An electrophysiologic evaluation of whether open and laparoscopic techniques used in pediatric inguinal hernia repairs affect the genitofemoral nerve

Background

A prospective study was performed to evaluate the effect of inguinal hernia repairs on the genitofemoral nerve (GFN), and to compare postoperative electrophysiologic changes in the GFN of patients who had undergone either open or laparoscopic surgery.

Methods

Seventy patients with a mean age of 6.48 ± 3.49 were enrolled in the study. Either open or laparoscopic techniques were used to operate on the patients' inguinal hernias. In all cases, bilateral GFN motor responses were investigated electrophysiologically using surface electrodes on three occasions: preoperatively, in the first month, and third month postoperatively. t-Tests were used to compare changes in the GFN.

Results

Preoperative mean latency of the GFN in all groups was found to be significantly prolonged on the hernia side, compared with the non-hernia side (P = 0.01). Although no difference was observed in the latency levels of the GFN on the operated side at the preoperative and early postoperative stages, GFN latency levels decreased significantly in the late postoperative period in the laparoscopic group (P < 0.05). In the late postoperative period, amplitudes of GFN motor responses were significantly higher in the laparoscopic group than the open repair group (0.91 ± 0.11 mV and 0.57 ± 0.053 mV, respectively; P < 0.05).

Conclusion

Preoperative prolonged latency of GFN on the hernia side is likely to occur due to the pressure on the nerve caused by the hernia mass. By surgically removing the hernia mass, this buildup of pressure is prevented, decreasing the latency of the GFN. The significantly higher motor response amplitudes and decreased latency in the late postoperative stage for the laparoscopic group may be due to the fact that this technique is less invasive.     

Pre- and post-intervention study to assess the impact of a sedation protocol in critically ill surgical patients

Introduction

Sedation and pain management for mechanically ventilated critically ill surgical patients pose many challenges for the intensivist. Even though daily interruption of sedatives and opioids is appropriate in medical intensive care unit (ICU) patients, it may not be feasible in the surgical patients with pain from surgical incision or trauma. Therefore we developed an analgesia/sedation based protocol for the surgical ICU population.

Methods

We performed a two-phase prospective observational control study. We evaluated a prescriber driven analgesia/sedation protocol (ASP) in a 12-bed surgical ICU. The pre-ASP group was sedated as usual (n = 100) and the post-ASP group was managed with the new ASP (n = 100). Each phase of the study lasted for 5 mo. Comparisons between the two groups were performed by χ² or Fisher’s exact test for categorical variables and the Mann-Whitney test for nonparametric variables. A P value <0.05 was statistically significant.

Results

We found a significant reduction in the use of fentanyl (P < 0.001) and midazolam (P = 0.001). We achieved sedation goals of 86.8% in the post-ASP group compared to 74.4% in the pre-ASP (P < 0.001). Mean mechanical ventilations days in pre- and post-ASP group were 5.9 versus 3.8 (P = 0.033).

Conclusion

In our cohort of critically ill surgery patients implementation of an ASP resulted in reduced use of continuously infused benzodiazepines and opioids, a decline in cumulative benzodiazepine and analgesic dosages, and a greater percentage of Richmond Agitation Sedation Scale scores at goal. We also showed reduced mechanical ventilation days.     

Monitoring Biomarkers After Pediatric Heart Surgery: A New Paradigm on the Horizon

Until recently, risk scoring systems for adult patients consisted of only clinical criteria. Currently, we are experiencing an abundant surge of literature integrating a wide range of biomarker arrays to clinical criteria in assessing the risk in an adult. In fact, novel risk scoring systems such as Reynolds criteria have emerged by combining the validated biomarkers to the traditional risk factors. Novel biomarkers potentially improve clinical management of cardiovascular disease, but there are gaps in understanding their role during childhood. The reason might be related to relatively lower prevalence of cardiovascular disease in children compared to the adult population. One exceptional group is the children with congenital heart disease. Recent studies indicate that novel biomarkers can alert the clinician in a timely manner about neurological and myocardial injury and their inflammatory consequences. Current technologies enable us to measure several biomarkers using only a few microliters of plasma. The preliminary studies show that novel biomarkers in addition to the traditionally studied biomarkers can help the clinician to identify children at high risk following pediatric heart surgery. Future studies are needed to confirm the role of biomarkers in monitoring children after cardiopulmonary bypass.