Opioids and Operations Snyder, Charles L
Pediatrics,
01/2018, Volume:
141, Issue:
1
Journal Article
Peer reviewed
Open access
The opioid crisis is currently front-page news. The US leads the world in per capita opioid use as global consumption steadily increases. The percentage of deaths from opioids, fentanyl, and heroin ...is rising year after year. Harbaugh et al used a commercial claims database (Truven Marketscan) to investigate the incidence of persistent opioid use (POU, defined as a filled opioid prescription 3-6 months after an index procedure) in opioid-naive children undergoing 1 of 13 common operations. The incidence of POU was 4.8% in children who had undergone an operation (versus 0.1% in controls who had not undergone an operation), similar to findings reported in adults. The risk factors for POU included female sex, older age, comorbid mental and medical conditions, and a history of previous substance abuse.
Objectives 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. Study design 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. Results 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%). In multivariable analysis, Hispanic ethnicity, non-Hispanic black race, and the presence of ≥3 chronic conditions were independently associated with ED revisits; gastroesophageal reflux and not having a concomitant fundoplication at time of GT placement were independently associated with hospital readmission. Timing of GT placement (scheduled vs late) was not associated with either ED revisits or hospital readmission. Conclusions GT placement is associated with high rates of ED revisits and hospital readmissions in the first 30 days after hospital discharge. The association of nonmodifiable risk factors such as race/ethnicity and medical complexity is an initial step toward understanding this population so that interventions can be developed to decrease these potentially preventable occurrences given their importance among accountable care organizations.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK, ZRSKP
Background
Early plasma transfusion is life‐saving for bleeding trauma patients. Freeze‐dried plasma (FDP) provides unique formulation advantages for infusion in the prehospital setting. We describe ...characterization and clinical safety data of the first, next‐generation FDP stored in plastic bags with rapid reconstitution.
Study design and methods
Coagulation and chemistry parameters on 155 pairs of fresh frozen plasma (FFP) and their derivative FDP units were compared. Next, a first‐in‐human, dose‐escalation safety evaluation of FDP, involving 24 healthy volunteers who donated either whole blood or apheresis plasma to create autologous FDP, was performed in three dose cohorts (270, 540, and 810 ml) and adverse events (AEs) were monitored. Cohort 3 was randomized, double‐blind with a cross‐over arm that compared FDP versus FFP using descriptive analysis for AEs, coagulation, hematology, and chemistry parameters.
Results
FDP coagulation factors, clotting times, and product quality (pH, total protein, and osmolality) post‐lyophilization were preserved. FDP infusions, of up to 810 ml per subject, were found to be safe and with no serious AEs (SAEs) related to FDP. The average time to reconstitute FDP was 67 s (range: 43–106). No differences in coagulation parameters or thrombin activation were detected in subjects infused with 810 ml of FDP compared with FFP.
Conclusion
This first next‐generation FDP product preserves the potency and safety of FFP in a novel rugged, compressible, plastic container, for rapid transfusion, allowing rapid access to plasma in resuscitation protocols for therapy in acute traumatic hemorrhage.
See editorial on page 257–260, in this issue
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BFBNIB, FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SAZU, SBCE, SBMB, UL, UM, UPUK
Pain following bar placement for pectus excavatum is the dominant factor post-operatively and determines length of stay (LOS). We recently adopted intercostal cryoablation as our preferred method of ...pain control following minimally invasive pectus excavatum repair. We compared the outcomes of cryoablation to results of a recently concluded trial of epidural (EPI) and patient-controlled analgesia (PCA) protocols.
We conducted a prospective observational study of patients undergoing bar placement for pectus excavatum using intercostal cryoablation. Results are reported and compared with those of a randomized trial comparing EPI with PCA. Comparisons of medians were performed using Kruskal-Wallis H tests with alpha 0.05.
Thirty-five patients were treated with cryoablation compared to 32 epidural and 33 PCA patients from the trial. Cryoablation was associated with longer operating time (101 min, versus 58 and 57 min for epidural and PCA groups, p < 0.01), resulted in less time to pain control with oral medication (21 h, versus 72 and 67 h, p < 0.01), and decreased LOS (1 day, versus 4.3 and 4.2 days, p < 0.01).
Intercostal cryoablation during minimally invasive pectus excavatum repair reduces LOS and perioperative opioid consumption compared with both EPI and PCA.
II.
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Available for:
GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
8.
Reverend Bayes and Appendicitis Rentea, Rebecca M; Snyder, Charles L
Pediatrics,
02/2020, Volume:
145, Issue:
2
Journal Article
Pediatric appendicitis: state of the art review Rentea, Rebecca M.; Peter, Shawn D. St; Snyder, Charles L.
Pediatric Surgery International,
03/2017, Volume:
33, Issue:
3
Journal Article, Book Review
Peer reviewed
Appendicitis is a common cause of abdominal pain in children. The diagnosis and treatment of the disease have undergone major changes in the past two decades, primarily as a result of the application ...of an evidence-based approach. Data from several randomized controlled trials, large database studies, and meta-analyses have fundamentally affected patient care. The best diagnostic approach is a standardized clinical pathway with a scoring system and selective imaging. Non-operative management of simple appendicitis is a reasonable option in selected cases, with the caveat that data in children remain limited. A minimally invasive (laparoscopic) appendectomy is the current standard in US and European children’s hospitals. This article reviews the current ‘state of the art’ in the evaluation and management of pediatric appendicitis.
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EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OBVAL, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
10.
Neonatal bowel obstruction Juang, David; Snyder, Charles L
The Surgical clinics of North America,
06/2012, Volume:
92, Issue:
3
Journal Article
Peer reviewed
Newborn intestinal obstructions are a common reason for admission to neonatal ICUs. The incidence is estimated to be approximately 1 in 2000 live births. There are 4 cardinal signs of intestinal ...obstruction in newborns: (1) maternal polyhydramnios, (2) bilious emesis, (3) failure to pass meconium in the first day of life, and (4) abdominal distention. The presentation may vary from subtle and easily overlooked findings on physical examination to massive abdominal distention with respiratory distress and cardiovascular collapse. A careful history and physical examination often identify the diagnosis. Concomitant resuscitation (volume, gastric decompression, and ventilatory support) may be necessary.
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