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  Preventing Migration Of Esophageal Silicone Covered Self-Expanding Metal Stent Using Dental Floss In A Pediatric Patient

  Sofia Colon Guzman, Nadia Ibrahimi, and Amornluck Krasaelap

  Temporary esophageal stents are an important and effective treatment for benign esophageal strictures, such as those caused by caustic ingestions. Fully covered self-expanding metal stents (FCSEMS) provide the benefit of continuous dilation pressure over longer periods of time compared to bougie or balloon dilation. However, stent migration is the most common complication and can be observed in up to 40% of patients, especially with FCSEMS and in refractory strictures. Typically, the stent is secured by using clips or suturing devices. However, we present a case where traditional methods of securing a stent were not possible due to the location of the stricture, and how we attempted to prevent migration using the dental floss method. The patient is an 18-year-old male with complex proximal esophageal stenosis secondary to caustic ingestion thar, at diagnosis measured 3mm diameter, 5cm in length, and was located 19cm from the incisors. The patient underwent 21 dilations within 7 months using different modalities. The last two were FCSEMS. The first stent could not be fixed with clips or sutures and migrated distally after 2 hours. For the second attempt, dental floss was tied to the proximal end of the stent before placement, and it was secured by threading through a nasogastric tube and taping to the side of the face. This allowed the stent to stay in place for 30 hours before it also migrated distally. We propose that this type of strategy Is useful in cases where stent placement does not allow for traditional methods like clipping and suturing, and could be more effective if attached to two sides of the proximal end of the stent.

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  Machine Learning Applications for Psychiatric Pharmacogenetics

  Ethan Poweleit

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  Minimally Invasive Repair of Pectus Excavatum Without Stabilizers Does Not Result in Increased Bar Displacement or Other Post-operative Complications

  Meredith Elman, Seth Saylors, Ismael Elhalaby, and Pablo Aguayo

  Introduction/Purpose Since the Nuss procedure was first performed in the 1990s, surgeons have adopted various modifications and techniques that vary by practice to optimize patient outcomes and minimize complications following pectus excavatum repair. Bar dislocation is a particularly dreaded complication, and as such, many Nuss bars are secured using unilateral or bilateral stabilizers. However, additional foreign body use can be associated with increased morbidity such as infection at stabilizer sites (~3% incidence), and pain attributed to stabilizer presence. Beginning in 2020, individuals in our practice did not place stabilizers in patients undergoing minimally invasive repair of pectus excavatum (MIRPE), and instead, secured the bar with bilateral FiberWire, 2-point Tevdek, or Vicryl fixation. All patients received cryoablation intra-operatively and there were no adjustments in post-operative restrictions, which aimed for return to normal activity two weeks after surgery. In this study, we aim to evaluate morbidity and patient outcomes in patients who undergo MIRPE without stabilizer use. Methods This is a single-institution, retrospective review of all patients undergoing MIRPE without stabilizers during Nuss bar placement. Demographics were recorded, as well as Haller index, corrective index, presence of post-operative infection, post-operative analgesia use, length of stay, and any instance of bar displacement. All values are reported as medians with interquartile range (IQR). Results A total of 26 patients since 2020 underwent MIRPE without stabilizer placement. The cohort was predominantly male (85%, n=22) with a median age at the time of bar placement of 15 years (IQR 14,17), a median Haller index of 4 (IQR 3.6,4.6), and median corrective index of 25 (IQR 17,44). Median time from surgery was 11 months (IQR 3,16). Thirty one percent (n=8) of patients were discharged home the same day as surgery, 62% (n=16) were discharged home on post-op day #1, and 7% (n=2) stayed more than 1-day post-op (one due to pain and one due to a management of post-op pneumothorax). Zero patients experienced bar displacement, surgical site infection, or hospital re-admission related to surgery. Thirteen patients could recount post-op opioid use. For these patients, the median number of days following discharge that they required opioids was 5 (IQR 3,7). Of 22 patients at their one-month follow-up appointment, 73% (n=16) were no longer regularly using any form of over the counter (e.g., Tylenol, ibuprofen) analgesia for post-op pain. Conclusion Nuss bar placement without stabilizers can be a safe means of correcting pectus excavatum without increased risk of bar displacement. Minimizing the amount of foreign material has the potential to mitigate post-op infection, irritation, and pain from surgery.

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  Variation in Systemic Corticosteroid Prescribing During Asthma-Related Hospitalizations Across Children’s Hospitals

  Sian Best, Matt Hall, Jessica L. Bettenhausen, Shelby Chesbro, Nicholas Clark, Megan Collins, Adrienne DePorre, Jonathan Ermer, Bridgette Jones, Leah Jones, Jessica Markham, Elisha McCoy, Maria Newmaster, Laura Plencner, Henry T. Puls, Smit Shah, and Kathryn Kyler

