Implementing Change: Sustaining Enhanced Recovery After Surgery Protocols in Pediatric Surgery Using Iterative Assessments.

INTRODUCTION: While Enhanced Recovery After Surgery (ERAS) protocols are becoming more common in pediatric surgery, there is still little published about protocol compliance and sustainability. METHODS: This is a prospective observational study to evaluate the compliance of an ERAS protocol for pectus repair at a large academic children's hospital. Our primary outcome was overall protocol compliance at 1-y postimplementation of the ERAS protocol. Our comparison group included all pectus repairs for 2 y before protocol implementation. RESULTS: Overall protocol compliance at 12 mo was 89%. Of the 16 pectus repairs included in the ERAS protocol group, 94% (n = 15) and 94% (n = 15) received preoperative acetaminophen and gabapentin, respectively, which was significantly greater than the historical control group (P < 0.001). For the intraoperative components analyzed, only the intrathecal morphine was significantly different than historical controls (100% versus 49%, P < 0.001). Postoperatively, the time from operating room to return to normal diet was shorter for the ERAS group (0.53 d versus 1.16 d, P < 0.001). There was no significant difference in readmission rates between the two groups. CONCLUSIONS: ERAS protocol compliance varies based on phase of care. Solutions to sustain protocols depend on the institution and the patient population. However, the utilization of implementation science fundamentals was invaluable in this study to identify and address areas for improvement in protocol compliance. Other institutions may adapt these strategies to improve protocol compliance at their centers.

Needs Assessment for a Resuscitative Thoracotomy Curriculum for General Surgery Residents in the Northeast Region.

INTRODUCTION: Resuscitative thoracotomy (RT) is a high-acuity low occurrence (HALO) procedure with which general surgical resident (GSR) experience and confidence are unknown. We sought to identify and describe this educational gap by conducting a targeted needs assessment for an RT curriculum for GSRs. METHODS: An online regional needs assessment survey was conducted for an RT curriculum for GSRs. The survey was developed by a group of trauma stakeholders and revised after being piloted on a small, representative group of GSRs. We surveyed GSRs in the Northeast region regarding their experience and confidence with RT; interest in an RT curriculum; and content, format, and scope for an RT curriculum. RESULTS: The survey response rate was 43%, reflecting the viewpoints of GSRs at 8 major training centers across the Northeast. Only 13% of respondents were interested in pursuing a career in Trauma and Critical Care despite 97% of them training at a Level I Trauma Center. Twenty-nine percent and 33% of GSRs had ever assisted with or performed RT, respectively. Twenty-one percent of GSRs reported feeling confident performing RT. Most respondents (98%) agreed or strongly agreed that an RT curriculum would add value to their general surgery education. The most positively rated content topics were resuscitative maneuvers (100% positive responses [PR]), when to cease resuscitative efforts (100% PR), and morbidity and mortality associated with RT (98% PR). The most highly rated learning methods were individual RT simulation time (97% PR) and a tour of the trauma bay equipment (97% PR). CONCLUSIONS: This needs assessment demonstrates a lack of experience and confidence with RT, a strong learner interest in an RT curriculum, and a desire for experiential learning methods. Learning objectives are defined herein, and the next steps involve developing educational materials for an RT curriculum for GSRs.

Ventriculoatrial and ventriculoperitoneal shunt malfunction and infection in infants with necrotizing enterocolitis.

