Acute appendicitis is a common condition emergency physician encounter during pediatric emergency visits. With a reported incidence of 1 in 50,000 appendectomies, stump appendicitis, an acute ...inflammation of the residual appendicular tissue, is a rare post-operative complication. The diagnosis of stump appendicitis is time-critical to prevent associated morbidities of abscess formation, perforation and sepsis. Another atypical presentation of appendicitis includes recurrent appendicitis, which is recognized as one or more previous episodes of similar clinical presentation as acute appendicitis, but symptoms subside within 24 to 48 hours. Intervals between attacks may vary from weeks to years during which the patient may be asymptomatic. Although recurrent appendicitis is rare, emergency physicians should be aware of this possibility and to not assume that previous appendectomy precludes recurrent appendicitis. This case highlights the importance of considering such unusual condition in a patient presenting with recurrent right-sided abdominal pain.
Traumatic injury is responsible for eight million childhood deaths annually. In Uganda, there is a paucity of comprehensive data describing the burden of pediatric trauma, which is essential for ...resource allocation and surgical workforce planning. This study aimed to ascertain the burden of non-adolescent pediatric trauma across four Ugandan hospitals.
We performed a descriptive review of four independent and prospective pediatric surgical databases in Uganda: Mulago National Referral Hospital (2012-2019), Mbarara Regional Referral Hospital (2015-2019), Soroti Regional Referral Hospital (SRRH) (2016-2019), and St Mary's Hospital Lacor (SMHL) (2016-2019). We sub-selected all clinical encounters that involved trauma. The primary outcome was the distribution of injury mechanisms. Secondary outcomes included operative intervention and clinical outcomes.
There was a total of 693 pediatric trauma patients, across four hospital sites: Mulago National Referral Hospital (n = 245), Mbarara Regional Referral Hospital (n = 29), SRRH (n = 292), and SMHL (n = 127). The majority of patients were male (63%), with a median age of 5 interquartile range = 2, 8. Chiefly, patients suffered blunt injury mechanisms, including falls (16.2%) and road traffic crashes (14.7%) resulting in abdominal trauma (29.4%) and contusions (11.8%). At SRRH and SMHL, from which orthopedic data were available, 27% of patients suffered long-bone fractures. Overall, 55% of patients underwent surgery and 95% recovered to discharge.
In Uganda, non-adolescent pediatric trauma patients most commonly suffer injuries due to falls and road traffic crashes, resulting in high rates of abdominal trauma. Amid surgical workforce deficits and resource-variability, these data support interventions aimed at training adult general surgeons to provide emergency pediatric surgical care and procedures.
Health care spending in the US remains excessively high. Aside from complicated, large-scale efforts at health care cost reduction, there are still relatively simple ways in which individual ...hospitals can cut unnecessary costs from everyday operations. Inspired by recent publications, our group sought to decrease the costs associated with surgical instrument processing at a large, multihospital academic center.
This was a single-site observational study conducted at a large academic medical center. At the study start, all attending surgeons within the section of pediatric surgery agreed to standardize the pediatric surgery trays and to eliminate instruments that were deemed unnecessary from each tray. A multidisciplinary start-up meeting was held, and this meeting included stakeholders from central sterile processing, operating room nursing, scrub technicians, and materials management along with all five pediatric surgeons. Each tray was addressed individually. Instruments were eliminated from trays only if there was unanimous agreement among all the surgeons in the group. If no instruments in a given surgical tray were deemed necessary, the entire tray was eliminated from sterile processing rotation. Feedback questionnaires were drafted by the multidisciplinary team that participated in the start-up meeting. Surgeons were allowed to request for certain instruments to be placed back into the trays at any time, and the questionnaires also allowed for free-hand comments. Surgical kit preparation time was obtained from the institutional barcode scanning system. The cost per second of sterile processing labor was calculated using regional median salary for sterile processing technicians in the state of Connecticut. Using the pediatric surgery section as the model unit, this method was then applied to pediatric urology, neurosurgery, spine surgery, and orthopedics.
The pediatric surgery section eliminated an average of 59.5% of instruments per tray, resulting in an overall reduction of 1826 (39.5%) instruments from rotation, 45,856 fewer instruments processed per year, and nine trays eliminated completely from regular rotation. Processing time for six commonly used trays was reduced by an average of 28.7%. The urology section eliminated 18 trays from regular rotation and 179 (10.1%) instruments in total. Pediatric orthopedics, neurosurgery, and spine sections eliminated 708 (17.1%), 560 (92.7%), and 31 (32.2%) instruments, respectively, resulting in approximately 18,804 fewer instruments processed per year. Among all five surgical sections, annual instrument cost avoidance after tray optimization was estimated at $53,193 to $531,929 using average instrument life spans ranging from 1-10 y. Negative feedback and requests for instrument replacement were both minimal on feedback questionnaires.
