Routine Urology Consultation and Follow-up After Pediatric Blunt Renal Trauma is Likely Unnecessary.

INTRODUCTION: This study examines the outcomes of high-grade renal trauma in pediatric patients and evaluates the intervention rate. In our hospital, we routinely consult urology on all high-grade injuries. We anticipated minimal intervention, casting doubt on the need for routine urology consultation and follow-up. METHODS: We conducted a retrospective review at a single pediatric trauma center from January 2018 to June 2023, focusing on patients with severe (grade III-V) renal injuries. Data collected included demographics, trauma-related variables, hospital course, interventions, and follow-up. When the grade was not readily available in the electronic medical record, we had a board-certified pediatric radiologist review the imaging and provide the grade. Follow-up was included only if it was with a pediatric urologist. RESULTS: There were 92 patients that met our inclusion criteria. Of these, 47 were grade III, 32 were grade IV, and 13 were grade V. Six (6.5%) patients required inpatient renal stent procedures. Follow-up occurred in 55/92 (60%) patients with a pediatric urologist. Follow-up by grade is as follows: 22/47 (47%) grade III, 22/32 (69%) grade IV, and 11/13 (85%) grade V. Overall 5.8% of patients required antihypertensive medications and this was more likely as injury grade increased. All stents were removed outpatient and there were 3 (3.3%) additional outpatient interventions, all in patients that were symptomatic. CONCLUSION: Given the low prevalence of interventions after discharge, routine consultation and follow-up with urology is likely unnecessary in the absence of an inpatient urologic procedure during the index hospitalization. Patients with high-grade injuries should instead follow up with a trauma clinic or general provider with urology follow-up based on symptoms. TYPE OF STUDY: Retrospective Review. LEVEL OF EVIDENCE: Level III.

Evaluation and Management of Biliary Dyskinesia in Children and Adolescents: A Systematic Review From the APSA Outcomes and Evidence-Based Committee.

INTRODUCTION: The diagnosis and management of biliary dyskinesia in children and adolescents remains variable and controversial. The American Pediatric Surgical Association Outcomes and Evidence-Based Practice Committee (APSA OEBP) performed a systematic review of the literature to develop evidence-based recommendations. METHODS: Through an iterative process, the membership of the APSA OEBP developed five a priori questions focused on diagnostic criteria, indications for cholecystectomy, short and long-term outcomes, predictors of success/benefit, and outcomes of medical management. A systematic review was conducted, and articles were selected for review following Preferred Reporting Items for Systematic Review and Meta-analyses (PRISMA) guidelines. Risk of bias was assessed using Methodologic Index for Non-Randomized Studies (MINORS) criteria. The Oxford Levels of Evidence and Grades of Recommendation were utilized. RESULTS: The diagnostic criteria for biliary dyskinesia in children and adolescents are not clearly defined. Cholecystectomy may provide long-term partial or complete relief in some patients; however, there are no reliable predictors of symptom relief. Some patients may experience resolution of symptoms with non-operative management. CONCLUSIONS: Pediatric biliary dyskinesia remains an ill-defined clinical entity. Pediatric-specific guidelines are necessary to better characterize the condition, guide work-up, and provide management recommendations. Prospective studies are necessary to more reliably identify patients who may benefit from cholecystectomy. LEVEL OF EVIDENCE: Level 3-4. TYPE OF STUDY: Systematic Review of Level 3-4 Studies.

Classification and Surgical Management of Anorectal Malformations: A Systematic Review and Evidence-based Guideline From the APSA Outcomes and Evidence-based Practice Committee.

