Efficacy of aprotinin in children undergoing craniofacial surgery

2003 ◽  
Vol 99 (2) ◽  
pp. 287-290 ◽  
Author(s):  
Celia C. D'Errico ◽  
Hamish M. Munro ◽  
Steven R. Buchman ◽  
Deborah Wagner ◽  
Karin M. Muraszko
Keyword(s):  
Placebo Group ◽  
Blood Transfusion ◽  
Pediatric Patients ◽  
Craniofacial Surgery ◽  
Blood Transfusions ◽  
Double Blind ◽  
Craniofacial Reconstruction ◽  
Content Type ◽  
Transfusion Requirements ◽  
Fine Print

Object. This prospective, randomized, placebo-controlled, double-blind trial was undertaken to assess the efficacy of aprotinin in reducing the need for blood transfusions in 39 children undergoing reconstructive craniofacial surgery. Methods. Two demographically similar groups—a total of 39 patients with a mean age of 1.2 ± 1.2 years—were studied. The efficacy of aprotinin (240 mg/m2 administered intravenously over 20 minutes, followed by infusions of 56 mg/m2/hr) was compared with that of an equal infusion of 0.9% saline (placebo). Patients in the aprotinin group received less blood per kilogram of body weight than patients in the placebo group (32 ± 25 ml/kg compared with 52 ± 34 ml/kg, respectively; p = 0.04). Those patients in whom aprotinin was administered experienced less change in their hematocrit levels during surgery (aprotinin −33 ± 13% compared with placebo −44 ± 9%, p = 0.01). Each patient underwent a transfusion as per study protocol, and there was no significant change in hematocrit levels from the beginning to the end of surgery. The surgical faculty judged blood loss in patients in the aprotinin group to be significantly less than usual (p = 0.03). The use of aprotinin was also associated with reduced blood transfusion requirements during the first 3 postoperative days (p = 0.03). There was no adverse event reported in either the aprotinin or placebo group. Conclusions. Aprotinin decreased blood transfusion requirements in pediatric patients undergoing craniofacial reconstruction, thereby reducing the risks associated with exposure to banked blood components.

Increased hematocrit and decreased transfusion requirements in children given erythropoietin before undergoing craniofacial surgery

1998 ◽  
Vol 88 (4) ◽  
pp. 704-708 ◽  
Author(s):  
Mark A. Helfaer ◽  
Benjamin S. Carson ◽  
Carol S. James ◽  
Judy Gates ◽  
David Della-Lana ◽  
...  
Keyword(s):  
Elective Surgery ◽  
Clinical Situation ◽  
Craniofacial Surgery ◽  
Blood Transfusions ◽  
Content Type ◽  
Time Of Surgery ◽  
Transfusion Requirements ◽  
Complete Blood Counts ◽  
The Individual ◽  
Fine Print

Object. This study was undertaken to determine the efficacy of preoperative erythropoietin administration in infants scheduled for craniofacial surgery and, in so doing, to minimize problems associated with blood transfusions. Methods. Families were offered the option of having their children receive erythropoietin injections before undergoing craniofacial surgery. The children whose families accepted this option received daily iron and 300 U/kg erythropoietin three times per week for 3 weeks preoperatively. Weekly complete blood counts with reticulocyte counts were measured and transfusion requirements were noted. Blood transfusions were administered depending on the clinical condition of the child. A case-matched control population was also evaluated to compare initial hematocrit levels and transfusion requirements. Thirty patients in the erythropoietin treatment group and 30 control patients were evaluated. The dose of erythropoietin administered was shown to increase hematocrit levels from 35.4 ± 0.9% to 43.3 ± 0.9% during the course of therapy. The resulting hematocrit levels in patients treated with erythropoietin at the time of surgery were higher compared with baseline hematocrit levels obtained in control patients at the time of surgery (34.2 ± 0.5%). Transfusion requirements also differed: all control patients received transfusions, whereas 64% (19 of 30) of erythropoietin-treated patients received transfusions. Conclusions. The authors conclude that treatment with erythropoietin in otherwise healthy young children will increase hematocrit levels and modify transfusion requirements. Erythropoietin therapy for elective surgery in children of this age must be individualized according to the clinical situation, family and physician beliefs, and cost effectiveness, as evaluated at the individual center.

