Publications by authors named "Adam M Vogel"

66 Publications

Central venoarterial extracorporeal life support in pediatric refractory septic shock: a single center experience.

Perfusion 2021 Mar 15:2676591211001782. Epub 2021 Mar 15.

Division of Pediatric Critical Care Medicine, Department of Pediatrics, Texas Children's Hospital and Baylor College of Medicine, Houston, TX, USA.

Objective: Venoarterial extracorporeal membrane oxygenation (VA ECMO) is recognized as a potential support therapy for pediatric patients with refractory septic shock (RSS). This review aims to report our experience with central VA cannulation in pediatric patients with RSS, and to compare this with peripheral VA ECMO cannulations for this condition at our institution.

Design: Retrospective case series.

Setting: Pediatric and cardiac intensive care units in an academic pediatric hospital.

Patients: All patients 0-18 years old meeting criteria of RSS placed on VA ECMO between January 2011 and December 2018.

Interventions: None.

Measurements: Demographics, relevant clinical variables, ECMO run details, and outcomes were collected.

Results: Between 2011 and 2018, 14 children were placed on VA ECMO for RSS. Nine were cannulated centrally, with the rest placed on peripheral VA ECMO. Overall survival to hospital discharge was 57.1% (8/14), with 66.7% of the central cannulation cohort surviving versus 40% in the peripheral cannulation (p = 0.34). Median ECMO duration was 147.1 hours (IQR: 91.9-178.6 hours), with survivors having a median length of 147.1 (IQR: 138.5-185.7) versus non survivors 114.7 hours (IQR: 63.7-163.5), p = 0.48. Overall median ICU length of stay (LOS) was 19 days (IQR: 10.5-42.2). The median % maximum flow achieved on VA ECMO was higher in the central cannulation group at 179.6% (IQR: 154.4-188.1) versus the peripheral with 133.5% (98.1-149.1), p = 0.01. Functional status scale (FSS) was used to capture morbidity. All survivors had a mean increase in their FSS from baseline. In the centrally cannulated group, 50% (4/8) received mediastinal exploration, but none developed mediastinitis. In terms of blood product utilization, the central cannulation received more platelets compared to the peripherally cannulated group (median 15.6 vs 3.3 mL/kg/day, p = 0.03).

Conclusion: A central approach to VA ECMO cannulation is feasible and has potential for good patient outcomes in selected patients.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1177/02676591211001782DOI Listing
March 2021

Favorable postoperative outcomes for children with COVID-19 infection undergoing surgical intervention: Experience at a free-standing children's hospital.

J Pediatr Surg 2021 Jan 27. Epub 2021 Jan 27.

Michael E. DeBakey Department of Surgery, Division of Pediatric Surgery, Baylor College of Medicine, Texas Children's Hospital, 6701 Fannin Street, Suite 1210, Houston, TX 77030, United States. Electronic address:

Background: Current literature has shown that adult patients with perioperative Coronavirus Disease-2019 (COVID-19) have increased rates of postoperative morbidity and mortality. We hypothesized that children with COVID-19 have favorable postoperative outcomes compared to the reported adult experience.

Methods: We performed a retrospective cohort study for children with a confirmed preoperative COVID-19 diagnosis from April 1st, 2020 to August 15th, 2020 at a free-standing children's hospital. Primary outcomes evaluated were postoperative complications, readmissions, reoperations, and mortality within 30 days of operation. Secondary outcomes included hospital resource utilization, hospital length of stay, and postoperative oxygen support.

Results: A total of 66 children with preoperative confirmed COVID-19 were evaluated with median age of 9.5 years (interquartile range (IQR) 5-14) with 65% male and 70% Hispanic White. Sixty-five percent of patients had no comorbidities, with abdominal pain identified as the most common preoperative symptom (65%). Twenty-three percent of patients presented with no COVID-19 related symptoms. Eighty-two percent of patients had no preoperative chest imaging and 98% of patients did not receive preoperative oxygen support. General pediatric surgeons performed the majority of procedures (68%) with the most common diagnosis appendicitis (47%). Forty-one percent of patients were discharged the same day as surgery with 9% of patients utilizing postoperative intensive care unit resources and only 5% receiving postoperative invasive mechanical ventilation. Postoperative complications (7%), readmission (6%), and reoperation (6%) were infrequent, with no mortality.

Conclusion: COVID-19+ children requiring surgery have a favorable postoperative course and short-term outcomes compared to the reported adult experience.

Type Of Study: Prognosis Study.

Level Of Evidence: Level IV.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jpedsurg.2021.01.033DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7838581PMC
January 2021

Management of Congenital Diaphragmatic Hernia Treated With Extracorporeal Life Support: Interim Guidelines Consensus Statement From the Extracorporeal Life Support Organization.

ASAIO J 2021 02;67(2):113-120

Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center, Houston and Children's Memorial Hermann Hospital, Houston, Texas.

The management of infants with congenital diaphragmatic hernia (CDH) receiving extracorporeal life support (ECLS) is complex. Significant variability in both practice and prevalence of ECLS use exists among centers, given the lack of evidence to guide management decisions. The purpose of this report is to review existing evidence and develop management recommendations for CDH patients treated with ECLS. This article was developed by the Extracorporeal Life Support Organization CDH interest group in cooperation with members of the CDH Study Group and the Children's Hospitals Neonatal Consortium.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/MAT.0000000000001338DOI Listing
February 2021

Magnet Extraction Through Appendectomy Laparoscopically (METAL) technique as a novel method to manage ingested magnets in children.

Am Surg 2020 Dec 7:3134820954849. Epub 2020 Dec 7.

Division of Pediatric Surgery, Texas Children's Hospital, 3989Baylor College of Medicine, USA.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1177/0003134820954849DOI Listing
December 2020

Safely repositioning dual-lumen ECMO cannulas with a transfemoral lasso snare.

Perfusion 2020 Nov 23:267659120969031. Epub 2020 Nov 23.

Division of Interventional Radiology, Baylor College of Medicine/Texas Children's Hospital, Houston, TX, USA.

Introduction: Dual-lumen cannulas were designed to provide venovenous extracorporeal membrane oxygenation (VV ECMO) with single-vessel access. Anatomic and size considerations may make appropriate placement challenging in children. Dual-lumen cannulas are repositioned in 20-69% of pediatric patients, which can be difficult without transient discontinuation of ECMO support.

Methods: We repositioned three dual-lumen ECMO cannulas introduced via the right internal jugular vein using a transfemoral snare technique under real-time ultrasound and fluoroscopy.