OBJECTIVE: Treatment of neonates with anorectal malformations (ARMs) can be challenging due to variability in anatomic definitions, multiple approaches to surgical management, and heterogeneity of reported outcomes. The purpose of this systematic review is to summarize existing evidence, identify treatment controversies, and provide guidelines for perioperative care. METHODS: The American Pediatric Surgical Association Outcomes and Evidence Based Practice Committee (OEBP) drafted five consensus-based questions regarding management of children with ARMs. These questions were related to categorization of ARMs and optimal methods and timing of surgical management. A comprehensive search strategy was performed, and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were used to perform the systematic review to attempt to answer five questions related to surgical care of ARM. RESULTS: A total of 10,843 publications were reviewed, of which 90 were included in final recommendations, and some publications addressed more than one question (question: 1 n = 6, 2 n = 63, n = 15, 4 n = 44). Studies contained largely heterogenous groups of ARMs, making direct comparison for each subtype challenging and therefore, no specific recommendation for optimal surgical approach based on outcomes can be made. Both loop and divided colostomy may be acceptable methods of fecal diversion for patients with a diagnosis of anorectal malformation, however, loop colostomies have higher rates of prolapse in the literature reviewed. In terms of timing of repair, there did not appear to be significant differences in outcomes between early and late repair groups. Clear and uniform definitions are needed in order to ensure similar populations of patients are compared moving forward. Recommendations are provided based primarily on A-D levels of evidence. CONCLUSIONS: Evidence-based best practices for ARMs are lacking for many aspects of care. Multi-institutional registries have made progress to address some of these gaps. Further prospective and comparative studies are needed to improve care and provide consensus guidelines for this complex patient population.

Validation of the Subaxial Cervical Spine Injury Classification score in children: a single-institution experience at a level 1 pediatric trauma center.

OBJECTIVE: The Subaxial Cervical Spine Injury Classification (SLIC) score has not been previously validated for a pediatric population. The authors compared the SLIC treatment recommendations for pediatric subaxial cervical spine trauma with real-world pediatric spine surgery practice. METHODS: A retrospective cohort study at a pediatric level 1 trauma center was conducted in patients < 18 years of age evaluated for trauma from 2012 to 2021. An SLIC score was calculated for each patient, and the subsequent recommendations were compared with actual treatment delivered. Percentage misclassification, sensitivity, specificity, positive (PPV) and negative predictive value (NPV), and area under the receiver operating characteristic (ROC) curve (AUC) were calculated. RESULTS: Two hundred forty-three pediatric patients with trauma were included. Twenty-five patients (10.3%) underwent surgery and 218 were managed conservatively. The median SLIC score was 2 (interquartile range = 2). Sixteen patients (6.6%) had an SLIC score of 4, for which either conservative or surgical treatment is recommended; 27 children had an SLIC score ≥ 5, indicating a recommendation for surgical treatment; and 200 children had an SLIC score ≤ 3, indicating a recommendation for conservative treatment. Of the 243 patients, 227 received treatment consistent with SLIC score recommendations (p < 0.001). SLIC sensitivity in determining surgically treated patients was 79.2% and the specificity for accurately determining who underwent conservative treatment was 96.1%. The PPV was 70.3% and the NPV was 97.5%. There was a 5.7% misclassification rate (n = 13) using SLIC. Among patients for whom surgical treatment would be recommended by the SLIC, 29.6% (n = 8) did not undergo surgery; similarly, 2.5% (n = 5) of patients for whom conservative management would be recommended by the SLIC had surgery. The ROC curve for determining treatment received demonstrated excellent discriminative ability, with an AUC of 0.96 (OR 3.12, p < 0.001). Sensitivity decreased when the cohort was split by age (< 10 and ≥ 10 years old) to 0.5 and 0.82, respectively; specificity remained high at 0.98 and 0.94. CONCLUSIONS: The SLIC scoring system recommended similar treatment when compared with the actual treatment delivered for traumatic subaxial cervical spine injuries in children, with a low misclassification rate and a specificity of 96%. These findings demonstrate that the SLIC can be useful in guiding treatment for pediatric patients with subaxial cervical spine injuries. Further investigation into the score in young children (< 10 years) using a multicenter cohort is warranted.

Elevating Black fathers' experiences in the National Fatherhood Initiative: Strengths and areas for improvement of 24/7 Dad® curriculum and case management services.

