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Cramm SL, Graham DA, Feng C, Allukian M, Blakely ML, Chandler NM, Cowles RA, Kunisaki SM, Lipskar AM, Russell RT, Santore MT, Campbell BT, Commander SJ, DeFazio JR, Dukleska K, Echols JC, Esparaz JR, Gerall C, Griggs CL, Hanna DN, He K, Keane OA, McLean SE, Pace E, Scholz S, Sferra SR, Tracy ET, Zhang L, Rangel SJ. Use of Antipseudomonal Antibiotics is Not Associated With Lower Rates of Postoperative Drainage Procedures or More Favorable Culture Profiles in Children With Complicated Appendicitis: Results From a Multicenter Regional Research Consortium. Ann Surg 2024; 279:1070-1076. [PMID: 37970676 DOI: 10.1097/sla.0000000000006152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2023]
Abstract
OBJECTIVE To compare rates of postoperative drainage and culture profiles in children with complicated appendicitis treated with the 2 most common antibiotic regimens with and without antipseudomonal activity [piperacillin-tazobactam (PT) and ceftriaxone with metronidazole (CM)]. BACKGROUND Variation in the use of antipseudomonal antibiotics has been driven by a paucity of multicenter data reporting clinically relevant, culture-based outcomes. METHODS A retrospective cohort study of patients with complicated appendicitis (7/2015-6/2020) using NSQIP-Pediatric data from 15 hospitals participating in a regional research consortium. Operative report details, antibiotic utilization, and culture data were obtained through supplemental chart review. Rates of 30-day postoperative drainage and organism-specific culture positivity were compared between groups using mixed-effects regression to adjust for clustering after propensity matching on measures of disease severity. RESULTS In all, 1002 children met the criteria for matching (58.9% received CM and 41.1% received PT). In the matched sample of 778 patients, children treated with PT had similar rates of drainage overall [PT: 11.8%, CM: 12.1%; odds ratio (OR): 1.44 (OR: 0.71-2.94)] and higher rates of drainage associated with the growth of any organism [PT: 7.7%, CM: 4.6%; OR: 2.41 (95% CI: 1.08-5.39)] and Escherichia coli [PT: 4.6%, CM: 1.8%; OR: 3.42 (95% CI: 1.07-10.92)] compared to treatment with CM. Rates were similar between groups for drainage associated with multiple organisms [PT: 2.6%, CM: 1.5%; OR: 3.81 (95% CI: 0.96-15.08)] and Pseudomonas [PT: 1.0%, CM: 1.3%; OR: 3.42 (95% CI: 0.55-21.28)]. CONCLUSIONS AND RELEVANCE The use of antipseudomonal antibiotics is not associated with lower rates of postoperative drainage procedures or more favorable culture profiles in children with complicated appendicitis.
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Affiliation(s)
- Shannon L Cramm
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Dionne A Graham
- Center for Applied Pediatric Quality Analytics, Boston Children's Hospital, Boston, MA
| | - Christina Feng
- Department of Surgery, Children's National Hospital, Washington, DC
| | - Myron Allukian
- Division of Pediatric, General, Thoracic, and Fetal Surgery, Children's Hospital of Philadelphia, Perelman Medical School at the University of Pennsylvania, Philadelphia, PA
| | - Martin L Blakely
- Division of Pediatric Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Nicole M Chandler
- Division of Pediatric Surgery, Johns Hopkin's All Children's Hospital, St. Petersburg, FL
| | - Robert A Cowles
- Department of Pediatric Surgery, Yale New Haven Children's Hospital, Yale School of Medicine, New Haven, CT
| | - Shaun M Kunisaki
- Department of Surgery, Johns Hopkins Children's Center, Johns Hopkins School of Medicine, Baltimore, MD
| | - Aaron M Lipskar
- Division of Pediatric Surgery, Cohen Children's Medical Center, Zucker School of Medicine at Hoftsra/Northwell, New Hyde Park, NY
| | - Robert T Russell
- Division of Pediatric Surgery, Children's of Alabama, Birmingham, AL
- Division of Pediatric Surgery, Department of Surgery, Children's of Alabama, University of Alabama at Birmingham, Birgmingham, AL
| | - Matthew T Santore
- Department of Surgery, Children's Healthcare of Atlanta, Emory University, Atlanta, GA
| | | | - Sarah J Commander
- Department of Surgery, Duke Children's Hospital and Health Center, Durham, NC
| | - Jennifer R DeFazio
- Division of Pediatric Surgery, New York Presbyterian Morgan Stanley Children's Hospital, Columbia University Vagelos College of Physicians and Surgeons, New York, NY
| | - Katerina Dukleska
- Department of Surgery, Connecticut Children's Hospital, Hartford, CT
| | - Justice C Echols
- Department of Surgery, University of North Carolina Health System, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Joseph R Esparaz
- Division of Pediatric Surgery, Children's of Alabama, Birmingham, AL
- Division of Pediatric Surgery, Department of Surgery, Children's of Alabama, University of Alabama at Birmingham, Birgmingham, AL
| | - Claire Gerall
- Department of Surgery, UT Health San Antonio, San Antonio, TX
| | - Cornelia L Griggs
- Department of Surgery, Division of Pediatric Surgery, Massachusetts General Hospital, Boston, MA
| | - David N Hanna
- Division of Pediatric Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Katherine He
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Olivia A Keane
- Department of Surgery, Children's Healthcare of Atlanta, Emory University, Atlanta, GA
| | - Sean E McLean
- Division of Pediatric Surgery, University of North Carolina Health System, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Elizabeth Pace
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Stefan Scholz
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Shelby R Sferra
- Department of Surgery, Johns Hopkins Children's Center, Johns Hopkins School of Medicine, Baltimore, MD
| | - Elisabeth T Tracy
- Department of Surgery, Duke Children's Hospital and Health Center, Duke University School of Medicine, Durham, NC
| | - Lucy Zhang
- Department of Pediatric Surgery, Yale New Haven Children's Hospital, Yale School of Medicine, New Haven, CT
| | - Shawn J Rangel
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA
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McNevin K, Nicassio L, Rice-Townsend SE, Katz CB, Goldin A, Avansino J, Calkins CM, Durham MM, Page K, Ralls MW, Reeder RW, Rentea RM, Rollins MD, Saadai P, Wood RJ, van Leeuwen KD, Smith CA. Comparison of the PCPLC Database to NSQIP-P: A Patient Matched Comparison of Surgical Complications Following Repair of Anorectal Malformation. J Pediatr Surg 2024; 59:997-1002. [PMID: 38365475 DOI: 10.1016/j.jpedsurg.2024.01.004] [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] [Received: 06/21/2023] [Revised: 11/27/2023] [Accepted: 01/05/2024] [Indexed: 02/18/2024]
Abstract
BACKGROUND Anorectal malformations (ARM) are rare and heterogenous which creates a challenge in conducting research and offering recommendations for best practice. The Pediatric Colorectal and Pelvic Learning Consortium (PCPLC) was formed in 2016 to address this challenge and created a shared national data registry to collect information about pediatric colorectal patients. There has been no external validation of the data collected. We sought to evaluate the database by performing a patient matched analysis comparing 30-day outcomes identified in the PCPLC registry with the NSQIP-P database for patients undergoing surgical repair of ARM. METHODS Patients captured in the PCPLC database from 2016 to 2021 at institutions also participating in NSQIP-P who underwent ARM repair younger than 12 months old were reviewed for 30-day complications. These patients were matched to their NSQIP-P record using their hospital identification number, and records were compared for concordance in identified complications. RESULTS A total of 591 patient records met inclusion criteria in the PCPLC database. Of these, 180 patients were also reviewed by NSQIP-P. One hundred and fifty-six patient records had no complications recorded. Twenty-four patient records had a complication listed in one or both databases. There was a 91 % concordance rate between databases. When excluding complications not tracked in the PCPLC registry, this agreement improved to 93 %. CONCLUSION Including all patients evaluated for this subpopulation, a 91 % concordance rate was observed when comparing PCPLC collected complications to NSQIP-P. Future efforts can focus on further validating the data within the PCPLC for other patient populations. LEVEL OF EVIDENCE V.
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Affiliation(s)
- Kathryn McNevin
- Department of General Surgery, Seattle Children's Hospital, University of Washington, 4800 Sandpoint Way NE, Seattle, WA 98105, USA.
| | - Lauren Nicassio
- Department of General Surgery, Seattle Children's Hospital, University of Washington, 4800 Sandpoint Way NE, Seattle, WA 98105, USA
| | - Samuel E Rice-Townsend
- Department of General Surgery, Seattle Children's Hospital, University of Washington, 4800 Sandpoint Way NE, Seattle, WA 98105, USA
| | - Cindy B Katz
- Department of General Surgery, Seattle Children's Hospital, University of Washington, 4800 Sandpoint Way NE, Seattle, WA 98105, USA
| | - Adam Goldin
- Department of General Surgery, Seattle Children's Hospital, University of Washington, 4800 Sandpoint Way NE, Seattle, WA 98105, USA
| | - Jeffrey Avansino
- Department of General Surgery, Seattle Children's Hospital, University of Washington, 4800 Sandpoint Way NE, Seattle, WA 98105, USA
| | - Casey M Calkins
- Department of Surgery, Children's Wisconsin, Medical College of Wisconsin, 999 N 92 St Suite 320, Milwaukee, WI 53226, USA
| | - Megan M Durham
- Department of Surgery, Children's Healthcare of Atlanta, Emory University School of Medicine, 1405 Clifton Rd NE, Atlanta, GA 30322, USA
| | - Kent Page
- Department of Pediatrics, University of Utah, 295 Chipeta Way, Salt Lake City, UT 84108, USA
| | - Matthew W Ralls
- Department of Surgery, C.S. Mott Children's Hospital, University of Michigan, 1540 E Hospital Drive Level 4, Ann Arbor, MI 48109, USA
| | - Ron W Reeder
- Department of Pediatrics, University of Utah, 295 Chipeta Way, Salt Lake City, UT 84108, USA
| | - Rebecca M Rentea
- Department of Surgery, Children's Mercy Hospital, University of Missouri-Kansas City, 2401 Gillham Rd, Kansas City, MO 64108, USA
| | - Michael D Rollins
- Department of Surgery, Primary Children's Hospital, University of Utah, 100 North Mario Capecchi Dr., Ste 3800 Salt Lake City, UT 84112, USA
| | - Payam Saadai
- Department of Surgery, UC Davis Children's Hospital, University of California Davis, 2521 Stockton Blvd, 4th Floor Suite 4100, Sacramento, CA 95817, USA
| | - Richard J Wood
- Department of Surgery, Nationwide Children's Hospital, The Ohio State University, 700 Children's Drive, Columbus, OH 43205, USA
| | - Kathleen D van Leeuwen
- Department of Surgery, Phoenix Children's Hospital, University of Arizona, 1919 E. Thomas Rd, Phoenix, AZ 85016, USA
| | - Caitlin A Smith
- Department of General Surgery, Seattle Children's Hospital, University of Washington, 4800 Sandpoint Way NE, Seattle, WA 98105, USA
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Cramm SL, Graham DA, Blakely ML, Kunisaki SM, Chandler NM, Cowles RA, Feng C, He K, Russell RT, Allukian M, Campbell BT, Commander SJ, DeFazio JR, Dukleska K, Echols JC, Esparaz JR, Gerall C, Griggs CL, Hanna DN, Keane OA, Lipskar AM, McLean SE, Pace E, Santore MT, Scholz S, Sferra SR, Tracy ET, Zhang L, Rangel SJ. Postoperative Antibiotics, Outcomes, and Resource Use in Children With Gangrenous Appendicitis. JAMA Surg 2024; 159:511-517. [PMID: 38324276 PMCID: PMC10851140 DOI: 10.1001/jamasurg.2023.7754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Accepted: 11/04/2023] [Indexed: 02/08/2024]
Abstract
Importance Gangrenous, suppurative, and exudative (GSE) findings have been associated with increased surgical site infection (SSI) risk and resource use in children with nonperforated appendicitis. Establishing the role for postoperative antibiotics may have important implications for infection prevention and antimicrobial stewardship. Objective To compare SSI rates in children with nonperforated appendicitis with GSE findings who did and did not receive postoperative antibiotics. Design, Setting, and Participants This was a retrospective cohort study using American College of Surgeons' National Surgical Quality Improvement Program (NSQIP)-Pediatric Appendectomy Targeted data from 16 hospitals participating in a regional research consortium. NSQIP data were augmented with operative report and antibiotic use data obtained through supplemental medical record review. Children with nonperforated appendicitis with GSE findings who underwent appendectomy between July 1, 2015, and June 30, 2020, were identified using previously validated intraoperative criteria. Data were analyzed from October 2022 to July 2023. Exposure Continuation of antibiotics after appendectomy. Main Outcomes and Measures Rate of 30-day postoperative SSI including both incisional and organ space infections. Complementary hospital and patient-level analyses were conducted to explore the association between postoperative antibiotic use and severity-adjusted outcomes. The hospital-level analysis explored the correlation between postoperative antibiotic use and observed to expected (O/E) SSI rate ratios after adjusting for differences in disease severity (presence of gangrene and postoperative length of stay) among hospital populations. In the patient-level analysis, propensity score matching was used to balance groups on disease severity, and outcomes were compared using mixed-effects logistic regression to adjust for hospital-level clustering. Results A total of 958 children (mean [SD] age, 10.7 [3.7] years; 567 male [59.2%]) were included in the hospital-level analysis, of which 573 (59.8%) received postoperative antibiotics. No correlation was found between hospital-level SSI O/E ratios and postoperative antibiotic use when analyzed by either overall rate of use (hospital median, 53.6%; range, 31.6%-100%; Spearman ρ = -0.10; P = .71) or by postoperative antibiotic duration (hospital median, 1 day; range, 0-7 days; Spearman ρ = -0.07; P = .79). In the propensity-matched patient-level analysis including 404 patients, children who received postoperative antibiotics had similar rates of SSI compared with children who did not receive postoperative antibiotics (3 of 202 [1.5%] vs 4 of 202 [2.0%]; odds ratio, 0.75; 95% CI, 0.16-3.39; P = .70). Conclusions and Relevance Use of postoperative antibiotics did not improve outcomes in children with nonperforated appendicitis with gangrenous, suppurative, or exudative findings.
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Affiliation(s)
- Shannon L. Cramm
- Department of Surgery, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Dionne A. Graham
- Program for Patient Safety and Quality, Boston Children’s Hospital, Boston, Massachusetts
| | - Martin L. Blakely
- Division of Pediatric Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Shaun M. Kunisaki
- Department of Surgery, Johns Hopkins Children’s Center, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Nicole M. Chandler
- Division of Pediatric Surgery, Johns Hopkin’s All Children’s Hospital, St. Petersburg, Florida
| | - Robert A. Cowles
- Department of Pediatric Surgery, Yale New Haven Children’s Hospital, Yale School of Medicine, New Haven, Connecticut
| | - Christina Feng
- Department of Surgery, Children’s National Hospital, Washington, D.C
| | - Katherine He
- Department of Surgery, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Robert T. Russell
- Division of Pediatric Surgery, Children’s of Alabama; Department of Surgery, University of Alabama at Birmingham, Birmingham
| | - Myron Allukian
- Division of Pediatric, General, Thoracic, and Fetal Surgery, Children’s Hospital of Philadelphia, Perelman Medical School at the University of Pennsylvania, Philadelphia
| | - Brendan T. Campbell
- Department of Surgery, Connecticut Children’s Hospital, Hartford, Connecticut
| | - Sarah J. Commander
- Department of Surgery, Duke Children’s Hospital and Health Center, Durham, North Carolina
| | - Jennifer R. DeFazio
- Division of Pediatric Surgery, New York Presbyterian Morgan Stanley Children’s Hospital, Columbia University Vagelos College of Physicians and Surgeons, New York
| | - Katerina Dukleska
- Department of Surgery, Connecticut Children’s Hospital, Hartford, Connecticut
| | - Justice C. Echols
- Department of Surgery, University of North Carolina Health System, University of North Carolina School of Medicine, Chapel Hill
| | - Joseph R. Esparaz
- Division of Pediatric Surgery, Children’s of Alabama; Department of Surgery, University of Alabama at Birmingham, Birmingham
| | - Claire Gerall
- Department of Surgery, UT Health San Antonio, San Antonio, Texas
| | - Cornelia L. Griggs
- Department of Surgery, Division of Pediatric Surgery, Massachusetts General Hospital, Boston
| | - David N. Hanna
- Division of Pediatric Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Olivia A. Keane
- Department of Surgery, Children’s Healthcare of Atlanta, Emory University, Atlanta, Georgia
| | - Aaron M. Lipskar
- Division of Pediatric Surgery, Cohen Children’s Medical Center, Zucker School of Medicine at Hoftsra/Northwell, New Hyde Park, New York
| | - Sean E. McLean
- Division of Pediatric Surgery, University of North Carolina Health System, University of North Carolina School of Medicine, Chapel Hill
| | - Elizabeth Pace
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Matthew T. Santore
- Department of Surgery, Children’s Healthcare of Atlanta, Emory University, Atlanta, Georgia
| | - Stefan Scholz
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Shelby R. Sferra
- Department of Surgery, Johns Hopkins Children’s Center, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Elisabeth T. Tracy
- Department of Surgery, Duke Children’s Hospital and Health Center, Durham, North Carolina
| | - Lucy Zhang
- Department of Pediatric Surgery, Yale New Haven Children’s Hospital, Yale School of Medicine, New Haven, Connecticut
| | - Shawn J. Rangel
- Department of Surgery, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
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Belcher R, Kolosky T, Moore JT, Strauch ED, Englum BR. The Association of Weight With Surgical Morbidity in Infants Undergoing Enterostomy Reversal: A Study of the NSQIP-Pediatrics Database. J Pediatr Surg 2024:S0022-3468(24)00158-1. [PMID: 38580546 DOI: 10.1016/j.jpedsurg.2024.03.007] [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] [Received: 10/25/2023] [Revised: 02/19/2024] [Accepted: 03/07/2024] [Indexed: 04/07/2024]
Abstract
INTRODUCTION Optimal criteria and timing for enterostomy closure (EC) in neonates is largely based on clinical progression and adequate weight, with most institutions using 2.0-2.5 kg as the minimum acceptable weight. It is unclear how the current weight cutoff affects post-operative morbidity. AIM To determine how infant weight at the time of EC influences 30-day complications. METHODS Infants weighing ≤4000 g who underwent EC were identified in the 2012-2019 ACS NSQIP-P database. Demographics, comorbidities, and 30-day outcomes were assessed using univariate analysis. Multivariable logistic regression controlling for ASA score, nutritional support, and ventilator support was used to estimate the independent association of weight on risk of 30-day complications. RESULTS A total of 1692 neonates from the NSQIP-P database during the years 2012-2019 met inclusion criteria. Neonates weighing <2.5 kg were significantly more likely to have a younger gestational age, require ventilator support, and have concurrent comorbidities. Major morbidity, a composite outcome of the individual postoperative complications, was observed in 283 (16.7%) infants. ASA classifications 4 and 5, dependence on nutritional support, and ventilator support were independently associated with increased risk of 30-day complications. With respect to weight, we found no significant difference in major morbidity between infants weighing <2.5 kg and infants weighing ≥2.5 kg. CONCLUSION Despite using a robust, national dataset, we could find no evidence that a defined weight cut-off was associated with a reduction in major morbidity, indicating that weight should not be a priority factor when determining eligibility for neonatal EC. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Rachael Belcher
- University of Maryland School of Medicine, Baltimore, MD, USA
| | - Taylor Kolosky
- University of Maryland School of Medicine, Baltimore, MD, USA
| | - James T Moore
- Division of Pediatric and Urologic Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Eric D Strauch
- Division of Pediatric and Urologic Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Brian R Englum
- Division of Pediatric and Urologic Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA.
