Carlos J. Sivit

Catheter-related thrombosis in critically ill children: Comparison of catheters with and without heparin bonding

OBJECTIVE To compare the incidence of and factors associated with vascular thrombosis after placement of heparin-bonded and standard femoral venous catheters. DESIGN Prospective, masked, clinical study. SETTING Multidisciplinary, tertiary, pediatric intensive care unit. PATIENTS Consecutive cases (n = 50) of critically ill children admitted to a pediatric intensive care unit in whom either a heparin-bonded (n = 25) or a standard (n = 25) femoral venous catheter was placed. MEASUREMENTS AND MAIN RESULTS Patients were examined by ultrasonography within 3 days of catheter insertion, weekly while the catheter was in place, and after catheter removal for evidence of vascular thrombosis. Data were collected prospectively regarding clinical evidence of catheter thrombosis, infusate composition, and positive blood culture results. Of 50 patients, 13 (26%) had thrombotic complications, 11 (44%) of the 25 patients in the standard-catheter group, in comparison with 2 (8%) of the 25 patients in the heparin-bonded catheter group (p = 0.004). In addition, there was a significantly higher incidence of positive blood culture results among patients in the standard-catheter group (24% vs 0%; p = 0.009). Positive catheter blood culture results were obtained in 38% of patients with thrombosis versus 3% without thrombosis (p = 0.001). Clinical evidence of thrombosis was found in 69% of patients with, versus 27% of patients without, ultrasound-proved thrombosis (p = 0.007). CONCLUSION Heparin bonding of catheters is associated with significantly fewer thrombotic complications. A reduced incidence of positive catheter-related blood culture results may be associated with the absence of thrombosis.

Nonoperative management of blunt hepatic and splenic injury in children.

OBJECTIVE The authors assessed the risks of nonoperative management of solid visceral injuries in children (age range, 4 months-14 years) who were consecutively admitted to a level I pediatric trauma center during a 6-year period ending in 1991. METHOD One hundred seventy-nine children (5.0%) sustained injury to the liver or spleen. Nineteen children (11.2%) died. Of the 160 children who survived, 4 received emergency laparotomies; 156 underwent diagnostic computer tomography and were managed nonoperatively. The percentage of children who were successfully treated nonoperatively was 97.4%. Delayed diagnosis of enteric perforations occurred in two children. Fifty-three children (34.0%) received transfusions (mean volume 16.7 mL/kg); however, transfusion rates during the latter half of the study decreased from 50% to 19% in children with hepatic injuries, despite increasing grade of injury, and decreased from 57% to 23% in the splenic group with similar injury grade (p < 0.005, chi square test and Students t test). CONCLUSION Pediatric blunt hepatic and splenic trauma is associated with significant mortality. Nonoperative management based on physiologic parameters, rather than on computed tomography grading of organ injury, was highly successful, with few missed injuries and a low transfusion rate.

Ultrasonography as an Adjunct in the Diagnosis of Acute Appendicitis: A 4-Year Experience

This study was designed to evaluate the sensitivity and specificity of abdominal ultrasonography as a diagnostic modality in a large series of children who presented with possible appendicitis. From August 1990 to July 1994, 452 children (203 boys, 249 girls) with an average age of 11 years (range, 1 to 20 years) underwent graded compression ultrasonography of the right lower quadrant of the abdomen for the evaluation of possible appendicitis. In the first 18 months of the study all patients with the possible diagnosis of appendicitis (group I; 180 patients) had abdominal ultrasonography after members of the surgical team evaluated and documented their findings in the medical record. In the second study period (30 months), abdominal ultrasonography was recommended only when the clinical diagnosis of acute appendicitis was equivocal (group II; 272 patients). Abdominal ultrasonography was performed using the graded compression technique with a 5.0-MHz linear array transducer. A positive ultrasound study for appendicitis was defined as the presence of an enlarged noncompressible appendix with an outer wall to outer wall diameter of greater than 6 mm, the presence of a complex mass, or the presence of an appendicolith. The sonographic data were correlated with surgical and pathological findings. Appendicitis was confirmed in 112 of the 452 cases. In 17 of these, the appendix was perforated. In the overall group of 452 children, abdominal ultrasonography had a sensitivity of 90%, specificity of 96%, and accuracy of 95%. There was no significant morbidity in the 11 patients with a false-negative study result. All 11 patients had an uncomplicated appendectomy. There were 11 false-positive results; 10 of these patients had a negative laparotomy result (negative laparatomy rate, 8.9%). For the two groups, the sensitivity and specificity of ultrasonography in the diagnosis of appendicitis were equivalent (group 1: 88% sensitivity, 96% specificity; group 2: 92% sensitivity, 97% specificity). On the basis of the high sensitivity and specificity rates, ultrasonography of the appendix can be a useful adjunct to standard examination in the diagnosis of acute appendicitis.

