A pediatric acute wound service: a novel approach in wound management.

INTRODUCTION: In 2001, in response to an overwhelming increase in patient visits for various pediatric abscesses, burns, and other wounds, an ambulatory burn and procedural sedation program (Pediatric Acute Wound Service, or PAWS) was developed to minimize operating room utilization. The purpose of this study is to report our initial 7-year experience with the PAWS program. METHODS: The hospital records of all children managed through PAWS from 2001 to 2007 were reviewed. Outcomes measured include patient demographics, number and location of visits per patient, procedure information, cause of wounds, and reimbursement. chi(2) test and linear regression were performed using GraphPad Prism (GraphPad Software Inc, San Diego, CA). RESULTS: Overall, 7620 children (age 0-18 years) received wound care through PAWS from 2001 to 2007. There were no differences in patient age, race, and sex during this time period. Between 2001 and 2007, the percentage of patients seen as outpatients increased from 51% to 68% (P < .05), and the average number of visits per patient decreased from 3.9 to 2.4 (P = .05). In, 2007, 46% of the children required only 1 visit. In 2007, 74% of the visits were for management of wound and soft tissue infections, compared with only 9% in 2001 (P < .05). The contribution margin of a PAWS visit and total contribution margin in 2007 were $1052 and $4.0 million, respectively. CONCLUSION: The creation of PAWS has allowed for the transition in management of most pediatric skin and soft tissue wounds and infections to an independent ambulatory setting, alleviating the need for operating room resources, while functioning at a profitable cost margin for the hospital.

Routine insertion of a silastic spring-loaded silo for infants with gastroschisis.

BACKGROUND/PURPOSE: Gastroschisis traditionally is managed by emergency operating room closure (EC), with a silo reserved for cases that cannot be closed primarily. The authors recently began using routine insertion of a SILASTIC (Dow Corning, Midland, MI) spring-loaded silo (SLS), followed by elective closure. METHODS: A total of 43 consecutive neonates with gastroschisis were treated between 1993 and 1998. RESULTS: Thirty patients underwent EC, and 13 underwent closure after insertion of a SLS (10 at bedside, 3 in the operating room). Eight infants treated by EC required staged repair. There were no differences with respect to gestational age, birth weight, gender, Apgar score, maternal age, or mode of delivery. Median length of stay was 32 days for EC and 25 days for SLS (P = .05). The SLS group required fewer days on a ventilator (4 v 6 days, P = .03) and had lower intraoperative (28 v 21, P = .02) and early postoperative peak airway pressures. The time to tolerate full feedings was 21 days for SLS and 27 days for EC (P = .07). The SLS group had fewer complications and a lower median hospital charge ($71,498 v $85,147; P = .05). CONCLUSION: SLS followed by elective repair permits gentle, gradual reduction of the viscera. When compared with EC, SLS is associated with significantly lower airway pressures, earlier extubation, fewer complications, and decreased length of stay and hospital charges.

Intestinal obstruction after lung transplantation in children with cystic fibrosis.

