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Pneumonia in children after abdominal operations

Pneumonia in children after abdominal operations



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Consequently, young children are prone to suffer from pneumonia after abdominal operations, because they resist breathing (being abdominal) due to pain. As a result the secretions in the lungs tend to accumulate, which may become infected and cause pneumonia.

Iam unable to find which secretions are they and how breathing removes them from lungs?

I thought it could be pleural effusion but unable to figure out the mechanism involved and how it gets infected if it remains there for long.


Abdominal surgery results in a painful wound that affects the abdominal muscles, which are important for coughing. The Lungs and respiratory tracts constantly secrete mucus that flows upwards to the Trachea then down the Oesophagus. The trachea is lined with a moist mucous-membrane layer composed of cells containing small hairlike projections called Cilia. The Cilia project into the channel (lumen) of the trachea to trap particles. The Cilia constantly move in a manner that pushes the mucus up to help clear the respiratory tract of pollutants, debris and bacteria. Here is a link to show the Cilia Movement:

https://www.britannica.com/science/cilium/media/117814/16442

Abdominal Surgery reduces the efficiency of the cough reflex due to abdominal wound pain, while the Anaesthetic results in an increase in mucus due to the upper respiratory tract trauma, with some anaesthetic drugs also increasing these secretions and suppressing Cilia movement. All that eventually results in secretions being produced at a higher rate than being evacuated leading them to accumulate and resulting in an increased risk of lung infection.


Pneumonia after abdominal surgery can develop due to:

  • Decreased breathing movements when lying in the bed
  • Anesthetics/sedation use that decrease the sensation of irritation in the lungs and hence coughing out mucus
  • Pain preventing coughing
  • Eventual mechanical ventilation, especially when the organism is not immune to hospital-acquired (nosocomial) organisms, especially staphylococci
  • Spread of bacteria from the gut to the lungs via the blood)
  • Eventual underlying lung disease

Source: Post-operative pneumonia (TeachMeSurgery)


The association between major complications of immobility during hospitalization and quality of life among bedridden patients: A 3 month prospective multi-center study

While the data does not contain any personal sensitive identifiers, it's deemed as sensitive as it contains sufficient clinical information about patients such as hospital type, unit, length of stay and clinical events for there to be a potential risk of patient re-identification. The Ethics Committee of Peking Union Medical College Hospital that approved the study prohibits the authors from making the research data set publicly available. Access to data may be requested via the Ethics Committee of Peking Union Medical College Hospital ([email protected]).


Evaluation of abdominal pain in children

The differential diagnoses for pediatric abdominal pain are broad and encompass almost every organ system. In addition, distinguishing acute from chronic abdominal pain may be particularly difficult in children. Although the most common etiologies are not immediately life threatening, the ability to diagnose urgent pathology remains paramount. A thorough history and physical exam, and an understanding of the more common diseases affecting the child's age group, are essential.

Gastrointestinal

Gastrointestinal (GI) sources are the most common etiology of abdominal pain in children, encompassing infectious, congenital, functional, and mechanical causes.

A common condition, with a reported pooled prevalence of 9.5%. [1] Koppen IJ, Vriesman MH, Saps M, et al. Prevalence of functional defecation disorders in children: a systematic review and meta-analysis. J Pediatr. 2018 Jul198:121-30.e6. http://www.ncbi.nlm.nih.gov/pubmed/29656863?tool=bestpractice.com

Childhood constipation is typically characterized by infrequent bowel evacuations, large stools, and difficult or painful defecation. [2] Nurko S, Zimmerman LA. Evaluation and treatment of constipation in children and adolescents. Am Fam Physician. 2014 Jul 1590(2):82-90. https://www.aafp.org/afp/2014/0715/p82.html http://www.ncbi.nlm.nih.gov/pubmed/25077577?tool=bestpractice.com

Symptoms usually result from low-fiber, poor-nutrient intake, and too little water, which leads to high levels of colonic reabsorption of water and hardening of the stool. Additional risk factors include genetic predisposition, infection, stress, obesity, low birth weight, cerebral palsy, spina bifida, and learning difficulties.

Constipation starts as an acute problem but can progress to fecal impaction and chronic constipation.

It tends to develop during three stages of childhood: weaning (infants), toilet training (toddlers), starting school (older children).

Develops when the appendiceal lumen becomes obstructed by stool, barium, food, or parasites.

Can occur in all age groups, but is rare in infants. A cohort study in Sweden found that 2.5% of children had had appendicitis by age 18 years. [3] Omling E, Salö M, Saluja S, et al. Nationwide study of appendicitis in children. Br J Surg. 2019 Nov106(12):1623-31. https://bjssjournals.onlinelibrary.wiley.com/doi/full/10.1002/bjs.11298 http://www.ncbi.nlm.nih.gov/pubmed/31386195?tool=bestpractice.com

If left untreated, acute appendicitis progresses to ischemia, necrosis, and eventually perforation. The overall rate of perforation is about 30%. [4] Howell EC, Dubina ED, Lee SL. Perforation risk in pediatric appendicitis: assessment and management. Pediatric Health Med Ther. 2018 Oct 269:135-45. https://www.dovepress.com/perforation-risk-in-pediatric-appendicitis-assessment-and-management-peer-reviewed-fulltext-article-PHMT http://www.ncbi.nlm.nih.gov/pubmed/30464677?tool=bestpractice.com Risk of perforation increases if appendectomy is delayed. [5] Papandria D, Goldstein SD, Rhee D, et al. Risk of perforation increases with delay in recognition and surgery for acute appendicitis. J Surg Res. 2013 Oct184(2):723-9. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4398569 http://www.ncbi.nlm.nih.gov/pubmed/23290595?tool=bestpractice.com [Figure caption and citation for the preceding image starts]: Necrotic appendix From the collection of Dr KuoJen Tsao used with permission [Citation ends]. [Figure caption and citation for the preceding image starts]: CT scan demonstrating fecalith (white arrow) outside the lumen of the appendix consistent with perforated appendix From the collection of Dr KuoJen Tsao used with permission [Citation ends].

May be due to acute or chronic viral infection (especially rotavirus), or bacterial or parasitic infection.

Causes vague, cramping abdominal pain in association with fever, vomiting, and diarrhea.

Eosinophilic gastroenteritis, defined as a condition affecting the GI tract with eosinophil-rich inflammation without a known cause for the eosinophilia, can result in significant abdominal pain. [6] Sunkara T, Rawla P, Yarlagadda KS, et al. Eosinophilic gastroenteritis: diagnosis and clinical perspectives. Clin Exp Gastroenterol. 2019 Jun 512:239-53. https://www.dovepress.com/eosinophilic-gastroenteritis-diagnosis-and-clinical-perspectives-peer-reviewed-fulltext-article-CEG http://www.ncbi.nlm.nih.gov/pubmed/31239747?tool=bestpractice.com

Hemolytic uremic syndrome, characterized by microangiopathic hemolytic anemia, thrombocytopenia, and nephropathy, can occur as a complication of gastroenteritis caused by verotoxin-producing Escherichia coli. Abdominal pain is a common presenting symptom. [7] Salvadori M, Bertoni E. Update on hemolytic uremic syndrome: diagnostic and therapeutic recommendations. World J Nephrol. 2013 Aug 62(3):56-76. https://www.wjgnet.com/2220-6124/full/v2/i3/56.htm http://www.ncbi.nlm.nih.gov/pubmed/24255888?tool=bestpractice.com

Occurs when a proximal segment of the intestine telescopes into the lumen of an immediately distal segment. In most cases, the intussusception is in the ileocecal area. [Figure caption and citation for the preceding image starts]: Intussusception: blood vessels become trapped between layers of intestine, leading to reduced blood supply, edema, strangulation of bowel, and gangrene. Sepsis, shock, and death may eventually occur Created by the BMJ Knowledge Centre [Citation ends].

