Joseph A. Sujka

Withholding urinary catheters in children receiving patient-controlled analgesia for appendicitis

BACKGROUNDnIn some institutions, urinary catheters (UCs) have been placed in all patients receiving opioid patient-controlled analgesia (PCA) because of the increased incidence of urinary retention. Our institutional data demonstrated no UC replacements in 48 children who had PCA for perforated appendicitis who had their catheters removed before discontinuation of the PCA. As part of a quality improvement initiative, we discontinued the practice of requiring UC with PCA for perforated appendicitis.nnnMATERIALS AND METHODSnA prospective list of patients with perforated appendicitis was maintained. Data were gathered regarding 60 consecutive patients. UC placement was allowed for specific indications including urinary retention and surgeon discretion.nnnRESULTSnSixteen patients (27%) received a UC with 14 of these being placed in the operating room (OR). Two UCs were placed outside the OR for urinary retention. Patients who underwent UC placement in the OR weighed significantly more than those who did not (33 versus 42xa0kg, Pxa0=xa00.05). No patients required replacement of the catheter once removed. There were no postoperative urinary tract infections. Median PCA duration was 68xa0h (50, 98) for patients with UC placed in the OR compared with 60xa0h (47, 78) (Pxa0=xa00.42). Median postoperative length of stay for patients with UC placed in the OR was 95xa0h (76, 140) compared with 90xa0h (70, 113) (Pxa0=xa00.09).nnnCONCLUSIONSnUC can be withheld from patients with perforated appendicitis who are placed on PCA with a very low placement rate. UC placement at time of operation did not lengthen time receiving PCA or length of stay.

Quantification of Pectus Excavatum: Anatomic Indices

Pectus excavatum is the most common chest wall deformity in children. The central portion of the chest is displaced posteriorly relative to the remainder of the anterior chest wall. Quantification of defect severity can be performed with multiple imaging modalities or external thoracic measures, but is most commonly quantified by the Haller Index (HI) or Pectus Correction Index (PCI). These two measures provide a measure of the chest based on cross sectional imaging, most commonly CT scans, allowing for standard comparison and definitions of pectus defects. The purpose of this article is to describe the creation, calculation, and limitations of the methods quantifying pectus defects.

The impact of thromboelastography on resuscitation in pediatric liver transplantation

Although TEG directs effective resuscitation in adult surgical patients, pediatric data are lacking. We performed a retrospective comparative review of the effect of TEG on blood product utilization and outcomes following pediatric liver transplantation in 38 patients between 2008 and 2014. Diagnoses, laboratory values, fluid and blood product use, and outcomes were examined. Nineteen patients underwent liver transplantation prior to the implementation of TEG, and 19 had perioperative TEG. The most common indications for transplant were BA (n = 14), HB (n = 7), and metabolic disorders (n = 7). Intraoperative blood loss, urine output, fluid and blood product use were similar between groups. However, the use of fresh frozen plasma decreased significantly in TEG patients within the first 24 hours (29 vs 0 mL/kg, P < .01), and between 24 and 48 hours (12 vs 0 mL/kg, P = .01) post‐operatively. The total use of fresh frozen plasma during hospitalization was markedly reduced (111 vs 17 mL/kg, P < .01). Four patients in the TEG group had thromboembolic graft complications, including portal vein or hepatic artery thrombosis, and underwent retransplantation. The decreased use of fresh frozen plasma since implementation of TEG is an important finding for resource utilization and patient safety. However, the increased incidence of thromboembolic complications requires further investigation.

Letter to the Editor concerning: “Results of pectus excavatum correction using a minimally invasive approach with subxyphoid incision and three-point fixation”

We read with great interest the article by Bond et al. regarding results of pectus excavatum correction using a modified minimally invasive approach with subxyphoid incision and three-point fixation [1]. The authors demonstrated safety and excellent outcomes with the procedure comparable to the standard Nuss procedure. Interestingly, since 1999, our institution modified the minimally invasive Nuss procedure to include a subxyphoid incision, as described by the author. However, we utilize a two-point fixation. Our institution recently reviewed our experience with the modified Nuss procedure. In our analysis of 554 patients over a 15-year period, our rate of bar repositioning for rotation was < 1% and our rate of stabilizer removal due to chronic discomfort was similarly low at 1.4% [2]. We have also not encountered any cardiac injury or required multiple bars. We have occasionally used a single stabilizer with no increase in the incidence of bar displacement in this cohort (unpublished data). The authors in their article describe a three-point fixation compared to the standard two-point fixation. The cited rate of bar displacement in their study was 2.7%. As mentioned earlier, our rate of bar displacement with the two-point fixation was 1.4%, lower than that in this study. The inclusion of a third fixation point as described by the author, therefore, may be unnecessary and possibly eliminated to further simplify the steps of the procedure during placement. More so, opening the third (subxyphoid) incision may be required during bar removal, if the fixation has to be released. This will potentially not be required with a two-point fixation. We again compliment the authors on their excellent article and thank them for their contribution to it.

