Management of Pediatric Aortic Pseudoaneurysm Due to Penetrating Trauma.

Due to the increasing frequency of pediatric penetrating trauma, pediatric surgeons need to be prepared to evaluate and manage complex penetrating injuries. In this report, we discuss the endovascular management of a traumatic aortic pseudoaneurym and subsequent bullet retrieval following penetrating chest trauma in a child. The key to successful management included multidisciplinary decision making and use of an expandable covered stent generally used for management of aortic coarctation.

Management of Concurrent Pediatric Blunt Aortic and Traumatic Brain Injury.

This is the case of a pediatric blunt trauma patient who presented with a concurrent blunt traumatic aortic and severe brain injury. We describe successful simultaneous management of the aortic and brain injury with delayed endovascular repair of the aorta. This report details the importance of multidisciplinary discussion in definitive management of children with these concurrent injuries and the endovascular technical considerations in children.

Preoperative resource utilization prior to minimally invasive repair of pectus excavatum.

BACKGROUND: Preoperative testing to assess the physiologic impact of pectus excavatum is sometimes ordered to meet third-party payor preauthorization requirements. This study describes the utility of physiologic testing prior to minimally invasive repair of pectus excavatum (MIRPE). METHODS: We retrospectively reviewed patients that underwent MIRPE from 1/2012-7/2016 at two academic children's hospitals. Data collected included demographics, insurance, Haller Index (HI), pulmonary function tests (PFTs) and echocardiograms (ECHO) obtained, and preauthorization denials. RESULTS: A total of 360 patients (mean age 15.7 ± 2.0 years; mean HI 4.5 ± 1.5) underwent MIRPE (Hospital 1: 189, Hospital 2: 171). Commercial insurers covered 84% of patients. Hospital 1 obtained more frequent preoperative testing (PFTs: 73% vs 6%, p < 0.0001). Overall, 72% of PFTs were normal with abnormal studies limited to mild findings. Similarly, 85% of ECHOs were normal. Third-party payors more frequently denied preauthorization for MIRPE at Hospital 2 (11% vs. 5%, p = 0.03). CONCLUSIONS: More frequent preoperative testing may decrease initial preauthorization denials for MIRPE; however, this increased utilization of resources may not be necessary as the majority of test results are normal.

Keeping Children Safe at Home: Parent Perspectives to Firearms Safety Education Delivered by Pediatric Providers.

OBJECTIVES: The aims of this study were to assess parent acceptance of firearms education delivered by clinical providers, determine whether parents engage in firearms safety dialog with their children, and evaluate reasons for ownership and storage behaviors. METHODS: The parents of children ages 0 to 18 years completed surveys while in a pediatric inpatient setting in Texas. Demographics, acceptability, current behaviors, and storage practices were queried. Responses between firearms owners and nonowners were analyzed using the Fisher exact and χ2 tests. RESULTS: Of the 115 parents who completed surveys, 41% reported owning firearms. Most parents were likely or highly likely to follow their pediatrician's gun safety advice (67%), were accepting of safety videos in waiting rooms (59%), and accepted firearms locks distributed by clinical providers (69%). Nonowners were less likely than owners to have spoken to their children about gun safety (P = 0.004). Parents owned firearms for self-protection and recreation (50%), self-protection only (38%), or recreation only (12%). Owners stored them unloaded (75%), used safety devices (95%), and stored them in the closet of the master bedroom (54%). CONCLUSIONS: Talking about firearms safety in a healthcare setting was not a contentious issue in the majority of our sample. Parents were accepting of provider-led firearms guidance regardless of ownership status. This provides an opportunity for providers to focus on effective messaging and time-efficient delivery of firearms safety education.

An assessment of provider satisfaction with the use of a standardized visual aid for informed consent for appendectomy in children.

