Progress in anesthesia and management of the newborn surgical patient

Impact of propofol versus sevoflurane anesthesia on molecular subtypes and immune checkpoints of glioma during surgery

Background

Sevoflurane and propofol are two popular anesthetics used during glioblastoma (GBM) surgery. This investigation compared the molecular subtypes and immune checkpoints of cancer cells following GBM surgery under sevoflurane and propofol anesthesia.

Method

The expression profile data and clinical information of glioma samples of different grades were downloaded from The Cancer Genome Atlas database. Weighted gene coexpression network analysis was used to identify hub modules and key genes related to glioma grades (G2 and G3). The GEO database (GSE179004) was used to retrieve glioma surgical specimens with different anesthetic gene expression profiles. The differential expression of immune checkpoint genes under various anesthetic settings was examined using the R-ggplot2.

Results

Compared to sevoflurane, propofol significantly downregulated SERPINI1 and CAMK2A expression. These are also important factors in glioma grading. Simultaneously, SERPINI1 and CAMK2A were also significantly related to the prognosis of GBM and lower-grade glioma patients and acted as potential tumor suppressors. In addition, propofol increases the expression of the immune checkpoint molecule, PD-L1.

Conclusions

Our study revealed that sevoflurane can more effectively prevent the development of glioma after surgery than propofol, and SERPINI1 can be used as a new independent prognostic factor for glioma.

Neurodevelopmental outcomes in individuals with VACTERL association. A population-based cohort study

BACKGROUND

Studies on neurodevelopmental outcomes in individuals with congenital anomalies who undergo neonatal surgery are scarce and have reported contradictory findings based on small study groups. The congenital condition VACTERL association includes at least three malformations: vertebral anomalies, anorectal malformations, cardiac defects, tracheoesophageal fistula with or without esophageal atresia, renal anomalies and limb deformities. Most of these patients undergo surgery during their first days of life. Neurodevelopmental disorders include a broad group of disabilities involving some form of disruption to brain development. Attention deficit hyperactivity disorder (ADHD), autism spectrum disorders (ASD) and intellectual disability (ID) are diagnoses included in this group. The aim of the study was to investigate the risk of ADHD, ASD and ID in a cohort of individuals with VACTERL association.

METHOD

Data was obtained from four Swedish national health registers and analyzed using the Cox proportional hazards model. Patients born 1973-2018 in Sweden with the diagnosis of VACTERL association were included in the study. For each case five healthy controls matched for sex, gestational age at birth, birth year and birth county were obtained.

RESULTS

The study included 136 individuals with VACTERL association and 680 controls. Individuals with VACTERL had significantly higher risk of ADHD, ASD and ID than the controls; 2.25 (95% CI, 1.03-4.91), 5.15 (95% CI, 1.93-13.72) and 8.13 (95% CI, 2.66-24.87) times respectively.

CONCLUSIONS

A higher risk of ADHD, ASD and ID was found among individuals with VACTERL association compared to controls. These results are of importance to caregivers and to professionals participating in follow ups of these patients in providing early diagnosis and support, aiming to optimize the quality of life of these patients.

Perioperative outcomes in minimally-invasive versus open surgery in infants undergoing repair of congenital anomalies

BACKGROUND

This study compared perioperative outcomes among infants undergoing repair of congenital anomalies using minimally invasive (MIS) versus open surgical approaches.

METHODS

The ACS NSQIP Pediatric (2013-2018) was queried for patients undergoing repair of any of the following 9 congenital anomalies: congenital lung lesion (LL), mediastinal mass (MM), congenital malrotation (CM), anorectal malformation (ARM), Hirschsprung disease (HD), congenital diaphragmatic hernia (CDH), tracheoesophageal fistula (TEF), hepatobiliary anomalies (HB), and intestinal atresia (IA). Inverse probability of treatment weights (IPTW) derived from propensity scores were utilized to estimate risk-adjusted association between surgical approach and 30-day outcomes.

