Hemispherectomy: a hemidecortication approach and review of 52 cases.

Between 1975 and 1994, 52 hemispherectomies, of which two were anatomical and 50 hemidecortications, were performed at Johns Hopkins Medical Institutions. Eighteen patients were 2 years old or less. There were three perioperative mortalities and one patient died 9 months later from causes not related to surgery. One patient developed hydrocephalus 6 years postsurgery and has been treated effectively. Seizure control and the functional status of each patient were measured as outcome variables. Forty-six (96%) of the surviving patients were seizure free or had reduced seizures as of their last follow-up examination. Twenty-one individuals (44%) were participating in age-appropriate classes or working independently, 18 were classified as semiindependent, and nine children will likely depend on a lifetime of assisted living. The relationships between the outcome variables and the patient's age at surgery, the interval to surgery, and the etiology of the disease were compared. The authors' clinical experiences strongly suggest the importance of a multidisciplinary approach to patient selection and follow-up care. Moreover, anesthetic management of infant surgery is a major component of success.

Emergency management of hypercyanotic crises in tetralogy of Fallot.

We report the case of a 3-month-old girl with tetralogy of Fallot who was resuscitated from a near-fatal hypercyanotic episode (Tet spell). While tetralogy of Fallot is rare (1 in 10,000 live births), failures of diagnosis or management may result in catastrophic outcomes for an eminently survivable condition. An understanding of the pathophysiology of hypercyanotic spells will allow the emergency specialist to understand and apply a treatment option--compression of the abdominal aorta--not previously reported in the emergency medicine literature.

Reducing perioperative pain and anxiety.

As outpatient surgery becomes the norm, pediatricians are increasingly involved in preparing children--and their families--for the experience. This anesthesiologist's approach can help you guide your patients toward a smooth recovery.

Effects of hypoxia on interleukin-2 mRNA expression by T lymphocytes.

OBJECTIVE: To investigate the effects of hypoxia on T-lymphocyte expression of IL-2 messenger RNA (mRNA), after cell activation with phorbol ester and ionomycin. DESIGN: Prospective, controlled, cellular trial. SETTING: University research laboratory. SUBJECTS: EL4.6.1 cells, a murine T-cell lymphoma line. INTERVENTIONS: Tissue culture media was deoxygenated and flushed continuously with 100% helium to maintain a PO2 of 30 to 40 torr (< 40 torr [< 5.3 kPa]), or flushed with 10% oxygen/90% helium to maintain a PO2 of 45 to 55 torr (> 45 torr [> 6.0 kPa]). The pH was maintained between 7.3 and 7.6. The media was inoculated with EL4 cells. Aliquots of cells were obtained at intervals and divided into two groups: an immediate group, stimulated immediately, and an overnight group that was returned to normal incubator conditions of 5% CO2/humidified room air for 18 hrs before stimulation. MEASUREMENTS AND MAIN RESULTS: Gas tension, pH, cell count, and viability were determined for each aliquot. Cells were stimulated with phorbol myristate acetate and ionomycin for 4 hrs, at which time levels of interleukin-2 (IL-2) messenger RNA (mRNA) and gamma actin mRNA were measured by solution hybridization and enzyme immunoassay. The results were expressed as IL-2 mRNA/gamma actin mRNA ratio, normalised to baseline room air values. Cell viability and housekeeping functions (gamma actin mRNA expression) were unaffected by hypoxia. Cells exposed to a PO2 of < 40 torr (< 5.3 kPa) demonstrated a dramatic reduction in IL-2 mRNA expression with increasing duration of hypoxia. These effects persisted after an 18-hr recovery period. There was no effect on IL-2 mRNA expression when cells were exposed to a PO2 of > 45 torr (> 6.0 kPa). CONCLUSIONS: The regulation of IL-2 transcription in the T lymphocyte appears to be exquisitely sensitive to changes in oxygen tension. Exposure to a PO2 of < 40 torr (< 5.3 kPa) causes prolonged impairment of IL-2 mRNA expression. IL-2 is an important growth factor for T and NK cells, and plays a pivotal role in the regulation of the host's immune response. The long-lasting effects of brief hypoxic exposure may, in part, explain the critically ill patient's predisposition to infectious complications.

Perioperative approach to children.

There has been a tremendous amount of progress in the perioperative approach to the child since Levy wrote "Psychic trauma of operations in children and a note on combat neurosis" nearly 50 years ago. Recognition of prolonged behavioral derangements following the anesthetic-surgical-hospital experience and the prominent role that the parent and physician play in modifying these have dramatically changed the contemporary pediatric perioperative care. Of paramount importance is the psychological preparation of family and child. With increasing outpatient or same-day admission surgery and free-standing surgical centers, preoperative preparation will, of necessity, increasingly become the responsibility of the pediatrician.