A comprehensive examination of the immediate recovery of children following tonsillectomy and adenoidectomy.

OBJECTIVES: Using multiple well-validated measures and a large sample size, the goal of this paper was to describe the immediate clinical and behavioral recovery of children following tonsillectomy with or without an adenoidectomy (T&A) during the first two weeks following surgery. STUDY DESIGN: Observational, longitudinal study. SETTING: Four major pediatric hospitals in the U.S. consisting of Children's Hospital of Orange County, Children's Hospital of Los Angeles, Lucile Packard Children's Hospital, and Children's Hospital Colorado. SUBJECTS: and Methods: Participants included 827 patients between 2 and 15 years of age who underwent tonsillectomy with or without adenoidectomy surgery. Baseline and demographic information were gathered prior to surgery, and measures of clinical, behavioral, and physical recovery were recorded immediately following and up through two weeks after surgery. RESULTS: Pain following T&A was clinically significant through the first post-operative week and nearly resolved by the end of the second week. Negative behavioral changes were highly prevalent after surgery (75.6% of children at Day 0) through the first week (63.9% at Week 1), and over 20% of children continued to evidence new onset negative behavioral changes at two weeks post-operatively. Children were rated as experiencing significant functional impairment in the immediate three days following surgery and most children returned to baseline functioning by the end of the second week. CONCLUSIONS: Results of this study suggest that children show immediate impairment in functioning and experience clinically significant pain throughout the first week following T&A, and new onset maladaptive behavioral changes persisting even up to the two-week assessment period.

Impairment of wound healing by reactive skin decontamination lotion (RSDL®) in a Göttingen minipig® model.

Reactive Skin Decontamination Lotion (RSDL®) is an FDA-approved skin decontamination kit carried by service members for removal and neutralisation of vesicants and nerve agents. The RSDL kit, comprised of a lotion-impregnated sponge, was shown to be the superior medical decontamination device for chemical warfare agent (CWA) exposure on intact skin. In the event of a chemical exposure situation (i.e. terrorism, battlefield) physical injuries are probable, and preservation of life will outweigh the risk associated with application of RSDL to compromised skin. The purpose of this study was to quantify the rate and quality of wound healing in epidermal skin wounds treated with RSDL in a porcine model. Degree of wound healing was assessed using bioengineering methods to include ballistometry, colorimetry, evaporimetry, and high-frequency ultrasonography. Clinical observation, histopathology and immunohistochemistry were also utilised. All pigs received four bilateral superficial abdominal wounds via a pneumatic dermatome on their ventral abdomen, then were treated with the following dressings over a seven-day period: RSDL sponge, petroleum based Xeroform® gauze, 3 M™ Tegaderm™ Film, and 3 M™ Tegaderm™ Foam. Two additional non-wounded sites on the flank were used as controls. Two groups of pigs were then evaluated for a 21- or 56-day time period, representing short- and long-term wound-healing progression. Our findings indicated RSDL had a negative impact on wound-healing progression at both 21 and 56 days post-injury. Wounds receiving RSDL demonstrated a decreased skin elasticity, significant transepidermal water loss, and altered skin colouration and thickness. In addition, the rate of wound healing was delayed, and return to a functional skin barrier was altered when compared to non-RSDL-treated wounds. In conclusion, wound management care and clinical therapeutic intervention plans should be established to account for a prolonged duration of healing in patients with RSDL-contaminated wounds.

Children and their parents' assessment of postoperative surgical pain: Agree or disagree?

