Abstract

Pediatricians are frequently involved in the care of cyanotic newborns in the labor and delivery room, as well as in the well baby nursery. Causes of hypoxia and cyanosis in the term newborn can be found within all physiological systems. Congenital heart structural diseases account for the largest diagnostic category. There have been significant advances during the past years in the diagnosis and treatment of neonates with critical congenital heart disease, especially in the field of pre- and post-operative intensive care.

The term hypoplastic left heart syndrome (HLHS) describes a spectrum of cardiac structural abnormalities characterized by marked hypoplasia of the left ventricle and ascending aorta. Prenatal diagnosis, initial resuscitation and optimal preoperative management are key elements that allow the best opportunity for low mortality and normal neurodevelopment in affected newborns.  Preoperatively, the goal is to achieve adequate systemic oxygen delivery. Patency of the ductus arteriosus (DA) is critical for survival until surgery. Blood flow to the pulmonary and systemic circulations should be nearly balanced (goal Qp/Qs ratio of 1).  The immediate therapy for all infants with HLHS is an intravenous infusion of prostaglandin E1 (PGE1) in order to manipulate the DA and maintain ductal patency. Oxygen saturations of 75% to 85% by pulse oximetry suggest an adequate balance between systemic and pulmonary blood flow.  Judicious use of inotropic support is initiated if evidence of low cardiac output is detected. Diuretics may be necessary to help alleviate the increased volume load on the right ventricle. The goal of respiratory management is to increase pulmonary vascular resistance and decrease systemic vascular resistance.  Infants with HLHS who are born with a severely restricted or no inter-atrial communication, a rare occurrence, have profound hypoxemia.  The severe restriction of blood flow across the atrial septum results in a life-threatening situation and these patients, which present with severe cyanosis and hemodynamic instability, require urgent postnatal cardiac catheterization to relieve the septal obstruction and improve oxygenation. Special attention should be paid to the prevention of brain injury and poor neurodevelopmental outcome.

Care for infants with HLHS is complex, and often multiple specialists are involved. Despite an increase in the number of newborns with complex congenital heart disease and a growing percentage of patients with single-ventricle physiology, it is possible to care for this particular group of patients and achieve acceptable mortality risks, even in centres with no pediatric cardiac surgery facilities, if good preoperative management protocols are followed.

Key words: congenital heart disease, newborn, intensive care, hemodynamics, PGE1, ductus arteriosus

Abstract

Transfusion-related acute lung injury (TRALI) is a complication following transfusion of blood products and is potentially a life-threatening adverse event of transfusion. The first case of fatal pulmonary edema following transfusion was reported in the 1950s. In recent time, TRALI has developed from an almost unknown transfusion reaction to the most common cause of transfusion related major morbidities and fatalities. A clinical definition of TRALI was established in 2004, based on acute respiratory distress which has temporal association with transfusion of blood components. In 2008 a distinction between classic and delayed syndrome was proposed. However, pathophysiology of TRALI still remains controversial. A number of different models were proposed to explain the pathogenesis. The two, presently most accepted models, are not mutually exclusive. The first is the antibody mediated model and the second is the two-event model.

In this review article the definition of TRALI, patient predisposition, treatment, prevention and reporting guidelines are examined. The current knowledge on the topic TRALI is summarized.

Key words: transfusion, acute lung injury

Abstract

Introduction: Gastrointestinal stromal tumors constitute a distinct group of rare gastrointestinal tract tumors that originate from the interstitial cells of Cajal. These jejunoileal lesions are a rare cause of obstruction but can be associated with substantial morbidity.

Case: A 59-year-old woman presented to the emergency department with abdominal pain and distention. Physical examination revealed tenderness and rebound in right lower quadrant. Computed tomography revealed a mass in lower right quadrant. A 9x9x4 cm exophytic ileal mass was observed at exploration. Preoperative diagnose was a small bowel tumor and then segmental resection and primary anastomosis were performed. Histopathological investigation revealed spindle cells that stained strongly for C-117, consistent with a diagnosis of a malign gastrointestinal stromal tumor.

Conclusion: We conclude that exophytic small bowel gastrointestinal stromal tumors are rare lesions, which should be kept in mind by physicians among the diagnosis of small bowel obstructions in order to reduce substantial morbidity and mortality.

