Postoperative analgesia for Kasai portoenterostomy using external oblique intercostal blocks.

BACKGROUND: External Oblique Intercostal (EOI) fascial plane blockade is a relatively new regional anesthetic technique used for a variety of upper abdominal surgical procedures. Proponents of this block praise its simple sonoanatomy, extensive local anesthetic (LA) spread, and ease of catheter placement, while avoiding encroachment into the surgical field or dressing sites; nevertheless, it is underutilized in pediatric surgery. Kasai portoenterostomy is a common pediatric surgical procedure for biliary atresia typically done via an open abdominal approach with an extended subcostal incision. Postoperative analgesic management with epidural anesthetic techniques are considered but may be limited by periprocedural coagulopathy concerns. CASE PRESENTATION: We present a case of a neonate who underwent successful analgesic management of Kasai portoenterostomy with bilateral EOI block catheters. Opioid consumption and other postoperative outcomes were comparative to previously reported literature of epidural analgesia in this patient population. CONCLUSIONS: The purpose of this report is to describe the outcomes and technical approach in a neonate who received EOI blocks as an alternative to epidural anesthetic management. Further studies are needed to compare the efficacy and complication rate of EOI blockade to epidural analgesia for Kasai portoenterostomy surgery.

Reducing Disposable Surgical Items: Decreasing Environmental Impact and Costs at a Children's Hospital, a Pilot Study.

INTRODUCTION: United States landfill waste generated in the operating room (OR) is estimated to be three billion tons per year. The goal of this study was to analyze the environmental and fiscal impact of right-sizing surgical supplies at a medium-sized children's hospital using lean methodology to reduce physical waste generated in the operating room. METHODS: A multidisciplinary task force was created to reduce waste in the OR of an academic children's hospital. A single-center case study, proof-of-concept, and scalability analysis of operative waste reduction was performed. Surgical packs were identified as a target. Pack utilization was monitored during an initial pilot analysis for 12 d then followed by a focused 3-week period, capturing all unused items by participating surgical services. Items discarded in more than 85% of cases were excluded in subsequent preformed packs. RESULTS: Pilot review identified 46 items in 113 procedures for removal from surgical packs. Subsequent 3-week analysis focusing on two surgical services, and 359 procedures identified a potential $1,111.88 savings with elimination of minimally used items. Over 1 y, removal of all minimally used items from seven surgical services diverted two tons of plastic landfill waste, saved $27,503 in surgical pack acquisition-costs, and prevented the theoretical loss of $13,824 in wasted supplies. Additional purchasing analysis has resulted in another $70,000 of savings through supply chain streamlining. Application of this process nationally could prevent >6000 tons of waste in the United States per year. CONCLUSIONS: Application of a simple iterative process to reduce waste in the OR can result in substantial waste diversion and cost savings. Broad adoption of such a process to reduce OR waste could greatly reduce the environmental impact of surgical care.

Impact of institutional prophylaxis guidelines on rates of pediatric venous thromboembolism following trauma-A multicenter study from the pediatric trauma society research committee.

BACKGROUND: A paucity of data exists with regard to the incidence, management, and outcomes of venous thromboembolism (VTE) in injured children. We sought to determine the impact of institutional chemoprophylaxis guidelines on VTE rates in a pediatric trauma population. METHODS: A retrospective review of injured children (≤15 years) admitted between 2009 and 2018 at 10 pediatric trauma centers was performed. Data were gathered from institutional trauma registries and dedicated chart review. The institutions were surveyed as to whether they had chemoprophylaxis guidelines in place for high-risk pediatric trauma patients, and outcomes were compared based on the presence of guidelines using χ 2 analysis ( p < 0.05). RESULTS: There were 45,202 patients evaluated during the study period. Three institutions (28,359 patients, 63%) had established chemoprophylaxis policies during the study period ("Guidelines"); the other seven centers (16,843 patients, 37%) had no such guidelines ("Standard"). There were significantly lower rates of VTE in the Guidelines group, but these patients also had significantly fewer risk factors. Among critically injured children with similar clinical presentations, there was no difference in VTE rate. Specifically within the Guidelines group, 30 children developed VTE. The majority (17/30) were actually not indicated for chemoprophylaxis based on institutional guidelines. Still, despite protocols only one VTE patient in the guidelines group who was indicated for intervention ended up receiving chemoprophylaxis prior to diagnosis. No consistent ultrasound screening protocol was in place at any institution during the study. CONCLUSION: The presence of an institutional policy to guide chemoprophylaxis for injured children is associated with a decreased overall frequency of VTE, but this disappears when controlling for patient factors. However, the overall efficacy is impacted by a combination of deficits in guideline compliance and structure. Further prospective data are needed to help determine the ideal role for chemoprophylaxis and protocols in pediatric trauma. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.

