Use of Opioids and Nonopioid Analgesics to Treat Pediatric Postoperative Pain in the Emergency Department

OBJECTIVES

The incidence, demographic characteristics, and treatment approaches for pediatric patients who present to the ED with a primary complaint of postoperative pain have not been well described. The purpose of this study was to describe opioid and nonopioid prescribing patterns for pediatric patients evaluated for postoperative pain in the Emergency Department (ED).

METHODS

Pediatric Health Information System is an administrative database of encounter-level data from 48 children's hospitals. Emergency department visits for postoperative pain from January 2014 to September 2017 were analyzed. Visits were matched by the Pediatric Health Information System identifier to associate corresponding same site surgery encounters directly preceding ED visits.

RESULTS

There were 7365 ED visits for acute postoperative pain, for which 4044 could be linked to corresponding surgical procedure. Eight-one percent of ED visits were within 7 days of surgery. Opioids were given at 1979 (49%) of visits, and nonopioids at 678 (17%) of visits. The most common surgeries preceding a postoperative pain ED visit were for tonsils and adenoids (48.5%). Age, sex, length of stay for both procedure and ED visits, procedure specialty, and the number of days between procedure discharge and admission to ED were associated with opioid administration during ED visits (P < 0.05).

CONCLUSIONS

Pediatric patients treated in the ED for postoperative pain were often treated with opioid and nonopioid analgesics, with wide prescriber variability. Further research is warranted to help balance optimal pain management and safe prescribing practices.

Management of broncho-esophageal fistula after button battery ingestion

Button battery ingestion can cause serious injury or death in young children who cannot communicate symptoms. An 18-month-old male presented after his mother noted drooling, nonbilious emesis and a metallic smell to his breath. He underwent rigid esophagoscopy and a 3-V 20-mm button battery was removed. Subsequent bronchoscopy after a 1-week interval revealed progression to a large broncho-esophageal fistula on the posterior wall of the right mainstem bronchus past the carina. A fenestrated nasogastric tube for local control of secretion and a feeding jejunostomy was placed. Six weeks later, the patient underwent a right thoracotomy for division and repair of the fistula and intercostal muscle flap interposition. Utilizing a well-placed fenestrated nasogastric tube to manage secretions can help reduce fistula size and improve conservative management results. When surgical repair is required, an intercostal muscle flap can reinforce fistula closure while simultaneously buttressing the bronchus and esophagus.

Achieving expert performance through simulation-based education and application of mastery learning principles

Medical education has undergone significant change as we have moved from a purely apprenticeship model to one of competence. Simulation-based education can and does play a significant role in the development of an expert surgeon. Proven concepts of simulation-based education include distributed deliberate practice, content that challenges the learner, formative and summative feedback. The application of mastery learning principles is critical to achieve the best retention and outcomes related to an educational program. In this manuscript, we explore the methodology and justification for Mastery Learning as the gold standard of surgical education.

Caregiver Reported Reasons for Delay of Neonatal Circumcision

OBJECTIVES

To determine caregiver-reported reasons for delay of desired neonatal circumcision.

METHODS

Caregivers requesting elective outpatient circumcision at two urban tertiary care hospitals were surveyed from 1/2017 to 12/2018. Boys >3 years and those with abnormal penile anatomy were excluded. Patient/parent demographics, insurance status, comorbidities, birth history, family history, reasons circumcision was desired, and reasons for circumcision delay were obtained.

RESULTS

Surveys were completed by 206/229 caregivers (90% response rate). Respondents were primarily mothers (74%) who identified as African-American (62%). Eligible boys presented at a median 7.5 months [0.3-35.6] and were predominantly African-American (63%), publicly-insured at birth (83%), and publicly-insured at present (86%). 80% were full-term. 83% had no comorbidities. Most caregivers (84%) requested inpatient circumcision, primarily for penile cleanliness (75%) and infection prevention (72%). Common reasons for delay included neonatal circumcision not being performed by the birth physician/hospital (26%) and prematurity (16%). Publicly-insured boys were more likely to encounter delays related birth physician/hospital not performing circumcisions (P = .02). Non-Caucasian/mixed race boys were less likely to be eligible for circumcision without general anesthesia (P = .004). In 108 cases (52%), circumcision was requested for full-term boys without comorbidities. Of these, 72 (35% of the cohort) now require general anesthesia to undergo circumcision.

CONCLUSION

Among 206 boys experiencing circumcision delay, most were full-term, African-American, and publicly-insured. Common reasons for delay included neonatal circumcision not being performed by the birth hospital/physician and prematurity. General anesthesia could have been avoided in >35% of boys if circumcision was performed at birth.

Prevention of hypergranulation tissue after gastrostomy tube placement: A randomised controlled trial of hydrocolloid dressings

Hypergranulation tissue formation is a common complication after gastrostomy tube (G-tube) placement, occurring in 44%-68% of children. Hydrocolloid dressings are often used in the treatment of hypergranulation tissue but have not been studied for the prevention of postoperative hypergranulation tissue. An institutional review board (IRB)-approved, prospective, randomised study was performed in paediatric patients who underwent G-tube placement at a single, large children's hospital from January 2011 to November 2016. After placement, patients were randomly assigned to (1) standard postoperative G-tube care, (2) standard hydrocolloid G-tube dressing, or (3) silver-impregnated hydrocolloid G-tube dressing, and the incidences of postoperative hypergranulation tissue formation, tube dislodgement, infection, and emergency department use were compared. A total of 171 patients were enrolled; 128 patients (75%) had at least 4 months of follow up and were included in the analyses. Eighty-nine patients (69.5%) developed hypergranulation tissue during the postoperative period, with no significant differences in incidence among the three treatment arms. Of those who developed hypergranulation tissue, 46 (56%) visited the emergency department, compared with 6 of the 39 patients (19%) who did not develop hypergranulation tissue. Hydrocolloid dressings (standard or silver-impregnated) do not prevent the development of hypergranulation tissue or other complications after G-tube placement in paediatric patients.

