Surgical Care Of Children Research Articles

Use of Extracorporeal Membrane Oxygenation and Mortality in Pediatric Cardiac Surgery Patients With Genetic Conditions: A Multicenter Analysis.

Congenital heart disease is commonly a manifestation of genetic conditions. Surgery and/or extracorporeal membrane oxygenation were withheld in the past from some patients with genetic conditions. We hypothesized that surgical care of children with genetic conditions has increased over the last decade, but their cardiac extracorporeal membrane oxygenation use remains lower and mortality greater. Retrospective cohort study. Patients admitted to the Pediatric Health Information System database 18 years old or younger with cardiac surgery during 2003-2014. Genetic conditions identified by International Classification of Diseases, 9th Edition codes were grouped as follows: trisomy 21, trisomy 13 or 18, 22q11 deletion, and all "other" genetic conditions and compared with patients without genetic condition. A total of 95,253 patients met study criteria, no genetic conditions (85%), trisomy 21 (10%), trisomy 13 or 18 (0.2%), 22q11 deletion (1%), and others (5%). None. Annual surgical cases did not vary over time. Compared to patients without genetic conditions, trisomy 21 patients, extracorporeal membrane oxygenation use was just over half (odds ratio, 0.54), but mortality with and without extracorporeal membrane oxygenation were similar. In trisomy 13 or 18 patients, extracorporeal membrane oxygenation use was similar to those without genetic condition, but all five treated with extracorporeal membrane oxygenation died. 22q11 patients compared with those without genetic condition had similar extracorporeal membrane oxygenation use, but greater odds of extracorporeal membrane oxygenation mortality (odds ratio, 3.44). Other genetic conditions had significantly greater extracorporeal membrane oxygenation use (odds ratio, 1.22), mortality with extracorporeal membrane oxygenation (odds ratio, 1.42), and even greater mortality odds without (odds ratio, 2.62). The proportion of children undergoing cardiac surgery who have genetic conditions did not increase during the study. Excluding trisomy 13 or 18, all groups of genetic conditions received and benefited from extracorporeal membrane oxygenation, although extracorporeal membrane oxygenation mortality was greater for those with 22q11 deletion and other genetic conditions.

Do-not-resuscitate orders and high-risk pediatric surgery: professional nuisance or medical necessity?

BackgroundThere is a paucity of data in the literature regarding end-of-life care and do-not-resuscitate (DNR) status of the pediatric surgical patient, although invasive procedures are frequently performed in very high risk and critically ill children. Despite significant efforts in adult medicine to enhance discussions around end-of-life care, little is known about similar endeavors in the pediatric population. MethodsA retrospective review of the National Surgical Quality Improvement Program Pediatric database was performed. Patients aged <18 y with American Society of Anesthesiologists class 3 or greater who underwent elective surgical procedure in 2012-2013 were included. Demographic factors, principal diagnosis, associated conditions, DNR status, and mortality were extracted. Descriptive analysis was performed. ResultsA total of 20,164 patients met the inclusion criteria. Only 36 (0.2%) patients had a signed DNR order before surgical procedure. Of severely ill American Society of Anesthesiologists four patients, only 1% had DNR status. There were no differences in gender, race, ethnicity, or surgical specialty by the presence of a DNR order. Notably, 17.1% of children who died within this period had multiple surgical procedures performed before expiring. ConclusionsThe rate of documented DNR status is extremely low in the high-risk pediatric surgical population undergoing elective surgery, even among severely ill children. Well-informed end-of-life care discussions in a patient-focused approach are essential in the surgical care of children with complex medical conditions and critical illness. Better documentation of DNR discussion will also allow better tracking and benchmarking.

Transplantation and Mechanical Circulatory Support in Congenital Heart Disease: A Scientific Statement From the American Heart Association.

