Surfactant Therapy in Congenital Diaphragmatic Hernia and Fetoscopic Endoluminal Tracheal Occlusion

INTRODUCTION

Congenital diaphragmatic hernia (CDH) is a complex pathology with severe pulmonary morbidity. Administration of surfactant in CDH is controversial, and the advent of fetoscopic endoluminal tracheal occlusion (FETO) has added further complexity. While FETO has been shown to improve survival outcomes, there are risks of prematurity and potential surfactant deficiency. We aim to evaluate the characteristics and outcomes of surfactant administration for CDH infants and elucidate potential benefits or risks in this unique population.

METHODS

A single-center retrospective cohort review of patients with unilateral CDH from September 2015 to July 2022 was performed. Demographics, prognostic perinatal imaging features, and outcomes were collected. Patients were stratified by surfactant administration and history of FETO. Data were analyzed with descriptive statistics, two-sample t-tests, chi-squared analyses, and logistic regression.

RESULTS

Of 105 included patients, 19 (18%) underwent FETO and 25 (24%) received surfactant. Overall, surfactant recipients were born at earlier gestational ages and lower birthweights regardless of FETO history. Surfactant recipients possessed significantly worse prenatal prognostic features such as observed to expected total fetal lung volume, observed to expected lung to head ratio, and percent liver herniation. In CDH patients without FETO history, surfactant recipients demonstrated worse outcomes than nonrecipients. This association is notably absent in the FETO population, where surfactant recipients have more favorable survival and comparable outcomes. When controlling for defect severity or surfactant usage, as a proxy for respiratory status, surfactant recipients that underwent FETO trended toward improved survival and decreased ECMO use.

CONCLUSIONS

Surfactant administration is not associated with increased morbidity and mortality and may be beneficial in CDH patients that have undergone FETO.

Prevalence and Outcomes of High versus Low Ratio Plasma to Red Blood Cell Resuscitation in a Multi-Institutional Cohort of Severely Injured Children

BACKGROUND

The benefit of targeting high ratio fresh frozen plasma (FFP):red blood cell (RBC) transfusion in pediatric trauma resuscitation is unclear as existing studies are limited to patients who retrospectively met criteria for massive transfusion. The purpose of this study is to evaluate the use of high ratio FFP:RBC transfusion and the association with outcomes in children presenting in shock.

METHODS

A post-hoc analysis of a 24-institution prospective observational study (4/2018-9/2019) of injured children <18 years with elevated age-adjusted shock index was performed. Patients transfused within 24 hours were stratified into cohorts of low (<1:2) or high (>1:2) ratio FFP:RBC. Nonparametric Kruskal-Wallis and chi-square were used to compare characteristics and mortality. Competing risks analysis was used to compare extended (≥75th percentile) ventilator, intensive care, and hospital days while accounting for early deaths.

RESULTS

Of 135 children with median (IQR) age 10 (5,14) years and weight 40 (20,64) kg, 85 (63%) received low ratio transfusion and 50 (37%) high ratio despite similar activation of institutional massive transfusion protocols (MTP; low-38%, high-46%, p = .34). Most patients sustained blunt injuries (70%). Median injury severity score was greater in high ratio patients (low-25, high-33, p = .01); however, hospital mortality was similar (low-24%, high-20%, p = .65) as was the risk of extended ventilator, ICU, and hospital days (all p > .05).

CONCLUSION

Despite increased injury severity, patients who received a high ratio of FFP:RBC had comparable rates of mortality. These data suggest high ratio FFP:RBC resuscitation is not associated with worst outcomes in children who present in shock. MTP activation was not associated with receipt of high ratio transfusion, suggesting variability in MTP between centers.

LEVEL OF EVIDENCE

Prospective cohort study, Level II.

Outcomes of Extracorporeal Life Support Utilization for Pediatric Patients With COVID-19 Infections

Outcomes of pediatric patients who received extracorporeal life support (ECLS) for COVID-19 remain poorly described. The aim of this multi-institutional retrospective observational study was to evaluate these outcomes and assess for prognostic factors associated with in-hospital mortality. Seventy-nine patients at 14 pediatric centers across the United States who received ECLS support for COVID-19 infections between January 2020 and July 2022 were included for analysis. Data were extracted from the electronic medical record. The median age was 14.5 years (interquartile range [IQR]: 2-17 years). Most patients were female (54.4%) and had at least one pre-existing comorbidity (84.8%), such as obesity (44.3%, median body mass index percentile: 97% [IQR: 67.5-99.0%]). Venovenous (VV) ECLS was initiated in 50.6% of patients. Median duration of ECLS was 12 days (IQR: 6.0-22.5 days) with a mean duration from admission to ECLS initiation of 5.2 ± 6.3 days. Survival to hospital discharge was 54.4%. Neurological deficits were reported in 16.3% of survivors. Nonsurvivors were of older age (13.3 ± 6.2 years vs. 9.3 ± 7.7 years, p  = 0.012), more likely to receive renal replacement therapy (63.9% vs. 30.2%, p  = 0.003), demonstrated longer durations from admission to ECLS initiation (7.0 ± 8.1 days vs. 3.7 ± 3.8 days, p  = 0.030), and had higher rates of ECLS-related complications (91.7% vs. 69.8%, p  = 0.016) than survivors. Pediatric patients with COVID-19 who received ECLS demonstrated substantial morbidity and further investigation is warranted to optimize management strategies.

Utility of Hospital Failure to Rescue for Analyzing Variation in Pediatric Postoperative Mortality

OBJECTIVES

To evaluate the association between pediatric hospital performances in terms of failure to rescue (FTR), defined as postoperative mortality after a surgical complication, and mortality among patients without a surgical complication.

DESIGN

Retrospective cohort study.

SETTING

Forty-eight academic, pediatric hospitals; data obtained from Pediatric Health Information System database (Child Health Corporation of America, Shawnee Mission, KS) (2012-2020).

PATIENTS

Children who underwent at least one of 57 high-risk operations associated with significant postoperative mortality.

EXPOSURES

Hospitals were stratified into quintiles of reliability adjusted FTR (lower than average FTR in quintile 1 [Q1], higher than average FTR in quintile 5 [Q5]). Multivariable hierarchical regression was used to evaluate the association between hospital FTR performance and mortality among patients who did not have a surgical complication.

MEASUREMENTS AND MAIN RESULTS

Among 203,242 children treated across 48 academic hospitals, the complication and overall postoperative mortality rates were 8.8% and 2.3%, respectively. Among patients who had a complication, the FTR rate was 8.8%. Among patients who did not have a complication, the mortality rate was 1.7%. There was a 6.5-fold increase in reliability adjusted FTR between the lowest and highest performing hospitals (lowest FTR hospital-2.7%; 95% CI [1.6-3.9]; highest FTR hospital-17.8% [16.8-18.8]). Complex chronic conditions were highly prevalent across hospitals (Q1, 72.7%; Q2, 73.8%; Q3, 72.2%; Q4, 74.0%; Q5, 74.8%; trend test p < 0.01). Relative to Q1 hospitals, the odds of mortality in the absence of a postoperative complication significantly increased by 33% at Q5 hospitals (odds ratio 1.33; 95% CI [1.07-1.66]). This association was consistent when limited to patients with a complex chronic condition and neonates.

CONCLUSION

FTR may be a useful and valid surgical quality measure for pediatric surgery, even when considering patients without a postoperative complication. These findings suggest practices and processes for preventing FTR at high performing pediatric hospitals might help mitigate the risk of postoperative mortality even in the absence of a postoperative complication.

Factors associated with enteral autonomy after reanastomosis in infants with intestinal failure and ostomy: A descriptive cohort study

BACKGROUND

To determine variables associated with outcomes in infants with intestinal failure (IF) and ostomy following reanastomosis (RA).

METHODS

A single-center, descriptive cohort study of 120 infants with IF and a stoma from January 2011 to December 2020 with subsequent RA during initial hospitalization. The primary outcome was achievement of enteral autonomy (EA) following RA. Other outcomes were duration of hospital stay, and mortality. Penalized logistic regression and linear regression were used for data analysis.

RESULTS

The median gestational age was 26 weeks, and the median birth weight was 890 g. Three infants died. The median duration between ostomy creation and RA was 80 days (interquartile range; 62.5, 100.5). For each additional day of discontinuity, the odds of EA decreased by 2% (odds ratio [OR] = 0.980; 95% confidence interval [CI]: 0.962, 0.999; P = 0.038), and death increased by 4.2% (OR = 1.042; 95% CI: 1.010, 1.075; P = 0.009). For each additional mL/kg/day of enteral feeds at RA, the odds of EA increased by 7.5% (OR = 1.075; 95% CI: 1.027, 1.126, P = 0.002) and duration of hospital stay decreased by 0.35 days (slope coefficient = -0.351; 95% CI: -0.540, -0.163; P < 0.001).

CONCLUSION

Shorter duration of intestinal discontinuity and enteral nutrition before RA could positively influence EA and duration of stay in infants with IF and ostomy following RA.

Outcome of Extracorporeal Cardiopulmonary Resuscitation in Pediatric Patients Without Congenital Cardiac Disease: Extracorporeal Life Support Organization Registry Study

OBJECTIVES

To describe the use of extracorporeal cardiopulmonary resuscitation (ECPR) in pediatric patients without congenital heart disease (CHD) and identify associations with in-hospital mortality, with a specific focus on initial arrest rhythm.

DESIGN

Retrospective cohort study using data from pediatric patients enrolled in Extracorporeal Life Support Organization (ELSO) registry between January 1, 2017, and December 31, 2019.

