Postoperative Pediatric Patients Research Articles

Pediatric Differentiated Thyroid Carcinoma: Outcome in Response to Initial Treatment

Introduction: Though the differentiated thyroid carcinoma in children is a common pediatric endocrine malignancy, its prognosis is excellent with a proper initial treatment. Objectives: This is to evaluate the initial treatment patern for a good prognosis with longterm outcome in pediatric DTC patients. Methods: This study is a prospective one done in BSMMU during a period of 10 years in 52 post-operative pediatric DTC patients after excluding the follow-up missing patients. These patients are yet in a regular follow-up were outcome evaluated with clinical, pathological & imaging studies. Results: All the patients got initial treatment of total thyroidectomy. About half of the group had undergone neck dissection along with total thyroidectomy. Forty six patients had taken 131-I therapy. The survival is 100%. Conclusion: The life expectancy for children with DTC is excellent. However, many patients experience adverse effects from thyroid surgery, resulting in life long complications. Bangladesh J of Otorhinolaryngology; October 2018; 24(2): 143-148

The Effects of Peppermint Oil on Post-Operative Urinary Retention

Background: As a primarily postoperative unit, postoperative urinary retention is a common complication. Standard nursing interventions like running water and getting the patient up to the restroom, were not always successful which frequently led to the patient needing to be catheterized. A patient’s mother reported as a Labor and Delivery nurse she had successfully used peppermint oil in postpartum moms. A literature review did not reveal any Evidence Based nursing interventions to treat postoperative urinary retention. Peppermint oil was a nursing intervention in textbooks on postpartum care, with no evidence to support this indication for use. Due to a lack of evidence, a research project was started. Research Question: Does the use of peppermint oil in postoperative pediatric patients result in a reduced need for cauterization when experiencing urinary retention? Methods: The subject must be postoperative, continent, between the ages of 3 and 17, and experiencing urinary retention. A peppermint oil infused patch is placed on the patient for the patient to inhale while attempting to void. After one hour the patch is removed and physician is notified if no void. Results: Over 13 months 23 patients were enrolled. Of those, 15 were able to void within one hour of patch placement. Three patients voided after the patch was removed. A total of five patients required catheterization. A total of 22% of the study patients were catheterized after the use of peppermint oil. The retrospective chart search was performed to determine the control group. The search found 13 patients that met the research criteria. Of those 13, seven required catheterization which equates to a 54%. Conclusion: Even though there was a 32% decrease in the need for catheterization after the implementation of peppermint oil, the data did not prove to be statistically significant (p value of 0.07) due to the small sample size of both the study population and the retrospective chart search. Peppermint oil is now available to any patients meeting criteria for urinary retention. View a PDF of this Poster Presentation

A comparison study assessing neuropsychological outcome of patients with post-operative pediatric cerebellar mutism syndrome and matched controls after proton radiation therapy.

Post-operative pediatric cerebellar mutism syndrome (CMS), characterized by mutism, ataxia/hypotonia, and emotional lability, can result in long-term deficits following resection of posterior fossa (PF) tumors. This longitudinal study compared neuropsychological outcomes of pediatric patients with post-operative CMS to a matched control patient group without CMS. Fifty-eight PF tumor patients received post-surgical proton radiation therapy (PRT) and testing at baseline and at ≥ 1-year post-PRT over a 10-year period. Of these, 18 (31%) had post-operative CMS with baseline and follow-up neuropsychological test data. Those participants were matched to 18 controls by tumor location, age, gender, and handedness; no significant group differences were found at baseline for clinical/demographic variables. Total mean age at baseline was 7.26years (SD = 4.42); mean follow-up interval was 3.26years (SD = 2.24). Areas assessed: overall intelligence, expressive and receptive vocabulary, visuomotor integration, fine motor speed, inhibition, emotional control, depression, and anxiety. Patients were 52% male; 86% medulloblastoma/14% ependymoma; 86% craniospinal irradiation/14% focal radiation; and 86% chemotherapy. No group differences were found between most mean baseline scores; expressive vocabulary and fine motor speed were significantly lower in the post-operative CMS group (p< 0.05). Mean change scores revealed no significant differences for the sample; scores were within the normal range except fine motor skills were impaired for both groups. Longitudinal neuropsychological outcomes for post-operative pediatric CMS patients did not differ significantly from matched controls without this condition. Patients were in the normal range in all areas except fine motor speed, which was impaired for both groups independent of CMS diagnosis.

