Ultrasound-Guided Percutaneous Cryoanalgesia for Pectus Excavatum: When Should It be Applied?

INTRODUCTION: The addition of ultrasound-guided percutaneous cryoanalgesia (PCr) for pain management after pectus excavatum (PE) surgery offers a new and advantageous approach. Our aim is to describe our experience with PCr applied on the same day, 24 hours, and 48 hours prior to PE surgery. MATERIAL AND METHODS: Prospective pilot study in patients undergoing ultrasound-guided PCr (2019-2022) was divided into three groups: PCr on the same day of surgery (PCrSD), PCr 24 hours before (PCr24), and PCr 48 hours before (PCr48). We describe the application of technique and data obtained by comparing the three groups. RESULTS: We present 42 patients (25 PCrSD, 11 PCr24, 6 PCr48). PCr24 had a shorter procedure duration than PCrSD (65.8 vs. 91.2 minute; p = 0.048). Related to analgesia, PCr24 and PCr48 showed lower opioid consumption than PCrSD in PCA volume (48.5 and 49.6 vs. 75.1 mL; p = 0.015) and PCA time (23.3 and 23.8 vs. 34.3 hours; p = 0.01). Degree of pain (VAS scale) on the day of surgery and on the second postoperative day was lower in PCr24 and PCr48 than in PCrSD (4 and 2 vs. 5; p = 0.012; 0 and 1 vs. 2; p = 0.01, respectively) as well as shorter hospital stay (3 and 3.5 vs. 5 days; p = 0.021). In addition, PCr24 showed lower opioid consumption and hospital stay than PCr48 (p > 0.05). The greatest savings in hospital costs were obtained in the PCr24 group. CONCLUSION: PCr48 and PCr24 prior to PE surgery offers lower opioid consumption, less pain and shorter hospital stay than PCrSD. PCr24 is comparable to PCr48, but seems to show advantages and simpler logistics for the patient and the hospital.

Rhabdomyolysis following Nuss Procedure: A Prospective Study in Children.

INTRODUCTION: Postoperative rhabdomyolysis (RML) has been documented after several surgical procedures in adults. Musculoskeletal remodeling after Nuss procedure for pectus excavatum (PE) could cause RML. We evaluated the incidence of RML after Nuss procedure in children. METHODS: This study was a prospective study from 2018 to 2021. We enrolled all otherwise healthy patients who underwent PE correction with only one bar. Studied variables included demographic and clinical data, duration of surgery, complications, and length of hospitalization. The patients included underwent serial measurements of serum creatine kinase (CK), troponin I, N terminal pro B-type natriuretic peptide (NT-proBNP), serum creatinine, urea, and glomerular filtration rate at 6 and 48 hours postoperatively, and hospital discharge. RESULTS: Forty-six patients met criteria (40 males/6 females), with a mean age of 15.1 ± 1.4 years. Mean duration of surgery was 74 ± 28 minutes, and length of hospitalization was 4.6 ± 1.6 days. RML was diagnosed in 30.4% of patients at 6 hours, 91.3% at 48 hours, and 21.7% at hospital discharge. Mean preoperative CK value was 181.1 ± 141.6 IU/L, and postoperative values were 863.3 ± 302.6 IU/L at 6 hours, 1,675.2 ± 561 IU/L at 48 hours, and 850 ± 683.7 IU/L at hospital discharge, with statistically significant differences (p = 0.001). High-sensitivity troponin I and NT-proBNP levels increased significantly during the postoperative time (p = 0.001). Renal function remained stable (p = 0.55). CONCLUSION: Nuss technique produces RML without kidney injury in healthy patients. This knowledge should be considered for patients at increased risk of developing acute kidney injury and other complications.

Postoperative Pneumoperitoneum in Pediatric Patients: Residual Air or Surgical Complication? A Prospective Study.