A randomized placebo-controlled double-blind trial of nimodipine after SAH in monkeys

1984 ◽  
Vol 60 (6) ◽  
pp. 1167-1175 ◽  
Author(s):  
Francisco Espinosa ◽  
Bryce Weir ◽  
Thomas Overton ◽  
William Castor ◽  
Michael Grace ◽  
...  
Keyword(s):  
Placebo Group ◽  
Autologous Blood ◽  
Neurological Status ◽  
Anterior Circulation ◽  
Double Blind ◽  
Content Type ◽  
Average Percentage ◽  
Before And After ◽  
Chronic Cerebral Vasospasm ◽  
Fine Print

✓ The authors have developed a method to induce chronic cerebral vasospasm after subarachnoid hemorrhage (SAH) in monkeys. With microsurgical techniques, 33 monkeys had a frontotemporal craniectomy and unilateral opening of the subarachnoid cisterns. Cerebrospinal fluid was drained and a fresh hematoma, obtained from an average of 7 ml of autologous blood, was carefully placed against the major arteries of the anterior circulation on one side. The 30 monkeys studied for 7 to 14 days after the SAH were allocated randomly to two treatment groups of 15: one group received placebo and the other nimodipine, 1 mg/kg every 8 hours. Indices monitored before and after SAH included neurological status, cerebral blood flow, computerized tomography, and angiographic vessel caliber. In the placebo group, delayed ischemic neurological deficit developed in one monkey 4 days after clot placement and was present at sacrifice on Day 14. No such deficit occurred in the nimodipine group. The effect of nimodipine on vessel caliber at this dosage was equivocal. Significant vasospasm (31% to 100% reduction in vessel caliber) developed in 87% (26 of 30) of the animals. Overall, vasospasm was slightly more common in the placebo group: in this group, on Days 7 and 14, the incidence of vasospasm was significantly higher (p < 0.05) than in the nimodipine group. However, the average percentage reduction in vessel caliber of the maximally constricted vessel in each monkey was not significantly different between the two groups.

Phenytoin and postoperative epilepsy

1983 ◽  
Vol 58 (5) ◽  
pp. 672-677 ◽  
Author(s):  
J. Brian North ◽  
Robert K. Penhall ◽  
Ahmad Hanieh ◽  
Derek B. Frewin ◽  
William B. Taylor
Keyword(s):  
Head Injury ◽  
High Risk ◽  
Seizure Control ◽  
Active Drug ◽  
Double Blind Trial ◽  
Double Blind ◽  
Content Type ◽  
Routine Prophylaxis ◽  
Risk Patients ◽  
Fine Print

✓ A double-blind trial of phenytoin therapy following craniotomy was performed to test the hypothesis that phenytoin is effective in reducing postoperative epilepsy. A significant reduction in the frequency of epilepsy was observed in the group receiving the active drug up to the 10th postoperative week. Half of the seizures occurred in the first 2 weeks and two-thirds within 1 month of cranial surgery. High rates of epilepsy were observed after surgery in patients with meningioma, metastasis, aneurysm, and head injury. Routine prophylaxis with phenytoin (in a dosage of 5 to 6 mg/kg/day) would seem to be indicated, particularly in high-risk patients and, where possible, this treatment should be started 1 week preoperatively. Seizure control is best when therapeutic levels of phenytoin are maintained.

No effect of enoxaparin on outcome of aneurysmal subarachnoid hemorrhage: a randomized, double-blind, placebo-controlled clinical trial

2003 ◽  
Vol 99 (6) ◽  
pp. 953-959 ◽  
Author(s):  
Jari Siironen ◽  
Seppo Juvela ◽  
Joona Varis ◽  
Matti Porras ◽  
Kristiina Poussa ◽  
...  
Keyword(s):  
Clinical Trial ◽  
Molecular Weight ◽  
Subarachnoid Hemorrhage ◽  
Low Molecular Weight Heparin ◽  
Aneurysmal Subarachnoid Hemorrhage ◽  
Intracranial Bleeding ◽  
Low Molecular Weight ◽  
Double Blind ◽  
Content Type ◽  
Fine Print

