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BACKGROUND Pediatric patients with a mediastinal mass can experience severe complications while undergoing anesthesia. Nearly, all published reviews involve either patients with an anterior mediastinal mass or patients with an oncologic disease. AIM The identification of risk factors for anesthetic-related complications in pediatric patients with any type of mediastinal mass. METHODS From January 1, 2008 to December 31, 2019, patients with a newly diagnosed mediastinal mass that underwent anesthesia were retrospectively identified. Each patient's medical record was reviewed for presenting symptoms, preprocedure imaging results, the type of anesthetic delivered, and the occurrence of any anesthetic-related complications. A complication was defined as severe hypoxia, severe hypotension, or loss of endtidal carbon dioxide. RESULTS Eighty-six patients presented with a new mediastinal mass. Six of these patients (7%) had a complication. Complications were no more likely in patients with orthopnea than in patients without orthopnea (P = 1.00; relative risk (RR) = 0.95; 95% CI (0.1, 7.5). Complication rates in patients with anterior, middle, and posterior mediastinal masses were similar, as were complication rates in patients with large, medium, and small masses. Six of the 41 patients (15%) who had tracheal compression had a complication, while none of the 45 patients (0%) who did not have tracheal compression had a complication (p = .0096). Six of the 48 patients (13%) that were intubated had a complication, while none of the 38 patients (0%) who were not intubated had a complication (p = .032). Five of 36 patients (14%) who had mainstem bronchus compression had a complication, while one of 50 patients (2%) who did not have mainstem bronchus compression had a complication (p = .078; RR = 6.9l; 95% CI (0.8, 56.9)). CONCLUSIONS Anesthetic-related complications were associated with airway compression and endotracheal intubation. The absence of preprocedure orthopnea did not ensure that the anesthetic would be uncomplicated. Complications occurred in similar frequencies in patients with a mediastinal mass of any location or size.

This Regional Spotlight considers the issue of over-tourism and the (ecological) survival of Venice as a destination. In Venice, ecology, economics and culture are inextricably linked to the conflict between human and natural capital. The attempts to neatly arrange the challenges in sustaining the city, convenient categorical interest groups and occasional hostility in implementing policies call for an ambidextrous management approach (exploitation and exploration) instead of the Trexit approach suggested by the anti-tourism movements.

