Drainage In Children Research Articles

Outcomes of Surgery for Mixed Total Anomalous Pulmonary Venous Drainage in Children

Total anomalous pulmonary venous drainage (TAPVD) is an uncommon cardiac defect in children. The mixed subset accounts for 5%-10% of the TAPVD and is variable in its anatomy. The outcomes associated with this subset of patients are rarely reported. A retrospective review of all patients with mixed TAPVD undergoing repair at a single institution (1984-2014) was conducted. A descriptive analysis was performed. Twenty-four patients underwent repair for mixed TAPVD (6 univentricular physiology, 18 biventricular physiology). The mixed TAPVD anatomy included 8 patients in group I (2 + 2 veins), 11 patients in group II (3 + 1 veins), and 5 patients in group III (atypical). Preoperative pulmonary venous obstruction occurred in 8 patients (33%). The median age at repair was 2.2 months (range 2 days to 3 years) and median weight was 4.2 kg (range 1.9 to 12.5 kg). Operative mortality was 13% (3 of 24), 33.3% (2 of 6) for patients with univentricular physiology, and 5.6% (1 of 18) for patients with biventricular physiology. There have been no operative deaths in the biventricular group since 1997 (n = 11). Survival at 30-days was 83% ± 15% (95% confidence interval: 27%-97%) and 94% ± 5% (95% confidence interval: 67%-99%) for the univentricular and biventricular groups, respectively. Reoperation for recurrent pulmonary venous obstruction was required in 2 patients (8.3%) where the sutureless technique was used. The average follow-up after surgery was 9.3 ± 6.4 years (5 months to 21 years), and all surviving patients were asymptomatic. Mixed TAPVD can be repaired with good results in children, particularly in those undergoing biventricular repair.

Endoscopic Ultrasound-Guided Pancreatic Pseudocyst Drainage in Children

Background: Endoscopic drainage of pancreatic pseudocysts is well established in adults and known to be associated with complications including perforation and hemorrhage. One reason for this is that endoscopic drainage is a blind procedure and to overcome this, EUS guided drainage was established. However, there are limited data regarding this procedure in the pediatric age group. The reasons for this are the limited number of cases seen in children and the lack of experienced pediatric gastroenterologist with this technique. Add to this another technical limitation with EUS is that the therapeutic echo endoscope is 14.6 mm in diameter and has a rigid tip that restricts its use in young children. Patients, methods and results: This report describes a 4-year old child weighing 14 kg with a large pancreatic pseudocyst (8x8x12cm) that was treated successfully using adult endoscopic ultrasound scope (The Olympus EVIS LUCERA Ultrasound Gastrovideoscope GF-UCT 260, 14.6 mm distal tip). Conclusion: Endoscopic drainage of symptomatic pancreatic pseudocysts can be achieved safely and effectively in children using the adult EUS scope.

Warden repair for superior sinus venosus atrial septal defect and anomalous pulmonary venous drainage in children: Anesthesia and transesophageal echocardiography perspectives.

Objective:Review of intraoperative anesthetic challenges and the role of transesophageal echocardiography in children with sinus venosus atrial septal defect and partial anomalous pulmonary venous drainage undergoing Warden repair.Design:A retrospective observational case series.Methodolgy:Pediatric patients who underwent Warden repair between October 2011-September 2015 were recruited. Their preoperative clinical details, anesthetic techniques, intraoperative TEE findings and postoperative events were recorded from the medical records. The categorical variables and the continuous variables were expressed as number (percentages) and mean ± SD respectively.Results:A total of 35 patients were operated for Warden repair during the study period. Anesthesia was induced with the aim to prevent any fall in pulmonary vascular resistance. The right internal jugular vein was cannulated under ultrasound guidance using a short length cannula to monitor right superior vena cava pressure. Intraoperative TEE revealed the drainage of PAPVC high into RSVC in 22 patients. Persistent LSVC was found in 9 patients. After repair, TEE imaging detected a high gradient at Warden anastomotic site in 5 patients and 3 of them required revision of surgery. Rerouted pulmonary veins required surgical correction in 2 patients in view of obstruction. None of them had pulmonary venous and SVC obstruction in the postoperative period.Conclusion:The primary aim of anesthesia is to avoid any fall in PVR. Right IJV cannulation can be beneficial. The intraoperative TEE can help in delineating the anatomy of lesion and detecting anastomotic site obstruction.

