Central Arterial Line Placement for Pediatric Cardiac Surgery: A Single-Center Experience.

BACKGROUND: Peripheral arterial line placement is a common, low-risk procedure in pediatric patients undergoing cardiac surgery. Central arterial cannulation may be used when peripheral cannulation is not feasible. At present, there are limited data to guide central arterial-line site selection in pediatric patients. We aimed to (1) quantify the rate of complications associated with central arterial-line placement in pediatric patients undergoing cardiac surgery, (2) determine risk factors associated with central arterial-line complications, and (3) describe placement trends during the last decade. METHODS: This was a retrospective, single-center cohort study of pediatric patients who underwent intraoperative placement of an axillary or femoral arterial line for cardiac surgery between July 1, 2012 and June 30, 2022. The primary outcome studied was the incidence of complications, defined as vascular compromise, pulse loss, ultrasound-confirmed thrombus or flow abnormality, and/or positive blood cultures not attributable to another source. Patients' characteristics and perioperative factors were analyzed using univariate and multivariate analysis to examine the relationship between these factors and line-associated complications. RESULTS: A total of 1263 central arterial lines were analyzed-195 axillary arterial lines and 1068 femoral arterial lines. The overall incidences of vascular compromise and pulse loss from central arterial-line placement were 17.8% and 8.3%, respectively. Axillary lines had lower rates of vascular compromise (6.2% vs 19.9%, P < .001), pulse loss (2.1% vs 9.5%, P < .001), and ultrasound-confirmed thrombus of flow abnormalities (14.3% vs 81.1%, P = .001) than femoral lines. Complications were more common in neonates and infants. By multivariate logistic regression, femoral location (odds ratio [OR], 4.16, 95% confidence interval [CI], 1.97-8.78), presence of a genetic syndrome (OR, 1.68, 95% CI, 1.21-2.34), prematurity (OR, 1.48, 95% CI, 1.02-2.15), and anesthesia time (OR, 1.17 per hour, 95% CI, 1.07-1.27 per hour) were identified as independent risk factors for vascular compromise. Femoral location (OR, 7.43, 95% CI, 2.08-26.6), presence of a genetic syndrome (OR, 1.86, 95% CI, 1.18-2.93), prematurity (OR, 1.65, 95% CI, 1.02-2.67), and 22-G catheter size (OR, 3.26, 95% CI, 1.16-9.15) were identified as independent risk factors for pulse loss. CONCLUSIONS: Axillary arterial access is associated with a lower rate of complications in pediatric patients undergoing cardiac surgery as compared to femoral arterial access. Serious complications are rare and were limited to femoral arterial lines in this study.

Inpatient Resource Utilization for Hypoplastic Left Heart Syndrome from Birth Through Fontan.

Completing 3-stage palliation for hypoplastic left heart syndrome requires significant resources. An analysis of recent data has not been performed. We aimed to determine total charges necessary to complete all 3 stages of single-ventricle palliation, including interstage encounters. We also aimed to determine overall resource utilization, including hospital days, interstage admissions, and interstage procedures. We performed a retrospective cohort study using data from the Pediatric Health Information System database between 2016 and 2021, including all patients who completed 3-stage palliation for hypoplastic left heart syndrome. We identified 199 patients who underwent 3-stage palliation of hypoplastic left heart syndrome between 2016 and 2021. Median total adjusted charges (interquartile range, IQR) over the course of 3-stage palliation were $1,475,800 ($1,028,900-2,191,700). Median adjusted charges (IQR) for stage 1, 2, and 3 hospitalizations were $604,300 ($419,000-891,400), $234,000 ($164,300-370,800), and $256,260 ($178,300-345,900), respectively. Median hospital length of stay (IQR) for stages 1, 2, and 3 was 36 (26,53), 9 (6,17), and 10 (7,14) days, respectively. Pulmonary artery stenosis was the most common admitting diagnosis for interstage hospitalizations (3.4% of hospitalizations). Cardiac catheterization (24.1% of procedures) and feeding tube placement (10.0% of procedures) were the most common principal procedures during interstage hospitalizations. Total inpatient charges incurred throughout 3-stage palliation of hypoplastic left heart syndrome are substantial and have risen since prior studies. Gastrointestinal comorbidities and feeding optimization contribute considerably to this resource utilization.

Transcatheter Ductal Stents Versus Surgical Systemic-Pulmonary Artery Shunts in Neonates With Congenital Heart Disease With Ductal-Dependent Pulmonary Blood Flow: Trends and Associated Outcomes From the Pediatric Health Information System Database.

