Use of Opioids and Nonopioid Analgesics to Treat Pediatric Postoperative Pain in the Emergency Department.

OBJECTIVES: The incidence, demographic characteristics, and treatment approaches for pediatric patients who present to the ED with a primary complaint of postoperative pain have not been well described. The purpose of this study was to describe opioid and nonopioid prescribing patterns for pediatric patients evaluated for postoperative pain in the Emergency Department (ED). METHODS: Pediatric Health Information System is an administrative database of encounter-level data from 48 children's hospitals. Emergency department visits for postoperative pain from January 2014 to September 2017 were analyzed. Visits were matched by the Pediatric Health Information System identifier to associate corresponding same site surgery encounters directly preceding ED visits. RESULTS: There were 7365 ED visits for acute postoperative pain, for which 4044 could be linked to corresponding surgical procedure. Eight-one percent of ED visits were within 7 days of surgery. Opioids were given at 1979 (49%) of visits, and nonopioids at 678 (17%) of visits. The most common surgeries preceding a postoperative pain ED visit were for tonsils and adenoids (48.5%). Age, sex, length of stay for both procedure and ED visits, procedure specialty, and the number of days between procedure discharge and admission to ED were associated with opioid administration during ED visits (P < 0.05). CONCLUSIONS: Pediatric patients treated in the ED for postoperative pain were often treated with opioid and nonopioid analgesics, with wide prescriber variability. Further research is warranted to help balance optimal pain management and safe prescribing practices.

Management of broncho-esophageal fistula after button battery ingestion.

Button battery ingestion can cause serious injury or death in young children who cannot communicate symptoms. An 18-month-old male presented after his mother noted drooling, nonbilious emesis and a metallic smell to his breath. He underwent rigid esophagoscopy and a 3-V 20-mm button battery was removed. Subsequent bronchoscopy after a 1-week interval revealed progression to a large broncho-esophageal fistula on the posterior wall of the right mainstem bronchus past the carina. A fenestrated nasogastric tube for local control of secretion and a feeding jejunostomy was placed. Six weeks later, the patient underwent a right thoracotomy for division and repair of the fistula and intercostal muscle flap interposition. Utilizing a well-placed fenestrated nasogastric tube to manage secretions can help reduce fistula size and improve conservative management results. When surgical repair is required, an intercostal muscle flap can reinforce fistula closure while simultaneously buttressing the bronchus and esophagus.

Can Intraoperative Video Recordings Contribute to Improving Laparoscopic Percutaneous Extraperitoneal Closure in Children with Inguinal Hernia and Prevent Recurrence? A Pilot Study.

Aim: We reviewed intraoperative video recordings (IVRs) of laparoscopic percutaneous extraperitoneal closure (LPEC) for inguinal hernia in children blindly to assess performance. Methods: IVRs of 183 LPEC performed between April 2013 and March 2016, graded by the operating surgeon as difficult (D; n = 8), straightforward (S; n = 96), or easy (E; n = 79), were scored by a panel of reviewers with advanced (group A; >400 LPEC cases; n = 5), intermediate (group I; 50-150 cases; n = 5), and basic (group B; <10 cases; n = 5) experience, according to suturing, dissection plane, vas/vessel dissection, bleeding, and peritoneal injury. They also allocated a recurrence risk rank (RRR; highest = 6; lowest = 1) for each IVR. Mean score variance for each IVR was also compared between reviewers. Results: There was one recurrence (R; 4-year-old male; level E). RRR were: 1, 2, and 2 for reviewers A, I, and B, respectively. Reviewer A scores for "suturing" and "bleeding," and reviewer I scores for "dissection plane" and "peritoneal injury" correlated significantly with RRR. No reviewer B scores correlated with RRR. Score variance between A and I and A and B for cases D1 and D2 were statistically significant. Conclusion: Advanced reviewers showed greatest variance, questioning the validity of whether experience alone improves surgical technique.

Achieving expert performance through simulation-based education and application of mastery learning principles.

Medical education has undergone significant change as we have moved from a purely apprenticeship model to one of competence. Simulation-based education can and does play a significant role in the development of an expert surgeon. Proven concepts of simulation-based education include distributed deliberate practice, content that challenges the learner, formative and summative feedback. The application of mastery learning principles is critical to achieve the best retention and outcomes related to an educational program. In this manuscript, we explore the methodology and justification for Mastery Learning as the gold standard of surgical education.

