Komal Kamra

All Publications

• Management of a Pediatric Patient With a Left Ventricular Assist Device and Symptomatic Acquired von Willebrand Syndrome Presenting for Orthotopic Heart Transplant. Seminars in cardiothoracic and vascular anesthesia Flannery, K. M., Kamra, K., Maeda, K., Shuttleworth, P., Almond, C., Navaratnam, M. 2020: 1089253220949386

  Abstract

  We present the successful perioperative management of an 11-year-old patient presenting for heart transplant with a left ventricular assist device, symptomatic acquired von Willebrand syndrome, and recent preoperative intracranial hemorrhage. A brief review of the pathophysiology of acquired von Willebrand syndrome is included. As the number of pediatric patients supported with ventricular assist devices continues to increase, the management of symptomatic acquired von Willebrand syndrome during the perioperative period is an important consideration for anesthesiologists.

  View details for DOI 10.1177/1089253220949386

  View details for PubMedID 32772894

• Left ventricular retraining in corrected transposition: Relationship between pressure and mass. The Journal of thoracic and cardiovascular surgery Mainwaring, R. D., Patrick, W. L., Arunamata, A., Chan, F., Newman, B., Rosenblatt, T. R., Kamra, K., Hanley, F. L. 2019

  Abstract

  BACKGROUND: A subset of patients with corrected transposition of the great arteries (CC-TGA) will require left ventricular (LV) retraining before undergoing a double-switch procedure. LV retraining results in an immediate increase in LV pressure but not in LV mass. The purpose of this study was to evaluate the relationship between LV pressure and mass during LV retraining.METHODS: This was a retrospective review of 36 patients with CC-TGA who were enrolled in LV retraining. The median age at enrollment was 12months. The majority (82%) had an Ebstenoid tricuspid valve or moderate to severe tricuspid valve regurgitation before pulmonary artery banding.RESULTS: Twenty-seven of the 36 patients underwent LV retraining and a double switch, including 14 patients with a single pulmonary artery band (PAB), 12 patients with 2 PABs, and 1 patient with 3 PABs. There was no early or late mortality associated with these procedures. Ninety percent of the patients demonstrated a linear relationship between LV pressure and mass; however, 3 patients (10%) demonstrated a different LV retraining pattern characterized by excess LV mass compared to LV pressure. Two of these 3 patients are LV retraining failures, whereas the third patient did undergo a double switch.CONCLUSIONS: The data show that the majority of patients enrolled in LV retraining have a predictable relationship between LV mass and pressure. A minority demonstrate an excess accrual of mass with respect to pressure load. These results suggest there may be an important distinction between normal and pathological hypertrophy during the LV retraining process.

  View details for DOI 10.1016/j.jtcvs.2019.10.053

  View details for PubMedID 31761342

• Surgical results of unifocalization revision Mainwaring, R. D., Patrick, W. L., Rosenblatt, T. R., Ma, M., Kamra, K., Arunamata, A., Hanley, F. L. MOSBY-ELSEVIER. 2019: 534–44

  View details for DOI 10.1016/j.jtcvs.2018.09.135

  View details for Web of Science ID 000475496900070

• Role of echocardiography in the assessment of right ventricular function in the pediatric population PEDIATRIC ANESTHESIA Kamra, K., Punn, R. 2019; 29 (5): 530–38

  View details for DOI 10.1111/pan.13641

  View details for Web of Science ID 000468217100018

• Role of echocardiography in the assessment of right ventricular function in the pediatric population. Paediatric anaesthesia Kamra, K., Punn, R. 2019

  Abstract

  This review article summarizes the use of echocardiography in the evaluation of right ventricle with special emphasis on pediatric patients. After reading this article, the anesthesiologists will develop a better understanding of anatomy and echocardiographic parameters for hemodynamic and functional assessment of the right ventricle. This knowledge will assist with the perioperative management of patients with cardiopulmonary disorder. This article is protected by copyright. All rights reserved.

