Surgical Risk, Operative Time, and Anesthesia Time Associated With Combining Tracheostomy and Gastrostomy Tube Placement Under a Single Anesthetic.

INTRODUCTION: Pediatric patients may need both tracheostomy and gastrostomy tube (G-tube) placement to satisfy both oxygen and nutritional requirements for sustaining life. It is unclear if combining both procedures under one anesthetic is associated with reductions in total operative time or surgical risk, compared to performing the two procedures separately. METHODS: Our study used the 2016-2021 National Surgical Quality Improvement Program-Pediatric Participant Use Files. Patients age 0-2 years were included if they underwent elective tracheostomy or G-tube placement and no concomitant procedures other than direct laryngoscopy or bronchoscopy. The initial cohort included 14,047 patients undergoing G-tube placement only, 571 undergoing tracheostomy only, and 236 undergoing both procedures concurrently. Multivariable analysis used propensity score matching to compare combined procedures to matched synthetic controls, created by combining data from patients undergoing each procedure independently (N = 180 matched pairs). RESULTS: After matching, combined procedures were associated with lower complication risk (odds ratio: 0.42; 95% confidence interval [CI]: 0.27, 0.65) and reduced anesthesia time (mean difference: 57 min; 95% CI: 47, 68) when compared to synthetic controls, but did not differ on total operative time (mean difference: -4.5 min; 95% CI: -12.6, +3.6). CONCLUSION: Combined procedures are theorized to reduce risks associated with prolonged exposure to anesthesia. We found a reduction in total anesthesia time associated with combining tracheostomy and G-tube placement under one anesthetic, and lower risk of complications, but no change in total operative time relative to performing 2 separate surgeries. LEVEL OF EVIDENCE: III.

Emergency Medical Service Transport Time in Rural Farm and Non-Farm Pediatric Trauma.

OBJECTIVES: Pediatric farm injuries tend to be more severe and have poorer outcomes compared to injuries sustained in non-farm settings. Timely emergency medical service (EMS) response and transport to definitive care is crucial for optimizing outcomes for trauma patients. We aimed to determine if pediatric farm injuries were associated with longer EMS response and transport times compared to pediatric non-farm injuries in rural communities. METHODS: The 2021 National EMS Information System (NEMSIS) database was used to identify rural EMS activations where injured pediatric patients who were transported to a hospital. Median transport times for farm and non-farm injuries, as well as other components of prehospital time and use of air EMS transport, were compared between injuries on farms and injuries in non-farm rural settings. RESULTS: The analytic sample included 22,248 rural EMS activations for pediatric injuries, of which 156 (1%) were for pediatric farm injuries. For non-farm and farm injuries, the median transport times were 20 minutes and 28 minutes, respectively. Median total prehospital time was 50 minutes compared to 62 minutes, and 9.8% of patients with non-farm injuries versus 20.5% of those with farm injuries were transported to a hospital by air EMS units. After multivariable adjustment, farm vs. non-farm injury location was associated with a 4 minute increase in EMS transport time, but no difference in initial EMS response time, EMS time on scene, or use of air EMS units. CONCLUSION: Among children sustaining an injury that resulted in rural EMS activation, farm injuries were associated with prolonged transport time compared to non-farm injuries, which may contribute to worse in-hospital outcomes described to pediatric farm injuries in prior research.

Stop the Bleed®: Medical Students as Instructors of the Bleeding Control Basics Course.

BACKGROUND: The Bleeding Control Basics (B-Con) Course was developed to teach lifesaving hemorrhage control techniques to the public. Currently, medical students (MS) without prior clinical experience (CE) may not act as autonomous instructors, limiting the instructor pool. PURPOSE: To assess the bleeding control knowledge of MS (phase I) and compare the knowledge of students taught by a certified instructor vs a medical student (phase II). METHODS: Phase I: 20 MS, 6 with prior CE and 14 without clinical experience (NCE) completed a pre-course and post-course knowledge assessment. Results were assessed by independent sample t-tests. Phase II: 91 first-year MS were taught the B-Con Course by either a third-year MS (n = 45) or certified instructor (n = 46). An analysis of covariance (ANCOVA) was performed to compare scores by instructor type (certified vs MS) using prior CE and pretest scores as confounding variables. RESULTS: In Phase I, the CE group scored higher on the pretest assessment compared to the NCE group (P = .003). All students improved in posttest scoring, and there was no difference in posttest scores between the groups (P = .597). In Phase II, despite no difference in pretest scores between groups, the MS taught learners scored significantly higher on the posttest compared to the certified instructor group (P < .01). Prior CE did not correlate to posttest scores (P = .719). DISCUSSION: Medical students are as effective as certified instructors at conveying the B-Con learning objectives. Based on near-perfect assimilation of content by students, MS should be permitted to teach B-Con Courses.

Emergency department thoracotomy in children: A Pediatric Trauma Society, Western Trauma Association, and Eastern Association for the Surgery of Trauma systematic review and practice management guideline.

