Spinal anesthesia compared with general anesthesia for neonates with hypertrophic pyloric stenosis. A retrospective study.

BACKGROUND: Studies of spinal anesthesia in children are limited to a reduced group of high-risk patients and it remains relatively underused compared with general anesthesia in this age group in most institutions. In our experience, spinal anesthesia appears to be a good alternative to general anesthesia during pyloromyotomy in neonates and infants. AIMS: The purpose of this study was to retrospectively evaluate respiratory morbidity of spinal anesthesia compared to general anesthesia in infants undergoing pyloromyotomy. METHODS: The University Hospital of Salamanca used spinal or general anesthesia on infants undergoing pyloromyotomy between 2003 and 2017. The primary outcome assessed was the prevalence of apnea. The second one was the prevalence of oxygen saturation below 95%. An analysis was performed using t test or Mann-Whitney U test for continuous variables, and Chi-square for categorical variables. Logistic regression was done to account for differences in demographic and clinical covariates. RESULTS: The study sample consisted of 68 infants and neonates undergoing pyloromyotomy (48 with spinal anesthesia and 20 with general anesthesia). There was a significant difference in apneic episodes after surgery between general (number/percentage = 5/20, 25%) and spinal (number/percentage = 0/48, 0%) groups. Absolute risk reduction is 25% (CI 95%: 6%-44%), P < .001. CONCLUSION: Spinal anesthesia in neonates with hypertrophic pyloric stenosis undergoing pyloromyotomy was a viable alternative to general anesthesia, reducing the respiratory morbidity associated with the latter.

Evaluation of a Mapleson D CPAP system for weaning of mechanical ventilation in pediatric patients.

BACKGROUND: Over the last years, we have used a flow-inflating bag circuit with a nasotracheal or nasopharyngeal tube as an interface to deliver effective CPAP support in infants ("Mapleson D CPAP system"). The primary goal of this study was to assess the usefulness of the "Mapleson D CPAP system" for weaning of mechanical ventilation (MV) in infants who received MV over 24 h. MATERIALS AND METHODS: All infants who received MV for more than 24 h in the last year were enrolled in the study. Demographic data included age, gender, weight, and admission diagnosis. Heart rate, respiratory rate, blood pressure, and oxygen saturation were measured during MV, 2 h after the nasotracheal Mapleson D CPAP system and 2 h after extubation. Patients were classified into two groups: patients MV more than 48 h, and patients with MV fewer than 48 h. P < 0.05 was considered statistically significant. RESULTS: A total of 50 children were enrolled in the study, with a median age was 34 ± 45 months (range, 1-59 months) and median weight was 11.98 ± 9.31 kg (range, 1-48 kg). Median duration of MV was 480 h (range, 2-570). There were no significant differences in PaO2, PaCO2, and pH among MV, 2 h after the nasotracheal Mapleson D CPAP system and 2 h after extubation and spontaneous ventilation with the nasopharyngeal Mapleson D CPAP system or with nasal prongs. The overall extubation failure rate was 26% (n = 13). Weight and age were significantly associated with extubation failure (P < 0.05). CONCLUSIONS: The Mapleson D CPAP system, in our opinion, is a useful and safe alternative to more complex and expensive noninvasive CPAP and BiPAP weaning from MV in infants.

In vitro thromboelastometric evaluation of the efficacy of frozen platelet transfusion.

BACKGROUND: Although frozen platelets are extensively used in remote locations and military environments, scientific evidence of their efficacy is scarce. The objective of this study was to evaluate the in vitro hemostatic efficacy of frozen versus fresh platelet transfusions by rotational thromboelastometry (ROTEM) to ascertain whether the freezing and thawing process impaired platelet contribution to clot strength. METHODS: An experimental study was performed using platelet in vitro transfusions. Blood samples were collected from 12 patients with non-autoimmune thrombocytopenia. The samples were each transfused with one of 6 pairs of fresh platelet concentrates and platelet concentrates frozen with dimethylsulfoxyde. Optical platelet counts, coagulation studies and ROTEM (EXTEM and FIBTEM) were performed for the baseline and the post-transfusion samples. RESULTS: Only fresh platelet transfusions significantly increased the EXTEM maximum clot firmness (MCF) and maximum clot elasticity (MCE) over baseline (p<0.001), achieving values within the normal range. The frozen platelet contribution to MCE was negligible. However, the EXTEM clotting time (CT) was significantly (p<0.001) shorter after the frozen platelet transfusion compared with the fresh platelet transfusion. The EXTEM clot formation time (CFT) was significantly shortened after the transfusion of fresh platelets (p=0.002). CONCLUSION: The ROTEM analysis assessment indicates a dual effect in frozen platelet transfusion: it produces a hypercoagulable state (shortening of CT), and a second, more predominant effect of frozen platelets' functionality impairment compared with fresh platelets (shorter MCF/MCE and longer CFT).

C-reactive protein in the diagnosis of postoperative infection in pediatric patients: a prospective observational study of 103 patients.

BACKGROUND: Surgical stress elicits a systemic inflammatory response syndrome that contributes to the development of septic complications. C-reactive protein (CRP) is an acute phase protein released in inflammatory states. To analyze the usefulness of CRP as a marker of infection in surgical pediatric patients, we analyzed its kinetics in these patients in comparison with usual markers, such temperature, leukocytes, or fibrinogen. METHODS: One hundred three pediatric patients undergoing major surgery were enrolled consecutively in this observational study. C-reactive protein, leukocytes, neutrophils, platelets, fibrinogen, glycemia, and temperature were determined daily after surgery. Patients were classified as infected or not infected. Sensitivity, specificity, positive predictive value, negative predictive value, efficiency, precocity, positive likelihood ratio, and number of subjects to be treated were calculated. RESULTS: Peak in CRP was detected at 48 ± 24 hours. C-reactive protein was higher in the infected group from the first day, with significant differences between groups from the second day. Best cutoff for detecting infection was increases in CRP of 11 mg/dL in 48 hours, with a sensitivity of 87%, specificity of 89%, precocity of 1.7 days (0.82-2.54), number of subjects to be treated of 1.7 (1.4-2.6), and positive likelihood ratio of 7.9. Application of other markers alone or in combination did not surpass the sensitivity, specificity, or precocity for increases in CRP of 11 mg/dL in 48 hours. CONCLUSIONS: Increases of CRP constitute an easy and cheap prognostic alert system and may be used to establish strategies aimed to detect infection in surgical pediatric patients.