Endoscopic Ultrasound-Guided Drainage of Deep Pelvic Abscess in Children: Case Series

Introduction: Acute appendicitis with perforation is the most common cause of deep pelvic abscess in children. Image-guided drainage of the deep pelvic abscess becomes a preferable standard procedure prior to surgical intervention. For pediatric population, only transcutaneous and transrectal imageguided are favorable accesses. Transrectal ultrasound with fluoroscopy-guided is the only pelvic abscess drainage technique, which access the abscess rectally, reported in pediatric population so far. Endoscopic ultrasound-guided drainage of pelvic abscess (EUS-DPA) has shown to be safe and feasible in adult. However EUS-DPA in children has never been reported. In this article, we report our experience in three successful cases of EUS-DPA in pediatric population. Methods: This is a retrospective single center case series for pediatric patients who underwent EUS-DPA during March 2013 to April 2015. Following are inclusion criteria. 1) Age group between 1 to 18 year old. 2) Abscess cannot be drain via percutaneous, transabdominal routes by US and/or CT guidance. 3) Peri-rectal or peri-colonic were consider as deep pelvic abscesses. Results: EUS-DPA was performed in 3 patients. Mean age of patients was 13 years. All three patient, the abscess developed due to rupture appendicitis. Median size of abscess was 41 mm x34 mm. All three patients received puncture site dilation, normal saline mixed with gentamicin flushing to abscess cavity. 7F x 4 cm double pigtail stent were placed in all patients. Stent was remove 2 weeks after EUS-DPA procedure. There was no complication from procedure in all patients. In 1 patients received transabdominal percutaneous drainage prior to EUS-DPA procedure. Patients became afebrile within 72 h after the procedures. The aspirated fluid grew Escherichia coli in 2 patients and Pseudomonas aeruginosa in 1 patient. CT showed resolution in all patients and stents were removed 2 weeks after procedure. Two patients underwent interval appendectomy 3 months after the procedure. All patients were asymptomatic on follow up in 6 month. Conclusion: EUS-DPA represents a safe and useful role for the deep pelvic abscess drainage in children. EUS-DPA might be the first option for single deep pelvic abscess drainage or a supplement to percutaneous drainage in case of multiple pelvic abscesses in pediatric population. Further studies will need to be performed to confirm the efficacy, safety and complications of EUS-DPA for the other causes and locations of pelvic abscesses.Figure 1Figure 2Figure 3

164 Autogenic drainage and assisted autogenic drainage in children with cystic fibrosis: A systematic review

Chest physiotherapy is considered an essential part of symptomatic, multidisciplinary management in cystic fibrosis (CF), as it facilitates clearance of viscous pulmonary secretions. Objectives To determine the effect of autogenic drainage (AD) and assisted autogenic drainage (AAD) compared to no; sham; or other types of chest physiotherapy in children with CF. Methods Six databases, clinicaltrials.gov and pactr.org were searched. We included randomized controlled trials, quasi-randomized controlled trials and randomized cross-over trials on AD and AAD in children younger than 18 years, diagnosed with CF. One author conducted the database search. Titles, abstracts and data were evaluated by two independent reviewers with agreement by discussion and consensus. Results A total of 126 titles were screened, of which seven were eligible. However, only two studies made a clear distinction between pediatric (ntotal = 47; n1 = 36 & n2 = 9) and adult data, and were therefore analyzed. We were unable to perform a meta-analysis, as only one study clearly indicated separate results for the different periods of the cross-over. Based on the pediatric data of this one study, participants who received AD had a significant improvement in Huang scores; a tendency to have fewer hospital admissions during one year when compared to postural drainage; and a clear preference for AD by participants. One other study reported pediatric data, however no significance levels were provided. Conclusion Due to the lack of pediatric-specific randomized controlled trials, small sample sizes and unclear risk of bias of most studies, we were unable to determine the efficacy and/or safety of AD and AAD in children with CF.

