To Scan or Not to Scan: Overutilization of Computed Tomography for Minor Head Injury at a Pediatric Trauma Center.

BACKGROUND: Degree of compliance with Pediatric Emergency Care Applied Research Network (PECARN) recommendations for radiographic evaluation following minor head injury in children is not well understood. The aim of this study was to assess PECARN compliance at a pediatric trauma center. The secondary aim was to determine whether children with indeterminate history of loss of consciousness (LOC) are at greater risk for clinically important traumatic brain injury (ciTBI) than those with no LOC. MATERIALS AND METHODS: We identified children aged 0-17 y who presented <24 h after minor head injury with Glasgow Coma Scale ≥14 in our institutional trauma registry. Predictor variables for ciTBI (TBI resulting in admission ≥2 nights, intubation ≥24 h, neurosurgery, or death) were reviewed. Simple and multivariate logistic regressions were performed to estimate the independent effects of demographic and clinical characteristics on the outcome of ciTBI. RESULTS: We included 739 children. Incidence of ciTBI was 5.4%. Only 5.6% did not undergo computed tomography (CT). PECARN compliance was 92.6% overall, but only 23.0% in those for whom CT was not indicated. Among those for whom either CT or observation was acceptable, 93.7% underwent CT. LOC history was indeterminate in 8.5%. On multivariate analysis, indeterminate LOC was not a risk factor for ciTBI. Vomiting and presence of occipital/parietal/temporal scalp hematoma were independent risk factors for ciTBI. CONCLUSIONS: CT is overutilized in pediatric trauma patients presenting to our institution after minor head injury when compared to PECARN criteria. Indeterminate LOC history was not a risk factor for ciTBI. Education of parents and clinicians regarding the risk to benefit ratio of CT in trauma patients with minor head injury is needed.

Implications of non-accidental trauma on resource utilization and outcomes.

PURPOSE: The purpose was to compare the resource utilization and outcomes between patients with suspected (SUSP) and confirmed (CONF) non-accidental trauma (NAT). METHODS: The institutional trauma registry was reviewed for patients aged 0-18 years presenting from 2007 to 2012 with a diagnosis of suspicion for NAT. Patients with suspected and confirmed NAT were compared. RESULTS: There were 281 patients included. CONF presented with a higher heart rate (142 ± 27 vs 128 ± 23 bpm, p < 0.01), lower systolic blood pressure (100 ± 18 vs 105 ± 16 mm Hg, p = 0.03), and higher Injury Severity Score (15 ± 11 vs 9 ± 5, p < 0.01). SUSP received fewer consultations (1.6 ± 0.7 vs 2.4 ± 1.1, 95% CI - 0.58 to - 0.09, p < 0.01) and had a shorter length of stay (1.6 ± 1.3 vs 7.8 ± 9.8 days, 95% CI - 4.58 to - 0.72, p < 0.01). SUSP were more often discharged home (OR 94.22, 95% CI: 21.26-417.476, p < 0.01). CONF had a higher mortality rate (8.2 vs 0%, p < 0.01). CONCLUSIONS: Patients with confirmed NAT present with more severe injuries and require more hospital resources compared to patients in whom NAT is suspected and ruled out.

Enhancing recovery after minimally invasive repair of pectus excavatum.

PURPOSE: There are variations in the perioperative management of patients who undergo minimally invasive repair of pectus excavatum (MIRPE). The purpose is to analyze the change in resource utilization after implementation of a standardized practice plan and describe an enhanced recovery pathway. METHODS: A standardized practice plan was implemented in 2013. A retrospective review of patients who underwent MIRPE from 2012 to 2015 was performed to evaluate the trends in resource utilization. A pain management protocol was implemented and a retrospective review was performed of patients who underwent repair before (2010-2012) and after (2014-2015) implementation. RESULTS: There were 71 patients included in the review of resource utilization. After implementation, there was a decrease in intensive care unit length of stay (LOS), and laboratory and radiologic studies ordered. There were 64 patients included in the pain protocol analysis. After implementation, postoperative morphine equivalents (3.3 ± 1.4 vs 1.2 ± 0.5 mg/kg, p < 0.01), urinary retention requiring catheterization (33 vs 14%, p = 0.07), and LOS (4 ± 1 vs 2.8 ± 0.8 days, p < 0.01) decreased. CONCLUSION: The implementation of an enhanced recovery pathway is a feasible and effective way to reduce resource utilization and improve outcomes in pediatric patients who undergo minimally invasive repair of pectus excavatum.

