Pam Pieper

Impact of gestational age on the clinical presentation and surgical outcome of necrotizing enterocolitis

Objective:This investigation tests the hypothesis that the clinical presentation and the outcome of necrotizing enterocolitis (NEC) vary with gestational age (GA).Methods:All infants admitted to our center between October 1991 and September 2003 were evaluated weekly to identify confirmed cases of NEC. Based upon GA, these infants were divided into five groups: Extremely premature (EP, 23 to 26 weeks), very premature (VP, 27 to 29 weeks), moderately premature (MP, 30 to 34 weeks), near-term (NT, 35 to 36 weeks), and term (T, 37 to 42 weeks).Results:A total of 202 infants developed NEC. The most common sign of NEC among EP infants was ileus (77%), followed by abdominal distention (71%), emesis (58%), pneumoperitoneum (54%), fixed intestinal loop (52%), gasless abdomen (42%) and bloody stools (17%). Intramural gas was detected in 100% of T but was present in only 29% of EP infants (P<0.0001). Similarly, portal venous gas was common in T but infrequent in the EP infants (47 vs 10%, P<0.0001). Despite a higher peritoneal drain insertion rate (31 vs 5%, P<0.001) and a higher mortality rate (33 vs 10%, P=0.05) in EP compared to T infants, other clinical outcomes were not different.Conclusions:The clinical presentation of NEC is different in EP compared to more mature infants; however, outcome among NEC survivors is similar across all GA. Reliance solely on observation of intramural or on portal venous gas in EP infants may lead to a delay or failure in the diagnosis.

Do pediatric patients with trauma in Florida have reduced mortality rates when treated in designated trauma centers

OBJECTIVE The purposes of the study were to compare the survival associated with treatment of seriously injured patients with pediatric trauma in Florida at designated trauma centers (DTCs) with nontrauma center (NCs) acute care hospitals and to evaluate differences in mortality between designated pediatric and nonpediatric trauma centers. METHODS Trauma-related inpatient hospital discharge records from 1995 to 2004 were analyzed for children aged from 0 to 19 years. Age, sex, ethnicity, injury mechanism, discharge diagnoses, and severity as defined by the International Classification Injury Severity Score were analyzed, using mortality during hospitalization as the outcome measure. Children with central nervous system, spine, torso, and vascular injuries and burns were evaluated. Instrumental variable analysis was used to control for triage bias, and mortality was compared by probabilistic regression and bivariate probit modeling. Children treated at a DTC were compared with those treated at a nontrauma center. Within the population treated at a DTC, those treated at a DTC with pediatric capability were compared with those treated at a DTC without additional pediatric capability. Models were analyzed for children aged 0 to 19 years and 0 to 15 years. RESULTS For the 27,313 patients between ages 0 and 19 years, treatment in DTCs was associated with a 3.15% reduction in the probability of mortality (P < .0001, bivariate probit). The survival advantage for children aged 0 to 15 years was 1.6%, which is not statistically significant. Treatment of 16,607 children in a designated pediatric DTC, as opposed to a nonpediatric DTC, was associated with an additional 4.84% reduction in mortality in the 0- to 19-year age group and 4.5% in the 0 to 15 years group (P < .001, bivariate probit). CONCLUSIONS Optimal care of the seriously injured child requires both the extensive and immediate resources of a DTC as well as pediatric-specific specialty support.

Timing of surgical intervention in necrotizing enterocolitis can be determined by trajectory of metabolic derangement

