Management of outpatient pediatric burns at a pediatric burn center

Burn injuries are a serious emergency. Most burn injuries in children can be treated as outpatients. The aim of this study was to present the clinical and epidemiologic characteristics of pediatric burn injuries treated in our outpatient burn clinic. This study included pediatric patients treated in an outpatient burn clinic over an eight-year period. The demographic and clinical characteristics of the patients were retrospectively analyzed. The patients were divided into four groups according to their age groups, and the differences between the groups were investigated. Statistical analysis was performed using IBM SPSS Statistics, Version 25.0. P<0.05 was accepted as statistically significant. Of the total 5,167 patients, 2,811 (54.4%) were male. Scald burns were the most common cause of burns (81.4%). Contact burns accounted for 12.2% of all burns. There were no differences between sexes for any variable. The highest incidence was seen in children in the 2-5-year-old age group (28.3%). There were differences between age groups in terms of sex, burn area, burn visit, burn type, burn location, need for wound dressing under anesthesia, and need for grafting. Among the patients, 4.9% were hospitalized due to the need for wound dressing under anesthesia. However, most of the patients (95.1%) were treated as outpatients. In conclusion, the majority of pediatric burn patients can be treated as outpatients. This allows pediatric patients to complete treatment in a psychologically comfortable environment and have low complication rates. Outpatient treatment should become the standard for children who are suitable for outpatient follow-up and who have home support.

Esophageal Atresia Associated with Congenital Duodenal Obstruction: Turkish Esophageal Atresia Registry (TEAR) Evaluation

INTRODUCTION

 Coexistent congenital duodenal obstruction and esophageal atresia (EA) is known to have significant morbidity and mortality. Management strategies are not well-defined for this association. The data from the Turkish EA registry is evaluated.

MATERIALS AND METHODS

 A database search was done for the years 2015 to 2022.

RESULTS

 Among 857 EA patients, 31 (3.6%) had congenital duodenal obstruction. The mean birth weight was 2,104 (± 457) g with 6 babies weighing less than 1,500 g. Twenty-six (84%) had type C EA. The duodenal obstruction was complete in 15 patients and partial in 16. Other anomalies were detected in 27 (87%) patients. VACTERL-H was present in 15 (48%), anorectal malformation in 10 (32%), a major cardiac malformation in 6 (19%), and trisomy-21 in 3 (10%). Duodenal obstruction diagnosis was delayed in 10 (32%) babies for a median of 7.5 (1-109) days. Diagnosis for esophageal pathologies was delayed in 2. Among 19 babies with a simultaneous diagnosis, 1 died without surgery, 6 underwent triple repair for tracheoesophageal fistula (TEF), EA, and duodenal obstruction, and 3 for TEF and duodenal obstruction in the same session. A staged repair was planned in the remaining 9 patients. In total, 15 (48%) patients received a gastrostomy, the indication was long-gap EA in 8. Twenty-five (77%) patients survived. The cause of mortality was sepsis (n = 3) and major cardiac malformations (n = 3).

CONCLUSION

 Congenital duodenal obstruction associated with EA is a complex problem. Delayed diagnosis is common. Management strategies regarding single-stage repairs or gastrostomy insertions vary notably depending on the patient characteristics and institutional preferences.

The effect of postoperative ventilation strategies on postoperative complications and outcomes in patients with esophageal atresia: Results from the Turkish Esophageal Atresia Registry

OBJECTIVES

Postoperative ventilatory strategies in patients with esophageal atresia (EA) and tracheoesophageal fistula (TEF) may have an impact on early postoperative complications. Our national Esophageal Atresia Registry was evaluated to define a possible relationship between the type and duration of respiratory support on postoperative complications and outcome.

STUDY DESIGN

Among the data registered by 31 centers between 2015 and 2021, patients with esophago-esophageal anastomosis (EEA)/tracheoesophageal fistula (TEF) were divided into two groups; invasive ventilatory support (IV) and noninvasive ventilatory support and/or oxygen support (NIV-OS). The demographic findings, gestational age, type of atresia, associated anomalies, and genetic malformations were evaluated. We compared the type of repair, gap length, chest tube insertion, follow-up times, tensioned anastomosis, postoperative complications, esophageal dilatations, respiratory problems requiring treatment after the operation, and mortality rates.