BACKGROUND/PURPOSE: Distal intestinal obstruction syndrome (DIOS) occurs in 15% of patients with cystic fibrosis (CF). The authors reviewed their experience to determine the incidence, risk factors, and natural history of adhesive intestinal obstruction and DIOS after lung transplantation. METHODS: Eighty-three bilateral transplants were performed in 70 CF patients between January 1990 and September 1998. All were on pancreatic enzymes preoperatively, and none had preoperative bowel preparation. Fifty-six patients (80%) had prior gastrostomy (n = 54) or jejunostomy (n = 2). Eighteen patients (25.7%) had a previous laparotomy for meconium ileus (n = 8), fundoplication (n = 4), liver transplant (n = 1), jejunal atresia (n = 1), Janeway gastrostomy takedown (n = 1), pyloromyotomy (n = 1), free air (n = 1), or appendectomy (n = 1). RESULTS: After lung transplantation, 7 patients (10%) required laparotomy for bowel obstruction (6 during the same hospitalization, and 1 during a subsequent hospitalization). The causes of obstruction were adhesions only (n = 1), DIOS only (n = 2), and a combination of DIOS and adhesions (n = 4). Adhesiolysis was performed in the 5 patients with adhesions, and a small bowel resection was also performed in 1 patient. DIOS was treated by milking secretions distally without an enterotomy (n = 3) with an enterotomy and primary closure (n = 1) or with an end ileostomy and mucus fistula (n = 2). Five had recurrent DIOS early postoperatively. One resolved with intestinal lavage, 2 were treated successfully with hypaque disimpaction, and 2 underwent reoperation; 1 required an ileostomy. The most important risk factor for posttransplant obstruction was a previous major abdominal operation. Obstruction occurred in 7 of 18 (39%) who had undergone a prior laparotomy versus 0 of 52 who had not (P < .001, chi2). CONCLUSIONS: (1) The incidence of intestinal obstruction is high after lung transplantation in children with CF. (2) Previous laparotomy is a significant risk factor. (3) Recurrent obstruction after surgery for this condition is common. (4) Preventive measures such as pretransplant bowel preparation and early postoperative bowel lavage may be beneficial in these patients.

Experience with procedural sedation in a pediatric burn center.

BACKGROUND: Burn care requires daily debridement, dressing changes, and assessment regarding the need for skin grafting. These procedures are painful and may require an operating room environment. METHODS: The authors reviewed their experience with 912 consecutive procedural sedations (PS) in 220 pediatric burn patients over a 2-year period to identify what influence PS had on patient care. Median patient age was 32 months, and body surface area burn was 7.2%+/-6%. Pharmacological techniques included oral and intravenous medications and N2O. The authors included all sedations given in the burn treatment area and excluded all treatments given in the intensive care unit or emergency unit. RESULTS: PS allowed for early aggressive wound debridement, virtually eliminated the need for operating room debridement (used in only 22 patients), and eliminated patient discomfort and fear often associated with subsequent debridements. Burn wound-related complications occurred in 54 patients and included wound infection (n = 18), graft loss (n = 9), and pneumonia (n = 4). The incidence of PS complications was 7% with the most common problems including decreased arterial saturation (n = 41), emesis (n = 11), and agitation (n = 8). No patient required intubation or transfer to an intensive care unit bed. The average length of stay (LOS) for all patients was 8.7+/-6.2 days, and 6.2+/-3.8 days in the 200 patients not admitted to the intensive care unit. This compares favorably with the 9.5-day LOS of patients treated in 1990. CONCLUSIONS: PS in burn patients allows for early aggressive debridement, decreases the use of the operating room for debridement, and a decrease in length of stay when compared with our previous burn patients. PS has a modest risk of complications, enhances the family's cooperation and satisfaction with health care provided, and should be an integral part of burn care in children.

Recognition and management of nonpenetrating cardiac trauma in children.

OBJECTIVE: To characterize the evaluation and clinical course of children with nonpenetrating injury to the heart. METHODS: We reviewed the medical records for children admitted to St. Louis Children's Hospital between the years 1987 to 1992 with traumatic cardiac injury. Patients with penetrating trauma were excluded; eight children, ages 4 to 13 years, were the study subjects. Chest x-ray studies, electrocardiograms, and serum creatine kinase values were obtained on admission. Two-dimensional echocardiography was performed when indicated by unexplained hemodynamic instability or abnormal radiographic findings. RESULTS: All children with nonpenetrating cardiac trauma were involved in a motor vehicle accident. The principal cardiac diagnoses were ventricular septal defect (1), mitral regurgitation (1), pericardial effusion (2), contusion (3), and arrhythmia (1). Multisystem injury was present in each case, but cardiac injury was not suspected at the time of admission in seven of the eight patients. The hemodynamic status of four children was compromised 12 to 48 hours after admission; echocardiography was diagnostic in each instance, but the electrocardiogram and creatine kinase values were nonspecific. Two patients eventually required cardiac surgery. CONCLUSIONS: Recognition of blunt cardiac trauma in children may be confounded by associated multisystem injury and the delayed onset of clinical manifestations. Echocardiography is a sensitive diagnostic tool for hemodynamically significant disease, and should be performed promptly when patients have unexplained hypotension or diminished peripheral perfusion.

