A pilot study on secondhand tobacco exposure: parental knowledge about health impact and feasibility of cessation

Introduction

As the primary source of smoke exposure is in the home, the smoking behaviors of parents and other caregivers are key determinants of a child's exposure to secondhand smoke. The perioperative period offers an opportunity to discuss smoking cessation strategies.

Methods

This prospective study included 97 parents or caregivers of patients undergoing dental surgery. Caregivers were surveyed in the dental waiting room during the preoperative phase. The primary aim was to determine the feasibility of using the preoperative encounter to offer smoking cessation resources to parents of pediatric patients. The secondary aim was to compare willingness to receive smoking cessation resources according to the knowledge of the risks of secondhand smoking (ie, being aware of secondhand smoking and knowing that it posed a risk to their child).

Results

Awareness of risks due to secondhand smoking was 65% in the overall cohort and 58% among current smokers (P=0.284 vs nonsmokers). Among smokers in our study, only a small percentage (12%) were interested in smoking cessation help. Knowledge of the risks of secondhand smoke may not be sufficient for smokers to express willingness to receive help.

Conclusion

The outpatient clinic may be a teaching opportunity for smoking cessation for caregivers. However, we found that only a small percentage of caregivers were interested in receiving information about smoking cessation. This was despite the fact they were aware of the potential adverse effects of secondhand smoke on their children.

Progress to publication of survey research presented at anesthesiology society meetings

BACKGROUND

Understanding how survey methodology and quality measures are associated with progress from abstract presentation to manuscript publication can help optimize the design of survey research in anesthesiology, and enhance respondents' confidence in the value of survey participation.

AIMS

The aim of this study was to determine if adherence to survey method recommendations and attainment of high response rates are associated with faster progress to publication among abstracts initially presented at anesthesiology society meetings.

METHODS

Abstracts from the American Society of Anesthesiologists' (ASA) Annual Meeting, Association of Anaesthetists of Great Britain and Ireland (AAGBI) Annual Congress, and the International Anesthesia Research Society (IARS) Annual Meeting from 2011-2014 were reviewed. Abstracts reporting original survey data collection were included in a systematic search for resulting publications in peer-reviewed academic journals. Cox proportional hazards regression was used to analyze progress to publication.

RESULT

Ninety-nine ASA, 76 AAGBI, and 30 IARS abstracts met inclusion criteria. Among these abstracts, 43 (43%) from ASA, none from AAGBI, and 7 (23%) from IARS have been published as original research articles or brief reports. Surveying patients or caregivers, as opposed to medical professionals, was associated with increased likelihood of publication (hazard ratio [HR] = 4.4, 95% confidence interval [CI]: 1.6, 12.4, P = 0.005) as was a larger sample size (eg, >500 vs <100; HR = 12.9, 95% CI: 3.8, 43.6, P < 0.001).

CONCLUSIONS

While abstract presentation facilitates rapid dissemination of survey research findings, the impact and utility of such studies may be limited until a full manuscript is published. In our review, 25% of abstracts presenting survey data at major anesthesiology meetings were eventually published. Larger sample sizes and a target population of patients or caregivers increased the likelihood of survey research being published in full form.

A comparison of supraglottic devices in pediatric patients

Background

When managing patients with a difficult airway, supraglottic airways (SGAs) have been used as rescue devices or to serve as a conduit for endotracheal intubation. The current study compares various clinical outcomes, including the bronchoscopic view of the glottis when using 2 SGAs, the Air-Q^® laryngeal mask airway (LMA) and the i-gel^® SGA, in pediatric patients.

Methods

Patients ≤18 years of age were prospectively randomized to receive either the Air-Q^® LMA or the i-gel^® SGA. Following SGA placement, a flexible fiberoptic bronchoscope was inserted through the SGA to visualize the glottis. Time taken to obtain the bronchoscopic view and place the SGA, and the ability to seal the airway at 20 cmH₂O were compared. The bronchoscopic view obtained was graded as follows: 1) glottic aperture seen completely; 2) glottic aperture seen partially with visual obstruction <50%; 3) glottic aperture seen, but visual obstruction >50%; and 4) glottic aperture not seen.

