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Surgery for children with disabilities: not without risk
Developmental Medicine & Child Neurology ( IF 3.8 ) Pub Date : 2020-11-23 , DOI: 10.1111/dmcn.14742
Michael H Livingston 1 , J Mark Walton 2 , Eyal Cohen 3
Affiliation  

Surgery has become routine in many parts of the world but is not without risk. Even in the best circumstances, there can be complications. Maybe these are small, like some hoarseness that lasts a day or two after the endotracheal tube is removed, or a wound infection that requires oral antibiotics. Or maybe there are bigger problems, like a pneumonia that prolongs hospital stay, necessitates admission to the intensive care unit, or results in a perioperative mortality. We like to think of these outcomes as rare events. But there is increasing evidence that complications are more common than we might assume. There are two new reports on the surgical care of children with disabilities, using big data from administrative databases in Taiwan and the United States. In the study by Huang et al., children with intellectual disabilities were found to have approximately double the odds of postoperative pneumonia, sepsis, and mortality. Interestingly, the odds of adverse events were increased in both tertiary and non-tertiary settings. Children with intellectual disabilities also experienced longer stays in hospital and increased medical expenditures compared to their matched peers. The risk of complications in children with disabilities increases with additional medical complexity. Berry et al. used administrative data from 49 children’s hospitals in the United States to better understand the use of inpatient resources in children with neurological complex chronic conditions who underwent reconstructive hip surgery. They showed that as the number of co-existing conditions increased from one to four or more, length of stay increased by 67%, costs by 41%, and readmissions by 240%. Malnutrition was particularly associated with increased resource use postoperatively. Studies in other pediatric populations have shown similar findings. Many children’s hospitals (although not all) have recognized that children with medical complexity need to be managed in multidisciplinary teams before, during, and after surgery. This has led to the development of complex care teams and the ‘Perioperative Surgical Home’. These teams bring together a range of specialists that integrate care beyond the technical issues that are the focus of the surgeon and the immediate safety priorities of the anesthetist. This includes a review of nutrition, respiratory status, and cardiac function, among others. Preoperative checklists have also been implemented at most children’s hospitals. These documents focus on immediate safety concerns: correct patient, appropriate procedure, need for preoperative antibiotics, etc. For our most complex patients, however, we need to broaden our timeline and perspective: is this patient growing appropriately and nutritionally replete? Are there other surgical procedures that should be completed before, during, or after the upcoming anesthetic? Is now an appropriate time to proceed with this particular operation? Are there nonoperative options that should be more fully explored? These are not the kind of conversations that we can defer until the day of surgery. We owe it to our patients and their families to systematically assess and discuss these issues ahead of time. Is surgery for children with disabilities safe? It is certainly not without risk, even for seemingly routine procedures in outpatient settings. For children with disabilities undergoing ‘big operations,’ such as those performed in tertiary care centers, we must continue to develop strategies to ensure preoperative optimization and the best possible outcomes.
更新日期:2020-11-23
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