Author: Nathan Novotny

Cryoablation for Postoperative Pain Control after the Nuss Procedure for Pectus Excavatum

Posted on by Nathan Novotny
Cryoablation for Postoperative Pain Control after the Nuss Procedure for Pectus Excavatum
Jonathan Bucan, MD and Nathan M Novotny, MD
Beaumont Health, Royal Oak

A rare few pediatric surgeons have impacted the field to the extent that deserves a paradigm shift and naming of a procedure after the surgeon. Donald Nuss is one of those rare few. Nuss’ development of a minimally invasive approach revolutionized the treatment of pectus excavatum and the procedure was rapidly adopted. One major challenge of the treatment of pectus excavatum however is the postoperative pain. Cryoablation for postoperative pain control after the Nuss procedure is the newest attempt at controlling one of the Nuss procedure’s biggest challenges.

Due to significant post-operative pain following the Nuss Procedure, common methods of pain control include patient-controlled analgesia (PCA) and thoracic epidurals. These methods often include continuous flow of narcotics, weaned over the course of the hospital stay, and transitioned to oral analgesia for home use. However, these types of analgesia do not come without risk. Epidurals can be misplaced and malfunction, while PCAs have conflicting data on whether they adequately control early post-operative pain, and the risk for opioid dependence continues to linger in the background.1 While PCAs have been shown to be beneficial over epidurals, hospital length of stays and pain scores are unacceptably high(Is there a reference for this?). Enter cryoablation. Intraoperative cryoablation of intercostal nerves is the next best thing to happen to pediatric surgery since the development of electrocautery surgery! (Maybe a little over the top, but you get the point) cryoanalgesia helps prevent pain following the Nuss Procedure by freezing affected peripheral nerves and producing pain relief that is long lasting and leads to decreased length of stay.2 According to one study, mean postoperative length of stay was significantly shorter in patients with cryoanalgesia (N = 10) than in a previous cohort treated with thoracic epidural (N = 15), and pain was well controlled.3 Another study which randomized 20 patients to receive either cryoablation (N = 10) or thoracic epidural (n = 10) suggested that median LOS decreased by 2 days in patients undergoing cryoablation, to 3 days from 5 days.4 Finally, one other study took 35 patients treated with cryoablation compared to 32 epidural and 33 PCA patients which resulted in less time to pain control with oral medication (21 h, versus 72 and 67 h, p < 0.01), and decreased LOS (1 day, versus 4.3 and 4.2 days, p < 0.01).5 Pause for a moment. Read that again. Cryoablation patients stayed a single day in the hospital versus 4+ days for our conventional methods of pain control. And yet, there is no free lunch. Astute clinicians will ask, ‘what is it going to cost me?’ Across the three studies mentioned above, mean operating time increased anywhere from 30 minutes –46.5 minutes.3,4,5Also, due to

immediate pain relief following the procedure from cryoablation, patients may ignore activity restrictions and require re-intervention due to a possible displaced Nuss bar.6(wonder if its worth re-wording slightly to make it clear that it’s a suggestion of potential increased bar displacement and that its not been shown …yet .. possibly 😉 )And yet still compelling.The Nuss Procedurewas a revolutionary approach to correct pectus excavatum. But it hurts like a bitch-unsure. Agree with the sentiment, would very much use it myself and possibly worse -( i spent most of yesterday with every sentance including twat) But wonder whether for the sake of a sentance, it’s worth not offending. I dont feel strongly though. Cryoablation of intercostal nerves takes a little time in the operating room but is a potential solution to days and weeks of pain postoperatively for patient and surgeon. Cryoablation provides instantaneous pain relief, decreased length of stay, and better overall pain control than previous conventional methods. Cryoablation may be that revolutionary approach to pain control that Dr. Nuss’s revolutionary procedure needs.References1.Shawn D St Peter, Kathryn A Weesner, Eric E Weissend, et al, “Epidural vs patient-controlled analgesia for postoperative pain after pectus excavatum repair: a prospective, randomized trial”, Journal of Pediatric Surgery. 2012 Jan;47(1):148-53. Doi: 10.1016/j.jpedsurg.2011.10.0402.Sunghoon Kim, Olajire Idowu, Barnard Palmer, Sang H. Lee, “Use of transthoracic cryoanalgesia during the Nuss Procedure”, Journal of Thoracic Cardiovascular Surgery. 2016 Mar;151(3):887-888. Doi: 10.1016/j.jtcvs.2015.09.1103.Claire Graves, Olarjire Idowu, Sang Lee, et al, “Intraoperative cryoanalgesia for managing pain after the Nuss procedure”, Journal of Pediatric Surgery. 2017 Jan;52(6):920-924. Doi: 10.1016/j.jpedsurg.2017.03.0064.Claire E Graves, Jarrett Moyer, Michael J. Zobel, et al, “Intraoperative intercostal nerve cryoablation during the Nuss procedurereduces length of stay and opioid requirement: A randomized clinical trial”, Journal of Pediatric Surgery. 2019;54(11):2250. Doi: 10.1016/j.jpedsurg.2019.02.0575.Dekonenko C, Dorman RM, Duran Y, et al, “Post operative pain control modalities for pectus excavatum repair: A prospective observational study of cryoablation compared to results of a randomized trial of epidural vs patient-controlled analgesia”, Journal of Pediatric Surgery. 2019 Oct 26;S0022-3468 Doi: 10.1016/j.jpedsurg.2019.09.0216.Benjamin Keller, Sandra Kabagambe, James Becker, et al, “Intercostal nerve cryoablation versus thoracic epidural catheters for postoperative analgesia following pectus excavatum repair: Preliminary outcomes in twenty-six cryoablation patients”, Journal of Pediatric Surgery. 2016 Dec;51(12):2033-2038 Doi: 10.1016/j.jpedsurg.2016.09.034

