Comparative effectiveness of catheter salvage strategies for pediatric catheter-related bloodstream infections.

BACKGROUND: Intravascular catheter salvage may be attempted in clinically suitable cases in pediatric patients with catheter-related bloodstream infections. The purpose of this study was to assess the effectiveness of ethanol and hydrochloric acid (HCl) locks in achieving catheter salvage through decision-analysis modeling. METHODS: A Markov decision model was created to simulate catheter salvage using three management strategies: systemic antibiotics alone, antibiotics plus HCl lock, and antibiotics plus ethanol lock. One-way and two-way sensitivity analyses were performed for all model variables. Infection control rates and recurrence rates for each strategy were derived from prospective institutional data and existing pediatric literature. Costs were derived from institutional charges. RESULTS: With antibiotics alone, 73% of patients would require line replacement within 100days, compared to only 31% and 19% of patients treated with HCl and ethanol lock, respectively. Incremental cost per additional catheter salvaged is $89 for HCl lock and $456 for ethanol lock. Superior efficacy of adjunct lock therapy is insensitive to changes in the anticipated duration of central access requirement and to clinically relevant variations in all model input variables. CONCLUSION: HCl or ethanol locks are cost-effective adjuncts to systemic antibiotics for attempted catheter salvage in the setting of catheter-related bloodstream infections.

Chest radiography does not alter the treatment course for children after rigid bronchoscopy.

The purpose of this study was to evaluate the usefulness of chest radiography in the direction of postbronchoscopy clinical therapy. From 2001 to 2011, 368 rigid bronchoscopies were performed at a single institution in 221 children. Indications for bronchoscopy, concomitant bronchoscopic procedures, and results of postoperative chest radiography were evaluated. Rigid bronchoscopy was performed in children at a median age of 2.21 years (range, two days to 20 years). Chest radiography was performed at the discretion of the primary surgeon after 275 (74.7%) procedures. Malpositioning of the endotracheal or tracheostomy tube occurred in 1.5 per cent (n = three of 203) of ventilated patients postbronchoscopy. Pneumothorax occurred in 0.5 per cent (n = two of 368) of children and followed laser degranulation (n = one of 117 [0.9%]) and removal of an aspirated foreign body (n = one of 80 [1.3%]). Neither child required tube thoracostomy. Three children necessitated intraoperative tube thoracostomy placement for symptomatic pneumothoraces before radiographic assessment. No children sustained postprocedural complications in the absence of postbronchoscopy radiography. Postbronchoscopy chest radiography in the absence of defined symptomatology is not associated with a change in the postprocedural treatment course, suggesting selective application may be appropriate after at-risk bronchoscopic interventions. Such practice will limit the future cost and radiation exposure associated with this common procedure.

Estimating pediatric surgical need in developing countries: a household survey in Rwanda.

PURPOSE: Surgical services for children are often absent in resource-limited settings. Identifying the prevalence of surgical disease at the community level is important for developing evidence-based pediatric surgical services and training. We hypothesize that the untreated surgical conditions in the pediatric population are largely uncharacterized and that such burden is significant and poorly understood. Furthermore, no such data exist at the population level to describe this population. METHODS: We conducted a nationwide cross-sectional cluster-based population survey to estimate the magnitude of surgical disease in Rwanda. Conducted as a verbal questionnaire, questions included representative congenital, acquired, malignant and injury-related conditions. Pediatric responses were analyzed using descriptive statistics and univariate analysis. RESULTS: A total of 1626 households (3175 individuals) were sampled with a 99% response rate; 51.1% of all individuals surveyed were younger than age 18. An estimated 50.5% of the total current surgical need occurs in children. Of all Rwandan children, 6.3% (95% CI 5.4%-7.4%), an estimated 341,164 individuals, were identified to have a potentially treatable surgical condition at the time of the interview. The geographic distribution of surgical conditions significantly differed between adults and children (p<0.001). CONCLUSIONS: The results emphasize the magnitude of the pediatric surgery need as well as the need for improved education and resources. This may be useful in developing a collaborative local training program.

The effect of race and gender on pediatric surgical outcomes within the United States.