RESULTS

12,871 patients undergoing congenital anomaly repair were included (10,343 open; 2528 MIS). After IPTW, MIS was associated with longer operative time (difference; 95% CI) (16 min; 9-23) and anesthesia time (13 min; 6-21), but less postoperative ventilation days (-1.0 days; -1.4- -0.6) and shorter postoperative length of stay (-1.4 days; -2.4- -0.3). MIS repairs had decreased risk of any surgical complication (risk difference: -6.6%; -9.2- -4.0), including hematologic complications (-7.3%; -8.9- -5.8). There was no significant difference in risk of complication when hematologic complications were excluded (RD -2.3% [-4.7%, 0.1%]). There were no significant differences in the risk of unplanned reoperation (0.4%; -1.5-2.2) or unplanned readmission (0.2%; -1.2-1.5).

CONCLUSIONS

MIS repair of congenital anomalies is associated with improved perioperative outcomes when compared to open. Additional studies are needed to compare long-term functional and disease-specific outcomes.

MINI-ABSTRACT

In this propensity-weighted multi-institutional analysis of nine congenital anomalies, minimally invasive surgical repair was associated with improved 30-day outcomes when compared to open surgical repair.

LEVEL OF EVIDENCE

III.

Growth and risk of adverse neurodevelopmental outcome in infants with congenital surgical anomalies: a systematic review

Survival of infants with congenital anomalies requiring surgical correction has increased dramatically, shifting the focus of clinical care and research toward optimising growth and neurodevelopment.To determine the impact of growth on neurodevelopmental outcomes of infants with congenital surgical anomalies. Studies that reported association of growth with developmental outcomes in infants with congenital anomalies who had surgery, were eligible for inclusion. The search strategy was prospectively drafted, and relevant studies were identified by electronic searches. The Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library 2022, issue 1), MEDLINE and EMBASE from their earliest date to February 2022 were searched. Seven studies met the inclusion criteria. Variability in selection of growth measures, developmental assessment tools and assessment endpoints for neurodevelopment, precluded a meta-analysis. Four studies reported the association between growth and neurodevelopmental outcomes in infants with gastroschisis with two noting adverse outcomes in infants who were small for gestational age. Birthweight, reported in four studies, was not associated with adverse developmental outcomes. Postnatal growth, reported in three studies, was associated with adverse outcome. The data linking growth restriction in infants with congenital surgical anomalies and neurodevelopmental outcome is limited. There is limited published research examining the longitudinal effects of intra- and extra-uterine growth parameters on neurodevelopmental outcomes.

MicroRNA-424-5p Alleviates Isoflurane Anesthesia-Induced Neurotoxicity in Human Embryonic Stem Cell-Derived Neurons by Targeting FASN

Isoflurane (ISO) is a type of anesthetic that might cause neurotoxicity in children. Although miR-424-5p is considerably downregulated in ISO-treated rat brain samples, its physiological role in ISO-induced neuronal injury in human embryonic stem cell-derived neurons remains unknown (hESC-derived neurons). miR-424-5p expression and fatty acid synthase (FASN) in ISO-treated hESC-derived neurons were tested via qRT-PCR. The amount of protein for Bax, Cleaved-caspase-8, Bcl-2, and FASN was investigated through western blot analysis. The viability and apoptosis of hESC-derived neurons were estimated through cell counting kit-8 assessment and TUNEL assay, accordingly. Superoxide dismutase, glutathione, and malondialdehyde levels were discovered via corresponding kits. The contents of inflammatory factors including interleukin-6 and tumor necrosis factor-α were examined by enzyme-linked immunosorbent assays. The combination between FASN and miR-424-5p was resolute via dual-luciferase reporter assessment. After exposure to ISO, induced neurotoxicity and a decreased miR-424-5p production were identified in hESC-derived neurons. Upregulation of miR-424-5p repressed ISO-induced apoptosis and mitigated ISO-induced inflammatory response and oxidative stress in vitro. FASN expression levels were reduced by elevation of miR-424-5p and upregulated after ISO treatment. Mechanically, FASN was directly targeted by miR-424-5p in hESC-derived neurons. Of note, the miR-424-5p elevation-suppressed neuronal apoptosis, inflammatory response, and oxidative stress were countered by upregulation of FASN.

