Postoperative coagulopathy among otherwise healthy pediatric patients undergoing open craniosynostosis repair: a retrospective study.

Significant blood loss and resultant transfusion may lead to coagulopathy. The need for routine transfusion of non-RBC blood products in healthy pediatric patients suffering significant, yet controlled, intra-operative blood loss is controversial. Open craniosynostosis surgery is often associated with significant intra-operative blood loss and transfusion, and routinely preformed on otherwise healthy pediatric patients. Therefore, we found it as a useful model for our study, which aimed to assess the need for routine transfusion of non-RBC blood products in healthy pediatric patients suffering significant intra-operative blood loss. We conducted a retrospective cohort study of otherwise healthy pediatric patients, undergoing open craniosynostosis surgery and transfused solely with packed red blood cells (pRBCs) in a single large-volume tertiary surgical center, between January 2010 and December 2021. Among 457 eligible patients, 34 (7.4%) developed significant postoperative coagulopathy. Median [IQR] intra-operative pRBC transfusion volume was 17.4 ml kg-1 [13.3, 23.1]. Patients who developed coagulopathy did not have higher postoperative pRBC transfusion rate (8.8% vs 3.8%, P = 0.16) or volume (median [IQR], 0 [0, 0] vs 0 [0, 0] ml, P = 0.15), nor higher hospital LOS (5 [4, 5] vs 5 [4, 5] days, P = 0.66). ICU LOS was 0.8 [0.7, 1] vs 0.7 [0.6, 0.8] days (P = 0.02), a difference of no clinical significance.  Conclusions: The incidence of significant coagulopathy after craniosynostosis surgery was low, and not associated with clinically important complications. In otherwise healthy pediatric patients, even significant intra-operative blood loss can be safely managed solely with intravenous fluids and pRBC transfusion. What is Known: • Significant intra-operative blood loss and resultant transfusion may lead to postoperative coagulopathy. • There are potential deleterious effects from both coagulopathy and administration of blood products. What is New: • Open craniosynostosis corrective surgery is a useful model for studying coagulopathy after significant intra-operative blood loss and transfusion in otherwise healthy children. • Under certain conditions, in otherwise healthy pediatric patients, even significant intra-operative blood loss can be safely treated with intravenous fluids and pRBC transfusion alone, with no clinically significant postoperative coagulopathy or its complications.

Epilepsy surgery in infants up to 3 months of age: Safety, feasibility, and outcomes: A multicenter, multinational study.

OBJECTIVE: Drug-resistant epilepsy (DRE) during the first few months of life is challenging and necessitates aggressive treatment, including surgery. Because the most common causes of DRE in infancy are related to extensive developmental anomalies, surgery often entails extensive tissue resections or disconnection. The literature on "ultra-early" epilepsy surgery is sparse, with limited data concerning efficacy controlling the seizures, and safety. The current study's goal is to review the safety and efficacy of ultra-early epilepsy surgery performed before the age of 3 months. METHODS: To achieve a large sample size and external validity, a multinational, multicenter retrospective study was performed, focusing on epilepsy surgery for infants younger than 3 months of age. Collected data included epilepsy characteristics, surgical details, epilepsy outcome, and complications. RESULTS: Sixty-four patients underwent 69 surgeries before the age of 3 months. The most common pathologies were cortical dysplasia (28), hemimegalencephaly (17), and tubers (5). The most common procedures were hemispheric surgeries (48 procedures). Two cases were intentionally staged, and one was unexpectedly aborted. Nearly all patients received blood products. There were no perioperative deaths and no major unexpected permanent morbidities. Twenty-five percent of patients undergoing hemispheric surgeries developed hydrocephalus. Excellent epilepsy outcome (International League Against Epilepsy [ILAE] grade I) was achieved in 66% of cases over a median follow-up of 41 months (19-104 interquartile range [IQR]). The number of antiseizure medications was significantly reduced (median 2 drugs, 1-3 IQR, p < .0001). Outcome was not significantly associated with the type of surgery (hemispheric or more limited resections). SIGNIFICANCE: Epilepsy surgery during the first few months of life is associated with excellent seizure control, and when performed by highly experienced teams, is not associated with more permanent morbidity than surgery in older infants. Thus surgical treatment should not be postponed to treat DRE in very young infants based on their age.

Filum terminale lipomas-the role of intraoperative neuromonitoring.