OBJECTIVE: The purpose of this study is to compare postoperative pain scores between children undergoing tonsillectomy and adenoidectomy (T&A) surgery and their parents, identify potential predictors for this disagreement, and determine possible impact on analgesic administration. METHODS: This is a prospective longitudinal study conducted with children undergoing outpatient T&A in 4 major tertiary hospitals and their parents. Children and their parents were enrolled prior to surgery and completed baseline psychological instruments assessing parental anxiety (STAI), parental coping style (MBSS), child temperament (EAS) and parental medication administration attitude questionnaire (MAQ). Postoperatively, parents and children completed at-home pain severity ratings (Faces Pain Scale-Revised, children; Numeric Rating Scale, parents) on postoperative recovery days 1, 2, and 3, reflecting an overall pain level for the past 24 h. Parents also completed a log of analgesic administration. Based on postoperative pain scores, parent-child dyads were classified as overestimators (i.e., parents rated their child's pain higher than children rated their own pain), in agreement (i.e., rating in agreement), or underestimators (i.e., parents rated their child's pain lower than children rated their own pain). RESULTS: A significant proportion of parent-child pairs disagreed on pain ratings on postoperative days 1-3 (30.05%-35.95%). Of those pairs in disagreement, the majority of parents overestimated their child's pain on all three postoperative days, specifically such that a total of 24-26% parents overestimated their child's pain on postoperative days 1, 2, and 3. Repeated measures ANOVA demonstrated that parents in the overestimator group administered higher, though still within safe limits, amounts of ibuprofen and oxycodone (mg/day) than did the underestimator or agreement groups. Multiple regression models showed hospital site as the only independent predictor for postoperative pain rating disagreement between children and parents. CONCLUSIONS: Since parents overestimate their child's postoperative pain and may administer more analgesics to their child, it is essential to develop a standardized method of child pain assessment and a tailored recommended postoperative analgesic regimen amongst medical providers for children undergoing T&A.

Marijuana Lollipop-Induced Myocardial Infarction.

A 70-year-old man with known coronary artery disease presented with crushing chest pain, diaphoresis, and pallor after consuming a marijuana lollipop; the pain began within 30 minutes of consumption. His troponin T increased from 94 ng/L to 216 ng/L, with slight ST changes but no gross ST elevations. Discharge diagnosis was non-ST-elevation myocardial infarction, and subsequent nuclear medicine wall motion studies showed worsening ejection fraction (40% to 31%). He also described worsening functional status and exercise capacity after the event. The outcome of this case is important with new marijuana legalization-hopefully with marijuana use no longer criminalized, more research into the cardiovascular side effects will emerge.

Parental satisfaction of child's perioperative care.

BACKGROUND: Satisfaction in the hospital setting is an important component of both hospital funding and patient experience. When it comes to a child's hospital experience, parent satisfaction of their child's perioperative care is also necessary to understand. However, little research has been conducted on the predictors of this outcome. Therefore, the purpose of this current study was to validate a priori selected predictors for parental satisfaction in their child's perioperative process. METHODS: Eight hundred and ten pediatric patients who underwent tonsillectomy and adenoidectomy surgery and their parents were included in this study. The primary outcome was assessed using a 21-item parent satisfaction questionnaire resulting in three satisfaction scores: overall care satisfaction, OR/induction satisfaction, and total satisfaction. RESULTS: Descriptive statistics and correlational analysis found that sedative-premedication, parental presence at anesthesia induction, child social functioning, parental anxiety, and language were all significant predictors of various components of the satisfaction score. Regression models, however, revealed that only parent anxiety and child social functioning remained significant predictors such that parents who reported lower state anxiety (OR/induction satisfaction: OR = 0.975, 95% CI [0.957, 0.994]; total satisfaction: OR = 0.968, 95% CI [0.943, 0.993]) and who had higher socially functioning children (overall care satisfaction: OR = 1.019, 95% CI [1.005, 1.033]; OR/induction satisfaction: OR = 1.011, 95% CI [1.000, 1.022]) were significantly more satisfied with the perioperative care they received. CONCLUSION: Lower parent anxiety and higher child social functioning were predictive of higher parental satisfaction scores.

An evaluation of preoperative anxiety in Spanish-speaking and Latino children in the United States.

BACKGROUND: There is a large body of literature examining factors associated with children's preoperative anxiety; however, cultural variables such as ethnicity and language have not been included. AIMS: The purpose of this investigation was to examine the role of Latino ethnicity and Spanish-speaking families in pediatric preoperative anxiety. METHODS: Participants were 294 children aged 2-15 years of age undergoing outpatient, elective tonsillectomy and/or adenoidectomy surgery and general anesthesia. Participants were recruited and categorized into 3 groups: English-speaking non-Latino White (n = 139), English-speaking Latino (n = 88), and Spanish-speaking Latino (n = 67). Children's anxiety was rated at 2 time points before surgery: the time the child entered the threshold of the operating room (Induction 1) and the time when the anesthesia mask was placed (Induction 2). RESULTS: Results from separate linear regression models at Induction 1 and Induction 2, respectively, showed that being from a Spanish-speaking Latino family was associated with higher levels of preoperative anxiety compared with being from an English-speaking family. In addition, young age and low sociability was associated with higher preoperative anxiety in children. CONCLUSION: Clinicians should be aware that younger, less sociable children of Spanish-speaking Latino parents are at higher risk of developing preoperative anxiety and manage these children based on this increased risk.

