- Anesthesia, Pediatric
Internship: George Washington University Office of the Registrar (1984) DC
Residency: George Washington University Anesthesiology Residency (1986) DC
Medical Education: University of Missouri Kansas City School of Medicine Registrar (1983) MO
Board Certification: American Board of Anesthesiology, Anesthesia (1988)
Fellowship: Denver Children's Hospital (1987) CO
- Mending a broken heart: The Anatomy, Physiology and Psychology of congenital heart disease
ANES 74Q (Spr)
- Independent Studies (5)
Prior Year Courses
Case report: airway and concurrent hemodynamic management in a neonate with oculo-auriculo-vertebral (Goldenhar) syndrome, severe cervical scoliosis, interrupted aortic arch, multiple ventricular septal defects, and an unstable cervical spine
2012; 22 (9): 932-934
We report the challenging case of a 1-week-old, term, 2.4 kg neonate with Goldenhar syndrome (including microcephaly, left microtia, left facial palsy, dextro-scoliosis of the cervical spine, and cervico-thoracic levoscoliosis), multiple ventricular septal defects, a type B interrupted aortic arch, a large patent ductus arteriosis, and radiographic and clinical signs concerning for an unstable cervical spine. Our anesthesia team was consulted for perioperative management of this patient during her surgical repair. This case report describes the use of the Air-Q size 1 laryngeal airway (LA) to assist fiberoptic intubation in an ASA 4 neonate with cardiac disease, an anticipated difficult airway with the addition of an unstable cervical spine, as well as the anesthetic techniques used to maintain hemodynamic stability while the airway was secured.
View details for DOI 10.1111/j.1460-9592.2012.03915.x
View details for Web of Science ID 000306900400017
View details for PubMedID 22834469
- Regional anesthesia and postoperative pain management ANESTHESIA FOR CONGENITAL HEART DISEASE 2010: 356–70
A randomized, controlled trial of aprotinin in neonates undergoing open-heart surgery
2008; 18 (9): 812-819
Neonates undergoing open-heart surgery are especially at risk for massive bleeding and pronounced inflammation. The efficacy of aprotinin, a serine protease inhibitor, at ameliorating these adverse effects of cardiopulmonary bypass has not been clearly demonstrated in neonates.Term neonates were enrolled and randomly assigned in a blinded fashion to receive saline (group P, placebo) or high-dose aprotinin (group A). Intraoperative management was standardized: surgeon, anesthesia, cardiopulmonary bypass and hemostasis therapy. Patients were admitted postoperatively to a pediatric cardiac intensive care unit. Primary outcome measure of efficacy was duration of the postoperative mechanical ventilation. Secondary outcome measures were total volume and units of blood products transfused intraoperatively and for 24 h after surgery, duration of chest tube in situ, and intensive care and hospital stays after surgery.Twenty-six neonates were enrolled; 13 received aprotinin and 13 received placebo. The study was halted prematurely because of US Food and Drug Administration's concerns about aprotinin's safety. Baseline patient, surgery and cardiopulmonary bypass characteristics were similar between groups. No outcome variables differed between groups (P > 0.05). Duration of postoperative ventilation was 115 +/- 139 h (group A); 126 +/- 82 h (group P); P = 0.29, and total blood product exposure was 8.2 +/- 2.6 U (group A); 8.8 +/- 1.4 U (group P); P = 0.1. Postoperative blood creatinine values did not differ between groups. In-hospital mortality rate was 4%.Aprotinin was not shown to be efficacious in neonates undergoing open-heart surgery. It is unclear whether adult aprotinin safety data are relevant to neonates undergoing open-heart surgery.
View details for DOI 10.1111/j.1460-9592.2008.02678.x
View details for Web of Science ID 000257990900002
View details for PubMedID 18768040
Ketamine does not increase pulmonary vascular resistance in children with pulmonary hypertension undergoing sevoflurane anesthesia and spontaneous ventilation
ANESTHESIA AND ANALGESIA
2007; 105 (6): 1578-1584
The use of ketamine in children with increased pulmonary vascular resistance is controversial. In this prospective, open label study, we evaluated the hemodynamic responses to ketamine in children with pulmonary hypertension (mean pulmonary artery pressure >25 mm Hg).Children aged 3 mo to 18 yr with pulmonary hypertension, who were scheduled for cardiac catheterization with general anesthesia, were studied. Patients were anesthetized with sevoflurane (1 minimum alveolar anesthetic concentration [MAC]) in air while breathing spontaneously via a facemask. After baseline catheterization measurements, sevoflurane was reduced (0.5 MAC) and ketamine (2 mg/kg IV over 5 min) was administered, followed by a ketamine infusion (10 microg x kg(-1) x min(-1)). Catheterization measurements were repeated at 5, 10, and 15 min after completion of ketamine load. Data at various time points were compared (ANOVA, P < 0.05).Fifteen patients (age 147, 108 mo; median, interquartile range) were studied. Diagnoses included idiopathic pulmonary arterial hypertension (5), congenital heart disease (9), and diaphragmatic hernia (1). At baseline, median (interquartile range) baseline pulmonary vascular resistance index was 11.3 (8.2) Wood units; 33% of patients had suprasystemic mean pulmonary artery pressures. Heart rate (99, 94 bpm; P = 0.016) and Pao2 (95, 104 mm Hg; P = 007) changed after ketamine administration (baseline, 15 min after ketamine; P value). There were no significant differences in mean systemic arterial blood pressure, mean pulmonary artery pressure, systemic or pulmonary vascular resistance index, cardiac index, arterial pH, or Paco2.In the presence of sevoflurane, ketamine did not increase pulmonary vascular resistance in spontaneously breathing children with severe pulmonary hypertension.
View details for DOI 10.1213/01.ane.0000287656.29064.89
View details for PubMedID 18042853
Modified and conventional ultrafiltration during pediatric cardiac surgery: Clinical outcomes compared
JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY
2006; 132 (6): 1291-1298
This prospective study compared clinical outcomes after heart surgery between three groups of infants with congenital heart disease. One group received dilutional conventional ultrafiltration (group D), another received modified ultrafiltration (group M), and a third group received both dilutional conventional and modified ultrafiltration (group B). We hypothesized that group B patients would have the best clinical outcome.Children younger than 1 year undergoing heart surgery for biventricular repair by the same surgeon were randomly allocated to one of the three study groups. Patient management was standardized, and intensive care staff were blinded to group allocation. Primary outcome measure was duration of postoperative mechanical ventilation. Other outcome measures recorded included total blood products transfused, duration of chest tube in situ, chest tube output, and stays in intensive care and in the hospital.Sixty infants completed study protocol. Mean age and weight were as follows: group D (n = 19), 61 days, 4.3 kg; group M (n = 20), 64 days, 4.5 kg; and group B (n = 21), 86 days, 4.4 kg. Preoperative and intraoperative characteristics were similar between groups. Ultrafiltrate volumes obtained were 196 +/- 93 mL/kg in group D, 105 +/- 33 mL/kg in group M, and 261 +/- 113 mL/kg in group B. There were no significant differences between groups for any outcome variable. Technical difficulties prevented completion of modified ultrafiltration in 2 of 41 infants.There was no clinical advantage in combining conventional and modified ultrafiltration. Because clinical outcomes were similar across groups, relative risks of the ultrafiltration strategies may influence choice.
View details for DOI 10.1016/j.jtcvs.2006.05.059
View details for PubMedID 17140945
Anesthetic management of infants with palliated hypoplastic left heart syndrome undergoing laparoscopic Nissen fundoplication
ANESTHESIA AND ANALGESIA
2005; 100 (6): 1631-1633
The safety of laparoscopic surgery in infants with single ventricle physiology has been a subject of controversy despite potential benefits over open surgery. We present the anesthetic management of five infants with palliated hypoplastic left heart syndrome that underwent laparoscopic Nissen fundoplication. After anesthetic induction and tracheal intubation, an intraarterial catheter was placed for hemodynamic monitoring. Insufflation pressure was limited to 12 mm Hg and was well tolerated by all patients. There were no intraoperative or postoperative complications. In patients with hypoplastic left heart syndrome, laparoscopic Nissen fundoplication can be safely performed with careful patient selection and close intraoperative monitoring.
View details for DOI 10.1213/01.ANE.0000149899.03904.3F
View details for Web of Science ID 000229305600013
View details for PubMedID 15920186
Postoperative analgesia after spinal blockade in infants and children undergoing cardiac surgery
ANESTHESIA AND ANALGESIA
2005; 100 (5): 1283-1288
The aim of this prospective, randomized, controlled clinical trial was to define the opioid analgesic requirement after a remifentanil (REMI)-based anesthetic with spinal anesthetic blockade (SAB+REMI) or without (REMI) spinal blockade for open-heart surgery in children. We enrolled 45 patients who were candidates for tracheal extubation in the operating room after cardiac surgery. Exclusion criteria included age <3 mo and >6 yr, pulmonary hypertension, congestive heart failure, contraindication to SAB, and failure to obtain informed consent. All patients had an inhaled induction with sevoflurane and maintenance of anesthesia with REMI and isoflurane (0.3% end-tidal). In addition, patients assigned to the SAB+REMI group received SAB with tetracaine (0.5-2.0 mg/kg) and morphine (7 mug/kg). After tracheal extubation in the operating room, patients received fentanyl 0.3 mug/kg IV every 10 min by patient-controlled analgesia for pain score = 4. Pain scores and fentanyl doses were recorded every hour for 24 h or until the patient was ready for discharge from the intensive care unit. Patients in the SAB+REMI group had significantly lower pain scores (P = 0.046 for the first 8 h; P =0.05 for 24 h) and received less IV fentanyl (P = 0.003 for the first 8 h; P = 0.004 for 24 h) than those in the REMI group. There were no intergroup differences in adverse effects, including hypotension, bradycardia, highest PaCO(2), lowest pH, episodes of oxygen desaturation, pruritus, and vomiting.
View details for DOI 10.1213/01.ANE.0000148698.84881.10
View details for PubMedID 15845670
Haemodynamic changes during high spinal anaesthesia in children having open heart surgery
2003; 13 (1): 48-52
This prospective series examined the haemodynamic effects of high spinal anaesthesia in combination with light general anaesthesia in infants and children undergoing open heart surgery who were candidates for immediate or early postoperative extubation.After midazolam premedication and sevoflurane inhalation induction, 30 patients, aged 7 months to 13 years, who were undergoing open heart surgery, received spinal anaesthetics with 0.5% tetracaine D10 mixed with morphine. The spinal blocks were placed at the L2,3 or L3,4 interspace with cephalad spread being promoted by positioning the patient in 30 degrees of Trendelenburg for a minimum of 10 min. Maintenance of anaesthesia was with isoflurane 0.2-0.5% in 70% nitrous oxide to maintain heart rate and blood pressure within 20% of postinduction baseline values. Haemodynamic values were recorded at predetermined timed intervals and intraoperative events up to and including aortic cannulation. For analysis of the data, patients were divided into four age groups (< 1 years, 1-3 years, 4-6 years and > 7 years).Haemodynamic stability was demonstrated in all four age groups. Statistically significant slowing of the heart rate did occur in the groups older than 1 year at 25 min, although clinically significant bradycardia requiring treatment never occurred. Hypotension did occur during specific surgical manipulations but recovered spontaneously. Atropine, fluid boluses and vasopressors were never used. At the conclusion of surgery, all patients met extubation criteria and could move all four extremities.High spinal anaesthesia with hyperbaric tetracaine and morphine in combination with light general anaesthesia is well tolerated haemodynamically by the paediatric population studied.
View details for Web of Science ID 000180433300009
View details for PubMedID 12535039
The effect of baricity of intrathecal morphine in children receiving tetracaine spinal anaesthesia for cardiac surgery: a preliminary report
2002; 12 (4): 327-331
This prospective, randomized study examined the effect of baricity of intrathecal preservative-free morphine on the duration of postoperative analgesia and incidence of side-effects in infants and children receiving high spinal anaesthesia with hyperbaric tetracaine in combination with a light general anaesthetic.Fourteen infants and children, aged 7-91 months, undergoing repair of either uncomplicated atrial or ventricular septal defects, were randomized to receive either 10 microg x kg(-1) of intrathecal morphine in combination with 0.5% tetracaine D10 (hyperbaric morphine group) or intrathecal morphine mixed with saline and injected sequentially after the administration of 0.5% tetracaine D10 (hypobaric morphine group). After spinal injection, patients were positioned in 30 degrees of Trendelenburg for a minimum of 10 min. Postoperatively, patients were monitored for a minimum of 12 h. Pain scores and the incidence and severity of side-effects were recorded every 1 h.All patients were extubated at the conclusion of surgery without any incidence of respiratory depression. There was a decreased incidence of vomiting in the hypobaric morphine group and no significant difference in the duration of analgesia.When intrathecal morphine is administered in conjunction with a hyperbaric tetracaine spinal to paediatric cardiac patients in the head down position, sequential administration of the hypobaric solution may mitigate side-effects.
View details for Web of Science ID 000175654600008
View details for PubMedID 11982840
- Anesthesia for outpatient repair of patent ductus arteriosus JOURNAL OF CARDIOTHORACIC AND VASCULAR ANESTHESIA 2001; 15 (6): 750-752
Combined regional and light general anesthesia: are the risks increased or minimized?
Current opinion in anaesthesiology
1999; 12 (3): 321-323
Regional anesthesia during general anesthesia has become increasingly popular in recent years. Most pediatric anesthesiologists are proponents of this practice, and believe that surgical morbidity is reduced, but controversy remains regarding safety. Neuraxial anesthesia during general anesthesia is especially controversial. Unfortunately, outcome studies are lacking but the literature reflects an absence of reported serious morbidity or mortality.
View details for PubMedID 17013331
Outcomes after single injection caudal epidural versus continuous infusion epidural via caudal approach for postoperative analgesia in infants and children undergoing patent ductus arteriosus ligation
1999; 9 (2): 139-143
Adequate postoperative analgesia enhances deep breathing and minimizes respiratory complications after thoracotomy. This study compares postoperative outcomes after single injection caudal epidural vs continuous infusion epidural via caudal approach for postoperative analgesia in infants and children undergoing thoracotomy for patent ductus arteriosus (PDA) ligation. A retrospective chart review was performed for 27 children who had undergone PDA ligation. The children were divided into three groups. We compared patient demographics, surgical duration, anaesthesia duration, length of ICU stay, incidence of emesis requiring treatment, time required to establish regular oral intake, requirement for supplemental intravenous opioids during the first postoperative day, and length of hospital stay. For paediatric patients undergoing PDA ligation, postoperative analgesia with continuous infusion epidural via caudal approach produced shorter ICU stay, less occurrence of postoperative emesis, earlier oral intake, elimination of intravenous opioid supplementation, and shorter hospital stay compared with single injection caudal epidural techniques.
View details for PubMedID 10189655
Post-transplant lymphoproliferative disease may present with severe airway obstruction
1998; 89 (1): 263-265
View details for PubMedID 9667319