Minimizing hospital length of stay in children undergoing ureteroneocystostomy

Comprehensive review of a large cohort of outpatient versus inpatient open renal and bladder surgery in children

INTRODUCTION

Outpatient surgery and pediatric ambulatory surgery centers continue to have increasing popularity among pediatric urologist for minor surgeries. Past studies have shown that open renal and bladder surgeries (i.e. nephrectomy, pyeloplasty and ureteral reimplantation) can also be done in an outpatient setting. With health care costs continuing to rise, it may be reasonable to explore performing these surgeries as an outpatient and consider performing them in a pediatric ambulatory surgery center.

OBJECTIVE

Our study assesses the safety and utility of outpatient open renal and bladder surgeries in children compared to those done as inpatients.

STUDY DESIGN

IRB-approved chart review was performed on patients undergoing nephrectomy, ureteral reimplantation, complex ureteral reimplantation, and pyeloplasty by a single pediatric urologist between January 2003-March 2020. Procedures were performed at a freestanding pediatric surgery center (PSC) and a children's hospital (CH). Demographics, type of procedures, American Society of Anesthesiologists score, operative times, time to discharge, ancillary procedures, readmission or ER visits within 72 h were reviewed. Home zip codes were used to determine the distance from pediatric surgery center and children's hospital.

RESULTS

980 procedures were evaluated. Of these, 94% procedures were performed as an outpatient and 6% procedures were performed as inpatients. 40% of patients underwent ancillary procedures. Outpatients had a significantly lower age, ASA score, operative time, and readmission or return to ER within 72 h (1.5% vs. 6.2%). Twelve patients were readmitted (9 outpatient, 3 inpatient) and six returned to the ER (5 outpatient, 1 inpatient). 15/18 of these patients underwent reimplantations. Four required early reoperation on postoperative day (POD)2-3. Only one outpatient reimplant was admitted one day later. PSC patients lived farther away.

DISCUSSION

Outpatient open renal and bladder surgery was found to be safely performed in our patients. In addition, it did not matter whether the operation was done in the children's hospital or pediatric ambulatory surgery center. Since outpatient surgery has been shown to be significantly less expensive than inpatient surgery, it is reasonable for pediatric urologist to consider performing these operations in the outpatient setting.

CONCLUSIONS

Our experience shows that an outpatient approach to open renal and bladder procedures is safe and should be considered when counseling families about treatment options.

Acute pain management in infants and children-Part 2: Intravenous opioids, intravenous nonsteroidal anti-inflammatory drugs, and managing adverse effects

The field of pediatric pain management continues to evolve, with ongoing changes in our appreciation of the impact of pain on our fragile patients, a better understanding of how to assess pain, and refinements of the medications and techniques used to provide analgesia to patients with acute pain of various etiologies. The following article reviews the use of intravenous opioid and nonsteroidal anti-inflammatory agents for the treatment of moderate to severe pain. Options to manage specific adverse effects that may occur with opioids are presented.

Evaluation of a process-of-care model for open intravesical ureteral reimplantation in children from a contemporary health care perspective

INTRODUCTION

Surgical management of patients with vesicoureteral reflux consists of both open and minimally invasive approaches. Open approaches are associated with postoperative hospitalization and stays of 2 to 3 days, dependent on the type of procedure; alternately, when endoscopic correction is performed, it is a same-day procedure. Changes in health care policy emphasize reduction in cost while maintaining and improving quality of care. We sought to evaluate the impact of a "1-night cost-saving process-of-care" model for open surgical correction of vesicoureteral reflux in children on quality of care, which was defined as a return to the emergency room (ER)/office or readmission to the hospital within 2 days of discharge.

MATERIALS AND METHODS

An institutional review board-approved retrospective chart review of all open ureteral reimplantations for uncomplicated vesicoureteral reflux from January 2009 through January 2013 was performed. Children who underwent ureteral stent placement and those who did not have a caudal anesthetic were excluded from the study. Length of postoperative stay, ER records, hospitalizations, and office records were reviewed to assess for presentation to the ER/office or readmission to the hospital within 2 days of discharge.

RESULTS

During the 4-year study period, 92 children (23 males, 69 females) underwent open ureteral reimplantation-there were 83 (89.1%) discharges on the first postoperative day; 9 (9.8%) on the second postoperative day; and 1 (1.1%) on the third postoperative day. One patient presented to the ER within 2 days of discharge, and 4 patients presented to the ER/office or were readmitted > 2 days after discharge.

CONCLUSION

Use of a caudal anesthetic, earlier catheter removal, a knowledgeable nursing team, and parental education allowed us to decrease the length of stay to 1 night in 82 of 92 patients (89.1%). These procedural changes allowed for a decrease in hospital stay comparable with and potentially shorter than robotic-assisted laparoscopic approaches. Additionally, these changes did not seem to increase the risk of early (≤ 2 days of discharge) presentation to the ER/office or readmission.

