Day-case laparoscopic cholecystectomy in childhood: outcomes from a clinical care pathway.

AIM: The aim of this study was to report clinical outcomes following the use of a pediatric day-case laparoscopic cholecystectomy (DCLC) clinical care pathway. The pathway was modified in September 2009 and we compare the clinical outcomes before and after this modification. METHODS: A care pathway for DCLC was introduced in 2008 with emphasis on the day of admission, timing of surgery, choice of anesthetic agents, analgesia, postoperative feeding, mobilization, and pain scoring. Demographic and clinical data were recorded prospectively from January 2008 to January 2012. In September 2009, two modifications were made to the pathway. Induction of anesthesia was changed to total intravenous anesthesia, using propofol (target 4 to 6 µg/mL) and remifentanil (target 3 to 5 ng/mL) and the use of the gaseous anesthetic sevoflurane was eliminated with the aim of reducing the risk of postoperative nausea and vomiting (PONV). The postoperative feeding regime was changed from unrestricted to light diet for 72 hours. The rest of the pathway was unchanged. Data before (group 1) and following the modifications (group 2) were compared. RESULTS: We admitted 25 children with symptomatic cholelithiasis for DCLC under the care of one surgeon: 12 in group 1 and 13 in group 2. There were no significant differences in age between group 1 (median 13 [range 6 to 15] years) and group 2 (median 15 [9 to 16] years) (p = 0.07). There were no intra- or postoperative complications. The day-case rate increased from 6/12 (50%) in group 1 to 12/13 (92%) in group 2 (p = 0.03). The incidence of PONV reduced from 7/12 (58%) in group 1 to 0/13 in group 2 (p = 0.002). PONV in group 1 resulted in overnight stay (n = 6) and readmission (n = 1). One patient in group 2 had an overnight stay due to poor mobilization. CONCLUSIONS: Adoption of a DCLC pathway is feasible and safe for children. Emphasis on adequate pain management and avoidance of PONV results in a high rate of day-case surgery equivalent to that achieved in adult practice.

Predictors of blood loss in fronto-orbital advancement and remodeling.

Fronto-orbital advancement and remodeling for craniosynostosis is extensive surgery and is associated with potential risks; the most significant of these is blood loss. We prospectively studied 116 consecutive patients undergoing fronto-orbital advancement by the same surgical team for a 5-year 6-month period to determine what factors are associated with blood loss and transfusion of blood products. The data collected on the calvarial sutures involved were whether the patient had a diagnosed syndrome, the age at operation, the length of the operation, the estimated blood volume lost during the perioperative course, the number of units of packed cells transfused (donor exposures), and the use of other blood products. The mean (SD) total blood volume lost was 116% (5.4) of the estimated preoperative volume. The median number of whole units of packed cells transfused was 2 units. Other blood products were given in 28% of the cases. There was significantly greater blood loss in those patients with recognized craniofacial syndromes, pansynostosis, an operating time longer than 5 hours, and an age of 18 months or younger at operation. The use of other blood products was associated with those patients losing a blood volume higher than the mean.

Incidents and complications during pediatric cardiac catheterization.

BACKGROUND: Cardiac catheterization has revolutionized the management of pediatric cardiac disease. There has been little information on adverse events during these cases from an anesthesia viewpoint. The aim of this audit was to determine the incident rate during pediatric cardiac catheterization as contemporaneously reported by the anesthetist and to identify both the types of events and which procedures had the highest risk. METHODS: Since 1993, data have been collected prospectively on an audit form for every anesthetic given in our institution, and in-theatre events were recorded on this form. We have reviewed the data collected on pediatric cardiac catheterizations over a period of 9 years. RESULTS: A total of 4454 cardiac catheterizations were recorded. The overall incidence of events was 9.3%. Cardiac catheterization with occlusion of a patent ductus arteriosus (PDA) or a secundum atrial septal defect (ASD) had the lowest event rate at 4.2%. The figure for cardiac catheterization with other therapeutic interventions was 11.6 and 9.3% for solely diagnostic cardiac catheterization. The event rate in infants under the age of 1 year was 13.9% compared with 6.7% for those children over the age of 1 year. Of the 253 reports from cardiac catheterizations that could be analyzed further, there were 91 major complications including four deaths, 72 minor complications and 90 other incidents. CONCLUSIONS: Adverse events occur more commonly during cardiac catheterization than during pediatric anesthesia in general. Cases with highest risk are those in the under 1 year olds and those including a therapeutic intervention other than PDA or ASD occlusion.