PURPOSE: We previously validated a visual aid for the use in the consent process for an appendectomy showing improved parental satisfaction and understanding. In this study, we evaluated provider satisfaction and perceived value of using the visual aid. METHODS: An IRB approved survey was developed assessing provider experience with use of the visual aid. This was distributed and analyzed via Research Electronic Data Capture (RedCap) Database. RESULTS: We administered 58 surveys (45% response rate). Participants included faculty (n = 2), fellows (n = 1), residents (n = 6), and physician assistants (n = 17). The visual aid was used >10 times by 50% of providers. The most common reason for not using the visual aid was not remembering it was available. Nearly half (40%) did not feel the visual aid added any time. 9/20 (45%) felt it added a small amount of time. Slightly over half of providers (52%) felt using the visual aid significantly increased family ability to give informed consent and made the consenting process easier for both providers and families. CONCLUSION: Using a visual aid in consenting families for appendectomy does not add significant time and subjectively improves the process for providers and increases provider perception of parental understanding. LEVEL OF EVIDENCE: Cost effectiveness, Level IV.

Understanding non-accidental trauma in the United States: A national trauma databank study.

BACKGROUND: The purpose of this study is to characterize the epidemiology, injury patterns, outcomes and trends of non-accidental trauma (NAT) in the United States using a large national database. METHODS: Children <15 years presenting after NAT were identified in the 2007-2014 National Trauma Databank research datasets. Clinical and outcome data were analyzed using descriptive statistics, chi-square and logistic regression. RESULTS: Of 678,503 children admitted for traumatic injuries, 3% (19,149) were victims of NAT. The majority (95%) were under 5 years and 71% under 1 year old. The majority (59%) were male. The median injury severity score (ISS) was 10 (IQR:5-19). African Americans were disproportionally affected (27% vs 17% of all traumas), and the majority had public or no insurance (85%). Incidence was highest in the midwest and lowest in the northeast regions of the country, although trends varied over time. NAT resulted in 43% of trauma deaths in children <1 year and 31% of trauma deaths in children <5. Traumatic brain injury (TBI) was the most commonly encountered diagnosis (50%). Polytrauma was common, and certain injury patterns were identified. Urgent operation was required in 6%, 43% were admitted to intensive care, and 9% died. Mortality was independently associated with TBI, thoracic injury, hollow viscus injury and older age. CONCLUSION: Non-accidental trauma is a leading cause of trauma mortality in young children. Multiple injuries are common, requiring comprehensive evaluation and early surgical involvement. The data presented in this study could serve as a guide to target injury prevention efforts. LEVEL OF EVIDENCE: III STUDY TYPE: Prognostic and Epidemiological.

Management of Pediatric Adhesive Small Bowel Obstruction: Do Timing of Surgery and Age Matter?

BACKGROUND: Adhesive small bowel obstruction (ASBO) in children is generally managed with initial observation. However, no clear guidelines exist regarding indications to operate. Our purpose was to compare outcomes of ASBO management to determine whether timing of surgery and patient age should affect management. MATERIALS AND METHODS: A retrospective review of children admitted to a tertiary care children's hospital for ASBO between 2011 and 2015 was performed. Data included demographics, imaging, operative findings, and clinical management, which were analyzed using χ2 test, Fischer's exact test, t-test, analysis of variance, or logistic regression when appropriate. RESULTS: We identified 258 admissions for 202 patients. Urgent operation was performed in 12% and the rest had nonoperative management (NOM), which was successful in 54%. Patients younger than 1 y of age were more likely to require operation (odds ratio 3.71, 95% confidence interval [CI] 1.69-8.15; P < 0.01), and patients with prior ASBO were less likely to require operation (odds ratio 0.51, 95% CI 0.31-0.84; P < 0.01). At presentation, fever was most common in patients who had urgent operation (22.3% versus failure of NOM 7.6% versus successful NOM 6.6%; P = 0.02), but there were no differences in leukocytosis or abdominal pain. Excluding urgent operations, bowel resection was more common when operation was delayed more than 48 h (32.6% versus 15.3%; P = 0.04). CONCLUSIONS: In children with adhesive small bowel obstruction, NOM can be successful, but when failure is suspected, early operation before 48 h should be considered to avoid bowel loss, especially in children younger than 1 y of age.

