Potassium Chloride-Induced Phlebitis via a Malpositioned Central Venous Catheter.

We present a case of potassium chloride-induced phlebitis with severe, burning, left-sided chest pain when infused via a malpositioned central venous catheter. Using a malpositioned central venous catheter requires careful consideration, but this novel case prompts the need for additional review before its use for the infusion of potentially irritating medications.

Quality improvement methodology can reduce hospitalisation for abscess management.

BACKGROUND: Abscesses are a common reason for ED visits. While many are drained in the ED, some require drainage in the operating room (OR). We observed that a higher percentage of patients at our institution in Columbus, Ohio, were admitted to the hospital with abscesses for incision and drainage (I&D) in the OR than other institutions, including paediatric institutions. Our aim was to decrease hospitalisations for abscess management. METHODS: A multidisciplinary team convened to decrease hospitalisation for patients with abscesses and completed multiple 'Plan-Do-Study-Act' cycles, including increasing I&Ds performed in the ED. Other interventions included implementation of a clinical pathway, training of procedure technicians (PT), updating the electronic medical record (EMR), credentialing advanced practice nurses in sedation and individual follow-up with providers for admitted patients. Data were analysed using statistical process control charts. Gross average charges were assessed. RESULTS: Admissions for I&D decreased from 26.3% to 13.7%. Abscess drainage in the ED improved from 79.3% to 96.5%. Mean length of stay decreased from 19.5 to 11.5 hours for all patients. Patients sedated increased from 3.3% to 18.2%. The number of repeat I&Ds within 30 days decreased from 4.3% to 1.7%. CONCLUSION: We decreased hospitalisations for abscess I&D by using quality improvement methodology. The most influential intervention was an initiative to increase I&Ds performed in the ED. Additional interventions included expanded training of PTs, implementation of a clinical pathway, updating the EMR, improving interdepartmental communication and increasing sedation providers.

Improving care through standardized treatment of spontaneous pneumothorax.

PURPOSE: The objective of this quality improvement (QI) initiative was to implement a standardized clinical treatment protocol for patients presenting with primary spontaneous pneumothorax (PSP) in order to decrease hospital length of stay (LOS), diagnostic radiation exposure, and related cost. METHODS: Baseline data from patients admitted with PSP from January 1, 2016 to July 31, 2018 were compared to data from patients managed using a newly developed evidence-based treatment pathway from August 1, 2018 to December 31, 2019. Standard QI methodology was used to track results. RESULTS: Fifty-six episodes of PSP were observed during the baseline period and 40 episodes of PSP following initiation of the PSP protocol. The average LOS decreased from 4.5 days to 2.9 days. Patients underwent an average of 8.8 X-rays per admission preintervention versus 5.9 postintervention. The rate of CT scans decreased from 45% to 15% (p = 0.002). There was no significant difference in the rates of 30-day recurrence between the preintervention (13%) and postintervention (10%) groups (p = 0.7). Average admission costs per patient decreased by $1322 after adoption of the pathway. CONCLUSIONS: Adoption of a standardized treatment protocol for PSP led to a reduction in LOS, diagnostic imaging utilization, and cost without increasing clinical recurrence. TYPE OF STUDY: Quality improvement. LEVEL OF EVIDENCE: Level III.

The pediatric surgery match by the numbers: Defining the successful application.

BACKGROUND: Pediatric surgery remains the most competitive general surgery subspecialty. The authors suspected significant inflation in academic metrics since the last published paper. This study aimed to identify factors associated with applicant success in the match. METHODS: After IRB approval, all applications to a single accredited pediatric surgery fellowship program were reviewed for match years 2014-2018. Matched and unmatched applicants were compared in an unadjusted and adjusted analysis. RESULTS: This training program received 414 of 425 total applications (97%). Match results were available for 388 (94%). Matched applicants were more likely to train in programs with pediatric surgery fellowships (64% vs. 28%) and to have dedicated research time (55% vs. 21%; all p < 0.01). Matched applicants had more total publications (median: 12 vs. 7, p < 0.01) and higher ABSITE scores (median: 64th vs. 59th percentile, p < 0.01). Training in multiple programs negatively impacted the chance to match (p < 0.01). The median number of publications per applicant increased over the study time period from 7 to 11 (p < 0.01). CONCLUSIONS: The likelihood of matching into a pediatric surgery fellowship was related to the type of residency attended, dedicated research time, ABSITE scores, and number of publications. Overall, the total number of publications reported by all applicants increased. TYPE OF STUDY: Retrospective Comparative Study. LEVEL OF EVIDENCE: Level III.

