Comparison of Extracorporeal Life Support Anticoagulation Using Activated Clotting Time Only to a Multimodal Approach in Pediatric Patients.

OBJECTIVE: To evaluate an institutional practice change from an extracorporeal life support (ECLS) anticoagulation monitoring strategy of activated clotting time (ACT) alone to a multimodal strategy including ACT, activated partial thrombin time, heparin anti-factor-Xa, and thromboelastography. METHODS: This was a retrospective review of patients younger than 18 years on ECLS and heparin between January 2014 and June 2020 at a single institution. RESULTS: Twenty-seven patients used an ACT-directed strategy and 25 used a multimodal strategy. The ACT-directed group was on ECLS for a shorter median duration than the multimodal group (136 versus 164 hours; p = 0.046). There was a non-significant increase in major hemorrhage (85.1% versus 60%; p = 0.061) and a significantly higher incidence of central nervous system (CNS) hemorrhage in the ACT-directed group (29.6% versus 0%; p = 0.004). Rates of thrombosis were similar, with a median of 3 circuit changes per group (p = 0.921). The ACT-directed group had larger median heparin doses (55 versus 34 units/kg/hr; p < 0.001), required more dose adjustments per day (3.8 versus 1.7; p < 0.001), and had higher rates of heparin doses >50 units/kg/hr (62.9% versus 16%; p = 0.001). More anticoagulation parameters were supratherapeutic (p = 0.015) and fewer were therapeutic (p < 0.001) in the ACT-directed group. CONCLUSIONS: Patients with a multimodal strategy for monitoring anticoagulation during ECLS had lower rates of CNS hemorrhage and decreased need for large heparin doses of >50 units/kg/hr without an increase in clotting complications, compared with ACT-directed anticoagulation. Multimodal anticoagulation monitoring appears superior to ACT-only strategies and may reduce heparin exposure and risk of hemorrhagic complications for pediatric patients on ECLS.

Management of Abdominal Solid Organ Injury After Blunt Trauma.

Injury to the solid abdominal organs-liver, spleen, kidney, and pancreas-is one of the most common injury patterns in pediatric blunt trauma. Pediatric trauma centers are becoming increasingly successful in managing these injuries without operative intervention. Well-validated guidelines have been established for liver and spleen injury management, and operative intervention is reserved for patients who show evidence of active bleeding after resuscitation. No such guidelines yet exist for the management of traumatic injury of the kidney or pancreas. Exploratory laparotomy remains the treatment of choice in patients suffering hemodynamic collapse, but interventional radiologic or endoscopic procedures are increasingly used to manage all but the most devastating solid organ injuries. [Pediatr Ann. 2016;45(7):e241-e246.].

Willingness to respond in a disaster: a pediatric nurse practitioner national survey.

OBJECTIVE: The objective of this study was to examine factors associated with pediatric nurse practitioners (PNPs) reporting to work in the event of a disaster. METHODS: An anonymous national survey of PNPs was conducted. Several domains were explored, including demographics, personal preparedness plans, disaster training, prior disaster experience, and likelihood of responding in the event of a disaster. A logistic regression analysis was conducted to determine which factors were associated with the respondent's likelihood of responding in the event of a disaster. RESULTS: Factors associated with increased likelihood of responding included gender (being a male PNP), military experience, and disaster training. The most significant factor associated with an increased likelihood of responding to work during a disaster was having a specified role in the workplace disaster plan. PNPs with a specified role were three times more likely to respond than were those without a specified role. CONCLUSIONS: PNPs are health care workers with advanced skill sets. This untapped resource is available to provide care for a vulnerable population: our children. Disaster planners should explore the possibility of utilizing these highly skilled health care workers in their disaster plans.

Factors associated with willingness to respond to a disaster: a study of healthcare workers in a tertiary setting.

