Ventilator Dependence Research Articles

Factors associated with early mortality in pediatric tracheostomy placement: a retrospective cohort study.

Numerous factors are associated with an increased likelihood of early mortality following tracheostomy placement. These findings are particularly relevant for planning the timing for tracheostomy among critically ill children and engaging in discussions with caregivers about the heightened risks for mortality and complications of the procedure. • The prevalence of tracheostomies in children has risen significantly due to major advancements in neonatal and pediatric intensive care treatments. • Nonetheless, the mortality rate among children undergoing tracheostomy remains elevated, with approximately one-third of them experiencing mortality during the same hospital admission in which their tracheostomy is carried out. • We hypothesize that certain risk factors may discourage tracheostomy placement, potentially advocating for a more conservative management in carefully selected cases of critically ill children. • In children who underwent tracheostomy placement, the 30-day mortality rate was 10.9%, and the complication rate was 26%. • Prematurity, age < 12 months, American Society of Anesthesiologists class 4, congenital heart disease, heart failure, and ventilatory dependency were associated with a higher likelihood of mortality. These children also exhibited higher rates of postoperative complications. • These findings are particularly relevant for planning the timing for tracheostomy among critically ill children and engaging in discussions with caregivers about the heightened risks for mortality and complications of the procedure.

Effects of Family Caregiver-Nurse Communication on Family Management and Family Caregiver Uncertainty Regarding the Care of Children With Long-Term Ventilator Dependence.

Nurses caring for hospitalized children with long-term ventilator dependence (LTVD) assess family management capability and teach new skills through communication with family caregivers. This theoretically-based quantitative, descriptive study aimed to determine the communication behaviors associated with family caregiver uncertainty and management of the child with LTVD's care after discharge. One hundred families and 48 nurses enrolled. Family caregiver-nurse conversations were recorded and transcripts coded for communication behaviors. Family management and uncertainty data were gathered during hospitalization and after discharge. Data analysis included correlations and linear mixed models. Family caregivers and nurses used advocating and negotiating roles communication behaviors least frequently; however, these communication behaviors were associated with the most aspects in terms of uncertainty about the child's condition and ease of management of the child's care after discharge to home. Nurses should assess family caregiver ease in managing care, provide support, and engage in collaborative problem-solving through respectful communication.

Ligation of Patent Ductus Arteriosus in Preterm Infant with Comorbidities: An Unforgotten Nightmare

Patent ductus arteriosus (PDA) is a common congenital anomaly in preterm infants. We report here a case of 28-day-old preterm infant, weighing 1.6 kg, with significant PDA, having bronchopulmonary dysplasia, necrotizing enterocolitis, intraventricular hemorrhage, hydrocephalus, and meningitis; presented for PDA ligation in view of prolonged ventilator dependence, non-responsiveness to pharmacological therapy for PDA closure, and continuous worsening of hemodynamics due to the presence of large PDA.

Features Associated With the Presence of Specific Bacterial Strains in Pediatric Tracheostomy.

Tracheostomy bypasses physical barriers that decrease microbial access to the lower airway, which can lead to changes to the lung microbiota. Patients often become chronically colonized with potential pathogens. This study described the incidence and prevalence of specific organisms in a 5-y cohort of children with tracheostomy. This retrospective cohort of children aged 0-18 y with tracheostomy identified associations between microbial species and subject characteristics including reason for tracheostomy, gastrostomy tube (G-tube), fundoplication, and ventilator use using chi-square test or Fisher exact test. Of 113 eligible patients, 79 (57% male) met study inclusion criteria. Reasons for tracheostomy included airway obstruction secondary to craniofacial anomalies in 16 children (20%), upper-airway obstruction in 14 subjects (17.3%), neuromuscular disorder in 19 subjects (24%), bronchopulmonary dysplasia with or without pulmonary hypertension in 17 subjects (21%), and congenital heart disease in 13 subjects (16%). Most (69%) used a ventilator for at least 6 h/d; 63% had a G-tube; 41% also had a Nissen fundoplication. Of the 20% with upper-airway obstruction, one third were ventilator dependent, unlike other diagnoses where 57% used a ventilator. Staphylococcus aureus (52/113), Pseudomonas aeruginosa (43/113), and Stenotrophomonas species (39/113) were the most frequently identified bacterial species. Most microbes identified were not associated with subjects underlying diagnoses, ventilator use, or feeding type. However, there was a significant association between upper-airway obstruction and group B Streptococcus species and G-tube with P. aeruginosa. This retrospective single-site descriptive cohort analysis of pediatric subjects with long-term tracheostomy identified trends in microbial prevalence. The presence of specific bacterial strains was more likely to follow individual subject trajectories than sequential appearance of species. P. aeruginosa was associated with G-tube and Streptococcus species with upper-airway obstruction. Ventilator dependence was not associated with specific microbial profiles.

