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Tian BWCA, Stahel PF, Picetti E, Campanelli G, Di Saverio S, Moore E, Bensard D, Sakakushev B, Galante J, Fraga GP, Koike K, Di Carlo I, Tebala GD, Leppaniemi A, Tan E, Damaskos D, De'Angelis N, Hecker A, Pisano M, Maier RV, De Simone B, Amico F, Ceresoli M, Pikoulis M, Weber DG, Biffl W, Beka SG, Abu-Zidan FM, Valentino M, Coccolini F, Kluger Y, Sartelli M, Agnoletti V, Chirica M, Bravi F, Sall I, Catena F. Assessing and managing frailty in emergency laparotomy: a WSES position paper. World J Emerg Surg 2023; 18:38. [PMID: 37355698 DOI: 10.1186/s13017-023-00506-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 05/27/2023] [Indexed: 06/26/2023] Open
Abstract
Many countries are facing an aging population. As people live longer, surgeons face the prospect of operating on increasingly older patients. Traditional teaching is that with older age, these patients face an increased risk of mortality and morbidity, even to a level deemed too prohibitive for surgery. However, this is not always true. An active 90-year-old patient can be much fitter than an overweight, sedentary 65-year-old patient with comorbidities. Recent literature shows that frailty-an age-related cumulative decline in multiple physiological systems, is therefore a better predictor of mortality and morbidity than chronological age alone. Despite recognition of frailty as an important tool in identifying vulnerable surgical patients, many surgeons still shun objective tools. The aim of this position paper was to perform a review of the existing literature and to provide recommendations on emergency laparotomy and in frail patients. This position paper was reviewed by an international expert panel composed of 37 experts who were asked to critically revise the manuscript and position statements. The position paper was conducted according to the WSES methodology. We shall present the derived statements upon which a consensus was reached, specifying the quality of the supporting evidence and suggesting future research directions.
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Affiliation(s)
- Brian W C A Tian
- Department of General Surgery, Singapore General Hospital, Singapore, Singapore
| | - Philip F Stahel
- Department of Orthopedic Surgery and Department of Neurosurgery, Denver Health Medical Center and University of Colorado School of Medicine, Denver, CO, USA
| | - Edoardo Picetti
- Department of Anesthesia and Intensive Care, Azienda Ospedaliero-Universitaria Parma, Parma, Italy
| | | | - Salomone Di Saverio
- Unit of General Surgery, San Benedetto del Tronto Hospital, av5 Asur Marche, San Benedetto del Tronto, Italy
| | - Ernest Moore
- Department of Surgery, Denver Health Medical Center, Denver, CO, USA
| | - Denis Bensard
- Department of Surgery, Denver Health Medical Center, Denver, CO, USA
| | - Boris Sakakushev
- Research Institute of Medical University Plovdiv/University Hospital St George Plovdiv, Plovdiv, Bulgaria
| | - Joseph Galante
- Trauma Department, University of California, Davis, Sacramento, CA, USA
| | - Gustavo P Fraga
- Faculdade de Ciências Médicas (FCM), Unicamp Campinas, Campinas, SP, Brazil
| | - Kaoru Koike
- Department of Primary Care and Emergency Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Isidoro Di Carlo
- Department of Surgical Sciences and Advanced Technologies "GF Ingrassia", University of Catania, Cannizzaro Hospital, Via Messina 829, 95126, Catania, Italy
| | - Giovanni D Tebala
- Oxford University Hospitals NHSFT John Radcliffe Hospital, Headley Way, HeadingtonOxford, OX3 9DU, UK
| | - Ari Leppaniemi
- General Surgery Department, Helsinki University Hospital, Helsinki, Finland
| | - Edward Tan
- Department of Surgery, Radboud University Medical Center, Nijmegen, Netherlands
| | - Dimitris Damaskos
- General and Emergency Surgery, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Nicola De'Angelis
- Hôpital Henri Mondor, Université Paris Est, Service de Chirurgie Digestive et Hépato-Bilio-Pancréatique, Créteil, France
| | - Andreas Hecker
- Department of General and Thoracic Surgery, University Hospital, Giessen, Germany
| | - Michele Pisano
- General and Emergency Surgery, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Ron V Maier
- Department of Surgery, Harborview Medical Centre, University of Washington, Seattle, USA
| | - Belinda De Simone
- Department of Emergency Surgery, Centre Hospitalier Intercommunal de Villeneuve-Saint-Georges, Villeneuve-Saint-Georges, France
| | - Francesco Amico
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Marco Ceresoli
- General Surgery, Monza University Hospital, Monza, Italy
| | - Manos Pikoulis
- 3Rd Department of Surgery, Attikon General Hospital, National and Kapodistrian University of Athens (NKUA), Athens, Greece
| | - Dieter G Weber
- Department of General Surgery, Royal Perth Hospital, University of Western Australia, Perth, Australia
| | - Walt Biffl
- Department of Trauma and Acute Care Surgery, Scripps Memorial Hospital La Jolla, La Jolla, San Diego, CA, USA
| | - Solomon Gurmu Beka
- School of Medicine and Health Science, University of Otago, Wellington Campus, Wellington, New Zealand
| | - Fikri M Abu-Zidan
- The Research Office, College of Medicine and Health Sciences, United Arab Emirates University, Al-Ain, UAE
| | | | - Federico Coccolini
- General, Emergency and Trauma Surgery Department, Pisa University Hospital, Pisa, Italy
| | - Yoram Kluger
- Division of General Surgery, Rambam Health Care Campus, Haifa, Israel
| | | | - Vanni Agnoletti
- Anesthesia and Intensive Care Unit, AUSL Romagna, M. Bufalini Hospital, Cesena, Italy
| | - Mircea Chirica
- Service de Chirurgie Digestive, Centre Hospitalier Universitaire Grenoble Alpes, Grenoble, France
| | - Francesca Bravi
- Healthcare Administration, Santa Maria Delle Croci Hospital, Ravenna, Italy
| | - Ibrahima Sall
- Department of General Surgery, Military Teaching Hospital, Hôpital Principal Dakar, Dakar, Senegal.
| | - Fausto Catena
- Department of Emergency and Trauma Surgery, Bufalini Hospital, Cesena, Italy
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Stevens J, Reppucci ML, Pickett K, Acker S, Carmichael H, Velopulos CG, Bensard D, Kulungowski A. Using the Social Vulnerability Index to Examine Disparities in Surgical Pediatric Trauma Patients. J Surg Res 2023; 287:55-62. [PMID: 36868124 DOI: 10.1016/j.jss.2023.01.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Revised: 12/31/2022] [Accepted: 01/27/2023] [Indexed: 03/05/2023]
Abstract
INTRODUCTION The Social Vulnerability Index (SVI) is a composite measure geocoded at the census tract level that has the potential to identify target populations at risk for postoperative surgical morbidity. We applied the SVI to examine demographics and disparities in surgical outcomes in pediatric trauma patients. METHODS Surgical pediatric trauma patients (≤18-year-old) at our institution from 2010 to 2020 were included. Patients were geocoded to identify their census tract of residence and estimated SVI and were stratified into high (≥70th percentile) and low (<70th percentile) SVI groups. Demographics, clinical data, and outcomes were compared using Kruskal-Wallis and Fisher's exact tests. RESULTS Of 355 patients included, 21.4% had high SVI percentiles while 78.6% had low SVI percentiles. Patients with high SVI were more likely to have government insurance (73.7% versus 37.2%, P < 0.001), be of minority race (49.8% versus 19.1%, P < 0.001), present with penetrating injuries (32.9% versus 19.7%, P = 0.007), and develop surgical site infections (3.9% versus 0.4%, P = 0.03) compared to the low SVI group. CONCLUSIONS The SVI has the potential to examine health care disparities in pediatric trauma patients and identify discrete at-risk target populations for preventative resources allocation and intervention. Future studies are necessary to determine the utility of this tool in additional pediatric cohorts.
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Affiliation(s)
- Jenny Stevens
- Division of Pediatric Surgery, Children's Hospital Colorado, Aurora, Colorado; Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado.
| | - Marina L Reppucci
- Division of Pediatric Surgery, Children's Hospital Colorado, Aurora, Colorado; Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado
| | - Kaci Pickett
- The Center for Research in Outcomes for Children's Surgery, Center for Children's Surgery, University of Colorado School of Medicine, Aurora, Colorado
| | - Shannon Acker
- Division of Pediatric Surgery, Children's Hospital Colorado, Aurora, Colorado; Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado
| | - Heather Carmichael
- Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado
| | | | - Denis Bensard
- Division of Pediatric Surgery, Children's Hospital Colorado, Aurora, Colorado; Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado
| | - Ann Kulungowski
- Division of Pediatric Surgery, Children's Hospital Colorado, Aurora, Colorado; Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado
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Podda M, De Simone B, Ceresoli M, Virdis F, Favi F, Wiik Larsen J, Coccolini F, Sartelli M, Pararas N, Beka SG, Bonavina L, Bova R, Pisanu A, Abu-Zidan F, Balogh Z, Chiara O, Wani I, Stahel P, Di Saverio S, Scalea T, Soreide K, Sakakushev B, Amico F, Martino C, Hecker A, de'Angelis N, Chirica M, Galante J, Kirkpatrick A, Pikoulis E, Kluger Y, Bensard D, Ansaloni L, Fraga G, Civil I, Tebala GD, Di Carlo I, Cui Y, Coimbra R, Agnoletti V, Sall I, Tan E, Picetti E, Litvin A, Damaskos D, Inaba K, Leung J, Maier R, Biffl W, Leppaniemi A, Moore E, Gurusamy K, Catena F. Follow-up strategies for patients with splenic trauma managed non-operatively: the 2022 World Society of Emergency Surgery consensus document. World J Emerg Surg 2022; 17:52. [PMID: 36224617 PMCID: PMC9560023 DOI: 10.1186/s13017-022-00457-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 09/26/2022] [Indexed: 11/16/2022] Open
Abstract
Background In 2017, the World Society of Emergency Surgery published its guidelines for the management of adult and pediatric patients with splenic trauma. Several issues regarding the follow-up of patients with splenic injuries treated with NOM remained unsolved.
