Effect of Early vs Late Inguinal Hernia Repair on Serious Adverse Event Rates in Preterm Infants: A Randomized Clinical Trial.

Importance: Inguinal hernia repair in preterm infants is common and is associated with considerable morbidity. Whether the inguinal hernia should be repaired prior to or after discharge from the neonatal intensive care unit is controversial. Objective: To evaluate the safety of early vs late surgical repair for preterm infants with an inguinal hernia. Design, Setting, and Participants: A multicenter randomized clinical trial including preterm infants with inguinal hernia diagnosed during initial hospitalization was conducted between September 2013 and April 2021 at 39 US hospitals. Follow-up was completed on January 3, 2023. Interventions: In the early repair strategy, infants underwent inguinal hernia repair before neonatal intensive care unit discharge. In the late repair strategy, hernia repair was planned after discharge from the neonatal intensive care unit and when the infants were older than 55 weeks' postmenstrual age. Main Outcomes and Measures: The primary outcome was occurrence of any prespecified serious adverse event during the 10-month observation period (determined by a blinded adjudication committee). The secondary outcomes included the total number of days in the hospital during the 10-month observation period. Results: Among the 338 randomized infants (172 in the early repair group and 166 in the late repair group), 320 underwent operative repair (86% were male; 2% were Asian, 30% were Black, 16% were Hispanic, 59% were White, and race and ethnicity were unknown in 9% and 4%, respectively; the mean gestational age at birth was 26.6 weeks [SD, 2.8 weeks]; the mean postnatal age at enrollment was 12 weeks [SD, 5 weeks]). Among 308 infants (91%) with complete data (159 in the early repair group and 149 in the late repair group), 44 (28%) in the early repair group vs 27 (18%) in the late repair group had at least 1 serious adverse event (risk difference, -7.9% [95% credible interval, -16.9% to 0%]; 97% bayesian posterior probability of benefit with late repair). The median number of days in the hospital during the 10-month observation period was 19.0 days (IQR, 9.8 to 35.0 days) in the early repair group vs 16.0 days (IQR, 7.0 to 38.0 days) in the late repair group (82% posterior probability of benefit with late repair). In the prespecified subgroup analyses, the probability that late repair reduced the number of infants with at least 1 serious adverse event was higher in infants with a gestational age younger than 28 weeks and in those with bronchopulmonary dysplasia (99% probability of benefit in each subgroup). Conclusions and Relevance: Among preterm infants with inguinal hernia, the late repair strategy resulted in fewer infants having at least 1 serious adverse event. These findings support delaying inguinal hernia repair until after initial discharge from the neonatal intensive care unit. Trial Registration: ClinicalTrials.gov Identifier: NCT01678638.

Characteristics and predictors of intensive care unit admission in pediatric blunt abdominal trauma.

BACKGROUND: Pediatric trauma patients sustaining blunt abdominal trauma (BAT) with intra-abdominal injury (IAI) are frequently admitted to the intensive care unit (ICU). This study was performed to identify predictors for ICU admission following BAT. METHODS: Prospective study of children (< 16 years) who presented to 14 Level-One Pediatric Trauma Centers following BAT over a 1-year period. Patients were categorized as ICU or non-ICU patients. Data collected included vitals, physical exam findings, laboratory results, imaging, and traumatic injuries. A multivariable hierarchical logistic regression model was used to identify predictors of ICU admission. Predictive ability of the model was assessed via tenfold cross-validated area under the receiver operating characteristic curves (cvAUC). RESULTS: Included were 2,182 children with 21% (n = 463) admitted to the ICU. On univariate analysis, ICU patients were associated with abnormal age-adjusted shock index, increased injury severity scores (ISS), lower Glasgow coma scores (GCS), traumatic brain injury (TBI), and severe solid organ injury (SOI). With multivariable logistic regression, factors associated with ICU admission were severe trauma (ISS > 15), anemia (hematocrit < 30), severe TBI (GCS < 8), cervical spine injury, skull fracture, and severe solid organ injury. The cvAUC for the multivariable model was 0.91 (95% CI 0.88-0.92). CONCLUSION: Severe solid organ injury and traumatic brain injury, in association with multisystem trauma, appear to drive ICU admission in pediatric patients with BAT. These results may inform the design of a trauma bay prediction rule to assist in optimizing ICU resource utilization after BAT. STUDY DESIGN: Prognosis study.

