The first board examination in pediatric surgery.

The inaugural certifying examination for special competence in pediatric surgery in North America was given by the American Board of Surgery (ABS) in April 1975, the day before the sixth meeting of the American Pediatric Surgical Association at a resort near San Juan, PR. The event came after failed applications before the ABS and the Advisory Board for Medical Specialties in 1957, 1961, and 1967. The specialty had matured with a scholarly publication devoted to the field (Journal of Pediatric Surgery, 1965), the establishment of standards for training and training programs (1966), and a society independent of pediatrics and devoted solely to pediatric surgery (American Pediatric Surgical Association, first meeting 1970). Harvey Beardmore had guided the successful campaign for a certificate for pediatric surgery under the aegis of the ABS that was approved in June 1972. Pediatric surgery had thus gained full recognition as a specialty of surgery. A group photograph of its participants became one of the iconic images in our specialty. Thanks to Jim and Nancy Hopkins of Windsor Heights, IA, and to their many friends and colleagues, nearly half (71 of 151) of the pediatric surgeons in the photo were identified, marking their places in the history of pediatric surgery.

Effectiveness of Pulse Oximetry Versus Doppler for Tourniquet Monitoring.

BACKGROUND: Pulse oximeters are common and include arterial pulse detection as part of their methodology. The authors investigated the possible usefulness of pulse oximeters for monitoring extremity tourniquet arterial occlusion. METHODS: Tactical Ratcheting Medical Tourniquets were tightened to the least Doppler-determined occluding pressure at mid-thigh or mid-arm locations on one limb at a time on all four limbs of 15 volunteers. A randomized block design was used to determine the placement locations of three pulse oximeter sensors on the relevant digits. The times and pressures of pulsatile signal absences and returns were recorded for 200 seconds, with the tourniquet being tightened only when the Doppler ultrasound and all three pulse oximeters had pulsatile signals present (pulsatile waveform traces for the pulse oximeters). RESULTS: From the first Doppler signal absence to tourniquet release, toe-located pulse oximeters missed Doppler signal presence 41% to 50% of the times (discrete 1-second intervals) and missed 39% to 49% of the pressure points (discrete 1mmHg intervals); fingerlocated pulse oximeters had miss rates of 11% to 15% of the times and 13% to 19% of the pressure points. On toes, the pulse oximeter ranges of sensitivity and specificity for Doppler pulse detection were 71% to 90% and 44% to 51%, and on fingers, the respective ranges were 65% to 77% and 78% to 83%. CONCLUSION: Use of a pulse oximeter to monitor limb tourniquet effectiveness will result in some instances of an undetected weak arterial pulse being present. If a pulse oximeter waveform is obtained from a location distal to a tourniquet, the tourniquet should be tightened. If a pulsatile waveform is not detected, vigilance should be maintained.

Significant Pressure Loss Occurs Under Tourniquets Within Minutes of Application.

BACKGROUND: Pressure decreases occur after tourniquet application, risking arterial occlusion loss. Our hypothesis was that the decreases could be mathematically described, allowing creation of evidence-based, tourniquet-reassessment- time recommendations. METHODS: Four tourniquets with width (3.8cm, 3.8cm, 13.7cm, 10.4cm), elasticity (none, none, mixed elastic/nonelastic, elastic), and mechanical advantage differences (windlass, ratchet, inflation, recoil) were applied to 57.5cm-circumference 10% and 20% ballistic gels for 600 seconds and a 57.5cmcircumference thigh and 31.5cm-circumference arm for 300 seconds. Time 0 target completion-pressures were 262mmHg and 362mmHg. RESULTS: Two-phase decay equations fit the pressure-loss curves. Tourniquet type, gel or limb composition, circumference, and completionpressure affected the curves. Curves were clinically significant with the nonelastic Combat Application Tourniquet (C-A-T), nonelastic Ratcheting Medical Tourniquet (RMT), and mixed elastic/nonelastic blood pressure cuff (BPC), and much less with the elastic Stretch Wrap And Tuck-Tourniquet (SWATT). At both completion-pressures, pressure loss was faster on 10% than 20% gel, and even faster and greater on the thigh. The 362mmHg completion-pressure had the most pressure loss. Arm curves were different from thigh but still approached plateau pressure losses (maximal calculated losses at infinity) in similar times. With the 362mmHg completion-pressure, thigh curve plateaus were -68mmHg C-A-T, -62mmHg RMT, -34mmHg BPC, and -13mmHg SWATT. The losses would be within 5mmHg of plateau by 4.67 minutes C-A-T, 6.00 minutes RMT, 4.98 minutes BPC, and 6.40 minutes SWATT and within 1mmHg of plateau by 8.18 minutes C-A-T, 10.52 minutes RMT, 10.07 minutes BPC, and 17.68 minutes SWATT. Timesequenced images did not show visual changes during the completion to 300 or 600 seconds pressure-drop interval. CONCLUSION: Proper initial tourniquet application does not guarantee maintenance of arterial occlusion. Tourniquet applications should be reassessed for arterial occlusion 5 or 10 minutes after application to be within 5mmHg or 1mmHg of maximal pressure loss. Elastic tourniquets have the least pressure loss.