A clinical study of neck abscesses requiring drainage in children

A clinical study of neck abscesses requiring drainage in children

Determinants of postoperative abscess occurrence and percutaneous drainage in children with perforated appendicitis.

Postoperative abscesses after perforated appendicitis have no clear risk factors or indications for percutaneous drainage. Our study addressed these two issues. A logistic regression model was used to delineate risk factors for postoperative abscess in children with perforated appendicitis treated during a recent 5-year period. Drainage of abscess was compared to antibiotic treatment. Postoperative abscess occurred in 42 (14.8%) of 284 patients. Higher WBC count, presence of bowel obstruction at presentation, diffuse peritonitis with a dominant abscess at surgery, and one specific surgeon were significantly associated with postoperative abscess, while fever or pain requiring narcotics at the time of abscess diagnosis was significantly associated with drainage. Compared to non-drainage, those drained had longer hospital stay including readmissions (15.9 ± 5.3 vs. 12.2 ± 4.6 days, p < 0.005) and less readmissions (9.5 vs. 33.3%, p = 0.06). Over the 5-year period, there was no increased trend in abscess occurrence (p = 0.56), but there was an increased trend in the use of percutaneous drainage (p = 0.02). The risk of a postoperative abscess can be predicted by specific clinical characteristics, surgical findings, and treatment-related factors. Percutaneous drainage was associated with longer hospital stays, but less readmissions.

Ureteric stents vs percutaneous nephrostomy for initial urinary drainage in children with obstructive anuria and acute renal failure due to ureteric calculi: a prospective, randomised study

To compare percutaneous nephrostomy (PCN) tube vs JJ ureteric stenting as the initial urinary drainage method in children with obstructive calcular anuria (OCA) and post-renal acute renal failure (ARF) due to bilateral ureteric calculi, to identify the selection criteria for the initial urinary drainage method that will improve urinary drainage, decrease complications and facilitate the subsequent definitive clearance of stones, as this comparison is lacking in the literature. A series of 90 children aged ≤12 years presenting with OCA and ARF due to bilateral ureteric calculi were included from March 2011 to September 2013 at Cairo University Pediatric Hospital in this randomised comparative study. Patients with grade 0-1 hydronephrosis, fever or pyonephrosis were excluded. No patient had any contraindication for either method of drainage. Stable patients (or patients stabilised by dialysis) were randomised (non-blinded, block randomisation, sealed envelope method) into PCN-tube or bilateral JJ-stent groups (45 patients for each group). Initial urinary drainage was performed under general anaesthesia and fluoroscopic guidance. We used 4.8-6 F JJ stents or 6-8 F PCN tubes. The primary outcomes were the safety and efficacy of both groups for the recovery of renal functions. Both groups were compared for operative and imaging times, complications, and the period required for a return to normal serum creatinine levels. The secondary outcomes included the number of subsequent interventions needed for clearance of stones. Additional analysis was done for factors affecting outcome within each group. All presented patients completed the study with intention-to-treat analysis. There was no significant difference between the PCN-tube and JJ-stent groups for the operative and imaging times, period for return to a normal creatinine level and failure of insertion. There were significantly more complications in the PCN-tube group. The stone size (>2 cm) was the only factor affecting the rates of mucosal complications, operative time and failure of insertion in the JJ-stent group. The degree of hydronephrosis significantly affected the operative time for PCN-tube insertion. Grade 2 hydronephrosis was associated with all cases of insertion failure in the PCN-tube group. The total number of subsequent interventions needed to clear stones was significantly higher in the PCN-tube group, especially in patients with bilateral stones destined for chemolytic dissolution (alkalinisation) or extracorporeal shockwave lithotripsy (ESWL). We recommend the use of JJ stents for initial urinary drainage for stones that will be subsequently treated with chemolytic dissolution or ESWL, as this will lower the total number of subsequent interventions needed to clear the stones. This is also true for stones destined for ureteroscopy (URS), as JJ-stent insertion will facilitate subsequent URS due to previous ureteric stenting. Mild hydronephrosis will prolong the operative time for PCN-tube insertion and may increase the incidence of insertion failure. We recommend the use of PCN tube if the stone size is >2 cm, as there was a greater risk of possible iatrogenic ureteric injury during stenting with these larger ureteric stones in addition to prolongation of operative time with an increased incidence of failure.

