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BACKGROUND: The present study explores the frequency, diagnostic approach, and therapeutic management of cerebral vasospasm in a cohort of children with moderate-to-severe traumatic and nontraumatic subarachnoid hemorrhage (SAH). METHODS: This was a single-center retrospective study performed over a 10-year period, from January 2010 to December 2019. Children aged from one month to 18 years who were admitted to the pediatric or adult intensive care unit with a diagnosis of SAH were eligible. Cerebral vasospasm could be suspected by clinical signs or transcranial Doppler (TCD) criteria (mean blood flow velocity > 120 cm/s or an increase in mean blood flow velocity by > 50 cm/s within 24 h) and then confirmed on cerebral imaging (with a reduction to less than 50% of the caliber of the cerebral artery). RESULTS: Eighty patients aged 8.6 years (3.3-14.8 years, 25-75th centiles) were admitted with an initial Glasgow Coma Scale score of 8 (4-12). SAH was nontraumatic in 21 (26%) patients. A total of 14/80 patients (18%) developed cerebral vasospasm on brain imaging on day 6 (5-10) after admission, with a predominance of nontraumatic SAH (12/14). The diagnosis of cerebral vasospasm was suspected on clinical signs and/or significant temporal changes in TCD monitoring (7 patients) and then confirmed on cerebral imaging. Thirteen of 14 patients with vasospasm were successfully treated using a continuous intravenous infusion of milrinone. The Pediatric Cerebral Performance Category score at discharge from the intensive care unit was comparable between children with vasospasm (score of 2 [1-4]) vs. children without vasospasm (score of 4 [2-4]) (p = 0.09). CONCLUSIONS: These findings indicate that cerebral vasospasm exists in pediatrics, particularly after nontraumatic SAH. The use of TCD and milrinone may help in the diagnostic and therapeutic management of cerebral vasospasm.
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Hemorragia Subaracnóidea , Vasoespasmo Intracraniano , Adulto , Criança , Humanos , Milrinona/uso terapêutico , Estudos Retrospectivos , Hemorragia Subaracnóidea/complicações , Hemorragia Subaracnóidea/diagnóstico , Hemorragia Subaracnóidea/terapia , Ultrassonografia Doppler Transcraniana , Vasoespasmo Intracraniano/diagnóstico por imagem , Vasoespasmo Intracraniano/etiologiaRESUMO
BACKGROUND: Positive communication behaviour within anaesthesia teams may decrease stress response and improve clinical performance. We aimed to evaluate the effect of positive communication during medical handover on the subsequent team-based clinical performance in a simulated critical situation. We also assessed the effect of positive communication behaviour on stress response. METHODS: This single-centre RCT involved anaesthesia teams composed of a resident and a nurse in a high-fidelity scenario of anaesthesia-related paediatric laryngospasm after a standardised handover. During the handover, similar information was provided to all teams, but positive communication behaviour was adopted only for teams in the intervention group. Primary outcome was team-based clinical performance, assessed by an independent blinded observer, using video recordings and a 0-to 100-point scenario-specific scoring tool. Three categories of tasks were considered: safety checks before the incision, diagnosis/treatment of laryngospasm, and crisis resource management/non-technical skills. Individual stress response was monitored by perceived level of stress and HR variability. RESULTS: The clinical performance of 64 anaesthesia professionals (grouped into 32 teams) was analysed. The mean (standard deviation) team-based performance score in the intervention group was 44 (10) points vs 35 (12) in the control group (difference: +8.4; CI95% [0.4-16.4]; P=0.04). The effects were homogeneous over the three categories of tasks. Perceived level of stress and HR variability were not significantly different between groups. CONCLUSIONS: Positive communication behaviour between healthcare professionals during medical handover improved team-based performance in a simulation-based critical situation. CLINICAL TRIAL REGISTRATION: NCT03375073.
