Case series of therapeutic hypothermia for neonatal hypoxic-ischemic encephalopathy during extracorporeal life support.

Therapeutic hypothermia initiated within 6 hours of birth is currently the standard of care for the management of neonates with hypoxic-ischemic encephalopathy. Neonates undergoing therapeutic hypothermia for hypoxic-ischemic encephalopathy are also at risk for severe respiratory failure and need for extracorporeal life support. The risks and benefits of therapeutic hypothermia for hypoxic-ischemic encephalopathy during extracorporeal life support are still not well defined. We report our experience of a case series of six neonates who underwent therapeutic hypothermia for hypoxic-ischemic encephalopathy during extracorporeal life support. We also report long-term neurodevelopmental follow-up from 6 to 24 months and add to the current body of evidence regarding feasibility, clinical experience, and short-term complications.

Hollow Fiber Oxygenator Composition Has a Significant Impact on Failure Rates in Neonates on Extracorporeal Membrane Oxygenation: A Retrospective Analysis.

In extracorporeal life support (ECLS), there are two main types of oxygenators in clinical use for neonates: polymethylpentene (PMP) hollow fiber and polypropylene (PP) hollow fiber. A retrospective study was performed on neonates ( n = 44) who had undergone ECLS for noncardiac indications from 2009 to 2015. Between the two groups (PMP n = 21, PP n = 23), the PP oxygenators failed 91% of the time, whereas the PMP oxygenators failed 43% of the time ( p < 0.05). Analysis suggests PMP oxygenators are less prone to failure than PP oxygenators, and they require fewer number of oxygenator changes during a neonatal ECLS.

Epithelioid hemangioendothelioma encasing the left brachiocephalic vein.

Epithelioid hemangioendotheliomas are rare vascular tumors, often arising from medium to large veins in the extremities. Symptoms of these tumors vary depending upon location. Rarely, tumors may arise in chest and involve large vessels in the mediastinum. We present a case of a 17-year-old male presenting with compressive symptoms of the left upper extremity who was found to have a large epithelioid hemangioendothelioma encasing the left brachiocephalic vein.

Primary Closure without Diversion in Management of Operative Blunt Duodenal Trauma in Children.

Background. Operative blunt duodenal trauma is rare in pediatric patients. Management is controversial with some recommending pyloric exclusion for complex cases. We hypothesized that primary closure without diversion may be safe even in complex (Grade II-III) injuries. Methods. A retrospective review of the American College of Surgeons' Trauma Center database for the years 2003-2011 was performed to identify operative blunt duodenal trauma at our Level 1 Pediatric Trauma Center. Inclusion criteria included ages <14 years and duodenal injury requiring operative intervention. Duodenal hematomas not requiring intervention and other small bowel injuries were excluded. Results. A total of 3,283 hospital records were reviewed. Forty patients with operative hollow viscous injuries and seven with operative duodenal injuries were identified. The mean Injury Severity Score was 10.4, with injuries ranging from Grades I-IV and involving all duodenal segments. All injuries were closed primarily with drain placement and assessed for leakage via fluoroscopy between postoperative days 4 and 6. The average length of stay was 11 days; average time to full feeds was 7 days. No complications were encountered. Conclusion. Blunt abdominal trauma is an uncommon mechanism of pediatric duodenal injuries. Primary repair with drain placement is safe even in more complex injuries.

Burkitt lymphoma in a child with atopic dermatitis and a 7-year history of regular topical tacrolimus use.

We describe the case of a boy who presented with abdominal Burkitt lymphoma; he had been regularly using tacrolimus ointment 0.1% for severe recurrent atopic dermatitis for 7 years immediately prior to developing cancer. We present his medical history and review the current knowledge regarding a link between topical tacrolimus and malignancy risk.

Improved survival in venovenous vs venoarterial extracorporeal membrane oxygenation for pediatric noncardiac sepsis patients: a study of the Extracorporeal Life Support Organization registry.

BACKGROUND/PURPOSE: There are few studies comparing venoarterial (VA) and venovenous (VV) extracorporeal membrane oxygenation (ECMO) in pediatric noncardiac sepsis patients. METHODS: Following approval, we reviewed the Extracorporeal Life Support Organization registry data from 1990 to 2008 for patients 0 to 18 years with a diagnosis of sepsis and without diagnosis of congenital heart disease. Survival to discharge was compared between VA and VV ECMO using χ(2) analysis and multivariable logistic regression. RESULTS: Four thousand three hundred thirty-two ECMO runs were reviewed, 3256 VA (75%) and 1076 VV (25%). A majority of VA modality was noted in each decade studied. Overall survival was 68% and was higher in VV (79%) than in VA ECMO (64%, P < .001). Survival decreased with increasing age (73% in newborns ≤ 1 month, 40% in children 1 month to 12 years, and 32% in adolescents >12 years, P < .001). VA ECMO had increased mortality risk after adjustment for age, use of vasoactive agents, and advanced respiratory support (odds ratio, 2.06; 95% confidence interval, 1.74-2.44; P < .001). CONCLUSIONS: These data demonstrate improved survival in VV vs. VA ECMO in select pediatric septic patients without congenital heart disease. When technically feasible, physicians should consider VV ECMO as first therapeutic choice in this patient population.

