Temporary Diverting End-Colostomy in Critically Ill Children with Severe Perianal Wound Infection.

ABSTRACT: Broad and deep perianal wounds are challenging in both adult and pediatric ICUs. These wounds, if contaminated with gastrointestinal flora, can cause invasive sepsis and death, and recovery can be prolonged. Controlling the source of infection without diverting stool from the perianal region is complicated. The option of protective colostomy is not well-known among pediatric critical care specialists, but it can help patients survive extremely complicated critical care management. These authors present three critically ill children who required temporary protective colostomy for perianal wounds because of various clinical conditions. Two patients were treated for meningococcemia, and the other had a total artificial heart implantation for dilated cardiomyopathy. There was extensive and profound tissue loss in the perianal region in the patients with meningococcemia, and the patient with cardiomyopathy had a large pressure injury. Timely, transient, protective colostomy was beneficial in these cases and facilitated the recovery of the perianal wounds. Temporary diverting colostomy should be considered as early as possible to prevent fecal transmission and accelerate perianal wound healing in children unresponsive to local debridement and critical care.

Allogeneic hematopoietic stem cell and liver transplantation in a young girl with dedicator of cytokinesis 8 protein deficiency.

DOCK8 deficiency is a rare inherited combined immunodeficiency, caused by mutations in the DOCK8 gene. We describe a case with DOCK8 deficiency associated with severe CLD in whom orthotopic LT was performed successfully after allogeneic HSCT. A 5 year-old girl with DOCK8 deficiency presented with mild direct hyperbilirubinemia and abnormal GGT level and without a previous history of jaundice. She had severe growth retardation, hepatosplenomegaly and generalized eczema. Progressive worsening of CLD was observed within 4 months. Investigations for etiology of liver disease were negative. Liver biopsy showed bridging necrosis, cholestasis and, cirrhosis. Recurrent immune hemolytic crisis and several viral infections developed in follow-up. She underwent whole cadaveric LT for end-stage liver disease (ESLD) 1 year after allogenic HSCT from a full matched related donor. The postoperative course was uneventful. The patient is alive with normal liver function and moderate skin graft versus host disease for 36 months after LT. In conclusion DOCK8 deficiency can be associated with severe CLD. Successful LT following HSCT is possible in patients with ESLD in DOCK8 deficiency. The timing of LT is challenging in patients requiring both HSCT and LT since conditioning regimens for HSCT can be highly hepatotoxic and the patients with suboptimal liver function can become decompensated during HSCT.

Pediatric laparoscopic sleeve gastrectomy in Turkey: Short-term results.

BACKGROUND: Obesity is one of the most rapidly increasing health problems in children. Laparoscopic sleeve gastrectomy (LSG) is one of the best treatment options and is feasible and safe in children. The aim of this study was to present the short-term results of a laparoscopic sleeve gastrectomy series in children. METHODS: Children who underwent LSG in 2014-2017 were included in the study. Charts were investigated retrospectively and short-term weight loss was analyzed. RESULTS: Patients who had surgery in 2014-2017 were included in the study. There were six girls and two boys, and the median age was 15 years (range, 11-18 years). Mean weight was 159.25 ± 19.78 kg, and mean body mass index was 61.05 ± 8.5 kg/m2 . Mean operation time was 70 min (range, 65-90 min), mean hospital stay was 5.1 days (range, 3-7 days), and mean follow up was 19.2 months (range, 1-43 months). Of these patients, five had hypertension and were under medication and two of these five also had hyperinsulinemia. One of the five children had Bardet-Biedl syndrome and one had bronchial asthma. After operation, medication was stopped in four of the eight children. At the time of writing, six patients were doing well without postoperative complications, or the need for reoperation. CONCLUSION: Even though the follow-up period was short and the number of patients was small, LSG was a feasible and promising surgical method for morbidly obese children. A multidisciplinary approach and lifelong behavior therapy are key steps for success.

Is Laryngeal Mask a Good Alternative in Children Undergoing Laparoscopic Inguinal Hernia Repair with Percutaneous Internal Ring Suturing Under and Over Two Years Old?

Objective: This study aimed to evaluate respiratory parameters during percutaneous internal ring suturing (PIRS) for inguinal hernia repair in two different-aged pediatric patients in whom the airway is provided with a laryngeal mask or endotracheal tube for general anaesthesia. Methods: After local ethics committee and parental consent, 180 ASAI-II children were randomly allocated to 4 groups; according to their age (0-24 months / 25-144 months) and airway device laryngeal mask (LMA) / endotracheal tube (ETT) used for general anaesthesia (45 children each) for laparoscopic inguinal hernia repair. Standard anaesthesia induction was done with lidocaine, propofol, and fentanyl, and 0.6 mg kg-1 rocuronium was added to the ETT groups. Sevoflurane is used for maintenance. Hemodynamic parameters, peak airway pressure, end-tidal carbon dioxide (EtCO2), and peripheric oxygen saturation (SpO2) values were recorded after induction, before, and during pneumoperitoneum. The duration of anaesthesia, surgery, recovery time, and surgical satisfaction was recorded. Airway complications (cough, laryngospasm, bronchospasm, desaturation, and aspiration) were recorded. Results: Hundred and eighty patients (45 in each group) were analyzed. Duration of surgery and surgical satisfaction were similar in all groups. Duration of anaesthesia and recovery times were significantly shorter in the LMA groups. Peak airway pressure and EtCO2 levels were significantly lower in the LMA groups. Rare airway complications were observed without significance. Conclusion: In laparoscopic inguinal hernia repair with the PIRS technique, LMA offered comparable operating conditions and surgical satisfaction.

