Blood Lost: A Retrospective Review of Blood Wastage from a Massive Transfusion Protocol in a Tertiary Paediatric Hospital.

BACKGROUND: The paediatric massive transfusion protocol (MTP) is activated in the paediatric population for both trauma and non-trauma related indications. While it helps to improve the efficiency and efficacy of the delivery of blood products, it can also result in increased wastage. We aimed to evaluate the wastage rates from our paediatric MTP activations from 2013 to 2018. METHOD: As part of an audit, we retrospectively reviewed the records of the paediatric patients who had MTP activations. We collected the following data: reason for MTP activation, weight of patient, number of cycles of MTP required, blood products used, blood products wasted, deviation from our institution's recommended MTP blood product ratio, and reason for wastage. RESULT: We had 26 paediatric MTP activations within the audit period. There was an overall wastage rate of 1.5%, with wastage occurring in 3 out of 26 patients. The reason for all wastage was demise of the patient. Most patients' transfusion ratios deviated from our institution's MTP protocol. CONCLUSION: Our wastage rates are low likely because of clear MTP activation guidelines and a flexible MTP workflow.

The use of negative-pressure wound therapy over a cultured epithelial autograft for full-thickness wounds secondary to purpura fulminans in an infant.

Purpura fulminans is a serious condition that can result in severe morbidity in the pediatric population. Although autologous skin grafts remain the gold standard for the coverage of partial- to full-thickness wounds, they have several limitations in pediatric patients, including the lack of planar donor sites, the risk of hemodynamic instability, and the limited graft thickness. In Singapore, an in-house skin culture laboratory has been available since 2005 for the use of cultured epithelial autografts (CEAs), especially in burn wounds. However, due to the fragility of CEAs, negative-pressure wound therapy (NPWT) dressings have been rarely used with CEAs. With several modifications, we report a successful case of NPWT applied over a CEA in an infant who sustained 30% total body surface area full-thickness wounds over the anterior abdomen, flank, and upper thigh secondary to purpura fulminans. We also describe the advantages of using NPWT dressing over a CEA, particularly in pediatric patients.

Home-Initiated-Programme-to-Prepare-for-Operation: evaluating the effect of an animation video on peri-operative anxiety in children: A randomised controlled trial.

BACKGROUND: Hospital admissions and surgical operations commonly trigger anxiety in young children. Despite employing numerous support measures in our hospital, such as a pre-operative play room, the encouragement of parental companionship during induction of anaesthesia and distraction therapy, allaying the anxiety of our young surgical patients remains a challenge. OBJECTIVES: To evaluate the effectiveness of a Home-Initiated-Programme-to-Prepare-for-Operation (HIPPO) on emotional manifestation and anxiety in children undergoing surgery. DESIGN, SETTING AND PATIENTS: One hundred and thirty children were randomly assigned to either control or intervention group between February 2018 and April 2019 in a tertiary paediatric hospital in Singapore. INTERVENTION: In addition to our standard pre-operative workflow, the intervention group received an additional home preparation kit consisting of an animated video on preoperative preparation and age-specific preoperative preparation activity sheets. MAIN OUTCOME MEASURES: The primary outcome was the Children's Emotional Manifestation Scale score to evaluate behaviour and emotion in the children before and during induction of anaesthesia. Secondary outcomes evaluated anxiety levels in parents and children, the child's behaviour and degree of co-operation using the State-Trait Anxiety Inventory scores, State-Trait Anxiety Inventory Children scores, the Induction Compliance Checklist scores, the Visual Analogue Scale scores for anxiety and the feedback questionnaire. RESULTS: The difference between the Children's Emotional Manifestation Scale score in control and intervention groups was not statistically significant. A promising difference was however observed in one of the secondary outcomes where the state-State-Trait Anxiety Inventory Children scores of 7 to 10-year olds in the intervention group almost reached significance; P = 0.067. CONCLUSION: Despite being a child-friendly, easily accessible and affordable tool for patient education, HIPPO did not reduce anxiety experienced by children in the pre-operative waiting area or during induction of anaesthesia. TRIAL REGISTRATION: ClinicalTrials.gov, identifier: NCT04271553.