Reducing Exposure to Opioid and Benzodiazepine Medications for Pediatric Cardiac Intensive Care Patients: A Quality Improvement Project.

To evaluate the effect of implementation of a comfort algorithm on infusion rates of opioids and benzodiazepines in postneonatal postoperative pediatric cardiac surgery patients. A quality improvement project, using statistical process control methodology. Twenty-five-bed tertiary care pediatric cardiac ICU in an urban academic Children's hospital. Postoperative pediatric cardiac surgery patients. Implementation of a guided comfort medication algorithm which consisted of key components; a low dose opioid continuous infusion, judicious use of frequent as needed opioids, initiation of dexmedetomidine infusion postoperatively, and minimal use of benzodiazepines. Among the baseline group admitted over the 18 month period prior to comfort algorithm implementation, 58 of 116 intubated patients (50%) received a continuous opioid infusion, compared with 30 of 41 (73%) for the implementation group over the 9-month period following implementation. Following algorithm implementation, opioid infusion rates were decreased and benzodiazepine infusions were nearly eliminated. Dexmedetomidine use and infusion rates did not change. Although mean duration of sedative drug infusions did not change with implementation, the frequency of high outliers was diminished. Duration of mechanical ventilation, length of ICU stay (outcome measures), and the frequency of unplanned extubation (balancing measure) were not affected by implementation. Implementation of a pediatric comfort algorithm reduced opioid and benzodiazepine dosing, without compromising safety for postoperative pediatric cardiac surgical patients.

Arterial spin-labeling cerebral perfusion changes after revascularization surgery in pediatric moyamoya disease and syndrome.

Moyamoya disease is a dynamic cerebrovascular condition that often requires vascular surveillance. Arterial spin labeling (ASL) is an MR perfusion method that is increasingly used for stroke and other various neurovascular pathologies. Unlike perfusion-weighted MRI, ASL uses endogenous water molecules for signal and therefore obviates gadolinium use; and provides direct, not relative, quantitative cerebral blood flow (CBF) measures. Presently, the potential role of ASL for evaluating postoperative pediatric moyamoya patients is relatively unexplored. This study investigated the role for ASL in evaluating cerebral hemodynamic changes in children who underwent revascularization surgery. This retrospective study examined 15 consecutive pediatric patients with moyamoya disease (n = 7) or moyamoya syndrome (n = 8) presenting between 2010 and 2014 who underwent revascularization and in whom 3T ASL was performed pre- and postoperatively. Postoperative MRI at least 3 months after revascularization procedure was used for analysis. Quantitative CBF in various vascular territories was interrogated: anterior, middle, and posterior cerebral arteries, and basal ganglia supplied by the lenticulostriate collaterals, resulting in evaluation of 20 brain regions. After revascularization, CBF in the high middle cerebral artery territory significantly increased (p = 0.0059), accompanied by a decrease in CBF to the ipsilateral lenticulostriate-supplied basal ganglia (p = 0.0053). No perfusion changes occurred in the remaining cerebral vascular territories after surgery. ASL-based quantitative CBF showed improved cerebral perfusion to the middle cerebral artery territory after revascularization in children with both moyamoya syndrome and disease. Reduced perfusion to the basal ganglia might reflect pruning of the lenticulostriate collaterals, potentially from effects of revascularization. ASL can quantitatively evaluate hemodynamic changes in children with moyamoya after revascularization, and it may be a useful adjunct to routine clinical MRI surveillance.