Results: Two of three patients were supported on VV ECMO and one on veno-veno-arterial (VV-A) ECMO. Two of the three patients had their dual-lumen cannula repositioned under ultrasound and fluoroscopy guidance and one was repositioned just with ultrasound. No patient experienced a complication from the transfemoral snare technique such as femoral hematoma, hemorrhage or limb ischemia.

Conclusion: We describe three patients who successfully had dual-lumen cannulas repositioned without cessation of ECMO using a transfemoral "lasso" technique.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1177/0267659120969031DOI Listing
November 2020

Mortality trends in neonatal ECMO for pulmonary hypoplasia: A review of the Extracorporeal Life Support Organization database from 1981 to 2016.

J Pediatr Surg 2020 Sep 16. Epub 2020 Sep 16.

Department of Pediatrics, Section of Neonatology, Baylor College of Medicine/Texas Children's Hospital, Houston, TX, USA.

Background: The purpose of this review is to provide ECMO outcome data for medical personnel who counsel families of patients with pulmonary hypoplasia (PH), often secondary to renal abnormalities. We report diagnoses and outcomes associated with PH in neonates that were treated with ECMO over the past 35 years.

Methods: Retrospective cohort study using the ELSO database for neonates born between 1981 and 2016 with a primary or secondary diagnosis of PH. Five patient groups were created based on ICD-9 codes. Mortality rates were compared and trends over time were investigated.

Results: Thirty-three percent of the 1385 patients survived to discharge. Congenital diaphragmatic hernia (CDH) patients had significantly higher mortality than PH patients secondary to renal dysplasia (p < 0.001). Mortality decreased significantly over time for all groups (p < 0.001). The proportion of patients alive at discharge increased over time for CDH patients (p < 0.001), whereas survival decreased for patients with PH secondary to renal dysplasia (p = 0.012).

Conclusions: Neonates with PH that require ECMO have high mortality rates, which have generally decreased over the past 35 years; however, mortality for neonates with PH secondary to renal dysplasia continues to increase. We speculate that the apparent rise in mortality for these patients is because of changes in patient selection subsequent to improvements in non-ECMO ventilatory support.

Level Of Evidence: II.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jpedsurg.2020.09.005DOI Listing
September 2020

Outcomes After Extracorporeal Life Support Cannulation in Pediatric Patients With Trisomy 13 and Trisomy 18.

J Surg Res 2021 01 27;257:260-266. Epub 2020 Aug 27.

Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas; Department of Pediatric Surgery, Texas Children's Hospital, Houston, Texas. Electronic address:

Background: Indications for extracorporeal life support (ECLS) have evolved and expanded, yet its use in trisomy 13 (T13) and trisomy 18 (T18) patients remains controversial. We reviewed the experience of the Extracorporeal Life Support Organization with ECLS in these patients to inform practice at our institution.

Methods: The Extracorporeal Life Support Organization registry was queried for all patients younger than 18 y with an International Classification of Diseases, Ninth Edition/Tenth Edition code for T13 or T18 from 2000 to 2018. Basic demographics, ECLS details, and clinical outcomes were recorded. Descriptive statistics were performed.

Results: Twenty-eight patients were identified (15 with T13; 13 with T18), representing 0.06% (28 of 46,901) of pediatric ECLS cannulations. The median weight was 3.5 kg (range, 1.4-13), and age at cannulation was 52 d (range, 0 d-6.8 y). Time on ECLS ranged from 13 to 478 h (median, 114). Cardiac defects were diagnosed in 19 (68%) patients, of which 13 (46%) underwent surgical repair. Median oxygenation index pre-ECLS was 45. Venoarterial cannulations accounted for 82% of patients, whereas 14% underwent venovenous cannulation. Overall survival to hospital discharge was 46% with 86% of patients experiencing one or more complications. There were no survivors when cannulation continued past 12 d.

Conclusions: Although complications are frequent, the mortality rate in patients with T13 and T18 remains within the reported range for the general pediatric population. T13 and T18 alone should not be viewed as absolute contraindications to ECLS within the pediatric population but rather considered during the evaluation of a patient's potential candidacy.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jss.2020.07.036DOI Listing
January 2021

Multiple Congenital Esophageal Stenoses in a 15-Month-old Child.

J Pediatr Gastroenterol Nutr 2020 09;71(3):e97

Department of Pediatrics, Section of Pediatric Gastroenterology, Hepatology and Nutrition, Baylor College of Medicine.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/MPG.0000000000002766DOI Listing
September 2020

The economics of a pediatric surgical ICU.

Curr Opin Pediatr 2020 06;32(3):424-427

Surgery and Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA.

Purpose Of Review: The purpose of this review is to describe quality and financial economic principles that form the foundation for complex care delivery systems for the critically ill pediatric surgical population.

Recent Findings: Advances in neonatology along with innovation in surgical techniques in children led to the need to care for more complex postoperative surgical patients. Several studies have demonstrated improved outcomes in specialized pediatric centers. Furthermore, there is some evidence to suggest that there is overall financial benefit with decreased costs and more efficient resource use to pediatric subspecialty critical care.

Summary: As more becomes known regarding the impact of specialized ICU environments, pediatric surgical critical care, and pediatric surgical ICUs have the potential to improve the value of care delivered to these complex patients. Well-designed, prospective, observational studies are needed to assist in defining appropriate outcome and quality measures to inform the development of these specialized units. Currently, there are a variety of models used in children's hospitals to care for critically ill surgical patients. This represents a tremendous opportunity for a collaborative, multidisciplinary effort amongst pediatric medical and surgical intensivists.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/MOP.0000000000000893DOI Listing
June 2020

Timing and volume of crystalloid and blood products in pediatric trauma: An Eastern Association for the Surgery of Trauma multicenter prospective observational study.