PURPOSE: The purpose of this study was to examine risk-adjusted associations between race and gender on postoperative morbidity, mortality, and resource utilization in pediatric surgical patients within the United States. METHODS: 101,083 pediatric surgical patients were evaluated using the U.S. national KID Inpatient Database (2003 and 2006): appendectomy (81.2%), pyloromyotomy (9.8%), intussusception (6.2%), decortication (1.9%), congenital diaphragmatic hernia repair (0.7%), and colonic resection for Hirschsprung's disease (0.2%). Patients were stratified according to gender (male: 63.1%, n=63,783) and race: white (n=58,711), Hispanic (n=26,118), black (n=9,103), Asian (n=1,582), Native American (n=474), and other (n=5,096). Multivariable logistic regression modeling was utilized to evaluate risk-adjusted associations between race, gender, and outcomes. RESULTS: After risk adjustment, race was independently associated with in-hospital death (p=0.02), with an increased risk for black children. Gender was not associated with mortality (p=0.77). Postoperative morbidity was significantly associated with gender (p<0.001) and race (p=0.01). Gender (p=0.003) and race (p<0.001) were further associated with increased hospital length of stay. Importantly, these results were dependent on operation type. CONCLUSION: Race and gender significantly affect postoperative outcomes following pediatric surgery. Black patients are at disproportionate risk for postoperative mortality, while black and Hispanic patients have increased morbidity and hospital resource utilization. While gender does not affect mortality, gender is a determinant of both postoperative morbidity and increased resource utilization.

Surgical outcomes analysis of pediatric peritoneal dialysis catheter function in a rural region.

PURPOSE: The purpose of this study was to analyze the experience with peritoneal dialysis (PD) at a high-volume, single center institution that supports a rural population. METHODS: From 2000 to 2010, 88 children (median age: 1.98 years, [range: 2 days-20.2 years]) received 134 PD catheters for the management of acute and chronic renal failure. The primary outcome of interest was the incidence of primary PD catheter failure (replacement or revision within 60 days). Operative technique, longitudinal outcomes, and time intervals to transplantation were analyzed. RESULTS: Median time to transplant from the institution of dialysis was 1.4 years [range: 0.3-6.4 years]. Primary catheter failure occurred in 24.6% of cases. Infants less than 6 months of age demonstrated an increased incidence of primary catheter failure (p = 0.02). The operative technique for catheter placement was not associated with the incidence of primary failure. Postoperative complications included peritonitis (22.7%), omental plugging (11.9%), pericatheter drainage (9.0%), and exit site infection (3.0%). CONCLUSION: Peritoneal dialysis provides a safe and effective renal replacement therapy for regional pediatric centers that serve a rural population. However, primary catheter failure rates remain high at 24.6%. The surgical technique for placement had no effect on this failure rate in our patient population. Infants less than 6 months of age are at increased risk for primary catheter failure and warrant intensive surveillance.

Pediatric cervicomediastinal hibernoma: a case report.

Hibernoma is a rare lipomatous tumor of brown fat origin. Though uniformly benign in nature these tumors may cause symptoms secondary to extrinsic compression of neighboring structures. Hibernomas may be found anywhere that normal fetal brown fat may be located but are most commonly located in the thigh. We present a case of a hibernoma presenting as an unusual cervicomediastinal mass in a 6-year-old male. This mass was discovered during a diagnostic chest x-ray for pneumonia and treated by resection. Complete surgical resection is considered curative. Hibernoma should be considered in the differential diagnosis of any lipomatous tumor.

Primary payer status is significantly associated with postoperative mortality, morbidity, and hospital resource utilization in pediatric surgical patients within the United States.

PURPOSE: Current healthcare reform efforts have highlighted the potential impact of insurance status on patient outcomes. The influence of primary payer status (PPS) within the pediatric surgical patient population remains unknown. The purpose of this study was to examine risk-adjusted associations between PPS and postoperative mortality, morbidity, and resource utilization in pediatric surgical patients within the United States. METHODS: A weighted total of 153,333 pediatric surgical patients were evaluated using the national Kids' Inpatient Database (2003 and 2006): appendectomy, intussusception, decortication, pyloromyotomy, congenital diaphragmatic hernia repair, and colonic resection for Hirschsprung's disease. Patients were stratified according to PPS: Medicare (n=180), Medicaid (n=51,862), uninsured (n=12,539), and private insurance (n=88,753). Multivariable hierarchical regression modeling was utilized to evaluate risk-adjusted associations between PPS and outcomes. RESULTS: Overall median patient age was 12 years, operations were primarily non-elective (92.4%), and appendectomies accounted for the highest proportion of cases (81.3%). After adjustment for patient, hospital, and operation-related factors, PPS was independently associated with in-hospital death (p<0.0001) and postoperative complications (p<0.02), with increased risk for Medicaid and uninsured populations. Moreover, Medicaid PPS was also associated with greater adjusted lengths of stay and total hospital charges (p<0.0001). Importantly, these results were dependent on operation type. CONCLUSIONS: Primary payer status is associated with risk-adjusted postoperative mortality, morbidity, and resource utilization among pediatric surgical patients. Uninsured patients are at increased risk for postoperative mortality while Medicaid patients accrue greater morbidity, hospital lengths of stay, and total charges. These results highlight a complex interaction between socioeconomic and patient-related factors, and primary payer status should be considered in the preoperative risk stratification of pediatric patients.

