Effect of Body Mass Index Category on Body Surface Area Calculation in Children Undergoing Cardiac Procedures.

BACKGROUND: Many of the common equations used for body surface area determination were either introduced before the widespread prevalence of childhood obesity, contained very few children in their sample, or have not been assessed in overweight/obese children. Therefore, we compared 6 body surface area formulae to determine their performance across body mass index categories using cross-sectional anthropometric data of children who underwent elective cardiac procedures. METHODS: We selected 6 formulae from the literature that included data from pediatric subjects in their derivation. We then substituted measured height and weight into each equation to compute body surface area data for the study subjects. The average values of the 6 formulae were calculated for each patient and used as reference for comparison. Comparisons between each formula and the reference standard were made with the 1-way ANOVA, Pearson correlation coefficient (measure of precision), the Lin concordance correlation coefficient (measure of bias and precision), and the Bland-Altman limit-of-agreement. All comparisons were made across age, sex, and body mass index categories. RESULTS: Among the 1000 (mostly Caucasian: 76.1%) subjects, 16.7% were overweight, while 14.1% were obese and 51.2% were girls. All calculated body surface area data showed a strong positive correlation with each other and the derived reference body surface area values (0.99-1.00; P < .001). Calculated body surface area values for all the formulae were significantly higher in overweight and obese children across every age group. CONCLUSIONS: Obesity status is a critical factor in the determination of body surface area values in children undergoing elective cardiac procedures. We caution that indexed hemodynamic and other therapeutic interventions may be inappropriate if limitations of body surface area formulae and the effect of obesity are not taken into consideration when caring for overweight and obese children. Body surface area studies utilizing accurate contemporary techniques that include sufficient number of overweight and obese children of various races are urgently needed.

Factors Associated With Recovery Room Intravenous Opiate Requirement After Pediatric Outpatient Operations.

BACKGROUND: Many children recovering from anesthesia experience pain that is severe enough to warrant intravenous (IV) opioid treatment within moments of admission to the postanesthesia care unit (PACU). Postoperative pain has several negative consequences; therefore, preventing significant PACU pain in children is both a major clinical goal and a moral/ethical imperative. This requires identifying patient-level and perioperative factors that may be used to predict PACU IV opioid requirement. This should allow for the development of personalized care protocols to prevent clinically significant PACU pain in children. Our objective was to develop prediction models enabling practitioners to identify children at risk for PACU IV opioid requirement after various painful ambulatory surgical procedures. METHODS: After Institutional Review Board approval, clinical, demographic, and anthropometric data were prospectively collected on 1256 children 4-17 years of age scheduled for painful ambulatory surgery (defined as intraoperative administration of analgesia or local anesthetic infiltration). Three multivariable logistic regression models to determine possible predictors of PACU IV opioid requirement were constructed based on (1) preoperative history; (2) history + intraoperative variables; and (3) history + intraoperative variables + PACU variables. Candidate predictors were chosen from readily obtainable parameters routinely collected during the surgical visit. Predictive performance of each model was assessed by calculating the area under the respective receiver operating characteristic curves. RESULTS: Overall, 29.5% of patients required a PACU IV opioid, while total PACU analgesia requirement (oral or IV) was 41.1%. Independent predictors using history alone were female sex, decreasing age, surgical history, and non-Caucasian ethnicity (model area under the receiver operating characteristic curve [AUROC], 0.59 [95% confidence interval {CI}, 0.55-0.63]). Adding a few intraoperative variables improved the discriminant ability of the model (AUROC for the history + intraoperative variables model, 0.71 [95% CI, 0.67-0.74]). Addition of first-documented PACU pain score produced a substantially improved model (AUROC, 0.85 [95% CI, 0.82-0.87]). CONCLUSIONS: Postoperative pain requiring PACU IV opioid in children may be determined using a small set of easily obtainable perioperative variables. Our models require validation in other settings to determine their clinical usefulness.

Factors associated with acute kidney injury or failure in children undergoing cardiopulmonary bypass: a case-controlled study.

