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Introduction: Primary care physicians serve on the front lines of care and provide comprehensive care to patients who may have difficulty accessing subspecialists. However, not enough students are entering residency in primary care fields to meet the primary care physician shortage. The authors sought to compare primary care match rates among graduates of medical schools in the state of North Carolina from 2014 to 2018. Methods: The 4 allopathic medical schools in the state of North Carolina were selected for this study: East Carolina University (ECU) Brody School of Medicine, University of North Carolina (UNC) Chapel Hill, Duke School of Medicine, and Wake Forest School of Medicine. Primary care specialties were defined as family medicine, internal medicine, pediatrics, and internal medicine/pediatrics. The proportion of students matching to a residency in any of these fields, and in each specific field, was compared across schools. Results: Over 2014-2018, 214 ECU Brody School of Medicine graduates, 386 UNC graduates, 165 Duke graduates, and 196 Wake Forest graduates matched to a primary care specialty. ECU had the highest proportion of its graduates match in a primary care specialty (53%, compared with 34% to 45% at other schools; P < .001), and was particularly distinguished by having the highest proportions of graduates match to residencies in family medicine (18%) and pediatrics (16%). Conclusion: During the study period of 2014-2018, the ECU Brody School of Medicine matched more medical students into primary care specialties than the other medical schools in the state. This school’s community-driven mission and rural location, among other characteristics facilitating sustained student commitment to primary care careers, can inform the development of new medical schools in the United States to overcome the primary care physician shortage.

Objective Accurate assessment of risk factors such as congenital heart disease (CHD) can aid in risk stratification of children presenting for surgery. Risk stratification is especially important in tonsillectomy ± adenoidectomy (T/A), a common pediatric procedure that is usually performed electively, but that has a high rate of adverse events. In this study, we examined the association of CHD with revisits after T/A. Methods We identified children who underwent T/A at hospitals and hospital-owned facilities during 2010 to 2014 using the State Inpatient Databases and State Ambulatory Surgery and Services Databases of Florida, Georgia, Iowa, New York, and Utah. We evaluated the association between CHD severity and the occurrence of an unplanned hospital readmission or ED visit within 30 days following discharge using multivariable logistic regression. Results The analysis included 244,598 patients, of whom 858 had minor or major CHD. In multivariable analysis, CHD was not associated with an increased risk of 30-day revisits (minor OR = 1.1; 95% CI: 0.8, 1.5; P = .65; major OR = 1.2; 95% CI: 0.9, 1.6; P = .34). Other comorbidities, including chromosomal anomalies (OR = 1.4; 95% CI: 1.2, 1.6; P < .001), congenital airway anomalies (OR = 1.3; 95% CI: 1.03, 1.7; P = .03), and neuromuscular impairment (OR = 1.4; 95% CI: 1.2, 1.7; P < .001) predicted an increased likelihood of revisits. Conclusion Neither minor nor major CHD was independently associated with an increased risk of 30-day revisits among children undergoing T/A. Other characteristics, particularly non-cardiac comorbidities, socioeconomic status, and geographic region may be of greater utility for predicting revisit risk following pediatric T/A. Level of Evidence 2b.

The peer review process provides a foundation for the credibility of scientific findings in medicine. The following article discusses the history of peer review in scientific and medical journals, the process for the selection of peer reviewers, and how journal editors arrive at a decision on submitted manuscripts. To aid authors who are invited to revise their manuscripts for further consideration, we outline steps for considering reviewer comments and provide suggestions for organizing the author's response to reviewers. We also examine ethical issues in peer review and provide recommendations for authors interested in becoming peer reviewers themselves.

There is an increased need for Family Medicine physicians who make up approximately 40% of the primary care work. In this article the authors share perspective on how to engage the community in increasing the rural workforce of Family Physicians. Suggestions include introducing the school to the community in which it lives, matching the applicant to the needs of the community and not just the needs of the school, including community members as part of the admissions process and recruiting applicants primarily from inside the state.

Background Influenza vaccine participation in adolescents is low. Barriers to the influenza vaccine may be shared with the measles-mumps-rubella (MMR) vaccine. Methods We studied adolescents aged 13–17 years who participated in the National Immunization Survey-Teen between 2011 and 2017 (N = 129,200). Data were analyzed to determine whether MMR vaccination status was associated with being up-to-date on the influenza vaccination. Results A total of 49% adolescents received at least one dose of the influenza vaccine within the past 3 years, and 92% completed the MMR series. In multivariable analysis, not initiating or not completing the MMR series was associated with lower odds of being up-to-date on influenza vaccination. Conclusions Adolescents who do not initiate or complete the MMR vaccine series have lower odds of being up-to-date on their influenza vaccination. Lower influenzavaccine participation is associated with lower socioeconomic status, lack of insurance, increased time since last child visit, and higher maternal education.

Background Colonoscopy is highly sensitive for the visualization of the entire colon. Inpatient colonoscopies pose a special risk of poor preparation. We reviewed bowel preparation methods and patient factors to identify predictors of inadequate bowel preparation for inpatient colonoscopy at our institution. The purpose of this study was to identify factors that predict inadequate bowel preparation for inpatient colonoscopies. Methods All patients ages >18 years of age undergoing inpatient colonoscopy in 2017-2018 were reviewed. The primary outcome was inadequate bowel preparation and secondary outcomes were successful cecal intubation, duration of colonoscopy, and hospital length of stay (LOS). Outcomes were compared using multivariable regression with stepwise covariate selection. Results The analysis included 315 patients (median age =67 years; 45% female). Visualization was deemed adequate in 56%, fair in 27%, and poor in 17% of cases. Cecal intubation was successful in 84% of cases. The median duration of colonoscopy was 25 min and LOS was 2 days. Unsuccessful cecal intubation was most likely with poor visualization compared to adequate visualization (36% vs. 11%, P=0.014). There was no increased colonoscopy duration with poor visualization (P=0.075). There was no significant LOS with worse visualization quality (P=0.185). Factors predicting worse visualization quality included older age, history of congestive heart failure (CHF), cirrhosis, and motility disorders. Conclusions At our institution, patients who were older or had significant comorbid conditions (chronic artery disease, CHF, chronic obstructive pulmonary disease, motility disorders, or cirrhosis) were more likely to have inadequate inpatient bowel preparation. Bowel preparation type did not affect the duration, quality of visualization, or successful cecal intubation.

Decrease the incidence of inadequate diuresis (ID, loss of

Background Anesthesia services are frequently provided outside of the traditional operating room environment for children. It is unclear if adverse events which occur in off-site anesthetizing locations result in more severe outcomes compared to events in traditional operating rooms. Aim We used a multi-institutional registry of pediatric patients to compare outcomes of perioperative adverse events between location types. Methods De-identified data from 24 pediatric tertiary care hospitals participating in the Wake Up Safe registry during 2010-2015 were analyzed. Peri-procedural adverse events occurring in operating rooms or off-site locations were included. The primary outcome was whether the adverse event was severe, defined as requiring escalation of care or resulting in temporary or significant harm. Multivariable logistic regression was used to compare location type (operating room vs. off-site) and the likelihood of a severe outcome among reported events. Results There were 1594 adverse events, of which 362 were associated with off-site anesthetizing locations. In multivariable logistic regression, off-site location was associated with greater odds of severe adverse event outcome (adjusted odds ratio, 1.31; 95% confidence interval: 1.01, 1.69; P = 0.044). Comparing adverse events in cardiac catheterization suites to events in operating rooms confirmed higher odds of severe outcome in the former group (adjusted odds ratio = 1.48; 95% confidence interval: 1.05, 2.08; P = 0.025), while this difference was not found for other off-site locations. Conclusion Multivariable analysis of a large registry revealed a greater likelihood of severe outcome for adverse events occurring in cardiac catheterization suites (but not other out of the OR sites), compared to adverse events occurring in the operating room. Additional prospective studies are needed which better control for patient and environmental characteristics and their effect on severe outcomes after anesthesia.