Management and outcomes of peripancreatic fluid collections and pseudocysts following non-operative management of pancreatic injuries in children.

BACKGROUND: Peripancreatic fluid collection and pseudocyst development is a common sequela following non-operative management (NOM) of pancreatic injuries in children. Our purpose was to review management strategies and assess outcomes. METHODS: A multicenter, retrospective review was conducted of children treated with NOM following blunt pancreatic injury at 22 pediatric trauma centers between the years 2010 and 2015. Organized fluid collections were called "acute peripancreatic fluid collection" (APFC) if identified < 4 weeks and "pseudocyst" if > 4 weeks following injury. Data analysis included descriptive statistics Wilcoxon rank-sum, Kruskal-Wallis and t tests. RESULTS: One hundred patients with blunt pancreatic injury were identified. Median age was 8.5 years (range 1-16). Forty-two percent of patients (42/100) developed organized fluid collections: APFC 64% (27/42) and pseudocysts 36% (15/42). Median time to identification was 12 days (range 7-42). Most collections (64%, 27/42) were observed and 36% (15/42) underwent drainage: 67% (10/15) percutaneous drain, 7% (1/15) needle aspiration, and 27% (4/15) endoscopic transpapillary stent. A definitive procedure (cystogastrostomy/pancreatectomy) was required in 26% (11/42). Patients with larger collections (≥ 7.1 cm) had longer time to resolution. Comparison of outcomes in patients with observation vs drainage revealed no significant differences in TPN use (79% vs 75%, p = 1.00), hospital length of stay (15 vs 25 median days, p = 0.11), time to tolerate regular diet (12 vs 11 median days, p = 0.47), or need for definitive procedure (failure rate 30% vs 20%, p = 0.75). CONCLUSIONS: Following NOM of blunt pancreatic injuries in children, organized fluid collections commonly develop. If discovered early, most can be observed successfully, and drainage does not appear to improve clinical outcomes. Larger size predicts prolonged recovery. LEVEL OF EVIDENCE: III STUDY TYPE: Case series.

Accuracy of surgeon prediction of appendicitis severity in pediatric patients.

PURPOSE: Clinical prediction of disease severity is important as one considers nonoperative management of simple appendicitis. This study assesses the accuracy of surgeons' prediction of appendicitis severity. METHODS: From February to August 2016, pediatric surgeons at a single institution were asked to predict whether patients had simple or complex appendicitis preoperatively based on clinical data, imaging, and general assessment. Receiver operating characteristic curves were generated to determine area under the curve (AUC) and optimal cutoff points of clinical findings for diagnosing simple appendicitis. Outcomes included sensitivity and specificity of variables to identify simple appendicitis. Predictions were compared to operative findings using χ2. A p-value<0.05 was considered statistically significant. RESULTS: Of 125 cases (median age 9 years [IQR 7-13], 58% male), simple appendicitis was predicted in 77 (62%) and complex appendicitis in 48 (38%). Predictions were accurate in 59 (77%) simple cases and 45 (94%) complex cases. Although surgeon prediction was more accurate than individual imaging or clinical findings and was highly sensitive (95%) for diagnosing simple appendicitis, specificity was only 71%. Lower WBC (<15.5 × 103/µL, AUC 0.61, p = 0.05), afebrile (<100.4 °F, AUC 0.86, p < 0.01), and shorter symptom duration (≤ 1.5 days, AUC 0.71, p < 0.001) were associated with simple appendicitis. Of 18 complex cases (14%) inaccurately predicted as simple, 17 (94%) lacked diffuse tenderness, 15 (83%) were well-appearing, 11 (61%) had ultrasound findings of simple appendicitis, 11 (61%) had ≤2 days of symptoms, and 8 (44%) were afebrile (<100.4 °F). CONCLUSION: While surgeon prediction of simple appendicitis is more accurate than ultrasound or clinical data alone, diagnostic accuracy is still limited. TYPE OF STUDY: Prospective survey. LEVEL OF EVIDENCE: II.