  Background: Asthma exacerbations are a leading cause of pediatric hospitalizations, and systemic corticosteroids remain a key component of inpatient treatment. Emergency department-focused studies have shown dexamethasone to be equivalent to prednisone/prednisolone in terms of outcomes such as readmission rates, but less is known about the trends in dexamethasone use versus other systemic corticosteroids, and associated outcomes in the inpatient setting. Objectives/Goal: To describe variability and trends in inpatient systemic corticosteroid prescribing practices for acute asthma exacerbations, and to determine associations between the prescribed steroid and hospitalization outcomes. Methods/Design: This retrospective cross-sectional study utilized the PHIS database to examine patients aged 2-18 years hospitalized with an acute asthma exacerbation/status asthmaticus between 01/01/2016-06/30/2023 that were administered dexamethasone, prednisone, prednisolone, or methylprednisolone. Patients with concurrent diagnoses of bronchiolitis, bacterial pneumonia, complex chronic conditions, or those who received other systemic corticosteroids were excluded. Children with more severe illness were excluded: patients with length of stay (LOS) >5 days, those who received mechanical ventilation, non-invasive ventilation, ECMO or CPR. Hospitals that did not consistently participate in PHIS throughout the study period were excluded. We used generalized estimating equations to analyze the association of annual hospital level dexamethasone use with hospitalization outcomes, with models adjusted for age, ICU stay, LOS, and illness severity (H-RISK). Results: There were 113,730 asthma hospitalizations identified across 37 hospitals. The proportion of encounters in which dexamethasone was administered increased from 43% to 76% from 2016 to 2023 (Fig 1). There was substantial variability in dexamethasone use across hospitals and years (Fig 2). The proportion of hospitals prescribing dexamethasone for >80% of hospitalization encounters rose from 18% of hospitals in 2016 to 60% in 2023. No difference in 7 or 30-day ED revisits, 7 or 30-day readmissions, or LOS were found based on annual hospital-level dexamethasone use, or between dexamethasone and prednisone/prednisolone usage (p>0.05). Conclusions: Dexamethasone use during asthma hospitalizations has steadily increased since 2016, without differences in readmissions or length of stay among hospitals. Substantial variation in inpatient dexamethasone use may reflect limited clinical trial data focused on children hospitalized with asthma, and its current exclusion from national guidelines.

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  Call Me Telephone triage skills for pediatricians across multiple settings

  Cody Clary, Jonathan Ermer, Rebecca Callahan, Kayla Heller, Luke Stephens, Margaret Kirkpatrick, Nehal Parikh, Cody Tigges, and Madhuradhar Chegondi

  Come explore current evidence surrounding telephone triage skills across a variety of settings and learn ways to teach these valuable skills while promoting best practices. Outpatient pediatricians, hospitalists, ICU physicians and ED providers all have telephone calls incorporated into their work. Often physicians are operating with very little training in this area, and methodology about teaching these skills to pediatric trainees is limited. We will highlight educational innovations at a variety of programs designed to improve resident and fellow education, sharing our results and providing opportunities for others to design their own content relevant to their own practice. Participants will engage in interactive collaboration, applying a tool developed by facilitators to assess and provide feedback after simulated phone calls.

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  Variation in systemic corticosteroid prescribing during asthma-related hospitalizations across children's hospitals

  Sian Best, Matt Hall, Jessica L. Bettenhausen, Shelby Chesbro, Nicholas Clark, Megan Collins, Adrienne G. DePorre, Jonathan Ermer, Bridgette Jones, Leah Jones, Jessica Markham, Elisha McCoy, Maria Newmaster, Laura Plencner, Henry T. Puls, Smit Shah, and Kathryn Kyler

  Asthma exacerbations are a leading cause of pediatric hospitalizations, and systemic corticosteroids remain a key component of inpatient treatment. Emergency department-focused studies have shown dexamethasone to be equivalent to prednisone/prednisolone in terms of outcomes such as readmission rates, but less is known about the trends in dexamethasone use versus other systemic corticosteroids, and associated outcomes in the inpatient setting. Objective (216) To describe variability and trends in inpatient systemic corticosteroid prescribing practices for acute asthma exacerbations, and to determine associations between the prescribed steroid and hospitalization outcomes. Design/Methods (949) This retrospective cross-sectional study utilized the PHIS database to examine patients aged 2-18 years hospitalized with an acute asthma exacerbation/status asthmaticus between 01/01/2016-06/30/2023 that were administered dexamethasone, prednisone, prednisolone, or methylprednisolone. Patients with concurrent diagnoses of bronchiolitis, bacterial pneumonia, complex chronic conditions, or those who received other systemic corticosteroids were excluded. Children with more severe illness were excluded: patients with length of stay (LOS) >5 days, those who received mechanical ventilation, non-invasive ventilation, ECMO or CPR. Hospitals that did not consistently participate in PHIS throughout the study period were excluded. We used generalized estimating equations to analyze the association of annual hospital level dexamethasone use with hospitalization outcomes, with models adjusted for age, ICU stay, LOS, and illness severity (H-RISK). Results (636) There were 113,730 asthma hospitalizations identified across 37 hospitals. The proportion of encounters in which dexamethasone was administered increased from 43% to 76% from 2016 to 2023 (Fig 1). There was substantial variability in dexamethasone use across hospitals and years (Fig 2). The proportion of hospitals prescribing dexamethasone for >80% of hospitalization encounters rose from 18% of hospitals in 2016 to 60% in 2023. No difference in 7 or 30-day ED revisits, 7 or 30-day readmissions, or LOS were found based on annual hospital-level dexamethasone use, or between dexamethasone and prednisone/prednisolone usage (p>0.05). Conclusions (345) Dexamethasone use during asthma hospitalizations has steadily increased since 2016, without differences in readmissions or length of stay among hospitals. Substantial variation in inpatient dexamethasone use may reflect limited clinical trial data focused on children hospitalized with asthma, and its current exclusion from national guidelines.

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  Antimicrobial Duration Stewardship Project: A QI approach

  Joshua Saucedo, Rana El Feghaly, Amanda Nedved, Leslie Hueschen, Marsha Dannenburg, Tanis Stewart, Patty Philips, and Jennifer Floyd

  A QI project aimed at increasing the percentage of children discharged home from the emergency department with a diagnosis of community acquired pneumonia (CAP) or acute bacterial rhinosinusitis (ABRS) treated with an optimal antibiotic duration (5 days or less for CAP, 7 days or less for ABRS) from 22% to 70% by July 2025. Additionally, assess for differences in care based on demographic and socioeconomic factors such as the area deprivation index. National guidelines and CMH clinical pathways recommend short antibiotic durations (5-7 days) for most infections (5 days for community acquired pneumonia, 5-7 days for acute bacterial rhinosinusitis). At CMH ED, our clinicians are using first-line guideline-recommended antibiotics as an appropriate choice for the majority of patients (per our ASP report tracking), however, duration continues to be a problem. When evaluating all infections treated in the ED through a benchmarking work, only 50% of all patients receive 7 days or less of antibiotics. Some patients who are diagnosed with pharyngitis or AOM where 10 days may be appropriate, would require longer courses; however, we suspect many patients with the diagnoses listed above continue to receive prolonged courses of antibiotics.