Epidemiology of Pedestrian-Motor Vehicle Fatalities and Injuries, 2006-2015.

INTRODUCTION: Pedestrian road safety remains a public health priority. The objective of this study is to describe trends in fatalities and injuries after pedestrian-motor vehicle collisions in the U.S. and identify associated risk factors for pedestrian fatalities. METHODS: This is a cross-sectional study of U.S. pedestrian-motor vehicle collisions from 2006 to 2015 (performed in 2017). Pedestrian fatality and injury data were obtained from the National Highway Traffic Safety Administration's Fatality Analysis Reporting System and National Automotive Sampling System General Estimates System. Frequencies of fatalities, injuries, and associated characteristics were calculated. Multivariable logistic regression was performed for risk of fatality, controlling for demographic and crash-related factors. RESULTS: There were 47,789 pedestrian fatalities and 674,414 injuries during the 10-year study period. Fatality rates were highest among the elderly aged 85 years and older (2.95/100,000 population), whereas injury rates were highest for those aged 15-19 years (35.23/100,000 population). Predictors associated with increased risk for death include the following: male sex (AOR=1.36, 95% CI=1.15, 1.62), age ≥65 years (AOR=3.44, 95% CI=2.62, 4.50), alcohol involvement (AOR=2.63, 95% CI=1.88, 3.67), collisions after midnight (AOR=5.21, 95% CI=3.20, 8.49), at non-intersections (AOR=2.76, 95% CI=2.21, 3.45), and involving trucks (AOR=2.15, 95% CI=1.16, 3.97) and buses (AOR=5.82, 95% CI=3.67, 9.21). CONCLUSIONS: Potentially modifiable factors are associated with increased risk of death after pedestrian-motor vehicle collisions. Interventions including elder-friendly intersections and increasing visibility of pedestrians may aid in decreasing pedestrian injuries and deaths.

Development of an isotopic stream index connecting physiographic characteristics of montane catchments.

This study is to develop an isotopic catchment-effect index (CEI) connecting the physiographic characteristics of stream catchments. A CEI, describing the extent of difference in stable water isotopic compositions (δ values) between stream water and local precipitation at any given sampling site, can help in judging whether water resource management should be focused on upstream regions of streams or local hydrology issues. To establish the isotopic CEI, this study measured δ values of stream water and derived δ18 O of local precipitation based on regional isotopic altitude gradient at montane catchments of various sizes. Results indicate that the CEI is strongly related to catchment physiographic characteristics, such as length of main stream, mean area, mean elevation, perimeter, and slope. These characteristics are considered important indices of streamflow. Based on mathematical regression modeling describing the relationships between CEI and respective physiographic factors, CEI values can predict respective physiographic factors and vice versa. Moreover, according to the multiple equations derived in this study, catchments of larger size and steeper slope give elevated CEI values while greater stream length reduces the CEI's value. A greater CEI value indicates that local stream water is principally sourced from upstream reaches rather than contributions from local precipitation. In addition, CEI values are greater in winter than in summer resulting from monsoon effect. Consequently, this study establishes CEI as a useful descriptor of the physiographic characteristics of catchments.

Postoperative steroid therapy for biliary atresia: Systematic review and meta-analysis.

