Blunt thoracic trauma (BTT) and the resultant isolated mitral papillary muscle avulsion, pericardial rupture, and cardiac herniation injuries are each rarely diagnosed clinical entities. We describe the first case of combined pericardial tear with cardiac herniation and ruptured mitral papillary muscles following BTT. Preoperative transesophageal echocardiography (TEE) diagnosed the delayed mitral papillary muscle rupture while all previous diagnostic modalities failed to delineate the pericardial rupture and cardiac herniation. Particular emphasis is placed on the clinical and radiologic aspects of the case that would heighten clinical suspicion in the emergency setting where blunt cardiac injury sequelae are suspected and frequently missed.

•Epsilon-aminocaproic acid (EACA) is used to minimize blood loss.•Dosing regimens have been detailed in adults, but not in pediatrics.•Effects of two EACA dosing regimens were studied in pediatric craniofacial surgery.•Higher dose of EACA trends towards reducing transfusion requirements.•A larger sample size may be able to detect differences in dosing regimen outcomes.

OBJECTIVE The primary aim of this pilot study was to assess feasibility and to evaluate if peri-operative pain management with regional analgesia resulted in decreased use of narcotic medication and earlier return to preoperative respiratory/nutritional status. STUDY DESIGN Cases were defined as infants who received regional analgesia as part of their perioperative anesthetic management. Controls were matched for surgical procedures without regional analgesia. RESULTS Fifteen cases were identified and matched with 17 controls. Infants undergoing inguinal hernia repair returned to baseline earlier and were not intubated. There was no difference in time to extubation in other thoracoabdominal surgeries. There was no difference in cumulative narcotic analgesia administered between the two groups. CONCLUSION Postoperative regional analgesia is feasible in neonates. Inguinal hernia repair with regional anesthesia was performed without intubation and returned to preoperative status earlier. No differences were observed with other surgeries. Further prospective, randomized, multicenter studies are needed.

Kyphoplasty is a minimally invasive procedure intended to stabilize the fractured bone and restore bone height. It involves percutaneous introduction of an inflatable bone tamp into a fractured vertebral body, followed by injection of bone cement into the ballooned pocket. Anesthetic options typically considered for this procedure include intravenous sedation or general anesthesia. These patients are often elderly, frail, in significant pain, and may poorly tolerate sedation or general anesthesia in the prone position. Spinal anesthesia has been suggested as an alternative method. However, it has major limitations. We would like to report a case of a 79-year-old patient with multiple comorbidities, who presented for kyphoplasty, where epidural anesthesia was conducted and successfully provided adequate analgesia as well as optimal surgical conditions.

Background: Significant resource constraints and critical care training gaps are responsible for the limited development of intensive care units (ICUs) in resource limited settings. We describe the implementation of an ICU in Haiti and report the successes and difficulties encountered throughout the process. We present a consecutive case series investigating an anesthesiologist, emergency, and critical care physician implemented endotracheal intubation and mechanical ventilation protocol in an austere environment with the assistance of telemedicine. Methods: A consecutive case series of fifteen patients admitted to an ICU at St. Luc Hospital located in Portau-Prince, Haiti, between the months of February 2012 to April 2014 is reported. Causes of respiratory failure and the clinical course are presented. Patients were followed to either death or discharge. Results: Fifteen patients (eight women and seven men) were included in the study with an average age of 37.7 years. The mean duration of ventilation was three days. Of the fifteen patients intubated, five patients (33.3%) survived and were discharged from the ICU. Of the five surviving patients, two were intubated for status epilepticus, one for status asthmaticus and one for hyperosmolar coma associated with intracerebral hemorrhage. Of the patients dying on the ventilator, four patients died from pneumonia, two from renal failure, and one from tetanus. The remaining three died from strokes and cardiac arrests. Conclusions: Mortality of mechanically ventilated patients in a resource-limited country is significant. Focused training in core critical care skills aimed at increasing the endotracheal intubation and ventilatory management capacity of local medical staff should be a priority in order to continue to develop ICUs in these austere environments. Collaborative educational and training efforts directed by anesthesiologists, emergency, and critical care physicians, and aided by telemedicine can facilitate realizing this goal.

