Caudal catheter placement for repeated epidural morphine doses after neonatal upper abdominal surgery.

Effective pain control after major surgery in neonates presents many challenges. Parenteral opioids (and co-analgesics) are often used but inadequate analgesia and oversedation are not uncommon. Although continuous thoracic epidural analgesia is highly effective and opioid-sparing, its associated risks and the need for staff with specialised skills and/or neonatal intensive care unit staff buy-in may preclude this option even in many academic centres. We present the case of a six-day-old infant who underwent upper abdominal surgery and received intermittent morphine doses via a tunnelled caudal epidural catheter, which provided satisfactory analgesia and facilitated early extubation.

The Surgical Skills and Technology Elective Program (SSTEP): A comprehensive simulation-based surgical skills initiative for preclerkship medical students.

BACKGROUND: The Surgical Skills and Technology Elective Program (SSTEP) is a voluntary preclerkship surgical bootcamp that uses simulation learning to build procedural knowledge and technical skills before clerkship. METHODS: Eighteen second year students (n = 18) participated in simulation workshops over the course of 7 days to learn clerkship-level procedural skills. A manual was supplied with the program outline. Assessment of the participants involved: 1) a written exam 2) a single videotaped Objective Structured Assessment of Technical Skill (OSATS) station 3) an exit survey to document changes in career choices. RESULTS: Compared to the mean written pre-test score students scored significantly higher on the written post-test (35.83 ± 6.56 vs. 52.11 ± 5.95 out of 73) (p = 0.01). Technical skill on the OSATS station demonstrated improved performance and confidence following the program (10.10 vs. 17.94 out of 25) (p = 0.05). Most participants (72%) re-considered their choices of surgical electives. CONCLUSIONS: A preclerkship surgical skills program not only stimulates interest in surgery but can also improve surgical knowledge and technical skills prior to clerkship.

Is it safe to discharge intussusception patients after successful hydrostatic reduction?

PURPOSE: The aim of this study was to evaluate whether discharge from the emergency department (ED) after successful hydrostatic reduction (HR) of intussusception is safe. METHODS: We conducted a single institution review of patient records with a diagnosis code of intussusception from 1995 to 2006. Data collected included age, clinical presentation, imaging, surgical interventions, pathology, recurrence, and disposition. Statistical analysis utilized chi(2) tests, where P < or = .05 was considered significant. RESULTS: A total of 309 patients with intussusception were identified. One hundred twenty-three patients (39.8%) required surgical intervention, 138 (44.6%) patients were managed nonoperatively as inpatients, and 48 (15.5%) were treated nonoperatively and discharged from the ED. There were 18 recurrences (5.8%). Recurrence rates did not significantly differ between patients who required operative reduction and those who were managed nonoperatively with HR and either observed as inpatients or discharged from the ED. Seven patients with recurrences required surgical intervention, and 1 of those children had a pathologic lead point, which was nonneoplastic. CONCLUSIONS: Recurrence rates do not differ between children observed as inpatients and those discharged home after successful HR. Missed neoplastic pathologic lead points were not found in the patients who required an operation after a recurrence. Our data suggests that it is safe to discharge patients selectively from the ED after successful HR.

Health-related quality of life after pediatric trauma.

PURPOSE OF REVIEW: Pediatric injury results in significant preventable morbidity and functional limitations, with long-term impact on the quality of life of children and their families. The purpose of this review is to outline recent research in health-related quality of life (HRQOL) in pediatric trauma, with an emphasis on identification of predictors of outcome that will impact interventions and allocation of resources to optimize recovery. RECENT FINDINGS: Studies of HRQOL in pediatric trauma use a variety of generic measurement tools that have now been validated in this patient population. Most children experience rapid recovery of physical and psychological functioning after injury, but children with traumatic brain injury continue to demonstrate long-term impairments. Decrease in HRQOL of children after trauma contributes to increase in caregiver stress and family burden of injury. There is increasing recognition of post-traumatic stress disorder (PTSD) in pediatric trauma, correlating with and impacting HRQOL. SUMMARY: Evaluation of HRQOL in children after trauma should become incorporated into standards of care, with development of family-centered interventions and evidence-based allocation of resources for high-risk children and families to optimize long-term outcomes.

Quality of life and functional outcome after pediatric trauma.

BACKGROUND: Injury is the leading cause of preventable morbidity and functional limitation in children. Long-term sequelae are measured best by the degree of impairment after recovery from the acute traumatic event. The specific aim of this study was to determine the quality of life and functional status of moderately to severely injured pediatric trauma patients at hospital discharge and at 1, 6, and 12 months postinjury. METHODS: We conducted a prospective longitudinal study of children aged 1 to 18 years with blunt injury and Injury Severity Score >/= 9, excluding head and spinal cord injury. Children were evaluated at hospital discharge and at 1, 6, and 12 months postinjury, using the Child Health Questionnaire (CHQ), the Functional Independence Measure, and the Impact on Family Scale. Baseline and 1- and 6-month data analyses are reported. RESULTS: One hundred sixty-two children were enrolled in the study, and 156 had completed 6-month data entry. The mean age was 9.3 +/- 5.3 years, and the mean Injury Severity Score was 14 +/- 7.4. The most common cause of injury was motor vehicular-related (43%). Fifty-eight (37%) had multisystem injuries. Femur fracture represented the most common injury (54.8%). Families experienced economic, social, and personal strain, as measured by the Impact on Family scale. There was a significant improvement in CHQ and Functional Independence Measure scores between baseline and 1 month and between 1 month and 6 months postinjury. However, at 6 months, physical scores remained lower than age-matched norms. CONCLUSION: Injury in children results in a significant burden on families. Although children demonstrate a rapid recovery of function and quality of life after blunt injury, physical function remains lower than age-matched norms at 6 months postinjury. It is unclear whether this represents a plateau in recovery or whether further improvements can be expected over longer time intervals.

Mechanisms of pediatric trauma deaths in Canada and the United States: the role of firearms.

BACKGROUND: This study aimed to determine whether firearms are a more prevalent cause of pediatric death in the United States than in Canada. METHODS: All pediatric trauma deaths from 1991 to 1996 in Ontario and Missouri were reviewed. Socioeconomic data were compiled for the two jurisdictions. RESULTS: During the period reviewed, there were 1,146 pediatric trauma deaths in Ontario (10.4 per 100,000 population) and 1,782 in Missouri (32.4 per 100,000 population). Firearm injuries accounted for 19% of the trauma deaths in Missouri and 0.5% of such deaths in Ontario. Overall, a child was 100 times more likely to die of firearm injury in Missouri (6 per 100,000 population) than in Ontario (0.06 per 100,000 population). The incidences of violent acts unrelated to firearms were similar between the two groups. Both populations were similar in terms of socioeconomic and education parameters, but differed in their rates for guns carried. CONCLUSION: The significantly higher death rate from firearm injuries in Missouri likely reflects differing gun control attitudes and legislation, and provides a rationale for prevention and future investigation.