Tertiary Pediatric Referral Hospital Research Articles

Retrospective evaluation of acute kidney injury in paediatric COVID-19 patients: a tertiary referral hospital experience.

Coronavirus disease 2019 (COVID-19) has been recognised as a risk factor for acute kidney injury (AKI). Our aim was to investigate the risk factors contributing to hospitalised and outpatient paediatric COVID-19-associated AKI. A retrospective observational study was conducted on patients aged 1month to 18years with diagnosed COVID-19-associated AKI applied to a tertiary paediatric referral hospital between March 1, 2020 and March 1, 2022. A total of 6683 patients were evaluated and 486 patients were included in the study. Acute kidney injury was observed in 3.7% of outpatients and 23.9% of hospitalised patients. Multivariate logistic regression analysis showed that, on admission, a history of contact with a COVID-19 positive person (p < 0.001), age below 12months (p = 0.004), presence of comorbidities (p < 0.001), abdominal pain (p = 0.008), anorexia (p = 0.003), dyspnoea (p = 0.005), higher lactate dehydrogenase values (p = 0.004), neutrophilia (p < 0.001), higher neutrophil-to-lymphocyte ratio (NLR) (p = 0.003), higher white blood cell counts (p = 0.006), elevated C-reactive protein (CRP) levels (p = 0.002), anaemia (p = 0.015), hypoalbuminaemia (p < 0.001), hyperglycaemia (p = 0.006), and presence of proteinuria (p = 0.003) were independent predictors of AKI. Higher rates of hospitalisation (p < 0.001) and admission to the paediatric intensive care unit (PICU) (p < 0.001), longer length of hospitalisation (p < 0.001), and greater need for mechanical ventilation (p < 0.001) were associated with AKI. This study reveals that not only hospitalised children, but also paediatric patients are at risk for AKI. The presence of comorbidities, abdominal pain, anorexia, dyspnoea, anaemia, inflammation, hypoalbuminaemia, proteinuria and history of contact with a COVID-19 positive person were the main risk factors for AKI. COVID-19-associated AKI was associated with worse outcomes.

Quantification of Sickle Cells in the Peripheral Smear as a Marker of Disease Severity in Sickle Cell Disease in Paediatric Patients

Background: Sickle cells are easily identified on the peripheral smear however quantification of sickle cells is seldom done. This study attempts to understand the importance of the sickling index in the reporting of peripheral smear in patients with SCD. Objectives: This study aims to standardize the methodology of quantification of sickle cells on the peripheral smear in paediatric SCD cases and study its relation to the patient characteristics like age and sex, SCD genotype, and treatment. Materials and Methods: A prospective study of 6 months duration was conducted at a tertiary paediatric referral hospital for 6 months. 30 known cases of SCD were admitted during this period. Routinely studied peripheral smears were used in the study. 30 normal smears of age-matched patients were also used for comparative purpose. The sickling index was calculated in both patient and age matched smears. The sickling index was compared in both the groups and also the index in the known SCD cases was studied in relation to the patient's age, SCD genotype, and treatment with blood transfusions or hydroxyurea. Statistical analysis: Descriptive statistics were used in the study Results &amp; Conclusion: Hb SS was the commonest genotype seen in 69% of the cases. Higher sickling index was noted in older children, SS genotype and those on treatment with blood transfusions or Hydroxyurea. Sickling index is an interesting prospect which may provide helpful information regarding cases with increasing hemolysis and vasocclusive crises and also help in follow up of patients on treatment. Keywords: Paediatric, Disease severity, Sickling index

Vestibular and Balance Impairment Is Common in Children With Primary Ciliary Dyskinesia.

