a trend of increased use of beta-blockers (P < 0.0005) and aspirin (P < 0.03) by women over the course of the study. Quarterly prevalence rates for outpatient medication use were greatest for beta-blockers and least for aspirin. Patients were more likely to be taking a statin, aspirin, or oral antiplatelet medication if they were receiving chronic beta-blocker therapy (P < 0.0001 for each medication). CONCLUSION: Aggregating anesthesia management information systems data provides an epidemiological perspective of community care of patients presenting for surgery. We found that gender disparities in outpatient medical treatment of patients with CAD, which previously favored men, have diminished primarily as a result of increased use of these medications in women. Nonetheless, despite evidence supporting the use of risk-reduction strategies, our patients are undertreated with standard medical therapies.