1
|
Adler A, Radhakrishnan K, Yeaney N. Implementation of standardized feeding pathways for infants with gastroschisis to improve patient outcomes: A quality improvement project in a level IV surgical NICU. Nutr Clin Pract 2024. [PMID: 39319372 DOI: 10.1002/ncp.11216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Revised: 08/23/2024] [Accepted: 08/31/2024] [Indexed: 09/26/2024] Open
Abstract
Gastroschisis is a leading cause of pediatric intestinal failure. Feeding guidelines may lead to improved patient outcomes including decreased time to reach full feeds, a reduction in the duration of parenteral nutrition, and reduced length of stay. However, there is limited evidence on what the ideal feeding guidelines are for this complex gastrointestinal diagnosis. In this quality improvement project, after completing a literature review, we created three pathways based on the complexity of the gastroschisis. We reviewed historical data without a defined feeding pathway/guideline to our newly created pathways in the intervention group. The study included 35 patients with varying degrees of gastroschisis complexity, consisting of 9 current patients (October 2021-December 2022) who were provided with defined feeding pathways and 26 historical patients before the protocol was implemented (January 2015-August 2021). There were no significant differences in the number of days required for full feeds between the two groups. However, the mean duration of parenteral nutrition was 18.9 days (95% CI, -31.8 to -7.0) shorter in the intervention group. Although not statistically significant, the patients in the intervention group had a mean length of stay that was 13.1 days (95% CI, -50.0 to 25.4) shorter than the historical group. The creation of standardized feeding guidelines for the gastroschisis population resulted in a statistically nonsignificant decrease in time to reach full enteral feeds, a statistically significant reduced duration of parenteral nutrition, and a statistically nonsignifiant decreased length of stay.
Collapse
Affiliation(s)
- Andrea Adler
- Department of Gastroenterology, Hepatology, and Nutrition, Cleveland Clinic Children's Hospital, Cleveland, Ohio, USA
| | - Kadakkal Radhakrishnan
- Department of Gastroenterology, Hepatology, and Nutrition, Cleveland Clinic Children's Hospital, Cleveland, Ohio, USA
| | - Natalie Yeaney
- Division of Neonatology and Neonatal Director Fetal Care Center, Cleveland Clinic Children's Hospital, Cleveland, Ohio, USA
| |
Collapse
|
2
|
Baerg J, McAteer J, Miniati D, Somme S, Slidell M. Improving outcomes for uncomplicated gastroschisis: clinical practice guidelines from the American Pediatric Surgical Association Outcomes and Evidence-based Practice Committee. Pediatr Surg Int 2024; 40:246. [PMID: 39222260 DOI: 10.1007/s00383-024-05819-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/10/2024] [Indexed: 09/04/2024]
Abstract
BACKGROUND The authors sought better outcomes for uncomplicated gastroschisis through development of clinical practice guidelines. METHODS The authors and the American Pediatric Surgical Association Outcomes and Evidenced-based Practice Committee used an iterative process and chose two questions to develop clinical practice guidelines regarding (1) standardized nutrition protocols and (2) postnatal management strategies. An English language search of PubMed, MEDLINE, OVID, SCOPUS, and the Cochrane Library Database identified literature published between January 1, 1970, and December 31, 2019, with snowballing to 2022. The Appraisal of Guideline, Research and Evaluation reporting checklist was followed. RESULTS Thirty-three studies were included with a Level of Evidence that ranged from 2 to 5 and recommendation Grades B-D. Nine evaluated standardized nutrition protocols and 24 examined postnatal management strategies. The adherence to gastroschisis-specific nutrition protocols promotes intestinal feeding and reduces TPN administration. The implementation of a standardized postnatal clinical management protocol is often significantly associated with shorter hospital stays, less mechanical ventilation use, and fewer infections. CONCLUSIONS There is a lack of comparative studies to guide practice changes that improve uncomplicated gastroschisis outcomes. The implementation of gastroschisis-specific feeding and clinical care protocols is recommended. Feeding protocols often significantly reduce TPN administration, although the length of hospital stay may not consistently decrease.