J Trauma Acute Care Surg 2020 07;89(1):36-42

From the Division of Pediatric General and Thoracic Surgery (S.F.P., S.M., R.A.F., T.M.J.), Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Le Bonheur Children's Hospital (R.F.W.), Memphis, Tennessee; College of Medicine (M.L.K.), Florida Atlantic University, Boca Raton, Florida and the Palm Beach Children's Hospital, West Palm Beach, Florida; Children's National Medical Center (E.C.A., R.S.B.), Washington, DC; UCHealth Memorial Hospital (T.J.S.), Colorado Springs, Colorado; Loma Linda University (J.E.B., A.M.), Loma Linda, California; Children's Hospital of Richmond (W.B.R., L.A.B.), Virginia Commonwealth University, Richmond, Virginia; Denver Health Medical Center (E.M.C., C.R.), Denver, Colorado; Hennepin Healthcare (R.M.N., C.J.R.), Minneapolis, Minnesota; The Medical University of South Carolina (D.I.G., C.J.S.), Charleston, South Carolina; Wake Forest Baptist Medical Center (M.G., J.K.P.), Brenner Children's Hospital, Winston-Salem, North Carolina; Children's Health Dallas (C.G., S.P.), Dallas, Texas; Children's of Alabama (A.M.W., R.T.R.), Birmingham, Alabama; College of Medicine (B.K.Y., J.M.), University of Florida-Jacksonville, Jacksonville, Florida; Dayton Children's Hospital (J.P.), Dayton, OH; Children's Healthcare of Atlanta (M.T.S.), Atlanta, Georgia; Mayo Clinic (T.M., D.B.K.), Mayo Eugenio Litta Children's Hospital, Rochester, Minnesota; Carilion Children's Hospital (S.D.S., T.T.), Carilion Roanoke Memorial Hospital, Roanoke, Virginia; Texas Children's Hospital (A.M.V., M.C.), Houston, Texas; ProMedica Toledo and Toledo Children's Hospital (C.B.), Toledo, Ohio; Children's Hospital Los Angeles (J.R., R.G.S., A.R.J.), Los Angeles, California; Boston Children's Hospital (B.J.F., D.P.M.), Boston, Massachusetts; Arkansas Children's Hospital (B.K., M.S.D.), Little Rock, Arkansas; and Cooper University Hospital (A.G.-S., J.S.R.), Camden, New Jersey.

Background: The purpose of this study was to determine the relationship between timing and volume of crystalloid before blood products and mortality, hypothesizing that earlier transfusion and decreased crystalloid before transfusion would be associated with improved outcomes.

Methods: A multi-institutional prospective observational study of pediatric trauma patients younger than 18 years, transported from the scene of injury with elevated age-adjusted shock index on arrival, was performed from April 2018 to September 2019. Volume and timing of prehospital, emergency department, and initial admission resuscitation were assessed including calculation of 20 ± 10 mL/kg crystalloid boluses overall and before transfusion. Multivariable Cox proportional hazards and logistic regression models identified factors associated with mortality and extended intensive care, ventilator, and hospital days.

Results: In 712 children at 24 trauma centers, mean age was 7.6 years, median (interquartile range) Injury Severity Score was 9 (2-20), and in-hospital mortality was 5.3% (n = 38). There were 311 patients(43.7%) who received at least one crystalloid bolus and 149 (20.9%) who received blood including 65 (9.6%) with massive transfusion activation. Half (53.3%) of patients who received greater than one crystalloid bolus required transfusion. Patients who received blood first (n = 41) had shorter median time to transfusion (19.8 vs. 78.0 minutes, p = 0.005) and less total fluid volume (50.4 vs. 86.6 mL/kg, p = 0.033) than those who received crystalloid first despite similar Injury Severity Score (median, 22 vs. 27, p = 0.40). On multivariable analysis, there was no association with mortality (p = 0.51); however, each crystalloid bolus after the first was incrementally associated with increased odds of extended ventilator, intensive care unit, and hospital days (all p < 0.05). Longer time to transfusion was associated with extended ventilator duration (odds ratio, 1.11; p = 0.04).

Conclusion: Resuscitation with greater than one crystalloid bolus was associated with increased need for transfusion and worse outcomes including extended duration of mechanical ventilation and hospitalization in this prospective study. These data support a crystalloid-sparing, early transfusion approach for resuscitation of injured children.

Level Of Evidence: Therapeutic, level IV.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/TA.0000000000002702DOI Listing
July 2020

A multidisciplinary approach to VA ECMO cannulation in children.

J Pediatr Surg 2020 Jul 11;55(7):1405-1408. Epub 2020 Mar 11.

Texas Children's Hospital, Department of Pediatric Surgery, Houston, TX. Electronic address:

Purpose: Extracorporeal membrane oxygenation (ECMO) supports gas exchange and circulation in critically ill patients. This study describes a multidisciplinary approach to ECMO cannulation using the expertise of pediatric surgery (PS) and interventional radiology (IR).

Material And Methods: Pediatric patients (<18 years) undergoing percutaneous cannulation for peripheral veno-arterial (VA) ECMO by PS and IR from April 2017 to May 2018 were included. Cardiac patients and children cannulated by PS alone were excluded.

Results: Five patients were included in the series. Median age was 16 [12.5-17] years and 3 were female. Median ECMO arterial and venous catheter sizes were 19 [17-22] Fr and 25 [25-28] Fr, respectively. Both catheters were placed in the common femoral vessels. A 6Fr antegrade distal perfusion cannula (DPC) was also placed in the superficial femoral artery by IR at the time of cannulation. The median time from admission to procedure start was 10 [7-50] hours and the children were on ECMO for a median length of 3.2 [2.3-4.8] days. There were two episodes of bleeding. No patients had loss of limb circulation.

Conclusion: A multidisciplinary approach to peripheral VA ECMO cannulation is feasible and safe. Maintenance of limb perfusion by percutaneous placement and removal of DPC may be an advantage of this collaborative approach.

Level Of Evidence: IV.

Type Of Research: Case series.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jpedsurg.2020.03.001DOI Listing
July 2020

Barely benign: The dangers of BB and other nonpowder guns.

J Pediatr Surg 2020 Aug 19;55(8):1604-1609. Epub 2020 Feb 19.

Division of Pediatric Surgery, Department of Surgery, Baylor College of Medicine and Texas Children's Hospital, Houston, TX. Electronic address:

Objective: To characterize the risks of nonpowder guns commonly used by children for recreation.

Methods: We conducted a retrospective review of children ≤18 years of age treated for nonpowder gun injuries at a pediatric level I trauma center during 2013-2017. Demographics, injury characteristics, treatments, and outcomes were reviewed and analyzed using descriptive statistics.

Results: Forty-six cases were identified; of these, 78% were male and the median age was 10 years (IQR 7-13). All guns were either ball-bearing or pellet guns. Eighty-five percent (38/46) of injuries were penetrating. The most common location was the head and neck (28%), followed by the anterior torso (26%) and eye (24%). Significant injuries that penetrated organs or body cavities occurred in 39% (18/46) and included subarachnoid hemorrhage; lung, liver, and kidney lacerations; pulmonary artery injury; and tracheal injury. Nine percent (4/26) were admitted to the intensive care unit, 37% (17/46) underwent surgery, and there were no deaths.

