Seminars in pediatric surgery
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Improvement in anesthesia outcomes has derived from advances in safety science related to equipment, drugs, human factors analysis, professional standardization and organization, subspecialty care, and regionalization. Outcomes of pediatric anesthesia have improved, but universal outcome measures are lacking. Because of the limitations of small numbers, future improvement efforts will necessarily involve multiple disciplines, institutions, and regions, and will require sophisticated systems approaches.
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Semin. Pediatr. Surg. · Feb 2008
ReviewRespiratory failure and extracorporeal membrane oxygenation.
Conventional treatment of respiratory failure involves positive pressure ventilation with high concentrations of inspired oxygen. If adequate gas exchange still cannot be achieved extracorporeal membrane oxygenation (ECMO) may be an option. The general indication for ECMO for respiratory insufficiency is a reversible pulmonary disease, which cannot be managed by conventional means. ⋯ Aspiration and viral pneumonia are the pediatric diagnoses with the highest survival rates. Randomized controlled studies have shown a significant advantage of ECMO with regard to survival in neonates. In the pediatric age group, nonrandomized studies have shown lower mortality in ECMO-treated patients.
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Thoracic trauma is relatively frequent in children and causes considerable mortality. This is mainly due to the multiorganic nature of the trauma. The lung is more often affected even in the absence of rib fractures because of the considerable pliability of the chest wall that allows direct transfer of energy to this organ. ⋯ Most traumatic lung injuries may be treated with rest, respiratory support, and eventually intercostal drainage. Large hemorrhage may require thoracotomy, and persistent pneumothorax (indicative of tracheobronchial disruption) may require intubation with fiberoptic bronchoscopic assistance and eventually reparative or ablative surgery. Adult respiratory distress syndrome is very rarely seen in children with thoracic trauma, but it remains highly lethal.
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Semin. Pediatr. Surg. · Feb 2008
ReviewRespiratory infections: pneumonia, lung abscess, and empyema.
Pneumonia is an important clinical problem that affects children of all ages. Although effectively treated on an outpatient basis in the majority of cases, some children with respiratory infections still require hospitalization. ⋯ This article focuses on the clinical presentation, etiology, and treatment of childhood pneumonia, with special consideration given to the immunocompromised child. Two specific complications of pneumonia, lung abscess and empyema, are discussed.
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Hypertrophic pyloric stenosis (HPS) is a common condition affecting infants that presents with progressive projectile nonbilious vomiting. The pyloric portion of the stomach becomes abnormally thickened and manifests as gastric outlet obstruction. The cause is unknown. ⋯ This article reviews the diagnostic work up and imaging, preoperative resuscitation, the various surgical approaches used, and the effect of subspecialty training on outcomes after pyloromyotomy. Postoperative care and the variety of postoperative feeding regimens applied after pyloromyotomy are reviewed, as well as intra- and postoperative complications. Finally, medical management, in lieu of surgery, is discussed.