Pediatric arterial catheters: Complications and associated risk factors

BACKGROUND/PURPOSE

Arterial catheter complications are a common problem in a pediatric critical care setting, but reported complication rates and risk factors associated with peripheral arterial catheter complications vary. We conducted a retrospective cohort study to identify risk factors in a pediatric patient population.

METHODS

We performed a detailed abstraction of provider notes in the electronic medical records of inpatients ≤18years of age who underwent arterial line placement between January 1, 2008 and January 1, 2013 at a university-affiliated standalone pediatric hospital. Inpatient records were assessed for complications associated with arterial catheterization and risk factors inherent to arterial catheter insertion.

RESULTS

Two hundred twenty-eight children were identified, of whom 75 (33%) had a total of 106 arterial catheter complications. Complications included line malfunctions (59%, n=63), bleeding (16%, n=17), multiple complications (11%, n=12), infiltration (8%, n=9), and hematoma (4%, n=4). Line malfunction was reported in all patients with multiple complications. Independent predictors of complications associated with arterial catheterization were the presence of more than one provider during the insertion (p=0.007) and insertion attempts at multiple sites (p=0.036).

CONCLUSIONS

Our analysis suggests the need for a prospective study to comprehensively assess provider-related risk factors associated with arterial catheter complications in children.

LEVEL OF EVIDENCE

IV.

Simulation-Based Educational Module Improves Intern and Medical Student Performance of Closed Reduction and Percutaneous Pinning of Pediatric Supracondylar Humeral Fractures

BACKGROUND

Simulation-based education has been integrated into many orthopaedic residency programs to augment traditional teaching models. Here we describe the development and implementation of a combined didactic and simulation-based course for teaching medical students and interns how to properly perform a closed reduction and percutaneous pinning of a pediatric supracondylar humeral fracture.

METHODS

Subjects included in the study were either orthopaedic surgery interns or subinterns at our institution. Subjects all completed a combined didactic and simulation-based course on pediatric supracondylar humeral fractures. The first part of this course was an electronic (e)-learning module that the subjects could complete at home in approximately 40 minutes. The second part of the course was a 20-minute simulation-based skills learning session completed in the simulation center. Subject knowledge of closed reduction and percutaneous pinning of supracondylar humeral fractures was tested using a 30-question, multiple-choice, written test. Surgical skills were tested in the operating room or in a simulated operating room. Subject pre-intervention and post-intervention scores were compared to determine if and how much they had improved.

RESULTS

A total of 21 subjects were tested. These subjects significantly improved their scores on both the written, multiple-choice test and skills test after completing the combined didactic and simulation module. Prior to the module, intern and subintern multiple-choice test scores were significantly worse than postgraduate year (PGY)-2 to PGY-5 resident scores (p < 0.01); after completion of the module, there was no significant difference in the multiple-choice test scores. After completing the module, there was no significant difference in skills test scores between interns and PGY-2 to PGY-5 residents. Both tests were validated using the scores obtained from PGY-2 to PGY-5 residents.

CONCLUSIONS

Our combined didactic and simulation course significantly improved intern and subintern understanding of supracondylar humeral fractures and their ability to perform a closed reduction and percutaneous pinning of these fractures.

An institution-wide approach to submission, review, and funding of simulation-based curricula

This article describes the development, implementation, and modification of an institutional process to evaluate and fund graduate medical education simulation curricula. The goals of this activity were to (a) establish a standardized mechanism for proposal submission and evaluation, (b) identify simulation-based medical education (SBME) curricula that would benefit from mentored improvement before implementation, and (c) ensure that funding decisions were fair and defensible. Our intent was to develop a process that was grounded in sound educational principles, allowed for efficient administrative oversight, ensured approved courses were high quality, encouraged simulation education research and scholarship, and provided opportunities for medical specialties that had not previously used SBME to receive mentoring and faculty development.

Preliminary Evaluation of a Novel Rigid Bronchoscopy Simulator

PURPOSE

Emergent retrieval of airway foreign bodies (AFBs) in children remains a priority skill set for pediatric surgeons. In the setting of low procedural volume, simulation-based education with deliberate practice is essential to ensure trainees reach expected surgical competency. The purposes of this work were to (1) create a realistic rigid bronchoscopy for AFB retrieval simulation model and (2) to evaluate preliminary validity evidence of a novel simulator for the use of training and assessing pediatric surgical trainees' rigid bronchoscopy skills.

METHODS

After institutional review board exemption determination, 18 participants performed AFB retrieval of two different objects on a novel simulator that represented an 18-month-old pediatric tracheobronchial airway. Participants reported their experience and comfort level, and rated the simulator across two domains-Authenticity and their Ability to perform tasks. Authenticity was measured by 23 items across five subdomains (Visual Attributes, Materials' Response, Realism of Experience, Value and Relevance, and Global Value). Participants who had previously performed ≥10 rigid bronchoscopies were categorized as "experienced," while those reporting <10 were considered "novice." Validity evidence relevant to test content and internal structure was evaluated using a many-facet Rasch model.

RESULTS

Novice surgeons (n = 12) had previously performed a mean of 2.7 (±2.0) rigid bronchoscopies, compared to 15.4 (±7.7) by experienced surgeons (n = 6). For both models, the Value and Relevance subdomain received the highest ratings (observed average [OA] = 3.9, while Materials' Response received the lowest (OA <3.0). Participants' Global Value rating for this model was consistent with "requires minor improvements before it can be considered for use in rigid bronchoscopy training."

