Search

OBJECTIVES The incidence, demographic characteristics, and treatment approaches for pediatric patients who present to the ED with a primary complaint of postoperative pain have not been well described. The purpose of this study was to describe opioid and nonopioid prescribing patterns for pediatric patients evaluated for postoperative pain in the Emergency Department (ED). METHODS Pediatric Health Information System is an administrative database of encounter-level data from 48 children's hospitals. Emergency department visits for postoperative pain from January 2014 to September 2017 were analyzed. Visits were matched by the Pediatric Health Information System identifier to associate corresponding same site surgery encounters directly preceding ED visits. RESULTS There were 7365 ED visits for acute postoperative pain, for which 4044 could be linked to corresponding surgical procedure. Eight-one percent of ED visits were within 7 days of surgery. Opioids were given at 1979 (49%) of visits, and nonopioids at 678 (17%) of visits. The most common surgeries preceding a postoperative pain ED visit were for tonsils and adenoids (48.5%). Age, sex, length of stay for both procedure and ED visits, procedure specialty, and the number of days between procedure discharge and admission to ED were associated with opioid administration during ED visits (P < 0.05). CONCLUSIONS Pediatric patients treated in the ED for postoperative pain were often treated with opioid and nonopioid analgesics, with wide prescriber variability. Further research is warranted to help balance optimal pain management and safe prescribing practices.

Medical education has undergone significant change as we have moved from a purely apprenticeship model to one of competence. Simulation-based education can and does play a significant role in the development of an expert surgeon. Proven concepts of simulation-based education include distributed deliberate practice, content that challenges the learner, formative and summative feedback. The application of mastery learning principles is critical to achieve the best retention and outcomes related to an educational program. In this manuscript, we explore the methodology and justification for Mastery Learning as the gold standard of surgical education.

Background/purpose Arterial catheter complications are a common problem in a pediatric critical care setting, but reported complication rates and risk factors associated with peripheral arterial catheter complications vary. We conducted a retrospective cohort study to identify risk factors in a pediatric patient population. Methods We performed a detailed abstraction of provider notes in the electronic medical records of inpatients ≤18years of age who underwent arterial line placement between January 1, 2008 and January 1, 2013 at a university-affiliated standalone pediatric hospital. Inpatient records were assessed for complications associated with arterial catheterization and risk factors inherent to arterial catheter insertion. Results Two hundred twenty-eight children were identified, of whom 75 (33%) had a total of 106 arterial catheter complications. Complications included line malfunctions (59%, n=63), bleeding (16%, n=17), multiple complications (11%, n=12), infiltration (8%, n=9), and hematoma (4%, n=4). Line malfunction was reported in all patients with multiple complications. Independent predictors of complications associated with arterial catheterization were the presence of more than one provider during the insertion (p=0.007) and insertion attempts at multiple sites (p=0.036). Conclusions Our analysis suggests the need for a prospective study to comprehensively assess provider-related risk factors associated with arterial catheter complications in children. Level of evidence IV

Although minimally invasive repair of pectus excavatum has been shown to have a low complication rate in large series, several case reports have documented life-threatening complications, including bleeding and cardiac perforation. We present a rare case of an arteriovenous malformation from the internal thoracic artery to the pulmonary artery caused by occlusion of the internal thoracic artery by the Nuss bar followed by an unidentified angiogenic process. The patient became symptomatic and required transcatheter coil embolization.

Adhesive small bowel obstruction is a significant cause of short- and long-term morbidity in infants and children. Unfortunately, the majority of scientific literature relative to adhesive obstructions continues to be dominated by adult studies. In this article, the existing literature for infant and pediatric adhesive obstructions is reviewed, with relevant comparisons to the available adult data. In addition, general guidelines for the management of infant and pediatric adhesive obstructions are recommended, based on the best available evidence.

Education in the knowledge, skills, and attitudes necessary for a surgeon to perform at an expert level in the operating room, and beyond, must address all potential cognitive and technical performance gaps, professionalism and personal behaviors, and effective team communication. Educational strategies should also seek to replicate the stressors and distractions that might occur during a high-risk operation or critical care event. Finally, education cannot remain fixed in an apprenticeship model of "See one, do one, teach one," whereby patients are exposed to the risk of harm inherent to any learning curve. The majority of these educational goals can be achieved with the addition of simulation-based education (SBE) as a valuable adjunct to traditional training methods. This article will review relevant principles of SBE, explore currently available simulation-based educational tools for pediatric surgeons, and finally make projections for the future of SBE and performance assessments for pediatric surgeons.