Background: The UK will develop new trading relationships after separating from the European Union (EU). Although the Comprehensive Economic and Trade Agreement (CETA) between Canada and the EU will remain in effect with the UK over a transition period post-Brexit, a new Canada-UK trade agreement could eventually replace it. Furthermore, any new international trade agreements are an opportunity for developing a worldwide circular economy, eliminating waste while supporting social justice. Thus, the new trade agreement between Canada and the UK could be precedent-setting in regards to engendering a worldwide circular economy. Objectives and Methodology: Through a literature review focusing on academic journal articles, this report investigates existing trade theory and trade agreements regarding circular economy principles to inform the design and implementation of future trade agreements between Canada and the UK, post-Brexit. This report identifies gaps in that knowledge base and recommends future research that may facilitate Canada-UK circular economy trade. A recent OECD report lays out a framework conceptualizing the potential usefulness of circular economy trade and calls for more research on the subject (Yamaguchi, 2018). The report proposes various linkages or interfaces along international value chains where circular economy dynamics could be facilitated by international trade. This coincidence of similar thought between the OECD and the researchers of this report implies the importance and relevance of research into the role trade may have as part of a global circular economy. By primarily reviewing existing academic literature, we provide an overview of five themes consequential for the design and implementation of circular economy trade agreements including: 1) inputs to trade agreement design such as the experience with CETA, design elements of circular economy trade agreements in respect of, 2) governance, 3) and tariffs and non-tariff barriers, and some outputs of circular economy trade as related to, 4) technology and cross-border trade also leading to, 5) sustainability and prosperity. A conceptual framework pictorially shows the linkages among this report’s themes. A literature review was conducted from both Canadian and UK perspectives. As well, researchers from both countries found experts across government, academia, and industry to validate and provide feedback on a draft version of the review. These experts, acknowledged in a list in an appendix, were asked to read self-selected sections based on their expertise. In some cases, the interviewees voluntarily read the entire draft. Their helpful and voluntary anonymous feedback has either been incorporated into the report as changes to the draft document or included as combined and summarized bullet point comments in an appendix. After finalizing the report as the main output of this endeavor, the researchers created a list of the key takeaways and gaps in literature important for moving ahead with UK-Canada circular economy trade post-Brexit. Some highlighted takeaways are mentioned in this executive summary and in the conclusions section. Because this work is extensive, the appendix holds a more comprehensive list of takeaways and research questions. Results and Key Messages: In regards to identifying key takeaways and gaps in the literature for the eventual development of a post-Brexit U.K.-Canada trade agreement that includes circular economy principles, this summary highlights key messages and suggestions for future research. Overall, we found recognition in the literature and in interviewee responses that a future UK-Canada trade agreement could support circular economy trade. Sustainable aspects of the Canada-Europe trade agreement (CETA) could represent a foundation. However, the CETA chapters regarding sustainability do not explicitly refer to the circular economy and any future trade agreement might review and revise sections to include circularity. In a future bilateral trade agreement, additional consideration for resource and waste management, as well as design collaboration is required. Science-based case research could clarify the full cost environmental impact of activities such as resource and waste management in the context of trade. An evidence-based understanding of such activities in a global circular economy trade context is not readily available. Moreover, evidence for the gains from circular trade could be addressed in future research. This same research could first establish a baseline with an investigation of the existing dynamics between Canada, the U.K., and other countries and then investigate how a circular economy approach could be motivated. Another suggested area of study is the examination of negotiating conditions for circular economy trade. For example, the structure of the working groups involved in the negotiations could facilitate or hinder increasingly complex negotiations. Also, stakeholder interests and representation in negotiations is an important area of consideration. This issue has arisen in the past as related to difficulties in the adoption of terms governed by subnational levels when they have not been satisfactorily represented in negotiations. Moreover, research could clarify which industries are most prepared to engage in circular economy trade to increase the likelihood of implementation. How the negotiations could best include industry representatives could be incorporated into stakeholder research. For example, advanced manufacturing may be of strategic interest to both nations and this industry influenced by ISO standards may embrace waste reduction and increased efficiencies and cost savings in processes. Negotiations should also focus on the clarity of the agreement and enforcement mechanisms. Terminology and transparency are crucial elements in future international trade agreements between the UK and Canada. For example, a common understanding of circularity must be consistently communicated and applied across industries and between countries. In addition, negotiations should take into account both a formal trade agreement and complementary non-trade treaties. Also, negotiators should be cognizant that well-structured trade agreements can lead to reduced trade volatility through tighter integration of the respective economies. Furthermore, the complexity of issue linkage in trade agreements would likely increase when incorporating circularity across industry sectors and countries so this needs consideration. The clarity of the agreement and the ability to enforce it is also in tension with complex issue linkages. Ultimately, both sides will want to develop scenarios for how negotiation strategies could lead to gains from trade and foreign direct investment across sectors. Finally, a common view discovered through the interviews is that countries do not typically add new terms to trade agreements unrelated to existing national agendas and activities. Thus, a circular economy trade agreement is unlikely unless all parties to the agreement are already on a path to waste reduction and sustainability. Such agreements may formally reinforce and normalize a global circular economy.

