Opioid Prescriptions at Discharge After Minimally Invasive Repair of Pectus Excavatum Are Reduced With Cryoablation.

BACKGROUND: The minimally invasive repair of pectus excavatum (MIRPE) is associated with significant postoperative pain and opioid use. The objective of this study was to determine the effect of intercostal nerve cryoablation (Cryo) on inpatient and post-hospital opioid prescription practices following MIPRE. METHODS: A retrospective review at a single pediatric center was conducted of patients ≤21 years old who underwent MIRPE. Oral morphine equivalents (OME) of inpatient and discharge opioids were compared between Cryo and no-Cryo cohorts. RESULTS: 579 patients were identified (82.8% male, mean age 15.4 ± 2.0 years). Cryo was performed in 73.5% of patients. The total inpatient OME use was less in the Cryo group (0.89 ± 0.68 vs. 1.6 ± 0.5 OME/kg/day; p < 0.001). Patients who underwent Cryo were prescribed significantly less OME at discharge compared to the no-Cryo group (3.9 ± 1.7 vs. 10.0 ± 4.1 OME mg/kg, p < 0.001). There was no statistically significant difference in the proportion of patients who required an opioid prescription refill (Cryo 12.4% vs. no-Cryo 11.5%, p = 0.884) or were readmitted (Cryo 5.3% vs. no-Cryo 4.6%, p = 0.833). CONCLUSION: Patients who underwent cryoablation during MIRPE were prescribed significantly less opioid at the time of discharge without increasing the need for opioid refills or hospital readmissions. LEVEL OF EVIDENCE: Treatment study; Level III evidence.

A Pediatric Teletrauma Program Pilot Project: Improves Access to Pediatric Trauma Care and Timely Assessment of Pediatric Traumas.

BACKGROUND: Geographic location is a barrier to providing specialized care to pediatric traumas. In 2019, we instituted a pediatric teletrauma program in collaboration with the Statewide Pediatric Trauma Network at our level 1 pediatric trauma center (PTC). Triage guidelines were provided to partnering hospitals (PH) to aid in evaluation of pediatric traumas. Our pediatric trauma team was available for phone/video trauma consultation to provide recommendations on disposition and management. We hypothesized that this program would improve access and timely assessment of pediatric traumas while limiting patient transfers to our PTC. METHODS: A retrospective cohort study was conducted at the PTC between January 2019 to May 2023. All pediatric trauma patients age < 18 years who had teletrauma consults (TC) were included. We also evaluated all avoidable transfers without TC defined as admission for less than 36 hours without an intervention or imaging as a comparison group. RESULTS: A total of 151 TCs were identified: 62% male and median age of 8 years [IQR:4-12]. TC increased from 12 in 2019 to 100 in 2022-2023 and the number of partnering hospitals increased from 2 to 32. PH were 15-554 miles from the pediatric trauma center, with a median distance of 34 miles [IQR:28-119]. Following consultation, we recommended discharge 34%, admission 29%, or transfer to PTC 35%. Of those that were not transferred, 3% (3/97) required subsequent treatment at the PTC. Non-transferred TC had a higher percentage of TBI (61% vs 31%;p < 0.001) and were from farther, (40 miles[IQR:28-150] vs 30 miles[IQR:28-50];p < 0.001) compared to avoidable transferred patients without a TC. CONCLUSIONS: TC is a safe and viable addition to a pediatric trauma program faced with providing care to a large geographical catchment area. The pediatric teletrauma program provided management recommendations to 32 partnering hospitals and avoided transfer in approximately 63% of cases. LEVEL OF EVIDENCE: IV Treatment study.

A Prospective Study of Sensory Changes in Pediatric Patients After Minimally Invasive Repair of Pectus Excavatum With Cryoablation.