SETTING

International, multicenter.

PATIENTS

We included ECPR patients under 18 years old, and excluded those with CHD. Subgroup analysis of patients with initial arrest rhythm.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We identified 567 patients: neonates (12%), infants (27%), children between 1 and 5 years old (25%), and children over 5 years old (36%). The patient cohort included 51% males, 43% of White race, and 89% not obese. Most suffered respiratory disease (26%), followed by acquired cardiac disease (25%) and sepsis (12%). In-hospital mortality was 59%. We found that obesity (adjusted odds ratio [aOR], 2.28; 95% CI, 1.21-4.31) and traumatic injury (aOR, 6.94; 95% CI, 1.55-30.88) were associated with greater odds of in-hospital mortality. We also identified lower odds of death associated with White race (aOR, 0.64; 95% CI, 0.45-0.91), ventricular tachycardia (VT) as an initial arrest rhythm (aOR, 0.36; 95% CI, 0.16-0.78), return of spontaneous circulation before cannulation (aOR, 0.56; 95% CI, 0.35-0.9), and acquired cardiac disease (aOR, 0.43; 95% CI, 0.29-0.64). Respiratory disease was associated with greater odds of severe neurologic complications (aOR, 1.64; 95% CI, 1.06-2.54).

CONCLUSIONS

In children without CHD undergoing ECPR, we found greater odds of in-hospital mortality were associated with either obesity or trauma. The ELSO dataset also showed that other variables were associated with lesser odds of mortality, including VT as an initial arrest rhythm. Prospective studies are needed to elucidate the reasons for these survival differences.

Hospital Variation in Mortality and Failure to Rescue after Surgery for High-Risk Neonatal Diagnoses

INTRODUCTION

A large proportion of postoperative mortality after pediatric surgery occurs among neonates with specific high-risk diagnoses. The extent to which there is hospital-level mortality variation among patients with these diagnoses and whether this variation is associated with differences in failure to rescue (FTR) is unclear.

METHODS

The Pediatric Health Information System® database (2012-2020) was used to identify patients who underwent surgery for eight high-risk neonatal diagnoses: gastroschisis; volvulus; necrotizing enterocolitis; intestinal atresia; meconium peritonitis; tracheoesophageal fistula; congenital diaphragmatic hernia; and perinatal intestinal perforation. Hospitals were stratified into tertiles of reliability-adjusted inpatient mortality rates (lower than average mortality - tertile 1 [T1]; higher than average mortality - tertile 3 [T3]). Multivariable hierarchical regression was used to evaluate the association between hospital-level, reliability-adjusted mortality and FTR.

RESULTS

Overall, 20,838 infants were identified across 48 academic, pediatric hospitals. Adjusted hospital mortality rates ranged from 4.0% (95% CI, 0.0-8.2) to 16.3% (12.2-20.4). Median case volume (range, 80-1,238) and number of NICU beds (range, 24-126) were not significantly different across hospital tertiles. Compared to the hospitals with the lowest postoperative mortality (T1), the odds of FTR were significantly higher in hospitals with the highest (T3) postoperative mortality (odds ratio 1.97 [1.50-2.59]).

CONCLUSIONS

Significant variation in neonatal hospital mortality for high-risk diagnoses does not appear to be explained by hospital structural characteristics. Rather, difference in FTR suggests quality improvement interventions targeting early recognition and management of postoperative complications could improve surgical quality and safety for high-risk neonatal care.

Child traumatic physical abuse rates and comparisons during the COVID-19 pandemic: Retrospective paediatric single institution review in Texas

AIM

The COVID-19 pandemic drastically altered human behaviour and socialisation and may have created an environment that could lead to increased incidence of domestic abuse and non-accidental trauma, or child physical abuse (CPA). Initial reports about the effect of the COVID-19 pandemic on the rates of CPA have been mixed. The purpose of this study is to describe the effects of COVID-19 on rates of CPA in a large metropolitan paediatric hospital and level I paediatric trauma centre.

METHODS

We identified and compared all CPA admissions under 18 years from May 2019 to February 2020 and considered that to be the pre-COVID time frame. The ensuing 12-month period of March 2020 to February 2021 was considered to be the intra-COVID time frame.

RESULTS

There were 49 (0.32%) unique CPA patients pre-COVID and 83 (0.85%) unique CPA patients intra-COVID (P < 0.001) with lower total admissions for any reason during the intra-COVID time frame. Monthly CPA cases were increased (P < 0.03) during the intra-COVID time period (mean 6.9, 95% confidence interval: 5.8-12.7) compared to the pre-COVID time period (mean 4.9, 95% confidence interval: 3.3-8.2).

CONCLUSION

During the COVID-19 pandemic, there were decreased overall hospital admissions in the period of mandated shutdowns and isolation. However, we saw an increased rate of CPA admissions compared to the time period prior to the pandemic. Knowledge of such data, trends and circumstances will help keep health-care providers alert and vigilant in identifying children at risk for maltreatment, and may impact child abuse protocols and guidelines.

Development of the Red Flag Scorecard Screening Tool for Identification of Child Physical Abuse in the Emergency Department

BACKGROUND

Child physical abuse (CPA) may have subtle presenting signs and can be challenging to identify, especially at emergency centers that do not treat many children. The purpose of this study is to determine the performance of a simple CPA screening tool to identify children most at risk.

METHODS

A screening tool ("Red Flag Scorecard") was developed utilizing available evidence-based presenting findings and expert consensus. Retrospective chart review of children treated for injuries between 2014 and 2018 with suspected or confirmed CPA at a level I pediatric trauma center was then performed to validate the screening tool. Descriptive statistics and chi square tests were used to analyze the data.

RESULTS

Of 408 cases, median age was 7 months and 60% were male. The majority (69%) were under 1 year of age. The most common history finding was delay in seeking care (58%, 236/408; p = <0.0001), the most common physical exam finding was bruising located away from bony prominences (45%, 182/408), and the most common imaging finding was unexplained brain injury (49%, 201/408). The majority, 84% (343/408), had at least 2 history findings. The combination score of at least 2 history findings and 1 physical/imaging finding was most sensitive (79%). The scorecard would have identified 94% of children who presented with no trauma history (198/211).

CONCLUSION

The Red Flag Scorecard may serve as a quick and effective screening tool to raise suspicion for child physical abuse in emergency centers. Prospective study is planned to validate these results.

LEVEL OF EVIDENCE

IV.

Hospital Variation in Mortality After Inpatient Pediatric Surgery

OBJECTIVE

The aim was to determine the association between risk adjusted hospital perioperative mortality rates, postoperative complications, and failure to rescue (FTR) after inpatient pediatric surgery.

BACKGROUND

FTR has been identified as a possible explanatory factor for hospital variation in perioperative mortality in adults. However, the extent to which this may be the case for hospitals that perform pediatric surgery is unclear.

METHODS

The Pediatric Health Information System database (2012-2020) was used to identify patients who underwent one of 57 high-risk operations associated with significant perioperative mortality (n=203,242). Academic, pediatric hospitals (n=48) were stratified into quintiles based on risk adjusted inpatient mortality [lower than average, quintile 1 (Q1); higher than average, quintile 5 (Q5)]. Multivariable hierarchical regression was used to evaluate the association between hospital mortality rates, complications, and FTR.

RESULTS

Inpatient mortality, complication, and FTR rates were 2.3%, 8.8%, and 8.8%, respectively. Among all patients who died after surgery, only 34.1% had a preceding complication (Q1, 36.1%; Q2, 31.5%; Q3, 34.7%; Q4, 35.7%; Q5, 32.2%; trend test, P =0.49). The rates of observed mortality significantly increased across hospital quintiles, but the difference was <1% (Q1, 1.9%; Q5; 2.6%; trend test, P <0.01). Relative to Q1 hospitals, the odds of complications were not significantly increased at Q5 hospitals [odds ratio (OR): 1.02 (0.87-1.20)]. By comparison, the odds of FTR was significantly increased at Q5 hospitals [OR: 1.60 (1.30-1.96)] with a dose-response relationship across hospital quintiles [Q2-OR: 0.99 (0.80-1.22); Q3-OR: 1.26 (1.03-1.55); Q4-OR: 1.33 (1.09-1.63)].

CONCLUSIONS

The minority of pediatric surgical deaths are preceded by a postoperative complication, but variation in risk adjusted mortality across academic, pediatric hospitals may be partially explained by differences in the recognition and management of postoperative complications. Additional work is needed to identify children at greatest risk of postoperative death from perioperative complications as opposed to those at risk from pre-existing chronic conditions.

Impact of institutional prophylaxis guidelines on rates of pediatric venous thromboembolism following trauma-A multicenter study from the pediatric trauma society research committee

BACKGROUND

A paucity of data exists with regard to the incidence, management, and outcomes of venous thromboembolism (VTE) in injured children. We sought to determine the impact of institutional chemoprophylaxis guidelines on VTE rates in a pediatric trauma population.

METHODS

A retrospective review of injured children (≤15 years) admitted between 2009 and 2018 at 10 pediatric trauma centers was performed. Data were gathered from institutional trauma registries and dedicated chart review. The institutions were surveyed as to whether they had chemoprophylaxis guidelines in place for high-risk pediatric trauma patients, and outcomes were compared based on the presence of guidelines using χ 2 analysis ( p < 0.05).

