Multi-stage open surgical and endovascular treatment of progressive aortic degeneration in a patient with Marfan syndrome.

Aortic interventions in patients with underlying connective tissues disorders present a unique challenge. The inevitable degeneration of the native aorta can lead to the need for multiple staged interventions with significant risk of complications associated with reoperative aortic procedures. We present a challenging case of progressive aortic degeneration in a patient with Marfan syndrome treated with multi-staged open surgical and endovascular procedures.

Pectus carinatum.

PURPOSE OF REVIEW: Pectus carinatum has been termed the undertreated chest wall deformity. Recent advances in patient evaluation and management, including the development of nonoperative bracing protocols, have improved the care of children with this condition. RECENT FINDINGS: Recent evidence confirms that children with pectus carinatum have a disturbed body image and a reduced quality of life. Treatment has been shown to improve the psychosocial outcome of these patients. SUMMARY: Patients with pectus carinatum are at risk for a disturbed body image and reduced quality of life. Until recently, treatment required surgical reconstruction. A growing body of literature, however, now supports the use of orthotic bracing as a nonoperative alternative in select patients. This article reviews the current literature and describes the evaluation and management of children with pectus carinatum deformity.

Management and outcomes of traumatic hemothorax in children.

BACKGROUND: Adult guidelines for the management of traumatic hemothorax are well established; however, there have been no similar studies conducted in the pediatric population. The purpose of our study was to assess the management and outcomes of children with traumatic hemothorax. MATERIALS AND METHODS: Following Institutional Review Board approval, we conducted a retrospective cross-sectional study of all trauma patients diagnosed with a hemothorax at a Level-1 pediatric trauma center from 2007 to 2012. RESULTS: Forty-six children with hemothorax were identified, 23 from blunt mechanism and 23 from penetrating mechanism. The majority of children injured by penetrating mechanisms were treated with tube thoracostomy while the majority of blunt injury patients were observed (91.3% vs. 30.4% tube thoracostomy, penetrating vs. blunt, P = 0.00002). Among patients suffering from blunt mechanism, children who were managed with chest tubes had a greater volume of hemothorax than those who were observed. All children who were observed underwent serial chest radiographs demonstrating no progression and required no delayed procedures. Children with a hemothorax identified only by computed tomography, after negative plain radiograph, did not require intervention. No child developed a delayed empyema or fibrothorax. CONCLUSION: The data suggest that a small-volume hemothorax resulting from blunt mechanism may be safely observed without mandatory tube thoracostomy and with overall low complication rates.

Enteral nutrition in neonatal and pediatric extracorporeal life support: a survey of current practice.

PURPOSE: The purpose of this study was to characterize enteral (EN) nutrition practices in neonatal and pediatric patients receiving extracorporeal life support (ECLS). METHODS: A Web-based survey was administered to program directors and coordinators of Extracorporeal Life Support Organization centers providing neonatal and pediatric ECLS. The survey assessed patient and clinical factors relating to the administration of EN. RESULTS: A total of 122 responses (122/521, 23.4%) from 96 institutions (96/187; 51.3%) were received. One hundred fifteen provided neonatal or pediatric ECLS, and 84.2% reported utilizing EN during ECLS. 55% and 71% of respondents provide EN 'often' or 'always' for venoarterial and venovenous ECLS, respectively. EN was reported as given 'often' or 'always' by 24% with increased vasopressor support, 53% with "stable" vasopressor support, and 60% with weaning of vasopressor support. Favorable diagnosis for providing EN includes respiratory distress syndrome, pneumonia, asthma, trauma/post-operative, pulmonary hemorrhage, and infectious cardiomyopathy. Vasopressor requirement and underlying diagnosis were the primary or secondary determinant of whether to provide EN 81% and 72% of the time. 38% reported an established protocol for providing EN. CONCLUSION: EN support is common but not uniform among neonatal and pediatric patients receiving ECLS. ECLS mode, vasopressor status, and underlying diagnosis play an important role in the decision to provide EN.

Management of Traumatic Wounds and a Novel Approach to Delivering Wound Care in Children.

Significance: The costs and morbidity of pediatric traumatic wounds are not well known. The literature lacks a comprehensive review of the volume, management, and outcomes of children sustaining soft tissue injury. We briefly review the existing literature for traumatic wounds such as open fractures and burns. Such injuries require dedicated wound care and we propose a novel approach for more efficient and more effective delivery of dedicated pediatric wound care. Recent Advances: New pediatric literature is emerging regarding the long-term effects of wound care pain in traumatic injuries-especially burns. A variety of wound dressings and alternative management techniques exist and are geared toward reducing wound care pain. Our institution utilizes a unique model to provide adequate sedation and pain control through a dedicated pediatric wound care unit. We believe that this model reduces the cost of wound care by decreasing emergency department and operating room visits as well as hospital length of stay. Critical Issues: First, medical costs related to pediatric traumatic wound care are not insignificant. The need for adequate pain control and sedation in children with complex wounds is traditionally managed with operating room intervention. Afterward, added costs can be from a hospital stay for ongoing acute wound management. Second, morbidities of complex traumatic wounds are shown to be related to the acute wound care received. Future Directions: Further guidelines are needed to determine the most effective and efficient care of complex traumatic soft tissue injuries in the pediatric population.

The use of a lightly preserved cadaver and full thickness pig skin to teach technical skills on the surgery clerkship--a response to the economic pressures facing academic medicine today.

BACKGROUND: In response to declining instruction in technical skills, the authors instituted a novel method to teach basic procedural skills to medical students beginning the surgery clerkship. METHODS: Sixty-three medical students participated in a skills training laboratory. The first part of the laboratory taught basic suturing skills, and the second involved a cadaver with pig skin grafted to different anatomic locations. Clinical scenarios were simulated, and students performed essential procedural skills. RESULTS: Students learned most of their suturing skills in the laboratory skills sessions, compared with the emergency room or the operating room (P = .01). Students reported that the laboratory allowed them greater opportunity to participate in the emergency room and operating room. Students also felt that the suture laboratory contributed greatly to their skills in wound closure. Finally, 90% of students had never received instruction on suturing, and only 12% had performed any procedural skills before beginning the surgery rotation. CONCLUSIONS: The laboratory described is an effective way of insuring that necessary technical skills are imparted during the surgery rotation.