BACKGROUND: Cryoablation during minimally invasive repair for pectus excavatum (MIRPE) reduces opioid use and hospital length of stay. Skin hypoesthesia of the chest wall also occurs. This study sought to determine the frequency, onset, duration, and location of sensory changes and neuropathic pain after cryoablation. METHODS: A prospective study was conducted on patients aged ≤21 years undergoing MIRPE with cryoablation of T3 to T7 dermatomes bilaterally for 120 s at a single institution between March 2021 to December 2022. Patients underwent sensory testing of the chest wall and neuropathic pain surveys (S-LANSS) preoperatively and then postoperatively for 6 months. Incidence and duration of hypoesthesia and neuropathic pain were evaluated. RESULTS: Of 61 patients enrolled in the study, 45 completed evaluations at six months postoperatively. All patients had skin hypoesthesia on postoperative day (POD)1. The mean percentage of the treated anterior chest wall surface area (TACWSA) with hypoesthesia to cold stimulus was 52% (±29.3) on POD 0 and 55% (±19.7) on POD 1. Sensation returned over time, with hypoesthesia affecting 11.1% (±15.5) TACWSA at 6 months. At study completion 58% of patients (26/45) had complete return of sensation; hypoesthesia was found at: 1 dermatome 13% (2/45), 2 dermatomes 22% (11/45), and 3 dermatomes 4% (2/45). Neuropathic pain (S-LANSS ≥12) was documented in 16% (9/55) of patients at hospital discharge but decreased to 6.7% of patients at 6 months. CONCLUSION: Onset of skin hypoesthesia after cryoablation occurred on POD0 and affected 52% of the TACWSA. All patients experienced return of sensation to varying degrees, with 58% experiencing normal sensation in all dermatomes by 6 months. The etiology of persistent hypoesthesia to select dermatomes is unknown but may be related to operative technique or cryoablation. Chronic neuropathic pain is uncommon. LEVEL OF EVIDENCE: II. TYPE OF STUDY: Prognosis Study.

National Management Trends in Pediatric Splenic Trauma - Are We There yet?

INTRODUCTION: Guidelines recommend nonoperative management of blunt splenic injury (BSI) for hemodynamically stable children. The aim of this study was to determine the contemporary national trends of nonoperative management in pediatric BSI. METHODS: A retrospective review was preformed utilizing KIDS database between 2012 and 2019. Pediatric BSI cases age ≤16 years were selected for analysis. Patient demographics, severity, and interventions were compared between hospital types. RESULTS: 8,296 BSIs were identified, with 74.3% treated at non-pediatric hospitals. Overall, 96.3% of BSI were nonoperative; 2.5% undergoing angioembolization. Rates of splenectomy from 2012 to 2019 remained stable (6.8% versus 7.1% (p = 0.856)). Splenic injuries treated at adult hospitals were more likely to undergo operative management (11.9% versus 4.4%, OR 2.94, p < 0.001) and more likely to undergo angiography (4.8% vs 1.3%, OR 3.133, p < 0.001). On multivariate regression pediatric BSI treated at adult centers were associated with triple the risk of splenectomy (OR 3.50, p < 0.001). Over seven years, high grade BSI treated at children's hospitals increased from 14.6% to 51.7% (p < 0.001) and, splenectomy rates at children's hospitals increased from 1% to 4% (p < 0.001). CONCLUSION: More than 70% of pediatric splenic injuries are treated at adult hospitals, however, children's hospitals predominately caring for high-grade BSI. After controlling for confounding factors, children treated at adult centers continue to have 3-fold likelihood of splenectomy. Over the last 7 years, pediatric hospitals have seen a significant rise in their overall splenectomy rate, which may suggest a shift in case severity to children's hospitals. LEVEL OF EVIDENCE: Level III. TYPE OF STUDY: Treatment study.

Long-Term Sensory Function 3 years after Minimally Invasive Repair of Pectus Excavatum with Cryoablation.

