Complications of internal fixation in paediatric fractures

BACKGROUND: Most displaced fractures in children can be managed by closed treatment. Internal fixation of fractures is sometimes required to achieve satisfactory reduction with certain fractures. The aim of this study was to document the rate of complications associated with internal fixation of fractures in the paediatric age group. METHODS: A retrospective study was carried out on 268 consecutive children who had internal fixation of fractures from January 2000 to July 2004. The complications were categorized as major or minor. RESULTS: The average age was 9.2 years (range, 1.4-16.9). There were 327 fractures. Fifty-nine children had fractures of two bones. Humeral fractures accounted for 45.7% of fractures, forearm fractures 31.3%, tibial and fibular fractures 14.1% and femoral fractures 4.9%. There were 27 children (10%) with major complications and 49 children (18%) with minor complications. There were 18 children (6.7%) with both major and minor complications. A total of 66 (24.6%) children had complications. There were 23 children (8.5%) requiring further surgery. CONCLUSIONS: In this study, 24.6% of children had complications associated with internal fixation. The risk of complications should be considered when electing to proceed with surgical treatment. Closed treatment should always be attempted in children unless there is a good indication for internal fixation.     

Survey of the health and nutrition status of a squatter community in Khayelitsha

The findings of a nutrition and health survey in Site B, a squatter area in Khayelitsha close to Cape Town, are reported. Of the children under 6 years, 16.8% were found to be under weight for age, 23.5% were stunted and 2.5% wasted, indicating a serious nutritional crisis in this community. Children with a low-birth-weight had a 3 times greater risk of being under weight for age and a 2 times greater risk of being stunted than children with birth-weights greater than 2,500 g. Of the children born outside Cape Town, 21.9% were under weight for age compared with 13.5% of children born in Cape Town. Of the pre-school children, 4.2% had completed or were on antituberculosis treatment compared with 2% of the children in the age group 6-18 years and 3.2% of adults. Sixty per cent of the pre-school children with tuberculosis were under weight for age. Half the adult population was fully employed, and 22% of households had no wage earners. Assuming literacy after 4 years of schooling, 76% of the adults were literate, but only 2.5% had completed Standard 10. Women were generally better qualified than men.     

Anesthesia for children with pericardial effusion: a case series

Objectives and aims: To review the anesthetic management of children requiring surgical intervention for pericardial effusion, determine the nature and frequency of complications and define risk factors that predict perioperative risk. Background: Anesthesia in the presence of a pericardial effusion may be associated with significant hemodynamic compromise particularly during induction. However, the literature specifically concerning children is limited to a single‐case report. Methods: A retrospective case review of children undergoing general anesthesia for surgical treatment for pericardial effusion between 1999 and 2008 at a single institution. Results: Sixty‐five children underwent 79 general anesthetics for surgical treatment for pericardial effusion. Median age was 4 years (2 weeks–16 years), and median weight 15 kg (range, 2.5–96 kg). Fifty‐five children (84%) developed effusions following cardiac surgery. The commonest induction agent was ketamine (25/65, 38%), and the majority of children (52/65, 80%) were intubated and ventilated for the procedure. Seven children (11%) suffered from eight major complications, and 14 children (22%) suffered from a minor complication. Major complications were more common in children with preoperative tachypnoea (P = 0.01) and cardiac tamponade on preoperative echocardiogram (ECHO) (P = 0.001). Preoperative hypoxia had a sensitivity of 92% and a positive likelihood ratio of 5.2 (95% CI 1.5–17.5) for predicting all complications. Conclusions: Anesthesia for pericardial effusion in children was associated with an adverse physiological event in one‐third of children. Major complications may be predicted by preoperative tachypnoea and cardiac tamponade on preoperative ECHO, and all complications may be predicted by preoperative hypoxia. The anesthetic technique included a variety of induction agents, and we cannot recommend a particular approach.     

Antithrombin activity in children with chylothorax.

