Drainage In Children Research Articles

Laparoscopic treatment of appendiceal peritonitis without drainage in children—A prospective randomized clinical trial

BackgroundRoutine placement of a drain for complicated appendicitis is one of the approaches to reduce postoperative complication. In a resource-limited hospital where radiologist-directed monitoring is not feasible, drainage is beneficial for complication follow-up. Nevertheless, emerging studies indicated drainage did not significantly impact on amelioration of patients’ outcomes. This study aimed to compare the postoperative results of pediatric patients with or without drainage after laparoscopic appendectomy for complicated appendicitis at a rural children's hospital. MethodsWe performed a quasi-randomized recruitment of pediatric patients who underwent laparoscopic treatment for complicated appendicitis with or without drainage. Several parameters, including operative time, lengths of stay, complication rate, duration of antibiotic administration, and hospital charges were monitored for assessment. ResultsFrom 05/2020 to 05/2022, there were 184 cases of recruited pediatric patients who underwent laparoscopic appendectomy for complicated appendicitis, with 91 patients in drain-placing group (49.5%). Demographic baseline and pre-surgery symptoms did not indicate any differences between two groups. Data of postoperative complications including intra-abdominal abscesses and wound infections showed no significance in discrepancy. Notably, patients of drainage group experienced longer length of stay than non-drainage group, with average of 8.5 days and 7.5 days, respectively (p<0.0001). Additionally, the significantly higher number of hospital charges was observed in the those with peritoneal drain (p<0.0001). ConclusionOur records showed that routine placement of a peritoneal drain after laparoscopic appendectomy in pediatric patients with complicated appendicitis did not impact on the outcomes, but prolonged hospital stay and caused more hospital charges.

Image-guided abscess drainage in children with perforated appendicitis - can it wait?

Image-guided drainage is the management of choice for perforated appendicitis with intra-abdominal abscess/es. However, there is paucity of data regarding the optimal time for intervention in children. The purpose of this study is to assess the relationship between the time from diagnosis of a drainable abscess to abscess drainage (delta time) and the clinical outcome in patients with complicated acute appendicitis. This is an institutional review board (IRB)-approved retrospective study comprising 80 pediatric patients who had image-guided abscess drainage due to perforated acute appendicitis. Delta time was associated with clinical outcome including length of stay, catheter dwell time, need for additional interventions, and need for tissue plasminogen activator (t-PA). Gamma regression models were used to assess the adjusted effect of delta time on the "length of stay" and "catheter dwell time" using "volume of the largest abscess" and "number of collections" as severity indices. Logistic regression was used to assess the effect of delta time on the "need for the t-PA" and "need for additional interventions." Mean age (SD) was 10.2 (3.8) years. Mean time between diagnosis and intervention (delta time) was 1.5 (1.2) days. There was no evidence that delta time effects the length of stay, catheter dwell time, need for t-PA, and need for additional interventions (P > 0.05). However, there was an association between the number of collections and volume of the largest abscess with length of stay (P = 0.006; P = 0.058), catheter dwell time (P = 0.029; P < 0.001), and need for additional interventions (P = 0.029; P = 0.016). Our results suggest that time between diagnosis of an appendicitis associated abscess and intervention is not significantly associated with need for tPA, need for additional intervention, drain dwell time, or length of stay.

Digital Thoracic Drainage System: A New Tool For Pediatric Thoracic Surgery.

Digital thoracic drainage systems usage in pediatrics is underreported, making current recommen- dations based on those for adults. We aim to review our experience on the use of this digital system and to evaluate the adequacy of those recommendations. Retrospective analysis of patients in whom digital thoracic drainage system was used. All patients were submitted to thoracoscopic bleb/apical lung resection for primary spontaneous pneumothorax. Initially patients were man- aged using the few existing recommendations for children, but after 2 unsuccessful cases we changed our approach into tube clamping after continuous air leak < 5mL/min for at least 24 hours. Seventeen procedures (median 17.2-years) were performed; there were no intraoperative complications. After changing the air leak target, 11 procedures were consecutively managed without complications; the median number of chest radiographs per procedure was 3.0 and the median number of days with chest tube was 4.0 days. This is the first report on the usage of this system in children in Portugal. This system constitutes an important technological innovation, but it needs more data gathering and prospective trials in order to maximize its use in children. The authors suggest an algorithm for the management of thoracic digital drainage in children: removal of chest tubes when the air leak is <5mL/min for 24 hours and to perform chest tube clamping for a minimum of 6 hours before removal.