Dramatic evolution in the medical and surgical care of children with congenital heart disease (CHD) has led to a growing number of adults with late-onset complications, including heart failure (HF).1 In parallel with an overall increase in hospital admissions for adults with CHD (ACHD) and HF,2 CHD complexity has increased substantially in survivors over the past 2 decades.3 Heart transplant (HTx) specialists face the challenge of determining eligibility for advanced HF treatments among an increasingly complex population of CHD patients in whom guidelines for HTx and mechanical circulatory support (MCS) are scant. The purpose of this review is to provide a state-of-the-art update on HTx and MCS in CHD. HTx remains the surgical procedure of choice for eligible patients with severe advanced HF,4,5 with little change in the number of transplants performed yearly over the past decade. The body of information related to transplantation for CHD is derived almost entirely from registry and single-center–based outcome data; no randomized clinical trial or meta-analysis data are available. CHD presents additional challenges to successful HTx compared with HTx in patients with acquired HF. Many CHD patients require complex vascular reconstruction at the time of transplantation. The presence of antibodies to human leukocyte antigen (HLA) and ABO blood group sensitization are also impediments to timely transplantation. The ability of patients with single-ventricle physiology to survive during the waiting period is also limited by the additional burden of “outgrowing” their pulmonary blood flow and the resultant cyanosis. It is not surprising that CHD remains a risk factor during the waiting period and after transplantation. Therefore, although the management of the CHD patient with end-stage HF must include the option of HTx, its indication and timing are very different from that for acquired HF. Patients with ACHD represent an increasing …

Ranking and Rating Analyses of Barriers to Surgical Care for Children in Guatemala

Background: Barriers to surgical care for children in low and middle income countries (LMICs) remain poorly defined. In this study, we used two consumer decision analysis tools to measure how families view the importance of different barriers to pediatric surgical care in Guatemala. Methods: Our subject population was a convenience sample of parents or guardians of children receiving surgical care at a single non-governmental organization in Guatemala City. Respondents performed rating and ranking surveys to determine the relative importance of eight barriers to surgical care using a structured questionnaire. Results: We included 46 respondents in this study. By rating analysis, the most significant barriers to care were the cost of surgery, perceived quality of care, and transportation issues. By ranking analysis, the most significant barriers to care were the cost of surgery, waiting time for surgery, and perceived quality of care. Conclusions: Based on rating and ranking analyses, the cost of care is the most significant barrier to pediatric surgical care in Guatemala, although perceived quality of care is also important for families. Using complementary analysis tools provided enhanced insight into how families view the importance of different barriers to care, and should help policy makers develop programs to enhance surgical access for children.

Cleft Missions: Don't Miss the Opportunity: A Special Opinion Piece

Missions to developing countries to provide surgical care for children and adults with cleft lip and palate constitute unique opportunities for speech-language pathologists (SLPs). The SLP helps determine if a patient will actually benefit from a planned procedure, and occasionally has the chance to perform short-term therapy. The clinical experience gained on a 2-week mission is invaluable.

Public insurance and timing of polysomnography and surgical care for children with sleep-disordered breathing.

Although children with low socioeconomic status (SES) have increased risk for sleep-disordered breathing (SDB), their access to subspecialty care is often limited. Polysomnography (PSG) is the gold standard diagnostic test used to characterize SDB and diagnose obstructive sleep apnea; however, it is unknown whether SES impacts timeliness of obtaining PSG and surgical treatment with adenotonsillectomy (AT). To evaluate the impact of SES on the timing of PSG, surgery with AT, and loss to follow-up for children with SDB. Retrospective cohort analysis conducted in tertiary outpatient pediatric otolaryngology clinics among patients newly evaluated for SDB over a 3-month period who did not have prior PSG ordered and had a minimum of 1-year follow-up. Public insurance (Medical Assistance [MA]) was used as a proxy for low SES. Demographics and disposition between groups were compared using t tests and χ2 analysis. Logistic regression adjusting for disposition and insurance was used to predict loss to follow-up. Days to PSG and days to AT were evaluated using the Kaplan-Meier estimator, and the log-rank test was used to compare distribution of time to events between insurance groups. A total of 136 children (without PSG) were evaluated for SDB over the course of 3 months; 62 (45.6%) had MA. Polysomnography was recommended for 55 children (27 of 55 [49%] with MA vs 28 of 55 [50%] with private insurance; P > .99). After the initial visit, 24 of 55 children with PSG requested (44%) were completely lost to follow-up (9 of 27 [33%] with MA vs 15 of 28 [54%] private insurance; P = .34). Children with MA who obtained PSG experienced longer intervals between initial encounter and PSG (mean interval, 141.1 days) than privately insured children (mean interval, 49.9 days) (P = .001). For those children who ultimately underwent AT surgery after obtaining PSG (n = 14), mean (SD) time to AT was longer for children with MA (222.3 [48.2] days vs 95.2 [66.1] days; P = .001). Children with public insurance experienced longer intervals from initial evaluation to PSG or surgery. Almost half of patients with PSG requested were lost to follow-up, regardless of SES. These findings suggest that PSG may be a deterrent for definitive care for all children, and particularly for children with public insurance or low SES. This study emphasizes the need to understand factors contributing to disparities surrounding delay in care with PSG and surgery for children with SDB.

