Metabolic evaluation of urolithiasis and obesity in a midwestern pediatric population.

PURPOSE: The incidence of urolithiasis has been proved to be increasing in the adult population, and evidence to date suggests that the same holds true for the pediatric population. While adult urolithiasis is clearly linked to obesity, studies of pediatric patients have been less conclusive. We hypothesized that a population of otherwise healthy children with stones would have an increased body mass index compared to a control population, and that obese pediatric stone formers would have results on metabolic assessment that are distinct from nonobese stone formers. MATERIALS AND METHODS: We retrospectively reviewed the charts of all patients 10 to 17 years old with upper tract urolithiasis without comorbidities treated between 2006 and 2011. Mean body mass index of our population was compared to state data, and 24-hour urine collection results were compared between obese and nonobese patients with stones. RESULTS: The obesity rate in 117 patients with urolithiasis did not differ significantly from the obesity rate derived from the 2007 National Survey of Children's Health (observed/expected ratio 1.11, 95% CI 0.54-1.95). Using t-test and chi-square comparisons, overall 24-hour urine collection data did not show statistically significant differences. CONCLUSIONS: Our results do not confirm obesity as a risk factor for pediatric urolithiasis in otherwise healthy patients. We also found no substantial metabolic differences between healthy nonobese stone formers and obese patients. While the pediatric literature is mixed, our study supports the majority of published series that have failed to establish a link between pediatric urolithiasis and obesity.

Perioperative opiate requirements in children with previous opiate infusion.

BACKGROUND: Critically ill children often require continuous opiate infusions. Tolerance may develop requiring a weaning strategy to prevent withdrawal symptoms. These children may also require subsequent surgical procedures. This is the first study to investigate whether previously opiate-tolerant patients require higher doses of opiates for adequate pain management perioperatively. METHODS: A retrospective study was conducted at a tertiary children's hospital to investigate whether children previously exposed to continuous opiates for 10 or more days with subsequent weaning from those opiates will have similar or increased perioperative opiate requirements when compared to opioid-naïve controls. Study patients included 31 children with previous continuous opiate exposure for 10 or more days followed by weaning and without signs of withdrawal for at least 72 h prior to the surgical procedure. Excluded were patients over 18 years of age, those whose surgical procedures would be unlikely to require perioperative opiates, oncological patients, burn patients, neurologically devastated patients, and patients who received regional anesthesia in addition to perioperative narcotics. The control group consisted of 31 age- and case-matched opiate-naïve patients who underwent a surgical procedure during a similar time frame as the study patient. The medication administration record was reviewed for the length of continuous opiate exposure, date of last opiate use prior to a subsequent surgical procedure, and opiate use during the perioperative period. Opiate use was calculated as morphine equivalents per kilogram body weight (MSEQ·kg(-1)). The Wilcoxon rank sum test was used for univariate comparisons between matched pairs, and P-values <0.05 were considered statistically significant. RESULTS: The perioperative opiate requirements in opiate-exposed patients (median, interquartile range: 0.14, 0.08-0.25 MSEQ·kg(-1)) were not significantly different from opiate-naïve patients (median, interquartile range 0.10, 0.05-0.2 MSEQ·kg(-1), P = 0.19). Pain scores indicated that patients were generally comfortable in the perioperative period. CONCLUSIONS: The perioperative opiate requirements of pediatric patients who were successfully weaned after prolonged opiate use were similar to opiate-naïve patients. A history of prolonged opiate use alone does not necessitate special pain management for future procedures.

Incidence and risk factors for venous thromboembolism in critically ill children with cardiac disease.

Cardiac disease is a risk factor for venous thromboembolism (VTE) in children. In this study, we investigated the incidence and risk factors of VTE in critically ill children with cardiac disease, who were prospectively followed-up for VTE after admission to a tertiary care pediatric intensive care unit (PICU). Risk factors were compared between VTE cases and (1) patients in the cohort who did not develop VTE and (2) the next three cardiac patients sequentially admitted to the PICU (case control). Forty-one cases of VTE were identified from 1070 admissions (3.8%). Thirty-seven percent of VTE cases were central venous catheter (CVC)-associated, and 56% of cases were intracardiac. Sixty-six percent of patients were receiving anticoagulation at the time of VTE diagnosis. Increased VTE incidence was associated with unscheduled PICU admission, age <6 months, extracorporeal membrane oxygenation, increased number of CVCs, increased number of CVC days, higher risk of mortality score, and longer PICU stay. Using logistic regression, VTE was associated with single-ventricle physiology (odds ratio [OR] 11.2, 95% CI 3.0-41.9), widened arterial-to-somatic oxygen saturation gradient (SpO(2)-rSO(2) >30) (OR 4.3, 95% CI 1.1-16), and more CVC days (OR 1.1, 95% CI 1.04-1.13). Risk factors for VTE in critically ill children with cardiac disease include younger age, single-ventricle cardiac lesions, increased illness severity, unscheduled PICU admission, and complicated hospital course.

Can omphalocele ratio predict postnatal outcomes?