BACKGROUND: Filum terminale lipomas (FTL) represent a sub-type of spinal lipomas, where there is fatty infiltration of the filum. It becomes a surgical entity when it manifests as clinical or radiological tethered cord syndrome. Intraoperative neuromonitoring (IONM) has been suggested as a valuable tool in children for tethered cord surgeries. FTL is distinct and cannot be compared with complex tethered cord syndrome (TCS). Untethering an FTL is a relatively straightforward microsurgical exercise, usually based on anatomical findings. Neurological morbidity in FTL untethering is extremely low. The necessity of IONM in FTL has not been evaluated. The objective of this study was to identify the role of IONM in untethering an FTL METHODS: Available electronic data and case files were interrogated to identify children (0-18 years) who underwent an untethering of FTL between 2008 and 2019. We had a shift in our policy and tried to use IONM as often as possible in all tethered cord surgery from 2014. All children were categorised under 'IONM implemented' or 'no IONM' group. Outcomes analysed were as follows: (1) Clinical status on short-term and long-term follow-up, (2) alteration of surgical course by IONM and (3) complications specifically associated with IONM RESULTS: Among 80 children included in this study, IONM was implemented in 37 children and 43 children underwent untethering without IONM. 32.5% of children were 'syndromic'. Seventy-five percent of children were under age 3 years during surgery. Both groups (No IONM vs. IONM implemented) were well matched in most variables. Majority of 'no IONM' surgeries were performed prior to 2014. There was no neurological morbidity in the entire cohort. Mean duration of follow-up was 49.10 (± 33.67) months. Short-term and long-term clinical status remained stable in both cohorts. In 16 children, the filum was stimulated. Based on our protocol, majority had a negative response. One child showed a positive response, contradicted by thorough microscopic inspection. Despite a positive response, the filum was untethered. IONM was not associated with any complication in this study. CONCLUSION: FTL untethering is an inherently low-risk microsurgery in experienced hands with rarely reported neurological morbidity. IONM may not be required for all FTL and may be used more judiciously.

Utility of three-dimensional modeling of the fetal airway for ex utero intrapartum treatment.

Recent technological developments in three-dimensional (3D) printing have created new opportunities for applications in clinical medicine. 3D printing has been adopted for teaching and planning complicated surgeries, including maxillofacial, orthopedic reconstructions, and airway manipulation for one-lung ventilation or airway stenting. We present here the first use of such technology to print a model from in utero imaging for intrapartum treatment planning. A 32-week fetus presented with congenital high airway obstruction syndrome (CHAOS) due to a large cervical lymphatic malformation. An ex utero intrapartum treatment (EXIT) procedure was planned to allow delivery of a viable infant. We printed a 3D model of the fetal airway by printing separate elements: mandible, tongue, mass, larynx, and trachea from the fetal MRI. The elements were stuck together maintaining correct anatomical relationships. Airway planning was then performed in consultation with a pediatric ear nose and throat (ENT) surgeon. 3D modeling in utero presents many challenges: the resolution of the 3D model generated from a fetal MRI is less crisp than from CT images, fetal position may be variable and not in a defined anatomical plane, movement artifact occurs. Nevertheless, pre-procedure simulations with the aid of 3D modeling promoted team cooperation and well-prepared management of the fetus during EXIT.

Respiratory complications after adenotonsillectomy in high-risk children with obstructive sleep apnea: A retrospective cohort study.

BACKGROUND: Obstructive sleep apnea (OSA) occurs in 1%-4% of children; adenotonsillectomy is an effective treatment. Mortality/severe brain injury occurs among 0.6/10 000 adenotonsillectomies; in children, 60% are secondary to airway/respiratory events. Earlier studies identified that children aged <2 years, extremes of weight, with co-morbidities of craniofacial, neuromuscular, cardiac/respiratory disease, or severe OSA are at high risk for adverse post-operative respiratory events (AE). We aimed to: Firstly, investigate which risk factors were associated with AEs either in the post-anesthesia care unit (PACU), pediatric intensive care unit (PICU), or both in this population. Secondly, we investigated factors associated with post-operative PICU AE despite no event in the PACU in order to predict need of post-operative PICU after their PACU stay. METHODS: Retrospective study of children admitted to the PICU after adenotonsillectomy between 08/2006-09/2015. Demographics, risk factors, and occurrence of AE (oxygen saturation <92, stridor, bronchospasm, pneumonia, pulmonary edema, re-intubation) were recorded. RESULTS: During the studied time period 4029 tonsil/adenoid procedures were performed in 3997 children. 179, admitted to the PICU post-operatively, met criteria for analysis. PICU AEs occurred in 59%: 44%-83% in any particular risk category. PACU AEs occurred in 42%. Of those with PACU events: 92% suffered AEs in the PICU; however, 35% of those without a PACU AE still suffered a PICU AE. CONCLUSIONS: Among high-risk children undergoing TA, absence of adverse events in PACU during a 2-hour observation period does not predict absence of subsequent AEs in the PICU.

