Uncomplicated gastroschisis care in the US and Kenya: Treatment at two tertiary care centers

BackgroundGastroschisis is a common birth defect with < 5% mortality in high income countries, but mortality in sub Saharan Africa remains high. We sought to compare gastroschisis management strategies and patient outcomes at tertiary pediatric referral centers in the United States and Kenya.MethodsThis retrospective chart review examined uncomplicated gastroschisis patients treated at Riley Hospital for Children in Indianapolis, USA (n = 110), and Shoe4Africa Children's Hospital in Eldoret, Kenya (n = 75), from 2010 to 2018. Analyzed were completed using Chi square, Fisher's exact, and independent samples t tests and medians tests at the 95% significance level.ResultsSurvival in the American cohort was double that of the Kenyan cohort (99.1% vs 45.3%, p< 0.001). Sterile bag use for bowel containment was lower in Kenya (81.3% vs 98.1%, p< 0.001), but silo use was comparable at both institutions (p = 0.811). Kenyan patients had earlier median enteral feeding initiation (4vs 10 days, p< 0.001) and accelerated achievement of full enteral feeding (10vs 23 days, p< 0.001), but none received TPN. Despite earlier feeding, Kenyan patients displayed a higher prevalence of wound infections (70.8% vs 17.1%, p< 0.001) and sepsis (43.9% vs 4.8%, p< 0.001). In Kenya, survivors and non survivors displayed no difference in sterile bag use, hemodynamic stability, all cause infection rates, or antibiotic free hospital days. Defect closure (p< 0.001) and enteral feeding initiation (p< 0.001) were most predictive of survival.ConclusionImproving immediate response strategies for gastroschisis in Kenya could improve survival and decrease infection rates. Care strategies in the US can center on earlier enteral feeding initiation to reduce time to full feeding.Level of evidence: Level III.     

Use of breast milk in infants with uncomplicated gastroschisis: A retrospective cohort study

BackgroundInfants with gastroschisis often experience slow return of bowel function following closure. The purpose of this study was to determine whether exclusive breast milk is associated with decreased time to enteral autonomy.MethodsWe conducted a retrospective cohort study of infants with uncomplicated gastroschisis from a tertiary pediatric hospital. The primary outcome was enteral autonomy, defined as days from initiating enteral feeds to stopping parenteral nutrition. Secondary outcomes included days of parenteral nutrition, length of stay, positive culture, necrotizing enterocolitis, cholestasis, additional surgery, readmission, and mortality.ResultsWe identified 100 infants with gastroschisis treated from 2005 to 2019. Twenty-five were excluded due to gestational age <32 weeks, birth weight <1500 g, or gastroschisis-associated complications (e.g., intestinal atresia). Seventy-five were included in the analysis. Mean gestational age was 36 weeks, 48% were female, and all were diagnosed antenatally. Sixty-five infants (87%) received exclusive maternal (n = 64) or donor (n = 1) breast milk, while 10 others (13%) were fed formula for 1–16 days (mean 7 days). Two infants received formula only. Demographics and gastroschisis prognostic scores were similar between groups. Infants who were given breast milk exclusively demonstrated decreased time to enteral autonomy (median 18 versus 25 days, p = 0.023) and shorter duration of parenteral nutrition (median 20 versus 26 days, p = 0.037).ConclusionExclusive breast milk may be associated with improved outcomes among infants with gastroschisis. Further research is needed to evaluate the economic impact of this association and explore possible confounders. These efforts may expand the role of donor breast milk for these patients.     

The value of compassion: Healthcare savings of palliative care consults in trauma

