Scoliosis in Children: Impact of Goal-Directed Therapies on Intraoperative and Postoperative Outcomes

Background: Scoliosis is among interventions with high postoperative complication rates due to the characteristics of the surgery, where blood loss, transfusion and fluid requirements can be increased. A monocentric retrospective observational study was undertaken earlier to determine predictors of intraoperative and postoperative outcomes in surgical patients. In this initial cohort, there were patients who underwent scoliosis surgery, and a secondary analysis to describe outcomes in these patients was realized and presented here. Objective: To describe intraoperative and postoperative outcomes in patients under 18 years old in scoliosis surgery included in the initial study and to propose improvement and implementation measures. Methods: A secondary analysis of patients undergoing scoliosis surgery from 1 January 2014 to 17 May 2017 was undertaken in our institution—Necker Enfants Malades university hospital. The study was approved by the Ethics Committee. Results: There were 116 patients with a mean age of 147.5 ± 40.2 months. Twenty-eight patients (24.1%) presented intraoperative and/or postoperative complications. The most common intraoperative complication was hemorrhagic shock in 3 patients (2.6%). The most common postoperative organ failure was neurologic in seven patients (6%), respiratory in 3 patients (2.6%), cardio-circulatory in 2 patients (1.7%) and renal failure in 1 patient (0.9%). The most common postoperative infection was surgical wound sepsis in 8 patients (6.9%), urinary sepsis in 3 patients (2.6%), and abdominal sepsis and septicemia in 2 patients (1.7%). 12 patients (10.3%) had reoperations. Fifty-six patients (48.3%) had intraoperative transfusion. There was no in-hospital mortality. Conclusion: The portion of patients with intraoperative and or postoperative complications was 24.1%, integrating goal-directed therapies in this surgical setting could improve postoperative outcomes.

Intraoperative Goal-Directed Therapies in Femoral and Pelvic Osteotomies in Children and In-Hospital Postoperative Outcomes

Background: Femoral and pelvic osteotomies are potential hemorrhagic interventions where transfusion requirements can be necessary. Objective: We undertook a secondary analysis of patients who underwent femoral and pelvic osteotomy in the initial cohort. The objective of this secondary analysis was to describe intraoperative and postoperative outcomes and to describe intraoperative management in these patients in terms of blood product management and fluid and hemodynamic therapy with the aim of implementing optimization management protocols for postoperative outcome improvement. Methods: A secondary analysis of patients who underwent femoral and pelvic osteotomy surgery was included in the initial retrospective study. Results: There were eighteen patients with a mean age of 104 ± 47.1 months. Four (22.2%) patients had intraoperative and/or postoperative complications. One patient (5.6%) had an intraoperative hemorrhagic shock, two patients (11.1%) had postoperative neurologic failure, and one patient (5.6%) had postoperative wound sepsis. The transfusion rate was 50% in nine patients. Conclusion: Femoral and pelvic osteotomies are interventions where blood, transfusion and fluid requirements can be increased;thus, this implies the necessity of a global patient blood management protocol with point-of-care tests and fluid- and hemodynamic-guided protocols with validated tools in children for intraoperative and postoperative outcome optimization.

Veno-Venous Extra-Corporeal Membrane Oxygenation (ECMO) in a Child with Hemoptysis and Fontan Circulation

Background: Extracorporeal membrane oxygenation is a rescue life support technique used in life threatening conditions of refractory respiratory and/or cardiac distress. Indication for extracorporeal life support in children depends on age and varies from pulmonary to cardiac pathologies. In some cases, it may be used as a bridge to a therapeutic procedure. We described here the management of respiratory failure due to hemoptysis in a child with a Fontan circulation and veno-venous extracorporeal membrane oxygenation which served as a bridge to angio-embolization. Hemoptysis can be a life threatening condition which can lead to hypovolemic shock and impaired alveolar gas exchange. The latter can result in respiratory failure and consequent asphyxia. When hemoptysis occurs in a patient with a univentricular heart and a Fontan circulation, management of this clinical situation can be challenging due to the particular physiology of the latter. Total cavopulmonary connection is a palliative surgical repair which constitutes Fontan circulation as a definitive treatment in patients with a univentricular heart. Methods: Case report description of a 16 year-old boy with a univentricular heart and a Fontan circulation who presented hemoptysis managed with a veno-venous extracorporeal membrane oxygenation (ECMO) as a bridge to angio-embolization. Results: Hemoptysis due to diffuse intra-alveolar hemorrhage from collateral circulation was successfully treated in this young patient with pulmonary vascular embolization. This allowed to wean the patient from extra-corporeal membrane oxygenation. Conclusion: Veno-venous ECMO can be life-saving as a bridge to angio-embolization for severe hemoptysis in patients with Fontan circulation. The reported case allows to underline that our multidisciplinary approach in this complex pediatric patient surely participated to improve outcome.