OBJECTIVE: Necrotizing enterocolitis (NEC) and posthemorrhagic hydrocephalus are both conditions that can affect preterm infants. The peritoneum is the preferred terminus for shunt placement, but another terminus is sometimes used due to subjective concerns about infection and complications related to NEC. The aim of this study was to examine the rates of ventriculoatrial (VA) and ventriculoperitoneal (VP) shunt infection and failure in pediatric patients with a history of NEC. METHODS: A single-center retrospective review of medical records from 2009 to 2021 was performed to identify pediatric patients with NEC who underwent shunt placement before 2 years of age. Patients were excluded if shunt placement preceded NEC diagnosis. Patient demographic characteristics, timing of shunt placement, type of shunt, shunt infections or revisions, and timing and management of NEC were extracted. The Student t-test and Fisher exact test were used to calculate significance. Kaplan-Meier curves were calculated. RESULTS: Twenty-two patients met the inclusion criteria. Most patients underwent VP shunt placement (16 [71.4%]). Patients who underwent surgical management of NEC compared with those who underwent medical management were more likely to have a VA shunt placed (p = 0.02). One VA shunt and 3 VP shunts became infected during follow-up (p = 0.7). The mean time until infection was not significantly different between VA and VP shunts (p = 0.73). Significantly more VA shunts required revision (83% vs 31%, p = 0.04), and VA shunts had a significantly shorter time until failure (3.0 ± 0.8 vs 46.3 ± 7.55 months, p = 0.03). CONCLUSIONS: VP shunts had a significantly longer time until failure than VA shunts; these shunts had similar infection rates in infants with prior NEC. When feasible, neurosurgeons and pediatric general surgeons can consider placing a VP shunt even if the patient has a history of NEC.

Views of American Pediatric Surgeons on Diversity, Equity, and Inclusion.

INTRODUCTION: Diversity, Equity, and Inclusion (DEI) are concepts common in surgery. However, these can be difficult to define, and what constitutes DEI can be vague. Closing this knowledge gap, particularly within pediatric surgery, would be helpful to understand the views and needs of current surgeons. METHODS: 1558 APSA members were sent an anonymous survey, of which 423 (27%) responded. Respondents were asked about their demographics, views on what constitutes diversity as well as questions on how DEI is handled within APSA and definitions of common DEI terms. RESULTS: Of 11 possible diversity measures, members agreed that a median of 9 (IQR 7-11) counted towards diversity. The most common being race and ethnicity (98%), gender (96%), sexual orientation (93%), religion (92%), age (91%), and disability (90%). On a 5-point Likert scale, the median response was 4 or greater on questions regarding how APSA handles issues related to DEI. However, members who identify as black were less likely to score in favor of APSA, and members identifying as women were more likely to rank higher importance of DEI initiatives. We also captured subjective responses on DEI terminology. CONCLUSION: Respondents had broad definitions of diversity. There is support for further DEI initiatives and how APSA handles DEI, however this perception differs based on identities. There is significant variability in beliefs and views regarding DEI definitions and understanding this is helpful for the organization moving forward. LEVEL OF EVIDENCE: IV. TYPE OF STUDY: Original Research.

Procalcitonin and Pediatric Traumatic Brain Injury: Differentiating Neuro-storming From Infection.

INTRODUCTION: Recurrent febrile episodes represent a diagnostic challenge in the pediatric traumatic brain injury (TBI) population as they may indicate presence of infection versus sterile neuro-storming. Procalcitonin (PCT) is a promising biomarker used in pediatric sepsis; however, data are limited regarding use in TBI. We hypothesized PCT helps discern neuro-storming from sepsis in children with TBI. MATERIALS AND METHODS: A single-institution retrospective review (2014-2021) identified pediatric patients (aged 0-18 y) with moderate-to-severe TBI and intensive care unit admission > 2 d. Patients with multiple febrile events who underwent infectious evaluation including cultures and PCT drawn within 48 h of fever were included. Demographics, vital signs, infectious biomarkers including PCT, and culture data were captured. Univariate and multivariate analyses were performed to determine variables associated with culture positive status. RESULTS: One hundred and fifty six patients were admitted to the intensive care unit with moderate-to-severe TBI during the study period. Eighty five patients (54%) experienced recurrent febrile episodes. Twenty four (28%) met inclusion criteria, undergoing 32 total infectious workups. Twenty one workups were culture-positive (66%) in a total of 18 patients. Median PCT levels were not statistically different between culture-positive and culture-negative workups (P = 0.94). In multivariate modeling, neither PCT [odds ratio 0.89 (confidence interval: 0.75-1.05)] nor temperature [odds ratio 7.34 (confidence interval: 0.95-57.16)] correlated with positive bacterial cultures. CONCLUSIONS: In this small pilot analysis, recurrent febrile episodes were common and PCT did not correlate with sepsis or neuro-storming in pediatric TBI patients. Prospective protocols are needed to better understand the utility of PCT and identify predictors of bacterial infection to improve early diagnosis of sepsis in this population.