OBJECTIVE: To determine whether increased antithrombin loss is present in children with chylothorax after cardiac surgery. METHODS: Plasma and pleural effusion samples of children with chylous and non-chylous pleural effusion were assayed for antithrombin activity. RESULTS: Ten children with chylothorax and five children with non-chylous pleural effusion were investigated. There was statistically significant increase in mean antithrombin activity in chylous samples (32.2+/-11.4%) compared to non-chylous samples (14.4+/-13.9%), and significant decrease in plasma of children with chylothorax (44.6+/-15.4%) compared to children with non-chylous pleural effusion (69.9+/-22.4%). Seven of 10 children with chylous and none of the children without chylous developed thrombosis (p<0.007). CONCLUSIONS: Increased loss of antithrombin is present in children with chylothorax, potentially predisposing these children to an increased risk of thrombosis. Repeated antithrombin substitution should be considered in critically ill children with chylothorax.     

Pain management in intellectually disabled children: a survey of perceptions and current practices among Dutch anesthesiologists

Background: Intellectually disabled children are more likely to undergo surgical interventions and almost all have comorbidities that need to be managed. Compared with controls, intellectually disabled children tend to receive less intraoperative analgesia and fewer of them are assessed for postoperative pain. Aim: To evaluate perceptions and practices of anesthesiologists in the Netherlands concerning pain management in intellectually disabled children. Methods/Materials: We surveyed members of the Section on Pediatric Anesthesiology of the Netherlands Society of Anesthesiology in 2005 and 2009, using a self‐designed questionnaire. Results: The response rate was 47% in both years. In 2005, 32% of the anesthesiologists rated intellectually disabled children as ‘more sensitive to pain’ than nonintellectually disabled children – vs 25% in 2009. But no more than 7% in 2005 vs 6% in 2009 agreed with the statement ‘children with intellectually disabled children need more analgesia’. Most anesthesiologists gave similar doses of intraoperative opioids for intellectually disabled and nonintellectually disabled children, 92% in 2005 vs 89% in 2009. In 2005, only 3% applied a pain assessment tool validated for intellectually disabled children, vs 4% in 2009. Conclusions: Anesthesiologists in the Netherlands take a different approach when caring for intellectually disabled children and they were not aware of pain observation scales for these children. However, the majority think that intellectually disabled children are not more sensitive to pain or require more analgesia. These opinions did not change over the 4‐year period. One way to proceed is to implement validated pain assessment tools and to invest in education.     

Sevoflurane inhalation conscious sedation for children having dental treatment

An audit at the Queensway Anxiety Management Clinic of 2014 children, referred for dental treatment, showed that relative analgesia by inhalation of nitrous oxide and oxygen failed in 40% of cases successfully to complete treatment. We therefore investigated the efficacy of a new inhalation conscious sedation technique, which reduced the need for general anaesthesia. Seventy-five children aged 3-15 years were given inhalation conscious sedation, with sevoflurane 0.1-0.3% and nitrous oxide 40% in oxygen. In 69 children (92%), the dental treatment was completed successfully. Most children (93%) had recovered fully within 10 min without side-effects. Treatment was fully accepted by 88% of children and 91% of their parents. The use of sevoflurane in low concentrations to supplement nitrous oxide and oxygen for conscious sedation in children appears to be safe and effective and further study is currently in progress.     