INTRODUCTION: Minimally invasive repair of pectus excavatum (MIRPE) with intercostal nerve cryoablation (Cryo) decreases length of hospitalization and opioid use, but long-term recovery of sensation has been poorly described. The purpose of this study was to quantify long-term hypoesthesia and neuropathic pain after MIRPE with Cryo. METHODS: A prospective cohort study was conducted single-institution of patients ≤21 years who presented for bar removal. Consented patients underwent chest wall sensory testing and completed neuropathic pain screening. Chest wall hypoesthesia to cold, soft touch, and pinprick were measured as the percent of the treated anterior chest wall surface area (TACWSA); neuropathic pain was evaluated by questionnaire. RESULTS: The study enrolled 47 patients; 87% male; median age 18.4 years. The median bar dwell time was 2.9 years. A median of 2 bars were placed; 80.9% were secured with pericostal sutures. At enrollment, 46.8% of patients had identifiable chest wall hypoesthesia. The mean percentage of TACWSA with hypoesthesia was 4.7 ± 9.3% (cold), 3.9 ± 7.7% (soft touch), and 5.9 ± 11.8% (pinprick). Hypoesthesia to cold was found in 0 dermatomes in 62%, 1 dermatome in 11%, 2 dermatomes in 17% and ≥3 dermatomes in 11%. T5 was the most common dermatome with hypoesthesia. Neuropathic symptoms were identified by 13% of patients; none required treatment. CONCLUSION: In long-term follow up after MIRPE with Cryo, 46.8% of patients experienced some chest wall hypoesthesia; the average TACWSA with hypoesthesia was 4-6%. Hypoesthesia was mostly limited to 1-2 dermatomes, most commonly T5. Chronic symptomatic neuropathic pain was rare. LEVEL OF EVIDENCE: Level IV.

Pediatric surgical interventions on ECMO.

Extra Corporeal Membrane Oxygenation (ECMO) has historically been reserved for refractory pulmonary and cardiac support in children and adult. Operative intervention on ECMO was traditionally contraindicated due to hemorrhagic complications exacerbated by critical illness and anticoagulation needs. With advancements in ECMO circuitry and anticoagulation strategies operative procedures during ECMO have become feasible with minimal hemorrhagic risks. Here we review anticoagulation and operative intervention considerations in the pediatric population during ECMO cannulation. Pediatric surgical interventions currently described in the literature while on ECMO support include thoracotomy/thoracoscopy, tracheostomy, laparotomy, and injury related procedures i.e. wound debridement. A patient should not be precluded from a surgical intervention while on ECMO, if the surgery is indicated.

Pediatric venoarterial and venovenous ECMO.

Extracorporeal membrane oxygenation (ECMO) is an invaluable resource in the treatment of critically ill children with cardiopulmonary failure.  To date, over 36,000 children have been placed on ECMO and the utilization of this life saving treatment continues to expand with advances in ECMO technology.  This article offers a review of pediatric ECMO including modes and sites of ECMO cannulation, indications and contraindications, and cannulation techniques.  Furthermore, it summarizes the basic principles of pediatric ECMO including circuit maintenance, nutritional support, and clinical decision making regarding weaning pediatric ECMO and decannulation.  Finally, it gives an overview of common pediatric ECMO complications including overall mortality and long-term outcomes of ECMO survivors. The goal of this article is to provide a comprehensive review for healthcare professionals providing care for pediatric ECMO patients.

Preoperative Metal Allergy Testing for Pectus Excavatum Repair Does Not Effectively Identify Patients Who Develop Metal bar Allergy.