Discussion: Injuries from recreational nonpowder guns such as ball-bearing or pellet guns can cause severe injuries in children. A thorough penetrating trauma workup should always be undertaken. Safety precautions should be taken when using these guns and access to young children should be restricted.

Level Of Evidence: Prognosis level IV.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jpedsurg.2020.02.010DOI Listing
August 2020

Progression to colectomy in the era of biologics: A single center experience with pediatric ulcerative colitis.

J Pediatr Surg 2020 Sep 3;55(9):1815-1823. Epub 2020 Feb 3.

Department of Pediatric Gastroenterology, Baylor College of Medicine, Texas Children's Hospital, 6701 Fannin St, MW1010, Houston, TX, 77030; USDA/ARS Children's Nutrition Research Center, 1100 Bates Ave, Houston, TX, 77030.

Background/purpose: Clinical outcomes in pediatric ulcerative colitis (UC) in the era of biologic agents are poorly defined. We aimed to describe risk factors for colectomy in pediatric UC in the era of infliximab therapy.

Methods: We reviewed 217 pediatric patients at Texas Children's Hospital with newly diagnosed UC between 2003 and 2015; 117 had a minimum of 5 years of follow-up. Extent of disease at diagnosis, medication exposure, the presence of extraintestinal manifestations (EIMs), and need for surgery were noted.

Results: Average length of follow up was 5.02 ± 2.27 years. Forty-two percent presented with pancolitis. Infliximab was used in 39%, immunomodulators in 65%, and steroids in 89% of patients. EIMs occurred in 24.9% of patients. The cumulative rate of colectomy was 12.9% at 5 years. Children presenting as E2 (Paris Classification) and children prescribed oral steroid monotherapy at diagnosis progressed to surgery faster than any other group. Of the children who received infliximab, females and children less than 5 years old were less likely to respond to therapy.

Conclusions: The natural course of pediatric UC remains aggressive despite the addition of infliximab to the standard of care and suggests a need for early aggressive clinical intervention.

Level-of-evidence Rating: Level IV.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jpedsurg.2020.01.054DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7396289PMC
September 2020

The utility and promise of Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) in the pediatric population: An evidence-based review.

J Pediatr Surg 2020 Oct 1;55(10):2128-2133. Epub 2020 Feb 1.

Texas Children's Hospital, Michael E. DeBakey Department of Surgery, Division of Pediatric Surgery, 6701 Fannin St, Houston, TX, 77030, USA. Electronic address:

Hemorrhage is the main cause of preventable death in both military and civilian trauma, and many of these patients die from non-compressible torso injuries. Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a minimally invasive method used for hemodynamic control of the hemorrhaging patient and has been compared to resuscitative thoracotomy (RT) with cross clamping of the aorta. REBOA has received a great deal of attention in recent years for its applicability and promise in adult trauma and non-trauma settings, but its utility in children is mostly unknown. The purpose of this review article is to summarize and consolidate what is currently known about the use of REBOA in children. Some of the challenges in implementing REBOA in children include small vascular anatomy and lack of outcomes data. Although the evidence is limited, there are established instances in the literature of children and adolescents who have undergone endovascular occlusion of the aorta for hemorrhage control with positive outcomes and survival rates equivalent to their adult counterparts. There is a need for further formal evaluation of REBOA in pediatric patients with prospective studies to look at the safety, feasibility and efficacy of the technique. STUDY TYPE: Narrative Literature Review LEVEL OF EVIDENCE: IV.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jpedsurg.2020.01.052DOI Listing
October 2020

A Multicenter Study of Nutritional Adequacy in Neonatal and Pediatric Extracorporeal Life Support.

J Surg Res 2020 05 8;249:67-73. Epub 2020 Jan 8.

LeBonheur Children's Hospital, Memphis, Tennessee.

Background: Malnutrition in critically ill patients is common in neonates and children, including those that receive extracorporeal life support (ECLS). We hypothesize that nutritional adequacy is highly variable, overall nutritional adequacy is poor, and enteral nutrition is underutilized in this population.

Materials And Methods: A retrospective study of neonates and children (age<18 y) receiving ECLS at 5 centers from 2012 to 2014 was performed. Demographic, clinical, and outcome data were analyzed. Continuous variables are presented as median [IQR]. Adequate nutrition was defined as meeting 66% of daily caloric goals during ECLS support.

Results: Two hundred and eighty three patients received ECLS; the median age was 12 d [3 d, 16.4 y] and 47% were male. ECLS categories were neonatal pulmonary 33.9%, neonatal cardiac 25.1%, pediatric pulmonary 17.7%, and pediatric cardiac 23.3%. The predominant mode was venoarterial (70%). Mortality was 41%. Pre-ECLS enteral and parenteral nutrition was present in 80% and 71.5% of patients, respectively. The median percentage days of adequate caloric and protein nutrition were 50% [0, 78] and 67% [22, 86], respectively. The median percentage days with adequate caloric and protein nutrition by the enteral route alone was 22% [0, 65] and 0 [0, 50], respectively. Gastrointestinal complications occurred in 19.7% of patients including hemorrhage (4.2%), enterocolitis (2.5%), intra-abdominal hypertension or compartment syndrome (0.7%), and perforation (0.4%).

Conclusions: Although nutritional delivery during ECLS is adequate, the use of enteral nutrition is low despite relatively infrequent observed gastrointestinal complications.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jss.2019.11.018DOI Listing
May 2020

The significance of abdominal radiographs with paucity of gas in pediatric adhesive small bowel obstruction.

Am J Surg 2020 07 29;220(1):208-213. Epub 2019 Oct 29.

Department of Pediatric Surgery, Texas Children's Hospital, 6701 Fannin Street, #1210, Houston, TX, 77030, USA. Electronic address:

Purpose: Management of children with adhesive small bowel obstruction (ASBO) is often based on abdominal radiographs (AXR). Our purpose was to determine the significance of paucity of gas on initial AXR.

Methods: Retrospective, single center review of children with ASBO between 2011 and 2015. Analysis included chi-square, non-parametric tests and multivariate regression.

Results: Of 207 cases, 99 were operative. Initial AXR showed paucity of gas in 41% and gaseous loops in 59%. Paucity was more common in operative patients (49% vs. 32%, p = 0.01). At operation, 71% of patients with paucity had closed loop or high-grade obstruction, compared to 29% of patients with gaseous loops (p = <0.001).

