Variation in Complications and Mortality According to Infant Diagnosis.

OBJECTIVE: Investigate patterns of infant perioperative mortality, describe the infant diagnoses with the highest mortality burden, and evaluate the association between types of postoperative complications and mortality in infants. BACKGROUND: The majority of mortality events in pediatric surgery occur among infants (ie, children <1 y old). However, there is limited data characterizing patterns of infant perioperative mortality and diagnoses that account for the highest proportion of mortality. METHODS: Infants who received inpatient surgery were identified in the National Surgical Quality Improvement Program-Pediatric database (2012-2019). Perioperative mortality was stratified into mortality associated with a complication or mortality without a complication. Complications were categorized as wound infection, systemic infection, pulmonary, central nervous system, renal, or cardiovascular. Multivariable logistic regression was used to evaluate the association between different complications and complicated mortality. RESULTS: Among 111,946 infants, the rate of complications and perioperative mortality was 10.4% and 1.6%, respectively. Mortality associated with a complication accounted for 38.8% of all perioperative mortality. Seven diagnoses accounted for the highest proportion of mortality events (40.3%): necrotizing enterocolitis (22.3%); congenital diaphragmatic hernia (7.3%); meconium peritonitis (3.8%); premature intestinal perforation (2.5%); tracheoesophageal fistula (1.8%); gastroschisis (1.4%); and volvulus (1.1%). Relative to wound complications, cardiovascular [odds ratio (OR): 19.4, 95% confidence interval (95% CI): 13.9-27.0], renal (OR: 6.88; 4.65-10.2), and central nervous system complications (OR: 6.50; 4.50-9.40) had the highest odds of mortality for all infants. CONCLUSIONS: A small subset of diagnoses account for 40% of all infant mortality and specific types of complications are associated with mortality. These data suggest targeted quality improvement initiatives could be implemented to reduce adverse surgical outcomes in infants.

Complications and Failure to Rescue After Inpatient Pediatric Surgery.

OBJECTIVE: To describe the frequency and patterns of postoperative complications and FTR after inpatient pediatric surgical procedures and to evaluate the association between number of complications and FTR. SUMMARY AND BACKGROUND: FTR, or a postoperative death after a complication, is currently a nationally endorsed quality measure for adults. Although it is a contributing factor to variation in mortality, relatively little is known about FTR after pediatric surgery. METHODS: Cohort study of 200,554 patients within the National Surgical Quality Improvement Program-Pediatric database (2012-2016) who underwent a high (≥ 1%) or low (< 1%) mortality risk inpatient surgical procedures. Patients were stratified based on number of postoperative complications (0, 1, 2, or ≥3) and further categorized as having undergone either a low- or high-risk procedure. The association between the number of postoperative complications and FTR was evaluated with multivariable logistic regression. RESULTS: Among patients who underwent a low- (89.4%) or high-risk (10.6%) procedures, 14.0% and 12.5% had at least 1 postoperative complication, respectively. FTR rates after low- and high-risk procedures demonstrated step-wise increases as the number of complications accrued (eg, low-risk- 9.2% in patients with ≥3 complications; high-risk-36.9% in patients with ≥ 3 complications). Relative to patients who had no complications, there was a dose-response relationship between mortality and the number of complications after low-risk [1 complication - odds ratio (OR) 3.34 (95% CI 2.62-4.27); 2 - OR 10.15 (95% CI 7.40-13.92); ≥3-27.48 (95% CI 19.06-39.62)] and high-risk operations [1 - OR 3.29 (2.61-4.16); 2-7.24 (5.14-10.19); ≥3-20.73 (12.62-34.04)]. CONCLUSIONS: There is a dose-response relationship between the number of postoperative complications after inpatient surgery and FTR, ever after common, "minor" surgical procedures. These findings suggest FTR may be a potential quality measure for pediatric surgical care.

Variations in analgesic, sedation, and delirium management between trauma and non-trauma critically ill children.

