CE: Original Research: The Efficacy and Safety of an RN-Driven Ketamine Protocol for Adjunctive Analgesia During Burn Wound Care.

: Objective: Traditional analgesic regimens often fail to control the severe pain patients experience during burn wound care, and the drugs are frequently administered at doses that can cause oversedation and respiratory depression. Ketamine may be an ideal agent for adjunctive analgesia in such patients because of its unique mechanism of action and lack of association with respiratory depression. This study evaluated the efficacy and safety of a critical care RN-driven protocol for IV ketamine administration during burn wound care. METHODS: This retrospective cohort study examined all adult burn patients who received ketamine as part of a critical care RN-driven ketamine protocol for burn wound care from September 2011 through September 2013. Efficacy outcomes were opioid and benzodiazepine requirements (expressed as fentanyl and midazolam equivalents, respectively) four hours after ketamine administration compared with four hours before such administration. Safety parameters assessed were neurologic, hemodynamic, and respiratory effects. RESULTS: Twenty-seven patients received 56 ketamine doses as part of this protocol; the mean (SD) dose was 0.75 (0.35) mg/kg. Twenty patients (74%) were male and seven (26%) were female; mean age was 39 years. The average percentage of total body surface area burned was 23.4%. With the protocol, opioid and benzodiazepine requirements were reduced by 29% and 20%, respectively. One patient experienced an episode of oversedation after concomitant administration of ketamine and fentanyl. No patients experienced neurologic or hemodynamic complications following ketamine administration. CONCLUSIONS: The administration of ketamine during burn wound care using a critical care RN-driven protocol was associated with reduced opioid and benzodiazepine requirements and few adverse effects. Prospective studies are needed to investigate additional patient outcomes and the independent administration of ketamine by critical care RNs.

Hand-to-hand coupling and strategies to minimize unintentional energy transfer during laparoscopic surgery.

BACKGROUND: Energy-based devices are used in nearly every laparoscopic operation. Radiofrequency energy can transfer to nearby instruments via antenna and capacitive coupling without direct contact. Previous studies have described inadvertent energy transfer through bundled cords and nonelectrically active wires. The purpose of this study was to describe a new mechanism of stray energy transfer from the monopolar instrument through the operating surgeon to the laparoscopic telescope and propose practical measures to decrease the risk of injury. METHODS: Radiofrequency energy was delivered to a laparoscopic L-hook (monopolar "bovie"), an advanced bipolar device, and an ultrasonic device in a laparoscopic simulator. The tip of a 10-mm telescope was placed adjacent but not touching bovine liver in a standard four-port laparoscopic cholecystectomy setup. Temperature increase was measured as tissue temperature from baseline nearest the tip of the telescope which was never in contact with the energy-based device after a 5-s open-air activation. RESULTS: The monopolar L-hook increased tissue temperature adjacent to the camera/telescope tip by 47 ± 8°C from baseline (P < 0.001). By having an assistant surgeon hold the camera/telescope (rather than one surgeon holding both the active electrode and the camera/telescope), temperature change was reduced to 26 ± 7°C (P < 0.001). Alternative energy devices significantly reduced temperature change in comparison to the monopolar instrument (47 ± 8°C) for both the advanced bipolar (1.2 ± 0.5°C; P < 0.001) and ultrasonic (0.6 ± 0.3°C; P < 0.001) devices. CONCLUSIONS: Stray energy transfers from the monopolar "bovie" instrument through the operating surgeon to standard electrically inactive laparoscopic instruments. Hand-to-hand coupling describes a new form of capacitive coupling where the surgeon's body acts as an electrical conductor to transmit energy. Strategies to reduce stray energy transfer include avoiding the same surgeon holding the active electrode and laparoscopic camera or using alternative energy devices.

Single-incision laparoscopic surgery increases the risk of unintentional thermal injury from the monopolar "Bovie" instrument in comparison with traditional laparoscopy.

