The signs and symptoms of Ernest Shackleton

Ernest Shackleton, an accomplished Antarctic explorer, developed a life-threatening illness during the Discovery Antarctic expedition of 1901-4. His documented signs and symptoms included inflamed gums attributed to scurvy, severe dyspnea, and exercise intolerance, presenting in a setting of nutritional deficiency. Physical examinations at a later date, also following a prolonged diet of limited fresh food, revealed a pulmonary systolic murmur. Thiamine deficiency with cardiomyopathy, either alone or subsequently exacerbated by advanced scurvy, may have been a prominent cause of Shackleton's condition.

Beyond Ether Day: Betsey Magoun, The Forgotten Patient

Although the analgesic effects of ether were conclusively established during a series of public demonstrations of anesthesia at Massachusetts General Hospital in 1846, ether anesthesia was neither immediately nor universally introduced into practice. Betsey Magoun, the fourth patient undergoing surgery under anesthesia at the hospital, suffered life-threatening hypoxia and respiratory complications. Severe intraoperative problems witnessed by large audience may have contributed to the cautious introduction of anesthesia into routine practice. Ether inhalation was not commonly used until more effective methods of induction and maintenance of anesthesia were discovered.

Ether Day Revisited: The Surgical Records of Edward Gilbert Abbott

Background

The details of the public demonstration of the effects of ether that initiated the modern era of surgery and anesthesia are often misreported. Existing published transcripts of the clinical records are incomplete or inaccurate.

Methods

The patient notes of Gilbert Abbott were photographed, transcribed, and reviewed.

Results

The records are handwritten in "Surgical Records for 1846; Volume 30," of the Massachusetts General Hospital. The patient was admitted on September 25. The presenting condition was a congenital, mobile, compressible, multilobed, small lesion at the angle of the left mandible, and base of tongue. The operation on October 16 was an attempted ligation of the blood supply to the lesion. The postoperative diagnosis was a vascular lesion ("erectile tumor"). Postoperative management included application of sclerosants. The mass was unchanged in size on discharge on December 7. There is no documentation of the anesthetic administration in the progress note but a retrospective report of the anesthetic is pasted into the Records book. This account reported that the patient did not respond to the initial incision. He moved and cried out during the latter part of the procedure. Although he was aware of the operation taking place, he later said he had not experienced pain. The commentary concluded that the demonstration of the analgesic effectiveness of ether was inconclusive but that subsequently ether was shown to be effective.

Conclusions

The surgery on October 16, an unsuccessful ligation of a congenital lymphovascular malformation, was performed under incomplete general anesthesia. Examination of the primary documents may allow for more accurate accounts of circumstances surrounding the discovery of anesthesia.

Surgical, Obstetric, and Anesthetic Mortality Measurement at a Ugandan Secondary Referral Hospital

BACKGROUND

The health care systems of low-income countries have severely limited capacity to treat surgical diseases and conditions. There is limited information about which hospital mortality outcomes are suitable metrics in these settings.

METHODS

We did a 1-year observational cohort study of patient admissions to the Surgery and the Obstetrics and Gynecology departments and of newborns delivered at a Ugandan secondary referral hospital. We examined the proportion of deaths captured by standardized metrics of mortality.

RESULTS

There were 17,015 admissions and 9612 deliveries. A total of 847 deaths were documented: 385 (45.5%) admission deaths and 462 (54.5%) perinatal deaths. Less than one-third of admission deaths occurred during or after an operation (n = 126/385, 32.7%). Trauma and maternal mortality combined with perioperative mortality produced 79.2% (n = 305/385) of admission deaths. Of 462 perinatal deaths, 412 (90.1%) were stillborn, and 50 (10.9%) were early neonatal deaths. The combined metrics of the trauma mortality rate, maternal mortality ratio, thirty-day perioperative mortality rate, and perinatal mortality rate captured 89.8% (n = 761/847) of all deaths documented at the hospital.

CONCLUSIONS

The combination of perinatal, maternal, trauma, and perioperative mortality metrics captured most deaths documented at a Ugandan referral hospital.

The evolution of pediatric sedation and anesthesia patient safety: An interview with Dr Charles J. "Charlie" Coté

The career of Dr Charles J. Coté covered a period of major advances in pediatric anesthesia patient safety. Dr Coté (1946 --), Professor Emeritus in Anaesthesia at Harvard Medical School, helped develop pediatric sedation guidelines, conducted influential clinical research, edited a major textbook, and promoted pediatric anesthesia training fellowships in low- and middle-income countries. Based on a series of interviews with Dr Coté, this article reviews the career of this Robert M. Smith Award winner through the lens of improvements in pediatric sedation and anesthesia patient safety.