Ketorolac is underutilized after ureteral reimplantation despite reduced hospital cost and reduced length of stay

OBJECTIVES

To examine patterns of ketorolac use and its association with hospital outcomes. Although ureteral reimplantation (UR) reliably corrects vesicoureteral reflux, postoperative pain and bladder spasm often occur. Multiple studies show that ketorolac markedly reduces postoperative pain after UR, but there is no information on whether ketorolac is routinely used.

METHODS

The Pediatric Health Information System is a national database collected by over 40 US children's hospitals. We identified children with primary vesicoureteral reflux who underwent UR between 2003 and 2008. Billing data were reviewed to identify patients who received ketorolac during hospitalization. Multivariate models were used to examine ketorolac use and postoperative outcomes including complication rates, length of stay, and hospital costs.

RESULTS

We identified 12,239 children undergoing UR, 6362 (52%) of whom received ketorolac postoperatively. Factors associated with ketorolac use include older age, female gender, and decreased disease severity (all P <.0001). Ketorolac use was associated with reduced length of stay (2 vs 3 days, P <.0001) and decreased hospital costs ($14,223 vs $16,382, P <.0001). Complication rates were slightly higher in patients not receiving ketorolac (4% vs 3%). After adjusting for confounding factors, ketorolac use remained highly associated with decreased length of stay (P = .01) and decreased costs (P = .002), with no significant differences in complication rates (P = .4).

CONCLUSIONS

In a contemporary nationwide sample, only half of children undergoing UR received ketorolac. Ketorolac use is independently associated with reduced procedure costs and reduced length of stay after UR, without increased complications. This suggests underutilization of ketorolac after UR.

Transvesicoscopic Cohen ureteric reimplantation for vesicoureteral reflux in children: a single-centre 5-year experience

PURPOSE

To evaluate our results with a new method of intravesical ureteric reimplantation using laparoscopic pneumovesicum in children.

MATERIALS AND METHODS

Seventy-two patients (mean age 4.2 years, range 0.5-20 years) with primary vesicoureteral reflux (VUR) underwent a laparoscopic transtrigonal ureteric reimplantation with CO(2) pneumovesicum. Ports were inserted suprapubically - 5mm for the camera and two 3-5-mm working ports. Having mobilized the ureter(s) intravesically, a submucosal tunnel is created and ureteric reimplantation performed with 5/0 and 6/0 absorbable sutures. Bladder drainage was maintained for 2-3 days postoperatively. Patients were followed up with clinical assessment and renal ultrasonography+/-voiding cystourethrogram.

RESULTS

Ninety percent had VUR grade > or =3. A total of 113 ureters were reimplanted. The mean operative time was 82min for unilateral and 130min for bilateral reimplantation. Four cases (6%) were converted. Three patients presented with temporary ureteric dilatation without symptoms on follow-up renal ultrasound. Seven patients had postoperative urinary tract infection without persistent reflux on cystography. Follow-up cystogram was performed in 50 patients (81 ureters). Reflux persisted in four patients (8%).

CONCLUSIONS

Laparoscopic ureteric reimplantation with CO(2) pneumovesicum is technically feasible with a high success rate (92%). The role of this new technique in the treatment of VUR remains to be determined.

Safety and efficacy of ketorolac in children after cardiac surgery

OBJECTIVE

To evaluate the nephrotoxic and opioid-sparing effects of ketorolac in children after cardiac surgery.

DESIGN

A retrospective cohort study.

SETTING

A Cardiac Critical Care Unit in a university-affiliated children's hospital.

SUBJECTS

Children less than 18 years of age who underwent low-risk cardiac surgery from July 2002 to December 2005.

RESULTS

Among 248 children studied, 108 received ketorolac and 140 did not. The ketorolac group was older, included a larger proportion of atrial septum defect repairs and a smaller proportion of ventricular septum defect repairs compared to the control group. The median change in serum creatinine did not differ between the ketorolac group and the control group (% change [IQR]); 12% [1-25] increase versus 12% [-3 to 31] increase, P = 0.86. On postoperative day 0 or 1, the ketorolac group received less opioids than control group. There was no difference in duration of mechanical ventilation or in length of stay between groups.

CONCLUSION

Ketorolac started in the first 12 h after a low-risk cardiac surgery in children is not associated with a measurable difference in renal function. The data suggest that ketorolac may be effective in reducing the exposure to opioids. Further studies are required to define subsets of children after cardiac surgery who could safely benefit from ketorolac therapy to reduce pain.

Strategies for the removal of short-term indwelling urethral catheters in adults

BACKGROUND

Approximately 15% to 25% of all hospitalised patients have indwelling urethral catheters, mainly to assist clinicians to accurately monitor urine output during acute illness or following surgery, to treat urinary retention, and for investigative purposes.

