Perioperative Care Of Children Research Articles

Application of multidisciplinary collaborative nursing with family care for enhanced recovery after surgery in children with inguinal hernia.

Perioperative nursing can reduce the stress reaction and improve the prognosis of children. To elucidate the influence of multidisciplinary collaborative nursing for enhanced recovery after surgery (ERAS) with family care in perioperative nursing children with an inguinal hernia and its impact on the prognosis. The data of 100 children with inguinal hernia were retrospectively analyzed. The participants were divided into three groups according to different nursing methods: Groups A (n = 38), B (n = 32), and C (n = 30). Group A received multidisciplinary collaborative ERAS nursing combined with family care nursing; Group B received multidisciplinary collaborative nursing for ERAS; and Group C received routine nursing. The postoperative recovery results of the three groups were compared, including intraoperative blood loss and postoperative feeding time, time of getting out of bed, hospitalization time, and defecation time. Furthermore, the incidence of common complications was also compared between the three groups. There was less intraoperative blood loss in Groups A and B than in Group C (P < 0.05), and the time of getting out of bed and postoperative hospitalization and defecation times were also decreased in Group C (P < 0.05). There was no significant difference in postoperative feeding time among the three groups (P > 0.05). Each index had no statistical significance between Groups A and B (P > 0.05). The incidence of urinary retention, infection, hematoma, and hernia recurrence in Group A was less than that in Group C (P < 0.05). No significant difference was observed in the overall complication rate between Groups A and B and between Groups B and C (P > 0.05). The application of multidisciplinary collaborative nursing combined with family care in the perioperative care of children with an inguinal hernia for ERAS may promote postoperative rehabilitation for children and reduce the incidence of complications.

Error traps in the perioperative care of children with chronic pain.

Pediatric patients with a history of chronic pain frequently have complex health needs that are challenging to meet in the perioperative period. Error traps are consequences or errors that are known to occur due to either gaps in knowledge or cognitive errors. Avoiding common error traps in these children can contribute to improved patient care and patient outcomes and overall better patient and family satisfaction. In patients with chronic pain, common errors during their perioperative care included as follows: failure to adequately prepare the patient and family; failure to incorporate past pain history and therapy into current treatment plans; failure to provide adequate multimodal analgesia; and failure to provide multidisciplinary and multimodal analgesia by incorporating other services such as mental health services and physical therapy. Cognitive errors may play a role in these error traps. Recognizing and avoiding them may improve and optimize pain care and outcome.

Perioperative Care of Children with Severe Neurological Impairment and Neuromuscular Scoliosis-A Practical Pathway to Optimize Peri-Operative Health and Guide Decision Making.

Neuromuscular scoliosis is a common feature in children with severe neurological impairment (SNI), including those with severe cerebral palsy. Surgical correction of scoliosis is the mainstay of treatment. This group of patients also have associated medical complexity. The complication rates post-surgery are high, although, for many, they are worth the risk. There are currently no published practice guidelines or care pathways for children with SNI who are undergoing scoliosis corrective surgery. In response to the high uptake of this surgery, coupled with the expected complication rates, our hospital established a perioperative clinic. The purpose of this paper is to describe our perioperative approach. This clinic has developed into a service beyond perioperative care and, with the collaborative meeting, enables shared decision-making to identify the right candidate for surgery. The process involves surgical expertise, understanding the family and child at the centre, and optimisation of medical care pre- and post-surgery. In this paper, we describe the process in a step-by-step manner. We provide clinical vignettes, as well as the proformas that we use, and we highlight the benefits of the team-based process.

Perioperative Care of Children with Acute Exogenous Lipoid Pneumonia Submitted to BAL/FB

ObjectiveThe present study evaluates the psychosocial care and the bronchoalveolar lavage (BAL)/fiberoptic bronchoscopy (FB) procedure in children with pediatric acute exogenous lipoid pneumonia (ELP) and summarizes the critical points of nursing.MethodsData on the psychosocial factors of the patients and clinical information were collected. Participants comprised 41 children within three years of age.ResultsAll the children were cooperative with the BAL/FB procedure. The children’s pain scores were between 4–6, and the psychological conditions of the children and caregivers were nervous/anxious upon admission. After the medical staff’s psychological care and health education, the children’s postoperative pain scores were reduced to 0–3, and the psychological state of the caregivers was positive.ConclusionPsychological care can alleviate families’ adverse emotions and promote treatment cooperation and recovery from the acute ELP.