Intraoperative neurophysiology in pediatric supratentorial surgery: experience with 57 cases.

PURPOSE: Utilization of intraoperative neurophysiology (ION) to map and assess various functions during supratentorial brain tumor and epilepsy surgery is well documented and commonplace in the adult setting. The applicability has yet to be established in the pediatric age group. METHODS: All pediatric supratentorial surgery utilizing ION of the motor system, completed over a period of 10 years, was analyzed retrospectively for the following variables: preoperative and postoperative motor deficits, extent of resection, sensory-motor mappability and monitorability, location of lesion, patient age, and monitoring alarms. Intraoperative findings were correlated with antecedent symptomatology as well as short- and long-term postoperative clinical outcome. The monitoring impact on surgical course was evaluated on a per-case basis. RESULTS: Data were analyzed for 57 patients (ages 3-207 months (93 ± 58)). Deep lesions (in proximity to the pyramidal fibers) constituted 15.7% of the total group, superficial lesions 47.4%, lesions with both deep and superficial components 31.5%, and ventricular 5.2%. Mapping of the motor cortex was significantly more successful using the short-train technique than Penfield's technique (84% vs. 25% of trials, respectively), particularly in younger children. The youngest age at which motor mapping was successfully achieved was 3 vs. 93 months for each method, respectively. Preoperative motor strength was not associated with monitorability. Direct cortial motor evoked potential (dcMEP) was more sensitive than transcranial (tcMEP) in predicting postoperative motor decline. dcMEP decline was not associated with tumor grade or extent of resection (EOR); however, it was associated with lesion location and more prone to decline in deep locations. ION actively affected surgical decisions in several aspects, such as altering the corticectomy location and alarming due to a MEP decline. CONCLUSION: ION is applicable in the pediatric population with certain limitations, depending mainly on age. When successful, ION has a positive impact on surgical decision-making, ultimately providing an added element of safety for these patients.

Ultrasonographic Assessment of Bladder Volumes in Children Undergoing Penile Surgery: Does the Type of Anesthesia Matter?

BACKGROUND: There are scant data reporting postoperative ultrasonographically measured bladder volumes in children undergoing penile surgery. STUDY QUESTION: We studied the effect of various anesthesia techniques on return of micturition after penile surgery in children, using ultrasonographically measured bladder volumes. DATA SOURCES: Ultrasonographically measured postvoiding residual bladder volumes indexed to age-appropriate capacity, and time elapsed between the end of surgery and spontaneous voiding after pediatric circumcision, distal hypospadias repair, or repair of urethrocutaneous fistula, were studied. STUDY DESIGN: Children between 4 months and 12 years were randomized to caudal block, intravenous (IV) fentanyl or penile block, in association with inhaled general anesthesia. Bladder volumes were measured before surgery and immediately after voiding for the first time. Time to first postsurgery void was also recorded. RESULTS: Thirty-one children completed all assessments; 12 underwent caudal block, 9 IV fentanyl anesthesia, and 7 were given penile block. The mean first postvoid bladder residual volumes were highest in the caudal and lowest in the penile block children (27.5 vs. 17.3 mL, P = 0.003). The time elapsing between the end of surgery and first voiding was the longest in the fentanyl group compared with caudal and penile blocks (232, 178, 150 minutes, respectively, P = 0.02). CONCLUSIONS: None of the anesthetic techniques provoked postoperative urinary retention after minor penile surgery in children. The penile block appears superior to caudal block or to IV fentanyl-based anesthesia with regard to postoperative recovery of normal micturition.

Visual deterioration during pregnancy due to skull base tumors compressing the optic apparatus.

