Traditional surgical attitude regarding error and complications has focused on individual failing... more Traditional surgical attitude regarding error and complications has focused on individual failings. Human factors research has brought new and significant insights into the occurrence of error in healthcare, helping us identify systemic problems that injure patients while enhancing individual accountability and teamwork. This article introduces human factors science and its applicability to teamwork, surgical culture, medical error, and individual accountability.
Burnout has attained epidemic proportions in all reaches of society. Only recently, has its impac... more Burnout has attained epidemic proportions in all reaches of society. Only recently, has its impact in healthcare become a burning platform. Second victim syndrome, a consequence of an unforeseen adverse event, often precipitated by an error, can lead to a post-traumatic stress-like reaction, that is unique to healthcare workers. Often, the second victim suffers in silence, forced to rely on resilience. Peer support has been demonstrated to be beneficial in assisting healthcare workers in recovering from both burnout and second victim syndrome. Institutions and organizations must be more influential and responsive in supporting physicians and other healthcare workers in need.
Gastroschisis is a periumbilical, abdominal wall defect arising to the right of the umbilicus. We... more Gastroschisis is a periumbilical, abdominal wall defect arising to the right of the umbilicus. We describe the clinical course of a left-sided gastroschisis in a term female born at 39 weeks’ gestation. To our knowledge, there have been only 14 left-sided abdominal wall defects reported in the literature. We discuss our case and review the literature to try to determine if there is any clinic difference between right- versus left-sided lesions to make recommendations as to management.
Aim of the study: Enhanced recovery after surgery (ERAS) protocols have been shown to decrease le... more Aim of the study: Enhanced recovery after surgery (ERAS) protocols have been shown to decrease length of stay (LOS) and complications in adult surgical populations. Our purpose was to compare outcomes before and after implementation of a pediatric-specific ERAS protocol in children undergoing elective colorectal surgery. Methods: A multidisciplinary approach was used to develop a pediatric ERAS protocol that was implemented at a single center between 1/2015-12/2016. A retrospective review was performed including 43 patients (54%) in the pre-ERAS period (2012-2014) and 36 patients (46%) in the post-ERAS period (2015-2016). Outcomes of interest included the number of ERAS elements received, LOS, complications, and readmissions. Main results: The most common diagnosis among study subjects was inflammatory bowel disease (n=70;87%). The pre-ERAS cohort included 17 (40%) ileocecectomies, 16 (37%) partial/total colectomies, 9 (21%) proctectomy and ileo-anal J-pouches, and 1 (2%) ileostomy reversal, while the post-ERAS cohort included 7 (19%) ileocecectomies, 17 (47%) partial/total colectomies, 6 (17%) proctectomy and ileo-anal J-pouches, and 6 (17%) ileostomy reversals. The median number of ERAS elements received per patient increased from 5 the pre-ERAS period to 11 in the post-ERAS period. The median LOS decreased from 5 in 2012 to 3 days in the post-ERAS period(Figure). We observed a decrease in median time to regular diet (2 to 1 day(s);p<0.001), mean dose of intraoperative (0.52 to 0.07 mg/kg;p<0.001) and postoperative narcotics (1.15 to 0.20 mg/kg;p<0.001), and mean volume of intraoperative fluids (9.20 to 5.43 mL/kg/hr;p<0.001) in the post-ERAS period. The complication rate (21% vs. 17%;p=0.85) and the 30-day readmission rate (23% vs. 11%;p=0.63) were not significantly different between the pre-and post-ERAS periods. Conclusions: These preliminary results suggest that implementation of a pediatric ERAS protocol in children undergoing colorectal surgery is feasible, safe and may lead to shorter LOS and improved outcomes without an increase in readmissions.
Our aim was to implement a standardized US report that included secondary signs of appendicitis (... more Our aim was to implement a standardized US report that included secondary signs of appendicitis (SS) to facilitate accurate diagnosis of appendicitis and decrease the use of computed tomography (CT) and admissions for observation. A multidisciplinary team implemented a quality improvement (QI) intervention in the form of a standardized US report and provided stakeholders with monthly feedback. Outcomes including report compliance, CT use, and observation admissions were compared pretemplate and posttemplate. We identified 387 patients in the pretemplate period and 483 patients in the posttemplate period. In the posttemplate period, the reporting of SS increased from 5.4% to 79.5% (p<0.001). Despite lower rates of appendix visualization (43.9% to 32.7%, p<0.001) with US, overall CT use (8.5% vs 7.0%, p=0.41) and the negative appendectomy rate remained stable (1.0% vs 1.0%, p=1.0). CT utilization for patients with an equivocal ultrasound and SS present decreased (36.4% vs 8.9%, ...