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Fernandez PG, Dexter F, Brown J, Whitney G, Koff MD, Cao S, Loftus RW. Epidemiology of Enterococcus , Staphylococcus aureus , Klebsiella , Acinetobacter , Pseudomonas , and Enterobacter Species Transmission in the Pediatric Anesthesia Work Area Environment With and Without Practitioner Use of a Personalized Body-Worn Alcohol Dispenser. Anesth Analg 2024; 138:152-160. [PMID: 36623234 PMCID: PMC10918764 DOI: 10.1213/ane.0000000000006326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND Personalized body-worn alcohol dispensers may serve as an important tool for perioperative infection control, but the impact of these devices on the epidemiology of transmission of high-risk Enterococcus , Staphylococcus aureus , Klebsiella, Acinetobacter , Pseudomonas , and Enterobacter (ESKAPE) pathogens is unknown. We aimed to characterize the epidemiology of ESKAPE transmission in the pediatric anesthesia work area environment with and without a personalized body-worn alcohol dispenser. METHODS This controlled before and after study included 40 pediatric patients enrolled over a 1-year study period. Two groups of operating room cases were compared: (1) operating room cases caring for patients with usual care (December 17, 2019, to August 25, 2020), and (2) operating room cases caring for patients with usual care plus the addition of a personalized, body-worn alcohol hand rub dispenser (September 30, 2020, to December 16, 2020). Operating rooms were randomly selected for observation of ESKAPE transmission in both groups. Device use was tracked via wireless technology and recorded in hourly hand decontamination events. RESULTS Anesthesia providers used the alcohol dispenser 3.3 ± 2.1 times per hour. A total of 57 ESKAPE transmission events (29 treatment and 28 control) were identified. The personalized body-worn alcohol dispenser impacted ESKAPE transmission by increasing the contribution of provider hand contamination at case start (21/29 device versus 10/28 usual care; relative risk, [RR] 2.03; 99.17% confidence interval [CI], 1.025-5.27; P = .0066) and decreasing the contribution of environmental contamination at case end (3/29 device versus 12/28 usual care; RR, 0.24; 99.17% CI, 0.022-0.947; P = .0059). ESKAPE pathogen contamination involved 20% (8/40) of patient intravascular devices. There were 85% (34/40) of preoperative patient skin surfaces contaminated with ≥1 (1.78 ± 0.19 [standard deviation {SD}]) ESKAPE pathogens. CONCLUSIONS A personalized body-worn alcohol dispenser can impact the epidemiology of ESKAPE transmission in the pediatric anesthesia work area environment. Improved preoperative patient decolonization and vascular care are indicated to address ESKAPE pathogens among pediatric anesthesia work area reservoirs.
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Affiliation(s)
- Patrick G Fernandez
- From the Division of Pediatric Anesthesiology, Department of Anesthesiology, University of Colorado, Aurora, Colorado
| | - Franklin Dexter
- Department of Anesthesia, University of Iowa, Iowa City, Iowa
| | - Jeremiah Brown
- Department of Epidemiology, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
| | - Gina Whitney
- From the Division of Pediatric Anesthesiology, Department of Anesthesiology, University of Colorado, Aurora, Colorado
| | - Matthew D Koff
- Department of Anesthesiology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Scott Cao
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Randy W Loftus
- Department of Anesthesia, University of Iowa, Iowa City, Iowa
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Mack SJ, Pace DJ, Patil S, Cooke-Barber J, Boelig MM, Berman L. Concurrent Cholecystectomy Does Not Increase Splenectomy Morbidity in Patients With Hemolytic Anemia: A Pediatric NSQIP Analysis. J Pediatr Surg 2024; 59:117-123. [PMID: 37833213 DOI: 10.1016/j.jpedsurg.2023.09.010] [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] [Received: 08/14/2023] [Accepted: 09/06/2023] [Indexed: 10/15/2023]
Abstract
PURPOSE Children undergoing splenectomy for hemolytic anemia often have cholelithiasis, which may or may not be symptomatic. It is unclear whether concurrent cholecystectomy increases length of stay or morbidity after splenectomy. The purpose of this study was to compare morbidity among children undergoing laparoscopic splenectomy alone versus splenectomy with concurrent cholecystectomy in patients with hemolytic anemia. METHODS We retrospectively evaluated children with hemolytic anemia undergoing non-traumatic laparoscopic splenectomy in the National Surgical Quality Improvement Program-Pediatric database (2012-2020). Outcomes were compared for patients undergoing splenectomy alone (n = 1010) versus splenectomy with cholecystectomy (n = 371). Pearson's Chi-square and Student's t-tests were utilized as appropriate. Propensity score-matching was completed, controlling for eight demographic and clinical variables. RESULTS 1381 patients were identified, 73.1% undergoing splenectomy alone and 26.9% splenectomy with cholecystectomy. Splenectomy with cholecystectomy patients were older (10.9 years vs. 8.4 years, p < 0.01), more likely to have hereditary spherocytosis (56.1% vs. 40.8%, p < 0.01), less likely to have sickle cell disease (12.1% vs. 33.5%, p < 0.01), more likely ASA class 1 or 2 (49.3% vs. 42.1%, p < 0.01), and had similar preoperative hematocrit levels (29.6 vs. 29.3, p = 0.33). The splenectomy with cholecystectomy group was less likely to receive preoperative blood transfusions (13.5% vs. 25.4%, p < 0.01). There were 360 pairs selected on propensity score-matching, and splenectomy with cholecystectomy was associated with increased operative time (182 min vs. 145 min, p < 0.01) and decreased occurrences of a postoperative transfusion (4.2% vs. 8.9%, p = 0.01). Length of stay after surgery (2.5 days vs. 2.3 days, p = 0.13), composite morbidity (3.9% vs. 3.4%, p = 0.69), and 30-day readmission rates (3.3% vs. 7.4%, p = 0.08) were all similar. CONCLUSIONS Splenectomy with cholecystectomy is associated with similar postoperative morbidity, length of stay and readmission rates compared to splenectomy alone. These data support the safety of concurrent cholecystectomy with splenectomy for children with cholelithiasis in the setting of hemolytic anemia. TYPE OF STUDY Retrospective Cohort Study. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Shale J Mack
- Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA, USA.
| | - Devon J Pace
- Thomas Jefferson University Hospital, Philadelphia, PA, USA; Department of Surgery, Nemours Children's Health, Wilmington, DE, USA
| | - Sanath Patil
- Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA, USA
| | - Jo Cooke-Barber
- Department of Surgery, Nemours Children's Health, Wilmington, DE, USA
| | - Matthew M Boelig
- Department of Surgery, Nemours Children's Health, Wilmington, DE, USA
| | - Loren Berman
- Department of Surgery, Nemours Children's Health, Wilmington, DE, USA
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7
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Mack SJ, Pace DJ, Patil S, Cooke-Barber J, Berman L, Boelig MM. Association of Age at Duodenal Atresia Repair With Outcomes: A Pediatric NSQIP Analysis. J Pediatr Surg 2024; 59:18-25. [PMID: 37833211 DOI: 10.1016/j.jpedsurg.2023.09.009] [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] [Received: 08/14/2023] [Accepted: 09/06/2023] [Indexed: 10/15/2023]
Abstract
PURPOSE Neonates with duodenal atresia (DA) are often born prematurely and undergo repair soon after birth, while others are delayed to allow for growth until closer to term corrected gestational age (cGA). Premature infants have been demonstrated to experience worse outcomes, but it is unclear whether delaying surgery mitigates the increased morbidity. This study evaluates the association of timing of DA repair with postoperative morbidity. METHODS We retrospectively evaluated neonates undergoing DA repair from the National Surgical Quality Improvement Program-Pediatric database (2015-2020). A multivariable regression analyzed factors associated with composite morbidity, including cGA and age in days of life (DOL) at surgery. A propensity score matched analysis was completed in premature neonates born at ≤35 weeks gestation to compare outcomes at similar birth gestational ages (bGA) and birth weight who underwent early (<7 DOL) versus delayed (≥7 DOL) repair. RESULTS 809 neonates were included with a median bGA of 36 weeks (IQR 34-38), birth weight of 2.46 kg (IQR 1.96-2.95), and DOL at surgery of 2 (IQR 1-5). Infants born ≤35 weeks represented 35.23% of the cohort. On multivariable analysis, increasing cGA at surgery was associated with decreased morbidity (OR: 0.91, CI [0.84, 0.99]), and increasing DOL at surgery was associated with increased morbidity (OR: 1.02, CI [1.00, 1.04]). On propensity score matched analysis, delayed repairs were associated with increased postoperative ventilation (6 days vs. 2 days, p < 0.05); however, there were no differences in composite or surgical morbidity between early and delayed repairs. CONCLUSIONS Morbidity after DA repair in neonates ≤35 weeks cGA is primarily driven by non-surgical causes, but delaying surgery does not appear to mitigate the risks associated with prematurity. It seems reasonable to consider repair in neonates around 33-34 weeks gestation without prohibitive risk factors. Optimal timing of DA repair requires a delicate balance between these factors. LEVEL OF EVIDENCE Level III. TYPE OF STUDY Retrospective Cohort Study.
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Affiliation(s)
- Shale J Mack
- Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA, USA.
| | - Devon J Pace
- Thomas Jefferson University Hospital, Philadelphia, PA, USA; Department of Surgery, Nemours Children's Health, Wilmington, DE, USA
| | - Sanath Patil
- Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA, USA
| | - Jo Cooke-Barber
- Department of Surgery, Nemours Children's Health, Wilmington, DE, USA
| | - Loren Berman
- Department of Surgery, Nemours Children's Health, Wilmington, DE, USA
| | - Matthew M Boelig
- Department of Surgery, Nemours Children's Health, Wilmington, DE, USA
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8
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Lapp V, Ben Khallouq B, Bentley D, Kirkland A, Dykstra-Nykanen J, Ayotte K. Does a Presurgical Antisepsis Protocol Decrease Surgical Site Infections in Young Children? AORN J 2024; 119:59-71. [PMID: 38149889 DOI: 10.1002/aorn.14057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 10/05/2022] [Accepted: 01/11/2023] [Indexed: 12/28/2023]
Abstract
National standards for surgical site infection (SSI) prevention for children remain elusive. Our institution developed a presurgical antisepsis protocol that included the three components of chlorhexidine gluconate bathing wipes, chlorhexidine gluconate oral rinse, and povidone-iodine nasal swab. This retrospective cohort study examined data from electronic health records to compare SSI rates before and after protocol implementation. We included children aged 2 through 11 years undergoing any surgical procedure with the use of an incision in the OR (N = 1,356). We did not find any difference in the occurrence of SSI before and after the protocol was implemented. Logistic regression showed that an infection present at the time of surgery was the only significant predictor of an SSI. The implementation of a presurgical antisepsis protocol was not associated with SSI rate reduction in this pediatric cohort.
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9
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Cramm SL, Chandler NM, Graham DA, Kunisaki SM, Russell RT, Blakely ML, Lipskar AM, Allukian M, Aronowitz DI, Campbell BT, Collins DT, Commander SJ, Cowles RA, DeFazio JR, Esparaz JR, Feng C, Griggs CL, Guyer RA, Hanna DN, Kahan AM, Keane OA, Lamoshi A, Lopez CM, Pace E, Regan MD, Santore MT, Scholz S, Tracy ET, Williams SA, Zhang L, Rangel SJ. Association Between Antibiotic Redosing Before Incision and Risk of Incisional Site Infection in Children With Appendicitis. Ann Surg 2023; 278:e863-e869. [PMID: 36317528 DOI: 10.1097/sla.0000000000005747] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
OBJECTIVE To evaluate whether redosing antibiotics within an hour of incision is associated with a reduction in incisional surgical site infection (iSSI) in children with appendicitis. BACKGROUND Existing data remain conflicting as to whether children with appendicitis receiving antibiotics at diagnosis benefit from antibiotic redosing before incision. METHODS This was a multicenter retrospective cohort study using data from the Pediatric National Surgical Quality Improvement Program augmented with antibiotic utilization and operative report data obtained though supplemental chart review. Children undergoing appendectomy at 14 hospitals participating in the Eastern Pediatric Surgery Network from July 2016 to June 2020 who received antibiotics upon diagnosis of appendicitis between 1 and 6 hours before incision were included. Multivariable logistic regression was used to compare odds of iSSI in those who were and were not redosed with antibiotics within 1 hour of incision, adjusting for patient demographics, disease severity, antibiotic agents, and hospital-level clustering of events. RESULTS A total of 3533 children from 14 hospitals were included. Overall, 46.5% were redosed (hospital range: 1.8%-94.4%, P <0.001) and iSSI rates were similar between groups [redosed: 1.2% vs non-redosed: 1.3%; odds ratio (OR) 0.84, (95%,CI, 0.39-1.83)]. In subgroup analyses, redosing was associated with lower iSSI rates when cefoxitin was used as the initial antibiotic (redosed: 1.0% vs nonredosed: 2.5%; OR: 0.38, (95% CI, 0.17-0.84)], but no benefit was found with other antibiotic regimens, longer periods between initial antibiotic administration and incision, or with increased disease severity. CONCLUSIONS Redosing of antibiotics within 1 hour of incision in children who received their initial dose within 6 hours of incision was not associated with reduction in risk of incisional site infection unless cefoxitin was used as the initial antibiotic.
