Is Ultrasound-Guided Single-Shot Quadratus Lumborum Block a Viable Alternative to a Caudal Block in Pediatric Urological Surgery?

OBJECTIVE: To review our experience with quadratus lumborum block (QLB) in pediatric urology. MATERIALS AND METHODS: This mixed prospective-retrospective study included 41 patients who received QLB following induction of general anesthesia. Data collected included: the duration of block induction, surgery, hospitalization, postoperative pain score, and the use of rescue analgesia. The results were compared with a matched cohort of patients who received caudal block (CB) during similar surgeries from our retrospectively acquired data registry. RESULTS: There was no difference between the type and length of surgery, weight, sex, and age of the patients between the two groups. The duration of block induction was significantly shorter in the CB group compared with the QLB group (35.6 ± 14.6 vs. 239 ± 33.4 seconds [p < 0.0001]). There was no difference between the groups in pain scores at 1, 4, and 24 hours postoperatively, in the time to first rescue analgesia, or in the postoperative opioid requirements. However, the QLB group required more rescue analgesia compared with CB group (p = 0.016). Finally, no differences were found in the use of rescue analgesics at home, pain record behavior, and overall satisfaction. CONCLUSION: Our data show that QLB might serve as a viable alternative to CB in pediatric urological surgery.

Diabetes blockade of sevoflurane postconditioning is not restored by insulin in the rat heart: phosphorylated signal transducer and activator of transcription 3- and phosphatidylinositol 3-kinase-mediated inhibition.

BACKGROUND: The possibility of restoring sevoflurane postconditioning (sevo-postC) cardioprotection in diabetic animals is uncertain. We hypothesized that attenuation of myocardial injury by sevo-postC might be hindered by inhibition of signal transducer and activator of transcription (STAT) 3-regulated activity of phosphatidylinositol 3-kinase (PI3K) in diabetic animals. To determine whether postC cardioprotection can be restored by normoglycemia, we treated rats with insulin. METHODS: Diabetic or nondiabetic rats were randomly subjected to 30-min ischemia/reperfusion, with ischemic postC or sevo-postC, with and without mitochondrial adenosine triphosphate-dependent potassium channel blocker 5-hydroxy decanoate sodium and PI3K antagonist wortmannin. The infarct area, phosphorylated STAT3, and apoptosis were examined. Studies were repeated after insulin treatment. RESULTS: Ischemic postC and sevo-postC significantly reduced infarct size by 50% in the nondiabetic rats (P < 0.002), a phenomenon completely reversed by 5-hydroxy decanoate sodium and wortmannin. Diabetes mellitus blocked the protective effect of postC, and insulin treatment to achieve normoglycemia did not restore cardioprotection. Phosphorylated STAT3 nuclear retention was significantly increased after ischemia-reperfusion and was further enhanced in response to ischemic postC (P < 0.05) but was significantly reduced in diabetic rats (by 43%; P < 0.01). CONCLUSIONS: The effective reduction in infarct size and apoptosis in the nondiabetic rat heart by postC was completely abrogated in diabetic rats. This inhibition is not relieved by insulin-induced normoglycemia. The PI3K pathway and mitochondrial adenosine triphosphate-dependent potassium channel activation are involved in the mechanism of postC. In diabetic rats, STAT3 activation was strongly reduced, as was postC cardioprotection, suggesting that the inability of insulin to restore postC may be attributed to diabetes-induced STAT3-mediated inhibition of PI3K signaling.

Use of Caudal Analgesia Supplemented with Low Dose of Morphine in Children Who Undergo Renal Surgery.