RESULTS

There were 45,202 patients evaluated during the study period. Three institutions (28,359 patients, 63%) had established chemoprophylaxis policies during the study period ("Guidelines"); the other seven centers (16,843 patients, 37%) had no such guidelines ("Standard"). There were significantly lower rates of VTE in the Guidelines group, but these patients also had significantly fewer risk factors. Among critically injured children with similar clinical presentations, there was no difference in VTE rate. Specifically within the Guidelines group, 30 children developed VTE. The majority (17/30) were actually not indicated for chemoprophylaxis based on institutional guidelines. Still, despite protocols only one VTE patient in the guidelines group who was indicated for intervention ended up receiving chemoprophylaxis prior to diagnosis. No consistent ultrasound screening protocol was in place at any institution during the study.

CONCLUSION

The presence of an institutional policy to guide chemoprophylaxis for injured children is associated with a decreased overall frequency of VTE, but this disappears when controlling for patient factors. However, the overall efficacy is impacted by a combination of deficits in guideline compliance and structure. Further prospective data are needed to help determine the ideal role for chemoprophylaxis and protocols in pediatric trauma.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level IV.

Systemic anticoagulation in ECMO

While unfractionated heparin (UFH) remains the mainstay of anticoagulation during pediatric extracorporeal life support, direct thrombin inhibitors (DTIs) are increasingly used. In this article, we will review most recent evidence regarding utilization of both UFH and DTIs and compare their known advantages and disadvantages. We will present anticoagulation monitoring strategies during ECMO and outline the most recent Extracorporeal Life Support Organization's anticoagulation guidelines, however with the caveat that there are no true consensus recommendations for anticoagulation management in pediatric ECMO. With these updates, we will serve as the bedside clinician's refresher on common practices for anticoagulation during "routine" ECMO. We will additionally highlight special circumstances, including high risk surgical procedures during ECMO, in which adjustments in anticoagulation and/or addition of antifibrinolytic therapy might mitigate risk.

Variation in Complications and Mortality According to Infant Diagnosis

OBJECTIVE

Investigate patterns of infant perioperative mortality, describe the infant diagnoses with the highest mortality burden, and evaluate the association between types of postoperative complications and mortality in infants.

BACKGROUND

The majority of mortality events in pediatric surgery occur among infants (ie, children <1 y old). However, there is limited data characterizing patterns of infant perioperative mortality and diagnoses that account for the highest proportion of mortality.

METHODS

Infants who received inpatient surgery were identified in the National Surgical Quality Improvement Program-Pediatric database (2012-2019). Perioperative mortality was stratified into mortality associated with a complication or mortality without a complication. Complications were categorized as wound infection, systemic infection, pulmonary, central nervous system, renal, or cardiovascular. Multivariable logistic regression was used to evaluate the association between different complications and complicated mortality.

RESULTS

Among 111,946 infants, the rate of complications and perioperative mortality was 10.4% and 1.6%, respectively. Mortality associated with a complication accounted for 38.8% of all perioperative mortality. Seven diagnoses accounted for the highest proportion of mortality events (40.3%): necrotizing enterocolitis (22.3%); congenital diaphragmatic hernia (7.3%); meconium peritonitis (3.8%); premature intestinal perforation (2.5%); tracheoesophageal fistula (1.8%); gastroschisis (1.4%); and volvulus (1.1%). Relative to wound complications, cardiovascular [odds ratio (OR): 19.4, 95% confidence interval (95% CI): 13.9-27.0], renal (OR: 6.88; 4.65-10.2), and central nervous system complications (OR: 6.50; 4.50-9.40) had the highest odds of mortality for all infants.

CONCLUSIONS

A small subset of diagnoses account for 40% of all infant mortality and specific types of complications are associated with mortality. These data suggest targeted quality improvement initiatives could be implemented to reduce adverse surgical outcomes in infants.

Crystalloid volume is associated with short-term morbidity in children with severe traumatic brain injury: An Eastern Association for the Surgery of Trauma multicenter trial post hoc analysis

OBJECTIVE

This study examined differences in clinical and resuscitation characteristics between injured children with and without severe traumatic brain injury (sTBI) and aimed to identify resuscitation characteristics associated with improved outcomes following sTBI.

METHODS

This is a post hoc analysis of a prospective observational study of injured children younger than 18 years (2018-2019) transported from the scene, with elevated shock index pediatric-adjusted on arrival and head Abbreviated Injury Scale score of ≥3. Timing and volume of resuscitation products were assessed using χ 2t test, Fisher's exact t test, Kruskal-Wallis, and multivariable logistic regression analyses.

RESULTS

There were 142 patients with sTBI and 547 with non-sTBI injuries. Severe traumatic brain injury patients had lower initial hemoglobin (11.3 vs. 12.4, p < 0.001), greater initial international normalized ratio (1.4 vs. 1.1, p < 0.001), greater Injury Severity Score (25 vs. 5, p < 0.001), greater rates of ventilator (59% vs. 11%, p < 0.001) and intensive care unit (ICU) requirement (79% vs. 27%, p < 0.001), and more inpatient complications (18% vs. 3.3%, p < 0.001). Severe traumatic brain injury patients received more prehospital crystalloid (25% vs. 15%, p = 0.008), ≥1 crystalloid boluses (52% vs. 24%, p < 0.001), and blood transfusion (44% vs. 12%, p < 0.001) than non-sTBI patients. Among sTBI patients, receipt of ≥1 crystalloid bolus (n = 75) was associated with greater ICU need (92% vs. 64%, p < 0.001), longer median ICU (6 vs. 4 days, p = 0.027) and hospital stay (9 vs. 4 days, p < 0.001), and more in-hospital complications (31% vs. 7.5%, p = 0.003) than those who received <1 bolus (n = 67). These findings persisted after adjustment for Injury Severity Score (odds ratio, 3.4-4.4; all p < 0.010).

CONCLUSION

Pediatric trauma patients with sTBI received more crystalloid than those without sTBI despite having a greater international normalized ratio at presentation and more frequently requiring blood products. Excessive crystalloid may be associated with worsened outcomes, including in-hospital mortality, seen among pediatric sTBI patients who received ≥1 crystalloid bolus. Further attention to a crystalloid sparing, early transfusion approach to resuscitation of children with sTBI is needed.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level IV.

Inhaled Nitric Oxide Utilization in Congenital Diaphragmatic Hernia Treated With Extracorporeal Life Support: A Propensity Score Analysis

Although used commonly, ability of inhaled nitric oxide (iNO) to improve outcomes in infants with congenital diaphragmatic hernia (CDH) who receive extracorporeal life support (ECLS) remains controversial. We sought to determine the association between pre-ECLS use of iNO and mortality in infants with CDH from the Extracorporeal Life Support Organization (ELSO) Registry. Neonates who underwent ECLS for CDH were identified from the ELSO Registry from 2009 to 2019. Patients were categorized into those treated with iNO versus not prior to initiating ECLS. Patients were then matched 1:1 for case-mix based on pre-ECLS covariates using the propensity score (PS) for iNO treatment. The matched groups were compared for mortality. The matched cohorts were also compared for ELSO-defined systems-based complications as secondary outcomes. There were a total of 3,041 infants with an overall mortality of 52.2% and a pre-ECLS iNO use rate of 84.8%. With 1:1 matching, there were 461 infants with iNO use and 461 without iNO use. Following matching, use of iNO was not associated with a difference in mortality (odds ratio [OR] = 0.805; 95% confidence interval [CI], 0.621-1.042; p = 0.114). Results were similar in unadjusted analyses, and after controlling for covariates in the full cohort of patients and in the 1:1 matched data. Patients receiving iNO had significantly higher odds of renal complications (OR = 1.516; 95% CI, 1.141-2.014; p = 0.004), but no other significant differences were observed among secondary outcomes. ECLS use of iNO in CDH patients was not associated with a difference in mortality. Future randomized controlled studies are needed to delineate the utility of iNO in CDH patients.

Use of Berlin EXCOR Cannulas in both Veno-Venous and Veno-Arterial Central ECMO Configurations Overcomes the Problem of Cannula Instability while Bridging Infants and Young Children to Lung Transplant

Objectives

Infants and young children awaiting lung transplantation present challenges that often preclude successful extracorporeal membrane oxygenation support as a bridge to transplantation. Instability of neck cannulas often results in the need for intubation, mechanical ventilation, and muscle relaxation creating a worse transplant candidate. With the use of Berlin Heart EXCOR cannulas (Berlin Heart, Inc) in both venoarterial and venovenous central cannulation configurations, 5 pediatric patients were successfully bridged to lung transplant.

Methods

We performed a single-center retrospective case review of central extracorporeal membrane oxygenation cannulation used as a bridge to lung transplantation cases performed at Texas Children's Hospital between 2019 and 2021.

Results

Six patients, 2 with pulmonary veno-occlusive disease (15-month-old male and 8-month-old male), 1 with ABCA3 mutation (2-month-old female), 1 with surfactant protein B deficiency (2-month-old female), 1 with pulmonary arterial hypertension in the setting of D-transposition of the great arteries after repair as a neonate (13-year-old male), and 1 with cystic fibrosis and end-stage lung disease, were supported for a median of 56.3 days on extracorporeal membrane oxygenation while awaiting transplantation. All patients were extubated after initiation of extracorporeal membrane oxygenation, participating in rehabilitation until transplant. No complications due to central cannulation and use of the Berlin Heart EXCOR cannulas were observed. One patient with cystic fibrosis developed fungal mediastinitis and osteomyelitis resulting in discontinuation of mechanical support and death.

Conclusions

Novel use of Berlin Heart EXCOR cannulas for central cannulation eliminates the problem of cannula instability allowing extubation, rehabilitation, and bridge to lung transplant for infants and young children.