Results

Fifty patients were enrolled and 48 (22/26 male/female) were included in the analysis. Median age was 13 years (IQR: 7, 16) and median weight was 49 kg (IQR: 25, 70). The Air-Q^® LMA and i-gel^® SGA groups did not differ in device placement time (median of 19 vs 21 seconds; 95% CI of difference in medians: - 2 to 7; P=0.331), the time to achieve fiberoptic view of the glottis (median of 25 vs 21 seconds; 95% CI of difference: - 9 to 8; P=0.489) or the grade of the bronchoscopic view of the airway. Eight Air-Q^® and 6 i-gel^® supraglottic devices sealed the airway at 20 cmH₂O.

Discussion

The time required for successful placement of the SGA, the time required for bronchoscopic view, and the quality of bronchoscopic view through the Air-Q^® LMA and the i-gel^® SGA did not differ.

Unmet Need for Care Coordination Among Children with Special Health Care Needs

Socioeconomic disparities in access to care coordination have been noted among children with special health care needs (CSHCN). Following recent policy developments and technological innovation, care coordination has become more widespread, possibly leading to reduced disparity in care coordination access. This study investigates whether child and household characteristics remain associated with unmet need for care coordination among CSHCN. CSHCN (aged <18 years) requiring ≥2 types of health services in the past year were identified in the 2016 National Survey of Children's Health (NSCH). Care coordination was defined as help with arranging the child's care among different doctors or services. Children were classified as not needing care coordination, receiving sufficient care coordination (met need), or needing but not receiving care coordination (unmet need). Weighted multinomial logistic regression examined the association of child characteristics with this outcome. The analysis included 5622 children with no need for care coordination, 1466 with a met need, and 980 with unmet needs. Children with mental health conditions were more likely to have unmet rather than met needs for care coordination (odds ratio = 4.1; 95% confidence interval: 2.7, 6.1; P < 0.001). After multivariable adjustment, race/ethnicity, income, family structure, insurance coverage, place of birth, and use of English in the home were not associated with having unmet rather than met needs for care coordination. Among CSHCN, the latest data from NSCH reveal no evidence of previously described socioeconomic disparities in access to care coordination. Nevertheless, unmet needs for care coordination remain prevalent, especially among children with mental health conditions.

Rapid fluid administration: an evaluation of two techniques

OBJECTIVE

Rapid administration of fluid remains a cornerstone in treatment of shock and when caring for trauma patients. A range of devices and technologies are available to hasten fluid administration time. While new devices may optimize fluid delivery times, impact on subjective experience compared to traditional methods is poorly documented. Our study evaluated administration time and provider experience using two unique methods for fluid administration.

MATERIALS AND METHODS

Prospective comparison of objective and subjective outcomes using a novel infusion device (LifeFlow® Rapid Infuser) and the traditional push-pull syringe method in a simulated model of rapid fluid infusion. Ten paired trials were conducted for each of three intravenous catheter gauges. Providers administered 500 mL of isotonic crystalloid through an intravenous catheter with both LifeFlow and a push-pull device. Administration time was compared between devices using paired t-tests. Participants' subjective physical demand, effort, pain, and fatigue using each device were recorded using 21-point visual analog scales and compared between devices using sign-rank tests.

RESULTS

Fluid administration time was significantly decreased with LifeFlow compared to the push-pull device with the 18-gauge catheter (2.5±0.8 vs 3.8±1.0 minutes; 95% CI of difference: 0.9, 1.8 minutes; P<0.001). Findings were similar for other catheter sizes. No improvements in subjective experience were noted with the LifeFlow device. Increased physical demand with the LifeFlow device was noted with 18 and 22 gauge catheters, and increased fatigue with the LifeFlow device was noted for all catheter sizes.

CONCLUSION

The LifeFlow device was faster than the push-pull syringe method in our simulated scenario. However, provider subjective experience was not improved with the LifeFlow device.

