Dissertations / Theses on the topic 'Pediatrcic Surgery'

For most of the patients with brain tumors and/or epilepsy, surgical resection of brain lesions, when applicable, remains one of the optimal treatment options. The success of the surgery hinges on accurate demarcation of neoplastic and epileptogenic brain tissue. The primary goal of this PhD dissertation is to demonstrate the feasibility of using various optical techniques in conjunction with sophisticated signal processing algorithms to differentiate brain tumor and epileptogenic cortex from normal brain tissue intraoperatively. In this dissertation, a new tissue differentiation algorithm was developed to detect brain tumors in vivo using a probe-based diffuse reflectance spectroscopy system. The system as well as the algorithm were validated experimentally on 20 pediatric patients undergoing brain tumor surgery at Nicklaus Children’s Hospital. Based on the three indicative parameters, which reflect hemodynamic and structural characteristics, the new algorithm was able to differentiate brain tumors from the normal brain with a very high accuracy. The main drawbacks of the probe-based system were its high susceptibility to artifacts induced by hand motion and its interference to the surgical procedure. Therefore, a new optical measurement scheme and its companion spectral interpretation algorithm were devised. The new measurement scheme was evaluated both theoretically with Monte Carlo simulation and experimentally using optical phantoms, which confirms the system is capable of consistently acquiring total diffuse reflectance spectra and accurately converting them to the ratio of reduced scattering coefficient to absorption coefficient (µs’(λ)/µa(λ)). The spectral interpretation algorithm for µs’(λ)/µa(λ) was also validated based on Monte Carlo simulation. In addition, it has been demonstrated that the new measurement scheme and the spectral interpretation algorithm together are capable of detecting significant hemodynamic and scattering variations from the Wistar rats’ somatosensory cortex under forepaw stimulation. Finally, the feasibility of using dynamic intrinsic optical imaging to distinguish epileptogenic and normal cortex was validated in an in vivo study involving 11 pediatric patients with intractable epilepsy. Novel data analysis methods were devised and applied to the data from the study; identification of the epileptogenic cortex was achieved with a high accuracy.

Most pediatric orthopaedic interventions are intended to improve or preserve physical function, yet their outcomes have been assessed using primarily surrogate measures (e.g., radiographic indices) that may not accurately represent patients'function. Physical function may be more appropriately measured with activity-based scales, but these have been infrequently applied in surgical studies. The purpose of this study was to identify existing activity-based physical-function scales appropriate for pediatric orthopaedics, to present criteria useful for scale selection, and to discuss the special problems of measuring physical function in children. Twenty-one scales relevant to pediatric orthopaedics are described according to their target population, purpose, method of administration, content, and quality of standardization. These scales have been further classified according to a new taxonomy. The unique aspects of measuring physical function in children are discussed and include the effect of age and development, method of reporting, and question formats. Standardized measures of physical function based on physical-activity ability exist and should be used more frequently to assess pediatric orthopaedic interventions

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Hospital Das Clinicas da Faculdade de Medicina de Botucatu
Secretaria de Saúde do Estado de São Paulo
A hospitalização é uma experiência complexa e pode apresentar-se como agradável ou não, sendo agravada no caso de necessidade de intervenção cirúrgica, principalmente quando o paciente é criança. Na prática, observa-se todo um movimento de reorganização pessoal do paciente e de seus familiares para enfrentar esse momento. Quando a cirurgia é suspensa, o paciente e seus familiares estão sujeitos a um desconforto maior, que pode gerar sentimentos de insegurança, angústia e ansiedade. Este estudo teve como objetivo identificar e descrever a percepção de quinze mães e/ou responsáveis por crianças de 0 a 18 anos, internadas num hospital de ensino do interior do Estado de São Paulo, após receberem a notícia de que a cirurgia de seu filho (a) seria suspensa. Foi um estudo descritivo com abordagem qualitativa, que utilizou o referencial teórico da Comunicação Interpessoal e o referencial metodológico da Análise de Conteúdo. Os resultados evidenciaram que as suspensões de cirurgias pediátricas são um fato presente na instituição, que trazem repercussões ao paciente e seus familiares e à organização institucional; que a comunicação entre profissionais da equipe de saúde, pacientes e familiares sobre procedimentos a serem realizados ou não, é inadequada; que a atuação da enfermagem no momento da notícia da suspensão da cirurgia precisa ser pontual e efetiva.
Hospitalization is a complex experience which may or may not be agreeable; this can be made worse if surgical intervention is required, especially when the patient is a child. In practice a personal struggle can be seen in the patient and family to brave this moment. When surgery is suspended, the patient and family are subjected to a stronger discomfort, which can cause feelings of insecurity, distress, and anxiety. The objective of this study was to identify and describe the perceptions of fifteen mothers or guardians of children between 0 and 18 years old admitted in a teaching hospital in the interior of São Paulo State Brazil, after receiving news that surgery for their child was suspended. This was a descriptive qualitative study which used Interpersonal Communication as theoretical reference and Analysis of Content as the methodology. Results showed that suspension of pediatric surgery in our institution causes repercussions to patients, their families, and institution organisation; that communication between health team professionals, patients and families about procedures to be performed or not performed, is inadequate; and that nursing action at the moment when news of surgery suspension is given must be prompt and effective.

