Biomedical subjects

S L Bratton

Publications and source records attributed to S L Bratton.

At least 19 recordsLinked to original sources

PubMed2006

Pregnant mothers out of the perinatal regionalization's reach.

INTRODUCTION: Birth of very low birth weight (VLBW) infants outside subspecialty perinatal centers increases risk for death and major morbidities. OBJECTIVE: The purpose of this study is to evaluate barriers to utilizing a regional perinatal center for the birth of VLBW infants to mothers not living in the immediate vicinity of the center. METHODS: We conducted a retrospective cohort study of VLBW infants residing in the catchment area of a community level II, Specialty Neonatal Unit (SN) admitted to a Regional Subspecialty Neonatal Intensive Care Unit (RC) between January 1999 and December 31, 2004. Maternal demographics and prenatal care as well as outcomes were compared by place of birth. RESULTS: Out of 98 VLBW infants admitted to the RC, 49 (50%) were delivered outside the RC (out-born) and 49 (50%) were born at the RC (in-born). There was no statistical difference in insurance coverage, race, gestational age, severity of illness or maternal demographic factors between out-born and in-born infants. Less than adequate prenatal care rather than distance of maternal residence from the RC was associated with birth outside the RC. Adjusting for prenatal care, distance of residence from the RC increased the risk for delivering outside the center in the subset of mothers insured by Medicaid. CONCLUSIONS: Mothers of VLBW infants who received less than adequate prenatal care and did not live in the vicinity of a subspecialty center had an increased risk for delivery outside that center compared to those with adequate care. Appropriate place of birth for VLBW infants to low-income mothers may be influenced by the distance of their residence to an RC.

Cohort Studies↗

PubMed2001

Hospitalizations for pediatric intoxication in Washington State, 1987-1997.

BACKGROUND: Intoxication (or poisoning) that necessitates hospitalization remains an important source of morbidity in children. OBJECTIVE: To determine changes, during an 11-year period (1987-1997), in the incidence of hospitalization due to intoxication among children in Washington State and circumstances of ingestion, agents used, hospital length of stay, charges, and mortality. METHODS: A computerized database of all hospital discharges (Comprehensive Hospital Abstract Reporting System [CHARS] database) in Washington was used. Cases included all children younger than 19 years with a primary or secondary diagnosis for an intoxication or with an external cause of injury code (E code) for an intoxication from 1987 to 1997. RESULTS: There were 7322 hospitalizations (45 per 100 000 children per year); the annual rate significantly decreased during the study period. Most patients (75%) were teenagers. Sixty-five percent were female. Pharmaceutical agents were used in 80% of cases. Analgesics were the most commonly used (34%), followed by antidepressants (12%) and psychotropic drugs (8%). Nonpharmaceutical agents were more prevalent in children younger than 12 years than in teenagers. Self-inflicted intoxication was the most frequent cause identified by E codes (47%). Median length of stay was 1 day, and median hospital charges were $2096. Mortality was low (0.2%) and did not change significantly over time. CONCLUSIONS: Acute intoxication continues to be an important cause of hospitalization in children. The type of agent involved did not change significantly over time. Teenage girls continue as the highest risk group for suicide attempt from ingestions. Self-inflicted intoxications were associated with higher costs, length of stay, and readmissions. Although preventive measures and development of poison centers have contributed to decrease mortality from acute intoxication in children in the last 50 years, efforts need to be targeted toward suicide prevention, especially among teenage girls.

Adolescent↗

PubMed2001

Intussusception: hospital size and risk of surgery.