Objective: To determine whether epsilon-aminocaproic acid (EACA) load of 50 mg.kg(-1) before skin incision, and infusion of 25 mg.kg(-1.)h(-1) until skin closure during cranial vault reconstruction (CVR) were associated with decreased estimated blood loss and transfusion requirements.Background: Antifibrinolytic medications decrease bleeding and transfusion requirements during cardiothoracic and orthopedic surgeries with high blood loss, but practical reductions in blood loss and transfusion requirements have not been consistently realized in children undergoing CVR. Current dosing recommendations are derived from adult extrapolations, and may or may not have clinical relevance.Method: Retrospective case-controlled study of 45 consecutive infants and children undergoing primary craniosynostosis surgery at Covenant Children's Hospital during years 2010-2014. Exclusion criteria included revision surgery, and chromosomal abnormalities associated with bleeding disorders. Blood loss and blood transfusion volumes as a percent of estimated blood volume were compared in the presence of EACA while controlling for age, suture phenotype, use of bone grafting, and length of surgery. Secondary outcomes measures included volume of crystalloid infused, length of hospital stay, and any postoperative intubation requirement.Results: When analyzed based on length of surgery, EACA did reduce blood loss and blood transfusion (R-2 = 0.19, P =.005 and R-2 = 0.18, P =.010, respectively) with shorter surgeries.Conclusions and relevance: Using a standardized dosing regimen of EACA during craniosynostosis surgery, we found statistical significance in blood loss and transfusion requirements in surgeries of the shortest duration. We suspect this may be due to our selected dosing regimen, which may be lower than recently recommended. This study contributes to the growing body of evidence supporting EACA in CVR for craniosynostosis. (C) 2016 Elsevier Inc. All rights reserved.

OBJECTIVE:Ultrasound-guided (USG) cannulation of the brachiocephalic vein (BCV) has been shown to be technically easy. We hypothesised that adoption of USG in-plane cannulation of the BCV as the primary approach to central venous cannulation at our institution would lead to central venous cannulation for a greater variety of indications. METHODS:We performed retrospective, descriptive comparison of all central lines placed in patients aged <16 years who underwent any surgical operation during calendar years 2012-2014 at a small, free-standing children's hospital. The use and management of a central line was reviewed until the patient was discharged from the hospital. Analysis of the data was performed using simple comparative statistical methods. RESULTS:Forty-nine patients were identified, 20 who weighed <10 kg and 29 who weighed >10 kg. Cannulation was successful in all patients. No significant late complications occurred. Catheters were well tolerated post-operatively, with no accidental dislodgement and no removal because of discomfort. The average duration of insertion was 6.3 (3-20±3.77) days. Nine catheters were placed for access during emergency surgery. 15 were placed in patients with difficult peripheral intravenous (PIV) access. The central lines remained in place until discharge in 79.6% of patients. In 40% of patients, the PIV catheter was removed, and the central line was retained because of preference. Total parenteral nutrition (TPN) was administered in 11 (22.4%) patients. CONCLUSION:Cannulation of BCV was well tolerated by children, with an average insertion duration of 6.3 days, which often lasted beyond the removal/failure of the PIV cannula. Catheters were useful for primary venous access during hospitalisation and for short TPN courses.

•Severe scoliosis need not be considered a contraindication to regional analgesia.•Paravertebral catheters can safely be inserted under USG.•USG improves success rate and reduce complications with paravertebral blocks.

Department of Anesthesiology University at Buffalo Buffalo, New York Women & Children’s Hospital of Buffalo Buffalo, New York [email protected]

The study objective is to describe our experience with placement and management of thoracic paravertebral block catheters in 2 neonates. The design is retrospective chart review of 2 consecutive newborns undergoing repair of tracheoesophageal fistula. Ultrasound-guided oblique intercostal approach for catheter placement and infusions of dilute ropivicaine for 4-5 days. The measurements are postoperative narcotics and sedatives administered. The main results are neither infant required continuous infusions of sedatives or narcotics. Thoracic paravertebral block catheter infusions for neonatal thoracotomy and chest tube placement may eliminate the need for continuous narcotic infusions and may avoid the need for narcotic and benzodiazepine taper or weaning.

