The dicrotic pulse: a common, non-ominous finding after the Ross operation.

We noted a dicrotic pulse in several patients following a Ross operation. Although the etiology of this unique arterial waveform is not completely understood, it has been reported as a sign of low cardiac output and a poor prognosis. We reviewed preoperative echocardiograms and postoperative radial arterial pressure tracings in 33 patients who underwent a Ross procedure between 2000 and 2004. We found a dicrotic pulse to occur commonly (20/33; 61%) following a Ross operation. Moderate to severe preoperative aortic insufficiency was present in 19/20 patients (95%) in whom a dicrotic pulse was noted and in only 3/13 (23%) who did not exhibit a postoperative dicrotic pulse (p<0.001). A dicrotic pulse was not associated with an increased use of vasoactive infusions or longer hospitalization following the Ross operation. The dicrotic pulse should be recognized as a common postoperative finding in Ross patients that does not herald a delayed postoperative convalescence. The mechanism for a dicrotic pulse in these patients is speculative but may result from changes in vascular compliance secondary to chronic aortic insufficiency.

Nalmefene to prevent epidural narcotic side effects in pediatric patients: a pharmacokinetic and safety study.

STUDY OBJECTIVE: To determine the pharmacokinetics and preliminary efficacy of nalmefene in children in preventing epidural-induced narcotic side effects. DESIGN: Double-blind, placebo-controlled study. SETTING: University-affiliated children's hospital. PATIENTS: Thirty-four children (aged 2-12 yrs) undergoing cardiothoracic surgery with epidural anesthesia. INTERVENTIONS: Patients were randomized to receive intravenous bolus nalmefene 1 microg/kg or placebo. MEASUREMENTS AND MAIN RESULTS: Six blood samples (one before nalmefene administration and five from 13 randomly designated time points) from each patient were assayed to determine plasma nalmefene concentrations. Patients were assessed for pain, nausea, vomiting, and urinary retention for 24 hours after administration. Concentration-time data were analyzed by a limited sampling strategy with adult pharmacokinetic parameters used as Bayesian priors. A two-compartment, first-order model was fitted to the data using ADAPT II. Pharmacokinetic parameter estimates in these patients were similar to values reported in adults. The initial disposition half-life (t(1/2alpha)) was 0.36+/-0.11 hour, the terminal elimination half-life (t(1/2beta)) 8.7+/-2.3 hours, clearance 0.729+/-0.172 L/kg/hr, and steady-state volume of distribution 7.21+/-2.49 L/kg. Ability to prevent epidural narcotic-induced side effects could not be documented at the 1-microg/kg dose. No statistically significant differences were noted between study and placebo groups with regard to pain, nausea, vomiting, or urinary retention. CONCLUSION: Nalmefene has similar pharmacokinetics in children as in adults. It was administered safely to these patients and did not produce unmanageable pain.

Analgesia for pediatric thoracostomy tube removal.

Eutectic mixture of local anesthetics (EMLA; Astra Pharmaceuticals, Wayne, PA) has been shown to reduce the pain of blood draws in children. We investigated the use of EMLA versus IV morphine for providing analgesia during chest tube removal (CTR) in children. One hundred twenty pediatric cardiothoracic surgery patients were enrolled. Patients were randomly assigned to receive either morphine (0.1 mg/kg up to 10 mg IV 30 min before CTR) or EMLA cream (5 g per chest tube cutaneously 3 h before CTR). A single, trained observer rated the patient's pain before, during, and after CTR using a 10-cm visual analog scale. The sites were evaluated for adverse effect. Methylhemoglobin levels were monitored in infants. Before CTR, the pain scores of the children who received morphine were rated lower than those who received EMLA (P < 0.01). During CTR, there was no difference in the pain score between the morphine or EMLA group. The change from baseline pain score in the morphine group was significantly larger than in the EMLA group (P < 0.01). We conclude that EMLA is safe and useful for blunting the pain of CTR.

Increased susceptibility to gingival colonization by specific HACEK microbes in children with congenital heart disease.