OBJECTIVE: To determine whether the risk of operative management of children with intussusception varies by hospital pediatric caseload. DESIGN: A cohort of all children with intussusception in Washington State from 1987 through 1996. SETTING: All hospitals in Washington State. METHODS: Five hundred seventy children with a hospital discharge diagnosis of intussusception were identified. Sixty-two were excluded because of missing data. Procedure codes for operative management and radiologic management were also identified. RESULTS: Fifty-three percent of the children had operative reduction and 20% had resection of bowel. Children with operative reduction did not differ from those with nonoperative care by median age or gender; however, children with operative care were significantly more likely to receive care in hospitals with smaller pediatric caseloads and to have a coexisting condition associated with intussusception. Sixty-four percent of children who received care in a large children's hospital had nonoperative reduction, compared with 36% of children who received care in hospitals with 0 to 3000 annual pediatric admissions and 24% of children who had care in hospitals with 3000 to 10 000 annual pediatric admissions. Median length of stay and charges were significantly less in the large children's hospital, compared with other centers. CONCLUSIONS: Children who received care for intussusception in a large children's hospital had decreased risk of operative care, shorter length of stay, and lower hospital charges compared with children who received care in hospitals with smaller pediatric caseloads.

Child, Preschool↗

PubMed2000

Pediatric acetaminophen overdose: risk factors associated with hepatocellular injury.

OBJECTIVES: To characterize demographic and clinical factors associated with pediatric acetaminophen overdose and identify risk factors for hepatocellular injury. DESIGN: Retrospective 10-year chart review. SETTING: Two regional children's hospitals. MATERIALS AND METHODS: Records of patients examined because of acetaminophen ingestion from January 1, 1988, through December 31, 1997, were reviewed. Hepatocellular injury was defined as elevation of serum aminotransferase levels greater than 2 times the reference values. Severe hepatotoxic effect was defined as hepatotoxic effect with evidence of encephalopathy and/or coagulopathy. RESULTS: Data from 322 patients (208 girls and 114 boys, aged 1-17 years) were obtained. Ingestions were intentional in 140 patients (median age, 14 years) and unintentional in 172 (median age, 2 years). Another 10 cases represented dosing errors with therapeutic intent (median age, 3.5 years). Twenty-seven patients had hepatocellular injury; of these, 4 had severe hepatotoxic effects and 1 died. Hepatocellular injury occurred in 10.0% of the dosing error group, 17.9% of the intentional group, and 0.6% of the unintentional group. No patients underwent liver transplantation. Hepatocellular injury was associated with presentation longer than 24 hours after ingestion (odds ratio [OR], 335.0; 95% confidence interval [CI], 40.8-275.0), age 10 to 17 years (OR, 36.9; 95% CI, 4.9-275.4), intentional overdose (OR, 37.2; 95% CI, 5.0-278.2), dose greater than 150 mg/kg (OR, 17.9; 95% CI, 2.3-139.2), and white race (OR, 2.8; 95% CI, 1.1-7.2). CONCLUSIONS: Intentional and unintentional acetaminophen overdoses occurred with similar frequency. Therapeutic misadventure was relatively uncommon, as was hepatocellular injury. Practitioners should have greater suspicion of acetaminophen-associated hepatocellular injury in patients who present more than 24 hours after ingestion, older children, and those who have intentional ingestion.

Acetaminophen↗

PubMed2000

Nonpulmonary organ failure and outcome in children treated with high-frequency oscillatory ventilation.

PURPOSE: The purpose of this study was to quantitate the contribution of nonpulmonary organ failure to mortality of patients treated with high-frequency oscillatory ventilation (HFOV) and to determine which gas-exchange differences are associated with improvement on HFOV. MATERIALS AND METHODS: Charts of all patients treated with HFOV in our pediatric intensive care unit from January 1992 until January 1997 were retrospectively reviewed. RESULTS: Sixty-six patients were treated and 21 patients improved during HFOV (group 1); 45 patients did not improve (group 2). Seventeen patients (26%) had isolated respiratory failure and their mortality was 12%. Percentages of patients with 2, and 3 or more organ failure were 45%, 29%, and their mortality was significantly higher, 67% and 95%, respectively. Patients with primary respiratory failure demonstrated a significantly greater risk of improvement on HFOV (RR ratio of 2.5, 95% CI 1.5 to 4.2). There was a significantly greater proportion of patients with primary cardiac failure who did not improve on HFOV compared with all other patients. Oxygenation index significantly improved over the first 72 hours for both groups, but then significantly worsened over the next 48 hours in group 2 but not in group 1. CONCLUSION: Patients with nonpulmonary organ failure were significantly less likely to improve on HFOV and had a significantly higher mortality than patients with isolated respiratory failure. Children who do not improve on HFOV appear to reach a plateau in oxygenation indices after 3 days of HFOV.