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  Effectiveness of a Medical Writing Center in an Academic Teaching Hospital

  Heather McNeill, Jacqueline Hill, Myles Chandler, Eric T. Rush, and Martha Montello

  Background and/or theoretical framework and importance to the field: Despite the importance of the skill in their careers, physicians do not often receive formal training in writing manuscripts or grant proposals. While some academic medical centers provide editing and resources for faculty and trainees to improve clarity of scholarly writing, most are university-affiliated centers, not independent teaching hospitals. Innovation Design: Our writing center within an independent pediatric teaching hospital provides free editing, consultations, and training, as well as how-to guides and templates, to faculty and trainees. Evaluation Plan: We assessed writing center effectiveness by evaluating satisfaction and outcomes data collected over a seven-year period. We also recorded the number of times how-to guides and templates were accessed since April 2023. Outcomes: During 2015-2022, the writing center received 697 service requests, 88.4% to edit a document. Of those documents, 81.3% of manuscripts and 44.4% of grant proposals edited by the writing center were published or funded. When rating their experience, 97.8% of respondents rated the edits “helpful,” 96.7% indicated the edits “improved readability,” and 99.3% stated they planned to use the writing center in the future. Since April 2023, the writing center had 755 views of its 20 how-to guides and 14 templates. Innovation’s strengths and limitations: Our writing center provides editing services and resources at no cost. In interpreting our outcomes data, we acknowledge that quality of writing is only one of several factors contributing to publication and funding success. Feasibility and transferability: Our writing center has been successful because of our hospital’s commitment to increasing scholarly productivity. Other independent teaching hospitals can similarly support and promote writing center services to increase scholarly productivity of faculty and trainees.

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  Improving Frequency of Peer Review of Abnormal Genital Exam Findings in Patients Undergoing Sexual Abuse Evaluation

  Lyndsey Hultman, Terra N. Frazier, and Jennifer Hansen

  Background/Objectives: 2023 Child Advocacy Center (CAC) accreditation standards require that “all medical professionals providing services to CAC clients must demonstrate that 100% of all findings deemed abnormal or “diagnostic” of trauma from sexual abuse have undergone expert review by an advanced medical consultant”. Prior to program implementation, scheduled Case Review occurred among the authors’ institution child abuse pediatricians (CAPs), but typical practice was to review cases upon CAP request. The authors’ institution faced practice standard implementation barriers of high case volumes and collaboration with multiple different CACs. Our primary aim was to increase peer review of abnormal exams from a baseline of 27% to 75% by March 15, 2023. Methods: Quality improvement methodology including a process map, fault tree, fishbone diagram, driver diagram, and PICK chart were used. Using published consensus of interpretation of exam findings, criteria were defined for review: trauma, indeterminate findings, medical conditions which could be mistaken for abuse, and visual signs of significant anogenital infections. Education was provided to CAPs on the new requirement for peer review. In the first PDSA cycle, CAPs completed a brief QR code linked REDCap form at the time of the exam to generate a case list for review and store data for CAC accreditation. Our outcome measure was completion of peer review of abnormal findings, our process measure was number of cases reported for review, and our balancing measure was CAP rating of satisfaction of balance of case types at case review. Results: Initial education resulted in a decrease to 19% of cases reviewed. Subsequent implementation of the QR code linked REDCap reporting process to generate case lists and designation of time for peer review improved results to 93% of cases reviewed. Balancing measure of CAP rating of case types at case review improved from 70% to 100%. Process measure monitoring showed a decrease in reported number of cases, triggering a manual chart review for compliance. Peer review rate decreased to 57% for the reviewed period. Exploration of process barriers revealed review of acute sexual assaults driving this decrease. Current overall outcome measure is 84% of indicated cases reviewed. Conclusions: The CAP team was able to make significant improvements to the outcome measure of peer reviewed abnormal exams. The QR code linked to a REDCap streamlined case tracking for case review and securely stores data for partner CAC accreditation requirements. Further PDSA cycles are planned to optimize process standardization and automation to increase sustainability of our results.

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  Testing for Bleeding Disorders in Child Abuse: Adherence to AAP Recommendations and Results of Testing

  Lyndsey Hultman, Angela Doswell, Henry T. Puls, Shannon L. Carpenter, Angela Bachim, Kristine Campbell, Daniel Lindberg, Joanne Wood, and James Anderst

  Background: The American Academy of Pediatrics (AAP) recommends evaluations for bleeding disorders in children who have bruising and/or intracranial hemorrhage (ICH) concerning for abuse. Adherence to these recommendations is not known nor are the frequencies of identification of bleeding disorders or laboratory findings suggestive of a bleeding disorder. Objective: Using a multicenter research network (CAPNET), the objectives of this study were to characterize (1) the adherence to AAP recommendations for bleeding disorder testing in total and across CAPNET sites and (2) the frequency of identification of specific bleeding disorders and laboratory values concerning for bleeding disorders. Methods: We performed a descriptive study of bleeding disorder evaluations among children younger than 10 years of age who presented with bruising and/or ICH concerning for abuse from February 2021-May 2022 utilizing CAPNET. Cases were classified as (1) Bruising without ICH or (2) ICH with or without bruising. Based on AAP guidance, testing was not recommended in cases with concomitant suspicious injuries, inflicted injury history, patterned injury, and low clinical concern for abuse. The primary outcome was adherence to AAP recommendations for testing based on study group. We also calculated the frequency of identification of specific bleeding disorders. As CAPNET has a data entry window that may exclude final diagnosis of a bleeding disorder, we identified cases with abnormal bleeding disorder testing not specifically labeled as a bleeding disorder in CAPNET. Results: A total of 2,655 children presented with Bruising and/or ICH concerning for abuse during the study period. The study group had a mean age of 26.1 months and was 59.6% male, 64.5% white, 19.2% African American, 17.1% Hispanic, and 69.7% publicly insured. 25.6% (679/2655) of subjects (516 with bruising and 163 with ICH) were recommended to have testing based on AAP criteria. Of these, 9.5% (49/516) cases of bruising and 32.5% (53/163) cases of ICH had all AAP recommended bleeding disorder testing completed. Among CAPNET centers, completion of AAP recommended testing ranged from 0-34.1% of bruising cases and 0-100% of ICH cases. A total of 0.94% (25/2655) cases had a specific bleeding disorder identified. Analyzing abnormal test results, 7.66% (52/679) of cases with testing recommended had abnormal results but were not diagnosed with bleeding disorders. Conclusions: Testing for bleeding disorders based on AAP recommendations frequently did not occur and varied by CAPNET center. Although rare, bleeding disorders were present among cases with testing.