BackgroundThe effects of palliative care (PC) consultation on patient costs and hospitalization metrics in the adult trauma population are unclear.Study DesignWe interrogated our Level I trauma center databases from 1/1/19 to 3/31/21 for patients age ≥18 admitted to the trauma service. Patients undergoing PC consult were matched using propensity scoring to those without PC consultation based on age, admission Glasgow Coma Scale score, Injury Severity Score and Head Abbreviated Injury Scale. Total costs, total cost per day, hospital length of stay (LOS), ICU LOS, intubation days, discharge disposition, and rates of nephrology consultation and tracheostomy/feeding tube placements were compared.Results140 unique patients underwent PC consultation and were matched to a group not receiving PC consult during the same period. Median total costs in the PC cohort were $39,532 compared to $70,330 in the controls (p<0.01).  Median costs per day in the PC cohort were $3,495 vs $17,970 in the controls (p<0.01).  Median costs per ICU day in the PC cohort were $3,774 vs $17,127 in the controls (p<0.01).  Mean hospital LOS (15.7 vs 7 days), ICU LOS (7.9 vs 2.9 days), and ventilator days (5.1 vs 1.5) were significantly higher in the PC cohort (all p<0.01).  Rates of nephrology consultation (8.6 vs 2.1%, p = 0.03) and tracheostomy/feeding tube placements (12.1 vs 1.4%, p<0.01) were also higher in the PC group.  Patients were more likely to discharge to hospice if they received a PC consult (33.6 vs 2.1%, p<0.01).  Mean time to PC consult was 7.2 days (range 1 hour to 45 days). LOS post-consult correlated positively with time to PC consultation (r = 0.27, p<0.01).ConclusionExpert PC services are known to alleviate suffering and avert patient goal- and value-incongruent care. While trauma patients demand significant resources, PC consultation offered in concordance with life-sustaining interventions is associated with significant savings to patients and the healthcare system. Given the correlation between LOS following PC consult and time to PC consult, savings may be amplified by earlier PC consultation in appropriate patients.     

Early enteral feeding versus traditional feeding in neonatal congenital gastrointestinal malformation undergoing intestinal anastomosis: A randomized multicenter controlled trial of an enhanced recovery after surgery (ERAS) component

Purposethe aim of this clinical trial was to evaluate the safety and efficacy of early enteral feeding (EEN) following intestinal anastomosis in neonates with congenital gastrointestinal malformation.Methodsa multicenter, prospective, randomized controlled trial (registered under chictr.org.cn Identifier no.ChiCTR-INR-17014179) was conducted between 2018 and 2019. Four centers in China analyzed 156 newborns of congenital gastrointestinal malformation undergoing intestinal anastomosis to EEN group (n = 78) or control (C) group (n = 78). The primary outcomes of this study were length of postoperative stay (LOPS) and time to full feeds. Secondary outcomes included morbidity of complications, parenteral nutrition (PN) duration, feeding intolerance, 30 day mortality rate and 30 day readmission rate.Resultsthe mean time to full feeds and LOPS in the EEN group were 15.0 (9.8–22.8) days and 17.6 (12.0–29.8) days, while that were 18.0 (12.0–24.0) days and 20.0 (15.0–30.3) days in C groups respectively. There was no significant difference between two groups(P >0.05). No significant intergroup difference was found with respect to postoperative morbidity, PN duration or feeding intolerance(P >0.05).Conclusionsearly enteral feeding following intestinal anastomosis in neonates with congenital gastrointestinal malformation is safe. Post-operative outcomes demonstrated a trend toward improvement.Level of evidenceLevel Ⅰ.     

The effect of standardized feeding protocol on early outcome following gastroschisis repair: A systematic review and meta-analysis

BackgroundImproved post-operative outcomes following gastroschisis repair are attributed to advancement in perioperative and post-operative care and early enteral feeding. This study evaluates the role of standardized postoperative feeding protocols in gastroschisis.Study designA systematic review and meta-analysis of studies published from January 2000 to April 2019 in MEDLINE, EMBASE, Cochrane Library databases and Google Scholar was conducted. Primary outcomes were duration to full enteral feeding and cessation of parenteral nutrition. Secondary outcomes included days to first enteral feeding, length of stay, compliance, complication and mortality rates. Meta-analysis was done using the RevMan Analysis Statistical Package in Review Manager (Version 5.3) using a random effects model and reported as pooled Risk Ratio and Mean Difference. p-value < 0.05 was considered statistically significant.ResultsEight observational cohort studies were identified and their data analyzed. Significant heterogeneity was noted for some outcomes. Standardized feeding protocols resulted in fewer days to first enteral feeding by 3.19 days (95% CI: -4.73, -1.66, p < 0.0001) than non-protocolized feeding, less complication rates, reduced mortality and better compliance to care. The duration of parenteral nutrition and time to full enteral feeding were not significantly affected.ConclusionProtocolized feeding post-gastroschisis repair is associated with early initiation of enteral feeding. There is a likelihood of reduced rates of sepsis; shorter duration of parenteral nutrition, length of hospital stay and time to full enteral feeding. However, the latter trends are not statistically significant and will require further studies best accomplished with a prospective randomized trial or more cohort studies.     