Primary ciliary dyskinesia (PCD) is a rare genetic disorder that presents with a wide range of respiratory complaints. The most common otologic associated disorder is middle ear effusion. We ask if children with PCD suffer from vestibular impairment. Cross-sectional cohort study. Tertiary pediatric referral hospital. Children with confirmed PCD. All included participants were clinically assessed to be at baseline then basic demographics and medical histories were collected, including the specific genetic mutation these patients have. After which, all patients underwent two vestibular tests. The first was to assess their ability to stand on one foot with their eyes open and then with their eyes closed and the second was video head impulse test (vHIT). Ability standing on one foot with the eyes closed and vHIT. During this period, 25 children with PCD were recruited for the study. The mean age at recruitment was 11.26 years (4-18 yr). There were 11 women and 14 men. All patients were able to participate in both tests. Nineteen participants (76%) had vestibular impairment. Fifteen of them failed to stand on one foot with their eyes closed and six of 25 had abnormal vHIT. The most common involved gene was DNAH5 8/25 (32%) and it was associated with vestibular impairment in seven of eight participants (87.5%). The majority of children with PCD that we tested suffered from vestibular impairment that was previously undiagnosed. This potentially indicates that imbalance and vestibular pathology is under-diagnosed in children with PCD.

Pitfalls in the histological diagnosis of total colonic aganglionosis on appendicectomy specimens

Background: Hirschsprung’s disease is the most important cause of functional intestinal obstruction in children. It is characterized by the absence of ganglion cells in the submucosal and myenteric plexuses on histology. In 10% of Hirschsprungs disease patients, involvement of the entire colon is seen in a condition called total colonic aganglionosis (TCA). The absence of ganglion cells in the appendix on histology has been considered diagnostic of TCA. The validity of this histological finding being taken as criteria for diagnosis is not clear. Aims and Objectives: This study examines the presence and the number of myenteric and submucosal ganglion cells in the appendices of suspected cases of TCA and compares these findings with controls, specimens of acute appendicitis, and histologically normal appendix in pediatric cases. Materials and Methods: Thirty-six appendix specimens of suspected TCA cases and controls, that is, ten each of acute appendicitis and histologically normal appendix in pediatric age group were included in this study taken up in the pathology department of a tertiary pediatric referral hospital. The presence or absence and the number of ganglion cells in each specimen was semiquantitatively evaluated in a blinded manner. These findings were descriptively compared and analyzed. The difficulties faced by the pathologist in reporting the pediatric appendix specimens were also documented. Results: The cases and controls showed that aganglionosis and no significant difference were noted in the number of ganglion cells per high power field between the cases and controls. The reporting pathologists enumerated quite a few pitfalls and problems encountered by them in the process of interpreting ganglion cell status of pediatric, particularly neonatal appendicectomy specimens. Conclusion: Aganglionosis of the appendix on histology may not be an ideal tool for the diagnosis of TCA. Difficulties in histological characterization of ganglion cells, technical errors in tissue embedding and the presence aganglionic skip areas might cause errors in the interpretation of ganglion cell status of appendix specimens, particularly infants, and neonates.

The Feasibility of Utilizing Malunion Criteria to Limit Radiographs After Spica Casting for Pediatric Femur Fractures.

There are no existing guidelines regarding the timing or frequency of postoperative radiographs following spica casting for pediatric femur fractures. The purpose of this study was to evaluate established femoral malunion criteria as a potential screening tool to limit postoperative radiographs by identifying patients at risk for unacceptable alignment in the early treatment period. A retrospective chart review was conducted for pediatric femoral shaft fractures presenting to a tertiary pediatric referral hospital from 2012 to 2017. Pediatric femur malunion criteria were applied to radiographs at initial presentation, first follow-up visit, and final follow-up visit. The primary outcome was a change in management based on radiographic findings in the early postoperative period. Secondary outcomes included radiographic measures, number of follow-up visits, and complications. Of 449 consecutive pediatric femur fractures treated at our center, 149 patients aged 1 to 4 years (mean age: 2.5±1.6 y) met inclusion criteria. At initial presentation, 36.9% (55/149) of patients met malunion criteria. Only 4.0% (6/149) of patients had a change in management following initial closed reduction and spica cast application due to radiographic findings at subsequent follow-up. Of these patients, 67% (4/6) were identified on preoperative imaging, and 83.3% (5/6) were identified by their first clinic appointment. Four of the 149 patients were converted to definitive surgical fixation, and 2 patients required cast wedging due to either unacceptable fracture shortening or coronal/sagittal angulation. Routine early postoperative radiographs may not be necessary for all pediatric femur fractures managed with closed reduction and spica casting. The value of this study is that it is the first to demonstrate the feasibility of limiting postoperative radiographs using a preoperative screening tool. However, the established femoral malunion criteria utilized in this study were limited in their predictive value, and further work is necessary to improve the sensitivity and specificity before widespread clinical application. Level IV.

