Delphi Process for Validation of Fluid Treatment Algorithm for Critically Ill Pediatric Trauma Patients.

INTRODUCTION: While intravenous fluid therapy is essential to re-establishing volume status in children who have experienced trauma, aggressive resuscitation can lead to various complications. There remains a lack of consensus on whether pediatric trauma patients will benefit from a liberal or restrictive crystalloid resuscitation approach and how to optimally identify and transition between fluid phases. METHODS: A panel was comprised of physicians with expertise in pediatric trauma, critical care, and emergency medicine. A three-round Delphi process was conducted via an online survey, with each round being followed by a live video conference. Experts agreed or disagreed with each aspect of the proposed fluid management algorithm on a five-level Likert scale. The group opinion level defined an algorithm parameter's acceptance or rejection with greater than 75% agreement resulting in acceptance and greater than 50% disagreement resulting in rejection. The remaining were discussed and re-presented in the next round. RESULTS: Fourteen experts from five Level 1 pediatric trauma centers representing three subspecialties were included. Responses were received from 13/14 participants (93%). In round 1, 64% of the parameters were accepted, while the remaining 36% were discussed and re-presented. In round 2, 90% of the parameters were accepted. Following round 3, there was 100% acceptance by all the experts on the revised and final version of the algorithm. CONCLUSIONS: We present a validated algorithm for intavenous fluid management in pediatric trauma patients that focuses on the de-escalation of fluids. Focusing on this time point of fluid therapy will help minimize iatrogenic complications of crystalloid fluids within this patient population.

Impact of insertion site on complications in central venous access devices.

PURPOSE: There is still debate over the safest route for the placement of long-term central venous access devices. The aim of this study was to review a large, single-institution experience to determine the impact of access location on peri-operative complications. METHODS: The records of patients undergoing subcutaneous port (SQP) and tunneled catheter insertion over a seven-year period were reviewed. Vein cannulated (subclavian (SCV) versus internal jugular (IJ) vein), and 30-day complications were assessed. Surgical complications included pneumothorax, hemothorax, infections, arrhythmia or malpositioning requiring intervention. RESULTS: A total of 1,309 patients were included (618 SQP, 691 tunneled catheters). The location for insertion was SCV (909, 69.4%) and IJ (400, 30.6%). There were 69 complications (5.2%) (41, 4.5% SCV, 28, 7.0% IJV) including: malpositioning/malfunctioning (SCV 13, 1.4% and IJV 14, 3.0%), pneumothorax (SCV 4, 0.4% and IJV 1, 0.3%), hemothorax (SCV 0 and IJV 1, 0.3%), arrhythmia (SCV 1, 0.1%, and IJV 0), and infection within 30 days of placement (SCV 20, 2.2% and IJ 11, 2.8%). The complication rates were not significantly different based on site (p = 0.080). CONCLUSION: There was no significant difference in complication rates when using the subclavian versus the internal jugular vein as the site for long-term central venous access. LEVEL OF EVIDENCE: III, retrospective comparative study.

Mandibular muscle troponin of the Florida carpenter ant Camponotus floridanus: extending our insights into invertebrate Ca2+ regulation.

Ants use their mandibles for a variety of functions and behaviors. We investigated mandibular muscle structure and function from major workers of the Florida carpenter ant Camponotus floridanus: force-pCa relation and velocity of unloaded shortening of single, permeabilized fibres, primary sequences of troponin subunits (TnC, TnI and TnT) from a mandibular muscle cDNA library, and muscle fibre ultrastructure. From the mechanical measurements, we found Ca2+-sensitivity of isometric force was markedly shifted rightward compared with vertebrate striated muscle. From the troponin sequence results, we identified features that could explain the rightward shift of Ca2+-activation: the N-helix of TnC is effectively absent and three of the four EF-hands of TnC (sites I, II and III) do not adhere to canonical sequence rules for divalent cation binding; two alternatively spliced isoforms of TnI were identified with the alternatively spliced exon occurring in the region of the IT-arm α-helical coiled-coil, and the N-terminal extension of TnI may be involved in modulation of regulation, as in mammalian cardiac muscle; and TnT has a Glu-rich C-terminus. In addition, a structural homology model was built of C. floridanus troponin on the thin filament. From analysis of electron micrographs, we found thick filaments are almost as long as the 6.8 µm sarcomeres, have diameter of ~ 16 nm, and typical center-to-center spacing of ~ 46 nm. These results have implications for the mechanisms by which mandibular muscle fibres perform such a variety of functions, and how the structure of the troponin complex aids in these tasks.

