Craniocervical Dissociation in Pediatric Patients: Pearls and Pitfalls of Diagnosis and Management.

AIMS: The aims of this study were to document the injury pattern in pediatric traumatic craniocervical dissociation (CCD) and identify features of survivors. METHODS: Pediatric traumatic CCDs, diagnosed between January 2004 and July 2016, were reviewed. Survivors and nonsurvivors were compared. Categorical and continuous variables were analyzed with Fisher exact and t tests, respectively. RESULTS: Twenty-seven children were identified; 10 died (37%). The median age was 60 months (ranges, 6-109 months [survivors], 2-98 months [nonsurvivors]). For survivors, the median follow-up was 13.4 months (range, 1-109 months). The median time to mortality was 1.5 days (range, 1-7 days). The injury modality was motor vehicle collision in 18 (67%), pedestrian struck in 8 (30%), and 1 shaken infant (3%). For nonsurvivors, CCD was equally diagnosed by plain radiograph and head/cervical spine computed tomography scan. For survivors, CCD was diagnosed by computed tomography in 7 (41%), magnetic resonance imaging in 10 (59%), and none by radiograph. Seven diagnosed by magnetic resonance imaging (41%) had nondiagnostic initial imaging but persistent neck pain. Magnetic resonance imaging was obtained and was diagnostic of CCD in all 7 (P < 0.01). Survivors required significantly less cardiopulmonary resuscitation (P < 0.01), had lower Injury Severity Scores (P < 0.01), higher Glasgow Coma Scale scores (P < 0.01), and shorter transport times (P < 0.01). Significantly more involved in motor vehicle collisions survived (P = 0.04). Nine (53%) had no disability at follow-up evaluation. CONCLUSIONS: In pediatric CCD, high-velocity mechanism, cardiac arrest, high Injury Severity Score, and low Glasgow Coma Scale score are associated with mortality. If CCD is correctly managed in the absence of cardiac arrest or traumatic brain or spinal cord injury, children may survive intact.

Cerebral and Renal Oxygenation in Infants Undergoing Laparoscopic Gastrostomy Tube Placement.

AIM: The aim of this study was to evaluate the effects of a carbon dioxide pneumoperitoneum on cerebral and renal oxygenation and oxygen extraction, in a cohort of infants from the neonatal intensive care unit, undergoing laparoscopic gastrostomy. METHODS: After institutional review board approval, between February 2018 and June 2019, infants 0-3 mo corrected age, undergoing laparoscopic gastrostomy tube placement, were included. Strict exclusion criteria created a homogeneous cohort. Cerebral and renal tissue oxygen saturation (rSO2) by near-infrared spectroscopy, skin surface oxygen saturation (SpO2), by pulse oximetry, and amplitude-integrated electroencephalography were measured. Monitoring was divided into preoperative, intraoperative and postoperative time periods. Cerebral and renal fractional tissue oxygen extraction was calculated using arterial (SpO2) and tissue oxygen saturation (rSO2): (SpO2-rSO2SpO2)X100. Data were averaged into one-minute epochs and significant changes from baseline during the intraoperative and postoperative periods were detected using one-way analysis of variance with repeated measures. RESULTS: This pilot study examined sixteen infants, born at a median gestational age of 34.2 wk (range: 23.0-40.6) with a median corrected age of 42.9 wk (range: 40.0-46.3) at operation. None had seizure activity or altered sleep-wake cycles. No statistically significant variations in cerebral and renal tissue oxygenation and extraction were observed. Pulse oximetry did demonstrate significant variation from baseline on analysis of variance, but post hoc analysis did not identify any one specific time point at which this difference was significant. CONCLUSIONS: During a short infant laparoscopic procedure, no significant alteration in cerebral or renal oxygenation or oxygen extraction was observed. No seizure activity or changes in infant sleep-wake cycles occurred.

Intestinal Function after Early versus Late Appendectomy in Children with Perforated Appendicitis.

