Determining duration of antibiotic use in children with complicated appendicitis.

BACKGROUND: The introduction of broad spectrum antibiotics has substantially decreased rates of mortality and morbidity associated with complicated appendicitis in children. The generally recommended therapy for children with complicated (gangrenous or perforated) appendicitis is administration of postoperative antibiotics for 3 to 14 days, but the decision as to the specific duration of treatment lies with the treating physician. AIM: This study evaluates whether the recommendation that the combination of the patient's being afebrile and eating and having a normal white blood cell (WBC) count and < or = 3% band forms can be used to decide when sufficient antibiotics have been given and can be safely discontinued. METHODS: Thirty-three consecutive patients seen in the pediatric surgical service with perforated or gangrenous appendicitis were studied prospectively. All patients received a standard protocol of resuscitation, appendectomy and broad spectrum antimicrobial therapy to be continued until they were eating, afebrile and had normal white blood cell counts with < or = 3% immature neutrophils (band forms). RESULTS: Thirty-two children were treated until they met all criteria when antibiotics were stopped and the patients were discharged. Of these patients 31 had unremarkable courses of recovery with no development of intraabdominal abscess or wound infection [predictive value of criteria, 97% (31 of 32)]. The remaining patient who met the criteria required rehospitalization for treatment of intraabdominal abscess. Another patient was discharged prematurely when he failed to meet the criterion of afebrility. Although he was eating and his WBC count was normal, he had a temperature of 38.5 degrees C during the 24 h before discharge. He was readmitted for surgical drainage of an intraabdominal abscess, yielding a 100% predictive value for the criterion mismatch (1 of 1). CONCLUSION: Based on our observations, when a patient with complicated appendicitis is afebrile for 24 h (temperature < 38 degrees C), is eating and has a WBC count with < or = 3% band forms, antibiotics can be safely discontinued with small risk of recurrent intraabdominal abscess.

The chest tube: a simple device for the tunneling of central venous catheters.

The chest tube is presented as a device for the tunneling of central venous catheters. It offers several advantages over currently recommended tunneling devices. It is readily available in multiple sizes to accommodate different diameter catheters, produces lengthy atraumatic tunnels, and can be bent into various shapes to facilitate passage through the subcutaneous tissues.

Skin necrosis from extravasation of intravenous fluids in children.

From 16,380 administrations of I.V. fluid in children during a 6-month period, there were 1,800 extravasations (11%) with 40 skin sloughs. All that resulted in either partial or full-thickness skin loss were treated by one of 3 conservative protocols, and no skin grafts were needed in this series. Most of the extravasations resulting in skin loss were associated with hypertonic fluids and the use of infusion pumps. Careful hourly monitoring of such cases seems highly desirable. We found no discernible differences in the healing among the 3 treatment regimens used. The importance of systematic monitoring of children receiving I.V. fluids by nursing personnel, the elevation of an extremity involved in an extravasation, and the care of any resulting wounds are discussed.

Selective placement of the Broviac catheter in the infant.

Infants frequently require the placement of a Broviac or Hickman catheter for prolonged administration of total parenteral nutrition. Proper catheter care in these patients may be difficult. We have addressed this problem in selected patients by exiting their central venous catheters from their backs.

Acute pancreatitis: the difficulties of diagnosis and therapy.

Acute pancreatitis in children is uncommon but is being recognized frequently. Twenty-four children provided clinical data to review the various manifestations and therapy of acute pancreatitis, all of these patients having survived a clinical episode. Recognition of acute pancreatitis has been improved by the advent of new diagnostic procedures such as serum amylase isoenzymes, amylase/creatinine ratio, ultrasonography, endoscopic retrograde cholangiopancreatography (ERCP), computerized axial tomography (CAT) scan, and peritoneal lavage. The causative factors in our series were: trauma, biliary disease,, viral (mumps), and steroid therapy. Treatment of acute pancreatitis was nonsurgical unless a specific surgical lesion was present.

Gastric emptying in children with gastroesophageal reflux. II. The relationship to retching symptoms following antireflux surgery.

Following antireflux surgery, children with persistent retching symptoms are presumably more likely to have delayed gastric emptying. We report 66 children between 2 weeks and 16 years of age who had an operation to control gastroesophageal reflux (GER). All patients had GER confirmed by 18- to 24-hour esophageal pH monitoring. Preoperative gastric emptying studies were performed in each patient with 99m-Tc sulfur colloid in apple juice. In addition to the percent gastric emptying (%GE), an effective gastric emptying was estimated by correcting the %GE for postcibal reflux (corrected %GE). Repeat 18- to 24-hour esophageal pH monitoring was performed postoperatively in all patients, and a repeat gastric emptying study was performed in 32 patients. After an average postoperative follow up of 6 months (range of 1 to 18 months), persistent retching was present in 12 (18%) patients. The retching was associated with dumping symptoms in six patients. Retching was seen in patients with a preoperative increase in effective gastric emptying (10/34, 29%, P less than .05) or a decrease in effective gastric emptying (2/15, 13%, NS), and not in patients with an effective gastric emptying within the control range (0/17, 0%). Postoperatively, retching with dumping symptoms was associated with an increased effective gastric emptying, and retching without dumping symptoms with a decreased effective gastric emptying. In conclusion, persistent retching followed anti-reflux surgery in children is related to extremes in effective gastric emptying. The preoperative measurement of corrected %GE identifies children at increased risk for this postoperative problem.

