RESUMEN
BACKGROUND: Utilization of same-day discharge (SDD) after appendectomy for uncomplicated appendicitis (UA) was closely examined to explore potential barriers to greater use of SDD. METHODS: Children (≤18 years) who underwent appendectomy for UA between 2015 and 2019 at a tertiary care children's hospital were reviewed. Associations with SDD were evaluated using multivariable regression models. RESULTS: Among 973 children, SDD was less frequently utilized after appendectomy performed between 12pm and 5pm (aOR 0.14, p < 0.001) and after 5pm (aOR 0.01, p < 0.001) compared to before 12pm. SDD utilization was also less frequent in those from lower resource neighborhoods (adjusted odds ratio [aOR] 0.90 per decile increase in Area Deprivation Index, p = 0.04), females (aOR 0.53, p = 0.005), and patients residing 30-60 min away (aOR 0.56, p = 0.04) compared to <30 min away. CONCLUSIONS: SDD utilization was primarily impacted by operative timing and socioeconomic and travel factors, focuses for quality improvement efforts to further increase utilization of SDD.
Asunto(s)
Apendicectomía , Alta del Paciente , Apendicitis/cirugía , Niño , Femenino , Humanos , Tiempo de Internación , MasculinoRESUMEN
BACKGROUND: Perioperative care after appendectomy may be the first exposure to opioids for many children. A quality improvement project was implemented to assess current practice of prescribing pain medications after a laparoscopic appendectomy to decrease unnecessary opioid use via simple, targeted steps. METHODS: Three measures were implemented in patients undergoing laparoscopic appendectomy for acute appendicitis: (1) ice packs to incision in postanesthesia care unit, (2) standard pain scores within 30â¯minutes of admission to ward postoperatively, and (3) standardized postoperative order set minimizing opioid utilization and limited number of opioids prescribed at discharge. Pre- and postimplementation data were compared with the primary outcome variable: opioid utilization during the postoperative period. RESULTS: There were no statistically significant differences in age or gender between the 814 preimplementation and 263 postimplementation patients. Postimplementation compliance is 66.9% for icepacks, 88% for pain scores, and 94.7% for postoperative order set. There were statistically significant decreases in intravenous and enteral opioids administered, number of opioid doses prescribed at discharge, and patients discharged with an opioid prescription. CONCLUSION: By using a multidisciplinary assessment of current state, culture, and management of parental, patient, and nursing expectations, our institution was able to reduce overall opioid consumption.
RESUMEN
BACKGROUND: Ambiguity regarding timing and duration of perioperative IV antibiotics in AA and CA exists. We wanted to determine if an association existed between surgical site infections (SSI) in children with acute (AA) or complicated appendicitis (CA) and timing and duration of perioperative antibiotics. METHODS: We performed a single institution, case control observational study of patients with (nâ¯=â¯988) and CA (nâ¯=â¯561) from 2013 to 2017. The exposure was the timing and/or duration of pre- and postoperative antibiotics. The outcome measure was SSI development within 60â¯days of surgery. RESULTS: SSI occurred in 2.5% AA and 19.1% CA patients. We identified 18-70â¯min before incision (MBI) as the best interval for preoperative antibiotic administration with regards to SSI occurrence with SSI ORâ¯=â¯3.0 (95% CI 1.35, 6.68) pâ¯=â¯0.0356 for antibiotics given 0-17 MBI and ORâ¯=â¯3.21 (95% CI 1.45, 7.09) pâ¯=â¯0.0108) for antibiotics given >70 MBI. Postoperative antibiotics did not confer protection from SSI in AA patients (pâ¯=â¯0.718). CA patients who achieved normal physiologic indices within ≤6â¯days (Early Responders, ER) had 8.8% SSI while the Late Responders (LR, normal by >6â¯days) had 49.3% SSI rate (pâ¯<â¯0.001). ER patients who received IV antibiotics for 1-2 postoperative days had higher SSI rates compared to 3, 4, 5, or 6â¯days, but higher odds of SSI were found only with 1â¯day. Additional oral antibiotics decreased SSI for ER (OR 0.36, 95% CI 0.159, 0.87; pâ¯=â¯0.0145), but not LR patients (OR 1.25, 95% CI 0.55, 2.85, pâ¯=â¯0.5951). CONCLUSIONS: Antibiotics given within 18-70 MBI for appendectomy may be associated with decreased SSI. Postoperative antibiotics should not be given for AA. In ER CA patients, additional oral antibiotics may decrease SSI. LEVEL OF EVIDENCE: Level III. TYPE OF STUDY: Retrospective comparative study.
