Abstract
Background
Patients undergoing corneal abrasion as part of Descemet membrane endothelial keratoplasty (DMEK) under general anesthesia suffer from early burning pain postoperatively. This ...pain appears to be poorly treatable with systemic analgesics. This study aims to evaluate postoperative pain management using topical lidocaine gel after DMEK with iatrogenic corneal abrasion.
Methods
Retrospective analysis of 28 consecutive patients undergoing DMEK with corneal abrasion from October 19, 2021, to November 12, 2021, at a German university hospital. Patients during week 1 and 2 received peri-operative standard pain treatment (cohort S) and additional local lidocaine gel during week 3 and 4 immediately postoperatively (cohort L).
Results
13 patients were included in cohort S and 15 patients in cohort L. At awakening all patients (100%) in cohort S reported burning pain, and six of 15 patients (40%) in cohort L reported burning pain. Burning pain scores were significantly lower in cohort L (p < 0.001 at awakening, p < 0.001 at 10 min, p < 0.001 at 20 min, p < 0.001 at 30 min, p = 0.007 at 40 min after awakening, and p < 0.001 at leaving recovery room). No significant differences between cohort S and cohort L were detected concerning surgical outcome during 1-month-follow-up (p = 0.901 for best corrected visual acuity).
Conclusion
Patients undergoing DMEK with corneal abrasion suffer significant pain in the recovery room. A single dose of topic lidocaine gel reduces the early postoperative burning pain sufficiently and does not affect the surgical outcome.
Overt heart failure, not improving with medications Failure to thrive, predominantly due to hemodynamic effects of the VSD Recurrent respiratory infections (defined as >6 events in the preceding 12 ...months) Mid-diastolic flow rumble at the apex on auscultation Electrocardiogram showing left atrial enlargement and left ventricular hypertrophy with standard criteria for children Cardiothoracic ratio on chest x-ray of >0.55 Left atrial to aortic diameter ratio on long-axis echocardiogram >1.5 Left ventricular end-diastolic z-score on echocardiogram, indexed to body surface area of >2.0 Estimated pulmonary to systemic blood flow ratio >1.5 at cardiac catheterization Morphologic inclusion criteria Isolated pmVSD VSD size <6.5 mm Upper margin of VSD to aortic valve distance >= 3 mm Morphologic exclusion criteria: VSD size >6.5 mm Perimembranous VSD with bidirectional or predominantly right to left shunt through the VSD on color Doppler echocardiography Perimembranous VSD associated with other structural heart defects requiring surgery Cardiac catheterization was performed under general anesthesia (n = 12) or intravenous sedation (n = 51), after informed consent was obtained. The VSDs larger than 6.5 mm diameter cannot be closed with the ADO II. Because the retention discs are symmetrical, a minimum distance of 3 mm is required between the upper margin of the VSD and the aortic valve.
Pediatric extracorporeal membrane oxygenation (ECMO) support is often the ultimate therapy for neonatal and pediatric patients with congenital heart defects after cardiac surgery. The impact of ...lactate clearance in pediatric patients during ECMO therapy on outcomes has been analyzed. Materials
We retrospectively analyzed data from 41 pediatric vaECMO patients between January 2006 and December 2016. Blood lactate and lactate clearance have been recorded prior to ECMO implantation and 3, 6, 9 and 12 h after ECMO start. Receiver operating characteristic (ROC) analysis was used to identify cut-off levels for lactate clearance.
Lactate levels prior to ECMO therapy (9.8 mmol/L vs. 13.5 mmol/L;
= 0.07) and peak lactate levels during ECMO support (10.4 mmol/L vs. 14.7 mmol/L;
= 0.07) were similar between survivors and nonsurvivors. Areas under the curve (AUC) of lactate clearance at 3, 9 h and 12 h after ECMO start were significantly predictive for mortality (
= 0.017,
= 0.049 and
= 0.006, respectively). Cut-off values of lactate clearance were 3.8%, 51% and 56%. Duration of ECMO support and respiratory ventilation was significantly longer in survivors than in nonsurvivors (
= 0.01 and
< 0.001, respectively).
Dynamic recording of lactate clearance after ECMO start is a valuable tool to assess outcomes and effectiveness of ECMO application. Poor lactate clearance during ECMO therapy in pediatric patients is a significant marker for higher mortality.
Selbst kleine medizinische Prozeduren können bei Kindern zu einer psychischen Traumatisierung und chronischen Schmerzen führen. Daher ist eine Ausschaltung von Bewusstsein und Schmerzen
essenziell, ...die entweder im Rahmen einer Allgemeinanästhesie oder einer Analgosedierung erfolgen kann. Wann welches Verfahren sinnvoll eingesetzt werden kann und welche organisatorischen und
personellen Voraussetzungen für hohe Patientensicherheit und optimale Untersuchungsergebnisse wichtig sind, beschreibt dieser Beitrag.
Abstract Background Ventricular preexcitation may be associated with dilated cardiomyopathy, even in the absence of recurrent and incessant tachycardia. Methods This report describes the clinical and ...electrophysiologic characteristics of 10 consecutive children (6 males), with median age of 8 years (range, 1-17 years), who presented with dilated cardiomyopathy and overt ventricular preexcitation on the 12-lead electrocardiogram. Incessant tachycardia as the cause of dilated cardiomyopathy could be excluded. Coronary angiography, right ventricular endomyocardial biopsy (4/10 patients), and metabolic and microbiologic screening were nondiagnostic. Results The electrocardiograms suggested right-sided pathways in all patients. A right-sided accessory pathway was demonstrated in 8 patients during invasive electrophysiologic study (superoparaseptal, n = 5; septal, n = 2; fasciculoventricular, n = 1). All pathways were successfully ablated (radiofrequency ablation in 7, cryoablation in 1). Two patients had spontaneous loss of ventricular preexcitation during follow-up. Left ventricular (LV) function completely recovered after a loss of preexcitation in all patients. Conclusions Right-sided accessory pathways with overt ventricular preexcitation and LV dyssynchrony may cause dilated cardiomyopathy. An association between such pathways and dilated cardiomyopathy is suggested by the rapid normalization of ventricular function and reverse LV remodeling after a loss of ventricular preexcitation.
