Anastomotic Leak and its Implications: A Multicenter Analysis of "Type C" Esophageal Atresia / Tracheo-esophageal fistula (EA/TEF).

PURPOSE: Repair of type C esophageal atresia with tracheo-esophageal fistula (EA/TEF) may be complicated by esophageal anastomotic leak. Risk factors associated with leak and the impact of leak on inpatient outcomes remains uncertain. Our objectives are to estimate the associations between clinical factors and esophageal anastomotic leak and quantify the association of leak with length of stay (LOS) in infants who underwent repair of type C EA/TEF. METHODS: Using the Children's Hospitals Neonatal Database (CHND), we identified infants with type C EA/TEF from 2021 to 2023. The main outcomes were anastomotic leak and LOS. Multivariable associations between patient and clinical factors and these outcomes were quantified using logistic regression (leak) and Cox proportional hazards modelling (LOS). RESULTS: Among 365 infants at 36 centers, anastomotic leak occurred in 55 (15.1 %) infants, and thoracoscopic approach, lower birthweight, small for gestational age less than 10th percentile, male sex, staged repair, ventricular septal defect, and center were independently associated with leak (area under receiver operating curve = 0.853). Also, LOS was increased in infants with leak compared to those without [hazard ratio (HR): 0.655, 95 % CI = 0.431-0.996, p = 0.044], independent of birth weight, surgical approach, male sex, or VSD. The adjusted LOS demonstrated a 11-fold inter-center variation (p = 0.034). CONCLUSIONS: Several clinical and operative factors are associated with esophageal anastomotic leak in infants after type C EA/TEF repair. Leak significantly prolongs LOS. The magnitude of inter-center variability in LOS also suggests that identifying best practices could aid in improving patient care in this patient population. TYPE OF STUDY: Retrospective Comparative Study. LEVEL OF EVIDENCE: III.

Increasing Caudal Block Utilization to Promote Opioid Stewardship in the NICU Population: A Quality Improvement Project.

BACKGROUND: Regional anesthetic techniques are safe and effective in reducing pain and the need for opioid analgesia but may be underutilized in neonatal intensive care unit (NICU) patients. We developed an opioid stewardship pathway aimed at reducing the use of opioid analgesia in neonates by increasing caudal block utilization from a baseline of 50%-90% within 18 months. METHODS: We used control charts to track intra-operative opioid utilization in morphine milligram equivalents per kilogram (MME/kg) and immediate post-operative extubation rates. Unrelieved pain (defined as two consecutive Neonatal Pain, Agitation & Sedation Scale (NPASS) scores >/ = 4), post-operative opioid use, and reintubation within 24 h were tracked as balancing measures. We ran sample statistical analysis comparing the outcome and balancing measures in surgeries with and without caudal block. RESULTS: There were 125 surgeries in the pre-intervention and 48 in the post-intervention group. Caudal block utilization increased to 63%, while intra-operative opioid utilization decreased (0.230 vs 0.416 MME/kg), and extubation rates increased (75% vs 70%). There were no increases in unrelieved pain or post-operative opioid utilization. Caudal block was associated with decreased intra-operative opioid use (0.000 vs 0.366 MME/kg, p < 0.001) and increased extubation rates (83% vs. 59%, p < 0.001) with no increase in unrelieved pain (23% vs. 22%, p = 0.75) or post-operative opioid use (0.151 vs 0.000 MME/kg, p = 0.35). No patients required reintubation within 24 h. CONCLUSION: The modest increase in caudal block utilization is associated with a reduction in intraoperative opioid use and increased postoperative extubation rates without compromising pain control. LEVEL OF EVIDENCE: Level III.

Cutting into the NICU: Improvements in Outcomes for Neonates with Surgical Conditions.

