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Lee J, Zhou E, Davis RL, Ouyang Y, Lin HM, Yudkowitz FS. Bleeding and Ketorolac Use in Pediatric Circumcision. Paediatr Anaesth 2023; 33:481-485. [PMID: 36892424 DOI: 10.1111/pan.14661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Revised: 03/01/2023] [Accepted: 03/03/2023] [Indexed: 03/10/2023]
Abstract
BACKGROUND Circumcision is a common surgical procedure performed among pediatric male patients. Ketorolac is an effective adjunct in multimodal regimens for postoperative pain control. However, many urologists and anesthesiologists refrain from administering ketorolac due to concern for postoperative bleeding. AIMS Compare the risk of clinically significant bleeding after circumcision with and without intraoperative ketorolac administration. METHODS A single center, retrospective cohort study was conducted of pediatric patients 1-18 years of age who underwent isolated circumcision by one urologist from 2016 to 2020. Clinically significant bleeding was defined as bleeding requiring intervention within the first 24 hours of circumcision. Interventions included use of absorbable hemostats, placement of sutures, or return to the operating room. RESULTS Of 743 patients, 314 (42.3%) did not receive ketorolac and 429 (57.7%) received intraoperative ketorolac 0.5 mg/kg. Postoperative bleeding requiring intervention occurred in one patient (0.32%) in the non-ketorolac group versus four patients (0.93%) in the ketorolac group (Difference 0.6%, 95% CI (-0.8%, 2.0%), p=0.403). CONCLUSIONS There was one patient (0.32%) with postoperative bleeding requiring intervention in the non-ketorolac group versus four patients (0.93%) in the ketorolac group (Difference 0.6%, 95% CI (-0.8%, 2.0%), p=0.403). As bleeding was a rare outcome, this study was not powered to detect a statistically significant difference between the two groups. Future studies regarding the association between ketorolac and postoperative bleeding are needed.
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Affiliation(s)
- Jennifer Lee
- Department of Anesthesiology, Perioperative, and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Eric Zhou
- Department of Anesthesiology, Perioperative Care & Pain Medicine, NYU Langone Health, NYU Grossman School of Medicine, New York, NY, United States
| | - Renee L Davis
- Department of Anesthesiology, Perioperative, and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Yuxia Ouyang
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Hung-Mo Lin
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Francine S Yudkowitz
- Department of Anesthesiology, Perioperative, and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, United States
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Politis GD, Gregory G, Yudkowitz FS, Fisher QA, Bhettay AZ, Wexler A. 2020 guidelines for conducting plastic reconstructive short-term surgical projects in low-middle income countries. Paediatr Anaesth 2020; 30:1308-1321. [PMID: 32621783 DOI: 10.1111/pan.13960] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 06/11/2020] [Accepted: 06/27/2020] [Indexed: 11/30/2022]
Abstract
Many low- or middle-income countries (LMICs) continue to suffer from a lack of safe and timely essential and emergency surgery despite growing attention to this problem. Short-term surgical projects (STSPs) continue to play an important role in addressing LMIC unmet surgical need and strengthening local healthcare systems. Guidelines here present recommendations for performing plastic reconstructive STSPs for pediatric patients in a safe, ethical, and effective manner. These guidelines represent consensus physician expert opinions, assembled collaboratively by members of Volunteers in Plastic Surgery and the Society for Pediatric Anesthesia's global health committee, with broad input from physicians practicing daily in LMICs. Organizations must partner with hosts to thoughtfully plan and carefully execute STSPs. We outline crucial items to STSP success, including choice of host facility, team selection, patient selection, staffing, ensuring proper equipment and supplies, disinfecting reusable equipment, creation of a safety culture, and data collection for quality assessment/improvement and research. Patient factors are discussed and recommendations given for developing exclusion criteria, as well as for determining which patients and procedures may require the team to include expertise in pediatric anesthesia or critical care. We recommend that educational opportunities for hosts are sought and advanced to optimize education/training at both the resident and post-trainee levels. Host education during STSPs has become crucial as LMICs ramp up training at a time when their surgical volumes remain grossly behind well-resourced countries. Recommendations here aim to assist organizations, hosts, and volunteers as they navigate the enormously complex and ever changing STSP environment. Patient safety and transfer of knowledge and skills should be central concerns of all who participate in this highly rewarding endeavor.