Risks associated with lung transplantation in cystic fibrosis patients

INTRODUCTION

Survival after lung transplantation lags behind outcomes of other solid organ transplants, and complications from lung transplant are the second most common cause of death in cystic fibrosis. Evolving surgical techniques, therapeutics, and perioperative management have improved short-term survival after lung transplantation, yet have not translated into significant improvement in long-term mortality. Areas covered: We review risk factors for poor long-term outcomes among patients with cystic fibrosis undergoing lung transplantation to highlight areas for improvement. This includes reasons for organ dysfunction, complications of immunosuppression, further exacerbation of extrapulmonary complications of cystic fibrosis, and quality of life. A literature search was performed using PubMed-indexed journals. Expert commentary: There are multiple medical and socioeconomic barriers that threaten long-term survival following lung transplant for patients with cystic fibrosis. An understanding of the causes of each could elucidate treatment options. There is a lack of prospective, multicenter, randomized control trials due to cost, complexity, and feasibility. Ongoing prospective studies should be reserved for the most promising interventions identified in retrospective studies in order to improve long-term outcomes.

Patients From Appalachia Have Reduced Access to Liver Transplantation After Wait-Listing

BACKGROUND

The Appalachian region is medically underserved and characterized by high morbidity and mortality. We investigated disparities among patients listed for liver transplantation (LT) in wait-list outcomes, according to residence in the Appalachian region.

METHODS

Data on adult patients listed for LT were obtained from the United Network for Organ Sharing for July 2013 to December 2015. Wait-list outcomes were compared using cause-specific hazard models by region of residence (Appalachian vs non-Appalachian) among patients listed at centers serving Appalachia. Posttransplant patient and graft survival were also compared. The study included 1835 LT candidates from Appalachia and 5200 from non-Appalachian regions, of whom 1016 patients experienced wait-list mortality or were delisted; 3505 received liver transplants.

RESULTS

In multivariable analyses, patients from Appalachia were less likely to receive LT (hazard ratio [HR] = 0.86; 95% confidence interval [CI]: 0.79-0.93; P < .001), but Appalachian residence was not associated with wait-list mortality or delisting (HR = 1.03; 95% CI: 0.89-1.18; P = .696). Among liver transplant recipients, patient and graft survival did not differ by Appalachian versus non-Appalachian residence.

CONCLUSION

Appalachian residence was associated with lower access to transplantation after listing for LT. This geographic disparity should be addressed in the current debate over reforming donor liver allocation and patient priority for LT.

Pediatric marginal donor hearts: Trends in US national use, 2005-2014

Pediatric patients awaiting heart transplant face high mortality rates due to donor organ shortages, including non-use of marginal donor hearts. We examined national trends in pediatric marginal donor heart use over time. UNOS data were queried for heart donors <18 years from 2005 to 2014. The proportion of donor hearts considered marginal was determined using previously cited marginal characteristics: left ventricular ejection fraction (LVEF) <50%, use of ≥2 inotropes, cerebrovascular death, CDC high-risk status, and eGFR < 30 mL/min/1.73 m² . Disposition of donor hearts was determined and stratified by marginal donor status. Of 6778 pediatric hearts offered from 2005 to 2014, 2373 (35.0%) were considered marginal. Non-use of marginal donor hearts was significantly higher than that of donor hearts without any marginal characteristics (59.5% vs 20.3%, P < .001). In particular, LVEF < 50% and donor inotropes were associated with high rates of organ non-use among pediatric donors. Yet, non-use of marginal donor organs decreased from 67% to 48% from 2005 to 2014 (P < .001). Although the proportion of pediatric donor hearts used for pediatric patients has increased, more than half of donor hearts are declined for use in pediatric recipients due, in part, to perceived marginal status.

Cohort contributions to trends in the incidence and mortality of intrahepatic cholangiocarcinoma

Background

The incidence and mortality of intrahepatic cholangiocarcinoma (ICC) are increasing worldwide. We used age-period-cohort (APC) modeling to evaluate the contribution of cohort effects to trends in ICC incidence and mortality in the US.