Variation in hospital costs for gastroschisis closure techniques

BackgroundIn newborns with gastroschisis, both primary repair and delayed fascial closure with initial silo placement are considered safe with similar outcomes although cost differences have not been explored.MethodsA retrospective review was performed of newborns admitted with gastroschisis at a single center from 2011 to 2016. Demographic, clinical, and cost data during the initial hospitalization were collected. Differences between procedure costs and clinical endpoints were analyzed using multivariable linear regression adjusting for prematurity, complicated gastroschisis, and performance of additional operations.Results80 patients with gastroschisis met inclusion criteria. Rates of primary fascial, primary umbilical cord closure, and delayed closure were 14%, 65%, and 21%, respectively. Delayed closure was associated with an increase in total hospital costs by 57% compared to primary repair (p < 0.001). In addition, delayed closure was associated with increased total and NICU LOS (p < 0.05), parenteral nutrition duration (p = 0.02), ventilator days (p < 0.001), time to goal enteral feeds (p = 0.01), and all cost sub-categories except ward room costs (p < 0.01).ConclusionDelayed fascial closure was associated with significantly greater hospital costs during the index admission.     

The association of inborn status and resource utilization among neonates who received extracorporeal membrane oxygenation

BackgroundMany studies have established that extracorporeal membrane oxygenation (ECMO) can be a cost-effective treatment in some populations, but limited data exist on which factors are associated with length of stay (LOS) and total hospital costs. This study aimed to determine if inborn (i.e., cared for in their birth hospitals) neonates who receive ECMO have different resource utilization and outcomes compared to outborn (i.e., not cared for in their birth hospitals) neonates who receive ECMO.MethodsA retrospective cohort study was conducted using the Healthcare Cost and Utilization Project's Kids' Inpatient Database from 1997–2012. Neonates (infants, <28 days) placed on ECMO were categorized as either inborn or outborn. Salient clinical characteristics were compared between groups. A multivariable analysis was performed to identify the factors associated with length of stay (LOS), total hospital costs, and mortality in these two patient populations.ResultsOf 5,152 neonates receiving ECMO, 800 were inborn and 4,352 were outborn. Inborn neonates were more frequently diagnosed with cardiac-related diagnoses (70.5% vs 62.1%, p < 0.001). After adjusting for demographics and hospital-level factors, inborn neonates had longer hospital LOS (13.2 days, 95% CI, 8.7–18.7; p < 0.001), higher total encounter costs ($62,000, 95% CI, 40,000–85,000; p < 0.001) and higher mortality (OR 2.4, 95% CI 1.9–2.9; p < 0.001) compared to outborn neonates.ConclusionsInborn neonates placed on ECMO were more frequently diagnosed with cardiac-related diseases or congenital diaphragmatic hernia, had longer LOS, higher total encounter costs, and higher mortality rates relative to their outborn counterparts, and likely represent a higher risk population. These two populations of infants may be inherently different and their differences should be further explored to inform decision making about optimal site of delivery.     

Retrospective study comparing outcomes of multimodal epidural and erector spinae catheter pain protocols after pectus surgery