Pediatric Post-anesthesia Care Unit Challenges Update

The purpose of this review is to discuss the current management of various challenges the health care provider faces in the pediatric post-anesthesia care unit (PACU). Efforts to ameliorate and manage PACU issues in the pediatric patient continue to evolve as new medications and methods of anesthesia delivery are introduced and incorporated into the perioperative period. In this review, emergence delirium (ED), postoperative nausea and vomiting (PONV), residual neuromuscular blockade, and tracheal extubation in the operating room versus the PACU are addressed. As ED may be self-limited, pharmacologic treatment may only be indicated if there is a concern for patient harm. Midazolam, fentanyl, and propofol have all been shown to be effective in the treatment of emergence delirium. Dexmedetomidine has been shown to decrease the incidence of ED when administered preoperatively or intraoperatively. This has led practitioners to use dexmedetomidine to treat ED in the PACU, though this has not been studied. Postoperative nausea is difficult to assess in the pediatric patient leading to under treatment. In order to capture these children, the BARF score, initially validated for use in oncologic pediatric patients, is validated for use in postoperative pediatric patients 6 years and older. The approach to treating breakthrough PONV in the PACU is guided by the medications administered intraoperatively for prophylactic treatment. Rescue medications from a different class should be selected if fewer than 6 h have passed since the administration of prophylactic antiemetics. Inadequate reversal of neuromuscular blockade intraoperatively results in adverse respiratory events in the PACU. In the past, when maximum doses of reversal agents are administered, the only recourse in the PACU is to provide assisted ventilation. With the introduction of sugammadex, assisted ventilation can be avoided since sugammadex is capable of reversing dense neuromuscular blockade by vecuronium or rocuronium. In the current environment of achieving greater OR efficiency and cost savings, some institutions are moving tracheal extubation from the operating room by trained anesthesiologists to the PACU by trained nurses with physicians immediately available. This practice in two different children’s hospitals is shown to be safe with no greater incidence of adverse respiratory events and with the added benefit of decreasing operating room time. PACU challenges in the pediatric patient continue to occur despite changes in anesthetic practice and introduction of newer medications. It is important to keep abreast of these newer modalities to best manage these PACU conditions.

Opioid-prescribing patterns, storage, handling, and disposal in postoperative pediatric urology patients

Emerging research on surgeons and the opioid epidemic have focused on the adult population. Consequently, little is known regarding opioid-prescribing practices in the pediatric population. The goal of this study is to examine postoperative opioid-prescribing and consumption patterns, as well as storage and disposal trends for specific pediatric urologic procedures. Patients undergoing surgery associated with specified Current Procedural Terminology codes were retrospectively identified, and details regarding opioid medications were obtained through our pharmacy database. Patients' guardians were contacted two weeks postoperatively to determine opioid usage. Opioids were prescribed at a standard dosing of 0.1mg/kg per dose or the equivalent. Of the 171 identified patients, 117 patients were successfully contacted, with 67 (39%) completing telephone surveys. The 3 most common pediatric urology procedures were inguinal hernia repair (N=39), circumcision (N=27), and cystoscopy (N=16). Across all procedures, there was an average excess of 9.8 doses prescribed, corresponding to an overprescription rate of 64%. Of the patients prescribed opioids, 41 (62%) had leftover opioid medication two weeks postoperatively. Thirty-two of 41 (78%) patients did not dispose of their leftover medication. Only 13 patients received perioperative counseling on appropriate storage and disposal of opiates. Prescribing practices for an array of pediatric urologic procedures are non-standardized and often generously excessive. We show universal overprescribing for all our reviewed urologic procedures. Sixty-two percent of pediatric urology patients did not use their entire prescribed opiate, leaving a significant pool of medicine within the pediatric family home. Given the low incidence of perioperative education, unsurprisingly a majority of our patients improperly handled and disposed off excess opioid medication. There is general overprescription of postoperative opioids and poor perioperative opioid education in the pediatric urology population.

