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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.
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Analgésicos não Narcóticos , Analgésicos Opioides , Analgésicos não Narcóticos/uso terapêutico , Analgésicos Opioides/uso terapêutico , Criança , Serviço Hospitalar de Emergência , Humanos , Manejo da Dor , Dor Pós-Operatória/tratamento farmacológico , Dor Pós-Operatória/epidemiologia , Padrões de Prática Médica , Estudos RetrospectivosRESUMO
BACKGROUND: The first-line treatment for intussusception is radiologic reduction with either air-contrast enema (AE) or liquid-contrast enema (LE). The purpose of this study was to explore relationships between self-reported institutional AE or LE intussusception reduction preferences and rates of operative intervention and bowel resection. METHODS: Pediatric Health Information System (PHIS) hospitals were contacted to assess institutional enema practices for intussusception. A retrospective study using 2009-2018 PHIS data was conducted for patients aged 0-5 y to evaluate outcomes. Chi-squared tests were used to test for differences in the distribution of surgical patients by hospital management approach. RESULTS: Of the 45 hospitals, 20 (44%) exclusively used AE, 4 (9%) exclusively used LE, and 21 (46%) used a mixed practice. Of 24,688 patients identified from PHIS, 13,231 (54%) were at exclusive AE/LE hospitals and 11,457 (46%) were at mixed practice hospitals. Patients at AE/LE hospitals underwent operative procedures at lower rates than at mixed practice hospitals (14.8% versus 16.5%, P< 0.001) and were more likely to undergo bowel resection (31.1% versus 27.1%, P= 0.02). CONCLUSIONS: Practice variation exists in hospital-level approaches to radiologic reduction of intussusception and mixed practices may impact outcomes.
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Intussuscepção , Criança , Pré-Escolar , Enema/métodos , Hospitais Pediátricos , Humanos , Lactente , Recém-Nascido , Prática Institucional , Intussuscepção/diagnóstico por imagem , Intussuscepção/cirurgia , Estudos Retrospectivos , Resultado do TratamentoRESUMO
BACKGROUND: There is an increasing national trend toward initial venovenous (VV) extracorporeal membrane oxygenation (ECMO) for infants and children with respiratory disease; however, some proportion of patients initiated on VV ECMO will ultimately require conversion to venoarterial (VA) support for circulatory augmentation. The purpose of this work is to describe patients who required conversion from VV to VA ECMO and to highlight the increased mortality in this population. MATERIALS AND METHODS: Demographic and disease-specific data on children who underwent VV-to-VA ECMO conversion were extracted from the Extracorporeal Life Support Organization registry. Survival comparisons to age-matched patients undergoing unconverted ECMO runs were made using the 2016 Extracorporeal Life Support Organization International Summary report. The relative risk (RR) of death associated with VV-to-VA conversion was calculated, and statistical analysis of survival was performed using a chi-squared test with P < 0.05 for significance. RESULTS: This study cohort consisted of 1382 patients who required VV-to-VA conversion. The overall hospital survival rate for neonates requiring conversion was 60%, compared with 83% for unconverted VV runs and 64% for unconverted VA runs (RR 1.23; 95% confidence interval, 1.14-1.34). Similarly, the survival of older children requiring conversion was 46% compared with 66% and 51%, respectively (RR 1.16; 95% confidence interval, 1.06-1.27). CONCLUSIONS: VV-to-VA conversion does occur and is associated with increased mortality. The need for conversion from VV to VA ECMO may represent an early failure to recognize physiologic parameters or disease severity that would be better managed with initial VA support. Further research is needed to pinpoint the cause of increased mortality and to identify predictors of VV failure to optimize initial mode selection.
