Jackson-Pratt drainage in pediatric craniofacial reconstructive surgery: is it helping or hurting?

Intraoperative Factors Affecting Pain Management and Postoperative Narcotic Use in Cranial Vault Remodeling: A Retrospective Review

Perioperative pain control in open cranial vault reconstruction (CVR) poses significant challenges. Narcotic use may confound signs of neurological deterioration and cause medication-induced complications. Previous studies have shown improved health outcomes in CVR with reduced narcotic use. The purpose of this study was to investigate the relationship between modifiable intraoperative factors on postoperative narcotic use. A retrospective cohort study was performed on 237 patients with craniosynostosis who presented to a tertiary pediatric hospital over a 10-year period for open CVR. There was a statistically significant relationship between total fluid volume infused intraoperatively (mL/kg) and total morphine equivalents (MEs, mL/kg) given throughout hospitalization ( P < 0.001). Longer operative times were associated with greater total hospitalization ME ( P ≤ 0.006) and total intraoperative blood products transfused ( P ≤ 0.001). Patients who received drains were given significantly higher total hospitalization ME compared with those who did not ( P < 0.001). Patients who received postoperative nonsteroidal anti-inflammatory drugs required significantly fewer total ME compared with children who did not ( P < 0.005) and patients who received intraoperative tranexamic acid were less likely to require postoperative blood transfusion ( P < 0.001). Postoperative nonsteroidal anti-inflammatory drug use is associated with decreased narcotic requirements during the immediate postoperative period whereas increased fluid requirements intraoperatively, longer operative durations, and drain placement are associated with higher narcotic use. Modifying intraoperative factors like these may lead to decreased postoperative pain, thus limiting narcotic use for patients, and improving overall outcomes.

Bidirectional Irrigation System to Treat a Difficult Wound: A Case Series

AIMS

To date, there is no distinct principle determining whether to use irrigation under negative-pressure wound therapy (NPWT). We developed a new economical device to manage difficult wounds, employing 1 of 2 techniques depending on the wound condition.

METHODS

This case series study was conducted in 12 patients with difficult wound, from 2017 to 2018. Four patients were treated with Type A bidirectional irrigation system (wound irrigation), while 8 patients were treated with Type B bidirectional irrigation system (wound irrigation combined with NPWT).

RESULTS

In the Type A device group, inflammatory profiles in case I, case IV, and case VIII were not monitored due to the stability of their wound. The mean recovery period was 3.75 weeks (2-8 weeks), with decreases in 100% healing rate. In the Type B device group, we noted an average of 71% reduction in inflammatory profiles. All patients' infections were resolved or were healing, and 7 patients recovered satisfactorily. The recovery period ranged from 4 to 17 weeks, with a median value of 7 weeks.

CONCLUSION

Bidirectional irrigation system decreases secondary infections and complications, and increases the healing rate in patients with difficult wound.

Design of an Automatic Jackson-Pratt Drain Auxiliary System for Postoperative Management Applications

Background: After surgery, the exudation at a surgical site can cause complications and infections. The exudation is periodically removed through a Jackson-Pratt (JP) drain while maintaining a negative pressure in the JP bulb. However, the JP drainage tube may be clogged due to blood clotting. Thus, the periodic management of the JP drain is essential. In particular, the postoperative management of the JP drain includes squeezing and stripping it. In this study, we proposed a JP drain auxiliary system that can perform automatic stripping to assist specialists and nurses. Methodology: The proposed system was designed based on pre-experimental measurements and operated as a gripping and rolling device. Experimental Results: Twenty experiments were performed, and an average stripping efficiency of 93.8% was obtained. Conclusions: Consequently, we think that the proposed auxiliary system can automatically contribute to increase working efficiency for specialists and nurses.

Postoperative Drain Use in Cranial Vault Remodeling: A Survey of Craniofacial Surgeon Practices and a Review of the Literature

BACKGROUND

The use of subgaleal drains following primary cranioplasty for craniosynostosis has undergone limited investigation. Proposed benefits include prevention of seroma, detection of postoperative bleeding, and cerebrospinal fluid leak. We conducted a systematic review of the literature and surveyed craniofacial surgeons to ascertain the current evidence pertaining to drain use following primary cranioplasty for craniosynostosis and to determine surgical practice patterns.

METHODS

PubMed and Embase databases were searched to identify relevant articles. Abstracts were reviewed by 2 investigators, and a Cohen κ statistic was calculated. Patient demographic and outcome data were extracted and compared. A 9-question survey was e-mailed to active and associate members of the American Society of Craniofacial Surgeons.

RESULTS

A total of 7395 unique citations were identified. Only 2 retrospective chart reviews met inclusion criteria. All objective parameters demonstrated no difference between patients with and without drains. A subjective benefit of limiting facial swelling was proposed without objective analysis. Fifty (32.5%) of the 154 craniofacial surgeons responded to the survey. Forty-two percent used postoperative drains. A significant association (P = .01) was found between the belief that drains limited facial swelling and their use.

CONCLUSIONS

The literature examining postoperative drain use in primary cranioplasty for craniosynostosis is restricted. The current studies show no definite benefit to drain use but are limited in their assessment of key outcomes. There is wide variability among surgeons regarding drain use, and this seems to be motivated by belief and tradition.