Coagulation abnormalities in pediatric and adult patients after sclerotherapy or embolization of vascular anomalies.

OBJECTIVE: The purpose of our study was to examine the coagulation status in patients with vascular anomalies who had undergone sclerotherapy or embolization. SUBJECTS AND METHODS: Ours was a prospective pilot study of 29 patients who had undergone sclerotherapy or embolization of large vascular anomalies. Fibrinogen, platelet, and d-dimer levels and prothrombin time were obtained before, immediately after, and on the day after the procedure. RESULTS: Five patients with venous malformations had positive d-dimer levels before the procedure. A subgroup analysis revealed a relationship between the type of agent used and the change in coagulation status. Specifically, a positive relationship was found between the use of dehydrated alcohol or sodium tetradecyl sulfate and a disruption in coagulation profiles as evidenced by a decrease in platelets and fibrinogen, an increase in prothrombin time, and a conversion from negative to positive d-dimers. In contrast, sclerotherapy or embolization with cyanoacrylic, polyvinyl alcohol foam particles, or platinum microcoils was not associated with coagulation disturbances. CONCLUSION: The coagulation disturbances that occur in response to dehydrated alcohol or sodium tetradecyl sulfate sclerotherapy or embolization could compromise the patient's clotting ability. Patients who receive dehydrated alcohol or sodium tetradecyl sulfate during a preoperative sclerotherapy or embolization may experience coagulation disturbances that could increase the risk of bleeding, thrombosis, or hematoma. This patient population may benefit from the use of glue, foam, or coils as a substitute for dehydrated alcohol or sodium tetradecyl sulfate.

Sedatives used in pediatric imaging: comparison of IV pentobarbital with IV pentobarbital with midazolam added.

OBJECTIVE: This study was designed to evaluate safety, efficacy, and success of adding IV midazolam to an established IV pentobarbital protocol for pediatric sedation for radiologic imaging. Outcomes included sedation and discharge times as well as adverse events SUBJECTS AND METHODS: This prospective study compared two different sedation protocols developed by the radiology sedation committee and approved by the hospital sedation committee at our institution. Patients in the pentobarbital group received IV pentobarbital alone, and patients in the pentobarbital--midazolam group received a combination of IV pentobarbital and midazolam. A total of 1070 infants and children were enrolled, and sedation data were entered into a computer database and reviewed at bimonthly radiology sedation committee meetings for safety, efficacy, efficiency, failed sedations, and adverse outcomes. RESULTS: Mean age distribution, sex, American Society of Anesthesiologists physical status classification, fasting status, weight, and types of examinations were similarly distributed between the two study groups. Analysis of variance indicated longer times were required to sedate and to discharge patients who had received pentobarbital--midazolam (p < 0.001 for both times), even after adjusting for differences in the patients' ages and weights. The pentobarbital--midazolam group required more time to be successfully sedated and more time to discharge from the recovery room. The rates of adverse events and failed sedations were similar for both groups. CONCLUSION: Midazolam does not have a beneficial effect on pentobarbital sedation and has no effect on the rate of adverse events. The prolonged time needed both to sedate and to discharge (timed from the initial dose of sedation) pediatric patients who have received midazolam should discourage physicians from combining it with pentobarbital for pediatric sedation.

Sedation for pediatric radiological procedures: analysis of potential causes of sedation failure and paradoxical reactions.

BACKGROUND: Sedation for diagnostic imaging and interventional radiologic procedures in pediatrics has greatly increased over the past decade. With appropriate patient selection and monitoring, serious adverse effects are infrequent, but failure to sedate and paradoxical reactions do occur. OBJECTIVE: The purpose of this study was to determine, among patients undergoing sedation for radiologic procedures, the incidence of sedation failure and paradoxical reaction to pentobarbital and to identify potentially correctable causes. MATERIALS AND METHODS: Records of 1665 patients who were sedated in the radiology department from 1 November 1997 to 1 July 1998 were reviewed. Patients failing sedation or experiencing paradoxical reaction were compared with respect to sex, age group, diagnosis, scan type, time of day, NPO status, use of IV contrast and type of sedation agent using the Fisher exact test, Pearson chi-square, analysis of variance (ANOVA), the Student t-test, and logistic regression. RESULTS: Data analysis revealed a sedation failure rate of 1 % and paradoxical reaction rate of 1.2 %. Stepwise multiple logistic regression revealed that the only significant independent multivariate predictor of failure was the need for the administration of a combination of pentobarbital, fentanyl, and midazolam IV. CONCLUSION: The low rate of sedation failure and paradoxical reactions to pentobarbital was near optimal and probably cannot be improved with the currently available sedatives.

