Kevin N. Johnson

Airway foreign bodies in pediatric patients: anatomic location of foreign body affects complications and outcomes

BackgroundAirway foreign bodies (FB) are a common medical emergency within the pediatric population. While deaths are not uncommon, the in-hospital mortality rates and correlation with anatomic location of the airway foreign body have not been previously reported.MethodsThe KID database was reviewed for 2003, 2006, 2009, and 2012 for pediatric patients with a discharge diagnosis of airway foreign body using ICD-9 codes (933.1, 934.x).Results11,793 patients, ages 0–17, were found to have an airway FB. Of patients admitted for airway FB 21.2xa0% required mechanical ventilation during their hospitalization, and the overall mortality rate was 2.5xa0%. Location of the airway FB was dependent on age (pxa0<xa00.01). Use of mechanical ventilation was dependent on the location of the airway FB (pxa0<xa00.01) and being transferred from another hospital (OR 2.59, pxa0<xa00.01). Univariate analysis demonstrated differences in in-hospital mortality based on location (pxa0<xa00.01), use of a ventilator during hospitalization (OR 24.4, pxa0<xa00.01), and transfer from another hospital (OR 2.11, pxa0<xa00.01).ConclusionsThe in-hospital mortality rate for airway foreign bodies is 2.5xa0%. The anatomic location of airway FB in pediatric patients varies by age, and affects the need for mechanical ventilation and in-hospital mortality.

Comparison of early versus delayed strategies for repair of congenital diaphragmatic hernia on extracorporeal membrane oxygenation

PURPOSEnFor the last seven years, our institution has repaired infants with CDH that require ECMO early after cannulation. Prior to that, we attempted to decannulate before repair, but repaired on ECMO if we were unable to wean after two weeks. This study compares those strategies.nnnMETHODSnFrom 2002 to 2016, 65 infants with CDH required ECMO. 67.7% were repaired on ECMO, and 27.7% were repaired after decannulation. Data were compared between patients repaired ≤5days after cannulation (early protocol, n=30) and >5days after cannulation or after de-cannulation (late protocol, n=35). We used Cox regression to assess differences in outcomes between groups.nnnRESULTSnSurvival for the early and late protocol groups was 43.3% and 68.8%, respectively (p=0.0485). For patients that were successfully decannulated before repair, survival was 94.4%. Moreover, the early repair protocol was associated with prolongation of ECMO (16.8±7.4 vs. 12.6±6.8days, p=0.0216). After multivariate regression, the early repair protocol was an independent predictor of both mortality (HR=3.48, 95% CI=1.28-9.45, p=0.015) and days on ECMO (IRR=1.39, 95% CI=1.07-1.79, p=0.012). All bleeding occurred in patients repaired on ECMO (29.5%, 13/44).nnnCONCLUSIONSnOur data suggest that protocolized CDH repair early after ECMO cannulation may be associated with increased mortality and prolongation of ECMO. However, early repair is not necessarily harmful for those patients who would otherwise be unable to wean from ECMO before repair. Further work is needed to better move towards individualized patient care.nnnTYPE OF STUDYnTreatment Study.nnnLEVEL OF EVIDENCEnLevel III.

Insertion of peripherally inserted central catheters in neonates less than 1.5 kg using ultrasound guidance.

BackgroundNeonates commonly require central access, and in those with very low or extremely low birthweight this can be challenging. Described here is a technique that uses ultrasound guidance in the placement of peripherally inserted central catheters (PICC) in neonates and an analysis of outcomes.MethodsA retrospective chart review was conducted of all patients below 1500xa0g that underwent placement of a peripherally inserted central catheter under ultrasound guidance between January 1, 2012, and December 31, 2014 at a single center. All patients had multiple previous attempts at PICC placement by experienced NICU vascular access nurses prior to referral. Complications were determined based on clinical and procedural notes.ResultsA total of ten patients were found during the study period. The average estimated gestational age was 29.8xa0weeks (range 26–38xa0weeks).The average weight at the time of PICC insertion was 968xa0g (range 485–1390xa0g). All attempts at placement were successful. There were no complications directly related to PICC insertion.ConclusionUltrasound guided PICC line placements using ultrasound is an effective technique, which can be applied to very low and extremely low birth weight infants, with excellent success rates and a low risk of complications.