Continuous Lumbar cerebrospinal fluid drainage in children . Can we facilitate ?

Continuous Lumbar cerebrospinal fluid drainage in children . Can we facilitate ?

Transiliopsoas approach: an alternative route to drain pelvic abscesses in children.

To evaluate an alternative route of pelvic abscess drainage in children via a transiliopsoas approach. Appendiceal perforations complicated by inflammatory masses, such as abscesses or phlegmon, are a common indication for abdominal drainage in pediatric interventional radiology. Certain locations of collections may present particular challenges for the operator, owing to numerous surrounding structures, including bowel and other pelvic anatomy. This series describes an alternative route for drainage, which involves traversing the iliopsoas muscle under US guidance to drain a deep pelvic abscess. Retrospective chart review was performed of the transiliopsoas approach for abscess drainage during a 5-year period. The technique, pre- and post-drainage imaging, aspiration/drain output, duration of catheter dwell, procedure-related complications and abscess recurrence were reviewed. Transiliopsoas needle placement was successful in 14 of 14 patients (100%). Catheter placement was successful in 13 patients. Abscess wall rupture precluded catheter placement in one patient. Mean catheter duration was 4.9 days, with a range of 2 to 9 days. Clinical improvement was achieved in all 14 patients (100%). There were no major complications. Post-procedure pain with ambulation was reported in 3 of 14 patients (21.4%), which was successfully controlled in each case with medication, and resolved after 2 days. The transiliopsoas route is a safe and effective route for US-guided abscess drainage and catheter placement in children with deep pelvic collections. In selected cases, this approach provides a more easily accessible and safer route than more traditional interventional approaches.

Timing and Predictors for Urinary Drainage in Children with Expectantly Managed Grade IV Renal Trauma

We determined which children sustaining blunt grade IV renal trauma are at greatest risk for failing nonoperative management and in what time frame they will likely present. We retrospectively reviewed children presenting with nonvascular grade IV blunt renal trauma between 2003 and 2012. We compared characteristics on computerized tomography, reasons for intervention, type and timing of surgery, length of hospital stay and need for readmission between children undergoing early intervention (less than 72 hours after admission) and those managed conservatively (with any subsequent intervention undertaken more than 72 hours after admission). A total of 26 children were identified with nonvascular grade IV blunt renal trauma. Conservative management was attempted in 16 cases (62%). Seven of these patients (44%) required intervention (ureteral stent and/or percutaneous drain placement), with a mean time to intervention of 11 days. Collecting system clot and larger urinoma (1.45 cm in cases with successful and 4.29 cm in those with failed conservative management) significantly predicted failure of conservative management (p<0.05). Presence of dissociated renal fragments (57% vs 11%) and interpolar contrast extravasation (57% vs 0%) were increased in the early intervention group compared to the conservatively managed group (p>0.05), as was rehospitalization (43% vs 0%), mean length of stay (7.9 vs 5.4 days) and transfusion (14% vs 0%, p>0.05). Collecting system hematoma and urinoma size significantly predicted failure of conservative management, with a mean time to intervention of 11 days. Children with failed conservative management had a greater incidence of dissociated renal fragments and interpolar extravasation. Early identification of these patients may decrease hospital readmissions, length of stay and prolonged morbidity.

