Pediatric Procedures Research Articles

Standardized addendums to reporting in neonatal and pediatric minimal access surgery

Minimal access surgeries (MAS) in children and neonates have proven to be safe and effective. Recent advances in technology have significantly contributed to this. However, currently, there is no standardized documentation of minimally access surgery (MAS) in pediatric or neonatal age group. Multiple experimental studies have reported hemodynamic changes taking place in this rather vulnerable cohort many of which are not completely understood. It is important that a standardized reporting tool for accurate documentation of pediatric and neonatal MAS is well overdue. The introduction of such a system will allow for accurate recording of procedures by documenting several variables and facilitate comparisons of various pediatric and MAS procedures between individual centers and institutions.

Met and Unmet Need for Pediatric Surgical Access in Uganda: A Country-Wide Prospective Analysis

IntroductionChildren's surgical access in low and low-middle income countries is severely limited. Investigations detailing met and unmet surgical access are necessary to inform appropriate resource allocation. Materials and methodsSurgical volume, outcomes, and distribution of pediatric general surgical procedures were analyzed using prospective pediatric surgical databases from four separate regional hospitals in Uganda. The current averted burden of surgical disease through pediatric surgical delivery in Uganda and the unmet surgical need based on estimates from high-income country data was calculated. ResultsA total of 8514 patients were treated at the four hospitals over a 6-year period corresponding to 1350 pediatric surgical cases per year in Uganda or six surgical cases per 100,000 children per year. The majority of complex congenital anomalies and surgical oncology cases were performed at Mulago and Mbarara Hospitals, which have dedicated pediatric surgical teams (P < 0.0001). The averted burden of pediatric surgical disease was 27,000 disability adjusted life years per year, which resulted in an economic benefit of approximately 23 million USD per year. However, the average case volume performed at the four regional hospitals currently represents 1% of the total projected pediatric surgical need. ConclusionsThis investigation is one of the first to demonstrate the distribution of pediatric surgical procedures at a country level through the use of a prospective locally created database. Significant disease burden was averted by local pediatric and adult surgical teams, demonstrating the economic benefit of pediatric surgical care delivery. These findings support several ongoing strategies to increase pediatric surgical access in Uganda.

Addition of Deep Parasternal Plane Block to Enhanced Recovery Protocol for Pediatric Cardiac Surgery.

This study aims to evaluate if the addition of deep parasternal plane blocks to a pre-existing enhanced recovery pathway for pediatric cardiac surgery improves outcomes. A retrospective review through an EMR query from June 2019 to June 2021 was performed for patients less than 18 years of age who underwent cardiac surgery via median sternotomy and were extubated immediately following surgery in a single academic tertiary care hospital. Patients receiving deep parasternal blocks as part of an enhanced recovery protocol were compared to similar patients from the year prior to block implementation. The primary outcome was intraoperative and postoperative opioid consumption. Secondary outcomes were pain scores, intensive care unit (ICU) length of stay and time to first oral intake. There was a statistically significant reduction in intraoperative opioid administration and pain scores in the first 24 hours post-operatively. There was also a statistically significant reduction in ICU length of stay. There was no statistically significant difference in post-operative opioid consumption and time to first oral intake. Bilateral deep parasternal blocks may reduce opioid consumption, provide effective postoperative pain control, and result in decreased length of intensive care unit stay across both simple and complex pediatric cardiac procedures when added to a pre-existing enhanced recovery protocol.

The December effect in pediatric elective surgery utilization: differences between privately and publicly insured children.

The objective of this study was to identify differences in December elective surgery utilization between privately and publicly insured children, given that increases in the prevalence and size of annual deductibles may be driving more families with commercial health insurance to delay elective pediatric surgical procedures until later in the calendar year. We identified patients aged <18years who underwent myringotomy, tonsillectomy±adenoidectomy, tympanoplasty, hydrocelectomy, orchidopexy, distal hypospadias repair, or repair of inguinal, umbilical, or epigastric hernia using the 2012-2019 state inpatient and ambulatory surgery and services databases of 9 states. Log-binomial regression models were used to compare relative probabilities of procedures being performed each month. Linear regression models were used to evaluate temporal trends in the proportions of procedures performed in December. Our study cohort (n=1 001 728) consisted of 56.7% privately insured and 41.8% publicly insured children. Peak procedure utilization among privately and publicly insured children was in December (10.1%) and June (9.6%), respectively. Privately insured children were 24% (95% CI 22%-26%) more likely to undergo surgery in December (P<.001), with a significant increase seen for 8 of 9 procedures. There was no trend over time in the percentage of procedures performed in December, except for hydrocelectomies, which increased by 0.4 percentage points/year among privately insured children (P=.02). Privately insured children are >20% more likely than publicly insured children to undergo elective surgery in December. However, despite increases in the prevalence of high deductibles, the proportion of procedures performed in December has not increased over recent years.

