Cerebral ultrasonography before and after cardiac surgery in infants

Summary Cerebral ultrasonography was performed in 66 infants before and after open heart surgery in order to study the incidence of cerebral complications. The underlying cardiac malformations were ventricular septal defect (n=28), transposition of the great arteries (n=11), tetralogy of Fallot (n=8), complete atrioventricular septal defect (n=5), total anomalous pulmonary venous drainage (n=3), truncus arteriosus communis (n=2), and complex cardiac malformations (n=9). In 60 of the 66 infants ultrasonography of the brain preoperatively was normal, 3 had minor structural abnormalities, and 3 had ventriculomegaly of various degrees. Postoperatively, 46 infants had a normal brain ultrasound scan; 6 had slight structural abnormalities; and 5 had slight symmetric or asymmetric widening of the ventricles. Five infants showed severe ventriculomegaly with cerebral atrophy, and in 4 patients there was intracerebral hemorrhage, associated in 2 cases with severe ventriculomegaly. On repeat examinations it was found that up to 4 weeks after the operation an initially normal cerebral ultrasound scan could convert to a pathologic one. Most of those children who showed significant deterioration on the cerebral ultrasound scan suffered from complex cardiac malformations or had severe problems during the postoperative period.     

Bacterial and fungal infections after cardiac surgery in children

Of 245 children operated on for congenital heart diseases in 1983–1984, bacterial and fungal infections occurred in 3.6% compared to 17.8% of 469 in 1968–1972. Staphylococcal infections decreased from 3.4%–0.8% and those by gramnegative bacteria from 6.9%–0%;Candida albicans infections increased from 0%–1.2%. Perioperative prophylaxis was performed with cefotaxime plus piperacillin in 1983–1984 versus oxacillin plus ampicillin in 1968–1972. It is argued that reduction of the infection rate is not only due to newer and more effective antibiotics but is mainly related to more advanced surgical techniques and improved hygiene in our intensive care units.     

Mid-term follow-up after multiple system organ failure following cardiac surgery in children

Multiple system organ failure after cardiac surgery in children is a severe complication with unknown mid- and long-term sequelae. We therefore evaluated 11 children (aged 20-126 mo, median: 67 mo) having survived multiple system organ failure after cardiac operations for congenital cardiac defects in a cross-sectional follow-up study 12-76 mo (median: 32 mo) after surgery. Clinical and laboratory examinations included cardiac, pulmonary, renal, hepatic, neurological and psychological function tests. All patients had adequate cardiac function. Lung mechanics were abnormal in three children and glomerular renal function was abnormal in two patients. Slight elevation of gamma-glutamyl transpeptidase and coagulation factor deficiency was present in six and seven patients, respectively (five of whom had undergone the Fontan operation). Severe neurological sequelae such as diplegia (n = 1) and mental retardation (n = 1) were observed in two patients. In addition, five children presented delayed motor, graphomotor and/or speech development. Two children were found to have abnormal intelligence. We conclude that with the exception of neurological impairment, mid-term sequelae of multiple system organ failure after cardiac surgery in children are mild. However, longer follow-up using an appropriate control group is mandatory.     

缺血后处理对法洛四联症患儿的心肺保护作用

目的：缺血后处理能减轻缺血、再灌注损伤,但在心脏外科手术中的效果尚缺乏大组病例报道。该研究观察了缺血后处理对法洛四联症患儿的心肺保护作用。方法：将105例法洛四联症根治术患者随机分为常规组和处理组,常规组行常规手术,处理组给予缺血后处理,即间断夹闭升主动脉3次。术后以两组患者的ICU治疗时间、输血量、正性肌力药物评分、血流动力学、呼吸功能以及乳酸代谢作为评价指标。结果：与常规组比较,处理组ICU治疗时间明显缩短［（37±21）h vs （54±26）h］,输血量及正性肌力药物计分明显减少［（308±230）mL vs （526±515）mL和（5.9±5.0） vs （10.3±7.7）］,血流动力学和呼吸功能恢复更好,乳酸蓄积明显减少。结论：缺血后处理对法洛四联症根治术患儿有心肺保护作用。［中国当代儿科杂志,2009,11（4）：273-276］     