Pediatric Spontaneous Pneumothorax: Does Initial Treatment Affect Outcomes?

BACKGROUND: Primary spontaneous pneumothorax (PSP) commonly occurs in adolescents, most commonly in males, and has recurrence rates between 20% and 60%. Surgical therapy has long been debated regarding its role in preventing recurrence, with no current consensus on guidelines for care. The purpose of this study is to examine the effect of treatment type on recurrence rates in pediatric PSP. METHODS: This is a single-institution, institutional review board-approved retrospective analysis of patients aged 1 to 18 diagnosed with their first occurrence of PSP between 2009 and 2017. Patient demographics, hospital course, and outcomes over a 2-y period were collected. Patients were divided into nonoperative (oxygen therapy only) management, chest tube placement, and surgical management. The primary outcome was the recurrence rate. RESULTS: Sixty-four patients diagnosed with PSP met inclusive criteria. The mean age was 15.5, and 48 (75%) of patients were men. Twenty-one patients (33%) underwent nonoperative treatment, 24 patients (37.5%) underwent operative treatment with video-assisted thoracoscopic surgery or open thoracotomy, and 19 patients (30%) underwent chest tube or pigtail placement alone. Fifteen patients (23.4%) experienced a recurrence within 2 y: 6 patients (29%) from the nonoperative treatment group, 4 (21%) who were treated with the chest tube only, and 5 (21%) who underwent video-assisted thoracoscopic surgery or open thoracotomy. No statistically significant difference in recurrence rates was found between treatment groups. Pneumothorax size was found to differ between treatment type; larger pneumothoraces were more likely to undergo surgical intervention (P = 0.0003). Smaller pneumothoraces were associated with higher rates of recurrence on multivariate logistic regression analysis (P = 0.046). CONCLUSIONS: Recurrence of PSP in adolescents was found to be 23.4% after 2-y follow-up. Smaller-sized pneumothoraces were associated with higher rates of recurrence, but treatment type did not significantly affect recurrence rates.

A Multicenter Study of Nutritional Adequacy in Neonatal and Pediatric Extracorporeal Life Support.

BACKGROUND: Malnutrition in critically ill patients is common in neonates and children, including those that receive extracorporeal life support (ECLS). We hypothesize that nutritional adequacy is highly variable, overall nutritional adequacy is poor, and enteral nutrition is underutilized in this population. MATERIALS AND METHODS: A retrospective study of neonates and children (age<18 y) receiving ECLS at 5 centers from 2012 to 2014 was performed. Demographic, clinical, and outcome data were analyzed. Continuous variables are presented as median [IQR]. Adequate nutrition was defined as meeting 66% of daily caloric goals during ECLS support. RESULTS: Two hundred and eighty three patients received ECLS; the median age was 12 d [3 d, 16.4 y] and 47% were male. ECLS categories were neonatal pulmonary 33.9%, neonatal cardiac 25.1%, pediatric pulmonary 17.7%, and pediatric cardiac 23.3%. The predominant mode was venoarterial (70%). Mortality was 41%. Pre-ECLS enteral and parenteral nutrition was present in 80% and 71.5% of patients, respectively. The median percentage days of adequate caloric and protein nutrition were 50% [0, 78] and 67% [22, 86], respectively. The median percentage days with adequate caloric and protein nutrition by the enteral route alone was 22% [0, 65] and 0 [0, 50], respectively. Gastrointestinal complications occurred in 19.7% of patients including hemorrhage (4.2%), enterocolitis (2.5%), intra-abdominal hypertension or compartment syndrome (0.7%), and perforation (0.4%). CONCLUSIONS: Although nutritional delivery during ECLS is adequate, the use of enteral nutrition is low despite relatively infrequent observed gastrointestinal complications.