Efficacy and safety of an abbreviated perioperative care bundle versus standard perioperative care in children undergoing elective bowel anastomoses: A randomized, noninferiority trial

PurposeThe aim was to evaluate if an abbreviated perioperative care bundle (APCB) is noninferior to the standard care, in terms of efficacy and safety, in pediatric patients undergoing bowel anastomoses. MethodsA randomized, open, noninferiority trial with two parallel groups of equal size was carried out at the National Institute of Pediatrics in Mexico City, Mexico, from April 2016 to July 2018. The total number analyzed was 74 (37 per group).The APCB comprised same day admission, avoidance of mechanical bowel preparation, optimized antibiotic prophylaxis, and early feeding. Statistical analysis was done with Fisher's exact test or Chi2, and Student's T test. ResultsNo significant differences were found for demographic variables and type of disease, either for the safety (anastomotic leakage, p 0.753; organ/space surgical site infection, p 0.500) or for some efficacy outcomes (ileus or bowel obstruction, p 0.693). Other efficacy outcomes were better in the study group, with shorter median times for feeding tolerance (19 h vs. 92 h, p < 0.001), for first bowel movement (15 h vs. 36 h, p < 0.001), and for discharge (1 vs. 6 days, p < 0.001). ConclusionThe abbreviated care bundle was proven to be as safe but more efficacious than the standard care. Level of evidenceI — randomized controlled trial with adequate statistical power.

Clinical practice guidelines in pediatric anesthesia: What constitutes high‐quality guidance?

The explosion of scientific evidence has outstripped the ability of individual clinicians to acquire, process, and apply it within a clinical context. Clinical practice guidelines bridge the gap between this large body of evidence and clinical practice by translating evidence into recommendations. As such, they are an important extension of the evidence-based medicine paradigm. Guidelines promise to translate evidence into actionable clinical recommendations. However, this promise can only be realized if they are both useful and trustworthy. As the number of guidelines increases users' question their role, the quality of the scientific evidence behind them and the strength of the recommendations made. In this article, we provide definitions and outline the features of the common forms of clinical guidance. We then describe the essential characteristics of good quality clinical guidance and outline initiatives aimed at improving quality. Specific issues and limitations related to guideline development in perioperative care of children are discussed. Finally, two clinical guidance documents, published recently in Pediatric Anesthesia, are discussed based upon these criteria.

Perioperative care of children with sickle cell disease: A systematic review and clinical recommendations.

Children with sickle cell disease (SCD) require specific perioperative care, and clinical practice in this area remains poorly defined. We aimed to conduct a systematic, PRISMA-based review of the literature, available clinical guidelines and practice recommendations. We also aimed to extract any valuable information for the "best of available-evidence"-based prevention of perioperative adverse events in children with SCD, and highlight the most urgent priorities in clinical research. As data sources, US National Library of Medicine, Medline, National Guideline Clearinghouse, International Guideline Network, TRIP databases were searched for any content until January 2019. We also included institutional, consortia and expert group guidelines. Included were reports/guidelines in English, French, German, and Italian. Excluded were reports on obstetrical and fetal management. We identified 202 reports/guidelines fulfilling the criteria outlined above. A majority focused on visceral, cardiovascular and orthopedic surgery procedures, and only five were multicenter randomized controlled trials and two prospective randomized studies. After grading of the quality of the evidence, the extracted data was summarized into clinical recommendations for daily practice. Additionally, we designed a risk-grading algorithm to identify contexts likely to be associated with adverse outcomes. In conclusion, we provide a systematic PRISMA-based review of the existing literature and ancillary practice and delineate a set of clinical recommendations and priorities for research.

Fluid choice during perioperative care in children: A survey of present-day proposing practice by anesthesiologists in a tertiary care hospital.

Background:Perioperative fluid therapy in pediatrics has always been a challenging avenue for anesthesiologists. Inappropriate choice of fluid leads to multiple side effects, for instance iatrogenic hyponatremia. Our aim was to observe the current practice of perioperative fluid therapy in pediatric population undergoing surgery in a tertiary care hospital.Methods:After obtaining approval from the Departmental Research Review Committee, a survey form including questions was emailed to anesthesiologists from January 2015 to June 2015. Individual responses were recorded and analyzed.Results:Overall response was 100% from consultant and resident, and total 55 anesthesiologists were participated in this survey. Majority of anesthesiologist have used, 1/2 dextrose saline (52.7%) as fluid of choice in routine intraoperative maintenance, while Hartmann's solution (41.8%) and normal saline 0.9% (5.5%) were used for rest of the them. The Holliday-Segar method for maintenance fluid was mentioned by 92.7% of anesthesiologists.Conclusion:The use of hypotonic fluid in perioperative care in pediatric population is still being practiced despite the current guidelines. These results point to a considerable gap between the available evidence and practice.