Ventilation Dependency after Cardiac Operation for Infective Endocarditis: Risk Factors and Focus on Preoperative Aortic Regurgitation

Introduction: The investigation was to elucidate predictors of ventilation dependency after cardiac operation for infective endocarditis. Methods: Patients with infective endocarditis undergoing cardiac operation were retrospectively investigated. Mechanical ventilation &gt;72 hours was defined as ventilation dependency after cardiac operation. Results: 896 patients with infective endocarditis who underwent cardiac operation were assigned to group of mechanical ventilation ≤72 h (n = 704) and &gt;72 h (n = 192). Multivariate analyses identified age, interval from symptoms to operation, vegetation size, aortic occlusion length, pump length, intensive care unit (ICU) retention length, serum creatinine before and 24 h after surgery, preoperative and postoperative left ventricular end diastolic dimension (LVEDD), preoperative aortic regurgitation and packed red blood cells to be associated with ventilation dependency after cardiac operation; ventilation dependency is significantly related to prolonged ICU stay (&gt;3 d), 1- and 5-year mortality after cardiac operation. All-time mortality (45.3% versus 5.6%, p &lt; 0.001) of mechanical ventilation &gt;72 h group was higher than that of mechanical ventilation ≤72 h group. A significant positive correlation exists between preoperative aortic regurgitation and ventilation dependency after cardiac operation. A value of preoperative aortic regurgitation &gt;5.25 cm2 was 100% sensitive and 64.6% specific for the diagnosis of ventilation dependency after cardiac operation. Conclusions: We found modifiable risk factors of ventilation dependency after cardiac operation including interval from symptoms to operation, vegetation size, aortic occlusion length, pump length, ICU retention length, serum creatinine before and 24 h after operation, preoperative and postoperative LVEDD, preoperative aortic regurgitation and packed red blood cells and optimization of pre-, peri-, and postoperative factors that can reduce incidence of ventilation dependency, contributing to better short- and long-term outcomes.

Prolonged Ventilator Dependency in a Pediatric ICU Patient With Pfeiffer Syndrome Following Le Fort I Osteotomy and Distraction Osteogenesis: A Case Report

Prolonged Ventilator Dependency in a Pediatric ICU Patient With Pfeiffer Syndrome Following Le Fort I Osteotomy and Distraction Osteogenesis: A Case Report

Clinical outcomes of children with COVID-19 and appendicitis: a propensity score matched analysis.

