Single- and double-lung ventilation in infants and children undergoing thoracoscopic lung resection.

INTRODUCTION: Video-assisted thoracoscopic surgery (VATS) has gained wide acceptance for the pediatric population. Single-lung ventilation (SLV) has been suggested for thoracoscopic lung resection to provide better surgical exposure, but its role and sequelae compared with double-lung ventilation (DLV) have not been determined. The aim of this study was to investigate the feasibility and effects of SLV and DLV in infants and children undergoing thoracoscopic lung resection. PATIENTS AND METHODS: Written informed consent from all guardians for anonymized data analysis and approval by the Institutional Review Board were obtained. A retrospective study on a consecutive series of infants and children who underwent thoracoscopic lung resection during an 11 years period was performed. SLV was selected mainly in lesions localized in the upper, middle, and/or central lung for reasons of surgical exposure. Patients with lower lobe lesions and those who underwent atypical resections were preferably operated under DLV. End points were conversion rate, duration of postoperative ventilation, and perioperative complications, such as, atelectasis or pneumonia. RESULTS: Of 114 pediatric patients (58 female and 56 male; ratio 1.04:1) with a mean age of 7.1 years (3 days to 18.1 years), 62 patients underwent DLV and 52 patients underwent SLV for thoracoscopic lung resection. There were no significant differences between the two groups for conversion rate (DLV 8.1 vs. SLV 6.1%; p = 0.53), prompt extubation (DLV 50 vs. SLV 34.6%; p = 0.14), and postoperative atelectasis (DLV 35.5 vs. SLV 25%; p = 0.32). No major cardiorespiratory events, such as bleeding or pneumonia, were observed. No perioperative mortality occurred. CONCLUSIONS: This is the first study on safety, effectiveness, and outcome of SLV and DLV in pediatric patients undergoing thoracoscopic lung resection. Our data suggest that both SLV and DLV can be safely performed with similar low rate of surgical complications, when specific selection criteria are applied.

Work breaks during minimally invasive surgery in children: patient benefits and surgeon's perceptions.

INTRODUCTION: We recently reported that 5-minute work breaks every 25 minutes during long lasting laparoscopy in children (intermittent pneumoperitoneum [IPP] scheme) decrease the surgeon's stress markers such as saliva cortisol and heart rate and improve time-concentration scores significantly. Data on the impact of breaks on the patient and on the surgeon's perception of breaks, however, are still lacking. MATERIALS AND METHODS: We present the comprehensive biometry data of a randomized trial including 26 patients operated with (IPP) and 26 patients without breaks (continuous pneumoperitoneum [CPP]). Moreover, we analyzed the surgeon's perception of the break scheme using behaviorally anchored 10-point rating scales. RESULTS: There were no significant intergroup differences in the pooled patients' hemodynamics including cardiac output, blood gas readings, and temperature during and after the operation. Infants <1 year of age undergoing IPP versus CPP produced significantly higher urine volumes (1.60 ± 1.8 vs. 0.67 ± 1.00 mL/h/m2, p < 0.05). The overall area under the curve (AUC) of their cardiac output was 106.7 ± 41.1 (IPP) versus 78.0 ± 41.3 (CPP). This difference became significant during long operations (p < 0.05 for AUC 150 to 270 minutes). Surgeon's break perception and acceptance: team communication shifted from an implicit "mute communication" to an explicit way "issues are outspoken" by +4.7 ± 2.6 (p < 0.05) with improved coherence between operator and assistants (+3.9 ± 2.1). However, when questioned whether there was one particular welcome (5.1 ± 1) or extremely disturbing (6.4 ± 2.4) break during the entire procedure, the latter yielded a higher score (p > 0.05). Acceptance varied according to the surgeon's own esteem of his/her work style. Operators with high self-ratings for "fast" were inclined to put up with shorter breaks ("fast" vs. "slow" = 3.5 ± 1.4 vs. 5.5 ± 0.7, p < 0.05). Overall the scheme was approved (5.9 ± 3.2). CONCLUSIONS: A break scheme has no detrimental effect on patient physiology and is beneficial in infants. It needs careful tailoring to both the surgeon's work situation and self-esteem to gain acceptance.

