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Mack SJ, Pace DJ, Patil S, Cooke-Barber J, Berman L, Boelig MM. Association of Age at Duodenal Atresia Repair With Outcomes: A Pediatric NSQIP Analysis. J Pediatr Surg 2024; 59:18-25. [PMID: 37833211 DOI: 10.1016/j.jpedsurg.2023.09.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 09/06/2023] [Indexed: 10/15/2023]
Abstract
PURPOSE Neonates with duodenal atresia (DA) are often born prematurely and undergo repair soon after birth, while others are delayed to allow for growth until closer to term corrected gestational age (cGA). Premature infants have been demonstrated to experience worse outcomes, but it is unclear whether delaying surgery mitigates the increased morbidity. This study evaluates the association of timing of DA repair with postoperative morbidity. METHODS We retrospectively evaluated neonates undergoing DA repair from the National Surgical Quality Improvement Program-Pediatric database (2015-2020). A multivariable regression analyzed factors associated with composite morbidity, including cGA and age in days of life (DOL) at surgery. A propensity score matched analysis was completed in premature neonates born at ≤35 weeks gestation to compare outcomes at similar birth gestational ages (bGA) and birth weight who underwent early (<7 DOL) versus delayed (≥7 DOL) repair. RESULTS 809 neonates were included with a median bGA of 36 weeks (IQR 34-38), birth weight of 2.46 kg (IQR 1.96-2.95), and DOL at surgery of 2 (IQR 1-5). Infants born ≤35 weeks represented 35.23% of the cohort. On multivariable analysis, increasing cGA at surgery was associated with decreased morbidity (OR: 0.91, CI [0.84, 0.99]), and increasing DOL at surgery was associated with increased morbidity (OR: 1.02, CI [1.00, 1.04]). On propensity score matched analysis, delayed repairs were associated with increased postoperative ventilation (6 days vs. 2 days, p < 0.05); however, there were no differences in composite or surgical morbidity between early and delayed repairs. CONCLUSIONS Morbidity after DA repair in neonates ≤35 weeks cGA is primarily driven by non-surgical causes, but delaying surgery does not appear to mitigate the risks associated with prematurity. It seems reasonable to consider repair in neonates around 33-34 weeks gestation without prohibitive risk factors. Optimal timing of DA repair requires a delicate balance between these factors. LEVEL OF EVIDENCE Level III. TYPE OF STUDY Retrospective Cohort Study.
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Affiliation(s)
- Shale J Mack
- Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA, USA.
| | - Devon J Pace
- Thomas Jefferson University Hospital, Philadelphia, PA, USA; Department of Surgery, Nemours Children's Health, Wilmington, DE, USA
| | - Sanath Patil
- Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA, USA
| | - Jo Cooke-Barber
- Department of Surgery, Nemours Children's Health, Wilmington, DE, USA
| | - Loren Berman
- Department of Surgery, Nemours Children's Health, Wilmington, DE, USA
| | - Matthew M Boelig
- Department of Surgery, Nemours Children's Health, Wilmington, DE, USA
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Archer VA, Samiee-Zafarghandy S, Farrokyhar F, Briatico D, Braga LH, Walton JM. Intravenous acetaminophen for postoperative pain in the neonatal intensive care unit: A protocol for a pilot randomized controlled trial (IVA POP). PLoS One 2023; 18:e0294519. [PMID: 37983228 PMCID: PMC10659208 DOI: 10.1371/journal.pone.0294519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Accepted: 10/20/2023] [Indexed: 11/22/2023] Open
Abstract
BACKGROUND In neonates, uncontrolled pain and opioid exposure are both correlated with short- and long-term adverse events. Therefore, managing pain using opioid-sparing approaches is critical in neonatal populations. Multimodal pain control offers the opportunity to manage pain while reducing short- and long-term opioid-related adverse events. Intravenous (IV) acetaminophen may represent an appropriate adjunct to opioid-based postoperative pain control regimes. However, no trials assess this drug in patients less than 36 weeks post-conceptual age or weighing less than 1500 g. OBJECTIVE The proposed study aims to determine the feasibility of conducting a randomized control trial to compare IV acetaminophen and fentanyl to a saline placebo and fentanyl for patients admitted to the neonatal intensive care unit (NICU) undergoing major abdominal or thoracic surgery. METHODS AND DESIGN This protocol is for a single-centre, external pilot randomized controlled trial (RCT). Infants in the NICU who have undergone major thoracic or abdominal surgery will be enrolled. Sixty participants will undergo 1:1 randomization to receive intravenous acetaminophen and fentanyl or saline placebo and fentanyl. After surgery, IV acetaminophen or placebo will be given routinely for eight days (192 hours). Appropriate dosing will be determined based on the participant's gestational age. Patients will be followed for eight days after surgery and will undergo a chart review at 90 days. Primarily feasibility outcomes include recruitment rate, follow-up rate, compliance, and blinding index. Secondary clinical outcomes will be collected as well. CONCLUSION This external pilot RCT will assess the feasibility of performing a multicenter RCT comparing IV acetaminophen and fentanyl to a saline placebo and fentanyl in NICU patients following major abdominal and thoracic surgery. The results will inform the design of a multicenter RCT, which will have the appropriate power to determine the efficacy of this treatment. TRIAL REGISTRATION ClinicalTrials.gov NCT05678244, Registered December 6, 2022.