Caregiver Reported Reasons for Delay of Neonatal Circumcision.

OBJECTIVES: To determine caregiver-reported reasons for delay of desired neonatal circumcision. METHODS: Caregivers requesting elective outpatient circumcision at two urban tertiary care hospitals were surveyed from 1/2017 to 12/2018. Boys >3 years and those with abnormal penile anatomy were excluded. Patient/parent demographics, insurance status, comorbidities, birth history, family history, reasons circumcision was desired, and reasons for circumcision delay were obtained. RESULTS: Surveys were completed by 206/229 caregivers (90% response rate). Respondents were primarily mothers (74%) who identified as African-American (62%). Eligible boys presented at a median 7.5 months [0.3-35.6] and were predominantly African-American (63%), publicly-insured at birth (83%), and publicly-insured at present (86%). 80% were full-term. 83% had no comorbidities. Most caregivers (84%) requested inpatient circumcision, primarily for penile cleanliness (75%) and infection prevention (72%). Common reasons for delay included neonatal circumcision not being performed by the birth physician/hospital (26%) and prematurity (16%). Publicly-insured boys were more likely to encounter delays related birth physician/hospital not performing circumcisions (P = .02). Non-Caucasian/mixed race boys were less likely to be eligible for circumcision without general anesthesia (P = .004). In 108 cases (52%), circumcision was requested for full-term boys without comorbidities. Of these, 72 (35% of the cohort) now require general anesthesia to undergo circumcision. CONCLUSION: Among 206 boys experiencing circumcision delay, most were full-term, African-American, and publicly-insured. Common reasons for delay included neonatal circumcision not being performed by the birth hospital/physician and prematurity. General anesthesia could have been avoided in >35% of boys if circumcision was performed at birth.

Unusual Complication of the Nuss Procedure: Fistulization of the Internal Thoracic Artery to the Pulmonary Artery.

Although minimally invasive repair of pectus excavatum has been shown to have a low complication rate in large series, several case reports have documented life-threatening complications, including bleeding and cardiac perforation. We present a rare case of an arteriovenous malformation from the internal thoracic artery to the pulmonary artery caused by occlusion of the internal thoracic artery by the Nuss bar followed by an unidentified angiogenic process. The patient became symptomatic and required transcatheter coil embolization.

Pediatric emergency department visits for uncontrolled pain in postoperative adenotonsillectomy patients.

OBJECTIVE: Identify demographic variables related to emergency department (ED) returns, and analgesic administration in the ED for postoperative pain after adenotonsillectomy (T&A). STUDY DESIGN: Pediatric Health Information System (PHIS) database analysis. METHODS: Forty-seven children's hospitals included in the PHIS database were queried for all ED visits within 30 days of surgery with a diagnosis of acute postoperative pain (n = 2459) from 2014 to 2015. The subset of postoperative T&A patients (n = 861) was further analyzed for variables associated with return, and for pain management strategies, specifically opioids, employed by the ED. RESULTS: Of the 2459 pediatric patients returning to the ED for acute postoperative pain, the largest subset included T&A patients (n = 861, 35%). Patients were seen an average of 4 days (SD 2.4) after their surgery. ED administration of opioids was not associated with gender, race, surgical diagnosis, or ethnicity. The rate of opioid administration by the ED increased with advancing age of the children analyzed (P = .01). The incidence was also higher for those with commercial versus Medicaid insurance carriers. A total of 204 (23.7%) patients received opioids while in the ED, 439 (51%) received both opioids and non-opioids, and only 51 (5.9%) received no pain medication. CONCLUSION: T&A patients make up the largest subset of patients returning to the ED for postoperative pain. A total of 74.7% of patients receive opioids, either alone or in combination with non-opioids, on return to the ED. ED opioid administration was associated with older age of the child and payer, but not with gender, race, surgical diagnosis, or ethnicity. LEVEL OF EVIDENCE: 4.

Prevention of hypergranulation tissue after gastrostomy tube placement: A randomised controlled trial of hydrocolloid dressings.