Mohammed Hakim,1 Shabana Zainab Shafy,1 Rebecca Miller,1 Kris R Jatana,2 Mark Splaingard,3 Dmitry Tumin,1 Joseph D Tobias,1,4 Vidya T Raman1,4 1Department of Anesthesiology & Pain Medicine, Nationwide Children’s Hospital, Columbus, OH, USA; 2Department of Pediatric Otorhinolaryngology, Nationwide Children’s Hospital, Columbus, OH, USA; 3Department of Sleep Disorders Centre, Nationwide Children’s Hospital, Columbus, OH, USA; 4Department of Anesthesiology & Pain Medicine, Ohio State University, Columbus, OH, USA Background: The incidence of obstructive sleep apnea (OSA) and sleep-disordered breathing (SDB) in children exceeds the availability of polysomnography (PSG) to definitively diagnose OSA and identify children at higher risk of perioperative complications. As sleep deficits are associated with slower reaction times (RTs), measuring RT may be a cost-effective approach to objectively identify SDB symptoms. Aim: The aim of this study is to compare RT on a standard 10-minute psychomotor vigilance test (PVT) based on children’s history of OSA/SDB. Methods : Children, 6–11 years of age, were enrolled from two different clinical groups. The SDB group included children undergoing adenotonsillectomy with a clinical history of SDB, OSA, or snoring. The control group included children with no history of SDB, OSA, or snoring who were scheduled for surgery other than adenotonsillectomy. RT was measured via 10-minute PVT (Ambulatory Monitoring Inc., Ardsley, NY, USA). Median RT was calculated for each patient based on all responses to stimuli during the PVT assessment and was compared to published age-sex-specific norms. The proportion of children exceeding RT norms was compared between study groups. Results: The study included 72 patients (36/36 male/female, median age 7 years), 46 with SDB and 26 without SDB. There was no difference in the RT between the two groups. Fifty-four percent of patients with SDB exceeded norms for median RT vs 42% of control patients (95% CI of difference: – 12, 36; P=0.326). Conclusion: Approximately half of the patients in both groups exceeded published norms for median RT on PVT. Despite its convenience, measurement of RT did not distinguish between patients with probable SDB/OSA for preoperative risk stratification. Keywords: psychomotor vigilance test, obstructive sleep apnea, anesthesia, polysomnography, sleep-disordered breathing

Background: Gaps in health insurance coverage may complicate asthma management and increase emergency department (ED) use. Using two nationally-representative surveys, we characterize the prevalenc...

Preoperative factors have been correlated with pre-incision hypotension (PIH) in children undergoing surgery, suggesting that PIH can be predicted through preoperative screening. We studied blood pressure (BP) changes in the 12 min following the induction of anesthesia to study the incidence of post-induction hypotension and to assess the feasibility of predicting PIH in low-risk children without preoperative hypotension or comorbid features.We retrospectively evaluated 200 patients ranging in age from 2 to 8 years with American Society of Anesthesiologists' (ASA) physical status I or II, undergoing non-cardiac surgery. Patients were excluded if they had preoperative (baseline) hypotension (systolic blood pressure (SBP) 5th percentile for age). BP and heart rate (HR) were recorded at 3 min intervals for 12 min after the induction of anesthesia. Pre-incision hypotension (PIH) was initially defined as SBP 5th percentile for age: (1) at any timepoint within 12 min of induction; (2) for the median SBP obtained during the 12 min study period; or (3) at 2 or more timepoints including the final point at 12 min after the induction of anesthesia (sustained hypotension). In addition, we examined PIH defined as 20% decrease in SBP from baseline: (4) at any timepoint within 12 min of the induction of anesthesia; (5) for the median SBP obtained during the 12 min study period; or (6) at two or more timepoints including the final point at 12 min after the induction of anesthesia. Agreement among the six definitions was analyzed, in addition to the effects of age, gender, type of anesthetic induction, use of premedication, preoperative BP, preoperative HR, and body mass index on the incidence of PIH according to each definition.Five patients were excluded due to baseline hypotension and six were excluded for missing data. In the remaining cohort, estimated PIH prevalence ranged from 4% [definition (Stewart et al., in Paediatr Anaesth 26:844-851, 2016), sustained PIH according to SBP percentile-for-age] to 57% [definition (Task Force on Blood Pressure Control in Children, in Pediatrics 79:1-25, 1987), at least one timepoint where SBP was 20% lower than baseline]. Pairwise agreement among the six definitions ranged from 49 to 91% agreement. No sequelae of PIH were noted during subsequent anesthetic or postoperative care. On multivariable analysis, no covariates were consistently associated with PIH risk across all six definitions of PIH.The present study describes the incidence and prediction of PIH in a cohort of relatively healthy children. In this setting, accurate prediction of PIH appears to be hampered by lack of agreement between definitions of PIH. Overall, there was a low PIH incidence when the threshold of SBP 5th percentile for age was used.II.

Senthil G Krishna,1,2 Faizaan Syed,1 Mohammed Hakim,1 Mumin Hakim,3 Dmitry Tumin,1 Giorgio C Veneziano,1,2 Joseph D Tobias1,2 1Department of Anesthesiology & Pain Medicine, Nationwide Children’s Hospital, Columbus, OH, USA; 2Department of Anesthesiology & Pain Medicine, The Ohio State University College of Medicine, Columbus, OH, USA; 3Department of Surgery, Montefiore Medical Centre, Bronx, NY, USA Background: When managing patients with a difficult airway, supraglottic airways (SGAs) have been used as rescue devices or to serve as a conduit for endotracheal intubation. The current study compares various clinical outcomes, including the bronchoscopic view of the glottis when using 2 SGAs, the Air-Q® laryngeal mask airway (LMA) and the i-gel® SGA, in pediatric patients. Methods: Patients ≤18 years of age were prospectively randomized to receive either the Air-Q® LMA or the i-gel® SGA. Following SGA placement, a flexible fiberoptic bronchoscope was inserted through the SGA to visualize the glottis. Time taken to obtain the bronchoscopic view and place the SGA, and the ability to seal the airway at 20 cmH2O were compared. The bronchoscopic view obtained was graded as follows: 1) glottic aperture seen completely; 2) glottic aperture seen partially with visual obstruction 50%; and 4) glottic aperture not seen. Results: Fifty patients were enrolled and 48 (22/26 male/female) were included in the analysis. Median age was 13 years (IQR: 7, 16) and median weight was 49 kg (IQR: 25, 70). The Air-Q® LMA and i-gel® SGA groups did not differ in device placement time (median of 19 vs 21 seconds; 95% CI of difference in medians: − 2 to 7; P=0.331), the time to achieve fiberoptic view of the glottis (median of 25 vs 21 seconds; 95% CI of difference: − 9 to 8; P=0.489) or the grade of the bronchoscopic view of the airway. Eight Air-Q® and 6 i-gel® supraglottic devices sealed the airway at 20 cmH2O. Discussion: The time required for successful placement of the SGA, the time required for bronchoscopic view, and the quality of bronchoscopic view through the Air-Q® LMA and the i-gel® SGA did not differ. Keywords: supraglottic airways, bronchoscopic view, glottic aperture