RESULTS

Among 650 registered patients, 502 patients with EEA/TEF repair included the study. Four hundred and seventy of patients require IV and 32 of them had NIV-OS treatment. The IV group had lower mean birth weights and higher incidence of respiratory problems when compared to NIV-OS group. Also, NIV-OS group had significantly higher incidence of associated anomalies than IV groups. The rates of postoperative complications and mortality were not different between the IV and NIV-OS groups.

CONCLUSION

We demonstrated that patients who required invasive ventilation had a higher incidence of low birth weight and respiratory morbidity. We found no relation between mode of postoperative ventilation and surgical complications. Randomized controlled trials and clinical guidelines are needed to define the best type of ventilation strategy in children with EA/TEF.

Determination of Factors to Distinguish MIS-C from Acute Appendicitis in Children with Acute Abdominal Pain

INTRODUCTION

 The aim of this study was to make the differential diagnosis between acute appendicitis and multisystem inflammatory syndrome in children (MIS-C) for patients presenting with the complaint of acute abdominal pain (AAP) and to identify the determining factors for the diagnosis of MIS-C.

MATERIALS AND METHODS

 Eighty-one children presenting with AAP/suspected AAP were evaluated. Of these, 24 (29.6%) were included in the MIS-C group (MIS-C/g) and 57 were included in the suspected appendicitis group (S-A/g), which consisted of two subgroups: appendicitis group (A/g) and control observation group (CO/g).

RESULTS

 Comparing MIS-C/g, A/g, and CO/g, duration of abdominal pain (2.4, 1.5, 1.8 days), high-grade fever (38.8, 36.7, 37°C), severe vomiting, and severe diarrhea were higher in MIS-C/g. Lymphocytes count (LC) was lower, while values of C-reactive protein (CRP), ferritin, and coagulopathy were higher in MIS-C/g (p < 0.05). The optimal cutoffs for the duration of abdominal pain was 2.5 days; the duration of fever, 1.5 days; peak value of fever, 39°C; neutrophil count, 13,225 × 1,000 cell/µMoL; LC, 600 × 1,000 cell/µMoL; ferritin, 233 µg/L; and D-dimer, 16.4 mg/L (p < 0.05). The optimal cutoff for CRP was 130 mg/L (sensitivity 88.9, specificity 100%, positive predictive value 100%, NPV, negative predictive value 92.5%, p < 0.001). All patients in MIS-C/g tested positive by serology by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2).

CONCLUSION

 The duration of abdominal pain, presence of high-grade and prolonged fever, and evaluation of hemogram in terms of high neutrophil count and low LC exhibit high sensitivity and negative predictive value for MIS-C presenting with AAP. In case of doubt, inflammatory markers such as CRP, ferritin, D-dimer, and serology for SARS-CoV-2 should be studied to confirm the diagnosis.

Analysis of risk factors of mortality for pediatric burned patients with inhalation injury and comparison of different treatment protocols

BACKGROUND

We present our approach of pediatric burned patients with the suspicion of inhalation injury.

METHODS

This retrospective study was conducted on children with the suspicion of inhalation injury admitted to our burn center from December 2009 to December 2019. We collected data on patient demographics, total burn surface area (TBSA), presence of inhalation injury, level of carboxyhemoglobin, grade of inhalation injury, duration of mechanical ventilation, reintubation rate, total length of hospital stay, and the mortality rate. We also reviewed the required treatment of patients with inhalation injury.

RESULTS

A total of sixty pediatric burn patients were suspected inhalation injury were included in this retrospective study. 40 pa-tients included in the study were male. Age average of the patients was 87.7 months. Total burned surface area average was 32%. 46 of these patients had inhalation injury. Patients with larger cutaneous burn and needed early intubation have a higher risk of inhalation injury. There was no significant relation between inhalation injury grades and mortality and treatment protocols. Higher levels of car-boxyhemoglobin and larger TBSA are the risk factors for mortality at univariate analysis. Pediatric patient with inhalation injury whose TBSA is higher than 47.5% has a 5 times higher risk of mortality at multivariate analysis.

CONCLUSION

This study demonstrated that TBSA is the risk factor that independently affects the mortality in pediatric patients with inhalation injury. Among the patients with higher than 47.5% burn surface area, the mortality rate rises 5 times.