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Affiliation(s)
- Victoria Anne Archer
- Division of General Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada
| | | | | | - Daniel Briatico
- Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - Luis H. Braga
- Division of Urology, McMaster University, Hamilton, ON, Canada
| | - J. Mark Walton
- Division of Pediatric General Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada
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Disma N, Veyckemans F, Virag K, Hansen TG, Becke K, Harlet P, Vutskits L, Walker SM, de Graaff JC, Zielinska M, Simic D, Engelhardt T, Habre W. Morbidity and mortality after anaesthesia in early life: results of the European prospective multicentre observational study, neonate and children audit of anaesthesia practice in Europe (NECTARINE). Br J Anaesth 2021; 126:1157-1172. [PMID: 33812668 DOI: 10.1016/j.bja.2021.02.016] [Citation(s) in RCA: 77] [Impact Index Per Article: 25.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 02/15/2021] [Accepted: 02/21/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Neonates and infants requiring anaesthesia are at risk of physiological instability and complications, but triggers for peri-anaesthetic interventions and associations with subsequent outcome are unknown. METHODS This prospective, observational study recruited patients up to 60 weeks' postmenstrual age undergoing anaesthesia for surgical or diagnostic procedures from 165 centres in 31 European countries between March 2016 and January 2017. The primary aim was to identify thresholds of pre-determined physiological variables that triggered a medical intervention. The secondary aims were to evaluate morbidities, mortality at 30 and 90 days, or both, and associations with critical events. RESULTS Infants (n=5609) born at mean (standard deviation [sd]) 36.2 (4.4) weeks postmenstrual age (35.7% preterm) underwent 6542 procedures within 63 (48) days of birth. Critical event(s) requiring intervention occurred in 35.2% of cases, mainly hypotension (>30% decrease in blood pressure) or reduced oxygenation (SpO2 <85%). Postmenstrual age influenced the incidence and thresholds for intervention. Risk of critical events was increased by prior neonatal medical conditions, congenital anomalies, or both (relative risk [RR]=1.16; 95% confidence interval [CI], 1.04-1.28) and in those requiring preoperative intensive support (RR=1.27; 95% CI, 1.15-1.41). Additional complications occurred in 16.3% of patients by 30 days, and overall 90-day mortality was 3.2% (95% CI, 2.7-3.7%). Co-occurrence of intraoperative hypotension, hypoxaemia, and anaemia was associated with increased risk of morbidity (RR=3.56; 95% CI, 1.64-7.71) and mortality (RR=19.80; 95% CI, 5.87-66.7). CONCLUSIONS Variability in physiological thresholds that triggered an intervention, and the impact of poor tissue oxygenation on patient's outcome, highlight the need for more standardised perioperative management guidelines for neonates and infants. CLINICAL TRIAL REGISTRATION NCT02350348.