The Children's Hospitals Neonatal Consortium (CHNC), established in 2010, seeks to improve care for infants with medically and surgically complex conditions who are cared for in level IV regional children's hospital NICUs across North America. Through patient-level individual data collection, comparative benchmarking, and multicenter quality improvement work, CHNC has contributed to knowledge and improved outcomes, leveraging novel collaborations between and across institutions. Focusing on antenatal and inpatient care for infants with surgical conditions including congenital diaphragmatic hernia, gastroschisis, and necrotizing enterocolitis, we summarize the progress made in these infants' care. We highlight the ways in which CHNC has enabled multidisciplinary and multicenter collaborations through the facilitation of diagnosis-specific focus groups, which enable comparative observations of outcomes through quality improvement and research initiatives. Finally, we review the importance of postbirth hospitalization needs of these infants and the application of telemedicine in this population.

Association of Operative Approach With Postoperative Outcomes in Neonates Undergoing Surgical Repair of Esophageal Atresia and Tracheoesophageal Fistula.

INTRODUCTION: Minimally invasive surgery (MIS) is gaining traction as a first-line approach to repair congenital anomalies. This study aims to evaluate outcomes for neonates undergoing open versus MIS repairs for esophageal atresia/tracheoesophageal fistula (EA/TEF). METHODS: In this retrospective study, neonates undergoing EA/TEF repair from 2013 to 2020 were identified using the National Surgical Quality Improvement Program-Pediatric database. Proportions of operative approach (open vs. MIS) over time were analyzed. A propensity score-matched analysis using preoperative characteristics was performed and outcomes were compared including composite morbidity and reintervention rates (overall, major [thoracoscopy, thoracotomy], and minor [chest/feeding tube placement, endoscopy]) between operative approaches. Pearson's chi-square or Fisher's exact tests were used as appropriate. RESULTS: We identified 1738 neonates who underwent EA/TEF repair. MIS utilization increased over time. Pre-match, neonates undergoing open repair were more likely to be premature, lower weight, ventilator dependent, and have cardiac risk factors with higher severity. Post-match, the groups were similar and included 340 neonates per group. MIS repair was associated with longer median operative time (209 vs. 174 min, p < 0.001) and increased overall post-operative intervention rates (7.6% vs. 2.9%, p = 0.01). There were no differences in composite morbidity (24.4% vs. 25.0%, p = 0.86) outside of reintervention. CONCLUSION: MIS approach for neonates with EA/TEF appears to be associated with a higher rate of reinterventions. Further studies evaluating MIS approaches for the repair of EA/TEF are needed to better define short- and long-term outcomes. TYPE OF STUDY: Retrospective comparative study. LEVEL OF EVIDENCE: Level III.

Factors Associated With Isolated Fallopian Tube Torsion in Pediatric Patients.

BACKGROUND: Isolated fallopian tube torsion (IFTT) is a rare form of adnexal torsion that is more difficult to diagnose, which may lead to delays in treatment. Our objectives were to identify clinical and radiologic factors associated with surgically-confirmed IFTT and compare them with those of patients without torsion and with adnexal torsion (AT) in a large pediatric population. METHODS: We conducted a retrospective chart review of all patients who underwent surgery for suspected adnexal torsion from 2016 to 2019. Torsion was determined intraoperatively, with IFFT defined as those with only tubal but no ovarian torsion and AT defined as those with ovarian torsion, with or without involvement of the ipsilateral fallopian tube. Clinical and radiologic variables were compared between patients with IFTT and those without torsion and with AT using descriptive statistics. A previously-described composite score to predict torsion based on the presence of vomiting and adnexal volume (VVCS) was calculated for each patient. RESULTS: Of 291 patients who underwent surgery for suspected torsion, 168 had confirmed torsion: 33 (19.6%) IFTT and 135 (80.4%) AT. Patients with IFTT were more likely to be younger (12.8 vs. 14.2 years, P = 0.02), premenarchal (29.0% vs. 10.7%, P = 0.009), experience nausea (90.6% vs. 70.9%, P = 0.02) and vomiting (81.3% vs. 32.8%, P < 0.001), have a paratubal cyst on imaging (18.8% vs. 2.5%, P = 0.003), and have larger adnexal volume (143.3 vs. 64.9 ml, P < 0.001) than those without torsion. Higher BMI (26.6 vs. 22.9 kg/m2, P = 0.03), a paratubal cyst on imaging (18.8% vs. 1.5%, P < 0.001), presence of arterial (65.5% vs. 44.1%, P = 0.04) and venous Doppler flow (79.3% vs. 55.9%, P = 0.02), and radiologic impression indicating lack of torsion (37.9% vs. 16.8%, P = 0.04) were more common in IFTT than AT. The accuracy of the VVCS in predicting torsion for the IFFT group was 83.9%. CONCLUSIONS: IFTT has a similar clinical presentation to AT but with a higher likelihood of a paratubal cyst and preserved Doppler flow on imaging. IFTT should be strongly considered in patients who present with pain, nausea, and vomiting and have an adnexal mass separate from the ovary on imaging, regardless of Doppler flow. LEVEL OF EVIDENCE: Level II. TYPE OF STUDY: Prognosis study.

Peer Support to Promote Surgeon Well-being: The APSA Program Experience.

BACKGROUND: Peer support programs have evolved to train physicians to provide outreach and emotional first aid to their colleagues when they experience the inevitable challenge of a serious adverse event, whether or not it is related to a medical error. Most pediatric surgeons have experienced the trauma of a medical error, yet, in a survey of APSA membership, almost half said that no one reached out to them, and few were satisfied with their institution's response to the error. Thus, the APSA Wellness Committee developed an APSA-based peer support program to meet this need. METHODS: Peer supporters were nominated by fellow APSA members, and the group was vetted to ensure diversity in demographics, practice setting, and seniority. Formal virtual training was conducted before the program went live in 2020. Trained supporters were surveyed 6 months after the program launched to evaluate their experiences with providing peer support. RESULTS: 15 referrals were made in the first year, 60 % of which were self-initiated. Most referrals were for distress related to adverse events or toxic work environments (33 % each). While only about 25 % of trained supporters had provided formal support through the APSA program, more than 80 % reported using the skills to support colleagues and trainees within their own institutions. CONCLUSION: Our experience in the first year of the APSA peer support program demonstrates the feasibility of building and maintaining a national program to provide emotional first aid by a professional society to expand the safety net for surgeons who are suffering.

Application of a Composite Score to Predict Adnexal Torsion in Premenarchal and Menarchal Children and Adolescents.

STUDY OBJECTIVE: The study objective was to apply a previously created composite score for the prediction of adnexal torsion in children and adolescents to a larger group of heterogeneous patients to test its validity and to refine this scoring system to more accurately predict adnexal torsion. METHODS: This was a retrospective chart review at a tertiary care children's hospital and its affiliates. Participants were female patients 0-20 years of age who underwent surgery for suspected adnexal torsion from 2016 to 2019. Data were collected from outpatient, emergency department, and inpatient notes, radiographic data, and operative reports. The primary outcome was the accuracy and predictive value of the total composite score (TCS) to identify or exclude adnexal torsion. RESULTS: Of the 291 patients with suspected adnexal torsion who went to the operating room during the study period, 168 (57.8 %) had confirmed adnexal torsion. The accuracy of the TCS, which included presence of vomiting, adnexal volume, and adnexal ratio, in predicting or excluding torsion was 83.6 % for all patients, 92.1 % for premenarchal patients, and 81.3 % for menarchal patients. A variation of the TCS that included only vomiting and adnexal volume had an accuracy of 85.8 %. CONCLUSIONS: Our study demonstrates the accuracy and reproducibility of a previously published composite score to predict adnexal torsion in children and adolescents. It also further refines this score to a potentially more clinically useful tool. Future studies are needed to prospectively evaluate these composite scores and their implementation in clinical settings. LEVEL OF EVIDENCE: III.

Association of Age at Duodenal Atresia Repair With Outcomes: A Pediatric NSQIP Analysis.

PURPOSE: Neonates with duodenal atresia (DA) are often born prematurely and undergo repair soon after birth, while others are delayed to allow for growth until closer to term corrected gestational age (cGA). Premature infants have been demonstrated to experience worse outcomes, but it is unclear whether delaying surgery mitigates the increased morbidity. This study evaluates the association of timing of DA repair with postoperative morbidity. METHODS: We retrospectively evaluated neonates undergoing DA repair from the National Surgical Quality Improvement Program-Pediatric database (2015-2020). A multivariable regression analyzed factors associated with composite morbidity, including cGA and age in days of life (DOL) at surgery. A propensity score matched analysis was completed in premature neonates born at ≤35 weeks gestation to compare outcomes at similar birth gestational ages (bGA) and birth weight who underwent early (<7 DOL) versus delayed (≥7 DOL) repair. RESULTS: 809 neonates were included with a median bGA of 36 weeks (IQR 34-38), birth weight of 2.46 kg (IQR 1.96-2.95), and DOL at surgery of 2 (IQR 1-5). Infants born ≤35 weeks represented 35.23% of the cohort. On multivariable analysis, increasing cGA at surgery was associated with decreased morbidity (OR: 0.91, CI [0.84, 0.99]), and increasing DOL at surgery was associated with increased morbidity (OR: 1.02, CI [1.00, 1.04]). On propensity score matched analysis, delayed repairs were associated with increased postoperative ventilation (6 days vs. 2 days, p < 0.05); however, there were no differences in composite or surgical morbidity between early and delayed repairs. CONCLUSIONS: Morbidity after DA repair in neonates ≤35 weeks cGA is primarily driven by non-surgical causes, but delaying surgery does not appear to mitigate the risks associated with prematurity. It seems reasonable to consider repair in neonates around 33-34 weeks gestation without prohibitive risk factors. Optimal timing of DA repair requires a delicate balance between these factors. LEVEL OF EVIDENCE: Level III. TYPE OF STUDY: Retrospective Cohort Study.

Concurrent Cholecystectomy Does Not Increase Splenectomy Morbidity in Patients With Hemolytic Anemia: A Pediatric NSQIP Analysis.

PURPOSE: Children undergoing splenectomy for hemolytic anemia often have cholelithiasis, which may or may not be symptomatic. It is unclear whether concurrent cholecystectomy increases length of stay or morbidity after splenectomy. The purpose of this study was to compare morbidity among children undergoing laparoscopic splenectomy alone versus splenectomy with concurrent cholecystectomy in patients with hemolytic anemia. METHODS: We retrospectively evaluated children with hemolytic anemia undergoing non-traumatic laparoscopic splenectomy in the National Surgical Quality Improvement Program-Pediatric database (2012-2020). Outcomes were compared for patients undergoing splenectomy alone (n = 1010) versus splenectomy with cholecystectomy (n = 371). Pearson's Chi-square and Student's t-tests were utilized as appropriate. Propensity score-matching was completed, controlling for eight demographic and clinical variables. RESULTS: 1381 patients were identified, 73.1% undergoing splenectomy alone and 26.9% splenectomy with cholecystectomy. Splenectomy with cholecystectomy patients were older (10.9 years vs. 8.4 years, p < 0.01), more likely to have hereditary spherocytosis (56.1% vs. 40.8%, p < 0.01), less likely to have sickle cell disease (12.1% vs. 33.5%, p < 0.01), more likely ASA class 1 or 2 (49.3% vs. 42.1%, p < 0.01), and had similar preoperative hematocrit levels (29.6 vs. 29.3, p = 0.33). The splenectomy with cholecystectomy group was less likely to receive preoperative blood transfusions (13.5% vs. 25.4%, p < 0.01). There were 360 pairs selected on propensity score-matching, and splenectomy with cholecystectomy was associated with increased operative time (182 min vs. 145 min, p < 0.01) and decreased occurrences of a postoperative transfusion (4.2% vs. 8.9%, p = 0.01). Length of stay after surgery (2.5 days vs. 2.3 days, p = 0.13), composite morbidity (3.9% vs. 3.4%, p = 0.69), and 30-day readmission rates (3.3% vs. 7.4%, p = 0.08) were all similar. CONCLUSIONS: Splenectomy with cholecystectomy is associated with similar postoperative morbidity, length of stay and readmission rates compared to splenectomy alone. These data support the safety of concurrent cholecystectomy with splenectomy for children with cholelithiasis in the setting of hemolytic anemia. TYPE OF STUDY: Retrospective Cohort Study. LEVEL OF EVIDENCE: Level III.

Assessing Alternative Approaches for Wound Closure in a National Pediatric Learning Health System.

INTRODUCTION: Our objective was to perform a feasibility study using real-world data from a learning health system (LHS) to describe current practice patterns of wound closure and explore differences in outcomes associated with the use of tissue adhesives and other methods of wound closure in the pediatric surgical population to inform a potentially large study. METHODS: A multi-institutional cross-sectional study was performed of a random sample of patients <18 y-old who underwent laparoscopic appendectomy, open or laparoscopic inguinal hernia repair, umbilical hernia repair, or repair of traumatic laceration from January 1, 2019, to December 31, 2019. Sociodemographic and operative characteristics were obtained from 6 PEDSnet (a national pediatric LHS) children's hospitals and OneFlorida Clinical Research Consortium (a PCORnet collaboration across 14 academic health systems). Additional clinical data elements were collected via chart review. RESULTS: Of the 692 patients included, 182 (26.3%) had appendectomies, 155 (22.4%) inguinal hernia repairs, 163 (23.6%) umbilical hernia repairs, and 192 (27.8%) traumatic lacerations. Of the 500 surgical incisions, sutures with tissue adhesives were the most frequently used (n = 211, 42.2%), followed by sutures with adhesive strips (n = 176, 35.2%), and sutures only (n = 72, 14.4%). Most traumatic lacerations were repaired with sutures only (n = 127, 64.5%). The overall wound-related complication rate was 3.0% and resumption of normal activities was recommended at a median of 14 d (interquartile ranges 14-14). CONCLUSIONS: The LHS represents an efficient tool to identify cohorts of pediatric surgical patients to perform comparative effectiveness research using real-world data to support medical and surgical products/devices in children.

Implementation of a quadratus lumborum regional block protocol with assessment of effectiveness for patients with appendicitis: a quality improvement project.

PURPOSE: This study analyzes the implementation of the routine use of quadratus lumborum blocks (QLBs) on postoperative pain and opioid consumption among children undergoing laparoscopic appendectomy compared to those not receiving regional anesthesia. METHODS: Children undergoing laparoscopic appendectomy within a multi-hospital children's healthcare system were retrospectively reviewed from 2017 to 2021. Patients were stratified by appendicitis type (uncomplicated vs. complicated). Pain scores and opioid consumption in the post-anesthesia care unit (PACU) and within the first 24 h postoperatively were compared by block status (no block [NB] vs. QLB) and appendicitis type. RESULTS: 2033 patients were reviewed, and 610 received a QLB. The frequency of rescue opioid use was reduced in the PACU (uncomplicated: QLB 46.6% vs. NB 54.6%, p = 0.005; complicated: QLB 28.5% vs. NB 39.9%, p = 0.01) and postoperatively (complicated: QLB 33.7% vs. NB 52.9%, p < 0.001) for those who received a QLB. This resulted in reduced opioid consumption as measured by morphine milligram equivalents per kilogram postoperatively. CONCLUSION: QLBs can be safely administered in children and provide improvements in opioid consumption postoperatively. QLBs should remain a strongly favored regional anesthetic technique because of their wide applicability for abdominal surgeries to minimize rescue opioid analgesic use. TYPE OF STUDY: Retrospective comparative study. LEVEL OF EVIDENCE: Level III.

Antimicrobial Stewardship in Neonates with Necrotizing Enterocolitis: A Quality Improvement Initiative.

BACKGROUND: Antibiotic overutilization in the neonatal intensive care unit (NICU) has many adverse effects, and necrotizing enterocolitis (NEC) is one of the most common indications for antibiotics in premature infants. Evidence for a preferred antibiotic regimen for NEC is lacking. This project aims to reduce piperacillin-tazobactam use and overall antibiotic duration in neonates with NEC through the implementation of an antibiotic stewardship pathway based on the modified Bell stage classification system. METHODS: A multidisciplinary team consisting of neonatology, pharmacy, infectious disease, and surgery developed an antibiotic protocol for the management of NEC based on Bell stage. Recommendations included 48 h of ampicillin/gentamicin (AG) for stage I, 5-10 days of AG for stage II, the addition of metronidazole for stage IIIA, and 7-14 days of piperacillin-tazobactam (PT) for stage IIIB. We evaluated overall antibiotic and PT exposure, progression to surgical NEC, NEC recurrence, antibiotic resistance, bacteremia/fungemia, and mortality 1 year pre- and post-protocol implementation. RESULTS: 27 patients pre-intervention and 44 post-intervention were analyzed. Antibiotic exposure was reduced from a median 119.19 to 80.65 days of therapy (DOT) per 1000 patient days (p = 0.11). PT exposure decreased after protocol implementation (median 68.78 vs. 7.97 DOT per 1000 patient days, p = 0.002). There were no significant differences in morbidity or mortality outcomes. CONCLUSIONS: Antibiotic stewardship strategies can be implemented in the NICU without compromising outcomes in patients with NEC. Bell stage stratification appears to be an effective method for antibiotic selection. Further studies are needed in a larger population to optimize regimens and ensure safety. TYPE OF STUDY: Retrospective comparative study. LEVEL OF EVIDENCE: Level III.

Quality improvement dissemination in pediatric surgery: The APSA quality and safety toolkit.

Shared experiential learning is critical in the field of pediatric surgery to support the translation of evidence into practice. Surgeons who develop QI interventions in their own institutions based on the best available evidence create work products that can accelerate similar projects in other institutions, rather than continuously reinventing the wheel. The American Pediatric Surgical Association (APSA) Quality and Safety Committee (QSC) toolkit was created to facilitate knowledge-sharing and thereby hasten the development and implementation of QI. The toolkit is an expanding open-access web-based repository of curated QI projects that includes evidence-based pathways and protocols, stakeholder presentations, parent/patient educational materials, clinical decision support (CDS) tools, and other components of successful QI interventions in addition to contact information for the surgeons who developed and implemented them. This resource catalyzes local QI endeavors by showcasing a range of projects that can be adapted to fit the needs of a given institution, and it also serves as a network to connect interested surgeons with successful implementers. As healthcare shifts towards value-based care models, quality improvement becomes increasingly important, and the APSA QSC toolkit will continue to adapt to the evolving needs of the pediatric surgery community.

Patient-Reported Outcomes in Pain Management After Ambulatory Pediatric General and Urologic Surgery.

BACKGROUND: Many studies evaluating opioid stewardship interventions' effects on postoperative pain rely on emergency department (ED) visits or readmissions, but patient-reported pain scores represent a more complete picture of the postoperative experience. This study compares patient-reported pain scores after ambulatory pediatric and urologic procedures and the effect of an opioid stewardship intervention that nearly eliminated the use of outpatient narcotics. METHODS: This is a retrospective comparative study including 3173 pediatric patients who underwent ambulatory procedures from 2015 to 2019, during which there was an intervention to reduce narcotic prescriptions. Postoperative day one phone calls assessed pain levels using a four-point scale (no pain, mild pain, moderate pain controlled with medication, or severe pain uncontrolled with medication). We quantified the proportion of patients prescribed opioids pre-versus post-intervention and compared pain scores for patients receiving opioid versus non-opioid regimens. RESULTS: Opioid prescription rates demonstrated a 6.5-fold reduction after opioid stewardship efforts. The majority of patients (2838) received non-opioids, with only 335 patients receiving opioids. Opioid patients reported moderate/severe pain slightly more than non-opioid patients (14.1% vs. 10.4%, p = 0.04). On by-procedure analyses, there were no subgroups in which non-opioid patients reported significantly higher pain scores. CONCLUSIONS: Non-opioid postoperative pain regimens appear to be effective, with only 10.4% of patients reporting moderate/severe pain after ambulatory procedures. Future studies assessing patient-reported outcomes are necessary to optimize pain control for all patients and to determine whether there is ever an indication for opioid prescription after ambulatory general pediatric or urologic surgery. TYPE OF STUDY: Retrospective comparative study. LEVEL OF EVIDENCE: Level III.