Intracranial tumors may rapidly enlarge during pregnancy. When the tumor abuts the optic apparatus, tumor growth may cause visual deterioration. The decisions regarding the management of these tumors should take into consideration visual function, fetal and maternal safety, and the ability for total resection of the tumor. The objective of the study was to describe our experience and to establish principles for management of intracranial tumors compressing the optic apparatus that present during pregnancy or in the early post partum period. A retrospective case-series review was conducted. Women who presented with visual deterioration either during pregnancy or in the early post partum period due to an intracranial tumor were included. Neurosurgical and obstetrical data were collected from the patients' hospital files and outpatient clinic records. Between 2005 and 2011, nine pregnant women with visual deterioration were diagnosed and treated. Of them, four underwent a neurosurgical procedure during pregnancy. Of the five patients who underwent surgery for tumor resection after delivery, three required urgent cesarean section either due to acute visual deterioration or obstetrical reasons. There was no maternal or fetal mortality and a good overall neonatal outcome was achieved. Improvement in visual acuity and visual fields was achieved in all patients. Postoperative complications included two cases of CSF leak, which resolved after treatment. Visual deterioration during pregnancy due to tumors that compress the optic apparatus requires treatment by a multi-disciplinary team. Surgery is well tolerated by mother and fetus during early and midpregnancy; thus, in cases where visual deterioration is detected, delay of surgery is not justified.

Preoperative Bladder Capacity Predicts Social Continence following Bladder Neck Reconstruction in Children Born with Exstrophy-Epispadias Complex.

INTRODUCTION: The aim of the study is to review the continence and volitional voiding rate in a single center cohort of exstrophy-epispadias patients following Young-Dees-Leadbetter bladder neck reconstruction and to explore factors which predict continence. MATERIALS AND METHODS: Children who underwent Young-Dees-Leadbetter bladder neck reconstruction as a final stage of repair in a large single low-volume center in a small-population country between 1997 and 2019 were included. Demographic and clinical details were extracted from the patients' charts. The primary end point was continence and volitional voiding. Patients were categorized as incontinent, socially continent (daytime dry intervals > 3 hours, wet nights) and fully continent (daytime dry intervals > 3 hours, dry nights). RESULTS: The study cohort included 27 patients whose median age at reconstruction was 5 years, and median follow-up was 7.8 years (interquartile range [IQR] 6-11.2). The cohort included 24 classic exstrophy patients (89%, 17 males and 7 females) and 3 isolated complete epispadias patients (11%, 1 male and 2 females). Nine (33%) patients achieved full continence and social continence was achieved by nine (33%) patients, for an overall social continence rate of 67%. Preoperative bladder capacity of 110 mL or more was associated with achieving social continence (odds ratio = 6.4, p = 0.047). The overall volitional voiding rate was 67%. CONCLUSION: Young-Dees-Leadbetter bladder neck reconstruction yielded rates of 33% for full continence and 67% for social continence and volitional voiding. These rates are comparable to those of large high-volume centers. A preoperative capacity of 110 mL or more was the sole predictor of social continence.

Postoperative Urinary Catheterization in Children Treated with or without Epidural Analgesia after Orthopedic Surgery: A Retrospective Review of Practice.

Epidural analgesia is effective and an accepted treatment for postoperative pain. Urinary retention is a known complication, but its description is mostly in the adult literature. Management of urinary catheter (UC) placement and removal is an important consideration in children receiving epidural analgesia. This is a single-center, retrospective observational study which examined UC management in children undergoing lower extremity orthopedic surgery under general anesthesia with or without epidural analgesia from January 2019−June 2021. Of 239 children included, epidural analgesia was used in 57 (23.8%). They were significantly younger and had more co-morbidities. In total, 75 UCs were placed in the OR, 9 in the ward, and 7 re-inserted. UC placement in the epidural group was more common (93% vs. 17%, p < 0.001) and remained longer (3 days vs. 1 day, p = 0.01). Among children without intra-operative UC, ward placement was more common in the epidural cohort (60% vs. 1.6%, p = 0.007). OR UC placement and ward re-insertion were more common in children with neuromuscular disease (61% vs. 22%, p < 0.001), (17% vs. 3%, p = 0.001), respectively. Based on these findings, we hypothesize that it is justifiable to routinely place a UC intra-operatively in children who undergo hip or lower extremity surgery and are treated with epidural analgesia, and caution is advised before early UC removal in orthopedic children with NMD.

Parental Regret Following Decision to Revise Circumcision.