Patient-Reported Outcomes in Pain Management After Ambulatory Pediatric General and Urologic Surgery

BackgroundMany studies evaluating opioid stewardship interventions’ effects on postoperative pain rely on emergency department (ED) visits or readmissions, but patient-reported pain scores represent a more complete picture of the postoperative experience. This study compares patient-reported pain scores after ambulatory pediatric and urologic procedures and the effect of an opioid stewardship intervention that nearly eliminated the use of outpatient narcotics. MethodsThis is a retrospective comparative study including 3173 pediatric patients who underwent ambulatory procedures from 2015 to 2019, during which there was an intervention to reduce narcotic prescriptions. Postoperative day one phone calls assessed pain levels using a four-point scale (no pain, mild pain, moderate pain controlled with medication, or severe pain uncontrolled with medication). We quantified the proportion of patients prescribed opioids pre-versus post-intervention and compared pain scores for patients receiving opioid versus non-opioid regimens. ResultsOpioid prescription rates demonstrated a 6.5-fold reduction after opioid stewardship efforts. The majority of patients (2838) received non-opioids, with only 335 patients receiving opioids. Opioid patients reported moderate/severe pain slightly more than non-opioid patients (14.1% vs. 10.4%, p = 0.04). On by-procedure analyses, there were no subgroups in which non-opioid patients reported significantly higher pain scores. ConclusionsNon-opioid postoperative pain regimens appear to be effective, with only 10.4% of patients reporting moderate/severe pain after ambulatory procedures. Future studies assessing patient-reported outcomes are necessary to optimize pain control for all patients and to determine whether there is ever an indication for opioid prescription after ambulatory general pediatric or urologic surgery. Type of studyRetrospective comparative study. Level of evidenceLevel III.

Development of an ultrafast brain MR neuronavigation protocol for ventricular shunt placement.

Advancements in MRI technology have provided improved ways to acquire imaging data and to more seamlessly incorporate MRI into modern pediatric surgical practice. One such situation is image-guided navigation for pediatric neurosurgical procedures, including intracranial catheter placement. Image-guided surgery (IGS) requires acquisition of CT or MR images, but the former carries the risk of ionizing radiation and the latter is associated with long scan times and often requires pediatric patients to be sedated. The objective of this project was to circumvent the use of CT and standard-sequence MRI in ventricular neuronavigation by investigating the use of fast MR sequences on the basis of 3 criteria: scan duration comparable to that of CT acquisition, visualization of ventricular morphology, and image registration with surface renderings comparable to standard of care. The aim of this work was to report image development, implementation, and results of registration accuracy testing in healthy subjects. The authors formulated 11 candidate MR sequences on the basis of the standard IGS protocol, and various scan parameters were modified, such as k-space readout direction, partial k-space acquisition, sparse sampling of k-space (i.e., compressed sensing), in-plane spatial resolution, and slice thickness. To evaluate registration accuracy, the authors calculated target registration error (TRE). A candidate sequence was selected for further evaluation in 10 healthy subjects. The authors identified a candidate imaging protocol, termed presurgical imaging with compressed sensing for time optimization (PICO). Acquisition of the PICO protocol takes 25 seconds. The authors demonstrated noninferior TRE for PICO (3.00 ± 0.19 mm) in comparison with the default MRI neuronavigation protocol (3.35 ± 0.20 mm, p = 0.20). The developed and tested sequence of this work allowed accurate intraoperative image registration and provided sufficient parenchymal contrast for visualization of ventricular anatomy. Further investigations will evaluate use of the PICO protocol as a substitute for CT and conventional MRI protocols in ventricular neuronavigation.