Understanding of the transition to adult healthcare services among individuals with VACTERL association in Sweden: A qualitative study

Current knowledge of transitional care from the perspective of individuals with congenital malformations is scarce. Their viewpoints are required for the development of follow-up programs and transitional care corresponding to patients’ needs. The study aimed to describe expectations, concerns, and experiences in conjunction with transfer to adult health care among adolescents, young adults, and adults with VACTERL association, (i.e. vertebral defects, anorectal malformations (ARM), cardiac defects (CHD), esophageal atresia (EA), renal, and limb abnormalities). Semi-structured telephone interviews were performed and analyzed with qualitative content analysis. Of 47 invited individuals, 22 participated (12 males and 10 females). An overarching theme emerged: Leaving the safe nest of pediatric health care for an unfamiliar and uncertain follow up yet growing in responsibility and appreciating the adult health care. The participants described expectations of qualified adult health care but also concerns about the process and transfer to an unfamiliar setting. Individuals who were transferred described implemented or absence of preparations. Positive and negative experiences of adult health care were recounted including being treated as adults. The informants described increasing involvement in health care but were still supported by their parents. Ongoing follow up of health conditions was recounted but also uncertainty around the continuation, missing follow up and limited knowledge of how to contact health care. The participants recommended information ahead of transfer and expressed wishes for continued health care with regular follow up and accessibility to a contact person. Based on the participants’ perspective, a transitional plan is required including early information about transfer and follow up to prepare the adolescents and reduce uncertainty concerning future health care. Meetings with the pediatric and adult team together with the patient and the parents are essential before transfer. Follow up should be centralized to centers with multi-professional teams well-experienced with the condition. Further studies are warranted to evaluate the transition process for adolescents and young adults with complex congenital health conditions.

Neonatal Surgical Morbidity and Mortality at a Single Tertiary Center in a Low- and Middle-Income Country: A Retrospective Study of Clinical Outcomes

Background

The most challenging and demanding issue in Pediatrics and Pediatric Surgery is to deal with neonatal surgery which almost always involves emergency neonatal surgical conditions. Emergency neonatal surgery most often involves congenital anomalies. More than 90% of these anomalies occur in low- and middle-income countries (LMICs) like Bangladesh. This considerable load of patients and inadequate resources in their management continue to be an unconquerable challenge for pediatric and neonatal surgeons in this region. We aim to review the challenges and constraints influencing the outcomes of emergency neonatal surgery which will guide to propose expectations from the global community.

Method

We reviewed hospital records of neonates admitted to a tertiary care pediatric hospital between January 2016 and December 2020. Demographic and clinical data were extracted using a questionnaire and analyzed using SPSS 25.

Results

A total of 3,447 neonates were admitted during the five-year study period. More than 80% of the patients had at least one prenatal ultrasonography (USG) scan, but less than 10% had a prenatal diagnosis. More than 70% of the anomalies of the patient involved the gastrointestinal tract and abdominal wall. Overall mortality was an alarming 14.6%. Gastroschisis (>90%) and esophageal atresia (>85%) mainly contributed to this high mortality. The challenges detected in this review were the absence of a prenatal diagnosis, limited access to intensive care facilities, unavailability of parenteral nutrition, inadequate monitoring, and hospital-acquired sepsis.

Conclusion

Emergency neonatal surgery contributes to a significant proportion of neonatal mortality. A holistic approach is essential to improve the situation, including the infrastructure and human resource development, identification of causes, and implementation of preventive measures to reduce the patient load. Global collaboration remains to be a vital factor to mitigate these multifactorial constraints.

Novel Use of a Bronchial Blocker in a Challenging Case of Congenital Diaphragmatic Hernia—A Case Report

The diagnosis of congenital diaphragmatic hernia (CDH) is associated with significant morbidity and mortality. Survival of neonates with CDH has improved recently, although the clinical course is complicated by sequelae of hypoplastic pulmonary parenchyma and vasculature, pulmonary hypertension, ventilation/perfusion (V/Q) mismatch, reduced pulmonary function and poor somatic growth. In this case report, we describe an infant with an antenatal diagnosis of CDH with a poor prognosis who underwent initial surgery followed by a tracheostomy but had a worsening clinical course due to a large area of ventilated but poorly perfused lung based on a V/Q nuclear scintigraphy scan. The emphysematous left lung was causing mediastinal shift and compression of the right lung, further compromising gas exchange. The infant had clinical improvement following bronchial blockade of the under-perfused left lung. This paved the way for further management with resection of the under-perfused lung lobe and continued clinical improvement. We present the novel use of selective bronchial blockade in a challenging case of CDH to determine if surgical lung resection may benefit the infant. We also review the physiology of gas exchange during the use of a bronchial occluder and the relevant literature.