INTRODUCTION: Studies have shown the benefit of intensive care unit (ICU) bundled protocols; however, they are primarily derived from medical patients. We hypothesized that patients and their medication profiles are different between critically ill medical, surgical, and trauma patients. METHODS: The Pediatric Health Information System 2017 dataset was used to perform a retrospective cohort study of critically ill children. The pediatric medical, surgical, and trauma cohorts were separated based on ICD-10 codes. Data collected included demographics, secondary diagnoses, outcomes, and medication data. Medications were grouped as opiates, GABA-agonists, alpha-2 agonists, anti-psychotics, paralytics, and "other" sedatives. A non-parametric Kolmogorov-Smirnov test (KS test) and odds ratios (reference group: medical cohort) were calculated to compare medication administration between the study cohorts for the first 30 ICU days. RESULTS: A total of 4488 critically ill children (medical 2078, surgical 1650, and trauma 760) were identified. The trauma cohort had increased incidence of delirium (medical 10.8%, surgical 11.5%, trauma 13.8%; p < 0.01) and mortality (medical 5.4%, surgical 2.4%, trauma 11.7%; p < 0.01). For all study cohorts, > 50% received GABA-agonists on ICU days 0-30. With the KS test, there was a significant difference in administration of opiates, GABA-agonists, alpha-2 agonists, anti-psychotics, and "other" sedatives over the first 30 days in the ICU. Relative to medical patients, trauma patients had significantly higher odds of receiving anti-psychotics on ICU days 10-20 and 22-24. CONCLUSION: Critically ill pediatric trauma, medical, and surgical patients are distinctly different patient populations with differing pharmacologic profiles for analgesia, sedation, and delirium. LEVEL OF EVIDENCE: Level III (Retrospective Comparative Study).

Outcomes After Extracorporeal Life Support Cannulation in Pediatric Patients With Trisomy 13 and Trisomy 18.

BACKGROUND: Indications for extracorporeal life support (ECLS) have evolved and expanded, yet its use in trisomy 13 (T13) and trisomy 18 (T18) patients remains controversial. We reviewed the experience of the Extracorporeal Life Support Organization with ECLS in these patients to inform practice at our institution. METHODS: The Extracorporeal Life Support Organization registry was queried for all patients younger than 18 y with an International Classification of Diseases, Ninth Edition/Tenth Edition code for T13 or T18 from 2000 to 2018. Basic demographics, ECLS details, and clinical outcomes were recorded. Descriptive statistics were performed. RESULTS: Twenty-eight patients were identified (15 with T13; 13 with T18), representing 0.06% (28 of 46,901) of pediatric ECLS cannulations. The median weight was 3.5 kg (range, 1.4-13), and age at cannulation was 52 d (range, 0 d-6.8 y). Time on ECLS ranged from 13 to 478 h (median, 114). Cardiac defects were diagnosed in 19 (68%) patients, of which 13 (46%) underwent surgical repair. Median oxygenation index pre-ECLS was 45. Venoarterial cannulations accounted for 82% of patients, whereas 14% underwent venovenous cannulation. Overall survival to hospital discharge was 46% with 86% of patients experiencing one or more complications. There were no survivors when cannulation continued past 12 d. CONCLUSIONS: Although complications are frequent, the mortality rate in patients with T13 and T18 remains within the reported range for the general pediatric population. T13 and T18 alone should not be viewed as absolute contraindications to ECLS within the pediatric population but rather considered during the evaluation of a patient's potential candidacy.

Prenatal Imaging Features and Postnatal Factors Associated with Gastrointestinal Morbidity in Congenital Diaphragmatic Hernia.

BACKGROUND: To perform a comprehensive assessment of postnatal gastrointestinal (GI) morbidity and determine the prenatal imaging features and postnatal factors associated with its development in patients with congenital diaphragmatic hernia (CDH). MATERIALS AND METHODS: A retrospective review was conducted of all infants evaluated for CDH at a quaternary fetal center from February 2004 to May 2017. Prenatal imaging features and postnatal variables were analyzed. GI morbidity was the primary outcome. The Mann-Whitney U test, the Kruskal-Wallis test with Dunnett's T3 post hoc analysis and logistic regression, and the χ2 test were performed when appropriate. RESULTS: We evaluated 256 infants; 191 (75%) underwent CDH repair and had at least 6 months of follow-up. Of this cohort, 60% had gastroesophageal reflux disease (GERD), 13% had gastroparesis, 32% received a gastrostomy tube (G-tube), and 17% needed a fundoplication. Large defect, patch repair, extracorporeal membrane oxygenation (ECMO), and prolonged use of mechanical ventilation were significantly associated with having GERD, gastroparesis, G-tube placement, and fundoplication (p < 0.05). Fetuses with stomach grades 3 and 4 were most likely to have GERD, a G-tube, and a long-term need for supplemental nutrition than fetuses with stomach grades 1 and 2 (p < 0.05). CONCLUSION: Survivors of CDH with large defects, prolonged use of mechanical ventilation, or that have received ECMO may be at an increased risk for having GERD, gastroparesis, and major GI surgery. Marked stomach displacement on prenatal imaging is significantly associated with GI morbidity in left-sided CDH.