BACKGROUND: Metal allergy following placement of a metal pectus bar for minimally invasive repair of pectus excavatum (MIRPE) is a rare complication with potentially significant morbidity. There is no consensus regarding preoperative metal allergy testing (MAT). This study aims to assess incidence of metal allergy and titanium bar use in tested and untested patients and trends in MAT with different approaches to MAT. METHODS: A retrospective chart review was performed on patients who underwent MIRPE from July 2009 to June 2022 at a single institution. During this time, MAT was performed routinely (RT; routine testing) and selectively (ST; selective testing). RESULTS: The cohort included 741 patients for analysis. Metal bar allergy was documented in 1.3 % of all patients; the incidence was 1.3 % in patients with MAT and 1.4 % without MAT. The incidence of bar allergy was 1.1 % in the RT group and 1.6 % in the ST group. In the RT group, bar allergy occurred in 1.4 % (3/216) of patients with a negative MAT. In the ST group, bar allergy occurred in 1.2 % (2/164) of patients with a negative MAT and in 1.9 % (3/162) of untested patients with a stainless-steel bar. Titanium bar use was not significantly different between the RT and ST groups (18.3 % vs 16.3 %, p > 0.05). CONCLUSION: The incidence of metal bar allergy after MIRPE was less than 2 %, and titanium bar use was not significantly different in routine and selective testing groups. MAT was not associated with a reduction in bar allergy, and its use remains unsupported. LEVEL OF EVIDENCE: III.

Vascular Reconstruction After Cannulation for Support With Extracorporeal Membrane Oxygenation: Literature Review of Data in the Pediatric Population.

OBJECTIVES: Extracorporeal membrane oxygenation (ECMO) is an invaluable life-support resource in the treatment of critically ill children. Traditionally, neck vascular cannulation requires ligation of the carotid artery and jugular vein. In this literature review, we identify rates of postoperative vessel patency, complications, and neurologic outcomes after vascular reconstruction following decannulation. DATA SOURCES: Embase, PubMed, and Cochrane Review. STUDY SELECTION: No publication date limits. Inclusion criteria comprised of studies addressing repair of the carotid artery and jugular vein after ECMO decannulation and outcomes from this procedure. DATA EXTRACTION: Authors identified publications on vascular reconstruction after ECMO decannulation, including possible technical considerations, complications, and outcomes. DATA SYNTHESIS: We identified 18 articles: 13 studies were limited to the neonatal population. The largest series included 51 patients after vascular reconstruction. The rate of postoperative arterial occlusion ranged from 11.8% to 17.8%, and overall patency rate postoperatively was 78.6%. No major thromboembolic events were reported. One study demonstrated an increase in neuroimaging abnormalities for patients undergoing ligation compared with vascular reconstruction. No studies demonstrated differences in functional neurodevelopmental testing. CONCLUSIONS: Vascular reconstruction after ECMO decannulation has been reported since 1990. Although reconstruction does not appear to carry significant short-term morbidity, there are no large prospective studies or randomized controlled trials demonstrating its efficacy in improving neurologic outcomes in ECMO patients. There is also a paucity of data regarding outcomes in older children or long-term ramifications of vascular reconstruction.

Intercostal nerve cryoablation therapy for the repair of pectus excavatum: a systematic review.

Introduction: The minimally invasive repair of pectus excavatum (PE) is a painful procedure that can result in long-term hospitalization and opioid use. To mitigate the length of stay and opioid consumption, many different analgesia strategies have been implemented. The aim of this study is to review the use and patient outcomes of intercostal nerve cryoablation (INC) during PE repair reported in the literature. Methods: An unfunded literature search using PubMed identifying articles discussing INC during PE repair from 1946 to 1 July 2023 was performed. Articles were included if they discussed patient outcomes with INC use during PE repair. Articles were excluded if they were reviews/meta-analyses, editorials, or not available in English. Each article was reviewed for bias by analyzing the study methods, data analysis, patient selection, and patient follow-up. Articles comparing outcomes of INC were considered significant if p-value was <0.05. Results: A total of 34 articles were included in this review that described INC use during pectus repair. Most supported a decreased hospital length of stay and opioid use with INC. Overall, INC was associated with fewer short-term and long-term complications. However, the researchers reported varied results of total hospital costs with the use of INC. Conclusion: The review was limited by a paucity of prospective studies and low number of patients who received INC. Despite this, the present data support INC as a safe and effective analgesic strategy during the repair of PE.

Expedited Laparoscopic Cholangiogram and Liver Biopsy in the Workup of Biliary Atresia.

