Education Empowers Emergency Department Nurses During Pediatric Traumas.

In January 2017, the Emergency Trauma Advocate (ETA) program was piloted at our Level 1 trauma center to promote patient advocacy, particularly in pediatric patients. The goal was to empower emergency department nurses by improving their knowledge base through interactive didactic sessions. This study reviews the preliminary findings of the program. Surveys were administered after each teaching session to participating ETA nurses to determine their personal academic interests and how to improve the program. We then performed a retrospective review of pediatric trauma admissions from January 2017 through April 2017 to delineate the most common injury patterns. Survey responses demonstrated the greatest nursing interest in learning critical care (n = 11), orthopedic management (n = 11), and neurosurgical trauma education (n = 9). During this study period, 113 pediatric patients arrived and had a mean age of 7.8 ± 5.2 years. The most common injury patterns were orthopedic (n = 38) and neurosurgical (n = 28), and 35 patients required critical care management. Bivariate analysis revealed a significant and positive relationship between injury frequency and educational interests (R = 98.8%, p = .0057). A nurse's interest in educational topics directly correlates with recent pediatric trauma injury patterns. Future work should focus on determining what impact the ETA program has had on pediatric outcomes.

Prevalence of Chronic Gastritis or Helicobacter pylori Infection in Adolescent Sleeve Gastrectomy Patients Does Not Correlate with Symptoms or Surgical Outcomes.

BACKGROUND: In adults undergoing gastric bypass surgery, it is routine practice to perform pre-operative testing for Helicobacter pylori infection. Evidence suggests that infection impairs anastomotic healing and contributes to complications. There currently are no data for adolescents undergoing bariatric procedures. Despite few patients with pre-operative symptoms, we noted occasional patients with H. pylori detected after sleeve gastrectomy. We reviewed our experience with our adolescent sleeve gastrectomy cohort to determine the prevalence of H. pylori infection, its predictive factors, and association with outcomes. We hypothesized that H. pylori infection would be associated with pre-operative symptoms, but not surgical outcomes. METHODS: All patients undergoing sleeve gastrectomy at our hospital were included. We conducted a chart review to determine pre- or post-operative symptoms of gastroesophageal reflux disease GERD or gastritis, operative complications, and long-term anti-reflux therapy after surgery. Pathology reports were reviewed for evidence of gastritis and H. pylori infection. RESULTS: 78 adolescents had laparoscopic sleeve gastrectomy from January 2010 through July 2014. The prevalence of chronic gastritis was 44.9% (35/78) and 11.4% of those patients had H. pylori (4/35). Only one patient with H. pylori had pre-operative symptoms, and only 25.7% (9/35) of patients with pathology-proven gastritis had symptoms. One staple line leak occurred but this patient did not have H. pylori or gastritis. Mean patient follow-up was 10 (3-26) mos. CONCLUSIONS: There is a moderate prevalence of gastritis among adolescents undergoing sleeve gastrectomy, but only a small number of these patients had H. pylori infection. Neither the presence of chronic gastritis nor H. pylori infection correlated with symptoms or outcomes. Thus, in the absence of predictive symptomology or adverse outcome in those who are infected, we advocate for continued routine pathologic evaluation without the required need for pre-operative determination unless or until H. pylori infection is associated with adverse surgical outcomes.

Conservative Treatment of Lung Perforation Secondary to Retained Catheter in an Extremely Low-Birth-Weight Premature Infant.

Airway injury may occur during the use of any instrumentation in premature infants. A surgical approach for the treatment of lung perforation in extremely low-birth-weight infants has been recommended in the past. Here, we present a case of lung perforation in an ex-28-week, 730-g premature infant, who sustained lung perforation, secondary to an 8-Fr suction catheter used to administer surfactant, in which the broken catheter was retained in the airway. Following removal of catheter by endoscopy, tension pneumothorax had occurred. Attempts were made to treat the patient with single chest tube, unfortunately as it was not efficacious, the second one was placed on the ipsilateral side of hemithorax and the patient recovered without further surgery.

The impact of leukoreduced red blood cell transfusion on mortality of neonates undergoing extracorporeal membrane oxygenation.