Ivabradine—The Final Crusader for Postoperative Junctional Ectopic Tachycardia, a Case Report with Literature Review

Background: Junctional ectopic tachycardia (JET) is one troublesome supraventricular arrhythmia in postoperative pediatric cardiac surgical patients. Unless treated timely and effectively it may lead to morbidity and even mortality. Aim: To understand the role of Ivabradine in the treatment of JET in postoperative pediatric cardiac surgical patients. Case: We present a postoperative case of complete repair of Tetralogy of Fallot who was in normal sinus rhythm in the preoperative period and developed JET 4 hours later in postoperative period which was persistent despite measures to optimize the internal milieu of the body and conventional antiarrhythmics, that was successfully treated with Ivabradine at a dose of 0.05 mg/kg/12 hourly. Conclusion: Ivabradine can be used to successfully treat postoperative JET in cases ofrefractory to other antiarrhythmic drugs like Digoxin and Amiodarone.

Comparison of Morphine- and Hydromorphone-Containing Patient-Controlled Epidural Analgesia Solutions in Pediatric Postoperative Patients.

The use of patient-controlled epidural analgesia (PCEA) in pediatric patients has been shown to be safe and effective in managing postoperative pain in children. However, the optimal opioid to use in the epidural regimen remains undetermined. Morphine, hydromorphone, and fentanyl have been the agents most often used, but comparison of effectiveness across studies is difficult. The goal of this study was to compare postoperative pain scores in patients receiving PCEA solutions that contained either ropivicaine plus morphine or ropivicaine plus hydromorphone. Retrospective chart review was used at a single center to identify pediatric patients between the ages of 5 and 17 years who used a morphine- or hydromorphone-containing PCEA solution postoperatively during an 18-month period. Maximum pain scores were recorded during 2 consecutive 24-hour periods postoperatively. The primary outcome was the number of patients who had a maximum pain score of ≤4 on postoperative day zero and postoperative day 1. Forty-six patients met the inclusion criteria and were analyzed. Patients prescribed morphine-containing PCEAs had a significantly higher incidence of maximal pain scores ≤4 in the 48 hours immediately after surgery compared with those patients prescribed hydromorphone-containing PCEAs (p = 0.03). Ropivicaine dosing in the epidural solution did not have a significant effect on pain scores and was not statistically different between opioid groups. Pediatric patients were able to effectively use the PCEA on-demand dose, with patients having pain scores >4 demanding significantly more on-demand doses from the PCEA than those patients with pain scores ≤4 (p ≤ 0.002). No serious adverse events were reported. Morphine-containing PCEAs may have an advantage in controlling postoperative pain in pediatric patients compared with hydromorphone-containing PCEAs. However, the heterogeneous nature of the procedures performed and the small sample size limit the generalizability of this study.

Cutaneous Patches to Monitor Myoelectric Activity of the Gastrointestinal Tract in Postoperative Pediatric Patients.

PurposeLimited means exist to assess gastrointestinal activity in pediatric patients postoperatively. Recently, myoelectric gastrointestinal activity recorded by cutaneous patches has been shown in adult patients to be predictive of clinical return of gastrointestinal function postoperatively. The aim of this case series is to demonstrate the feasibility of this system in pediatric patients and to correlate myoelectric signals with return of bowel function clinically.MethodsPediatric patients undergoing abdominal surgery were recruited to have wireless patches placed on the abdomen within two hours postoperatively. Myoelectric data were transmitted wirelessly to a mobile device with a user-interface and forwarded to a cloud server where processing algorithms identified episodes of motor activity, quantified their parameters and nominally assigned them to specific gastrointestinal organs based on their frequencies.ResultsThree patients (ages 5 months, 4 year, 16 year) were recruited for this study. Multiple patches were placed on the older subjects, while the youngest had a single patch due to space limitations. Rhythmic signals of the stomach, small intestine, and colon could be identified in all three subjects. Patients showed gradual increase in myoelectric intestinal and colonic activity leading up to the first recorded bowel movement.ConclusionMeasuring myoelectric intestinal activity continuously using a wireless patch system is feasible in a wide age range of pediatric patients. The increase in activity over time correlated well with the patients' return of bowel function. More studies are planned to determine if this technology can predict return of bowel function or differentiate between physiologic ileus and pathologic conditions.