Background: Residual postoperative pneumoperitoneum (RPP) can be confused with postoperative complications. Our aim was to study RPP characteristics in pediatric patients. Materials and Methods: Prospective study in children with noncomplicated appendicitis, from July to December 2019, divided into open appendectomy (OA) or laparoscopic appendectomy (LA). Abdominal ultrasounds were performed daily to assess RPP. Demographic, surgical data, and RPP characteristics were analyzed. Results: Forty-one patients (63% male) aged 9.8 ± 2.9 years were included: 19 had OA and 22 LA. RPP was present in 90.9% of LA patients versus 21.1% of OA (P < .001). RPP disappeared by the postoperative day (POD) 2, in all OA patients. RPP was present in 90.9% of LA patients in POD 1, 53.8% on POD 2, 25% on POD 3, and in no patient from POD 4. RPP prevalence was not associated with surgical duration, age, gender, or type of appendicitis. RPP was associated with pain radiating to the shoulders (PRS) (P = .018), with a sensitivity of 50.0% and specificity of 88.23% for diagnosis. Conclusions: Surgical approach was the main factor associated with RPP persistence. PRS in the physical examination may be helpful for diagnosis when RPP is suspected. The persistence of RPP beyond POD 4 is uncommon, and should be considered when making decisions.

Percutaneous Cryoanalgesia: A New Strategy for Pain Management in Pectus Excavatum Surgery.

INTRODUCTION: In recent years, pain protocols for pectus excavatum (PE) have incorporated cryoanalgesia through thoracoscopic approach. Since 2019, ultrasound-guided percutaneous cryoanalgesia (PCr) has been applied at our institution, either on the same day as the Nuss procedure or 48 hours before surgery. We carried out a preliminary retrospective review of patients with PE in whom PCr prior to surgery was performed at our institution between 2019 and 2021. MATERIALS AND METHODS: Two groups were evaluated: PCr on the same day (PCrSD) and PCr 48 hours before surgery (PCr48). Despite PCr, patients were treated with "patient-controlled analgesia" (PCA) with opioids for at least 24 hours, switching to conventional intravenous analgesia and oral analgesia in the following days. Demographic, clinical-radiological variables, PCA opioid use, pain grade according to the visual analog scale (VAS), and length of stay (LOS) were compared between the groups. A total of 20 patients were included (12 with PCrSD and 8 with PCr48), without significant differences in demographics or clinical-radiological variables. The overall median time of PCr was 65 minutes (55-127), with no differences between the groups. RESULTS: PCr48 group presented with significantly lower median number of hours of continuous PCA (24 vs. 32 hours; p = 0.031), lower median number of rescue boluses (11 vs. 18; p = 0.042), lower median VAS in the early postoperative hours (2 vs. 5.5; p = 0.043), and lower median LOS (3.5 vs. 5 days). CONCLUSION: PCr performed 48 hours prior to surgery is more effective in terms of PCA requirements, VAS, and LOS when compared with cryoanalgesia on the same day.

Healthcare staff as promoters of parental presence at anesthetic induction: Net Promoter Score survey.

BACKGROUND: Surgical intervention is usually a traumatic event that causes stress and anxiety in the pediatric patient and the family environment. To reduce the harmful effects of presurgical anxiety, parental presence during induction of anesthesia (PPIA) is one of the more notable interventions used in medical centers. However, data on this measure are difficult to evaluate and often face resistance from healthcare staff. AIM: To analyze the perception of the healthcare workers after the implementation of a PPIA program. METHODS: A survey was developed and sent by email to all the healthcare staff working in the children's area of a tertiary hospital. It consisted of 14 items divided into positive aspects of PPIA and negative aspects of PPIA evaluated with the use of a Likert scale (1 to 5). The demographics of the respondents were included in the data collected. The answers to the questions were interpreted through the Net Promoter Score (NPS). The statistical analysis compared the differences in the responses to each question of the survey made by the different groups of health personnel included. RESULTS: A total of 141 surveys were sent out, with a response rate of 69%. Of the total number of responses, 68% were from women and 32% from men. The average age of the participants was 42.3 ± 10.6 years. As for the positive questions about the PPIA, 83% had an NPS > 50, and only one had a score between 0 and 50, which means that the quality of the service was rated as excellent or good by 100% of the respondents. On the other hand, 100% of the negative questions about the PPIA had a negative NPS. Responses to the question "PPIA increases patient safety" were significantly different (P = 0.037), with a lower percentage of pediatric surgeons (70%) thinking that PPIA increased patient safety, compared with anesthesiologists (90%), nursing (92%), and other medical personnel (96%). CONCLUSION: The personnel who participated in the PPIA program at our center were in favor of implementation. There were no validated arguments to support worker resistance to the development of the PPIA.

