OBJECTIVE:To assess current clinical outcomes in children with prenatally diagnosed congenital lung malformations (CLMs) and to identify prenatal characteristics associated with adverse outcomes.
...SUMMARY BACKGROUND DATA:Despite a wide spectrum of clinical disease, the identification of fetal CLM subgroups at increased risk for hydrops and respiratory compromise at delivery have not been well defined.
METHODS:A retrospective cohort study was conducted using an operative database of prenatally diagnosed CLMs managed at eleven childrenʼs hospitals from 2009–2016. Statistical analyses were performed using non-parametric bivariate or multivariable logistic regression.
RESULTS:Three hundred forty-four children were analyzed. Fifteen (5.5%) fetuses were managed with maternal steroids in the setting of hydrops, and prenatal surgical intervention was uncommon (1.7%). Seventy-five (21.8%) had respiratory symptoms at birth, and 34 (10.0%) required neonatal lung resection. Congenital pulmonary airway malformation volume ratio (CVR) measurements were recorded in 169 (49.1%) cases and were significantly associated with perinatal outcome, including hydrops, respiratory distress at birth, need for supplemental oxygen, neonatal ventilator use, and neonatal resection (p < 0.001). An initial CVR ≤ 1.4 was significantly correlated with a reduced risk for hydrops area under the curve (AUC), 0.93; 95% confidence interval (CI), 0.87–1.00. A maximum CVR < 0.9 (AUC, 0.72; 95% CI, 0.67–0.85) was associated with a low risk for respiratory symptoms at birth.
CONCLUSION:In this large, multi-institutional study, an initial CVR ≤ 1.4 identifies fetuses at very low risk for hydrops, and a maximum CVR < 0.9 is associated with asymptomatic disease at birth. These findings represent an opportunity for standardization and quality improvement for prenatal counseling and delivery planning.
To review the outcomes of magnet ingestions from two children's hospitals and develop a clinical management pathway.
Children <18years old who ingested a magnet were reviewed from 1/2011 to 6/2016 ...from two tertiary center children's hospitals. Demographics, symptoms, management and outcomes were analyzed.
From 2011 to 2016, there were 89 magnet ingestions (50 from hospital 1 and 39 from hospital 2); 50 (56%) were males. Median age was 7.9 (4.0–12.0) years; 60 (67%) presented with multiple magnets or a magnet and a second metallic co-ingestion. Suspected locations found on imaging were: stomach (53%), small bowel (38%), colon (23%) and esophagus (3%). Only 35 patients (39%) presented with symptoms and the most common symptom was abdominal pain (33%). 42 (47%) patients underwent an intervention, in which 20 (23%) had an abdominal operation. For those undergoing abdominal surgery, an exact logistic regression model identified multiple magnets or a magnet and a second metallic object co-ingestion (OR 12.9; 95% CI, 2.4 – Infinity) and abdominal pain (OR 13.0; 95% CI, 3.2–67.8) as independent risk factors.
Magnets have a high risk of requiring surgical intervention for removal. Therefore, we developed a management algorithm for magnet ingestion.
Level III.
Abstract Background/Purpose Esophageal atresia/tracheoesophageal fistula (EA/TEF) is a rare congenital anomaly lacking contemporary data detailing patient demographics, medical/surgical management ...and outcomes. Substantial variation in the care of infants with EA/TEF may affect both shortand long-term outcomes. The purpose of this study was to characterize the demographics, management strategies and outcomes in a contemporary multi-institutional cohort of infants diagnosed with EA/TEF to identify potential areas for standardization of care. Methods A multi-institutional retrospective cohort study of infants with EA/TEF treated at 11 children's hospitals between 2009 and 2014 was performed. Over the 5 year period, 396 cases were identified in the 11 centers (9 ± 5 per center per year). All infants with a diagnosis of EA/TEF made within 30 days of life had surgical repair of their defect defined as esophageal reconstruction with or without ligation of TEF within the first six months of life. Demographic, operative, and outcome data were collected and analyzed to detect associations between variables. Results Prenatal suspicion or diagnosis of EA/TEF was present in 53 (13%). The most common anatomy was proximal EA with distal TEF (n = 335; 85%) followed by pure EA (n = 27; 7%). Clinically significant congenital heart disease (CHD) was present in 137 (35%). Mortality was 7.5% and significantly associated with CHD (p < 0.0001). Post-operative morbidity occurred in 62% of the population, including 165 (42%) cases with anastomotic stricture requiring intervention, anastomotic leak in 89 (23%), vocal cord paresis/paralysis in 26 (7%), recurrent fistula in 19 (5%), and anastomotic dehiscence in 9 (2%). Substantial variation in practice across our institutions existed: bronchoscopy prior to repair was performed in 64% of cases (range: 0%–100%); proximal pouch contrast study in 21% (0%–69%); use of interposing material between the esophageal and tracheal suture lines in 38% (0%–69%); perioperative antibiotics ≥ 24 h in 69% (36%–97%); transanastomotic tubes in 73% (21%–100%). Conclusion Contemporary treatment of EA/TEF is characterized by substantial variation in perioperative management and considerable post-operative morbidity and mortality. Future studies are planned to establish best practices and clinical care guidelines for infants with EA/TEF. Level of Evidence Type of study: Treatment Study. Level IV
Pediatric appendicitis: state of the art review Rentea, Rebecca M.; Peter, Shawn D. St; Snyder, Charles L.