Do health beliefs affect pain perception after pectus excavatum repair

PurposeThe pain experience is highly variable among patients. Psychological mindsets, in which individuals view a particular characteristic as either fixed or changeable, have been demonstrated to influence people’s actions and perceptions in a variety of settings including school, sports, and interpersonal. The purpose of this study was to determine if health mindsets influence the pain scores and immediate outcomes of post-operative surgical patients.MethodsAs part of a multi-institutional, prospective, randomized clinical trial involving patients undergoing a minimally invasive pectus excavatum repair of pectus excavatum, patients were surveyed to determine whether they had a fixed or growth health mindset. Their post-operative pain was followed prospectively and scored on a Visual Analog Scale and outcomes were measured according to time to oral pain medication use.ResultsFifty patients completed the Health Beliefs survey, 17 had a fixed mindset (8 epidural, 9 PCA) and 33 had a growth mindset (17 epidural, 16 PCA). Patients with a growth mindset had lower post-operative pain scores than patients with a fixed mindset although pain medication use was not different.ConclusionThis is the first usage of health mindsets as a means to characterize the perception of pain in the post-operative period. Mindset appears to make a difference in how patients perceive and report their pain. Interventions to improve a patient’s mindset could be effective in the future to improve pain control and patient satisfaction.

Outcomes of circumcision in children with single ventricle physiology

PurposeChildren with single ventricle physiology (SVP) have been shown to have a high morbidity and mortality after non-cardiac surgical procedures. Elective circumcision is one of the most common pediatric operations with low morbidity and mortality. The purpose of our study was to review our institutional experience with SVP children undergoing circumcisions to determine peri-operative course and outcomes.MethodsWe performed a retrospective review of children with SVP who underwent an elective circumcision from 2000 to 2017. Children with non-single ventricle physiology or children undergoing circumcision in combination with another case were excluded. Demographics, surgical characteristics, and outcomes were analyzed. Descriptive statistics were performed, all medians were reported with interquartile range.Results15 males underwent elective circumcision with a median age at the time of surgery of 1.13 (1.03, 1.38) years. Eighty-four percent underwent their circumcision after their 2nd stage cardiac operation. Most common operative indication was uncomplicated phimosis. Median operative time was 20 (16, 27)xa0mins. Median total length of stay was 229 (185, 242)xa0mins with no admissions. Post-operative complications included two (16%) hematomas with one requiring surgical intervention. There were no deaths.ConclusionChildren with SVP who undergo elective circumcision may have a higher risk of bleeding.

A safe and efficacious preventive strategy in the high-risk surgical neonate: cycled total parenteral nutrition

IntroductionHepatic dysfunction in patients reliant on total parenteral nutrition (TPN) may benefit from cycled TPN. A concern for neonatal hypoglycemia has limited the use of cycled TPN in neonates less than 1 week of age. We sought to determine both the safety and efficacy of cycled TPN in surgical neonates less than 1xa0week of age.MethodsA retrospective chart review was conducted on surgical neonates placed on prophylactic and therapeutic cycled TPN from January 2013 to March 2016. Specific emphasis was placed on identifying incidence of direct hyperbilirubinemia and hypoglycemic episodes.ResultsFourteen neonates were placed on cycled TPN; 8 were prophylactically cycled and 6 were therapeutically cycled. Median gestational age was 36 weeks (34, 37). Sixty-four percent (nu2009=u20099) had gastroschisis. There was no difference between the prophylactic and therapeutic groups in incidence of hyperbilirubinemiau2009>u20092xa0mg/dL (3 (37%) vs 5 (83%), pu2009=u20090.08) or the length of time to development of hyperbilirubinemia [24 days (4, 26) vs 27 days (25, 67), pu2009=u20090.17]. Time on cycling was similar though patients who were prophylactically cycled had a shorter overall time on TPN. Three (21%) infants had documented hypoglycemia, but only one infant became clinically symptomatic.ConclusionProphylactic TPN cycling is a safe and efficacious nutritional management strategy in surgical neonates less than 1xa0week of age with low rates of hypoglycemia and a shorter total course of TPN; however, hepatic dysfunction did not appear to be improved compared to therapeutic cycling.