 

Deciding Laparoscopic Versus Open Pyloromyotomy for Pyloric Stenosis

Posted on by Nathan Novotny

 

 

 

 

 

 

 

 

 

 

The age-old question: lap versus open fill-in-the-blank. Today, class, we will be answering the question of lap versus open pyloromyotomy. When I trained circa 2012, my attendings were doing about half and half open vs. lap. Since finishing training, I haven’t done a single open pyloromyotomy but there are plenty of surgeons including at least one esteemed editor of this site, who still do (and advocate for) open pyloromyotomy. What factors help a surgeon’s journey in deciding laparoscopic versus open pyloromyotomy for pyloric stenosis? I’m glad you asked.

 

A recent meta-analysis1 concluded that there were no differences between the two approaches in major or minor complications, operative time, and length of stay. The laparoscopic approach was associated with a shorter time to full feeds but, let’s be realistic here, who cares if it doesn’t change length of stay? Any of these studies reviewed by this paper that found a faster time to full feeds found their ‘statistically significant difference’ in hours, not days which, of course, renders this difference clinically insignificant.

 

Interestingly, they cited one paper2 that described improved cosmesis from the laparoscopic incisions versus the open incision. As you might expect, these included the traditional right upper quadrant incision and not the periumbilical incision that many surgeons now employ. 

 

Hypothetically speaking, if I had a 1 month old baby (jeez, this is just hypothetical, right?) with pyloric stenosis, which approach would I prefer? I think the answer is much simpler than you might expect. I would want the approach that my baby’s surgeon preferred. A comfortable, competent surgeon is better than not. This is not a situation where one approach is clearly beneficial over the other. Thankfully, this disease process has wonderful outcomes and these discussions are perfect for dogmatic lunchroom discussions and blogposts but probably don’t make much difference to the baby.

 

 

1Sathya C, Wayne C, Gotsch A, Vincent J, Sullivan KJ, Nasr A. Laparoscopic versus open pyloromyotomy in infants: a systematic review and meta-analysis. Pediatr Surg Int. 2017 Mar;33(3):325-333. doi: 10.1007/s00383-016-4030-y. Epub 2016 Dec 10. PMID: 27942806.

 

2Siddiqui S, Heidel RE, Angel CA, Kennedy AP Jr. Pyloromyotomy: randomized control trial of laparoscopic vs open technique. J Pediatr Surg. 2012 Jan;47(1):93-8. doi: 10.1016/j.jpedsurg.2011.10.026. PMID: 22244399.

 

 

 

 

 

 

To HIDA or not to HIDA in Possible Biliary Atresia

Posted on by Nathan Novotny

 

 

Zachary H. Rollins, BS and Nathan M. Novotny, MD

Beaumont Children’s and Oakland University William Beaumont School of Medicine

In order to maximize the clinical benefit of the Kasai hepatoportoenterostomy in biliary atresia (BA), time is liver. If operated on in the first 60 days of life roughly 70% of infants reestablish bile flow. If operated on even younger, such as at 30 days old, there is significantly increased survival with native liver[i]. HIDA scan is a controversial step in the diagnostic pathway for biliary atresia. To HIDA or not to HIDA in possible biliary atresia – that is the question.

The HIDA scan is often used as a catch-all term for hepatobiliary scintigraphy using derivatives of iminodiacetic acid (IDA). Tests such as PIPIDA, BrIDA, DISIDA, are included when referring to the HIDA scan in this article. In theory, the HIDA scan should make for an ideal screening test for biliary atresia. We are trying to figure out if bile is excreted into the bowel. If so, the baby doesn’t have biliary atresia. A 2013 systematic review and meta-analysis of HIDA for the diagnosis of BA determined that HIDA scan has a cumulative sensitivity of 98.7% (range 98.1-99.2%) and a specificity of 70.4 (range 68.5%-72.2%)[ii]. A subsequent 2015 meta-analysis found the sensitivity to be 93.4% (range 90.3%-95.7%) and specificity to be 69.2% (range 65.1%-73.1%)[iii]. Regardless, the specificity isn’t near good enough to correctly identify biliary atresia, but the sensitivity makes it a reasonable screening test for biliary patency. The question remains how much does this add to the workup of the cholestatic infant? Many of the potential causes of neonatal cholestasis such as Alagille syndrome, idiopathic neonatal hepatitis, and parenteral associated cholestasis commonly have non-excreting scans from secondary hepatic congestion. Put more succinctly, “scintigraphy adds little to the routine evaluation of the cholestatic infant, but may be of value in determining the patency of the biliary tract, thereby excluding BA.”[iv]  To further complicate matters excretion of contrast into the intestines does not always exclude BA. But, why?

