Coagulation abnormalities in pediatric and adult patients after sclerotherapy or embolization of vascular anomalies

OBJECTIVE

The purpose of our study was to examine the coagulation status in patients with vascular anomalies who had undergone sclerotherapy or embolization.

SUBJECTS AND METHODS

Ours was a prospective pilot study of 29 patients who had undergone sclerotherapy or embolization of large vascular anomalies. Fibrinogen, platelet, and d-dimer levels and prothrombin time were obtained before, immediately after, and on the day after the procedure.

RESULTS

Five patients with venous malformations had positive d-dimer levels before the procedure. A subgroup analysis revealed a relationship between the type of agent used and the change in coagulation status. Specifically, a positive relationship was found between the use of dehydrated alcohol or sodium tetradecyl sulfate and a disruption in coagulation profiles as evidenced by a decrease in platelets and fibrinogen, an increase in prothrombin time, and a conversion from negative to positive d-dimers. In contrast, sclerotherapy or embolization with cyanoacrylic, polyvinyl alcohol foam particles, or platinum microcoils was not associated with coagulation disturbances.

CONCLUSION

The coagulation disturbances that occur in response to dehydrated alcohol or sodium tetradecyl sulfate sclerotherapy or embolization could compromise the patient's clotting ability. Patients who receive dehydrated alcohol or sodium tetradecyl sulfate during a preoperative sclerotherapy or embolization may experience coagulation disturbances that could increase the risk of bleeding, thrombosis, or hematoma. This patient population may benefit from the use of glue, foam, or coils as a substitute for dehydrated alcohol or sodium tetradecyl sulfate.

Perioperative considerations in a hypothyroid infant with hepatic haemangioma

Hepatic haemangiomas in infants are rare. An infant with both a hepatic haemangioma and a severe hypothyroid condition, unresponsive to conventional thyroxine therapy, will be described. This case presented here is the perioperative management of a critically ill infant who had myocardial depression secondary to hypothyroidism and a hepatic haemangioma that required embolization. To our knowledge, this is the first published report describing intravenous triiodothyronine as a therapeutic modality to stabilize a hypothyroid infant prior to undergoing a general anaesthetic.

Serum ethanol levels in children and adults after ethanol embolization or sclerotherapy for vascular anomalies

PURPOSE

To evaluate the serum ethanol level in children and adults after ethanol embolization or sclerotherapy for vascular anomalies.

MATERIALS AND METHODS

Serum ethanol level was evaluated in 71 patients with vascular anomalies who underwent ethanol embolization, sclerotherapy, or both. Blood used to determine serum ethanol level was drawn at the end of each procedure.

RESULTS

The relationship between serum ethanol level and amount of ethanol administered was statistically significant. Results of stepwise linear regression analysis showed that the amount of ethanol administered (P <.001) and type of malformation (P =.02) were multivariate predictors of serum ethanol level. Results of logistic regression analysis revealed that the only uni- or multivariate predictor of legal intoxication was the amount of ethanol administered (P =.018). Five patients fulfilled the criteria for legal intoxication, and the mean amount of ethanol administered to these patients was 0.87 mL per kilogram of body weight +/- 0.18 (SD) (range, 0.55-0.99 mL/kg).

CONCLUSION

The volume of ethanol administered is the most reliable predictor of serum ethanol level and legal intoxication. Patients who receive up to 1.0 mL/kg ethanol during embolization or sclerotherapeutic procedures may have elevated serum ethanol levels that could put them at risk of respiratory depression, cardiac arrhythmias, seizures, rhabdomyolysis, and hypoglycemia.

Lung growth after reduced size transplantation in a sheep model

BACKGROUND

The growth of mature allografts is a critical issue in pediatric lung transplantation. This study explores the architectural changes of mature sheep lung when submitted to two different compensatory growth forces: either transplantation into a neonatal host or expansion in an otherwise empty adult hemithorax.