BACKGROUND: Blood products containing leukocytes have been associated with negative immunomodulatory and infectious effects. Transfusion-related acute lung injury is partially explained by leucocyte agglutination. The Food and Drug Administration has therefore recommended leukoreduction strategies for blood product transfusion. Our institution has been using leukocyte-reduced blood via filtration for neonates on Extracorporeal Membrane Oxygenation (ECMO). We hypothesized that the use of leukocyte-reduced blood would decrease mortality and morbidity of neonatal ECMO patients. METHODS: Retrospective review of noncardiac ECMO in neonates from 1984-2011, stratified into year groups I and II (≤1996 and ≥1997). Demographics, duration and type of ECMO, complications, and outcome data were collected. Blood product use data was collected. Univariate, bivariate, and multivariate analyses determined predictors of risk-adjusted mortality by year group. RESULTS: Patients (827) underwent ECMO with 65.3% (540) in group I. Overall median blood product use in mL/kg/d was 36.2 packed red blood cells (pRBC), 8.1 platelets, and 0 cyroprecipitate and/or fresh-frozen plasma. Overall mortality was 16.4%. Median pRBC used or transfused was 42.1 mL/kg/d in group I versus 19.1 mL/kg/d group II (P <0.001). On bivariate analysis, there was no difference in crude mortality between the 2 year groups (17.2% versus 16.0%, P = 0.66). However, on multivariate analysis adjusting for demographics, diagnosis, complications, and blood product use other than pRBCs, each additional transfusion of 10 mL/kg/d of pRBC was associated with a 33% increase in mortality in group I (P <0.05). Group II also showed an increase in mortality with each additional transfusion (21%) but this was not statistically significant (P = 0.07). Days on ECMO were not associated with pRBC transfusion in group I but increased in group II (additional 3 d for each 10 mL/kg/d transfused). There was no difference in infectious complications between groups I and II. CONCLUSIONS: Blood transfusion requirement has diminished in newborns undergoing ECMO at our institution. Transfusion of non leukocyte-reduced blood is associated with an increase in mortality whereas transfusion of leukocyte-reduced blood provided no benefit with a trend toward increased mortality. Further research is recommended to understand these trends.

Predicting sleep apnea in morbidly obese adolescents undergoing bariatric surgery.

INTRODUCTION: In adults, the association between obesity and obstructive sleep apnea (OSA) is established, and many are concerned OSA increases surgical risk. Pre-operative screening for OSA is standard, and this is also the case in adolescent bariatric surgery. We noted many of our patients were without significant OSA, despite being obese. We reviewed our experience with screening polysomnography (PSG) to determine any predictive variables or complications. METHODS: All bariatric surgery patients from our hospital who had undergone PSG were included, and were stratified into 'OSA' or 'no OSA' by obstructive apnea-hypopnea index (OAHI), as well as by sex. RESULTS: A total of 49 adolescents enrolled during the study period: 10 males and 39 females. OSA prevalence was 42.9 %; males 80 %, females 33.3 %. Height, weight, body mass index (BMI), and prevalence of hypertension were significantly higher in patients with OSA. By sex, females also had more metabolic syndrome and witnessed apneas, while only weight and BMI remained significant in males. There were no peri-operative complications. CONCLUSIONS: Despite uniform obesity, less than half our adolescents had significant OSA on PSG. As no modeling exists to predict OSA in morbidly obese adolescents, we continue to recommend routine PSG, especially in higher weight and BMI patients, and those with hypertension.

Transanal, full-thickness, Swenson-like approach for Hirschsprung disease.

PURPOSE: Swenson's procedure for Hirschsprung disease (HD) was thought to disturb fecal, urinary, and ejaculatory functions leading to other approaches including the Soave and Duhamel techniques. Given our Center's experience with a full-thickness rectal dissection for anorectal malformations, and using the new transanal concept, we chose to apply these ideas to the primary treatment of HD, and describe technical aspects and impact on fecal, urinary, and sexual function. METHODS: We reviewed our series of HD patients who underwent a transanal, Swenson-like rectosigmoid dissection, assessing for postoperative stricture, anastomotic leak, enterocolitis, and long-term results for bowel, urinary, and sexual function. RESULTS: Of 67 patients, 28 had a transanal resection, 5 had transanal plus laparoscopy, and 34 had transanal plus laparotomy, of those, 28 patients had a leveling colostomy prior to referral. The average length of resection was 27 cm ± 12.7 cm. Mean follow-up was 17.2 months (range 1-96 months). 44 patients were at least three years old at follow-up and were assessed for urinary and fecal continence; all (100%) had voluntary bowel movements and urinary continence. Enterocolitis occurred in 9 patients (14%) and constipation (requiring laxatives) occurred in 21 (32%). Of 24 male patients, 21 (88%) reported the occurrence of spontaneous erections post-operatively. CONCLUSION: Our data support the fact that a modification of Swenson's original transabdominal dissection concept using the recently described transanal approach is an excellent technique for Hirschsprung, and produces excellent long-term outcomes for fecal and urinary continence, and seems to preserve erectile function.

