Artiss fibrin sealant for the fixation of autografts in pediatric burn care.

BACKGROUND: Traditional fixation of autografts in the treatment of burns involves the use of sutures and staples. A novel fibrin sealant, Artiss, has been introduced as an alternate method of fixation and has shown promising safety and efficacy results in the adult population. Our study assessed the effectiveness of fibrin sealant to secure autologous split thickness skin grafts (ASTSG) in the pediatric burn population. METHODS: We performed a retrospective cohort study of pediatric patients under 18 years of age who received autografting for the treatment of burns at our institution between 2017 and 2023. We compared ASTSG secured with fibrin sealant to those managed traditionally with sutures or staples. Outcomes of interest include the need for return trips to the operating room (OR), time to wound healing, graft take, and total time in the operating room. RESULTS: 83 patients underwent a total of 142 individual ASTSGs for management of unique body area injuries. 66.3 % were male, median age was 79 months, and scald was the most common mechanism of injury (41.0 %). Forty-five (39.5 %) traditionally affixed ASTSG required at least one return to the OR while only one (3.6 %) ASTSG secured with fibrin sealant required an additional return to the OR (p < 0.001). Graft take was similar in both groups (92.9 % for fibrin sealant vs. 93.9 % for traditional methods, p = 1). Time to wound healing was also similar: 16 vs. 15 days for fibrin glue and traditional methods, respectively (p = 0.23). CONCLUSION: Outcomes from autograft fixation with fibrin sealant were comparable to those treated with traditional methods, with a reduction in the need for return trips to the operating room. These data suggest that fibrin sealant is a suitable alternative to traditional fixation methods in pediatric autografting.

Characteristics and trends of pediatric firepit burns: insights for prevention and safety.

Introduction: As fire pits grow in popularity, so do the associated burn injuries. Our study examines pediatric fire pit burns characteristics to raise awareness and promote safety precautions. Methods: We conducted a retrospective review of pediatric patients (≤21 years) with firepit burns at a tertiary care hospital from 2016 to 2021. Results: Eighty-four patients were identified, of whom 70.2% were male, with a median age of 62 months. The median percent total body surface area burned was 2% (interquartile range (IQR)=1-4). Thirty-five (41.7%) patients were admitted and 7 (8.3%) underwent grafting. Neck and trunk burns had the highest grafting rates (66% and 33%, respectively). The hands (41.7%) and the lower extremities (27.4%) were the most frequently burned body areas. The leading causes of burns were ashes/hot coals (34.5%), flames (31.0%), and direct contact (25.0%), often resulting from falling into the fire (59.5%) or running or playing in activities near it (26.2%). Thirty-five (41.7%) were admitted for inpatient management, while 49 (58.3%) were treated as outpatient. Eleven (13.2%) underwent at least one reconstructive surgery, 7 (8.4%) had at least one rehabilitation visit, and 65 (77.4%) had follow-up clinic visits. The median length of stay was 2 days (IQR=1.0-3.5). The peak months for burns were from August through October (n=40, 46.0%), with an increase observed from 10 cases in 2016 to 20 cases in 2020. Conclusions: Given the significant proportion of firepit burns resulting from unsafe fire behaviors, it is crucial that caretakers are aware of proper firepit safety precautions. Level of evidence: III.

Morbidity in children after fetoscopic endoluminal tracheal occlusion for severe congenital diaphragmatic hernia: Results from a multidisciplinary clinic.