Object. From the moment an intracranial aneurysm ruptures, cerebral blood flow is impaired, and this impairment mainly determines the outcome in patients who survive after the initial bleeding. The exact mechanism of impairment is unknown, but activation of coagulation and fibrinolysis correlate with clinical condition and outcome after aneurysmal subarachnoid hemorrhage (SAH). The purpose of this study was to determine whether enoxaparin, a low-molecular-weight heparin, which is a well-known anticoagulating agent, has any effect on the outcome of aneurysmal SAH postoperatively. Methods. In this randomized, double-blind, single-center clinical trial, 170 patients (85 per group) with aneurysmal SAH were randomly assigned to receive either enoxaparin (40 mg subcutaneously once daily) or a placebo, starting within 24 hours after occlusion of the aneurysm and continuing for 10 days. Analysis was done on an intention-to-treat basis. Outcome was assessed at 3 months on both the Glasgow Outcome and modified Rankin Scales. Patients were eligible for the study if surgery was performed within 48 hours post-SAH, and no intracerebral hemorrhage was larger than 20 mm in diameter on the first postoperative computerized tomography scan. At 3 months, there were no significant differences in outcome by treatment group. Of the 170 patients, 11 (6%) died, and only 95 (56%) had a good outcome. Principal causes of unfavorable outcome were poor initial condition, delayed cerebral ischemia, and surgical complications. There were four patients with additional intracranial bleeding in the group receiving enoxaparin. The bleeding was not necessarily associated with the treatment itself, nor did it require treatment, and there were no such patients in the placebo group. Conclusions. Enoxaparin seemed to have no effect on the outcome of aneurysmal SAH in patients who had already received routine nimodipine and who had received triple-H therapy when needed. Routine use of low-molecular-weight heparin should be avoided during the early postoperative period in patients with SAH, because this agent seems to increase intracranial bleeding complications slightly, with no beneficial effect on neurological outcome.

Total calvarial reconstruction for sagittal synostosis in older infants and children

1993 ◽  
Vol 78 (2) ◽  
pp. 199-204 ◽  
Author(s):  
Roger J. Hudgins ◽  
Fernando D. Burstein ◽  
William R. Boydston
Keyword(s):  
Blood Loss ◽  
Craniofacial Surgery ◽  
Acute Blood Loss ◽  
Skull Defect ◽  
Sagittal Suture ◽  
Sagittal Synostosis ◽  
Content Type ◽  
Biparietal Diameter ◽  
Postoperative Hyponatremia ◽  
Fine Print

✓ Premature closure of the sagittal suture is the most common form of craniosynostosis, but this condition occasionally goes unrecognized until the child is too old to undergo procedures that depend upon continued calvarial growth for success. As the entire calvaria is affected and thus misshapen by sagittal synostosis, late correction involves total calvarial reconstruction. The extensive nature of this undertaking has precluded its utilization despite the presence of significant deformities. Adapting the techniques and experience gained from craniofacial surgery, the authors performed total calvarial reconstruction on nine children with sagittal synostosis and subsequent scaphocephaly diagnosed after the age of 1 year. In each case the goals of shortening the anteroposterior length, widening the biparietal diameter, and reducing frontal and occipital deformities were met. Morbidity consisted of acute blood loss, postoperative hyponatremia, and in one case a residual skull defect. The rationale for this procedure and the techniques utilized are discussed.

Facial nevi associated with anomalous venous return and hydrocephalus

1976 ◽  
Vol 45 (1) ◽  
pp. 20-25 ◽  
Author(s):  
Kenneth Shapiro ◽  
Kenneth Shulman
Keyword(s):  
Pediatric Patients ◽  
Venous Return ◽  
Venous Hypertension ◽  
Communicating Hydrocephalus ◽  
Age Group ◽  
Content Type ◽  
Weber Syndrome ◽  
Sturge Weber Syndrome ◽  
The Relationship ◽  
Fine Print

✓ The authors describe two children with anomalous intracranial venous return associated with bilateral facial nevi, macrocrania, and cephalic venous hypertension. Both children had functional absence of the jugular bulbs, forcing the intracranial venous effluent to exit through persistent emissary pathways. Both children had sustained intracranial hypertension, with one child developing symptomatic communicating hydrocephalus that responded satisfactorily to shunting. The relationship between these patients and those with Sturge-Weber syndrome is discussed. The embryologic abnormality producing the anomalous venous return is characterized. The link between venous hypertension and the development of hydrocephalus is discussed. The increased cranial compliance seen in this age group may predispose certain pediatric patients to develop hydrocephalus when stressed by venous hypertension.

