Congenital diaphragmatic hernia in the preterm infant.

BACKGROUND: Congenital diaphragmatic hernia (CDH) remains a significant cause of death in newborns. With advances in neonatal critical care and ventilation strategies, survival in the term infant now exceeds 80% in some centers. Although prematurity is a significant risk factor for morbidity and mortality in most neonatal diseases, its associated risk with infants with CDH has been described poorly. We sought to determine the impact of prematurity on survival using data from the Congenital Diaphragmatic Hernia Registry (CDHR). METHODS: Prospectively collected data from live-born infants with CDH were analyzed from the CDHR from January 1995 to July 2009. Preterm infants were defined as \u3c37 weeks estimated gestational age at birth. Univariate and multivariate logistic regression analysis were\u3eperformed. RESULTS: During the study period, 5,069 infants with CDH were entered in the registry. Of the 5,022 infants with gestational age data, there were 3,895 term infants (77.6%) and 1,127 preterm infants (22.4%). Overall survival was 68.7%. A higher percentage of term infants were treated with extracorporeal membrane oxygenation (ECMO) (33% term vs 25.6% preterm). Preterm infants had a greater percentage of chromosomal abnormalities (4% term vs 8.1% preterm) and major cardiac anomalies (6.1% term vs 11.8% preterm). Also, a significantly higher percentage of term infants had repair of the hernia (86.3% term vs 69.4% preterm). Survival for infants that underwent repair was high in both groups (84.6% term vs 77.2% preterm). Survival decreased with decreasing gestational age (73.1% term vs 53.5% preterm). The odds ratio (OR) for death among preterm infants adjusted for patch repair, ECMO, chromosomal abnormalities, and major cardiac anomalies was OR 1.68 (95% confidence interval [CI], 1.34-2.11). CONCLUSION: Although outcomes for preterm infants are clearly worse than in the term infant, more than 50% of preterm infants still survived. Preterm infants with CDH remain a high-risk group. Although ECMO may be of limited value in the extremely premature infant with CDH, most preterm infants that live to undergo repair will survive. Prematurity should not be an independent factor in the treatment strategies of infants with CDH

Treatment evolution in high-risk congenital diaphragmatic hernia: ten years\u27 experience with diaphragmatic agenesis.

OBJECTIVE: The objective of this study was to evaluate the impact of newer therapies on the highest risk patients with congenital diaphragmatic hernia (CDH), those with agenesis of the diaphragm. SUMMARY BACKGROUND DATA: CDH remains a significant cause of neonatal mortality. Many novel therapeutic interventions have been used in these infants. Those children with large defects or agenesis of the diaphragm have the highest mortality and morbidity. METHODS: Twenty centers from 5 countries collected data prospectively on all liveborn infants with CDH over a 10-year period. The treatment and outcomes in these patients were examined. Patients were followed until death or hospital discharge. RESULTS: A total of 1,569 patients with CDH were seen between January 1995 and December 2004 in 20 centers. A total of 218 patients (14%) had diaphragmatic agenesis and underwent repair. The overall survival for all patients was 68%, while survival was 54% in patients with agenesis. When patients with diaphragmatic agenesis from the first 2 years were compared with similar patients from the last 2 years, there was significantly less use of ECMO (75% vs. 52%) and an increased use of inhaled nitric oxide (iNO) (30% vs. 80%). There was a trend toward improved survival in patients with agenesis from 47% in the first 2 years to 59% in the last 2 years. The survivors with diaphragmatic agenesis had prolonged hospital stays compared with patients without agenesis (median, 68 vs. 30 days). For the last 2 years of the study, 36% of the patients with agenesis were discharged on tube feedings and 22% on oxygen therapy. CONCLUSIONS: There has been a change in the management of infants with CDH with less frequent use of ECMO and a greater use of iNO in high-risk patients with a potential improvement in survival. However, the mortality, hospital length of stay, and morbidity in agenesis patients remain significant

Congenital Diaphragmatic Hernia Defect Size and Infant Morbidity at Discharge

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Utility of sonography in the diagnosis of bronchopulmonary sequestration

Sonography in six patients with pulmonary sequestration demonstrated findings associated with and indicative of that diagnosis. The most useful feature, which was seen in three cases and is diagnostic of sequestration, is the identification of an anomalous systemic artery arising from the aorta.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/31868/1/0000818.pd

Outcomes of truncal vascular injuries in children.