To define the incidence of 30-day postdischarge emergency department (ED) visits and hospital rea... more To define the incidence of 30-day postdischarge emergency department (ED) visits and hospital readmissions following pediatric gastrostomy tube (GT) placement across all procedural services (Surgery, Interventional-Radiology, Gastroenterology) in 38 freestanding Children's Hospitals. This retrospective cohort study evaluated patients <18 years of age discharged between 2010 and 2012 after GT placement. Factors significantly associated with ED revisits and hospital readmissions within 30 days of hospital discharge were identified using multivariable logistic regression. A subgroup analysis was performed comparing patients having the GT placed on the date of admission or later in the hospital course. Of 15 642 identified patients, 8.6% had an ED visit within 30 days of hospital discharge, and 3.9% were readmitted through the ED with a GT-related issue. GT-related events associated with these visits included infection (27%), mechanical complication (22%), and replacement (19%). ...
Introduction-Ultrasound (US) is the preferred imaging modality for evaluating appendicitis. Our p... more Introduction-Ultrasound (US) is the preferred imaging modality for evaluating appendicitis. Our purpose was to determine if including secondary signs (SS) improves diagnostic accuracy in equivocal US studies. Methods-Retrospective review identified 825 children presenting with concern for appendicitis and with a right lower quadrant (RLQ) US. Regression models identified which SS were associated with appendicitis. Test characteristics were demonstrated. Results-530 patients (64%) had equivocal US reports. Of 114 (22%) patients with equivocal US undergoing CT, those with SS were more likely to have appendicitis (48.6% vs 14.6%, p<0.001). Of 172 (32%) patients with equivocal US admitted for observation, those with SS were more likely to have appendicitis (61.0% vs 33.6%, p<0.001). SS associated with appendicitis included fluid collection (adjusted odds ratio (OR) 13.3, 95% Confidence Interval (CI) 2.1-82.8), hyperemia (OR=2.0, 95%CI 1.5-95.5), free fluid (OR=9.8, 95%CI 3.8-25.4), and appendicolith (OR=7.9, 95%CI 1.7-37.2). Wall thickness, bowel peristalsis, and echogenic fat were not associated with appendicitis. Equivocal US that included hyperemia, a fluid collection, or an appendicolith had 96% specificity and 88% accuracy.
Improving quality of care logically involves optimizing the duty-readiness and well-being of the ... more Improving quality of care logically involves optimizing the duty-readiness and well-being of the healthcare provider. Medical errors and poor outcomes adversely impact the involved providers, especially surgeons, as well as the patients and their families. Unfortunately our current system does little to support these "second victims" who experience various degrees of emotional and psychological stresses including confusion, loss of confidence, and debilitating anxiety. These factors contribute to the alarmingly high rates of professional "burnout," substance abuse, and suicide of healthcare providers as well as increase the likelihood of subsequent medical errors. Mindful efforts to improve the healthcare culture and develop personal support systems can help surgeons become more resilient, provide higher quality patient care, and have longer productive professional lives. Institutional support systems are also necessary to assist "second victims" to recover from the impact of an adverse patient event.
Variation in care may indicate an opportunity for quality improvement and to decrease waste. Vari... more Variation in care may indicate an opportunity for quality improvement and to decrease waste. Variation in appendicitis practice, resource use, and costs have not been well studied at non-children&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s hospitals (NCHs) where most children undergo care. The purpose of this study was to quantify variation in care for perforated pediatric appendicitis within and between children&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s hospitals (CHs) and NCH. Using the 2012 Kids&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; Inpatient Database, 11,216 children with perforated appendicitis were identified. Comparisons between CH and NCH were made in regard to operative approach (open versus laparoscopic), central line (CL) and total parenteral nutrition (PN) use, complication rates, length of stay (LOS), and total costs. NCHs cared for 8051 patients (72%) with perforated appendicitis. CHs were more likely to perform a laparoscopy compared to NCHs (odds ratio (OR) 10.2, 95% confidence interval (95% CI) 5.7-18.2), and to utilize CL or PN than NCHs (CL OR 2.4 (95% CI 1.5-3.8), PN OR 2.6 (95% CI 1.4-4.9)). Composite complication rates were lower at CH (OR 0.5 (95% CI 0.4-0.6)). While LOS was not different between CH and NCH in the fully adjusted model, costs were higher at CH (OR 6.8 (95% CI 3.9-12.2)). Low and high outliers could be identified for each variable and outcome of interest with no consistent performance regardless of CH or NCH status. Variation in operative approach, resource use, complications, LOS, and costs exist in the management of pediatric perforated appendicitis with greatest variation observed at NCH. Future quality improvement efforts should be tailored for implementation at both CH and high-volume NCH.