OBJECTIVES

The objective of this review was to determine the best strategies for the removal of catheters from patients with a short-term indwelling urethral catheter. The main outcome of interest was the number of patients who required recatheterisation following removal of indwelling urethral catheter.

SEARCH STRATEGY

We searched the Cochrane Incontinence Group Specialised Register (searched 7 December 2005), the Cochrane Central Register of Controlled Trials (The Cochrane Library 2006, Issue 2), MEDLINE (January 1966 to 12 July 2006), EMBASE (January 1980 to 12 July 2006), CINAHL (January 1982 to 12 July 2006), Nursing Collection (January 1995 to January 2002) and reference lists of relevant articles and conference proceedings were searched. We also contacted manufacturers and researchers in the field. No language or other restrictions were applied.

SELECTION CRITERIA

All randomised and quasi-randomised controlled trials (RCTs) that compared the effects of alternative strategies for removal of short-term indwelling urethral catheters on patient outcomes were considered for inclusion in the review.

DATA COLLECTION AND ANALYSIS

Eligibility of the trials for inclusion in the review, details of eligible trials and the methodological quality of the trials were assessed independently by two reviewers. Relative risks (RR) for dichotomous data and a weighted mean difference (WMD) for continuous data were calculated with 95% confidence intervals (CI). Where synthesis was inappropriate, trials were considered separately.

MAIN RESULTS

Twenty six trials involving a total of 2933 participants were included in the review. One trial included three treatment groups. In 11 RCTs amongst 1389 people, there was no significant difference in need for recatheterisation, although recatheterisation after removal at night was more likely to be during working hours. Pooled results demonstrated that, following urological surgery and procedures, patients whose indwelling urethral catheters were removed at midnight passed significantly larger volumes at their first void (Difference (fixed) 96 ml; 95% CI 62 to 130). Similar findings were reported for patients following TURP (Difference (fixed) 27; 95% CI 23 to 31). Removal at midnight was also associated with longer time to first void, and shorter lengths of hospitalisation (relative risk of not going home on day of removal = 0.71, 95% CI 0.64 to 0.79). Results in 13 trials amongst 1422 participants having early rather than delayed catheter removal were consistent with a higher risk of voiding problems and a lower risk of infection, with shorter hospitalisation. In three trials involving 234 participants the data were too few to assess differential effects of catheter clamping compared with free drainage prior to withdrawal. No eligible trials compared flexible with fixed duration of catheterisation, or assessed prophylactic alpha sympathetic blocker drugs prior to catheter removal.

AUTHORS' CONCLUSIONS

There is suggestive but inconclusive evidence of a benefit from midnight removal of the indwelling urethral catheter. There are resource implications but the magnitude of these is not clear from the trials. The evidence also suggests shorter hospital stay after early rather than delayed catheter removal but the effects on other outcomes are unclear. There is little evidence on which to judge other aspects of management, such as catheter clamping.

The effect of surgeon volume and hospital characteristics on in-hospital outcome after ureteral reimplantation in children

The aim of this study was to examine the association between surgeon and hospital characteristics on in-hospital outcome after ureteral reimplantation in children. Patients<18 years undergoing vesicoureteral reimplantation (n=3,109) were identified in Kids' Inpatient Database, an administrative database containing discharge records from 27 states during 2000 in the US. Based on patient volume in 2000, surgeons were designated as low volume (<11 procedures), medium volume (11-20 procedures) and high volume (>20 procedures) surgeons. Length of stay and hospital charges were analyzed using multivariate linear regression analysis. A significant association between shorter length of stay and higher surgeon volume (p=0.02) was observed that was independent of children's hospital status, hospital volume and other hospital characteristics. Length of stay was 20% shorter when the procedure was performed by the highest volume surgeons compared to when performed by the lowest. No significant effect of surgeon volume on hospital charges, however, was observed. Higher surgeon volume was associated with shorter length of stay but no difference in hospital charges among children undergoing vesicoureteral reimplantation.

UNILATERAL EXTRAVESICAL URETERAL REIMPLANTATION IN CHILDREN PERFORMED ON AN OUTPATIENT BASIS

PURPOSE

Unilateral extravesical ureteral reimplantation is comparable to intravesical procedures for resolution of primary vesicoureteral reflux (VUR). Defining whether this operation can be consistently performed on an outpatient basis is important.

MATERIALS AND METHODS

A total of 80 patients with unilateral VUR were treated with extravesical ureteral reimplantation, of whom 20 were treated on an inpatient basis and 60 on an outpatient basis. We retrospectively reviewed these groups and conducted a telephone survey to evaluate overall patient satisfaction, and pain and nausea on postoperative days 1 and 14.