Inter- and intra-observer reproducibility of quantitative renographic parameters of differential function and renal drainage in children

Purpose. To evaluate inter- and intra-observer reproducibility of renographic quantitative parameters of input and output in children. Methods. 100 children with unilateral or bilateral uropathy were selected, aiming to cover the entire range of ages, overall glomerular filtration rate (GFR), differential renal function (DRF) and quality of drainage. Renograms were acquired and processed according to the EANM guidelines, using a non-commercial software. Following parameters were tested: DRF using integral and Patlak methods, normalized residual activity (NORA) and output efficiency (OE) at 20 min and on the late post-erect post-micturition acquisition. Three observers from the same department and one from Santiago (Chile) processed independently the 100 renograms using the same renal software. Two observers reprocessed the 100 renograms again two months later in order to evaluate the intra-observer reproducibility. Results and conclusion. No significant difference was observed between the four observers, whatever the considered parameter of input function or output. For left DRF (Integral and Patlak methods), 95% of the individual differences were between −5% and +5 %. They were between −0.5 and +0.5 units for both NORA 20 and NORA PM, and between −10% and +10% for OE 20 and OE PM. Inter-and intra- observer reproducibility were comparable. Outliers tended to be more frequent for Patlak than for Integral. Very low GFR (< 20 mL/min/1.73 m2), very young age (first days of life), huge megaureters, NORA values higher than 2.0, OE values below 60% and bladder in the renal background area (ectopic kidney) were the main characteristics of extreme differences.

Multiple Large Splenic Abscesses Managed with Computed Tomography-guided Percutaneous Catheter Drainage in Children

Splenic abscess is a rare finding in children. Splenectomy combined with broad-spectrum antibiotics has been the treatment of choice for multiple splenic abscesses. Herein, we report the case of a 14-year-old girl with multiple large splenic abscesses that were successfully managed after two image-guided percutaneous drainage procedures and administration of intravenous antibiotics. Initially, an abscess located at the periphery in the lower pole of the spleen was aspirated under ultrasound guidance. Finally, another abscess located near the hilum of the spleen was drained under computed tomography guidance. To the best of our knowledge, this is the first report of multiple large splenic abscesses treated with computed tomography-guided percutaneous drainage.

Easily Removable Ureteral Catheters for Internal Drainage in Children: A Preliminary Report

PurposeWe review our experience using a new and easily removable ureteral catheter in patients who underwent complicated ureteral reimplantation. Our goal was to shorten hospital stay and lower anxiety during catheter removal without fear of postoperative ureteral obstruction.Materials and MethodsBetween April 2009 and September 2010, nine patients who underwent our new method of catheter removal after ureteral reimplantation were enrolled. Patients who underwent simple ureteral reimplantation were excluded from the study. Following ureteral reimplantation, a combined drainage system consisting of a suprapubic cystostomy catheter and a ureteral catheter was installed. Proximal external tubing was clamped with a Hem-o-lok clamp and the rest of the external tubing was eliminated. Data concerning the age and sex of each patient, reason for operation, method of ureteral reimplantation, and postoperative parameters such as length of hospital stay and complications were recorded.ResultsOf the nine patients, four had refluxing megaureter, four had a solitary or non-functional contralateral kidney and one had ureteral stricture due to a previous anti-reflux operation. The catheter was removed at postoperative week one. The mean postoperative hospital stay was 2.4 days (range 1-4 days), and the mean follow-up was 9.8 months. None of the patients had postoperative ureteral obstructions, and there were no cases of migration or dislodgement of the catheter.ConclusionOur new method for removing the ureteral catheter would shorten hospital stays and lower levels of anxiety when removing ureteral catheters in patients with a high risk of postoperative ureteral obstruction.

Advantages of abandoning abdominal cavity irrigation and drainage in operations performed on children with perforated appendicitis