Conclusion: For children with ASBO with paucity of gas on AXR, complicated obstruction (closed loop or high-grade) should be considered. In children with high clinical suspicion of complicated obstruction, additional imaging with CT or SBFT may clarify the clinical picture.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.amjsurg.2019.10.035DOI Listing
July 2020

Synthetic biology for improving cell fate decisions and tissue engineering outcomes.

Emerg Top Life Sci 2019 Nov;3(5):631-643

Department of Biomedical Engineering, University of Utah, Salt Lake City, UT 84112, U.S.A.

Synthetic biology is a relatively new field of science that combines aspects of biology and engineering to create novel tools for the construction of biological systems. Using tools within synthetic biology, stem cells can then be reprogrammed and differentiated into a specified cell type. Stem cells have already proven to be largely beneficial in many different therapies and have paved the way for tissue engineering and regenerative medicine. Although scientists have made great strides in tissue engineering, there still remain many questions to be answered in regard to regeneration. Presented here is an overview of synthetic biology, common tools built within synthetic biology, and the way these tools are being used in stem cells. Specifically, this review focuses on how synthetic biologists engineer genetic circuits to dynamically control gene expression while also introducing emerging topics such as genome engineering and synthetic transcription factors. The findings mentioned in this review show the diverse use of stem cells within synthetic biology and provide a foundation for future research in tissue engineering with the use of synthetic biology tools. Overall, the work done using synthetic biology in stem cells is in its early stages, however, this early work is leading to new approaches for repairing diseased and damaged tissues and organs, and further expanding the field of tissue engineering.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1042/ETLS20190091DOI Listing
November 2019

Bleeding Assessment Scale in Critically Ill Children (BASIC): Physician-Driven Diagnostic Criteria for Bleeding Severity.

Crit Care Med 2019 12;47(12):1766-1772

Division of Pediatric Critical Care Medicine, Department of Pediatrics, Children's Hospital of Richmond at VCU, Richmond, VA.

Objective: Although bleeding frequently occurs in critical illness, no published definition to date describes the severity of bleeding accurately in critically ill children. We sought to develop diagnostic criteria for bleeding severity in critically ill children.

Design: Delphi consensus process of multidisciplinary experts in bleeding/hemostasis in critically ill children, followed by prospective cohort study to test internal validity.

Setting: PICU.

Patients: Children at risk of bleeding in PICUs.

Interventions: None.

Measurements And Main Results: Twenty-four physicians worldwide (10 on a steering committee and 14 on an expert committee) from disciplines related to bleeding participated in development of a definition for clinically relevant bleeding. A provisional definition was created from 35 descriptors of bleeding. Using a modified online Delphi process and conference calls, the final definition resulted after seven rounds of voting. The Bleeding Assessment Scale in Critically Ill Children definition categorizes bleeding into severe, moderate, and minimal, using organ dysfunction, proportional changes in vital signs, anemia, and quantifiable bleeding. The criteria do not include treatments such as red cell transfusion or surgical interventions performed in response to the bleed. The definition was prospectively applied to 40 critically ill children with 46 distinct bleeding episodes. The kappa statistic between the two observers was 0.74 (95% CI, 0.57-0.91) representing substantial inter-rater reliability.

Conclusions: The Bleeding Assessment Scale in Critically Ill Children definition of clinically relevant bleeding severity is the first physician-driven definition applicable for bleeding in critically ill children derived via international expert consensus. The Bleeding Assessment Scale in Critically Ill Children definition includes clear criteria for bleeding severity in critically ill children. We anticipate that it will facilitate clinical communication among pediatric intensivists pertaining to bleeding and serve in the design of future epidemiologic studies if it is validated with patient outcomes.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/CCM.0000000000004025DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6861687PMC
December 2019

Prenatal Imaging Features and Postnatal Factors Associated with Gastrointestinal Morbidity in Congenital Diaphragmatic Hernia.

Fetal Diagn Ther 2020 21;47(4):252-260. Epub 2019 Aug 21.

Texas Children's Fetal Center, Texas Children's Hospital and the Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA,

Background: To perform a comprehensive assessment of postnatal gastrointestinal (GI) morbidity and determine the prenatal imaging features and postnatal factors associated with its development in patients with congenital diaphragmatic hernia (CDH).

Materials And Methods: A retrospective review was conducted of all infants evaluated for CDH at a quaternary fetal center from February 2004 to May 2017. Prenatal imaging features and postnatal variables were analyzed. GI morbidity was the primary outcome. The Mann-Whitney U test, the Kruskal-Wallis test with Dunnett's T3 post hoc analysis and logistic regression, and the χ2 test were performed when appropriate.

Results: We evaluated 256 infants; 191 (75%) underwent CDH repair and had at least 6 months of follow-up. Of this cohort, 60% had gastroesophageal reflux disease (GERD), 13% had gastroparesis, 32% received a gastrostomy tube (G-tube), and 17% needed a fundoplication. Large defect, patch repair, extracorporeal membrane oxygenation (ECMO), and prolonged use of mechanical ventilation were significantly associated with having GERD, gastroparesis, G-tube placement, and fundoplication (p < 0.05). Fetuses with stomach grades 3 and 4 were most likely to have GERD, a G-tube, and a long-term need for supplemental nutrition than fetuses with stomach grades 1 and 2 (p < 0.05).

Conclusion: Survivors of CDH with large defects, prolonged use of mechanical ventilation, or that have received ECMO may be at an increased risk for having GERD, gastroparesis, and major GI surgery. Marked stomach displacement on prenatal imaging is significantly associated with GI morbidity in left-sided CDH.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1159/000501555DOI Listing
January 2021

Management and outcomes of peripancreatic fluid collections and pseudocysts following non-operative management of pancreatic injuries in children.

Pediatr Surg Int 2019 Aug 3;35(8):861-867. Epub 2019 Jun 3.

Department of Surgery, Baylor College of Medicine, 6701 Fannin Street # 1210, Houston, TX, 77030, USA.

Background: Peripancreatic fluid collection and pseudocyst development is a common sequela following non-operative management (NOM) of pancreatic injuries in children. Our purpose was to review management strategies and assess outcomes.

Methods: A multicenter, retrospective review was conducted of children treated with NOM following blunt pancreatic injury at 22 pediatric trauma centers between the years 2010 and 2015. Organized fluid collections were called "acute peripancreatic fluid collection" (APFC) if identified < 4 weeks and "pseudocyst" if > 4 weeks following injury. Data analysis included descriptive statistics Wilcoxon rank-sum, Kruskal-Wallis and t tests.