Usually occurs in infants between 3 and 12 months of age. Peak incidence is 5 to 7 months of age. [8] Jiang J, Jiang B, Parashar U, et al. Childhood intussusception: a literature review. PLoS One. 20138(7):e68482. https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0068482 http://www.ncbi.nlm.nih.gov/pubmed/23894308?tool=bestpractice.com

Intussusception should be suspected in an infant in this age group presenting with colicky abdominal pain, flexing of the legs, fever, lethargy, and vomiting.

In infants <2 years of age, episodes of intussusception are most likely caused by mesenteric lymphadenopathy secondary to an associated illness (e.g., viral gastroenteritis). In older children, mesenteric lymphadenopathy is still the most likely cause, but other etiologies should be considered (e.g., intestinal lymphomas, Meckel diverticulum). Therefore, children ≥6 years or with jejunojejunal or ileoileal intussusception should be evaluated for a malignant lead point.

Ileoileal intussusception may also be indicative of Henoch-Schonlein purpura (HSP). HSP is a vasculitis that affects small veins and primarily occurs in children <11 years of age.

A finger-like projection located in the distal ileum arising from the antimesenteric border usually 40 to 60 cm from the ileocecal valve, measuring 1 to 10 cm long and 2 cm wide. [Figure caption and citation for the preceding image starts]: Intraoperative photo of Meckel diverticulum From the collection of Dr KuoJen Tsao used with permission [Citation ends].

The majority of symptomatic patients present before the age of 2 years.

The prevalence is estimated to be up to 3%. [9] Hansen CC, Søreide K. Systematic review of epidemiology, presentation, and management of Meckel's diverticulum in the 21st century. Medicine (Baltimore). 2018 Aug97(35):e12154. https://journals.lww.com/md-journal/Fulltext/2018/08310/Systematic_review_of_epidemiology,_presentation,.91.aspx http://www.ncbi.nlm.nih.gov/pubmed/30170459?tool=bestpractice.com

Intestinal obstruction is a known complication and may be observed in as many as 40% of all symptomatic Meckel diverticula (according to some series). [10] Elsayes KM, Menias CO, Harvin HJ, et al. Imaging manifestations of Meckel's diverticulum. AJR Am J Roentgenol. 2007 Jul189(1):81-8. https://www.ajronline.org/doi/full/10.2214/AJR.06.1257 http://www.ncbi.nlm.nih.gov/pubmed/17579156?tool=bestpractice.com [11] Lin XK, Huang XZ, Bao XZ, et al. Clinical characteristics of Meckel diverticulum in children: a retrospective review of a 15-year single-center experience. Medicine (Baltimore). 2017 Aug96(32):e7760. https://journals.lww.com/md-journal/Fulltext/2017/08110/Clinical_characteristics_of_Meckel_diverticulum_in.43.aspx http://www.ncbi.nlm.nih.gov/pubmed/28796070?tool=bestpractice.com

Refers to inflammation of the mesenteric lymph nodes. This process may be acute or chronic.

It is often mistaken for other diagnoses, such as appendicitis up to 23% of patients undergoing negative appendectomy have been found to have nonspecific mesenteric adenitis. [12] Karabulut R, Sonmez K, Turkyilmaz Z, et al. Negative appendectomy experience in children. Ir J Med Sci. 2011 Mar180(1):55-8. http://www.ncbi.nlm.nih.gov/pubmed/20658324?tool=bestpractice.com

One retrospective study reported that, compared with children who have appendicitis, patients who have mesenteric adenitis are more likely to have high fever (above 102.2°F [39°C]) and dysuria, and are less likely to have migratory pain, vomiting, or typical abdominal signs of appendicitis on examination. [13] Gross I, Siedner-Weintraub Y, Stibbe S, et al. Characteristics of mesenteric lymphadenitis in comparison with those of acute appendicitis in children. Eur J Pediatr. 2017 Feb176(2):199-205. http://www.ncbi.nlm.nih.gov/pubmed/27987102?tool=bestpractice.com

Most commonly diagnosed in the first year of life, but can present later in childhood slightly higher male preponderance.

Congenital condition characterized by partial or complete colonic obstruction associated with the absence of intramural ganglion cells. Because of the aganglionosis, the lumen is tonically contracted, causing a functional obstruction. The aganglionic portion of the colon is always located distally, but the length of the segment varies. [Figure caption and citation for the preceding image starts]: Abdominal x-ray of a neonate with abnormal stooling pattern and constipation. The dilated transverse and descending colon is suggestive of Hirschsprung disease From the collection of Dr KuoJen Tsao used with permission [Citation ends].

May be associated with Down syndrome and multiple endocrine neoplasia type IIA.

Small or large bowel obstruction may be the result of various etiologies and can occur at any age. Abdominal pain may not occur until the obstruction has progressed to include extensive abdominal distension or intestinal ischemia. Intestinal obstruction may mimic intestinal ileus, which usually does not require surgical intervention.

The etiology of intestinal obstruction can be congenital or acquired. Congenital causes include atresias or stenosis, which present in the newborn period. Acquired causes include small bowel adhesions, strangulated or incarcerated hernias, and tumors.

Duodenal atresia or stenosis may cause complete or partial obstruction of the duodenum as a result of failed recanalization during development. This results in either stenosis with incomplete obstruction of the duodenal lumen (allowing some but not all gas and liquid to pass) or an atresia where the duodenum ends blindly causing a true complete obstruction.

Jejunoileal atresia or stenosis is a complete or partial obstruction of any part of the jejunum or ileum. Although uncertain, it is believed to result from a vascular accident during development. Jejunal stenosis may still have bowel lumen continuity with a narrowed lumen and thickened muscular layer. There are four types of atretic bowel, and all result in a complete obstruction due to a blind-ending lumen.

Hernias may be internal or external and congenital or acquired.

Colonic atresia is an extremely rare complete obstruction of any part of the colon, although it usually occurs near the splenic flexure. Like jejunoileal atresia, it is thought to occur as a result of a vascular event. [Figure caption and citation for the preceding image starts]: Abdominal x-ray demonstrating double bubble gas pattern consistent with duodenal atresia From the collection of Dr KuoJen Tsao used with permission [Citation ends].

Meconium ileus is an important cause of intestinal obstruction in the neonatal period cystic fibrosis should be suspected as an associated disease. There may also be associated pancreatic abnormalities.

Duplication cysts occur most commonly in the small intestine they may serve as a lead point for volvulus and intussusception and can also result in obstruction. With duodenal duplication cysts, peptic ulcer disease, hemorrhage, or perforation may result secondary to ectopic gastric mucosa.

Tumors may be intraluminal or extra-intestinal.

Hernias may be internal or external and congenital or acquired. [Figure caption and citation for the preceding image starts]: Infant with right groin bulge consistent with incarcerated inguinal hernia. The lack of overlying skin edema and erythema does not rule out strangulation of the small intestine From the collection of Dr KuoJen Tsao used with permission [Citation ends].

A history of previous intra-abdominal surgery or inflammation (such as necrotizing enterocolitis) should prompt concern for adhesive small bowel obstruction.

Omental cysts, although rare, can present with intestinal obstruction may be confused with ovarian cysts on ultrasound.

In patients with cystic fibrosis, partial bowel obstruction may sometimes be referred to as distal intestinal obstruction syndrome (DIOS) or meconium ileus-equivalent syndrome. This entity is not related to meconium. This refers to a distal small bowel obstruction caused by impacted bowel contents it typically occurs in adolescents and adults with cystic fibrosis.