Pediatric Surgery International,
03/2017, Letnik:
33, Številka:
3
Journal Article, Book Review
Recenzirano
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.
Abstract Purpose Perioperative management of infants with esophageal atresia and tracheoesophageal fistula (EA/TEF) is frequently based on surgeon experience and dogma rather than evidence-based ...guidelines. This study examines whether commonly perceived important aspects of practice affect outcome in a contemporary multi-institutional cohort of patients undergoing primary repair for the most common type of esophageal atresia anomaly, proximal EA with distal TEF. Methods The Midwest Pediatric Surgery Consortium conducted a multi-center, retrospective study examining selected outcomes on infants diagnosed with proximal EA with distal TEF who underwent primary repair over a 5-year period (2009–2014), with a minimum one-year follow up, across 11 centers. Results 292 patients with proximal EA and distal TEF who underwent primary repair were reviewed. The overall mortality was 6% and was significantly associated with the presence of congenital heart disease (OR 4.82, p = 0.005). Post-operative complications occurred in 181 (62%) infants, including: anastomotic stricture requiring intervention (n = 127; 43%); anastomotic leak (n = 54; 18%); recurrent fistula (n = 15; 5%); vocal cord paralysis/paresis (n = 14; 5%); and esophageal dehiscence (n = 5; 2%). Placement of a transanastomotic tube was associated with an increase in esophageal stricture formation (OR 2.2, p = 0.01). Acid suppression was not associated with altered rates of stricture, leak or pneumonia (all p > 0.1). Placement of interposing prosthetic material between the esophageal and tracheal suture lines was associated with an increased leak rate (OR 4.7, p < 0.001), but no difference in the incidence of recurrent fistula (p = 0.3). Empiric postoperative antibiotics for > 24 h was used in 193 patients (66%) with no difference in rates of infection, shock or death when compared to antibiotic use ≤ 24 h (all p > 0.3). Hospital volume was not associated with post-operative complication rates (p > 0.08). Routine postoperative esophagram obtained on day 5 resulted in no delayed/missed anastomotic leaks or a difference in anastomotic leak rate as compared to esophagrams obtained on day 7. Conclusion Morbidity after primary repair of proximal EA and distal TEF patients is substantial, and many common practices do not appear to reduce complications. Specifically, this large retrospective series does not support the use of prophylactic antibiotics beyond 24 h and empiric acid suppression may not prevent complications. Use of a trans-anastomotic tube was associated with higher rates of stricture, and interposition of prosthetic material was associated with higher leak rates. Routine post-operative esophagram can be safely obtained on day 5 resulting in earlier initiation of oral feeds. Study type: Treatment study. Level III evidence.
Evidenced-based guidelines for management of infants and children with community-acquired pneumonia (CAP) were prepared by an expert panel comprising clinicians and investigators representing ...community pediatrics, public health, and the pediatric specialties of critical care, emergency medicine, hospital medicine, infectious diseases, pulmonology, and surgery. These guidelines are intended for use by primary care and subspecialty providers responsible for the management of otherwise healthy infants and children with CAP in both outpatient and inpatient settings. Site-of-care management, diagnosis, antimicrobial and adjunctive surgical therapy, and prevention are discussed. Areas that warrant future investigations are also highlighted.