The Healthy Marriage and Responsible Fatherhood grant program is one of the most robust mechanisms supporting fatherhood programming in the United States, with the gold standard of care including fatherhood curriculum (e.g., 24/7 Dad®) and case management services. Despite the fact that fatherhood in the United States is not a monolith and Black fathers make up over 40% of those served through Responsible Fatherhood (RF) program, little research explicitly centers the lived experiences of low-income Black fathers. The current study used focus groups with fathers (n = 23) and staff (n = 8) enrolled in a RF grantee program. Thematic analysis was used to determine programmatic mechanisms supporting these fathers' success and areas for improvement. Our findings highlight that the creation of a "safe space" by facilitators and the power of the group dynamic were essential elements for fathers' success overall. We also identified numerous programmatic mechanisms supporting Black fathers' success specific to fathering, healthy relationships, and economic stability. Finally, we highlighted important limitations that may impede the success of low-income, Black fathers related to the 24/7 Dad® curriculum, engagement efforts, and economic stability, and discuss related practice, policy, and research recommendations.

Attitudes of Surgical Trainees and Faculty Towards Parental Leave During Surgical Training.

OBJECTIVE: Our aim was to better understand attitudes towards parental leave from the perspective of both surgeon faculty and current surgical trainees. We hypothesized that support for trainees to take parental leave would vary by year of residency graduation and by parental status. DESIGN: We conducted a web-based survey regarding opinions on trainee parental leave. Quantitative and conventional content qualitative analyses were performed. PARTICIPANTS: Surveys were sent to surgeon faculty and current trainees from 5 large academic surgical residency programs. RESULTS: Survey response rates were 11.5% for surgeon faculty (68/589), and 17.7% for trainees (50/281). There were 80/118 (67.8%) respondents who reported they had or were currently expecting children, 40/80 (50%) of whom were the gestational carrier. Most thought that 6-12 weeks of parental leave should be given to child-bearing trainees (62/118, 52.5%); another 32.2% (38/118) thought >12 weeks should be given. Responses were similar amongst surgeon faculty and trainees, parents and nonparents, and respondents who identified as men and women. Qualitative analysis revealed that most respondents felt parental leave did not put unreasonable strain on other trainees and felt support could be shown both informally and with formal written policies facilitating patient care coverage. Current surgeon faculty were less likely to feel moderately/extremely supported by their faculty compared to trainees (39% vs 77%, p = 0.004). Less than a third (37/117, 31.6%) of respondents knew the current leave policies. CONCLUSIONS: Amongst survey respondents, there was broad support for parental leave for surgical trainees of at least 6 weeks amongst trainees and faculty, and those with and without children. Current trainees felt more supported than current surgical faculty, suggesting that parental leave is increasingly more accepted. Support can be shown both informally and through easily accessible written policies and procedures that facilitate patient care coverage.

Optimizing patient selection for ECMO after pediatric hypothermic cardiac arrest.

BACKGROUND: In 2004, our level 1 regional pediatric trauma center created a protocol to activate ECMO for children with suspected hypothermic cardiac arrest based on inclusion criteria: serum potassium ≤9, submersion <90 min, and core body temperature <30 °C. In 2017, Pasquier et al. developed a model to help predict the survival of adults after hypothermic cardiac arrest (HOPE score) that has not been validated in children. We sought to apply this score to our pediatric patient population to determine if it can optimize our patient selection. METHODS: This was a retrospective review of all patients cannulated onto VA ECMO for hypothermic cardiac arrest between 2004 and 2022. We used abstracted data points to calculate the HOPE score for our patient population, both with and without presumed asphyxia. RESULTS: Over 19 years, 18 patients were cannulated for suspected hypothermic arrest, with three survivors (17 %). The HOPE score survival prediction ranged from 1 to 86 % with presumed asphyxia and 6-98 % without presumed asphyxia. Survivor HOPE scores ranged from 9 to 86 % with presumed asphyxia and 42-98 % without presumed asphyxia. Non-survivors' scores ranged 1-29 % with asphyxia and 6-57 % without asphyxia. A cutoff of >5 % predicted survival with asphyxia for ECMO could have decreased our cannulations by half without missing survivors. CONCLUSION: ECMO can be a lifesaving measure for specific children after hypothermic arrest. However, identifying the patients that will benefit from this resource-intensive intervention remains difficult. HOPE score utilization may decrease the rate of futile cannulation in children, but multi-centered research is needed in the pediatric population.

Management and Outcomes of Pediatric Lymphatic Malformations: A Systematic Review From the APSA Outcomes and Evidence-Based Practice Committee.

