11.17 Pre-operative Oral Carbohydrate Supplementation Improves Clinical Outcomes: A Meta-analysis.

Posted on December 22, 2014

T. K. Woleston1,3, R. S. Chamberlain1,2,3  1Saint Barnabas Medical Center,Department Of Surgery,Livingston, NJ, USA 2Rutgers Univsersity,Department Of Surgery,Newark, NJ, USA 3St. George’s University School Of Medicine,St. George’s, ST. GEORGE’S, Grenada

Introduction: Preoperative fasting is an accepted precaution for patients undergoing surgery and is intended to prevent aspiration of gastric contents while under anesthesia. Surgery while in a fasting state can lead to increased metabolic stress and increased morbidity and mortality. Preoperative oral carbohydrate (OCH) supplementation has been proposed to decrease postoperative complications and improve clinical outcomes, however studies to date have produced inconsistent findings. This meta-analysis critically analyzes existing randomized controlled trials (RCTs) to establish an evidence-based perspective on preoperative OCH supplementation and its effect on length of stay, postoperative nausea/vomiting, insulin resistance, and post-operative complications.

Methods: A comprehensive search of PubMed, Google Scholar, and both the Cochrane and NIH Central Registry of Controlled Trials was completed (1990 – 2014). 15 RCTs were identified involving non-diabetic adult subjects undergoing elective surgery receiving a preoperative OCH dose greater than 25g or placebo/no therapy. Length of stay (LOS), postoperative nausea/vomiting, insulin resistance, and postoperative complications (including infection, wound dehiscence, anastomotic leak, atrial fibrillation, pneumonia, and ileus) were the outcomes assessed.

Results: 15 RCTs involving 1,380 patients were included in this meta-analysis. 605 subjects received preoperative OCH supplementation and 775 received traditional preoperative fasting or calorie-free placebo. OCH use decreased LOS by 1.8 days (6.9 vs. 8.7 days, p=0.026).  There was no significant decrease in the risk of postoperative complications (p=0.157), or postoperative nausea/vomiting (p=0.485).  The homeostatic model assessment for insulin resistance (HOMA-IR) value was 4.8% higher (2.44 vs. 2.30, p=0.009) in the OCH group than the control group preoperatively, however the postoperative day 1 values were not significantly different (p=0.6665).

Conclusions: Preoperative OCH supplementation is associated with a significant decrease in LOS when compared to fasting, and is comparable regarding postoperative complications. Preoperative caloric loading should be considered in all patients undergoing prolonged surgical procedures and may be superior to current practice. Additional well-designed large scale RCTs are required to evaluate ideal dose and timing of OCH, associated risks, and which procedures are most likely to benefit from OCH loading.

 

11.18 OBESITY IS A PREDICTOR OF BILE DUCT INJURIES

Posted on December 22, 2014

H. Aziz1, T. Jie1, V. Nfonsam1  1University Of Arizona,Tucson, AZ, USA

INTRODUCTION

Iatrogenic bile duct injury is a serious complication of cholecystectomy. The aim of this study was to assess predictors of bile duct injury using a national database.

METHODS

The Nationwide Inpatient Sample (2010-2012) was queried for cholecystectomy. We used a) diagnoses for bile duct injury and b) bile duct injury repair procedure codes as a surrogate marker for bile duct injuries.

RESULTS

A total of 316 patients had bile duct injury. The mean age was 58.2 ± 19.7 years, 53.5% were males, and median Charlson co-morbidity score was 2 [2-3]. Univariate analysis revealed age (p- < 0.001), male gender (p- 0.004), morbid obesity (p- 0.001), and teaching hospital status (p-0.021) to be associated with CBD injury. Multivariate analysis revealed morbid obesity (2.8[2.1-4.3]; p-0.03) as the independent predictors for bile duct injury in patients undergoing cholecystectomy.

CONCLUSION

Our study finds a new association between obesity and bile duct injuries which has never been reported in literature before. The effect of obesity on outcomes in biliary surgery needs prospective evaluation.

11.19 Study of routine upper gastrointestinal study to evaluate for leak after roux-en-Y gastric bypass

Posted on December 22, 2014

S. Gambhir1, P. Yenumula1, C. Moon1, P. Haan1, S. Kavuturu1  1Michigan State University,Surgery,Lansign, MI, USA

Introduction:  Routine Upper Gastrointestinal (UGI) x-ray use after laparoscopic Roux-en-y gastric bypass (LRYGB) is still practiced by many bariatric surgeons in order to investigate for anastomotic leaks.We present our experience with a large retrospective review of gastric bypass surgeries studying the usefulness of a routine drain placement. 

Methods:  Retrospective record of all patients undergoing LRYGB from September 2006 to November 2011 was performed. As we changed our practice in December 2009, we have two comparable groups; one with a routine UGI x-ray completed after surgery and one UGI was done selectively based on clinical suspicion and patient symptoms. A total of 613 LRYGBs were performed during the study period, the first 301 were routine UGI x-ray and the subsequent 312 without routine UGI x-ray. Demographics were statistically similar between the two groups.  