Methods

Incidence data were acquired from the Surveillance, Epidemiology and End-Results (SEER) program. Mortality data were obtained from the Centers for Disease Control and Prevention WONDER Database. APC models using restricted cubic splines were fitted to estimate change in incidence and mortality risk over age, and modification of incidence and mortality risks according to birth cohort and period of diagnosis or death. Likelihood ratio tests were used to summarize improvement in model fit with APC modeling.

Results

There were 4,053 cases of ICC at SEER registry sites between 1973-2012. ICC incidence increased with older age and across all birth cohorts examined. Inclusion of cohort effects tended to improve model fit relative to an age-period model (likelihood ratio test P=0.082). The national crude ICC-related mortality rate increased from 2.9 to 5.0 per 100,000 among males and 2.7 to 4.6 per 100,000 among females. Among males, ICC mortality risk varied across birth cohorts, and inclusion of cohort effects in a model predicting ICC mortality risk improved model fit (likelihood ratio test P=0.001), but cohort effects did not alter model fit among females (P=0.223).

Conclusions

ICC incidence and mortality have increased over time in the United States. Birth cohort effects influenced increased ICC incidence and ICC mortality among males, but were not evident in the trend of ICC mortality among females.

Pediatric Pulmonary Artery Rehabilitation: A Review of Our Experience and a Novel Approach Using Bronchial Blockers

Recent advances in the field of pediatric interventional cardiology have resulted in therapies for patients in need of augmented pulmonary artery (PA) flow. Catheter-based PA rehabilitation can be performed safely but not without the potential risk of pulmonary hemorrhage. When severe, this bleeding has the ability to contaminate the bronchi and trachea, and possibly occlude the endotracheal tube. This can result in a critical inability to ventilate and oxygenate these patients. Herein, we review our institutional experience with pulmonary hemorrhage associated with these procedures and the feasibility of predicting this outcome. The secondary aim was to discuss our novel anesthetic approach to a select group of these patients, involving the use of bronchial blockers to preemptively prevent contamination of bilateral bronchi and occlusion of the endotracheal tube.

Optimizing the securement of epidural catheters: an in vitro trial

Introduction

Epidural anesthesia is frequently used to provide postoperative analgesia following major surgical procedures. Secure fixation of the epidural catheter is necessary to prevent premature dislodgment and loss of epidural analgesia. Using an in vitro model, the current prospective study evaluates different types of dressings for securement of an epidural catheter by quantifying the force in Newtons (N) required for dislodgment using a digital force gage.

Methods

Four methods of epidural catheter securement were used on a simulator mannequin: 1) Suresite^® Window Clear Dressing, 2) Op-Site Post-Op^® Visible Dressing, 3) Steri-Strips^® and Suresite Window Clear Dressing, and 4) Steri-Strips and Op-Site Post-Op Visible Dressing. Each method of securement was assessed 10 times to calculate the mean force required to dislodge the catheter. Mean force of dislodgment for each method was compared using parametric tests.

Results

The force (mean ± SD) required for catheter dislodgment for the four methods was 14.0±2.9, 2, 10.7±1.5, 8.6±2.3, and 9.6±2.2 N, respectively. The pairwise difference showed that the Suresite Window Clear Dressing was the best securement method when compared with other methods.

Conclusion

Our study demonstrates the advantage of the Suresite Window Clear Dressing in securing the epidural catheter. Future clinical trials are needed to validate these findings.

Outcomes of domino liver transplantation compared to deceased donor liver transplantation: a propensity-matching approach

Domino liver transplantation (DLT) utilizes the explanted liver of one liver transplant recipient as a donor graft in another patient. While there may be unique risks associated with DLT, it is unclear if DLT has less favorable long-term outcomes than deceased donor liver transplantation (DDLT). We used a propensity score matching approach to compare the outcomes of DLT recipients to DDLT recipients. The United Network for Organ Sharing (UNOS) registry was queried for patients undergoing DLT or DDLT in 2002-2016. Each DLT recipient was matched to a unique DDLT recipient to compare mortality and graft failure. There were 126 DLT and 62 835 DDLT recipients meeting inclusion criteria. After propensity score matching on recipient pre-transplant characteristics, 123 DLT cases were matched to DDLT controls from the same UNOS region. On stratified Cox proportional hazards regression, DLT incurred no increase in the hazard of mortality [hazard ratio (HR) = 1.4; 95% confidence interval (CI): 0.8, 2.7; P = 0.265] or graft failure (HR = 1.2; 95% CI: 0.7, 2.1; P = 0.556) compared to DDLT. Using a large national registry, a propensity-matched analysis found no increased risk of mortality or graft failure associated with DLT compared to DDLT.