Pediatric traumatic hemorrhagic shock consensus conference research priorities

BACKGROUND

Traumatic injury is the leading cause of death in children and adolescents. Hemorrhagic shock remains a common and preventable cause of death in the pediatric trauma patients. A paucity of high-quality evidence is available to guide specific aspects of hemorrhage control in this population. We sought to identify high-priority research topics for the care of pediatric trauma patients in hemorrhagic shock.

METHODS

A panel of 16 consensus multidisciplinary committee members from the Pediatric Traumatic Hemorrhagic Shock Consensus Conference developed research priorities for addressing knowledge gaps in the care of injured children and adolescents in hemorrhagic shock. These ideas were informed by a systematic review of topics in this area and a discussion of these areas in the consensus conference. Research priorities were synthesized along themes and prioritized by anonymous voting.

RESULTS

Eleven research priorities that warrant additional investigation were identified by the consensus committee. Areas of proposed study included well-designed clinical trials and evaluations, including increasing the speed and accuracy of identifying and treating hemorrhagic shock, defining the role of whole blood and tranexamic acid use, and assessment of the utility and appropriate use of viscoelastic techniques during early resuscitation. The committee recommended the need to standardize essential definitions, data elements, and data collection to facilitate research in this area.

CONCLUSION

Research gaps remain in many areas related to the care of hemorrhagic shock after pediatric injury. Addressing these gaps is needed to develop improved evidence-based recommendations for the care of pediatric trauma patients in hemorrhagic shock.

Pediatric traumatic hemorrhagic shock consensus conference recommendations

ABSTRACT

Hemorrhagic shock in pediatric trauma patients remains a challenging yet preventable cause of death. There is little high-quality evidence available to guide specific aspects of hemorrhage control and specific resuscitation practices in this population. We sought to generate clinical recommendations, expert consensus, and good practice statements to aid providers in care for these difficult patients.The Pediatric Traumatic Hemorrhagic Shock Consensus Conference process included systematic reviews related to six subtopics and one consensus meeting. A panel of 16 consensus multidisciplinary committee members evaluated the literature related to 6 specific topics: (1) blood products and fluid resuscitation for hemostatic resuscitation, (2) utilization of prehospital blood products, (3) use of hemostatic adjuncts, (4) tourniquet use, (5) prehospital airway and blood pressure management, and (6) conventional coagulation tests or thromboelastography-guided resuscitation. A total of 21 recommendations are detailed in this article: 2 clinical recommendations, 14 expert consensus statements, and 5 good practice statements. The statement, the panel's voting outcome, and the rationale for each statement intend to give pediatric trauma providers the latest evidence and guidance to care for pediatric trauma patients experiencing hemorrhagic shock. With a broad multidisciplinary representation, the Pediatric Traumatic Hemorrhagic Shock Consensus Conference systematically evaluated the literature and developed clinical recommendations, expert consensus, and good practice statements concerning topics in traumatically injured pediatric patients with hemorrhagic shock.

Association of red blood cell transfusion volume with postoperative complications and mortality in neonatal surgery

INTRODUCTION

Red blood cell transfusion (RBCT) is commonly administered in neonatal surgical care in the absence of clear clinical indications such as active bleeding or anemia. We hypothesized that higher RBCT volumes are associated with worse postoperative outcomes.

METHODS

Neonates within the National Surgical Quality Improvement Program-Pediatric database who underwent inpatient surgery (2012-2016) were stratified by weight-based RBCT volume: <20cc/kg, 20-40cc/kg, and >40cc/kg. Postoperative complications were categorized as wound, systemic infection, central nervous system (CNS), renal, pulmonary, and cardiovascular. Multivariable logistic regression and cubic spline analysis were used to evaluate the association between RBCT volume, postoperative complications, and 30-day mortality. Sensitivity analysis was conducted by performing propensity score matching.

RESULTS

Among 9,877 neonates, 1,024 (10%) received RBCTs. Of those who received RBCT, 53% received <20cc/kg, 27% received 20-40cc/kg, and 20% received >40cc/kg. Relative to neonates who were not transfused, RBCT volume was associated with a dose-dependent increase in renal complications, CNS complications, cardiovascular complications, and 30-day mortality. With cubic spline analysis, a lone inflection point for 30-day mortality was identified at a RBCT volume of 30 - 35 cc/kg. After propensity score matching, the dose-dependent relationship was still present for 30-day mortality.

CONCLUSION

Total RBCT volume is associated with worse postoperative outcomes in neonates with a significant increase in 30-day mortality at a RBCT volume of 30 - 35 cc/kg. Future prospective studies are needed to better understand the association between large RBCT volumes and poor outcomes after neonatal surgery.

LEVEL OF EVIDENCE

Level IV, Retrospective cohort study.

Association of prematurity with complications and failure to rescue in neonatal surgery

BACKGROUND

The majority of failure to rescue (FTR), or death after a postoperative complication, in pediatric surgery occurs among infants and neonates. The purpose of this study is to evaluate the association between gestational age (GA) and FTR in infants and neonates.

METHODS

National cohort study of 46,452 patients < 1 year old within the National Surgical Quality Improvement Program-Pediatric database who underwent inpatient surgery. Patients were categorized as preterm neonates, term neonates, or infants. Neonates were stratified based on GA. Surgical procedures were classified as low- (< 1% mortality) or high-risk (≥ 1%). Multivariable logistic regression and cubic splines were used to evaluate the association between GA and FTR.

RESULTS

Preterm neonates had the highest FTR (28%) rates. Among neonates, FTR increased with decreasing GA (≥ 37 weeks, 12%; 33-36 weeks, 15%; 29-32 weeks, 30%; 25-28 weeks 41%; ≤ 24 weeks, 57%). For both low- and high-risk procedures, FTR significantly (trend test, p < 0.01) increased with decreasing GA. When stratifying preterm neonates by GA, all GAs ≤ 28 weeks were associated with significantly higher odds of FTR for low- (OR 2.47, 95% CI [1.38-4.41]) and high-risk (OR 2.27, 95% CI [1.33-3.87]) procedures. A lone inflection point for FTR was identified at 31-32 weeks with cubic spline analysis.

CONCLUSIONS

The dose-dependent relationship between decreasing GA and FTR as well as the FTR inflection point noted at GA 31-32 weeks can be used by stakeholders in designing quality improvement initiatives and directing perioperative care.

LEVEL OF EVIDENCE

Level IV, Retrospective cohort study.

Thyroid surgery outcomes at a children's hospital: The value of a multidisciplinary team approach

BACKGROUND

Our purpose is to describe the structure, function and outcomes of our multidisciplinary pediatric thyroid program and to evaluate our experience in comparison to other high-volume centers.

METHODS

We reviewed all thyroid operations performed 10/2012 through 09/2019, and examined number of cases per year, patient demographics, procedures, final diagnoses and results. Primary outcomes were hypoparathyroidism and recurrent laryngeal nerve (RLN) injury at 12 months. Data were analyzed using descriptive statistics and univariate analyses.

RESULTS

We performed 294 thyroid operations on 279 patients. Seventy-nine percent were female. Median age was 15 years (IQR: 12-17). Operations included total thyroidectomy (65%), lobectomy (30%) and completion thyroidectomy (5%). Most common diagnoses were Graves' disease (35%), malignancy (29%), and benign nodule (20%). We developed an evidence-based clinical pathway and conducted weekly multidisciplinary meetings. A clinical data specialist reviewed process and outcome measures routinely. Overall, 6 patients (2.0%) had hypoparathyroidism and 2 (0.7%) had unilateral RLN injury at 12 months. Two of the patients with clinical suspicion of permanent hypoparathyroidism were ultimately weaned off calcium. Both patients with RLN injury had extensive locally advanced malignant disease involving the nerve.

CONCLUSIONS

Our multidisciplinary team achieved excellent long-term outcomes for pediatric thyroid surgery comparable to other high-volume pediatric and adult centers.

Characteristics and predictors of intensive care unit admission in pediatric blunt abdominal trauma

BACKGROUND

Pediatric trauma patients sustaining blunt abdominal trauma (BAT) with intra-abdominal injury (IAI) are frequently admitted to the intensive care unit (ICU). This study was performed to identify predictors for ICU admission following BAT.

METHODS

Prospective study of children (< 16 years) who presented to 14 Level-One Pediatric Trauma Centers following BAT over a 1-year period. Patients were categorized as ICU or non-ICU patients. Data collected included vitals, physical exam findings, laboratory results, imaging, and traumatic injuries. A multivariable hierarchical logistic regression model was used to identify predictors of ICU admission. Predictive ability of the model was assessed via tenfold cross-validated area under the receiver operating characteristic curves (cvAUC).

RESULTS

Included were 2,182 children with 21% (n = 463) admitted to the ICU. On univariate analysis, ICU patients were associated with abnormal age-adjusted shock index, increased injury severity scores (ISS), lower Glasgow coma scores (GCS), traumatic brain injury (TBI), and severe solid organ injury (SOI). With multivariable logistic regression, factors associated with ICU admission were severe trauma (ISS > 15), anemia (hematocrit < 30), severe TBI (GCS < 8), cervical spine injury, skull fracture, and severe solid organ injury. The cvAUC for the multivariable model was 0.91 (95% CI 0.88-0.92).

CONCLUSION

Severe solid organ injury and traumatic brain injury, in association with multisystem trauma, appear to drive ICU admission in pediatric patients with BAT. These results may inform the design of a trauma bay prediction rule to assist in optimizing ICU resource utilization after BAT.

STUDY DESIGN

Prognosis study.