Delaying Appendectomy Does Not Lead to Higher Rates of Surgical Site Infections: A Multi-institutional Analysis of Children With Appendicitis.

OBJECTIVES: To investigate the association between time to appendectomy and the risk of surgical site infections (SSIs) in children with appendicitis across multiple NSQIP-Pediatrics institutions. BACKGROUND: Several recently published single institution retrospective studies have reported conflicting relationships between delaying appendectomy and the risk of increasing surgical site infections (SSI) in both children and adults. This study combines data from NSQIP-Pediatrics with institutional data to perform a multi-institutional analysis to examine the effects of delaying appendectomy on surgical site infections. METHODS: Data from NSQIP-Pediatrics between January 2010 and June 2012 for cases of appendectomy for appendicitis at 6 institutions (preoperative characteristics, time of operation, and postoperative occurrences) were combined with data from medical record review (length of symptoms; times of initial presentation, emergency department (ED) triage, and admission; and diagnosis as simple appendicitis (SA, acute) or complicated appendicitis (CA, gangrenous/ruptured)). Cochran-Armitage tests for trend and multivariable logistic regression models were used to evaluate associations between time to appendectomy and SSI. RESULTS: Of the 1338 patients included, 70% had SA and 30% had CA. Postoperative SSIs were more common in CA (5.7% vs 1.2%, P < 0.001). SSI rates did not differ significantly across hospitals (P = 0.17). Compared with patients who did not develop an SSI, patients who developed an SSI had similar times between ED triage and appendectomy (median (interquartile range) 11.5 hours (6.4-14.7) versus 9.7 hours (5.8-15.6, P = 0.36), and similar times from admission to appendectomy (5.5 hours (1.9-10.2) versus 4.3 hours (1.4-9.9), P = 0.36). Independent risk factors for SSI were CA (Odds Ratio (95% CI): 3.46 (1.48-8.10), P = 0.004), longer symptom duration (OR for a 10-hour increase: 1.05 (1.01-1.10), P = 0.02), and presence of sepsis/septic shock (2.70 (1.17-6.28), P = 0.02). CONCLUSIONS: A 16-hour delay from ED presentation or a 12-hour delay from hospital admission to appendectomy was not associated with an increased risk for SSI.

Newborn Direct or Conjugated Bilirubin Measurements As a Potential Screen for Biliary Atresia.

OBJECTIVES: Although screening for biliary atresia (BA) is associated with improved outcomes, no screening program currently exists in the United States. In this study, we explore the possibility of a screening strategy based on newborn direct or conjugated bilirubin (DB or CB) measurements. Our objective is to estimate testing's sensitivity and specificity for BA. METHODS: Two groups were examined retrospectively. For sensitivity calculations, a BA group consisting of infants born between January 2011 and December 2014, diagnosed with BA, and cared for at a pediatric gastroenterology referral center was examined. For specificity calculations, a non-BA group that comprised of infants born between June 2009 and August 2011 in a hospital with a policy of checking newborn bilirubin concentrations was studied. RESULTS: All 35 infants with newborn DB or CB measurements in the BA group had elevated concentrations, translating to a sensitivity of 100% (95% CI 87.7-100). In the non-BA group, 8936 of 9102 infants had DB concentrations within the laboratory's reference interval, translating to a specificity of 98.2% (95% CI 97.9-98.4). Three methods-calculating direct:total bilirubin ratios, using 99% reference intervals, and repeat testing-changed specificity to different degrees. CONCLUSIONS: Newborn DB or CB measurements may have a high sensitivity and specificity for BA. Specificity can be further improved by using 99% reference intervals and/or repeat testing. Our findings can serve as the foundation for larger prospective studies, to determine whether newborn DB or CB measurements can be an effective screening strategy for BA.

