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 (4/2018-9/2019) of injured children <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 chi-square 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 (IQR) 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 (MTP; low-38%, high-46%, p = .34). Most patients sustained blunt injuries (70%). Median injury severity score was greater in high ratio patients (low-25, high-33, p = .01); however, hospital mortality was similar (low-24%, high-20%, p = .65) as was the risk of extended ventilator, ICU, and hospital days (all p > .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. MTP activation was not associated with receipt of high ratio transfusion, suggesting variability in MTP between centers. LEVEL OF EVIDENCE: Prospective cohort study, Level II.

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.

Timing and volume of crystalloid and blood products in pediatric trauma: An Eastern Association for the Surgery of Trauma multicenter prospective observational study.

BACKGROUND: The purpose of this study was to determine the relationship between timing and volume of crystalloid before blood products and mortality, hypothesizing that earlier transfusion and decreased crystalloid before transfusion would be associated with improved outcomes. METHODS: A multi-institutional prospective observational study of pediatric trauma patients younger than 18 years, transported from the scene of injury with elevated age-adjusted shock index on arrival, was performed from April 2018 to September 2019. Volume and timing of prehospital, emergency department, and initial admission resuscitation were assessed including calculation of 20 ± 10 mL/kg crystalloid boluses overall and before transfusion. Multivariable Cox proportional hazards and logistic regression models identified factors associated with mortality and extended intensive care, ventilator, and hospital days. RESULTS: In 712 children at 24 trauma centers, mean age was 7.6 years, median (interquartile range) Injury Severity Score was 9 (2-20), and in-hospital mortality was 5.3% (n = 38). There were 311 patients(43.7%) who received at least one crystalloid bolus and 149 (20.9%) who received blood including 65 (9.6%) with massive transfusion activation. Half (53.3%) of patients who received greater than one crystalloid bolus required transfusion. Patients who received blood first (n = 41) had shorter median time to transfusion (19.8 vs. 78.0 minutes, p = 0.005) and less total fluid volume (50.4 vs. 86.6 mL/kg, p = 0.033) than those who received crystalloid first despite similar Injury Severity Score (median, 22 vs. 27, p = 0.40). On multivariable analysis, there was no association with mortality (p = 0.51); however, each crystalloid bolus after the first was incrementally associated with increased odds of extended ventilator, intensive care unit, and hospital days (all p < 0.05). Longer time to transfusion was associated with extended ventilator duration (odds ratio, 1.11; p = 0.04). CONCLUSION: Resuscitation with greater than one crystalloid bolus was associated with increased need for transfusion and worse outcomes including extended duration of mechanical ventilation and hospitalization in this prospective study. These data support a crystalloid-sparing, early transfusion approach for resuscitation of injured children. LEVEL OF EVIDENCE: Therapeutic, level IV.

Trauma Team Activation: Accuracy of Triage When Minutes Count: A Synthesis of Literature and Performance Improvement Process.

Accuracy and timeliness of trauma activations are vital to patient safety. The American College of Surgeons mandates the trauma surgeon's presence within 15 min of the patient's arrival to the emergency department (ED) 80% of the time. In 2015, at this Level II Pediatric Trauma Center, average mean activation times were approximately 16 min and activation accuracy (over- and undertriage) affected 27% of the trauma patient activations. This evidence-based quality improvement project set out to determine the most efficient method of Emergency Medical Services (EMS) intake. Communication Center (Com. Center) recordings were carefully reviewed to identify time when EMS notifies the Com. Center and actual time of trauma activation page. A timeline was formulated with assessment of time to activation and patient triage accuracy. An educational curriculum was developed as an intervention for the Com. Center staff. Education included a decision tree for trauma activations and the development of templates for our electronic health record and prompts to improve accurate activations. After additional focus groups analyzed present ED performance and the industry standard, a policy requiring only paramedic-trained staff was put in place. After implementation of the aforementioned intervention, the Com. Center performance revealed reduction in incorrect activations from 27.3% to 10.7% from 2015 to 2016. Mean activation time in January 2015 was 48.5 min before the intervention and 4.71 min postintervention in December 2016; this is a staggering reduction in activation times of 90%!

Neonatal Intestinal Anastomosis Using a 5 mm Laparoscopic Stapler.