When ordering a HIDA scan for BA it is important to remember that the disease course is progressive fibrotic obliteration of the extrahepatic bile ducts. If a HIDA scan is ordered too early in the disease course, results can be misleading. One case series reported 6 patients found to have biliary atresia who had biliary patency on initial HIDA scan. Five of these cases were found to have decreased or delayed excretion[v]. This reflects the early changes in the disease before complete obstruction occurs. This is the same time period for the infant with BA where surgical intervention would be most beneficial. It is our suggestion that if you choose to order a HIDA scan, any abnormality should limit the test’s ability to definitively rule out BA. If instead you decide to obtain a HIDA scan before proceeding to cholangiogram, be wary of a negative HIDA scan and persistent jaundice. In this case have a low threshold for reordering the scan after a few days if the cholestasis has not resolved and you are still not ready to perform the cholangiogram.

Pretreatment with phenobarbital can improve the specificity of the HIDA scan, but is it enough to significantly help? The suggested pretreatment protocol to improve HIDA specificity is phenobarbital at 5mg/kg per day for 3-5 days[vi]. The theory behind this is: pretreating with phenobarbital induces hepatic enzymes further stimulating biliary uptake and excretion. This will not change the outcome of a scan if the extrahepatic bile ducts are obstructed, but will make excretion more likely in cases where there is poor uptake from congestion. In the 2013 meta-analysis pretreatment with phenobarbital was found to increase the specificity of the HIDA scan to 72.2% [69.4%-97.8]. Uh, like a 2% increase? So not only do we not gain enough in specificity to make pretreatment worthwhile, it delays the diagnosis and time to take the patient to the operating room decreasing the success of the Kasai procedure.

There are certain situations where HIDA is even less useful. Beware the HIDA scan in the preemie on parenteral nutrition[vii]. Preemies on TPN are more likely to have TPN associated cholestasis which will also cause diminished tracer excretion. And finally, if the cholestatic infant has persistent acholic stools, a HIDA scan really doesn’t add anything that isn’t already clear from the clinical picture. An important tool for both clinician and parents, we have linked a stool cardwith images of cholic and acholic stools because one person’s clay is not another’s.

The HIDA scan can have value as a screening test, but it is important to realize its limitations in a progressive disease. Waiting 5 days for pretreatment is not recommended, especially when subsequent testing of greater value such as liver biopsy has an associated turnaround time. The one exception is if you are already planning an operation but the delay to operation is several days. Recent case reports have shown that it is safe to skip the HIDA scan entirely and proceed with the more invasive gold standard testing such as the cholangiogram and liver biopsy in the infant with cholestasis. To HIDA or not to HIDA in possible biliary atresia? If it helps you get to more definitive testing or if it helps rule out BA in a patient with low likelihood, go for it. However, chances are you probably don’t need it for the diagnosis of BA.

[i] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3888317/

[ii] https://link.springer.com/article/10.1007/s00247-013-2623-3#Tab2

[iii] https://link.springer.com/article/10.1007%2Fs12519-015-0071-x

[iv] https://journals.lww.com/jpgn/Fulltext/2017/01000/Guideline_for_the_Evaluation_of_Cholestatic.23.aspx

[v] https://www.sciencedirect.com/science/article/pii/S0022347619317342

[vi] https://www.sciencedirect.com/science/article/pii/S0140673609609466?via%3Dihub

[vii] https://pediatrics.aappublications.org/content/142/1_MeetingAbstract/214

Cryoablation for Postoperative Pain Control after the Nuss Procedure for Pectus Excavatum

Posted on by Nathan Novotny

Cryoablation for Postoperative Pain Control after the Nuss Procedure for Pectus Excavatum

Jonathan Bucan, MD¹ and Nathan M Novotny, MD¹’²

¹Beaumont Health, Royal Oak, MI, USA

²Monroe Carell, Jr. Children’s Hospital at Vanderbilt, Nashville, TN, USA

A rare few pediatric surgeons have impacted the field to the extent that deserves a paradigm shift and naming of a procedure after the surgeon. Donald Nuss is one of those rare few. Nuss’ development of a minimally invasive approach revolutionized the treatment of pectus excavatum and the procedure was rapidly adopted. Postoperative pain is one major challenge of the treatment of pectus excavatum. Cryoablation for postoperative pain control after the Nuss procedure is the newest attempt at controlling one of the Nuss procedure’s biggest challenges.

Due to significant post-operative pain following the Nuss Procedure, common methods of pain control include patient-controlled analgesia (PCA) and thoracic epidurals. These methods often include continuous flow of narcotics, weaned over the course of the hospital stay, and transitioned to oral analgesia for home use. However, these types of analgesia do not come without risk. Epidurals can be misplaced and malfunction, while PCAs have conflicting data on whether they adequately control early post-operative pain, and the risk for opioid dependence continues to linger in the background. While PCAs have been shown to be beneficial over epidurals, hospital length of stays and pain scores are unacceptably high.1 Enter cryoablation.