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Oxigenação por Membrana Extracorpórea/mortalidade , Oxigenação por Membrana Extracorpórea/métodos , Criança , Pré-Escolar , Estudos de Coortes , Feminino , Humanos , Lactente , Recém-Nascido , MasculinoRESUMO
BACKGROUND: Despite the frequency of acute appendicitis in children, there is no evidence-based consensus surrounding the urgency of the operation if a diagnosis is made after regular business hours. Although a modest delay in time to operation does not increase disease severity, postponing cases to the next calendar day may be associated with higher resource utilization. We aimed to evaluate the trend of delaying appendectomies to the next calendar day and its associated outcomes. METHODS: We queried the Pediatric Health Information System to analyze appendectomy patients younger than 18 y of age from 2010 to 2018. Same-day appendectomy and next-day appendectomy cohorts were created using admission hour and operative day. Healthcare cost, length of stay, surgical complications, and 30-day readmission rates were collected. Bivariate analyses and multivariable regressions were used to evaluate groups stratified by time of presentation. RESULTS: During the study period, 113,662 appendectomies were performed, comprising 88,715 (78.1%) same-day appendectomies and 24,947 (21.9%) next-day appendectomies. A higher proportion of same-day appendectomies (80.5%) were performed during hours 12:00am to 5:00pm and 19.5% were performed during hours 6:00pm to 11:00pm. The trend of next-day appendectomies increased during the study period from 13.9% to 20.2%. This was primarily evident in the 6:00pm to 11:00pm period. The 5:00pm cutoff was most predictive of a next-day appendectomy. Next-day appendectomies had similar rates of surgical complications; however, they were associated with higher costs, longer lengths of stay, and higher readmission rates. CONCLUSION: As the understanding of appendicitis urgency has changed, a more tempered approach of delivering surgical care has trended. Although short delays appear safe, postponement to the next calendar day is associated with higher resource utilization.
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Apendicite/cirurgia , Tempo para o Tratamento , Adolescente , Criança , Pré-Escolar , Feminino , Custos de Cuidados de Saúde , Humanos , Lactente , Recém-Nascido , Tempo de Internação , Masculino , Admissão do Paciente , Readmissão do Paciente/estatística & dados numéricos , Análise de Regressão , Estudos Retrospectivos , Fatores de Tempo , Tempo para o Tratamento/tendências , Estados UnidosRESUMO
PURPOSE: The presence of pain may interrupt sleep and impede normal postoperative recovery; however, no prior studies have quantified sleep loss due to pain in children undergoing inpatient surgery. Wearable accelerometers objectively measure sleep patterns in children. We aimed to quantify sleep loss associated with patient reported pain scores after a Modified Nuss operation. METHODS: Ten patients undergoing Modified Nuss operations were recruited during their inpatient stay. Children wore an Actigraph GT3X-BT accelerometer postoperatively during their hospital stay. Hourly sleep minutes were recorded using the Actigraph between 10â¯pm and 6â¯am. Patient reported pain scores were abstracted from patient charts. Mixed linear regression models, adjusting for within-subject random effects, were estimated to quantify the association between hourly sleep minutes and patient reported pain scores. RESULTS: Patients were 30% female, with an average age of 15.7â¯years (range 13-22). The majority (70%) of patients were white non-Hispanic. All patients received a patient controlled analgesic pump. Average postoperative length of stay was 4.8â¯days (range 4.0-6.0; SDâ¯=â¯0.8). A total of 240 sleep hours and associated pain scores were analyzed. Patients slept on average 48â¯min per hour. Mixed model analysis predicted that a 1-point increase in pain score was associated with 2.5â¯min per hour less sleep time. CONCLUSION: Increases in patient-reported pain scores are associated with sleep loss after a Modified Nuss operation. Objectively quantifying sleep loss associated with postoperative pain using accelerometer data may help clinicians better understand their patient's level of pain control. Our findings provide the basis for future studies aimed at more accurately titrating pain medication to optimize sleep and speed up recovery. LEVEL OF EVIDENCE: Case Series Without Comparison Group, Level IV.
