A role for conservative antibiotic treatment in early appendicitis in children.

PURPOSE: To evaluate whether antibiotics without surgery is sufficient treatment for children with clinically and ultrasonographically suspected acute appendicitis (AA). METHOD: Children with clinical, laboratory and radiological findings suspicious for AA were evaluated prospectively. Patients with mild clinical signs, without peritonitis were considered for IV followed by oral antibiotics without surgery. RESULTS: From 1 November 2013 through 30 June 2014, 45 children were diagnosed with early, acute appendicitis. Ages ranged from 4 to 15 years (mean 9.3) and 32 (75%) were boys. All had routine, clinical laboratory and ultrasound workup. Forty-two improved with antibiotic treatment and were discharged home within 3-5 days, without surgery. Three of them were operated on within 24 hours, another two underwent appendectomy for recurrent appendicitis: one at 2 weeks and the other 2 months after discharge. There was no more recurrent appendicitis in 6-14-month follow-up. CONCLUSION: Our series of patients with AA treated with antibiotics only are a product of the observation that some children improve with antibiotics alone at a stage in which surgery is still debatable. These results (89% success rate) support the conservative approach in cases of early appendicitis, without increased morbidity in failed cases.

Assessment of surgical discharge summaries and evaluation of a new quality improvement model.

BACKGROUND: Discharge summaries after hospitalization provide the most reliable description and implications of the hospitalization. A concise discharge summary is crucial for maintaining continuity of care through the transition from inpatient to ambulatory care. Discharge summaries often lack information and are imprecise. Errors and insufficient recommendations regarding changes in the medical regimen may harm the patient's health and may result in readmission. OBJECTIVES: To evaluate a quality improvement model and training program for writing postoperative discharge summaries for three surgical procedures. METHODS: Medical records and surgical discharge summaries were reviewed and scored. Essential points for communication between surgeons and family physicians were included in automated forms. Staff was briefed twice regarding required summary contents with an interim evaluation. Changes in quality were evaluated. RESULTS: Summaries from 61 cholecystectomies, 42 hernioplasties and 45 colectomies were reviewed. The average quality score of all discharge summaries increased from 72.1 to 78.3 after the first intervention (P < 0.0005) to 81.0 following the second intervention. As the discharge summary's quality improved, its length decreased significantly. CONCLUSIONS: Discharge summaries lack important information and are too long. Developing a model for discharge summaries and instructing surgical staff regarding their contents resulted in measurable improvement. Frequent interventions and supervision are needed to maintain the quality of the surgical discharge summary.

Fatores de risco para raquianestesia em recém-nascidos pré-termo submetidos a herniorrafia inguinal / Risk factors for spinal anesthesia in preterm infants undergoing inguinal hernia repair

OBJETIVOS: Investigar os fatores de risco e a incidência de efeitos adversos perioperatórios advindos da raquianestesia não suplementada em recém-nascidos pré-termo. Também foi avaliado o tempo decorrido até o reinício da alimentação oral e até a alta hospitalar. MÉTODOS: Foram coletados prospectivamente os dados perioperatórios de todos os recém-nascidos prematuros e ex-prematuros submetidos a herniorrafia inguinal com raquianestesia em um centro médico terciário. RESULTADOS: O grupo de estudo consistiu em 144 recém-nascidos com uma idade gestacional mediana de 30 semanas, idade concepcional de 37 semanas, peso de nascimento de 1.420 g, e peso de 2.140 g no momento da cirurgia. No total, seis (4,2%) recém-nascidos apresentaram complicações intraoperatórias, que incluíram apneia (2/1,4%), bradicardia (2/1,4%) e hipoxemia (4/2,8%). Complicações pós-operatórias ocorreram em 15 (10,4%) recém-nascidos, principalmente hipoxemia (3/2,1%), bradicardia (8/5,5%) e apneia (6/4,1%). Os fatores preditivos de desfecho desfavorável (apneia, alimentação oral > 6 h de pós-operatório, ou alta > 30 h de pós-operatório) foram displasia broncopulmonar [razão de chances (OR) = 3,2, intervalo de confiança de 95% (IC95%) 2,8-5,3; p = 0,01] e leucomalácia periventricular (OR = 2,8, IC95% 2,1-4,9; p = 0,03). CONCLUSÕES: A raquianestesia é segura e eficaz na herniorrafia inguinal em recém-nascidos pré-termo, levando a um reinício precoce da alimentação oral e a um menor período de hospitalização. Displasia broncopulmonar e leucomalácia periventricular podem acarretar risco de desfecho desfavorável.