The role of a colon resection in combination with a Malone appendicostomy as part of a bowel management program for the treatment of fecal incontinence.

PURPOSE: Surgical options previously described by us as part of a bowel management program for the treatment of soiling and fecal incontinence include (1) resection of a megarectosigmoid to reduce a patient's laxative requirement or (2) a Malone appendicostomy in patients who require enemas. We have found that some patients may benefit from both procedures. METHODS: We reviewed 18 fecally incontinent patients with structural or functional disorders of the anorectosigmoid (16 ARM, 1 spina bifida, and 1 SCT) who underwent both procedures. RESULTS: Of 18 patients, the enema regimen prior to resection had an average volume of 681 ml of saline (Range 400-1000 ml) and 60 ml (Range 48-117 ml) of additives (glycerine, castile soap and/or phosphate). Following the colon resection, the average volume of saline and additives was 335 ml (Range 130-650 ml) and 25 ml (Range 0-60 ml), respectively, a 50% reduction for both (P<0.01). The time for enema administration and evacuation was reduced by 25%, and the enemas were more effective, rendering the patients clean in 18 of 18 cases (follow-up was 3 months to 21 years). 2 patients later demonstrated that they could be managed with laxatives alone. CONCLUSION: In patients with poor continence potential and a megarectosigmoid, combining a colon resection with a Malone appendicostomy can make the enema more effective. In some rare cases we found the resection may allow for a better response to laxatives.

Incidence of delayed gastric emptying associated with revisional laparoscopic paraesophageal hernia repair.

BACKGROUND: Over the past 15 years, laparoscopic repair of primary paraesophageal hernias (PEH) has become the preferred operative approach. Today, more surgeons are approaching recurrent PEHs laparoscopically, though few studies exist on the long-term results of these revisional operations, particularly regarding the incidence of postoperative delayed gastric emptying (DGE). METHODS: A retrospective review was conducted of all laparoscopic repairs for recurrent PEH done by three surgeons at a single institution from 2003 to 2011. Data collected included age, sex, weight, BMI, pre- and postoperative symptoms, and operative data, but our primary focus was on those patients with pre- and postoperative delayed gastric emptying ultimately requiring operative intervention. RESULTS: Of 284 patients who underwent laparoscopic PEH repair, 91 (32 %) were performed for recurrent PEH. A sleeve gastrectomy was performed in ten of these patients (11 %) for concomitant morbid obesity which were excluded from our study group, leaving 81 study patients. The mean age was 56 years, and mean BMI was 30. All cases were completed laparoscopically; in 45 (56 %) either a partial or complete fundoplication was performed, and in 68 (84 %) a percutaneous gastrostomy tube (PEG) was placed at the time of revision. Sixty-eight patients underwent repair of a first recurrence, of which 8 (12 %) ultimately required a gastric emptying procedure to alleviate symptoms of DGE. There were nine patients who had a second recurrence repaired, and six (66 %) progressed to a gastric emptying procedure. Finally, of the four patients who had a third recurrence repaired, three (75 %) eventually needed a gastric emptying procedure. CONCLUSION: While the incidence of DGE associated with initial PEH repair is low, DGE is a significantly more common finding in patients requiring reoperation for recurrent PEH. This risk increases significantly with repair of each subsequent recurrence. Our data suggest that DGE should be anticipated and patients counseled of the ramifications of this problem preoperatively. Surgeons performing revisional PEH surgery should preemptively develop protocols for the postoperative management of DGE from the time of operation.

Rectal atresia and stenosis: unique anorectal malformations.

