The effect of volume of local anesthetic on the anatomic spread of caudal block in children aged 1-7 years

OBJECTIVES

To examine the anatomic spread of caudal local anesthetic solution in children aged 1-7 years.

AIM

To determine whether incremental increases in the volume of caudal injections of 0.5, 0.75, and 1.0 ml·kg(-1) result in reliable (>90%) and potentially clinically significant increases in the number of vertebral segments reached.

BACKGROUND

Caudal block is one of the most frequently performed pediatric regional analgesic techniques. Traditional formulae suggest that changes in the volume of caudal injectate in the range 0.5-1.0 ml·kg(-1) would have clinically useful effects.

METHODS

In a single blind design, 45 children aged 1-7 years undergoing caudal block received one of the three predetermined volumes (0.5, 0.75, and 1 ml·kg(-1) ) of local anesthetic solution containing radio-opaque contrast under controlled conditions. Following X-ray examination, the anatomic spread of the block was reported by a radiologist blinded to the volume of solution received.

RESULTS

There were 15 children in each group, and they were similar in terms of age, height, and weight. Spread was observed between the 5th lumbar (L5) and 12th thoracic (T12) vertebral levels. A volume of 1 ml·kg(-1) results in a small but significantly greater spread of solution than 0.5 ml·kg(-1) (P < 0.05), but there was no difference between 0.5 and 0.75 ml or between 0.75 and 1.0 ml. No volume reliably reached a level higher than the second lumbar vertebra (L2).

CONCLUSIONS

Incrementally increasing the volume of injectate between 0.5 and 1.0 results in a modest increase in the spread of the caudal solution. It is unlikely that volumes of <1 ml will reliably reach a vertebral level that is higher than L2.

Chronic facial pain following injection of sodium tetradecyl sulphate into an intraparotid haemolymphangioma

Objective:

We report a rare case of chronic facial pain following sclerotherapy for intraparotid haemolymphangioma, thereby highlighting an important clinical consideration when advising this treatment option as an alternative to surgery in the head and neck.

Method:

Case report, with a review of relevant literature.

Results:

Sclerotherapy of lymphangiomata is well reported in the literature. Unusually, our young patient with an intraparotid haemolymphangioma experienced severe, chronic pain following intralesional injection of sodium tetradecyl sulphate, which required management by a specialist pain service. We discuss the technique of sclerotherapy for such lesions, and also discuss the potential side effects of two agents commonly used in our centre: OK 432 and sodium tetradecyl sulphate.

Conclusion:

Non-surgical treatments of lymphangiomata and venous vascular malformations are not without complication. Both patient and clinician should be aware of this, and of the other potential side effects of sclerotherapy, prior to its use in the head and neck.

Primary thoracic myxoid variant of extrarenal rhabdoid tumor in childhood

Primary extrarenal rhabdoid tumors (RT) are now recognized as a specific entity in pediatric oncological pathology practice. We present an unusual case of a small cell myxoid variant of a thoracic RT in an infant and highlight the importance of recent molecular developments in the diagnosis of these tumors. An 8-month-old child presented with a short history of cough and shortness of breath. Imaging demonstrated a large mass occupying the majority of the thoracic cavity on the right side. A percutaneous needle biopsy of the mass showed fragments of tissue composed of malignant tumor with a predominant "small ovoid cell" phenotype and extensive myxoid change, with small nests and islands of tumor cells; occasional cells demonstrated open vesicular nuclei, prominent nucleoli, and eosinophilic cytoplasmic inclusions. Immunohistochemical staining revealed focal strong cytoplasmic positivity for cytokeratin, focal strong paranuclear cytoplasmic vimentin positivity, and INI1 staining showed normal nuclear positivity in control tissues but was negative in tumor cell nuclei. Electron microscopy demonstrated characteristic paranuclear whorls of intermediate filaments confirming the diagnosis of extrarenal malignant RT. The diagnosis of malignant rhabdoid tumor may be difficult, particularly in cases, such as the present, with a predominant small-cell myxoid phenotype. The characteristic expression patterns of cytokeratin and vimentin provide strong clues to the diagnosis, and the use of INI1 antibody now makes definitive diagnosis possible even on needle core biopsies.

Melanotic neuroectodermal tumor of infancy: clinical, radiological, and pathological features

We present a case of a 4-month-old female infant with a maxillary melanotic neuroectodermal tumor of infancy (MNTI) and review the pooled data from previous publications on this entity. The literature to date comprises 378 reported cases from 1918 to the present, from which data on the presence or absence of metastatic disease was available in 311, and on the presence or absence of local recurrence in 165. These pooled data suggest a local recurrence rate of 36% with metastasis occurring in 7% of cases. At present, the optimal management includes complete surgical excision with clear margins, but there are no reliable histopathological or molecular features to predict the biological behavior in individual cases.