OBJECTIVES: To investigate the risk factors and incidence of perioperative adverse effects from unsupplemented spinal anesthesia in preterm infants. Times to resumption of oral feeding and to home discharge were also evaluated. METHODS: Perioperative data were collected prospectively for all preterm and former preterm infants who underwent inguinal hernia repair with spinal anesthesia at a tertiary medical center. RESULTS: The study group consisted of 144 infants with a median gestational age of 30 weeks, postmenstrual age of 37 weeks, birth weight of 1,420 g, and weight at surgery of 2,140 g. Overall, six (4.2%) infants had intraoperative complications, which included apnea (2/1.4%), bradycardia (2/1.4%), and hypoxemia (4/2.8%). Postoperative complications occurred in 15 (10.4%) infants, mainly hypoxemia (3/2.1%), bradycardia (8/5.5%), and apnea (6/4.1%). Predictive factors of an unfavorable outcome (apnea, resumption of oral feeding > 6 h postoperatively, or discharge > 30 h postoperatively) were bronchopulmonary dysplasia (odds ratio [OR] = 3.2, 95% confidence interval [95%CI] 2.8-5.3; p = 0.01) and periventricular leukomalacia (OR = 2.8, 95%CI 2.1-4.9; p = 0.03). CONCLUSIONS: Spinal anesthesia is safe and effective for inguinal hernia repair in preterm infants, with early resumption of oral feeding and short hospitalization. Bronchopulmonary dysplasia and periventricular leukomalacia may pose risks for an unfavorable outcome.

Risk factors for spinal anesthesia in preterm infants undergoing inguinal hernia repair.

OBJECTIVES: To investigate the risk factors and incidence of perioperative adverse effects from unsupplemented spinal anesthesia in preterm infants. Times to resumption of oral feeding and to home discharge were also evaluated. METHODS: Perioperative data were collected prospectively for all preterm and former preterm infants who underwent inguinal hernia repair with spinal anesthesia at a tertiary medical center. RESULTS: The study group consisted of 144 infants with a median gestational age of 30 weeks, postmenstrual age of 37 weeks, birth weight of 1,420 g, and weight at surgery of 2,140 g. Overall, six (4.2%) infants had intraoperative complications, which included apnea (2/1.4%), bradycardia (2/1.4%), and hypoxemia (4/2.8%). Postoperative complications occurred in 15 (10.4%) infants, mainly hypoxemia (3/2.1%), bradycardia (8/5.5%), and apnea (6/4.1%). Predictive factors of an unfavorable outcome (apnea, resumption of oral feeding > 6 h postoperatively, or discharge > 30 h postoperatively) were bronchopulmonary dysplasia (odds ratio [OR] = 3.2, 95% confidence interval [95%CI] 2.8-5.3; p = 0.01) and periventricular leukomalacia (OR = 2.8, 95%CI 2.1-4.9; p = 0.03). CONCLUSIONS: Spinal anesthesia is safe and effective for inguinal hernia repair in preterm infants, with early resumption of oral feeding and short hospitalization. Bronchopulmonary dysplasia and periventricular leukomalacia may pose risks for an unfavorable outcome.

Is there a connection between paediatric acute idiopathic scrotal oedema and intestinal worm infestation?