INTRODUCTION Chronic opioid use is common after organ transplantation, and has been associated with poor outcomes in transplantation of abdominal organs. However, little is known about possible influences of chronic opioid use on outcomes of lung transplantation (LTx). OBJECTIVES We assessed whether long-term chronic opioid use influenced clinical outcomes among LTx recipients at our program. METHODS We retrospectively evaluated chronic opioid use among bilateral LTx recipients ages 12 and older followed at our institution 1-5 years post-transplant. Chronic opioid use was defined as ≥3 months of consecutive prescribed use. Outcomes included survival, hospitalization, emergency department and urgent care visits, forced expiratory volume in one second (FEV1), and allograft rejection. RESULTS Twenty-one patients ages 15-50 years met inclusion criteria. On multivariable analysis, initiation of chronic opioid use was followed by increased mortality hazard (hazard ratio=7.1; 95% confidence interval [CI]: 1.1, 45.0, P = 0.037) and decreased FEV1 (-16%; 95% CI: -24%, -7%; P

BACKGROUND Understanding how survey methodology and quality measures are associated with progress from abstract presentation to manuscript publication can help optimize the design of survey research in anesthesiology, and enhance respondents' confidence in the value of survey participation. AIMS The aim of this study was to determine if adherence to survey method recommendations and attainment of high response rates are associated with faster progress to publication among abstracts initially presented at anesthesiology society meetings. METHODS Abstracts from the American Society of Anesthesiologists' (ASA) Annual Meeting, Association of Anaesthetists of Great Britain and Ireland (AAGBI) Annual Congress, and the International Anesthesia Research Society (IARS) Annual Meeting from 2011-2014 were reviewed. Abstracts reporting original survey data collection were included in a systematic search for resulting publications in peer-reviewed academic journals. Cox proportional hazards regression was used to analyze progress to publication. RESULT Ninety-nine ASA, 76 AAGBI, and 30 IARS abstracts met inclusion criteria. Among these abstracts, 43 (43%) from ASA, none from AAGBI, and 7 (23%) from IARS have been published as original research articles or brief reports. Surveying patients or caregivers, as opposed to medical professionals, was associated with increased likelihood of publication (hazard ratio [HR] = 4.4, 95% confidence interval [CI]: 1.6, 12.4, P = 0.005) as was a larger sample size (eg, >500 vs

To provide optimal conditions for neurophysiological monitoring and rapid awakening, remifentanil is commonly used during pediatric spinal surgery. However, remifentanil may induce hyperalgesia and increase postoperative opioid requirements. We evaluated the potential of methadone or magnesium to prevent remifentanil-induced hyperalgesia. Using a prospective, randomized, blinded design, adolescents presenting for posterior spinal fusion to treat idiopathic scoliosis were assigned to receive desflurane with remifentanil alone (REMI), remifentanil + methadone (MET) (0.1 mg/kg IV over 15 min), or remifentanil + magnesium (MAG) (50 mg/kg bolus over 30 min followed by 10 mg/kg/h). Primary outcomes were opioid requirements and postoperative pain scores. Secondary outcomes included intraoperative anesthetic requirements, neurophysiological monitoring conditions, and emergence times. Data analysis included 60 patients. Total opioid requirement (hydromorphone) in the REMI group (received perioperatively and on the inpatient ward) was 0.34 ± 0.11 mg/kg compared to 0.26 ± 0.10 mg/kg in the MET group (95% confidence interval (CI) of difference: − 0.14, − 0.01; p = 0.035). The difference in opioid requirements between the REMI and MET group was related to intraoperative dosing (0.04 ± 0.02 mg/kg vs. 0.02 ± 0.01 mg/kg; 95% CI of difference: − 0.01, − 0.02; p = 0.003). No difference was noted in pain scores, and no differences were noted when comparing the REMI and MAG groups. With the dosing regimens in the current study, the only benefit noted with methadone was a decrease in perioperative opioid requirements. However, given the potential for hyperalgesia with the intraoperative use of remifentanil, adjunctive use of methadone appears warranted.

Domino liver transplantation (DLT) utilizes the explanted liver of one liver transplant recipient as a donor graft in another patient. While there may be unique risks associated with DLT, it is unclear if DLT has less favorable long-term outcomes than deceased donor liver transplantation (DDLT). We used a propensity score matching approach to compare the outcomes of DLT recipients to DDLT recipients. The United Network for Organ Sharing (UNOS) registry was queried for patients undergoing DLT or DDLT in 2002-2016. Each DLT recipient was matched to a unique DDLT recipient to compare mortality and graft failure. There were 126 DLT and 62 835 DDLT recipients meeting inclusion criteria. After propensity score matching on recipient pre-transplant characteristics, 123 DLT cases were matched to DDLT controls from the same UNOS region. On stratified Cox proportional hazards regression, DLT incurred no increase in the hazard of mortality [hazard ratio (HR) = 1.4; 95% confidence interval (CI): 0.8, 2.7; P = 0.265] or graft failure (HR = 1.2; 95% CI: 0.7, 2.1; P = 0.556) compared to DDLT. Using a large national registry, a propensity-matched analysis found no increased risk of mortality or graft failure associated with DLT compared to DDLT.

MohammedHakim,1 Alexander B Froyshteter,2 Hina Walia,1 Dmitry Tumin,1,3 Giorgio Veneziano,1 Tarun Bhalla,1,4 Joseph D Tobias1,3,4 1Department of Anesthesiology and Pain Medicine, Nationwide Children’s Hospital, Columbus, OH, USA; 2Department of Anesthesiology, Rush University Medical Center, Chicago, IL, USA; 3Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, USA; 4Department of Anesthesiology and Pain Medicine, The Ohio State University College of Medicine, Columbus, OH, USA Introduction: Epidural anesthesia is frequently used to provide postoperative analgesia following major surgical procedures. Secure fixation of the epidural catheter is necessary to prevent premature dislodgment and loss of epidural analgesia. Using an in vitro model, the current prospective study evaluates different types of dressings for securement of an epidural catheter by quantifying the force in Newtons (N) required for dislodgment using a digital force gage. Methods: Four methods of epidural catheter securement were used on a simulator mannequin: 1) Suresite® Window Clear Dressing, 2) Op-Site Post-Op® Visible Dressing, 3) Steri-Strips® and Suresite Window Clear Dressing, and 4) Steri-Strips and Op-Site Post-Op Visible Dressing. Each method of securement was assessed 10 times to calculate the mean force required to dislodge the catheter. Mean force of dislodgment for each method was compared using parametric tests. Results: The force (mean ± SD) required for catheter dislodgment for the four methods was 14.0±2.9, 2, 10.7±1.5, 8.6±2.3, and 9.6±2.2 N, respectively. The pairwise difference showed that the Suresite Window Clear Dressing was the best securement method when compared with other methods. Conclusion: Our study demonstrates the advantage of the Suresite Window Clear Dressing in securing the epidural catheter. Future clinical trials are needed to validate these findings. Keywords: epidural catheter, securement, dressings

Purpose: Living kidney donation is safe and effective, but patients in need of a transplant continue to outnumber donors. Disincentives to living donation include lost income, risk of job loss, perioperative complications, and unreimbursed medical expenses. Methods: This study uses US registry and follow-up data on living kidney donors from 2013 to 2015 to identify social predictors of return to work across gender following living kidney donation. Results: Using logistic regression, we find that predictors of return to work following living kidney donation differ for women and men. Among women, age, education, smoking status, and procedure type are associated with return to work. Among men, education, procedure type, and hospital readmission within 6 weeks postdonation are associated with return to work. Notably, single and divorced men are less likely to return to work compared to married men (odds ratio [OR] for single men 0.51, 95% confidence interval [CI], 0.37-0.69, P < .001; OR for divorced men 0.51, 95% CI, 0.34-0.75, P = .006). Marital status is not associated with return to work for women. Single and divorced men’s greater odds of not returning to work are robust to controls for relevant pre- and postdonation characteristics. Conclusions: Single and divorced men’s lack of social support may present an obstacle to work resumption following living kidney donation.