We report a 42-month experience at Egleston Children's Hospital in Atlanta, Ga., with a protocol ... more We report a 42-month experience at Egleston Children's Hospital in Atlanta, Ga., with a protocol under which venovenous extracorporeal membrane oxygenation (ECMO) was used Instead of venoarterlal ECMO. Fifty-five newborn Infants were referred for ECMO, four of whom had disqualifying conditions (all four died). Thirty-one infants were supported without recourse to ECMO, one of whom died. Of the 20 remaining patients, three were placed on a venoarterial EC.MO regimen because of our early uncertainty about the efficacy of venovenous ECMO or because of technical constraints. All other patients (n = 47), Including three with congenital diaphragmatic hernla, were supported with venovenous perfusion. No patient begun on a venovenous ECMO regimen required conversion to venoarterial bypass. Before ECMO, venovenous patients required an average dopamine dose of 46/~g/kg per minute and an average dobutamine dose of 6 ~g/kg per minute. Of 45 patients studied before ECMO, three had significantly Impaired contractility, and all had evidence of pulmonary hypertension on an echocardiogram. Mean blood pressure did not change while heart rate fell from 472 to 446 beats/min during the first 2 hours of ECMO and vasoactlve drug doses were reduced. Of the 47 venovenous ECMO patlents, 45 (88%) survived. We conclude that neonatal patients with severe hypoxla and substantial circulatory compromise can be effectively supported by venovenous ECMO In most cases.
Of the 102 neonates with respiratory failure supported with extracorporeal membrane oxygenation (... more Of the 102 neonates with respiratory failure supported with extracorporeal membrane oxygenation (ECMO) at this institution between 1984 and 1987, 8 patients developed severe myocardial dysfunction that was noted shortly after onset of bypass. The neonates in the cardiac dysfunction group were more hypoxic (average PaO, = 28 t 8 mm Hg v 41 k 19 mm Hg, P < .Ol) in the immediate pre-ECMO period. Seventy-five percent were unstable hemodynamically (8 hypotensive, 3 bradycardic, 2 sustained cardiac arrest, 4 required epinephrine pressor support). On ECMO. 5 of the 8 neonates developed an ischemic cardiomyopathy that lasted for less than 24 hours and resolved without therapeutic intervention. In the other 3 cases, prolonged periods of dysfunction were noted and afterload reduction through administration of tolazoline or hydralazine was beneficial. These 8 patients serve to demonstrate the reversible nature of postischemic cardiac dysfunction in patients on ECMO and in the neonatal population in general.
Recurrent fistulas occur in about 10% of infants treated for esophageal atresia with distal trach... more Recurrent fistulas occur in about 10% of infants treated for esophageal atresia with distal tracheoesophageal fistula. Failed repair of a recurrent fistula rarely requires esophageal replacement and removal or diversion of the native esophagus. We present a patient who underwent multiple operations for recurrent tracheosophageal fistula whose native esophagus was eventually replaced with a colonic interposition graft. Over the subsequent 9 years he experienced failure to thrive, respiratory distress, and repeated pulmonary infections attributed to chronic aspiration. Eventually, he developed respiratory failure and required endotracheal intubation and mechanical ventilation. He became increasingly difficult to ventilate and, in spite of aggressive efforts, suffered a cardiac arrest from which he could not be resuscitated. At postmortem, a dilated blind segment of native esophagus, which was compressing and obstructing the malacic trachea, was found in the posterior mediastinum. Death was caused by massive air embolus, which was in turn attributed to the high airway pressures needed to ventilate the patient. Tracheal compression by a remnant of native esophagus should be considered in the differential diagnosis of respiratory failure after esophageal replacement.