Laparoscopic versus conventional Kasai portoenterostomy does not facilitate subsequent liver transplantation in infants with biliary atresia.

PURPOSE: The benefit of laparoscopic Kasai portoenterostomy remains controversial. With the progression of the disease, significant numbers of patients require liver transplantation. It has been reported that reduced internal scarring and fewer adhesions could facilitate the subsequent liver transplantation and thus represent a potential advantage of the laparoscopic technique. SUBJECTS AND METHODS: All patients undergoing liver transplantation in our hospital between 2006 to 2008 after a laparoscopic or conventional Kasai procedure were included in this retrospective analysis. Primary outcome measure was duration of liver explantation. Secondary outcome measures were total duration of transplantation, amount of blood transfusion, and need for reoperation within the first year. RESULTS: In total, 19 patients were included: 11 patients after open Kasai and 8 patients after laparoscopic Kasai. There was no significant difference in patient characteristics. The mean duration of liver explantation was comparable in laparoscopic (125±8 minutes) and conventional (116±6 minutes) (P>.05) patients. Moreover, we did not identify any significant difference in the need for blood transfusions, total liver transplantation duration, and need for reoperation. CONCLUSIONS: We did not detect any measurable benefit of laparoscopic compared with conventional portoenterostomy for subsequent liver transplantation. Thus, prevention of adhesion formation and facilitating subsequent liver transplantation are not rationales for laparoscopic Kasai portoenterostomy.

Variable disease progression after successful stem cell transplantation: prospective follow-up investigations in eight patients with Hurler syndrome.

We report the results of a prospective, standardized follow-up programme of eight children (median age at SCT 1.2 yr) with mucopolysaccharidosis (MPS1H, M. Hurler) transplanted using a fludarabine-based SCT. SCT resulted in stable engraftment without transplant-related mortality. All patients are alive, engrafted and in ambulatory care. During follow-up (median five yr, 1.9-8 yr), six of eight showed developmental delay (two severe, two mild/no), all eight had spinal deformities and one received hip surgery for acetabular dysplasia. Hand surgery for carpal tunnel release and trigger digits was required in five of the patients. The cranio-cervical junction was narrowed in four patients, one child having already received surgery. CC was present in all patients prior to SCT. It remained unchanged in seven and regressed in one child. Severe cardiac dysfunction was present in two of the eight children before SCT. Cardiac pump function was normal in six patients and ameliorated in two, while valve abnormalities could be detected in six patients. Currently, transplantation seems no longer the major obstacle for MPS1H patients, but the variable musculoskeletal disease progression after successful SCT remains a challenge. Patients with Hurler syndrome need specialized follow-up care because of their manifold health problems. The standardized follow-up presented here is a step to optimize care for MPS children and their families after SCT.

Platelet concentrates transfusion in cardiac surgery in relation to preoperative point-of-care assessment of platelet adhesion and aggregation.

Platelet dysfunction is an important cause of bleeding early after cardiac surgery. Whole-blood multiple electrode aggregometry (MEA), investigating the adhesion and aggregation of activated platelets onto metal electrodes, has shown correlations with platelet concentrates transfusion in this setting. Platelet activity in vivo is dependent on shear stress, an aspect that cannot be investigated with MEA, but with the cone and plate(let) analyzer (CPA) Impact-R that measures the interaction of platelets and von Willebrand factor (vWF) in whole blood under shear. We hypothesized that preoperative CPA may show better correlation with platelet concentrates transfusion post-cardiac surgery than MEA, since it is dependent on both platelet activity and platelet interaction with vWF multimers. Blood was obtained preoperatively from 30 patients undergoing aorto-coronary bypass (ACB) and 20 patients with aortic valve (AV) surgery. MEA was performed in hirudin-anticoagulated blood. The Impact-R analyses were performed in blood anticoagulated with hirudin, heparin or the standard anticoagulant citrate. For the light microscopy images obtained, the parameter surface coverage (SC) was calculated. Preoperative Impact-R results were abnormally decreased in AV patients and significantly lower than in ACB patients. For the Impact-R analysis performed in citrated blood, no correlation with platelet concentrates transfusion was observed. In contrast, MEA was comparable between the groups and correlated significantly with intraoperative platelet concentrates transfusion in both groups (rho between -0.47 and -0.62, p < 0.05). Multiple electrode aggregometry appeared more useful and easier to apply than CPA for preoperatively identifying patients with platelet concentrates transfusion in cardiac surgery.