国内大型综合医院和儿童医院小儿术后镇痛调查

目的了解当今国内小儿术后镇痛工作在儿童手术量较大的大型综合医院和儿童医院的应用情况,为小儿术后镇痛在国内推广应用提供参考。方法对全国预计小儿麻醉年手术量超过1000例的40家医院的麻醉科进行了问卷调查。31家医院完成调查,剔除年小儿手术量低于1000例的4家,纳入27家医院进行分析。调查的内容包括医院镇痛管理相关政策和制度,小儿术后镇痛开展情况,如开展镇痛的年龄段、常用术后镇痛方式和药物、静脉镇痛泵配方、小儿术后镇痛存在的问题等。结果纳入分析的医院中88．9％开展了小儿术后镇痛工作,开展1岁～3岁幼儿术后镇痛的占81．5％,1个月-12个月婴儿术后镇痛的占55．6％,新生儿术后镇痛仅有25．9％。超过80％的医院建立了小儿术后镇痛相关培训,并有个性化镇痛方案和疗效评估,但只有59．3％的医院安排有专门的小儿术后镇痛人员,22．2％设置了术后镇痛服务小组。所有开展小儿术后镇痛的医院均使用静脉患者自控镇痛（patient controlled analgesia,PCA）,只有25．9％医院开展硬膜外PCA方式镇痛。局麻药被广泛用于小儿术后镇痛,包括罗哌卡因、利多卡因和布比卡因,阿片类药物以舒芬太尼、芬太尼和曲马多为主,经常使用非甾体类抗炎药（non-steroid anti-inflammatory drugs,NSAIDs）的医院仅占29．6％,只有11．1％的医院经常使用对乙酰氨基酚。结论小儿术后镇痛工作在我国儿童手术较多的大型综合性医院和儿童医院已经普遍开展,但婴儿和新生儿的术后镇痛工作有待加强。有必要普及术后切口局麻药浸润,更多开展外周神经阻滞;普及副作用少又经济实用的对乙酰氨基酚类药物的使用,增加NSAIDs的用量,加强阿片类药物治疗安全的监控。     

比较右旋美托咪啶与丙泊酚用于儿童磁共振成像睡眠的研究

背景 磁共振成像(MRI)睡眠研究有助于对难治性阻塞性睡眠呼吸暂停(OSA)儿童的保守治疗提供指导.因为OSA儿童容易受到镇静药和麻醉药的影响而引起呼吸抑制;这类患者行影像学检查时的麻醉具有挑战性.右旋美托咪啶(Dexmedetomidine)已经被证实具有模拟自然睡眠而引起最小呼吸抑制的药理效应.我们假定,与丙泊酚相...     

Management of burn injuries in children

120000 patients are seen with burns in emergency departments in the U.K. each year. Of these, 50% will be children. The average age of the children admitted to the North East Thames Regional Burns Unit (NETRBU) will be 4 years, and the size of the burn 10% body surface area. Some of the children admitted will be severely ill requiring intensive treatment. Many will be scarred, and have long-term morbidity. This paper offers a treatment protocol for burned children from first aid to management in the emergency department, and describes the regimen for treatment then followed in the NETRBU.     

Complications following use of the laryngeal mask airway in children

Anaesthetic records from 507 children anaesthetized using the laryngeal mask airway (LMA) breathing spontaneously were analysed. Failure to insert the LMA occurred in 10 (2.0%) children and there were difficulties with insertion in 36 (7.1%) children. There was a total of 81 (16%) children with complications in the recovery period. Most of these were not clinically significant. Twenty-three children showed evidence of trauma to the pharynx or larynx. This study demonstrates that the LMA is a safe and effective tool for use in paediatric anaesthesia. However, the incidence of trauma may be higher than expected and attempts should be made to minimize this with a gentle technique and adequate depth of anaesthesia.     

Laparoscopic inguinal hernia repair in children.

BACKGROUND: This study aimed to document the authors' experience with laparoscopic inguinal hernia repair in children. METHODS: Ninety-three hernia repairs were performed in 64 children. The neck was closed with a purse string suture by using 4-0 absorbable suture. RESULTS: Ninety-three indirect inguinal hernial sacs were closed in 64 children. Nine percent of children had an ectopic testis. The mean operating time for laparoscopic ring closure was 25 minutes (range, unilateral 21 to 35; bilateral, 28 to 50). The contralateral processus vaginalis was patent in 20% of children. In 24% of children, the final procedure was modified based on the findings of a dilated internal ring. A laparoscopic ilio-pubic tract repair was done in these cases. Laparoscopic mobilization, orchiopexy followed by ilio-pubic tract repair was done in 9% of children. Scrotal swelling occurred in one child. Hydrocoele occurred in one patient. Recurrence rate was 3.1%. CONCLUSION: Laparoscopic inguinal hernia repair in children can be offered, as it is safe, reproducible, and technically easy for experienced laparoscopic surgeons. Ilio-pubic tract repair may be added in cases with dilated internal ring. Recurrence following laparoscopic ring closure can be managed with laparoscopic ilio-pubic tract repair. The long-term follow-up of laparoscopic ilio-pubic tract repair is awaited.     