Comparative assessment of methicillin resistant Staphylococcus aureus diagnostic assays for use in resource-limited settings

BACKGROUND

The rise of methicillin-resistant Staphylococcus aureus (MRSA) is a global health concern. Paucity of data on MRSA carriage prevalence and diagnostic methods in resource-limited settings hampers efforts to define the problem and plan an appropriate response. Additionally, high variability in cost and logistical characteristics of MRSA screening methods may impede infection control efforts. We compared the performance of locally-available chromogenic agar BD CHROMagar MRSA II and two PCR-based assays (Hain GenoQuick MRSA and Cepheid Xpert SA Complete) for the detection of asymptomatic MRSA carriage in nasal swabs.

RESULTS

During 2015, we enrolled 500 patients from five hospital wards at a Ugandan regional referral hospital. We found 30% prevalence of methicillin-sensitive Staphylococcus aureus (MSSA) nasal carriage, and 5.4% MRSA nasal carriage prevalence. Compared to a composite reference standard defined as a positive test result on any one of the three assays, Hain GenoQuick MRSA demonstrated the highest sensitivity (96%) followed by direct plating on CHROMagar at (70%), with the lowest sensitivity observed with Xpert SA Complete (52%). Cepheid Xpert provided the most rapid results (< 1 h) but was the most expensive (US $45-50/test). Substantially more labor was required for the Hain GenoQuick MRSA compared to Xpert SA Complete or CHROMagar tests.

CONCLUSION

MRSA nasal carriage prevalence rates were low, and high diagnostic sensitivity was achieved using Hain GenoQuick MRSA. Chromogenic media had significantly lower sensitivity, but may represent a viable local option given its lower cost compared to PCR-based assays.

Half a century of anesthesia for children: An interview with Dr. Nishan G. 'Nick' Goudsouzian

The career of Dr Nishan Goudsouzian spanned half a century of pediatric anesthesia. His 50 years saw seminal contributions to the use of neuromuscular blocking agents in children, the development of proton beam therapy and magnetic resonance imaging for pediatric cancer, the introduction of the laryngeal mask airway, an explosion in the volume and depth of knowledge about pediatric anesthesia, the expansion of formal training in pediatric anesthesia, and the widening of academic efforts to improve anesthetic care for children worldwide. Based on interviews with Dr Goudsouzian, this article reviews the contributions of this Robert M. Smith Award winner to the development of pediatric anesthesia.

The analgesic effects of intrathecal morphine in comparison with ultrasound-guided transversus abdominis plane block after caesarean section: a randomised controlled trial at a Ugandan regional referral hospital

Both transversus abdominis plane block and intrathecal morphine may produce prolonged postoperative analgesia, but the respective clinical outcomes of these anaesthetic techniques in resource-limited settings are not well described. We randomly assigned patients undergoing caesarean section to receive a hyperbaric bupivacaine (10 mg) spinal anaesthetic followed by an ultrasound-guided transversus abdominis plane block, or a hyperbaric bupivacaine (10 mg) spinal anaesthetic with 100 mcg intrathecal morphine, followed by a postoperative sham block. Supplemental postoperative analgesia included self-administered oral diclofenac 50 mg and paracetamol 1 g every 8 h. Numerical pain rating scores, the need for rescue medication, side-effects and patient satisfaction were recorded at 8, 16 and 24 h. We enrolled a total of 130 patients, with 65 women in each group. The mean numerical rating score for intrathecal morphine vs. transversus abdominis plane blocks at 8 h were: at rest, 2.5 vs. 3.1 (p = 0.04); with coughing, 4.3 vs. 4.8 (p = 0.07); and with movement, 3.6 vs. 4.2 (p = 0.06). At 16 h, respective scores were: 2.9 vs. 3.1 (p = 0.40) at rest; 4.0 vs. 4.3 (p = 0.19) with coughing; and 4.8 vs. 5.0 (p = 0.33) with movement. At 24 h, the respective scores were: 2.9 vs. 2.3 (p = 0.01); 4.6 vs. 4.2 (p = 0.04) with coughing; and 3.9 vs. 3.4 (p = 0.02) with movement. The need for rescue medication and the incidence of pruritis, sedation and nausea and vomiting were similar in both groups. Patient satisfaction with pain control was similar in both groups, with the majority of patients reporting satisfaction as good or excellent. Intrathecal morphine and transversus abdominis plane block provided clinically similar outcomes for pain relief after caesarean section.

