Non-invasive aortic blood flow measurement in infants during repair of craniosynostosis

Strengthening molecular genetics and training in craniosynostosis: The need of the hour

Craniosynostosis (CS) is premature fusion of skull. It is divided into two groups: Syndromic craniosynostosis (SCS) and non-syndromic craniosynostosis (NSC). Its incidence in Indian population is 1:1000 live births where as in the USA it is 1:2500 live births. Its incidence varies from country to country. Molecular genetics having great interest and relevance in medical students, faculty, scientist, pediatric neurosurgeon and staff nurses, our objective was to educate the medical students, residents, researchers, clinicians, pediatric neurosurgeon, anesthetists, pediatricians, staff nurses and paramedics. We summarized here including with diagnosis, investigations, surgical therapy, induction therapy, and molecular therapy. Molecular genetics training is needed to know the information regarding development of skull, cranial connective tissue, craniofacial dysplasia, frame work, network of receptors and its etiopathogenesis. The important part is clinically with molecular therapy (MT) how to manage CS in rural sector and metropolitan cities need a special attention.

Use of the Esophageal Doppler Machine to help guide the intraoperative management of two children with pheochromocytoma

The anesthetic management of pheochromocytoma has been based upon the intraoperative control of blood pressure and fluid balance following adequate preoperative preparation. This can be difficult, especially in the presence of significant comorbidity such as cardiac or renal dysfunction. Two cases of children with pheochromocytoma are reported where the introperative management of fluid balance and blood pressure control were guided by measurement of changes in descending aortic blood flow using an esophageal Doppler probe. The advantages of such a technique compared with more invasive monitors are discussed.

Anaesthetic management in facial bipartition surgery: The experience of one centre

Facial bipartition is amongst the most radical craniofacial surgery undertaken but is performed rarely. There is little published information on its anaesthetic management. We undertook a retrospective case-note review of 22 consecutive patients undergoing bipartition surgery by the same surgical team in one centre in the period 1993-2001. There were incomplete data for two cases and these were therefore excluded. Patients were aged 2 months to 19 years. Conditions treated were facial cleft (n = 5), frontonasal dysplasia (n = 7) and facial dysostosis (n = 8).Intra-operative complications included major haemorrhage (n = 4), bradycardia (n = 3) and unintentional tracheal extubation (n = 1). There were no peri-operative deaths. All patients required intra-operative blood transfusion and 15% of them had a postoperative haemoglobin concentration > 115% of their pre-operative value. In this series, four patients required postoperative lung ventilation for a median duration of 3 days. Infants < 14 months old were significantly more likely to receive a massive blood transfusion (p = 0.0002), to have an excessively high postoperative haematocrit (p = 0.008) and to require postoperative lung ventilation (p = 0.0002) compared with older patients. We conclude that patients in this age group have a significantly increased risk of postoperative complications.

Comparison of perioperative blood salvage and postoperative reinfusion of drained blood during surgical correction of craniosynostosis in infants

BACKGROUND

The surgical correction of craniosynostosis may be associated with extensive blood loss and transfusion. The aim of this study was to compare the efficacy of the perioperative use of the continuous autotransfusion system (CATS group) and of the postoperative use of the CBCII ConstaVac(R) system (CV group) to reduce homologous transfusion in infants during repair of craniosynostosis.

METHODS

Two groups of consecutive infants, weighing <10 kg, and scheduled for the surgical correction of craniosynostosis, were compared retrospectively according to the blood salvaging system used: CATS group and CV group. The primary endpoint was the comparison of the total volume of homologous blood transfused.

RESULTS

There was no significant difference between the CV (n = 69) and the CATS (n = 135) groups with regard to physical, preoperative and postoperative data, except for the type of craniosysnostosis with more scaphocephaly in the CV group (P = 0.03). No significant difference in blood loss and homologous transfusion was observed between the two groups during the perioperative period. Two subgroups of patients were also compared: a subgroup including patients operated on with a linear craniectomy for scaphocephaly, and a subgroup including all other patients. There was also no significant difference in blood loss and homologous transfusion between the CV and the CATS groups for these two subgroups of patients.

CONCLUSION

Our results suggest that the postoperative use of the CBCII ConstaVac(R) system is as efficient as the perioperative use of the CATS(R) system for reducing homologous blood transfusion during repair of craniosynostosis in infants weighing <10 kg.

[Anesthetic management for craniosynostosis]

Surgical procedures for correction of craniosynostosis are performed in young infants with a small blood volume and represent major surgery with extensive blood loss. An accurate determination and a precise restoration of blood losses represent the major concern for the anaesthetist during this surgery. The preoperative assessment of these patients is usually simple, except in the cases where the craniosynostosis is associated with other congenital malformations. The anaesthetist should keep in mind that intracranial hypertension may be associated with craniosysnostosis, which modify the anaesthetic management, especially the induction of anaesthesia. Even though the psychological impact of a craniosynostosis should be taken into consideration, surgery is most often indicated for functional considerations, therefore parents should be informed of the risks related to the procedure. During the postoperative period the major concerns are related to the possibility of a persistent bleeding, which usually decreases and disappears over the first 12 hours.