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Affiliation(s)
- Shannon L Cramm
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Nicole M Chandler
- Division of Pediatric Surgery, Johns Hopkins All Children's Hospital, St. Petersburg, FL
| | - Dionne A Graham
- Program for Patient Safety and Quality, Boston Children's Hospital, Boston, MA
| | - Shaun M Kunisaki
- Division of General Pediatric Surgery, Johns Hopkins Children's Center, Johns Hopkins School of Medicine, Baltimore, MD
| | - Robert T Russell
- Division of Pediatric Surgery, Department of Surgery, University of Alabama at Birmingham, Children's of Alabama, Birmingham, AL
| | - Martin L Blakely
- Department of Pediatric Surgery, Vanderbilt Children's Hospital, Vanderbilt University Medical Center, Nashville, TN
| | - Aaron M Lipskar
- Division of Pediatric Surgery, Cohen Children's Medical Center, Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, NY
| | - Myron Allukian
- Division of Pediatric, General, Thoracic, and Fetal Surgery, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Danielle I Aronowitz
- Division of Pediatric, General, Thoracic, and Fetal Surgery, Children's Hospital of Philadelphia, Philadelphia, PA
| | | | - Devon T Collins
- Department of Surgery, Children's National Hospital, Washington, DC
| | - Sarah J Commander
- Department of Surgery, Duke Children's Hospital and Health Center, Duke University School of Medicine, Durham, NC
| | - Robert A Cowles
- Division of Pediatric Surgery, Yale New Haven Children's Hospital and Yale School of Medicine, New Haven, CT
| | - Jennifer R DeFazio
- Division of Pediatric Surgery, New York Presbyterian Morgan Stanley Children's Hospital, Columbia University Vagelos Colleges of Physicians and Surgeons, New York, NY
| | - Joseph R Esparaz
- Division of Pediatric Surgery, Department of Surgery, University of Alabama at Birmingham, Children's of Alabama, Birmingham, AL
| | - Christina Feng
- Department of Surgery, Children's National Hospital, Washington, DC
| | - Cornelia L Griggs
- Division of Pediatric Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Richard A Guyer
- Division of Pediatric Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - David N Hanna
- Department of Surgery, Vanderbilt Children's Hospital, Vanderbilt University Medical Center, Nashville, TN
| | - Anastasia M Kahan
- Division of Pediatric Surgery, New York Presbyterian Morgan Stanley Children's Hospital, Columbia University Vagelos Colleges of Physicians and Surgeons, New York, NY
- Department of Surgery, Mount Sinai Health System, New York, NY
| | - Olivia A Keane
- Division of Pediatric Surgery, Department of Surgery, Children's Healthcare of Atlanta, Emory University, Atlanta, GA
| | - Abdulraouf Lamoshi
- Division of Pediatric Surgery, Cohen Children's Medical Center, Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, NY
| | - Carla M Lopez
- Division of General Pediatric Surgery, Johns Hopkins Children's Center, Johns Hopkins School of Medicine, Baltimore, MD
| | - Elizabeth Pace
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Maia D Regan
- Department of Surgery, Connecticut Children's Hospital, Hartford, CT
| | - Matthew T Santore
- Division of Pediatric Surgery, Department of Surgery, Children's Healthcare of Atlanta, Emory University, Atlanta, GA
| | - Stefan Scholz
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Elisabeth T Tracy
- Department of Surgery, Duke Children's Hospital and Health Center, Duke University School of Medicine, Durham, NC
| | - Sacha A Williams
- Division of Pediatric Surgery, Johns Hopkins All Children's Hospital, St. Petersburg, FL
| | - Lucy Zhang
- Division of Pediatric Surgery, Yale New Haven Children's Hospital and Yale School of Medicine, New Haven, CT
| | - Shawn J Rangel
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA
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10
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He K, Cramm SL, Rangel SJ. Contemporary Epidemiology of and Risk Factors Associated with Removal of a Pathologically Normal Appendix in Children with Suspected Appendicitis. J Pediatr Surg 2023; 58:1613-1617. [PMID: 37130766 DOI: 10.1016/j.jpedsurg.2023.04.002] [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] [Received: 01/17/2023] [Revised: 03/20/2023] [Accepted: 04/04/2023] [Indexed: 05/04/2023]
Abstract
BACKGROUND The goal of this study was to characterize contemporary performance benchmarks and risk factors associated with negative appendectomy (NA) in children with suspected appendicitis. METHODS A multicenter retrospective cohort analysis of children undergoing appendectomy for suspected appendicitis was performed using data from the 2016-2021 NSQIP-Pediatric Appendectomy Targeted Public Use Files. Multivariable regression was used to evaluate the influence of year, age, sex, and WBC count on NA rate, and to generate rate estimates for NA based on different combinations of demographic characteristics and WBC profiles. RESULTS 100,322 patients were included from 140 hospitals. The overall NA rate was 2.4%, and rates decreased significantly during the study period (2016: 3.1% vs. 2021: 2.3%, p < 0.001). In adjusted analyses, the highest risk for NA was associated with a normal WBC (<9000/mm3; OR 5.31 [95% CI: 4.87-5.80]), followed by female sex (OR 1.55 [95% CI: 1.42-1.68]) and age <5 years (OR 1.64 [95% CI 1.39, 1.94]). Model-estimated risk for NA varied significantly across demographic and WBC strata, with a 14.4-fold range in rates between subgroups with the lowest and highest predicted risk (males 13-17 years with elevated WBC [1.1%] vs. females 3-4 years with normal WBC [15.8%]). CONCLUSIONS Contemporary NA rates have decreased over time, however NA risk remains high in children without a leukocytosis, particularly for girls and children <5 years of age. These data provide contemporary performance benchmarks for NA in children with suspected appendicitis and identify high-risk populations where further efforts to mitigate NA risk should be targeted. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Katherine He
- Boston Children's Hospital, Department of Surgery, United States
| | - Shannon L Cramm
- Boston Children's Hospital, Department of Surgery, United States
| | - Shawn J Rangel
- Boston Children's Hospital, Department of Surgery, United States.
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11
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Anandalwar SP, Milliren C, Graham DA, Newland JG, He K, Hills-Dunlap JL, Kashtan MA, Rangel SJ. Quantifying Procedure-level Prophylaxis Misutilization in Pediatric Surgery: Implications for the Prioritization of Antimicrobial Stewardship Efforts. Ann Surg 2023; 278:e158-e164. [PMID: 35797034 DOI: 10.1097/sla.0000000000005480] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To quantify procedure-level inappropriate antimicrobial prophylaxis utilization as a strategy to identify high-priority targets for stewardship efforts in pediatric surgery. BACKGROUND Little data exist to guide the prioritization of antibiotic stewardship efforts as they relate to prophylaxis utilization in pediatric surgery. METHODS This was a retrospective cohort analysis of children undergoing elective surgical procedures at 52 children's hospitals from October 2015 to December 2019 using the Pediatric Health Information System database. Procedure-level compliance with consensus guidelines for prophylaxis utilization was assessed for indication, antimicrobial spectrum, and duration. The relative contribution of each procedure to the overall burden of noncompliant cases was calculated to establish a prioritization framework for stewardship efforts. RESULTS A total of 56,845 cases were included with an overall inappropriate utilization rate of 56%. The most common reason for noncompliance was unindicated utilization (43%), followed by prolonged duration (32%) and use of excessively broad-spectrum agents (25%). Procedures with the greatest relative contribution to noncompliant cases included cholecystectomy and repair of inguinal and umbilical hernias for unindicated utilization (63.2% of all cases); small bowel resections, gastrostomy, and colorectal procedures for use of excessively broad-spectrum agents (70.1%) and pectus excavatum repair and procedures involving the small and large bowel for prolonged duration (57.6%). More than half of all noncompliant cases were associated with 5 procedures (cholecystectomy, small bowel procedures, inguinal hernia repair, gastrostomy, and pectus excavatum). CONCLUSIONS Cholecystectomy, inguinal hernia repair, and procedures involving the small and large bowel should be considered high-priority targets for antimicrobial stewardship efforts in pediatric surgery.
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Affiliation(s)
- Seema P Anandalwar
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Carly Milliren
- Center for Applied Pediatric Quality Analytics, Boston Children's Hospital, Boston, MA
| | - Dionne A Graham
- Center for Applied Pediatric Quality Analytics, Boston Children's Hospital, Boston, MA
| | - Jason G Newland
- Department of Pediatrics, Washington University in St. Louis School of Medicine, St. Louis, MO
| | - Katherine He
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Jonathan L Hills-Dunlap
- Department of Pediatric Surgery, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO
| | - Mark A Kashtan
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Shawn J Rangel
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA
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12
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Cramm SL, Graham DA, Allukian M, Blakely ML, Chandler NM, Cowles RA, Feng C, Kunisaki SM, Russell RT, Rangel SJ. Predictive Value of Routine WBC Count Obtained Before Discharge for Organ Space Infection in Children with Complicated Appendicitis: Results from the Eastern Pediatric Surgery Network. J Am Coll Surg 2023; 236:1181-1187. [PMID: 36503868 DOI: 10.1097/xcs.0000000000000520] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND The objective of this study was to evaluate the clinical utility of a routine predischarge WBC count (RPD-WBC) for predicting postdischarge organ space infection (OSI) in children with complicated appendicitis. STUDY DESIGN This was a multicenter study using NSQIP-Pediatric data from 14 hospitals augmented with RPD-WBC data obtained through supplemental chart review. Children with fever or surgical site infection diagnosed during the index admission were excluded. The positive predictive value (PPV) for postdischarge OSI was calculated for RPD-WBC values of persistent leukocytosis (≥9.0 × 10 3 cells/μL), increasing leukocytosis (RPD-WBC > preoperative WBC), quartiles of absolute RPD-WBC, and quartiles of relative proportional change from preoperative WBC. Logistic regression was used to calculate predictive values adjusted for patient age, appendicitis severity, and use of postdischarge antibiotics. RESULTS A total of 1,264 children were included, of which 348 (27.5%) had a RPD-WBC obtained (hospital range: 0.8 to 100%, p < 0.01). The median RPD-WBC was similar between children who did and did not develop a postdischarge OSI (9.0 vs 8.9; p = 0.57), and leukocytosis was absent in 50% of children who developed a postdischarge OSI. The PPV of RPD-WBC was poor for both persistent and increasing leukocytosis (3.9% and 9.8%, respectively) and for thresholds based on the quartiles of highest RPD-WBC values (>11.1, PPV: 6.4%) and greatest proportional change (<32% decrease from preoperative WBC; PPV: 7.8%). CONCLUSIONS Routine predischarge WBC data have poor predictive value for identifying children at risk for postdischarge OSI after appendectomy for complicated appendicitis.
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Affiliation(s)
- Shannon L Cramm
- From the Department of Surgery, Boston Children's Hospital/Harvard Medical School, Boston, MA (Cramm, Graham, Rangel)
| | - Dionne A Graham
- From the Department of Surgery, Boston Children's Hospital/Harvard Medical School, Boston, MA (Cramm, Graham, Rangel)
| | - Myron Allukian
- Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, PA (Allukian)
| | - Martin L Blakely
- Department of Pediatric Surgery, Vanderbilt Children's Hospital, Nashville, TN (Blakely)
| | - Nicole M Chandler
- Division of Pediatric Surgery, Johns Hopkins All Children's Hospital, St. Petersburg, FL (Chandler)
| | - Robert A Cowles
- Division of Pediatric Surgery, Yale New Haven Children's Hospital/Yale School of Medicine, New Haven, CT (Cowles)
| | - Christina Feng
- Department of Surgery, Children's National Hospital, Washington, DC (Feng)
| | - Shaun M Kunisaki
- Division of General Pediatric Surgery, Johns Hopkins Children's Center/Johns Hopkins School of Medicine, Baltimore, MD (Kunisaki)
| | - Robert T Russell
- Department of Surgery, Division of Pediatric Surgery, University of Alabama at Birmingham, Children's of Alabama, Birmingham, AL (Russell)
| | - Shawn J Rangel
- From the Department of Surgery, Boston Children's Hospital/Harvard Medical School, Boston, MA (Cramm, Graham, Rangel)
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13
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Brachio SS, Gu W, Saiman L. Next Steps for Health Care-Associated Infections in the Neonatal Intensive Care Unit. Clin Perinatol 2023; 50:381-397. [PMID: 37201987 DOI: 10.1016/j.clp.2023.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/20/2023]
Abstract
We discuss the burden of health care-associated infections (HAIs) in the neonatal ICU and the role of quality improvement (QI) in infection prevention and control. We examine specific QI opportunities and approaches to prevent HAIs caused by Staphylococcus aureus , multidrug-resistant gram-negative pathogens, Candida species, and respiratory viruses, and to prevent central line-associated bloodstream infections (CLABSIs) and surgical site infections. We explore the emerging recognition that many hospital-onset bacteremia episodes are not CLABSIs. Finally, we describe the core tenets of QI, including engagement with multidisciplinary teams and families, data transparency, accountability, and the impact of larger collaborative efforts to reduce HAIs.
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Affiliation(s)
- Sandhya S Brachio
- Division of Neonatology, Department of Pediatrics, Columbia University Vagelos College of Physicians and Surgeons, 622 West 168th Street, PH17, New York, NY 10032, USA.
| | - Wendi Gu
- Division of Neonatology, Department of Pediatrics, Columbia University Vagelos College of Physicians and Surgeons, 622 West 168th Street, PH17, New York, NY 10032, USA
| | - Lisa Saiman
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Columbia University Vagelos College of Physicians and Surgeons, 622 West 168th Street, PH1-470, New York, NY 10032, USA; Department of Infection Prevention and Control, NewYork-Presbyterian Hospital, New York, NY, USA
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14
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Parikh RM, Ata A, Edwards MJ. A Contemporary Review of Surgical Approach and Outcomes in Pediatric Hypertrophic Pyloric Stenosis. J Surg Res 2023; 285:142-149. [PMID: 36669393 DOI: 10.1016/j.jss.2022.12.034] [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: 09/01/2022] [Revised: 11/02/2022] [Accepted: 12/25/2022] [Indexed: 01/20/2023]
Abstract
INTRODUCTION In order to define optimal resources and outcome standards for infant pyloromyotomy, we sought to perform a contemporary analysis of surgical approach (laparoscopic versus open) and outcomes. METHODS The National Surgical Quality Improvement Project Pediatrics Participant Use File (NSQIP PUF) was queried from 2016 to 2020. Utilization of laparoscopy was trended over time. Complication rates and length of stay were compared by operative approach. RESULTS 9752 pyloromyotomies were included in the analysis. The utilization of laparoscopy steadily increased over the study time period (66% to 79%) and was associated with a shorter operative time. On multivariate regression, the utilization of laparoscopy was associated with a lower risk of overall complications, length of stay, and superficial surgical site infections. Overall complication rates were lower than previously reported (2.02%). The most common complication was superficial infection (1.2%). CONCLUSIONS In facilities reporting to pediatric National Quality Improvement Project, utilization of laparoscopy has steadily increased, and complication rates are lower than previously reported. Complication rates and length of stay were lower with the laparoscopic approach in this contemporary cohort. These results offer benchmarks for quality improvement initiatives. The laparoscopic approach should be standard in facilities performing this procedure.
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Affiliation(s)
| | - Ashar Ata
- Department of Surgery, Albany Medical Center, Albany, New York
| | - Mary J Edwards
- Department of Surgery, Albany Medical Center, Albany, New York.
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15
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Saito JM, Barnhart DC, Grant C, Brighton BK, Raval MV, Campbell BT, Kenney B, Jatana KR, Ellison JS, Cina RA, Allori AC, Uejima T, Roke D, Lam S, Johnson EK, Goretsky MJ, Byrd C, Iwaniuk M, Nayak R, Thompson VM, Cohen ME, Hall BL, Ko CY, Rangel SJ. The past, present and future of ACS NSQIP-Pediatric: Evolution from a quality registry to a comparative quality performance platform. Semin Pediatr Surg 2023; 32:151275. [PMID: 37075656 DOI: 10.1016/j.sempedsurg.2023.151275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/21/2023]
Abstract
Quality and process improvement (QI/PI) in children's surgical care require reliable data across the care continuum. Since 2012, the American College of Surgeons' (ACS) National Surgical Quality Improvement Program-Pediatric (NSQIP-Pediatric) has supported QI/PI by providing participating hospitals with risk-adjusted, comparative data regarding postoperative outcomes for multiple surgical specialties. To advance this goal over the past decade, iterative changes have been introduced to case inclusion and data collection, analysis and reporting. New datasets for specific procedures, such as appendectomy, spinal fusion for scoliosis, vesicoureteral reflux procedures, and tracheostomy in children less than 2 years old, have incorporated additional risk factors and outcomes to enhance the clinical relevance of data, and resource utilization to consider healthcare value. Recently, process measures for urgent surgical diagnoses and surgical antibiotic prophylaxis variables have been developed to promote timely and appropriate care. While a mature program, NSQIP-Pediatric remains dynamic and responsive to meet the needs of the surgical community. Future directions include introduction of variables and analyses to address patient-centered care and healthcare equity.
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Affiliation(s)
- Jacqueline M Saito
- Division of Pediatric Surgery, Washington University, St. Louis, MO, USA.
| | - Douglas C Barnhart
- Division of Pediatric Surgery, University of Utah, Salt Lake City, UT, USA
| | - Catherine Grant
- Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, IL, USA
| | - Brian K Brighton
- Division of Pediatric Orthopedic Surgery, Carolinas Medical Center, Wake Forest School of Medicine, Charlotte, NC, USA
| | - Mehul V Raval
- Division of Pediatric Surgery, Department of Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | | | - Brian Kenney
- Department of Pediatric Surgery, Nationwide Children's Hospital and Ohio State University, Columbus, OH, USA
| | - Kris R Jatana
- Department of Pediatric Otolaryngology, Nationwide Children's Hospital and Ohio State University, Columbus, OH, USA
| | - Jonathan S Ellison
- Division of Pediatric Urology, Department of Urology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Robert A Cina
- Division of Pediatric Surgery, Department of Surgery, Shawn Jenkins Children's Hospital, The Medical University of South Carolina, Charleston, SC, USA
| | - Alexander C Allori
- Division of Plastic, Maxillofacial and Oral Surgery, Department of Surgery and Department of Population Health Sciences, Duke University, Durham, NC, USA
| | - Tetsu Uejima
- Department of Pediatric Anesthesiology and Perioperative Medicine, Nemours Children's Hospital Delaware, Thomas Jefferson University, Philadelphia, USA
| | - Daniel Roke
- Department of Anesthesia & Critical Care Medicine, St. Louis University, St. Louis, MO, USA
| | - Sandi Lam
- Division of Pediatric Neurosurgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Department of Neurosurgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Emilie K Johnson
- Division of Urology, Ann & Robert H. Lurie Children's Hospital of Chicago, Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Michael J Goretsky
- Division of Pediatric Surgery, Children's Hospital of the King's Daughters, Eastern Virginia Medical School, Norfolk, VA, USA
| | - Claudia Byrd
- Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, IL, USA
| | - Marie Iwaniuk
- Independent Statistical Consultant, Phoenixville, PA, USA
| | - Raageswari Nayak
- Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, IL, USA
| | - Vanessa M Thompson
- Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, IL, USA
| | - Mark E Cohen
- Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, IL, USA
| | - Bruce L Hall
- Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, IL, USA; Department of Surgery, Washington University St. Louis School of Medicine and BJC Healthcare, St. Louis, MO, USA
| | - Clifford Y Ko
- Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, IL, USA
| | - Shawn J Rangel
- Department of Surgery, Boston Children's Hospital, Boston, MA, USA
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16
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Pace D, Lopez ME, Berman L. Quality improvement dissemination in pediatric surgery: The APSA quality and safety toolkit. Semin Pediatr Surg 2023; 32:151279. [PMID: 37075657 DOI: 10.1016/j.sempedsurg.2023.151279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/21/2023]
Abstract
Shared experiential learning is critical in the field of pediatric surgery to support the translation of evidence into practice. Surgeons who develop QI interventions in their own institutions based on the best available evidence create work products that can accelerate similar projects in other institutions, rather than continuously reinventing the wheel. The American Pediatric Surgical Association (APSA) Quality and Safety Committee (QSC) toolkit was created to facilitate knowledge-sharing and thereby hasten the development and implementation of QI. The toolkit is an expanding open-access web-based repository of curated QI projects that includes evidence-based pathways and protocols, stakeholder presentations, parent/patient educational materials, clinical decision support (CDS) tools, and other components of successful QI interventions in addition to contact information for the surgeons who developed and implemented them. This resource catalyzes local QI endeavors by showcasing a range of projects that can be adapted to fit the needs of a given institution, and it also serves as a network to connect interested surgeons with successful implementers. As healthcare shifts towards value-based care models, quality improvement becomes increasingly important, and the APSA QSC toolkit will continue to adapt to the evolving needs of the pediatric surgery community.