Feeding gastrostomy in children with complex heart disease: when is a fundoplication indicated?

PURPOSE: Malnutrition is common among children with complex heart disease (CHD). Feeding gastrostomies are often used to improve the nutritional status of such patients. Our purpose was to evaluate a cohort of children with CHD following open Stamm gastrostomy without fundoplication. METHODS: We reviewed all CHD patients who underwent feeding gastrostomy placement from 1/1/2004 to 4/7/2015. Demographic data, cardiac diagnoses, operative details, post-operative complications, and the need for GJ feeding and fundoplication were examined. RESULTS: Open Stamm gastrostomy was performed in 111 patients. Median age at surgery was 37 weeks (3 weeks-13.7 years); average weight was 5.3 ± 4.9 kg. Thirty-four patients (30 %) experienced a total of 37 minor complications, including tube dislodgement after stoma maturation (20), superficial surgical site infection (13), mechanical failure (3), and bleeding (1). Three patients experienced a major complication (need for return to the OR or peri-operative death <30 days). Three patients required a subsequent fundoplication. Fifty-six surviving patients (62 %) continue gastrostomy feeds, of which 7 (13 %) patients require GJ feeds. CONCLUSION: Children with CHD tolerate an open Stamm gastrostomy well with minimal major complications. These results support very selective use of fundoplication in infants and children with CHD who require a feeding gastrostomy.

Management of traumatic duodenal hematomas in children.

BACKGROUND: Duodenal hematomas from blunt abdominal trauma are uncommon in children and treatment strategies vary. We reviewed our experience with this injury at a large-volume children's hospital. MATERIALS AND METHODS: A retrospective case series was assembled from January 2003-July 2014. Data collected included demographics, clinical and radiographic characteristics, and hospital course. Patients with grade I injuries based on the American Association for the Surgery of Trauma Duodenum Injury Scale were compared with those with grade II injuries. RESULTS: Nineteen patients met inclusion criteria at a median age of 8.91 y (range, 1.7-17.2 y). Mechanisms of injury included direct abdominal blow or handle bar injury (n = 9), nonaccidental trauma (n = 5), falls (n = 3), and motor vehicle accident (n = 2). Ten patients had grade I hematomas and nine had grade II. Hematomas were most frequently seen in the second portion of the duodenum (n = 9). Five patients underwent a laparotomy for concerns for hollow viscus injury. No patients required operative drainage of the hematoma; however, one patient underwent percutaneous drainage. Twelve patients received parenteral nutrition (PN) for a median duration of 9 d (range, 5-14 d). Median duration of PN for grade I was 6.5 d (range, 5-8 d) versus 12 d for grade II (range, 9-14 d; P = 0.016). Complications included one readmission for concern of bowel obstruction requiring bowel rest. CONCLUSIONS: This study suggests that duodenal hematomas can be successfully managed nonoperatively. Grade II hematomas are associated with longer duration of PN therapy and consequently longer hospital stays. These data can assist in care management planning and parental counseling for patients with traumatic duodenal hematomas.

Management of appendiceal carcinoid tumors in children.

