Thomas M. Rouse

Is the Grass Greener? Early Results of the Nuss Procedure

BACKGROUND/PURPOSE Minimal access surgery (MIS, Nuss Procedure) is gaining acceptance rapidly as the preferred method for pectus excavatum repair. This shift in operative management has followed a single institutions evaluation of the procedure. This report describes an additional experience with the Nuss procedure. METHODS Twenty-one patients with pectus excavatum underwent repair by the Nuss Procedure. The patients ranged in age from 5 to 15 years (average, 8.2 years). There were 19 boys and 2 girls. RESULTS In 1 patient (age 5 years) the MIS procedure was aborted because of persistence of chest wall asymmetry. The other 20 patients had completion of their procedure without intraoperative complication. The operating times ranged from 45 to 90 minutes; however, there was an additional anesthetic set-up time (average, 45 minutes). All cases utilized a single support bar (11 to 17 inches). Patients underwent extubation in the operating room and were admitted to a ward bed with an epidural catheter in place for pain control and received intravenous analgesia. The hospital stay ranged from 4 to 11 days and averaged 4.9 days. Early postoperative complications included ileus (n = 1), bilateral pleural effusion (n = 2), atelectasis (n = 1), fungal dermatitis (n = 1), pneumothorax (n = 1), and flipped pectus bar (n = 2). Delayed complications included flipped pectus bar (n = 2), marked pectus carinatum requiring bar removal (n = 1), mild carinatum (n = 1), mild bar deviation (n = 1), progressive chest wall asymmetry (n = 3) with 1 requiring bar removal and open pectus repair, pleural effusion (n = 1), and chronic persistent pain requiring bar removal (n = 1). The length of follow-up is 3 to 20 months with an average of 12.3 months. CONCLUSIONS The Nuss Procedure is quick, minimally invasive, and a technically easy method to learn; however, our data indicate there is a significant learning curve. Although previous reports suggest that few complications occur, we believe further assessment of patient selection regarding age, presence of connective tissue disorder, and severe chest wall asymmetry are still needed. Long-term follow-up also will be required to assure both health professionals and the public that this is the procedure of choice for patients with pectus excavatum.

Steroids and poor nutrition are associated with infectious wound complications in children undergoing first stage procedures for ulcerative colitis

BACKGROUND Risk factors for postoperative infections have not been evaluated in pediatric patients with ulcerative colitis (UC). This review was undertaken to evaluate the effects of immunosuppressive therapy and other preoperative factors on infectious wound complications in children undergoing first stage surgical therapy for UC. METHODS A 10-year retrospective review of children under 18 years of age receiving first stage surgical therapy for UC at a major childrens hospital was performed. Preoperative clinical and treatment variables were identified and correlated with postoperative wound complications. RESULTS A total of 51 children were identified: 19 underwent colectomy with ileo-anal-pouch anastomosis and 32 underwent total abdominal colectomy with Hartmanns pouch. A total of 20 infectious complications were identified in 18 patients. Preoperative steroid use was associated with a greater postoperative wound infection rate. Preoperative hemoglobin less than 10 g/dL (P < .05) and albumin less than 3 g/dL (P = 0.1) were associated with greater rates of postoperative infection. Preoperative body mass index and other immunosuppressive agents did not influence postoperative infectious morbidity. CONCLUSIONS The majority of pediatric patients who require operative intervention for UC are debilitated from their disease and medication use. Children with normal serum albumin and hemoglobin who are not on steroid therapy have a low risk of postoperative infectious complications.

Detection of Missed Injuries in a Pediatric Trauma Center With the Addition of Acute Care Pediatric Nurse Practitioners

Missed injuries contribute to increased morbidity in trauma patients. A retrospective chart review was conducted of pediatric trauma patients from 2010 to 2013 with a documented missed injury. A significant percentage of missed injuries were identified (3.01% during July 2012 to December 2013 vs 0.39% during January 2010 to July 2012) with the addition of acute care trained pediatric nurse practitioners to the trauma service at a pediatric trauma center. The increase is thought to be due to improvement in charting, consistent personnel performing tertiary examinations, and improved radiology reads of outside films.