Methods Using a modified Delphi method, we sought to explore ongoing areas of controversy in the NOM of splenic trauma and reach a consensus among a group of 48 international experts from five continents (Africa, Europe, Asia, Oceania, America) concerning optimal follow-up strategies in patients with splenic injuries treated with NOM.
Results Consensus was reached on eleven clinical research questions and 28 recommendations with an agreement rate ≥ 80%. Mobilization after 24 h in low-grade splenic trauma patients (WSES Class I, AAST Grades I–II) was suggested, while in patients with high-grade splenic injuries (WSES Classes II–III, AAST Grades III–V), if no other contraindications to early mobilization exist, safe mobilization of the patient when three successive hemoglobins 8 h apart after the first are within 10% of each other was considered safe according to the panel. The panel suggests adult patients to be admitted to hospital for 1 day (for low-grade splenic injuries—WSES Class I, AAST Grades I–II) to 3 days (for high-grade splenic injuries—WSES Classes II–III, AAST Grades III–V), with those with high-grade injuries requiring admission to a monitored setting. In the absence of specific complications, the panel suggests DVT and VTE prophylaxis with LMWH to be started within 48–72 h from hospital admission. The panel suggests splenic artery embolization (SAE) as the first-line intervention in patients with hemodynamic stability and arterial blush on CT scan, irrespective of injury grade. Regarding patients with WSES Class II blunt splenic injuries (AAST Grade III) without contrast extravasation, a low threshold for SAE has been suggested in the presence of risk factors for NOM failure. The panel also suggested angiography and eventual SAE in all hemodynamically stable adult patients with WSES Class III injuries (AAST Grades IV–V), even in the absence of CT blush, especially when concomitant surgery that requires change of position is needed. Follow-up imaging with contrast-enhanced ultrasound/CT scan in 48–72 h post-admission of trauma in splenic injuries WSES Class II (AAST Grade III) or higher treated with NOM was considered the best strategy for timely detection of vascular complications. Conclusion This consensus document could help guide future prospective studies aiming at validating the suggested strategies through the implementation of prospective trauma databases and the subsequent production of internationally endorsed guidelines on the issue.
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Affiliation(s)
- Mauro Podda
- Department of Surgical Science, Emergency Surgery Unit, University of Cagliari, Cagliari, Italy.
| | - Belinda De Simone
- Department of Emergency, Digestive and Metabolic Minimally Invasive Surgery, Poissy and Saint Germain en Laye Hospitals, Poissy, France
| | - Marco Ceresoli
- General and Emergency Surgery Department, School of Medicine and Surgery, Milano-Bicocca University, Monza, Italy
| | - Francesco Virdis
- Trauma and Acute Care Surgery Department, Niguarda Hospital, Milan, Italy
| | - Francesco Favi
- Department of Emergency and Trauma Surgey, Bufalini Trauma Center, Cesena, Italy
| | - Johannes Wiik Larsen
- Department of Gastrointestinal Surgery, Stavanger University Hospital University of Bergen, Stavanger, Norway
| | - Federico Coccolini
- General, Emergency and Trauma Surgery Department, Pisa University Hospital, Pisa, Italy
| | | | - Nikolaos Pararas
- Department of General Surgery, Dr Sulaiman Al Habib/Alfaisal University, Riyadh, Saudi Arabia
| | - Solomon Gurmu Beka
- School of Medicine and Health Science, University of Otago, Wellington Campus, Wellington, New Zealand
| | - Luigi Bonavina
- Division of General Surgery, IRCCS Policlinico San Donato, University of Milan, Milan, Italy
| | - Raffaele Bova
- Department of Emergency and Trauma Surgey, Bufalini Trauma Center, Cesena, Italy
| | - Adolfo Pisanu
- Department of Surgical Science, Emergency Surgery Unit, University of Cagliari, Cagliari, Italy
| | - Fikri Abu-Zidan
- Department of Applied Statistics, The Research Office, College of Medicine and Health Sciences United Arab Emirates University, Abu Dhabi, UAE
| | - Zsolt Balogh
- Department of Traumatology, John Hunter Hospital and University of Newcastle, Newcastle, NSW, Australia
| | - Osvaldo Chiara
- Trauma and Acute Care Surgery Department, Niguarda Hospital, Milan, Italy
| | | | - Philip Stahel
- Department of Surgery, East Carolina University, Brody School of Medicine, Greenville, USA
| | - Salomone Di Saverio
- Department of Surgery, San Benedetto del Tronto Hospital, AV5, San Benedetto del Tronto, Italy
| | - Thomas Scalea
- Shock Trauma Center, University of Maryland School of Medicine, Baltimore, USA
| | - Kjetil Soreide
- Department of Gastrointestinal Surgery, Stavanger University Hospital University of Bergen, Stavanger, Norway
| | - Boris Sakakushev
- Research Institute of Medical University Plovdiv/University Hospital St George Plovdiv, Plovdiv, Bulgaria
| | - Francesco Amico
- Trauma Service, John Hunter Hospital, Newcastle, Australia.,The University of Newcastle, Newcastle, Australia
| | - Costanza Martino
- Department of Anesthesiology and Acute Care, Umberto I Hospital of Lugo, Ausl della Romagna, Lugo, Italy
| | - Andreas Hecker
- Department of General and Thoracic Surgery, University Hospital of Giessen, Giessen, Germany
| | - Nicola de'Angelis
- Unit of General Surgery, Henri Mondor Hospital, UPEC, Créteil, France
| | - Mircea Chirica
- Service de Chirurgie Digestive, Centre Hospitalier Universitaire Grenoble Alpes, Grenoble, France
| | - Joseph Galante
- Trauma Department, University of California, Davis, Sacramento, CA, USA
| | - Andrew Kirkpatrick
- General, Acute Care and Trauma Surgery Foothills Medical Centre, University of Calgary, Calgary, AB, Canada
| | - Emmanouil Pikoulis
- General Surgery, Hospital, National and Kapodistrian University of Athens (NKUA), Athens, Greece
| | - Yoram Kluger
- Division of General Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Denis Bensard
- Department of Surgery, Denver Health Medical Center, Denver, CO, USA
| | - Luca Ansaloni
- Unit of General Surgery, San Matteo Hospital, Pavia, Italy
| | - Gustavo Fraga
- Division of Trauma Surgery, University of Campinas, Campinas, SP, Brazil
| | - Ian Civil
- Director of Trauma Services, Auckland City Hospital, Auckland, New Zealand
| | | | - Isidoro Di Carlo
- Department of Surgical Sciences and Advanced Technologies, University of Catania, Catania, Italy
| | - Yunfeng Cui
- Department of Surgery, Tianjin Nankai Hospital, Nankai Clinical School of Medicine, Tianjin Medical University, Tianjin, China
| | - Raul Coimbra
- Riverside University Health System Medical Center, Moreno Valley, CA, USA
| | - Vanni Agnoletti
- Anesthesia and Intensive Care Unit, AUSL Romagna, M. Bufalini Hospital, Cesena, Italy
| | - Ibrahima Sall
- Department of General Surgery, Military Teaching Hospital, Hôpital Principal Dakar, Dakar, Senegal
| | - Edward Tan
- Department of Surgery, Radboudumc, Nijmegen, The Netherlands
| | - Edoardo Picetti
- Department of Anesthesia and Intensive Care, Parma University Hospital, Parma, Italy
| | - Andrey Litvin
- Department of Surgical Disciplines, Immanuel Kant Baltic Federal University, Regional Clinical Hospital, Kaliningrad, Russia
| | | | - Kenji Inaba
- University of Southern California, Los Angeles, USA
| | - Jeffrey Leung
- Division of Surgery and Interventional Science, University College London (UCL), London, UK.,Milton Keynes University Hospital, Milton Keynes, UK
| | | | - Walt Biffl
- Division of Trauma and Acute Care Surgery, Scripps Clinic Medical Group, La Jolla, La Jolla, CA, USA
| | - Ari Leppaniemi
- Abdominal Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Ernest Moore
- Ernest E. Moore Shock Trauma Center, University of Colorado School of Medicine, Denver, CO, USA
| | - Kurinchi Gurusamy
- Division of Surgery and Interventional Science, University College London (UCL), London, UK
| | - Fausto Catena
- Department of Emergency and Trauma Surgey, Bufalini Trauma Center, Cesena, Italy
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Stevens J, Phillips R, Meier M, Reppucci ML, Acker S, Shahi N, Shirek G, Bensard D, Moulton S. Novel tool (BIS) heralds the need for blood transfusion and/or failure of non-operative management in pediatric blunt liver and spleen injuries. J Pediatr Surg 2022; 57:202-207. [PMID: 34756419 DOI: 10.1016/j.jpedsurg.2021.09.043] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 09/10/2021] [Accepted: 09/21/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND Non-operative management (NOM) is the standard of care for the majority of children with blunt liver and spleen injuries (BLSI). The shock index pediatric age-adjusted (SIPA) was previously shown to predict the need for blood transfusions in pediatric trauma patients with BLSI. We combined SIPA with base deficit (BD) and International Normalized Ratio (INR) to create the BIS score. We hypothesized that the BIS score would predict the need for blood transfusions and/or failure of NOM in pediatric trauma patients with BLSI. METHODS Patients (≤ 18 years) who presented to our Level I pediatric trauma center with BLSI from 2009 to 2019 were identified. BIS scores were calculated by giving 1 point for each of the following: base deficit ≤ -8.8, INR ≥ 1.5, or elevated SIPA. Receiver operating characteristic curves (ROC) were generated for BIS scores ≥ 1, ≥ 2, and ≥ 3. Area under the curve (AUC), sensitivity, and specificity of each score were calculated for ability to predict need for blood transfusions and/or failure of NOM. RESULTS Of 477 children included, 19.9% required a blood transfusion and 6.7% failed NOM. A BIS score ≥ 1 was the best predictor of the need for blood transfusions with an AUC of 0.81 and a sensitivity of 96.0%. A BIS score ≥ 1 was also the best predictor of failure of NOM with an AUC of 0.72 and a sensitivity of 97.0%. CONCLUSION The BIS score is a highly sensitive tool that identifies pediatric patients with BLSI at risk for blood transfusions and/or failure of NOM. LEVEL OF EVIDENCE Level III. TYPE OF STUDY Retrospective comparative study.