Promoting coping in children facing pediatric surgery

Surgery is challenging for children and their families, calling upon them to cope with an invasive procedure, deal with the uncertainty of the surgical outcome, and manage the stress of hospitalization. Contributors to children's distress when facing pediatric surgery include their coping style, interactions with their parents, developmental level, and temperament. A pragmatic approach is outlined that can help surgeons promote successful coping in their patients while at the same time fostering successful working relationships with parents.     

Cerebral thrombosis in beta-thalassaemia major

Two patients with homozygous beta thalassaemia complicated by cerebral thrombosis are reported. An alteration in coagulability due to a sudden increase in haematocrit and platelets was the probable cause in one patient. Although the other patient had many complications of thalassaemia, the cause for cerebral thrombosis was not identifiable.     

Epilepsy surgery in children with accompanying impairments

The aim of this study was to assess seizure outcome 2 years after epilepsy surgery in a consecutive series of paediatric patients, with special focus on children with learning disabilities and other neuroimpairments in addition to the epilepsy.Outcome 2 years after surgery was assessed in 110 of 125 children operated upon for drug resistant epilepsy in Gothenburg 1987–2006.More than half of the children had learning disabilities, 43% motor impairments and 30% a neuropsychiatric diagnosis. Fifty-six per cent of those with an IQ < 70 became seizure-free or had a >75% reduction in seizure frequency, and two thirds if the operation was a resection. The corresponding figure in those with more than 100 seizures per month was 15 out of 31, and another seven had a 50–75% reduction in seizure frequency.The message is that learning disability, motor impairment and psychiatric morbidity should not be contraindications for paediatric epilepsy surgery. More than half of the children with learning disabilities had a worthwhile seizure outcome, with even better results after resective surgery. Children with drug resistant epilepsy and additional severe neurological impairments should have the benefit of referral to a tertiary centre for evaluation for epilepsy surgery.     

Postoperative exercise training develops normal levels of physical activity in a group of children following cardiac surgery

Summary Children with congenital heart defects often demonstrate a reduced capacity for exercise, even after surgical intervention. Forty subjects, with various heart defects, completed a 5-year study to evaluate the impact of a postoperative training program on their physical exercise capacity.All of the patients were significantly less active than their peers prior to the surgical intervention. Subjects who completed a simple, home exercise program during the first 3 postoperative months achieved a normal level of physical fitness. These benefits were maintained up to 5-years postoperatively without further intervention. Children who did not receive a postoperative training program remained significantly below their healthy peers. Therefore, a simple exercise training program, conducted early in the postoperative period would appear essential to the achievement of appropriate levels of physical activity for children with congenital heart defects.     

Staging surgery for intraventricular bilateral giant Rosai–Dorfman disease in children

Introduction:Rosai-Dorfman disease(RDD)is an uncommon,benign,and idiopathic histiocytic proliferative disorder.Multiple intracranial RDD is extremely rare and treatment varies.Case presentation:A 9-year-old girl was admitted with 3-month history of blurred vision and facial paralysis,a 2-month history of recurrent giggle,and cognitive impairment.Computed tomography and magnetic resonance imaging scans revealed bilateral ventricular masses based on the dural membrane and the diameters of the masses were 9.1 cm and 9.2 cm,respectively.The lesions were completely removed with staging surgeries.Fifteen months after operation,blurred vision was still present but facial paralysis and giggle and cognitive impairment disappeared.Imaging examinations suggested that there were no new or recurring lesions.Conclusion:For multiple large intracranial masses,surgical treatment is necessary and staged surgery benefits perioperative safety.Active follow-up with magnetic resonance imaging is necessary.     