Purpose: Revision surgery for the removal of excess foreskin after circumcision is a common procedure. The decision regret scale (DRS) is a validated questionnaire which assesses regret after medical decision making. The aim was to evaluate parental regret by means of the DRS and querying about factors associated with regret about deciding to revise their child's circumcision. Patients and Methods: Included were all pediatric patients who underwent revision of neonatal circumcision in a single center between 2010 and 2016. Excluded were children who underwent revision for reasons other than excess foreskin, those who underwent additional surgical procedures during the same anesthetic session, and those who had undergone previous penile surgery other than circumcision. Response to the DRS questionnaire was by a telephone call with the patient's parent. Regret was classified as none (a score of 0), mild (1-25), or moderate-to-strong (26-100). Surgical and baseline demographic data were obtained from the departmental database and compared between the no regret and regret groups. Results: Of the 115 revisions of circumcisions performed during the study period, 52 fulfilled the inclusion criteria, and the parents of 40 (77%) completed the DRS questionnaire. Regret was reported by 11/40 [28%: nine as mild (23%) and two as moderate-to-strong (5%)]. The average age of the child in the regret group was 17 months compared to 18 months in the no regret group (p = 0.27). The median weight percentile was 43% in both groups. Surgical variables, including anesthesia type (caudal vs. no block, p = 0.65), suture type (polyglactin vs. poliglecaprone, p = 0.29), operation time (28 vs. 25 min, p = 0.59), and anesthesia time (55 vs. 54 min, p = 0.57) were not significantly different between the groups. Conclusions: Regret for deciding upon revision surgery for removal of excess foreskin post-circumcision was reported by 27.5% of parents of children who underwent revision. No clinical, surgical, or demographic characteristics predicted parental decisional regret.

Concomitant Repair of Meatal Stenosis and Urethral Fistula Does Not Increase the Risk of Fistula Recurrence Post Hypospadias Surgery.

OBJECTIVE: To evaluate whether meatal stenosis treated concomitantly with urethral fistula repair alters the results of fistula closure. METHODS: A retrospective cohort study, included were all children who underwent local fistula closure following hypospadias repair between 2006 and 2017. Patients who underwent reoperative urethroplasty were excluded. Data were extracted from electronic records, and missing data were supplied by telephone interviews. Characteristics of patients and fistulas were compared between children who underwent fistula closure only and those who underwent meatoplasty for meatal stenosis during the same surgery. The primary endpoint was fistula recurrence. RESULTS: In total, 106 local repairs of urethrocutaneous fistulas were performed during the study period, and 25 of them included concomitant meatoplasty for meatal stenosis. There was no difference in terms of location, size, and number of fistulas or the number of recurrent fistulas between the 81 patients who underwent fistula closure only and the 25 who underwent concomitant meatoplasty. The fistula recurrence rate was 17 per 81 (21%) for the fistula only group and 5 per 25 (20%) for the fistula and meatoplasty group after a median follow-up of 7 and 8 years, respectively. Meatoplasty was required in a subsequent procedure in 5 of 81 in the former group vs 3 of 25 patients in the latter group. CONCLUSION: The presence and repair of meatal stenosis does not alter the recurrence rate of urethrocutaneous fistulas repaired concomitantly following hypospadias repair.

Immediate postoperative pain in orthopedic patients is more intense and requires more analgesia than in post-laparotomy patients.

OBJECTIVE: To compare the immediate postoperative pain intensity between orthopedic and general surgery patients and evaluate the extent of severe pain in each group. DESIGN: Observational, open-label study. SETTING: Post-anesthesia care unit (PACU) in a tertiary, university-affiliated hospital. PATIENTS: Patients undergoing orthopedic surgery or laparotomy under general anesthesia over a one-year period. INTERVENTIONS: Follow-up of patient self-rated pain visual analog scale (VAS, 0-10), and observation of the efficacy of the routine analgesic protocol of morphine, ketamine, and diclofenac administration in the PACU. OUTCOME MEASURES: We followed pain scores and sorted patients according to morphine requirements during the PACU immediate postoperative stay. Patients whose pain was controlled with ≤120 µg/kg intravenous morphine were considered pain-controllable. Where this amount was insufficient to control pain (VAS ≥5/10), patients were categorized as suffering from severe pain. They were further treated with repeated doses of 1 mg morphine plus 350 µg/kg ketamine (M+K) and eventually diclofenac. PACU follow-up lasted 3 hours. RESULTS: The overall rate of immediate severe postoperative pain within the entire cohort (3,460 patients) was 9.4%: 123 (6.6%) of laparotomy patients and 202 (12.7%) of orthopedic patients. Pain in the laparotomy patients identified as suffering from severe pain was controlled with 1.21±0.45 doses of M+K compared with 1.37±0.62 (P<0.0001) in the orthopedic counterparts. One-fifth of these laparotomy patients demanded more than one injection of M+K compared with one-third of the orthopedic subgroup (P=0.045). Twenty-seven orthopedic vs nine surgical patients (P=0.036) required diclofenac. CONCLUSIONS: More orthopedic than laparotomy patients suffered from severe immediate postoperative pain. They required more analgesia than that dictated by existing PACU analgesia protocols. Ketamine and morphine co-administration proved effective in controlling severe postoperative pain after each type of surgery.