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Affiliation(s)
- Jenny Stevens
- Division of Pediatric Surgery, Children's Hospital Colorado, 13213 E 16th Ave, Box 323, Anschutz Medical Campus, Aurora, CO 80045, United States; Department of Surgery, University of Colorado School of Medicine, Aurora, CO, United States.
| | - Ryan Phillips
- Division of Pediatric Surgery, Children's Hospital Colorado, 13213 E 16th Ave, Box 323, Anschutz Medical Campus, Aurora, CO 80045, United States; Department of Surgery, University of Colorado School of Medicine, Aurora, CO, United States
| | - Maxene Meier
- The Center for Research in Outcomes for Children's Surgery, Center for Children's Surgery, University of Colorado School of Medicine, Aurora, CO, United States
| | - Marina L Reppucci
- Division of Pediatric Surgery, Children's Hospital Colorado, 13213 E 16th Ave, Box 323, Anschutz Medical Campus, Aurora, CO 80045, United States; Department of Surgery, University of Colorado School of Medicine, Aurora, CO, United States
| | - Shannon Acker
- Division of Pediatric Surgery, Children's Hospital Colorado, 13213 E 16th Ave, Box 323, Anschutz Medical Campus, Aurora, CO 80045, United States
| | - Niti Shahi
- Division of Pediatric Surgery, Children's Hospital Colorado, 13213 E 16th Ave, Box 323, Anschutz Medical Campus, Aurora, CO 80045, United States; Department of Surgery, University of Colorado School of Medicine, Aurora, CO, United States
| | - Gabrielle Shirek
- Division of Pediatric Surgery, Children's Hospital Colorado, 13213 E 16th Ave, Box 323, Anschutz Medical Campus, Aurora, CO 80045, United States; Department of Surgery, University of Colorado School of Medicine, Aurora, CO, United States
| | - Denis Bensard
- Division of Pediatric Surgery, Children's Hospital Colorado, 13213 E 16th Ave, Box 323, Anschutz Medical Campus, Aurora, CO 80045, United States
| | - Steven Moulton
- Division of Pediatric Surgery, Children's Hospital Colorado, 13213 E 16th Ave, Box 323, Anschutz Medical Campus, Aurora, CO 80045, United States
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Stevens J, Phillips R, Reppucci ML, Pickett K, Moore H, Bensard D. Does the mechanism matter? Comparing thrombelastography between blunt and penetrating pediatric trauma patients. J Pediatr Surg 2022; 57:1363-1369. [PMID: 34588132 DOI: 10.1016/j.jpedsurg.2021.09.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Revised: 06/25/2021] [Accepted: 09/10/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND/PURPOSE The utility of thrombelastography (TEG) in pediatric trauma remains unknown, and differences in coagulopathy between blunt and penetrating mechanisms are not established. We aimed to compare TEG patterns in pediatric trauma patients with blunt solid organ injuries (BSOI) and penetrating injuries to determine the role of mechanism in coagulopathy. METHODS Highest-level pediatric trauma activations with BSOI or penetrating injuries and admission TEG at two pediatric trauma centers were included. TEG abnormalities were defined by each institution's normative values and compared separately by injury mechanism and evidence of shock (elevated SIPA) using Kruskal-Wallis or Fisher's exact tests. RESULTS Of 118 patients included, 64 had BSOI and 54 had penetrating injuries. There were no significant differences in TEG abnormalities between the BSOI and penetrating injury groups. Patients with shock were more likely to have decreased alpha-angles (30.9% vs. 8.0%, p = 0.01) and decreased maximum amplitude (MA) (44.1% vs. 8.0%, p < 0.001) compared to those without shock, regardless of mechanism of injury. CONCLUSIONS TEG abnormalities were not significantly different between the BSOI and penetrating groups, but there were significant differences in alpha-angle and MA in those with shock, independent of mechanism. Hemodynamic status, rather than mechanism of injury, may be more predictive of coagulopathy in pediatric trauma patients. LEVEL OF EVIDENCE/STUDY TYPE Level III, retrospective.
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Affiliation(s)
- Jenny Stevens
- Division of Pediatric Surgery, Department of General Surgery, Children's Hospital Colorado Anschutz Medical Campus, University of Colorado, 13123 E 16th Ave, Aurora, CO 80045, USA; Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA.
| | - Ryan Phillips
- Division of Pediatric Surgery, Department of General Surgery, Children's Hospital Colorado Anschutz Medical Campus, University of Colorado, 13123 E 16th Ave, Aurora, CO 80045, USA; Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Marina L Reppucci
- Division of Pediatric Surgery, Department of General Surgery, Children's Hospital Colorado Anschutz Medical Campus, University of Colorado, 13123 E 16th Ave, Aurora, CO 80045, USA; Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Kaci Pickett
- The Center for Research in Outcomes for Children's Surgery, Center for Children's Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Hunter Moore
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA; Department of Surgery, Denver Health Medical Center, Denver, CO, USA
| | - Denis Bensard
- Division of Pediatric Surgery, Department of General Surgery, Children's Hospital Colorado Anschutz Medical Campus, University of Colorado, 13123 E 16th Ave, Aurora, CO 80045, USA; Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA; Department of Surgery, Denver Health Medical Center, Denver, CO, USA
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Stevens J, Reppucci ML, Acker S, Bensard D, Moulton SL. Reply to Letter to the Editor: Pediatric massive transfusion protocols applied to intraoperative complications of common pediatric surgeries. J Pediatr Surg 2022; 57:1172. [PMID: 35221035 DOI: 10.1016/j.jpedsurg.2022.01.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Accepted: 01/28/2022] [Indexed: 10/19/2022]
Affiliation(s)
- Jenny Stevens
- Division of Pediatric Surgery, Children's Hospital Colorado, Aurora, CO, United States; Department of Surgery, University of Colorado School of Medicine, Aurora, CO, United States.
| | - Marina L Reppucci
- Division of Pediatric Surgery, Children's Hospital Colorado, Aurora, CO, United States; Department of Surgery, University of Colorado School of Medicine, Aurora, CO, United States
| | - Shannon Acker
- Division of Pediatric Surgery, Children's Hospital Colorado, Aurora, CO, United States; Department of Surgery, University of Colorado School of Medicine, Aurora, CO, United States
| | - Denis Bensard
- Division of Pediatric Surgery, Children's Hospital Colorado, Aurora, CO, United States; Department of Surgery, University of Colorado School of Medicine, Aurora, CO, United States
| | - Steven L Moulton
- Division of Pediatric Surgery, Children's Hospital Colorado, Aurora, CO, United States; Department of Surgery, University of Colorado School of Medicine, Aurora, CO, United States
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Shahi N, Kaizer A, Stevens J, Phillips R, Acker SN, Choi YM, Shirek G, Bensard D, Bruny J, Dannull K, Moulton SL. A surgeon's predicament: Clinical predictors of surgery and mortality in neutropenic enterocolitis. J Pediatr Surg 2022; 57:443-449. [PMID: 34635341 DOI: 10.1016/j.jpedsurg.2021.08.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Revised: 08/16/2021] [Accepted: 08/26/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Neutropenic enterocolitis is uncommon but potentially life-threatening, with the cornerstone of treatment being medical management (MM), and surgical intervention reserved for clinical deterioration or bowel perforation. We hypothesized that the Shock Index Pediatric Age-Adjusted (SIPA) is elevated in patients who are at greatest risk for surgical intervention and mortality. We also sought to identify computed tomography (CT) findings associated with surgical intervention and mortality. METHODS A single-center cancer registry was reviewed for neutropenic enterocolitis patients from 2006 -2018. Survival models compared patients with normal versus elevated SIPA throughout their hospitalizations for the time to surgical management (SM), as well as in-hospital mortality. RESULTS Seventy-four patients with neutropenic enterocolitis were identified; 7 underwent surgery. In-hospital mortality was 12% in MM and 29% in SM; mortality among patients with elevated SIPA was 4.7 times higher compared to those with normal SIPA (95% CI: 1.1, 19.83, p = 0.04). CT findings of bowel obstruction, pneumatosis, and a greater percentage of large bowel involvement were associated with surgical intervention (all ps < 0.05). CONCLUSION Select pre-operative CT findings were associated with need for operative management. Elevated SIPA was associated with increased mortality. Elevated SIPA in pediatric cancer patients with neutropenic enterocolitis may help to identify those with more severe disease and expedite beneficial interventions.