Skin impedance correlates to sedation grade, plasma propofol concentrations and bispectral index during a target-controlled infusion of propofol.

BACKGROUND AND OBJECTIVE: Sympathetic activity, measured as changes in electrical skin impedance, may be used to assess the adequacy of general anaesthesia. The aim of this prospective study was to evaluate electrical skin impedance in comparison with bispectral index values and the Observer's Assessment of Alertness and Sedation (OAAS) scale during propofol infusion. METHODS: Electrical skin impedance was measured with an electrosympathicograph. In 22 patients and eight healthy volunteers, anaesthesia was induced and maintained with propofol that was administered via a target-controlled infusion pump at increasing plasma concentrations. Bispectral index, electrosympathicograph and OAAS values were compared at six successive predicted target plasma concentrations (T 1-6: 0, 1.3, 1.7, 2.0, 2.4 and 2.8 microg ml(-1)). RESULTS: The changes in the electrical skin impedance measured with the assistance of the electrosympathicograph correlated with the changes in bispectral index values at each measurement time point and during the whole course (P < 0.0001), with the target plasma propofol concentrations (P < 0.0001), and with the OAAS scale (P < 0.0001). CONCLUSION: The observed correlations between electrical skin impedance, predicted plasma concentrations of propofol and OAAS scale appear to justify further investigation of skin impedance as a depth of anaesthesia monitor.

Lidocaine protects from myocardial damage due to ischemia and reperfusion in mice by its antiapoptotic effects.

BACKGROUND: Perioperative myocardial ischemia poses a vital threat to surgical patients. Means to protect postischemic myocardium are clinically not available. Lidocaine has been demonstrated to exert antiinflammatory pleiotropic effects. The authors set out to test if lidocaine protects ischemic myocardium from reperfusion injury. METHOD: A mouse model of transient coronary artery ligation (30 min) and reperfusion (24 h) was used with animal care committee approval. Infarct size and area-at-risk were determined. Leukocyte recruitment was quantified on immunohistochemical stainings. Apoptosis was assessed using enzyme-linked immunosorbent assay to detect histone modifications and terminal deoxynucleotidyl transferase dUTP nick end labeling assays. Lidocaine effects on leukocyte-endothelial interactions were assessed in vitro by using a parallel-plate flow chamber or static adhesion assays. RESULTS: Infarct size per area-at-risk was reduced by 27% in mice treated with a lidocaine bolus (1 mg/kg) before a continuous infusion (0.6 mg . kg(-1) . h(-1)) during ischemia (P < 0.005). Neutrophil density in the infarct and periinfarct zone was not reduced by lidocaine, although the size of the infiltrated area was. Terminal deoxynucleotidyl transferase dUTP nick end labeling-positive cardiomyocytes and endothelial cells were significantly reduced in the periinfarct zone by lidocaine. In vitro, no effect on leukocyte rolling or firm adhesion to resting or activated endothelium was demonstrable. In vitro, lidocaine reduced cardiomyocyte apoptosis induced by hypoxia and reoxygenation (3h/1h) significantly. Infarct size and in vitro cardiomyocyte apoptosis were likewise reduced when lidocaine bolus and infusion were administered after the ischemic insult. CONCLUSION: Lidocaine exerts cardioprotective effects when administered before or after the ischemic insult. This effect is mediated through an antiapoptotic and not through an antiinflammatory pathway and may be therapeutically exploitable.