Juvenile laryngeal papillomatosis: scary anaesthetic!

We describe three children ages 20 to 33 months who presented for surgical resection of their laryngeal papillomata. Their anaesthetic management revealed the severity of obstruction which these children presented and the obstacles that faced the anaesthesiologist trying to secure the airway and provide adequate ventilation. The airway obstruction had both a fixed and a dynamic component to it. This was evidenced by the ability of the children to maintain ventilation when spontaneously breathing. But, they exhibited total obstruction when ventilation was attempted via mask using positive pressure. It is possible to encounter obstruction to ventilation after the trachea has been intubated because of papillomata that were 'shaved off,' filling the tracheal tube lumen.

Noninvasive ventilation via bilevel positive airway pressure support in pediatric practice.

OBJECTIVE: To evaluate the efficacy of bilevel positive airway pressure support in critically ill children with underlying medical conditions. DESIGN: Prospective, clinical study. SETTING: Pediatric intensive care unit (ICU). PATIENTS: Thirty-four patients (6 mos to 20 yrs, mean 11.06 +/- 0.9 yrs) with impending respiratory failure were enrolled in the study. All patients required airway or oxygenation/ventilation support (awake or asleep) and required admission to our pediatric ICU. Each patient served as his or her own control. Exclusion criteria were absent cough or gag reflex, multiple organ system failure, age of <6 mos, vocal cord paralysis, and noncooperation with nasal mask. INTERVENTIONS: Bilevel positive airway pressure support ventilation. MEASUREMENTS AND MAIN RESULTS: Thirty-four patients with 35 episodes of respiratory insufficiency requiring airway support or oxygenation/ventilatory support were treated with bilevel positive airway pressure support ventilation. Dyspnea score decreased at least two deviations in all patients; dyspnea score decreased five deviations in 67% of patients. Resting heart rate decreased from 126 +/- 3.2 to 102 +/- 3.2 beats/min (p < .001), respiratory rate decreased from 39 +/- 3 to 25 +/- 1 breaths/min (p < .004), bicarbonate concentrations decreased from 30.0 +/- 1.0 to 24.0 +/- 0.7 mmol/L (p < .01), and room air saturation increased from 85 +/- 2% to 97 +/- 1%. Bilevel positive airway pressure support ventilation failure was characterized by an inability to stabilize progression of respiratory failure and the subsequent placement of an artificial airway. Three patients required placement of an artificial airway. CONCLUSIONS: A decrease in respiratory rate, heart rate, and dyspnea score and an improvement in oxygenation were noted in >90% of patients studied, resulting in only an 8% frequency of intubation. The efficacy of bilevel positive airway pressure support ventilation in selected groups of patients indicates the need to include this form of noninvasive pressure support ventilation in the care offered by pediatric ICUs.

Evaluation of a pediatric intensive care residency curriculum.

OBJECTIVE: To teach residents to recognize and treat critically ill or injured infants, children, and adolescents in a 1-month, intensivist-designed, second-year resident pediatric intensive care rotation curriculum while maintaining optimal patient care and resident educational satisfaction. DESIGN: Descriptive evaluation of an intensivist-designed, second-year resident pediatric intensive care rotation curriculum from September 1994 to May 1996. SETTING: Multispecialty 16-bed pediatric intensive care unit (ICU) staffed by five pediatric critical care physicians in a university-affiliated children's hospital supporting a pediatric residency program. PATIENTS: None. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Our second-year resident pediatric ICU rotation curriculum consisted of direct patient care, participation in clinical rounds under the supervision of a pediatric critical care attending physician, and a 1-month formal curriculum. A standardized test evaluated resident pediatric critical care knowledge before and after the pediatric ICU rotation. Number and type of resident procedures were documented. Four-point Likert scale questionnaires were used to evaluate resident educational satisfaction and resident performance. Opportunity cost, the graduate medical education return on educational investment, the critical care attending physician's return on resident investment, and the optimal teaching time for number of rotation residents were calculated. Unit demographics were documented. Data analysis included multivariate analysis, t-test, and chi-squared techniques. Significance was defined as p < .05, rotated factor loading > 0.5, and Eigenvalues > or = 1. Kmeans identified clusters. From September 1994 to May 1996, 71 residents, 34 (48%) from pediatric or medicine-pediatric programs and 37 (52%) from emergency medicine residency programs, participated in our second-year pediatric ICU resident educational process. All residents showed improvement between pretest and posttest knowledge scores (p < .05). Seventy percent of the variance in critical care attending physician evaluations of the residents during their pediatric ICU rotation was based on bedside clinical skills (31%), communication skills (20%), and basic knowledge base (19%). Critical care attending physician evaluations of residents placed residents into three clusters: "hands-on," "well-rounded," or "book-heavy" residents. Prerotation test scores, postrotation test scores, and numbers of procedures performed did not correlate with how critical care attending physicians evaluated overall performances of individual residents. Three factors explained 61% of the variances in resident satisfaction with the pediatric ICU rotation: clinical experience (27%), formal didactics (18%), and text availability (16%). Resident educational satisfaction did not appear to depend on access to procedures. Critical care attending physicians spent a minimum of 12.6 hrs/wk involved in resident education. The opportunity cost for using critical care attending physicians to provide 12.6 resident teaching hours per week was calculated as $111,384/yr. Pediatric ICU patient demographics, morbidity, and mortality did not change during the introduction of the resident educational program in the pediatric ICU. CONCLUSIONS: During a required pediatric ICU resident rotation, balancing the resident's educational and decision-making autonomy needs and the critical care attending physician's desire to provide consistent bedside care of the critically ill child is an ongoing interactive process that requires substantial personnel, time, and financial commitments. It is possible to maintain patient care in the pediatric ICU and provide residents with a satisfying pediatric ICU experience. Trends in financial reimbursement may limit our present time commitment to the resident pediatric ICU curriculum.