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Affiliation(s)
- Niti Shahi
- Division of Pediatric Surgery, Children's Hospital Colorado, Aurora, CO, United States; Department of Surgery, University of Colorado School of Medicine, Aurora, CO, United States; Department of Surgery, University of Massachusetts School of Medicine, 55 Lake Avenue North, Worcester, MA 01655, United States.
| | - Alexander Kaizer
- The Center for Research in Outcomes for Children's Surgery, University of Colorado School of Medicine, Aurora, CO, United States
| | - Jenny Stevens
- Division of Pediatric Surgery, Children's Hospital Colorado, Aurora, CO, United States; Department of Surgery, University of Colorado School of Medicine, Aurora, CO, United States
| | - Ryan Phillips
- Division of Pediatric Surgery, Children's Hospital Colorado, Aurora, CO, United States; Department of Surgery, University of Colorado School of Medicine, Aurora, CO, United States
| | - Shannon N Acker
- Division of Pediatric Surgery, Children's Hospital Colorado, Aurora, CO, United States; Department of Surgery, University of Colorado School of Medicine, Aurora, CO, United States
| | - Young Mee Choi
- Department of Surgery, Rutgers New Jersey Medical School, Newark, NJ, United States
| | - Gabrielle Shirek
- Division of Pediatric Surgery, Children's Hospital Colorado, Aurora, CO, United States
| | - Denis Bensard
- Division of Pediatric Surgery, Children's Hospital Colorado, Aurora, CO, United States; Department of Surgery, University of Colorado School of Medicine, Aurora, CO, United States; Department of Surgery, Denver Health Medical Center, Denver, CO, United States
| | - Jennifer Bruny
- Division of Pediatric Surgery, Children's Hospital Colorado, Aurora, CO, United States; Department of Surgery, University of Colorado School of Medicine, Aurora, CO, United States
| | - Kimberly Dannull
- Department of Radiology, Children's Hospital Colorado, Aurora, CO, United States
| | - Steven L Moulton
- Division of Pediatric Surgery, Children's Hospital Colorado, Aurora, CO, United States; Department of Surgery, University of Colorado School of Medicine, Aurora, CO, United States
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8
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Phillips R, Shahi N, Acker SN, Meier M, Shirek G, Stevens J, Recicar J, Moulton S, Bensard D. Not as simple as ABC: Tools to trigger massive transfusion in pediatric trauma. J Trauma Acute Care Surg 2022; 92:422-427. [PMID: 34538826 DOI: 10.1097/ta.0000000000003412] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Early and accurate identification of pediatric trauma patients who will receive massive transfusion (MT) is not well established. We developed the ABCD (defined as penetrating mechanism, positive focused assessment with sonography for trauma, shock index, pediatric age-adjusted [SIPA], lactate, and base deficit [BD]) and BIS scores (defined as a combination of BD, international normalized ratio [INR], and SIPA) and hypothesized that the BIS score would perform best in the ability to predict the need for MT in children. METHODS Pediatric trauma patients (≤18 years old) admitted to our trauma center between 2008 and 2019 were identified. Using a receiver operator curve, we defined cutoff points for lactate (≥3.2), BD (≤-6.9), and INR (≥1.4). ABCD scores were calculated by combining penetrating mechanism; positive focused assessment with sonography for trauma examination; SIPA; lactate; and BD. BIS scores were calculated by combining BD, INR, and SIPA. The sensitivity, specificity, and accuracy of each score were calculated based on receiving MT. RESULTS Seven hundred seventy-two patients were included, of which 59 (7.6%) underwent MT. The best predictor of receiving MT was achieved by a BIS score of ≥2 that was 98% sensitive and 23% specific with an area under the curve of 0.81. The ABCD score of ≥2 was 97% sensitive and 20% specific with an area under the curve of 0.77. CONCLUSION The BIS score, which takes into account derangements in acidosis, coagulopathy, and SIPA, is accurate and easy to perform and can be incorporated into a simple bedside screening tool for triggering MT in pediatric trauma patients. LEVEL OF EVIDENCE Diagnostic Tests or Criteria, Level IV.
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Affiliation(s)
- Ryan Phillips
- From the Division of Pediatric Surgery (R.P., N.S., S.N.A., G.S., J.S., J.R., S.M., D.B.), Children's Hospital Colorado; Department of Surgery (R.P., N.S., S.N.A., G.S., J.S., S.M., D.B.) and Center for Research in Outcomes for Children's Surgery (M.M.), Center for Children's Surgery, University of Colorado School of Medicine; Division of Nursing (J.R.), Children's Hospital Colorado, Aurora; and Department of Surgery (D.B.), Denver Health Medical Center, Denver, Colorado
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9
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Stevens J, Reppucci ML, Meier M, Phillips R, Shahi N, Shirek G, Acker S, Bensard D, Moulton S. Pre-hospital and emergency department shock index pediatric age-adjusted (SIPA) "cut points" to identify pediatric trauma patients at risk for massive transfusion and/or mortality. J Pediatr Surg 2022; 57:302-307. [PMID: 34753559 DOI: 10.1016/j.jpedsurg.2021.09.053] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Accepted: 09/27/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND Shock index pediatric age-adjusted (SIPA) is a validated measure to identify severely injured children. Previous literature categorized SIPA as normal or elevated, but the relationship between specific SIPA values and outcomes has not been determined. We sought to determine specific SIPA cut points in the pre-hospital and Emergency Department (ED) settings to identify patients at risk for massive transfusion (MT) and/or mortality. METHODS Patients ≤ 18 years old admitted to our Level I pediatric trauma center following trauma activation were included. Youdin J index was used to define pre-hospital and ED SIPA cut points to identify those at risk of MT and/or mortality for the following age groups: < 1 year, 1-6 years, 7-12 years, and > 12 years old. Sensitivity, specificity, accuracy, and area under the curve (AUC) were calculated to determine SIPA threshold values associated with MT and/or mortality. RESULTS Of 1,072 patients, 6.3% (n = 68) required MT and 8.4% (n = 90) died. For predicting MT, pre-hospital SIPA cut points performed best in the > 12 year-old age group (AUC = 0.86) and ED SIPA cut points performed best in the 6-12 year-old age group (AUC = 0.87). For predicting mortality, pre-hospital (AUC = 0.78) and ED SIPA cut points (AUC = 0.84) performed best in the > 12 year-old age group. CONCLUSION Pre-hospital and ED SIPA cut points performed better at predicting MT and/or mortality in older pediatric patients compared to very young children. Age remains an important factor when determining the validity of SIPA to predict outcomes in pediatric trauma patients. STUDY TYPE/LEVEL OF EVIDENCE Level III, Retrospective Cohort Study.
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Affiliation(s)
- Jenny Stevens
- Division of Pediatric Surgery, Children's Hospital Colorado, 13213 E 16th Ave, Box 323, Anschutz Medical Campus, Aurora, CO 80045, USA; Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA.
| | - Marina L Reppucci
- Division of Pediatric Surgery, Children's Hospital Colorado, 13213 E 16th Ave, Box 323, Anschutz Medical Campus, Aurora, CO 80045, USA; Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Maxene Meier
- The Center for Research in Outcomes for Children's Surgery, Center for Children's Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Ryan Phillips
- Division of Pediatric Surgery, Children's Hospital Colorado, 13213 E 16th Ave, Box 323, Anschutz Medical Campus, Aurora, CO 80045, USA; Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Niti Shahi
- Division of Pediatric Surgery, Children's Hospital Colorado, 13213 E 16th Ave, Box 323, Anschutz Medical Campus, Aurora, CO 80045, USA; Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Gabrielle Shirek
- Division of Pediatric Surgery, Children's Hospital Colorado, 13213 E 16th Ave, Box 323, Anschutz Medical Campus, Aurora, CO 80045, USA
| | - Shannon Acker
- Division of Pediatric Surgery, Children's Hospital Colorado, 13213 E 16th Ave, Box 323, Anschutz Medical Campus, Aurora, CO 80045, USA; Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Denis Bensard
- Division of Pediatric Surgery, Children's Hospital Colorado, 13213 E 16th Ave, Box 323, Anschutz Medical Campus, Aurora, CO 80045, USA; Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Steven Moulton
- Division of Pediatric Surgery, Children's Hospital Colorado, 13213 E 16th Ave, Box 323, Anschutz Medical Campus, Aurora, CO 80045, USA; Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
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10
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Diaz-Miron J, Reppucci ML, Weinman J, Kaizer A, Annam A, Orsborn J, Steward L, Wilson J, Bensard D. The use of ultrasound in establishing COVID-19 infection as part of a trauma evaluation. Emerg Radiol 2022; 29:227-234. [PMID: 34988751 PMCID: PMC8731214 DOI: 10.1007/s10140-021-02005-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Accepted: 11/29/2021] [Indexed: 11/25/2022]
Abstract
Purpose The use of lung ultrasound for diagnosis of COVID-19 has emerged during the pandemic as a beneficial diagnostic modality due to its rapid availability, bedside use, and lack of radiation. This study aimed to determine if routine ultrasound (US) imaging of the lungs of trauma patients with COVID-19 infections who undergo extended focused assessment with sonography for trauma (EFAST) correlates with computed tomography (CT) imaging and X-ray findings, as previously reported in other populations. Methods This was a prospective, observational feasibility study performed at two level 1 trauma centers. US, CT, and X-ray imaging were retrospectively reviewed by a surgical trainee and a board-certified radiologist to determine any correlation of imaging findings in patients with active COVID-19 infection. Results There were 53 patients with lung US images from EFAST available for evaluation and COVID-19 testing. The overall COVID-19 positivity rate was 7.5%. COVID-19 infection was accurately identified by one patient on US by the trainee, but there was a 15.1% false-positive rate for infection based on the radiologist examination. Conclusions Evaluation of the lung during EFAST cannot be used in the trauma setting to identify patients with active COVID-19 infection or to stratify patients as high or low risk of infection. This is likely due to differences in lung imaging technique and the presence of concomitant thoracic injury.