Sedative Agents in Minor Paediatric Oral Surgical ProceduresA Narrative Review

Sedation in pediatric dentistry reduces anxiety during surgical procedures and also helps cope with very stressful events encountered during dental treatment. Various sedative agents like Nitrous oxide, diazepam, midazolam, Ketamine, propofol, fentanyl, and dexmedetomidine have been administered through several sedation routes including oral, nasal, inhalation, intramuscular, and sub-mucosal to attain active sedation. However, it is evident that the sesedative drugs also have the prospective to causelethal complications. Aim: The present review was carried out to brief the clinical aspects of various sedative agents currently available in pediatric practices based on the existing literature with special emphasis on their role in minor pediatric oral surgical procedures. Discussion: Nitrous oxide is frequently used in combination with complextime-consuming procedures and dental extractions, particularly for young and anxious patients undergoing orthodontic extractions. Fentanyl decreases pain and anxiety but causes respiratory distress. Oral ketamine is a potent dissociative drug often combined with midazolam produces excellent analgesic and sedative effects. None the less, the most common combinations include sedatives with ketamine/opioids or dexmedetomidine to maintain the airway reflexes if given in small doses with precautions. Sometimes a combination of inhaled gases especially short-acting sevoflurane along with Diazepam is favored. Conclusion: Within the limitation, it is evident that a clear understanding of the proper selection of sedative agents, awareness of the intended level of sedation or route of drug administration, and knowledge of adverse responses during and after sedation are essential to achieve appropriate sedation levels during minor oral surgical procedures.

Aortic valve repair in the pediatric population: emerging role of aortic valve neocuspidization (AVNeo procedure).

Management of aortic valve diseases in children is challenging owing to the quality and quantity of the native tissue for repair, limitations in the currently available biological materials to supplement the repair and to achieve a long-lasting durable repair in an annulus where there is still growth potential. The aortic valve neocuspidization (AVNeo) procedure has emerged as a versatile alternative strategy in the armamentarium of pediatric aortic valve reconstructions that are currently available. In this review article, the focus of the discussion will be on the various aortic valve repair procedures in the pediatric population, with a special emphasis on the emerging role of AVNeo procedure in pediatrics and its outcomes.

Pediatric Sedation Unit: A Safe, Effective, and Satisfactory Alternative to Outpatient Pediatric Urological Procedures Under Anesthesia.

The operating room is an increasingly expensive and limited resource. The aim of this study was to evaluate the efficacy, safety, cost, and parental satisfaction of transitioning minor pediatric urology procedures from an operating room setting to a pediatric sedation unit. Minor urological procedures were transitioned from the operating room to the pediatric sedation unit if they could be completed in 20 minutes using minimal instrumentation. Information regarding patient demographics, procedure characteristics, rates of success and complications, and cost were collected from urology procedures performed in the pediatric sedation unit between August 2019 and September 2021. Patient demographics and cost data from the most common urology procedures performed in the pediatric sedation unit were compared to data from historical controls of cases occurring in the operating room. Parent surveys were performed following the completion of procedures in the pediatric sedation unit. A total of 103 patients, ranging from 6-207 months old (mean 72 months), underwent procedures in the pediatric sedation unit. The most common procedures were lysis of adhesions and meatotomy. All procedures were successfully completed with procedural sedation, and no procedure was complicated by serious sedation adverse events. The cost reduction for lysis of adhesions in the pediatric sedation unit was 53.5% compared to the operating room, and meatotomy was 27.9%, leading to approximately $57,000 cost savings per year. Fifty families completed a follow-up satisfaction survey, and 83% of parents were satisfied with the care their family received. The pediatric sedation unit can provide a successful and cost-efficient alternative to the operating room while preserving safety and high rates of parental satisfaction.

Evaluation of Undergraduate Learning Experiences in Pediatric Dentistry during the COVID-19 Pandemic.

The research was conducted among fifth-year dentistry students at Poznan University of Medical Sciences. Students who completed the entire course and passed the diploma exam in pediatric dentistry were asked to complete the anonymous questionnaire providing their opinion. The research results showed that, in the students' opinion, clinical classes-regardless of their form-allowed them to achieve the knowledge necessary to perform pediatric dental procedures. However, the students appreciated onsite classes significantly more compared to information and communication technologies (ICT) classes in gaining practical skills and social competence. (1) The significant limitations introduced because of the SARS-CoV-2 pandemic impacted the development and implementation of modern online teaching techniques, which may very well be applied to convey theoretical knowledge after the pandemic has ended. (2) Skills and social competence, indispensable in the future dental practice of dental students, can only be obtained during onsite classes. (3) Medical universities should design standards of teaching to enable them to address a possible epidemiological threat in the future, which will enable rapid response and safe continuation of practical dental education during a pandemic.