Early in the COVID-19 pandemic, many children with appendicitis and COVID-19 were initially treated non-operatively and later underwent interval appendectomy. Currently, children with both appendicitis and COVID-19 frequently undergo upfront appendectomy. The impact of this return to upfront surgical management on patient outcomes is unknown. This study compared outcomes of pediatric patients with and without COVID-19 infection undergoing appendectomy. A retrospective cohort study of children < 21y who underwent appendectomy from 3/19/2020 to 7/31/2022 at 50 Pediatric Health Information System children's hospitals was conducted. Children with documented COVID-19 were identified. Exclusions included preoperative ventilator or supplemental oxygen dependence, and missing data. To evaluate COVID-19 positive versus COVID-19 negative patients, we used a propensity score matched on sociodemographics, comorbidities, laparoscopy, perforation, and hospital. Chi-square and Mann-Whitney U tests identified differences between groups in length of stay, postoperative drain placement, 30-day re-admission, and mechanical ventilation requirements. Overall, 51,861 children of median age 11y (IQR: 8-14) underwent appendectomy, of whom 1,440 (2.3%) had COVID-19. Most were male (60.3%), White (72.1%) and non-Hispanic (61.4%). Public insurance was the most common (47.5%). We created a matched cohort of 1,360 COVID-19 positive and 1,360 COVID-19 negative children. Children with COVID-19 had shorter hospitalizations (1d, IQR: 1-4 vs. 2d, IQR: 1-5, p = 0.03), less postoperative peritoneal drain placement (2.4% vs. 4.1%, p = 0.01), and fewer 30-day readmissions (9.0% vs. 11.4%, p = 0.04). However, no difference in incidence or duration of mechanical ventilation (p > 0.05) was detected. Our findings suggest that upfront appendectomy for children with appendicitis and COVID-19 has similar outcomes compared to children without COVID-19. Level III.

7706 Racial Disparities in Thyroid-Related Procedure Reoperation Rates: Insights from NSQIP Database

Abstract Disclosure: H.A. Erol: None. A. Liu: None. K. Wardwell: None. S. Woodruff: None. Background: Racial disparities in health outcomes are well-documented, with specific conditions affecting racial groups differently. However, the influence of race on endocrine surgery outcomes remains an evolving field of study. This research seeks to evaluate the effect of race on unplanned reoperations using the National Surgical Quality Improvement Program(NSQIP)-database and to investigate additional risk factors for reoperations in this cohort. Methods: We analyzed the NSQIP-database for thyroid-related procedures from 2012-2021 using CPT codes. Patient demographics, including age, sex, height/weight, ASA classification, and comorbid conditions, were assessed for unplanned reoperations. Univariate, multivariable logistic regression, and adjusted residual analyses were conducted assessing individual variables, adjusted odds ratios(ORs), and for post-hoc analyses. Results: Over the 10-year period, 169,251 patients were identified, with an overall reoperation incidence of 1.32%. Univariate analysis revealed that race correlated with increased reoperation rates, with the highest incidence observed among American Indian/Alaska Native (2.13%) patients, followed by Native Hawaiian/Pacific Islander (1.93%), Black/African American(1.84%), White (1.22%), and Asian(1.08%) patients. In multivariate logistic regression analysis, Black/African American (OR 1.452, 95% CI 1.293-1.630, p &amp;lt; 0.001) and American Indian/Alaska Native (OR 1.775, 95% CI 1.039-3.031, p = 0.036) patients had a higher risk of reoperation compared to White patients. Other factors associated with increased reoperation risk included male gender, higher ASA class, smoking, partially dependent functional status, ventilator dependency, hypertension, dialysis, disseminated cancer, bleeding disorders, and systemic inflammatory response syndrome or sepsis. Most reoperations were hematoma related(63.02%), with statistical significance noted among different ethnicities and types of reoperations. White patients had lower rates of hematoma-related procedures, fewer tracheostomies, and more additional thyroid procedures. Black/African American patients had more tracheostomies and fewer lymphatic-related or additional thyroid procedures. Conclusions: Using the NSQIP-database, Black/African American and American Indian/Alaska Native patients were at a greater risk of reoperation following thyroid surgeries, even after accounting for multiple variables. Black/African American patients also had disparate types of reoperations. These findings highlight the impact of race on thyroidectomy-related outcomes. Further research is imperative to comprehensively understand the role of race in surgical outcomes and to address healthcare disparities and inequities. Presentation: 6/2/2024

