ABSTRACT
BACKGROUND: Packed red blood cell (PRBC) transfusion is a lifesaving intervention that also has proinflammatory and immunosuppressive effects. Adults with a malignancy who receive PRBC transfusion have increased rates of infection, tumor recurrence, and decreased survival. The effect of PRBC transfusion among children with solid tumors is unknown. METHODS: We performed a retrospective review of all children who underwent operative resection of a solid tumor malignancy. Data collected included demographic information, location of operation, nadir hemoglobin, and any PRBC transfusion within 30 days of tumor resection. RESULTS: Three hundred sixty children underwent tumor resection at our institution between 2002 and 2013; 194 (54%) received a perioperative blood transfusion. After adjusting for stage at diagnosis, tumor location, preoperative chemotherapy and nadir hemoglobin, blood transfusion was associated with a higher rate of postoperative infectious complications, shorter disease-free interval, and a higher rate of tumor recurrence. Each additional transfused unit increased the risk of postoperative infection (odds ratio 3.83; 95% confidence interval 1.21, 14.22, P =0.031). CONCLUSIONS: Among children with solid tumor malignancies, PRBC transfusion within 30 days of operation is associated with higher rates of postoperative infection. If transfusion becomes necessary, single unit increments should be transfused. LEVEL OF EVIDENCE: Level III.
Subject(s)
Blood Transfusion , Neoplasm Recurrence, Local , Adult , Child , Humans , Neoplasm Recurrence, Local/epidemiology , Neoplasm Recurrence, Local/etiology , Erythrocyte Transfusion/adverse effects , Postoperative Complications/etiology , Retrospective Studies , HemoglobinsABSTRACT
BACKGROUND: Adolescents with blunt solid organ injuries (BSOI) are cared for at both pediatric trauma centers (PTC) and adult trauma centers (ATC). Over the past decade, treatment strategies have shifted towards non-operative management with reported favorable outcomes. The aim of this study was to compare management strategies and outcomes between PTC and ATC. METHODS: We queried the 2016-2018 Trauma Quality Improvement Program (TQIP) datasets to identify adolescents between the ages of 16 and 19 with BSOI. Characteristics were stratified by center type (pediatric or adult) for comparative analyses. Separate logistic regressions were used to assess the association of hospital type, location of injury, age, gender, weight, Glascow Coma Score (GCS), Injury Severity Score (ISS), and intensive care unit (ICU) admissions for outcomes of interest. RESULTS: Among the 3,011,310 patients enrolled in the 2016-2018 TQIP datasets, 106,892 (3.5%) had a BSOI ICD9/10 code. Of those, 9,193 (8.6%) were between 16 and 19 years of age and included in this analysis. Within this cohort, 6,073 (66.1%) were managed at an ATC and 3,120 (33.9%) were managed at a PTC. While statistically different, there were no clinically relevant differences for age, weight, and sex between groups. A significantly higher ISS and lower GCS score were observed among those admitted to ATC compared to PTC. ICU admissions were more frequent at ATC. Number of blood transfusions by 4 h after presentation were also higher among those admitted to an ATC. Despite a lower ISS and higher GCS at presentation, mortality was higher among those treated at a PTC with an odds ratio (95% confidence interval) of 2.42 (1.31-4.53). After excluding adolescents with a traumatic brain injury, a common cause of mortality among adolescent trauma patients, these differences in outcomes persisted. CONCLUSIONS: Our data suggest that adolescents with BSOI managed at a PTC are less likely to receive blood transfusions by 4 h of admission or be admitted to the ICU than those managed at an ATC. However, this more conservative approach may come at the expense of higher overall mortality. Further work is needed to understand these differences and determine if PTC need to be more aggressive in managing BSOI.
Subject(s)
Trauma Centers , Wounds, Nonpenetrating , Adolescent , Adult , Child , Humans , Injury Severity Score , Odds Ratio , Retrospective Studies , Young AdultABSTRACT
Extrahepatic liver (EL) rests are rare, with a reported annual incidence of 0.24-0.47. While reports often note EL incidentally found on pathologic specimens of aberrant tissue, there has been a case report of hepatocellular carcinoma arising from one of these rests, highlighting the importance of surgical resection. EL has been reported to cause symptoms such as abdominal pain, intraperitoneal bleeding and compression of adjacent organs. Most commonly, it has been identified in the gallbladder, likely due to proximity of the gallbladder to the native liver. The paucity of diagnostic tests makes the preoperative diagnosis challenging. We present a case of a 12-year-old female presenting with severe epigastric pain secondary to incapsulated EL tissue attached to the stomach via a narrow stalk. By describing this case, we hope to improve the diagnosis and management of abdominal masses with unclear etiology.