The value of failure to rescue in determining hospital quality for pediatric trauma.

BACKGROUND: In adult trauma patients, high- and low-mortality trauma hospitals have similar rates of major complications but differ based on failure to rescue (mortality following a major complication), which has become a marker of hospital quality. The aim of this study is to examine whether failure to rescue is also an appropriate hospital quality indicator in pediatric trauma. METHODS: Children younger than 15 years were identified in the 2007 to 2014 National Trauma Databank research data sets. Hospitals were classified as a high, average or low mortality based on risk-adjusted observed-to-expected in-hospital mortality ratios using the modified Trauma Mortality Probability Model. Regression modeling was used to explore the impact of hospital quality ranking on the incidence of major complications and failure to rescue. RESULTS: Of 125,057 children, 31,600 were treated at low-mortality outlier hospitals, and 7,014 at high-mortality outlier hospitals. Low-mortality hospitals had a lower rate of major complications compared with high-mortality hospitals (0.5% [low] vs. 0.8% [high]; adjusted odds ratio [OR], 0.71; 95% confidence interval [CI], 0.61-0.83; p < 0.01) and a lower failure-to-rescue rate (17.6% [low] vs. 24.1% [high]; adjusted OR, 0.53 [high; 95% CI 0.34-0.83; p < 0.01]). When patients who died within 48 hours were excluded, low-mortality hospitals had a lower complication rate (OR, 0.81; 95% CI, 0.68, 0.96; p = 0.02), but similar failure-to-rescue rate compared to high-mortality hospitals. There was no correlation between trauma verification level and hospital mortality status based on the model. CONCLUSION: For pediatric trauma patients, mortality is more strongly associated with major complication rate than with failure to rescue. Thus, failure to rescue does not appear to be the key driver of hospital quality in this population as it does in the adult trauma population. LEVEL OF EVIDENCE: Prognostic and epidemiological, level III.

High-resolution manometric guidance during laparoscopic Heller myotomy: Impact on quality of life and symptom severity for children with achalasia.

BACKGROUND: High-resolution esophageal manometry (HREM) during laparoscopic Heller myotomy (LHM) with fundoplication for achalasia allows tailoring of myotomy length and wrap tightness. The purpose of this study is to quantify long-term postoperative symptom severity and quality of life using validated questionnaires. METHODS: Children ≤18 years with achalasia who previously underwent LHM with intraoperative HREM from 2010 to 2017 were prospectively surveyed. Eckardt Symptom Score (ESS), Achalasia Severity Questionnaire (ASQ), Pediatric Quality of Life Inventory (PedsQL), and Pediatric GERD Symptom and Quality of Life (PGSQ) questionnaires were administered. Scores for historical controls were obtained from prior survey instrument validation studies as comparison. RESULTS: Of 30 eligible patients, 12 (40%) completed the surveys. Mean age at time of surgery was 13 ±â€¯3 years. Assessment was performed at least 10 months after surgery with mean time elapsed of 3.6 ±â€¯2 years. Average premyotomy lower esophageal sphincter (LES) pressure, postmyotomy LES pressure, and postfundoplication LES pressure were 30 ±â€¯10 mmHg, 14 ±â€¯6 mmHg, and 18 ±â€¯9, respectively. ESS (2.3/12), ASQ (39/100 ±â€¯16), PGSQ (symptom: 0.6/4 ±â€¯0.4, school: 0.4/4 ±â€¯0.4), and overall PedsQL (82/100 ±â€¯15) were similar to those of healthy historical controls. CONCLUSION: Children with achalasia undergoing LHM with intraoperative HREM had sustained long-term symptom improvement and quality of life scores comparable to healthy patients. STUDY AND LEVEL OF EVIDENCE: Retrospective, II.

Sternal fractures in children: An analysis of the National Trauma Data Bank.

