Barbara A. Montagnino

Pediatric tracheostomies: a recent experience from one academic center.

Objectives: To describe the indications, surgical timing, length of stay, hospital charges, and discharge disposition of pediatric tracheostomy patients. Design: Retrospective case series. Setting: Large urban academic pediatric hospital. Patients: Seventy children and adolescents undergoing tracheostomy placement over a 24-month period. Interventions: None. Measurements and Main results: Hospital database records were used to determine demographics and readmission rates, tabulate charges, and confirm deaths. Indications for tracheostomies included airway obstruction, inadequate airway protection, chronic lung disease, neuromuscular weakness, and central hypoventilation. Surgical timing of the tracheostomy was grouped into three categories: prolonged mechanical ventilation, elective, or emergent. The overall median hospital stay was 46 days (range 14–254) with a median hospital charge of

LONG-TERM ADJUSTMENT ISSUES IN PATIENTS WITH EXSTROPHY

136,718 (range

Children With New Tracheostomies : Planning for Family Education and Common Impediments to Discharge

36,237–

The experiences of pediatric nurses caring for children in a persistent vegetative state

913,934). The prolonged mechanical ventilation group underwent a tracheostomy after a median of 26 days (mean 37.5 days) on the ventilator. Eighty-one percent of children were discharged home; 63% of children were readmitted within 6 months, with 11% requiring four or more admissions. The six-month mortality rate was 13%; no deaths were related to the tracheostomy. Conclusions: Children with tracheostomies are a heterogeneous population. Children who require tracheostomy for long-term mechanical ventilation have longer hospital stays than children who receive a tracheotomy on an elective or emergent basis. Hospital readmissions should be anticipated in this complex group of patients.

Open Catheter Drainage after Urethral Surgery

PURPOSE We explored the psychological adjustment of children with bladder or cloacal exstrophy. MATERIALS AND METHODS We assessed 29 subjects with a mean age plus or minus standard deviation of 7.8 +/- 3.97 years using age appropriate standard psychological instruments. Psychological adjustment scores in the exstrophy group were compared to the norms of the various instruments. Subjects were divided into dichotomous groups according to several medical and demographic factors. For each factor the differences between the means of the 2 groups on the outcome variables were calculated using a t test. RESULTS Children with exstrophy perceived their appearance more positively than the norm. Older children performed more poorly than younger children in adaptive behavior, specifically in skills related to functioning in school. Children who achieved continence after age 4 years were more likely to have problems with acting out behavior. There were no differences in adjustment in boys versus girls, bladder versus cloacal exstrophy, type of continence strategy or gender reassignment versus no reassignment. CONCLUSIONS Children with exstrophy did not have clinical psychopathology. Differences existed in adaptive and acting out behavior rather than depression or anxiety, suggesting that improved outcomes may be achieved through a focus on normal adaptation rather than on potential psychological distress.

Bilateral posterior pelvic resection osteotomies in patients with exstrophy of the bladder.

To describe an educational program and timeline for the discharge of children with a new tracheostomy and identify common impediments to the education and discharge process.

Laryngotracheal separation surgery for intractable aspiration: Our experience with 12 patients

Objective: The number of children surviving in a persistent vegetative state is increasing with advances in medical technology. Caring for a neurologically devastated child presents unique challenges not previously described. Our objective was to gain an understanding of the pediatric nurse’s experience of caring for children in a persistent vegetative state. Design: Qualitative phenomenologic study using in-depth interviews. Setting: Monitored step-down care unit of an academic children’s hospital. Participants: Eight registered nurses employed at a step-down care unit. Interventions: None. Measurements and Main Results: Nurses in this study described caring for children in a persistent vegetative state as a dynamic process with negative and positive aspects. Six themes emerged from this study: focusing on the parents, delivering sensorially offensive physical care, enduring conflicting emotions, suffering moral distress, finding relief and comfort, and gaining perspective. Conclusions: Our qualitative study suggests that caring for a child in a persistent vegetative state is difficult. Pediatric nurses described the experience as emotionally stressful and ethically challenging. To cope with the demands of caring for the child in a persistent vegetative state, the nurses in this study modified the traditional concept of the pediatric nurse–patient relationship.

The child with a tracheostomy and gastrostomy: parental stress and coping in the home--a pilot study.

A retrospective analysis of 100 patients, each managed by an intubated urinary diversion after undergoing repair of hypospadias and/or chordee or for a complication of previous urethral surgery, was performed to determine whether there was any difference in the incidence of postoperative urinary infection relative to the technique of catheter drainage (closed or open). In group 1 (50 patients) a traditional closed urinary drainage system was used, while in group 2 (50 patients) an open drainage system into doubled diapers was used. No significant difference in occurrence of urinary tract infections could be identified. Urinary infections occurred equally (24 per cent) in each group regardless of whether antibiotics were used postoperatively. Our results suggest that open urinary drainage using the double diaper technique is a safe and effective method of short-term catheter management after pediatric urethral surgery. This technique is comfortable for the patient, and is easy for parents to understand and master.

HOME TRANSITION WITH A PEDIATRIC TRACHEOSTOMY: IMPEDIMENTS TO PARENTAL EDUCATION AND DISCHARGE

This paper describes a modification of bilateral posterior iliac osteotomies for bladder exstrophy, in which a strip of ilium is resected subperiosteally lateral to the sacroiliac joints, allowing easier anterior closure with less breakdown compared with traditional osteotomies. Thirty-one children underwent repair of bladder exstrophy between 1974 and 1994. Orthopaedic procedures included: closed reduction and cast application in the newborn period (four patients), classic bilateral posterior iliac osteotomies (12 patients), and bilateral posterior resection osteotomies (15 patients). Dehiscence occurred after one closed reduction, five classic osteotomies, and one resection osteotomy. Urinary continence was obtained in four patients who underwent closed reduction, nine patients who underwent classic posterior osteotomies, and nine patients who underwent posterior resection osteotomies.

008–Home Transition with a Pediatric Tracheostomy: Impediments to Parental Education and Discharge

OBJECTIVE Laryngotracheal separation surgery (LTS) was performed as a treatment for recurrent or intractable aspiration pneumonia in 12 pediatric patients. The effectiveness of LTS surgery for preventing aspiration pneumonia, and the complications of this procedure were investigated. METHODS A retrospective chart review, conducted at a tertiary academic hospital in conjunction with a private practice, was used to identify children who underwent Laryngotracheal Separation Surgery (LTS) from September 2001 to July 2007. The main outcome measure was the number of hospital admissions for pneumonia in the pre LTS and post LTS period. A students t-test was used for statistical analysis. RESULTS LTS surgery decreased the frequency of pulmonary infections and respiratory events in all patients, resulting in far fewer hospitalizations. These patients experienced an average of 5 hospital admissions for pneumonia in the 2 years prior to LTS surgery, and an average of 1.1 hospital admissions for pneumonia after the LTS surgery. There were no major complications related to the surgery. Several minor complications following surgery were easily and effectively dealt with in the perioperative period. CONCLUSIONS LTS surgery is an effective and safe procedure in children with intractable aspiration. Parents do not perceive the care of the LTS stoma as burdensome. This procedure should be considered as an option in the surgical intervention for the management of chronic aspiration pneumonia in severely neurologically impaired children.