AIM: Based on our experience with acute idiopathic scrotal oedema (AISO) and observations of the incidence of intestinal worm infestation (IWI), we decided to test the hypothesis that IWI occurs more frequently among children with AISO than it does in the general population. METHODS: A retrospective questionnaire-based study was conducted comparing the frequency of IWI between children who had AISO and a matched control group who had inguinal hernia surgery in our Pediatric Surgery Department during 2003-2009. This second group was chosen to represent the incidence of IWI in the paediatric community in our region. Records of all patients admitted to the Department of Pediatric Surgery for AISO during 2003-2009 were reviewed. RESULTS: Seventeen out of thirty-eight (44.7%) AISO patients had a history of IWI compared with 5/38 (13.1%) in the control group (P= 0.0047). CONCLUSIONS: Our data clearly show that AISO in children is frequently associated with a history of IWI. Although well-documented, prospective studies are needed to establish these findings, we feel that this report provides a reasonable clue to a possible aetiology of AISO.

The impact of early sonographic evaluation on hospital admissions of children with suspected acute appendicitis.

PURPOSE: Early ultrasound (US) evaluation of children with abdominal pain and suspected acute appendicitis (AA) is an important diagnostic tool. Since 2007, US has become part of routine emergency room (ER) work-up performed for suspected pediatric AA in our hospital. METHODS: We retrospectively compared hospital admissions from 2007 to 2008 with those from 2005 to 2006, when most ultrasounds were done after admission to Pediatric Surgery for observation. RESULTS: During the study (2005-2008), 6,511 children came to the ER with acute abdominal pain. Although pediatric ER sonography increased from 28.1% (865/3,079) in 2005-2006 to 51.7% (1,775/3,432) in 2007-2008 (p < 0.0001), hospitalizations decreased from 33 to 30.1% (p = 0.011). Concurrently, ER US for AA increased from 20.8% (639/2,440) to 38.9% (1,336/2,096) (p < 0.0001), admissions for suspected AA decreased from 51.8% (331/639) to 42% (561/1,336) (p < 0.0001). CONCLUSIONS: Sonography led to a significant decline in admissions and better selection of patients who required surgery for AA. Recurrent ER referrals for the same complaint within 2 weeks was very low (2.9%) with no difference between the two study periods (p = 1); none had AA. These findings encourage us to continue early US in children with suspected AA. This effective tool decreases unnecessary hospital stays, investigative procedures, and surgery, while reducing costs.

Premarketing surveillance of ibuprofen suppositories in febrile children.

In many countries, ibuprofen is available only in oral formulations. The authors aimed to investigate parental satisfaction and possible adverse reactions among children receiving newly marketed ibuprofen suppositories, prior to their arrival at the pharmaceutical points of distribution. Children needing antipyretic medication were recruited from 11 pediatric wards and clinics in Israel. Each patient received ibuprofen suppositories (5-10 mg/kg/dose) after completing a data collection form. After 3 to 7 days of treatment, information regarding parent satisfaction, possible adverse reactions, and concomitant use of drugs was obtained. Overall, 490 children completed the study. Parents' satisfaction was high (4.5 ± 0.47 on a scale of 1-5), and 92.2% reported that they would use the medication in the future. Adverse reactions were reported in 8 patients (1.63%, 95% confidence interval = 1.77-3.25), the most common being diarrhea. Rectal administration of ibuprofen suppositories is well tolerated and overall satisfaction and the repeated expected use were high.

Blood sampling through peripheral venous catheters is reliable for selected basic analytes in children.

