Patterns for Child Protective Service Referrals in a Pediatric Burn Cohort.

BACKGROUND: Pediatric non-accidental trauma often necessitates the involvement of protective services. However, the subjectivity and lack of standardization of referral infrastructure may result in some discrepancies between referral patterns and instances of child abuse. METHODS: An institutional retrospective chart review was conducted between 2015 and 2021, in which all cases of patients under the age of 14 who suffered a burn injury and received a child protective service (CPS) consult were reviewed. Baseline demographics and characteristics were defined. Multivariate analysis was utilized to identify predictors of CPS involvement, while the regression analysis was employed to parse associations between burn injuries and CPS involvement. RESULTS: Between July 2015 and December 2021, 340 patients (median age two years, IQR: 1-6 years) under the age of 14 who experienced a burn injury were evaluated. Forty-four (12.9%) of the patients' cases received a CPS referral, of which three (0.9%) resulted in a CPS intervention. The most common mechanism of burn within the cohort was scald (241 patients, 70.9%). The median total body surface area (TBSA) was 3.0% (IQR: 1.0%-6.0%), and 76 (22.4%) suffered a high TBSA (>75th percentile). Caucasian race (p < 0.001) and scald mechanisms (p = 0.014) were associated with higher TBSA. When considering how such injuries translated to CPS referrals, increasing age was found to be associated with a decreased likelihood of CPS involvement. Meanwhile, the Black race (p = 0.027) and increasing area deprivation index (ADI) (p = 0.038) were associated with CPS involvement. Those with CPS involvement experienced a greater length of hospital stay (p = 0.001). Black race and intensive care unit level of care were found to be positive predictors of CPS involvement. In total, three (6.82%) of the 44 cases with CPS involvement were found to be substantiated. The three children who required CPS intervention were discharged to foster care settings. CONCLUSION: Hospitalized pediatric burn injuries must be investigated due to concern of child abuse, yet external factors such as race and socioeconomic status may play a role in the involvement of CPS. Such referrals may not always be substantiated and could lead to further injurious sequelae for children and their families.

Poor socioeconomic status is associated with delayed femoral fracture fixation in adolescent patients.

INTRODUCTION: Healthcare disparities continue to exist in pediatric orthopedic care. Femur fractures are the most common diaphyseal fracture and the leading cause of pediatric orthopedic hospitalization. Prompt time to surgical fixation of femur fractures is associated with improved outcomes. OBJECTIVE: The objective of this study was to evaluate associations between socioeconomic status and timing of femoral fixation in adolescents on a nationwide level. METHODS: The 2016-2020 National Inpatient Sample (NIS) database was queried using International Classification of Disease, 10th edition (ICD-10) codes for repair of femur fractures. Patients between the ages of 10 and 19 years of age with a principal diagnosis of femur fracture were selected. Patients transferred from outside hospitals were excluded. Baseline demographics and characteristics were described. Patients were categorized as poor socioeconomic status (PSES) if they were classified in the Healthcare Cost and Utilization Project's (HCUP) lowest 50th percentile median income household categories and on Medicaid insurance. The primary outcome studied was timing to femur fixation. Delayed fixation was defined as fixation occurring after 24 h of admission. Secondary outcomes included length of stay (LOS) and discharge disposition. RESULTS: From 2016-2020, 10,715 adolescent patients underwent femur fracture repair throughout the United States. Of those, 765 (7.1 %) underwent late fixation. PSES and non-white race were consistently associated with late fixation, even when controlling for injury severity. Late fixation was associated with decreased rate of routine discharge (p < 0.01), increased LOS (p < 0.01) and increased total charges (p < 0.01). CONCLUSION: Patients of PSES or non-white race were more likely to experience delayed femoral fracture fixation. Delayed fixation led to worse outcomes and increased healthcare resource utilization. Research studying healthcare disparities may provide insight for improved provider education, implicit bias training, and comprehensive standardization of care.

SAP BusinessObjects in Medical Informatics.