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Affiliation(s)
- Devon Pace
- Department of Pediatric Surgery, Nemours Children's Health, Wilmington, DE, United States; Department of Surgery, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA, United States
| | - Monica E Lopez
- Department of Pediatric Surgery, Section of Surgical Sciences, Vanderbilt University Medical Center, Monroe Carrell Jr. Children's Hospital at Vanderbilt, Nashville, TN, United States
| | - Loren Berman
- Department of Pediatric Surgery, Nemours Children's Health, Wilmington, DE, United States; Department of Surgery, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA, United States.
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17
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Mullen MC, Yan F, Ford ME, Patel KG, Pecha PP. Racial and Ethnic Disparities in Primary Cleft Lip and Cleft Palate Repair. Cleft Palate Craniofac J 2023; 60:482-488. [PMID: 34967229 PMCID: PMC9793871 DOI: 10.1177/10556656211069828] [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] [Indexed: 12/30/2022] Open
Abstract
OBJECTIVE To examine the impact of race/ethnicity on timing and postoperative outcomes of primary cleft lip (CL) and cleft palate (CP) repair. DESIGN Cross-sectional analysis of the National Surgical Quality Improvement Program Pediatric (NSQIP-P) database from 2013 to 2018. PATIENTS AND MAIN OUTCOME MEASURES Patients under 2 years of age who underwent primary CL or CP repair were identified in the NSQIP-P. Outcomes were the timing of surgery and 30-day readmission and reoperation rates stratified by race and ethnicity. RESULTS In total, 6021 children underwent CL and 6938 underwent CP repair. Adjusted rates of CL repair over time were 10% lower in Hispanic children (95%CI: 0.84-0.96) and 38% lower for Asian children (95%CI: 0.55-0.70) compared with White infants. CP repair rates over time were 13% lower in Black (95%CI: 0.79-0.95), 17% lower in Hispanic (95%CI: 0.77-0.89), and 53% lower in Asian children (95%CI: 0.43-0.53) than in White infants. Asian patients had the highest rates of delayed surgical repair, with 19.3% not meeting American Cleft Palate-Craniofacial Association (ACPA) guidelines for CL (P < .001) and 28.2% for CP repair (P< .001). Black and Hispanic children had 80% higher odds of readmission following primary CL repair (95%CI: 1.16-2.83 and 95%CI: 1.27-2.61, respectively). CONCLUSIONS This study of a national database identified several racial/ethnic disparities in primary CL and CP, with reduced receipt of cleft repair over time for non-White children. Asian patients were significantly more likely to have delayed cleft repair per ACPA guidelines. These findings underscore the need to better understand disparities in cleft repair timing and postoperative outcomes.
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Affiliation(s)
| | - Flora Yan
- Medical University of South Carolina, Charleston, SC, USA
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18
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Heiss K. Invited commentary on Vanderhoek S, et al.: Association of dysglycemia with post-operative outcomes in pediatric surgery. J Pediatr Surg 2023; 58:373-374. [PMID: 36384933 DOI: 10.1016/j.jpedsurg.2022.10.013] [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: 10/14/2022] [Accepted: 10/17/2022] [Indexed: 11/05/2022]
Affiliation(s)
- Kurt Heiss
- Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, 6088 Millstone Run, Stone Mountain, GA 30087, United States.
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Maisat W, Yuki K. Surgical site infection in pediatric spinal fusion surgery revisited: outcome and risk factors after preventive bundle implementation. PERIOPERATIVE CARE AND OPERATING ROOM MANAGEMENT 2023; 30:100308. [PMID: 36817803 PMCID: PMC9933986 DOI: 10.1016/j.pcorm.2023.100308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Background Surgical site infections (SSI) contribute to significant morbidity, mortality, length of stay, and financial burden. We sought to evaluate the incidence and risk factors of surgical site infection following pediatric spinal fusion surgery in patients for whom standard perioperative antibiotic prophylaxis and preventive strategies have been implemented. Methods We conducted a retrospective study of children aged <18 years who underwent spinal fusion surgery from January 2017 to November 2021 at a quaternary academic pediatric medical center. Univariable analysis was used to evaluate associations between potential risk factors and SSI. Results Of 1111 patients, 752 (67.6%) were female; median age was 14.2 years. SSI occurred in 14 patients (1.3%). Infections were superficial incisional (n=2; 14.3%), deep incisional (n=9; 64.3%), and organ/space (n=3; 21.4%). Median time to SSI was 14 days (range, 8 to 45 days). Staphylococcus aureus and Escherichia coli were the most frequently-isolated bacteria. Potential risk factors for SSIs included low body weight (Odds ratio (OR) 0.96, 95% confidence interval (CI) 0.93-0.99, p=0.026), ASA classification of ≥3 (OR 24.53, 95%CI 3.20-188.22, p=0.002), neuromuscular scoliosis (OR 3.83, 95%CI 3.82-78.32, p<0.001), prolonged operative time (OR 1.56, 95%CI 1.28-1.92, p<0.001), prolonged anesthetic time (OR 1.65, 95%CI 1.35-2.00, p<0.001), administration of prophylactic antibiotic ≥60 minutes before skin incision (OR 11.52, 95%CI 2.34-56.60, p=0.003), and use of povidone-iodine alone for skin preparation (OR 5.97, 95%CI 1.27-28.06, p=0.024). Conclusion In the context of a robust bundle for SSI prevention; low body weight, ASA classification of ≥3, neuromuscular scoliosis, prolonged operative and anesthetic times, administration of prophylactic antibiotic ≥60 minutes before skin incision, and use of povidone-iodine alone for skin preparation increased the risk of SSI. Administration of prophylactic antibiotic within 60 minutes of skin incision, strict adherence to high-risk preventive protocol, and use of CHG-alcohol could potentially reduce the rate of SSI.
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Affiliation(s)
- Wiriya Maisat
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Boston, USA
- Department of Anaesthesia, Harvard Medical School, Boston, USA
- Department of Anesthesiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Koichi Yuki
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Boston, USA
- Department of Anaesthesia, Harvard Medical School, Boston, USA
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Cramm SL, Graham DA, Blakely ML, Chandler NM, Cowles RA, Kunisaki SM, Russell RT, Allukian M, DeFazio JR, Griggs CL, Santore MT, Scholz S, Aronowitz DI, Campbell BT, Collins DT, Commander SJ, Engwall-Gill A, Esparaz JR, Feng C, Gerall C, Hanna DN, Keane OA, Lamoshi A, Lipskar AM, Orlas Bolanos CP, Pace E, Regan MD, Tracy ET, Williams S, Zhang L, Rangel SJ. Outcomes and resource utilization associated with use of routine pre-discharge white blood cell count for clinical decision-making in children with complicated appendicitis: A multi-center hospital-level analysis. J Pediatr Surg 2023; 58:1178-1184. [PMID: 37030979 DOI: 10.1016/j.jpedsurg.2023.02.039] [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] [Received: 01/27/2023] [Accepted: 02/10/2023] [Indexed: 02/25/2023]
Abstract
BACKGROUND The objective was to explore the hospital-level relationship between routine pre-discharge WBC utilization (RPD-WBC) and outcomes in children with complicated appendicitis. METHODS Multicenter analysis of NSQIP-Pediatric data from 14 consortium hospitals augmented with RPD-WBC data. WBC were considered routine if obtained within one day of discharge in children who did not develop an organ space infection (OSI) or fever during the index admission. Hospital-level observed-to-expected ratios (O/E) for 30-day outcomes (antibiotic days, imaging utilization, healthcare days, and OSI) were calculated after adjusting for appendicitis severity and patient characteristics. Spearman correlation was used to explore the relationship between hospital-level RPD-WBC utilization and O/E's for each outcome. RESULTS 1528 children were included. Significant variation was found across hospitals in RPD-WBC use (range: 0.7-100%; p < 0.01) and all outcomes (mean antibiotic days: 9.9 [O/E range: 0.56-1.44, p < 0.01]; imaging: 21.9% [O/E range: 0.40-2.75, p < 0.01]; mean healthcare visit days: 5.7 [O/E 0.74-1.27, p < 0.01]); OSI: 14.1% [O/E range: 0.43-3.64, p < 0.01]). No correlation was found between RPD-WBC use and antibiotic days (r = +0.14, p = 0.64), imaging (r = -0.07, p = 0.82), healthcare days (r = +0.35, p = 0.23) or OSI (r = -0.13, p = 0.65). CONCLUSIONS Increased RPD-WBC utilization in pediatric complicated appendicitis did not correlate with improved outcomes or resource utilization at the hospital level. LEVEL OF EVIDENCE III. TYPE OF STUDY Clinical Research.
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Affiliation(s)
- Shannon L Cramm
- Department of Surgery, Boston Children's Hospital, Boston, MA, USA
| | - Dionne A Graham
- Program for Patient Safety and Quality, Boston Children's Hospital, Boston, MA, USA
| | - Martin L Blakely
- Department of Surgery, Vanderbilt Children's Hospital, Vanderbilt School of Medicine, Nashville, TN, USA
| | - Nicole M Chandler
- Division of Pediatric Surgery, Johns Hopkin's All Children's Hospital, St. Petersburg, FL, USA
| | - Robert A Cowles
- Department of Pediatric Surgery, Yale New Haven Children's Hospital, Yale School of Medicine, New Haven, CT, USA
| | - Shaun M Kunisaki
- Division of General Pediatric Surgery, Johns Hopkins Children's Center, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Robert T Russell
- Department of Surgery, Division of Pediatric Surgery, University of Alabama at Birmingham, Children's of Alabama
| | - Myron Allukian
- Division of Pediatric, General, Thoracic, and Fetal Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Jennifer R DeFazio
- Division of Pediatric Surgery, New York Presbyterian Morgan Stanley Children's Hospital, Columbia University Vagelos Colleges of Physicians and Surgeons, New York, NY, USA
| | - Cornelia L Griggs
- Department of Surgery, Division of Pediatric Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Matthew T Santore
- Department of Surgery, Division of Pediatric Surgery, Children's Healthcare of Atlanta, Emory University, Atlanta, GA, USA
| | - Stefan Scholz
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Danielle I Aronowitz
- Division of Pediatric, General, Thoracic, and Fetal Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Brendan T Campbell
- Department of Surgery, Connecticut Children's Hospital, Hartford, CT, USA
| | - Devon T Collins
- Department of Surgery, Children's National Hospital, Washington, D.C, USA
| | - Sarah J Commander
- Department of Surgery, Duke Children's Hospital and Health Center, Durham, NC, USA
| | - Abigail Engwall-Gill
- Division of General Pediatric Surgery, Johns Hopkins Children's Center, Baltimore, MD, USA
| | - Joseph R Esparaz
- Department of Surgery, Division of Pediatric Surgery, University of Alabama at Birmingham, Children's of Alabama, Birmingham, AL, USA
| | - Christina Feng
- Department of Surgery, Duke Children's Hospital and Health Center, Durham, NC, USA
| | - Claire Gerall
- Department of Surgery, UT Health San Antonio, San Antonio, TX, USA
| | - David N Hanna
- Department of Surgery, Vanderbilt Children's Hospital, Nashville, TN, USA
| | - Olivia A Keane
- Department of Surgery, Division of Pediatric Surgery, Children's Healthcare of Atlanta, Emory University, Atlanta, GA, USA
| | - Abdulraouf Lamoshi
- Division of Pediatric Surgery, Cohen Children's Medical Center, New Hyde Park, NY, USA
| | - Aaron M Lipskar
- Division of Pediatric Surgery, Cohen Children's Medical Center, Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, NY, USA
| | - Claudia P Orlas Bolanos
- Department of Surgery, Division of Pediatric Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Elizabeth Pace
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Maia D Regan
- Department of Surgery, Children's National Hospital, Washington, D.C, USA
| | - Elisabeth T Tracy
- Department of Surgery, Duke Children's Hospital and Health Center, Duke University School of Medicine, Durham, NC, USA
| | - Sacha Williams
- Division of Pediatric Surgery, Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA
| | - Lucy Zhang
- Department of Pediatric Surgery, Yale New Haven Children's Hospital, New Haven, CT, USA
| | - Shawn J Rangel
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA.
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Scaggs Huang F, Mangeot C, Sucharew H, Simon K, Courter J, Risma K, Schaffzin JK. Beta-Lactam Allergy Association with Surgical Site Infections in Pediatric Procedures: A Matched Cohort Study. J Pediatric Infect Dis Soc 2023; 12:123-127. [PMID: 36591894 DOI: 10.1093/jpids/piac138] [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] [Received: 09/14/2022] [Accepted: 12/30/2022] [Indexed: 01/03/2023]
Abstract
BACKGROUND Little is known about surgical site infection (SSI) risk among pediatric patients with reported beta-lactam allergy (BLA). METHODS We performed a retrospective cohort study at a quaternary children's hospital and compared procedures in patients ages 1-19-years-old with and without BLA that required antimicrobial prophylaxis (AMP) during 2010-2017. Procedures were matched 1:1 by patient age, complex chronic conditions, year of surgery, and National Surgical Quality Improvement Program current procedural terminology category. The primary outcome was SSI as defined by National Healthcare Safety Network. The secondary outcome was AMP protocol compliance as per American Society of Health-System Pharmacists. RESULTS Of the 11,878 procedures identified, 1021 (9%) had a reported BLA. There were 35 (1.8%) SSIs in the matched cohort of 1944 procedures with no significant difference in SSI rates in BLA procedures (1.8%) compared to no BLA (1.9%) procedures. Tier 3 AMP was chosen more frequently among BLA procedures (p<0.01). Unmatched analysis of all procedures showed that 23.7% of BLA procedures received beta-lactam-AMP (vs. 93.7% of procedures without BLA). There were no major differences in SSI on sensitivity analysis of BLA procedures that did not receive beta-lactam AMP (1.4%) compared to no BLA procedures with beta-lactam AMP (1.6%) . CONCLUSIONS Our retrospective matched analysis of 1944 pediatric procedures found no increase in SSIs in procedures with reported BLA, which differs from studies in adults. We observed that choice of beta-lactam-AMP was common, even in BLA procedures. More data are needed to delineate an association of non-beta-lactam AMP and SSI in children.
