BackgroundOver the years the need for surgical treatment, timing of intervention, and the type of surgical approach have been discussed, but the treatment of congenital lung malformations remains controversial. The aim of this study was to compare the thoracotomy approach with the thoracoscopic technique by evaluating different surgical outcomes (duration of surgery, postoperative hospital stay, and complications).MethodsAll patients operated from January 2011 to March 2015 for suspected congenital cystic lung were included in the study. Patients treated for congenital lobar emphysema and tracheobronchial neoplasms were excluded from the study.ResultsIn the analyzed period, 31 asymptomatic patients were treated: 18 lung resections were performed with thoracotomy (Group A) and 13 with the thoracoscopic approach (Group B). No significant differences were observed between the age and weight at surgery, length of the procedures, complications, and the need for postoperative intensive care between the two groups. The postoperative hospital stay in Group A was twice that for Group 2 (p = 0.0009).ConclusionComparing thoracoscopic surgery with the traditional open approach, we confirmed the superiority of minimally invasive treatment in terms of postoperative hospital stay. Common technical recommendations can help pediatric centers to develop the thoracoscopic approach for the treatment of congenital pulmonary malformations.
Respiratory adverse events in adults with COVID-19 undergoing general anaesthesia can be life-threatening. However, there remains a knowledge gap about respiratory adverse events in children with COVID-19. We created an international observational registry to collect airway management outcomes in children with COVID-19 who were having a general anaesthetic. We hypothesised that children with confirmed or suspected COVID-19 would experience more hypoxaemia and complications than those without. Between 3 April 2020 and 1 November 2020, 78 international centres participated. In phase 1, centres collected outcomes on all children (age ≤ 18 y) having a general anaesthetic for 2 consecutive weeks. In phase 2, centres recorded outcomes for children with test-confirmed or suspected COVID-19 (based on symptoms) having a general anaesthetic. We did not study children whose tracheas were already intubated. The primary outcome was the incidence of hypoxaemia during airway management. Secondary outcomes included: incidence of other complications; and first-pass success rate for tracheal intubation. In total, 7896 children were analysed (7567 COVID-19 negative and 329 confirmed or presumed COVID-19 positive). The incidence of hypoxaemia during airway management was greater in children who were COVID-19 positive (24 out of 329 (7%) vs. 214 out of 7567 (3%); OR 2.70 (95%CI 1.70-4.10)). Children who had symptoms of COVID-19 had a higher incidence of hypoxaemia compared with those who were asymptomatic (9 out of 51 (19%) vs. 14 out of 258 (5%), respectively; OR 3.7 (95%CI 1.5-9.1)). Children with confirmed or presumed COVID-19 have an increased risk of hypoxaemia during airway management in conjunction with general anaesthesia.
Guidelines for the management of pre-operative paediatric clear fluid fasting historically recommend a minimum of 2 h. In particular, the published guideline from European Society of Anaesthesiology (ESA) in 2011, dedicated a section to peri-operative fasting in children and infants.1 This guideline stated that: 'Children should be encouraged to drink clear fluids (including water, pulp-free juice and tea or coffee without milk) up to 2 h before elective surgery', with an evidence level 1++ and a recommendation grade A. Similarly, the American Society of Anaesthesiology (ASA) published their updated guidelines in 2017.2 ASA guidelines stated that 'clear fluids may be ingested for up to 2 h before procedures requiring general anesthesia, regional anesthesia, or procedural sedation and analgesia', with category A1-E evidence on gastric volume and category A2-B evidence demonstrating children are more thirsty and hungry when fasted in excess of 4 h. These recommendations, as others, were based on published reviews and meta-analyses of randomised controlled trials, primarily aimed at minimising the risk of pulmonary aspiration of gastric contents. However, pulmonary aspiration is a very rare event (less than 3 to 4/10 000),3,4 and harm resulting from clear fluid aspiration in children is rarer still.4 It is also known that the stomach of a healthy child empties clear fluids within 30 min after intake (or even faster if fluids contain glucose), that gastric pH does not change 1 h after water intake, and that age does not affect the speed of gastric emptying.5,6 The new evidence and the need for a new statement The recently published APRICOT study,7 performed on a population of more than 30 000 children undergoing anaesthesia, showed that the risk of aspiration was approximately 9/10 000, and none of these children suffered significant clinical consequences, in terms of increased morbidity or mortality. Likewise, more liberalised clear fluid fasting regimes in other large cohorts of children, have shown no increase in the incidence of pulmonary aspiration.8,9 Furthermore, although gastric volume is a poor surrogate for the risk of aspiration, the gastric pH and residual volumes do not differ whether clear fluid fasting is 1 or 2 h in children.10 Moreover, the traditional 2-h clear fasting policy results in actual duration of fasting ranging from 6 to 15 h.11 Shortening the fasting regimen to 1 h, or even less with a liberalised regimen, reduces the duration of fasting with positive impact on children's psychology, metabolism and hemodynamic tolerance to the induction of anaesthesia, without increasing risks.12,13 A recently endorsed statement Based on the above new evidence, the European