Pediatric surgery readmissions: a root cause analysis.

INTRODUCTION: Hospital readmission rates are used as a metric of the quality of patient care in adults. Readmission data is lacking for pediatric surgical patients. The objective of this study is to evaluate our institution's 30-day unexpected pediatric surgical readmission data to identify potentially preventable readmissions. METHODS: An internal database of all pediatric surgical 30-day readmissions to two tertiary-referral children's hospitals in a single health system was reviewed. All pediatric general surgery admissions between January 2008 and May 2013 with hospital readmission within 30 days were included in the study. Patient demographics, diagnoses, cause of readmission, procedure performed, and length of stay were recorded. Charts were individually reviewed to evaluate causality of readmission. RESULTS: There were 2217 pediatric general surgery admissions during the study period. Of these, 145 (6.5%) experienced unexpected readmission within 30 days. One-third of all readmissions occurred in infants between 0 and 364 days of age, 50% occurred in those under 2 years and wholly 80% of all readmissions occurred in those under 9 years of age. A majority of readmissions were associated with chronic comorbid conditions. CONCLUSION: Analysis of pediatric surgical readmission data may assist hospitals in focusing quality of care and cost effectiveness strategies. Development of coordination of care strategies and discharge planning involving both pediatric surgical teams and pediatric hospitalists/specialists may reduce pediatric surgical readmission rates.

Staging laparotomy for Hodgkin's disease in children. Evaluation of the technique.

The evaluation of a technique of laparotomy for the staging of Hodgkin's disease in childhood, including 52 operative procedures, is reviewed. A standard protocol, including splenectomy, multiple hepatic and bone marrow biopsies, and the routine sampling of at least six designated lymph node groups, was employed. It was demonstrated that the surgeon is unable to identify Hodgkin's disease by gross inspection and that the biopsy of node groups previously not included in routine laparotomy studies, ie, mesenteric and porta hepatis nodes is essential to staging in childhood. Stage was altered from stages I and II to stages III and IV in 35% of the patients. The incidence of abdominal recurrence following a negative laparotomy was 7%, and the incidence of post-splenectomy hyperacute infection was 4.5%. This study included minimal use of the lymphangiogram (33%), which accounted for the relatively larger group of patients in clinical stages I and II.

Nutritional care of the surgical neonate.

The function of the nutritionist was to identify and anticipate nutritional problems, to facilitate complete care for each infant, and to serve as an educational resource to staff, patients, and families. Neonatal nutrition is an open and challenging field for nutritionists. An expanded role for the nutritionist as a member of the physician-nutritionist team, as demonstrated in this article, may provide direction for the organization of such a team in other health care facilities with neonatal intensive care units.

Survey of nutritional problems encountered in children with neuromotor disorders.

A survey of 200 patients ranging in age from 5-21 yr was undertaken in 3 facilities in central Pennsylvania: state- (100), county- (13), and privately-operated (66), together with 21 children being cared for at home. Their diagnoses included chromosomal, metabolic, and anatomic abnormalities, and other encephalopathies. The following nutritional problems were identified: 1) inadequate nutrient intake due to feeding technique, swallowing difficulties, or regurgitation; 2) obesity and low activity level; 3) constipation; 4) nutrient-drug interactions and allergies; and 5) inadequate standards with which to compare growth and adequacy of nutrient intake. The nutritional problems encountered in these pediatric patients with neuromotor disorders warrant management by a physician-nutritionist team skilled in nutritional assessment and techniques of providing nutritional support.

Hirschsprung's disease in a kindred: a possible clue to the genetics of the disease.

A nine generation kindred, the first generation dating back to the early 18th century, existing in the Mennonite population of central Pennsylvania is described in terms of the incidence of documented and presumptive Hirschsprung's disease. This kindred was developed by tracing back family lines, by the use of the "circle letter" and three family history books, and by personal interviews with key family members. In the ninth (current) generation, involving at least 5 families, 8 out of 14 children (57%) have documented evidence of Hirschsprung's disease; 4 out of 14 had congenital deafness (29%); 2 had Waardenburg's syndrome (14%); and 1 had Down's syndrome (7%). Only 1 out of the 14 had total colonic involvement. Investigation of the sixth-ninth (last 4) generations shows 22 out of 100 (22%) to have definite or strongly presumptive evidence of Hirschsprung's disease. The opportunity to study this unique kindred, which can be traced back to a single source, exhibiting a very high incidence of Hirschsprung's disease with an unusually high incidence of associated congenital anomalies and without significant association of total colonic disease has provided us with a better understanding of the genetics underlying this disease.