Catastrophic and Critical Intraoperative Events during Pediatric Craniofacial Surgery.

The data reviewed included the operative procedures of two senior craniofacial surgeons over an 18-year period at a tertiary care pediatric craniofacial center. Catastrophic or critical intraoperative events were defined as events requiring the activation of an emergency code during surgery. The operative details and acute outcomes were reviewed and analyzed. This study reviewed 7214 procedures performed between January 2002 and January 2019. There were 2072 (29%) cases classified as major craniofacial procedures (transcranial, mixed trans-and-extracranial, or major extracranial facial osteotomies), and code events occurred in 14 cases (0.67%; one in 148 patients): venous air embolism (n = 4), cardiac complications (n = 3), major hemorrhage (n = 3), trigeminocardiac reflex (n = 2), acute intracranial hypertension (n = 1), and acute airway obstruction (n = 1). Two cases (14%) experienced a critical event that was anesthesia-related. Cardiac arrest requiring compressions and/or defibrillation was necessary for eight patients. There were no mortalities. Surgery was curtailed in seven cases and successfully completed in seven patients. Catastrophic life-threatening events during pediatric craniofacial surgery are, fortunately, rare. In our institution, experienced teams in the management of catastrophic and critical intraoperative events during major pediatric craniofacial procedures resulted in no mortalities.

Scheduling doesn't matter! A noninferiority study of block versus longitudinal scheduling for emergency medicine resident pediatric procedural training experience.

Emergency medicine (EM) residencies offer a wide variety of scheduling models for pediatric patient experience, including blocked weeks in pediatric emergency departments and longitudinal models with pediatric emergency pod/department shifts integrated within other clinical experiences. Concerns with autonomy, attending entrustment, and resident comfort imply that these different scheduling models may impact EM residents' pediatric procedure volumes. The purpose of this study is to quantitatively compare EM residents' pediatric procedure experience and volumes between block versus longitudinal scheduling models. We hypothesize noninferiority between the scheduling models. A retrospective review characterized the numbers and types of procedures performed by The Ohio State Emergency Medicine residents at the tertiary care pediatric hospital where residents' receive their pediatric emergency medicine clinical experience. Procedure numbers and variety were compared across six academic years: four with a block model, one reorganization year, and one integrated longitudinal year. 2552 procedures were performed by 266 resident academic years over the 6-year period. Overall, no statistically significant differences in the number of procedures performed per year or the variety of types of procedures performed per year were found when comparing the block and longitudinal models. Differences were seen in experience of PGY1 versus PGY3 residents between scheduling models and the overall experience and volumes of the PGY2 residents during the reorganization year. Our study quantitatively concluded that the longitudinal scheduling model is noninferior to the more traditional block scheduling model for emergency medicine residents' pediatric emergency medicine clinical experience when reviewing volumes and types of procedures performed in a pediatric emergency department. This suggests that procedural opportunities do not need to dictate scheduling models.

Radiation risk-benefit communication during paediatric CT imaging: Experiences of radiographers at two public hospitals

IntroductionRadiation dose knowledge and effective communication skills are essential for both radiographers and radiologists to be able to appropriately fulfil their legal responsibilities to justify each medical exposure. Furthermore, they enable the optimisation of imaging protocols and techniques according to the child's characteristics and underlying clinical conditions. Previous studies have shown that radiographers do not provide paediatric patients and their parents/guardians with adequate information about doses and risks before a procedure. However, they have a legal responsibility to explain the radiation risk associated with performing the procedure as well as the associated risk of not performing the same procedure. There are several obstacles to describing ionizing radiation risk, including the ionizing radiation language that is not readily understood by non-imaging personnel. This study aimed to explore and describe the radiographers' experiences of radiation risk-benefit communication during paediatric CT imaging at two public hospitals. This is important to understand the effectiveness of the communication process and institute corrective action where shortcomings are evident. MethodsA qualitative, exploratory, descriptive research design was applied. The sample consisted of 12 purposively selected radiographers who were trained and working in the CT imaging department. Data were collected using face-to-face individual interviews. Tesch's 8 steps were used to analyse the data collected and generate themes and subthemes. ResultsTwo themes emerged from the data collected: (1)Positive experiences with two sub-themes (job satisfaction and mutual benefit) and (2) negative experiences with three sub-themes (.professional deprecation, ineffectual outcomes and communication impediments). ConclusionPositive experiences boosted radiographers' confidence and enhanced their participation in radiation risk-benefit communication with paediatric patients’ parents and guardians while negative experiences hindered patient-centred care in the process of risk-benefit communication. Implications for practiceContinuous education of radiographers and doctors on radiation risk-benefit communication before paediatric CT procedures is recommended, in line with their scope of practice, to improve patient-centred care.