Genetics of Valvular Heart Disease

Valvular heart disease is associated with significant morbidity and mortality and often the result of congenital malformations. However, the prevalence is increasing in adults not only because of the growing aging population, but also because of improvements in the medical and surgical care of children with congenital heart valve defects. The success of the Human Genome Project and major advances in genetic technologies, in combination with our increased understanding of heart valve development, has led to the discovery of numerous genetic contributors to heart valve disease. These have been uncovered using a variety of approaches including the examination of familial valve disease and genome-wide association studies to investigate sporadic cases. This review will discuss these findings and their implications in the treatment of valvular heart disease.

The Provision of Surgical Care for Children with Cardiac Disease: The Jamaican Experience – An 18-year Review

The aim of this article is to review the local experience over the last 18 years (1994-2011) in providing surgical intervention for children with heart conditions in Jamaica. Eight hundred and sixty-three children received cardiac surgery during this period, 441 were done with the assistance of visiting overseas teams and 422 by the local surgical teams. The majority of cases receiving cardiac surgery were for congenital heart defects; however 3% of cases were for rheumatic heart disease. The overall survival rate was 94% for the period 1994 to 2008.

Implementing a Pediatric Obesity Care Guideline in a Freestanding Children's Hospital to Improve Child Safety and Hospital Preparedness

Medical and surgical care of children with severe obesity is complicated and requires recognition of the problem, appropriate equipment, and safe management. There is little literature describing patient, provider, and institutional needs for the severely obese pediatric patient. Nonetheless, the limited data suggest 3 broad categories of needs unique to this population: (a) airway management, (b) drug dosing and pharmacology, and (c) equipment and infrastructure. We describe an opportunity at the Children's Hospital Colorado to better prepare and optimize care for this patient population by creation of a Pediatric Obesity Care Guideline that focused on key areas of quality and safety.

(P1-105) The Surgical Care of Children with Gunshot Wounds in a Children's Field Hospital

IntroductionThe treatment of victims with gunshot wounds has gained importance over the past 10–15 years due to continuous military conflicts and the increase in terrorist and criminal acts. Since 1992, a group of pediatric surgeons has been trained to treat gunshot wounds in both children and adults in field hospitals of the Russian Service of Disaster Medicine in Northern Caucasus.MethodsTwo working models of a Children's Field Hospital (ChFH) were reviewed. In the first model, a ChFH was implemented for 14 months (April 2001–July 2002) during a military conflict in the Chechen Republic. There were no other hospitals rendering medical aid to children in the area. In the second model, a field hospital was created for children following a terrorist act in Beslan, Northern Ossetia in 2004.ResultsOver the 14 month period, the Chechen Republic ChFH rendered medical aid to 102 adults and 20 (16.4%) children with gunshot wounds. Self-made explosives and unexpected munitions were blamed for explosive trauma in children. Two children died in the ChFH, and one child with amputated lower limbs was transported to Moscow for prosthetics placement. Three hundred eleven children presented to ChFH, including 55 children not requiring medical aid, and 256 wounded children, who were divided into 3 groups: 5 dying; 52 wounded and requiring emergency treatment; and 199 wounded who were transported to hospitals in Vladikavkaz after receiving initial medical aid at the ChFH. In total, 47 operations were performed, including seven abdominal and chest surgeries. Re-animation aid was provided at the Intensive Care Department of the ChFH for the stabilization of the critically wounded prior to their evacuation.ConclusionIn the situation of mass admissions of wounded patients, the most important considerations are triage and the arrangement of operations according to urgent indications.