One-stage versus two-stage Soave pull-through for Hirschsprung's disease in the first year of life.

Several investigators have reported good results after a one-stage Soave procedure without a stoma for infants with Hirschsprung's disease. The authors reviewed their concurrent experience with the one- and two-stage approaches, comparing the two groups with respect to rate of complications and clinical outcome. Over a 3-year period, 36 infants with colonic Hirschsprung's disease presenting in the first year of life were treated with a Soave pull-through. Thirteen had a one-stage pull-through, and 23 had a two-stage procedure using an initial stoma. There was no difference with respect to median age at time of diagnosis, median follow-up period, length of aganglionosis, or male:female ratio between the groups. The incidences of major complications such as small bowel obstruction, segmental or acquired aganglionosis, anastomotic leak, and malabsorption were equal between the two groups. However, 13% of the two-stage patients required revision of the stoma. All major complications in the one-stage group were in those who weighed less than 4 kg at the time of surgery. Minor complications such as wound infection, perianal excoriation, and need for repeated dilatation were similar between the groups, but minor stoma-related complications (prolapse or retraction) occurred in 26% of the two-stage infants. When complications were stratified using a more sophisticated scale of severity, no significant difference was found between the groups. The overall complication rate was 1.5 events per patient in the one-stage group and 2.0 events per patient in the two-stage group. This small difference was related to the presence of a stoma in the two-stage group. Overall, 10 of 12 survivors in the one-stage group and 22 of 23 in the two-stage group were doing well, with normal bowel function noted on long-term follow-up (mean period, of 14 and 19 months, respectively). Both one- and two-stage approaches were associated with a significant complication rate, although long-term outcome was excellent in both groups. The higher complication rate in the two-stage group was attributable to the presence of a stoma. For small infants, it may be beneficial to delay the one-stage pull-through until weight exceeds 4 kg.

Esophageal disease in the pediatric age group.

This article reviews the congenital disorder, esophageal atresia (EA) and tracheoesophageal fistula (TEF), and the acquired problem of gastroesophageal reflux (GER). Each can cause significant morbidity, but if treated appropriately can have gratifying results. EA and TEF anomalies exemplify a congenital disorder which is life threatening, but have been treated with improved success over the past three decades and continue to challenge pediatric surgeons. GER is an abnormal physiologic event which with overt emesis can present pulmonary problems or pathologies involving the esophagus alone. Recognition of GER as part of a foregut motility disorder enhances our understanding of the problem and its treatment.

MR imaging of annular pancreas.

The appearance of annular pancreas on magnetic resonance (MR) images is described in a 14-year-old with pancreatitis and incomplete pancreas divisum. The presence of the coexisting abnormalities complicated the interpretation of an upper gastrointestinal series and computed tomographic (CT) study. MR imaging was useful as a problem-solving technique to supplement the conventional imaging tests.

Fetus in fetu: molecular analysis of a fetiform mass.

Fetus-in-fetu is a rare condition presenting as a calcified intra-abdominal mass in the newborn infant. Over 50 cases of fetus-in-fetu have been reported since 1800. Karyotype analysis in 8 cases and protein polymorphisms in 4 documented identical findings in the host and fetiform mass. We report a case of fetus-in-fetu in a newborn female including cytogenetic and molecular studies of both the host and mass. Genotypic information from 7 polymerase chain reaction (PCR) assays representing 4 chromosomes demonstrates heterozygous and identical alleles in the infant and fetus-in-fetu at all loci studied. A review of the literature is provided including a discussion regarding the impact of molecular data on present hypotheses of fetus-in-fetu pathogenesis.

Neonatal survival during a 2,500-mile flight.