The utility of Endoscopic Functional Luminal Imaging (EndoFLIP) in the diagnosis and management of children with achalasia.

BACKGROUND: Per-oral endoscopic myotomy (POEM) has is an alternative treatment to laparoscopic Heller myotomy for children with achalasia. The EndoFLIP functional luminal imaging system is used to measure esophagogastric junction (EGJ) distensibility pre- and post-POEM. Previous adult studies have established a correlation between obstructive symptoms and Distensibility Index (DI). Here we analyze the utility of EndoFLIP in diagnosis and management of achalasia in the largest study on pediatric POEM patients and hypothesize that DI may aid diagnosis and treatment of pediatric achalasia. METHODS: Demographics, preoperative basal and residual pressures measured on manometry, and EndoFLIP measurements pre- and post-POEM were recorded for children that underwent POEM. Pearson correlation coefficient and T-scores were used to assess for correlation between manometry measurements and pre-POEM DI. Linear regression was conducted to analyze the relationship between pre-POEM DI, Eckardt scores, and manometry pressures. RESULTS: Of 33 patients that underwent POEM and EndoFLIP since 2014 (21 male, 12 female), the median pre-POEM Eckardt score decreased from 7 to 1 post-POEM. The median basal pressure was 50 ± 25 mmHg, pre-POEM DI was 0.9 (0.8-1.6) mm2/mmHg and the post-POEM DI was 3.8 (3.2-4.4) mm2/mmHg. There was no correlation between DI and basal pressure or residual pressure, though there was a strong negative correlation between Eckardt scores and DI. CONCLUSION: The EndoFLIP system is a valuable tool in adult patients in diagnosing achalasia and defining the endpoint of the POEM procedure. We find that there is a role for EndoFLIP in the pediatric population in diagnosis and management of the disease. TYPE OF STUDY & LEVEL OF EVIDENCE: Study of diagnostic test; Level IV.

Venous thromboembolic screening in pediatric trauma: A prospective cohort study of risk-stratified ultrasonography.

BACKGROUND: This prospective observational cohort study evaluates risk-stratified venous thromboembolism (VTE) screening in injured children. While the reported incidence of VTE is 6% to 10% among critically injured children, there is no standard for screening. Venous thromboembolism may have long-term sequelae in children, including postthrombotic syndrome. METHODS: Patients admitted to a level 1 pediatric trauma center were risk stratified for VTE using a validated prediction algorithm. Children at high risk (risk scores ≥523; i.e., ≥1% risk) received screening duplex ultrasonography. Children at moderate risk (risk scores 410-522; i.e., 0.3-0.99% risk) were screened as a comparison/control. RESULTS: Three-hundred fifty-five children were consecutively risk stratified from October 2019 to May 2021. Forty-seven children received screening duplex ultrasounds: 21 from a high-risk cohort and 26 from a moderate-risk cohort. Four children were diagnosed with VTE in the high-risk cohort compared with seven in the moderate-risk cohort ( p = 0.53). Total incidence of VTE among screened children was 23.4% (11 of 47). Asymptomatic VTE accounted for 81.8% of all events (9 of 11). Fifty-four percent (6 of 11) of VTE were central venous catheter associated. Venous thromboembolism in surviving children resolved by 3 to 6 months with no symptoms of postthrombotic syndrome after 1 year. No cases of VTE were identified in unscreened children, yielding an institutional VTE incidence of 3.1% (11 of 355). DISCUSSION: Risk-stratified screening demonstrates a significant incidence of asymptomatic VTE in injured children. These results may guide reevaluation of prediction algorithms developed from symptomatic VTE risk and longitudinal study of the sequelae of asymptomatic VTE. LEVEL OF EVIDENCE: Prognostic and Epidemiological; Level III.

