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Bennett EE, Aljabari S, Short S, Scaife E, Poss WB. Perioperative extracorporeal membrane oxygenation in traumatic bronchial avulsion. Journal of Pediatric Surgery Case Reports 2018. [DOI: 10.1016/j.epsc.2018.05.012] [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: 11/25/2022] Open
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Abstract
The authors present the first case of a Cushing ulcer in an infant with medulloblastoma who, despite being administered stress ulcer prophylaxis, worsened after corticosteroids were initiated. An 8-month-old boy presented with progressive vomiting, lethargy, and decreased oral intake. Imaging revealed a heterogeneous fourth ventricular mass. Preoperatively, the patient was started on dexamethasone. The patient underwent an uncomplicated external ventricular drain placement and suboccipital craniotomy for resection of the lesion. The results of the pathological analysis were consistent with medulloblastoma. Postoperatively, the patient had melanotic stools, which were reported to be occurring for months prior to presentation. Two proximal duodenal bulb ulcers were found and required definitive surgical repair. The patient recovered from the acute postsurgical course after continued stress ulcer prophylaxis and is currently undergoing chemotherapy.
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Affiliation(s)
- Walavan Sivakumar
- 1 Department of Neurosurgery, Division of Pediatric Neurosurgery, 2 Department of Surgery, Division of Pediatric Surgery, Primary Children's Hospital, University of Utah, Salt Lake City, Utah, USA
| | - Heather S Spader
- 1 Department of Neurosurgery, Division of Pediatric Neurosurgery, 2 Department of Surgery, Division of Pediatric Surgery, Primary Children's Hospital, University of Utah, Salt Lake City, Utah, USA
| | - Eric Scaife
- 1 Department of Neurosurgery, Division of Pediatric Neurosurgery, 2 Department of Surgery, Division of Pediatric Surgery, Primary Children's Hospital, University of Utah, Salt Lake City, Utah, USA
| | - Robert J Bollo
- 1 Department of Neurosurgery, Division of Pediatric Neurosurgery, 2 Department of Surgery, Division of Pediatric Surgery, Primary Children's Hospital, University of Utah, Salt Lake City, Utah, USA
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Jedrzkiewicz J, Scaife E, Hong B, South S, Alashari M. Congenital peribronchial myofibroblastic tumor: Case report and review of literature. Journal of Pediatric Surgery Case Reports 2015. [DOI: 10.1016/j.epsc.2015.02.012] [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: 10/23/2022] Open
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Stewart CL, Metzger RR, Pyle L, Darmofal J, Scaife E, Moulton SL. Helicopter versus ground emergency medical services for the transportation of traumatically injured children. J Pediatr Surg 2015; 50:347-52. [PMID: 25638635 DOI: 10.1016/j.jpedsurg.2014.09.040] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [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: 09/06/2014] [Accepted: 09/08/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND Helicopter emergency medical services (HEMS) are a common mode of transportation for pediatric trauma patients. We hypothesized that HEMS improve outcomes for traumatically injured children compared to ground emergency medical services (GEMS). METHODS We queried trauma registries of two level 1 pediatric trauma centers for children 0-17 years, treated from 2003 to 2013, transported by HEMS or GEMS, with known transport starting location and outcome. A geocoding service estimated travel distance and time. Multivariate regression analyses were performed to adjust for injury severity variables and travel distance/time. RESULTS We identified 14,405 traumatically injured children; 3870 (26.9%) transported by HEMS and 10,535 (73.1%) transported by GEMS. Transport type was not significantly associated with survival, ICU length of stay, or discharge disposition. Transport by GEMS was associated with a 68.6%-53.1% decrease in hospital length of stay, depending on adjustment for distance/time. Results were similar for children with severe injuries, and with propensity score matched cohorts. Of note, 862/3850 (22.3%) of HEMS transports had an ISS<10 and hospitalization<1 day. CONCLUSIONS HEMS do not independently improve outcomes for traumatically injured children, and 22.3% of children transported by HEMS are not significantly injured. These factors should be considered when requesting HEMS for transport of traumatically injured children.