Postoperative Outcome in Children Aged between 6 and 10 Years in Major Abdominal Surgery, Neurosurgery and Orthopedic Surgery

Background: Anticipating postoperative evolution in surgical patients is an important issue in our daily practice. We demonstrated in a previous study that there were multiple predictors of postoperative outcome, including American Society of Anesthesiologists status (ASA), transfusion, emergency, surgery and age. A secondary analysis describing intraoperative and postoperative outcomes was undertaken in children aged between 6 and 10 years old included in the initial study. Objective: To describe intraoperative and postoperative outcomes in children aged between 6 and 10 years old included in the initial cohort in abdominal surgery, neurosurgery and orthopedics. Methods: The secondary analysis of postoperative outcomes in children aged between 6 and 10 years old was retrospectively included in the initial study of 594 patients. The study was approved by the Ethics Committee. Results: There were 88 patients with a mean age of 98.7 ± 13.8 months. The most common surgical interventions were scoliosis in 23 patients (26.1%), limb tumor resection in 8 patients (9.1%), femoral osteotomy in 6 patients (6.8%), intracerebral tumor resection in 6 patients (6.8%), intestinal resection in 5 patients (5.6%), Chiari’s malformation in 4 patients (4.5%), pelvic osteotomy in 4 patients (4.5%) and renal transplantation in 4 patients (4.5%). Most patients (45%) were American Society of Anesthesiologists grade 3 (ASA 3), and 13 (14.8%) were ASA grade 4. Twenty-two (25%) patients had intraoperative and/or postoperative complications (organ dysfunction or sepsis). Two patients (2.3%) had intraoperative hemorrhage, 1 patient (1.1%) had intraoperative difficult intubation, and 1 patient experienced intraoperative anaphylaxis. Nine patients (10.2%) had postoperative neurologic failure, and 2 (2.3%) had postoperative cardio-circulatory failure. Three patients (3.4%) had postoperative septicemia, 2 patients (2.3%) had postoperative pulmonary and urinary sepsis, and 1 patient (1.1%) had postoperative abdominal sepsis. 3 patients (3.4%) had re-operations. 42 (47.7%) patients had intra-operative transfusion. There was 1 in-hospital death (1.1%). The median total length of hospital stay was 9 days [5 - 16]. Conclusion: Twenty-five percent of the patients had intraoperative and/or postoperative complications, and most of them were ASA grade 3 3. Integrating goal-directed therapies to optimize intraoperative management in these patients could be necessary to improve postoperative outcomes in surgical pediatric patients.

Postoperative Complications after Major Abdominal Surgery in Preterm Infants: A Single Institute Record

Backgrounds: Post-operative complications in pediatric surgery are important issues, especially that after major abdominal surgery for preterm infants: complications sometimes lead to mortality/morbidity even though the surgical procedures were successful. We here attempted to demonstrate and record post-operative complications in preterm infants after major abdominal surgery. This is a secondary analysis of our cohort (n = 594) previously reported regarding pediatric postoperative complications (not confined to preterm infants). Methods: Of 594 patients, 25 preterm (born <37 weeks of gestation) infants underwent major abdominal surgery. We identified their characteristics, especially the postoperative complications. The Ethics Committee approved this study. Results: The mean weight was 2.43 ± 0.75 kg. Of 25, nine suffered postoperative complications: postoperative respiratory failure (n = 4), pulmonary sepsis (n = 2), and the followings were observed in one patient: intra-operative cardiac arrest, wound sepsis, septicemia, and multi-organ sepsis. There was no in-hospital mortality. Conclusion: In preterm infants undergoing major abdominal surgery, the most common postoperative complication was respiratory;respiratory failure and pulmonary sepsis. This data is roughly the same as that observed in the previous studies, which made us reconfirm the importance of the vigilance on respiratory complications in this population.

Patient Blood Management in Craniosynostosis Surgery

Background: Craniosynostosis surgery is one of the most hemorrhagic interventions, where transfusion rates vary from 20% to 100% depending on the study. Objective: To describe intraoperative and postoperative outcomes in a secondary analysis of children who underwent craniosynostosis surgery included in the initial retrospective study with the aim of proposing intraoperative implementation optimization protocols for postoperative outcome improvement. Methods: Secondary analysis. The study was approved by the Ethics Committee. Results: There were 69 children with a median age of 10 [0 - 207] months. Eight (11.6%) patients had intraoperative and/or postoperative complications. One patient (1.5%) had intraoperative hemorrhagic shock, and two patients (2.9%) had intraoperative broncholaryngospasm. One patient (1.5%) had postoperative anaphylaxis. One patient (1.5%) had postoperative hemorrhagic shock. One patient (1.5%) had postoperative respiratory failure. Two patients (2.9%) had postoperative neurologic failure. One patient (1.5%) had neuro-meningeal sepsis. One patient (1.5%) had a re-operation. There was no in-hospital mortality. Fourty-eight patients (69.6%) had intraoperative transfusions. Conclusion: Transfusion protocols guided with point-of-care tests should be included in patient blood management programs in craniosynostosis surgery.