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Affiliation(s)
- Felicia Scaggs Huang
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA.,Division of Infectious Diseases, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Colleen Mangeot
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Heidi Sucharew
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA.,Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Katherine Simon
- James M Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Joshua Courter
- Division of Pharmacy, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Kimberly Risma
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA.,Division of Allergy and Immunology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Joshua K Schaffzin
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA.,Division of Infectious Diseases, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
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22
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Gil LA, Asti L, Apfeld JC, Sebastião YV, Deans KJ, Minneci PC. Perioperative outcomes in minimally-invasive versus open surgery in infants undergoing repair of congenital anomalies. J Pediatr Surg 2022; 57:755-762. [PMID: 35985848 DOI: 10.1016/j.jpedsurg.2022.08.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 07/22/2022] [Accepted: 08/03/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND This study compared perioperative outcomes among infants undergoing repair of congenital anomalies using minimally invasive (MIS) versus open surgical approaches. METHODS The ACS NSQIP Pediatric (2013-2018) was queried for patients undergoing repair of any of the following 9 congenital anomalies: congenital lung lesion (LL), mediastinal mass (MM), congenital malrotation (CM), anorectal malformation (ARM), Hirschsprung disease (HD), congenital diaphragmatic hernia (CDH), tracheoesophageal fistula (TEF), hepatobiliary anomalies (HB), and intestinal atresia (IA). Inverse probability of treatment weights (IPTW) derived from propensity scores were utilized to estimate risk-adjusted association between surgical approach and 30-day outcomes. RESULTS 12,871 patients undergoing congenital anomaly repair were included (10,343 open; 2528 MIS). After IPTW, MIS was associated with longer operative time (difference; 95% CI) (16 min; 9-23) and anesthesia time (13 min; 6-21), but less postoperative ventilation days (-1.0 days; -1.4- -0.6) and shorter postoperative length of stay (-1.4 days; -2.4- -0.3). MIS repairs had decreased risk of any surgical complication (risk difference: -6.6%; -9.2- -4.0), including hematologic complications (-7.3%; -8.9- -5.8). There was no significant difference in risk of complication when hematologic complications were excluded (RD -2.3% [-4.7%, 0.1%]). There were no significant differences in the risk of unplanned reoperation (0.4%; -1.5-2.2) or unplanned readmission (0.2%; -1.2-1.5). CONCLUSIONS MIS repair of congenital anomalies is associated with improved perioperative outcomes when compared to open. Additional studies are needed to compare long-term functional and disease-specific outcomes. MINI-ABSTRACT In this propensity-weighted multi-institutional analysis of nine congenital anomalies, minimally invasive surgical repair was associated with improved 30-day outcomes when compared to open surgical repair. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Lindsay A Gil
- Center for Surgical Outcomes Research, Abigail Wexner Research Institute and Department of Surgery, Nationwide Children's Hospital, 700 Children's Dr., Columbus, OH 43205, USA; Center for Child Health Equity and Outcomes Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, 700 Children's Dr., Columbus, OH 43205, USA
| | - Lindsey Asti
- Center for Surgical Outcomes Research, Abigail Wexner Research Institute and Department of Surgery, Nationwide Children's Hospital, 700 Children's Dr., Columbus, OH 43205, USA; Center for Child Health Equity and Outcomes Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, 700 Children's Dr., Columbus, OH 43205, USA
| | - Jordan C Apfeld
- Center for Surgical Outcomes Research, Abigail Wexner Research Institute and Department of Surgery, Nationwide Children's Hospital, 700 Children's Dr., Columbus, OH 43205, USA; Center for Child Health Equity and Outcomes Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, 700 Children's Dr., Columbus, OH 43205, USA
| | - Yuri V Sebastião
- Center for Surgical Outcomes Research, Abigail Wexner Research Institute and Department of Surgery, Nationwide Children's Hospital, 700 Children's Dr., Columbus, OH 43205, USA; Center for Child Health Equity and Outcomes Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, 700 Children's Dr., Columbus, OH 43205, USA; Division of Global Women's Health, School of Medicine, University of North Carolina, Chapel Hill, NC 27514, USA
| | - Katherine J Deans
- Center for Surgical Outcomes Research, Abigail Wexner Research Institute and Department of Surgery, Nationwide Children's Hospital, 700 Children's Dr., Columbus, OH 43205, USA; Center for Child Health Equity and Outcomes Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, 700 Children's Dr., Columbus, OH 43205, USA
| | - Peter C Minneci
- Center for Surgical Outcomes Research, Abigail Wexner Research Institute and Department of Surgery, Nationwide Children's Hospital, 700 Children's Dr., Columbus, OH 43205, USA; Center for Child Health Equity and Outcomes Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, 700 Children's Dr., Columbus, OH 43205, USA.
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23
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Ahn JJ, Garrison MM, Merguerian PA, Shnorhavorian M. Racial and ethnic disparities in the timing of orchiopexy for cryptorchidism. J Pediatr Urol 2022; 18:696.e1-696.e6. [PMID: 36175288 PMCID: PMC9771941 DOI: 10.1016/j.jpurol.2022.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Revised: 08/12/2022] [Accepted: 09/07/2022] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Many children do not undergo surgery for cryptorchidism in a timely fashion, increasing risk of infertility and malignancy. Racial and ethnic disparities in surgery timing has been suggested in other specialties, but has not been well-explored in Pediatric Urology. OBJECTIVES Our aim was to investigate the association of race and ethnicity with age at orchiopexy. MATERIALS AND METHODS We performed a retrospective cohort study of individuals <18 years of age as captured in the NSQIPP PUF from 2012 to 2016. Those with cancer were excluded. The primary outcome of interest was age at time of surgery. Secondary outcome was the proportion of individuals undergoing surgery by recommended age. Generalized linear models and logistic regression models were created for the outcomes of interest. RESULTS The median age at orchiopexy was 17.4 months (10.7, 43.0) and overall, 51% of subjects underwent orchiopexy by 18 months of age. Non-Hispanic white individuals were most likely to have undergone orchiopexy by 18 months of age, at 56%, compared with only 44% of non-Hispanic black individuals (p < 0.001). When adjusting for co-morbidities and developmental delay, Hispanic patients underwent orchiopexy 5 months later than white patients, on average, and black patients had a delay of 7 months compared to white patients. DISCUSSION These data suggest that orchiopexy is happening at younger ages compared to prior large-scale studies. However, minority patients are on average older at time of orchiopexy, potentially increasing future risk of infertility or malignancy. While an estimated average delay of 5-7 months may not seem high, studies suggest there is an appreciable change in risk with a 6-month delay. Patient, provider, and system-level factors likely all contribute, and these need to be further elucidated. CONCLUSIONS Many racial and ethnic minorities with cryptorchidism have later orchiopexies, and are more likely to have surgery outside the recommended timeframe. Further investigation is warranted to determine the factors contributing to these disparities.
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Affiliation(s)
- Jennifer J Ahn
- University of Washington, Department of Urology, USA; Seattle Children's Hospital, Division of Pediatric Urology, USA.
| | - Michelle M Garrison
- University of Washington School of Public Health, Department of Health Services, USA
| | - Paul A Merguerian
- University of Washington, Department of Urology, USA; Seattle Children's Hospital, Division of Pediatric Urology, USA
| | - Margarett Shnorhavorian
- University of Washington, Department of Urology, USA; Seattle Children's Hospital, Division of Pediatric Urology, USA
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Hu A, Iwaniuk M, Thompson V, Grant C, Matthews A, Byrd C, Saito J, Hall B, Raval MV. The influence of decreasing variable collection burden on hospital-level risk-adjustment. J Pediatr Surg 2022; 57:9-16. [PMID: 34801250 DOI: 10.1016/j.jpedsurg.2021.10.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2021] [Revised: 09/30/2021] [Accepted: 10/04/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND Risk-adjustment is a key feature of the American College of Surgeons National Surgical Quality Improvement Program-Pediatric (NSQIP-Ped). Risk-adjusted model variables require meticulous collection and periodic assessment. This study presents a method for eliminating superfluous variables using the congenital malformation (CM) predictor variable as an example. METHODS This retrospective cohort study used NSQIP-Ped data from January 1st to December 31st, 2019 from 141 hospitals to compare six risk-adjusted mortality and morbidity outcome models with and without CM as a predictor. Model performance was compared using C-index and Hosmer-Lemeshow (HL) statistics. Hospital-level performance was assessed by comparing changes in outlier statuses, adjusted quartile ranks, and overall hospital performance statuses between models with and without CM inclusion. Lastly, Pearson correlation analysis was performed on log-transformed ORs between models. RESULTS Model performance was similar with removal of CM as a predictor. The difference between C-index statistics was minimal (≤ 0.002). Graphical representations of model HL-statistics with and without CM showed considerable overlap and only one model attained significance, indicating minimally decreased performance (P = 0.058 with CM; P = 0.044 without CM). Regarding hospital-level performance, minimal changes in the number and list of hospitals assigned to each outlier status, adjusted quartile rank, and overall hospital performance status were observed when CM was removed. Strong correlation between log-transformed ORs was observed (r ≥ 0.993). CONCLUSIONS Removal of CM from NSQIP-Ped has minimal effect on risk-adjusted outcome modelling. Similar efforts may help balance optimal data collection burdens without sacrificing highly valued risk-adjustment in the future. LEVEL OF EVIDENCE Level II prognosis study.
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Affiliation(s)
- Andrew Hu
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, 633 N. Saint Clair St, 20th Floor, Chicago, IL 60011, USA.
| | - Marie Iwaniuk
- Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, IL, USA
| | - Vanessa Thompson
- Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, IL, USA
| | - Catherine Grant
- Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, IL, USA
| | - Alaina Matthews
- Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, IL, USA
| | - Claudia Byrd
- Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, IL, USA
| | - Jacqueline Saito
- Division of Pediatric Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Bruce Hall
- Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, IL, USA; Department of Surgery, Washington University School of Medicine, and BJC Healthcare, St. Louis, MO, USA
| | - Mehul V Raval
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, 633 N. Saint Clair St, 20th Floor, Chicago, IL 60011, USA
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25
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Cramm SL, Lipskar AM, Graham DA, Kunisaki SM, Griggs CL, Allukian M, Russell RT, Chandler NM, Santore MT, Aronowitz DI, Blakely ML, Campbell B, Collins DT, Commander SJ, Cowles RA, DeFazio JR, Echols JC, Esparaz JR, Feng C, Guyer RA, Hanna DN, He K, Kahan AM, Keane OA, Lamoshi A, Lopez CM, McLean SE, Pace E, Regan MD, Scholz S, Tracy ET, Williams SA, Zhang L, Rangel SJ. Association of Gangrenous, Suppurative, and Exudative Findings With Outcomes and Resource Utilization in Children With Nonperforated Appendicitis. JAMA Surg 2022; 157:685-692. [PMID: 35648410 PMCID: PMC9161124 DOI: 10.1001/jamasurg.2022.1928] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Importance The clinical significance of gangrenous, suppurative, or exudative (GSE) findings is poorly characterized in children with nonperforated appendicitis. Objective To evaluate whether GSE findings in children with nonperforated appendicitis are associated with increased risk of surgical site infections and resource utilization. Design, Setting, and Participants This multicenter cohort study used data from the Appendectomy Targeted Database of the American College of Surgeons Pediatric National Surgical Quality Improvement Program, which were augmented with operative report data obtained by supplemental medical record review. Data were obtained from 15 hospitals participating in the Eastern Pediatric Surgery Network (EPSN) research consortium. The study cohort comprised children (aged ≤18 years) with nonperforated appendicitis who underwent appendectomy from July 1, 2015, to June 30, 2020. Exposures The presence of GSE findings was established through standardized, keyword-based audits of operative reports by EPSN surgeons. Interrater agreement for the presence or absence of GSE findings was evaluated in a random sample of 900 operative reports. Main Outcomes and Measures The primary outcome was 30-day postoperative surgical site infections (incisional and organ space infections). Secondary outcomes included rates of hospital revisits, postoperative abdominal imaging, and postoperative length of stay. Multivariable mixed-effects regression was used to adjust measures of association for patient characteristics and clustering within hospitals. Results Among 6133 children with nonperforated appendicitis, 867 (14.1%) had GSE findings identified from operative report review (hospital range, 4.2%-30.2%; P < .001). Reviewers agreed on presence or absence of GSE findings in 93.3% of cases (weighted κ, 0.89; 95% CI, 0.86-0.92). In multivariable analysis, GSE findings were associated with increased odds of any surgical site infection (4.3% vs 2.2%; odds ratio [OR], 1.91; 95% CI, 1.35-2.71; P < .001), organ space infection (2.8% vs 1.1%; OR, 2.18; 95% CI, 1.30-3.67; P = .003), postoperative imaging (5.8% vs 3.7%; OR, 1.70; 95% CI, 1.23-2.36; P = .002), and prolonged mean postoperative length of stay (1.6 vs 0.9 days; rate ratio, 1.43; 95% CI, 1.32-1.54; P < .001). Conclusions and Relevance In children with nonperforated appendicitis, findings of gangrene, suppuration, or exudate are associated with increased surgical site infections and resource utilization. Further investigation is needed to establish the role and duration of postoperative antibiotics and inpatient management to optimize outcomes in this cohort of children.
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Affiliation(s)
- Shannon L. Cramm
- Department of Surgery, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Aaron M. Lipskar
- Division of Pediatric Surgery, Cohen Children’s Medical Center, Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, New York
| | - Dionne A. Graham
- Program for Patient Safety and Quality, Boston Children’s Hospital, Boston, Massachusetts
| | - Shaun M. Kunisaki
- Division of General Pediatric Surgery, Johns Hopkins Children’s Center, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Cornelia L. Griggs
- Division of Pediatric Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Myron Allukian
- Division of Pediatric, General, Thoracic, and Fetal Surgery, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Robert T. Russell
- Division of Pediatric Surgery, Department of Surgery, University of Alabama at Birmingham, Children’s of Alabama, Birmingham
| | - Nicole M. Chandler
- Division of Pediatric Surgery, Johns Hopkins All Children’s Hospital, St Petersburg, Florida
| | - Matthew T. Santore
- Division of Pediatric Surgery, Department of Surgery, Children’s Healthcare of Atlanta, Emory University, Atlanta, Georgia
| | - Danielle I. Aronowitz
- Division of Pediatric, General, Thoracic, and Fetal Surgery, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Martin L. Blakely
- Department of Surgery, Vanderbilt Children’s Hospital, Vanderbilt School of Medicine, Nashville, Tennessee
| | - Brendan Campbell
- Department of Surgery, Connecticut Children’s Hospital, Hartford
| | - Devon T. Collins
- Department of Surgery, Children’s National Hospital, Washington, DC
| | - Sarah J. Commander
- Department of Surgery, Duke Children’s Hospital and Health Center, Duke University School of Medicine, Durham, North Carolina
| | - Robert A. Cowles
- Department of Pediatric Surgery, Yale New Haven Children’s Hospital Yale School of Medicine, New Haven, Connecticut
| | - Jennifer R. DeFazio
- Division of Pediatric Surgery, New York Presbyterian Morgan Stanley Children’s Hospital, Columbia University Vagelos Colleges of Physicians and Surgeons, New York
| | - Justice C. Echols
- Division of Pediatric Surgery, University of North Carolina Health System, University of North Carolina School of Medicine, Chapel Hill
| | - Joseph R. Esparaz
- Division of Pediatric Surgery, Department of Surgery, University of Alabama at Birmingham, Children’s of Alabama, Birmingham
| | - Christina Feng
- Department of Surgery, Children’s National Hospital, Washington, DC
| | - Richard A. Guyer
- Division of Pediatric Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - David N. Hanna
- Department of Surgery, Vanderbilt Children’s Hospital, Vanderbilt School of Medicine, Nashville, Tennessee
| | - Katherine He
- Department of Surgery, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Anastasia M. Kahan
- Division of Pediatric Surgery, New York Presbyterian Morgan Stanley Children’s Hospital, Columbia University Vagelos Colleges of Physicians and Surgeons, New York
- Department of Surgery, Mount Sinai Health System, New York, New York
| | - Olivia A. Keane
- Division of Pediatric Surgery, Department of Surgery, Children’s Healthcare of Atlanta, Emory University, Atlanta, Georgia
| | - Abdulraouf Lamoshi
- Division of Pediatric Surgery, Cohen Children’s Medical Center, Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, New York
| | - Carla M. Lopez
- Division of General Pediatric Surgery, Johns Hopkins Children’s Center, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Sean E. McLean
- Division of Pediatric Surgery, University of North Carolina Health System, University of North Carolina School of Medicine, Chapel Hill
| | - Elizabeth Pace
- Division of Pediatric Surgery, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Maia D. Regan
- Department of Surgery, Connecticut Children’s Hospital, Hartford
| | - Stefan Scholz
- Division of Pediatric Surgery, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Elisabeth T. Tracy
- Department of Surgery, Duke Children’s Hospital and Health Center, Duke University School of Medicine, Durham, North Carolina
| | - Sasha A. Williams
- Division of Pediatric Surgery, Johns Hopkins All Children’s Hospital, St Petersburg, Florida
| | - Lucy Zhang
- Department of Pediatric Surgery, Yale New Haven Children’s Hospital Yale School of Medicine, New Haven, Connecticut
| | - Shawn J. Rangel
- Department of Surgery, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
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Alramadhan MM, Al Khatib HS, Murphy JR, Tsao K, Chang ML. Using Artificial Neural Networks to Predict Intra-Abdominal Abscess Risk Post-Appendectomy. ANNALS OF SURGERY OPEN 2022; 3:e168. [PMID: 37601615 PMCID: PMC10431380 DOI: 10.1097/as9.0000000000000168] [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: 09/27/2021] [Accepted: 04/18/2022] [Indexed: 11/26/2022] Open
Abstract
Objective To determine if artificial neural networks (ANN) could predict the risk of intra-abdominal abscess (IAA) development post-appendectomy. Background IAA formation occurs in 13.6% to 14.6% of appendicitis cases with "complicated" appendicitis as the most common cause of IAA. There remains inconsistency in describing the severity of appendicitis with variation in treatment with respect to perforated appendicitis. Methods Two "reproducible" ANN with different architectures were developed on demographic, clinical, and surgical information from a retrospective surgical dataset of 1574 patients less than 19 years old classified as either negative (n = 1,328) or positive (n = 246) for IAA post-appendectomy for appendicitis. Of 34 independent variables initially, 12 variables with the highest influence on the outcome selected for the final dataset for ANN model training and testing. Results A total of 1574 patients were used for training and test sets (80%/20% split). Model 1 achieved accuracy of 89.84%, sensitivity of 70%, and specificity of 93.61% on the test set. Model 2 achieved accuracy of 84.13%, sensitivity of 81.63%, and specificity of 84.6%. Conclusions ANN applied to selected variables can accurately predict patients who will have IAA post-appendectomy. Our reproducible and explainable ANNs potentially represent a state-of-the-art method for optimizing post-appendectomy care.
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Affiliation(s)
- Morouge M. Alramadhan
- From the Division of Infectious Diseases, Department of Pediatrics, UTHealth Houston McGovern Medical School, Houston, TX
| | - Hassan S. Al Khatib
- From the Division of Infectious Diseases, Department of Pediatrics, UTHealth Houston McGovern Medical School, Houston, TX
| | - James R. Murphy
- From the Division of Infectious Diseases, Department of Pediatrics, UTHealth Houston McGovern Medical School, Houston, TX
| | - KuoJen Tsao
- Division of General and Thoracic Pediatric Surgery, Department of Pediatric Surgery, UTHealth Houston McGovern Medical School, Houston, TX
| | - Michael L. Chang
- From the Division of Infectious Diseases, Department of Pediatrics, UTHealth Houston McGovern Medical School, Houston, TX
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Staphylococcus aureus infections after elective pediatric surgeries. Infect Control Hosp Epidemiol 2022; 43:1625-1633. [DOI: 10.1017/ice.2021.462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Abstract
Objective:
To determine the 180-day cumulative incidence of culture-confirmed Staphylococcus aureus infections after elective pediatric surgeries.