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Affiliation(s)
- George D Politis
- Department of Anesthesiology, University of Virginia Health System, Charlottesville, Virginia, USA
| | - George Gregory
- Department of Anesthesia & Perioperative Care, University of California, San Francisco, California, USA
| | - Francine S Yudkowitz
- Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, Mount Sinai Hospital, New York, New York, USA
| | - Quentin A Fisher
- Department of Anesthesiology, Pain, and Perioperative Medicine, Children's National Medical Center, Washington, District of Columbia, USA
| | - Anisa Z Bhettay
- Department of Anaesthesia and Perioperative Medicine, Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa
| | - Andrew Wexler
- Department of Plastic and Reconstructive Surgery, Kaiser Permanente, Los Angeles, California, USA.,Division of Plastic and Reconstructive Surgery, University of Southern California, Los Angeles, California, USA
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Butler M, Drum E, Evans FM, Fitzgerald T, Fraser J, Holterman AX, Jen H, Kynes M, Kreiss J, McClain CD, Newton M, Nwomeh B, O'Neill J, Ozgediz D, Politis G, Rice H, Rothstein D, Sanchez J, Singleton M, Yudkowitz FS. Guidelines and checklists for short-term missions in global pediatric surgery: Recommendations from the American Academy of Pediatrics Delivery of Surgical Care Global Health Subcommittee, American Pediatric Surgical Association Global Pediatric Surgery Committee, Society for Pediatric Anesthesia Committee on International Education and Service, and American Pediatric Surgical Nurses Association, Inc. Global Health Special Interest Group. Paediatr Anaesth 2018; 28:392-410. [PMID: 29870136 DOI: 10.1111/pan.13378] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/15/2018] [Indexed: 12/19/2022]
Abstract
Pediatric surgeons, anesthesia providers, and nurses from North America and other high-income countries are increasingly engaged in resource-limited areas, with short-term missions as the most common form of involvement. However, consensus recommendations currently do not exist for short-term missions in pediatric general surgery and associated perioperative care. The American Academy of Pediatrics (AAP) Delivery of Surgical Care Subcommittee and American Pediatric Surgical Association (APSA) Global Pediatric Surgery Committee, with the American Pediatric Surgical Nurses Association, Inc. (APSNA) Global Health Special Interest Group, and the Society for Pediatric Anesthesia (SPA) Committee on International Education and Service generated consensus recommendations for short-term missions based on extensive experience with short-term missions. Three distinct, but related areas were identified: (i) Broad goals of surgical partnerships between high-income countries and low- and middle-income countries. A previous set of guidelines published by the Global Paediatric Surgery Network Collaborative (GPSN) was endorsed by all groups; (ii) Guidelines for the conduct of short-term missions were developed, including planning, in-country perioperative patient care, post-trip follow-up, and sustainability; and (iii) travel and safety considerations critical to short-term mission success were enumerated. A diverse group of stakeholders developed these guidelines for short-term missions in low- and middle-income countries. These guidelines may be a useful tool to ensure safe, responsible, and ethical short-term missions given increasing engagement of high-income country providers in this work.
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Affiliation(s)
- Marilyn Butler
- Division of Pediatric Surgery, Department of Surgery, Oregon Health & Science University, Portland, OR, USA
| | - Elizabeth Drum
- Department of Anesthesiology & Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
| | - Faye M Evans
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | | | - Jason Fraser
- Department of Pediatric Surgery, Children's Mercy Hospital, Kansas City, MO, USA
| | - Ai-Xuan Holterman
- Division of Pediatric Surgery, University of Illinois College of Medicine at Peoria, Peoria, IL, USA
| | - Howard Jen
- Division of Pediatric Surgery, University of California, Los Angeles, CA, USA
| | - Matthew Kynes
- Department of Anesthesia, Vanderbilt Children's Hospital, Vanderbilt University, Nashville, TN, USA
| | - Jenny Kreiss
- Division of Pediatric Surgery, Seattle Children's Hospital, Seattle, WA, USA
| | - Craig D McClain
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Mark Newton
- Department of Anesthesia, Vanderbilt Children's Hospital, Vanderbilt University, Nashville, TN, USA.,Department of Anesthesiology and Pediatrics, Kijabe Hospital, Kijabe, Kenya
| | - Benedict Nwomeh
- Department of Pediatric Surgery, Nationwide Children's Hospital, Columbus, OH, USA
| | - James O'Neill
- Department of Pediatric Surgery, Vanderbilt University, Nashville, TN, USA
| | - Doruk Ozgediz
- Section of Pediatric Surgery, Yale University, New Haven, CT, USA
| | - George Politis
- Department of Anesthesiology, University of Virginia Health System, Charlottesville, VA, USA
| | - Henry Rice
- Division of Pediatric Surgery, Duke University, Durham, NC, USA
| | - David Rothstein
- Division of Pediatric Surgery, Children's Hospital of Buffalo, Buffalo, NY, USA
| | - Julie Sanchez
- Division of Pediatric Surgery, University of Texas at Austin, Austin, TX, USA
| | - Mark Singleton
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Pal Alto, CA, USA.,Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, CA, USA