The Role of Ethnicity and Acculturation in Preoperative Distress in Parents of Children Undergoing Surgery.

This study examined the effects of acculturation on anxiety and stress in Latino and non-Latino white parents of children undergoing outpatient surgery. Participants included 686 parent-child dyads from four major children's hospitals in the United States. Latino parents who grew up in the U.S. reported higher levels of anxiety (p = 0.009) and stress (p < 0.001) compared to parents who grew up in a Latin American country. Additionally, English-speaking Latino parents reported higher anxiety and stress compared to both Spanish-speaking Latino and non-Latino white parents (p's < 0.05), whereas Spanish-speaking Latino and non-Latino white parents reported similar levels of stress and anxiety. Results of the current study were consistent with the immigrant health paradox in that more acculturated Latino parents reported higher levels of anxiety and stress than less acculturated Latino and non-Latino white parents, supporting the need for culturally tailored interventions in the perioperative environment.

A randomized trial examining preoperative sedative medication and postoperative sleep in children.

STUDY OBJECTIVE: Midazolam has been found to have beneficial effects on anxiety in children in the preoperative setting. Prior studies have examined various postoperative behaviors of children, but little research has examined the effects of preoperative use of midazolam with postoperative sleep. The purpose of this investigation was to compare postoperative sleep in children as a function of preoperative sedative medication use. DESIGN: This study was a 2-group randomized controlled trial. SETTING: Participants were recruited from Yale-New Haven Children's Hospital. PATIENTS: Participants included a convenience sample of 70 children between the ages of 3 to 12 years undergoing ambulatory tonsillectomy and adenoidectomy. INTERVENTIONS: Children were randomly assigned to 1 of 2 groups: a control group who received preoperative acetaminophen only (n = 32) and an experimental group who received both acetaminophen and midazolam preoperatively (n = 38). MEASUREMENTS: Parents completed measures of postoperative behavioral recovery and a subset of children wore actigraphs to examine objective sleep data. MAIN RESULTS: Children who received midazolam experienced similar sleep changes compared to children in the control group. The actigraph data revealed that children who received midazolam were awake significantly less during the night compared to the control group (P= .01). CONCLUSION: Children who received midazolam before surgery had similar postoperative sleep changes compared to children who did not receive midazolam. Further understanding of the postoperative behavioral effects of midazolam on children will help guide healthcare providers in their practice.

Revisiting a measure of child postoperative recovery: development of the Post Hospitalization Behavior Questionnaire for Ambulatory Surgery.

BACKGROUND: The Post Hospitalization Behavior Questionnaire (PHBQ) was designed for assessing children's posthospitalization and postoperative new-onset behavioral changes. However, the psychometric properties of the scale have not been re-evaluated in the past five decades despite substantial changes in the practice of surgery and anesthesia. In this investigation, we examined the psychometric properties of the PHBQ to potentially increase the efficacy and relevance of the instrument in current perioperative settings. METHOD: This study used principal components analysis, a panel of experts, Cronbach's alpha, and correlations to examine the current subscale structure of the PHBQ and eliminate items to create the Post Hospitalization Behavior Questionnaire for Ambulatory Surgery (PHBQ-AS). Data from previous investigations (N = 1064, Mage  = 5.88) which utilized the PHBQ were combined for the purposes of this paper. RESULTS: A principal components analysis revealed that the original subscale structure of the PHBQ could not be replicated. Subsequently, a battery reduction, which utilized principal components analysis and a panel of experts, was used to eliminate the subscale structure of the scale and reduce the number of items from 27 to 11, creating the PHBQ-AS. The PHBQ-AS demonstrated good internal consistency reliability and concurrent validity with another measure of children's psychosocial and physical functioning. CONCLUSION: Revising the former subscale structure and reducing the number of items in the PHBQ to create the PHBQ-AS may provide a means for reducing the burden of postoperative behavioral assessment through decreasing time of administration and eliminating redundancy of items and allow for more accurate measurement of child postoperative behavioral changes.

Therapeutic hypothermia for out-of-hospital cardiac arrest: An analysis comparing cooled and not cooled groups at a Canadian center.