Approaches of 112 ambulance service staffers to children with burns: A survey assessment

BACKGROUND

We aimed to evaluate the knowledge of 112 ambulance service staffers (doctors, nurses, emergency medical technicians [EMTs], and paramedics [PMs]) who were the first intervention to pediatric patients with burn injuries regarding first intervention and patient transfer.

METHODS

The study included 373 personnel working in 112 ambulance services in Ankara province. Participants were asked 17 questions to measure their knowledge of burns in children. Statistical analysis was performed with the Statistical Package for Social Sciences 21.0.

RESULTS

Of the participants, 26 (7%) were doctors, 25 (6.7%) nurses, 180 (48.3%) EMTs, and 142 (35.3%) PMs. Of the participants, 118 stated that they always calculate the burn surface area, while only five (1.3%) marked the correct choice of the Lund Browder scheme to the question by which method they calculated. One hundred twenty one personnel (32.4%) use the Parkland formula to calculate the amount of fluid to be given during transfer while only 7 (1.9%) use the Galveston formula, which is more suitable for chil-dren. Of the participants, 56 (15%) answered as lactated Ringer's solution which is the correct fluid to the question of which fluid do you give at the scene and during the transfer. One hundred fifty-three participants (41%) responded correctly to the scenario question expected to recognize inhalation damage while only 138 (37%) responded correctly as 'I do immediately intubate' to the inhalation injury described scenario question. One out of 373 (0.3%) participants marked the appropriate procedure for a patient who had a 50% scald burn during the first intervention and transfer. The rate of topical lidocaine use of participants was high (70.8%). Of the 373 participants, only 33 (8.8%) thought themselves competent for first aid and transfer of children with burns. If training on the subject was held, 333 personnel (89.3%) wanted to participate.

CONCLUSION

It is expected that the knowledge of 112 ambulance services who see pediatric burn patients first, perform the first intervention, and provide transfer would be suitable. However, our questionnaire shows that these personnel have insufficient knowledge and need to be trained.

Comparison of Optical Forceps-Assisted Single-Port Laparoscopic PIRS and Open Surgery in Morgagni Hernia Repair

INTRODUCTION

 This study aimed to compare the results of classical surgery (CS) and optical forceps-assisted single-port laparoscopic percutaneous internal ring suturing (SP-PIRS) repair for the treatment of Morgagni hernia.

MATERIALS AND METHODS

 Patients with Morgagni hernia who were operated on between January 2005 and July 2020 were included in the study. Patients were divided into two groups (CS or SP-PIRS) and compared retrospectively in terms of demographic data, defect size, duration of hospitalization, costs, postoperative complications, and recurrence.

RESULTS

 Thirty-two patients were included in this study. There were no statistically significant differences between the groups in terms of gender, defect size, postoperative complications, and recurrence (p > 0.05). The SP-PIRS group had a shorter operation time (p < 0.01), shorter hospital stay (p = 0.02), and lower cost (p < 0.01) than the CS group. The average follow-up was 24 months, and recurrence was detected in two patients in each group.

CONCLUSION

 SP-PIRS repair is recommended because it is practical to perform and reduces the duration of surgery, hospital stay, and cost. It is superior to other laparoscopic techniques, as there is no need to use additional study forceps, except in extreme cases, and the surgeon can perform the procedure without an assistant to hold the laparoscope.

A unique case of a newborn with a hemangioma on the omphalocele sac

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Evaluation of dynamic/thiol disulphide balance and ischaemia modified albumin in children with trauma

AIM

Trauma is the most common cause of death in childhood. Tissue damage, ischaemia-reperfusion injury and inflammatory response are mainly responsible for increasing free oxygen radicals. In this study, we aimed to investigate the use of thiol-disulphide and ischaemia-modified albumin levels as a diagnostic laboratory parameter in trauma children.

METHODS

Of 202 children, 101 were hospitalised in the paediatric surgical intensive care unit with trauma, and 101 were healthy children. Levels of native thiol (-SH), total thiol (SH + SS), dynamic disulphide (SS), dynamic disulphide (SS)/total thiol (SH + SS), albumin and ischaemic modified albumin (IMA) were measured from the sera of patients and healthy volunteers. For statistical analyses, SPSS 17.0 was used. Mann-Whitney U and paired correlation tests were used where appropriate. P < .05 was considered significant.