IntroductionThere are no optimal postoperative analgesia regimens for Nuss procedures. We compared the effectiveness of thoracic epidurals (EPI) and novel ambulatory erector spinae plane (ESP) catheters as part of multimodal pain protocols after Nuss surgery.MethodsData on demographics, comorbidities, perioperative details, length of stay (LOS), in hospital and post discharge pain/opioid use, side effects, and emergency department (ED) visits were collected retrospectively in children who underwent Nuss repair with EPI (N = 114) and ESP protocols (N = 97). Association of the group with length of stay (LOS), in hospital opioid use (intravenous morphine equivalents (MEq)/kg over postoperative day (POD) 0–2), and oral opioid use beyond POD7 was analyzed using inverse probability of treatment weighting (IPTW) with propensity scores, followed by multivariable regression.ResultsGroups had similar demographics. Compared to EPI, ESP had longer block time and higher rate of ketamine and dexmedetomidine use. LOS for ESP was 2 days IQR (2, 2) compared to 3 days IQR (3, 4) for EPI (p < 0.01). Compared to EPI, ESP group had higher opioid use (in MEq/kg) intraoperatively (0.32 (IQR 0.27, 0.36) vs. 0.28 (0.24, 0.32); p < 0.01) but lower opioid use on POD 0 (0.09 (IQR 0.04, 0.17) vs. 0.11 (0.08, 0.17); p = 0.03) and POD2 (0.00 (IQR 0.00, 0.00) vs. 0.04 (0.00, 0.06) ; p < 0.01). ESP group also had lower total in hospital opioid use (0.57 (IQR 0.42, 0.73) vs.0.82 (0.71, 0.91); p < 0.01), and shorter duration of post discharge opioid use (6 days (IQR 5,8) vs. 9 days (IQR 7,12) (p < 0.01). After IPTW adjustment, ESP continued to be associated with shorter LOS (difference -1.20, 95% CI: -1.38, -1.01, p < 0.01) and decreased odds for opioid use beyond POD7 (OR 0.11, 95% CI: 0.05, 0.24); p < 0.01). However, total in hospital opioid use in MEq/kg (POD0–2) was now similar between groups (difference -0.02 (95% CI: -0.09, -0.04); p = 0.50). The EPI group had higher incidence of emesis (29% v 4%, p < 0.01), while ESP had higher catheter malfunction rates (23% v 0%; p < 0.01) but both groups had comparable ED visits/readmissions.Discussion/conclusionCompared to EPI, multimodal ambulatory ESP protocol decreased LOS and postoperative opioid use, with comparable ED visits/readmissions. Disadvantages included higher postoperative pain scores, longer block times and higher catheter leakage/malfunction.Levels of evidenceLevel III     

Outcomes following burn injury in intensive care patients with major psychiatric disorders

AimsPatients with psychiatric comorbidity have been shown to experience high rates of burn injury. Burn epidemiology, etiology, and outcomes have been sparsely documented for patients with major psychiatric disorders. The aim of this study was to analyze the epidemiologic characteristics and outcomes in intensive care burn patients with pre-existing and acute major psychiatric disorders .MethodsA retrospective study was performed including intensive care burn patients admitted between March 2007 and December 2020. Demographic, clinical and epidemiological data were collected and analyzed. Major psychiatric co-morbidities were collected according to ICD-9 and ICD-10 classifications. Patients were stratified according to F-diagnoses.ResultsA total of 1325 patients were included. 16.6 % of all patients had one or more major psychiatric disorders- 9.3 % with anxiety, dissociative, stress-related, somatoform and other nonpsychotic mental disorders, 9.2 % with mood (affective) disorders, 3.5 % with schizophrenia and other non-mood psychotic disorders, and 1.8 % with disorders of adult personality and behavior. Patients with major psychiatric disorders presented with significantly higher burn severity, reflected by higher abbreviated burn severity index (ABSI) scores (5.9 vs. 5.3, p < 0.001) and larger total body surface area (TBSA) affected (15.9 vs. 12.5 %, p = 0.002). Burned TBSA ≥ 30 and inhalation injuries were observed more frequently in patients with MDP, however without statistical significance. They also experienced prolonged hospital length-of-stay (LOS) (25.5 vs. 16.3 days, p < 0.001), prolonged intensive care unit LOS (14.8 vs. 7.7 days, p < 0.001), underwent surgical interventions (3.5 vs. 2.3, p < 0.001) and mechanical ventilation more frequently (34.1 % vs. 16.5 %, p = 0.43) and had significantly longer ventilation durations (73.5 vs. 31.2 h, p = 0.002). Mortality rates were lower compared to patients without major psychiatric disorders (5.9 vs. 8.1, p < 0.001).ConclusionsThe prevalence of major psychiatric disorders in burn patients is considerably high. Patients with psychiatric comorbidities were found to have greater burn severity, prolonged total hospital and ICU LOS, underwent surgical interventions and mechanical ventilation more frequently and had prolonged ventilation duration. Our results highlight the importance of identifying burn patients with major psychiatric disorders who may necessitate additional resources and require extensive inpatient psychiatric care and counseling.     