Age-Dependent Changes in the Propofol-Induced Electroencephalogram in Children With Autism Spectrum Disorder

Patients with autism spectrum disorder (ASD) often require sedation or general anesthesia. ASD is thought to arise from deficits in GABAergic signaling leading to abnormal neurodevelopment. We sought to investigate differences in how ASD patients respond to the GABAergic drug propofol by comparing the propofol-induced electroencephalogram (EEG) of ASD and neurotypical (NT) patients. This investigation was a prospective observational study. Continuous 4-channel frontal EEG was recorded during routine anesthetic care of patients undergoing endoscopic procedures between July 1, 2014 and May 1, 2016. Study patients were defined as those with previously diagnosed ASD by DSM-V criteria, aged 2-30 years old. NT patients were defined as those lacking neurological or psychiatric abnormalities, aged 2-30 years old. The primary outcome was changes in propofol-induced alpha (8-13 Hz) and slow (0.1-1 Hz) oscillation power by age. A post hoc analysis was performed to characterize incidence of burst suppression during propofol anesthesia. The primary risk factor of interest was a prior diagnosis of ASD. Outcomes were compared between ASD and NT patients using Bayesian methods. Compared to NT patients, slow oscillation power was initially higher in ASD patients (17.05 vs. 14.20 dB at 2.33 years), but progressively declined with age (11.56 vs. 13.95 dB at 22.5 years). Frontal alpha power was initially lower in ASD patients (17.65 vs. 18.86 dB at 5.42 years) and continued to decline with age (6.37 vs. 11.89 dB at 22.5 years). The incidence of burst suppression was significantly higher in ASD vs. NT patients (23.0% vs. 12.2%, p < 0.01) despite reduced total propofol dosing in ASD patients. Ultimately, we found that ASD patients respond differently to propofol compared to NT patients. A similar pattern of decreased alpha power and increased sensitivity to burst suppression develops in older NT adults; one interpretation of our data could be that ASD patients undergo a form of accelerated neuronal aging in adolescence. Our results suggest that investigations of the propofol-induced EEG in ASD patients may enable insights into the underlying differences in neural circuitry of ASD and yield safer practices for managing patients with ASD.

Retrospective Descriptive Study of an Intensive Care Unit at a Ugandan Regional Referral Hospital

BACKGROUND

We describe delivery and outcomes of critical care at Mbarara Regional Referral Hospital, a Ugandan secondary referral hospital serving a large, widely dispersed rural population.

METHODS

Retrospective observational study of ICU admissions was performed from January 2008 to December 2011.

RESULTS

Of 431 admissions, 239 (55.4 %) were female, and 142 (33.2 %) were children (<18 years). The median length of stay was 2 (IQR 1-4) days, with 365 patients (85 %) staying less than 8 days. Indications for admission were surgical 49.3 % (n = 213), medical/pediatric 27.4 % (n = 118), or obstetrical/gynecological 22.3 % (n = 96). The overall mortality rate was 37.6 % (162/431) [adults 39.3 % (n = 113/287), children 33.5 % (n = 48/143), unspecified age 100 % (n = 1/1)]. Of the 162 deaths, 76 (46.9 %) occurred on the first, 20 (12.3 %) on the second, 23 (14.2 %) on the third, and 43 (26.5 %) on a subsequent day of admission. Mortality rates for common diagnoses were surgical abdomen 31.9 % (n = 29/91), trauma 45.5 % (n = 30/66), head trauma 59.6 % (n = 28/47), and poisoning 28.6 % (n = 10/35). The rate of mechanical ventilation was 49.7 % (n = 214/431). The mortality rate of ventilated patients was 73.5 % (n = 119/224). The multivariate odd ratio estimates of mortality were significant for ventilation [aOR 6.15 (95 % CI 3.83-9.87), p < 0.0001] and for length of stay beyond seven days [aOR 0.37 (95 % CI 0.19-0.70), p = 0.0021], but not significant for decade of age [aOR 1.06 (95 % CI 0.94-1.20), p = 0.33], gender [aOR 0.61(95 % CI 0.38-0.99), p = 0.07], or diagnosis type [medical vs. surgical aOR 1.08 (95 % CI 0. 63-1.84), medical vs. obstetric/gynecology aOR 0.73 (95 % CI 0.37-1.43), p = 0.49].

CONCLUSIONS

The ICU predominantly functions as an acute care unit for critically ill young patients, with most deaths occurring within the first 48 h of admission. Expansion of critical care capacity in low-income countries should be accompanied by measurement of the nature and impact of this intervention.

Prevalence and correlates of MRSA and MSSA nasal carriage at a Ugandan regional referral hospital

Background

Despite increasing antimicrobial resistance globally, data are lacking on prevalence and factors associated with Staphylococcus aureus (SA) and MRSA carriage in resource-limited settings.