CONCLUSIONS

We successfully designed, assembled, and evaluated a novel pediatric rigid bronchoscopy model for AFB retrieval. The model was considered as relevant to educational needs and valuable as a testing and training tool. With recommended improvements, the model could be used for implementation with a Mastery Learning curriculum.

Automated data extraction: merging clinical care with real-time cohort-specific research and quality improvement data

BACKGROUND/PURPOSE

Although prohibitively labor intensive, manual data extraction (MDE) is the prevailing method used to obtain clinical research and quality improvement (QI) data. Automated data extraction (ADE) offers a powerful alternative. The purposes of this study were to 1) assess the feasibility of ADE from provider-authored outpatient documentation, and 2) evaluate the effectiveness of ADE compared to MDE.

METHODS

A prospective collection of data was performed on 90 ADE-templated notes (N=71 patients) evaluated in our bowel management clinic. ADE captured data were compared to 59 MDE notes (N=51) collected under an IRB-exempt review. Sixteen variables were directly comparable between ADE and MDE.

RESULTS

MDE for 59 clinic notes (27 unique variables) took 6months to complete. ADE-templated notes for 90 clinic notes (154 unique variables) took 5min to run a research/QI report. Implementation of ADE included eight weeks of development and testing. Pre-implementation clinical documentation was similar to post-implementation documentation (5-10min).

CONCLUSIONS

ADE-templated notes allow for a 5-fold increase in clinically relevant data that can be captured with each encounter. ADE also results in real-time data extraction to a research/QI database that is easily queried. The immediate availability of these data, in a research-formatted spreadsheet, allows for rapid collection, analyses, and interpretation of the data.

LEVEL OF EVIDENCE

IV.

TYPE OF STUDY

Retrospective Study.

Preliminary Evaluation of a Laparoscopic Common Bile Duct Simulator for Pediatric Surgical Education

PURPOSE

Laparoscopic common bile duct exploration (LCBDE) decreases overall costs and length of stay in patients with choledocolithiasis. However, utilization of LCBDE remains low. We sought to evaluate a previously developed general surgery LCBDE simulator among a cohort of pediatric surgical trainees. The study purpose was to evaluate the content validity of an LCBDE simulator to support or refute its use in pediatric surgery education.

MATERIALS AND METHODS

After IRB exempt determination, 30 participants performed a transcystic LCBDE using a previously developed simulator and evaluated the simulator using a self-reported 28-item instrument. The instrument consisted of two primary domains (Quality and Ability to Perform) that were rated using twenty-five 4-point rating scales and one 4-point global rating scale. Validity evidence relevant to test content was evaluated using a many-facet Rasch model. Interitem consistency was estimated using Cronbach's alpha. P < .05 was considered statistically significant.

RESULTS

The highest combined observed averages were for the Value subdomain (OA = 3.79), whereas the lowest ratings were for the Physical/visual attributes subdomain (OA = 3.19). The averaged global rating was 3.14, consistent with this simulator can be considered for use in pediatric LCBDE training, but could be improved slightly. Rasch indices were favorable and supported evidence relevant to test content. Interitem consistency estimates were also favorable, with α values of 0.94 and 0.56 for Qualities and Ability, respectively.

CONCLUSIONS

Overall, participants rated the LCBDE simulator highly valuable for pediatric surgical education and felt that it could be used as an educational tool with minor modifications.

A Multi-Institutional Review of Thoracoscopic Congenital Diaphragmatic Hernia Repair

INTRODUCTION

Thoracoscopic repair of a congenital diaphragmatic hernia (CDH) in the neonate is controversial due to reports of increased hernia recurrence. A multicenter review on thoracoscopic CDH repair was conducted to evaluate outcomes and to identify factors that are associated with recurrence.

METHODS

A multicenter retrospective review was conducted from 2009 to 2015 in neonates who were treated for CDH with thoracoscopic repair. Demographics, preoperative, intraoperative, including repair techniques, and postoperative variables were analyzed by using descriptive statistics. Comparative analysis was performed between those patients who were repaired entirely thoracoscopically with hernia recurrence and those without.

RESULTS

One hundred nine infants, of whom 57% were male with an average gestational age at time of surgery of 39.6 ± 4.6 weeks and a weight of 3.4 ± 1.1 kg, were included. The median age at repair was 5 days (range: 3-9), 61% patients required vasopressor support, and 1.8% patients required extracorporeal membrane oxygenation (ECMO) cannulation before repair. Forty-five percent were repaired on high-frequency oscillatory ventilation (HFOV). Repair was completed thoracoscopically in 83 patients (76%), 68 (82%) were repaired primarily, 15 (18%) were repaired with a patch, and 50 (60%) had extracorporeal/rib fixation sutures. Recurrence occurred in 7 (8.4%) of those completed thoracoscopically. Factors found to be significant for recurrence included: vasopressor therapy (P = .02), repair on HFOV (P = .04), and the presence of the spleen in the chest (P = .04). There was no significant difference identified between technical variations in repair.

CONCLUSIONS

These data suggest that thoracoscopic repair of CDH is feasible in carefully selected patients. However, there is currently no evidence to support a standardized surgical approach to thoracoscopic repair.

Advances in Pediatric Surgical Education: A Critical Appraisal of Two Consecutive Minimally Invasive Pediatric Surgery Training Courses

BACKGROUND

Mandates for improved patient safety and increasing work hour restrictions have resulted in changes in surgical education. Educational courses increasingly must meet those needs. We sought to determine the experience, skill level, and the impact of simulation-based education (SBE) on two cohorts of pediatric surgery trainees.