Intra-abdominal hypertension in neonates following congenital diaphragmatic hernia repair: Correlation with early postoperative respiratory and gastrointestinal outcomes

BackgroundIncreased intra-abdominal pressure (IAP) is seen in patients after congenital diaphragmatic hernia (CDH) repair owing to reduction of thoracic contents into the relatively smaller abdominal cavity. In infants, IAP ≥11 mmHg is considered intra-abdominal hypertension (IAH). We aim to determine the incidence of IAH and its relationship with duration of ventilatory support, and gastrointestinal function post CDH repair.MethodsWe prospectively recruited all neonates who had CDH repair in four hospitals in Malaysia from June 2018 to October 2020. Intra vesical pressure was used as a proxy for IAP and was measured for 5 consecutive days post surgery. The daily median value was used for analysis. We categorized IAP as <11 mmHg (no IAH), 11–15 mmHg (IAH), and >15 mmHg (severe IAH). Incidence of IAH, its effects on the duration of ventilatory support, and gastrointestinal function were studied.ResultsThere were 24 neonates included in this study. They were operated between day 1 and 6 of life (median: 4 days old). IAH was detected within the first 3 days post surgery, with 83% occurring on day one. Those requiring ventilatory support for more than 3 days contributed the largest proportion of IAH (n = 17, 71%). There was strong correlation between days of IAH and duration of ventilation (p < 0.001, r = 0.70). There was moderate correlation between days of IAH and duration taken to achieve full enteral feeding (p < 0.005, r = 0.70).ConclusionIAP measurement is a safe and useful adjunct in post CDH monitoring and in predicting ventilatory support requirements and the time needed to establish feeding.     

Use of trans-anastomotic tubes in congenital duodenal obstruction

AimDespite data to suggest benefit of trans- anastomotic tube (TAT) feeding in infants following repair of congenital duodenal obstruction (CDO), TAT usage is limited. We aimed to report a large series of infants with CDO treated with or without TAT in order to improve the evidence underlying this simple intervention.MethodSingle centre retrospective review of all infants CDO over a 20-year period (January 1999 – November 2020, inclusive). Important outcomes were compared between infants treated with or without TAT. Data are median [IQR].ResultsNinety-six infants were included. A TAT was placed in 54 infants (56%). Median time to full enteral feed was significantly shorter in the TAT group (6 [5–8] days vs 10 [7.5–12], p <0.001). Time to first feed was shorter in the TAT group (2 [2–2.8] days vs 3 [2–5], p<0.001). Significantly fewer infants with a TAT placed received a central venous catheter (CVC, 15% vs 76%, p <0.001). Infants without a TAT received parenteral nutrition (PN) for longer (0 [0–0] vs 7 [0–11] days, p <0.001). There was no change in length of stay between TAT and no TAT group (16 [13–21.8] vs 15 [12–21.8] days, p = 0.722). Eight infants (15%) in the TAT group required a CVC and PN. One infant in the TAT group developed a perforation that required surgical management and nine infants in the non-TAT group had complications related to the CVC (21%), including one infant that required general anaesthetic for tunnelled central line placement (2.3%).ConclusionIn infants with CDO, TAT use was associated with earlier establishment of full enteral feeds, reduced need for CVC and PN and reduced complications. Further research should focus on the barriers to wider use of TAT by surgeons and neonatologists in infants with CDO.Level III evidence     

Splenic artery embolization improves outcomes and decreases the length of stay in hemodynamically stable blunt splenic injuries – A level 1 Australian Trauma centre experience

BackgroundSplenic injuries are the most common visceral injury following blunt abdominal trauma. Increasingly, non-operative management (NOM) and the use of adjunctive splenic angioembolization (ASE) is favoured over operative management (OM) for the hemodynamically stable patient. However, clinical predictors for successful NOM, particularly the role of ASE as an adjunct, remain poorly defined. This study aims to evaluate the outcomes of patients undergoing ASE vs NOM.MethodsA retrospective clinical audit was performed of all patients admitted with blunt splenic injury (BSI) from January 2005 to January 2018 at the Royal Adelaide Hospital. The primary outcome was ASE or NOM failure rate. Secondary outcomes were grade of splenic injury, Injury Severity Score (ISS), length of hospital stay (LOS), and delayed OM or re-angioembolization rates.ResultsOf 208 patients with BSI, 60 (29%) underwent OM, 54 (26%) ASE, and 94 (45%) NOM only. Patients were predominantly male 165 (79%), with a median age of 33 (IQR 24–51) years. The median ISS was 29 (20–38). There was no difference in the overall success rates for each modality of primary management (48 (89%) ASE vs 77 (82%) NOM, p = 0.374), though patients managed with ASE were older (38 vs 30 years, p = 0.029), had higher grade of splenic injury (grade ≥ IV 42 (78%) vs 8 (8.5%), p<0.001), with increased rates of haemo-peritoneum (46 (85%) vs 51 (54%), p<0.001) and contrast blush (42 (78%) vs 2 (2%), p<0.001). However, for grade III splenic injury, patients managed with ASE had a trend towards better outcome with no failures when compared to the NOM group (0 (0%) vs 8 (35%), p = 0.070) with a significant reduction in LOS (7.2 vs 10.8 days, p = 0.042). Furthermore, the ASE group overall had a significantly shorter LOS compared to the NOM group (10.0 vs 16.0 days, p<0.001).ConclusionASE as an adjunct to NOM significantly reduces the length of stay in BSI patients and is most successful in managing AAST grade III injuries.     