Influencia de la pandemia por coronavirus 2(sars-cov-2) en la apendicitis aguda. Sars-cov-2 en la apendicitis aguda / Influence of the coronavirus 2 (sars-cov-2) pandemic on acute apendicitis

INTRODUCCIÓN: La apendicitis aguda (AA) es la urgencia quirúrgica abdominal más frecuente. No encontramos estudios específicos que evalúen el impacto de la pandemia causada por el coronavirus 2 (SARS-Cov-2) sobre la AA y su tratamiento quirúrgico. Analizamos la influencia de esta nueva patología sobre la AA. MATERIAL Y MÉTODOS: Estudio observacional retrospectivo en pacientes intervenidos por AA desde enero hasta abril de 2020. Fueron clasificados según el momento de la apendicectomía, antes de la declaración del estado de alarma (Pre-COVID19) y después de la declaración del estado de alarma (Post-COVID19) en España. Se evaluaron variables demográficas, duración de la sintomatología, tipo de apendicitis, tiempo quirúrgico, estancia hospitalaria y complicaciones postoperatorias. RESULTADOS: Se incluyeron 66 pacientes (41 Pre-COVID19; 25 Post-COVID19 con edad media de 10.7 ± 3 y 9.3 ± 3.1; p = 0.073; respectivamente). La fiebre se encontró en un mayor número de pacientes post-COVID19 (52 vs 19.5%; p = 0.013), así como una PCR más elevada (72.7 ± 96.2 vs 31.3 ± 36.2 mg/dl; p = 0.042). Este grupo presentó una mayor proporción de apendicitis complicada al compararle con el Pre-COVID19 (32 vs 7.3%; p = 0.015). La estancia media hospitalaria fue mayor en el grupo Post-COVID19 (5.6 ± 5.9 vs 3.3 ± 4.3 días; p = 0.041). No se encontraron diferencias en el tiempo de evolución de los síntomas ni en el tiempo quirúrgico. CONCLUSIONES: La pandemia por SARS-Cov-2 influye en el momento de diagnóstico de la apendicitis, así como en su grado de evolución y estancia hospitalaria. La peritonitis fue lo más frecuentemente observado. Una sospecha y orientación clínica más temprana, es necesaria para evitar un manejo inadecuado de este trastorno quirúrgico común

INTRODUCTION: Acute appendicitis (AA) is the most common abdominal surgical emergency. No specific studies have been found that evaluate the impact of the coronavirus 2 (SARS-Cov-2) pandemic on AA and its surgical management. An analysis was made on the influence of this new pathology on the clinical course of AA. MATERIAL AND METHODS: Retrospective observational study was conducted on patients operated on for AA from January to April 2020. They were classified according to the time of the appendectomy, before the declaration of the state of alarm (Pre-COVID-19), and after its declaration (Post-COVID-19) in Spain, one the most affected countries in the world. An evaluation was made of demographic variables, duration of symptoms, type of appendicitis, surgical time, hospital stay, and postoperative complications. RESULTS: The study included 66 patients (41 Pre-COVID-19; 25 Post-COVID-19) with mean age of 10.7 ± 3 and 9.3 ± 3.1; P = .073, respectively. Fever was found in a higher number of post-COVID-19 patients (52 vs 19.5%; P = .013), as well as a higher CRP (72.7 ± 96.2 vs 31.3±36.2 mg/dL; P = .042). This group presented with a higher proportion of complicated appendicitis when compared to Pre-COVID-19 (32 vs 7.3%; P = .015). The mean hospital stay was longer in the Post- COVID-19 group (5.6 ± 5.9 vs 3.2 ± 4.3 days; P = .041). No differences were found in the time of onset of symptoms or surgical time. Conclusions. The SARS-Cov-2 pandemic influenced the time of diagnosis of appendicitis, as well as its course, and mean hospital stay. Peritonitis was more frequently seen. As a result of the significant circumstances, delaying diagnosis and treatment of AA during SARS-Cov-2 pandemic, inappropriate management of this common surgical disorder has been noticed

[Influence of the coronavirus 2 (SARS-Cov-2) pandemic on acute appendicitis]. / Influencia de la pandemia por coronavirus 2 (SARS-Cov-2) en la apendicitis aguda.

