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Evaluate the efficacy of advanced life support interventions using the pediatric Utstein guidelines.Charts from all patients for whom a cardiorespiratory arrest code was called during a six-year period in a university affiliated centre were reviewed. Data were recorded according to the pediatric Utstein guidelines and a P0.05 was considered significant.Of the 234 calls, 203 were retained for analysis. The overall survival rate at one year was 26.0% of which 10% had deterioration of their neurologic status compared to the pre-cardiorespiratory arrest evaluation. Time to achieve sustained return of spontaneous circulation (ROSC; P0.0001) and sustained measurable blood pressure (P = 0.002), to perform endotracheal intubation (P = 0.04) and the dose of sodium bicarbonate (P0.0001) were indicators of long-term survival. Two patients were alive at one year with unchanged neurologic status despite a time to achieve sustained ROSC longer than 30 min (38 and 44 min). The mean first epinephrine dose of patients for whom ROSC was achieved but unsustained was higher than those for whom ROSC was achieved and sustained (0.038 +/- 0.069 mg*kg(-1) vs 0.011 +/- 0.006 mg*kg(-1); P = 0.004). Survival rate and mean first epinephrine dose of patients who received their first epinephrine dose endotracheally (13.3%; 0.011 +/- 0.004 mg*kg(-1)) were comparable to those of patients who received their first epinephrine dose intravenously (7%; 0.015 +/- 0.027 mg*kg(-1)).For intravenously administered epinephrine, a dose of 0.01 mg*kg(-1) seems appropriate as the first dose. The endotracheal route is a valuable alternative for epinephrine administration and, for infants, the dose does not need to be increased. A minimal resuscitation duration time of 30 min can be misleading if ROSC is used as the indicator.

Background: Neither droperidol nor ondansetron has been proven completely effective, and there are conflicting data comparing the efficacy of the two agents. The purpose of this study was to compare the efficacy, safety and cost of a combination of ondansetron administered intravenously in the operating room followed by oral ondansetron treatment at home with the more commonly used treatment of intravenous droperidol therapy and oral dimenhydrinate therapy, for the prevention and treatment of postoperative nausea and vomiting in children undergoing strabismus surgery. Methods: Double-blind randomized clinical trial with parallel comparison groups. All patients aged 6 months to 18 years who underwent strabismus surgery at a pediatric hospital in Montreal between Nov. 13, 2000, and June 12, 2001, were included. The exclusion criteria were nausea or vomiting, or use of antiemetics or narcotics in the 24 hours preceding surgery, and past history of hepatic, gastric or renal disease. The outcome measures were frequency of nausea and vomiting, severity of nausea and adverse effects in hospital, during transportation home and during the first 24 hours at home. Data were obtained through nursing notes and through a telephone interview conducted 24 to 48 hours after discharge. Results: Of the 208 eligible patients, 172 were randomly assigned to the study groups (88 to the ondansetron group and 84 to the droperidolldimenhydrinate group). We found no statistically significant difference in the incidence of nausea and vomiting in hospital or at home between the two groups (25.3% vs. 31.6%, p = 0.371). There was a significant difference between the two groups in the rate of vomiting during transportation home (3.6% vs. 12.6%, p = 0.044). The incidence of severe nausea was 14.4% with ondansetron and 15.4% with droperidol, a nonsignificant difference ( p = 1.00). No significant difference was observed between the two groups in the incidence of any nausea ( p = 0.434) or adverse effects ( p = 0.220). We calculated that the combination of droperidol and dimenhydrinate was seven times less costly than the ondansetron regimen. Interpretation: In this study, the efficacy and safety of intravenous administration of droperidol followed by oral use of dimenhydrinate did not differ from that of intravenous followed by oral use of ondansetron in children undergoing strabismus surgery. Since treatment with ondansetron is much more costly than the combination of droperidol and dimenhydrinate, at this time the use of ondansetron in the prevention and treatment of vomiting and nausea in this population may not be beneficial on a cost basis if all other variables are considered.

The authors attempted to determine the relative importance of factors that influence bleeding during and after spinal fusion. Data from 30 ASA I patients with idiopathic scoliosis were prospectively collected and analyzed. Intraoperative bleeding was 1971 ± 831 ml (mean ± SD) (61.5 ± 27% of estimated blood volume (EBV) and correlated with the number of fused vertebrae (r = 0.66, P < 0.0001) and the duration of surgery (r = 0.46, P = 0.0105). There was no correlation between intraoperative bleeding and the Cobb curve angle (43 to 86°), the mean arterial blood pressure (MAP) (63 to 86 mmHg), the central venous pressure (CVP), the quantity of epinephrine infiltrated, muscle relaxants or opioids used, nor in the type of opioids used, the minimal body temperature or whether stored or autologous blood was used. Postoperative bleeding was 1383 ± 369 ml (43.1 ± 11.7% of EBV) and correlated with the length of time the Hemovac drain was in place (r = 0.40, P = 0.0285) and MAP (r = 0.40, P = 0.0285). There was no correlation between postoperative and intraoperative bleeding nor in the number of fused vertebrae. Six patients had greater postoperative than intraoperative bleeding. The total bleeding (intra-plus postoperative) was 3347 ± 920 ml (104.2 ± 30.6 of EBV) and correlated with the number of fused vertebrae (r = 0.63, P = 0.0001) and with the duration of surgery (r = 0.42, P = 0.0208). We conclude that the number of fused vertebrae is the key factor in predicting intraoperative and total bleeding. Postoperative bleeding is considerable (up to 76.9% of EBV). No other factors allow for adequate prediction of postoperative bleeding and these patients must be kept under strict surveillance after surgery.

Eleven uremic children with osteodystrophy aged 3 to 17 years were studied during administration of l, 25-(OH)2D, for periods up to 21 months. Nine children presented with pure hyperparathyroidism, one with osteomalacia and one with mixed bone disease. Bone biopsies were performed before initiation of therapy and after 6 to 21 months of treatment following double tetracycline labeling. Skeletal lesions were improved but not cured in 5 of 9 children with hyperparathyroidism. In three instances lesions remained unchanged and worsened in one. No significant change was observed in the child with osteomalacia. Moderate improvement was noted in the patient with mixed bone disease. The propensity to develop hypercalcemia was the major factor associated with treatment failure since it precluded administration of adequate amounts of medication. Therapy with l, 25-(OH)2D3 was associated with a spectacular improvement in growth velocity in two of six children under age twelve.

The long-term damaging potential of remnant nephron hyperperfusion was investigated in patients who had undergone unilateral nephrectomy in childhood. 27 such patients were examined after a mean of 23·3 years postnephrectomy. The average creatinine clearance was 83·9±16·5 ml/min/1·73 m 2 or 74·3% of that in healthy controls with two kidneys; it was a value similar to that reported 3 to 6 months postnephrectomy in kidney donors. Age at the time of nephrectomy, duration of follow-up, or sex had no influence on the residual creatinine clearance. None of these patients had clinically important hypertension or proteinuria. Since so little evidence of kidney damage could be documented after such a long observation period, hyperperfusion would seem to be seldom of clinical importance in man unless other factors were present.