Obesity and single-incision laparoscopic appendectomy in children.

BACKGROUND: Single-incision laparoscopic appendectomy (SILA) has emerged as a less-invasive alternative to conventional laparoscopy. The purpose of this study was to assess the impact of body habitus on outcomes after SILA in the pediatric population. METHODS: A retrospective review of 413 patients who underwent SILA from 2012 to 2015 was performed. Body mass index (BMI) was calculated, and the BMI percentile was obtained per Center for Disease Control guidelines. Standard definitions for overweight (BMI 85th-94th percentile) and obese (BMI > 95th percentile) were used. General demographic and outcome data were analyzed. RESULTS: SILA was performed in 413 patients during the study period, of which 66.3% were normal weight, 16% were overweight, and 17.7% were obese. There were no significant differences in age at presentation, time to diagnosis, or intraoperative classification of appendicitis. There were no significant differences in operative time (27.0 ± 9.1 versus 27 ± 9.8 versus 28.4 ± 9.4 min, P = 0.514), postoperative length of stay (0.97 ± 1.65 versus 1.53 ± 4.15 versus 1.14 ± 2.27 d, P = 0.214), 30-d surgical site infections (6.9% versus 12.1% versus 8.2%, P = 0.377), emergency department visits (8.4% versus 10.6% versus 11%, P = 0.726), or readmissions (4.7% versus 4.1% versus 4.5%, P = 0.967) among normal, overweight, and obese groups. CONCLUSIONS: Our results indicate that obesity does not significantly impact outcomes after SILA. SILA can be performed in overweight and obese children with no significant difference in operative time, length of stay, or incidence of surgical site infection. SILA should continue to be offered to overweight and obese children.

Laparoscopic-guided versus transincisional rectus sheath block for pediatric single-incision laparoscopic cholecystectomy: A randomized controlled trial.

PURPOSE: The purpose of our study was to compare the effectiveness of transincisional (TI) versus laparoscopic-guided (LG) rectus sheath block (RSB) for pain control following pediatric single-incision laparoscopic cholecystectomy (SILC). METHODS: Forty-eight patients 10-21 years old presenting to a single institution for SILC from 2015 to 2018 were randomized to TI or LG RSB. Apart from RSB technique, perioperative care protocols were identical between groups. Pain scores were assessed with validated measures upon arrival in the postanesthesia care unit (PACU) and at regular intervals until discharge. The patients and those assessing them were blinded to RSB technique. The primary outcome was pain score 60 min after PACU arrival. Secondary outcomes included pain scores throughout the PACU stay, opioids (reported as morphine milligram equivalents (MME) per kg bodyweight) administered in PACU, length of stay, outpatient pain scores and opioid use, and adverse events. Groups were compared on outcomes using t test and generalized estimating equations for continuous variables and Fisher's exact test for categorical variables with significance at α = 0.05. RESULTS: Mean age of the 48 subjects was 15 years (range = 11-20). The majority (79%) were female. Indications for surgery included symptomatic cholelithiasis (n = 41), acute cholecystitis (n = 4), gallstone pancreatitis (n = 2) and choledocholithiasis (n = 1). Mean (standard deviation) operative time was 61 (±23) min overall. No statistically significant differences in demographics, indication, operative time, or intraoperative analgesia were observed between TI (n = 24) and LG (n = 24) groups. The mean 60-min pain score was 3.4 (±2.6) in the LG group versus 3.8 (±2.1) in the TI group (p = 0.573). No significant differences were detected between groups in overall PACU or outpatient pain scores, PACU or outpatient opioid use, length of stay, or incidence of complications. Overall, mean opioid use was 0.1 MME/kg in the PACU and 0.5 MME/kg in the outpatient setting. Mean postoperative length of stay was 0.2 day. There were no major complications. CONCLUSION: Laparoscopic-guided rectus sheath block is not superior to transincisional rectus sheath block for pain control following pediatric single-incision laparoscopic cholecystectomy. The single-incision laparoscopic approach combined with rectus sheath block resulted in effective pain control, low opioid use, and expedited length of stay with no major complications. LEVEL OF EVIDENCE: Level I, treatment study, randomized controlled trial.