ACADEMIC EMERGENCY MEDICINE 2012; 19:361–364 © 2012 by the Society for Academic Emergency Medicine Abstract Background: No single confirmatory device can accurately distinguish between endotracheal, endobronchial, and esophageal intubation. Bedside ultrasound (US) shows promising potential for endotracheal tube (ETT) verification. Image acquisition depends on the approach used and the experience of the sonographer. Air within the trachea remains a challenge for interpretation of US images. Insufflation of the ETT cuff with saline helps overcome this difficulty and allows easy visualization of the cuff. This novel approach has not been studied in ETT verification among novice sonographers. Objectives: The objective was to evaluate the accuracy of novice sonographers in identifying proper ETT location and depth using US visualization of a saline-filled cuff. Methods: Eight pediatric emergency medicine (PEM) fellows without prior training in airway bedside US participated in this prospective pilot study. Baseline US knowledge was assessed using a pretraining questionnaire. Fellows received a 20-minute didactic training session focused on airway US, followed by a 30-minute practice session. Using a linear US probe placed at the suprasternal notch, fellows identified the saline-filled cuff of an ETT in both the trachea and the esophagus. Following training, the ETT was placed in either the esophagus or the trachea of the cadaver model by the principal investigator. ETT depth (adequacy) was confirmed by chest radiograph. Each PEM fellow, blinded to the placement of the ETT, used bedside US to determine ETT location and depth. If placement was determined to be tracheal, the fellow was asked to comment on adequacy of tube placement. Adequate placement was defined as complete visualization of the ETT cuff within the trachea at the suprasternal notch. This was used as a surrogate for correct depth. This study sequence was repeated five times for each trainee, following varying placement of the ETT in the trachea or esophagus. Results: The PEM fellows displayed limited baseline knowledge of US prior to receiving the training module (average score of 50% on pretest questionnaire). None had any prior airway bedside US experience. Following training, PEM fellows correctly identified ETT location in 39 of 40 scans, with a sensitivity of 96% (23 of 24) for identifying tracheal location. The tube depth was correctly identified in 22 of 23 scans identified as tracheal intubations. Conclusions: PEM fellows, lacking formal airway bedside US training, were able to identify the location and depth of a saline-filled ETT above or at the suprasternal notch in an adult cadaver model following a 50-minute teaching module. Filling the ETT cuff with saline allowed novice sonographers to accurately visualize the ETT within the trachea.

HISTORY OF PRESENT ILLNESS A 14-year-old White girl who weighed 38 kg (5th percentile) and whose height was 147.3 cm (3rd percentile) presented with a 5-day history of periumbilical abdominal pain, non-bilious emesis, fatigue, and intermittent low-grade temperatures. While at school, the nurse noted that she had an unsteady gait and purple discoloration of her lips and hands. She was sent home to seek medical attention. The only ill contact was a sister, who had flu-like symptoms the previous week.

OBJECTIVE. Sedating critically ill patients often involves prolonged opioid infusions causing opioid tolerance. Naloxone has been hypothesized to limit opioid tolerance by decreasing adenylate cyclase/cyclic adenosine monophosphate activation. The study purpose was to investigate the effect of low-dose naloxone on the maximum cumulative daily fentanyl dose in critically ill children. METHODS. We conducted a double-blinded, randomized, placebo-control trial from December 2002 through July 2004 in a university PICU. We enrolled 82 children age 1 day to 18 years requiring mechanical ventilation and fentanyl infusions anticipated to last for >4 days were eligible for enrollment. Those receiving additional oral analgesia or sedation, having a history of drug dependence or withdrawal, or having significant neurologic, renal, or hepatic disease were excluded. In addition to fentanyl infusions, patients received low-dose naloxone or placebo infusions. Medications were adjusted using the Modified Motor Activity Assessment Scale. Withdrawal was monitored using the Modified Narcotic Withdrawal Scale. Intervention was a low-dose naloxone infusion (0.25 μg/kg per hour) and the main outcome variable was the maximum cumulative daily fentanyl dose (micrograms per kilogram per day). RESULTS. There was no difference in the maximum cumulative daily fentanyl dose between patients treated with naloxone (N = 37) or those receiving placebo (N = 35). Adjustment for the starting fentanyl dose also failed to reveal group differences. Total fentanyl dose received throughout the study in the naloxone group (360 μg/kg) versus placebo (223 μg/kg) was not statistically different. Placebo patients trended toward fewer rescue midazolam boluses (10.7 vs 17.8), lower total midazolam dose (11.6 mg/kg vs 23.9 mg/kg), and fewer rescue fentanyl boluses (18.5 vs 23.9). CONCLUSIONS. We conclude that administration of low-dose naloxone (0.25 μg/kg per hour) does not decrease fentanyl requirements in critically ill, mechanically ventilated children.

