Joseph A. Iocono

Improved survival in venovenous vs venoarterial extracorporeal membrane oxygenation for pediatric noncardiac sepsis patients: a study of the Extracorporeal Life Support Organization registry

BACKGROUND/PURPOSE There are few studies comparing venoarterial (VA) and venovenous (VV) extracorporeal membrane oxygenation (ECMO) in pediatric noncardiac sepsis patients. METHODS Following approval, we reviewed the Extracorporeal Life Support Organization registry data from 1990 to 2008 for patients 0 to 18 years with a diagnosis of sepsis and without diagnosis of congenital heart disease. Survival to discharge was compared between VA and VV ECMO using χ(2) analysis and multivariable logistic regression. RESULTS Four thousand three hundred thirty-two ECMO runs were reviewed, 3256 VA (75%) and 1076 VV (25%). A majority of VA modality was noted in each decade studied. Overall survival was 68% and was higher in VV (79%) than in VA ECMO (64%, P < .001). Survival decreased with increasing age (73% in newborns ≤ 1 month, 40% in children 1 month to 12 years, and 32% in adolescents >12 years, P < .001). VA ECMO had increased mortality risk after adjustment for age, use of vasoactive agents, and advanced respiratory support (odds ratio, 2.06; 95% confidence interval, 1.74-2.44; P < .001). CONCLUSIONS These data demonstrate improved survival in VV vs. VA ECMO in select pediatric septic patients without congenital heart disease. When technically feasible, physicians should consider VV ECMO as first therapeutic choice in this patient population.

A Middle Fidelity Model Is Effective in Teaching and Retaining Skill Set Needed to Perform a Laparoscopic Pyloromyotomy

INTRODUCTION An inanimate technical skills trainer for laparoscopic pyloromyotomy (LP) has not been described. A middle fidelity model, reproducing the three consistent steps in LP, was developed as a component of a teaching module for surgical residents, and tested on medical students, residents, and pediatric surgeons. MATERIALS AND METHODS In the first phase of the study, a cohort of 29 pediatric surgeons used the LP model and completed questionnaires about the models realism and accuracy. Descriptive statistics were used to analyze questionnaire responses. Chi-square tests were performed to determine if level of experience influenced responses. For the second phase of the study, medical students and surgical residents individually participated in the training of cognitive knowledge about hypertrophic pyloric stenosis and skills acquisition for LP. Subject testing consisted of simulator task performance and multiple-choice quiz administration immediately after training and repeated at 8 weeks after training. Data were analyzed by using paired sample t-tests and one-way analyses of variance (ANOVA). RESULTS The pediatric surgeons agreed that the model accurately simulated essential components of the pyloromyotomy, and that the model would be an excellent tool to introduce surgeons to LP. A total of 26 students and early surgical residents completed the training and testing. Knowledge-based test performance improved from pre- to postinstruction by 17.45 [standard error of the mean (SEM) + 3.5] (P < 0.001) and from preinstruction to 8 weeks by 4.54 (SEM = 3.2) (P = 0.17). Mean improvement in time of simulator task performance was 85.2 +/- 75.4 seconds. Based on a one-way ANOVA, higher level of training was associated with decreased mean times (P = 0.04). CONCLUSIONS Face and content validities of the simulation were demonstrated by the pediatric surgeons. An effective training experience was demonstrated with medical students and residents. At 2 months, simulator task-completion rates and task-performance times showed technical skills were retained, whereas, based on test scores, cognitive knowledge was not as well retained.

Thoracoscopic resection of an intrathoracic accessory liver lobe: An incidental finding in the workup of a child with a respiratory infection

A case of an intrathoracic accessory liver lobe in a five-year-old female is presented, representing an incidental finding during workup for a respiratory infection. MRI was used to identify what appeared to be an accessory intrathoracic liver lobe. Thoracoscopy confirmed the diagnosis, and removal was achieved through a minimally invasive surgical procedure. Based on an electronic literature search, this is the first known report of minimally invasive techniques to remove accessory liver from the chest in a pediatric patient.

Epistaxis due to Wegener's granulomatosis in a pediatric patient

Epistaxis is a common problem in children that typically is not severe and seldom requires hospitalization. The nose is a highly vascular structure with a large surface area; subsequently, it is highly predisposed to bleeding. Childhood vasculitides are very rare and are commonly diagnosed by characteristic lesions on imaging studies along with syndrome recognition by clinicians. We present a case of recurrent epistaxis that persisted over 3 months due to Wegeners granulomatosis in an adolescent that was misdiagnosed as a benign hemorrhage from Kiesselbachs plexus.

Management of Abdominal Compartment Syndrome in a Very Low Birth Weight Neonate Using Penrose Drains and Subsequent Management of Abdominal-Wall Defects

Percutaneous drainage of the peritoneal cavity has been recently evaluated for the treatment of perforated viscous in the very low birth weight (VLBW) neonate and percutaneous decompression for abdominal compartment syndrome (ACS) has been studied in older patient populations. This is the first reported case of using this technique to treat ACS in a VLBW neonate.