Risk Factors of Recurrent Appendiceal Abscess after Initial Non-Surgical Treatment without Drainage of Children with Appendiceal Abscess: A Single Center Retrospective Review.

Background: Exploration of the risk factors of recurrent appendiceal abscess after initial non-surgical treatment without drainage in children with appendiceal abscess. Patients and Methods: The medical records of all children diagnosed with appendiceal abscess and who were treated conservatively in the Children's Hospital of Chongqing Medical University from June 2012 to June 2020 were collected. The collected cases were divided into the recurrent group and the non-recurrent group, and all clinical indicators were compared. Logistic regression analysis was used to determine the risk factors for recurrent appendiceal abscess in children. Results: One hundred twenty-four patients were included and among them, 62 (50.0%) had clinical manifestations of recurrent appendiceal abscess (the recurrent group) and five patients (8%) suffered several instances of recurrence. Duration of intravenous antibiotic agents (odds ratio [OR], 0.905; 95% confidence interval [CI], 0.820-1.000) was independently associated with the recurrence of appendiceal abscess. The risk of recurrence was increased in children with the white blood cell (WBC) count at discharge greater than 8 × 109/L (OR, 2.702; 95% CI,1.172-6.231), the ratio of mass size to body surface area (BSA) at discharge greater than 4.255 (OR, 1.369; 95% CI, 1.104-1.697), and without continuous oral antibiotic agents after discharge (OR, 3.111; 95% CI, 1.240-7. 802). Conclusions: Interval appendectomy is recommended for children with WBC count at discharge greater than 8 × 109/L, and the ratio of mass size to BSA at discharge greater than 4.255, because they are more likely to develop recurrent appendiceal abscess after initial conservative treatment. The duration of intravenous antibiotic agents is an independent factor of the recurrence of appendiceal abscess, and a longer course of intravenous antibiotic agents is strongly associated with a reduced risk of recurrence. Continued oral antibiotic agents after discharge can effectively reduce the risk of recurrence of appendiceal abscesses.

Pancreas trauma in children

Pancreatic trauma in children is rare in the context of abdominal trauma and difficult to diagnose, a delay in it can lead to complications such as: pseudocysts, peritonitis and endocrine or exocrine insufficiency, which are associated with high morbidity and mortality. Pseudocysts of the pancreas appear after an isolated or complex trauma, as a result of the ductoacrinary ruptures, with the extravasation of the pancreatic fluid in the retro-stomach cavity, the peripheral and visceral peritoneum. Recent studies show that 25% of pancreatic pseudocysts are traumatic in nature. The objectives of the surgical treatment are: complete evacuation of the contents of the pseudocyst, resection of the lips of the anterior wall with external drainage in children, unlike adults, where internal drainage is practiced, so an internal derivation on the loop. We present the cases of 3 patients examined and treated in the National Scientific-Practical Center for Pediatric Surgery „Natalia Gheorghiu” during 4 years (2018-2021). The evolution of the patients was favorable, due to the treatment tactics adapted to each individual case.

Comparison of catheter drainage with incision drainage in children with soft tissue abscesses.