  View details for PubMedID 30934152

• Younger age remains a risk factor for prolonged length of stay after bidirectional cavopulmonary anastomosis. Cardiology in the young Koth, A. M., Algaze, C. A., Sakarovitch, C., Long, J., Kamra, K., Wright, G. E., Alexander-Banys, B., Maeda, K., Shin, A. Y. 2019: 1–6

  Abstract

  OBJECTIVE: This study sets out to determine the influence of age at the time of surgery as a risk factor for post-operative length of stay after bidirectional cavopulmonary anastomosis.METHODS: All patients undergoing a Glenn procedure between January 2010 and July 2015 were included in this retrospective cohort study. Demographic data were examined. Standard descriptive statistics was used. A univariable analysis was conducted using the appropriate test based on data distribution. A propensity score for balancing the group difference was included in the multi-variable analysis, which was then completed using predictors from the univariable analysis that achieved significance of p<0.1.RESULTS: Over the study period, 50 patients met the inclusion criteria. Patients were separated into two cohorts of ⩾4 months (28 patients) and <4 months (22 patients). Other than height and weight, the two cohorts were indistinguishable in their pre-operative saturation, medications, catheterisation haemodynamics, atrioventricular valve regurgitation, and ventricular function. After adjusting group differences, younger age was associated with longer post-operative length of hospitalisation - adjusted mean 15 (±2.53) versus 8 (±2.15) days (p=0.03). In a multi-variable regression analysis, in addition to ventricular dysfunction (beta coefficient=8.8, p=0.05), Glenn procedures performed before 4 months were independently associated with longer length of stay (beta coefficient=-6.9, p=0.03).CONCLUSION: We found that Glenn procedures performed after 4 months of age had shorter post-operative length of stay when compared to a younger cohort. These findings suggest that balancing timing of surgery to decrease the inter-stage period should take into consideration differences in post-operative recovery with earlier operations.

  View details for PubMedID 30698131

• Fibrinogen Concentrate as an Alternative to Cryoprecipitate in a Postcardiopulmonary Transfusion Algorithm in Infants Undergoing Cardiac Surgery: A Prospective Randomized Controlled Trial. Anesthesia and analgesia Downey, L. A., Andrews, J., Hedlin, H., Kamra, K., McKenzie, E. D., Hanley, F. L., Williams, G. D., Guzzetta, N. A. 2019

  Abstract

  Infants undergoing cardiac surgery are at risk for bleeding and massive transfusion due to an immature coagulation system, complex surgeries, and cardiopulmonary bypass (CPB) effects. Hemodilution from CPB promotes an acquired hypofibrinogenemia that results in impaired fibrin formation, inadequate clot formation, and increased bleeding. In North America, the current standard of care to supplement fibrinogen is cryoprecipitate. An alternative option is the off-label use of fibrinogen concentrate (FC; RiaSTAP; CSL Behring, Marburg, Germany), a purified fibrinogen. Because perioperative allogenic transfusions are associated with increased morbidity and mortality, we sought to determine whether FC would be an acceptable alternative to cryoprecipitate in a post-CPB transfusion algorithm in infants undergoing open-heart surgery.We randomized 60 infants (<12 months) undergoing nonemergent cardiac surgery with CPB at 2 tertiary care children's hospitals to receive either cryoprecipitate or FC in a post-CPB transfusion algorithm. Infants underwent a stratified randomization based on institution and surgical complexity. The primary outcome was the difference in number of intraoperative allogenic blood product transfusions. Secondary outcomes included 24-hour chest tube output (CTO), mechanical ventilation time, adverse events (AEs), intensive care unit (ICU) length of stay (LOS), hospital LOS, postoperative thrombosis, and death within 30 days of surgery. The primary analysis followed the intent-to-treat (ITT) principle and was performed using linear regression adjusted for institution and complexity of surgery. A per-protocol (PP) analysis was also performed.Between June 2016 and January 2018, we enrolled 60 patients with complete data available for 25 patients who received cryoprecipitate and 29 patients who received FC. Patients in the cryoprecipitate group (median age: 4 months [2-6 months]) received 5.5 (4.0-7.0) allogeneic blood units in the ITT analysis and 6.0 units (5.0-7.0 units) in the PP analysis. Patients in the FC group (median age: 4 months [2-5]) received 4 units (3.0-5.0 units) in the ITT analysis and 4.0 units (3.0-5.0 units) in the PP analysis. In the adjusted ITT analysis, the FC group received 1.79 units (95% confidence interval [CI], 0.64-2.93; P = .003) less than the cryoprecipitate group. In the adjusted PP analysis, the FC group received 2.67 units (95% CI, 1.75-3.59; P < .001) less than the cryoprecipitate group. There were no significant differences in secondary outcomes or AEs.Our findings suggest that FC may be considered as an alternative to cryoprecipitate for the treatment of hypofibrinogenemia in infants with bleeding after CPB. Although we found no significant differences between secondary outcomes or AEs, further studies are needed to assess safety.