INTRODUCTION: Due to recent disasters, disaster planners increasingly are focusing on healthcare worker preparedness and response in the event of a disaster. In this study, factors associated with pediatric healthcare workers' willingness to respond are identified. HYPOTHESIS: It was hypothesized that personal factors may affect a pediatric healthcare worker's willingness to respond to work in the event of a disaster. METHODS: Employees of a tertiary, pediatric care hospital in Los Angeles were asked to complete a brief, 24-question online survey to determine their willingness to respond in the event of a disaster. Information on demographics, employment, disaster-related training, personal preparedness, and necessary resources was collected. A logistic regression model was performed to derive adjusted odds ratios (OR) and their corresponding 95% confidence intervals (95% CI). RESULTS: Eight hundred seventy-seven pediatric healthcare employees completed the survey (22% response rate). Almost 50% (n = 318) expressed willingness to respond in the event of a disaster. Men were more likely to be willing to respond to a disaster than were women (OR = 2.4; 95%CI = 1.6-3.6), and single/divorced/widowed employees were more willing to respond than married or partnered employees (OR = 1.5; 95%CI = 1.1-2.1). An inverse relationship was observed between number of dependents and willingness to respond (OR = 0.45; 95%CI = 0.25-0.80, ≥3 dependents compared to 0). An inverse dose response relationship between commuting distance and number of necessary resources (ptrend = 0.0485 and 0.0001, respectively) was observed. There was no association between previous disaster experience, disaster training, or personal preparedness and willingness to respond. CONCLUSIONS: Number of dependents and resources were major factors in willingness to respond. Healthcare facilities must clearly communicate their disaster plans as well as any provisions they may make for their employees' families in order to improve willingness among hospital employees.

P-glycoprotein induction by breast milk attenuates intestinal inflammation in experimental necrotizing enterocolitis.

P-glycoprotein (Pgp), a product of the multi-drug resistance gene MDR1a, is a broad specificity efflux ATP cassette transmembrane transporter that is predominantly expressed in epithelial tissues. Because mdr1a(-/-) mice tend to develop spontaneous colitis in bacteria-dependent manner, Pgp is believed to have a role in protection of the intestinal epithelium from luminal bacteria. Here we demonstrate that levels of Pgp in the small intestine of newborn rodents dramatically increase during breastfeeding, but not during formula feeding (FF). In rats and mice, levels of intestinal Pgp peak on days 3-7 and 1-5 of breastfeeding, respectively. The mdr1a(-/-) neonatal mice subjected to FF, hypoxia, and hypothermia have significantly higher incidence and pathology, as well as significantly earlier onset of necrotizing enterocolitis (NEC) than congenic wild type mice. Breast-fed mdr1a(-/-) neonatal mice are also more susceptible to intestinal damage caused by the opportunistic pathogen Cronobacter sakazakii that has been associated with hospital outbreaks of NEC. Breast milk, but not formula, induces Pgp expression in enterocyte cell lines in a dose- and time-dependent manner. High levels of ectopically expressed Pgp protect epithelial cells in vitro from apoptosis induced by C. sakazakii. Taken together, these results show that breast milk-induced expression of Pgp may have a role in the protection of the neonatal intestinal epithelium from injury associated with nascent bacterial colonization.

Inversion herniotomy: a laparoscopic technique for female inguinal hernia repair.

PURPOSE: Laparoscopic inversion herniotomy (LIH) is a method of inguinal hernia repair for female patients. In this article, we report our technique and outcomes for this procedure. We propose that LIH is a valid alternative to conventional open herniorraphy. METHODS: Following institutional review board approval, we reviewed the charts of patients who underwent LIH or open inguinal hernia repair (OIH) from 2004 to 2007. LIH was performed with three instrument sites and no groin incision. The diagnosis, operative time, and complications were reviewed. Follow-up ranged from 5 months to 4 years. RESULTS: We performed 79 LIH repairs (15 bilateral, 23 left, and 26 right) in 63 female children. We also performed 76 contemporaneous OIH repairs in girls. The age range was 1 month to 18 years (median, 3.8 years). Operative times for both the unilateral and bilateral LIH repairs were significantly shorter than those for OIH (P = 0.001). There were 2 recurrences after laparoscopic inguinal hernia repair, both within 5 months following repair early in our experience, compared to no hernia recurrences with OIH. The first recurrence was repaired conventionally via an open technique. The second case was repaired laparoscopically. CONCLUSIONS: LIH is an effective method for the repair of pediatric indirect inguinal hernia in female patients. The procedure allows the evaluation of the asymptomatic contralateral side without the necessity of a second long inguinal incision.

A survey of academic surgeons: work, stress, and research.