Peripheral total parenteral nutrition employing a lipid emulsion (Intralipid): complications encountered in pediatric patients.

The clinical records of 180 pediatric patients who received Intralipid via peripheral veins at a single institution (1964-1977) were retrospectively analyzed, with particular reference to the complications of this form of therapy. Intralipid was used in a dose range of 2--4 g/kg/day in order to supply 40% of the daily calorie requirements. The patients were neonates, infants, children, and adolescents with a wide range of clinical diagnoses. Local complications associated with Intralipid therapy were minimal. Transient elevations in serum enzyme levels (SGOT, SGPT, and LDH) were observed in 4% of patients, but all of these returned to the normal range after cessation of therapy. Ten patients had histologic evidence of cholestasis, the significance of which is discussed. The lipid emulsion was employed in patients with preexisting hyperbilirubinemia with concomitant resolution of jaundice. Intralipid was administered to patients with known severe thrombocytopenia (secondary to sepsis or myelosuppression) with return of the platelet counts to normal levels during the course of infusion therapy. The use of Intralipid in patients with established sepsis did not delay its response to conventional surgical or antibiotic therapy. There were no instances of the "overloading" syndrome observed.

The effects of enteral stimulation on gallbladder bile during total parenteral nutrition in the neonatal piglet.

The neonatal piglet is a satisfactory model for the human neonate requiring total parenteral nutrition (TPN). Bile status and subsequent liver and gallbladder dysfunction have long been documented as serious complications of long-term TPN. The purpose of this study was to determine whether small amounts of enteral formula during TPN will maintain normal bile appearance and composition. Thirty-one Hanford miniswine, 3 to 6 days old underwent surgery for the placement of central venous catheters. Two days postoperatively, the animals were separated into three groups, according to dietary regimens. Group 1 (n = 10), the control group, received pig formula (SPF-lac) orally (200 cal/kg/d); group 2 (n = 11), was maintained on TPN (180 cal/kg/d) with an enteral supplement of SPF-lac (20 cal/kg/d); group 3 (n = 10), was maintained on TPN only (200 cal/kg/d). The TPN formula consisted of 35 g/kg/d of glucose, 10 g/kg/d of protein, and 3 g/kg/d of lipid. The animals were maintained on these diets for 6 weeks. At necropsy, gallbladder with bile was weighed and bile volume and appearance was recorded. Chemical analyses was performed on 26 bile samples. Gallbladder weight was significantly decreased in groups 2 and 3 compared with group 1 (P less than .0003, P less than .033, respectively, using Students t test with Bonferoni adjustment). Volume was significantly decreased only in group 2 (P less than .003). Group differentiation in relation to bile appearance was determined by the presence or absence of either bile sludge or crystals.(ABSTRACT TRUNCATED AT 250 WORDS)

Accessory diaphragm in an infant.

Accessory diaphragm is a rare congenital abnormality that almost always occurs on the right side and is often associated with cardiovascular anomalies. This paper describes the clinical presentation, radiologic diagnosis, and surgical treatment of the condition. Early recognition and prompt surgical treatment will prevent the chronic pulmonary complications reported in the literature.

Necrotizing enterocolitis in a neonatal piglet model.

The aim of this study was to develop an animal model for necrotizing enterocolitis (NEC). Twenty-five neonatal Hanford minipigs had carotid artery and external jugular vein catheters and rectal Clinical Tonomitors placed under anesthesia. Experimental animals were subjected to a hypoxic insult (50% reduction in baseline PaO2 for 30 minutes) and hypothermic stress (core temperature reduced to 35 degrees C for 30 minutes). Regular oral diet was resumed and the survivors were euthanized 3 to 4 days later. All animals underwent necropsy with gross and histopathological evaluation of the entire bowel. Of 22 experimental animals, 14 survived (64%) and 8 (36%) died of pulmonary hemorrhage. Of the 14 survivors, 8 (57%) had gross and microscopic evidence of NEC. Six of the total 25 animals (24%) sustained rectal perforations from the tonometer. Of 3 control animals, one died of pulmonary hemorrhage and the two survivors had normal intestine. This model successfully produced gross and histological evidence of NEC. The tonometer shows promise as a predictor of NEC provided technical modifications can reduce the complication rate.

Food cravings, mood, and the menstrual cycle.