Imaging the child with right lower quadrant pain and suspected appendicitis: current concepts

Acute appendicitis is the most common condition presenting with right lower quadrant pain requiring acute surgical intervention in childhood. The clinical diagnosis of acute appendicitis is often not straightforward and can be challenging. Approximately one-third of children with the condition have atypical clinical findings and are initially managed non-operatively. Complications usually result from perforation and include abscess formation, peritonitis, sepsis, bowel obstruction and death. Cross-sectional imaging with sonography and computed tomography (CT) have proven useful for the evaluation of suspected acute appendicitis in children. The principal advantages of sonography are its lower cost, lack of ionizing radiation, and ability to precisely delineate gynecologic disease. The principal advantages of CT are its operator independency with resultant higher diagnostic accuracy, enhanced delineation of disease extent in perforated appendicitis, and improved patient outcomes including decreased negative laparotomy and perforation rates.

Lumbar compression fractures secondary to lap-belt use in children

The correlation between flexion-distraction injuries and lap-belt use has been well documented. Over a 10-year period, we identified seven children admitted to Childrens National Medical Center, Washington, DC, with compression fractures of the lumbar spine secondary to lap-belt use. Four were rear seat passengers, and three were in the front seat. The average age was 7 years. Four of the seven (57%) suffered associated abdominal injuries. One died of an associated head injury. We hypothesize that the mechanism of injury in these cases was similar to that in flexion-distraction injuries. The increased elasticity in the posterior ligamentous complex in children may be responsible for the occurrence of these compression fractures rather than the expected flexion-distraction-type injuries.

Computed tomography before transfer to a level I pediatric trauma center risks duplication with associated increased radiation exposure

INTRODUCTION Community hospitals commonly obtain computed tomographic (CT) imaging of pediatric trauma patients before triaging to a level I pediatric trauma center (PTC). This practice potentially increases radiation exposure when imaging must be duplicated after transfer. METHODS A retrospective review of our level 1 PTC registry from January 1, 2004, to December 31, 2006, was conducted. Level I and II trauma patients were grouped based on whether they had undergone outside CT examination (head and/or abdomen) at a referring hospital (group 1) or received initial CT examination at our institution (group 2). Subgroups were analyzed based on whether duplicate CT examination was required at our PTC (Fischers Exact test). RESULTS A duplicate CT scan (within 4 hours of transfer) was required in 91% (30/33) of group 1 transfer patients, whereas no group 2 patient required a duplicate scan (0/55; P < .0001). There was no significant difference within the groups for weight, age, or intensive care unit length of stay. CONCLUSION A significant number of pediatric trauma patients who receive CT scans at referring hospitals before transfer to our level I PTC require duplicate scans of the same anatomical field(s) after transfer, exposing them to increase potential clinical risk and cost.

Blunt renal trauma in children: Healing of renal injuries and recommendations for imaging follow-up

Initial CT grading of renal injury was correlated with the frequency of complications and the time course of healing in 35 children. All renal contusions (grade 1, 8) and small parenchymal lacerations (grade 2, 8) healed without complications. All lacerations extending to the collecting system (grade 3, 9) resulted in mild to severe loss of renal function with progressive healing over 4 months. One of four segmental infarcts (grade 4A), and five of six vascular pedicle injuries (grade 4B) resulted in severe loss of renal function. Complications, including urinoma (2), sepsis (1), hydronephrosis (1), and persistent hypertension (2), were limited to grade 3 and 4 injuries. Our results suggest that mild renal injuries do not require follow-up imaging. Major renal lacerations and vascular pedicle injuries, however, often result in loss of renal function and should be followed up closely due to the risk of delayed complications. Follow-up examinations should continue for 3–4 months until healing is documented.