RESULTS

The mean age of the patients in the trauma group (boys: 61 girls: 40) was 7.88 years and the control group was 8.00 years. In the trauma group, 86 children were exposed to blunt trauma, 15 children had penetrating trauma and 54 patients had multiple trauma. Surgical procedures were performed on 17 patients. In the trauma group, native thiol, total thiol, dynamic disulphide/total thiol, albumin and IMA levels were significantly lower than that of the control (P < .001), and their dynamic disulphide (P = .001) was higher compared with the control. There was no difference thiol-disulphide parameters in trauma groups sub-division as surgery (n = 17) vs follow-up (n = 84) groups or multiple trauma (n = 54) vs isolated organ trauma (n = 47) groups or penetrating (n = 15) or blunt trauma (n = 86) groups.

CONCLUSION

Thiol-disulphide balance and IMA levels show changes in favour of oxidative stress in children with trauma; however, it cannot be used as a laboratory marker that helps to show the system and organ affected by the trauma and to decide the surgical intervention.

Infections in Pediatric Burn Patients: An Analysis of One Hundred Eighty-One Patients

Background: Infectious complications are one of the most life-threatening complications and result in substantial mortality and morbidity in children who have been burned. The goal of the study is to assess the risk factors for sepsis in pediatric burn patients in a referral hospital. Methods: This study was performed at the Pediatric Burn Unit of Ankara Child Health and Diseases Hematology Oncology Training and Research Hospital during the period between January 2014 and June 2017. The patients were evaluated for age, sex, burn etiology, burned body surface area (BSA), the presence of inhalation injury, sepsis, positive cultures, the micro-organisms cultured samples, and septic focus. Results: A total of 181 patients were included in the study. The most common cause of burns was scalds in 120 patients (66.3%). Forty-one patients (22.7%) developed health-care-associated infection and sepsis. Gram-negative micro-organisms were isolated in 40 (97.6%) patients (Acinetobacter spp., Pseudomonas aeruginosa, Klebsiella pneumonia) with sepsis. Carbapenem resistance was detected in 31 (93.8%) of 40 patients. Mortality was observed in 11 patients (6.1%) in the group with sepsis. Burn surface area, burn depth, C-reactive protein (CRP) values, mortality, Garcés index, and Baux index were higher in the group with sepsis (p < 0.05). Multiple regression analysis revealed that mechanism of injury (flame), burned BSA ≥25%, C-reactive protein ≥6 mg/dL (area under the curve [AUC]: 0.76 p < 0.001 and AUC: 0.90, p < 0.001, respectively) at admission were independent parameters for development of sepsis in pediatric burn patients. Conclusion: Multi-drug-resistant Pseudomonas aeruginosa and Acinetobacter baumannii were important agents of blood stream infection in burned children. Burned BSA ≥25% and CRP ≥6 mg/dL were risk factors for developing sepsis in pediatric burn patients.

Is there an association between histopathological changes in the lower ureter and renal functions? Evaluation of patients who underwent ureteroneocystostomy for ureterovesical obstruction or vesicoureteral reflux

BACKGROUND/AIM

We aimed to assess the relationship between the histological changes of the ureterovesical junction (UVJ) and renal functions. Therefore, we evaluated histological changes of the lower ureter and renal scintigraphy findings of patients for whom ureteroneocystostomy was performed because of vesicoureteral reflux (VUR) or ureterovesical junction obstruction (UVO).

MATERIALS AND METHODS

UVJ specimens were obtained from 18 children. We investigated the changes in neuronal innervation, muscular morphology, extracellular matrix, and apoptosis rate with renal scintigraphy findings.

RESULTS

Seven UVO and 11 VUR patients were treated. Alpha-actin expression in smooth muscle cells was found to be lower (P < 0.001) while neuronal defect was more prominent in the UVO group (P = 0.002). The renal functions decreased as the smooth muscle structural defect increased in the VUR group (P < 0.05).

CONCLUSION

Neuronal tissue and muscle tissue were more defective in the UVO group. The decrease in neuronal fibers and muscle cells explains the pathogenesis of the obstructive group, but no difference was observed regarding the accumulation of collagen type 3 and cellular apoptosis between the VUR and UVO groups. In the VUR group, renal functions decreased while the smooth muscle defect at the distal end of the ureter increased.