Clinicopathological profile of paediatric vitellointestinal duct anomalies

Background: Vitellointestinal duct (VID) or Omphalomesenteric duct (OMD) is the embryonic connection between the yolk sac and the primitive midgut. Anomalies result from failure of the involution of the VID. Normally, it obliterates between the fifth and seventh weeks of fetal life. They include Meckel’s diverticulum (MD), fibrous band, fistula, sinus tract, cyst, and umbilical polyp. Symptomatic cases require surgical correction. They are characterised by different clinical presentations and histological appearances. This study gathers a single paediatric institutional experience of VID remnants, their demographic, clinical profile, varied histomorphology including the presence of ectopic tissues. Aims and Objectives: The objective of this study was to retrospectively review all the symptomatic cases of VID abnormalities at a tertiary pediatric referral hospital. The demographic profile, clinical presentation, and histopathology were reviewed and descriptively analyzed. We classified these anomalies based on embryology and histology. The findings of this study will provide insights to pathologists and treating clinicians less exposed to these rare lesions. Materials and Methods: Data was retrieved retrospectively from the pathology records of a tertiary paediatric referral institute for 3 years. Histological slides of VID anomalies were reviewed and a descriptive analysis of the findings was performed. A thorough review of the literature was also done on these very rare lesions and their findings compared to our results. Results: A total of 60 cases of VID anomalies were encountered during the study period. There was significant male preponderance. The most common age group at surgery was infancy. MD was the commonest VID anomaly. The least common was vitelline fistula and only a single case was encountered in the study period. Ectopic tissues were seen in 25% of the cases and included gastric and colonic mucosae and pancreatic tissue. Conclusion: The histopathology of VID anomalies provides an interesting diagnostic experience for the reporting pathologist. Awareness of the embryology, presentation and histology of these lesions aids in accurate diagnosis.

Intraoperative Burden of Flexible Intramedullary Nailing and Spica Casting for Femur Fractures in Young Children.

Spica casting (Spica) remains the widely accepted treatment of closed femoral shaft fractures in young children aged 6 months to 5 years. In some centers, there has been a recent trend towards surgical fixation of these fractures with flexible intramedullary nails (FINs). Despite numerous studies evaluating both Spica and FIN treatment of femoral shaft fractures, there remains a paucity of data regarding patient burden during the intraoperative period. The purpose of this study was to compare the intraoperative burden, defined as anesthetic exposure, fluoroscopic duration, and radiation load, between Spica and FIN treatment of femoral shaft fractures in young children. A retrospective chart review was conducted for pediatric femoral shaft fractures presenting to a tertiary pediatric referral hospital from 2012 to 2017. Comparison groups included pediatric femur fractures treated with Spica and those treated with FIN. Outcomes included anesthetic exposure, fluoroscopy duration, and radiation exposure. In addition, length of stay, clinic visits, and complications were recorded. Of 449 consecutive pediatric femur fractures treated at our center, 143 patients ages 2 to 6 years (mean age 3.8±1.4 y) met inclusion criteria. The Spica group contained 91 patients; FIN contained 52 patients. Mean anesthetic exposure was less for Spica compared with FIN [45.1 min, 95% confidence interval (CI): 38.0-52.3 vs. 90.7 min, 95% CI: 80.5-100.8 min; P<0.001]. On average, Spica procedures required less fluoroscopy time compared with FIN (15.4 s, 95% CI: 4.8-26.0 vs. 131.6 s, 95% CI: 117.6-145.6 s; P<0.001). Mean radiation load was less for Spica compared with FIN (1.6 mGy, 95% CI: 0.6-2.6 vs. 6.9 mGy, 95% CI: 5.7-8.1 mGy; P<0.001). There was no difference in length of hospital stay (P=0.831), follow-up visits (P=0.248), or complication rate (P=0.645) between Spica and FIN groups. The most common complication was skin irritation for Spica (18.7%) and symptomatic hardware for FIN (17.3%). The findings of this study suggest that pediatric patients with femoral shaft fractures experience an increased intraoperative burden when treated with FIN compared with Spica. Treatment with FIN was associated with increased exposure to anesthesia, fluoroscopic duration, and radiation load despite similar complication rates when compared with Spica. Level III.