Background Injuries are the leading cause of death in the United States for children between the ages of 1 and 19 years. Weekend hospital admission has been associated with poor outcomes and higher mortality rates for a variety of diseases. We examined the impact of weekend versus weekday admission on in-hospital morbidity and case-fatality rates for pediatric trauma patients. Methods We performed a cross-sectional analysis on the 2016 Kids’ Inpatient Database. The study population included pediatric trauma patients under the age of 19 years which were stratified by weekend vs weekday admission. Weightings were used to produce national estimates. Multiple logistic regression analyses were performed to assess the odds of in-hospital complications and death after adjusting for a variety of potentially confounding demographic and clinical factors. Results Patients admitted on a weekend were older, more frequently male, White, and privately insured. Weekend admissions had a higher Injury Severity Score (6.7 vs 5.4, p<0.001), as well as higher rate of intensive care unit (ICU) admission (8.5% vs 7.1%, p<0.001) and in-hospital case-fatality rate (1.3% vs 1.1%, p=0.003), but lower rate of in-hospital complications (6.1% vs 6.8%, p<0.001). Unadjusted logistic regression demonstrated that weekend admission was associated with higher odds of in-hospital death as compared to weekday admission (odds ratio 1.20, 95% confidence interval [CI] 1.07 – 1.35), but in the multivariable adjusted model this was no longer statistically significant (adjusted odds ratio [aOR] 1.06, 95% CI 0.94 – 1.20). Weekend admission was associated with lower odds of in-hospital complications (aOR 0.90, 95% CI 0.86 - 0.95), but higher odds of ICU admission (aOR 1.12, 95% CI 1.06 – 1.18). Conclusions Weekend admission in pediatric trauma is associated with higher odds of ICU admission. There does not appear to be an association between weekend admission and odds of in-hospital death, however it may be associated with lower odds of in-hospital complications.

Abstract Background: Intraoperative Near Infra-Red Spectroscopy (NIRS) may reduce postoperative neurologic complications. Use in pediatric populations, NIRS increases, and variations in sensor placement are understudied. Objective: To explore NIRS performance in a pediatric population undergoing cardiac surgery; to describe significant (20%) NIRS deviations from baseline; to correlate events with physiologic variables; to examine the relevance of a second sensor. Methods: Retrospective review of prospectively collected NIRS data. Associations were assessed using Student's t-test, chi-squared test and logistic regression. Results: Significant deviations from baseline were common. Many occurred when unsupported by CPB (cardiopulmonary bypass) or upon CPB initiation. NIRS decreases and increases were significantly associated with PaO2, hematocrit, and MAP (mean arterial pressure) (p<0.05) and paCO2 (p<0.01), respectively. Unilateral deviations were frequent, particularly amongst cyanotic and male patients. Conclusion: In this population, significant NIRS deviations are associated with physiologic variables. A second sensor provided significant information.
Introduction: Le Near Infra-Red Spectroscopy (NIRS) utilitisé durant la période opératoire peut réduire les complications neurologiques postopératoires. L'utilisation du NIRS chez la population pédiatrique et les variations associées au placement des senseurs sont sous étudiées. Objectifs: Explorer les performances du NIRS chez les enfants lors de chirurgies cardiaques; décrire les variations significatives du NIRS (20%) en comparaison aux niveaux témoins; établir des corrélations entre les événements et les variables mesurées; établir l'utilité d'un second senseur. Méthodes: Une revue rétrospective de données NIRS obtenues de façon prospective. Les relations observées seront évaluées avec les tests Student-t, chi-squared, et de régression logistique. Résultats: Des variations significatives en comparaison aux valeurs témoins ont été observées. Plusieurs de ces variations ont eu lieu lorsque les patients n'étaient pas supportés par la circulation extracorporelle ou lors de son initiation. Les augmentations et diminutions du NIRS sont significativement reliées au PaO2, à l'hématocrite, à la pression artérielle moyenne (p<0.05) et au paCO2 (p<0.01), respectivement. Des variations unilatérales du NIRS sont fréquentes, particulièrement chez les patients cyanosés et chez les patients males. Conclusion: Chez cette population pédiatrique, des déviations significatives du NIRS sont associées à certaines variables physiologiques. Le deuxième senseur ajoute des informations utiles.

The purpose of this study was to investigate the neuropsychological outcomes of pediatric subjects undergoing temporal lobe surgery, and then compare the outcomes between subjects in the iMRI and the standard operating suites. This study involved 77 children ages one to 21 years (M = 11.98) at time of surgery for intractable epilepsy. Forty-seven returned for repeat neuropsychological assessment. At baseline, subjects with early onset of epilepsy (≤ 7 years) scored worse on a measure of attention (p = .02), FSIQ (p < .01), perceptual reasoning (p < .01), and processing speed (p = .06). At one-year follow-up, interactions were observed for the response style domain of the attention measure (p = .03), FSIQ (p = .06) and working memory (p = .08). Follow-up at one year, for the group as a whole, revealed decline in verbal memory (p = .04) and reading comprehension (p = .02); and improvement for word reading (p = .05). No significant differences were observed between the iMRI and standard operating suite. Though, hemisphere, duration of epilepsy, preoperative seizure frequency, lesional disease, seizure type, presence of epileptogenic focus, and number of lobes involved accounted for variance in neuropsychological outcomes. These results provide further support for that certain preoperative individual, disease, and therapeutic variables are predictive of neurocognitive outcome following surgery for temporal lobe epilepsy. Additionally, the results demonstrated that surgery may also impact attention.