Ultrasound assessment of abdominal adhesions in neonates: data over dogma for re-operative timing.

INTRODUCTION: Neonatal abdominal reoperation is difficult and can be complicated by abdominal adhesions. Identifying patients who could safely undergo early reoperation would save TPN and central line days, decrease associated infection and liver injury, and NICU and hospital length of stay. We sought to determine if ultrasound (US) could accurately assess the location and severity of adhesions in neonates as an objective dynamic marker capable of informing reoperation timing. METHODS: After IRB approval, we conducted a prospective observational study including neonates undergoing abdominal operations. Patients received surgeon-performed US approximately every 2 weeks until reoperation or discharge. Adhesions were assessed in five zones: right upper quadrant (RUQ), right lower quadrant (RLQ), left upper quadrant (LUQ), left lower quadrant (LLQ) and peri-incision (INC). RESULTS: Over a 6-month study period, 16 neonates were enrolled. Median gestational age was 34 weeks at birth and median weight 2.2 kg. 6 underwent reoperation within initial NICU admission. At time of operation US correctly identified the absence or presence and severity of adhesions in: RUQ (3/3); RLQ (6/6); LUQ (4/5); LLQ (6/6); and INC (5/5). CONCLUSION: US can identify location and severity of post-operative adhesions in neonates, potentially identifying patients who can safely undergo reoperation earlier than predetermined wait periods. LEVEL OF EVIDENCE: IV.

Implementation Science Fundamentals: Pediatric Surgery Enhanced Recovery After Surgery Protocol for Pectus Repair.

INTRODUCTION: Surgical repair of pectus excavatum and carinatum in children has historically been associated with severe postoperative pain and prolonged hospitalization. Enhanced Recovery After Surgery (ERAS) is a multidisciplinary, multimodal approach designed to fast-track surgical care. However, obstacles to implementation have led to very few within pediatric surgery. The aim of this study is to outline the process of development and implementation of an ERAS protocol for pectus surgical repair using fundamental principles of implementation science. METHODS: A multidisciplinary team of providers worked collaboratively to develop an ERAS protocol for surgical repair of pectus excavatum and carinatum and methods for identifying eligible patients. The surgical champion collaborated with all end users to review and revise the ERAS protocol, assessing all foreseeable barriers and facilitators prior to implementation. RESULTS: Our entire pediatric surgery team, nurses at every stage (clinic/preoperative/recovery/floor), physical therapy, and information technology contributed to the creation and implementation of an ERAS protocol with seven phases of care. The finalized version was implemented by end users focusing on four main areas: pain control, ambulation, diet, and education. Barriers and facilitators were continually addressed with an iterative process to improve the success of implementation. CONCLUSIONS: This is one of the first studies in children which details the step-by-step process of developing and implementing an ERAS protocol for pectus excavatum and carinatum. The process of development and implementation of an ERAS protocol as outlined in this manuscript can serve as a model for future ERAS protocols in pediatric surgery.

APSA Members experience bias and discrimination in training and practice.