Results: One hundred patients with blunt pancreatic injury were identified. Median age was 8.5 years (range 1-16). Forty-two percent of patients (42/100) developed organized fluid collections: APFC 64% (27/42) and pseudocysts 36% (15/42). Median time to identification was 12 days (range 7-42). Most collections (64%, 27/42) were observed and 36% (15/42) underwent drainage: 67% (10/15) percutaneous drain, 7% (1/15) needle aspiration, and 27% (4/15) endoscopic transpapillary stent. A definitive procedure (cystogastrostomy/pancreatectomy) was required in 26% (11/42). Patients with larger collections (≥ 7.1 cm) had longer time to resolution. Comparison of outcomes in patients with observation vs drainage revealed no significant differences in TPN use (79% vs 75%, p = 1.00), hospital length of stay (15 vs 25 median days, p = 0.11), time to tolerate regular diet (12 vs 11 median days, p = 0.47), or need for definitive procedure (failure rate 30% vs 20%, p = 0.75).

Conclusions: Following NOM of blunt pancreatic injuries in children, organized fluid collections commonly develop. If discovered early, most can be observed successfully, and drainage does not appear to improve clinical outcomes. Larger size predicts prolonged recovery.

Level Of Evidence: III STUDY TYPE: Case series.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s00383-019-04492-3DOI Listing
August 2019

Understanding non-accidental trauma in the United States: A national trauma databank study.

J Pediatr Surg 2020 Apr 9;55(4):693-697. Epub 2019 May 9.

Department of Pediatric Surgery, Texas Children's Hospital and Baylor College of Medicine, Houston, TX. Electronic address:

Background: The purpose of this study is to characterize the epidemiology, injury patterns, outcomes and trends of non-accidental trauma (NAT) in the United States using a large national database.

Methods: Children <15 years presenting after NAT were identified in the 2007-2014 National Trauma Databank research datasets. Clinical and outcome data were analyzed using descriptive statistics, chi-square and logistic regression.

Results: Of 678,503 children admitted for traumatic injuries, 3% (19,149) were victims of NAT. The majority (95%) were under 5 years and 71% under 1 year old. The majority (59%) were male. The median injury severity score (ISS) was 10 (IQR:5-19). African Americans were disproportionally affected (27% vs 17% of all traumas), and the majority had public or no insurance (85%). Incidence was highest in the midwest and lowest in the northeast regions of the country, although trends varied over time. NAT resulted in 43% of trauma deaths in children <1 year and 31% of trauma deaths in children <5. Traumatic brain injury (TBI) was the most commonly encountered diagnosis (50%). Polytrauma was common, and certain injury patterns were identified. Urgent operation was required in 6%, 43% were admitted to intensive care, and 9% died. Mortality was independently associated with TBI, thoracic injury, hollow viscus injury and older age.

Conclusion: Non-accidental trauma is a leading cause of trauma mortality in young children. Multiple injuries are common, requiring comprehensive evaluation and early surgical involvement. The data presented in this study could serve as a guide to target injury prevention efforts.

Level Of Evidence: III STUDY TYPE: Prognostic and Epidemiological.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jpedsurg.2019.03.024DOI Listing
April 2020

Fetal echocardiography (ECHO) in assessment of structural heart defects in congenital diaphragmatic hernia patients: Is early postnatal ECHO necessary for ECMO candidacy?

J Pediatr Surg 2019 May 20;54(5):920-924. Epub 2019 Feb 20.

Texas Children's Fetal Center, Baylor College of Medicine, Texas Children's Hospital, Houston, TX; Michael E. DeBakey Department of Surgery-Division of Pediatric Surgery, Baylor College of Medicine, Texas Children's Hospital, Houston, TX. Electronic address:

Purpose: The purpose of this study was to determine the accuracy of fetal echocardiogram (ECHO) for detecting cardiac structural anomalies that may impact Extracorporeal Membrane Oxygenation (ECMO) candidacy in infants with Congenital Diaphragmatic Hernia (CDH).

Methods: A retrospective review was performed on fetuses with CDH (January 2007-June 2017). Inclusion criteria were inborn and at least one prenatal and postnatal ECHO. ECHOs were evaluated for structural heart defects. Primary outcomes were accuracy of prenatal fetal ECHO and identify differences between prenatal and postnatal ECHO. Descriptive statistics and Chi-square analysis were performed.

Results: 131 inborn patients were identified. Mean gestational age of fetal ECHO was 26.6 ± 5.5 weeks. The median time to postnatal ECHO was DOL 1 [0-30]. Fetal ECHO had 92% accuracy, 83% sensitivity, 93% specificity, PPV of 95%, NPV of 92%, and a 90% accuracy for visualization of at least one pulmonary vein into the left atrium on the contralateral (non-CDH) side. Thirty-five percent of patients received ECMO, and 26% had an associated cardiac anomaly. All ECMO patients had an accurate structural fetal ECHO.

Conclusion: Fetal ECHO is sufficient for identifying major structural heart defects at large volume centers with trained pediatric cardiologists and may be used to guide clinical management, particularly in regards to ECMO candidacy.

Level Of Evidence: Level III.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jpedsurg.2019.01.022DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6709683PMC
May 2019

The value of failure to rescue in determining hospital quality for pediatric trauma.

J Trauma Acute Care Surg 2019 10;87(4):794-799

From the Department of Pediatric Surgery (E.H.R., B.J., S.R.S., A.M.V., B.N-M.), and Outcomes & Impact Services (W.Z.), Texas Children's Hospital and Baylor College of Medicine, Houston, Texas.

Background: In adult trauma patients, high- and low-mortality trauma hospitals have similar rates of major complications but differ based on failure to rescue (mortality following a major complication), which has become a marker of hospital quality. The aim of this study is to examine whether failure to rescue is also an appropriate hospital quality indicator in pediatric trauma.

Methods: Children younger than 15 years were identified in the 2007 to 2014 National Trauma Databank research data sets. Hospitals were classified as a high, average or low mortality based on risk-adjusted observed-to-expected in-hospital mortality ratios using the modified Trauma Mortality Probability Model. Regression modeling was used to explore the impact of hospital quality ranking on the incidence of major complications and failure to rescue.