Collapse
Affiliation(s)
- Joanne Baerg
- Division of Pediatric Surgery, Presbyterian Healthcare Services, Albuquerque, NM, USA.
| | - Jarod McAteer
- Division of Pediatric Surgery, Providence Sacred Heart Children's Hospital, Spokane, WA, USA
| | - Doug Miniati
- Division of Pediatric Surgery, Kaiser Permanente Northern California, Roseville, CA, USA
| | - Stig Somme
- Division of Pediatric Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Mark Slidell
- Division of Pediatric Surgery, Johns Hopkins Children's Center, Baltimore, MD, USA
| |
Collapse
|
3
|
De Rose DU, Lapillonne A, Iacobelli S, Capolupo I, Dotta A, Salvatori G. Nutritional Strategies for Preterm Neonates and Preterm Neonates Undergoing Surgery: New Insights for Practice and Wrong Beliefs to Uproot. Nutrients 2024; 16:1719. [PMID: 38892652 PMCID: PMC11174646 DOI: 10.3390/nu16111719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2024] [Revised: 05/22/2024] [Accepted: 05/30/2024] [Indexed: 06/21/2024] Open
Abstract
The nutrition of preterm infants remains contaminated by wrong beliefs that reflect inexactitudes and perpetuate old practices. In this narrative review, we report current evidence in preterm neonates and in preterm neonates undergoing surgery. Convictions that necrotizing enterocolitis is reduced by the delay in introducing enteral feeding, a slow advancement in enteral feeds, and the systematic control of residual gastric volumes, should be abandoned. On the contrary, these practices prolong the time to reach full enteral feeding. The length of parenteral nutrition should be as short as possible to reduce the infectious risk. Intrauterine growth restriction, hemodynamic and respiratory instability, and patent ductus arteriosus should be considered in advancing enteral feeds, but they must not translate into prolonged fasting, which can be equally dangerous. Clinicians should also keep in mind the risk of refeeding syndrome in case of high amino acid intake and inadequate electrolyte supply, closely monitoring them. Conversely, when preterm infants undergo surgery, nutritional strategies are still based on retrospective studies and opinions rather than on randomized controlled trials. Finally, this review also highlights how the use of adequately fortified human milk is strongly recommended, as it offers unique benefits for immune and gastrointestinal health and neurodevelopmental outcomes.
Collapse
Affiliation(s)
- Domenico Umberto De Rose
- Neonatal Intensive Care Unit, “Bambino Gesù” Children’s Hospital IRCCS, 00165 Rome, Italy; (I.C.); (A.D.); (G.S.)
- PhD Course in Microbiology, Immunology, Infectious Diseases, and Transplants (MIMIT), Faculty of Medicine and Surgery, “Tor Vergata” University of Rome, 00133 Rome, Italy
| | - Alexandre Lapillonne
- Department of Neonatology, APHP, Necker-Enfants Malades University Hospital, EHU 7328 Paris Cite University Paris, 75015 Paris, France;
- Children’s Nutrition Research Center, Baylor College of Medicine, Houston, TX 77024, USA
| | - Silvia Iacobelli
- Réanimation Néonatale et Pédiatrique, Centre Hospitalier Universitaire Saint-Pierre, BP 350, 97448 Saint Pierre CEDEX, France;
- Centre d’Études Périnatales de l’Océan Indien (UR 7388), Université de La Réunion, BP 350, 97448 Saint Pierre CEDEX, France
| | - Irma Capolupo
- Neonatal Intensive Care Unit, “Bambino Gesù” Children’s Hospital IRCCS, 00165 Rome, Italy; (I.C.); (A.D.); (G.S.)
| | - Andrea Dotta
- Neonatal Intensive Care Unit, “Bambino Gesù” Children’s Hospital IRCCS, 00165 Rome, Italy; (I.C.); (A.D.); (G.S.)
| | - Guglielmo Salvatori
- Neonatal Intensive Care Unit, “Bambino Gesù” Children’s Hospital IRCCS, 00165 Rome, Italy; (I.C.); (A.D.); (G.S.)