Background Surgical systemic-to-pulmonary artery shunts have been the standard approach to establish stable pulmonary blood flow in neonates with congenital heart disease with ductal-dependent pulmonary blood flow. More recently, transcatheter ductal stents have been performed as an alternative, less invasive intervention. We aimed to characterize trends in the utilization of surgical shunts versus ductal stents and compare associated outcomes. Methods and Results Using data from the Pediatric Health Information System, we retrospectively analyzed neonates with congenital heart disease with ductal-dependent pulmonary blood flow who underwent surgical shunt or ductal stent placement between January 2016 and December 2021. Patients were identified by International Classification of Diseases, Tenth Revision (ICD-10) diagnosis and procedure codes. The primary outcome was length of hospital stay. Secondary outcomes were reintervention risk and adjusted hospital costs. Of 936 patients included, 65.2% underwent a surgical shunt over the 6-year period. The proportion who underwent ductal stenting increased from 19% to 53.4% from 2016 to 2021. The median adjusted difference in postintervention length of hospital stay was 11 days greater for the surgical shunt cohort (95% CI, 7.2-14.8; P<0.001). The adjusted reintervention risks within 3 (odds ratio [OR], 3.37 [95% CI, 1.91-5.95], P<0.001) and 6 months (OR, 2.43 [95% CI, 1.62-3.64], P<0.001) were significantly greater in the ductal stent group. Median adjusted index hospital costs were $198 300 ($11 6400-$340 000) versus $120 400 ($81 800-$192 400) for the surgical shunt and ductal stent cohorts, respectively (P<0.001). Conclusions Ductal stenting has become an increasingly utilized palliative approach to secure pulmonary blood flow in neonates with congenital heart disease with ductal-dependent pulmonary blood flow in the United States. Ductal stenting is associated with decreased length of hospital stay and reduced overall cost for the index hospitalization but with a greater reintervention risk than surgical shunting.

Trend and Outcomes for Surgical Versus Transcatheter Patent Ductus Arteriosus Closure in Neonates and Infants at US Children's Hospitals.

Background Pharmacologic therapy for patent ductus arteriosus closure is not consistently successful. Surgical ligation (SL) or transcatheter closure (TC) may be needed. Large multicenter analyses comparing outcomes and resource use between SL and TC are lacking. We hypothesized that patients undergoing TC have improved outcomes compared with SL, including mortality, hospital and intensive care unit length of stay, and mechanical ventilation. Methods and Results Using the 2016 to 2020 Pediatric Health Information System database, characteristics, outcomes, and charges of patients aged <1 year who underwent TC or SL were analyzed. A total of 678 inpatients undergoing TC (n=503) or SL (n=175) were identified. Surgical patients were younger (0.1 versus 0.53 years; P<0.001) and more premature (60% versus 20.3%; P<0.001). Surgical patients had higher mortality (1.7% versus 0%; P=0.02). Using inverse probability of treatment weighting by the propensity score, multivariable-adjusted analyses demonstrated favorable outcomes in TC: intensive care unit admission rates (adjusted odds ratio [OR], 0.2; 95% CI, 0.11-0.32; P<0.001); mechanical ventilation rates (adjusted OR, 0.3; 95% CI, 0.19-0.56; P<0.001); and shorter hospital (adjusted coefficient, 2 days shorter; 95% CI, 1.3-2.7; P<0.001) and postoperative (adjusted coefficient, 1.2 days shorter; 95% CI, 0.1-2.3; P=0.039) stays. Overall charges and readmission rates were similar. Among premature neonates and infants, hospital (adjusted difference in medians, 4 days; 95% CI, 1.7-6.3 days; P<0.001) and postoperative stays (adjusted difference in medians, 3 days; 95% CI, 1.1-4.9 days; P=0.002) were longer for SL. Conclusions TC is associated with lower mortality and reduced length of stay compared with SL. Rates of TC continue to increase compared with SL.

Sequestration of Midazolam, Fentanyl, and Morphine by an Ex Vivo Cardiopulmonary Bypass Circuit.

