The ex utero intrapartum treatment (EXIT) procedure was primarily developed to reverse temporary tracheal occlusion in patients with fetal surgery for congenital diaphragmatic hernia. Nowadays, it is widely used to resect fetal neck masses and to maintain an unobstructed airway. It is indicated for the management of several cardiothoracic diseases, including mediastinal or lung mass resection, drainage of pleural effusions, palliative treatment of critical congenital heart disease and establishment of EXIT-to-extracorporeal membrane oxygenation (ECMO). EXIT has been attempted successfully in many centers, and it has been proven that mothers and babies tolerate the procedure well. Maternal and fetal surveillance during anesthesia is important to maintain maternal blood pressure and placental blood flow and fetal oxygenation. The aim of this article is to discuss the application of the EXIT procedure for the management of fetal cardiothoracic diseases.
Key words: anesthesia, fetus, mediastinal neoplasms, pleural effusion
The spleen plays an important role in removing normal and abnormal cells from the blood and in providing an immunologic response to encapsulated bacteria. Surgical splenectomy provides effective treatment for several pediatric disorders, such as congenital and acquired hemolytic anemias, abdominal traumas and immunological and metabolic disorders, but it is associated with an immediate and lifelong risk of overwhelming infection. An alternative to conventional splenectomy is partial splenectomy, recommended especially in children younger than 5 years of age. Recommendations for the prevention of overwhelming post-total splenectomy infection include: Pneumococcal, Haemophilus influenzae type B and Meningococcal immunizations, antimicrobial prophylaxis and prompt antibiotic treatment of acute febrile illness; conversely, there is no clear evidence indicating which prevention measures are to be performed in patients undergoing partial splenectomy.
Key words: partial splenectomy, children, immunization
Background. We studied the effects of a parallel phenylephrine infusion during bispectral index guided anaesthesia induction with propofol on haemodynamic parameters. We hypothesised that mean arterial pressure and cardiac index would be better maintained in the group of patients receiving the phenylephrine infusion during induction.
Methods. We studied ASA I-III patients scheduled for oncological abdominal surgery. Forty patients randomly received either a 0.9% NaCl or a phenylephrine (0.5 μg/kg/min) infusion during the induction of anaesthesia with propofol to a bispectral index value of 60. Mean arterial pressure, stroke volume index and systemic vascular resistance index were recorded, starting at one minute before induction for 20 minutes, at one-minute intervals.
Results. After induction of anaesthesia before intubation mean arterial pressure and stroke volume index decreased significantly compared to baseline in both groups, while the systemic vascular resistance index increased slightly. At the end of measurements, mean arterial pressure (66 11 vs. 94 14 mmHg; 0.9% NaCl vs. phenylephrine group p<0.01) and stroke volume index (34.2 9.1 vs. 44.0 9.7 ml/m2; 0.9% NaCl vs. phenylephrine group p<0.01) were lower in both groups in comparison to baseline values, but were better maintained in the phenylephrine group, whereas systemic vascular resistance index was higher than at baseline (2308 656 vs. 3198 825 dynes s/cm5/m2; 0.9% NaCl vs. phenylephrine group p<0.01) with significant differences between groups.
Conclusion. Our study shows that a continuous phenylephrine infusion can attenuate the drop in mean arterial pressure and stroke volume index during anaesthesia induction with propofol.
Key words: anaesthetics, propofol, monitoring, depth of anaesthesia, consciousness monitors, bispectral index, sympathetic nervous system, phenylephrine, measurement techniques, cardiac output
Background. One lung ventilation (OLV) has become a standard procedure for the vast majority of interventions in pulmonary surgery. The most commonly used are left sided double-lumen tubes (DLTs) which are placed into the left main bronchus and the right or left lung can be isolated.
The aim of our study was to compare DLTs with and without a hook.
Materials and methods. Fifty-four patients undergoing lung resection were included in the randomized, controlled, single-blinded study. Recruited patients were randomly allocated to each group (hook/without hook). Demographic data, procedural data, type of tube used, and difficult intubation criteria were recorded. Complications, according to intubation and position of the tube, were also recorded. After the operation, we aske patients about a sore throat, hoarseness, haemoptysis and their satisfaction with the procedure.
Results. Baseline characteristics were well balanced between groups. Time to place DLT was shorter in the group without a hook (47.7±45.5 vs 15.8±15.1s; P=0.01). The incidence of adequate positioning at the first attempt was higher in the group with a hook and the repositioning rate was higher in the group without a hook (22.22 vs 59.25%; P=0.004). Patients in both groups suffered similar incidences of hoarseness, sore throat or postoperative haemoptysis (5/5/1 vs 3/3/0; P = 0.44). Patient satisfaction was higher in the group without a hook (31.85% vs 34.81%;0.03).
Conclusion. The study showed the advantage of DLTs without a hook in comparison with DLTs with a hook. In our institution we decided to use DLTs without a hook, with fiberoptic control.
Key words: double-lumen tube, carinal hook, pulmonary surgery
Trial registration: ClinicalTrials.gov NCT02857504
Background. Ventilator-associated pneumonia (VAP) still remains a common device-associated hospital acquired infection in pediatric and adult intensive care units. The aim of our study was to determine ways of microbial transmission to the lower airways in intubated patients admitted to a single tertiary-care pediatric intensive care unit.
Methods. This was a prospective observational study. A total of 284 sample sets (oropharyngeal swabs, swabs from the lumen of the proximal tip of an endotracheal tube, and bronchoalveolar lavage samples) were collected from 62 consecutive pediatric patients intubated for > 24 hours. Pulsed-field gel electrophoresis was performed on all isolated pathogens, which were later identified by MALDI biotyper (MALDI-TOF mass spectrometry).
Results. Overall colonization rates were high and did not differ significantly at different time points in the oropharynx (75%–100%) and the lower airways (50%–76.5%). The endotracheal tube was colonized at lower rates: on day 1–3 (28.8%), on day 4–6 (52.7%), on day 7–9 (61.8%) and on day 10-12 (52.9%) (P < 0.001). A total of 191 matched sample sets from the lower airways and at least one site above were collected from 46 (74.2%) patients. In the oropharynx-lower airways group, Candida spp. (76.9%) and upper airway bacteria (63.2%); in the endotracheal tube-lower airway group, S. aureus (15.7%) and upper airway bacteria (21.1%); in the oropharynx-endotracheal tube-lower airway group, Enterobacteriaceae (70.8%) prevailed (P < 0.001). The mean survival (entrance) time to lower airways for the Acinetobacter/Pseudomonas/Stenotrophomonas group was 8.28 ± 0.81 days; for the Enterobacteriaceae group, 5.63 ± 0.41; and for Candida spp. group, 3.00 ± 0.82 days (P < 0.005).
Conclusions. Oropharyngeal contamination of the lower airways is the most important route of colonization. Different pathogens enter the lower airways at different time intervals from the insertion of an endotracheal tube.
Key words: colonization, airway, intubation, mechanical ventilation, bronchoalveolar lavage, ventilator-associated pneumonia