External caliper-based measurements of the modified percent depth as an alternative to cross-sectional imaging for assessing the severity of pectus excavatum.

BACKGROUND: Cross-sectional imaging (CSI) may be clinically unnecessary in the evaluation of pectus excavatum (PE). The purpose of our study was to prospectively evaluate the accuracy and reliability of the modified percent depth (MPD), derived from caliper-based external measurements, in identifying PE. METHODS: Children 11-21 years old presenting for evaluation of PE or to obtain thoracic cross-sectional imaging for other indications were measured to derive the Modified Percent Depth. The Haller Index (HI) and Correction Index (CI) were calculated from CSI. Receiver-Operator Characteristic (ROC) analysis was used to compare the sensitivity and specificity of MPD, HI, and CI. Interrater reliability was assessed using Spearman's correlation coefficient and Cohen's Kappa coefficient. RESULTS: Of 199 patients, 76 (38%) had severe PE. Median age was 16 years (range = 11-21). The median Modified Percent Depth was 21.4% (IQR = 16.2-26.3) among those with PE versus 4.1% (IQR = 1.7-6.4) in those without (p < 0.001). MPD ≥ 11% exhibited similar sensitivity and specificity to HI ≥ 3.25 and CI ≥ 10 for identifying PE (ROC 0.98 vs. 0.97 vs. 0.98, respectively, p = 0.41). With respect to interrater reliability, independent clinicians' caliper measurements exhibited 87% agreement when identifying MPD ≥ 11% (p < 0.001) with excellent correlation (Spearman's ρ > 0.71, p < 0.001). CONCLUSION: Caliper-based, physical examination measurements of the Modified Percent Depth reliably identify pectus excavatum and represent an alternative to CSI-based measurements for the assessment of PE. TYPE OF STUDY: Diagnostic test. LEVEL OF EVIDENCE: Level II.

Efficacy of Videoconference Interviews in the Pediatric Surgery Match.

PURPOSE: The pediatric surgery match is highly competitive with the interview process requiring significant resources. The purpose of this study was to evaluate the efficacy of videoconference interviewing (VI) as a screening tool in the pediatric surgery match process. METHODS: During the 2017 interview season, applicants participated in VI prior to on-site interviews. Applicants and faculty completed 15 and 8-question surveys, respectively, regarding their experiences. RESULTS: Both faculty and applicants agreed VI was easily workable and allowed them to accurately represent themselves. Faculty agreed VI would change how they rank candidates and that it is a helpful screening tool. Most disagreed VI could substitute for on-site interviews. Most applicants reported the cost and time required for on-site interviews was a hardship. Overall, applicants moved an average of 5.5 ± 2.9 (median 3) positions from the pre-VI to post-VI rank list. Thirty-seven percent of applicants moved out of the top ten rank list following VI. Of the lowest 5 applicants on the post-VI rank list, only 20% matched successfully. CONCLUSION: The pediatric surgery match requires a significant investment of time and money that creates a hardship for most applicants. VI may be an effective screening tool that could potentially reduce on-site interviews and alleviate the burden on applicants and general surgery training programs.

Outpatient management of intussusception: a systematic review and meta-analysis.

