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Peripherally inserted central catheter (PICC) lines are used routinely in neonates requiring prolonged drugs and parenteral nutrition and complications are usually infectious, mechanical, or thrombotic in nature. Spontaneous extravascular migration is extremely rare, and presentation with large volume chest tube output even rarer. We present a case involving a neonate on extracorporeal membrane oxygenation (ECMO) after congenital diaphragmatic hernia (CDH) repair and discuss management strategies.

Abstract Background Bronchopulmonary foregut malformations are rare congenital malformations. It is extremely rare to have malformations that occur simultaneously. There is literature to show that extralobar sequestration is associated with other congenital anomalies, most commonly diaphragmatic hernias, and also with other bronchopulmonary foregut malformations (e.g., extralobar sequestration and congenital pulmonary airway malformations). However, very few case reports were found that reported extralobar sequestration and foregut duplication cysts and only one report of a right-sided complex foregut malformation with pulmonary sequestration. Case presentation We present a case of a 3-month-old male infant with a prenatal diagnosis of a cystic lung lesion who, after developing symptoms of respiratory distress, was found to have concurrent right-sided extralobar pulmonary sequestration and a mediastinal bronchogenic cyst. Conclusions The concurrent occurrence of these malformations in one patient could help support the theory that these malformations result from an early error in development during the time when both the lung buds and foregut are developing simultaneously.

Introduction: Paradoxical arterial embolization secondary to penetrating trauma from a gunshot wound (GSW) is a rarely described phenomenon that occurs when a missile crosses from the venous to arterial systemic circulation. There are few cases reported in the literature, and none in a preadolescent patient. Here we describe paradoxical arterial embolization from the pulmonary vein to the femoral bifurcation in a 5-year-old. Case report: A 5-year-old child presented after an accidental GSW to the right chest. The patient was hemodynamically stable on room air. The right lower extremity was pulseless, but without motorsensory deficit. Imaging was obtained which demonstrated a missile tract passing through the anterior chest wall and lung parenchyma toward the hilum. There was a small associated hemopneumothorax. The missile was found lodged distally in the right femoral artery bifurcation, having entered the arterial system via the pulmonary vein. The patient was transferred to a Level 1 trauma center and taken emergently to the operating room approximately 6 h post-injury where a right femoral artery cut-down was performed. A transverse arteriotomy was made and the missile was extracted. A thromboembolectomy catheter was passed distally where a small amount of thrombus was retrieved and retrograde flow was restored. There was excellent antegrade flow. The arteriotomy was closed primarily. Fasciotomies were not performed. A right chest tube was placed and a hemothorax was evacuated. The patient was admitted to the intensive care unit with palpable pedal pulses and treated with 48 h of systemic heparin. She developed no signs or symptoms of calf compartment syndrome. The chest tube was removed on post-operative day 3 and she was discharged home with no further medical therapy. Conclusion: Paradoxical arterial embolization secondary to a GSW is a rare entity, particularly in the pediatric population. Management of the ischemic limb is similar to that of any arterial embolization, and additional long-term medical therapy is unnecessary.

Purpose: Numerous definitive surgical techniques exist for the treatment of pilonidal disease with varied recurrence rates and wound complications. Due to the wide array of techniques and lack of consensus on the best approach, we proposed to study our experience treating pilonidal disease in adolescents and young adults.Methods: A retrospective analysis was conducted of patients 10–24 years old treated at a tertiary medical center from 2011 to 2016. Data including demographics, management, and outcomes were collected and analyzed. Primary outcome was recurrence of disease.Results: One hundred and thirty three patients with pilonidal disease underwent operative management. Fifty one percent underwent primary closure and 49% healed by secondary intention with no significant difference in recurrence rates (primary 18%, secondary 11%; p = 0.3245). Secondary healing patients had significantly lower wound complication rates (primary 51%, secondary 23%; p = 0.0012). After accounting for sex, race, weight, and operative technique, age was predictive of disease recurrence with an adjusted odds ratio (OR) of 0.706 (0.560–0.888; p = 0.003). Age and sex were both predictive of wound complications. Older patients had decreased risk of wound complication (adjusted OR 0.806, 95% CI 0.684–0.951; p = 0.0105), and male patients had increased risk of wound complication (adjusted OR 2.902, 95% CI 1.001–8.409; p = 0.0497).Conclusion: In summary, there is no significant difference in the recurrence rates between operative techniques for pilonidal disease. Older patients have decreased risk of recurrence following intervention. Wound complication rates are lower in patients undergoing secondary healing, though this may be better explained by differences in age and sex. Additional research investigating newer, minimally-invasive techniques needs to be pursued.

Infantile hypertrophic pyloric stenosis (IHPS) is an idiopathic disorder of infancy where the hypertrophic and enlarged pyloric muscle causes gastric obstructive symptoms of progressive emesis leading to hypochloremic, hypokalemic, metabolic alkalosis. Although this condition is ultimately treated surgically, it may present as a medical emergency due to electrolyte derangements. In the modern era, up to 88% of infants have normal electrolyte levels at presentation and very rarely do patients present with a bicarbonate >35 mmol/L. In this report, we present a unique case of a 13-week-old infant with a 9-week history of emesis who presents in hypovolemic shock with respiratory distress and the most severe electrolyte disturbances reported for an infant presenting with IHPS: base excess >30 mmol/L, sodium of 118 mmol/L, potassium of 1.6 mmol/L, chloride of 52 mmol/L and bicarbonate >50 mmol/L. Keywords: Infantile hypertrophic pyloric stenosis, Electrolyte abnormalities, Pyloromyotomy

IntroductionData examining rates of postoperative complications among SARS-CoV-2 positive children are limited. The purpose of this study was to evaluate the impact of symptomatic and asymptomatic SARS-CoV-2 positive status on postoperative respiratory outcomes for children.MethodsThis retrospective cohort study included SARS-CoV-2 positive pediatric patients across 20 hospitals who underwent general anesthesia from March to October 2020. The primary outcome was frequency of postoperative respiratory complications, including: high-flow nasal cannula/non invasive ventilation, reintubation, pneumonia, Extracorporeal Membrane Oxygenation (ECMO), and 30-day respiratory-related readmissions or emergency department (ED) visits. Univariate analyses were used to evaluate associations between patient and procedure characteristics and stratified analyses by symptoms were performed examining incidence of complications.ResultsOf 266 SARS-CoV-2 positive patients, 163 (61.7%) were male, and the median age was 10 years (interquartile range 4-14). The majority of procedures were emergent or urgent (n = 214, 80.5%). The most common procedures were appendectomies (n = 78, 29.3%) and fracture repairs (n = 40,15.0%). 13 patients (4.9%) had preoperative symptoms including cough or dyspnea. 26 patients (9.8%) had postoperative respiratory complications, including 15 requiring high-flow oxygen, 8 with pneumonia, 4 requiring non invasive ventilation, 3 respiratory ED visits, and 2 respiratory readmissions. Respiratory complications were more common among symptomatic patients than asymptomatic patients (30.8% vs. 8.7%, p = 0.01). Higher ASA class and comorbidities were also associated with postoperative respiratory complications.ConclusionsPostoperative respiratory complications are less common in asymptomatic versus symptomatic SARS-COV-2 positive children. Relaxation of COVID-19-related restrictions for time-sensitive, non urgent procedures in selected asymptomatic patients may be reasonably considered. Additionally, further research is needed to evaluate the costs and benefits of routine testing for asymptomatic patients.Level of evidenceIii, Respiratory complications.