Electronic health record (EHR) generates a large amount of data filled with opportunities to enhance documentation compliance, quality improvement, and other metrics. Various software tools exist, but many clinicians are unaware of them. Our institution switched from a hybrid of paper and multiple small EHRs to one all-inclusive EHR system. We faced significant challenges beyond the typical new software deployment phase that affected our departmental regulatory compliance, quality measures, and research initiatives. We aimed to navigate these issues through the use of medical informatics. We used a multidimensional database software analysis tool called SAP BusinessObjects® (SAP SE. Released 2020. SAP BusinessObjects, Version 14.2.8.3671. Waldorf, Germany) to design automated queries for the patient database to generate various reports for our department. As a result, We improved our anesthesia documentation non-compliance from 13-17% of all cases to 4% within months. We have also used this tool to automatically generate various reports such as preoperative beta-blocker administrations, caseloads, case complications, procedure logs, and medication records. Even today many departments rely on manual checks for even the most basic documentation and quality metric compliance, which can be time consuming and costly. Using medical informatics tools is a highly efficient alternative. Fortunately, many software tools exist within most modern EHR packages, and most people can learn to use these tools productively.

Risk Factors for Postoperative Unplanned Reintubation in a Cohort of Patients Undergoing General Anesthesia.

Background Unplanned post-operative reintubation (UPR) is a complication of general anesthesia (GA) that can be associated with worsened outcomes. Objective Evaluate characteristics associated with UPR in patients undergoing procedures under GA. Methods Patients over the age of 18 undergoing surgical procedures under GA were extracted from our institution's electronic medical record. Patient baseline, procedural, and anesthesia characteristics were evaluated for associations with UPR. Results In 29,284 surgical procedures undergoing GA, there were 29 (0.1%) patients that required UPR. The most common surgical service with UPR was otolaryngology; the most common surgical positioning was supine. When controlling for operative time and case complexity, UPR was predicted by high-dose opioids, defined as opioid administration greater than the 75th percentile of our institutional cohort. Prolonged operative time, estimated blood loss (EBL), body mass index (BMI), extubation time after reversal, or age were not independently associated with UPR. Conclusion Our analysis revealed that high-dose opioid administration is independently associated with intraoperative UPR. Awareness of patients at the highest risk for UPR along with provider education regarding techniques to avoid respiratory depression in this patient population is essential in reducing patient morbidity and mortality. This knowledge will help guide perioperative physicians in medical optimization, appropriate selection of intraoperative analgesics, and cautious extubation criteria to ensure patient safety.

High area deprivation index is associated with increased injury severity in pediatric burn patients.

BACKGROUND: Burn injuries play a significant role in pediatric injury-related mortality and morbidity. In this study, we aim to explore the relationship between patient demographics, socioeconomic factos and burn severity in pediatric patients. METHODS: Patients under age 14 hospitalized at Westchester Medical Center for burn injury between 2015 and 2021 were reviewed. Demographic variables including mechanism of burn, total body surface area (TBSA) involvement, surgical intervention, hospital length of stay (LOS), and LOS per TBSA burn were extracted. The Area Deprivation Index (ADI) was calculated to further assess socioeconomic factors. RESULTS: We included 399 patients under the age of 14 hospitalized for burn injuries at our institution between 2015 and 2021. The median age was 2 (IQR 1-6) years old, and 42.6% were female. High ADI (p = 0.018), Caucasian race (p = 0.001), and flame mechanism (p < 0.001) were independently associated with burn TBSA> 5%. LOS per TBSA was shorter in the Caucasian population (p = 0.022). CONCLUSION: In burn injury patients, further research is necessary to investigate modifiable risk factors in individuals of Caucasian race or lower socioeconomic status to target effective prevention campaigns.

Risk factors for posttraumatic hydrocephalus after decompressive hemicraniectomy in pediatric patients with traumatic brain injury.

