M van Dijk

Intraoperative awareness during paediatric anaesthesia

BACKGROUND Previous studies indicate a higher incidence of awareness during anaesthesia in children than in adults, that is, around 1% vs 0.2%. In this prospective cohort study, we determined the incidence of intraoperative awareness in children undergoing elective or emergency surgery at a university childrens hospital. METHODS Data from 928 consecutive paediatric patients, aged 5-18 yr, were collected prospectively over a 12 month period. Interviews using a structured questionnaire were scheduled at three time points: within 24 h after the operation, and 3-7 and 30 days after operation. Reports of suspected awareness were sent to four independent adjudicators. If they all agreed, the case was classified as a true awareness case. RESULTS The interviews generated 26 cases of suspected awareness. Six cases were judged to be true awareness, equalling a 0.6% incidence (95% confidence interval 0.03-1.40%). Auditory and sensory perceptions were the sensations most reported by these six children. Pain, anxiety, and paralysis were less often mentioned. The children in general did not report awareness as stressful. CONCLUSIONS The incidence of awareness in this study, in children undergoing general anaesthesia, is comparable with recent reports from other countries, and appears to be higher than that reported in adults.

Functional capillary density decreases after the first week of life in term neonates.

Background: Changes in the microcirculation have been recognized to play a crucial role in many disease processes. In premature neonates, functional capillary density (FCD) decreases during the first months of life. Objectives: The aims of this study were to obtain microcirculatory parameters in term neonates and older children who did not present with compromised respiration or circulation and to determine developmental changes in the microcirculation in young children. Methods: This single-center prospective observational study was performed at a level III university children’s hospital. Subjects eligible for inclusion were children up to the age of 3 years who did not have any respiratory compromise, circulatory compromise or signs of dehydration. The buccal mucosa of 45 children was assessed, using orthogonal polarization spectral imaging. Results: We found a significantly higher FCD in neonates younger than 1 week compared with older children. The median FCD was 8.1 cm/cm2 (range 7.3–9.4) for 0- to 7-day-old neonates (n = 12), 6.9 cm/cm2 (range 4.7–8.7) for 8- to 28-day-olds (n = 10), 7.3 cm/cm2 (range 6.1–8.8) for 1- to 6-month-olds (n = 19) and 6.7 cm/cm2 (range 6.5–9.2) for 3-year-olds (n = 4). After the first week, there was no significant correlation between age and FCD. Conclusion: FCD of the buccal mucosa decreases after the first week of life.

Interleukin‐10 is an Unequivocal Th2 Parameter in the Rat, whereas Interleukin‐4 is Not *

Exposure of Wistar rats to the immunotoxic compounds hexachlorobenzene (HCB), bis(tri‐n‐butyltin)oxide, and benzo(a)pyrene was previously found to affect mRNA expression of interleukin (IL)‐2, IL‐2R α‐chain, and interferon (IFN)‐γ, the prototypic Th1 cytokine. In contrast, the mRNA expression of IL‐4, the prototypic Th2 cytokine, was unaffected. This latter finding suggested that the IL‐4 mRNA expression may not be an unequivocal parameter for Th2 responses in the rat. In order to obtain such a parameter the present study was performed, consisting of two types of experiments. Expression and production of IL‐4 as well as IL‐10, a second Th2 cytokine, were measured. First, Lewis (Th1 prone) and Brown Norway (BN; Th2 prone) rats were exposed to HCB. Exposure was previously found to increase the serum immunoglobulin (Ig)E levels, an IL‐4‐dependent response, in BN but not Lewis rats, and in Lewis rats to aggravate experimental allergic encephalomyelitis (EAE), severity being inversely related to IL‐10 levels. Secondly, BN rats were infected with Trichinella spiralis, an infection previously found to induce IL‐4 production. HCB exposure did not affect IL‐4 mRNA expression in either strain, while IL‐4 production was decreased in Lewis and unaffected in BN rats. In Lewis rats both the mRNA expression and the production of IL‐10 were decreased. The T. spiralis infection induced IL‐4 and IL‐10 mRNA expression, as well as IL‐10 production. In contrast, the IL‐4 production was strongly reduced. Thus, both the IL‐10 mRNA expression and production correlated with the EAE development and T. spiralis infection. In HCB exposed Lewis rats and T. spiralis infected BN rats the IL‐4 mRNA expression correlated with IgE levels and T. spiralis infection, respectively, whereas the IL‐4 production lacked correlation in all cases. Collectively, these results suggest that IL‐10 is an unequivocal Th2 parameter in the rat, whereas IL‐4 is not.

