Prevalence and Outcomes of High versus Low Ratio Plasma to Red Blood Cell Resuscitation in a Multi-Institutional Cohort of Severely Injured Children.

BACKGROUND: The benefit of targeting high ratio fresh frozen plasma (FFP):red blood cell (RBC) transfusion in pediatric trauma resuscitation is unclear as existing studies are limited to patients who retrospectively met criteria for massive transfusion. The purpose of this study is to evaluate the use of high ratio FFP:RBC transfusion and the association with outcomes in children presenting in shock. METHODS: A post-hoc analysis of a 24-institution prospective observational study (4/2018-9/2019) of injured children <18 years with elevated age-adjusted shock index was performed. Patients transfused within 24 hours were stratified into cohorts of low (<1:2) or high (>1:2) ratio FFP:RBC. Nonparametric Kruskal-Wallis and chi-square were used to compare characteristics and mortality. Competing risks analysis was used to compare extended (≥75th percentile) ventilator, intensive care, and hospital days while accounting for early deaths. RESULTS: Of 135 children with median (IQR) age 10 (5,14) years and weight 40 (20,64) kg, 85 (63%) received low ratio transfusion and 50 (37%) high ratio despite similar activation of institutional massive transfusion protocols (MTP; low-38%, high-46%, p = .34). Most patients sustained blunt injuries (70%). Median injury severity score was greater in high ratio patients (low-25, high-33, p = .01); however, hospital mortality was similar (low-24%, high-20%, p = .65) as was the risk of extended ventilator, ICU, and hospital days (all p > .05). CONCLUSION: Despite increased injury severity, patients who received a high ratio of FFP:RBC had comparable rates of mortality. These data suggest high ratio FFP:RBC resuscitation is not associated with worst outcomes in children who present in shock. MTP activation was not associated with receipt of high ratio transfusion, suggesting variability in MTP between centers. LEVEL OF EVIDENCE: Prospective cohort study, Level II.

Bio-impedance spectroscopy for total body water assessment in pediatric surgical patients: A single center pilot cohort study.

BACKGROUND: Excess peri­operative fluid administration is associated with higher morbidity and mortality. We aimed to examine the feasibility of bio-impedance spectroscopy (BIS) to record serial peri­operative fluid volumes in the pediatric surgical population. METHODS: Children who underwent major elective general surgery from March 2019 to March 2020 were included. Total body water (TBW) assessment by BIS was recorded prior to surgery and on subsequent post-operative days (POD). We recorded the duration, tolerance and completion of each BIS assessment. We used Spearman coefficient and Bland Altman analysis to examine correlation and agreement between fluid balance (FB) in ml/kg calculated from intake/output (IO) recording and measured by BIS. RESULTS: 20 (87%) of 23 consented patients, median age 2.5 (1-17) years and 13 (65%) male, completed pre-operative and post-operative measurements, and were included in the analysis. Median time required for BIS assessments was 10 (5-15) minutes, and there were no recorded side effects or intolerance. The correlation coefficient for fluid balance measurements on POD 1 between BIS and IO methods was 0.59 (p = 0.01); mean bias (limits) of agreement was 26 (111 to 163) mL/kg. The trend in TBW measured by BIS declined from POD 1-3, while the recorded FB increased. CONCLUSION: Bedside BIS is feasible and well-tolerated. Despite moderate correlation between fluid balance assessment by BIS and IO on POD 1, the wide limits of agreement between values from these methods preclude their use interchangeably. The role of BIS in assessment of fluid status in the pediatric surgical population should be further examined. LEVEL OF EVIDENCE: Level III.

New mental health diagnoses in parents of infants admitted to a neonatal intensive care unit-a retrospective review of the Military Health System database.

