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Pediatric cardiac interventions via percutaneous common carotid artery (CCA) access have been shown to be safe and effective. However, the impact of placement of a sheath in the carotid artery for interventions on cerebral perfusion is unknown. In this study we used cerebral near-infrared spectroscopy (NIRS) to analyze the effects of percutaneous CCA access for cardiac interventions on cerebral perfusion. This study is a retrospective chart review carried out at a tertiary care center on all pediatric patients who underwent percutaneous cardiac catheterization via carotid artery access from January 2010 to January 2020. All patients who had ipsilateral NIRS recorded on the side of carotid artery access were included. Patients with only partial or no ipsilateral NIRS data were excluded. The primary outcome measure was the change in NIRS upon CCA access; the mean NIRS for 15 min before obtaining access was compared to the mean NIRS during the procedure and to the mean NIRS 15 min after removal of the CCA sheath. We hypothesized that there would be a significant drop in NIRS values on the side of CCA access. There were 48 catheterizations in the study period where percutaneous CCA was accessed. Of those, 21 catheterizations had complete data and were included in the study. 13 (62%) were of males. The median age was 23 days (IQR 7–79). The indications for CCA access were patent ductus arteriosus stent implantation (n = 13; 62%), aortic valvuloplasty (n = 5; 24%), balloon angioplasty of coarctation of aorta (n = 2; 10%), and renal artery angioplasty (n = 1; 4%). In 16 patients (72%), the left common carotid artery was accessed. The median weight of the patients was 3.3 kg (IQR 2.8–2.9). The most common sheath size used was 4F, in 16 patients (72%). The mean NIRS prior to the procedure was 67 ± 15%, during the procedure was 68 ± 20%, and after removal of sheath was 68 ± 21%. Paired t test of cerebral NIRS before, during, and after the procedure showed no significant change with CCA access (P = 0.08). No patient in the series had a documented neurologic deficit following the procedure. Percutaneous CCA access was not associated with a decrease in NIRS on the side of the access during the procedure, suggesting there was no significant acute change in cerebral perfusion with CCA access.

This article is a review of the highlights of pertinent literature published in 2019, which is of interest to the pediatric cardiac anesthesiologist. After a search of the United States National Library of Medicine PubMed database, several topics emerged in which significant contributions were made in 2019. The authors of this manuscript considered the following topics noteworthy and were included in this review: advances in pediatric heart transplantation, blood management in pediatric cardiac surgery, the impact of nutrition on outcomes in congenital heart surgery, and the use of vasopressin in patients after Fontan palliation.

Background Pediatric radial artery cannulation is challenging because of the small vessel size. Nitroglycerin is a potent vasodilator and facilitates radial artery cannulation by increasing the internal diameter and preventing the vasospasm in adult patients. The authors hypothesize that subcutaneous nitroglycerin injection will improve the success rate of pediatric radial artery cannulation. Methods This double-blind, randomized, controlled, single-center study enrolled pediatric patients (n = 113, age less than 2 yr) requiring radial artery cannulation during general anesthesia. The participants were randomized into the nitroglycerin group (n = 57) or control group (n = 56). After inducing general anesthesia, nitroglycerin solution (5 μg/kg in 0.5 ml), or normal saline (0.5 ml) was subcutaneously injected above the chosen radial artery over 10 s with ultrasound guidance. Three minutes later, the ultrasound-guided radial artery cannulation was performed. Radial artery diameter was measured before and after the subcutaneous injection and after cannulation. The primary outcome was the first-attempt successful cannulation rate. The secondary outcomes included the diameter of the radial artery and the overall complication rate including hematoma and vasospasm. Results A total of 113 children were included in the analysis. The nitroglycerin group had a higher first-attempt success rate than the control group (91.2% [52 of 57] vs. 66.1% [37 of 56]; P = 0.002; odds ratio, 5.3; 95% CI, 1.83 to 15.6; absolute risk reduction, –25.2%; 95% CI, –39.6 to –10.7%). Subcutaneous nitroglycerin injection increased the diameter of the radial artery greater than normal saline (25.0 ± 19.5% vs. 1.9 ± 13.1%; 95% CI of mean difference, 16.9 to 29.3%; P < 0.001). Overall complication rate was lower in the nitroglycerin group than in the control group (3.5% [2 of 57] vs. 31.2% [18 of 56]; P = 0.001; odds ratio, 0.077; 95% CI, 0.017 to 0.350; absolute risk reduction, 28.6%; 95% CI, 15.5 to 41.8%). Conclusions Subcutaneous nitroglycerin injection before radial artery cannulation improved the first-attempt success rate and reduced the overall complication rates in pediatric patients. Editor’s Perspective What We Already Know about This Topic What This Article Tells Us That Is New