Objective: To compare the efficacy of catheter drainage with incision and drainage in children having soft tissue abscess. Study Design: Randomized Control Trial. Setting: Department of Paediatric Surgery, Allied Hospital Faisalabad. Period: January 2016 to June 2017. Material &amp; Methods: After taking approval from the hospital ethical committee, 160 patients coming through OPD of the department who fulfilled the inclusion criteria were enrolled, and informed consent was taken from them. The patients were randomly divided into two groups using a computer-generated random number table. In group A, patients underwent catheter drainage method, and in group B, patients underwent incision and drainage method. Results: Out of 160 cases (80 in each group), 60% (n=48) in Group-A and 67.5% (n=54) in Group-B were between 1-6 years while 40% (n=32) in Group-A and 32.5% (n=26) in Group-B were 7-12 years of age. 70% (n=56) in Group-A and 67.5% (n=54) in Group-B were males. On efficacy comparison, it was shown that 73.75% (n=59) in Group-A and 47.5% (n=38) in Group-B had efficacy; the p-value was calculated as 0.0007, showing a significant difference. Conclusion: We concluded that catheter drainage is better than incision and drainage in children having soft tissue abscess in terms of length of hospital stay ˂ 24 hours.

Implantation of monocusp valve prolongs the duration of chest tube drainage in children with tetralogy of fallot after corrective surgery.

Right ventricular outflow tract obstruction relief is one of the major procedures during the total correction of tetralogy of Fallot (TOF). Pulmonary insufficiency (PI) is usually inevitable after a transannular incision with a patch repair is performed. Therefore, some surgeons advocate to place a monocusp valve within the transannular patch (TAP) in order to decrease the severity of the PI. However, the monocusp valve seemed not be very effective in some patients who underwent the complete TOF repair. Patients who had the classic form of TOF between January 2009 and January 2017 and underwent the corrective surgery with a TAP by the same cardiovascular surgeon were identified for further analysis. Clinical information including demographics at operation, perioperative data, and postoperative outcome were collected retrospectively and compared between the group with and without a monocusp valve. A total of 24 TOF cases were included in the final analysis, and 16 (66.7%) patients received a monocusp valve placement. The patients' characteristics before and during the surgery were similar between the two groups. The median duration of chest tube drainage after the total correction in the monocusp group was longer than those without the valve (p = 0.04). There was no difference in the immediate postoperative data, including the inflammation/infection status, the duration of mechanical ventilation, and the length of ICU and hospital stay. Implantation of a monocusp valve during the total TOF correction using a TAP did not bring benefit to improve the immediate postoperative outcomes, especially the duration of the pleural drainage. Further study with a prospective design and a larger number of cases is needed.

Outcomes of Endoscopic Drainage in Children with Pancreatic Fluid Collections: A Systematic Review and Meta-Analysis.

PurposeEndoscopic drainage is an established treatment modality for adult patients with pancreatic fluid collections (PFCs). Available data regarding the efficacy and safety of endoscopic drainage in pediatric patients are limited. In this systematic review and meta-analysis, we aimed to analyze the outcomes of endoscopic drainage in children with PFCs.MethodsA literature search was performed in Embase, PubMed, and Google Scholar for studies on the outcomes of endoscopic drainage with or without endoscopic ultrasonography (EUS) guidance in pediatric patients with PFCs from inception to May 2021. The study’s primary objective was clinical success, defined as resolution of PFCs. The secondary outcomes included technical success, adverse events, and recurrence rates.ResultsFourteen studies (187 children, 70.3% male) were included in this review. The subtypes of fluid collection included pseudocysts (60.3%) and walled-off necrosis (39.7%). The pooled technical success rates in studies where drainage of PFCs were performed with and without EUS guidance were 95.3% (95% confidence interval [CI], 89.6–98%; I2=0) and 93.9% (95% CI, 82.6–98%; I2=0), respectively. The pooled clinical success after one and two endoscopic interventions were 88.7% (95% CI, 82.7–92.9%; I2=0) and 92.3% (95% CI, 87.4–95.4%; I2=0), respectively. The pooled rate of major adverse events was 6.3% (95% CI, 3.3–11.4%; I2=0). The pooled rate of recurrent PFCs after endoscopic drainage was 10.4% (95% CI, 6.1–17.1%; I2=0).ConclusionEndoscopic drainage is safe and effective in children with PFCs. However, future studies are required to compare endoscopic and EUS-guided drainage of PFCs in children.

Rapid Administration of Ketamine for Abscess Drainage in Children-A Dose Finding Study.