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  Single-step Collagen-elastin Dermal Matrix with Split-thickness Skin Grafting for Keloid Burn Scars: A Case Series

  Meredith Elman and Pablo Aguayo

  Introduction Keloids may pose significant difficulty to affected patients: they can be painful, itchy, impact mobility if they cross joints, and most disruptively, can be physically disfiguring and cause emotional distress. While multiple treatments exist, none reliably provide scar resolution, and up to 100% of keloids return after surgical excision. MatriDerm is a dermal replacement scaffold that has shown previous efficacy in management of a variety of acute and chronic wounds in adults, including burns. In this two patient case series, we aim to demonstrate the efficacy of single-step application of MatriDerm dermal substitute with split-thickness skin grafting in the management of keloid scars caused by burns in the pediatric population. Methods Both patient A and B experienced a scald burn (patient A – suprapubic, patient B – right buttock) that initially healed with supportive care, but subsequently developed significant scarring refractory to initial laser therapy and Kenalog injection. They each underwent excision of keloid scar, application of dermal matrix (MatriDerm), and application of split-thickness skin graft. Patient A had a negative pressure wound therapy device applied to their surgical site, while patient B had application of a bolster. Both patients subsequently underwent two laser ablation procedures to reduce the risk of recurrent keloid formation. Patient A required additional post-operative Kenalog injection one month following MatriDerm application. Results Post-operative wounds of patient A and B demonstrate marked improvement in scar size, composition, and elevation. No re-excision of keloid or hypertrophic scar has been required. Post-operative pain was managed with over-the-counter analgesia as needed (acetaminophen, ibuprofen). No post-operative infections were reported. There were no inpatient re-admissions for post-operative complications.

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  Large Single Center Experience with Extubation During Neonatal and Pediatric Extracorporeal Membrane Oxygenation

  Cara Holton, Johanna I. Orrick, Debra E. Newton, and Jenna Miller

  Introduction: Extubation of neonatal and pediatric patients supported with extracorporeal membrane oxygenation (ECMO) may avoid ventilator induced lung injury, decrease neurosedative exposure, and improve rehabilitation and mobility. Few studies have evaluated incidence and outcomes of pediatric patients extubated during ECMO. Methods: A single-center retrospective cohort study was performed to describe our experience with extubation on ECMO. All patients extubated on ECMO from 2013-2022 were included. Patients who had a tracheostomy prior to ECMO cannulation were excluded. Patients who had a tracheostomy placed during their ECMO run were included if extubation took place prior to tracheostomy placement. Results: Forty patients were extubated during their ECMO run, representing 8.6% of all ECMO patients during that time. Twenty-five patients (62.5%) were on veno-arterial (VA) ECMO, 14 (35%) veno-venous (VV) ECMO and 1 (2.5%) patient was initially on VV but converted to VA. The most common indication for ECMO was ARDS (50%), followed by pulmonary hypoplasia (12.5%), severe bronchospasm (7.5%), congenital diaphragmatic hernia (7.5%), sepsis (5%), and heart failure (5%). Median mean airway pressure prior to cannulation was 18 cm H2O, oxygenation index was 25.5 and vasoactive inotropic score was 4. Median weight was 7.3 kg, ECMO run time was 429.5 hours and extubation duration on ECMO was 7 days. The median percentage of ECMO run spent extubated was 47%. The most common form of respiratory support while extubated was heated humidified high-flow nasal cannula (67.5%). Half of all patients were on room air for some of their extubation course. Most patients were on a continuous opiate infusion (92.5%) and/or a dexmedetomidine infusion (85%) while extubated. Eleven (27.5%) patients were able to eat by mouth. Five patients (12.5%) were able to sit over the edge of the bed, two (5%) were able to be held by a caregiver, two (5%) were able to stand and one patient (2.5%) was able to walk independently with a gait aid. Five patients (12.5%) underwent ECMO decannulation while extubated. The most common reasons for reintubation were for lung recruitment (27.8%) and bronchoscopy (18.5%). Overall 85% survived to decannulation and 75% survived to ICU discharge. In comparison, survival for all ECMO patients during the same period was 62.1%. Discussion/Conclusions: Extubation on ECMO is feasible and associated with excellent outcomes. With careful titration of neurosedatives, ECMO sweep gas and respiratory support, patients on ECMO can be safely and comfortably extubated.