OBJECTIVE: The goal was to determine the interchangeability of peripheral venous catheter (PVC) and venipuncture blood sampling (BS). METHODS: Paired blood samples from hospitalized children were obtained through venipuncture and from existing PVCs, following discard of 2 mL of blood. Comparisons of 9 complete blood count indices (white and red blood cell counts, hemoglobin and hematocrit levels, mean corpuscular volume, mean corpuscular hemoglobin level, red blood cell distribution width, platelet count, and mean platelet volume) and 5 basic chemical analysis indices (sodium, potassium, glucose, chloride, and urea levels) were performed, and hemolysis was documented. RESULTS: Irrespective of gauge, blood samples were obtained successfully from 40 (85.1%) of 47 PVCs, with no abnormal hemolysis. BS through venipuncture took longer than BS from PVCs (175.8 +/- 229.6 vs 104.5 +/- 53.4 seconds; P = .053) and was associated with significantly more distress/crying (73.1% vs 0%; P < .001). There were no significant differences between venipuncture and PVC samples (paired t test). Twenty-one (6%) of 348 pairs analyzed with the Clinical Laboratory Improvement Amendment standards fell outside the range of acceptable variance (8 of 21 aberrations were attributed to glucose measurements). Bland-Altman analysis indicated that, with the exclusion of glucose measurements, BS from PVCs is reliable, with 29 (6.5%) of 448 pairs exceeding the limits of agreement. Of those, 9 cases were clinically significant, but none would have altered clinical management. CONCLUSIONS: PVC sampling was shown to be a pain-reducing method that can be used for children for selected basic analytes. The findings for glucose were unreliable.

Gastric emptying time of oral contrast material in children and adolescents undergoing abdominal computed tomography.

OBJECTIVES: : Considering the hazards of pulmonary aspiration of oral contrast material (OCM) during general anesthesia, we investigated the gastric emptying time (GET) of OCM in children and adolescents undergoing abdominal computed tomography (CT). PATIENTS AND METHODS: : Included in the study were 101 consecutive patients ages 3.1 to 17.9 years (mean age 12.2 +/- 3.3 years), who underwent contrast-enhanced abdominal CT for suspected acute appendicitis (n = 90), abdominal trauma (n = 10), or suspected ileus (n = 1). Oral iodinated ioxithalamate was given for bowel opacification. Background data (age, sex, weight, chronic diseases, and medication intake), time of initiation and completion of OCM, and time of CT scanning were recorded. To estimate the GET of OCM, CT images were reviewed to examine whether the stomach was empty or full of OCM at the time of imaging. RESULTS: : The Kaplan-Meier curve showed that 75% of the patients had OCM in the stomach 48 +/- 5.2 minutes after its completion, 50% after 74 +/- 7.9 minutes, and 25% after 135 +/- 32.5 minutes; 1 patient still had OCM after 162 minutes. Except for the length of time taken to drink the contrast material (< or =90 minutes was associated with slower empting of the stomach; log rank, P = 0.03), GET of OCM was not correlated with sex (P = 0.16), age (P = 0.15), weight (P = 0.13), or type of diagnosis (P = 0.41). CONCLUSIONS: : Given the variability of GET of OCM and if clinically feasible, we advocate waiting at least 3 hours between completion of OCM ingestion and general anesthesia induction.

Management of acute appendicitis: an imaging strategy in children.

The pre-operative diagnosis of acute appendicitis (AA) has markedly changed during the last couple of decades due to the advent of modern imaging technology. Nowadays, the use of imaging has dramatically changed the way we approach children admitted to emergency room for abdominal pain with suspected AA. This change is mainly manifested in our diagnostic strategy.

Continuous lumbar/thoracic epidural analgesia in low-weight paediatric surgical patients: practical aspects and pitfalls.

PURPOSE: Continuous epidural anaesthesia attenuates perioperative stress and avoids the need for systemic opioids. In addition, it may prevent the need for postoperative mechanical ventilation. The aim of the study was to prospectively follow the perioperative course of young infants treated with continuous thoracic/lumbar epidural anaesthesia for major surgery. METHODS: Data were collected prospectively from 44 epidural anaesthetics in 40 infants (18 premature or former premature) weighing 1,400-4,300 g who underwent major abdominal surgery (33 cases), thoracic surgery (5), or both (1), or ano-rectal surgery (5) at our centre. RESULTS: Epidural placement was achieved easily in all cases, with high quality analgesia for 24-96 h. Tracheal extubation was delayed after 4 anaesthetics due to muscle relaxant overdose (n = 1), surgeon's request (n = 2), and systemic opioid administration before epidural anaesthesia was considered (n = 1). Intraoperative complications included haemodynamic instability (n = 1) and vascular catheter placement (n = 5). Postoperative complications included meningitis (n = 1), insertion site erythema (n = 7), apnoea (n = 6; 4 premature and 2 full-term infants) and tracheal re-intubation (n = 6). CONCLUSIONS: Continuous epidural analgesia is effective in low-weight infants undergoing major surgery. The trachea may be extubated immediately after surgery. Attention should be paid to the unique anatomical, physiological, and pharmacological aspects. The patients should be monitored carefully for pain, respiratory failure, and meningitis (an extremely rare complication).