Protect Our Kids: a novel program bringing hemorrhage control to schools.

BACKGROUND: Following the shooting at Sandy Hook Elementary School, the Hartford Consensus produced the Stop the Bleed program to train bystanders in hemorrhage control. In our region, the police bureau delivers critical incident training to public schools, offering instruction in responding to violent or dangerous situations. Until now, widespread training in hemorrhage control has been lacking. Our group developed, implemented and evaluated a novel program integrating hemorrhage control into critical incident training for school staff in order to blunt the impact of mass casualty events on children. METHODS: The staff of 25 elementary and middle schools attended a 90-minute course incorporating Stop the Bleed into the critical incident training curriculum, delivered on-site by police officers, nurses and doctors over a three-day period. The joint program was named Protect Our Kids. At the conclusion of the course, hemorrhage control kits and educational materials were provided and a four-question survey to assess the quality of training using a ten-point Likert scale was completed by participants and trainers. RESULTS: One thousand eighteen educators underwent training. A majority were teachers (78.2%), followed by para-educators (5.8%), counselors (4.4%) and principals (2%). Widely covered by local and state media, the Protect Our Kids program was rated as excellent and effective by a majority of trainees and all trainers rated the program as excellent. CONCLUSIONS: Through collaboration between trauma centers, police and school systems, a large-scale training program for hemorrhage control and critical incident response can be effectively delivered to schools.

Applying LEAN Healthcare in Lean Settings: Launching Quality Improvement in Resource-Limited Regions.

BACKGROUND: Lean methodology is frequently utilized in high income settings to maximize capacity and operational efficiency during process improvement (PI) initiatives. To date there has been little published on the application of these techniques in low- and-middle-income countries (LMIC) despite the potential benefits in resource limited settings. We describe a pilot project developed in 2018 to promote sustainable operating theater efficiency at two hospitals in Abuja, Nigeria. This study details the first known attempt to use Lean techniques to improve surgical care systems in LMIC. METHODS: Perioperative committees were established at two Nigerian institutions to evaluate current processes, identify problems, and compile a list of priorities. A physician champion and a PI specialist in conjunction with local physician-partners held a workshop to teach practical applications of PI methodology as part of an ongoing collaboration. Pre and post-workshop surveys were administered, and theme coding was used to categorize free responses. Results were compared with a chi-square test. RESULTS: In total, 42 individuals attended the PI workshop. After the workshop, 37 respondents reported the workshop as valuable both personally and for the perioperative committee (P < 0.001), and all reported that PI methodology could benefit the institution overall. CONCLUSIONS: By identifying stakeholders, holding a workshop to teach tools of PI, and establishing a committee for ongoing improvement, it is possible to implement quality improvement techniques at LMIC hospitals, which may be of future benefit. Sustainability in this project will be facilitated by tele mentoring, and future efforts include expansion beyond the perioperative setting.

Pediatric Rapid Response Nurse Deployment to Pediatric Trauma Activations: A Process Improvement Initiative.