Objectives

To determine the prevalence of SA and MRSA nasal carriage and factors associated with carriage among Ugandan regional referral hospital patients.

Methods

We enrolled a cross-section of 500 adults, sampling anterior nares for SA and MRSA carriage using Cepheid Xpert SA Nasal Complete.

Results

Mean age was 37 years; 321 (64%) were female and 166 (33%) were HIV infected. Overall, 316 (63%) reported risk factors for invasive SA infection; 368 (74%) reported current antibiotic use. SA was detected in 29% and MRSA in 2.8%. MRSA and MSSA carriers were less likely than SA non-carriers to be female (50% and 56% versus 68%, P  = 0.03) or to have recently used β-lactam antibiotics (43% and 65% versus 73%, P  = 0.01). MRSA carriers were more likely to have open wounds than MSSA carriers and SA non-carriers (71% versus 27% and 40%, P  = 0.001) and contact with pigs (21% versus 2% and 6%, P  = 0.008). MRSA carriage ranged from 0% of HIV clinic participants to 8% of inpatient surgical ward participants ( P  =   0.01). In multivariable logistic regression analysis, male sex was independently associated with SA carriage (OR 1.68, 95% CI 1.12-2.53, P  =   0.01) and recent β-lactam antibiotic use was associated with reduced odds of SA carriage (OR 0.61, 95% CI 0.38-0.97, P  =   0.04).

Conclusions

MRSA nasal carriage prevalence was low and associated with pig contact, open wounds and surgical ward admission, but not with HIV infection.

Age-dependency of sevoflurane-induced electroencephalogram dynamics in children

BACKGROUND

General anaesthesia induces highly structured oscillations in the electroencephalogram (EEG) in adults, but the anaesthesia-induced EEG in paediatric patients is less understood. Neural circuits undergo structural and functional transformations during development that might be reflected in anaesthesia-induced EEG oscillations. We therefore investigated age-related changes in the EEG during sevoflurane general anaesthesia in paediatric patients.

METHODS

We analysed the EEG recorded during routine care of patients between 0 and 28 yr of age (n=54), using power spectral and coherence methods. The power spectrum quantifies the energy in the EEG at each frequency, while the coherence measures the frequency-dependent correlation or synchronization between EEG signals at different scalp locations. We characterized the EEG as a function of age and within 5 age groups: <1 yr old (n=4), 1-6 yr old (n=12), >6-14 yr old (n=14), >14-21 yr old (n=11), >21-28 yr old (n=13).

RESULTS

EEG power significantly increased from infancy through ∼6 yr, subsequently declining to a plateau at approximately 21 yr. Alpha (8-13 Hz) coherence, a prominent EEG feature associated with sevoflurane-induced unconsciousness in adults, is absent in patients <1 yr.

CONCLUSIONS

Sevoflurane-induced EEG dynamics in children vary significantly as a function of age. These age-related dynamics likely reflect ongoing development within brain circuits that are modulated by sevoflurane. These readily observed paediatric-specific EEG signatures could be used to improve brain state monitoring in children receiving general anaesthesia.

Malignant hyperthermia in the early days of pediatric anesthesia: an interview with anesthesiology pioneer, Dr. John F. Ryan

Dr. John F. Ryan (1935 - ), Associate Professor of Anaesthesia at the Harvard Medical School, influenced the careers of hundreds of residents and fellows-in-training while instilling in them his core values of resilience, hard work, and integrity. His authoritative textbook, A Practice of Anesthesia for Infants and Children, remains as influential today as it did when first published decades ago. Although he had had many accomplishments, he identified his experiences caring for patients with malignant hyperthermia and characterizing the early discovery of this condition as his defining contribution to medicine. Based on a series of interviews with Dr. Ryan, this article reviews a remarkable career that coincides with the dawn of modern pediatric anesthetic practice.

Ultrasound guided transversus abdominis plane versus sham blocks after caesarean section in an Ugandan village hospital: a prospective, randomised, double-blinded, single-centre study

BACKGROUND

Transversus abdominis plane (TAP) block provides 12-24 h of analgesia to the parietal peritoneum and abdominal wall, and are best used combined with oral or intravenous medications. Despite ease of use, a large margin of safety, and a high success rate, TAP blocks remain under used in settings where patients could most benefit from their use. Previous studies have used oral or intravenous narcotics for supplementation. However, the efficacy of TAP blocks in low-resourced settings where patients do not have dependable access to these medications is unknown. This study examines TAP block analgesic efficacy after caesarean section in a poorly resourced setting. We compared the post-operative status of 170 women with self-administered paracetamol-diclofenac with or without TAP blocks. We hypothesised that the block would decrease pain at 8 h, 16 h, and 24 h at rest, with coughing and upon standing.