OBJECTIVE: Studies suggest that parents of NICU infants are at increased risk of mental health disorders. We sought to characterize this risk using a large database. STUDY DESIGN: The Military Health System was used to retrospectively link records between parents and infants admitted to a NICU over 5 years and were matched to similar families without NICU exposure. The total study population included 35,012 infants. Logistic regression was used to estimate the association between NICU exposure and parental mental health diagnoses within 5 years of infant birth. RESULTS: Maternal NICU exposure was associated with incident diagnoses of depression (OR: 1.18-1.27, p < 0.0001), anxiety (OR: 1.06-1.18, p = 0.0151), alcohol/opiate dependence (OR: 1.29-1.52, p = 0.0079), and adjustment disorder (OR: 0.97-1.18, p = 0.0224). Paternal NICU exposure was associated with alcohol/opiate dependence (OR: 0.78-1.42, p = 0.0339). CONCLUSION: Parents of NICU infants are at risk of developing mental health disorders. Future work should identify characteristics that predict highest risk to develop effective interventions.

Variation in management of pediatric post-traumatic urine leaks.

PURPOSE: High-grade pediatric renal trauma may be associated with a urine leak and appropriate management remains unclear. METHOD: Data on patients with a traumatic renal injury were retrieved from the trauma registry and data warehouse of a pediatric level 1 trauma center over a 15-year period. Demographics, diagnoses, imaging, interventions performed, and follow-up information on patients with a urine leak were analyzed. RESULTS: 187 renal injuries were identified and 32 (17%) were high grade. There were 21 (11%) diagnoses of urine leak, comprising the study population. Leaks were identified 0-10 day post-injury. All patients underwent initial computerized tomography (CT); however, 10 (48%) lacked excretory-phase imaging, leading to repeat CT. Ten patients (48%) did not undergo an intervention for their leak, and 11 (52%) underwent at least one, most commonly stent placement (10). Comparing non-intervention and intervention groups: Injury Severity Score (ISS) and initial Shock Index - Pediatric Adjusted (SIPA) were similar, but there was variation in antibiotic prophylaxis (60% vs 100%), average number of imaging studies performed (6.4 vs 8.1) and average length of hospital stay in days (7.7 vs 8.6). CONCLUSION: Traumatic urine leaks are unusual, and half require no intervention. Management is variable and the development of care guidelines could decrease variation. Given their infrequency a multi-institutional study is required to generate sufficient patient volume.

Adult survivors of moderate and great complexity congenital heart disease undergoing general surgery procedures: How do they fare?

BACKGROUND: Patients with complex congenital heart disease (CHD) are now commonly surviving well into adulthood. We describe the clinical characteristics and outcomes for a cohort of adult patients with moderate and great complexity CHD undergoing general surgery procedures. METHODS: The electronic records of two tertiary centers were queried to identify adult patients with moderate and great complexity CHD who underwent a general surgery procedure between 2007 and 2017. RESULTS: 118 adult patients were included in the analysis. The mean age was 36 ± 17 years and 49.2% were male. The most common cardiac diagnoses were pulmonary valve anomaly (24.6%), tetralogy of Fallot (18.6%), coarctation of the aorta (15.3%) and common/single ventricle (10.2%). The most common general surgery procedures performed were cholecystectomy (23.7%), herniorrhaphy (23.7%) and colorectal resection (9.3%). In-hospital mortality and morbidity were 2.5% and 11.9%, respectively. CONCLUSION: Adults survivors of moderate and great complexity CHD undergoing common general surgery procedures in this study experienced excellent in-hospital outcomes.

Geographic Distance to Extracorporeal Life Support Centers for Pediatric Patients Within the Continental United States.

