Shawn J. Rangel

Implementing a Pediatric Surgical Safety Checklist in the OR and Beyond

An international study about implementation of the World Health Organization Surgical Safety Checklist showed that use of the checklist reduced complication and death rates in adult surgical patients. Clinicians at Childrens Hospital Boston, Massachusetts, modified the Surgical Safety Checklist for pediatric populations. We pilot tested the Pediatric Surgical Safety Checklist and created a large checklist poster for each OR to allow the entire surgical team to view the checklist simultaneously and to promote shared responsibility for conducting the time out. Results of the pilot test showed improvements in teamwork, communication, and adherence to process measures. Parallel efforts were made in other areas of the hospital where invasive procedures are performed. Compliance with the checklist at our facility has been good, and team members have expressed satisfaction with the flow and content of the checklist.

Laparoscopic Repair of Paraesophageal Hiatal Hernias

BACKGROUND Regardless of symptoms, paraesophageal hiatal hernias should be repaired in order to prevent complications. This study reports the University of California San Francisco experience with laparoscopic repair of paraesophageal hiatal hernias, emphasizing the technical steps essential for good results. PATIENTS AND METHODS From May 1993 to September 1997, 55 patients, 27 women and 28 men, with a mean age of 67 years (range, 35-102 years) underwent laparoscopic repair of paraesophageal hernias at the University of California San Francisco. Symptoms, which had been present an average of 85 months before surgery, consisted mainly of pain (55%), heartburn (52%), dysphagia (45%), and regurgitation (41%). Of the four patients who presented with acute illness, two had gastric obstruction, one had severe dyspnea, and one had gastric bleeding. Endoscopy demonstrated esophagitis in 25 (69%) of 36 patients, and 24-hour pH-monitoring demonstrated acid reflux in 22 (67%) of 33 patients. Manometry detected severely impaired distal esophageal peristalsis in 17 (52%) of 33 patients. The preferred operation consisted of reduction of the hernia, excision of the sack and the gastric fat pad, closure of the enlarged hiatus without mesh, and construction of a fundoplication anchored by sutures within the abdomen. RESULTS Of the 55 patients, the operations of 49 were completed laparoscopically using the following reconstructions: Guarner (270-degree) fundoplication (30 patients); Nissen fundoplication (10 patients); and gastropexy (9 patients). Five (9%) operations were converted to laparotomies. The average operating time was 219 minutes; the average blood loss was less than 25 mL; resumption of an unrestricted diet, 27 hours; and mean hospital stay, 58 hours. Intraoperative technical complications occurred in five (9%) patients. One patient died during surgery from a sudden pulmonary embolus. Two (4%) patients required a second operation for recurrent paraesophageal hernias. CONCLUSIONS Laparoscopic repair of paraesophageal hiatal hernias is safe and effective, but the operation is difficult and good results hinge on details of the operative technique and the surgeons experience. In this series, the crus could always be closed securely without using mesh. We realized early that a fundoplication should be a routine step, because it corrects reflux and is the best method to secure the gastroesophageal junction in the abdomen.

Parenteral nutrition–associated cholestasis: an American Pediatric Surgical Association Outcomes and Clinical Trials Committee systematic review

OBJECTIVE The aim of this study was to review evidence-based data addressing key clinical questions regarding parenteral nutrition-associated cholestasis (PNAC) and parenteral nutrition-associated liver disease (PNALD) in children. DATA SOURCE Data were obtained from PubMed, Medicine databases of the English literature (up to October 2010), and the Cochrane Database of Systematic Reviews. STUDY SELECTION The review of PNAC/PNALD has been divided into 4 areas to simplify ones understanding of the current knowledge regarding the pathogenesis and treatment of this disease: (1) nonnutrient risk factors associated with PNAC, (2) PNAC and lipid emulsions, (3) nutritional (nonlipid) considerations in the prevention of PNAC, and (4) supplemental medications in the prevention and treatment of PNAC. RESULTS The data for each topic area relevant to the clinical practice of pediatric surgery were reviewed, evaluated, graded, and summarized. CONCLUSIONS Although the conditions of PNAC and PNALD have been well recognized for more than 30 years, only a few concrete associations and treatment protocols have been established.

