Brian D. Kenney

Rare but serious complications of central line insertion.

Discussions on the complications of central venous catheterization in children typically focus on infectious and the more common mechanical complications of pneumothorax, hemothorax, or thrombosis. Rare complications are often more life-threatening, and inexperience may compound the problem. Central venous catheter complications can be broken down into early or late, depending on when they occur. The more serious complications are typically mechanical and occur early, but delayed presentations of pericardial effusions, cardiac tamponade, and pleural effusions may be of equal severity, and delay in diagnosis can be catastrophic. Careful insertion techniques, as well as continued vigilance in the correct position and function of central venous catheters, are imperative to help prevent serious complications.

Definitive percutaneous treatment of lymphatic malformations of the trunk and extremities.

PURPOSE The aim of this study is to investigate a new treatment regimen for macrocystic and microcystic lymphatic malformations (LMs) of the trunk and extremities. METHODS Sixteen patients (aged 2 months-22 years) underwent percutaneous treatment for LM of the trunk and extremities from 2002 to 2007. The LM involved the arm, leg, axilla, chest, abdomen, scrotum, and penis. Eleven patients underwent primary treatment of LM; 5 were treated for recurrence after prior operative resection. Macrocysts (>or=1 cm) were treated with dual-drug chemoablation (sequential intracystic sodium tetradecyl sulfate and ethanol); doxycycline was used for microcysts. Macrocysts and microcysts were treated after complete cyst aspiration using sonographic guidance. Twenty-four macrocysts and 103 microcysts were treated. The goal of treatment was complete cyst ablation documented by sonography or magnetic resonance imaging. RESULTS The mean number of treatments was 1.7 per patient; the mean number of treatments for macrocysts was 1.3 and for microcysts was 1.7. Ablation efficacy was 100% (127/127 cysts). Treatments included massive intraperitoneal cysts and cysts surrounding the adventitia of the brachial artery and brachial nerve. Infection occurred in 2 (13%) of 16 patients. No patient experienced postprocedural pain, skin necrosis, neuropathy, bowel obstruction, skin retraction, or myoglobinuria. CONCLUSIONS Percutaneous sclerotherapy provides effective treatment for macrocystic and microcystic LM as primary treatment or for recurrence after surgical resection.

Reducing computed tomography scans for appendicitis by introduction of a standardized and validated ultrasonography report template.

PURPOSE Computed tomography (CT) for the diagnosis of appendicitis is associated with radiation exposure and increased cost. In an effort to reduce the diagnostic use of CT scans, we implemented a standardized ultrasound report template based on validated secondary signs of appendicitis. METHODS In September 2012, as part of a quality improvement project, we developed and introduced a four category standardized ultrasound report template for limited right lower quadrant abdominal ultrasounds. Outcomes for patients undergoing ultrasound or CT scan for appendicitis between 9/10/2012 and 12/31/2013 (Period 2, n=2033) were compared to the three months prior to implementation (Period 1, n=304). RESULTS In Period 1, 78 of 304 (25.7%) patients had appendicitis versus 385 of 2033 (18.9%) in Period 2 (p=0.006). Non-diagnostic exams decreased from 48% to 0.1% (p<0.001). Ultrasound sensitivity improved from 66.67% to 92.2% (p<0.001). Specificity did not significantly change (96.9% to 97.69%, p=0.46). CT utilization for appendicitis decreased from 44.3% in Period 1 to 14.5% at the end of Period 2 (p<0.001). CONCLUSIONS Implementation of a standardized ultrasound report template based on validated secondary signs of appendicitis nearly eliminated non-diagnostic exams, improved diagnostic accuracy, and resulted in a striking decrease in CT utilization.

Blunt intraabdominal arterial injury in pediatric trauma patients: injury distribution and markers of outcome