[Anesthesia-resuscitation for intracranial expansive processes in children]

The most frequent space-occupying cerebral lesions in children are brain tumors, mostly posterior fossa tumors and haematoma resulting from arteriovenous malformation rupture. They result in intracranial hypertension, directly or by compression of the cerebrospinal fluid pathway resulting in hydrocephalus. Their localization and compressive effects are responsible for specific neurological deficits and general problems. Posterior fossa lesions carry a high risk of obstructive hydrocephalus, cranial nerves palsy and brain stem compression, pituitary and chiasmatic tumors a risk of blindness, pituitary deficiency and diabetes insipidus, and cortical tumors a risk of motor deficit and epilepsy. All these parameters must be analyzed before choosing anaesthetic protocols, and surgical techniques. In the presence of life-threatening intracranial hypertension, emergency anaesthetic induction, tracheal intubation and ventilation are life-saving. The specific treatment consists in either hydrocephalus derivation, initial medical treatment with osmotherapy, or rarely surgical removal. In other situations, surgical process requires a highly deep, stable anaesthesia with perfect control of cerebral haemodynamics. Surgical positioning is complex for these long lasting procedures and carries specific risks. The most common is venous air embolism in the sitting position that must be prevented by the use of specific measures. In the postoperative period, the risk of neurological and general complications commands close surveillance, fast track extubation must be adapted on an individual basis.

Accuracy and limitations of continuous oesophageal aortic blood flow measurement during general anaesthesia for children: comparison with transcutaneous echography-Doppler

BACKGROUND

Because it is noninvasive and easy to use, oesophageal Doppler ultrasonography appears to be a worthwhile alternative for continuous assessment of cardiac output measurement during anaesthesia. A new oesophageal Doppler-echography device (Dynemo 3000, Sometec, Paris, France) can simultaneously determine aortic diameter and aortic blood flow at the same anatomical level (DEeso). The purpose of this study was to assess the accuracy and the potential limitations of this device during general anaesthesia among 20 children, using transcutaneous Doppler-echocardiography for comparison (DEtra).

METHODS

The reproducibility of paired measurements of mean aortic blood flow velocity (MAFV), aortic diameter (ØAo) and aortic blood flow (ABF) was analysed with both methods. Second, haemodynamic values were measured simultaneously in a blinded manner by both methods before and after surgery.

RESULTS

The percent change (%Delta) in MAFV and ABF was calculated with both methods for each child. The age and weight of children included in this study was 8.3 +/- 2.5 years and 27 +/- 8 kg, respectively. Intraoperator reproducibility of MAFVtra, ABFtra, MAFVeso and ABFeso, was 5.0 +/- 4.1%, 7.0 +/- 5.6%, 20.1 +/- 17.5% and 22.0 +/- 16.6%, respectively. ABFtra was significantly linked to ABFeso (R=0.55, P < 0.01). Bias +/- SD of ABF measurements between both methods was 2.2 +/- 1.1 l. min-1. %DeltaABFtra was significantly linked to %DeltaABFeso (R=0.62, P < 0.01). The bias +/- SD inherent to %DeltaABF measurements with both methods was -0.02 +/- 18%.

CONCLUSION

These results suggest that this new oesophageal Doppler method is unsuitable to measure accurately absolute CO values and relative CO changes in children during anaesthesia.

Perioperative blood salvage during surgical correction of craniosynostosis in infants

Surgical correction of craniosynostosis in infants is a very haemorrhagic procedure. The aim of this study was to determine whether the perioperative use of the continuous autotransfusion system (CATS) would reduce homologous transfusion during repair of craniosynostosis. Two groups of patients were studied according to the availability of the CATS in our hospital. The control group had surgery before the system was introduced and the study group had operations subsequently. Use of CATS was associated with a significant decrease in the median (95% confidence interval) volume of homologous blood transfused [413 (250-540) ml in the control group versus 317 (150-410) ml in the CATS group, P = 0.02] and in the median (95% confidence interval) number of packed red cell units transfused [2 (1-2) in the control group versus 1 (1-2) in the CATS group, P = 0.04] in the perioperative period. Use of CATS is associated with a reduction in homologous transfusion during the surgical correction of craniosynostosis in infants.

Non-invasive aortic blood flow measurement

Invasive monitoring is rarely used for children undergoing routine anaesthesia, whereas usual non-invasive haemodynamic measurements such as heart rate and blood pressure monitoring are unable to detect cardiovascular changes rapidly and precisely. In contrast, oesophageal aortic blood flow echo-Doppler is an easy, non-invasive and accurate method to monitor cardiac performance properly and continuously. Therefore, it could represent a useful addition to peri-anaesthetic monitoring techniques, particularly in infants and small children.