METHODS

Right upper lobes (RUL) (mean+/-SEM, 66.7+/-1.9 kg) from 4- to 5-year old (adult sheep) were transplanted into newborn (n=6) lambs (5.4+/-0.3 kg, 5+/-2 days old) that were then allowed to survive for 45 days. Changes in pulmonary volume and architecture were measured before and after transplantation. Allografts were compared with both normal adult RUL (n=10) and adult (65.8+/-2.2 kg and 4 to 5 year old) RUL that remained in situ for 45 days after resection of the corresponding middle and lower lobes (n=6). Statistical differences were analyzed using two-sample and paired t tests.

RESULTS

In adult animals, RUL remaining in the otherwise empty hemithorax compensated by an 85% increase in volume (251.5+/-18.7 ml vs. 466+/-32.8 ml) (P<0.0001). Concomitant increases in total internal alveolar surface area (48%) and alveolar size were prominent. The number of alveoli per volume decreased proportionately to the increases in volume (P<0.0001). There was no significant change in the calculated number of alveoli (345.6+/-40.5 x 10(6)) compared with the normal adult RUL (402.4+/-40.7x10(6)) (P=0.37). Transplant recipients received a reduced-size normal adult RUL (49%) in volume (125.3+/-21.5 ml). Allografts 45 days after transplantation showed a 73% increase in volume (216.4+/-21.3 ml) (P<0.0001) with a parallel (83%) increase in total internal alveolar surface area (P=0.008). The number of alveoli per volume remained constant (P=0.21) despite the increase in volume. There was therefore a significant increase in the calculated number of alveoli from before transplantation (172.5+/-35.9x 106) compared with that observed 45 days after transplantation (389.7+/-77.7x10(6)) (P=0.012).

CONCLUSIONS

We conclude that mature sheep RUL parenchyma compensates with dilation of the respiratory structures in the adult animal, whereas there is alveolar multiplication when transplanted into newborn recipients.

Size disparity in pediatric lung transplantation

Donor scarcity and the limitations of organ preservation dictate that a wide size range be used to maximize effective donor utilization in pulmonary transplantation. Problems of size disparity are magnified in the pediatric population, where relevant dimensions vary considerably by age. There have been 10 pediatric lung recipients (7 bilateral, 2 single, 1 heart-lung) at our institution since 1991. The age range was 3 to 26 years (mean, 13.7), and the weight range was 15 to 57 kg (mean, 33.6). Diagnoses included cystic fibrosis (5), pulmonary fibrosis (2), pulmonary hypertension (2), and arteriovenous malformation (1). The donor-to-recipient weight ratio ranged from 0.45 to 1.9, and the donor-to-recipient thoracic height ratio ranged from 0.6 to 1.6. Lobar resection and delayed chest closure was required in one case and was successful. Cardiopulmonary bypass was used electively in seven cases. No reexplorations for bleeding were necessary. Two of the three hospital deaths resulted from right ventricular failure, judged to be secondary to excessive pulmonary artery pressures intraoperatively associated with small donor allografts. Elective bypass had not been used. Inhaled nitric oxide (6 patients) and/or extracorporeal membrane oxygenation (2 patients) were used for temporary postoperative support. The hospital survival rate was 70% (7/10). One late death occurred 14 months postoperatively and was caused by obliterative bronchiolitis. The authors conclude that size disparity is a significant problem in pediatric lung transplantation. However, with elective use of cardiopulmonary bypass and aggressive postoperative support, a broad size range can be used.

Postintubation croup in children

Incidence of and contributory factors in postintubation laryngeal edema were determined in 7875 children under 17 years of age. Data were assembled in the manner of a prospective study. With an overall incidence of 1 percent, children between ages 1 and 4 were most susceptible. Excessive size of the endotracheal tube was suspect in half of the cases. Other factors that increase trauma to the larynx while an endotracheal tube is in place showed significant correlation to the total incidence of postintubation laryngeal edema. No tracheostomies were required.