This can occur in any age group, but is most common in children <1 year old at least 60% of children present before 1 month of age. [14] Shalaby MS, Kuti K, Walker G. Intestinal malrotation and volvulus in infants and children. BMJ. 2013 Nov 26347:f6949. http://www.ncbi.nlm.nih.gov/pubmed/24285798?tool=bestpractice.com Midgut volvulus is the most common type. Sigmoid volvulus can also occur.

Green (bilious) vomiting is a cardinal symptom of duodenal obstruction secondary to midgut volvulus. [14] Shalaby MS, Kuti K, Walker G. Intestinal malrotation and volvulus in infants and children. BMJ. 2013 Nov 26347:f6949. http://www.ncbi.nlm.nih.gov/pubmed/24285798?tool=bestpractice.com

Intestinal malrotation is a term used to encompass the entire spectrum of anatomic arrangements that result from incomplete rotation of the gut during embryonic development. Volvulus of the entire small bowel and part of the colon is only possible when malrotation exists.

In malrotation, the most significant pathologic concerns are a lack of gut fixation to the retroperitoneum and narrow midgut mesenteric base that predisposes patients to midgut volvulus, which occurs when the duodenum or colon twist around this mesenteric base.

A disease primarily of premature infants, particularly those weighing less than 1500 g. The pathogenesis is multifactorial and not well understood, although ischemia, reperfusion injury, and infectious pathogens may play a role.

Typical symptoms are feed intolerance, abdominal distension, and bloody diarrhea at 8 to 10 days of age. [15] Neu J, Walker WA. Necrotizing enterocolitis. N Engl J Med. 2011 Jan 20364(3):255-64. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3628622 http://www.ncbi.nlm.nih.gov/pubmed/21247316?tool=bestpractice.com Other signs and symptoms include apnea, lethargy, abdominal tenderness, abdominal wall erythema, and bradycardia.

Gastric and duodenal ulcers are uncommon among the pediatric population. [16] Sullivan PB. Symposium: gastroenterology. Peptic ulcer disease in children. Paediatr Child Health. 2010 Oct20(10):462-4. https://www.paediatricsandchildhealthjournal.co.uk/article/S1751-7222(10)00093-4/abstract When they occur, they are classified as primary or secondary peptic ulcers.

Primary ulcers occur without predisposing factors and are most commonly located in the duodenum or pyloric channel. They manifest most often in older children and adolescents with a positive family history. Rarely, primary peptic ulcers can occur in the first month of life, presenting with bleeding and possible perforation. Most are located in the stomach. Primary ulcers may be associated with Helicobacter pylori.

Secondary ulcers are usually associated with stress, burns, trauma, infection, neonatal hypoxia, chronic illness, and ulcerogenic medications or lifestyle habits (e.g., NSAIDs, salicylates, corticosteroids, smoking, intake of caffeine, nicotine, or alcohol). It is important to treat the predisposing condition. Exacerbations and remissions can last for weeks to months.

Inflammatory bowel disease

This category includes ulcerative colitis and Crohn disease.

Ulcerative colitis affects the rectum and extends proximally, and is characterized by diffuse inflammation of the colonic mucosa and a relapsing, remitting course. Ulcerative colitis is uncommon in people younger than 10 years old.

Crohn disease may involve any or all parts of the entire GI tract from mouth to perianal area. Unlike ulcerative colitis, Crohn disease is characterized by skip lesions. The transmural inflammation often leads to fibrosis, causing intestinal obstruction. The inflammation can also result in sinus tracts that burrow through and penetrate the serosa, thereafter giving rise to perforations and fistulas. The peak age of onset is between 15 and 40 years.

Ulcerative colitis often presents with bloody diarrhea, whereas this is an unusual presentation in Crohn disease. Both conditions cause cramping abdominal pain, anorexia, and weight loss when they present late in the course of the disease. Depending on the intestinal location of Crohn disease, it may mimic other disease processes such as acute appendicitis.

Systemic autoimmune disease triggered by dietary gluten peptides found in wheat, rye, barley, and related grains.

Immune activation in the small intestine leads to villous atrophy, hypertrophy of the intestinal crypts, and increased numbers of lymphocytes in the epithelium and lamina propria. Locally these changes lead to GI symptoms and malabsorption.

Celiac disease is a common disorder in the US and in Europe. A relatively uniform prevalence has been found in many countries, with pooled global seroprevalence and biopsy-confirmed prevalence of 1.4% and 0.7%, respectively. [17] Singh P, Arora A, Strand TA, et al. Global prevalence of celiac disease: systematic review and meta-analysis. Clin Gastroenterol Hepatol. 2018 Jun16(6):823-36.e2. https://www.cghjournal.org/article/S1542-3565(17)30783-8/fulltext http://www.ncbi.nlm.nih.gov/pubmed/29551598?tool=bestpractice.com

Patients may present with recurrent abdominal pain, cramping, or distension. [18] National Institute for Health and Care Excellence. Coeliac disease: recognition, assessment and management. Sep 2015 [internet publication]. https://www.nice.org.uk/guidance/ng20 Other common symptoms include bloating and diarrhea. Dermatitis herpetiformis, an intensely pruritic papulovesicular rash that affects the extensor limb surfaces, almost universally occurs in association with celiac disease.

Cholelithiasis describes the entity of stones in the gallbladder (usually asymptomatic or an incidental finding). Biliary colic refers to the classic description of intermittent, recurrent right upper quadrant (RUQ) pain that resolves without intervention. This is usually caused by intermittent obstruction of the cystic duct due to cholelithiasis and contraction of a distended gallbladder. [Figure caption and citation for the preceding image starts]: Gallbladder ultrasound demonstrating cholelithiasis with characteristic shadowing From the collection of Dr KuoJen Tsao used with permission [Citation ends]. [Figure caption and citation for the preceding image starts]: Abdominal x-ray with opacities in the RUQ consistent with gallstones From the collection of Dr Kuojen Tsao used with permission [Citation ends].

Cholecystitis refers to inflammation of the gallbladder precipitated by obstruction of bile through the cystic duct. Symptoms do not usually resolve spontaneously, and there are specific findings on diagnostic imaging. Cholecystitis may be acalculous (without stones) or calculous (with stones). Choledocholithiasis is the term describing a gallstone(s) in the common bile duct.

Characterized by symptoms of biliary colic (intermittent, recurrent RUQ pain that resolves without intervention) in the absence of documented stones in the gallbladder the diagnosis should be considered in those with symptoms suggestive of biliary colic but with negative laboratory tests and ultrasound in their workup for symptomatic cholelithiasis.

Caused by abnormal or altered contraction of the gallbladder resulting in biliary colic. Patients frequently have gone through a comprehensive workup prior to being diagnosed with this entity increasing recognition and testing for the disease has led to more frequent diagnosis in children.

The viral hepatitides include A, B, C, D, and E.

Hepatitis A virus remains a significant etiology of acute viral hepatitis and jaundice, particularly in developing countries, in travelers to those countries, and in sporadic food-borne outbreaks in developed countries.

Hepatitis B virus (HBV) frequently causes acute hepatitis and is the most common cause of chronic hepatitis in Africa and the Far East.

Hepatitis C virus (HCV) represents the leading cause of chronic viral hepatitis in developed countries.

Hepatitis D virus is a defective virus that needs the presence of hepatitis B to cause clinically recognizable disease.

Hepatitis E virus represents a major cause of mortality in developing countries, especially among pregnant females.

Refers to inflammation of the pancreas it does not necessarily imply that infection is present.