- Donor Human Milk Bank, “Bambino Gesù” Children’s Hospital IRCCS, 00165 Rome, Italy
| |
Collapse
|
4
|
Predictors of length of stay for simple gastroschisis: analysis of ACS NSQIP-P database. Pediatr Surg Int 2022; 38:1371-1376. [PMID: 35876903 DOI: 10.1007/s00383-022-05189-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/13/2022] [Indexed: 10/16/2022]
Abstract
PURPOSE We aimed to assess predictors of length of stay for simple gastroschisis utilizing the NSQIP-Pediatric Database. METHODS The NSQIP-P Participant Use Data File was queried to identify patients with simple gastroschisis. We defined short length of stay (LOS) as patients discharged home ≤ 30 days from birth. We compared patients with short LOS versus prolonged LOS > 30 days. Predictors and outcomes were evaluated. RESULTS There were 888 patients with simple gastroschisis identified. Half of patients had LOS ≤ 30 days. Patients with LOS ≤ 30 were younger at repair (median age 1 day vs. 3 days, p = 0.0001), had higher birth weight (median 2.5 kg vs. 2.4 kg, p = 0.0001), and were less premature (37 week vs. 36 weeks, p = 0.0001). However, only gestational age and weight at birth were significant predictors of LOS on multivariate analysis (p = 0.0001). Prolonged LOS patients had more instances of ventilation, oxygen supplementation, sepsis (n = 2/446 or 0.4% vs. n = 9/442 or 2%, p = 0.003), bleeding/transfusion (n = 7/446 or 1.6% vs. n = 43/442 or 9.7%, p = 0.0001), line infections (n = 1/446 or 0.2% vs. n = 12/442, p = 0.001), and reoperations (n = 9/446 or 2% vs. n = 26/442 or 5.9%, p = 0.003). CONCLUSION Prematurity and birth weight are significant predictors of length of stay in simple gastroschisis patients. Prenatal counseling should continue to be one of the main factors to improve the outcomes for patients with gastroschisis. Type of study Retrospective cohort study. Level of evidence Level IV.
Collapse
|
5
|
Merritt RJ. Gastroschisis: Progress and Challenges. J Pediatr 2022; 243:8-11. [PMID: 34958830 DOI: 10.1016/j.jpeds.2021.12.049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 12/21/2021] [Indexed: 11/25/2022]
Affiliation(s)
- Russell J Merritt
- Department of Pediatrics, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, California.
| |
Collapse
|
6
|
Dekonenko C, Fraser JD, Deans K, Fallat ME, Helmrath M, Kabre R, Leys CM, Burns RC, Corkum K, Dillon PA, Downard C, Wright TN, Gadepalli SK, Grabowski J, Hernandez E, Hirschl R, Johnson KN, Kohler J, Landman MP, Landisch RM, Lawrence AE, Mak GZ, Minneci P, Rymeski B, Sato TT, Slater BJ, Peter SSD. Does Use of a Feeding Protocol Change Outcomes in Gastroschisis? A Report from the Midwest Pediatric Surgery Consortium. Eur J Pediatr Surg 2022; 32:153-159. [PMID: 33368085 DOI: 10.1055/s-0040-1721074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
INTRODUCTION Gastroschisis feeding practices vary. Standardized neonatal feeding protocols have been demonstrated to improve nutritional outcomes. We report outcomes of infants with gastroschisis that were fed with and without a protocol. MATERIALS AND METHODS A retrospective study of neonates with uncomplicated gastroschisis at 11 children's hospitals from 2013 to 2016 was performed.Outcomes of infants fed via institutional-specific protocols were compared with those fed without a protocol. Subgroup analyses of protocol use with immediate versus delayed closure and with sutured versus sutureless closure were conducted. RESULTS Among 315 neonates, protocol-based feeding was utilized in 204 (65%) while no feeding protocol was used in 111 (35%). There were less surgical site infections (SSI) in those fed with a protocol (7 vs. 16%, p = 0.019). There were no differences in TPN duration, time to initial oral intake, time to goal feeds, ventilator use, peripherally inserted central catheter line deep venous thromboses, or length of stay. Of those fed via protocol, less SSIs occurred in those who underwent sutured closure (9 vs. 19%, p = 0.026). Further analyses based on closure timing or closure method did not demonstrate any significant differences. CONCLUSION Across this multi-institutional cohort of infants with uncomplicated gastroschisis, there were more SSIs in those fed without an institutional-based feeding protocol but no differences in other outcomes.