Results:There were 3 leaks in the routine UGI group (1%) and 5 leaks in the selective UGI group (1.6%)  (p >0.05). In the Routine UGI group, the sensitivity and specificity of the UGI to detect a leak are 25% and 99.7% respectively. Where as in the selective UGI group, the sensitivity and specificity of the UGI to detect a leak are 50% and 99.7% respectively. Clinical suspicion has a sensitivity and specificity of 100% and 99.3% in the routine UGI group, and 100% and 97.4% in the selective UGI group.

Conclusion: There is no difference in the leak rate or morbidity with routine use of UGI after a laparoscopic gastric bypass. Change in clinical parameters can accurately diagnose a patient with ongoing anastomotic leak. Selective use of UGI based on clinical suspicion for a leak is prudent and economically efficient.
 

11.20 Nutritional And Psychiatric Weight Loss Predictors Following Bariatric Surgery

Posted on December 22, 2014

B. T. Fox1, E. Y. Chen1, A. Suzo2, S. A. Jolles1, J. A. Greenberg1, G. M. Campos1, M. J. Garren1, C. I. Voils3,4, L. M. Funk1  3Center For Health Services Research In Primary Care,Department Of Veterans Affairs,Durham, NC, USA 4Duke University Medical Center,Department Of Medicine,Durham, NC, USA 1University Of Wisconsin,Department Of Surgery,Madison, WI, USA 2Ohio State University,Department Of Surgery,Columbus, OH, USA

Introduction

Identifying morbidly obese patients who will succeed following bariatric surgery remains challenging. While numerous studies have focused on preoperative factors associated with weight loss following bariatric surgery, the critical nutritional and psychological characteristics remain unclear. The purpose of this study was to measure the association between preoperative nutritional and psychological characteristics and the likelihood of successful weight loss among bariatric patients.

Methods

Our study is a retrospective cohort study of all patients who underwent primary laparoscopic Roux-en-Y gastric bypass from September 1, 2011 to June 1, 2013 at the University of Wisconsin Hospital and Clinics (124 patients). Patient demographics, comorbidities, nutritional and psychological factors, and excess weight loss were collected from the electronic medical record. “Successful” weight loss was defined as loss of ≥ 50% of excess body weight one year after surgery.  To evaluate bivariate associations between predictors and successful weight loss, Fisher’s exact and student’s T-tests were used for categorical and continuous variables, respectively. Variables significant (p<.05) in bivariate analyses were included in a multivariable logistic regression model with successful weight loss as the outcome.

Results

78% (n=97) of patients had at least one year of follow-up data and were included in analyses. Of those, 69% (67) experienced successful weight loss. Mean excess body weight loss was 69.0% (+/- 16.6%) for these patients vs. 39.0% (+/- 9.4%) for patients with suboptimal weight loss (p=0.01). In bivariate analyses, successful weight loss was associated with lower preoperative weight (268.1 vs. 301.4 lbs, p=0.02), a lower maximum past weight loss attempt (40.0 vs. 65.6 lbs, p=0.01), no diabetes history (81.4% of non-diabetics vs. 59.3% of diabetics were successful, p=0.03), being able to quit soda consumption before surgery (81.8% who quit vs. 59.3% with unchanged drinking habits were successful, p=0.04) and greater autonomy (mean percentile rank of 68.7% in successful vs. 38.8% in unsuccessful patients, p=0.01). On multivariate analysis, diabetes and a past weight loss > 50 lbs were inversely associated with success (Table 1).

Conclusion

Dietary habits and psychological characteristics were not associated with weight loss success after adjusting for measurable confounders. Identification of predictive dietary and psychological variables for patients in our program remains elusive. Diabetic patients warrant especially close follow-up after surgery given their propensity to experience suboptimal weight loss.

12.01 Variability In Same Day Discharge For Pediatric Appendicitis: An Analysis Of The KID database

Posted on December 22, 2014

T. A. Oyetunji1, E. M. Knott1, A. Desai1, B. Dalton1, K. W. Schnell1, J. J. Dehmer1, P. Aguayo1, B. C. Nwomeh2  1Children’s Mercy Hospital- University Of Missouri Kansas City,Surgery,Kansas City, MO, USA 2Nationwide Children’s Hospital,Columbus, OH, USA

Introduction:
Recent single institutional data point to the feasibility of same day discharge (SDD) after appendectomy for non-perforated appendicitis and its potential as a quality indicator of care. Also the opportunities for SDD are greatest the sooner the appendectomy is performed after admission.  We examine a national database to assess the pattern of utilization of SDD among children that had an appendectomy on the same day.

