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Management of a pediatric airway can be a challenge, especially for the non-pediatric anesthesiologists. Structured algorithms for an unexpected difficult pediatric airway have been missing so far. A recent step wise algorithm, based on the Difficult Airway society (DAS) adult protocol, is a step in the right direction. There have been some exciting advances in development of pediatric extra-glottic devices for maintaining ventilation, and introduction of pediatric versions of new 'non line of sight' laryngoscopes and optical stylets. The exact role of these devices in routine and emergent situations is still evolving. Recent advances in simulation technology has become a valuable tool in imparting psychomotor and procedural skills to trainees and allied healthcare workers. Moving toward the goal of eliminating serious adverse events during the management of routine and difficult pediatric airway, authors propose that institutions develop a dedicated Difficult Airway Service comprising of a team of experts in advanced airway management.

Ebstein anomaly accounts for 1% of all congenital heart disease. It is a right ventricular myopathy with failure of tricuspid valve delamination and highly variable tricuspid valve morphology that usually results in severe regurgitation. It is the only congenital heart lesion that has a range of clinical presentations, from the severely symptomatic neonate to an asymptomatic adult. Neonatal operation has high operative mortality, whereas operation performed beyond infancy and into adulthood has low operative mortality. Late survival and quality of life for hospital survivors are excellent for the majority of patients in all age brackets. Atrial tachyarrhythmias are the most common late complication. There have been more techniques of tricuspid repair reported in the literature than any other congenital or acquired cardiac lesion. This is largely due to the infinite anatomic variability encountered with this anomaly. The cone reconstruction of Ebstein anomaly can achieve near anatomic restoration of the tricuspid valve anatomy. Early and intermediate results with these repairs are promising. Reduced right ventricular function continues to be a challenge for some patients, as is the need for reoperation for recurrent tricuspid regurgitation. The purpose of this article is to outline the current standard of care for diagnosis and treatment of Ebstein anomaly and describe innovative strategies to address poor right ventricular function and associated right-sided heart failure.

BACKGROUND: There are few comparative data on the analgesic options used to manage patients undergoing minimally invasive repair of pectus excavatum (MIRPE). The Society for Pediatric Anesthesia Improvement Network was established to investigate outcomes for procedures where there is significant management variability. For our first study, we established a multicenter observational database to characterize the analgesic strategies used to manage pediatric patients undergoing MIRPE. Outcome data from the participating centers were used to assess the association between analgesic strategy and pain outcomes. METHODS: Fourteen institutions enrolled patients from June 2014 through August 2015. Network members agreed to an observational methodology where each institution managed patients based on their institutional standards and protocols. There was no requirement to standardize care. Patients were categorized based on analgesic strategy: epidural catheter (EC), paravertebral catheter (PVC), wound catheter (WC), no regional (NR) analgesia, and intrathecal morphine techniques. Primary outcomes, pain score and opioid consumption by postoperative day (POD), for each technique were compared while adjusting for confounders using multivariable modeling that included 5 covariates: age, sex, number of bars, Haller index, and use of preoperative pain medication. Pain scores were analyzed using repeated-measures analysis of variance with Bonferroni correction. Opioid consumption was analyzed using a multivariable quantile regression. RESULTS: Data were collected on 348 patients and categorized based on primary analgesic strategy: EC (122), PVC (57), WC (41), NR (120), and intrathecal morphine (8). Compared to EC, daily median pain scores were higher in patients managed with PVC (POD 0), WC (POD 0, 1, 2, 3), and NR (POD 0, 1, 2), respectively (P < .001–.024 depending on group). Daily opioid requirements were higher in patients managed with PVC (POD 0, 1), WC (POD 0, 1, 2), and NR (POD 0, 1, 2) when compared to patients managed with EC (P < .001). CONCLUSIONS: Our data indicate variation in pain management strategies for patients undergoing MIRPE within our network. The results indicate that most patients have mild-to-moderate pain postoperatively regardless of analgesic management. Patients managed with EC had lower pain scores and opioid consumption in the early recovery period compared to other treatment strategies.

Recent reports associate Staphylococcus lugdunensis with severe infection in humans. The frequency of this microorganism in urine cultures is unknown. Five hundred isolates of coagulase-negative staphylococci (CoNS) were recovered from 4,652 consecutive urine specimens submitted for culture to the Mayo Clinic Microbiology Laboratory. Thirty-one (6%) of 500 isolates of CoNS were identified as S. lugdunensis. In no case was S. lugdunensis isolated in pure culture; 29 (94%) of 31 S. lugdunensis isolates were part of mixed nonpathogenic flora. Medical records were reviewed for 30 of the 31 patients from whom these 31 isolates were isolated. Twenty-one (70%) of the 30 evaluable patients were not treated with antibiotics; the remaining 9 (30%) of 30 patients were treated with antibiotics that may be effective against S. lugdunensis. S. lugdunensis may be an unrecognized yet infrequent cause of urinary tract infection.Staphylococcus lugdunensis is a member of the coagulasenegative staphylococci (CoNS) which has been associated with serious infections in humans. Patients infected with the organism have a clinical presentation much like that of patients infected with Staphylococcus aureus. Reports have associated S. lugdunensis with skin and soft tissue infections (3, 5), respiratory infections (3), bacteremia, including endocarditis (1,2,3,6,7,8,11), intravascular catheter or pacemaker infections (3), prosthetic joint infections (9), and peritonitis (10).We are aware of only one study which has determined the frequency of S. lugdunensis in consecutive clinical cultures. Herchline and Ayers (3) surveyed S. lugdunensis isolates from clinical specimens in their laboratory over a 63-month period. They noted the following anatomical distribution frequencies for 229 S. lugdunensis isolates recovered from 155 specimens submitted from 143 patients: skin, n ϭ 7 (4.5%); abscesses, n ϭ 14 (9.0%); wounds, n ϭ 65 (41.9%); respiratory tract, n ϭ 13 (8.4%); blood, n ϭ 15 (9.7%); intravascular catheters, n ϭ 11 (7.7%); urogenital tract, n ϭ 15 (9.7%); and other, n ϭ 15 (9.7%) (3). Those investigators did not specify how many of the specimens from the urogenital site were urine specimens, and they did not indicate the reporting procedures for urine specimens. For example, it is not known whether S. lugdunensis isolates were identified in urine or whether these isolates occurred in pure culture or were part of a mixed flora, and the colony counts are not known.The objectives of the present study were to determine the frequency of S. lugdunensis in 4,652 consecutive urine specimens submitted to our laboratory for bacterial culture and the relationship between these isolates and urinary tract infection.Patient population. All urine specimens for culture were collected from patients evaluated at the Mayo Medical Center in Rochester, Minnesota, between 24 July 2000 and 12 September 2000. The study was reviewed and approved by the Mayo Clinic Institutional Review Board; samples from patients who declined use of their specimens and medical his...