2132 International Abstracts of Pediatric Surgery

Evaluation of a multidisciplinary pediatric mock trauma code Pseudoaneurysm rupture after liver injury in a 14-year-old boy
educational initiative: a pilot study Hacker HW, Schwöbel MG, Allgayer B. Eur J Pediatr Surg 2008 (April);
Mikrogianakis A, Osmond MH, Nuth JE. J Trauma 2008 (March);64/3: 18/2:126-128
761-767
Today, hemodynamically stable children with blunt liver trauma are treated
The purpose of this initiative was to develop and evaluate a multi- conservatively and can be discharged from hospital within 1 week. The authors
disciplinary pediatric mock trauma code orientation program for residents report on a 14-year-old boy with a blunt hepatic trauma grade 3 who showed a
on their pediatric hospital rotation. pseudoaneurysm with active bleeding into the abdominal cavity after
A before and after evaluation of trauma team residents from various mobilization on day 9. Supraselective angiography of the right hepatic artery
programs was conducted. The 1-hour educational session consisted of a 15- was performed, and 2 titanium coils and gelatin sponge particles were placed
minute mock trauma code, a debriefing and teaching intervention, and then a for embolization. In view of this complication, the authors suggest performing
new postintervention mock trauma code. Before and after each session, color Doppler sonography to rule out pseudoaneurysm in children with blunt
residents completed a self-assessment questionnaire. All codes were hepatic trauma before discharge from hospital.—Thomas A. Angerpointner
videotaped and later evaluated by 2 blinded observers using a standardized
evaluation tool to assess patient management and team functioning. doi:10.1016/j.jpedsurg.2008.06.026
Thirty-seven prequestionnaire (pre) and postquestionnaire (post) pairs were
completed. Residents reported a significant improvement in their
(1) comfort in managing pediatric trauma (median pre, 3; post, 5; P b
.001), (2) understanding of their role on the trauma team (median pre, Thorax
4.5; post, 6; P b .001), (3) familiarity with the resuscitation room (median
pre, 4; post, 5; P = .001), (4) comfort with procedural skills (median pre, 4; Early complications of the Nuss procedure for pectus excavatum:
post, 5; P = .001), and (5) awareness of pediatric trauma resuscitation a prospective study
management priorities (median pre, 5; post, 6; P = .007). Postintervention, Castellani C, Schalamon J, Saxena AK. Pediatr Surg Int 2008 (June);
residents reported lower knowledge scores in locating equipment in the 24(6):659-666
resuscitation room (P b .001). There was no significant difference in team
performance on the videotaped assessments (premean score = 79.8,
The Nuss procedure is a minimally invasive method for the correction of
postmean score = 79.5).
pectus excavatum, with several centers reporting its successful applica-
The pediatric mock trauma code educational initiative improved residents'
tion. Complications related to the Nuss procedure are not uncommon, and
self-reported confidence, knowledge, and comfort level in managing
life-threatening complications have been reported. This study focuses on
pediatric trauma. The experience also raised residents' awareness of
the incidence and management of complications in a series of 167
knowledge gaps. We were unable to measure a significant change in team
children and adults with funnel chest corrected by Nuss procedure.
functioning postintervention.—Steven Stylianos
Guidelines and strategies to avoid the most common and typical
complications are proposed. All patients with funnel chest, operated
doi:10.1016/j.jpedsurg.2008.06.024 between April 2000 and 2006, were evaluated prospectively. Our surgical
approach involved the submuscular insertion of the pectus bar under
Malpractice risk: trauma care vs other surgical and medical right-sided thoracoscopic control. The bar was secured in most cases with
specialties one stabilizer on the right side on the underlying rib to prevent bar
displacement. Postoperative pain was primarily managed by epidural
McGwin G, Wilson SL, Bailes J. J Trauma 2008 (March);64/3:607-613
catheters. All data in the patient report forms were prospectively entered
in a database. All complications were documented and classified into
Medical malpractice has been noted to play an important role in physicians'
major or minor complication. A major complication was noted if an organ
decisions to pursue or remain in certain presumed high-risk specialties such
injury occurred or if a significant surgical intervention became necessary.
as trauma surgery despite little evidence suggesting an elevated malpractice
A minor complication was documented if either an endoscopy or an
risk. The objective of this study was to compare the malpractice experience
evacuation of fluid or gas from the thorax by puncture was necessary.
for trauma care and other medical and surgical specialties at an academic
One hundred sixty-seven patients (136 males and 31 females) with a
medical center.
mean age of 16.3 (range, 5-40 years) were included in this study.
Information regarding all potentially compensable medical events (hereafter
Major complications occurred in 7 patients (4.2%) and consisted of one
“events”) and actual lawsuits that occurred between 2003 and 2006 at one
intraoperative heart perforation, one piercing of the liver with the
academic medical institution, including the department or service primarily
trocar, bar infections (n = 2), and significant bar displacement (n = 3).
involved, the current medical-legal disposition of the event, and the actual or
Minor complications were seen in 122 patients (73.1%) and consisted
expected expenses, was obtained. The number of patients admitted to each
of breakage of wires used to secure the lateral stabilizer plate (n = 48),
service and the time they spent in the hospital were also obtained, and the
pleural effusions (n = 28), intraoperative rupture of the intercostal
number of events per capita and length of stay were calculated.
muscle (n = 15), pericardial tears without clinical significance (n = 7),
Among the 13 medical and surgical specialties considered, there were 194
and lung atelectasis (n = 4). Major complications related to the Nuss
total events, 183,392 patients seen, and 757,880 days of hospitalization. The
procedure were rare but preventable and could mainly be attributed to
trauma service had the fewest events and lawsuits per 10,000 patient-days
the learning curve. Most minor complications can be avoided by
and ranked 10th (11th for lawsuits) on a per capita basis and 9th in total
changing the technique, for example, fixation of the bar and the
estimated cost.
stabilizer onto the underlying rib, use of PDS cords instead of metal
With the fewest events and lawsuits per patient-days and a relatively low
wires to fix the bar and the stabilizer, entrance into and exit of the
amount set aside for claims, trauma care has better claim experience than
thorax medial to the rim of the pectus excavatum, and so on. Some
almost every other clinical service line. Although these results have some
complications are related to the technique, such as minor pleural
limitations, they refute the perception that trauma care is a higher
effusion or remaining gas in the thorax. Clear guidelines in regard to
medicolegal risk. This observation should not be cited as a disincentive
the technique are presented to prevent most complications and thereby
for surgeons to provide trauma care.—Steven Stylianos
shorten the learning curve.—Federico G. Seifarth

doi:10.1016/j.jpedsurg.2008.06.025 doi:10.1016/j.jpedsurg.2008.06.027