BACKGROUND: The role of emergency department resuscitative thoracotomy (EDT) in traumatically injured children has not been elucidated. We aimed to perform a systematic review and create evidence-based guidelines to answer the following PICO (population, intervention, comparator, and outcome) question: should pediatric patients who present to the emergency department pulseless (with or without signs of life [SOL]) after traumatic injuries (penetrating thoracic, penetrating abdominopelvic, or blunt) undergo EDT (vs. no EDT) to improve survival and neurologically intact survival? METHODS: Using Grading of Recommendations Assessment, Development and Evaluation methodology, a group of 12 pediatric trauma experts from the Pediatric Trauma Society, Western Trauma Association, and Eastern Association for the Surgery of Trauma assembled to perform a systematic review. A consensus conference was conducted, a database was queried, abstracts and manuscripts were reviewed, data extraction was performed, and evidence quality was determined. Evidence tables were generated, and the committee voted on guideline recommendations. RESULTS: Three hundred three articles were identified. Eleven studies met the inclusion criteria and were used for guideline creation, providing 319 pediatric patients who underwent EDT. No data were available on patients who did not undergo EDT. For each PICO, the quality of evidence was very low based on the serious risk of bias and serious or very serious imprecision. CONCLUSION: Based on low-quality data, we make the following recommendations. We conditionally recommend EDT when a child presents pulseless with SOL to the emergency department following penetrating thoracic injury, penetrating abdominopelvic injury and after blunt injury if emergency adjuncts point to a thoracic source. We conditionally recommend against EDT when a pediatric patient presents pulseless without SOL after penetrating thoracic and penetrating abdominopelvic injury. We strongly recommend against EDT in the patient without SOL after blunt injury.

An in-situ simulation-based educational outreach project for pediatric trauma care in a rural trauma system.

BACKGROUND: Outcome disparities between urban and rural pediatric trauma patients persist, despite regionalization of trauma systems. Rural patients are initially transported to the nearest emergency department (ED), where pediatric care is infrequent. We aim to identify educational intervention targets and increase provider experience via pediatric trauma simulation. METHODS: Prospective study of simulation-based pediatric trauma resuscitation was performed at three community EDs. Level one trauma center providers facilitated simulations, providing educational feedback. Provider performance comfort and skill with tasks essential to initial trauma care were assessed, comparing pre-/postsimulations. Primary outcomes were: 1) improved comfort performing skills, and 2) team performance during resuscitation. RESULTS: Provider comfort with the following improved (p-values <0.05): infant airway, infant IV access, blood administration, infant C-spine immobilization, chest tube placement, obtaining radiographic images, initiating transport, and Broselow tape use. The proportion of tasks needing improvement decreased: 42% to 27% (p-value=0.001). Most common deficiencies were: failure to obtain additional history (75%), beginning secondary survey (58.33%), log rolling/examining the back (66.67%), calling for transport (50%), calculating medication dosages (50%). CONCLUSIONS: Simulation-based education improves provider comfort and performance. Comparison of patient outcomes to evaluate improvement in pediatric trauma care is warranted. LEVEL OF EVIDENCE RATING: IV.

Growth factors: possible roles for clinical management of the short bowel syndrome.

The structural and functional changes during intestinal adaptation are necessary to compensate for the sudden loss of digestive and absorptive capacity after massive intestinal resection. When the adaptive response is inadequate, short bowel syndrome (SBS) ensues and patients are left with the requirement for parenteral nutrition and its associated morbidities. Several hormones have been studied as potential enhancers of the adaptation process. The effects of growth hormone, insulin-like growth factor-1, epidermal growth factor, and glucagon-like peptide 2 on adaptation have been studied extensively in animal models. In addition, growth hormone and glucagon-like peptide 2 have shown promise for the treatment of SBS in clinical trials in human beings. Several lesser studied hormones, including leptin, corticosteroids, thyroxine, testosterone, and estradiol, are also discussed.

Extent of small bowel resection does not influence the magnitude of intestinal adaptation in the mouse.

PURPOSE: The magnitude of intestinal adaptation is considered to correlate with the extent of small bowel resection (SBR). However, this association has never been tested in mice. We sought to test the hypothesis that a greater SBR will induce a greater adaptation response. METHODS: C57/B6 mice underwent 50% SBR, 75% SBR, or sham operation and were killed on postoperative day 7. The magnitude of adaptation was compared between 50% SBR and 75% SBR as changes in villus height, crypt depth, as well as rates of apoptosis and proliferation. RESULTS: Seventy-five percent SBR led to decreased survival and increased weight loss compared with 50% SBR. The remnant ileum of both 50% SBR and 75% SBR displayed similar crypt expansion, enhanced villi, and increased apoptotic indices. Proliferation rates increased after 50% and 75% SBR equally. CONCLUSION: Models of resection greater than 50% in mice result in greater morbidity and mortality and do not magnify the adaptation response to massive SBR. The use of more extreme resection models does not appear to provide added benefit for investigating mechanisms of intestinal adaptation.

Dietary bile acid supplementation improves intestinal integrity and survival in a murine model.