Neonatal respiratory failure, no matter what the cause, may not always respond to standard mechanical ventilation techniques. Extracorporeal membrane oxygenation has emerged over the last 15 years as an adjunct to the treatment of these babies with a greater than 80% survival nationwide. Limited resources and personnel costs can be prohibitive, forcing regionalization of extracorporeal membrane oxygenation (ECMO) centers. Geographic distance from a center should not limit its potential application, however. Familiarity with the technique, early application of the modality and the availability of medical air transport, allows for referral and transfer of neonates over great distances with excellent results and outcomes. We present a case of respiratory failure in a neonate transported 2,500 miles for ECMO therapy with an excellent outcome and a rapid return home.

Decreasing transfusion exposure risk during extracorporeal membrane oxygenation (ECMO).

Extracorporeal membrane oxygenation (ECMO) is a lifesaving therapy for neonatal pulmonary hypertension but carries a significant risk for transfusion-related complications. Packed red blood cell (PRBC) and platelet exposure were quantified and reviewed in 17 ECMO survivors prior (Group I, n = 9) and subsequent to (Group II, n = 8) changes in transfusion protocols. Blood product requirements included ECMO circuit priming, maintenance of haematocrit > 0.40 or platelet count > 50 x 10(9)/l, and colloid volume expansion. Group I was exposed to 13.8 +/- 10.2 (x +/- SD) different PRBC units. In Group II, multiple transfusions from single donor units decreased exposure 71% to 3.9 +/- 0.7 units (P < 0.05). Decreases in blood withdrawn (11%) and transfusion volume (7%) were coincident with a 15% reduction in mean bypass time. Platelet volume transfusion decreased from 159 +/- 213 to 93 +/- 64 ml using volume-reduced platelet packs. Total transfusion exposure decreased 59% from 20.8 +/- 17.8 units to 8.6 +/- 2.4 donor units. No transfusion complications occurred during the aggregate 1,926 h on bypass. We conclude that neonates on ECMO have a significant transfusion exposure risk increasing with prolonged duration of ECMO therapy. In addition we noted that concentrated platelet packs decreased transfusion volume by 41%, and multiple PRBC transfusions from single donor units decreased donor exposure by 71% while both strategies decreased the overall transfusion exposure risk by 59%.

Pulmonary edema and fluid mobilization as determinants of the duration of ECMO support.

The physiological variables that govern recovery of pulmonary function during neonatal extracorporeal membrane oxygenation (ECMO) remain poorly understood. We hypothesized that pulmonary hypertension (PHN) resolves soon after starting ECMO and that neonatal weight gain, pulmonary edema, and fluid mobilization are major determinants of recovery of pulmonary function and the ability to decrease ECMO support. To evaluate this, 17 consecutive neonates requiring ECMO for severe respiratory failure were reviewed. PHN was studied by daily echocardiography to assess the direction of ductal shunting. To evaluate fluid flux, pulmonary function, and edema during ECMO, we measured body weight, urine output, and ECMO flow every 12 hours. To evaluate pulmonary edema, serial chest radiographs obtained every 12 hours were randomly reviewed and scored by two radiologists with a semiquantitative chest radiograph index score (CRIS). By 25% of bypass time, PHN had resolved in all patients. However, at that time, weight had increased to 9.16% +/- 1.78% above birth weight, and the CRIS was 44% worse than the value just prior to ECMO. From 25% time on bypass, as urine output increased, patient weight and CRIS progressively decreased, allowing ECMO support to be weaned. At the time of discontinuation of ECMO support, weight had decreased to 2.0% +/- 1.3% above birth weight, and urine output remained steady at 3.0 +/- 0.3 mL/kg/h. Within 24 hours of stopping ECMO, the CRIS showed a 58% improvement compared to maximal scores during ECMO. We conclude that PHN decreases early in ECMO and that edema and its mobilization are important determinants of the improvement in pulmonary function and duration of ECMO.(ABSTRACT TRUNCATED AT 250 WORDS)

Surgical correction of hydrothorax from diaphragmatic eventration in children on peritoneal dialysis.