12615 Extremely High-dose Insulin Requirement In A Child With Covid-19 Infection

Abstract Disclosure: R. Pratibha: None. T.R. Langner: None. Background: COVID-19 infection has been associated with new diagnosis of diabetes, worsening of hyperglycemia, and increased frequency and severity of diabetic ketoacidosis (DKA) in type 1 diabetes (DM) patients. Stress- related and steroid induced hyperglycemia are also well described during COVID infection with poor glycemic control being linked to more severe SARS-CoV-2 infection outcomes. While insulin needs increase during infection, extremely high insulin requirement is uncommon and not described in the pediatric population. We present here a case of mild COVID infection with transient markedly high insulin requirements. Clinical Case A 16-year-old-African-American- female with history of fairly well controlled type 2 diabetes mellitus on closed loop system insulin pump (Omnipod) with continuous glucose monitor (CGM), was admitted with COVID-19, aspiration pneumonia and hyperglycemia. She had been diagnosed 10 months prior with Hemoglobin A1c (HbA1c) of 11.4% and mild diabetic ketoacidosis (DKA). Diabetes antibodies were negative. Four months prior to admission her HbA1c was 7.8%. Upon this hospitalization she had no hypoxemia or respiratory failure and did not need steroids. Procalcitonin level 0.09 ng/mL was normal. Developmental delay, non-ambulatory and non-verbal status, an underlying mitochondrial neurological disease with G tube and ventilator dependence added to the medical complexity. HbA1c (8.1%) and Fructosamine 316 (n 200-285 mcmol/L) were not indicative of poor control. While her pneumonia resolved promptly, blood sugar (BG) elevation prolonged her hospitalization. She was not in DKA. Despite increasing her basal rate by 50% and an additional 20% higher temporary basal rate via her insulin pump there was little response. She was switched to Insulin drip by the 7th day. Her Insulin rate had increased to 26 units per hour (at 0.64 Units/Kg/hour) by day 8. This high insulin-dose need lasted for around 36 hours, before gradually reducing over a week. She has a history of recurrent pancreatitis. Lipase 335 U/L was elevated initially but started reducing within 2 days and had normalized by day 13. She was transitioned back to her pump although at higher basal rate than the previous home regimen, by 14th day. Conclusion While a constellation of factors such as stress, steroids, underlying poor glycemic control may cause hyperglycemia in COVID-19, these do not explain the high insulin demand in our patient. COVID infection with impaired insulin secretion, mild pancreatitis may have contributed to the brief remarkably high-dose insulin requirement, but it appears to be increased insulin resistance which could possibly explain the transient derangement. To our knowledge this has previously not been described in a pediatric diabetic patient. Presentation: 6/3/2024

Lung-Protective Mechanical Ventilation in Patients with Severe Acute Brain Injury: A Multicenter Randomized Clinical Trial (PROLABI).

Rationale: Lung-protective strategies using low Vt and moderate positive end-expiratory pressure (PEEP) are considered best practice in critical care, but interventional trials have never been conducted in patients with acute brain injuries because of concerns about carbon dioxide control and the effect of PEEP on cerebral hemodynamics. Objectives: To test the hypothesis that ventilation with lower VT and higher PEEP compared to conventional ventilation would improve clinical outcomes in patients with acute brain injury. Methods: In this multicenter, open-label, controlled clinical trial, 190 adult patients with acute brain injury were assigned to receive either a lung-protective or a conventional ventilatory strategy. The primary outcome was a composite endpoint of death, ventilator dependency, and acute respiratory distress syndrome (ARDS) at Day 28. Neurological outcome was assessed at ICU discharge by the Oxford Handicap Scale and at 6 months by the Glasgow Outcome Scale. Measurements and Main Results: The two study arms had similar characteristics at baseline. In the lung-protective and conventional strategy groups, using an intention-to-treat approach, the composite outcome at 28 days was 61.5% and 45.3% (relative risk [RR], 1.35; 95% confidence interval [CI], 1.03-1.79; P = 0.025). Mortality was 28.9% and 15.1% (RR, 1.91; 95% CI, 1.06-3.42; P = 0.02), ventilator dependency was 42.3% and 27.9% (RR, 1.52; 95% CI, 1.01-2.28; P = 0.039), and incidence of ARDS was 30.8% and 22.1% (RR, 1.39; 95% CI, 0.85-2.27; P = 0.179), respectively. The trial was stopped after enrolling 190 subjects because of termination of funding. Conclusions: In patients with acute brain injury without ARDS, a lung-protective ventilatory strategy, as compared with a conventional strategy, did not reduce mortality, percentage of patients weaned from mechanical ventilation, or incidence of ARDS and was not beneficial in terms of neurological outcomes. Because of the early termination, these preliminary results require confirmation in larger trials. Clinical trial registered with www.clinicaltrials.gov (NCT01690819).

