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Background Considering the recent increase in medical care provided to patients from foreign countries and the diversity of languages spoken by families living within the United States, it is important to determine whether non-English-speaking patients have access to participate in clinical research from which they may benefit. Aims We aimed to determine the number of non-English-speaking patients presenting to Boston Children's Hospital for medical care between 2011 and 2016, the number of clinical research protocols active within the Department of Anesthesiology, Critical Care and Pain Medicine approved to enroll non-English-speaking patients, as well as the number of both non-English- and English-speaking patients approached and enrolled in these studies. Furthermore, we attempted to determine barriers that may have prevented non-English-speaking patients from inclusion in clinical research. Methods We conducted a retrospective review of various data sources during a 5-year period. Data included the number of non-English-speaking patients presenting to Boston Children's Hospital for care as well as the number of English- and non-English-speaking patients approached for studies at the Department of Anesthesiology each year. Additionally, we reviewed data from the IRB which included the justification that research teams provided when opting to exclude non-English-speaking participants. In addition, we attempted to determine the barriers that may have prevented these patients from inclusion in research protocols. Results We found that the number of non-English-speaking patients presenting to Boston Children's Hospital increased over time. However, the number of studies approved to enroll non-English-speaking patients within the Department of Anesthesiology and the rate of enrollment of these patients did not increase at the same rate. Conclusion In order to increase the number of non-English-speaking patients approached to participate in research, we must improve cultural awareness and provide investigators with resources for interpreter and translation services.

Operative treatment of craniosynostosis is associated with substantial blood loss, often requiring transfusion of packed red blood cells (PRBC) and coagulation products.The aim of this prospective study was to analyze thromboelastographic (TEG) parameters and platelet fibrinogen product to determine predictors of substantial blood loss, and the need for PRBC transfusion and coagulation products.With IRB approval, we enrolled 120 children undergoing craniosynostosis repair with a standardized anesthetic, fluid management, and TEG measurements at predefined times. Outcomes of interest were intraoperative blood loss, and need for PRBC transfusion and coagulation products. Multivariable logistic regression and receiver operating characteristic (ROC) curve analysis was applied to determine independent predictors of substantial blood loss and need for coagulation products.One hundred and eighteen children were included in the analysis. Forty-four required PRBC transfusion (median 26 ml·kg(-1) ; IQR: 22-42) with median blood loss of 56 ml·kg(-1) (IQR: 43-83). Factors associated with the PRBC transfusion included type of surgery, duration of surgery, and three TEG parameters, α-angle, MA, and K-time (all P0.001). A predictive algorithm was developed by subgroup analysis of cranial vault reconstruction (CVR) patients for substantial intraoperative blood loss (defined as ≥60 ml·kg(-1) ) and need for coagulation products with ROC-derived cut-off values: platelet fibrinogen product,343; α-angle,62°; MA,55 mm; K-time,2.1 min. The best prognostic combination included at least two of these four predictors (sensitivity 89%, specificity 90%). Multivariable regression identified MA as the only independent predictor of coagulation product administration (P0.001) and ROC analysis identified MA46 mm as the optimal cut-off (sensitivity 86%, specificity 94%).Risk for substantial intraoperative blood loss can be assessed using TEG parameters and platelet fibrinogen product, whereas the need for coagulation products is strongly related to low MA. Patients susceptible to substantial blood loss can be risk stratified based on their TEG/platelet fibrinogen product profile.

Summary Background The incidence and risk factors for postoperative vomiting (POV) after pediatric cardiac surgery has not been studied. Aims This study sought to assess the incidence and risk factors for POV in children undergoing surgical repair of an atrial septal defect (ASD). Methods We retrospectively collected perioperative data from 160 patients who underwent surgical repair of an ASD and met early extubation criteria. Demographic and clinical data that could potentially influence the incidence of POV were collected. Univariate analysis was performed using Student t-test or Wilcoxon rank test to identify factors associated with POV. Continuous variables were dichotomized based on the cutoff values derived from the receiver operating characteristic (ROC) curve analysis and the Youden-J index. We used multivariate logistic regression analysis using backward selection to determine the independent predictors using a univariate cutoff of P 0.05 for removal to determine factors independently associated with POV. The accuracy of our multivariate model was assessed by the area under the ROC curve (AUC). Results Overall the incidence of POV was 37.5% in all the children who underwent surgical ASD repair. POV did not significantly differ between patients who received and did not receive antiemetics intraoperatively. Age of ≥4 years and cardiopulmonary bypass (CPB) time ≥51 min were identified as independent risk predictors for POV and the AUC of logistic regression model was 0.650 (95% confidence interval; 0.565–0.735). Conclusions The incidence of POV in children undergoing surgical ASD repair was 37.5%. Age ≥4 years and CPB time ≥51 min were identified as independent predictors.