Effects of intraperitoneal bupivacaine injection in laparoscopic appendectomy in children on post-operative pain: A controlled randomized double-blinded study.

BACKGROUND: The aim of this study is to determine the effects of local anesthetics administered intraperitoneally in laparoscopic appendectomy. METHODS: Patients who underwent laparoscopic appendectomy due to acute appendicitis were enrolled in the study. The children were divided into two groups. Intraperitoneal bupivacaine injection to appendectomy site and subdiaphragmatic area was performed after resection of appendix and aspirastion of intraperitoneal reactive fluid in Group 1 while Group 2 did not receive this therapy. The children were questioned by a nurse at postoperative 1st, 6th, 12th, and 24th h. Pain scores (PS) (abdominal), abdominal wall incisional pain (IP), shoulder pain (SP), and first need for analgesics were recorded. RESULTS: One hundred and twenty children were enrolled to the study. There was no significant difference in PS values and IP values between the two groups (p>0.05). SP values at 12th and 24th h were significantly lower in Group 1 (p<0.05). There was a statistically significant reduce in analgesic need in Group 1 (p=0.007). CONCLUSION: Intraperitoneal bupivacaine instillation to surgery site and subdiaphragmatic area seems to reduce the SP post-opera-tive and also reduce post-operative analgesic need. More meaningful results can be obtained with an increase in the number of patients.

Therapeutic plasma exchange in an intensive care unit (ICU): a 10-year, single-center experience.

Therapeutic plasma exchange (TPE) is a blood purification method that effectively allows for the removal of waste substances by separating out plasma from other components of blood and the removed plasma is replaced with solutions such as albumin and/or plasma, or crystalloid/colloid solutions. Plasma exchange therapies are becoming increasingly essential, being used in daily practice in critical care settings for various indications, either as a first-line therapeutic intervention or as an adjunct to conventional therapies. This retrospective clinical study analyzes 10-year therapeutic plasma exchange activity experience in an 18-bed ICU at a tertiary care university hospital with a large, critically-ill patient population. Medical records of 1188 plasma exchange procedures on 329 patients with different diagnoses admitted from January 2000 to July 2010 were evaluated. The aim of the study was to determine the TPE indications and outcomes of the patients who underwent TPE in the ICU with conventional therapy. The secondary endpoints were to determine the differences between different patient groups (septic vs. non-septic indications) in terms of adverse events and procedural differences.

Comparison of the C-MAC D-Blade videolaryngoscope and direct laryngoscope in pediatric patients: Randomized controlled trial.

BACKGROUND: Endotracheal intubation is a key skill for clinicians and may be challenging in some patients due to various reasons. Nowadays, various kinds of videolaryngoscopes are available and usually used as a rescue device when direct laryngoscopy failed. Pediatric airway has some differences when compared with adults and may be challenging. This study aims to compare and evaluate C Mac D-Blade and commonly used Macintosh laryngoscope in pediatric patients. METHODS: In this study, 56 pediatric patients, 5-10 years old (10-40 kgs) who had undergone elective surgery and need endotracheal intubation were included after obtaining ethical board approval and informed consent from parents. The patients were randomized into two equal groups for laryngoscopy and intubation by either with Macintosh laryngoscope or C Mac D-Blade videolaryngoscope. Glottic view, number of attempts, intubation time, any complications and hemodynamic variables were recorded. A value of p<0.05 was considered significant. RESULTS: In pediatric patients with unanticipated difficult airway, the mean intubation time was significantly shorter with C Mac D-Blade (21±9 and 41±7 seconds, respectively (p<0.001). The results of the two groups were similar concerning the remaining parameters. CONCLUSION: C Mac D-Blade videolaryngoscope shortened intubation time about twice when compared to Macintosh blade C Mac D-Blade videolaryngoscope, Videolaryngoscopes may be a good alternative for routine intubation, education and a rescue device for difficult intubation.

First Reported Cochlear Implantation in a Child with Total Artificial Heart.

We report a case of 15-year-old boy with postlingual bilateral total hearing loss following ototoxic medication during his pediatric intensive care unit stay. The patient received the SynCardia total artificial heart implant (50 mL; SynCardia Systems, Inc., Tucson, AZ, USA) for end-stage biventricular heart failure as a bridge to heart transplant. During his time on the urgent heart transplant wait list, he underwent successful cochlear implantation following optimized coagulation and hemostasis status and appropriate anesthetic preparation. Our case represents the world's first successful cochlear implant in a pediatric patient who received an artificial heart. Despite complexities in this patient population, elective surgical procedures can be performed safely with acceptable morbidity using a collaborative approach with the heart transplant team, including input from cardiovascular surgery, pediatric cardiology, anes thesiology, consultation-liaison psychiatry, physical therapy and rehabilitation, infectious diseases and clinical microbiology, and intensive care unit staff.