Collapse
Affiliation(s)
- Charlene Dekonenko
- Department of Surgery, Children's Mercy Hospital, Kansas City, Missouri, United States
| | - Jason D Fraser
- Department of Surgery, Children's Mercy Hospital, Kansas City, Missouri, United States
| | - Katherine Deans
- Department of Surgery, Nationwide Children's Hospital, Columbus, Ohio, United States
| | - Mary E Fallat
- Department of Surgery, Norton Children's Hospital, Louisville, Kentucky, United States
| | - Michael Helmrath
- Department of Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, United States
| | - Rashmi Kabre
- Department of Surgery, Ann and Robert H Lurie Children's Hospital of Chicago, Chicago, Illinois, United States
| | - Charles M Leys
- Division of Pediatric Surgery, Department of Surgery, University of Wisconsin, Madison, United States
| | - R Cartland Burns
- Division of Pediatric Surgery, Indiana University School of Medicine, Indianapolis, Indiana, United States
| | - Kristine Corkum
- Department of Surgery, Ann and Robert H Lurie Children's Hospital of Chicago, Chicago, Illinois, United States
| | - Patrick A Dillon
- Department of Surgery, St Louis Children's Hospital PACT, St. Louis, Missouri, United States
| | - Cynthia Downard
- Department of Surgery, Norton Children's Hospital, Louisville, Kentucky, United States
| | - Tiffany N Wright
- Department of Surgery, Norton Children's Hospital, Louisville, Kentucky, United States
| | - Samir K Gadepalli
- Department of Surgery, C S Mott Children's Hospital, Ann Arbor, Michigan, United States
| | - Julia Grabowski
- Department of Pediatric Surgery, Ann and Robert H Lurie Children's Hospital of Chicago, Chicago, Illinois, United States
| | - Edward Hernandez
- Department of Surgery, Riley Hospital for Children at Indiana University Health, Indianapolis, Indiana, United States
| | - Ronald Hirschl
- Department of Surgery, C S Mott Children's Hospital, Ann Arbor, Michigan, United States
| | - Kevin N Johnson
- Department of Surgery, C S Mott Children's Hospital, Ann Arbor, Michigan, United States
| | - Jonathan Kohler
- Department of Surgery, University of Wisconsin Madison, Madison, Wisconsin, United States
| | - Matthew P Landman
- Department of Surgery, Riley Hospital for Children at Indiana University Health, Indianapolis, Indiana, United States
| | - Rachel M Landisch
- Department of Surgery, Children's Hospital of Wisconsin, Milwaukee, Wisconsin, United States
| | - Amy E Lawrence
- Department of Surgery, Nationwide Children's Hospital, Columbus, Ohio, United States
| | - Grace Z Mak
- Department of Surgery, University of Chicago Comer Children's Hospital, Chicago, Illinois, United States
| | - Peter Minneci
- Center for Surgical Outcomes Research, Nationwide Children's Hospital, Columbus, Ohio, United States
| | - Beth Rymeski
- Department of Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, United States
| | - Thomas T Sato
- Department of Surgery, Children's Hospital of Wisconsin, Milwaukee, Wisconsin, United States
| | - Bethany J Slater
- Department of Surgery, University of Chicago Comer Children's Hospital, Chicago, Illinois, United States
| | - St Shawn D Peter
- Department of Surgery, Center for Prospective Trials, Children's Mercy Hospital, Kansas City, Missouri, United States
