Purpose: Detection of intravascular injection of local anaesthetic during placement of regional blocks in children by using epinephrine-induced tachycardia or hypertension may produce false positive and false negative findings. This study evaluates ECG changes as markers of intravascular injection of local anaesthetics with epinephrine, during placement of epidural blocks in children. Methods: Observational study in a teaching hospitaJ of all epiduraJ anaesthetics administered to paediatric patients during one year, General anaesthesia, where used, was not controlled. An ECG rhythm strip was recorded during test dose iniection and analyzed for changes in rate, rhythm, and T-wave configuration. Results: During the study period, 742 paediatric epidural blocks were administered. There were 644 caudal (284 without catheters), 97 lumbar, and one thoracic epidural anaesthetics. Satisfactory placement was achieved in 97.7% of patients. Intravascular injection was detected in 42 (5.6%) of epidural anaesthetics (3.8% and 6.7% of straight needle and catheter injections, respectively). Detection was by immediate aspiration of blood in six patients, and by heart t-ate increases >10 bpm in 30. Five had heart rate decreases suggesting a baroreceptor response. Five had heart rate increases < I 0 bpm that were possible responses to noxious stimuli. Of 30 patients with known intravascular injection and for whom ECG strips were available, 25 (83%) had T-wave amplitude ~ncreases > 25%, and 29 (97%) had ECG changes in T-wave or rhythm in response to the epinephrine injection. There were no false positives. Conclusion: In order to reduce risks associated with epidural anaesthesia in children, epinephrine should be added to the local anaesthetic test dose, the ECG should be monitored continuously for changes in heart rate, rhythm, and T-wave amplitude. Epidural injections should be given in small increments.

Background: Data on long-term outcomes after valve-in-valve (ViV) transcatheter aortic valve replacement (TAVR) are scarce. The objective of this study was to determine the long-term clinical outcomes and structural valve degeneration (SVD) over time in patients undergoing ViV-TAVR. Methods and Results: Consecutive patients undergoing ViV-TAVR in 9 centers between 2009 and 2015 were included. Patients were followed yearly, and clinical and echocardiography data were collected prospectively. SVD was defined as subclinical (increase >10 mm Hg in mean transvalvular gradient+decrease >0.3 cm 2 in valve area or new-onset mild or moderate aortic regurgitation) and clinically relevant (increase >20 mm Hg in mean transvalvular gradient+decrease >0.6 cm 2 in valve area or new-onset moderate-to-severe aortic regurgitation). A total of 116 patients (mean age, 76±11 years; 64.7% male; mean Society of Thoracic Surgeons score, 8.0±5.1%) were included. Balloon- and self-expandable valves were used in 47.9% and 52.1% of patients, respectively, and 30-day mortality was 6.9%. At a median follow-up of 3 years (range, 2–7 years), 30 patients (25.9%) had died, 20 of them (17.2%) from cardiovascular causes. Average mean transvalvular gradients remained stable up to 5-year follow-up ( P =0.92), but clinically relevant SVD occurred in 3/99 patients (3.0%), and 15/99 patients (15.1%) had subclinical SVD. One patient with SVD had redo ViV-TAVR. Conclusions: About one-fourth of ViV-TAVR recipients had died after a median follow-up of 3 years. Overall valve hemodynamics remained stable over time and clinically relevant SVD was infrequent, but 1 out of 10 patients exhibited some degree of SVD.

Our study showed that in this setting it is feasible to track anesthesia practice patterns and adverse perioperative events. We identified issues for further examination.

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We studied the time to postoperative micturition and the duration of analgesia in 82 children aged 6 mo to 10 yr undergoing herniorrhaphy or orchiopexy under general anesthesia with N2O and halothane. All received D5 lactate Ringer's solution equivalent to 6 h maintenance intraoperatively, and oral fluids postoperatively ad libitum. At the end of surgery, patients were randomly assigned to receive one of three regional anesthetic injections using 0.25% bupivacaine: caudal, 0.75 mL/kg (group I); caudal with 1:200,000 epinephrine, 0.75 mL/kg (group II); or ilioinguinaliliohypogastric nerve block with epinephrine through the wound by the surgeon (group III). Postoperatively, blinded observers scored pain at 30 min, hourly until discharge, and by telephone at 24-36 h. In the 74 patients with successful blocks (mean age 2.5 +/- 2.4 yr), the times to micturition (group I, 202 +/- 130 min; group II, 262 +/- 164 min; group III, 196 +/- 101 min) did not differ significantly among groups. Seven patients who took more than 8 h to void required no intervention. There was no difference in the numbers without pain for > or = 4 h (74%, 64%, and 69% of groups I, II, and III), or those requiring analgesics by 24 h (66% overall). The time to postoperative voiding in children is variable and not prolonged by caudal analgesia; caudal bupivacaine with or without epinephrine and ilioinguinaliliohypogastric nerve block are equally effective for postoperative analgesia.

Organizations from high-resource nations, including The Plastic Surgery Education Foundation (PSEF), began providing surgical services and training in low-income or middle-income countries (LMICs) in the 1950s. The primary model used has been the short-term surgical project (STSP), which sends surgical and medical specialists to LMICs for 1-4 weeks to perform surgery for patients that otherwise lack that

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