Does anesthesia duration or number of cases per patient predict safety events?

BACKGROUND

The need for dental rehabilitation under general anesthesia is increasing, with varying needs between patients. Mortality has been found to be a rare event in these patients; however other perioperative events can and do occur. Previous studies have established increased incidence of perioperative events with younger, sicker children, and longer anesthetics, however, no studies to date have evaluated if the incidence of perioperative events is more closely associated with one long anesthetic or multiple anesthetics per patient.

AIMS

To evaluate the association of perioperative events related to single anesthetic duration or number of anesthetics per patient for dental rehabilitation.

METHODS

After Children's Wisconsin Human Research Protection Program determined this quality activity did not meet the definition of human subjects research, we performed an epidemiologic observational evaluation by extracting all dental related cases (dental alone or with oral surgeon vs. dental with other specialties) with an associated general anesthesia encounter from Children's Wisconsin electronic data warehouse from June 1, 2015 to December 31, 2021. These cases occurred at a free-standing children's hospital or associated pediatric-only ambulatory surgery center. The risk of perioperative safety events was analyzed for previously identified risk groups such as American Society of Anesthesiologists Physical Status (ASA-PS), patient age, anesthesia case time with the addition of number of dental cases per patient.

RESULTS

In this study, 8468 procedures were performed on 8082 patients. Of this cohort, 7765 patients underwent one procedure for dental care while 317 patients underwent a total of 703 dental-related procedures, ranging from two to five procedures per patient. Multivariable logistic regression identified increased risk of perioperative events in patients with ASA-PS 3 (n = 1459, rate 1.78%, p value .001, OR 5.7, CI 2.1-15.5) and ASA-PS 4 (n = 86, rate 5.8%, p < .001, OR 17.2, CI 4.4-67.3), anesthesia duration (p < .001, OR 1.46, CI 1.21-1.76), but no increased risk with number of anesthetics per patient (p value .54, OR 0.81, CI 0.4-1.61).

CONCLUSIONS

Limiting dental care under general anesthesia to multiple short cases may decrease the risk of perioperative events when compared to completing all treatment in one long operative session.

Delayed hematopoietic recovery after auto-SCT in patients receiving arsenic trioxide-based therapy for acute promyelocytic leukemia: a multi-center analysis

A potential link between arsenic (ATO)-based therapy and delayed hematopoietic recovery after autologous hematopoietic SCT (HSCT) for acute promyelocytic leukemia (APL) has previously been reported. We retrospectively reviewed the clinical histories of 58 patients undergoing autologous HSCT for APL at 21 institutions in the United States and Japan. Thirty-three (56%) of the patients received ATO-based therapy prior to stem cell collection. Delayed neutrophil engraftment occurred in 10 patients (17%): 9 of the 10 patients (90%) received prior ATO (representing 27% of all ATO-treated patients), compared with 1 of the 10 patients (10%) not previously treated with ATO (representing 4% of all ATO-naïve patients; P<0.001). Compared with ATO-naïve patients, ATO-treated patients experienced significantly longer times to ANC recovery (median 12 days vs 9 days, P<0.001). In multivariate analysis, the only significant independent predictor of delayed neutrophil engraftment was prior treatment with ATO (hazard ratio 4.87; P<0.001). Of the available stem cell aliquots from APL patients, the median viable post-thaw CD34+ cell recovery was significantly lower than that of cryopreserved autologous stem cell products from patients with non-APL AML. Our findings suggest that ATO exposure prior to CD34+ cell harvest has deleterious effects on hematopoietic recovery after autologous HSCT.

Reliability of the quadriceps angle measurement

The quadriceps angle (Q-angle) is used to determine patellofemoral alignment. Although this measurement has been used to evaluate and treat patellofemoral joint pathology, few studies have examined its reliability. This study evaluated the interobserver and intraobserver reliability of the Q-angle measurement. To investigate the interobserver reliability of the Q-angle, 25 individuals of varying levels of training served as observers and participants as each measured the other 24 participants. To investigate the intraobserver reliability of the Q-angle, 3 of the observers measured 13 of the participants an additional 2 times. Additionally, clinically derived Q-angle measurements were compared with radiographically derived measurements. The reliability analysis was performed using intraclass correlation coefficients. For interobserver measurements, the intraclass correlation coefficients ranged from 0.17-0.29 for the four variables evaluated (right and left, extension and flexion). For intraobserver measurements, the intraclass correlation coefficients ranged from 0.14-0.37. The average intraclass correlation coefficient between the clinically and radiographically derived measurements ranged from 0.13-0.32. This study demonstrates poor interobserver and intraobserver reliability of Q-angle measurement and poor correlation between clinically and radiographically derived Q-angles.