BACKGROUND: Appendiceal carcinoid tumors, also know as well-differentiated neuroendocrine neoplasms, are rare lesions detected incidentally after appendectomy in children. There are limited data about the natural history of these tumors, and guidelines regarding family counseling and need for additional surgery or follow-up imaging are not established in the pediatric age group. The purpose of this study was to review our institutional experience with appendiceal carcinoid tumors to provide data that might improve management. METHODS: After institutional review board approval, the charts of all patients treated at our institution for an appendiceal carcinoid tumor between 2002 and 2014 were reviewed. Data collected included patient demographics, pathologic details, postoperative management, and follow-up information. Descriptive analyses were performed. RESULTS: Twenty-eight patients were identified, which represents an incidence of 0.2% of children undergoing appendectomy during that time interval. The mean age at surgery was 13.8 ± 2.1 y; 54% were females. Two patients had symptoms suspicious for carcinoid syndrome at presentation, though none had evidence of metastatic disease. The mean tumor size was 0.73 ± 0.4 cm. Five patients (18%) underwent subsequent ileocecectomy or right hemicolectomy because of pathologic findings of invasion of the mesoappendix (n = 4) or lymphovascular invasion and subserosal extension (n = 1), two of whom had residual disease in the resected specimen (one in a lymph node). No recurrences have been detected at mean follow-up of 1.8 y. CONCLUSIONS: Appendiceal carcinoid tumors are discovered incidentally in about 0.2% of children undergoing appendectomy. Based on findings from a large contemporary series, we can conclude that these tumors are generally small and demonstrate lymphovascular invasion or mesenteric extension in fewer than 20% of cases. Prospective, multicenter studies are necessary to better define the indication for ileocecectomy and follow-up imaging protocols.

Image-guided prediction of pseudocyst formation in pediatric pancreatic trauma.

BACKGROUND: To determine if there is an effective alternative to the current standard of computed tomography (CT) grading of pediatric pancreatic injuries. We hypothesized that the Wong grading scale, which is based on the depth and location of the pancreatic laceration, is more predictive of pseudocyst formation than the American Association for the Surgery of Trauma (AAST) scale after nonoperative management of traumatic pancreatic injury in children. MATERIALS AND METHODS: A retrospective review of children admitted for pancreatic trauma to two level 1 pediatric trauma centers between 2000 and 2012 was conducted. Patients who underwent primary operation were excluded. Initial CT scans were reviewed by two radiologists blinded to clinical outcomes, and injury grades from both scales were assigned. The primary outcome was pseudocyst formation. RESULTS: Fifty-three patients (ages 7 mo-17 y) were included. As per the Wong scale, pseudocysts occurred in 0/20 patients with grade A injuries, 2/17 (12%) with BI/CI injuries, and 9/15 (60%) with BII/CII injuries. Using the AAST scale, pseudocysts developed in 2/27 (7%) patients with grade I/II injuries, 7/20 (35%) patients with III/IV/V injuries, and 1/6 (17%) patients with a scan that was indeterminate between grades II and III. Positive Predictive value, negative predictive value, sensitivity, and specificity for pseudocyst formation were all higher using the Wong scale (AAST/Wong: Positive Predictive value 42%/50%, negative predictive value 91%/94%, sensitivity 80%/82%, and specificity 65%/77%). CONCLUSIONS: The Wong CT grading scale may be superior to the AAST scale for early risk stratification for pseudocyst development after nonoperative management of pediatric pancreatic trauma; however, a larger study is needed for verification of these findings.

Performance of CT examinations in children with suspected acute appendicitis in the community setting: a need for more education.

OBJECTIVE: Despite a recent focus on the preferential use of ultrasound over CT for pediatric appendicitis, most children transferred from community hospitals still undergo diagnostic CT scans. The purpose of this study was to evaluate CT techniques performed for children with acute appendicitis at nonpediatric treatment centers. MATERIALS AND METHODS: All patients treated for acute appendicitis at our tertiary-care pediatric hospital from July 1, 2011, through June 30, 2012, were identified. Patient demographics, imaging modality used to diagnoses appendicitis (CT or ultrasound), location (home or referral institution), and CT technique parameters were collected. The estimated mean organ radiation dose, number of imaging phases, and use of contrast media were evaluated at home and referral institutions. RESULTS: During the study period, 1215 patients underwent appendectomies after imaging, with 442 (36.4%) imaged at referral facilities. Most referral patients received a diagnosis by CT (n=384, 87%), compared with 73 of 773 (9.4%) who received a diagnosis by CT at the home institution. The estimated mean (±SD) organ radiation dose was not statistically significantly different between home and referral institutions (13.5±7.3 vs 12.9±6.4 mGy; p=0.58) for single-phase examinations. Of 384 referral patients, 344 had images available for review. In total, 40% (138/344) of patients from referral centers were imaged with suboptimal CT techniques: 50 delayed phase only, 52 dual phase (eight of which were imaged twice in delayed phase), eight triple phase, and 36 without IV contrast agent. CONCLUSION: CT parameters and radiation doses from single-phase examinations in children with appendicitis were similar at nonpediatric treatment centers and a tertiary care children's hospital. Future educational outreach should focus on optimizing other technical parameters.

