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Said SM, Marey G, Knutson S, Rodgers N, Richtsfeld M, Joy B, Griselli M. Outcomes of Surgical Repair of Vascular Rings and Slings in Children: A Word for the Asymptomatic. Semin Thorac Cardiovasc Surg 2020; 33:492-500. [PMID: 32977012 DOI: 10.1053/j.semtcvs.2020.09.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Accepted: 09/08/2020] [Indexed: 11/11/2022]
Abstract
Vascular rings (VRs) are rare aortic arch anomalies that may present with a wide variety of symptoms related to esophageal and/or airway compression. We reviewed our surgical experience in both symptomatic and asymptomatic children. All children (n = 58) who underwent surgical repair of VRs or slings (mean age 27.4 ± 45.60 months; 36 males [62%]) between March 2000 and April 2020 were included. The most common anatomic variant was a right aortic arch (RAA) with aberrant left subclavian artery (ALSCA) (n = 29; 50%). Kommerell's diverticulum was present in 23 of these patients (79%). The second most common variant was a double aortic arch (n = 22; 38%), followed by pulmonary artery sling (n = 4; 6%), RAA with mirror image branching and left ligamentum arteriosum (n = 3; 5.2%), and left aortic arch (LAA) with aberrant right subclavian artery (n = 1; 1.7%). One patient had a double ring with pulmonary artery sling and RAA with ALSCA. Symptoms were present in 42 patients (72%). Left lateral thoracotomy was the approach in 50 patients (86%), while sternotomy was used in 8 (14%). Symptomatic improvement occurred in the majority of symptomatic patients (93%). There was one perioperative mortality (1.7%) in the symptomatic group which was non-VR related. Morbidities included recurrent laryngeal nerve injury in three patients (5.2%) and transient chylothorax in two (3.4%). Persistence/recurrence of symptoms resulted in one early and one late reoperation. The mean follow-up was 3 ± 5 years. In the current era, VR repair in children including asymptomatic ones can be performed with excellent results. We recommend complete repair of RAA with aberrant LSCA by resection of Kommerell's diverticulum and translocation of the ALSCA to avoid recurrence.
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Affiliation(s)
- Sameh M Said
- Divisions of Pediatric Cardiovascular Surgery, Masonic Children's Hospital, University of Minnesota, Minneapolis, Minnesota; Department of Cardiothoracic Surgery, Faculty of Medicine, Alexandria University, Alexandria, Egypt.
| | - Gamal Marey
- Divisions of Pediatric Cardiovascular Surgery, Masonic Children's Hospital, University of Minnesota, Minneapolis, Minnesota
| | - Stacie Knutson
- Pediatric Cardiology, Masonic Children's Hospital, University of Minnesota, Minneapolis, Minnesota
| | - Nathan Rodgers
- Pediatric Cardiology, Masonic Children's Hospital, University of Minnesota, Minneapolis, Minnesota
| | - Martina Richtsfeld
- Pediatric Anestheiology, Masonic Children's Hospital, University of Minnesota, Minneapolis, Minnesota
| | - Brian Joy
- Pediatric Critical Care, Masonic Children's Hospital, University of Minnesota, Minneapolis, Minnesota
| | - Massimo Griselli
- Divisions of Pediatric Cardiovascular Surgery, Masonic Children's Hospital, University of Minnesota, Minneapolis, Minnesota
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Kloesel B, Dua N, Eskuri R, Hall J, Cohen M, Richtsfeld M, Belani K. Anesthetic management of pediatric patients diagnosed with X-linked adrenoleukodystrophy: A single-center experience. Paediatr Anaesth 2020; 30:124-136. [PMID: 31841242 DOI: 10.1111/pan.13786] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Revised: 12/01/2019] [Accepted: 12/06/2019] [Indexed: 01/14/2023]
Abstract