Intraoperative cryoablation of intercostal nerves is the next best thing to happen to pediatric surgery since the development of electrocautery surgery! Okay, maybe that is a little over the top, but you get the point. Cryoanalgesia helps prevent pain following the Nuss Procedure by freezing affected peripheral nerves and producing pain relief that is long lasting and leads to decreased length of stay.2 According to one study, mean postoperative length of stay was significantly shorter in patients with cryoanalgesia (N = 10) than in a previous cohort treated with thoracic epidural (N = 15), and pain was well controlled.3 Another study which randomized 20 patients to receive either cryoablation (N = 10) or thoracic epidural (n = 10) suggested that median LOS decreased by 2 days in patients undergoing cryoablation, to 3 days from 5 days.4 Finally, one other study took 35 patients treated with cryoablation compared to 32 epidural and 33 PCA patients which resulted in less time to pain control with oral medication (21 h, versus 72 and 67 h, p < 0.01), and decreased LOS (1 day, versus 4.3 and 4.2 days, p < 0.01).5  Pause for a moment. Read that again. Cryoablation patients stayed a single day in the hospital versus 4+ days for our conventional methods of pain control. And yet, there is no free lunch. Astute clinicians will ask, ‘what is it going to cost me?’ Across the three studies mentioned above, mean operating time increased anywhere from 30 minutes – 46.5 minutes.3,4,5 Also, due to immediate pain relief following the procedure from cryoablation, it is conceivable that patients may ignore activity restrictions and unknowingly displace the bar.6 And yet cryoablation is still compelling.

The Nuss Procedure was a revolutionary approach to correct pectus excavatum. But it hurts like crazy. Cryoablation of intercostal nerves takes a little time in the operating room but is a potential solution to days and weeks of pain postoperatively for patient and surgeon. Cryoablation provides instantaneous pain relief, decreased length of stay, and better overall pain control than previous conventional methods.

Cryoablation may be that revolutionary approach to pain control that Dr. Nuss’s revolutionary procedure needs.

 

References

  1. Shawn D St Peter, Kathryn A Weesner, Eric E Weissend, et al, “Epidural vs patient-controlled analgesia for postoperative pain after pectus excavatum repair: a prospective, randomized trial”, Journal of Pediatric Surgery. 2012 Jan;47(1):148-53. Doi: 10.1016/j.jpedsurg.2011.10.040
  2. Sunghoon Kim, Olajire Idowu, Barnard Palmer, Sang H. Lee, “Use of transthoracic cryoanalgesia during the Nuss Procedure”, Journal of Thoracic Cardiovascular Surgery. 2016 Mar;151(3):887-888.Doi: 10.1016/j.jtcvs.2015.09.110
  3. Claire Graves, Olarjire Idowu, Sang Lee, et al, “Intraoperative cryoanalgesia for managing pain after the Nuss procedure”, Journal of Pediatric Surgery. 2017 Jan;52(6):920-924.  Doi: 10.1016/j.jpedsurg.2017.03.006
  4. Claire E Graves, Jarrett Moyer, Michael J. Zobel, et al, “Intraoperative intercostal nerve cryoablation during the Nuss procedure reduces length of stay and opioid requirement: A randomized clinical trial”, Journal of Pediatric Surgery. 2019;54(11):2250.Doi: 10.1016/j.jpedsurg.2019.02.057
  5. Dekonenko C, Dorman RM, Duran Y, et al, “Post operative pain control modalities for pectus excavatum repair: A prospective observational study of cryoablation compared to results of a randomized trial of epidural vs patient-controlled analgesia”, Journal of Pediatric Surgery. 2019 Oct 26;S0022-3468Doi: 10.1016/j.jpedsurg.2019.09.021
  6. Benjamin Keller, Sandra Kabagambe, James Becker, et al, “Intercostal nerve cryoablation versus thoracic epidural catheters for postoperative analgesia following pectus excavatum repair: Preliminary outcomes in twenty-six cryoablation patients”, Journal of Pediatric Surgery. 2016 Dec;51(12):2033-2038                                                                                                                                                                          Doi: 10.1016/j.jpedsurg.2016.09.034

Not All Free Air in the NICU is Necrotizing Enterocolitis

Posted on by Nathan Novotny

Not All Free Air in the NICU is Necrotizing Enterocolitis 

Paul Holtrop MD1, Paras Khandhar MD1, and Nathan Novotny MD1, 2

1Beaumont Children’s, Royal Oak, MI, USA

2Monroe Carell, Jr. Children’s Hospital at Vanderbilt, Nashville, TN, USA

When a tiny preterm baby in our neonatal intensive care unit (NICU) has an intestinal perforation, it is always necrotizing enterocolitis (NEC), right? Not so fast, my friend. Many of these preterm infants who perforate have free air from spontaneous intestinal perforation (SIP) and not NEC. As it turns out, not all free air in the NICU is NEC.  How can you tell the difference and does it matter?  

