Pulmonary aspiration of gastric contents during the perioperative period in infants and children may be associated with postoperative mortality or pulmonary morbidity. There has not been a recent ...determination of the frequency of this event and its outcomes in infants and children.
The authors prospectively identified all cases of pulmonary aspiration of gastric contents during the perioperative courses of 56,138 consecutive patients younger than 18 yr of age who underwent 63,180 general anesthetics for procedures performed in all surgical specialties from July 1985 through June 1997 at the Mayo Clinic.
Pulmonary aspiration occurred in 24 patients (1: 2,632 anesthetics; 0.04%). Children undergoing emergency procedures had a greater frequency of pulmonary aspiration compared to those undergoing elective procedures (1:373 vs. 1:4,544, P < 0.001). Fifteen of the 24 children who aspirated gastric contents did not develop respiratory symptoms within 2 h of aspiration, and none of these 15 developed pulmonary sequelae. Five of these nine children who aspirated and in whom respiratory symptoms developed within 2 h subsequently had pulmonary complications treated with respiratory support (P < 0.003). Three children were treated with mechanical ventilation for more than 48 h, but no child died of sequelae of pulmonary aspiration.
In this study population, the frequency of perioperative pulmonary aspiration in children was quite low. Serious respiratory morbidity was rare, and there were no associated deaths. Infants and children with clinically apparent pulmonary aspiration in whom symptoms did not develop within 2 h did not have respiratory sequelae.
Controversy exists as to the risk for postoperative apnea in former preterm infants. The conclusions of published studies are limited by the small number of patients.
The original data from eight ...prospective studies were subject to a combined analysis. Only patients having inguinal herniorrhaphy under general anesthesia were included; patients receiving caffeine, regional anesthesia, or undergoing other surgical procedures were excluded. A uniform definition for apnea was used for all patients. Eleven risk factors were examined: gestational age, postconceptual age, birth weight, history of respiratory distress syndrome, bronchopulmonary dysplasia, neonatal apnea, necrotizing enterocolitis, ongoing apnea, anemia, and use of opioids or nondepolarizing muscle relaxants.
Two hundred fifty-five of 384 patients from eight studies at four institutions fulfilled study criteria. There was significant variation in apnea rates and the location of apnea (recovery room and postrecovery room) between institutions (P < 0.001). There was considerable variation in the duration and type of monitoring, definitions of apnea, and availability of historical information. The incidence of detected apnea was greater when continuous recording devices were used compared to standard impedance pneumography with alarms or nursing observations. Despite these limitations, it was determined that: (1) apnea was strongly and inversely related to both gestational age (P = 0.0005) and postconceptual age (P < 0.0001); (2) an associated risk factor was continuing apnea at home; (3) small-for-gestational-age infants seemed to be somewhat protected from apnea compared to appropriate- and large-for-gestational-age infants; (4) anemia was a significant risk factor, particularly for patients > 43 weeks' postconceptual age; (5) a relationship to apnea with history of necrotizing enterocolitis, neonatal apnea, respiratory distress syndrome, bronchopulmonary dysplasia, or operative use of opioids and/or muscle relaxants could not be demonstrated.
The analysis suggests that, if it is assumed that the statistical models used are equally valid over the full range of ages considered and that the average rate of apnea reported across the studies analyzed is accurate and representative of actual rates in all institutions, the probability of apnea in nonanemic infants free of recovery-room apnea is not less than 5%, with 95% statistical confidence until postconceptual age was 48 weeks with gestational age 35 weeks. This risk is not less than 1%, with 95% statistical confidence, for that same subset of infants, until postconceptual age was 56 weeks with gestational age 32 weeks or postconceptual age was 54 weeks and gestational age 35 weeks. Older infants with apnea in the recovery room or anemia also should be admitted and monitored. The data do not allow prediction with confidence up to what age this precaution should continue to be taken for infants with anemia. The data were insufficient to allow recommendations regarding how long infants should be observed in recovery. There is additional uncertainty in the results due to the dramatically different rates of detected apnea in different institutions, which appear to be related to the use of different monitoring devices. Given the limitations of this combined analysis, each physician and institution must decide what is an acceptable risk for postoperative apnea.
OBJECTIVE To assess adherence to evidence-based guidelines for the diagnosis and management of uncomplicated urinary tract infection (UTI) in a family medicine residency clinic setting. PATIENTS AND ...METHODS We retrospectively reviewed the medical records of female patients seen in 2005 at the Mayo Clinic Family Medicine Center in Scottsdale, Ariz, who were identified by International Classification of Diseases, Ninth Revision code 599.0 (UTI). We assessed documentation rates, use of diagnostic studies, and antibiotic treatments. Antibiotic sensitivity patterns from outpatient urine culture and sensitivity analyses were determined. RESULTS Of 228 patients, 68 (30%) had uncomplicated UTI. Our physicians recorded essential history and examination findings for most patients. Documentation of the risk of sexually transmitted disease differed between residents and attending physicians and was affected by patient age. Urine dipstick and urine culture and sensitivity analyses were ordered in 57 (84%) and 52 (76%) patients, respectively. Eighty percent of patients with positive results on urine dipstick analyses also had urine culture and sensitivity analyses. Sulfamethoxazole-trimethoprim (SMX-TMP) was used as initial therapy in 26 patients (38%). Sixty-one percent of SMX-TMP and ciprofloxacin prescriptions were appropriately provided for 3 days. Escherichia coli was sensitive to SMX-TMP in 33 (94%) of 35 cultures. Treatment was not changed in any patient with an uncomplicated UTI because of results of urine culture and sensitivity analyses. Antibiotic sensitivity patterns for outpatients were significantly different from those for inpatients. CONCLUSION Only 30% of our patients had uncomplicated UTI, making their management within clinical guidelines appropriate. However, of those patients with uncomplicated UTI, less than 25% received empirical treatment as suggested. Urine culture and sensitivity analyses were performed frequently, even in patients who already had positive results on a urine dip-stick analysis. Although SMX-TMP is effective, it is underused. On the basis of these findings, we hope to provide interventions to increase SMX-TMP prescription, decrease use of urine culture and sensitivity analyses, and increase the frequency of 3-day antibiotic treatments at our institution.