Overexpression of miR-133b protects against isoflurane-induced learning and memory impairment

A number of microRNAs (miRs) have been identified as being involved in the regulation of anesthesia-induced cognitive impairment. The aim of the present study was to investigated the role and potential mechanism of miR-133b in isoflurane-induced learning and memory impairment. An animal model of isoflurane exposure was established using neonatal Sprague-Dawley rats. The rats were trained for Morris water maze (MWM) testing to assess their spatial learning and memory ability. Reverse transcription-quantitative polymerase chain reaction was used for the measurement of miR-133b expression in hippocampal tissues and primary hippocampal neuron cultures. Cell viability was assessed using a Cell Counting Kit-8 assay, and flow cytometric analysis was used to determine the rate of apoptosis. The MWM test results indicated that during the training period, the time required to locate the platform was significantly increased for rats exposed to isoflurane, and this increased time was reduced by the overexpression of miR-133b. The results of a probe trial indicated that isoflurane exposure increased escape latency and decreased the time spent in the platform area for isoflurane-treated rats; however, these effects were reversed by the injection of miR-133b agomir. The in vitro experiments demonstrated that the overexpression of miR-133b attenuated the reduction of neuronal cell viability induced by isoflurane, and inhibited the isoflurane-induced apoptosis of hippocampal neurons. In conclusion, the present study revealed that the overexpression of miR-133b attenuated isoflurane-induced learning and memory impairment in rats. Furthermore, miR-133b overexpression promoted the viability of hippocampal neurons and their resistance to apoptosis when exposed to isoflurane.

The bedside practice of sonographic guided internal jugular vein access in critically ill premature infants

BACKGROUND

Intrahospital transport, general anesthesia, and the prolonged duration of the central venous catheterization (CVC) in unfavorable conditions pose a significant risk to a critically-ill premature infant. We aimed to demonstrate a minimalized and safe manner of CVC in this patient population.

METHODS

We worked on a prospective study in 51 critically-ill premature infants in which a 22 Gauge catheter was put in one of the central thoracic veins with the guidance of sonography as a bedside procedure. Of the patients, 27 (53%) were extremely premature, and 21 (41%) were extremely low birth weight infants (ELBW). The mean gestational age was 29 ± 5 weeks, and the mean weight at the time of the procedure was 1655 ± 1028 grams. While no anesthetic and sedative drugs were administered to ELBW infants during procedures, in the remainder of the cohort, procedures were carried out only under sedoanalgesia.

RESULTS

Vascular access was achieved in 48 (94%) of the patients after a mean number of 1.47 ± 0.75 attempts. Body heat loss of the patients at the end of the procedures was not statistically significant (p=0.164). However, ELBW infants lost their body heat significantly more than the rest of the cohort (p=0.032). We experienced clinically insignificant common carotid artery puncture in three patients and hemothorax in one patient.

CONCLUSIONS

CVC of critically ill premature infants can be safely and successfully achieved in incubators using sonography guidance, protecting them from hypothermia and anesthetic drugs.

Risk factors of early mortality after neonatal surgery in Tunisia

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.

The role of the spinal cyclooxygenase (COX) for incisional pain in rats at different developmental stages

BACKGROUND

Cyclooxygenase enzymes (COX)-1 and COX-2 are important targets for pain relief after surgery, but the spinal contribution of both isoforms is still unclear, e.g., from a developmental point of view. Here, we studied changes of spinal COX-1 and COX-2 expression and their functional relevance in rats of different ages for pain-related behaviour after incision.

METHODS

Mechanical paw withdrawal thresholds (PWT) were assessed before and after incision and after intrathecal administration (IT) of SC-560 (COX-1 inhibitor) or NS-398 (COX-2 inhibitor) in rats aged 5, 14 and 28 days (P5, P14, P28). Furthermore, spinal expressions of COX m-RNA and proteins were investigated.