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  Successful Hepatectomy, Anhepatic State, and Liver Transplant on ECMO

  Jenna Miller, Kari L. Davidson, Bhargava Mullapudi, Richard J. Hendrickson, Ryan T. Fischer, Lisa Conley, Wes Ware, Michelle McKain, and Tara Benton

  We discuss the case of a 13-month-old previously healthy male who presented with acute liver failure (ALF) of unknown etiology. He progressed to fulminant cardiopulmonary failure requiring mechanical ventilation and high dose inotropes with persistent lactate >20. He was cannulated to VA ECMO and tandem continuous renal replacement therapy (CRRT) with single pass albumin dialysis (SPAD) and plasma exchange (PLEX) therapies. He required high dose inotropes on ECMO and had persistently elevated lactate despite maximal medical therapy. Limited imaging studies suggested cirrhotic liver and possible intestinal pneumatosis. Due to evidence of fulminant ALF and potential for a reversible process, he was listed for liver transplant status 1A. Given his refractory acidosis, a multidisciplinary team planned for laparotomy to exclude intestinal ischemia and then proceed with hepatectomy and portocaval shunt. An organ offer had been accepted with a backup recipient. Anhepatic time would continue to be supported with CRRT, SPAD and PLEX twice daily. Multiple multidisciplinary huddles occurred prior to the OR for optimal communication and planning. To prepare for the first hepatectomy on ECMO in our institution, we followed our program’s bleeding protocol for our congenital diaphragmatic hernia repairs on ECMO. Intraoperatively, he had minimal surgical bleeding outside of expected losses. Preparations were made for variable venous return pressures due to IVC clamping, but they remained manageable. The liver was noted to be necrotic without evidence of pneumatosis of the bowel and hepatectomy was completed successfully. The portal flow was managed via portocaval shunt. His acidosis resolved with improved coagulopathy and inotrope requirements in the following 24 hours. He proceeded back to the OR the following day for a liver transplant. The liver was successfully re-perfused. His biliary reconstruction was left incomplete due to bleeding. The bile duct was cannulated and connected to an external drainage bag. Patient perfusion pressure was adequate throughout the case. Postoperatively, he quickly weaned from inotropes and liver support therapies. Graft function was excellent. ECMO flows were weaned aggressively, and he was decannulated on post liver transplant day #1. He was taken back to the operating room for biliary reconstruction and second stage closure on post operative day #5. The process to complete a novel and high-risk operation is worth sharing as ALF is becoming a more common indication to consider extracorporeal support. We encourage closed-loop and frequent preoperative discussions with anesthesiology, surgery, intensive care and ECMO practitioners to ensure adequate planning.

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  Improving Nutritional Delivery to Pediatric Patients on Continuous Renal Replacement Therapy

  Jennifer Ruiz-Boada, Sarah Brunner, Tara Benton, and Vimal Chadha

  INTRODUCTION: Continuous renal replacement therapy (CRRT) is used in critically ill children with acute renal failure. CRRT can lead to malnutrition by removing essential proteins and micronutrients. Malnutrition is associated with worse outcomes, including increased length of stay and mortality. CRRT guidelines suggest the importance of early nutrition and ensuring high protein intake. After evaluating our CRRT patients, we found sub-optimal adherence to the guidelines. This Quality Improvement project aimed to increase the percentage of patients achieving 75% of their goal protein and caloric intake by day 5 of CRRT initiation by 15% by August 2023. METHODS: A multidisciplinary group of dietitians, nurses, nephrologists, and intensivists identified a knowledge gap in nutritional goals through surveys and a fishbone diagram. Outcome metrics were percentage of goal protein and calorie delivery by day 5 of CRRT initiation. Our interventions included educating bedside nurses, dietitians, and intensivists, implementing a nutrition checklist on rounds, and utilizing CRRT-specific nutrition notes in the EMR. Our process metrics included the completion of the nutrition checklist and EMR-notes. RESULTS: A total of 18 CRRT patients were evaluated pre-implementation (Jan 2021 to Dec 2021) and 11 post-implementation (Oct 2022 to July 2023). The number of patients meeting at least 75% of goal protein by day five of CRRT initiation increased to 82% from 72%. Those meeting at least 75% of goal caloric intake increased to 72% from 62%. The nutritional initiation checklist and CRRT EMR-nutrition notes were completed 72% and 100% of the time, respectively. Those that did not meet the goal protein intake (n=2) were receiving enteral nutrition. Common reasons for not meeting nutritional goals with enteral nutrition include procedure interruptions, vasoactive medications, and slow up-titration to goal feeds. CONCLUSIONS: Implementing an educational program, a CRRT nutrition checklist and new CRRT-specific EMR nutrition notes have increased the percentage of patients meeting goal caloric and protein intake. Future Plan-Do-Study-Act cycles will aim to improve checklist compliance and reduce enteral feed interruptions.

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  Position Specific Injury Patterns in Male Developmental Academy Soccer Players

  Andrew Donaldson, Catharine Kral, Shannon Margherio, McKeenna Noe, and Brian S. Harvey

  Background: Despite the availability of high-quality evidence describing injury patterns in European professional soccer players, there is a paucity of data regarding American athletes. This disparity is accentuated for elite youth athletes. Our study identifies position-specific injury patterns occurring in elite youth male soccer players. Hypothesis: We hypothesize that there are injury types, locations, and specific injuries that occur most frequently in elite youth soccer players and that certain positions have a higher frequency of these injuries than others. Methods: Data from a retrospective review of the IRB-approved Male Academy Soccer Registry from August 1, 2019 through June 30, 2022 including demographics, team (U15, U17, or U19), injury details, and severity was obtained. Results: 260 injuries occurred in 201 athletes for an injury rate of 1.29 injuries per person-year. Rates of injuries were highest in forwards and defenders at 1.42 and 1.3 respectively. The incidence rate was consistently the highest for forwards, markedly increasing from U15 to U19. Goalkeepers had the lowest rate of 1.08 injuries per person-year. In the U19 team, goalkeepers had a significantly lower injury incidence of 0.167 compared to other positions at 1.6 (p<0.001). U19 goalkeepers had a significantly lower rate of injuries than their U17 counterparts (p<0.02). Hand and finger injuries comprised 25% of goalkeeper injuries. Among defenders, 29.7% of injuries were sustained to the thigh with 15.45% sustained to the hip and groin. Among midfielders, the hip and groin were most injured at 27.4%, followed by thigh injuries at 19.3%. Forwards sustained more ankle injuries than the other positions at 23.5%. Though goalkeepers had the lowest injury incidence, 50% of their injuries were classified as severe, requiring more than 28 days of recovery. Of injuries sustained by forwards, midfielders, and defenders, less than 25% were severe. Stress reactions were 2.7% of injuries. Surgery was required in 3.46% of injuries. Thigh injuries were 43.6% of overall injuries compared to 37.8% for the hip and groin. Conclusion: Treatment and prevention of injury is one of the primary tasks of sports medicine physicians and requires an understanding of underlying mechanisms and epidemiology of injury. Recognition of injury patterns in pediatric athletes allows those dedicated to the care of such athletes to provide developmentally tailored recommendations to coaches and athletic trainers. While further research is still needed to elicit injury patterns, our data provides an initial insight to help navigate the next steps in keeping elite male soccer academy athletes safe during sport.