Anaesthesia and postoperative analgesia in surgical neonates with or without Down's syndrome: is it really different?

BACKGROUND Reports conflict on optimal postoperative analgesic treatment in children with intellectual disability. We retrospectively compared postoperative analgesics consumption between neonates with and without Downs syndrome in relation to anaesthesia requirements and pain scores. METHODS We analysed hypnotic and analgesic drug administration, pain scores [COMFORT-Behaviour (COMFORT-B) scale], and duration of mechanical ventilation during the first 48 h after surgical repair of congenital duodenal obstruction in neonates, between 1999 and 2011. Data of 15 children with Downs syndrome were compared with data of 30 children without Downs syndrome. RESULTS General anaesthesia requirements did not differ. The median (inter-quartile range) maintenance dose of morphine during the first 24 h after operation was 9.5 (7.8-10.1) µg kg(-1) h(-1) in the Downs syndrome group vs 7.7 (5.0-10.0) µg kg(-1) h(-1) in the control group (P=0.46). Morphine doses at postoperative day 2 and COMFORT-B scores at day 1 did not significantly differ between the two groups. COMFORT-B scores at day two were lower in children with Downs syndrome (P=0.04). The duration of postoperative mechanical ventilation did not statistically differ between the two groups (P=0.89). CONCLUSIONS In this study, neonates with and without Downs syndrome received adequate postoperative analgesia, as judged from comparable analgesic consumption and pain scores. We recommend prospective studies in children of different age groups with Downs syndrome and in other groups of intellectually disabled children to provide further investigation of the hypothesis that intellectual disability predisposes to different analgesic requirements.

Children with intellectual disabilities and pain perception: a review and suggestions for future assessment protocols.

AIM: This was to review what is known about pain assessment in children with intellectual disabilities and to translate findings into clinical dental practice. METHODS: Literature review. REVIEW: The association between anxiety and pain as reported in the literature was explored. The specific pain expressions for individuals with Down’s syndrome and those with autism are discussed with available literature. Various pain assessment instruments for cognitively impaired children have comparable content but vary in number of items. However, none of these instruments has been tested or implemented in the dental setting. Five pain assessment instruments for children with intellectual disabilities are described in more detail and these instruments were primarily tested for postoperative children. There are only limited data available on their use in dental treatments. Suggestions for step-by-step implementation of pain assessment in dental practice are given. CONCLUSION: Further studies in dental practice are recommended to achieve optimal pain management during dental procedures in individuals with intellectual disabilities.

Parental satisfaction with follow-up services for children with major anatomical congenital anomalies

BACKGROUND Since 1999 a multidisciplinary follow-up programme for parents and children with major anatomical congenital anomalies is in place in our hospital, run by a dedicated team. The aim of the present study was to evaluate the services of this team from a parental perspective. METHODS Parents completed a questionnaire including open and closed questions about satisfaction with the various professional disciplines involved in the follow-up, statements on usefulness of the follow-up services and suggestions for improvement. RESULTS Four hundred and sixty-nine surveys were sent out, of which 71% were returned. Non-responding parents included significantly more parents of non-Dutch origin (P= 0.038) and parents who never responded to invitations for follow-up examinations (P < 0.001). Parental satisfaction differed for the various disciplines. Eighty per cent of the parents were (very) satisfied with the social worker, compared with 92% with nurses. More than half of the parents agreed that the follow-up services give peace of mind. Almost a quarter of parents, however, considered the follow-up services as redundant. The children of these parents had significantly shorter intensive care unit stay (P= 0.02), were older at the time of the questionnaire (P= 0.04), of higher socio-economic status (P= 0.001) and less likely to be of non-Dutch origin (P= 0.008). Sixty-one per cent of the parents had contacted the 24-h helpline. Ninety per cent of the parents were satisfied with the intensive care unit, almost 80% with the general ward. CONCLUSION Overall, parents were satisfied with the services of the follow-up team. Some parents, however, saw room for improvement related to better communication, recognizability of the team and better planning and organization.

O-145 Pain And Distress In A Paediatric Intensive Care Unit: Is The Comfort Behaviour Scale Sensitive To Change In Children Aged 0–3 Years?

