79 resultados para Pediatrics.


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Background: CO2 monitoring is recommended for thoracic telescopic procedures and for spontaneous breathing general anesthesia in children. During flexible bronchoscopy (FB) in children, the various currently available methods of CO2 measurements are limited. The CO2 falls and increases have been reported in FB but it is unknown whether airway lesions predispose to CO2 change. The aim of this study was to describe and validate endoscopic intratracheal CO2 measurements in children undergoing FB under spontaneously breathing GA. Methods: Endtidal CO2 (PECO2) measurements at the start (Start-CO2) and end (End-CO2) of FB on 100 consecutive children were performed using a newly designed endoscopic intratracheal method. To validate the method blood gas sampling was simultaneously performed in 28 children and results analyzed using the Bland and Altman method, intraclass correlation and 95% range for repeatability. Results: End-CO2 and CO2-change (End-CO2 minus Start-CO2) were significantly different in children with airway lesions (CO2 change: no lesion = 3 mmHg, extrathoracic airway lesion = 4.5, intrathoracic airway lesion = 8, P = 0.038). There was no significant difference in Start-CO2 values among the groups. CO2-change in those aged > 12 months was similar to those >12 months. Intratracheal CO2 measurements were comparable with arterial blood values in the Bland and Altman plots. The intraclass correlation was 0.69 and 95% range for repeatability was 3.7-4.17 mmHg. Conclusions: Midtracheal PECO2 provides a useful estimate of PaCO2 for monitoring the respiratory status of children undergoing FB. The presence of airway lesions rather than age is associated with significant increased PCO2 rise.

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Dr James George Beaney (1828-1891) was a flamboyant and controversial Melbourne surgeon and paediatrician. He was the first in Australia, in 1859, to publish a medical textbook; and the first, in 1873, to publish a paediatric text, Children: their treatment in health and disease. An analysis of four of his published works relating to paediatrics and paediatric surgery establishes his place as a true pioneer in the chronology of children's medicine and welfare in his adopted land. He undertook heroic yet conservative surgery on children, was the first to write in detail about paediatric anaesthesia, and was the pioneer of family planning in Australia. In Children: their treatment in health and disease, he described in detail the supreme importance of breastfeeding, detailed clear practical concepts for the weaning of infants and discussed the diagnosis and management of diseases of the mouth, ears, eyes and teeth of infants. Beaney was shunned by much of the established medical profession because of his self-promoting flamboyance and his egotism. However, an audit of surviving archives and of his published works affords him a place as another, hitherto unacknowledged true pioneer of Australian paediatrics.

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Paediatric outreach services are provided in Australia and overseas to regional and rural communities. More recently telehealth services have been established to support the delivery of paediatric services and clinical management at distant sites. It is suggested that with the large distances separating centres in Australia that a combination of telehealth clinics and outreach visits may provide the most efficient means of delivering paediatric specialty and subspecialty care to these centres.

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Classifications of perinatal deaths have been undertaken for surveillance of causes of death, but also for auditing individual deaths to identify suboptimal care at any level, so that preventive strategies may be implemented. This paper describes the history and development of the paired obstetric and neonatal Perinatal Society of Australia and New Zealand (PSANZ) classifications in the context of other classifications. The PSANZ Perinatal Death Classification is based on obstetric antecedent factors that initiated the sequence of events leading to the death, and was developed largely from the Aberdeen and Whitfield classifications. The PSANZ Neonatal Death Classification is based on fetal and neonatal factors associated with the death. The classifications, accessible on the PSANZ website (http://www.psanz.org), have definitions and guidelines for use, a high level of agreement between classifiers, and are now being used in nearly all Australian states and New Zealand.

