Advances in pediatric surgery

Recent advances in pediatric surgery have been made in several fields. Hydrocephalus is again being treated by draining the cerebrospinal fluid into either the ureter, the mastoid antrum or the peritoneal cavity. Funnel chest should be corrected surgically. Congenital atresia of the esophagus is best treated by a one-stage operative repair. Patent ductus should be closed. Operations are available for cyanotic children. Intussusception is again being treated by barium enema in selected cases. Megacolon can be benefited by surgical procedures, which now are directed at the distal spastic segment rather than the proximal dilated segment.     

Treatment of acute abscesses in the casualty department.

In the treatment of acute pyogenic soft-tissue abscess incision, curettage, and primary suture was compared with incision and drainage alone in a randomised prospective trial. Operations were performed under antibiotic cover by casualty officers, and patients were reviewed by an independent observer in a septic dressing clinic. Altogether 114 patients were studied, of whom 54 were treated by curettage and primary suture and 60 by simple drainage. The mean healing time was 8.9 days in those treated by primary suture and 7.8 days in those treated by simple drainage (p less than 0.05). Primary healing failed to occur in 19 (35%) of the sutured wounds, but there were no other complications in either group. It is concluded that incision and drainage alone is adequate treatment for acute soft-tissue abscess.     

外科深部真菌感染的病原学分析

目的分析外科住院患者合并真菌感染状况。方法分离的真菌用API 20C AUX真菌鉴定条,用ATB FUNGUS-2进行药敏试验。结果真菌的种类分布中第1位是白色念珠菌占53%,第2位是热带念珠菌占20%,第3位是光滑念珠菌占14%,第4位是近平滑念珠菌占4%,第5位是其余念珠菌占2%;真菌在外科各区分布中,外科ICU占42%,移植外科占25%;真菌在各类标本分布中,痰占43%,尿液占13%,粪便占10%,引流液占9%,血液占7%;真菌对药物5-氟胞嘧啶、两性霉素B、氟康唑、伊曲康唑的药物敏感性分别是93%、98.9%、90.8%、59.8%。结论外科真菌感染集中在重症病区(ICU),分离的致病真菌主要是白色念珠菌、热带念珠菌、光滑念珠菌,真菌对两性霉素B敏感性最高。     

Management of the pediatric patient after cardiac surgery

The medical management of the child with congenital cardiac disease prior to and following cardiac surgery has made a substantial contribution to the improved morbidity and mortality attributed to surgical advances. This paper provides a framework for understanding the problems that arise in the perioperative period and a systematic approach, by organ system, to monitoring and management of these problems. The discussion is intended to be of general application, focusing on initial stabilization following surgery and the cardiorespiratory, renal, metabolic, hematologic, and neurologic alterations that result from surgery with cardiopulmonary bypass. An approach for the management of the low output state is also provided. Little attempt has been made to focus on problems unique to a specific type of cardiac disease or certain operative approaches. Rather, it is the contention that an understanding of general principles and an appreciation of the common problems will provide adequate preparation for those responsible for the care of the child.     

Patient-controlled analgesia with ketorolac in pediatric surgery

Our aim was to quantify the analgesic efficiency of the patient-controlled analgesia technique (PCA), using ketorolac, in children aged 6-14 undergoing a surgical intervention. We carried out a double-blind test with two randomly selected groups: the PCA group comprising patients submitted to intravenous PCA, with "bolus on demand" and the Standard group, with conventional analgesia dispensed with ketorolac I.V. (0.5 mg/kg/6 hours). Evaluation of pain experienced was performed using the Hannallah behavioural scale and quantification of the summing of pain intensity. Analgesic efficiency was determined by the pain intensity difference (PID) score. Evaluation of pain experienced during hour 1 reveals a marked reduction with time for each group; no inter-group differences were found. At hour 6 there were neither intra-group nor inter-group differences. The accumulated pain score revealed a significant reduction in hour 6, with no differences between the two groups. Evaluation of the analgesic effect revealed no differences, either intra-group or intergroup, during the experimental period. The sum of the PIDs revealed significant differences in the standard group between the values for hours 1 and 6. Under the experimental conditions described, both techniques were equally effective for pain treatment, but the efficiency was higher for the PCA group.     