Mediastinal Lymphadenopathy in Children With Histoplasmosis.

BACKGROUND: Mediastinal lymphadenopathy (ML) in children can arise from malignancy, infection, or rheumatic illness among others, and may be found incidentally on imaging or during workup for a variety of symptoms. Our aim was to describe the clinical presentation and natural history of histoplasmosis in children who present to a tertiary care center with ML in an endemic area of the country. METHODS: After institutional review board approval, a retrospective study of all children (aged < 21 y) presenting with proven (positive serologies) or suspected histoplasmosis (negative serologies, negative tuberculosis testing, and benign outcomes in follow-up) over a 5-y period was done. Seventy-four patients were tested; those with another diagnosis (n = 6) or without ML (n = 26) were excluded, for a total cohort of 44 patients. Demographics, clinical presentation, symptoms, laboratory data, treatment course, radiography studies, and inpatient and outpatient visits were examined. RESULTS: Of the 44 patients with ML, 27 had proven histoplasmosis, and 19 had suspected histoplasmosis. The median follow-up by imaging or clinical examination was 6.9 mo (0.3-73.2 mo). Sixteen patients received antifungal therapy with itraconazole, and 15 patients received at least one course of steroids, nearly all for respiratory symptoms; 11 patients (24%) received both. There was no difference in readmission rate (n = 5 versus 2, P = 0.7) or recurrence of symptoms (n = 2 versus 5, P = 0.4) between patients who received an antifungal and those that did not. Receiving steroid therapy was associated with airway narrowing and a higher readmission rate (n =6 versus 2 who were not treated with steroids, P = 0.04), but not with symptom recurrence. Nine lymph node or mass biopsies were performed; however, the pathology only confirmed nonspecific infection in three and was nondiagnostic in the remaining six patients. Twenty-seven patients had at least one confirmatory laboratory test positive for histoplasmosis. Thirty-nine of the 44 patients (84%) with a diagnosis of histoplasmosis (proven or suspected) were asymptomatic by 1-2 mo follow up, with the remainder having intermittent chest pain or reactive airway disease. CONCLUSIONS: ML because of proven or suspected histoplasmosis is usually a self-limiting disease that can be managed with treatment of the child's symptoms. Antifungals and steroids are of unclear benefit and may not alter the natural course of the disease. Biopsies are rarely diagnostic in the setting of ML, and invasive procedures should be avoided.

Surgical and anesthetic management for hepatectomy in two pediatric patients with trisomy 18, pulmonary hypertension, and hepatoblastoma.

Children with trisomy 18 are surviving longer and undergoing more aggressive life-sustaining therapy. This report describes two patients with trisomy 18 and hepatoblastoma (HB) successfully resected in the setting of significant pulmonary hypertension. Forty-four previously published cases of the association between HB and trisomy 18 are reviewed. With careful multidisciplinary preoperative planning, successful resection of HB in children with trisomy 18 who have significant pulmonary hypertension is feasible. Because HB and trisomy 18 are increasing in prevalence, the need for timely liver tumor resection in the setting of pulmonary hypertension will be more common.

In-hospital Pediatric Endoscopic Retrograde Cholangiopancreatography Is Associated With Shorter Hospitalization for Children With Choledocholithiasis.

OBJECTIVES: Children with choledocholithiasis are frequently managed at tertiary children's hospitals that do not have available endoscopic retrograde cholangiopancreatography (ERCP) proceduralists. We hypothesized that patients treated at hospitals without ERCP proceduralists would have a longer hospital length of stay (LOS) than those with ERCP proceduralists. METHODS: Charts were reviewed for patients who underwent cholecystectomy and ERCP at 3 tertiary children's hospitals over 10 years. Trauma and complicated pancreatitis patients were excluded. Comparisons between patients requiring and not requiring transfer for ERCP were made using Wilcoxon rank-sum tests for continuous variables and Fisher's exact tests for categorical variables. RESULTS: One hundred and sixty-four children underwent ERCP for suspected choledocholithiasis: 79 (48%) in the transfer group and 85 (52%) in the no transfer group.Median LOS was longer for patients requiring transfer (7 vs 5 days, P < 0.0001). One-third (34%) of the transfer patients had magnetic resonance cholangiopancreatography compared to only 7% that did not require transfer (P < 0.0001). Among the 123 patients who underwent ERCP before cholecystectomy, 53% required (66/123) transfer and 47% (57/123) did not. Transfer group patients had longer median hospital LOS (P < 0.0001), more days between admission and ERCP (P < 0.0001), and more days between ERCP and surgery (P = 0.0004). CONCLUSIONS: Overall median LOS was significantly shorter for patients who underwent ERCP at the admitting facility. Patients who underwent ERCP before cholecystectomy at hospitals without available ERCP proceduralists incurred longer LOS. There is a need for more pediatric proceduralists appropriately trained to perform ERCP in children.