MATERIALS AND METHODS

After Institutional Review Board (IRB) exempt determination, a retrospective review was performed of evaluations for an annual advanced minimally invasive surgery (MIS) course over 2 consecutive years. The courses included didactic content and hands-on skills training. Simulation included neonatal/infant models for rigid bronchoscopy-airway foreign body retrieval, laparoscopic common bile duct exploration, and real tissue diaphragmatic hernia (DH), duodenal atresia (DA), pulmonary lobectomy, and tracheoesophageal fistula models. Categorical data were analyzed with chi-squared analyses with t-tests for continuous data.

RESULTS

Participants had limited prior advanced neonatal MIS experience, with 1.95 ± 2.84 and 1.16 ± 1.54 prior cases in the 2014 and 2015 cohorts, respectively. The 2015 cohort had significantly less previous experience in lobectomy (P = .04) and overall advanced MIS (P = .007). Before both courses, a significant percentage of participants were not comfortable with DH repair (39%-42%), DA repair (50%-74%), lobectomy (34%-43%), and tracheoesophageal fistula repair (54%-81%). After course completion, > 60% of participants reported improvement in comfort with procedures and over 90% reported that the course significantly improved their perceived ability to perform each operation safely.

CONCLUSION

Pediatric surgery trainees continue to have limited exposure to advanced MIS during clinical training. SBE results in significant improvement in both cognitive knowledge and trainee comfort with safe operative techniques for advanced MIS.

White Paper on P4 Concepts for Pediatric Imaging

Over the past decade, innovations in the field of pediatric imaging have been based largely on single-center and retrospective studies, which provided limited advances for the benefit of pediatric patients. To identify opportunities for potential "quantum-leap" progress in the field of pediatric imaging, the ACR-Pediatric Imaging Research (PIR) Committee has identified high-impact research directions related to the P4 concept of predictive, preventive, personalized, and participatory diagnosis and intervention. Input from 237 members of the Society for Pediatric Radiology was clustered around 10 priority areas, which are discussed in this article. Needs within each priority area have been analyzed in detail by ACR-PIR experts on these topics. By facilitating work in these priority areas, we hope to revolutionize the care of children by shifting our efforts from unilateral reaction to clinical symptoms, to interactive maintenance of child health.

Trends in technical and team simulations: Challenging the status Quo of surgical training

Traditional opportunistic and experiential surgical training can expose patients to excess risk of harm, particularly when new technology or surgical approaches are applied to highly complex operations. Declining birth rates, decreasing academic regionalization of complex neonatal procedures, duty hour restrictions, and the increasing need for highly specialized surgical skills all serve to further degrade the educational opportunities for surgical trainees. Even more concerning, practicing pediatric surgeons are also struggling with declines in neonatal surgical volumes, with fewer opportunities to maintain established cognitive, technical, and nontechnical skills in the operating room. In an effort to balance patient safety with a deeply rooted commitment to surgical education, surgical educators have developed a number of innovative educational strategies to achieve these goals.

Preliminary evaluation of a novel thoracoscopic infant lobectomy simulator

PURPOSE

Thoracoscopic lobectomy in infants requires advanced minimally invasive skills. Simulation-based education has the potential to improve complex procedural skills without exposing the patient to undue risks. The study purposes were (1) to create a size-appropriate infant lobectomy simulator and (2) to evaluate validity evidence to support or refute its use in surgical education.

MATERIALS AND METHODS

In this Institutional Review Board-exempt study, a size-appropriate rib cage for a 3-month-old infant was created. Fetal bovine tissue completed the simulator. Thirty-three participants performed the simulated thoracoscopic lobectomy. Participants completed a self-report, 26-item instrument consisting of 25 4-point rating scales (from 1=not realistic to 4=highly realistic) and a one 4-point Global Rating Scale. Validity evidence relevant to test content and response processes was evaluated using the many-facet Rasch model, and evidence of internal structure (inter-item consistency) was estimated using Cronbach's alpha.

RESULTS

Experienced surgeons (observed average=3.6) had slightly higher overall rating than novice surgeons (observed average=3.4, P=.001). The highest combined observed averages were for the domain Physical Attributes (3.7), whereas the lowest ratings were for the domains Realism of Experience and Ability to Perform Tasks (3.4). The global rating was 2.9, consistent with "this simulator can be considered for use in infant lobectomy training, but could be improved slightly." Inter-item consistency for items used to evaluate the simulator's quality was high (α=0.90).

CONCLUSIONS

With ratings consistent with high physical attributes and realism, we successfully created an infant lobectomy simulator, and preliminary evidence relevant to test content, response processes, and internal structure was supported. Participants rated the model as realistic, relevant to clinical practice, and valuable as a learning tool. Minor improvements were suggested prior to its full implementation as an educational and testing tool.

Adhesive small bowel obstruction--acute management and treatment in children

Adhesive small bowel obstruction is a significant cause of short- and long-term morbidity in infants and children. Unfortunately, the majority of scientific literature relative to adhesive obstructions continues to be dominated by adult studies. In this article, the existing literature for infant and pediatric adhesive obstructions is reviewed, with relevant comparisons to the available adult data. In addition, general guidelines for the management of infant and pediatric adhesive obstructions are recommended, based on the best available evidence.

Evaluation of Three Sources of Validity Evidence for a Synthetic Thoracoscopic Esophageal Atresia/Tracheoesophageal Fistula Repair Simulator

PURPOSE

Thoracoscopic esophageal atresia (EA)/tracheoesophageal fistula (TEF) repair is technically challenging. We have previously reported our experiences with a high-fidelity hybrid model for simulation-based educational instruction in thoracoscopic EA/TEF, including the high cost of the tissue for these models. The purposes of this study were (1) to create a low-cost synthetic tissue EA/TEF repair simulation model and (2) to evaluate the content validity of the synthetic tissue simulator.