ABSTRACT
AIM OF THE STUDY: Postoperative pain management is a significant challenge in patients undergoing Nuss repair for pectus excavatum chest wall deformity. Therapeutic anesthetic options primarily include patient-controlled intravenous analgesia, thoracic epidural analgesia (TEA), and cryoanalgesia. However, TEA is limited to inpatient use and both TEA and cryoanalgesia can result in neurologic injury. The novel technique of ultrasound-guided erector spinae plane regional analgesia has been used recently in our patients undergoing the Nuss repair and has shown impressive pain relief, but without the potential complications of other modalities. Erector spinae plane block (ESPB) postoperative pain management outcomes were studied as compared to TEA. METHODS: Thirty consecutive patients with severe pectus excavatum undergoing Nuss repair and placement of ultrasound-guided ESPB were each paired to a historical cohort control patient with TEA postoperative pain management. The cohort patient match was defined by age (± 2 years), gender, and CT pectus index (± 15%). Study variables included hospital length of stay (LOS), pain scores, and pain medication usage. RESULTS: Pain scores as measured by area under the curve per hour (Day 1: 2.72 (SDâ¯=â¯1.37) vs. 3.90 (SDâ¯=â¯1.81), Pâ¯=â¯0.006; Day 2: 2.83 (SDâ¯=â¯1.32) vs. 3.97 (SDâ¯=â¯1.82), Pâ¯=â¯0.007) and oral morphine equivalent (OME) pain medication usage (Day 1: 11.9 (SDâ¯=â¯4.9) vs 56.0 (SDâ¯=â¯32.2), P < 0.001; Day 2: 14.7 (SDâ¯=â¯7.1) vs. 38.0 (SDâ¯=â¯21.7), P < 0.001) were higher for the first two postoperative days in the ESPB group. However, mean hospital LOS was nearly one day shorter for ESPB patients (3.78 (SDâ¯=â¯0.82) vs. 2.90 (SDâ¯=â¯0.87), P < 0.001) who were discharged home with the catheter in place until removal, typically at 5-7 days postoperatively. CONCLUSION: Ultrasound-guided ESPB is thus a feasible, safe, and effective alternative to TEA in postoperative pain management after Nuss repair and results in decreased hospital stay. LEVEL OF EVIDENCE: III.
Subject(s)
Analgesia, Epidural , Funnel Chest , Nerve Block , Funnel Chest/surgery , Humans , Pain, Postoperative/drug therapy , Ultrasonography, InterventionalABSTRACT
BACKGROUND: The management of childhood empyemas has transformed over the past decade, with current trends favoring chest tube placement and intrapleural fibrinolytic therapy. Although this strategy often avoids the need for video-assisted thoracoscopic surgery (VATS), hospital length of stay can be long. METHODS: To characterize national trends and outcomes associated with empyema management, the Pediatric Health Information System (PHIS) database was queried to identify children (2 months-18 years) treated for an empyema between January 2010 and December 2017. The cohort was divided into those treated with primary VATS and those treated with chest tube and intrapleural fibrinolysis. Number of chest radiographic studies obtained, frequency of pediatric intensive care unit (PICU) admission, mechanical ventilation requirements, and length of hospitalization were compared between groups. RESULTS: A total of 3,365 otherwise healthy children met inclusion criteria. Among them, 523 (16%) were managed with primary VATS and 2,842 (84%) were managed with chest tube and fibrinolytic therapy. Of those who were treated with chest tube and fibrinolysis, 193 (6.8%) subsequently underwent VATS. The percentage of children treated with chest tube and fibrinolysis increased from 65% in 2010 to 95% in 2017 (p<0.001). After adjusting for age, race, ethnicity, payer, and region, children who underwent primary VATS received fewer chest radiographic studies, were less likely to be admitted to the PICU or require mechanical ventilation and had a shorter PICU and hospital length of stay compared to those who were treated with chest tube and fibrinolytic therapy (p<0.001 for all analyses). DISCUSSION: Although national trends favor chest tube and fibrinolysis, primary VATS are associated with a shorter hospital and PICU length of stay and a lower requirement for mechanical ventilation. Future studies should aim to risk stratify children who may suffer from a protracted course with the goal to offer primary VATS to this subset of children and return them to normal life more expeditiously. LEVEL OF EVIDENCE: III.