Surgical tray optimization represents a relatively simple microsystem improvement that could result in significant hospital cost reduction. Although difficult to quantify, other gains from surgical kit optimization include decreased weight per tray, decreased materials cost, and decreased labor required to count, decontaminate, and pack surgical trays.
Surgeon overprescription of opioids is a modifiable contributor to the opioid epidemic. No clear guidelines exist for prescribing opioids to younger patients after surgery. We sought to determine ...postoperative opioid needs in pediatric/young adult patients after laparoscopic appendectomy.
Patients 5–20 years old who underwent laparoscopic appendectomy were included for study. All consented patients underwent chart review and were additionally called for an attempted interview. Caregivers were queried on analgesic use and adequacy of pain relief. The main outcome measures were: quantity of opioid used, desire for an opioid, presence of pain ≥4/10, and need for follow-up/call owing to pain. All opioids were converted into morphine milligram equivalents (MME).
Seventy-three patients qualified for the study, 49 of whom completed a postoperative telephone interview. Of the interviewees, 83% did not use or desire an opioid and reported pain <4/10 after discharge. Five patients used an opioid upon discharge, and the average MME consumed was 23 (equivalent to 3 pills of 5 mg oxycodone). No zero-opioid patients had unanticipated follow-up for pain concerns.
After hospital discharge following laparoscopic appendectomy, most patients have adequate analgesia without opioids. Opioid prescriptions should be offered sparingly and for no more than 25 MME.
Level II.
Prognosis study.
Abstract The body of literature addressing surgical and anesthesia care for children in low- and middle-income countries (LMICs) is small. This lack of research hinders full understanding of the ...nature of many surgical conditions in LMICs and compromises potential efforts to alleviate the significant health, welfare and economic burdens surgical conditions impose on children, families and countries. This article will evaluate the need for improved global pediatric surgery research by (1) presenting the current state of surgical research for children in LMICs and (2) discussing methods and opportunities for improvement within the political context of current global health priorities.
Adolescents who use prescription opioids have an increased risk for future drug abuse and overdose, making them a high-risk population. Appendectomy is one of the most common surgical procedures in ...this age group, often requires opioid analgesia, and is performed by both pediatric and general surgeons. Prescription patterns comparing these two provider groups have not yet been evaluated; we hypothesize that general surgery providers prescribe more opioids for adolescent and young adult patients than do pediatric surgery providers.
A retrospective chart review was conducted across a single health system consisting of four hospitals. All uncomplicated laparoscopic appendectomies performed between January 1, 2016 and August 14, 2017 on patients aged 7-20 were included for analysis. Any case coded for multiple procedures, identified as converted to open, or had a length of stay >48 h were excluded. The primary outcome measure was amount of opioid prescribed postoperatively. To standardize different formulations and types of analgesia prescribed, prescriptions were converted into oral morphine equivalents (OMEs). For reference, one 5 mg pill of oxycodone equals 7.5 OME. Linear regression was performed controlling for patient weight, gender, race, insurance status, provider type (pediatric versus general surgery), and provider level (resident, advanced practice provider, and attending).
A total of 336 pediatric laparoscopic appendectomies were analyzed, 148 by general surgeons and 188 by pediatric surgeons. Pediatric surgeons prescribed less opioid than general surgeons overall (59 OME versus 90 OME, P < 0.0001). For patients aged <13 y, there was no significant difference between pediatric (26 OME) and general (37 OME, P = 0.8921) surgeons. However, for the age group 13-20 y, pediatric surgeons prescribed 25% less opioid than general surgeons (90 OME versus 112.5 OME, P < 0.0001). Regression analysis demonstrated that being cared for by a general surgery service (+24.1 OME 95% confidence interval 9.8-38.3) was associated with high prescribing, whereas having Medicaid was associated with lower prescription amounts (−16.4 OME 95% confidence interval −32.5 to −0.3).
After an uncomplicated laparoscopic appendectomy, general surgeons prescribe significantly more opioid to adolescent patients than do pediatric surgeons, even when controlling for age and weight. One substantial and modifiable contributor of the opioid epidemic is the amount of opioid prescribed. The variability of prescribing habits to adolescents and young adults demonstrates a clear need for increased education and guidelines on this topic, especially for surgeons who do not frequently treat the younger and more vulnerable population.
Though evidence-based clinical pathways for the diagnosis and treatment of pediatric appendicitis have been established, protocols guiding management of percutaneous abscess drains are lacking. We ...hypothesized a drain management protocol utilizing drain output and clinical factors instead of fluoroscopic drain studies would reduce interventional radiologic procedures without adversely impacting clinical outcomes.
A standardized protocol was uniformly adopted at a tertiary-care children's hospital in April 2016. A retrospective chart review included all cases of appendicitis requiring abscess drainage by interventional radiology three years pre- and postprotocol implementation.