BACKGROUND: Single-incision laparoscopic surgery (SILS) places multiple instruments in close, parallel proximity, an orientation that may have implications in the production of stray current from the monopolar "Bovie" instrument. The purpose of this study was to compare the energy transferred during SILS compared to traditional four-port laparoscopic surgery (TRD). METHOD: In a laparoscopic simulator, instruments were inserted via SILS or TRD setup. The monopolar generator delivered energy to a laparoscopic L-hook instrument for 5-s activations on 30-Watts coag mode. The primary outcome (stray current) was quantified by measuring the heat of liver tissue held adjacent to the non-electrically active 10-mm telescope tip and Maryland grasper in both the SILS and TRD setups. To control for the potential confounder of stray energy coupling via wires outside the surgical field, the camera cord and active electrode wires were oriented parallel or completely separated. RESULTS: SILS and TRD setups create similar amounts of stray current as measured by increased tissue temperature at the non-electrically active telescope tip (41 ± 12 vs. 39 ± 10 °C; p = 0.71). Stray current was greater in SILS compared to TRD at the tip of the non-electrically active Maryland forceps (38 ± 9 vs. 20 ± 10 °C; p < 0.01). Separation of the active electrode and camera cords did not change the amount of stray energy in the SILS orientation for either telescope (39 ± 10 °C bundled vs. 36 ± 10 °C separated; p = 0.40) or grasper (38 ± 9 °C bundled vs. 34 ± 11 °C separated; p = 0.19) but did in the TRD orientation (41 ± 12 bundled vs. 24 ± 10 separated; p < 0.01). When SILS was compared to TRD with the cords separated, SILS increased stray energy at both the telescope tip and grasper tip (36 ± 10 vs. 24 ± 10 °C; p < 0.01 and 34 ± 11 vs. 17 ± 8 °C; p < 0.01). CONCLUSION: SILS increases stray energy transfer nearly twice as much as TRD with the use of the monopolar instrument. Strategies to mitigate the amount of stray energy in the TRD setup such as separation of the active electrode and camera cords are not effective in the SILS setup. These practical findings should enhance surgeons using the SILS approach of increased stray energy that could result in injury.

An Effective Curriculum for Focused Assessment Diagnostic Echocardiography: Establishing the Learning Curve in Surgical Residents.

BACKGROUND: Simulation training and competency-based assessment are the evolving standard for surgical education. The Focused Assessment Diagnostic Echocardiography (FADE) examination is a bedside, limited transthoracic ultrasound to assess cardiac function, anatomy, and volume status. FADE can be used to noninvasively evaluate and guide resuscitation of critically ill patients. The purpose of this study was to determine the learning curve for surgical residents to perform and interpret the results of the FADE examination using simulation and competency-based assessment. METHODS: Novice surgical residents were enrolled in a FADE curriculum prospectively. The curriculum involved 4 successive sessions of 45 minutes of simulation followed by 5 FADE examinations on surgical intensive care unit patients. Examination performance was evaluated using a standardized scoresheet (15 points total) and plotted by session. Independent and paired t test and linear regression were used for statistical analysis. RESULTS: In total, 20 individuals completed 390 FADE examinations. Performance increased from 45 ± 13% accuracy in the first session to 89 ± 9% accuracy in the fourth session (p < 0.001 between all sessions). Accuracy at central venous pressure prediction reached 88% by the final session (p < 0.001). Independent predictors of score included proportion of curriculum completed (odds ratio = 2.2; 95% confidence interval: 2.0-2.3; p < 0.001) and examination of thoracic surgery patients (odds ratio = 0.2; 95% confidence interval: 0.01-0.4; p = 0.04). CONCLUSION: Surgical residents are able to achieve proficiency at performing and interpreting the results of FADE examination and predicting central venous pressure. Residents achieved mastery of evaluation of ventricular function, pericardial assessment, and volume status after 4 training sessions. The ability to teach surgical residents the use of the FADE examination can guide resuscitation without invasive monitoring.

Structured simulation improves learning of the Fundamental Use of Surgical Energy™ curriculum: a multicenter randomized controlled trial.