RESULTS

There were no significant differences in age, gender, laterality or operative time between the groups. Average length of hospital stay was 31.25 hours (range 20 to 120) for the inpatient group and 6.6 hours (3.25 to 11.20) for the outpatient group. Average intravenous narcotic use in the inpatient group was 0.39 mg/kg, compared to 0.14 mg/kg for the outpatient group (p < 0.005), and included 1.76 mg/kg ketorolac in inpatients and 0.74 ketorolac in outpatients (p < 0.005), and 0.2 mg/kg ondansetron in inpatients and 0.12 mg/kg ondansetron in outpatients (p = 0.004). Four of the 60 outpatients (6.7%) were either hospitalized postoperatively or rehospitalized on postoperative day 1. The results of the survey for the 2 groups were not significantly different.

CONCLUSIONS

Extravesical ureteral reimplantation for unilateral VUR may be performed without compromise in quality on an outpatient basis with significantly less use of intravenous analgesics and anti-emetics.

Ketorolac after congenital heart surgery: does it increase the risk of significant bleeding complications?

BACKGROUND

The routine use of ketorolac after congenital heart surgery in infants and children is limited by concerns for postoperative bleeding complications. The object of this study was to determine if the use of ketorolac is associated with an increased risk of significant postoperative bleeding after congenital heart surgery in infants and children.

METHODS

A retrospective chart review was performed. The exposure of interest was postoperative use of ketorolac after congenital heart surgery in infants and children. The outcome measured was postoperative bleeding requiring surgical exploration. The patients who received ketorolac were compared with an age- and diagnosis-matched comparison group who did not receive ketorolac.

RESULTS

Records of 842 infants and children who underwent congenital heart surgery between July 2001 and October 2002 were reviewed. 94 (11.1%) patients were treated with ketorolac postoperatively. The comparison group consisted of 94 matched subjects selected from the patients that did not receive ketorolac. The mean age of patient in the ketorolac group was 8.5 (+/-6.1) years. No (0%) patients in the ketorolac group and four (4.2%) patients in the nonketorolac group developed postoperative bleeding requiring surgical exploration. The relative risk for postoperative bleeding that required surgical exploration in the ketorolac group compared with the nonketorolac group was 0.2 (95% CI 0.02-1.67).

CONCLUSIONS

The use of ketorolac after congenital heart surgery in infants and children does not significantly increase the risk of bleeding complications requiring surgical exploration.

Policies for the removal of short-term indwelling urethral catheters

BACKGROUND

Approximately 15% to 25% of all hospitalised patients have indwelling urethral catheters, mainly to assist clinicians to accurately monitor urine output during acute illness or following surgery, to treat urinary retention, and for investigative purposes.

OBJECTIVES

The objective of this review was to determine the best strategies for the removal of catheters from patients with a short-term indwelling urethral catheter.

SEARCH STRATEGY

We searched the Cochrane Incontinence Group specialised register (searched 16 December 2002), the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 2, 2004), MEDLINE (January 1966 to 12 October 2004), EMBASE (January 1980 to 12 October 2004), CINAHL (January 1982 to 12 October 2004), Nursing Collection (January 1995 to January 2002) and reference lists of relevant articles and conference proceedings were searched. We also contacted manufacturers and researchers in the field. No language or other restrictions were applied.

SELECTION CRITERIA

All randomised and quasi-randomised controlled trials (RCTs) that compared the effects of alternative strategies for removal of short-term indwelling urethral catheters on patient outcomes were considered for inclusion in the review.

DATA COLLECTION AND ANALYSIS

Eligibility of the trials for inclusion in the review, details of eligible trials and the methodological quality of the trials were assessed independently by two reviewers. Relative risks (RR) for dichotomous data and a weighted mean difference (WMD) for continuous data were calculated with 95% confidence intervals (CI). Where synthesis was inappropriate, trials were considered separately.

MAIN RESULTS

Eighteen trials involving a total of 1964 participants were included in the review. One trial included three treatment groups. In eight RCTs amongst 1020 people, removal at midnight was associated with large volumes of urine at first void, longer times to first void, and shorter lengths of hospitalisation. There was no significant difference in need for recatheterisation, although recatheterisation after removal at night was more likely to be during working hours. In eight trials amongst 822 participants early rather than delayed catheter removal was associated with shorter hospitalisation, but the estimates of other differences were all imprecise. In three trials involving 234 participants the data were too few to assess differential effects of catheter clamping compared with free drainage prior to withdrawal. No eligible trials compared flexible with fixed duration of catheterisation, or assessed prophylactic alpha sympathetic blocker drugs prior to catheter removal.

AUTHORS' CONCLUSIONS

There is suggestive but inconclusive evidence of a benefit from midnight removal of the indwelling urethral catheter. There are resource implications but the magnitude of these is not clear from the trials. The evidence also suggests shorter hospital stay after early rather than delayed catheter removal but the effects on other outcomes are unclear. There is little evidence on which to judge other aspects of management, such as catheter clamping.

