Long-term multidisciplinary follow-up programs in pediatric cardiac arrest survivors.

Long-term outcome studies after pediatric cardiac arrest (CA) are few. They require a CA registry and dedicated outcome teams. Learning about the long-term outcomes is very important for developing prognostication guidelines, improving post-cardiac care, counseling caregivers about the future of their child, and creating opportunities for therapeutic intervention studies to improve outcomes. Few PICUs worldwide provide a multidisciplinary follow-up program as routine practice at an outpatient clinic with standardized measurements, using validated instruments including neuropsychological assessments by psychologists. The primary goal of such a follow-up program should be to provide excellent care to children and their caregivers, thereby resulting in a high attendance. Pediatric psychologists, neurologists and pediatricians/pediatric intensivists should ideally be involved to screen for delayed development and psychosocial problems and offer appropriate care at the same time. Preferably, outcomes should consist of evaluation of morbidity (physical and neuropsychological), functional health and Health Related Quality Of Life (QoL) of the patient and their caregivers.

Trends in community response and long-term outcomes from pediatric cardiac arrest: A retrospective observational study.

AIM: This study aimed to investigate trends over time in pre-hospital factors for pediatric out-of-hospital cardiac arrest (pOHCA) and long-term neurological and neuropsychological outcomes. These have not been described before in large populations. METHODS: Non-traumatic arrest patients, 1 day-17 years old, presented to the Sophia Children's Hospital from January 2002 to December 2020, were eligible for inclusion. Favorable neurological outcome was defined as Pediatric Cerebral Performance Categories (PCPC) 1-2 or no difference with pre-arrest baseline. The trend over time was tested with multivariable logistic and linear regression models with year of event as independent variable. FINDINGS: Over a nineteen-year study period, the annual rate of long-term favorable neurological outcome, assessed at a median 2.5 years follow-up, increased significantly (OR 1.10, 95%-CI 1.03-1.19), adjusted for confounders. Concurrently, annual automated external defibrillator (AED) use and, among adolescents, initial shockable rhythm increased significantly (OR 1.21, 95% CI 1.10-1.33 and OR 1.15, 95% CI 1.02-1.29, respectively), adjusted for confounders. For generalizability purposes, only the total intelligence quotient (IQ) was considered for trend analysis of all tested domains. Total IQ scores and bystander basic life support (BLS) rate did not change significantly over time. INTERPRETATION: Long-term favorable neurological outcome, assessed at a median 2.5 years follow-up, improved significantly over the study period. Total IQ scores did not significantly change over time. Furthermore, AED use (OR 1.21, 95%CI 1.10-1.33) and shockable rhythms among adolescents (OR1.15, 95%CI 1.02-1.29) increased over time.

Association between shockable rhythms and long-term outcome after pediatric out-of-hospital cardiac arrest in Rotterdam, the Netherlands: An 18-year observational study.

INTRODUCTION: Shockable rhythm following pediatric out-of-hospital cardiac arrest (pOHCA) is consistently associated with hospital and short-term survival. Little is known about the relationship between shockable rhythm and long-term outcomes (>1 year) after pOHCA. The aim was to investigate the association between first documented rhythm and long-term outcomes in a pOHCA cohort over 18 years. METHODS: All children aged 1 day-18 years who experienced non-traumatic pOHCA between 2002-2019 and were subsequently admitted to the emergency department (ED) or pediatric intensive care unit (PICU) of Erasmus MC-Sophia Children's Hospital were included. Data was abstracted retrospectively from patient files, (ground) ambulance and Helicopter Emergency Medical Service (HEMS) records, and follow-up clinics. Long-term outcome was determined using a Pediatric Cerebral Performance Category (PCPC) score at the longest available follow-up interval through august 2020. The primary outcome measure was survival with favorable neurologic outcome, defined as PCPC 1-2 or no difference between pre- and post-arrest PCPC. The association between first documented rhythm and the primary outcome was calculated in a multivariable regression model. RESULTS: 369 children were admitted, nine children were lost to follow-up. Median age at arrest was age 3.4 (IQR 0.8-9.9) years, 63% were male and 14% had a shockable rhythm (66% non-shockable, 20% unknown or return of spontaneous circulation (ROSC) before emergency medical service (EMS) arrival). In adolescents (aged 12-18 years), 39% had shockable rhythm. 142 (39%) of children survived to hospital discharge. On median follow-up interval of 25 months (IQR 5.1-49.6), 115/142 (81%) of hospital survivors had favorable neurologic outcome. In multivariable analysis, shockable rhythm was associated with survival with favorable long-term neurologic outcome (OR 8.9 [95%CI 3.1-25.9]). CONCLUSION: In children with pOHCA admitted to ED or PICU shockable rhythm had significantly higher odds of survival with long-term favorable neurologic outcome compared to non-shockable rhythm. Survival to hospital discharge after pOHCA was 39% over the 18-year study period. Of survivors to discharge, 81% had favorable long-term (median 25 months, IQR 5.1-49.6) neurologic outcome. Efforts for improving outcome of pOHCA should focus on early recognition and treatment of shockable pOHCA at scene.