Predicting major adverse events after cardiac surgery in children

OBJECTIVES: To develop a reliable predictor of major adverse events after pediatric cardiac surgery, with the aim of reducing mortality of cardiac extracorporeal life support through earlier, more accurate patient selection. DESIGN: Prospective observational study. SETTING: Tertiary level pediatric intensive care unit. PATIENTS: Fifty-two children undergoing open heart surgery considered above-average risk based on preoperative assessment. INTERVENTIONS: None; strictly observational study. MEASUREMENTS AND MAIN RESULTS: A wide range of measurements was made at 3, 6, 9, 12, and 24 hrs after surgery, including: oxygen consumption, central venous pressure and oxygen saturation (Scvo2), cardiac output (Fick), heart rate, arterial pressure, arterial lactate, urine output, core-toe temperature gradient, and derived hemodynamic variables. Six children had major adverse events; three needed extracorporeal life support, two died. There were no correlations between routine postoperative measurements (blood pressure, pulse, temperature gradient, central venous pressure) and any measure of cardiac function, and neither group of variables predicted adverse outcomes. Lactate (>8 mmol/L) and Scvo2 (<40%) had high sensitivity (both 73.7%) and specificity (96.3% and 95.4%, respectively), for predicting major adverse event but positive predictive values for both were low (63.6% and 58.3%, respectively). The ratio of the two had better predictive power than the individual values. When the ratio (Scvo2, %)/(lactate, mmol/L) fell below 5, the positive predictive value for major adverse event was 93.8% (sensitivity 78.9%, specificity 90.5%). The effect was present at all postoperative time points. CONCLUSIONS: Lactate and Scvo2 are the only postoperative measurements with predictive power for major adverse events. Forming a ratio of the two (Scvo2/lactate), seems to improve predictive power, presumably by combining their individual predictive strengths. Both measures have excellent specificities but lower sensitivities. Predictive power of single measures is only fair but can be improved, in high risk patients, by monitoring repeated measures over time.     

Heparinization during percutaneous cardiac catheterization in children

Summary The effect of heparin on blood clotting was studied by measuring the activated clotting time (ACT) in 120 infants and children with congenital heart disease after a single intravenous bolus of 100 IU heparin/kg body weight. Before heparinization, infants and children with cyanotic heart disease showed signs of hypocoagulation. Heparin bolus led to a threefold increase of ACT after 15 min. After 1 h, the ACT was still two times the normal value. Any further administration of heparin may be based on ACT monitoring.Dedicated to Prof. H. W. Rautenburg.     

Assessment of technical competency in pediatric cardiac surgery

Outcomes in pediatric cardiac surgery have improved dramatically since its infancy 40 years ago. Mortality has been reduced from as high as 90-100% in the initial years to around 4% for high complexity cases and virtually no mortality for simple cardiac defects. While part of this improvement can be attributed to advances in pediatric cardiac anesthesia, pediatric cardiopulmonary bypass and development of highly specialized pediatric cardiac intensive care units, outcomes continue to depend on the technical quality of the surgical repair. In this article we address the importance of the surgical technical performance on the outcomes and discuss the currently available tools for measurement of surgical competency. Our studies showed that the final technical (anatomical) result score had the strongest association with patient outcomes. We offer suggestions for a competency model that continues to evolve as we explore the use of immersive learning, deliberate practice, reflection in action, mentorship by senior surgeons and lifelong learning.     

