Martina Heinrich

Comparison of different training models for laparoscopic surgery in neonates and small infants

BackgroundMinimally invasive surgery in small children and infants requires special skills and training. This experimental study compares the efficiency of an in vitro pelvic trainer (PT) and an a in vivo animal model (AM).MethodsFor this study, 12 residents were prospectively randomized into two groups. Initially, all had to pass a basic skill assessment (3 tasks). Then endoscopic small bowel biopsy was performed (8 times) either with the in vitro PT (group A) or the in vivo AM (group B). Finally, all had to demonstrate this procedure in the in vivo AM and repeat the basic skill assessment. A quality index (complications, suture, biopsy) was evaluated.ResultsInitially, there was no difference between the two groups. Interestingly, the mean regression gradient of the index for the in vitro PT (group A) was significantly better than for the in vivo AM (group B). In the final in vivo operation, however, the mean index for the in vitro PT (group A) worsened significantly, whereas it increased for the in vivo AM (group B) (p = 0.037).ConclusionAdequate training for an isolated mechanical task such as gut biopsy can be supplied using a pelvic trainer or animal model with similar effects. However in vivo performance of the same task requires secondary surgical skills, which are conveyed during live training with greater success. Consequently, stepwise teaching with both modules seems reasonable before these procedures are approached in neonates or small children.

Screening for depression in adolescent paediatric patients: validity of the new Depression Screener for Teenagers (DesTeen).

BACKGROUND Depression in adolescents is often hard to detect. In many cases paediatricians are the first point of contact. In order to increase recognition rates, screening instruments may be a helpful support for health care professionals. However, there is a lack of valid and economical screening instruments for primary care patients. Thus, the aim of the study was the development of the new Depression Screener for Teenagers (DesTeen) and its validation in a paediatric sample. METHOD 326 patients between 13 and 16 years old completed the DesTeen and a diagnostic interview, serving as gold standard. Prevalence rate for any depressive disorder (minor depression, major depression and dysthymia) was 12.6%. Psychometric properties were calculated. For validity measures, the area under the receiver operating characteristic curves (AUC) for any depressive disorder and the diagnostic subgroups was computed. RESULTS DesTeen showed a high reliability (Cronbachs α=.87) and a high validity (AUC=.91). For the diagnostic subgroups AUC values did not significantly differ from overall accuracy of any depressive disorder (major depression: AUC=.95, p=.179; dysthymia: AUC=.88, p=.605; minor depression: AUC=.87, p=.327). The optimal cut-off point for any depressive disorder according to the Youden-Index yielded a sensitivity of .90 and a specificity of .80. An abbreviated 5-item version of DesTeen showed no loss in validity (AUC=.90, p=.695). CONCLUSIONS Overall, DesTeen can be regarded as a valid screening instrument for adolescent paediatric patients. For practical use, the 5-item version is even more promising. A replication of these results is essential.

Self-Administered Procedural Analgesia Using Nitrous Oxide/Oxygen (50:50) in the Pediatric Surgery Emergency Room: Effectiveness and Limitations

INTRODUCTION Minor surgical interventions in children are often at times challenging due to the lack of cooperation by the child. Procedural sedation and analgesia is often appropriate, but unpleasant or painful applications of medication add additional discomfort to the child. A mixture of nitrous oxide (N2O)/oxygen (O2) in a ratio of 50:50, functioning as an inhalational sedative analgesic, may be a viable alternative, in particular in an emergency care setting because such mixtures require no fasting period and are self-administered. Therefore, in this study we investigated the feasibility and the effectiveness of N2O/O2 (50:50) as a sedative analgesic when performing minor surgical procedures. PATIENTS AND METHODS Procedural sedation and analgesia with an N2O/O2 (50:50) mixture applied during minor surgical procedures were prospectively evaluated over 2.5 years in a major pediatric hospital in Germany. Indications for sedation were either minor painful interventions, the injection of a local anesthetic, or a digital block in an emergency care setting. Diagnosis, type of surgery, inhalation time, complications, side effects, pain scores, and the childs behavioral reaction were assessed. RESULTS A N2O/O2 (50:50) mixture was administered in 210 children, ages 2.7 to 16.5 years (mean 9.0 years). Three treatments were terminated because of lack of compliance, nausea, or dizziness. No other side effects were encountered. During the intervention, 80.5% of all patients were pain free, and 81.9% were relaxed and calm. A higher rate of insufficient pain control was observed when the indication was an injection of a digital block or a reposition of fractures and dislocations. CONCLUSIONS The use of self-administered N2O/O2 (50:50) mixture for minor painful procedures in children is safe and adequate pain control can be achieved in most cases. The benefits of this approach for the child and its parents are its good acceptance and adequate pain control. The benefit for the health care provider is the lack of a fasting period before administration, good anxiolysis at minimum sedation, and a cooperative patient. Limitations are unsatisfying analgesia in some cases. Though not found in our study, potentially serious adverse events are a possibility and standard safety guidelines for minimal sedation should always be applied.