BACKGROUND: Prolonged emergency department length of stay in trauma patients is associated with increased hospital length of stay and inhospital mortality. This problem is compounded in pediatric patients, as injured children have less physiologic reserve and may exhibit only subtle warning signs before decompensation. OBJECTIVE: To determine the impact of deploying pediatric rapid response nurses to full trauma activations for patients transferred to the pediatric intensive care unit on emergency department length of stay. METHODS: This is a before-and-after analysis of a quality improvement initiative deploying pediatric rapid response nurses to full trauma activations. Trauma registry data collected from January 2016 to August 2020 were statistically analyzed. Demographic and outcome variables were assessed by unpaired t test and χ2 analysis. RESULTS: A total of 94 patients met inclusion criteria as full activations admitted to the intensive care unit during the study period. The preimplementation group (n = 60) was 88% (n = 53) male, with a median age of 6.9 years and a median Injury Severity Score of 21. The postimplementation group (n = 34) was 62% (n = 21) male, with a median age of 5.6 years and a median Injury Severity Score of 17. The emergency department length of stay decreased from median (interquartile range) 48.5 (36.0-84.75) min (preimplementation) to 36.5 (27.5-55.5) min (postimplementation; p = .019). CONCLUSION: Deployment of pediatric rapid response nurses to full trauma activations facilitates the assessment and transfer of pediatric trauma to the intensive care unit and decreases emergency department length of stay.

Venous thromboembolic risk stratification in pediatric trauma: A Pediatric Trauma Society Research Committee multicenter analysis.

BACKGROUND: Venous thromboembolism (VTE) in injured children is rare, but its consequences are significant. Several risk stratification algorithms for VTE in pediatric trauma exist with little consensus, and all are hindered in development by relying on registry data with known inaccuracies. We performed a multicenter review to evaluate trauma registry fidelity and confirm the effectiveness of one established algorithm across diverse centers. METHODS: Local trauma registries at 10 institutions were queried for all patients younger than 18 years admitted between 2009 and 2018. Additional chart review was performed on all "VTE" cases and random non-VTE controls to assess registry errors. Corrected data were then applied to our prediction algorithm using 10 real-time variables (Glasgow Coma Scale, age, sex, intensive care unit admission, transfusion, central line placement, lower extremity/pelvic fracture, major surgery) to calculate VTE risk scores. Contingency table classifiers and the area under a receiver operator characteristic curve were calculated. RESULTS: Registries identified 52,524 pediatric trauma patients with 99 episodes of VTE; however, chart review found that 13 cases were misclassified for a corrected total of 86 cases (0.16%). After correction, the algorithm still displayed strong performance in discriminating VTE-fated encounters (sensitivity, 69%; area under the receiver operating characteristic curve, 0.96). Furthermore, despite wide institutional variability in VTE rates (0.04-1.7%), the algorithm maintained a specificity of >91% and a negative predictive value of >99.7% across centers. Chart review also revealed that 54% (n = 45) of VTEs were directly associated with a central line, usually femoral (n = 34, p < 0.001 compared with upper extremity), and that prophylaxis rates were underreported in the registries by about 50%; still, only 19% of the VTE cases had been on prophylaxis before diagnosis. CONCLUSION: The VTE prediction algorithm performed well when applied retrospectively across 10 diverse pediatric centers using corrected registry data. These findings can advance initiatives for VTE screening/prophylaxis guidance following pediatric trauma and warrant prospective study. LEVEL OF EVIDENCE: Clinical decision rule evaluated in a single population, level III.

Nurse-Driven Universal Concussion Screening: A Quality Improvement Initiative.

BACKGROUND: The purpose of this study was to provide an evaluation of a performance improvement initiative that operationalized universal concussion screening for all pediatric trauma admissions at a Level I pediatric trauma center. Mild traumatic brain injury may be difficult to identify in injured children. We implemented a screening tool to identify the risk for concussion after traumatic injury and to improve access to cognitive evaluation and intervention in children. Prior to implementation of our screening tool, children admitted without obvious head injury or those younger than 12 years were not being screened for concussion risk. METHODS: We employed a nurse-driven screening tool, derived from the Centers for Disease Control and Prevention Acute Concussion Evaluation, on all pediatric trauma patients ages 0-17 years. The screening tool identifies symptoms of physical, cognitive, sleep, or emotional deficits and prompts a cognitive evaluation with concussion education. The tool was administered by nursing and tracked in the electronic medical record. RESULTS: Key stakeholders were interviewed to identify workflow barriers and education gaps following implementation. Enhancements to the electronic medical record and refocused nursing education improved compliance from 41% in the first 12 months to 91% at 24 months post-implementation (p < .001). The increasing number of evaluations additionally resulted in overall more cognitive evaluations as an initial step in identifying and treating previously unrecognized traumatic brain injury. CONCLUSIONS: A pediatric concussion screening tool is simple to administer, applies to all developmental ages, and improves diagnostic capture of traumatic brain injury in pediatric trauma when administered by nurses with support through the electronic medical record.