Continuous ambulatory peritoneal dialysis (CAPD) is frequently used in the pediatric age group for reversible and end-stage renal failure. Most pediatric patients tolerate this therapy with few complications. Approximately 2% of children, however, develop massive unilateral hydrothorax. This major complication usually results in the discontinuation of peritoneal dialysis in all forms and the institution of hemodialysis. Occult diaphragmatic defects account for most adult and pediatric patients who develop this complication. Three pediatric patients receiving CAPD complicated by massive hydrothorax are described. All patients were successfully treated by thoracotomy and repair of the diaphragmatic eventration with an immediate return to CAPD. This is the first report of successful therapy of this kind in children. A review of the cause, diagnosis, and treatment of massive hydrothorax developing during CAPD therapy is presented.

Extracorporeal membrane oxygenation in the treatment of neonatal respiratory failure.

We report 18 consecutive neonates with severe respiratory failure due to pulmonary hypertension treated with extracorporeal membrane oxygenation. Extracorporeal membrane oxygenation was begun at 52 +/- 36 hours of age with an arterial partial pressure of oxygen (PO2) of 36 +/- 14 mm Hg despite maximal pharmacologic and ventilator support (inspired fraction of oxygen [FiO2], 0.99 +/- 0.03; respiratory rate, 98 +/- 31/min; and positive inspiratory pressure, 54 +/- 11 cm of water). With initial flows of 130 +/- 17 mL/kg per minute, ventilator settings were reduced to the following: FiO2, 0.30; respiratory rates, 15/min; and positive inspiratory pressure, 24 cm of water. Support using extracorporeal membrane oxygenation was gradually reduced to 22% of initial flows and arterial blood samples showed pH 7.48 +/- .05, PO2 of 106 +/- 27 mm Hg, and PCO2 of 36 +/- 5 mm Hg just prior to decannulation. After 107 +/- 45 hours, extracorporeal membrane oxygenation was stopped and infants were extubated 61 +/- 53 hours (median, 46 hours) afterward. There was one death (94.4% survival rate); all survivors were discharged and underwent a follow-up examination at 1 to 27 months of age. Complications included two intracranial hemorrhages (one death and one asymptomatic), one patent ductus arteriosus requiring ligation on extracorporeal membrane oxygenation, and chronic lung disease in one patient. In selected neonates, extracorporeal membrane oxygenation allows for resolution of pulmonary hypertension, results in improved survival, and is associated with a low incidence of chronic lung disease. Extracorporeal membrane oxygenation should be considered in the treatment of severe respiratory failure.

Emergency lung biopsy in immunocompromised pediatric patients.

Twenty-six lung biopsies were performed on immunocompromised children with interstitial pneumonia over a 4-year period. More than 50% of the patients had either bone marrow transplants or immunodeficiency syndromes. Biopsy diagnosis included viral (9), nonspecific interstitial pneumonitis (9), Pneumocystis carinii (7), and bacterial (1) etiologies. Findings caused a change in treatment in 15 (58%) patients, and nine of these 15 (60%) survived. Survivors included five children with viral infections treated with antiviral agents. Only one of nine patients requiring preoperative intubation survived, while 11 of 17 (65%) not intubated before operation survived. Overall survival was 46% and included 5 of 5 patients with leukemia, 2 of 3 patients with liver transplants, 2 of 6 patients with immunodeficiency syndromes, and 1 of 8 patients with bone marrow transplants. This report shows that (1) an infectious etiology was found in 65% of the cases; (2) there was a high incidence of viral pneumonitis; (3) biopsy indicated a change in treatment for the majority of the patients; (4) the change in treatment was associated with survival in 60%; (5) viral infections may be effectively treated; and (6) the timely use of lung biopsy is an important adjunct in the diagnostic and therapeutic regimen for immunocompromised children with interstitial pneumonia.

Accuracy of diagnostic imaging as determined by delayed operative intervention for advanced neuroblastoma.