PURPOSE: In vitro supplementation of the bile salt, taurodeoxycholic acid (TDCA), has been shown to stimulate proliferation and prevent intestinal apoptosis in IEC-6 cells. We hypothesize that addition of TDCA to a rodent liquid diet will be protective against induced intestinal injury. METHODS: C57Bl6 mice were fed a liquid diet with or without 50-mg/(kg d) TDCA supplementation. After 6 days, the mice were injected with lipopolysaccharide (LPS) (10 mg/kg) to induce intestinal injury. Specimens were obtained 24 hours later and evaluated for intestinal apoptosis, crypt proliferation, and villus length. A separate cohort of animals was injected with LPS (25 mg/kg) and followed 7 days for survival. RESULTS: Mice whose diet was supplemented with TDCA had significantly increased survival. After LPS-induced injury, mice supplemented with TDCA showed decreased intestinal apoptosis by both H&E and caspase-3. They also had increased intestinal proliferation by 5-bromo-2'deoxyuridine staining and increased villus length. CONCLUSIONS: Dietary TDCA supplementation alleviates mucosal damage and improves survival after LPS-induced intestinal injury. Taurodeoxycholic acid is protective of the intestinal mucosa by increasing resistance to injury-induced apoptosis, stimulating enterocyte proliferation, and increasing villus length. Taurodeoxycholic acid supplementation also results in an increased survival benefit. Therefore, bile acid supplementation may potentially protect the intestine from injury or infection.

Murine functional liver mass is reduced following partial small bowel resection.

INTRODUCTION: Liver mass is regulated in precise proportion to body mass in health and is restored by regeneration following acute injury. Despite extensive experimental analyses, the mechanisms involved in this regulation have not been fully elucidated. Previous investigations suggest that signals from the bowel may play an important role. The purpose of the studies reported here was to determine the effect of proximal partial small bowel resection on liver mass in a murine model. METHODS: Mice were subjected to a 50% proximal small bowel resection or sham surgery followed by primary anastomosis, then sacrificed at serial times for determination of liver:body mass ratio and analyses of liver tissue. RESULTS: Liver:body weight ratio was significantly decreased 72 h after small bowel resection, and this decrease correlated with reduced functional liver mass as assessed by determination of total hepatic tissue protein and alanine transaminase (ALT) activity. Liver from bowel-resected animals demonstrated increased expression of LC3-II, a marker of autophagy, and also of pro-apoptotic Bax compared to anti-apoptotic Bcl-2. CONCLUSION: These data support a role for signals from the intestine in liver mass regulation, and they have potential implications regarding the pathogenesis of liver injury following small bowel resection.

p21(waf1/cip1) deficiency does not perturb the intestinal crypt stem cell population after massive small bowel resection.

BACKGROUND: After small bowel resection (SBR), adaptation is initiated in intestinal crypts where stem cells reside. Prior studies revealed SBR-induced enterocyte proliferation requires the expression of p21(waf1/cip1). As deficient expression of p21(waf1/cip1) has been shown to result in reduced numbers of hematopoietic stem cells. We sought to test the hypothesis that p21(waf1/cip1)deficiency similarly perturbs the intestinal stem cell population after SBR. METHODS: Control (n = 21; C57Bl/6) and p21(waf1/cip1)-null mice (n = 30) underwent 50% proximal SBR or sham operation. After 3 days, the ileum was harvested and the crypt stem cell population evaluated by counting crypt base columnar cells on histologic sections, determining the expression of Musashi-1 and Lgr5, and profiling the transcriptional expression of 84 known stem cell genes. RESULTS: There were no significant differences in crypt base columnar cells, expression of Musashi-1 or Lgr5, or in stem cell gene expression after SBR in control mice. Furthermore, there were no differences in these markers between controls and p21(waf1/cip1)-null mice. CONCLUSION: In contrast with bone marrow stem cells, the stem cell population of the gut is unaffected by deficient expression of p21(waf1/cip1). Additional mechanisms for the role of p21(waf1/cip1) in small bowel proliferation and adaptation after massive SBR must be considered.

Intestinal resection induces angiogenesis within adapting intestinal villi.

PURPOSE: Adaptive growth of the intestinal mucosa in response to massive gut loss is fundamental for autonomy from parenteral nutrition. Although angiogenesis is essential for cellular proliferation in other tissues, its relevance to intestinal adaptation is unknown. We tested the hypothesis that resection-induced adaptation is associated with new blood vessel growth. METHODS: Male C57Bl/6 mice underwent either a 50% small bowel resection or a sham (transection and reanastomosis) operation. After 1, 3, or 7 days, capillary density within the intestinal villi was measured using confocal microscopy. A messenger RNA reverse-transcriptase polymerase chain reaction (RT-PCR) array was used to determine angiogenic gene expression during adaptation. RESULTS: Mice that underwent small bowel resection had a significantly increased capillary density compared to sham-operated mice at postoperative day 7. This morphological alteration was preceded by significant alterations in 5 candidate genes at postoperative day 3. CONCLUSION: New vessel blood growth is observed in the adapting intestine after massive small bowel loss. This response appears to follow rather than initiate the adaptive alterations in mucosal morphology that are characteristic of adaptation. A better understanding of this progress and the signaling factors involved may improve therapeutic options for children with short gut syndrome.