Subject(s)
Chest Tubes , Empyema, Pleural , Fibrinolytic Agents/therapeutic use , Child , Drainage , Empyema, Pleural/drug therapy , Empyema, Pleural/surgery , Humans , Length of Stay , Retrospective Studies , Thoracic Surgery, Video-Assisted , ThoracotomyABSTRACT
BACKGROUND: Juvenile myasthenia gravis (JMG) is an antibody mediated autoimmune disorder that manifests as progressive voluntary muscle weakness and fatigue. In medically refractory cases, thymectomy has been shown to abrogate symptoms and reduce glucocorticoid dependence. While transcervical or transsternal incisions have been the traditional approach, adult trends now favor thoracoscopic thymectomy. Little data exist to support this approach in children. METHODS: A retrospective review of all patients younger than 20â¯years of age who underwent a thymectomy for JMG at two pediatric institutions between 2001 and 2018 was performed. Children were divided into either an open (transcervical or transsternal) or thoracoscopic group and baseline characteristics, perioperative, and postoperative outcomes were compared. RESULTS: Thirty-four thymectomies were performed during the 18-year study period; 18 via an open and 16 via a thoracoscopic approach. The operative time was shorter for open procedures compared thoracoscopic ones (108⯱â¯49 and 145⯱â¯43â¯min, respectively, pâ¯=â¯0.025). Thoracoscopic thymectomy was associated with less intraoperative blood loss (5.5⯱â¯6.0 vs 55⯱â¯67â¯ml, pâ¯=â¯0.007), decreased duration of postoperative intravenous narcotic use (5.0⯱â¯1.5 vs 20⯱â¯23â¯h, pâ¯=â¯0.018), and a shorter length of hospitalization (1.7⯱â¯1.0 vs 2.7⯱â¯1.1â¯days, pâ¯=â¯0.009). No perioperative complication occurred in either group. Clinical improvement was reported in 94% of children in both groups. CONCLUSIONS: Thoracoscopic thymectomy in children is a safe and effective surgical technique for the treatment of JMG. Increased acceptance of this minimally invasive approach by children, families, and referring neurologists may enable earlier surgical intervention. TYPE OF STUDY: Clinical research paper. LEVEL OF EVIDENCE: III.
Subject(s)
Myasthenia Gravis/surgery , Thoracoscopy , Thymectomy , Adolescent , Blood Loss, Surgical/statistics & numerical data , Child , Humans , Length of Stay/statistics & numerical data , Retrospective Studies , Thoracoscopy/adverse effects , Thoracoscopy/methods , Thymectomy/adverse effects , Thymectomy/methods , Young AdultABSTRACT
BACKGROUND: Nonoperative management protocols of blunt liver and spleen injury in children usually call for serial monitoring of the child's hemoglobin and hematocrit (H/H) at scheduled intervals. We previously demonstrated that the need for emergent intervention is triggered by changes in vital signs, not the findings of scheduled blood draws and changed our protocol accordingly. The current aim is to evaluate the safety of this change. METHODS: We performed a retrospective review of all children admitted following blunt liver or spleen injury during two periods; the historic cohort 1/09-12/13 and the protocol cohort 8/15-7/17. Data evaluated included the need for intervention, number of H/H checks, and outcomes. RESULTS: 330 children were included (216 historic; 114 protocol). Groups did not differ in percentage of male patients, injury severity score, or GCS. Median age in the historic cohort was younger than the protocol cohort (9 vs 12â¯years; pâ¯=â¯0.02). More children in the protocol group had a grade 5 injury (1% vs 9%; pâ¯<â¯0.0001). Groups did not differ in the number who required intervention or discharge disposition (including mortality). The protocol group had fewer H/H checks (median 5 vs 4, pâ¯<â¯0.0001); the two groups did not differ in their nadir H/H. The historic group had a longer median hospital length of stay (3â¯days vs 2, pâ¯=â¯0.0007). CONCLUSIONS: Decreasing the number of scheduled blood draws following a blunt liver or spleen injury in children is safe. Additional benefits include a decrease in the number of blood draws and a decrease in length of hospital stay. STUDY TYPE: Cost-effectiveness. LEVEL OF EVIDENCE: Level III.