Anesthetics affect peripheral venous pressure waveforms and the cross-talk with arterial pressure.

Analysis of peripheral venous pressure (PVP) waveforms is a novel method of monitoring intravascular volume. Two pediatric cohorts were studied to test the effect of anesthetic agents on the PVP waveform and cross-talk between peripheral veins and arteries: (1) dehydration setting in a pyloromyotomy using the infused anesthetic propofol and (2) hemorrhage setting during elective surgery for craniosynostosis with the inhaled anesthetic isoflurane. PVP waveforms were collected from 39 patients that received propofol and 9 that received isoflurane. A multiple analysis of variance test determined if anesthetics influence the PVP waveform. A prediction system was built using k-nearest neighbor (k-NN) to distinguish between: (1) PVP waveforms with and without propofol and (2) different minimum alveolar concentration (MAC) groups of isoflurane. 52 porcine, 5 propofol, and 7 isoflurane subjects were used to determine the cross-talk between veins and arteries at the heart and respiratory rate frequency during: (a) during and after bleeding with constant anesthesia, (b) before and after propofol, and (c) at each MAC value. PVP waveforms are influenced by anesthetics, determined by MANOVA: p value < 0.01, η2 = 0.478 for hypovolemic, and η2 = 0.388 for euvolemic conditions. The k-NN prediction models had 82% and 77% accuracy for detecting propofol and MAC, respectively. The cross-talk relationship at each stage was: (a) ρ = 0.95, (b) ρ = 0.96, and (c) could not be evaluated using this cohort. Future research should consider anesthetic agents when analyzing PVP waveforms developing future clinical monitoring technology that uses PVP.

Eliminating Use of Home Oral Antibiotics in Pediatric Complicated Appendicitis.

BACKGROUND: Postoperative oral antibiotic management at discharge for perforated appendicitis varies by institution. A prior study at our institution led to a decrease in antibiotic therapy in patients without leukocytosis. A subsequent protocol change eliminated the white blood cell count check and oral antibiotics if discharge criteria were met by postoperative day seven. We hypothesized this change could be made without an increase in abscess or readmission rates. METHODS: We conducted a retrospective review of patients with perforated appendicitis over two 1-year periods after institutional review board approval (262061). In the pre-protocol group, a white blood cell count was checked at discharge and patients with leukocytosis were prescribed oral antibiotics to complete a total of 7 d. In the post-protocol group, no white blood cell count was checked and patients were discharged home without antibiotics. RESULTS: There were a total of 174 patients with complicated appendicitis in the two 1-year periods with 129 (74%) patients with perforated appendicitis discharged before postoperative day seven. The pre-protocol group included 71 children, and post-protocol included 58 children. There were no differences between mean postoperative days to discharge (2.57 versus 3, P = 0.0896), postoperative abscess rate (12.7% versus 12.1%, P = 1.0000), or readmission rate (12.7% versus 17.2%, P = 0.6184). None of the patients in the post-protocol group were discharged home with oral antibiotics compared with 22.5% in the pre-protocol group (P < 0.001). CONCLUSIONS: For pediatric patients with perforated appendicitis discharged before postoperative day seven, stopping antibiotics at the time of discharge significantly decreased our home antibiotic use without an increase in postoperative morbidity.

Venous Physiology Predicts Dehydration in the Pediatric Population.

BACKGROUND: No standard dehydration monitor exists for children. This study attempts to determine the utility of Fast Fourier Transform (FFT) of a peripheral venous pressure (PVP) waveform to predict dehydration. MATERIALS AND METHODS: PVP waveforms were collected from 18 patients. Groups were defined as resuscitated (serum chloride ≥ 100 mmol/L) and hypovolemic (serum chloride < 100 mmol/L). Data were collected on emergency department admission and after a 20 cc/kg fluid bolus. The MATLAB (MathWorks) software analyzed nonoverlapping 10-s window signals; 2.4 Hz (144 bps) was the most demonstrative frequency to compare the PVP signal power (mmHg). RESULTS: Admission FFTs were compared between 10 (56%) resuscitated and 8 (44%) hypovolemic patients. The PVP signal power was higher in resuscitated patients (median 0.174 mmHg, IQR: 0.079-0.374 mmHg) than in hypovolemic patients (median 0.026 mmHg, IQR: 0.001-0.057 mmHg), (P < 0.001). Fourteen patients received a bolus regardless of laboratory values: 6 (43%) resuscitated and 8 (57%) hypovolemic. In resuscitated patients, the signal power did not change significantly after the fluid bolus (median 0.142 mmHg, IQR: 0.032-0.383 mmHg) (P = 0.019), whereas significantly increased signal power (median 0.0474 mmHg, IQR: 0.019-0.110 mmHg) was observed in the hypovolemic patients after a fluid bolus at 2.4 Hz (P < 0.001). The algorithm predicted dehydration for window-level analysis (sensitivity 97.95%, specificity 93.07%). The algorithm predicted dehydration for patient-level analysis (sensitivity 100%, specificity 100%). CONCLUSIONS: FFT of PVP waveforms can predict dehydration in hypertrophic pyloric stenosis. Further work is needed to determine the utility of PVP analysis to guide fluid resuscitation status in other pediatric populations.