BACKGROUND: Energy devices can result in devastating complications to patients. Yet, they remain poorly understood by trainees and surgeons. A single-institution pilot study suggested that structured simulation improves knowledge of the safe use of electrosurgery (ES) among trainees (Madani et al. in Surg Endosc 28(10):2772-2782, 2014). The purpose of this study was to estimate the extent to which the addition of this structured bench-top simulation improves ES knowledge across multiple surgical training programs. METHODS: Trainees from 11 residency programs in Canada, the USA and UK participated in a 1-h didactic ES course, based on SAGES' Fundamental Use of Surgical Energy™ (FUSE) curriculum. They were then randomized to one of two groups: an unstructured hands-on session where trainees used ES devices (control group) or a goal-directed hands-on training session (Sim group). Pre- and post-curriculum (immediately and 3 months after) knowledge of the safe use of ES was assessed using separate examinations. Data are expressed as mean (SD) and N (%), *p < 0.05. RESULTS: A total of 289 (145 control; 144 Sim) trainees participated, with 186 (96 control; 90 Sim) completing the 3-month assessment. Baseline characteristics were similar between the two groups. Total score on the examination improved from 46% (10) to 84% (10)* for the entire cohort, with higher post-curriculum scores in the Sim group compared with controls [86% (9) vs. 83% (10)*]. All scores declined after 3 months, but remained higher in the Sim group [72% (18) vs. 64% (15)*]. Independent predictors of 3-month score included pre-curriculum score and participation in a goal-directed simulation. CONCLUSIONS: This multi-institutional study confirms that a 2-h curriculum based on the FUSE program improves surgical trainees' knowledge in the safe use of ES devices across training programs with various geographic locations and resident volumes. The addition of a structured interactive bench-top simulation component further improved learning.

Unintended stray energy from monopolar instruments: beware the dispersive electrode cord.

BACKGROUND: The monopolar instrument emits stray radiofrequency energy from its cord when activated. This is a source of unintended thermal injury to patients. Stray energy emitted from the dispersive electrode cord has not been studied. The purpose of this study was to determine whether, and to what extent, the dispersive electrode cord contributes to unintentional energy transfer and describe practical steps to minimize risk. METHODS: In a laparoscopic simulator, a monopolar generator delivered radiofrequency energy to an L-hook. Thermal imaging quantified the change in tissue temperature nearest to the tip of a non-electrical instrument following activation. The orientation of the dispersive electrode cord was varied relative to other instruments. RESULTS: When the dispersive electrode cord is parallel to the camera cord, tissue temperature increased at the telescope tip by 46 ± 6 °C from baseline (p < 0.001). Similar heat was generated when the camera cord was oriented parallel to the active electrode cord (46 ± 6 vs. 48 ± 7 °C, respectively, p = 0.48). Adding a second dispersive electrode decreased the temperature change (46 ± 6 vs. 25 ± 9 °C, p < 0.001). Temperature increase was greater with coagulation versus cut mode (33 ± 7 vs. 22 ± 6 °C, p < 0.001). CONCLUSION: Stray energy emitted from the dispersive electrode cord heats tissue >40 °C via antenna coupling; the same magnitude as the active electrode cord. Practical steps to minimize stray energy transfer include avoiding orienting the dispersive electrode cord in parallel with other cords, adding a second dispersive electrode, and using low-voltage cut mode.

Surgical Risk and Comorbidity in Older Urologic Patients.

Almost two-thirds of urology operations are performed in patients 65 years and older. Older adults are at higher risk for complications and mortality compared with their younger counterparts. There are 2 primary methods to quantify surgical risk in these patients, frailty measurement and organ/comorbidity-based surgical risk calculators. A frailty assessment can be used to independently forecast the risk of postoperative complications. A paradigm shift in the preoperative assessment of the geriatric patient has occurred, which emphasizes the evaluation of frailty over more traditional surgical risk assessment, which uses comorbidities and single end-organ dysfunction to define risk.

Separating the Laparoscopic Camera Cord From the Monopolar "Bovie" Cord Reduces Unintended Thermal Injury From Antenna Coupling: A Randomized Controlled Trial.

OBJECTIVE(S): The monopolar "Bovie" is used in virtually every laparoscopic operation. The active electrode and its cord emit radiofrequency energy that couples (or transfers) to nearby conductive material without direct contact. This phenomenon is increased when the active electrode cord is oriented parallel to another wire/cord. The parallel orientation of the "Bovie" and laparoscopic camera cords cause transfer of energy to the camera cord resulting in cutaneous burns at the camera trocar incision. We hypothesized that separating the active electrode/camera cords would reduce thermal injury occurring at the camera trocar incision in comparison to parallel oriented active electrode/camera cords. METHODS: In this prospective, blinded, randomized controlled trial, patients undergoing standardized laparoscopic cholecystectomy were randomized to separated active electrode/camera cords or parallel oriented active electrode/camera cords. The primary outcome variable was thermal injury determined by histology from skin biopsied at the camera trocar incision. RESULTS: Eighty-four patients participated. Baseline demographics were similar in the groups for age, sex, preoperative diagnosis, operative time, and blood loss. Thermal injury at the camera trocar incision was lower in the separated versus parallel group (31% vs 57%; P = 0.027). CONCLUSIONS: Separation of the laparoscopic camera cord from the active electrode cord decreases thermal injury from antenna coupling at the camera trocar incision in comparison to the parallel orientation of these cords. Therefore, parallel orientation of these cords (an arrangement promoted by integrated operating rooms) should be abandoned. The findings of this study should influence the operating room setup for all laparoscopic cases.