[Pharmachologic treatment of acute postoperative pain: A clinical practice guideline of The Turkish Society of Algology]. / Akut postoperatif agrinin farmakolojik tedavisi: Türk Algoloji-Agri Dernegi klinik uygulama kilavuzu.

Satisfactory pain relief is a fundamental right of every patient suffering from pain. Despite the developments on pharmachologic treatment modalities and interventions for pain control, inadequacy of postoperative pain management is still a major problem. After surgical intervention, 66% of patients experience moderate to severe pain during discharge, 9% after two weeks. Untreated postoperative pain may lead to prolonged hospital stay, increased intensive care needs, development of chronic pain, and reduced the patients quality of life. In the following guideline all aspects of postoperative pain briefly evaluated. The clinical practice of postoperative analgesia, recommendations, the diagnosis, assessment and pharmachologic treatment of acute postoperative pain with the current available agents in Turkey are discussed in this article. Our aim is to promote awareness of effective, and safe postoperative pain management strategies to meet the needs of the patients; minor patient groups, such as paediatric population, pregnant patients, elderly, patient with high body mass index and covid 19 diesease. Despite all the recommendations, any guidelines special cases where standard modalities fail to treat postoperative pain management as in patients with chronic pain who previously used opioids, drug addicts, the patient should be consulted with an pain specialist.

Stuck tunneled central venous catheters in children: Four cases removed by angiography assistance.

Ates U, Tastekin NY, Mammadov F, Ergün E, Göllü G, Can ÖS, Uçar T, Bingöl-Kologlu M, Yagmurlu A, Aktug T. Stuck tunneled central venous catheters in children: Four cases removed by angiography assistance. Turk J Pediatr 2018; 60: 221-224. Adherent tunneled catheters can usually be removed by a surgical cut down, but in some cases the line can become stuck to the wall of the central veins. In such cases, forceful traction can cause vascular injury, or fracture of the catheter. We present four cases of fixated cuffed tunneled catheters. Three children had acute lymphoblastic leukemia and one had an immunodeficiency syndrome. All catheters were made from polyurethane. Indwelling times were 12-24 months. All patients` catheters were removed with great difficulty by trans-femoral access. The angiography-assisted technique is safe and easily-applied for the removal of stuck catheters in pediatric patients. These cases raise important questions concerning the maximum indwelling time and the choice of catheter material when implanting permanent central venous catheters (CVCs) in children.

Comparison of different extubation techniques in lumbar surgery: prone extubation versus supine extubation with or without prior injection of intravenous lidocaine.

The aim of this study was to evaluate the incidence of coughing and breath holding in patients undergoing lumbar surgery extubated in prone position, supine position, or supine position with intravenous lidocaine before extubation. About 105 ASA I to II patients undergoing lumbar surgery were extubated in prone position in group P (n = 35), in supine position in group S (n = 35) and in supine position with intravenous 1.5 mg/kg lidocaine 10 minutes before extubation in group SL (n = 35). The number of patients who coughed and demonstrated breath holding was noted at emergence period. The time of loss of monitoring while repositioning the patient was recorded. The frequency of cough in group S was higher compared with group P at 1 minute after extubation (P = 0.008). Two and three minutes after extubation, the patients in group S demonstrated higher cough incidence compared with groups P and SL (P < 0.05). The incidence of breath holding in the first 6 minutes was lower in group P (n = 11) compared with groups S (n = 29) and SL (n = 25)(P = 0.001). The loss of monitoring time was longer in groups S (62 +/- 40 s) and SL (53 +/- 39 s) when compared with group P (0 s) (P < 0.01). Prone emergence and supine emergence with intravenous lidocaine provides an alternative approach to conventional supine emergence and prone extubation offers less cough and breath holding and continuation of monitoring.

CHALLENGES OF OBSTETRIC ANESTHESIA: DIFFICULT LARYNGEAL VISUALIZATION.

Obstetric anesthesia is one of the high risk subspecialties of anesthesia practice. Anesthesia related complications are the sixth leading cause of maternal mortality. Difficult or failed intubation following induction of general anesthesia for CS remains the major contributory factor to anesthesia-related maternal complications. The airway management of obstetric patients is a challenging issue for several reasons. Anatomic and physiologic changes related to pregnancy may increase the difficult and failed intubation rates compared to the general surgical population. Proper evaluation of the airway anatomy and airway structures is vital to prevent airway management related catastrophes. In addition to basic airway and intubation equipment, each anesthesia department must have difficult intubation equipment cart including fiber optic laryngoscope, video laryngoscopes, and different types of laryngeal masks. It is essential that all anesthesiologists have a preconceived and well thought-out algorithm and emergency airway equipment to deal with airway emergencies during difficult or failed intubation of a parturient.