OBJECTIVES: Distance to subspecialty surgical care is a known impediment to the delivery of high-quality healthcare. Extracorporeal life support is of benefit to pediatric patients with specific medical conditions. Despite a continued increase in the number of extracorporeal life support centers, not all children have equal access to extracorporeal life support due to geographic constraints, creating a potential disparity in healthcare. We attempted to better define the variation in geographic proximity to extracorporeal life support centers for pediatric patients using the U.S. Decennial Census. DESIGN: A publicly available listing of voluntarily reporting extracorporeal life support centers in 2019 and the 2010 Decennial Census were used to calculate straight-line distances between extracorporeal life support zip code centroids and census block centroids. Disparities in distance to care associated with urbanization were analyzed. SETTING: United States. PATIENTS: None. INTERVENTIONS: Large database review. MEASUREMENTS AND MAIN RESULTS: There were 136 centers providing pediatric extracorporeal life support in 2019. The distribution varied by state with Texas, California, and Florida having the most centers. Over 16 million children (23% of the pediatric population) live greater than 60 miles from an extracorporeal life support center. Significant disparity exists between urban and rural locations with over 47% of children in a rural setting living greater than 60 miles from an extracorporeal life support center compared with 17% of children living in an urban setting. CONCLUSIONS: Disparities in proximity to extracorporeal life support centers were present and persistent across states. Children in rural areas have less access to extracorporeal life support centers based upon geographic distance alone. These findings may affect practice patterns and treatment decisions and are important to the development of regionalization strategies to ensure all children have subspecialty surgical care available to them, including extracorporeal life support.

Contemporary management of pediatric open skull fractures: a multicenter pediatric trauma center study.

OBJECTIVE: The authors sought to evaluate the contemporary management of pediatric open skull fractures and assess the impact of variations in antibiotic and operative management on the incidence of infectious complications. METHODS: The records of children who presented from 2009 to 2017 to 6 pediatric trauma centers with an open calvarial skull fracture were reviewed. Data collected included mechanism and anatomical site of injury; presence and depth of fracture depression; antibiotic choice, route, and duration; operative management; and infectious complications. RESULTS: Of the fractures among the 138 patients included in the study, 48.6% were frontal and 80.4% were depressed; 58.7% of patients underwent fragment elevation. The average duration of intravenous antibiotics was 4.6 (range 0-21) days. Only 53 patients (38.4%) received a single intravenous antibiotic for fewer than 4 days. and 56 (40.6%) received oral antibiotics for an average of 7.3 (range 1-20) days. Wounds were managed exclusively in the emergency department in 28.3% of patients. Two children had infectious complications, including a late-presenting hardware infection and a superficial wound infection. There were no cases of meningitis or intracranial abscess. Neither antibiotic spectrum or duration nor bedside irrigation was associated with the development of infection. CONCLUSIONS: The incidence of infectious complications in this population of children with open skull fractures was low and was not associated with the antibiotic strategy or site of wound care. Most minimally contaminated open skull fractures are probably best managed with a short duration of a single antibiotic, and emergency department closure is appropriate unless there is significant contamination or fragment elevation is necessary.

Unintentional Window Falls in Children and Adolescents.

OBJECTIVE: Unintentional window falls represent a preventable source of injury and death in children. Despite major campaigns in some larger cities, there continue to be unintentional falls from windows throughout the United States. We aimed to identify risk factors and trends in unintentional window falls in the pediatric population in a national and regional sample. METHODS: A retrospective analysis of annual emergency department (ED) visits from the National Electronic Injury Surveillance System using product codes specific to windows, as well as patient encounters for unintentional window falls from January 2007 to August 2017 using site-specific trauma registries from 10 tertiary care children's hospitals in New England. National and state-specific census population estimates were used to compute rates per 100,000 population. RESULTS: There were 38,840 ED visits and 496 regional patients who unintentionally fell from a window across the study period between 0 and 17 years old. The majority of falls occurred in children under the age of 6 and were related to falls from a second story or below. A decreased trend in national ED visits was seen, but no change in rates over time for regional trauma center encounters. A high number of falls was found to occur in smaller cities surrounding metropolitan areas and from single family residences. CONCLUSIONS: Falls from windows represent a low proportion of overall types of unintentional sources of injury in children but are a high risk for severe disability. These results provide updated epidemiologic data for targeted intervention programs, as well as raise awareness for continued education and advocacy.