Design:
Retrospective cohort study utilizing the Premier Healthcare database (PHD).
Setting:
Inpatient and hospital-based outpatient elective surgical discharges.
Patients:
Pediatric patients <18 years who underwent surgery during elective admissions between July 1, 2010, and June 30, 2015, at any of 181 PHD hospitals reporting microbiology results.
Methods:
In total, 74 surgical categories were defined using ICD-9-CM and CPT procedure codes. Microbiology results and ICD-9-CM diagnosis codes defined S. aureus infection types: bloodstream infection (BSI), surgical site infection (SSI), and other types (urinary tract, respiratory, and all other). Cumulative postsurgical infection incidence was calculated as the number of infections divided by the number of discharges with qualifying elective surgeries.
Results:
Among 11,874 inpatient surgical discharges, 180-day S. aureus infection incidence was 1.79% overall (1.00% SSI, 0.35% BSI, 0.45% other). Incidence was highest among children <2 years of age (2.76%) and lowest for those 10–17 years (1.49%). Among 50,698 outpatient surgical discharges, incidence was 0.36% overall (0.23% SSI, 0.05% BSI, 0.08% others); it was highest among children <2 years of age (0.57%) and lowest for those aged 10–17 years (0.30%). MRSA incidence was significantly higher after inpatient surgeries (0.68%) than after outpatient surgeries (0.14%; P < .0001). Overall, the median days to S. aureus infection was longer after outpatient surgery than after inpatient surgery (39 vs. 31 days; P = .0116).
Conclusions:
These findings illustrate the burden of postoperative S. aureus infections in the pediatric population, particularly among young children. These results underscore the need for continued infection prevention efforts and longer-term surveillance after surgery.
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Predictors of Blood Transfusion for Endoscopic Assisted Craniosynostosis Surgery. J Craniofac Surg 2021; 33:1327-1330. [PMID: 34930880 DOI: 10.1097/scs.0000000000008441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 11/25/2021] [Indexed: 11/25/2022] Open
Abstract
ABSTRACT Blood loss is a main cause of morbidity after craniofacial procedures. The purpose of this study is to identify the incidence and predictors for transfusion of blood products in the endoscopic assisted strip craniectomy population. Data was prospectively collected from a single-center multi-surgeon cohort of 78 consecutive patients who underwent endoscopic assisted strip craniectomy for craniosynostosis between July 2013 and December 2020. The authors reviewed patient and treatment characteristics and outcomes. Of the 78 patients, 26 patients were transfused yielding an overall rate of transfusion of 33%. The most common fused suture was sagittal (n = 42, 54%) followed by metopic (n = 15, 19%), multiple (n = 10, 13%), coronal (n = 7, 9%) and finally lambdoid (n = 4, 5%). On univariate analysis, patients' weight in the transfusion cohort were significantly lower than those who did not receive a transfusion (5.6 ± 1.1 versus 6.5 ± 1.1 kg, P = 0.0008). The transfusion group also had significantly lower preoperative hemoglobin compared to the non-transfusion group (10.6 versus 11.1, P = .049). Eleven percent patients admitted to step-down received a transfusion, whereas 39% of patients admitted to the pediatric intensive care unit received a transfusion (P = 0.042). On multivariate analysis, only higher patient weight (operating room [OR] 0.305 [0.134, 0.693], P = 0.005) was protective against a transfusion, whereas colloid volume (OR 1.018 [1.003, 1.033], P = 0.019) predicted the need for a transfusion. Our results demonstrate that endoscopic craniosynostosis cases carry a moderate risk of transfusion. Individuals with lower weight and those that receive colloid volume are also at elevated risk.
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Kashtan MA, Graham DA, Anandalwar SP, Hills-Dunlap JL, Rangel SJ. Variability, outcomes and cost associated with the use of parenteral nutrition in children with complicated appendicitis: A hospital-level propensity matched analysis. J Pediatr Surg 2021; 56:2299-2304. [PMID: 33814183 DOI: 10.1016/j.jpedsurg.2021.03.005] [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] [Received: 11/30/2020] [Revised: 02/27/2021] [Accepted: 03/05/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND/PURPOSE To examine the influence of parenteral nutrition (PN) on clinical outcomes and cost in children with complicated appendicitis. METHODS Retrospective study of 1,073 children with complicated appendicitis from 29 hospitals participating in the NSQIP-Pediatric Appendectomy Pilot Collaborative (1/2013-6/2015). Mixed-effects regression was used to compare 30-day postoperative outcomes between high and low PN-utilizing hospitals after propensity matching on demographic characteristics, BMI and postoperative LOS as a surrogate for disease severity. RESULTS Overall PN utilization was 13.6%, ranging from 0-10.3% at low utilization hospitals (n = 452) and 10.3-32.4% at high utilization hospitals (n = 621). Outcomes were similar between low and high utilization hospitals for rates of overall complications (12.3% vs. 10.5%, OR: 0.80 [0.46,1.37], p = 0.41), SSIs (11.3% vs. 8.8%, OR: 0.72 [0.40,1.32], p = 0.29) and revisits (14.7% vs. 15.9%, OR: 1.10 [0.75,1.61], p = 0.63). Adjusted mean 30-day cumulative hospital cost was 22.9% higher for patients receiving PN ($25,164 vs. $20,478, p < 0.01) after controlling for postoperative LOS. CONCLUSION Following adjustment for patient characteristics and postoperative length of stay, higher rates of PN utilization in children with complicated appendicitis were associated with higher cost but not with lower rates of overall complications, surgical site infections or revisits. Level of Evidence Level III: Treatment study - Retrospective comparative study.
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Affiliation(s)
- Mark A Kashtan
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Dionne A Graham
- Center for Applied Pediatric Quality Analytics, Boston Children's Hospital, Boston, MA, USA
| | - Seema P Anandalwar
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | | | - Shawn J Rangel
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA.
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Association of operative approach with outcomes in neonates with esophageal atresia and tracheoesophageal fistula. J Pediatr Surg 2021; 56:2172-2179. [PMID: 33994203 DOI: 10.1016/j.jpedsurg.2021.04.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 03/17/2021] [Accepted: 04/05/2021] [Indexed: 01/04/2023]
Abstract
PURPOSE We sought to evaluate the impact of thoracoscopic repair on perioperative outcomes in infants with esophageal atresia and tracheoesophageal fistula (EA/TEF). METHODS The American College of Surgeons National Surgical Quality Improvement Program pediatric database from 2014 to 2018 was queried for all neonates who underwent operative repair of EA/TEF. Operative approach based on intention to treat was correlated with perioperative outcomes, including 30-day postoperative adverse events, in logistic regression models. RESULTS Among 855 neonates, initial thoracoscopic repair was performed in 133 (15.6%) cases. Seventy (53%) of these cases were converted to open. Those who underwent thoracoscopic repair were more likely to be full-term (p = 0.03) when compared to those in the open repair group. There were no significant differences in perioperative outcome measures based on surgical approach except for operative time (thoracoscopic: 217 min vs. open: 180 min, p<0.001). A major cardiac comorbidity (OR 1.6, 95% CI 1.2-2.1; p = 0.003) and preoperative ventilator requirement (OR 1.4, 95% CI 1.0-1.9; p = 0.034) were the only risk factors associated with adverse events. CONCLUSIONS Thoracoscopic neonatal repair of EA/TEF continues to be used sparingly, is associated with high conversion rates, and has similar perioperative outcomes when compared to open repair. LEVEL OF EVIDENCE III.
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France DJ, Slagle J, Schremp E, Moroz S, Hatch LD, Grubb P, Vogus TJ, Shotwell MS, Lorinc A, Lehmann CU, Robinson J, Crankshaw M, Sullivan M, Newman TA, Wallace T, Weinger MB, Blakely ML. Defining the Epidemiology of Safety Risks in Neonatal Intensive Care Unit Patients Requiring Surgery. J Patient Saf 2021; 17:e694-e700. [PMID: 32168276 PMCID: PMC8590832 DOI: 10.1097/pts.0000000000000680] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
OBJECTIVE The aim of the study was to determine the incidence, type, severity, preventability, and contributing factors of nonroutine events (NREs)-events perceived by care providers or skilled observers as a deviations from optimal care based on the clinical situation-in the perioperative (i.e., preoperative, operative, and postoperative) care of surgical neonates in the neonatal intensive care unit and operating room. METHODS A prospective observational study of noncardiac surgical neonates, who received preoperative and postoperative neonatal intensive care unit care, was conducted at an urban academic children's hospital between November 1, 2016, and March 31, 2018. One hundred twenty-nine surgical cases in 109 neonates were observed. The incidence and description of NREs were collected via structured researcher-administered survey tool of involved clinicians. Primary measurements included clinicians' ratings of NRE severity and contributory factors and trained research assistants' ratings of preventability. RESULTS One or more NREs were reported in 101 (78%) of 129 observed cases for 247 total NREs. Clinicians reported 2 (2) (median, interquartile range) NREs per NRE case with a maximum severity of 3 (1) (possible range = 1-5). Trained research assistants rated 47% of NREs as preventable and 11% as severe and preventable. The relative risks for National Surgical Quality Improvement Program - pediatric major morbidity and 30-day mortality were 1.17 (95% confidence interval = 0.92-1.48) and 1.04 (95% confidence interval = 1.00-1.08) in NRE cases versus non-NRE cases. CONCLUSIONS The incidence of NREs in neonatal perioperative care at an academic children's hospital was high and of variable severity with a myriad of contributory factors.
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Affiliation(s)
- Daniel J. France
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee
- Center for Research and Innovation in Systems Safety, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jason Slagle
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee
- Center for Research and Innovation in Systems Safety, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Emma Schremp
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee
- Center for Research and Innovation in Systems Safety, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Sarah Moroz
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee
- Center for Research and Innovation in Systems Safety, Vanderbilt University Medical Center, Nashville, Tennessee
| | - L. Dupree Hatch
- Center for Research and Innovation in Systems Safety, Vanderbilt University Medical Center, Nashville, Tennessee
- Department of Pediatrics, Division of Neonatology, Monroe Carell Jr. Children’s Hospital at Vanderbilt, Nashville, Tennessee
| | - Peter Grubb
- Department of Pediatrics, Division of Neonatology, Primary Children’s Hospital, University of Utah, Salt Lake City, Utah
| | - Timothy J. Vogus
- Owen Graduate School of Management, Vanderbilt University, Nashville, Tennessee
| | - Matthew S. Shotwell
- Department of Biostatistics and Vanderbilt University Medical Center, Nashville, Tennessee
| | - Amanda Lorinc
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee
- Center for Research and Innovation in Systems Safety, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Christoph U. Lehmann
- Department of Pediatrics, Division of Neonatology, Monroe Carell Jr. Children’s Hospital at Vanderbilt, Nashville, Tennessee
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jamie Robinson
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee
- Department of Pediatric Surgery, Monroe Carell Jr. Children’s Hospital at Vanderbilt, Nashville, Tennessee
| | - Marlee Crankshaw
- Department of Neonatal Intensive Care Unit, Monroe Carell Jr. Children’s Hospital at Vanderbilt, Nashville, Tennessee
| | - Maria Sullivan
- Perioperative Services, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Timothy A. Newman
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee
- Center for Research and Innovation in Systems Safety, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Tamara Wallace
- Neonatal Intensive Care Unit, Nationwide Children’s Hospital, Columbus, Ohio
| | - Matthew B. Weinger
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee
- Center for Research and Innovation in Systems Safety, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Martin L. Blakely
- Department of Pediatric Surgery, Monroe Carell Jr. Children’s Hospital at Vanderbilt, Nashville, Tennessee
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Swanson MA, Auslander A, Morales T, Jedrzejewski B, Magee WP, Siu A, Ayala R, Swanson JW. Predictors of Complication Following Cleft Lip and Palate Surgery in a Low-Resource Setting: A Prospective Outcomes Study in Nicaragua. Cleft Palate Craniofac J 2021; 59:1452-1460. [PMID: 34658290 DOI: 10.1177/10556656211046810] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Higher rates of postoperative complication following cleft lip or palate repair have been documented in low resource settings, but their causes remain unclear. This study sought to delineate patient, surgeon, and care environment factors in cleft complications in a low-income country. DESIGN Prospective outcomes study. SETTING Comprehensive Cleft Care Center. PATIENTS Candidate patients presenting for cleft lip or palate repair or revision. INTERVENTIONS Patient anthropometric, nutritional, environmental and peri- and post-operative care factors were collected. Post-operative evaluation occurred at standard 1-week and 2-month postoperative intervals. MAIN OUTCOME MEASURES Complication was defined as fistula, dehiscence and/or infection. RESULTS Among 408 patients enrolled, 380 (93%) underwent surgery, of which 208 (55%) underwent lip repair (124) or revision (84), and 178 (47%) underwent palate repair (96) or revision (82). 322 (85%) were evaluated 1 week and 166 (44%) 2 months postoperatively. 50(16%) complications were identified, including: 25(8%) fistulas, 24(7%) dehiscences, 17(5%) infections. Mid-upper arm circumference (MUAC) ≤12.5 cm was associated with dehiscence after primary lip repair (OR = 28, p = 0.02). Leukocytosis ≥11,500 on pre-operative evaluation was associated with dehiscence (OR = 2.51, p = 0.04) or palate revision fistula (OR = 64, p < 0.001). Surgeons who performed fewer previous-year palate repairs had higher likelihood of palate complications, (OR = 3.03, p = 0.01) although there was no difference in complication rate with years of surgeon experience or duration of surgery. CONCLUSIONS Multiple patient, surgeon, and perioperative factors are associated with higher rates of complication in a low-resource setting, and are potentially modifiable to reduce complications following cleft surgery.
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Affiliation(s)
- Marco A Swanson
- School of Medicine, 24575Case Western Reserve University, Cleveland, OH.,20313Operation Smile International, Virginia Beach, VA
| | - Allyn Auslander
- Institute for Global Health, 5116University of Southern California, Los Angeles, CA
| | | | | | - William P Magee
- Institute for Global Health, 5116University of Southern California, Los Angeles, CA.,5150Children's Hospital Los Angeles, Los Angeles, CA
| | - Armando Siu
- 2569Operación Sonrisa Nicaragua, Managua, Nicaragua
| | - Ruben Ayala
- 20313Operation Smile International, Virginia Beach, VA
| | - Jordan W Swanson
- 5150Children's Hospital Los Angeles, Los Angeles, CA.,20313Operation Smile International, Virginia Beach, VA.,Perelman School of Medicine, 6567Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
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Devin CL, Teeple EA, Linden AF, Gresh RC, Berman L. The morbidity of open tumor biopsy for intraabdominal neoplasms in pediatric patients. Pediatr Surg Int 2021; 37:1349-1354. [PMID: 34148111 DOI: 10.1007/s00383-021-04942-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/31/2021] [Indexed: 11/26/2022]
Abstract
PURPOSE Tumor biopsy is often essential for diagnosis and management of intraabdominal neoplasms found in children. Open surgical biopsy is the traditional approach used to obtain an adequate tissue sample to guide further therapy, but image-guided percutaneous core-needle biopsy is being used more often due to concerns about the morbidity of open biopsy. We used a national database to evaluate the morbidity associated with open intraabdominal tumor biopsy. METHODS We identified all patients undergoing laparotomy with tumor biopsy in the National Surgical Quality Improvement Project-Pediatric (NSQIP-P) database from 2012 to 2018 and measured the frequency of complications in the 30 days postoperatively. We tested associations between patient characteristics and outcomes to identify risk factors for complications. RESULTS We identified 454 patients undergoing laparotomy for biopsy of an intraabdominal neoplasm. Median postoperative hospital stay was 7 days (IQR 4-12) and operative time was 117 min (IQR 84-172). The overall complication rate was 12.1%, with post-operative infection (6%) and bleeding (4.2%) being the most common complications. Several patient characteristics were associated with bleeding, but the only significant association on multivariable analysis was underlying hematologic disorder. CONCLUSION Open abdominal surgery for pediatric intraabdominal tumor biopsy is accompanied by significant morbidity. Postoperative infection was the most common complication, which can delay initiation of further therapy, especially chemotherapy. These findings support the need to prospectively compare percutaneous image-guided core-needle biopsy to open biopsy as a way to minimize risk and optimize outcomes for this vulnerable population.