The Influence of Anesthesia On Perioperative Outcome in Children - Institutional and Individual Factors

The perioperative care of children is challenging for health care providers. Since anesthetists cannot affect the nature of the disease and have hardly an impact on the decision for surgery we summarized in this review individual and institutional factors for improving perioperative outcome by anesthetists. Individual factors include the level of education and the professional experience of the anesthetist as well as an anesthetic management that is focused on the maintenance of an adequate cerebral perfusion. Besides individual factors this review emphasizes the importance of institutional factors as measures to reduce anxiety and insecurity of the parents which result in less distress and coping of the children in the postanesthesia care unit as well as less need for pain medication, less emergence delirium and less sleep disorders. A behaviorally oriented preoperative preparation of parents and children also affects the postoperative course of the pediatric patients positively as well as institutional concepts for the reduction of perioperative medication errors and adverse drug events. We believe that perspectively pediatric surgery will be increasingly performed in high volume hospitals which are able to guarantee beneficial institutional structures as well as a high educational level and high professional experience of the employed anesthetists.

Cleft Lip and Cleft Palate Surgery: Malpractice Litigation Outcomes.

This study examined malpractice claims related to cleft lip and cleft palate surgery to identify common allegations and injuries and reviewed financial outcomes. The WestlawNext legal database was analyzed for all malpractice lawsuits and settlements related to the surgical repair of cleft lip and palate. Inclusion criteria included patients undergoing surgical repair of a primary cleft lip or palate or revision for complications of previous surgery. Data evaluated included patient demographics, type of operation performed, plaintiff allegation, nature of injury, and litigation outcomes. A total of 36 cases were identified, with 12 unique cases from 1981 to 2006 meeting the inclusion criteria. Six cases (50%) were decided by a jury and six by settlement. Five cases involved complications related to the specific surgery, and the other seven were associated with any surgery and perioperative care of children and adults. Cleft palate repair (50%) was the most frequently litigated surgery. Postoperative negligent supervision was the most common allegation (42%) and resulted in a payout in each case (mean = $3,126,032). Death (42%) and brain injury (25%) were the most frequent injuries reported. Financial awards were made in nine cases (after adjusting for inflation, mean = $2,470,552, range = $0 to $7,704,585). The awards were significantly larger for brain injury than other outcomes ($4,675,395 versus $1,368,131 after adjusting for inflation, P = .0101). Malpractice litigation regarding cleft lip and palate surgery is uncommon. However, significant financial awards involving perioperative brain injury have been reported.

A retrospective review of anesthesia and perioperative care in children with medium-chain acyl-CoA dehydrogenase deficiency.

Medium-chain acyl-CoA dehydrogenase deficiency is the most common genetically determined disorder of mitochondrial fatty acid oxidation. Decompensation can result in hypoglycemia, seizures, coma, and death but may be prevented by ensuring glycogen stores do not become depleted. Perioperative care is of interest as surgery, fasting, and infection may all trigger decompensation and the safety of anesthetic agents has been questioned. Current guidelines from the British Inherited Metabolic Disease Group advise on administering fluid containing 10% glucose during the perioperative period. To review the management of anesthesia and perioperative care for children with medium-chain acyl-CoA dehydrogenase deficiency and determine the frequency and nature of any complications. A retrospective review of case notes of children with medium-chain acyl-CoA dehydrogenase deficiency undergoing anesthesia between 1997 and 2014. Fourteen patients underwent 21 episodes of anesthesia. In 20 episodes, the patient received a glucose-containing fluid during their perioperative fast, of which eight received fluid containing 10% dextrose throughout the entire perioperative period. No episodes of hypoglycemia or decompensation occurred, but perioperative hyperglycemia occurred in five episodes. A propofol bolus was administered at induction in 16 episodes and volatile agents were administered for maintenance of anesthesia in all episodes without any observed complications. In one episode, delayed offset of atracurium was reported. Perioperative metabolic decompensation and hypoglycemia appear to be uncommon in children who are well and receive glucose supplementation. Hyperglycemia may occur as a consequence of surgery and glucose supplementation. Propofol boluses and volatile anesthetic agents were used without any apparent complications. Prolonged action of atracurium was reported in one case, suggesting that nondepolarizing muscle relaxants may have delayed offset in this patient group. We do not recommend any particular approach to anesthesia but would advise administering glucose supplementation according to current guidelines, frequent monitoring of blood glucose perioperatively, and monitoring of neuromuscular blockade.

