Impact of a quality improvement initiative with a dedicated anesthesia team on outcomes after surgery for adult congenital heart disease.

Objectives: A quality improvement initiative was introduced to the adult congenital cardiac surgery program at Toronto General Hospital in January 2016. A dedicated Adult Congenital Anesthesia and intensive care unit team was introduced within the cardiac group. The use of factor concentrates was introduced. The study compares perioperative mortality, adverse events, and transfusion burden before and after this process change. Methods: We performed a retrospective analysis of all adult congenital cardiac surgeries from January 2004 to July 2019. Two groups were analyzed: patients undergoing operation before and after 2016. The primary outcome was in-hospital mortality. One-year mortality and prevalence of key morbidities were analyzed as secondary outcomes. A separate analysis looked at patients who had and had not attended an anesthesia-led preassessment clinic. Results: In-hospital mortality was significantly reduced in patients undergoing operation after 2016 (1.1% vs 4.3%, P = .003) despite a higher risk profile. One-year mortality (1.3% vs 5.8%, P = .003) and ventilation times (5.5 hours [3.4-13.0] vs 6.3 hours [4.2-16.2], P = .001) were also reduced. The incidence of stroke and renal failure was similar between groups. Blood product exposure was comparable, but the incidence of chest reopening decreased (1.8% vs 4.8%, P = .022), despite more patients with multiple previous chest wall incisions, on anticoagulation, and with more complex cardiac anatomy. There were no significant outcome differences between those who did or did not attend the preassessment clinic. Conclusions: Both in-hospital and 1-year mortality were significantly reduced after the introduction of a quality improvement program, despite a higher risk profile. Blood product exposure remained unchanged, but there were less chest reopenings.

Tracheal Resection for Critical Airway Obstruction in Morquio A Syndrome.

Introduction: The primary cause of death in Morquio A syndrome (mucopolysaccharidosis (MPS) IVA) is airway obstruction, brought about by an inexorable and pathognomonic multilevel airway tortuosity, buckling, and obstruction. The relative pathophysiological contributions of an inherent cartilage processing defect versus a mismatch in longitudinal growth between the trachea and the thoracic cage are currently a subject of debate. Enzyme replacement therapy (ERT) and multidisciplinary management continue to improve life expectancy for Morquio A patients by slowing many of the multisystem pathological consequences of the disease but are not as effective at reversing established pathology. An urgent need has developed to consider alternatives to palliation of progressive tracheal obstruction to preserve and maintain these patients' hard-won good quality of life, as well as to facilitate spinal and other required surgery. Case Report. Following multidisciplinary discussion, transcervical tracheal resection with limited manubriectomy was successfully performed, without the need for cardiopulmonary bypass, in an adolescent male on ERT with the severe airway manifestations of Morquio A syndrome. His trachea was found to be under significant compressive forces at surgery. On histology, chondrocyte lacunae appeared enlarged, but intracellular lysosomal staining and extracellular glycosaminoglycan staining was comparable to control trachea. At 12 months, this has resulted in a significant improvement in respiratory and functional status, with corresponding enhancement to his quality of life. Conclusion: This addressing of tracheal/thoracic cage dimension mismatch represents a novel surgical treatment approach to an existing clinical paradigm and may be useful for other carefully selected individuals with MPS IVA. Further work is needed to better understand the role and optimal timing of tracheal resection within this patient cohort so as to individually balance considerable surgical and anaesthetic risks against the potential symptomatic and life expectancy benefits.

Spontaneous intracerebral haemorrhage secondary to 5-ALA-induced thrombocytopaenia in a paediatric patient: case report and literature review.