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.

Pediatric Vascular Surgical Practice Patterns.

BACKGROUND: Vascular surgeons infrequently care for pediatric patients. As such, variability in operative management and available hospital resources at free-standing children's hospitals (CHs) may exist. The study aims were (1) to determine vascular surgeon comfort level with pediatric vascular surgery and (2) to determine variations in pediatric vascular surgery practice patterns. METHODS: A survey composed of clinical vignettes emailed to all members of Vascular and Endovascular Surgery Society was designed to assess operative management of pediatric vascular conditions and hospital resources. Comparisons of surgeon satisfaction between free-standing CHs and a CH within an adult general hospital were made using Wilcoxon rank-sum tests. Comparison of surgeon comfort between hospital types was made using a McNemar's test. P-values less than or equal to 0.05 indicated statistical significance. RESULTS: Response rate was 18% (93/525) with 96% (89/93) indicating completion of a 2 year vascular fellowship. Surgeon satisfaction with operative equipment (P = 0.002), support staff (P < 0.001), and vascular laboratory availability (P = 0.01) was significantly lower at CHs. Eighty-seven percent of surgeons operated on fewer than 2 children over the preceding 3 months. For the different clinical vignettes, there was a wide variation in practice patterns with a range of 50-89% of the surgeons performing fewer than 5 cases over the preceding 10 years. There was a significant decrease in surgeon's comfort level with elective pediatric vascular operations compared to the operative management of pediatric vascular trauma (P = 0.0025). CONCLUSIONS: Most vascular surgeons do not feel comfortable in the operative management of pediatric vascular disease, and optimal resource availability within pediatric CHs may be lacking. Centralized care of this patient population may be warranted.

Optimizing peripheral venous pressure waveforms in an awake pediatric patient by decreasing signal interference.

The purpose of this technological notes paper is to describe our institution's experience collecting peripheral venous pressure (PVP) waveforms using a standard peripheral intravenous catheter in an awake pediatric patient. PVP waveforms were collected from patients with hypertrophic pyloric stenosis. PVP measurements were obtained prospectively at two time points during the hospitalization: admission to emergency department and after bolus in emergency department. Data was collected from thirty-two patients. Interference in the PVP waveforms data collection was associated with the following: patient or device motion, system set-up error, type of IV catheter, and peripheral intravenous catheter location. PVP waveforms can be collected in an awake pediatric patient and adjuncts to decrease signal interference can be used to optimize data collection.

Optimal timing of appendectomy in the pediatric population.

BACKGROUND: No consensus has been reached on optimal timing for performing appendectomies. We compared immediate and delayed appendectomies in pediatric patients presenting with suspected acute appendicitis to determine differences in postsurgical complications and perforation rates. METHODS: A retrospective cohort study was performed of all children who underwent appendectomy during a 4-y period. Cutoffs used were 6, 8, and 12 h from admission to operating room (OR). The Student t-tests and chi-square tests were performed to compare continuous and categorical variables, respectively. A logistic regression model was fitted to determine predictors of appendiceal perforation. P values <0.05 were considered significant. RESULTS: Analysis included 484 patients with mean elapsed time from admission to OR of 394 min, with 262 subjects in the immediate and 222 subjects in the delayed >6 h groups. Surgical site infections (SSIs), perforations, and small bowel obstructions were similar between groups, and no statistically significant differences were found for SSIs in the nonperforated delayed versus immediate groups (P = 0.964). Time from admission to the OR did not predict perforation (P = 0.921), although white blood cell count at the time of admission was a significant predictor of perforation (odds ratio, 1.08; P < 0.001). CONCLUSIONS: For suspected acute appendicitis, delaying appendectomy after admission for >6 h demonstrated no differences in SSI or perforation rates compared with immediate appendectomy. Waiting to perform an appendectomy until the following day has equal outcomes to immediate surgical procedure and may improve overall quality of patient care by limiting surgeon fatigue.