Management of Recurrent and Delayed Post-Tonsillectomy and Adenoidectomy Hemorrhage in Children.

To review our experience on post-tonsillectomy and/or adenoidectomy hemorrhage (PTAH) at a tertiary pediatric referral hospital and to evaluate the management and risk factors for recurrent postoperative hemorrhage and for delayed bleeding after day 14. A retrospective chart review was performed for all pediatric patients admitted to The Children's Hospital at Westmead for PTAH between July 01, 2014, and June 30, 2019. Patients with recurrent hemorrhage and those with bleeding after day 14 were selected for subanalysis. Of the 291 patients admitted for PTAH, 31 (11%) patients had recurrent postoperative hemorrhage, and 11 (4%) patients had delayed bleeding after day 14. Surgical intervention for cessation of hemorrhage was required in 88 (30%) patients, including 2 patients who required return to the theater more than once. Nine (3%) patients received blood transfusions. The average number of days between bleeding episodes was 4 days. Recurrent postoperative hemorrhage occurred in 8.5% of patients who were managed operatively at their first presentation compared to 11.4% of patients who were managed nonoperatively (odds ratio: 1.1; 95% confidence interval 0.43-2.8). No association was found between abnormal coagulation profile, surgical indication, and risk of delayed postoperative hemorrhage. Recurrent or delayed postoperative hemorrhage represents a small proportion of children with postoperative bleeding and cannot be reliably predicted. Management of first presentations with either a conservative or a surgical approach is reasonable since the risk of recurrent of PTAH may be unrelated to the choice of management at initial presentation. Careful preoperative counseling of patients and their families is important to help set expectations in the event of PTAH.

English

BACKGROUND Neonatal necrotising enterocolitis (NNEC) is very common among premature infants. However, its incidence in term babies has also been on the rise. It is a potentially devastating condition with variable mortality. The diagnosis and management of NNEC is clinically supported by modified Bell’s grading. In cases where surgical resection of bowel is performed, histological findings are rarely given much importance. In this study, we have studied the histopathology of resected bowel in NNEC in term babies and correlated these findings with the age of the neonate and also with modified Bell’s grading. METHODS 25 cases of small bowel specimens of term infants received at the pathology department of a tertiary paediatric referral hospital were studied in detail for gross and microscopic features. The histological parameters considered were transmural coagulative necrosis, granulation tissue, crypt distortion, pseudomembrane formation, villous atrophy and pneumatosis intestinalis. These findings were compared with the age of the neonates and also correlated with the modified Bell’s grading. The clinical presentation and histology were also compared in early presenting term neonates less than a week in age and term infants of more than a week. RESULTS We found early neonates of age less than a week to have higher Bell’s grading and more severe histology. CONCLUSIONS Term neonates also present with severe NNEC, requiring surgical resection of the bowel. Early presentation and higher Bell’s grading are associated with more severe histopathological changes. KEYWORDS NNEC, Term Neonates, Bell’s Grading, Histopathology

Failure of primary closure predicts prolonged length of stay in gastroschisis patients.

Current literature regarding outcomes of gastroschisis closure methods do not highlight differences in patients who successfully undergo primary closure with those who fail and require silo placement. We hypothesize that failure of primary closure has significant effects on clinical outcomes such as length of stay and time to enteral feeding. We conducted a retrospective review between 2009 and 2018 of gastroschisis patients at a tertiary pediatric referral hospital. We compared patients successfully undergoing primary closure to patients who failed an initial primary closure attempt. Bivariate and multivariate linear regression models were used to assess the association of closure method on clinical outcomes. Sixty-eight neonates were included for analysis, with 44 patients who underwent primary closure and 24 who failed primary closure. On multivariate regression analysis, primary closure patients had shorter estimated time to starting and to full enteral feeds and decreased LOS as compared to those who failed primary closure. Two patients (4.44%) had complications related to primary closure. Patients able to undergo primary closure for gastroschisis were more likely to have a shorter length of stay, shorter time to enteral feeds, and use much fewer medical resources. Initial primary closure is a safe method for most patients.