LEVEL OF EVIDENCE: 1

Variations in analgesic, sedation, and delirium management between trauma and non-trauma critically ill children

INTRODUCTION

Studies have shown the benefit of intensive care unit (ICU) bundled protocols; however, they are primarily derived from medical patients. We hypothesized that patients and their medication profiles are different between critically ill medical, surgical, and trauma patients.

METHODS

The Pediatric Health Information System 2017 dataset was used to perform a retrospective cohort study of critically ill children. The pediatric medical, surgical, and trauma cohorts were separated based on ICD-10 codes. Data collected included demographics, secondary diagnoses, outcomes, and medication data. Medications were grouped as opiates, GABA-agonists, alpha-2 agonists, anti-psychotics, paralytics, and "other" sedatives. A non-parametric Kolmogorov-Smirnov test (KS test) and odds ratios (reference group: medical cohort) were calculated to compare medication administration between the study cohorts for the first 30 ICU days.

RESULTS

A total of 4488 critically ill children (medical 2078, surgical 1650, and trauma 760) were identified. The trauma cohort had increased incidence of delirium (medical 10.8%, surgical 11.5%, trauma 13.8%; p < 0.01) and mortality (medical 5.4%, surgical 2.4%, trauma 11.7%; p < 0.01). For all study cohorts, > 50% received GABA-agonists on ICU days 0-30. With the KS test, there was a significant difference in administration of opiates, GABA-agonists, alpha-2 agonists, anti-psychotics, and "other" sedatives over the first 30 days in the ICU. Relative to medical patients, trauma patients had significantly higher odds of receiving anti-psychotics on ICU days 10-20 and 22-24.

CONCLUSION

Critically ill pediatric trauma, medical, and surgical patients are distinctly different patient populations with differing pharmacologic profiles for analgesia, sedation, and delirium.

LEVEL OF EVIDENCE

Level III (Retrospective Comparative Study).

Executive Summary of Recommendations and Expert Consensus for Plasma and Platelet Transfusion Practice in Critically Ill Children: From the Transfusion and Anemia EXpertise Initiative-Control/Avoidance of Bleeding (TAXI-CAB)

OBJECTIVES

Critically ill children frequently receive plasma and platelet transfusions. We sought to determine evidence-based recommendations, and when evidence was insufficient, we developed expert-based consensus statements about decision-making for plasma and platelet transfusions in critically ill pediatric patients.

DESIGN

Systematic review and consensus conference series involving multidisciplinary international experts in hemostasis, and plasma/platelet transfusion in critically ill infants and children (Transfusion and Anemia EXpertise Initiative-Control/Avoidance of Bleeding [TAXI-CAB]).

SETTING

Not applicable.

PATIENTS

Children admitted to a PICU at risk of bleeding and receipt of plasma and/or platelet transfusions.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

A panel of 29 experts in methodology, transfusion, and implementation science from five countries and nine pediatric subspecialties completed a systematic review and participated in a virtual consensus conference series to develop recommendations. The search included MEDLINE, EMBASE, and Cochrane Library databases, from inception to December 2020, using a combination of subject heading terms and text words for concepts of plasma and platelet transfusion in critically ill children. Four graded recommendations and 49 consensus expert statements were developed using modified Research and Development/UCLA and Grading of Recommendations, Assessment, Development, and Evaluation methodology. We focused on eight subpopulations of critical illness (1, severe trauma, intracranial hemorrhage, or traumatic brain injury; 2, cardiopulmonary bypass surgery; 3, extracorporeal membrane oxygenation; 4, oncologic diagnosis or hematopoietic stem cell transplantation; 5, acute liver failure or liver transplantation; 6, noncardiac surgery; 7, invasive procedures outside the operating room; 8, sepsis and/or disseminated intravascular coagulation) as well as laboratory assays and selection/processing of plasma and platelet components. In total, we came to consensus on four recommendations, five good practice statements, and 44 consensus-based statements. These results were further developed into consensus-based clinical decision trees for plasma and platelet transfusion in critically ill pediatric patients.

CONCLUSIONS

The TAXI-CAB program provides expert-based consensus for pediatric intensivists for the administration of plasma and/or platelet transfusions in critically ill pediatric patients. There is a pressing need for primary research to provide more evidence to guide practitioners.

Plasma and Platelet Transfusion Strategies in Critically Ill Children Following Noncardiac Surgery and Critically Ill Children Undergoing Invasive Procedures Outside the Operating Room: From the Transfusion and Anemia EXpertise Initiative-Control/Avoidance of Bleeding

OBJECTIVES

To present consensus statements and supporting literature for plasma and platelet transfusions in critically ill children following noncardiac surgery and critically ill children undergoing invasive procedures outside the operating room from the Transfusion and Anemia EXpertise Initiative - Control/Avoidance of Bleeding.

DESIGN

Systematic review and consensus conference of international, multidisciplinary experts in platelet and plasma transfusion management of critically ill children.

SETTING

Not applicable.

PATIENTS

Critically ill children undergoing invasive procedures outside of the operating room or noncardiac surgery.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

A panel of 10 experts developed evidence-based and, when evidence was insufficient, expert-based statements for plasma and platelet transfusions in critically ill children following noncardiac surgery or undergoing invasive procedures outside of the operating room. These statements were reviewed and ratified by the 29 Transfusion and Anemia EXpertise Initiative-Control/Avoidance of Bleeding experts. A systematic review was conducted using MEDLINE, EMBASE, and Cochrane Library databases, from inception to December 2020. Consensus was obtained using the Research and Development/University of California, Los Angeles Appropriateness Method. Results were summarized using the Grading of Recommendations Assessment, Development, and Evaluation method. We developed eight expert consensus statements focused on the critically ill child following noncardiac surgery and 10 expert consensus statements on the critically ill child undergoing invasive procedures outside the operating room.

CONCLUSIONS

Evidence regarding plasma and platelet transfusion in critically ill children in this area is very limited. The Transfusion and Anemia EXpertise Initiative-Control/Avoidance of Bleeding Consensus Conference developed 18 pediatric specific consensus statements regarding plasma and platelet transfusion management in these critically ill pediatric populations.

Research Priorities for Plasma and Platelet Transfusion Strategies in Critically Ill Children: From the Transfusion and Anemia EXpertise Initiative-Control/Avoidance of Bleeding

OBJECTIVES

To present a list of high-priority research initiatives for the study of plasma and platelet transfusions in critically ill children from the Transfusion and Anemia EXpertise Initiative-Control/Avoidance of Bleeding.

DESIGN

Systematic review and consensus conference of international, multidisciplinary experts in platelet and plasma transfusion management of critically ill children.

SETTING

Not applicable.

PATIENTS

Critically ill pediatric patients at risk of bleeding and receiving plasma and/or platelet transfusions.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

A panel of 13 experts developed research priorities for the study of plasma and platelet transfusions in critically ill children which were reviewed and ratified by the 29 Transfusion and Anemia EXpertise Initiative-Control/Avoidance of Bleeding experts. The specific priorities focused on the following subpopulations: severe trauma, traumatic brain injury, intracranial hemorrhage, cardiopulmonary bypass surgery, extracorporeal membrane oxygenation, oncologic diagnosis or stem cell transplantation, acute liver failure and/or liver transplantation, noncardiac surgery, invasive procedures outside of the operating room, and sepsis and/or disseminated intravascular coagulation. In addition, tests to guide plasma and platelet transfusion, as well as component selection and processing, were addressed. We developed four general overarching themes and 14 specific research priorities using modified Research and Development/University of California, Los Angeles methodology.

CONCLUSIONS

Studies are needed to focus on the efficacy/harm, dosing, timing, and outcomes of critically ill children who receive plasma and/or platelet transfusions. The completion of these studies will facilitate the development of evidence-based recommendations.

Plasma and Platelet Transfusion Strategies in Critically Ill Children Following Severe Trauma, Traumatic Brain Injury, and/or Intracranial Hemorrhage: From the Transfusion and Anemia EXpertise Initiative-Control/Avoidance of Bleeding

OBJECTIVES

To present consensus statements and supporting literature for plasma and platelet transfusions in critically ill children with severe trauma, traumatic brain injury, and/or intracranial hemorrhage from the Transfusion and Anemia EXpertise Initiative-Control/Avoidance of Bleeding.

DESIGN

Systematic review and consensus conference of international, multidisciplinary experts in platelet and plasma transfusion management of critically ill children.

SETTING

Not applicable.

PATIENTS

Critically ill neonates and children with severe trauma, traumatic brain injury, and/or intracranial hemorrhage.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

A panel of eight experts developed expert-based statements for plasma and platelet transfusions in critically ill neonates and children with severe trauma, traumatic brain injury, and/or intracranial hemorrhage. These statements were reviewed and ratified by the 29 Transfusion and Anemia EXpertise Initiative-Control/Avoidance of Bleeding experts. A systematic review was conducted using MEDLINE, EMBASE, and Cochrane Library databases, from inception to December 2020. Consensus was obtained using the Research and Development/University of California, Los Angeles Appropriateness Method. Results were summarized using the Grading of Recommendations Assessment, Development, and Evaluation method. We developed one good practice statement and six expert consensus statements.

CONCLUSIONS

The lack of evidence precludes proposing recommendations on monitoring of the coagulation system and on plasma and platelets transfusion in critically ill pediatric patients with severe trauma, severe traumatic brain injury, or nontraumatic intracranial hemorrhage.

Plasma and Platelet Transfusions Strategies in Neonates and Children Undergoing Cardiac Surgery With Cardiopulmonary Bypass or Neonates and Children Supported by Extracorporeal Membrane Oxygenation: From the Transfusion and Anemia EXpertise Initiative-Control/Avoidance of Bleeding

OBJECTIVES

To present the recommendations and consensus statements with supporting literature for plasma and platelet transfusions in critically ill neonates and children undergoing cardiac surgery with cardiopulmonary bypass or supported by extracorporeal membrane oxygenation from the Transfusion and Anemia EXpertise Initiative-Control/Avoidance of Bleeding.