The surgical management of empyema consists of (1) aggressive therapy with thoracotomy and decort... more The surgical management of empyema consists of (1) aggressive therapy with thoracotomy and decortication or (2) conservative treatment with chest tube drainage and intravenous antibiotics. Recently, Kern and Rodgers introduced thoracoscopic debridement as an adjunct to the management of children with empyema, with promising results. Hence, the authors report their experience with thoracoscopy in the management of pediatric patients with empyema. In the last years, 10 children have undergone thoracoscopic debridement (TD) for empyema. The average age was 6.9 years (range, 2 to 16). Children underwent TD an average of 14 days (range, 8 to 16) after initial presentation and 4 days (range, 2 to 6) after admission to the authors&#39; hospital. Indications for TD were persistent requirement of supplemental oxygen and failure of conservative medical management that consisted of antibiotics and tube thoracostomy. Three children had positive pleural fluid cultures for Streptococcus pneumoniae. In all cases, preoperative ultrasound or chest computed tomography examination showed dense pleural fluid with septation. During surgery, TD allowed for lung expansion and precise chest tube placement in all patients except one who required conversion to minithoracotomy and decortication for persistent encasement with a thick pleural peel. There were no postoperative complications related to the procedure. After TD, all children had prompt clinical improvement. The patients were weaned from supplemental oxygen by postoperative day 2, and following early chest tube removal, nine children were discharged home by postoperative day 7 (range, 3 to 10). One child required further hospitalization for underlying renal failure. In the authors&#39; hands, TD was effective in producing prompt clinical improvement in children with empyema.(ABSTRACT TRUNCATED AT 250 WORDS)
The treatment of portal hypertension in the pediatric population has undergone an evolution towar... more The treatment of portal hypertension in the pediatric population has undergone an evolution toward less invasive methods of care. With the advent of endoscopic sclerotherapy, surgery is less common in the acute care of these patients. Few reports deal with the role of portosystemic shunting in the emergent management of variceal hemorrhage in children. To address this issue, the authors studied the medical records of all pediatric patients at their institution who underwent placement of a shunt for portal hypertension during the last 10 years. Nine patients underwent a total of 10 emergent or semiurgent shunting procedures. Seven were boys and two were girls. Six patients had portal hypertension as a result of intrahepatic disease. Two had extrahepatic portal vein thrombosis. Five children had abnormal hepatic function. The median age at the time of the procedure was 9 years. The indication for surgical shunting in all cases was gastrointestinal hemorrhage not responsive to sclerotherapy. Eight patients underwent emergent distal splenorenal shunts (DSRS), and two underwent a nonselective mesocaval shunt, with one undergoing both. Postoperatively all patients had cessation of bleeding. Operative mortality was zero. Early complications included ascites (3), small bowel obstruction (1), and hepatorenal syndrome (1). The child who underwent a nonselective shunt procedure had encephalopathy. Two DSRS thrombosed, requiring reexploration; eight shunts remained patent. Three patients eventually had orthotopic liver transplantation (OLT) because of progressive hepatic failure. Two children died; neither death was shunt related.(ABSTRACT TRUNCATED AT 250 WORDS)
Pancreatic pseudocysts (PPSs) are common sequelae of pancreatitis and pancreatic trauma. The mana... more Pancreatic pseudocysts (PPSs) are common sequelae of pancreatitis and pancreatic trauma. The management is based upon the pseudocyst size and presence of symptoms. Those requiring intervention are often drained using several available options. The use of laparoscopic cystogastrostomy for large and recurrent PPSs has been described in adult patients as a less morbid alternative to open drainage procedures. This technique is considered a novel approach in children. We describe 2 children who had PPSs amenable to laparoscopic cystogastrostomy. The first was an 11-year-old girl who had blunt abdominal trauma from a bicycle handlebar. The second patient was a 7-year-old girl who developed idiopathic pancreatitis. Briefly, 2 ports were placed through the anterior abdominal and gastric walls, and into the lumen of the stomach. This intraluminal placement provided access to the posterior gastric wall. Using electrocautery diathermy, an incision was made through the posterior gastric wall and into the adjacent pseudocyst to obtain complete and unobstructed drainage. Both children tolerated the procedures well with resolution of their PPSs. The patients were each discharged on the fourth postoperative day and have been asymptomatic on 2 years follow-up. Laparoscopic cystogastrostomy is a safe and effective alternative to open cystogastrostomy for the minimally invasive management of PPSs in the pediatric population.
Toronto, Ontario 0 Eleven newborns with pure esophageal atresia were treated between 1980 and 198... more Toronto, Ontario 0 Eleven newborns with pure esophageal atresia were treated between 1980 and 1989 inclusive; there were six girls and five boys. Their gestational age ranged from 31 to 40 weeks (average, 37 weeks) and weight from 1.1 to 3.0 kg (average, 2.2). The only associated anomalies were Down's syndrome, respiratory distress syndrome, and patent ductus arteriosus. All babies received an immediate gastrostomy. Several radiologic studies were done to see if the distance between the two esophageal pouches was decreasing. Dilatations of the upper pouch were carried out in two patients. After a wait of 1 to 7 months (average, 3%) a primary anastomosis was attempted; the weight of six babies doubled during this time. Eight neonates had a primary repair (two were aided by a circular myotomy). Two had a staged gastric tube constructed, and one baby had a gastric pull-up procedure. Three of the infants with a primary anastomosis required a subsequent antireflux operation, and one needed her anastomosis resected 16 months later. Ten of these 11 newborns are alive and well; one of the gastric tube children died from an adhesive small bowel obstruction at age four years. We conclude that: (1) newborns who have a pure esophageal atresie occur at a ratio of one to every 15 neonates with the common type of esophageal atresia and distal tracheoesophageal fistula; (2) there are few associated congenital defects; (3) primary repair is successful in three quarters of such infants if the wait is past 3 months and/or the newborn weight is at least doubled; (4) one third of the primary repair babies will require antireflux surgery within 3 months of the primary anastomosis; and (5) survival rate is over 90%.