BACKGROUND X-linked adrenoleukodystrophy is a progressive demyelinating disease that primarily affects males with an incidence of 1:20 000-30 000. The disease has a wide spectrum of phenotypic expression and may include adrenal insufficiency, cerebral X-linked adrenoleukodystrophy and adrenomyeloneuropathy. The condition has implications for the administration of anesthesia and reports of anesthetic management in those patients are limited at this point. AIM To review the perioperative care, complications and outcomes of patients diagnosed with X-linked adrenoleukodystrophy at the University of Minnesota Masonic Children's Hospital. METHOD After obtaining IRB approval, we performed a retrospective chart review of pediatric patients diagnosed with X-linked adrenoleukodystrophy who underwent either surgery or diagnostic/therapeutic procedures that included anesthesia services between January 2014 and December 2016. Data included demographics, American Society of Anesthesiologists classification, preoperative diagnosis, history of hematopoietic stem cell transplant, anesthetic approaches, airway management, medications used, intra- and postoperative complications, and patient disposition. RESULTS We identified 38 patients who had a total of 166 anesthetic encounters. The majority of patients underwent procedures in the sedation unit (75.9%) and received a total intravenous anesthetic with spontaneous ventilation via a natural airway (86.1%). Preoperative adrenal insufficiency was documented in 87.3% of the encounters. Stress-dose steroids were administered in 70.5% of the performed anesthetics. A variety of anesthetic agents were successfully used including sevoflurane, isoflurane, propofol, midazolam, ketamine, and dexmedetomidine. There were few perioperative complications noted (6.6%) and the majority were of low severity. No anesthesia-related mortality was observed. CONCLUSIONS With the availability of skilled pediatric anesthesia care, children with X-linked adrenoleukodystrophy can undergo procedures under anesthesia in sedation units and regular operating rooms with low overall anesthesia risk.
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Affiliation(s)
- Benjamin Kloesel
- Division of Pediatric Anesthesiology, Department of Anesthesiology, Masonic Children's Hospital, University of Minnesota, Minneapolis, Minnesota
| | - Nupur Dua
- Division of Pediatric Anesthesiology, Department of Anesthesiology, Masonic Children's Hospital, University of Minnesota, Minneapolis, Minnesota
| | - Ryan Eskuri
- Division of Pediatric Anesthesiology, Department of Anesthesiology, Masonic Children's Hospital, University of Minnesota, Minneapolis, Minnesota
| | - Jason Hall
- Division of Pediatric Anesthesiology, Department of Anesthesiology, Masonic Children's Hospital, University of Minnesota, Minneapolis, Minnesota
| | - Melissa Cohen
- Division of Pediatric Anesthesiology, Department of Anesthesiology, Masonic Children's Hospital, University of Minnesota, Minneapolis, Minnesota
| | - Martina Richtsfeld
- Division of Pediatric Anesthesiology, Department of Anesthesiology, Masonic Children's Hospital, University of Minnesota, Minneapolis, Minnesota
| | - Kumar Belani
- Division of Pediatric Anesthesiology, Department of Anesthesiology, Masonic Children's Hospital, University of Minnesota, Minneapolis, Minnesota
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Marey G, McHugh KM, Sakhitab-Kerestes AM, Jang S, Steiner ME, John R, Richtsfeld M, Said SM, Ameduri R, Griselli M. HeartMate III as a Bridge to Transplantation in an Adolescent With Failed Fontan Circulation. JACC Case Rep 2019; 1:512-515. [PMID: 34316867 PMCID: PMC8288983 DOI: 10.1016/j.jaccas.2019.09.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Revised: 09/10/2019] [Accepted: 09/19/2019] [Indexed: 06/13/2023]
Abstract
HeartMate III is an emerging, small-sized centrifugal ventricular assist device. Its lower pump thrombosis and stroke rates make it favorable for use in pediatrics. We report the use of HeartMate III as a bridge to transplantation in an adolescent with failed Fontan circulation. (Level of Difficulty: Advanced.).