A study of desmopressin and blood loss during spinal fusion for neuromuscular scoliosis: a randomized, controlled, double-blinded study.

BACKGROUND: Studies examining the use of desmopressin acetate (DDAVP) have shown variable results in DDAVP's efficacy for reducing blood loss. Studies of adults having cardiac surgery and of children having spinal fusion have suggested that patients with complicated medical histories and complex surgical procedures may benefit from use of DDAVP. Therefore, this study was designed to examine the homeostatic effects of DDAVP in children with severe cerebral palsy undergoing spinal fusion. METHODS: A randomized, double-blinded, and placebo-controlled trial of DDAVP was designed to enroll 40 patients. However, termination of the study was advised by the Institutional Review Board after 21 patients were enrolled. All patients had spastic quadriplegic-type cerebral palsy and were randomly assigned to one of two groups. The DDAVP group received 0.3 microg/kg DDAVP in 100 ml normal saline, and the placebo group received normal saline alone. All patients were anesthetized with nitrous oxide, oxygen, isoflurane, and fentanyl. Factor VIIIC and von Willebrand's factor (vWF) concentrations were measured in blood drawn before DDAVP infusion and 1 h after infusion. Blood pressure was maintained at a systolic pressure of less than 100 mmHg. Use of crystalloids, packed erythrocytes, platelets, and fresh frozen plasma were based on criteria established by protocol. Estimated blood loss was assessed by weighing sponges and measuring suctioned blood from canisters. RESULTS: Estimated blood loss (intraoperative and postoperative) and amount of packed erythrocytes transfused were similar for the DDAVP and placebo groups. Concentrations of both factor VIIIC and vWF were significantly greater after DDAVP infusion when compared with concentrations after placebo infusion. CONCLUSIONS: In the children who had complex spinal fusion, there was no difference in estimated blood loss between those who received DDAVP and those who received a placebo. Administration of DDAVP significantly increased factor VIIIC and vWF levels.

Comparison of cuffed and uncuffed endotracheal tubes in young children during general anesthesia.

