Minimizing variance in Care of Pediatric Blunt Solid Organ Injury through Utilization of a hemodynamic-driven protocol: a multi-institution study.

BACKGROUND: An expedited recovery protocol for management of pediatric blunt solid organ injury (spleen, liver, and kidney) was instituted across two Level 1 Trauma Centers, managed by nine pediatric surgeons within three hospital systems. METHODS: Data were collected for 18months on consecutive patients after protocol implementation. Patient demographics (including grade of injury), surgeon compliance, National Surgical Quality Improvement Program (NSQIP) complications, direct hospital cost, length of stay, time in the ICU, phlebotomy, and re-admission were compared to an 18-month control period immediately preceding study initiation. RESULTS: A total of 106 patients were treated (control=55, protocol=51). Demographics were similar among groups, and compliance was 78%. Hospital stay (4.6 vs. 3.5days, p=0.04), ICU stay (1.9 vs. 1.0days, p=0.02), and total phlebotomy (7.7 vs. 5.3 draws, p=0.007) were significantly less in the protocol group. A decrease in direct hospital costs was also observed ($11,965 vs. $8795, p=0.09). Complication rates (1.8% vs. 3.9%, p=0.86, no deaths) were similar. CONCLUSIONS: An expedited, hemodynamic-driven, pediatric solid organ injury protocol is achievable across hospital systems and surgeons. Through implementation we maintained quality while impacting length of stay, ICU utilization, phlebotomy, and cost. Future protocols should work to further limit resource utilization. TYPE OF STUDY: Retrospective cohort study. LEVEL OF EVIDENCE: Level II.

Clinical features and treatment outcome of intussusception in premature neonates.

BACKGROUND/PURPOSE: Less than 1.3% of all cases of intussusception occur in term neonates. Intussusception in premature neonates (IPN) is exceedingly rare. Its rarity and difficulty to differentiate IPN from common neonatal diseases like necrotizing enterocolitis (NEC) often delays its diagnosis. The authors set out to characterize diagnosis, treatment, and outcome of this rare condition. METHODS: The authors analyzed 2 new cases of IPN and 33 previously reported cases from the literature. RESULTS: The 35 patients with IPN had an average gestational age, postconceptual age at diagnosis, and birth weight of 28.4 +/- 0.6 weeks (all data, mean +/- SEM), 31.1 +/- 0.5 weeks, and 1,165 +/- 21 g, respectively. Gastrointestinal symptoms first presented at age 8 +/- 1 days. A preoperative diagnosis of NEC was assumed in 24 patients, delaying diagnosis by 10 +/- 2 days. Intussusception was diagnosed radiographically in 2 patients (1 contrast enema and 1 ultrasound scan) and during surgery or autopsy in the remainder. Resection was reported in 28 patients for bowel that was irreducible, necrotic, or perforated. The overall mortality rate was 20%, mainly owing to sepsis. CONCLUSIONS: Intussusception in the premature neonate often is misdiagnosed as NEC, delaying operative intervention. Contrast enema has limited diagnostic capability. Early diagnosis may be achieved with use of ultrasound scan. Intussusception can be treated successfully with resection and primary anastomosis, achieving good results.