Perioperative specific management of blood volume loss in craniosynostosis surgery.

Accurate assessment and replacement of blood loss and fluid-electrolyte deficit during craniosynostosis repair is difficult owing to patient size and the diversity of surgical technique. Forty-three patients undergoing primary craniosynostosis repair over a 10-year period were studied retrospectively to determine blood loss and fluid deficit and to assess blood transfusion practices during both intraoperative and postoperative periods. Blood loss was calculated on the basis of estimated red cell mass (ERCM) and fluid-electrolyte imbalance was investigated with blood samplings. Blood transfusion was considered appropriate if the postoperative or posttransfusion ERCM was within 12% of the preoperative value. Estimated fluid requirement (EFR) was used in 4 ml kg(-1) h(-1) except for neonates. Intraoperatively, 80% of all patients were appropriately managed with respect to blood transfusion and EFR. Postoperatively only 20% of the patients receiving transfusions were transfused appropriately. In 23.3% of these patients (10/43) unexpected respiratory distress developed immediately after their recovery from the anesthesia. With the measurement of estimated blood volume and allowable blood loss, appropriate transfusion could be achieved for the successful treatment of the primary craniosynostosis.

The effects of experimental brain-stem ischaemia on brain-stem auditory evoked potentials in primates.

We related intracranial auditory brain-stem evoked potentials (BAEPs) to the surface BAEP using a model of focal brain-stem ischaemia. In 17 baboons anaesthetised with alpha-chloralose, BAEPs were recorded bilaterally at the mastoids and in the caudal lateral lemniscus (LL) and inferior colliculus (IC), in response to monaural click stimulation. Electrodes at these sites were each connected to the positive input of a differential amplifier, and one other electrode, placed at the vertex, was connected to all the negative inputs. Measurements of local cerebral blood flow (CBF) by hydrogen clearance were made at the LL and IC sites. The LL wave form contained 5-7 positive peaks, the second (B wave) being dominant and coinciding with the negative wave II of the surface BAEP. Following graded ischaemia, produced by basilar artery occlusion and controlled hypotension, the latency changes of these two peaks were significantly correlated, as were those of the third wave (C wave) of the LL response and the surface wave III. In the IC, the contralateral wave form contained 4 positive waves (A-D) and a later, dominant, slow negative wave; changes in its peak latency and those of the slow negative surface wave were similarly correlated. The thresholds of local CBF for increases in latency of waves B and C in the LL were similar (12-15 ml/100 g/min), but in the IC the thresholds were 20, 30-35 and 20-24 ml/100 g/min for the B, C and slow negative waves, respectively. Our data indicate that a gradient of sensitivity to ischaemia is present along the brain-stem auditory pathways; this could explain the earlier change of the late, rather than early, BAEP components as reported in clinical cases involving brain-stem lesions.