Arachnoid collapse is a previously unreported complication of endoscopic choroid plexus coagulation (ECPC) treatment of hydranencephaly and is demonstrated in this case report. The variable anatomy found in hydranencephaly supports the use of ECPC as the preferred treatment option. However, the same anatomical anomalies predispose the procedure to this unique complication. A brief literature review of hydranencephaly has also been performed and is reported through the discussion. Neurosurgeons must be aware of this very dangerous complication and a discussion of preventative measures are made. The use of ECPC and the clinical expectations of treating patients with hydranencephaly is also discussed.

Pediatric AnesthesiaVolume 24, Issue 10 p. 1110-1111 Correspondence Preventing neurotoxicity: don't forget high-dose narcotic anesthetic Mark E. Thompson, Mark E. Thompson [email protected] Departments of Pediatrics and Anesthesiology, Texas Tech University Health Sciences Center, Lubbock, TX, USA Covenant Children's Hospital, Lubbock, TX, USASearch for more papers by this author Mark E. Thompson, Mark E. Thompson [email protected] Departments of Pediatrics and Anesthesiology, Texas Tech University Health Sciences Center, Lubbock, TX, USA Covenant Children's Hospital, Lubbock, TX, USASearch for more papers by this author First published: 05 September 2014 https://doi.org/10.1111/pan.12502Citations: 1Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL No abstract is available for this article. References 1Anand KJS, Sippell WG, Aynsley-Green A. Randomised trial of fentanyl anaesthesia in preterm babies undergoing surgery: effects on the stress response. Lancet 1987; 1: 62– 66. 2Tourrel F, Lendeu PK, Abily-Donval L et al. The Antiapoptotic effect of remifentanil on the immature mouse brain: an ex vivo study. Anesth Analg 2014; 118: 1041– 1051. 3Penido MG, Garra R, Sammartino M et al. Remifentanil in neonatal intensive care and anaesthesia practice. Acta Paediatr 2010; 99: 1454– 1463. Citing Literature Volume24, Issue10October 2014Pages 1110-1111 ReferencesRelatedInformation

BACKGROUND CONTEXT: Blood loss in patients with adolescent idiopathic scoliosis (AIS) who are undergoing posterior spinal instrumentation and fusion (PSIF) varies greatly. The reason for this wide range is not clear. There are reports of unexpected massive hemorrhage during these surgeries. Many studies reflect authors' preferences for describing blood loss in terms of levels fused, weight, or percent blood volume.PURPOSE: We sought to define excessive blood loss clinically, determine its incidence in our study population, and identify associated variables. Results are intended to inform perioperative preparation for these cases. Results may be used to inform prospective study designs.STUDY DESIGN: This was a retrospective uncontrolled case series.PATIENT SAMPLE: A total of 311 consecutive AIS PSIF cases during the years 2005-2010 performed at Children's Hospital Colorado were studied.OUTCOME MEASURES: We measured estimated blood loss (EBL) and its association with multiple patient, surgical, and anesthetic variables.METHODS: Thirty-one variables potentially related to blood loss were collected retrospectively from electronic medical records for analysis. When no cases of clearly excessive blood loss were identified on the basis of visual examination of EBL distribution, we chose to use the top 10% of blood loss cases as an arbitrary determinant of excessive blood loss. Three cut-off strategies captured the top 10% of EBL cases with little variation in who was selected: 1) >1,700 mL of EBL, 2) >50% EBL/estimated blood volume, and 3) >150 mL/level fused EBL. Variables were compared with the chi(2) test, Fisher exact, or t-tests, when appropriate. A generalized linear mixed logistic model was used to determine the probability of excessive blood loss based on the number of levels fused.RESULTS: The average EBL was 89.17 mL/level fused (range, 45-133 mL). EBL fit a progressively wider distribution as surgical complexity (number of levels fused) increased. Number of levels fused (p<.0001), operative time (p=.0139), number of screws (p<.0001), and maximal preoperative Cobb angle (p=.0491) were significantly associated with excessive blood loss. The variable that was most strongly associated with excessive blood loss was the number of levels fused, with >= 12 levels having a probability of >10% of excessive hemorrhage.CONCLUSION: Excessive blood loss may be an arbitrary number until future research suggests otherwise. We show that the probability of exceeding one of our arbitrary definitions is approximately 10% when 12 or more levels are fused. If a 10% incidence of excessive blood loss is determined to be clinically relevant, teams might wish to pursue hematologic consultation and maximal blood conservation strategy when 12 or more levels are planned for fusion. (C) 2014 Elsevier Inc. All rights reserved.