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Dor Pós-Operatória , Procedimentos de Cirurgia Plástica/efeitos adversos , Transtornos do Sono-Vigília , Actigrafia , Adolescente , Adulto , Analgésicos/uso terapêutico , Feminino , Tórax em Funil/cirurgia , Humanos , Masculino , Dor Pós-Operatória/complicações , Dor Pós-Operatória/diagnóstico , Dor Pós-Operatória/tratamento farmacológico , Sono/fisiologia , Transtornos do Sono-Vigília/diagnóstico , Transtornos do Sono-Vigília/etiologia , Resultado do Tratamento , Adulto JovemRESUMO
BACKGROUND: Phrenic nerve injury (PNI) from birth trauma is a recognized phenomenon, generally occurring with ipsilateral brachial plexus palsy (BPP). In severe cases, PNI results in diaphragm paresis (DP) and respiratory insufficiency. Surgical diaphragmatic plication (SDP) is a potential management strategy for patients with PNI and DP, but timing and outcomes associated with SDP have not been rigorously studied. METHODS: Records from 49 tertiary United States pediatric hospitals in the Pediatric Health Information System from 2004 to 2018 were analyzed. The study cohort included patients diagnosed with BPP from birth trauma who were documented to have PNI or DP. Patients who underwent congenital cardiac operations were excluded. RESULTS: A total of 5832 patients were identified with BPP from birth trauma during the study period, 122 (2%) of whom were found to have concomitant DP. Of those, 65 (53%) were male, 39 (32%) were infants of diabetic mothers, 80 (65%) required mechanical ventilation, and 33 (27%) underwent SDP. SDP was performed at a median (range) age of 36 (7-95) days. Median (range) total and postoperative hospital lengths of stay (LOS) were 34 (6-180) and 15 (4-132) days, respectively. There was also an observed increase in post-operative LOS with increase in age at operation. CONCLUSION: Neonatal DP is rare and is managed with SDP in a minority of instances. Age at repair affects total and postoperative length of stay, proxies for resource utilization and morbidity. Repair prior to 45â¯days of life appears to result in a shorter postoperative hospital stay. This analysis will help guide surgeons with respect to indications and operative timing for infant DP. TYPE OF STUDY: Retrospective Comparative Study. LEVEL OF EVIDENCE: Level III.
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Diafragma/cirurgia , Paralisia Obstétrica/etiologia , Paralisia Obstétrica/cirurgia , Nervo Frênico/lesões , Paralisia Respiratória/etiologia , Paralisia Respiratória/cirurgia , Feminino , Humanos , Recém-Nascido , Tempo de Internação , Masculino , Paralisia Obstétrica/terapia , Respiração Artificial , Paralisia Respiratória/terapia , Estudos RetrospectivosRESUMO
BACKGROUND: Preoperative physical activity (PA) is an important reference point to evaluate recovery, yet is not attainable for emergent surgical admissions. We investigated the validity of PA of healthy children recruited from within the same community as surgical patients and a nationally representative sample as alternative baseline PA for pediatric surgical patients. METHODS: Patients undergoing an elective operation were matched to community-recruited healthy controls (CRHC) on sex, age, and weight, and their PA was assessed using an Actigraph accelerometer. National Health and Nutrition Examination Survey (NHANES) Actigraph PA data were used as a nationally representative match for baseline PA. Surgical patients wore the accelerometer for 2â¯days preoperatively, CRHC for 2â¯days, and NHANES participants for 7â¯days. PA was categorized as light (LPA) or moderate vigorous (MVPA). Means were compared between the 3 groups. RESULTS: Thirty patients were matched with 80 CRHC and 3147 NHANES participants. LPA was similar between surgical patients and CRHC. However, CRHC averaged 19â¯min/day more MVPA than surgery patients (pâ¯=â¯0.04), and both groups averaged 58â¯min and 67â¯min/day higher MVPA than the matched NHANES sample, respectively (pâ¯<â¯0.01). CONCLUSIONS: CRHC LPA was similar to preoperative LPA in surgical patients and may be an alternative. LEVEL OF EVIDENCE: Level II.
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Exercício Físico , Período Pré-Operatório , Acelerometria , Adolescente , Estudos de Casos e Controles , Criança , Feminino , Nível de Saúde , Humanos , Masculino , Inquéritos NutricionaisRESUMO
Clinical History. A 4.4 kg male was born to a 25-year-old, G2P1, nondiabetic woman at 39 and 5/7 weeks. Delivery was complicated by shoulder dystocia requiring forceps-assisted vaginal delivery, resulting in left arm Erb's palsy secondary to left brachial plexus injury. He was born with low muscle tone and bradycardia and subsequently required intubation for poor respiratory effort. He was extubated on day one of life but continued to be tachypneic and have borderline oxygen saturation, requiring intensive care. Chest radiographs demonstrated a progressive clearing of his lung fields, consistent with presumptively diagnosed meconium aspiration. However, a persistent elevation of the right hemidiaphragm was noted, and his tachypnea and increased work of breathing continued. Focused ultrasound of the diaphragm was performed, confirming decreased motion of the right hemidiaphragm. Following a multidisciplinary discussion, thoracoscopic right diaphragm plication was performed on the 33rd day of life. He was extubated postoperatively and subsequently weaned to room air with a notable decrease in tachypnea over 48 hours. He was discharged on postoperative day 12 and continues to thrive at 6 months of age without respiratory embarrassment. Purpose. Ipsilateral phrenic nerve injury with diaphragm paralysis from shoulder dystocia during vaginal delivery is a recognized phenomenon. Herein, we present a case of contralateral diaphragm paralysis in order to draw attention to the clinician that this discordance is possible. Key Points. According to Raimbault et al., clinical management of newborns who experience birth injury is a multidisciplinary effort. According to Fitting and Grassino, though most cases of phrenic nerve injuries are ipsilateral to shoulder dystocia brachial plexus palsy, contralateral occurrence is possible and should be considered. According to Waters, diaphragm plication is a safe and effective operation.