Traditional surgical attitude regarding error and complications has focused on individual failing... more Traditional surgical attitude regarding error and complications has focused on individual failings. Human factors research has brought new and significant insights into the occurrence of error in healthcare, helping us identify systemic problems that injure patients while enhancing individual accountability and teamwork. This article introduces human factors science and its applicability to teamwork, surgical culture, medical error, and individual accountability.
Burnout has attained epidemic proportions in all reaches of society. Only recently, has its impac... more Burnout has attained epidemic proportions in all reaches of society. Only recently, has its impact in healthcare become a burning platform. Second victim syndrome, a consequence of an unforeseen adverse event, often precipitated by an error, can lead to a post-traumatic stress-like reaction, that is unique to healthcare workers. Often, the second victim suffers in silence, forced to rely on resilience. Peer support has been demonstrated to be beneficial in assisting healthcare workers in recovering from both burnout and second victim syndrome. Institutions and organizations must be more influential and responsive in supporting physicians and other healthcare workers in need.
Gastroschisis is a periumbilical, abdominal wall defect arising to the right of the umbilicus. We... more Gastroschisis is a periumbilical, abdominal wall defect arising to the right of the umbilicus. We describe the clinical course of a left-sided gastroschisis in a term female born at 39 weeks’ gestation. To our knowledge, there have been only 14 left-sided abdominal wall defects reported in the literature. We discuss our case and review the literature to try to determine if there is any clinic difference between right- versus left-sided lesions to make recommendations as to management.
Aim of the study: Enhanced recovery after surgery (ERAS) protocols have been shown to decrease le... more Aim of the study: Enhanced recovery after surgery (ERAS) protocols have been shown to decrease length of stay (LOS) and complications in adult surgical populations. Our purpose was to compare outcomes before and after implementation of a pediatric-specific ERAS protocol in children undergoing elective colorectal surgery. Methods: A multidisciplinary approach was used to develop a pediatric ERAS protocol that was implemented at a single center between 1/2015-12/2016. A retrospective review was performed including 43 patients (54%) in the pre-ERAS period (2012-2014) and 36 patients (46%) in the post-ERAS period (2015-2016). Outcomes of interest included the number of ERAS elements received, LOS, complications, and readmissions. Main results: The most common diagnosis among study subjects was inflammatory bowel disease (n=70;87%). The pre-ERAS cohort included 17 (40%) ileocecectomies, 16 (37%) partial/total colectomies, 9 (21%) proctectomy and ileo-anal J-pouches, and 1 (2%) ileostomy reversal, while the post-ERAS cohort included 7 (19%) ileocecectomies, 17 (47%) partial/total colectomies, 6 (17%) proctectomy and ileo-anal J-pouches, and 6 (17%) ileostomy reversals. The median number of ERAS elements received per patient increased from 5 the pre-ERAS period to 11 in the post-ERAS period. The median LOS decreased from 5 in 2012 to 3 days in the post-ERAS period(Figure). We observed a decrease in median time to regular diet (2 to 1 day(s);p<0.001), mean dose of intraoperative (0.52 to 0.07 mg/kg;p<0.001) and postoperative narcotics (1.15 to 0.20 mg/kg;p<0.001), and mean volume of intraoperative fluids (9.20 to 5.43 mL/kg/hr;p<0.001) in the post-ERAS period. The complication rate (21% vs. 17%;p=0.85) and the 30-day readmission rate (23% vs. 11%;p=0.63) were not significantly different between the pre-and post-ERAS periods. Conclusions: These preliminary results suggest that implementation of a pediatric ERAS protocol in children undergoing colorectal surgery is feasible, safe and may lead to shorter LOS and improved outcomes without an increase in readmissions.
Our aim was to implement a standardized US report that included secondary signs of appendicitis (... more Our aim was to implement a standardized US report that included secondary signs of appendicitis (SS) to facilitate accurate diagnosis of appendicitis and decrease the use of computed tomography (CT) and admissions for observation. A multidisciplinary team implemented a quality improvement (QI) intervention in the form of a standardized US report and provided stakeholders with monthly feedback. Outcomes including report compliance, CT use, and observation admissions were compared pretemplate and posttemplate. We identified 387 patients in the pretemplate period and 483 patients in the posttemplate period. In the posttemplate period, the reporting of SS increased from 5.4% to 79.5% (p<0.001). Despite lower rates of appendix visualization (43.9% to 32.7%, p<0.001) with US, overall CT use (8.5% vs 7.0%, p=0.41) and the negative appendectomy rate remained stable (1.0% vs 1.0%, p=1.0). CT utilization for patients with an equivocal ultrasound and SS present decreased (36.4% vs 8.9%, ...