BACKGROUND: The clinical course of patients with omphalocele is challenging to predict. There is no standard method to characterize omphalocele size. Previous studies suggest that the ratio of abdominal circumference to omphalocele defect in-utero is indicative of postnatal outcomes. We hypothesize that omphalocele ratio correlates with outcomes of primary closure versus staged closure. METHODS: A retrospective chart review of all neonates diagnosed with omphalocele from 2002 to 2013 with prenatal ultrasounds available (n=30) was conducted. Omphalocele ratio was defined as omphalocele diameter/abdominal circumference (OD/AC). Data collected included primary versus staged closure, time to full feeds, duration of mechanical ventilation, and length of stay (LOS). Long-term outcomes and quality of life were also reported. RESULTS: ROC curve analysis generated optimal OD/AC ratio of 0.26. Twenty of 30 patients had a ratio less than this cutoff. Sixty percent (12/20) in the low-ratio group achieved primary closure versus zero (0/10) in the high-ratio group (p=0.001). Time on mechanical ventilation was 15.8 days (low-ratio) versus 79 days (high-ratio) (p=0.05). LOS was 33.8 days (low-ratio) versus 85.6 days (high-ratio) (p=0.119). PedsQL™ mean score was 85.5 ± 11.0 (n=20) at long-term follow-up. Readmission rates yielded no difference. CONCLUSIONS: The omphalocele ratio is a promising predictor of postnatal outcomes.

Gastrojejunostomy Tube Bowel Perforations in Low-Weight Infants.

This is a case series in which 3 infants with gastrojejunostomy tube (GJT) insertion developed delayed perforation secondary to pressure necrosis. A review of all patients who underwent a GJT placement in 2013 was performed. Three of these patients developed surgically confirmed perforation secondary to pressure necrosis during this time period; no patients developed perforation at the time of GJT insertion. The indications for GJT insertion for all 3 patients were severe gastroesophageal reflux disease; 2 patients also had recurrent aspiration. The patients were between 9 weeks and 10 months of age at the time of GJT insertion. The site of perforation for all 3 cases occurred just distal to the ligament of Treitz between 48 and 72 hours following insertion. Given our 3 cases of perforation in patients weighing <10 kg, there may be a higher risk of perforation in low-weight patients.

Safe and effective management of esophageal coins in children with bougienage.

BACKGROUND: Coins are the foreign body most commonly ingested in infants and children. Coins retained in the esophagus require intervention to prevent complications. Management of retained esophageal coins remains variable both between and within institutions. We hypothesize that the incorporation of bougienage in the management of pediatric esophageal coins is safe and more cost-effective compared with traditional management strategies that use endoscopy. METHODS: We conducted a retrospective review of infants and children diagnosed with an esophageal foreign body managed at Children's Hospital of Wisconsin between January 2003 and June 2012. Pediatric otolaryngologists (ear-nose-throat, ie, ENTs) or pediatric surgeons manage all children with esophageal foreign bodies in a prospective call schedule that alternates weekly. RESULTS: During an 8.5-year period, 1,642 children were diagnosed with esophageal foreign bodies and 518 had a retained coin. For esophageal coins, ENT managed 218 cases and pediatric surgery managed 300. ENTs preferentially used endoscopy for coin removal, whereas pediatric surgeons used either endoscopy or esophageal bougienage for selected children meeting specific criteria. Bougienage was successful at advancing the coin into the stomach in 94% of patients, and endoscopy was successful at removing the coin from the esophagus in 100% of patients. The mean duration of stay was 0.6 days for endoscopy by ENT, 0.6 days for endoscopy by pediatric surgery, and 0.1 days for bougienage (P < .05). The median hospital charge was $4,593 for endoscopy by ENT, $5,379 for endoscopy by pediatric surgery, and $579 for bougienage (P < .05). There were 3 complications each in the endoscopy group for ENT and pediatric surgery. There were no complications in children undergoing bougienage. CONCLUSION: This is the first case series evaluating the management of children with esophageal coins using a prospective assignment to endoscopy versus endoscopy or bougienage. Our data support bougienage as a safe and cost-effective treatment for managing retained esophageal coins in selected children.

Effectiveness of clinical guidelines for deep vein thrombosis prophylaxis in reducing the incidence of venous thromboembolism in critically ill children after trauma.

BACKGROUND: Historically, 6% of critically ill children developed clinically apparent venous thromboembolism (VTE) after trauma at our Level I pediatric trauma center. We hypothesized that implementation of clinical guidelines for thrombosis prophylaxis incorporating both VTE risk and bleeding risk would reduce VTE incidence without increased bleeding. METHODS: VTE, both clinically apparent and those only detected by guideline-directed screening, were prospectively identified for all children admitted to the intensive care unit after trauma during three time periods: preimplementation of guidelines for VTE thromboprophylaxis (PRE; April 1, 2006-June 30, 2007), the intervening period (ROLL OUT; July 1, 2007-November 4, 2008), and postguideline implementation (POST; November 5, 2008-June 1, 2010). For patients classified as high risk for VTE, anticoagulation was recommended. For those patients at high risk of VTE with high risk of bleeding, anticoagulation was deferred and screening ultrasound performed. RESULTS: Fourteen of 546 subjects developed VTE. There was a decrease in total VTE (p = 0.041) and clinical VTE (p = 0.001) after guideline implementation. The nine VTE PRE (5.2%) were clinically symptomatic, while the three VTE POST (1.8%) were detected by guideline-directed screening ultrasound. Implementation of guidelines did not increase overall thromboprophylaxis, with decreased anticoagulation in patients at low risk of VTE. No bleeding complications occurred. No patients classified by the guidelines as low risk for VTE developed VTE. CONCLUSION: The incidence of clinical VTE and total VTE decreased after implementation of clinical guidelines for thromboprophylaxis in critically ill children after trauma. This decrease in VTE was not associated with increased prophylactic anticoagulation nor increased bleeding. The guidelines were predictive in identifying patients at low risk for VTE. LEVEL OF EVIDENCE: II, therapeutic study.