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Affiliation(s)
- Jose Diaz-Miron
- Division of Pediatric Surgery, Department of Surgery, Children's Hospital Colorado, University of Colorado School of Medicine, 13123 E 16th Ave, B-323, Aurora, CO, 80045, USA.
| | - Marina L Reppucci
- Division of Pediatric Surgery, Department of Surgery, Children's Hospital Colorado, University of Colorado School of Medicine, 13123 E 16th Ave, B-323, Aurora, CO, 80045, USA
| | - Jason Weinman
- Division of Pediatric Radiology, Department of Radiology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Alexander Kaizer
- Center for Innovative Design and Analysis, Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado, Aurora, CO, USA
| | - Aparna Annam
- Division of Pediatric Radiology, Department of Radiology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Jonathan Orsborn
- Division of Pediatric Emergency Medicine, Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Lauren Steward
- Division of Gastrointestinal, Trauma, and Endocrine Surgery, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Juliana Wilson
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Denis Bensard
- Division of Pediatric Surgery, Department of Surgery, Children's Hospital Colorado, University of Colorado School of Medicine, 13123 E 16th Ave, B-323, Aurora, CO, 80045, USA
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Stevens J, Pickett K, Moore H, Reppucci ML, Phillips R, Moulton S, Bensard D. Thrombelastography and transfusion patterns in severely injured pediatric trauma patients with blunt solid organ injuries. J Trauma Acute Care Surg 2022; 92:152-158. [PMID: 34446654 DOI: 10.1097/ta.0000000000003392] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Thrombelastography (TEG) has emerged as a useful tool to diagnose coagulopathy and guide blood product usage during trauma resuscitations. This study sought to evaluate the correlation between TEG-directed blood product administration in severely injured pediatric trauma patients with blunt solid organ injuries (BSOIs). METHODS Patients (≤18 years) with severe BSOIs who presented as highest-level trauma activations at two pediatric trauma centers were included. Thrombelastography results were evaluated to determine indications for blood product administration and rates of TEG-directed resuscitation. Tetrachoric correlations and regression modeling were used to correlate TEG-directed resuscitation with clinical outcomes. RESULTS Of 64 patients who met the inclusion criteria, 32.8% (21) had elevated R times and 23.4% (15) had shortened α angles. Maximum amplitude was shortened in 29.7% (19), and percent clot lysis 30 minutes after maximum amplitude that is >3% was seen in 17.0% (9). Thrombelastography-directed resuscitation of fresh frozen plasma was followed 54.7% of the time compared with 67.2% and 81.2% for platelets and cryoprecipitate, respectively. Thrombelastography-directed resuscitation with platelets (odds ratio, 0.56; 95% confidence interval, 0.33-0.93; p = 0.03) and/or cryoprecipitate (odds ratio, 0.09; 95% confidence interval, 0.01-0.42, p = 0.003) were associated with decreased hospital length of stay and mortality, respectively. CONCLUSION Severely injured pediatric trauma patients with BSOIs were often coagulopathic upon presentation to the emergency department. Thrombelastography-directed resuscitation with platelets and/or cryoprecipitate was followed for the majority of patients and was associated with improved outcomes. LEVEL OF EVIDENCE Therapeutic/Care Management, level III.
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Affiliation(s)
- Jenny Stevens
- From the Division of Pediatric Surgery (J.S., M.L.R., R.P., S.M., D.B.), Children's Hospital Colorado, Division of Pediatric Surgery, Department of Surgery (J.S., M.L.R., R.P., S.M., D.B.), and Center for Research in Outcomes for Children's Surgery (K.P.), Center for Children's Surgery, University of Colorado School of Medicine, Aurora; and Department of Surgery (H.M., D.B.), Denver Health Medical Center, Denver, Colorado
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12
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Reppucci ML, Phillips R, Meier M, Acker SN, Stevens J, Moulton SL, Bensard D. Pediatric age-adjusted shock index as a tool for predicting outcomes in children with or without traumatic brain injury. J Trauma Acute Care Surg 2021; 91:856-860. [PMID: 34695062 DOI: 10.1097/ta.0000000000003208] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The pediatric age-adjusted shock index (SIPA) accurately identifies severely injured children following trauma without accounting for neurological status. Understanding how the presence of traumatic brain injury (TBI) affects the generalizability of SIPA as a bedside triage tool is important given high rates of TBI in the pediatric trauma population. We hypothesized that SIPA combined with TBI (SIPAB+) would more accurately identify severely injured children. METHODS Patients (1-18 years old) in the American College of Surgeons Pediatric Trauma Quality Improvement Program database (2014-2017) with an elevated SIPA upon arrival to a pediatric trauma center were included. Pediatric age-adjusted shock index combined with TBI was defined as elevated SIPA with Glasgow Coma Scale score of ≤8. Pediatric age-adjusted shock index without TBI (SIPAB-) was defined as elevated SIPA with Glasgow Coma Scale score of >9. Patients were stratified into SIPAB+ and SIPAB-. A subanalysis of patients with isolated brain injury and those with brain injury and multisystem injuries was also performed. Data were compared through univariate models and three separate logistic regression models. RESULTS Overall, 25,068 had an elevated SIPA, with 12.3% classified as SIPAB+ and the remainder SIPAB-. Patients classified as SIPAB+ received more blood transfusions within 4 hours of injury and had higher mortality rates. On logistic regression, SIPAB+ patients had significantly higher odds of early blood transfusion and a combination of both. Mortality and early blood transfusion were also higher in SIPAB+ patients on subanalysis for patients with isolated TBI and those with multisystem injuries. CONCLUSION The use of SIPAB+ as a bedside triage tool accurately identifies traumatically injured children at high risk for early blood transfusion and/or death while incorporating the presence of neurological injury. This is true for patients with isolated TBI and those with multisystem injury, indicating its utility in predicting outcomes for TBI patients with elevated SIPA regardless of presence of concomitant injuries. Incorporation of this as a triage tool should be considered to better predict resources in this population. LEVEL OF EVIDENCE Prognostic, level III.
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Affiliation(s)
- Marina L Reppucci
- From the Pediatric Surgery (M.L.R., R.P., S.N.A., J.S., S.L.M., D.B.), Children's Hospital Colorado; Division of Pediatric Surgery, Department of Surgery (M.L.R., R.P., S.N.A., J.S., S.L.M., D.B.), University of Colorado School of Medicine; The Center for Research in Outcomes for Children's Surgery, Center for Children's Surgery (M.M.), University of Colorado School of Medicine, Aurora; and Department of Surgery (D.B.), Denver Health Medical Center, Denver, Colorado
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13
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Shahi N, Phillips R, Rodenburg C, Meier M, Shirek G, Recicar J, Moulton S, Bensard D. Combining Cribari matrix and Need For Trauma Intervention (NFTI) to accurately assess undertriage in pediatric trauma. J Pediatr Surg 2021; 56:1401-1404. [PMID: 32951889 DOI: 10.1016/j.jpedsurg.2020.08.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2020] [Revised: 08/07/2020] [Accepted: 08/16/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND/PURPOSE The American College of Surgeons (ACS) Committee on Trauma targets undertriage (UT) rates of <5% to optimize the chances of survival. The Cribari Matrix (CM) has traditionally been employed to identify undertriage, but it likely overestimates actual undertriage. An innovative tool called "Need For Trauma Intervention" (NFTI), demonstrates a more accurate assessment of undertriage in adults. We hypothesized that using the combination of CM and NFTI would more accurately identify UT in pediatric trauma patients, compared to CM alone. METHODS We reviewed undertriage rates using CM and NFTI criteria. Univariate analysis was used to compare the need for surgical management, transfusion requirements, ventilator days, ICU length of stay (LOS), hospital LOS, and hospital costs between CM, NFTI, and the combination of CM and NFTI. RESULTS Undertriage rates were 8.2% with CM and 4.6% with NFTI. When CM and NFTI were combined, the UT rate was 2.7%. Pediatric patients categorized as UT by the combination of CM and NFTI had significantly longer ICU Length of Stay (LOS) (p < 0.001), hospital LOS (p < 0.001), higher mortality rates (p = 0.004), and higher hospitalization costs (p < 0.001). CONCLUSIONS The combination of CM and NFTI identified UT in children, more accurately than CM or NFTI alone. Injured children who are undertriaged had higher mortality, morbidity, and cost of care. The use of CM in combination with NFTI to evaluate undertriage rates led to the identification of risk factors that may modify the activation criteria for highest and modified level trauma team activations. LEVEL OF EVIDENCE III STUDY TYPE: Retrospective study without negative criteria (Therapeutic/Care Management).