PURPOSE: The purpose of this study was to describe the epidemiology and evaluate the clinical significance of traumatic sternal fractures. METHODS: Patients age ≤18 years with sternal fractures in the National Trauma Database research datasets from 2007-2014 were identified. Patient demographics, injuries, procedures, and outcomes were analyzed using descriptive statistics and logistic regression. RESULTS: Three thousand one hundred sixty patients with sternal fracture were identified. Ninety percent of injuries occurred in patients between 12 and 18 years old. Median injury severity score (ISS) was 17 [9,29]. Exploratory thoracotomy was performed in 1%. Thirty-nine percent were admitted to the intensive care unit (ICU). On multivariate regression, predictors of ICU stay >1 day were increasing ISS, lack of the use of protective devices, decreasing Glasgow Coma Score (GCS), tachycardia, and pulmonary contusion. Median hospital length of stay was 4 [2, 9] days. In-hospital mortality was 8%. Predictors of mortality were lower GCS, increasing ISS, decreasing oxygen saturation, hypotension, and cardiac arrest. Use of protective devices and seat belts did not affect mortality. CONCLUSION: Sternal fractures in patients increase in incidence with age, and poor outcomes are impacted by associated injuries and complications. The presence of a sternal fracture should trigger a careful diagnostic evaluation. LEVEL OF EVIDENCE: III STUDY TYPE: Treatment Study.

Defining massive transfusion in civilian pediatric trauma.

PURPOSE: The purpose of this study was to identify an optimal definition of massive transfusion (MT) in civilian pediatric trauma. METHODS: Severely injured children (age ≤18 years, injury severity score ≥25) in the Trauma Quality Improvement Program research datasets 2014-2015 that received blood products were identified. Children with traumatic brain injury and non-survivable injuries were excluded. Early mortality was defined as death within 24 h and delayed mortality as death after 24 h from hospital admission. Receiver operating curves and sensitivity and specificity analysis identified an MT threshold. Continuous variables are presented as median [IQR]. RESULTS: Of the 270 included children, the overall mortality was 27% (N = 74). There were no differences in demographics or mechanism of injury between children that lived or died. Sensitivity and specificity for early mortality was optimized at a 4-h transfusion volume of 37 ml/kg. After controlling for other significant variables, a threshold of 37 ml/kg/4 h predicted the need for a hemorrhage control procedure (OR 8.60; 95% CI 4.25-17.42; p < 0.01) and early mortality (OR 4.24; 95% CI 1.96-9.16; p < 0.01). CONCLUSION: An MTP threshold of 37 mL/kg/4 h of transfused blood products predicted the need for hemorrhage control procedures and early mortality. This threshold may provide clinicians with a timely prognostic indicator, improve research methodology, and resource utilization. TYPE OF STUDY: Diagnostic Test. LEVEL OF EVIDENCE: III.

Bowel preparation for colostomy reversal in children.

PURPOSE: Pediatric bowel preparation protocols used before colostomy reversal vary. The aim of this study is to determine institutional practices at our institution and evaluate the impact of bowel preparations on postoperative outcomes and hospital length of stay in children. METHODS: This was a retrospective review of children ≤18 years old undergoing colostomy reversal at Texas Children's Hospital (TCH) between 12/2013 and 8/2017. Preoperative bowel regimens and outcomes were collected and analyzed using descriptive statistics, Wilcoxon Rank-Sum and Fishers Exact tests. Continuous variables are presented as median [IQR]. RESULTS: Sixty-one children underwent colostomy reversal. Thirty-eight (62%) did not receive a preoperative bowel preparation. The two cohorts were similar in age, gender, and race. The most common indication for colostomy was anorectal malformation for thirty-seven (61%). Time from admission to surgery (19 h [17, 23] vs 3 [2, 3]; p < 0.01) and HLOS (6 days [5, 8] vs 5 [4, 6]; p = 0.02) were both longer in the bowel preparation cohort. Complications (3 [13%] vs 5 [22%]; p = 0.12) and 90-day readmissions (3 [13%] vs 6 [16%]; p = 0.64) were similar in both cohorts. CONCLUSION: Foregoing bowel preparation may have the potential to improve cost and reduce morbidity in children undergoing colostomy closure. LEVEL OF EVIDENCE: III. STUDY TYPE: Treatment study.