Neurosurgery and pregnancy.

BACKGROUND: Pregnant women with pathological conditions requiring a neurosurgical intervention pose a unique therapeutic challenge. Changes in normal physiology add to the complexity of patient management. We describe our experience in treating various neurosurgical diseases in parturient women. METHODS: Thirty-four pregnant and early postpartum women were treated at our center between 2003 and 2010. The general guideline used in these patients (now deserving re-evaluation based on the presented data) was to postpone surgery until the patient reached term (weeks 34-38 of gestation) unless there was evidence of a life- or function-threatening condition, in which case surgery was promptly performed. RESULTS: Sixteen patients underwent neurosurgical intervention during pregnancy between 11 to 34 weeks of gestation (7 tumor, 3 vascular, 2 VP shunt, 2 spinal, 2 trauma). Thirteen women underwent a neurosurgical procedure after delivery (12 tumor, 1 spine), and 5 women were treated conservatively (2 vascular lesions, 3 trauma). Three patients underwent abortions (one spontaneous and two elective). The other 31 women delivered at 30-42 weeks' gestation. Of 12 patients whose definitive neurosurgical procedure was initially delayed, 5 were not able to complete their pregnancy naturally. Of 21 patients that underwent a cesarean section (CS), 3 were performed urgently. Although two pairs of twins and two singletons had an initial low Apgar score (<7), the outcome for all the neonates was good. Neurosurgical outcome was satisfactory. CONCLUSIONS: Our experience demonstrates the safety of neurosurgical intervention and anesthesia during pregnancy. Delaying intervention often resulted in maternal deterioration and urgent intervention. Thus, pregnancy by itself should not be considered a major contraindication for performing a neurosurgical procedure, which should be considered early rather than late in most patients.

Comparison of Caudal Block vs. Penile Block vs. Intravenous Fentanyl Only in Children Undergoing Penile Surgery: A Prospective, Randomized, Double Blind Study.

Objectives: Penile surgery is commonly performed in pediatric surgical centers. There is no consensus regarding which analgesic method is most effective in controlling pain in these children. Methods: Consecutive children between 4 months and 16 years of age who underwent elective penile surgery were recruited. After inhaled induction of anesthesia, children were randomized to one of three methods of intraoperative analgesia: caudal block, IV fentanyl titrated to surgical response and spontaneous respiration, or dorsal penile nerve block (DPNB). All patients were given inhaled agents; fentanyl was added if either block was insufficient. Demographic data, analgesic use and pain scores were recorded by a blinded investigator in the PACU and ward. Pain scores, analgesic requirement, and recovery parameters of returning to normal activity level, eating, and voiding post-operatively for up to 4 days, were compared. Results: 116 children were recruited. Pain scores in the post anesthesia care unit were significantly lower in the DPNB and caudal block groups compared to the fentanyl group for the first 30 postoperative min. Pain scores and analgesic use were subsequently similar among the three groups for the rest of the study period. There was no statistical difference in time to eat, return to normal activity or in parental satisfaction scores among the groups. There was a trend toward earliest time to void in the DPNB group. Conclusions: Regional blocks most effectively controlled pain for 30 min after surgery. The choice of intra-operative analgesia protocol had no effect on later pain and recovery parameters.

In Support of a Simple Urethrocutaneous Fistula Closure Technique Following Hypospadias Repair.

OBJECTIVE: To evaluate the success rates of a simple posthypospadias urethrocutaneous fistula repair. STUDY DESIGN: We evaluated children who underwent urethrocutaneous fistula closure by means of a simple standard technique in which the fistula tract was dissected to its base and resected and the urethral defect closed with a single layer of continuous sutures and covered with local subcutaneous tissue. No urethral stents or catheters were used, and the patients were discharged on the same day. Excluded were children who underwent fistula repair by a different technique, revision hypospadias repair for fistula, or concomitant meatoplasty for meatal stenosis. Study endpoints were fistula recurrence and the need for further penile surgery other than fistula repair. RESULTS: Seventy-two children underwent 81 repairs. The mean follow-up was 7.9 years. Recurrence occurred in 17 cases (21%). Seven children (9%) underwent penile surgery other than fistula repair, including meatoplasty (n = 5) and re-do hypospadias repair for a diagnosis other than fistula recurrence (n = 2). There was no significant difference in recurrence rate between large and small fistulas, coronal or more proximal fistulas, or children w/wo prior fistula repairs. CONCLUSION: Standard fistula closure solely by adjacent tissues yielded success rates of 79% after long-term follow-up. This repair can be safely offered with the expectation of similar results for a variety of urethrocutaneous fistulas in children.