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  Pediatric Idiopathic Intracranial Hypertension (IIH)

  Jourdan Valkner Krause

  A case presentation on a 17 year old patient with IIH and severe papilledema unresponsive to max dose of Acetazolamide referred to neurosurgery for surgery intervention. A re-read of MRV revealed stenosed transverse sinus. A stent was placed and the patient's condition significantly improved.

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  What is the Evidence Telling Me and How Do I Become and Evidence Detective?

  Andrea Melanson and Kelli Ott

  Evidence plays a vital role in practice (Myers et al., 2019). However, many healthcare professionals lack the foundational skills to critically appraise the literature (Odierna et al., 2015). How many times has something been reported leaving the reader wondering if the information is truly accurate? As a means to stimulate curiosity and quell burnout, this short course aims to provide guidance on how to interpret the literature using the available tools to conduct a rapid systematic review. Upon completion, the learner will have the knowledge and confidence to justify if the intervention is effective for application.

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  Leadership Across the Career Continuum: Using Self-Reflection Effective Leadership Practices for Optimal Team Functioning

  Emily Bonanni, Grant M. Latta, Michael Platt, Christine Irvin, Angela Etzenhouser, Megan Collins, Sian Best, Jonathan Ermer, Joy L. Solano, and Jacqueline M. Walker

  Have you ever found yourself in a formal or informal leadership role and felt underprepared because of a lack of formal leadership training? Have you noticed unused potential in those around you and wondered how you maximize it? As academic pediatricians, we are identified as leaders by patients and their families, trainees of all levels, members of our multi-disciplinary care teams, and our peers. We are a group of passionate clinician educators who have found ourselves in both formal and informal leadership roles and have found success in these roles with leadership training. Our interactive workshop will give you the tools necessary to lead trainees and colleagues successfully through challenging situations by introducing you to renowned leadership paradigms and helping you to apply these techniques to your roles through self-reflection. We intend to teach this in a way that keeps you mindful of well-intentioned missteps in which we accidentally undermine the intelligence and talents of those around us. After we identify these common subversive actions, we will apply leadership frameworks to overcome them so we can maximize our teams' potential and success.

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  Treatment of Post-Operative Pain in Children with Severe Neurological Impairment

  Jordan Keys

  Background: The assessment of pain in children with severe neurologic impairment (SNI) can be more challenging than in neurotypical children.

  Objective: To describe the type, number of classes, and duration of post-operative pain medications for procedures common among children with SNI. Secondarily, to describe the variability in pain management strategies across children’s hospitals, specifically for opioid administration.

  Design/Methods: This retrospective cohort study of the Pediatric Health Information System included children hospitalized with SNI aged 0-21 years old who underwent common procedures during 2019. We defined SNI using previously described high-intensity neurologic impairment (HINI) diagnosis codes and identified six common (>500 encounters) procedures among our population (e.g., fracture treatment, tracheostomy, spinal fusion, ventriculoperitoneal shunt placement (VP shunt), colostomy, or heart valve repair) using the clinical classifications software (CCS). Clinical and demographic information were summarized using bivariate statistics. Children excluded from this cohort did not undergo any of the six preselected procedures, had multiple procedures performed, or received an organ transplant. Medication classes were defined using the Classification of Palliative Care Pain Medications. Non-opioid medications were excluded from analysis to hone in on opioid administration.

  Results: The cohort consisted of 7180 children; 65.9% had 1 HINI diagnosis, and 12.0% had 3+ HINI diagnoses. The proportion of post-operative days with pain medications ranged from the least 28.8% (VP shunt) to the most 71.7% (spinal fusion). The number of classes of pain medications ranged from the least 0-1 (VP shunt) to the most 2-4 (Tracheostomy, Table 2). We observed notable variability in the use of opioids across hospitals (0% to 100% overall, p<.001) and by procedure (Colostomies, Heart Valve Repair, Tracheostomies and VP Shunts at 0% to 100% for Spinal Fusion, Figure 1).

  Conclusion: Children with SNI experienced variability in the type, number of classes, and duration of all pain medications delivered post-operatively. This included an inconsistent use of opioids based upon hospital and procedure. Our findings indicate the need for both a standardized approach to the assessment of pain and post-operative pain management for children with SNI.