Perioperative care of children and young people with diabetes

### Key points Diabetes mellitus affects an estimated 497 000 children globally between the ages of 0 and 14 yr, accounting for 0.02% of the total child population. This is likely to be a significant underestimate due to underdiagnosis, especially in areas of socio-economic deprivation. As in adults, diabetes is the most common cause of metabolic co-morbidity and the UK has the fifth largest population of Children and Young People (CAYP) with type 1 diabetes mellitus (T1DM) in the world. T1DM remains the most prevalent form of childhood diabetes, affecting 97% of British diabetic children. The incidence of T1DM is increasing, with the greatest increase in younger children. However, the peak age for diagnosis remains in the 10–14 age range. Additionally, the number of CAYP with type 2 diabetes mellitus (T2DM) is increasing, which is associated with the growth in childhood obesity and physical inactivity.1 Compared with the rest of Europe, the UK has some of the poorest outcomes of care in paediatric diabetes. The annual National Paediatric Diabetes Audit in England and Wales has repeatedly shown poor glycaemic control in CAYP with only 16% achieving the National Institute for Health and Care Excellence (NICE) target value of a glycated haemoglobin (HbA1c) …

Perioperative Care of Children with Eisenmenger Syndrome Undergoing Non-cardiac Surgery.

The Eisenmenger syndrome (ES) is a severe form of pulmonary arterial hypertension and arises in congenital heart disease with a systemic-to-pulmonary shunt. Patients with ES have multisystem involvement as a result of chronic hypoxemia with hematologic, skeletal, renal, and neurologic systems, causing significant morbidity and mortality. In contrast to pulmonary arterial hypertension, survival prospects are far superior in patients with ES and a growing number of ES patients are surviving into adulthood. As a result, many face the prospect of incidental surgery. To date, there is no guideline for the perioperative care of ES patients in children and limited data available for adult patients. This review provides an overview of appropriate measures for the safe perioperative care of patients, based on an understanding of the pathophysiological changes that occur in ES.

先天性心疾患の周術期管理における取組み

先天性心疾患の周術期管理における取組み

Preoperative Anaemia and Blood Transfusion Requirements in Children Undergoing Surgery under General Anaesthesia at the University of Benin Teaching Hospital, Nigeria

Background : Anaemia prevalence among children in Nigeria is a serious morbidity although it's prevalence in Benin has not been determined in recent times. The purpose of this study was to determine the prevalence of preoperative anaemia, its' associated factors and blood transfusion requirements in children undergoing surgery under general anaesthesia at our facility. Methodology : A retrospective study of children aged 0 -17 years who had surgery under general anaesthesia at the University of Benin Teaching Hospital, Benin from January 2006 to June 2008, was carried out after ethical approval. The master register, anaesthetic charts and case notes of paediatric patients were used to determine the prevalence of preoperative anaemia, causes of anaemia, complications of anaemia and that of its' treatment and blood transfusion requirements. Data was analysed and subjected to statistical tests using the Statistical Package for Social Sciences. Results : Six hundred and fifty two (652) children scheduled for anaesthesia were studied. An incidence of preoperative anaemia of 12% in paediatric surgical patients was found (n=80). The complications of anemia and its' treatment include pulmonary oedema, hypotension, prolong recovery and urticaria (n=35 i.e. 44%, p Conclusion : The prevalence of anaemia of 12% was found in children undergoing surgery at UBTH. Anaemia is anaesthesia related risk and knowledge of its prevalence is important for research statistics for health planning. This would lead to improved peri-operative care in children.

The perioperative dialogue reduces postoperative stress in children undergoing day surgery as confirmed by salivary cortisol

To evaluate the efficacy of 'the perioperative dialogue (PD)' by analyzing salivary cortisol, in 5- to 11-year-old children undergoing day surgery. To deal with anxiety prior to investigations and/or procedures, children need to be confident and informed about what is going to happen. Therefore, intervention strategies should be initiated before admission to hospital. Children (n = 93), 79 boys and 14 girls, scheduled for elective day surgery requiring general anesthesia were randomly recruited into three groups: (i) standard perioperative care (n = 31), (ii) standard perioperative care including preoperative information (n = 31), and (iii) the PD (n = 31). Saliva was sampled for cortisol analysis at specific time points during the pre- and perioperative procedures. The children who received the PD had significantly lower (P = 0.003) salivary cortisol concentrations postoperatively. Moreover, it continuously decreased during the day of surgery compared with the other two groups (P < 0.01). Among the children who received analgesics, the PD group received significantly less morphine (P = 0.014) related to bodyweight: the mean dose was 0.1 mg·kg(-1) (n = 9) in the control group vs 0.04 mg·kg(-1) (n = 6) in the PD group. Irrespective of group, there was a positive correlation between the children's morphine consumption and salivary cortisol concentration (r = 0.56; P = 0.038). The W-B scale score was higher in the group that received morphine (median = 3 vs median=1; P = 0.001). The PD's caring, continuity, and on-going dialogues were associated with low concentrations of salivary cortisol postoperatively and reduced morphine consumption and thus appears to be a valuable complement to standard perioperative care in children undergoing day surgery.