When to take it out? Optimal timing of interval appendectomy in 500 consecutive children.

PURPOSE: While interval appendectomy following nonoperative management of perforated appendicitis is delayed until several weeks after presentation, the optimal time from presentation to interval appendectomy is unknown. METHODS: The data warehouse of a large children's hospital was queried for interval appendectomies from 2006 to 2019. Data extracted included demographics, initial and operative hospitalization details, and pathology findings. Student's t-test and logistic regression were used where appropriate. RESULTS: 500 patients were identified with a mean age of 10 years, 53% male. Mean time to operation was 12.7 weeks. Operation prior to 12 weeks was associated with increased odds of acute inflammation on pathology (OR = 2, p < 0.01). Acute inflammation was associated with increased mean operative time (101 vs 84 min, p < 0.01). Presence of an appendicolith, initial hospitalization length, drain placement, readmission prior to operation, age and gender were all non-predictive of acute inflammation. Only 11% of appendices had an occluded lumen and 17% an appendicolith. Carcinoid tumors were identified in 6 patients (1.2%). CONCLUSION: Acute inflammation is found many weeks after perforation and is associated with increased operative time. Acute inflammation is more likely to be present in operations performed prior to 12 weeks.

A minimally invasive pilonidal protocol improves quality of life in adolescents.

BACKGROUND: Pilonidal disease adversely affects the quality of life (QoL) of adolescents with this condition. We report the impact of minimally invasive care on the QoL of a series of adolescent patients in a dedicated Pilonidal Care Clinic. METHODS: Beginning in February 2019, all patients completed QoL surveys prior to each visit reporting current symptoms and their QoL impact. Data were collected prospectively with objective disease severity and treatment details. Patients with at least 2 clinic visits were included. Demographics, procedures performed, and median QoL scores by severity were analyzed. RESULTS: 74 patients were included. Mean age was 17.3 years (SD 2.4), mean BMI was 27.5 (SD 6.2), median follow-up duration was 4 months (2-12). At intake patients reported a median total QoL impact of 12 for those with mild disease, 11 for those with moderate disease, and 12 with severe disease. Median total QoL impact resolved by the second visit for patients with mild disease, the third for moderate disease, and decreased 88% by the fourth visit for patients with severe disease. CONCLUSION: Pilonidal disease has a profound impact on most patients' quality of life. Minimally invasive care promptly resolves negative impacts on quality of life in adolescents.

Endoscopic cyst gastrostomy for traumatic pancreatic pseudocysts in children: a case series.

BACKGROUND: Pancreatic pseudocysts may develop after high-grade pancreatic injuries in children. Many resolve without intervention, and the management of symptomatic pseudocysts that persist remains controversial, with various open, percutaneous and laparoscopic approaches to intervention described. Successful endoscopic cyst gastrostomy has been reported in children with pancreatic pseudocysts of mixed etiology. METHODS: The trauma registry and electronic medical record of a level 1 pediatric trauma center were queried for children with a symptomatic pseudocyst following pancreatic trauma over a 12-year period, from 2008 to 2019. RESULTS: We describe a case series of five consecutive children with persistent symptomatic pancreatic pseudocysts following blunt abdominal trauma all successfully treated with endoscopic cyst gastrostomy. DISCUSSION: Endoscopic cyst gastrostomy appears to be safe and effective in the management of symptomatic pancreatic pseudocysts in children following pancreatic trauma. LEVEL OF EVIDENCE: 5 - retrospective case series.

Eliminating Opiate Prescribing for Children after Non-Perforated Appendectomy.