BACKGROUND: Out of hospital cardiac arrest is a devastating event and is associated with poor outcomes; however, therapeutic hypothermia (TH) is a novel treatment which may improve neurological outcome and decrease mortality. Despite this, TH is not uniformly implemented across Coronary Care and Intensive Care Units in Canada. OBJECTIVE: The purpose of this study was to compare cerebral recovery and mortality rates between patients in our Coronary Care Unit who received TH with a historical control group. MATERIALS AND METHODS: A retrospective chart review was performed of patients admitted to a tertiary care center with out-of-hospital cardiac arrest. Twenty patients who were admitted and cooled after December 2006 were compared with 29 noncooled patients admitted in the 5 years prior as a historical control group. The primary outcomes of interest were in-hospital mortality and neurological outcome. RESULTS: Eleven of 20 (11/20, 55%) patients who were cooled as per protocol survived to hospital discharge, all having a good neurological outcome. Eleven of 29 (11/29, 38%) noncooled patients survived to hospital discharge (Odds Ratio: 0.50, 95% CI: 0.16- 1.60, P=0.26). Eleven of 20 patients who were cooled had a good neurological outcome (CPS I-II, 11/20, 55%), versus 7 of 29 (7/29, 24%) of noncooled patients (Odds ratio: 3.84, 95% CI: 1.13- 13.1, P=0.03). One hundred percent (11/11) of survivors in the cooled group had a good neurological outcome. CONCLUSION: In our center, the use of TH in out-of-hospital cardiac arrest survivors was associated with improved neurological outcome.

Medical management of cutaneous sulfur mustard injuries.

BACKGROUND: Sulfur mustard (2,2'-dichlorodiethyl sulfide; HD) is a potent vesicating chemical warfare agent that poses a continuing threat to both military and civilian populations. Significant cutaneous HD injuries can take several months to heal, necessitate lengthy hospitalizations, and result in long-term complications. There are currently no standardized or optimized methods of casualty management. New strategies are needed to provide for optimal and rapid wound healing. OBJECTIVE: The primary aim of this research was to develop improved clinical strategies (treatment guidelines) for optimal treatment of superficial dermal (second degree) cutaneous HD injuries, with the goal of returning damaged skin to optimal appearance and normal function in the shortest period of time. METHODS: Superficial dermal HD injuries were created on the ventral abdominal surface of weanling pigs. At 48h post-exposure, lesions were laser debrided and a treatment adjunct applied. Cultured epithelial allografts and 11 commercial off-the-shelf (COTS) products were examined for their efficacy in improving wound healing of these injuries. Clinical evaluations and a variety of non-invasive bioengineering methods were used at 7 and 14 days post-surgery to follow the progress of wound healing and evaluate various cosmetic and functional properties of the wounds. Measurements included reflectance colorimetry to measure erythema; evaporimetry to examine transepidermal water loss as a method of evaluating barrier function; torsional ballistometry to evaluate the mechanical properties of skin firmness and elasticity; and two-dimensional high frequency ultrasonography (HFU) to monitor skin thickness (e.g., edema, scar tissue). Histopathology and immunohistochemistry were performed 14 days following surgery to examine structural integrity and quality of healing. Logical Decisions((R)) for Windows was used to rank the 12 treatment adjuncts that were studied. RESULTS: The most efficacious treatment adjuncts included (1) Vacuum Assisted Closure, V.A.C., involving application of topical negative pressure, (2) Amino-Plex Spray (biO(2) Cosmeceuticals International, Inc., Beverly Hills, CA), a nutritive cosmeceutical product that is designed to increase oxygen in cells, stimulate ATP synthesis, improve glucose transportation, stimulate collagen formation, and promote angiogenesis, and (3) ReCell Autologous Cell Harvesting Device (Clinical Cell Culture Americas LLC, Coral Springs, Florida), an innovative medical device that was developed to allow rapid harvesting of autologous cells from a thin split-thickness biopsy followed by spray application of a population of skin cells onto wounds within 30 min of collecting the biopsy, without the need of culturing the keratinocytes in a clinical laboratory. CONCLUSIONS: Complete re-epithelialization of debrided HD injuries in 7 days is possible. In general, shallow laser debridement through the basement membrane zone (100 microm) appears to provide better results than deeper debridement (400 microm) with respect to early re-epithelialization, cosmetic appearance, functional restoration, and structural integrity. Of the 12 treatment adjuncts examined, the most promising included Vacuum Assisted Closure, Amino-Plex Spray, and ReCell Autologous Cell Harvesting Device.

