Effect of Dexmedetomidine on Incidence of Hypertension Following Repair of Coarctation of the Aorta.

OBJECTIVE: Recent literature suggests a potential role for dexmedetomidine in reducing the incidence and severity of hypertension following repair of coarctation of the aorta (CoA). The primary aim of this study was to assess the association between dexmedetomidine use and the incidence of hypertension following repair of CoA in pediatric patients. METHODS: This was a single-center, retrospective cohort study in patients younger than 19 years who underwent surgical repair of CoA between January 1, 2016, and September 30, 2021. Patients were divided into 2 groups: dexmedetomidine initiation within the first 3 hours after surgery or no dexmedetomidine. The primary outcome was incidence of hypertension within the first 4 to 24 hours after repair. Secondary outcomes included the incidence of hypotension and bradycardia. RESULTS: A total of 80 patients were included, 25 (31.25%) received dexmedetomidine. Median age at the time of procedure was 26 days (IQR, 13-241) in the dexmedetomidine group and 14 days (IQR, 8-53) in the no dexmedetomidine group (p = 0.014). The primary outcome of hypertension was met in 7 patients (28%) in the dexmedetomidine group and 12 patients (21.8%) in the no dexmedetomidine group, p = 0.547. The only variable found to be associated with the incidence of hypertension was age greater than 30 days at the time of procedure. More patients who received dexmedetomidine experienced bradycardia. There was no difference in the incidence of hypotension. CONCLUSIONS: There was no association between the use of dexmedetomidine and the incidence of -hypertension following repair of CoA in pediatric patients.

Streptococcus pyogenes purpura fulminans and septic shock: A case highlighting the ethical considerations of high-risk extracorporeal membrane oxygenation.

Separately, refractory septic shock and purpura fulminans have very poor outcomes. The ethics involved in offering extracorporeal membrane oxygenation to very high-risk patients is complex. We report a novel case of refractory shock requiring veno-arterial extracorporeal membrane oxygenation and continuous renal replacement therapy due to Streptococcus pyogenes bacteremia with purpura fulminans to highlight the ethical challenges in offering extracorporeal membrane oxygenation to a patient with such a poor likelihood of survival.

A Novel Use of Long-Term Subcutaneous Hydration Therapy for a Pediatric Patient With Intestinal Failure and Chronic Dehydration: A Case Report.

Long-term subcutaneous hydration has not been described in pediatrics. A case of a 4-year-old born prematurely with subsequent intestinal failure, large vessel thrombi, and repeated central line-associated bloodstream infections prompting catheter removal is discussed. Chronic dehydration ensued and was managed with long-term subcutaneous fluid infusions with no serious complications.

Opioid-induced toxic leukoencephalopathy: A case report and review of the literature.

IMPORTANCE: Reports of toxic leukoencephalopathy (TLE) due to opioids have been extensively documented within the adult literature. There is a paucity of literature with respect to the incidence, complications, and outcomes of TLE in the pediatric population. OBJECTIVE: To describe a rare complication of opioid ingestion in the pediatric population and serve as the first large review of published cases of opioid-induced leukoencephalopathy. Thirteen case reports with varying treatments are herein reviewed in addition to our own case. The range of treatment modalities, morbidity and mortality are broad and outcomes secondary to supportive care versus neurosurgical intervention is explored. EVIDENCE REVIEW: All cases of pediatric opioid-induced toxic leukoencephalopathy published on pubmed and google scholar were included in this review. FINDINGS: We report the case of a 4-year old male surgically treated for acute oxycodone-induced TLE who initially presented with Glascow Coma Scale of 4 and a comatose state for weeks. Over the next several months he recovered with spasticity of all extremities, oral aversion, substantial vision loss, and the ability to speak in short sentences. In addition, we found thirteen other reported cases of opioid-induced leukoencephalopathy reported in the literature. The treatment approaches described range from supportive care alone, to invasive neurosurgical interventions including placement of extraventricular drains, removal of hemorrhagic tissue, and craniectomy. The outcomes of patients with opioid-induced leukoencephalopathy is also variable. Reports demonstrate a range of outcomes that include patients who died to those with no residual neurologic deficits. CONCLUSIONS: This review of reported pediatric cases of opioid-induced leukoencephalopathy highlights the importance of early neurosurgical intervention for prevention of devastating outcomes.

Oblique coronary artery prolongation in anomalous left coronary artery arising from the pulmonary artery: A case series.

BACKGROUND: Anomalous left coronary artery (LMCA) arising from the pulmonary artery (ALCAPA) is a life-threatening congenital birth defect. Prompt surgical correction by reimplantation of the LMCA into the aorta is the treatment of choice, however, unfavorable LCA location or length can make direct reimplantation difficult or even impossible without causing significant stretching or tension on the LMCA. This tension can lead to stenosis of the artery and coronary ischemia and must be avoided if possible. METHODS: A chart review from January 2010 to December 2018 of patients who had ALCAPA repair. Patients were excluded if direct reimplantation was possible. Herein, we describe four cases in which remote LMCA position necessitated the creation of a tubular prolongation of the LMCA. RESULTS: A generous coronary button from the pulmonary artery along with the oblique flap of aorta served as the prolongation of the left main coronary artery. This allowed for a tension-free anastomosis using native tissue with the ability to grow with the patient. The pulmonary artery and the aorta were then patched using pericardial tissue. All four patients had improvement in left ventricular function and degree of mitral regurgitation within weeks of surgery. No patient required extracorporeal membrane oxygenation support. Subsequent long-term angiographic follow-up has revealed excellent durability and patency of these coronary conduits. CONCLUSIONS: The variable nature of ALCAPA requires modification of the surgical approach on a patient by patient basis, and the above described technique adds an alternate and reliable long-term treatment option.