Identification of patients at high risk for post-discharge venous thromboembolism after hepato-pancreato-biliary surgery: which patients benefit from extended thromboprophylaxis?

BACKGROUND

The objective of the current study was to define risk factors associated with the 30-day post-operative risk of VTE after HPB surgery and create a model to identify patients at highest risk of post-discharge VTE.

METHODS

Patients who underwent hepatectomy or pancreatectomy in the ACS-NSQIP Participant Use Files 2011-2015 were identified. Logistic regression modeling was used; a model to predict post-discharge VTE was developed. Model discrimination was tested using area under the curve (AUC).

RESULTS

Among 48,860 patients, the overall 30-day incidence of VTE after hepatectomy and pancreatectomy was 3.2% (n = 1580) with 1.1% (n = 543) of VTE events occurring after discharge. Patients who developed post-discharge VTE were more likely to be white, had a higher median BMI, have undergone pancreatic surgery, had longer median operative times, and to have had a transfusion. A weighted prediction model demonstrated good calibration and fair discrimination (AUC = 0.63). A score of ≥-4.50 had maximum sensitivity and specificity, resulting in 44% of patients being treating with prophylaxis for an overall VTE risk of 1.1%.

CONCLUSIONS

Utilizing independent factors associated with post-discharge VTE, a prediction model was able to stratify patients according to risk of VTE and may help identify patients who are most likely to benefit from pharmacoprophylaxis.

The expression of Mirc1/Mir17-92 cluster in sputum samples correlates with pulmonary exacerbations in cystic fibrosis patients

INTRODUCTION

Cystic fibrosis (CF) is a multi-organ disorder characterized by chronic sino-pulmonary infections and inflammation. Many patients with CF suffer from repeated pulmonary exacerbations that are predictors of worsened long-term morbidity and mortality. There are no reliable markers that associate with the onset or progression of an exacerbation or pulmonary deterioration. Previously, we found that the Mirc1/Mir17-92a cluster which is comprised of 6 microRNAs (Mirs) is highly expressed in CF mice and negatively regulates autophagy which in turn improves CF transmembrane conductance regulator (CFTR) function. Therefore, here we sought to examine the expression of individual Mirs within the Mirc1/Mir17-92 cluster in human cells and biological fluids and determine their role as biomarkers of pulmonary exacerbations and response to treatment.

METHODS

Mirc1/Mir17-92 cluster expression was measured in human CF and non-CF plasma, blood-derived neutrophils, and sputum samples. Values were correlated with pulmonary function, exacerbations and use of CFTR modulators.

RESULTS

Mirc1/Mir17-92 cluster expression was not significantly elevated in CF neutrophils nor plasma when compared to the non-CF cohort. Cluster expression in CF sputum was significantly higher than its expression in plasma. Elevated CF sputum Mirc1/Mir17-92 cluster expression positively correlated with pulmonary exacerbations and negatively correlated with lung function. Patients with CF undergoing treatment with the CFTR modulator Ivacaftor/Lumacaftor did not demonstrate significant change in the expression Mirc1/Mir17-92 cluster after six months of treatment.

CONCLUSIONS

Mirc1/Mir17-92 cluster expression is a promising biomarker of respiratory status in patients with CF including pulmonary exacerbation.

County socioeconomic characteristics and pediatric renal transplantation outcomes

BACKGROUND

Existing risk adjustment models for solid organ transplantation omit socioeconomic status (SES). With limited data available on transplant candidates' SES, linkage of transplant outcomes data to geographic SES measures has been proposed. We investigate the utility of county SES for understanding differences in pediatric kidney transplantation (KTx) outcomes.

