Christopher R. Reed

Contact isolation is a risk factor for venous thromboembolism in trauma patients.

BACKGROUND Contact isolation (CI) is a series of precautions used to prevent the transmission of medically significant infectious pathogens in the health care setting. Our institution’s implementation of CI includes limiting patient movement to the assigned room. Our objective was to define the association between CI and venous thromboembolism (VTE) at our Level I trauma center. METHODS Our institution’s prospective trauma database was retrospectively queried for all patients admitted to the trauma service between January 1, 2011, and December 31, 2012. Data including demographics, Injury Severity Score (ISS), preexisting medical conditions, injury type, and VTE development were collected. CI status data were obtained from our institution’s infection control database. &khgr;2 was used to examine the unadjusted relationship between CI status and VTE. As the groups were not equivalent, logistic regression was then used to examine the relationship between CI and VTE while adjusting for relevant covariates including sex, age, ISS, and comorbidities. RESULTS Of the 4,423 trauma patients admitted during the study period, 4,318 (97.6%) had complete records and were included in subsequent analyses. A total of 249 (5.8%) of the patients were on CI. VTE occurred in 44 patients (17.7%) on CI versus 141 patients (3.5%) who were not isolated (p < 0.0001; odds ratio, 6.0; 95% confidence interval, 4.1–8.6). With the use of lasso [least absolute shrinkage and selection operator] regression to adjust for patient risk factors, this relationship remained highly significant (p < 0.0001; odds ratio, 2.61; 95% confidence interval, 1.7–4.0). CONCLUSION CI, ISS, hospital length of stay, and cardiac comorbidity were associated with VTE. After adjustment for other risk factors, CI remained most strongly associated with VTE. Although any medical intervention may come with unintended consequences, the risks and benefits of CI in this population need to be reevaluated. Further study is planned to identify opportunities to mitigate this increased VTE risk. LEVEL OF EVIDENCE Prognostic/epidemiologic study, level III; therapeutic study, level IV.

Higher surgical critical care staffing levels are associated with improved National Surgical Quality Improvement Program quality measures.

BACKGROUND The changing face of American health care demands careful scrutiny of resource allocation. The impact of the surgical intensivist model on general surgical quality measures has not been studied. Our objective was to investigate the relationship between surgical critical care staffing and indicators of general surgical quality measured by the National Surgical Quality Improvement Program (NSQIP). METHODS We retrospectively examined the number of attending surgical intensivists at our tertiary care center biannually from January 2008 through June 2012. Risk-adjusted indicators of general surgical quality were captured and reported semiannually by NSQIP. Mortality, overall morbidity, patients on ventilator for more than 48 hours, unplanned intubations, and venous thromboembolism were included. Student’s t test was used to compare the staffing levels and associated NSQIP odds ratios of a 3-year control period of full commitment with a 2-year period following significant provider attrition. RESULTS The number of full-time surgical intensivists ranged from 2 to 8, with a period of rapid decline in late 2010 to early 2011 followed by slow recovery. There was a mean of 6.6 surgical intensivists during the 3 years before the decline and a mean of 4 in the 2 years after the decline and recovery (p < 0.005). This period of decline was associated with a significant increase in the odds ratio of ventilation for more than 48 hours (before, 0.936; after, 1.87; p = 0.0086) and of venous thromboembolism (before, 0.844; after 1.43; p = 0.0268). A trend in increased unplanned intubations was also observed. Overall morbidity and mortality were not affected. Notably, quality indicators seemed to rapidly approach baseline levels as new surgical intensivists were recruited. CONCLUSION Institutional commitment to recruitment and retention of a surgical critical care team leads to improved NSQIP general surgery quality measures. LEVEL OF EVIDENCE Care management study, level IV.

Outcomes of laparoscopic resection of Meckel's diverticulum are equivalent to open laparotomy

PURPOSE Meckels diverticulum (MD) is a common congenital anomaly caused by failure of involution of the omphalomesenteric duct. Enthusiasm for minimally invasive surgery (MIS) in children has burgeoned as technologies have advanced, but the outcomes of laparoscopic resection in comparison to open laparotomy for MD remain poorly defined. We queried a large national database to compare current practice patterns and clinical outcomes between surgical approaches for MD in the pediatric population. METHODS The National Surgical Quality Improvement Program-Pediatric (NSQIP-Ped) database was queried for patients undergoing surgical intervention for MD (2011-2014). Patients were stratified by surgical approach. Baseline characteristics, intraoperative variables, and perioperative complications were compared by univariate analysis using Pearsons χ2 test for categorical variables and Kruskall-Wallis test for continuous variables. Primary outcomes of interest were length of stay (LOS), rate of readmission, and 30-day mortality. Secondary outcomes included operative time, anesthesia time, postoperative complications, and rates of reoperation. RESULTS A total of 148 cases of MD were identified, of which 73 (49.3%) were initially managed with a laparoscopic approach and 75 (50.7%) were managed with an open approach. We found a high rate of conversion from laparoscopy to an open approach (20/73 or 27.4%). The median age of the laparoscopic group was higher than the open group (8.3 vs. 2.5years, p<0.001). Operative and anesthesia time, LOS, 30-day mortality, post-operative complications, and rates of reoperation and readmission were similar between groups (all p>0.05). CONCLUSION Nearly half of all resections for MD in children are now approached laparoscopically. This approach has equivalent outcomes to traditional open laparotomy. More widespread use of a hybrid approach with laparoscopy and exteriorization of the small bowel through an extended port site may facilitate avoiding open laparotomy. Routine conversion to open for palpation of the MD or segmental small bowel resection should be avoided in the absence of compelling intra-operative findings or operative complications. LEVEL OF EVIDENCE Level III (retrospective comparative study).