BACKGROUND: Variability in management of intussusception after enema reduction exists. Historically, inpatient observation was recommended; however, there is a lack of evidence-based guidelines for this practice. METHODS: A systematic review and meta-analysis evaluating outcomes between inpatient (IP) and outpatient (OP) management after enema reduction was performed. The following databases were searched: PubMed, EBSCOhost CINAHL, EMBASE, Web of Science, and Cochrane Database. Data from an institutional review were included in the meta-analysis. RESULTS: Ten studies of patients aged 0-18 years with intussusception who underwent successful enema reduction that reported outcomes of outpatient management were included. Overall recurrence rates were 6% for IP and 8% for OP (p = 0.20). Recurrences within 24 (IP: 1% vs OP: 0%, p = 0.90) and 48 h (IP: 1% vs OP: 2%, p = 0.11) were similar. There was no significant difference in the rate of return to the emergency department (IP: 6% vs OP: 14%, p = 0.11). Both groups had a similar rate of requiring an operation (IP: 2% vs OP: 1%, p = 0.84). CONCLUSIONS: Outpatient management of intussusception after enema reduction results in a shorter hospital stay with no difference in the rate of return to the emergency department, recurrence, need for operation, or mortality. The findings of the meta-analysis suggest that outpatient management may be safe and could reduce hospital resource utilization. TYPE OF STUDY: Treatment study. LEVEL OF EVIDENCE: III.

Effect of hospital type on the treatment of acute appendicitis in teenagers.

BACKGROUND: Teenagers receive appendicitis care at both adult and pediatric facilities. The purpose of this study was to evaluate outcomes following treatment of acute appendicitis in teenagers based on the type of hospital facility. METHODS: Patients aged 13-17years with acute appendicitis who were discharged from acute care hospitals from 2009 to 2014 were identified using a statewide discharge dataset. Hospitals were classified as pediatric or adult and outcomes were compared. RESULTS: There were 5585 patients treated in adult hospitals and 1625 in pediatric hospitals. Fewer patients at adult hospitals had complicated appendicitis (20.4% vs. 33.0%, p<0.01). Open appendectomy occurred more often in adult hospitals compared to pediatric hospitals (12.6% vs. 6.0%, p<0.01). Pediatric hospitals had higher rates of non-operative management (10% vs. 3.4%, p<0.01) and percutaneous drain placement (1.2% vs. 0.4%, p<0.01). Postoperative complication rates did not significantly differ between hospital types. CONCLUSION: Most teenagers undergo appendectomy at adult facilities; however, a greater proportion of younger patients and patients with complicated appendicitis is treated at pediatric hospitals. Treatment at a freestanding children's hospital results in lower rates of open procedures and no difference in complications. Opportunities may exist to standardize care across treating facilities to optimize outcomes and resource use. TYPE OF STUDY: Prognosis study. LEVEL OF EVIDENCE: II.

The idle central venous catheter in the NICU: When should it be removed?

PURPOSE: There is debate regarding the optimal timing of central line removal in the neonatal intensive care unit (NICU). The purpose was to evaluate outcomes of idle peripherally inserted central catheters (PICCs) and tunneled central venous catheters (TCVCs) and determine the incidence of line-related infections and replacements. METHODS: Patients in the NICU with T-CVCs placed between 11/2008 and 8/2015 (n=134) or PICCs placed between 7/2013 and 10/2015 (n=467) were included. Demographics and outcomes were compared. RESULTS: The most common indications for line placement were parenteral nutrition for PICCs (74%) and lack of access for T-CVCs (53%). T-CVCs had a greater proportion of idle days (T-CVC- 25.2% vs PICC- 5.1%, p<0.001) and removal within 24h of discharge (T-CVC-53% vs PICC-5.8%, p<0.001). Conversely, 81% of PICCs were removed within 24h of nonuse. Line replacement after removal for nonuse was required in 6% of PICCs and zero T-CVCs. In both groups, the central line-associated bloodstream infection (CLABSI) rate was lower in idle lines compared to ones in use. CONCLUSION: Patients treated with PICCs and T-CVCs are different populations and should have different guidelines for removal. In neonates with difficult access, the low risk of CLABSIs in idle surgically placed catheters may justify maintaining access until discharge. TYPE OF STUDY: Treatment study. LEVEL OF EVIDENCE: III.

Timing of antimicrobial prophylaxis and infectious complications in pediatric patients undergoing appendectomy.

