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Lung transplantation in the United States has steadily grown over the last decade. Major attention has been with the understanding of lung ischemia-reperfusion injury and how it relates to primary graft dysfunction. In 2015, our institution implemented the use of a pulmonoplegia solution during recipient surgery of lung transplantation. A unique circuit utilizing the heart lung machine is used to deliver the pulmonoplegia solution. This system is considered to be a key contributing factor to the success of our lung transplant program.

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PURPOSE: The published literature on the use of dexmedetomidine as an adjunct to sedation and analgesia in the management of pediatric narcotic withdrawal was reviewed. SUMMARY: Pediatric narcotic withdrawal syndromes are reported to be increasingly frequent in pediatric intensive care units. A number of tools specifically designed for assessment of withdrawal in newborns and infants are in current use, including the widely used Finnegan Scoring System. A limited number of studies and case reports suggest that dexmedetomidine, an α(2)-receptor agonist with a mechanism of action similar to that of clonidine but with greater α(2)-receptor specificity, might have a role in the treatment of pediatric withdrawal (by blunting withdrawal symptoms without causing respiratory depression and by permitting shorter narcotic tapering schedules) and also in the prevention of pediatric narcotic withdrawal (by reducing narcotic requirements). Potential adverse effects associated with dexmedetomidine use in pediatric patients are generally associated with use of bolus doses and mainly involve central nervous system effects (e.g., hypotension, bradycardia), with no hemodynamic manifestations. When bolus doses are used, strategies described in published reports entail a loading dose of 0.5-1.0 µg/kg administered over 5-10 minutes, followed by a continuous infusion at 0.1-1.4 µg/kg/hr for a period of 1-16 days. More research is needed to define the optimal use of dexmedetomidine in the management of pediatric narcotic withdrawal. CONCLUSION: A limited body of published evidence from retrospective studies and case reports suggests a potential role for dexmedetomidine as an adjunct therapy to provide sedation and analgesia to reduce narcotic withdrawal symptoms in pediatric patients.

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Bivalirudin is a direct thrombin inhibitor approved for use in adult patients with heparin-induced thrombocytopenia (HIT) undergoing percutaneous coronary intervention. Recently, its use in the pediatric population has increased due to its anti-thrombin-independent mechanism of action. As heparin products produce great inter- and intraindividual variability in pediatric patients, often due to decreased anti-thrombin concentrations in the first year of life, some practitioners have turned to direct thrombin inhibitors, such as bivalirudin, for more predictable pharmacokinetics and effects on bound and circulating thrombin. We report our experience using bivalirudin in a 2-month-old female with recurrent systemic thrombi despite continuous unfractionated heparin infusion. Due to the patient's inability to maintain therapeutic activated partial thromboplastin time (aPTT) values during heparin infusion, bivalirudin was initiated at 0.1 mg/kg/h and increased due to subtherapeutic aPTTs to a maximum of 0.58 mg/kg/h. Therapeutic aPTTs were achieved at the increased dose; however, the patient's worsening renal impairment with resultant drug accumulation and overwhelming sepsis on day 5 of therapy led to discontinuation of the infusion and the initiation of comfort measures.

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Neurotoxicity related to the use of ifosfamide is a well-known complication. While the use of methylene blue is a known antidote, symptomatic treatment of the central nervous system (CNS) effects can be challenging. We present a case of class IV neurotoxicity with the successful treatment of symptomology. In this case report we present a 2-year-old female with relapsed alveolar rhabdomyosarcoma undergoing palliative chemotherapy. Patient received ifosfamide in addition to etoposide and mesna. The patient developed acute hallucinations, agitation, and delirium. The patient was transferred to the pediatric intensive care unit where she was administered dexmedetomidine overnight in addition to methylene blue. The patient awoke the next morning following discontinuation of the dexmedetomidine infustion and subsequently had no further central nervous system effects. This case demonstrates the novel use of an alpha-2 agonist in the treatment of neurotoxicity related to ifosfamide administration.

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