OBJECTIVE: Traumatic brain injuries (TBIs) play a significant role in pediatric mortality and morbidity. Decompressive hemicraniectomy (DHC) is a treatment option for severe pediatric TBI (pTBI) not amenable to medical management of intracranial pressure. Posttraumatic hydrocephalus (PTH) is a known sequela of DHC that may lead to further injury and decreased capacity for recovery if not identified and treated. The goal of this study was to characterize risk factors for PTH after DHC in patients with pTBI by using the Kids' Inpatient Database (KID). METHODS: The records collected in the KID from 2016 to 2019 were queried for patients with TBI using International Classification of Diseases, 10th Revision codes. Data defining demographics, complications, procedures, and outcomes were extracted. Multivariate regression was used to identify risk factors associated with PTH. The authors also investigated length of stay and hospital charges. RESULTS: Of 68,793 patients with pTBI, 848 (1.2%) patients underwent DHC. Prolonged mechanical ventilation (PMV) was required in 475 (56.0%) patients with pTBI undergoing DHC. Three hundred (35.4%) patients received an external ventricular drain (EVD) prior to DHC. PTH was seen in 105 (12.4%), and 50 (5.9%) received a ventriculoperitoneal shunt. DHC before hospital day 2 was negatively associated with PTH (OR 0.464, 95% CI 0.267-0.804; p = 0.006), whereas PMV (OR 2.204, 95% CI 1.344-3.615; p = 0.002) and EVD placement prior to DHC (OR 6.362, 95% CI 3.667-11.037; p < 0.001) were positively associated with PTH. PMV (OR 7.919, 95% CI 2.793-22.454; p < 0.001), TBI with subdural hematoma (OR 2.606, 95% CI 1.119-6.072; p = 0.026), and EVD placement prior to DHC (OR 4.575, 95% CI 2.253-9.291; p < 0.001) were independent predictors of ventriculoperitoneal shunt insertion. The mean length of stay and total hospital charges were significantly increased in patients with PMV and in those with PTH. CONCLUSIONS: PMV, presence of subdural hematoma, and EVD placement prior to DHC are risk factors for PTH in patients with pTBI who underwent DHC. Higher healthcare resource utilization was seen in patients with PTH. Identifying risk factors for PTH may improve early diagnosis and efficient resource utilization.

Effect of tracheostomy timing in pediatric patients with traumatic brain injury.

BACKGROUND: Traumatic brain injury (TBI) is a prevalent cause of disability and death in the pediatric population, often requiring prolonged mechanical ventilation. Patients with significant TBI or intracranial hemorrhage require advanced airway management to protect against aspiration, hypoxia, and hypercarbia, eventually necessitating tracheostomy. While tracheostomy is much less common in children compared to adults, its prevalence among pediatric populations has been steadily increasing. Although early tracheostomy has demonstrated improved outcomes in adult patients, optimal tracheostomy timing in the pediatric population with TBI remains to be definitively established. OBJECTIVE: This retrospective cohort analysis aims to evaluate pediatric TBI patients who undergo tracheostomy and to investigate the impact of tracheostomy timing on outcomes. DESIGN/METHODS: The Healthcare Cost and Utilization Project (HCUP) Kids' Inpatient Database (KID), collected between in 2016 and 2019, was queried using International Classification of Disease 10th edition (ICD10) codes for patients with traumatic brain injury who had received a tracheostomy. Baseline demographics, insurance status, and procedural day data were analyzed with univariate and multivariate regression analyses. Propensity score matching was performed to estimate the incidence of medical complications and mortality related to early versus late tracheostomy timing (as defined by median = 9 days). RESULTS: Of the 68,793 patients (mean age = 14, IQR 4-18) who suffered a TBI, 1,956 (2.8%) received a tracheostomy during their hospital stay. TBI patients who were tracheostomized were older (mean age = 16.5 vs 11.4 years), more likely to have injuries classified as severe TBIs and more likely to have accumulated more than one indicator of parenchymal injury as measured by the Composite Stroke Severity Scale (CSSS >1) than non-tracheostomized TBI patients. TBI patients with a tracheostomy were more likely to encounter serious complications such as sepsis, acute kidney injury (AKI), meningitis, or acute respiratory distress syndrome (ARDS). They were also more likely to necessitate an external ventricular drain (EVD) or decompressive hemicraniectomy (DHC) than TBI patients without a tracheostomy. Tracheostomy was also negatively associated with routine discharge. Procedural timing was assessed in 1,867 patients; older children (age >15 years) were more likely to undergo earlier placements (p < 0.001). Propensity score matching (PSM) comparing early versus late placement was completed by controlling for age, gender, and TBI severity. Those who were subjected to late tracheostomy (>9 days) were more likely to face complications such as AKI or deep vein thrombosis (DVT) as well as a host of respiratory conditions such as pulmonary embolism, aspiration pneumonitis, pneumonia, or ARDS. While the timing did not significantly impact mortality across the PSM cohorts, late tracheostomy was associated with increased length of stay (LOS) and ventilator dependence. CONCLUSIONS: Tracheostomy, while necessary for some patients who have sustained a TBI, is itself associated with several risks that should be assessed in context of each individual patient's overall condition. Additionally, the timing of the intervention may significantly impact the trajectory of the patient's recovery. Early intervention may reduce the incidence of serious complications as well as length of stay and dependence on a ventilator and facilitate a timelier recovery.