Clinical outcomes of splenectomy in children: report of the splenectomy in congenital hemolytic anemia registry.

The outcomes of children with congenital hemolytic anemia (CHA) undergoing total splenectomy (TS) or partial splenectomy (PS) remain unclear. In this study, we collected data from 100 children with CHA who underwent TS or PS from 2005 to 2013 at 16 sites in the Splenectomy in Congenital Hemolytic Anemia (SICHA) consortium using a patient registry. We analyzed demographics and baseline clinical status, operative details, and outcomes at 4, 24, and 52 weeks after surgery. Results were summarized as hematologic outcomes, short-term adverse events (AEs) (≤30 days after surgery), and long-term AEs (31-365 days after surgery). For children with hereditary spherocytosis, after surgery there was an increase in hemoglobin (baseline 10.1 ± 1.8 g/dl, 52 week 12.8 ± 1.6 g/dl; mean ± SD), decrease in reticulocyte and bilirubin as well as control of symptoms. Children with sickle cell disease had control of clinical symptoms after surgery, but had no change in hematologic parameters. There was an 11% rate of short-term AEs and 11% rate of long-term AEs. As we accumulate more subjects and longer follow-up, use of a patient registry should enhance our capacity for clinical trials and engage all stakeholders in the decision-making process.

Surgeon-performed ultrasound: accurate, reproducible, and more efficient.

PURPOSE: A study previously performed at our institution demonstrated that surgeon-performed ultrasound (SPUS) was accurate compared to radiology department ultrasound (RDUS) when evaluating children with suspected appendicitis. The purpose of this study was to determine if these results were reproducible and if SPUS decreased time to definitive diagnosis. METHODS: A surgery resident performed examinations and ultrasounds on children with suspected appendicitis. Final diagnosis was confirmed by pathology. Results were compared to RDUS and combined with the previous study for a final comparison with RDUS. Mean time to diagnosis was recorded. Data were analyzed using Fisher exact and Student's t test. RESULTS: Fifty-eight patients underwent SPUS, of these 35 had RDUS. The accuracy of SPUS alone was 93% (54/58) and RDUS accuracy was 94% (33/35) (p = 1). When SPUS was combined with clinical examination accuracy increased to 95% (55/58). When results were combined with the previous study, overall accuracy of SPUS was 90% (101/112) compared to overall RDUS accuracy of 89 % (50/56). Mean time to diagnosis for RDUS was 135 min (n = 35), whereas mean time to diagnosis for SPUS was 30 min (n = 58; p = 0.0001). CONCLUSION: SPUS is accurate and reproducible in evaluating children with suspected appendicitis. SPUS potentially decreases time to definitive therapy and emergency department wait times.

Surgeon-performed bedside ultrasound to assess volume status: a feasibility study.

PURPOSE: Rapid assessment of volume status in children is often difficult. The purpose of this study was to evaluate the feasibility of surgeon-performed ultrasound to assess volume status in patients with hypertrophic pyloric stenosis. METHODS: Ultrasounds were performed on admission and before operation. The diameters of the inferior vena cava (IVC) and aorta (Ao) were measured and IVC/Ao ratios were calculated. Electrolytes were measured on admission and repeated if warranted. Logistic regression was used to associate the clinical outcome, defined as CO2 ≤30 mEq/L, with IVC/Ao ratios. Predictive capacity was estimated from the logistic regression for IVC/Ao ratios. Linear regression was used to estimate associations between CO2 values and IVC/Ao ratios. RESULTS: Thirty-one patients were enrolled. The IVC/Ao ratio is highly associated with actual CO2 values (P < 0.001) and the clinical outcome (P = 0.004). For every 0.05 unit increase in IVC/Ao ratio, predicted CO2 decreased 1.1 units. For every 0.05 unit increase in the IVC/Ao ratio, the odds of having a CO2 ≤30 mEq/L increased 48% [OR = 1.48, 95% CI (1.13,1.94)]. Predictive capacity is maximized at an IVC/Ao ratio of 0.75 as 83.9 % of subjects were correctly classified and specificity and PPV = 100%. CONCLUSIONS: Surgeon-performed ultrasound to determine IVC/Ao ratio is feasible. An IVC/Ao ratio of 0.75 predicted adequate resuscitation.