BACKGROUND: An academic surgeon's workweek is divided among patient care, administrative duties, education, and research. The time available for research activities may change as a surgeon's career evolves. We sought to determine involvement of academic surgeons in research and to assess how this research endeavor was affected by demographic and workplace characteristics. METHODS: We constructed a survey to explore the following 4 domains: demographics, time allotment, research activities, and effects of stressors. We distributed the survey to members of the Society of University Surgeons. In addition to performing descriptive statistics, we defined an active researcher as someone with a funding source who devoted 15% or more work hours to research. Using this definition, we performed statistical analyses to assess the significance of independent variables on research. Stress factors were evaluated on a Likert scale with responses ranging from 1 (not at all) to 5 (extremely). RESULTS: We received 314 completed surveys (response rate 23%). Of the respondents, 274 (87%) stated that they were involved in some kind of research activity; however, only 143 (46%) were active researchers. Using univariate logistic regression analysis, younger respondents and surgeons who practiced for more than 10 years were more likely to be active researchers (odds ratio [OR]: 1.93, confidence interval [CI]: 1.51-2.46 and OR: 2.06, CI: 1.64-2.59, respectively). Males were less likely than females to be active researchers (OR: 0.32, CI: 016-0.67); however, by multivariate analysis, we found that the "years in practice" of an active researcher was the most significant predictor of research activity, whereas age and sex were not. In regard to stress, most respondents reported scores of 1-3 for all 7 stressors, which is consistent with minimal to moderate stress. CONCLUSION: Academic surgeons are involved actively in research; however, this involvement decreases as other professional responsibilities increase. To optimize the surgical research environment, departments should invest time and resources in young investigators to prevent them from decreasing their research activities.

Laparoscopic choledochal cyst excision: lessons learned in our experience.

BACKGROUND: Choledochal cyst (CDC) is a rare biliary disorder. Surgical treatment consists of CDC excision and biliary-enteric reconstruction. Recently, some institutions have reported successful CDC excision by using minimally invasive techniques. In this study, we report our experience with the laparoscopic management of CDC, with a focus on key operative maneuvers that enhance the likelihood of successful excision. METHODS: Following institutional review board approval, we performed a retrospective review of patients who underwent the laparoscopic excision of CDC and Roux-en-Y hepaticojejunostomy. Between October 2003 and November 2007, we performed laparoscopic CDC excision in 9 patients (8 female and 1 male). Median age was 4 years (range, 8 months to 16 years). There were 7 type I and 2 type IV cysts, according to Todani's classification. Average cyst size was 4.4 cm (range, 1.3-8.5). The procedures were performed by utilizing four or five trochars. RESULTS: Six of 9 children presented with preoperative pancreatitis, 1 with abdominal pain, 1 with jaundice, and 1 was found incidentally. Three patients required the conversion to laparotomy due to dense adhesions, secondary to pancreatitis. Six patients underwent successful laparoscopic procedures, 5 had complete cyst excisions, and 1 underwent a proximal excision with distal mucosectomy. Of the 3 patients who required conversion, 2 underwent complete excisions; the other underwent a proximal excision, distal mucosectomy. There were no intraoperative complications. One patient had a postoperative bile leak that required an open hepaticojejunostomy revision. Eight patients had an uneventful recovery. Oral feedings were resumed within an average of 3.4 days (range, 2-9). Average time to discharge was 6.1 days (range, 5-12). Average follow-up time was 18 months (range, 4-48). No further laboratory abnormalities were detected in any of the patients. CONCLUSIONS: Laparoscopic resection of CDC and Roux-en-Y hepaticojejunostomy in children is an excellent treatment option. Preoperative pancreatitis may cause increased technical difficulty, necessitating a conversion. Proximal excision with distal mucosectomy

Combined laparoscopic and thoracoscopic esophagectomy and gastric pull-up in a child.

Severe caustic burns to the esophagus may necessitate esophagectomy with replacement, if stictures form which are not amenable to dilation. Traditionally, the operation is performed via open transabdominal and/or thoracic approaches. Here we describe our minimally invasive approach, combining laparoscopy and thoracoscopy for esophagectomy, stomach tubularization and a cervical esophagogastrotomy. We successfully performed the procedure in a 4-year-old boy. There were no intraoperative complications, and his initial esophagram showed good patency with no leaks. However, one week postoperatively he was noted to have a retained foreign body and a minor anastomotic leak, which was most likely caused by the foreign body. He underwent a neck re-exploration,removal of the foreign body, and repair of the anastomotic leak. His subsequent hospital course was uneventful. He tolerated feedings and was discharged home on an unrestricted diet. The minimally invasive approach to esophagectomy and esophageal replacement is feasible and is an excellent option in select patients.

Enterobacter sakazakii enhances epithelial cell injury by inducing apoptosis in a rat model of necrotizing enterocolitis.