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Competência Clínica/normas , Comunicação , Cuidados Críticos/normas , Pessoal de Saúde/normas , Equipe de Assistência ao Paciente/normas , Transferência da Responsabilidade pelo Paciente/normas , Treinamento por Simulação/normas , Adulto , Cuidados Críticos/métodos , Feminino , Humanos , Masculino , Estudos Prospectivos , Treinamento por Simulação/métodosRESUMO
BACKGROUND: Many applications of transcranial Doppler (TCD) as a diagnosis or monitoring tool have raised interest in the last decades. It is important that clinicians know when and how to perform TCD in this population, what parameter to assess and monitor and how to interpret it. OBJECTIVE: This review aims to describe the emerging clinical applications of TCD in critically ill children excluding those suffering from trauma. METHODS: Databases Web of Science, Cochrane and PubMed were searched in May 2020. We considered all publications since the year 2000 addressing the use of TCD as a prognostic, diagnostic or follow-up tool in children aged 0 to 15 years admitted to intensive care or emergency units, excluding neonatology and traumatic brain injury. Two independent reviewers selected 82 abstracts and full-text articles from the 2011 unique citations identified at the outset. RESULTS: TCD provides crucial additional information at bedside about cerebrovascular hemodynamics. Many clinical applications include the diagnosis and management of various medical and surgical neurologic conditions (central nervous system infections, arterial ischemic stroke, subarachnoid hemorrhage and vasospasm, brain death, seizures, metabolic disease, hydrocephalus) as well as monitoring the impact systemic conditions on brain perfusion (hemodynamic instability, circulatory assistance). CONCLUSION: To conclude, TCD has become an invaluable asset for non-invasive neuromonitoring in critically ill children excluding those suffering from trauma. However, the scope of TCD remains unclearly defined yet and reference values in critically ill children are still lacking.
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Acidente Vascular Cerebral , Hemorragia Subaracnóidea , Criança , Cuidados Críticos , Estado Terminal , Humanos , Ultrassonografia Doppler TranscranianaRESUMO
PURPOSE: This study aims to describe the epidemiology and management of chest trauma in our center, and to compare patterns of mechanical ventilation in patients with or without associated moderate-to-severe traumatic brain injury (TBI). METHODS: All children admitted to our level-1 trauma center from February 2012 to December 2018 following chest trauma were included in this retrospective study. RESULTS: A total of 75 patients with a median age of 11 [6-13] years, with thoracic injuries were included. Most patients also had extra-thoracic injuries (n = 71, 95%) and 59 (79%) had TBI. A total of 52 patients (69%) were admitted to intensive care and 31 (41%) were mechanically ventilated. In patients requiring mechanical ventilation, there was no difference in tidal volume or positive end-expiratory pressure in patients with moderate-to-severe TBI when compared with those with no-or-mild TBI. Only one patient developed Acute Respiratory Distress Syndrome. A total of 6 patients (8%) died and all had moderate-to-severe TBI. CONCLUSION: In this small retrospective series, most patients requiring mechanical ventilation following chest trauma had associated moderate-to-severe TBI. Mechanical ventilation to manage TBI does not seem to be associated with more acute respiratory distress syndrome occurrence.
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Lesões Encefálicas Traumáticas , Síndrome do Desconforto Respiratório , Traumatismos Torácicos , Adolescente , Lesões Encefálicas Traumáticas/complicações , Lesões Encefálicas Traumáticas/epidemiologia , Lesões Encefálicas Traumáticas/terapia , Criança , Humanos , Respiração com Pressão Positiva , Respiração Artificial , Estudos Retrospectivos , Traumatismos Torácicos/complicações , Traumatismos Torácicos/epidemiologia , Traumatismos Torácicos/terapiaRESUMO
Tracheobronchial endoscopy with general anaesthesia for suspected foreign body aspiration exposes toddlers to acute hypoxemia. Better quantification of intraoperative hypoxemia could help identify and manage the most severe patients. We explored the hypoxic burden approach to account for both duration and depth of desaturation episodes during the procedure and determined risk factors for high hypoxic burden. We retrospectively analysed tracheobronchial endoscopies performed from September 2015 to September 2018 in children ≤ 36 months for suspected foreign body aspiration, in two French university hospitals. The hypoxic burden (area under 90% of the SpO2/time curve) was calculated. The median of non-zero burdens was used to delineate a subgroup with high hypoxic burden. Risk factors for high hypoxic burden were identified using multivariable analysis. Of 96 procedures, 56 (58%) were associated with at least one SpO2 value < 90%. Of them, the median [interquartile] hypoxic burden was 25 [5-87] %.min. Bradycardia < 100 bpm occurred in 11 procedures (11%). Initial admission to general hospitals (OR 0.23, 95% CI 0.06-0.86) and airway anaesthesia with topical lidocaine (OR 0.15, 95% CI 0.03-0.62) were associated with a reduced risk of high hypoxic burden. High hypoxic burden was associated with an increased risk of postoperative invasive ventilation (OR 32, 95% CI 1.7-617) and of hospital stay > 24 h (OR 4.0, 95% CI 1.6-10). No postoperative neurological sequelae were found. The hypoxic burden approach, when applied in tracheobronchial endoscopy for suspected foreign body aspiration in toddlers, enabled the quantification of hypoxemia and the search for specific risk factors.