BACKGROUND: Although fetoscopic endoluminal tracheal occlusion (FETO) was recently shown to improve survival in a multicenter, randomized trial of severe congenital diaphragmatic hernia (CDH), morbidity outcomes remain essentially unknown. The purpose of this study was to assess long-term outcomes in children with severe CDH who underwent FETO. METHODS: We conducted a prospective study of severe CDH patients undergoing FETO at an experienced North American center from 2015-2021 (NCT02710968). This group was compared to a cohort of non-FETO CDH patients with severe disease as defined by liver herniation, large defect size, and/or ECMO use. Clinical data were collected through a multidisciplinary CDH clinic. Statistics were performed with t-tests and Chi-squared analyses (p≤0.05). RESULTS: There were 18 FETO and 17 non-FETO patients. ECMO utilization was 56% in the FETO cohort. Despite significantly lower median observed/expected lung-to-head ratio (O/E LHR) in the FETO group, [FETO: 23% (IQR:18-25) vs. non-FETO: 36% (IQR: 28-41), p<0.001], there were comparable survival rates at discharge (FETO: 78% vs. non-FETO: 59%, p = 0.23) and at 5-years (FETO: 67% vs. non-FETO: 59%, p = 0.53) between the two cohorts. At a median follow up of 5.8 years, metrics of pulmonary hypertension, pulmonary morbidity, and gastroesophageal reflux disease improved among patients after FETO. However, most FETO patients remained on bronchodilators/inhaled corticosteroids (58%) and were feeding tube dependent (67%). CONCLUSIONS: These North American data show that prenatal tracheal occlusion, in conjunction with a long-term multidisciplinary CDH clinic, is associated with acceptable long-term survival and morbidity in children after FETO. LEVEL OF EVIDENCE: Level III.

Factors Associated With Pediatric Burn Clinic Follow-up After Emergency Department Discharge.

Attrition between emergency department discharge and outpatient follow-up is well documented across a variety of pediatric ailments. Given the importance of outpatient medical care and the lack of related research in pediatric burn populations, we examined sociodemographic factors and burn characteristics associated with outpatient follow-up adherence among pediatric burn patients. A retrospective review of medical records was conducted on patient data extracted from a burn registry database at an urban academic children's hospital over a 2-year period (January 2018-December 2019). All patients were treated in the emergency department and discharged with instructions to follow-up in an outpatient burn clinic within 1 week. A total of 196 patients (Mage = 5.5 years; 54% male) were included in analyses. Average % TBSA was 1.9 (SD = 1.5%). One third of pediatric burn patients (33%) did not attend outpatient follow-up as instructed. Older patients (odds ratio [OR] = 1.00; 95% confidence interval [CI]: [0.99-1.00], P = .045), patients with superficial burns (OR = 9.37; 95% CI: [2.50-35.16], P = .001), patients with smaller % TBSA (OR = 1.37; 95% CI: [1.07-1.76], P = .014), and patients with Medicaid insurance (OR = 0.22; 95% CI: [0.09-0.57], P = .002) or uninsured/unknown insurance (OR = 0.07; 95% CI: [0.02-0.26], P = .000) were less likely to follow up, respectively. Patient gender, race, ethnicity, and distance to clinic were not associated with follow-up. Follow-up attrition in our sample suggests a need for additional research identifying factors associated with adherence to follow-up care. Identifying factors associated with follow-up adherence is an essential step in developing targeted interventions to improve health outcomes in this at-risk population.

Predictors of Follow-up Compliance in Pediatric Burn Patients During the Time of COVID.

The effect of the COVID-19 pandemic has led to increased isolation and potentially decreased access to healthcare. We therefore evaluated the effect of COVID-19 on rates of compliance with recommended post-injury follow-up. We hypothesized that this isolation may lead to detrimental effects on adherence to proper follow-up for children with burn injuries. We queried the registry at an ABA-verified Level 1 pediatric burn center for patients aged 0-18 years who were treated and released from March 30 to July 31, 2020. As a control, we included patients treated during the same time frame from 2016 to 2019. Patient and clinical factors were compared between the COVID and pre-COVID cohorts. Predictors of follow-up were compared using chi-squared and Kruskal-Wallis tests. Multivariable logistic regression was used to evaluate for predictors of compliance with follow-up. A total of 401 patients were seen and discharged from the pediatric ED for burns. Fifty-eight (14.5%) of these patients were seen during the pandemic. Burn characteristics and demographic patterns did not differ between the COVID and pre-COVID cohorts. Likewise, demographics did not differ between patients with follow-up and those without. The rate of compliance with 2-week follow-up was also not affected. Burn size, burn depth, and mechanism of injury all were associated with higher compliance to follow up. After adjusting for these variables, there was still no difference in the odds of appropriate follow-up. Despite concerns about decreased access to healthcare during COVID, follow-up rates for pediatric burn patients remained unchanged at our pediatric burn center.