This article is a review of the highlights of pertinent literature of interest to the congenital cardiac anesthesiologist and was published in 2021. After a search of the United States National Library of Medicine PubMed database, several topics emerged where significant contributions were made in 2021. The authors of this manuscript considered the following topics noteworthy to be included in this review: risk stratification in adult congenital heart disease surgery, physician burnout in pediatric cardiac anesthesia, transfusion practice in pediatric congenital heart surgery, and racial disparity and outcomes in pediatric patients with congenital heart disease.

BACKGROUND Carotid artery (CA) and axillary artery (AA) access are increasingly used for transcatheter stenting of the patent ductus arteriosus (PDA), although reports are limited. METHODS The Congenital Catheterization Research Collaborative (CCRC) reviewed multicenter data from infants who underwent PDA stenting via the CA or AA approach from 2008 to 2017, and compared outcomes to those of infants undergoing PDA stenting via the femoral artery (FA) approach. Post-procedure ultrasound (US) imaging was reviewed. RESULTS Forty-nine infants underwent PDA stenting from the CA (n = 43) or AA (n = 6) approach, compared with 55 infants who underwent PDA stenting from the FA approach. The PDA was the sole pulmonary blood flow (PBF) source in 61% of infants in the CA/AA cohort, compared with 33% of the FA cohort (p

THIS ARTICLE IS a review of the highlights of pertinent literature published during the 12 months of 2018 that is of interest to the congenital cardiac anesthesiologist. During a search of the US National Library of Medicine PubMed database, several topics that displayed significant contributions to the field in 2018 emerged. The authors of the present review consider the following topics noteworthy: the patient with high-risk congenital heart disease (CHD) presenting for noncardiac surgery, cardiopulmonary resuscitation in infants and children with CHD, dexmedetomidine use in pediatric patients, point-of-care lung ultrasound, and regional anesthesia in pediatric cardiac surgery.

Pediatric cardiac interventions via percutaneous common carotid artery (CCA) access have been shown to be safe and effective. However, the impact of placement of a sheath in the carotid artery for interventions on cerebral perfusion is unknown. In this study we used cerebral near-infrared spectroscopy (NIRS) to analyze the effects of percutaneous CCA access for cardiac interventions on cerebral perfusion. This study is a retrospective chart review carried out at a tertiary care center on all pediatric patients who underwent percutaneous cardiac catheterization via carotid artery access from January 2010 to January 2020. All patients who had ipsilateral NIRS recorded on the side of carotid artery access were included. Patients with only partial or no ipsilateral NIRS data were excluded. The primary outcome measure was the change in NIRS upon CCA access; the mean NIRS for 15 min before obtaining access was compared to the mean NIRS during the procedure and to the mean NIRS 15 min after removal of the CCA sheath. We hypothesized that there would be a significant drop in NIRS values on the side of CCA access. There were 48 catheterizations in the study period where percutaneous CCA was accessed. Of those, 21 catheterizations had complete data and were included in the study. 13 (62%) were of males. The median age was 23 days (IQR 7-79). The indications for CCA access were patent ductus arteriosus stent implantation (n = 13; 62%), aortic valvuloplasty (n = 5; 24%), balloon angioplasty of coarctation of aorta (n = 2; 10%), and renal artery angioplasty (n = 1; 4%). In 16 patients (72%), the left common carotid artery was accessed. The median weight of the patients was 3.3 kg (IQR 2.8-2.9). The most common sheath size used was 4F, in 16 patients (72%). The mean NIRS prior to the procedure was 67 ± 15%, during the procedure was 68 ± 20%, and after removal of sheath was 68 ± 21%. Paired t test of cerebral NIRS before, during, and after the procedure showed no significant change with CCA access (P = 0.08). No patient in the series had a documented neurologic deficit following the procedure. Percutaneous CCA access was not associated with a decrease in NIRS on the side of the access during the procedure, suggesting there was no significant acute change in cerebral perfusion with CCA access.