Infantile Congenital Mesoblastic Nephroma Leading to Multi-Systemic End-Organ Disease.

Congenital mesoblastic nephroma (CMN) is a rare infantile abdominal tumor that is highly curable with early surgical intervention. However, chronic, unrecognized tumor burden can cause significant compression of local vascular and solid structures, resulting in multi-systemic end-organ dysfunction. In this case report, we describe the effects of chronic abdominal compartment syndrome in an infant due to a solid renal tumor and its anesthetic implications.

Socioeconomic characteristics of pediatric traumatic brain injury patients.

BACKGROUND: Traumatic brain injuries (TBIs) play a significant role in pediatric mortality and morbidity. Environment may play a role in the type, severity, and outcome of pediatric TBI (pTBI). Our objective was to characterize the impact of poor socioeconomic status (PSES) on the incidence, treatment, and outcomes of pTBI patients. METHODS: The Kids' Inpatient Database (KID) was queried from 2016 to 2019 for with TBI using International Classification of Disease, 10th revision (ICD 10) codes. Data defining demographics, complications, procedures, and outcomes was extracted. PSES was defined as Medicaid insurance and Q1 median income category. RESULTS: 26,417 patients had pTBI. 11,040 (41.8 %) of pTBI patients were on Medicaid insurance. 13,119 and 8165 (30.9 %) were in Q1 median income category. Land transport caused the majority of pTBI (41 %). Patients on Medicaid or Q1 median income were more likely to experience assault (OR 2.927, CI 95 % 2.455-3.491, p < 0.001 OR 2.033, CI 95 % 1.722-2.4000 p < 0.001 respectively). On propensity matched analysis, PSES was associated with increased mortality (OR 1.667, 95 % CI 1.322-2.100, p < 0.01), length of stay (LOS) (OR 1.369, 95 % CI 1.201-1.559, p < 0.01), and major complicated trauma (OR 1.354 95 % CI 1.090-1.682 p = 0.007). Total hospital charges were higher in pTBI patients on Medicaid ($112,101.52, +/- $203,716.35) versus non-Medicaid ($109,064.37 +/- $212,057.98) (p < 0.001). CONCLUSION: PSES is correlated with increased mortality, complications, and longer LOS. Healthcare coverage and clinical training should take these disparities into account to provide improved care and optimize healthcare resource utilization. LEVEL OF EVIDENCE: Level IV, Retrospective Database.

Mandatory Grand Rounds Evaluations: More Data, Less Information.

AIMS: For several years, physicians have been required to evaluate a continuing medical education (CME) session before receiving a certificate of participation from an accredited provider. The mandatory nature of these evaluations has led to a high number of evaluations that offer information of questionable utility. MATERIAL AND METHODS: We asked our CME evaluation vendor Eeds for all of the CME evaluation timestamps for our grand rounds from August 5 to September 16, 2020. We obtained time-stamped evaluation data from our CME services vendor and compared the times that sessions were evaluated to the start and completion times of those CME sessions. RESULTS: While almost all attendees completed electronic evaluations, 8% did so before the start of the session and half did so before its completion. CONCLUSIONS: Making evaluations mandatory has had the effect of lowering the quality of the data thus obtained. In an age that has been described as the "graying of grand rounds," there are more effective strategies to enhance educational value and learner satisfaction.

Congenital Diaphragmatic Hernia Repair in a Patient With Pallister-Killian Mosaic Syndrome and Left Ventricular Hypoplasia.

We present the case of a two-week-old infant with congenital diaphragmatic hernia (CDH) and Pallister-Killian mosaic syndrome (PKS) for CDH repair. We discuss the pathophysiologic findings of both conditions and the resulting anesthetic challenges from their interplay.

Case Report: Desmoglein-3 Gene Mutation Leading to Airway Compromise in Fraternal Twin Infants.

The desmoglein 3 18q11 gene mutation has not been well described in humans, except for a few case reports. The desmoglein 3 gene controls a transmembrane component of the desmosome complex that mediates epidermal cell adhesion and integrity of the oropharyngeal mucosa. We present two fraternal twin infants who exhibited features of airway compromise and respiratory distress shortly after birth. These infants presented with chronic, cyclical sloughing of the upper airway, larynx, and pharynx associated with difficult airway management and eventual respiratory failure. It is imperative that practitioners be aware of the severity of this rare mutation.

Perioperative use of glucose containing solutions in infants less than 6 months of age: A clinical practice survey among US academic centers.

BACKGROUND: Although there is a wide breadth of literature on glucose homeostasis in infants, standardization of perioperative hypoglycemia diagnosis and management is lacking. AIMS: Survey of academic pediatric anesthesiology departments across the USA to evaluate institutional policies regarding the perioperative use of glucose containing solutions in infants less than 6 months of age. METHODS: A questionnaire was sent to 20 United States university affiliated academic pediatric anesthesiology departments. RESULTS: The responses suggest that, in the centers surveyed, glucose administration in infants is largely practitioner dependent. Two respondents (10%) claim to have a departmental policy regarding glucose administration in infants less than 6 months of age. In premature infants, 75% of respondents administer glucose. When administering glucose, 75% of physicians surveyed replete infants at their maintenance intravenous fluid rate. There was discrepancy among practitioners regarding initiation of hypoglycemia treatment, 35% treat infants at a blood glucose level of 70 mg/dl, 30% at BG 60 mg/dl, 25% at 50 mg/dl, and 10% are unsure. DISCUSSION: This survey highlights the lack of consensus, at least among pediatric anesthesiologists working in US academic centers, regarding blood glucose management in infants less than 6 months of age. There is a need to define the indications for using glucose containing solutions in infants during the perioperative period, their ideal content, the appropriate thresholds for hypo- and hyperglycemia as well as the optimal point-of care glucose monitoring intervals.

A Dangerous Mimic: Chronic Pancreatitis Masquerading As Pancreatic Adenocarcinoma.

Pancreatic adenocarcinoma (PAC) is the most common form of pancreatic cancer in adults, although extremely rare before the age of 40 years. It is known that the cytology of chronic pancreatitis can mimic pancreatic adenocarcinoma. We present a case of a 13-year-old male with chronic pancreatitis that was misdiagnosed as PAC. The patient subsequently underwent a Whipple procedure, highlighting the importance of a correct diagnosis prior to undergoing invasive surgical procedures.

Airway Anesthesia for Awake Tracheal Intubation: A Review of the Literature.

Airway topicalization is frequently utilized by anesthesiologists to facilitate open airway procedures, aid intubation for a difficult airway, and prevent adverse respiratory events. This review article summarizes the techniques available for airway topicalization for a patient who is deemed to be difficult to intubate. We focus on the indications for use, local anesthetic maximum dosages and safety profiles, sedation techniques, and trials and pitfalls during airway topicalization for difficult intubation.

Intraoperative Transesophageal Echocardiography to Monitor for Pulmonary Emboli in a Pediatric Patient Undergoing Undifferentiated Embryonal Sarcoma of the Liver Resection.

A minimally invasive monitoring technique, intraoperative transesophageal echocardiography (TEE), has been utilized to provide real-time data on volume status and ventricular function in patients undergoing liver transplantation. In this case, TEE was utilized in an 8-year-old female undergoing undifferentiated embryonal sarcoma of the liver resection to monitor for pulmonary emboli, particularly a saddle embolus. In addition to visualization of cardiac structures, TEE can also be utilized to monitor the liver, lungs, spleen, and kidneys. Monitoring for echocardiographic findings of pulmonary embolism in this high-risk patient was an integral part of effective intraoperative management.

The Perfect Cytokine Storm: Utilization of Lung Ultrasound During Urgent Surgery in an Infant With Multisystem Inflammatory Syndrome in Children and Hemophagocytic Lymphohistiocytosis.

Reports of children with a temporal association to severe acute respiratory syndrome coronavirus-2 hospitalized with cardiogenic shock or Kawasaki-like disease began emerging in April 2020. In May 2020, the Centers for Disease Control and Prevention published the criteria for what came to be known as multisystem inflammatory syndrome in children, a postinfectious inflammatory immune response to coronavirus disease 2019 exposure. Hemophagocytic lymphohistiocytosis is a heterogeneous disease state associated with systemic hyperinflammation secondary to immune dysregulation. We describe the utility of perioperative lung ultrasound in an infant with both disease states.