It can be challenging to tell the difference, but SIP tends to occur earlier in life, often within the first week, whereas NEC usually occurs slightly later. One analysis of a large data set showed the median age of onset of SIP was seven days after birth versus 15 days for NEC (1). SIP often occurs in babies who have never been fed or have only had trophic feeds, while many babies who develop NEC have had significant amounts of enteral nutrition or are on full feeds. SIP often presents with a relatively sudden onset of abdominal distention, not uncommonly with associated hypotension. NEC patients are more likely to have feeding intolerance or bloody stools noted before progressing to intestinal perforation.  

The physical exam can be different, too.  While infants with SIP and NEC will usually both have abdominal distention, those with SIP tend to have some bluish discoloration on the skin, whereas in NEC, the skin on the distended abdomen can be erythematous, with crepitus and induration in severe cases (2,3). Obviously, there is overlap in the physical exam between the two. But think of it this way: with SIP, the perforation comes first and necrosis, with inflammation, comes later.  With NEC, the inflammation and necrosis come first, followed by perforation.

On x-ray, SIP babies usually have just free air, without many other abdominal findings. NEC babies can have dilated intestinal loops, pneumatosis intestinalis, and sometimes a fixed dilated loop of bowel. If the baby has those, especially pneumatosis intestinalis, it is NEC and not SIP. 

The most definitive way to differentiate is by looking at the bowel in the operating room. SIP usually occurs in the terminal ileum and has normal bowel proximal and distal to the perforation – although it can occur in the jejunum or colon – while NEC will show abnormality of a more extensive section of intestine, with ischemic and necrotic areas.  

While the most definitive way is to look at the intestine, we often do not get the chance to see the bowel in these types of infants. For babies who weigh less than 1,000 grams, the treatment of choice if they have free air in the abdomen, regardless of whether it’s NEC or SIP, has usually been to place a peritoneal drain at the bedside. The classic teaching has been that a third never need another intervention, a third fail and need an operation (either acutely or for a stricture, later) and a third succumb. Some pediatric surgeons have seen that drain as just a temporizing measure and believe most will need a laparotomy later. Regardless, that recommendation might be changing. Forthcoming data suggest that even for babies less than 1000 grams, if the preoperative diagnosis is NEC, the better treatment is a laparotomy. If the diagnosis is SIP, placing a peritoneal drain is the way to go and will frequently be the only intervention needed. Stay tuned for more information about that. This would be a huge shift in our thinking of treatment which makes differentiating between the two, prior to intervening, even more important.

Even if there is some diagnostic uncertainty between SIP and NEC, all of our small patients need to be closely monitored. If the infant has SIP, the drain may be all the surgical treatment they need for now. However, in NEC, a drain might not help, and the baby can deteriorate after the drain as the disease progresses. A laparotomy might then be necessary, if the baby can tolerate it and has a reasonable chance of survival.  

So, does it matter if it’s NEC or SIP? If the above unpublished data is confirmed, it matters because it influences your choice of treatment and helps to counsel parents regarding outcomes.  Precision in diagnosis allows for precision in terminology which will give us an opportunity for precision in treatment. Finally, it makes a difference to your hospital statistics, which will please your hospital quality assurance chief. The disease process is different, which makes the terminology different, which (likely) makes the treatment different. Not all free air in the NICU is NEC. 

References

  1.  Attridge JT, Clark R, Walker MW, Gordon PV. New insights into spontaneous intestinal perforation using a national data set.  (1) SIP is associated with early indomethacin exposure.  J Perinatol 2006: 26:93. 
  2.  Kim, Jae H.  Neonatal necrotizing enterocolitis: clinical features and diagnosis.  In: Kim, Melanie S, and Abrams, Steven A, eds. UpToDate.  https://www.uptodate.com/contents/neonatal-necrotizing-enterocolitis-clinical-features-and-diagnosis?search=necrotizing%20enterocolitis&source=search_result&selectedTitle=2~150&usage_type=default&display_rank=2. Accessed July 10, 2020.
  3. Kim ES and Brand ML.  Spontaneous Intestinal Perforation of the Newborn.  In: Kim, Melanie S, and Garcia-Prats, Joseph A, eds. UpToDate.  https://www.uptodate.com/contents/spontaneous-intestinal-perforation-of-the-newborn?search=spontaneous%20intestinal%20perforation&source=search_result&selectedTitle=1~43&usage_type=default&display_rank=1. Accessed July 10, 2020. 

High Flow Nasal Cannula in the Surgical Patient

Posted on by Nathan Novotny

High Flow Nasal Cannula in the Surgical Patient

Morta Lapkus, MD and Paras Khandhar, MD

Beaumont Health, Royal Oak, MI, USA

No matter how much they want it, airway management and the decision to place a surgical patient on a ventilator should not just be for the PICU physicians to decide. The type of ventilation a patient receives can affect the surgical patient both positively and negatively. Could High Flow Nasal Cannula in the surgical patient be beneficial? Imagine a patient with an esophageal anastomosis that is extubated to CPAP. Now imagine the tears that would flow from the surgeon when they discover bilateral pneumothoraces and a blown-out anastomosis. Tragic. Therefore, we must weigh the risks and benefits of intubation versus the various respiratory adjuncts as a multidisciplinary group rather than territorial separatists.

