Fast-track concepts in routine pediatric surgery: a prospective study in 436 infants and children.

BACKGROUND AND AIMS: The aim of this study was to investigate fast-track concepts in routine pediatric surgery in a university clinic over 1 year. PATIENTS/METHODS: Fast-track concepts were established for procedures requiring hospital admission in patients up to 15 years of age. Patients were studied prospectively from June 2006 to June 2007. RESULTS: Out of a total of 436 potentially suitable patients, 155 (36%) were finally treated following the protocols. The mean intensity of pain in children younger than 4 years (CHIPPS, 0-10) was 1.3 +/- 1.5 the evening of the operation day and decreased to <1 at all other time points. The initial postoperative mean pain intensity in older children (Smiley/VAS, 1-10) was 3.7 +/- 2.2 and decreased constantly thereafter. The mean hospital stay of fast-track patients was significantly shorter compared with German diagnosis-related group data (4.6 +/- 2.9 versus 9.7 +/- 3.8, p < 0.01). There were four (3%) readmissions for minor complications. At follow-up after 2 weeks, 95% of patients and parents judged fast-track care as excellent. CONCLUSION: Fast-track concepts are feasible in one third of pediatric patients undergoing routine in-hospital surgery. Fast-track pediatric surgery achieves accelerated convalescence, minimal hospital stay, and high patient and parent satisfaction.

Impact of Capnoperitoneum on Renal Perfusion and Urine Production in Infant and Adolescent Pigs: Crystalloid versus Colloid Fluid Resuscitation.

BACKGROUND: Infants are likely to develop anuria during laparoscopy which is uncommon in older patients. The reason for this susceptibility remains unknown. We compared the impact of CO2 pneumoperitoneum on renal perfusion and urine production in piglets compared with adolescent pigs. We furthermore investigated the effects of different resuscitation strategies. MATERIALS AND METHODS: Male piglets (n = 21) were divided into four groups: (a) infant controls (n = 5), (b) infants with crystalloid restitution (n = 6), (c) infants with colloidal restitution (n = 5), and (d) adolescents with crystalloid restitution (n = 5). Animals were ventilated, the central vessels and ureters were cannulated, and the animals were subjected to a 3-hour, 10 mm Hg CO2 pneumoperitoneum followed by 2-hour resuscitation. Renal perfusion was assessed by fluorescent microspheres and the rate of urine flow was measured. RESULTS: Urine production significantly decreased after insufflation only in the infant crystalloid and adolescent group, but not in controls or infants treated with colloids. In the infant crystalloid group, urine production remained at levels below 20% of baseline throughout the experiment. In this group, the renal perfusion dropped significantly after the beginning of the capnoperitoneum and remained significantly reduced throughout the experiment. CONCLUSION: Our data indicates that capnoperitoneum impairs renal perfusion and urine production in infants. In moderate-pressure capnoperitoneum, this effect cannot be compensated by application of crystalloids but with colloids.

Whole blood coagulation measured by modified thrombelastography (ROTEM) is impaired in infants with congenital heart diseases.

Patients with congenital heart disease (CHD) often do have a variety of coagulation abnormalities that results in bleeding diathesis. Our study aimed to determine the impact of cyanosis and CHD on modified thrombelastography parameters, compared with children without CHD. Preoperative blood samples were taken for TEM analyses from a total of 51 infants scheduled for surgery. The following groups were examined: normal patients without CHD, acyanotic patients with acyanotic CHD, and cyanotic patients with CHD and with preoperative hemoglobin values higher than 15 g dl(-1). Mean values of all patient groups as well as all individual values of normal patients were within their normal ranges. Within these limits, however, clots were significantly inferior in cyanotic patients (worse mean values of eight out of 10 measured TEM parameters representing the intrinsic, extrinsic, and plasmatic pathways of coagulation) and in acyanotic patients (two out of 10 TEM parameters). Individually, pathological TEM parameters were found in seven (41%) cyanotic patients (P=0.003; vs. normal patients) and in three (17%) acyanotic patients (P=0.01). More than one abnormal TEM coagulation parameter was found in four patients, all of them cyanotic patients. Hyperfibrinolysis was detected in one patient, a cyanotic patient. The present investigation confirms previous findings that in patients with CHD the heart defect itself compromises coagulation monitored with TEM, but in addition, we demonstrate that cyanosis and/or polycythemia exert the essential negative impact on hemostasis. Preoperative hyperfibrinolysis detected with TEM seems to play no important role.

Physiological responses to endoscopic surgery in children.

The knowledge on the physiological impact of endoscopic surgery in infants and children is limited. Cardiovascular effects of pneumoperitoneum are mainly the result of an increase in intraabdominal pressure, absorption of carbon dioxide, and a stimulation of the neurohumoral vasoactive system. In infants, pneumoperitoneum alters the heart rate, mean arterial pressure, left ventricular endsystolic and end-diastolic volume, and meridional wall stress. Urine production is significantly reduced, and cerebral oxygenation and blood flow are altered. However, postoperative immune function is preserved or restored faster, and specific physiological responses to endoscopic surgery are well tolerated by otherwise healthy infants and children. The effects in children with specific conditions, such as sepsis, cancer, or organ dysfunction, remain to be investigated.

Single- and double-lung ventilation in infants and children undergoing thoracoscopic lung resection.