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Butler M, Drum E, Evans FM, Fitzgerald T, Fraser J, Holterman AX, Jen H, Kynes JM, Kreiss J, McClain CD, Newton M, Nwomeh B, O'Neill J, Ozgediz D, Politis G, Rice H, Rothstein D, Sanchez J, Singleton M, Yudkowitz FS. Guidelines and checklists for short-term missions in global pediatric surgery: Recommendations from the American Academy of Pediatrics Delivery of Surgical Care Global Health Subcommittee, American Pediatric Surgical Association Global Pediatric Surgery Committee, Society for Pediatric Anesthesia Committee on International Education and Service, and American Pediatric Surgical Nurses Association, Inc. Global Health Special Interest Group. J Pediatr Surg 2018; 53:828-836. [PMID: 29223665 DOI: 10.1016/j.jpedsurg.2017.11.037] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2017] [Revised: 11/05/2017] [Accepted: 11/06/2017] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Pediatric surgeons, anesthesia providers, and nurses from North America and other high-income countries (HICs) are increasingly engaged in resource-limited areas, with short-term missions (STMs) as the most common form of involvement. However, consensus recommendations currently do not exist for STMs in pediatric general surgery and associated perioperative care. METHODS The American Academy of Pediatrics (AAP) Delivery of Surgical Care Subcommittee and American Pediatric Surgical Association (APSA) Global Pediatric Surgery Committee, with the American Pediatric Surgical Nurses Association, Inc. (APSNA) Global Health Special Interest Group, and the Society for Pediatric Anesthesia (SPA) Committee on International Education and Service generated consensus recommendations for STMs based on extensive experience with STMs. RESULTS Three distinct, but related areas were identified: 1) Broad goals of surgical partnerships between HICs- and low and middle-income countries (LMICs). A previous set of guidelines published by the Global Paediatric Surgery Network Collaborative (GPSN), was endorsed by all groups; 2) Guidelines for the conduct of STMs were developed, including planning, in-country perioperative patient care, post-trip follow-up, and sustainability; 3) travel and safety considerations critical to STM success were enumerated. CONCLUSION A diverse group of stakeholders developed these guidelines for STMs in LMICs. These guidelines may be a useful tool to ensure safe, responsible, and ethical STMs given increasing engagement of HIC providers in this work. LEVEL OF EVIDENCE 5.
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Affiliation(s)
- Marilyn Butler
- Division of Pediatric Surgery, Department of Surgery, Oregon Health & Science University
| | - Elizabeth Drum
- Department of Anesthesiology & Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania
| | - Faye M Evans
- Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Harvard Medical School
| | | | - Jason Fraser
- Department of Pediatric Surgery, Children's Mercy Hospital, Kansas City
| | - Ai-Xuan Holterman
- Division of Pediatric Surgery, University of Illinois College of Medicine at Peoria
| | - Howard Jen
- Division of Pediatric Surgery, University of California, Los Angeles
| | - J Matthew Kynes
- Department of Anesthesia, Vanderbilt Children's Hospital, Vanderbilt University
| | - Jenny Kreiss
- Division of Pediatric Surgery, Seattle Children's Hospital
| | - Craig D McClain
- Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Harvard Medical School
| | - Mark Newton
- Department of Anesthesia, Vanderbilt Children's Hospital, Vanderbilt University
| | - Benedict Nwomeh
- Department of Pediatric Surgery, Nationwide Children's Hospital, Columbus, OH
| | - James O'Neill
- Department of Pediatric Surgery, Vanderbilt University
| | | | - George Politis
- Department of Anesthesiology, University of Virginia Health System
| | - Henry Rice
- Division of Pediatric Surgery, Duke University
| | - David Rothstein
- Division of Pediatric Surgery, Children's Hospital of Buffalo
| | - Julie Sanchez
- Division of Pediatric Surgery, University of Texas at Austin
| | - Mark Singleton
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Department of Anesthesia and Perioperative Care, University of California San Francisco
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Heller BJ, Yudkowitz FS, Lipson S. Can we reduce anesthesia exposure? Neonatal brain MRI: Swaddling vs. sedation, a national survey. J Clin Anesth 2017; 38:119-122. [DOI: 10.1016/j.jclinane.2017.01.034] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2016] [Revised: 01/13/2017] [Accepted: 01/21/2017] [Indexed: 11/26/2022]
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Silverman ER, Lai YH, Osborn IP, Yudkowitz FS. Percutaneous radiofrequency ablation of hepatocellular lesions in segment II of the liver: a risk factor for cardiac tamponade. J Clin Anesth 2013; 25:587-90. [PMID: 23988803 DOI: 10.1016/j.jclinane.2013.04.014] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2012] [Revised: 03/20/2013] [Accepted: 04/04/2013] [Indexed: 10/26/2022]
Abstract
Percutaneous radiofrequency ablation (PRFA) is a minimally invasive procedure used for the treatment of small hepatocellular carcinomas. PRFA is regarded as a much safer alternative to surgical resection or orthotopic liver transplantation. However, serious complications, including cardiac tamponade, have been reported. Two cases of severe cardiac tamponade during PRFA were successfully treated.