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  Exploring Bidirectional Partnerships in Global Health Training Programs

  Anik Patel, Pauline Kamau, Ashley Combs, Justus Simba, and Megan Song McHenry

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  Hypertrophic Pyloric Stenosis Protocol: A Single Center Study

  Nelimar Cruz-Centeno, James A. Fraser MD, Shai Stewart MD, Derek Marlor, Rebecca M. Rentea, Pablo Aguayo, David Juang, Richard J. Hendrickson, Charles L. Snyder, Shawn D. St.Peter, Jason D. Fraser, and Tolulope A. Oyetunji

  Introduction: Initial management of hypertrophic pyloric stenosis (HPS) is correction of electrolyte disturbances with fluid resuscitation. In 2015, our institution implemented a fluid resuscitation protocol based on previous data that focused on minimizing blood draws and allowing immediate ad libitum feeds postoperatively. Here we describe the protocol and subsequent outcomes. Methods: We conducted a single-center retrospective review of patients diagnosed with HPS from 2016-2020. All patients were managed per the protocol outlined in Figure 1. All were given formula or breast milk after the post-anesthesia care unit and discharged home after tolerating three consecutive feeds. Feedings were given every 2-3 hours even if emesis occurred. Full feeds were defined as 60 ml of full-strength formula or breast milk every 2–3 hours ad lib. The primary outcome was the postoperative hospital length of stay (LOS). Secondary outcomes included the total number of preoperative labs drawn, time from arrival to the hospital to surgery, time from surgery to initiation of feeds, time from surgery to full feeds, and re-admission rate. Results: There were 271 patients included. The majority of the patients were male (83%, n=225) and Caucasian (77.5%, n=210). The median age and weight were 5 weeks (IQR 3.9,6.5) and 3.9 kg (IQR 3.4,4.4), respectively. None of the patients required a nasogastric tube or arterial blood gas sample. A total of 117 patients (43.2%) had electrolytic disturbances that required fluid boluses in addition to (1.5 x) maintenance fluids before surgical intervention. The median number of lab draws was 2 (IQR 1,2), with a median time from arrival to surgery of 19.2 hours (IQR 15.1,24.9). The median time from surgery to first feed and full feeds was 1.9 hours (IQR 1.2,2.7) and 11.4 hours (IQR 6.2,19.1), respectively. Patients had a median postoperative LOS of 22.2 hours (IQR 9.6,30.6). Re-admission rate within the first 30 postoperative days was 3.3% (9/271), with 2.2% (n=6) of re-admissions occurring within 72 hours of discharge. Indications for re-admission included stridor (1), decreased oral intake (1), and vomiting (7). One patient (0.4%) required re-operation due to incomplete pyloromyotomy. Conclusion: This protocol is a valuable tool for perioperative and postoperative management of all patients with HPS while minimizing uncomfortable interventions.

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  Parent satisfaction with same day discharge after laparoscopic appendectomy for non perforated appendicitis

  Nelimar Cruz-Centeno, James Fraser, Shai Stewart MD, Derek Marlor, Rebecca M. Rentea, Pablo Aguayo, David Juang, Richard J. Hendrickson, Charles L. Snyder, Bhargava Mullapudi, Shawn D. St.Peter, Jason D. Fraser, and Tolulope A. Oyetunji

  Background: Same-day discharge (SDD) after laparoscopic appendectomy for acute non-perforated appendicitis is safe, without an increased rate of postoperative complications, emergency department visits, or re-admissions. We aimed to evaluate caregiver satisfaction with this protocol. Materials and Methods: Patients discharged on the day of laparoscopic appendectomy for non-perforated acute appendicitis were identified between January 2022-August 2022. Surveys to evaluate satisfaction with the protocol were distributed to the caregivers via e-mail or text message 96 hours after discharge. Telephone surveys were conducted if there were no responses to the initial online survey. The surveys assessed comfort with SDD, post-operative pain control adequacy, post-operative provider contact, and overall satisfaction. The protocol focused on avoidance of narcotics in the postoperative period and immediate return to a regular diet. Results: A total of 255 cases of non-perforated acute appendicitis underwent SDD. The survey response rate was 50.6% (n=129). Most respondents were Caucasian (69.0%, n=89) and male (51.9%, n=67), with a median age of 12.0 years (IQR 8.9,14.7). The median postoperative length of hospital stay was 3.8 hours (IQR 3.2,4.8). The overall satisfaction rate was 91.5%, with 118 caregivers feeling satisfied with SDD. Most caregivers felt comfortable with the SDD protocol (89.9%, n=116), with 22.5% (n=29) calling a medical provider postoperatively. Approximately nine out of ten caregivers reported that pain was adequately controlled (91.5%, n=118). In contrast, those that were dissatisfied reported issues with pain control and anxiety with SDD after a surgical procedure. Conclusions: Caregiver satisfaction and comfort with same-day discharge following laparoscopic appendectomy is high with appropriate anticipatory guidance and preoperative education.

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  Persistent Pediatric Breast Abscesses Following Initial Treatment at Tertiary and Community Centers

  Derek Marlor, Kayla B. Briggs, Shai Stewart MD, Nelimar Cruz-Centeno, Charlene Dekonenko, Tolulope A. Oyetunji, and Jason D. Fraser

  Introduction: Our institution previously reported on outcomes of children with untreated and not spontaneously draining breast abscesses. This study aimed to evaluate the outcomes of all patients with breast abscesses who were evaluated at our institution. Methods: Following IRB approval, all patients < 18-years-old with breast abscesses were included. A total of 145 patients treated from January 2008-December 2018 were identified. Patients were divided into 2 groups; Group 1 included patients initially evaluated at our institution and Group 2 included patients who were initially evaluated at referring centers. The primary outcome was disease persistence. Secondary outcomes were antibiotic utilization, number and type of procedures performed, and risk factors for recurrence. Statistical analysis was performed using STATA® 17 with a p-value of <0.05 indicating significance. Results: A total of 145 patients were identified: 111 (76.6%) in Group 1 and 34 (23.4%) in Group 2. Demographics were similar between groups. Of the 111 patients in Group 1, 2 (1.8%)) were treated with observation alone, 58 (52.3%) were treated with antibiotics alone, 26 (23.4%) were treated with aspiration, and 25 (22.5%) were treated with incision and drainage. Of the 34 patients in Group 2, 4 (11.8%) were treated initially with observation, 22 (64.7%) with antibiotics alone, 5 (14.7%) with manual expression, 2 (5.9%) with incision and drainage, and 1 (2.9%) with warm compresses. Patients in Group 1 were more likely to receive needle aspiration (23.4% vs. 0%; p<0.001) or incision and drainage (22.5.% vs. 5.9%; p<0.001) as initial treatment. Compared to Group 2, patients in Group 1 were more likely to be prescribed clindamycin when treated with antibiotics alone (69.9% vs 18.2%; p<0.001). They also had a 12.6% persistent disease rate (n=14). Second treatment in those with persistent disease included aspiration in 50% (n=7), incision and drainage 45.5% (n=5), antibiotics 7.1% (n=1), and manual expression 7.1% (n=1). No patients had persistent disease following second treatment. Patients in Group 2 were more likely to be treated with antibiotics alone (64.7% vs. 52.3%; p<0.001), with trimethoprim/sulfamethoxazole being the most commonly prescribed antibiotic (54.6%). In patients with persistent disease treated at our institution following initial evaluation at a referring center, 50.0% were treated with antibiotics alone, 26.5% with aspiration, 17.7% with incision and drainage, and 5.9% with manual expression. Following treatment at our institution, the rate of persistent disease was similar between groups (12.6% vs 11.8%;). Conclusions: Persistent breast abscesses may be treated with antibiotics alone in community and tertiary care centers. Disease persistence is similar regardless of the initial treatment setting.