Variability in the evalution of pediatric blunt abdominal trauma.

PURPOSE: To describe the practice pattern for routine laboratory and imaging assessment of children following blunt abdominal trauma (BAT). METHODS: Children (age < 16 years) presenting to 14 pediatric trauma centers following BAT over a 1-year period were prospectively identified. Injury, demographic, routine laboratory and imaging utilization data were collected. Descriptive, comparative, and correlation analysis was performed. RESULTS: 2188 children with a median age of 8 (4,12) years were included and the median injury severity score was 5 (1,10). There were significant differences in activation status, injury severity, and mechanism across centers; however, there was no correlation of level of activation, injury severity, or severe mechanism with test utilization. Routine laboratory and imaging utilization for hematocrit, hepatic enzymes, pancreatic enzymes, base deficit urine microscopy, chest and pelvis X-ray, and abdominal computed tomography (CT) varied significantly among centers. Only obtaining a hematocrit had a moderate correlation with CT use. There was no correlation between centers that were high or low frequency laboratory utilizers with CT use. CONCLUSIONS: Wide variability exists in the routine initial laboratory and imaging assessment in children following BAT. This represents an opportunity for quality improvement in pediatric trauma. LEVEL OF EVIDENCE: Level II.

The utility of presacral drainage in penetrating rectal injuries in adult and pediatric patients.

BACKGROUND: With changing weaponry associated with injuries in civilian trauma, there is no clinical census on the utility of presacral drainage (PSD) in penetrating rectal injuries (PRIs), particularly in pediatric patients. METHODS: Patients with PRI from July 2004-June 2014 treated at two free-standing children's hospitals and two adult level 1 trauma centers were compared by age (pediatric patients ≤16 years) and PSD. A stratified analysis was performed based on age. The primary outcome was pelvic/presacral abscess. RESULTS: We identified 81 patients with PRI; 19 pediatric, 62 adult. Forty patients had PSD; only three pediatric patients had a drain. Adult patients were more likely to have sustained gunshot wounds (84%), whereas pediatric patients were more likely to sustain impalement injuries (59%). Pediatric patients were more likely to have distal extraperitoneal injuries (56% versus 27% in adults, P = 0.03). PSD was more common in adult patients (59% versus 14%, P = 0.0004), African-Americans (71% versus 11% Caucasian, P < 0.01), and those sustaining gun shot wounds (63% versus 18% impalement, P < 0.01); only race remained significant in stratified analysis for both adult and pediatric patients. There were three cases of pelvic/presacral abscess, all in the adult patients (P = 0.31); one patient with PSD and two without PSD (P = 0.58). In stratified analysis, there were no differences in any infectious complication between those with and without PSD. CONCLUSIONS: Pelvic/presacral abscess is a rare complication of PRI, especially in pediatric patients. PSD is not associated with decreased rates of infectious complications and may not be necessary in the treatment of PRI.

Treatment of congenital pulmonary airway malformations: a systematic review from the APSA outcomes and evidence based practice committee.

