Reno-portal anastomosis as an approach to pediatric kidney transplantation in the setting of inferior vena cava thrombosis

In pediatric renal transplantation in the setting of IVC thrombosis, the retrohepatic IVC or gonadal veins are often used for outflow. However, if use of systemic venous outflow is unsuccessful, options become limited. We report the use of the portal vein for venous outflow in kidney retransplantation in the setting of IVC thrombosis. The patient is a 19-month-old male who developed end-stage renal failure at seven months of age secondary to hypotension after spontaneous rupture of an accessory renal vein. The IVC was occluded during emergent laparotomy, and the patient developed extensive IVC thrombosis. The first two transplant attempts used the retrohepatic IVC for venous outflow. Despite good initial flow, in both instances the renal vein thrombosed on post-operative day 1. In an unsuccessful salvage attempt of the second transplant, a reno-portal anastomosis was performed. With few options for vascular access, a third transplant was attempted. The reno-portal stump from the second transplant was used for outflow. The patient recovered well from his third transplant (creatinine 0.6 mg/dL 35 months post-surgery), demonstrating that the portal vein can be used for outflow in cases of extensive IVC thrombosis.

Stretched and sheared microcatheter retained after onyx embolization of infantile myofibromatosis

We describe a rare neurointerventional complication, namely a stretched and sheared microcatheter, extending 52 cm from its point of retention within an Onyx cast in an infant patient's neck mass, to the groin. The tumor was an unusual manifestation of infantile myofibromatosis and prior attempts at resection had proven impossible due to bleeding. Recommendations regarding microcatheter selection, diagnostic workup, and management of the ensuing complication are given.

Intra-abdominal sacrococcygeal mature teratoma or fetus in fetu in a third-trimester fetus

This case report describes a fetus with a large intra-abdominal, complex, vascular mass, displacing the normal intra-abdominal organs due to its large size. Extension to the presacral area was also identified, facilitating the diagnosis of a sacrococcygeal teratoma. Because of its highly mature nature, this was considered a fetus in fetu which was totally intra-abdominal.

Inhaled nitric oxide in the treatment of postoperative graft dysfunction after lung transplantation

Pulmonary hypertension and transient graft dysfunction may complicate the postoperative course of patients undergoing lung transplantation. We report the acute effect of inhaled nitric oxide (80 ppm) on hemodynamics and gas exchange in 6 patients (median age, 14 years; range, 5 to 21 years) after lung transplantation as well as the effect of extended treatment over 40 to 69 hours in 2 patients. In 5 patients with pulmonary hypertension nitric oxide lowered mean pulmonary artery pressure (from 38.4 +/- 1.6 to 29.4 +/- 3.1 mm Hg; p < 0.05), pulmonary vascular resistance index (from 9.3 +/- 1.4 to 6.4 +/- 1.3 Um2; p < 0.05), and intrapulmonary shunt fraction (from 28.6% +/- 8.3% to 21.0% +/- 5.7%; p < 0.05). There was a 28.4% +/- 7.2% reduction in transpulmonary pressure gradient with only minor accompanying effects on the systemic circulation. Mean arterial pressure decreased only 2.7% +/- 5% (from 76.4 +/- 2.2 to 74 +/- 2.3 mm Hg; p = not significant), and systemic vascular resistance index by 4.2% +/- 9.7% (from 21.7 +/- 3.1 to 20.6 +/- 3.6 Um2; p = not significant). Cardiac index was unchanged (from 3.5 +/- 0.8 to 3.6 +/- 0.7 L.min-1.m-2; p = not significant). Nitric oxide caused a sustained improvement in oxygenation and pulmonary artery pressure during extended therapy at doses of 10 ppm. There were no major side effects. However, transient methemoglobinemia (9%) developed in 1 patient after 10 hours of nitric oxide treatment. Nitric oxide may be useful in the treatment of pulmonary hypertension and the impaired gas exchange that occurs after lung transplantation.

Outcome of renal transplantation in children less than two years of age

Twenty-two renal transplants were performed in 21 children less than two years of age at Children's Hospital. Fourteen were from living related donors and eight were from cadaveric donors. The five year patient and graft survivals of these recipients were compared to all other pediatric recipients between two and 18 years of age who received renal transplants over the same time period. Five year graft survival for recipients less than two years of age was 86% following living-related donor transplantation and 38% following cadaver donor transplantation. Older pediatric recipients aged between two and 18 years had a five year graft survival of 73% following living-related donor renal transplantation, which was similar to that for recipients less than two years of age. Although older cadaveric recipients had a comparable five year graft survival to younger recipients, at 42%, the patterns of graft loss were different. Graft failures in young recipients occurred within the first seven months post-transplant, whereas the older recipient's grafts failed more gradually. Actuarial five-year patient survival in recipients less than two years of age was 86% following living-related donor renal transplantation and 70% following cadaver-donor renal transplantation. Recipients less than two years of age had a poorer patient survival than older recipients following both living-related donor renal transplantation (P = 0.06) and cadaver-donor renal transplantation (P less than 0.05). These findings suggest that the graft survival of living-related donor renal transplantation in recipients less than two years of age is better than that of cadaver-donor renal transplantation.(ABSTRACT TRUNCATED AT 250 WORDS)

Regional analgesia on pediatric medical and surgical wards

Regional anesthetic approaches to pain management were examined in 72 children and young adults (ages 3 weeks to 31 years) who were observed on the surgical or medical wards of a children's hospital separate from intensive care areas. A protocol was devised to permit safe conduct of these techniques on the ward. Full resuscitation supplies were kept at each bedside. All patients receiving epidural narcotics had an apnea monitor, hourly counting of respiratory rates, and restriction of systemic analgesics. All bolus re-injections into the catheters were performed by an anesthesiologist who monitored the patient for 20 min. Minor side-effects, including pruritus, nausea, and urinary retention were common, but manageable. Significant complications included: one case of decubitus ulcers requiring skin-grafting, one episode of mild hypotension in a patient with terminal malignancy, requiring ephedrine and phenylephrine, and one mild toxic reaction on test dosing due to presumed intravascular migration of a lumber sympathetic catheter. Regional analgesic techniques can provide excellent analgesia on the wards for selected children and young adults, provided precautions are taken. Further study is required to define specific indications, risks and benefits relative to simpler techniques.

Use of the postductal PaO2 as a predictor of pulmonary vascular hypoplasia in infants with congenital diaphragmatic hernia

Infants with congenital diaphragmatic hernia (CDH) demonstrate a wide range of anatomic and physiologic abnormalities that result in decreased pulmonary perfusion. We have used the patients' ability to achieve at least one postductal PaO2 greater than 100 torr while on maximal ventilation with 100% oxygen during the first 24 hours of life as the clinical marker to identify the degree of pulmonary perfusion. Patients were grouped as follows: group 1 had at least one postductal PaO2 greater than 100 torr, and group 2 patients never had a postductal PaO2 above 100 torr. To see if this classification did reflect pulmonary vascular abnormalities, we compared the pulmonary arteriograms of these two groups of CDH infants for size of the main pulmonary arteries (PAs), size of the lungs, and degree of peripheral vascular obstructive disease (PVO). Infants in group 2 had significantly smaller ipsilateral and contralateral main PAs, as well as smaller ipsilateral lungs with more severe PVO. We propose the postductal PaO2 as the clinical marker for identification of the degree of pulmonary perfusion.