PurposeThis study evaluates the effect of peritoneal irrigation and drainage on postoperative morbidity when used together for perforated appendicitis. Material and methodsThis study was conducted on children undergoing open appendectomy for perforated appendicitis. Sixty-one children with perforated appendicitis operated on with irrigation and drainage between July 1998 and September 2001 (group DI) and 173 children with perforated appendicitis who underwent surgery without irrigation and drainage (group NDI) between October 2001 and November 2011 were retrospectively evaluated (a total of 234 patients). All patients were treated and followed up by the same pediatric surgeon using the same protocol. Both groups were compared in respect to postoperative complications, including wound infection, wound dehiscence, intraabdominal abscess, prolonged ileus, the presence of small bowel obstruction requiring surgery, operative time, and length of postoperative hospital stay. ResultsOf the total 234 patients, 151 were male and 83 were female with a mean age of 8.9 ± 3.7 years (range, 1.5-15 years). The wound infection rates were 4.9% in group DI and 1.7% in group NDI (P = .184). Wound dehiscence was seen in 1.6% vs 0%, prolonged ileus in 8% vs 2.3%, intraabdominal abscess in 4.9% vs 1.7%, and small bowel obstruction requiring surgery in 1.6% vs 0.6% of the patients (P = .261, P = .054, P = .184, and P = .454, respectively). No statistically significant difference in postoperative infectious complications was found between both groups. The length of postoperative hospital stay was 9.9 ± 4.1 days in group DI vs 6.3 ± 2.4 days in group NDI (P < .001). The operation times were 39 ± 8 and 31 ± 11 minutes, respectively (P < .001). ConclusionThis study demonstrates that peritoneal irrigation and drainage in children with perforated appendicitis is not required, and in fact, these procedures cause an increase in operative time.

Antibiotic therapy for pediatric deep neck abscesses: A systematic review

ObjectiveTo evaluate the current evidence regarding the safety and efficacy of medical management for deep neck abscesses in children. Data sourcesPubmed and Embase databases accessed 3/27/2012. Review methodsAn a priori protocol defining inclusion and exclusion criteria was developed to identify all articles addressing medical therapy of pediatric deep neck abscesses where details regarding diagnostic criteria, specifics of medical therapy and definitions of failure were presented. The search included electronic databases to identify candidate articles as well as a manual crosscheck of references. The level of evidence was assessed and data extracted by three authors independently. Data were pooled using a random effects model due to significant study heterogeneity. ResultsEight articles met inclusion criteria. The overall level of evidence was grade C. There was significant heterogeneity among the studies (I2=98.8%; p<.001). However, each article uniformly presented cases suggesting that medical therapy may be a viable alternative to surgical drainage in some patients. The pooled success rate of medical therapy in avoiding surgical drainage in children with deep neck infections was 0.517 (95%CI: 0.335, 0.700). When patients taken immediately to surgery were excluded and patients were placed on author defined medical protocols, the success rate increased to 0.951 (95%CI: 0.851, 1.051). Subgroup analysis by duration of intravenous antibiotic trial greater than 48h demonstrated a pooled success rate of 0.740 (95%CI: 0.527, 0.953). ConclusionThe current literature suggests medical management may be a safe alternative to surgical drainage of deep neck abscesses in children. However, the level of evidence lacks strength and further investigation is warranted.

The persistent primitive marginal sinus—observations in children with Vein of Galen malformation

Knowledge of venous anatomy and drainage in children with neurovascular diseases is crucial. The primitive marginal sinuses (PMS) are embryonic sinuses forming the later superior sagittal sinus. Their angiographic persistence has not been reported before. The purpose of this study is to demonstrate the angiographic characteristics in children with Vein of Galen malformation and to discuss their embryology and clinical significance. We retrospectively reviewed digital subtraction angiography and magnetic resonance venography of 102 Vein of Galen malformations (VGM) from the database of two high-load centres for paediatric neurovascular diseases. We found 10 persistent PMS in 102 children indicating a frequency of 9.8%. Illustrative cases are shown to demonstrate the vast spectrum of venous variability. The PMS becomes visualised in situations of high-flow arteriovenous shunt in children and can even disappear or remodel after successful shunt reduction or closure. Knowledge and recognition of the PMS are important for neurointerventionalists in endovascular treatment planning using the transvenous route and can help neurosurgeons in avoiding severe surgical complications.