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Affiliation(s)
- Camille L Stewart
- University of Colorado School of Medicine, Department of Surgery, 12631 E. 17th Ave, C302, Aurora, CO 80045; Children's Hospital Colorado, Division of Pediatric Surgery, 13123 E. 16th Ave, B232, Aurora, CO 80045.
| | - Ryan R Metzger
- Primary Children's Hospital, Division of Pediatric Surgery, 100 N Mario Capecchi Dr, Suite 2600, Salt Lake City, UT 84113.
| | - Laura Pyle
- University of Colorado School of Medicine, Department of Pediatrics, 13001 E. 17th Place, C290, Aurora, CO 80045.
| | - Joe Darmofal
- Children's Hospital Colorado, Department of Transport & EMS Outreach and Education, 13123 E. 16th Ave, B245, Aurora, CO 80045.
| | - Eric Scaife
- Primary Children's Hospital, Division of Pediatric Surgery, 100 N Mario Capecchi Dr, Suite 2600, Salt Lake City, UT 84113.
| | - Steven L Moulton
- University of Colorado School of Medicine, Department of Surgery, 12631 E. 17th Ave, C302, Aurora, CO 80045; Children's Hospital Colorado, Division of Pediatric Surgery, 13123 E. 16th Ave, B232, Aurora, CO 80045.
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Skarda DE, Schall K, Rollins M, Andrews S, Olson J, Greene T, McFadden M, Thorell EA, Barnhart D, Meyers R, Scaife E. Response-based therapy for ruptured appendicitis reduces resource utilization. J Pediatr Surg 2014; 49:1726-9. [PMID: 25487470 DOI: 10.1016/j.jpedsurg.2014.09.012] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [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: 08/18/2014] [Accepted: 09/05/2014] [Indexed: 11/15/2022]
Abstract
PURPOSE We examined the effectiveness of a postoperative ruptured appendicitis protocol that eliminated Pseudomonas coverage and based the duration of IV antibiotic treatment and length of hospital stay on the patient's clinical response. METHODS In our new protocol, IV antibiotics were administered until the patient met discharge criteria: adequate oral intake, pain control with oral medications, and afebrile for 24h. We collected data on all patients with ruptured appendicitis at our institution following protocol implementation (May 1, 2012, to April 30, 2013) and compared them to a control group. RESULTS 306 patients were treated (154 prior protocol, 152 new protocol). The new clinical response-based protocol led to a decrease in hospital stay from 134h (SD 66.1) to 94.5h (SD 61.7) (p<0.001) and total cost of care per patient also decreased from $13,610 (SD $6859) to $9870 (SD $5670) (p<0.001). CONCLUSION Our clinical response-based protocol for pediatric patients with ruptured appendicitis decreased LOS, cost, and IV antibiotics use without significant changes in adverse events.
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Affiliation(s)
- David E Skarda
- Division of Pediatric Surgery, University of Utah, Primary Children's Hospital, Salt Lake City, UT.
| | - Kathy Schall
- Division of Pediatric Surgery, University of Utah, Primary Children's Hospital, Salt Lake City, UT
| | - Michael Rollins
- Division of Pediatric Surgery, University of Utah, Primary Children's Hospital, Salt Lake City, UT
| | - Seth Andrews
- Systems Improvement Primary Children's Hospital, Salt Lake City, UT
| | - Jared Olson
- Department of Pharmacology, Primary Children's Hospital, Salt Lake City, UT
| | - Tom Greene
- University of Utah School of Medicine, Division of Epidemiology, Salt Lake City, UT
| | - Molly McFadden
- University of Utah School of Medicine, Division of Epidemiology, Salt Lake City, UT
| | - Emily A Thorell
- University of Utah School of Medicine, Department of Pediatrics, Division of Pediatric Infectious Diseases, Salt Lake City, UT
| | - Doug Barnhart
- Division of Pediatric Surgery, University of Utah, Primary Children's Hospital, Salt Lake City, UT
| | - Rebecka Meyers
- Division of Pediatric Surgery, University of Utah, Primary Children's Hospital, Salt Lake City, UT
| | - Eric Scaife
- Division of Pediatric Surgery, University of Utah, Primary Children's Hospital, Salt Lake City, UT
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McRae R, Lambert LM, Lee J, Gociman B, Scaife E, Eckhauser A. Repair of a wide sternal cleft in a young female. Journal of Pediatric Surgery Case Reports 2014. [DOI: 10.1016/j.epsc.2014.05.005] [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: 11/29/2022] Open
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Eckhauser AW, Hannon D, Molitor M, Scaife E, Gruber PJ. Repair of traumatic aortoinnominate disruption using CorMatrix. Ann Thorac Surg 2013; 95:e99-e101. [PMID: 23522243 DOI: 10.1016/j.athoracsur.2012.09.060] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2012] [Revised: 09/14/2012] [Accepted: 09/24/2012] [Indexed: 11/30/2022]
Abstract
Blunt traumatic injuries to the innominate artery are rare but potentially devastating injuries. Patients with an innominate injury who survive typically have an isolated intimal tear with an intact adventitia. There are multiple case reports and series describing off-pump repair of innominate injuries using synthetic grafts, and even reports of successful endovascular stenting. We report the first successful case of innominate artery disruption and repair using CorMatrix (CorMatrix Alpharetta, GA) extracellular matrix.