Intracranial hypertension and cerebral perfusion pressure: influence on neurological deterioration and outcome in severe head injury

2000 ◽  
Vol 92 (1) ◽  
pp. 1-6 ◽  
Author(s):  
Niels Juul ◽  
Gabrielle F. Morris ◽  
Sharon B. Marshall ◽  
_ _ ◽  
Lawrence F. Marshall
Keyword(s):  
Head Injury ◽  
Intracranial Hypertension ◽  
Cerebral Perfusion Pressure ◽  
Cerebral Perfusion ◽  
Severe Head Injury ◽  
Perfusion Pressure ◽  
Neurological Deterioration ◽  
Double Blind ◽  
Content Type ◽  
Fine Print

Object. Recently, a renewed emphasis has been placed on managing severe head injury by elevating cerebral perfusion pressure (CPP), which is defined as the mean arterial pressure minus the intracranial pressure (ICP). Some authors have suggested that CPP is more important in influencing outcome than is intracranial hypertension, a hypothesis that this study was designed to investigate.Methods. The authors examined the relative contribution of these two parameters to outcome in a series of 427 patients prospectively studied in an international, multicenter, randomized, double-blind trial of the N-methyl-d-aspartate antagonist Selfotel. Mortality rates rose from 9.6% in 292 patients who had no clinically defined episodes of neurological deterioration to 56.4% in 117 patients who suffered one or more of these episodes; 18 patients were lost to follow up. Correspondingly, favorable outcome, defined as good or moderate on the Glasgow Outcome Scale at 6 months, fell from 67.8% in patients without neurological deterioration to 29.1% in those with neurological deterioration. In patients who had clinical evidence of neurological deterioration, the relative influence of ICP and CPP on outcome was assessed. The most powerful predictor of neurological worsening was the presence of intracranial hypertension (ICP ≥ 20 mm Hg) either initially or during neurological deterioration. There was no correlation with the CPP as long as the CPP was greater than 60 mm Hg.Conclusions. Treatment protocols for the management of severe head injury should emphasize the immediate reduction of raised ICP to less than 20 mm Hg if possible. A CPP greater than 60 mm Hg appears to have little influence on the outcome of patients with severe head injury.

Anatomical suitability of C1–2 transarticular screw placement in pediatric patients

2000 ◽  
Vol 92 (1) ◽  
pp. 7-11 ◽  
Author(s):  
Douglas L. Brockmeyer ◽  
Julie E. York ◽  
Ronald I. Apfelbaum
Keyword(s):  
Pediatric Patients ◽  
Screw Fixation ◽  
Vascular Complications ◽  
Screw Placement ◽  
Atlantoaxial Instability ◽  
Os Odontoideum ◽  
Transarticular Screw ◽  
Content Type ◽  
Transarticular Screw Fixation ◽  
Fine Print

Object. Craniovertebral instability is a challenging problem in pediatric spinal surgery. Recently, C1–2 transarticular screw fixation has been used to assist in craniovertebral joint stabilization in pediatric patients. Currently there are no available data that define the anatomical suitability of this technique in the pediatric population. The authors report their experience in treating 31 pediatric patients with craniovertebral instability by using C1–2 transarticular screws. Methods. From March 1992 to October 1998, 31 patients who were 16 years of age or younger with atlantooccipital or atlantoaxial instability, or both, were evaluated at our institution. There were 21 boys and 10 girls. Their ages ranged from 4 to 16 years (mean age 10.2 years). The most common causes of instability were os odontoideum (12 patients) and ligamentous laxity (eight patients). Six patients had undergone a total of nine previous attempts at posterior fusion while at outside institutions. All patients underwent extensive preoperative radiological evaluation including fine-slice (1-mm) computerized tomography scanning with multiplanar reconstruction to evaluate the anatomy of the C1–2 joint space. Preoperatively, of the 62 possible C1–2 joint spaces in 31 patients, 55 sides (89%) were considered suitable for transarticular screw placement. In three patients the anatomy was considered unsuitable for bilateral screw placement. In three patients the anatomy was considered inadequate on one side. Fifty-five C1–2 transarticular screws were subsequently placed, and there were no neurological or vascular complications. Conclusions. The authors conclude that C1–2 transarticular screw fixation is technically possible in a large proportion of pediatric patients with craniovertebral instability.

