PURPOSE:Gabapentin is used for treating postoperative pain and preventing neuropathic pain. We aimed to examine the effects of gabapentin on opioid use and neuropathic pain following minimally invasive repair of pectus excavatum with intercostal nerve cryoablation (MIRPE-INC). METHODS:A prospective comparison study was conducted among patients ≤21 years old undergoing MIRPE-ICN. Patients were grouped based on perioperative gabapentin use (gabapentin beginning 2 weeks prior to MIRPE-INC from March 2021 to December 2022 and no-gabapentin cohorts from June 2023 to June 2024). Participants underwent chest wall sensory examination and neuropathic pain screening (S-LANSS) pre-MIRPE and post-MIRPE (postoperative day 1 (POD1), 2 weeks, 2 months). S-LANSS score ≥12 was suggestive of neuropathic pain. Additionally, inpatient opioid use, inpatient pain scores, and length of stay (LOS) were recorded. Outcomes were compared between cohorts. RESULTS:Of the 112 patients enrolled, 39 received perioperative gabapentin and 73 did not. Age, Haller index, correction index, and BMI were similar between cohorts. The gabapentin cohort was less likely to have neuropathic pain symptoms (S-LANNS ≥12) on POD1 (11.4 % vs 31.9 %, p = 0.023). At 2 weeks and 2 months postoperatively, the frequency of s-LANSS scores ≥12 was similar between treatment groups, as was the incidence of hyperesthesia on chest wall sensory examination. Total inpatient oral morphine equivalents were similar between cohorts. CONCLUSIONS:Perioperative gabapentin use was associated with a decreased incidence of neuropathic pain symptoms immediately post-MIRPE-INC but did not decrease perioperative opioid use or LOS. Gabapentin did not decrease neuropathic pain symptoms outside the immediate perioperative period. LEVEL OF EVIDENCE:Level 2.

BACKGROUND:Cryoablation during minimally invasive repair for pectus excavatum (MIRPE) reduces opioid use and hospital length of stay. Skin hypoesthesia of the chest wall also occurs. This study sought to determine the frequency, onset, duration, and location of sensory changes and neuropathic pain after cryoablation. METHODS:A prospective study was conducted on patients aged ≤21 years undergoing MIRPE with cryoablation of T3 to T7 dermatomes bilaterally for 120 s at a single institution between March 2021 to December 2022. Patients underwent sensory testing of the chest wall and neuropathic pain surveys (S-LANSS) preoperatively and then postoperatively for 6 months. Incidence and duration of hypoesthesia and neuropathic pain were evaluated. RESULTS:Of 61 patients enrolled in the study, 45 completed evaluations at six months postoperatively. All patients had skin hypoesthesia on postoperative day (POD)1. The mean percentage of the treated anterior chest wall surface area (TACWSA) with hypoesthesia to cold stimulus was 52% (±29.3) on POD 0 and 55% (±19.7) on POD 1. Sensation returned over time, with hypoesthesia affecting 11.1% (±15.5) TACWSA at 6 months. At study completion 58% of patients (26/45) had complete return of sensation; hypoesthesia was found at: 1 dermatome 13% (2/45), 2 dermatomes 22% (11/45), and 3 dermatomes 4% (2/45). Neuropathic pain (S-LANSS ≥12) was documented in 16% (9/55) of patients at hospital discharge but decreased to 6.7% of patients at 6 months. CONCLUSION:Onset of skin hypoesthesia after cryoablation occurred on POD0 and affected 52% of the TACWSA. All patients experienced return of sensation to varying degrees, with 58% experiencing normal sensation in all dermatomes by 6 months. The etiology of persistent hypoesthesia to select dermatomes is unknown but may be related to operative technique or cryoablation. Chronic neuropathic pain is uncommon. LEVEL OF EVIDENCE:II. TYPE OF STUDY:Prognosis Study.