Key words: intestinal obstruction, gastrointestinal stromal tumor, small bowel, surgery

Abstract

Introduction. Multiresistant Pseudomonas aeruginosa (MRPA) nosocomial pneumonia is a significant cause of mortality and morbidity in the ICU. We report our experience with aerosolized colistin in the treatment of MRPA nosocomial pneumonia.

Patients and methods. It is a prospective, observational study performed over 2 years (2006-2007). Patients who developed MRPA nosocomial pneumonia and were treated with aerosolized colistin were included. The criteria used to assess if treatment was successful were extubation and ICU mortality rates.

Results. We report 32 patients of whom 12 were women and 20 men. The mean age was 48 ± 19 years. All patients were receiving mechanical ventilation. The mean length of ventilation was 22 ± 5.5 days. The bronchial sampling technique used was broncho-alveolar lavage. The mean delay of infection (duration between intubation and pneumonia diagnosis) was 7 ± 2 days. Isolated MRPA was susceptible only to colistin. The treatment was aerosolized colistin for all patients (4 MUI/day). A positive blood culture (n=5) was a prerequisite for administering colistin intravenously (4 MUI/day). Any potential toxicity was observed. The mean delay of extubation after starting treatment was 10 days. Sterile samples were obtained on average by the eighth day. No deaths were recorded.

Conclusion. It seems that aerosolized colistin is an important alternative to treat MRPA nosocomial pneumonia in ICU. Our results need further confirmation by other multicentre studies.

Keywords: multi-resistant Pseudomonas aeruginosa, colistin, nebulization, ICU

Abstract

Study objectives. To compare the effect of remifentanil versus fentanyl isoflurane general anesthesia on Aldrete score, emergence, extubation and discharge times from the operating room (OR) and postanesthesia care unit (PACU) following short outpatient urologic procedures (panendoscopy and cystoscopy, bladder hydrodilatation, stent placement).

Patients and methods. 40 patients 18 years of age or older scheduled for short elective outpatient urological procedures with an expected duration of less than 30 minutes.

Following Institutional Review Board (IRB) approval and written informed consent, 40 American Society of Anesthesiologists (ASA) physical class 1-3 adult outpatients were enrolled and equally (n=20) randomized into remifentanil and fentanyl groups. Preoperatively, all subjects received intravenous (IV) midazolam 1-2 mg and were induced with propofol 2 mg/kg IV. Muscle relaxation was achieved with succinylcholine or rocuronium, followed by intubation. The remifentanil group received remifentanil 1 g/kg IV at induction with a maintenance dose of remifentanil 0.1 to 2 g/kg/min IV in the presence of 60% nitrous oxide (N2O)/40% oxygen (O2) and end-tidal isoflurane of 0.3 to 0.4% (for amnesia). The fentanyl group received fentanyl 2 g/kg IV at induction, maintenance dose of fentanyl 2 to 3 g/kg IV intermittent bolus, and 60% N2O/40% O2 with 2% end-tidal isoflurane. Muscle relaxation was reversed at the end of anesthesia as needed. Times for OR entry, emergence, extubation, total OR time (entry to exit) and PACU discharge time, as well as Aldrete scores at time of OR exit and PACU discharge were determined. Data was evaluated by ANOVA, t-test and Mann-Whitney tests. A p<0.05 value was considered statistically significant.

Results. There was no significant difference between groups in age, gender, weight, ASA class, PACU analgesic or antiemetic use, or times of emergence, extubation, OR exit and PACU discharge. There was a significant difference (p<0.05) in OR exit Aldrete score but not PACU discharge Aldrete score. No adverse events were noted.

Conclusions. While there was no difference between the remifentanil and fentanyl groups regarding recovery time from OR and PACU, remifentanil patients had significantly better OR exit Aldrete scores with less sedation upon arrival at phase I PACU recovery than the fentanyl group. This anesthesia technique may prove helpful for fast-track eligibility of these patients.

Key words: remifentanil, fentanyl, isoflurane, general anesthesia, urologic procedures, outpatient surgery, Aldrete score, recovery time, discharge time