Traumatic diaphragmatic rupture in pediatric age: review of the literature.

PURPOSE: Traumatic diaphragm rupture (TDR) is a rare complication of trauma in pediatric age and may be easily missed by the severity of associated injuries so that delayed emergent presentation can occur with increased rate of morbidity and mortality. No review has been available to guide clinicians through the pitfalls and the initial diagnostic approach to pediatric TDR. METHODS: A Medline thorough search on TDR was conducted using different queries. English language citations were identified during the period of January 2000 through December 2014 limiting the search to pediatric age (0-18 years). Abstracts were reviewed to determine eligibility and texts were obtained for further review. Differences were resolved by consensus and only reliable data were included. RESULTS: Most frequently reported presenting symptoms of TDR are respiratory and abdominal. While respiratory symptoms are among the most frequently described at the onset in pediatric and adult series, abdominal symptoms result to be more frequent in adult than pediatric patients. Chest X-ray (CXR) is the first-line imaging exam which is reported to show pathognomonic or suspect findings in 85 %. CT was the second main radiological technique used, in particular to confirm the suspicion of TDR. CONCLUSIONS: A high clinical index of suspicion is needed to diagnose and effectively manage diaphragmatic rupture. TDR should be kept in mind while dealing with patients assessed for abdominal or respiratory symptoms whenever there is history of trauma or blunt injury especially in children as the increasing of non-operative management of blunt abdominal trauma could result in missing important injuries as TDR.

Introducing the advanced burn life support (ABLS) course in Italy.

Systematic education based on internationally standardized programs is a well-established practice in Italy, especially in the emergency health care system. However, until recently, a specific program to treat burns was not available to guide emergency physicians, nurses, or volunteers acting as first responders. In 2010, two national faculty members, acting as ABA observers, and one Italian course coordinator, trained and certified in the United States, conducted a week-long training program which fully certified 10 Italian instructors. Authorized ABLS provider courses were conducted in Italy between 2010 and 2012, including one organized prior to the 20th annual meeting of the Italian Society of Burns (SIUst). In order to increase the effectiveness and diffusion of the course in Italy, changes were approved by the ABA to accommodate societal differences, including the translation of the manual into Italian. The ABA has also approved the creation and publication of a bilingual ABLS Italian website for the purpose of promoting the ABLS course in Italy. In response to high demand, a second ABLS Instructor course was organized in 2012 and has been attended by physicians and nurses from several Italian burn centers. In the following discourse the experiences of the first 15 Italian ABLS courses will be discussed.

Plasma levels of lignocaine during tumescent local anaesthesia in children with burns.

The aim of the study was to assess the changes in plasma lignocaine concentrations over time when the tumescent solution is injected into subcutaneous tissue of children undergoing surgical treatment of burns. Sixteen consecutive children with burns were studied using a prospective study design. After induction of general anesthesia, tumescent lignocaine solution 0.1% with adrenaline in nine patients (adrenaline group) for the treatment of postburn sequelae, or without adrenaline in seven patients (no-adrenaline group) for the treatment of acute burns, was injected into the subcutaneous tissue of burned and donor areas. The maximum dose of lignocaine was 7 mg/kg. Blood samples were collected before the start of the injection as well as at 5, 10, 20, 30, 45, 60, 90 minutes and 2, 4, 8, 12, 24 hours after the infiltration was completed. The course of lignocaine plasma levels was chaotic in the adrenaline group and biphasic during the first hour in the no-adrenaline group. The maximum plasma concentration of lignocaine was 2.09 microg/ml in the adrenaline group and 1.98 microg/ml in the no-adrenaline group. No adverse reactions were noted. Tumescent injection in burned children resulted in lignocaine plasma concentrations that were always lower than the often quoted value of 5 microg/ml, considered to be the toxic plasma threshold in adults. These data lend support to the use of lignocaine using the tumescent technique in burned paediatric patients.

Incidence of vomiting in susceptible children under regional analgesia with two different anaesthetic techniques.

BACKGROUND: Postoperative vomiting (POV) is a frequent side-effect of paediatric surgery and a leading cause of unplanned admission. Many antiemetic drugs have been studied, but less attention has been given to the effects on POV of the anaesthetic technique adopted. The aim of this study was to compare two different anaesthetic techniques in children under regional analgesia at risk for POV. METHODS: We studied 135 children suffering from motion sickness or with a previous history of POV. The patients were randomized to receive inhalation anaesthesia (group S) with sevoflurane by LMA or intravenous (i.v.) anaesthesia with ketamine and propofol (group P). All the patients were treated with an ilio-inguinal block after induction of anaesthesia. Postoperatively, the children were followed by the nursing staff and by their parents, none of whom were aware of the anaesthesia technique used. RESULTS: A significant decrease was observed in the incidence of early (0-6 h) and delayed (6-24 h) POV in those children who received i.v. sedation. There was no difference between the two groups in the level of analgesia either at the end of surgery or 2 h postoperatively. CONCLUSIONS: Anaesthesia based on propofol and ketamine is better than inhalation anaesthesia with sevoflurane by LMA for reducing POV in children at risk under an ilio-inguinal block. Tailoring the anaesthetic to the specific needs of children susceptible to POV should be considered before resorting to the routine use of expensive antiemetic prophylaxis.

The use of the cuffed oropharyngeal airway in paediatric patients.

BACKGROUND: The cuffed oropharyngeal airway (COPA) is a device which has already been demonstrated to be suitable for anaesthetized adult patients undergoing either spontaneous or mechanical ventilation. There are few reports on the use of the COPA in children. In this study, the authors assessed the COPA in paediatric patients undergoing minor surgery. METHODS: The same anaesthesiologist inserted the COPA in 40 consecutive paediatric patients, ASA I and II, aged 1.8-15.3 years. (7.4 +/- 3.9), after induction of anaesthesia with N2O/O2/sevoflurane. COPA size was chosen by measuring the distal tip of the device at the angle of the jaw with the COPA perpendicular to the patient's bed. The proper positioning of the COPA was assessed by observing thoracoabdominal movements, regular capnograph trace, the reservoir bag movements and SpO2 > 94% with a fraction of inspired oxygen of 0.5. Anaesthesia was maintained with 1 MAC halothane, sevoflurane, or isoflurane in N2O/O2 (50%) and the patients were spontaneously breathing. The stability of the COPA following changes in head, neck and body position was tested. We recorded the duration time for COPA insertion, the side-effects of placement of the COPA and during the intraoperative period, the number of attempts, the type of manipulation in order to provide an effective airway and postoperative symptoms, such as the presence of blood on the device, sore throat, neckache, jaw pain and PONV. RESULTS: Successful COPA insertion at the first attempt was 90% and at the second attempt in the remaining 10%. The most frequent airway manipulations were head tilt in 27.5% (obtained by a pillow under shoulders) and chin lift in 5%. No complications both at COPA placement nor during the intraoperative period were observed. On the basis of weight and age, the COPA size was no. 8 in 50%, no. 9 in 30%, no. 10 in 12.5%, and no. 11 in 7.5%. The COPA demonstrated stability after changes in head, neck and body position. Postoperative complications were the presence of blood stains in one case and PONV in six cases (15%). CONCLUSIONS: The COPA is an extratracheal airway device suitable in paediatric patients undergoing general anaesthesia with spontaneous ventilation for minor surgery and other painful procedures. This study shows that for paediatric patients: (i) complications seem to be rare; (ii) the COPA allows hands free anaesthesia; (iii) specific indication for the COPA could be obese patients with a small mouth; and (iv) COPA sizing can be easily established by the weight or age of the patients.

[Intensive therapy in general surgery]. / La terapia intensiva in chirurgia generale.

A good diagnostic protocol as well as a proper preparation to surgery and a careful intensive observation (associated if necessary with an intensive therapy) can lead to a better prognosis in major surgical procedures or routine surgery in poor risk patients. Candidates to ICU are divided in three classes: type A is a stable patient requiring constant monitoring for high probability of complications, type B is still a stable patient who needs an intensive nursing; finally type C is an instable patient who requires a true intensive care. In the surgical department of USL 20/B Figline Valdarno (FI) a postoperative Intensive Care Unit (ICU) has been established in the last three years: a three-bed section with its own staff is located in the surgical department itself. In 37 months 467 operated patients requiring intensive observation or intensive therapy have been admitted.