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Affiliation(s)
- Nicola Disma
- Department of Anaesthesia, Unit for Research & Innovation, Istituto Giannina Gaslini, Genova, Italy.
| | - Francis Veyckemans
- Département d'Anaesthésie-Réanimation pédiatrique, Hôpital Jeanne de Flandre, CHRU de Lille, Lille, France
| | - Katalin Virag
- Department of Medical Physics and Informatics, University of Szeged, Szeged, Hungary
| | - Tom G Hansen
- Department of Anaesthesia and Intensive Care -Paediatrics, Odense University Hospital, Odense, Denmark; Department of Clinical Research - Anaesthesiology, University of Southern Denmark, Odense, Denmark
| | - Karin Becke
- Department of Anaesthesia and Intensive Care, Cnopf Children's Hospital/Hospital Hallerwiese, Nürnberg, Germany
| | - Pierre Harlet
- Research Department, European Society of Anaesthesiology, Brussels, Belgium
| | - Laszlo Vutskits
- Department of Anaesthesiology, Pharmacology, Intensive Care and Emergency Medicine, University Hospitals of Geneva, Geneva, Switzerland; University of Geneva, Geneva, Switzerland
| | - Suellen M Walker
- Department of Anaesthesia and Pain Management, Great Ormond Street Hospital NHS Foundation Trust, London, United Kingdom
| | - Jurgen C de Graaff
- Department of Anesthesia, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Marzena Zielinska
- Department of Paediatric Anaesthesiology and Intensive Care, Wroclaw Medical University, Wroclaw, Poland
| | - Dusica Simic
- Department of Pediatric Anesthesia and Intensive Care, University Children's Hospital, Medical Faculty University of Belgrade, Belgrade, Serbia
| | - Thomas Engelhardt
- Department of Anaesthesia, Montreal Children's Hospital, Montreal, QC, Canada
| | - Walid Habre
- Department of Anaesthesiology, Pharmacology, Intensive Care and Emergency Medicine, University Hospitals of Geneva, Geneva, Switzerland; University of Geneva, Geneva, Switzerland
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Risk factors of early mortality after neonatal surgery in Tunisia. J Pediatr Surg 2020; 55:2233-2237. [PMID: 32654833 DOI: 10.1016/j.jpedsurg.2020.05.035] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Revised: 05/19/2020] [Accepted: 05/29/2020] [Indexed: 11/21/2022]
Abstract
BACKGROUND Research concerning factors of death after neonatal surgery is scarce. Insight into mortality might improve perioperative care. This study aimed to identify predictive factors of mortality after neonatal surgery in a low income country (LIC). METHODS Charts of all newborn patients who underwent surgical procedures under general anesthesia during the neonatal period in our department of pediatric surgery between January 2010 and December 2017 were reviewed. We used univariate and multivariate analysis to evaluate perioperative variables potentially predictive of early postoperative mortality. RESULTS One hundred eighty-two cases were included in the study: 41 newborns (28.6%) were premature (<37 weeks of gestation) and 52 (22.5%) weighed less than 2.5 kg. The most commonly diagnosed conditions were esophageal atresia (24%) and bowel obstruction (19%). Forty-four patients (24%) died during hospitalization. The highest rate of mortality was observed for congenital diaphragmatic hernia. Univariate analysis showed that perinatal predictive variables of mortality were prematurity, low birth weight, the necessity of preoperative intubation, and duration of surgery more than 2 h. Logistic regression showed three independent risk factors, which are the duration of surgery, low birth weight and the necessity of preoperative intubation. CONCLUSION The overall mortality in infants undergoing neonatal surgery is still high in LICs. Knowledge of independent risk factors of early mortality may help clinicians to more adequately manage the high-risk population. TYPE OF THE STUDY Clinical research paper. LEVEL OF EVIDENCE III.
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Mpody C, Shepherd EG, Thakkar RK, Dairo OO, Tobias JD, Nafiu OO. Synergistic effects of sepsis and prematurity on neonatal postoperative mortality. Br J Anaesth 2020; 125:1056-1063. [PMID: 32868040 DOI: 10.1016/j.bja.2020.07.026] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Revised: 07/01/2020] [Accepted: 07/02/2020] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION Compared with term neonates, preterm babies are more likely to die from sepsis. However, the combined effects of sepsis and prematurity on neonatal postoperative mortality are largely unknown. Our objective was to quantify the proportion of neonatal postoperative mortality that is attributable to the synergistic effects of preoperative sepsis and prematurity. METHODS We performed a multicentre, propensity-score-weighted, retrospective, cohort study of neonates who underwent inpatient surgery across hospitals participating in the United States National Surgical Quality Improvement Program-Pediatric (2012-2017). We assessed the proportion of the observed hazard ratio of mortality and complications that is attributable to the synergistic effect of prematurity and sepsis by estimating the attributable proportion (AP) and its 95% confidence interval (CI). RESULTS We identified 19 312 neonates who realised a total of 321 321 person-days of postsurgical observations, during which 683 died (mortality rate: 2.1 per 1000 person-days). The proportion of mortality risk that is attributable to the synergistic effect of prematurity and sepsis was 50.5% (AP=50.5%; 95% CI, 28.8-72.3%; P < 0.001). About half of mortality events among preterm neonates with sepsis occurred within 24 h after surgery. Just over 45% of postoperative complications were attributable to the synergistic effect of prematurity and sepsis when both conditions were present (AP=45.8; 95% CI, 13.4-78.1%; P<0.001). CONCLUSION Approximately half of postsurgical mortality and complications were attributable to the combined effect of sepsis and prematurity among neonates with both exposures. These neonates typically died within a few days after surgery, indicating a very narrow window of opportunity to predict and prevent mortality. CLINICAL TRIAL NUMBER AND REGISTRY Not applicable.