Patient Factors Associated with Access to Outpatient Pediatric General Surgical Care in a Rural State.

BACKGROUND: We sought to understand factors impacting timely access to outpatient pediatric general surgical care in a largely rural state. METHODS: We conducted a multi-site retrospective cohort study, evaluating patients <18 years referred for outpatient pediatric general surgical evaluation from 11/1/2017-7/31/2022. Outcomes included obtaining an appointment, completing an appointment, and undergoing an operation. Time to appointment and operation were calculated. Bivariate analysis and multivariable logistic regression were performed to evaluate for associations between patient factors and the primary outcomes, as well as delay to appointment. RESULTS: Of 5270 patients, mean age was 7.1 years (SD = 6) with 59% male. All patients obtained an appointment; 85% (n = 4498) completed an appointment within one year. Forty percent (n = 2092) underwent an operation. Mean times from referral to appointment and operation were 22.5 (SD = 33.4) and 81.5 days (SD = 137.5), respectively. Patients who identified as African American/Black (OR = 1.94, p < 0.001), had self-pay (OR = 6.33, p < 0.001), or lived >100 miles away (OR = 1.55, p < 0.001) were more likely to not complete appointments. Patients with high household income (OR = 0.70, p = 0.009) and private insurance (OR = 0.60, p < 0.001) were less likely to not complete appointments. Delay to appointment was associated with race (p = 0.020). Patients with private insurance (p < 0.001) and higher income (p = 0.020) were more likely to undergo operation. CONCLUSION: Fifteen percent of patients referred for outpatient pediatric general surgical evaluation did not complete an appointment within one year. Race, household resources, insurance, and travel distance were associated with completing appointments. Information about groups that have disparate access to care will inform interventions to improve this access. TYPE OF STUDY: Retrospective Cohort Study. LEVEL OF EVIDENCE: III.

Implementation of Guidelines Limiting Postoperative Opioid Prescribing at a Children's Hospital.

OBJECTIVES: Variability in opioid-prescribing practices after common pediatric surgical procedures at our institution prompted the development of opioid-prescribing guidelines that provided suggested dose limitations for narcotics. The aims of this study were to improve opioid prescription practices through implementation of the developed guidelines and to assess compliance and identify barriers preventing guideline utilization. METHODS: We conducted a single-center cohort study of all children who underwent the most common outpatient general surgery procedures at our institution from August 1, 2018, to February 1, 2020. We created guidelines designed to limit opioid prescription doses based on data obtained from standardized postoperative telephone interviews. Three 6-month periods were evaluated: before guideline implementation, after guideline initiation, and after addressing barriers to guideline compliance. Targeted interventions to increase compliance included modification of electronic medical record defaults and provider educations. Differences in opioid weight-based doses prescribed, filled, and taken, as well as protocol adherence between the 3 timeframes were evaluated. RESULTS: A total of 1033 children underwent an outpatient procedure during the 1.5-year time frame. Phone call response rate was 72.22%. There was a significant sustained decrease in opioid doses prescribed ( P < 0.0001), prescriptions filled ( P = 0.009), and opioid doses taken ( P = 0.001) after implementation, without subsequent increase in reported pain on postoperative phone call ( P = 0.96). Protocol compliance significantly improved (62.39% versus 83.98%, P < 0.0001) after obstacles were addressed. CONCLUSIONS: Implementation of a protocol limiting opioid prescribing after frequently performed pediatric general surgery procedures reduced opioids prescribed and taken postoperatively. Interventions that addressed barriers to application led to increased protocol compliance and sustained decreases in opioids prescribed and taken without a deleterious effect on pain control.

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 (April 2018 to September 2019) of injured children younger than 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 χ 2 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 (interquartile range) 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 (low-38%, high-46%, p = 0.34). Most patients sustained blunt injuries (70%). Median injury severity score was greater in high ratio patients (low-25, high-33, p = 0.01); however, hospital mortality was similar (low-24%, high-20%, p = 0.65) as was the risk of extended ventilator, intensive care unit, and hospital days (all p > 0.05). 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. Massive transfusion protocol activation was not associated with receipt of high ratio transfusion, suggesting variability in MTP between centers. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level III.

An animal model of necrotizing enterocolitis (NEC) in preterm rabbits.