Long-term life expectancy in severe traumatic brain injury: a systematic review.

Traumatic brain injuries (TBIs) pose significant challenges to public health, medicine, and society due to their substantial impact on victims, caregivers, and the community. While indicators like life expectancy or death rates provide insights into mortality and long-term outcomes, they fail to address how TBIs affect aging, neurological sequelae, cognitive impairment, and psychological or psychiatric disorders. Moreover, most studies are limited to North America, limiting the generalizability of findings across different social welfare systems. As a result, clinicians face difficulties in providing optimal care and prognosis, hindering the improvement of life quality for victims and caregivers and efficient public health service planning. This study aims to address these limitations by examining life expectancy, mortality rates, and long-term outcomes in severely injured individuals. PubMed/Medline, Web of Science, Cochrane Library, Google Scholar, and PEDro search engines were systematically searched for studies investigating life expectancy and long-term outcomes in severe traumatic brain injuries. The final search date for all sources/databases was July 31, 2023. We conducted a systematic review, and only original research articles published in English were eligible for inclusion. After the screening process, data were extracted about life expectancy, follow-up, and conclusions. This study analyzed 24 studies out of 343 identified. Life expectancy in the TBI population is lower than that of the general population. Older age and severity of functional impairments are major risk factors for mortality. Mortality rates are particularly high in the first two months. Mortality trends suggest a bimodal distribution, with a peak in the first five years followed by no further deaths until nine years after injury. The most influential factors include age, sex, trauma severity, independence in walking and feeding, time since injury, ventilator dependence, and cognitive and communication impairments. Respiratory and circulatory complications are among the leading causes of TBI-related deaths, followed by epilepsy, suicide, and respiratory infections. Further research is required, considering the different long-term outcomes after TBI and their impact on families and society, to accurately estimate the life expectancy necessary for clinicians, caregivers, national health institutions, and medico-legal settlements.

Clinicoepidemiological Profile of Retinopathy of Prematurity.

Purpose In previously performed studies, retinopathy of prematurity (ROP) has been shown to occur postpartum. As a result, mechanical ventilation and oxygen dependence were eventually connected to the development of ROP in these preterm children, and ROP prevalence is on the rise globally. Despite various improvements in childcare, ROP still tends to arise due to various risk factors associated with the disease. So, clinically the research was performed to determine the clinical and epidemiological profile of ROP. Materials and methods A total of 268 participants were to be enrolled in the study. It was an observational, cross-sectional study carried out at Department of Ophthalmology and Neonatal Intensive Care Unit in Veer Surendra Sai Institute of Medical Sciences and Research Centre, Burla, Sambalpur, Odisha, India. Ethical approval was provided on 30 November 2019. Results Overall 123 (46%) infants out of 268 infants developed retinopathy of prematurity. Majorly, the infants had stage 1 and stage 2 ROP. Most of the infants were male. Birth weight in ROP patients was 1000 g or less in 54% of infants, 1000-1500 g in 46% of infants and >1500 g in 33% of infants. Gestational age was found to be a predictor of retinopathy of prematurity. The adverse events that were found to be associated with retinopathy of prematurity were sepsis (53%), respiratory distress syndrome (RDS) (54.6%), intraventricular haemorrhage (IVH) (60%), anaemia (61.5%). Conclusion It has been observed that babies with higher birth weights and older gestations are also susceptible to developing ROP. Therefore, the greater birth weight newborns up to 1750 g and older gestational age babies >34 weeks should also be included in the screening criteria, especially if they have risk factors such as oxygen supplementation, sepsis, RDS, and anaemia.