BACKGROUND: Significant variation in management strategies for lymphatic malformations (LMs) in children persists. The goal of this systematic review is to summarize outcomes for medical therapy, sclerotherapy, and surgery, and to provide evidence-based recommendations regarding the treatment. METHODS: Three questions regarding LM management were generated according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Publicly available databases were queried to identify articles published from January 1, 1990, to December 31, 2021. A consensus statement of recommendations was generated in response to each question. RESULTS: The initial search identified 9326 abstracts, each reviewed by two authors. A total of 600 abstracts met selection criteria for full manuscript review with 202 subsequently utilized for extraction of data. Medical therapy, such as sirolimus, can be used as an adjunct with percutaneous treatments or surgery, or for extensive LM. Sclerotherapy can achieve partial or complete response in over 90% of patients and is most effective for macrocystic lesions. Depending on the size, extent, and location of the malformation, surgery can be considered. CONCLUSION: Evidence supporting best practices for the safety and effectiveness of management for LMs is currently of moderate quality. Many patients benefit from multi-modal treatment determined by the extent and type of LM. A multidisciplinary approach is recommended to determine the optimal individualized treatment for each patient.

Comparison of current to past outcomes in congenital diaphragmatic hernia using MRI observed-to-expected total fetal lung volume.

BACKGROUND: Fetal Centers use imaging studies to predict congenital diaphragmatic hernia (CDH) prognosis and the need for fetal therapy. Given improving CDH survival, we hypothesized that current fetal imaging severity predictions no longer reflect true outcomes and fail to justify the risks of fetal therapy. METHODS: We analyzed our single-center contemporary data in a left-sided CDH cohort (n = 58) by prognostic criteria determined by MRI observed-to-expected total fetal lung volumes: severe <25%, moderate 25-35%, and mild >35%. We compared contemporary survival to prior studies and the TOTAL trials. RESULTS: Contemporary survival was significantly higher than past studies for all prognostic classifications (mild 100% vs 80-94%, moderate 95% vs 59-75%, severe 79% vs 13-25%; P < 0.01), and to either control or fetal therapy arms of the TOTAL trials. CONCLUSIONS: Current fetal imaging criteria are overly pessimistic and may lead to unwarranted fetal intervention. Fetal therapies remain experimental. Future studies will require updated prognostic criteria.

Two-Stage Liver Transplantation and Tricuspid Valve Replacement After Blunt Trauma in a Pediatric Patient.

In cases of uncontrollable hepatic hemorrhage or acute hepatic failure after trauma, liver transplantation can be a lifesaving procedure. Traumatic tricuspid valve injuries are rare, and symptoms can range from indolent to acute right heart failure. When concomitant, traumatic liver transplant and tricuspid injuries have significant physiologic interplay and management implications. We present a 14-year-old male injured in an all-terrain vehicle accident, who sustained a devastating disruption of the common bile duct and celiac artery injury, leading to acute hepatic failure, necessitating a two-stage liver transplantation. He was subsequently found to have a severe traumatic tricuspid injury, which required tricuspid valve replacement. At 4 years post-injury, he is without major complications. This is the first case presentation of the cooccurrence of these complex pathologies. Importantly, we demonstrate the complex decision-making surrounding traumatic liver transplantation and timing of subsequent tricuspid valve repair, weighing the complex interplay of these 2 pathologies.

The sensitivity of limited-sequence magnetic resonance imaging in identifying pediatric cervical spine injury: A Western Pediatric Surgery Research Consortium multicenter retrospective cohort study.