Pancreatitis in children is often due to drugs, infection, anatomic abnormalities, or trauma. [19] Suzuki M, Sai JK, Shimizu T. Acute pancreatitis in children and adolescents. World J Gastrointest Pathophysiol. 2014 Nov 155(4):416-26. https://www.wjgnet.com/2150-5330/full/v5/i4/416.htm http://www.ncbi.nlm.nih.gov/pubmed/25400985?tool=bestpractice.com Corticosteroids, adrenocorticotropic hormones, estrogens including contraceptives, azathioprine, asparaginase, tetracycline, chlorothiazides, and valproic acid may induce pancreatitis. Congenital causes include choledochal cyst causing abnormal pancreas and bile drainage and pancreas divisum. Infectious causes include mumps and infectious mononucleosis.

Excessive alcohol and gallstones are the most common causes of pancreatitis in adults these causes are relatively less common in children, although they may still occur. Pediatric pancreatitis is rare, but the growing population of children with gallstones will likely increase future incidence. [Figure caption and citation for the preceding image starts]: CT scan of teenage girl presenting with mid-epigastric abdominal pain as a result of gallstone pancreatitis. The large fluid collection in the pancreatic bed (white arrow) and lack of pancreatic enhancement suggest liquefactive necrosis of the pancreas From the collection of Dr KuoJen Tsao used with permission [Citation ends].

Splenic infarction and cysts

Cysts are classified as either primary or secondary (acquired). Primary cysts are usually congenital and have a true epithelial lining. Eighty percent of splenic cysts are pseudocysts related to infection, infarction, or trauma. [20] Burgener FA, Meyers SP, Tan RK, et al. Differential diagnosis in magnetic resonance imaging. New York: Thieme 2002: 530. Most cysts are incidental diagnoses, although some patients may present with dull, left-sided abdominal pain. In pediatric patients, the most common splenic masses are congenital and/or acquired cysts. [21] Aslam S, Sohaib A, Reznek RH. Reticuloendothelial disorders: the spleen. In: Adam A, Dixon A, eds. Grainger and Allison's Diagnostic radiology. 5th ed. Philadelphia: Churchill Livingstone 2008: 1759-70. [Figure caption and citation for the preceding image starts]: CT scan demonstrating fluid-filled cyst within the spleen From the collection of Dr Kuojen Tsao used with permission [Citation ends]. [Figure caption and citation for the preceding image starts]: Intraoperative photo of large splenic cyst From the collection of Dr KuoJen Tsao used with permission [Citation ends].

Splenic infarction occurs when there is occlusion of the splenic blood supply. It may affect the whole organ or only a portion of the spleen, depending on the blood vessels involved. The incidence of splenic infarction is difficult to assess.

A multicenter prospective study found that abdominal trauma accounted for 3% of admissions to pediatric trauma units. [22] Bradshaw CJ, Bandi AS, Muktar Z, et al. International study of the epidemiology of paediatric trauma: PAPSA Research Study. World J Surg. 2018 Jun42(6):1885-94. https://link.springer.com/article/10.1007%2Fs00268-017-4396-6 http://www.ncbi.nlm.nih.gov/pubmed/29282513?tool=bestpractice.com

Generally classified as penetrating or blunt. Occult blunt abdominal trauma should always be considered in the setting of vague or inconsistent history. The liver, spleen, and kidneys are the most commonly injured intra-abdominal organs in blunt trauma. Most cases of blunt injury to the liver and spleen are managed nonoperatively.

It is important to exclude duodenal and/or pancreatic injuries with bicycle handlebar injuries and/or direct blows to the abdomen. Hollow viscus injuries (e.g., stomach and intestines) are more common with penetrating trauma.

It is essential to consider child abuse/nonaccidental trauma in this patient population (e.g., a kick to the abdomen).

Genitourinary

Urinary tract infection (UTI)

Infection may arise along any part of the urinary tract including the urethra, bladder, ureter, and kidney. Diagnosis and treatment is paramount to prevent potential long-term side effects, including renal or urinary tract scarring and hypertension.

Estimates of the true incidence of UTI depend on rates of diagnosis and investigation. UTI is more common in girls. UTIs affect approximately 4% and 10% of children by ages 1 year and 6 years, respectively. [23] Ladomenou F, Bitsori M, Galanakis E. Incidence and morbidity of urinary tract infection in a prospective cohort of children. Acta Paediatr. 2015 Jul104(7):e324-9. http://www.ncbi.nlm.nih.gov/pubmed/25736706?tool=bestpractice.com

Bacterial infections are the most common cause, particularly Escherichia coli infection.

Dysmenorrhea, or painful menstruation, is one of the most common gynecologic conditions affecting females of reproductive age. [24] De Sanctis V, Soliman A, Bernasconi S, et al. Primary dysmenorrhea in adolescents: prevalence, impact and recent knowledge. Pediatr Endocrinol Rev. 2015 Dec13(2):512-20. http://www.ncbi.nlm.nih.gov/pubmed/26841639?tool=bestpractice.com

Primary dysmenorrhea is characterized by menstrual pain in the absence of pelvic pathology.

Refers to stones that may be located anywhere in the genitourinary tract the majority of stones are noted in the kidneys, followed by the bladder and ureter.

Most patients have a predisposing factor, such as a family history of nephrolithiasis, high-risk diet (e.g., high oxalate intake), or chronic disease (e.g., renal tubular acidosis).

Stones less than 5 mm in diameter will generally pass spontaneously.

A urologic emergency caused by the twisting of the testicle on the spermatic cord, leading to constriction of the vascular supply and time-sensitive ischemia and/or necrosis of testicular tissue. [25] Sharp VJ, Kieran K, Arlen AM. Testicular torsion: diagnosis, evaluation, and management. Am Fam Physician. 2013 Dec 1588(12):835-40. https://www.aafp.org/afp/2013/1215/p835.html http://www.ncbi.nlm.nih.gov/pubmed/24364548?tool=bestpractice.com [Figure caption and citation for the preceding image starts]: Young boy with right testicular pain. The testicle is swollen, tender, and erythematous as a result of torsion of the appendix testes. The clinical signs and symptoms mimic those of testicular torsion From the collection of Dr KuoJen Tsao used with permission [Citation ends]. [Figure caption and citation for the preceding image starts]: Infant boy with swollen, tender, and erythematous left testicle. The testicle is retracted consistent with testicular torsion From the collection of Dr KuoJen Tsao used with permission [Citation ends]. [Figure caption and citation for the preceding image starts]: Torsion of an appendix testis resulting in acute infarction From the collection of Dr KuoJen Tsao used with permission [Citation ends].

Has a bimodal distribution, with extravaginal torsion affecting neonates in the perinatal period, and intravaginal torsion affecting males of any age but most commonly adolescent boys. [25] Sharp VJ, Kieran K, Arlen AM. Testicular torsion: diagnosis, evaluation, and management. Am Fam Physician. 2013 Dec 1588(12):835-40. https://www.aafp.org/afp/2013/1215/p835.html http://www.ncbi.nlm.nih.gov/pubmed/24364548?tool=bestpractice.com

Pain from torsion of a testicular appendage may develop more gradually (over days to weeks) and frequently is pinpoint (superior pole of testes). In addition, systemic symptoms such as nausea and vomiting are not usually present.

Ovarian cyst rupture is rare and may occur in conjunction with torsion.

Symptoms usually occur prior to the expected time of ovulation and may mimic ruptured ectopic pregnancy. Pain arises from local peritonitis secondary to hemorrhage. [26] Katz VL. Benign gynecologic lesions: vulva, vagina, cervix, uterus, oviduct, ovary. In: Katz VL, Lentz GM, Lobo RA, et al., eds. Comprehensive gynecology. Philadelphia: Mosby 2007: Chap. 18. [27] Boyle KJ, Torrealday S. Benign gynecologic conditions. Surg Clin North Am. 2008 Apr88(2):245-64. http://www.ncbi.nlm.nih.gov/pubmed/18381112?tool=bestpractice.com [28] Schultz KA, Ness KK, Nagarajan R, et al. Adnexal masses in infancy and childhood. Clin Obstet Gynecol. 2006 Sep49(3):464-79. http://www.ncbi.nlm.nih.gov/pubmed/16885654?tool=bestpractice.com

Although it can affect females of any age it most commonly occurs in the early reproductive years. [29] Emeksiz HC, Derinöz O, Akkoyun EB, et al. Age-specific frequencies and characteristics of ovarian cysts in children and adolescents. J Clin Res Pediatr Endocrinol. 2017 Mar 19(1):58-62. http://cms.galenos.com.tr/Uploads/Article_15636/58-62.pdf http://www.ncbi.nlm.nih.gov/pubmed/28044991?tool=bestpractice.com

In children, torsion of the ovary is often associated with the presence of an ovarian tumor, most commonly a teratoma.