BACKGROUND: Uncuffed endotracheal tubes are routinely used in young children. This study tests a formula for selecting appropriately sized cuffed endotracheal tubes and compares the use of cuffed versus uncuffed endotracheal tubes for patients whose lungs are mechanically ventilated during anesthesia. METHODS: Full-term newborns and children (n = 488) through 8 yr of age who required general anesthesia and tracheal intubation were assigned randomly to receive either a cuffed tube sized by a new formula [size(mm internal diameter) = (age/4) + 3], or an uncuffed tube sized by the modified Cole's formula [size(mm internal diameter) = (age/4) + 4]. The number of intubations required to achieve an appropriately sized tube, the need to use more than 21.min-1 fresh gas flow, the concentration of nitrous oxide in the operating room, and the incidence of croup were compared. RESULTS: Cuffed tubes selected by our formula were appropriate for 99% of patients. Uncuffed tubes selected by Cole's formula were appropriate for 77% of patients (P < 0.001). The lungs of patients with cuffed tubes were adequately ventilated with 2 1.min-1 fresh gas flow, whereas 11% of those with uncuffed tubes needed greater fresh gas flow (P < 0.001). Ambient nitrous oxide concentration exceeded 25 parts per million in 37% of cases with uncuffed tubes and in 0% of cases with cuffed tubes (P < 0.001). Three patients in each group were treated for croup symptoms (1.2% cuffed; 1.3% uncuffed). CONCLUSIONS: Our formula for cuffed tube selection is appropriate for young children. Advantages of cuffed endotracheal tubes include avoidance of repeated laryngoscopy, use of low fresh gas flow, and reduction of the concentration of anesthetics detectable in the operating room. We conclude that cuffed endotracheal tubes may be used routinely during controlled ventilation in full-term newborns and children during anesthesia.

Patient selection for primary laryngotracheal separation as treatment of chronic aspiration in the impaired child.

Chronic aspiration in the neurologically impaired child is associated with significant medical and social complications. Traditional surgical management has often relied on tracheotomy. This may well fail to control aspiration. The purpose of this retrospective study was to determine which neurologically impaired children would benefit from a laryngotracheal separation (LTS), as opposed to tracheotomy, as the primary surgical procedure to control chronic salivary aspiration. Patient selection was based on neurologic status, verbal communication ability, likelihood of neurologic recovery, and failure of previous treatments to control aspiration. Nineteen neurologically impaired children aged 8-172 months with chronic salivary aspiration underwent LTS. A total of 73.6% of these patients had prior tracheotomies, yet they continued to aspirate. Two early and three late complications were noted. No instances of fistula formation were noted. There were no deaths related to complications of the surgery or persistent aspiration. Follow-up 1-62 months after surgery demonstrated that complete control of the aspiration was achieved in all of these children. Two of the children who had achieved verbal communication prior to the procedure lost this ability. Improved general health and ability to resume oral intake was noted in all patients. This, combined with a decrease in the need of frequent suctioning, was felt by the families of these children to be a major improvement in the quality of life. Laryngotracheal separation appears to be a simple and effective means of controlling chronic aspiration. It should be considered as a primary treatment of aspiration in the properly selected child with neurologic disease.

The use of a laryngotracheal separation procedure in pediatric patients.

The objective of this study was to review experience, outcome, and satisfaction after a laryngotracheal separation (LTS) procedure in pediatric patients. Chart reviews and phone questionnaires were used. Factors reviewed included hospitalizations and infections prior to and after LTS, morbidity, and impact on quality of life. Twenty-one pediatric patients ranging in age from 8 to 172 months underwent LTS. Follow-up time ranged from 1 to 49 months. Complications were minor. Eighty-eight percent of patients had fewer hospitalizations or were discharged for the first time after LTS. Number of pneumonias and suctioning frequency decreased, mobility increased in patients with prior tracheostomies, and care requirements decreased in 95% of patients. Parents reported satisfaction and improved quality of life. LTS is a low-risk, successful procedure which increases quality of life and decreases morbidity in pediatric patients with irreversible upper airway dysfunction.

Dose response of succinylcholine at the adductor pollicis of children with cerebral palsy during propofol and nitrous oxide anesthesia.

Children with cerebral palsy may be resistant to paralysis induced by nondepolarizing neuromuscular blocking drugs. Potency of a bolus of succinylcholine in children with cerebral palsy has not been studied previously. Therefore, we measured the response of the adductor pollicis to succinylcholine in children with cerebral palsy anesthetized with propofol and nitrous oxide. Forty children between the ages of 2 and 10.2 yr with spastic quadriplegic cerebral palsy were randomly assigned to receive 100, 175, 250, or 375 micrograms/kg of succinylcholine during anesthesia with propofol and nitrous oxide. The ulnar nerve was stimulated with a train-of-four supramaximal stimulus every 10 s and the compound electromyogram of the adductor pollicis recorded by a Datex NMT monitor. Plasma cholinesterase activity was measured in all patients with three different substrates (propionylthiocholine, benzoylcholine, and succinylcholine). Dibucaine number was also determined using inhibition of benzoylcholine degradation. ED50 of succinylcholine was 146.8 micrograms/kg with 95% confidence intervals of 111.4-193.7 micrograms/kg. ED95 of succinylcholine was 360.5 micrograms with 95% confidence intervals of 273.3-475.5 micrograms/kg. We conclude that children with cerebral palsy are slightly sensitive to succinylcholine, but probably not sufficiently to be clinically important.