Introduction: Cryoablation of intercostal nerves is performed for pain control after minimally invasive repair of pectus excavatum (MIRPE). Cryoablation affects both sensory and motor neurons, resulting in temporary anesthesia to the chest wall and loss of intercostal motor function. The study objective is to determine the effect of cryoablation on incentive spirometry (IS) volumes, as a measure of pulmonary function, after MIRPE.Materials and Methods: A single-institution retrospective review of pediatric patients undergoing MIRPE was performed. All patients received a multimodal regimen (MMR) of analgesics postoperatively. Three groups were compared-cryoablation (CRYO), elastomeric pain pump (EPP), and MMR alone. The primary outcomes were postoperative IS volumes and IS volumes as a ratio of preoperative forced vital capacity (FVC). Secondary outcomes included pain scores, opioid use, length of stay (LOS), and infectious complications.Results: MIRPE was performed in 115 patients: 50 CRYO, 50 EPP, and 15 MMR alone. Groups were similar for demographics and pectus excavatum severity. Postoperative spirometry measurements were similar across groups: IS (CRYO 750 mL [500,961] versus EPP 750 mL [590,1019] versus MMR 696 mL [500,1037], P = .77); IS/FVC (CRYO 0.19 [0.14,0.26] versus EPP 0.20 [0.16,0.26] versus MMR 0.16 [0.15,0.24], P = .69). Although pain scores were also similar across groups, CRYO patients used less opioid (P < .05) and had shorter LOS (P < .05). Postoperative pneumonia was rare and similar across groups (P = 1.00).Conclusion: Intercostal nerve cryoablation during MIRPE does not adversely affect postoperative IS volumes or increase pneumonia rate, despite the temporary loss of motor innervation to intercostal muscles. Cryoablation provides effective pain control with less opioid use.

INTRODUCTION:Current studies show cryoablation decreases opioid requirements and lengths of stay (LOS) in patients undergoing the Nuss procedure for pectus excavatum. This study evaluated the relationship between cryoablation and clinical outcomes for the Nuss procedure. METHODS:A retrospective single-center chart review was performed on patients undergoing the Nuss procedure with intercostal cryoablation from December 2017-August 2021. Demographics, hospital course, and postoperative complications were abstracted. To evaluate the evolution of outcomes over time, the earliest quarter (Q1) of cryoablation patients was compared to the last quarter (Q4). RESULTS:Over 45 months, 350 Nuss procedures with cryoablation were performed. The mean age at operation was 15.7 ± 2.3 years with an average Haller Index of 5.4 ± 4.2. The mean operative time was 136 ± 40.5 minutes. On average, patients used 2.8 ± 2.5 OME/kg of opioid in hospital with a LOS of 2.7 ± 1.1 days. The Q4 patients were discharged 1.3 days earlier (p<0.05) than Q1 patients, with 80% of Q4 discharged by postoperative day #2 vs. 23% in Q1 (p<0.05). Q4 patients received 74% (p<0.05) less opioid in hospital and 21% (p<0.05) less on discharge. Within 90 days postoperatively, complication rates (chest tube placement, wound infection, readmission, neuropathic pain) were similar. Only two patients (0.6%) required reoperation for bar migration/slippage. CONCLUSION:With increased experience, cryoablation for the Nuss procedure decreased opioid use by 74% and was associated with 80% of patients achieving early discharge. Major complication rates were not increased. Cryoablation can be successfully implemented as an effective method of postoperative analgesia. LEVEL OF EVIDENCE:Level III.

Background: Intercostal nerve cryoablation (cryoanalgesia) is increasingly used for pain control in mini-mally invasive repair of pectus excavatum (MIRPE) by Nuss procedure. Cryoanalgesia may lower core body temperature and increase the risk of postoperative infectious complications. We investigated cryoanalge-sia effects on infectious complications following MIRPE. Method: We performed a retrospective review of patients undergoing MIRPE at our institution. Pa-tients treated via multimodal analgesia with cryoanalgesia (Cryo) were compared to patients treated via multimodal analgesia +/-elastomeric pain pumps (Non-cryo). Core body and intraoperative mini-mum/maximum temperatures were recorded. Primary outcomes were wound infection and pneumonia; secondary outcome was length of stay (LOS). Fisher's Exact and Mann-Whitney U tests compared proportions and medians respectively, p-value <= 0.05 being significant. Results: 80 patients were included, 35(43.7%) Cryo and 45(56.3%) Non-cryo. There were no significant differences in median [IQR] for age(15[13.3,16.0];p = 0.86), number of bars inserted (2[1,2]; p = 0.57), or operative time(123.5[98.3, 148.8]; p = 0.11) between the two groups. We found no significant differences in median [IQR] minimum temperature (35.4 degrees C [35.0,35.8]; p = 0.76), median change in intraoperative temperature (-0.13 degrees C [-0.44,0.00]; p = 0.94) or median recovery temperature (-1.10 degrees C [-1.56,-0.65]; p = 0.59) between Cryo and Non-cryo. PACU temperature was significantly lower in the Cryo group, 36.4 degrees C [36.2,36.6] p = 0.04. There were no postoperative wound infections in either group and no significant difference in incidence of postoperative pneumonia (8.57% versus 2.22%, p = 0.31) or median[IQR] for LOS (4[3,4]; p = 0.57), between Cryo and Non-cryo patients. Conclusion: Although cryoanalgesia for MIRPE resulted in lower core body temperature, there appears to be no significant difference between Cryo and Non-Cryo patients for LOS or infectious complications. (C) 2022 Published by Elsevier Inc.