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Purpose: From the experience of a large combined series of transperitoneal. (TP) and retroperitoneal (RP) endoscopic complete and partial nephroureterectornies in children, we present a logical selective endoscopic approach to benign renal pathology. Materials and Methods: During a 5-year period 122 complete nephrectomies and nephroureterectomies (bilateral 2, invisible ectopic 8) and 63 partial nephroureterectomies for duplex (52 upper, 8 lower) or singleton polar disease (xanthogranulomatous pyelonephritis 1, cyst 2) were performed. Of the partial nephrectomies, ureterectomy, bladder repair and lower moiety reimplantation were performed in 8. Patient age ranged from 2.7 months to 14 years (mean 2.9 years). Preoperative weight ranged from 2.7 to 98 kg (mean 12.3). The position of the renal remnant, the presence or absence of a refluxing ureter and the need for ureterectomy were the major determining factors affecting choice of endoscopic approach. Results: A total of 179 (96.7%) procedures were successfully completed endoscopically. The 6 open conversions (3.2%) occurred early in our experience. The operating time reflected the complexity of the excision and lower urinary reconstruction (lateral and posterior RP 25 to 145 minutes [mean 921) TP with ureterocelectomy and bladder neck repair 105 to 355 minutes [mean 153]. Hospital stay for RP and simple TP was 1.5 days (mean 1 to 4) and for complicated TP 2 to 8 days (mean 3.5). Conclusions: We suggest a posterior retroperitoneal approach with isolated renal excision without extended ureterectomy. The lateral retroperitoneal approach allows complete ureterectomy as well as better exposure to horseshoe and pelvic kidneys and, therefore, avoids exposure to intraperitoneal. structures. Finally, the transperitoneal approach is recommended when complete moiety excision with lower urinary reconstruction is anticipated.

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We review a single surgeon and surgical centre's experience with congenital cystic adenomatoid malformation of the lung (CCAML) in relation to clinical spectrum, operative experience, and postoperative course. A retrospective hospital record review was done on surgically treated cases of CCAML over a 10-year period, focusing on number with antenatal diagnosis, spectrum of postnatal presentation, type of surgery performed, and outcome. Forty-seven patients from birth to 14 years of age underwent surgery for CCAML. Antenatal diagnosis (ante) was made in 30 cases. Of these, 10 became symptomatic before surgery. Six of the 17 postnatally-diagnosed (pnd) cases were an asymptomatic incidental finding. Overall, 16 were symptomatic in the 1st year of life, and five were symptomatic beyond 1 year of age. Symptoms varied from respiratory distress (seven ante, six pnd) to chronic cough (three, and recurrent chest infection (three ante, two pnd). All preoperative diagnoses were confirmed with chest CT. Most patients (25) were operated on before 3 months of age. Eleven were operated on in the first 2 weeks of life as emergency surgery for respiratory distress. The most common lobe involved was the right upper lobe (16), and lobectomy was performed in 42 cases, segmentectomy in four, and pneumonectomy in one. Seventeen cases were extubated immediately postoperatively; 29 required postoperative ventilation overnight, and nine needed more prolonged ventilation. Early postoperative complications included pneumothorax (two), pleural effusion (one), and chylous effusion (one). Late complications included recurrence in three cases (all segmentectomy), who then subsequently underwent lobectomy. There was one death from respiratory failure. Because there is an increasing trend in the detection of asymptomatic antenatally-diagnosed CCAML, consideration of early surgical excision to prevent complications is suggested by our series. CT scanning is mandatory for postnatal evaluation because chest x-ray could be normal. Safe elective excision after 3 months is supported by our low morbidity and less need for postoperative ventilation. Lobectomy is the procedure of choice to prevent recurrence.

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Objective: To investigate the cognitive performance and educational attainment at school-age of children with bronchopulmonary dysplasia (BPD), compared with a preterm control group of children. Methods: Seventy preterm infants with BPD and 61 birth weight matched controls were prospectively followed-up to school-age. The Weschler Intelligence Scale for Children - III (WISC), the Wide Range Achievement Test (WRAT) and the Developmental Test of Visual Motor Integration (VMI) were administered. The results were compared between the two groups and multiple regression analyses were performed to determine the effect of confounding variables. Results: The children in the BPD group performed less well on the Full Scale IQ (mean 86.7 vs 93.5; 95% CI, 1.9-11.7), Verbal IQ (mean 87.1 vs 94.1; 95% CI, 2.0-12.0) and the Performance IQ (mean 88.6 vs 95.2; 95% CI, 2.0-11.2) of the WISC, the reading component of the WRAT (mean 93.8 vs 98.9; 95% CI, 0.3-9.8) and the VMI (mean 88.9 vs 93.3; 95%, CI 1.1-7.8). Despite controlling for social and biological variables, statistical differences persisted for Full Scale and Verbal IQ and reading. A Verbal IQ >1 SD below the mean was found in 41% of BPD children compared to 21% of controls, while on the reading component of the WRAT a greater proportion of BPD children also had scores>1 SD below the mean. Conclusion: Impaired psychoeducational performance was found in preterm children with BPD compared to controls, especially in the areas of language abilities and reading skills. This supports a greater need for special educational services and counseling for parents for these children.