Permissive hypercapnia in the management of congenital diaphragmatic hernia: our institutional experience.

BACKGROUND: Congenital diaphragmatic hernia (CDH) is a potentially lethal anomaly associated with pulmonary hypoplasia and persistent pulmonary hypertension. Permissive hypercapnia is a strategy designed to reduce lung injury from mechanical ventilation in infants. It has been shown to be a potentially superior method of ventilator management for patients with CDH. In 2001, the Divisions of Neonatology and Pediatric Surgery at the University of Virginia Children's Hospital established permissive hypercapnia as the management strategy for treatment of CDH. We hypothesized that permissive hypercapnia would be associated with improved outcomes in this patient population. STUDY DESIGN: This retrospective review compares outcomes of infants treated for CDH in the extracorporeal membrane oxygenation (ECMO) era before and after initiation of permissive hypercapnia at a single institution. Outcomes were compared using univariate statistical analysis. RESULTS: Ninety-one patients were available for analysis and were divided into 2 groups: 42 (Group 1) treated before and 49 (Group 2) treated after implementation of permissive hypercapnia. Survival was higher in Group 2 (85.8% vs 54.8%; p = 0.001; relative risk [RR] 3.17). Morbidity was lower in Group 2 and approached statistical significance (65.3% vs 83.3%; p = 0.052). Patients in Group 2 were repaired later, had a lower rate of ECMO use, and were extubated earlier. There was no difference in hospital stay. CONCLUSIONS: The use of permissive hypercapnia for infants with CDH was associated with decreased mortality, a longer period of ventilation before repair with a shorter period of ventilation after repair, a lower rate of ECMO use, and no lengthening of hospital stay. Permissive hypercapnia remains the standard of care for ventilation of infants with CDH at our institution.

The ventriculo-gallbladder shunt in the treatment of refractory hydrocephalus: a review of the current literature.

The ventriculo-gallbladder (VGB) shunt has been reported on several occasions for the alleviation of ventriculo-peritoneal (VP) -shunt-refractory hydrocephalus. There is little data regarding VGB shunts and a need for delineating appropriate surgical therapy when cerebrospinal fluid drainage to the peritoneum becomes infeasible. We report our experience with VGB shunt placement in three patients with chronic hydrocephalus. All three had a history of prior VP-shunt placements and revisions due to distal obstruction or infection, or contraindications to alternative forms of ventricular drainage. In one patient, the VGB shunt functioned well for 9 years but was revised due to contamination during an unrelated operation. Neither of the other two patients have experienced VGB shunt-related complications. VP shunts are presently regarded as the standard of care for uncomplicated hydrocephalus. When VP shunts fail, the most common alternatives have been ventriculo-atrial and ventriculo-pleural shunts. In five case series involving 59 patients with VGB shunts, the long-term success rate was 62.7 per cent. Infection (10.2%) and obstruction (10.2%) were the most common complications. Based on durability and a low incidence of complications, it is the current consensus that VGB shunts are a viable alternative with good outcomes in the case of failed VP shunts.

The use of octreotide to treat congenital chylothorax.

We report the use of the octreotide (a somatostatin analogue) in the treatment of idiopathic congenital chylothorax in a patient with Turner's syndrome who had previously failed conservative medical therapy. The patient improved rapidly after initiation of octreotide with complete resolution after 5 days of continuous therapy (10 microg/kg per hour).

Pancreatic pseudoaneurysm in a child with hereditary pancreatitis: diagnosis with multidetector CT angiography.