METHODS

Between Oct 31, and Dec 28, 2013, 180 women were enrolled and randomly assigned to receive either TAP or sham blocks after caesarean section. Bi-institutional (Mbarara Regional Referral Hospital and Massachusetts General Hospital) institutional review board approval was obtained for this single-centre study. After informed written consent, patients received TAP or sham blocks after caesarian section. Inclusion criteria for enrolment were: age 18 years or older, weight at least 50 kg, no allergies to study medications, otherwise healthy (American Society of Anesthesiologists classification status I or II), and having undergone elective, urgent, or emergent caesarian section under spinal anaesthesia without sedation. Under ultrasound guidance, 20-25 mL of 0·25% bupivacaine (epinephrine 1:400 000) were injected near the triangles-of-Petit. Sham blocks consisted of a transducer with a needleless syringe pressed over each flank. In the post-anaesthesia recovery area, all patients received 1000 mg paracetamol and 50 mg diclofenac, orally, to be continued on an 8-h schedule for 3 days. A skilled (masked) research nurse collected all data. The primary outcomes measured were numerical rating scale at 8 h, 16 h, and 24 h at rest, with coughing, and upon standing. The association between the pain scores at each time and type of treatment (TAP vs sham blocks) was assessed using general linear model with repeated measures. Demographics were compared using the two sample t-test (appendix).

FINDINGS

170 patients completed the study; 86 in the sham group and 84 in the study group. Demographics (age, weight, and parity) were similar between both study groups. One participant from the sham group was missing parity information (appendix). Preliminary data analysis showed reduced pain scores at all times, and with all degrees of movement for the TAP group (appendix). The largest reduction in pain was at 8 h (resting 33%, coughing 36%, and standing 44%). With time, the pain scores of the TAP group changed a little, whereas a decreasing trend can be noted in the sham group. No adverse events occurred.

INTERPRETATION

This study show a significant improvement in pain scores for obstetric patients receiving a transversus abdominis plane block in comparison to standard of care in a low income, limited resource setting. The use of these blocks shows the use of an easy, inexpensive, and achievable pain control option. Especially in resource-limited areas, this approach could allow for better pain management and a new standard of care for the world's most common operative procedure.

FUNDING

Eleanor and Miles Harvard Medical School Shore Fellowship Grant, and Massachusetts General Hospital, DACCPM Faculty Development Grant.

Continuous noninvasive cardiac output in children: is this the next generation of operating room monitors? Initial experience in 402 pediatric patients

BACKGROUND

Electrical Cardiometry(™) (EC) estimates cardiac parameters by measuring changes in thoracic electrical bioimpedance during the cardiac cycle. The ICON(®), using four electrocardiogram electrodes (EKG), estimates the maximum rate of change of impedance to peak aortic blood acceleration (based on the premise that red blood cells change from random orientation during diastole (high impedance) to an aligned state during systole (low impedance)).

OBJECTIVE

To determine whether continuous cardiac output (CO) data provide additional information to current anesthesia monitors that is useful to practitioners.

METHODS

After IRB approval and verbal consent, 402 children were enrolled. Data were uploaded to our anesthesia record at one-minute intervals. Ten-second measurements (averaged over the previous 20 heart beats) were downloaded to separate files for later comparison with routine OR monitors.

RESULTS

Data from 374 were in the final cohort (loss of signal or improper lead placement); 292,012 measurements during 58,049 min of anesthesia were made in these children (1 day to 19 years and 1 to 107 kg). Four events had a ≥25% reduction in cardiac index at least 1 min before a clinically important change in other monitored parameters; 18 events in 14 children confirmed manifestations of other hemodynamic measures; eight events may have represented artifacts because the observed measurements did not seem to fit the clinical parameters of the other monitors; three other events documented decreased stroke index with extreme tachycardia.

CONCLUSIONS

Electrical cardiometry provides real-time cardiovascular information regarding developing hemodynamic events and successfully tracked the rapid response to interventions in children of all sizes. Intervention decisions must be based on the combined data from all monitors and the clinical situation. Our experience suggests that this type of monitor may be an important addition to real-time hemodynamic monitoring.