To estimate the minimum dose and total sedation time of rapidly infused ketamine that achieves 3 to 5 minutes of effective sedation in children undergoing abscess incision and drainage in the emergency department. The Up-Down method was used to estimate the dose of intravenous ketamine infused over 5 seconds or less that provided effective sedation in 50% (ED50) and 95% (ED95) for healthy children aged 2 to 5 years and 6 to 11 years undergoing abscess incision and drainage. None were pretreated with opioids. Three investigators blinded to ketamine dose independently graded sedation effectiveness by viewing a video recording of the first 5 minutes of sedation. Recovery was determined when patients reached a Modified Aldrete score of 10. We enrolled 20 children in each age group. The estimated ED50 was 0.9 and 0.6 mg/kg for the 2 to 5 years and 6 to 11 years' groups and the estimated ED95 was 1.1 mg/kg for both groups. The median time to full recovery for the 2 groups was 20.5 and 17.5 minutes when only 1 dose of ketamine was administered and 27.5 and 35 minutes when additional doses of ketamine were administered. No participants experienced serious adverse events. We estimated ED50 and ED95 for rapidly infused ketamine for 2 age groups undergoing abscess incision and drainage. Further studies are needed to get a more precise estimate of ED95. The total sedation time with this technique in the abscess group was shorter than most previous studies and is consistent with our previous observations in patients undergoing fracture reduction.

The use of assisted autogenic drainage in children with cystic fibrosis; a pilot randomized controlled study

BACKGROUND:Airway clearance therapy (ACT) is standard practice to promote pulmonary mucus clearance in children with cystic fibrosis (CF). However, the efficacy of assisted autogenic drainage (AAD) in children has not been studied. OBJECTIVES:To pilot a home-based randomized controlled trial (RCT) to compare the effects of AAD to standard ACT in children with CF aged one to eight years. METHODS:Children with CF, aged one to eight years, were randomly assigned into intervention (AAD) or control (standard ACT) groups. The ACTs were taught to parents and children, to perform twice daily for a year. Primary outcome measures were number of hospitalizations, days of hospitalization, exacerbations and days of antibiotic therapy in one year. Secondary outcome measures included spirometry, and adherence assessed on every visit (through calendar and sticker system); parental proxy health related quality of life score (EQ-5D-Y), current clinical status (CF Clinical Score), weight-, height-, and BMI-for-age z-scores assessed at baseline and after one year; and preference of ACT and mortality rates were assessed at the end of the study. At the end of the study, a self-designed one on one subjective semi-structured interview with the parent(s)/caregiver(s) regarding physiotherapy management was conducted. RESULTS:Of 36 children screened for inclusion, 16 were enrolled. Seven were randomly allocated to the control group (median [IQR] age 5.7 [3.0–6.0] years, four male and three female), and nine to the intervention group (median [IQR] age 5.8 [5.5–6.6] years, five male and four female). There were no significant between-group differences, however number of exacerbations revealed medium (Cohen’s d = 0.55) effect sizes, favoring the intervention group. Although no significant improvements were seen within the intervention group, large effect sizes were found for the CF subjective and total clinical scores; and health related quality of life (Cohen’s d = 1.07, d = 0.87, and d = 0.86 respectively). This pilot study identified a number of concerns, mainly poor adherence to home-therapy in both arms of the study, and no participant in the intervention group solely performing AAD as per pre-set methodology, limiting interpretation of results. CONCLUSION:There is a need for confirmatory, adequately powered trials to evaluate safety and efficacy of AAD in children with CF. Future research needs to also consider measures to ensure better adherence to ACT.