Ondansetron reduces the incidence and severity of poststrabismus repair vomiting in children.

This prospective, randomized, placebo-controlled, double-blinded study evaluated the antiemetic efficacy of ondansetron and metoclopramide in 90 ASA physical status I or II children, 2-17 yr of age, undergoing strabismus repair. After anesthetic induction and prior to eye muscle manipulation, subjects received normal saline 0.3 mL/kg (Group 1), metoclopramide 0.25 mg/kg (Group 2), or ondansetron 0.15 mg/kg (Group 3), intravenously. There were no differences between groups with respect to age, weight, gender, fluids received, number of eye muscles repaired, anesthetic technique, or time in the operating room. The incidence of vomiting in Groups 1, 2, and 3 was 50%, 27%, and 10% prior to discharge, and 67%, 53%, and 30% during the 24 h after surgery, respectively. The number of children vomiting prior to discharge and within 24 h of surgery was significantly reduced in Group 3 compared with Group 1 (P < 0.003 and P < 0.015, respectively). The number of vomiting episodes per patient in Groups 1, 2, and 3 was 1.1, 0.5, and 0.1 prior to discharge, and 4.5, 2.6, and 1.2 during the 24 h after surgery (P < 0.0005 and P < 0.004, respectively). Ondansetron 0.15 mg/kg intravenously after the induction of anesthesia reduces the incidence and severity of vomiting after strabismus repair both prior to discharge from the hospital and during the 24 h after surgery.

Efficacy of intranasal midazolam in facilitating suturing of lacerations in preschool children in the emergency department.

Sedating children safely and effectively for minor laceration repair is a well-recognized clinical problem. A randomized, double-blind, and controlled study was conducted to evaluate the efficacy of intranasal midazolam for reducing stress during the suturing of lacerations in preschool children. Fifty-nine children with simple lacerations that required suturing were randomly assigned to one of three groups. Group 1 received intranasal midazolam, 0.4 mg/kg, prior to suturing. Group 2 received an equivalent volume of normal saline intranasally prior to suturing as a placebo. Group 3 was the control group and received no intervention prior to suturing. Heart rate, respiratory rate, blood pressure, and pulse oximetry were monitored at 5-minute intervals throughout the procedure. Subjective variables were also measured at 5-minute intervals and included a cry score, a motion score, and a struggle score. Parent satisfaction was measured via a short telephone interview the following day. There were no significant differences in outcome between the placebo group and the control group. Their results were pooled and compared with the results for the midazolam group. The midazolam group showed significant reductions for mean heart rate, maximum heart rate, and maximum systolic blood pressure when compared with the placebo/control group. Scores for two of the three subjective variables, cry and struggle, were significantly reduced for the midazolam group. The papoose board was considered unnecessary in retrospect for more than half of patients in the midazolam group compared with only one fifth of patients in the placebo/control group.(ABSTRACT TRUNCATED AT 250 WORDS)

Quality assurance and continuous quality improvement: history, current practice, and future directions.

Quality Assurance (QA) provides opportunities for physicians and allied health professionals to improve patient care and disease outcomes. Its goals are increased efficiency and efficacy in healthcare. QA activities are based upon objective criteria and systematic review and make important contributions to the effectiveness of hospitals and other care facilities. Successful programs help to maximize health status of patients while minimizing resource utilization. Beginning in 1917, early QA efforts were often informal and subjective but now include standards for QA and strategies for monitoring and evaluating patient care. Central to its new "Agenda for Change," the Joint Commission on Accreditation of Healthcare Organizations has embraced the concept of continuous quality improvement (CQI). This moves the focus of review away from department- or practitioner-specific activities and toward a "systems" form of evaluation. CQI is rooted in patient-care realities, is easy to implement, is based upon scientific assessments, and solves practical problems in an incremental and ongoing fashion.

Chronic respiratory failure in infants with prolonged ventilator dependency.