Subject(s)
Liver/injuries , Phlebotomy/statistics & numerical data , Spleen/injuries , Wounds, Nonpenetrating/surgery , Adolescent , Child , Female , Humans , Injury Severity Score , Length of Stay/statistics & numerical data , Male , Retrospective StudiesABSTRACT
BACKGROUND: Despite advancements in medical therapy for ulcerative colitis (UC), a significant proportion of children progress to colectomy with ileal pouch-anal anastomosis (IPAA). Procedural related complications between two- and three-stage operations in children have not been well described. METHODS: We performed a retrospective review of patients who underwent a colectomy for UC or inflammatory bowel disease unclassified between 2008 and 2018. RESULTS: Forty-nine children underwent an IPAA at the time of colectomy (two stage) or during a subsequent operation (three stage). Preoperative hemoglobin and albumin concentrations were lower among those undergoing three-stage procedures. The rate of early complications (≤30 days) was similar between the two groups (p = 0.46); however, late complications (>30 days) were more commonly associated with three-stage procedures (p = 0.03). Time with a stoma was 3.2 months longer among those who underwent a three-stage procedure. While three-stage procedures were more often performed during the first half of the study period (2008-2012), two-stage procedures became more common during the second half (2013-2018). During this transition to favor two-stage procedures, complication rates did not significantly change. CONCLUSION: Although three-stage procedures were thought to be associated with fewer complications, we found comparable complication rates as we transition to two-stage procedures.
Subject(s)
Colectomy/methods , Colitis, Ulcerative/surgery , Colonic Pouches , Forecasting , Child , Female , Follow-Up Studies , Humans , Male , Proctocolectomy, Restorative/methods , Retrospective StudiesABSTRACT
BACKGROUND: Acute appendicitis is the most common emergent surgical procedure performed among children in the United States, with an incidence exceeding 80,000 cases per year. Appendectomies are often performed by both pediatric surgeons and adult general/trauma and acute care (TACS) surgeons. We hypothesized that children undergoing appendectomy for acute appendicitis have equivalent outcomes whether a pediatric surgeon or a TACS surgeon performs the operation. METHODS: A retrospective chart review was performed for patients 6 to 18 years of age, who underwent appendectomy at either a regional children's hospital (Children's Hospital of Colorado [CHCO], n = 241) or an urban safety-net hospital (n = 347) between July 2010 and June 2015. The population of patients operated on at the urban safety-net hospital was further subdivided into those operated on by pediatric surgeons (Denver Health Medical Center [DHMC] pediatric surgeons, n = 68) and those operated on by adult TACS surgeons (DHMC TACS, n = 279). Baseline characteristics and operative outcomes were compared between these patient populations utilizing one-way analysis of variance and χ test for independence. RESULTS: When comparing the CHCO and DHMC TACS groups, there were no differences in the proportion of patients with perforated appendicitis, operative time, rate of operative complications, rate of postoperative infectious complications, or rate of 30-day readmission. Length of stay was significantly shorter for the DHMC TACS group than that for the CHCO group. CONCLUSIONS: Our data demonstrate that among children older than 5 years undergoing appendectomy, length of stay, risk of infectious complications, and risk of readmission do not differ regardless of whether they are operated on by pediatric surgeons or adult TACS surgeons, suggesting resources currently consumed by transferring children to hospitals with access to pediatric surgeons could be allocated elsewhere. LEVEL OF EVIDENCE: Therapeutic/Care management, level III.
Subject(s)
Appendectomy , Appendicitis/diagnosis , Hospitals, Pediatric/statistics & numerical data , Referral and Consultation/statistics & numerical data , Adolescent , Appendicitis/epidemiology , Appendicitis/surgery , Child , Child, Preschool , Colorado/epidemiology , Female , Humans , Incidence , Male , Retrospective StudiesABSTRACT
Introduction In the adult population, assessment of blood consumption (ABC) score [penetrating mechanism, positive focused assessment sonography for trauma (FAST), systolic blood pressure < 90, and heart rate (HR) > 120] ≥2 identifies trauma patients who require massive transfusion (MT) with sensitivity and specificity of 75 and 86%. We hypothesized that the adult criteria cannot be applied to children, as the vital sign cut-offs are not age-adjusted. We aimed to determine if the use of a shock index, pediatric age-adjusted (SIPA) would improve the discriminate ability of the ABC score in children. Materials and Methods A retrospective review of children age 4 to 15 who received a packed red blood cell (PRBC) transfusion during admission for trauma between 2008 and 2014 was performed. We compared the sensitivity and specificity of ABC score ≥ 2, elevated SIPA, and age-adjusted ABC score (ABC-S) utilizing SIPA in place of HR and BP, to determine the need for MT. Results A total of 50 children were included, 31 received PRBC transfusion within 6 hours of injury, 7 children had a positive FAST, and 3 suffered penetrating trauma, all in the early transfusion group. ABC score ≥ 2 is 29% sensitive and 100% specific at predicting need for MT while ABC-S score ≥ 1 is 65% sensitive and 84% specific. Conclusions Adult-based criteria for activation of MT perform poorly in the pediatric population. The use of SIPA modestly improves the sensitivity of the ABC score in children; however, the sensitivity and specificity of this score are still worse than when used in an adult population. This suggests the need to develop a new score that takes into account the low rate of penetrating trauma and positive FAST in the pediatric population.