Spinal anesthesia (SA) is being increasingly used in infants to avoid the potential negative neurocognitive effects of general anesthesia (GA). However, SA has been reported to provide a relatively short duration of surgical anesthesia. We retrospectively reviewed SA cases for surgical procedures lasting more than 60 min in children up to 3 years old. All patients received bupivacaine 0.5% (1 mg/kg up to 7 mg) with clonidine 1 µg/kg ± epinephrine. The primary outcome was success of SA without subsequent conversion to GA. Thirty-five patients met inclusion criteria (all males, age 7 ± 5 months, weight 8 ± 2 kg). Procedures included male genital, groin and multiple site surgeries. Average surgical duration was 71 ± 12 min (range 60–111 min). SA was successful in 31 of 35 patients (89%; 95% confidence interval 78, 99%). The cause of failure was rarely due to the duration of surgery (1 of 4 patients). Six patients with successful SA required sedation with dexmedetomidine ± fentanyl. Differences in procedure duration and patient characteristics were not statistically significant between successful and failed SA. SA is a highly successful technique and may offer an alternative to GA in children undergoing appropriate surgery expected to last as long as 60–100 min.

Recent advances in the field of pediatric interventional cardiology have resulted in therapies for patients in need of augmented pulmonary artery (PA) flow. Catheter-based PA rehabilitation can be performed safely but not without the potential risk of pulmonary hemorrhage. When severe, this bleeding has the ability to contaminate the bronchi and trachea, and possibly occlude the endotracheal tube. This can result in a critical inability to ventilate and oxygenate these patients. Herein, we review our institutional experience with pulmonary hemorrhage associated with these procedures and the feasibility of predicting this outcome. The secondary aim was to discuss our novel anesthetic approach to a select group of these patients, involving the use of bronchial blockers to preemptively prevent contamination of bilateral bronchi and occlusion of the endotracheal tube.

Background Studies have shown significant variation in the tracheobronchial angles in pediatric-aged patients. The current study revisits tracheobronchial angle measurements in children using accurate computed tomography-based 3-dimensional images to add clarity to the understanding of tracheobronchial angles. The primary objective of the current study was to measure the right and left bronchial angle take off from the trachea using 3-dimensional computed tomography-based images of the air column in the tracheobronchial tree. Methods Computed tomography-based images of 45 children younger than 8 years were reviewed. The children were evaluated during spontaneous ventilation either during natural sleep or with sedation. The right and left bronchial angles were computed between the central axes of the respective main bronchi and a vertical line passing through the central axis of the longitudinal tracheal air column. The right and left bronchial angles were compared using paired t tests, and the age dependence of the right bronchial angle and left bronchial angle difference was evaluated using Pearson's correlation coefficient. Results The study cohort included 18 males and 27 females with an average age of 49 ± 25 months. The right bronchial angle ranged from 23° to 56° (mean 42 ± 7°), whereas left bronchial angle varied between 25° and 68° (mean 43 ± 9°). The difference in means of 1 degree was not statistically significant (95% confidence interval of difference: -1°, 4°; P = .282). No association was found between left and right bronchial angle difference and patient age (r = -.019). Conclusion According to computed tomography-based 3-dimensional imaging, right and left bronchial angles are virtually identical in children up to 8 years of age, and the difference between right and left bronchial angles does not vary with age in this population.

u ca Background There are limited data to guide the selection of the appropriate sized endobronchial tube for main stem intubation to provide one-lung ventilation in children. The relationship between the cricoid and the main bronchi (right and left) has been previously evaluated using two-dimensional computed tomography (CT) imaging and video-bronchoscopic images. The present study defines the three-dimensional, CT-derived volume-based relationships between the right main-stem bronchus (RMB), left main-stem bronchus (LMB), and the cricoid ring. Methods The three-dimensional CT images of 35 children, less than 8 years of age, undergoing radiological evaluation unrelated to airway or mediastinal symptomatology were examined. The images of the airway column were evaluated at the level of the cricoid and main stem bronchi (right and left). Volumes were calculated and comparisons made between these levels. Results There was no statistically significant difference based on gender for the cricoid and main stem bronchi volumes. A statistically significant difference was observed between the cricoid and left main stem bronchi volumes as well as between the right and left main stem bronchi. Conclusion The relationship (ratio) between the volumes of the cricoid and main stem bronchi remains constant by age. The cricoid dimensions can be used to predict the main stem bronchi dimensions.

OBJECTIVES General anesthesia or sedation can facilitate the completion of diagnostic radiological studies in children. We evaluated the incidence, predictors, and causes of adverse events (AEs) when general anesthesia is provided for diagnostic radiological imaging. METHODS Deidentified data from 24 pediatric tertiary care hospitals participating in the Wake-Up Safe registry during 2010-2015 were obtained for analysis. Children 18 years or younger receiving general anesthesia for radiological procedures were identified using Current Procedural Terminology codes, and reported AEs were analyzed if they were associated with anesthetic care at magnetic resonance imaging or computed tomography locations. Logistic regression was used to determine predictors of AE occurrence in cases with complete covariate data. RESULTS We identified 175,486 anesthetics for diagnostic radiological exams, compared with 83 AEs in magnetic resonance imaging or computed tomography locations (AE incidence of 0.05%). In multivariable analysis, AEs were more likely among patients with American Society of Anesthesiologists physical status IV compared with American Society of Anesthesiologists physical status I patients (adjusted odds ratio, 8.9; 95% confidence interval, 2.8-28.0; P < 0.001). Twenty-three AEs resulted in harm to the patient, whereas 32 AEs required unplanned hospital or intensive care unit admission. Anesthetic complications or issues were the most common cause of AEs (n = 52). CONCLUSIONS Anesthesia provided for pediatric radiological studies is very safe and with an overall low AE incidence. The contribution of anesthetic complications to reported AEs suggests opportunities for further process improvement in this setting.

Marriage promotion initiatives presume substantial health benefits of marriage. Current literature, however, has provided inconsistent results on whether these benefits would be shared by people unlikely to marry. We investigate whether the physical and mental health benefits of marriage depend on the likelihood of marriage. Whereas prior studies have compared health benefits of marriage across a single predictor of marriage chances, we define the likelihood of marriage as a composite of demographic, economic, and health characteristics. Using the National Longitudinal Survey of Youth 1979, we find that married adults are only modestly healthier than unmarried adults in both physical and mental dimensions. People with a higher likelihood of marriage generally do not reap greater health benefits from marriage than their counterparts. The only exception is that continuous marriage is more strongly associated with improved mental health among men who are more likely to be married.