DESIGN

Systematic review and consensus conference of international, multidisciplinary experts in platelet and plasma transfusion management of critically ill children.

SETTING

Not applicable.

PATIENTS

Critically ill neonates and children following cardiopulmonary bypass or supported by extracorporeal membrane oxygenation.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

A panel of nine experts developed evidence-based and, when evidence was insufficient, expert-based statements for plasma and platelet transfusions in critically ill neonates and children following cardiopulmonary bypass or supported by extracorporeal membrane oxygenation. These statements were reviewed and ratified by the 29 Transfusion and Anemia EXpertise Initiative-Control/Avoidance of Bleeding experts. A systematic review was conducted using MEDLINE, EMBASE, and Cochrane Library databases, from inception to December 2020. Consensus was obtained using the Research and Development/University of California, Los Angeles Appropriateness Method. Results were summarized using the Grading of Recommendations Assessment, Development, and Evaluation method. We developed one good practice statement, two recommendations, and three expert consensus statements.

CONCLUSIONS

Whereas viscoelastic testing and transfusion algorithms may be considered, in general, evidence informing indications for plasma and platelet transfusions in neonatal and pediatric patients undergoing cardiac surgery with cardiopulmonary bypass or those requiring extracorporeal membrane oxygenation support is lacking.

Favorable postoperative outcomes for children with COVID-19 infection undergoing surgical intervention: Experience at a free-standing children's hospital

BACKGROUND

Current literature has shown that adult patients with perioperative Coronavirus Disease-2019 (COVID-19) have increased rates of postoperative morbidity and mortality. We hypothesized that children with COVID-19 have favorable postoperative outcomes compared to the reported adult experience.

METHODS

We performed a retrospective cohort study for children with a confirmed preoperative COVID-19 diagnosis from April 1st, 2020 to August 15th, 2020 at a free-standing children's hospital. Primary outcomes evaluated were postoperative complications, readmissions, reoperations, and mortality within 30 days of operation. Secondary outcomes included hospital resource utilization, hospital length of stay, and postoperative oxygen support.

RESULTS

A total of 66 children with preoperative confirmed COVID-19 were evaluated with median age of 9.5 years (interquartile range (IQR) 5-14) with 65% male and 70% Hispanic White. Sixty-five percent of patients had no comorbidities, with abdominal pain identified as the most common preoperative symptom (65%). Twenty-three percent of patients presented with no COVID-19 related symptoms. Eighty-two percent of patients had no preoperative chest imaging and 98% of patients did not receive preoperative oxygen support. General pediatric surgeons performed the majority of procedures (68%) with the most common diagnosis appendicitis (47%). Forty-one percent of patients were discharged the same day as surgery with 9% of patients utilizing postoperative intensive care unit resources and only 5% receiving postoperative invasive mechanical ventilation. Postoperative complications (7%), readmission (6%), and reoperation (6%) were infrequent, with no mortality.

CONCLUSION

COVID-19+ children requiring surgery have a favorable postoperative course and short-term outcomes compared to the reported adult experience.

TYPE OF STUDY

Prognosis Study.

LEVEL OF EVIDENCE

Level IV.

What happens after the hospital? An analysis of longitudinal care needs in children treated for child physical abuse

BACKGROUND

Victims of child physical abuse (CPA) undergo stabilization and social evaluation during initial management. Current data guides the initial hospital course, but few studies evaluate post-hospital care. The aim of this study was to evaluate compliance with recommended post-discharge visits.

METHODS

A retrospective review of our trauma database at a Level I pediatric trauma center from 2014-2018 was performed. Data included demographics, injuries, and longitudinal outcomes. Descriptive statistics and univariate analyses were performed.

RESULTS

There were 401 patients (409 unique presentations). Median age was 7 months. Mortality was 6%. Ninety-five percent (358/377) had recommended appointments with multiple specialty services. Compliance with all recommended visits during the first year after injury was 88%. Patients with complex injuries were as likely to comply with recommended follow-up [72% vs. 67%, p = 0.4]; however, they were more likely to still be receiving care at 1 year (58% vs. 14%, p = 0.0001). Those discharged to CPS custody were more likely to be compliant with their follow-up (90% vs. 82%, p = 0.03).

CONCLUSION

Patients significantly injured due to CPA require more post-hospital care over time. CPA management guidelines should include a mechanism to provide resources to these patients and manage multiple coordinating consultants .

Context-Responsive Anticoagulation Reduces Complications in Pediatric Extracorporeal Membrane Oxygenation

Purpose: We sought to determine the impact of a comprehensive, context-responsive anticoagulation and transfusion guideline on bleeding and thrombotic complication rates and blood product utilization during extracorporeal membrane oxygenation (ECMO).

Design: Single-center, observational pre- and post-implementation cohort study.

Setting: Academic pediatric hospital.

Patients: Patients in the PICU, CICU, and NICU receiving ECMO support.

Interventions: Program-wide implementation of a context-responsive anticoagulation and transfusion guideline.

Measurements: Pre-implementation subjects consisted of all patients receiving ECMO between January 1 and December 31, 2012, and underwent retrospective chart review. Post-implementation subjects consisted of all ECMO patients between September 1, 2013, and December 31, 2014, and underwent prospective data collection. Data collection included standard demographic and admission data, ECMO technical specifications, non-ECMO therapies, coagulation parameters, and blood product administration. A novel grading scale was used to define hemorrhagic complications (major, intermediate, and minor) and major thromboembolic complications.

Main Results: Seventy-six ECMO patients were identified: 31 during the pre-implementation period and 45 in the post-implementation period. The overall observed mortality was 33% with no difference between groups. Compared to pre-implementation, the post-implementation group experienced fewer major hemorrhagic and major thrombotic complications and less severe hemorrhagic complications and received less RBC transfusion volume per kg.

Conclusions: Use of a context-responsive anticoagulation and transfusion guideline was associated with a reduction in hemorrhagic and thrombotic complications and reduced RBC transfusion requirements. Further evaluation of guideline content, compliance, performance, and sustainability is needed.

In neonatal-onset surgical short bowel syndrome survival is high, and enteral autonomy is related to residual bowel length

BACKGROUND

In an era of improved management and treatment options, this study aims to describe the long-term outcomes and factors predictive of outcomes of neonatal-onset intestinal failure (IF) due to surgical short bowel syndrome (SBS).

METHODS

Retrospective, single-center cohort study of infants born between January 2011 and December 2018 with inclusion criteria: <44 weeks postmenstrual age at SBS diagnosis, <28 days on admission, parenteral nutrition dependence >60 days, and documented intestinal resection. Primary outcomes included survival and achievement of enteral autonomy (EA). Data analysis utilized Fisher.s exact test, Kruskal-Wallis test, survival analysis methods, Cox proportional hazards regression, linear regression and logistic regression.

RESULTS

Ninety-five patients (males 56%) were studied with median follow-up of 38 months (IQR 19, 59). Survival at last follow-up was 96%, and EA was achieved in 85%. Forty-eight patients had documented residual bowel length (RBL) with median length of 49 cm (IQR 36, 80). Survival in patients with RBL of <30cm (n = 8), 30-59cm (n = 19), and >60cm (n = 21) was 100%, 95%, and 95% respectively. Shorter RBL was associated with longer time to achieve EA (p = 0.007), but not with survival (p = 0.81). Delay in achieving EA was associated with absence of ileocecal valve (p = 0.002) and bloodstream infections (p < 0.001). Peak conjugated bilirubin correlated with increased mortality (p = 0.002).

CONCLUSION

Overall high rate of survival and achievement of EA was found in neonatal onset IF due to SBS. EA but not survival was correlated with RBL. Ileocecal valve, bloodstream infections, and conjugated bilirubin levels were the other predictive factors of outcomes.

Mortality trends in neonatal ECMO for pulmonary hypoplasia: A review of the Extracorporeal Life Support Organization database from 1981 to 2016

BACKGROUND

The purpose of this review is to provide ECMO outcome data for medical personnel who counsel families of patients with pulmonary hypoplasia (PH), often secondary to renal abnormalities. We report diagnoses and outcomes associated with PH in neonates that were treated with ECMO over the past 35 years.

METHODS

Retrospective cohort study using the ELSO database for neonates born between 1981 and 2016 with a primary or secondary diagnosis of PH. Five patient groups were created based on ICD-9 codes. Mortality rates were compared and trends over time were investigated.

RESULTS

Thirty-three percent of the 1385 patients survived to discharge. Congenital diaphragmatic hernia (CDH) patients had significantly higher mortality than PH patients secondary to renal dysplasia (p < 0.001). Mortality decreased significantly over time for all groups (p < 0.001). The proportion of patients alive at discharge increased over time for CDH patients (p < 0.001), whereas survival decreased for patients with PH secondary to renal dysplasia (p = 0.012).

CONCLUSIONS

Neonates with PH that require ECMO have high mortality rates, which have generally decreased over the past 35 years; however, mortality for neonates with PH secondary to renal dysplasia continues to increase. We speculate that the apparent rise in mortality for these patients is because of changes in patient selection subsequent to improvements in non-ECMO ventilatory support.

LEVEL OF EVIDENCE

II.