RESULTS

In P5 rats, only IT-administered NS-398 but not SC-560 significantly reversed the decreased PWT after incision. In P14 rats, none of the substance modified PWT, and in P28 rats, only SC-560 increased PWT. Spinal COX-2 mRNA and protein were increased in P5 but not in P14 and P28 rats after incision. Whereas COX-2 is located in spinal neurons, COX-1 is mainly found in spinal microglia cells.

CONCLUSION

Our results demonstrate a possible developmental transition from COX-2 to COX-1 activation. Whereas in adult rats spinal COX-1 but not COX-2 is involved in pain-related behaviour after incision, it seems opposite in P5 rats. Interestingly, in P14, neither COX-1 nor COX-2 seems to play a role. This switch may relate to altered neuronal/microglia activation. Our findings indicate specific mechanisms to pain after incision that are age-dependent and may guide further research improving paediatric pain management.

SIGNIFICANCE

Postoperative pain in pediatric patients after surgery is still poorly controlled; this might contribute to long-lasting alteration in the nociceptive system and prolonged chronic pain. Here we show a possible developmental switch in the COX-dependent pathway for nociceptive spinal transmission that may explain why pain management in young children needs to be related to age-dependent mechanisms.

Burden and Outcomes of Neonatal Surgery in Uganda: Results of a Five-Year Prospective Study

BACKGROUND

Ninety-four percent of congenital anomalies occur in low- and middle-income countries. In Uganda, only three pediatric surgeons and three pediatric anesthesiologists serve more than 20 million children. This study estimates burden, outcomes, coverage, and economic benefit of neonatal surgical conditions in Uganda.

METHODS

A prospectively collected database was reviewed for neonatal surgical admissions from January 1, 2012, to December 31, 2017, at the only two sites with specialist pediatric surgical coverage. Outcomes were compared with high-income countries. Met and unmet need were estimated using disability-adjusted life years. Economic benefit was estimated using a value of statistical life-year approach.

RESULTS

For 1313 neonatal admissions, the median age of presentation was 3 d, overall mortality was 36%, and median distance traveled was 40 km. Anorectal malformations were most common (18%). Postoperative mortality was 24%. Mortality was significantly associated with surgical intervention (P < 0.0001). Met need was 4181 disability-adjusted life years per year, which corresponds to a $3.5 million net economic benefit to Uganda, with a potential additional benefit of $153 million if unmet need were fully addressed. Approximately 2% of the total need is met by the health care system.

CONCLUSIONS

Neonatal surgery is associated with improved survival for most conditions. Despite increases in workforce and infrastructure, a limited proportion of the need for neonatal surgery is currently being met. This is multifactorial, including lack of access to surgical care and severe shortages of workforce and infrastructure. Current and potential economic benefit to Uganda appears substantial.

The disproportionate cost of operation and congenital anomalies in infancy

BACKGROUND

Congenital anomalies are the leading cause of infant death and pediatric hospitalization, but existing estimates of the associated costs of health care are either cross-sectional surveys or economic projections. We sought to determine the percent of total hospital health care expenditures attributable to major anomalies requiring surgery within the first year of life.

METHODS

Utilizing comprehensive California statewide data from 2008 to 2012, cohorts of infants undergoing major surgery, with birth defects and with surgical anomalies, were constructed alongside a referent group of newborns with no anomalies or operations. Cost-to-charge and physician fee ratios were used to estimate hospital and professional costs, respectively. For each cohort, costs were broken down according to admission, birth episode, and first year of life, with additional stratifications by birth weight, gestational age, and organ system.

RESULTS

In total, 68,126 of 2,205,070 infants (3.1%) underwent major surgery (n = 32,614) or had a diagnosis of a severe congenital anomaly (n = 57,793). These accounted for $7.7 billion of the $18.9 billion (40.7%) of the total health care costs/expenditures of the first-year-of-life hospitalizations, $7.0 billion (48.6%) of the costs for infants with comparatively long birth episodes, and $5.2 billion (54.7%) of the total neonatal intensive care unit admission costs. Infants with surgical anomalies (n = 21,264) totaled $4.1 billion (21.7%) at $80,872 per infant. Cardiovascular and gastrointestinal diseases accounted for most admission costs secondary to major surgery or congenital anomalies.