The Role of Structured Goals of Care Discussions in Critically Ill Thoracic Surgery Patients.

Objective: The American College of Surgeons recommends structured family meetings (FM) for high-risk surgical patients. We hypothesized that goals of care discussions (GOCD) in the form of an FM, multidisciplinary family meeting (MDFM), or palliative care consult (PCC) would be underutilized in imminently dying thoracic surgery patients. Methods: A retrospective chart review at a tertiary academic medical center was performed on all inpatient mortalities and discharges to hospice after any thoracic surgery operation. The utilization of GOCDs was compared between the 2 groups. Secondary outcomes were length-of-stay, comatose status and ventilator dependence during initial GOCD, and timing of code status change. Results: In total, 56 patients met inclusion criteria: 44 of 56 (78.6%) died and 12 of 56 (21.4%) were discharged to hospice. Most patients had a FM (79.5% mortality vs 100% hospice, P = .29) and few had an MDFM (25.0% mortality vs 25.0% hospice, P = 1.00). Patients discharged to hospice were more likely to have a PCC (66.7% vs 31.2%, P = .03) and less likely to be comatose (16.7% vs 59.1%, P = .009) or ventilator dependent during initial GOCD (16.7% vs 70.5%, P = .001). Among patients who died and were DNR-CC (do not resuscitate-comfort care; 37 of 44), 75.7% died the same day of code status change and 67.6% died within 48 h of initial GOCD. Discussion: Although FMs were common, MDFMs were infrequent. Patients discharged to hospice were more likely to have a PCC. Most deaths occurred shortly after initial GOCD and most code status changes occurred on day-of-death. This data suggest an opportunity to improve GOCDs in critically ill thoracic surgery patients.

Comparison of supraglottic airway device and endotracheal tube in former preterm infants receiving general anesthesia: a randomized controlled trial

To date, endotracheal tube (ETT) remains the mainstream for preterm infants receiving general anesthesia. We aim to compare the perioperative respiratory adverse events between using supraglottic airway device (SAD) and ETT in former preterm infants receiving general anesthesia. Former preterm infants below 52 weeks of postmenstrual age scheduled for herniorrhaphy were randomized to receive SAD or ETT for general anesthesia. Infants with severe congenital cardiopulmonary disease, prolonged oxygen or mechanical ventilation dependence, and recent respiratory tract infection were excluded. Muscle relaxant agents and opioids were avoided in this study. 40 infants were assigned into SAD or ETT groups. Infants in the SAD group had a much lower rate of intraoperative desaturation than those in the ETT group (21.1% vs. 73.7%, p = 0.003). Incidences of other intraoperative and postoperative 24-h respiratory adverse events were similar between groups, including laryngospasm/bronchospasm, cough and stridor during anesthesia, and postoperative apnea, bradycardia, and supplemental oxygen use. All participants were extubated successfully in the operation room. SAD is recommended in former preterm infants receiving general anesthesia for herniorrhaphy in their early infancy as it much decreases the incidence of intraoperative desaturation compared to ETT.

Characteristics and Outcomes of Home-Ventilated Children Undergoing Noncardiac Surgery.