BACKGROUND The epidemiology of pediatric blunt intraabdominal arterial injury is ill defined. We analyzed a multiinstitutional trauma database to better define injury patterns and predictors of outcome. METHODS The American College of Surgeons National Trauma Database was evaluated for all patients younger than 16 years with blunt intraabdominal arterial injury from 2000 to 2004. Injury distribution, operative treatment, and variables associated with mortality were considered. RESULTS One hundred twelve intraabdominal arterial injuries were identified in 103 pediatric blunt trauma patients. Single arterial injury (92.2%) occurred most frequently: renal (36.9%), mesenteric (24.3%), and iliac (23.3%). Associated injuries were present in 96.1% of patients (abdominal visceral, 75.7%; major extraabdominal skeletal/visceral, 77.7%). Arterial control was obtained operatively (n = 46, 44.7%) or by endovascular means (n = 6, 5.8%) in 52 patients. Overall mortality was 15.5%. Increased mortality was associated with multiple arterial injuries (P = .049), intraabdominal venous injury (P = .011), head injury (P = .05), Glasgow Coma Score less than 8 (P < .001), cardiac arrest (P < .001), profound base deficit (P = .007), and poor performance on multiple injured outcomes scoring systems (Revised Trauma Score [P < .001], Injury Severity Score [P = .001], and TRISS [P = .002]). CONCLUSION Blunt intraabdominal arterial injury in children usually affects a single vessel. Associated injuries appear to be nearly universal. The high mortality rate is influenced by serious associated injuries and is reflected by overall injury severity scores.

Anticoagulation without catheter removal in children with catheter-related central vein thrombosis

Catheter-related central venous thrombosis is a serious and common problem among children. The traditional management has been anticoagulation and early catheter removal. Unfortunately, many patients require a new catheter, which is associated with complications that include possible further thrombosis. Although others have used thrombolytic agents in attempts to avoid catheter removal, the authors of the present study believe that the associated complications occur too frequently and are too serious. They have had success with standard anticoagulation in a limited number of patients. Between February 1991 and April 1994, 17 patients (6 weeks to 19 years of age) were treated for catheter-related deep venous thrombosis. Eight patients underwent early catheter removal accompanied by anticoagulation; two of them had intrinsic catheter problems that necessitated removal, and one had hemophilia. Nine others received anticoagulation without catheter removal. Of these, one required catheter removal after 10 days heparin administration failed to diminish the thrombosis. Another patient responded well to anticoagulation but required catheter removal several weeks later because of catheter-site infection. The other seven patients responded well to anticoagulation, and their catheters were retained. For patients with a functional catheter essential to their care, anticoagulation may safely prevent catheter removal.

Does delay in appendectomy affect surgical site infection in children with appendicitis

PURPOSE The purpose of this study was to investigate the association between time from diagnosis to operation and surgical site infection (SSI) in children undergoing appendectomy. METHODS Pediatric patients undergoing appendectomy in 2010-2012 were included. We collected data on patient demographics; length of symptoms; times of presentation, admission and surgery; antibiotic administration; operative findings; and occurrence of SSI. RESULTS 1388 patients were analyzed. SSI occurred in 5.1% of all patients, 1.4% of simple appendicitis (SA) patients, and 12.4% of complex appendicitis (CA) patients. SSI did not increase significantly as the length of time between ED triage and operation increased (all patients, p=0.51; SA patients, p=0.91; CA patients, p=0.44) or with increased time from admission to operation (all patients, p=0.997; SA patients, p=0.69; CA patients, p=0.96). However, greater length of symptoms was associated with an increased risk of SSI (p<0.05 for all, SA and CA patients). In univariable analysis, obesity, and increased admission WBC count were each associated with significantly increased SSI. In multivariable analysis, only CA was a significant risk factor for SSI (p<0.0001). CONCLUSION We found no significant increase in the risk of SSI related to delay in appendectomy. A future multi-institutional study is planned to confirm these results.

Increased use of enoxaparin in pediatric trauma patients

PURPOSE Venous thromboembolism (VTE) in pediatric trauma patients has been reported from 0.7 to 4.2 patients per 1000 admissions. There are no clear guidelines for prophylactic anticoagulation in children. The purpose of this study was to examine the use of enoxaparin in pediatric trauma patients. METHODS The Pediatric Health Information System database was queried from 2001 to 2008 for patients 0 to 18 years with a primary diagnosis of trauma based on International Classification of Diseases, Ninth Revision, codes. Patients who received enoxaparin and/or diagnosed with VTE were identified using pharmacy and International Classification of Diseases, Ninth Revision, codes. Logistic regression was used to identify patient and hospital characteristics associated with VTE and enoxaparin use. RESULTS Among 260,078 pediatric trauma patients, 3195 were prescribed enoxaparin (1.23%), 2915 (1.12%) of whom were given enoxaparin without a diagnosis of VTE. The incidence of VTE remained stable (0.23%-0.28%), whereas the use of enoxaparin increased (0.75%-1.54%), especially in patients without VTE (0.65%-1.43%). Venous thromboembolism was significantly associated with pelvic fractures, intensive care unit stay, and central venous catheters (P = .017, P < .001, P < .001). CONCLUSIONS Despite a stable VTE incidence, the use of enoxaparin significantly increased in pediatric trauma patients, suggesting that use of pharmacologic thromboprophylaxis is increasing in pediatric trauma centers.

