Management of Patients with Left Ventricular Assist Device during the COVID-19 Pandemic

The novel coronavirus disease 2019 (COVID-19) is an infectious disease with multi-organ involvement, including the cardiovascular system. The disease may cause several cardiovascular complications, and may increase morbidity and mortality among patients with background cardiovascular disease. Patients with advanced heart failure are often treated with left ventricular assist device (LVAD), and represent a unique population mandating multi-disciplinary approach. Several aspects of COVID-19 should be taken into account in LVAD implants, including right ventricular involvement, hemodynamic alterations, thromboembolic and haemorrhagic complications, and the psychological effects of social isolation. Patients with VAD and suspected COVID-19 should be transferred to specialized centers for better management of complications. Here, we review the implications of COVID-19 pandemic on LVAD patients with our recommendations for appropriate management.

The Incidence and Causes of Unplanned Reoperations as a Quality Indicator in Pediatric Surgery

Background: Unplanned return to the operating room (uROR) within the 30-day postoperative period can be used as a quality indicator in pediatric surgery. The aim of this study was to investigate and evaluate uROR as a quality indicator. Methods: The case records of pediatric patients who underwent reoperation within the 30-day period after primary surgery, from 1 January 2018 to 31 December 2020 were retrospectively reviewed. The primary outcome of the study was the rate of uROR as a quality indicator in pediatric surgery. Secondary outcomes were indications for primary and secondary surgery, types and management of complications, factors that led to uROR, length of hospital stay, duration of surgery and anesthesia, and starting time of surgery. Results: A total of 3982 surgical procedures, under general anesthesia, were performed during the three-year study period (2018, n = 1432; 2019, n = 1435; 2020, n = 1115). Elective and emergency surgeries were performed in 3032 (76.1%) and 950 (23.9%) patients, respectively. During the study period 19 (0.5%) pediatric patients, with the median age of 11 years (IQR 3, 16), underwent uROR within the 30-day postoperative period. The uROR incidence was 6 (0.4%), 6 (0.4%), and 7 (0.6%) for years 2018, 2019, and 2020, respectively (p = 0.697). The incidence of uROR was significantly higher in males (n = 14; 73.7%) than in females (n = 5; 26.3%) (p = 0.002). The share of unplanned reoperations in studied period was 4.5 times higher in primarily emergency surgeries compared to primarily elective surgeries (p < 0.001). The difference in incidence was 0.9% (95% CI, 0.4–1.4). Out of children that underwent uROR within the 30-day period after elective procedures, 50% had American Society of Anesthesiologists (ASA) score three or higher (p = 0.016). The most common procedure which led to uROR was appendectomy (n = 5, 26.3%) while the errors in surgical technique were the most common cause for uROR (n = 11, 57.9%). Conclusion: Unplanned reoperations within the 30-day period after the initial surgical procedure can be a good quality indicator in pediatric surgery. Risk factors associated with uROR are emergency surgery, male gender, and ASA score ≥3 in elective pediatric surgery.

A Case of A 15-Year Old with Perforated Gallbladder Type II Secondary To Acute Acalculous Cholecystitis, Severe Secondary to Typhoid Fever with Bile Peritonitis, in Sepsis

Typhoid fever is one of the most common enteric fever in low to middle income countries. In the pediatric population, it is a rare cause of acalculous cholecystitis in which one of the dreaded complication is gall bladder perforation. This was a case of a 15-year-old male with 1-month history of intermittent undocumented fever, anorexia and weight loss. The patient presented with signs of pancytopenia and abdominal examination revealed acute abdomen. Patient was optimized and prepared for surgery. Intraoperative findings revealed Type II gall bladder perforation with bile peritonitis, and patient underwent exploratory laparotomy, cholecystectomy, lavage, Jackson-Pratt drain. The sepsis eventually resolved postoperatively, and the patient was discharged. Preoperative diagnosis in patients with gall bladder perforation is often challenging and sophisticated, due to its rarity. However, it should be considered as one of the differential diagnoses in pediatric patients presenting with atypical history of abdominal pain. At present, there are no specific guidelines in the management of complications such as gall bladder perforation in patients with typhoid fever. Therefore, early diagnosis and immediate surgical intervention of gall bladder perforation are of prime importance in the successful outcomes of these patients, given the high morbidity and mortality associated with this condition.