Risk factors for perioperative hypothermia and infectious outcomes in gastroschisis patients

IntroductionPrior data suggest that infants with gastroschisis are at high risk for hypothermia and infectious complications (ICs). This study evaluated the associations between perioperative hypothermia (PH) and ICs in gastroschisis using a multi-institutional cohort.MethodsRetrospective review of infants with gastroschisis who underwent abdominal closure from 2013–2017 was performed at 7 children's hospitals. Any-IC and surgical site infection (SSI) were stratified against the presence or absence of PH, and perioperative characteristics associated with PH and SSI were determined using multivariable logistic regression.ResultsOf 256 gastroschisis neonates, 42% developed PH, with 18% classified as mild hypothermia (35.5–35.9°C), 10.5% as moderate (35.0–35.4°C), and 13% severe (<35°C). There were 82 (32%) ICs with 50 (19.5%) being SSIs. No associations between PH and any-IC (p = 0.7) or SSI (p = 0.98) were found. Pulmonary comorbidities (odds ratio (OR)=3.76, 95%CI:1.42–10, p = 0.008) and primary closure (OR=0.21, 95%CI:0.12–0.39, p<0.001) were associated with PH, while silo placement (OR=2.62, 95%CI:1.1–6.3, p = 0.03) and prosthetic patch (OR=3.42, 95%CI:1.4–8.3, p = 0.007) were associated with SSI on multivariable logistic regression.ConclusionsPrimary abdominal closure and pulmonary comorbidities are associated with PH in gastroschisis, however PH was not associated with increased risk of ICs. Independent risk factors for SSI include silo placement and prosthetic patch closure.     

Repeat serial transverse enteroplasty procedure (reSTEP): Is it worth it?

Background: The utility of repeat serial transverse enteroplasty (reSTEP) has been questioned after patients failed to achieve enteral autonomy. We compared the outcomes after reSTEP to one lifetime STEP (oneSTEP), and tried to identify patients at risk for reSTEP failure.Methods: All STEPs done at our institution were reviewed. Growth, enteral autonomy, bowel-derived bloodstream infection hospital admissions, complications, and need for bowel transplantation were evaluated (p<0.05 considered significant).Results: 24 patients underwent 32 STEP (16 oneSTEP, 8 reSTEP). reSTEP patients were younger at first surgery (1.01±1.05 vs. oneSTEP 3.06±4.73 years, p = 0.24). Median time to reSTEP was 1.1 year (0.6–5.7). Weight-for-length z-scores improved after reSTEP (0.02±1.40 to 0.22±1.42, p = 0.81). Bowel-derived bloodstream infections decreased after surgery (oneSTEP 1.50±2.25 to 0.94±1.73, p = 0.50; reSTEP 1.88±2.10 to 1.66±2.32, p = 0.52). 37.5% (9/24) patients achieved enteral autonomy at last follow-up: 7/16 oneSTEP, 2/8 reSTEP (p = 0.37). Two complications occurred after oneSTEP (staple line ulcer, leak), none following reSTEP. Three patients (oneSTEP 1/16, reSTEP 2/8, p = 0.19) underwent bowel transplantation (all gastroschisis).Conclusion: Similar postoperative outcomes after reSTEP and single STEP (improved enteral tolerance, reduced rates of infections) support the use of reSTEP when clinically indicated, although reSTEP in young infants with a history of gastroschisis may need further evaluation.     