Society for Paediatric Anaesthesiology (http://www.euroespa.com/news/consensus-statement-on-clear-fluids-fasting-for-elective-pediatirc-general-anesthesia/), L'Association Des Anesthesistes-Reanimateurs Pediatriques d'Expression Francaise and the Association of Paediatric Anaesthetists of Great Britain and Ireland (https://www.apagbi.org.uk/sites/default/files/paragraphs/files/Fasting%20Consensus%20statement%20signatures%20Word.pdf) endorsed a new statement that advocates reducing the fasting time for clear fluids from 2 to 1 h.14 The new statement on clear fluid fasting in children Following the above initiative, and supported by the recent scientific advancements, the ESA endorses the new consensus statement for good clinical practice. The new statement can be considered applicable to all ages unless contraindicated by specific medical conditions or surgical reasons. The type and volume of fluids are deliberately not included in this statement, as they might be specified or defined by the national scientific societies and/or local institutional policies. The statement represents a global achievement and can be used as an update of the previously published guidelines on clear fluids fasting regimen in children. Consensus statement of the European Society of Anaesthesiology 'It is safe and recommended for all children able to take clear fluids, to be allowed and encouraged to have them up to 1 h before elective general anaesthesia'. In accordance with the above statement, there is an urgent need to update the published paediatric pre-operative fasting guidelines in a collaborative manner. We acknowledge that publishing state of the art scientific guidelines is a time and effort consuming endeavour and that very few societies have policies for fast-track guidelines and statements. Thus, this statement could act as a stimulus for future collaborative guidelines in paediatric anaesthesia. Acknowledgements relating to this article Assistance with the Editorial: none. Financial support and sponsorship: none. Conflict of interest: none. Comment from the Editor: this Editorial was checked and accepted by the Editors, but was not sent for external peer-review. FV is an associate editor of the European Journal of Anaesthesiology.
Summary All commonly used general anesthetics have been shown to cause neurotoxicity in animal models, including nonhuman primates. Opinion, however, remains divided over how cumulative evidence from preclinical and human studies in this field should be interpreted and its translation to current practices in pediatric anesthesia and surgery. A group of international experts in laboratory and clinical sciences recently convened in Genoa, Italy, to evaluate the current state of both laboratory and clinical research and discuss future directions for basic, translational, and clinical studies in this field. This paper describes those discussions and conclusions. A central goal identified was the importance of continuing to pursue laboratory research efforts to better understand the biological pathways underlying anesthesia neurotoxicity. The distinction between basic and translational experimental designs in this field was highlighted, and it was acknowledged that it will be important for future animal research to try to causally link structural changes with long‐term cognitive abnormalities. While inherent limitations will continue to affect the ability of even large observational cohorts to determine if anesthesia impacts neurodevelopment or behavioral outcomes, the importance of conducting further large well‐designed cohort studies was also emphasized. Adequately powered cohorts could clarify which populations are at increased risk, provide information on environmental and healthcare‐related risk modifiers, and guide future interventional trials. If anesthetics cause structural or functional adverse neurological effects in young children, alternative or mitigating strategies need to be considered. While protective or mitigating strategies have been repeatedly studied in animals, there are currently no human data to support alternative anesthetic strategies in clinical practice. Lastly, it was noted that there is still considerable debate over the clinical relevance of anesthesia neurotoxicity, and the need to evaluate the impact of other aspects of perioperative care on neurodevelopment must also be considered.
Abstract Purpose This study presents the implementation of a web and mobile application within a clinical trial at Giannina Gaslini Children’s Hospital, aimed at simplifying questionnaire completion for Pectus Excavatum condition, including medical history, preoperative, postoperative, and follow-up evaluations. The ultimate aim focuses on enhancing data collection efficiency, reducing errors, and improving patient engagement within a digital healthcare framework. Methods The approach involved careful design based on clinician input, resulting in an intuitive application structure with three main screens. XTENS managed data, and Ionic facilitated cross-platform app development, ensuring secure and adaptable data handling. Results Preliminary analysis showcased successful patient enrollment, balanced representation across treatment groups and genders. Notably, cryoanalgesia demonstrated significantly reduced hospitalization days compared to standard therapy, validating treatment efficacy. Conclusion This work signifies a step towards modernizing healthcare through digital transformation and patient-centered models. The application shows promise in streamlined data collection and patient engagement, although improvements in multilingual support, data validation, and incentivizing questionnaire completion are warranted. Overall, this study highlights the potential of digital health solutions in revolutionizing healthcare practices, fostering patient involvement, and improving care quality.