Development and validation of an ultrasound scoring system for children with suspected acute appendicitis.

BACKGROUND: To facilitate consistent, reliable communication among providers, we developed a scoring system (Appy-Score) for reporting limited right lower quadrant ultrasound (US) exams performed for suspected pediatric appendicitis. OBJECTIVE: The purpose of this study was to evaluate implementation of this scoring system and its ability to risk-stratify children with suspected appendicitis. MATERIALS AND METHODS: In this HIPAA compliant, Institutional Review Board-approved study, the Appy-Score was applied retrospectively to all limited abdominal US exams ordered for suspected pediatric appendicitis through our emergency department during a 5-month pre-implementation period (Jan 1, 2013, to May 31, 2013), and Appy-Score use was tracked prospectively post-implementation (July 1, 2013, to Sept. 30,2013). Appy-Score strata were: 1 = normal completely visualized appendix; 2 = normal partially visualized appendix; 3 = non-visualized appendix, 4 = equivocal, 5a = non-perforated appendicitis and 5b = perforated appendicitis. Appy-Score use, frequency of appendicitis by Appy-Score stratum, and diagnostic performance measures of US exams were computed using operative and clinical finding as reference standards. Secondary outcome measures included rates of CT imaging following US exams and negative appendectomy rates. RESULTS: We identified 1,235 patients in the pre-implementation and 686 patients in the post-implementation groups. Appy-Score use increased from 24% (37/155) in July to 89% (226/254) in September (P < 0.001). Appendicitis frequency by Appy-Score stratum post-implementation was: 1 = 0.5%, 2 = 0%, 3 = 9.5%, 4 = 44%, 5a = 92.3%, and 5b = 100%. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were 96.3% (287/298), 93.9% (880/937), 83.4% (287/344), and 98.8% (880/891) pre-implementation and 93.0% (200/215), 92.6% (436/471), 85.1% (200/235), and 96.7% (436/451) post-implementation - only NPV was statistically different (P = 0.012). CT imaging after US decreased by 31% between pre- and post-implementation, 8.6% (106/1235) vs. 6.0% (41/686); P = 0.048). Negative appendectomy rates did not change (4.4% vs. 4.1%, P = 0.8). CONCLUSION: A scoring system and structured template for reporting US exam results for suspected pediatric appendicitis was successfully adopted by a pediatric radiology department at a large tertiary children's hospital and stratifies risk for children based on their likelihood of appendicitis.

Overuse of fluoroscopic gastrostomy studies in a children's hospital.

BACKGROUND: Gastrostomy tubes are often dislodged or exchanged in children. Indications for fluoroscopic examination of gastrostomy location include concern for malposition, dislodgement, leak, or gastric outlet obstruction. We hypothesized that most of the studies obtained at our institution were not ordered for one of the aforementioned indications and do not ultimately affect patient management. METHODS: All fluoroscopic gastrostomy studies performed from January 2011 to December 2012 were reviewed. Transgastric jejunostomy studies were excluded. Patient demographics, indications for the study, elapsed time since placement, imaging findings, and short-term outcomes were recorded. Chi-square analysis was used to evaluate relationships between categorical variables. RESULTS: During the study period, 337 patients who underwent fluoroscopic gastrostomy studies were identified; median age was 2.5 y (0.05-23.8). Sixty-two percent (208/337) of the studies were ordered in asymptomatic patients to confirm tube placement location after routine exchange or replacement. Symptomatic patients accounted for 38% of the studies. Ordering physicians were primarily nonsurgeons (72%, 242/337). Abnormal findings were observed in 4.8% (16/337) of patients, six (1.7%) of whom required an operative intervention. The 2.9% (6/208) abnormal study rate for asymptomatic patients was significantly lower than the 7.9% (10/129) rate in the patients who were evaluated for symptomatic indications (P = 0.03). CONCLUSIONS: Most of the fluoroscopic gastrostomy studies ordered at a tertiary care center did not appear to alter patient care. Development of a standardized management algorithm based on clinical indications is necessary to decrease the number of extraneous gastrostomy studies.

