Neuroblastoma in Children: Intraoperative Goal Directed Therapy, Intraoperative and Postoperative Outcomes

Background: Neuroblastoma is the most common tumor in children. Anesthetic management can be challenging due to the localization and catecholamine-secreting characteristics of the tumor. We undertook a secondary analysis in a previous study to describe patients who underwent neuroblastoma resection. Objective: To describe intraoperative and postoperative outcomes in patients who underwent neuroblastoma resection and to propose optimal intraoperative management for postoperative outcome improvement. Methods: This was a secondary analysis of children who underwent neuroblastoma resection in the initial retrospective study. Results: There were 16 patients with a mean age of 39.3 ± 22.1 months. Seven (43.8%) patients presented with intraoperative or postoperative complications. One (6.3%) patient had intraoperative broncho-laryngospasm and difficult intubation. Two (12.5%) patients had intraoperative hemorrhagic shock. One patient (6.3%) had postoperative renal failure. Two patients (12.5%) had postoperative respiratory failure, and 3 (18.8%) patients had postoperative cardiocirculatory failure. One (6.3%) had postoperative pulmonary sepsis and septicemia. Thirteen (81.3%) patients were intraoperatively transfused. There was no in-hospital mortality. Conclusion: In this cohort, 43.8% of the patients had intraoperative and or postoperative complications in terms of organ dysfunction or sepsis. 81.3% of the patients received intraoperative transfusion. Neuroblastoma surgery can be a challenging situation where cardiovascular instability, high blood loss and transfusion requirements can be encountered. Consequently, preoperative preparation and optimal intraoperative management with validated tools in children could be necessary for a better postoperative outcome in this surgical setting.

The Effect of Non-Invasive Goal Directed Fluid Administration on Graft Function in Deceased Donor Renal Transplantation: A Pilot Study

Background: Non-invasive goal directed fluid therapy during deceased donor renal transplant (CRT) may reduce the incidence of delayed graft function. Plethysmograph Variability Index (PVI) has been shown to predict fluid responsiveness during surgery. This pilot study evaluated the feasibility of goal directed fluid administration protocol based upon PVI studying the incidence of delayed graft function (DGF) in renal transplant recipients. Methods: Twenty patients underwent primary CRT. The Control group received intravenous fluid (IVF) at a calculated constant rate. The Treatment group received a baseline IVF infusion throughout the surgery. PVI values greater than 13% were treated with 250 ml boluses of IVF. Primary end point was DGF;total IVF administration and urinary biomarker NGAL levels were secondary endpoints. Results: Treatment group at every time point received significantly less IVF. There was no significant difference in incidence of DGF between the groups. 2 patients in the Control group and 6 in the Treatment group developed DGF. NGAL was not associated with the group assignment or total IVF given (p < 0.2). Conclusions: The effectiveness of goal directed fluid therapy with non-invasive dynamic parameters has not been validated in renal transplant surgery and larger prospective studies are needed to determine its utility in renal transplantation.

Comparing a non-invasive hemodynamic monitor with minimally invasive monitoring during major open abdominal surgery

As part of the enhanced recovery after surgery （ERAS） protocol, the goal-directed fluid management with hemodynamic monitoring can effectively guide perioperative fluid use and significantly improve the outcomes in highrisk patients undergoing major surgeries. Several minimally invasive and non-invasive monitoring devices are commercially available for clinical use. As part of an internal evaluation, we reported the results from three different hemodynamic monitoring devices used in a patient undergoing a major abdominal surgery.

Veno-Venous Extra-Corporeal Membrane Oxygenation (ECMO) in a Child with Hemoptysis and Fontan Circulation

Background: Extracorporeal membrane oxygenation is a rescue life support technique used in life threatening conditions of refractory respiratory and/or cardiac distress. Indication for extracorporeal life support in children depends on age and varies from pulmonary to cardiac pathologies. In some cases, it may be used as a bridge to a therapeutic procedure. We described here the management of respiratory failure due to hemoptysis in a child with a Fontan circulation and veno-venous extracorporeal membrane oxygenation which served as a bridge to angio-embolization. Hemoptysis can be a life threatening condition which can lead to hypovolemic shock and impaired alveolar gas exchange. The latter can result in respiratory failure and consequent asphyxia. When hemoptysis occurs in a patient with a univentricular heart and a Fontan circulation, management of this clinical situation can be challenging due to the particular physiology of the latter. Total cavopulmonary connection is a palliative surgical repair which constitutes Fontan circulation as a definitive treatment in patients with a univentricular heart. Methods: Case report description of a 16 year-old boy with a univentricular heart and a Fontan circulation who presented hemoptysis managed with a veno-venous extracorporeal membrane oxygenation (ECMO) as a bridge to angio-embolization. Results: Hemoptysis due to diffuse intra-alveolar hemorrhage from collateral circulation was successfully treated in this young patient with pulmonary vascular embolization. This allowed to wean the patient from extra-corporeal membrane oxygenation. Conclusion: Veno-venous ECMO can be life-saving as a bridge to angio-embolization for severe hemoptysis in patients with Fontan circulation. The reported case allows to underline that our multidisciplinary approach in this complex pediatric patient surely participated to improve outcome.

Early Goal Directed Sedation, a bridge to better clinical outcomes

Critical care has become a central part of modern medicine and an integral essential to improve the outcomes in acute care.The increasing complexity of surgical procedures,severity of co-morbid diseases,life expectancy and societal expectation is likely to escalate the burden and the global need for critical care resources.While millions of patients are ventilated worldwide every year,projections suggest that the number of ventilated patients is expected to rise by 31% over the following decade.1