Comparison of high-flow nasal cannula versus conventional oxygen therapy following extubation after paediatric cardiac surgery

Background: Respiratory complications after cardiac surgery increase morbidity, mortality and length of hospital stay. Oxygen administered using a high-flow nasal cannula (HFNC) improves oxygenation because of its ease of implementation, tolerance and clinical effectiveness. We sought to compare this technique with conventional oxygen therapy (OT) after extubation following paediatric cardiac surgery. We compared HFNC versus conventional OT in postoperative paediatric cardiac surgical patients. Our primary objective was to evaluate the relative efficiency of improving PaCO2elimination in the first 48 h following extubation. Patients and Methods: A single-centre, prospective, unblinded, randomised controlled trial was conducted in a 15-bedded post-cardiac intensive care unit on 50 paediatric cardiac surgical patients

Effects of Play Therapy on the Pain Management of Post-Operative Pediatric Patients

Studies on play therapy in other disciplines have been done but post-operative pain management in pediatric patients has not been considered. This study determined the effects of play therapy using storytelling, bubble blowing, singing and film viewing on the pain management of post-operative pediatric patients. The single-group pretest-posttest design was employed. Post-operative pediatric patients of the orthopedic ward ages 2-7 years old assessed to have acute pain were chosen; seven out of 12 patients qualified and were given a pretest to assess the level of pain. Experimental treatment was administered; a posttest was administered thereafter. The level of pain was assessed before and after the intervention with the use of Wong-Baker FACES Pain Rating Scale, FLACC technique scale to assess the behavior and assessment of the vital signs. Play was used as the intervention and significant differences in the level of alleviated pain using self-assessment was computed by getting the decrement level of pain from pre to post assessment and subjecting it to the Kruskal-Wallis test. Storytelling was found to be the most effective resulting to lowered respiratory rate, heart rate and a normal blood pressure reading; however, it did not prove statistical significance as indicated by p-values greater than the 0.05 alpha level. Computed W coefficients associated with p-values revealed that pre-assessment data results were statistically different from the post-assessment data results in terms of self, behavioral and physiological assessments across the four types of play. The pain decrement from the pretest to posttest was statistically significant. A pain management program was proposed.

Pressure injury prevention for paediatric cardiac surgical patients using a nurse-driven standardized clinical assessment and management plan.

The description of pressure injury development is limited in children with CHD. Children who develop pressure injuries experience pain and suffering and are at risk for additional morbidity. The objective of this study was to develop a standardized clinical assessment and management plan to describe the development of pressure injury in paediatric cardiac surgical patients and evaluate prevention strategies. Using a novel quality improvement initiative, postoperative paediatric cardiac surgical patients were started on a nurse-driven pressure injury prevention standardized clinical assessment and management plan on admission. Data were recorded relevant to nursing assessments and management based on pre-defined targeted data statements and algorithm. Nursing feedback regarding diversions was recorded and analysed. Data on 674 congenital paediatric cardiac surgical patients who met criteria were collected between May, 2011 and June, 2012. In 5918 patient days, a total of 4603 skin assessments were completed by nurses from the cardiac ICU and the cardiac inpatient unit, representing 77% of the expected assessments. The majority (70%, 21/30) of the 30 pressure injuries were medical-device-related and 30% (9/30) were immobility-related. The overall incidence of pressure injury was 4.4%: device-related was 3.1% and immobility-related was 1.3%. Most pressure injuries were Stage 1 (40%), followed by Stage 2 (26.7%), mucosal membrane injury (26.7%), and suspected deep tissue injuries (6.7%). A nurse-driven pressure injury prevention standardized clinical assessment and management plan supported a programme-based evaluation of nursing practice and patient outcomes. Review of practices highlighted opportunities to standardise and focus prevention practices and ensure communication of patient vulnerabilities.