To determine the frequency of children with chronic respiratory failure (CRF) and home ventilator dependence undergoing surgery at a tertiary children's hospital, and to describe periprocedural characteristics and outcomes. We conducted a retrospective cohort study of patients with CRF and home ventilator dependence who underwent noncardiac surgery from January 1, 2013, to December 31, 2019. Descriptive statistics were used to report patient and procedural characteristics. Univariable and multivariable analyses were used to assess for factors associated with 30-day readmission. We identified 416 patients who underwent 1623 procedures. Fifty-one percent of patients used transtracheal mechanical ventilation (trach/vent) support at the time of surgery; this cohort was younger (median age 5.5 vs 10.8 years) and more complex according to American Society of Anesthesiologists status compared with bilevel positive airway pressure-dependent patients. Postoperatively, compared with bilevel positive airway pressure-dependent patients, trach/vent patients were more likely to be admitted to the ICU with longer ICU length of stay (median 5 vs 2 days). Overall 30-day readmission rate was 12% (n = 193). Presence of chronic lung disease (adjusted odds ratio 1.65, 95% confidence interval 1.01-1.69) and trach/vent dependence (adjusted odds ratio 1.65, 95% confidence interval 1.02-2.67) were independently associated with increased odds for readmission. Children with CRF use anesthetic and surgical services frequently and repeatedly. Those with trach/vent dependence have higher hospital and ICU resource utilization. Although overall mortality for these patients is quite low, underlying diagnoses, nuances of technology dependence, and other factors for frequent readmission require further study to optimize resource utilization and outcomes.

Optimal timing of surgery for inguinal hernia in premature neonates

AbstractAimThe surgical repair of inguinal hernias represents a significant risk for premature infants. Despite ongoing discourse, the optimal approach to hernia management remains contentious. Our investigation aims to establish the most favourable timing for inguinal repair in premature neonates.Patients and MethodsOur investigation involved the analysis of medical records for 536 neonates, born prematurely, who underwent inguinal hernia repair from January 2018 to December 2023. We dichotomised the cohort into two groups: those who received early repair and those who underwent late repair. The timing of the surgery was primarily determined by the surgeon's decision, in conjunction with familial consent to the surgical intervention. The primary endpoints were the incidence of recurrence or incarceration within 1 year after surgery. The secondary endpoints encompassed length of neonatal intensive care unit stay, post‐operative ventilator dependency, and frequency of return visits, whether to the inpatient and emergency department or an outpatient clinical setting, for hernia‐related issues.ResultsThe analysis encompassed a total of 454 neonates born prematurely, of which 163 underwent early repair, while 291 received late repair for inguinal hernia. The demographic data between the two groups demonstrated no significant differences. The occurrences of hernia recurrence and post‐operative apnoea presented similar trends across both cohorts. Notably, the late repair group exhibited an increased incidence of preoperative incarceration and return visits due to hernia complications. In this group, testicular atrophy or ovarian necrosis was observed in five cases, despite the overall absence of significant differences.ConclusionsOur findings suggest that the surgical repair of inguinal hernia in preterm neonates, performed at the time of presentation to our clinics, is both safe and feasible. However, a delay in hernia repair appears to be associated with a heightened risk of severe complications, such as testicular atrophy or ovarian necrosis.

Improving Antibiotic Stewardship in a Pediatric Long-term Care Facility.

Antimicrobial stewardship is little studied in pediatric long-term care facilities. We sought to determine whether empirical ciprofloxacin for febrile respiratory illnesses could be safely reduced in our pediatric long-term care facility. All patients living in the 45-bed facility were included. A 1-year educational intervention for antimicrobial stewardship was implemented. Days of ciprofloxacin therapy, infections, microbiology, hospitalizations, other antibiotic use, methicillin-resistant Staphylococcus aureus and Clostridioides difficile infections, and mortality were recorded at regular intervals retrospectively from 5 years before intervention and prospectively for 8 years after intervention. Data were analyzed using statistical process control charts. A majority of patients had tracheostomy tubes (96%) and ventilator dependence (58%). Ciprofloxacin use declined by 76% (17 to 4 days/1000 facility patient days). Antibiotic prescriptions for bacterial tracheitis decreased by 89% (38 to 4 courses per 6-month period). No increases in positive blood or urine cultures, hospitalizations, or need for hospital antibiotics were observed. An antimicrobial stewardship intervention in a pediatric long-term care facility led to decreases in ciprofloxacin use, bacterial tracheitis diagnoses, and overall antibiotic use without increasing negative outcomes.