Summary Background Optimizing systemic oxygen delivery (DO2) and hemodynamics in children with hypoplastic left heart syndrome (HLHS) is a clinical challenge. Mathematical modeling of the HLHS circulation has been used to determine the relationship between oxygen kinetic parameters and DO2 and to determine how DO2 might be optimized. The model demonstrates that neither arterial oxygen saturation (SaO2) nor mixed venous oxygen saturation (SvO2) alone accurately predicts DO2. Objectives Oxygen delivery kinetics predicted by previously described mathematical modeling were compared with actual patients' hemodynamic data. We sought to determine which patient derived parameters correlated best with DO2. Methods Patients with HLHS who underwent cardiac catheterization prior to surgery to create a superior cavopulmonary anastomosis from 2007 to 2011 were identified. Hemodynamic data obtained were compared with the data derived from the mathematical model. Correlations between SaO2, SvO2, SaO2-SvO2, SaO2/(SaO2-SvO2), pulmonary-to-systemic blood flow ratio (Qp/Qs), and DO2 were evaluated using both linear and nonlinear analyses, and R2 was calculated. Results/Conclusions Patients' data fit most aspects of the mathematical model. DO2 had the best correlation with SaO2/(SaO2-SvO2; R2 = 0.8755) followed by SaO2-SvO2 (R2 = 0.8063), while SaO2 or SvO2 alone did not demonstrate a significant correlation as predicated by the mathematical model (R2 = 0.09564 and 0.4831, respectively). SaO2/(SaO2-SvO2) would be useful clinically to track changes in DO2 that occur with changes in patient condition or with interventions.

Despite remarkable improvements in perioperative care, adverse neurobehavioral outcomes following neonatal and infant cardiac surgery are commonplace and are associated with substantial morbidity. It is becoming increasingly clear that complex congenital heart disease is associated with both abnormalities in neuroanatomic development and a delay in fetal brain maturation. Substantial cerebral ischemic/hypoxic injury has been detected in neonates with complex congenital heart disease both prior to and following corrective cardiac surgery. The brain of the neonate with complex congenital heart disease appears to be uniquely vulnerable to the types of ischemic/hypoxic injury associated with perioperative care. It remains to be determined whether delaying surgical correction to allow for brain maturation will be associated with improvements in neurobehavioral outcomes.

Summary Background : General anaesthesia is frequently necessary in infants and small children undergoing cardiac magnetic resonance imaging (MRI), because of the imaging techniques, MRI environment and potential need for breath-holding to facilitate imaging. Anaesthetizing paediatric patients with congenital heart disease (CHD) for cardiac MRI poses many challenges for the anaesthetist and this report reviews our experience. Methods : We retrospectively reviewed the anaesthesia and MRI records of all patients who had undergone cardiac MRI between January 2000 and October 2002. Results : A total of 250 children with cardiac disease underwent general anaesthesia for cardiac MRI. ASA classification included class I, 2%; class II; 26%; class III, 60% and class IV, 12%. A total of 168 patients (67%) had undergone previous cardiac surgery, 182 patients (94%) were discharged the same day and 48 patients (19.2%) had cyanotic cardiac defects (SpO2 between 55 and 85%). No scans were interrupted because of low oxygen saturation during breath-hold or haemodynamic instability. No patient was admitted to the hospital from complications related to general anaesthesia, but one inhouse patient from the cardiology ward was admitted to the cardiac intensive care unit (CICU) after the MRI because of cyanosis and low cardiac output. Seven patients from the CICU were on inotropic infusions when they underwent the MRI procedure and two others needed inotropic support after induction of anaesthesia. Five patients had a brief episode of hypotension during the MRI and responded quickly to interventions. Conclusion : Our experience demonstrates that general anaesthesia for cardiac MRI can be provided safely in infants and small children with CHD, despite the complexity and pathophysiology of many defects, the frequent breath-holding for image acquisitions and the MRI environment.