Pancreatic pseudocyst drainage in children by image-guided cystogastrostomy and stent insertion

BackgroundEndoscopic ultrasound is seldom available at paediatric centres; therefore drainage of pancreatic pseudocysts in children has traditionally been achieved by surgery.ObjectiveThis study assessed the feasibility and safety of performing image-guided internal drainage of pancreatic pseudocysts with a flanged self-expanding covered nitinol pancreatic pseudocyst drainage stent.Materials and methodsWe conducted a retrospective case note review of children undergoing image-guided cystogastrostomy at two paediatric hospitals. Percutaneous access to the stomach was achieved via an existing gastrostomy tract or image-guided formation of a new tract. Under combined ultrasound, fluoroscopic or cone-beam CT guidance the pancreatic pseudocysts were punctured through the posterior wall of the stomach. A self-expanding covered nitinol stent was deployed to create a cystogastrostomy opening.ResultsImage-guided cystogastrostomy was performed in 6 children (4 male; median age 6 years, range 46 months to 15 years; median weight 18 kg, range 13.8–47 kg). Two children had prior failed attempts at surgical or endoscopic drainage. Median maximum cyst diameter was 11.5 cm (range 4.7–15.5 cm) pre-procedure. Technical success was 100%. There were no complications. There was complete pseudocyst resolution in five children and a small (2.1-cm) residual pseudocyst in one. Pseudocyst-related symptoms resolved in all children.ConclusionPancreatic pseudocyst drainage can be successfully performed in children by image-guided placement of a cystogastrostomy stent. In this cohort of six children there were no complications.

Superior Vena Cava Inflow Following Repair for Anomalous Right Pulmonary Venous Drainage in Children.

Risk of superior vena cava (SVC) obstruction following repair of anomalous right upper pulmonary veins in children is unclear. The incidence and outcome of subclinical obstruction remained unknown. Retrospective single institutional study (07/1993-02/2017) in a pediatric population (N = 42, median age 3.9-year, range 0.1-15.3years). 33 (79%) children had repair without SVC translocation ("non-Warden") and 9 (21%) had Warden-type surgery. Echocardiographic SVC obstruction was defined as (I) turbulent flow across SVC and (II) continuous flow pattern without return to baseline velocity (0m/s); severe obstruction was defined as loss of distinct biphasic profile ± mean gradient ≥ 5mmHg. 3 (7%) patients required intra-operative revision due to obstruction (non-Warden: 1, Warden: 2). After discharge, 2 (5%) patients required reintervention (3 and 6-month post-op) for severe symptomatic obstruction (non-Warden: 1, Warden-type: 1). Both patients responded to balloon angioplasty with symptomatic resolution (one required repeat catheter reintervention). 10 (24%) patients had subclinical echocardiographic obstruction (2, 22% Warden vs. 8, 24% non-Warden; p = 1.0; 8 of 10 patients had mild gradient), which resolved and remained well without reintervention. At follow-up (mean 7.2-year, range 0-23years), all patients were alive. Freedom from SVC reintervention at 10 and 20-year is 95% (97% at 10, 20-year in non-Warden and 89% at 5, 8-year in Warden-type group; log-rank p = 0.34). Surgical repair for anomalous right upper pulmonary veins is associated with risk of SVC obstructionin children. The needfor reintervention for severe obstruction is rare at late follow-up. Patients with subclinical obstruction remain asymptomatic and demonstrate echocardiographic improvement.

Excision of preauricular sinus with abscess drainage in children.

To introduce a feasible approach for excising a preauricular sinus with abscess in children. Patients under 14 years old with a preauricular sinus abscess and volunteering for surgery were involved in this study. Neither recurrence nor local deformity was found in these patients with a follow-up of 3 to 72 months. Excising the preauricular sinus with abscess in children is a feasible approach to treatment.

An analysis of perioperative outcomes following cervical abscess drainage in children under 2 years