Adolescent↗

PubMed2000

Outcome of children who require mechanical ventilatory support after bone marrow transplantation.

OBJECTIVE: To identify clinically measurable factors that could predict outcome for pediatric patients undergoing mechanical ventilatory support after bone marrow transplant. DESIGN: Cohort study. SETTING: A referral center for bone marrow transplant patients in Seattle, Washington. PATIENTS: Children <17 yrs old who received a bone marrow transplant and subsequently required mechanical ventilatory support for > or =24 hrs between 1983 and 1996. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Data were abstracted from the charts of 121 pediatric patients who received a bone marrow transplant and subsequently required mechanical ventilatory support. A total of 19 patients (16%) survived to be extubated and survived for > or =30 days postextubation. Major risk factors for death included respiratory failure as the reason for endotracheal intubation (4% survival), the presence of pulmonary infection (6% survival), and impairment of more than one organ system (2% survival if more than one organ system was dysfunctional on day 7 postintubation). CONCLUSIONS: Although the prognosis generally is poor among pediatric bone marrow transplant recipients who subsequently require mechanical ventilatory support, there appear to be some groups within this population in whom the likelihood of survival is close to 0. Because the chance of survival was so small for children with dysfunction of more than one organ system on day 7 after intubation, a recommendation to limit medical support for these children could be considered pending the results of other studies.

Adolescent↗

PubMed2000

Acute appendicitis risks of complications: age and Medicaid insurance.

OBJECTIVES: To describe the epidemiology of acute appendicitis in children from Washington State, and to determine important risk factors for complications. DESIGN: Retrospective cohort study. SETTING: All children (<17 years old) treated in Washington State who were identified by hospital discharge diagnosis codes from 1987 through 1996. METHODS: The hospital discharge data were reviewed for all children with a primary diagnosis code for acute appendicitis. Complicated disease was defined as perforation or abscess formation. RESULTS: Young children (0-4 years old) had the lowest annual incidence of acute appendicitis, but they had a 5-fold increased risk of complicated disease (odds ratio: 4.9; 95% confidence interval: 4.0-5.9), compared with teenagers. Children with Medicaid insurance had a 1.3-fold increased risk of complicated disease, compared with children with commercial insurance (odds ratio: 1.3: 95% confidence interval: 1.2-1.4). Children with Medicaid insurance had significantly longer average length of stay (4.0+/-3.7 days) than all other payers (commercial insurance: 3.3+/-4.0 days; health maintenance organization: 3.5+/-3.1 days; and self-insured: 3.7+/-5.8 days). CONCLUSIONS: Very young children had the greatest risk of complicated disease. Children with Medicaid insurance had increased risk of complicated disease, compared with children with commercial health insurance and longer length of stay. Additional studies are needed to evaluate barriers to care for children with Medicaid insurance.

Abdominal Abscess↗

PubMed1999

Coagulation tests during cardiopulmonary bypass correlate with blood loss in children undergoing cardiac surgery.

OBJECTIVES: To examine whether coagulation tests, sampled before and during cardiopulmonary bypass (CPB), are related to blood loss and blood product transfusion requirements, and to determine what test value(s) provide the best sensitivity and specificity for prediction of excessive hemorrhage. DESIGN: Prospective. SETTING: University-affiliated, pediatric medical center. PARTICIPANTS: Four hundred ninety-four children. INTERVENTIONS: Coagulation tests. MEASUREMENTS AND MAIN RESULTS: Demographic, coagulation test, blood loss, and transfusion data were noted in consecutive children undergoing cardiac surgery. Laboratory tests included hematocrit (Hct), prothrombin time, partial thromboplastin time (PTT), platelet count, fibrinogen concentration, and thromboelastography. Stepwise linear regression analysis indicated that platelet count during CPB was the variable most significantly associated with intraoperative blood loss (in milliliters per kilogram) and 12-hour chest tube output (in milliliters per kilogram). Other independent variables associated with blood loss were thromboelastography maximum amplitude (MA) during CPB, preoperative PTT, preoperative Hct, and preoperative thromboelastography angle and shear modulus values. Thromboelastography MA during CPB was the only variable associated with total products transfused (in milliliters per kilogram). Of all tests studied, platelet count during CPB (< or = 108,000/microL) provided the maximum sensitivity (83%) and specificity (58%) for prediction of excessive blood loss (receiver operating characteristic analysis). Blood loss was inversely related to patient age; neonates received the most donor units (median, 8 units; range, 6 to 10 units). CONCLUSIONS: During cardiac surgery, coagulation tests (including thromboelastography) drawn pre-CPB and during CPB are useful to identify children at risk for excessive bleeding. Platelet count during CPB was the variable most significantly associated with blood loss.