Prospective randomized trial of ketorolac after congenital heart surgery

OBJECTIVE

Ketorolac is a potent nonsteroidal analgesic agent used to treat postoperative pain. It produces excellent analgesia without the sedating side effects of opioid analgesics. Routine use of ketorolac after cardiac surgery is limited by concerns of bleeding complications. The purpose of this study was to evaluate the risk of bleeding complications of ketorolac for treatment of pain after congenital heart surgery in infants and children.

DESIGN

Prospective randomized, controlled trial.

SETTING

Pediatric cardiac intensive care unit in tertiary teaching hospital.

PARTICIPANTS

Seventy infants and children, median age 10 months (range 2.5-174), who underwent congenital heart surgery requiring cardiopulmonary bypass were randomized in the trial.

INTERVENTION

Pain control was performed with ketorolac and opioid analgesics in one arm of the study and opioid analgesics alone in the other arm.

OUTCOME MEASURES

The main outcome evaluated was bleeding complications measured by chest-tube drainage and wound and gastrointestinal bleeding.

RESULTS

Thirty-five patients were randomized to each treatment arm. In the ketorolac group, the median chest-tube drainage was 13.3 (range 4-22) mL/kg/d, no patient had significant wound bleeding, and 1 (0.03%) patient had gastrointestinal bleeding. In the control group, the median chest-tube drainage was 16.5 (range 3-24) mL/kg/d, 1 (0.03%) patient had wound bleeding, and no patient had gastrointestinal bleeding.

CONCLUSION

Ketorolac can be used to treat pain after congenital heart surgery without an increased risk of bleeding complications.

Ureteroneocystostomy Without Urethral Catheterization Shortens Hospital Stay Without Compromising Postoperative Success

PURPOSE

We determine whether routinely performing catheterless ureteroneocystostomy would minimize hospital stays without compromising postoperative outcomes.

MATERIALS AND METHODS

Between May 1996 and February 2002 patients who underwent ureteroneocystostomy at a single major tertiary care institution were identified. Patients who underwent additional, simultaneous surgical procedures were excluded from the study. Data recorded included patient demographics, reflux grade, use of a bladder catheter, length of hospital stay, medication use, postoperative complications and subsequent rehospitalization.

RESULTS

Of the 300 patients included in the study 266 were girls and 34 were boys, with a median age of 4 years (range 3 months to 19 years). Reimplantation was bilateral in 215 cases and unilateral in 85. Reflux was grade I in 1% of cases, grade II in 18%, grade III in 47%, grade IV in 25% and grade V in 9%. Similar distributions were observed among the 76 patients who received bladder catheters and the 224 who did not. The average length of postoperative hospitalization for patients who received catheters compared to those who did not was 2.1 versus 1.4 days (p <0.001), and the rate of prolonged hospitalization are 18% versus 5%, respectively (p <0.01). Postoperative complication rates were 17% versus 8% (p <0.05) for patients who received catheters compared to those who did not. There was no statistically significant difference in the rate of rehospitalization whether urethral catheters were used (1.3% vs 4.9%, respectively, p = 0.07). Furthermore, there was no statistically significant difference in the amount of either ketorolac or oxybutynin used by patients who received catheters compared to those who did not.

CONCLUSIONS

Surgical repair of vesicoureteral reflux via catheterless ureteroneocystostomy can reduce hospital stay without adversely affecting complication rates, rehospitalization rates and the amount of medications needed postoperatively.

Nonsteroidal anti-inflammatory drugs for postoperative pain: a focus on children

Pain is a common symptom after surgery in children, and the need for effective pain management is obvious. For example, after myringotomy, despite the brief nature of the procedure, at least one-half of children have significant pain. After more extended surgery, such as tonsillectomy, almost all children have considerable pain longer than 7 days. Nonsteroidal anti-inflammatory drugs (NSAIDs) are useful for postoperative pain management because surgery causes both pain and inflammation. Several pediatric studies indicate NSAIDs are effective analgesics in the management of mild and moderate pain. In the treatment of severe pain, NSAIDs should be given with acetaminophen (paracetamol) or opioids, and the use of an appropriate regional analgesic technique should be considered. NSAIDs are more effective in preventing pain than in the relief of established pain. Pain following surgery is best managed by providing medication on a regular basis, preventing the pain from recurring. This proactive approach should be implemented for any procedure where postoperative pain is the likely outcome. In children, the choice of formulation can be more important than the choice of drug. Intravenous administration is preferred for children with an intravenous line in place; thereafter mixtures and small tablets are feasible options. Children dislike suppositories, and intramuscular administration should not be used in nonsedated children. Ibuprofen, diclofenac, ketoprofen and ketorolac are the most extensively evaluated NSAIDs in children. Only a few trials have compared different NSAIDs, but no major differences in the analgesic action are expected when appropriate doses of each drug are used. Whether NSAIDs differ in the incidence and severity of adverse effects is open to discussion. Because NSAIDs prevent platelet aggregation they may increase bleeding. A few studies indicate that ketorolac may increase bleeding more so than other NSAIDs, but the evidence is conflicting. Severe adverse effects of NSAIDs in children are very rare, but it is important to know about adverse effects in order to recognize and treat them when they do occur. NSAIDs are contraindicated in patients in whom sensitivity reactions are precipitated by aspirin (acetylsalicylic acid) or other NSAIDs. They should be used with caution in children with liver dysfunction, impaired renal function, hypovolemia or hypotension, coagulation disorders, thrombocytopenia, or active bleeding from any cause. In contrast, it seems that most children with mild asthma may use NSAIDs.