The aim was to prospectively document the impact of early versus late appendectomy on intestinal function in pediatric perforated appendicitis. After Institutional Review Board approval, between September 2016 and August 2017, complete data were prospectively collected for children undergoing planned appendectomy for perforated appendicitis. One hundred children with pathologist-confirmed transmural perforations were included. The median time to operation after pain onset was three days. Operation on day 1 or 2 (early) was compared with that on day 3 or after (late) (range, 3-9 days). Emesis, nasogastric tubes, and time to tolerate diet evaluated intestinal function. Categorical and continuous variables were analyzed by chi-square and t tests. Of the 100, there were 45 in the early and 55 in the late group, with 22/55(40%) operated on day 3. Children with early appendectomy were significantly younger, 7.8 (3.5) versus 9.5 (3.8) years (P = 0.02). Pre-appendectomy, more than 80 per cent of each group had emesis (P = 0.84), but the late group had a 10-fold increase in nasogastric tube use (P = 0.02). The early group tolerated regular diet significantly faster, 2.5 (2.1) versus 4.4 (4.1) days (P = 0.01), and had a significantly shorter hospital stay, 3.5 (2.2) versus 5.6 (4.3) days (P = 0.01). When pain onset to appendectomy is less than three days, the time to return of intestinal function is significantly reduced.

Surgery Residents and Family Dynamics: Are Our Trainees Equipped to Handle Patient Care Beyond Disease?

Surgical trainees are expected to demonstrate family-centered care. However, it is unclear if residents know how to address psychosocial issues of pediatric patients and their families. Our aim was to evaluate surgical trainees' knowledge of family dynamics. Over a six-month period, trainees (n = 16) were surveyed regarding their comfort and familiarity with the psychosocial aspects of patient care and family dynamics. Residents recorded their comfort level with managing various behaviors using a Likert scale, and indicated which family issues they felt least prepared to handle. Most trainees lacked knowledge of family adjustment phases (50%), relational triangles (78%), developmental stages of families (40%), ambiguous loss (75%), ABCX model of family stress (100%), and the SPIKES model (88%). Excluding anxiety and sadness, almost half of residents felt unprepared for dealing with a variety of challenging behaviors. Finally, trainees were least comfortable with breaking bad news. A Family Dynamics curriculum could potentially increase resident management skills and improve patient care.

Cervical spine injuries in young children: pattern and outcomes in accidental versus inflicted trauma.

BACKGROUND: The aim of the study was to compare the cervical spine (c-spine) pattern of injury and outcomes in children below 3 y with a head injury from confirmed inflicted versus accidental trauma. METHODS: After Institutional Review Board approval, data were prospectively collected between July 2011 and January 2016. Inclusion criteria were age below 3 y, a loss of consciousness, and any one of the following initial head computed tomography (CT) findings (subdural hematoma, intraventricular, intraparenchymal, subarachnoid hemorrhage, or cerebral edema). A protocol of brain and neck magnetic resonance imaging and magnetic resonance angiography was instituted. Brain and neck imaging results, clinical variables, and outcomes were recorded. Data were compared by t-test for continuous and Fisher exact test for categorical variables. RESULTS: 73 children were identified, 52 (71%) with inflicted and 21 (29%) with accidental trauma. The median age was 11 mo; (range: 1-35 mo). Ten (14%) had c-spine injuries, 7/52 (13%) inflicted, and 3/21 (14%) accidental. The mechanism was shaking for all inflicted and motor vehicle accident or pedestrian struck for accidental c-spine injuries. The inflicted group were significantly younger (P = 0.03), had higher Injury Severity Scores (P = 0.02), subdural hematomas (P = 0.03), fractures (P = 0.03), retinal hemorrhages (P = 0.02), brain infarcts (P = 0.01), and required cardiopulmonary resuscitation (P = 0.01). Seven with inflicted trauma died from brain injury (9.5%), one had atlanto-occipital dissociation. Six mortalities (86%) had no c-spine injury. Six with inflicted c-spine injuries survived with neurologic impairment, whereas three with accidental survived without disability, including one atlanto-occipital dissociation. CONCLUSIONS: Compared to accidental trauma, young children with inflicted c-spine injuries have more multisystem trauma, long-term disability from brain injury, and an injury pattern consistent with shaking.

Cervical spine imaging for young children with inflicted trauma: Expanding the injury pattern.