Management of Pediatric Delirium in Pediatric Cardiac Intensive Care Patients: An International Survey of Current Practices.

The purpose of this study was to describe how pediatric cardiac intensive care clinicians assess and manage delirium in patients following cardiac surgery. Descriptive self-report survey. A web-based survey of pediatric cardiac intensive care clinicians who are members of the Pediatric Cardiac Intensive Care Society. Pediatric cardiac intensive care clinicians (physicians and nurses). None. One-hundred seventy-three clinicians practicing in 71 different institutions located in 13 countries completed the survey. Respondents described their clinical impression of the occurrence of delirium to be approximately 25%. Most respondents (75%) reported that their ICU does not routinely screen for delirium. Over half of the respondents (61%) have never attended a lecture on delirium. The majority of respondents (86%) were not satisfied with current delirium screening, diagnosis, and management practices. Promotion of day/night cycle, exposure to natural light, deintensification of care, sleep hygiene, and reorientation to prevent or manage delirium were among nonpharmacologic interventions reported along with the use of anxiolytic, antipsychotic, and medications for insomnia. Clinicians responding to the survey reported a range of delirium assessment and management practices in postoperative pediatric cardiac surgery patients. Study results highlight the need for improvement in delirium education for pediatric cardiac intensive care clinicians as well as the need for systematic evaluation of current delirium assessment and management practices.

Humidification of Blow-By Oxygen During Recovery of Postoperative Pediatric Patients: One Unit's Journey

To examine the practice of nebulizer cool mist blow-by oxygen administered to spontaneously breathing postanesthesia care unit (PACU) pediatric patients during Phase one recovery. Existing evidence was evaluated. Informal benchmarking documented practices in peer organizations. An invitro study was then conducted to simulate clinical practice and determine depth and amount of airway humidity delivery with blow-by oxygen. Informal benchmarking information was obtained by telephone interview. Using a three-dimensional printed simulation model of the head connected to a breathing lung simulator, depth and amount of moisture delivery in the respiratory tree were measured. Evidence specific to PACU administration of cool mist blow-by oxygen was limited. Informal benchmarking revealed that routine cool mist oxygenated blow-by administration was not widely practiced. The laboratory experiment revealed minimal moisture reaching the mid-tracheal area of the simulated airway model. Routine use of oxygenated cool mist in spontaneously breathing pediatric PACU patients is not supported.

Effect of an Evidence Based Nursing Intervention on the Early Detection of Pediatric Warning Signs

postoperative children are at risk for clinical deterioration, and it is vital that this risk will be controlled. For this reason, the purpose of this study was to assess the effect of an evidence based nursing intervention on early detection of pediatric warning signs. The design of this study was quasi experimental design. It was conducted at the surgical department in Menoufia University Hospital and Shebin El-kom Teaching Hospital. For data collection, a convenient sample of 33 nurses was obtained from the previous mentioned settings. Instruments of this study were structured interview questionnaire sheet, The Pediatric Early Warning Signs Likert Scale and Observational checklist for nurse's practice regarding application of warning signs scale for postoperative children. The results of this study showed significant improvement in nurses' knowledge and practices after implementation of educational program regarding pediatric early warning signs . For example, total nurses 'knowledge scores about pediatric early warning signs were 16.15 ± 1.30 compared to 24.88 ± 1.16 and 22.06 ± 1.98 on posttest and follow-up tests respectively. It was concluded that implementation of evidence based nursing intervention improved nurses' knowledge and practices regarding pediatric early warning signs for postoperative pediatric patients on posttest than on pre test . Also, it led to early identification of clinical deterioration in postoperative pediatric patients. Therefore, this study recommended that ongoing in-service education programs must be designed and implemented at all pediatric units to improve nurses' knowledge and practices concerning care provided for pediatric patients.