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Aims: To evaluate the thermal responses and weight gain in preterm infants nursed in a cot on a heated, water-filled mattress (HWM) compared with infants receiving care in an air-heated incubator and to compare mothers' stress, anxiety levels and perceptions of their infants in the two groups. Methods: Stable preterm infants weighing 1300 to 1500 g were enrolled, being randomly allocated to either the study group (n = 41) receiving care in a cot on an HWM, or the control group ( n = 33) receiving incubator care. The mean daily body temperature and episodes of cold stress and hyperthermia were recorded. Weight gain (g kg(-1) body weight d(-1)) was also calculated. The mothers completed questionnaires on their perceptions of their infants, and their anxiety and stress levels before randomization, and 2 - 3 wk later during the trial. Results: The mean body temperature was similar for the first week of the trial ( study group 36.9degreesC vs controls 36.9degreesC). There were no significant differences in the incidence of cold stress, while more hyperthermic episodes were seen in the study group ( p = 0.03). There were no significant differences in weight gain during the first ( study group 21.4 g vs controls 19.6 g) or second weeks of the trial ( study group 20.5 g vs controls 19.2 g). Neonatal morbidity did not differ between the groups. There were no differences in mothers' perceptions of their babies, or feelings of stress or anxiety. Conclusion: There were no differences between infants cot-nursed on an HWM and those receiving incubator care, with the exception of episodes of high temperature. The results suggest that the HWM may be used safely for low-weight preterm infants.

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Objective: To assess the effect of reduced skin exposure in preterm infants receiving overhead phototherapy treatment on total serum bilirubin (TSB). Methods: Randomized controlled trial. Preterm infants (>1500 g birthweight and less than or equal to 36 weeks gestation) were randomized to being nursed either partially clothed with only disposable nappies and in posturally supported positions (n = 30) or naked without postural support (n = 29). Primary outcome was mean TSB percentage change at 24 h of completed conventional overhead phototherapy treatment (irradiance of 6 muWcm(-2)/nm at a wavelength of 425-475 nm). The incidence of rebound jaundice, number of infants continuing to receive phototherapy treatment at 24 h periods, parental stress, mother-infant interaction and mean TSB percentage change at 24 h of completed conventional overhead phototherapy treatment were examined. Results: Mean TSB percentage change at 24 h of completed treatment for the partially clothed group was 15.4% (+/-18) and for the naked group 19% (+/-15) (mean difference 3.6% 95% CI -5.1, 12.3). No other outcomes were significantly affected by reduced skin exposure to overhead phototherapy treatment. Conclusion: Our results show no statistically significant difference in TSB level change using either nursing practice.

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Objective: To audit effective quality assurance methods to monitor outcomes following paediatric cardiac surgery at a single institution. Methods: All patients undergoing cardiac surgery from January 1996 to December 2001 were enrolled prospectively. Patients were stratified by complexity of surgical procedure into four groups, with Category 4 being the most complex procedure. Outcome measures included death, length of admission and morbidity from complications. Results: A total of 1815 patients underwent 1973 surgical procedures. Of these, 1447 (73.3%) were cardiopulmonary bypass procedures, and 543 (27.5%) were more complex (Category 3 and 4) procedures. Median patient age was 3.5 years (range, 1 day-20 years) and patient weight 15.0 kg (range, 900 g to 90 kg). Sixty-six patients (3.6%) died during the study period. Of the procedures in 1996, 22.7% were classified as complex compared with 29.2% of procedures in 2001. The annual surgical mortality ranged from 1.9-4.7% (P=0.20), and when mortality was adjusted for complexity of surgery, there was no significant yearly variation in the mortality rate (P=0.57). Analysis of individual surgeon's results showed no significant difference in the mortality rate by complexity of surgery performed (P=0.90). Mean ventilation times did not change significantly over time (P=0.79). The yearly incidence of significant neurological complications ranged from 0.6% to 4.5% and the incidence of arrhythmias from 4.2% to 8.0%. No difference was detected between the years. Conclusions: Stratifying complexity of surgery proved valuable in monitoring surgical outcomes and detecting differences in performance over time as large subgroups were created for analysis.