Surgical Energy-Based Device Injuries and Fatalities Reported to the Food and Drug Administration.

BACKGROUND: Energy-based devices are used in virtually every operation. Our purposes were to describe causes of energy-based device complications leading to injury or death, and to determine if common mechanisms leading to injury or death can be identified. STUDY DESIGN: The FDA's Manufacturer and User Facility Device Experience (MAUDE) database was searched for surgical energy-based device injuries and deaths reported over 20 years (January 1994 to December 2013). Device-related complications were recorded and analyzed. RESULTS: We analyzed 178 deaths and 3,553 injuries. Common patterns of complications were: thermal burns, 63% (n = 2,353); hemorrhage, 17% (n = 642); mechanical failure of device, 12% (n = 442); and fire, 8% (n = 294). Events were identified intraoperatively in 82% (3,056), inpatient postoperatively in 9% (n = 351), and after discharge in 9% (n = 324). Of the deaths, 12% (n = 22) occurred after discharge home. Common mechanisms for thermal burn injuries were: direct application, 30% (n = 694); dispersive electrode burn, 29% (n = 657); and insulation failure, 14% (n = 324). Thermal injury was the most common reason for death (39%, n = 70). The mechanism for these thermal injuries was most frequently direct application (84%, n = 59, p < 0.001 vs all other mechanisms). Fires were most common with monopolar "Bovie" instruments (88%, n = 258, p < 0.001 vs all other devices) when they were used in head and neck operations (66%, n = 193, p < 0.001 vs all other locations). CONCLUSIONS: Complications due to energy-based devices occur from 4 main causes: thermal burn, hemorrhage, mechanical failure, and fire. Thermal direct application injuries are the most common reason for both injury and death.

Antenna coupling explains unintended thermal injury caused by common operating room monitoring devices.

INTRODUCTION: Unintended thermal injury from patient monitoring devices (eg, electrocardiogram pads, neuromonitoring leads) results in third-degree burns. A mechanism for these injuries is not clear. The monopolar "bovie" emits radiofrequency energy that transfers to nearby, nonelectrically active cables or wires without direct contact by capacitive and antenna coupling. The purpose of this study was to determine if, and to what extent, radiofrequency energy couples to common patient monitoring devices. MATERIALS AND METHODS: In an ex vivo porcine model, monopolar radiofrequency energy was delivered to a handheld "bovie" pencil. Nonelectrically active neuromonitoring and cardiac-monitoring leads were placed in proximity to the monopolar pencil and its cord. Temperature changes of tissue touched by the monitoring lead were measured using a thermal camera immediately after a 5-second activation. The energy-device cords were then separated by 15 cm, the power was reduced from 30 W coag to 15 W coag and different cord angulation was tested. An advanced bipolar device, a plasma-based device, and an ultrasonic device were also tested at standard settings. RESULTS: The neuromonitoring lead increased tissue temperature at the insertion site by 39 ± 13°C (P<0.001) creating visible char at the skin. The electrocardiogram lead raised tissue temperature by 1.3 ± 0.5°C (P<0.001). Decreasing generator power from 30 W to 15 W and separating the bovie cord from the neuromonitoring cord by 15 cm significantly reduced the temperature change (39 ± 13°C vs. 26±5°C; P<0.001 and 39 ± 13°C vs. 10 ± 5°C; P<0.001, respectively). Lastly, monopolar energy increased tissue temperatures significantly more than argon beam energy (34 ± 15°C), advanced bipolar energy (0.2 ± 0.4°C), and ultrasonic energy (0 ± 0.3°C) (all P<0.001). CONCLUSIONS: Stray energy couples to commonly used patient monitoring devices resulting in potentially significant thermal injury. The handheld bovie cord transfers energy via antenna coupling to neuromonitoring leads that can raise tissue temperatures over 100°F (39°C) using standard settings. The most effective ways to decrease this energy coupling is to reduce generator power, increase the separation between wires, or utilize lower voltage energy devices such as ultrasonic or bipolar energy.

Electromagnetic interference caused by common surgical energy-based devices on an implanted cardiac defibrillator.