INTRODUCTION: The primary objective of neurosurgical management of malignant gliomas is maximal safe resection of the tumour. One of the main obstacles in achieving this is the ability to accurately discriminate between tumour edges and the surrounding healthy brain tissue. The use of fluorescence-guided surgery utilising 5-aminolevulinic acid (5-ALA), first introduced more than 20 years ago, has become an invaluable adjunct in high-grade glioma surgery in adults. However, as 5-ALA is not licensed for use in paediatric patients, the safety profile for such use remains undetermined. CASE REPORT: We describe the case of a 4-year-old boy who underwent 5-ALA-guided resection of a fourth ventricle anaplastic ependymoma. Although complete resection was achieved and the patient awoke from surgery well with no neurological deficits, the patient developed acute transaminitis, anaemia, thrombocytopaenia and coagulopathy postoperatively. The patient had a sudden neurological deterioration on postoperative day 2; imaging revealed that he had suffered a spontaneous right frontal intracerebral haemorrhage. The patient returned to theatre for surgical decompression and evacuation of the haematoma, and ultimately went on to make a full recovery. CONCLUSION: The use of 5-ALA in paediatric patients can be helpful in maximising surgical resection, but the associated safety profile remains undefined. Further research is urgently warranted in order to characterise the efficacy and risk of the use of 5-ALA in the paediatric population.

Awake tracheal intubation: Videolaryngoscopy in a pediatric institution: Use of guidelines and multidisciplinary team preparation to facilitate performance of an unfamiliar technique in a pediatric setting.

Formal guidelines for awake tracheal intubation have recently been published providing a streamlined process for the first time. We present a case of awake videolaryngoscopy in the pediatric setting, not previously reported. Application of guidelines and careful team preparation facilitated performance of a novel technique in our pediatric institution. A multidisciplinary approach with ENT colleagues provided a patient-specific airway management plan for a rare airway pathology.

Use of Simulation to Visualize Healthcare Worker Exposure to Aerosol in the Operating Room.

SUMMARY STATEMENT: Simulation resources offer an opportunity to highlight aerosol dispersion within the operating room environment. We demonstrate our methodology with a supporting video that can offer operating room teams support in their practical understanding of aerosol exposure and the importance of personal protective equipment.

Pruning chemicals from the green building landscape.

Green building design has substantially minimized environmental impacts by reducing energy consumption compared with traditional buildings. Yet, it is not uncommon for a green building to meet the highest criteria for energy efficiency and be built with materials that contain chemicals hazardous to occupant health. Because of this discrepancy in achieving holistic sustainability, the architecture/engineering/construction (AEC) industry has never been more interested in occupant health and well-being than it is today. At the same time, numerous scientific studies have documented exposures to and associated health effects of chemicals used in building materials. Opportunities to translate environmental health research so that it is useful to the AEC community exist across the landscape of healthier buildings. For example, research can be conducted to prioritize building material and chemical combinations to demonstrate how green building certification systems, government building codes, and the building products marketplace can increase energy performance while also addressing the greatest chemical exposures and health impacts. In order for scientific research to be used to create and support healthier environments, researchers should design and translate their research with this landscape in mind and should consider experts in the AEC industry as ambassadors for change. We provide key examples of how scientists have promoted healthy building practices and highlight additional research opportunities.

Accuracy of pediatric cricothyroid membrane identification by digital palpation and implications for emergency front of neck access.

BACKGROUND: Emergency front of neck access in a "can't intubate can't oxygenate" scenario in pediatrics is rare. Ideally airway rescue would involve the presence of an ear, nose, and throat surgeon. If unavailable however, responsibility lies with the anesthesiologist and accurate identification of anterior neck structures is essential for success. AIM: We assessed anesthesiologists' accuracy in identification of the pediatric cricothyroid membrane by digital palpation in three predefined age groups (37 weeks to <1 year old, 1-8 years old, and 9-16 years old) and whether accuracy improved with repetition. We also investigated a novel hypothetical vertical skin incision strategy to successfully expose the cricothyroid membrane. METHODS: We asked anesthesiologists to identify the location of the cricothyroid membrane of anesthetized children in the extended neck position. Accuracy was defined as a mark made within the margins of the cricothyroid membrane using ultrasound as a reference standard. The position of the cricothyroid membrane relative to the neck midpoint, between the suprasternal notch and mentum, was defined for each child. Using this neck midpoint, we determined the hypothetical vertical skin incision lengths required to successfully expose the cricothyroid membrane ("midpoint incision"). RESULTS: Ninety-seven patients were included in this study. There were 14, 58, and 25 patients recruited across the three predefined groups. Accurate anesthesiologist identification of the location of the cricothyroid membrane occurred in 29.4%, 28.6%, and 38.2% of attempts, respectively. The majority of inaccurate assessments (64.1%) were below the cricothyroid membrane. There was no improvement in accuracy with repetition. Hypothetical "midpoint incision" lengths of 20, 30, and 35 mm were required. CONCLUSION: Significant anesthesiologist inaccuracy exists in locating the cricothyroid membrane in children of all ages. This has implications for the technical approach to emergency front of neck access and how we teach the management of "can't intubate can't oxygenate" in pediatric practice.