Creation of an animal model of necrotizing enterocolitis (NEC) allowing adjustment of severity and potential recoverability is needed to study effectiveness of prevention and treatment strategies. This study describes a novel model in preterm rabbits capable of adjusting severity of NEC-like histologic changes. Rabbit pups (n = 151) were delivered by cesarean section 2 days preterm. In the treatment groups, tissue adhesive was applied to anal openings to simulate the poor intestinal function and dysmotility of preterm neonates. Pups were placed into five groups: 3INT (3 day intermittent block), 4INT (4 day intermittent block), 3COM (3 day complete block), 4COM (4 day complete block), based on differences in type of anal blockage and day of life sacrificed. The fifth group, 4CON, was comprised of a control arm (n = 28) without anal block, with sacrifice of subjects on day 4. All pups were gavage fed with formula contaminated with Enterobacter cloacae, ranitidine, and indomethacin. Following sacrifice, the intestines were harvested for pathologic evidence of NEC. A blinded pathologist graded histologic changes consistent with NEC using a grading scale 0-4 with 4 being most severe. Fifty-seven pups (57/123) (46%) in the research arm survived to sacrifice, compared to 26/28 (93%) in the control arm of the investigation, p < 0.0001. The incidence and severity of NEC-like damage increased with the duration and completeness of the anal blockage. 44/57 (77%) of survivors revealed various degrees of NEC-like damage to large and small bowel, and 3/26 (12%) exhibited early NEC-like mucosal injury in the research and control arms, respectively. This animal model produces NEC-like pathologic changes in both small and large intestine in preterm rabbits. Because incidence and severity of damage increases with duration and completeness of intestinal dysmotility, this allows future effectiveness studies for nonsurgical treatment and prevention of NEC.

Blue Rubber Bleb Nevus Syndrome: A Rare Case of Gastrointestinal Hemorrhage Necessitating Bowel Resection.

Blue Rubber Bleb Nevus Syndrome is a congenital rarity that manifests as vascular malformations throughout the body, including the gastrointestinal tract. With fewer than 300 cases reported, the etiology and clinical course is poorly understood; however, the literature suggests TEK mutations on chromosome 9 result in unregulated angiogenesis. We present the case of a young female treated for anemia of unknown etiology who presented in hemorrhagic shock due to gastrointestinal hemorrhage necessitating small bowel resection, with cutaneous, intestinal, hepatic, and lingual vascular malformations associated with a single somatic pathologic TEK mutation. Although uncommon, this case suggests that Blue Rubber Bleb Nevus Syndrome should be considered in the differential of a patient with persistent anemia and cutaneous lesions, carrying the potential for multiple gastrointestinal vascular malformations progressing to hemorrhage necessitating operative management. Additionally, a severe phenotype can occur without a double-hit TEK mutation.

The Sepsis Bundle Effect: An Evaluation of Culture Results and Utilization in Pediatric Appendicitis.

INTRODUCTION: Sepsis prevention pathways, which often include blood and urine cultures, are common in children's hospitals. Fever and tachycardia, signs often seen in patients with appendicitis, frequently trigger these pathways. We hypothesized that cultures were frequently obtained in children with appendicitis. MATERIALS AND METHODS: We conducted a single-center retrospective cohort study evaluating children with image-confirmed appendicitis from 4/1/2019 to 10/1/2020, coinciding with the initiation of sepsis prevention pathways. Factors associated with culture acquisition, as well as culture results, treatment, and outcomes were evaluated. RESULTS: Six hundred and fifty eight children presented with acute appendicitis during the 1.5-year period, with a median age of 10.67 years (interquartile range (IQR) 8.17-14.08). Cultures were obtained in 22.9%, including blood culture (BCx) in 8.1% and urine culture (UCx) in 17.9%. Culture acquisition decreased by 17.6% after sepsis protocol initiation. Blood culture acquisition correlated with fever (P = .003) and younger age (P = .03), whereas the attainment of BCx and UCx was associated with female sex (P = .04, P < .0001), complicated appendicitis (P = .0001, P = .03), and unknown diagnosis (P < .0001, P < .0001). There were five positive UCx (4.24%); however, all remained asymptomatic despite a short antibiotic duration dictated by institutional appendicitis protocol. The one positive BCx (1.89%) was suspected contamination and not treated. DISCUSSION: The findings of this cohort suggest a low incidence of positive culture as well as lack of impact on clinical management in image-proven appendicitis and the initiation of a sepsis bundle without automatic culture acquisition may result in decreased culture attainment.