Pediatric blunt cerebrovascular injuries: A national trauma database study.

BACKGROUND: The incidence of blunt cerebrovascular injuries (BCVIs) in children is unknown. We aimed to determine the rate and consequences of BCVIs in pediatric blunt trauma patients. METHODS: We queried the National Trauma Data Bank (NTDB) for all blunt trauma patients between 2007 and 2014. BCVI patients were identified by ICD-9 codes. Demographic, emergency room, and concomitant injury data were analyzed. RESULTS: There were 732,702 blunt trauma patients, and 1682 BCVIs were identified (0.23%). 791 (47%) sustained carotid artery injuries (CAIs), 957 (57%) had vertebral artery injuries (VAIs), and 4% of patients sustained both. A majority of the injuries occurred in white patients (61%) and in motor vehicle accidents (53%). The average age was 12.1 ±â€¯5.4 years. CAIs had more skull base fractures (55% vs 35%, p < 0.0001), and cervical spine fractures were more common in VAIs (26 vs 11%, p < 0.0001). Intensive care length of stay was longer in the CAI patients (9.2 vs 7.9 days, p = 0.03), as was length of stay (12.5 vs 9.7 days, p = 0.0002). 5% of CAI patients were coded for stroke, versus 2% of VAIs (p = 0.002). CONCLUSIONS: BCVIs are rare in children. Vertebral injuries are more common. Carotid injuries are associated with a longer length of stay and higher stroke rates. TYPE OF STUDY: Retrospective cohort study. LEVEL OF EVIDENCE: III.

Volume of Irrigation Does Not Affect Rate of Abscess in Perforated Appendicitis.

Background: Although previous studies have evaluated whether use of irrigation decreases postoperative intraabdominal abscess (PO-IAA) formation, these studies treated irrigation as a dichotomous variable and concluded that no irrigation resulted in a decreased incidence of PO-IAA formation. However, a recent study found decreased incidence with small aliquots to a total volume of 6 L. We hypothesized that higher volumes of irrigation would result in a lower incidence of PO-IAA. Materials and Methods: A postoperative template was developed as a quality improvement initiative and included descriptors for complex appendicitis and volume of irrigation. Data were prospectively collected from February 2016 to December 2018. Patients with complex appendicitis (fibropurulent exudate, extraluminal fecalith, well-formed abscess, visible hole in the appendix) were identified and analyzed by using standard statistical analysis. Volume of irrigation was categorized for analysis. Results: Two thousand three hundred six appendicitis patients were identified; 408 had complex appendicitis (17.7%). Three hundred eighty-four patients with complex appendicitis had documented irrigation volumes. The overall incidence of PO-IAA was 13.8%. Irrigation was commonly used (92.7%). The median amount of irrigation was 1000 mL (500 mL, 2500 mL), but it ranged from none to 9000 mL. There was no overall difference in the volume of irrigation used between those who developed a PO-IAA and those who did not (P = .34). No specific intraoperative finding was associated with the development of PO-IAA. Increasing volume of irrigation did not lower PO-IAA incidence (P = .24). Conclusions: The volume of irrigation did not appear to affect the rate of PO-IAA formation. The use of irrigation should be left to the discretion of the operating surgeon.

Use of a Gastroschisis Feeding Guideline to Improve Standardization of Care and Patient Outcomes at an Urban Children's Hospital.

BACKGROUND: This study examined clinical outcomes associated with the use of a gastroschisis-specific (GS) feeding advancement guideline. METHODS: We performed a retrospective study of all simple gastroschisis babies (N = 65) treated between June 2009June 2015. We compared patients treated on a postintestinal surgery guideline using either a 1-day (1D) or 3-day (3D) feeding advancement from August 2009-August 2013 with infants treated on a GS guideline from September 2013-June 2015. RESULTS: Patients in the 2 groups were similar in sex, race, gestational age, weight, and comorbidities. Median time to full enteral nutrition (EN) was 11 days for the 1D group, 22 days for the 3D group, and 18 days for the GS group (P < .01). However, lengths of stay and estimated weight gain per day were similar among the groups. A total of 3 infants (10%) in the 1D group developed necrotizing enterocolitis compared with none in the 3D or GS groups. Control chart analysis showed reduced variation in median time to full EN in the GS group when compared with the 1D and 3D groups. Guideline adherence was significantly better with the GS guideline when compared with the 1D or 3D guidelines (94% vs 72% vs 90%; P < .01). CONCLUSION: A GS protocol yielded reduced variation in median time to full EN, significant improvement in percent adherence to the guideline, and zero cases of necrotizing enterocolitis. Weight gain and lengths of stay were not adversely affected by slower feeds.