To define the incidence of 30-day postdischarge emergency department (ED) visits and hospital rea... more To define the incidence of 30-day postdischarge emergency department (ED) visits and hospital readmissions following pediatric gastrostomy tube (GT) placement across all procedural services (Surgery, Interventional-Radiology, Gastroenterology) in 38 freestanding Children's Hospitals. This retrospective cohort study evaluated patients <18 years of age discharged between 2010 and 2012 after GT placement. Factors significantly associated with ED revisits and hospital readmissions within 30 days of hospital discharge were identified using multivariable logistic regression. A subgroup analysis was performed comparing patients having the GT placed on the date of admission or later in the hospital course. Of 15 642 identified patients, 8.6% had an ED visit within 30 days of hospital discharge, and 3.9% were readmitted through the ED with a GT-related issue. GT-related events associated with these visits included infection (27%), mechanical complication (22%), and replacement (19%). ...
Introduction-Ultrasound (US) is the preferred imaging modality for evaluating appendicitis. Our p... more Introduction-Ultrasound (US) is the preferred imaging modality for evaluating appendicitis. Our purpose was to determine if including secondary signs (SS) improves diagnostic accuracy in equivocal US studies. Methods-Retrospective review identified 825 children presenting with concern for appendicitis and with a right lower quadrant (RLQ) US. Regression models identified which SS were associated with appendicitis. Test characteristics were demonstrated. Results-530 patients (64%) had equivocal US reports. Of 114 (22%) patients with equivocal US undergoing CT, those with SS were more likely to have appendicitis (48.6% vs 14.6%, p<0.001). Of 172 (32%) patients with equivocal US admitted for observation, those with SS were more likely to have appendicitis (61.0% vs 33.6%, p<0.001). SS associated with appendicitis included fluid collection (adjusted odds ratio (OR) 13.3, 95% Confidence Interval (CI) 2.1-82.8), hyperemia (OR=2.0, 95%CI 1.5-95.5), free fluid (OR=9.8, 95%CI 3.8-25.4), and appendicolith (OR=7.9, 95%CI 1.7-37.2). Wall thickness, bowel peristalsis, and echogenic fat were not associated with appendicitis. Equivocal US that included hyperemia, a fluid collection, or an appendicolith had 96% specificity and 88% accuracy.
Improving quality of care logically involves optimizing the duty-readiness and well-being of the ... more Improving quality of care logically involves optimizing the duty-readiness and well-being of the healthcare provider. Medical errors and poor outcomes adversely impact the involved providers, especially surgeons, as well as the patients and their families. Unfortunately our current system does little to support these "second victims" who experience various degrees of emotional and psychological stresses including confusion, loss of confidence, and debilitating anxiety. These factors contribute to the alarmingly high rates of professional "burnout," substance abuse, and suicide of healthcare providers as well as increase the likelihood of subsequent medical errors. Mindful efforts to improve the healthcare culture and develop personal support systems can help surgeons become more resilient, provide higher quality patient care, and have longer productive professional lives. Institutional support systems are also necessary to assist "second victims" to recover from the impact of an adverse patient event.
Variation in care may indicate an opportunity for quality improvement and to decrease waste. Vari... more Variation in care may indicate an opportunity for quality improvement and to decrease waste. Variation in appendicitis practice, resource use, and costs have not been well studied at non-children&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s hospitals (NCHs) where most children undergo care. The purpose of this study was to quantify variation in care for perforated pediatric appendicitis within and between children&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s hospitals (CHs) and NCH. Using the 2012 Kids&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; Inpatient Database, 11,216 children with perforated appendicitis were identified. Comparisons between CH and NCH were made in regard to operative approach (open versus laparoscopic), central line (CL) and total parenteral nutrition (PN) use, complication rates, length of stay (LOS), and total costs. NCHs cared for 8051 patients (72%) with perforated appendicitis. CHs were more likely to perform a laparoscopy compared to NCHs (odds ratio (OR) 10.2, 95% confidence interval (95% CI) 5.7-18.2), and to utilize CL or PN than NCHs (CL OR 2.4 (95% CI 1.5-3.8), PN OR 2.6 (95% CI 1.4-4.9)). Composite complication rates were lower at CH (OR 0.5 (95% CI 0.4-0.6)). While LOS was not different between CH and NCH in the fully adjusted model, costs were higher at CH (OR 6.8 (95% CI 3.9-12.2)). Low and high outliers could be identified for each variable and outcome of interest with no consistent performance regardless of CH or NCH status. Variation in operative approach, resource use, complications, LOS, and costs exist in the management of pediatric perforated appendicitis with greatest variation observed at NCH. Future quality improvement efforts should be tailored for implementation at both CH and high-volume NCH.