Management of pediatric appendicitis during the COVID-19 pandemic: A nationwide multicenter cohort study.

BACKGROUND: The COVID-19 pandemic has impacted timely access to care for children, including patients with appendicitis. This study aimed to evaluate the effect of the COVID-19 pandemic on management of appendicitis and patient outcomes. METHODS: A multicenter retrospective study was performed including 19 children's hospitals from April 2019-October 2020 of children (age≤18 years) diagnosed with appendicitis. Groups were defined by each hospital's city/state stay-at-home orders (SAHO), designating patients as Pre-COVID (Pre-SAHO) or COVID (Post-SAHO). Demographic, treatment, and outcome data were obtained, and univariate and multivariable analysis was performed. RESULTS: Of 6,014 patients, 2,413 (40.1%) presented during the COVID-19 pandemic. More patients were managed non-operatively during the COVID-19 pandemic compared to before the pandemic (147 (6.1%) vs 144 (4.0%), p < 0.001). Despite this change, there was no difference in the proportion of complicated appendicitis between groups (1,247 (34.6%) vs 849 (35.2%), p = 0.12). COVID era non-operative patients received fewer additional procedures, including interventional radiology (IR) drain placements, compared to pre-COVID non-operative patients (29 (19.7%) vs 69 (47.9%), p < 0.001). On adjusted analysis, factors associated with increased odds of receiving non-operative management included: increasing duration of symptoms (OR=1.01, 95% CI: 1.01-1.012), African American race (OR=2.4, 95% CI: 1.3-4.6), and testing positive for COVID-19 (OR=10.8, 95% CI: 5.4-21.6). CONCLUSION: Non-operative management of appendicitis increased during the COVID-19 pandemic. Additionally, fewer COVID era cases required IR procedures. These changes in the management of pediatric appendicitis during the COVID pandemic demonstrates the potential for future utilization of non-operative management.

Crystalloid volume is associated with short-term morbidity in children with severe traumatic brain injury: An Eastern Association for the Surgery of Trauma multicenter trial post hoc analysis.

OBJECTIVE: This study examined differences in clinical and resuscitation characteristics between injured children with and without severe traumatic brain injury (sTBI) and aimed to identify resuscitation characteristics associated with improved outcomes following sTBI. METHODS: This is a post hoc analysis of a prospective observational study of injured children younger than 18 years (2018-2019) transported from the scene, with elevated shock index pediatric-adjusted on arrival and head Abbreviated Injury Scale score of ≥3. Timing and volume of resuscitation products were assessed using χ 2t test, Fisher's exact t test, Kruskal-Wallis, and multivariable logistic regression analyses. RESULTS: There were 142 patients with sTBI and 547 with non-sTBI injuries. Severe traumatic brain injury patients had lower initial hemoglobin (11.3 vs. 12.4, p < 0.001), greater initial international normalized ratio (1.4 vs. 1.1, p < 0.001), greater Injury Severity Score (25 vs. 5, p < 0.001), greater rates of ventilator (59% vs. 11%, p < 0.001) and intensive care unit (ICU) requirement (79% vs. 27%, p < 0.001), and more inpatient complications (18% vs. 3.3%, p < 0.001). Severe traumatic brain injury patients received more prehospital crystalloid (25% vs. 15%, p = 0.008), ≥1 crystalloid boluses (52% vs. 24%, p < 0.001), and blood transfusion (44% vs. 12%, p < 0.001) than non-sTBI patients. Among sTBI patients, receipt of ≥1 crystalloid bolus (n = 75) was associated with greater ICU need (92% vs. 64%, p < 0.001), longer median ICU (6 vs. 4 days, p = 0.027) and hospital stay (9 vs. 4 days, p < 0.001), and more in-hospital complications (31% vs. 7.5%, p = 0.003) than those who received <1 bolus (n = 67). These findings persisted after adjustment for Injury Severity Score (odds ratio, 3.4-4.4; all p < 0.010). CONCLUSION: Pediatric trauma patients with sTBI received more crystalloid than those without sTBI despite having a greater international normalized ratio at presentation and more frequently requiring blood products. Excessive crystalloid may be associated with worsened outcomes, including in-hospital mortality, seen among pediatric sTBI patients who received ≥1 crystalloid bolus. Further attention to a crystalloid sparing, early transfusion approach to resuscitation of children with sTBI is needed. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.