Splenic function is not maintained long-term after partial splenectomy in children with sickle cell disease.

BACKGROUND: Partial splenectomy (PS) may allow preservation of splenic function in cases where splenectomy is indicated for hematologic diseases; however, the long-term outcomes are uncertain. We investigated the long-term outcomes of PS in patients with sickle cell disease (SCD). METHODS: A single-institution retrospective chart review was performed for children with SCD who underwent PS from 1997 to 2017. For comparison, we reviewed outcomes for patients who underwent PS for hereditary spherocytosis (HS). The primary endpoint was viability of the splenic remnant as inferred by the presence of remnant perfusion on ultrasound and/or liver spleen scan. RESULTS: Nine patients with SCD and 26 patients with HS underwent PS at a median age of 11 (IQR, 9-14) and 7.5 (IQR, 6-13) years, respectively. All underwent laparoscopic PS with three (7.9%) conversions to open. Two SCD patients were lost to long-term follow-up. The remaining seven SCD patients had initial postoperative splenic remnant perfusion demonstrated by ultrasonography. By 42 months postoperatively, however, none had a functioning splenic remnant. The median time to loss of splenic remnant was 12.6 (IQR 9.2-28.5) months. In contrast, all HS patients demonstrated robust splenic remnant blood flow with a median follow-up of 46 (IQR 37-82) months. CONCLUSION: No patient with SCD who underwent PS had viable splenic tissue for more than 42 months, likely due to continued autoinfarction typical of patients with this disease. Therefore, we believe that PS to preserve splenic function is not indicated in patients with SCD. LEVEL OF EVIDENCE: III.

Clinical Diagnosis of Infection in Surgical Intensive Care Unit: You're Not as Good as You Think!

Background: Because of the everincreasing costs and the complexity of institutional medical reimbursement policies, the necessity for extensive laboratory work-up of potentially infected patients has come into question. We hypothesized that intensivists are able to differentiate between infected and non-infected patients clinically, without the need to pan-culture, and are able to identify the location of the infection clinically in order to administer timely and appropriate treatment. Methods: Data collected prospectively on critically ill patients suspected of having an infection in the surgical intensive care unit (SICU) was obtained over a six-month period in a single tertiary academic medical center. Objective evidence of infection derived from laboratory or imaging data was compared with the subjective answers of the three most senior physicians' clinical diagnoses. Results: Thirty-nine critically ill surgical patients received 52 work-ups for suspected infections on the basis of signs and symptoms (e.g., fever, altered mental status). Thirty patients were found to be infected. Clinical diagnosis differentiated infected and non-infected patients with only 61.5% accuracy (sensitivity 60.3%; specificity 64.4%; p = 0.0049). Concordance between physicians was poor (κ = 0.33). Providers were able to predict the infectious source correctly only 60% of the time. Utilization of culture/objective data and SICU antibiotic protocols led to overall 78% appropriate initiation of antibiotics compared with 48% when treatment was based on clinical evaluation alone. Conclusion: Clinical diagnosis of infection is difficult, inaccurate, and unreliable in the absence of culture and sensitivity data. Infection suspected on the basis of signs and symptoms should be confirmed via objective and thorough work-up.

Diagnosis of Invasive Fungal Infection Among Pediatric Oncology Patients.