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Affiliation(s)
- Aaron W Eckhauser
- Primary Children's Medical Center, Department of Surgery, Division of Pediatric Cardiothoracic Surgery, University of Utah, Salt Lake City, Utah 84113, USA.
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Skarda D, Barnhart D, Scaife E, Molitor M, Meyers R, Rollins M. Extracorporeal cardiopulmonary resuscitation (EC-CPR) for hypothermic arrest in children: is meaningful survival a reasonable expectation? J Pediatr Surg 2012; 47:2239-43. [PMID: 23217883 DOI: 10.1016/j.jpedsurg.2012.09.014] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2012] [Accepted: 09/01/2012] [Indexed: 11/17/2022]
Abstract
PURPOSE We have previously reported the use of EC-CPR for the treatment of hypothermic cardiac arrest with an overall survival of 50%. As we have continued this protocol for an additional 5 years, we sought to update this information. METHODS We reviewed all of the activations for hypothermic cardiac arrest from 2005 to 2011. Results are presented as means with minimum and maximum values. The 95% confidence interval for the point estimate of survival was calculated using a binomial distribution. RESULTS Nine children were placed on EC-CPR for hypothermic cardiac arrest. Two patients survived to discharge and were neurologically normal. The other seven patients were adequately supported with veno-arterial EC-CPR but met brain death criteria after rewarming prompting withdrawal of support. Four of these went on to multiple organ donation. The overall survival in the series was 22% with a 95% confidence interval from 4% to 58%. CONCLUSION Cold water drowning and avalanche suffocations cause dramatic hypothermic cardiac arrests in previously robust children. A protocolized rapid response with EC-CPR can save some of these children despite prolonged periods of cardiac arrest prior to initiation of bypass. The overall survival rate is likely less than our prior more optimistic report suggested.
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Affiliation(s)
- David Skarda
- Division of Pediatric Surgery at Primary Children's Medical Center, Department of Surgery, University of Utah, Salt Lake City, Utah 84113, USA.
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Moore JC, Thompson K, Lafleur B, Book LS, Jackson WD, O'Gorman MA, Black RE, Downey E, Johnson DG, Matlak ME, Meyers RL, Scaife E, Guthery SL. Clinical variables as prognostic tools in pediatric-onset ulcerative colitis: a retrospective cohort study. Inflamm Bowel Dis 2011; 17:15-21. [PMID: 20629099 DOI: 10.1002/ibd.21393] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Clinical variables may identify a subset of patients with pediatric-onset ulcerative colitis (UC) (≤18 years at diagnosis) at risk for adverse outcomes. We postulated that routinely measured clinical variables measured at diagnosis would predict colectomy in patients with pediatric-onset UC. METHODS We conducted a chart review of patients with pediatric-onset UC at a single center over a 10-year period. We compared patients with and without colectomy across several variables, used proportional hazards regression to adjust for potential confounders, and assessed the ability of a UC risk score to predict colectomy. RESULTS Among 470 patients with inflammatory bowel disease ICD9-coded encounters, 155 patients had UC and 135 were eligible for analysis. The 1- and 3-year colectomy rates were 16.7% (95% confidence interval [CI]: 11.0%-24.8%) and 35.6% (26.7%-45.4%). White blood cell (WBC) count and hematocrit measured at diagnosis were associated with colectomy at 3 years, even after correcting for potential confounding variables. A UC Risk Score derived from the WBC count and hematocrit was strongly associated with colectomy risk, with a high negative predictive value (NPV) for colectomy at 1 and 3 years (NPV = 0.95 and 0.89, respectively), but low positive predictive value (PPV = 0.22 and 0.38, respectively). CONCLUSIONS A risk score calculated from WBC and hematocrit measured at diagnosis was associated with, but incompletely predictive of, colectomy in pediatric-onset UC. These data suggest 1) routinely measured clinical variables may have a prognostic role in risk stratification, and 2) multicenter prospective studies are needed to optimize risk stratification in pediatric UC. Our findings have impact on the design of such studies.