Evidenced-based guidelines for management of infants and children with community-acquired pneumonia (CAP) were prepared by an expert panel comprising clinicians and investigators representing ...community pediatrics, public health, and the pediatric specialties of critical care, emergency medicine, hospital medicine, infectious diseases, pulmonology, and surgery. These guidelines are intended for use by primary care and subspecialty providers responsible for the management of otherwise healthy infants and children with CAP in both outpatient and inpatient settings. Site-of-care management, diagnosis, antimicrobial and adjunctive surgical therapy, and prevention are discussed. Areas that warrant future investigations are also highlighted.
Abstract Purpose Recent reports suggest that an abbreviated bed rest protocol (ABRP) may safely reduce length of stay (LOS) and resource utilization in pediatric blunt spleen and liver injury (BSLI) ...patients. This study evaluates national temporal trends in BLSI management and estimates national reduction in LOS using an ABRP. Methods Pediatric patients (< 18 years old) sustaining BLSI were identified in the Kids’ Inpatient Database from 2000 to 2009. Yearly rates of injury and operative intervention were examined and stratified by type of injury. APSA guidelines and the reported ABRP were applied based on abbreviated injury score (AIS) and compared with actual LOS. Results 22,153 patients were identified. Over the study period, operative rates for spleen and liver injuries and overall mortality significantly declined: LOS = 3.1 days (± 1.6) and 2.7 days (± 1.9) for spleen and liver, respectively. If APSA guidelines were followed, the rates were LOS = 3.7 days (± 1.1) and 3.4 days (± 0.7), respectively. Application of the ABRP would result in LOS = 1.3 days (± 0.5) for all BSLI patients. An ABRP could potentially save 1.7 hospital days/patient or 36,964 patient hospital days nationally. Conclusion Our study confirms a significant national decrease in operative intervention and overall mortality in patients with BSLI. Additionally, it appears that a shorter observation period than the APSA guidelines is being utilized. The implementation of ABRP holds potential in further reducing LOS and resource utilization.
Pediatric Appendicitis Rentea, Rebecca M; St Peter, Shawn D
The Surgical clinics of North America,
02/2017, Letnik:
97, Številka:
1
Journal Article
Recenzirano
Appendicitis is one of the most common surgical pathologies in children. It can present with right lower quadrant pain. Scoring systems in combination with selective imaging and surgical examination ...will diagnose most children with appendicitis. Clinical pathways should be used. Most surgical interventions for appendicitis are now almost exclusively laparoscopic, with trials demonstrating better outcomes for children who undergo index hospitalization appendectomies when perforated. Nonoperative management has a role in the treatment of both uncomplicated and complicated appendicitis. This article discusses the workup and management, modes of treatment, and continued areas of controversy in pediatric appendicitis.
Abstract Introduction In a previous randomized trial, we found children with perforated appendicitis could be safely discharged prior to completion of a 5 day intravenous antibiotics course. To ...progress the protocol further, patients who met discharge criteria early were discharged without oral antibiotics if leukocyte counts were normal. Methods Children undergoing laparoscopic appendectomy for perforated appendicitis were prospectively observed after institution of a new antibiotic regimen consisting of daily intravenous dosing ceftriaxone/metronidazole while an inpatient. Patients discharged prior to 5 days were discharged home without oral amoxicillin-clavulanate if no leukocytosis at discharge. Outcomes were compared to the previous protocol of daily intravenous ceftriaxone/metronidazole with completion of a 7-day antibiotic course with amoxicillin-clavulanate of all patients discharged prior to 5 days. Results 540 patients (270 new protocol, 270 old protocol) were identified. There was no significant difference in patient demographics, admission leukocyte count, time to regular diet, or length of stay. Postoperative abscess occurred in 21.8% in the new protocol compared to 19.3% of the previous (P = 0.5). There was a significant decrease in the number of patients discharged home on oral antibiotic therapy (P < 0.001). Conclusions Patients meeting discharge criteria with normal leukocyte count prior to completion of 5 days IV antibiotic therapy can be safely discharged home without oral antibiotics after laparoscopic appendectomy for perforated appendicitis.
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