| |
Collapse
|
7
|
The role of feeding advancement strategy on length of stay and hospital costs in newborns with gastroschisis. J Pediatr Surg 2022; 57:356-359. [PMID: 34020775 DOI: 10.1016/j.jpedsurg.2021.04.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Revised: 03/25/2021] [Accepted: 04/10/2021] [Indexed: 11/21/2022]
Abstract
BACKGROUND Infants with gastroschisis require prolonged hospitalization for surgical repair and gradual advancement of feeds. The present study explores the effect of a change in a protocolized enteral feeding regimen with length of hospital stay (LOS) and total costs in newborns with gastroschisis. METHODS A retrospective review was performed in neonates with uncomplicated gastroschisis at a free-standing pediatric institution from 2012 to 2020. The effect of two different enteral feed advancement protocols on clinical outcomes and hospital costs was analyzed. RESULTS Seventy-four patients were identified, of which 50 (68%) underwent 10 ml/kg/day feeding advancements, and 24 (32%) underwent 20 ml/kg/day feeding advancements. Compared to neonates who underwent 10 ml/kg/day enteral advancements, neonates receiving 20 ml/kg/day advancements reached goal feeds faster (14 vs 20 days, p<0.001), were younger at goal feeds (26 vs 34 days, p = 0.001), required fewer days of parenteral nutrition (22 vs 29 days, p = 0.001), and had shorter LOS (30 vs 36 days, p = 0.001). On multivariable analysis, total costs decreased by 9.77% in the 20 ml/kg/day advancement cohort (p = 0.071). CONCLUSION In neonates with uncomplicated gastroschisis who underwent primary repair, a nutritional protocol that incorporated 20 ml/kg/day feeding advancements was safe and resulted in faster attainment of goal feeds and shorter LOS. LEVEL OF EVIDENCE II/III.
Collapse
|
8
|
Raduma OS, Jehangir S, Karpelowsky J. The effect of standardized feeding protocol on early outcome following gastroschisis repair: A systematic review and meta-analysis. J Pediatr Surg 2021; 56:1776-1784. [PMID: 34193345 DOI: 10.1016/j.jpedsurg.2021.05.022] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Revised: 04/27/2021] [Accepted: 05/25/2021] [Indexed: 12/27/2022]
Abstract
BACKGROUND Improved 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 DESIGN A 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. RESULTS Eight 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. CONCLUSION Protocolized 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.
Collapse
Affiliation(s)
- Ochieng Sephenia Raduma
- Department of Surgery, Defence Forces Memorial Hospital, Nairobi, Kenya; Division of Surgery, University of Sydney, NSW, Australia; Division of Child and Adolescent Health, Sydney Medical School, University of Sydney, NSW, Australia
| | - Susan Jehangir
- Department of Paediatric Surgery, The Children's hospital at Westmead, NSW, Australia; Christian Medical College, Vellore, Tamil Nadu, India
| | - Jonathan Karpelowsky
- Division of Surgery, University of Sydney, NSW, Australia; Department of Paediatric Surgery, The Children's hospital at Westmead, NSW, Australia; Division of Child and Adolescent Health, Sydney Medical School, University of Sydney, NSW, Australia.
