The rectus sheath block has been used with success for postoperative analgesia in adults. This paper reviews the anatomy of the rectus sheath, and presents our initial experience of using the block to provide intra- and postoperative analgesia in children having repair of umbilical and paraumbilical hernia. The rectus sheath block appears to be a useful technique in children, particularly for paediatric day-cases surgery.
Background
Pediatric hematology-oncology (PHO) patients are at significant risk for developing central line-associated bloodstream infections (CLA-BSIs) due to their prolonged dependence on such catheters. Effective strategies to eliminate these preventable infections are urgently needed. In this study, we investigated the implementation of bundled central line maintenance practices and their effect on hospital-acquired CLA-BSIs.
Materials and Methods
CLA-BSI rates were analyzed within a single-institution’s PHO unit between January 2005 and June 2011. In May 2008, a multidisciplinary quality improvement team developed techniques to improve the PHO unit’s safety culture and implemented the use of catheter maintenance practices tailored to PHO patients. Data analysis was performed using time-series methods to evaluate the pre- and post-intervention effect of the practice changes.
Results
The pre-intervention CLA-BSI incidence was 2.92 per 1000-patient days (PD) and coagulase-negative Staphylococcus was the most prevalent pathogen (29%). In the post-intervention period, the CLA-BSI rate decreased substantially (45%) to 1.61 per 1000-PD (p<0.004). Early on, blood and marrow transplant (BMT) patients had a three-fold higher CLA-BSI rate compared to non-BMT patients (p<0.033). With additional infection control countermeasures added to the bundled practices, BMT patients experienced a larger CLA-BSI rate reduction such that BMT and non-BMT CLA-BSI rates were not significantly different post-intervention.
Conclusions
By adopting and effectively implementing uniform maintenance catheter care practices, learning multidisciplinary teamwork, and promoting a culture of patient safety, the CLA-BSI incidence in our study population was significantly reduced and maintained.
A prospective, randomized, double-blind study was conducted to examine the effect of a propofol infusion on the incidence of postoperative emesis in children undergoing outpatient strabismus surgery. Seventy-eight children, aged 3-12 yr, were allocated randomly to receive either nitrous oxide and halothane or nitrous oxide and a propofol infusion for the maintenance of anesthesia. The overall incidence of vomiting during the first 24 h was 64% in those receiving halothane and 41% in those receiving the propofol infusion; this difference was statistically significant (P < 0.05). In children who received no opioids postoperatively, the incidence of vomiting in the first 24 h was 71% in the halothane group and 24% in the propofol group; this difference was also significant (P = 0.001). We conclude that propofol was effective in reducing the incidence of postoperative emesis in pediatric outpatient strabismus surgery.
A prospective, double-blind study was conducted to compare the effect of pressure at the P6 (Neikuan) point with placebo as an antiemetic in children. Sixty-six patients, ages 3-12 yr, undergoing outpatient surgery for correction of strabismus, were allocated randomly to receive either bilateral P6 acupressure or placebo during the perioperative period. The study was designed to detect a 50% difference in the incidence of postoperative vomiting between the two groups, with a 90% power of achieving a statistically significant result at the 5% level (two-tailed). The incidence of postoperative vomiting for the placebo group was 58% before discharge from hospital, 73% at home and 82% in the first 24 h after surgery. The corresponding results for the acupressure group were 58% before discharge, 71% at home and 94% in the first 24 h. These differences were not significant; P6 acupressure did not reduce the incidence of postoperative vomiting in children undergoing strabismus surgery.
In a prospective, double-blind, randomized study, we have compared i.v. ketorolac and morphine in paediatric outpatients undergoing strabismus surgery. Forty-two ASA I or II children, aged 2-12 yr, were allocated randomly to receive either ketorolac 0.75 mg kg-1 i.v. or morphine 0.1 mg kg-1 i.v. and metoclopramide 0.15 mg kg-1. Anaesthesia was induced with propofol and maintained with propofol and nitrous oxide. Pain was assessed at 15-min intervals until discharge, and the incidence of nausea and vomiting was recorded for the first 24 h. There was no difference in pain behaviour scores or recovery times. The incidence of nausea and vomiting during the first 24 h was 19% in the ketorolac group and 71% in the morphine group (P < 0.001). We concluded that ketorolac was an effective analgesic for this type of surgery and that it was associated with less postoperative emesis than morphine and metoclopramide.
Cancellation of planned surgery because of child refusal is not uncommon. It is important to recognize the potentially uncooperative child, particularly older children with developmental delay or a lack of understanding. Discussion with child and parents, selective use of premedication and different induction agents, distraction, play techniques, gentle restraint and the option of cancellation and review should all be considered.
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