Prevalence and ethnicity of sleep-disordered breathing and obesity in children

OBJECTIVES: To compare the prevalence of obesity in children with sleep-disordered breathing (SDB) who undergo adenotonsillectomy to that in the general pediatric population. DESIGN: Cross-sectional controlled study. METHODS: A body-mass-index (BMI-for-age) percentile was determined for children with SDB and for matched controls from a general pediatric clinic. Children who were obese (>85th %) were analyzed. Groups were compared using a t test or chi(2) analysis. Risk factors were estimated with logistic regression. RESULTS: The study population included 299 children, of whom 170 (56.9%) had SDB. Compared with controls, more children with SDB were obese (46% vs 33%, P = 0.029) or underweight (8% vs 3%, P = 0.110), and fewer children with SDB were healthy weight (46% vs 64%, P = 0.002). Among African American children, those who were obese were more likely to have SDB (OR, 2.22, P < 0.01). CONCLUSIONS: Children with SDB who undergo adenotonsillectomy are more likely to be obese than children seen in a general pediatric clinic. African American children who are obese are more likely to have SDB.     

Cholelithiasis in infants, children and adolescents

The prevalence of cholelithiasis is estimated within 0.13% and 2% of children under 19 years of age. Pigment stones are the commonest type of gallstones in children, without recognizable predisposing factors in infants or secondary to a predisposing disease such as chronic hemolysis and ileal disease in children. In adolescents, idiopathic cholesterol gallstones accounts for the majority, such as in adults. Gallbladder stones are found in 80 to 90% of cases and common bile duct stones in 10 to 20% of cases. When common bile duct stones are found, a choledocal cyst with anomalous pancreatobiliary duct junction needs to be excluded. Magnetic resonance cholangiopancreatography should be performed in first line. Cholecystectomy is not indicated for silent gallstones, except in children with a predisposing disease such as chronic hemolysis. Treatment of common bile duct stones includes interventional radiologic, endoscopic or surgical procedures. Stone extraction may be performed at endoscopic retrograde cholangiopancreatography with or without sphincterotomy, combined with laparoscopic cholecystectomy. In children without a predisposing disease or no residual gallstones indicating a cholescystectomy, conservative management (percutaneous cholangiography with biliary drainage) may be proposed in specialised centers, especially for infants. A hepaticojejunostomy is indicated in cases of choledocal cyst with anomalous pancreatobiliary duct junctions.     

Proximal humerus and humeral shaft fractures in children

Proximal humerus fractures and fractures of the humeral shaft are relatively rare in children. The incidence of the former is about 1 to 3 cases/1000 population per year, comprising fewer than 3% of all pediatric fractures. Fractures of the humeral shaft represent fewer than 10% of all humerus fractures in children. Both types of fractures in babies and young children can be treated nonsurgically, because of the joint's ability to remodel. Simple swaddling with a sling or swaddling cloth can be the solution. For older children, splints and braces may be necessary for short periods of time. Fractures can sometimes be a sign of parental child abuse, so suspicion should remain high when evaluating children with these injuries.     

Demography and function of children with limb loss

This retrospective study was designed for the period 1982-2002 to collect the basic data on the demography, level and side of the amputation, involved limbs, age, gender, and prosthetic functional level in children with limb loss. A total of 232 children were assessed through their prosthetic records. Seventy-two percent (195 children) presented lower-limb involvement, and 28% (77 children) had upper-limb loss. The age of the children varied between 1 and 15 years with a mean age of 9.90 +/- 2.32 years. Results of the study revealed that the leading amputation cause in children was congenital limb absence. The most frequent levels were determined as trans-tibial and trans-radial in lower and upper limbs, respectively. Findings showed that more boys (60%) were affected, and 84% of all amputations were found to be unilateral. It was also seen that right-side amputations (54%) were more common than left-side amputations (46%). The outcome of the study showed that 96% of children with lower-limb loss reached a functional gait pattern without any aids, while the percentage of independence in activities of daily living was found to be 88% in upper-limb loss.     