Trends in pediatric adjusted shock index predict morbidity and mortality in children with severe blunt injuries

PURPOSE The utility of measuring the pediatric adjusted shock index (SIPA) at admission for predicting severity of blunt injury in pediatric patients has been previously reported. However, the utility of following SIPA after admission is not well described. METHODS The trauma registry from a level-one pediatric trauma center was queried from January 1, 2010 to December 31, 2015. Patients were included if they were between 4 and 16years old at the time of admission, sustained a blunt injury with an Injury Severity Score≥15, and were admitted less than 12h after their injury (n=286). Each patients SIPA was then calculated at 0, 12, 24, 36, and 48h after admission and then categorized as elevated or normal at each time frame based upon previously reported values. Trends in outcome variables as a function of time from admission for patients with an abnormal SIPA to normalize as well as patients with a normal admission SIPA to abnormal were analyzed. RESULTS In patients with a normal SIPA at arrival, 18.4% of patients who developed an elevated SIPA at 12h after admission died, whereas 2.4% of patients who maintained a normal SIPA throughout the first 48h of admission died (p<0.01). Among patients with an elevated SIPA at arrival, increased length of time to normalize SIPA correlated with increased length of stay (LOS) and intensive care unit (ICU) LOS. Similarly, elevation of SIPA after arrival in patients with a normal initial SIPA correlated to increased LOS and ICU LOS. CONCLUSIONS Patients with a normal SIPA at time of arrival who then have an elevated SIPA in the first 24h of admission are at increased risk for morbidity and mortality compared to those whose SIPA remains normal throughout the first 48h of admission. Similarly, time to normalize an elevated admission SIPA appears to directly correlate with LOS, ICU LOS, and other markers of morbidity across a mixed blunt trauma population. Whether trending SIPA early in the hospital course serves only as a marker for injury severity or if it has utility as a resuscitation metric has not yet been determined. TYPE OF STUDY Prognostic. LEVEL OF EVIDENCE Level II.

The trauma registry compared to All Patient Refined Diagnosis Groups (APR-DRG)

BACKGROUND Literature has shown there are significant differences between administrative databases and clinical registry data. Our objective was to compare the identification of trauma patients using All Patient Refined Diagnosis Related Groups (APR-DRG) as compared to the Trauma Registry and estimate the effects of those discrepancies on utilization. METHODS Admitted pediatric patients from 1/2012-12/2013 were abstracted from the trauma registry. The patients were linked to corresponding administrative data using the Pediatric Health Information System database at a single childrens hospital. APR-DRGs referencing trauma were used to identify trauma patients. We compared variables related to utilization and diagnosis to determine the level of agreement between the two datasets. RESULTS There were 1942 trauma registry patients and 980 administrative records identified with trauma-specific APR-DRG during the study period. Forty-two percent (816/1942) of registry records had an associated trauma-specific APR-DRG; 69% of registry patients requiring ICU care had trauma APR-DRGs; 73% of registry patients with head injuries had trauma APR-DRGs. Only 21% of registry patients requiring surgical management had associated trauma APR-DRGs, and 12.5% of simple fractures had associated trauma APR-DRGs. CONCLUSION APR-DRGs appeared to only capture a fraction of the entire trauma population and it tends to be the more severely ill patients. As a result, the administrative data was not able to accurately answer hospital or operating room utilization as well as specific information on diagnosis categories regarding trauma patients. APR-DRG administrative data should not be used as the only data source for evaluating the needs of a trauma program.

Seat belt misuse by a child transported in belt-positioning booster seat with deadly consequences.

Child passenger safety has been a major public health victory, but there is still work to be done. This case presentation is about a 5-year-old boy who placed the shoulder portion of the lap-shoulder seat belt behind his back who was recently killed in a motor vehicle crash. This article reviews what trauma nurses need to know about the latest improvements in child passenger safety practices. Also presented are important resources for trauma nurses to share with families to improve travel safety.