INTRODUCTION: Bias and discrimination remain pervasive in the medical field and increase the risk of burnout, mental health disorders, and medical errors. The experiences of APSA members with bias and discrimination are unknown, therefore the APSA committee on Diversity, Equity and Inclusion conducted a survey to characterize the prevalence of bias and discrimination. METHODS: 1558 APSA members were sent an anonymous survey, of which 423 (27%) responded. Respondents were asked about their demographics, knowledge of implicit bias, and experience of bias and discrimination within their primary workplace, APSA, and APSA committees. Data were analyzed using Fisher's Exact test, Kruskal-Wallis test, and multivariable logistic regression as appropriate with significance defined as p<0.05. RESULTS: Discrimination was reported across all levels of practice, academic appointments, race, ethnicity, and gender identities. On multivariable analysis, surgical trainees (OR 3.6) as well as Asian American and Pacific Islander (OR 4.8), Black (OR 5.2), Hispanic (OR 8.2) and women (OR 8.7) surgeons were more likely to experience bias and discrimination in the workplace. Community practice surgeons were more likely to experience discrimination within APSA committees (OR 3.6). Members identifying as Asian (OR 0.4), or women (OR 0.6) were less likely to express comfort reporting instances of bias and discrimination. CONCLUSION: Workplace discrimination exists across all training levels, academic appointments, and racial and gender identities. Trainees and racial- and gender-minority surgeons report disproportionately high prevalence of bias and discrimination. Improving reporting mechanisms and implicit bias training are possible initiatives in addressing these findings.

Diversity and demographics of APSA members: Understanding our identity.

INTRODUCTION: There are existing healthcare disparities in pediatric surgery today. Identity and racial incongruity between patients and providers contribute to systemic healthcare inequities and negatively impacts health outcomes of minoritized populations. Understanding the current demographics of the American Pediatric Surgical Association and therefore the cognitive diversity represented will help inform how best to strategically build the organization to optimize disparity solutions and improve patient care. METHODS: 1558 APSA members were sent an anonymous electronic survey. Comparative data was collected from the US Census Bureau and the Association of American Medical Colleges. Results were analyzed using standard statistical tests. RESULTS: Of 423 respondents (response rate 27%), the race and ethnicity composition were 68% non Hispanic White, 12% Asian American and Pacific Islander, 6% Hispanic, 5% multiracial, and 4% Black/African American. Respondents were 35% women, 63% men, and 1% transgender, androgyne, or uncertain. Distribution of sexual identity was 97% heterosexual and 3% LGBTQIA. Religious identity was 50% Christian, 22% Agnostic/Atheist, 11% Jewish, 3% Hindu, and 2% Muslim. 32% of respondents were first-generation Americans. Twenty-four different primary languages were spoken, and 46% of respondents were conversational in a second language. These findings differ in meaningful ways from the overall American population and from the population of matriculants in American medical schools. CONCLUSION: There are substantial differences in the racial, gender, and sexual identity composition of APSA members compared with the overall population in the United States. To achieve excellence in patient care and innovate solutions to existing disparities, representation, particularly in leadership is essential. TYPE OF STUDY: Survey; original research. LEVEL OF EVIDENCE: Level IV.

Do preoperative factors predict success of antegrade continence enemas in children?

INTRODUCTION: Antegrade continent enemas (ACE) procedures are one treatment option in children with medically refractory constipation or encopresis and predicting success is difficult. We hypothesize that there are preoperative factors that can be identified to help with patient selection and family counseling. METHODS: We conducted a retrospective study of children who underwent a cecostomy or appendicostomy for an ACE program between 2015 and 2021. Underlying diagnosis, pre-operative bowel regimen and imaging were analyzed. Patients were reviewed for success at 3-, 6- and 12-months post-procedure. Data was analyzed with Fisher's Exact, Kruskal-Wallis and logistic regression where applicable with significance defined as p < 0.05. RESULTS: Forty-three children were identified; 28 were male, 15 were female, mean age at time of operation was 8 years old. 76% were considered successful at 3-months, 86% at 6-months, and 87% at 12-months post- procedure. Univariate analysis showed that a pre-ACE retrograde enema program predicted success at 3-months (94% vs. 64% p = 0.03) but no difference at 6- or 12-months. At one year after ACE procedure there was a significant reduction in number of enteral medications (2 to 0, p < 0.01) and 94% of patients were on one or fewer at one year follow-up. Age, gender, weight at time of operation, contrast enema, anorectal manometry and colonic transit time results were not predictive of outcomes. CONCLUSION: In this study, we characterized expected time to success in our population as well as identified use of a pre-operative retrograde enema program as a potential predictor of success at 3-months in children undergoing an ACE procedure. LEVEL OF EVIDENCE: IV. TYPE OF STUDY: Prognosis study.