Use of ketorolac tromethamine in children undergoing scoliosis surgery. an analysis of complications

BACKGROUND CONTEXT

Ketorolac Tromethamine (ketorolac) is a nonsteroidal anti-inflammatory drug (NSAID) with proven efficacy in decreasing postoperative pain in various surgical settings, including the treatment of spine deformities. However, some studies have raised questions regarding the potential side effects of this agent, such as increased bleeding and inhibition of bony fusion.

PURPOSE

This study was conducted to determine whether there is any association between the use of ketorolac and postoperative complications in a group of children who underwent scoliosis surgery.

STUDY DESIGN/SETTING

This is a retrospective review of a group of children who underwent spinal fusion between 1989 to 1999 at our institution.

PATIENT SAMPLE

Data on a total of 208 children were analyzed in this study. Sixty received ketorolac and 148 did not.

OUTCOME MEASURES

Postoperative transfusion and reoperation rates were the two main outcome measures of interest.

METHODS

A retrospective review of 208 children who underwent scoliosis surgery was conducted, with a focus on ketorolac use. Univariate analysis and logistic regression were used to quantify the determinants of postoperative complications.

RESULTS

Our analyses detected no significant differences in a broad range of socioclinical variables between the two patient groups, including age at surgery, gender, type of scoliosis, surgical approach, use of erythropoietin, levels of curvature and degree of curvature. Analysis of complication rates focusing on postoperative transfusion and revision surgery showed that there were no significant differences between the two groups.

CONCLUSIONS

In this retrospective study of 208 children undergoing spine surgery, postoperative use of ketorolac did not significantly increase complications, including transfusion and reoperation.

Catheter-less Cohen transtrigonal ureteric reimplantation

OBJECTIVE

To review the profile and outcome of patients in whom it was elected not to insert a bladder catheter as part of the management of Cohen transtrigonal ureteric reimplantation surgery.

PATIENTS AND METHODS

Between April 2000 and April 2001, 37 patients underwent ureteric reimplantation by the senior author, using the Cohen transtrigonal technique. The use of the catheter-less protocol began after the blockage of a suprapubic catheter soon after surgery; the catheter was removed with no adverse event. Subsequently, 27 of those undergoing ureteric reimplantation were selected not to have a bladder catheter. Later in the study a greater proportion of patients had no catheter inserted, as confidence with the catheter-less technique increased. Caudal anaesthetic, oral analgesia and a single dose of intravesical bupivacaine were used for pain relief. The children were monitored closely after surgery and a urethral catheter inserted in the one patient who had not voided after 6 h.

RESULTS

The patients generally tolerated the lack of a bladder catheter well. Of the 27 patients who did not have a catheter inserted at surgery, one required catheterization (a girl with bilateral duplex systems and large ureteroceles). Two children stayed in hospital for 2 days after surgery, one was discharged on the day of surgery, and the remainder went home on oral analgesia on the first day after surgery. Since starting the catheter-less approach, 10 patients have had a suprapubic catheter because they had more complex surgery, were older or because the approach had not developed sufficiently at the time of surgery.

CONCLUSIONS

Intravesical ureteric reimplantation is not only safe when omitting a bladder catheter but, if used selectively, there appears to be a significant decrease in the hospital stay and discomfort after surgery.