Cardiopulmonary bypass (CPB) circuits can significantly sequester intravenous anesthetics. Adsorption of medications by our institution's standard circuit (Terumo CAPIOX FX05 oxygenator; noncoated polyvinylchloride tubing) has not been described. We prepared ex vivo CPB circuits with and without oxygenators. Medication combinations studied included midazolam (0.5 mg), fentanyl (50 µg), midazolam (0.5 mg) with morphine (0.5 mg), and midazolam (0.5 mg) with fentanyl (50 µg). Medications were administered after obtaining baseline samples. Samples were drawn at 2, 5, 15, 30, 60, 120, and 180 minutes, and analyzed for concentration of injected medications. Midazolam demonstrated no sequestration after 180 minutes. Fentanyl concentration at 180 minutes was lower with an oxygenator (52.7 ± 12.5 vs. 110.9 ± 12.0 ng/ml, P = 0.00432). More fentanyl was found in solution after 180 minutes when given with midazolam compared to fentanyl given alone in the presence of an oxygenator (101 ± 22.3 vs. 52.7 ± 12.5 ng/ml, P = 0.044). Less midazolam was present after 180 minutes when given with morphine compared to midazolam given alone in the absence of an oxygenator (1264.9 ± 425.6 vs. 2124 ± 254 ng/ml, P = 0.037). We successfully characterized the adsorption of various combinations of midazolam, fentanyl, and morphine to our CPB circuit, showing that fentanyl and midazolam behave differently based on other medications present.

Incidental Flexor Carpi Radialis Tendinopathy on Magnetic Resonance Imaging.

Background: Wrist pain is often nonspecific. Magnetic resonance imaging (MRI) is regularly obtained to evaluate wrist pain. Variations and pathophysiology identified on MRI may not account for patient's clinical symptoms. This study aims to quantify the prevalence of flexor carpi radialis (FCR) tendinopathy on MRI and the coexistence of trapeziometacarpal (TMC) or scaphotrapeziotrapezoid (STT) osteoarthritis. Methods: Using an institutional research database, we identified 3631 adult patients who obtained an MRI of the wrist during a 15-year period. Text search in the radiology reports identified 302 patients with possible FCR signal abnormalities. After reviewing the medical records, 98 patients were identified with FCR tendinopathy. Furthermore, medical records were used to identify pain located on the volar radial part of the wrist. In the absence of a documented examination consistent with FCR tendinopathy, we considered any signal change in the FCR incidental. Results: We identified 55 patients (55%) with incidental FCR tendinopathy. In a bivariate analysis, we found FCR signal changes on the MRI were associated with older age, white race, clinically suspected FCR tendinopathy, volar-radial sided wrist pain, and TMC and STT arthritis. Using multivariable logistic regression to account for confounding, older age and volar-radial sided wrist pain were independently associated with FCR signal changes on MRI. Conclusions: Signal changes in the FCR are infrequent and often incidental (asymptomatic) or associated with peritrapezial osteoarthritis.

Presumed Malignant Hyperthermia Treated During Cardiopulmonary Bypass in a Pediatric Patient Undergoing Aortic Valve Replacement: A Case Report.

There are no case reports of malignant hyperthermia in pediatric patients treated on cardiopulmonary bypass (CPB). We report the case of a 10-year-old boy undergoing aortic valve replacement. The patient developed progressive tachycardia and hypercarbia. In addition, EtCO2 and PaCO2 were equal and myoglobinuria was suspected given darkened urine. Numerous dantrolene boluses were given on CPB, and a dantrolene infusion was started. The patient's base deficit and creatine phosphokinase normalized by postoperative day 2. This case demonstrates the importance of expeditious diagnosis of malignant hyperthermia, and the need for additional dantrolene when treating patients whose blood volume is diluted on CPB.

Can variable practice habits and injection port dead-volume put patients at risk?

Injection ports used to administer medications and draw blood samples have inherent dead-volume. This volume can potentially lead to inadvertent drug administration, contribute to erroneous laboratory values by dilution of blood samples, and increase the risk of vascular air embolism. We sought to characterize provider practice in management of intravenous (IV) and arterial lines and measure dead-volumes of various injection ports. A survey was circulated to anesthesiology physicians and nurses to determine practice habits when administering medications and drawing blood samples. Dead-volume of one and four-way injection ports was determined by injecting methylene blue to simulate medication administration or blood sample aspiration and using absorption spectroscopy to measure sample concentration. Among the 65 survey respondents, most (64.52%) increase mainstream flow rate to flush medication given by a 1-way injection port. When using 4-way stopcocks, 56.45% flush through the same injection site. To obtain a sample from an arterial line, 67.74% draw back blood and collect the sample from the same 4-way stopcock; 32.26% use a different stopcock. Mean (SD) dead-volume in microliters ranged from 0.1 (0.0) to 5.6 (1.0) in 1-way injection ports and from 54.1 (2.8) to 126.5 (8.3) in 4-way injection ports. The practices of our providers when giving medications and drawing blood samples are variable. The dead-volume associated with injection ports used at our institution may be clinically significant, increasing errors in medication delivery and laboratory analysis.