Unusual presentation of congenital infantile fibrosarcoma in seven infants with molecular-genetic analysis.

Congenital infantile fibrosarcoma (CIFS) is a rare mesenchymal tumor that primarily presents in the soft tissue of the distal extremities and occasionally in unusual locations such as the lung and retroperitoneum. Herein, we report seven cases of unusual presentations of CIFS. These cases include three in the lungs, one in the retroperitoneum with cord compression, one in the posterior trunk, one in the heart, and one infratemporal involving the sphenoid bone. All tumors demonstrated CIFSs characteristic t(12;15)(p13;q25) and associated ETV6-NTRK3 gene fusion. One of the three lung cases was previously reported as primary bronchopulmonary fibrosarcoma (PBPF), but molecular analysis of the paraffin embedded tissue revealed the ETV6-NTRK3 gene fusion consistent with CIFS. We show that CIFS may occur in unusual sites including visceral locations, and we propose that neoplasms displaying the ETV6-NTRK3 gene fusion represent the visceral components of CIFS.

Extracorporeal membrane oxygenation as a lifesaving modality in the treatment of pediatric patients with burns and respiratory failure

PURPOSE Several case series have described successful utilization of extracorporeal membrane oxygenation (ECMO) for the treatment of pediatric burn patients with respiratory failure. This study examines the Extracorporeal Life Support Organization registry experience in the treatment of these patients. METHODS The Extracorporeal Life Support Organization registry was queried from 1999 to 2008 for all patients not older than 18 years who suffered a burn-related injury. RESULTS Thirty-six patients met inclusion criteria. The mean age was 4.45 years, with an average weight of 20.9 kg. Survivors vs nonsurvivors had a shorter average time to ECMO (97 vs 126 hours, P = .890) and shorter average ECMO run times (193 vs 210 hours, P = .745). Seventeen patients underwent venovenous ECMO and 19 patients underwent venoarterial ECMO, with survival of 59% (n = 10) and 47% (n = 9), respectively (P = .493; odds ratio, 1.587; 95% confidence interval, 0.424-5.945). Overall survival was 53% (n = 19). Complications occurred in 28 patients (33 mechanical, 101 medical). The venoarterial group had 21 mechanical (n = 8) and 61 medical complications (n = 17), compared with the venovenous group with 12 mechanical (n = 8) and 40 medical complications (n = 11). CONCLUSIONS Extracorporeal membrane oxygenation can be a lifesaving modality for pediatric burn patients with respiratory failure. Survival is comparable to the reported survival of non-burn-related pulmonary failure pediatric patients requiring ECMO.

Morbidity of peripherally inserted central catheters in pediatric complicated appendicitis

BACKGROUND The purpose of this study was to compare postoperative outcomes of pediatric patients with complicated appendicitis managed with or without a peripherally inserted central catheter (PICC). METHODS Patients aged ≤18 y in the Pediatric Health Information System database with complicated appendicitis that underwent appendectomy during their index admission in 2000-2012 were grouped by whether they had a PICC placed using relevant procedure and billing codes. Rates of subsequent encounters within 30 d of discharge along with associated diagnoses and procedures were determined. A propensity score-matched (PSM) analysis was performed to account for differences in baseline exposures and severity of illness. RESULTS We included 33,482 patients with complicated appendicitis; of whom, 6620 (19.8%) received a PICC and 26,862 (80.2%) did not. The PICC group had a longer postoperative length of stay (median 7 versus 5 d, P<0.001) and were more likely to undergo intra-abdominal abscess drainage during the index admission (14.4% versus 2.1%, P<0.001), and have a reencounter (17.5% versus 11.4%, P<0.001) within 30 d of discharge. However, in the PSM cohort (n=4428 in each group), outcomes did not differ between treatment groups, although the PICC group did have increased odds for the development of other postoperative complications (odds ratio=3.95, 95% confidence interval: 1.45, 10.71). CONCLUSIONS After accounting for differences in severity of illness by PSM, patients managed with PICCs had a similar risk for nearly all postoperative complications, including reencounters. Postoperative management of pediatric complicated appendicitis with a PICC is not clearly associated with improved outcomes.