Emergence delirium (ED), also known as emergence agitation, is a postoperative condition characterized by aberrant cognitive and psychomotor behaviors following general anesthesia. The incidence of ED is 3 to 8 times higher in children 5 years of age or less. There is no standard of nursing practice for managing ED symptoms in the pediatric surgical population. The purpose of this quality improvement project was to address a gap in knowledge needed to inform clinical decision-making when managing ED in the postoperative setting. Using an educational presentation for post anesthesia care unit (PACU) nurses, this project introduced the use of non-pharmacological interventions to mitigate symptoms of ED in the pediatric population as inspired by The Green Star Initiative, an Army program at Fort Carson. The project aim was to describe the effectiveness of ED-specific interventions from the nursing perspective. Using tenets of the Iowa model, this quality improvement project included a needs assessment survey, PowerPoint presentation, parent education leaflet, ED cheat sheet, and a post-intervention survey. Applying the context, input, process, product model for evaluation, this project increased knowledge of ED-specific interventions used by nurses that demonstrates a change in clinical decision-making. PACU nurses rated the interventions 43% effective on pediatric patients. This project addressed the gap in practice by providing structured education on ED, inspiring the use of ED-specific interventions, and promoting readiness to care for the pediatric surgical population. Outcomes add to the nursing literature by introducing ED-specific interventions to manage pediatric ED in facilities nationwide. A social implication of this project is to improve the care of pediatric surgical patients.

During procedures like venipuncture, Child Life Specialists are able to incorporate non-pharmacological measures when most medical staff focused on pharmacological measures. There is little research about what types of interventions Child Life Specialists believe are effective at minimizing children's pain and increasing coping skills during venipuncture. The purpose of the current study was to examine Child Life Specialists' perspectives on the different techniques available in the hospital setting. An online survey of 75 Certified Child Life Specialists asked about the types of techniques that Child Life Specialists use during venipuncture. Further, questions asked how Child Life Specialists felt about the efficacy of pharmacological and non-pharmacological techniques with a variety of different ages. Results revealed that Child Life Specialists felt that combining two techniques helps to minimize pain during venipuncture for pediatric patients more than the use of a single technique. These results applied to preschoolers, school-aged children and adolescents.

Keywords: child life specialist, venipuncture, pain, distress

Most surgeries and many medical procedures commonly make use of some form of anesthesia to maximize patient comfort and safety. However, all are associated with risks. Obesity and related health care problems are relatively common in anesthesia and also have a negative effect on morbidity and mortality. Trends in pediatric obesity show increases in both the prevalence and risks for the development of other disease. Using the 1997 through 2009 Kids’ Inpatient Database (KID), this study will assess diagnostic codes to identify complications related to anesthesia in the obese pediatric population. Information gained from this study may serve to advance research and the development of anesthetic techniques to improve both safety and overall health for this population.

Orientador: Eliana Mara Braga
Banca: Maria Alice Ornellas Pereira
Banca: Lígia Gomes Fahl
Resumo: A hospitalização é uma experiência complexa e pode apresentar-se como agradável ou não, sendo agravada no caso de necessidade de intervenção cirúrgica, principalmente quando o paciente é criança. Na prática, observa-se todo um movimento de reorganização pessoal do paciente e de seus familiares para enfrentar esse momento. Quando a cirurgia é suspensa, o paciente e seus familiares estão sujeitos a um desconforto maior, que pode gerar sentimentos de insegurança, angústia e ansiedade. Este estudo teve como objetivo identificar e descrever a percepção de quinze mães e/ou responsáveis por crianças de 0 a 18 anos, internadas num hospital de ensino do interior do Estado de São Paulo, após receberem a notícia de que a cirurgia de seu filho (a) seria suspensa. Foi um estudo descritivo com abordagem qualitativa, que utilizou o referencial teórico da Comunicação Interpessoal e o referencial metodológico da Análise de Conteúdo. Os resultados evidenciaram que as suspensões de cirurgias pediátricas são um fato presente na instituição, que trazem repercussões ao paciente e seus familiares e à organização institucional; que a comunicação entre profissionais da equipe de saúde, pacientes e familiares sobre procedimentos a serem realizados ou não, é inadequada; que a atuação da enfermagem no momento da notícia da suspensão da cirurgia precisa ser pontual e efetiva.
Abstract: Hospitalization is a complex experience which may or may not be agreeable; this can be made worse if surgical intervention is required, especially when the patient is a child. In practice a personal struggle can be seen in the patient and family to brave this moment. When surgery is suspended, the patient and family are subjected to a stronger discomfort, which can cause feelings of insecurity, distress, and anxiety. The objective of this study was to identify and describe the perceptions of fifteen mothers or guardians of children between 0 and 18 years old admitted in a teaching hospital in the interior of São Paulo State Brazil, after receiving news that surgery for their child was suspended. This was a descriptive qualitative study which used Interpersonal Communication as theoretical reference and Analysis of Content as the methodology. Results showed that suspension of pediatric surgery in our institution causes repercussions to patients, their families, and institution organisation; that communication between health team professionals, patients and families about procedures to be performed or not performed, is inadequate; and that nursing action at the moment when news of surgery suspension is given must be prompt and effective.
Mestre