Comparing Digital Photography via Email Correspondence With Traditional Telephone Communication for Assessment of Postoperative Pediatric Urology Patients

Introduction Postoperative concerns are commonly managed by a nurse practitioner (NP) via traditional telephone conversation (TTC). In recent years, electronic interaction, including digital photographs sent via email (PEC), has become an alternative, novel strategy to evaluate surgical site concerns. Its use may result in fewer unplanned clinic or emergency room (ER) visits as well as improve patient satisfaction. Herein, we present a pilot a study to determine the feasibility of conducting a definitive trial comparing the effectiveness of PEC versus TTC in reducing the number of unplanned clinic and ER visits as well as improving patient experience. Materials and Methods Children &lt; 18 years old at the time of surgery and within the 30-day postoperative period were recruited from June 2015 to January 2016 at a tertiary children’s hospital. Exclusion criteria were concerns occurring outside the 30-day postoperative period and inability/unwillingness to email photographs. Patients were allocated to PEC or TTC after initiating contact with the NP through an electronic centralized blocked randomization system. A standardized telephone script was used to gather relevant clinical data for both groups. These data informed a clinical plan, with those randomized to the PEC group sending digital photographs of the surgical site in addition to the traditional telephone call. Within 48 hours, families were sent a link to an electronic survey measuring patient experience using a validated questionnaire. Feasibility data on recruitment rates, compliance with sending photographs, and completing patient experience questionnaires were collected. Secondary outcomes included number of unplanned clinic/ER visits, number of follow-up phone calls, and patient experience scores. Results Of the 328 children who underwent urological procedures during the recruitment period, 215 (66%) consented to participate in the study. Of these, 42(13%) contacted the NP with postoperative concerns and were randomized. Two patients in the PEC group were excluded after randomization (one for contacting on Postoperative Day 31 and one for not sending photographs), resulting in 19 patients in the PEC group and 21 patients in the TTC group. Penile surgeries (hypospadias repair and circumcisions [43%]) were the most common procedures with postoperative concerns. Ninety-eight percent of the PEC patients were compliant in sending photographs. Overall, 98% of surveys were completed. Twice as many unplanned clinic visits were observed in the TTC group when compared with the PEC group (p = .28), despite a similar number of follow-up phone calls between groups (Table 1). Patient experience scores were also comparable in both groups, with families scoring high satisfaction with the experience regardless of the modality of communication. Conclusions A definitive trial examining the effectiveness of PEC versus TTC appears feasible and safe as seen by the high recruitment, photographic compliance, hospital visits, and survey completion rates in this pilot study.

Pulmonary Dead Space Fraction and Extubation Success in Children After Cardiac Surgery.

1) Determine the correlation between pulmonary dead space fraction and extubation success in postoperative pediatric cardiac patients; and 2) document the natural history of pulmonary dead space fractions, dynamic compliance, and airway resistance during the first 72 hours postoperatively in postoperative pediatric cardiac patients. A retrospective chart review. Cardiac ICU in a quaternary care free-standing children's hospital. Twenty-nine with balanced single ventricle physiology, 61 with two ventricle physiology. None. We collected data for all pediatric patients undergoing congenital cardiac surgery over a 14-month period during the first 72 hours postoperatively as well as prior to extubation. Overall, patients with successful extubations had lower preextubation dead space fractions and shorter lengths of stay. Single ventricle patients had higher initial postoperative and preextubation dead space fractions. Two-ventricle physiology patients had higher extubation failure rates if the preextubation dead space fraction was greater than 0.5, whereas single ventricle patients had similar extubation failure rates whether preextubation dead space fractions were less than or equal to 0.5 or greater than 0.5. Additionally, increasing initial dead space fraction values predicted prolonged mechanical ventilation times. Airway resistance and dynamic compliance were similar between those with successful extubations and those who failed. Initial postoperative dead space fraction correlates with the length of mechanical ventilation in two ventricle patients but not in single ventricle patients. Lower preextubation dead space fractions are a strong predictor of successful extubation in two ventricle patients after cardiac surgery, but may not be as useful in single ventricle patients.