BACKGROUND: Pediatric truncal vascular injuries occur infrequently and have a reported mortality rate of 30% to 50%. This report examines the demographics, mechanisms of injury, associated trauma, and outcome of patients presenting for the past 10 years at a single institution with truncal vascular injuries. METHODS: A retrospective review (1997-2006) of a pediatric trauma registry at a single institution was undertaken. RESULTS: Seventy-five truncal vascular injuries occurred in 57 patients (age, 12 +/- 3 years); the injury mechanisms were penetrating in 37%. Concomitant injuries occurred with 76%, 62%, and 43% of abdominal, thoracic, and neck vascular injuries, respectively. Nonvascular complications occurred more frequently in patients with abdominal vascular injuries who were hemodynamically unstable on presentation. All patients with thoracic vascular injuries presenting with hemodynamic instability died. In patients with neck vascular injuries, 1 of 2 patients who were hemodynamically unstable died, compared to 1 of 12 patients who died in those who presented hemodynamically stable. Overall survival was 75%. CONCLUSIONS: Survival and complications of pediatric truncal vascular injury are related to hemodynamic status at the time of presentation. Associated injuries are higher with trauma involving the abdomen

2014 Wolfson Memorial Lecture: Mentoring-Notes from the Trenches

Outline: 1. What is mentoring Who was Mentor Define it 2. What good is mentoring Data from SUS/Industry 3. Roles involved Mentor Role Mentee Role 4. Feedback from My Mentees 5. Lessons learned Presentation: 43 minute

Pediatric surgical wound infections

Postoperative wound infections are one of the most common nosocomial infections in surgical patients and the third most common nosocomial infection in all hospitalized patients. Surgical wound infections commonly increase the need for antibiotics and increase the length of stay and hospital costs. Although this subject has been discussed frequently in the adult literature, fewer than 10 articles exist on the subject in the pediatric patient population, despite the rate of surgical wound infection, which ranges from 3 to 20 percent. Surgical site infections are potentially preventable complications that increase hospital costs as well as patient morbidity and discomfort. Recognizing the patient who is at high risk for a surgical site infection and providing appropriate antibiotic prophylaxis to those patients is an important step in decreasing surgical site infections. This article discusses the risks of surgical site infection specific to pediatric surgical procedures, as well as appropriate antibiotic prophylaxis and treatment. Copyright © 2001 by W.B. Saunders Compan

Treatment Strategies for Congenital Diaphragmatic Hernia: Change Sometimes Comes Bearing Gifts

ObjectiveTo report treatment strategies’ evolution and its impact on congenital diaphragmatic hernia (CDH) outcome.DesignRegistry-based cohort study using the CDH Study Group database, 1995–2013.SettingInternational multicenter database.PatientsCDH patients entered into the registry. Late presenters or patients with very incomplete data were excluded. Patients were divided into three Eras (1995–2000; 2001–2006; 2007–2013).Main outcome measuresTreatment strategies and outcomes. One-way ANOVA, X2 test, and X2 test for trend were used. A Sydak-adjusted p < 0.0027 was considered significant. Prevalence or mean (SE) are reported.ResultsPatients: 8,603; included: 7,716; Era I: 2,146; Era II: 2,572; Era III: 2,998. From Era I to Era III, significant changes happened. Some severity indicators such as gestational age, prevalence of prenatal diagnosis, and inborn patients significantly worsened. Also, treatment strategies such as the use of prenatal steroids and inhaled nitric oxide, age at operation, prevalence of minimal access surgery, and the use of surfactant significantly changed. Finally, length of hospital stay became significantly longer and survival to discharge slightly but significantly improved, from 67.7 to 71.4% (p for trend 0.0019).ConclusionTreatment strategies for patients registered since 1995 in the CDH Study Group significantly changed. Survival to discharge slightly but significantly improved

Emergent abdominal decompression with patch abdominoplasty in the pediatric patient

Background/Purpose: Abdominal compartment syndrome (ACS) is the cardiac, pulmonary, and renal dysfunction that occurs as a result of elevated intraabdominal pressure. The authors present their experience with patch abdominoplasty (PA) in pediatric patients as a means to treat and prevent ACS. Methods: The charts of patients who underwent PA were reviewed retrospectively. ACS was defined as the increased oxygen requirements and elevation of peak inspiratory pressures (PIP) associated with abdominal distension and worsening renal and or cardiac function. Results: A total of 23 patients (13 boys) were treated (average age, 23 months). Diagnoses included necrotizing enterocolitis (NEC, n = 13), trauma (n = 3), Hirschsprung's enterocolitis (n = 2), perforated bowel (n = 4), and bilateral Wilms' tumor with bowel obstruction (n = 1). Oxygen requirements decreased after patch abdominoplasty (mean preoperative FIO2, 0.87 ± 24, mean postoperative, 0.67 ± 24 [P =.01]). The PIP decreased significantly in the 13 patients who survived (mean preoperative PIP, 33 ± 8, mean postoperative PIP, 27 ± 7 [P =.01]). These PIPs failed to respond in the 8 nonsurvivors (mean preoperative PIP, 35 ± 10, mean postoperative PIP, 33 ± 14 [P value not significant]). Six of the 8 nonsurvivors had NEC. Complications of intraabdominal abscess and enterocutaneous fistula were seen in 5 patients, all of who had NEC. Conclusions: Patch abdominoplasty effectively decreases airway pressures and oxygen requirements associated with ACS. Complications with PA occur primarily in patients with NEC. Failure to respond with a decrease in PIP and FIO2 requirements is an ominous sign. J Pediatr Surg 35:705-708. Copyright © 2000 by W.B. Saunders Company