 

It should come as no surprise that intubation and reintubation may result in significant consequences: prolonged care in the hospital, ventilator induced lung injury, ventilator associated pneumonia, increased use of sedatives, and an increased mortality. There are several adjuncts that can help prevent respiratory morbidity in children including blow-by or aerosol mask, nasal cannula, high-flow nasal cannula (HFNC), and noninvasive positive pressure ventilation (NIPPV), which is comprised of CPAP and BiPAP. All abbreviations aside, what these modalities do is to help provide a combination of oxygenation and ventilation without an endotracheal tube.

 

Seemingly one step up from nasal cannula, high flow nasal cannula (HFNC) is a type of noninvasive ventilation that provides patients with humidified, heated air at a high flow. HFNC, at approximately 0.5-2 L/Kg flow, reduces anatomic dead space, reduces airway resistance, maintains airway pressures, and increases mucus clearance.1 It not only provides a constant flow of oxygen, but helps remove CO2 and keeps the airways open with a small amount of positive pressure. HFNC is not all rainbows and unicorns, it has it disadvantages as well. HFNC can be detrimental in pediatric surgical patients if they cannot handle their secretions, are at risk for aspiration, or if they recently had gastrointestinal surgery – think about the “fictitious” esophageal anastomosis we discussed earlier. In spite of that, HFNC is much more comfortable and physically tolerable when compared to CPAP or BiPAP. Patients on HFNC can talk and sometimes even eat. The humidified air also decreases likelihood of dry mucous membranes that can become very sore. Two downsides: 1) there is no measurement of the pressure at the level of the airway2 and 2) the pressure delivered can be decreased if a patient’s mouth is open making the amount of pressure present quite variable.

 

Studies have shown that HFNC does indeed decrease intubation rate and therefore the associated complications listed above.3 It has also been used in post-extubation respiratory failure in order to prevent reintubation. Instead of intubating a patient, you may be able to support them enough using this non-invasive technology. Already popular in adult ICUs, HFNC is gaining popularity on the pediatric side too.

 

Your take-home point? It is not as benign as nasal cannula but not as malignant as CPAP or BiPAP. HFNC: prevention of tears from esophageal surgeons and it might just save your patient a reintubation and all the risks associated.

 

References:

1Mikalsen, I. B., Davis, P., & Øymar, K. (2016, July 12). High flow nasal cannula in children: A literature review. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine. BioMed Central Ltd. https://doi.org/10.1186/s13049-016-0278-4

 

2Adjuncts in Respiratory Care. (2016). In Waldhausen, J., Powell, D., & Hirschl, R. (Eds.), Pediatric Surgery NaT. American Pediatric Surgical Association. Retrieved June 29, 2020, from https://www.pedsurglibrary.com/apsa/view/Pediatric-Surgery-NaT/829021/all/Adjuncts_in_Respiratory_Care

 

3McKiernan, C., Chua, L. C., Visintainer, P. F., & Allen, H. (2010). High Flow Nasal Cannulae Therapy in Infants with Bronchiolitis. Journal of Pediatrics, 156(4), 634–638. https://doi.org/10.1016/j.jpeds.2009.10.039

Readiness for Extubation for Pediatric Patients

Posted on by Nathan Novotny

Readiness for Extubation for Pediatric Patients

Ameer Al-Hadidi MD¹, Morta Lapkus MD², and Paras Khandhar MD³

¹ Department of Pediatric Surgery, Nationwide Children’s Hospital, Columbus, OH, USA

² Department of Surgery, Beaumont Health, Royal Oak, MI, USA

³ Department of Pediatrics, Beaumont Children’s, Royal Oak, MI, USA

 

Why Should Surgeons Care?

Assessing the readiness for extubation for pediatric patients is not just the decision of the PICU doctors. It must require discussion and agreement of a multi-disciplinary team that includes the operating surgeon and intensivist for the best outcomes. Spontaneous breathing trials are the mainstay of assessing a patient’s readiness for extubation – the entire team must pay close attention to fully understand the readiness for extubation for pediatric patients.

Of course, there are the ‘straight forward’ patients intubated temporarily to obtain imaging, to undergo a necessary procedure, or for protecting an airway during an altered mental state. However, more complicated patients with significant comorbidities, substantial pulmonary contusions following chest trauma, or even a delicate proximal anastomosis, the decision to extubate from a ventilator cannot be taken lightly and must be approached in a multi-disciplinary fashion. 

We know patients who require reintubation following a failed attempt at extubation tend to have longer PICU length of stay, longer hospital length of stay, more likely to develop ventilator-associated complications, more likely to require discharge to rehab or long-term care facilities, and have a higher risk of mortality. Even though there has been a significant advancement in the development of respiratory rescue therapies (link to HFNC article) to support patients who are struggling to breathe on their own adequately, their success is not 100%. 