CONCLUSION

In a population-based cohort of infant births compared with other critically ill neonates, surgical congenital anomalies are disproportionately costly within the United States health care system. The care of these infants, half of whom are covered by Medi-Cal or Medicaid, stands as a particular focus in an age of reform of health care payments.

Spinal anaesthesia in neonates and infants: what about the cerebral oxygen saturation?

Background

Spinal Anaesthesia (SA) has been firmly established as an efficient and safe technique, with minimal cardio-respiratory disturbance when administered in the neonatal period. Our objective was to assess the haemodynamic consequences of SA in infants, particularly its impact on cerebral perfusion using near-infrared spectroscopy (NIRS)-based cerebral oximetry (rSco2).

Methods

All infants up to 60 weeks' postmenstrual age, whether formerly preterm or not, and undergoing spinal anaesthesia, were enrolled. Haemodynamic data records, rSco2 and mean arterial blood pressure (MAP), were prospectively collected before SA (T0) and every five min for 30 min (T30) after the puncture. Compared with baseline measures, any changes of > 10% in rSco2 and of > 20% in MAP were considered clinically significant. Relative variations of data between T0 and T30 were analysed.

Results

Data of 103 infants were analysed. The mean relative changes in rSco2 were -2.25% (97.5% CI [-3.97; -0.5]) at T15, and 0.11% (97.5% CI [-1.67; 1.90]) at T30. No significant variation of rSco2 was recorded. The mean changes in MAP were respectively -13.94% (97.5% CI [-17.74; -10.14]) at T15 and -20.27% (97.5% CI [-24,25; -16.29]) at T30. MAP decrease was statistically and clinically significant 30 min after SA. No correlation between changes in MAP and rSco2 was found. The subgroup analysis did not reveal any effect of added intrathecal clonidine or preterm birth history on these results.

Conclusions

In neonate and infants, SA did not cause clinically significant variation in cerebral oxygen saturation. Despite a significant decrease in MAP, cerebral auto-regulation seems to remain effective in neonates and not altered by spinal anaesthesia.

Preoperative cardiopulmonary evaluation in specific neonatal surgery

Preoperative assessment of surgical neonates often relates to issues of prematurity, low birth weight, or associated malformations. This review explores the preoperative cardiopulmonary evaluation in specific newborn surgical populations, the role of echocardiography in congenital diaphragmatic hernia perioperative management, the impact of bronchopulmonary dysplasia in the ex-preterm surgical neonate and a brief discussion on the risk of general anesthesia and specific anesthetic considerations for any surgical neonate. Newborns with congenital anomalies requiring early general surgical intervention should have an assessment for congenital heart disease. In the asymptomatic neonate, a thorough physical exam may be sufficient preoperatively. Neonates born with esophageal atresia or anorectal malformations should have a full evaluation for VACTERL associations. Initial echocardiography in congenital diaphragmatic hernia is used to evaluate anatomy, but there is emerging evidence to suggest the use of echocardiography in the ongoing surveillance of CDH to influence the timing of surgical intervention. Bronchopulmonary dysplasia is present in up to 40% of ex-premature neonates and increases the risk of postoperative apneas and need for ventilatory support. However, all surgical neonates have an increased risk of post-operative apneas, and the need for surgical intervention should be balanced with the risk of general anesthesia.

A different perspective: anesthesia for extreme premature infants: is there an age limitation or how low should we go?

PURPOSE OF REVIEW

To put in perspective, the various challenges that faces pediatric anesthesiologists because of the recently lowered limits with regards to the viability of a fetus. Both medical and ethical considerations will be highlighted.

RECENT FINDINGS

Issues related to: who should anesthetize these tiny babies; can we provide adequate and legal monitoring during the anesthetic; does these immature babies need hypnosis and amnesia and the moral/ethical implications associated with being involved with care of doubtful long-term outcome are reviewed.

SUMMARY

There does currently not exist sufficient research data to provide any evidence-based guidelines for the anesthetic handling of extreme premature infants. Current practice relies on extrapolations from other patient groups and from attempting to preserve normal physiology. Thus, focused research initiatives within this specific field of anesthesia should be a priority. Furthermore, in-depth multiprofessional ethical discussions regarding long-term outcome of aggressive care of extremely premature babies are urgently needed, including the new concepts of disability-free survival and number-need-to-suffer.