INTRODUCTION: The diagnosis of pulmonary invasive fungal infection (IFI) in the pediatric oncology patient is challenging. Consensus criteria developed in 2008 state that bronchioalveolar lavage (BAL) results cannot confirm this diagnosis. A video-assisted thoracoscopic biopsy (VATS-biopsy) of lungs has been increasingly used to assist in evaluating these children for IFI. Our goal was to evaluate the impact of BAL and VATS-biopsy results on the management of IFI among pediatric oncology patients. METHODS: A retrospective review of all oncology patients evaluated for IFI with VATS-biopsy and/or BAL over 9 years was carried out at a single free-standing children's hospital. The primary outcome was management changes in the use of antifungal therapy on the basis of diagnostic procedure, fungal culture results, lung imaging, and serological markers. RESULTS: A total of 102 patients underwent 122 diagnostic evaluations for IFI. Ninety-one workups included only BAL, 17 evaluations involved only VATS-biopsy, and 14 cases involved both BAL and VATS-biopsy. The diagnostic yield of VATS-biopsy (38.7%) was superior to that of BAL (27.6%). There was poor concordance between VATS-biopsy and BAL results in the 14 cases where both were performed. Upon workup completion, IFI was proven in 12 children, probable in 29, and possible in 52. The odds of continuing antifungals increased 3-fold for patients with probable IFI and 12.7 times for those with the proven disease. DISCUSSION: On the basis of the inferior diagnostic yield of BAL, we believe that VATS-biopsy may be a more useful diagnostic adjuvant in the diagnosis of IFI in the immunocompromised pediatric oncologic patient population.

Puestow Procedure for the Management of Pediatric Chronic Pancreatitis.

OBJECTIVE: Recurrent pancreatitis significantly impacts childhood development and quality of life. Our goal was to evaluate the efficacy of the Puestow procedure. MATERIALS AND METHODS: After obtaining the Institutional Review Board approval, we reviewed the charts of all patients who underwent lateral pancreaticojejunostomy from January 1999 to January 2014. Statistical analysis was performed using paired Student's t-test and Fisher's exact test as appropriate. RESULTS: During the 15-year study period, 13 patients underwent a lateral pancreaticojejunostomy for chronic pancreatitis. The most common causes of pancreatitis were hereditary (n = 5) or obstructive (n = 5); pancreas divisum (n = 2), one iatrogenic stricture, one idiopathic stricture, and one unresectable pancreatic head mass); two patients had idiopathic disease, and one case was drug-induced. Six patients had failed management with endoscopic retrograde cholangiopancreatography and pancreatic duct stenting. Preoperatively, the median body mass index (BMI) percentile-for-age was 61.0% (range 11.0-99.0%). Median age at operation was 12.8 years (range 7.7-16.7). There were no deaths, four patients developed postoperative ileus, and one patient developed an intra-abdominal abscess, which resolved with antibiotics. Median postoperative length of stay was 7 days (range 5-15).Two patients were lost to follow-up; median follow-up for the remaining 12 patients was 35.5 months (range 4.9-131.2). Four patients were readmitted within 90 days: three due to abdominal pain which were not recurrences of pancreatitis, and one due to complications of chemotherapy. Postoperatively, there was no change in the average BMI percentile-for-age (p = 0.64). Seven patients reported resolution or significant improvement in their abdominal pain symptoms at the time of last follow-up. Patients with obstructive causes of pancreatitis were not more likely to experience relief than those with nonobstructive causes (42.9 vs. 80.0%, p = 0.29). CONCLUSION: In our experience, lateral pancreaticojejunostomy results in durable improvement or resolution of abdominal pain symptoms in nearly 60% of patients with chronic pancreatitis regardless of etiology.

Laparoscopic Appendectomy: A Report on 1164 Operations at a Single-Institution, Safety-Net Hospital.