INTRODUCTION: Clinical clearance of a child's cervical spine after trauma is often challenging because of impaired mental status or an unreliable neurologic examination. Magnetic resonance imaging (MRI) is the criterion standard for excluding ligamentous injury in children but is constrained by long image acquisition times and frequent need for anesthesia. Limited-sequence magnetic resonance imaging (LSMRI) is used in evaluating the evolution of traumatic brain injury and may also be useful for cervical spine clearance while potentially avoiding the need for anesthesia. The purpose of this study was to assess the sensitivity and negative predictive value of LSMRI as compared with criterion standard full-sequence MRI as a screening tool to rule out clinically significant ligamentous cervical spine injury. METHODS: We conducted a 10-center, 5-year retrospective cohort study (2017-2021) of all children (0-18 years) with a cervical spine MRI after blunt trauma. Magnetic resonance imaging images were rereviewed by a study pediatric radiologist at each site to determine if the presence of an injury could be identified on limited sequences alone. Unstable cervical spine injury was determined by study neurosurgeon review at each site. RESULTS: We identified 2,663 children younger than 18 years who underwent an MRI of the cervical spine with 1,008 injuries detected on full-sequence studies. The sensitivity and negative predictive value of LSMRI were both >99% for detecting any injury and 100% for detecting any unstable injury. Young children (younger than 5 years) were more likely to be electively intubated or sedated for cervical spine MRI. CONCLUSION: Limited-sequence magnetic resonance imaging is reliably detects clinically significant ligamentous injury in children after blunt trauma. To decrease anesthesia use and minimize MRI time, trauma centers should develop LSMRI screening protocols for children without a reliable neurologic examination. LEVEL OF EVIDENCE: Diagnostic Test/Criteria; Level III.

Acute superior mesenteric artery syndrome complicated by severe gastric, pancreatic and renal ischaemia.

Superior mesenteric artery syndrome (SMAS) is a rare and potentially life-threatening cause of small bowel obstruction in which the superior mesenteric artery impinges on the third portion of the duodenum. SMAS is typically encountered in patients with low body fat and a history of rapid weight loss and is often diagnosed as a chronic or subacute condition. Here, we describe a case of a healthy adolescent boy without typical SMAS prodromal symptoms presenting with a severe, hyperacute proximal small bowel obstruction due to SMAS. Complications arising from massive gastric and duodenal distension, including gastric, pancreatic and renal ischaemia, necessitated emergent surgical intervention consisting of the duodenojejunostomy bypass with partial gastric resection. The patient recovered without significant lasting consequences.

Decision-Making in Pleural Drainage Following Lung Resection in Children: A Western Pediatric Surgery Research Consortium Survey.

INTRODUCTION: Studies of adults undergoing lung resection indicated that selective omission of pleural drains is safe and advantageous. Significant practice variation exists for pleural drainage practices for children undergoing lung resection. We surveyed pediatric surgeons in a 10-hospital research consortium to understand decision-making for placement of pleural drains following lung resection in children. METHODS: Faculty surgeons at the 10 member institutions of the Western Pediatric Surgery Research Consortium completed questionnaires using a REDCap survey platform. Descriptive statistics and bivariate analyses were used to characterize responses regarding indications and management of pleural drains following lung resection in pediatric patients. RESULTS: We received 96 responses from 109 surgeons (88 %). Most surgeons agreed that use of a pleural drain after lung resection contributes to post-operative pain, increases narcotic use, and prolongs hospitalization. Opinions varied around the immediate use of suction compared to water seal, and half routinely completed a water seal trial prior to drain removal. Surgeons who completed fellowship within the past 10 years left a pleural drain after wedge resection in 45 % of cases versus 78 % in those who completed fellowship more than 10 years ago (p = 0.001). The mean acceptable rate of unplanned post-operative pleural drain placement when pleural drainage was omitted at index operation was 6.3 % (±4.6 %). CONCLUSIONS: Most pediatric surgeons use pleural drainage following lung resection, with recent fellowship graduates more often omitting it. Future studies of pleural drain omission demonstrating low rates of unplanned postoperative pleural drain placement may motivate practice changes for children undergoing lung resection. LEVEL OF EVIDENCE: V.

Utility of Enteral Contrast Protocols in Pediatric Adhesive Small Bowel Obstruction: A Prospective Multicenter Observational Study.