Introduction: Ultra-short bowel syndrome (USBS) was once considered incompatible with life. It can be secondary to multiple cases but most rarely infection or autoimmune disease. Case: We discuss a 13-yr old female with Polyarteritis Nodosa complicated by a necrotizing fungal infection due to C. tropicalis who developed USBS after requiring extensive resection of her bowel, omentum and abdominal wall due to an invasive fungal infection, leaving her with less than 5 cm of jejunum and residual left colon. With intestinal rehabilitation she was able to be weaned down to 70% enteral nutrition and 30% TPN. Conclusion: Ultra-short bowel syndrome is increasing in the pediatric population as rates of survival continue to improve. After management of the acute disease, in this case severe infection and vascular disease, long term management with a focus on providing high-quality multidisciplinary intestinal rehabilitation is vital as well as minimizing PN complications.

PurposeTo assess the diagnostic accuracy of limited abdominal ultrasound (US) examination for midgut volvulus (MGV) and to evaluate how clinical practice has changed in a free-standing children's hospital leading to the near obsolescence of upper GI (UGI) studies for the diagnosis of MGV.Materials and methodsAll patients with suspected MGV who underwent abdominal US during 2016–2017 were identified using keyword search tools in the radiology information system. Retrospective, blinded image review was performed by a certificate of added qualification (CAQ), board certified pediatric radiologist. US images were evaluated for the presence of the superior mesenteric artery (SMA) cutoff sign and twisting of the bowel and mesentery around the SMA (whirlpool sign). The results were compared with the operative reports.Results195 US studies were performed from 2016 to 2017. The most common presentations were vomiting (44%), abdominal pain (7%), and suspected malrotation (10%) 195 US studies were reviewed, of which 16 were nondiagnostic. The remaining 179 diagnostic studies showed MGV in 14 patients. Those 14 patients were surgically explored and confirmed to have midgut volvulus. 7 of the 16 nondiagnostic US studies were further evaluated with UGI examination with 1 patient demonstrating malrotation without volvulus, which was confirmed at surgery. 2 had CT exams which were normal. 4 were followed clinically. The remaining 3 patients went to surgery, all of which did not show MGV. There were 164 negative US, none of whom went to surgery. US was diagnostic in 92% of patients and when diagnostic the positive and negative predictive values of US were 100%.ConclusionLimited abdominal US is a highly accurate examination for the diagnosis of midgut volvulus. UGI exposes patients to ionizing radiation and should be reserved for patients in whom US is nondiagnostic or inconclusive.Type of studyRetrospective review.Level of evidenceLevel 3.

Parathyroid glands are critical for calcium and phosphate homeostasis. Parathyroid disease is relatively rare in the pediatric population, but there are some important pediatric-specific considerations and conditions. This article reviews parathyroid physiology, disorders of hyper- and hypo- function, operative management, and uniquely pediatric diagnoses such as neonatal severe hyperparathyroidism. Advances in preoperative imaging, intra-operative gland identification, and management of post-thyroidectomy hypocalcemia are also presented in detail. This article combines a review of fundamentals with recent advances in care, emphasizing pediatric-specific publications.

More children with congenital heart disease are surviving and require noncardiac surgery. A high-yield summary of congenital heart anatomy and pathophysiology is presented to contextualize these patients for surgeons. Preoperative planning including risk stratification, anesthetic management and timing of elective surgery are discussed. Specific intraoperative considerations for particular cases, such as the use of laparoscopy and thoracic surgery, are reviewed. Postoperative outcomes and recommended management required to mitigate complications are summarized.