Underutilization of laparoscopy for ovarian surgeries in the pediatric population: A nationwide analysis

PurposeOophorectomy and ovarian detorsion are some of the most frequent operations performed in the female pediatric population. Despite the advent of laparoscopy, many surgeons continue to utilize open surgical approaches in these patients. This study sought to compare nationwide trends and postoperative outcomes in laparoscopic and open ovarian operations in the pediatric population. MethodsFemales less than 21 years old who underwent ovarian operations (oophorectomy, detorsion, and/or drainage) from 2016 to 2017 were identified from the Nationwide Readmissions Database. Patients were stratified by surgical approach (laparoscopic or open). Hospital characteristics and outcomes were compared using standard statistical tests. ResultsThere were 13,202 females (age 17 [14–20] years) who underwent open (59%) or laparoscopic (41%) ovarian operations. The most common indications for surgery were ovarian mass (48%), cyst (36%), and/or torsion (19%) for which oophorectomy (88%), detorsion (26%), and drainage (13%) were performed most frequently. The open approach was utilized more frequently for oophorectomy (95% vs. 77% laparoscopic) and detorsion (33% vs. 16% laparoscopic), both p < 0.001. A greater proportion of laparoscopic procedures were performed at large (67% vs. 61% open), teaching (82% vs. 76% open) hospitals in patients with private insurance (47% vs. 42% open), all p < 0.001. Patients undergoing open procedures had significantly higher index length of stay (LOS) and rates of wound infections. Thirty-day and overall readmission rates, as well as overall readmission costs, were higher in patients who received open surgeries. ConclusionsDespite fewer overall complications, decreased cost, fewer readmissions, and shorter LOS, laparoscopic approaches are underutilized for pediatric ovarian procedures. Type of StudyRetrospective Comparative. Level of EvidenceLevel III.

Opioids and pediatric urology: A prospective study evaluating prescribing habits and patient postoperative pain and narcotic utilization

Few pediatric urologists believe patients require a majority of the doses of opioids prescribed to them postoperatively. Seeking a better understanding of postoperative pain and analgesia in pediatric urology patients may help reduce opioid over prescription while still adequately managing postoperative pain. We sought to better understand: 1) the postoperative pain levels experienced by pediatric urology patients, 2) the factors that correlate with postoperative pain and number of opioids consumed following pediatric urologic procedures, and 3) the patients who do not require opioids after surgery. Pediatric patients undergoing circumcision, inguinal hernia repair, orchidopexy, or hypospadias repair were eligible to participate. Patients were enrolled in the prospective cohort on the day of the procedure. For each of the first 7 postoperative days, patients' parents completed a text message-based questionnaire, quantifying their child's pain level and the doses of pain medication the child consumed. 165 participants were enrolled. 57 patients underwent circumcision, 54 underwent orchiopexy, 32 underwent hypospadias repair, and 22 underwent inguinal hernia repair. For all procedure types, pain scores (p<0.01) and doses of oxycodone consumed were highest on postoperative day one and steadily declined thereafter. Overall, average 7-day pain score (2.02; 0.86-5.14) and doses of narcotics consumed (3.50; 0-5) were low. Patients in each surgical subgroup were prescribed narcotics in excess of what was consumed. There was an average excess of 10.9 doses (0-39.0) for hypospadias repair, 8.6 (1.0-30.0) for circumcision, 9.0 (3.0-21.0) for inguinal hernia repair, and 6.1 (0-22.0) for orchiopexy. Overall, reported pain scores and number of narcotics consumed were low regardless of surgery type. Opioids were overprescribed regardless of surgery type. Our findings indicate that level of pain and opioid use varies by procedure type, but that number of narcotics prescribed greatly exceeds number needed.

Effectiveness of dexmedetomidine and midazolam for pediatric dental procedures: A systematic review and meta-analysis.

Effectiveness of dexmedetomidine and midazolam for pediatric dental procedures: A systematic review and meta-analysis.

