Does the participation of a senior plastic surgeon improve conditions of hospitalisation in craniosynostosis repair surgery?

INTRODUCTION: The real impact of the participation of other surgical specialties together with neurosurgeons on perioperative care in craniosynostosis repair surgery has not been determined. The purpose of this study was to determine whether the participation of a second senior surgeon (plastic surgeon) during surgical repair of pediatric monosutural craniosynostosis improved perioperative medical care. MATERIAL AND METHODS: The authors retrospectively reviewed 2 cohorts of patients who had consecutively undergone primary repair surgery for trigonocephaly and unicoronal craniosynostosis. Infants were operated on by a single senior pediatric neurosurgeon before December 2017, and with the collaboration of a senior plastic surgeon after January 2018. RESULTS: Overall, 60 infants were included in the study: 29 in group 1 (single surgeon, 2011-2017), and 31 in group 2 (pair of surgeons, 2018-2021). Median surgery time was significantly shorter in group 2 than group 1: 180 vs. 167minutes; P=0.0045. There was no significant difference between the 2 groups in blood loss or intra/postoperative packed erythrocyte transfusion. Postoperative drain output was significantly lower in group 2. Median length of hospital and intensive care stay were significantly shorter in group 2, by 1 and 2 days, respectively; P<0.0001. Volume of infused solution, diuresis, immediate postoperative hemoglobin level, hematocrit, hemostasis (platelet count, fibrinogen, prothrombin time and activated partial thromboplastin time), and return to oral feeding did not differ from one group to the other. CONCLUSION: Results confirmed our impression of an improvement in perioperative medical care. However, the role of surgical experience and the influence of the medical/nursing staff must not be minimized in these complex surgical procedures.

Effectiveness and complications of ultrasound-guided subclavian vein cannulation in children and neonates.

BACKGROUND: The ultrasound (US)-guided supraclavicular approach to subclavian vein (Sup-SCV) catheterisation in children has recently been described and evaluated in a small cohort. The aim of this study was to assess this technique in a large paediatric cohort including neonates. METHODS: We conducted a prospective observational study between November 2010 and December 2013 which included 615 children divided into two groups according to their weight: Group 1≤5kg (n=124), Group 2>5kg (n=491). All procedures were performed under general anaesthesia by an anaesthesiologist or a supervised resident. The success rates of catheter insertion, the number of punctures required, the procedure time, and the complication rates were analysed. RESULTS: Sup-SCV catheterisation was successful in 98% of the cases and was higher in Group 2 than in Group 1 (99.4% versus 92.7%, P<0.001). The success rate after the first attempt was higher and the incidence of multiple attempts (≥3 punctures) was lower in Group 2 than in Group 1 (84.2% versus 64.5%, P<0.001 and 4.5% versus 19.4%, P<0.001). The success rate was similar between right and left cannulations (P=0.404), and according to physician experience (P=1.000). Procedure time was fast in both groups with a median time for all procedures of 40 seconds [30-90]. Among the procedures recorded, only five arterial punctures and no cases of pneumothorax were observed. CONCLUSION: US-guided Sup-SCV catheterisation appears to be fast and safe in children and neonates, even if it remains a little more difficult to achieve in lower-weight patients.

Transvesical Intra-Abdominal Pressure Measurement in Newborn: What Is the Optimal Saline Volume Instillation?

OBJECTIVE: To determine the optimal saline volume bladder instillation to measure intravesical pressure in critically ill newborns weighing less than 4.5 kg, and to establish a reference of intra-abdominal pressure value in this population. DESIGN: Prospective monocentric study. SETTING: Neonatal ICU and PICU. PATIENTS: Newborns, premature or not, weighing less than 4.5 kg who required a urethral catheter. MEASUREMENTS AND MAIN RESULTS: Patients were classified into two groups according to whether they presented a risk factor for intra-abdominal hypertension. Nine intravesical pressure measures per patient were performed after different volume saline instillation. The first one was done without saline instillation and then by increments of 0.5 mL/kg to a maximum of 4 mL/kg. Linear models for repeated measurements of intravesical pressure with unstructured covariance were used to analyze the variation of intravesical pressure measures according to the conditions of measurement (volume instilled). Pairwise comparisons of intravesical pressure adjusted mean values between instillation volumes were done using Tukey tests, corrected for multiple testing to determine an optimal instillation volume. Forty-seven patients with completed measures (nine instillations volumes) were included in the analysis. Mean intravesical pressure values were not significantly different when measured after instillation of 0.5, 1, or 1.5 mL/kg, whereas measures after instillation of 2 mL/kg or more were significantly higher. The median intravesical pressure value in the group without intra-abdominal hypertension risk factor after instillation of 1 mL/kg was 5 mm Hg (2-6 mm Hg). CONCLUSIONS: The optimal saline volume bladder instillation to measure intra-abdominal pressure in newborns weighing less than 4.5 kg was 1 mL/kg. Reference intra-abdominal pressure in this population was found to be 5 mm Hg (2-6 mm Hg).

Long-term mortality and quality of life after septic shock: a follow-up observational study.

PURPOSE: In septic shock, short-term outcomes are frequently reported, while long-term outcomes are not. The aim of this study was to evaluate mortality and health-related quality of life (HRQOL) in survivors 6 months after an episode of septic shock. METHODS: This single-centre observational study was conducted in an intensive care unit in a university hospital. All patients with septic shock were included. Mortality was assessed 6 months after the onset of septic shock, and a comparison between patients who survived and those who died was performed. HRQOL was assessed using the MOS SF-36 questionnaire prior to hospital admission (baseline) and at 6 months in survivors. HRQOL at baseline and at 6 months were compared to the general French population, and HRQOL at baseline was compared to 6-month HRQOL. RESULTS: Ninety-six patients were included. Six-month mortality was 45%. Survivors were significantly younger, had significantly lower lactate levels and SAPS II scores, required less renal support, received less frequent administration of corticosteroids, and had a longer length of hospital stay. At baseline (n = 39) and 6 months (n = 46), all of the components of the SF-36 questionnaire were significantly lower than those in the general population. Compared to baseline (n = 23), the Physical Component Score (CS) improved significantly at 6 months, the Mental CS did not differ. CONCLUSIONS: Mortality 6 months after septic shock was high. HRQOL at baseline was impaired when compared to that of the general population. Although improvements were noted at 6 months, HRQOL remained lower than that in the general population.