1
|
Robinson V, Achey MA, Nag UP, Reed CR, Pahl KS, Greenberg RG, Clark RH, Tracy ET. Thrombosis in infants in the neonatal intensive care unit: Analysis of a large national database. J Thromb Haemost 2021; 19:400-407. [PMID: 33075167 DOI: 10.1111/jth.15144] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Revised: 10/11/2020] [Accepted: 10/13/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Thrombosis in the neonatal population is rare, but increasing. Its incidence and management are not well understood. OBJECTIVES To investigate the incidence, associated factors, and management of thrombosis in the neonatal intensive care unit (NICU) population. PATIENTS/METHODS We performed a retrospective cohort study of infants admitted to a Pediatrix Medical Group-affiliated NICU from 1997 through 2015. We determined the prevalence of venous and arterial thrombosis, and assessed demographic characteristics and known risk factors. Categorical variables were compared with the Pearson χ2 test and continuous variables with Wilcoxon rank-sum tests. Stepwise logistic regression was used to identify associated factors. The primary outcome was incidence of thrombosis. Secondary analyses investigated correlations between clinical and demographic characteristics and thrombosis. RESULTS Among 1 158 755 infants, we identified 2367 (0.20%) diagnosed with thrombosis. In a multivariable regression analysis, prematurity, male sex, congenital heart disease, sepsis, ventilator support, vasopressor receipt, central venous catheter, invasive procedures, and receipt of erythropoietin were associated with increased risk of thrombosis, while Black race and Hispanic ethnicity were associated with reduced risk. The majority of infants diagnosed with thrombosis (73%) received no anticoagulation, but anticoagulant use in infants with thrombosis was higher than those without (27% versus 0.2%, P < .001). Thrombosis in infants was associated with higher mortality (11% versus 2%, P < .001) and longer hospital stays (57 days, [interquartile range (IQR) 28--100] versus 10 days, [IQR 6--22], P < .001). CONCLUSIONS In the largest national study to date, we found that thrombosis in NICU patients is associated with prematurity, low birth weight, sepsis, and invasive procedures.
Collapse
Affiliation(s)
| | | | - Uttara P Nag
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | | | - Kristy S Pahl
- Division of Pediatric Hematology-Oncology, Department of Pediatrics, Duke University Medical Center, Durham, NC, USA
| | - Rachel G Greenberg
- Division of Neonatology, Department of Pediatrics, Duke University Medical Center, Durham, NC, USA
- Duke Clinical Research Institute, Durham, NC, USA
| | | | - Elisabeth T Tracy
- Division of Pediatric Surgery, Department of Surgery, Duke University Medical Center, Durham, NC, USA
| |
Collapse
|
2
|
Achey MA, Nag UP, Robinson VL, Reed CR, Arepally GM, Levy JH, Tracy ET. The Developing Balance of Thrombosis and Hemorrhage in Pediatric Surgery: Clinical Implications of Age-Related Changes in Hemostasis. Clin Appl Thromb Hemost 2020; 26:1076029620929092. [PMID: 32584601 PMCID: PMC7427005 DOI: 10.1177/1076029620929092] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Revised: 04/14/2020] [Accepted: 04/30/2020] [Indexed: 12/17/2022] Open
Abstract
Bleeding and thrombosis in critically ill infants and children is a vexing clinical problem. Despite the relatively low incidence of bleeding and thrombosis in the overall pediatric population relative to adults, these critically ill children face unique challenges to hemostasis due to extreme physiologic derangements, exposure of blood to foreign surfaces and membranes, and major vascular endothelial injury or disruption. Caring for pediatric patients on extracorporeal support, recovering from solid organ transplant or invasive surgery, and after major trauma is often complicated by major bleeding or clotting events. As our ability to care for the youngest and sickest of these children increases, the gaps in our understanding of the clinical implications of developmental hemostasis have become increasingly important. We review the current understanding of the development and function of the hemostatic system, including the complex and overlapping interactions of coagulation proteins, platelets, fibrinolysis, and immune mediators from the neonatal period through early childhood and to young adulthood. We then examine scenarios in which our ability to effectively measure and treat coagulation derangements in pediatric patients is limited. In these clinical situations, adult therapies are often extrapolated for use in children without taking age-related differences in pediatric hemostasis into account, leaving clinicians confused and impacting patient outcomes. We discuss the limitations of current coagulation testing in pediatric patients before turning to emerging ideas in the measurement and management of pediatric bleeding and thrombosis. Finally, we highlight opportunities for future research which take into account this developing balance of bleeding and thrombosis in our youngest patients.
Collapse
Affiliation(s)
| | - Uttara P. Nag
- Department of Surgery, Duke University School of Medicine, Durham, NC, USA
| | | | | | - Gowthami M. Arepally
- Division of Hematology, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Jerrold H. Levy
- Departments of Anesthesiology, Critical Care, and Surgery, Duke University School of Medicine, Durham, NC, USA
| | - Elisabeth T. Tracy
- Division of Pediatric Surgery, Department of Surgery, Duke University School of Medicine, Durham, NC, USA
| |
Collapse
|
3
|
Leraas HJ, Kuchibhatla M, Nag UP, Kim J, Ezekian B, Reed CR, Rice HE, Tracy ET, Adibe OO. Cervical seatbelt sign is not associated with blunt cerebrovascular injury in children: A review of the national trauma databank. Am J Surg 2019; 218:100-105. [DOI: 10.1016/j.amjsurg.2018.10.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2018] [Revised: 09/20/2018] [Accepted: 10/05/2018] [Indexed: 12/31/2022]
|
4
|
Kamyszek RW, Leraas HJ, Nag UP, Olivere LA, Nash AL, Kemeny HR, Kim J, Hill KD, Fleming GA, Jooste EH, Otto J, Tracy ET. Routine postprocedure ultrasound increases rate of detection of femoral arterial thrombosis in infants after cardiac catheterization. Catheter Cardiovasc Interv 2018; 93:652-659. [DOI: 10.1002/ccd.28009] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [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: 07/26/2018] [Revised: 10/17/2018] [Accepted: 11/06/2018] [Indexed: 11/08/2022]
Affiliation(s)
- Reed W. Kamyszek
- School of MedicineDuke University, Duke University Medical Center Durham North Carolina
| | - Harold J. Leraas
- Department of SurgeryDuke University, Duke University Medical Center Durham North Carolina
| | - Uttara P. Nag
- Department of SurgeryDuke University, Duke University Medical Center Durham North Carolina
| | - Lindsey A. Olivere
- School of MedicineDuke University, Duke University Medical Center Durham North Carolina
| | - Amanda L. Nash
- School of MedicineDuke University, Duke University Medical Center Durham North Carolina
| | - Hanna R. Kemeny
- School of MedicineDuke University, Duke University Medical Center Durham North Carolina
| | - Jina Kim
- Department of SurgeryDuke University, Duke University Medical Center Durham North Carolina
| | - Kevin D. Hill
- Department of SurgeryDuke University, Duke University Medical Center Durham North Carolina
| | - Gregory A. Fleming
- Department of SurgeryDuke University, Duke University Medical Center Durham North Carolina
| | - Edmund H. Jooste
- Department of SurgeryDuke University, Duke University Medical Center Durham North Carolina
| | - James Otto
- Department of SurgeryDuke University, Duke University Medical Center Durham North Carolina
| | - Elisabeth T. Tracy
- Department of SurgeryDuke University, Duke University Medical Center Durham North Carolina
| |
Collapse
|
5
|
Cox ML, Risucci DA, Gilmore BF, Nag UP, Turner MC, Sprinkle SR, Migaly J, Sudan R. Validation of the Omni: A Novel, Multimodality, and Longitudinal Surgical Skills Assessment. J Surg Educ 2018; 75:e218-e228. [PMID: 30522827 PMCID: PMC10765322 DOI: 10.1016/j.jsurg.2018.10.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/02/2018] [Revised: 10/17/2018] [Accepted: 10/21/2018] [Indexed: 06/09/2023]
Abstract
OBJECTIVE The breadth of technical skills included in general surgery training continues to expand. The current competency-based training model requires assessment tools to measure acquisition, learning, and mastery of technical skill longitudinally in a reliable and valid manner. This study describes a novel skills assessment tool, the Omni, which evaluates performance in a broad range of skills over time. DESIGN The 5 Omni tasks, consisting of open bowel anastomosis, knot tying, laparoscopic clover pattern cut, robotic needle drive, and endoscopic bubble pop, were developed by general surgery faculty. Component performance metrics assessed speed, accuracy, and quality, which were scaled into an overall score ranging from 0 to 10 for each task. For each task, ANOVAs with Scheffé's post hoc comparisons and Pearson's chi-squared tests compared performance between 6 resident cohorts (clinical years (CY1-5) and research fellows (RF)). Paired samples t-tests evaluated changes in performance across academic years. Cronbach's alpha coefficient determined the internal consistency of the Omni as an overall assessment. SETTING The Omni was developed by the Department of Surgery at Duke University. Annual assessment and this research study took place in the Surgical Education and Activities Lab. PARTICIPANTS All active general surgery residents in 2 consecutive academic years spanning 2015 to 2017. RESULTS A total of 62 general surgery residents completed the Omni and 39 (67.2%) of those residents completed the assessment in 2 consecutive years. Based on data from all residents' first assessment, statistically significant differences (p < 0.05) were observed among CY cohorts for bowel anastomosis, robotic, and laparoscopic task metrics. By pair-wise comparisons, mean bowel anastomosis scores distinguished CY1 from CY3-5 and CY2 from CY5. Mean robotic scores distinguished CY1 from RF, and mean laparoscopic scores distinguished CY1 from RF, CY3, and CY5 in addition to CY2 from CY3. Mean scores in performance on the knot tying and endoscopic tasks were not significantly different. Statistically significant improvement in mean scores was observed for all tasks from year 1 to year 2 (all p < 0.02). The internal consistency analysis revealed an alpha coefficient of 0.656. CONCLUSIONS The Omni is a novel composite assessment tool for surgical technical skill that utilizes objective measures and scoring algorithms to evaluate performance. In this pilot study, 3 tasks demonstrated discriminative ability of performance by CY, and all 5 tasks demonstrated construct validity by showing longitudinal improvement in performance. Additionally, the Omni has adequate internal consistency for a formative assessment. These results suggest the Omni holds promise for the evaluation of resident technical skill and early identification of outliers requiring intervention.
Collapse
Key Words
- ABS, American Board of Surgery
- ACS, American College of Surgeons
- APDS, Association of Program Directors in Surgery
- CY, clinical year
- FES, Fundamentals of Endoscopic Surgery
- FLS, Fundamentals of Laparoscopic Surgery
- General surgery
- Medical Knowledge
- OSATS, Objective Structured Assessment of Technical Skills
- Omni
- Patient Care
- Practice-Based Learning and Improvement
- REDCap, Research Electronic Data Capture
- RF, research fellow
- Resident
- SD, standard deviation
- Skills assessment
- df, degrees of freedom
Collapse
Affiliation(s)
- Morgan L Cox
- Department of Surgery, Duke University, Durham, North Carolina.
| | | | - Brian F Gilmore
- Department of Surgery, Duke University, Durham, North Carolina
| | - Uttara P Nag
- Department of Surgery, Duke University, Durham, North Carolina
| | - Megan C Turner
- Department of Surgery, Duke University, Durham, North Carolina
| | | | - John Migaly
- Department of Surgery, Duke University, Durham, North Carolina
| | - Ranjan Sudan
- Department of Surgery, Duke University, Durham, North Carolina
| |
Collapse
|
6
|
Gilmore BF, Fang C, Turner MC, Nag UP, Turley R, McCann RL, Cox MW. Jejunal arterial access for retrograde mesenteric stenting. J Vasc Surg 2018; 67:1613-1617. [PMID: 29567024 DOI: 10.1016/j.jvs.2017.12.041] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [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: 08/03/2017] [Accepted: 12/17/2017] [Indexed: 11/25/2022]
Abstract
Endovascular approaches have replaced open surgical revascularization in most patients with mesenteric ischemia; however, flush ostial occlusions may not be amenable to traditional antegrade access. Retrograde mesenteric stenting has been previously described, but this technique requires a formal laparotomy and dissection of the proximal superior mesenteric artery. We present here a modification of this technique that requires only a "mini-laparotomy" and no open vascular repair of the superior mesenteric artery as well as a review of our initial institutional experience with this procedure. Our approach differs from previously described work by minimizing mesenteric dissection, avoiding the need for repair of an arteriotomy, and limiting the size of the laparotomy incision in this population of profoundly comorbid patients.
Collapse
Affiliation(s)
- Brian F Gilmore
- Department of Surgery, Duke University Medical Center, Durham, NC.
| | | | - Megan C Turner
- Department of Surgery, Duke University Medical Center, Durham, NC
| | - Uttara P Nag
- Department of Surgery, Duke University Medical Center, Durham, NC
| | - Ryan Turley
- Cardiothoracic and Vascular Surgeons, Austin, Tex
| | - Richard L McCann
- Department of Surgery, Duke University Medical Center, Durham, NC
| | - Mitchell W Cox
- Department of Surgery, Duke University Medical Center, Durham, NC
| |
Collapse
|
7
|
Ezekian B, Englum B, Gilmore BF, Nag UP, Kim J, Leraas HJ, Routh JC, Rice HE, Tracy ET. Renal medullary carcinoma: A national analysis of 159 patients. Pediatr Blood Cancer 2017; 64. [PMID: 28485059 DOI: 10.1002/pbc.26609] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [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: 09/16/2016] [Revised: 03/04/2017] [Accepted: 03/27/2017] [Indexed: 11/06/2022]
Abstract
BACKGROUND Renal medullary carcinoma (RMC) is an aggressive malignancy seen predominantly in young males with sickle cell trait. RMC is poorly understood, with fewer than 220 cases described in the medical literature to date. We used a large national registry to define the typical presentation, treatments, and outcomes of this rare tumor. METHODS The National Cancer Database was queried for patients under 40 years of age diagnosed with RMC from 1998 to 2011. An analysis of patient and tumor characteristics, treatment details, and overall survival (OS) was undertaken, and factors associated with mortality were identified using multivariable regression analysis. RESULTS In total, 159 patients with RMC were identified, of whom a majority were male (71%), African American (87%), and had metastatic disease (71%). Median tumor size was 6 cm and median survival was 7.7 months. Most patients underwent surgery (60%) and chemotherapy (65%). Few patients received radiation (12%). Patients with metastatic disease had a significantly worse median survival (4.7 vs. 17.8 months, P < 0.001) and were less likely to receive surgery (42% vs. 91%, P < 0.001). Age and tumor size did not appear to impact OS. CONCLUSION In the largest cohort to date of patients with RMC, we found a dismal median survival of less than 8 months. Age and tumor size were not associated with OS. Metastatic disease at presentation was the main negative prognostic indicator in RMC and was present in a majority of patients at the time of diagnosis.
Collapse
Affiliation(s)
- Brian Ezekian
- Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Brian Englum
- Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Brian F Gilmore
- Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Uttara P Nag
- Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Jina Kim
- Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Harold J Leraas
- Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Jonathan C Routh
- Division of Urology, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Henry E Rice
- Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Elisabeth T Tracy
- Department of Surgery, Duke University Medical Center, Durham, North Carolina
| |
Collapse
|
8
|
Nag UP, Turner MC, Fang C, Wagner JK, Devulapalli K, Cox M, Avgerinos E, Dillavou E. IP159. Use of Hemodialysis Reliable Outflow (HeRO) With Immediate Access Arteriovenous Grafts. J Vasc Surg 2017. [DOI: 10.1016/j.jvs.2017.03.183] [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: 10/19/2022]
|