Con: Modified Ultrafiltration Should Not Be Routinely Used in Adult Cardiac Surgery

CARDIOPULMONARY BYPASS (CPB) is known to induce a systemic proinflammatory state and may contribute to postoperative organ dysfunction, primarily through complement activation secondary to blood passing through an artificial extracorporeal circuit. 1 Hall RI Smith MS Rocker G. The systemic inflammatory response to cardiopulmonary bypass: Pathophysiological, therapeutic, and pharmacological considerations. Anesth Analg. 1997; 85: 766-782 Crossref PubMed Google Scholar , 2 Wang W Huang HM Zhu DM et al. Modified ultrafiltration in paediatric cardiopulmonary bypass. Perfusion. 1998; 13: 304-310 Crossref PubMed Scopus (39) Google Scholar , 3 Thapmongkol S Masaratana P Subtaweesin T et al. The effects of modified ultrafiltration on clinical outcomes of adult and pediatric cardiac surgery. Asian Biomedicine. 2015; 9: 591-599 Crossref Scopus (4) Google Scholar Ultrafiltration may minimize some of the impact of the CPB-induced systemic inflammatory response. 4 Huang H Yao T Wang W et al. Continuous ultrafiltration attenuates the pulmonary injury that follows open heart surgery with cardiopulmonary bypass. Ann Thorac Surg. 2003; 76: 136-140 Abstract Full Text Full Text PDF PubMed Scopus (85) Google Scholar Traditionally, ultrafiltration may be conventional (CUF) or modified (MUF). Conventional ultrafiltration has been employed extensively during CPB, and involves hemoconcentration of both the priming volume and patient's blood volume at any point during CPB. 5 Darup J Bleese N Kalmar P et al. Hemofiltration during extracorporeal circulation (ECC). Thorac Cardiovasc Surg. 1979; 27: 227-230 Crossref PubMed Scopus (30) Google Scholar ,6 Klineberg PL Kam CA Johnson DC et al. Hematocrit and blood volume control during cardiopulmonary bypass with the use of hemofiltration. Anesthesiology. 1984; 60: 478-480 Crossref PubMed Scopus (19) Google Scholar In the early 1990s, Naik et al. introduced the concept of MUF 7 Elliott MJ. Ultrafiltration and modified ultrafiltration in pediatric open heart operations. Ann Thorac Surg. 1993; 56: 1518-1522 Abstract Full Text PDF PubMed Scopus (205) Google Scholar ,8 Andreasson S Gothberg S Berggren H et al. Hemofiltration modifies complement activation after extracorporeal circulation in infants. Ann Thorac Surg. 1993; 56: 1515-1517 Abstract Full Text PDF PubMed Scopus (88) Google Scholar ,9 Naik SK Knight A Elliott MJ. A successful modification of ultrafiltration for cardiopulmonary bypass in children. Perfusion. 1991; 6: 41-50 Crossref PubMed Scopus (164) Google Scholar in which the patient's blood volume is hemoconcentrated after separation from CPB. 10 Wang S Palanzo D Undar A. Current ultrafiltration techniques before, during and after pediatric cardiopulmonary bypass procedures. Perfusion. 2012; 27: 438-446 Crossref PubMed Scopus (40) Google Scholar Naik et al. postulated it may permit blood-free cardiac surgery. 11 Naik SK Knight A Elliott M. A prospective randomized study of a modified technique of ultrafiltration during pediatric open-heart surgery. Circulation. 1991; 84 (III422-31) PubMed Google Scholar Blood is typically removed from the arterial cannula and returned through the venous cannula. Others employ a modified technique in which blood is removed from the right atrium and infused into the aorta, potentially reducing concerns about cerebral shunting. 12 Myers GJ Leadon RB Mitchell LB et al. Simple modified ultrafiltration. Perfusion. 2000; 15: 447-452 Crossref PubMed Scopus (16) Google Scholar

Local reference and achievable dose levels for vascular and enterostomy access procedures in pediatric interventional radiology.

