A 16-YR-OLD obese male (body mass index: 35 kg/m 2 ) underwent a 5-h left knee multiligamentous reconstruction under tourniquet application for a football-related injury. Postoperative analgesia was provided with 0.2% ropivacaine infused through femoral and sciatic nerve catheters. After surgery the patient complained of excessive pressure in his thigh. On postoperative day 1, he developed loss of ankle dorsiflexion, cola-colored urine (myoglobinuria), and increased blood creatine phosphokinase (more than 32,000 units/l). His thigh compartment pressures were found to be high but did not warrant fasciotomy. He was treated with forced alkaline diuresis to prevent acute renal failure. His foot weakness recovered after 9 months of physical therapy.An axial fat saturated contrast enhanced T1-weighted magnetic resonance image of his left thigh ( fig.) was obtained on postoperative day 3. There is heterogeneous muscle enhancement involving anterior, medial, and posterior compartments (predominantly adductor magnus and vastus lateralis). Central areas of lack of enhancement indicate muscle necrosis (arrows), an imaging appearance consistent with rhabdomyolysis. 1Extreme tourniquet-induced ischemia causes metabolic (anaerobic), cellular, and microvascular changes (endothelial injury), leading to muscle breakdown (rhabdomyolysis) and compartment syndrome.2 Alhough there are no tourniquet guidelines specifically pertaining to muscle injury, inflation pressure Յ100 mmHg above systolic blood pressure, inflation time Յ120 min, deflation time Ն30 min, and reinflation time Յ90 min are recommended to prevent ischemic nerve injury.3 Tourniquet pressure (300 mmHg) and duration (150 min inflation, 30 min deflation, and 100 min reinflation) in our patient exceeded guidelines. It is likely that ischemia was exaggerated by tourniquet size-mismatch due to obesity. Our case calls for strict adherence to tourniquet guidelines, prompt diagnosis, and timely intervention to prevent tourniquet related morbidity. References1. Moratalla MB, Braun P, Fornas GM: Importance of MRI in the diagnosis and treatment of rhabdomyolysis. Eur J Radiol 2008; 65:311-5 2. Newman RJ: Metabolic effects of tourniquet ischaemia studied by nuclear magnetic resonance spectroscopy. J Bone Joint Surg Br 1984; 66:434 -40 3. Horlocker TT, Hebl JR, Gali B, Jankowski CJ, Burkle CM, Berry DJ, Zepeda FA, Stevens SR, Schroeder DR: Anesthetic, patient, and surgical risk factors for neurologic complications after prolonged total tourniquet time during total knee arthroplasty.

We describe a process by which we sought to determine how the addition of intraoperative neurophysiologic monitoring (IONM) impacted the management of cardiopulmonary bypass (CPB) during pediatric cardiac surgery. While maintaining a consistent team of surgeons, anesthesiologists, nurses, and perfusionists, a multi-modal, IONM program was established consisting of Near Infrared Spectroscopy, Transcranial Doppler, and eight channel electroencephalography. A retrospective review of cases from 1 year before the institution of the IONM program was compared with data obtained from cases performed after neurophysiologic monitoring was established as a standard of care for pediatric patients on CPB. This comparative analysis of CPB management revealed a significant increase in the use of donor blood added to the CPB circuit prime as well as in the maintenance of a higher hematocrit during the bypass period after the implementation of IONM. These changes in the management of pediatric CPB correlated with recommendations of previous studies that examined postoperative neurophysiologic outcomes, suggesting that these changes were not only consistent with best practices, but that the presence of IONM data facilitated a transition to evidence-based practice.

Pediatric patients with ESLD requiring liver transplantation often have a multitude of comorbidities ranging from pulmonary hypertension to renal and cardiovascular insufficiency that impairs our ability to safely care for these critically ill children. As organ allocation techniques advance, many of these patients may be healthier on arrival to the operating room. However, postoperative surgical complications and immunosuppressive regimens still daunt us. As we continue to care for these challenging patients, hopefully, advances in ESLD management and technology will dramatically improve outcomes in the future.

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