BACKGROUND: Surgical energy-based devices emit energy, which can interfere with other electronic devices (eg, implanted cardiac pacemakers and/or defibrillators). The purpose of this study was to quantify the amount of unintentional energy (electromagnetic interference [EMI]) transferred to an implanted cardiac defibrillator by common surgical energy-based devices. METHODS: A transvenous cardiac defibrillator was implanted in an anesthetized pig. The primary outcome measure was the average maximum EMI occurring on the implanted cardiac device during activations of multiple different surgical energy-based devices. RESULTS: The EMI transferred to the implanted cardiac device is as follows: traditional bipolar 30 W .01 ± .004 mV, advanced bipolar .004 ± .003 mV, ultrasonic shears .01 ± .004 mV, monopolar Bovie 30 W coagulation .50 ± .20 mV, monopolar Bovie 30 W blend .92 ± .63 mV, monopolar instrument without dispersive electrode .21 ± .07 mV, plasma energy 3.48 ± .78 mV, and argon beam coagulator 2.58 ± .34 mV. CONCLUSION: Surgeons can minimize EMI on implanted cardiac defibrillators by preferentially utilizing bipolar and ultrasonic devices.

Effect of radiofrequency energy emitted from monopolar "Bovie" instruments on cardiac implantable electronic devices.

BACKGROUND: The monopolar "Bovie" instrument emits radiofrequency energy that can disrupt the function of other implanted electronic devices through a phenomenon termed electromagnetic interference. The purpose of this study was to quantify the electromagnetic interference occurring on cardiac implantable devices (CIEDs) resulting from monopolar instrument use in common, modifiable clinical scenarios. STUDY DESIGN: Three anesthetized pigs underwent CIED placement (1 pacemaker and 2 defibrillators). Electromagnetic interference was quantified when changing the monopolar instrument parameters of generator power, generator mode, surgical technique, orientation of active electrode cord, pathway of current vector, and proximity of active electrode to the CIED. RESULTS: Monopolar instrument parameters that decreased the electromagnetic interference occurring on the CIED included decreasing generator power from 60 W to 30 W (p < 0.001), using cut mode rather than coag mode (p < 0.001), using desiccation technique rather than fulguration technique (p < 0.001), orienting the active electrode cord from the feet rather than across the chest wall (p < 0.001), and avoiding the current vector from crossing the CIED system (p < 0.001). Increasing the distance between the active electrode tool and the CIED system decreased electromagnetic interference occurring on the CIED in a dose-response fashion up to a distance of 10 cm (ANOVA, p < 0.001), after which the magnitude of electromagnetic interference remained constant. CONCLUSIONS: Electromagnetic interference occurring on CIEDs resulting from monopolar instruments is minimized by decreasing generator power, using cut mode, using desiccation technique, orienting the active electrode cord from the feet, avoiding the current vector for crossing the CIED system, and increasing the distance between the active electrode and the CIED. Surgeons and operating room staff can minimize electromagnetic interference on CIEDs during monopolar instrument use by accounting for these modifiable clinical factors.

Blend mode reduces unintended thermal injury by laparoscopic monopolar instruments: a randomized controlled trial.

BACKGROUND: The purpose of this study was to compare histologic evidence of thermal injury at the epigastric and umbilical incisions after elective laparoscopic cholecystectomy performed using the monopolar "Bovie" instrument set on the higher voltage coag mode versus the lower voltage blend mode. We hypothesized that the higher voltage coag mode would create more unintended thermal tissue injury at the epigastric trocar's incision. METHODS: A prospective blinded randomized controlled trial of patients undergoing elective laparoscopic cholecystectomy was performed. Patients were randomized to have their operation performed with the monopolar instrument set at 30 W on either the coag mode or the blend mode. Immediately at the end of the operation, a biopsy sample of skin was obtained from the lower edge of the epigastric incision (through which the monopolar instrument was inserted) and the umbilical incision (through which the camera/telescope was inserted). The outcomes measured were histologic evidence of thermal injury at the epigastric and umbilical incisions (determined by a blinded pathologist). RESULTS: Forty patients were randomized (20 per group). Baseline demographics in the two groups were similar for age, gender, body mass index, preoperative diagnosis, operative time, and blood loss. Unintentional thermal injury was found at 20 % of epigastric incisions and 35 % of umbilical incisions in the total group. The incidence of thermal injury was higher after operations using the coag mode compared to the blend mode at both the epigastric (35 vs. 5 %; p = 0.044) and umbilical (55 vs. 15 %; p = 0.019) trocar incisions. CONCLUSIONS: Radiofrequency energy from the monopolar Bovie instrument causes unintentional thermal injury to skin adjacent to the epigastric and umbilical trocar incisions. The incidence of thermal injury was reduced by using the lower voltage blend mode compared to the coag mode at both the epigastric and umbilical trocar incisions. REGISTRATION NUMBER: NCT016648060 ( www.clinicaltrials.gov ).