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Brônquios , Corpos Estranhos , Anestesia Geral/efeitos adversos , Broncoscopia , Humanos , Oxigênio , Estudos Retrospectivos , TraqueiaRESUMO
BACKGROUND: High-fidelity simulation improves participant learning through immersive participation in a stressful situation. Stress management training might help participants to improve performance. The hypothesis of this work was that Tactics to Optimize the Potential, a stress management program, could improve resident performance during simulation. METHODS: Residents participating in high-fidelity simulation were randomized into two parallel arms (Tactics to Optimize the Potential or control) and actively participated in one scenario. Only residents from the Tactics to Optimize the Potential group received specific training a few weeks before simulation and a 5-min reactivation just before beginning the scenario. The primary endpoint was the overall performance during simulation measured as a composite score (from 0 to 100) combining a specific clinical score with two nontechnical scores (the Ottawa Global Rating Scale and the Team Emergency Assessment Measure scores) rated for each resident by four blinded independent investigators. Secondary endpoints included stress level, as assessed by the Visual Analogue Scale during simulation. RESULTS: Of the 134 residents randomized, 128 were included in the analysis. The overall performance (mean ± SD) was higher in the Tactics to Optimize the Potential group (59 ± 10) as compared with controls ([54 ± 10], difference, 5 [95% CI, 1 to 9]; P = 0.010; effect size, 0.50 [95% CI, 0.16 to 0.91]). After specific preparation, the median Visual Analogue Scale was 17% lower in the Tactics to Optimize the Potential group (52 [42 to 64]) than in the control group (63 [50 to 73]; difference, -10 [95% CI, -16 to -3]; P = 0.005; effect size, 0.44 [95% CI, 0.26 to 0.59]. CONCLUSIONS: Residents coping with simulated critical situations who have been trained with Tactics to Optimize the Potential showed better overall performance and a decrease in stress level during high-fidelity simulation. The benefits of this stress management training may be explored in actual clinical settings, where a 5-min Tactics to Optimize the Potential reactivation is feasible prior to delivering a specific intervention.
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Anestesiologia/educação , Simulação de Paciente , Estresse Psicológico/psicologia , Adaptação Psicológica , Adulto , Competência Clínica , Avaliação Educacional , Serviços Médicos de Emergência , Feminino , Humanos , Internato e Residência , Masculino , Equipe de Assistência ao Paciente , Estudos Prospectivos , PsicometriaRESUMO
BACKGROUND: High-fidelity simulation is known to improve participant learning and behavioral performance. Simulation scenarios generate stress that affects memory retention and may impact future performance. The authors hypothesized that more participants would recall three or more critical key messages at three months when a relaxation break was performed before debriefing of critical event scenarios. METHODS: Each resident actively participated in one scenario and observed another. Residents were randomized in two parallel-arms. The intervention was a 5-min standardized relaxation break immediately before debriefing; controls had no break before debriefing. Five scenario-specific messages were read aloud by instructors during debriefings. Residents were asked by telephone three months later to recall the five messages from their two scenarios, and were scored for each scenario by blinded investigators. The primary endpoint was the number of residents participating actively who recalled three or more messages. Secondary endpoints included: number of residents observing who recalled three or more messages, anxiety level, and debriefing quality. RESULTS: In total, 149 residents were randomized and included. There were 52 of 73 (71%) residents participating actively who recalled three or more messages at three months in the intervention group versus 35 of 76 (46%) among controls (difference: 25% [95% CI, 10 to 40%], P = 0.004). No significant difference was found between groups for observers, anxiety or debriefing quality. CONCLUSIONS: There was an additional 25% of active participants who recalled the critical messages at three months when a relaxation break was performed before debriefing of scenarios. Benefits of relaxation to enhance learning should be considered for medical education.