Enteric duplication in children

IntroductionEnteric duplication is a congenital anomaly with varied clinical presentation that requires surgical resection for definitive treatment. This had been approached with laparotomy for resection, but has changed with minimally invasive technique. The purpose of our study was to determine the demographics, natural history, operative interventions, and outcomes of pediatric enteric duplication cysts in a contemporary cohort.MethodsWith IRB approval, we performed a retrospective chart review of all patients less than 18xa0years old treated for enteric duplication between January 2006 and August 2016. Demographics, patient presentation, operative technique, intraoperative findings, hospital course, and follow-up were evaluated. Descriptive statistical analysis was performed; all medians were reported with interquartile range (IQR).ResultsThirty-five patients underwent surgery for enteric duplication, with a median age at surgery of 7xa0months (2.5–54). Median weight was 7.2xa0kg (6–20). Most common patient presentations included prenatal diagnosis 37% (nu2009=u200913). Thirty-four patients (97%) had their cyst approached via minimally invasive technique (thoracoscopy or laparoscopy) with only three (8%) requiring conversion to an open operation. Median operative time was 85xa0min (54–133) with 27 (77%) patients requiring bowel resection. Median length of bowel resected was 4.5xa0cm (3–7). Most common site of duplication was ileocecal (nu2009=u200915, 42%). Postoperative median hospital length of stay was 3xa0days (2–5) and median number of days to regular diet was 3 (1–4). No patients required re-operation during their hospital stay. Median follow-up was 25xa0days (20–38).ConclusionIn our series, most enteric duplication cysts were diagnosed prenatally. These can be managed via minimally invasive technique with minimal short-term complications, even in neonates and infants.

Does muscle biopsy change the treatment of pediatric muscular disease

BackgroundMuscle biopsy is performed to confirm the diagnosis of neuromuscular disease and guide therapy. The purpose of our study was to determine if muscle biopsy changed patient diagnosis or treatment, which patients were most likely to benefit from muscle biopsy, and complications resulting from muscle biopsy.Materials and methodsAn IRB-approved retrospective chart review of all patients less than 18xa0years old undergoing muscle biopsy between January 2010 and August 2016 was performed. Demographics, patient presentation, diagnosis, treatment, hospital course, and follow-up were evaluated. Descriptive and comparative (student’s t test, Mann–Whitney U, and Fisher’s exact test) statistical analysis was performed. Medians were reported with interquartile range (IQR).Results90 patients underwent a muscle biopsy. The median age at biopsy was 5xa0years (2, 10). 37% (nu2009=u200934) had a definitive diagnosis. 39% (nu2009=u200935) had a change in their diagnosis. 37% (nu2009=u200934) had a change in their treatment course. In the 34 patients who had a change in their treatment, the most common diagnosis was inflammatory disease at 44% (nu2009=u200915). In the 56 patients who did not have a change in treatment, the most common diagnosis was hypotonia at 30% (nu2009=u200917). There was no difference in patients who had a change in treatment based on pathology versus those that did not. The median length of follow-up was 3xa0years (1, 5).ConclusionsMuscle biopsy should be considered to diagnose patients with symptoms consistent with inflammatory or dystrophic muscular disease. The likelihood of this altering the patient’s treatment course is around 40%.

Same-Day Discharge for Nonperforated Appendicitis in Children: An Updated Institutional Protocol

BACKGROUNDnThe evolving demands of our current health care system for enhanced efficiency and safety while decreasing hospital length of stay has led to our institutional protocol for same-day discharge (SDD) after laparoscopic appendectomy. We have previously demonstrated a 28% rate of SDD in children with nonperforated appendicitis. The purpose of our study is to assess the effectiveness of a mature protocol for SDD by evaluating discharge success, duration of hospital stay, and readmission rates.nnnMATERIALS AND METHODSnA retrospective review of prospectively collected data was conducted. All children undergoing a laparoscopic appendectomy for nonperforated appendicitis at Childrens Mercy Hospital between December 2015 and July 2017 were included. Patients were classified according to whether they were discharged home the same day as their operation or had an overnight stay. Demographic data, time of day the procedure was completed, postoperative length of stay, and readmission rates were abstracted from patient medical records. Comparative analysis was performed in STATA using chi-squared or Fisher exact tests for categorical variables and t-test or Wilcoxon rank sum test for continuous variables.nnnRESULTSnA total of 569 children were included, with 87% (nxa0=xa0495) discharged home the same day as their appendectomy. Of the patients discharged home the same day of surgery, their median length of postoperative stay was 4xa0h (IQR: 3, 5) compared with 19xa0h for the patients who stayed overnight (IQR: 15, 25, Pxa0<xa00.0001). Approximately two-thirds of patients who had their appendectomies after 6 PM stayed overnight. In addition, patients discharged home the same day had similar hospital readmission rates compared with patients who stayed overnight (2% vs. 4%, Pxa0=xa00.155).nnnCONCLUSIONSnAfter laparoscopic appendectomy in children with nonperforated appendicitis, SDD not only reduces postoperative length of stay but also is not associated with higher hospital readmission rates.