Na minha experiência profissional na assistência, em uma instituição hospitalar da rede estadual de saúde do Rio de Janeiro especializada em cardiologia, cuidando de crianças com cardiopatias congênitas, vivenciei algumas situações decorrentes da falta de orientação dos acompanhantes. A partir de então, surgiram alguns questionamentos quanto a que tipo de informação esses acompanhantes recebem quando chegam, a saber, que a criança será submetida a uma cirurgia e o que pode vir a acontecer com ela. Desse modo, o enfermeiro ao recepcioná-los na instituição hospitalar precisa atentar para alguns aspectos tais como: o acompanhante entender o que se passa com a criança desde a condição de saúde até o procedimento cirúrgico; além do que poderá ocorrer naquele contexto da internação. Nesse sentido, tracei como objeto de estudo o atendimento no ambulatório de cirurgia cardíaca pediátrica, e o objetivo de compreender a expectativa do acompanhante que vem para o atendimento no ambulatório de cirurgia cardíaca. Dessa forma, foi possível a apreensão do típico da ação do acompanhante que traz a criança ao atendimento no ambulatório de cirurgia cardíaca. Trata-se de estudo de caráter exploratório-descritivo, do tipo qualitativo, baseado fundamentalmente na fenomenologia sociológica de Alfred Schutz. Os sujeitos foram as acompanhantes de crianças que realizaram cirurgia cardíaca e que retornaram para a revisão ambulatorial. A entrevista fenomenológica foi o instrumento utilizado para a captação das falas desses sujeitos, que, na relação face a face, possibilitou a descrição de suas experiências vivenciadas e a apreensão do típico da ação desses atores sociais. Para tanto foi utilizada a seguinte questão orientadora que permitiu a captação do motivo para: Quais as suas expectativas quanto ao atendimento quando vem ao ambulatório? Assim, o típico da ação que surgiu das falas das acompanhantes de criança que se submeteram à cirurgia cardíaca é obter uma boa notícia. Essas mulheres têm em comum ter um filho que se submeteu à cirurgia cardíaca e essa vivência faz com que algumas delas tenham a preocupação de ter que passar por isto novamente, ou seja, seu filho realizar outra cirurgia cardíaca. Elas esperam que isto não ocorra, ou então, que o intervalo entre as consultas se prolongue para que o retorno delas à unidade hospitalar seja cada vez menor. Acredito que uma abordagem da enfermagem na consulta ambulatorial poderá diminuir as tensões criadas nessas acompanhantes pela expectativa de saber se a criança vai reinternar para realizar uma cirurgia ou não, e os esclarecimentos quanto aos cuidados domiciliares que podem auxiliar na tranqüilidade dessas mulheres. Deste modo, penso que o enfermeiro deva realizar a assistência à saúde centrada na criança e na pessoa que a acompanha ressaltando que o cuidar envolve todo o contexto entre a criança e o que está ao seu redor, ou seja, a acompanhante.
In my professional experience in assistance, in a state hospital specialized in Cardiology, taking care of children with congenital cardiopathy, I lived situations that occurred from less orientation to the companions. Then, surged some questions about what kind of information this companion receive when they know that the child will suffer a surgery and what can happen to them. Thus, when the nurse receive them, in the hospital, has to pay attention in some aspects as: the companion understand what happen with the child since the health condition of the child until the surgery procedure, besides what can occur in the hospitalization context. In this sense I traced as the object the study of the ambulatory of pediatric cardiopathy surgery, and the objective to comprehend the companion expectative that come from the attending of pediatric surgery cardiopathy. In this way, was possible the apprehensions of the typical actions of the companion that brought the child to the attending of cardiac surgery ambulatory. It is a study with descriptive - exploratory character, of qualitative type, fundamentally based on the Sociological Phenomenology of Alfred Schutz. The subjects were the companions of the children that suffered cardiac surgery and returned from the ambulatory review. The phenomenological interview was the tool utilized to suck in the speeches from this subjects, that in the face to face relation was enabled to comprehend the descriptions of the vivencial experiences and to apprehend the typical action of this social actors. Therefore utilized the orientation question that permitted the capitation of purpose-for: Which are your expectative for the attending when you come back to the ambulatory? Then the typical action grew up from the words of the child companions that suffered a cardiac surgery is to obtain a good news. These women has in common to have a child that suffered a cardiac surgery and this vivencial makes them with the preoccupation that must pass the same situation again, otherwise, the child has to suffer another cardiac surgery. They hope that this does not occur or the gap between the meetings become more distant and the return of them to the hospital become minor. I believe that the nursing approach at the nursing meeting can make less the tensions created in this companions from the expectative of knowing that the child would hospitalize to do another surgery or not, and the information about the homecare that can help them to make more tranquilized. Thus I think that the nurse must realize the health assistance centered on the child and the person who accompany jutting out that the care involves the entire context among the child and what is around, or else, the companion.

According to the pediatric medical traumatic stress model, pediatric medical experiences can create posttraumatic stress symptoms (PTSS) in pediatric patients and in their parents and siblings. While the impact of traumatic medical experiences has been studied in parents of children with a variety of pediatric conditions, little is known about how the resulting PTSS may affect parenting. The relational PTSD model suggests that suboptimal parenting patterns can result from parental PTSS. One condition with high potential for traumatic medical events is critical congenital heart disease (CHD), which requires open heart surgery during infancy. This qualitative study examined the experience of parental PTSS and parenting in a sample of parents (N=12; 4 fathers, 8 mothers) of children with critical CHD. Using interpretive phenomenological analysis, focus group data were analyzed to determine 1) the ways in which CHD has affected parents’ lives; 2) the parents’ experience of PTSS related to CHD; 3) parenting patterns; and 4) the relationships between parental PTSS and parenting patterns. The following themes emerged: seeking/receiving social support, giving back, positive changes, overprotective and permissive parenting, and lasting effects of the traumatic medical experiences. Parents reported experiencing PTSS from all four PTSD symptom clusters. In addition, vicarious trauma and continuous traumatic stress were reported. Parents reported parenting patterns of overprotection and permissiveness; overprotection was suggested by the relational PTSD model. Finally, parenting a child with CHD was found to be a gendered experience, with fathers and mothers reporting different experiences on a variety of themes. Clinical considerations include the importance of parent to parent support, the different experiences of fathers and mothers, and the need to screen for PTSS among parents of children with CHD. Future research should consider quantitative studies with larger samples to assess the relationship between PTSD and parenting in this population.