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Anestesiologia/educação , Competência Clínica/estatística & dados numéricos , Treinamento com Simulação de Alta Fidelidade/métodos , Internato e Residência , Memória/fisiologia , Relaxamento/fisiologia , Adulto , Feminino , Humanos , Masculino , Estudos ProspectivosRESUMO
OBJECTIVES: To analyze a clip from the program ? Acupuncture, osteopathy, hypnosis: do complementary medicines have superpowers ? about acupuncture as an anesthetic for surgical procedures in China. To propose a rational explanation for the phenomena observed. To describe the processes leading a public service broadcasting channel to offer this type of content at prime time and the potential consequences in terms of public health. METHOD: Analysis using critical thinking attitudes and skills, along with a bibliographical search of Medline, Google Scholar and Cochrane Library databases. RESULTS: The information delivered in the television clip is ambiguous. It does not allow the viewer to form an informed opinion on the relevance of acupuncture as an anesthetic for surgical procedures. It is reasonable to assume that the clip shows surgery performed with undisclosed epidural anesthesia coupled with mild intravenous anesthesia, sometimes performed in other countries. What needs to be highlighted here is the overestimation of acupuncture added to the protocol. The media tend to exaggerate the risks and expected effects of the treatments they report on, which can lead patients to turn to unproven therapies. CONCLUSION: Broadcasting such a clip at prime time underlines the urgent need for the public and all health professionals to be trained in sorting and critically analyzing health information.
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Analgesia por Acupuntura , Procedimentos Cirúrgicos Cardíacos , França , Humanos , TelevisãoAssuntos
Traumatismos em Atletas , COVID-19 , Esportes na Neve , Traumatismos em Atletas/epidemiologia , Criança , Humanos , Pandemias , SARS-CoV-2RESUMO
PURPOSE: Tracheobronchial foreign body aspiration is a common pediatric emergency and a leading cause of accidental deaths in children. The diagnosis remains sometimes difficult even with physical examination, medical history, and basic X-rays. This challenge necessitates the performance of endoscopy under general anesthesia, regardless of the potential for serious complications. The benefit of strategies like expiratory chest X-rays to reduce unnecessary endoscopies remains uncertain. We evaluated the effectiveness of expiratory chest X-rays in detecting airway foreign bodies to potentially reduce the need for endoscopies. METHODS: We retrospectively studied children with suspected foreign body aspiration who had X-ray and endoscopy. RESULTS: A total of 70 children were included in the study. Out of these, 19 cases (27.1 %) showed pathological findings on standard chest X-rays. However, when expiratory chest X-rays were added, the number of pathological radiographies increased to 37 cases (52.9 %). Out of the 36 foreign bodies that were present, only 2 were not detected. Furthermore, 3 chest X-rays displayed pathological results, while the endoscopies indicated normal findings. Consequently, the overall sensitivity, specificity, positive predictive value, and negative predictive value stood at 94.4 %, 91.1 %, 91.9 %, and 93.9 % respectively. CONCLUSION: The remarkable sensitivity of expiratory chest radiography can eliminate the need for unnecessary endoscopy, but it should be limited to centers lacking access to MDCT. The performance of endoscopy should only be considered when persistent clinical symptoms are observed during auscultation.