Chapter 24 Pediatric Critical Care Erin M. Garvey MD, Erin M. Garvey MDSearch for more papers by this authorJ. Craig Egan MD, J. Craig Egan MDSearch for more papers by this author Erin M. Garvey MD, Erin M. Garvey MDSearch for more papers by this authorJ. Craig Egan MD, J. Craig Egan MDSearch for more papers by this author Book Editor(s):Forrest "Dell" Moore MD, FACS, Forrest "Dell" Moore MD, FACS Vice Chief of Surgery Associate Trauma Medical Director John Peter Smith Health Network/Acclaim Physician Group, Fort Worth, TX, USASearch for more papers by this authorPeter Rhee MD, MPH, FACS, FCCM, DMCC, Peter Rhee MD, MPH, FACS, FCCM, DMCC Professor of Surgery at USUHS, Emory Morehouse Chief of Surgery and Senior Vice President of Grady, Atlanta, GA, USASearch for more papers by this authorGerard J. Fulda MD, FACS, FCCM, Gerard J. Fulda MD, FACS, FCCM Associate Professor Chairman Department of Surgery Department of Surgery, Jefferson Medical College, Philadelphia, PA Physician Leader Surgical Service Line, Christiana Care Health Systems, Newark, DE, USASearch for more papers by this author First published: 10 April 2018 https://doi.org/10.1002/9781119317913.ch24 AboutPDFPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShareShare a linkShare onFacebookTwitterLinked InRedditWechat Summary This is a unique question-and-answer chapter for surgical residents and trainees, concentrating on the pediatric critical care. The Transfusion Requirements in Pediatric Intensive Care Units study randomized to either transfusion threshold 9.5 g/dL or 7 g/dL using leukocyte-reduced packed red blood cells (PRBC). Deaths, Multiple organ dysfunction syndrome (MODS), adverse events, ventilator days, and nosocomial infections were not significantly different in the two groups. When split into subgroups of pediatric cardiac surgery patients and pediatric general surgery patients, the restrictive PRBC transfusion strategy showed no increase in MODS. PRBC transfusions appear to be independently linked to increased risk of morbidity and mortality in critically ill pediatric patients. Pediatric intensivists have recognized that acute respiratory distress syndrome (ARDS) in children is different from ARDS in adults. Recurrent hypotension in a pediatric trauma patient occurs late and may be an ominous sign. Surgical Critical Care and Emergency Surgery: Clinical Questions and Answers, Second Edition RelatedInformation

Background: Cardiac sympathetic denervation (CSD) is a surgical option for patients with life-threatening ventricular arrhythmias. Previously described cohorts included populations in which CSD was performed for primary and secondary prevention. We report the efficacy of CSD as adjunct therapy in children with medically refractory life-threatening arrhythmias. Materials and Methods: Retrospective review of patients undergoing thoracoscopic CSD at one institution between January 2008 and July 2017. Patient demographics, indications, procedural details, complications, length of stay, and effectiveness were evaluated. Results: Ten thoracoscopic CSD procedures were performed in 8 patients. Mean age was 8.2 years (8 days-19 years); mean weight was 32.6kg (2.7-57kg); and 50% were female. Four had long QT syndrome, 3 catecholaminergic polymorphic ventricular tachycardia, and 1 short QT syndrome. All patients had at least two (2 to >40) episodes of resuscitated ventricular arrhythmia and were maximized on medical therapy. Six patients had implantable cardioverter-defibrillators (ICD) with a mean of 11.9 appropriate discharges (1-40) before CSD. All patients underwent left CSD; 2 subsequently required right CSD. Four of the 6 ICD patients experienced dramatic improvement (total 48 ICD discharges pre-CSD; 3 post-CSD). Two patients noncompliant with medical therapy had no significant improvement (24 ICD discharges pre-CSD; 23 post-CSD) and also underwent right CSD, again with no improvement (23 discharges pre-right CSD; 28 post-right CSD). Conclusions: Thoracoscopic CSD can be safely performed in the neonate and pediatric populations. When utilized with medication therapy, CSD is an effective adjunct in reducing ICD discharges and arrhythmias.