The efficacy of Thal fundoplication in the treatment of gastroesophageal reflux: the influence of central nervous system impairment.

One hundred sixteen patients underwent a modified Thal fundoplication to correct gastroesophageal reflux (GER) between July 1, 1983, and January 30, 1987. Ninety-one percent of patients were relieved of GER. When patients were evaluated with respect to the presence or absence of CNS impairment there was a marked difference in the success rate of this procedure. Eight of 48 patients with CNS disorders had recurrent reflux with gastrostomy feedings after a modified Thal fundoplication (16%) while only two of 68 neurologically normal children had a failure of operation (3%; P less than .05). These data indicate that the modified Thal fundoplication is very effective in correcting GER in neurologically normal children but is less effective in children with CNS impairment.

Lower esophageal pressure changes with tube gastrostomy: a causative factor of gastroesophageal reflux in children?

In children, Stamm tube gastrostomy can initiate gastroesophageal reflux (GER) or worsen preexisting GER. We identified a possible mechanism for this problem in 25 children with GER who had esophageal manometry performed in conjunction with an antireflux operation. Intraoperative lower esophageal high pressure zone (LEHPZ) pressure and length were recorded for a simulated gastrostomy in all patients prior to performing the antireflux operation. These same parameters were then recorded for a simulated (11 patients) or real gastrostomy (14 patients) following the antireflux procedure. The LEHPZ pressure decreased with simulated Stamm gastrostomy (7.8 +/- 1.1----6.6 +/- 1.1 mm Hg, NS: Normal = 11.2 +/- 0.9 mm Hg). This decrease was less significant than the decrease in LEHPZ length (1.1 +/- 0.1----0.8 +/- 0.1 cm, P less than .01: Normal = 1.3 +/- 0.1 cm). Following Boerema gastropexy, simulated gastrostomy produced a similar decrease in LEHPZ pressure (20.8 +/- 3.8----17.1 +/- 2.7 mm Hg, NS) and length (3.3 +/- 0.4----2.5 +/- 0.3 cm, P less than .025). The LEHPZ pressure and length were not decreased by real gastrostomy performed with modified Thal fundoplication or with Nissen fundoplication. Thus, a decrease in LEHPZ length may be one mechanism whereby GER is initiated or worsened by tube gastrostomy in children. Tube gastrostomy has a similar effect when performed with a Boerema gastropexy, but not when performed with a Nissen or modified Thal fundoplication.

Postoperative small bowel obstruction in infants and children: a problem following Nissen fundoplication.

A serious consequence of antireflux surgery is postoperative small bowel obstruction in an infant who cannot speak and has been rendered unable to vomit. We reviewed the operative rate for small bowel obstruction following all antireflux operations (210 Nissen fundoplications, 16 Hill fundoplications, 12 modified Thal fundoplications, and 3 Boerema anterior gastropexies) performed on children at our institution between January 1977 and July 1984. Eighteen patients (17 Nissen fundoplications, one Hill fundoplication) were operated upon for small bowel obstruction within two years after the primary operation. The most consistent clinical findings in these children were abdominal distention and a decreased frequency of bowel movements. For operations performed between January 1982 and July 1984, reoperation for small bowel obstruction was needed in 6.1% (6/99) of children following Nissen fundoplication as compared to 0.9% (6/649), P less than 0.001) of children following other major laparotomies. A combination of our experience with that reported by others suggests an estimated incidence of postoperative adhesive small bowel obstruction of 5.5% (24/436) for Nissen fundoplication, 0.9% (3/347) for modified Thal fundoplication, and 0.8% (1/126) for Boerema anterior gastropexy. The performance of a Nissen fundoplication has led to a significant rate of reoperation for small bowel obstruction compared with other major laparotomies and antireflux operations performed in children.

The safety and cost-effectiveness of polyethylene glycol electrolyte solution bowel preparation in infants and children.

Golytely, a polyethylene glycol electrolyte solution (Braintree Laboratories, Braintree, MA), was evaluated in the preoperative bowel preparation of 21 infants and children. Weight, temperature, pulse, respiratory rate, and electrolyte concentrations were documented before and after mechanical bowel preparation. All children were given 25 mL/kg/h of Golytely until rectal effluent was clear and free of particulate matter. All preparations were started and completed the afternoon prior to surgery. Weight, vital signs, and electrolyte concentrations did not change significantly. All preparations were felt to be fair or excellent. Follow-up for 1 month postoperatively revealed no infectious complications. Golytely is safe and effective in preparing the bowel prior to surgery in children. Using Golytely can eliminate the need for multiple-day hospitalizations for bowel preparation and thus decrease the cost of medical care.

Agenesis of the left diaphragm: surgical repair and physiologic consequences.