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Affiliation(s)
- Niti Shahi
- Department of Surgery, University of Colorado School of Medicine, 12631 E. 17th Avenue, C-305, Aurora, CO 80045; Department of Pediatric Surgery, Children's Hospital Colorado, 13123 E. 16(th) Ave., Aurora, CO 80045; Department of Surgery, Department of Surgery, University of Massachusetts School of Medicine, 55 Lake Avenue North, Worcester, MA 01655.
| | - Ryan Phillips
- Department of Surgery, University of Colorado School of Medicine, 12631 E. 17th Avenue, C-305, Aurora, CO 80045; Department of Pediatric Surgery, Children's Hospital Colorado, 13123 E. 16(th) Ave., Aurora, CO 80045
| | - Christen Rodenburg
- Department of Pediatric Surgery, Children's Hospital Colorado, 13123 E. 16(th) Ave., Aurora, CO 80045
| | - Maxene Meier
- Department of Pediatric Surgery, Children's Hospital Colorado, 13123 E. 16(th) Ave., Aurora, CO 80045; The Center for Research in Outcomes for Children's Surgery, Children's Hospital Colorado, 13123 E. 16(th) Ave., Aurora, CO 80045
| | - Gabrielle Shirek
- Department of Pediatric Surgery, Children's Hospital Colorado, 13123 E. 16(th) Ave., Aurora, CO 80045
| | - John Recicar
- Department of Pediatric Surgery, Children's Hospital Colorado, 13123 E. 16(th) Ave., Aurora, CO 80045; Division of Nursing, Children's Hospital Colorado, 13123 E. 16th Ave., Aurora, CO 80045
| | - Steven Moulton
- Department of Surgery, University of Colorado School of Medicine, 12631 E. 17th Avenue, C-305, Aurora, CO 80045; Department of Pediatric Surgery, Children's Hospital Colorado, 13123 E. 16(th) Ave., Aurora, CO 80045
| | - Denis Bensard
- Department of Surgery, University of Colorado School of Medicine, 12631 E. 17th Avenue, C-305, Aurora, CO 80045; Department of Pediatric Surgery, Children's Hospital Colorado, 13123 E. 16(th) Ave., Aurora, CO 80045; Department of Pediatric Surgery, Denver Health, 777 Bannock St, Denver, CO 80204
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Shahi N, Phillips R, Acker SN, Meier M, Goldsmith A, Shirek G, Ladd P, Moulton SL, Bensard D. Enough is enough: Radiation doses in children with gastrojejunal tubes. J Pediatr Surg 2021; 56:668-673. [PMID: 32921427 DOI: 10.1016/j.jpedsurg.2020.08.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 07/16/2020] [Accepted: 08/06/2020] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Many children with gastric feeding intolerance require postpyloric tube feeding via a gastrojejunal (GJ) tube. Placement or positioning of these tubes is typically a procedure with a low dose of radiation. Although the risk of developing cancer from radiation exposure owing to computed tomography scans is well-documented in children, the risk of cumulative radiation exposure owing to frequent GJ tube replacement often goes unnoticed in the clinical decision-making process. We sought to define the frequency and cost of GJ tube replacement, quantify the radiation doses associated with the initial placement and replacements, and assess the number of conversions to surgical jejunostomies. METHODS All pediatric patients who underwent GJ tube placement or replacement by Interventional Radiology (IR), surgery, and gastroenterology between 2010 and 2018 at a single center were reviewed. We evaluated the total cost of the initial placement and replacement of each GJ tube, the total number of replacements, and the cumulative radiation dose (mGy). RESULTS We identified 203 patients who underwent GJ tube placement and/or replacement, of which 150 had radiation data available. Patients underwent a median of five GJ tube replacement procedures, and there was a wide range in the number of replacements per patient, from zero to 88. Patients were exposed to a median cumulative dose of 6.0 mGy (IQR: 2.2, 22.6). Nine percent of patients with available radiation data were exposed to more than 50 mGy, solely from GJ tube replacements. The median cost per replacement was $1170. The sum of the cost of the replacements for dislodged GJs translated to more than $1.4 million during the study period. CONCLUSIONS Overall, the average dose per GJ replacement was 3.50 mGy among all patients with available data. Nine percent of patients (14/150) were exposed to greater than 50 mGy cumulative radiation solely from GJ replacements. Patients who receive more than 50 mGy of cumulative radiation dose, who undergo seven GJ tube replacements in one year, or two consecutive GJ tube replacement procedures with radiation doses exceeding 10 mGy (per replacement) should be considered for a surgical jejunostomy. LEVEL OF EVIDENCE IV TYPE OF STUDY: Treatment study.
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Affiliation(s)
- Niti Shahi
- Division of Pediatric Surgery, Children's Hospital Colorado, Aurora, CO, USA; Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA.
| | - Ryan Phillips
- Division of Pediatric Surgery, Children's Hospital Colorado, Aurora, CO, USA; Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Shannon N Acker
- Division of Pediatric Surgery, Children's Hospital Colorado, Aurora, CO, USA; Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Maxene Meier
- The Center for Research in Outcomes for Children's Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Adam Goldsmith
- Division of Pediatric Surgery, Children's Hospital Colorado, Aurora, CO, USA
| | - Gabrielle Shirek
- Division of Pediatric Surgery, Children's Hospital Colorado, Aurora, CO, USA
| | - Patricia Ladd
- Division of Pediatric Surgery, Children's Hospital Colorado, Aurora, CO, USA; Department of Radiology, Children's Hospital Colorado
| | - Steven L Moulton
- Division of Pediatric Surgery, Children's Hospital Colorado, Aurora, CO, USA; Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Denis Bensard
- Division of Pediatric Surgery, Children's Hospital Colorado, Aurora, CO, USA; Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA; Department of Surgery, Denver Health Medical Center, Denver, CO, USA
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Shahi N, Shahi AK, Phillips R, Shirek G, Bensard D, Moulton SL. Decision-making in pediatric blunt solid organ injury: A deep learning approach to predict massive transfusion, need for operative management, and mortality risk. J Pediatr Surg 2021; 56:379-384. [PMID: 33218680 DOI: 10.1016/j.jpedsurg.2020.10.021] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Accepted: 10/20/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND The principal triggers for intervention in the setting of pediatric blunt solid organ injury (BSOI) are declining hemoglobin values and hemodynamic instability. The clinical management of BSOI is, however, complex. We therefore hypothesized that state-of-art machine learning (computer-based) algorithms could be leveraged to discover new combinations of clinical variables that might herald the need for an escalation in care. We developed algorithms to predict the need for massive transfusion (MT), failure of non-operative management (NOM), mortality, and successful non-operative management without intervention, all within 4 hours of emergency department (ED) presentation. METHODS Children (≤18 years) who sustained a BSOI (liver, spleen, and/or kidney) between 2009 and 2018 were identified in the trauma registry at a pediatric level 1 trauma center. Deep learning models were developed using clinical values [vital signs, shock index-pediatric adjusted (SIPA), organ injured, and blood products received], laboratory results [hemoglobin, base deficit, INR, lactate, thromboelastography (TEG)], and imaging findings [focused assessment with sonography in trauma (FAST) and grade of injury on computed tomography scan] from pre-hospital to ED settings for prediction of MT, failure of NOM, mortality, and successful NOM without intervention. Sensitivity, specificity, accuracy, and area under the receiver operating characteristic curve (AUC) were used to evaluate each model's performance. RESULTS A total of 477 patients were included, of which 5.7% required MT (27/477), 7.2% failed NOM (34/477), 4.4% died (21/477), and 89.1% had successful NOM (425/477). The accuracy of the models in the validation set was as follows: MT (90.5%), failure of NOM (83.8%), mortality (91.9%), and successful NOM without intervention (90.3%). Serial vital signs, the grade of organ injury, hemoglobin, and positive FAST had low correlations with outcomes. CONCLUSION Deep learning-based models using a combination of clinical, laboratory and radiographic features can predict the need for emergent intervention (MT, angioembolization, or operative management) and mortality with high accuracy and sensitivity using data available in the first 4 hours of admission. Further research is needed to externally validate and determine the feasibility of prospectively applying this framework to improve care and outcomes. LEVEL OF EVIDENCE III STUDY TYPE: Retrospective comparative study (Prognosis/Care Management).
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Affiliation(s)
- Niti Shahi
- Division of Pediatric Surgery, Children's Hospital Colorado, Aurora, CO, USA; Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA; Department of Surgery, University of Massachusetts, Worcester, MA, USA.
| | - Ashwani K Shahi
- Division of Pediatric Surgery, Children's Hospital Colorado, Aurora, CO, USA
| | - Ryan Phillips
- Division of Pediatric Surgery, Children's Hospital Colorado, Aurora, CO, USA; Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Gabrielle Shirek
- Division of Pediatric Surgery, Children's Hospital Colorado, Aurora, CO, USA
| | - Denis Bensard
- Division of Pediatric Surgery, Children's Hospital Colorado, Aurora, CO, USA; Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA; Department of Surgery, Denver Health Medical Center, Denver, CO, USA
| | - Steven L Moulton
- Division of Pediatric Surgery, Children's Hospital Colorado, Aurora, CO, USA; Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
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Phillips R, Meier M, Shahi N, Acker S, Reppucci M, Shirek G, Recicar J, Moulton S, Bensard D. Elevated pediatric age-adjusted shock-index (SIPA) in blunt solid organ injuries. J Pediatr Surg 2021; 56:401-404. [PMID: 33358417 DOI: 10.1016/j.jpedsurg.2020.10.022] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2020] [Accepted: 10/20/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND/PURPOSE Shock index-pediatric age-adjusted (SIPA) is a proven tool to predict outcomes in blunt pediatric trauma. We hypothesized that an elevated SIPA in either the pre-hospital or in the emergency department (ED) would identify children with blunt liver or spleen injury (BLSI) needing a blood transfusion and those at risk for failure of non-operative management (NOM). METHODS Pediatric patients (1-18 years) in the ACS pediatric-TQIP database (2014-2016) with a BLSI were included. Patients were stratified by the need for a blood transfusion and/or abdominal operation. RESULTS A total of 3561 patients had BLSI, of which 4% received a blood transfusion, and 4% underwent an abdominal operation. Patients who received blood had higher ISS scores (27.0 vs. 5.0, p < 0.001) and mortality (22% vs. 0.4%, p < 0.001). Those who failed NOM had higher ISS scores (17.0 vs. 5.0, p < 0.001) and mortality (7.9% vs. 0.9%, p < 0.001). On multivariable regression, an elevated SIPA score in either pre-hospital or ED was significantly associated with blood transfusion (odds ratio (OR) 8.2, 95% confidence intervals (CI) 5.8-11.5, p < 0.001) and failure of NOM (OR 2.3, CI 1.5-3.4, p < 0.001). CONCLUSIONS Hemodynamic instability, represented by an elevated pre-hospital or ED SIPA, accurately identifies children with BLSI who may need blood products or an operative intervention. TYPE OF STUDY Retrospective Comparative Study. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Ryan Phillips
- Division of Pediatric Surgery, Children's Hospital Colorado, Aurora, CO, USA; Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA.