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Brônquios , Corpos Estranhos , Radiografia Torácica , Humanos , Corpos Estranhos/diagnóstico por imagem , Estudos Retrospectivos , Masculino , Feminino , Pré-Escolar , Criança , Lactente , Radiografia Torácica/métodos , Brônquios/diagnóstico por imagem , Traqueia/diagnóstico por imagem , Broncoscopia/métodos , Aspiração Respiratória/diagnóstico por imagem , Sensibilidade e Especificidade , Valor Preditivo dos Testes , Expiração/fisiologia , AdolescenteRESUMO
PURPOSE: To report on our experience with a simplified, suction-bottle-drain technique of thoracic drain (Redon-like) combined with fully thoracoscopic vertebral body tethering (VBT) and a limited pleural approach, with particular focus on the rate of pulmonary complications. METHODS: A retrospective study was performed on all consecutive patients who underwent VBT for adolescent idiopathic scoliosis. For all subjects, a 10G Redon drain, an active drain system consisting of a perforated tube and a suction bottle, was placed intrathoracically and tunneled under the skin. All drains were removed on the first postoperative day. Perioperative and postoperative data such as type of access, length of surgery, amount of fluid collection in the drain, and length of hospital stay were collected. The type and number of pulmonary complications occurring in the first 3 months after surgery, along with their symptoms and management, were recorded. RESULTS: One Hundred eighty-two patients were included in the analysis. The mean length of surgery was 97 min (75-120). The average fluid collection in the drain was 30 ml (5-50), the mean length of hospital stay was 3 days (2-4). During the observation period, pulmonary complications occurred in five patients (2%). Two patients presented an aseptic right pleural effusion; for two patients, a residual pneumothorax was diagnosed on the X-rays in the recovery room and one patient developed a chylothorax. All patients recovered without sequelae. CONCLUSION: The simplified, Redon-like drain combined with a fully thoracoscopic VBT and limited pleural approach seems a safe and effective alternative to the chest drain. This technique allows to remove the drain on the first postoperative day, thus simplifying the management of the patients and improving their comfort.
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Pneumotórax , Corpo Vertebral , Adolescente , Humanos , Estudos Retrospectivos , Drenagem/efeitos adversos , Sucção/efeitos adversos , Sucção/métodos , Pneumotórax/etiologiaRESUMO
Non-anaesthetists commonly administer procedural sedation worldwide, posing the risk of respiratory events that can lead to severe complications. This study aimed to evaluate whether simulation-based learning could lead to enhancements in the clinical proficiency of non-anaesthesiology residents in managing sedation and related respiratory complications. Following the evaluation of baseline clinical performance through a pre-test simulation, 34 residents were randomly allocated to either participate in an innovative simulation-based learning module (intervention group) or view a brief self-learning video (control group). After a one-month period, their clinical performance was assessed again in a post-test simulation involving respiratory arrest during procedural sedation. Two independent assessors rated each resident's performance using video recordings and a scoring tool with scores ranging from 0 to 19/19. The two assessments were averaged for each performance, and the pre- to post-test change was calculated for each resident. While baseline clinical performance was similar, mean (SD) increase in clinical performance was significantly greater in the intervention group than in the control group (+2.4 (1.6) points versus +0.8 (1.3) points, respectively; p = 0.002). Our simulation-based learning sedation module resulted in the enhanced management of sedation-related complications compared to baseline and minimal self-learning. Simulation-based medical education may offer an effective approach for equipping non-anaesthesiology residents with essential skills to mitigate risks associated with sedation. (ClinicalTrials.gov identifier: NCT02722226).
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BACKGROUND: To date, the use of the plethysmographic variability index (PVI) has not been recommended to guide fluid management in the paediatric surgical population. This systematic review and meta-analysis aimed to summarise available evidence about the diagnostic accuracy of digital PVI to predict fluid responsiveness in mechanically ventilated children. METHODS: We searched the Pubmed, Embase and Web of Science databases, from inception to January 2022, to identify all relevant studies that investigated the ability of the PVI recorded at the finger to predict fluid responsiveness in mechanically ventilated children. Using a random-effects model, we calculated pooled values of diagnostic odds ratio, sensitivity, and specificity of PVI to predict the response to fluid challenge. RESULTS: Eight studies met the inclusion criteria with a total of 283 patients and 360 fluid challenges. All the studies were carried out in a surgical setting. The area under the summary receiver operating characteristic curve of PVI to predict fluid responsiveness was 0.82. The pooled sensitivity, specificity, and diagnostic odds ratio of PVI for the overall population were 72.4% [95% CI: 65.3-78.7], 65.9% [58.5-72.8], and 9.26 [5.31-16.16], respectively. CONCLUSION: Our results suggest that digital PVI is a reliable predictor for fluid responsiveness in mechanically ventilated children in the perioperative setting. The diagnostic performance of digital PVI reported in our work for discrimination between responders and non-responders to the fluid challenge was however not as high as previously reported in the adult population.