Avoidance of red blood cell (RBC) transfusions in patients awaiting heart transplantation (HTx) has been suggested to minimize the risk of allosensitization. Although recent studies have suggested that an immature immune system in younger HTx recipients may reduce risks associated with RBC transfusion, the role of age in moderating the influence of transfusion on HTx outcomes remains unclear. We used available data from a national transplant registry to explore whether the association between pre-transplant transfusions and outcomes of pediatric HTx varies by patient age. De-identified data were obtained from the United Network for Organ Sharing registry, including first-time recipients of isolated HTx performed at age 0-17 years in 1995-2015. The primary exposure was receiving blood transfusions within 2 weeks prior to HTx. Patient survival after HTx was evaluated using multivariable Cox proportional hazards, where age at transplant was interacted with exposure to pre-transplant transfusion. Age-specific hazard ratios (HRs) of pre-transplant transfusion were plotted across ages at transplant. There were 4883 patients meeting inclusion criteria, of whom 1258 died during follow-up (mean follow-up duration 6 ± 5 years). Patients receiving pre-transplant transfusions were distinguished by younger age, higher prevalence of prior cardiac surgery, greater likelihood of being in the intensive care unit, and greater use of left ventricular assist device bridge to transplant. In multivariable analysis, pre-transplant transfusions were associated with increased mortality hazard among infants

Use of spinal anesthesia (SA) in children may address concerns about potential neurocognitive effects of general anesthesia. We used near-infrared spectroscopy (NIRS) to assess the effects of SA on cerebral and tissue oxygenation in 19 patients aged 7 ± 3 months. Prior to SA placement, NIRS monitors were placed on the forehead (cerebral) and the thigh (tissue). Intraoperative cerebral and tissue saturation were 73 ± 7 and 80 ± 11%, respectively, before SA placement. NIRS measurements were monitored every minute for 30 min after SA placement and modeled using mixed-effects linear regression. Regression estimates showed that cerebral saturation remained stable from 67% [95% confidence interval (CI) 63, 71%] after SA placement to 68% (95% CI 65, 72%) at the conclusion of monitoring. After SA placement, tissue saturation was elevated compared to baseline values; but further change [from 91% (95% CI 89, 93%) to 93% (95% CI 91, 95%) at the end of monitoring] was clinically non-significant. All patients breathed spontaneously on room air without changes in oxygen saturation. Blood pressure and heart rate decreased after SA placement, but no changes in hemodynamic parameters required treatment. These data provide further evidence of the neutral effect of SA on cerebral oxygenation 30 min after block placement.

BACKGROUND Given the conflicting nature of reported risk factors for post-discharge venous thromboembolism (VTE) and unclear guidelines for post-discharge pharmacoprophylaxis, we sought to determine risk factors for 30-day post-discharge VTE after colectomy to predict which patients will benefit from post-discharge pharmacoprophylaxis. METHODS Patients who underwent colectomy in the American College of Surgeons National Surgical Quality Improvement Project Participant Use Files from 2011 to 2015 were identified. Logistic regression modeling was used. Receiver-operating characteristic curves were used and the best cut-points were determined using Youden's J index (sensitivity + specificity - 1). Hosmer-Lemeshow goodness-of-fit test was used to test model calibration. A random sample of 30% of the cohort was used as a validation set. RESULTS Among 77,823 cases, the overall incidence of VTE after colectomy was 1.9%, with 0.7% of VTE events occurring in the post-discharge setting. Factors associated with post-discharge VTE risk including body mass index, preoperative albumin, operation time, hospital length of stay, race, smoking status, inflammatory bowel disease, return to the operating room and postoperative ileus were included in logistic regression equation model. The model demonstrated good calibration (goodness of fit P = 0.7137) and good discrimination (area under the curve (AUC) = 0.68; validation set, AUC = 0.70). A score of ≥-5.00 had the maxim sensitivity and specificity, resulting in 36.63% of patients being treated with prophylaxis for an overall VTE risk of 0.67%. CONCLUSION Approximately one-third of post-colectomy VTE events occurred after discharge. Patients with predicted post-discharge VTE risk of ≥-5.00 should be recommended for extended post-discharge VTE prophylaxis.

Background: Curcumin is a polyphenol extracted from the turmeric plant which may have anti-inflammatory properties. We hypothesized that curcumin pretreatment would result in a reduction in inflammatory markers in a large animal model of extracorporeal support. Methods: A total of seven samples were obtained from three swine treated with curcumin and 16 samples were obtained from six swine in the control group (procedure terminated in two swine before last sample could be obtained). Results: Samples for interleukin (IL)-8 and IL-1b had concentrations below the limit of detection at all points and were discarded from further analysis. IL-6, tumor necrosis factor (TNF)-alpha, and intercellular adhesion molecule (ICAM)-1 concentrations were lower in curcumin pretreated animals when compared to control animals. This decrease was statistically significant for TNF-alpha, and ICAM-1. Conclusions: This project may provide information for the development of a translational study in humans as we noted that curcumin pretreatment in a large animal model of cardiopulmonary bypass (CPB) and extracorporeal support resulted in a decrease in TNF-alpha and ICAM-1 expression compared to control animals. Cardiol Res. 2018;9(1):7-10 doi: https://doi.org/10.14740/cr677w

Background:: The aim of this study was to evaluate the response of the LiDCO-rapid™ during intraoperative phlebotomy in anesthetized children prior to surgery for congenital heart disease. Methods:: After the induction of general anesthesia and endotracheal intubation, baseline vital signs were recorded, along with pulse pressure variability (PPV) and stroke volume variability (SVV) from the LiDCO-rapid™ and cerebral oxygenation (rSO 2 ) using near-infrared spectroscopy (NIRS). Phlebotomy was performed over 5 - 10 min with the volume of blood removed calculated to achieve a hematocrit of 24-28% on cardiopulmonary bypass. The primary outcome was a decline in rSO 2 ≥ 5 between the baseline value and the end of phlebotomy. At that time, the correlation of the starting and ending values of SVV and PPV with the NIRS was determined. Results:: The study cohort included 30 patients (mean age of 21 ± 11 years). Statistically significant changes during the study period were observed in rSO 2 , but not in the LiDCO-rapid™ parameters. In analysis of continuous NIRS data, the change in NIRS did not correlate with either baseline (r = 0.10, P = 0.644) or final (r = 0.02, P = 0.914) SVV. Likewise, the change in NIRS did not correlate with baseline (r = 0.01, P = 0.953) or final (r = 0.00, P = 0.982) PPV. Conclusion:: Baseline values as well as changes in the PVV and SVV from the LiDCO-rapid™ did not predict or correlate with changes in cerebral oxygenation measured by NIRS during intraoperative phlebotomy. Our preliminary data suggest that these parameters (PVV and SVV) are not useful in monitoring patient stability or the need for volume replacement during intraoperative phlebotomy prior to cardiac surgery. Cardiol Res. 2017;8(6):276-279 doi: https://doi.org/10.14740/cr634w

Objectives Cystic fibrosis (CF) is characterized by infection and inflammation of the sinorespiratory tract. Functional endoscopic sinus surgery (FESS) is an option for patients with severe sinusitis. We sought to evaluate pulmonary function testing after FESS in pediatric and adult patients with CF. Study Design Retrospective chart review using data from all patients with CF who underwent FESS from January 2009 to July 2014. Setting Patients were from a single institution. Subjects and Methods Data were extracted for 181 patients and 320 surgeries. Lung function data, including the forced expiratory volume in one second (FEV1), forced vital capacity (FVC), and FEV1/FVC, were retrieved within 1 year before and after surgery. Mixed-effects regression was used to compare FEV1 trajectories before and after surgery. The effect of surgery was stratified by presurgery FEV1 to compare patients with mild/no lung disease (FEV180%) and moderate/severe lung disease (FEV180%). Results Of the 181 patients reviewed, 131 with primary FESS had FEV1 data. Presurgery average age was 16 years (95% confidence interval [CI], 14.27-17.73), and FEV1 mean was 85% (95% CI, 81.02-88.98). There were 88 patients with FEV180% and 43 patients with FEV180%. For the entire cohort, lung function did not change related to FESS. Among patients with FEV180%, FEV1 declined presurgery by 3.5% per year (95% CI, -6.1% to -0.8%; P = .010), which halted after surgery with these patients, then showing no subsequent change in FEV1 (95% CI, 0.9%-3.7%; P = .240). No benefit was identified for patients with FEV180%. Conclusion Pulmonary function testing improved in patients with moderate/severe lung disease 1 year following FESS. This suggests FESS may benefit pulmonary outcomes.

