experience more rejection episodes than those on TAC after conversion.While a small, heterogenous population of patients makes firm interpretation difficult, we would suggest that RAPA therapy is effective and that future well-controlled trials are necessary.

Vilardell, M. E.; Schmucker, E.; Andreu, E.; Villaverde, I.; Munar, F.; Montferrer, N. Author Information

Advances in prenatal diagnosis and surgical techniques have resulted in an increasing number of fetal interventions. 1 Sydorak R.M. Hedrick M.H. Longaker M.T. Albanese C.T. Pathophysiologic patterns influencing fetal surgery. World J Surg. 2003; 27: 45-53 Crossref PubMed Scopus (4) Google Scholar We describe a fetoscopic cord occlusion procedure performed in a twin pregnancy that resulted in acute hemorrhage and the need for intrauterine fetal resuscitation.

Recessive dystrophic epidermolysis bullosa is inherited as a rare autosomal disorder which causes blisters to form in the skin. We describe the treatment of a 39-year-old parturient with this condition. She was scheduled for elective cesarean section at 37 weeks' gestation. The patient had widespread skin lesions, had lost fingers, and had esophageal stenosis. The cesarean was performed under spinal anesthesia without complications. Recessive dystrophic epidermolysis bullosa requires adaptation of anesthetic technique that includes control over posture and careful handling of the skin. Material for attaching monitoring devices and inserting venous lines must be adapted to the particular deformities and skin lesions present.

Recessive dystrophic epidermolysis bullosa is inherited as a rare autosomal disorder which causes blisters to form in the skin. We describe the treatment of a 39-year-old parturient with this condition. She was scheduled for elective cesarean section at 37 weeks' gestation. The patient had widespread skin lesions, had lost fingers, and had esophageal stenosis. The cesarean was performed under spinal anesthesia without complications. Recessive dystrophic epidermolysis bullosa requires adaptation of anesthetic technique that includes control over posture and careful handling of the skin. Material for attaching monitoring devices and inserting venous lines must be adapted to the particular deformities and skin lesions present.

OBJECTIVES To evaluate survival and lung growth in fetuses with severe congenital diaphragmatic hernia (CDH) treated with fetoscopic tracheal occlusion (FETO) compared with control fetuses and to analyze possible complications of the anesthetic techniques used. PATIENTS AND METHODS This prospective study was performed on fetuses with CDH. FETO was undertaken before the 29th week of gestation on fetuses with a lung-to-head ratio (LHR) less than 1. FETO was not performed on fetuses with an LHR between 1.0 and 1.5 or those with an LHR less than 1 where consent was not given. Lung growth was monitored by means of LHR. FETO was performed under fetal intramuscular anesthesia and maternal epidural anesthesia and sedation with remifentanil. RESULTS Seventeen fetuses were included in the study. FETO was performed on 11 fetuses and was effective in 9. The median percentage difference between LHR at diagnosis and prior to FETO was 1.15% (P=.183); between diagnosis and before removing the balloon, the difference was 130.5% (P=.003); and between diagnosis and before delivery, 90.18% (P=.003). In the control group (n=6), the median percentage difference between LHR at diagnosis and before delivery was 49.25% (P=.028). No significant hemodynamic or respiratory changes occurred in either mother or fetus during fetoscopy. All the fetuses in the control group died; 45.5% of those in the FETO group survived. CONCLUSIONS The use of FETO in cases of CDH appears to increase survival and lung growth. Fetal anesthesia in association with maternal epidural anesthesia and sedation makes it possible to place and remove the endotracheal balloon via fetoscopy with acceptable maternal comfort and without notable complications.

2 cm line, colored green, drawn on the dorsum of hand during outpatient clinic visit, acted as reinforcer in group I. Results: Both the groups were comparable for age, sex, body weight, parental literacy, socio-economic status, proposed procedure, surgical history and preoperative anxiety. Anxiety levels in pre-anesthesia room decreased in both the groups, though significant only in group I (p 0.001), when compared to the baseline. The time, in seconds, for parental separation and induction were significantly higher in group II (111.75 50.22 and 187.5 25.92) as compared to group I (63.81 35.49 and 140.31 40.64) (p 0.01). Children in group I were also more cooperative during induction. Conclusion(s): Behavioral reinforcement when added to play results in lesser anxiety, faster parental separation and induction time as compared to play alone in pediatric outpatients. References: 1 Saile H, Burgmeier R, Schmidt LR. Psychol Health 1997; 2: 107–32. 2 Kain ZN, Wang SM, Mayes LC, et al. Anesth Analg 1999; 88: 1042–47.

Manrique, S.; Munar, F.; Andreu, E.; Paños, M. L.; Peiró, J. L.; Montferrer, N.; Hervás, C.; Roigé, J. Author Information

OBJECTIVES:We describe our experience with infants suffering from interstitial pneumonia referred for lung transplantation.METHODS:From April 1998 to December 2000, three infants were admitted to our lung transplantation program: a 9-month-old girl (patient 1) suffering from surfactant protein C deficiency who had high oxygen requirements (fraction of inspired oxygen: 70% to 90%), and two boys, ages 2 (patient 2) and 9 months (patient 3), who were ventilator-dependent due to chronic pneumonitis of infancy.RESULTS:Patients were transplanted at the age of 5 months (patient 2) and 13 months (patients 1 and 3) at 87 to 105 days after being accepted for lung transplantation. All cases underwent a sequential double lung transplant on cardiopulmonary bypass. The immunosuppressive regime included tacrolimus, prednisone, and azathioprine. Patients 2 and 3 also received basiliximab. Two cases suffered a mild rejection episode that responded to high-dose steroids. Patient 2 was ventilator-dependent for 8 months after transplant, owing to severe bronchomalacia and left main bronchus stenosis. Bronchial stenosis resolved after pneumatic dilatation and endobronchial stenting. This patient also presented with a pulmonary artery anastomosis stricture that required percutaneous balloon dilatation. All three patients are at home, carrying out normal activities for their age, with no respiratory symptoms after a period of 8 to 29 months of follow-up.CONCLUSIONS:Interstitial pneumonia of infancy is a rare disease with a bad prognosis and no specific treatment; therefore, lung transplantation represents a good therapeutic option for these infants.

Epidural administration of combinations of opioids and a local anaesthetic provides prompt and effective analgesia and is increasingly used in paediatric anaesthesia. However, respiratory depression by rostral spread of opioid in the CSF is by far the greatest concern after epidural morphine. An infant of three months of age underwent portoenterostomy (Kasai's operation) for extrahepatic biliary duct atresia. A median approach at the L3–L4 epidural interspace was used and a dose of 1 ml·kg–1 of 0.125% bupivacaine with adrenaline 1:400 000 mixed with 50 μg·kg–1 morphine was injected using a 19 gauge Tuohy needle. Six h after epidural morphine, the infant developed respiratory depression with an increase in drowsiness, miosis and decreased respiratory rate. Low arterial saturation (SpO2) was detected by pulse oximetry and confirmed by blood gas analysis. An intravenous bolus of 5 μg·kg–1 naloxone followed by a 3‐h infusion of 2 μg·kg–1·h–1 resulted in complete reversal of signs and symptoms of respiratory depression. Epidural opioids should be limited to paediatric patients admitted to specialized recovery units for the first postoperative day.