Trans-Thoracic Echocardiographic Aortic Blood Flow Peak Velocity Variation, Distance Minute, Aortic Velocity Time Integral and Postoperative Outcome in Pediatric Surgical Patients—An Observational Pilot Study Protocol

Background: A Randomized Controlled Trial (RCT) has been elaborated where goal directed fluid and hemodynamic therapy (GDFHT) will be realized with trans-thoracic echocardiographic aortic blood flow peak velocity variation (ΔVpeak) and distance minute (DM) to guide fluid therapy and hemodynamics in high risk pediatric surgical patients. This RCT will clarify the impact of GDFHT with ΔVpeak and DM on postoperative outcome in terms of morbidity, length of stay in the intensive care unit (LOSICU), length of mechanical ventilation (LMV) and length of hospital stay (LOS) in children. To determine values of ΔVpeak, DM and VTI predictive of these postoperative outcomes, an observational pilot study will be realized. This pilot study is described here. The primary objective of this study is to determine values of ΔVpeak, DM and ITV predictive of postoperative outcome in children in terms of morbidity. The secondary objectives are to determine values of ΔVpeak, DM and ITV predictive of LOSICU, LMV, LOS, intraoperative, postoperative fluid administration and vasoactive-inotropic therapy. Methods: 500 - 1000 children aged less than 18 years will be included prospectively. Statistic analysis will be realized with XLSTAT 2019.4.2 software or plus. Results and Conclusions: This trial protocol will determine values of ΔVpeak, DM and ITV with echocardiography predictive of postoperative outcome in children.

Postoperative Outcomes in Exploratory Laparotomy and Intestinal Resection in Children: A Secondary Descriptive Observational Analysis

Background: We previously reported independent predictors of intraoperative and postoperative morbidity. These were age, American Society of Anesthesiologists Score (ASA), emergency situations, surgery and transfusion. ASA was the independent predictor of mortality. We conducted a secondary analysis of this previous retrospective study in patients who underwent exploratory laparotomy and intestinal resection. Objectives: The objective was to describe intraoperative and postoperative outcomes in patients who underwent exploratory laparotomy and intestinal resection in the initial study and to present a research protocol for intraoperative and postoperative optimization. Methods: Secondary analysis of the initial study was used. The Ethics Committee approved the study. Results: There were 54 patients with a median age of 15.5 [0 - 172] months. Thirty-seven (68.5%) patients underwent intestinal resection, nine (16.7%) underwent exploratory laparotomy, and eight (16.8%) underwent laparotomy for volvulus. Fourteen (25.9%) patients had intraoperative and/or postoperative complications. Two (3.7%) patients had an intraoperative hemorrhagic shock. Two (3.7%) patients had a postoperative cardio-circulatory failure. Three (5.6%) had postoperative respiratory failure. One (1.8%) patient had postoperative multiple organ failure and neurologic failure. Three (5.6%) patients had postoperative abdominal sepsis. One (1.8%) patient had postoperative multiple organ sepsis and neuromeningeal sepsis. Four (7.4%) patients had postoperative pulmonary sepsis. Two (3.7%) had postoperative septicemia. Six (11.1%) patients had reoperations. Seventeen (31.5%) patients had an intraoperative transfusion. The in-hospital mortality rate was 3.7% in two patients. Conclusion: The number of patients with postoperative complications in this cohort was not negligible. We, therefore, elaborated a research protocol where intraoperative patient management will be guided with transthoracic echocardiography for fluid and hemodynamic therapy optimization. The objective of this study protocol is to clarify the impact of intraoperative goal-directed fluid and hemodynamic therapy with transthoracic echocardiography on postoperative outcomes in terms of complications in pediatric surgical patients.

Neuroblastoma in Children: Intraoperative Goal Directed Therapy, Intraoperative and Postoperative Outcomes

Background: Neuroblastoma is the most common tumor in children. Anesthetic management can be challenging due to the localization and catecholamine-secreting characteristics of the tumor. We undertook a secondary analysis in a previous study to describe patients who underwent neuroblastoma resection. Objective: To describe intraoperative and postoperative outcomes in patients who underwent neuroblastoma resection and to propose optimal intraoperative management for postoperative outcome improvement. Methods: This was a secondary analysis of children who underwent neuroblastoma resection in the initial retrospective study. Results: There were 16 patients with a mean age of 39.3 ± 22.1 months. Seven (43.8%) patients presented with intraoperative or postoperative complications. One (6.3%) patient had intraoperative broncho-laryngospasm and difficult intubation. Two (12.5%) patients had intraoperative hemorrhagic shock. One patient (6.3%) had postoperative renal failure. Two patients (12.5%) had postoperative respiratory failure, and 3 (18.8%) patients had postoperative cardiocirculatory failure. One (6.3%) had postoperative pulmonary sepsis and septicemia. Thirteen (81.3%) patients were intraoperatively transfused. There was no in-hospital mortality. Conclusion: In this cohort, 43.8% of the patients had intraoperative and or postoperative complications in terms of organ dysfunction or sepsis. 81.3% of the patients received intraoperative transfusion. Neuroblastoma surgery can be a challenging situation where cardiovascular instability, high blood loss and transfusion requirements can be encountered. Consequently, preoperative preparation and optimal intraoperative management with validated tools in children could be necessary for a better postoperative outcome in this surgical setting.