Visualization of enlarged mesenteric lymph nodes at US examination

Purpose: To identify conditions associated with enlarged mesenteric lymph nodes in children with acute abdominal pain and determine the ability of US to detect associated abnormalities.Methods: Two hundred and fifty children with acute abdominal pain were evaluated for the presence of enlarged mesenteric lymph nodes (AP diameter >4 mm). Additionally, a reference group of 50 asymptomatic children was also studied for the presence of enlarged mesenteric lymph nodes.Results: Enlarged mesenteric lymph nodes were noted in 35 (14%) symptomatic children and two (4%) asymptomatic children. A specific diagnosis was established in 16/35 (46%) symptomatic children with mesenteric lymphadenopathy. Acute appendicitis was the most common diagnosis. The discharge diagnosis in the remaining 19 children was abdominal pain or gastroenteritis of unknown origin. US suggested the correct diagnosis in 12/16 (75%) children in whom a definite diagnosis was established. Histopathologic examination of enlarged mesenteric lymph nodes in three patients demonstrated non-specific inflammatory changes.Conclusion: Enlarged mesenteric lymph nodes in children with acute abdominal pain represents a nonspecific finding. Mesenteric lymphadenopathy is associated with a variety of medical and surgical conditions in symptomatic children and is occasionally seen in asymptomatic children. Sonography is useful in establishing a primary diagnosis in these children.

Pediatric hepatic trauma: Does clinical course support intensive care unit stay?☆

PURPOSE The objective of this study is to determine if grade of liver injury predicts outcome after blunt hepatic trauma in children and to initiate analysis of current management practices to optimize resource utilization without compromising patient care. METHODS A retrospective review of 36 children who had blunt hepatic trauma treated at a pediatric trauma center from 1989 to present was performed. Hepatic injuries graded (AAST Organ Injury Scaling) ranged from grade I to IV. Injury Severity Score (ISS), Glasgow Coma Score (GCS), transfusion requirements, liver transaminase levels, associated injuries, intensive care unit (ICU) length of stay, and survival were analyzed. RESULTS Mean (+/-SEM) age was 6.6+/-0.8 years, mean grade of hepatic injury was 2.4+/-0.2, mean ISS was 17+/-2.6, mean GCS was 13+/-1, and mean transfusion was 15.4 mL/kg of packed red blood cells (PRBC). There were three deaths with a mean ISS of 59+/-9 and a mean GCS of 3+/-0. Death was not associated with a high-grade liver injury, survivors versus nonsurvivors, 2.3+/-0.2 versus 2.7+/-0.3, but was associated with ISS, 13+/-1.4 versus 59+/-9 (P = .005) and GCS, 14+/-1 versus 3+/-0 (P = .005). Only one patient (grade III, ISS = 43) underwent surgery. There were no differences in mean ISS or GCS between grades I to IV patients. The hepatic injury grades of patients requiring transfusion versus no transfusion were significantly different, 3.4+/-0.2 versus 2.2+/-0.2 (P = 0.04). Abused patients had high-grade hepatic injuries and significant laboratory and clinical findings. Alanine aminotransferase (ALT) and aspartate aminotransferase (AST) were significantly higher in grade III and IV injuries than in grades I and II, 1,157+/-320 versus 333+/-61 (P= .02) and 1,176+/-299 versus 516+/-86 (P= .04), respectively. No children with grade I or II injury had a transfusion requirement or surgical intervention. There were no liver-related complications. CONCLUSIONS Mortality and morbidity rates in pediatric liver injuries, grades I to IV, correlate with associated injuries not the degree of hepatic damage. ALT, AST, and transfusion requirements are significantly related to degree of liver injury. Low-grade and isolated high-grade liver injuries seldom require transfusion. Blunt liver trauma rarely requires surgical intervention. In retrospect, the need for expensive ICU observation for low-grade and isolated high-grade hepatic injuries is questionably warranted.

Blunt hepatic and splenic trauma in children: Correlation of a CT injury severity scale with clinical outcome

The purpose of this report is to compare a computed tomography (CT) injury severity scale for hepatic and splenic injury with the following outcome measures: requirement for surgical hemostasis, requirement for blood transfusion and late complications. Sixty-nine children with isolated hepatic injury and 53 with isolated splenic injury were prospectively classified at CT according to extent of parenchymal involvement. Clinical records were reviewed to determine clinical outcome. Ninety-seven children (80%) were managed non-operatively without transfusion. One child with hepatic injury required surgical hemostasis, and 17 (25%) required transfusion of blood. Increasing severity of hepatic injury at CT was associated with progressively greater frequency of transfusion (P=0.002 by χ2-test). One child with splenic injury underwent surgery and eight (15%) required transfusion of blood. Splenic injury grade at CT did not correlate with frequency (P=0.41 by χ2-test) or amount (P=0.35 by factorial analysis of variance) of transfusion. There was one late complication in the nonsurgical group. A majority of children with hepatic and splenic injury were managed non-operatively without requiring blood transfusion. The severity of injury by CT scan did not correlate with need for surgery. Increasing grade of hepatic injury at CT was associated with increasing frequency of blood transfusion. CT staging was not discriminatory in predicting transfusion requirement in splenic injury.