One hundred one infants with chronic respiratory failure (CRF) who required prolonged mechanical ventilation were cared for in the pediatric intensive care unit at The Children's Hospital of Philadelphia between January 1967 and December 1984. Chronic respiratory failure of infancy is a condition that requires mechanical ventilation for more than 28 days in the first year of life. Thirty-six children had severe bronchopulmonary dysplasia, 50 had congenital anomalies, and 15 had neuromuscular disorders. The mean duration of mechanical ventilation for the 101 patients was 12.3 months. Seventy-one children were alive, and 53 (75%) of the 71 had been weaned from mechanical ventilation as of Dec 31, 1984. Pulmonary insufficiency and cardiac failure were the predominant causes of death in 17 of 22 infants in the first two years after the onset of CRF; four of eight deaths that occurred beyond two years were caused by airway- and ventilator-related accidents. Mechanical ventilatory support was emphasized for as long as necessary to provide normal blood gas tensions, nutrition, growth, and development rather than weaning as rapidly as possible. This clinical experience demonstrates that it is feasible to save over 70% of infants with the severest forms of CRF and prolonged ventilator dependency.

Pediatric home mechanical ventilation.

Infants and children with chronic respiratory failure are a byproduct of improvements in intensive care medicine. Home mechanical ventilation is an alternative to hospital care for the ventilator-assisted child. With proper preparation, safeguards, and support, these children are being successfully managed at home.

The heart is under the lower third of the sternum. Implications for external cardiac massage.

Current guidelines for cardiopulmonary resuscitation in children state that the heart lies under the midsternum in infancy and descends with age. To verify this statement, we studied 55 patients, aged 1 day to 19 years, including eight premature infants, during either routine chest x-ray films or right-sided heart angiography. Using a Cartesian coordinate system determined by radiopaque markers placed on the chest, and computer digitization, we located the center of each patient's cardiac silhouette and/or right ventricle. Using descriptive statistics, we found that the heart lay under the lower third of the sternum in all age groups. Analysis of variance indicated that there was no significant difference in this location between age groups. These results suggest that recommendations for external cardiac massage in infants and children may need to be revised.

Factors influencing outcome of cardiopulmonary resuscitation in children.

We evaluated 47 pediatric patients after cardiopulmonary arrest. Patients entered the study with the onset of advanced life support. We followed them until death, or discharge from the hospital, occurred. We identified three groups of patients: long-term survivors, who survived to discharge, short-term survivors, who survived longer than 24 hours after CPR but not until discharge, and nonsurvivors, who died within 24 hours of their arrest. All of the long-term surviving patients were discharged from the hospital without gross neurologic deficit attributable to the arrest or resuscitation effort. Twenty-seven (57%) children were successfully resuscitated. Eighteen (38%) were long term-survivors, while nine (19%) were short-term survivors. Favorable outcome is associated with the following factors: inhospital arrest, extreme bradycardia as the presenting arrhythmia, successful resuscitation with only ventilation, oxygen and closed chest massage, and a duration of CPR of less than 15 minutes. Age, sex, and race, as well as pupillary reaction and motor response at the onset of advanced life support, did not correlate with long-term survival.

Pediatric cardiopulmonary resuscitation. A review of 130 cases.

Cardiopulmonary resuscitation (CPR) records of 130 pediatric patients with cardiac arrest were reviewed. Ninety-six resuscitations were performed on patients hospitalized on the Medical and Surgical units of the Children's Hospital of Philadelphia (HP) and 34 on Emergency Department patients (EDPs). In HP, initial survival was 90%. In 27% of HPs, airway and breathing techniques alone were life saving. A mean of 2.45 drugs per patient were used for HP. In EDP, initial survival was 56%. There had been advanced CPR during the prehospital transport phase for the EDPs. All but two EDPs required drug management. The mean was 4.25 drugs per patient. Lidocaine and direct current defibrillation were used only rarely. Glucose was used frequently (33%) and should be considered in the list of essential resuscitation drugs. The necessity for resuscitation was most commonly associated with pulmonary diseases. These findings reflect differences between pediatric CPR and adult CPR, and suggest limitations in applying adult standards to infants and children. It is suggested that the medical community develop separate pediatric CPR courses as independent modules for those who assume responsibility for resuscitating children.

Management of the drowning victim.

Our ability to manage the near-drowning victim at the site of the accident and in the advanced life support facility has allowed for an increased survival and a decrease in morbidity. Nevertheless, the greatest strides in the management of drowning must of necessity be in the area of preventive medicine. A greater appreciation of the epidemiology of immersion accidents will allow the development of education and surveillance programs to minimize the frequency of these devastating accidents.