The utility of presacral drainage in penetrating rectal injuries in adult and pediatric patients.

BACKGROUND: With changing weaponry associated with injuries in civilian trauma, there is no clinical census on the utility of presacral drainage (PSD) in penetrating rectal injuries (PRIs), particularly in pediatric patients. METHODS: Patients with PRI from July 2004-June 2014 treated at two free-standing children's hospitals and two adult level 1 trauma centers were compared by age (pediatric patients ≤16 years) and PSD. A stratified analysis was performed based on age. The primary outcome was pelvic/presacral abscess. RESULTS: We identified 81 patients with PRI; 19 pediatric, 62 adult. Forty patients had PSD; only three pediatric patients had a drain. Adult patients were more likely to have sustained gunshot wounds (84%), whereas pediatric patients were more likely to sustain impalement injuries (59%). Pediatric patients were more likely to have distal extraperitoneal injuries (56% versus 27% in adults, P = 0.03). PSD was more common in adult patients (59% versus 14%, P = 0.0004), African-Americans (71% versus 11% Caucasian, P < 0.01), and those sustaining gun shot wounds (63% versus 18% impalement, P < 0.01); only race remained significant in stratified analysis for both adult and pediatric patients. There were three cases of pelvic/presacral abscess, all in the adult patients (P = 0.31); one patient with PSD and two without PSD (P = 0.58). In stratified analysis, there were no differences in any infectious complication between those with and without PSD. CONCLUSIONS: Pelvic/presacral abscess is a rare complication of PRI, especially in pediatric patients. PSD is not associated with decreased rates of infectious complications and may not be necessary in the treatment of PRI.

Acute procedural interventions after pediatric blunt abdominal trauma: A prospective multicenter evaluation.

BACKGROUND: Pediatric intra-abdominal injuries (IAI) from blunt abdominal trauma (BAT) rarely require emergent intervention. For those children undergoing procedural intervention, our aim was to understand the timing and indications for operation and angiographic embolization. METHODS: We prospectively enrolled children younger than 16 years after BAT at 14 Level I Pediatric Trauma Centers over a 1-year period. Patients with IAI who received an intervention (IAI-I) were compared with those who did not receive an intervention using descriptive statistics and univariate analysis; p less than 0.05 was considered significant. RESULTS: Two hundred sixty-one (11.9%) of 2,188 patients had IAI. Forty-five (17.2%) IAI patients received an acute procedural intervention (38 operations, seven angiographic embolization). The mean age for patients requiring intervention was 7.1 ± 4.1 years and not different from the population. Most patients (88.9%) with IAI-I were normotensive. IAI-I patients were significantly more likely to have a mechanism of motor vehicle collision (66.7% vs. 38.9%), more likely to present as a Level I activation (44.4% vs. 26.9%), more likely to have a Glascow Coma Scale less than 14 (31.1% vs. 15.5%), and more likely to have an abnormal abdominal physical examination (93.3% vs. 65.7%) than patients that did not require acute intervention. All patients underwent computed tomography scan before intervention. Operations consisted of laparotomy (n = 21), laparoscopy converted to open (n = 11), and laparoscopy alone (n = 6). The most common surgical indications were hollow viscus injury (HVI) (11 small bowel, 10 colon, 6 small bowel/colon, 2 duodenum). All interventions for solid organ injury, including seven angioembolic procedures, occurred within 8 hours of arrival; many had hypotension and received a transfusion. Procedural interventions were more common for HVI than for solid organ injury (59.2% vs. 7.6%). Postoperative mortality from IAI was 2.6%. CONCLUSION: Acute procedural interventions for children with IAI from BAT are rare, predominantly for HVI, are performed early in the hospital course and have excellent clinical outcomes. LEVEL OF EVIDENCE: Prognostic/epidemiologic study, level III; therapeutic study, level IV.

Focused assessment with sonography for trauma in children after blunt abdominal trauma: A multi-institutional analysis.