Cardiac complications of scrub typhus with special reference to electrocardiography - A twelve weeks follow up in two tertiary pediatric Hospital of Eastern India

Introduction: Scrub typhus is a rickettsial disease grossly underdiagnosed in India due to lack of easily available diagnostic test. Due to delay in the diagnosis and initiation of treatment mortality is 30%.No pediatric study highlighted the cardiac complication. Objective: To study the cardiac complication of scrub typhus and electrocardiographic changes. Method: All scrub typhus fever between age group 5 yrs to 15 yrs who were admitted with high fever at two tertiary pediatric referral hospital of eastern India were evaluated for cardiac complications. Those with cardiac involvement were subjected to electrocardiography at admission, two, six and twelve weeks. Result: Eleven out of forty three cases showed features of myocarditis requiring vasopressor and five cases showed long QT without progress to ventricular tachycardia. Conclusion: Scrub typhus is a multisystem disease with a mortality upto 30% , cardiac complication is serious and observed in 26% of cases.

Immunohistochemical Expression of Ki67 and p53 in Wilms Tumor and Its Relationship with Tumor Histology and Stage at Presentation.

Aim. Evaluate tumor proliferation marker (Ki67) and p53 tumor suppressor marker in Wilms tumor and correlate with histology, anaplasia, and staging. Design. Prospective, hospital based study conducted at a tertiary pediatric referral centre in south India. Setting. Wilms tumor is the most common childhood renal malignancy worldwide. Anaplasia on histology is associated with treatment resistance but not with aggressiveness clinical presentation. Chemotherapy for Wilms tumor is based on histology and staging. Most patients respond to current chemotherapy protocol. However, a small fraction relapses or metastasizes. Affordable prognostic markers are needed for histopathological evaluation of this tumor. Subjects. Cases of histologically confirmed Wilms tumor over five years. Cases after chemotherapy were excluded as the immunostaining was inconsistent in necrotic areas. Methods. The clinical and radiological findings of 31 cases of Wilms tumor were documented at a tertiary pediatric referral hospital over five years. In addition to Hematoxylin and Eosin staining, Ki67 proliferation index and p53 expression were correlated with tumor histology and staging. Results. Age incidence was 3–8 years with female preponderance. Significant correlation was noted between Ki67 proliferation index and tumor staging. p53 expression was not useful in stratification of Wilms tumor. Conclusion. Ki67 was cost-effective immunohistochemical marker for prognostication of pediatric Wilms tumor.

Near-Infrared Imaging in Intravenous Cannulation in Children: A Cluster Randomized Clinical Trial

Intravenous cannulation is a widespread medical procedure that can be difficult in children. Visualization of veins with near-infrared (NIR) light might support intravenous cannulation. Therefore, we investigated the effectiveness of an NIR vascular imaging system (VascuLuminator) in facilitating intravenous cannulation in children in the operating room. This was a pragmatic, cluster randomized clinical trial in all consecutive children (0-18 years) scheduled for elective surgery and in need of intravenous cannulation at a tertiary pediatric referral hospital. Daily operating rooms (770 patients) were randomized for allocation of the VascuLuminator or control group. The primary outcome was success at first attempt; the secondary outcome was time to successful cannulation. Success at first attempt was 70% (171/246) with and 71% (175/245) without the use of the VascuLuminator (P = .69). Time to successful cannulation was 162 (± 14) seconds and 143 (± 15) seconds respectively (P = .26). In 83.3%, the vein of first choice was visible with the VascuLuminator. Although it was possible to visualize veins with NIR in most patients, the VascuLuminator did not improve success rate or time to obtain intravenous cannulation. There are 3 possible explanations for this result: first, it could be that localization of the vein is not the main problem, and therefore visualization is not a solution; second, the type of system used in this study could be less than optimal; and, third, the choice of the patient population in this study could be inappropriate.