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Hidratação , Respiração Artificial , Adulto , Humanos , Criança , Hidratação/métodos , Respiração Artificial/métodos , Curva ROC , Monitorização Intraoperatória/métodos , Testes Diagnósticos de Rotina , Hemodinâmica/fisiologiaRESUMO
STUDY OBJECTIVE: Children with acute extremity fractures are commonly considered to be at risk of pulmonary aspiration of gastric contents during the induction of anesthesia. This study aimed to evaluate the proportion of such children with high-risk gastric contents using preoperative gastric ultrasound. DESIGN: Prospective observational cohort study. SETTING: Specialist pediatric center over a 30-month period. PATIENTS: Children undergoing surgery within 24 h of an acute extremity fracture. INTERVENTIONS: None. MEASUREMENTS: According to preoperative qualitative and quantitative ultrasound analysis of the antrum in the supine and right lateral decubitus positions, gastric contents were classified as high-risk (clear liquid with calculated gastric fluid volume > 0.8 mL.kg-1, thick liquid, or solid) or low-risk. Factors associated with high-risk gastric contents were identified by multivariable analysis. MAIN RESULTS: Forty-one children (37%; 95% CI: 28-47) of the 110 studied (mean(SD) age: 10(3) years) presented with high-risk gastric contents, including 26 (24%; 95% CI: 16-33) with solids/thick liquid contents. Scanning in the supine position alone allowed a diagnosis of high-risk gastric contents in 23 children out of the 63 for whom right lateral decubitus positioning was unfeasible. Gastric contents remained undetermined in 41 children, including one with a non-contributory gastric US (antrum non-visualized). Proximal limb fractures (OR: 2.5; 95% CI: 1.0-6.2), preoperative administration of opioids (OR: 3.9; 95% CI: 1.1-13), and the absence of bowel sounds (OR: 8.0; 95% CI: 1.4-44) were associated with high-risk gastric contents. Performing surgery the day following the trauma was a protective factor (OR: 0.1; 95% CI: 0.0-0.6). No cases of pulmonary aspiration occurred. CONCLUSIONS: At least one-third of children with an acute isolated extremity fracture had preoperative gastric contents identified as high risk for pulmonary aspiration. Although preoperative history can guide anesthetic strategy in this population, ultrasound allowed clear stratification of the risk of aspiration in most cases.
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Anestesia Geral , Antro Pilórico , Anestesia Geral/efeitos adversos , Criança , Estudos de Coortes , Extremidades , Humanos , Estudos Prospectivos , Antro Pilórico/diagnóstico por imagem , UltrassonografiaRESUMO
BACKGROUND: Communication and teamwork are critical non-technical skills in the operating theatre. However, prevention of events associated with communication failures by large simulation-based programs remains to be evaluated. The objective was to assess the impact of an interprofessional simulation-based training course on communication, teamwork, checklist adherence, and safety culture. METHODS: We aimed to assess the impact of an interprofessional simulation-based training course on communication, teamwork, checklist adherence, and safety culture. We conducted a before-and-after interventional study based on a mixed-methods approach combining qualitative and quantitative evaluation criteria. The study was performed in a University Hospital with 39 operating theatres operated by 300 providers before (period 1) and after (period 2) an interprofessional simulation-based training course. Surgical procedures were observed, and the primary outcome measure was the rate of procedures with at least one communication failure associated with adverse event. Additional outcomes measured included the rate of other communication failures, checklist adherence, while teamwork and safety culture were assessed by questionnaires. RESULTS: In total, 46 970 communication episodes were analysed during 131 (period 1) and 122 (period 2) surgical procedures. One hundred sixty-four professionals attended 40 simulation-based sessions. The rate of procedures with at least one communication failure associated with adverse events was not significantly different between the 2 periods (38% in period 1 and 43% in period 2; P = 0.47). Nevertheless, the rate of communication failures reduced between period 1 and 2 (8117/28 303 (29%) vs. 3868/18 667 (21%), respectively; P < 0.01). Teamwork scores and checklist adherence increased significantly after the intervention (8.1 (7.2-8.7) in period 1 vs. 8.6 (8.0-9.2) in period 2; P < 0.01 and 17% (0-35 %) in period 1 vs. 44% (26-57 %) in period 2; P < 0.01). Safety culture ratings did not change significantly. CONCLUSION: This study shows that although the rate of procedures with at least one communication failure associated with adverse event (primary endpoint) was not significantly different, a large interprofessional simulation-based training course has a positive effect on communication failures, teamwork, and checklist adherence.