INTRODUCTION: The utility of focused assessment with sonography for trauma (FAST) in children is poorly defined with considerable practice variation. Our purpose was to investigate the role of FAST for intra-abdominal injury (IAI) and IAI requiring acute intervention (IAI-I) in children after blunt abdominal trauma (BAT). METHODS: We prospectively enrolled children younger than 16 years after BAT at 14 Level I pediatric trauma centers over a 1-year period. Patients who underwent FAST were compared with those that did not, using descriptive statistics and univariate analysis; p value less than 0.05 was considered significant. FAST test characteristics were performed using computed tomography (CT) and/or intraoperative findings as the gold standard. RESULTS: Two thousand one hundred eighty-eight children (age, 7.8 ± 4.6 years) were included. Eight hundred twenty-nine (37.9%) received a FAST, 340 of whom underwent an abdominal CT. Ninety-seven (29%) of these 340 patients had an IAI and 27 (7.9%) received an acute intervention. CT scan utilization after FAST was 41% versus 46% among those who did not receive FAST. The frequency of FAST among centers ranged from 0.84% to 94.1%. There was low correlation between FAST and CT utilization (r = -0.050, p < 0.001). Centers that performed FAST at a higher frequency did not have improved accuracy. The test performance of FAST for IAI was sensitivity, 27.8%; specificity, 91.4%; positive predictive value, 56.2%; negative predictive value, 76.0%; and accuracy, 73.2%. There were 81 injuries among the 70 false-negative FAST. The test performance of FAST for IAI-I was sensitivity, 44.4%; specificity, 88.5%; positive predictive value, 25.0%; negative predictive value, 94.9%; and accuracy, 85.0%. Fifteen children with a negative FAST received acute interventions. Among the 27 patients with true positive FAST examinations, 12 received intervention. All had an abnormal abdominal physical examination. No patient underwent intervention before CT scan. CONCLUSION: As currently used, FAST has a low sensitivity for IAI, misses IAI-I and rarely impacts management in pediatric BAT. LEVEL OF EVIDENCE: Prognostic and epidemiologic study, level II; diagnostic tests or criteria study, level II; therapeutic/care management study, level III.

Health Disparities in the Appropriate Management of Cryptorchidism.

OBJECTIVE: To assess regional practices in management of cryptorchidism with regard to timely fixation by the current recommended age of 18 months. STUDY DESIGN: A retrospective study was performed. Charts of all patients who underwent surgical correction for cryptorchidism by a pediatric general surgeon or urologist within a tertiary pediatric hospital in an urban setting were systematically reviewed. RESULTS: We identified 1209 patients with cryptorchidism. The median age of surgical correction was 3.7 years (IQR: 1.4, 7.7); only 27% of patients had surgical correction before 18 months of age. Forty-six percent of our patients were white, 40% were African American, and 8% were Hispanic. African American and Hispanic patients were less likely to undergo timely repair (P?=?.01), as were those with public or no insurance (P?

Age at presentation and management of pediatric intussusception: A Pediatric Health Information System database study.

BACKGROUND: Intussusception is uncommon in children older than 3 years, and use of enema reduction in older children is controversial. We sought to determine whether older children are at greater risk of requiring operative intervention and/or having pathology causing lead points, such that enema reduction should not be attempted. METHODS: The Pediatric Health Information System database was reviewed from January 1, 2009-June 30, 2014. Patients were followed for 6 months from initial presentation or until bowel resection occurred. Successful enema reduction was defined as having radiologic reduction without additional procedures. RESULTS: A total of 7,412 patients were identified: 6,681 were <3 years old, 731 patients were >3 years old. In those >3 years old, 450 (62%) were treated successfully with enema reduction; the rate of patients with a tumor diagnosis was similar in patients <3 years old and patients >3 years old (5% vs 6%, P = .07). The rate of a Meckel's diagnosis was greater in patients >3 years old (2% vs 14%, P < .0001). In patients >3 years old, duration of stay between patients who underwent primary operative therapy versus those who underwent operative therapy after enema reduction was similar (4 days vs 4 days, P = .06). Older age was not associated with increased risk of recurrent admission for intussusception (P = .45). CONCLUSION: Pediatric Health Information System data suggest that enema reduction may be safe and effective for a majority of children even if older than 3 years.

Health disparities in infants with hypertrophic pyloric stenosis.