PURPOSE: Antibiotic administration within one hour prior to incision is a common quality metric; however, antibiotics are typically started at the time of diagnosis in pediatric patients with acute appendicitis. The purpose was to determine if antibiotic administration within one hour prior to incision reduces the incidence of surgical site infections (SSI) in pediatric patients with acute appendicitis started on parenteral antibiotics upon diagnosis. METHODS: A retrospective review was performed of 478 patients aged 0-18years who underwent appendectomy for acute appendicitis from 7/2013 to 4/2015. Patients were categorized based on timing of antibiotic administration; there were 198 patients in Group A (<60min before) and 280 in Group B (>60min before). RESULTS: Demographics and operative time (A: 30.5±9.9 vs B: 30.8±12.2min, p=0.51) were similar. Procedures were performed laparoscopically and the groups had similar proportions of single-incision operations (A: 53% vs B: 55%, p=0.64). There was no difference in the incidence of superficial SSI (A: 2.0% vs B: 2.1%, p=1.0) or intraabdominal abscess (A: 4.0% vs B: 3.6%, p=0.81) and this remained true when stratified by intraoperative classification. CONCLUSION: Antibiotic administration within one hour of appendectomy in pediatric patients with acute appendicitis who receive antibiotics at diagnosis did not change the incidence of postoperative infectious complications. TYPE OF STUDY: Treatment study. LEVEL OF EVIDENCE: III.

Impact of outpatient management following appendectomy for acute appendicitis: An ACS NSQIP-P analysis.

BACKGROUND: In 2012, a same-day discharge protocol following appendectomy for acute appendicitis was initiated. Our objective was to determine the success of the protocol by reviewing the National Surgical Quality Improvement Program-Pediatric (NSQIP-P) outcomes following protocol development. METHODS: The 2015 NSQIP-P Participant Use Data File was queried to identify patients with acute appendicitis who underwent appendectomy. Outcomes were compared to institutional outcomes. RESULTS: There were 154 institutional patients and 4973 from NSQIP-P centers. Institutional rate of outpatient management was higher compared to NSQIP-P (84% vs 48%, p<0.0001). Surgical length of stay was shorter compared to national rates (0.3±0.7 vs 1.1±1.9days, p<0.0001). There was no significant difference in the incidence of superficial (1.9% vs 1.0%, p=0.2), deep (0.6% vs 0.1%, p=0.17) or organ/space surgical site infections (1.3% vs 0.7%, p=0.31). The incidences of other complications (1.3% vs 0.6%, p=0.26) and 30-day readmissions (3.2% vs 2.6%, p=0.61) were similar. CONCLUSION: Outpatient management following appendectomy in children is possible with low morbidity and readmission rates. Comparison with other NSQIP-Pediatric centers suggests an opportunity to generalize this practice with considerable savings to the health care system. LEVEL OF EVIDENCE: Prognosis study, level II.

Antibiotic Powder Reduces Surgical Site Infections in Children After Single-Incision Laparoscopic Appendectomy for Acute Appendicitis.

BACKGROUND: Single-incision laparoscopic appendectomy (SILA) has a higher rate of wound infection than the multiport technique. The purpose of this project was to determine whether the use of topical antibiotic powder reduces surgical site infections (SSIs) in pediatric patients who undergo SILA. METHODS: Patients aged 0-21 years who underwent SILA for acute appendicitis from April 2015 to November 2016 were included in this quality improvement initiative. Cefoxitin powder was placed in the umbilical wound before skin closure. Data were prospectively collected and outcome measures were compared with a historical cohort who underwent SILA before the implementation of antibiotic powder. RESULTS: There were 108 patients in the historical group (HIST) and 126 in the powder group (POWD). The groups were similar in age (HIST: 11.5 ± 3.6 versus POWD: 12.2 ± 3.7 years, P = .15) and body mass index percentile (HIST: 57.6 ± 30.7 versus POWD: 58.8 ± 27.8, P = .84). Operative time was longer in the powder group (HIST: 26.5 ± 7.5 versus POWD: 29.7 ± 8.9 minutes, P = .004). Length of stay (HIST: 0.2 ± 0.4 versus POWD: 0.1 ± 0.4 days, P = .06), 30-day return to emergency department (HIST: 7% versus POWD: 8%, P = 1.0), and hospital readmissions (HIST: 5% versus POWD: 2%, P = .8) were similar. There was a significantly lower rate of superficial SSIs in the powder group (HIST: 4.6% versus POWD: 0%, P = .02). CONCLUSIONS: In pediatric patients undergoing SILA for acute appendicitis, the use of cefoxitin powder in the umbilical wound is a simple intervention to reduce the incidence of superficial SSIs.