Conversion from laparoscopic to open appendectomy: decreased risk at dedicated children’s hospitals

PurposeThe advent of laparoscopy has revolutionized surgical practice within the last 30xa0years. Conversion to open surgery, however, remains necessary at times, even for the most experienced laparoscopic surgeon.MethodsThe kids’ inpatient database was analyzed for 2006, 2009, and 2012 for patients who underwent laparoscopic appendectomy and conversion to open (CPT 470.1 and V64.41, respectively). Variables included in multivariable analysis were determined based on those variables found to have significance on univariate analysis.ResultsA total of 104,865 patients, ages 0–17xa0years, underwent laparoscopic appendectomy during the three study periods. Of these, 2370 (2.2%) laparoscopic surgeries were converted to open appendectomy. Multivariable logistic regression showed significantly higher rates of conversion amongst patients with peritonitis (OR 6.7, pu2009<u20090.001) or abscess (OR 14.3, pu2009<u20090.001), obesity (OR 2.02, pu2009<u20090.001), age >u200913xa0years (OR 1.53 for ages 13–15, OR 1.77 for ages 16–17, pu2009<u20090.001 for both), or cared for at rural hospitals (OR 1.55, pu2009=u20090.002). Rates of conversion decreased over time for children at adult hospitals and at urban hospitals, regardless of teaching status (pu2009<u20090.001 for both).ConclusionRisk factors for conversion from laparoscopic to open appendectomy included abscess, peritonitis, increased age, obesity, male gender, socioeconomic status and treatment at a non-pediatric-specific hospital, and the overall rate is decreasing over time.

Comparing outcomes with thoracic epidural and intercostal nerve cryoablation after Nuss procedure

BACKGROUNDnThis study aimed to evaluate postoperative outcomes after minimally invasive repair of pectus excavatum (Nuss procedure) using video-assisted intercostal nerve cryoablation (INC) compared to thoracic epidural (TE).nnnMATERIALS AND METHODSnWe performed a single center retrospective review of pediatric patients who underwent Nuss procedure with INC (nxa0=xa019) or TE (nxa0=xa013) from April 2015 to August 2017. Preoperative, intraoperative, and postoperative characteristics were collected. The primary outcome was length of stay (LOS) and secondary outcomes were intravenous and oral opioid use, pain scores, and complications. Opioids were converted to oral morphine milligram equivalents per kilogram (oral morphine equivalent [OME]/kg). Mann-Whitney U test was used for continuous and chi-squared analysis for categorical variables.nnnRESULTSnThere were no significant differences in patient characteristics, except Haller Index (INC: median [interquartile range] 4.3 [3.6-4.9]; TE: 3.2 [2.8-4.0]; Pxa0=xa00.03). LOS was shorter with INC (INC: 3 [3-4] days; TE: 6 [5-7] days; Pxa0<xa00.001). Opioid use was higher intraoperatively (INC: 1.08 [0.87-1.37] OME/kg; TE: 0.46 [0.37-0.67] OME/kg; Pxa0=xa00.002) and unchanged postoperatively (INC: 1.78 [1.26-3.77] OME/kg; TE: 1.82 [1.05-3.37] OME/kg; Pxa0=xa00.80), and prescription doses were lower at discharge in INC (INC: 30 [30-40] doses; TE: 42 [40-60] doses; Pxa0=xa00.005). There was no significant difference in postoperative complications (INC: 42.1%; TE: 53.9%; Pxa0=xa00.51).nnnCONCLUSIONSnINC during Nuss procedure reduced LOS, shifting postoperative opioid use earlier during admission. This may reflect the need for improved early pain control until INC takes effect. Prospective evaluation after INC is needed to characterize long-term pain medication requirements.

Is there a best approach for extracorporeal life support cannulation: a review of the extracorporeal life support organization

BACKGROUNDnNeurologic complications are common, and amongst the most devastating complications in pediatric patients undergoing extracorporeal life support (ECLS). Carotid artery cannulation (CAN) has been associated with an increase in these complications, thereby shaping practices to avoid this approach in most pediatric patients in which other cannulation approaches are viable.nnnMETHODSnA retrospective review of children (0-18years) in the ELSO database was undertaken from 1989 through 2013. Multivariate logistic regression analysis of rates of stroke and other neurologic complications based on cannulation technique was undertaken, adjusting for patient factors including age, underlying disease process, and severity of illness.nnnRESULTSnA total of 30,282 ECLS runs were found in the database. CAN was associated with higher rates of stroke (5.15% vs 3.74%) and overall neurologic complications. However, when correcting for patient factors, including age, underlying disease process, and support type, CAN was not associated with an increased rate of neurologic complications or stroke (p>0.05 for both).nnnCONCLUSIONnWhen correcting for patient related factors CAN is not associated with an increase in stroke or neurologic compilcations. CAN should be re-examined as a cannulation technique for older pediatric patients.nnnLEVEL OF EVIDENCEnIII.