PURPOSE: Recent studies demonstrate the success of Kasai portoenterostomy for biliary atresia (BA) is linearly related to infant age at time of Kasai. We sought to review the feasibility and safety of laparoscopic needle micropuncture cholangiogram with concurrent core liver biopsy (if needed) for expedited exclusion of BA in patients with direct conjugated hyperbilirubinemia. METHODS: Expedited laparoscopic cholangiogram and liver biopsy were instituted at our facility for infants with direct hyperbilirubinemia for whom clinical exam and laboratory workup failed to diagnose. A retrospective chart review was performed in infants <1 year with hyperbilirubinemia from 2016 to 2021. Demographics, preoperative evaluation, procedure details, and complications were reviewed. RESULTS: Two hundred ninety-seven infants with unspecified jaundice were identified, of which, 86 (29%) required liver biopsy. Forty-seven percutaneous liver biopsies were obtained including 8 (17%) in whom BA could not be excluded. Laparoscopic cholangiogram was attempted in 47 infants following basic workup; BA was diagnosed in 22 infants (47%) of which 3 were <18 days old. Biliary patency was demonstrated laparoscopically in 22 of 25 (88%); 3 (12%) required conversion to open cholangiogram. Infants with percutaneous liver biopsy had an average delay of 3 days (range: 2-36) to cholangiogram. Preoperative studies and liver biopsy alone did not reliably exclude the diagnosis of BA. CONCLUSION: Laparoscopic cholangiogram with liver biopsy is a safe procedure resulting in the confirmation or exclusion of BA in infants. Forty-seven percent of infants who underwent laparoscopic cholangiogram were found to have BA; those who were surgical candidates underwent Kasai during the same operation.

Intercostal Nerve Cryoablation for Postoperative Pain Control in Pediatric Thoracic Surgery: A Scoping Review.

Background: Cryoanalgesia uses the application of cold temperatures to temporarily disrupt peripheral sensory nerve function for pain control. This review outlines the principles of cryoablation, clinical applications, and clinical data for its use in pediatric thoracic surgery. Methods: A comprehensive PubMed search was performed using the principal terms and combinations of cryoablation, cryoanalgesia, Nuss, Nuss repair, pectus, pectus excavatum, thoracic surgery, thoracotomy, and chest wall. Pediatric articles were reviewed and included if relevant. Adult articles were reviewed for supporting information as needed. Reference lists of included articles were reviewed for possible additional sources. Discussion: The scientific and clinical principles of cryoablation are outlined, followed by a focused review of current clinical application and outcome data. Conclusion: Postoperative pain is a major challenge following thoracic surgery. Cryoanalgesia is emerging as an adjunct in pediatric thoracic surgery, particularly for the Nuss procedure or minimally invasive repair of pectus excavatum. It effectively controls pain, decreasing postoperative opioid use and hospital length of stay with few short-term complications. Although more long-term studies are needed, early evidence suggests there is reliable return of sensation to the chest wall and long-term neuropathic pain is rare.

Initial Outcomes Using Cryoablation in Surgical Management of Slipping Rib Syndrome.

