PDC 2020 Practice Gaps
With Dr. Liz Byerly & Dr. Eric Skarsgard · hosted by Dr. Todd Ponsky · Live Event Content
Cued at 57:58 · stops at 58:43 · press play
Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
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What the experts said
In the last 40 years, the prevalence of obesity has gone to over 18% of children worldwide
Kids who are obese and receiving therapy for DVT require closer monitoring of their enoxaparin levels because they can have altered drug metabolism due to obesity
A significant number of children with repaired esophageal atresia will have esophageal metaplasia or Barrett's esophagus, and symptoms often do not correlate with pathology
The most likely cause of cardiac arrest during laparoscopy in neonates is pneumopericardium from extraperitoneal insufflation
End-tidal CO2 is the most sensitive detector of a gas embolism during laparoscopic surgery
The problem occurs because insufflation tubing contains air with nitrogen, which is not soluble in blood, unlike carbon dioxide. It's like the baby gets the bends when you insufflate all that air
Prevention strategies include turning gas on and flushing tubing of air before connecting it to the patient, which decreases the amount of nitrogen and air delivered
On thromboelastography, if R time is abnormal, the patient needs FFP. If alpha angle is abnormal, administer cryoprecipitate. If maximum amplitude is abnormal, give platelets. If LY30 shows excessive fibrinolysis, give aminocaproic acid or tranexamic acid
Surgery is a stressor on the pulmonary vascular bed in CDH patients, so we want to see pulmonary artery pressures trending down and less than systemic pressures before operating
For CDH patients with predominantly right ventricular dysfunction on echo, treatment options are nitric oxide, sildenafil, and increasingly PGE1, which maintains the ductus open and allows a pop-off vent for the right ventricle
Giving excessive crystalloid worsens dilutional coagulopathy and increases metabolic acidosis in trauma patients
There is no evidence supporting intentional hypotensive resuscitation as a strategy in pediatric trauma
Half-life of even a living donor kidney is only about 23-24 years, so a 5-year-old receiving a transplant will face retransplant at age 27-28
NASPGHAN and European counterparts recommend screening endoscopy at 10 years of age for esophageal atresia patients, whether or not they're on anti-reflux medications
NASPGHAN guidelines recommend screening endoscopy in early adulthood for esophageal atresia patients, and then every 5 to 10 years for adults
Studies from the Netherlands and Finland showed an increased risk of esophageal carcinoma in patients with repaired esophageal atresia
A survey of pediatric surgeons in the United States found that 28% had experienced gas embolism during neonatal laparoscopy
Canadian CDH Collaborative readiness criteria for surgery include normal blood pressure for age, urine output >1cc/kg/hr, serum lactate <3, FiO2 <50%, preductal saturation around 90%, and pulmonary artery pressures less than systemic
A randomized trial of spontaneous pneumothorax showed roughly equivalent lung re-expansion by 8 weeks (high 90%) between conservative management and intervention groups
The spontaneous pneumothorax trial showed a threefold increase in adverse events in the interventional group, including bleeding, need for catheter repositioning, and continuing air leaks
The spontaneous pneumothorax trial showed a twofold increase in twelve-month recurrence rates for patients who received intervention versus conservative management
ATLS 10th edition guidelines recommend limiting crystalloid to not more than 20cc per kilogram in pediatric trauma resuscitation
Military data from Afghanistan and Iraq showed that increased use of massive transfusion protocols in pediatric trauma patients correlated with decreased mortality between 2001 and 2013
Early balanced blood product resuscitation (red cells, platelets, and plasma) results in using less blood products overall and significantly improved mortality and morbidity outcomes
Military studies clearly show a survival advantage from use of tranexamic acid in trauma patients
SCOPE Collaborative guidelines for peritoneal dialysis catheter placement include preoperative antibiotic with gram-positive coverage, downward or lateral exit site placement, and no suture at the exit site
Failure rates for dialysis access are quite high: 45% within two months for hemodialysis catheters and 30 to 50% for peritoneal dialysis catheters
Analysis of a large international registry shows over 70% of children have a hemodialysis catheter placed and only 26% receive an AV fistula
Multiple studies show superior primary and secondary patency rates for AV fistulas compared to catheters in pediatric patients
Organizations have recommended considering AV fistula use in children over 20 kg who will require at least 12 months of hemodialysis
Entyvio (vedolizumab) is a monoclonal antibody targeted at the gut epithelium with a great safety profile in adult studies
In a 2017 review of 64 children who had failed anti-TNF therapy, 25 reached steroid-free remission with Entyvio
The risk of cancer in complete androgen insensitivity is probably lower than previously thought, closer to 1 to 2% rather than 2 to 5%
Patients with androgen insensitivity report feeling abnormal after gonadectomy even when given estrogens, because the testes are a source of estrogen as well as testosterone that is converted peripherally
Women on estrogens for prolonged periods after gonadectomy have increased cardiovascular risk