The diagnosis and management of empyema in children: a comprehensive review from the APSA Outcomes and Clinical Trials Committee.

The aim of this study is to review the current evidence on the diagnosis and management of empyema. The American Pediatric Surgical Association Outcomes and Clinical Trials Committee compiled 8 questions to address. A comprehensive review was performed on each topic. Topics included the distinction between parapneumonic effusion and empyema, the optimal imaging modality in evaluating pleural space disease, when and how pleural fluid should be managed, the first treatment option and optimal timing in the management of empyema, the optimal chemical debridement agent for empyema, therapeutic options if chemical debridement fails, therapy for parenchymal abscess or necrotizing pneumonia and duration of antibiotic therapy after an intervention. The evidence was graded for each topic to provide grade of recommendation where appropriate.

Comparative Effectiveness of Intravenous vs Oral Antibiotics for Postdischarge Treatment of Acute Osteomyelitis in Children

IMPORTANCE Postdischarge treatment of acute osteomyelitis in children requires weeks of antibiotic therapy, which can be administered orally or intravenously via a peripherally inserted central catheter (PICC). The catheters carry a risk for serious complications, but limited evidence exists on the effectiveness of oral therapy. OBJECTIVE To compare the effectiveness and adverse outcomes of postdischarge antibiotic therapy administered via the PICC or the oral route. DESIGN, SETTING, AND PARTICIPANTS We performed a retrospective cohort study comparing PICC and oral therapy for the treatment of acute osteomyelitis. Among children hospitalized from January 1, 2009, through December 31, 2012, at 36 participating childrens hospitals, we used discharge codes to identify potentially eligible participants. Results of medical record review confirmed eligibility and defined treatment group allocation and study outcomes. We used within- and across-hospital propensity score-based full matching to adjust for confounding by indication. INTERVENTIONS Postdischarge administration of antibiotics via the PICC or the oral route. MAIN OUTCOMES AND MEASURES The primary outcome was treatment failure. Secondary outcomes included adverse drug reaction, PICC line complication, and a composite of all 3 end points. RESULTS Among 2060 children and adolescents (hereinafter referred to as children) with osteomyelitis, 1005 received oral antibiotics at discharge, whereas 1055 received PICC-administered antibiotics. The proportion of children treated via the PICC route varied across hospitals from 0 to 100%. In the across-hospital (risk difference, 0.3% [95% CI, -0.1% to 2.5%]) and within-hospital (risk difference, 0.6% [95% CI, -0.2% to 3.0%]) matched analyses, children treated with antibiotics via the oral route (reference group) did not experience more treatment failures than those treated with antibiotics via the PICC route. Rates of adverse drug reaction were low (<4% in both groups) but slightly greater in the PICC group in across-hospital (risk difference, 1.7% [95% CI, 0.1%-3.3%]) and within-hospital (risk difference, 2.1% [95% CI, 0.3%-3.8%]) matched analyses. Among the children in the PICC group, 158 (15.0%) had a PICC complication that required an emergency department visit (n = 96), a rehospitalization (n = 38), or both (n = 24). As a result, the PICC group had a much higher risk of requiring a return visit to the emergency department or for hospitalization for any adverse outcome in across-hospital (risk difference, 14.6% [95% CI, 11.3%-17.9%]) and within-hospital (risk difference, 14.0% [95% CI, 10.5%-17.6%]) matched analyses. CONCLUSIONS AND RELEVANCE Given the magnitude and seriousness of PICC complications, clinicians should reconsider the practice of treating otherwise healthy children with acute osteomyelitis with prolonged intravenous antibiotics after hospital discharge when an equally effective oral alternative exists.