The primary objective of the present investigation was to document positive changes in food cravings, food consumption, and mood changes over the menstrual cycle and to explore the relation between these factors and dieting habits. A total of 32 female undergraduates completed daily self-reports of food cravings, foods eaten, and mood, for 5 or more weeks. Comparisons of these measures in the 10 days preceding (luteal phase) and 10 days following menstruation onset (follicular phase) revealed that both food cravings and amount eaten were greater in the luteal phase than in the follicular phase. Although women also experienced less positive affect in the luteal phase, there was no correlation between mood and either cravings or amount eaten. Women rated as chronic dieters craved less than those rated an nondieters. The findings on mood and eating confirm previous research, whereas those on cravings extend such research by suggesting that carbohydrate cravings may be augmented by the luteal phase in healthy women.

Development of embryonic chick oviducts in organ culture under the influence of steroid hormones.

Explanted oviducts from 13- and 16-day embryonic female chicks responded to estradiol (1 to 4 micrograms/ml) in the culture medium by forming a thickened epithelium folded into crypts and containing goblet cells and by development of the stroma. In medium containing 3 micrograms/ml estradiol and 0.125 micrograms/ml hydrocortisone, 13-day embryonic oviducts exhibited further development: The columnar epithelial cells formed cilia and tubular glands were formed.

The incidence of emergence agitation associated with desflurane anesthesia in children is reduced by fentanyl.

UNLABELLED: The rapid emergence and recovery from general anesthesia provided by desflurane is associated with a frequent incidence of emergence agitation in children. We sought to determine the mean effective dose of fentanyl that would significantly reduce the incidence of emergence agitation while preserving rapid recovery. Thirty-two children undergoing adenoidectomy received general anesthesia with desflurane and a dose of fentanyl (1.25, 1.87, 2.8, and 4.2 microg/kg) determined by the classic up-down method. Recovery characteristics, including time to extubation, recovery, hospital discharge, agitation, pain, and vomiting, were recorded. Demographics and recovery features were assessed by analysis of variance and Kruskal-Wallis tests. The mean effective dose of fentanyl to reduce agitation was calculated with the Dixon-Massey method to be 2.5 +/- 6.2 microg. There were no significant differences when treatment groups were compared for recovery criteria. Postoperative emesis occurred in 75% of patients. The results of this study demonstrate that a dose of 2.5 microg/kg of fentanyl is sufficient to prevent emergence agitation while preserving the rapid recovery associated with desflurane anesthesia in children undergoing adenoidectomy. IMPLICATIONS: A dose of 2.5 microg/kg of fentanyl prevents emergence agitation associated with desflurane anesthesia in children undergoing adenoidectomy without delaying emergence.

The clinical and biochemical effects of propofol infusion with and without EDTA for maintenance anesthesia in healthy children undergoing ambulatory surgery.

UNLABELLED: We conducted this randomized, double-blinded, comparative, parallel-group study to determine whether adding EDTA to propofol would affect the clinical profile, calcium and magnesium homeostasis, or renal function in healthy children. After the induction of anesthesia with halothane, 69 ambulatory surgical patients (1 mo to <17 yr old), received propofol without EDTA (n = 33) or propofol with EDTA (n = 36). Blood samples were obtained for the measurement of ionized calcium, ionized magnesium, and laboratory indicators of renal function. Hemodynamic measurements, recovery, and adverse events were recorded. Propofol with EDTA produced no significant effects on clinical efficacy or renal function. Propofol and propofol EDTA produced a statistically significant decrease from baseline in serum concentrations of ionized calcium and magnesium during infusion (P<0.05), but with no apparent clinical effect. Hemodynamic measurements generally remained stable and were similar for both groups. Statistically significant changes in systolic blood pressure, mean arterial pressure, and heart rate were not considered clinically significant. Adverse events were mild or moderate. The addition of EDTA does not alter the clinical profile of propofol in pediatric ambulatory surgical patients. With or without EDTA, propofol is associated with a decrease in ionized calcium with no apparent clinical effect. IMPLICATIONS: The addition of EDTA does not alter the clinical profile of propofol in pediatric ambulatory surgical patients. With or without EDTA, propofol is associated with a decrease in ionized calcium with no apparent clinical effect.

Recovery characteristics of desflurane versus halothane for maintenance of anesthesia in pediatric ambulatory patients.