INTRODUCTION: Rectal atresia/stenosis is a rare disorder in the spectrum of anorectal malformations and is particularly associated with a presacral mass. These patients are born with a normal anal canal but have a stricture or complete atresia located a few centimeters proximal to the dentate line. We present a surgical technique for the management of these patients, as well as their unique clinical concerns and outcomes. METHODS: We reviewed the records of 14 patients with rectal atresia and 3 with rectal stenosis. We describe a novel technique that we have developed for the preservation of the anterior dentate line that was performed in the last 13 patients. RESULTS: Rectal atresia/stenosis was associated with a presacral mass in 5 patients (29%). Definitive repair was completed using a circular rectorectal anastomosis in the first 4 patients and an anterior dentate line sparing procedure in the last 13. All patients older than 3 years have demonstrated the ability to have voluntary bowel movements. CONCLUSION: With the largest reported series of rectal atresia/stenosis, we have demonstrated a safe and effective technique for repair. Preoperative evaluation must be thorough because a significant number of these patients will have an associated presacral mass.

Neoappendicostomy in the management of pediatric fecal incontinence.

PURPOSE: The Malone appendicostomy, for antegrade enemas, has improved the quality of life for many children with fecal incontinence. In patients whose appendix has been removed, a neo-appendix can be created. We describe our approach and experience with this procedure as an option for surgeons managing children with fecal incontinence. METHODS: The procedure involves creating a transverse flap of cecum that receives its blood supply by a transverse mesenteric branch. This flap is then tubularized around a feeding tube. The surrounding colon is plicated around the neo-appendix to prevent leakage of stool. The tip of the flap is then anastomosed to the deepest portion of the umbilicus. We reviewed our experience with this procedure, including results and complications. IRB approval was obtained. RESULTS: Eighty patients required a neo-appendicostomy. Sixty-six patients (82%) had an anorectal malformation, four had spina bifida, and ten had other diagnoses. The reasons for not having an appendix available included: "incidental" appendectomy (34, 42.5%), use of the appendix for a Mitrofanoff procedure (20, 25%), and Ladd's procedure (5, 6%). In fifteen patients (19%) we could find no appendix and assume that it was removed previously. Following neoappendicostomy, nine patients (11%) developed a stricture, and seven patients had leakage (9%). In 2004, we modified the appendiceal-umbilical anastomosis and among these patients, only one patient (3%) developed a stricture, compared with eight patients (18%) without the modification. All seven patients with leakage were within the first forty cases. No patient in the last forty cases had a leakage. CONCLUSIONS: In patients with the potential for fecal incontinence, the appendix should be preserved. In patients without an appendix, the neo-appendicostomy is a valuable tool for fecally incontinent patients. We have found that the V-V anastomosis had a reduced rate of stricture, and the rate of leakage seems to be related to surgical experience.

MRI of acquired posterior urethral diverticulum following surgery for anorectal malformations.

BACKGROUND: Posterior urethral diverticulum (PUD) is one of the most common postoperative complications associated with anorectal malformation (ARM) correction. OBJECTIVE: To describe our MRI protocol for evaluating acquired PUD following ARM surgery, and associated imaging findings. MATERIALS AND METHODS: Two radiologists retrospectively reviewed 61 pelvic MRI examinations performed for postoperative ARM for PUD identification and characteristics. Associated clinical, operative and cystoscopy reports were also reviewed and compared to MRI. RESULTS: An abnormal retrourethral focus suspicious for PUD was identified at MRI in 13 patients. Ten of these patients underwent subsequent surgery or cystoscopy, and PUD was confirmed in five. All of the confirmed PUD cases appeared as cystic lesions that were at least 1 cm in diameter in two imaging planes. Four of the false-positive cases were punctate retrourethral foci that were visible only on a single MRI plane. One patient had a seminal vesical cyst mimicking a PUD. CONCLUSION: Pelvic MRI can be a useful tool in the postoperative assessment of suspected PUD associated with ARM. Radiologists should have a high clinical suspicion for a postoperative PUD when a cystic lesion posterior to the bladder/posterior urethra is encountered on two imaging planes in these patients.

Pulmonary contusion in the pediatric population.

Pulmonary contusion in the adult population is an independent risk factor for respiratory failure, ventilator associated pneumonia, and acute respiratory distress syndrome. Pilot studies in adults note an increased risk when volume of pulmonary contusion exceeds 20 per cent of total lung volume. The purpose of this study was to determine if children with pulmonary contusion suffer the same morbidity as adults. From January 2005 to May 2007, all trauma patients ages 3 to 18-years-old were assessed for CT evidence of pulmonary contusion. Children were excluded if injury included confounding variables, which could result in respiratory failure independent of contusion status. CT images were reviewed and pulmonary contusion was calculated as a percentage of total lung volume. Outcomes including need for invasive ventilation, pneumonia, and development of oxygenation problems were recorded. Data collected included patient age, Injury Severity Score, arterial blood gas findings, and number of rib fractures. Twenty-six patients met criteria for the study with a mean age of 13.35 years and mean Injury Severity Score of 24. The mean percentage of pulmonary contusion was 19.81 per cent. No patients required intubation. Pediatric pulmonary contusion does not carry the same morbidity as noted in the adult population. Invasive airway management is rarely required.

