Interventions in the operating room for children near end of life: A multidisciplinary approach.

INTRODUCTION: Pediatric surgeons are often involved in the management of severely or terminally ill patients. However, articles addressing their specific roles in the context of palliative care are almost inexistent. We sought to characterize the involvement of pediatric surgeons caring for children near end of life. METHODS: Chart review of children who had a procedure under general anesthesia within 6months of their death over a five-year period at a tertiary children's hospital (excluding traumas and neonatology cases). In addition to demographic and clinical data, we recorded the aim of the procedures performed, the involvement of the palliative care service, and presence of DNAR orders. RESULTS: The analysis included 83 patients (mean age: 8years). Forty-four children had more than one procedure (range 2-10). Pediatric palliative care service was involved in 66 cases (80%). A majority of patients had cancer (50%), and the most frequent cause of death was oncologic progression (46%). Ten patients died of a complication following their intervention. The aim of the procedure was palliative in 48 cases (29 for symptoms control and 19 to facilitate care), diagnostic in 16, and curative in 19. Forty-five procedures were performed urgently and 14 despite DNAR orders. CONCLUSION: Surgeon involvement with children near end of life is not infrequent. The procedures performed are varied and can be categorized according to their aim. Lack of formal palliative care training by surgeons highlights the need for increased collaboration with palliative care services to provide children optimal care when they need it most. LEVEL OF EVIDENCE: IV.

Clinical characteristics and outcomes of patients with right congenital diaphragmatic hernia: A population-based study.

PURPOSE: The purpose of this study was to compare RCDH to LCDH from the perspective of prenatal diagnosis, illness severity, treatment, and outcome. METHODS: A retrospective study of all cases of CDH registered in the Canadian Pediatric Surgery Network (CAPSNet) database from 2005 to 2013 was conducted. Side of defect comparisons were made by prenatal diagnostic features, birth demographic data, intensity of medical treatment, timing and type of surgery, and outcomes. Outcomes prediction with logistic regression modeling using side of defect as an exploratory covariate was performed. RESULTS: The study cohort included 498 patients, of which 84 (17%) cases had RCDH. Prenatal diagnosis was more commonly made for LCDH. No difference existed in perinatal risk factors (GA, illness severity (SNAP-II) score, associated anomalies), preoperative treatment intensity (use of vasodilators, inotropes), timing of surgery, ventilation days, need for ECMO, LOS, and overall survival. Significant differences between RCDH and LCDH were detected for patch repair rate (48.2% vs. 30.6%; p=0.036) and recurrence (4.1% vs. 0.6%; p=0.038). Stepwise regression modeling identified side of hernia as independently predictive of need for patch. CONCLUSIONS: Overall, little difference exists between RCDH and LCDH in terms of prognostic factors and outcomes.