MATERIALS AND METHODS

Review of the literature and computed tomography images were used to create computer-aided drawings (CAD) for a synthetic, size-appropriate EA/TEF tissue insert. The inverse of the CAD image was then printed in six different sections to create a mold that could be filled with platinum-cured silicone. The silicone EA/TEF insert was then placed in a previously described neonatal thorax and covered with synthetic skin. Following institutional review board-exempt determination, 47 participants performed some or all of a simulated thoracoscopic EA/TEF during two separate international meetings (International Pediatric Endosurgery Group [IPEG] and World Federation of Associations of Pediatric Surgeons [WOFAPS]). Participants were identified as "experts," having 6-50 self-reported thoracoscopic EA/TEF repairs, and "novice," having 0-5 self-reported thoracoscopic EA/TEF repairs. Participants completed a self-report, six-domain, 24-item instrument consisting of 23 5-point rating scales and one 4-point Global Rating Scale. Validity evidence relevant to test content and response processes was evaluated using the many-facet Rasch model, and evidence of internal structure (interitem consistency) was estimated using Cronbach's alpha.

RESULTS

A review of the participants' ratings indicates there were no overall differences across sites (IPEG versus WOFAPS, P=.84) or experience (expert versus novice, P=.17). The highest observed averages were 4.4 (Value of Simulator as a Training Tool), 4.3 (Physical Attributes-chest circumference, chest depth, and intercostal space), and 4.3 (Realism of Experience-fistula location). The lowest observed averages were 3.5 (Ability to Perform-closure of fistula), 3.7 (Ability to Perform-acquisition target trocar sites), 3.8 (Physical Attributes-landmark visualization), 3.8 (Ability to Perform-anastomosis and dissection of upper pouch), and 3.9 (Realism of Materials-skin). The Global Rating Scale was 2.9, coinciding with a response of "this simulator can be considered for use in neonatal TEF repair training, but could be improved slightly." Material costs for the synthetic EA/TEF inserts were less than $2 U.S. per insert.

CONCLUSIONS

We have successfully created a low-cost synthetic EA/TEF tissue insert for use in a neonatal thoracoscopic EA/TEF repair simulator. Analysis of the participants' ratings of the synthetic EA/TEF simulation model indicates that it has value and can be used to train pediatric surgeons, especially those early in their learning curve, to begin to perform a thoracoscopic EA/TEF repair. Areas for model improvement were identified, and these areas will be the focus for future modifications to the synthetic EA/TEF repair simulator.

Design and development of low-cost tissue replicas for simulation of rare neonatal congenital defects

Studies have shown that simulation can be a valuable tool for training pediatric surgeons to perform thoracoscopic repair of rare congenital anomalies [1-3]. The previously evaluated models were high fidelity, hybrid models that required the use of fetal bovine or porcine tissue blocks within a simulated neonate chest cavity. Real tissue blocks can be expensive, and may not be readily available in some parts of the world. We have developed low-cost, portable simulators for esophageal atresia with tracheoesophageal fistula (EA/TEF) and duodenal atresia (DA) that recreate the 3-dimensional challenges for minimally invasive repair. These are fully simulated models of the thoracic and abdominal cavities containing synthetic tissue that replicates the required anatomy.

The evolution of design: a novel thoracoscopic diaphragmatic hernia repair simulator

As advanced minimally invasive techniques have become more prevalent, there has been an increase in the number of pediatric surgeons performing thoracoscopic repair of congenital diaphragmatic hernia (CDH). Opportunities to learn and practice this procedure are few. The use of a simulation model for thoracoscopic CDH repair may help reduce errors in the operating room. Prototypes for low and high fidelity CDH repair simulators were designed and built. These prototypes allow pediatric surgery trainees the opportunity to learn and practice thoracoscopic CDH repair before performing this operation on infants.

Design and development of a laparoscopic gastrostomy tube placement simulator

Laparoscopic gastrostomy tube placement is a common surgical procedure performed in infants. There are currently no commercially available simulation tools for pediatric surgeons to use for surgical training and practice purposes. We have created a low cost and reusable laparoscopic gastrostomy tube placement model for use in pediatric surgical education.

Umbilical arteriovenous malformation: a case report and literature review

Arteriovenous malformations can lead to life-threatening complications, particularly in neonates. Only a few case reports document arteriovenous malformations of the umbilicus, all presenting with complications and necessitating urgent surgical intervention. We report the case of a neonate with an incidentally noted umbilical arteriovenous malformation, treated with laparoscopic assisted resection.

The positive and negative predictive value of transabdominal color Doppler ultrasound for diagnosing ovarian torsion in pediatric patients

PURPOSE

The purposes of this study were to (1) determine the positive and negative predictive value (NPV) of transabdominal color Doppler ultrasound (CDU) for diagnosing ovarian torsion (OT) in pediatric patients and 2) identify predictors of a false-positive CDU result for OT.

METHODS

An IRB-approved retrospective chart review was performed on all female patients who underwent transabdominal CDU evaluation of the ovaries (664 CDUs in 605 patients) for acute abdominal pain. CDU reports were categorized as positive for OT if the report stated "cannot rule out torsion" or "positive for torsion."