Twisting or torsion of the ovary compromises the arterial inflow and venous outflow, producing ischemia, which, if not relieved promptly, can affect the viability of the ovary. [Figure caption and citation for the preceding image starts]: Intraoperative photo of ovarian mass that presented as ovarian torsion From the collection of Dr KuoJen Tsao used with permission [Citation ends]. [Figure caption and citation for the preceding image starts]: CT scan of a young girl presenting with ovarian torsion. The large pelvic cystic lesion contains calcifications (white arrow) consistent with a teratoma or dermoid cyst From the collection of Dr KuoJen Tsao used with permission [Citation ends].

Pelvic inflammatory disease (PID)

Represents a spectrum of upper genital tract infections that includes any combination of endometritis, salpingitis, pyosalpinx, tubo-ovarian abscess, and pelvic peritonitis usually caused by Neisseria gonorrhoeae or Chlamydia trachomatis and less commonly by normal vaginal flora including streptococci, anaerobes, and enteric gram-negative rods.

Adolescents are at higher risk of developing PID compared with older women. [30] Trent M. Pelvic inflammatory disease. Pediatr Rev. 2013 Apr34(4):163-72. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4530285 http://www.ncbi.nlm.nih.gov/pubmed/23547062?tool=bestpractice.com Sexually transmitted infections are a key risk factor.

PID in a young child should prompt workup for possible sexual abuse, as it is extremely rare for PID to occur in the absence of sexual activity.

Miscarriage and ectopic pregnancy should be a concern in any female of reproductive age presenting with lower abdominal pain, amenorrhea, and vaginal bleeding.

Miscarriage is defined as an involuntary, spontaneous loss of a pregnancy before 22 completed weeks. [31] WHO Department of Reproductive Health and Research. Vaginal bleeding in early pregnancy. Managing complications in pregnancy and childbirth: a guide for midwives and doctors. 2003:S-7. https://apps.who.int/iris/bitstream/handle/10665/43972/9241545879_eng.pdf The majority of spontaneous miscarriages occur in the first trimester. [32] American College of Obstetrics and Gynaecology. Early pregnancy loss. Practice bulletin 200. Nov 2018 [internet publication]. https://www.acog.org/clinical/clinical-guidance/practice-bulletin/articles/2018/11/early-pregnancy-loss

Ectopic pregnancy occurs when a fertilized ovum implants and matures outside the uterine endometrial cavity, with the most common sites being the fallopian tube (97%), the ovary (3.2%), and the abdomen (1.3%). [33] Bouyer J, Coste J, Fernandez H, et al. Sites of ectopic pregnancy: a 10 year population-based study of 1800 cases. Hum Reprod. 2002 Dec17(12):3224-30. https://academic.oup.com/humrep/article/17/12/3224/569616 http://www.ncbi.nlm.nih.gov/pubmed/12456628?tool=bestpractice.com Use of oral contraceptives before age 16 years is associated with increased risk of ectopic pregnancy. [34] Gaskins AJ, Missmer SA, Rich-Edwards JW, et al. Demographic, lifestyle, and reproductive risk factors for ectopic pregnancy. Fertil Steril. 2018 Dec110(7):1328-37. https://www.fertstert.org/article/S0015-0282(18)31831-4/fulltext http://www.ncbi.nlm.nih.gov/pubmed/30503132?tool=bestpractice.com The classic presentation includes lower abdominal pain, amenorrhea, and vaginal bleeding. Hemorrhage from a ruptured ectopic pregnancy can be fatal.

Pulmonary

Primary respiratory illnesses such as pneumonia or empyema may present as abdominal pain in the pediatric population. Recurrent pneumonia in children is usually the result of a particular susceptibility, such as disorders of immunity and leukocyte function, ciliary function, anatomic abnormalities, or specific genetic disorders such as cystic fibrosis. [35] Sectish TC, Prober CG. Pneumonia. In: Behrman RE, Kliegman RM, Jenson HB, eds. Nelson textbook of pediatrics. 18th ed. Philadelphia: WB Saunders 2007: 1795-800.

Functional abdominal pain

Functional abdominal pain is also referred to as nonspecific abdominal pain pain is usually chronic or recurrent. Visceral hyperalgesia is the final outcome of sensitizing medical and psychosocial events, on a background of genetic predisposition. [36] Hyams JS, Di Lorenzo C, Saps M, et al. Childhood functional gastrointestinal disorders: child/adolescent. Gastroenterology. 2016 May150(6):P1456-68.e2. http://www.ncbi.nlm.nih.gov/pubmed/27144632?tool=bestpractice.com Functional abdominal pain disorders are classified according to Rome IV criteria, which describe functional dyspepsia, irritable bowel syndrome, abdominal migraine, and functional abdominal pain - not otherwise specified. [36] Hyams JS, Di Lorenzo C, Saps M, et al. Childhood functional gastrointestinal disorders: child/adolescent. Gastroenterology. 2016 May150(6):P1456-68.e2. http://www.ncbi.nlm.nih.gov/pubmed/27144632?tool=bestpractice.com [37] Drossman DA, Chang L, Chey WD, et al. Rome IV: functional gastrointestinal disorders, disorders of gut-brain interaction. 4th ed. Raleigh, NC: Rome Foundation 2017.

Typically affects children between 5 and 14 years of age.

Prevalence estimates vary from 10% to 30% in samples of school students, to 87% in some gastroenterology clinics. [38] Boronat AC, Ferreira-Maia AP, Matijasevich A, et al. Epidemiology of functional gastrointestinal disorders in children and adolescents: a systematic review. World J Gastroenterol. 2017 Jun 723(21):3915-27. https://www.wjgnet.com/1007-9327/full/v23/i21/3915.htm http://www.ncbi.nlm.nih.gov/pubmed/28638232?tool=bestpractice.com

Family history of functional disorder common (irritable bowel syndrome, mental illness, migraine, anxiety).

Clarifying the type of functional disorder is important to determine which treatments are most likely to improve symptoms.

Defined as one or more of the following bothersome symptoms on at least 4 days per month: postprandial fullness, early satiation, epigastric pain, or burning not associated with defecation. After appropriate evaluation the symptoms cannot be fully explained by another medical condition. [36] Hyams JS, Di Lorenzo C, Saps M, et al. Childhood functional gastrointestinal disorders: child/adolescent. Gastroenterology. 2016 May150(6):P1456-68.e2. http://www.ncbi.nlm.nih.gov/pubmed/27144632?tool=bestpractice.com

Three criteria must be fulfilled for 2 months prior to diagnosis: [36] Hyams JS, Di Lorenzo C, Saps M, et al. Childhood functional gastrointestinal disorders: child/adolescent. Gastroenterology. 2016 May150(6):P1456-68.e2. http://www.ncbi.nlm.nih.gov/pubmed/27144632?tool=bestpractice.com

Abdominal pain at least 4 days per month associated with one or more of:

Change in stool frequency

In children with constipation, the pain does not resolve with resolution of constipation.

After appropriate evaluation the symptoms cannot be fully explained by another medical condition.