Hypergranulation tissue formation is a common complication after gastrostomy tube (G-tube) placement, occurring in 44%-68% of children. Hydrocolloid dressings are often used in the treatment of hypergranulation tissue but have not been studied for the prevention of postoperative hypergranulation tissue. An institutional review board (IRB)-approved, prospective, randomised study was performed in paediatric patients who underwent G-tube placement at a single, large children's hospital from January 2011 to November 2016. After placement, patients were randomly assigned to (1) standard postoperative G-tube care, (2) standard hydrocolloid G-tube dressing, or (3) silver-impregnated hydrocolloid G-tube dressing, and the incidences of postoperative hypergranulation tissue formation, tube dislodgement, infection, and emergency department use were compared. A total of 171 patients were enrolled; 128 patients (75%) had at least 4 months of follow up and were included in the analyses. Eighty-nine patients (69.5%) developed hypergranulation tissue during the postoperative period, with no significant differences in incidence among the three treatment arms. Of those who developed hypergranulation tissue, 46 (56%) visited the emergency department, compared with 6 of the 39 patients (19%) who did not develop hypergranulation tissue. Hydrocolloid dressings (standard or silver-impregnated) do not prevent the development of hypergranulation tissue or other complications after G-tube placement in paediatric patients.

The Case for Simulation-Based Mastery Learning Education Courses for Practicing Surgeons.

INTRODUCTION: Pediatric surgeons rely on simulation courses to develop skills for safe minimally invasive repair of complex congenital anomalies. The majority of minimally invasive surgery (MIS) training courses occur during short "exposure courses" at annual conferences. Little data are available to support the benefit of these courses relative to the safe implementation of new skills. The purpose of this article is to determine the impact of an exposure course for advanced neonatal MIS on self-perceived comfort levels with independent performance of advanced MISs. METHODS: Participants of a 4-hour hands-on course for neonatal MIS were surveyed regarding clinical practices and pre- and post-training perceived "comfort levels" of MIS skills for thoracoscopic esophageal atresia with tracheoesophageal fistula (tTEF) repair, thoracoscopic left upper lobe pulmonary lobectomy (tLobe), and laparoscopic duodenal atresia (lapDA) repair. Descriptive analyses were performed. RESULTS: Seventeen participants completed pre- and postcourse surveys. The majority of participants had no prior experience with tLobe (59%) or lapDA (53%), and 35% had no experience with tTEF repair. Similarly, the majority were "not comfortable" with these procedures. After the short course, the majority of surgeons reported that they were "likely to perform" these operations within 6 months, despite low levels of baseline experience and comfort levels. CONCLUSION: An exposure training course led to immediate perception of increased skills and confidence. However, these courses typically do not provide basic tenets of expert performance that demands deliberate practice. Future course design should transition to a mastery learning framework wherein regular skill assessments, milestones, and unlimited education time are prioritized before implementation of the new skills.

Pediatric arterial catheters: Complications and associated risk factors.

BACKGROUND/PURPOSE: Arterial catheter complications are a common problem in a pediatric critical care setting, but reported complication rates and risk factors associated with peripheral arterial catheter complications vary. We conducted a retrospective cohort study to identify risk factors in a pediatric patient population. METHODS: We performed a detailed abstraction of provider notes in the electronic medical records of inpatients ≤18years of age who underwent arterial line placement between January 1, 2008 and January 1, 2013 at a university-affiliated standalone pediatric hospital. Inpatient records were assessed for complications associated with arterial catheterization and risk factors inherent to arterial catheter insertion. RESULTS: Two hundred twenty-eight children were identified, of whom 75 (33%) had a total of 106 arterial catheter complications. Complications included line malfunctions (59%, n=63), bleeding (16%, n=17), multiple complications (11%, n=12), infiltration (8%, n=9), and hematoma (4%, n=4). Line malfunction was reported in all patients with multiple complications. Independent predictors of complications associated with arterial catheterization were the presence of more than one provider during the insertion (p=0.007) and insertion attempts at multiple sites (p=0.036). CONCLUSIONS: Our analysis suggests the need for a prospective study to comprehensively assess provider-related risk factors associated with arterial catheter complications in children. LEVEL OF EVIDENCE: IV.

Simulation-Based Educational Module Improves Intern and Medical Student Performance of Closed Reduction and Percutaneous Pinning of Pediatric Supracondylar Humeral Fractures.

BACKGROUND: Simulation-based education has been integrated into many orthopaedic residency programs to augment traditional teaching models. Here we describe the development and implementation of a combined didactic and simulation-based course for teaching medical students and interns how to properly perform a closed reduction and percutaneous pinning of a pediatric supracondylar humeral fracture. METHODS: Subjects included in the study were either orthopaedic surgery interns or subinterns at our institution. Subjects all completed a combined didactic and simulation-based course on pediatric supracondylar humeral fractures. The first part of this course was an electronic (e)-learning module that the subjects could complete at home in approximately 40 minutes. The second part of the course was a 20-minute simulation-based skills learning session completed in the simulation center. Subject knowledge of closed reduction and percutaneous pinning of supracondylar humeral fractures was tested using a 30-question, multiple-choice, written test. Surgical skills were tested in the operating room or in a simulated operating room. Subject pre-intervention and post-intervention scores were compared to determine if and how much they had improved. RESULTS: A total of 21 subjects were tested. These subjects significantly improved their scores on both the written, multiple-choice test and skills test after completing the combined didactic and simulation module. Prior to the module, intern and subintern multiple-choice test scores were significantly worse than postgraduate year (PGY)-2 to PGY-5 resident scores (p < 0.01); after completion of the module, there was no significant difference in the multiple-choice test scores. After completing the module, there was no significant difference in skills test scores between interns and PGY-2 to PGY-5 residents. Both tests were validated using the scores obtained from PGY-2 to PGY-5 residents. CONCLUSIONS: Our combined didactic and simulation course significantly improved intern and subintern understanding of supracondylar humeral fractures and their ability to perform a closed reduction and percutaneous pinning of these fractures.

Preliminary Evaluation of a Novel Rigid Bronchoscopy Simulator.

PURPOSE: Emergent retrieval of airway foreign bodies (AFBs) in children remains a priority skill set for pediatric surgeons. In the setting of low procedural volume, simulation-based education with deliberate practice is essential to ensure trainees reach expected surgical competency. The purposes of this work were to (1) create a realistic rigid bronchoscopy for AFB retrieval simulation model and (2) to evaluate preliminary validity evidence of a novel simulator for the use of training and assessing pediatric surgical trainees' rigid bronchoscopy skills. METHODS: After institutional review board exemption determination, 18 participants performed AFB retrieval of two different objects on a novel simulator that represented an 18-month-old pediatric tracheobronchial airway. Participants reported their experience and comfort level, and rated the simulator across two domains-Authenticity and their Ability to perform tasks. Authenticity was measured by 23 items across five subdomains (Visual Attributes, Materials' Response, Realism of Experience, Value and Relevance, and Global Value). Participants who had previously performed ≥10 rigid bronchoscopies were categorized as "experienced," while those reporting <10 were considered "novice." Validity evidence relevant to test content and internal structure was evaluated using a many-facet Rasch model. RESULTS: Novice surgeons (n = 12) had previously performed a mean of 2.7 (±2.0) rigid bronchoscopies, compared to 15.4 (±7.7) by experienced surgeons (n = 6). For both models, the Value and Relevance subdomain received the highest ratings (observed average [OA] = 3.9, while Materials' Response received the lowest (OA <3.0). Participants' Global Value rating for this model was consistent with "requires minor improvements before it can be considered for use in rigid bronchoscopy training." CONCLUSIONS: We successfully designed, assembled, and evaluated a novel pediatric rigid bronchoscopy model for AFB retrieval. The model was considered as relevant to educational needs and valuable as a testing and training tool. With recommended improvements, the model could be used for implementation with a Mastery Learning curriculum.

The Role of Simulation in Surgical Education.

The current healthcare environment demands optimization of patient outcomes in addition to maximal cost efficiency. Restrictions on resident work hours have placed limitations on the amount of time that trainee physicians can spend on patient care. For the surgery resident, the consequence is less time spent in the operating room under the supervision of a senior surgeon, the cornerstone of Halsted's approach to resident surgeon education. The use of simulation in graduate medical education has gained significant traction as a way to provide trainees with exposure to various techniques and procedures before use on the general patient population. This article describes simulation-based education with particular attention to surgical education. It proceeds to address competency-based education and mastery learning (ML) as key features of effective surgery education programs. A case study of ML in surgery is presented along with examples of translational medical education science from other medical specialties. The report concludes with a brief discussion about simulation-based surgical education today and prospects for the future.