Results: Of 125,057 children, 31,600 were treated at low-mortality outlier hospitals, and 7,014 at high-mortality outlier hospitals. Low-mortality hospitals had a lower rate of major complications compared with high-mortality hospitals (0.5% [low] vs. 0.8% [high]; adjusted odds ratio [OR], 0.71; 95% confidence interval [CI], 0.61-0.83; p < 0.01) and a lower failure-to-rescue rate (17.6% [low] vs. 24.1% [high]; adjusted OR, 0.53 [high; 95% CI 0.34-0.83; p < 0.01]). When patients who died within 48 hours were excluded, low-mortality hospitals had a lower complication rate (OR, 0.81; 95% CI, 0.68, 0.96; p = 0.02), but similar failure-to-rescue rate compared to high-mortality hospitals. There was no correlation between trauma verification level and hospital mortality status based on the model.

Conclusion: For pediatric trauma patients, mortality is more strongly associated with major complication rate than with failure to rescue. Thus, failure to rescue does not appear to be the key driver of hospital quality in this population as it does in the adult trauma population.

Level Of Evidence: Prognostic and epidemiological, level III.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/TA.0000000000002240DOI Listing
October 2019

Analgesia, sedation, and delirium in pediatric surgical critical care.

Semin Pediatr Surg 2019 Feb 18;28(1):33-42. Epub 2019 Jan 18.

Texas Children's Hospital, Division of Pediatric Surgery, Department of Surgery, 6701 Fannin Street, Houston, TX 77030, USA; Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX 77030, USA. Electronic address:

The alleviation of discomfort and distress is an essential component of the management of critically ill surgical patients. Pain and anxiety have multifocal etiologies that may be related to an underlying disease or surgical procedure, ongoing medical therapy, invasive monitors, an unfamiliar, complex and chaotic environment, as well as fear. Pharmacologic and non-pharmacologic therapies have complex risk benefit profiles. A fundamental understanding of analgesia, sedation, and delirium is essential for optimizing important outcomes in critically ill pediatric surgical patients. There has been a recent emphasis on goal directed, evidence based, and patient-centered management of the physical and psychological needs of these children. The purpose of this article is to review and summarize recent advances and describe current practice of these important subjects in the pediatric surgical intensive care environment.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1053/j.sempedsurg.2019.01.006DOI Listing
February 2019

Bowel preparation for colostomy reversal in children.

J Pediatr Surg 2019 May 2;54(5):1045-1048. Epub 2019 Feb 2.

Department of Pediatric Surgery, Texas Children's Hospital and Baylor College of Medicine, Houston, TX. Electronic address:

Purpose: Pediatric bowel preparation protocols used before colostomy reversal vary. The aim of this study is to determine institutional practices at our institution and evaluate the impact of bowel preparations on postoperative outcomes and hospital length of stay in children.

Methods: This was a retrospective review of children ≤18 years old undergoing colostomy reversal at Texas Children's Hospital (TCH) between 12/2013 and 8/2017. Preoperative bowel regimens and outcomes were collected and analyzed using descriptive statistics, Wilcoxon Rank-Sum and Fishers Exact tests. Continuous variables are presented as median [IQR].

Results: Sixty-one children underwent colostomy reversal. Thirty-eight (62%) did not receive a preoperative bowel preparation. The two cohorts were similar in age, gender, and race. The most common indication for colostomy was anorectal malformation for thirty-seven (61%). Time from admission to surgery (19 h [17, 23] vs 3 [2, 3]; p < 0.01) and HLOS (6 days [5, 8] vs 5 [4, 6]; p = 0.02) were both longer in the bowel preparation cohort. Complications (3 [13%] vs 5 [22%]; p = 0.12) and 90-day readmissions (3 [13%] vs 6 [16%]; p = 0.64) were similar in both cohorts.

Conclusion: Foregoing bowel preparation may have the potential to improve cost and reduce morbidity in children undergoing colostomy closure.

Level Of Evidence: III.

Study Type: Treatment study.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jpedsurg.2019.01.037DOI Listing
May 2019

Sternal fractures in children: An analysis of the National Trauma Data Bank.

J Pediatr Surg 2019 May 31;54(5):980-983. Epub 2019 Jan 31.

Department of Pediatric Surgery, Texas Children's Hospital and Baylor College of Medicine, Houston, TX. Electronic address:

Purpose: The purpose of this study was to describe the epidemiology and evaluate the clinical significance of traumatic sternal fractures.

Methods: Patients age ≤18 years with sternal fractures in the National Trauma Database research datasets from 2007-2014 were identified. Patient demographics, injuries, procedures, and outcomes were analyzed using descriptive statistics and logistic regression.

Results: Three thousand one hundred sixty patients with sternal fracture were identified. Ninety percent of injuries occurred in patients between 12 and 18 years old. Median injury severity score (ISS) was 17 [9,29]. Exploratory thoracotomy was performed in 1%. Thirty-nine percent were admitted to the intensive care unit (ICU). On multivariate regression, predictors of ICU stay >1 day were increasing ISS, lack of the use of protective devices, decreasing Glasgow Coma Score (GCS), tachycardia, and pulmonary contusion. Median hospital length of stay was 4 [2, 9] days. In-hospital mortality was 8%. Predictors of mortality were lower GCS, increasing ISS, decreasing oxygen saturation, hypotension, and cardiac arrest. Use of protective devices and seat belts did not affect mortality.

Conclusion: Sternal fractures in patients increase in incidence with age, and poor outcomes are impacted by associated injuries and complications. The presence of a sternal fracture should trigger a careful diagnostic evaluation.

Level Of Evidence: III STUDY TYPE: Treatment Study.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jpedsurg.2019.01.031DOI Listing
May 2019

Defining massive transfusion in civilian pediatric trauma.

J Pediatr Surg 2019 May 31;54(5):975-979. Epub 2019 Jan 31.

Department of Pediatric Surgery, Texas Children's Hospital and Baylor College of Medicine, Houston, TX. Electronic address:

Purpose: The purpose of this study was to identify an optimal definition of massive transfusion (MT) in civilian pediatric trauma.

Methods: Severely injured children (age ≤18 years, injury severity score ≥25) in the Trauma Quality Improvement Program research datasets 2014-2015 that received blood products were identified. Children with traumatic brain injury and non-survivable injuries were excluded. Early mortality was defined as death within 24 h and delayed mortality as death after 24 h from hospital admission. Receiver operating curves and sensitivity and specificity analysis identified an MT threshold. Continuous variables are presented as median [IQR].