Effects of intravenous patient-controlled analgesia with buprenorphine and morphine alone and in combination during the first 12 postoperative hours: a randomized, double-blind, four-arm trial in adults undergoing abdominal surgery.

BACKGROUND: Intense pain in the first 12 hours after major abdominal surgery requires the use of large amounts of analgesics, mainly opioids, which may produce undesirable effects. Buprenorphine (BUP) is not typically used intravenously in this setting, particularly in combination with morphine (MO), due to concerns that BUP might inhibit the analgesic effect of MO. OBJECTIVE: This study compared the analgesic effect of BUP and MO separately and in combination for postoperative pain control in patients undergoing abdominal surgery. METHODS: In this double-blind study, adult patients were randomized to receive 1 of 4 regimens for 12 hours: a basal BUP infusion (BUP-i) of 0.4 microg/kg/h + BUP boluses (BUP-b) of 0.15 microg/kg each; a basal MO infusion (MO-i) of 10 microg/kg/h + MO boluses (MO-b) of 5 microg/kg each; a basal BUP-i of 0.4 microg/kg/h + MO-b of 5 microg/kg each; or a basal MO-i of 10 microg/kg/h + BUP-b of 0.15 microg/kg each. Bolus doses were delivered by intravenous patient-controlled anesthesia, with a bolus lockout time of 7 minutes. Diclofenac 75 mg IM q6h was available as rescue pain medication. Every 15 minutes during the first 2 postoperative hours and hourly thereafter, patients used visual analog scales to rate their pain (from 0 = totally free of pain to 10 = unbearable pain), level of sedation (from 1 = totally awake to 10 = heavily sedated), and satisfaction with treatment (from 1 = totally unsatisfied to 10 = fully satisfied). Blood pressure, heart rate, respiration rate, and arterial blood oxygen saturation (SpO(2)) were monitored, and adverse effects reported by patients or noted by clinicians were recorded at the same times. Study end points included total opioid consumption (infusion + boluses), demand:delivery ratio, and use of rescue medication. RESULTS: One hundred twenty patients (63 men, 57 women; age range, 21-80 years; weight range, 40-120 kg) were included in the study. Seventy-four percent had other mild, treated diseases (American Society of Anesthesiologists physical class 2). Pain visual analog scale ratings were comparably high in all groups during the first 2 postoperative hours. Pain intensity ratings at 3 to 12 hours were significantly lower in those who received BUP-i + BUP-b compared with the other treatment groups (P = 0.018). The drug requirement during the postoperative period decreased significantly in all groups (P = 0.01); however, there was a significant difference between groups in the demand:delivery ratio at 3 to 12 hours (group * psydrug interaction, P = 0.026). The numerically lowest demand:delivery ratio was seen with BUP-i + BUP-b. BUP-i was associated with a significantly lower heart rate compared with the other groups (P = 0.027); there were no drug-related differences in respiration rate, SpO(2), or sedation. Patients' level of satisfaction with treatment was significantly higher in the group that received BUP-i + BUP-b compared with the other 3 groups (P < 0.001). Postoperative nausea and vomiting were mild and occurred at a similar incidence in all groups, as did rescue diclofenac use. CONCLUSIONS: In these patients undergoing abdominal surgery, the BUP-i + BUP-b regimen controlled postoperative pain as well as did MO-i + MO-b or the combinations of BUP and MO. BUP neither inhibited the analgesia provided by MO nor induced undesired sedation or hemodynamic or respiratory effects.

Monitored anaesthesia care in the elderly: guidelines and recommendations.