Extubation Indices 

The risk of a failed extubation in the pediatric population is 2-20%, comparable to adults at 10-23%. It’s pretty standard for patients in both groups to undergo a spontaneous breathing trial (SBT) to make sure they can maintain adequate ventilation and oxygenation, stable hemodynamics, and remain calm before attempting extubation. Indices like the rapid shallow breathing index (RSBI) and negative inspiratory force (NIF) are used regularly in adult intensive care units where RSBI is the most accurate predictor of adult post-extubation success, and NIF has a high negative predictive value. Unfortunately, none of these has held up in children, which makes the multi-disciplinary care of an intubated surgical patient even more imperative. 

Outside of sound clinical judgment, a systematic review of weaning and extubation of pediatric patients from mechanical ventilation failed to identify a single index, hint, or suggestion to make a surgeons’ job easier in improving the likelihood of extubation success. Paying close attention to any signs of cardiovascular compromise, increased respiratory effort with hypoxia or increases in end-tidal CO2, and any other signs of distress during an SBT are all cues that prognosticate failure. 

With approximately 30% of North American pediatric surgery training programs providing accredited critical care fellowships for trainees, pediatric surgeons are positioning themselves to contribute in the area of the critical care of infants and children. It is a mistake for surgeons to abdicate their role in critical decisions like the extubation of surgical patients.

 

References

Newth CJL, Venkataraman S, Willson DF, Meert KL, Harrison R, Dean JM, et al.: Weaning and extubation readiness in pediatric patients. Pediatr Crit Care Med 2009; 10(1):1-11

Frutos-Vivar F, Esteban A, Apezteguia C, González M, Arabi Y, Restrepo MI, et al.: Outcome of reintubated patients after scheduled extubation. J Crit Care 2011; 26(5):502-509

Postop Day 1 Fever is Never Atelectasis

Posted on by Nathan Novotny

Postop Day 1 Fever is Never Atelectasis

Elizabeth Boudiab MD and Paras Khandhar MD

Beaumont Health, Royal Oak, MI, USA

The Wrongful Conviction of Atelectasis Causing Fever on Postop Day 1

Postop day 1 fever is never atelectasis. It has been blamed for decades while even the latest editions of surgical textbooks disseminate this myth1. Whilst both fever and atelectasis are extraordinarily common after surgery – occurring in up to 40% and 90% of patients, respectively2  this is NOT the cause on Day 1. It is time that we exonerate this myth.

Postop day 1 fever is never atelectasis, it is due to inflammation and trauma of surgery. The concept that atelectasis was causing fever was derived principally from a study showing that alveolar macrophages sampled from an atelectatic rat lung demonstrated increased production of IL-1 & TNF, two known offenders of the febrile response. It was the macrophages responding to tissue damage caused by ligating the rats’ mainstem bronchus not the atelectasis3,4. According to the Matzinger danger model, the immune system responds to damage5. Damaged cells send out these alarm signals, called damage-associated molecular patterns (aka DAMPs), which activate innate immune cells to release pyrogenic cytokines, such as IL-1. The pyrogenic cytokines induce fever by acting on the hypothalamus. This theory also explains how bacteria cause fevers through the DAMPs co-conspirator, pathogen-associated molecular patterns (aka PAMPS). The short story is: DAMPS and PAMPS cause inflammation4.

Still not convinced? Well, another often-cited study on atelectasis was conducted on patients who underwent open-heart surgery2. On the first post-operative day, they found that 90% of patients with fever had atelectasis, but 75% of patients with atelectasis did NOT have a fever.  Again, a case of an association, not causation. If you needed more evidence, there is also an entire systematic review revealing similar conclusions4.

The general treatment for atelectasis is using some witchcraft machinery, such as incentive spirometry. The next time we have a day 1 post-operative patient on rounds with a fever, make sure they take a deep breath and voila – no fever! Sounds crazy? Perhaps because it is. But, before we suggest burning all the incentive spirometers in the hospital, we have to acknowledge that just because we absolve atelectasis from this particular crime does not mean it is ok to have atelectasis. Atelectasis still causes derangement in normal lung physiology and decreases forced vital capacity6, but that is a whole other topic of discussion.

It is crucial to understand that even routine surgery and general anesthesia elicit a massive stress response. This alone, or in combination with tissue damage, are the main contributor to  post op Day 1 fever.  All things being equal, if we can accept an early rise in the white blood cell count without firing the sepsis workup alarms, we should also be able to look past a fever.