Background and objective: Levobupivacaine is the most recently introduced local anaesthetic into clinical practice. In a randomized double-blinded study, the onset, intraoperative tolerance, postoperative analgesic effect, motor blockade and any adverse reactions produced by levobupivacaine were compared with ropivacaine. Methods: Sixty children, ASA I-II, 2-6 yr old, undergoing elective minor surgery, received a single caudal injection of 1 mL kg−1 of either levobupivacaine 0.25% or ropivacaine 0.25%. Caudal blocks were performed after induction of inhalation general anaesthesia using sevoflurane; anaesthesia was maintained via a laryngeal mask airway using a mixture of sevoflurane, oxygen and air. Results: Onset time, intraoperative tolerance, postoperative analgesic effect and motor blockade were comparable between the two groups. The mean onset of the block was 8.2 ± 2.2 min for levobupivacaine and 8.5 ± 3.0 min for ropivacaine (P = 0.66). Additional analgesics during operation were not required in any of the children. No significant difference was found for mean time to requirement of additional analgesia with rectal acetaminophen (paracetamol) (302 ± 29 min for the levobupivacaine group and 230 ± 38 min for the ropivacaine group (P = 0.32)). During the first 4 h after placement of caudal block, the pain assessment score (according to the Children Hospital Eastern Ontario Pain Scale) was comparable for the two groups. No motor block was observed in any group on awakening, nor during the observation period. Conclusions: We conclude that levobupivacaine 0.25% 1 mL kg−1 provides caudal block of comparable onset and duration, as produced by the same volume and concentration of ropivacaine.
This report is aimed at describing our preliminary experience with the preperitoneoscopic approach to the bladder neck for rectus fascial sling suspension in neurogenic bladder.A 13-year-old boy with spina bifida was admitted to our institution to treat bladder incontinence. A bladder neck suspension and bladder augmentation was planned. The preperitoneal space was progressively gained by blunt dissection under direct vision (laparoscopy with a single left subcostal trocar), and a total of three preperitoneal ports were inserted. Dissection of the bladder proved to be relatively easy, and the retropubic space as well as the deep pelvis were safely exposed. Owing to the excellent endoscopic visualization, the bladder was dissected downward from the rectum. Once complete mobilization of the bladder neck was achieved, an umbilical tape was passed around the proximal urethra to create an adequate passage for the fascial sling.The preperitoneoscopic procedure lasted 2 hours. No complications occurred. A good daytime dry period was achieved at the 4-month follow-up.Direct visualization of the bladder neck and minimal dissection to the deep pelvis are the key points of this approach. Provided certain technical details are considered, the minimally invasive preperitoneal access is a valuable alternative to the open approach for the rectus fascial sling procedure, particularly when dealing with male patients. Technical advances will, presumably, lead to a complete minimally invasive treatment of urinary incontinence in male patients with spina bifida.
Rett syndrome (RTT) is a rare and severe neurological disorder mainly affecting females, usually linked to methyl-CpG-binding protein 2 (MECP2) gene mutations. Manifestations of RTT typically include loss of purposeful hand skills, gait and motor abnormalities, loss of spoken language, stereotypic hand movements, epilepsy, and autonomic dysfunction. Patients with RTT have a higher incidence of sudden death than the general population. Literature data indicate an uncoupling between measures of breathing and heart rate control that could offer insight into the mechanisms that lead to greater vulnerability to sudden death. Understanding the neural mechanisms of autonomic dysfunction and its correlation with sudden death is essential for patient care. Experimental evidence for increased sympathetic or reduced vagal modulation to the heart has spurred efforts to develop quantitative markers of cardiac autonomic profile. Heart rate variability (HRV) has emerged as a valuable non-invasive test to estimate the modulation of sympathetic and parasympathetic branches of the autonomic nervous system (ANS) to the heart. This review aims to provide an overview of the current knowledge on autonomic dysfunction and, in particular, to assess whether HRV parameters can help unravel patterns of cardiac autonomic dysregulation in patients with RTT. Literature data show reduced global HRV (total spectral power and R-R mean) and a shifted sympatho-vagal balance toward sympathetic predominance and vagal withdrawal in patients with RTT compared to controls. In addition, correlations between HRV and genotype and phenotype features or neurochemical changes were investigated. The data reported in this review suggest an important impairment in sympatho-vagal balance, supporting possible future research scenarios, targeting ANS.
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