腹腔镜手术对心功能影响的动物实验研究

目的：探讨腹腔镜手术中的腹压增高导致的心功能主血液动力学的变化,方法：用腹腔内快速注入空气的方法制造7头乳猪急性腹压增高的模型,在腹压为基础值7．5,15及30mmHg时分别测量心输出量,左,右心房压,腹部下腔静脉压及心包压。结果：心输出量在轻度腹压增高时增加,当腹压超过15mmHg时下降,腹压轻度增高时右心室压与下腔静脉压平行增高,而超过15mmHg时,右心房压与下腔静脉压呈分离变化,右心房压停止增高,左心室透壁压和右心房透壁压与心输出量之间的变化关系明显不同,结论：腹腔镜手术中的腹压增高导致的心功能变化是一个复杂过程,不仅与气腹压力的大小有关,而且与机体所处的血流动力学状态相关。     

Ventilation and perfusion scanning in children

Ventilation and perfusion scintigraphy (VQ scans) provide a relatively non-invasive evaluation of lung function. They indicate the relative blood flow to each lung and allow a quantitative assessment of the perfusion of each lung segment. They can detect areas of abnormal aeration and demonstrate air trapping. However, VQ scanning gives relatively poor anatomical detail of the lungs and so is commonly used in conjunction with other radiological modalities, most notably the chest X-ray. VQ scans have been utilized for a large range of pathological conditions including congenital cardiac and lung abnormalities, suspected pulmonary emboli, the assessment of childhood diseases, including cystic fibrosis, bronchopulmonary dysplasia and asthma.     

Pediatric surgery during the COVID-19 pandemic

The coronavirus disease 2019 (COVID-19) pandemic has had a major impact on pediatric surgery. The infection is often asymptomatic and atypical in children, while overlapping presentations with other infectious diseases generate additional diagnostic challenges. The high probability of missed pediatric cases and the invasive nature of surgery generate great concern for widespread transmission in this setting. Current guidelines suggest that triage of cases should be made on a case-by-case basis by a multidisciplinary team of experts. Decision-making can be assisted by classifying cases as elective, urgent, or an emergency according to the risks of delaying their surgical management. A workflow diagram should ideally guide the management of all cases from admission to discharge. When surgery is necessary, all staff should use appropriate personal protective equipment, and high-risk practices, such as aerosol-generating tools or procedures, should be avoided if possible. Furthermore, carefully designed organizational protocols should be established to minimize transmission while ensuring the uninterrupted operation of pediatric surgery units. For example, surgical teams can be divided into small weekly rotating groups, and healthcare workers should be continuously monitored for COVID-19 symptoms. Additionally, team protocols in the operating room can optimize communication and improve adherence to personal protective equipment use. Isolated operating rooms, pediatric intensive care units, and surgical wards should be specifically designed for suspected or confirmed COVID-19 cases. Finally, transportation of patients should be minimal and follow designated short routes. All these measures can help mitigate the effects of the COVID-19 pandemic on pediatric surgery units.     

开胸抢救小儿体外循环心内直视手术后心搏循环骤停

目的 探讨小儿先天性心脏病术后心脏压塞及心跳循环骤停的起因、治疗和疗效。方法 床边开胸抢救18例心内直视手术后心脏压塞及心搏循环骤停患儿。其中出血性心脏压塞7例,非出血性心脏压塞6例,血容量不足2例,心律失常3例。14/18例发生于术后4h内。结果 初级复苏全部成功,15例存活病儿无并发症,3例于复苏后2d内死于顽固性心功能不全。结论 小儿心内直视手术后出现心脏压塞及心搏循环骤停立即床边开胸抢救可获得满意疗效。     