The development of a specialty: an interview with Dr. Mark C. Rogers, a pioneering pediatric intensivist

Dr. Mark C. Rogers (1942-), Professor of Anesthesiology, Critical Care Medicine, and Pediatrics at the Johns Hopkins University, was recruited by the Department of Pediatrics at Johns Hopkins Hospital in 1977 to become the first director of its pediatric intensive care unit. After the dean of the medical school appointed him to chair the Department of Anesthesia in 1979, Rogers changed the course and culture of the department. He renamed it the Department of Anesthesiology and Critical Care Medicine, and developed a long-term strategy of excellence in clinical care, research, and education. However, throughout this period, he never lost his connection to pediatric intensive care. He has made numerous contributions to pediatric critical care medicine through research and his authoritative textbook, Rogers' Textbook of Pediatric Intensive Care. He established a training programme that has produced a plethora of leaders, helped develop the pediatric critical care board examination, and initiated the first World Congress of Pediatric Intensive Care. Based on a series of interviews with Dr. Rogers, this article reviews his influential career and the impact he made on developing pediatric critical care as a specialty.

The use of Google Glass for airway assessment and management

Currently, information about airway assessment and tracheal intubation is communicated verbally or in writing. Google Glass can record this information in real time with minimal disruption to work flow, using standard operating room lighting.

The development of pediatric fluid resuscitation: an interview with Dr. Frederic A. 'Fritz' Berry

Dr. Frederic A. 'Fritz' Berry (1935), Professor Emeritus of Anesthesiology and Pediatrics at the University of Virginia, has played a pioneering role in the development of pediatric anesthesiology through training generations of anesthesiologists. He identifies his early advocacy of balanced electrolyte solution for perioperative fluid resuscitation as his defining contribution. Based on his clinical experiences, he pushed to extend the advances in adult fluid resuscitation into pediatric practice. He imparted these and other insights to his colleagues although textbooks, book chapters, original journal publications, and decades of Refresher Course Lectures at the American Society of Anesthesiologists' annual meetings. A model educator, clinician, and researcher, he shaped the careers of hundreds of physicians-in-training while advancing the field of pediatric anesthesiology.

The development of pediatric critical care medicine at The Children's Hospital of Philadelphia: an interview with Dr. John J. 'Jack' Downes

Dr. John J. 'Jack' Downes (1930-), the anesthesiologist-in-chief at The Children's Hospital of Philadelphia (1972-1996), has made numerous contributions to pediatric anesthesia and critical care medicine through a broad spectrum of research on chronic respiratory failure, status asthmaticus, postoperative risks of apnea in premature infants, and home-assisted mechanical ventilation. However, his defining moment was in January 1967, when The Children's Hospital of Philadelphia inaugurated its pediatric intensive care unit--the first of its kind in North America. During his tenure, he and his colleagues trained an entire generation of pediatric anesthesiologists and intensivists and set a standard of care and professionalism that continues to the present day. Based on an interview with Dr. Downes, this article reviews a career that advanced pediatric anesthesia and critical care medicine and describes the development of that first pediatric intensive care unit at The Children's Hospital of Philadelphia.

A survey of perioperative management of sickle cell disease in North America

BACKGROUND

Children with sickle cell disease frequently undergo surgical procedures that are associated with acute exacerbations of the disease. Current perioperative management practices are unclear.

OBJECTIVES

We aimed at describing the current management.

METHODS

We conducted an electronic survey of North American members of the Society for Pediatric Anesthesia, in which we asked about their perioperative management of sickle cell disease.

RESULTS

The response rate to valid addresses was 25% (n=510/2006). In four scenarios, (a patient with mild disease undergoing a minor procedure; a patient with mild disease undergoing a more invasive procedure; a patient with severe disease undergoing a minor procedure; and a patient with severe disease undergoing a more invasive procedure) 80%, 38%, 27%, and 16% of respondents, respectively, would rely on oral fluids to hydrate patients during the preoperative fast, while 13%, 34%, 44%, and 59%, respectively, would use intravenous fluid. For the same four scenarios, 64%, 28%, 33%, and 10%, respectively, would not transfuse patients in an attempt to prevent sickle cell exacerbations, while 17%, 49%, 36%, and 51%, respectively, would transfuse to a hemoglobin concentration of 10 g·dl(-1). The tendencies to administer preoperative intravenous fluid and to transfuse blood increased with disease severity and procedure invasiveness (P<0.001). Although 89% felt comfortable managing patients with sickle cell disease, 73% thought an advisory statement on optimal perioperative management was needed.

CONCLUSIONS

There is a wide variation in the management of children with sickle cell disease. Clinicians differentiate management based on disease severity and procedure type.