The purposes of this study were to (1) determine the positive and negative predictive value (NPV) of transabdominal color Doppler ultrasound (CDU) for diagnosing ovarian torsion (OT) in pediatric patients and 2) identify predictors of a false-positive CDU result for OT.An IRB-approved retrospective chart review was performed on all female patients who underwent transabdominal CDU evaluation of the ovaries (664 CDUs in 605 patients) for acute abdominal pain. CDU reports were categorized as positive for OT if the report stated "cannot rule out torsion" or "positive for torsion."There were 47 false-positive ultrasounds, 3 false negatives, 11 true positives, and 603 true negatives for OT. Sensitivity was 78.6%, specificity 92.3%, positive predictive value (PPV) 19.0%, and NPV 99.5%. False-positive CDU when compared to true positives were more common in older patients (p=0.004) and were more commonly read as "cannot rule out torsion" (p0.001). Ovarian cysts were larger in true-positive CDU than in false-positive CDU (p0.001). However, cyst presence/absence did not predict a true positive result.Transabdominal CDU has a low PPV and a high NPV for ovarian torsion in pediatric patients. False-positive results are more common in older patients and associated with small ovarian cysts.

Background/Purpose Although prohibitively labor intensive, manual data extraction (MDE) is the prevailing method used to obtain clinical research and quality improvement (QI) data. Automated data extraction (ADE) offers a powerful alternative. The purposes of this study were to 1) assess the feasibility of ADE from provider-authored outpatient documentation, and 2) evaluate the effectiveness of ADE compared to MDE. Methods A prospective collection of data was performed on 90 ADE-templated notes (N=71 patients) evaluated in our bowel management clinic. ADE captured data were compared to 59 MDE notes (N=51) collected under an IRB-exempt review. Sixteen variables were directly comparable between ADE and MDE. Results MDE for 59 clinic notes (27 unique variables) took 6months to complete. ADE-templated notes for 90 clinic notes (154 unique variables) took 5min to run a research/QI report. Implementation of ADE included eight weeks of development and testing. Pre-implementation clinical documentation was similar to post-implementation documentation (5–10min). Conclusions ADE-templated notes allow for a 5-fold increase in clinically relevant data that can be captured with each encounter. ADE also results in real-time data extraction to a research/QI database that is easily queried. The immediate availability of these data, in a research-formatted spreadsheet, allows for rapid collection, analyses, and interpretation of the data. Level of evidence IV. Type of study Retrospective Study.

Traditional opportunistic and experiential surgical training can expose patients to excess risk of harm, particularly when new technology or surgical approaches are applied to highly complex operations. Declining birth rates, decreasing academic regionalization of complex neonatal procedures, duty hour restrictions, and the increasing need for highly specialized surgical skills all serve to further degrade the educational opportunities for surgical trainees. Even more concerning, practicing pediatric surgeons are also struggling with declines in neonatal surgical volumes, with fewer opportunities to maintain established cognitive, technical, and nontechnical skills in the operating room. In an effort to balance patient safety with a deeply rooted commitment to surgical education, surgical educators have developed a number of innovative educational strategies to achieve these goals.

Herein is a case of a congenitally diagnosed mesenteric lymphatic malformation involving nearly the entire small bowel and colon. Although drainage and sclerotherapy were initially performed, extensive small and large bowel resection was ultimately necessary. A review of the literature is provided with a discussion of potential and optimal treatment modalities.

Arteriovenous malformations can lead to life-threatening complications, particularly in neonates. Only a few case reports document arteriovenous malformations of the umbilicus, all presenting with complications and necessitating urgent surgical intervention. We report the case of a neonate with an incidentally noted umbilical arteriovenous malformation, treated with laparoscopic assisted resection.