Recently, a 5 mm laparoscopic stapler entered the market and is currently used for a wide variety of pediatric applications. The aim of this article is to be the first report of the use of this 5 mm laparoscopic stapler for open neonatal intestinal anastomosis in humans. We used JustRight (Justright Surgical) 5 mm laparoscopic stapler® in 5 patients, with a total of six anastomoses being constructed. Enteroenterostomies after bowel resection were performed in these neonates with diagnoses of closed gastroschisis with ileal atresia, multiple intestinal atresia, ileal atresia, and jejunal atresia. Side-to-side, functional end-to-end, stapled anastomoses were performed in the standard antimesenteric manner. Using 2.5 cm long staple loads, the anastomoses approximated 1.5 cm. Minimal staple line overlap was incurred. Enteral feedings were initiated, and nutritional goals met, on postoperative days 8 and 15.2, respectively (means). Postoperative recovery was uneventful, notably without anastomotic complications of leak or stenosis. No long-term follow-up was done. The 5 mm laparoscopic stapler offers an attractive alternative in open neonatal intestinal anastomosis, particularly in both ease and time of anastomosis. Its more generalized use in neonatal intestinal reconstruction awaits further scientific investigation.

Ultrasound-guided transrectal drainage of deep pelvic abscesses in children: a modified and simplified technique.

BACKGROUND: Appendicitis is a common cause of acute surgical abdomen in children and often presents after perforation. Intra-abdominal abscesses can be drained percutaneously via transabdominal, transgluteal or, in the case of deep pelvis abscess, via transrectal approach. OBJECTIVE: To describe a modification of previously described techniques for transrectal drainage procedures, which involves the use of a transvaginal probe and a modified enema tip as a guide for the one-step trocar technique. We also aimed to evaluate the safety and effectiveness of this modified technique for drainage of deep pelvic abscesses in children. MATERIALS AND METHODS: A retrospective review of medical records was performed to identify all patients who underwent transrectal abscess drainage at our pediatric institution during a 5-year period. Surgical and radiologic procedure notes and imaging studies were evaluated. The data were analyzed to determine technical and clinical success rates, and to evaluate for any procedure-related complication. RESULTS: The study population consisted of 46 patients with a mean age of 10.9 years. Of the 46 children, 20 underwent transrectal abscess drainage solely using transrectal US for guidance; 2 also underwent minimal fluoroscopy at the time of transrectal drainage. Fifteen children required placement of one or more percutaneous transabdominal drains at the same time as transrectal catheter placement, and nine required addition percutaneous drainage catheters placed at another time. All transrectal drainage procedures were technically and clinically successful. There were no procedure-related complications. CONCLUSION: The described modified technique for US-guided transrectal drainage of deep pelvic abscesses resulting from perforated appendicitis in children is safe, effective and relatively easy to perform, with the added benefit of omitting radiation exposure in children.

Diffuse infantile hemangiomatosis of the ileum presenting with multiple perforations: a case report and review of the literature.

Hemangiomas of the small intestine are rare, accounting for only 0.05% of all intestinal neoplasms (Jarvi et al. J Pediatr Gastroenterol Nutr. 2008;46:593-597). The jejunum is the most common site of involvement in the small intestine (Levy et al. Am J Roentgenol. 2001;177:1073-1081). Small bowel hemangiomas are most commonly manifested by gastrointestinal bleeding, abdominal pain, obstruction, or intussusception. There are very few reported cases in the literature of hemangiomatosis presenting with perforation, and only 1 previously reported case of perforation in the ileum. We present a rare case of a 5-week-old female with diffuse hemangiomatosis of the ileum presenting with multiple ileal perforations and peritonitis.

Bleeding Meckel's diverticulum in a 4-month-old infant: Treatment with laparoscopic diverticulectomy. A case report and review of the literature.

A bleeding Meckel's diverticulum is presented in a 4-month-old African American infant. This event is rare at this age, and our patient is only the second 4-month-old infant reported in the English literature. The infant presented with painless frank rectal bleeding, the blood being maroon-colored, and clots were found in the diaper. There was also anemia, with an hemoglobin of less than 8 gm/dl. The color of the blood suggested a bleeding site in the ileo-cecal region, a Meckel's diverticulum was suspected, which was then confirmed by an isotope scan. A typical Meckel's diverticulum was found on laparoscopic surgery, was excised, and the infant made an uneventful recovery.