Kenneth W. Falterman

Appendicitis in children in the managed care era

Acute appendicitis is the most common condition requiring emergency operation in children. Late appendicitis is still a major source of morbidity and potential mortality. It has been suggested that managed care programs are responsible for a delay in surgical referral and consequently an increased risk of morbidity and mortality. In light of the increasing use of managed care, the authors reviewed their experience with pediatric acute appendicitis in managed care and indemnity insurance patients. The charts of all pediatric appendectomy patients treated between January 1990 and March 1995 were reviewed. Payor status, surgical and pathological findings, hospital course, and follow-up findings were documented. If the operative note or the pathology report described the appendix as gangrenous or perforated, the case was considered to be late appendicitis. Group I patients had traditional indemnity insurance; group II patients were in our institutions managed care plan. One hundred two patients were identified (28 in group 1, 74 in group II). Late appendicits was found less often in the managed care group (21.6% v 42.9%; P < .01). This resulted in a lower rate of major complications (1.4% v 3.6%) and a lower overall complication rate (2.7% v 7.1%). Group II also had a shorter hospital stay (2.6 days v 4.5 days; (P < .01) and lower average hospital charges (

A correlation of pulmonary hypoplasia, mean airway pressure, and survival in congenital diaphragmatic hernia treated with extracorporeal membrane oxygenation

6,507 v

Extracorporeal membrane oxygenation for nonneonatal respiratory failure

8,754 (P < .01). These results do not demonstrate any adverse affect on outcome for children with acute appendicitis who have a managed care plan. In fact, the incidence of late appendicitis among these patients was half of that of the indemnity-insured patients. The lower risk of late appendicitis resulted in a shorter length of stay and lower hospital charges. These results suggest that managed care programs can provide quality care along with a significant reduction in costs; no delay in appropriate surgical referral was demonstrated.

Improving Survival in the Treatment of Congenital Diaphragmatic Hernia

Thirty infants with congenital diaphragmatic hernia (CDH) who required therapy within the first day of life were treated in our institution over the past 3 years. Eighteen of these infants were not treated with extracorporeal membrane oxygenation (ECMO). Survival in this group was 83%. Twelve infants were treated with ECMO. Seven (58%) were weaned from ECMO and ventilator support with six (50%) long-term survivors. Minimum preoperative alveolar-arterial oxygen gradient (AaDO2), maximum postoperative mean airway pressure (MAP), and pulmonary hypoplasia were evaluated. Bohn et al have prospectively shown that the relationship of PaCO2 to mechanical ventilatory requirements accurately predicted survival in a group of 58 infants with CDH in whom ECMO was not a therapeutic option. This criteria would predict nonsurvival in all 12 of our patients treated with ECMO, including the seven survivors. Differences between our ECMO and non-ECMO groups were statistically significant for all three criteria. All P values less than .05. Morphometric analysis of the lungs of all ECMO nonsurvivors revealed hypoplastic ipsilateral lungs by lung weight to body weight ratios and radial alveolar counts when compared with experimental and historical controls (P less than .05). The contralateral lung was hypoplastic in 80% of the nonsurvivors. There is a strong correlation between the maximum postoperative MAP and the degree of contralateral pulmonary hypoplasia (r = .03, P = .02). We conclude that the maximum postoperative MAP is an accurate predictor of survival in the treatment of CDH and can be correlated with the degree of pulmonary hypoplasia.(ABSTRACT TRUNCATED AT 250 WORDS)

Pediatric extracorporeal membrane oxygenation in posttraumatic respiratory failure.

Extracorporeal membrane oxygenation (ECMO) has been used for 20 years in neonates and children with cardiac and respiratory failure. The number of neonates treated with ECMO has increased exponentially, but the number of older children treated is small. The selection and exclusion criteria for pediatric ECMO are poorly defined, and the results vary because of variable selection criteria and institutional experience with the technique. In order to help define the role of pediatric ECMO, we reviewed our experience in noneonatal pediatric respiratory failure. We have treated 22 patients ranging in age from 1 to 105 months and ranging in weight from 3 to 35 kg. Eighteen patients met the criteria for adult respiratory distress syndrome, two had respiratory syncytial virus pneumonia, and one had severe barotrauma complicating the management of reactive airway disease. All patients were considered by the referring institutions and by us to be failing conventional management as evidenced by hypoxia, hypercarbia, excessive ventilatory pressures, or progressive barotrauma. All were considered likely to die with continued conventional management. Sixteen of the 22 patients had complications (73%), but half of the last 10 patients had no complications. Hemorrhagic complications occurred in 12 patients. Mechanical complications included membrane failure, raceway rupture, pump malfunction, and improper cannula positioning. Other complications included culture-proven infection and renal failure. Eleven of the 22 patients survived (50%); nine of the last 12 survived (75%). These results suggest that ECMO may be a useful technique in selected pediatric patients with respiratory failure. Survival and complication rates improve as experience with the technique increases.

Complications of the fogarty catheter technique for removal of endobronchial foreign bodies

Thirty-two infants were treated for congenital diaphragmatic hernia at our institution from 1979 to 1984. Eight were in no or minimal distress at birth and had operative intervention when they were more than 24 hours old; survival was 100%. The remaining 24 neonates required immediate intubation and ventilation followed by operation at less than 12 hours of age. Overall survival was 54%; survival was 31% (4 of 13 patients, Group 1) in the first three years of the series and 82% (9 of 11 patients, Group 2) in the last three years (p less than 0.001). Apgar score, gestational age, birth weight, and incidence of associated congenital heart disease were equal for the two groups (all, p greater than 0.05). The two groups also were examined with reference to alveolar-arterial oxygen differences P(A-a)O2 and mean airway pressure (MAP). The best preoperative P(A-a)O2 was greater than 600 mm Hg for 7 neonates in Group 1 and 6 in Group 2, and survival was 0% and 71%, respectively (p less than 0.001). Infants with a postoperative MAP of 13 cm H2O or greater had a higher mortality (100% in Group 1 and 50% in Group 2, p greater than 0.05). Our treatment protocol was studied to determine those methods related to improved survival. Sodium bicarbonate infusion was used earlier in Group 2 as a prophylaxis against persistent fetal circulation (PFC) (p greater than 0.05). The incidence of severe PFC dropped from 85 to 54% (p greater than 0.05). Higher ventilator rates rather than pressures were used to achieve equally effective ventilation.(ABSTRACT TRUNCATED AT 250 WORDS)

Prolonged postoperative analgesia with lumbar epidural morphine in children undergoing thoracic and upper abdominal surgery

The leading cause of death in the pediatric population in the United States is trauma. A retrospective review of patients treated with extracorporeal membrane oxygenation (ECMO) for traumatic respiratory failure was performed. Eight children were treated at the Ochsner Medical Foundation and additional data on six children were available from the National Registry. Six children developed respiratory failure as a result of blunt trauma and eight as a result of near drowning. Standard venoarterial ECMO was used with a circuit very similar to that used in neonatal ECMO. Vascular access was via the common carotid artery and the internal jugular vein. Ventilatory support was weaned to minimal settings during ECMO. Central hyperalimentation and systemic antibiotics were used in all of the cases. Four of six children survived in the blunt trauma group; three of eight children survived in the near drowning group. Although significant conclusions cannot be drawn from a small group of patients the average pre-ECMO PO2 for survivors was 87 mm Hg, whereas for nonsurvivors the average PO2 was only 46 mm Hg. Ventilatory support for both groups was not remarkably different, and the average PCO2 was lower in the nonsurvivor group. The cause of death in this group of patients is usually multisystem organ failure. In the four patients treated at Ochsner who did not survive, all had positive blood cultures and presumed systemic sepsis. ECMO has been demonstrated to be very successful in neonatal respiratory failure. Predicting mortality and morbidity in pediatric respiratory failure has been more difficult.(ABSTRACT TRUNCATED AT 250 WORDS)

Uses of Extracorporeal Membrane Oxygenation in Nonneonatal Respiratory Patients: An Update

Extraction of endobronchial foreign bodies using the Fogarty catheter has been widely accepted. An unsuccessful application of this technique complicated by pneumothorax and catheter tip separation is presented. Avoidance of complications resulting from forceful instrumentation is emphasized.

Extracorporeal membrane oxygenation for respiratory and cardiac failure in infants and children.

Postoperative analgesia with lumbar epidural morphine was provided to 19 male and 7 female children (average age 11.3 years, range 3–18 years) who underwent 13 thoracic and 14 upper abdominal operations. Average duration of catheterization was 55.4 ± 28.7 h, and average time to first oral feedings 2 ± 1.5 days. Average overall time to dirst oral feedings 2 ± 2.6 days. Patients undergoing upper abdominal procedures had a significantly longer (P <0.05) time to first oral feedings and discharge home than children undergoing thoracic surgery. Average number of top-up doses of epidural morphine was 5.07 ± 2.5. Complications included: (1) pruritus in 11 patients (42%) treated medically; (2) urinary retention in 2 (8%) requiring catheterization; (3) gastrointestinal nausea and vomiting in 4 (15%), none of whom required nasogastric decompression; and (4) cardiorespiratory depression in 1 (4%). For 27 postoperative epidural analgesia procedures, 21 patients (78%) required no additional medications for pain or agitation. Four patients (15%) required diphenhydramine for agitation and sleeplessness. Three (11%) who had undergone thoracic procedures required one dose of intravenous morphine sulfate for additional pain relief in the immediate postoperative period.

Thymic enlargement in children

Neonatal extracorporeal membrane oxygenation (ECMO) has progressed rapidly from the experimental stage to a standard of care for certain infants who fail to respond to maximal conventional management. A broad diagnostic group of nonneonatal patients has now been supported by several different modes of ECMO with encouraging results. Selection criteria for nonneonatal patients that differ from those used for neonatal patients are emerging. Prospective randomized clinical trials are needed.