Early Experience with Single-Incision Laparoscopic Total Abdominal Colectomy in Children.

PURPOSE: Single-incision laparoscopic surgery for pediatric colorectal disease has been shown to be feasible and safe; however, the literature is scarce regarding the outcomes of single-incision laparoscopic total abdominal colectomy (SIL-TAC) in the pediatric population. The purpose of this pilot study was to review our initial experience and outcomes with SIL-TAC. MATERIALS AND METHODS: A retrospective review of patients who underwent SIL-TAC from 2013 to 2015 was performed. General demographic and outcome data were analyzed. RESULTS: Five patients were included. Indications included ulcerative colitis (n = 4) and colonic dysmotility (n = 1). The median age was 13.5 years (8.5-19.4 years) and the median body mass index (BMI) percentile was 77.4 (2.2-98). The median operative time was 182 minutes (163-244 minutes). One case was converted to an open procedure. The median postoperative self-reported pain score was 2.8 (1.2-4.5). The median time until initiation of a diet was 2 days (1-8 days). The median length of hospital stay was 5 days (3-11 days). There were no 30-day complications. CONCLUSION: SIL-TAC is feasible and safe in children and offers improved cosmesis.

A closer look at non-accidental trauma: Caregiver assault compared to non-caregiver assault.

PURPOSE: The purpose of this study was to examine the outcomes of non-accidental trauma (NAT) patients compared to other trauma (OT) patients across the state of Florida. In addition, NAT and OT patients with a mechanism of injury of assault were further analyzed. METHODS: A statewide database was reviewed from January 2010 to December 2014 for patients aged 0-18years who presented following trauma. Patients were sorted by admitting diagnosis into two groups: rule out NAT and all other diagnoses. Patients with a mechanism of assault were subanalyzed and outcomes were compared. RESULTS: There were 46,557 patients included. NAT patients were younger, had more severe injuries and had a higher mortality rate compared to OT patients. Assault was the mechanism of injury in 95% of NAT patients. NAT assault patients were younger, required more intensive care unit (ICU) resources, and had a higher mortality rate compared to other assault patients. CONCLUSION: Non-accidental trauma patients require more resources and have a higher mortality rate compared to accidental trauma patients, and these differences remain even when controlling for the mechanism of injury. LEVEL OF EVIDENCE: III.

The modified percent depth: Another step toward quantifying severity of pectus excavatum without cross-sectional imaging.

INTRODUCTION: Current approaches to quantifying the severity of pectus excavatum require internal measurements based on cross-sectional imaging. This study evaluated the modified percent depth (MPD), a novel index of severity that can be obtained with external measurements, potentially avoiding the need for cross-sectional imaging. METHODS: Patients undergoing surgical repair of pectus excavatum (pectus group), and those undergoing cross-sectional imaging for unrelated reasons (control group), between 2010 and 2016 were included. The MPD of the deformity was calculated using external (i.e. skin surface to skin surface) measurements from the radiographic images. The same external measurements were taken using chest calipers on a subset of these patients in the outpatient clinic. The optimal threshold for MPD that defined severe pectus deformity was derived from receiver-operator characteristic (ROC) analysis. Sensitivity and specificity of the MPD was compared with that of the Haller Index (HI) and Correction Index (CI). RESULTS: There were 92 children (49 pectus, 43 controls) included. The median MPD was 20.2% and 4.2% for pectus and control patients, respectively (p<0.0001). An MPD cutoff of 10% optimally discriminated between severe pectus patients and controls by ROC analysis. An MPD of >10% had 98% sensitivity and 98% specificity for severe pectus deformity. Sensitivity and specificity were respectively 93% and 93% for HI >3.25, and 100% and 79% for CI >10. CONCLUSION: An MPD >10% performs slightly better than the HI and CI in distinguishing patients with severe pectus deformities. This novel measurement approach offers distinct advantages over existing indices, in that it does not require cross-sectional imaging and can be done using chest calipers in the office setting. Further studies with larger sample size are needed to verify reproducibility of the technique. LEVEL OF EVIDENCE: Level II, Study of Diagnostic Test.