INTRODUCTION: Acute appendicitis (AA) is the most common abdominal surgical emergency. No specific studies have been found that evaluate the impact of the coronavirus 2 (SARS-Cov-2) pandemic on AA and its surgical management. An analysis was made on the influence of this new pathology on the clinical course of AA. MATERIAL AND METHODS: Retrospective observational study was conducted on patients operated on for AA from January to April 2020. They were classified according to the time of the appendectomy, before the declaration of the state of alarm (pre-COVID-19), and after its declaration (post-COVID-19) in Spain, one the most affected countries in the world. An evaluation was made of demographic variables, duration of symptoms, type of appendicitis, surgical time, hospital stay, and postoperative complications. RESULTS: The study included 66 patients (41 pre-COVID-19; 25 post-COVID-19) with mean age of 10.7 ± 3 and 9.3 ± 3.1; P = .073, respectively. Fever was found in a higher number of post-COVID-19 patients (52 vs. 19.5%; P = 0.013), as well as a higher CRP (72.7 ± 96.2 vs. 31.3 ± 36.2 mg/dL; P = 0.042). This group presented with a higher proportion of complicated appendicitis when compared to pre-COVID-19 (32 vs. 7.3%; P = 0.015). The mean hospital stay was longer in the post-COVID-19 group (5.6 ± 5.9 vs. 3.2 ± 4.3 days; P = 0.041). No differences were found in the time of onset of symptoms or surgical time. CONCLUSIONS: The SARS-Cov-2 pandemic influenced the time of diagnosis of appendicitis, as well as its course, and mean hospital stay. Peritonitis was more frequently seen. As a result of the significant circumstances, delaying diagnosis and treatment of AA during SARS-Cov-2 pandemic, inappropriate management of this common surgical disorder has been noticed.

Iatrogenic Compartment Syndrome Secondary to Burn Dressing in a 2-Year-Old Child.

We report a severe case of compartment syndrome due to a compressive burn dressing. An otherwise healthy 2-year-old girl presented at her local health center with a superficial partial-thickness thermal burn on the dorsum of the mid phalanx of the second finger of her right hand. A compressive dressing was applied solely to the affected finger. Forty-eight hours afterward, the patient presented in the emergency room with severe pain of the finger. After removal of the dressing, a circular constrictive eschar was observed at the base of the finger, secondary to ischemia due to the compressive dressing. Emergent lateral escharotomies were performed, with immediate recovery of distal perfusion. One week afterward, the patient underwent surgical debridement of the burn on the dorsum of her finger and escharectomy of the ischemic eschar at the base. The lesions were covered with partial-thickness skin grafts. This case shows that acute compartment syndrome can lead to severe sequelae, such as the loss of an extremity or body segment. We must take utmost care in all our actions to avoid any (negligent) act that could lead to severe or permanent damage to our patients.

Neutropthil-to-Lymphocyte Ratio as a Predictor of Postsurgical Intraabdominal Abscess in Children Operated for Acute Appendicitis.

Aim of the study: Postoperative intra-abdominal abscess (PIAA) is a frequent and severe complication of acute appendicitis (AA) with peritonitis. The neutrophil-to-lymphocyte ratio (NLR) is an inflammatory marker that has been related to the development of peritonitis; however, its diagnostic role in predicting PIAA has not been evaluated. This is the first study that analyzes the usefulness of NLR as a predictor of PIAA in children operated for AA. Material and Methods: Retrospective observational study in children operated for AA in our institution during 2017-2018. Patients aged under 5 years or with incomplete laboratory determinations at hospital admission (blood count, C-reactive protein, and fibrinogen) were excluded. Demographic and laboratory parameters and the development of PIAA were analyzed. NLR was calculated by dividing the absolute number of neutrophils by the absolute number of lymphocytes. By means of ROC curves, we determined the sensitivity and specificity of the different laboratory parameters to predict the development of PIAA. Results: A total of 388 patients aged 10.5 ± 2.9 year were included. Twenty (5.2%) developed PIAA. NLR presented an area under the curve (AUC) of 0.85, significantly higher than the determination of leukocytes (AUC 0.69, p < 0.001), neutrophils (AUC 0.74, p < 0.001), fibrinogen (AUC 0.68, p < 0.001) and C-reactive protein (AUC 0.73, p < 0.001). We estimated the optimal cut-off point of NLR > 10.5, with a sensitivity of 85% and a specificity of 75.2%. Conclusions: NLR is the laboratory parameter with the highest sensitivity and specificity for predicting the development of PIAA in children operated for AA. It can be useful as a predictor of worse postoperative course.