BACKGROUND/OBJECTIVES: Adjuvant steroid therapy has become popular in the postoperative management of biliary atresia. However, the benefits of steroid therapy are still not clear. We performed a systematic review and meta-analysis to determine the effect of steroids on bile drainage posthepatoportoenterostomy. METHODS: Studies published from 1968 to 2014 were searched from MEDLINE, EMBASE, Google scholar and Cochrane databases. A meta-analysis of randomized controlled trials (RCT) and observational studies comparing bile drainage between steroid and nonsteroid therapies posthepatoportoenterostomy was performed. RESULTS: Seven studies (2 RCTs and 5 observational studies) were included, comprising 259 cases of nonsteroid and 228 cases of steroid therapies. There was no statistical improvement in jaundice clearance in the steroid group [pooled odds ratio (OR)=1.51; 95% confidence interval (CI) 0.95-2.41; P=0.08; I(2)=30%]. Among 7 studies, 4 studies applied similar moderate high-dose steroid regimens (prednisolone 4-5mg/kg/day for 1-2 weeks followed by weeks of tapering dosage). However, these moderate high-dose regimens demonstrated improved jaundice clearance at 6 months posthepatoportoenterostomy (pooled OR=1.59; 95% CI 1.03-2.45; P=0.04; I(2)=0%). A subgroup analysis also showed that the effect of those moderate high-dose steroids was more pronounced in infants operated on by 70 days of age (pooled OR=1.86; 95% CI 1.08-3.22; P=0.03; I(2)=0%). CONCLUSION: Moderate high-dose steroid therapy improves jaundice clearance, especially for infants who undergo hepatoportoenterostomy by 70 days of age. However, more RCTs with longer follow-up are necessary to demonstrate the effect of steroids on the long-term outcomes of biliary atresia.

Resection of an intra-operative ruptured hepatocellular carcinoma with continuous pringle maneuver and in situ hypothermic perfusion through the inferior mesenteric vein: a case report.

Intra-operative tumor rupture is a serious complication during resection of large hepatocellular carcinoma (HCC) leading to more blood loss. We report our experience in applying continuous Pringle maneuver with in situ hypothermic perfusion via inferior mesenteric vein catheterization to the portal vein of the remnant liver for resection during an extended left lobectomy of a large HCC which ruptured intraoperatively. Using this method, we successfully managed the patient without any further morbidity. This technique provides easier accessibility of in situ perfusion, decreases operative blood loss and prevents warm ischemic injury to the remnant liver during parenchymal transection. This method could be effective for the resection of large ruptured HCC.

Intra-operative management of low portal vein flow in pediatric living donor liver transplantation.

For pediatric living donor liver transplantation, portal vein complications cause significant morbidity and graft failure. Routine intra-operative Doppler ultrasound is performed after graft reperfusion to evaluate the flow of portal vein. This retrospective study reviewed 65 children who had undergone living donor liver transplantation. Seven patients were detected with suboptimal portal vein flow velocity following vascular reconstruction and abdominal closure. They underwent immediate on-table interventions to improve the portal vein flow. Both surgical and endovascular modalities were employed, namely, graft re-positioning, collateral shunt ligation, thrombectomy, revision of anastomosis, inferior mesenteric vein cannulation, and endovascular stenting. The ultrasonographic follow-up assessment for all seven patients demonstrated patent portal vein and satisfactory flow. We reviewed our experience on the different modalities and proposed an approach for our future intra-operative management to improve portal vein flow at the time of liver transplantation.

Perforation: a rare complication of choledochal cysts in children.

PURPOSE: Spontaneous perforation is a rare complication of choledochal cyst (CDC) which is difficult to diagnose due to its nonspecific clinical presentation. The surgical treatment can be either single-staged cyst excision or two-staged procedure with an initial drainage followed by delayed cyst excision. Both biliary duct obstruction and irritation due to refluxed pancreatic juice have been proposed as possible aetiology. In this report, we describe six cases of CDC perforation in hope to have a better understanding on the clinical features and cause of this complication. METHODS: Medical records of six patients whose diagnoses of perforated CDC were confirmed with intra-operative findings were retrospectively reviewed. Clinical data, investigation results and post-operative outcomes were analysed. RESULTS: Vomiting and abdominal pain were the most common complaints. Few patients present with clinical jaundice. Overt sign of peritonitis was absent. Both single-staged and two-staged approach offered satisfactory outcome. CONCLUSION: Hyperbilirubinaemia and remote free intra-peritoneal fluid allude the diagnosis of perforated CDC. When presenting with cholangitis, it warrants timely surgical intervention to prevent perforation. Single-staged or two-staged surgical approach would depend on stability of patient and surgical expertise available. Reversible dilatation of intra-hepatic duct suggests that increased intra-ductal pressure is a contributing factor to the perforation.