Fifty-eight patients (preprotocol = 39, postprotocol = 19) underwent percutaneous abscess drainage, of whom 52 (preprotocol = 34, postprotocol = 18) required a drain. Baseline demographics and clinical presentation were similar across groups. Following protocol implementation, total number of IR procedures decreased from 2.4 to 1.3 per patient (p = 0.004). There was no significant difference in the number of postprocedure diagnostic imaging studies, readmissions, or inpatient days, and there was a trend towards a decrease in number of drain days (10.7 to 5.7, p = 0.067).
A standardized protocol for management of abscess drains for complicated appendicitis reduced the number of IR procedures without a negative impact on clinical outcomes or increase in alternative imaging studies. This approach may decrease radiation exposure, anesthetic administration, and resource utilization.
Treatment study (retrospective comparative study).
Level III.
Postnatal evaluation of prenatally identified congenital lung malformations (CLMs) often includes a chest x-ray (CXR) and neonatal intensive care unit (NICU) admission for observation. With current ...efforts aimed at prioritizing value and resource utilization, we sought to assess the utility of this practice in infants with known CLMs. We hypothesized that CXR and NICU admission are overused and could be deferred in the majority of cases.
Clinical and radiographic data for infants with CLM from 2007 to 2016 were reviewed with IRB approval. Regression models were developed for respiratory support (RS), symptoms within 30 days of discharge (Sx30), and abnormal CXR. Predictors included initial symptoms (IS), birth weight (BW), gestational age (GA), cyst-volume-ratio (CVR) and abnormal CXR. Odds ratios (ORs) and ROC curves were generated for significant predictors (p < 0.05).
Fifty-eight infants were identified. Eight were excluded because birth or surgery occurred outside of our institution. Another four were excluded for requiring immediate surgery, leaving forty-six for full analysis. All infants underwent initial CXR and NICU admission, and 22 (47.8%) had an abnormal CXR. Higher CVR (OR = 6.69, p = 0.024) and lower BW (OR = 0.27, p = 0.028) both increased the odds of an abnormal CXR. Applying optimal ROC cutoffs for CVR and BW would have safely eliminated 21 of 46 CXRs, increasing CXR sensitivity from 48% to 68%. For RS and Sx30, no variable, including abnormal CXR, significantly predicted outcomes. Twenty-seven infants (59%) had a NICU stay of <24 h and only three patients (6.8%) developed Sx30.
Both CXR and NICU admission appear to be overused in infants with CLM. CXR result did not predict need for respiratory support or symptoms following discharge, and thus may not aid in the initial evaluation or in the prediction of future care needs. Using CVR and birth weight can guide CXR use and optimize its sensitivity. Need for NICU admission could not be predicted, but a majority of infants spent <24 h in the NICU without intervention, suggesting that NICU admission was likely not needed for all infants in this setting.
Study of diagnostic test, Level II evidence.
Abstract Transverse vaginal septum is a rare, often overlooked congenital abnormality that is typically not diagnosed until adolescence. We present the case of a transverse vaginal septum and partial ...bicornuate uterus in a 16-year-old adolescent girl with developmental delay and cerebral palsy. Magnetic resonance is an excellent diagnostic tool to delineate the specific anatomy before surgery. The effects of delayed diagnosis and the utility of magnetic resonance in diagnosis will be discussed.
Abstract Background Established guidelines for pediatric abdominal CT scans include reduced radiation dosage to minimize cancer risk and the use of intravenous (IV) contrast to obtain the ...highest-quality diagnostic images. We wish to determine if these practices are being used at nonpediatric facilities that transfer children to a pediatric facility. Methods Children transferred to a tertiary pediatric facility over a 16-mo period with abdominal CT scans performed for evaluation of possible appendicitis were retrospectively reviewed for demographics, diagnosis, radiation dosage, CT contrast use, and scan quality. If CT scans were repeated, the radiation dosage between facilities was compared using Student t -test. Results Ninety-one consecutive children transferred from 29 different facilities had retrievable CT scan images and clinical information. Half of CT scans from transferring institutions used IV contrast. Due to poor quality or inconclusive CT scans, 19 patients required a change in management. Children received significantly less radiation at our institution compared to the referring adult facility for the same body area scanned on the same child (9.7 mSv versus 19.9 mSv, P = 0.0079). Conclusion Pediatric facilities may be using less radiation per CT scan due to a heightened awareness of radiation risks and specific pediatric CT scanning protocols. The benefits of IV contrast for the diagnostic yield of pediatric CT scans should be considered to obtain the best possible image and to prevent additional imaging. Every facility performing pediatric CT scans should minimize radiation exposure, and pediatric facilities should provide feedback and education to other facilities scanning children.