PURPOSE: Variation in management characterizes treatment of infants with a congenital pulmonary airway malformation (CPAM). This review addresses six clinically applicable questions using available evidence to provide recommendations for the treatment of these patients. METHODS: Questions regarding the management of a pediatric patient with a CPAM were generated. English language articles published between 1960 and 2014 were compiled after searching Medline and OvidSP. The articles were divided by subject area and by the question asked, then reviewed and included if they specifically addressed the proposed question. RESULTS: 1040 articles were identified on initial search. After screening abstracts per eligibility criteria, 130 articles were used to answer the proposed questions. Based on the available literature, resection of an asymptomatic CPAM is controversial, and when performed is usually completed within the first six months of life. Lobectomy remains the standard resection method for CPAM, and can be performed thoracoscopically or via thoracotomy. There is no consensus regarding a monitoring protocol for observing asymptomatic lesions, although at least one chest computerized tomogram (CT) should be performed postnatally for lesion characterization. An antenatally identified CPAM can be evaluated with MRI if fetal intervention is being considered, but is not required for the fetus with a lesion not at risk for hydrops. Prenatal consultation should be offered for infants with CPAM and encouraged for those infants in whom characteristics indicate risk of hydrops. CONCLUSIONS: Very few articles provided definitive recommendations for care of the patient with a CPAM and none reported Level I or II evidence. Based on available information, CPAMs are usually resected early in life if at all. A prenatally diagnosed congenital lung lesion should be evaluated postnatally with CT, and prenatal counseling should be undertaken in patients at risk for hydrops.

Pediatric scalds: do cooking-related burns have a higher injury burden?

BACKGROUND: Pediatric scald burns result in frequent emergency room visits and hospitalizations. We investigated whether cooking-related burns produce greater morbidity requiring more extensive care than noncooking burns. METHODS: We performed a 6-y review at our free-standing children's hospital. Children aged <18 y admitted for accidental scald burns were included. Demographics, injury pattern, treatment, and outcome (contractures and/or limited mobility and nonhealing and/or infected wounds) data were analyzed comparing cooking versus noncooking burns. The Mann-Whitney U test, a chi-square test, and the negative binomial were used to compare continuous, categorical, and count data between groups. Bivariate analysis was performed to identify risk factors among patients with adverse outcomes. RESULTS: We identified 308 patients; 262 (85%) cooking and 46 (15%) noncooking burns. Most patients were African-American males, with public insurance, and a median age of 2 y. Cooking burns preferentially occurred over the head, neck, and upper body; noncooking burns were distributed over the lower body (P < 0.02). Median total body surface area was equal for both groups (P > 0.11). In subgroup analysis, semisolid and grease burns resulted in increased rates of wound contractures and/or limited mobility when compared with noncooking burns (P = 0.05 and P = 0.008, respectively). Patients with complications were more likely to have third degree burns and required more consults, longer hospitalization, and more surgical debridements and clinic visits. CONCLUSIONS: Most accidental scald burns occurred in young children during food preparation. Greater long-term morbidity was found in patients with semisolid and grease burns. This subset of children has a higher injury burden and requires extensive care in the acute and long-term setting.

Management of Pediatric Solid Organ Injuries.

Solid organ injury (SOI) is common in children who experience abdominal trauma, and the management of such injuries has evolved significantly over the past several decades. In 2000, the American Pediatric Surgical Association (APSA) published the first societal guidelines for the management of blunt spleen and/or liver injury (BLSI), advocating for optimized resource utilization while maintaining patient safety. Nonoperative management (NOM) has become the mainstay of treatment for SOI, and since the publication of the APSA guidelines, numerous groups have evaluated how invasive procedures, hospitalization, and activity restrictions may be safely minimized in children with SOI. Here, we review the current evidence-based management guidelines in place for the treatment of injuries to the spleen, liver, kidney, and pancreas in children, including initial evaluation, inpatient management, and long-term care, as well as gaps that exist in the current literature that may be targeted for further optimization of protocols for pediatric SOI.

Call to Action: The Rise of Pediatric Gun Violence During the COVID-19 Pandemic.