| |
Collapse
|
9
|
Gilliam EA, Vu K, Rao P, Krishnaswami S, Hamilton N, Azarow K, Gingalewski C, Jafri M, Zigman A, Butler M, Fialkowski EA. Minimizing Variance in Gastroschisis Management Leads to Earlier Full Feeds in Delayed Closure. J Surg Res 2021; 257:537-544. [DOI: 10.1016/j.jss.2020.07.072] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 06/20/2020] [Accepted: 07/11/2020] [Indexed: 12/16/2022]
|
10
|
Fraser JD, Deans KJ, Fallat ME, Helmrath MA, Kabre R, Leys CM, Burns RC, Corkum K, Dillon PA, Downard CD, Gadepalli SK, Grabowski JE, Hernandez E, Hirschl RB, Johnson KN, Kohler JE, Landman MP, Landisch RM, Lawrence AE, Mak GZ, Minneci PC, Rymeski B, Sato TT, Scannell M, Slater BJ, Wilkinson KH, Wright TN, St Peter SD. Sutureless vs sutured abdominal wall closure for gastroschisis: Operative characteristics and early outcomes from the Midwest Pediatric Surgery Consortium. J Pediatr Surg 2020; 55:2284-2288. [PMID: 32151403 DOI: 10.1016/j.jpedsurg.2020.02.017] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Revised: 01/14/2020] [Accepted: 02/06/2020] [Indexed: 11/16/2022]
Abstract
PURPOSE To report outcomes of sutured and sutureless closure for gastroschisis across a large multi-institutional cohort. METHODS A retrospective study of infants with uncomplicated gastroschisis at 11 children's from 2014 to 2016 was performed. Outcomes of sutured and sutureless abdominal wall closure were compared. RESULTS Among 315 neonates with uncomplicated gastroschisis, sutured closure was performed in 248 (79%); 212 undergoing sutured closure after silo and 36 undergoing primary sutured closure. Sutureless closure was performed in 67 (21%); 37 primary sutureless closure, 30 sutureless closure after silo placement. There was no significant difference in gestational age, gender, birth weight, total days on TPN, and time from closure to initial oral intake or goal feeds. Sutureless closure patients had less general anesthetics, ventilator use/time, time from birth to final closure, antibiotic use after closure, and surgical site/deep space infections. Subgroup analysis demonstrated primary sutureless closure had less ventilator use and anesthetics than primary sutured closure. Sutureless closure after silo led to less ventilator use/time, anesthetics, and antibiotics compared to those with sutured closure after silo. CONCLUSION Sutureless abdominal wall closure of neonates with gastroschisis was associated with less general anesthetics, antibiotic use, surgical site/deep space infections, and decreased ventilator time. These findings support further prospective study by our group. LEVEL OF EVIDENCE Level III.
Collapse
Affiliation(s)
- Jason D Fraser
- Department of Surgery, Children's Mercy Kansas City, Kansas City, MO.
| | - Katherine J Deans
- Center for Surgical Outcomes Research, The Research Institute at Nationwide Children's Hospital, Department of Surgery, University of Ohio, Columbus, OH
| | - Mary E Fallat
- Division of Pediatric Surgery, Hiram C. Polk, Jr., M.D. Department of Surgery, University of Louisville, Louisville, KY
| | - Michael A Helmrath
- Division of Pediatric Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Rashmi Kabre
- Division of Pediatric Surgery, Department of Surgery, Feinberg School of Medicine of Northwestern University, Chicago, IL
| | - Charles M Leys
- Division of Pediatric Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - R Cartland Burns
- Division of Pediatric Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Kristine Corkum
- Division of Pediatric Surgery, Department of Surgery, Feinberg School of Medicine of Northwestern University, Chicago, IL
| | - Patrick A Dillon
- Division of Pediatric Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO
| | - Cynthia D Downard
- Division of Pediatric Surgery, Hiram C. Polk, Jr., M.D. Department of Surgery, University of Louisville, Louisville, KY
| | - Samir K Gadepalli
- Section of Pediatric Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Julia E Grabowski
- Division of Pediatric Surgery, Department of Surgery, Feinberg School of Medicine of Northwestern University, Chicago, IL
| | - Edward Hernandez
- Division of Pediatric Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Ronald B Hirschl
- Section of Pediatric Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Kevin N Johnson
- Section of Pediatric Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Jonathan E Kohler
- Division of Pediatric Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Matthew P Landman