This article is a review of the highlights of pertinent literature published during the 12 months of 2020 that are of interest to the congenital cardiac anesthesiologist. After a search of the US National Library of Medicine's PubMed database, several topics emerged for which significant contributions were made in 2020. The authors of the present article considered the following topics noteworthy to be included in this review: pediatric cardiac care in the coronavirus disease 2019 era, the use of mechanical circulatory support in coronavirus disease 2019-related multisystem inflammatory syndrome in children, transfusion and coagulation management in children undergoing congenital heart surgery, and pulmonary vein stenosis.

Background:We aimed to describe our experience with patients with sickle cell trait (SCT) and undergoing surgery on cardiopulmonary bypass (CPB).Methods:Data on all patients with SCT or sickle-α thalassemia who underwent surgery on CPB were collected (1996-2017).Results:Overall, 46 patients were included, 37 (80%) had SCT and 9 (20%) had sickle-α thalassemia. A total of 4 (9%) developed a potential sickle cell–related complication. Patients with sickle cell-related complications were significantly older (median 14 years vs 14 months, P = .037) and heavier (median 54 kg vs 9 kg, P = .041). Complications occurred, although without statistical significance, in patients who underwent longer median CPB times (249 minutes vs 137 minutes, P = .069), lower median temperature (31.7 °C vs 33.3 °C, P = .094), and a higher percentage underwent deep hypothermic circulatory arrest (50% vs 7%, P = .053). A total of 30 (65%) patients underwent exchange transfusion (ET) pre-bypass. Patients who underwent ET were significantly older (median 4 years vs 7 months, P = .003) and heavier (median 16 kg vs 6 kg, P = .015) than patients who did not undergo ET. The incidence of complications was comparable between patients who underwent ET (10%) and those who did not (6%).Conclusions:In this retrospective, single-center study, it has been shown that cardiac surgery requiring CPB in patients with SCT and sickle-α thalassemia had a low risk for sickle cell-associated complications. In this cohort of patients, older age, longer CPB times, lower median temperature, and the utilization of deep hypothermic circulatory arrest appear to play an important role in the development of complications.

The Congenital Cardiac Anesthesia Society is an international body instituted for collaboration among parties with interest in the perioepartive care of patients with congenial heart disease. This report is a review and update on the first 12 years of this society.

The first pediatric lung transplant was performed in 1987 at the University of Toronto in a 15-year-old with familial pulmonary fibrosis. Since that time, over 2000 children have received lung transplants worldwide, with an annual number ranging between 99 and 137 over the past decade. For the anesthesiologist charged with managing these rare patients, an understanding of the indications that lead to transplantation, their pathophysiology, and the physiology of the transplanted lungs are critical. To provide a context for the anesthetic management of the child undergoing lung transplantation, we discuss the case of a 2-month-old who underwent bilateral lung transplantation for intractable respiratory failure. Both the unique aspects of this case and pediatric lung transplantation, in general, are presented. Then a review of the literature is discussed.

Multi-institutional databases and registries have proliferated over the last decade in all specialties of medicine. They may be especially helpful in low-frequency/high-acuity fields such as pediatric and congenital heart diseases. The Society of Thoracic Surgeon’s Congenital Heart Surgery Database (STSCHSD) is the largest single data set for the congenital heart disease population and includes contemporaneous data from over 120 programs in the United States (and several outside of the United States), capturing greater than 98% of the congenital cardiac surgical procedures in the United States. In 2010, the Congenital Cardiac Anesthesia Society partnered with the STSCHSD to incorporate anesthesia-related elements into the data set. Voluntary site participation in the anesthesia data has grown steadily. Currently, over 60 sites performing more than 60% of cardiac bypass procedures in the STSCHSD are submitting anesthesia data annually into the STSCHSD. Anesthesia data include perioperative medication usage, modalities for hemodynamic and neurologic monitoring, blood product, antifibrinolytic and procoagulant use, and anesthesia-related adverse events. This special article provides a descriptive summary of relevant findings to date, reflecting the wide variety in anesthesia practice patterns present among institutions and illustrates the functionality of a multisite registry in pediatric cardiac anesthesia which can be utilized both locally and nationally.