Critical evaluation of pulmonary contusion in the early post-traumatic period: risk of assisted ventilation.

This study attempts to accurately quantify pulmonary contusion and predict those patients most likely to require assisted ventilation early in their hospital course. Patients admitted to a Level I trauma center were evaluated for pulmonary contusion by helical CT scan. Scans were reviewed by a single radiologist who attempted to accurately quantify contusion as a percentage of total lung volume. These patients were then followed for 48 hours in an attempt to use CT measurements of contusion to predict those that would require assisted ventilation early in their hospital course. After using numerous exclusion criteria, 152 patients were included in the study. Of these, 31 patients (20%) required assisted ventilation within 48 hours of hospital admission. Twenty per cent pulmonary contusion proved to be a highly predictive variable leading to need for assisted ventilation. Of patients sustaining <20 per cent contusion, only 7 of 92 (8%) required assisted ventilation versus 24 of 60 (40%) sustaining >20 per cent contusion. Pulmonary contusion is a significant injury especially when contusion volume exceeds 20 per cent of total lung volume. With accurate measurement of contusion, we can identify those patients at high risk of requiring assisted ventilation early in their hospital course.

Successful treatment of earlobe keloids in the pediatric population.

BACKGROUND: Keloid scars present a difficult treatment challenge. Recently, intralesional steroid injection has become a common treatment modality [Akoz et al. Aesthetic Plast Surg. 2002;6:184-188; Studdiford et al. JABFM. 2008;21:149-152]. Although this has become a proven treatment technique, there is no standard injection protocol to which treating physicians commonly adhere. We hypothesize that timing of steroid injection may improve outcomes using this treatment technique in combination with lesion excision. METHODS: Fifteen patients with 16 earlobe keloids were treated using a standard steroid injection protocol with Kenalog (Bristol-Myers Squibb, New York, NY), in combination with lesion excision. Strict follow-up was enforced, with repeat injections as needed at any sign of abnormal scar formation postoperatively. RESULTS: Of 16 lesions, 15 (94%) were treated successfully with no sign of lesion recurrence at 6 months of follow-up. A single lesion was lost to follow-up and presented 18 months postoperatively with recurrence. This lesion was subsequently retreated successfully. CONCLUSIONS: Kenalog injection in combination with excision is a well-tolerated and effective treatment of earlobe keloids in the pediatric population. We feel that timing of injection and adherence to a strict follow-up regimen is crucial to success.

Four years of an aggressive prophylaxis and screening protocol for venous thromboembolism in a large trauma population.

BACKGROUND: This retrospective review of a prospectively collected database was conducted to analyze the efficacy of 4 years of aggressive prophylaxis and screening protocols for venous thromboembolism (VTE) in a large population of trauma patients. METHODS: Trauma patients at a Level I Trauma Center found to be nonambulatory or otherwise high risk were placed on a protocol of lower-extremity (LE) compression devices and subcutaneous enoxaparin as soon as feasible after admission. Duplex scans of LEs were conducted weekly. RESULTS: During 4 years, 2,939 patients were admitted to trauma with length of stay >2 days. There was a 3.2% incidence of VTE in the length of stay >2 days population, 2.5% rate of deep venous thrombosis (DVT), and 0.7% pulmonary embolism. All VTE patients had factors known to increase risk of VTE and were included in our prophylaxis and screening protocol. Twenty-one percent of these received pharmacologic prophylaxis within the first 2 days of admission; 62% received enoxaparin at some point before diagnosis of VTE. Duplex scans were conducted in 982 patients. Notably, 86% of LE DVTs were found on routine screening duplex. CONCLUSION: To our knowledge, this is the largest population of trauma patients followed by screening duplexes. All patients with VTEs were identified as high risk, and screening revealed multiple patients with an asymptomatic DVT. We conclude our aggressive prophylaxis regimen lead to low rates of VTE and think screening duplex is a critical component for identifying unsuspected DVT.