Postoperative sepsis in infants below 6 months of age

Background: Sepsis is a threatening postoperative complication especially in small infants. Regarding the advances in perinatal medicine, its incidence is unknown to date. We aimed to investigate the incidence, risk factors, laboratory findings and outcome of postoperative sepsis in infants younger than 6 months old. Methods: We examined postoperative sepsis in babies below 6 months of age during a 4-year period at a tertiary pediatric institution. Results: The rate of postoperative sepsis was 6.9%. Laparotomy with enterotomy, thoracotomy and diaphragmatic hernia repair (P<0.05, respectively) as well as low postnatal age and long operation time (P<0.001, respectively) were correlated with the incidence of sepsis. Significant independent predictors for the development of sepsis were the presence of a central venous catheter and perioperative antibiotic treatment (P<0.001, respectively). Coagulase negative Staphylococci were the major infecting organism associated with postoperative sepsis, accounting for 53% of monomicrobial infections. Complete blood counts with differential were not different between infants with sepsis and controls, who had undergone the same surgical procedures. Outcome was favorable in all cases; however, the length of hospital stay was significantly longer in sepsis patients (P<0.05). Conclusions: Postoperative sepsis syndrome is a frequent complication in infants below 6 months of age and causes significant prolongation of hospital stay. Adequate prevention and therapeutic strategies warrant further prospective investigation

Effects of potato-derived protease inhibitors on perianal dermatitis after colon resection for long-segment Hirschsprung's disease

Background: After resection of long-segment Hirschsprung's disease, severe perianal dermatitis (SPAD) may occur because of high stool frequency and elevated concentrations of fecal pancreatic proteases. We investigated prospectively the effect of potato-derived protease inhibitors (PPI) on skin conditions in children with postoperative SPAD. Methods: Four children (aged 12 to 24 months) with therapy-resistant SPAD after transanal endorectal pull-through for long-segment Hirschsprung's disease received topical PPI (1% in 20% zinc ointment) with each diaper-change. Parents noted down a subjective dermatitis score daily. Photo documentation and outpatient visits were made to assess the treatment results. Results: No adverse effects were observed after treatment with PPI. A remarkable improvement of the dermatitis in 3 of the 4 patients as well as improvements in pain and sleep disorders were observed during the PPI-treatment course. Conclusion: The results of the study suggest that PPI may reduce otherwise intractable protease-induced skin irritation in infant

Effects of Intralipid infusion on hemorheology and peripheral resistance in neonates and children

Deleterious microcirculatory effects of Intralipid (IL) infusion may be caused by hemorheological or vascular effects. The aim of this investigation was to study vascular and hemorheological effects of IL in preterm and fullterm neonates and children. Ten preterm newborns, 10 fullterm neonates, and 10 children received an initial infusion of IL (0.6g/kg) over 4h. Calf blood flow (venous occlusion plethysmography), blood pressure (Dinamap), whole blood and plasma viscosity (capillary viscometer), red blood cell deformability (rheoscope), and erythrocyte aggregation (aggregometer) were measured before and after administration of IL. Plasma triglyceride levels showed the greatest increase in preterm infants. Whole blood viscosity decreased by about 10% in all three groups because of a similar reduction in hematocrit. Red blood cell aggregation decreased by about 20% after IL infusion. Blood pressure rose by 10%, and peripheral blood flow declined by about 10% in the three groups. Vascular hindrance, a calculation of blood pressure divided by blood flow and viscosity, was raised by about 20%, suggesting marked vasoconstriction of peripheral arteries. Vasoconstriction rather than hemorheological changes during infusion of IL may play a crucial role in the pathogenesis of circulatory alterations in parenterally-fed neonate

Aseptic intussuscepted incidental appendectomy: three successful cases

Background: Incidental appendectomy remains a controversial issue. We aimed to collect experience using a modified surgical technique that could be applied securely in infants. Methods: We performed aseptic intussuscepted incidental appendectomy (AIIA) in three patients using a technique that is thought to assure appendix necrosis along with intact cecal wall. Results: There was no perioperative morbidity due to AIIA in the three patients. In two infants the necrotic appendix was found in the diaper. One infant died secondary to diaphragmatic hernia. Autopsy with histological examination revealed that the cecum was intact along with appendix necrosis. Conclusions: Modified AIIA could securely be performed in the 3 reported cases. We advocate prospective evaluation of the metho

Aseptic intussuscepted incidental appendectomy: three successful cases

BACKGROUND: Incidental appendectomy remains a controversial issue. We aimed to collect experience using a modified surgical technique that could be applied securely in infants. METHODS: We performed aseptic intussuscepted incidental appendectomy (AIIA) in three patients using a technique that is thought to assure appendix necrosis along with intact cecal wall. RESULTS: There was no perioperative morbidity due to AIIA in the three patients. In two infants the necrotic appendix was found in the diaper. One infant died secondary to diaphragmatic hernia. Autopsy with histological examination revealed that the cecum was intact along with appendix necrosis. CONCLUSIONS: Modified AIIA could securely be performed in the 3 reported cases. We advocate prospective evaluation of the method