Postoperative outcome following pyeloplasty in children using miniflank incision and transanastomotic stent: a prospective observational study

To assess the postoperative outcome in children undergoing pyeloplasty, using a single transanastomotic indigenized stent. 329 pyeloplasties were performed by small miniflank incision (3-5 cm) with lateral position for unilateral cases and prone position for bilateral cases during 1993-2009. The procedure involved decompression of the hydronephrotic sac, single layer anastomosis at the PUJ using 5/6-0 suture (reduction of the pelvis if required). An indigenized # 6, Teflon transanastomotic stent (TAS) with multiple holes (modified recently to a self-retaining loop in pelvis) was placed and taken out through the renal pelvis and the main skin incision. The stent served both as a nephrostomy and a stent. The kidney was not mobilized during the procedure. Postoperative results were assessed for early complications. The mean age of the patients was 3.4 years (1 month-14 years). Bilateral simultaneous pyeloplasties were done in 16 cases with a mean age of 5.6 months (2-12). The stent was removed after 4-5 days in most cases after confirming distal flow on clamping. The post-operative complications included slippage of stent (11), blockage/nondrainage (7), difficult retrieval (4), urine leak (4), urinoma (3) and post-operative infection (1). DTPA scan at 3 months follow-up depicted improved drainage in 271 units, preserved renal function in 58 units and improved renal function more than 5% in 246 units. Pyeloplasty using a single Teflon TAS is helpful not only in achieving effective drainage in children undergoing pyeloplasty, but also avoids the complications usually encountered with the use of nephrostomies, or double J stents.

Instituting a Conservative Management Protocol for Pediatric Blunt Renal Trauma: Evaluation of a Prospectively Maintained Patient Registry

Retrospective studies show that even high grade pediatric renal trauma can be safely managed conservatively. We evaluated a prospective patient registry at our level 1 pediatric trauma center, where patients with renal trauma were treated with an institutional review board approved conservative blunt renal trauma protocol. Standardized treatment included a trial of expectant management for all stable cases. We identified 39 children with blunt renal trauma treated between 2003 and 2008. A strict conservative approach was used, ie nonoperative management in cases that were hemodynamically stable or had a favorable response with up to 2 units of blood transfused and no operative renal lesion on imaging. Adult imaging protocols were followed and exploratory laparotomy for nonrenal causes did not alter course of expectant renal management. Outcomes evaluated were injury grade, hematuria, operative management, length of stay and associated injuries. Based on the American Association for the Surgery of Trauma organ injury severity scale, 13 patients were considered to have grade I disease, 8 grade II, 11 grade III, 6 grade IV and 1 grade V. Conservative management resulted in a 97% nonoperative rate and a single renorrhaphy. Using a prospective patient registry, this study demonstrates that conservative treatment of blunt pediatric renal trauma is safe and effective. Also, serious renal injuries are not missed by applying adult diagnostic imaging protocols in children.

Topical anesthetic cream is associated with spontaneous cutaneous abscess drainage in children

Objective The objective of the study was to determine whether use of topical anesthetic cream increases spontaneous drainage of skin abscesses and reduces the need for procedural sedation. Methods A retrospective multicenter cohort study from 3 academic pediatric emergency departments was conducted for randomly selected children with a cutaneous abscess in 2007. Children up to 18 years of age were eligible if they had a skin abscess at presentation. Demographics, abscess characteristics, and use of a topical analgesic were obtained from medical records. Results Of 300 subjects, 58% were female and the median age was 7.8 years (interquartile range, 2-15 years). Mean abscess size was 3.5 ± 2.4 cm, most commonly located on the lower extremity (30%), buttocks (24%), and face (12%). A drainage procedure was required in 178 children, of whom 9 underwent drainage in the operating room. Of the remaining 169 children who underwent emergency department–based drainage, 110 (65%) had a topical anesthetic agent with an occlusive dressing placed on their abscess before drainage. Use of a topical anesthetic resulted in spontaneous abscess drainage in 26 patients, of whom 3 no longer required any further intervention. In the 166 patients who underwent additional manipulation, procedural sedation was required in 26 (24%) of those who had application of a topical anesthetic and in 24 (41%) of those who had no topical anesthetic (odds ratio, 0.45; 95% confidence interval, 0.23-0.89). Conclusions Topical anesthetic cream application before drainage procedures promotes spontaneous drainage and decreases the need for procedural sedation for pediatric cutaneous abscess patients.