Review of Superelastic Differential Force Archwires for Producing Ideal Orthodontic Forces: an Advanced Technology Potentially Applicable to Orthognathic Surgery and Orthopedics.

PURPOSE OF REVIEW: Gentle and continuous loads are preferred for optimum orthodontic tooth movement. Nitinol, an alloy of nickel and titanium developed for the aerospace industry, found its first clinical applications in orthodontics because it has ideal load-deflection behavior. The purpose of this review is to elucidate the criteria for effective orthodontic mechanics relative to emerging Nitinol technology. The specialized materials with variable stiffness that were originally developed for orthodontics are increasingly attractive for in the temporomandibular joint, orthognathic surgery, and orthopedics. RECENT FINDINGS: The evolution of orthodontic archwires is driven by a need to achieve low load-deflection characteristics and Nitinol is the alloy of choice. Scientific knowledge of the biological response to orthodontic forces continues to grow, but definitive guidance on optimal force levels for individual teeth is elusive. Finite element models (FEM) that take into account periodontal ligament (PDL) stresses indicate differential force archwires are needed to realize optimal treatment. However, previous wire fabrication methods, including welding of different materials and selective resistive heating, are limited by poor mechanical performance and spatial resolution. Recently, a novel laser processing technique was developed for precisely programing relative levels of stiffness in a single archwire. FEM was used to estimate the optimal force for each tooth by calculating the 3D bone-PDL surface area. There remains a general consensus that light and continuous forces are desirable for orthodontic treatment. New developments in archwire materials and technology have provided the orthodontist with a complete spectrum of load-deflection rates and differential force options to express these forces with maximized archwire economy. These technologies also appear to have application to orthopedic implant devices.

The Effect of Two Factors on Interobserver Reliability for Proximal Humeral Fractures.

INTRODUCTION: The purpose of this study was to assess whether training observers and simplifying proximal humeral fracture classifications improve interobserver reliability among a large number of orthopaedic surgeons. METHODS: One hundred eighty-five observers were randomized to receive training or no training in a simple classification for proximal humeral fractures before evaluating preoperative radiographs of a consecutive series of 30 patients who were treated with open reduction and internal fixation. RESULTS: The overall interobserver reliability of the simple proximal humeral fracture classification system was low and not significantly different between the training and the no training group (κ = 0.20 and κ = 0.18, respectively; P = 0.10). Subgroup analyses showed that training improved the agreement among surgeons who have been in independent practice ≤5 years (κ = 0.23 versus κ = 0.14; P < 0.001), surgeons from the United States (κ = 0.23 versus κ = 0.16; P = 0.002), and general orthopaedic surgeons (κ = 0.42 versus κ = 0.15; P = 0.021). DISCUSSION: Simplifying classifications and training observers did not improve the interobserver reliability for the diagnosis of proximal humeral fractures. However, training observers improved interobserver reliability of a simple proximal humeral fracture classification system among surgeons from the United States and, in particular, younger and less specialized surgeons. This finding may suggest that our interpretations of radiographic information might become more fixed and immutable with experience.

Systematic Review of Randomized Controlled Trials of Endothelin Receptor Antagonists for Pulmonary Arterial Hypertension.

BACKGROUND: There are currently three Food and Drug Administration approved endothelin receptor antagonists (ERAs): bosentan, ambrisentan, and macitentan. There is a growing body of evidence that demonstrates the beneficial effects of ERAs in patients with pulmonary arterial hypertension (PAH). OBJECTIVES: To compare the available evidence from randomized clinical trials for specific outcomes of different endothelin antagonists for the treatment of PAH. METHODS: A multi-database search of randomized controlled trials up to March 15, 2016 was conducted for those that would measure functional parameters of patients with PAH treated with ERA monotherapy versus placebo. Studies that analyzed 6-min walking distance, pulmonary vascular resistance, pulmonary arterial pressure, or WHO functional status were incorporated for analysis. A total of 15 trials and 2 subanalyses were compiled and quality and abovementioned outcomes were compared among studies. RESULTS: A constant decrease in pulmonary vascular resistance and pulmonary arterial pressure was globally reported among the different studies, resulting in increased 6-min walking distance and functional status compared to placebo. CONCLUSIONS: Although this evidence clearly shows the benefit of ERAs, studies, which compare ERAs against one another and with other therapies for progressive PAH, have been lacking. Larger and longer studies are necessary to define the role of ERAs as standalone agents and in combination therapies.

