Telemedicine pre-anesthesia evaluation: a randomized pilot trial.

OBJECTIVE: Pre-anesthesia evaluation allows discovery of conditions affecting perioperative planning, but when inadequate it may be associated with delays, cancellations, and preventable adverse events. Not all patients who could benefit will keep appointments. Telemedicine pre-anesthesia evaluation may provide for safe patient care while reducing patient inconvenience and cost. Herein we investigate the impact of telemedicine pre-anesthesia evaluation on perioperative processes. SUBJECTS AND METHODS: This was a single-center prospective randomized trial in 200 adults scheduled for head and neck surgery at Loma Linda University Medical Center, Loma Linda, CA. Consenting patients not meeting criteria for telephone pre-anesthesia evaluation were randomly assigned to the in-person or telemedicine group. The primary outcome measure was inadequate evaluation caused surgical delay or cancellation. Secondary measures included prediction of difficult airway management and concordance of physical examination. RESULTS: After consent, 40 patients met criteria for telephone screening. Five patients canceled surgery, none for inadequate pre-anesthesia evaluation; thus 155 were randomized. Delay occurred in 1 telemedicine patient awaiting results performed outside our system. Missing documentation at the time of the visit was less common for telemedicine. Difficult airway management was predicted equally but had low positive predictive value. Heart and lung examinations were highly concordant with day of surgery documentation. Patients and providers were highly satisfied with both evaluation modalities. CONCLUSIONS: Telemedicine and in-person evaluations were equivalent, with high patient and provider satisfaction. Telemedicine provides potential patient time and cost saving benefits without more day of surgery delay in our system. A prospective trial of patients from multiple surgical specialty clinics is warranted.

Evaluation of pulse cooximetry in patients undergoing abdominal or pelvic surgery.

BACKGROUND: Intraoperative transfusion decisions generally are guided by blood loss estimation and periodic invasive hemoglobin measurement. Continuous hemoglobin measurement by pulse cooximetry (pulse hemoglobin; Rainbow® SET Pulse CO-Oximeter, Masimo Corporation, Irvine, CA) has good agreement with laboratory hemoglobin in healthy volunteers and could aid transfusion decision-making. Because intraoperative physiology may alter performance of this device, this study investigated pulse hemoglobin during surgery. METHODS: Ninety-one adult patients undergoing abdominal or pelvic surgery in which large blood loss was likely were studied. Time-matched pulse hemoglobin measurements were recorded for each intraoperative arterial hemoglobin measurement obtained. Agreement between measurements was assessed by average difference (mean ± SD, g/dl), linear regression, and multiple measures Bland-Altman analysis. RESULTS: The average difference between 360 time-matched measurements (bias) was 0.50 ± 1.44 g/dl, with wider limits of agreement (-2.3 to 3.3 g/dl) than reported in healthy volunteers. The average difference between 269 paired sequential pulse and arterial hemoglobin changes was 0.10 ± 1.11 g/dl, with half between -0.6 and 0.7 g/dl of each other. The bias was larger in patients with blood loss of more than 1,000 ml; hemoglobin less than 9.0 g/dl; any intraoperative transfusion; or intraoperative decrease in arterial hemoglobin at the time of sampling ≥2 g/dl (all P < 0.001). The range of bias was narrower at deeper anesthesia (P < 0.001). CONCLUSIONS: Evaluation of the sensor and software version tested suggests that although pulse cooximetry may perform well in ambulatory subjects, in patients undergoing surgery in which large blood loss is likely, an invasive measurement should be used in transfusion decision-making.

A case of autonomically mediated pain due to spinal epidural abscess in an adolescent female.

Spinal epidural abscess (SEA) is a rare disease in children without predisposing risk factors. Atypical presentations of SEA without the classic triad of fever, back pain, and neurological signs, have previously been described. We report an atypical presentation of an acute SEA in a previously healthy adolescent female. This 15-year-old patient presented with right shoulder pain in the absence of the fever, back pain, or long-tract signs; therefore, the diagnosis of the spinal pathology was delayed. Eventually, a thoracic SEA was identified by gadolinium-enhanced magnetic resonance imaging and treated with surgical decompression followed by intravenously administered antibiotics. The patient's course was complicated by chronic headache. Our experience adds to the literature a case that demonstrates the difficulty in diagnosis of atypical presentations of SEA in previously healthy children. In addition, referred or autonomically mediated pain should be considered in unusual pain presentations. Children with significant extremity or abdominal pain should be considered for the possibility of sympathetically mediated pain syndrome due to a thoracic-level spinal cord lesion such as a SEA.