BACKGROUND One-lung ventilation is a challenging airway technique in the pediatric population. Multiple airway devices can be employed, but there is no consensus as to the most reliable and physiologically advantageous method. This report is a review of the methods of one-lung ventilation in children in our practice, as well as an analysis of the impact of airway device type, patient age, and duration of lung separation on respiratory mechanics and gas exchange. METHODS The records of all pediatric patients undergoing procedures requiring one-lung ventilation in a single center over an 18-month period were reviewed. Demographics, time required to achieve lung separation (anesthesia ready-time), and duration of one-lung ventilation were collected. Data from arterial blood gas analysis and ventilator parameters were collected at three time points: 15 minutes prior to one-lung ventilation (pre-OLV), 15 minutes after initiation of one-lung ventilation (during OLV), and 15 minutes after one-lung ventilation was ended (post-OLV). Standard equations for calculating compliance, the ratio of arterial partial pressure of oxygen to the fraction of inspired oxygen, and the alveolar-arterial oxygen gradient were used. RESULTS Forty-six patients were identified with a mean age of 9.3 (inner quartile range 3-15) years. All patients had significant changes in pulmonary function when comparing pre-OLV with during OLV and when comparing during OLV with post-OLV. There were no significant changes from pre- to post-OLV. On further analysis, there were more pronounced changes in compliance and gas exchange in older patients (P = 0.003; 95% CI: -0.62 to -0.14). There was also a significant decrease in post-OLV compliance with a longer duration of OLV (P = 0.018; 95% CI: -0.02 to

Large data sets have now become ubiquitous in clinical medicine; they are particularly useful in high-acuity, low-volume conditions such as congenital heart disease where data must be collected from many centers. These data fall into 2 categories: administrative data arising from hospital admissions and charges and clinical data relating to specific diseases or procedures. In congenital cardiac diseases, there are now over a dozen of these data sets or registries focusing on various elements of patient care. Using probabilistic statistic matching, it is possible to marry administrative and clinical data post hoc using common elements to determine valuable information about care patterns, outcomes, and costs. These data sets can also be used in a collaborative fashion between institutions to drive quality improvement (QI). Because these data may include protected health information (PHI), care must be taken to adhere to federal guidelines on their use. A fundamental principle of large data management is the use of a common language and definition (nomenclature) to be effective. In addition, research derived from these information sources must be appropriately balanced to ensure that risk adjustments for preoperative and surgical factors are taken into consideration during the analysis. Care of patients with cardiac disease both in the United States and abroad consistently shows wide variability in mortality, morbidity, and costs, and there has been a tremendous amount of discussion about the benefits of regionalization of care based on center volume and outcome measurements. In the absence of regionalization, collaborative learning techniques have consistently been shown to minimize this variability and improve care at all centers, but before changes can be made it is necessary to accurately measure accurately current patient outcomes. Outcomes measurement generally falls under hospital-based QI initiatives, but more detailed analysis and research require Institutional Review Board and administrative oversight. Cardiac anesthesia providers for these patients have partnered with the Society of Thoracic Surgeons Congenital Heart surgeons to include anesthesia elements to help in this process.

Cardiac catheterization plays an increasing role in the management of pediatric and adult patients with congenital heart disease. These days, the catheterization laboratory often also functions as a satellite operating room with hybrid capabilities that involve both the surgeons and interventional cardiologists. Delivering anesthesia in this environment is challenging, and the physical space is limited. Exposure to ionizing radiation increases in proximity to the patient during fluoroscopy. Furthermore, the medical complexity of the patient population cared for in this setting continues to broaden, as a wider range of interventions becomes available. In order to plan the safest anesthetic management, it is imperative for anesthesiologists to have a firm understanding of each patient’s physiology and how it will be affected by both the sedation/anesthesia and the proposed procedure. Teamwork and situational awareness are essential, as are anticipation and preparation for the rare occurrence of a major, life-threatening complication.