The anesthetic considerations of tracheobronchial foreign bodies in children: a literature review of 12,979 cases

Asphyxiation by an inhaled foreign body is a leading cause of accidental death among children younger than 4 years. We analyzed the recent epidemiology of foreign body aspiration and reviewed the current trends in diagnosis and management. In this article, we discuss anesthetic management of bronchoscopy to remove objects. The reviewed articles total 12,979 pediatric bronchoscopies. Most aspirated foreign bodies are organic materials (81%, confidence interval [CI] = 77%-86%), nuts and seeds being the most common. The majority of foreign bodies (88%, CI = 85%-91%) lodge in the bronchial tree, with the remainder catching in the larynx or trachea. The incidence of right-sided foreign bodies (52%, CI = 48%-55%) is higher than that of left-sided foreign bodies (33%, CI = 30%-37%). A small number of objects fragment and lodge in different parts of the airways. Only 11% (CI = 8%-16%) of the foreign bodies were radio-opaque on radiograph, with chest radiographs being normal in 17% of children (CI = 13%-22%). Although rigid bronchoscopy is the traditional diagnostic "gold standard," the use of computerized tomography, virtual bronchoscopy, and flexible bronchoscopy is increasing. Reported mortality during bronchoscopy is 0.42%. Although asphyxia at presentation or initial emergency bronchoscopy causes some deaths, hypoxic cardiac arrest during retrieval of the object, bronchial rupture, and unspecified intraoperative complications in previously stable patients constitute the majority of in-hospital fatalities. Major complications include severe laryngeal edema or bronchospasm requiring tracheotomy or reintubation, pneumothorax, pneumomediastinum, cardiac arrest, tracheal or bronchial laceration, and hypoxic brain damage (0.96%). Aspiration of gastric contents is not reported. Preoperative assessment should determine where the aspirated foreign body has lodged, what was aspirated, and when the aspiration occurred ("what, where, when"). The choices of inhaled or IV induction, spontaneous or controlled ventilation, and inhaled or IV maintenance may be individualized to the circumstances. Although several anesthetic techniques are effective for managing children with foreign body aspiration, there is no consensus from the literature as to which technique is optimal. An induction that maintains spontaneous ventilation is commonly practiced to minimize the risk of converting a partial proximal obstruction to a complete obstruction. Controlled ventilation combined with IV drugs and paralysis allows for suitable rigid bronchoscopy conditions and a consistent level of anesthesia. Close communication between the anesthesiologist, bronchoscopist, and assistants is essential.

Christmas: Years Like This. Ingested foreign bodies and societal wealth: three year observational study of swallowed coins

OBJECTIVE

To examine the relation between coins ingested by children and the Dow Jones Industrial Average.

DESIGN

Observational study. Main outcome measures Total value of coins ingested and number of incidents of coins versus other objects swallowed, measured before and after the stock market crash of October 2008.

RESULTS

Eighteen objects, including 11 coins, were ingested (NASDAQ (numismatic and sundry detritus acquired) composite of 18). The total value of the 11 coins swallowed was $1.03 (FTSE 100 (fraction of the US$ or 100 cents) index of 103). The pecuniary extraction ratio (PE ratio) was 0.57 (9/16). Comparing values for a period before and after October 2008, the mean monthly NASDAQ composite (0.41 (SD 0.67) v 0.5 (0.85), P=0.75), FTSE 100 index in cents (2.3 (6.8) v 3.1 (7.8), P=0.77), and PE ratio (0.54 (0.52) v 0.66 (0.29), P=0.50) did not change. The mean end-of-month closing value of the Dow Jones, however, decreased significantly (12 537 (841.4) v 8388 (699.8), P<0.001)

CONCLUSION

There was no detectable difference in the total value of coins ingested, or ratio of coins to other objects swallowed, before or after a massive stock market crash.

Mortality on Mount Everest, 1921-2006: descriptive study

OBJECTIVE

To examine patterns of mortality among climbers on Mount Everest over an 86 year period.

DESIGN

Descriptive study.

SETTING

Climbing expeditions to Mount Everest, 1921-2006.

PARTICIPANTS

14,138 mountaineers; 8030 climbers and 6108 sherpas.

MAIN OUTCOME MEASURE

Circumstances of deaths.

RESULTS

The mortality rate among mountaineers above base camp was 1.3%. Deaths could be classified as involving trauma (objective hazards or falls, n=113), as non-traumatic (high altitude illness, hypothermia, or sudden death, n=52), or as a disappearance (body never found, n=27). During the spring climbing seasons from 1982 to 2006, 82.3% of deaths of climbers occurred during an attempt at reaching the summit. The death rate during all descents via standard routes was higher for climbers than for sherpas (2.7% (43/1585) v 0.4% (5/1231), P<0.001; all mountaineers 1.9%). Of 94 mountaineers who died after climbing above 8000 m, 53 (56%) died during descent from the summit, 16 (17%) after turning back, 9 (10%) during the ascent, 4 (5%) before leaving the final camp, and for 12 (13%) the stage of the summit bid was unknown. The median time to reach the summit via standard routes was earlier for survivors than for non-survivors (0900-0959 v 1300-1359, P<0.001). Profound fatigue (n=34), cognitive changes (n=21), and ataxia (n=12) were the commonest symptoms reported in non-survivors, whereas respiratory distress (n=5), headache (n=0), and nausea or vomiting (n=3) were rarely described.