Evaluation of Nissen fundoplication in neurologically impaired children

The value of performing Nissen fundoplication in neurologically impaired children is a controversial issue. To evaluate the benefit of fundoplication in these children, hospital records were reviewed for 77 children who underwent fundoplication for gastroesophageal reflux (GER). Fifty-two children were neurologically impaired; 25 children had no neurological impairment. Impaired children had significantly fewer hospital admissions (1.8 v 0.7; P less than .005) and total days of hospitalization (36 v 14; P less than .005) during the first postoperative 6 months, compared with the immediate preoperative 6-month period. Normal children had fewer hospital admissions and days postoperatively, but the difference was not significant. Impaired children with preoperative failure to thrive (FTT had significantly increased average monthly weight gain over the first 6-month period postoperatively, compared with preoperative growth rate (3.0% v 0.9% of total body weight; P less than .05). Average monthly weight gain at 1 and 2 years postoperatively was not significantly different from preoperative values for impaired children. Growth rate of normal children with FTT did not change significantly postoperatively. Symptomatic relief was comparable in the normal and impaired children. Perioperative mortality was 0% in the normal children and 6% in the impaired children. This study demonstrates that Nissen fundoplication in neurologically impaired children with GER can be performed safely, reduces the frequency of hospitalization, and improves short-term weight gain.     

Pediatric renal transplantation and the dysfunctional bladder

We retrospectively reviewed our long-term experience with pediatric renal transplantation into a dysfunctional lower urinary tract to evaluate graft survival, function, and special urological complications. Between 1967 and March 2000, a total of 349 renal transplantations were performed in children younger than 18 years. Malformations of the lower urinary tract were the reasons for end-stage renal failure in 66 children (18.6%). The cause of urinary tract disorders included: meningomyelocele connected with neuropathic bladder (n=4 transplantations); prune belly syndrome (n=5 transplantations); VATER association (n=2 transplantations); posterior urethral valves (n=27 transplantations); and vesico-uretero-renal reflux (n=28 transplantations). The majority of the patients underwent surgical interventions to preserve renal function or to prepare renal transplantation. The 1- and 5-year graft survival rate was evaluated with special reference to the underlying disease. The 1-year graft survival rate in all children with lower urinary tract malformations was 83.3%, compared with 88% for all children. In those children with vesico-ureteral reflux, it was 92.8% and in the children with Vater association and prune belly syndrome, it was 85.7%. One graft was lost in the children who had neurogenic bladder, so the 1-year graft survival rate was 75%. The worst 1-year graft survival rate was obtained for boys who had posterior urethral valves (1-year graft survival rate: 74%; 5-year graft survival rate: 62.9%). Concerning the 5-year graft survival rate, it was 70% for all children with malformations of the urinary tract. The best rate was obtained for children with reflux in the native kidneys (78.5%), followed by those with VATER association and prune belly syndrome. As an additional child with neurogenic bladder lost his graft, the 5-year graft survival rate was 50%. Pediatric renal transplantation into a dysfunctional bladder can be connected with high urological complication rates which may contribute to worse graft survival. The 1- and 5-year graft survival rate in children with malformations of the lower urinary tract is worse than in children without bladder dysfunction. We regarded a striking difference between graft survival and the urological disorders which led to renal insufficiency. We obtained the worst graft survival rates in children with posterior urethral valves which are usually connected with bladder emptying problems and dysfunctional voiding. Potential pediatric transplant recipients must be classified according to pathophysiological as well as anatomical abnormalities of the urinary tract and all urological problems have to be solved prior to transplantation. At our center, living donors are favored to plan transplantation of these children properly.     