PURPOSE Seven metrics of metabolic derangement were evaluated as contributors to clinical decision support for operative intervention in infants with suspected necrotizing enterocolitis (NEC). METHODS Records of infants with suspected NEC without radiologic evidence of free air were queried for presence of 7 components of metabolic derangement (CMD), consisting of positive blood culture, acidosis, bandemia, thrombocytopenia, hyponatremia, hypotension, or neutropenia. Cases were stratified by clinical decision after each surgical evaluation as observation (OBS) or intervention (INT). Good outcome was defined as full enteric feeding by discharge and bad outcome as death or ongoing parenteral alimentation. Eleven infants undergoing operative intervention after an initial decision to observe were evaluated as matched pairs. Components of metabolic derangement/case and frequency of each CMD were determined for OBS and INT. Mann-Whitney U test was used to compare proportions of CMD in each group. Outcome was compared using chi(2). Observation was then stratified by outcome to determine whether 3 or more metabolic derangements warranting operative intervention would have changed initial clinical decision. The 11 matched cases were similarly analyzed using Wilcoxon-matched pairs. RESULTS Between March 2005 and July 2008, 35 infants with NEC received 53 surgical evaluations. A median of 1 CMD/case was defined in 32 instances of OBS. Surgical intervention was carried out in 19 infants with a median of 3 CMD/case. Mann-Whitney U test indicated significant difference in the frequencies of each CMD component in OBS vs INT (P = .04). Good outcome was achieved in 75% of OBS and 63% of INT (non-significant, NS). Analysis of OBS by outcome demonstrated a median 1 CMD/case of 25 with good outcome and 3 CMD/case in infants with bad outcome. Frequency of CMD was significantly higher in infants with bad outcome (P = .02). Wilcoxon-matched pair analysis of the 11 infants with paired evaluations demonstrated a similar distribution and frequency of CMD. CONCLUSION Progressive metabolic derangement of infants with NEC can be clinically tracked. The appearance of any 3 of these 7 metrics indicates timely operative intervention. Application of CMD trajectory to timing of surgical intervention may improve outcome and define the relationship between specific CMD and operative risk.

Pediatric trauma is very much a surgical disease.

ObjectiveThe evolution of nonoperative management of certain solid visceral injuries has stimulated speculation that management of the severely injured child is no longer a surgical exercise. The authors hypothesized that the incidence of injuries that require surgical evaluation is disproportionately high in children at risk of death or disability from significant injury. MethodsNational Pediatric Trauma Registry data were queried for all patients with ICDA-9-CM diagnoses requiring at least surgical evaluation. Selected diagnoses included CNS: 800 to 804, 850 to 854; thoracoabdominal: 860 to 870; pelvic fracture: 808; and acute vascular disruption: 900 to 904. Operative intervention was identified by ICDA-9-CM operative codes less than 60 and selected operative orthopedic codes between 79.8 and 84.4. At-risk patients were identified as those with at least one of the following: Glasgow Coma Scale score less than 15, Glasgow Coma Scale motor score less than 6, initial systolic blood pressure less than 90, or Injury Severity Scale score more than 10. The incidence of a surgical diagnosis in at-risk children was compared to the incidence in the population with no identifiable risk. Within the population undergoing surgical evaluation, resource utilization, as reflected by operative intervention and ICU days, and outcome, as reflected by mortality, were compared between the at-risk group and the group with no identifiable risk. ResultsFrom 1987 to 2000, 87,424 records were complete enough for analysis. Of those, 48,687 (55.6%) patients sustained at least one injury requiring a surgical evaluation and 28,645 (32.7%) children were determined to be at risk. Mortality for at-risk children was 5.8% versus 0.02% for those with no identifiable risk. Of the children at risk, 24,706 (86.2%) had at least one injury requiring a surgical evaluation. Of the 58,779 children with no risk, 23,981 (40.8%) also had at least one injury requiring a surgical evaluation. Operative intervention for surgical injuries was required in 20.5% of cases (n = 10,015). Of these, 5,562 (56%) were at-risk children, and they had a mortality rate of 11.5%. Of the children not at risk, 4,453 required operative care, and they had a mortality of 0.1%. At-risk children undergoing surgery required an average of 5.02 days of ICU care compared to 1.2 for cases performed on children without risk. ConclusionsThese data clearly demonstrate the primacy of surgical pathology as the major determinant of outcome in pediatric injury. Operative intervention and the option of timely operative care remain major components of clinical management of children with injuries that pose a significant risk of morbidity or mortality.

Nosocomial pneumonia in the pediatric trauma patient: a single center's experience.