Evaluation of femoral head viability via bone scintigraphy in the postoperative pediatric patient.

Evaluating postoperative patients with hardware is challenging following surgical intervention for hip maladies such as femoral neck fractures and slipped capital femoral epiphysis (SCFE). These children are at increased risk of developing avascular necrosis, and imaging may be requested to confirm or exclude this diagnosis. Children with Legg-Calvé-Perthes disease can be monitored for restoration of blood flow to the capital femoral epiphysis to guide management and help with prognosis. Although MRI is sensitive for detecting early avascular necrosis, the presence of hardware degrades image quality. This report examines the utility of bone scans for evaluating femoral head perfusion in children who have undergone surgery for femoral neck fractures, SCFE or Legg-Calvé-Perthes disease. A retrospective review of 20 patients (22 scans) after fixation for femoral neck fracture, SCFE or Legg-Calvé-Perthes disease from 2012 to 2015 was performed. The bone scan findings were correlated with the intraoperative findings or clinical follow-up. Twenty-one of the 22 (95%) bone scans in 19 of the 20 (95%) patients demonstrated findings consistent with clinical outcomes and/or the intraoperative appearance of the femoral head. Four of 20 patients (20%) had bone scan features of avascular necrosis, defined as "absent" or "moderately diminished" femoral head activity, which were confirmed intraoperatively and resulted in poor outcomes. Radionuclide imaging of hips in the postoperative setting is a valuable modality for assessing the risk of avascular necrosis, a complication of femoral neck fractures and SCFE and for evaluating the restoration of flow to the capital femoral epiphyses of children with Legg-Calvé-Perthes disease.

High Ionized Calcium Concentration Is Associated With Prolonged Length of Stay in the Intensive Care Unit for Postoperative Pediatric Cardiac Patients

There has been controversy regarding the beneficial effects of calcium on myocardial contractility and the harmful effects on myocardial cells, especially in children. The aim of this study was to investigate an association between ionized calcium concentration (iCa) and outcomes for pediatric patients after cardiac surgery. A retrospective, single-center study from May 2013 to December 2014. Referral high-volume pediatric cardiac center in a tertiary teaching hospital. Patients <72 months old with congenital heart disease who underwent palliative or definitive surgery. None. The association between pH-corrected iCa within 24 hours after surgery and intensive care unit (ICU) length of stay (ILOS) was defined as the primary outcome. The highest iCa (iCamax), lowest iCa (iCamin), and time-weighted average iCa (iCaave) were stratified and compared with the outcomes. The authors reviewed 5,468 ionized calcium measurements from 357 consecutive pediatric patients during the study period. One patient died at postoperative day 34 in the ICU. Significant differences in ILOS were observed among patients after cardiopulmonary bypass (CPB) according to iCaave, iCamax, and iCamin but not among patients without CPB. Patients with CPB and an iCaave value of 1.31-to-1.40 mmol/L, 1.41-to-1.50 mmol/L, 1.51-to-1.60 mmol/L, and >1.60 mmol/L stayed in the ICU for 7 (interquartile range [IQR] 4-10) days, 8 (IQR 6-16) days, 10 (IQR 8-14) days, and 19 (IQR 12-38) days, respectively, which was significantly longer than the ILOS of 5 (4-8) days for patients with an iCaave of 1.21-to-1.30 mmol/L. Even after adjustment for other predictors of ILOS using multivariable analyses, there were significant relationships of ILOS with iCaave and iCamin values of >1.50 mmol/L among patients with CPB. Higher iCa within 24 hours after congenital cardiac surgery using CPB was independently associated with longer LOS in the ICU.