Subject(s)
Erythrocyte Transfusion/standards , Severity of Illness Index , Shock, Hemorrhagic/diagnosis , Shock, Hemorrhagic/therapy , Wounds and Injuries/complications , Adolescent , Adult , Age Factors , Child , Child, Preschool , Female , Humans , Male , Retrospective Studies , Sensitivity and Specificity , Treatment OutcomeABSTRACT
BACKGROUND: We demonstrated previously that shock index, pediatric age-adjusted identifies severely injured children accurately after blunt trauma. We hypothesized that an increased shock index, pediatric age-adjusted would identify more accurately injured children requiring the highest trauma team activation than age-adjusted hypotension. METHODS: We reviewed all children age 4-16 admitted after blunt trauma with an injury severity score ≥15 from January 2007-June 2013. Criteria used as indicators of need for activation of the trauma team included blood transfusion, emergency operation, or endotracheal intubation within 24 hours of admission. Shock index, pediatric age-adjusted represents maximum normal shock index based on age. Cutoffs included shock index >1.22 (ages 4-6), >1.0 (7-12), and >0.9 (13-16). Age-adjusted cutoffs for hypotension were as follows: systolic blood pressure <90 (ages 4-6), systolic blood pressure <100 (7-16). RESULTS: A total of 559 children were included; 21% underwent operation, 37% endotracheal intubation, and 14% transfusion. Hypotension alone predicted poorly the need for operation (13%), endotracheal intubation (17%), or transfusion (22%). Operation (30%), endotracheal intubation (40%), and blood transfusion (53%) were more likely in children with an increased shock index, pediatric age-adjusted; 25 children required all three interventions, 3 (12%) were hypotensive at presentation, 15 (60%) had an increased shock index, pediatric age-adjusted (P < .001). CONCLUSION: An increased shock index, pediatric age-adjusted is superior to age-adjusted hypotension to identify injured children likely to require emergency operation, endotracheal intubation, or early blood transfusion.
Subject(s)
Hypotension/diagnosis , Shock/diagnosis , Wounds, Nonpenetrating/complications , Wounds, Nonpenetrating/physiopathology , Adolescent , Age Factors , Blood Transfusion , Child , Child, Preschool , Female , Humans , Hypotension/etiology , Hypotension/therapy , Injury Severity Score , Intubation, Intratracheal , Male , Needs Assessment , Retrospective Studies , Shock/etiology , Shock/therapy , Wounds, Nonpenetrating/therapyABSTRACT
OBJECTIVES: We sought to determine whether practice differences for fundoplication exist between 2 geographically distinct states, and to determine the reflux medication use pattern associated with concomitant fundoplication. METHODS: A retrospective observational cohort study of children in Colorado (CO) and North Carolina (NC) insured by Medicaid from 2006 to 2008. Children who received a surgical gastrostomy during the study period were included, and our primary outcome measure was the performance of a concomitant gastric fundoplication. Thirty-day prescription fills for reflux medications were examined before and after gastrostomy procedure. RESULTS: We examined 969 surgical gastrostomy admission in both states over the 3-year study period (CO, nâ=â341 and NC, nâ=â628). Patients in each state had similar age (median age, 6 months, Pâ=â0.97). Use of pH probe (CO: 15%, NC: 11%) and diagnosis of reflux (CO: 84%, NC: 72%) differed in each state. Concomitant fundoplication was performed in 60% of patients in CO and 43% in NC (Pâ<â0.01). Age less than 6 months was associated with an increased adjusted odds of fundoplication in CO (OR 9.77, CI, 3.91, 24.43), but less so in NC (OR 2.73, CI, 1.48, 5.04). Among patients undergoing gastrostomy, the proportion of patients on reflux medication 4 to 6 months post-discharge did not differ between those receiving fundoplication and those that did not in either state. CONCLUSIONS: Rates of concomitant fundoplication varied in the 2 states despite patients having similar demographic and clinical characteristics. Antireflux surgery was not associated with a reduction in reflux medications in either state.