Neonatal surgery in a developing country: Outcome of co-ordinated interdisciplinary collaboration

AIM

Neonatal surgery in low-income and middle-income countries has a poorer outcome when compared with high-income countries. This study evaluated the management challenges and outcomes of neonatal surgery before and after the introduction of focused interdisciplinary team management in 2013.

METHODS

We retrospectively analysed neonatal surgery undertaken at two referral hospitals in Enugu, south-eastern Nigeria from January 2011 to November 2015. Cases managed prior to July 2013 (group A) were compared with those managed from July 2013 (group B).

RESULTS

There were 91 cases (group A, 47; group B, 44). The common neonatal conditions were oesophageal atresia (21), anorectal malformation (18) and intestinal atresia (18). The surgical conditions, birthweight, age at presentation and associated anomalies did not differ in the two groups. The treatment was also similar except in oesophageal atresia, where cardiac banding was added to the temporary gastrostomy in late presenting cases with undernutrition in group B. Postoperative complications occurred in 43 (47.3%) cases (group A, 55.3%; group B, 38.6%; P > 0.05), and the overall mortality was 33 (35.3%: group A, 48.9%; group B, 22.7%: P < 0.05). Causes of mortality were unremitting sepsis (group A, 11; group B, 5), anaesthesia complications (group A, 5; group B, 0) and respiratory complication (group A, 7; group B, 5). Delayed presentation, inadequate facilities and defective health insurance scheme were challenges in the two groups.

CONCLUSION

Despite the persisting challenges, co-ordinated team management may result in the modest improvement of outcomes of neonatal surgery in our setting. Addressing these challenges may further improve outcomes.

Immediate Sequential Bilateral Pediatric Vitreoretinal Surgery: An International Multicenter Study

PURPOSE

To determine the feasibility and safety of bilateral simultaneous vitreoretinal surgery in pediatric patients.

DESIGN

International, multicenter, interventional, retrospective case series.

PARTICIPANTS

Patients 17 years of age or younger from 24 centers worldwide who underwent immediate sequential bilateral vitreoretinal surgery (ISBVS)-defined as vitrectomy, scleral buckle, or lensectomy using the vitreous cutter-performed in both eyes sequentially during the same anesthesia session.

METHODS

Clinical history, surgical details and indications, time under anesthesia, and intraoperative and postoperative ophthalmic and systemic adverse events were reviewed.

MAIN OUTCOME MEASURES

Ocular and systemic adverse events.

RESULTS

A total of 344 surgeries from 172 ISBVS procedures in 167 patients were included in the study. The mean age of the cohort was 1.3±2.6 years. Nonexclusive indications for ISBVS were rapidly progressive disease (74.6%), systemic morbidity placing the child at high anesthesia risk (76.0%), and residence remote from surgery location (30.2%). The most common diagnoses were retinopathy of prematurity (ROP; 72.7% [P < 0.01]; stage 3, 4.8%; stage 4A, 44.4%; stage 4B, 22.4%; stage 5, 26.4%), familial exudative vitreoretinopathy (7.0%), abusive head trauma (4.1%), persistent fetal vasculature (3.5%), congenital cataract (1.7%), posterior capsular opacification (1.7%), rhegmatogenous retinal detachment (1.7%), congenital X-linked retinoschisis (1.2%), Norrie disease (2.3%), and viral retinitis (1.2%). Mean surgical time was 143±59 minutes for both eyes. Higher ROP stage correlated with longer surgical time (P = 0.02). There were no reported intraoperative ocular complications. During the immediate postoperative period, 2 eyes from different patients demonstrated unilateral vitreous hemorrhage (0.6%). No cases of endophthalmitis, choroidal hemorrhage, or hypotony occurred. Mean total anesthesia time was 203±87 minutes. There were no cases of anesthesia-related death, malignant hyperthermia, anaphylaxis, or cardiac event. There was 1 case of reintubation (0.6%) and 1 case of prolonged oxygen desaturation (0.6%). Mean follow-up after surgery was 103 weeks, and anatomic success and globe salvage rates were 89.8% and 98.0%, respectively.