Agenesis of the hemidiaphragm is an unusual congenital anomaly associated with a high mortality. This paper presents the fourth patient to survive the neonatal period with agenesis of the hemidiaphragm. He was an identical twin, weighing 1.5 kg and his clinical course was characterized by ipsilateral pulmonary hypoplasia, large alveolar-arterial gradient for oxygen, persistent fetal circulatory pattern and ventilator dependence. These abnormalities suggest a pathophysiology similar to that observed in patients with Bochdalek hernia. The surgical correction, postoperative care and observation of pulmonary function following repair of agenesis of the left diaphragm are described.

Percutaneous subclavian venous catheters in neonates and children.

There were 191 central venous catheters placed through the subclavian vein in 135 neonates and children over a 20-mo period, providing central venous access for a total of 4525 patient days. There were 132 (69.2%) catheters inserted in patients who were in their first year of life and 60 (31.4%) weighed less than 2.5 kg. The procedure was associated with a low technical complication rate. The greatest potential intermediate or long-term complication was the development of primary catheter sepsis that occurred in 11 (5.8%) of the catheters placed.

Intraoperative esophageal manometry and early postoperative esophageal pH monitoring in children.

Intraoperative esophageal manometry has not been correlated with early postoperative extended esophageal pH monitoring (EEpHM) in children with gastroesophageal reflux. Twenty-seven children were studied with the following design: (1) abnormal preoperative EEpHM; (2) intraoperative measurement of lower esophageal high pressure zone (LEHPZ) pressure and length prior to and upon completion of an antireflux procedure; and (3) EEpHM seven to ten days postoperatively. Sixteen had a Nissen or modified Thal fundoplication and eleven a Boerema gastropexy. The postoperative EEpHM was normal in patients with fundoplication regardless of the increase in LEHPZ pressure (-4 to 36 mmHg) or length (0 to 2.5 cm). Four of the patients (36%) who had a gastropexy had abnormal EEpHM. The postoperative frequency of reflux was related inversely to the elevation of LEHPZ pressure (-3 to 39 mmHg), but not to the LEHPZ length (0 to 4.5 cm). Duration of reflux was independent of observed intraoperative manometric changes. In conclusion, early postoperative EEpHM in children having a gastropexy correlates with intraoperative increases in the LEHPZ pressure. There is no such correlation in children having a fundoplication procedure.

Successful long-term endoscopic closure of a recurrent tracheoesophageal fistula with fibrin glue in a child.

We present an unusual case of recurrent tracheoesophageal fistula after primary surgical repair of congenital esophageal atresia. Traditionally, this disorder has required open-surgical correction, but successful endoscopic closure of these fistulas has been reported. This case report describes our experience using fibrin glue, applied endoscopically in a 6-year-old child, with encouraging long-term results 4 years after treatment.

Nutrition and the rheumatoid hand patient.

The incidence of nutritional depletion in 40 rheumatoid patients and the factors that influence these patients' nutritional status were investigated. More than half of the patients (52.5%) were found to be nutritionally deficient.

Selection and nonoperative management of pediatric blunt trauma patients: the role of quantitative crystalloid resuscitation and abdominal ultrasonography.

One hundred thirty-nine pediatric blunt trauma patients 12 years of age or less were cared for using a protocol designed to identify which patients require aggressive surgical therapy and those who can be managed nonoperatively. Sixteen patients (average MISS score, 33) failed to respond to an estimated 20 cc per kilogram of crystalloid fluid resuscitation. Fifteen died, a mortality rate of 94%. One hundred twenty-three patients (average MISS score, 11) responded to less than or equal to 20 cc crystalloid fluid per kilogram with return of normal blood pressure, pulse rate, and nail bed capillary refill. Six died, a mortality rate of 5%, all from central nervous system injuries. Sixty-seven of these patients underwent ultrasound examination for suspected intra-abdominal injuries. Seventeen studies were positive. There were two complications (12%), but all 17 patients in this group were successfully managed nonoperatively. Our data suggest that quantitative crystalloid fluid resuscitation can identify pediatric blunt trauma patients suitable for nonoperative management and that ultrasound is a reliable tool for assessing intra-abdominal injury.

Virilizing adrenal adenoma in a 2-year-old girl.

A 2-year-old girl with virilization had an adrenal tumor that produced testosterone with little evidence of excessive urinary androgen excretion. Plasma testosterone concentration was 407 ng/dL and urinary 17-ketosteroid (17KS) levels were 3 and 2 mg/day. Excretion of 17KS decreased to 1.8 mg/day after suppression of dexamethasone therapy, but urinary 17-hydroxycorticosteroid excretion did not change from 1.0 to 0.7 mg/day after administration of dexamethasone. She had a blunted response to administration of metyrapone and insulin and a small diurnal variation in cortisol concentration suggesting suppression of corticotropin secretion, even though the plasma cortisol concentration was in the normal range and there were no clinical signs of cortisol excess. High-performance liquid chromatography was used to analyze the steroid content of tumor tissue. Those portions of the tumor that were rich in steroids contained predominantly testosterone.