RESULTS

There were 47 false-positive ultrasounds, 3 false negatives, 11 true positives, and 603 true negatives for OT. Sensitivity was 78.6%, specificity 92.3%, positive predictive value (PPV) 19.0%, and NPV 99.5%. False-positive CDU when compared to true positives were more common in older patients (p=0.004) and were more commonly read as "cannot rule out torsion" (p<0.001). Ovarian cysts were larger in true-positive CDU than in false-positive CDU (p<0.001). However, cyst presence/absence did not predict a true positive result.

CONCLUSION

Transabdominal CDU has a low PPV and a high NPV for ovarian torsion in pediatric patients. False-positive results are more common in older patients and associated with small ovarian cysts.

Design and development of a novel thoracoscopic tracheoesophageal fistula repair simulator

Thoracoscopic repair of esophageal atresia with tracheoesophageal fistula (EA/TEF) is a technically challenging surgical procedure. This congenital anomaly is rare; therefore, training opportunities for surgical trainees are limited. There are currently no validated simulation tools available to help train pediatric surgery trainees. The simulator that was developed is a low-cost, reusable model. It simulates the right side of a term neonate chest and contains a tissue block that has been surgically modified to replicate the anatomy of EA/TEF.

Increasing national burden of hospitalizations for skin and soft tissue infections in children

BACKGROUND

The number of children requiring treatment of skin and soft tissue infections (SSTIs) has increased since the emergence of methicillin-resistant Staphylococcus aureus.

METHODS

The 2000, 2003, and 2006 Kids' Inpatient Databases were queried for patients with a primary diagnosis of SSTI. Weighted data were analyzed to estimate temporal changes in incidence, incision and drainage (I&D) rate, and economic burden. Factors associated with I&D were analyzed by multivariable logistic regression.

RESULTS

Pediatric SSTI admissions increased (1) in number, (2) as a fraction of all hospital admissions, and (3) in incidence per 100,000 children from the years 2000 (17,525 ± 838; 0.65%; 23.2) to 2003 (27,463 ± 1652; 0.99%; 36.2) and 2006 (48,228 ± 2223; 1.77%; 62.7). Children younger than 3 years accounted for 49.6% of SSTI admissions in 2006, up from 32.5% in 2000. Utilization of I&D increased during the study period from 26.0% to 43.8%. Factors most associated with requiring I&D were age less than 3 years and calendar year 2006 (both P < .001). Hospital costs per patient increased over time and were higher in the group of patients who required I&D ($4296 ± $84 vs $3521 ± $81; P < .001; year 2006). Aggregate national costs reached $184.0 ± $9.4 million in 2006.

CONCLUSION

The recent spike in pediatric SSTIs has disproportionately affected children younger than 3 years, and an increasing fraction of these children require I&D. The national economic burden is substantial.

Should we be concerned about jejunoileal atresia during repair of duodenal atresia?

INTRODUCTION

During repair for duodenal atresia, it has been emphasized that inspection of the small bowel to identify a second atresia is required. The laparoscopic approach for repair of duodenal atresia has been criticized for its limitation to perform this step. Given that duodenal atresia and jejunoileal atresias do not share common embryologic origins, we question the validity of this concern. Therefore, we conducted a multicenter retrospective review of duodenal atresia patients to quantify the incidence of jejunoileal atresia in this population.

METHODS

After institutional review board approval (IRB #07-12-187X), a retrospective review was conducted on all patients who have undergone duodenal atresia repair at seven institutions over the past 7-12 years. Demographics and the presence or absence of a jejunoileal atresia were recorded.

RESULTS

Four hundred eight patients with duodenal atresia were identified. The mean gestaational age was 36.3 ± 2.9 weeks, and the mean weight was 2.5 ± 0.8 kg. Mean age at operation was 19 days (range, 1-1314). There was a 28% incidence of trisomy 21. Two patients (0.5%) were identified as having a second intestinal atresia, and both were type IIIb. One patient was diagnosed at the time of duodenal atresia repair; the other was a delayed diagnosis. Both patients did well after repair.

CONCLUSIONS

In this, the largest series of duodenal atresia patients compiled to date, the rate of a concomitant jejunoileal atresia is less than 1%. This low incidence is not high enough to mandate extensive inspection of the entire bowel in these patients, and a second atresia should not be a concern during laparoscopic repair of duodenal atresia.

Relief of superior mesenteric artery syndrome with correction of multiplanar spinal deformity by posterior spinal fusion

Superior mesenteric artery syndrome is obstruction of the third portion of the duodenum by compression between the abdominal aorta and superior mesenteric artery. Pediatric orthopedists are familiar with this entity, as the association between superior mesenteric artery syndrome and spinal fusion or body casting has been well established. However, patients with spinal deformities usually experience superior mesenteric artery syndrome after orthopedic intervention, with rates after corrective spinal surgery reported between 0.5% and 2.4%. Symptoms of superior mesenteric artery syndrome typically include nausea, bilious emesis, abdominal pain, early satiety, and anorexia. Initial treatment focuses on gastric decompression and maintaining euvolemia and electrolyte balance. The patient should receive enteral nutrition via nasojejunal tube or parenteral nutrition to allow for weight gain and subsequent resolution of the obstruction. The superior mesenteric artery takes off from the duodenum at an angle of 45 degrees to 60 degrees in normal individuals. The third portion of the duodenum is suspended between these vessels by the ligament of Treitz. Any variation in this relationship that decreases the arteriomesenteric angle may induce obstruction. Specifically, lumbar hyperextension or hyperlordosis can traction the mesentery and vessels. Only 2 cases of superior mesenteric artery syndrome in patients with sagittal plane spinal deformity have been described in the literature. In patients with concomitant superior mesenteric artery syndrome and spinal deformity, correction of the deformity may help alleviate the obstruction and result in faster recovery. The contribution of spinal column deformity to the arteriomesenteric angle should not be overlooked.

