Seminars in pediatric surgery
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Semin. Pediatr. Surg. · Feb 2015
ReviewControversies in nutritional support for critically ill children.
Nutritional support for critically ill infants and children is of paramount importance and can greatly affect the outcome of these patients. The energy requirement of children is unique to their size, gestational age, and physiologic stress, and the treatment algorithms developed in adult intensive care units cannot easily be applied to pediatric patients. This article reviews some of the ongoing controversial topics of fluid, electrolyte, and nutritional support for critically ill pediatric patients focusing on glycemic control and dysnatremia. The use of enteral and parenteral nutrition as well as parenteral nutritional-associated cholestasis will also be discussed.
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The use of Extracorporeal Life Support (ECLS) in children and adults has markedly increased during the past few years with over 4000 patients placed on ECLS every year in over 200 centers. This article focuses on updates to the physiology and mechanics of ECLS with use of magnetically levitated centrifugal pumps, hollow-fiber gas-exchange devices, and bi-caval dual-lumen catheters. We also explore controversies in management including indications, cannulation approaches, renal replacement, monitoring of anticoagulation, early ambulation, and termination of ECLS. Finally, we present changes in the systems that provide ECLS including the single-provider model and regionalization of care.
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Semin. Pediatr. Surg. · Feb 2015
Current concepts in acute respiratory support for neonates and children.
Current trends in mechanical respiratory support are evolving toward gentle approaches to avoid short- and long-term problems that are historically associated with mechanical ventilation. These ventilator-associated issues include the need for long-term sedation, muscle deconditioning, ventilator-associated lung injury (VALI), and ventilator-associated pneumonia (VAP). This article will describe recent trends of ventilatory support in neonates and children: (1) utilization of volume ventilation in infants, (2) synchrony and improving patient-ventilator interaction specifically using neurally adjusted ventilatory assist (NAVA), and (3) use of noninvasive ventilation techniques. When applicable, their uses in the surgical newborn and pediatric patients are described.
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The alleviation of pain and anxiety is an important component of caring for a critically ill child. Sedation and analgesia regimens are utilized as adjuncts to procedures, facilitate mechanical ventilation, and assist with management of a critically ill child. ⋯ Sedation regimens continue to be a challenging aspect of the care of a critically ill child, and they have been associated with significant morbidity in this population. This article will discuss the sedative use in the intensive care unit, morbidity associated with sedatives and analgesics, and the importance of establishing sedation and analgesia algorithms to reduce morbidity and mortality.
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Semin. Pediatr. Surg. · Dec 2014
ReviewEpidemiology of adhesions in infants and children following open surgery.
Adhesions following intra-abdominal surgery are a major cause of small bowel obstruction. The nature of surgical interventions in children (especially neonates) increases the risk of adhesion-related complications. Following laparotomy in neonates, the collective literature reveals an aggregate mean incidence of adhesive small bowel obstruction (ASBO) of 6.2%; malrotation, 14.2%; gastroschisis, 12.6%; necrotising enterocolitis, 10.4%; exomphalos, 8.6%; Hirschsprung's disease, 8.1%; congenital diaphragmatic hernia, 6.3% and intestinal atresia, 5.7%. In children beyond the neonatal period, the aggregate mean incidence was 4.7%; colorectal surgery, 14%; open fundoplication, 8.2%; small bowel surgery, 5.7%; cancer surgery, 5.5%; choledochal cyst, 3.1%; appendicectomy, 1.4% and pyloromyotomy, 0.1%.