Study Objective: To evaluate the efficacy of intravenous (IV) lidocaine in suppressing the cough reflex and increases in intraocular pressure (IOP), heart rate (HR), and mean arterial pressure (MAP) ...elicited by endotracheal intubation.
Design: Prospective, randomized, placebo-controlled, blinded study.
Patients: 60 ASA physical status I premedicated children aged 2 to 6 years undergoing induction of anesthesia with halothane-nitrous oxide (N
2O) for surgery to correct strabismus.
Interventions: Patients were randomly divided into two groups of 30 each. The control group (C) received saline and the treatment group (L) received 2 mg/kg IV lidocaine 90 seconds prior to endotracheal intubation.
Measurements and Main Results: Awake HR and MAP; IOP, HR, and MAP 45 seconds prior to endotracheal intubation, immediately after endotracheal intubation, and 1 minute later, were recorded. Coughing was noted at endotracheal intubation. Lidocaine prevented coughing and a significant increase in IOP. Although significant increases in HR and MAP were observed in both groups (comparing preintubation and postintubation values), these increases were significantly less in the L group compared with the C group.
Conclusions: In healthy premedicated children, aged 2 to 6 years, who are undergoing induction of anesthesia with halothane-N
2O, 2 mg/kg of lidocaine given 90 seconds prior to laryngoscopy effectively suppresses the cough reflex and increase in IOP secondary to endotracheal intubation and attenuates increases in HR and MAP.
Background. Metastatic basal cell carcinoma (MBCC) is rare. Risk factors for the development of MBCC include a history of persistent basal cell carcinoma (BCC) for many years, refractory to ...conventional methods of treatment and previous radiation treatment either in early adulthood or for localized cancer. Most MBCC originate from large tumors.
Methods. The authors report five patients with basal cell carcinomas (BCC) of the ear (two patients), scalp, inner canthus, and nasolabial fold that metastasized to the regional lymph nodes, skin, and submandibular gland. In addition, the authors reviewed more than 40 reports of MBCC (n = 65) from 1981 to 1991 and tabulated the primary tumors by size and depth of invasion according to TNM classification, a classification that previously has not been used for BCC.
Results. The authors tabulated the size distribution of tumors of 45 patients with MBCC. The overall mean and median diameters of the primary BCC were 8.7 and 7.0 cm, respectively. The mean area of the primary MBCC lesion that originated on the face and trunk was 62 and 217 cm2, respectively. Using the TNM classification, approximately 9% of MBCC originate from tumors smaller than 10 cm2. In addition, the authors found that large (T2 and T3) and deep (T4) BCC account for approximately 75% of the metastatic tumors. Metastatic BCC from primary tumors smaller than 1 cm in diameter are exceptionally rare.
Conclusions. Approximately 67% of MBCC (n = 238) originate from facial sites. Using the data base of the Mohs Surgery Clinic, the authors found that BCC greater than 3 cm in diameter have approximately a 1.9% incidence of metastasis, and the overall rate of metastases for morpheaform BCC is less than 1%. Patients with tumors classified as T3 and T4 lesions ideally should be followed up for 10 or more years for the remote possibility of the development of MBCC.
The authors conducted a double-blind study to compare premedication with oral glycopyrrolate and oral atropine in prevention of bradycardia and hypotension during induction of anesthesia with ...halothane-N2O in 90 outpatient infants and children aged 1-18 mo who were randomized into three groups to receive either an oral placebo, oral atropine (0.02 mg/kg), or oral glycopyrrolate (0.05 mg/kg) approximately 1 h before induction of anesthesia. Heart rate and mean arterial pressure were measured before drug administration, just before induction of anesthesia, and every minute until surgical stimulation occurred. Glycopyrrolate, at the dose used, was significantly less effective than atropine in attenuating bradycardia during induction; neither glycopyrrolate nor atropine altered the incidence or degree of hypotension. Antisialagogic activity and side effects were comparable, except for significantly more flushing with atropine.
The Rey Dot Counting Test was administered to 100 patients with suspect effort drawn from two separate settings (personal injury/disability,
n=86; prison hospital,
n=14) and to 251 subjects in nine ...clinical groups (head injury, learning disability, right and left cerebrovascular accident, schizophrenia, older normals, depressed elderly, and mild and moderate dementia). Sensitivity of cut-offs for individual test scores (mean grouped dot counting time, ratio of mean grouped to ungrouped dot counting time, and number of errors) differed markedly across the two suspect effort groups (e.g., 28–100%), indicating that noncredible patients drawn from different settings employ somewhat differing approaches in their fabrication of cognitive symptoms. Use of a cut-off of ≥17 applied to a combination score (mean ungrouped dot counting time+meangrouped dot counting time+number of errors) resulted in 100% sensitivity in the forensic suspect effort group and 75% sensitivity in the civil litigation/disability suspect effort group, while maintaining specificity of ≥90% for the clinical groups combined (excluding moderate dementia).
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