Risks and benefits of nonsteroidal anti-inflammatory drugs in children: a comparison with paracetamol

Nonsteroidal anti-inflammatory drugs (NSAIDs) possess antipyretic, analgesic and anti-inflammatory effects. They are frequently used in children and have numerous therapeutic indications, the most common ones being fever, postoperative pain and inflammatory disorders, such as juvenile idiopathic arthritis (JIA) and Kawasaki disease. Their major mechanism of action is through inhibition of prostaglandin biosynthesis by blockade of cyclo-oxygenase (COX). The disposition of most NSAIDs has been mainly studied in infants > or = 2 years of age. Compared with adults, the volume of distribution and clearance of NSAIDs such as diclofenac, ibuprofen (infants aged between 3 months and 2.5 years), ketorolac and nimesulide were increased in children. The elimination half-life was similar in children to that in adults. These pharmacokinetic differences might be clinically significant with the need for higher loading and/or maintenance doses in children. Ibuprofen, acetylsalicylic acid (ASA) and acetaminophen are the most frequently used agents for fever reduction in children. Over the past 20 years, because of the association between ASA use and Reye's syndrome, most of the interest has been directed toward ibuprofen and acetaminophen. In view of its comparable antipyretic efficacy, but superior tolerability profile, acetaminophen, when used appropriately with age-adapted formulations, should remain the first-line therapy in the treatment of childhood fever. At the moment, there is no scientific evidence to recommend simultaneous use of these two antipyretic drugs. Most NSAIDs provide mild to moderate analgesia, with the exception of ketorolac which has a strong analgesic activity. The analgesic efficacy of ketorolac, ketoprofen, diclofenac and ibuprofen in the treatment of postoperative pain has been mainly studied following a single dose, in children of > or = 1 year of age undergoing minor surgeries. In this setting, when used either alone or in adjunct to caudal or epidural anaesthesia, they were associated with an opioid-sparing effect and were well tolerated. With the exception of ketorolac use in children undergoing tonsillectomy, where controversy exists regarding the risk of postoperative haemorrhage, NSAIDs have not been associated with an increased risk of perioperative bleeding. NSAIDs are the first-line therapy in JIA. They appear to be equally effective and tolerated, with the exception of ASA which is associated with more adverse effects. ASA has been used for many years in the treatment of Kawasaki disease and is part of the standard modality of treatment in combination with intravenous gammaglobulins. More recently, lung inflammation associated with cystic fibrosis (CF) has become a new target for NSAIDs. Despite promising preliminary results with ibuprofen, numerous questions need to be answered before this new strategy becomes part of the conventional treatment of patients with CF. In summary, NSAIDs are effective in reducing fever, alleviating pain and reducing inflammation in children, with a good tolerance profile. Pharmacokinetic studies are needed to characterise the disposition of NSAIDs in very young infants in order to use them rationally. To date, no studies have been published on the disposition, tolerability and efficacy of specific COX-2 inhibitors in children. Further clinical experience with these agents in adults is warranted before undergoing trials with specific COX-2 inhibitors in children.

EXTRAVESICAL URETERAL REIMPLANTATIONS FOR THE CORRECTION OF PRIMARY REFLUX CAN BE DONE AS OUTPATIENT PROCEDURES

PURPOSE

Extravesical ureteral reimplantations are thought to be less morbid compared with traditional intravesical techniques. We believe a shorter length of stay can be achieved in children undergoing extravesical reimplantation for the correction of primary reflux without experiencing a reduction in quality of care.

MATERIALS AND METHODS

During a 16-month period 2 boys and 42 girls underwent extravesical ureteral reimplantation and received similar postoperative care by a single pediatric urologist (D. P. S.). These children were 1 to 14 years old (mean age 4.7) and underwent reimplantation for correction of primary vesicoureteral reflux due to breakthrough urinary tract infections, moderate/high grade reflux and parental desire. Unilateral and bilateral reimplantations were done in 21 and 23 children, respectively, and 9 underwent reimplantation of duplex systems. Each child received 0.25 to 0.5% marcaine locally instead of caudal at termination of the surgical procedure. Criteria for patient discharge home included sufficient urine output, toleration of a liquid diet, adequate pain control with oral analgesics and "parental readiness." Renal and bladder ultrasound was obtained no earlier than 1 month following surgery. Postoperative cystograms were obtained in any child with a febrile urinary tract infection or at parental request. Charts were reviewed for demographics, operative procedures, postoperative intravenous analgesic doses, catheter requirements and length of stay, defined as hours from surgery to discharge home. Surgical outcomes were analyzed specifically for perioperative complications and resolution of reflux on postoperative cystograms.

RESULTS

The length of stay for all children ranged from 5 to 30 hours (average plus or minus standard deviation 13.3 +/- 6.8). Of the children 31 (70.5%) were discharged home the same day while the remaining 13 (29.5%) went home the next day. When comparing the outpatient surgical group to those hospitalized for 1 night, there were no significant differences in age, operative times and technique (unilateral versus bilateral). Children discharged home the same day required significantly fewer doses of intravenous analgesics (1.7 +/- 0.23 versus 2.7 +/- 0.36, p = 0.025). Intravenous narcotics were primarily used in the recovery room and ketorolac tromethamine was administered on the surgical ward. Seven children were discharged home with urethral catheters due to urinary tract infection in 1, transient urinary retention in 4 and surgeon preference in 2. Those patients discharged home with an indwelling catheter had a significantly longer length of stay (hours) compared to those without catheters (20.3 +/- 8.3 versus 12.0 +/- 5.6, p = 0.026). The child discharged home with a catheter due to urinary tract infection was rehospitalized 2 days later and received 48 hours of intravenous antibiotics. Postoperative cystograms revealed resolution of reflux in 12 of 13 children (92.3%). One child with preoperative bilateral high grade reflux had unilateral reflux on postoperative cystogram. Followup of 41 children at 3 to 19 months (mean 9.1) revealed no other significant complications.