Do Ventriculoperitoneal Shunts Increase Complications After Laparoscopic Gastrostomy in Children?

BACKGROUND: In patients requiring gastrostomies, ventriculoperitoneal (VP) shunts are a frequently encountered comorbidity. The objective of this study is to evaluate the postoperative management of children with VP shunts that undergo laparoscopic gastrostomy placement and determine their incidence of complications. MATERIALS AND METHODS: Children 18 y old or younger who underwent laparoscopic gastrostomy placement at a freestanding academic children's hospital between January 2014 and October 2016 were reviewed. Data collected included demographics, management, and outcomes. Patients were compared based on their presence of a VP shunt before laparoscopic gastrostomy. Statistical analysis was performed using chi square, Fisher's exact, and Wilcoxon rank-sum tests. RESULTS: We reviewed the medical records of 270 children that underwent laparoscopic gastrostomy placement by 15 pediatric surgeons. Of these, 9% (25) had a previously placed VP shunt. In comparing patients with a VP shunt with those without a VP shunt, there was no significant difference in median age (4 versus 3 y, P = 0.92), gender (48% versus 51% males, P = 0.80), body mass index (15 versus 16, P = 0.69), preoperative diet (48% versus 47% nasogastric tube dependent, P = 0.60), or procedure time (43 versus 42 min, P = 0.37). The postoperative management of these children was similar: day of initiation of postoperative feeds (84% versus 73% on postoperative day #1, P = 0.70), method of initiation of feeds (60% versus 55% continuous, P = 0.25), and type of initial feeds (83% versus 71% Pedialyte, P = 0.24). Similarly, there was no difference in hospital length of stay, return to the emergency department, or postoperative complications within 90 d (P > 0.05). CONCLUSIONS: Children with ventriculoperitoneal shunts do not have a higher rate of immediate complications after laparoscopic gastrostomy placement and may be managed similar to other children in the postoperative period.

Defining Massive Transfusion in Civilian Pediatric Trauma With Traumatic Brain Injury.

BACKGROUND: The purpose of this study was to identify an optimal definition of massive transfusion in civilian pediatric trauma with severe traumatic brain injury (TBI) METHODS: Severely injured children (age ≤18 y) with severe TBI in the Trauma Quality Improvement Program research data sets 2015-2016 that received blood products were identified. Data were analyzed using descriptive statistics, Wilcoxon rank-sum, chi-square, and logistic regression. Continuous variables are presented as median (interquartile range). Massive transfusion thresholds were determined based on receiver operating curves and optimization of sensitivity and specificity RESULTS: Of the 460 included children, the mortality rate was 43%. There were no differences in demographics, heart rate at presentation, or injury severity score between children that lived or died. However, those who died had lower Glasgow coma scores (3 [3, 8] versus 3 [3, 3]; P < 0.01), were more likely to have had a penetrating injury (20% versus 11%; P < 0.01) and were more likely to be hypotensive for age (62% versus 34%; P < 0.01). Total blood products infused were greater in those who died (34 mL/kg/4-h [17, 65] versus 22 [12, 44]; P < 0.01). Sensitivity and specificity for delayed mortality was optimized at 40 mL/kg/4 h, and for the need for a hemorrhage control procedure at 50 mL/kg/4 h. These thresholds predicted delayed mortality (OR 2.12; 95% CI 1.28-3.50; P < 0.01) and the need for hemorrhage control procedures (5.47; 95% CI 2.82-10.61; P < 0.01) CONCLUSIONS: For children with TBI, a massive transfusion threshold of 40 mL/kg/4-h of total administered blood products may be used to identify at-risk patients, improve resource utilization, and guide future research methodology.