A prospective study of acute movement disorders in children

The purpose of this study was to report a prospective cohort of children with acute-onset movement disorders. We report on 52 individuals (31 females, 21 males; mean age 6y 5mo, range 2mo-15y) with acute-onset movement disorders managed at a busy tertiary paediatric referral hospital over a 40-month period. In descending order of frequency, the movement disorders reported were chorea, dystonia, tremor, myoclonus, and parkinsonism. It was possible to divide the participants into three groups: (1) those with inflammatory or autoimmune disorders (n=22), (2) those with non-inflammatory disorders (n=18), and (3) those with psychogenic disorders (n=12). The inflammatory or autoimmune aetiologies included N-methyl-D-aspartate receptor encephalitis (n=5), opsoclonus-myoclonus syndrome (n=4), Sydenham chorea (n=3), systemic lupus erythematosus (n=3), acute necrotizing encephalopathy (n=3), and other types of encephalitis (n=4). Other important non-inflammatory movement disorder aetiologies included drug-induced movement disorder (n=6), post-pump chorea (n=5), metabolic (n=3) and vascular (n=2) disease. The participants with psychogenic movement disorders (n=12) were all over 10 years of age and were more likely to be female. Tremor and myoclonus were significantly over-represented in the psychogenic movement disorder subgroup. The outcomes of the total cohort were variable, and included full recovery, severe morbidity, and death. Acute-onset movement disorders in children are important and may be treatable. Management should focus upon identifying the cause and treating the underlying disease process, as symptomatic treatment of the abnormal movements is variably effective.

Thoracopagus: a first case of incomplete conjoint twins in Eritrea

An eight hour old boy with incomplete duplication of the head was admitted in a tertiary paediatric referral hospital in Asmara, the capital city of Eritrea. The incompletely developed head with the neck of one twin was attached to the much larger and more fully developed one on the anterior aspect (ventral) of the chest. This abnormal union or fixation is termed thoracopagus which is the second most common distribution of ventral unions, parapagus (pelvis and variable trunk) being the most common. Although thoracopagus twins are more frequent, omphalopagus twins are more commonly encountered at birth, due to lower fetal mortality. The neonate also presented with multiple abnormalities, omphalocele, and congenital heart disease with VSD, deformed left external ear, high arched palate and supernumerary digit on the left 5th finger of the hand.

IV Maintenance Fluid Composition and Rate Affect Serum Sodium

Hospital Medicine| December 01 2009 IV Maintenance Fluid Composition and Rate Affect Serum Sodium AAP Grand Rounds (2009) 22 (6): 67. https://doi.org/10.1542/gr.22-6-67 Views Icon Views Article contents Figures & tables Video Audio Supplementary Data Peer Review Share Icon Share Twitter LinkedIn Tools Icon Tools Get Permissions Cite Icon Cite Search Site Citation IV Maintenance Fluid Composition and Rate Affect Serum Sodium. AAP Grand Rounds December 2009; 22 (6): 67. https://doi.org/10.1542/gr.22-6-67 Download citation file: Ris (Zotero) Reference Manager EasyBib Bookends Mendeley Papers EndNote RefWorks BibTex toolbar search toolbar search search input Search input auto suggest filter your search All PublicationsAll JournalsAAP Grand RoundsPediatricsHospital PediatricsPediatrics In ReviewNeoReviewsAAP NewsAll AAP Sites Search Advanced Search Topics: hypotonicity, serum sodium level, sodium, fertilization in vitro, hypoglycemia, maintenance or restoration of fluid or electrolyte balance Source: Yung M, Keeley S. Randomised controlled trial of intravenous maintenance fluids. J Paediatr Child Health. 2009;45(1–2):9–14; doi:10.1111/j.1440–1754.2007.01254.x Whether hypotonic fluids at a maintenance rate are appropriate for hospitalized patients is currently being debated. Researchers from a tertiary pediatric referral hospital in South Australia report results of a prospective, randomized, double-blind, controlled study designed to describe the association of plasma sodium concentration with the choice and rate of intravenous maintenance fluid replacement. Traditional maintenance fluid at the study hospital consists of hypotonic dextrose saline (DS) (0.18% saline combined with 4% dextrose), given at a rate determined by the 4:2:1 guideline based on Holliday and Segar’s article published in Pediatrics in 1957.1 Patients were eligible for inclusion if they were admitted to the pediatric intensive care unit with a normal serum sodium and required intravenous fluids (IVF) for at least 12 hours. Neonates and patients with hypoglycemia, diabetes, renal failure, or shock were excluded. Eligible patients were enrolled and randomly assigned to one of four treatment groups: 1) isotonic fluids (0.9% saline [normal saline]) at the traditional rate; 2) isotonic fluids at two-thirds the traditional rate; 3) hypotonic fluids (DS) at the traditional rate; and 4) hypotonic fluids (DS) at two-thirds the traditional rate. The primary outcome measure was the change in serum sodium 12 to 24 hours after admission. In all patients, serum sodium levels fell: mean fall was 2.3 (standard deviation 4.0) mmol/L. Hypotonic fluids produced a greater mean decrease in sodium (difference of 3 mmol/L; 95% CI, 0.8 to 5.1; P=.0063) compared to isotonic fluids. This difference was greater for surgical patients with a decrease of 4.4 mmol/L (95% CI, 1.9 to 6.8; P=.0009). Although the full maintenance rate produced a greater drop in sodium compared to the restricted rate, the difference of 1.6 mmol/L (95% CI, −0.7 to 3.9; P=.12) was not statistically significant. There were no adverse events related to hyponatremia. For intravenous fluid maintenance in sick or postoperative patients, the authors recommend NS at restricted rates and recommend against using 4% dextrose in 0.18% saline as maintenance fluid. Dr Pate has disclosed no financial relationship relevant to this commentary. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device. A recent alert from The Institute for Safe Medication Practices reminds us that even healthy children hospitalized for elective surgical procedures are at risk of hyponatremia when given hypotonic IVF. 2 Hyponatremia may be encountered in many common inpatient diagnoses such as pneumonia, meningitis, intracranial surgery, and trauma and other conditions causing pain and stress. Important limitations of Yung and Keeley’s study include a small sample size and lack of homogeneity between study groups, as well as failure to account for 20% to 40% of the IVF received by participants. Results may be poorly generalizable to other populations due to the short duration of therapy and use of a hypotonic maintenance fluid that is atypical for the United States (ie,... You do not currently have access to this content.