This study examines and describes circumstances involving non-fatal firearm injuries in a pediatric population from a Level I Pediatric Trauma Center in the southeastern U.S. Researchers analyzed Firearm Injury Questionnaire (FIQ) data collected from 144 children and adolescents, aged 2-17 years, who were treated in the emergency department and/or admitted to the hospital for non-fatal firearm injuries. Descriptive statistics are presented regarding participant demographics and FIQ responses, such as caregiver information, mental health history, adverse childhood experience (ACE) exposure, firearm access, injury intent, relationship to shooter, type of firearm used, and context of injury. Most patients identified as Black (82%) and male (75%), with most injuries categorized as intentional (72%) versus unintentional (24%) assaults. The average ACEs score was .60, with only 37% of patients' reporting any ACE experience; however, nearly half (47%) of patients reported experiencing a traumatic event beyond an identified ACE. Community violence was the most common context that attributed to patients' assaults (56%). As U.S. pediatric gun injury and fatality trends are increasing, this study provides timely data regarding pediatric firearm injuries and exposure to community violence. These findings highlight the need to provide integrated health services to pediatric patients experiencing non-fatal firearm injuries. Researchers discuss public health implications for integrated mental health care services, hospital- and school-based violence intervention programs, policy recommendations, and directions for future research. Supplementary Information: The online version contains supplementary material available at 10.1007/s40653-023-00568-4.

Pediatric Surgery Firearm Injury Collaborative Symposium.

Injury from a firearm is now the leading cause of death of children and youth under age 19 in the United States (U.S.) [1] and the incidence of these deaths continues to increase each year [2]. For every death from firearm violence, there are several young people who have been injured by a bullet but not killed. As pediatric surgeons, we are on the front lines of treating these young patients. We have the unforgettable memories of delivering the horrible news to parents in "quiet rooms." [3]. As these injuries fall within our scope of practice, it is incumbent on us as professionals to work to prevent these injuries, apply best practices and work for the best pathways to recovery for our patients who do survive. There is a diverse community of pediatric surgeons tackling this public health problem in a variety of ways [4]. In a pre-meeting symposium at the APSA 2023 Annual meeting, we brought together a community of pediatric surgeons working on this critical area. The following summarizes the presentations of the symposium, with topics including Risk Factors, Injury Prevention, Treatment, Public Initiatives, and National Collaborative Efforts. TYPE OF STUDY: Review Article, Proceedings of a Symposium. LEVEL OF EVIDENCE: 1 through 4 all presented.

Pediatric Firearm Trauma on the Rise: A Retrospective Review of Over 1,100 Cases in 12 Years at One Center.

BACKGROUND: Gunshot injuries are the leading cause of death among children in the United States. The goal of this study was to better understand if certain age groups, mechanisms of injury, and type of firearms were associated with the increasing rates of pediatric gun-related trauma. We hypothesized that the extremities were disproportionately targeted when compared with the random likelihood of striking specific body-surface areas. METHODS: This study includes pediatric firearm-related injury (FRI) patients who presented to a single free-standing level 1 pediatric hospital or died at the scene from 2010 to 2021. The hospital data was collected prospectively as part of a level 1 trauma system electronic database. Death data was collected from the local coroner's office. RESULTS: Between 2010 and 2021, 1,126 pediatric FRI occurred in the geographic region studied. Demographic information available for 1,118 patients showed that 897 (80.23%) were male, and that black individuals had a statistically significant increased rate of FRI compared with white or Hispanic individuals. Mean age was 13.69 years. Most injuries were caused by handguns. CONCLUSIONS: This data could help leaders design strategies to combat the violence, such as legislation that limits handgun access to all, especially children, and mandates safe storage of handguns. Gun-lock programs, universal background checks, and firearm-ownership education also might help stem this tide of violence. LEVEL OF EVIDENCE: Level II Prognosis study.

Prevalence and Outcomes of High versus Low Ratio Plasma to Red Blood Cell Resuscitation in a Multi-Institutional Cohort of Severely Injured Children.