INTRODUCTION: Video-assisted thoracoscopic surgery (VATS) has gained wide acceptance for the pediatric population. Single-lung ventilation (SLV) has been suggested for thoracoscopic lung resection to provide better surgical exposure, but its role and sequelae compared with double-lung ventilation (DLV) have not been determined. The aim of this study was to investigate the feasibility and effects of SLV and DLV in infants and children undergoing thoracoscopic lung resection. PATIENTS AND METHODS: Written informed consent from all guardians for anonymized data analysis and approval by the Institutional Review Board were obtained. A retrospective study on a consecutive series of infants and children who underwent thoracoscopic lung resection during an 11 years period was performed. SLV was selected mainly in lesions localized in the upper, middle, and/or central lung for reasons of surgical exposure. Patients with lower lobe lesions and those who underwent atypical resections were preferably operated under DLV. End points were conversion rate, duration of postoperative ventilation, and perioperative complications, such as, atelectasis or pneumonia. RESULTS: Of 114 pediatric patients (58 female and 56 male; ratio 1.04:1) with a mean age of 7.1 years (3 days to 18.1 years), 62 patients underwent DLV and 52 patients underwent SLV for thoracoscopic lung resection. There were no significant differences between the two groups for conversion rate (DLV 8.1 vs. SLV 6.1%; p = 0.53), prompt extubation (DLV 50 vs. SLV 34.6%; p = 0.14), and postoperative atelectasis (DLV 35.5 vs. SLV 25%; p = 0.32). No major cardiorespiratory events, such as bleeding or pneumonia, were observed. No perioperative mortality occurred. CONCLUSIONS: This is the first study on safety, effectiveness, and outcome of SLV and DLV in pediatric patients undergoing thoracoscopic lung resection. Our data suggest that both SLV and DLV can be safely performed with similar low rate of surgical complications, when specific selection criteria are applied.

Bicarbonate buffered ultrafiltration leads to a physiologic priming solution in pediatric cardiac surgery.

Pediatric cardiopulmonary bypass (CPB) involves a high ratio of priming blood volume to patient blood volume. The composition of packed red blood cells (RBCs) is very unphysiological in terms of acid-base, electrolyte and metabolite values. Therefore, we tested the hypothesis whether ultrafiltration of the prime and replacement with bicarbonate buffered hemofiltration solution (BB-HS) is sufficient for reducing the metabolic load and reaching a physiologic state. For planned surgery of congenital heart defects with cardiopulmonary bypass, 20 CPB circuits were primed with BB-HS, gelatin and 1 unit of RBCs. The fluid was hemofiltrated using an ultrahemofilter at 300 ml/min until approximately 1000 ml of ultrafiltrate was restored with BB-HS. Blood gas analyses were obtained from the priming blood, once before and once after bicarbonate buffered ultrafiltration (BBUF). The measured substrates decreased significantly (P<0.001) after BBUF (glucose from 13.0+/-2.6 to 6.3+/-1.0 and lactate from 3.8+/-1.5 to 2.3+/-1.0 mmol/l). Acid-base parameters increased (P<0.001) to normal or high normal values (pH from 7.01+/-0.09 to 7.68+/-0.12; HCO(3) from 12.1+/-2.4 to 25.4+/-3.6 mmol/l and BE from -15.4+/-3.6 to -0.8+/-3.7 mmol/l). Even the electrolytes sodium, potassium and calcium changed significantly (P<0.001) toward the physiologic range. BBUF is an efficient method of reducing the metabolic load of priming. After BBUF, even the electrolyte and acid-base balance reached a physiologic state, which is important for minimizing electrolyte and acid-base disturbances after initiation of CPB.

Fast-track surgery in infants and children.

BACKGROUND/PURPOSE: Fast-track surgery is not well established for infants and children. The aim of our prospective study was to investigate the feasibility of fast-track concepts for pediatric surgical procedures including laparoscopic techniques. METHODS: Fast-track concepts, including immediate postoperative feeding, immediate mobilization, and morphine sparing pain treatment, were established for pyeloplasty, appendectomy, bowel anastomosis, fundoplication, hypospadia repair, and full/partial nephrectomy. All consecutive patients undergoing these procedures were prospectively investigated from June 2004 to June 2005. Patients with additional relevant diseases, reoperation, and perforated appendicitis were excluded from fast-track treatment. The length of hospital stay was compared with data derived from the German reimbursement system with German diagnosis-related groups for patients with a similar case mix index and hospitals with a similar structure. RESULTS: Of a total of 159 patients (mean age, 5.8 +/- 5.3 years), 113 (71%) were finally treated according to the fast-track protocols. There were no complications associated with fast-track surgery. The intensity of pain during the immediate postoperative period was higher than 5 on a 10-point scale in children older than 4 years. Analgesia was excellent at all other time points. The mean hospital stay of fast-track patients was 2.3 +/- 1 days and was significantly shorter (P < .01) compared with German diagnosis-related group data for all procedures (pyeloplasty, 1.9 +/- 0.9 vs 12.2 +/- 0.2; nephrectomy, 1.9 +/- 1.0 vs 14.4 +/- 2.8; bowel anastomosis, 3.2 +/- 0.6 vs 12.9 +/- 2.4; fundoplication, 3.2 +/- 0.8 vs 15.2 +/- 4.2; appendectomy, 3.7 +/- 2.4 vs 6.3 +/- 1.8; hypospadia repair, 2.1 +/- 1 vs 8.4 +/- 1.4). Two readmissions were recorded. Ninety-six percent of patients and parents scored the fast-track concepts as excellent. CONCLUSION: The feasibility of fast-track concepts in children is excellent, with short duration of hospitalization and high comfort.