Bicycle-related injuries: a survey in a pediatric emergency department.

The number of bicycle-related injuries has risen significantly with the increased popularity of bicycle riding in Canada. The risk of injury is highest among children. To assess the magnitude of the problem and to identify the contributing factors we used a questionnaire, injury reports and patient charts to survey bicycle-related injuries among children brought to the emergency department of the Children''s Hospital of Eastern Ontario, Ottawa, between May 1 and Sept. 30, 1988. The questionnaire was completed for 517 (91%) of the 568 children; 70% were boys, and the mean age was 9.4 years. Only 2% of the patients had been wearing a helmet at the time of injury, although 13% claimed to own one for cycling. Over 60% of the accidents were attributable to carelessness or poor bicycle control; mechanical failure and environmental hazards were minor factors. Over 80% of the injuries occurred within a kilometre of the child''s home. Of the 97 children admitted to hospital 49% had head and skull injuries and 40% had limb fractures. Bicycle-related injuries represented 14.8% of all nonwinter (Apr. 1 to Oct. 31) trauma admissions among children 5 years or older. Our results further document bicycle-related injuries as an important childhood problem and underscore the need for improved safety measures.     

Surveillance of airborne adenovirus and Mycoplasma pneumoniae in a hospital pediatric department

This investigation evaluated the distributions of airborne adenovirus and Mycoplasma pneumoniae in public areas in the pediatric department of Children's Hospital in northern Taiwan. The airborne viral and bacterial concentrations were evaluated twice a week for a year using filter sampling with an airflow rate of 12 liters per minute for eight hours in the pediatric outpatient department and 24 hours in the pediatric emergency room. Real-time polymerase chain reaction assays were conducted for analysis. Approximately 18% of the air samples from the pediatric emergency room were found to contain adenovirus. Approximately forty-six percent of the air samples from the pediatric outpatient department contained Mycoplasma pneumoniae DNA products. High detection rates of airborne adenovirus DNA were obtained in July and August in the pediatric public areas. Airborne Mycoplasma pneumoniae was detected only in July in the pediatric emergency room and the peak levels were found from August to January in the pediatric outpatient department. Airborne particles that contained adenovirus and Mycoplasma pneumoniae were the most prevalent in the pediatric public areas. The potential relationship between these airborne viral/bacterial particles and human infection should be examined further.     

Treatment of pediatric brain tumors

Over the past decades considerable advances have been made in neurosurgery, radiotherapy and chemotherapy resulting in improved survival and cure rates for children with brain tumors. Here we review four of the most common subtypes of pediatric brain tumors, low-grade and high-grade astrocytomas, medulloblastomas and ependymomas, highlighting their molecular features regarding their tumor biology, and promising potential therapeutic targets that may hold promise for finding new "molecular targeted" drugs. Importantly, appropriate clinical trial design will play a critical role in the evaluation of new and novel treatment approaches for pediatric brain tumors.     

Patient-controlled and analgesia with ketorolac in pediatric surgery

Our aim was to quantify the analgesic efficiency of the patient-controlled analgesia technique (PCA), using ketorolac, in children aged 6–14 undergoing a surgical intervention. We carried out a double-blind test with two randomly selected groups: the PCA group comprising patients submitted to intravenous PCA, with “bolus on demand” and the Standard group, with conventional analgesia dispensed with ketorolac I.V. (0.5 mg/kg/6 hours). Evaluation of pain experienced was performed using the Hannallah behavioural scale and quantification of the summing of pain intensity. Analgesic efficiency was determined by the pain intensity difference (PID) score. Evaluation of pain experienced during hour 1 reveals a marked reduction with time for each group; no inter-group differences were found. At hour 6 there were neither intra-group nor inter-group differences. The accumulated pain score revealed a significant reduction in hour 6, with no differences between the two groups. Evaluation of the analgesic effect revealed no differences, either intra-group or intergroup, during the experimental period. The sum of the PIDs revealed significant differences in the standard group between the values for hours 1 and 6. Under the experimental conditions described, both techniques were equally effective for pain treatment, but the efficiency was higher for the PCA group.     

Estimating the probability of bacterial infection using a novel biomarker among pediatric patients in the emergency department

Context: IL-27 is a novel biomarker to identify bacterial infection in children.

Objective: IL-27 was evaluated among pediatric emergency department (ED) patients and compared with procalcitonin (PCT).

Methods and results: Children undergoing blood, urine, or cerebrospinal fluid cultures had IL-27 and PCT assays performed. Bacterial infection was defined as a positive culture or a clinical diagnosis based on chart review. IL-27 and PCT were increased among patients with bacterial infection and demonstrated comparable AUC’s (0.62 versus 0.61). A decision tree incorporating IL-27, PCT, and white blood cell count improved the AUC (0.80).

Conclusion: IL-27 is a viable candidate biomarker to identify bacterial infection among ED patients and is comparable with PCT.     

Characteristics of children presenting with chest pain to a pediatric emergency department.

Chest pain among children is a common complaint in primary care practice. However, the demographic features and treatment of such patients are controversial. We distributed a questionnaire to 336 consecutive patients with a complaint of chest pain seen during 1 year at an urban pediatric emergency department. Such visits represented 0.6% of all emergency encounters; the male:female ratio was 1.0. Physical examination was done in 325 patients. Chest-wall pain was the most common diagnosis (in 28% of cases). Other causes included pulmonary (in 19%), minor traumatic (in 15%), idiopathic (in 12%) and psychogenic (in 5%); miscellaneous causes (in 21%) most often indicated pain referred from the upper respiratory tract and the abdomen. The most common physical finding was chest tenderness (in 41% of cases). Investigations included chest radiography (in 50% of cases), electrocardiography (in 18%) and determination of the hemoglobin concentration and of the leukocyte count (in 13%); the results were rarely positive. Only eight patients (2%) required admission to hospital, and there were no cases of myocardial ischemia. The findings suggest that health care costs may be reduced by more judicious use of investigations. We conclude that chest pain is an uncommon and usually benign complaint in the pediatric emergency department. Most causes are evident on careful physical examination.     

瑞芬太尼复合丙泊酚静脉全麻与异氟醚吸入全麻在小儿眼科手术中比较

目的：比较瑞芬太尼复合丙泊酚静脉全麻用于小儿眼科手术麻醉的安全性、有效性及可控性。方法：选择择期眼科手术的小儿40例,随机分为两组：瑞芬太尼复合丙泊酚静脉全麻组（RP组）和异氟醚吸入全麻组（Ⅰ组）,每组20例。麻醉诱导采用咪唑安定0．05mg·kg^-1,丙泊酚2mg·kg^-1,维库溴胺0．1mg·kg^-1,观察组用瑞芬太尼2μg·kg^-1,对照组用芬太尼3μg·kg^-1,气管插管后机械通气,RP组麻醉维持采用静脉持续输注瑞芬太尼0．1μg·kg^-1min^-1和丙泊酚,Ⅰ组麻醉维持用异氟醚吸入,术中根据麻醉深度调整异氟醚吸入浓度和丙泊酚输注速度。观察围术期两组血流动力学变化、自主呼吸恢复、气管拔管和清醒的时间,苏醒后躁动和恶心呕吐的发生率。结果：两组病人平均动脉压（MAP）变化：两组T1、T2、T3、T4与T0比较,MAP明显降低（P〈0．05）,T5与T0比较,MAP无明显差异（P〉0．05）;组间比较,两组在T0、T1、T2、T3、T4、T5点,MAP无明显差异（P〉0．05）。两组病人心率（HR）变化：Ⅰ组：T3、T4、T5与T0比较,心率显著增快（P〈0．05）,RP组：T1、T2、T3、T4与T0比较,心率明显降低（P〈0．05）,T5与T0比较,心率变化无明显差异（P〉0．05）。组间比较,两组在T0心率无明显差异,T1、T2、L、T4、T5观察组与对照组比较,心率明显降低（P〈0．01）。麻醉苏醒时间比较：RP组与Ⅰ组比较,病人自主呼吸恢复时间、意识恢复时间和拔管时间均明显缩短（P〈0．05）。RP组术后躁动、恶心呕吐发生率,均低于Ⅰ组（P〈0．05）。结论：瑞芬太尼复合丙泊酚静脉全麻可为小儿眼科手术提供稳定血流动力学状态,快速苏醒,适用于小儿眼科手术麻醉。