All of the following criteria must be fulfilled for at least 6 months prior to diagnosis and on at least two occasions: [36] Hyams JS, Di Lorenzo C, Saps M, et al. Childhood functional gastrointestinal disorders: child/adolescent. Gastroenterology. 2016 May150(6):P1456-68.e2. http://www.ncbi.nlm.nih.gov/pubmed/27144632?tool=bestpractice.com

Paroxysmal episodes of intense, acute periumbilical, midline, or diffuse abdominal pain lasting at least 1 hour. The abdominal pain must be the most severe and distressing symptom.

Episodes separated by weeks or months.

Pain is incapacitating and interferes with normal activities.

Stereotypical pattern and symptoms in the individual.

Pain associated with 2 or more of:

After appropriate evaluation the symptoms cannot be fully explained by another medical condition.

Functional abdominal pain - not otherwise specified

Three diagnostic criteria must be fulfilled at least four times per month, for 2 months prior to diagnosis: [36] Hyams JS, Di Lorenzo C, Saps M, et al. Childhood functional gastrointestinal disorders: child/adolescent. Gastroenterology. 2016 May150(6):P1456-68.e2. http://www.ncbi.nlm.nih.gov/pubmed/27144632?tool=bestpractice.com

Episodic or continuous abdominal pain that does not occur solely during physiologic events (e.g., eating, menstruation)

Insufficient criteria for irritable bowel syndrome, functional dyspepsia, or abdominal migraine diagnosis

After appropriate evaluation the symptoms cannot be fully explained by another medical condition.

Alarm features in children with chronic abdominal pain, which may indicate an organic or motility-related rather than a functional cause, include: [36] Hyams JS, Di Lorenzo C, Saps M, et al. Childhood functional gastrointestinal disorders: child/adolescent. Gastroenterology. 2016 May150(6):P1456-68.e2. http://www.ncbi.nlm.nih.gov/pubmed/27144632?tool=bestpractice.com

Family history of inflammatory bowel disease, celiac disease, or peptic ulcer disease


Physical Examination

A complete examination with attention to pharyngeal erythema or exudate and focal consolidation in the lungs should be performed in children with acute abdominal pain. An abdominal examination in a sick, crying child can be difficult to perform. A family member can assist by placing his or her hands on the abdomen with the examiner's hands on top of them until the child allows the examination. Asking the child to point to the part of the abdomen that hurts the most, and then initially avoiding that area, can also facilitate the examination.

Auscultation of bowel sounds can help a clinician understand where the abdomen is painful because the child may try to block the stethoscope from that area. Absent bowel sounds can indicate ileus or peritonitis, whereas hyperactive bowel sounds may indicate obstruction. Beginning palpation just above the iliac crest in the lower quadrants of the abdomen will help identify an enlarged liver, spleen, or other abdominal mass. Gentle palpation can elicit guarding, and percussion without deep palpation can elicit rebound pain. Guarding and rebound pain can be consistent with peritonitis. Signs suggestive of the possible need for surgery for acute abdominal pain are listed in Table 3 . Rectal examination may be necessary to identify a pelvic abscess or occult blood in the stool. Pelvic examination is required in pubertal girls to evaluate for pregnancy complications and sexually transmitted infections scrotal examination is indicated in boys.

Signs Indicating the Possible Need for Surgery in Patients with Acute Abdominal Pain

Bloody diarrhea or occult blood in stool

Elevated temperature (≥ 100.4°F [38.0°C])

Rigidity (involuntary guarding)

Signs Indicating the Possible Need for Surgery in Patients with Acute Abdominal Pain

Bloody diarrhea or occult blood in stool

Elevated temperature (≥ 100.4°F [38.0°C])

Rigidity (involuntary guarding)


Preoperative risk stratification

Risk prediction models can be used to identify patients at high risk of complications and so may enable more informed consent and optimal perioperative management. Many prediction models for PPCs have been published in the last 5 yr, most of which have limitations as a result of being developed from retrospective databases, 5 , 10 , 11 , 13 , 14 , 19 , 25 focused on a single adverse outcome (e.g. pneumonia, 13 , 25 respiratory failure, 11 , 29 unplanned re-intubation, 10 , 14 or acute lung injury/ARDS), 17 , 19 or from a lack of inclusion of intraoperative risk factors. There is therefore no ‘one size fits all’ model for PPC risk stratification.

Here, we describe three related risk prediction models, which were prospective, multicentre trials, using EPCO definitions for composite outcomes. ARISCAT (assess respiratory risk in surgical patients in Catalonia) developed a seven-variable regression model, stratifying patients into low-, intermediate-, and high-risk groups. Respective incidences of PPC development in their validation group were 1.6, 13.3, and 42.1%. The independent variables are low preoperative peripheral oxygen saturation ( ⁠ S p O 2 ⁠ <96%), respiratory infection in the last month, age, preoperative anaemia (<100 g dl − 1 ), intrathoracic/upper abdominal surgery, duration of procedure (>2 h), and emergency surgery. 4 Definition of a PPC was the development of at least one of the outcomes subsequently defined by EPCO ( Table 1).

PERISCOPE (prospective evaluation of a risk score for postoperative pulmonary complications in Europe) externally validated ARISCAT with good discrimination c-statistic 0.80 [confidence interval (CI) 0.78–0.82]. 6 In 2015, secondary analysis of these data (sample size 5384) was used to develop and validate a score to predict postoperative respiratory failure (PRF). The incidence of PRF was 4.2%, and seven factors were used to stratify patients into low-, intermediate-, and high-risk groups, with incidences of PRF of 1.1, 4.6, and 18.8%, respectively. However, the independent variables differ slightly from those found in ARISCAT: low preoperative S p O 2 ⁠ , at least one preoperative respiratory symptom, chronic liver disease, congestive heart failure, intrathoracic/upper abdominal surgery, procedure >2 h, and emergency surgery. 29

One other prospective multicentre cohort study, with a small sample size of 268, focused specifically on risk-stratifying patients with upper abdominal incisions. 32 They defined PPCs as shown for Scholes and colleagues 32 in Table 2. Five independent risk factors were identified in the regression model, including duration of anaesthesia, surgical category, respiratory co-morbidity, current smoker, and predicted maximal oxygen uptake. A score of 2.02 or less derived from a clinical prediction rule was associated with a high risk of PPCs [odds ratio (OR) (CI) 8.41 (3.33–21.26)]. This model requires external validation before clinical implementation. Further risk prediction models have been summarized in Table 2.

These studies highlight the complexity of choosing an appropriate risk prediction model. Although they have undoubtedly furthered our understanding of which patient groups are susceptible to PPCs, the lack of agreement between studies and the complexity of the scoring systems currently make them impractical for routine clinical use.


4. Diagnosis

Diagnosis may be difficult, as acute respiratory distress syndrome, atelectasis and pulmonary edema can mimic NP. In addition, cultures from sputum or endotracheal suctioning frequently represent colonizing organisms. Most case definitions of NP include clinical symptoms, signs, and radiological changes, whereas those from the Centers for Disease Control and European Nosocomial Infection Survey also contain laboratory evidence.[58] American Thoracic Society (ATS) guidelines for the diagnosis of NP in adults include clinical, radiological, and bacteriological evaluation.[59]

NP should be suspected when there is an unexplained change in clinical status, including fever, drop in oxygenation, increased oxygen or ventilation requirements, new chest signs, metabolic acidosis, or alteration in the type or quantity of respiratory secretions. Chest x-ray findings are usually nonspecific but the development of new or progressive pulmonary infiltrates, consolidation or pleural effusion may provide radiological evidence of NP.[58] S. aureus, P. aeruginosa and K. pneumoniae may produce a rapidly progressive necrotizing pneumonia. The epidemiological circumstances of the patient and nursing environment may also suggest NP for example, recent in-hospital exposure to RSV. The resident bacterial flora in the ward should also be considered.