INTRODUCTION: To test the efficacy and safety of caudal anesthesia (CA) supplemented by low dose morphine in children who undergo renal surgery. MATERIALS AND METHODS: Forty patients aged 2 months-14 years were enrolled and randomly divided into two groups of 20 patients each: Group A (bupivacaine 0.2% with fentanyl); Group B (bupivacaine with morphine). The duration of surgery and hospitalization time were recorded. Postoperative pain score was measured by Face Legs Activity Cry Consolability scale and Wong-Baker Faces scale for those who are older. Overall use of rescue analgesics was calculated. RESULTS: There was no statistical difference in the length of surgery, incidence of pruritus, postoperative nausea, vomiting and urinary retention between the two groups. However the postoperative opioid requirements were significantly higher in Group A 1.03 ± 0.9 mg/kg compared to Group B, in which only one patient required opioid therapy (p < 0.0001). Moreover the need for non-opioid rescue analgesic was higher in Group A, (36 ± 5.7 mg/kg of paracetamol) compared to morphine CA group there only 26 ± 3.6 mg/kg required during first 24 h of the postoperative period (p = 0.0312). The Face Legs Activity Cry Consolability pain score (1, 4, and 24 h after surgery) and Wong-Baker Faces scale were significantly higher in Group A. The hospitalization period was shorter in the CA morphine group, but the difference did not reach statistical significance. None developed hemodynamic instability or respiratory depression. CONCLUSIONS: Our data show that CA supplemented with low dose morphine provides a longer duration of analgesia without significant side-effects in children undergoing renal surgery.

Endoscopic correction of VUR using vantris as a new non-biodegradable tissue augmenting substance: three years of prospective follow-up.

OBJECTIVE: To evaluate the efficacy of Vantris in children with vesicoureteral reflux (VUR) after 3 years of prospective follow-up. MATERIAL AND METHODS: Over the last 3 years, 109 children (72 girls and 37 boys) with a mean age of 6.2 ± 3.4 years (mean ± SD) underwent endoscopic correction of reflux using Vantris. VUR was unilateral in 53 and bilateral in 56 patients comprising 165 renal refluxing units (RRUs). Of these, primary VUR was present in 139 RRUs (84.2%) and 26 (15.8%) were complex cases. Ultrasound scan was performed 1 month, 1 year, and 3 years after injection, and voiding cystourethrogram (VCUG) was performed 3 months, 1 year, and 3 years after endoscopic correction. RESULTS: The reflux was corrected in 153 RRUs (92.7%) after a single injection and in 7 RRUs (4.2%) after a second injection. In 5 RRUs (3.1%), VUR downgraded to grade I (3 RRUs) and grade II (2 RRUs) and they were taken off antibiotic prophylaxis. Two patients (1.8%) had afebrile urinary tract infections (UTIs) and 2 patients (1.8%) developed febrile UTI. VCUG was performed in 32 of 71 children (39.1%) who completed 1 year and in 6 of 15 (40%) who completed 3 years of follow-up. None showed VUR recurrence. Ultrasound scan demonstrated normal appearance of kidneys in all but 2 patients (1.8%). One patient required stent insertion because of deterioration of hydronephrosis that resulted in complete resolution of obstruction and another patient required ureteral reimplantation. CONCLUSION: Our data show that Vantris injection provides a high level of reflux resolution with good clinical outcome during prospective follow-up.

Downgrading of high-grade vesicoureteral reflux is a reliable option in the treatment of children with grade IV‒V reflux accompanied by breakthrough infections.

PURPOSE: To evaluate incidence of urinary tract infection (UTI) and natural history of downgraded vesicoureteral reflux (VUR) in children with high-grade VUR following endoscopic correction. MATERIALS AND METHODS: We retrospectively studied 54 children (13 males and 41 females) with a mean age of 1.8 years who underwent endoscopic correction of Grade IV‒V VUR due to breakthrough infections while on antibiotic prophylaxis. Reflux was Grade IV in 40 (74%) and V in 14 (26%) patients comprising 95 renal refluxing units (RRU). Reflux was corrected in 72 (76%) RRU. 18 (34%) patients/23 (24%) RRU demonstrated downgrading of VUR. 21 of the 23 RRU showed Grade II and 2 Grade III VUR, and were taken off antibiotic prophylaxis and allocated to observation. Patients were followed for 2-22 years (median 14 years). RESULTS: Technetium 99m dimercaptosuccinic acid renal scan demonstrated preoperative renal scarring in 21 (78%) of the 23 RRU with downgraded VUR. None of the children developed febrile UTI after surgery. 1 RRU showed renal function deterioration. 8 (44%) of the 18 patients underwent follow-up voiding cystourethrogram, and in 7 (88%) there was either spontaneous resolution of VUR or downgrade to Grade I VUR. CONCLUSIONS: Downgrading of VUR is a reasonable option in patients with high-grade VUR suffering from breakthrough infections while on antibiotic prophylaxis. It leads to the cessation of febrile UTIs, further spontaneous resolution of VUR and may potentially avoid renal damage.