Background Children have a lower incidence of postinjury multiple organ failure (MOF) compared with adults with equivalent injury severity. Because MOF appears to be the end result of systemic hyperinflammation, children may have either an attenuated proinflammatory response or an augmented antiinflammatory response compared with adults. The purpose of this study was to determine the lipopolysaccharide (LPS)-induced pro- and antiinflammatory cytokine response of pediatric versus adult peritoneal macrophages (PM). The authors hypothesized that pediatric PMs would have an enhanced antiinflammatory response compared with adults. Methods Human PMs were collected during elective laparoscopic procedures and stimulated with LPS. (Pediatric cohort: n=9 [mean, 5.4 years], adult cohort: n=8 [mean, 41.6 years]). P less than .05 was accepted as significant. Results LPS-induced a 50-fold increase in interleukin-10 (IL-10) antiinflammatory cytokine production in pediatric versus adult PMs. LPS-induced tumor necrosis factor-α (TNF-α) production was also increased in pediatric versus adult PMs. The anti-proinflammatory cytokine ratio (IL-10 to TNF-α) was 20-fold higher in pediatric versus adult PMs. Conclusions LPS-induced macrophage production of both IL-10 and TNF-α was increased in children. The anti-proinflammatory cytokine ratio (IL-10 to TNF-α) was strikingly higher in pediatric versus adult PMs. These data suggest that the age-related balance of anti- and proinflammatory cytokines in resident macrophages is different in children compared with adults.

Purpose A validated high fidelity simulation model would provide a safe environment to teach thoracoscopic EA/TEF repair to novices. The study purpose was to evaluate validity evidence for performance measures on an EA/TEF simulator. Methods IRB-exempt data were collected from 12 self-reported "novice" and 8 "experienced" pediatric surgeons. Participants evaluated the EA/TEF repair simulator using survey ratings that were analyzed for test content validity evidence. Additionally, deidentified operative performances were videotaped and independently rated by two surgeons using the Objective Structured Assessment for Technical Skills (OSATS) instrument. Novice and experienced OSATS were compared with p Results Participants had high overall simulator ratings. Internal structure was supported by high interitem consistency (α=.95 and .96) and interrater agreement (ICC) [.52, .84] for OSATS ratings. Experienced surgeons performed at a significantly higher level than novices for all five primary and two supplemental OSATS items (p Conclusion Favorable participant ratings indicate the simulator is relevant to clinical practice and valuable as a learning tool. Further, performance ratings can discriminate experienced and novice performances of EA/TEF repair. These findings support the use of the simulator for performance assessment, representing the first validated measures from a simulator intended for pediatric surgical training.

Purpose We sought to create and validate a high fidelity, anatomically correct real tissue simulation model for thoracoscopic esophageal atresia/tracheoesophageal fistula (EA/TEF) repair. Methods A scale reproduction of a neonatal rib cage was created. Surgically modified (EA/TEF) fetal bovine tissue completed the simulator. Nine pediatric surgery fellows and two attending pediatric surgeons (n = 11) performed the simulated thoracoscopic EA/TEF repair. Participants completed a self-report rating scale, ranging from 1 (Don’t know) to 5 (Highly realistic). Construct validity relevant to test content was evaluated by examining the ratings using the many-Facet Rasch model. Results Analyses indicated no differences when comparing faculty (Observed Average (OA) = 4.5/5.0) to fellow (OA = 3.3) ratings, p = .71. In descending order, observed averages of the domains were 4.7 (Relevance), 4.5 (Physical attributes), 4.5 (Realism of materials), 4.4 (Ability to perform task), and 4.2 (Value). The observed Global opinion rating indicated the simulator can be considered for teaching thoracoscopic EA/TEF repair but could be improved slightly. Conclusions Fellow and faculty ratings indicated the simulator was valuable as a learning tool with minor modifications. Comments were consistent with high physical attribute ratings.

An 18 year old male with a history of prune belly syndrome (PBS) presented with acute abdominal pain and palpable left upper quadrant mass. Computed tomography (CT) of the abdomen revealed a medialized spleen with a "whirl sign" in the splenic vessels, consistent with splenic torsion. Coincidentally, the small bowel was also noted to be on the right side of the abdomen, while the colon was located on the left, indicative of malrotation. Emergent diagnostic laparoscopy confirmed splenic torsion and intestinal malrotation. Successful laparoscopic reduction of the splenic torsion was achieved, however, conversion to an open procedure by a vertical midline incision was necessary owing to the patient's unique anatomy. Open splenopexy with a mesh sling and Ladd's procedure were subsequently performed. Malrotation and wandering spleen are known, rare associated anomalies in PBS; however, both have not been reported concurrently in a patient with PBS in the literature. In patients with PBS, acute abdominal pain, and an abdominal mass, high clinical suspicion for gastrointestinal malformations and prompt attention can result in spleen preservation and appropriate malrotation management. We present a case of a teenager who presented with a history of PBS, acute abdominal pain, and a palpable abdominal mass. The patient was found to have splenic torsion and intestinal malrotation. The clinical findings, diagnostic imaging, and surgical treatment options of splenic torsion are reviewed.