BACKGROUND: This study investigates whether health disparities exist in infants with hypertrophic pyloric stenosis (HPS), to identify factors affecting definitive treatment, and if more morbidity occurs. METHODS: A 6-year retrospective analysis was performed on infants with HPS. Analysis of variance was used to evaluate the impact of socioeconomic factors on disease severity and hospitalization. General linear models were used to assess the impact of risk factors on the outcomes. RESULTS: There were a total of 584 infants. African-American's had lower serum chloride (P < .001), higher bicarbonate (P = .001), and sodium levels (P = .006), adding to longer hospitalization than whites (P = .03). Uninsured infants had lower sodium and chloride (P < .001) and higher bicarbonate (P < .001), resulting in a longer time to operation (P = .05) than privately insured infants. In multivariable analyses, African-American's were associated with chloride (P = .002) and higher bicarbonate (P = .009), and uninsured status remained significantly associated with all electrolyte abnormalities. CONCLUSIONS: African-American and poorly insured infants with HPS had greater risk of metabolic derangements. This required more time to correct dehydration and electrolytes, adding to longer hospitalizations.

Standardization of Feeding Advancement After Neonatal Gastrointestinal Surgery: Does It Improve Outcomes?

BACKGROUND: Postabdominal intestinal surgery (PAIS) infants pose many complex management issues. Utilization of feeding guidelines has been shown to improve outcomes in preterm and low-birth-weight infants. We propose that standardization of feeding for PAIS infants is safe. METHODS: We identified 163 PAIS infants: 93 prior to and 70 after implementation of a feeding guideline. The primary outcome was time to full enteral nutrition (EN). A propensity score-matched analysis was performed. RESULTS: The preimplementation and postimplementation PAIS infants were similar at baseline. No significant differences were seen in matched groups for time to full EN, parenteral nutrition days, or time to discharge, but cholestasis was less severe in the postimplementation group and breast milk use increased. Good compliance (67%) to daily guideline use was achieved during the initial 2 years. CONCLUSIONS: Utilization of a feeding guideline is safe and standardizes care within an institution, improving compliance to evidence-based practices and outcomes.

Real-time ultrasonography for placement of central venous catheters in children: A multi-institutional study.

BACKGROUND: Recommendations for the use of real-time ultrasonography for placement of central venous catheters in children are based on studies involving adults treated by nonsurgeons. Our purpose was to determine the frequency of use of real-time ultrasonography use by pediatric surgeons during central venous catheter placement, patient and procedure factors associated with real-time ultrasonography use, and adverse event rates. METHODS: Using data gathered from 14 institutions, we performed a retrospective cohort study of patients <18 years old who underwent central venous catheter placement. Patient demographics and operative details were collected. We used a logistic regression model to evaluate factors associated with real-time ultrasonography use. RESULTS: Real-time ultrasonography was used in 33% of attempts (N = 1,146). The subclavian vein (64%) was accessed preferentially for first site insertion. Real-time ultrasonography was less likely to be used for subclavian vein (odds ratio = 0.002; P < .0001) and more likely to be used when coagulopathy (international normalized ratio >1.5) was present (odds ratio = 11.1; P = .03). The rate of mechanical complications was 3.5%. Real-time ultrasonography use was associated with greater procedural success rates on first-site attempt, but also with a greater risk of hemothorax. CONCLUSION: Pediatric surgeons access preferentially the subclavian vein for central venous access, yet are less likely to use real-time ultrasonography at this site. Real-time ultrasonography was superior to the landmark techniques for the first-site procedure success, yet was associated with greater rates of hemothorax. Prospective trials involving children treated by pediatric surgeons are needed to generate more definitive data.

Improving gastroschisis outcomes: does birth place matter?

PURPOSE: Babies born in the hospital where they obtain definitive surgical care do not require transportation between institutions and may have shorter time to surgical intervention. Whether these differences result in meaningful improvement in outcomes has been debated. A multi-institutional retrospective study was performed comparing outcomes based on birthplace. METHODS: Six institutions within the PedSRC reviewed infants born with gastroschisis from 2008 to 2013. Birthplace, perinatal, and postoperative data were collected. Based on the P-NSQIP definition, inborn was defined as birth at the pediatric hospital where repair occurred. The primary outcome was days to full enteral nutrition (FEN; 120kcal/kg/day). RESULTS: 528 patients with gastroschisis were identified: 286 inborn, 242 outborn. Days to FEN, time to bowel coverage and abdominal wall closure, primary closure rate, and length of stay significantly favored inborn patients. In multivariable analysis, birthplace was not a significant predictor of time to FEN. Gestational age, presence of atresia or necrosis, primary closure rate, and time to abdominal wall closure were significant predictors. CONCLUSIONS: Inborn patients had bowel coverage and definitive closure sooner with fewer days to full feeds and shorter length of stay. Birthplace appears to be important and should be considered in efforts to improve outcomes in patients with gastroschisis.