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  Clinical features and outcomes in pediatric severe scald burn patients

  Ashley Daniel

  Introduction/Hypothesis Young children with scald burns experience severe complications compared to older children. A paucity of data exists to support these observations. This study compares clinical features and complications of younger versus older pediatric patients with scald burns at four children’s hospitals participating in the Pediatric Injury Quality Improvement Collaborative (PIQIC). This collaborative includes five pediatric burn centers that utilize research to improve quality of burn care. 485 Methods This is a retrospective cohort study of scald burn patients admitted from 2010 to 2020 to four pediatric hospitals participating in PIQIC. Patients with total body surface area (TBSA) < 15% were excluded. Patients were categorized by age into three groups: toddlers (0–3 years), children (3-10 years), and adolescents (>10 years). The adolescent group was excluded with three patients in this group. Demographics, clinical features and adverse events were compared between age groups. For categorical variables, counts and percentages are reported; P-values were determined by Fisher’s Exact test. Continuous variables are reported using median and inter-quartile range; P-values were determined using the Wilcoxon Rank Sum test. Results Ninety-five patients were identified; 73 (76%) were in the toddler group. Although median burn size was larger in children (24 [21-36] vs 21 [18-30] % TBSA, p<0.001), toddlers had longer median intensive care unit (ICU) LOS (3 [2-16] vs 3 [2-9], p<0.001) and more median mechanical ventilator (MV) days (13 [1-137] vs 5 [2-138], p<0.001) than the child group. There was notable incidence of sepsis, nosocomial infection and abdominal catastrophe in the toddler group. Abdominal catastrophes only occurred in the toddler group, with 5 patients (7%) affected. Mortality was only observed in the child group (n=2, 9%). Conclusions Scald burns are more prevalent in the toddler group compared to the child group. Mortality risk may not be higher in this group, but they encounter longer ICU LOS, higher MV days, and incidence of sepsis, nosocomial infection, and abdominal catastrophe. This is one of the largest reports of abdominal catastrophe in this patient population to our knowledge. Continued investigation will help better understand this patient population.

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  Pediatric In-Hospital Cardiac Arrests: We Have More to Learn About Patient Demographics and Outcomes

  Nathan LaVoy, John Cowden, Jenna Miller, Asdis Finnsdottir Wagner, Shekinah Hensley, and Stephen Pfeiffer

  Introduction: Prior pediatric studies show an association between patient demographics and mortality after in-hospital cardiac arrests (IHCA). To our knowledge, this has not been assessed in pediatric intensive care units (PICU). This study aims to evaluate the impact of demographics and code characteristics on outcomes after IHCA in a quaternary referral PICU. Methods: A single center retrospective review of PICU IHCA events from 2010-2021 was performed. Patient demographics included age, gender, race/ethnicity, and language. Primary diagnosis was defined as cardiac or non-cardiac. The use of ECMO, CRRT, or defibrillation were included as code characteristics. The primary outcome was survival to hospital discharge. Adjusted odds of mortality (aOR) were obtained using PRISM III scores to adjust for illness severity. Data obtained via Virtual Pediatric System© and chart review. Results: 377 patients (median age 11 months) had 520 PICU IHCA events. 59.4% identified as White, 16.2% Black, 8.3% Hispanic, and 1.5% Asian. Overall survival was 49%. Adjusting for disease severity, there was no difference in survival rates between females (43.3%) vs. males (54%) [aOR 1.26(p=0.278)] or racial/ethnic groups: Hispanic 39.5% [aOR 1.75(p=0.214)], Asian 25.0% [aOR 4.74(p=0.063)], Black 51.2% [aOR 1.13(p=0.664) vs. White 51.1%. Language had no impact on survival: Spanish 36.8% vs. English 49.3% [aOR 1.08(p=0.912)]. Cardiac diagnosis survival was 54.5% vs. non-cardiac 42.2% [aOR 0.75(p=0.166)]. Although different, survival rates were not statistically significant in patients requiring ECMO (Black 33.3% [OR 1.70(p=0.485), Asian 0% [OR 1.99(p=0.302)] vs. White 45.9%), CRRT (Hispanic 20% [OR 1.49(p=0.999)], Asian 0% [OR: 1.34(p=0.819)] vs. White 27.3%), or defibrillation (Asian 0% vs. White 39.1% [OR 0.60(p=0.999)]). Conclusion: Controlling for illness severity, there were no statistically significant outcome differences based on demographics after IHCA in the PICU. This is inconsistent with previously published data on outcomes following IHCA. While this single center study did not assess CPR performance or post-arrest care, it provides framework for future analysis of IHCA in the PICU and identifying risk factors for mortality in this specific patient population.