It is well established that infective endocarditis (IE) involving the HACEK (Hemophilus, Actinobacillus, Cardiobacter, Eikenella, Kingella) group of microbes occurs in patients with congenital heart defects (CHD) and in those with prosthetic grafts. Dental caries and gingival disease have been presumed to be the focus of microbial shedding. The purpose of this study was to determine if children with CHD had a more severe gingival inflammatory condition and harbored the HACEK group of microbes to a greater extent than normal children. Two groups of 12 age and sex matched children were selected for this study. The experimental group consisted of twelve children with CHD, 1-1/2 to 8 years of age. The control group consisted of 12 healthy children 2 to 8 years of age. Each child had a gingival index score recorded as described by Massler. Subgingival cultures were obtained. Gingival samples were cultured for HACEK microbes and total Streptococcus (spp) using standard techniques. Fisher's exact test was performed with significance defined at P < 0.05. Children with CHD had more severe gingival inflammatory index than the control group (P < 0.05). 8/12 CHD patient had Actinobacillus actinomycetemcomitans (A.a.) as compared with 2/12 controls (P < 0.05). Furthermore, all cyanotic CHD patients (4/4) had A.a. whereas, only 2/12 controls did (P < 0.05). 4/12 CHD patients harbored Eikenella corrodens (E.c.) compared to 1/12 controls (N.S.). There was no significant difference in colonization with E.c. or A.a. between cyanotic and acyanotic patients. No significant difference in total Streptococcus (spp) was found between the two groups. This study suggests that children with CHD have a more severe gingival inflammatory index and are colonized with specific HACEK microbes more so than normal children.

Aspiration of a primary tooth in a patient with a tracheostomy.

Aspiration of a foreign object is uncommon in a patient with a tracheostomy. The following case history describes the consequences of failure to diagnose an aspirated object and how the aspiration of an exfoliated tooth can occur despite the presence of a tracheostomy tube. Dentists play an important role in preventing foreign body aspiration in debilitated patients.

Chlorhexidine spray effects on plaque accumulation in developmentally disabled patients.

Chlorhexidine gluconate has been studied as an adjunct to standard oral hygiene techniques in developmentally disabled patients in reducing plaque accumulation. The purpose of this double blind crossover study was to determine the efficacy of two concentrations of chlorhexidine spray (0.12% and 0.06%) on plaque accumulation in developmentally disabled patients. Informed consent was obtained for 8 developmentally disabled patients 12 to 33 years of age. Patients were randomly assigned to one of two groups of four each. One group received twice daily 0.12% chlorhexidine spray while the other received the 0.06% chlorhexidine spray for 30 days, followed by twice daily chlorhexidine spray (0.12% and 0.06%) alternating groups, for a period of 30 days. Final plaque indices were determined. Normal oral hygiene practices continued throughout the study. Significant plaque reduction occurred with the 0.12% and 0.06% spray solutions. No significant differences occurred between the two concentrations. The results of this study suggest that twice daily chlorhexidine spray at a concentration of 0.06% is as effective in reducing plaque accumulation as a 0.12% chlorhexidine concentration.

Suspected inappropriate secretion of antidiuretic hormone in a male with mental retardation.

The syndrome of inappropriate secretion of antidiuretic hormone (SIADH) is a disorder in which a sustained release of antidiuretic hormone occurs because of certain diseases, pharmacological agents, or trauma. Fluid volume expands with a resultant hyponatremia which, depending on the degree, may be asymptomatic or result in death. This case report describes a 38-year-old male in whom SIADH was strongly suspected secondary to Tegretol therapy to control a seizure disorder. Medical consultation is imperative for these patients before administering a fluid challenge during general anesthesia.

Outpatient dental treatment of pediatric patients with malignant hyperthermia: report of three cases.

Malignant hyperthermia is a skeletal muscle disorder thought to be genetically acquired. Inhalation anesthesia presents a dangerous risk to the patient predisposed to the condition.

Pregnancy tumor in a 16-year-old: case report and treatment considerations.

A sixteen-year-old female in the third trimester of pregnancy was evaluated for treatment of a pregnancy granuloma. No surgical treatment was rendered. The patient was given a thorough dental prophylaxis and oral hygiene instructions. The tumor was noted to have decreased in size four weeks post partum. Observation of such lesions in conjunction with standard oral hygiene procedures is warranted in lieu of surgical removal.