METHODS

We identified patients < 18 years of age receiving first-time KTx using United Network for Organ Sharing registry data in two eras: 2006-2010 and 2011-2015, corresponding to periods of county SES data collection. In each era, counties were ranked by 1-year rates of survival with intact graft, and by county SES score. We used Spearman correlation (ρ) to evaluate the association between county rankings on SES and transplant outcomes in each era and consistency between these measures across eras. We also evaluated the utility of county SES for improving prediction of individual KTx outcomes.

RESULTS

The analysis included 2972 children and 108 counties. County SES and transplant outcomes were not correlated in either 2006-2010 (ρ = 0.06; p = 0.525) or 2011-2015 (ρ = 0.162, p = 0.093). County SES rankings were strongly correlated between eras (ρ = 0.99, p < 0.001), whereas county rankings of transplant outcomes were not correlated between eras (ρ = 0.16, p = 0.097). Including county SES quintile in individual-level models of transplant outcomes did not improve model predictive utility.

CONCLUSIONS

Pediatric kidney transplant outcomes are unstable from period to period at the county level and are not correlated with county-level SES. Appropriate adjustment for SES disparities in transplant outcomes could require further collection of detailed individual SES data.

Marital Status and Return to Work After Living Kidney Donation

PURPOSE

Living kidney donation is safe and effective, but patients in need of a transplant continue to outnumber donors. Disincentives to living donation include lost income, risk of job loss, perioperative complications, and unreimbursed medical expenses.

METHODS

This study uses US registry and follow-up data on living kidney donors from 2013 to 2015 to identify social predictors of return to work across gender following living kidney donation.

RESULTS

Using logistic regression, we find that predictors of return to work following living kidney donation differ for women and men. Among women, age, education, smoking status, and procedure type are associated with return to work. Among men, education, procedure type, and hospital readmission within 6 weeks postdonation are associated with return to work. Notably, single and divorced men are less likely to return to work compared to married men (odds ratio [OR] for single men 0.51, 95% confidence interval [CI], 0.37-0.69, P < .001; OR for divorced men 0.51, 95% CI, 0.34-0.75, P = .006). Marital status is not associated with return to work for women. Single and divorced men's greater odds of not returning to work are robust to controls for relevant pre- and postdonation characteristics.

CONCLUSIONS

Single and divorced men's lack of social support may present an obstacle to work resumption following living kidney donation.

Change in Health Insurance Coverage After Liver Transplantation Can Be Associated with Worse Outcomes

BACKGROUND

Health insurance coverage changes for many patients after liver transplantation, but the implications of this change on long-term outcomes are unclear.

AIMS

To assess post-transplant patient and graft survival according to change in insurance coverage within 1 year of transplantation.

METHODS

We queried the United Network for Organ Sharing for patients between ages 18-64 years undergoing liver transplantation in 2002-2016. Patients surviving > 1 year were categorized by insurance coverage at transplantation and the 1-year transplant anniversary. Multivariable Cox regression characterized the association between coverage pattern and long-term patient or graft survival.

RESULTS

Among 34,487 patients in the analysis, insurance coverage patterns included continuous private coverage (58%), continuous public coverage (29%), private to public transition (8%) and public to private transition (4%). In multivariable analysis of patient survival, continuous public insurance (HR 1.29, CI 1.22, 1.37, p < 0.001), private to public transition (HR 1.17, CI 1.07, 1.28, p < 0.001), and public to private transition (HR 1.14, CI 1.00, 1.29, p = 0.044), were associated with greater mortality hazard, compared to continuous private coverage. After disaggregating public coverage by source, mortality hazard was highest for patients transitioning from private insurance to Medicaid (HR vs. continuous private coverage = 1.32; 95% CI 1.14, 1.52; p < 0.001). Similar differences by insurance category were found for death-censored graft failure.

CONCLUSION

Post-transplant transition to public insurance coverage is associated with higher risk of adverse outcomes when compared to retaining private coverage.