CONCLUSIONS

This study found ISBVS to be a feasible and safe treatment paradigm for pediatric patients with bilateral vitreoretinal pathologic features when repeated general anesthesia is undesirable or impractical.

Challenges of management and outcome of neonatal surgery in Africa: a systematic review

BACKGROUND

Disparity still exists in the outcome of neonatal surgery between high-income countries and low-income and middle-income countries. This study reviews publications on neonatal surgery in Africa over 20 years with a focus on challenges of management, trends in outcome, and potential interventions to improve outcome.

METHODS

We did a literature review by searching PubMed and African Index Medicus for original articles published in any language between January 1995 and September 2014. A data extraction sheet was used to collect information, including type of study, demographics, number of cases, outcome, challenges, and suggestions to improve outcome.

RESULTS

A total of 51 studies from 11 countries met the inclusion criteria. The 16 studies in the first 10 years (1995-2004; group A) were compared with the 35 in the last 10 years (2005-2014; group B). Nigeria (n = 32; 62.7 %), South Africa (n = 7; 13.7 %), Tanzania (n = 2; 3.9 %), and Tunisia (n = 2; 3.9 %) were the predominant sources of the publications, which were retrospective in 38 (74.5 %) studies and prospective in 13 (25.5 %) studies. The mean sample size of the studies was 95.1 (range 5-640). Overall, 4849 neonates were studied, with median age of 6 days (range 1-30 days). Common neonatal conditions reported were intestinal atresia in 28 (54.9 %) studies, abdominal wall defects in 27 (52.9 %), anorectal malformations 25 in (49.0 %), and Hirschsprung's disease, necrotising enterocolitis, and volvulus neonatorum in 23 (45.1 %) each. Mortality was lowest (<3 %) in spina bifida and facial cleft procedures, and highest (>50 %) in emergency neonatal surgeries involving bowel perforation, bowel resection, congenital diaphragmatic hernia, oesophageal atresia, and ruptured omphalocele or gastroschisis. Overall average mortality rate was higher in group A than group B (36.9 vs 29.1 %; p < 0.001), and varied between the groups for some conditions. The major documented challenges were delayed presentation and inadequate facilities in 39 (76.5 %) studies, dearth of trained support personnel in 32 (62.7 %), and absence of neonatal intensive care in 29 (56.9 %). The challenges varied from country to country but did not differ in the two groups.

CONCLUSION

Improvement has been achieved in outcomes of neonatal surgery in Africa in the past two decades, although several of the studies reviewed are retrospective and poorly designed. Cost effective adaptations for neonatal intensive care, improved health-care funding, coordinated neonatal surgical care via regional centres, and collaboration with international partners are potential interventions that could help to address the challenges and further improve outcome.

Neonatal surgical care: a review of the burden, progress and challenges in sub-Saharan Africa

The outcome of neonatal surgery has significantly improved over the decades in high-income countries. In sub-Saharan Africa (SSA), however, it has lagged behind. This is a review of the current state of neonatal surgery in SSA. The conditions requiring surgery in the newborn are largely congenital but the rate of emergency surgery is high, reaching 40% of all neonatal surgery in some settings. Most operations are for intestinal obstruction, commonly owing to anorectal malformations and intestinal atresia, as well as abdominal wall defects. Many of the patients are delivered outside a hospital facility and often present or are referred late and are very ill at time of presentation. The morbidity following surgery is high, particularly from surgical site infections and respiratory problems. Mortality is high, sometimes reaching 45%, but has decreased in recent times. Because of a lack of trained paediatric anaesthetists, anaesthesia is often problematic and surgery is sometimes undertaken using a local anaesthetic. Further care, including bowel management and orthopaedic and neurological rehabilitation, are sub-optimal owing to a lack of appropriately trained personnel and financial constraints. While the number of paediatric surgeons has increased, there are still few anaesthetists. In order to significantly improve the outcome for neonates with surgical problems in SSA, paediatric surgery, anaesthesia, neonatology and neonatal nursing capacity need to be scaled up and fast-tracked. To make neonatal surgery safer in these settings, neonatal intensive care facilities need to be provided and improved.