Accuracy of ultrasound in measurement of the pediatric cricothyroid membrane.

BACKGROUND: Emergency front of neck airway is a recommended airway rescue strategy in children over 1 year old. Surgical tracheostomy is advocated as the first-line technique, but in the absence of an ear, nose and throat surgeon cricothyroidotomy or tracheostomy is proposed. Recent research shows that clinical identification of the cricothyroid membrane is frequently inaccurate in older children and adults and has prompted investigation of ultrasound as a potential clinical tool for emergency front of neck airway. Advance knowledge of the dimensions of the pediatric cricothyroid membrane may assist clinicians in determining the feasibility of emergency front of neck airway, optimum technique, and equipment. AIMS: The aim of this study was to assess the accuracy of ultrasound-assisted pediatric cricothyroid membrane localization and dimension measurement using magnetic resonance imaging as the reference standard. METHODS: After structured training, two pediatric anesthesiology trainees used ultrasound to identify and measure the dimensions of the cricothyroid membrane in pediatric patients undergoing elective magnetic resonance imaging of the head and neck under general anesthesia. A pediatric radiologist reviewed the corresponding magnetic resonance imaging scans and measured the height of the cricothyroid membrane. The accuracy of the cricothyroid membrane height as measured by ultrasound was compared to that measured by magnetic resonance imaging. RESULTS: Twenty-two patients were included in the study. The cricothyroid membrane was accurately identified by ultrasound in all cases. The correlation coefficient for cricothyroid membrane height measured by ultrasound and that measured by magnetic resonance imaging was 0.98 (95% C.I 0.95-0.99, P < 0.0001). The bias was -0.16 mm and the precision was 0.19 mm. All differences were within the a priori limits of agreement. The 95% limits of agreement were -0.54 to 0.22 mm. CONCLUSION: Ultrasound can be used to accurately identify and measure cricothyroid membrane height in pediatric patients. This approach could have clinical and research utility.

Direct targeting of alphavbeta3 integrin on tumor cells with a monoclonal antibody, Abegrin.

The humanized monoclonal antibody Abegrin, currently in phase II trials for treatment of solid tumors, specifically recognizes the integrin alphavbeta3. Due to its high expression on mature osteoclasts, angiogenic endothelial cells, and tumor cells, integrin alphavbeta3 functions in several pathologic processes important to tumor growth and metastasis. Targeting of this integrin with Abegrin results in antitumor, antiangiogenic, and antiosteolytic activities. Here, we exploit the species specificity of Abegrin to evaluate the effects of direct targeting of tumor cells (independent of targeting of endothelia or osteoclasts). Flow cytometry analysis of human tumor cell lines shows high levels of alphavbeta3 on many solid tumors, including cancers of the prostate, skin, ovary, kidney, lung, and breast. We also show that tumor growth of alphavbeta3-expressing tumor cells is inhibited by Abegrin in a dose-dependent manner. We present a novel finding that high-dose administration can actively impair the antitumor activity of Abegrin. We also provide evidence that antibody-dependent cellular cytotoxicity contributes to in vitro and in vivo antitumor activity. Finally, it was observed that peak biological activity of Abegrin arises at serum levels that are consistent with those achieved in clinical trials. These results support a concept that Abegrin can be used to achieve selective targeting of the many tumor cells that express alphavbeta3 integrin. In combination with the well-established concept that alphavbeta3 plays a key role in cancer-associated angiogenesis and osteolytic activities, this triad of activity could provide new opportunities for therapeutic targeting of cancer.