Peri-operative red blood cell transfusion in neonates and infants: NEonate and Children audiT of Anaesthesia pRactice IN Europe: A prospective European multicentre observational study

BACKGROUND: Little is known about current clinical practice concerning peri-operative red blood cell transfusion in neonates and small infants. Guidelines suggest transfusions based on haemoglobin thresholds ranging from 8.5 to 12 g dl-1, distinguishing between children from birth to day 7 (week 1), from day 8 to day 14 (week 2) or from day 15 (≥week 3) onwards. OBJECTIVE: To observe peri-operative red blood cell transfusion practice according to guidelines in relation to patient outcome. DESIGN: A multicentre observational study. SETTING: The NEonate-Children sTudy of Anaesthesia pRactice IN Europe (NECTARINE) trial recruited patients up to 60 weeks' postmenstrual age undergoing anaesthesia for surgical or diagnostic procedures from 165 centres in 31 European countries between March 2016 and January 2017. PATIENTS: The data included 5609 patients undergoing 6542 procedures. Inclusion criteria was a peri-operative red blood cell transfusion. MAIN OUTCOME MEASURES: The primary endpoint was the haemoglobin level triggering a transfusion for neonates in week 1, week 2 and week 3. Secondary endpoints were transfusion volumes, 'delta haemoglobin' (preprocedure - transfusion-triggering) and 30-day and 90-day morbidity and mortality. RESULTS: Peri-operative red blood cell transfusions were recorded during 447 procedures (6.9%). The median haemoglobin levels triggering a transfusion were 9.6 [IQR 8.7 to 10.9] g dl-1 for neonates in week 1, 9.6 [7.7 to 10.4] g dl-1 in week 2 and 8.0 [7.3 to 9.0] g dl-1 in week 3. The median transfusion volume was 17.1 [11.1 to 26.4] ml kg-1 with a median delta haemoglobin of 1.8 [0.0 to 3.6] g dl-1. Thirty-day morbidity was 47.8% with an overall mortality of 11.3%. CONCLUSIONS: Results indicate lower transfusion-triggering haemoglobin thresholds in clinical practice than suggested by current guidelines. The high morbidity and mortality of this NECTARINE sub-cohort calls for investigative action and evidence-based guidelines addressing peri-operative red blood cell transfusions strategies. TRIAL REGISTRATION: ClinicalTrials.gov, identifier: NCT02350348

Urachal mucinous cystadenoma in infant: First case report in infant and review of literature

Introduction: As only ten cases have been described in current literature, urachal mucinous cystadenoma seems rare. All studied cases concerned adults or adolescents; this paper reports the first infant presenting urachal mucinous cystadenoma. Case report: A seven-month-old boy affected by urachal mucinous cystadenoma, presented as only sign persistent purulent umbilical discharge. Ultrasonography showed nodular structure with liquid content evoking urachal cyst. Radical surgical excision was performed. Histopathology proved diagnosis of urachal mucinous cystadenoma. No complications were observed. Follow-up consultation eight days postoperative was reassuring, evaluating infection and recurrence absence, and scar healing. Discussion: Preservation of urachus lumen may lead to urachal diseases: patent, diverticulum, sinus and cyst. Mucinous cystadenoma is rarely found in urachus. Solely umbilical purulent discharge was observed, in contrast to all reported cases. Same type of investigation, ultrasonography, was conducted to evoke diagnosis. Since urachal mucinous cystadenoma may transform into adenocarcinoma, prophylactic excision is recommended, and prognosis depends on its radicalness. No long-term outcome for infants is available in literature. We propose annual follow-up by ultrasonography. Conclusion: Urachal mucinous cystadenoma in infants is uncommon. Umbilical discharge must indicate ultrasonography. Surgical excision is recommended in case of suspicion. Long term outcomes are yet to be evaluated.SCOPUS: ar.jinfo:eu-repo/semantics/publishe

Evaluation of the Explorer Endoscopy Mask(©) for esogastroduodenoscopy in children: a retrospective study of 173 cases.

AIMS: The aim of this study was to evaluate the usability and safety of the Explorer Endoscopy Mask(®) (EM) as an alternative to endotracheal intubation in children undergoing elective esogastroduodenoscopy (EGD) under general anesthesia (GA). METHODS: This study was a retrospective observational study. The study was undertaken at the pediatric digestive endoscopy suite in the Cliniques universitaires Saint-Luc, Brussels, Belgium. We retrospectively analyzed the occurrence of minor and major airway-related adverse effects during pediatric EGD procedures performed under GA with the EM between June 2014 and March 2015. RESULTS: During the study period, 173 patients underwent EGD. Their mean age was 8.4 years (median: 9.1 years, range 4 months to 16 years). Mean duration of endoscopy (from insertion to removal of the endoscope) was 12.6 min (median: 12 min, range 3-47 min). The use of EM was uneventful in 159 (92%) cases. There were 24 airway-related adverse events in 14 children. Hypoxemia (SpO2 <90%) (13 events, 7.5%) was the most commonly encountered complication followed by laryngo- or bronchospasm (five events, 2.89%), cough (five events, 2.89%), and intubation (one event, 0.58%). No cases of regurgitation/aspiration were observed. CONCLUSIONS: Our data support the EM use in pediatric EGD. There were few transient respiratory adverse events which were easily solved with minor interventions

Evaluation du masque endoscopique Explorer pour l'endoscopie digestive haute de l'enfant: revue rétrospective de 87 cas

Chez l'enfant, l'oesophago-gastro-duodénoscopie (OGD) peut être réalisée sous anesthésie générale avec intubation, sous sédation IV (Propofol) ou sous inhalation de MEOPA. Nous rapportons notre expérience récente de l'utilisation du masque endoscopique Explorer d'intersurgical (MEE) pour les OGD de l'enfant

Novel insights into the assessment of risk of upper gastrointestinal bleeding in decompensated cirrhotic children

OBJECTIVES: Cirrhotic children wait-listed for liver transplant are prone to bleeding from gastrointestinal varices. Grade 2-3 esophageal varices, red signs, and gastric varices are well-known risk factors. However, the involvement of hemostatic factors remains controversial because of the rebalanced state of coagulation during cirrhosis. METHODS: Children suffering from decompensated cirrhosis were prospectively included while being on waitlist. Portal hypertension was assessed by ultrasound and endoscopy. Coagulopathy was evaluated through conventional tests, thromboelastometry, and platelet function testing. The included children were followed up until liver transplantation, and all bleeding episodes were recorded. Children with or without bleeding were compared according to clinical, radiological, endoscopic, and biological parameters. In addition, validation of a predictive model for risk of variceal bleeding comprising of grade 2-3 esophageal varices, red spots, and fibrinogen level <150 mg/dL was applied on this cohort. RESULTS: Of 20 enrolled children, 6 had upper gastrointestinal bleeding. Significant differences were observed in fibrinogen level, adenosine diphosphate, and thrombin-dependent platelet aggregation. The model used to compute the upper gastrointestinal bleeding risk had an estimated predictive performance of 81.0%. Platelet aggregation analysis addition improved the estimated predictive performance up to 89.0%. CONCLUSIONS: We demonstrated an association between hemostatic factors and the upper gastrointestinal bleeding risk. A low fibrinogen level and platelet aggregation dysfunction may predict the risk of bleeding in children with decompensated cirrhosis. A predictive model is available to assess the upper gastrointestinal bleeding risk but needs further investigations. Clinicaltrials.gov number: NCT03244332