We reviewed the current state of knowledge regarding pediatric sedation mainly for nonpainful procedures, such as MRI studies. The increasing number of requests for pediatric sedation has triggered intense research for finding various solutions that would enable the safe administration of sedation by nonanesthesiologist physicians, supervised trained nursing personnel (CRNAs and/or RNs), or sedation teams combining different provider types. We also reviewed the current data on the use of dexmedetomidine in children, as a sedative agent in the MRI suite. Dexmedetomidine is an excellent sedative, has analgesic properties, and appears to be clinically safe from a respiratory point of view even at high doses, although instances of bradycardia and hypotension have been reported. Dexmedetomidine appears to be a promising option for sedation in the pediatric population in the MRI setting.

OBJECTIVE. The physiologic responses to chloral hydrate sedation in the setting of a pediatric echocardiography laboratory have not been well documented; neither has the population at risk been identified adequately. The purpose of this study was to describe the physiologic responses to chloral hydrate sedation, to report the occurrence of adverse events, and to identify any risk factors that predicted these adverse events in children who underwent sedation for echocardiography at our institution.METHODS. We analyzed retrospectively 1095 patients who were sedated for echocardiography. Vital signs and oxygen saturations were recorded every 5 minutes, and adverse events were noted. Potential risk factors for sedation-related adverse events were analyzed.RESULTS. Thirty-eight percent of patients were classified as American Society of Anesthesiologists class 3 or 4, reflecting the significant comorbidity in the study population. Hemodynamic responses to chloral hydrate sedation included ≥20% decreases in heart rate (24% of the patients) and blood pressure (59% of the patients). There were no deaths or permanent morbidity. Adverse events occurred in 10.8% of patients and included apnea (n = 3 [0.3%]), airway obstruction (n = 15 [1.4%]), hypoxia (n = 65 [5.9%]), hypercarbia (n = 40 of 603 [6.6%]), hypotension with poor perfusion (n = 4 [0.4%]), vomiting (n = 4 [0.4%]), and prolonged sedation (n = 36 [3.3%]). No intervention was required in 92.5%, minor interventions were necessary in 7%, and major interventions were required in 0.5% of all patients. Multivariate analysis identified only age younger than 6 months as a predictor for adverse events, whereas cyanosis, hospitalization, American Society of Anesthesiologists class, fasting time, oxygen requirement, and use of additional sedation were not predictors.CONCLUSIONS. Moderate decreases in heart rate and blood pressure, in the absence of clinical deterioration, are expected responses to chloral hydrate sedation in this pediatric population. The majority of adverse events were minor, and major events were uncommon. Infants who were younger than 6 months were found to be at higher risk for serious adverse events.

Calcium channel blocker (CCB) toxicity is associated with refractory hypotension and can be fatal. A 13 year old young woman presented to the emergency department(ED) six hours after an intentional overdose of amlodipine, barbiturates, and alcohol. She remained extremely hypotensive despite the administration of normal saline and calcium chloride and despite infusions of norepinephrine, epinephrine, insulin, and dextrose. Due to increasing evidence of end organ dysfunction, Extracorporeal Life Support (ECLS) was initiated 9 hours after presentation to the ED. The patient's blood pressure and end organ function immediately improved after cannulation. She was successfully decannulated after 57 hours of ECLS and was neurologically intact. Patients with calcium channel blocker overdose who are resistant to medical interventions may respond favorably to early ECLS.