Results: Of the 270 included children, the overall mortality was 27% (N = 74). There were no differences in demographics or mechanism of injury between children that lived or died. Sensitivity and specificity for early mortality was optimized at a 4-h transfusion volume of 37 ml/kg. After controlling for other significant variables, a threshold of 37 ml/kg/4 h predicted the need for a hemorrhage control procedure (OR 8.60; 95% CI 4.25-17.42; p < 0.01) and early mortality (OR 4.24; 95% CI 1.96-9.16; p < 0.01).

Conclusion: An MTP threshold of 37 mL/kg/4 h of transfused blood products predicted the need for hemorrhage control procedures and early mortality. This threshold may provide clinicians with a timely prognostic indicator, improve research methodology, and resource utilization.

Type Of Study: Diagnostic Test.

Level Of Evidence: III.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jpedsurg.2019.01.029DOI Listing
May 2019

Defining Massive Transfusion in Civilian Pediatric Trauma With Traumatic Brain Injury.

J Surg Res 2019 04 4;236:44-50. Epub 2018 Dec 4.

Department of Pediatric Surgery, Texas Children's Hospital and Baylor College of Medicine, Houston, Texas. Electronic address:

Background: The purpose of this study was to identify an optimal definition of massive transfusion in civilian pediatric trauma with severe traumatic brain injury (TBI) METHODS: Severely injured children (age ≤18 y) with severe TBI in the Trauma Quality Improvement Program research data sets 2015-2016 that received blood products were identified. Data were analyzed using descriptive statistics, Wilcoxon rank-sum, chi-square, and logistic regression. Continuous variables are presented as median (interquartile range). Massive transfusion thresholds were determined based on receiver operating curves and optimization of sensitivity and specificity RESULTS: Of the 460 included children, the mortality rate was 43%. There were no differences in demographics, heart rate at presentation, or injury severity score between children that lived or died. However, those who died had lower Glasgow coma scores (3 [3, 8] versus 3 [3, 3]; P < 0.01), were more likely to have had a penetrating injury (20% versus 11%; P < 0.01) and were more likely to be hypotensive for age (62% versus 34%; P < 0.01). Total blood products infused were greater in those who died (34 mL/kg/4-h [17, 65] versus 22 [12, 44]; P < 0.01). Sensitivity and specificity for delayed mortality was optimized at 40 mL/kg/4 h, and for the need for a hemorrhage control procedure at 50 mL/kg/4 h. These thresholds predicted delayed mortality (OR 2.12; 95% CI 1.28-3.50; P < 0.01) and the need for hemorrhage control procedures (5.47; 95% CI 2.82-10.61; P < 0.01) CONCLUSIONS: For children with TBI, a massive transfusion threshold of 40 mL/kg/4-h of total administered blood products may be used to identify at-risk patients, improve resource utilization, and guide future research methodology.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jss.2018.10.053DOI Listing
April 2019

A High Ratio of Plasma: RBC Improves Survival in Massively Transfused Injured Children.

J Surg Res 2019 01 31;233:213-220. Epub 2018 Aug 31.

Department of Pediatric Surgery, Texas Children's Hospital, Houston, Texas. Electronic address:

Background: Massive transfusion protocols with balanced blood product ratios have been associated with improved outcomes in adult trauma. The impact on pediatric trauma is unclear.

Material And Methods: A retrospective review of the Pediatric Trauma Quality Improvement Program data set was performed using data from January 2015 to December 2016. Trauma patient's ≤ 18 y of age, who received red blood cells (RBCs) and were massively transfused were included. Children with burns, dead on arrival, and nonsurvivable injuries were excluded. Outcome data and mortality were assessed based on low (<1:2), medium (≥1:2, <1:1), and high (≥1:1) plasma and platelet to RBC ratios.

Results: There were 465 children included in the study (median age, 8 [2-16] y; median injury severity score, 34 [29-34]; mortality rate, 38%). Those transfused a medium plasma:RBC ratio received the greatest blood product volume in 24 h (90 [56-164] mL/kg; P < 0.01). Those in the low plasma:RBC group underwent fewer hemorrhage control procedures [56 (34%); P < 0.01], but ratio was not significant when controlling for age and other variables. Survival was improved for those who received a high plasma:RBC ratio (P = 0.02). Platelet transfusions were skewed toward lower ratios (95%) with no difference in clinical outcomes between the groups.

Conclusions: A high ratio of plasma:RBC may result in decreased mortality in severely injured children receiving a massive transfusion. Prospective, multicenter studies are needed to determine optimal resuscitation strategies for these critically ill children.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jss.2018.08.007DOI Listing
January 2019

Congenital diaphragmatic hernia repair in patients on extracorporeal membrane oxygenation: How early can we repair?

J Pediatr Surg 2019 Jan 5;54(1):50-54. Epub 2018 Oct 5.

Baylor College of Medicine, Michael E. DeBakey Department of Surgery, Houston, TX, USA; Texas Children's Hospital, Department of Pediatric Surgery, Houston, TX, USA. Electronic address:

Background: The benefits to early repair (<72 h postcannulation) of infants with congenital diaphragmatic hernia (CDH) on extracorporeal membrane oxygenation (ECMO) are increasingly recognized. Yet it is not known if even earlier repair (<24 h) results in comparable or improved patient outcomes. The goal of this study was to compare "super-early" (<24 h) to early repair (24-72 h) of CDH patients on ECMO.

Methods: A retrospective review of infants with CDH placed on ECMO (2004-2017; n = 72) was performed. Data collected on the patients repaired while on ECMO within 72 h of cannulation (n = 33) included pre- and postnatal disease severity stratification variables and postnatal outcomes. Comparison groups were those patients repaired within 24 h of cannulation (n = 14) and those repaired between 24 and 72 h postcannulation (n = 19).

Results: Patients undergoing "super-early" (<24 h) repair had an average survival of 71.4% compared to the average survival of 59.7% in the early repair group. Pre- and postnatal variables predicting disease severity were not significantly different between the groups. Mean hospital stays, ventilator days, and cannulation days were statistically similar between the groups.

Conclusions: Repair of patients with CDH patients on ECMO at less than 24 h postcannulation achieves outcomes that are comparable to those of repair between 24 and 72 h. While the present data suggest that there is not a "too early" time point for CDH repair on ECMO, larger multicenter studies are needed to validate our findings and determine the overall benefits.

Type Of Study: Retrospective comparative study.

Level Of Evidence: Level III.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jpedsurg.2018.10.038DOI Listing
January 2019