Analysis of adverse events in pediatric surgery using criteria validated from the adult population: justifying the need for pediatric-focused outcome measures

Introduction Little is known regarding the incidence and financial impact of adverse events associated with the surgical care of children. The purpose of this study was to characterize the epidemiology and resource utilization associated with these events using definitions validated from the adult population. Methods We conducted a 6-year audit (Jan 2003-Dec 2008) of adverse events associated with the 100 most common general pediatric surgical procedures from the Pediatric Health Information System database. We audited 23 events as defined by the National Surgical Quality Improvement Project and modified Agency for Healthcare Research and Quality Patient Safety Indicators. Excess length of stay and total hospital charges attributable to events were determined for each procedure after adjusting for confounders. Results Overall 30-day incidence of any adverse event was 10.3% in our sample of 331,093 patients. The most common events were transfusions (30% of all events), wound complications (15%), and events associated with central access (11%). The cumulative incidence of serious events including cardiac arrest, stroke, deep venous thrombosis and pulmonary embolish was less than 0.3%. Ten procedures accounted for 62% of all events, and all 10 were associated with significant ( P < .01) increases in length of stay and total hospital charges when any event occurred. Circumcisions, soft-tissue biopsies, pyloromyotomies, and repair of abdominal wall hernias accounted for only 3% of events despite comprising nearly 25% of operative volume. Conclusions A relatively small number of pediatric surgical procedures contribute to a disproportionate share of adverse events. Although the National Surgical Quality Improvement Project and Agency for Healthcare Research and Quality criteria can identify pediatric procedures associated with a significant risk of morbidity, the relatively high 30-day event rates captured for some procedures may be heavily influenced by underlying co-morbidity profiles not related to the surgical disease or intervention. Furthermore, the validity of applying adult-focused “adverse” event definitions for the pediatric population should be further explored. Collaborative efforts will be needed to develop more clinically meaningful outcome measures for the purpose of quality improvement end points.

“Now walks like others”: a preliminary enquiry into the Northampton Crippled Children's Fund

Interest into the history of child health and disability has intensified over the years. However, it is a relatively recent and unresearched area and still in its early development. Care available to poor, “crippled children” in Victorian England is a generally unexplored subject. Before the introduction of universal free access to healthcare, there was little available for those unable to afford it, beside voluntary organisations. One such example was the Northampton Crippled Children9s Fund (NCCF), which from 1893 to 1925, provided care to the “crippled children” of the town. It funded medical and surgical care for children with deformities. Besides operations (which were rare), it also provided surgical boots, carriages and nourishment as well as providing an annual holiday to its seaside “colony” in Llandudno. Primary sources concerning disabled people in history are difficult to find and the study of disability history is challenging. However, this presentation using primary sources from the Archive, Northampton General Hospital will reconstruct such voluntary healthcare provided to “Crippled Children in straightened circumstances living in the town of Northampton under 17 years of age.” NCCF annual reports from 1905 to 1925 include records of treatments, their costs and their dates given to each named child. Within the record books, some individual cases also include early x-rays, hand drawn vignettes pre and post treatment, together with relevant newspaper cuttings. The 1911 census online is also used. In a consecutive case series of twenty children randomly taken from a NCCF record book, the recorded pathologies were: nine rickets (45%), four spinal pathology (20%), three tuberculosis (15%), two paralysis (10%), one hemiplegia (5%), and one carcinoma (5%). Treatments were mainly medical, involving surgical boots but rarely surgical. The NCCF material provides insight into child health and disability and shows considerable potential for further exploration by social and medical historians. Lastly, the NCCF material will also be examined alongside that of other contemporary Charities such as the Birmingham9s Cripples Union, which was founded in 1896. Although there have been considerable advances in clinical science since the early nineteenth century, many of these conditions remain considerable therapeutic challenges in the early twenty-first century.

The surgical care of children: ethical dimensions

The surgical care of children: ethical dimensions

The surgical care of children: Ethical dimensions

The Kennedy Report highlighted ethical concerns related to paediatric surgery. Annette Dearmun and Ewen MacKinnon provide some examples of how such concerns are considered by the Ethics Advisory Committee of the British Association of Paediatric Surgeons

Epidemiology of paediatric surgical admissions to a government referral hospital in the Gambia.