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Affiliation(s)
- Courtney L Devin
- Department of Surgery, Sidney Kimmel Medical College at Thomas Jefferson University Hospital, 1015 Walnut Street, Curtis Building, Suite 620, Philadelphia, PA, 19107, USA.
| | - Erin A Teeple
- Department of Surgery, Sidney Kimmel Medical College at Thomas Jefferson University Hospital, 1015 Walnut Street, Curtis Building, Suite 620, Philadelphia, PA, 19107, USA
- Department of Surgery, Nemours AI duPont Hospital for Children, Wilmington, DE, USA
| | - Allison F Linden
- Department of Surgery, Sidney Kimmel Medical College at Thomas Jefferson University Hospital, 1015 Walnut Street, Curtis Building, Suite 620, Philadelphia, PA, 19107, USA
- Department of Surgery, Nemours AI duPont Hospital for Children, Wilmington, DE, USA
| | - Renee C Gresh
- Department of Pediatrics, Nemours AI duPont Hospital for Children, Wilmington, DE, USA
| | - Loren Berman
- Department of Surgery, Sidney Kimmel Medical College at Thomas Jefferson University Hospital, 1015 Walnut Street, Curtis Building, Suite 620, Philadelphia, PA, 19107, USA
- Department of Surgery, Nemours AI duPont Hospital for Children, Wilmington, DE, USA
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Yalamanchi P, Parent AL, Baetzel AE, Crowe SM, Gutting AA, Gisondo G, Portice LC, Thorne MC, Wagner DS, Bates KE, Tribble AC. Optimization of Antibiotic Prophylaxis Delivery for Pediatric Surgical Procedures. Pediatrics 2021; 148:peds.2020-001669. [PMID: 34272341 DOI: 10.1542/peds.2020-001669] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/09/2021] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES To optimize prophylactic antibiotic timing and delivery across all surgeries performed at a single large pediatric tertiary care center. METHODS A multidisciplinary surgical quality team conducted a quality improvement initiative from July 2015 to December 2019 by using the A3 problem-solving method to identify and evaluate interventions for appropriate antibiotic administration. The primary outcome measure was the percentage of surgical encounters for pediatric patients with appropriate timing of antibiotic administration before surgical incision. Surgical site infection rates was the secondary outcome. Intervention effectiveness was assessed by using statistical process control. RESULTS A total of 32 192 eligible surgical cases for pediatric patients were completed during the study period. Identified barriers to timely perioperative antibiotic administration included failure to order antibiotics before the surgical date and lack of antibiotic availability in the operating room at the time of administration. Resulting sequential interventions included updating institutional guidelines to reflect procedure-specific antibiotic choices and clarifying timing of administration to optimize pharmacokinetics, creating a hard-stop antibiotic order within electronic health record case requests, optimizing pharmacy and nursing workflow, and implementing an automatic antibiotic prophylaxis timer in the operating room. Administration of prophylactic antibiotics during the recommended preincision time window significantly improved; the correct timing was recorded in 38.6% of preintervention cases versus 94.0% at the conclusion of rollout of the sequential interventions (P < .001). Surgical site infection rates remained stable. CONCLUSIONS Here we demonstrate utility of the A3 problem-solving schematic to successfully optimize prophylactic antibiotic timing and delivery in the surgical setting for pediatric patients by implementing systems-based interventions.
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Affiliation(s)
| | - Ashley L Parent
- C.S. Mott Children's Hospital and University of Michigan, Ann Arbor, Michigan
| | - Anne E Baetzel
- C.S. Mott Children's Hospital and University of Michigan, Ann Arbor, Michigan
| | - Susan M Crowe
- C.S. Mott Children's Hospital and University of Michigan, Ann Arbor, Michigan
| | - Andrew A Gutting
- C.S. Mott Children's Hospital and University of Michigan, Ann Arbor, Michigan
| | - Gino Gisondo
- C.S. Mott Children's Hospital and University of Michigan, Ann Arbor, Michigan
| | - Lynda C Portice
- C.S. Mott Children's Hospital and University of Michigan, Ann Arbor, Michigan
| | - Marc C Thorne
- C.S. Mott Children's Hospital and University of Michigan, Ann Arbor, Michigan
| | - Deborah S Wagner
- C.S. Mott Children's Hospital and University of Michigan, Ann Arbor, Michigan
| | - Katherine E Bates
- C.S. Mott Children's Hospital and University of Michigan, Ann Arbor, Michigan
| | - Alison C Tribble
- C.S. Mott Children's Hospital and University of Michigan, Ann Arbor, Michigan
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Finkelstein JB, Berrondo C, Prasad MM, Ellison JS. Beyond morbidity and mortality: Measuring processes and procedure specifics in the National Surgical Quality Improvement Program Pediatric (NSQIPP). J Pediatr Urol 2021; 17:426-429. [PMID: 33836967 DOI: 10.1016/j.jpurol.2021.03.008] [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: 02/03/2021] [Revised: 03/08/2021] [Accepted: 03/10/2021] [Indexed: 10/21/2022]
Affiliation(s)
- Julia B Finkelstein
- Division of Pediatric Urology, Columbia University Medical Center, Morgan Stanley Children's Hospital of New York Presbyterian, New York, NY, USA
| | - Claudia Berrondo
- Department of Surgery, Division of Urologic Surgery Children's Hospital and Medical Center and University of Nebraska Medical Center, Omaha, NE, USA
| | - Michaella M Prasad
- Department of Surgery and Pediatrics, Division of Urology, Atlantic Health System, Morristown, NJ, USA
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Almogbel GT, Altokhais TI, Alhothali A, Aljasser AS, Al-Qahtani KM, Arab SF, Alsweirki HMH, Albassam A. Risk Factors for Surgical Site Infections in Pediatric General Surgery: A Case–Control Study. J PEDIAT INF DIS-GER 2021. [DOI: 10.1055/s-0041-1726469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Abstract
Objective Despite being the most common postoperative complication and having associated morbidity and mortality that increase health care costs, surgical site infection (SSI) has not received adequate attention and deserves further study. Previous reports in children were limited to SSI in certain populations. We conducted this retrospective case–control study to determine the incidence and possible risk factors for SSI following pediatric general surgical procedures.
Methods This was a retrospective case–control matched cohort study of all patients aged 0 to 14 years who underwent pediatric general surgical procedures between June 2015 and July 2018. The electronic medical records were searched for a diagnosis of SSI. Control subjects were randomly selected at a 4:1 ratio from patients who underwent identical procedures. Multiple risk factors were evaluated by bivariate analysis and multivariable conditional logistic regression.
Results A total of 1,520 patients underwent a general pediatric procedure during the study period, and of these, 47 (3.09%) developed SSIs. A bivariate analysis showed that patients with SSIs were younger, were admitted to the neonatal intensive care unit/pediatric intensive care unit (NICU/PICU) preoperatively, were more severely ill as measured by the ASA classification, underwent multiple procedures, had more surgical complications, and were transferred to the NICU/PICU postoperatively. A multivariate analysis identified four independent predictors of SSI: age, preoperative NICU/PICU admission, number of procedures, and ASA classification.
Conclusion Younger children with preoperative admission to the NICU/PICU, those who underwent multiple procedures and those who were severely ill as measured by their ASA classification were significantly more likely to develop SSIs.
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Affiliation(s)
- Gassan T. Almogbel
- King Saud University Medical City & College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Tariq I. Altokhais
- Division of Pediatric Surgery, Department of Surgery, King Saud University Medical City & College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Abdulaziz Alhothali
- King Saud University Medical City & College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Abdulaziz Sami Aljasser
- King Saud University Medical City & College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Khalid M. Al-Qahtani
- King Saud University Medical City & College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Sadiq F. Arab
- King Saud University Medical City & College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Helmi M. H. Alsweirki
- King Saud University Medical City & College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Abdulrahman Albassam
- Division of Pediatric Surgery, Department of Surgery, King Saud University Medical City & College of Medicine, King Saud University, Riyadh, Saudi Arabia
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Anandalwar SP, Graham DA, Kashtan MA, Hills-Dunlap JL, Rangel SJ. Influence of Oral Antibiotics Following Discharge on Organ Space Infections in Children With Complicated Appendicitis. Ann Surg 2021; 273:821-825. [PMID: 31274648 DOI: 10.1097/sla.0000000000003441] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
OBJECTIVE To compare postdischarge rates of organ space infections (OSI) in children with complicated appendicitis between those receiving and not receiving oral antibiotics (OA) following discharge. SUMMARY BACKGROUND DATA Existing data regarding the clinical utility of extending antibiotic treatment following discharge in children with complicated appendicitis are limited. METHODS Retrospective cohort study of children ages 3 to 18 years undergoing appendectomy for complicated appendicitis from January 2013 to June 2015 across 17 hospitals participating in the NSQIP-Pediatric Appendectomy Pilot Collaborative (n = 711). Multivariable mixed-effects regression was used to compare postdischarge OSI rates between patients discharged with and without OA after propensity matching on demographic characteristics and disease severity. A subgroup analysis was performed for high-severity patients (multiple intraoperative findings of complicated disease or length of stay≥6 d). RESULTS The overall rates of OA utilization and OSI following discharge were 57.0% (hospital range: 3-100%) and 5.2% (range: 0-16.7%), respectively. In the propensity-matched analysis of the entire cohort, use of OA was associated with a 38% reduction in the odds of OSI following discharge compared with children not discharged on OA (4.2% vs. 6.6%, OR 0.62 [0.29, 1.31], P = 0.21). In the high-severity matched cohort (n = 324, 46%), use of OA was associated with a 61% reduction in the odds of OSI following discharge (4.3% vs 10.5%; OR 0.39 [0.15, 0.96], P = 0.04). CONCLUSIONS Use of oral antibiotics following discharge may decrease organ space infections in children with complicated appendicitis, and those presenting with high-severity disease may be most likely to benefit.
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Affiliation(s)
- Seema P Anandalwar
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Dionne A Graham
- Center for Applied Pediatric Quality Analytics, Boston Children's Hospital, Boston, MA
| | - Mark A Kashtan
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | | | - Shawn J Rangel
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA
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Winch PD, Mpody C, Murray-Torres TM, Rudolph S, Tobias JD, Nafiu OO. Unplanned Postoperative Reintubation in Children with Bronchial Asthma. J Pediatr Intensive Care 2021; 11:287-293. [DOI: 10.1055/s-0041-1724097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Accepted: 01/14/2021] [Indexed: 10/22/2022] Open
Abstract
AbstractUnplanned postoperative reintubation is a serious complication that may increase postsurgical hospital length of stay and mortality. Although asthma is a risk factor for perioperative adverse respiratory events, its association with unplanned postoperative reintubation in children has not been comprehensively examined. Our aim was to determine the association between a preoperative comorbid asthma diagnosis and the incidence of unplanned postoperative reintubation in children. This was a retrospective cohort study comprising of 194,470 children who underwent inpatient surgery at institutions participating in the National Surgical Quality Improvement Program–Pediatric. The primary outcome was the association of preoperative asthma diagnosis with early, unplanned postoperative reintubation (within the first 72 hours following surgery). We also evaluated the association between bronchial asthma and prolonged hospital length of stay (longer than the 75th percentile for the cohort). The incidence of unplanned postoperative reintubation in the study cohort was 0.5% in patients with a history of asthma compared with 0.2% in patients without the diagnosis (odds ratio [OR]: 2.23, 95% confidence interval [CI]: 1.71–2.89). This association remained significant after controlling for several clinical characteristics (OR: 1.54, 95% CI: 1.17–2.20). Additionally, asthmatic children were more likely to require a hospital length of stay longer than the 75th percentile for the study cohort (adjusted OR: 1.05, 95% CI: 1.01–1.10). Children with preoperative comorbid asthma diagnosis have an increased incidence of early, unplanned postoperative reintubation and prolonged postoperative hospitalization following inpatient surgery. By identifying these patients as having higher perioperative risks, it may be possible to institute strategies to improve their outcomes.
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Affiliation(s)
- Peter D. Winch
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio, United States
- Department of Anesthesiology and Pain Medicine, The Ohio State University College of Medicine, Columbus, Ohio, United States
| | - Christian Mpody
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio, United States
- Department of Anesthesiology and Pain Medicine, The Ohio State University College of Medicine, Columbus, Ohio, United States
| | - Teresa M. Murray-Torres
- Department of Anesthesiology, St. Louis Children's Hospital, Washington University School of Medicine, St. Louis, Missouri, United States
| | - Shannon Rudolph
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio, United States
- Medical Student Research Program, The Ohio State University College of Medicine, Columbus, Ohio, United States
| | - Joseph D. Tobias
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio, United States
- Department of Anesthesiology and Pain Medicine, The Ohio State University College of Medicine, Columbus, Ohio, United States
| | - Olubukola O. Nafiu
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio, United States
- Department of Anesthesiology and Pain Medicine, The Ohio State University College of Medicine, Columbus, Ohio, United States
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Measuring malnutrition and its impact on pediatric surgery outcomes: A NSQIP-P analysis. J Pediatr Surg 2021; 56:439-445. [PMID: 33190812 DOI: 10.1016/j.jpedsurg.2020.10.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2020] [Revised: 09/17/2020] [Accepted: 10/01/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND There is a limited understanding of the impact of pediatric malnutrition indicators on post-operative outcomes. MATERIALS AND METHODS All pediatric surgical patients captured in the ACS NSQIP-Pediatric database from 2016 to 2018 were included. Multivariable logistic regression was used to estimate odds of 30-day post-operative infection by malnutrition definition (stunted, wasted, requiring nutritional support, pre-operative hypoalbuminemia). RESULTS Among pediatric surgery patients (n = 282,056), 19% of patients met one definition of malnutrition, 6% met two, 1% met 3, and <0.1% met all 4. After adjustment, requiring nutritional support (OR 1.47, 95% CI 1.36-1.60), stunting (OR 1.17, 95% CI 1.10-1.25), and hypoalbuminemia (OR 1.17 95% CI 1.04-1.32) were associated with increased odds of post-operative infection while wasting was not. Requiring nutritional support was associated in an increase of 10.17 days (95% CI 9.89-10.44) in time from admission to surgery. CONCLUSIONS The metric used to define malnutrition changed the association with post-operative outcomes. Nutritional supplementation, stunting, and hypoalbuminemia were associated with poorer postoperative outcomes. These findings have implications for pre-operative patient level counseling, accurate risk stratification, surgical planning, and patient optimization in pediatric surgery. LEVEL OF EVIDENCE III.
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Bruny J, Inge T, Rannie M, Acker S, Levitt G, Cumbler E, Brumbaugh D. Transforming surgical morbidity and mortality into a systematic case review. J Pediatr Surg 2021; 56:80-84. [PMID: 33139023 DOI: 10.1016/j.jpedsurg.2020.09.036] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2020] [Accepted: 09/22/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND/PURPOSE The surgical morbidity and mortality (M&M) conferences at a regional children's hospital achieved the goals of case by case peer review and education for trainees but provided limited data for trending and analysis. In 2019, an institution-wide effort was initiated to create an electronic case review system with the goals of improving event capture and real-time practice performance feedback. Surgical M&M was migrated to this structured case review format to provide a platform for surgical performance improvement. METHODS An online secure database was created with a 3-step classification system based on Clavien-Dindo severity score, peer review, and causality fishbone analysis. The data entered were available in an interactive dashboard. Retrospective tabulation of the 2018 M&M data was performed using the archived paper system used prior to 2019. RESULTS For the calendar year of 2019, the division of pediatric surgery captured and categorized 193 complications in the case review system. The capture rate was 50 per 1000 surgical procedures. For a similar time frame in 2018, the capture rate was 35 per 1000 surgical procedures. The dashboard provided run charts of the incidence and types of complications by procedure and by surgeon. Similar trend data were not available in 2018. The dashboard output has made possible the creation of (non- risk adjusted) individual surgeon performance reports. The output has been used to direct process improvement projects and educational content. CONCLUSION Creation of an online database with interactive dashboard has allowed surgical M&M to evolve into a systematic case review that greatly facilitates quality improvement efforts. This system increased the event capture rate and provided novel practice performance feedback, resulting in process improvement projects and educational objectives predicated on the trending data. These electronic reporting tools are now available to all surgical divisions and represent a transformative approach to surgical case review. TYPE OF STUDY Retrospective Historical control; Quality improvement. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Jennifer Bruny
- Children's Hospital Colorado, Aurora, CO; University of Colorado, Aurora, CO.
| | - Thomas Inge
- Children's Hospital Colorado, Aurora, CO; University of Colorado, Aurora, CO
| | | | - Shannon Acker
- Children's Hospital Colorado, Aurora, CO; University of Colorado, Aurora, CO
| | | | | | - David Brumbaugh
- Children's Hospital Colorado, Aurora, CO; University of Colorado, Aurora, CO
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Dukleska K, Vinocur CD, Brenn BR, Lim DJ, Keith SW, Dirnberger DR, Berman L. Preoperative Blood Transfusions and Morbidity in Neonates Undergoing Surgery. Pediatrics 2020; 146:peds.2019-3718. [PMID: 33087550 DOI: 10.1542/peds.2019-3718] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/25/2020] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Blood transfusions in the neonatal patient population are common, but there are no established guidelines regarding transfusion thresholds. Little is known about postoperative outcomes in neonates who receive preoperative blood transfusions (PBTs). METHODS Using the American College of Surgeons National Surgical Quality Improvement Program-Pediatric Participant Use Data Files from 2012 to 2015, we identified all neonates who underwent surgery. Mortality and composite morbidity (defined as any postoperative complication) in neonates who received a PBT within 48 hours of surgery were compared with that in neonates who did not receive a transfusion. RESULTS A total of 12 184 neonates were identified, of whom 1209 (9.9%) received a PBT. Neonates who received a PBT had higher rates of preoperative comorbidities and worse postoperative outcomes when compared with those who did not receive a transfusion (composite morbidity: 46.2% vs 16.2%; P < .01). On multivariable regression analysis, PBTs were independently associated with increased 30-day morbidity (odds ratio [OR] = 1.90; 95% confidence interval [CI]: 1.63-2.22; P < .01) and mortality (OR = 1.98; 95% CI: 1.55-2.55; P < .01). In a propensity score-matched analysis, PBTs continued to be associated with increased 30-day morbidity (OR = 1.53; 95% CI: 1.29-1.81; P < .01) and mortality (OR = 1.58; 95% CI: 1.24-2.01; P = .01). CONCLUSIONS In a propensity score-matched model, PBTs are independently associated with increased morbidity and mortality in neonates who undergo surgery. Prospective data are needed to better understand the potential effects of a red blood cell transfusion in this patient population.