To report withdrawal symptoms experienced by an infant following the prolonged use of dexmedetomidine.Case report.Pediatric intensive care unit at a freestanding tertiary care children's hospital.One pediatric patient with respiratory failure following pertussis infection that required prolonged intubation and sedation. The patient required dexmedetomidine to maintain optimal sedation before ventilator weaning. Subsequent to receiving dexmedetomidine the patient developed withdrawal symptoms.In patients who fail to achieve adequate sedation with the use of traditional medications, dexmedetomidine is an adequate alternative. However, abrupt discontinuation of dexmedetomidine may result in withdrawal symptoms that may be avoided with a dexmedetomidine taper.

We recently saw two unusual manifestations of Haemophilus influenzae infection in adults in the Seattle area: fulminant sepsis in an otherwise-healthy man and three episodes of bacteremia in a woman with chronic liver disease. We retrospectively identified 79 bacteremic and 40 non-bacteremic cases of invasive H. influenzae infection developing in patientsor = 9 years of age between 1 January 1980 and 31 December 1990. The most common clinical presentations among patients with bacteremia included pneumonia (52%), septicemia (27%), meningitis (8%), gynecologic infection (5%), and epiglottitis (5%). Underlying illnesses were common in these patients, and overall mortality was 35.5%. Factors associated with mortality included underlying neurological disease, polymicrobial bacteremia, and advanced age. The clinical presentations of the 40 patients without bacteremia included soft-tissue abscesses (45%), lung abscesses (18%), peritonitis (13%), meningitis (8%), gynecologic infection (8%), epididymitis (5%), mastoiditis (3%), and osteomyelitis (3%). Thus H. influenzae disease has a variety of presentations and is associated with significant mortality in older children and adults. Further study is required to determine whether widespread administration of H. influenzae type b conjugate vaccine to infants will alter the development of subsequent disease in later life.

To compare the efficacy of a low-dose methadone tapering schedule to a high-dose methadone tapering schedule in pediatric intensive care unit patients exposed to infusions of fentanyl, with or without infusions of midazolam, for ≥ 5 days.Prospective, double-blind, randomized trial.Pediatric intensive care unit in a tertiary care children's hospital.Seventy-eight patients, 74 of whom had been receiving infusions of both fentanyl and midazolam, were randomized. Forty-one patients were randomized to the low-dose methadone group and 37 were randomized to the high-dose methadone group. Sixty patients successfully completed the trial, 34 were in the low-dose methadone group, and 26 were in the high-dose methadone group.Patients were randomized to receive methadone either at a starting dose of 0.1 mg/kg/dose (low-dose methadone group) or at a starting dose based on both the patient's weight and the most recent fentanyl infusion rate (high-dose methadone group). In each group, methadone was administered every 6 hrs for the first 24 hrs and then every 12 hrs for the second 24 hrs. The methadone was then decreased to once daily and tapered off over the next 10 days. Patients were monitored for withdrawal symptoms using the Modified Narcotic Withdrawal Score.The percentage of patients who successfully completed the 10-day methadone taper was the same in the low-dose methadone group as in the high-dose methadone group (56% vs. 62%; p = .79). Patients that failed to complete the assigned methadone taper had a greater total fentanyl dose and longer pediatric intensive care unit length of stay compared to patients who completed the assigned methadone taper.Patients who received infusions of fentanyl for at least 5 days were just as likely to complete a low-dose methadone taper as a high-dose methadone taper. Because of the risks of both withdrawal and oversedation with any fixed methadone schedule, the methadone dose must be adjusted according to each patient's response.

Forty-one previously healthy children

Systemic IL-6, IL-8, and RANTES Response in Children with Respiratory Syncytial Virus Disease