Laparoscopic appendectomy (LA) is the standard of care for the treatment of acute appendicitis. There is an ongoing debate regarding the optimal management of appendicitis, which led us to study outcomes after an appendectomy at a large safety-net hospital. We hypothesize that despite a high-risk population, LA remains a safe and effective treatment for acute appendicitis. A retrospective review was performed of all patients who underwent an appendectomy from 2011 to 2013. The primary end point was significant morbidity defined as a score of three or greater on the Clavien-Dindo scale of surgical morbidity. Thousand hundred and sixty-four patients underwent an appendectomy. A total of 1102 (94.7%) patients underwent either an LA or laparoscopic converted to open appendectomy, and 62 (5.3%) patients underwent an open appendectomy (OA). Two hundred and forty six patients (21.1%) had complicated appendicitis. Laparoscopic converted to OA conversion rate was 4.4 per cent and differed between years (P < 0.001). LA had a significantly shorter length of stay, shorter length of postoperative antibiotics, and less postoperative morbidity. When limited to only patients with complicated appendicitis, major morbidity was still greater in the OA group (22.6 vs 52.0%, P = 0.001). Length of stay was significantly longer in the OA group [3.42 (2.01, 5.97) vs 7.04 (5.05, 10.13), P < 0.001]. Odds for complication were 2.6 times greater in the OA group compared with the LA group. In the absence of peritonitis and systemic illness necessitating urgent laparotomy, patients who are laparoscopic surgical candidates should be offered an LA. Our study demonstrates that these patients have better outcomes and shorter hospital stays.

Thromboelastometry analysis of severe North American pit viper-induced coagulopathy: A case report.

CASE DETAILS: A 51-year-old man presented with rapid onset encephalopathy and respiratory failure after a suspected intravascular envenomation from a North American pit viper. The patient received antivenom and was transferred to a tertiary care facility where he had cardiovascular collapse and persistent coagulopathy requiring 28 vials of Crotalidae polyvalent immune Fab antivenom for initial control and six vials for maintenance. The patient's coagulopathy was monitored using "traditional" measures (platelets, fibrinogen, and prothrombin time/international normalized ratio) and rotational thromboelastometry (ROTEM®). The patient also subsequently developed intestinal necrosis requiring exploratory laparotomy with ileum and colonic resections, and anuric renal failure requiring continuous renal replacement therapy. After coordinated multidisciplinary management, he was discharged to an acute inpatient rehabilitation on hospital day 25 and has since made a full recovery. DISCUSSION: In the setting of a severe intravascular pit viper envenomation, thromboelastometry correlated well with "traditional" measures. During recovery, ROTEM® demonstrated measurable improvements in the extrinsic coagulation pathway while the INR remained between 1.5 and 1.6. Patient's intestinal necrosis may have resulted from microvascular thrombosis due to Crotalinae venom. The patient's ultimate recovery necessitated a coordinated multidisciplinary effort. ROTEM® abnormalities after North American pit viper envenomation may be more sensitive than "traditional" measures and may have prognostic value to determine the severity of envenomation, but further research to define its utility is required.

The Effect of Illicit Drug Use on Outcomes Following Burn Injury.

Illicit drug use is common among patients admitted following burn injury. The authors sought to evaluate whether drug abuse results in worse outcomes. The National Burn Repository (NBR) was queried for data on all patients with drug testing results available. Outcomes included mortality, hospital length of stay (LOS), intensive care unit (ICU) LOS, and duration of ventilator support. Propensity score weighting was performed to control for age, alcohol use, burn size, gender, and etiology of burn. A total of 20,989 patients had drug screen data available; 11,642 (55.5%) tested positive for at least one drug of abuse. Illicit drug use was associated with a higher proportion of patients with flame burn (53.2 vs 48.4%) and larger average burn size (11.2 vs 9.5% TBSA, P < .001). Attempted suicide was more likely if the patient had used drugs (2.8 vs 1.7%, P < .001). Drug use resulted in longer hospital and ICU LOS (14.2 vs 11.4 and 8.5 vs 5.6 days, P < .001), but did not increase the risk of mortality (5.7 vs 5.2, P = .08). After propensity score weighting, drug use did not affect mortality, hospital LOS, or duration of ventilator support, but did increase the average ICU LOS by 1.2 days (P = .001). Drug use does not affect mortality, hospital LOS, or duration of ventilator support among burned patients. After controlling for burn size, age, mechanism of injury, and gender, patients with a positive drug screen had an average increase in ICU LOS by 1 day.