UNLABELLED: Acute kidney injury (AKI) is a serious complication that occurs commonly following cardiopulmonary bypass (CPB) in infants and children. Underlying risk factors for AKI remain unclear, given changes in CPB practices during recent years. This retrospective, case-control study examined the relationships between patient, perioperative factors, AKI, and kidney failure in children who underwent CPB. METHODS: Cohorts of children with and without AKI were identified from the cardiac perfusion and nephrology consult databases. Demographic, perioperative, and postoperative outcome data were extracted from the databases and from medical records. Children were stratified into groups based on the Acute Dialysis Quality Initiative's RIFLE definitions for acute kidney risk or injury (AKI-RI) and kidney failure. RESULTS: The study groups included 308 controls (no AKI-RI or failure), 161 with AKI-RI, and 89 with failure. Young age, preoperative need for mechanical ventilation, milrinone, or gentamicin; intraoperative use of milrinone and furosemide; durations of CPB and anesthesia; multiple cross-clamp and transfusion of blood products were significantly associated with AKI or failure. Young age, perioperative use of milrinone, multiple cross-clamps, extracorporeal membrane oxygenation, cardiac failure, neurological complications, sepsis, and failure significantly increased the odds of mortality. CONCLUSION: This study identified multiple perioperative risk factors for AKI-RI, failure, and mortality in children undergoing CPB. In addition to commonly known risk factors, perioperative use of milrinone, particularly in young infants, and furosemide were independently predictive of poor renal outcomes in this sample. Findings suggest a need for the development of protocols aimed at renal protection in specific at risk patients.

Echocardiographic diagnosis of right ventricular inflow compression associated with pectus excavatum during spinal fusion in prone position.

INTRODUCTION: Pectus excavatum is commonly viewed as a benign condition. Associated alterations in hemodynamics are rare. We present an unusual case of right ventricular inflow obstruction and hemodynamic compromise as a consequence of pectus excavatum encountered during surgical intervention. CASE: a 15-year-old male with pectus excavatum and thoracolumbar scoliosis developed severe hypotension after induction of general anesthesia and placement in the prone position for elective spinal fusion. A transesophageal echocardiogram revealed anterior compression of the right heart by the sternum with peak and mean right ventricular inflow gradients of 7 and 4 mm Hg, respectively. The gradient resolved with supine positioning and was reproduced with direct compression of the sternum. CONCLUSIONS: Although pectus excavatum is generally a benign condition, the cardiologist should be aware of the potential for serious hemodynamic compromise related to positioning in these patients.

Giant pulmonary sequestration: the rare case requiring the EXIT procedure with resection and ECMO.

Although most prenatally diagnosed pulmonary sequestrations (PS) are asymptomatic, large lesions are associated with pleural effusions and pulmonary hypoplasia. We present the first reported case of a prenatally diagnosed giant extralobar pulmonary sequestration that required the ex utero intrapartum treatment (EXIT) procedure with resection and extracorporeal membrane oxygenation (ECMO). We discuss the compelling rationale for performing EXIT-resection-ECMO in the setting of a large thoracic mass and anticipated severe respiratory failure at birth.

The use of aprotinin in children undergoing operative repair of isolated atrial septal defects.

BACKGROUND: The purpose of this retrospective study was to examine the benefits, risks and costs associated with aprotinin use in children who underwent repair of an atrial septal defect (ASD). The primary aim was to determine whether the transfusion rate is lower in children who received aprotinin compared with those who did not during ASD repair. The use of aprotinin has been shown to reduce transfusion requirements for children undergoing primary or secondary repair of congenital cardiac anomalies. However, past studies have not reported the benefits of this agent during low complexity procedures such as ASD repair. METHODS: All children who underwent ASD repair over 6 years (3 years pre- and postroutine use of aprotinin for all CPB cases in the institution) were identified, and their medical records reviewed. Children with multiple congenital cardiac lesions were excluded. The following data were recorded: demographics and baseline laboratory findings, intraoperative use of aprotinin, cardiopulmonary bypass information including details of ultrafiltration, all intraoperative and postoperative transfusions, postoperative bleeding and relevant laboratory findings. RESULTS: One hundred and fifteen children were included, 66 of whom received aprotinin. Transfusion rates were not different between children who received aprotinin [n = 8 (12%)] and those who did not [n = 3 (6%)]. Furthermore, changes in hematocrit were not different between groups. These findings were similar when children 15 kg. CONCLUSIONS: This study suggests that aprotinin use offers no benefit for children undergoing isolated repair of an ASD.