Pediatric cardiac anesthesia as a discipline has evolved over the years to become a well recognized sub-specialty. Education and training in the field has also continued to change and develop. In this review, the author outline the changes in the field over the years and suggest a structure for an organized fellowship training process.

Pediatric cardiac anesthesiology has evolved as a subspecialty of both pediatric and cardiac anesthesiology and is devoted to caring for individuals with congenital heart disease ranging in age from neonates to adults. Training in pediatric cardiac anesthesia is a second-year fellowship with variability in both training duration and content and is not accredited by the Accreditation Council on Graduate Medical Education. Consequently, in this article and based on the Accreditation Council on Graduate Medical Education Milestones Model, an expert panel of the Congenital Cardiac Anesthesia Society, a section of the Society of Pediatric Anesthesiology, defines 18 milestones as competency-based developmental outcomes for training in the pediatric cardiac anesthesia fellowship.

Loeys-Dietz syndrome (LDS) is a rare connective tissue disorder predisposing to aortic and arterial aneurysms. Presentations are classified into subtypes based on gene mutations. Pregnancy in patients with LDS is considered very high risk due to the potential for aortic dissection and uterine rupture. We report successful management of an elective cesarean delivery in a 16-year-old patient with LDS type IV using epidural anesthesia. Perioperative considerations and multidisciplinary management specific to taking care of parturients with LDS are discussed.

From the Baylor College of Medicine, Texas Children’s Hospital, Houston, TX. J.R.W. is cardiac anesthesia fellow. Address reprint requests to Jamie R.Wingate, MD, Baylor College of Medicine, Texas Children’s Hospital, 6621 Fannin Street, WT, 17317B, Houston, TX 77030. E-mail: hwarraic@bidmc.harvard.edu © 2014 Elsevier Inc. All rights reserved. 1053-0770/2602-0033$36.00/0 http://dx.doi.org/10.1053/j.jvca.2014.04.004

Introduction: The diagnosis of trisomy 21 in children has been associated with failed extubation after CHD surgery. Dexmedetomidine may be a useful agent to improve postoperative outcomes in these patients, such as ventilator time, ICU length of stay, or hospital length of stay. Materials and methods: The Pediatric Health Information System database was queried from January, 2008 to December, 2010 for patients with trisomy 21 who underwent CHD surgery. Patients who received dexmedetomidine were matched to patients who did not by propensity score. The primary outcome was ventilator days charged, and secondary outcomes included ICU and hospital length of stay. Results: A total of 1088 patients (544 matched pairs) met inclusion criteria. Patient characteristics were similar, with the exception of more patients in the dexmedetomidine group undergoing repair of complete atrioventricular canal and fewer undergoing mechanical valve replacement (pConclusions: The use of dexmedetomidine was not associated with the decreased ventilatory time. Routine use of dexmedetomidine is not warranted in this patient population.

There are currently in North America more adults with congenital heart disease than children. This article discusses the anesthetic considerations in adults with single-ventricle physiology and prior repairs who present for Fontan conversion surgery as a demonstration of the challenges of caring for adults undergoing interventions for the repair of congenital heart defects. The care of these patients requires an understanding of the impact of passive pulmonary blood flow and single systemic ventricular physiology. The perioperative morbidity in this patient population remains high.

Summary The population of children with end-stage heart failure requiring mechanical circulatory support is growing. These children present for diagnostic imaging studies, various interventions and noncardiac surgical procedures that require anesthetic care. This article is a review of the population demographics of children on mechanical cardiac support, the alternative devices available, and the important concepts for safe perioperative management of these patients. The discussion will be limited to devices for short- and long-term cardiac support, excluding extracorporeal membrane oxygenation (ECMO) for respiratory support.