Immature patients in a mature system: Regional analysis of Florida's pediatric trauma system.

BACKGROUND: The state of Florida's trauma system is organized into seven regions, two of which lack designated pediatric trauma centers. Injured children residing in these regions often require transfer out of their home region for definitive care. The purpose of this study was to evaluate the effectiveness and efficiency of the current regionalization approach, focusing on variations between regions. METHODS: Using the Florida Agency for Health Care Administration database, we identified all trauma patients 15 years old or younger admitted between 2009 and 2014. Patients with high-risk injury (ICD-9 Injury Severity Score < 0.85) who did not receive definitive treatment at a pediatric trauma center (PTC) were considered undertriaged. Outcomes of interest included mortality and long-term disability. Patients who were definitively treated at a facility outside their home region, but who had low risk injuries (ICD-9 Injury Severity Score > 0.9), required no procedures or ICU monitoring, and were discharged within 48 hours, were considered to have received potentially avoidable out-of-region treatment. Regions were compared, and patients treated in-region were compared to those treated out-of-region. Regression models were used to adjust for covariates. RESULTS: Of 34,816 patients, 8% had high-risk injuries and the overall mortality rate was 1%. Risk-adjusted outcomes were generally similar across all regions. Regional rates of undertriage varied from 0.4% to 4.7% and were highest in regions lacking a PTC. Eleven percent of patients required definitive treatment outside their home region; these patients had higher hospital charges and stayed in the hospital 0.96 days longer (least-squares mean). Rates of potentially avoidable out-of-region treatment ranged from 7% to 12% in the two regions lacking a PTC. After adjustment for confounders, significant unexplained differences in potentially avoidable out-of-region treatment remained between these two regions (OR 2.0, 95% CI 1.6-2.6). CONCLUSIONS: Florida's regionalized pediatric trauma system performs effectively, with low undertriage and acceptable outcomes. Out-of-region treatment, an inevitable byproduct of the current regionalization approach, imposes a measurable burden on the treating facility and patient/family. Unexplained variations in potentially avoidable out-of-region treatment suggest improvements can be made in system efficiency. LEVEL OF EVIDENCE: Economic/decision study, level III.

Percutaneous ultrasound-guided vs. intraoperative rectus sheath block for pediatric umbilical hernia repair: A randomized clinical trial.

BACKGROUND: Regional anesthesia is commonly used in children. Our hypothesis was that percutaneous ultrasound-guided (PERC) rectus sheath blocks would result in lower postoperative pain scores compared to intraoperative (IO) rectus sheath blocks following umbilical hernia repair. METHODS: A single-institution randomized blinded trial was conducted in pediatric patients undergoing elective umbilical hernia repair. The primary outcome was mean postoperative Wong-Baker pain score. Secondary outcomes included narcotic requirements and length of postoperative stay. RESULTS: Fifty-eight patients were included: 28 PERC and 30 IO. Operating room time was significantly longer in the PERC group (41 vs. 35min, p<0.01). Mean postoperative pain scores (PERC-2.6 vs. IO-3.3, p=0.11), morphine equivalents intraoperatively (PERC-0 vs. IO-0.04mg/kg, p=0.29) and postoperatively (PERC-0.04 vs. IO-0.09mg/kg, p=0.17), time to first postoperative narcotic dose (PERC-30 vs. IO-22min, p=0.33, log-rank test), and postoperative length of stay (PERC-76 vs. IO-80min, p=0.44) were similar. CONCLUSION: Following umbilical hernia repair in children, percutaneous ultrasound-guided and intraoperative rectus sheath blocks resulted in similar mean postoperative pain scores. There were no differences in secondary outcomes such as time to first narcotic, narcotic requirements, and length of stay. The additional resources required to complete a percutaneous ultrasound-guided rectus sheath block may not be warranted. TYPE OF STUDY: Randomized controlled trial. LEVEL OF EVIDENCE: Level I.