Handlebar injuries in children

Introduction: Handlebar injuries in children may lead to severe organ lesions despite minimal initial signs and without visible skin bruise. We present our experiences applying a diagnostic and therapeutic algorithm for blunt abdominal trauma, and present the history of two selected cases. Materials and methods: We retrospectively assessed the charts of children below 16years of age, only who were observed for 24h or more in our institution due to a handlebar injury between 2004 and 2011. All children were treated according to an institutional algorithm. Results: 40 patients with a median age of 9.5years were included. Diagnosed lesions were: ruptures of the liver (n=6), spleen (n=5), kidney (n=1), and pancreas (n=2), small bowel perforation (n=3), and hernias of the abdominal (n=2) or thoracic wall (n=1). Surgical interventions were performed in 8 patients. The outcome was favorable in all the cases. Overall median hospitalization duration was 4.5days (range 1-19days). The overall duration between the accident and arrival at our emergency unit was 2.75h (median, range 1-19h). 20 children presented directly at our emergency unit after a median of 1.7h (range 1-19.5h). 20 children were referred by a family physician or a primary hospital after a median of 4.0h (range 1-46h). Conclusion: Handlebar injuries in children resulted in serious trunk lesions in half of the present patient series. The spectrum of injuries in handlebar accidents varies widely, especially injuries to the abdomen can unmask often only in the course. We advocate close observation of patients with thoracic and abdominal handlebar injuries which may be regarded as blunt stab wounds. An institutional algorithm for blunt abdominal trauma management is supportive for emergency care in patients with handlebar injurie

The relationship between coagulation and the extend of surgery and postoperative infection in surgical infants below 6 months of age

AIM: First to assess coagulation changes after surgery in children below 6 months of age. Second to detect differences attributable to the extent of surgery and postoperative infection. MATERIALS AND METHODS: Blood counts, haemoglobin concentration (Hb), haematocrit (Ht), prothrombine time (PT), activated partial thromboplastine time (aPTT) and thrombelastography (TEG) were studied pre- and 2+/-1/2 d postoperatively. Patients were divided in 3 groups. I: minor surgery without access to the abdomen or thorax (n=51); II: abdominal or thoracic interventions (n=24); III: abdominal surgery with postoperative sepsis (n=11). RESULTS: Preoperative values of Hb, Ht and INR were related to the age of the infant. Postoperatively clot strength and formation rate increased in gr. I (p<0.05). In gr. II, clot formation was initiated earlier (p<0.05) even though PT decreased (p<0.05). In group III, patients postoperatively developed a tendency for hypocoagulability in all TEG-parameters, but not in plasmatic coagulation. Postoperative TEG measurements were significantly inferior in gr. III when compared to gr. I and II. CONCLUSION: Our findings suggest activation of whole blood coagulation in the uncomplicated postoperative period despite of a decrease in plasmatic coagulation. In sepsis, only thrombelastography, but not plasmatic coagulation was affected

The syndromology of anorectal malformations revisited: from patterns of associated malformations to the recognition of syndromes

ackground: Although the frequency of associated malformation is high, the incidence of inheritable syndromes is widely underestimated in children with anorectal malformation (ARM). Data sources: OMIM database, patient records and charts of the Department of Pediatric Surgery, Johannes Gutenberg-University, Mainz, Germany. Methods: We analyzed all associations, sequences and syndromes listed in the OMIM database that can be accompanied by ARM. A large cohort of children born with ARM was then retrospectively investigated as to the type of ARM, presence of additional malformations and possible categorization as a syndrome, sequence or association. For this process a syndrome finder was developed and employed. This simplistic tool allows for a rapid first check of possible syndromes before a more complex analysis is started using the OMIM database and consulting specialists. Results: Among 317 children with ARM, associated malformations were present in 77.7% of 127 children with high ARM, in 68.7% of 32 with intermediate ARM, and in 25.3% of 158 with a low type ARM. Three or more organ systems were involved in 29.1% children with high type ARM and 25% with intermediate ARM and 8.2% with a low type ARM. An association of the vertebral anal tracheo-esophageal renal (VATER) and vertebral anal cardiac tracheo-esophageal renal limb (VACTERL) type was found in a total of 35 patients. Before analysis, 11 syndromes and 35 associations which were not clear previously in this patient cohort were described. In other 17 patients, 14 syndromes and 3 associations were identified. Conclusions: The high number of only retrospectively identified syndromes suggests that a routine search is necessary in every patient with ARM and additional malformations