We report a 42-month experience at Egleston Children's Hospital in Atlanta, Ga., with a protocol ... more We report a 42-month experience at Egleston Children's Hospital in Atlanta, Ga., with a protocol under which venovenous extracorporeal membrane oxygenation (ECMO) was used Instead of venoarterlal ECMO. Fifty-five newborn Infants were referred for ECMO, four of whom had disqualifying conditions (all four died). Thirty-one infants were supported without recourse to ECMO, one of whom died. Of the 20 remaining patients, three were placed on a venoarterial EC.MO regimen because of our early uncertainty about the efficacy of venovenous ECMO or because of technical constraints. All other patients (n = 47), Including three with congenital diaphragmatic hernla, were supported with venovenous perfusion. No patient begun on a venovenous ECMO regimen required conversion to venoarterial bypass. Before ECMO, venovenous patients required an average dopamine dose of 46/~g/kg per minute and an average dobutamine dose of 6 ~g/kg per minute. Of 45 patients studied before ECMO, three had significantly Impaired contractility, and all had evidence of pulmonary hypertension on an echocardiogram. Mean blood pressure did not change while heart rate fell from 472 to 446 beats/min during the first 2 hours of ECMO and vasoactlve drug doses were reduced. Of the 47 venovenous ECMO patlents, 45 (88%) survived. We conclude that neonatal patients with severe hypoxla and substantial circulatory compromise can be effectively supported by venovenous ECMO In most cases.
Of the 102 neonates with respiratory failure supported with extracorporeal membrane oxygenation (... more Of the 102 neonates with respiratory failure supported with extracorporeal membrane oxygenation (ECMO) at this institution between 1984 and 1987, 8 patients developed severe myocardial dysfunction that was noted shortly after onset of bypass. The neonates in the cardiac dysfunction group were more hypoxic (average PaO, = 28 t 8 mm Hg v 41 k 19 mm Hg, P < .Ol) in the immediate pre-ECMO period. Seventy-five percent were unstable hemodynamically (8 hypotensive, 3 bradycardic, 2 sustained cardiac arrest, 4 required epinephrine pressor support). On ECMO. 5 of the 8 neonates developed an ischemic cardiomyopathy that lasted for less than 24 hours and resolved without therapeutic intervention. In the other 3 cases, prolonged periods of dysfunction were noted and afterload reduction through administration of tolazoline or hydralazine was beneficial. These 8 patients serve to demonstrate the reversible nature of postischemic cardiac dysfunction in patients on ECMO and in the neonatal population in general.
Recurrent fistulas occur in about 10% of infants treated for esophageal atresia with distal trach... more Recurrent fistulas occur in about 10% of infants treated for esophageal atresia with distal tracheoesophageal fistula. Failed repair of a recurrent fistula rarely requires esophageal replacement and removal or diversion of the native esophagus. We present a patient who underwent multiple operations for recurrent tracheosophageal fistula whose native esophagus was eventually replaced with a colonic interposition graft. Over the subsequent 9 years he experienced failure to thrive, respiratory distress, and repeated pulmonary infections attributed to chronic aspiration. Eventually, he developed respiratory failure and required endotracheal intubation and mechanical ventilation. He became increasingly difficult to ventilate and, in spite of aggressive efforts, suffered a cardiac arrest from which he could not be resuscitated. At postmortem, a dilated blind segment of native esophagus, which was compressing and obstructing the malacic trachea, was found in the posterior mediastinum. Death was caused by massive air embolus, which was in turn attributed to the high airway pressures needed to ventilate the patient. Tracheal compression by a remnant of native esophagus should be considered in the differential diagnosis of respiratory failure after esophageal replacement.