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Purpose: To review the results and techniques of surgical treatment of consecutive exotropia. Methods: We performed a retrospective chart review of all patients who underwent surgery for consecutive exotropia in a pediatric ophthalmology practice between 1992 and 2001. Patients were excluded if follow-up lasted < 6 weeks or if exotropia was caused by other ocular disorders such as previous trauma or congenital cataracts. Results: Fifty-nine patients were identified. The procedure performed in the majority of cases was unilateral lateral rectus recession and medial rectus advancement to the original insertion. Seven patients underwent bilateral lateral rectus recession, and 6 underwent lateral rectus recession combined with medial rectus resection. The mean interval between original surgery and surgery for consecutive exotropia was 14.1 years (range 4 months to 47.5 years). The mean preoperative distance exodeviation was 31.7 prism diopters (PD). Satisfactory alignment lie, within 10 PD of orthophoria) was achieved in 36 patients (61%) at week 1 and 42 patients (71%) at final follow-up. Mean follow up was 16.0 months. Thirty-nine patients (66%) demonstrated an exodrift after surgery (mean 7.6 PD). Conclusion: Consecutive exotropia may occur many years, even decades, after esotropia surgery. Lateral rectus recession with advancement of the previously recessed medial rectus is an effective treatment. An exotropic drift occurs after consecutive exotropia surgery, usually within the first 6 weeks. A suitable ocular alignment immediately after surgery for consecutive exotropia is a small-angle esotropia of 5 to 10 PD.

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In a previous study of 37 autopsied stillbirths with non-dysmorphic intrauterine growth retardation ( IUGR), 26 cases were associated with placental infarction, a morphologic marker of uteroplacental insufficiency. Nine of the 26 cases with both IUGR and placental infarction, where archival tissue was available, had grey matter ischaemic lesions that were subsequently identified as pontosubicular necrosis. This lesion is now regarded as a localized form of apoptosis. A further eight third trimester stillbirth cases with both IUGR and placental infarction were ascertained prospectively. Sixteen of these 17 cases showed pontosubicular apoptosis, identified morphologically and verified using activated caspase-3 and TUNEL. Five of the 17 cases showed apoptosis in the frontal or temporal cortex as well. In this current study, pontosubicular apoptosis was strongly associated with IUGR and placental infarction in third trimester stillborns, suggesting that uteroplacental insufficiency leading to chronic fetal hypoxaemia may cause cerebral apoptosis.

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Objectives: To identify and demonstrate necrotizing dermatitis in infancy; an uncommon, puzzling syndrome, in which anecdotal reporting and personal experience indicates that one third of cases may require skin grafting. Much informed discussion about the pathogenesis of this distressing syndrome centres on the role of spider envenomation; and in particular on the speculative role of the Australian White-tailed spider, Lampona cylindrata. Methods: We present here six cases of necrotizing dermatitis treated surgically at the Royal Children's Hospital and Mater Children's Hospital in Brisbane over the period from 1991 to 1999. Clinical history, surgical details and pathological investigations were reviewed in each case. Microbiological investigation of necrotic ulcers included standard aerobic and anaerobic culture. Result: Nocardia and Staphylococcus were cultured in two cases, but no positive bites were witnessed and no spiders were identified by either the children or their parents. All cases were treated with silver sulphadiazine creme. Two of the infants required general anaesthesia, excision debridement and split skin grafting. The White-tailed spider, Lampona cylindrata, does not occur in Queensland, but Lampona murina does; neither species has necrotizing components in its venom. Circumstantial evidence is consistent with this syndrome being due to invertebrate envenomation, possibly following arachnid bites. Conclusion: In our experience there is insufficient evidence to impute a specific genus as the cause, at this stage of scientific knowledge. If the offending creature is a spider, we calculate that the syndrome of necrotizing dermatitis occurs in less than 1 in 5000 spider bites.