Initial tourniquet pressure does not affect tourniquet arterial occlusion pressure.

BACKGROUND: Effective nonelastic strap-based tourniquets are typically pulled tight and friction or hook-and-loop secured before engaging a mechanical advantage system to reach arterial occlusion pressure. This study examined the effects of skin surface initial secured pressure (Friction Pressure) on the skin surface pressure applied at arterial occlusion (Occlusion Pressure) and on the use of the mechanical advantage system. METHODS: Combat Application Tourniquets(®) (CATs; combattourniquet.com) and Tactical Ratcheting Medical Tourniquets (RMTs; www .ratchetingbuckles.com) were applied to 12 recipient thighs with starting Friction Pressures of 25 (RMT only), 50, 75, 100, 125, 150, 175 (CAT only), and 200mmHg (CAT only). The CAT strap was single threaded. Pressure was measured with an air-filled, size #1, neonatal blood pressure cuff under the Base (CAT), Ladder (RMT), and Strap (CAT and RMT) of each 3.8cm-wide tourniquet. RESULTS: Base or Ladder pressure and Strap pressure were related but increasingly different at increasing pressures, with Strap pressures being lower (Friction Pressure, r > 0.91; Occlusion Pressure, r > 0.60). Friction Pressure did not affect Occlusion Pressure for either design. Across the 12 thighs, the correlation coefficient for Strap Friction Pressure versus CAT windlass turns was r = -0.91 ± 0.04, and versus RMT ladder distance traveled was r = -0.94 ± 0.06. Friction Pressures of 150mmHg or greater were required to achieve CAT Occlusion with two or fewer windlass turns. CAT and RMT Strap Occlusion Pressures were similar on each recipient (median, minimum - maximum; CAT: 318mmHg, 260 - 536mmHg; RMT: 328mmHg, 160 - 472mmHg). CONCLUSIONS: Achieving high initial strap tension is desirable to minimize windlass turns or ratcheting buckle travel distance required to reach arterial occlusion, but does not affect tourniquet surface-applied pressure needed for arterial occlusion. For same-width, nonelastic strap-based tourniquets, differences in the mechanical advantage system may be unimportant to final tourniquet-applied pressure needed for arterial occlusion.

Preliminary resuscitation for perforated necrotizing enterocolitis: 2 cases treated with initial direct peritoneal resuscitation.

We used peritoneal infusions of 2.5% dextrose solution as an adjunct to resuscitation of 2 very low-birth-weight infants having perforated necrotizing enterocolitis. This was repeated every 12 hours for 7 days before and 1 day after extensive bowel resection. The designation of this research method has been termed direct peritoneal resuscitation. We discuss our observations and the evolution of this technique from studies in the animal laboratory to a recent trial in patients with abdominal trauma. We propose that the early response benefit of this preoperative resuscitation seen in our 2 cases be investigated by others. Prospective controlled trials could then be considered for those high-risk patients having diffuse disease and shock.