Subject(s)
Fundoplication/methods , Gastroesophageal Reflux/therapy , Gastrointestinal Agents/therapeutic use , Gastrostomy/methods , Adolescent , Child , Child, Preschool , Colorado , Female , Fundoplication/statistics & numerical data , Gastrostomy/statistics & numerical data , Humans , Infant , Infant, Newborn , Infant, Premature , Male , North Carolina , Postoperative Period , Retrospective StudiesABSTRACT
INTRODUCTION: Following complicated appendicitis, there are limited data available to guide the surgeon regarding antibiotic selection, specifically in regards to route of administration. We hypothesized that among children with appendicitis who are discharged home with antibiotic therapy, the post-discharge readmission and complication rates do not differ between those children who receive IV antibiotics and those who receive PO antibiotics. METHODS: We performed a retrospective review of all children discharged home on antibiotics following appendectomy at a single institution between 11/10-10/14. We compared outcomes including ED and hospital readmission rates, and development of postoperative complications, between those children who were discharged on IV antibiotics and those discharged on PO antibiotics. RESULTS: 325 children were discharged with antibiotics following appendectomy (n=291 PO antibiotics group; n=34 IV group). On both univariate and multivariate analysis, rate of each complication did not differ between the two groups including inpatient readmission (5% PO vs. 6% IV; p=0.8), ED readmission (10% vs. 11%; p=0.8), postdischarge complications related to the operation (10% vs. 15%; p=0.4), or abscess development post-discharge (4% vs. 3%; p=1). CONCLUSIONS: Among children with complicated appendicitis who are discharged home with ongoing antibiotic therapy, our data demonstrate no differences in outcomes between those children who receive IV and PO antibiotics. Further data, collected in a prospective fashion, are needed to clarify the role of IV and PO antibiotics among children with perforated appendicitis.
Subject(s)
Anti-Bacterial Agents/administration & dosage , Appendicitis/drug therapy , Postoperative Care/methods , Administration, Oral , Adolescent , Anti-Bacterial Agents/therapeutic use , Appendectomy , Appendicitis/surgery , Child , Child, Preschool , Combined Modality Therapy , Female , Humans , Injections, Intravenous , Male , Patient Discharge , Patient Readmission/statistics & numerical data , Postoperative Complications/epidemiology , Postoperative Complications/etiology , Retrospective Studies , Treatment OutcomeABSTRACT
INTRODUCTION: Before gastrostomy tube (GT) placement, many pediatric surgeons request that children undergo a preoperative upper gastrointestinal contrast study (UGI) to evaluate for the presence of either gastroesophageal reflux (GER) or intestinal malrotation. We hypothesized that routine UGI is unnecessary before GT placement. MATERIALS AND METHODS: We performed a retrospective review of 500 consecutive children who had a GT placed in a single children's hospital from 2009 to 2012. RESULTS: There were 403 children who underwent UGI before planned GT placement; 196 of which were placed during the same hospitalization. Only 1/403 (0.25%) diagnosis of malrotation was identified on UGI, and treated with a Ladd procedure at the time of GT placement. There were 154 children who had evidence of reflux on UGI; 97 underwent an antireflux procedure in conjunction with GT placement. An additional 57 children with no evidence of reflux on UGI also underwent a concurrent antireflux procedure. Of these 160 children who underwent concurrent fundoplication, only 3 (2%) had a confirmatory pH probe study performed before GT placement. CONCLUSIONS: We found that in children undergoing routine preoperative UGI before GT placement (1) the risk of malrotation is less than 1%; (2) the decision to perform an antireflux procedure weakly correlates with the UGI findings of GER; and (3) one in five patients without radiographic GER still underwent concomitant fundoplication with or without confirmatory pH probe study. We conclude that the practice of routine UGI before laparoscopic gastrostomy placement in children is likely unnecessary.
