Seminars in pediatric surgery
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Fetal surgery pushes the limits of knowledge and therapy beyond conventional paradigms by treating the developing fetus as a patient. Providing anesthesia for fetal surgery is challenging for many reasons. It requires integration of both obstetric and pediatric anesthesia practice. ⋯ Work is needed to study possible neurotoxicity caused by exposure of the developing brain to anesthetic agents. The effects of stress on the developing fetus also must be further delineated. Anesthetic techniques vary by institution, and prospective studies to determine optimal anesthetic regimens are warranted.
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The management of neonatal surgical problems continues to pose considerable challenges, particularly in low-resource settings. The burden of neonatal surgical diseases in Africa is not well documented. The characteristics of some neonatal surgical problems are highlighted. ⋯ Proper training of all staff involved in neonatal health care coupled with community awareness must be vigorously pursued by all stakeholders. Various governments throughout the continent of Africa, in conjunction with international donor agencies, must not only provide an adequate budget for health care services and improve infrastructures, but must also deliberately encourage and provide funding for neonatal surgical care and research across the continent. The well-established pediatric surgical training programs, particularly in North and South Africa, should hold the moral responsibility of training all possible numbers of young surgeons from other African countries that do not have any existing pediatric surgical training programs or those countries suffering from remarkable shortage of trained pediatric surgeons.
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Head injury occurs frequently in childhood and results in approximately 500,000 emergency department visits and over $1 billion in costs annually. Nearly 75% of these children are ultimately diagnosed with mild traumatic brain injury (MTBI), a misnomer because many will have radiographically identified intracranial injuries and long-term consequences. Identification of the brain at risk and prevention of secondary injury is associated with the largest reduction in head trauma morbidity and mortality. This article reviews the current literature to discuss the initial evaluation, management, and long-term outcomes in children sustaining MTBI.
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Semin. Pediatr. Surg. · Nov 2010
ReviewMassive transfusion and blood product use in the pediatric trauma patient.
Hemorrhagic shock in the pediatric trauma patient is an uncommon but fundamental problem for the treating clinician. Current management of hemorrhagic shock involves initial resuscitation with crystalloid fluids followed by infusion of blood components as necessary. In management of the adult trauma patient, many institutions have implemented massive transfusion protocols to guide transfusion in situations requiring or anticipating the use of greater than 10 U of packed red blood cells. ⋯ Adult trauma transfusion protocols can be applied to children until a pediatric protocol is validated. Here, we attempt to identify certain principles of transfusion therapy specific to pediatric trauma and outline a sample pediatric massive transfusion protocol that may be used to guide resuscitation. Also, adjuncts to transfusion, such as colloid fluids, other plasma expanders or hemoglobin substitutes, and recombinant activated factor VII, are discussed.
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Semin. Pediatr. Surg. · Nov 2010
ReviewManagement strategies for severe closed head injuries in children.
Brain injuries represent the most common cause of mortality and long-term morbidity from trauma in children. The management of closed head injuries focuses on prevention of secondary injury by optimizing the delivery of oxygen and nutrients to the injured brain while minimizing neuronal metabolic demand. ⋯ Therapies intended to minimize secondary brain injury, such as cerebrospinal fluid drainage, hypertonic saline infusion, barbiturate coma induction, brain cooling, and decompressive craniectomy, vary widely in their clinical application among practitioners and trauma centers and have unclear indications, benefits, and long-term consequences. Prospective studies on brain injury management in children are needed to develop treatment strategies that optimize outcomes.