Background Pediatric tonsillectomies are increasingly being performed as an outpatient procedure thereby increasing the parental role in post-operative pain management. However, it is unclear if parents receive adequate teaching regarding pain management. We introduced a video teaching tool and compared its efficacy alone and in combination with the standard verbal instruction. Methods A prospective study which randomized parents or caregivers of children undergoing tonsillectomy ± adenoidectomy into three groups: 1) standard verbal post-operative instructions; 2) watching the video teaching tool along with standard verbal instructions or 3) video teaching tool only. Parents completed pre and post-instruction assessments of their knowledge of post-operative pain management with responses scored from 0 to 8. Telephone assessments were conducted within 48 post-operative hours with a subjective rating of the helpfulness of the video teaching tool. Results The study cohort included 99 patients and their families. The median pre-instruction score was 5 of 8 points (Interquartile range [IQR]: 4, 6) and this remained at 5 following instruction. (IQR:4, 6; p = 0.702 difference from baseline). Baseline scores did not vary across the groups (p = 0.156) and there was no increase in the knowledge score from pre to post-test across the three groups. Groups B and C rated the helpfulness of the video teaching tool with a median score of 4 of 5. (IQR: 4, 5). Conclusions A baseline deficit exists in parental understanding of post-operative pain management that did not statistically improve regardless of the form post-operative instruction used (verbal vs. video-based instruction). However, the high helpfulness scores in both video groups support the use of video instruction as an alternative to or to complement to verbal instruction. However, further identification of knowledge deficits is required for optimization of post-operative educational materials.

Increasing incidence of lifelong obesity and associated nonalcoholic steatohepatitis in younger birth cohorts may have contributed to growing incidence of hepatocellular carcinoma (HCC) in the USA. Yet, the contribution of cohort effects to trends in HCC incidence is unclear. Using data from the Surveillance, Epidemiology, and End Results (SEER) program 1973–2013, race- and gender-specific trends in HCC incidence in the USA were decomposed using age-period-cohort (APC) modeling. Among SEER registry sites included in the analysis, there were 25,532 cases of HCC diagnosed including 15,867 (62%) White males, 3541 (14%) Black males, 5009 (20%) White females, and 1115 (4%) Black females. HCC incidence increases across periods, especially among men. Underlying this increase, APC models found significant cohort effects among White men, White women, and Black men, with rapid growth in HCC risk among cohorts born after 1940. A similar cohort trend among Black women did not reach statistical significance when compared to an age-period model. Cohort-specific trends have significantly contributed to increasing HCC incidence in recent decades. The rapid increase in HCC risk among younger cohorts suggests that the incidence of HCC will continue increasing in the near future.

OBJECTIVES Adequate pain control is an important component in the postoperative outcome for pediatric adenotonsillectomy patients with sleep-disordered breathing (SDB). Intravenous acetaminophen appears to be a favorable analgesic adjunct owing to its predictable pharmacokinetics and opioid-sparing effects; however, its role in pediatric adenotonsillectomy pain management remains unclear. METHODS In this prospective, randomized, double-blinded, controlled study, subjects with the diagnosis of SDB, aged 2 to 8 years, who required extended postoperative admission, received intravenous acetaminophen (15 mg/kg) or saline placebo intraoperatively in addition to morphine (0.1 mg/kg) for postoperative surgical analgesia. Pain scores in the postanesthesia care unit (PACU) using the FLACC (Faces, Leg, Activity, Cry, Consolability) score were used to determine the need for supplemental analgesic agents in the PACU. The PACU time and time to the first request for pain medication on the inpatient ward were also measured. RESULTS A total of 239 patients were included in the final data analysis (118 in the intravenous acetaminophen group and 121 in the saline placebo group). The 2 groups did not differ in the proportion of patients reaching FLACC scores = 4 in the PACU (p = 0.223); mean FLACC scores in the PACU (p = 0.336); mean PACU time (p = 0.883); or time to requesting pain medication on the inpatient ward (p = 0.640). CONCLUSIONS A single intraoperative dose of intravenous acetaminophen did not alter the postoperative course of pediatric patients with SDB following adenotonsillectomy.

Nicole M Elsey,1 Joseph D Tobias,1–3 Kevin E Klingele,4 Ralph J Beltran,1,2 Tarun Bhalla,1,2 David Martin,1,2 Giorgio Veneziano,1,2 Julie Rice,1,2 Dmitry Tumin1,2 1Department of Anesthesiology and Pain Medicine, Nationwide Children’s Hospital, 2The Ohio State University, 3Department of Pediatrics, Nationwide Children’s Hospital and The Ohio State University College of Medicine, 4Department of Orthopedic Surgery and Sports Medicine, Nationwide Children’s Hospital and The Ohio State University, Columbus, OH, USA Background: Traumatic injury of the femur resulting in femoral fracture may result in significant postoperative pain. As with other causes of acute pain, regional anesthesia may offer a benefit over conventional therapy with intravenous opioids. This study prospectively assesses the effects of femoral nerve blockade with a lateral femoral cutaneous nerve block (FN-LFCN) on intraoperative anesthetic requirements, postoperative pain scores, and opioid requirements.Materials and methods: Seventeen pediatric patients (age 2–18 years) undergoing surgical repair of a traumatic femur fracture fulfilled the study criteria and were randomly assigned to general anesthesia with either an FN-LFCN block (n = 10) or intravenous opioids (n = 7). All patients received a general anesthetic with isoflurane for maintenance anesthesia during the surgical repair of the femur fracture. Patients randomized to the FN-LFCN block group received ultrasound-guided nerve blockade using ropivacaine (0.2%/0.5% based on patient weight). At the conclusion of surgery, the airway device was removed once tracheal extubation criteria were achieved, and patients were transported to the post-anesthesia care unit (PACU) for recovery and assessment of pain by a blinded study nurse.Results: The final study cohort included 17 patients (n = 10 for FN-LFCN block group; n=7 for the intravenous opioid group). Although the median of the maximum postoperative pain scores in the regional group was 0, this did not reach statistical significance when compared to the median pain score of 3 in the intravenous opioid group. Likewise, no difference between the two groups was noted when comparing intraoperative anesthetic requirements, opioid requirements (intraoperative, in the post-anesthesia recovery room, and in the inpatient ward), and the time to first opioid requirement postoperatively in the inpatient ward.Conclusion: This prospective, randomized, double-blinded study failed to demonstrate a clear benefit of regional anesthesia over intravenous opioids intraoperatively and postoperatively during repair of femoral shaft fractures in the pediatric population. Keywords: pediatric, femur fracture repair, femoral nerve block&nbsp