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BACKGROUND: In 2012, the American Academy of Pediatrics (AAP) concluded the health benefits of circumcision during the neonatal period outweigh the risks. This study describes recent trends in male circumcision in freestanding children's hospitals in the United States. METHODS: Using the Pediatric Health Information System (PHIS), male patients <18â¯years of age who were circumcised without any additional procedures between the years 2010 and 2017 were identified. Data included age at procedure (neonate: 0-30â¯days, infant: 31-365â¯days, early childhood: ≥1 to <5â¯years, and older child: ≥5 to<18â¯years), cost, and specialty performing the circumcision. RESULTS: Of the 171,680 circumcisions performed, 85,270 (50%) were during neonatal period, 29,060 (17%) during infancy, 30,276 (18%) early childhood, and 26,355 (16%) thereafter. Circumcision in neonates increased from 39% to 58% (pâ¯<â¯0.001), and the proportion performed during infancy decreased over time. System level cost for ambulatory circumcision averaged $32 million USD annually, and median cost per ambulatory circumcision was $2892 USD. Obstetricians and Pediatricians are performing proportionally more circumcisions. CONCLUSION: Since 2012, proportionally more neonates are undergoing circumcision in US children's hospitals. Perinatal specialties are performing an increasing proportion of circumcisions. Circumcision during the birth hospitalization in the neonatal period is more resource-effective than postponing until later in infancy. TYPE OF STUDY: Retrospective, cross-sectional analysis. LEVEL OF EVIDENCE: Level IV.
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Circuncisão Masculina/tendências , Hospitais Pediátricos/tendências , Padrões de Prática Médica/tendências , Adolescente , Distribuição por Idade , Criança , Pré-Escolar , Circuncisão Masculina/economia , Estudos Transversais , Custos Hospitalares/estatística & dados numéricos , Hospitais Pediátricos/economia , Humanos , Lactente , Recém-Nascido , Masculino , Padrões de Prática Médica/economia , Estudos Retrospectivos , Estados UnidosRESUMO
BACKGROUND: In the midst of our national opioid crisis, recommendations have encouraged judicious stewardship of opioid prescription through the expanded use of non-opioid analgesic medications. This study aims to characterize trends in perioperative pain medication use for children undergoing ambulatory operations. METHODS: A cross-sectional, retrospective review was conducted using the Pediatric Health Information System. Patients younger than 18 years of age who underwent ambulatory surgery during 2010 to 2017 by one of five surgical subspecialties (otolaryngology, general pediatric, plastic or reconstructive, orthopedics, and urology) were included. Medications were identified using Current Procedural Terminology codes based on billing information for 18 commonly used analgesics along with the route of administration during their encounter. RESULTS: A total of 1,795,329 patients with a median age of 10 years were identified, of whom 84.3% received an opioid or non-opioid analgesic. Opioid use in the perioperative setting for ambulatory procedures decreased during the study period from 74.9% to 66.9% as a proportion of total analgesic prescriptions. Among opioids commonly used, intravenous morphine decreased the most from 19.8% to 15.4%, and intravenous hydromorphone and oral oxycodone use remained largely unchanged. Conversely, non-opiate medications increased, specifically intravenous ketorolac from 8.4% to 13.6%, and intravenous acetaminophen use increased from 0% to 8.5%. Intravenous acetaminophen use more than doubled between 2013 and 2017 (3.4% to 8.2%) and was accompanied by a decrease in oral acetaminophen use (14.4% to 9.3%). CONCLUSION: Overall, perioperative opioid utilization appears to be decreasing in favor of non-opioid analgesics. Other trends, such as increased intravenous acetaminophen, raise concerns for the cost effectiveness of perioperative analgesia and resource utilization.