  View details for DOI 10.1213/ANE.0000000000004384

  View details for PubMedID 31490252

• A Prospective Assessment of Optimal Mechanical Ventilation Parameters for Pediatric Catheter Ablation PEDIATRIC CARDIOLOGY Janson, C. M., Ceresnak, S. R., Choi, J. M., Dubin, A. M., Motonaga, K. S., Mann, G. E., Kahana, M., Fitz-James, I., Wise-Faberowski, L., Kamra, K., Nappo, L., Trela, A., Pass, R. H. 2019; 40 (1): 126–32

  Abstract

  Catheter stability, an important factor in ablation success, is affected by ventilation. Optimal ventilation strategies for pediatric catheter ablation are not known. We hypothesized that small tidal volume and positive end-expiratory pressure are associated with reduced ablation catheter movement at annular positions. Subjects aged 5-25 years undergoing ablation for supraventricular tachycardia (SVT) or WPW at two centers from March 2015 to September 2016 were prospectively enrolled and randomized to receive mechanical ventilation with either positive end-expiratory pressure of 5 cm H2O (PEEP) or 0 cm H2O (ZEEP). Movement of the ablation catheter tip at standard annular positions was measured using 3D electroanatomic mapping systems under two conditions: small tidal volume (STV) (3-5 mL/kg) or large TV (LTV) (6-8 mL/kg). 58 subjects (mean age 13.8 years) were enrolled for a total of 266 separate observations of catheter movement. STV ventilation was associated with significantly reduced catheter movement, compared to LTV at all positions (right posteroseptal: 2.5 ± 1.4 vs. 5.2 ± 3.1 mm, p < 0.0001; right lateral: 2.7 ± 1.6 vs. 6.3 ± 3.5 mm, p < 0.0001; left lateral: 1.8 ± 1.0 vs. 4.3 ± 1.9 mm, p < 0.0001). The presence or absence of PEEP had no effect on catheter movement. In multivariable analysis, STV was associated with a 3.1-mm reduction in movement (95% CI 2.6-3.5, p < 0.0001), adjusting for end-expiratory pressure, annular location, and patient size. We conclude that STV ventilation is associated with reduced ablation catheter movement compared to a LTV strategy, independent of PEEP and annular position.

  View details for PubMedID 30178187

• Surgical results of unifocalization revision. The Journal of thoracic and cardiovascular surgery Mainwaring, R. D., Patrick, W. L., Rosenblatt, T. R., Ma, M., Kamra, K., Arunamata, A., Hanley, F. L. 2018

  Abstract

  OBJECTIVE: Midline unifocalization has been developed for the surgical treatment of pulmonary atresia with ventricular septal defect and major aortopulmonary collateral arteries. All patients will eventually require reoperation due to the presence of a conduit, and some may also require revision of the distal unifocalized bed. The purpose of this study was to evaluate the surgical results of unifocalization revision.METHODS: This was a retrospective review of 254 patients who underwent midline unifocalization for treatment of pulmonary atresia with ventricular septal defect and major aortopulmonary collateral arteries. Forty-eight of 254 patients (18%) have subsequently undergone unifocalization revision. Thirty-two of these patients had previously undergone a single-stage complete repair, whereas 16 had a unifocalization and placement of a central shunt.RESULTS: For the 32 patients who previously underwent a complete repair, there have been no early or late deaths. The peak systolic pulmonary artery to aortic pressure ratio was 0.44±0.11 after the initial repair and increased to 0.82±0.18 before revision. The pressure ratio decreased to 0.41±0.09 after revision. Three of 32 patients (9%) have subsequently undergone a second unifocalization revision. The 16 patients who previously had a unifocalization/shunt underwent unifocalization revision and complete repair (n=14) and revision and repeat shunt (n=2). There was 1 operative mortality and 3 late deaths (25% total) in this cohort. Three (25%) of 12 survivors have subsequently undergone a second unifocalization revision.CONCLUSIONS: The data demonstrate that unifocalization revision can be performed with a successful outcome in a majority of patients. Patients who underwent an initial unifocalization/shunt had a higher failure rate than patients who were initially repaired.