Introduction Chronic obstructive pulmonary disease (COPD) is common but often underdiagnosed in the United States (US). Public health insurance coverage expansion may increase the prevalence of diagnosed COPD due to improved access to care and diagnosis. Objective We sought to determine the effects of Medicaid expansion on the prevalence of diagnosed COPD among low-income US adults. Methods The 2011-2015 Behavioral Risk Factor Surveillance System survey data were used to identify adults with annual household income

Objective Adults with congenital heart disease may require heart transplantation for end-stage heart failure. Whereas heart transplantation potentially allows adults with congenital heart disease to resume their usual activities, employment outcomes in this population are unknown. Therefore, we investigated the prevalence and predictors of work participation after heart transplantation for congenital heart disease. Design Retrospective review of a prospective registry. Setting United Network for Organ Sharing registry of transplant recipients in the United States. Patients Adult recipients of first-time heart transplantation with a primary diagnosis of congenital heart disease, performed between 2004 and 2015. Interventions None. Outcome measures Employment status reported by transplant centers at required follow-up intervals up to 5 y posttransplant. Results Among 470 patients included in the analysis (mean follow-up: 5 ± 3 y), 127 (27%) worked after transplant, 69 (15%) died before beginning or returning to work, and 274 (58%) survived until censoring, but did not participate in paid work. Multivariable competing-risks regression analysis examined characteristics associated with posttransplant employment, accounting for mortality as a competing outcome. In descriptive and multivariable analysis, pretransplant work participation was associated with a greater likelihood of posttransplant employment, while the use of Medicaid insurance at the time of transplant was associated with a significantly lower likelihood of working after transplant (subhazard ratio compared to private insurance: 0.55; 95% confidence interval: 0.32, 0.95; P = .032). Conclusions Employment was rare after heart transplantation for congenital heart disease, and was significantly less common than in the broader population of adults with congenital heart disease. Differences in return to work were primarily related to pretransplant employment and the use of public insurance, rather than clinical characteristics.

Objective Marriage is considered to protect health via multiple mechanisms, but this effect may have weakened as marriage has become deinstitutionalized in the United States. This article tests for cross-cohort decline in the protective effect of marriage. Methods Change in the association between marital status and subjective general health over three birth cohorts was estimated using the 1984–2011 Panel Study of Income Dynamics (N = 12,373). Analyses included least-squares, random-effects, and fixed-effects regression models, representing increasingly conservative approaches to ruling out selection bias. Results Despite associations between marriage and better health among both men and women, estimated by least-squares and random-effects regression, the fixed-effects models found health improvement relative to remaining unmarried only in very long (≥10 year) marriages, and only among women. This effect was completely attenuated among women in the youngest birth cohort. Conclusion The modest benefit of marriage for women's subjective health has eroded in recent cohorts.

Data on the safety of endoscopic sinus surgery (ESS) are limited in children with cystic fibrosis (CF). We used a multi-institutional surgical registry to examine ESS outcomes in children with CF.The 2014-2015 American College of Surgeons' National Surgical Quality Improvement Program-Pediatric database was queried for patients age18 years undergoing elective ESS. Prolonged hospital stay (1 day), 30-day readmission, and 30-day unplanned reoperation were compared according to presence of CF diagnosis.The data included 213 children with CF (age 10 ± 5 years, 105/108 male/female) and 821 children without CF (age 10 ± 5 years, 504/317 male/female). CF patients were more likely than non-CF patients to require prolonged hospital stay (30% vs. 9%, p 0.001), yet had similar rates of readmission (6% vs. 4%; p = 0.189) and reoperation (0 vs. 1%; p = 0.133). All readmissions but one among CF patients were unrelated to ESS. In the non-CF cohort, reasons for ESS-related readmissions included recurrence of sinusitis, postoperative pain, and bleeding.We demonstrate the safety of ESS in the largest cohort of children with CF reviewed to date. Multi-institutional review of ESS safety may contribute to monitoring expansion of this intervention in children with CF.

Background The average ages of lung transplant (LTx) recipients and donors are increasing. With older recipients considered to be especially at high risk of posttransplant mortality, we sought to determine whether the use of allografts from older donors affects survival among older patients undergoing LTx. Methods The United Network for Organ Sharing registry was used to identify patients aged 65-80 y receiving a first-time LTx between 1987 and 2013. Survival analysis examined implications of a donor-recipient age difference >10 y using Cox proportional hazards regression. Results The cohort selected for analysis included 3227 elderly LTx recipients, of whom 263 (8.15%) had donors within 10 y of their age at transplantation. Univariate Cox models found no differences with LTx involving donors at least 10 y younger than the recipient with respect to overall survival (hazard ratio = 0.979; 95% confidence interval [CI] = 0.807-1.188; P = 0.831) or conditional survival past 1 y (hazard ratio = 1.067; 95% CI = 0.819-1.391; P = 0.629) relative to LTx involving donors within 10 y of an elderly recipient's age. These findings were substantiated in multivariate analysis adjusting for potential confounders. Conclusions In elderly LTx recipients aged 65-80 y at transplantation, intermediate-term survival was not influenced by donor age. For the viable elderly LTx candidate, a carefully selected older donor should be considered to increase donor availability.

Cystic fibrosis (CF) is a common indication for lung transplantation (LTx) in children and adults with severe and irreversible lung disease. In the setting of LTx in the CF population, immunosuppressive medications are used to prevent allograft rejection despite the majority of these patients being chronically infected with numerous, and often antibiotic-resistant, pathogens. There is limited evidence for the optimal post-LTx immunosuppression regimen in patients with CF, particularly in children. This article provides a review of immunosuppression regimens in the pediatric and adult CF post-LTx population, investigating drug dosing and monitoring, and medication combinations. Currently used immunosuppressive medications and related systemic adverse effects are reviewed. With limitations of data in the pediatric population, future research should address immunosuppression in these children to help guide pediatric drug management as a means to optimize clinical outcomes after LTx.

The current study prospectively evaluates the administration of fluid through commonly used vascular cannulas of various length and diameter.Observational, in vitro experiment.Not applicable.No human subjects.None.Fluid (500 mL) was administered via gravity flow and with pressure assistance (pressure bag set at 300 mm Hg) through various vascular cannulas including peripheral IV catheters (22 gauge, 1 inch; 20 gauge, 1.16 and 1.88 inch; and 18 gauge, 1.16 and 1.88 inch), 3-Fr central line lumens (lengths 50, 80, and 120 mm), and a 4-Fr, 10 cm Micropuncture catheter (Cook Medical, Bloomington, IN). During gravity flow, drain time decreased by approximately 50% when moving from a 22 to 20 to 18 gauge cannula and increased by approximately 20% as the catheter length increased from 50 to 80 to 120 cm. Flow rates were highest with the Micropuncture catheter, which achieved a drain time of 2.7 minutes for the 500 mL bag when infused with pressure assistance.In general, the delivery of crystalloid solutions through commonly used vascular cannulas was fastest with larger diameter and shorter length cannulas. Pressure-assisted flow was able to partially compensate for the increased resistance with smaller and longer catheters. The unique design of the tip of the Micropuncture catheter compensated for the increased length and allowed for rapid fluid delivery. This design may compensate for the increased length when longer catheters are needed for ultrasound-guided placement.