Laparoscopic fundoplication after previous open abdominal operations in infants and children

BACKGROUND

There have been multiple reports in the adult literature stating that previous open operations should no longer be considered a contraindication to the laparoscopic approach. However, there are little data on this topic in the pediatric population, particularly in patients with neonatal abdominal pathology unique to the newborn population. Therefore, we reviewed our experience with laparoscopic fundoplication after a variety of previous abdominal conditions and operations in the pediatric population.

METHODS

An institutional review board-approved retrospective chart review was performed on all patients undergoing laparoscopic fundoplication after a previous open operation between October 2000 and December 2007. The data collected demographics, comorbid conditions, previous abdominal operations, gastrostomy tube placement, time interval between the initial operation and laparoscopic fundoplication, conversions, and complications.

RESULTS

Forty-five patients underwent a laparoscopic Nissen fundoplication after an open operation during the study interval. Mean age was 41.3 months (range, 1-233) with a mean weight of 14.3 kg (range, 2.9-63.6), and 31 were (78.9%) male. A total of 61 previous abdominal operations were performed (range, 1-4). Mean time between last open operation and laparoscopic fundoplication was 27.3 months (range, 0.5-147). Mean operative time was 161 minutes (range, 73-420). There were no conversions and 3 perioperative complications occurred (splenic hematoma, clogged gastrostomy tube, and liver bleed). Early reoperations were performed in 2 patients (4.4%): 1 for bleeding on day 2 and the other for leaking gastrostomy day 12.

CONCLUSION

Our data demonstrate that laparoscopic fundoplication after a previous open operation is feasible and safe.

Hazardous complications of multiple ingested magnets: report of four cases

Foreign body ingestion is a common occurrence in the pediatric population. Frequent culprits include coins, toys, sharp objects and bones, which most often pass spontaneously. Magnet ingestion, however, can be a serious matter, especially when more than one is taken in. The extremely strong magnetic force between multiple magnets may result in numerous complications including bowel necrosis, perforation, obstruction, fistula formation, volvulus and death. We present the largest series reported to date, with four cases of multiple magnet ingestion at our institution with varied presentations and findings. We review the literature, and discuss the importance of having a high index of suspicion.

Laparoscopic versus open Nissen fundoplication in infants after neonatal laparotomy

BACKGROUND

Nissen fundoplication is an effective treatment of gastroesophageal reflux in infants. Laparoscopic procedures after previous laparotomy are technically more challenging. The role of laparoscopic Nissen fundoplication after neonatal laparotomy for diseases unrelated to reflux is poorly described.

METHODS

This was a retrospective review of open vs laparoscopic Nissen fundoplication in infants after neonatal laparotomy. Of 32 infants who underwent neonatal laparotomy, 26 required a surgical antireflux operation within the first year of life. Twelve infants underwent laparoscopic Nissen fundoplication versus 14 infants who underwent open Nissen fundoplication. Parameters like age, weight, operative time, number of previous operations, length of stay following fundoplication, time to feedings, and complications were compared between the 2 groups.

RESULTS

No statistically significant differences existed between most of the parameters compared following laparoscopic vs open Nissen fundoplication. No conversions to open procedures were necessary in infants undergoing laparoscopic fundoplication, and these infants resumed enteral feeds earlier than those who underwent the open procedure.

CONCLUSION

Laparoscopic compared with open Nissen fundoplication performed in infants after a neonatal laparotomy were comparable procedures across most data points studied. However, a laparoscopic fundoplication did allow for earlier return to enteral feeds compared with the open approach. Laparoscopic Nissen fundoplication is technically feasible, safe, and effective in the treatment of gastroesophageal reflux in infants with a previous neonatal laparotomy.

Renovascular Injury: An Argument for Renal Preservation

BACKGROUND

Renovascular injury is uncommon among children. This study hypothesized that preservation of the severely injured kidney can be achieved safely without renal insufficiency, postinjury hypertension, or the need for hemodialysis.

METHODS

Retrospective chart review of renal injuries seen between 1997 and 2001 at a level 1 pediatric trauma center was conducted. Severity of injury was graded by the American Association for the Surgery of Trauma Organ Injury Severity Scale. The outcome variables included the need for hemodialysis, impaired renal function (creatinine), and postinjury hypertension.

RESULTS

In this study, 34 children presented with grade 1, 2, or 3 injury (74%), whereas 13 children presented with grade 4 or 5 renovascular injury (28%). The children with unilateral renovascular injury who underwent either nephrectomy or renal preservation had comparable outcomes with no hypertension, hemodialysis, or renal insufficiency in either group.

CONCLUSIONS

The treatment outcomes were not different between the patients who underwent renal preservation and those who had immediate nephrectomy. The authors conclude that renal preservation should be attempted for all children with grade 4 or 5 renovascular injury.

Endotoxin induces an exaggerated interleukin-10 response in peritoneal macrophages of children compared with adults

BACKGROUND

Children have a lower incidence of postinjury multiple organ failure (MOF) compared with adults with equivalent injury severity. Because MOF appears to be the end result of systemic hyperinflammation, children may have either an attenuated proinflammatory response or an augmented antiinflammatory response compared with adults. The purpose of this study was to determine the lipopolysaccharide (LPS)-induced pro- and antiinflammatory cytokine response of pediatric versus adult peritoneal macrophages (PM). The authors hypothesized that pediatric PMs would have an enhanced antiinflammatory response compared with adults.

METHODS

Human PMs were collected during elective laparoscopic procedures and stimulated with LPS. (Pediatric cohort: n = 9 [mean, 5.4 years], adult cohort: n = 8 [mean, 41.6 years]). P less than.05 was accepted as significant.