Current treatment of newly diagnosed widespread neuroblastoma may include chemotherapy, delayed surgical resection, marrow ablative chemoradiotherapy, and bone marrow transplantation. Diagnostic imaging (DI) with computerized tomography (CT) or magnetic resonance imaging (MRI) has been used to determine response to therapy and timing of delayed resection. We assessed the accuracy of DI in 25 patients (26 total cases) treated over 21 months. Tumor size and location were estimated prior to surgical resection by DI, and the sensitivity and specificity of these studies were determined from operative findings. DI consisted of CT (15), MRI (8), and MRI and CT (3). Discordance between DI and operative findings was found in ten patients (38%). This included three errors of sensitivity (12%), including two false-positives and one false-negative. Seven errors of specificity were noted; they included a positive scan with no viable tumor identified (3), much more extensive disease (3), or less extensive disease (1). Viable tumor was identified in 18 cases, and in 11 patients, complete resection of macroscopic tumor at the primary site was carried out. Ten of 13 patients operated on within 5 months of beginning chemotherapy were rendered grossly free of neuroblastoma at the primary site after surgery. Eight of 12 patients operated on 6 months or longer after starting chemotherapy were rendered grossly free of tumor at the primary site. Bone marrow transplantation was performed in 21 patients, ten of whom are alive with a median follow up of 20 months. Survival was similar for patients who underwent surgical resection at less than or equal to 5 v greater than 6 months after starting chemotherapy.(ABSTRACT TRUNCATED AT 250 WORDS)

Operative treatment for the gastroesophageal reflux syndrome in children.

Surgical treatment for symptomatic gastroesophageal reflux (GER) was performed on 420 infants and children over a 19-year period. Esophageal motility disorders were present in more than 35% of patients and delayed gastric emptying (DGE) was present in approximately 50% of patients studied. Gastroesophageal fundoplication (GEF) alone was performed for 357 patients, whereas 51 patients underwent GEF and pyloroplasty; 12 patients underwent pyloroplasty alone. When there is more than 60% gastric retention of technetium-99m sulphur colloid in semisolid feedings at 90 minutes, pyloroplasty appears to be useful. Twenty-two percent of the last 275 refluxing children underwent pyloroplasty combined with GEF. Most infants and young children undergoing evaluation for severe GER, particularly those with neurologic disorders, may benefit from having a gastric emptying study. Children with severe reflux and esophageal dysmotility should have a loose GEF performed. The absence of persistent dumping, and the very low incidence of complications suggests that pyloroplasty should be used more frequently when significant DGE is present.

Fetal and postnatal testis shows immunoprivilege as donor tissue.

We evaluated the immunogenicity of the testis by transplanting adult, postnatal, and fetal rat testicular tissue into outbred adult female and male rats for 10 days. Testis grafts were evaluated morphometrically and histologically, and selectively compared to renal grafts previously reported in part. Testis grafts from days 15 to 21 of gestation, and from three, nine, 12 and 15 days after birth showed an overall increase in growth, with maintenance of architecture and minimal lymphocytic infiltrate. In contrast, only fetal renal tissue from days 15 to 17 demonstrated an increase in growth with maintenance of architecture and minimal lymphocytic infiltrate; grafts from later in gestation grew only slightly and showed progressive deterioration in architecture with an increasing lymphocytic infiltrate. Fifteen day fetal testis grafts were also implanted for longer intervals up to 45 days. The fetal testis grafts implanted for 20 and 30 days showed an increase in size with maintenance of architecture and minimal lymphocytic infiltrate. The observed fetal and postnatal testis growth in the non-immunosuppressed adult host makes compelling further studies directed at determining those factors contributing to the decreased immunogenicity of this organ.

Retrograde colostomy and ileostomy enemas in neonates and infants: a simple combination of techniques.

A combination of previously known techniques for retrograde opacification of ileostomies and colostomies has been used successfully in neonates and infants. This combination of techniques used on very small stomas allows easy retrograde opacification of bowel. The technique uses a small feeding tube, a larger Foley catheter with an inflatable balloon, and a Lucite compression device, the construction and use of which are discussed here.