Subject(s)
Gastroesophageal Reflux/diagnostic imaging , Gastrostomy , Intestinal Volvulus/diagnostic imaging , Intubation, Gastrointestinal , Laparoscopy , Preoperative Care/methods , Upper Gastrointestinal Tract/diagnostic imaging , Child , Contrast Media , Fundoplication , Gastroesophageal Reflux/surgery , Gastrostomy/methods , Humans , Intestinal Volvulus/surgery , Intubation, Gastrointestinal/methods , Retrospective StudiesABSTRACT
BACKGROUND: Current management protocols for children with blunt solid organ injury to the liver and spleen call for serial monitoring of the child's hemoglobin and hematocrit every 6, 12, or 24 hours, depending on the injury grade. We hypothesized that children who require emergent intervention in the form of laparotomy, angioembolization, or packed red blood cell (PRBC) transfusion because of bleeding from a solid organ injury will have changes in their vital signs that alert the clinician to the need for intervention, making scheduled laboratory evaluation unnecessary. METHODS: We performed a retrospective review of all children admitted to either of two pediatric trauma centers following blunt trauma with any grade liver or spleen injury from January 2009 to December 2013. Data evaluated include a need for intervention, indication for intervention, and timing of intervention. RESULTS: A total of 245 children were admitted with blunt liver or spleen injury. Six patients (2.5%) underwent emergent exploratory laparotomy for hypotension a median of 4 hours after injury (range, 2-4 hours), four of who required splenectomy. No child required laparotomy for delayed bleeding from a solid organ injury. One child (0.4%) underwent angioembolization for blunt splenic injury. Forty-one children (16.7%) received a PRBC transfusion during hospitalization, 32 of whom did not undergo laparotomy or angioembolization. Children who underwent an intervention had a lower nadir hematocrit (median, 22.9 vs. 32.8; p < 0.0001), longer time from injury to nadir hematocrit (median, 35.5 vs. 16 hours; p < 0.0001), and more total blood draws for hemoglobin and hematocrit monitoring (median, 20 vs. 5; p < 0.0001). CONCLUSION: Among children with blunt liver or spleen injury, a need for emergent intervention in the form of laparotomy or PRBC transfusion for hemorrhagic shock occurs within the first 24 hours of injury. Ongoing, scheduled monitoring of serum hemoglobin and hematocrit values may not be necessary. LEVEL OF EVIDENCE: Retrospective study with no negative criteria, prognostic study, level III.
Subject(s)
Hematocrit , Hemoglobins/analysis , Liver/injuries , Spleen/injuries , Wounds, Nonpenetrating/blood , Adolescent , Blood Transfusion , Child , Child, Preschool , Embolization, Therapeutic , Female , Humans , Laparotomy , Male , Retrospective Studies , Splenectomy , Wounds, Nonpenetrating/therapyABSTRACT
PURPOSE: We have previously demonstrated that a shock index, pediatric age adjusted (SIPA) accurately identifies severely blunt injured children. We aimed to determine if SIPA could more accurately identify children with severe traumatic brain injury (TBI) than hypotension alone. METHODS: We performed subset analysis of those children with TBI among a cohort of children age 4-16 years with blunt trauma and injury severity score ≥15 from 1/07 to 6/13. We evaluated the ability of four markers to identify the most severely brain injured children. Markers included hypotension, elevated SIPA, abnormal GCS motor score (GMS), and elevated SIPA or abnormal GMS. We aimed to determine which of these four markers had the highest sensitivity in identifying severely injured children. RESULTS: Three hundred and ninety-two (392) children were included. Hypotension was present in 24 patients (6%); elevated SIPA in 106 (27 %), abnormal GMS in 172 (44%), and elevated SIPA or abnormal GMS in 206 (53%). All markers were able to accurately identify severely injured children with TBI. Elevated SIPA or abnormal GMS identified a greater percentage of patients with each of seven complications with higher sensitivity than each of the three other markers. CONCLUSION: Among blunt injured children with TBI, elevated SIPA or abnormal GMS identifies severely brain injured children.
Subject(s)
Blood Pressure/physiology , Brain Injuries/physiopathology , Glasgow Coma Scale , Heart Rate/physiology , Injury Severity Score , Adolescent , Child , Child, Preschool , Cohort Studies , Female , Humans , Male , Reproducibility of ResultsABSTRACT
INTRODUCTION: We hypothesized that the finding of diffuse slowing on bedside EEG in children with moderate to severe traumatic brain injury (TBI) is associated with prolonged hospital stay and worse functional outcomes. METHODS: We reviewed the medical records of all patients admitted to a single level I pediatric trauma center with moderate or severe TBI from 1/10-12/12 (defined by GCS<10 on admission). EEG monitoring results, patient demographics, clinical characteristics, length of stay and postinjury outcomes were recorded. We compared outcomes between patients with and without diffuse slowing on EEG. Data are presented as mean±SEM; p<0.05 was considered statistically significant. RESULTS: 219 children with TBI were identified; 81 had a bedside EEG performed within 48 hours of admission. Diffuse slowing was present in 50 (mean age 5.7+0.7 years) and absent in 31 (n=31, mean age 4.2+0.9 years). Patients with diffuse slowing had a significant increase in ventilator days, ICU LOS, need for rehabilitation, and rehabilitation length of stay. CONCLUSION: The presence of diffuse slowing on EEG in children with TBI is associated with prolonged patient recovery and poor functional outcomes. This finding should prompt early consideration for rehabilitation and the need for intensive therapy.