Therapie akuter Schmerzen bei Kindern und Jugendlichen

ZusammenfassungSchmerzen gehören zu den häufigsten Ursachen für eine Konsultation des Kinderarztes. Die Stärke akuter Schmerzen kann anhand von Selbstbewertungs- oder Beobachtungsskalen erhoben werden. Akute Schmerzen jeder Genese müssen schnellstmöglich behandelt werden. Nach Ursachenerforschung und kausal ausgerichteter Therapie sind Ibuprofen und Paracetamol die am häufigsten eingesetzten Analgetika. Bei Letzterem sind das niedrige analgetische Potenzial sowie die geringe therapeutische Breite zu beachten. Bei starken bis sehr starken akuten Schmerzen sollten auch bei Kindern Opioide Mittel der ersten Wahl sein. Im Rahmen der postoperativen Schmerzbehandlung kommen Analgetikaregimes mit Basis- und Bedarfsanalgesie zum Einsatz. Starke Schmerzerfahrungen im Kindesalter können zur psychischen Traumatisierung führen und über die Ausbildung eines Schmerzgedächtnisses langfristig das Schmerzempfinden beeinflussen. Schmerzen müssen deshalb konsequent zu vermeiden versucht bzw. behandelt werden.AbstractPain is one of the most common causes for consultation of a paediatrician and represents a major problem in paediatrics. Simple self-reporting and behavioural pain scales are suitable for assessment of intensity of acute pain. Acute pain of whatever origin should be treated immediately. The most commonly used analgesics are ibuprofen and paracetamol (acetaminophen). In the case of paracetamol the narrow therapeutic range should be kept in mind. Opioids should be first choice in therapy of severe pain, also for children. Perioperative pain should be treated with a combination of non-pharmacological and pharmacological strategies with basis medication and medication on demand. Experience of severe pain can result in the generation of a chronic pain memory with emotional trauma which can have a long-term influence on the sensitivity to pain. Therefore, every effort should be made to prevent pain and to treat it effectively.

Evaluation of a Pilot Project to Introduce Simulation-Based Team Training to Pediatric Surgery Trauma Room Care

Introduction. Several studies in pediatric trauma care have demonstrated substantial deficits in both prehospital and emergency department management. Methods. In February 2015 the PAEDSIM collaborative conducted a one and a half day interdisciplinary, simulation based team-training course in a simulated pediatric emergency department. 14 physicians from the medical fields of pediatric surgery, pediatric intensive care and emergency medicine, and anesthesia participated, as well as four pediatric nurses. After a theoretical introduction and familiarization with the simulator, course attendees alternately participated in six simulation scenarios and debriefings. Each scenario incorporated elements of pediatric trauma management as well as Crew Resource Management (CRM) educational objectives. Participants completed anonymous pre- and postcourse questionnaires and rated the course itself as well as their own medical qualification and knowledge of CRM. Results. Participants found the course very realistic and selected scenarios highly relevant to their daily work. They reported a feeling of improved medical and nontechnical skills as well as no uncomfortable feeling during scenarios or debriefings. Conclusion. To our knowledge this pilot-project represents the first successful implementation of a simulation-based team-training course focused on pediatric trauma care in German-speaking countries with good acceptance.

Immune Response after Conventional and Minimally Invasive Surgery in Children: Lymphocyte Subpopulations and HLA-DR Expression on Monocytes

Background: The present study was performed to investigate the differences in lymphocyte subpopulations and HLA-DR expression on monocytes as markers for the systemic immune response in children undergoing either minimal invasive surgery (MIS) or conventional (open) surgery. Methods: In a prospective study we compared 20 children admitted for fundoplication or chest wall correction. The surgical access was decided based upon the individual anatomy. Postoperative inflammatory immune response was assessed for the MIS versus open group by measuring the level of C-reactive protein (CRP) and lymphocyte subpopulations (CD3, CD4, CD8, NK cells, CD25, and HLA-DR on monocytes) by a flow cytometer. Blood samples were collected preoperatively and 12, 24, 72 h, and 7 days after surgery. Results: Postoperatively in the open surgery group a significantly greater increase of CRP was recorded. Open surgery, but not MIS, was found to cause a significant reduction of all lymphocyte subpopulations and HLA-DR on monocytes. A...

Der kleine Schmerzpatient

ZusammenfassungNeben Fieber sind akute Schmerzen bei Kindern und Jugendlichen die häufigste Ursache für ungeplante Vorstellungen in Notfallambulanzen und beim Kinderarzt. Eine adäquate und altersentsprechende Schmerztherapie orientiert sich an der Schmerzstärke, -ursache und -dauer. Akute Schmerzen müssen schnell und suffizient behandelt werden. Die am häufigsten verwendeten Analgetika bei Kindern sind dabei Ibuprofen, Paracetamol und Metamizol. Leiden Kinder unter starken akuten Schmerzen, sind auch hier Opioide indiziert. Bei diagnostischen und therapeutischen Interventionen müssen Kinder vor Schmerzen, Angst und Behandlungsstress geschützt werden.