Pediatric burn-trauma patients have increased length of stay compared to trauma-only patients: A propensity matched analysis

BackgroundTrauma is the leading cause of mortality in children. Burn injury involves intensive resources, especially in pediatric patients. We hypothesized that among pediatric trauma patients, combined burn-trauma (BT) patients have increased length of stay (LOS) and mortality compared to trauma-only (T) patients.MethodsThe Pediatric Trauma Quality Improvement Program (2014–2016) was queried and BT patients were 1:2 propensity-score-matched to T patients based on age, gender, hypotension on admission, injury type and severity.Results93 BT patients were matched to 186 T patients. There were no differences in matched characteristics. BT patients had a longer median LOS (4 vs 2 days, p < 0.001) with no difference in mortality (1.1% vs 1.1%, p = 1.00), intensive care unit (ICU) LOS (3 vs 3 days, p = 0.55), or complications including decubitus ulcer (0% vs 1.1%, p = 0.32), deep vein thrombosis (0% vs 0.5%, p = 0.48), extremity compartment syndrome (1.1% vs 0%, p = 0.16), and urinary tract infection (1.1% vs 1.1%, p = 1.00).ConclusionPediatric BT patients had twice the LOS compared to a matched group of pediatric T patients. There was no difference between the cohorts in ICU LOS, complications or mortality rate. When evaluating risk-stratified quality metrics such as LOS, concomitant burn injury should be incorporated.     

Meconium peritonitis: A 22-year review in a tertiary referral center

BackgroundMeconium peritonitis (MP) is a sterile, chemical peritonitis resulting from in-utero fetal bowel perforation. Severe cases may lead to serious morbidities and mortalities.ObjectiveTo review the common antenatal ultrasound abnormalities associated with MP, and identify radiological and clinical prognostic factors.Materials and methodsRetrospective review of all neonates with MP from January 1997 to December 2019 treated in our hospital was performed. Antenatal ultrasound findings, clinical presentations and outcomes were analyzed.ResultsThirty-five neonates (17 males, 18 females) were included in the study. Thirty-two (91.4%) attended antenatal screening, and 27 (84.4%) of them had abnormalities identified on antenatal ultrasound. The most common abnormality was polyhydramnios (43.8%). Nineteen (54.3%) patients were inborn. Twenty (57.1%) patients were born prematurely. Laparotomy was required in 85.7% of patients. The median time to laparotomy was shorter in the inborn group [1 day (0–9 days) vs 4 days (2–34 days), p = 0.001], but the duration of post-operative hospital stay was comparable [71 days (16–423 days) vs 73.5 days (23–231 days)]. However, such duration was found to be significantly longer in the pre-term group when compared to full-term [58.5 days (16–89 days) vs 85 (21–423 days), p = 0.01]. The most common pathology was small bowel atresia and there were two mortalities.ConclusionDue to the advancement in prenatal detection, pediatric anesthesia, intensive care and surgical techniques, the morbidity and mortality of MP has much decreased. Effective multi-disciplinary antenatal counseling facilitated the perinatal management of MP and resulted in comparable prognosis and outcome in inborn and outborn neonates.Level of evidence3     

Intercostal nerve cryoablation during surgical stabilization of rib fractures decreases post-operative opioid use,ventilation days,and intensive care days

BackgroundIntercostal nerve cryoablation is an adjunctive measure that has demonstrated pain control, decrease in opioid consumption, and decrease in hospital length of stay (LOS) in patients who undergo surgical stabilization of rib fractures (SSRF).MethodsSSRF patients from January 2015 to September 2021 were retrospectively compared. All patients received multimodal pain regimens post-operatively and the independent variable was intraoperative cryoablation.Results241 patients met inclusion criteria. 51 (21%) underwent intra-operative cryoablation during SSRF and 191 (79%) did not. Patients with standard treatment consumed 9.4 more daily MME (p = 0.035), consumed 73 percent more post-operative total MME (p = 0.001), spent 1.55 times as many days in the intensive care unit (p = 0.013), and spent 3.8 times as many days on the ventilator than patients treated with cryoablation, respectively. Overall hospital LOS, operative case time, pulmonary complications, MME at discharge, and numeric pain scores at discharge were no different (all p>0.05).ConclusionIntercostal nerve cryoablation during SSRF is associated with fewer ventilator days, ICU LOS, total post-operative, and daily opioid use without increasing time in the operating room or perioperative pulmonary complications.     