Noninvasive methods for determining lesion depth from vesicant exposure.

Before sulfur mustard (HD) injuries can be effectively treated, assessment of lesion depth must occur. Accurate depth assessment is important because it dictates how aggressive treatment needs to be to minimize or prevent cosmetic and functional deficits. Depth of injury typically is assessed by physical examination. Diagnosing very superficial and very deep lesions is relatively easy for the experienced burn surgeon. Lesions of intermediate depth, however, are often problematic in determining the need for grafting. This study was a preliminary evaluation of two noninvasive bioengineering methodologies, laser Doppler perfusion imaging (LDPI) and indocyanine green fluorescence imaging (ICGFI), to determine their ability to accurately diagnose depth of sulfur mustard lesions in a weanling swine model. Histological evaluation was used to assess the accuracy of the imaging techniques in determining burn depth. Six female weanling swine (8-12 kg) were exposed to 400 microl of neat sulfur mustard on six ventral sites for 2, 8, 30, or 60 minutes. This exposure regimen produced lesions of varying depths from superficial to deep dermal. Evaluations of lesion depth using the bioengineering techniques were conducted at 24, 48, and 72 hours after exposure. After euthanasia at 72 hours after exposure, skin biopsies were taken from each site and processed for routine hematoxylin and eosin histological evaluation to determine the true depth of the lesion. Results demonstrated that LDPI and ICGFI were useful tools to characterize skin perfusion and provided a good estimate of HD lesion depth. Traditional LDPI and the novel prototype ICGFI instrumentation used in this study produced images of blood flow through skin lesions, which provided a useful assessment of burn depth. LDPI and ICGFI accurately predicted the need for aggressive treatment (30- and 60-minute HD lesions) and nonaggressive treatment (2- and 8-minute HD lesions) for the lesions generated in this study. Histological evaluation confirmed the accuracy of the assessment. The ICGFI instrument offers several advantages over LDPI including real-time blood flow imaging, low cost, small size, portability, and not requiring the patient to be repositioned. A negative, however, is the need for intravenous dye injection. Although this would not be an issue in a hospital, it may be problematic in a mass casualty field setting. Additional experiments are required to determine the exposure time necessary to produce a graded series of partial-thickness HD lesions and to optimize instrumental parameters. The data generated in this follow-on study will allow for a full assessment of the potential LDPI and ICGFI hold for predicting the need for aggressive treatment after HD exposure. The lasting message is that objective imaging techniques can augment the visual judgment of burn depth.

Improved wound healing of cutaneous sulfur mustard injuries in a weanling pig model.

OBJECTIVE: The objective was to examine the efficacy of several treatment regimens in improving wound healing of cutaneous sulfur mustard (HD) injuries. METHODS: Wound healing studies were conducted in weanling pigs. Superficial dermal HD injuries were debrided at 48 hours postexposure using an erbium-doped yttrium aluminum garnet (Er:YAG) laser, followed by application of a treatment adjunct. A variety of noninvasive bioengineering methods were conducted during the postsurgical observation period to examine the various cosmetic and functional aspects of the skin. Histopathology was performed at the end of each study (14 or 21 days postsurgery). RESULTS: As noted clinically, reepithelialization was nearly complete by 7 days postsurgery for many of the sites treated with petrolatum and scarlet red dressings. By 21 days, the skin elasticity of the petrolatum-dressed sites was not significantly different from that of sham-exposed skin. Upon dressing removal on postsurgery day 4, the neoepidermis of allograft- and thin film-dressed sites was partially removed, with resultant petechial hemorrhaging. Mean pathology scores for hydrocolloid-dressed sites were significantly lower than those of untreated HD-exposed sites on postsurgery day 14. CONCLUSIONS: Care must be taken during bandage changes, and a nonadherent dressing that could be left in place for a longer period of time (eg, 7 days) would be beneficial. The use of cultured epithelial allograft material may have a potential role if grown on a completely nonadherent backing and left undisturbed for at least a week. Xeroform Petrolatum and Scarlet Red Ointment dressings are effective and inexpensive treatment adjuncts for HD injuries.