The accuracy of noninvasive and continuous total hemoglobin measurement by pulse CO-Oximetry in human subjects undergoing hemodilution.

BACKGROUND: Total hemoglobin (tHb) is one the most frequently ordered laboratory measurements. Pulse CO-Oximetry™ (Masimo Corp., Irvine, CA) is a multi-wavelength spectrophotometric method for noninvasive and continuous hemoglobin monitoring (SpHb). In this study, we evaluated the accuracy of SpHb compared with laboratory CO-Oximeter measurement of tHb from arterial blood samples in 20 healthy volunteer subjects undergoing hemodilution. METHODS: After enrollment, approximately 500 mL of blood was drawn from subjects through an arterial or venous catheter. Each subject then rapidly received crystalloid i.v. fluid to compensate for the decrease in intravascular volume and reduce the hemoglobin concentration. Subjects received a maximum of 30 mL/kg i.v. fluid. SpHb was continuously monitored and recorded, and serial arterial blood samples were taken during the procedure. SpHb accuracy was analyzed by pairing SpHb and tHb measurements after the arterial blood draw with the resulting tHb test result. Bias, precision, and the average root-mean-square error were calculated. RESULTS: One hundred sixty-five tHb measurements were collected. The average decrease in tHb during the blood removal and hemodilution procedure was 2.4 ± 0.8 g/dL (mean ± SD). The average difference between 335 paired measurements of SpHb and tHb was -0.15 g/dL, 1 SD of the difference was 0.92 g/dL, and the average root-mean-square difference was 0.94 g/dL. The difference between SpHb and tHb was <2.0 g/dL for 97% of the measurements. The difference was <1.5 g/dL for 97% of the measurements when tHb was <10 g/dL. CONCLUSIONS: Pulse CO-Oximetry-based SpHb measurement is accurate within 1.0 g/dL (1 SD) compared with laboratory CO-Oximeter tHb measurement in subjects undergoing hemodilution.

Myasthenia gravis in an adolescent patient presenting to the pediatric emergency department.

Myasthenia gravis is a rare, chronic, autoimmune disorder characterized by postsynaptic dysfunction at the neuromuscular junction. The disease affects more females than males. We describe the case of a 17-year-old female adolescent with recurrent episodes of dysarthria and dysphagia and a history of aspiration pneumonia. A bedside edrophonium (Tensilon) test in our emergency department confirmed the diagnosis of myasthenia gravis.

Acute transient encephalopathy following paclitaxel treatment in an adolescent with a recurrent suprasellar germinoma.

Paclitaxel is an antineoplastic agent that is used in the treatment of a variety of solid tumors. Dose-limiting side effects of myelosuppression and peripheral neuropathy are well known. Paclitaxel has minimal penetration of the blood-brain barrier and central nervous system side effects are rare. However, transient encephalopathy following paclitaxel infusion has been described in adults but not in children. We present the case of a 14-year-old female with a recurrent suprasellar germinoma who developed an acute encephalopathy 4-6 hr following paclitaxel infusion.

Pediatric stroke and methylenetetrahydrofolate reductase polymorphisms: an examination of C677T and A1298C mutations.

Although rare in children, stroke is becoming increasingly recognized as an important cause of morbidity and mortality with an annual incidence of approximately 3 per 100,000 per year. While several studies have documented the underlying mechanisms and pathogenesis related to stroke in adults, including genetic and acquired prothrombotic conditions, the data available on similar conditions in children is limited. Evidence suggests that mutations in methylenetetrahydrofolate reductase (MTHFR) appear to be linked with hyperhomocysteinemia (HHC) and cerebral-thrombotic events in children. While the C677T common missense mutation is the best-characterized MTHFR polymorphism, another common missense mutation, A1298C also exists. A recent study of children demonstrated that the homozygous form of C677T polymorphism occurred two-times as often in those with stroke versus healthy controls. In our retrospective chart review of 33 children seen at Children's Hospital of Orange County from January 1, 2000 to September 30, 2003 with the diagnosis of stroke, we examined both the C677T and A1298C polymorphisms for occurrence and type. In the subset (n=21), which excluded those with a confounding disorder, we observed a significant increase in the frequency of A1298C and C677T homozygosity (0.25 [p=0.01] and 0.20 [p=0.100], respectively); expected rate: (0.06 and 0.08, respectively). Our observed rates of heterozygosity for both MTHFR mutations (0.35 and 0.40, respectively) were consistent with expected rates (0.28 and 0.38, respectively). In all subjects, homocysteine (HC) levels were normal. The results of our study suggest that mutations in MTHFR are associated with pediatric stroke. However, additional studies are required to confirm our findings and to determine if this relationship is causal.