RESULTS

LPS-induced a 50-fold increase in interleukin-10 (IL-10) antiinflammatory cytokine production in pediatric versus adult PMs. LPS-induced tumor necrosis factor-alpha (TNF-alpha) production was also increased in pediatric versus adult PMs. The anti-proinflammatory cytokine ratio (IL-10 to TNF-alpha) was 20-fold higher in pediatric versus adult PMs.

CONCLUSIONS

LPS-induced macrophage production of both IL-10 and TNF-alpha was increased in children. The anti-proinflammatory cytokine ratio (IL-10 to TNF-alpha) was strikingly higher in pediatric versus adult PMs. These data suggest that the age-related balance of anti- and proinflammatory cytokines in resident macrophages is different in children compared with adults.

Hemorrhage-induced acute lung injury is TLR-4 dependent

Toll-like receptor 4 (TLR-4), initially identified as an LPS receptor, is critical to the signaling of a variety of danger signals, including heat shock protein 60, fibrinogen, and fibronectin. Recent data also suggest that TLR-4 plays a role in determining survival in both endotoxemia and hemorrhagic shock. We hypothesized that a functional TLR-4 would be required for hemorrhage and endotoxin-induced acute lung injury. Hemorrhage- and endotoxin-induced lung TNF-alpha mRNA and protein production, neutrophil accumulation, and protein permeability were dependent on a functional TLR-4. Hemorrhage-induced nuclear factor (NF)-kappaB activation was independent of functional TLR-4, whereas endotoxin-induced activation of NF-kappaB requires a functional TLR-4 for full response. Therefore, we conclude that 1) hemorrhage-induced acute lung injury is TLR-4 dependent and 2) hemorrhage has a different and distinct TLR-4-dependent intracellular activation mechanism compared with endotoxemia.

IL-1beta induces an exaggerated pro- and anti-inflammatory response in peritoneal macrophages of children compared with adults

Children have a lower incidence of acute lung injury (ALI) compared with adults. Because ALI appears to be the end result of systemic hyperinflammation, children may either have 1) an attenuated pro-inflammatory response or 2) an augmented anti-inflammatory response compared with adults. The purpose of this study was to determine the IL-1-induced pro- and anti-inflammatory response of pediatric vs. adult peritoneal macrophages (PMs). We hypothesized that pediatric PMs would have an enhanced anti-inflammatory response compared with adult PMs. Human PMs were collected during elective laparoscopic procedures, cultured, and stimulated with IL-1beta. IL-6, IL-8, IL-10, and TNFalpha production were determined by ELISA. Statistical analyses were by ANOVA; a P <0.05 was significant. Our results showed that IL-1beta induced an 11-fold increase in IL-10 production in pediatric PMs (659+/-103 vs. 60+/-25 control, P <0.05). There was no IL-10 production in IL-1beta-stimulated adult PMs. IL-1beta-induced TNF production was greater in children compared with adults (2152+/-166 vs. 592+/-188, P <0.05). Similarly, IL-1beta-induced IL-6 production was greater in pediatric PMs compared with adults (532+/-3 vs. 444+/-52, P <0.05). There was no difference in IL-1beta-induced IL-8 production in children compared with adults. The IL-10:TNFalpha ratio after IL-1beta stimulation was 0.306+/-0.056 in pediatric macrophages and 0.020+/-0.015 in adult macrophages ( P<0.01). In conclusion, IL-1beta-induced IL-6 and TNFalpha production were greater in pediatric than adult PMs. Furthermore, pediatric PMs had an 11-fold increase in IL-1beta-induced IL-10 production, while adult PMs did not produce IL-10. Therefore, IL-1beta induces both a pro- and an anti-inflammatory response in pediatric PMs, whereas adult PMs produce only pro-inflammatory cytokines in response to IL-1beta. The exaggerated anti-inflammatory IL-10 response in children may be an important factor in the observed differences in ALI between children and adults.

Blunt Diaphragmatic Rupture in Children

BACKGROUND

Although several series of blunt diaphragmatic rupture in adults have been published, this injury remains largely uncharacterized in the pediatric population.

METHODS

We queried our trauma registry for all children admitted with blunt diaphragmatic rupture over a 10-year period at a Level I pediatric trauma center.

RESULTS

Six children (aged 2-15 years; mean, 7 years) were identified with blunt diaphragmatic rupture (three right, two left, one bilateral), representing 0.4% of admissions. All of the children had associated injuries (4.5 per child), with a mean Injury Severity Score of 32. Four diaphragmatic injuries were identified during the initial evaluation. The two missed injuries were diagnosed at postinjury days 5 and 8. There were no deaths and all children were eventually discharged without sequelae.

CONCLUSION

Blunt diaphragmatic rupture occurs in children with a frequency and severity commensurate with that observed in adults. Our data suggest improved survival compared with adults with this injury.

The positive predictive value of rib fractures as an indicator of nonaccidental trauma in children

BACKGROUND

Rib fractures have a strong association with nonaccidental trauma (NAT) and severe trauma. The purposes of this study were to evaluate rib fractures in children to determine (1) the positive predictive value of a rib fracture in defining NAT and (2) the frequency of rib fractures as the only skeletal manifestation of NAT.

METHODS

We reviewed the medical records and imaging of all children with rib fractures over a 6-year period. NAT was determined by the Child Advocacy and Protection team.

RESULTS

In children younger than 3 years of age, the positive predictive value (PPV) of a rib fracture as an indicator of NAT was 95%. The positive predictive value increased to 100% once historical and clinical circumstance excluded all other causes for rib fractures.

CONCLUSION

In this study, rib fracture(s) were the only skeletal manifestation of NAT in 29% of the children.