ObjectiveTo identify risk factors and determine perioperative morbidity of children under 2 years of age undergoing cervical abscess drainage. MethodsPatients who underwent cervical abscess drainage 1–18 years of age were queried via the ACS-National Surgical Quality Improvement Program-Pediatric (NSQIP-P) database (2012–2015). Analyzed outcomes include length of stay, operative time, readmission/reoperation rate, and postoperative complications. ResultsA total of 2181 children were identified, 858 were <2 (51.5% male) and 1323 were >2 years (57.1% male) (p = 0.011). The younger cohort was found to undergo more lateral approaches for cervical abscess drainage whereas the older cohort was found to undergo more intraoral approaches for pharyngeal abscess drainage (p < 0.001), suggesting a difference in abscess location related to age at clinical presentation. The younger cohort was also found to have a higher preoperative white blood cell count (20.7 vs. 17.5, p < 0.001) but no significant difference in preoperative fulminant sepsis was observed. Younger children were found to have both a longer wait-time until surgery (1.4 vs. 1.1 days, p = 0.003) and a prolonged length of stay (LOS) (4.3 vs. 3.4 days, p < 0.001). Operative time was found to be lower in the younger cohort (18.4 vs. 21.5 min, p = 0.003), Finally, the younger cohort was found to have an increased incidence and duration of postoperative mechanical ventilation (63 vs. 41, and 0.4 vs. 0.1 days, respectively, p < 0.001.). There were no differences in post-op complications (wound infection, dehiscence, pneumonia, reintubation, and reoperation/readmission). Linear regression for LOS showed that major contributors were operative time, days of postop ventilation, and days from admission to surgery with R = 0.700. ConclusionChildren under 2 years of age have longer LOS that may in part be due to a greater likelihood of postoperative ventilation and a delay in operative intervention, despite having surgical approaches associated with a shorter LOS. They are no more prone to complications than are older children. Recognition of these critical factors plays a role in optimizing perioperative risk assessment and procedural planning within this patient population.

Fluid Management With Peritoneal Dialysis After Pediatric Cardiac Surgery.

Children who undergo cardiac surgery with cardiopulmonary bypass are a unique population at high risk for postoperative acute kidney injury (AKI) and fluid overload. Fluid management is important in the postoperative care of these children as fluid overload is associated with increased morbidity and mortality. Peritoneal dialysis catheters are an important tool in the armamentarium of a cardiac intensivist and are used for passive drainage for fluid removal or dialysis for electrolyte and uremia control in AKI. Prophylactic placement of a peritoneal catheter is a safe method of fluid removal that is associated with few major complications. Early initiation of peritoneal dialysis has been associated with improved clinical markers and outcomes such as early achievement of a negative fluid balance, lower vasoactive medication needs, shorter duration of mechanical ventilation, and decreased mortality. In this review, we discuss the safety and potential benefits of peritoneal catheters for dialysis or passive drainage in children following cardiopulmonary bypass.

Outcomes of the Warden procedure for partial anomalous pulmonary venous drainage in children.

When drainage of an anomalous pulmonary vein is high into the superior vena cava (SVC), traditional techniques of 1-patch or 2-patch repair may be challenging. The cavoatrial anastomosis technique (the Warden procedure) was developed to reduce the risk of sinus node dysfunction and SVC obstruction. Herein, we describe the outcomes of the Warden procedure in children at a single institution. A retrospective study was conducted on all children with partial anomalous pulmonary venous drainage (PAPVD) undergoing the Warden procedure from 1996 to 2015. There were 42 PAPVD patients with a right upper pulmonary vein entering into the SVC undergoing the Warden procedure. The mean age of the patients at surgery was 5.5 years (71 days to 15.4 years). There was no operative mortality. Median hospital stay was 5 (3-25) days. One (2.4%) patient developed cavoatrial (SVC) obstruction. This patient required percutaneous intervention (stenting and balloon dilatation). There was 1 (2.4%) late death in a patient with PAPVD and pulmonary atresia due to a hypoxic brain injury following catheter intervention for a stenotic conduit. Survival was 97 ± 3% (95% confidence interval 83-100%) at 5 and 7 years. All patients were asymptomatic at a mean follow-up of 6 years (range 1 month to 21 years) after surgery. No patient had sick sinus syndrome, sinus node dysfunction or required permanent pacemaker at follow-up. The Warden procedure for repair of PAPVD to the SVC can be performed with no operative mortality or permanent pacemaker requirement. Mid-term outcomes are excellent with a low occurrence of SVC obstruction.

Autogenic Drainage in Children With Cystic Fibrosis.