Exploring the lived-experience of childhood cancer survivors.

The purpose of this qualitative phenomenological study was to explore the lived-experience of childhood cancer survivors with regard to their patterns of interaction with family and the environment using Newman's theory of Health as Expanding Consciousness, which proposes that experiencing a devastating event promotes an expanded consciousness. The sample consisted of five young adults, ages 23 to 26 years, who had experienced childhood cancer and now are considered to be cured of their initial cancer. A hermeneutic dialectic approach was used, with each subject being asked to respond to one open-ended question, "What are the most meaningful events in your life?" The interviews were analyzed for evidence of expanded consciousness, changing relatedness, and other universal themes. Individual patterns emerged and themes were identified that supported Newman's theory, such as optimism and hope, stronger bonds to family and friends, increased capacity for empathy, a desire to help others, and deeper feelings for the value of life. The intensely personal and professional relationship that develops between pediatric oncology nurses and their patients can only be strengthened by the knowledge that these patients generally grew up to be caring and empathetic individuals, perhaps as a result of the nurses' loving care for them. This research also provided support for Newman's theory as a sound paradigm for nursing practice.

Durability of passive measles antibody in Jamaican children.

Measles antibody titres were determined by haemagglutination inhibition and by neutralization in 221 sets of serum collected from delivering mothers, umbilical cords, and infants when about six months of age. Radio-immunoassay was also used to measure antibody in 120 sera. Total IgG concentration was determined in the infant sera. All mothers had measles antibody and the mean titre was high. At the time of birth, measles antibody had been further concentrated in the infant. Nevertheless, many children lost protective titres before six months of age. The rate of loss was correlated with the infant's total serum IgG so that high IgG levels at six months correlated with rapid loss of measles-specific antibody. It is suggested that in homes where sanitation is poor, antibody is made to many agents at an early age. To maintain physiological balance, homeostatic mechanisms then increase the rate of catabolism of all IgG, including that passively acquired. In keeping with its stage of sanitary development, vaccination in Jamaica can profitably be given earlier than in the United States, but it must be later than in many African countries.

Durability of passive measles antibody in Jamaican children

Measles antibody titres were determined by haemagglutination inhibition and by neutralization in 221 sets of serum collected from delivering mothers, umbilical cords, and infants when about six months of age. Radio-immunoassay was also used to measure antibody in 120 sera. Total IgG concentration was determined in the infant sera. All mothers had measles antibody and the mean titre was high. At the time of birth, measles antibody had been further concentrated in the infant. Nevertheless, many children lost protective titres before six months of age. The rate of loss was correlated with the infant's total serum lgG so that high lgG levels at six months correlated with rapid loss of measles-specific antibody. It is suggested that in homes where sanitation is poor, antibody is made to many agents as an early age. To maintain physiological balance, homeostatic mechanisms then increase the rate of catabolism of all lgG, including that passively acquired. In keeping with its stage of sanitary development, vaccination in Jamaica can profitably be given earlier than in the United States, but it must be later than in many African countries. (AU)

Maternal and cord serum titres as predictors of the age of measles susceptibility and vaccine responsiveness in Jamaica - abstract

Wide geographic variation in the age of measles susceptibility and vaccine responsiveness provides good reason for differences in the recommended age of immunization, varying from six months in some African countries to fifteen months in the United States. We have developed a method for determining the optimal age of measles immunization, without performing formal tests of vaccine responsiveness in children of those age groups known to be suboptimal for immunization. We have measured measles neutralizing the haemagglutination-inhibiting antibody titres in Jamaica maternal and umbilical cord sera, and in infant sera taken at age five to seven months. The mean maternal neutralizing antibody titre was 7.7 log 2 units; it was concentrated to 8.2 log 2 units across the placenta. These values are the highest obtained for developing countries. The estimated half-life of passively acquired maternal measles antibody was 43 days as measured by the neutralization test and 48 days by the haemagglutination test. These half-lives were similar to those obtained from smaller groups of infants in Taiwan and New Haven, United States. The optimal age for mass measles vaccination was determined by statistical methods to be 10 to 11 months in Jamaica. In other populations, the same methodology could be used to determine the optimal ages for measles immunization (AU)