Blood Coagulation Tests↗

PubMed1999

Efficacy of epsilon-aminocaproic acid in children undergoing cardiac surgery.

OBJECTIVE: To compare coagulation test results, blood loss, and blood product transfusions between patients receiving prophylactic epsilon-aminocaproic acid (EACA) and a control group matched for age, resternotomy, and surgery in children undergoing cardiac surgery. DESIGN: Nested case-control study. SETTING: University-affiliated, pediatric medical center. PARTICIPANTS: Same study period; 70 patients in EACA group and 70 patients in control group. INTERVENTIONS: Prophylactic EACA administered intravenously (load, 150 mg/kg, infusion; 30 mg/kg/h) to 70 patients at increased risk for bleeding (reoperation or Ross procedure). MEASUREMENTS AND MAIN RESULTS: Coagulation test values were measured before, during, and after cardiopulmonary bypass (CPB). Intraoperative blood loss, postoperative chest tube output, and allogenic blood product transfusions were recorded. Comparison of demographic and surgical data indicated close matching of the EACA and control groups. The EACA group ([median, 25th to 75th quartile] 15.6 mL/kg; 9.2 to 26.3 mL/kg) had less intraoperative blood loss than the control group (22.2 mL/kg; 14.3 to 36.3 mL/kg; p = 0.02). Postoperative chest tube output at 6 hours (p = 0.08), 12 hours (p = 0.07), and 24 hours (p = 0.08) was not significantly different between groups. Fewer EACA group patients required reexploration for bleeding (p < 0.05). There was no difference between groups in blood products transfused (in milliliters per kilogram or allogenic exposure per patient). Thromboelastography values (maximum amplitude [MA], whole blood clot lysis index at 30 minutes after MA) during CPB were better preserved in the EACA group. CONCLUSION: EACA reduced intraoperative blood loss but did not significantly decrease blood product transfusions. Lack of efficacy may be related to relative underdosing and should be further studied.

Adolescent↗

PubMed1999

Factors associated with blood loss and blood product transfusions: a multivariate analysis in children after open-heart surgery.

UNLABELLED: In this prospective cohort study of 548 children undergoing open-heart surgery, we evaluated demographic and perioperative factors to identify variables associated with perioperative blood loss and blood product transfusions. Using multivariate analysis, younger patient age was found to be the variable most significantly associated with bleeding and transfusions. Higher preoperative hematocrit, complex surgery, lower platelet count during cardiopulmonary bypass (CPB), and longer duration of deep hypothermic circulatory arrest were also significantly associated with bleeding and transfusion. Excessive postoperative chest tube (CT) drainage was associated with intraoperative bleeding. Independently associated variables accounted for 76% of the variability in CT output measured after 2 h in intensive care. Patients were subdivided into children aged < or =1 yr (infants) and children >1 yr; infants bled more intraoperatively (P<0.005); had greater cumulative CT output at 2, 6, 12, and 24 h (P<0.0001); and received more blood products (P<0.0001). Factors associated with bleeding and transfusions varied with patient age. Lower body core temperature during CPB was highly associated with blood loss and transfusions in infants, whereas resternotomy, preoperative congestive heart failure, and prolonged duration of CPB were significant factors associated with bleeding and transfusions in children >1 yr old. IMPLICATIONS: Knowledge of the factors associated with blood loss and blood product transfusions can help to identify children at risk of excessive bleeding after open-heart surgery.