There is a paucity of published data on the type of conditions that require surgery among children in sub-Saharan Africa. Such information is necessary for assessing the impact of such conditions on child health and for setting priorities to improve paediatric surgical care. Described in the article is a 29-month prospective study of all children aged < 15 years who were admitted to a government referral hospital in the Gambia from January 1996 to May 1998. A total of 1726 children were admitted with surgical problems. Surgical patients accounted for 11.3% of paediatric admissions and 34,625 total inpatient days. The most common admission diagnoses were injuries (46.9%), congenital anomalies (24.3%), and infections requiring surgery (14.5%). The diagnoses that accounted for the greatest number of inpatient days were burns (18.8%), osteomyelitis (15.4%), fractures (12.7%), soft tissue injuries (3.9%), and head injuries (3.4%). Gambian children were rarely admitted for appendicitis and never admitted for hypertrophic pyloric stenosis. The leading causes of surgical deaths were burns, congenital anomalies, and injuries other than burns. Prevention of childhood injuries and better trauma management, especially at the primary and secondary health care levels, should be the priorities for improving paediatric surgical care in sub-Saharan Africa. Surgical care of children should be considered an essential component of child health programmes in developing countries.

Healing the Children: medical missions

In 1993, I started documenting medical missions organised by the American-based, non-profit organisation Healing the Children (HTC). With 14 chapters in 21 states, HTC has helped tens of thousands of children worldwide since it was founded in 1979. The organisation arranges specialised medical treatment and surgical care for children whose families cannot afford it or whose communities do not offer it. HTC relies entirely on volunteers. In 1995, the northeast chapter of HTC alone provided more than $7.5 million in services to about 2300 children. HTC also provides treatment and assistance to disadvantaged children in US communities, arranges special care in the USA for children from nearly 60 countries, and recruits organisations to provide supplies and refurbished equipment to hospitals in underdeveloped countries. In October, 1994, I travelled with an HTC team of over 50 medical personnel on a cardiac trip to Guatemala City. More recently, in April, 1996, I documented a team of 11 who travelled to Cochahamba, Bolivia, to carry out soft tissue surgery.

BOOK REVIEWS

Book reviewed in this article:Mind Blindness: An Essay on Autism and Theory of Mind By Simon Baron‐Cohen Cambridge: MIT Press, 1995Magnetic Resonance Scanning and Epilepsy By S. D. Shorvon, R. D. Fish, F. Andermann, G. M. Bydder, H. Stefan New York: Plenum Press, 1994Topics in Down Syndrome. Medical and Surgical Care for Children with Down Syndrome. A Guide for Parents Edited by D. C. Van Dyke et al. Bethesda: Woodbine House, 1995Fetus and Neonate: Physiology and Clinical Applications, Vol. 2: Breathing Edited by Mark A. Hanson, John A. D. Spencer and Charles H. Rodeck Cambridge

Organization of surgical care for children with chronic nonspecific lung diseases

During the last decades all over the world there has been an increase in disability and mortality associated with the growing number of chronic nonspecific lung diseases. The development of the mentioned diseases, in particular bronchiectasis, is dominated by dysontogenetic causes. However, some authors emphasize that the progression of chronic nonspecific lung diseases depends on the organization of specialized sections of pulmonological care for children.

Letter to the Editor. Vol. 69, No. 3 (1988)

We would like to share the experience of the interdistrict children's surgery department, which was organized in February 1980 at Leninogorsk Children's Hospital. The department's profile is to provide scheduled and round-the-clock emergency surgical care for children (107631 people) living in six (Leninogorsk, Almetyevsk, Aznakaevsk, Bugulma, Bavly, Cheremshansk) districts attached to TASSR.

Kinderchirugische Erkankungen, Band 1, Grundzuge zur Diagnostick

This book, as it is presented, is a very complete compilation of surgical diseases with diagnostic steps necessary in recognizing them. This is part one of a two-part book; the second volume, as yet unpublished, will deal with surgical therapy. In the forward of the book the author sets forth his purpose to compile, in as simple a form as possible, the various diseases one sees in the surgical care of children. He has noted in his forward that he has chosen the method of instructive rather than a comprehensive description as a more practical guide to the practicing physician. He states that he has omitted theoretical explanation and embryology of the abnormalities as well as any bibliography or literary citation so that it will remain a simple, practical manual for the practicing physician. The volume is quite comprehensive in its coverage of surgical diseases of childhood from the