  View details for PubMedID 30982588

• Analysis of achieving an "ideal" outcome following midline unifocalization. Asian cardiovascular & thoracic annals Mainwaring, R. D., Patrick, W. L., Rosenblatt, T. R., Nasirov, T., Kamra, K., Hanley, F. L. 2018: 218492318814079

  Abstract

  OBJECTIVE: Pulmonary atresia with ventricular septal defect and major aortopulmonary collateral arteries is a complex form of congenital heart disease. Midline unifocalization has been developed for the surgical treatment of this condition. There are 3 outcome measures that determine long-term success: patients are alive, patients have achieved complete repair (i.e. ventricular septal defect closure), and patients have a relatively low right ventricle-to-aortic pressure ratio (<0.45). However, to date, no studies have combined these 3 outcome measures to analyze the likelihood of achieving an ideal outcome.METHODS: This was a retrospective review of 255 patients who underwent midline unifocalization for pulmonary atresia with ventricular septal defect and major aortopulmonary collateral arteries. The median age at unifocalization was 4.5 months.RESULTS: Two hundred thirty-five (92%) patients were alive at a mean follow-up of 5.3 years. Two hundred and seventeen (85%) patients underwent single-stage complete repair, and 38 (15%) had an initial unifocalization and shunt. Twenty-four of the 38 palliated patients have subsequently undergone repair. Thus 241 (94%) patients ultimately achieved complete repair. Of the 241 patients who were repaired, 219 (86%) had a right ventricle-to-aortic peak systolic pressure ratio <0.45. Combining these outcome measures, 77% of patients achieved an ideal outcome at one month, 73% at 6 months, 76% at one year, and 80% at 4 years.CONCLUSIONS: Most (80%) patients can achieve all 3 measures of favorable outcome at 4 years following midline unifocalization. We speculate that this will be a favorable portend for the future of these patients.

  View details for DOI 10.1177/0218492318814079

  View details for PubMedID 30417684

• Applying Lessons from an Inaugural Clinical Pathway to Establish a Clinical Effectiveness Program. Pediatric quality & safety Algaze, C. A., Shin, A. Y., Nather, C., Elgin, K. H., Ramamoorthy, C., Kamra, K., Kipps, A. K., Yarlagadda, V. V., Mafla, M. M., Vashist, T., Krawczeski, C. D., Sharek, P. J. 2018; 3 (6): e115

  Abstract

  Introduction: Clinical effectiveness (CE) programs promote standardization to reduce unnecessary variation and improve healthcare value. Best practices for successful and sustainable CE programs remain in question. We developed and implemented our inaugural clinical pathway with the aim of incorporating lessons learned in the build of a CE program at our academic children's hospital.Methods: The Lucile Packard Children's Hospital Stanford Heart Center and Center for Quality and Clinical Effectiveness partnered to develop and implement an inaugural clinical pathway. Project phases included team assembly, pathway development, implementation, monitoring and evaluation, and improvement. We ascertained Critical CE program elements by focus group discussion among a multidisciplinary panel of experts and key affected groups. Pre and postintervention compared outcomes included mechanical ventilation duration, cardiovascular intensive care unit, and total postoperative length of stay.Results: Twenty-seven of the 30 enrolled patients (90%) completed the pathway. There was a reduction in ventilator days (mean 1.0+0.5 versus 1.9+1.3 days; P < 0.001), cardiovascular intensive care unit (mean 2.3+1.1 versus 4.6+2.1 days; P < 0.001) and postoperative length of stay (mean 5.9+1.6 versus 7.9+2.7 days; P < 0.001) compared with the preintervention period. Elements deemed critical included (1) project prioritization for maximal return on investment; (2) multidisciplinary involvement; (3) pathway focus on best practices, critical outcomes, and rate-limiting steps; (4) active and flexible implementation; and (5) continuous data-driven and transparent pathway iteration.Conclusions: We identified multiple elements of successful pathway implementation, that we believe to be critical foundational elements of our CE program.