OBJECTIVE: Our objective was to determine the utility of enteral contrast-based protocols in the diagnosis and management of adhesive small bowel obstruction (ASBO) for children. BACKGROUND: Enteral contrast-based protocols for adults with ASBO are associated with decreased need for surgery and shorter hospitalization. Pediatric-specific data are limited. METHODS: We conducted a prospective observational study between October 2020 and December 2022 at nine children's hospitals who are members of the Western Pediatric Surgery Research Consortium. Inclusion criteria were children aged 1-20 years diagnosed with ASBO who underwent a trial of nonoperative management (NOM) at hospital admission. Comparisons were made between those children who received an enteral contrast challenge and those who did not. The primary outcome was need for surgery. RESULTS: We enrolled 136 children (71% male; median age: 12 y); 84 (62%) received an enteral contrast challenge. There was no difference in rate of operative intervention between the no contrast (34.6%) and contrast groups (36.9%; P=0.93). Eighty-seven (64%) were successfully managed nonoperatively with no difference in median length of stay (P=0.10) or rate of unplanned readmission (P=0.14). Among the 49 children who required an operation, there was no significant difference in time from admission to surgery or rate of small bowel resection based on prior contrast administration. CONCLUSIONS: The addition of enteral contrast-based protocols for management of pediatric ASBO does not decrease the likelihood of surgery or shorten hospitalization. Larger randomized studies may be needed to further define the role of radiologic contrast in the management of ASBO in children.

A pediatric teletrauma program pilot project: Improves access to pediatric trauma care and timely assessment of pediatric traumas.

BACKGROUND: Geographic location is a barrier to providing specialized care to pediatric traumas. In 2019, we instituted a pediatric teletrauma program in collaboration with the Statewide Pediatric Trauma Network at our level 1 pediatric trauma center (PTC). Triage guidelines were provided to partnering hospitals (PHs) to aid in evaluation of pediatric traumas. Our pediatric trauma team was available for phone/video trauma consultation to provide recommendations on disposition and management. We hypothesized that this program would improve access and timely assessment of pediatric traumas while limiting patient transfers to our PTC. METHODS: A retrospective cohort study was conducted at the PTC between January 2019 and May 2023. All pediatric trauma patients younger than 18 years who had teletrauma consults were included. We also evaluated all avoidable transfers without teletrauma consults defined as admission for less than 36 hours without an intervention or imaging as a comparison group. RESULTS: A total of 151 teletrauma consults were identified: 62% male and median age of 8 years (interquartile range [IQR], 4-12 years). Teletrauma consults increased from 12 in 2019 to 100 in 2022 to 2023, and the number of PHs increased from 2 to 32. Partnering hospitals were 15 to 554 miles from the PTC, with a median distance of 34 miles (IQR, 28-119 miles). Following consultation, we recommended discharge (34%), admission (29%), or transfer to PTC (35%). Of those who were not transferred, 3% (3 of 97) required subsequent treatment at the PTC. Nontransferred teletrauma consults had a higher percentage of TBI (61% vs. 31%, p < 0.001) and were from farther distances (40 miles [IQR, 28-150 miles] vs. 30 miles [IQR, 28-50 miles], p < 0.001) compared with avoidable transferred patients without a teletrauma consult. CONCLUSION: Teletrauma consult is a safe and viable addition to a pediatric trauma program faced with providing care to a large geographical catchment area. The pediatric teletrauma program provided management recommendations to 32 PHs and avoided transfer in approximately 63% of cases. LEVEL OF EVIDENCE: Prognostic and Epidemiological; Level III.

Use of a statewide solid organ injury procotcol to optimize triage, treatment, and transfer for pediatric abdominal trauma.

BACKGROUND: The Utah Pediatric Trauma Network (UPTN) is a non-competitive collaboration of all 51 hospitals in the state of Utah with the purpose of improving pediatric trauma care. Created in 2019, UPTN has implemented evidence-based guidelines based on hospital resources and capabilities with quarterly review of data collected in a network-specific database. A blunt solid organ injury (SOI) protocol was developed to optimize treatment of these injuries statewide. The purpose of this study was to review the effectiveness of the SOI guideline. METHODS: The UPTN REDCap® database was retrospectively reviewed from 2021 through 2022. We compared admissions from the Level 1 pediatric trauma center (PED1) to non-pediatric hospitals (non-PED1) of children with low-grade (I-II) and high-grade (III-V) SOIs. RESULTS: In 2 years, 172 patients were treated for blunt SOI, with or without concomitant injuries. There were 48 (28%) low-grade and 124 (72%) high-grade SOIs. 33 (69%) patients were triaged with low-grade SOI injuries at a non-PED1 center, and 17 (35%) were transferred to the PED1 hospital. Most had multiple injuries, but 7 (44%) were isolated, and none required a transfusion or any procedure/operation at either hospital. Of the 124 patients with high-grade injuries, 41 (33%) primarily presented to the PED1 center, and 44 (35%) were transferred there. Of these, 2 required a splenectomy and none required angiography. Thirty-nine children were treated at non-PED1 centers without transfer, and 4 required splenectomy and 6 underwent angiography/embolization procedures. No patient with an isolated SOI died. CONCLUSION: Implementation of SOI guidelines across UPTN successfully allowed non-pediatric hospitals to safely admit children with low-grade isolated SOI, keeping families closer to home, while standardizing pediatric triage for blunt abdominal trauma in the state. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.