Small evidence for small incisions: pediatric laparoscopy and the need for more rigorous evaluation of novel surgical therapies

BACKGROUND/PURPOSE Laparoscopic surgery has been widely adopted for many pediatric surgical diseases for its potential to reduce morbidity and hospital stay. To date, no study has examined the qualitative state of evidence supporting the use of these techniques in children. The authors present a systematic and objective review of this evidence. METHODS The authors identified all clinical reports during the last 10 years for the 3 most common pediatric surgical diseases managed laparoscopically (appendicitis, gastroesophageal reflux, and conditions requiring splenectomy). Standardized and previously validated quality assessment instruments were used to examine individual studies in 4 areas: (1) clinical relevance, (2) generalizability to clinical practice, (3) reporting methodology, and (4) strength of conclusions. RESULTS The authors evaluated a total of 131 clinical reports (39 to 48 per disease). Ninety-three percent of all studies were retrospective, with single institution case reports accounting for the majority of evidence. Only 23% of studies used a control group of any kind. Randomized trials comprised 3% of all evidence (4 studies). Forty-five percent of nonrandomized studies were found to be of poor quality, and 55% were of fair quality by epidemiologic standards. The distribution of quality scores was not significantly different between the 3 operative indications examined (analysis of variance P =0.10). Randomized studies also were found to be of poor methodologic quality by standardized assessment criteria. CONCLUSIONS The current body of evidence is of insufficient quality to justify the widespread adoption of laparoscopic techniques into accepted standards of care. Wider use of prospective studies such as multicenter databases and randomized trials are needed to clarify the indications and outcomes for these innovative techniques. Significant improvement in the quality of published observational studies is also warranted, and this may be facilitated by the adoption of standardized reporting guidelines specific to nonrandomized data.

Variation in practice and resource utilization associated with the diagnosis and management of appendicitis at freestanding children's hospitals: implications for value-based comparative analysis.

Objective:To characterize the scope and magnitude of practice variation associated with the diagnosis and treatment of appendicitis at freestanding childrens hospitals. Background:Variation in care has been associated with poor outcomes and is believed to be a key driver of excess health care spending. Methods:Retrospective cohort study of 13,328 patients treated with appendicitis at 34 childrens hospitals (9/2010–9/2011). Patients were divided into complicated and uncomplicated cohorts and examined for interhospital variation in the use of diagnostic imaging (computed tomography or ultrasonography), laboratory tests, parenteral nutrition (PN), peripherally inserted central catheters (PICC), and hospital cost. The number and distribution of statistical outliers were calculated for all measures. Results:Significant variation was found for all measures, including a 3.5-fold difference in preoperative imaging (aggregate rate: 49.0%, range across hospitals: 21.2%–73.5%, P < 0.001) and a 5-fold difference in preoperative laboratory utilization (aggregate median: 2 tests/encounter, range: 1–5 tests/encounter, P < 0.001). For patients with complicated appendicitis, we characterized a 12-fold difference in postoperative imaging (aggregate rate: 19.4%, range: 4.9%–61.6%, P < 0.001), a 48-fold difference in PICC lines (aggregate rate: 18.9%, range: 1.7%–81.8%, P < 0.001), and a 100-fold difference in PN utilization (aggregate rate: 9.3%, range: 0.4%–42.0%, P < 0.001). Median hospital cost differed 4-fold for patients with uncomplicated disease (aggregate median:

The appendix as a conduit for antegrade continence enemas in patients with anorectal malformations: lessons learned from 163 cases treated over 18 years

6804, range:

Recent trends in the use of antibiotic prophylaxis in pediatric surgery

4200–

Alarming trends in the improper use of motor vehicle restraints in children : implications for public policy and the development of race-based strategies for improving compliance

16,796, P < 0.001) and 4.6-fold for patients with complicated disease (aggregate median: