Disposition of levobupivacaine during intraoperative continuous caudal epidural analgesia in a preterm neonate

Background. Continuous caudal epidural analgesia used intraoperatively in children is an effective and safe technique. However, in preterm neonates, developmental factors may significantly affect levobupivacaine disposition, leading to variable pharmacokinetics, pharmacodynamics, and potential large-variable systemic toxicity of local anesthetics. Objective. To our knowledge, this is the first case report describing the disposition of levobupivacaine used for intraoperative caudal epidural analgesia in a preterm neonate treated for the postoperative pain profile. Method. 4-days old neonate (postmenstrual age 35+5, weight 2140 g) with congenital anal atresia received continuous caudal epidural long-term analgesia (loading dose 1.694 mg/kg, initial infusion 0.34 mg/kg/hour) before correction surgery. The blood samples were obtained at 1.0, 1.5, 6.5, 12, and 36.5 h after the start of epidural infusion. The pharmacokinetic profile of levobupivacaine was determined by using the Stochastic Approximation Expectation Maximization algorithm. COMFORT and NIPS pain scores were used for the assessment of epidural analgesia. Results. The levobupivacaine absorption rate constant, apparent volume of distribution, apparent clearance, and elimination half-life were 10.8 h-1, 0.9 L, 0.086 L/h, and 7.3 h, respectively. Conclusion. The results confirm our hypothesis of altered pharmacokinetics in the preterm neonate. Therefore, levobupivacaine therapy in these patients should be carefully monitored. Since therapeutic drug monitoring of levobupivacaine is not established in clinical routines, we suggest monitoring the intraoperative pain profile using validated scores. Trial Registration: EudraCT number: 2020-000595-3

Hydroxyethyl starch 130/0.42/6:1 for perioperative plasma volume replacement in 1130 children: results of an European prospective multicenter observational postauthorization safety study (PASS)

Introduction: Third-generation hydroxyethyl starch (HES) is now approved also for the use in children, but safety studies including large numbers of pediatric patients are still missing. Therefore, we performed an European multicentric prospective observational postauthorization safety study (PASS) to evaluate the use of HES 130/0.42/6:1 in normal saline (ns-HES) or a balanced electrolyte solution (bal-HES) in children undergoing surgery. Methods: Children aged up to 12 years with ASA risk scores of I-III receiving nsHES (Venofundin 6%; Braun) or bal-HES (Tetraspan 6%; Braun) were followed perioperatively. Demographic data, surgical procedures performed, anesthesia, hemodynamic and laboratory data, adverse events (AE), and adverse drug reactions (ADR) were documented using a standardized case report form. Results: Of 1130 children studied at 11 European pediatric centers from 2006 to 2009 (ns-HES, 629 children; bal-HES, 475 children; mean age, 3.6 +/- 3.8 [ range, day of birth-12 years]; and body weight, 15.4 +/- 13 [0.9-90 kg]), 1104 were included for analysis. The mean infused HES volume was 10.6 +/- 5.8 (0.83-50) ml.kg(-1). In the 399 (36.1%) cases with blood gas analysis before and after HES infusion, hemoglobin and strong ion difference decreased significantly in both groups, whereas bicarbonate and base excess (BE before infusion: ns-HES) 1.8 +/- 3.1, bal-HES) 1.2 +/- 3.3 mM; after infusion: ns-HES) 2.5 +/- 2.8; bal-HES) 1.1 +/- 3.2 mM, P <0.05) decreased only with ns-HES but remained stable with bal-HES. Chloride concentrations increased in both groups and were significantly higher with ns-HES (Cl before infusion: ns-HES 105.5 +/- 3.6, bal-HES 104.9 +/- 2.9 mM; Cl after infusion: ns-HES 107.6 +/- 3.4, bal-HES 106.3 +/- 2.9 mM, P <0.05). For the AE/ADR rates, dose-response but no age relationships could be demonstrated. No serious and no severe ADR directly related to HES (i. e. anaphylactoid reaction, clotting disorders, renal failure) were observed. Conclusion: Moderate doses of HES 130/0.42/6: 1 for perioperative plasma volume replacement seem to be safe even in neonates and small infants. The probability of serious ADR is lower than 0.3%. Changes in acid-base balance may be decreased when HES is used in an acetate-containing balanced electrolyte solution instead of normal saline. Caution should be exercised in patients with renal function disturbances and those with an increased bleeding ris

Geología y estratigrafía de la hoja 3246-ii miramar, costa rica

The oldest rocks of the Miramar sheet are represented by sediments of the Punta Carballo Formation(Miocene), which are exposed at the SW corner. However, volcanic rocks of the older Aguacate Group (Miocene-Pliocene) and overlying Monteverde Formation (Lower Pleistocene) dominate the area. The Pliocene to Pleistocenesilicic ignimbrites and Quaternary sediments are subordinate. New K-Ar ages yielded 4,41±0,15 to 4,99±0,36 Ma forthe Aguacate Group and 1,71±0,22 to 1,77±0,11 Ma for the Monteverde Formation. Gabrodioritic stock was newlymapped in the Aguacate Group accompanying numerous other intrusive bodies of variable composition. New K-Arages were obtained for the rhyodacitic domes: 1,71±0,14 Ma for the cerro La Cruz Dome and 1,59±0,12 Ma for thecerro San Miguel Dome. Definition of volcanic units is based on detailed petrography, XRD, microprobe and 33 newbulk-rock chemical analyses. Las rocas más antiguas de la hoja Miramar están conformadas por los sedimentos de la FormaciónPunta Carballo del Mioceno que afloran al SO de la hoja. Las vulcanitas del Grupo Aguacate (Mioceno-Plioceno)sobreyacidas por vulcanitas de la Formación Monteverde (Pleistoceno Inferior), representan la mayor extensión del mapa. En menor superficie se encuentran las ignimbritas del Plioceno hasta Pleistoceno y sedimentos del Cuaternario.Nuevas dataciones con el método K-Ar establecieron edades de 4,41±0,15 y 4,99±0,36 Ma para el Grupo Aguacate y de1,77±0,11 y 1,71±0,22 Ma para la Formación Monteverde. El Grupo Aguacate también está conformado por una seriede cuerpos intrusivos de composición variable, entre ellos un stock gabrodiorítico que fue recién mapeado y se describepor primera vez con este trabajo. Se hicieron nuevas dataciones K-Ar del domo riodacítico cerro La Cruz, cuya edadfue datada en 1,71±0,14 Ma y del domo cerro San Miguel en 1,59±0,12 Ma. La definición de las unidades volcánicasse basa en la petrografía detallada de las rocas, así como en los resultados de la difractometría de rayos X, microsondaelectrónica y 33 análisis químicos. 

Comparison of the BMI of patients with choledocholithiasis who underwent the ERCP procedure (ERCP 1) with that of the control group.

<p>Comparison of the BMI of patients with choledocholithiasis who underwent the ERCP procedure (ERCP 1) with that of the control group.</p

Comparison of patients with cholelithiasis with those in the control group.

<p>Comparison of patients with cholelithiasis with those in the control group.</p

Cholelithiasis and choledocholithiasis in children; risk factors for development - Fig 1

<p>X-ray during ERCP showing choledocholithiasis (X1) and dilatation of the choledochal duct (X2).</p

Comparison of the BMI of patients with simple cholelithiasis who did not undergo ERCP (ERCP 0) with that of the control group.

<p>Comparison of the BMI of patients with simple cholelithiasis who did not undergo ERCP (ERCP 0) with that of the control group.</p

Age range of the operated patients.

<p>Age range of the operated patients.</p

Comparison of patients with cholelithiasis with the anthropometric data of the Czech Republic.

<p>Comparison of patients with cholelithiasis with the anthropometric data of the Czech Republic.</p