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

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

Cessation of Antibiotics for Complicated Appendicitis at Discharge Does Not Increase Risk of Post-operative Infection.

PURPOSE: The utilization of home antibiotic therapy following surgery for complicated pediatric appendicitis is highly variable. In 2019, we stopped home antibiotic therapy in this cohort at our institution. We sought to evaluate our outcomes following this protocol change. METHODS: We queried our institutional NSQIP Pediatrics data for all children undergoing appendectomy for complicated appendicitis between January 2015 and May 2022. We identified two cohorts: those discharged with home antibiotics (1/1/15-4/30/19) and those discharged with no home antibiotics (5/1/19-4/30/22). Both groups were treated with response based parenteral antibiotics while hospitalized and discharged when clinically well. Our primary outcome was postoperative deep organ space infection requiring intervention (drainage, aspiration, reoperation, or antibiotics). Secondary outcomes included length of stay, superficial site infection, Clostridium difficile colitis, ER visits, post-operative CT imaging, and readmission. RESULTS: There were 185 patients in the home antibiotic group (83% discharged with antibiotics) and 121 patients in the no home antibiotic group (8.3% discharged with antibiotics). There were no significant differences in deep organ space infection requiring intervention (7% vs. 7.4%, p = 1.0). Our length of stay was not different (4.5 days vs. 3.95 days, p = 0.32), nor were other secondary outcomes or patient characteristics. All patients had documented follow-up. CONCLUSIONS: We did not identify differences in deep organ space infections, length of stay or other events after eliminating home antibiotic therapy in our complicated appendicitis cohort. The use of home antibiotics following surgery for complicated appendicitis should be reconsidered. LEVEL OF EVIDENCE: III.

Cervical Collar-Associated Pressure Injury in Pediatric Trauma Patients: A Western Pediatric Surgery Research Consortium Study.

BACKGROUND: Healthcare-associated pressure injuries (HAPI) are known to be associated with medical devices and are preventable. Cervical spine immobilization is commonly utilized in injured children prior to clinical clearance or for treatment of an unstable cervical spinal injury. The frequency of HAPI has been quantified in adults with cervical spine immobilization but has not been well-described in children. The aim of this study was to describe characteristics of children who developed HAPI associated with cervical immobilization. METHODS: We analyzed a retrospective cohort of children (0-18 years) who developed a stage two or greater cervical HAPI. This cohort was drawn from an overall sample of 49,218 registry patients treated over a five-year period (2017-2021) at ten pediatric trauma centers. Patient demographics, injury characteristics, and cervical immobilization were tabulated to describe the population. RESULTS: The cohort included 32 children with stage two or greater cervical HAPI. The median age was 5 years (IQR 2-13) and 78% (n = 25) were admitted to the intensive care unit. The median (IQR) time to diagnosis of HAPI was 11 (7-21) days post-injury. The majority of cervical HAPI (78%, 25/32) occurred in children requiring immobilization for cervical injuries, with only four children developing HAPI after wearing a prophylactic cervical collar in the absence of a cervical spine injury. CONCLUSION: Advanced-stage HAPI associated with cervical collar use in pediatric trauma patients is rare and usually occurs in patients with cervical spine injuries requiring immobilization for treatment. More expedient cervical spine clearance with MRI is unlikely to substantially reduce cervical HAPI in injured children. LEVEL OF EVIDENCE: Level III (Epidemiologic and Prognostic).