Diagnostic accuracy of imaging studies in congenital lung malformations

Background Although fetal ultrasound, fetal MRI and postnatal CT are now widely used in the evaluation of congenital lung malformations (CLM), their diagnostic accuracy remains undefined. Objective To correlate prenatal and postnatal imaging studies with pathological data after CLM resection. Design Retrospective, descriptive case series study. Setting A North American tertiary care centre. Patients One hundred and three consecutive lung resections for a suspected CLM between 1 January 2005 and 31 December 2015. Main outcome measures Diagnostic accuracy of imaging diagnosis compared with pathological evaluation. Results Pathological diagnoses included congenital pulmonary airway malformation ((CPAM) n=45, 44%), bronchopulmonary sequestration (BPS; n=25, 24%), CPAM/BPS hybrid lesions (n=22, 21%) and pleuropulmonary blastoma (n=2, 2%). Fetal ultrasound detected 85 (82.5%) lesions and correctly diagnosed whether or not a lesion was a CPAM in 75% of cases (sensitivity 93%, specificity 32%). Fetal MRI had a similar concordance rate (73%) but was superior in correctly determining whether a systemic feeding vessel was present in 80% of cases (sensitivity 71%, specificity 88%) compared with an ultrasound accuracy rate of 72% (sensitivity 49%, specificity 93%). By comparison, postnatal CT correctly diagnosed whether a CPAM was present in 84% of cases (sensitivity 86%, specificity 77%) and whether a systemic feeding vessel was present in 90% of cases (sensitivity 92%, specificity 88%). Conclusions Fetal ultrasound remains an important tool in the detection and evaluation of congenital lung malformations. However, it does not correctly predict histology in approximately 25% of prenatally detected CLMs and remains limited by relatively poor sensitivity for systemic feeding vessels pathognomic for a bronchopulmonary sequestration. These data suggest the importance of obtaining additional cross-sectional imaging, preferably a postnatal CT scan, in all patients to help counsel families and to guide in the optimal management of these lesions.

Steroid use for refractory hypotension in congenital diaphragmatic hernia

PurposeGuidelines for diagnosis and treatment of adrenal insufficiency (AI) in newborns with congenital diaphragmatic hernia (CDH) are poorly defined.MethodsFrom 2002 to 2016, 155 infants were treated for CDH at our institution. Patients with shock refractory to vasopressors (clinically diagnosed AI) were treated with hydrocortisone (HC). When available, random cortisol levels <10xa0μg/dL were considered low. Outcomes were compared between groups.ResultsHydrocortisone was used to treat AI in 34% (53/155) of patients. That subset of patients was demonstrably sicker, and mortality was expectedly higher for those treated with HC (37.7 vs. 17.6%, pxa0=xa00.0098). Of the subset of patients with random cortisol levels measured before initiation of HC, 67.7% (21/31) had low cortisol levels. No significant differences were seen in survival between the high and low groups, but mortality trended higher in patients with high cortisol levels that received HC. After multivariate analysis, duration of HC stress dose administration was associated with increased risk of mortality (OR 1.11, 95% CI 1.02–1.2, pxa0=xa00.021), and total duration of HC treatment was associated with increased risk of sepsis (OR 1.04, 95% CI 1.005–1.075, pxa0=xa00.026).ConclusionAI is prevalent amongst patients with CDH, but prolonged treatment with HC may increase risk of mortality and sepsis.

Laparoscopic Management of Pediatric Inflammatory Bowel Disease

Management of inflammatory bowel disease in children is complex with multiple treatment modalities, including surgery. The use of laparoscopic surgery in the treatment of these disease processes has many advantages over standard laparotomy incisions, including faster recovery and making future operations safer and less complex due to less scarring. Described here are the evaluation, operative techniques, and outcomes related to the use of laparoscopy in the treatment of inflammatory bowel disease in the pediatric population.