As the number of elderly patients undergoing surgery continues to rise, it is important to consider anaesthetic options that minimize physiological stress in these patients. Monitored anaesthesia care (MAC), or sedation and monitoring during surgery, is an attractive option for certain common procedures. However, those administering MAC must consider the normal decline in functional reserve in patients aged >70 years. This includes loss of normal compensation for the stress of hypovolaemia, decreased peripheral vascular resistance, altered mental status and reduced response to hypoxia and hypercarbia associated with the perioperative and sedated state in this population. In addition, vigilance is necessary to identify co-morbid states, which increase in incidence with age and often present atypically. Elderly patients have increased sensitivity to all sedatives and opioids (doubled by age 80 years, quadrupled by age 90 years with benzodiazepines). As a result of changes in body composition, as well as senescence of renal and hepatic function, the time to onset and offset of even short-acting sedatives will be prolonged. There is also extreme variability in the response to sedatives among these patients. Anaesthetic dosing should be in smaller increments in the elderly, boluses reduced by half and infusions reduced by as much as two-thirds. Caution must be exercised through full monitoring of intra-operative and postoperative mental status, oxygenation and perfusion states. Pain is best treated using smaller doses in a multimodal regimen, the aim being to reduce adverse effects while ensuring adequate pain relief. In this way, a huge range of procedures can be safely performed in our aging population with expectations for a full and early return to baseline functional status.

Elaborate mapping of the posterior visual pathway in awake craniotomy.

OBJECTIVE Resection of intraaxial tumors adjacent to the optic radiation (OR) may be associated with postoperative visual field (VF) deficits. Intraoperative navigation using MRI-based tractography and electrophysiological monitoring of the visual pathways may allow maximal resection while preserving visual function. In this study, the authors evaluated the value of visual pathway mapping in a series of patients undergoing awake craniotomy for tumor resection. METHODS A retrospective analysis of prospectively collected data was conducted in 18 patients who underwent an awake craniotomy for resection of intraaxial tumors involving or adjacent to the OR. Preoperative MRI-based tractography was used for intraoperative navigation, and intraoperative acquisition of 3D ultrasonography images was performed for real-time imaging and correction of brain shift. Goggles with light-emitting diodes were used as a standard visual stimulus. Direct cortical visual evoked potential (VEP) recording, subcortical recordings from the OR, and subcortical stimulation of the OR were used intraoperatively to assess visual function and proximity of the lesion to the OR. VFs were assessed pre- and postoperatively. RESULTS Baseline cortical VEP recordings were available for 14 patients (77.7%). No association was found between preoperative VF status and baseline presence of cortical VEPs (p = 0.27). Five of the 14 patients (35.7%) who underwent subcortical stimulation of the OR reported seeing phosphenes in the corresponding contralateral VF. There was a positive correlation (r = 0.899, p = 0.04) between the subcortical threshold stimulation intensity (3-11.5 mA) and the distance from the OR. Subcortical recordings from the OR demonstrated a typical VEP waveform in 10 of the 13 evaluated patients (76.9%). These waveforms were present only when recordings were obtained within 10 mm of the OR (p = 0.04). Seven patients (38.9%) had postoperative VF deterioration, and it was associated with a length of < 8 mm between the tumor and the OR (p = 0.05). CONCLUSIONS Intraoperative electrophysiological monitoring of the visual pathways is feasible but may be of limited value in preserving the functional integrity of the posterior visual pathways. Subcortical stimulation of the OR may identify the location of the OR when done in proximity to the pathways, but such proximity may be associated with increased risk of postoperative worsening of the VF deficit.

Subcortical Mapping Using an Electrified Cavitron UltraSonic Aspirator in Pediatric Supratentorial Surgery.

BACKGROUND: Intraoperative electrophysiology is increasingly used for various lesion resections, both in adult and pediatric brain surgery. Subcortical mapping is often used in adult surgery when lesions lie in proximity to the corticospinal tract (CST). We describe a novel technique of continuous subcortical mapping using an electrified Cavitron UltraSonic Aspirator (CUSA) in children with supratentorial lesions. METHODS: We evaluated the method of subcortical mapping using a CUSA as a stimulation probe. Included in this study were children (<18 years of age) with supratentorial lesions in proximity to the CST in which the CUSA stimulator was applied. Data were collected retrospectively. RESULTS: Eleven children were included. Lesions were located in the thalamus (3), basal-ganglia (2), lateral ventricle (1), and convexity (5). Lesions included low-grade gliomas (6), arteriovenous malformation (1), cavernoma (1), cortical dysplasia (1), ependymoma grade II (1), and high-grade glioma (1). Seven patients had positive mapping responses to CUSA-based stimulation at various stimulation intensities. These responses led to a more limited resection in 5 cases. There were no complications related to the mapping technique. CONCLUSION: Continuous CUSA-based subcortical stimulation is a feasible mapping technique for assessing proximity to the CST during resection of supratentorial lesions in children. Future studies should be performed to better correlate the current threshold for eliciting a motor response with the distance from the CST, as well as the effect of age on this technique.