To evaluate the effects of transesophageal echocardiography (TEE) probe insertion on the endotracheal cuff pressure (CP).Prospective observational study.Single standing, not-for-profit pediatric hospital.A total of 80 pediatric patients (aged 6 days to 18.4 years) who underwent cardiac surgery and intraoperative TEE.None.Following anesthesia induction and endotracheal intubation, the CP was recorded at 4 points: before the insertion of the TEE (P1), at TEE insertion (P2), during TEE examination (P3), and after the probe was advanced into the stomach (P4). Twenty patients were enrolled in each of the following age groups:1 year of age; 1-4 years of age; 5-8 years of age; and 9-18 years of age. CP was compared between pairs of time points using paired t-tests, and differences in CP over time were compared among age groups using repeated-measures analysis of variance. CP at P1, P2, P3, and P4 was 18.7±11.6, 26.7±14.4, 22.3±12.4, and 20.6±12.6 cmH2O, respectively. Although CP significantly increased from P1 to P2 (p0.001), there was no significant difference between P1 and P4 (95% CI; -0.3 to 4.1; p = 0.083). There was no significant difference in CP change based on the age of the patient.Following a transient increase in CP with TEE probe insertion, the CP returned to baseline after the tip of the TEE probe was advanced into the stomach. There was no variation among age groups in the magnitude of the CP change during the study.

Intraoperative abnormalities of coagulation function may occur for various reasons. In most scenarios, treatment is directed by laboratory parameters. Unfortunately, standard laboratory testing may take 1–2 h. The purpose of the current study was to evaluate a point-of-care testing device (CoaguChek® XS System) in pediatric patients. Patients ranging in age from 2 to 18 years, undergoing posterior spinal fusion (PSF) or cardiac surgery using cardiopulmonary bypass (CPB) were eligible for inclusion. After CPB and/or the surgical procedure, 2.8 ml of blood was obtained and simultaneously tested on both the standard laboratory apparatus and the CoaguChek® XS System. The study cohort consisted of 100 patients (50 PSF and 50 cardiac cases) with 13 cases excluded, leaving 87 patients (49 PSF and 38 cardiac cases) for analysis. In PSF cases, reference laboratory international normalized ratio (INR) ranged from 0.98 to 1.77 while CoaguChek® XS INR ranged from 1.0 to 1.3. The correlation coefficient was 0.69. The results of the Bland–Altman analysis showed a bias of 0.09, precision of 0.1, and 95% limits of agreement ranging from −0.11 to 0.28. In cardiac cases, reference INR ranged from 1.68 to 14.19, while CoaguChek® XS INR ranged from 1.4 to 7.9. The correlation coefficient was 0.35. The results of the Bland–Altman analysis showed a bias of −1.8, precision of 2.1, and 95% limits of agreement ranging from −6.0 to 2.4. INR values obtained from CoaguChek® XS showed a moderate correlation with reference laboratory values within the normal range. However, in the presence of coagulopathy, the discrepancy was significantly greater, thereby making the CoaguChek® XS clinically unreliable.

SummaryBackground In children, the size of the cuffed endotracheal tube is based on various age-based formulas. However, such formulas may over or underestimate the size of the cuffed endotracheal tube. There are no data on the impact of different-sized cuffed endotracheal tubes (ETT) on the intracuff pressure in children. Aim The current study measures intracuff pressure with different-sized cuffed ETT. Method The study was conducted in an in vitro and in vivo phase. For the in vitro phase, 10 cuffed ETT of size 4.0, 4.5, and 5 mm internal diameter (ID) each were randomly placed inside a 1.0 cm ID plastic tube (mimicking the trachea), which was in turn connected to a 1 l test lung. After inflation of the cuff using the air leak test at a continuous positive airway pressure of 20 cmH2O, the intracuff pressure was measured. The in vivo phase was conducted in 100 children (4–8 years) and were randomly divided into two groups to receive either a cuffed endotracheal tube based on the Khine formula (Group R) or a cuffed endotracheal tube that was a half-size (0.5 mm ID) smaller (Group S). Following the inflation of the cuff to seal the trachea, the intracuff pressure was measured. Results In the in vitro phase, the intracuff pressure was 45 ± 6, 23 ± 1, and 14 ± 6 cmH2O with size 4.0, 4.5, and 5 mm ID cuffed ETT, respectively (F-test P < 0.001 for difference among three groups). In the in vivo phase, the mean intracuff pressure in Group R was 25 ± 19 cmH2O vs 37 ± 35 cmH2O in Group S (95% CI of difference: 1, 23; P = 0.039). Conclusion If the cuffed endotracheal tube is too small, the trachea can still be sealed by inflating the cuff with additional air. However, this transforms the cuff from the intended high-volume, low-pressure cuff to an undesirable high-volume, high-pressure cuff.

Objectives The objectives of this study were to evaluate the effect of ventricular morphology on perioperative outcomes during Fontan surgery. Design Retrospective cohort study. Setting Single standing, not-for-profit pediatric hospital. Participants A total of 72 patients who underwent Fontan surgery using cardiopulmonary bypass without aortic cross-clamp between January 1, 2009 and December 31, 2014. Interventions None. Measurements and Main Results The patients were divided into 3 categories depending on their single-ventricle lesions: (1) LV group (n = 20): left dominant and hypoplastic right ventricle; (2) RV group (n = 37): right dominant and hypoplastic left ventricle; and (3) BV group (n = 15): biventricular or indeterminate dominance. Perioperative major adverse events were collected based on the Society of Thoracic Surgeons database. The need for perioperative allogeneic blood transfusions also was determined. The mean age was 3.3±1.7 years and the mean weight was 13.6±4.0 kg. All patients had extracardiac lateral tunnel or conduit Fontan procedures. Sixty-nine of the patients (96%) underwent tracheal extubation in the operating room. Anesthesia, surgery, and CPB times were 326±68, 239±73, and 70±41 minutes, respectively. Eleven patients (15%) required allogeneic blood products intraoperatively, while 30 patients (42%) required allogeneic blood products during the perioperative period. Length of cardiac intensive care unit stay and hospital stay (median [IQR]) were 1 [1,2] and 12 [9,18] days, respectively. There was no mortality and no significant differences between groups in major postoperative complications, anesthetic or surgical variables. Conclusions No difference in the immediate perioperative outcomes was noted based on ventricular morphology.

Young adult heart transplantation (HTx) recipients experience high mortality risk attributed to increased nonadherence to immunosuppressive medication in this age window. This study sought to test whether a high-risk age window in HTx recipients persisted in the absence of reported nonadherence.Heart transplantation recipients aged 2 to 40 years, transplanted between October 1999 and January 2007, were identified in the United Network for Organ Sharing database. Multivariable survival analysis was used to estimate influences of age at transplantation and attained posttransplant age on mortality hazard among patients stratified by center report of nonadherence to immunosuppression that compromised recovery.Three thousand eighty-one HTx recipients were included, with univariate analysis demonstrating peak hazards of mortality and reported nonadherence among 567 patients transplanted between ages 17 and 24 years. Multivariable analysis adjusting for reported nonadherence demonstrated lower mortality among patients transplanted at younger (hazards ratio, 0.813; 95% confidence interval, 0.663-0.997; P = 0.047) or older (hazards ratio, 0.835; 95% confidence interval, 0.701-0.994; P = 0.042) ages. Peak mortality hazard at ages 17 to 24 years was confirmed in the subgroup of patients with no nonadherence reported during follow-up. This result was replicated using attained age after HTx as the time metric, with younger and older ages predicting improved survival in the absence of reported nonadherence.Late adolescence and young adulthood coincide with greater mortality hazard and greater chances of nonadherence to immunosuppressive medication after HTx, but the elevation of mortality hazard in this age range persists in the absence of reported nonadherence. Other causes of the high-risk age window for post-HTx mortality should be demonstrated to identify opportunities for intervention.