Blood Component Transfusion↗

PubMed1999

Ventilatory response to CO2 in children with obstructive sleep apnea from adenotonsillar hypertrophy.

UNLABELLED: We measured the ventilatory response to CO2 as an indicator of respiratory control dysfunction in children with obstructive sleep apnea (OSA) scheduled for adenotonsillectomy. Measurements were performed in unpremedicated children via an endotracheal tube under 0.4%-0.5% end-tidal halothane anesthesia. Mean ventilatory CO2 response slopes for 11 children with OSA requiring adenotonsillectomy (Group I) were compared with those for 14 children without OSA requiring adenotonsillectomy (Group II) and 15 children without OSA requiring nonairway surgery (Group III). The mean ventilatory slope corrected for body surface area for Groups I, II, and III were 539 +/- 338, 828 +/- 234, and 850 +/- 380 mL.min-1.mm Hg ETCO2(-1).m-2, respectively (P < 0.05, Group I versus Groups II and III). Historical data--including snoring, apneic episodes > 10 s, daytime hypersomnolence, and nocturnal enuresis--defined those with OSA. Obesity occurred more frequently in patients with OSA and with depressed ventilatory responses (P < 0.001). Children with OSA from adenotonsillar hypertrophy have a diminished ventilatory response to CO2 stimulation, compared with those without OSA symptoms. The depressed response may account, in part, for the reported increased risk of perioperative respiratory complications in this population. IMPLICATIONS: Children with obstructive sleep apnea undergoing adenotonsillar surgery are at risk of postoperative respiratory compromise. We found that patients with a clinical history suggesting obstructive sleep apnea have a diminished ventilatory response to CO2 rebreathing, compared with controls.

Adenoidectomy↗

PubMed1999

Clinical uses and controversies of neuromuscular blocking agents in infants and children.

OBJECTIVE: To review the pharmacology of neuromuscular blocking drugs (NMBDs), their use in critically ill or injured infants and children, and the relevance of developmental changes in neuromuscular transmission. DATA SOURCES: Computerized search of the medical literature. STUDY SELECTION: Studies specifically examining the following were reviewed: a) the developmental changes in neuromuscular transmission; b) the pharmacokinetics and pharmacodynamics of all clinically available NMBDs in neonates, infants, children, and adults; and c) clinical experience with NMBDs in the critical care setting. Particular attention was directed toward studies in the pediatric population. DATA SYNTHESIS: Neuromuscular transmission undergoes maturational changes during the first 2 months of life. Alterations in body composition and organ function affect the pharmacokinetics and pharmacodynamics of the NMBDs throughout active growth and development. Numerous NMBDs have been developed during the last two decades with unique pharmacologic profiles and potential clinical advantages. The NMBDs are routinely used in critically ill or injured patients of all ages. This widespread use is associated with rare but significant clinical complications, such as prolonged weakness. CONCLUSIONS: Significant gaps in our knowledge of the pharmacokinetics and pharmacodynamics of NMBDs in infants and children continue to exist. Alterations in electrolyte balance and organ-specific drug metabolism may contribute to complications with the use of NMBDs in the critical care arena.

Adult↗

PubMed1999

Predictors of successful extubation in children.

Objective criteria to predict extubation outcome in mechanically ventilated children are not available. Our goal was to study factors associated with extubation success and to evaluate the usefulness of the rapid shallow breathing index (RSBI) and the compliance, resistance, oxygenation, and pressure index (CROP index) in children. Data were prospectively collected on 227 mechanically ventilated children. Patients successfully extubated had significantly better lung compliance (Cdyn: 0.59 +/- 0.91 versus 0.39 +/- 0.14 ml/kg/cm H(2)O), higher Pa(O(2))/FI(O(2)) ratio (382.4 +/- 181.2 versus 279.8 +/- 93.9), and lower Pa(CO(2)) (41.3 +/- 6.7 versus 47.3 +/- 8.5 mm Hg). Spontaneous breathing parameters showed significantly lower respiratory rates (RR) (36.6 +/- 17.9 versus 52.8 +/- 23 breaths/min), larger tidal volumes (VT) (7.3 +/- 2.6 versus 4.9 +/- 1.8 ml/kg), and greater muscle strength (negative inspiratory force [NIF]: 41.8 +/- 15.4 versus 35.1 +/- 12.5 cm H(2)O) in successfully extubated children. Extubation failures had higher RSBIs and lower CROP index values. A RSBI value of </= 8 breaths/ml/kg had a sensitivity of 74% and specificity of 74%, whereas a CROP value of >/= 0.15 ml/kg/breaths/min had a sensitivity of 83% and specificity of 53% for extubation success. Children failing extubation demonstrate abnormalities of respiratory function. The RSBI and CROP index are useful to predict pediatric extubation success.