Failure of primary closure predicts prolonged length of stay in gastroschisis patients.

PURPOSE: Current literature regarding outcomes of gastroschisis closure methods do not highlight differences in patients who successfully undergo primary closure with those who fail and require silo placement. We hypothesize that failure of primary closure has significant effects on clinical outcomes such as length of stay and time to enteral feeding. METHODS: We conducted a retrospective review between 2009 and 2018 of gastroschisis patients at a tertiary pediatric referral hospital. We compared patients successfully undergoing primary closure to patients who failed an initial primary closure attempt. Bivariate and multivariate linear regression models were used to assess the association of closure method on clinical outcomes. RESULTS: Sixty-eight neonates were included for analysis, with 44 patients who underwent primary closure and 24 who failed primary closure. On multivariate regression analysis, primary closure patients had shorter estimated time to starting and to full enteral feeds and decreased LOS as compared to those who failed primary closure. Two patients (4.44%) had complications related to primary closure. CONCLUSION: Patients able to undergo primary closure for gastroschisis were more likely to have a shorter length of stay, shorter time to enteral feeds, and use much fewer medical resources. Initial primary closure is a safe method for most patients.

Significant practice variability exists in the prevention of venous thromboembolism in injured children: results from a joint survey of the Pediatric Trauma Society and the Trauma Center Association of America.

BACKGROUND/PURPOSE: The purpose of this study was to characterize current practices to prevent venous thromboembolism (VTE) in children and measure adherence to recent joint consensus guidelines from the Pediatric Trauma Society and Eastern Association for the Surgery of Trauma (PTS/EAST). METHODS: An 18-question survey was sent to the membership of PTS and the Trauma Center Association of American. Responses were compared with Chi-square test. RESULTS: One hundred twenty-nine members completed the survey. Most respondents were from academic (84.5%), Level 1 pediatric (62.0%) trauma centers. Criteria for VTE prophylaxis varied between hospitals with freestanding pediatric trauma centers significantly more likely to stratify children by risk factors than adult trauma centers (p = 0.020). While awareness of PTS/EAST guidelines (58.7% overall) was not statistically different between hospital types (44% freestanding adult, 52% freestanding pediatric, 71% combined adult pediatric, p = 0.131), self-reported adherence to these guidelines was uniformly low at 37.2% for all respondents. Lastly, in three clinical scenarios, respondents chose VTE screening and prophylaxis plans in accordance with a prospective application of PTS/EAST guidelines 55.0% correctly. CONCLUSION: Currently no consensus regarding the prevention of VTE in pediatric trauma exists. Prospective application of PTS/EAST guidelines has been limited, likely due to poor quality of evidence and a reliance on post-injury metrics. Results of this survey suggest that further investigation is needed to more clearly define the risk of VTE in children, evaluate, and prospectively validate alternative scoring systems for VTE prevention in injured children. LEVEL OF EVIDENCE: N/A-Survey.

Contemporary postoperative imaging practices among pediatric surgeons for image-guided central venous line placement: A survey of the American Pediatric Surgical Association.