Small tunneled central venous catheters as an alternative to a standard hemodialysis catheter in neonatal patients

Background/PurposeContinuous renal replacement therapy (CRRT) is difficult in neonates for several reasons, including problems with catheter placement and maintenance. We sought to compare outcomes between standard hemodialysis catheters (HDC) and 6Fr-tunneled central venous catheters (TC-6Fr).MethodsWe evaluated neonates who received CRRT from December 2013 – January 2018. All patients received CRRT with the Aquadex (Baxter Corporation, Minneapolis, Minnesota) circuit. Data regarding patient demographics, CRRT indication, catheter days, reason for removal, and catheter-specific complications were analyzed.ResultsForty-six catheters were placed in 26 neonates; nine of these were 6Fr-tunneled catheters. The median age and mean weight at CRRT initiation was 9.5 days (IQR 4–31) and 3.5 kg (+/- 0.6 kg), respectively. TC-6Fr lasted longer (median of 28 days vs 10 days, p = 0.02), required fewer revisions (0 vs 0.16/10 catheter days) and were less commonly removed due to bleeding complications (0% vs 10.8%), occlusion (11.1% vs 18.9%), or malposition (0% vs 8.1%); none of these differences were statistically significant. TC-6Fr were associated with higher infection rates (33.3% vs 0%, p = 0.01) than HDC.ConclusionsTC-6Fr use resulted in less need for catheter revisions and provided longer-lasting vascular access, which may influence infection rates. This catheter provides neonates in need of CRRT more reliable vascular access.Level of evidence: III.     

Prehospital personnel discretion pediatric trauma team activations: Too much of a good thing?

PurposeTrauma team activation is essential to provide rapid assessment of injured patients, however excessive utilization can overburden systems. We aimed to identify predictors of over triage and evaluate impact of prehospital personal discretion trauma activations on the over triage rate.MethodsRetrospective comparative study of pediatric trauma patients (<18 years) evaluated after activation of the trauma team to those evaluated as a trauma consult treated between 2010 and 2013. Cohort matching of trauma activated and consult patients was done on the basis of patients’ age and ISS.Results1363 patients including 359 trauma team activations were evaluated. Median age was 6 years, Injury Severity Score (ISS) 4, 116 (8.5%) required operative intervention and 20 (1.4%) died.Matched analysis using age and ISS showed trauma activated patients were more likely to have penetrating MOI (4.7% vs.1.7%; p = 0.03) and need ICU admission(32.9% vs.16.7%; p = 0.0001). State of Florida discrete criteria based trauma activated patients when compared to paramedic discretion activations had a higher ISS (9 vs.5; p = 0.014), need for ICU admission (36.5% vs.20.4%; p = 0.004), ICU LOS(2 vs.0 days; p = 0.02), hospital LOS(2 vs.2 days; p = 0.014) and higher likelihood of death(4.9% vs.0%;p = 0.0001). Moreover, paramedic discretion trauma activated patients were similar to trauma consult patients in terms of ISS score(p = 0.86), need for ICU admission(p = 0.86), operative intervention(p = 0.86), death(p = 0.86) and hospital LOS(p = 0.86), with a considerably higher cost of care(p = 0.0002).ConclusionDiscrete criteria-based trauma team activations appear to more reliably identify patients likely to benefit from initial multidisciplinary management.     

Postoperative complications in pediatric patients with cerebral palsy

Background/PurposeTo assess surgical outcomes of patients with cerebral palsy (CP) and if they differ from patients without CP.MethodsThe NSQIP-Pediatric database from 2012 to 2019 was used to compare differences in presenting characteristics and outcomes between patients with and without CP. Chi-square tests and multivariable logistic regression analysis were used to determine significance.Results119,712 patients, 433 (0.4%) with CP, 119,279 (99.6%) without, were identified. Patients with CP had more postoperative complications (19.4% vs. 6.9%, p < 0.001) with an OR of 3.2, (95%CI 2.5–4.1, p < 0.001) on univariable analysis. They underwent fewer laparoscopic procedures (79.1% vs. 90.8%, p < 0.001), had more readmissions (10.2% vs. 3.8%, p < 0.001), reoperations (5.1% vs. 1.2%, p < 0.001), and longer length of stays (LOS) (median 3 versus 1 day, p < 0.001). On multivariable analysis, having CP did not increase the odds of postoperative morbidity (OR 0.99, 95% CI 0.7–1.3), but higher ASA class, congenital lung malformation, gastrointestinal disease, coagulopathy, preoperative inotropic support, oxygen use, nutritional support, and steroid use significantly increase the odds of morbidity, all of which were more common in patients with CP.ConclusionPatients with CP have more postoperative complications, open procedures, and longer LOS. Patient complexity may account for these differences and risk-directed perioperative planning may improve outcomes.Level of EvidenceLevel IV.