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Affiliation(s)
- Christian Mpody
- Department of Anaesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA
| | - Edward G Shepherd
- Comprehensive Center for Bronchopulmonary Dysplasia, Nationwide Children's Hospital, Columbus, OH, USA
| | - Rajan K Thakkar
- Department of Pediatric Surgery, Nationwide Children's Hospital, Columbus, OH, USA
| | - Olamide O Dairo
- Department of Anaesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA
| | - Joseph D Tobias
- Department of Anaesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA
| | - Olubukola O Nafiu
- Department of Anaesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA.
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Berry MJ, Port LJ, Gately C, Stringer MD. Outcomes of infants born at 23 and 24 weeks' gestation with gut perforation. J Pediatr Surg 2019; 54:2092-2098. [PMID: 31072679 DOI: 10.1016/j.jpedsurg.2019.03.017] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2018] [Revised: 02/25/2019] [Accepted: 03/24/2019] [Indexed: 11/17/2022]
Abstract
PURPOSE The provision of neonatal intensive care to infants born at 23 or 24 weeks' gestation poses medical, surgical and ethical challenges. Gastrointestinal perforation is a well-recognized complication of preterm birth, occurring most often as a result of necrotizing enterocolitis (NEC) or spontaneous intestinal perforation (SIP). Given the risk of morbidity and mortality in these 'periviable' infants, this complication may prompt transition from active management to palliative care. In our institution, the surgical care of periviable infants with gut perforation has not been dictated by gestational age. This study reports our outcomes. METHODS A retrospective cohort analysis of integrated neonatal medical and surgical care of all infants born between 23+0 and 24+6 weeks' gestation admitted to a tertiary level neonatal intensive care unit (NICU) during a 16 year period (2002-2017). RESULTS A total of 198 periviable neonates (73 born at 23 weeks' gestation and 125 born at 24 weeks) were admitted during the 16-year period; most were inborn with only 26 retrieved from regional centers. Twenty-six of these infants developed gut perforation: 14 SIP, 8 NEC, 3 esophageal perforation and one after reduction of an incarcerated inguinal hernia. Twelve (46%) periviable infants with gut perforation survived to discharge home, seven of whom had no/mild disability at 2-3 years corrected gestational age. Of the 198 periviable infants admitted to NICU, 116 (58%) were alive at a corrected gestational age of 2-3 years and 29 of the 56 (51%) assessed had mild or no disability. CONCLUSIONS In the setting of combined medical and surgical care in a tertiary level NICU almost half of all periviable infants with a gut perforation survived, many with no/mild disability at 2-3 years corrected gestational age. Rigid protocols that rely on gestational age alone to guide treatment are not appropriate. These results support the contention that, when possible, extremely preterm infants should be born and cared for in units with combined medical and surgical expertise. LEVEL OF EVIDENCE Level III cohort study.
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Affiliation(s)
- Mary J Berry
- Neonatal Intensive Care Unit, Wellington Hospital and Department of Paediatrics and Child Health, University of Otago, Wellington, New Zealand
| | - Laura J Port
- Neonatal Intensive Care Unit, Wellington Hospital and Department of Paediatrics and Child Health, University of Otago, Wellington, New Zealand
| | - Callum Gately
- Neonatal Intensive Care Unit, Wellington Hospital and Department of Paediatrics and Child Health, University of Otago, Wellington, New Zealand
| | - Mark D Stringer
- Neonatal Intensive Care Unit, Wellington Hospital and Department of Paediatrics and Child Health, University of Otago, Wellington, New Zealand.
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