The effect of placing a tensioned graft across open growth plates. A gross and histologic analysis

BACKGROUND

Midsubstance tears of the anterior cruciate ligament in skeletally immature patients are increasingly common and are a challenging problem. The results of nonoperative treatment are no better in children than they are in adults. Physeal-sparing reconstructive procedures have yielded poor results. Reconstructive procedures that are utilized in adults violate the physis, potentially resulting in growth abnormalities. The objective of this study was to provide a model for reconstruction of the anterior cruciate ligament in skeletally immature patients by evaluating the effects of a tensioned connective-tissue graft placed across the canine physis.

METHODS

Twelve ten-week-old beagles underwent reconstruction of the anterior cruciate ligament consisting of placement of fascia lata autograft through drill-holes across the femoral and tibial physes, tensioning of the graft to 80 N, and fixing it with screws and washers. The contralateral limb served as a control. One dog was eliminated from the study secondary to a postoperative infection. Four months postoperatively, the dogs were killed and were inspected grossly, radiographically, and histologically for any evidence of growth disturbance.

RESULTS

Significant valgus deformity of the distal part of the femur (p < 0.001) and significant varus deformity of the proximal part of the tibia (p = 0.03) developed in the treated limbs. Neither radiographic nor histologic examination demonstrated any evidence of physeal bar formation.

CONCLUSIONS

Significant growth disturbances occur with excessively tensioned transphyseal reconstruction of the anterior cruciate ligament in the canine model. These growth disturbances occur without radiographic or histologic evidence of physeal bar formation.

Properties and ionic mechanisms of a metabotropic glutamate receptor-mediated slow afterdepolarization in neocortical neurons

1. Pyramidal neurons from layer V of rat neocortex were recorded intracellularly in a brain slice preparation to study their response to stimulation of metabotropic glutamate receptors (mGluRs) by bath application of the selective mGluR agonist (1S,3R)-1-aminocyclopentane-1,3-dicarboxylic acid (1S,3R-ACPD) and by the nonselective agonists glutamate and quisqualate. 2. The principal postsynaptic effect of mGluR stimulation in the presence of ionotropic glutaminergic and muscarinic cholinergic antagonists was the appearance of a slow afterdepolarization (ADP) after evoked spikes. Only an afterhyperpolarization (AHP) was present in control perfusate. After 20 spikes evoked individually at 100 Hz the ADP peaked at 317 +/- 117 (SD) ms after the spike train, ranged from 1 to 12 mV in peak amplitude, and decayed over 7.4 +/- 4.7 s. This effect was not blocked by L-2-amino-3-phosphono-propionic acid (1 mM). Spikes evoked in the presence of the ionotropic glutamate receptor agonist R,S-alpha-amino-3-hydroxy-5-methylisoxazole-4-proprionic acid (AMPA) did not have an ADP. 3. A detectable ADP appeared at concentrations of 0.1 microM quisqualate or 0.5 microM 1S,3R-ACPD. Maximum ADP amplitude was obtained with 5 microM quisqualate or 100 microM 1S,3R-ACPD. The ADP appeared after a single evoked spike in most cells tested and ADP amplitude increased to a maximum as the number of spikes evoked at 100 Hz was increased to between 5 and 20. 4. The ionic mechanisms underlying the ADP were examined by ion substitution and the application of channel-blocking agents. No difference in ADP amplitude was observed when the recording electrode contained CH3SO4. instead of Cl.. The ADP was present after 3 mM extracellular Cs+ were added to block the hyperpolarization-activated cation current or when 100 microM Ba2+ were included to block voltage-gated K+ currents. The ADP was abolished when Mn2+ was substituted for Ca2+ in the perfusate or when the Ca2+ chelator 5,5'-dimethyl-bis-(o-aminophenoxy)-N,N,N',N'-tetraacetic acid was included in the recording electrode. A large ADP followed Ca2+ spikes evoked in the presence of 1 microM tetrodotoxin with 20 mM tetraethylammonium in the perfusate or with Cs+ substituted for K+ in the recording electrode. The amplitude of the ADP after the Ca2+ spikes was reduced by 49% when extracellular Na+ concentration was reduced from 136 to 26 mM. 5. The voltage dependence of the ADP was examined in relation to K+ equilibrium potential (EK).(ABSTRACT TRUNCATED AT 400 WORDS)