Airway clearance is an essential part of the management of cystic fibrosis (CF) as it facilitates clearance of viscous pulmonary secretions. This review aimed to determine the effect of autogenic drainage (AD) and assisted autogenic drainage (AAD) compared with no, sham, or other types of airway clearance in children with CF. Two pediatric randomized cross-over trials were identified on the use of AD in children with CF; no studies were available on the use of AAD. In one study AD had a positive influence on the Huang score, and is preferred over postural drainage in this population. We could not determine the efficacy of AD and AAD in children with CF. We recommend the implementation of pediatric-specific randomized controlled trials with adequate sample sizes, appropriate clinical outcome measures, and analysis of adverse effects.

Commentary on "Autogenic Drainage in Children With Cystic Fibrosis".

“How could I apply this information?” Cystic fibrosis (CF), a disease that begins at conception, is not considered just a disease of childhood. People with CF are living well into adulthood and have options for living long, fulfilling lives. However, the pulmonary complications of the disease mandate that individuals must regularly clear secretions from their lungs to minimize infections that lead to lung function decline. Airway clearance techniques of many types have been the mainstay of pulmonary treatment for generations. Although research has attempted to determine the optimal technique, these techniques are shown to be equivalent to each other in outcomes such as sputum clearance, pulmonary exacerbation rates, or rate of lung function decline. The authors of this systematic review found similar results in children as have been shown many times in the adult population. This systematic review gives clinicians confidence that autogenic drainage can be effective and may be preferred by some children to postural drainage with percussion. “What should I be mindful about when applying this information?” Because clearing the lungs must be performed daily, there needs to be a variety of techniques available to patients and families to adapt for the differences each day, such as availability of help, comfort, energy required, skill level in performing a technique, conditions of illness or good health, at home or away, active participation or passive, concomitant health issues, social support, and financial resources. We also feel, contrary to the authors, that autogenic drainage has proven its safety by lack of adverse events noted in the key, well-designed studies they cite. Although the authors conclude it may be useful to teach this technique to children older than 8 years, we caution clinicians to assess the maturity and readiness to learn of each individual with CF to help determine the best timing and variety of airway clearance techniques to recommend. Anne K. Swisher, PT, PhD, CCS, FAPTA West Virginia University Morgantown, West Virginia Karen von Berg, PT, DPT Johns Hopkins Hospital Baltimore, Maryland

A clinical decision rule for the use of ultrasound in children presenting with acute inflammatory neck masses.

To identify the association between clinical and ultrasound findings and surgical drainage in children with inflammatory neck masses and to create a clinical decision rule that allows for reduction of unnecessary use of ultrasound in inflammatory neck masses. We reviewed data on patients ≤18years who visited our emergency department between 2012 and 2014 with inflammatory neck swelling and who underwent ultrasound examinations of the neck. We used multivariate logistic regression to identify factors associated with drainage within 24h of ultrasound study (early drainage). Recursive partitioning was used for risk stratification. Of 341 consecutive patients included in this study, 37 patients underwent early drainage and all had purulent material drained. All patients but one with non-suppurative adenitis and 95% (97/102) of those with suppurative adenitis or early/suspicious abscess on ultrasound were initially treated medically. Of those with a definite diagnosis of abscess/fluid collection, 89% (32/36) underwent early drainage. Patients who underwent drainage were more likely to be younger, female and have a longer duration of neck swelling, with fluctuance and erythema on exam. Recursive partitioning analysis revealed that among children with neck swelling >3days and ≤3days, the rate of early drainage was 24.3% and 4.4%, respectively. None of the children >7months with neck swelling ≤3days underwent early drainage. Children older than 1year with inflammatory neck swelling ≤3days are at low risk of having ultrasound findings that require drainage. In this subgroup of patients, ultrasound could be avoided unless the patient fails to improve after a trial of antibiotic therapy.

経皮的ドレナージが有効であった小児外傷性仮性膵嚢胞の 1 例

経皮的ドレナージが有効であった小児外傷性仮性膵嚢胞の 1 例