Central venoarterial extracorporeal life support in pediatric refractory septic shock: a single center experience

OBJECTIVE

Venoarterial extracorporeal membrane oxygenation (VA ECMO) is recognized as a potential support therapy for pediatric patients with refractory septic shock (RSS). This review aims to report our experience with central VA cannulation in pediatric patients with RSS, and to compare this with peripheral VA ECMO cannulations for this condition at our institution.

DESIGN

Retrospective case series.

SETTING

Pediatric and cardiac intensive care units in an academic pediatric hospital.

PATIENTS

All patients 0-18 years old meeting criteria of RSS placed on VA ECMO between January 2011 and December 2018.

INTERVENTIONS

None.

MEASUREMENTS

Demographics, relevant clinical variables, ECMO run details, and outcomes were collected.

RESULTS

Between 2011 and 2018, 14 children were placed on VA ECMO for RSS. Nine were cannulated centrally, with the rest placed on peripheral VA ECMO. Overall survival to hospital discharge was 57.1% (8/14), with 66.7% of the central cannulation cohort surviving versus 40% in the peripheral cannulation (p = 0.34). Median ECMO duration was 147.1 hours (IQR: 91.9-178.6 hours), with survivors having a median length of 147.1 (IQR: 138.5-185.7) versus non survivors 114.7 hours (IQR: 63.7-163.5), p = 0.48. Overall median ICU length of stay (LOS) was 19 days (IQR: 10.5-42.2). The median % maximum flow achieved on VA ECMO was higher in the central cannulation group at 179.6% (IQR: 154.4-188.1) versus the peripheral with 133.5% (98.1-149.1), p = 0.01. Functional status scale (FSS) was used to capture morbidity. All survivors had a mean increase in their FSS from baseline. In the centrally cannulated group, 50% (4/8) received mediastinal exploration, but none developed mediastinitis. In terms of blood product utilization, the central cannulation received more platelets compared to the peripherally cannulated group (median 15.6 vs 3.3 mL/kg/day, p = 0.03).

CONCLUSION

A central approach to VA ECMO cannulation is feasible and has potential for good patient outcomes in selected patients.

Safely repositioning dual-lumen ECMO cannulas with a transfemoral lasso snare

INTRODUCTION

Dual-lumen cannulas were designed to provide venovenous extracorporeal membrane oxygenation (VV ECMO) with single-vessel access. Anatomic and size considerations may make appropriate placement challenging in children. Dual-lumen cannulas are repositioned in 20-69% of pediatric patients, which can be difficult without transient discontinuation of ECMO support.

METHODS

We repositioned three dual-lumen ECMO cannulas introduced via the right internal jugular vein using a transfemoral snare technique under real-time ultrasound and fluoroscopy.

RESULTS

Two of three patients were supported on VV ECMO and one on veno-veno-arterial (VV-A) ECMO. Two of the three patients had their dual-lumen cannula repositioned under ultrasound and fluoroscopy guidance and one was repositioned just with ultrasound. No patient experienced a complication from the transfemoral snare technique such as femoral hematoma, hemorrhage or limb ischemia.

CONCLUSION

We describe three patients who successfully had dual-lumen cannulas repositioned without cessation of ECMO using a transfemoral "lasso" technique.

The utility and promise of Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) in the pediatric population: An evidence-based review

Hemorrhage is the main cause of preventable death in both military and civilian trauma, and many of these patients die from non-compressible torso injuries. Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a minimally invasive method used for hemodynamic control of the hemorrhaging patient and has been compared to resuscitative thoracotomy (RT) with cross clamping of the aorta. REBOA has received a great deal of attention in recent years for its applicability and promise in adult trauma and non-trauma settings, but its utility in children is mostly unknown. The purpose of this review article is to summarize and consolidate what is currently known about the use of REBOA in children. Some of the challenges in implementing REBOA in children include small vascular anatomy and lack of outcomes data. Although the evidence is limited, there are established instances in the literature of children and adolescents who have undergone endovascular occlusion of the aorta for hemorrhage control with positive outcomes and survival rates equivalent to their adult counterparts. There is a need for further formal evaluation of REBOA in pediatric patients with prospective studies to look at the safety, feasibility and efficacy of the technique. STUDY TYPE: Narrative Literature Review LEVEL OF EVIDENCE: IV.

Progression to colectomy in the era of biologics: A single center experience with pediatric ulcerative colitis

BACKGROUND/PURPOSE

Clinical outcomes in pediatric ulcerative colitis (UC) in the era of biologic agents are poorly defined. We aimed to describe risk factors for colectomy in pediatric UC in the era of infliximab therapy.

METHODS

We reviewed 217 pediatric patients at Texas Children's Hospital with newly diagnosed UC between 2003 and 2015; 117 had a minimum of 5 years of follow-up. Extent of disease at diagnosis, medication exposure, the presence of extraintestinal manifestations (EIMs), and need for surgery were noted.

RESULTS

Average length of follow up was 5.02 ± 2.27 years. Forty-two percent presented with pancolitis. Infliximab was used in 39%, immunomodulators in 65%, and steroids in 89% of patients. EIMs occurred in 24.9% of patients. The cumulative rate of colectomy was 12.9% at 5 years. Children presenting as E2 (Paris Classification) and children prescribed oral steroid monotherapy at diagnosis progressed to surgery faster than any other group. Of the children who received infliximab, females and children less than 5 years old were less likely to respond to therapy.

CONCLUSIONS

The natural course of pediatric UC remains aggressive despite the addition of infliximab to the standard of care and suggests a need for early aggressive clinical intervention.

LEVEL-OF-EVIDENCE RATING

Level IV.

Outcomes After Extracorporeal Life Support Cannulation in Pediatric Patients With Trisomy 13 and Trisomy 18

BACKGROUND

Indications for extracorporeal life support (ECLS) have evolved and expanded, yet its use in trisomy 13 (T13) and trisomy 18 (T18) patients remains controversial. We reviewed the experience of the Extracorporeal Life Support Organization with ECLS in these patients to inform practice at our institution.

METHODS

The Extracorporeal Life Support Organization registry was queried for all patients younger than 18 y with an International Classification of Diseases, Ninth Edition/Tenth Edition code for T13 or T18 from 2000 to 2018. Basic demographics, ECLS details, and clinical outcomes were recorded. Descriptive statistics were performed.

RESULTS

Twenty-eight patients were identified (15 with T13; 13 with T18), representing 0.06% (28 of 46,901) of pediatric ECLS cannulations. The median weight was 3.5 kg (range, 1.4-13), and age at cannulation was 52 d (range, 0 d-6.8 y). Time on ECLS ranged from 13 to 478 h (median, 114). Cardiac defects were diagnosed in 19 (68%) patients, of which 13 (46%) underwent surgical repair. Median oxygenation index pre-ECLS was 45. Venoarterial cannulations accounted for 82% of patients, whereas 14% underwent venovenous cannulation. Overall survival to hospital discharge was 46% with 86% of patients experiencing one or more complications. There were no survivors when cannulation continued past 12 d.

CONCLUSIONS

Although complications are frequent, the mortality rate in patients with T13 and T18 remains within the reported range for the general pediatric population. T13 and T18 alone should not be viewed as absolute contraindications to ECLS within the pediatric population but rather considered during the evaluation of a patient's potential candidacy.

Barely benign: The dangers of BB and other nonpowder guns

OBJECTIVE

To characterize the risks of nonpowder guns commonly used by children for recreation.

METHODS

We conducted a retrospective review of children ≤18 years of age treated for nonpowder gun injuries at a pediatric level I trauma center during 2013-2017. Demographics, injury characteristics, treatments, and outcomes were reviewed and analyzed using descriptive statistics.

RESULTS

Forty-six cases were identified; of these, 78% were male and the median age was 10 years (IQR 7-13). All guns were either ball-bearing or pellet guns. Eighty-five percent (38/46) of injuries were penetrating. The most common location was the head and neck (28%), followed by the anterior torso (26%) and eye (24%). Significant injuries that penetrated organs or body cavities occurred in 39% (18/46) and included subarachnoid hemorrhage; lung, liver, and kidney lacerations; pulmonary artery injury; and tracheal injury. Nine percent (4/26) were admitted to the intensive care unit, 37% (17/46) underwent surgery, and there were no deaths.

DISCUSSION

Injuries from recreational nonpowder guns such as ball-bearing or pellet guns can cause severe injuries in children. A thorough penetrating trauma workup should always be undertaken. Safety precautions should be taken when using these guns and access to young children should be restricted.

LEVEL OF EVIDENCE

Prognosis level IV.

Understanding non-accidental trauma in the United States: A national trauma databank study

BACKGROUND

The purpose of this study is to characterize the epidemiology, injury patterns, outcomes and trends of non-accidental trauma (NAT) in the United States using a large national database.

METHODS

Children <15 years presenting after NAT were identified in the 2007-2014 National Trauma Databank research datasets. Clinical and outcome data were analyzed using descriptive statistics, chi-square and logistic regression.

RESULTS

Of 678,503 children admitted for traumatic injuries, 3% (19,149) were victims of NAT. The majority (95%) were under 5 years and 71% under 1 year old. The majority (59%) were male. The median injury severity score (ISS) was 10 (IQR:5-19). African Americans were disproportionally affected (27% vs 17% of all traumas), and the majority had public or no insurance (85%). Incidence was highest in the midwest and lowest in the northeast regions of the country, although trends varied over time. NAT resulted in 43% of trauma deaths in children <1 year and 31% of trauma deaths in children <5. Traumatic brain injury (TBI) was the most commonly encountered diagnosis (50%). Polytrauma was common, and certain injury patterns were identified. Urgent operation was required in 6%, 43% were admitted to intensive care, and 9% died. Mortality was independently associated with TBI, thoracic injury, hollow viscus injury and older age.