Revisiting the Anterior Rectus Sheath Repair for Incisional Hernia: A 10-Year Experience.

BACKGROUND: Surgeons continue to seek an incisional hernia repair technique which minimizes cost and morbidity while maximizing durability. We present a single surgeon's experience with a technique described by N.L. Browse and J.P. Chevrel in 1979. METHODS: The Chevrel/Browse repair consists of a bilateral anterior rectus sheath release, hernia sac imbrication, bilateral rectus complex medialization, and repair reinforcement with an anterior prosthetic mesh. Data were collected on all patients who underwent herniorrhaphy between April 2003 and April 2013. RESULTS: A total of 123 patients underwent repair. These had undergone an average of 2.6 prior abdominal operations and 0.7 prior hernia repairs; the average defect size was 64.77 ± 86.79 cm2. Twelve patients had lateral components release in addition to release of the anterior rectus sheath to achieve midline re-approximation with minimal tension. Synthetic mesh was used in 81 % of repairs and biologic mesh in 19 %. The most common complications were seroma formation (21 %) and incisional skin breakdown (30 %); no deaths occurred. The overall recurrence rate was 5.1 %, and 7 % for the group which had follow-up greater than 36 months. Use of biologic mesh increased the rate of seroma formation compared with synthetic mesh (50 vs. 14 %, p < 0.001), but did not increase the rate of wound breakdown (36.3 vs. 29.6 %, p = 0.72). CONCLUSION: This case series describes the utilization of anterior rectus sheath release and mesh placement which is anterior to the rectus muscle. Hernia recurrence and intra-abdominal complications are observed to be uncommon after repair using this technique. Future prospective randomized studies are warranted.

Evaluating Pre Burn Center Intubation Practices: An Update.

A significant proportion of patients appeared to arrive at our American Burn Association-verified burn center intubated without clear benefit. The current study aims to evaluate regional prehospital intubation practices and their outcomes. All consecutive admissions from November 2012 to June 2014 were reviewed for data points associated with intubation. Demographics and outcomes for patients who were intubated before arrival or within 24 hours of admission were compared using χ, Fisher's exact test, and the Kruskal-Wallis test as appropriate. During this period, 958 patients were admitted. Of these, 120 were intubated before arrival, and 91 survived their injuries. Of these 91 survivors, 45 were extubated within 2 days, suggesting unnecessary intubation rate in 37.5%. Intubation-related complications were roughly three times as common among those intubated before arrival (12.5% vs 4.4%). Patients intubated before arrival to our burn center had a shorter median duration of intubation (1.0 vs 4.0 days), median hospital LOS (5.0 vs 22.0 days), and median intensive care unit length of stay (3.0 vs 10.0 days). Furthermore, we found a significant difference in the pattern of ventilator support duration between those arriving intubated, with a median of 2.0 days, and those intubated at our burn center, with a median of 5.5 days. Patients intubated by pre burn center providers have shorter intubation durations and shorter hospitalizations, suggesting inappropriate use of resources. Impending loss of airway appears unlikely among patients with adequate gas exchange at the time of examination. The current criteria for prehospital intubation should be revised to more accurately identify those who truly benefit from advanced airway maneuvers.

Characterizing End-of-Life Care after Geriatric Burns at a Verified Level I Burn Center.