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Affiliation(s)
- Gamal Marey
- Department of Surgery, University of Minnesota Masonic Children’s Hospital, Minneapolis, Minnesota
| | - Kristy M. McHugh
- Department of Solid Organ Transplant, Fairview, Minneapolis, Minnesota
| | | | - Subin Jang
- Department of Surgery, University of Minnesota Masonic Children’s Hospital, Minneapolis, Minnesota
| | - Marie E. Steiner
- Department of Pediatrics, University of Minnesota Masonic Children’s Hospital, Minneapolis, Minnesota
| | - Ranjit John
- Department of Surgery, University of Minnesota, Minneapolis, Minnesota
| | - Martina Richtsfeld
- Department of Anesthesiology, University of Minnesota Masonic Children’s Hospital, Minneapolis, Minnesota
| | - Sameh M. Said
- Department of Surgery, University of Minnesota Masonic Children’s Hospital, Minneapolis, Minnesota
| | - Rebecca Ameduri
- Department of Pediatrics, University of Minnesota Masonic Children’s Hospital, Minneapolis, Minnesota
| | - Massimo Griselli
- Department of Surgery, University of Minnesota Masonic Children’s Hospital, Minneapolis, Minnesota
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Kloesel B, Richtsfeld M, Konia M, Bass JL. Management and Anesthetic Considerations for Patients With Anomalous Aortic Origin of a Coronary Artery. Semin Cardiothorac Vasc Anesth 2018; 22:383-394. [PMID: 30095030 DOI: 10.1177/1089253218793888] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
The term "coronary artery anomalies" encompasses a large and heterogeneous group of disorders that may affect origin, intrinsic anatomy, course, location, and termination of the coronary arteries. With these different anatomies, presentation, symptoms, and outcomes are heterogeneous as well. While significant efforts are directed toward improving diagnosis and risk-stratification, best evidence-guided practices remain in evolution. Data about anesthetic management of patients with coronary anomalies are lacking as well. This review aims to provide the anesthesiologist with a better understanding of an important subgroup of coronary artery anomalies: anomalous aortic origin of a coronary artery. We will discuss classification, pathophysiology, incidence, evaluation, management, and anesthetic implications of this potentially fatal disease group.
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Affiliation(s)
- Benjamin Kloesel
- 1 Masonic Children's Hospital, University of Minnesota, Minneapolis, MN, USA
| | - Martina Richtsfeld
- 1 Masonic Children's Hospital, University of Minnesota, Minneapolis, MN, USA
| | - Mojca Konia
- 1 Masonic Children's Hospital, University of Minnesota, Minneapolis, MN, USA
| | - John L Bass
- 1 Masonic Children's Hospital, University of Minnesota, Minneapolis, MN, USA
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Richtsfeld M, Konia M, Hiremath G, Kloesel B. Anesthetic Management During Atrial Septostomy in a Conjoined Thoraco-Omphalopagus Twin With Tricuspid Atresia and d-Transposition of the Great Arteries Before Separation. A A Pract 2018; 10:298-301. [DOI: 10.1213/xaa.0000000000000691] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Gniadek TJ, Richtsfeld M, Pulkrabek S, Hansen KR, Barnett SL, Joyner N, Kinney S, Zantek ND, Azakie A, Cohn CS. Mechanical hemolysis in pediatric patients associated with rapid transfusion and one-way valve. Transfusion 2018; 58:1228-1233. [DOI: 10.1111/trf.14554] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2017] [Revised: 12/07/2017] [Accepted: 01/13/2018] [Indexed: 11/26/2022]
Affiliation(s)
- Thomas J. Gniadek
- Department of Laboratory Medicine and Pathology; University of Minnesota; Minneapolis Minnesota
| | - Martina Richtsfeld
- Department of Anesthesiology; University of Minnesota; Minneapolis Minnesota
| | - Shelley Pulkrabek
- Department of Laboratory Medicine and Pathology; University of Minnesota; Minneapolis Minnesota
| | | | | | - Nitasha Joyner
- Clinical Perfusionist; University of Minnesota; Minneapolis Minnesota
| | - Stephanie Kinney
- Department of Laboratory Medicine and Pathology; University of Minnesota; Minneapolis Minnesota
| | - Nicole D. Zantek
- Department of Laboratory Medicine and Pathology; University of Minnesota; Minneapolis Minnesota
| | - Anthony Azakie
- Division of Pediatric Cardiac Surgery; University of Minnesota; Minneapolis Minnesota
| | - Claudia S. Cohn
- Department of Laboratory Medicine and Pathology; University of Minnesota; Minneapolis Minnesota
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Affiliation(s)
- Martina Richtsfeld