Repetitive Imaging following Minimally Invasive Repair of Pectus Excavatum Is Unnecessary.

INTRODUCTION: The objective of this study was to evaluate the necessity of repeat imaging after an initial chest radiograph (CXR) following minimally invasive repair of pectus excavatum (MIRPE). MATERIALS AND METHODS: A retrospective review was performed on patients who underwent MIRPE from January 2012 to July 2016 at two academic children's hospitals. Data collected included demographics, severity of pectus defect (Haller index [HI]), utilization of CXRs, outpatient follow-up, and clinical outcomes. RESULTS: A total of 360 patients (171 at Hospital 1 and 189 at Hospital 2) underwent MIRPE. Median age was 15.6 years and 84% were males. The median HI was 4.0. Median postoperative hospital length of stay was 4.2 days and median time to bar removal was 34 months. There was significant variation in postoperative imaging between the hospitals, including frequency of immediate postoperative CXR, total number of CXRs during hospitalization, and number of postoperative outpatient CXRs prior to bar removal. However, there was no significant difference in outcomes between the hospitals, including postoperative pneumothorax, postoperative chest tube placement, and complications. CONCLUSION: These data suggest that increased repetitive imaging after an initial postoperative CXR does not affect clinical outcomes and may not be necessary after MIRPE.

A High Ratio of Plasma: RBC Improves Survival in Massively Transfused Injured Children.

BACKGROUND: Massive transfusion protocols with balanced blood product ratios have been associated with improved outcomes in adult trauma. The impact on pediatric trauma is unclear. MATERIAL AND METHODS: A retrospective review of the Pediatric Trauma Quality Improvement Program data set was performed using data from January 2015 to December 2016. Trauma patient's ≤ 18 y of age, who received red blood cells (RBCs) and were massively transfused were included. Children with burns, dead on arrival, and nonsurvivable injuries were excluded. Outcome data and mortality were assessed based on low (<1:2), medium (≥1:2, <1:1), and high (≥1:1) plasma and platelet to RBC ratios. RESULTS: There were 465 children included in the study (median age, 8 [2-16] y; median injury severity score, 34 [29-34]; mortality rate, 38%). Those transfused a medium plasma:RBC ratio received the greatest blood product volume in 24 h (90 [56-164] mL/kg; P < 0.01). Those in the low plasma:RBC group underwent fewer hemorrhage control procedures [56 (34%); P < 0.01], but ratio was not significant when controlling for age and other variables. Survival was improved for those who received a high plasma:RBC ratio (P = 0.02). Platelet transfusions were skewed toward lower ratios (95%) with no difference in clinical outcomes between the groups. CONCLUSIONS: A high ratio of plasma:RBC may result in decreased mortality in severely injured children receiving a massive transfusion. Prospective, multicenter studies are needed to determine optimal resuscitation strategies for these critically ill children.

Use of standardized visual aids improves informed consent for appendectomy in children: A randomized control trial.

BACKGROUND: Obtaining informed consent for surgical procedures is often compromised by patient and family educational background, complexity of the forms, and language barriers. We developed and tested a visual aid in order to improve the informed consent process for families of children with appendicitis. METHODS: Families were randomized to receive either a standard surgical consent or a standard consent plus visual aid. Univariate and multivariate analyses were performed to assess the effectiveness of adding the visual aid to the consent procedure. RESULTS: Parents in both cohorts were similar in age, gender and education level (p > 0.05). On multivariate analysis, visual consent had the strongest influence on parent/guardian comprehension (OR 4.0; 95%CI 2.2-7.2; p < 0.01), followed by post-secondary education (OR 2.7; 95%CI 1.5-4.9; p < 0.01), and use of external resources to look up appendicitis (OR 2.0; 95%CI 1.1-3.6; p = 0.02). CONCLUSION: Visual aids improve understanding and retention of information given during the informed consent process of children with appendicitis.