This project was designed to investigate the ability of newborn infants to respond to surgical stress and to consider alternative methods of anaesthetic management in view of their hormonal and metabolic response. Concentrations of blood metabolites (glucose, lactate, pyruvate, alanine, acetoacetate, 3-hydroxybutyrate, glycerol, non-esterified fatty acids, triglycerides) and plasma hormones (insulin, glucagon, noradrenaline, adrenaline, aldosterone, corticosterone, cortisol, 11-deoxycorticosterone, 11-deoxycortisol, progesterone, 17-hydroxyprogesterone, cortisone) were measured in blood samples drawn before and after surgery, at 6, 12 and 24 hours postoperatively. Urinary total nitrogen and 3-methylhistidine/ creatinine ratios were measured for 3 days postoperatively. Peri-operative management was standardised and severity of surgical stress was assessed by a scoring method. In a preliminary study of 29 neonates, substantial hormonal and metabolic changes demonstrated the ability of neonates to mount a stress response to surgery. Compared to adult responses, the magnitude of these changes was greater but their duration was remarkably short-lived. Significant differences were found between preterm and term neonates, and between neonates given different anaesthetic management. Randomised controlled trials were designed for studying the effects of : (1) halothane anaesthesia in 36 neonates undergoing general surgical procedures, (2) fentanyl anaesthesia in 16 preterm neonates undergoing ligation of patent ductus arteriosus, (3) high-dose fentanyl anaesthesia in 13 neonates undergoing cardiac surgery. On comparing the responses of neonates within each trial, the stress response of neonates given halothane or fentanyl anaesthesia was diminished; their : (a) catecholamine responses were decreased or abolished, (b) glucocorticoid responses were suppressed, (c) changes in blood glucose and gluconeogenic precursors were decreased, (d) postoperative analgesic requirements were reduced, and (e) their clinical condition after surgery was more stable. The neonatal response was related to the severity of surgical stress, as assessed by the scoring method. Thus, hormonal and metabolic changes following surgery in preterm and term neonates are distinctly different from those of adult patients; the lack of adequate anaesthesia may cause an accentuation of the stress response.

Objective measurement of the subglottic lumen is still lacking in clinical practice. The objective of this study is to evaluate the accuracy of ultrasound and video-bronchoscopy in measuring the subglottic diameter in the pediatric population. This was a blind, prospective clinical study. Ten children undergoing non-life threatening bronchoscopy had their subglottic diameters measured with ultrasound, video-bronchoscopy and endotracheal tube sizing.
Ultrasound and video-bronchoscopy strongly correlated with endotracheal tube sizing in measuring the subglottic diameter. Ultrasound had measurements that were always smaller while video-bronchoscopy had measurements that were slightly larger than endotracheal tube sizing. Video-bronchoscopy may be more accurate than endotracheal tube sizing as the latter method will often underestimate the size of the lumen due to its own limitations. The smaller values obtained by ultrasound suggest it is not ideal to give absolute measurements in this area, but rather a potential tool to detect change of lumen size on follow-up.

