Characteristics and Predictors of Intensive Care Unit Admission in Pediatric Blunt Abdominal Trauma

BACKGROUND: Pediatric trauma patients sustaining blunt abdominal trauma (BAT) with intra-abdominal injury (IAI) are frequently admitted to the intensive care unit (ICU). This study was performed to identify predictors for ICU admission following BAT. METHODS: Prospective study of children (\u3c 16 years) who presented to 14 Level-One Pediatric Trauma Centers following BAT over a 1-year period. Patients were categorized as ICU or non-ICU patients. Data collected included vitals, physical exam findings, laboratory results, imaging, and traumatic injuries. A multivariable hierarchical logistic regression model was used to identify predictors of ICU admission. Predictive ability of the model was assessed via tenfold cross-validated area under the receiver operating characteristic curves (cvAUC). RESULTS: Included were 2,182 children with 21% (n = 463) admitted to the ICU. On univariate analysis, ICU patients were associated with abnormal age-adjusted shock index, increased injury severity scores (ISS), lower Glasgow coma scores (GCS), traumatic brain injury (TBI), and severe solid organ injury (SOI). With multivariable logistic regression, factors associated with ICU admission were severe trauma (ISS \u3e 15), anemia (hematocrit \u3c 30), severe TBI (GCS \u3c 8), cervical spine injury, skull fracture, and severe solid organ injury. The cvAUC for the multivariable model was 0.91 (95% CI 0.88-0.92). CONCLUSION: Severe solid organ injury and traumatic brain injury, in association with multisystem trauma, appear to drive ICU admission in pediatric patients with BAT. These results may inform the design of a trauma bay prediction rule to assist in optimizing ICU resource utilization after BAT. STUDY DESIGN: Prognosis study

Association of Gangrenous, Suppurative, and Exudative Findings With Outcomes and Resource Utilization in Children With Nonperforated Appendicitis.

IMPORTANCE: The clinical significance of gangrenous, suppurative, or exudative (GSE) findings is poorly characterized in children with nonperforated appendicitis. OBJECTIVE: To evaluate whether GSE findings in children with nonperforated appendicitis are associated with increased risk of surgical site infections and resource utilization. DESIGN, SETTING, AND PARTICIPANTS: This multicenter cohort study used data from the Appendectomy Targeted Database of the American College of Surgeons Pediatric National Surgical Quality Improvement Program, which were augmented with operative report data obtained by supplemental medical record review. Data were obtained from 15 hospitals participating in the Eastern Pediatric Surgery Network (EPSN) research consortium. The study cohort comprised children (aged ≤18 years) with nonperforated appendicitis who underwent appendectomy from July 1, 2015, to June 30, 2020. EXPOSURES: The presence of GSE findings was established through standardized, keyword-based audits of operative reports by EPSN surgeons. Interrater agreement for the presence or absence of GSE findings was evaluated in a random sample of 900 operative reports. MAIN OUTCOMES AND MEASURES: The primary outcome was 30-day postoperative surgical site infections (incisional and organ space infections). Secondary outcomes included rates of hospital revisits, postoperative abdominal imaging, and postoperative length of stay. Multivariable mixed-effects regression was used to adjust measures of association for patient characteristics and clustering within hospitals. RESULTS: Among 6133 children with nonperforated appendicitis, 867 (14.1%) had GSE findings identified from operative report review (hospital range, 4.2%-30.2%; P \u3c .001). Reviewers agreed on presence or absence of GSE findings in 93.3% of cases (weighted κ, 0.89; 95% CI, 0.86-0.92). In multivariable analysis, GSE findings were associated with increased odds of any surgical site infection (4.3% vs 2.2%; odds ratio [OR], 1.91; 95% CI, 1.35-2.71; P \u3c .001), organ space infection (2.8% vs 1.1%; OR, 2.18; 95% CI, 1.30-3.67; P = .003), postoperative imaging (5.8% vs 3.7%; OR, 1.70; 95% CI, 1.23-2.36; P = .002), and prolonged mean postoperative length of stay (1.6 vs 0.9 days; rate ratio, 1.43; 95% CI, 1.32-1.54; P \u3c .001). CONCLUSIONS AND RELEVANCE: In children with nonperforated appendicitis, findings of gangrene, suppuration, or exudate are associated with increased surgical site infections and resource utilization. Further investigation is needed to establish the role and duration of postoperative antibiotics and inpatient management to optimize outcomes in this cohort of children