Delayed presentation of coarctation of the aorta can be associated with severe complications. A challenging case of aortoenteric fistula secondary to an aneurysm from coartation of the aorta presented with massive gastrointestinal hemorrhage. The clinical management of this patient and a review of the literature are presented.

Infants have a shorter neuraxial length and shorter skin to epidural space than adults. Even small amounts of migration may produce significant and unintended effects. Optimal fixation to prevent migration, bacterial colonization, and leakage is not clear from the literature. We report the case of a thoracic epidural that migrated inward for six centimeters, associated with loss of analgesic effect.

CTRC-AACR San Antonio Breast Cancer Symposium: 2008 Abstracts Abstract #6105 Background: Extended 7-year follow-up of the US Oncology Adjuvant Trial 9735 demonstrated that docetaxel plus cyclophosphamide (TC) as adjuvant treatment of operable invasive breast cancer significantly improves disease-free survival (DFS) and overall survival (OS) compared to doxorubicin plus cyclophosphamide (AC). DFS was 81% vs. 75%, respectively (p = 0.033) and OS was 87% vs. 82%, respectively (p = 0.032). A lifetime cost-effectiveness analysis of TC versus AC was conducted from a Canadian (province of Ontario) government payer perspective, based on head-to-head clinical data from Trial 9735. Methods: Survival and monthly risk of disease recurrence of women with early stage breast cancer (base case typifying those entered into the trial) was estimated up to 7 years using OS and DFS data from Trial 9735. Survival was extrapolated to lifetime using life expectancy estimates from the Canadian general population. Canadian resource utilization and unit costs were applied to estimate the costs of chemotherapy (including drug and administration costs), chemotherapy-related toxicities and disease recurrence. Quality of life (utility) weights for health states and events, used in the calculation of quality-adjusted life years (QALYs), were derived from the literature. Total costs, life years and QALYs were calculated for a lifetime horizon. Results: Life years and QALYs were higher for TC patients compared to AC patients, due primarily to longer survival and fewer recurrences for patients receiving TC. The predicted life expectancy of patients receiving TC and AC was 14.64 and 14.02 years, respectively. Mean total lifetime disease-related costs were $12,840 with TC and $8,579 with AC; the difference in costs was driven by higher drug acquisition costs for TC. Cost per life year gained (TC vs. AC) was $6,842 and cost per QALY gained was $8,251, discounting costs and outcomes at 5% per year. Base case results were most sensitive to assumptions regarding time horizon. In a sensitivity analysis conducted with a 7-year time horizon (the time frame of the clinical trial), cost per life year gained was $36,120 and cost per QALY gained was $43,248. In additional one-way sensitivity analyses conducted with a lifetime horizon and alternative assumptions regarding survival extrapolation, utility estimates, costs and discount rate, cost per life year gained remained between $2,982 and $7,538 and cost per QALY gained remained between $3,600 and $9,090. Conclusion: In patients with early stage, operable, invasive breast cancer, adjuvant treatment with TC provides gains in terms of life years and QALYs compared to AC and results in favourable cost-effectiveness ratios that should be acceptable in most jurisdictions. Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 6105.