Insurance Coverage and Acute Care Revisits After Pediatric Ambulatory Tonsillectomy

We investigated whether patterns of health insurance coverage were associated with 30-day all-cause acute care revisits after ambulatory tonsillectomy at a free-standing quaternary-care pediatric hospital. Insurance patterns were classified from past encounters as continuous private, continuous Medicaid, Medicaid-to-private change, or private-to-Medicaid change. Among 478/675 boys/girls (age 9 ± 4 years) selected for analysis, 148 (13%) had 30-day revisits, whereas 96 (8%) changed from Medicaid to private insurance, and 99 (9%) changed from private insurance to Medicaid. Revisits were most common in the private-to-Medicaid group, compared with continuous private coverage (19% vs 10%; 95% CI of difference: 1%-18%; P = .007). The private-to-Medicaid group was most likely to be overweight, have symptoms of sleep disordered breathing, and have more past clinical encounters. In multivariable analysis, the greater risk of acute care revisits among children with private-to-Medicaid change in coverage was attributable to greater comorbidity burden and past health care utilization.

Plasma Free Hemoglobin Generation Using the EOS PMP™ Oxygenator and the CentriMag® Blood Pump

Hemolysis is a known consequence of extracorporeal membrane oxygenation (ECMO) resulting from shear force within the different components of the extracorporeal circuit. The primary aim of this study was to evaluate the EOS PMP^™ oxygenator for generation of plasma free hemoglobin (PfHg) over 24 hours at nominal operating range flow rates. The EOS ECMO^™ (LivaNova, Inc.; formerly Sorin, Arvada, CO) is equipped with a plasma tight polymethylpentene (PMP) hollow fiber oxygenator. We hypothesized that PfHg generation would be elevated in circuits with higher flow rates, because of the significant pressure drop across the oxygenator according to manufacturer provided flow charts. Generated PfHg concentrations were compared with PfHg concentrations from blood not exposed to an ECMO circuit. The secondary aim was to evaluate circuit flow-rate-induced changes in platelet count and platelet function over 24 hours. Circuits contained a CentriMag^® (St. Jude Medical, St. Paul, MN) blood pump and an EOS ECMO PMP^™ oxygenator. Circuits in triplicate were run continuously for 24 hours at three flow rates [1, 3, and 5 liters per minute {LPM}]. PfHg was analyzed at baseline, 6, 12, 18, and 24 hours. Platelet count and function were measured at baseline and 24 hours. Concentrations of PfHg at baseline for circuits operating at 1, 3, and 5 LPM were 24.4 ± 4.0, 38.4 ± 28.6, and 26.7 ± 6.9 mg/dL, respectively. PfHg concentrations after 24 hours were statistically compared for the three flow rates using analysis of variance; PfHg concentrations at 1 LPM (181.4 ± 29.1 mg/dL), 3 LPM (145.9 ± 8.7 mg/dL), and 5 LPM (100.1 ± 111.3 mg/dL) circuits. The F-test was not statistically significant (p = .632), indicating that PfHg generation at 24 hours was similar among the three flow rates. Excessive hemolysis using PfHg levels in the EOS PMP^™ membrane oxygenator was not observed.

Tracheobronchial angles in children: Three-dimensional computed tomography-based measurements

BACKGROUND

Studies have shown significant variation in the tracheobronchial angles in pediatric-aged patients. The current study revisits tracheobronchial angle measurements in children using accurate computed tomography-based 3-dimensional images to add clarity to the understanding of tracheobronchial angles. The primary objective of the current study was to measure the right and left bronchial angle take off from the trachea using 3-dimensional computed tomography-based images of the air column in the tracheobronchial tree.

METHODS

Computed tomography-based images of 45 children younger than 8 years were reviewed. The children were evaluated during spontaneous ventilation either during natural sleep or with sedation. The right and left bronchial angles were computed between the central axes of the respective main bronchi and a vertical line passing through the central axis of the longitudinal tracheal air column. The right and left bronchial angles were compared using paired t tests, and the age dependence of the right bronchial angle and left bronchial angle difference was evaluated using Pearson's correlation coefficient.