Foreign body ingestion is a common occurrence in the pediatric population. Frequent culprits include coins, toys, sharp objects and bones, which most often pass spontaneously. Magnet ingestion, however, can be a serious matter, especially when more than one is taken in. The extremely strong magnetic force between multiple magnets may result in numerous complications including bowel necrosis, perforation, obstruction, fistula formation, volvulus and death. We present the largest series reported to date, with four cases of multiple magnet ingestion at our institution with varied presentations and findings. We review the literature, and discuss the importance of having a high index of suspicion.

A novel case of Nuss bar displacement with near-fatal hemorrhage 3 months after insertion and 3 weeks after unreported bar movement is presented. Salient features of presentation, evaluation, and treatment are described including how to divide the bar from an intrathoracic approach.

Children have a lower incidence of acute lung injury (ALI) compared with adults. Because ALI appears to be the end result of systemic hyperinflammation, children may either have 1) an attenuated pro-inflammatory response or 2) an augmented anti-inflammatory response compared with adults. The purpose of this study was to determine the IL-1-induced pro- and anti-inflammatory response of pediatric vs. adult peritoneal macrophages (PMs). We hypothesized that pediatric PMs would have an enhanced anti-inflammatory response compared with adult PMs. Human PMs were collected during elective laparoscopic procedures, cultured, and stimulated with IL-1beta. IL-6, IL-8, IL-10, and TNFalpha production were determined by ELISA. Statistical analyses were by ANOVA; a P0.05 was significant. Our results showed that IL-1beta induced an 11-fold increase in IL-10 production in pediatric PMs (659+/-103 vs. 60+/-25 control, P0.05). There was no IL-10 production in IL-1beta-stimulated adult PMs. IL-1beta-induced TNF production was greater in children compared with adults (2152+/-166 vs. 592+/-188, P0.05). Similarly, IL-1beta-induced IL-6 production was greater in pediatric PMs compared with adults (532+/-3 vs. 444+/-52, P0.05). There was no difference in IL-1beta-induced IL-8 production in children compared with adults. The IL-10:TNFalpha ratio after IL-1beta stimulation was 0.306+/-0.056 in pediatric macrophages and 0.020+/-0.015 in adult macrophages ( P0.01). In conclusion, IL-1beta-induced IL-6 and TNFalpha production were greater in pediatric than adult PMs. Furthermore, pediatric PMs had an 11-fold increase in IL-1beta-induced IL-10 production, while adult PMs did not produce IL-10. Therefore, IL-1beta induces both a pro- and an anti-inflammatory response in pediatric PMs, whereas adult PMs produce only pro-inflammatory cytokines in response to IL-1beta. The exaggerated anti-inflammatory IL-10 response in children may be an important factor in the observed differences in ALI between children and adults.

Objective To determine the utility of lung biopsy in immunocompromised pediatric patients with suspected infectious lung disease and to evaluate the risks and benefits of biopsy in the era of minimally invasive thoracic surgery. Study design We reviewed charts for 50 immunocompromised patients who underwent surgical lung biopsy between January 2000 and July 2011 at a free-standing, tertiary care, urban children's hospital. The primary outcome variable was "benefit from biopsy," defined as change in therapy based on biopsy results. The secondary outcome variable was survival to discharge. The χ 2 analysis was used for categorical variables and Student t test for continuous variables. Results Biopsy provided a definitive histopathologic or microbiologic diagnosis in 25 patients (50%), the most common diagnosis being fungal infection (22%). Diagnostic and nondiagnostic biopsy results yielded benefit in 25 surviving patients (50%) for whom the biopsy results were used to tailor treatment. Taking more than one biopsy specimen did not improve diagnostic yield. Six patients (12%) had a major morbidity including reinsertion of chest tube after initial chest tube removal (3), prolonged air leak (1), and a new requirement for mechanical ventilation postoperatively (2). Two patients died postoperatively, but the mortalities were not clearly related to surgery. Underlying diagnoses included hematologic malignancy (64%), primary immunodeficiency (12%), organ transplant recipient (12%), and solid malignancy (10%). Twelve patients (24%) had undergone stem cell transplantation. Conclusion Lung biopsy in immunocompromised pediatric patients alters therapy in 50% of cases, but predictably carries identifiable morbidities. This study is limited by its retrospective nature.