Impaired cerebral autoregulation and 6-month outcome in children with severe traumatic brain injury: preliminary findings.

The objective of this study was to describe the incidence of impaired cerebral autoregulation and to describe the relationship between impaired cerebral autoregulation and outcome after severe pediatric traumatic brain injury (TBI). We prospectively examined cerebral autoregulation in 28 children

Cerebral autoregulation in children during sevoflurane anaesthesia.

INTRODUCTION: Little is known about cerebral autoregulation in children. The aim of this study was to examine cerebral autoregulation in children. METHODS: Cerebral autoregulation testing was performed during less than 1 MAC sevoflurane anaesthesia in children (from 6 months to 14 yr) and in adults (18-41 yr). Mean middle cerebral artery flow velocities (V(MCA)) were measured using transcranial Doppler ultrasonography. Mean arterial pressure (MAP) was increased to whichever was greater: 20% above baseline or (i) 80 mm Hg for less than 9 yr, (ii) 90 mm Hg for 9-14 yr, and (iii) 100 mm Hg for adults. Cerebral autoregulation was considered intact if the autoregulatory index was > or =0.4. RESULTS: There were 13 subjects less than 2 yr old (Group 1), 13 subjects 2-5 yr (Group II), 14 subjects 6-9 yr (Group III), 12 subjects 10-14 yr (Group IV), and 12 adults (Group V; control group). All subjects had an autoregulatory index > or =0.4. There was no difference in autoregulatory index between children in Groups I-IV or between children and adults. DISCUSSION: We found no age-related differences in autoregulatory capacity during low-dose sevoflurane anaesthesia. We report no differences in autoregulatory capacity between children and adults.

Dynamic cerebral autoregulation in healthy adolescents.

BACKGROUND: : There is little information on the limits of cerebral autoregulation and the autoregulatory capacity in children. The aim of this study was to compare dynamic cerebral autoregulation between healthy adolescents and adults. METHODS: : Seventeen healthy volunteers 12-17 years (n = 8) and 25-45 years (n = 9) were enrolled in this study. Bilateral mean middle cerebral artery flow velocities (Vmca; (cm/s)) were measured using transcranial Doppler ultrasonography (TCD). Mean arterial blood pressure (MAP) and end-tidal carbon dioxide were measured continuously during dynamic cerebral autoregulation studies. Blood pressure cuffs were placed around both thighs and inflated to 30 mmHg above the systolic blood pressure for 3 min and then rapidly deflated, resulting in transient systemic hypotension. The change of Vmca to change in MAP constitutes the autoregulatory response, and the speed of this response was quantified using computer model parameter estimation. The dynamic autoregulatory index (ARI) was averaged between the two sides. RESULTS: : Adolescents had significantly lower ARI (3.9 +/- 2.1 vs. 5.3 +/- 0.8; P=0.05), and higher Vmca (75.2 +/- 15.2 vs. 57.6 +/- 15.0; P<0.001) than adults. CONCLUSION: : The autoregulatory index is physiologically lower in normal adolescents 12-17 years of age than in adults.

A comparison of oral transmucosal fentanyl citrate and oral oxycodone for pediatric outpatient wound care.

Analgesia for pediatric burn wound care in the outpatient clinic is constrained by time, personnel, and/or monitoring capabilities, yet may improve patient satisfaction and comfort, clinic efficiency, and patient throughput. The ideal analgesic in this increasingly common setting should be palatable, provide potent, rapid, and brief analgesia, and require minimal appropriate monitoring. Using a placebo-controlled, double-blind design we compared oral transmucosal fentanyl citrate (OTFC, approximately 10 microg/kg) and oral oxycodone (0.2 mg/kg) in 22 pediatric outpatient wound care procedures (ages 5-14 years). Pulse oximetry, vital signs, side effects, patient pain scores, and observer scores for cooperation, anxiety, and sedation were recorded. OTFC and oral oxycodone resulted in similar outcome measures and vital signs, and no significant side effects. The taste of OTFC was preferred. We conclude that OTFC and oral oxycodone are safe and effective analgesics in the setting of monitored outpatient wound care in children, and that OTFC offers the advantage of improved palatability.

The influence of inhaled nitric oxide on cerebral blood flow and metabolism in a child with traumatic brain injury.

IMPLICATIONS: The effects of inhaled nitric oxide (INO) on cerebrovascular hemodynamics are not well established. We report no adverse cerebral effects with INO therapy in a child with traumatic brain injury.

Cerebral autoregulation before and after blood transfusion in a child.

The authors present the case of an anemic 22-month-old child undergoing lower extremity surgery in whom the lower limit of cerebral autoregulation was shifted to the right.

Coagulopathy predicts poor outcome following head injury in children less than 16 years of age.

The authors examined the relationship between fibrin degradation products (FDP) and outcome in children with isolated head injury by reviewing the records of 69 children who met the following criteria: (1) less than 16 years of age; (2) diagnosis of isolated head injury and (3) FDP levels. Outcome was evaluated using the following Glasgow Outcome Scale (GOS): 1 = death; 2 = vegetative state; 3 = functionally impaired; 4 = minimal dysfunction; 5 = premorbid level of functioning. Poor outcome was defined as GOS 1-3. Twenty-nine of 33 patients with FDP > 1000 (g/mL had GOS scores < 4 compared to 4/36 patients (11%) with FDP < 1000 microg/mL (Fisher's Exact Probability Test P < .0001). When stratified by GCS, no other prognosticator of outcome was needed when GCS was < 7 and > 12. In patients with GCS 7-12, however, 4/6 with FDP >1000 microg/mL had a poor outcome and all 12 patients with FDP < 1000 microg/mL had a good outcome (P = .004). The authors conclude that FDP > 1000 microg/mL predicts poor outcome in children with isolated head injury. Fibrin degradation products are a strong independent prognosticator of outcome in children when GCS is between 7 and 12.

Radiation therapy for alveolar soft-part sarcoma.

A clinical experience with radiotherapy in 18 patients with alveolar soft-part sarcoma is presented. Adjuvant radiotherapy was associated with prolonged local control in six of six patients without metastatic disease at diagnosis; later one patient relapsed systematically. Meaningful palliation was achieved in all patients with extra-skeletal (and possibly skeletal) metastatic disease. Radiation therapy may be beneficial for patients with alveolar soft-part sarcoma by enhancing local control achieved with limited surgery, by retarding progression of metastatic deposits, and by providing meaningful palliation.