The pathophysiology of oral pharyngeal apraxia and mutism following posterior fossa tumor resection in children

1995 ◽  
Vol 83 (3) ◽  
pp. 467-475 ◽  
Author(s):  
Andrew T. Dailey ◽  
Guy M. McKhann ◽  
Mitchel S. Berger
Keyword(s):  
Posterior Fossa ◽  
Pediatric Patients ◽  
Tumor Resection ◽  
Posterior Fossa Tumor ◽  
Posterior Fossa Tumors ◽  
Lower Cranial Nerve ◽  
Content Type ◽  
Cranial Nerve Function ◽  
Pharyngeal Musculature ◽  
Fine Print

✓ Mutism following posterior fossa tumor resection in pediatric patients has been previously recognized, although its pathophysiology remains unclear. A review of the available literature reveals 33 individuals with this condition, with only a few adults documented in the population. All of these patients had large midline posterior fossa tumors. To better understand the incidence and anatomical substrate of this syndrome, the authors reviewed a 7-year series of 110 children who underwent a posterior fossa tumor resection. During that time, nine (8.2%) of the 110 children exhibited mutism postoperatively. They ranged from 2.5 to 20 years of age (mean 8.1 years) and became mute within 12 to 48 hours of surgery. The period of mutism lasted from 1.5 to 12 weeks after onset: all children had difficulty coordinating their oral pharyngeal musculature as manifested by postoperative drooling and inability to swallow. Further analysis of these cases revealed that all children had splitting of the entire inferior vermis at surgery, as confirmed on postoperative magnetic resonance studies. Lower cranial nerve function was intact in all nine patients. Current concepts of cerebellar physiology emphasize the importance of the cerebellum in learning and language. The syndrome described resembles a loss of learned activities, or an apraxia, of the oral and pharyngeal musculature. To avoid the apraxia, therefore, the inferior vermis must be preserved. For large midline tumors that extend to the aqueduct, a combined approach through the fourth ventricle and a midvermis split may be used to avoid injuring the inferior vermis.

The therapeutic value of nimodipine in experimental focal cerebral ischemia

1987 ◽  
Vol 67 (1) ◽  
pp. 81-87 ◽  
Author(s):  
Isabelle M. Germano ◽  
Henry M. Bartkowski ◽  
Mary E. Cassel ◽  
Lawrence H. Pitts
Keyword(s):  
Cerebral Ischemia ◽  
Mechanism Of Action ◽  
Neurological Outcome ◽  
Focal Cerebral Ischemia ◽  
Ischemic Insult ◽  
Double Blind ◽  
Content Type ◽  
Therapeutic Value ◽  
Fine Print ◽  
Neuropathological Evaluation

✓ Recent studies suggest that nimodipine, a potent calcium-channel antagonist that causes significant cerebrovascular dilatation, may improve neurological outcome after acute experimental permanent focal cerebral ischemia when given before or immediately after occlusion of the middle cerebral artery (MCA) in various animals. The authors describe the effect of nimodipine on cerebral ischemia in a rat model. At 1,4, or 6 hours after occlusion of the MCA, rats were treated in a double-blind technique with either nimodipine, placebo, or saline. Neurological and neuropathological evaluation was performed at 24 hours. Neurological outcome was better in rats treated with nimodipine 1, 4, or 6 hours after occlusion (p < 0.001, p < 0.01, p < 0.05, respectively), and the size of areas of infarction was statistically smaller in nimodipine-treated groups (p < 0.01, p < 0.01, p < 0.05, respectively) when compared with control rats treated with saline or placebo. The best neurological outcome and the smallest area of infarction were found in nimodipine-treated rats 1 hour after occlusion. Compared with controls, the size of the periphery of the infarcted area was smaller in nimodipine-treated rats. The results show that nimodipine improves neurological outcome and decreases the size of infarction when administered up to 6 hours after ischemic insult. These results suggest a possible mechanism of action of nimodipine on the “penumbra” of the ischemic area.

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