An institution-wide approach to submission, review, and funding of simulation-based curricula.

This article describes the development, implementation, and modification of an institutional process to evaluate and fund graduate medical education simulation curricula. The goals of this activity were to (a) establish a standardized mechanism for proposal submission and evaluation, (b) identify simulation-based medical education (SBME) curricula that would benefit from mentored improvement before implementation, and (c) ensure that funding decisions were fair and defensible. Our intent was to develop a process that was grounded in sound educational principles, allowed for efficient administrative oversight, ensured approved courses were high quality, encouraged simulation education research and scholarship, and provided opportunities for medical specialties that had not previously used SBME to receive mentoring and faculty development.

Automated data extraction: merging clinical care with real-time cohort-specific research and quality improvement data.

BACKGROUND/PURPOSE: Although prohibitively labor intensive, manual data extraction (MDE) is the prevailing method used to obtain clinical research and quality improvement (QI) data. Automated data extraction (ADE) offers a powerful alternative. The purposes of this study were to 1) assess the feasibility of ADE from provider-authored outpatient documentation, and 2) evaluate the effectiveness of ADE compared to MDE. METHODS: A prospective collection of data was performed on 90 ADE-templated notes (N=71 patients) evaluated in our bowel management clinic. ADE captured data were compared to 59 MDE notes (N=51) collected under an IRB-exempt review. Sixteen variables were directly comparable between ADE and MDE. RESULTS: MDE for 59 clinic notes (27 unique variables) took 6months to complete. ADE-templated notes for 90 clinic notes (154 unique variables) took 5min to run a research/QI report. Implementation of ADE included eight weeks of development and testing. Pre-implementation clinical documentation was similar to post-implementation documentation (5-10min). CONCLUSIONS: ADE-templated notes allow for a 5-fold increase in clinically relevant data that can be captured with each encounter. ADE also results in real-time data extraction to a research/QI database that is easily queried. The immediate availability of these data, in a research-formatted spreadsheet, allows for rapid collection, analyses, and interpretation of the data. LEVEL OF EVIDENCE: IV. TYPE OF STUDY: Retrospective Study.

A Multi-Institutional Review of Thoracoscopic Congenital Diaphragmatic Hernia Repair.

INTRODUCTION: Thoracoscopic repair of a congenital diaphragmatic hernia (CDH) in the neonate is controversial due to reports of increased hernia recurrence. A multicenter review on thoracoscopic CDH repair was conducted to evaluate outcomes and to identify factors that are associated with recurrence. METHODS: A multicenter retrospective review was conducted from 2009 to 2015 in neonates who were treated for CDH with thoracoscopic repair. Demographics, preoperative, intraoperative, including repair techniques, and postoperative variables were analyzed by using descriptive statistics. Comparative analysis was performed between those patients who were repaired entirely thoracoscopically with hernia recurrence and those without. RESULTS: One hundred nine infants, of whom 57% were male with an average gestational age at time of surgery of 39.6 ± 4.6 weeks and a weight of 3.4 ± 1.1 kg, were included. The median age at repair was 5 days (range: 3-9), 61% patients required vasopressor support, and 1.8% patients required extracorporeal membrane oxygenation (ECMO) cannulation before repair. Forty-five percent were repaired on high-frequency oscillatory ventilation (HFOV). Repair was completed thoracoscopically in 83 patients (76%), 68 (82%) were repaired primarily, 15 (18%) were repaired with a patch, and 50 (60%) had extracorporeal/rib fixation sutures. Recurrence occurred in 7 (8.4%) of those completed thoracoscopically. Factors found to be significant for recurrence included: vasopressor therapy (P = .02), repair on HFOV (P = .04), and the presence of the spleen in the chest (P = .04). There was no significant difference identified between technical variations in repair. CONCLUSIONS: These data suggest that thoracoscopic repair of CDH is feasible in carefully selected patients. However, there is currently no evidence to support a standardized surgical approach to thoracoscopic repair.