The Sluder method in the Netherlands and the incidence of postoperative haemorrhage in a pediatric hospital

Objective Analysis of the method of tonsillectomy in use in the Netherlands and the incidence of postoperative haemorrhage in an academic tertiary pediatric referral hospital. Study design and setting (A) An explorative study of the Sluder tonsillectomy method in the Netherlands and (B) a retrospective case file review at the Sophia Children's Hospital in Rotterdam. Methods (A) A telephone and e-mail survey amongst 107 hospitals in the Netherlands. (B) A review of patients younger than 16 years who underwent a tonsillectomy or adenotonsillectomy between January 1, 1998, and February 22, 2008. This part of the study surveyed the intubated Sluder method and analyzed the incidence of primary and secondary haemorrhage in an academic tertiary pediatric referral hospital. Results (A) The Sluder method was commonly used in 102 (95.32%) hospitals; the traditional dissection technique was exclusively used only in five hospitals (4.67%). Of the 102 hospitals using the Sluder method, 67 (65.68%) report using only inhalation mask anaesthesia, while the remaining 35 use intubation. (B) Of 1797 patients studied, 40 patients experienced postoperative tonsillar haemorrhage (2.23%), with 35 (1.95%) patients primary haemorrhage of which 32 (1.78%) within 6 h after the surgery. Secondary haemorrhage occurred in five (0.28%) patients. Conclusions The Sluder method is still generally used in the majority of hospitals in the Netherlands today. Because of the low incidence of especially secondary haemorrhage and most of the primary haemorrhages occurring within 6 h after the surgery, this technique is ideally suited for day care tonsillectomy.