BACKGROUND: End-of-life (EoL) care after geriatric burns (geri-burns) is understudied. OBJECTIVE: To examine the practices of burn surgeons for initiating EoL discussions and the impact of decisions made on the courses of geri-burn patients who died after injury. METHODS: This retrospective cohort study examined all subjects ≥65 years who died on our Level I burn service from April 1, 2009, to December 31, 2014. Measurements obtained were timing of first EoL discussion (EARLY <24 hours post-admission; LATE ≥24 hours post-admission), decisions made, age, total body surface area burned, and calculated probability of death at admission. RESULTS: The cohort consisted of 57 subjects, of whom 54 had at least one documented EoL care discussion between a burn physician and the patient/surrogate. No differences were seen between groups for the likelihood of an immediate decision for comfort care after the first discussion (p = 0.73) or the mean number of total discussions (p = 0.07). EARLY group subjects (n = 38) had significantly greater magnitudes of injury (p = 0.002), calculated probabilities of death at admission (p ≤ 0.001), shorter times to death (p ≤ 0.001), and fewer trips to the operating theater for burn excision and skin grafting (p ≤ 0.001) than LATE subjects (n = 16). LATE subjects' first discussion occurred at a mean of 9.3 ± 10.0 days. DISCUSSION: The vast majority of geri-burn deaths on our burn service occur after a discussion about EoL care. The timing of these discussions is driven by magnitude of injury, and it does not lead to higher proportions of an immediate decision for comfort care. The presence and timing of EoL discussions bears further study as a quality metric for geri-burn EoL care.

Long-term central venous access in a pediatric leukemia population.

BACKGROUND: Central venous access devices (CVADs) play an important role in the management of pediatric oncology patients; unfortunately, they are also associated with potentially serious complication rates. We hypothesized that, despite the significantly different disease courses typical of acute lymphoblastic leukemia and acute myelogenous leukemia, there would be identifiable risk factors for premature CVAD removal. METHODS: We retrospectively studied clinical characteristics and procedure records for all patients admitted with a leukemia diagnosis at our institution from May 2009 to July 2014. RESULTS: Our observed perioperative complication rate was 6%; over 70% of lines had at least one long-term complication (thrombosis, catheter-related bloodstream infection, or unexplained line malfunction). Obesity (odds ratio [OR], 6.9; 95% CI, 1.62-29.43), preoperative dosage of packed red blood cells (in mL/kg; OR, 3.13; 1.07-9.21), bloodstream infection (OR, 5.75; 1.69-19.56) were associated with increased risk of premature catheter removal; unexplained malfunction was associated with a lower risk (OR, 0.28; 0.09-0.93). CONCLUSIONS: Obesity, the preoperative dosage of packed red blood cells, the presence of a bloodstream infection, and unexplained line malfunction are significant predictors of premature CVAD removal in a pediatric leukemia population.

Future Therapies in Burn Resuscitation.

Since the 1940s, the resuscitation of burn patients has evolved with dramatic improvements in mortality. The most significant achievement remains the creation and adoption of formulae to calculate estimated fluid requirements to guide resuscitation. Modalities to attenuate the hypermetabolic phase of injury include pharmacologic agents, early enteral nutrition, and the aggressive approach of early excision of large injuries. Recent investigations into the genomic response to severe burns and the application of computer-based decision support tools will likely guide future resuscitation, with the goal of further reducing mortality and morbidity, and improving functional and quality of life outcomes.

A case for less workup in near hanging.

BACKGROUND: No guidelines exist for the evaluation of patients after near hanging. Most patients receive a comprehensive workup, regardless of examination. We hypothesize that patients with a normal neurologic examination, without major signs or symptoms suggestive of injury, require no additional workup. METHODS: We reviewed medical charts of adult trauma patients who presented to a Level I trauma center between 1995 and 2013 after an isolated near-hanging episode. Demographics, Glasgow Coma Scale (GCS) score, imaging, and management were collected. Patients were stratified by neurologic examination into normal (GCS score = 15) and abnormal (GCS score <15) groups. Comparison between the groups was completed using univariate analyses. RESULTS: One hundred twenty-five patients presented after near hanging: 42 (33.6%) had abnormal GCS score, and 83 (66.4%) were normal. Among the normal patients, seven patients (8.5%) reported cervical spine tenderness; these patients also had abnormal examination findings including dysphagia, dysphonia, stridor, or crepitus. The normal group underwent 133 computed tomography scans and seven magnetic resonance imaging scans, with only two injuries identified: C5 facet fracture and a low-grade vertebral artery dissection. Neither injury required intervention. In patients with normal GCS score, cervical spine tenderness and at least one significant examination finding were 100% sensitive and 79% specific for identifying an underlying injury. CONCLUSION: Patient with normal GCS score, without signs and symptoms of injury, are unnecessarily receiving extensive diagnostic imaging. Imaging should be reserved for patients with cervical spine tenderness and dysphagia, dysphonia, stridor, and/or crepitus without the fear of incomplete workup. All patients with signs of additional trauma or decreased GCS score should be studied based on preexisting protocols. LEVEL OF EVIDENCE: Therapeutic/care management study, level V.