A 2-year-old patient with hypoplastic left heart syndrome presented 6 months following Fontan completion with protein-losing enteropathy (PLE). He had undergone stent implantation in the left ...pulmonary artery after the Norwood procedure, followed by redilation of the stent prior to Fontan completion. Combined bronchoscopic and catheterization studies during spontaneous breathing confirmed left bronchial stenosis behind the stent, and diastolic systemic ventricular pressure during expiration of 25 mm Hg. We postulate that the stent acts as a valve, against which the patient generates high expiratory pressures, which are reflected in the ventricular diastolic pressure. This may be the cause of PLE.
Background
Many different sedation concepts for magnetic resonance imaging have been described for prematurely and term‐born infants, ranging from “no sedation” to general anesthesia. Dexmedetomidine ...is an alpha‐2 receptor agonist that is frequently used to sedate older children, because the anesthesiologist can easily adjust sedation depth, the patient maintains spontaneous breathing, and awakens rapidly afterwards.
Aims
The present study evaluates whether dexmedetomidine could safely be used as the sole sedative for prematurely and term‐born infants less than 60 weeks postconceptional age undergoing diagnostic procedures.
Methods
We performed a retrospective monocentric analysis of n = 39 prematurely and term‐born infants (<60 weeks postconceptional age or a body weight <5 kg) who were sedated with dexmedetomidine for an MRI at a German university hospital from August 2016 to November 2018.
Results
Successful imaging was achieved in all cases. The median initial bolus of dexmedetomidine administered over 10 min was 1.39 μg kg−1 body weight (range 0.34–3.64 μg kg−1), followed with a continuous infusion at a median rate of 1.00 μg kg−1 h−1 (range 0.5–3.5 μg kg−1 h−1); however, 3 patients (7%) needed some additional sedation (ketamine or propofol). All patients, including 10 infants who had previously required respiratory support, underwent the procedure without any relevant desaturation or apnea. Bradycardia was observed in up to 15 out of 39 cases (38.5%), but only four (10.3% in total and 26.7% of bradycardia) required atropine.
Conclusions
These results indicate that dexmedetomidine can be safely used for procedural sedation in the high‐risk cohort of prematurely and term‐born infants less than 60 weeks postconceptional age. Apnea during procedural sedation and subsequent stay in the recovery room is avoided, but bradycardia remains a relevant risk that may require treatment.
Congenital heart disease is the most frequent malformation in newborns. The postoperative mortality of these patients can be assessed with the Risk Adjustment in Congenital Heart Surgery-1 (RACHS-1) ...score. This study evaluates whether the RACHS-1 score can also be used as a predictor for the length of postoperative ventilation and what is the influence of age.
In a retrospective study over the period from 2007 to 2013, all patient records were evaluated: 598 children with congenital heart disease and cardiac surgery were identified and 39 patients have been excluded because of additional comorbidities. For evaluation of mortality, 559 patients could be analysed, after exclusion of 39 deceased patients, 520 cases remained for analysis of postoperative ventilation.
Overall mortality was 7% with a dependency on RACHS-1 categories. The median length of postoperative ventilation rose according to the RACHS-1 categories: RACHS-1 category 1: 9 hours (interquartile range (IQR) 7-13 hours), category 2: 30 hours (IQR 12-85 hours), category 4: 58 hours (IQR 13-135 hours), category 4: 71 hours (IQR 29-165 hours), and category 6: 189 hours (IQR 127-277 hours). Some of the RACHS-1 subgroups differed significantly from the categories, especially the repair of tetralogy of Fallot with a longer ventilation time and strong variability. Younger age was an independent factor for longer postoperative ventilation.
RACHS-1 is a good predictor for the length of postoperative ventilation after cardiac surgery with the exception of some subgroups. Younger age is another independent factor for longer postoperative ventilation. These data provide better insight into ventilation times and allow better planning of operations in terms of available intensive care beds.
Paediatric early warning score systems are used for early detection of clinical deterioration of patients in paediatric wards. Several paediatric early warning scores have been developed, but most of ...them are not suitable for children with cyanotic CHD who are adapted to lower arterial oxygen saturation.
The present study compared the original paediatric early warning system of the Royal College of Physicians of Ireland with a modification for children with cyanotic CHD.
Retrospective single-centre study in a paediatric cardiology intermediate care unit at a German university hospital.
The distribution of recorded values showed a significant shift towards higher score values in patients with cyanotic CHD (p < 0.001) using the original score, but not with the modification. An analysis of sensitivity and specificity for the factor "requirement of action" showed an area under the receiver operating characteristic for non-cyanotic patients of 0.908 (95% CI 0.862-0.954). For patients with cyanotic CHD, using the original score, the area under the receiver operating characteristic was reduced to 0.731 (95% CI 0.637-0.824, p = 0.001) compared to 0.862 (95% CI 0.809-0.915, p = 0.207), when the modified score was used. Using the critical threshold of scores ≥ 4 in patients with cyanotic CHD, sensitivity and specificity for the modified score was higher than for the original (sensitivity 78.8 versus 72.7%, specificity 78.2 versus 58.4%).
The modified score is a uniform scoring system for identifying clinical deterioration, which can be used in children with and without cyanotic CHD.
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