Introducció. La infecció de ferida quirúrgica (IFQ) és una infecció relacionada amb l’assistència sanitària freqüent, amb important impacte clínic. El bon ús de la profilaxi antibiòtica quirúrgica (PAQ) ha demostrat ser una mesura eficaç en la disminució de la incidència de la IFQ. Tot i això, la adherència a les guies de PAQ és subòptima, amb un ús excessiu d’antibiòtics. Tots els programes PROA (adults; pediàtrics) han de comptar amb una línia de treball estratègica per a millorar la PAQ. Des de l’instuticionalització del PROA pediàtric del nostre centre (PROA-NEN) en 2015, l’optimització de la PAQ fou un objectiu clau. Objectiu: avaluar l’impacte de la intervenció d’un programa PROA específic pediàtric (PROA-NEN) en la qualitat de la PAQ i de la incidència d’IFQ d’un hospital pediàtric de tercer nivell. Pacients i mètodes. Estudi prospectiu, quasiexperimental, unicèntric, a un hospital pediàtric de tercer nivell. Es van incloure pacients pediàtrics no nounats, sotmesos a cirurgies no ambulatòries durant 5 períodes d’estudi de 21 dies cadascú (2016-2018). S’analitzaren variables basals dels pacients i de les cirurgies realitzades. L’anàlisi de la qualitat de la PAQ es va realitzar amb indicadors de procés i de resultat. Els indicadors de procés van ser els publicats per l’ECDC al 2013: disponibilitat d’un equip multidisciplinar destinat a la implantació de la PAQ, disponibilitat d’un responsable del compliment de la PAQ dins de quiròfan, l’adequació temporal de la PAQ, adequació de la indicació, tipus d’antibiòtic i redosificació intraoperatòria de la PAQ i la durada de la PAQ. Referent als indicadors de resultat, es va calcular el consum d’antibiòtics a la PAQ a través de DOT (dies de tractament) i com indicador clínic es va avaluar la incidència d’IFQ. Resultats. S’analitzaren 425 cirurgies (62 preintervenció i 363 posintervenció), de totes les especialitats quirúrgiques pediàtriques. Un total de 403 pacients, 56,6% de sexe masculí, amb una mediana d’edat de 6,3 anys, (p25: 2,1, p75: 11,9). Segons el grau de contaminació, un 72% foren cirurgies netes, un 20%, netes-contaminades i un 8%, brutes. En un 52% la PAQ estava indicada. Referent a l’anàlisis posterior, va haver una millora generalitzada de tots els indicadors de procés. L’adequació en el moment de l’administració de la dosi preoperatòria va augmentar des d’un 34,4% fins al 49,2% (p=0,12). Es va observar un ascens en l’adequació de la indicació de la PAQ, des d’un 77% fins a un 91,5% (p=0,002). Amb una millora significativa en la no administració de la PAQ quan no estava indicada (des d’un 54,5% fins a un 87% d’adequació, p=0,001). En referència a l’ús adequat de l’antibiòtic, va haver un augment del compliment, del 67,5% fins al 91,4% a la posintervenció (p=0,001). La durada de la PAQ, inferior a les 24 hores, va ser adequada en un 67,6% durant el període preintervenció i en un 79,5% posteriorment (p=0,129). El compliment complet de la PAQ va augmentar significativament des d’un 31,5% fins a un 57% (p<0,005). Pel que fa al consum dels antibiòtics a les àrees quirúrgiques, es va veure una tendència al descens, amb DOT/100 estades de 69 durant el periode preintervenció i de 60, l’any 2018. Els resultats clínics van mostrar un índex d’infecció del 3 % en el primer període i del 0,8% després de la intervenció PROA-NEN. Conclusió. Una intervenció PROA, dirigida a la PAQ ha demostrat millorar la qualitat del seu ús, amb un descens del consum innecessari i inadequat dels antibiòtics administrats amb aquesta indicació amb un descens de incidència de la IFQ.
Introducción. La infección de la herida quirúrgica (IHQ) es una infección relacionada con la asistencia sanitaria frecuente, con importante impacto clínico. El buen uso de la profilaxis antibiótica quirúrgica (PAQ) ha demostrado ser una medida eficaz en la disminución de la incidencia de IHQ. No obstante, la adherencia a las guías de PAQ es subóptima, con un uso excesivo de los antibióticos. Todos los programas PROA (adultos y pediátricos) deben poseer una línea de trabajo estratégica para mejorar la PAQ. Desde la institucionalización del PROA pediátrico de nuestro centro (PROA-NEN) en 2015, la optimización de la PAQ fue un objetivo primordial. Objetivo: evaluar el impacto de una intervención de un programa PROA específico pediátrico (PROA-NEN) en la calidad de la PAQ y en la incidencia de IHQ en un hospital pediátrico de tercer nivel. Pacientes y métodos. Estudio prospectivo, cuasiexperimental, unicéntrico, de un hospital pediátrico de tercer nivel. Se incluyeron pacientes pediátricos no neonatales, sometidos a cirugías no ambulatorias durante 5 periodos de estudio de 21 días cada uno (2016-2018). Se analizaron variables basales de los pacientes y de las cirugías realizadas. El análisis de la calidad de la PAQ se realizó con indicadores de proceso y de resultado. Los indicadores de proceso fueron los publicados en 2013 por el ECDC: disponibilidad de un equipo multidisciplinar destinado a la implantación de la PAQ, disponibilidad de un responsable del cumplimiento de la PAQ intraquirófano, adecuación temporal de la PAQ, adecuación de la indicación, tipo de antibiótico y redosificación intraoperatoria de la PAQ y duración de la PAQ. Referente a indicadores de resultado, se midió el consumo del antibiótico en PAQ a través de DOT (días de tratamiento) y como indicador clínico se evaluó la incidencia de IHQ. Resultados. Se analizaron 425 cirugías (62 preintervención y 363 posintervención), de todas las especialidades quirúrgicas pediátricas. Un total de 403 pacientes, 56,6% de sexo masculino y con una mediana de edad de 6,3 años, (p25: 2,1, p75: 11,9 años). Según el grado de contaminación, un 72% fueron cirugías limpias, un 20%, limpias-contaminadas y un 8%, sucias. En un 52% la PAQ estaba indicada. Referente al análisis posterior, hubo una mejora generalizada de todos los indicadores de proceso. La adecuación en el tiempo de administración de la PAQ previo a la cirugía aumentó desde un 34,4% hasta el 49,2% (p=0,12). Se observó una mejora en la adecuación de la indicación de la PAQ, desde un 77% hasta un 91,5% (p=0,002). Con una mejoría significativa en la no administración de la PAQ cuando no estaba indicada (desde un 54,5% a un 87% de adecuación, p=0,001). En referencia al uso adecuado del antibiótico, hubo un aumento del cumplimiento, del 67,5% al 91,4% posintervención (p=0,001). La duración de la PAQ, inferior a las 24 horas, fue adecuada en el 67,6% en el periodo preintervención y en un 79,5% posteriormente (p=0,129). El cumplimiento completo de la PAQ aumentó de manera significativa desde un 31,5% hasta un 57% (p<0,005). En cuanto al consumo de antibióticos en las áreas quirúrgicas, se observó una tendencia al descenso, con DOT/100 estancias de 69 en el periodo preintervención, y de 60, en el año 2018. Los resultados clínicos mostraron un índice de infección del 3 % en el primer periodo y del 0,8% tras la intervención PROA-NEN. Conclusión. Una intervención PROA, dirigida a la PAQ ha demostrado mejorar la calidad de su uso, con un descenso del consumo innecesario e inadecuado de los antibióticos administrados con dicha indicación, y disminuir la incidencia de IHQ.
Introduction. Surgical site infection (SSI) is a common healthcare-related infection with significant clinical impact. The correct use of surgical antibiotic prophylaxis (SAP) has proven to be an effective measure in reducing the incidence of SSI. However, adherence to SAP guidelines is suboptimal, with excessive use of antibiotics. All antibiotic stewardship programs (ASP) must have a strategic line of work to improve SAP. Since the institutionalization of the paediatric ASP of our centre (PROA-NEN) in 2015, the optimization of the SAP has been a primary objective. Objective: to evaluate the impact of an intervention of a specific paediatric ASP (PROA-NEN) on the quality of the SAP and on the incidence of SSI in a tertiary paediatric hospital. Patients and methods. A prospective, quasi-experimental, single-centre study of a third-level paediatric hospital. Non-neonatal paediatric patients, who underwent non-ambulatory surgeries during 5 study periods of 21 days each (2016-2018), were included. Baseline variables of the patients and the surgeries performed were analysed. The analysis of the quality of the SAP was carried out with process and result indicators. The process indicators were those published in 2013 by the ECDC: availability of a multidisciplinary team for the implementation of the SAP, availability of a person responsible for compliance with the intraoperative SAP, temporal adequacy of the SAP, adequacy of the indication, type of antibiotic and intraoperative redosing of SAP and duration of SAP. Regarding outcome indicators, the consumption of the antibiotic in SAP was measured through DOT (days of treatment) and the incidence of SSI was evaluated as a clinical indicator. Results. 425 surgeries were analysed (62 pre-intervention and 363 post-intervention), from all paediatric surgical specialties. A total of 403 patients, 56.6% male and with a median age of 6.3 years ( p25: 2,1, p75: 11,9 years) According to the degree of contamination, 72% were clean surgeries, 20% were clean-contaminated and 8% were dirty. In 52% the SAP was indicated. Regarding the subsequent analysis, there was a general improvement of all the process indicators. The adequacy in the time of administration of the SAP prior to surgery increased from 34.4% to 49.2% (p = 0.12). An improvement in the adequacy of the SAP indication is projected, from 77% to 91.5% (p = 0.002). With a significant improvement in not administering SAP when it was not indicated (from 54.5% to 87% of adequacy, p = 0.001). Regarding the appropriate use of the antibiotic, there was an increase in compliance, from 67.5% to 91.4% post-intervention (p = 0.001). The duration of the PAQ, less than 24 hours, was adequate in 67.6% in the pre-intervention period and in 79.5% afterwards (p = 0.129). Complete compliance with the SAP increased significantly from 31.5% to 57% (p <0.005). Regarding the consumption of antibiotics in surgical areas, a downward trend is shown, with DOT / 100 stays of 69 in the pre-intervention period, and 60, in 2018, in the first period and 0.8% after the PROA-NEN intervention. Conclusion: An ASP intervention, aimed at SAP has been shown to improve the quality of its use, with a decrease in the unnecessary and inappropriate use of antibiotics administered with this indication, with decreasing the incidence of SSI.
Universitat Autònoma de Barcelona. Programa de Doctorat en Pediatria, Obstetrícia i Ginecologia