- From the *Department of Anesthesiology, University of Minnesota Medical School, Minneapolis, Minnesota; †Pediatric Cardiac Anesthesia, University of Minnesota Masonic Children's Hospital, Minneapolis, Minnesota; ‡Department of Anesthesiology, Pediatrics and Medicine, University of Minnesota Medical School, Minneapolis, Minnesota; and §Department of Pediatric Anesthesiology, University of Minnesota Masonic Children's Hospital, Minneapolis, Minnesota
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Abstract
BACKGROUND Recent reports indicate increased incidence of Clostridium botulinum infections, particularly among drug abusers and tissue allograft recipients. Botulinum toxin also has potential application in biochemical warfare. The neurotoxin-induced paralysis often requires mechanical ventilation with and without muscle relaxants. The authors investigated the long-term effects of botulinum toxin on muscle function, expression of nicotinic acetylcholine receptors (nAChRs), and their interaction with muscle relaxant, atracurium. METHODS Rats (n=30) were injected with varying doses (0.625, 2.5, and 10 U) of botulinum toxin into the tibialis muscle. Control animals (n=9) received an equivalent volume of saline. At 128 days after injection, neuromuscular function, pharmacodynamics of atracurium, and nAChRs were evaluated. RESULTS Nerve-evoked tensions, including tetanic tension and muscle mass, were decreased on the toxin-injected side in a dose-dependent manner relative to saline-injected controls as well as the contralateral side. Specific muscle tension and specific tetanic muscle tension (tensions/muscle mass) were not reduced. The ED10 of atracurium was reduced, the ED50 was unchanged, and the ED90 was increased in the highest (10-U) dose of toxin group. The atracurium plasma concentration to maintain a steady state 50% paralysis was significantly reduced in the 10-U toxin group. The nAChR concentrations in the tibialis muscle were significantly increased in a dose-dependent manner in all experimental groups. CONCLUSION Botulinum toxin causes dose-dependent long-term neuromuscular changes. The loss of tension generating capacity is almost exclusively related to muscle atrophy, because the specific tension did not change. The decreased ED10, unaltered ED50, and increased ED90 to atracurium suggest its interactions with different isoforms of receptors having varying sensitivity to atracurium. The absence of fade, despite the persistent botulinum toxin-induced denervation (increased nAChRs), suggests that the up-regulated nAChRs may have compensated for the prejunctional effects of botulinum toxin.
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Affiliation(s)
- Christiane G Frick
- Department of Anesthesia and Critical Care, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts 02114, USA.
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Abstract
Lethal hyperkalemic response to succinylcholine continues to be reported, but the molecular mechanisms for the hyperkalemia have not been completely elucidated. In the normal innervated mature muscle, the acetylcholine receptors (AChRs) are located only in the junctional area. In certain pathologic states, including upper or lower motor denervation, chemical denervation by muscle relaxants, drugs, or toxins, immobilization, infection, direct muscle trauma, muscle tumor, or muscle inflammation, and/or burn injury, there is up-regulation (increase) of AChRs spreading throughout the muscle membrane, with the additional expression of two new isoforms of AChRs. The depolarization of these AChRs that are spread throughout the muscle membrane by succinylcholine and its metabolites leads to potassium efflux from the muscle, leading to hyperkalemia. The nicotinic (neuronal) alpha7 acetylcholine receptors, recently described to be expressed in muscle also, can be depolarized not only by acetylcholine and succinylcholine but also by choline, persistently, and possibly play a critical role in the hyperkalemic response to succinylcholine in patients with up-regulated AChRs.
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Richtsfeld M, Yasuhara S, Blobner M, Martyn J. Chronische Behandlung mit Pyridostigmin vermindert die Expression von Acetylcholinrezeptoren. Anasthesiol Intensivmed Notfallmed Schmerzther 2005. [DOI: 10.1055/s-2005-861734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Mayer B, Richtsfeld M, Gordan L, Michaelis C, Blobner M. Cognitive Deficits in a Sepsis Model of iNOS-Induction but Not in E. Coli Sepsis. Anesthesiology 2002. [DOI: 10.1097/00000542-200209002-00366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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