Outcomes following elective resection of congenital pulmonary airway malformations are equivalent after 3 months of age and a weight of 5 kg

PURPOSE Resection of congenital pulmonary airway malformations (CPAMs) is often performed to reduce the risk of recurrent infection and malignant transformation. However, there is substantial variation in the timing of resection. This study was performed to determine the association of age and weight on outcomes following elective resection of CPAMs. METHODS The American College of Surgeons National Surgical Quality Improvement Program-Pediatric database from 2012 to 2014 was queried for infants undergoing elective resection of a CPAM. Infants were categorized based on age (0-3months, 3-6months, 6-9months, 9-12months, and >12months) and weight (0-5kg, 5-10kg, and >10kg). Groups were compared for baseline characteristics and outcomes including a morbidity composite of pneumonia, reintubation, ventilator days >0, reoperation, readmission, hospital length of stay >7days, and mortality. RESULTS A total of 311 infants met study criteria. The morbidity composite was significantly more common among infants <3months of age compared to infants >3months of age (31.3% vs. 15.6%, p=0.01) and among infants <5kg as compared to infants >5kg (37.5% vs. 15.8%, p<0.01). CONCLUSIONS Infants should be observed until three months of age and a weight of five kilograms prior to elective resection of CPAMs. LEVEL OF EVIDENCE Level III.

Pediatric phyllodes tumors: A review of the National Cancer Data Base and adherence to NCCN guidelines for phyllodes tumor treatment

BACKGROUND Phyllodes tumors are fibroepithelial breast lesions that are uncommon in women and rare among children. Due to scarcity, few large pediatric phyllodes tumor series exist. Current guidelines do not differentiate treatment recommendations between children and adults. We examined national guideline adherence for children and adults. METHODS We queried the NCDB (2004-2014) for female patients with phyllodes tumor histology, excluding patients with missing age or survival data. Patients were stratified by age (pediatric <21, adult ≥21), and compared based on patient characteristics, treatment patterns, and survival. RESULTS We identified 2787 cases of phyllodes tumor (2725 adult, 62 pediatric). Median age was 17years in children and 52years in adults. Margin positivity rates and median tumor size were similar between adults and children. Treatment was discordant with NCCN guidelines in 28.6% of adults and 14.5% of children through use of axillary staging, chemotherapy, adjuvant endocrine therapy, and radiotherapy. Five-year and ten-year survival were comparable between both groups. CONCLUSION Children and adults present with similarly sized phyllodes tumors. Trends reveal high margin positivity rates, and overtreatment with regional axillary staging and systemic adjuvant therapies. Particularly in children, treatment decisions must consider risks of adjuvant therapy including radiation-related second primary cancers, given uncertain benefit. TYPE OF STUDY Retrospective Comparative Study. LEVEL OF EVIDENCE Level III.

Cervical seatbelt sign is not associated with blunt cerebrovascular injury in children: A review of the national trauma databank

BACKGROUND Blunt cerebrovascular injury (BCVI) is a rare consequence of blunt trauma. There appears to be benefit to an aggressive approach to screening for BCVI due to catastrophic sequelae of unrecognized injury. However, screening for BCVI carries extensive cost and oncologic risk to young patients. Foundational BCVI studies examined adults primarily, leaving question to the effectiveness of these criteria in children. We sought to evaluate BCVI screening criteria developed in primarily adult populations using a nationally representative pediatric dataset. METHODS We queried the 2008-2014 National Trauma Data Bank for patients with BCVI. Patients were stratified by age (adults>18yrs, pediatric≤18yrs). Screening factors from the Modified Denver Criteria and Modified Memphis Criteria (GCS≤8, C1C3 cervical fracture, cervical subluxation, seatbelt sign, basilar skull fracture, mid-facial fracture, mandibular fracture, significant blood loss, coma, stroke, and hanging) were examined using univariate analysis and backwards-stepwise logistic regression to verify predictors of BCVI. RESULTS Blunt injury occurred in 2,174,244 adults and 422,181 children; 5970 adults and 809 children sustained BCVI. In univariate analysis, all screening factors correlated with BCVI in both groups (p < 0.001). When comparing BCVI patients, children more commonly experienced GCS≤8, seatbelt sign, basilar skull fracture, mid-facial fracture, mandibular fracture, and coma (p < 0.05). In multivariable analysis, seatbelt sign was not associated with pediatric BCVI. CONCLUSION Many adult-associated BCVI risk factors apply to children. Although children more commonly experience seatbelt sign, it does not independently cause increased BCVI risk. Given the rarity of pediatric BCVI, prospective multi-institutional studies are warranted to establish screening criteria specific to children.

PC178 Age Associated With Mortality and Outcomes in Pediatric Vascular Trauma

two patients. Viabahn stents were then deployed, covering the injured popliteal lumen, with three-vessel runoff and palpable pedal pulses in all cases (Fig 2). Conclusions: Endovascular repair of popliteal artery injury in the setting of posterior knee dislocation is feasible. It may lead to decreased patient morbidity, shorter operative times, and quicker time to reperfusion. Further study will facilitate better understanding of long-term patency rates and clinical outcomes.