A middle fidelity model is effective in teaching and retaining skill set needed to perform a laparoscopic pyloromyotomy.

INTRODUCTION: An inanimate technical skills trainer for laparoscopic pyloromyotomy (LP) has not been described. A middle fidelity model, reproducing the three consistent steps in LP, was developed as a component of a teaching module for surgical residents, and tested on medical students, residents, and pediatric surgeons. MATERIALS AND METHODS: In the first phase of the study, a cohort of 29 pediatric surgeons used the LP model and completed questionnaires about the model's realism and accuracy. Descriptive statistics were used to analyze questionnaire responses. Chi-square tests were performed to determine if level of experience influenced responses. For the second phase of the study, medical students and surgical residents individually participated in the training of cognitive knowledge about hypertrophic pyloric stenosis and skills acquisition for LP. Subject testing consisted of simulator task performance and multiple-choice quiz administration immediately after training and repeated at 8 weeks after training. Data were analyzed by using paired sample t-tests and one-way analyses of variance (ANOVA). RESULTS: The pediatric surgeons agreed that the model accurately simulated essential components of the pyloromyotomy, and that the model would be an excellent tool to introduce surgeons to LP. A total of 26 students and early surgical residents completed the training and testing. Knowledge-based test performance improved from pre- to postinstruction by 17.45 [standard error of the mean (SEM) + 3.5] (P < 0.001) and from preinstruction to 8 weeks by 4.54 (SEM = 3.2) (P = 0.17). Mean improvement in time of simulator task performance was 85.2 +/- 75.4 seconds. Based on a one-way ANOVA, higher level of training was associated with decreased mean times (P = 0.04). CONCLUSIONS: Face and content validities of the simulation were demonstrated by the pediatric surgeons. An effective training experience was demonstrated with medical students and residents. At 2 months, simulator task-completion rates and task-performance times showed technical skills were retained, whereas, based on test scores, cognitive knowledge was not as well retained.

Hyperglycemia and infections in pediatric trauma patients.

Hyperglycemia has been associated with poor outcome in children with head injuries and burns. However, there has not been a correlation noted between hyperglycemia and infections in severely injured children. The trauma registry of a Level I trauma center was queried for injured children <13 years admitted between July 1, 1999 and August 31, 2003. The records of severely injured children [Injury Severity Score (ISS) > 15] were examined for survival, age, weight, ISS, infection, length of stay (LOS), and maximum glucose levels within the first 24 hours of injury (D1G). Statistical analysis was performed using a t test, Fisher's exact test, a Mann-Whitney Rank Sum test, or Kendall's Tau where appropriate. Eight hundred and eighty eight children under 13 years of age were admitted. One hundred and nine had an ISS > 15, and 57 survived to discharge with measured D1G. Patients excluded were those who died in less than 72 hours or had an LOS less than 72 hours. The survivors were divided into high glucose (> or =130 mg/dL; n = 48) and normal glucose (<130 mg/dL; n = 9). There was no difference between the groups with respect to age, weight, incidence of head injury, and ISS. An elevated D1G correlated with an increased risk of infection (P = 0.05) and an increased LOS (P = 0.01). These data suggest that severely injured children are often hyperglycemic in the first 24 hours after injury. Hyperglycemia in this study population correlated with an increased incidence of infection and increased length of stay. This suggests that strict control of hyperglycemia in injured children may be beneficial.

Extracorporeal life support.

Extracorporeal life support (ECLS) denotes the use of prolonged extracorporeal cardiopulmonary bypass in patients with acute, reversible cardiac or respiratory failure. As technology has advanced, organ support functions other than gas exchange, such as liver, renal, and cardiac support, have been provided by ECLS, and others, such as immunologic support, will be developed. The future of ECLS will include improvements in devices accompanied by circuit simplification and auto-regulation. Such enhancements in technology will allow application of ECLS to populations currently excluded from such support; for example, thromboresistant circuits will eliminate the need for systemic anticoagulation and lead to the use of this technique in premature newborns. As the ECLS technique becomes safer and simpler, and as morbidity and mortality are minimized, criteria for application of ECLS will be relaxed. New approaches to ECLS, such as pumpless arteriovenous bypass, the artificial placenta, arteriovenous CO(2) removal (AVCO(2)R), and intravenous oxygenators (IVOX), will become more commonly applied. Such advances in technology will allow broader and more routine application of ECLS for lung and other organ system failure.