Thesis (M.A.)--Boston University
Objective: Despite extensive literature on chronic pain in surgical and nonsurgical adult patient populations and in the pediatric nonsurgical patient population, the acute to chronic postsurgical pain transition in children has been a largely neglected area of research. The purpose of this study was to examine the prevalence of persistent postsurgical pain in patients with adolescent idiopathic scoliosis who undergo spinal fusion surgery and to explore baseline differences between patients in varying longitudinal pain trajectories. Methods: The Scoliosis Research Society Questionnaire-30, which includes pain, self- image, mental health, and activity subscales, was administered to 219 patients at a large Northeast children’s hospital preoperatively and at one- and two-years postoperatively through their involvement in the Prospective Pediatric Scoliosis Study. A subset of these patients (n=77) also completed follow-up data at five-years post-surgery. Pain among this sample (in the past six months, in the past month, and at rest) was examined at each of the time points. Longitudinal pain trajectories were identified using the SAS PROC TRAJ procedure, and trajectory groups were compared for baseline differences in age, self-image, and mental health functioning through one-way analysis of variance and post- hoc analyses. Results: Preoperative pain was high in this sample, with 36% of patients prior to surgery reporting pain in the past month. The number of patients reporting pain in the past month postoperatively fell to 13% at one-year post-surgery but increased to 17% and 20% respectively at two- and five-years follow-up. A five-trajectory model emerged with a “no pain” group, a “pain improvement” group, a “short-term pain” group, a “delayed pain” group, and a “high pain” group with significant differences in baseline age (p<.01), self-image (p<.01), and mental health functioning (p<.01) found across groups. Conclusions: The study suggests that pediatric persistent postsurgical pain is potentially a significant health concern. This study also provides preliminary evidence that baseline psychosocial factors may contribute to patients’ longitudinal pain experiences postoperatively. Efforts should be taken to better understand the role that these predictors play in the emergence of persistent postsurgical pain in pediatric surgical patients and to explore how biological factors affect somatosensory phenotypes in this patient population.

The purpose of this thesis was to investigate the impact of enteral nutrition (EN) support factors on days of mechanical ventilation (MV) and length of stay (LOS) in a pediatric intensive care unit (PICU) among subjects age 3 7 weeks to 21 years. Specifically, nutrition support factors included a) days to reach prescribed calories, b) days to reach prescribed protein, c) percentage of prescribed calories received, and d) percentage of prescribed protein received through the use of EN.

Purposive sampling was used to select subjects that received nutrition support in the PICU. Data was collected via chart review within the time frame January 1, 2011 to August 1, 2013.

The results demonstrated MV days and LOS were significantly different for patients who reached prescribed calories and protein within 72 hours of admission. LOS was also significantly different for patients who received at least 80% prescribed calories.