Long-term outcomes after pediatric peripheral revascularization secondary to trauma at an urban level I center

Objective The purpose of this investigation was to determine our limb‐related contemporary pediatric revascularization perioperative and follow‐up outcomes after major blunt and penetrating trauma. Methods A retrospective review was performed of a prospectively maintained pediatric trauma database spanning January 2010 to December 2017 to capture all level I trauma activations that resulted in a peripheral arterial revascularization procedure. All preoperative, intraoperative, and postoperative continuous variables are reported as a mean ± standard deviation; categorical variables are reported as a percentage of the population of interest. Results During the study period, 1399 level I trauma activations occurred at a large‐volume, urban childrens hospital. The vascular surgery service was consulted in 2.6% (n = 36) of these cases for suspected vascular injury based on imaging or physical examination. Our study population included only patients who received an arterial revascularization, which was performed in 23 of the 36 consultations (1.6% of total traumas; median age, 11 years). These injuries were localized to the upper extremity in 60.9% (n = 14), lower extremity in 30.4% (n = 7), and neck in 8.7% (n = 2). The mean Injury Severity Score in the revascularized cohort was 14.0 (±7.6). Bone fractures were associated with 39.1% of the vascular injuries (90% of blunt injuries). Restoration of in‐line flow was achieved by an endovascular solution in one patient and open surgery in the remainder, consisting of arterial bypass in 59.1% and direct repair in 40.9%. Within 30 days of the operation, we observed no deaths, no infections of the arterial reconstruction, and no major amputations. One patient required perioperative reintervention by the vascular team secondary to the development of a superficial seroma without evidence of graft involvement. Mean follow‐up in our cohort was 43.3 (±35.4) months. During this phase, no additional deaths, amputations, chronic wounds, or limb length discrepancies were observed. All vascular repairs were patent, and all but one patient reported normal function of the affected limb at the latest clinic visit. Conclusions Traumatic peripheral vascular injury is rare in the pediatric population but is often observed secondary to a penetrating force or after long bone fracture. However, contemporary perioperative and long‐term outcomes after surgical revascularization are excellent as demonstrated in this institutional case series.

Assessing outpatient follow-up care compliance, complications, and sequelae in children hospitalized for isolated traumatic abdominal injuries

BACKGROUND Currently there is limited knowledge on compliance with follow-up care in pediatric patients after abdominal trauma. The Indiana Network for Patient Care (INPC) is a large regional health information exchange with both structured clinical data (e.g., diagnosis codes) and unstructured data (e.g., provider notes). The objective of this study is to determine if regional health information exchanges can be used to evaluate whether patients receive all follow-up care recommended by providers. METHODS We identified 61 patients treated at a Pediatric Level I Trauma Center who were admitted for isolated abdominal injuries. We analyzed medical records for two years following initial hospital discharge for injury using the INPC. The encounters were classified by the type of encounter: outpatient, emergency department, unplanned readmission, surgery, imaging studies, and inpatient admission; then further categorized into injury- and non-injury-related care, based on provider notes. We determined compliance with follow-up care instructions given at discharge and subsequent outpatient visits, as well as the prevalence of complications and sequelae. RESULTS After reviewing patient records, we found that 78.7% of patients received all recommended follow-up care, 6.6% received partial follow-up care, and 11.5% did not receive follow-up care. We found that 4.9% of patients developed complications after abdominal trauma and 9.8% developed sequelae in the two years following their initial hospitalization. CONCLUSIONS Our findings suggest that health information exchanges such as the INPC are useful in evaluation of follow-up care compliance and prevalence of complications/sequelae after abdominal trauma in pediatric patients. LEVEL OF EVIDENCE Level IV.

Complex Injuries of the Competitive Young Athlete: A Case Series of Significant Injuries Beyond the Concussion and Fractures

Introduction The aim of this study was to provide a case series detailing the occurrence of significant and life-threatening injuries outside isolated orthopedic or head injuries sustained by athletes treated at our institution. Methods This study is a retrospective case series utilizing the trauma registry at a Level I pediatric trauma center. Inclusion criteria included an abdominal solid organ injury Grade III or higher, a major thoracic injury, or an injury resulting in death. Conclusions Although there have been great strides in research related to prevention and management of concussions sustained by athletes, there is little formal reporting of the incidence or potential complications of the intrathoracic and intra-abdominal injuries. The four cases described represent a compilation of the most significant competitive sports-related injuries managed at a Level I pediatric trauma center during 2012–2013. The case series shows how competitive sports can lead to injuries that require hospitalization with extensive monitoring and interventions, which may predispose the athlete to further complications and, in the rare case, death. Also significant is that these injuries are not solely limited to high contact sports like football but can be seen in a sport like baseball, which may not be as commonly regarded among parents and coaches as posing a risk for serious contact-related injuries.