Analgosedation in paediatric severe traumatic brain injury (TBI): practice, pitfalls and possibilities.

Analgosedation is a fundamental part of traumatic brain injury (TBI) treatment guidelines, encompassing both first and second tier supportive strategies. Worldwide analgosedation practices continue to be heterogeneous due to the low level of evidence in treatment guidelines (level III) and the choice of analgosedative drugs is made by the treating clinician. Current practice is thus empirical and may result in unfavourable (often hemodynamic) side effects. This article presents an overview of current analgosedation practices in the paediatric intensive care unit (PICU) and addresses pitfalls both in the short and long term. We discuss innovative (pre-)clinical research that can provide the framework for initiatives to improve our pharmacological understanding of analgesic and sedative drugs used in paediatric severe TBI and ultimately facilitate steps towards evidence-based and precision pharmacotherapy in this vulnerable patient group.

Effects of anesthetic agents on seizure-induction with intra-cortical injection of convulsants.

RATIONALE: Studies of partial or generalized seizure pathophysiology often require the use of intact animals. Additionally, anesthesia may be required for ethical reasons or paralysis if instrumental measures require immobilization. We examined three commonly used injected anesthetic for their impact on seizures induced by three convulsant agents. METHODS: We prepared rats, under pentobarbitone anesthesia (65 mg/kg) with a catheter, electrodes and a dural window, for later non-noxious experimentation. Three to seven days later, kainic acid (1.25 µg), picrotoxin (225 ng) or fluorocitrate (0.8 nmol) were injected intra-cortically in animals paralysed with succinylcholine, or anesthetised with pentobarbitone, urethane or fentanyl plus droperidol. We recorded EEG activity, the latencies to seizure discharges, the occurrence of spreading depressions and the presence of movements in response to the convulsants. RESULTS: Fentanyl plus droperidol was the only anesthetic agent permissive for seizure-discharges and spreading depressions. No significant differences in the time for seizure onset for fentanyl plus droperidol compared to paralyzed unanesthetised rats were seen for any of the convulsants (Student's t-test p>0.20). Movements during seizures as well as other drug-induced behaviors continued to be expressed during anesthesia. CONCLUSION: Fentanyl plus droperidol has useful properties as an anesthetic agent in studies of seizure induction with different convulsants.

A rare complication after laparoscopic gastric banding: connecting-tube penetration into the hilus of the kidney.

Laparoscopic adjustable gastric banding is a common operation for morbid obesity. Late complications mainly originate from either the injection port (dislocation, infection, leakage) or the gastric band (pouch dilatation, slippage, leakage, gastric erosion). Complications from the tube, connecting the port with the band, are rarely described. We report the penetration of a loose connecting tube into the kidney 8 months after removal of an infected injection port.

Obesity surgery: discouraging long term results with Mason's vertical banded gastroplasty.