Pseudoaneurysm formation is a serious vascular complication of pancreatitis. It most commonly affects splenic and gastroduodenal arteries. We report a rare case of superior mesenteric artery pseudoaneurysm in a child with hereditary pancreatitis. Multidetector CT angiography allowed the comprehensive assessment of the aneurysm and allowed accurate surgical planning obviating the need for catheter angiography.

Bladder wall necrosis in an extremely low-birth-weight infant: a thought-provoking complication of necrotizing enterocolitis.

An 879-g baby boy had catastrophic necrotizing enterocolitis (NEC) at 29 days of life and underwent surgical laparotomy with a subsequent ileostomy and peritoneal drain placement. The infant was subsequently stable until 42 days of life when a spontaneous perforation of the bladder apex was diagnosed by a suprapubic cystogram. Laparotomy on day of life 46 found a loop of dead bowel herniating into a necrotic hole of the bladder dome. This case shows a previously unreported complication of NEC and discusses the possibility that prolonged use of a peritoneal drain may have permitted its genesis.

Thoracoscopic treatment of spontaneous pneumothorax in children.

BACKGROUND/PURPOSE: This study describes the authors experience and results with thoracoscopic treatment of spontaneous pneumotrorax (SP) in 22 children. METHODS: A total of 32 thoracoscopic procedures were performed in 22 children. The patients ranged in age from 9 to 21 years at the time of their first thoracoscopy. SP was primary in 9 and secondary in 13 patients. Pleurodesis was performed in all thoracoscopies using talc in 28 and pleural abrasion in 4 procedures. In 2 of these, apical pleurectomy was added to abrasion. Blebectomy was the additional surgical procedure associated with pleurodesis in 4 patients. RESULTS: Thoracoscopy usually was performed with the patient under general anesthesia. In children with severe respiratory insufficiency, regional anesthesia was used. The mean operative time was 42.6 minutes (range, 8 to 114 minutes). The mean time of postoperative chest tube drainage was 4.6 days (range, 2 to 12 days). Three patients with cystic fibrosis had prolonged air leak lasting longer than 7 days after thoracoscopy. None of them required an additional surgical intervention, and the air leak ceased in 8, 8, and 12 days with continuous suction. One patient required a repeat thoracoscopy for bleeding from an intercostal artery on postoperative day one. The mean follow-up was 4 years (range, 2.5 months to 14 years). There have been 2 partial recurrences (6.25%), both in patients with secondary SP, which were treated by a repeat thoracoscopy and talc pleurodesis. CONCLUSIONS: Thoracoscopic treatment of SP is safe and effective in children. It can be performed under regional anesthesia also in children with severe respiratory insufficiency. Because the complications and recurrences are encountered more frequently in children with an underlying lung disease, special care in surgical manipulation is required in this subgroup of patients with SP.

Extravasation of hyperalimentation into the liver parenchyma from a peripherally inserted central catheter.

A neonate receiving hyperalimentation through a peripherally inserted central catheter (PICC) had acute abdominal distension and respiratory distress. She was found to have extravasated a 9-cm x 9-cm pocket of hyperalimentation into the liver parenchyma, most likely caused by arterial placement of the PICC. She had severe anasarca and markedly decreased synthetic liver function. After 3 weeks of intensive care, she began to diurese. Her respiratory status subsequently improved, she started feeding, and her liver function test results returned to normal. This case shows the remarkable regenerative capacity of the neonatal liver and provides a rationale for conservative management of this rare but morbid PICC complication.

The role of thoracoscopy in pediatric surgical practice.

Originally described in the early 20th century, the technique of thoracoscopy was first applied to children in the mid 1970s. Since that time, the technique has become adopted widely by pediatric surgeons and is currently considered to be the optimum technique for management of many intrathoracic disorders in children. In most pediatric surgical practices, the most common indications for thoracoscopy include pleural debridement for empyema, mediastinal lymph node biopsy, and pulmonary parenchymal biopsy for inflammatory infiltrates or nodules. With proper adherence to patient selection and preoperative imaging as well as appropriate anesthetic techniques, this procedure has proven to be extremely accurate in achieving a diagnosis and very successful in treating most patients. Postoperative recovery is rapid, and complications of the procedure have been relatively infrequent. As pediatric surgeons gain more experience with this technique and as better instrumentation becomes available, thoracoscopy surely will be used for an increasing number of complex intrathoracic disorders.