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Postoperative management of children after single-stage laryngotracheal reconstruction
B R Jacobs1, B A Salman, R T Cotton
1Department of Otolaryngology, Children's Hospital Medical Center, Cincinnati, OH 45229, USA. jacobs@chmcc.org
Insights
Postoperative care after single-stage laryngotracheal reconstruction in children can avoid physical and pharmacologic restraints. This approach leads to shorter hospital stays and fewer adverse events for developmentally appropriate patients.
Area of Science:
- Pediatric Surgery
- Otolaryngology
- Critical Care Medicine
Background:
- Single-stage laryngotracheal reconstruction is a complex procedure in children.
- Postoperative management traditionally involves sedation and physical restraints.
- The safety and efficacy of alternative postoperative strategies require investigation.
Purpose of the Study:
- To evaluate a postoperative approach for single-stage laryngotracheal reconstruction that omits pharmacologic and physical restraints.
- To assess the impact of liberal physical activity on patient outcomes.
- To compare outcomes between unrestrained and restrained pediatric patients.
Main Methods:
- Retrospective study of 133 children undergoing single-stage laryngotracheal reconstruction (laryngotracheoplasty, tracheal resection, cricotracheal resection).
- Comparison of awake, unrestrained, tracheally intubated patients (n=54) with sedated, restrained patients (n=79).
- Data collected over a 5-year period on postoperative care and complications.
Main Results:
- Unrestrained patients had significantly shorter pediatric intensive care unit (PICU) and hospital lengths of stay.
- Adverse events, including atelectasis and postextubation stridor, were significantly lower in the unrestrained group.
- Withdrawal syndromes were absent in unrestrained patients, compared to 43% in the restrained group.
Conclusions:
- Postoperative management avoiding restraints and allowing physical activity is safe and effective for developmentally appropriate children after single-stage laryngotracheal reconstruction.
- This approach reduces PICU and hospital stays and decreases adverse events.
- Consideration should be given to implementing non-restraint, liberal activity protocols in pediatric intensive care units.
Objective:
To report the safety and efficacy of a postoperative approach that avoids pharmacologic and physical restraints and allows liberal physical activity after single-stage laryngotracheal reconstruction in children.
Design:
Retrospective study.
Setting:
Tertiary care pediatric intensive care unit.
Patients:
One hundred thirty-three children who underwent single-stage laryngotracheal reconstruction, including laryngotracheoplasty, tracheal resection, and cricotracheal resection.
Interventions:
Five-year period of data collection regarding postoperative care and complications.
Measurements And Main Results:
The medical records of all patients (age range, 2-336 months; mean age +/- SEM, 66 +/- 5 months) who underwent single-stage laryngotracheoplasty, tracheal resection, or cricotracheal resection between 1993 and 1998 were reviewed. Tracheally intubated, awake, and unrestrained patients (group 1, n = 54; mean age, 113 +/- 8 months) were compared with tracheally intubated, sedated, and restrained patients (group 2, n = 79; mean age, 33 +/- 3 months). Pediatric intensive care unit length of stay was less in group 1 in comparison with group 2 patients (11.2 +/- 0.5 days vs. 13.7 +/- 0.6 days; p = .007). Hospital length of stay was less in group 1 than group 2 patients (16.7 +/- 1.0 days vs. 21.1 +/- 1.1 days; p = .01). Adverse events were fewer in group 1 compared with group 2 patients: atelectasis, 44% vs. 73% (p < .001); postextubation stridor, 22% vs. 53% (p < .001); and withdrawal syndromes, 0% vs. 43% (p < .001). The occurrence of pneumonia, airleak syndromes, unplanned extubation, and aspiration events was not different between groups.
Conclusions:
For developmentally appropriate children, postoperative management after single-stage laryngotracheal reconstruction does not require the use of physical and pharmacologic restraints. Older children who are not sedated or restrained and who are allowed liberal physical activity have shorter pediatric intensive care unit and hospital lengths of stay, and a decreased incidence of postoperative adverse events. Centers performing single-stage laryngotracheal reconstruction should consider a postoperative management strategy that avoids sedatives, muscle relaxants, and physical restraints, and allows liberal bedside physical activity in developmentally appropriate children.
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