 

  1. Chu DI, Agarwal S. Post-operative complications. In: Doherty GM, ed. CURRENT Diagnosis & Treatment: Surgery, 14e Ed. New York, NY: McGraw-Hill Education; 2015. https://accesssurgery.mhmedical.com/content.aspx?bookid=1202&sectionid=71515821.
  2. Engoren M. Lack of association between atelectasis and fever. Chest. 1995. doi:10.1378/chest.107.1.81
  3. Kisala JM, Ayala A, Stephan RN, Chaudry IH. A model of pulmonary atelectasis in rats: Activation of alveolar macrophage and cytokine release. Am J Physiol – Regul Integr Comp Physiol. 1993. doi:10.1152/ajpregu.1993.264.3.r610
  4. Crompton JG, Crompton PD, Matzinger P. Does Atelectasis Cause Fever after Surgery? Putting a Damper on Dogma. JAMA Surg. 2019. doi:10.1001/jamasurg.2018.5645
  5. Pradeu T, Cooper EL. The danger theory: 20 years later. Front Immunol. 2012. doi:10.3389/fimmu.2012.00287
  6. Lindberg P, Gunnarsson L, Tokics L, et al. Atelectasis and lung function in the post-operative period. Acta Anaesthesiol Scand. 1992. doi:10.1111/j.1399-6576.1992.tb03516.x

 

Energy Options in Minimally Invasive Pediatric Surgery

Posted on by Nathan Novotny
energy options

Energy options in minimally invasive pediatric surgery

 

Since the advent of laparoscopic surgery in the early 1980s by gynecologists, we have struggled to provide safe energy to divide tissues and seal vessels safely. Over the last 20 years major advances have been made and there are now major players in the marketplace that provide vessel sealing technology to both adult and pediatric patients through reasonably safe instruments. There are key aspects of a safe and usable energy device that vary widely from one instrument to another. Effectiveness of seal, speed of the seal, spread of energy (collateral damage), heat of the instrument after activation, plume of smoke or steam that obscures the operative field, and the ‘feel’ or usability of the instrument in the surgeon’s hands all contribute to the applicability and ultimate adoption of a device.

energy options

 

 

 

 

 

 

The energy options in minimally invasive pediatric surgery  include monopolar energy, bipolar energy, and ultrasonic shears. Each has its benefits and drawbacks. Monopolar (hook cautery) is by far the least expensive but also has a large plume of smoke associated with it and a large amount of spread of energy to adjacent structures. Bipolar energy comes in a variety of platforms and seems to have the least spread, heat production, and plume but is expensive and some platform’s seal times are slow. Ultrasonic energy is also expensive and may have an edge on some bipolar platform’s seal time but the jaws are quite hot and there is a large amount of steam produced from the seal. In general, monopolar sealing is much more variable and so the durability of the seal is less consistent when compared to the advanced energy devices which all have very safe and reproducible seals for physiologic pressures. One product engineer told me in confidence, and so I feel it’s safe to tell you, that the size of vessel that many manufacturers are ‘rated’ to seal is nowhere near what they can actually seal. That being said, don’t be stupid, ok?

 

In the US the market share is dominated by the Ligasure (Medtronic – bipolar energy) and the Harmonic Scalpel (Johnson and Johnson – ultrasonic shears). There are other devices that are vying for adoption: Sonicision (Medtronic – cordless ultrasonic shears), Enseal (Johnson and Johnson – bipolar) Thunderbeat (Olympus – bipolar and ultrasonic combination), and the JustRight Sealer (Bolder Surgical – bipolar with decreased seal times and energy (read: spread, heat, etc) and a 3 mm instrument). I know that is a lot to take in. There are plusses and minuses to each and each should be applied by the surgeon’s experience and comfortability as well as tailored to each case.

 

Specific Applications

 

Only the JustRight Sealer was developed for pediatric patients and so the others have been adopted in pediatric practice. Because of this, there are specific cases where the strengths or weaknesses come into play. The JustRight sealer is the only 3 mm sealer on the market and is peerless when it comes to neonatal laparoscopy and thoracoscopy. The obvious downside of the sealer is that it does not have a cutting option, it seals and the tissue is ‘distracted’ (read: torn) and it is pricier than other sealers. There is a learning curve but the instrument is really impressive once you are used to it. The upsides are striking and they use much lower energy than adult bipolar instruments which means less plume, less heat, less spread, and ridiculously fast seal times – somehow. It is my go-to instrument for any case that uses shorter instrument lengths (comes in 20 cm shaft length).

 

The hook cautery shines for cases where spread of heat doesn’t matter – think laparoscopic cholecystectomy – the liver is very forgiving. Its cost consciousness balances out many of its shortcomings however, when encountering a big vessel or in a small space and spread, plume, or a cool instrument is important, look elsewhere.

 

In my mind, the Ligasure is the workhorse of the 5 mm instruments. The other currently available 5 mm options (Thunderbeat, Enseal, etc) come down to preference and what you’re used to. I haven’t heard a convincing argument from them on why I should switch.

 

Ultrasonic shears are very good when you need an active jaw to enter tissue – think partial nephrectomy. One of my colleagues also uses it (cool side down) for Heller myotomies though I have not been impressed with that application. I don’t know anyone who has a strong preference between Ethicon’s and Covidien’s shears – the cordless option is nice in theory but a bit heavy in my experience.

All in all, there are many options on the table for pediatric surgeons to choose among. For our smaller patients nothing beats the JustRight Sealer and I’m eager to see their future developments – more to come on this soon! Until then, my choice is the Ligasure for any 5 mm case given how versatile and relatively safe it is.