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Affiliation(s)
- Katerina Dukleska
- Surgery, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania.,Department of Pediatric Surgery, Connecticut Children's Medical Center, Hartford, Connecticut
| | - Charles D Vinocur
- Surgery, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania.,Departments of Surgery and
| | - B Randall Brenn
- Department of Anesthesiology, Monroe Carrell Jr Children's Hospital at Vanderbilt, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Doyle J Lim
- Anesthesiology, Nemours/Alfred I. duPont Hospital for Children, Wilmington, Delaware; and
| | - Scott W Keith
- Division of Biostatistics, Departments of Pharmacology and Experimental Therapeutics and
| | | | - Loren Berman
- Surgery, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania; .,Departments of Surgery and
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Jaffray B. Am I out of control? The application of statistical process control charts to children's surgery. J Pediatr Surg 2020; 55:1691-1698. [PMID: 32145972 DOI: 10.1016/j.jpedsurg.2019.12.027] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Revised: 11/16/2019] [Accepted: 12/31/2019] [Indexed: 12/11/2022]
Abstract
AIMS To illustrate the construction of statistical control charts and show their potential application to analysis of outcomes in children's surgery. PATIENTS AND METHODS Two datasets recording outcomes following esophageal atresia repair and intestinal resection for Crohn's disease maintained by the author were used to construct four types of charts. The effects of altering the target signal, the alarm signal and the limits are illustrated. The dilemmas in choice of target rate are described. Simulated data illustrate the advantages over hypothesis testing. RESULTS The charts show the author's institutional leak rate for esophageal atresia repair may be within acceptable limits, but that this is dependent on the target set. The desirable target is contentious. The leak rate for anastomoses following intestinal resection for Crohn's disease leak is also within acceptable limits when compared to published experience, but may be deteriorating. The charts are able to detect deteriorating levels of performance well before hypothesis testing would suggest a systematic problem with outcomes. CONCLUSIONS Statistical process control charts can provide surgeons with early warning of systematic poor performance. They are robust to volume-outcome influences, since the outcome is tested sequentially after each procedure or patient. They have application in a specialty with low frequencies of operations such as children's surgery. TYPE OF STUDY Diagnostic test. LEVEL OF EVIDENCE Level II.
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Affiliation(s)
- Bruce Jaffray
- Department of paediatric surgery, The Great North Children's Hospital, Queen Victoria Road, Newcastle upon Tyne NE1 4LP.
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Chouairi F, Mercier MR, Persing JS, Gabrick KS, Clune J, Alperovich M. National Patterns in Surgical Management of Syndactyly: A Review of 956 Cases. Hand (N Y) 2020; 15:666-673. [PMID: 30770023 PMCID: PMC7543215 DOI: 10.1177/1558944719828003] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Purpose: Being one of the most common congenital hand malformations, syndactyly is repaired by orthopedic, plastic, and fellowship-trained general surgeons. Limited multi-institutional outcomes analyses regarding incidence, timing, and type of repair exist. Methods: All syndactyly cases performed over a 5-year period from 2012-2016 were isolated from the National Surgical Quality Improvement Program Pediatric database. Patient demographics, surgical factors, perioperative outcomes, and risk factors were analyzed using χ2, Fisher exact, and t-test analysis. Results: A total of 956 patients who underwent syndactyly repair were identified. Most cases were simple syndactyly with nearly even case distribution among plastic and orthopedic surgeons. Most patients were men and Caucasian. Mean age at the time of surgery was 2.6 years. Most cases were performed as outpatient surgery. Patients of plastic surgeons had significantly more airway abnormalities and shorter operative times. Patients with complex syndactyly had significantly more ventilator dependence, tracheostomy, and comorbidities when compared with those with simple syndactyly. Cases with complex syndactyly also had longer operative times and a higher rate of superficial surgical site infections. Conclusions: Syndactyly repair is a safe procedure with few major or minor reconstructive complications regardless of the surgical specialty or syndactyly type. Patients with complex syndactyly have significantly more preoperative comorbidities with comparable outcomes. orthopedic surgeons have significantly longer operative times than plastic surgeons, likely due to caring for increased number of patients with complex syndactyly.
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Affiliation(s)
| | | | | | | | - James Clune
- Yale University School of Medicine, New Haven, CT, USA
| | - Michael Alperovich
- Yale University School of Medicine, New Haven, CT, USA,Michael Alperovich, Section of Plastic and Reconstructive Surgery, Department of Surgery, Yale University School of Medicine, 330 Cedar Street, Boardman Building, 3rd Floor, New Haven, CT 06510, USA.
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The safety and efficacy of using negative pressure incisional wound VACs in pediatric and neonatal patients. J Pediatr Surg 2020; 55:1470-1474. [PMID: 31839369 DOI: 10.1016/j.jpedsurg.2019.10.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Revised: 09/06/2019] [Accepted: 10/08/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND Surgical site infection (SSI) rates are an important surgical quality metric. Decreased SSI rates have been demonstrated using negative pressure incisional wound vac device (NPIWV) dressings in adults but have not been studied in children. MATERIALS AND METHODS A retrospective review of patients treated with NPIWV at our institution between February 2016 and February 2018 was performed. NPIWV dressings were applied by previously described techniques. Using the same CPT codes from our study patients, we queried the National Surgical Quality Improvement Program-Pediatric (NSQIP-P) data between January 2014 and January 2016 to identify preimplementation controls (PIC). NPIWV patients were compared to historical controls to assess safety and efficacy of SSI prevention. RESULTS There were 32 patients managed with NPIWV, and 65 patients in the PIC group. There were no NPIWV-associated complications. There was a trend toward reduced incidence of SSI in NPIWV patients, with 1 SSI in 32 cases (3.1%) versus 7 SSIs in the 65 historical control patients (10.8%) (p = 0.22). CONCLUSIONS Our study shows that NPIWV dressings can be used safely in pediatric and neonatal patients undergoing surgery, with a trend toward decreased SSI rates. These findings should be confirmed in a larger, prospective trial. TYPE OF STUDY Retrospective comparative study. LEVEL OF EVIDENCE Level III.
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Nguyen N, Leveille E, Guadagno E, Kalisya LM, Poenaru D. Use of mobile health technologies for postoperative care in paediatric surgery: A systematic review. J Telemed Telecare 2020; 28:331-341. [PMID: 32605411 DOI: 10.1177/1357633x20934682] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Mobile health (mHealth) is the use of mobile communication devices such as smartphones, wireless patient monitoring devices and tablet computers to deliver health services. Paediatric surgery patient care could potentially benefit from these technologies. This systematic review summarises the current literature on the use of mHealth for postoperative care after children's surgery. METHODS Seven databases were searched by a senior medical librarian. Studies were included if they reported the use of mHealth systems for postoperative care for children <18 years old. Data extraction and risk of bias assessment were performed in duplicate. RESULTS A total of 18 studies were included after screening. mHealth use was varied and included appointment or medication reminders, postoperative monitoring and postoperative instruction delivery. mHealth systems included texting systems and mobile applications, and were implemented for a wide range of surgical conditions and countries. DISCUSSION Studies showed that mHealth systems can increase the postoperative follow-up appointment attendance rate (p < 0.001), decrease the rate of postoperative complications and returns to the emergency department and reliably monitor postoperative pain. mHealth systems were generally appreciated by patients. Most non-randomised and randomised studies had many methodological problems, including lack of appropriate control groups, lack of blinding and a tendency to devote more time to the care of the intervention group. mHealth systems have the potential to improve postoperative care, but the lack of high-quality research evaluating their impact calls for further studies exploring evidence-based mHealth implementation.
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Affiliation(s)
- Nam Nguyen
- Faculty of Medicine, McGill University, Canada
| | | | - Elena Guadagno
- Department of Paediatric Surgery, McGill University Health Centre, Canada
| | | | - Dan Poenaru
- Department of Paediatric Surgery, McGill University Health Centre, Canada
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Development and Implications of an Evidence-based and Public Health-relevant Definition of Complicated Appendicitis in Children. Ann Surg 2020; 271:962-968. [PMID: 30308607 DOI: 10.1097/sla.0000000000003059] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
OBJECTIVE To characterize the influence of intraoperative findings on complications and resource utilization as a means to establish an evidence-based and public health-relevant definition for complicated appendicitis. SUMMARY OF BACKGROUND DATA Consensus is lacking surrounding the definition of complicated appendicitis in children. Establishment of a consensus definition may have implications for standardizing the reporting of clinical research data and for refining reimbursement guidelines. METHODS This was a retrospective cohort study of patients ages 3 to 18 years who underwent appendectomy from January 1, 2013 to December 31, 2014 across 22 children's hospitals (n = 5002). Intraoperative findings and clinical data from the National Surgical Quality Improvement Program-Pediatric Appendectomy Pilot Database were merged with cost data from the Pediatric Health Information System Database. Multivariable regression was used to examine the influence of 4 intraoperative findings [visible hole (VH), diffuse fibrinopurulent exudate (DFE) extending outside the right lower quadrant (RLQ)/pelvis, abscess, and extra-luminal fecalith] on complication rates and resource utilization after controlling for patient and hospital-level characteristics. RESULTS At least 1 of the 4 intraoperative findings was reported in 26.6% (1333/5002) of all cases. Following adjustment, each of the 4 findings was independently associated with higher rates of adverse events compared with cases where the findings were absent (VH: OR 5.57 [95% CI 3.48-8.93], DFE: OR 4.65[95% CI 2.91-7.42], abscess: OR 8.96[95% CI 5.33-15.08], P < 0.0001, fecalith: OR 5.01[95% CI 2.02-12.43], P = 0.001), and higher rates of revisits (VH: OR 2.02 [95% CI 1.34-3.04], P = 0.001, DFE: OR 1.59[95% CI 1.07-2.37], P = 0.02, abscess: OR 2.04[95% CI 1.2-3.49], P = 0.01, fecalith: OR 2.31[95% CI 1.06-5.02], P = 0.04). Each of the 4 findings was also independently associated with increased resource utilization, including longer cumulative length of stay (VH: Rate ratio [RR] 3.15[95% CI 2.86-3.46], DFE: RR 3.06 [95% CI 2.83-3.13], abscess: RR 3.94 [95% CI 3.55-4.37], fecalith: RR 2.35 [95% CI 1.87-2.96], P = < 0.0001) and higher cumulative hospital cost (VH: RR 1.97[95% CI 1.64-2.37], P < 0.0001, DFE: RR 1.8[95% CI 1.55-2.08], P = < 0.0001, abscess: RR 2.02[95% CI 1.61-2.53], P < 0.0001, fecalith: RR 1.49[95% CI 0.98-2.28], P = 0.06) compared with cases where the findings were absent. CONCLUSION AND RELEVANCE The presence of a visible hole, diffuse fibrinopurulent exudate, intra-abdominal abscess, and extraluminal fecalith were independently associated with markedly worse outcomes and higher cost in children with appendicitis. The results of this study provide an evidence-based and public health-relevant framework for defining complicated appendicitis in children.
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Egberg MD, Phillips M, Galanko JA, Kappelman M. Total Abdominal Colectomies With Proctectomy Are Associated With Higher 30-Day Readmission Rates in Children With Ulcerative Colitis. Inflamm Bowel Dis 2020; 27:493-499. [PMID: 32426816 PMCID: PMC7957218 DOI: 10.1093/ibd/izaa099] [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] [Received: 04/12/2020] [Indexed: 12/09/2022]
Abstract
BACKGROUND Hospital readmissions are a burden on patients and families and place financial strain on the health care system. Thirty-day readmission rates for adult patients undergoing colectomy are as high as 30%, and inflammatory bowel disease is a risk factor for readmission. We used a multicenter pediatric surgical database to determine the 30-day readmission rate for pediatric patients with ulcerative colitis (UC) undergoing total abdominal colectomy (TAC) and to identify risk factors for 30-day hospital readmission. METHODS We used the National Surgical Quality Improvement Program-Pediatrics database to identify pediatric patients with UC undergoing a TAC between 2012 and 2017. We identified patient and procedural data from the index hospitalization and used logistic regression to identify risk factors for 30-day readmission rates, adjusting for confounding factors. RESULTS We identified 489 pediatric UC TAC hospitalizations between 2012 and 2017, and 19.4% were readmitted within 30 days of surgical discharge. Patient demographics and preoperative laboratory values were not associated with risk of readmission. The TAC procedures that included a proctectomy were at a 2-fold (odds ratio = 2.4; 95% confidence interval, 1.1-5.2) higher risk of 30-day readmission than TAC alone after adjusted analysis. CONCLUSIONS Nearly 20% of annual pediatric UC hospitalizations involving a colectomy resulted in a 30-day hospital readmission. Notably, TAC procedures that included a proctectomy had significantly higher readmission rates compared to TAC alone. These results can inform risk management strategies aimed at reducing morbidity and hospital readmissions for children with UC.
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Affiliation(s)
- Matthew D Egberg
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology, and Nutrition, University of North Carolina, Chapel Hill, North Carolina, USA,Center for Gastrointestinal Biology and Disease, University of North Carolina, Chapel Hill, North Carolina, USA,Address correspondence to: Matthew D. Egberg, MD, MPH, MMSc, Division of Pediatric Gastroenterology and Hepatology, Center for Gastrointestinal Biology and Disease, University of North Carolina at Chapel Hill, 130 Mason Farm Road, Bioinformatics Building, CB #4101, Chapel Hill, NC 27599 ()
| | - Michael Phillips
- Department of Surgery, Division of Pediatric General Surgery, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Joseph A Galanko
- Center for Gastrointestinal Biology and Disease, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Michael Kappelman
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology, and Nutrition, University of North Carolina, Chapel Hill, North Carolina, USA,Center for Gastrointestinal Biology and Disease, University of North Carolina, Chapel Hill, North Carolina, USA
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Operative management of urachal remnants: An NSQIP based study of postoperative complications. J Pediatr Surg 2020; 55:873-877. [PMID: 32145974 DOI: 10.1016/j.jpedsurg.2020.01.028] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Accepted: 01/25/2020] [Indexed: 12/11/2022]
Abstract
PURPOSE The identification of urachal remnants is occurring more in infancy. Despite evidence that nonoperative management is effective, operative management remains common and has a high complication rate. We sought to determine if the complication rate after urachal resection is associated with age. METHODS Patients undergoing urachal remnant resection were identified from ACS NSQIP Pediatric from 2013 to 2017. Exclusion criteria included emergent operations, contaminated wounds, and any additional procedures. Patients were compared based on complication rates, need for reoperation or readmission, and length of stay. RESULTS A complication occurred in 16 of 476 patients (3.3%), 6 (1.3%) had reoperation, and 11 (2.3%) were readmitted. The median age for patients requiring reoperation was lower (0.1 years) than those not (1.3 years; p = 0.004). The median age of those readmitted was lower (0.4 years) than those not (1.4 years, p = 0.03), and a weak trend of longer length of stay in younger patients was identified (ρ = -0.16, p < 0.001). CONCLUSIONS Operative management of younger patients resulted in greater risk of reoperation, readmission, and longer length of stay. Given that nonoperative management is effective, it may be of benefit to delay resection of urachal remnants to after 1 year of age. STUDY TYPE Treatment study. LEVEL OF EVIDENCE Level III.
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Ceftriaxone Combined With Metronidazole is Superior to Cefoxitin Alone in the Management of Uncomplicated Appendicitis in Children: Results from a Multicenter Collaborative Comparative Effectiveness Study. Ann Surg 2020; 274:e995-e1000. [PMID: 32149827 DOI: 10.1097/sla.0000000000003704] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To compare rates of surgical site infection between the 2 most commonly utilized narrow-spectrum antibiotic regimens in children with uncomplicated appendicitis (ceftriaxone with metronidazole and cefoxitin alone). SUMMARY OF BACKGROUND DATA Narrow-spectrum antibiotics have been found to be equivalent to extended-spectrum (antipseudomonal) agents in preventing surgical site infection (SSI) in children with uncomplicated appendicitis. The comparative effectiveness of different narrow-spectrum agents has not been reported. METHODS This was a multicenter retrospective cohort study using clinical data from the Pediatric National Surgical Quality Improvement Program Appendectomy Collaborative Pilot database merged with antibiotic utilization data from the Pediatric Health Information System database from January 2013 to June 2015. Multivariable logistic regression was used to compare outcomes between antibiotic treatment groups after adjusting for patient characteristics, surrogate measures of disease severity, and clustering of outcomes within hospitals. RESULTS Eight hundred forty-six patients from 14 hospitals were included in the final study cohort with an overall SSI rate of 1.3%. A total of 56.0% of patients received ceftriaxone with metronidazole (hospital range: 0%-100%) and 44.0% received cefoxitin (range: 0%-100%). In the multivariable model, ceftriaxone with metronidazole was associated with a 90% reduction in the odds of a SSI compared to cefoxitin [0.2% vs 2.7%; odds ratio: 0.10 (95% confidence interval 0.02-0.60); P = 0.01]. CONCLUSIONS Ceftriaxone combined with metronidazole is superior to cefoxitin alone in preventing SSIs in children with uncomplicated appendicitis.
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Benzon HA, Bobrowski A, Suresh S, Wasson NR, Cheon EC. Impact of preoperative hyponatraemia on paediatric perioperative mortality. Br J Anaesth 2019; 123:618-626. [DOI: 10.1016/j.bja.2019.07.024] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2019] [Revised: 06/28/2019] [Accepted: 07/22/2019] [Indexed: 10/26/2022] Open
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