To evaluate the impact of dexmedetomidine on early extubation in post-operative pediatric cardiac patients compared to patients on standard sedation regimens without dexmedetomidine.Retrospective study comparing dexmedetomidine infusion (DEX) to our standard sedation regimens (control).A total of 269 patients were included (control: n = 180; DEX: n = 89). The mean duration of DEX was 34 ± 2 h. Extubation was achieved in the operating room in 42% of the control group and 42% of the DEX group. Extubation within 24 h of surgery was achieved in 75% of the control group and 76% of the DEX group. Ventilator time in the DEX group was 35 ± 29 h compared to 29 ± 35 h in the control group. The mean cardiovascular intensive care unit (CV ICU) and hospital length of stays were 3 ± 2 and 8 ± 4 days in the DEX group and 3 ± 3 and 8 ± 5 days in the control group. Reintubation rates in the CV ICU were not significantly different. DEX patients received significantly less total intraoperative fentanyl and midazolam but significantly more midazolam rescue doses than the control group in the postoperative period. Post-extubation ventilation was clinically similar in the DEX group as measured by 1 h post-extubation PaCO₂ levels.Dexmedetomidine did not significantly impact the postoperative course of children compared to standard practice as measured by success of early extubation, ventilator time, and length of stay.

In this case series, a group of 10 patients with significantly high preoperative hematocrit secondary to congenital cardiovascular disease for whom regional cerebral oxygen saturation was unmeasureable via nearinfrared spectroscopy were identified. Institutional review board approval was obtained for the review of records and data collection for patients with failure of intraoperative NIRS detection. In a period of 1 year (2010), 10 of 1,820 (0.55%) patients were identified intraoperatively and in the cardiac catheterization laboratory with failed NIRS monitoring and profound polycythemia (ie, hematocrit values significantly above the laboratory reference range). After the induction of anesthesia, appropriate-sized bilateral INVOS 5100 sensors (Somanetics Corp, Troy, MI) were placed on the patient’s forehead. If the rSO2 was unobtainable (failure to display a value on the monitor screen), the probes were removed and placed on the attending anesthesiologist to confirm that the probes and equipment were functional. The probes were replaced onto the patient’s forehead, and again an rSO2 value failed to display. Data collection included demographics, hematocrit, hemodynamic variables, and ventilatory variables, and the presence or absence of rSO2 detection was recorded with every arterial blood gas analysis.

IMPLICATIONS: The authors describe the management of a patient with arrhythmogenic right ventricular dysplasia treated with right ventricular exclusion surgery.

UNLABELLED The glial-derived protein S100B is a serum marker of cerebral ischemia and correlates with negative neurological outcome after cardiopulmonary bypass (CPB) in adults. We sought to characterize the S100B release pattern before and after CPB in neonates and infants with congenital heart disease and correlate it with surgical mortality. Serum was collected before surgery and at 24 postoperative h from 109 neonates and infants with congenital heart disease. All patients had presurgical transthoracic echocardiograms and CPB with or without hypothermic circulatory arrest. S100B concentrations were determined using a two-site immunoluminometric assay (Sangtec 100). Thirty-day surgical mortality was observed. All neonates had significantly increased S100B concentrations before surgery that decreased by 24 postoperative h. Preoperative S100B concentrations in 32 neonates with hypoplastic left heart syndrome correlated inversely with the forward flow and size of the ascending aorta and postoperative mortality (r(2) = -0.63; P = 0.03). Among infants, increased pulmonary blood flow was associated with higher S100B levels before surgery than cyanosis. There was no correlation with postoperative S100B and time on CPB, hypothermic circulatory arrest, or 30-day surgical mortality. In conclusion, preoperative S100B concentrations correlate inversely with the size of the ascending aorta in hypoplastic left heart syndrome and may serve as a marker for preexisting brain injury and mortality. IMPLICATIONS Neonates with hypoplastic left heart syndrome and no forward flow in the ascending aorta may have brain injury at birth before heart surgery.

