Impact of caudal block on revision rates after hypospadias repair: Multi-institution review.

INTRODUCTION: There is controversy surrounding the association between caudal block and complication rates after hypospadias repair. Conflicting results have been reported mostly from single-center, low volume studies and those that did not include relevant variables. OBJECTIVES: We hypothesized that caudal block is not associated with increased rates of reoperation after primary repair and is associated with more complex hypospadias surgery. STUDY DESIGN: The Clinical Practice Solutions Center database was queried to identify patients who received a primary hypospadias repair between 2009 and 2010. Primary hypospadias repair was further categorized as meatal advancement and glanduloplasty, distal, one-stage proximal, or one-stage perineal repair. Anesthesia coding was evaluated to identify those who received a caudal block. Any revision surgery was captured between 2009 and 2019 and the types of revision surgeries were identified. Variables such as caudal block, age, insurance type, surgeon volume, and surgeon years in practice were analyzed with mixed effects multiple logistic regression models. RESULTS: The dataset query identified 3343 pediatric males who had primary hypospadias repair. The procedures were performed by 50 surgeons at 27 hospitals. Primary surgeries included meatal advancement and glanduloplasty (23%), distal (69%), proximal (6.9%), and perineal repairs (1%). Caudal block was administered to 42% of patients. Utilization of caudal block was not associated with type of primary surgery (p = 0.21). Adjusting for all other variables, increased patient age was associated with decreased usage of caudal block (p < 0.001). Analysis did not demonstrate a statistically significant association between utilization of caudal block with rates of revision surgery. CONCLUSIONS: This large, multi-institution study demonstrates that the use of caudal block was not associated with more complex hypospadias surgery nor statistically significantly associated with increased rates of revision surgery after primary hypospadias repair.

Novel Use of a Bronchial Blocker in a Challenging Case of Congenital Diaphragmatic Hernia-A Case Report.

The diagnosis of congenital diaphragmatic hernia (CDH) is associated with significant morbidity and mortality. Survival of neonates with CDH has improved recently, although the clinical course is complicated by sequelae of hypoplastic pulmonary parenchyma and vasculature, pulmonary hypertension, ventilation/perfusion (V/Q) mismatch, reduced pulmonary function and poor somatic growth. In this case report, we describe an infant with an antenatal diagnosis of CDH with a poor prognosis who underwent initial surgery followed by a tracheostomy but had a worsening clinical course due to a large area of ventilated but poorly perfused lung based on a V/Q nuclear scintigraphy scan. The emphysematous left lung was causing mediastinal shift and compression of the right lung, further compromising gas exchange. The infant had clinical improvement following bronchial blockade of the under-perfused left lung. This paved the way for further management with resection of the under-perfused lung lobe and continued clinical improvement. We present the novel use of selective bronchial blockade in a challenging case of CDH to determine if surgical lung resection may benefit the infant. We also review the physiology of gas exchange during the use of a bronchial occluder and the relevant literature.

Anisocoria in a 10-month old girl in the immediate preoperative setting: can you proceed with surgery?

We report the case of a 10-month old girl with a significant past medical history who presented for elective surgery with a new-onset fixed, dilated pupil. We briefly review the diagnostic approach to such patients and provide guidelines for managing these patients in the immediate preoperative setting.