Perioperative Care of Children with Tetralogy of Fallot

Complete surgical repair of tetralogy of Fallot (TOF) around 3months of age is the commonly undertaken management strategy in many centers and has excellent outcomes. Intervention at an earlier age, including the newborn period, may be required for children with symptoms. Early extubation from mechanical ventilation where possible may help improve outcomes for children undergoing complete repair of TOF.

Antibiotic prophylaxis and the prevention of surgical site infection

Surgical site infection (SSI) is one of the most common complications of surgery in both adults and children. The purpose of the present review is to highlight the progress in the understanding of SSIs and the current role of antimicrobial prophylaxis (AMP). An SSI is diagnosed by a constellation of clinical findings occurring within 30 days of surgery. Pathologic organisms responsible for the development of an SSI are mainly limited to Gram-positive bacteria. Two well documented risk factors for the development of SSI in children are wound classification by the Centers for Disease Control (CDC) and procedure duration. Administration of appropriate AMP prior to skin incision has been shown to reduce the incidence of SSI in selected procedures. However, there is a lack of consensus on which procedures in children require AMP. Improvement in the perioperative care of children has reduced both the incidence and outcomes of SSI. However, several controversies still exist in the use of AMP in children. Future work by pediatricians, pediatric surgeons, and pediatric infectious disease specialists will enable us to better understand the specific indications and appropriate AMP in children.

Perioperative care of children with inherited metabolic disorders

The expression ‘inborn error of metabolism’ was coined to describe disorders resulting from the failure of a step or steps within a metabolic pathway. The number and complexity of metabolic processes required to maintain homeostasis is vast and so it follows that the spectrum of human disorders ascribed to inherited defects in metabolism is considerable. 1 Although some of these conditions do not have much impact on the perioperative management plan, others such as the mucopolysaccharidoses (MPS) represent some of the most challenging patients who an anaesthetist is likely to encounter. This short article does not provide comprehensive details of all inherited metabolic disorders (IMDs) but aims to provide the reader with a concise description of some of these rare conditions and highlight some of the key principles of perioperative management. IMDs are a genetically heterogenous group and may present at any age. Inheritance is often autosomal recessive but this is not invariable. Many conditions are extremely rare and reports of experience of anaesthesia in the literature are limited. An overview of some of the commoner IMDs is presented in Table 1. 2

Anesthesia can be safely provided for children in a high-field intraoperative magnetic resonance imaging environment

To describe the challenges associated with providing safe anesthesia and perioperative care for children in a remote intraoperative magnetic resonance (iMR) operating room (OR) and to identify perioperative anesthesia outcomes, including adverse events related to the iMR environment. Increasingly, children undergo neurosurgical procedures in a high-field iMR OR. We describe a 10-year experience of providing anesthesia for children in this environment with a mobile 1.5-Tesla magnet. A 10-year retrospective analysis was conducted of children who underwent neurosurgical procedures in a high-field mobile iMR OR. Primary outcomes related to perioperative adverse events and recovery profiles. Results were expressed as mean ± sd or median (range), as appropriate. One hundred and five procedures were performed on 98 children, aged 4 months-18 years, weighing 6-112 kg. The commonest two diagnostic categories were tumor (n = 52) and seizures (n = 27). Median anesthetic time was 439 (185-710) mins. There were no significant adverse events related to the iMR environment. The mean postanesthetic care unit admission temperature was 37 ± 0.9°C and the mean modified Aldrete Score at 30 mins was 7.2 ± 0.9. Two patients experienced seizures in the immediate postoperative period, readily controlled with propofol. There was one breach of MR safety protocol, and no adverse events related to patient transport. Anesthesia and perioperative care of children in an iMR setting were associated with a very low incidence of complications, despite the duration of the procedures involved. Such success depends upon a cohesive team-based approach.