Quality improvement 101 for surgeons: Navigating the alphabet soup

It is a fundamental value of the surgical profession to improve care for its patients. In the last 100 years, the principles of prospective quality improvement have started to work their way into the traditional method of retrospective case review in morbidity and mortality conference. This article summarizes the history of improvement science and its intersection with the field of surgery. It attempts to clarify the principles and jargon that may be new or confusing to surgeons with a different vocabulary and experience. This is done to bring the significant power and resources of improvement science to the traditional efforts to improve surgical care

Epiphrenic esophageal diverticulum in an adolescent with a history of a Nissen fundoplication: A case report

Epiphrenic esophageal diverticuli (EED) are exceedingly rare in children. While esophageal dysmotility is often associated with this diagnosis in adults, the few reports in children implicate retained foreign bodies as the cause. The patient presented here is an 18 year-old female with a distant history of a Nissen fundoplication who developed dysphagia, gastroesophageal reflux, and weight loss, and was found to have an EED. Her symptoms completely resolved following laparoscopic diverticulectomy and hiatal hernia repair. Though the exact etiology of her EED remained unclear, it may have been related to her fundoplication. This potential late complication may be seen more frequently as a large number of children with a history of fundoplication are reaching adulthood

Repair of congenital H-type tracheoesophageal fistula by electrocautery

Background: Congenital H-type tracheoesophageal fistula is a rare type of congenital tracheoesophageal malformation. In this malformation, the esophagus remains unobstructed, complicating and delaying the diagnosis. We present our experience with three infants with congenital H-type tracheoesophageal fistula who were initially treated by a minimally invasive approach via endoscopy with electrocautery. Results: Two of the three patients ultimately required a surgical procedure after failure to close the fistula via electrocautery despite multiple attempts over several months. One of the three patients was successfully treated via electrocautery after the second procedure. Conclusions: In our center, three infants with congenital H-type tracheoesophageal fistula were initially treated endoscopically with electrocautery. Two out of the three ultimately required a surgical procedure. If considering endoscopy with electrocautery, providers and families should recognize that the procedure may need to be performed several times before the fistula is successfully closed. Additionally, failed attempts may put patients at risk for complications such as respiratory decompensation, pneumonia and poor growth and may prolong hospitalization

A tissue engineering approach for prenatal closure of myelomeningocele: Comparison of gelatin sponge and microsphere scaffolds and bioactive protein coatings

Miho Watanabe, Hiaying Li, Jessica Roybal, Matthew Santore, Antonetta Radu, Jun-Ichiro Jo, Michio Kaneko, Yasuhiko Tabata, and Alan Flake. Tissue Engineering Part A.Apr 2011.1099-1110. http://doi.org/10.1089/ten.tea.2010.039

Minimally invasive surgery for pediatric trauma - A multicenter review

© Mary Ann Liebert, Inc. 2015. Introduction: The published experience with minimally invasive techniques to treat injured children is currently small. In this multicenter case series, we aimed to characterize the contemporary role of minimally invasive surgery (MIS) in pediatric trauma. Materials and Methods: After obtaining Institutional Review Board approval at six pediatric regional trauma centers in the United States, a retrospective review was conducted on children who have undergone thoracoscopy or laparoscopy for the management of trauma over the past 13 years. Results: There were 200 patients with a mean age of 9.6±4.2 years, and 73% were male. Laparoscopy was performed for 187 (94%) and thoracoscopy for 8 (4%), whereas 5 (2%) patients had both, for a total of 205 MIS procedures. Conversion to open surgery occurred in 36% (n=73). Median operative time was 77 (range, 16-369) minutes. Of the 132 procedures completed without conversion, 81 (61%) were diagnostic, whereas the remaining were therapeutic, including the repair of bowel injuries (n=20), distal pancreatectomy (n=5), splenectomy (n=2), repair of traumatic abdominal wall hernias (n=2), evacuation of hemothorax (n=3), and other thoracoscopic or laparoscopic interventions (n=19). Procedures that required conversion were most commonly for bowel injury (n=56). Patients with peritonitis were most likely to require conversion to an open procedure (77.4%). Mean time to a regular diet was 4.2±8.6 days, and mean hospital stay was 6.3±6.5 days. Postoperative complications occurred in 19 patients, long-term sequelae in 10 patients, and permanent disability in 2 patients. There were no deaths or missed injuries. Conclusions: In the stable pediatric trauma patient, laparoscopy and thoracoscopy can be performed safely and effectively for both diagnostic and therapeutic purposes