CONCLUSIONS

Debilitating symptoms consistent with high altitude cerebral oedema commonly present during descent from the summit of Mount Everest. Profound fatigue and late times in reaching the summit are early features associated with subsequent death.

Anaesthesia and high altitude: a history

During an expedition to climb Everest in 1933, expedition doctor Raymond Greene administered an open-drop chloroform anaesthetic to a Tibetan patient at an altitude of more than 14,000 feet. The patient's subsequent apparent cardiopulmonary arrest has long been attributed to the effects of altitude on anaesthetic delivery. However, anaesthetics can be safely administered at a wide variety of altitudes by adequately trained and experienced anaesthetists. The problems may have arisen from an inadequate depth of anaesthesia consequent to decreased chloroform vaporisation in a cold environment, Greene's concern about potential depression of ventilation and the contemporary lack of a precise approach to assessing depth of anaesthesia.

Anaesthesia for peculiar cells--a century of sickle cell disease

Sickle cell disease is a congenital haemoglobinopathy with a high incidence of perioperative complications. Traditional anaesthetic management, based largely on extrapolation from biochemical models, has emphasized avoidance of red cell sickling to prevent exacerbations of the disease. This historical review outlines the evolution of the traditional approach to sickle cell pathology, assesses the validity of this model, describes the emergence of the concept of the disease as one defined by chronic inflammatory vascular damage, and outlines the practical implications of this new approach.

Transient High Altitude Neurological Dysfunction: An Origin in the Temporoparietal Cortex

This case report describes three separate episodes of isolated ataxia, hallucinations of being accompanied by another person, and bilateral dressing apraxia occurring in a single individual without prior warning signs. These symptoms are attributable to disruption of vestibular processing in the temporoparietal cortex or associated limbic structures. Neurological dysfunction at high altitude is usually ascribed to high altitude cerebral edema or acute mountain sickness. However, transient neurological symptoms occur abruptly at more extreme altitudes, often following vigorous exertion, without overt altitude-induced prodromes. These symptoms may be caused by intense neuronal discharge or neuronal synchronization as a feature of epileptic discharges or cortical spreading depression. Transient high altitude neurological dysfunction should be recognized as a separate complication of extreme altitude, distinct from high altitude cerebral edema.

Transfusion-related acute lung injury or acute chest syndrome of sickle cell disease? — A case report

PURPOSE

To describe how to differentiate transfusion-related acute lung injury from acute chest syndrome of sickle cell disease.

CLINICAL FEATURES

A neurosurgical patient with sickle cell disease received two units of packed red blood cells postoperatively. Four hours later she developed progressive respiratory distress, diffuse geographical airspace disease and bilateral pulmonary edema. The patient recovered sufficiently to be transferred from the intensive care unit within four days. The temporal relationship to transfusion, features on computerized tomographic scan, and the rapid resolution of severe edema point to a diagnosis of transfusion related acute lung injury. Granulocyte or human leukocyte antigen antibodies in donor plasma may confirm a diagnosis of transfusion injury.

CONCLUSION

The clinician should appreciate that erythrocyte transfusion to prevent or treat acute chest syndrome may cause transfusion related acute lung injury, a condition that mimics, exacerbates or possibly triggers the syndrome it was intended to treat.

Systemic embolism in an infant following haemangioma embolization: a two-step process

A case is presented of therapeutic embolization of a hypervascular hamartoma of the liver, in a term baby. During the procedure signs of pulmonary embolism occurred and the baby subsequently died from myocardial ischaemia. Potential intrathoracic shunts of the newborn together with changes associated with the vascular tumour are thought to have allowed systemic embolization of the embolic material.

Management of multiple intracranial aneurysms: neuroanesthetic considerations of sickle cell disease

Intracranial aneurysms are a common complication of sickle cell disease. The management of a patient with multiple intracranial aneurysms and sickle cell disease is described. The English language literature is reviewed. Neuroanesthetic management has traditionally been based on the avoidance of factors said to lead to erythrocyte sickling; however neuropathology typically arises from arterial intimal damage, not from venous sickling. Neuroanesthesia should be based on an appreciation of this pathophysiological model. Consideration of precipitants of vaso-occlusive crises, such as hypothermia, dehydration and possibly altered hemodynamics, should influence management.