BACKGROUND: Desflurane is a new potent, inhaled anesthetic agent with low blood-gas solubility that should allow for the rapid induction of and emergence from anesthesia. However, its extreme pungency makes desflurane unacceptable for induction of anesthesia in children. This study was undertaken to determine the airway properties of desflurane administered by mask after anesthetic induction with halothane and nitrous oxide, and to compare the emergence and recovery properties of minimum alveolar concentration (MAC)-equivalent concentrations of desflurane or halothane in nitrous oxide in pediatric patients undergoing ambulatory surgery. METHODS: Forty-five children undergoing ambulatory surgery for inguinal hernia repair, orchiopexy, and/or circumcision were randomized into two groups. Both groups were premedicated with intranasal midazolam and given halothane and nitrous oxide by mask to induce anesthesia. A caudal block was placed in children in both groups after anesthetic induction. For maintenance of anesthesia, group I patients (n = 22) were switched over to desflurane (1 MAC) and nitrous oxide, and group II patients (n = 23) continued to receive halothane (1 MAC) and nitrous oxide. All patients breathed spontaneously throughout the entire procedure, and all anesthetics were terminated abruptly at the conclusion of surgery. Recovery indicators (time to first response, length of time in the recovery room and length of time in the hospital) and the quality of the anesthetic emergence were assessed by a nurse blinded to each patient's anesthetic. This observer was present with the patient throughout his or her ambulatory hospitalization and continuously assessed the recovery indicators according to preset criteria. RESULTS: The groups did not differ with respect to age, weight, or dose of midazolam. Although group I (desflurane) had a longer anesthesia time (52 +/- 12 min vs. 42 +/- 10 min), their time to first response (9.5 +/- 6.8 min vs. 20.9 +/- 14.7 min) and their recovery room time (21 +/- 10.7 min vs. 29 +/- 14.6 min) were less than those in group II (halothane). There was a trend for patient emergence from desflurane anesthesia to be associated with a higher incidence of emergence delirium (50% vs. 21%). The two groups were similar with respect to overall duration of postoperative ambulatory hospitalization. CONCLUSIONS: In children premedicated with intranasal midazolam, desflurane maintenance anesthesia allows for a faster recovery. However, depending on the institution's criteria for ambulatory surgical patient discharge, desflurane may or may not affect the overall hospitalization time.

Secondary infection of post-traumatic pulmonary cavitary lesions in adolescents and young adults: role of computed tomography and operative debridement and drainage.

Secondary infection of post-traumatic cavitary lung lesions is unusual. This report describes the clinical course of four patients who sustained severe blunt chest trauma and developed pulmonary pseudocysts that became foci for systemic sepsis. All four patients were adolescents or young adults. Hemophilus species and aerobic Gram-negative rods were the predominant pathogens recovered. Computed tomography of the chest was instrumental in establishing the diagnosis in each case. Despite appropriate antibiotic therapy, all four patients remained septic for weeks. One of the patients died as a result of this infectious process. One patient underwent successful operative debridement and drainage of the involved lung and pleural space. Because infected traumatic pseudocysts may not respond like typical lung abscesses to appropriate antibiotic management, early exploratory thoracotomy should be considered in those patients with prolonged fever and pulmonary deterioration.

Sonography of hypertrophic pyloric stenosis: frequency and cause of nonuniform echogenicity of the thickened pyloric muscle.

In hypertrophic pyloric stenosis, the muscle is typically described as hypoechoic on sonography. However, we have frequently noted a nonuniform pattern; the pyloric muscle seen in the transverse plane is more echogenic in the near and far fields and less echogenic on the sides. The muscle also appears almost as echogenic as the liver on midline longitudinal sonograms. To establish the frequency of these findings, we reviewed the sonograms of 71 infants with hypertrophic pyloric stenosis. The muscle was imaged directly during surgery in three patients. In an in vitro experiment, muscle arranged to stimulate the pyloric ring was scanned in a water bath. Then, using two sections of muscle, we compared the echogenicity when scanning in a plane perpendicular to the long axis of the muscle fibers with that seen with the beam parallel to the long axis of the muscle fibers. In the transverse plane, nonuniform echogenicity of the pyloric muscle was seen in 59 (98%) of 60 patients. In the midline longitudinal plane, the muscle was equal to or slightly less echogenic than the liver in all patients. Both the in vivo and in vitro studies show that the echogenicity varies with the relationship of the ultrasound beam to the orientation of the circular muscle fibers; this phenomenon is known as the anisotropic effect. Our results show that nonuniform echogenicity of the hypertrophied pyloric muscle is a characteristic sonographic finding caused by the anisotropic effect, which is related to the orientation of the ultrasound beam with respect to the circular fibers of the pyloric muscle.