RESULTS

The study cohort included 18 males and 27 females with an average age of 49 ± 25 months. The right bronchial angle ranged from 23° to 56° (mean 42 ± 7°), whereas left bronchial angle varied between 25° and 68° (mean 43 ± 9°). The difference in means of 1 degree was not statistically significant (95% confidence interval of difference: -1°, 4°; P = .282). No association was found between left and right bronchial angle difference and patient age (r = -.019).

CONCLUSION

According to computed tomography-based 3-dimensional imaging, right and left bronchial angles are virtually identical in children up to 8 years of age, and the difference between right and left bronchial angles does not vary with age in this population.

A study on the efficacy and safety of combining dental surgery with tonsillectomy in pediatrics

Purpose

Few data exist on combining pediatric surgical procedures under a single general anesthetic encounter (general anesthesia). We compared perioperative outcomes of combining dental surgical procedures with tonsillectomy during one anesthetic vs separate encounters.

Methods

We classified elective tonsillectomy ± adenoidectomy and restorative dentistry as combined (group C) or separate (group S). Outcomes included anesthesia time, recovery duration, the need for overnight hospital stay, and postoperative complications.

Results

Patients aged 4±1 years underwent tonsillectomy and dental surgery in combination (n=7) or separately (n=27). No differences were noted in total anesthesia time (C: median: 150, interquartile range [IQR]: 99, 165 vs S: median: 109, IQR: 92, 132; 95% CI of difference in median: −58, +10 minutes; P=0.115) and total recovery time (C: median: 54, IQR: 40, 108 vs S: median: 72, IQR: 58, 109; 95% CI of difference in median: −16, +48 minutes; P=0.307). The need for overnight stay (C: 4 of 7, S: 20 of 27; P=0.394) did not differ between the groups. No postoperative complications were noted in either group.

Conclusion

These preliminary data support the potential feasibility of combining dental procedures with tonsillectomy during a single anesthetic encounter. Such care may not only reduce costs but also limit parental work absences and increase convenience for patient families. When compared with procedures performed separately, combined procedures did not result in increased morbidity or significant changes in postoperative outcomes.

Dura to spinal cord distance at different vertebral levels in children and its implications on epidural analgesia: A retrospective MRI-based study

BACKGROUND

The distance from the dura to spinal cord is not uniform at different vertebral levels. The dura to spinal cord distance may be a critical factor in avoiding the potential for neurological injury caused by needle trauma after a dural puncture. Typically, the greater the dura to spinal cord distance, the larger the potential safety margin. The objective of our study is to measure dura to spinal cord distance at two thoracic levels T₆ -₇ , T₉ -₁₀ , and one lumbar level L₁ -₂ using MRI images.

METHODS

Eighty-eight children under the age of 8 years old qualified for the study. The distance from dural side of ligamentum flavum to the posterior margin of the spinal cord was defined as dura to spinal cord distance. Sagittal T₂ -weighted images of the thoracic and lumbar spine were used to measure the dura to spinal cord distance at the T_6-7 , T_9-10 , and L_1-2 interspaces. Measurements were taken perpendicular to long axis of the vertebral body at each level.

RESULTS

The dura to spinal cord distance was 5.9 ± 1.6 mm at T_6-7 (range: 1.4-9.9 mm), 5.0 ± 1.6 mm at T_9-10 (1.2-8.1 mm), and 3.6 ± 1.2 mm at L_1-2 (1.2-6.8 mm). There were no evident differences in dura to spinal cord distance by gender, age, height, or weight.

CONCLUSION

The present study reports that the largest dura to spinal cord distance is found at the T_5-6 level, and the shortest dura to spinal cord distance at the L_1-2 level. There appears to be substantially more room in the dorsal subarachnoid space at the thoracic level. The risk of spinal cord damage resulting from accidental epidural needle advancement may be greater in the lumbar region due to a more dorsal location of the spinal cord in the vertebral canal compared to the thoracic region.