CONCLUSIONS

In our experience extravesical ureteral reimplantation for the correction of primary reflux can be done on an outpatient basis in the majority of children without an increase in morbidity. Pain management and catheter placement significantly influence length of stay in children undergoing extravesical ureteral reimplantation.

Extravesical ureteral reimplantations for the correction of primary reflux can be done as outpatient procedures

PURPOSE

Extravesical ureteral reimplantations are thought to be less morbid compared with traditional intravesical techniques. We believe a shorter length of stay can be achieved in children undergoing extravesical reimplantation for the correction of primary reflux without experiencing a reduction in quality of care.

MATERIALS AND METHODS

During a 16-month period 2 boys and 42 girls underwent extravesical ureteral reimplantation and received similar postoperative care by a single pediatric urologist (D. P. S.). These children were 1 to 14 years old (mean age 4.7) and underwent reimplantation for correction of primary vesicoureteral reflux due to breakthrough urinary tract infections, moderate/high grade reflux and parental desire. Unilateral and bilateral reimplantations were done in 21 and 23 children, respectively, and 9 underwent reimplantation of duplex systems. Each child received 0.25 to 0.5% marcaine locally instead of caudal at termination of the surgical procedure. Criteria for patient discharge home included sufficient urine output, toleration of a liquid diet, adequate pain control with oral analgesics and "parental readiness." Renal and bladder ultrasound was obtained no earlier than 1 month following surgery. Postoperative cystograms were obtained in any child with a febrile urinary tract infection or at parental request. Charts were reviewed for demographics, operative procedures, postoperative intravenous analgesic doses, catheter requirements and length of stay, defined as hours from surgery to discharge home. Surgical outcomes were analyzed specifically for perioperative complications and resolution of reflux on postoperative cystograms.

RESULTS

The length of stay for all children ranged from 5 to 30 hours (average plus or minus standard deviation 13.3 +/- 6.8). Of the children 31 (70.5%) were discharged home the same day while the remaining 13 (29.5%) went home the next day. When comparing the outpatient surgical group to those hospitalized for 1 night, there were no significant differences in age, operative times and technique (unilateral versus bilateral). Children discharged home the same day required significantly fewer doses of intravenous analgesics (1.7 +/- 0.23 versus 2.7 +/- 0.36, p = 0.025). Intravenous narcotics were primarily used in the recovery room and ketorolac tromethamine was administered on the surgical ward. Seven children were discharged home with urethral catheters due to urinary tract infection in 1, transient urinary retention in 4 and surgeon preference in 2. Those patients discharged home with an indwelling catheter had a significantly longer length of stay (hours) compared to those without catheters (20.3 +/- 8.3 versus 12.0 +/- 5.6, p = 0.026). The child discharged home with a catheter due to urinary tract infection was rehospitalized 2 days later and received 48 hours of intravenous antibiotics. Postoperative cystograms revealed resolution of reflux in 12 of 13 children (92.3%). One child with preoperative bilateral high grade reflux had unilateral reflux on postoperative cystogram. Followup of 41 children at 3 to 19 months (mean 9.1) revealed no other significant complications.

CONCLUSIONS

In our experience extravesical ureteral reimplantation for the correction of primary reflux can be done on an outpatient basis in the majority of children without an increase in morbidity. Pain management and catheter placement significantly influence length of stay in children undergoing extravesical ureteral reimplantation.

Analgesic efficacy of ketorolac and morphine in neonatal rats

Ketorolac is a potent nonsteroidal antiinflammatory drug (NSAID). In adult humans and animals, its analgesic efficacy can be comparable to opiates. However, it has not been studied in neonatal animals. We conducted a blinded, controlled study comparing the effects of ketorolac and morphine in neonatal rats using the formalin model. Animals were given intraperitoneal (i.p.) injections of ketorolac or morphine at 3 or 21 days of age. Ketorolac had an analgesic and antiinflammatory effect in 21-day-old pups, but not in the 3-day-olds. Morphine had a significant analgesic, but no antiinflammatory effect at both ages. These results indicate that ketorolac is an effective analgesic agent in preweaning, but not neonatal rats. Opiates may be more appropriate analgesics in neonates.