Age and sex predilection of unmanageable Hispanic pediatric dental patients.

The Tell-Show-and-Do behavior management technique has been the most frequently utilized method to obtain cooperation from pediatric dental patients. The purpose of this study was to determine the age and sex predilection of unmanageable Hispanic pediatric patients. Five hundred sixteen normal Hispanic pediatric dental patients, ranging in age from three to fourteen years, were introduced to and received dental treatment using only the Tell-Show-and-Do, positive reinforcement, and voice-control behavior-management techniques. The majority of these patients (95.7 percent) were successfully managed. Cooperation was not obtained for twenty-two of these patients (4.3 percent) who ranged in age from three to six years. Uncooperative female patients, three to four years of age, outnumbered three-to-four-year-old uncooperative male patients, by approximately twofold. Explanations for the difference in the lack of cooperation between males and females included lack of parental presence in the operatory, sex of the patient, and maternal anxiety.

Idiopathic myelofibrosis: dental treatment considerations.

Idiopathic myelofibrosis is a myeloproliferative disorder of unknown origin. The bone marrow becomes fibrotic with an associated decrease in hematopoiesis resulting in anemia, bleeding problems, splenomegaly, and other secondary abnormalities. Although idiopathic myelofibrosis is usually diagnosed in middle age, there have been a few reports of the disorder in the pediatric population. This case report documents dental treatment considerations in a 6-year-old female with idiopathic myelofibrosis, severe anemia, and abnormal blood coagulation studies. The patient was successfully treated in a hospital after medical consultation, transfusion of packed red blood cells, and administration of prophylactic antibiotics. Local hemostatic measures following multiple extractions of carious teeth controlled bleeding. No postoperative sequelae occurred.

Conscious sedation and analgesia with rectal ketamine in the Macaca fuscata monkey.

Conscious sedation is commonly utilized in pediatric dentistry. Although opioid analgesics are often employed, patient safety would be enhanced if nonopioid drugs were used. The purpose of this study was to determine if rectal ketamine could produce plasma concentrations that would achieve both conscious sedation and analgesia to gingival needle puncture. Five 2-year-old male Macaca fuscata monkeys were given rectal ketamine at a dosage of 60 mg/kg and 90 mg/kg one week apart. Blood was drawn at selected times after administration, and vital signs, level of sedation, and consciousness were assessed. Plasma ketamine concentrations ranged from 240 to 820 ng/mL and from 390 to 3120 ng/mL after rectal administration at doses of 60 mg/kg and 90 mg/kg, respectively. Two monkeys after the high dose showed analgesia to a gingival needle puncture at plasma ketamine concentrations that ranged from 1390 to 3120 ng/mL. A good level of sedation was consistently observed in four monkeys (80%) following rectal ketamine at a dosage of 90 mg/kg, whereas one monkey showed a consistently good level at a dosage of 60 mg/kg. Sedation and dose were significantly (P less than 0.001) associated with plasma ketamine concentrations; physiologic parameters were not (P greater than 0.05). The results of this study suggest that rectal ketamine can produce plasma concentrations of the drug sufficient to achieve sedation in the monkey. The attainment of concomitant analgesia to a gingival needle puncture was not as predictable.

Traumatic avulsion of the mandibular right primary lateral incisor and cuspid.

Premature loss of the primary mandibular cuspid has been considered rare. When this occurs, however, space maintenance should be considered to prevent distal drifting of the lateral incisor. The purpose of this case report was to document traumatic avulsion of the mandibular right lateral and cuspid. A lingual arch appliance with a spur was fabricated to maintain space and prevent movement of the mandibular incisors. Sequelae of premature loss of primary teeth is presented.

Parotitis in a three-year-old.

Facial swelling cannot routinely be attributed to dento-alveolar infections until a thorough head, neck and oral examination has been completed. Facial swelling from parotitis is not commonly encountered in the pediatric patient. The purpose of this report was to document a case of unilateral parotid gland infection presumably secondary to traumatic obstruction of Stenson's duct. The parotitis resolved following a course of oral penicillin VK and lemon juice to stimulate salivary flow. Several parotid gland disorders which involve facial swelling were discussed.