Colorectal carcinoma in childhood: a retrospective multicenter study.

OBJECTIVES: Colorectal carcinoma, a common adult malignancy, has an estimated childhood incidence of 0.3 to 1.5/million in Western countries and 0.2/million in Israel. Diagnosis is difficult because adult screening measures are unfeasible in children. The tumor is frequently associated with predisposing genetic factors, aggressive biological behavior, and poor prognosis. The aim of this multicenter study was to document the clinical profile, treatment and prognosis of colorectal carcinoma in children in Israel. PATIENTS AND METHODS: The clinical, laboratory, therapeutic, and prognostic parameters of all 7 children from 4 medical centers in Israel who were diagnosed with colorectal carcinoma over a 25-y period were reviewed. RESULTS: Patients presented with rectal bleeding (4 of 7), abdominal pain (2 of 7), and abdominal distension (2 of 7). Average time to diagnosis was 6 months. Six patients underwent surgery (1 refused), and 5 received chemotherapy. Histopathological studies showed poorly differentiated mucinous adenocarcinoma, signet-ring type, in 4 cases, moderately differentiated adenocarcinoma in 2, and well-differentiated carcinoma in 1. Three patients died of the disease, 2 shortly after diagnosis. One patient with recurrent metastatic disease was lost to follow-up. CONCLUSION: Colorectal carcinoma in children is characterized by aggressive tumor behavior and delayed diagnosis, resulting in a worse prognosis than in adults. Heightened physician awareness of the possibility of this disease in children, with special attention to adolescents with predisposing factors and rectal bleeding, could help to improve outcome.

[Lumbar epidural anesthesia in a very-low-birth-weight infant].

In this case study two combined, light-general and lumbar epidural anesthetics were administered to a premature neonate for the repair of gastroschisis. The female infant's body weight was 1400 grams (first operation) and 1700 grams (second operation). The epidural catheter was inserted between the low-lumbar vertebrae using the "loss of resistance" for saline technique. Intra- and postoperative analgesia were based on epidural administration of bupivacaine and fentanyl. No systemic opioids were administered. The infant recovered from general anesthesia at the end of both operations. Excellent analgesia was accomplished throughout the peri-operative course except for short periods during and after the second operation that resolved after the epidural catheter was withdrawn by a few centimeters. Neither respiratory or hemodynamic depression, nor bupivacaine toxicity were observed. The anesthetic and analgesic management is presented in the article. Technical aspects of lumbar epidural anesthesia, it's advantages over the caudal approach and dosages of epidural anesthetics in small infants, as well as complications and risks are emphasized.

[Spinal anesthesia in premature infants--indications, technical aspects and results].