Pressure ulcers are a hospital-acquired condition with reported incidence of up to 27% in acutely ill infants and children, who are particularly vulnerable during long periods of immobilization. Pressure is a key risk factor for pressure ulcer formation and pressure-redistributing surfaces are used in the clinical setting to mitigate this risk. However, there is a lack of information on the most effective surfaces available to redistribute pressure in pediatric patients, especially because the occiput is the highest risk location for pediatric patients, while the sacrum and heels are at highest risk for adults. The aim of this research is to evaluate the pressure-redistributing properties of surfaces used to redistribute pressure under the bony prominence of the occiput of hospitalized pediatric patients through pressure mapping experiments on healthy children.

A commercially available pressure mapping system is validated for use in the pediatric population through studies on sensitivity, accuracy, creep and repeatability. Then, the capacitive pressure sensor is used to measure mean peak pressure and contact area between the occipital region of the skull of children under 6 years old and each of four pressure-redistributing surfaces: gel, foam, fluidized, and air cushion. Lastly, finite element analysis is performed to simulate the pressure generated on the occiput during contact with a foam surface for two loading conditions. Predictions from the finite element model are compared to experimental pressure mapping data. The results of this study provide clinical recommendations for pediatric pressure ulcer prevention protocols.

Наук. кер.: Д.В. Овечкін
Останні десятиліття спостерігається стрімкий розвиток дитячої хірургії Сумщини, з’являються її нові напрями, відбувається вдосконалення медичного обладнання та лікувально-діагностичних методик. Не припиняється науково-педагогічна робота, завдяки якій область повністю забезпечує себе висококласними фахівцями відповідного профілю та ведеться підготовка лікарів-дитячих хірургів навіть для інших країн світу. Проте, досі в науковій літературі не існує жодного дослідження, присвяченого історії розвитку дитячої хірургії Сумщини, хоча знання основних віх минулого свого фаху є невід’ємною складовою лікаря - професіонала. При цитуванні документа, використовуйте посилання http://essuir.sumdu.edu.ua/handle/123456789/27364

This thesis reports a series of laboratory and clinical studies designed to investigate the acute effect of surgical palliation on ventricular function in children with functionally single ventricle anatomy. Ventricular volume and pressure were measured using a combined pressure-conductance catheter. Initial laboratory-based experiments were performed using a physical model of the left ventricle, which allowed examination of the measurement techniques used in the clinical studies but under controlled conditions. These experiments identified a non-linear conductance-absolute volume relationship and demonstrated for the first time that the calibration coefficient, \(\alpha_{SV}\) produced a significant, volume-dependent measurement error. These experiments also demonstrated that conductance volume measurements were adversely influenced by other electrical signals. The ventricular electrogram produced clinically important measurement error that has not previously been described. Two clinical studies were then undertaken to investigate the separate effects of the bidirectional cavo-pulmonary anastomosis (BCPA) and the completion total cavo-pulmonary connection (TCPC). These studies represent the core of the thesis. Both procedures were associated with significant changes in the pressure and volume conditions of the dominant ventricle. In addition, the BCPA was associated with a substantial and immediate improvement in ventricular systolic function but this was accompanied by an increase in diastolic chamber stiffness. By contrast, the TCPC was not associated with a significant change ventricular systolic or diastolic function in spite of the changes in ventricular load. Comparable changes were observed in patients with a dominant ventricle of either left or right ventricular morphology. These studies provide a more detailed understanding about the acute events that accompany surgical palliation in children with functionally single ventricle anatomy. These findings confirm the validity of staged surgical palliation in the management of these children.

CHAPTER ONE: The literature review critically evaluates research that has explored the psychological impact of parental acquired brain injury (ABI) on children. The review identifies a number of factors that affect the psychological well-being of children, including both adverse and protective factors. Evidence from the studies reviewed indicates that children are vulnerable to experiencing a range of emotional and behavioural difficulties following parental ABI. Clinical implications of the review findings are discussed, and directions for future research considered. CHAPTER TWO: The empirical paper aimed to explore the role of mutual support in Traumatic Brain Injury (TBI) survivors’ reformation of their identity among individuals attending a mutual support group. Using a Grounded Theory approach, a model of the participants experience was developed. The core category reflected how participants regained a sense of self through getting to know the “new” me. Five conceptual categories were identified in relation to identity formation: pre-injury self, comparison with others; accessing the social world of brain injury; purpose and self-efficacy; and acceptance of the post-injury self. The findings highlight a potentially important role for mutual support in identity reformation following TBI and implications for brain injury rehabilitation programmes are discussed. CHAPTER THREE: The third paper presents my personal and professional reflections of the research process and how my views have changed over the course of training. To illustrate these changes, elements of the grounded theory model proposed in the empirical paper (Chapter 2) have been applied to my own experiences. It is hoped that this approach will evidence my experience and exploration of getting to know the scientist-practitioner.

Secondary malnutrition, due to an underlying disease or disorder, is a considerable concern for medical staff when a child is resident at a hospital. Nutrition for growth of the child is in competition with necessary nutrition used during metabolic stress. The intention of this investigation is to indicate if nutrition goals are being met to prevent or improve acute malnutrition, and if further investigation is necessary for potential hospital wide intervention. The data obtained includes goal rates (80-110% of prescribed caloric goals) of nutrition administered to patients (ages 2-18 years) on enteral nutrition, parenteral nutrition, and a combination of enteral and parenteral nutrition on the 7^th day of admission during a singular calendar year. An audit of existing electronic records for 2011 of the pediatric hospital identified approximately 50% of patients were meeting 80-110% of their prescribed caloric goals to help prevent or manage existing malnutrition.