Bacterial contamination of central venous catheters during insertion: a double blind randomised controlled trial

Static electricity within sterile packaging may result in bacterial contamination of central venous catheters (CVCs) prior to insertion. To prevent this, some surgeons inject saline into the pack before opening it. This trial was designed to determine the effect of this procedure. A double blind randomised controlled trial of 47 CVCs comparing injection of 2 ml of sterile saline into the pack prior to opening with no injection was performed. Five centimetre lengths cut from the tip of the catheter before and after subcutaneous tunnelling were sent for microbiological culture. Eight catheters (17%) showed evidence of bacterial contamination prior to insertion into the vein. Two (4.2%) were contaminated prior to tunnelling and seven (14.9%) afterwards. One catheter was contaminated before and after tunnelling. All but one of the contaminating bacteria were coagulase negative staphylococci. There was no significant difference in the contamination rate between catheters from packs that had been injected (5/25) and those that had not (3/22), P = 0.56. Just under one-fifth of the catheters were contaminated with bacteria prior to insertion into the vein but this was not influenced by prior injection of saline into the pack. We conclude that there is no evidence to support the practice of injecting the catheter pack prior to opening.

Massive cardiac chondroma presenting with heart failure and superior vena cava obstruction in a teenage boy

Histologically benign soft-tissue chondromas have been reported at many anatomical sites but are an uncommon cause of soft tissue mass lesions in childhood, accounting for less than 1% of cases. The most frequent sites for extraosseous soft-tissue chondromas are the hands and feet. For the extremely rare visceral chondromas, the site can be lung, where they may represent a component of Carney's syndrome of extra-adrenal paraganglioma, pulmonary chondroma, and epithelioid leiomyosarcoma of the gastrointestinal tract. Primary cardiac chondromas are exceptionally rare in patients of any age although cardiac chondrosarcoma, both primary and metastatic, is well reported. We present a case of a teenage boy with a fatal cardiac chondroma

Anaesthetic management of hepatic artery chemoembolization in a paediatric patient

We present a case of a 3-year-old child who underwent hepatic artery chemoembolization. The anaesthetic management, prophylaxis of tumour lysis syndrome, nausea and vomiting and the management of perioperative pain relief are all discussed.

Current management and outcome of tracheobronchial malacia and stenosis presenting to the paediatric intensive care unit

OBJECTIVE

To identify factors associated with mortality and prolonged ventilatory requirements in patients admitted to our paediatric intensive care unit (PICU) with tracheobronchial malacia and stenosis diagnosed by dynamic contrast bronchograms.

DESIGN

Retrospective review.

SETTING

Tertiary paediatric intensive care unit.

PATIENTS

Forty-eight cases admitted to our PICU over a 5-year period in whom a diagnosis of tracheobronchial malacia or stenosis was made by dynamic contrast bronchography (1994-1999).

INTERVENTIONS

Conservative management, tracheostomy and long-term ventilation, surgical correction, internal or external airway stenting.

MEASUREMENTS AND RESULTS

Recording of clinical details, length of invasive ventilation and appearance at contrast bronchography. Five groups of patients were defined: isolated primary airway pathology (n = 7), ex-premature infants (n = 11), vascular rings (n = 9), complex cardiac and/or syndromic pathology (n = 17) and tracheo-oesophageal fistulae (n = 4). The overall mortality was 29%. Median length of invasive ventilation in survivors was 38 days and in patients who died 45. Mortality was highest in the patients with complex cardiac and/or syndromic pathology (p = 0.039 Cox regression analysis) but was not related to any other factor. Patients with stenosis required a significantly longer period of ventilatory support (median length of ventilation 59 days) than patients with malacia (39 days).

CONCLUSIONS

Length of ventilation and bronchographic diagnosis did not predict survival. The only factor found to contribute significantly to mortality was the presence of complex cardiac and/or syndromic pathology. However, patients with stenosis required longer ventilatory support than patients with malacia.

Testicular catch-up growth after varicocele correction in adolescents

We evaluated retrospectively the outcome of artery-sparing (AS) versus non-artery-sparing (NAS) laparoscopic varicocelectomy and measured any reversal of testicular growth. Twenty patients (13 left and 7 bilateral varicoceles) were evaluated after surgery. A total of 27 varicocelectomies (20 AS and 7 NAS) were performed. The indication for surgery was smaller testicular size on the affected side in all patients and discomfort/pain in 3. The mean age was 12.9 years (range 8-15 years) at surgery. The testicular volumes were determined clinically and by color Doppler sonography (US). The follow-up time was 6-48 months after surgery. There were 4 recurrences out of 27 varicocelectomies (15%), of which 1 has been reoperated. Testicular volumes were equal in both groups after surgery, indicating catch-up growth except in the cases with minor recurrences (2 AS and 2 NAS varicocelectomies). In 12 testes, dilated veins in the pampiniform plexus were revealed by US. No severe intraoperative complications occurred. Three patients had a hydrocele after surgery (11%). These data show that there is testicular catch-up growth after varicocelectomy, but some questions remain unanswered: (1) should the remaining dilated veins detected by Doppler US be tackled; and (2) is an AS operation worthwhile?