Pediatric Off-label Use of Recombinant Factor VIIa

Our goal was to report our institutional experience with recombinant factor VIIa for the treatment and/or prevention of bleeding in nonhemophiliac children. This was a retrospective case series in a tertiary pediatric referral hospital. During 1999-2006, 135 patients received recombinant factor VIIa for off-label use. The median number of doses was 2; the median dose was 88 mug/kg. The most common diagnoses among patients receiving recombinant factor VIIa were disseminated intravascular coagulation/sepsis (28), surgical bleeding (19), procedural prophylaxis (16), and trauma (15). The median volume of blood products administered 24 hours before recombinant factor VIIa treatment was 29.7 vs 11.7 mL/kg 24 hours after treatment. Only 1 high-risk patient had significant bleeding after receiving prophylactic recombinant factor VIIa before an invasive procedure. Nonsurvivors had significantly increased incidence of multiple organ dysfunction syndrome (75%) compared with survivors (23%). The largest group of patients (n = 28) received recombinant factor VIIa for bleeding and/or coagulopathy because of disseminated intravascular coagulation; the mortality in this group was 26 (93%) of 28. Eleven patients received multiple doses of recombinant factor VIIa to treat bleeding complications after hematopoietic stem cell transplant, without improvement in blood use. Mortality in medical patients was 58% vs 16% in surgical patients. Three patients had significant thrombotic adverse events after receiving recombinant factor VIIa, resulting in 2 deaths and 1 leg amputation. Off-label use of recombinant factor VIIa significantly decreases blood-product administration; surgical patients had control of life-threatening bleeding with low associated mortality. Prophylactic recombinant factor VIIa may be effective in preventing bleeding if given before invasive procedures in children at high risk. Prolonged use of recombinant factor VIIa for bleeding complications after hematopoietic stem cell transplant is not effective in preventing packed red blood cell transfusion. Presence of disseminated intravascular coagulation and mulitorgan dysfunction syndrome may help predict futility of recombinant factor VIIa treatment. Off-label use of recombinant factor VIIa is associated with thromboembolic events in children.

Making something of it: one ward's application of evidence into practice

AbstractImplementing evidence into practice can be a challenging and time consuming process for clinical teams. We conducted a qualitative study of the experiences of care for children, parents and nurses on an inpatient ward at a tertiary paediatric referral hospital in Sydney, Australia. We considered the conduct of the research to be only one step in a process of change commenced before the initiation of the research project and continuing well after its conclusion. The subsequent step was to share what we had learned with ward staff to enable them to act to improve the experience of care for everybody. This article reports the place of the project in the overall program of change on the ward, the strategies undertaken to share the finding of the research and the ongoing steps being undertaken to translate the research findings into improvements in care. Although the process is incomplete, it continues to gather momentum as the staff celebrate their achievements to date and look for new ways to proceed into the future. Copyright © 2008 John Wiley &amp; Son, Ltd.

Effect of a pediatric trauma response team on emergency department treatment time and mortality of pediatric trauma victims.

Delay in the provision of definitive care for critically injured children may adversely effect outcome. We sought to speed care in the emergency department (ED) for trauma victims by organizing a formal trauma response system. A case-control study of severely injured children, comparing those who received treatment before and after the creation of a formal trauma response team. A tertiary pediatric referral hospital that is a locally designated pediatric trauma center, and also receives trauma victims from a geographically large area of the Western United States. Pediatric trauma victims identified as critically injured (designated as "trauma one") and treated by a hospital trauma response team during the first year of its existence. Control patients were matched with subjects by probability of survival scores, and were chosen from pediatric trauma victims treated at the same hospital during the year preceding the creation of the trauma team. A trauma response team was organized to respond to pediatric trauma victims seen in the ED. The decision to activate the trauma team (designation of patient as "trauma one") is made by the pediatric emergency medicine (PEM) physician before patient arrival in the ED, based on data received from prehospital care providers. Activation results in the notification and immediate travel to the ED of a pediatric surgeon, neurosurgeon, emergency physician, intensivist, pharmacist, radiology technician, phlebotomist, and intensive care unit nurse, and mobilization of an operating room team. Most trauma one patients arrived by helicopter directly from accident scenes. Data recorded included identifying information, diagnosis, time to head computerized tomography, time required for ED treatment, admission Revised Trauma Score, discharge Injury Severity Score, surgical procedures performed, and mortality outcome. Trauma Injury Severity Score methodology was used to calculate the probability of survival and mortality compared with the reference patients of the Major Trauma Outcome Study, by calculation of z score. Patients treated in the ED after trauma team initiation had statistically shorter times from arrival to computerized tomography scanning (27 +/- 2 vs 21 +/- 4 minutes), operating room (63 +/- 16 vs 623 +/- 27 minutes) and total time in the ED (85 +/- 8 vs 821 +/- 9 minutes). Calculation of z score showed that survival for the control group was not different from the reference population (z = -0.8068), although survival for trauma-one patients was significantly better than the reference population (z = 2.102). Before creation of the trauma team, relevant specialists were individually called to the ED for patient evaluation. When a formal trauma response team was organized, time required for ED treatment of severe trauma was decreased, and survival was better than predicted compared with the reference Major Trauma Outcome Study population.