Tunneled Central Venous Catheters in Young Children: Complication Profile Can Guide Choice of Line.

INTRODUCTION: Placement of tunneled central venous catheters (CVCs) is one of the most common procedures performed in children and can either be externally accessed or internally accessed. However, there are no data-driven guidelines on when to offer each line type, particularly in small children aged less than 5 y. Our hypothesis is that the two types of lines have different complication profiles and indications that can guide providers and families in this decision. METHODS: A single-institution retrospective chart review was performed for patients aged less than 5 y who underwent initial placement of a tunneled CVC between 2014 and 2016. Patients were included if they underwent initial tunneled CVC placement within the study period and were excluded if line was emergently placed for hemodynamic instability or was a replacement catheter. Data were compared by type of CVC, weight more than or less than 10 kg, indications for CVC, complications, and duration of catheter. RESULTS: We identified 148 patients who underwent initial tunneled CVC during study period. Seventy one patients (48%) received an externally accessed type and 77 (52%) received internally accessed type. The indications for line placement were TPN in 24 patients (16%), chemotherapy in 67 (45%), vascular access in 45 (31%), and nonchemotherapy infusions in 12 (8%). Externally accessed catheters had higher late complications (> 30 d) in patients > 10 kg compared to internally accessed catheters (63% versus 21%, P < 0.01). CONCLUSIONS: While some diagnoses determine line type, there are other indications that may qualify patients for either line. Our data demonstrate a lower long-term complication rate with internally accessed catheters and suggest they be considered over externally accessed lines in appropriate patients.

'Step Up' approach to the application of REBOA technology in a rural trauma system.

Our group has developed a 'Step Up' approach to the application of Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) in a rural trauma system. This incorporates viewing REBOA as a spectrum of technology. Examples of REBOA technology use to improve outcomes and provision of our system's clinical practice guideline for the Step-Up application of REBOA technology in the care of trauma patients are presented.

Cytomegalovirus and human immunodeficiency virus in semen of homosexual men.

OBJECTIVE: To assess the accuracy of serology to predict the presence of cytomegalovirus (CMV) in semen of homosexual men without and with HIV coinfection. DESIGN: Semen CMV was detected by electron microscopy and by polymerase chain reaction (PCR) amplification; paired serum was tested for CMV IgG/IgM. Semen HIV was detected by reverse transcription-PCR. SETTING: Licensed clinical and research laboratory. PATIENT(S): Sixty-eight men. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Frequency of CMV and HIV in semen. RESULT(S): Cytomegalovirus was detected by electron microscopy in 3 of 10 specimens examined. Forty-six (89%) of 52 HIV-infected men were seropositive for CMV by combined assay for IgG/IgM; two more (48 of 52, 92%) were seropositive for CMV IgG by separate assay; 25 (48%) of the HIV-infected men had PCR-detectable CMV DNA in at least one semen specimen, 22 of whom (42%) had CMV in all specimens. Nineteen (13%) of the 150 specimens tested positive for HIV, whereas 67 (45%) tested positive for CMV; seven specimens tested positive for both CMV and HIV. Cytomegalovirus, but not HIV, detection in semen correlated with decreased CD4(+) lymphocytes in peripheral blood (<700/µL) but was not accurately predicted by serology, leukocytospermia, or age. CONCLUSION(S): Cytomegalovirus in semen is not accurately predicted by serology. Sperm banking needs to include direct assessment of CMV in semen specimens. Strategies to eliminate CMV from semen specimens are needed to alleviate the risk of virus transmission.