Airway Resistance↗

PubMed1998

Efficacy of peripherally inserted central venous catheters placed in noncentral veins.

BACKGROUND: Peripherally inserted central venous catheters (PICCs) are commonly used intravenous access devices in children. Although PICCs are intended to be placed in central veins, many fail to reach this location. These noncentral PICCs are used for administration of medications and isotonic solutions. OBJECTIVES: To examine the efficacy of noncentral PICCs for completion of therapy, the complications associated with their use, and the effectiveness of noncentral PICCs as compared with PICCs placed in a central vein. DESIGN: A prospective cohort study of children in whom PICCs were inserted, from January 1, 1994, to January 1, 1996. SETTING: A university-affiliated teaching institution. MAIN OUTCOME MEASUREMENT: Completion of intravenous therapy. RESULTS: A total of 587 PICCs were studied. Thirty-nine percent of PICCs were placed in noncentral veins. Centrally placed PICCs had significantly longer catheter duration compared with those placed noncentrally (16.6 vs 11.4 days, respectively). However, central and noncentral PICCs had similar therapy completion rates (73% and 69%, respectively). Catheter failure because of occlusion and accidental dislodgment were similar for central and noncentral PICCs. Likewise, complications caused by exit-site infection, phlebitis, and catheter-associated sepsis were also similar for catheters in the 2 locations. Catheter survival curves were similar for central and noncentral PICCs. CONCLUSIONS: Our study demonstrates that PICCs placed in noncentral veins provide reliable and safe intravenous access for administration of many medications and isotonic solutions for about 2 weeks' duration. The placement of PICCs in central veins may be restricted to those children who need central vascular access because of the type of intended therapy.

Catheterization, Central Venous↗

PubMed1998

Association between age and blood loss in children undergoing open heart operations.

BACKGROUND: Although recent studies indicated young children are at risk for increased perioperative hemorrhage after open heart operations, the associations between patient age, blood loss and blood product transfusions have not been fully defined in children. METHODS: Perioperative blood loss and blood product transfusion data were recorded for 414 consecutive children undergoing open heart procedures. The children were in the following age groups: 1 month or younger, group 1; older than 1 month to 12 months, group 2; older than 1 year to 5 years, group 3; and older than 5 years, group 4. RESULTS: Postoperative blood loss and blood product transfusions were inversely related to age and differed significantly between the four age groups. Multiple preoperative and intraoperative factors that possibly influence hemostasis also differed significantly between age groups. Median units transfused within 72 hours differed significantly with age (p < 0.0001): group 1, 8 units (range, 1 to 19 units); group 2, 6 units (range, 0 to 21 units); group 3, 2 units (range, 0 to 23 units); and group 4, 0 units (range, 0 to 38 units). CONCLUSIONS: Blood loss and transfusions vary inversely with age. Per kilogram of body weight, neonates bled more and received more donor products than any other age group.

Age Factors↗

PubMed1998

Delivery of hyperbaric oxygen therapy to critically ill, mechanically ventilated children.