Identifying and reducing early complications of surgical central lines in infants and toddlers.

BACKGROUND: Hospitalized infants>1 y old often require central venous catheters (CVC) for prolonged therapy. There are limited data describing the complication profile for this young population. The purpose of this study was to review outcomes associated with CVC insertion in this high-risk group and compare them to those in older children to develop directed quality improvement projects. MATERIALS AND METHODS: Patients receiving their first CVC, a tunneled central line or port-a-cath, from 2007-2010 were included. Femoral, non-tunneled, and hemodialysis catheters were excluded. Patients aged 0-12.0 mo (infants) were compared with those 12.1-36 mo (toddlers). Complications (<30 d) included infection, malposition, malfunction, intraoperative, and the need for operative exchange. Statistical analysis included Student t-test, chi-square, and a Kaplan-Meier survival analysis. RESULTS: We identified 115 infants and 129 toddlers who underwent CVC insertion during the study period. Complication rates were higher in the infant group than in the toddler group, as was the operative exchange rate. Higher infection rates in the infant group appeared to contribute to the difference in early complications and exchange rates. A survival analysis indicated improved catheter duration in toddlers (P=0.001). CONCLUSIONS: In this cohort study, infants had a higher early complication rate, mostly attributable to infection, than their older counterparts. This difference could be explained by increased use of a tunneled central line for daily total parented nutrition in infants with gastrointestinal anomalies, as opposed to port-a-cath for chemotherapy infusion in older children. These data have prompted a number of targeted quality improvement initiatives to address relevant complications in this infant population.

Comparing characteristics and outcomes in infants with prenatal and postnatal diagnosis of esophageal atresia.

BACKGROUND: Previous studies of infants with esophageal atresia (EA) suggest those diagnosed prenatally have worse outcomes because of a higher incidence of associated anomalies. The purpose of this study was to compare characteristics and outcomes of infants with EA diagnosed after fetal center evaluation to those diagnosed postnatally. METHODS: The records of all neonates treated for EA at our institution from 2002-2012 were reviewed. Infants with a prenatal diagnosis of EA were compared with those postnatally diagnosed using chi-square and Student t-test as appropriate. RESULTS: Of 91 patients treated with EA during the study period, 15 (16%) were diagnosed prenatally at our fetal center. Although those prenatally diagnosed had a higher incidence of pure EA and polyhydramnios, the gestational age and birth weight in that group were similar to those diagnosed postnatally. There were no differences in outcomes between groups with regard to the incidence of major cardiac anomalies, surgical complications, hospital length of stay, and survival. CONCLUSIONS: Treatment at a tertiary care center provides excellent outcomes for all infants with EA, despite an 80% frequency of concurrent anomalies. Prenatal diagnosis of EA and attentive obstetric management of polyhydramnios decrease the risk for prematurity and prematurity-associated morbidity.

The management of an ectopic ovary in the inguinal canal: literature review and discussion.

We report the case of a female adolescent who had an ectopic ovary in the inguinal canal without an associated hernia, a unicornuate uterus, and ipsilateral renal agenesis. The incidental discovery of the ectopic ovary and other Mullerian anomalies, as well as the surgical correction that followed, highlights important fertility considerations in children and available treatment algorithms for these rare cases.

Assessment and standardization of resident handoff practices: PACT project.

BACKGROUND: Accreditation Council for Graduate Medical Education duty hour guidelines have resulted in increased patient care transfers. Although structured hand-over processes are required in the guidelines, how to implement these processes is not defined. The purpose of this study is to investigate current handoff methods at our center in order to develop an effective structured handoff process. MATERIALS AND METHODS: This is a prospective study conducted at two hospitals with large in-house patient censuses. Resident focus groups were used to define current practices and future directions. Based on this input, we developed a direct observation handoff analysis tool to study time spent in handoffs, content, quality, and number of interruptions. RESULTS: Trained medical students observed 86 handoffs. Survey response rates among junior and senior residents were 63% and 54%, respectively. Average daily patient census was 36 ± 10 patients with an average handoff time of 12 ± 9 min. There were 1.5 ± 1.8 interruptions per handoff. The majority of handoffs were unstructured. Based on information they were given in the handoff, junior residents had a 58% rate of incompletion of the assigned tasks and 54% incidence of being unable to answer a key patient status question. CONCLUSIONS: Current handoffs are primarily unstructured, with significant deficits. Determination of key elements of an effective handoff coupled with evaluation of existing deficiencies in our program is essential in developing an institution-specific method for effective handoffs. We propose utilization of the mnemonic PACT (Priority, Admissions, Changes, Task) to standardize handoff communication.