| | - Maxene Meier
- The Center for Research in Outcomes for Children's Surgery, Center for Children's Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Niti Shahi
- Division of Pediatric Surgery, Children's Hospital Colorado, Aurora, CO, USA; Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Shannon Acker
- Division of Pediatric Surgery, Children's Hospital Colorado, Aurora, CO, USA; Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Marina Reppucci
- Division of Pediatric Surgery, Children's Hospital Colorado, Aurora, CO, USA; Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Gabrielle Shirek
- Division of Pediatric Surgery, Children's Hospital Colorado, Aurora, CO, USA; Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - John Recicar
- Division of Pediatric Surgery, Children's Hospital Colorado, Aurora, CO, USA; Division of Nursing, Children's Hospital Colorado, Aurora, CO, USA
| | - Steven Moulton
- Division of Pediatric Surgery, Children's Hospital Colorado, Aurora, CO, USA; Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Denis Bensard
- Division of Pediatric Surgery, Children's Hospital Colorado, Aurora, CO, USA; Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA; Department of Surgery, Denver Health Medical Center, Denver, CO, USA
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Phillips R, Acker S, Shahi N, Shirek G, Meier M, Goldsmith A, Recicar J, Moulton S, Bensard D. The shock index, pediatric age-adjusted (SIPA) enhanced: Prehospital and emergency department SIPA values forecast transfusion needs for blunt solid organ injured children. Surgery 2020; 168:690-694. [DOI: 10.1016/j.surg.2020.04.061] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Revised: 04/12/2020] [Accepted: 04/27/2020] [Indexed: 11/25/2022]
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Shahi N, Phillips R, Meier M, Nehler M, Jacobs D, Recicar J, Bensard D, Moulton S. Anti-coagulation management in pediatric traumatic vascular injuries. J Pediatr Surg 2020; 55:324-330. [PMID: 31732119 DOI: 10.1016/j.jpedsurg.2019.10.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Accepted: 10/17/2019] [Indexed: 11/19/2022]
Abstract
BACKGROUND Pediatric traumatic vascular injuries are rare. Given the paucity of data to guide anti-coagulation (AC) management of these injuries in children, who have a lower overall risk for thrombosis compared to their adult counterparts, we sought to examine and summarize our recent experience. METHOD We conducted a retrospective review of all patients (<18 years old) who sustained traumatic vascular injuries between 2010-2018 at a Level 1 and Level 2 Pediatric Trauma Center. RESULTS Ninety-nine patients had traumatic vascular injuries. Eighty-four patients sustained a major arterial injury, 26 had a major venous injury, and 11 had both arterial and venous injuries. The arterial injury cohort had a median age of 13.3 years. Most of the arterial injury patients (65/84, 77%) required vascular repair. In-hospital AC management for the arterial injury patients consisted of a post-operative heparin drip (18%, 15/84), aspirin (39%, 26/84), enoxaparin (23%, 19/84), or none (42%, 43/84). Approximately one-half of the patients with arterial injuries (54%, 45/84) were discharged home on AC therapy, most commonly aspirin. Fifty-six patients (66%) followed up post-injury, of which 25% (14/56) had experienced complications. CONCLUSION Pediatric traumatic arterial injuries that require surgical intervention other than ligation should be considered for discharge AC - most commonly aspirin - in the absence of contraindications. Pediatric patients with vascular injuries to the aorta, carotid artery, inferior vena cava, portal vein, or lower extremities that are managed non-operatively should also be considered for AC. The preferred AC for pediatric venous injuries is enoxaparin, in the absence of contraindications. STUDY TYPE Treatment Study LEVEL OF EVIDENCE: IV.
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Affiliation(s)
- Niti Shahi
- Division of Pediatric Surgery, Children's Hospital Colorado, Aurora, CO, USA; Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA.
| | - Ryan Phillips
- Division of Pediatric Surgery, Children's Hospital Colorado, Aurora, CO, USA; Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Maxene Meier
- The Center for Research in Outcomes for Children's Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Mark Nehler
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Donald Jacobs
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - John Recicar
- Division of Pediatric Surgery, Children's Hospital Colorado, Aurora, CO, USA
| | - Denis Bensard
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA; Department of Surgery, Denver Health Medical Center, Denver, CO, USA
| | - Steven Moulton
- Division of Pediatric Surgery, Children's Hospital Colorado, Aurora, CO, USA; Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
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Phillips R, Acker SN, Shahi N, Meier M, Leopold D, Recicar J, Kulungowski A, Patrick D, Moulton S, Bensard D. The ABC-D score improves the sensitivity in predicting need for massive transfusion in pediatric trauma patients. J Pediatr Surg 2020; 55:331-334. [PMID: 31718872 DOI: 10.1016/j.jpedsurg.2019.10.008] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Accepted: 10/14/2019] [Indexed: 01/31/2023]
Abstract
PURPOSE Early and accurate identification of pediatric trauma patients who will require massive transfusion (MT) remains difficult, and MT activation criteria are not well established. In children, the addition of shock index-pediatric age-adjusted (SIPA) to the ABC score (ABC-S) only modestly improves the sensitivity of the ABC score. We hypothesized that the discriminate ability of the ABC-S score would improve with the addition of elevated serum lactate and base deficit (ABCD score). METHODS We identified children between 1 and 18 years old who received a pRBC transfusion between 2008 and 2018 from our trauma registry. We calculated sensitivity, specificity, and accuracy of the ABC, ABC-S, and ABCD scores to determine the need for MT. RESULTS We included 211 children, of which 66 required MT. The best predictor of MT was achieved by adding BD and lactate to the ABC-S score, with an AUC of 0.805. An ABCD score of 3 or greater was 77.4% sensitive and 78.8% specific at predicting the need for MT. Pediatric trauma patients that required MT had higher injury severity score (p = 0.005), lactate (p = 0.002), base deficit (p = <0.0001). Mortality was higher in the MT group (45.5% vs 15.3%, p = 0.0004). CONCLUSIONS The ABCD score improves the sensitivity of activating MT in pediatric trauma patients. STUDY TYPE Treatment Study. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Ryan Phillips
- Division of Pediatric Surgery, Children's Hospital Colorado, Aurora, CO, USA; Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA.
| | - Shannon N Acker
- Division of Pediatric Surgery, Children's Hospital Colorado, Aurora, CO, USA; Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Niti Shahi
- Division of Pediatric Surgery, Children's Hospital Colorado, Aurora, CO, USA; Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Maxene Meier
- Children's Hospital Center for Research in Outcomes for Children's Surgery, Children's Hospital Colorado, Aurora, CO, USA
| | - David Leopold
- Division of Pediatric Surgery, Children's Hospital Colorado, Aurora, CO, USA; Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - John Recicar
- Division of Pediatric Surgery, Children's Hospital Colorado, Aurora, CO, USA
| | - Ann Kulungowski
- Division of Pediatric Surgery, Children's Hospital Colorado, Aurora, CO, USA; Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA; Department of Surgery, Denver Health Medical Center, Denver, CO, USA
| | - David Patrick
- Division of Pediatric Surgery, Children's Hospital Colorado, Aurora, CO, USA; Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Steven Moulton
- Division of Pediatric Surgery, Children's Hospital Colorado, Aurora, CO, USA; Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Denis Bensard
- Division of Pediatric Surgery, Children's Hospital Colorado, Aurora, CO, USA; Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA; Department of Surgery, Denver Health Medical Center, Denver, CO, USA
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Nordin A, Coleman A, Shi J, Wheeler K, Xiang H, Acker S, Bensard D, Kenney B. Validation of the age-adjusted shock index using pediatric trauma quality improvement program data. J Pediatr Surg 2017; 53:S0022-3468(17)30645-0. [PMID: 29108845 DOI: 10.1016/j.jpedsurg.2017.10.023] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2017] [Accepted: 10/05/2017] [Indexed: 01/29/2023]
Abstract
PURPOSE In adults, shock index (SI; heart rate/systolic blood pressure) >0.9 predicts injury severity and trauma outcomes. However, age-adjusted shock index (SIPA) out-performs SI in blunt trauma patients 4-16years old. We sought to confirm these findings and expand this tool to include penetrating trauma and children aged 1-4years. METHODS We developed cutoff values for patients 1-3years old using age-based vital signs and queried the 2014 Pediatric Trauma Quality Improvement Program (TQIP) database for patients aged 1-16years sustaining blunt or penetrating trauma. Outcomes measured included injury severity, transfusion within 24h, intensive care unit (ICU) and hospital length of stay (LOS), and mortality. SI and SIPA were compared using Student's t-test and chi-square tests. RESULTS We identified 22,344 blunt and 613 penetrating trauma patients. SI was elevated in 41.3% and 40.0% of these groups, respectively, whereas SIPA was elevated in 15.6% and 19.4% of patients. SIPA was a significantly better predictor of transfusion needs, injury severity, ICU admission, ventilator use, and mortality for both blunt and penetrating trauma. CONCLUSION SIPA identifies severe injury and predicts transfusion needs and mortality more effectively than SI for both blunt and penetrating pediatric trauma. Further investigation should evaluate its use as a triage tool. TYPE OF STUDY Prognosis Study. LEVEL OF EVIDENCE II.