ObjectivesTo evaluate a single center’s experience with the frequency rate, patterns of occurrence, and impact on outcome of nosocomial pneumonia in the critically injured child. DesignRetrospective review of prospectively collected data. SettingLevel I university trauma center with a pediatric trauma intensive care unit. PatientsA total of 523 consecutive critically injured children admitted to the pediatric intensive care unit during an 80-month interval. Measurements and ResultsThirty-five episodes of nosocomial pneumonia were identified in 29 children (frequency rate of 5.5%). The mean age of the children was 9.2 yrs, and the mean Injury Severity Score was 27 ± 9. In 91% of patients (26 children), nosocomial pneumonia was associated with mechanical ventilation. This represented a 13% frequency rate in injured children who were ventilated during the study period. The most common organisms recovered were Staphylococcus aureus (21%), Haemophilus influenzae (19%), Pseudomonas (11%), and Enterobacter (11%). Early pneumonia (diagnosed ≤7 days after injury) was predominantly caused by Haemophilus species. In contrast, Enterobacter and/or Pseudomonas were isolated primarily in late pneumonia (diagnosed >7 days after injury). Staphylococcus was prominent throughout the hospitalization. Overall, children with nosocomial pneumonia were more severely injured (Injury Severity Score 27 vs. 17, p < .001) and had a longer hospital stay (26 vs. 7 days, p < .001). Despite this, mortality (6.9% vs. 7.9%, p = NS) was not significantly different from injured children without pneumonia. ConclusionsIn this study of a single pediatric trauma center, nosocomial pneumonia occurred in a small but significant percentage of injured children. The frequency rate increased two- to three-fold with mechanical ventilation. Microbiology varied with day of onset. In contrast to the adult, mortality did not seem to be significantly altered by this complication. Analysis of additional pediatric trauma centers is encouraged to confirm these characteristics of nosocomial pneumonia in the injured child.

The evaluation of pediatric trauma care using audit filters.

Objective To evaluate the experience of a pediatric trauma system with specific reference to prehospital, trauma center resuscitation, and critical care phases of treatment. Design Descriptive review of concurrent audit. Setting A tertiary care referral adult and pediatric trauma center. Patients All pediatric trauma victims in the trauma registry (includes patients ≤14 years old, who died or were hospitalized for ≥24 hours) Interventions None. Measurements and main results Age, pediatric trauma, injury severity, and Glasgow Coma Scale scores as well as outcome (death or discharge disability score) were analyzed. Primary filters (those with the potential to contribute to morbidity and mortality), secondary filters (minor deviations from care), missed injuries and all deaths were reviewed. Of 250 patients in the registry, 20 died. One hundred thirteen had filters, with 49 having primary filters (34 with one, 14 with two, and one with four filters). Fifty percent of primary filters occurred in the prehospital phase of care with inadequate airway management and venous access accounting for 60%. Overall, primary filters occurred more commonly in patients with severe injuries (lower Pediatric Trauma and Glasgow Coma Scale and higher Injury Severity scores). Primary filters were also statistically more common in patients who died or who were disabled. In three patients (25%) who died, our review suggested that filters may have contributed to demise. Missed injuries were mostly extremity fractures and did not contribute to mortality or long-term morbidity. Conclusion Deviations from care occur, even in a dedicated pediatric trauma system. Mortality of and by itself is not an adequate indicator of the quality of function of a trauma system. Since most primary filters occurred outside of the trauma center, improvement in trauma outcome may be expected with better training of personnel involved in the prehospital care of injured children. A comprehensive review of death and disability should include audit filters of prehospital care, triage, definitive care, and rehabilitation.

Pediatric penetrating thoracic trauma: a five-year experience

Penetrating thoracic trauma is managed nonoperatively in 85% of adult patients. We hypothesized that similar trauma in children would lead to proportionately more vital tissue damage and a higher rate of operative intervention. The pediatric penetrating thoracic trauma experience of a level one trauma center was analyzed over a five-year period. Data reviewed included circumstances of injury, Pediatric Trauma Score (PTS), interventions performed, and outcome. Of 61 children with thoracic trauma, 13 had penetrating injuries. Of these 13, seven were unintentional (five from firearms); the rest were caused by assaults. Seven patients (54%) underwent thoracotomy or laparotomy. All five patients with a PTS <8 underwent surgical intervention, whereas only two of the eight patients with a PTS >8 needed surgery (P <0.05). There was one death. We reached the following conclusions: 1) Children with penetrating thoracic trauma are more likely to require surgical intervention than adults. 2) Penetrating thoracic trauma in children should elicit a thorough search for operative lesions. 3) About half these injuries are unintentional, and thus potentially preventable.