Preliminary Evaluation of a Laparoscopic Common Bile Duct Simulator for Pediatric Surgical Education.

PURPOSE: Laparoscopic common bile duct exploration (LCBDE) decreases overall costs and length of stay in patients with choledocolithiasis. However, utilization of LCBDE remains low. We sought to evaluate a previously developed general surgery LCBDE simulator among a cohort of pediatric surgical trainees. The study purpose was to evaluate the content validity of an LCBDE simulator to support or refute its use in pediatric surgery education. MATERIALS AND METHODS: After IRB exempt determination, 30 participants performed a transcystic LCBDE using a previously developed simulator and evaluated the simulator using a self-reported 28-item instrument. The instrument consisted of two primary domains (Quality and Ability to Perform) that were rated using twenty-five 4-point rating scales and one 4-point global rating scale. Validity evidence relevant to test content was evaluated using a many-facet Rasch model. Interitem consistency was estimated using Cronbach's alpha. P < .05 was considered statistically significant. RESULTS: The highest combined observed averages were for the Value subdomain (OA = 3.79), whereas the lowest ratings were for the Physical/visual attributes subdomain (OA = 3.19). The averaged global rating was 3.14, consistent with this simulator can be considered for use in pediatric LCBDE training, but could be improved slightly. Rasch indices were favorable and supported evidence relevant to test content. Interitem consistency estimates were also favorable, with α values of 0.94 and 0.56 for Qualities and Ability, respectively. CONCLUSIONS: Overall, participants rated the LCBDE simulator highly valuable for pediatric surgical education and felt that it could be used as an educational tool with minor modifications.

Advances in Pediatric Surgical Education: A Critical Appraisal of Two Consecutive Minimally Invasive Pediatric Surgery Training Courses.

BACKGROUND: Mandates for improved patient safety and increasing work hour restrictions have resulted in changes in surgical education. Educational courses increasingly must meet those needs. We sought to determine the experience, skill level, and the impact of simulation-based education (SBE) on two cohorts of pediatric surgery trainees. MATERIALS AND METHODS: After Institutional Review Board (IRB) exempt determination, a retrospective review was performed of evaluations for an annual advanced minimally invasive surgery (MIS) course over 2 consecutive years. The courses included didactic content and hands-on skills training. Simulation included neonatal/infant models for rigid bronchoscopy-airway foreign body retrieval, laparoscopic common bile duct exploration, and real tissue diaphragmatic hernia (DH), duodenal atresia (DA), pulmonary lobectomy, and tracheoesophageal fistula models. Categorical data were analyzed with chi-squared analyses with t-tests for continuous data. RESULTS: Participants had limited prior advanced neonatal MIS experience, with 1.95 ± 2.84 and 1.16 ± 1.54 prior cases in the 2014 and 2015 cohorts, respectively. The 2015 cohort had significantly less previous experience in lobectomy (P = .04) and overall advanced MIS (P = .007). Before both courses, a significant percentage of participants were not comfortable with DH repair (39%-42%), DA repair (50%-74%), lobectomy (34%-43%), and tracheoesophageal fistula repair (54%-81%). After course completion, > 60% of participants reported improvement in comfort with procedures and over 90% reported that the course significantly improved their perceived ability to perform each operation safely. CONCLUSION: Pediatric surgery trainees continue to have limited exposure to advanced MIS during clinical training. SBE results in significant improvement in both cognitive knowledge and trainee comfort with safe operative techniques for advanced MIS.

White Paper on P4 Concepts for Pediatric Imaging.

Over the past decade, innovations in the field of pediatric imaging have been based largely on single-center and retrospective studies, which provided limited advances for the benefit of pediatric patients. To identify opportunities for potential "quantum-leap" progress in the field of pediatric imaging, the ACR-Pediatric Imaging Research (PIR) Committee has identified high-impact research directions related to the P4 concept of predictive, preventive, personalized, and participatory diagnosis and intervention. Input from 237 members of the Society for Pediatric Radiology was clustered around 10 priority areas, which are discussed in this article. Needs within each priority area have been analyzed in detail by ACR-PIR experts on these topics. By facilitating work in these priority areas, we hope to revolutionize the care of children by shifting our efforts from unilateral reaction to clinical symptoms, to interactive maintenance of child health.