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Affiliation(s)
- Andrew Nordin
- Nationwide Children's Hospital, Department of Pediatric Surgery, Columbus, OH; State University of New York University at Buffalo, Department of General Surgery, Buffalo, NY
| | - Alan Coleman
- Nationwide Children's Hospital, Department of Pediatric Surgery, Columbus, OH
| | - Junxin Shi
- Center for Pediatric Trauma Research, The Research Institute at Nationwide Children's Hospital, Columbus, OH; Center for Injury Research and Policy, The Research Institute at Nationwide Children's Hospital, Columbus, OH
| | - Krista Wheeler
- Center for Pediatric Trauma Research, The Research Institute at Nationwide Children's Hospital, Columbus, OH; Center for Injury Research and Policy, The Research Institute at Nationwide Children's Hospital, Columbus, OH
| | - Henry Xiang
- Center for Injury Research and Policy, The Research Institute at Nationwide Children's Hospital, Columbus, OH; The Ohio State University College of Medicine, Columbus, OH
| | - Shannon Acker
- University of Colorado, Department of General Surgery, Aurora, CO
| | - Denis Bensard
- Denver Health Medical Center, Department of Surgery, Denver, CO
| | - Brian Kenney
- Nationwide Children's Hospital, Department of Pediatric Surgery, Columbus, OH; Center for Pediatric Trauma Research, The Research Institute at Nationwide Children's Hospital, Columbus, OH.
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Stewart C, Pyle L, Smith D, Bensard D, Moulton S, Reiter S. 0019 Mapping injury data to inform targeted approaches to prevention. Inj Prev 2015. [DOI: 10.1136/injuryprev-2015-041602.17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Boatright DH, Byyny RL, Hopkins E, Bakes K, Hissett J, Tunson J, Easter JS, Sasson C, Vogel JA, Bensard D, Haukoos JS. Validation of rules to predict emergent surgical intervention in pediatric trauma patients. J Am Coll Surg 2013; 216:1094-102, 1102.e1-6. [PMID: 23623222 DOI: 10.1016/j.jamcollsurg.2013.02.013] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2012] [Revised: 01/27/2013] [Accepted: 02/12/2013] [Indexed: 11/18/2022]
Abstract
BACKGROUND Trauma centers use guidelines to determine when a trauma surgeon is needed in the emergency department (ED) on patient arrival. A decision rule from Loma Linda University identified patients with penetrating injury and tachycardia as requiring emergent surgical intervention. Our goal was to validate this rule and to compare it with the American College of Surgeons' Major Resuscitation Criteria (MRC). STUDY DESIGN We used data from 1993 through 2010 from 2 level 1 trauma centers in Denver, CO. Patient demographics, injury severity, times of ED arrival and surgical intervention, and all variables of the Loma Linda Rule and the MRC were obtained. The outcome, emergent intervention (defined as requiring operative intervention by a trauma surgeon within 1 hour of arrival to the ED or performance of cricothyroidotomy or thoracotomy in the ED), was confirmed using standardized abstraction. Sensitivities, specificities, and 95% confidence intervals were calculated. RESULTS There were 8,078 patients included, and 47 (0.6%) required emergent intervention. Of the 47 patients, the median age was 11 years (interquartile range [IQR] 7 to 14 years), 70% were male, 30% had penetrating mechanisms, and the median Injury Severity Score (ISS) was 25 (IQR 9 to 41). At the 2 institutions, the Loma Linda Rule had a sensitivity and specificity of 69% (95% CI 45% to 94%) and 76% (95% CI 69% to 83%), respectively, and the MRC had a sensitivity and specificity of 80% (95% CI 70% to 92%) and 81% (95% CI 77% to 85%), respectively. CONCLUSIONS Emergent surgical intervention is rare in the pediatric trauma population. Although precision of predictive accuracies of the Loma Linda Rule and MRC were limited by small numbers of outcomes, neither set of criteria appears to be sufficiently accurate to recommend their routine use.
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Affiliation(s)
- Dowin H Boatright
- Department of Emergency Medicine, Denver Health Medical Center, Denver, CO 80204, USA
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Abstract
BACKGROUND Sentinel lymph node (SLN) status is the strongest predictor of survival in adult melanoma. However, the prognostic value of SLN status in children and adolescents with melanoma is unknown. METHODS Records of 327 patients aged 12 to 86 years undergoing SLN biopsy for melanoma or other melanocytic lesions were reviewed. A literature search identified additional patients younger than 21 years undergoing SLN biopsy for the same indications and these patients were combined with our series for meta-analysis. RESULTS Sentinel lymph node metastases were found in 8 (40%) of 20 patients aged 12 to 20 years compared with 55 (18%) of 307 adults (P < .05). Median follow-up was 35 and 17 months for the groups, respectively. Sentinel lymph node-positive pediatric patients did not recur, whereas 14 (25%) adults recurred within this period. Of the 55 adults, 5 (9.1%) have died of disease. Of the combined SLN-positive children and adolescents from the literature (total n = 25), only a single (4%) child recurred at 6 months. The difference in survival for adult and pediatric patients was significant. CONCLUSION Pediatric patients have a higher incidence of SLN metastases than adults yet have a lower incidence of recurrence. Sentinel lymph node status does not predict early recurrence in pediatric patients with melanoma or atypical Spitz nevi.
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Affiliation(s)
- J Brent Roaten
- Department of Surgery, University of Colorado Health Science Center, Denver, CO 80262, USA
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Wachtel TL, Coniglio R, Bourg P, Hawkes A, Knight S, Mayer K, Bensard D. The synergistic relationship between a level I trauma center and a regional pediatric trauma center. Semin Pediatr Surg 2001; 10:38-43. [PMID: 11172573 DOI: 10.1053/spsu.2001.19394] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
A regional pediatric trauma center and a level I trauma center with pediatric commitment in the same city developed a synergistic relationship addressing all aspects of care for pediatric trauma patients. Although it is unlikely that this model could be used in its entirety by all similar institutions, the principles may prove helpful in creating guidelines and relationships. Categorization, optimal use of resources, timely transportation of seriously injured children to the appropriate facility, and maintaining urgent care capabilities of each institution to care for seriously injured children are imperative. The combined effort resulted in our level I trauma center being verified by the American College of Surgeons and designated by our state Health Department as meeting all the criteria for pediatric trauma care. This experience should encourage every pediatric trauma center located in a children's hospital to become a regional pediatric trauma center. The real benefit from the relationship is that injured children receive optimal care at both institutions.
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Affiliation(s)
- T L Wachtel
- St Anthony Central Hospital, Denver, CO, USA
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Garrington T, Silliman CC, Bensard D, Ingram JD. Response to successful management of a child with asparaginase- induced hemorrhagic pancreatitis. Med Pediatr Oncol 1998; 31:127. [PMID: 9714616 DOI: 10.1002/(sici)1096-911x(199808)31:2<127::aid-mpo19>3.0.co;2-k] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- T Garrington
- University of Colorado School of Medicine, Denver, Colorado
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Abstract
BACKGROUND Octreotide is a synthetic somatostatin analogue which has been suggested for use in the management of acute pancreatitis. While studies have looked at octreotide use in the setting of pancreatitis due to chronic alcohol use or trauma, little is known of its role in management of drug induced acute pancreatitis; particularly in the pediatric setting. PATIENTS AND METHODS We present a case of a 5 1/2-year-old white female who developed severe, necrotizing, hemorrhagic pancreatitis with pseudocyst formation secondary to L-asparaginase use as a part of her therapy for acute lymphoblastic leukemia (ALL). She was managed initially with intravenous fluids, bowel rest, nasogastric suctioning, parenteral narcotices, and broad spectrum antibiotics. In addition, within 12 hours of admission to The Children's Hospital (TCH) in Denver, Colorado, she began therapy with octreotide (5 micrograms/kg/day IV divided b.i.d.). With this management, her pseudocyst decompressed without need for surgical intervention, her pancreatitis fully resolved, and she recovered full pancreatic function without any long-term sequelae. CONCLUSION Use of octreotide may have served a role in limiting the severity of the disease process in this case. Further studies need to be done to verify its usefulness in this setting.
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Affiliation(s)
- T Garrington
- Department of Pediatrics, University of Colorado School of Medicine, Denver, USA
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Hoffenberg EJ, Rothenberg SS, Bensard D, Sondheimer JM, Sokol RJ. Outcome after exploratory laparoscopy for unexplained abdominal pain in childhood. Arch Pediatr Adolesc Med 1997; 151:993-8. [PMID: 9343009 DOI: 10.1001/archpedi.1997.02170470027006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Abdominal pain in childhood is common yet frustrating when unexplained. OBJECTIVE To describe the clinical features and outcome of 8 children (6 girls and 2 boys; mean[+/- SD] age, 13 +/- 2 years) with unexplained abdominal pain who underwent exploratory laparoscopy. SETTING All 8 patients were examined at an academic pediatric gastroenterology center and referred for exploratory laparoscopy because of unexplained abdominal pain. Laparoscopy was offered after family agreement to pursue behavioral management if the pain and disability did not improve. RESULTS In all 8 children, laparoscopy detected an anomaly at a site corresponding to that of the abdominal pain. Findings were adhesions in 7 children (3 colonic, 2 ileocecal, 1 gastric, and 1 appendiceal) and ovarian torsion in 1 child. At a mean follow-up of 12.6 months, the abdominal pain had completely resolved in 6 children, notably improved in 1 child, and continued unchanged in 1 child. Disability completely resolved in 2 of 3 children. CONCLUSIONS In children with unexplained abdominal pain that is acute in onset, well described, and suggestive of peritoneal involvement, exploratory laparoscopy (1) successfully ends the cycle of abdominal pain in most cases; and (2) commonly identifies abnormalities, usually adhesions. However, whether laparoscopy, the placebo effect, or both promote the healing process is unclear. Further study is needed to develop criteria for referral for laparoscopic evaluation of unexplained abdominal pain.
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Affiliation(s)
- E J Hoffenberg
- Department of Pediatrics, University of Colorado School of Medicine, Denver, USA
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