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Relações Interprofissionais , Treinamento por Simulação , Comunicação , Humanos , Equipe de Assistência ao Paciente , Gestão da SegurançaRESUMO
ABSTRACT: In pediatric patients, pain remains the most common complaint after surgery. This French multicenter epidemiological study (AlgoDARPEF) aimed to evaluate the use of a smartphone application (App) to assess the duration and severity of pain experienced by children undergoing outpatient surgery. Children younger than 18 years scheduled for an elective outpatient procedure in one of the participating centers were eligible. Parents were invited to provide daily information for 10 days regarding their child's pain and comfort through a smartphone App using the Parents' Postoperative Pain Measure-Short-Form (PPPM-SF). Children older than 6 years could also provide self-assessments of pain using a numerical rating scale (NRS)-11. Data regarding pain medication, preoperative anxiety, postoperative nausea and vomiting, and parent satisfaction were also analyzed. Repeated-measures analyses of variances (ANOVAs) were used to compare the self-assessments and hetero-assessments of pain. Eleven centers participated in the study, and 1573 patients were recruited. Forty-nine percentage of parents (n = 772) actually used the App at least once. In all surgeries, the average pain rating on the PPPM-SF scale did not exceed 3/10 throughout the follow-up period, as well as for 4 main surgical specialties. Age, visceral surgery, and preoperative anxiety ≥ 4/10 were identified as independent risk factors for experiencing at least 1 episode of pain ≥4/10 during the first 48 postoperative hours. Although these findings indicated that postoperative pain management seems to be satisfactory in the families who used the App, some improvements in anxiety management are suggested. This study shows that inviting parents to use a smartphone App to assess and report the quality of postoperative management in pediatric patients provides useful information. A continuous report regarding pain and adverse events over a 10-day postoperative period by a self-reporting or parent's contribution is possible. Future studies should investigate the ability of live data collection using an App to ensure fast, efficient interactions between patients and physicians.
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Procedimentos Cirúrgicos Ambulatórios , Smartphone , Procedimentos Cirúrgicos Ambulatórios/efeitos adversos , Criança , Seguimentos , Humanos , Dor Pós-Operatória/tratamento farmacológico , Estudos ProspectivosRESUMO
BACKGROUND: Little is known about the effect of under triage on early mortality in trauma in a pediatric population. Our objective is to describe the effect of under triage on 24-h mortality after major pediatric trauma in a regional trauma system. METHODS: This cohort study was conducted from January 2009 to December 2017. Data were obtained from the registry of the Northern French Alps Trauma System. The network guidelines triage pediatric trauma patients according to an algorithm shared with adult patients. Under triage was defined by the number of pediatric trauma patients that required specialized trauma care transported to a non-level I pediatric trauma center on the total number of injured patients with critical resource use. The effect of under triage on 24-h mortality was assessed with inverse probability treatment weighting (IPTW) and a propensity score (Ps) matching analysis. RESULTS: A total of 1143 pediatric patients were included (mean [SD], age 10 [5] years), mainly after a blunt trauma (1130 [99%]). Of the children, 402 (35%) had an ISS higher than 15 and 547 (48%) required specialized trauma care. Nineteen (1.7%) patients died within 24 h. Under triage rate was 33% based on the need of specialized trauma care. Under triage of children requiring specialized trauma care increased the risk of death in IPTW (risk difference 6.0 [95% CI 1.3-10.7]) and Ps matching analyses (risk difference 3.1 [95% CI 0.8-5.4]). CONCLUSIONS: In a regional inclusive trauma system, under triage increased the risk of early death after pediatric major trauma.