Sexual dimorphism in hematocrit response following red blood cell transfusion of critically ill surgical patients.

The change in hematocrit (ΔHct) following packed red blood cell (pRBCs) transfusion is a clinically relevant measurement of transfusion efficacy that is influenced by post-transfusion hemolysis. Sexual dimorphism has been observed in critical illness and may be related to gender-specific differences in immune response. We investigated the relationship between both donor and recipient gender and ΔHct in an analysis of all pRBCs transfusions in our surgical intensive care unit (2006-2009). The relationship between both donor and recipient gender and ΔHct (% points) was assessed using both univariate and multivariable analysis. A total of 575 units of pRBCs were given to 342 patients; 289 (49.9%) donors were male. By univariate analysis, ΔHct was significantly greater for female as compared to male recipients (3.81% versus 2.82%, resp., P < 0.01). No association was observed between donor gender and ΔHct, which was 3.02% following receipt of female blood versus 3.23% following receipt of male blood (P = 0.21). By multivariable analysis, recipient gender remained associated significantly with ΔHct (P < 0.01). In conclusion, recipient gender is independently associated with ΔHct following pRBCs transfusion. This association does not appear related to either demographic or anthropomorphic factors, raising the possibility of gender-related differences in recipient immune response to transfusion.

The age of transfused blood predicts hematocrit response among critically ill surgical patients.

BACKGROUND: In vitro data suggest that erythrocytes undergo storage time-dependent degradation, eventuating in hemolysis. We hypothesize that transfusion of old blood, as compared with newer blood, results in a smaller increment in hematocrit. METHODS: We performed an analysis of packed red blood cell transfusions administered in the surgical intensive care unit. Age of blood was analyzed as continuous, dichotomized at 14 days (old vs new), and grouped by weeks old. RESULTS: A total of 136 U of packed red blood cells were given to 52 patients; 110 (80.9%) were 14 days old or more. A linear, inverse correlation was observed between the age of blood and the increment in hematocrit (r(2) = -.18, P = .04). The increment in hematocrit was greater after transfusion of new as compared with old blood (5.6% vs 3.5%, respectively; P = .005). A linear relationship also was observed between the age of transfused blood in weeks and the increment in hematocrit (P = .02). CONCLUSIONS: There is an inverse relationship between the age of blood and the increment in hematocrit. The age of blood should be considered before transfusion of surgical patients with intensive care unit anemia.

Intramedullary spinal cord astrocytomas in children.

BACKGROUND: Intramedullary spinal cord astrocytomas are uncommon tumors in childhood. There is little information on therapy and outcome of astrocytomas in this location. PROCEDURE: A retrospective review was performed for the 10 children who were treated between 1996 and 2003 for spinal cord astrocytomas in our institution. Only one had metastatic disease. All ten patients underwent surgical resection, nine partial and one total. Eight had low-grade tumors, and two high-grade tumors. Two had surgery only, four had chemotherapy only, two had radiation only, and two had both radiation and chemotherapy. RESULTS: Progression free survival was 58% and survival was 68% at 4 years. Four patients had disease progression, of which three died. Both children with high-grade astrocytomas died. Two of eight of the children with low-grade astrocytomas of the cord recurred, one having received radiation as initial therapy and the other chemotherapy. The child, who relapsed after radiation, had a spastic quadriplegia from radiation myelitis and no salvage therapy was attempted. The four patients, all with low-grade astrocytomas, who treated with chemotherapy alone, received carboplatin and vincristine. Of these four, three are in continuous remission and one relapsed, but was salvaged with radiation. CONCLUSIONS: Chemotherapy and radiation did not benefit those with high-grade astrocytomas of the spinal cord. Good outcomes can be achieved by conservative surgery for low-grade astrocytomas of the cord when adjuvant therapy is given. Carboplatin and vincristine appeared to be effective, safe therapy for those with low-grade astrocytomas of the cord.