PURPOSE: The purpose of this article is (1) to describe our method of mechanical ventilation and monitoring of critically ill children during administration of hyperbaric oxygen therapy (HBO2) in a multiplace chamber; and (2) to review the complications they experienced during transport to the HBO2 chamber and HBO2 treatment. MATERIALS AND METHODS: A case series from a university-affiliated children's hospital and regional hyperbaric medicine treatment facility. Patients studied included all children who required HBO2 therapy while mechanically ventilated at any time between April 1985 and June 1995. RESULTS: Thirty-two children were treated with HBO2 while mechanically ventilated. Ages ranged from 3 days to 11.3 years (mean 4.8+/-3.5 years). There were 22 males. Twenty-one children had necrotizing infections, 9 had carbon monoxide (CO) poisoning, and 2 had iatrogenic arterial air embolism. Complications or events occurring during HBO2 therapy included hypotension (63%), bronchospasm (34%), hemotympanum (13%), and progressive hypoxemia (6%). The only complication during transport was one accidental extubation (3%). CONCLUSION: Hyperbaric oxygen therapy can be administered safely to most critically ill children in a multiplace chamber if they are monitored closely. Although complications are not uncommon, most can be managed easily by a team skilled in treating ill children and knowledgeable of possible complications of HBO2 therapy.

Child↗

PubMed1998

Teaching successful central venous cannulation in infants and children: audio Doppler versus anatomic landmarks.

OBJECTIVE: To determine if vein localization with an audio Doppler increases successful central venous cannulation and decreases complications in infants and children when performed by inexperienced operators, compared with vein localization by anatomic landmarks (ALs). DESIGN: A prospective cohort of infants and children undergoing central venous cannulation for cardiac surgery. SETTING: A university-affiliated children's hospital with a pediatric anesthesia fellowship program. PARTICIPANTS: All infants and children undergoing cardiac surgery between July 1, 1996, and January 1, 1997. INTERVENTIONS: Subjects had central venous catheters (CVCs) placed by an anesthesia fellow by either ALs or audio-Doppler localization of the veins. MEASUREMENTS AND MAIN RESULTS: Eighty-four children were studied. Internal jugular vein (IJV) cannulation was attempted in 71 (85%) children and femoral vein cannulation in 13 (15%) children. Time to catheter insertion, number of needle passes, and artery puncture were noted. Sixty-one of 63 (97%) children had successful central venous cannulation by an anesthesia fellow using audio-Doppler vein localization. This was significantly greater than the 13 of 21 (62%) successful cannulations among children who had veins localized by ALs. Time to insertion did not differ by method of vein localization; however, the number of needle passes was significantly greater in the AL group. Artery puncture did not differ significantly by method of vein localization. CONCLUSION: Vein localization by audio Doppler significantly increases the rate of successful central venous cannulation and decreases the number of needle passes in pediatric patients when used by inexperienced operators.

Adolescent↗

PubMed1998

Fibrinolysis in pediatric patients undergoing cardiopulmonary bypass.

OBJECTIVE: Thromboelastographic evaluation of the influence of fibrinolysis on blood loss and blood product transfusions in children during cardiac surgery. DESIGN: Prospective study. SETTING: University-affiliated, pediatric medical center. PARTICIPANTS: Two hundred seventy-eight consecutive children undergoing cardiac surgery. INTERVENTIONS: Blood sampling for coagulation tests, including native and protamine-modified thromboelastography. MEASUREMENTS AND MAIN RESULTS: Blood coagulation tests were measured before, during, and after cardiopulmonary bypass (CPB). Demographic data, perioperative blood loss, and blood product transfusions were prospectively recorded. Fibrinolysis was defined as thromboelastography of A30/MA less than 0.85 (MA, maximum amplitude; A30, amplitude 30 minutes after MA) and was noted in 3% of children pre-CPB, 16% during CPB, and 3% post-CPB. Fibrinolysis before CPB was associated with poor cardiac output. Fibrinolysis during CPB occurred in young children (aged 350 +/- 836 days) undergoing complex surgery with prolonged CPB (119 +/- 48.8 minutes) and deep hypothermia (25.6 degrees C +/- 4.7 degrees C). These patients received blood products after CPB and were not fibrinolytic after transfusion. They incurred similar blood loss (in mL/kg) and received similar volumes of blood products (mL/kg) as age-matched and surgery-matched patients without fibrinolysis. CONCLUSION: A group of children at risk for fibrinolysis during CPB was identified. However, fibrinolysis during CPB did not influence blood loss or the total volume of blood products transfused.

Blood Loss, Surgical↗