- Division of Pediatric Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Rachel M Landisch
- Division of Pediatric Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Amy E Lawrence
- Center for Surgical Outcomes Research, The Research Institute at Nationwide Children's Hospital, Department of Surgery, University of Ohio, Columbus, OH
| | - Grace Z Mak
- Section of Pediatric Surgery, Department of Surgery, The University of Chicago Medicine, Chicago, IL
| | - Peter C Minneci
- Center for Surgical Outcomes Research, The Research Institute at Nationwide Children's Hospital, Department of Surgery, University of Ohio, Columbus, OH
| | - Beth Rymeski
- Division of Pediatric Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Thomas T Sato
- Division of Pediatric Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Madeline Scannell
- Division of Pediatric Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO
| | - Bethany J Slater
- Section of Pediatric Surgery, Department of Surgery, The University of Chicago Medicine, Chicago, IL
| | - Kathryn H Wilkinson
- Division of Pediatric Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Tiffany N Wright
- Division of Pediatric Surgery, Hiram C. Polk, Jr., M.D. Department of Surgery, University of Louisville, Louisville, KY
| | - Shawn D St Peter
- Department of Surgery, Children's Mercy Kansas City, Kansas City, MO
| | | |
Collapse
|
11
|
Hobson D, Spence K, Trivedi A, Thomas G. Differences in attitudes to feeding post repair of Gastroschisis and development of a standardized feeding protocol. BMC Pediatr 2019; 19:475. [PMID: 31801489 PMCID: PMC6894280 DOI: 10.1186/s12887-019-1858-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Accepted: 11/26/2019] [Indexed: 12/12/2022] Open
Abstract
Background The purpose of this study was to examine differences in attitudes to feeding in neonates with Gastroschisis between clinical groups and to develop a standardized feeding protocol. Confusion, inconsistencies in practice and lack of evidence could be contributing to avoidable delays in the establishment of enteral feeds resulting in lengthy requirements for central venous access, dependence on total parenteral nutrition (TPN), increased risk of sepsis, TPN related cholestasis and prolongation in length of hospital stay. Methods A national survey of clinicians (neonatologists, neonatal intensive care nurses and paediatric surgeons), looking after neonates with gastroschisis was undertaken to determine differences in feeding practice post repair. In addition, an audit of practice in one hospital was undertaken to examine variations in practices between clinicians. A feeding protocol was then developed using inputs from surgeons and neonatologists. Results Gastric aspirates and residuals were typically used as indicators of feed readiness and feed tolerance; however, there was very little consistency within and between clinical groups in definitions of tolerance or intolerance of feeds and in how to initiate and progress feeds. A feeding protocol with clear definition of feed readiness and a clear pathway to progression of feeds was developed to help overcome these variations in practice with the possibility that this might reduce the length of stay (LOS) and have other secondary benefits. The protocol included early introduction of enteral feeds particularly direct breast or sucking feeds. Conclusions Wide differences in attitudes to feeding neonates post Gastroschsis repair exist and the need for a consistent protocolized approach was felt. The feeding protocol we developed requires a change of practice and further clinical trials are needed to evaluate its effectiveness.
Collapse
Affiliation(s)
- Donna Hobson
- Grace Centre for Newborn Care, The Children's Hospital at Westmead, Locked Bag 4001, Westmead, NSW, 2145, Australia
| | - Kaye Spence
- Grace Centre for Newborn Care, The Children's Hospital at Westmead, Locked Bag 4001, Westmead, NSW, 2145, Australia. .,Western Sydney University, School of Nursing and Midwifery, Locked Bag 1797, Penrith, NSW, 2751, Australia.
| | - Amit Trivedi
- Grace Centre for Newborn Care, The Children's Hospital at Westmead, Locked Bag 4001, Westmead, NSW, 2145, Australia.,The Children's Hospital at Westmead Clinical School, The University of Sydney, Locked Bag 4001, Westmead, NSW, 2145, Australia
| | - Gordon Thomas
- The Children's Hospital at Westmead Clinical School, The University of Sydney, Locked Bag 4001, Westmead, NSW, 2145, Australia.,Department of Surgery, The Children's Hospital at Westmead, Locked Bag 4001, Westmead, NSW, 2145, Australia
| |
Collapse
|