BACKGROUND/PURPOSE: Rare life-threatening complications after central venous line (CVL) placement in children may encourage the routine use of postoperative imaging, despite multiple studies demonstrating the limited utility of this practice. The aim of this study was to investigate the nature of this discordance. METHODS: A 10-question survey was sent to 1,239 members of the American Pediatric Surgical Association (APSA) addressing contemporary practices regarding CVL placement and postoperative imaging. RESULTS: Five hundred eighteen (42%) surveys were completed. The majority of respondents routinely obtain a chest radiograph (CXR) after image-guided CVL placement (52%). Years in practice, operative volume, and practice type were not statistically associated with postoperative CXR usage (all p > 0.05). 'Routine' users were more likely to cite "standard of care" (p < 0.001), position verification (p < 0.001), and complication identification (p < 0.001) as indications for use than those who use CXR selectively. CONCLUSION: Routine use of postoperative CXR after image-guided CVL placement remains common among pediatric surgeons. Significant variation exists in the indication for this study, with considerable disagreement between 'selective' and 'routine' users. Consideration should be given for an APSA standardized guideline utilizing a clinically-driven approach to CVL placement and postoperative imaging to align with evidence-based practice. LEVEL OF EVIDENCE: N/A - descriptive analysis of survey results.

Pediatric trauma triage: A Pediatric Trauma Society Research Committee systematic review.

BACKGROUND: Significant variability exists in the triage of injured children with most systems using mechanism of injury and/or physiologic criteria. It is not well established if existing triage criteria predict the need for intervention or impact morbidity and mortality. This study evaluated existing evidence for pediatric trauma triage. Questions defined a priori were as follows: (1) Do prehospital trauma triage criteria reduce mortality? (2) Do prehospital trauma scoring systems predict outcomes? (3) Do trauma center activation criteria predict outcomes? (4) Do trauma center activation criteria predict need for procedural or operative interventions? (5) Do trauma bay pediatric trauma scoring systems predict outcomes? (6) What secondary triage criteria for transfer of children exist? METHODS: A structured, systematic review was conducted, and multiple databases were queried using search terms related to pediatric trauma triage. The literature search was limited to January 1990 to August 2019. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methodology was applied with the methodological index for nonrandomized studies tool used to assess the quality of included studies. Qualitative analysis was performed. RESULTS: A total of 1,752 articles were screened, and 38 were included in the qualitative analysis. Twelve articles addressed questions 1 and 2, 21 articles addressed question 3 to 5, and five articles addressed question 6. Existing literature suggest that prehospital triage criteria or scoring systems do not predict or reduce mortality, although selected physiologic parameters may. In contrast, hospital trauma activation criteria can predict the need for procedures or surgical intervention and identify patients with higher mortality; again, physiologic signs are more predictive than mechanism of injury. Currently, no standardized secondary triage/transfer protocols exist. CONCLUSION: Evidence supporting the utility of prehospital triage criteria for injured children is insufficient, while physiology-based trauma system activation criteria do appropriately stratify injured children. The absence of strong evidence supports the need for further prehospital and secondary transfer triage-related research. LEVEL OF EVIDENCE: Systematic review study, level II.

Establishing best practices for structured NSQIP review.

INTRODUCTION: We describe an institutional program (INR- Interval NSQIP Review), to augment NSQIP utility through structured, multidisciplinary review of surgical outcomes in order to create near 'real-time' adverse event (AE) monitoring and improve surgeon awareness. METHODS: INR is a monthly meeting of quality analysts, surgeons and nursing leadership initiated to validate AE with NSQIP criteria, review data in real-time, and perform in-depth case analyses. Occurrence classification concerns were referred for national NSQIP review. Monthly reports were distributed to surgeons with AE rates and case-specific details. RESULTS: Since implementation, 377/3,026 AE underwent in-depth review. Of those, 7 occurrences were referred for clarification by central NSQIP review. Overall 37 (1.2%) were not consistent with NSQIP-defined AE after INR. Time from occurrence to surgeon review decreased by 223 days (296 vs. 73 days, p = 0.006). DISCUSSION: Structured monthly institutional review of AE prior to submission can create greater transparency and confidence of NSQIP data, reduce time from occurrence to surgeon recognition, and improve stakeholder understanding of AE definitions. This approach can be tailored to institutional needs and should be evaluated for downstream improvement in patient outcomes.

Validation of a venous thromboembolism prediction algorithm for pediatric trauma: A national trauma data bank (NTDB) analysis.