Health-related quality-of-life in the first year following a childhood concussion

Abstract Objectives: (1) To compare pre-injury health-related quality-of-life (HRQoL) of children who have sustained mild traumatic brain injury (mTBI) to their HRQoL at 1, 3, 6 and 12 months post-injury and (2) to compare the HRQoL of children with mTBI, children with mild non-brain injuries and children who were uninjured at the same time points. Child and parent responses were obtained for both objectives. Patients and methods: This prospective cohort study involved a self-selected convenience sample to evaluate child and parent perspectives of the HRQoL of 5–17 year old children with mTBI using the PedsQL Generic Core Scales and Cognitive Functioning Scale. Total sample size was 120 child/parent dyads, with 40 dyads each in the study and two control groups. Children who required hospitalization greater than 24 hours were excluded from the study. Results: HRQoL of children with mTBI was not significantly different between pre- and post-injury at all-time points. However, children and parents in the mild non-brain injury group reported significantly lower physical HRQoL 1 month post-injury. Conclusions: Children with mTBI had similar pre- and post-injury HRQoL. Thus, children who sustain mTBI and have significantly lower HRQoL within the first year post-injury merit further evaluation.

Trajectory of Metabolic Derangement in Infants with Necrotizing Enterocolitis Should Drive Timing and Technique of Surgical Intervention

BACKGROUND Seven clinical metrics of metabolic derangement (MD7) have improved the timing of surgical intervention in infants with necrotizing enterocolitis (NEC). We compared surgical NEC outcomes based on MD7 at our center (unit S) with a similar center (unit B) that based its intervention on abdominal radiograph. STUDY DESIGN Premature infants undergoing surgical care for NEC were evaluated. MD7 included positive blood culture, acidosis, bandemia, hyponatremia, thrombocytopenia, hypotension, and neutropenia. Surgical recommendations were stratified as observation or intervention. Good outcomes included full enteric feeding by discharge and poor outcomes were death or dependence on parenteral nutrition. For unit S and unit B, the frequency, median, and mode of MD7 component per case were determined for observation and intervention. Mann-Whitney U test and Wilcoxon matched pairs were used to compare positive MD7 frequency for observation with intervention. Institutional mortality was compared and metabolic severity of unit cohorts was evaluated by incidence of MD7 in each. RESULTS From March 2005 to July 2008, forty-one infants at unit S underwent 62 surgical evaluations. Observation was elected in 38 (median 1 MD7 per case, mode 0). Operative intervention occurred in 24 (median 4 MD7 per case, mode 4). Proportional MD7 difference between observation and intervention was significant (p = 0.018, U = 6). From February 2007 to December 2008, sixty-five unit B infants received 81 evaluations, recommending 37 observations (median 2 MD7 per case, mode 2), and 44 interventions (median 3 MD7 per case, mode 3). MD7 proportions between observation and intervention were not significant (p = 0.318, U = 16). Poor outcomes rates for unit S and unit B infants were 24% and 66%, respectively (p = 0.0001). Severity of MD7 did not differ between institutions (p = 0.53, U = 19). CONCLUSIONS These data demonstrate variability in surgical approach to NEC. The MD7 panel describes the trajectory of metabolic derangement, defines more timely surgical intervention, and demonstrates that waiting for free air is too late.

Practical aspects of performance improvement in pediatric trauma.

Pediatric trauma performance improvement programs may share some of the criteria tracked by their counterparts in the adult trauma world. However, some of the criteria must be specific to the unique diagnostic and therapeutic needs of children. Nine criteria are defined in terms of the critical issues, what information is required to evaluate the appropriateness of the care provided in regards to those issues, and acceptable thresholds for review. In addition, practical aspects of multi-disciplinary peer review in the performance improvement process is presented.