Asunto(s)
Antibacterianos , Profilaxis Antibiótica/estadística & datos numéricos , Apendicitis/cirugía , Infección de la Herida Quirúrgica , Antibacterianos/administración & dosificación , Antibacterianos/uso terapéutico , Apendicectomía/efectos adversos , Apendicectomía/métodos , Niño , Humanos , Estudios Retrospectivos , Infección de la Herida Quirúrgica/tratamiento farmacológico , Infección de la Herida Quirúrgica/prevención & control , Tiempo de Tratamiento/estadística & datos numéricosRESUMEN
BACKGROUND/PURPOSE: Surgical management of appendicitis accounts for ~30% of total expenditure in the practice of pediatric surgery and is associated with high cost variation. We hypothesize that incorporating single-incision laparoscopy (SILS) and the resultant by-product dual-incision laparoscopy (DILS) into a historically three-incision laparoscopic (TILS) appendectomy practice affords equal outcomes at lower cost. METHODS: Appendectomies performed at a large-volume tertiary care children's hospital from 1/2015-12/2017 were retrospectively reviewed. Appendectomy technique and appendicitis severity were stratified against operative and admission direct variable (DV) costs. Secondary outcomes included perioperative time course and 30-day postoperative outcomes. RESULTS: A total of 970 appendectomies were analyzed during the study period (61% acute, 39% complex appendicitis). SILS and DILS had significantly lower mean DV costs and OR times compared to TILS for both acute and complex appendicitis while maintaining equivalent outcomes. CONCLUSIONS: SILS and DILS appendectomy techniques can be incorporated into pediatric surgical practice at lower cost than TILS appendectomy while maintaining equivalent outcomes. Further, the introduction of a tiered approach to laparoscopic appendectomy, in which all cases are started as SILS with additional incisions added based on operative difficulty, is estimated to save $74,580 annually in operative DV costs at a pediatric surgical center averaging 314 laparoscopic appendectomies per year. TYPE OF STUDY: Treatment Study. LEVEL OF EVIDENCE: Level III.
Asunto(s)
Apendicectomía/métodos , Apendicitis/cirugía , Costos Directos de Servicios/estadística & datos numéricos , Laparoscopía/métodos , Enfermedad Aguda , Adolescente , Apendicectomía/economía , Apendicitis/economía , Niño , Preescolar , Femenino , Humanos , Lactante , Laparoscopía/economía , Masculino , Tempo Operativo , Periodo Posoperatorio , Estudios Retrospectivos , Índice de Severidad de la EnfermedadRESUMEN
BACKGROUND: Information regarding the use of negative pressure wound therapy (NPWT) in the pediatric population is limited. Because of adverse outcomes in adult patients, the Food and Drug Administration issued a warning in 2011 about the use of NPWT in infants and children. METHODS: We performed an institutional review board-approved, single-institution, retrospective review of pediatric patients who had undergone NPWT from 2007-2011. We collected the types of wounds for which NPWT was initiated, the NPWT outcomes, and the complications encountered. RESULTS: The data from 290 consecutive patients were reviewed. Their average age was 9.3 y (range 12 d to 18 y), and their average weight was 46.5 kg (range 1.1-177). Of the wounds, 66% were classified as acute, 10% as chronic, and 24% as traumatic. The two most common indications were surgical wound dehiscence (n = 47) and skin grafting (n = 41). NPWT was used in 15 wounds containing surgical hardware, with 2 devices requiring eventual removal. NPWT was used for a median of 9 d per patient (two dressing changes). Complications occurred in 5 patients (1.7%). Documentation problems were noted in 44 patients. After NPWT, about one-third of the patients (n = 95 patients) were able to undergo delayed primary closure. CONCLUSIONS: NPWT is an effective adjunct in wound healing and closure in the pediatric population, with no mortality ascribed to NPWT. Also, the complication rates were low.
Asunto(s)
Terapia de Presión Negativa para Heridas/métodos , Trasplante de Piel/métodos , Dehiscencia de la Herida Operatoria/terapia , Infección de la Herida Quirúrgica/terapia , Heridas y Lesiones/terapia , Técnicas de Cierre de Herida Abdominal , Adolescente , Neoplasias Óseas/epidemiología , Neoplasias Óseas/cirugía , Niño , Preescolar , Comorbilidad , Nutrición Enteral , Femenino , Hidradenitis Supurativa/epidemiología , Hidradenitis Supurativa/cirugía , Humanos , Lactante , Recién Nacido , Masculino , Osteosarcoma/epidemiología , Osteosarcoma/cirugía , Nutrición Parenteral , Leucemia-Linfoma Linfoblástico de Células Precursoras/epidemiología , Estudios Retrospectivos , Dehiscencia de la Herida Operatoria/dietoterapia , Dehiscencia de la Herida Operatoria/epidemiología , Infección de la Herida Quirúrgica/dietoterapia , Infección de la Herida Quirúrgica/epidemiología , Cicatrización de Heridas , Heridas y Lesiones/dietoterapia , Heridas y Lesiones/epidemiologíaRESUMEN
The vacuum-assisted closure (VAC) system has become an accepted treatment modality for acute and chronic wounds in adults. The use of negative-pressure dressing has been documented in adults and, to some extent, in children. However, its use in premature infants has not been reported in the literature. The results of using the VAC system were examined in two premature infants with complex wounds. The VAC system was found to be effective in facilitating the closure of large and complex wounds in these patients. Complete epithelialization of the wounds was achieved in both patients without skin grafting. In conclusion, in two premature neonates with extraordinary soft tissue defects, the VAC system was a safe and effective choice to assist in closing these wounds.