The surgical management of empyema consists of (1) aggressive therapy with thoracotomy and decort... more The surgical management of empyema consists of (1) aggressive therapy with thoracotomy and decortication or (2) conservative treatment with chest tube drainage and intravenous antibiotics. Recently, Kern and Rodgers introduced thoracoscopic debridement as an adjunct to the management of children with empyema, with promising results. Hence, the authors report their experience with thoracoscopy in the management of pediatric patients with empyema. In the last years, 10 children have undergone thoracoscopic debridement (TD) for empyema. The average age was 6.9 years (range, 2 to 16). Children underwent TD an average of 14 days (range, 8 to 16) after initial presentation and 4 days (range, 2 to 6) after admission to the authors&#39; hospital. Indications for TD were persistent requirement of supplemental oxygen and failure of conservative medical management that consisted of antibiotics and tube thoracostomy. Three children had positive pleural fluid cultures for Streptococcus pneumoniae. In all cases, preoperative ultrasound or chest computed tomography examination showed dense pleural fluid with septation. During surgery, TD allowed for lung expansion and precise chest tube placement in all patients except one who required conversion to minithoracotomy and decortication for persistent encasement with a thick pleural peel. There were no postoperative complications related to the procedure. After TD, all children had prompt clinical improvement. The patients were weaned from supplemental oxygen by postoperative day 2, and following early chest tube removal, nine children were discharged home by postoperative day 7 (range, 3 to 10). One child required further hospitalization for underlying renal failure. In the authors&#39; hands, TD was effective in producing prompt clinical improvement in children with empyema.(ABSTRACT TRUNCATED AT 250 WORDS)
The treatment of portal hypertension in the pediatric population has undergone an evolution towar... more The treatment of portal hypertension in the pediatric population has undergone an evolution toward less invasive methods of care. With the advent of endoscopic sclerotherapy, surgery is less common in the acute care of these patients. Few reports deal with the role of portosystemic shunting in the emergent management of variceal hemorrhage in children. To address this issue, the authors studied the medical records of all pediatric patients at their institution who underwent placement of a shunt for portal hypertension during the last 10 years. Nine patients underwent a total of 10 emergent or semiurgent shunting procedures. Seven were boys and two were girls. Six patients had portal hypertension as a result of intrahepatic disease. Two had extrahepatic portal vein thrombosis. Five children had abnormal hepatic function. The median age at the time of the procedure was 9 years. The indication for surgical shunting in all cases was gastrointestinal hemorrhage not responsive to sclerotherapy. Eight patients underwent emergent distal splenorenal shunts (DSRS), and two underwent a nonselective mesocaval shunt, with one undergoing both. Postoperatively all patients had cessation of bleeding. Operative mortality was zero. Early complications included ascites (3), small bowel obstruction (1), and hepatorenal syndrome (1). The child who underwent a nonselective shunt procedure had encephalopathy. Two DSRS thrombosed, requiring reexploration; eight shunts remained patent. Three patients eventually had orthotopic liver transplantation (OLT) because of progressive hepatic failure. Two children died; neither death was shunt related.(ABSTRACT TRUNCATED AT 250 WORDS)
Pancreatic pseudocysts (PPSs) are common sequelae of pancreatitis and pancreatic trauma. The mana... more Pancreatic pseudocysts (PPSs) are common sequelae of pancreatitis and pancreatic trauma. The management is based upon the pseudocyst size and presence of symptoms. Those requiring intervention are often drained using several available options. The use of laparoscopic cystogastrostomy for large and recurrent PPSs has been described in adult patients as a less morbid alternative to open drainage procedures. This technique is considered a novel approach in children. We describe 2 children who had PPSs amenable to laparoscopic cystogastrostomy. The first was an 11-year-old girl who had blunt abdominal trauma from a bicycle handlebar. The second patient was a 7-year-old girl who developed idiopathic pancreatitis. Briefly, 2 ports were placed through the anterior abdominal and gastric walls, and into the lumen of the stomach. This intraluminal placement provided access to the posterior gastric wall. Using electrocautery diathermy, an incision was made through the posterior gastric wall and into the adjacent pseudocyst to obtain complete and unobstructed drainage. Both children tolerated the procedures well with resolution of their PPSs. The patients were each discharged on the fourth postoperative day and have been asymptomatic on 2 years follow-up. Laparoscopic cystogastrostomy is a safe and effective alternative to open cystogastrostomy for the minimally invasive management of PPSs in the pediatric population.
Toronto, Ontario 0 Eleven newborns with pure esophageal atresia were treated between 1980 and 198... more Toronto, Ontario 0 Eleven newborns with pure esophageal atresia were treated between 1980 and 1989 inclusive; there were six girls and five boys. Their gestational age ranged from 31 to 40 weeks (average, 37 weeks) and weight from 1.1 to 3.0 kg (average, 2.2). The only associated anomalies were Down's syndrome, respiratory distress syndrome, and patent ductus arteriosus. All babies received an immediate gastrostomy. Several radiologic studies were done to see if the distance between the two esophageal pouches was decreasing. Dilatations of the upper pouch were carried out in two patients. After a wait of 1 to 7 months (average, 3%) a primary anastomosis was attempted; the weight of six babies doubled during this time. Eight neonates had a primary repair (two were aided by a circular myotomy). Two had a staged gastric tube constructed, and one baby had a gastric pull-up procedure. Three of the infants with a primary anastomosis required a subsequent antireflux operation, and one needed her anastomosis resected 16 months later. Ten of these 11 newborns are alive and well; one of the gastric tube children died from an adhesive small bowel obstruction at age four years. We conclude that: (1) newborns who have a pure esophageal atresie occur at a ratio of one to every 15 neonates with the common type of esophageal atresia and distal tracheoesophageal fistula; (2) there are few associated congenital defects; (3) primary repair is successful in three quarters of such infants if the wait is past 3 months and/or the newborn weight is at least doubled; (4) one third of the primary repair babies will require antireflux surgery within 3 months of the primary anastomosis; and (5) survival rate is over 90%.
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