CONCLUSION

Non-accidental trauma is a leading cause of trauma mortality in young children. Multiple injuries are common, requiring comprehensive evaluation and early surgical involvement. The data presented in this study could serve as a guide to target injury prevention efforts.

LEVEL OF EVIDENCE

III STUDY TYPE: Prognostic and Epidemiological.

The significance of abdominal radiographs with paucity of gas in pediatric adhesive small bowel obstruction

PURPOSE

Management of children with adhesive small bowel obstruction (ASBO) is often based on abdominal radiographs (AXR). Our purpose was to determine the significance of paucity of gas on initial AXR.

METHODS

Retrospective, single center review of children with ASBO between 2011 and 2015. Analysis included chi-square, non-parametric tests and multivariate regression.

RESULTS

Of 207 cases, 99 were operative. Initial AXR showed paucity of gas in 41% and gaseous loops in 59%. Paucity was more common in operative patients (49% vs. 32%, p = 0.01). At operation, 71% of patients with paucity had closed loop or high-grade obstruction, compared to 29% of patients with gaseous loops (p = <0.001).

CONCLUSION

For children with ASBO with paucity of gas on AXR, complicated obstruction (closed loop or high-grade) should be considered. In children with high clinical suspicion of complicated obstruction, additional imaging with CT or SBFT may clarify the clinical picture.

Prenatal Imaging Features and Postnatal Factors Associated with Gastrointestinal Morbidity in Congenital Diaphragmatic Hernia

BACKGROUND

To perform a comprehensive assessment of postnatal gastrointestinal (GI) morbidity and determine the prenatal imaging features and postnatal factors associated with its development in patients with congenital diaphragmatic hernia (CDH).

MATERIALS AND METHODS

A retrospective review was conducted of all infants evaluated for CDH at a quaternary fetal center from February 2004 to May 2017. Prenatal imaging features and postnatal variables were analyzed. GI morbidity was the primary outcome. The Mann-Whitney U test, the Kruskal-Wallis test with Dunnett's T3 post hoc analysis and logistic regression, and the χ2 test were performed when appropriate.

RESULTS

We evaluated 256 infants; 191 (75%) underwent CDH repair and had at least 6 months of follow-up. Of this cohort, 60% had gastroesophageal reflux disease (GERD), 13% had gastroparesis, 32% received a gastrostomy tube (G-tube), and 17% needed a fundoplication. Large defect, patch repair, extracorporeal membrane oxygenation (ECMO), and prolonged use of mechanical ventilation were significantly associated with having GERD, gastroparesis, G-tube placement, and fundoplication (p < 0.05). Fetuses with stomach grades 3 and 4 were most likely to have GERD, a G-tube, and a long-term need for supplemental nutrition than fetuses with stomach grades 1 and 2 (p < 0.05).

CONCLUSION

Survivors of CDH with large defects, prolonged use of mechanical ventilation, or that have received ECMO may be at an increased risk for having GERD, gastroparesis, and major GI surgery. Marked stomach displacement on prenatal imaging is significantly associated with GI morbidity in left-sided CDH.

Management and outcomes of peripancreatic fluid collections and pseudocysts following non-operative management of pancreatic injuries in children

BACKGROUND

Peripancreatic fluid collection and pseudocyst development is a common sequela following non-operative management (NOM) of pancreatic injuries in children. Our purpose was to review management strategies and assess outcomes.

METHODS

A multicenter, retrospective review was conducted of children treated with NOM following blunt pancreatic injury at 22 pediatric trauma centers between the years 2010 and 2015. Organized fluid collections were called "acute peripancreatic fluid collection" (APFC) if identified < 4 weeks and "pseudocyst" if > 4 weeks following injury. Data analysis included descriptive statistics Wilcoxon rank-sum, Kruskal-Wallis and t tests.

RESULTS

One hundred patients with blunt pancreatic injury were identified. Median age was 8.5 years (range 1-16). Forty-two percent of patients (42/100) developed organized fluid collections: APFC 64% (27/42) and pseudocysts 36% (15/42). Median time to identification was 12 days (range 7-42). Most collections (64%, 27/42) were observed and 36% (15/42) underwent drainage: 67% (10/15) percutaneous drain, 7% (1/15) needle aspiration, and 27% (4/15) endoscopic transpapillary stent. A definitive procedure (cystogastrostomy/pancreatectomy) was required in 26% (11/42). Patients with larger collections (≥ 7.1 cm) had longer time to resolution. Comparison of outcomes in patients with observation vs drainage revealed no significant differences in TPN use (79% vs 75%, p = 1.00), hospital length of stay (15 vs 25 median days, p = 0.11), time to tolerate regular diet (12 vs 11 median days, p = 0.47), or need for definitive procedure (failure rate 30% vs 20%, p = 0.75).

CONCLUSIONS

Following NOM of blunt pancreatic injuries in children, organized fluid collections commonly develop. If discovered early, most can be observed successfully, and drainage does not appear to improve clinical outcomes. Larger size predicts prolonged recovery.

LEVEL OF EVIDENCE

III STUDY TYPE: Case series.

Bowel preparation for colostomy reversal in children

PURPOSE

Pediatric bowel preparation protocols used before colostomy reversal vary. The aim of this study is to determine institutional practices at our institution and evaluate the impact of bowel preparations on postoperative outcomes and hospital length of stay in children.

METHODS

This was a retrospective review of children ≤18 years old undergoing colostomy reversal at Texas Children's Hospital (TCH) between 12/2013 and 8/2017. Preoperative bowel regimens and outcomes were collected and analyzed using descriptive statistics, Wilcoxon Rank-Sum and Fishers Exact tests. Continuous variables are presented as median [IQR].

RESULTS

Sixty-one children underwent colostomy reversal. Thirty-eight (62%) did not receive a preoperative bowel preparation. The two cohorts were similar in age, gender, and race. The most common indication for colostomy was anorectal malformation for thirty-seven (61%). Time from admission to surgery (19 h [17, 23] vs 3 [2, 3]; p < 0.01) and HLOS (6 days [5, 8] vs 5 [4, 6]; p = 0.02) were both longer in the bowel preparation cohort. Complications (3 [13%] vs 5 [22%]; p = 0.12) and 90-day readmissions (3 [13%] vs 6 [16%]; p = 0.64) were similar in both cohorts.

CONCLUSION

Foregoing bowel preparation may have the potential to improve cost and reduce morbidity in children undergoing colostomy closure.

LEVEL OF EVIDENCE

III.

STUDY TYPE

Treatment study.

Fetal echocardiography (ECHO) in assessment of structural heart defects in congenital diaphragmatic hernia patients: Is early postnatal ECHO necessary for ECMO candidacy?

PURPOSE

The purpose of this study was to determine the accuracy of fetal echocardiogram (ECHO) for detecting cardiac structural anomalies that may impact Extracorporeal Membrane Oxygenation (ECMO) candidacy in infants with Congenital Diaphragmatic Hernia (CDH).

METHODS

A retrospective review was performed on fetuses with CDH (January 2007-June 2017). Inclusion criteria were inborn and at least one prenatal and postnatal ECHO. ECHOs were evaluated for structural heart defects. Primary outcomes were accuracy of prenatal fetal ECHO and identify differences between prenatal and postnatal ECHO. Descriptive statistics and Chi-square analysis were performed.

RESULTS

131 inborn patients were identified. Mean gestational age of fetal ECHO was 26.6 ± 5.5 weeks. The median time to postnatal ECHO was DOL 1 [0-30]. Fetal ECHO had 92% accuracy, 83% sensitivity, 93% specificity, PPV of 95%, NPV of 92%, and a 90% accuracy for visualization of at least one pulmonary vein into the left atrium on the contralateral (non-CDH) side. Thirty-five percent of patients received ECMO, and 26% had an associated cardiac anomaly. All ECMO patients had an accurate structural fetal ECHO.

CONCLUSION

Fetal ECHO is sufficient for identifying major structural heart defects at large volume centers with trained pediatric cardiologists and may be used to guide clinical management, particularly in regards to ECMO candidacy.

LEVEL OF EVIDENCE

Level III.

Defining massive transfusion in civilian pediatric trauma

PURPOSE

The purpose of this study was to identify an optimal definition of massive transfusion (MT) in civilian pediatric trauma.

METHODS

Severely injured children (age ≤18 years, injury severity score ≥25) in the Trauma Quality Improvement Program research datasets 2014-2015 that received blood products were identified. Children with traumatic brain injury and non-survivable injuries were excluded. Early mortality was defined as death within 24 h and delayed mortality as death after 24 h from hospital admission. Receiver operating curves and sensitivity and specificity analysis identified an MT threshold. Continuous variables are presented as median [IQR].

RESULTS

Of the 270 included children, the overall mortality was 27% (N = 74). There were no differences in demographics or mechanism of injury between children that lived or died. Sensitivity and specificity for early mortality was optimized at a 4-h transfusion volume of 37 ml/kg. After controlling for other significant variables, a threshold of 37 ml/kg/4 h predicted the need for a hemorrhage control procedure (OR 8.60; 95% CI 4.25-17.42; p < 0.01) and early mortality (OR 4.24; 95% CI 1.96-9.16; p < 0.01).

CONCLUSION

An MTP threshold of 37 mL/kg/4 h of transfused blood products predicted the need for hemorrhage control procedures and early mortality. This threshold may provide clinicians with a timely prognostic indicator, improve research methodology, and resource utilization.

TYPE OF STUDY

Diagnostic Test.

LEVEL OF EVIDENCE

III.