The Parkland Burn Center experience with 297 cases of child abuse from 1974 to 2010.

INTRODUCTION: Pediatric burns due to abuse are unfortunately relatively common, accounting for 5.8-8.8% of all cases of abuse annually. Our goal was to evaluate our 36-year experience in the evaluation and management of the victims of abuse in the North Texas area. METHODS: A prospectively maintained database containing records on all admissions from 1974 through 2010 was queried for all patients aged less than 18 years. Patients admitted for management of a non-burn injury were excluded from the analysis. RESULTS: Of 5,553 pediatric burn admissions, 297 (5.3%) were due to abuse. Children with non-accidental injuries tended to be younger (2.1 vs. 5.0 years, p<0.0001) and male (66.0 vs. 56.5%, p=0.0008). Scald was the most common mechanism of injury overall (44.8%), and was also the predominant cause of inflicted burns (89.6 vs. 42.3%, p<0.0001). Multivariate logistic regression identified age, gender, presence of a scald, contact, or chemical burn, and injury to the hands, bilateral feet, buttocks, back, and perineum to be significant predictors of abuse. Victims of abuse were also found to have worse outcomes, including mortality (5.4 vs. 2.3%, p=0.0005). After adjusting for age, mechanism of injury, and burn size, abuse remained a significant predictor of mortality (OR 3.3, 95% CI 1.5-7.2) CONCLUSIONS: Clinicians should approach all burn injuries in young children with a high index of suspicion, but in particular those with scalds, or injuries to the buttocks, perineum, or bilateral feet should provoke suspicion. Burns due to abuse are associated with worse outcomes, including length of stay and mortality.

Creation of a decision aid for goal setting after geriatric burns: a study from the prognostic assessment of life and limitations after trauma in the elderly [PALLIATE] consortium.

OBJECTIVES: We hypothesized that a decision-support aid to predict index admission mortality and discharge disposition for geriatric burns could be constructed using the well-accepted Baux score (age +total body surface area burned) in a geriatric-specific cohort. METHODS: National Burn Repository version 8.0 (2002-2011) was queried for all subjects aged 65 years or older. Baux scores were calculated and patients grouped into deciles. Three discharge outcomes (death,home, discharge to nonhome setting) were measured per decile. A receiver operating characteristic analysis was used to determine optimal Baux score cutpoints based on the Youden Index. The odds of mortality at various Baux score cutoffs were estimated using logistic regression. RESULTS: The sample was composed of 8,001 subjects. Withdrawal of care was documented in 264 deaths; median time to withdrawal was three days. As Baux score increased, three peaks in disposition were seen. Less than 50% of patients with a Baux score of 80 or greater were discharged home. Patients with a moderate Baux score (80-130) had an increased likelihood of discharge to a nonhome setting. Baux scores of 130 or greater were nearly uniformly fatal (mortality, 94-100%). Baux score of 86.15 or less was predictive of discharge home (area under the curve, 0.698; sensitivity, 75.28%; specificity, 54.64%), and a score greater than 93.3 was predictive of mortality (area under the curve, 0.779; sensitivity, 57.46%; specificity, 87.08%). CONCLUSION: For geriatric patients whose Baux scores exceed 86, return-to-home rates drop drastically; mortality increases at a score greater than 93, and mortality is nearly universal at a score ≥130 or greater. We are piloting a display of these findings as a decision-making aid when setting goals of care with stakeholders after geriatric burns. LEVEL OF EVIDENCE: Epidemiologic/prognostic study, level III; therapeutic/care management, level IV.