Clinical experience and complications with limited pleural dissection combined with a novel, simplified technique for thoracic Redon-like drain in vertebral body tethering.

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.

A follow-up of pain reported by children undergoing outpatient surgery using a smartphone application: AlgoDARPEF multicenter descriptive prospective study.

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.

Assessing gastric contents in children before general anesthesia for acute extremity fracture: An ultrasound observational cohort study.

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.

Traumatic brain injury in children with thoracic injury: clinical significance and impact on ventilatory management.

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.

Effect of under triage on early mortality after major pediatric trauma: a registry-based propensity score matching analysis.

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.

Oxygen desaturation and time burden during tracheobronchial endoscopy for suspected foreign body in toddlers.

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.

Simulation of difficult airway management for residents: prospective comparative study / Simulação de manejo de via aérea difícil para residentes: estudo comparativo prospectivo

Abstract Background and objectives Procedural simulation training for difficult airway management offers acquisition opportunities. The hypothesis was that 3 hours of procedural simulation training for difficult airway management improves: acquisition, behavior, and patient outcomes as reported 6 months later. Methods This prospective comparative study took place in two medical universities. Second-year residents of anesthesiology and intensive care from one region participated in 3 h procedural simulation (intervention group). No intervention was scheduled for their peers from the other region (control). Prior to simulation and 6 months later, residents filled-out the same self-assessment form collecting experience with different devices. The control group filled-out the same forms simultaneously. The primary endpoint was the frequency of use of each difficult airway management device within groups at 6 months. Secondary endpoints included modifications of knowledge, skills, and patient outcomes with each device at 6 months. Intervention cost assessment was provided. Results 44 residents were included in the intervention group and 16 in the control group. No significant difference was observed for the primary endpoint. In the intervention group, improvement of knowledge and skills was observed at 6 months for each device, and improvement of patient outcomes was observed with the use of malleable intubation stylet and Eschmann introducer. No such improvement was observed in the control group. Estimated intervention cost was 406€ per resident. Conclusions A 3 h procedural simulation training for difficult airway management did not improve the frequency of use of devices at 6 months by residents. However, other positive effects suggest exploring the best ratio of time/acquisition efficiency with difficult airway management simulation. ClinicalTrials.gov Identifier NCT02470195.

Resumo Justificativa e objetivos O treinamento em simulação para o manejo de via aérea difícil oferece oportunidades de aprendizagem. A hipótese foi que um treinamento em simulação de procedimentos de três horas, para o manejo de via aérea difícil, melhoraria o aprendizado, o comportamento e os resultados dos pacientes, conforme relatado seis meses após o treinamento. Métodos Este estudo comparativo prospectivo foi realizado em duas universidades médicas. Residentes do segundo ano de anestesiologia e terapia intensiva de uma região participaram de um curso de três horas em simulação de procedimentos (grupo intervenção). Nenhuma intervenção foi programada para seus pares da outra região (grupo controle). Antes da simulação e seis meses após, os residentes preencheram a mesma ficha de autoavaliação sobre sua experiência com diferentes dispositivos. O grupo controle preencheu os mesmos formulários simultaneamente. O desfecho primário foi a frequência de uso de cada dispositivo para o manejo de via aérea difícil dentro dos grupos aos seis meses. Os pontos de corte secundários incluíram modificações em relação ao conhecimento, às habilidades e aos resultados dos pacientes com cada dispositivo aos seis meses. A avaliação do custo da intervenção foi registrada. Resultados Foram incluídos no grupo intervenção 44 residentes e 16 no grupo controle. Nenhuma diferença significativa foi observada para o ponto de corte primário. No grupo intervenção, a melhoria do conhecimento e das habilidades foi observada aos seis meses para cada dispositivo e a melhoria dos desfechos dos pacientes foi analisada com o uso de estilete maleável e do introdutor de Eschmann para intubação. Nenhuma melhoria foi observada no grupo controle. O custo da intervenção estimado foi de 406€ por residente. Conclusões Um treinamento simulado de três horas para o manejo de via aérea difícil não melhorou a frequência do uso de dispositivos pelos residentes aos seis meses. No entanto, outros efeitos positivos sugerem a exploração da melhor relação tempo/eficiência de aquisição de conhecimento com a simulação do manejo de via aérea difícil. ClinicalTrials.gov Identifier NCT02470195.

[Open heart surgery under acupuncture ? Decrypting a program broadcast on France 2] / Une opération à cœur ouvert sous acupuncture ? Décryptage d'une émission diffusée sur France 2

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.