Background Critically ill children admitted to a Paediatric Intensive Care Unit (PICU) experience pain and distress. The COMFORT Behaviour (COMFORT B) Scale is a widely used pain and distress assessment scale, validated in children less than 3 years. Minimal studies assess whether the scale is sensitive to detect changes in pain and sedation levels after a treatment intervention is administered. Sensitivity to change, defined as the ability of a measure to detect statistically significant changes after pain treatment, is a relevant psychometric property for pain instruments. With many PICUs now making decisions about analgesia and sedation management based on COMFORT B assessments, it is crucial that these issues are rigorously explored. The aim of the study is to determine if the COMFORT B Scale is sensitive to change. Methods The study is a prospective observational study. Admissions to the PICU of children less than 3 years, who had a COMFORT B score indicating pain or under sedation were included. Re-administration of the COMFORT B scale within 2 h of an intervention was performed to assess sensitivity to change. Results An initial pilot study found excellent interrater reliability in 97 assessments performed by 2 nurses blinded to each other’s scores. Consequently, single nurse paired assessments were completed before and after an intervention and sensitivity to change was established. Conclusions The study identifies that the COMFORT B scale is sensitive to detect change following pharmacological and non pharmacological interventions. Thus proposing the COMFORT B scale effectively guides pain and sedation management.

Children’s outcomes at 2-year follow-up after 4 years of structured multi-professional medical-ethical decision-making in a neonatal intensive care unit

Objective:We reviewed our decisions about continuation/withdrawal of life-sustaining treatments in a group of critically ill newborns who were discussed in structured medical ethical decision-making meetings, and provide the surviving children’s outcomes at 2-year follow-up.Study Design:In an explorative observational study, 61 cases were evaluated. The children involved had been discussed in such a structured way from 2009 to 2012 in a level III-D neonatal intensive care unit.Results:Decisions made were: full treatment (n=6), earlier restriction cancelled (n=3), treatment restriction (n=30) and palliative care (n=22). Parents of six children disagreed with the decision proposed. Thirteen (54%) of the 24 children who survived (39%) had moderate to severe neurological problems; 8 (33%) had additional sequelae; only one 2-year-old child was healthy.Conclusions:Decisions made varied to a large extent. The poor outcomes should be disseminated among decision makers. Future studies must explore new ways to improve outcome prediction, extend follow-up periods and consider what living with severe handicaps really means for both child and family.

The hospital costs associated with acute paediatric burn injuries : research

BACKGROUND Ongoing rationing of healthcare threatens services that are well established, and cripples others that desperately require investment. Burn, for one, remains a neglected epidemic in South Africa (SA), despite the magnitude of the problem. OBJECTIVE To identify the prominent components contributing to the cost of hospital admission with paediatric burn injury. Determining the true costs of specialist services is important, so that resources can be allocated appropriately to achieve the greatest possible impact. METHODS A retrospective study was undertaken over 1 year to determine patient demographics and injury details of 987 patients admitted with burn injuries to Red Cross War Memorial Childrens Hospital, Cape Town, SA. The in-hospital financial records of 80 randomly selected patients were examined. This was followed by a prospective study to determine the financial implications of four cost drivers, i.e. bed cost per day, costs of medications received, costs of dressings for wound care, and costs of surgical intervention. A random selection of 37 dressing changes (in 31 paediatric patients) and 19 surgical interventions was observed, during which all costs were recorded. RESULTS As expected, severe flame burns are responsible for more prolonged hospital stays and usually require surgical intervention. Scald burns comprise the greatest proportion of burn injuries, and therefore account for a considerable part of the hospitals expenditure towards burn care. CONCLUSION While community programmes aiming to prevent burn injuries are important, this study motivates for the implementation of accessible ambulatory services in low-income areas. This strategy would enable the burn unit to reduce its costs by limiting unnecessary admissions, and prioritising its resources for those with more severe burn injuries.

The Management of Pediatric Polytrauma: Review

Polytrauma is a major cause of mortality and morbidity in both developed and developing countries. The primary goal of this review is to provide a comprehensive overview on current knowledge in the management of pediatric polytrauma patients (PPPs). A database review was conducted based on a search in the Embase, Medline OVID-SP, Web of Science, Cochrane central, and Pubmed databases. Only studies with “paediatric population” and “polytrauma” as criteria were included. A total of 3310 citations were retrieved. Of these, 3271 were excluded after screening, based on title and abstract. The full texts of 39 articles were assessed; further selection left 25 articles to be included in this review. The most crucial point in the management of PPPs is preparedness of the staff and an emergency room furnished with age-appropriate drugs and equipment combined with a systemic approach.