Subject(s)
Brain Injuries/diagnosis , Electroencephalography , Adolescent , Brain Injuries/physiopathology , Brain Injuries/therapy , Child , Child, Preschool , Female , Humans , Infant , Infant, Newborn , Length of Stay/statistics & numerical data , Male , Outcome Assessment, Health Care , Prognosis , Recovery of Function , Retrospective StudiesABSTRACT
BACKGROUND: Recent progress has been made in the care of infants with hypertrophic pyloric stenosis (HPS), including earlier operative intervention and shorter hospital length of stay (LOS), which is attributable to expedited postoperative feeding protocols developed and implemented by surgeons. We hypothesized that patients with HPS admitted to a unit that is co-managed by nonsurgeon providers postoperatively have a longer LOS than those on the surgical ward. MATERIALS AND METHODS: We reviewed the medical records of infants who underwent pyloromyotomy for HPS at a single institution from April, 2009-July, 2013. RESULTS: A total of 259 patients underwent pyloromyotomy (35 female; 13.5%), 205 (79%) were admitted to the surgical ward; 46 had a planned neonatal intensive care unit (NICU) admission (18%) and were co-managed with the neonatology team. Eight (3%) had an unplanned NICU admission and were excluded from the analysis. The groups did not differ in terms of sex, age, serum electrolytes at presentation, or time between surgeon evaluation and operative intervention. Surgical ward patients had longer preoperative symptom duration. Operative time was longer in the NICU patients. Comparing the two groups, there was no difference in postoperative apnea, hypoxic, or bradycardic episodes. NICU patients achieved ad libitum feeds later than floor patients (2.0 versus 1.4 d; P = 0001) and had a longer postoperative LOS (2.2 versus 1.6 d; P = 0.0012). CONCLUSIONS: Patients with HPS admitted to the NICU postoperatively had a longer time to full feeds and hospital LOS. The reduction in LOS between hospital wards may be improved with implementation of a hospital-wide postoperative protocol for patients with HPS.
Subject(s)
Intensive Care Units, Neonatal , Length of Stay/statistics & numerical data , Postoperative Care/methods , Pyloric Stenosis, Hypertrophic/surgery , Surgery Department, Hospital , Clinical Protocols/standards , Enteral Nutrition/methods , Enteral Nutrition/statistics & numerical data , Female , Humans , Infant , Infant, Newborn , Intensive Care Units, Neonatal/standards , Male , Postoperative Care/standards , Postoperative Care/statistics & numerical data , Surgery Department, Hospital/standards , Treatment OutcomeABSTRACT
PURPOSE: Recent data demonstrate that surgical lung biopsy in immunocompromised children, including oncology patients, alters therapy in only 50% of cases. We hypothesized that there are factors identifiable preoperatively which can predict the patients who will or will not benefit from surgical biopsy. METHODS: We reviewed the medical records of all children with malignancy who underwent surgical lung biopsy between 2004 and 2013 at a single institution, excluding those children who had previously undergone a solid organ or bone marrow transplant. RESULTS: Eighty lung wedge biopsies were performed (median age 13 years, IQR 5.25-16; 63% male, n=50) 53 (66%) of which led to a change in patient management. The majority of biopsies were performed to diagnose a new mass or differentiate infection from metastases (mass group) (n=68, 85%), and 12 biopsies (15%) were performed to diagnose a known infection for antibiotic guidance (infection group). Children in the infection group were more likely to be febrile preoperatively, were more likely to be an inpatient preoperatively, and had a lower absolute neutrophil count at the time of biopsy. Patients in the infection group had higher postoperative mortality rates and higher rates of major complications. CONCLUSION: In pediatric oncology patients, surgical lung biopsy has a lower diagnostic yield and higher complication rate when performed for antibiotic guidance. Prior to proceeding with biopsy in this high-risk patient population, surgeons and oncologists should carefully weigh the potential risks and benefits.