Necrotizing enterocolitis (NEC) is an inflammatory intestinal disorder that affects 2%-5% of all premature infants. Enterobacter sakazakii, a common contaminant of milk-based powdered infant formula, has been implicated as a causative agent of sepsis, meningitis, and NEC in newborn infants, with high mortality rates. However, the role played by E. sakazakii in the pathogenesis of NEC is, to date, not known. Here, we demonstrate for the first time that E. sakazakii can induce clinical and histological NEC in newborn rats. E. sakazakii was found to bind to enterocytes in rat pups at the tips of villi and to intestinal epithelial cells (IEC-6) in culture, with no significant invasion. Exposure to E. sakazakii induced apoptosis and increased the production of interleukin-6 in IEC-6 cells and in the animal model. These data suggest that E. sakazakii could be a potential pathogen that induces NEC and triggers intestinal disease by modulating enterocyte intracellular signaling pathways.

Disaster management among pediatric surgeons: preparedness, training and involvement.

INTRODUCTION: Contemporary events in the United States (eg, September 2001, school shootings), Europe (eg, Madrid train bombings), and the Middle East have raised awareness of mass casualty events and the need for a capable disaster response. Recent natural disasters have highlighted the poor preparation and infrastructure in place to respond to mass casualty events. In response, public health policy makers and emergency planners developed plans and prepared emergency response systems. Emergency response providers include first responders, a subset of emergency professionals, including firemen, law enforcement, paramedics, who respond to the incident scene and first receivers, a set of healthcare workers who receive the disaster victims at hospital facilities. The role of pediatric surgeons in mass casualty emergency response plans remains undefined. The authors hypothesize that pediatric surgeons' training and experience will predict their willingness and ability to be activated first receivers. The objective of our study was to determine the baseline experience, preparedness, willingness, and availability of pediatric surgeons to participate as activated first receivers. METHODS: After institutional review board approval, the authors conducted an anonymous online survey of members of the American Pediatric Surgical Association in 2007. The authors explored four domains in this survey: (1) demographics, (2) disaster experience and perceived preparedness, (3) attitudes regarding responsibility and willingness to participate in a disaster response, and (4) availability to participate in a disaster response. The authors performed univariate and bivariate analyses to determine significance. Finally, the authors conducted a logistic regression to determine whether experience or preparedness factors affected the respondent's availability or willingness to respond to a disaster as a first receiver RESULTS: The authors sent 725 invitations and received 265 (36.6 percent) completed surveys. Overall, the authors found that 77 percent of the respondents felt "definitely" responsible for helping out during a disaster but only 24 percent of respondents felt "definitely"prepared to respond to a disaster. Most felt they needed additional training, with 74 percent stating that they definitely or probably needed to do more training. Among experiential factors, the authors found that attendance at a national conference was associated with the highest sense of preparedness. The authors determined that subjects with actual disaster experience were about four times more likely to feel prepared than those with no disaster experience (p < 0.001). The authors also demonstrated that individuals with a defined leadership position in a disaster response plan are twice as likely to feel prepared (p = 0.002) and nearly five times more willing to respond to a disaster than those without a leadership role. The authors found other factors that predicted willingness including the following: a contractual agreement to respond (OR 2.3); combat experience (OR 2.1); and prior disaster experience (OR 2.0). Finally, the authors found that no experiential variables or training types were associated with an increased availability to respond to a disaster. CONCLUSIONS: A minority of pediatric surgeons feel prepared, and most feel they require more training. Current training methods may be ineffectual in building a prepared and willing pool of first receivers. Disaster planners must plan for healthcare worker related issues, such as transportation and communication. Further work and emphasis is needed to bolster participation in disaster preparedness training.

The role of nitric oxide in intestinal epithelial injury and restitution in neonatal necrotizing enterocolitis.

Necrotizing enterocolitis (NEC) is the most common life-threatening gastrointestinal disease encountered in the premature infant. Although the inciting events leading to NEC remain elusive, various risk factors, including prematurity, hypoxemia, formula feeding, and intestinal ischemia, have been implicated in the pathogenesis of NEC. Data from our laboratory and others suggest that NEC evolves from disruption of the intestinal epithelial barrier, as a result of a combination of local and systemic insults. We postulate that nitric oxide (NO), an important second messenger and inflammatory mediator, plays a key role in intestinal barrier failure seen in NEC. Nitric oxide and its reactive nitrogen derivative, peroxynitrite, may affect gut barrier permeability by inducing enterocyte apoptosis (programmed cell death) and necrosis, or by altering tight junctions or gap junctions that normally play a key role in maintaining epithelial monolayer integrity. Intrinsic mechanisms that serve to restore monolayer integrity following epithelial injury include enterocyte proliferation, epithelial restitution via enterocyte migration, and re-establishment of cell contacts. This review focuses on the biology of NO and the mechanisms by which it promotes epithelial injury while concurrently disrupting the intrinsic repair mechanisms.