Knowledge of radiation quantities delivered in routine practice is an essential responsibility of a pediatric interventional radiology department. To review radiation indices in frequently performed vascular and enterostomy access procedures at a quaternary pediatric hospital to formulate dosimetric reference levels and achievable levels. A retrospective review of patient demographics, procedure information and quantitative dose metrics over a 2-year period was performed. Dosimetric details forcommon procedures (central line insertions, gastrostomy/gastrojejunostomy insertions and maintenance) were evaluated, correlated with demographic data and stratified acrossfive weight groups (0-5kg, 5-15kg, 15-30kg, 30-50kg, 50-80kg).Achievable (50th percentile) and reference (75thpercentile)levels with confidence intervals were established for each procedure. Within the evaluation period, 3,165 studies satisfied the inclusion criteria. Five were classified as device insertions (peripherally inserted central catheter, n=1,145; port-a-catheter, n=321; central venous line, n=285; gastrostomy-tube [G-tube], n=262, and gastrojejunostomy-tube [GJ-tube], n=66),and two were classified as maintenance procedures (G-tube, n=358, and GJ-tube, n=728, checks, exchanges and reinsertions). Representative reference and achievable levels were calculated for each procedure category and weight group. This work highlights the creation of local reference and achievable levels for common pediatric interventional procedures. These data establish a dosimetric reference to understand the quantity of radiation routinely applied, allowing for improved relative radiation risk assessment and enriched communication to interventionalists, health care providers, parents and patients.

Beta-Lactam Allergy Association with Surgical Site Infections in Pediatric Procedures: A Matched Cohort Study.

Little is known about surgical site infection (SSI) risk among pediatric patients with reported beta-lactam allergy (BLA). We performed a retrospective cohort study at a quaternary children's hospital and compared procedures in patients ages 1-19 years old with and without BLA that required antimicrobial prophylaxis (AMP) during 2010-2017. Procedures were matched 1:1 by patient age, complex chronic conditions, year of surgery, and National Surgical Quality Improvement Program current procedural terminology category. The primary outcome was SSI as defined by National Healthcare Safety Network. The secondary outcome was AMP protocol compliance as per American Society of Health-System Pharmacists. Of the 11 878 procedures identified, 1021 (9%) had a reported BLA. There were 35 (1.8%) SSIs in the matched cohort of 1944 procedures with no significant difference in SSI rates in BLA procedures (1.8%) compared to no-BLA (1.9%) procedures. Tier 3 AMP was chosen more frequently among BLA procedures (P < .01). Unmatched analysis of all procedures showed that 23.7% of BLA procedures received beta-lactam-AMP (vs. 93.7% of procedures without BLA). There were no major differences in SSI on sensitivity analysis of BLA procedures that did not receive beta-lactam AMP (1.4%) compared to no-BLA procedures with beta-lactam AMP (1.6%). Our retrospective matched analysis of 1944 pediatric procedures found no increase in SSIs in procedures with reported BLA, which differs from studies in adults. We observed that the choice of beta-lactam-AMP was common, even in BLA procedures. More data are needed to delineate an association between non-beta-lactam AMP and SSI in children.

Reasons Behind Patients Defaulting from Elective Pediatric Urology Procedures at a Tertiary Private Teaching Hospital in South India.

The aims of the study are to audit the default rate of the provisional date of elective surgery in pediatric urology private practice and to study the factors involved in the postponement of elective operation dates by patients. The audit involved analysis of reasons behind patients defaulting from elective pediatric urology procedures between January 2019 and December 2019 at a tertiary private teaching hospital in South India. The details were obtained from the outpatient register kept for elective booking. The details of actual procedures performed were obtained from OT records. From the defaulters, the reasons for postponement were obtained through personal/telephonic interview. A total of 289 patients were given dates for elective procedures. Among this, 72 (24.9%) defaulted, leaving 217 patients who underwent elective surgery. Among those who underwent surgery, 90 (41%) were elective day case (DC) procedures, whereas 127 (59%) were inpatient (IP) procedures. The default rate was 26/116 (22.4%) for DC procedures, whereas 46/173 (26.6%) for IP procedures, with no significant difference between them (P = 0.64). Among the 72 defaulters, the reasons for cancellation were as follows: financial factors (FFs) 22 (30.6%), lack of family support 19 (26.4%), function/grievance in house 10 (13.9%), respiratory illness 14 (19.4%), and treatment at a different center 7 (9.7%). FF (insurance denial) was significantly higher (P = 0.001) in crucial IP procedures at 19/46 (41%) compared to DC procedures at 3/26 (12%). The various diagnoses denied insurance were UPJO (7), VUR (6), hypospadias (4), UDT (3), and PUV (2). FFs were mainly responsible for parents postponing their children's elective pediatric urology procedures in India. Universal insurance coverage for congenital anomalies might help overcome this most important cause of cancellations.