BACKGROUND: Opiates are the traditional treatment for postoperative pain. Recognition that increased availability of opiates in the community is associated with increased addiction has led to efforts to decrease postoperative opiate distribution. However, there are concerns that without opiates, pain relief might be inadequate. STUDY DESIGN: We analyzed opiate prescriptions to children who had undergone appendectomy during 3 time periods: before intervention (July 2012 through February 2013), after opiate prescriptions were standardized and reduced (December 2016 through December 2017), and after opiate prescriptions were eliminated (January 2018 through December 2018). We determined how many opiate prescriptions had been written and how many had been filled in each time period. Patients were contacted by phone to identify their medication use and quality of pain management. RESULTS: Pre-intervention, 75 children underwent appendectomy, and all received opiate prescriptions, with a mean of 15 doses of oxycodone prescribed per patient. After reduction, 208 children underwent appendectomy and 30% received opiate prescriptions, for a mean of 1.5 doses of oxycodone per patient. After elimination, 270 patients underwent appendectomy and 3 patients (1.1%) received opiate prescriptions, for a mean of 0.05 doses of oxycodone per patient. Patients contacted by phone expressed no pain relief issues and no patients needed opiates later. CONCLUSIONS: Using a stepwise process, we have eliminated the use of opiates for postdischarge pain in children undergoing laparoscopic appendectomy. This intervention has resulted in the elimination of 4,035 doses of oxycodone from the community during the study period, while ensuring that postoperative pain control has been adequate.

Timing and volume of crystalloid and blood products in pediatric trauma: An Eastern Association for the Surgery of Trauma multicenter prospective observational study.

BACKGROUND: The purpose of this study was to determine the relationship between timing and volume of crystalloid before blood products and mortality, hypothesizing that earlier transfusion and decreased crystalloid before transfusion would be associated with improved outcomes. METHODS: A multi-institutional prospective observational study of pediatric trauma patients younger than 18 years, transported from the scene of injury with elevated age-adjusted shock index on arrival, was performed from April 2018 to September 2019. Volume and timing of prehospital, emergency department, and initial admission resuscitation were assessed including calculation of 20 ± 10 mL/kg crystalloid boluses overall and before transfusion. Multivariable Cox proportional hazards and logistic regression models identified factors associated with mortality and extended intensive care, ventilator, and hospital days. RESULTS: In 712 children at 24 trauma centers, mean age was 7.6 years, median (interquartile range) Injury Severity Score was 9 (2-20), and in-hospital mortality was 5.3% (n = 38). There were 311 patients(43.7%) who received at least one crystalloid bolus and 149 (20.9%) who received blood including 65 (9.6%) with massive transfusion activation. Half (53.3%) of patients who received greater than one crystalloid bolus required transfusion. Patients who received blood first (n = 41) had shorter median time to transfusion (19.8 vs. 78.0 minutes, p = 0.005) and less total fluid volume (50.4 vs. 86.6 mL/kg, p = 0.033) than those who received crystalloid first despite similar Injury Severity Score (median, 22 vs. 27, p = 0.40). On multivariable analysis, there was no association with mortality (p = 0.51); however, each crystalloid bolus after the first was incrementally associated with increased odds of extended ventilator, intensive care unit, and hospital days (all p < 0.05). Longer time to transfusion was associated with extended ventilator duration (odds ratio, 1.11; p = 0.04). CONCLUSION: Resuscitation with greater than one crystalloid bolus was associated with increased need for transfusion and worse outcomes including extended duration of mechanical ventilation and hospitalization in this prospective study. These data support a crystalloid-sparing, early transfusion approach for resuscitation of injured children. LEVEL OF EVIDENCE: Therapeutic, level IV.

Nutrition Support During Pediatric Extracorporeal Membrane Oxygenation.

Providing adequate nutrition to critically ill pediatric patients is essential and positively impacts outcomes. Critically ill infants and children receiving extracorporeal membrane oxygenation (ECMO) therapy are nutritionally vulnerable, yet there are challenges to reliable assessment of nutrition requirements and to the delivery of optimal nutrition in this cohort. In this review of the relevant literature, we present the current evidence and guidelines for the optimal prescription and delivery of nutrition for pediatric patients receiving ECMO. We also discuss nutrient delivery considerations in ECMO survivors and identify areas where further study is needed.