Postoperative Respiratory Complications in SARS-CoV-2 Positive Pediatric Patients Across 20 United States Hospitals: A Cohort Study.

INTRODUCTION: Data examining rates of postoperative complications among SARS-CoV-2 positive children are limited. The purpose of this study was to evaluate the impact of symptomatic and asymptomatic SARS-CoV-2 positive status on postoperative respiratory outcomes for children. METHODS: This retrospective cohort study included SARS-CoV-2 positive pediatric patients across 20 hospitals who underwent general anesthesia from March to October 2020. The primary outcome was frequency of postoperative respiratory complications, including: high-flow nasal cannula/non invasive ventilation, reintubation, pneumonia, Extracorporeal Membrane Oxygenation (ECMO), and 30-day respiratory-related readmissions or emergency department (ED) visits. Univariate analyses were used to evaluate associations between patient and procedure characteristics and stratified analyses by symptoms were performed examining incidence of complications. RESULTS: Of 266 SARS-CoV-2 positive patients, 163 (61.7%) were male, and the median age was 10 years (interquartile range 4-14). The majority of procedures were emergent or urgent (n = 214, 80.5%). The most common procedures were appendectomies (n = 78, 29.3%) and fracture repairs (n = 40,15.0%). 13 patients (4.9%) had preoperative symptoms including cough or dyspnea. 26 patients (9.8%) had postoperative respiratory complications, including 15 requiring high-flow oxygen, 8 with pneumonia, 4 requiring non invasive ventilation, 3 respiratory ED visits, and 2 respiratory readmissions. Respiratory complications were more common among symptomatic patients than asymptomatic patients (30.8% vs. 8.7%, p = 0.01). Higher ASA class and comorbidities were also associated with postoperative respiratory complications. CONCLUSIONS: Postoperative respiratory complications are less common in asymptomatic versus symptomatic SARS-COV-2 positive children. Relaxation of COVID-19-related restrictions for time-sensitive, non urgent procedures in selected asymptomatic patients may be reasonably considered. Additionally, further research is needed to evaluate the costs and benefits of routine testing for asymptomatic patients. LEVEL OF EVIDENCE: Iii, Respiratory complications.

Clinical and radiologic factors associated with adnexal torsion in premenarchal and menarchal children and adolescents.

BACKGROUND: Adnexal torsion is a gynecologic emergency in children and adolescents but remains a challenging diagnosis, with no consistent clinical or radiologic diagnostic criteria. Our objective was to identify risk factors associated with adnexal torsion in premenarchal and menarchal patients with surgically confirmed torsion compared with those without torsion. METHODS: We conducted a retrospective chart review of all patients who underwent surgery between January 2016 and December 2019 for possible adnexal torsion. Data on demographics, clinical characteristics, radiologic variables, and operative findings were compared using descriptive statistics. Independent predictors of torsion were then examined in multivariate logistic regression models. RESULTS: Of the 291 patients who underwent surgery, 168 (57.7%) had torsion. Patients with torsion were younger than those without torsion (11.9 vs. 14.2 years, P < .01). Vomiting was significantly associated with torsion for all patients (P < .001). Large adnexal volume and absent arterial Doppler flow were associated with torsion for the total population and menarchal subgroup. A logistic regression model for the total population that controlled for age and menarchal status found that vomiting (adjusted odds ratio [aOR] 5.92, 95% confidence interval [CI] 2.87-12.22), highest adnexal volume category (aOR 4.92, 95% CI 2.25-10.75), and absent arterial Doppler flow (aOR 2.674, 95% CI 1.28-5.60) were associated with torsion. CONCLUSIONS: Vomiting, enlarged adnexal volume, and absent arterial Doppler flow were associated with adnexal torsion. However, no single risk factor accurately diagnosed torsion, and multiple factors should be interpreted together. LEVEL OF EVIDENCE: Study of Diagnostic Test, Level II.