PURPOSE: To present our experience with spinal anesthesia in premature and former premature infants, and to focus on technical aspects and pitfalls enlightened with increasing experience. METHODS: The perioperative course of all premature and former premature infants below 60 weeks postconceptual age undergoing spinal anesthesia within an 35-month-period was analyzed. Lumbar puncture was performed while the patient was held seated at L4-5 or L5-S1. Anesthetics included hyperbaric tetracaine or bupivacaine, dose 1 mg/kg with adrenaline. The patients were positioned in the reverse Trendelenburg for 2-3 minutes, and later horizontally. RESULTS: Sixty seven infants (gestational age 30.1 +/- 3.6 weeks, postconceptual age 42.9 +/- 3.4, weight 3234 +/- 1165 grams) underwent spinal anesthesia and surgery. Thirty two had other diseases, including congenital heart (12), lung (15) brain pathology (8) and urological findings (6). Sixty five patients underwent hernia repair and two underwent pyloromyotomy. N2O was added in three infants, and two required general anesthesia. All were found to have lower limb motor blockade postoperatively. Intraoperatively, hypoxemia was diagnosed in two infants, short apnea in two cases and bradycardia in one. The apnea and hypoxemia episodes were successfully treated by reverse Trendelenburg positioning and bag and mask ventilation and the bradycardia that did not respond to tactile stimulation was relieved by atropine. Postoperatively, a short episode of apnea and hypoxemia (one patient) and hypoxemia (one patient) responded to free oxygen administration with/without tactile stimulation. Brief bradycardia (three infants) terminated without intervention. Supplementation and postoperative complication rates resembled previous studies. CONCLUSION: Successful spinal anesthesia in premature and former premature infants depends on close attention to preoperative assessment, patient positioning during and immediately after anesthetic induction, drug dosing and perioperative monitoring. A relatively high dose of local anesthetic should be administered.

Preoperative ultrasound and intraoperative findings of inguinal hernias in children: A prospective study of 642 children.

BACKGROUND/PURPOSE: Preoperative sonographic studies of the groins have become a routine evaluation of inguinal hernia in children. Its value is not only to confirm the clinical diagnosis, but also to accurately assess the opposite side and to prevent an unnecessary exploration or additional operation at a later stage. The purpose of this study is to report more definitive criteria of inguinal hernias (IH) and patent process vaginalis (PPV) established from 1,284 groin examinations. METHODS: From January 1999 to October 2000 the authors compared prospectively the sonographic dimensions of the inguinal canal to the operative findings as reported by the surgeons (blinded to the results) for 642 pediatric patients (ages 1 to 176 months) undergoing inguinal hernia repairs. RESULTS: A normal inguinal canal was found at operation when a preoperative sonographic groin width of 3.6 +/- 0.8 mm, on average, was detected. A PPV was found when a groin width of 4.9 +/- 1.1 mm was detected. A full hernia was found when a groin width of 7.2 +/- 2.0 mm was detected. A large hernia was found when a groin width of 12.8 +/- 3.6 mm was detected, and a hydrocele was found along with a groin width of 4.8 +/- 2.2 mm. CONCLUSIONS: Establishing accurate sonographic criteria for inguinal hernia and patent processus vaginalis is an important tool for the pediatric surgeon to plan the approach before groin surgery.

Spinal anesthesia in 62 premature, former-premature or young infants--technical aspects and pitfalls.

PURPOSE: To highlight technical aspects and pitfalls of spinal anesthesia (SA) in infants. METHODS: The medical history and perioperative course of all infants who underwent SA over a 28-month period were collected (retrospectively in the first 20). RESULTS: Sixty-two infants underwent surgery under SA. Fifty-five were premature and former-premature, postconceptional age 43.3 +/- 5.0 weeks, weight 3261 +/- 1243 g. Of these, 21 had co-existing disease: cerebral (six), cardiac (nine), pulmonary (11) and urological (six). Hyperbaric tetracaine or bupivacaine 1 mg x kg(-1) with adrenaline was administered. Four infants (three premature) required N(2)O supplementation and three needed general anesthesia. The supplementation rate was similar or lower than in previous studies. Postoperatively, all seven were shown to have lower limb motor and sensory blockade. Complications in premature patients included intraoperative hypoxemia (two), apnea (two) and bradycardia (one). Postoperative complications included bradycardia (three), hypoxemia (one) and apnea and hypoxemia (one). The postoperative complication rate was similar to previous studies. CONCLUSION: Successful SA in infants depends on close attention to preoperative assessment, appropriate patient positioning during and after lumbar puncture, drug dosing and intra- and postoperative cardiorespiratory monitoring. A relatively high dose of hyperbaric solution of tetracaine or bupivacaine with adrenaline should be administered.