Case report of transfusion-related acute lung injury in a pediatric spine surgery patient transfused leukoreduced red blood cells.

Despite leukoreduced red blood cells (LR-RBCs) reducing the risk of transfusion-related acute lung injury (TRALI), we present a case of a 16-year-old female with kyphosis who received a transfusion of one unit of LR-RBCs, which lead to life-threatening, intraoperative TRALI. The clinical presentation included pulmonary edema, severe postoperative lactic acidosis, left ventricular dysfunction, increased creatine phosphokinase, fatty infiltration of the liver, and hemodynamic instability requiring inotropic support. This presentation is not the classic description of TRALI. Our patient improved with supportive treatment and was successfully extubated on postoperative day 4. TRALI work-up revealed antibody formation to HLA A2, A68, B44, and DQA 5 for the LR-RBCs unit administered.

To Pretreat or Not to Pretreat: Prophylactic Anticholinergic Administration Before Dexmedetomidine in Pediatric Imaging.

BACKGROUND: Dexmedetomidine (Dex) appears to be very effective as a sole sedative for pediatric imaging when used at high doses, but at an increased risk of transient hypertension, hypotension, and bradycardia. There are no clinical evidence/guidelines to guide anesthesia providers as to whether patients should be pretreated with an anticholinergic. The aim of this study was to demonstrate the changes in hemodynamic parameters after Dex sedation attributed to receiving or not receiving an anticholinergic pretreatment and compare for any differences or similarities. A subgroups analysis was performed in children with Down syndrome (DS). METHODS: In this retrospective descriptive study, we reviewed the records of 163 children receiving Dex anesthesia during MRI studies. Data analyzed included demographics, history of DS, and hemodynamics (heart rate [HR], systolic blood pressure [SBP], and diastolic blood pressure [DBP]) following Dex loading and infusion and the administration of an anticholinergic (atropine or glycopyrrolate). RESULTS: The mean age was 94.5 months, and 52 (32%) patients had DS. The generalized linear mixed-effects regression model showed a significant reduction in HR and SBP in all patients when no anticholinergic was administered compared with when it was administered. There was no significant change with DBP. During the scan period, the HR of the no-anticholinergic group decreased 26.6%, whereas that of the anticholinergic group decreased by only 16.7% from baseline (P < 0.01). The maximal SBP increased by a significantly greater percentage, compared with baseline, in the anticholinergic group in comparison with the no-anticholinergic group (20.2% vs 10.4%, respectively; P = 0.02). In the DS group, the difference in the maximal SBP change during the scan period was exaggerated, with a percentage increase that was 36 times larger in the anticholinergic group compared with the no-anticholinergic group (22% vs 0.6%, respectively; P< 0.01). CONCLUSIONS: Administration of a prophylactic anticholinergic with Dex shows no advantage other than a transient clinically insignificant increase in HR and SBP, and it may precipitate transient exaggerated SBP in more patients compared with not using a prophylactic anticholinergic.

Systematic review of risk factors for surgical site infection in pediatric scoliosis surgery.

BACKGROUND CONTEXT: Risk factors for surgical site infection (SSI) in children derived from the studies in the adult population are potentially misleading because of differences in pathophysiology and management. PURPOSE: This systematic review addresses the key question: What are the risk factors for SSI in pediatric patients undergoing scoliosis surgery? STUDY DESIGN: This is a qualitative systematic literature review. PATIENT SAMPLE: Retrospective and observational trials of children undergoing scoliosis surgery reported on the occurrence of risk factors for SSI and the occurrence of SSI. METHODS: Pubmed (Medline), Ovid Evidence-Based Medicine Reviews (EBMR), Scopus, and Cumulative Index to Nursing and Allied Health (CINAHL) were searched electronically for relevant articles in all the languages between January 1, 1991 and August 27, 2012, and cross-references were checked. Two independent reviewers identified articles and appraised quality with the Agency for Healthcare Research and Quality (AHRQ) criteria based on a weighted scoring of 0 to 100. RESULTS: Our search identified 135 abstracts and 14 studies meeting the inclusion criteria. The AHRQ grading showed that five articles were high quality with a score of greater than 67, and five articles were moderate quality with a score between 50 and 67. The percent agreement between the two independent reviewers was 84%, and kappa agreement score was 0.91 (95% confidence interval [CI]: 0.78-1.03). There were 76 risk factors identified, of which 22 factors were reported in more than one study. Odds ratios and 95% CIs were reported inconsistently. Pooled p analysis of high- and moderate-quality articles identified five risk factors predictive of SSI: inappropriate antibiotic use (p=.001), neuromuscular scoliosis (p=.014), instrumentation (p=.023), increased hospital stay days (p=.003), and residual postoperative curve (p=.003). CONCLUSIONS: The systematic review identified inappropriate antibiotic use, neuromuscular scoliosis, instrumentation, increased hospital stay days, and residual postoperative curve as risk factors for SSI after pediatric scoliosis surgery.

Knockout mice: is it just genetics? Effect of enriched housing on fibulin-4(+/-) mice.

BACKGROUND: Fibulin-4 is an extracellular matrix protein expressed by vascular smooth muscle cells that is essential for maintaining arterial integrity. Fibulin-4(-/-) mice die just before birth due to arterial hemorrhage, but fibulin-4(+/-) mice appear to be outwardly normal. Experiments were therefore performed to determine whether fibulin-4(+/-) mice display arterial pathologies on a microscopic scale. After preliminary experiments were performed, a second purpose developed, which was to test the hypothesis that any observed pathologies would be ameliorated by housing the animals in enriched cages. METHODOLOGY: Fibulin-4(+/-) and wild-type mice were housed either four/cage in standard cages or two per cage in larger cages, each cage containing a tunnel and a wheel. After three weeks the mice were sacrificed, and the aortas perfusion-fixed and excised for light and electron microscopy. PRINCIPLE FINDINGS: When the mice were in standard cages, localized regions of disorganized extracellular matrix and collagen fibers consistently appeared between some of the medial smooth muscle cells in the fibulin-4(+/-) mice. In the wild-type mice, the smooth muscle cells were closely connected to each other and the media was more compact. The number of disorganized regions per square mm was significantly greater for fibulin-4(+/-) mice (172+/-43 (SEM)) than for wild-type mice (15+/-8) (p<0.01, n = 8). When the mice were in enriched cages, the fibulin-4(+/-) mice showed significantly fewer disorganized regions than those in standard cages (35+/-12) (p<0.05, n = 8). The wild type mice also showed fewer disorganized regions (3+/-2), but this difference was not significant. CONCLUSIONS: These results indicate that arterial pathologies manifested in fibulin-4(+/-) mice can be reduced by enriching the housing conditions, and imply that appropriate environments may counteract the effects of some genetic deficiencies.