Blunt trauma in adults and children: a comparative analysis

Trauma remains the major cause of death in children and young adults. Adult and pediatric patients differ significantly in both mechanism of and physiologic response to injury. We reviewed the records of all consecutive adult and pediatric blunt trauma patients admitted to a major metropolitan trauma center for a 10-year period. An extensive computerized database has been maintained for all patients since 1977. A comparative statistical analysis of mechanism of injury, specific organ injury, and clinical outcome was performed. Altogether, 1,722 adults and 289 children were treated during the study period. Blunt trauma accounted for 82.8% of adult and 94.3% of pediatric injury (p = 0.00005), and only these patients were considered for analysis. Diagnostic peritoneal lavage was performed in 249 children and 1,464 adults, with a respective accuracy of 99.6% and 97.2%. Mechanism of injury was comparable for both groups, although children were far more likely to be injured by falls, bicycle accidents, or struck by an automobile. Comparative analysis of specific injuries demonstrated significantly fewer pediatric chest (p = 0.001), spine (p = 0.03), and pelvic (p = 0.003) injuries. Central nervous system (CNS) injury in children was a strong determinant of outcome: serious pediatric CNS trauma was associated with a tenfold increase in mortality. Mortality for children in the absence of CNS injury was less than 3%. Spinal injury also appeared to be a predictor of poor outcome in the pediatric population, with an associated mortality of greater than 50%. Overall, survival was age independent (82.5% of adults and 85.8% of children were survivors.(ABSTRACT TRUNCATED AT 250 WORDS)     

Comparison of pulmonary hydatid cysts in children and adults

BACKGROUND: The purpose of the present study was to compare the clinical features and the surgical approaches of the pulmonary hydatid cysts in children and adults. METHODS: One hundred and thirty-four patients, operated on for pulmonary hydatid cysts over the last 10 years were retrospectively evaluated in two groups: 39 children who were younger than 18 years old (29%) and 95 adults (71%). The patients in each group were analysed according to their clinical, radiological and surgical findings. RESULTS: The frequency of pulmonary hydatid cysts in children was significantly higher in boys (74%) than in girls (26%). However, there was no sex tendency in adults (52% in male vs 48% in women). The sex difference in hydatid cyst frequencies between adults and children was significant (P < 0.05). Among preoperative pleural complications, pneumothorax (15.5%) in children and empyema (11%) in adults were more frequent. The frequency of concomitant hepatic cysts was less in children than in adults (33%vs 79%). Huge pulmonary cysts (=10 cm) were more common in children (31%) than in adults (22%). Cystotomy with capitonnage was the most frequently preferred method in both groups. Postoperative complications developed in six children (16%) and 19 adults (19%), and were more frequent in patients with huge cysts (27%vs 16%). No recurrence was observed in both groups. CONCLUSIONS: Isolated pulmonary cysts are more common in children than adults. The cysts also tend to be bigger in children than adults. The frequency of concomitant hepatic cysts is less in children. Because of higher lung expansion ability and improvement capacity in children, resection should be avoided and lung saving surgical procedures should be performed. In spite of differences observed in the clinical features it does not change the treatment of pulmonary hydatid cysts in children.     

Chronic pain in children in the UK: a survey of pain clinicians and general practitioners

Background: There is a lack of information about the prevalence, manifestations, and management of chronic pain in children in the UK. We surveyed consultants with an interest in chronic pain management and general practitioners (GPs) in the UK in order to understand their perspective on chronic pain in children. Methods: We conducted a postal survey of clinicians with an interest in chronic pain management and GPs in the UK. The survey contained questions relating to the following aspects of managing children with chronic pain: (i) clinicians’ training and experience; (ii) available resources; (iii) perceived prevalence, presentation, and referral patterns; (iv) interventions; and (v) outcomes. Results: 472 pain clinicians and 131 GPs were contacted. The response rates were 55% and 61% respectively. Of the respondents, 77% of pain clinicians and 95% of GPs acknowledged a lack of adequate training for managing children with chronic pain. 57% of the pain clinicians and 63% of the GPs reported that the prevalence of chronic pain in children was <5%. In the comments section, 22% of those respondents who frequently manage children with chronic pain reported an increase in the incidence of this problem over the last 5 years. The common chronic pain syndromes in children were reported to be: musculoskeletal and limb pain, recurrent abdominal and pelvic pain, and headache. 15% of the respondents advised that children with chronic pain would be best managed in specialist pediatric centers and 75% opined that majority of children with chronic pain have a fair to good prognosis. Conclusions: More information is required about prevalence, manifestations and long‐term effects of chronic pain in children in the UK. There is a need for increasing training and resources amongst GPs and pain clinicians for managing chronic pain in the pediatric age group.