The efficacy of invasive diagnostic techniques remains controversial as they have not reduced morbidity or mortality, nor has the most reliable method for microbiologic confirmation of NP been defined.[59,60] Transbronchial, percutaneous, and open lung biopsies are definitive diagnostic procedures but are rarely done in children as they are invasive, may be complicated by bleeding or pneumothorax, and can be especially risky in patients who are very ill or unstable. A variety of methods have been developed to obtain cultures from the lower respiratory tract, including sputum induction,[61] endotracheal aspiration,[62] bronchoalveolar lavage (BAL),[63] and protected bronchial specimen brushings (PSB).[64] Sputum induction can be effectively and safely performed, even in infants.[61] In intubated children, nonbronchoscopic BAL or aspiration of peripheral bronchial secretions by briefly inserting a catheter through the endotracheal tube may provide specimens from the distal airways[63–65] however, qualitative cultures of tracheobronchial secretions are a sensitive but not specific method for evaluating the lower respiratory tract flora as these sampling procedures do not distinguish between colonizing organisms and those causing pulmonary infection. Nevertheless, tracheobronchial cultures do have a high negative predictive value, as a negative culture in the absence of antimicrobial pretreatment may exclude NP. Similarly, they may be useful for excluding specific pathogens.[59]

To improve diagnostic sensitivity, techniques such as Gram stain of specimens, microscopic examination for pus cells, and semiquantitative culture have been used. The role of quantitative invasive diagnostic testing for NP is also controversial. Moreover, the results may be influenced by the stage of pneumonia, antimicrobial use, differences in diagnostic technique, variability of the sampling methods, and the ability of laboratories to do quantitative culturing. Gram stain of BAL fluid has been reported to be useful for the early diagnosis of VAP, with a sensitivity of 90% and specificity of 74%.[66] In adults, the presence of bacteria, especially if intracellular, has been reported to correlate with histologically confirmed pneumonia.[67] The presence of white cells, particularly polymorphonuclear cells, in high numbers (>25 per low-power field) with low numbers of squamous epithelial cells (≪10 per low-power field) is indicative of lower respiratory tract secretions[68] however, few studies have validated the different techniques with biopsy confirmation of pneumonia. Chastre and colleagues[69] reported a good correlation between quantitative bacterial culture of >10 4 colony forming units (CFU)/ml for BAL, and postmortem histology and microbiology lung features in ventilated patients who died. BAL fluid cultures were also found to be a sensitive and specific method for diagnosing NP compared with PSB in adult ventilated patients using a threshold for bacterial growth of 10 4 CFU/ml for BAL and 10 3 CFU/ml for PSB[70] however, BAL, fiberoptic bronchial aspirates, and percutaneous lung needle aspiration had poor sensitivity (50, 44 and 25% respectively) compared with histopathology for diagnosis of NP in ventilated adults on antibacterials.[71]

Pleural effusions, if present, should be aspirated and investigated for infectious agents. Percutaneous fine needle aspiration may be useful for culture of pulmonary pathogens. An analysis of 59 studies of the etiology of childhood pneumonia found that aspiration yielded a bacterial cause in approximately 50% of patients, and was associated with few complications.[72] In immunocompromised children with NP unresponsive to broad-spectrum antibacterials, open lung biopsy for histology and culture may confirm fungal pneumonia.

Nasal washings are useful for viral isolates. Respiratory secretions should be obtained for culture and antigen detection. The use of new rapid diagnostic testing for RSV and other respiratory viruses is important for early identification, and institution of appropriate infection control precautions. Fluorescent microscopy of respiratory secretions may aid in the identification of P. carinii and L. pneumophila.

Blood culture, when positive, may be useful for identifying bacterial pathogens and their antimicrobial sensitivity[73] however, only about 10 to 31% of blood cultures are positive in NP.[74] Moreover, data from adults with VAP suggest that blood cultures have a low sensitivity for detecting the same pathogen as BAL.[75] Nevertheless, blood cultures are minimally invasive, relatively inexpensive and indicative of severe, life-threatening infection.[76] Urine antigen detection may be useful for detection of Streptococcus pneumoniae, Haemophilus influenzae and L. pneumophila. Serologic studies are unhelpful for the diagnosis of NP except for retrospective confirmation of viral or Legionella infections however, they may have epidemiologic value.[59]


Management

Treatment should be directed at the underlying cause. In many patients, the key to diagnosis is repeated physical examination by the same physician over an extended time.21 Indications for surgical consultations are listed in Table 3 . Traditionally, the use of analgesics is discouraged in patients with abdominal pain for fear of interfering with accurate evaluation and diagnosis. However, several prospective, randomized studies have shown that judicious use of analgesics actually may enhance diagnostic accuracy by permitting detailed examination of a more cooperative patient.22-24 [References 22 and 23𠅎vidence level A, randomized controlled trials]


Risk reduction strategies for the aspiration gastric contents

The multiple strategies available to anaesthetists to reduce the risk of aspiration are summarized in Table 1.

A summary of the available strategies for reducing aspiration risk

Reducing gastric volume Preoperative fasting
Nasogastric aspiration
Prokinetic premedication
Avoidance of general anaesthetic Regional anaesthesia
Reducing pH of gastric contents Antacids
H2 histamine antagonists
Proton pump inhibitors
Airway protection Tracheal intubation
Second-generation supra-glottic airway devices
Prevent regurgitation Cricoid pressure
Rapid sequence induction
Extubation Awake after return of airway reflexes
Position (lateral, head down or upright)
Reducing gastric volume Preoperative fasting
Nasogastric aspiration
Prokinetic premedication
Avoidance of general anaesthetic Regional anaesthesia
Reducing pH of gastric contents Antacids
H2 histamine antagonists
Proton pump inhibitors
Airway protection Tracheal intubation
Second-generation supra-glottic airway devices
Prevent regurgitation Cricoid pressure
Rapid sequence induction
Extubation Awake after return of airway reflexes
Position (lateral, head down or upright)

A summary of the available strategies for reducing aspiration risk

Reducing gastric volume Preoperative fasting
Nasogastric aspiration
Prokinetic premedication
Avoidance of general anaesthetic Regional anaesthesia
Reducing pH of gastric contents Antacids
H2 histamine antagonists
Proton pump inhibitors
Airway protection Tracheal intubation
Second-generation supra-glottic airway devices
Prevent regurgitation Cricoid pressure
Rapid sequence induction
Extubation Awake after return of airway reflexes
Position (lateral, head down or upright)
Reducing gastric volume Preoperative fasting
Nasogastric aspiration
Prokinetic premedication
Avoidance of general anaesthetic Regional anaesthesia
Reducing pH of gastric contents Antacids
H2 histamine antagonists
Proton pump inhibitors
Airway protection Tracheal intubation
Second-generation supra-glottic airway devices
Prevent regurgitation Cricoid pressure
Rapid sequence induction
Extubation Awake after return of airway reflexes
Position (lateral, head down or upright)

After a review of 5000 closed claims, an Australian study recommended more didactic guidelines (Table 2), which if used would have potentially reduced the incidence of aspiration by up to 60%. 7

Guidelines to reduce the risk of aspiration 7

1. Experienced anaesthesia assistance available to all times
2. Intubate all emergency cases
3. Apply appropriate cricoid pressure with all inductions using neuromuscular blocking agents
4. Intubate/seriously consider intubation in the following:
Delayed gastric emptying (pregnancy, opioids, diabetes mellitus, renal failure)
Increased intra-abdominal pressure (obesity, ascites, masses)
5. Extubate high-risk cases awake and on their side. Extubate all others on their side
1. Experienced anaesthesia assistance available to all times
2. Intubate all emergency cases
3. Apply appropriate cricoid pressure with all inductions using neuromuscular blocking agents
4. Intubate/seriously consider intubation in the following:
Delayed gastric emptying (pregnancy, opioids, diabetes mellitus, renal failure)
Increased intra-abdominal pressure (obesity, ascites, masses)
5. Extubate high-risk cases awake and on their side. Extubate all others on their side