Thoracotomies in children

Thoracotomies in children have been less extensively studied, as the incidence of diseases necessitating thoracotomies is low in the pediatric age group. This study reviews childhood thoracic diseases, thoracotomy approaches, indications, and complications. Surgical procedures and complications of a total of 196 children below 16 years of age who underwent thoracotomy for various reasons at the Department of Thoracic Surgery, Ataturk Chest Diseases and Chest Surgery Training and Research Hospital, between January 2000 and December 2004, were reviewed in this study. Out of the 196 patients, 77 were female (39%) and 119 (61%) were male. The most commonly encountered indications for surgery were hydatid cyst (35%), bronchiectasis (25%), chronic nonspecific pleuritis (13%), chest wall deformities (10%), and mediastinal cystic formations and masses (10%). The other indications included tuberculosis (3%), aspergilloma (0.5%), fibrohyalinized cyst (0.5%), resection of trachea (0.5%), bronchogenic cyst (0.5%), inflammatory pseudo-tumor (0.5%), sequestration (1%), lipoblastoma (0.5%), and eosinophilic granuloma (1%). Out of the 196 patients, 176 underwent lateral thoracotomy and 20 patients with a chest wall deformity underwent midsternal incision. Complications were seen in 35 patients (18%): atelectasia and secretory retention (54%), wound infection (17%), hemorrhage (3%), chylothorax (3%), intrathoracic space (3%), and postoperative extended air leakage (20%). The mean hospital stay was 15 days and we did not encounter any mortality. The physiology and anatomy of the respiratory system and especially the respiratory control mechanism in pediatric patients vary from those of the adults, resulting in a more morbid course after thoracic surgery in children. Despite severe postoperative pain, posterolateral thoracotomy is the preferred approach in adults because of an advanced intrathoracic exposure and easy manipulation. On the other hand, lower pain threshold and the different types of diseases seen in children make lateral thoracotomy a more appropriate choice for thoracotomy, which, at the same time, spares the serratus anterior muscle decreasing its negative impact on postoperative respiratory function.     

新生儿先天性心脏病术后血液动力学的临床研究

目的 通过测定心指数(CI)、血清乳酸浓度(Lac)、混合静脉血氧饱和度(SvO2)等指标,评估新生儿在经过体外循环术后的早期血液动力学状况.方法 2007年1月至11月,80例患儿作心脏术后48 h的血液动力学评估,包括新生儿组47例,年龄3～29 d,体重2.6～4.2 kg;婴儿组33例,年龄30～180 d,体重3.1～6 kg.并初步讨论新生儿心脏术后较高死亡率原因.结果 术后存活患儿两组比较中,新生儿组CI值[(2.01±0.35)L/(min·m~2)]<婴儿组[(2.26±0.39)L/(min·m~2)],术后2、6 h两组CI均值差异有统计学意义(P<0.05);新生儿组脉压<婴儿组,CI与新生儿组脉压的相关性有统计学意义;心率155次/min是心输出量的适宜心率;新生儿组血清Lac婴儿组,术后12 h两组差异有统计学意义;新生儿存活患儿的术后SvO_2均60%,SvO_2两组间均值差异无统计学意义;CI与SvO_2相关性有统计学意义(P<0.05),与血清Lac相关性无统计学意义.新生儿4例死亡(死亡率8.5%),与术前心跳骤停,严重酸中毒,冠状动脉畸形,体外循环时间过长有关,术后6～12 h血清Lac值10 mmol/L,SvO_2<50%;婴儿组1例死亡(死亡率3.0%),与手术方法增加了心脏前后负荷有关.结论 新生儿心脏术后的心输出量能满足全身脏器的氧需,血清Lac水平和变化趋势可以评估疗效和预后,SvO_2能及时反映心输出量对组织器官的供氧状况.新生儿心脏术后的较高死亡率可能同本身病种的复杂性、危重性有关.     

Cerebral malaria in children

Presented here is our experience with 30 cases of cerebral malaria. The diagnosis in all of them was based on a positive smear report. Plasmodium falciparum accounted for 26 cases while P. vivax was responsible for cerebral malaria in the remaining 4. There were 21 males and 9 females. Sixteen children were older than 8 and 9 between 4 and 7, and the remaining 5 less than 3 years of age. Thirty per cent were ill for over a week before reporting for admission; 83 per cent sought hospital care within 24 hours of the appearance of neurological signs. Fever and altered consciousness were present in all the 30 cases while 23 gave a history of convulsion. Isolated cranial nerve palsy of III and VII nerves were also seen on admission. Six children died. All the rest but one made a complete recovery. Of prognostic significance were the pretreatment levels of serum C₃ and C₄ fraction which were found to be significantly lower (p<0·05) in patients with fatal ending.