Time from Booking Until Appointment and Healthcare Utilization in Hand Surgery Patients with Discretionary Conditions.

Delaying treatment for benign musculoskeletal conditions may allow patients to learn self-efficacy and develop coping strategies, leading to less medical intervention and reduced cost. We tested the hypothesis that time from booking until appointment is not associated with healthcare costs. We further tested the secondary hypothesis that time from booking to appointment is not associated with specific healthcare utilizations. We identified 16,750 patients (55 % women; mean age 50 years) making first clinic visits to hand surgeons at our hospital between January 1, 2003 and December 31, 2012. Booking time was defined as the time between the scheduling of an appointment and the actual visit. Imaging procedures, injections, nerve conduction studies, occupational therapy visits, surgery, and referrals were determined up until the patient's second visit with the surgeon, or 90 days. Costs were determined in Relative Value Units. Duration between booking and office visit was not associated with higher cost (regression coefficient [ß] 0.0023, P = 0.77). Duration between booking and office visit was associated with a higher rate of nerve conduction studies (odds ratio [OR] 1.02, P < 0.001) and a lower rate of occupational therapy (OR 0.98, P < 0.001). There was substantial variation between surgeons. Greater wait time was not therapeutic, but is associated with different diagnostic and treatment measures that suggest people that are willing to wait have different types of problems. The variation by surgeon may make variation based on other factors, including time between booking and appointment, difficult to discern.

Incidental signal changes in the extensor carpi ulnaris on MRI.

BACKGROUND: Magnetic resonance imaging (MRI) commonly finds musculoskeletal abnormalities incidental to the reason for ordering the test. The purpose of this study was to determine if the prevalence of extensor carpi ulnaris (ECU) signal changes on MRI varies between patients undergoing upper extremity MRI for assessment of clinically suspected ECU tendinopathy and those undergoing upper extremity MRI for other indications. Our secondary null hypotheses were that the prevalence of ECU signal changes on MRI does not vary based on patient age or sex and that the prevalence of ECU signal changes on MRI does not vary among other indications for MRI. METHODS: We searched MRI reports of all patients undergoing MRI of the hand, wrist, or arm at our institution between 2001 and 2014 for signal changes in the ECU. The medical record was reviewed to determine the indication for the MRI and the presence of clinically suspected ECU tendinopathy. RESULTS: ECU signal changes (overall prevalence of 13 %) were more common in patients undergoing MRI for a working clinical diagnosis of ECU tendinopathy or ulnar-sided wrist pain compared to patients evaluated for nonspecific pain and other indications. Age was independently associated with ECU signal changes on MRI. MRI signal changes are uncommonly associated with symptomatic tendinopathy (low positive predictive value). CONCLUSIONS: ECU signal changes on MRI are common and often asymptomatic.

Convenient and improved protocols for the hydrogenation of esters using Ru catalysts derived from (P,P), (P,N,N) and (P,N,O) ligands.

An improved protocol where a pre-cursor, [Ru(Cl)(2)(NBD)(Py)(2)], is treated with ligands to form [RuCl(2)(bidentate ligand)(diamine)] pre-catalysts for ester hydrogenation is reported. This family of catalysts, as well as a range of ruthenium complexes of tridentate P^N^X (X = NR(2), OH) ligands have been investigated in the hydrogenation of aromatic esters. A range of aromatic esters can be hydrogenated in high yields at temperatures between 30 °C and 100 °C.

Increasing supervisory effectiveness in a laboratory animal facility.

Management personnel expressed concern that the allocation of work was not properly aligned to permit maximum efficiency in the supervisor job family. Employees at various levels in the supervisor job family also felt that there needed to be greater definition regarding which tasks needed to be done by which level in the organization. Using data collection and interviews, a team of staff employees and consultants successfully evaluated the facility operation and supervision. The information was analyzed and compared with the existing supervisory job descriptions. An action plan was developed and presented to management personnel to increase efficiency and stratify the responsibility of the existing supervisory levels. Supervisory reassignment was proposed.