Guidelines to reduce the risk of aspiration 7

1. Experienced anaesthesia assistance available to all times
2. Intubate all emergency cases
3. Apply appropriate cricoid pressure with all inductions using neuromuscular blocking agents
4. Intubate/seriously consider intubation in the following:
Delayed gastric emptying (pregnancy, opioids, diabetes mellitus, renal failure)
Increased intra-abdominal pressure (obesity, ascites, masses)
5. Extubate high-risk cases awake and on their side. Extubate all others on their side
1. Experienced anaesthesia assistance available to all times
2. Intubate all emergency cases
3. Apply appropriate cricoid pressure with all inductions using neuromuscular blocking agents
4. Intubate/seriously consider intubation in the following:
Delayed gastric emptying (pregnancy, opioids, diabetes mellitus, renal failure)
Increased intra-abdominal pressure (obesity, ascites, masses)
5. Extubate high-risk cases awake and on their side. Extubate all others on their side

The guidelines recommended anaesthetists to extubate all patients on their sides. However, contrary to this advice, a survey of anaesthetic practice noted the emerging trend to manage extubation in the head-up or sitting position. 8 The survey revealed that 90 out of 593 consultant anaesthetists (15%) manage some emergency patients in the supine position for extubation. Worryingly, evidence suggests that even when the risk of regurgitation is high enough to indicate rapid sequence induction, the same logic is not applied to extubation, when the risk of regurgitation is unlikely to have diminished. The tendency to view aspiration risk as only relevant at induction contradicts evidence that aspiration also occurs during maintenance (13 of 23 cases in NAP4) 2 and during emergence (1 in 23 cases in NAP4). 2 Other studies have shown that up to 20% of aspiration occurs after extubation. 7

The guidelines (Table 1) are contentious given the recommendation to use cricoid pressure whenever neuromuscular blocking agents are used. Cricoid pressure can increase the frequency of difficult intubation, especially if excessive force is used, and the evidence base does not robustly support its effectiveness in reducing regurgitation. So, whilst the universal use of cricoid pressure may reduce regurgitation, the recommendation needs to be balanced by the likelihood that it would increase problems with intubation.


Simple breathing training with a physiotherapist before surgery prevents postoperative pneumonia

Pneumonia, and other serious lung complications, after major abdominal surgery were halved when patients were seen by a physiotherapist before surgery and taught breathing exercises that the patient needed to start performing immediately on waking from the operation, finds a trial published by The BMJ today.

The researchers say their results "are directly applicable to the tens of millions of patients listed for elective major abdominal surgery worldwide" and that this service "could be considered for all patients awaiting upper abdominal surgery."

Upper abdominal surgery involves opening up the abdomen - for example to treat bowel, liver or kidney conditions. It is the most common major surgical procedure performed in developed countries, but it carries a risk of serious lung (pulmonary) complications, such as pneumonia and lung collapse, that are linked to high mortality and healthcare costs.

Previous trials have indicated that teaching patients breathing exercises before their surgery may help prevent complications, although evidence is inconclusive. So a team of researchers based in Australia and New Zealand set out to assess whether educating patients about postoperative lung complications and teaching simple breathing exercises to patients before upper abdominal surgery reduces subsequent pulmonary complications following the operation.

The study involved 441 adults who were within six weeks of elective upper abdominal surgery and were randomly assigned to receive either an information booklet (control) or an additional 30 minute face-to-face physiotherapy education and breathing exercise training session (intervention) by a physiotherapist.

After surgery, patients were assessed every day for 14 days for signs of pulmonary complications. Longer term measures, such as length of hospital stay, use of intensive care unit services, hospital costs, and all cause mortality, were also recorded.

After taking account of potentially influential factors, such as patient age and presence of other disorders (comorbidities), the rate of pulmonary complications within 14 days of surgery, including hospital acquired pneumonia, was halved in the intervention group compared with the control group, with an absolute risk reduction of 15%.

This association seemed to be stronger in patients having bowel (colorectal) surgery, those younger than 65 years, men, or where an experienced physiotherapist provided the training.

The researchers also estimate that for every seven patients given breathing training before surgery, one pulmonary complication is avoided. However, no significant differences in other outcomes were detected.

The researchers point to some limitations, such as imbalances between the groups at the start of the trial, and including only English speakers in developed Western countries. Nevertheless, they were able to adjust for a range of potentially influential factors and further analyses testing the results strengthened the benefit of physiotherapy further.

As such, they say this trial "provides strong evidence that a single preoperative physiotherapy session that educates patients on the reason and necessity to do breathing exercises immediately after surgery halves the incidence of postoperative respiratory complications." And they call for further research "to investigate benefits to mortality and length of stay."

Disclaimer: AAAS and EurekAlert! are not responsible for the accuracy of news releases posted to EurekAlert! by contributing institutions or for the use of any information through the EurekAlert system.


Pediatric Pneumonia Clinical Presentation

Newborns with pneumonia rarely cough more commonly they present with poor feeding and irritability, as well as tachypnea, retractions, grunting, and hypoxemia. Grunting in a newborn suggests a lower respiratory tract disease and is due to vocal cord approximation as they try to provide increased positive end-expiratory pressure (PEEP) and to keep their lower airways open.

After the first month of life, cough is the most common presenting symptom of pneumonia. Infants may have a history of antecedent upper respiratory symptoms. Grunting may be less common in older infants however, tachypnea, retractions, and hypoxemia are common and may be accompanied by a persistent cough, congestion, fever, irritability, and decreased feeding. Any maternal history of Chlamydia trachomatis infection should be determined.

Infants with bacterial pneumonia are often febrile. But those with viral pneumonia or pneumonia caused by atypical organisms may have a low-grade fever or may be afebrile. The child's caretakers may complain that the child is wheezing or has noisy breathing. Toddlers and preschoolers most often present with fever, cough (productive or nonproductive), tachypnea, and congestion. They may have some vomiting, particularly post-tussive emesis. A history of antecedent upper respiratory tract illness is common.

Older children and adolescents may also present with fever, cough (productive or nonproductive), congestion, chest pain, dehydration, and lethargy. In addition to the symptoms reported in younger children, adolescents may have other constitutional symptoms, such as headache, pleuritic chest pain, and vague abdominal pain. Vomiting, diarrhea, pharyngitis, and otalgia/otitis are other common symptoms.

Travel history is important because it may reveal an exposure risk to a pathogen more common to a specific geographic area (eg, dimorphic fungi). Any exposure to tuberculosis (TB) should always be determined. In addition, possible exposure to birds (psittacosis), bird droppings (histoplasmosis), bats (histoplasmosis), or other animals (zoonoses, including Q fever, tularemia, and plague) should be considered.

In children with evidence for recurrent sinopulmonary infections, a careful history to determine the underlying cause is needed. The recurrent nature of the infections may serve to unveil an innate or acquired immune deficiency, an anatomic defect, or another genetic disease (eg, cystic fibrosis, ciliary dyskinesia).

Tuberculosis

A history of TB exposure to possible sources should be obtained in every patient who presents with signs and symptoms of pneumonia (eg, immigrants from Africa, certain parts of Asia, and Eastern Europe contacts with persons in the penal or detention system close contact with known individuals with TB). Children with TB usually do not present with symptoms until 1-6 months after primary infection. These may include fever, night sweats, chills, cough (which may include hemoptysis), and weight loss.