  View details for DOI 10.1097/pq9.0000000000000115

  View details for PubMedID 31334447

• Surgical algorithm and results for repair of pulmonary atresia with ventricular septal defect and major aortopulmonary collaterals. The Journal of thoracic and cardiovascular surgery Mainwaring, R. D., Patrick, W. L., Roth, S. J., Kamra, K., Wise-Faberowski, L., Palmon, M., Hanley, F. L. 2018

  Abstract

  OBJECTIVE: Pulmonary atresia with ventricular septal defect and major aortopulmonary collateral arteries is a complex and heterogeneous form of congenital heart disease. There is a controversy regarding the optimal treatment of pulmonary atresia with ventricular septal defect and major aortopulmonary collateral arteries. The purpose of this study was to summarize our algorithm and surgical results for pulmonary atresia with ventricular septal defect and major aortopulmonary collateral arteries.METHODS: This was a retrospective review of 307 patients undergoing primary surgical treatment of pulmonary atresia with ventricular septal defect and major aortopulmonary collateral arteries. Excluded from this analysis were patients who had undergone prior surgical treatment at another institution and patients with single ventricle and major aortopulmonary collateral arteries. There were 3 surgical pathways, including midline unifocalization (n=241), creation of an aortopulmonary window (n=46), and other (n=20).RESULTS: For the 241 patients who underwent midline unifocalization, 204 (85.4%) had a single-stage complete repair. There were 37 patients who underwent a midline unifocalization and central shunt, and 24 have subsequently undergone complete repair. Forty-six patients underwent an aortopulmonary window, of whom 36 have subsequently had a complete repair. There were 20 patients who had complex anatomy and underwent procedures other than described, and14 have subsequently undergone complete repair. Thus, for the patients currently eligible, 280 (93.0%) have achieved complete repair. For the 204 patients who had a single-stage complete repair, the mean right ventricle to aortic pressure ratio was 0.36±0.09. Seventy-six patients underwent a staged repair, and the mean right ventricle to aortic pressure ratio was 0.40±0.09 (P<.05 compared with single-stage repair). There were 3 (1.5%) early and 8 (4.0%) late deaths for the single-stage complete repair cohort versus 4 (4.0%) early and 15 (14.9%) late deaths for all other procedures (P<.01).CONCLUSIONS: The data demonstrate that more than 90% of patients with pulmonary atresia with ventricular septal defect and major aortopulmonary collateral arteries achieved complete repair. The overall mortality was significantly lower in the subgroup of patients who underwent single-stage complete repair.

  View details for PubMedID 29789151

• Reply to Breschan et al, re 'central venus catheter placement in children'. Paediatric anaesthesia Kamra, K., Hammer, G. 2014; 24 (3): 345-?

  View details for DOI 10.1111/pan.12352

  View details for PubMedID 24467577

• Central venous catheter placement in children: 'How good is good enough?' PEDIATRIC ANESTHESIA Kamra, K., Hammer, G. B. 2013; 23 (11): 971–73

  View details for PubMedID 24088200

• Role of transesophageal echocardiography in the management of pediatric patients with congenital heart disease PEDIATRIC ANESTHESIA Kamra, K., Russell, I., Miller-Hance, W. C. 2011; 21 (5): 479-493

  Abstract

  Transesophageal echocardiography (TEE) has become a critical diagnostic and perioperative management tool for patients with congenital heart disease (CHD) undergoing cardiac and noncardiac surgical procedures. This review highlights the role of TEE in routine management of pediatric cardiac patient population with focus on indications, views, applications and technological advances.

  View details for DOI 10.1111/j.1460-9592.2011.03570.x

  View details for PubMedID 21481076

• Perioperative complications in children with pulmonary hypertension undergoing general anesthesia with ketamine PEDIATRIC ANESTHESIA Williams, G. D., Maan, H., Ramamoorthy, C., Kamra, K., Bratton, S. L., Bair, E., Kuan, C. C., Hammer, G. B., Feinstein, J. A. 2010; 20 (1): 28-37