BACKGROUND: The benefit of targeting high ratio fresh frozen plasma (FFP):red blood cell (RBC) transfusion in pediatric trauma resuscitation is unclear as existing studies are limited to patients who retrospectively met criteria for massive transfusion. The purpose of this study is to evaluate the use of high ratio FFP:RBC transfusion and the association with outcomes in children presenting in shock. METHODS: A post-hoc analysis of a 24-institution prospective observational study (4/2018-9/2019) of injured children <18 years with elevated age-adjusted shock index was performed. Patients transfused within 24 hours were stratified into cohorts of low (<1:2) or high (>1:2) ratio FFP:RBC. Nonparametric Kruskal-Wallis and chi-square were used to compare characteristics and mortality. Competing risks analysis was used to compare extended (≥75th percentile) ventilator, intensive care, and hospital days while accounting for early deaths. RESULTS: Of 135 children with median (IQR) age 10 (5,14) years and weight 40 (20,64) kg, 85 (63%) received low ratio transfusion and 50 (37%) high ratio despite similar activation of institutional massive transfusion protocols (MTP; low-38%, high-46%, p = .34). Most patients sustained blunt injuries (70%). Median injury severity score was greater in high ratio patients (low-25, high-33, p = .01); however, hospital mortality was similar (low-24%, high-20%, p = .65) as was the risk of extended ventilator, ICU, and hospital days (all p > .05). CONCLUSION: Despite increased injury severity, patients who received a high ratio of FFP:RBC had comparable rates of mortality. These data suggest high ratio FFP:RBC resuscitation is not associated with worst outcomes in children who present in shock. MTP activation was not associated with receipt of high ratio transfusion, suggesting variability in MTP between centers. LEVEL OF EVIDENCE: Prospective cohort study, Level II.

A dedicated automated injection system for dynamic contrast-enhanced MRI experiments in mice.

PURPOSE: To develop a reproducible small-animal dynamic contrast-enhanced (DCE) MRI set-up for mice through which volumes <100 µL can be accurately and safely injected and to test this set-up by means of DCE measurements in resting muscle and tumor tissue. MATERIALS AND METHODS: The contrast agent (CA) injection system comprised 2 MR-compatible syringe pumps placed 50 cm from the 7T magnet bore where the fringe field is approximately 40 mT. Microbore tubing and T-connector, close to the injection site, minimized dead volume (<10 µL). For DCE-MRI measurements in 8 CB-17 SCID mice with 1500-2500 mm(3) large orthotopic neuroblastoma, a bolus of 10-fold-diluted Gd-DTPA CA solution (0.1 mmol/kg) was delivered (5 µL/s), followed by a 50-µL saline flush. Retro-orbital injections were given instead of tail vein injections, because the peripheral vasculature was reduced because of large tumor burden. RESULTS: The CA injection was successful in 19 of 24 experiments. Optical assessment showed minimal dispersion of ink-colored CA bolus. Mean (± SD) pharmacokinetic parameters retrieved from DCE-MRI examinations in resting muscle (K(trans) = 0.038 ± 0.025 min(-1), k(ep) = 0.66 ± 0.48 min(-1), v(e) = 0.060 ± 0.014, v(p) = 0.033 ± 0.021) and tumor (K(trans) = 0.082 ± 0.071 min(-1), k(ep) = 0.82 ± 0.80 min(-1), v(e) = 0.121 ± 0.075, v(p) = 0.093 ± 0.051) agreed with those reported previously. CONCLUSION: We successfully designed and implemented a DCE-MRI set-up system with short injection lines and low dead volume. The system can be used at any field strength with the syringe pumps placed at a sufficiently low fringe field (<40 mT).

TQIP mortality reporting system case reports: Unanticipated mortality due to communication and handoff failures.

ABSTRACT: The TQIP Mortality Reporting System is an online anonymous case reporting system designed to share experiences from rare events that may have contributed to unanticipated mortality at contributing trauma centers. The TQIP Mortality Reporting System Working group monitors submitted cases and organizes them into emblematic themes. This report summarizes unanticipated mortality from two cases of failure of communication and handoff, and presents strategies to mitigate these events locally with the hope of decreasing unanticipated mortality nationwide.

TQIP mortality reporting system case reports: Unanticipated mortality due to failures in clinical performance.

ABSTRACT: The Trauma Quality Improvement Program Mortality Reporting System is an online anonymous case reporting system designed to share experiences from rare events that may have contributed to unanticipated mortality at contributing trauma centers. The Trauma Quality Improvement Program Mortality Reporting System Working group monitors submitted cases and organizes them into emblematic themes. This report summarizes unanticipated mortality from two cases of failure of clinical performance and presents strategies to mitigate these events locally with the hope of decreasing unanticipated mortality nationwide.