OBJECTIVE: To evaluate the long term results of Mason's vertical banded gastroplasty (VBG) using accepted criteria, and to find out which factors predicted success. DESIGN: Retrospective survey of a cohort of 40 severely obese patients (mean initial body mass index (BMI in kg/m2): 43, range 34-62). SETTING: General teaching hospital, The Netherlands. MAIN OUTCOME MEASURES: Success according to three definitions: weight loss of more than 25%; percentage of excess weight 50% or less; and BMI < 30. RESULTS: Mean follow-up was 7.4 years (range 0.5-10) or 85%. The distribution over MacLean and Reinhold criteria shows a shift towards unfavourable categories. The consecutive percentages of success at five years were 35%, 62%, and 35%. Logistic regression analysis of success at 5 years shows that the following factors significantly predicted success: Definition I: age odds ratio (95% confidence interval): 0.88 (0.78 to 0.99). Definition II: age: 0.84 (0.69-1.01), outlet > or = 5 cm: 176 (2.4 to 12774), percentage of ideal weight > or = 100%: 0.03 (0.002 to 0.48). Definition III: age: 0.86 (0.75 to 0.99), pouch size > or = 15 ml: 10.64 (1.48 to 76.6). CONCLUSION: The long term results of VBG are disappointing when assessed by the standard criteria.

Adjustable silicone gastric banding: can We continue the original technique of Kuzmak?

BACKGROUND: Kuzmak developed a horizontal gastroplasty for morbid obesity using his adjustable silicone gastric banding (ASGB). The aim of this study was to evaluate the efficiency at weight loss, early and late morbidity and mortality. METHOD: The records of 44 patients (mean age 36 years) were reviewed. The indication for ASGB was a BMI >40 (group A = 37 patients) or a BMI between 35 and 40 with obesity-related morbidity (group B = 7 patients). The mean preoperative BMI was 44 (+/-5). The paired t test was used to evaluate the BMI. RESULTS: Early complications occurred in 5 patients: splenic injury (n = 1), aspiration pneumonia (n = 1), wound infection (n = 1), gastric perforation (n = 2); mortality was 2%. Late complications occurred in 19 patients: 17 patients (39%) had a functional stenosis with pouch dilatation (FSPD) and 6 patients had an injection port leakage (14%). At the 1-year follow-up, the mean BMI (of the 39 patients available) was 30 (+/-5) and remained stable. At 36 months, 54% of group A and 100% of group B had a BMI <30. CONCLUSION: The original technique of Kuzmak is effective to lose weight. However the technique must be adjusted in order to decrease the unacceptable high incidence of FSPD.

[Bariatric surgery using an adjustable gastric band for morbid obesity: initial 30 patients in The Netherlands]. / Bariatrische chirurgie met een variabele maagband voor morbide obesitas: eerste 30 patiënten in Nederland.

OBJECTIVE: Early evaluation of efficacy and safety of Adjustable Silicone Gastric Banding (ASGB) in the treatment of morbid obesity. DESIGN: Descriptive. SETTING: Red Cross Hospital, Beverwijk, the Netherlands. METHOD: In the period September 1991-September 1993, 30 eligible patients (5 men and 25 women, median age 37 years (range 22-60), median excessive weight 63 kg (18-94), median body mass index (BMI) 43 kg/m2 (28-53)) were operated. A horizontal gastroplasty was performed resulting in a pouch of 25 ml and a new stomach outlet with a diameter of 12 mm. The volume of the band may be increased in order to diminish the diameter of the outlet according to clinical needs postoperatively. RESULTS: The follow-up was 10 months in 13 of the 30 patients. After 6 months median BMI was 33 kg/m2 (23-38) and median loss of excessive weight 53% (27-94), after 10 months these 28 kg/m2 (23-38) and 67% (27-98) respectively. No patients died perioperatively; 52 gastric band adjustments were necessary in 17 patients. Complications consisted of: band dislocation (1 patient), functional stenosis (2), gastric perforation (2) and wound infection (1). Four patients needed reoperation. CONCLUSION: In this short term follow-up ASGB gave a good weight reduction. Advantages of ASGB are the reversibility of the operation and the adjustable outlet.

The role of A-O-incompatible blood transfusions in porcine orthotopic liver transplantations.

The consequences of administrations of A-O-incompatible blood transfusions during porcine orthotopic liver transplantations (OLT) are described. Two series, both subjected to the same standard procedure except for the administration of compatible or incompatible blood, are compared. The striking differences in peroperative and direct post-operative morbidity, mortality, and causes of death between the two series are presented. Although not generally applied, blood transfusions in experimental surgery should undergo the same precautionary measures as blood transfusions in humans.