INTRODUCTION: Minimally invasive repair of pectus excavatum (MIRPE) and cartilaginous rib excision (CRE) for slipping rib syndrome (SRS) are painful procedures. Intercostal nerve cryoablation (Cryo) controls pain and decreases opioid use in MIRPE. Herein, we describe our experience with cryoablation in CRE. METHODS: A retrospective chart review was performed of all patients undergoing CRE between 2018 and 2022. Data on demographics, clinical characteristics, operative details, and hospital course were collected. RESULTS: A total of 98 patients underwent CRE: 68 CRE without cryo, 22 CRE + Cryo, and 8 combined MIRPE + CRE + Cryo. Ninety percent of patients underwent bioabsorbable rib plating. Patients were predominantly female (79%, 73%, 50% respectively) with median ages 17.6, 16.9, and 14.2 years respectively. CRE + Cryo patients used significantly less opioids in hospital (0.6 OME/kg [0.1,1.2]) compared to CRE without cryo (1.0 OME/kg [0.6,2.1]), p < 0.05. The median length of stay (LOS) in CRE + Cryo was 1 day [1,2] compared to 2 days in CRE without cryo [1,2], p = 0.09. MIRPE + CRE + Cryo patients used 0.6 OME/kg [0.2,8.0] with a 2 day [1,5.5] LOS. Ninety-one percent of Cryo patients had cryoablation of T9 and/or T10 intercostal nerves, with no documented abdominal wall laxity at median follow-up of 16 days. Cryo was applied extra-thoracically in CRE + cryo without thoracoscopy or lung isolation, while MIRPE + CRE + Cryo used a combination extra-/intra-thoracic cryoablation in with thoracoscopy. CONCLUSION: Intercostal nerve cryoablation reduces opioid use and LOS in patients undergoing cartilaginous rib excision for slipping rib syndrome. Cryotherapy to as low as T10 did not result in abdominal wall laxity and can be applied extra-thoracically without the need for thoracoscopy. Ongoing prospective studies are required to assess the long-term outcomes. LEVEL OF EVIDENCE: III.

High ligation in adolescents: Is it enough?

BACKGROUND: In adults, the gold standard for surgical repair of an inguinal hernia is a mesh repair, whereas, in children, the standard is high ligation of the hernia sac. However, adolescents represent a "gray zone" between children and adults, and there is no consensus on the most appropriate operation for inguinal hernias in these patients. We aimed to describe the outcomes in adolescents undergoing high ligation for inguinal hernia repair and determine what factors may portend an increased risk of recurrence in this population. METHODS: A retrospective cohort study was performed of all children that underwent open high ligation for an inguinal hernia at our tertiary children's hospital from January 2000 to January 2018, who were 12 to 18 years old at the time of surgery. We compared the patient demographic data, medical history, and repair characteristics for the cohort of hernias that developed a recurrence to the cohort that did not. RESULTS: During our study period, 256 adolescent patients underwent repair with 11 of those patients having both sides repaired for a total of 267 hernias repaired. The median age at surgery was 14.7 years, and 83.9% of the hernias were in male patients. There was a 6.0% recurrence rate, and all patients that developed recurrence underwent a reoperation. The median time from surgery to reoperation for recurrence was 3.1 years. Patients with recurrence were more likely to have cardiac (25.0% vs. 5.8%, p = 0.02) and gastrointestinal comorbidities (25% vs. 7.1%, p = 0.01). There were no other significant differences between the two cohorts. CONCLUSION: High ligation of the hernia sac in adolescents is effective and has an acceptable risk of recurrence while avoiding any additional morbidity that may come from the use of mesh. Patients with cardiac and gastrointestinal comorbidities should be counseled on the higher risk of recurrence.

Effectiveness of ECMO for burn-related acute respiratory distress syndrome.

INTRODUCTION: Acute respiratory distress syndrome (ARDS) is a complication that affects approximately 40% of burn patients and is associated with high mortality rates. Extracorporeal membrane oxygenation (ECMO) therapy is a management option for severe refractory hypoxemic respiratory failure; however, there is little literature reporting the effectiveness of this therapy in burns. Our study objective was to review patient outcomes in burns following severe ARDS treated with ECMO. METHODS: We retrospectively reviewed all patients treated with ECMO for ARDS who received their burn care at a single regional burn center between 9/1/2006 and 8/31/2016. Primary patient outcome examined was discharge disposition. RESULTS: We identified 8 patients who had ARDS secondary to burn who were placed onto ECMO during this 10-year period. The average APACHE score, SOFA score, and P/F ratio were 21±3, 9±2, and 59±8, respectively, at the time of decision for ECMO. No ECMO-related complications were identified. Out of the 8 patients reviewed, 1 died, 4 were discharged to acute rehabilitation or a long-term acute care facility, and 3 were discharged to home. CONCLUSION: Mortality in burn patients with ARDS who are managed with ECMO is extremely low. Careful selection and timely intervention with ECMO contributed to good clinical outcomes.