AIM: The purpose of this study was to document the incidence and pattern of cervical spine (c-spine) injuries in children below 36months with inflicted trauma. METHODS: An IRB approved, prospective cohort study was performed between July 2011 and January 2016. Inclusion criteria were: age below 36months, loss of consciousness after inflicted trauma, and one initial head computed tomography finding: a subdural, intraventricular, intraparenchymal, subarachnoid hemorrhage, diffuse axonal injury, hypoxic injury, or cerebral edema. A protocol of brain and neck magnetic resonance imaging and angiography was obtained within 48h. Variables were compared by t-test and Fisher-exact test. RESULTS: There were 53 children (median age: five months; range: 1-35months), 38 males (71.7%), of which seven died (13.2%). C-spine injury was identified in 8 (15.1%): ligamentous injury (2), vertebral artery shear injury (1), atlantooccipital dissociation (AOD) (1), cord injury with cord epidural hematoma (2), and isolated cord epidural hematoma (2). Retinal hemorrhages (p=0.02), shaking (p=0.04), lower Glasgow coma score (GCS) (p=0.01), brain infarcts (p=0.01), and hypoxic/ischemic injury (p=0.01) were associated with c-spine injury. One with AOD died. Six had significant disability. CONCLUSION: For small children with inflicted trauma, the c-spine injury incidence is 15.1%. The injury pattern includes retinal hemorrhages, shaking, lower GCS, and brain injury. Evaluation of shaken infants should include c-spine imaging. LEVEL OF EVIDENCE: Level 2 A- This is a prospective cohort study with complete follow-up to hospital discharge or death. In all cases, inflicted trauma was confirmed. Owing to the nature of child abuse, the precise time of injury is not known. All children underwent a strict imaging protocol on arrival to hospital that was supervised on a prospective basis.

Factors associated with mortality after Nissen fundoplication in children.

PURPOSE: The purpose of this article was to identify factors associated with mortality after Nissen fundoplication in children. METHODS: After Institutional Review Board approval, children younger than 18 years, from two children's hospitals, with Nissen fundoplication performed between January 1994 and December 2010, were retrospectively reviewed. Inclusion required complete data and follow-up to October 2011. Survivors and nonsurvivors were compared, using t-tests for continuous and chi-square tests for categorical variables, to identify factors associated with mortality. Patient factors present before the first fundoplication were analyzed. Surgical factors were surgical complications, gastrostomy placement, operative technique, and redos. Logistic regression evaluated for independence of variables. RESULTS: A total of 823 children were identified, 412 were included and 63 died (15.3%). The median follow-up time for the cohort was 3.7 years (mean, 4.5 ± 3.2 years). For nonsurvivors, the median time to death after fundoplication was 6.0 months (mean, 13.2 ± 8.0 months). Significant factors after univariate analysis were surgical complications (p = 0.001), female gender (p = 0.001), neurological impairment (p = 0.010), and fundoplication performed before the age of 18 months (p = 0.035). Independent predictors were surgical complications, odds ratio (OR), 3.30 (95% confidence interval [CI], 1.31-8.29), neurological impairment, OR, 2.58 (95% CI, 1.38-4.83), fundoplication before the age of 18 months, OR, 2.46 (95% CI, 1.23-4.94), and female gender, OR, 2.25 (95% CI, 1.26-4.00). CONCLUSION: After Nissen fundoplication in children, surgical complications, neurological impairment, fundoplication performed before the age of 18 months, and female gender are associated with mortality. The median time to death for nonsurvivors was 6 months.

A multicenter study of the incidence and factors associated with redo Nissen fundoplication in children.

AIM: The objective of this study was to identify the incidence and factors associated with redo Nissen fundoplication in children. METHODS: After Institutional Review Board approval (5100277), data for children under 18 years of age from two children's hospitals with fundoplication performed between January 1994 and December 2010 were reviewed. Children with one fundoplication were compared to those with redos to identify factors associated with redo. Variables were compared using t-tests for continuous and chi-square tests for categorical variables. Logistic regression evaluated for independence. RESULTS: There were 823 patients and 54.7% were male. A redo fundoplication was required in 100 (12.2% of cohort); 82 had 1 redo, 14 had 2 redos, and 4 had 3 redos. Follow-up ranged from 0.01 to 16.9 years (median: 2.9 years). Factors associated with redo were: younger age at first fundoplication, (p=0.002), hiatal dissection (p<0.001), and male gender (p=0.008). Independent predictors of redo were: hiatal dissection at first fundoplication, OR: 8.45 (95% CI: 2.45-29.11), retching, OR: 3.59 (95% CI: 1.56-8.25) and younger age at first fundoplication, OR: 0.98 (95% CI: 0.97-0.98). CONCLUSION: The incidence of redo fundoplication in children is 12.2%. The risk of redo is significantly increased if patients are younger, have retching, and if the esophageal hiatus is dissected at the first fundoplication.