Modification of an evidence-based protocol for advanced appendicitis in children.

INTRODUCTION: We previously developed an evidence-based clinical pathway for children with advanced appendicitis. The pathway standardized the choice and duration of antibiotic therapy and established discharge criteria. Initially, the pathway led to a 50% decrease in the rate of superficial and deep surgical site infections and a significant decrease in hospital length of stay. Four years after implementation, we noted an increase in the infectious complication rate and the emergence of resistant bacteria to commonly used antibiotics. In this study, we prospectively collected peritoneal fluid cultures at the time of appendectomy in an effort to optimize our antibiotic therapy and decrease complication rates. METHODS: Microbiology analysis of peritoneal fluid cultures obtained at the time of appendectomy was performed in patients with an intraoperative diagnosis of advanced appendicitis. Clinical information, including demographics, laboratory data, and postoperative outcomes were collected and compared to the historic cohort. X(2), Student's t-test, and Fisher exact test were used where appropriate. RESULTS: The historic and prospective cohorts were similar with respect to clinical and demographic data. The postoperative intra-abdominal abscess rate remained unchanged (28% from 24%, P = 0.603). Escherichia coli and Pseudomonas aeruginosa were the most commonly isolated aerobic bacteria from peritoneal fluid in the prospective cohort. Thirty-two percent of these patients had Pseudomonas spp., and 12% had Enterococcus spp. or Escherichia coli resistant to cefoxitin in their peritoneal fluid cultures. DISCUSSION: A significant proportion (40%) of children with advanced appendicitis had organisms either not susceptible or resistant to our first line antibiotic in their peritoneal fluid cultures. Our clinical pathway now recommends piperacillin-tazobactam as the most effective empiric therapy for advanced appendicitis in children. Microbiologic analysis of peritoneal fluid at appendectomy may be used to tailor antibiotic therapy in advanced appendicitis.

Evaluating the effectiveness of a discharge protocol for children with advanced appendicitis.

BACKGROUND: In 2006, an evidence-based protocol for the management of children with appendicitis was established at our institution. Discharge criteria for patients with advanced appendicitis were based on a combination of clinical parameters and laboratory values. The purpose of this study is to evaluate the utility of laboratory values in guiding patient management with a discharge protocol for advanced appendicitis. MATERIALS AND METHODS: We reviewed charts of patients with advanced appendicitis as defined by the surgeon intraoperatively from 2008-2009. We evaluated the sensitivity and specificity of the laboratory values at discharge for predicting postoperative intra-abdominal abscess (IAA) formation using a receiver operator curve. A logistic regression analysis was performed to identify predictors of IAA formation. RESULTS: We identified 450 patients (mean age 8.9 ± 3.9 y). The postoperative IAA rate was 25%. The sensitivity and specificity for developing an abscess with a white blood cell count >12,000/UL were 52% and 82%, respectively (AUC 0.72, 95% CI 0.67-0.78, P < 0.001). The sensitivity and specificity for bands >3% were 47% and 70% (AUC 0.60, 95% CI 0.53-0.67, P = 0.002), respectively. On logistic regression analysis, an elevated white blood cell count was independently associated with an increased likelihood of a postoperative IAA (OR 1.27, 95% CI 1.19-1.35, P < 0.001). CONCLUSIONS: The absence of leukocytosis is useful for identifying children with a decreased risk of postappendectomy IAA formation who otherwise meet clinical discharge parameters. A band count is not as predictive of risk. The use of laboratory evaluation as a component of discharge criteria in advanced appendicitis can stratify a subset of patients who are at increased IAA risk and may benefit from continued antibiotic therapy.