Thirty-day outcomes of surgery for hydrocephalus: metrics in a large cohort from the National Surgical Quality Improvement Program-Pediatric.

Hydrocephalus is a lifelong condition punctuated in most cases by unpredictable hospital admissions for surgical maintenance. It occupies more of the attention of the pediatric neurosurgeon than any other condition. Benchmarks for the measurement of outcomes are of interest to patients, their families, and the healthcare system. Compared to other metrics, 30-day outcomes require modest resources to collect, are conceptually transparent, and are responsive to process improvement. The National Surgical Quality Improvement Program-Pediatric of the American College of Surgeons was queried for operations for hydrocephalus in the years 2013 through 2020. Demographic data and data regarding comorbidities were collected. Thirty-day rates of return to the operating room, of shunt infection, and of readmission to hospital were analyzed on a univariate basis and in multivariate models. There were 29,098 surgical procedures in the sample, including 10,135 shunt insertions, 16,420 shunt revisions, and 2543 endoscopic third ventriculostomies. The overall 30-day reoperation rate was 10.3%. The most powerful associations were with the nature of the index procedure and with a history of extreme prematurity. The 30-day shunt infection rate was 1.80%. The major associations were with young age, major cardiac risk factors, nutritional support, and ventilator dependence. The 30-day readmission rate was 17.2%. The nature of the index procedure, current malignancy, nutritional support, and recent steroid administration were major associations. Comorbidities negatively associated with these outcomes were highly prevalent. Precise benchmarks for important 30-day outcomes have been calculated from a very large sample of operations for hydrocephalus in childhood.

Restoration of respiration in high cervical spinal cord injury via phrenic nerve reinnervation: illustrative case.

Traumatic high cervical spinal cord injury (SCI) can result in a devastating loss of functional respiration, leaving patients permanently dependent on mechanical ventilation. Nerve transfer is a promising reinnervation strategy that has the potential to restore connectivity in paralyzed distal muscles. The spinal accessory nerve (SAN) remains functional in most cases after high cervical SCI and can serve as a donor to reinnervate the phrenic nerve (PN), thereby improving diaphragmatic function. Information regarding thorough physical, electrodiagnostic, and pulmonary assessments to establish candidacy for nerve transfer, as well as the surgical procedure, was summarized with an illustrative case. The patient demonstrated improvement in pulmonary function testing but did not achieve independent respiration. A systematic literature review identified 3 studies with 9 additional patients who had undergone SAN-to-PN transfer. The nerve transfer meaningfully restored diaphragmatic function, improving pulmonary function tests and reducing ventilator dependency. Respiratory dependency significantly impacts the quality of life of patients with a high cervical SCI. The use of the lower SAN motor branch for PN transfer is safe and does not result in a meaningful downgrade in trapezius function. Outcomes following this procedure are promising but heterogeneous, indicating a need for significant innovation and improvement for future therapies. https://thejns.org/doi/10.3171/CASE24236.

Design and optimisation of soft robotic actuators for augmented lung-ventilation

Pulmonary rehabilitation through invasive ventilation involves the insertion of an endotracheal tube into the trachea of a sedated patient to control breathing via a ventilating machine. Invasive ventilation offers benefits such as greater control over oxygen supply, higher efficiency in supporting patient respiration, and the ability to manage airway secretions. However, this method also poses treatment challenges like ventilator-induced pneumonia, airway injury, long recovery times, and ventilator dependence. Here, we explore an alternative invasive ventilation technique using soft robotic actuators to mimic the biological function of the diaphragm for augmenting and assisting ventilation. We investigated two actuator geometries, each at two locations superior to the diaphragm. These actuators were tested on a bespoke ex vivo testbed that accurately simulated key diaphragmatic characteristics throughout the respiratory cycle. From this, we have been able to drive intrathoracic pressures greater than the 5 cmH2O required for ventilation in a human male. Additionally, by optimising the placement and geometry of these soft robotic actuators we have been able to generate maximum intrathoracic pressures of (6.81 ± 0.39) cmH2O.