PURPOSE: We sought to validate a risk model to predict venous thromboembolism (VTE) in pediatric trauma through an analysis of a contemporary cohort in the National Trauma Data Bank (NTDB). STUDY DESIGN: Prospective internal validation was performed in 10 randomly stratified samples of children (age 0-17 years) from the NTDB 2013-2016. Model discrimination was determined by calculation of the c-statistic (AUC), and calibration was evaluated through analysis of observed to expected (O:E) ratio. Recalibration was performed with application of a mixed-effects logistic regression. Model parameters were reestimated based on recalibration. RESULTS: Retrospective review identified 481,485 pediatric trauma patients with 729 (0.2%) episodes of VTE. Discriminatory ability of the model in all random cohorts was significant with AUC > 0.93 (p < 0.001). Inadequate calibration was noted in 4 of 10 cohorts and the entire dataset (p < 0.001) with an O:E ratio of 1.79. Model recalibration resulted in similar discrimination (AUC = 0.95) with improved calibration (O:E ratio = 1.33, p < 0.0001). CONCLUSION: Pediatric trauma prediction models can provide useful data for VTE risk stratification in injured children, but these models must be validated and calibrated prior to use. Recalibration of the model in question resulted in improved accuracy in a contemporary NTDB dataset. These data provide an appropriately calibrated and validated model for clinical use. LEVEL OF EVIDENCE: II - Prospective internal validation of a multivariable prediction model.

Minimizing variance in pediatric surgical care through implementation of a perioperative colon bundle: A multi-institution retrospective cohort study.

BACKGROUND: Employing an institutional initiative to minimize variance in pediatric surgical care, we implemented a set of perioperative bundled interventions for all colorectal procedures to reduce surgical site infections (SSIs). METHODS: Implementation of a standard colon bundle at two children's hospitals began in December 2014. Subjects who underwent a colorectal procedure during the study period were analyzed. Demographics, outcomes, and complications were compared with Wilcoxon Rank-Sum, Chi-square and Fisher exact tests, as appropriate. Multivariable logistic regression was performed to assess the influence of time period (independent of protocol implementation) on the rate of subsequent infection. RESULTS: One hundred and forty-five patients were identified (preprotocol=68, postprotocol= 77). Gender, diagnosis, procedure performed and wound classification were similar between groups. Superficial SSIs (21% vs. 8%, p=0.031) and readmission (16% vs. 4%, p=0.021) were significantly decreased following implementation of a colon bundle. Median hospital days, cost, reoperation, intraabdominal abscess, and anastomotic leak were unchanged before and after protocol implementation (all p > 0.05). Multivariable logistic regression found time period to be independent of SSIs (OR: 0.810, 95% CI: 0.576-1.140). CONCLUSION: Implementation of a standard pediatric perioperative colon bundle can reduce superficial SSIs. Larger prospective studies are needed to evaluate the impact of colon bundles in reducing complications, hospital stay and cost. LEVEL OF EVIDENCE: III - Retrospective cohort study.

Optimization of percutaneous biopsy for diagnosis and pretreatment risk assessment of neuroblastoma.

BACKGROUND: Image-guided percutaneous core needle biopsy (PCNB) is increasingly utilized to diagnose solid tumors. The objective of this study is to determine whether PCNB is adequate for modern biologic characterization of neuroblastoma. PROCEDURE: A multi-institutional retrospective study was performed by the Pediatric Surgical Oncology Research Collaborative on children with neuroblastoma at 12 institutions over a 3-year period. Data collected included demographics, clinical details, biopsy technique, complications, and adequacy of biopsies for cytogenetic markers utilized by the Children's Oncology Group for risk stratification. RESULTS: A total of 243 children were identified with a diagnosis of neuroblastoma: 79 (32.5%) tumor excision at diagnosis, 94 (38.7%) open incisional biopsy (IB), and 70 (28.8%) PCNB. Compared to IB, there was no significant difference in ability to accurately obtain a primary diagnosis by PCNB (95.7% vs 98.9%, P = .314) or determine MYCN copy number (92.4% vs 97.8%, P = .111). The yield for loss of heterozygosity and tumor ploidy was lower with PCNB versus IB (56.1% vs 90.9%, P < .05; and 58.0% vs. 88.5%, P < .05). Complications did not differ between groups (2.9 % vs 3.3%, P = 1.000), though the PCNB group had fewer blood transfusions and lower opioid usage. Efficacy of PCNB was improved for loss of heterozygosity when a pediatric pathologist evaluated the fresh specimen for adequacy. CONCLUSIONS: PCNB is a less invasive alternative to open biopsy for primary diagnosis and MYCN oncogene status in patients with neuroblastoma. Our data suggest that PCNB could be optimized for complete genetic analysis by standardized protocols and real-time pathology assessment of specimen quality.