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Affiliation(s)
- Eric R Silverman
- Department of Anesthesiology, Montefiore Medical Center, Bronx, NY 10467, USA.
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Abstract
In the past decade, concern has been raised about the safety of anesthetic agents on the developing brain. Animal studies have shown an increase in apoptosis in the developing brain when exposed to N-methyl-D-asparate receptor blockers and/or gamma-aminobutyric acid receptor agonists that is related to the dose and duration of anesthetic agents. Whether these studies can be extrapolated to humans is being investigated. The Food and Drug Administration in 2007 convened an advisory committee to look at this issue. They found that the animal data available were inadequate to extrapolate to humans and determined that human studies were necessary. Human studies are underway but the challenge they face is how to delineate the effects of anesthesia from those of the underlying medical condition and surgery itself. At this time, we must continue to make decisions based on the known risks and benefits of anesthetics and apply it on an individual basis.
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Abstract
Pediatric orthotopic liver transplantations (OLT) are commonly performed nowadays. Two primary reasons for OLT in children are complications from either extrahepatic biliary atresia (EHBA) or inborn errors of metabolism. However, congenital liver disease may be associated with significant other congenital abnormalities. We present a case of a successful OLT in a pediatric patient with a history of EHBA, situs inversus, and complex congenital heart disease. The cardiac anomalies include dextrocardia, absence of the atrial septum (single atrium), single atrioventricular valve (a-v canal), and an incomplete ventricular septum. Prior surgery include a Kasai procedure for EHBA, banding of the proximal main pulmonary artery, and Broviac catheter placement. We present the anesthesia concerns and management for this complicated case.
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Abstract
Pediatric liver transplantations are becoming increasingly more common. Recent advances in the surgical and anesthetic management of these cases have greatly improved the survival rate. In order to successfully manage the anesthesia in these patients, one needs to have a thorough understanding of the pathophysiology of end-stage liver disease and the subsequent anesthetic implications. It is also necessary to appreciate the stages of the surgical procedure, as each stage presents different dilemmas to the anesthesiologist. This article will review the pathophysiology of liver failure in pediatric patients and outline the particular issues related to each stage of liver transplantation, allowing for the anticipation and management of the derangements that occur during surgery.
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Affiliation(s)
- Francine S Yudkowitz
- Department of Anesthesiology, The Mount Sinai School of Medicine, New York, NY 10029-6574, USA.
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10
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Abstract
The inter-observer reliabilities of three scoring systems (Excitement Score, Face Mask Acceptance Score, Steward Score) were assessed by pairs of independent evaluators who observed 21 children during emergence from general anaesthesia. Each scoring system was analysed using the intraclass correlation coefficient giving values of 0.997 and 0.988 for the Excitement and Face Mask Acceptance Scores, respectively. Those for the Steward Score were 0.956, 0.924 and 0.295 for the 'consciousness', 'airway', and 'movement' subdivisions, respectively. Ambiguous wording and inexplicit instructions may explain the lower correlations for the Steward Score. Reliability of scoring systems cannot be assumed and systems of undocumented reliability bring into question the results of the studies in which they are employed.
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Affiliation(s)
- N J Keegan
- Department of Anesthesiology, Mount Sinai School of Medicine, New York, New York 10029, USA
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