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Affiliation(s)
- Jill C Moore
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, University of Utah School of Medicine, Salt Lake City, Utah, USA
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Abstract
OBJECTIVES Traumatic brain injury is a leading cause of death and disability in children. Guidelines have been established to prevent secondary brain injury caused by hypotension or hypoxia. The purpose of this study was to identify the prevalence, monitoring, and treatment of hypotension and hypoxia during "early" (prehospital and emergency department) care and to evaluate their relationship to vital status and neurologic outcomes at hospital discharge. METHODS This was a retrospective study of 299 children with moderate-to-severe traumatic brain injury presenting to a level 1 pediatric trauma center. We recorded vital signs and medical provider response to hypotension and/or hypoxia during all portions of early care. RESULTS Blood pressure (31%) and oxygenation (34%) were not recorded during some portion of "early care." Documented hypotension occurred in 118 children (39%). An attempt to treat documented hypotension was made in 48% (57 of 118 children). After adjusting for severity of illness, children who did not receive an attempt to treat hypotension had an increased odds of death of 3.4 and were 3.7 times more likely to suffer disability compared with treated hypotensive children. Documented hypoxia occurred in 131 children (44%). An attempt to treat hypoxia was made in 92% (121 of 131 children). Untreated hypoxia was not significantly associated with death or disability, except in the setting of hypotension. CONCLUSIONS Hypotension and hypoxia are common events in pediatric traumatic brain injury. Approximately one third of children are not properly monitored in the early phases of their management. Attempts to treat hypotension and hypoxia significantly improved outcomes.
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Affiliation(s)
- Michelle Zebrack
- Division of Pediatric Critical Care, University of Utah School of Medicine, Salt Lake City Utah, USA.
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Mattix KD, Tataria M, Holmes J, Kristoffersen K, Brown R, Groner J, Scaife E, Mooney D, Nance M, Scherer L. Pediatric pancreatic trauma: predictors of nonoperative management failure and associated outcomes. J Pediatr Surg 2007; 42:340-4. [PMID: 17270545 DOI: 10.1016/j.jpedsurg.2006.10.006] [Citation(s) in RCA: 79] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND Nonoperative management (NOM) is an accepted treatment of pediatric solid organ injuries and is typically successful. Blunt pancreatic trauma tends to require operative intervention more frequently. We sought to identify predictors of failure of NOM and compare the outcome of operative management against NOM. METHODS A retrospective analysis was performed from January 1993 to December 2002 of all children with blunt pancreatic injuries from the trauma registries of 7 designated level 1 pediatric trauma centers. Failure of NOM was defined as the need for intraabdominal operative intervention. Injuries were graded I to V, and ductal injury was defined as grades III to V. Parameters included mechanism of injury, injury severity score (ISS), organ grade, Glasgow Coma Scale score, and outcome. Data were analyzed by Fisher exact test and Mann-Whitney U test, with mean values +/- SD and significance of P < .05. RESULTS Pancreatic injuries were present in 173 (9.2%) of 1823 patients. Of these, 43 (26.0% [43/173]) required an operation. Valid morbidity data was obtained in 118 of 173 patients. ISS was significantly higher in all patients treated operatively. Patients with an injury of grade III to V failed NOM more frequently than all patients with pancreatic injury (P =.0169). Length of stay was longer, and the incidence of pseudocysts, drainage procedures, and pancreatitis was higher in NOM patients, although not significant. CONCLUSIONS Patients with pancreatic injuries had a NOM failure rate of 26.0%. ISS and injury grades III to V were predictors of NOM failure. Patients with pancreatic ductal injury require more aggressive management.
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Affiliation(s)
- Kelly D Mattix
- Riley Hospital for Children, Indiana University, Indianapolis, IN 46202, USA.
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Abstract
BACKGROUND Freestanding children's hospitals may lack resources, especially surgical manpower, to meet American College of Surgeons trauma center criteria, and may organize trauma care in alternative ways. MATERIALS AND METHODS At a tertiary care children's hospital, attending trauma surgeons and anesthesiologists took out-of-hospital call and directed initial care for only the most severely injured patients, whereas pediatric emergency physicians directed care for patients with less severe injuries. Survival data were analyzed using TRISS methodology. RESULTS A total of 903 trauma patients were seen by the system during the period 10/1/96-6/30/01. Median Injury Severity Score was 16, and 508 of patients had Injury Severity Score > or =15. There were 83 deaths, 21 unexpected survivors, and 13 unexpected deaths. TRISS analysis showed that z-score was 4.39 and W-statistic was 3.07. CONCLUSIONS Mortality outcome from trauma in a pediatric hospital using this alternative approach to trauma care was significantly better than predicted by TRISS methodology.
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Affiliation(s)
- Donald D Vernon
- Department of Pediatrics, and the Intermountain Injury Control Research Center, University of Utah School of Medicine, Salt Lake City, UT 84113, USA.
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Affiliation(s)
- Lars Wagner
- Department of Pediatrics, Division of Hematology/Oncology, Primary Children's Medical Center, University of Utah, 100 N. Medical Drive, Salt Lake City, UT 84113, USA.
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