Objectives To determine the incidence and degree of acute lung reperfusion injury (ARI) in patients undergoing balloon angioplasty of branch pulmonary artery stenosis and to evaluate the correlation and efficacy of an oxygenation index in confirming the clinical diagnosis. Design Retrospective, single-center observational study. Setting Cardiac catheterization laboratory at a tertiary care children’s hospital. Patients Patients with congenital heart disease undergoing pulmonary artery balloon angioplasty. Intervention Review of patient medical and catheterization records. Measurements and Main Results The records of all patients with biventricular physiology undergoing balloon angioplasty of branch pulmonary artery stenosis over a period of 2 years (12/2006-12/2008) were reviewed. Data collection included demographics, details of pulmonary artery intervention, right ventricle/femoral artery systolic pressure (RV/FA) ratio, and post-procedure recovery condition. Markers of ARI, including clinical, radiographic, and blood gas analysis, were examined. Criteria for ARI were based on the International Society of Heart and Lung Transplantation (ISHLT) grading system, in which a PaO 2 /F I O 2 of 200 to 300 indicates ARI. The distribution of PaO 2 /F I O 2 after pulmonary artery intervention, the relation of clinical to laboratory manifestation of ARI, and the correlation among different oxygenation indices were examined. During the study period, 46 patients with congenital heart disease and branch pulmonary artery stenosis were identified. Patient age ranged from 2 months to 25 years (mean 6.2±6 years) and weight ranged from 5 to 86 kg (mean 23±18 kg). ARI was identified in 10 of 46 patients (22%) using clinical criteria and correlated with ISHLT gas exchange criteria. Analysis of RV/FA ratio before (0.82±0.34) and after (0.71±0.22) balloon angioplasty revealed statistically significant decrease (p 2 /F I O 2 ratio had a strong correlation with A-aDO 2 (r = 0.75) and SpO 2 /F I O 2 (r = 0.7) and a strong specificity (0.78) to identify patients with clinical ARI. Conclusion ARI often can occur after pulmonary artery interventions. The PaO 2 /F I O 2 is a valuable test for identifying patients at risk of developing ARI and can help guide the care of these patients in the postintervention period.

The population of children with end-stage heart failure requiring mechanical circulatory support is growing. These children present for diagnostic imaging studies, various interventions and noncardiac surgical procedures that require anesthetic care. This article is a review of the population demographics of children on mechanical cardiac support, the alternative devices available, and the important concepts for safe perioperative management of these patients. The discussion will be limited to devices for short- and long-term cardiac support, excluding extracorporeal membrane oxygenation (ECMO) for respiratory support.

Study Objectives To determine whether the first-attempt tracheal intubation incidence using the GlideScope videolaryngoscope is higher in patients with predicted increased risk of difficult laryngoscopy, and to assess the ability of other a priori defined standard risk factors to predict first-attempt intubation success, in aggregate and by forming scores. Design Prospective study. Setting Operating room in a tertiary-care academic center. Patients 357 patients intubated with the GlideScope for nonemergent general anesthesia. Interventions and Measurements Mallampati airway class was used to create two groups of patients, one with higher and the other, lower, potential difficult laryngoscopy (Mallampati classes 3-4 and 1-2, respectively). Intubation success on the first attempt with the GlideScope videolaryngoscope in patients with a Mallampati class 3 or 4 airway versus those with Mallampati class 1 or 2 airway was tested. We also evaluated the predictive ability of the Mallampati airway class (1 and 2 vs 3 and 4) along with 9 other possible predictors of difficult intubation on first-attempt intubation success: gender, age, body mass index, level of training within our anesthesia residency program (Clinical Anesthesia Resident years 1, 2, and 3), ASA physical status, mouth opening, thyromental distance, neck flexion, and neck extension. Main Results None of the standard predictors of difficult intubation was significantly associated with outcome after adjusting for other predictors. A multivariable model containing the aggregate set of variables predicted outcome significantly better than a risk score formed as the sum of 10 predictors ("Risk 10"; P = 0.0176). Conclusions With GlideScope-assisted tracheal intubation, Mallampati airway class is not an independent risk factor for difficult intubation. Other standard clinical risk factors of difficulty with direct laryngoscopy also do not appear to be individually predictive of first-attempt success of tracheal intubation.