Pediatric trauma venous thromboembolism prediction algorithm outperforms current anticoagulation prophylaxis guidelines: a pilot study.

PURPOSE: Venous thromboembolism (VTE) in injured children is rare, but sequelae can be morbid and life-threatening. Recent trauma society guidelines suggesting that all children over 15 years old should receive thromboprophylaxis may result in overtreatment. We sought to evaluate the efficacy of a previously published VTE prediction algorithm and compare it to current recommendations. METHODS: Two institutional trauma registries were queried for all pediatric (age < 18 years) patients admitted from 2007 to 2018. Clinical data were applied to the algorithm and the area under the receiver operating characteristic (AUROC) curve was calculated to test algorithm efficacy. RESULTS: A retrospective review identified 8271 patients with 30 episodes of VTE (0.36%). The VTE prediction algorithm classified 51 (0.6%) as high risk (> 5% risk), 322 (3.9%) as moderate risk (1-5% risk) and 7898 (95.5%) as low risk (< 1% risk). AUROC was 0.93 (95% CI 0.89-0.97). In our population, prophylaxis of the 'moderate-' and 'high-risk' cohorts would outperform the sensitivity (60% vs. 53%) and specificity (96% vs. 77%) of current guidelines while anticoagulating substantially fewer patients (373 vs. 1935, p < 0.001). CONCLUSION: A VTE prediction algorithm using clinical variables can identify injured children at risk for venous thromboembolic disease with more discrimination than current guidelines. Prospective studies are needed to investigate the validity of this model. LEVEL OF EVIDENCE: III-Clinical decision rule evaluated in a single population.

Perioperative neutropenia is not an independent risk factor for infectious complications of central venous line placement in children: A propensity score-matched analysis.

BACKGROUND: The infectious risk of central venous line (CVL) placement in children with neutropenia (absolute neutrophil count [ANC] <500/mm3) is not well defined. This study aims to investigate the early (≤30 days) and late (>30 days) infectious complications of CVLs placed in pediatric patients with and without neutropenia. METHODS: A retrospective review was conducted of all CVLs placed by pediatric surgeons at two institutions from 2010 to 2017. Multivariable logistic regression was performed to identify risk factors for line infection. Propensity score-matched cohorts of patients with and without neutropenia were compared in a 1:1 ratio. Wilcoxon rank-sum, Chi-square, Fisher's exact, and log-rank tests were also performed. RESULTS: Review identified 1,102 CVLs placed in 937 patients. Fifty-four patients were neutropenic at the time of placement. Multivariable analysis demonstrated tunneled catheters and subclavian access as associated with line infection. The propensity score-matched cohort included 94 patients, 47 from each group. Demographic and preoperative data were similar between the groups (p > 0.05). Patients with neutropenia were no more likely to develop early (4.3% vs. 2.1%, p = 1.000) or late (19.1% vs. 17.0%, p = 1.000) infectious complications than patients without neutropenia, with similar median time to infection (141 vs. 222 days, p = 0.370). CONCLUSION: A policy of selective CVL placement in neutropenic patients with standardized postoperative line maintenance is safe. Future directions include defining criteria by which neutropenic patients could be prospectively selected for safe CVL placement. LEVEL OF EVIDENCE: II - Retrospective cohort study.