  Abstract

  Pulmonary arterial hypertension (PAH) is associated with significant perioperative risk for major complications in children, including pulmonary hypertensive crisis and cardiac arrest. Uncertainty remains about the safety of ketamine anesthesia in this patient population.Retrospectively review the medical records of children with PAH to ascertain the nature and frequency of peri-procedural complications and to determine whether ketamine administration was associated with peri-procedural complications.Children with PAH (mean pulmonary artery pressure > or =25 mmHg and pulmonary vascular resistance index > or =3 Wood units) who underwent general anesthesia for procedures during a 6-year period (2002-2008) were enrolled. Details about the patient, PAH, procedure, anesthetic and postprocedural course were noted, including adverse events during or within 48 h of the procedure. Complication rates were reported per procedure. Association between ketamine and peri-procedural complications was tested.Sixty-eight children (median age 7.3 year, median weight 22 kg) underwent 192 procedures. Severity of PAH was mild (23%), moderate (37%), and severe (40%). Procedures undertaken were major surgery (n = 20), minor surgery (n = 27), cardiac catheterization (n = 128) and nonsurgical procedures (n = 17). Ketamine was administered during 149 procedures. Twenty minor and nine major complications were noted. Incidence of cardiac arrest was 0.78% for cardiac catheterization procedures, 10% for major surgical procedures and 1.6% for all procedures. There was no procedure-related mortality. Ketamine administration was not associated with increased complications.Ketamine appears to be a safe anesthetic option for children with PAH. We report rates for cardiopulmonary resuscitation and mortality that are more favorable than those previously reported.

  View details for DOI 10.1111/j.1460-9592.2009.03166.x

  View details for PubMedID 20078799

• A randomized, controlled trial of aprotinin in neonates undergoing open-heart surgery PEDIATRIC ANESTHESIA Williams, G. D., Ramamoorthy, C., Pentcheva, K., Boltz, M. G., Kamra, K., Reddy, V. M. 2008; 18 (9): 812-819

  Abstract

  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 Williams, G. D., Philip, B. M., Chu, L. F., Boltz, M. G., Kamra, K., Terwey, H., Hammer, G. B., Perry, S. B., Feinstein, J. A., Ramamoorthy, C. 2007; 105 (6): 1578-1584

  Abstract

  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 Williams, G. D., Ramamoorthy, C., Chu, L., Hammer, G. B., Kamra, K., Boltz, M. G., Pentcheva, K., McCarthy, J. P., Reddy, V. M. 2006; 132 (6): 1291-1298

  Abstract

  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

• Esophageal saturation during antegrade cerebral perfusion: a preliminary report using visible light spectroscopy PEDIATRIC ANESTHESIA Heninger, C., Ramamoorthy, C., Amir, G., Kamra, K., Reddy, V. M., Hanley, F. L., Brock-Utne, J. G. 2006; 16 (11): 1133-1137

  Abstract

  Visible light spectroscopy (VLS) is newer technology that measures real-time tissue oxygenation. It has been validated in detecting mucosal ischemia in adults. During complex neonatal heart surgery, antegrade cerebral perfusion (ACP) maintains cerebral saturation. Whether ACP maintains peripheral tissue perfusion in humans is not known.Five patients undergoing neonatal open heart surgery with hypothermic cardiopulmonary bypass (CPB) were studied using a VLS esophageal probe in addition to bilateral near infrared cerebral oximetry. Three of five patients required ACP for arch repair, while two patients did not. VLS and cerebral saturation data were collected and analyzed in 5 min intervals prior to CPB, during CPB, and during ACP.In the two patients undergoing heart surgery with routine hypothermic CPB, both cerebral and esophageal saturations were maintained. However in all three neonates requiring ACP, although cerebral saturations did not decrease, esophageal saturation fell below the ischemic threshold (35%). Following establishment of normal CPB, esophageal saturation returned to baseline.Antegrade cerebral perfusion maintains cerebral oxygen delivery, however, it does not adequately perfuse the esophagus in neonates. This could have clinical implications.

  View details for DOI 10.1111/j.1460-9592.2006.01965.x

  View details for Web of Science ID 000241245400004

  View details for PubMedID 17040301

• Postoperative analgesia after spinal blockade in infants and children undergoing cardiac surgery ANESTHESIA AND ANALGESIA Hammer, G. B., Ramamoorthy, C., Cao, H., Williams, G. D., Boltz, M. G., Kamra, K., Drover, D. R. 2005; 100 (5): 1283-1288

  Abstract

  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