Methods:
The 2009 Kids Inpatient Database (KID) was queried for children with a diagnosis of acute appendicitis. All perforated appendicitis and those with no procedure code for open or laparoscopic appendectomy were excluded.  Day from admission to procedure day and total length of stay (LOS) were then analyzed by demographics, type of procedure (laparoscopic vs. open), children’s hospital designation and hospital region. After stratifying all patients udergoing appendectomy on day of admission into 2 groups by LOS (<=1 day vs. >1 day), a multivariate analysis was this subset to determine the predictors of prolonged LOS (>1day).

Results:
A total of 51,133 records, representing a weighed estimate of 73,956 patients with a diagnosis of non perforated appendicitis were analyzed of which 76% met the inclusion criteria of admission day appendectomy. Median age was 14 yrs with inter-quartile range (IQR) of 10- 17yrs. Median LOS was 1 day (IQR  1-2 days) and the majority (71.8%), had laparoscopic appendectomy. On adjusted analysis, laparoscopic cases were 50% less likely to be discharged later compared to their open counterparts (OR 0.50, 95% CI 0.47-0.53).  Compared to Whites, significantly more Hispanics (OR 1.44, 95% CI 1.36-1.56) and African Americans (OR 1.57, 95% CI 1.42-1.73) had a LOS > 1 day.  Table 1 shows the SDD rates based on children’s hospital designation and hospital region. 

Conclusion:
SDD is increasingly utilized for children with non-perforated appendicitis, but there is significant variability in the utilization of SDD for different ethnicities and hospital regions. Also, these data demonstrate that SDD is more likely to occur the sooner an appendectomy is performed after admission for non-perforated appendicitis. Further research is still required.
 

12.02 Pediatric Lung Malformations: Resource Utilization and Outcomes following Resection.

Posted on December 22, 2014

J. Tashiro1, J. E. Sola1, H. L. Neville1, A. R. Hogan1, E. A. Perez1  1University Of Miami,Division Of Pediatric Surgery, DeWitt Daughtry Family Department Of Surgery,Miami, FL, USA

Introduction: Congenital Cystic Adenomatoid Malformation (CCAM) and Pulmonary Hypoplasia/Sequestration (H/S) are rare lung malformations.

Methods: Kids’ Inpatient Database (1997-2009) was used to identify all CCAM and H/S patients undergoing resection. Cases were analyzed using standard and multivariate regression methods. Open and thoracoscopic CCAM resections were compared using propensity score-matched analysis (PSMA).

Results: Overall, 1,548 cases comprised the cohort (CCAM 56%, H/S 40%, both 4%). Survival was 97%. Average length of stay (LOS) decreased, while total charges (TC) increased during the study period (p<0.001). Mean age at admission was 2.2 years. CCAM had 1.4% mortality with self-pay, lowest income quartile patients, and small bedsize hospitals having higher mortality (p<0.05). H/S had 4.6% mortality with rural hospitals having higher mortality vs urban teaching hospitals, p=0.027. When pooled, survival, pneumothorax (PTX), and thoracoscopic procedure rates were higher in children having resection at ≥3 vs <3 months of age (p<0.001). Transfusion rates and LOS however, were lower in patients ≥3 vs <3 months of age (p<0.001), whereas lobectomy rates were unchanged. Analysis for ≥6 vs <6 months of age produced similar results. On multivariate analysis of the cohort, LOS was shorter in children’s general hospitals (CGH) and non-children’s hospitals (NCH) vs children’s units in general hospitals (CUGH), p<0.05. LOS was longer for older patients, those with Medicaid, and those admitted in Midwestern and Southern U.S. (all p<0.001) and for CCAM (p=0.006). TC were lower for the 2nd/3rd income quartile, but higher for Western U.S. (p<0.004) and Medicaid patients (p=0.015). Small and medium bedsize hospitals had higher mortality vs large hospitals, p<0.005. NCH and CGH had higher survival vs CUGH, p<0.04. Segmentectomy and lobectomy patients had improved survival (p<0.02), while pneumonectomy patients had higher mortality (p<0.025). PSMA for thoracoscopy vs thoracotomy in CCAM patients showed no difference in LOS, disposition, TC, resection type, or transfusion / PTX rates.

Conclusion: Surgery for CCAM and H/S has high associated survival. When analyzed by age at resection, children <3 months of age had higher mortality, thoracotomy, and transfusion rates vs those ≥3 months, though PTX were more common ≥3 months. Socioeconomic status, age, diagnosis, hospital type, and region were independent indicators for resource utilization. Hospital bed size, type, and extent of resection were independent prognostic indicators for survival. On PSMA thoracoscopic resection does not affect resource utilization, disposition, or transfusion / PTX rates.

12.03 Cost and Utilization Varies with Procedure Type in Pediatric Gastrointestinal Foreign Bodies.

Posted on December 22, 2014

J. Tashiro1, R. S. Kennedy1, E. A. Perez1, F. Mendoza2, J. E. Sola1  1University Of Miami,Division Of Pediatric Surgery, DeWitt Daughtry Family Department Of Surgery,Miami, FL, USA 2Baptist Children’s Hospital,Children’s Emergency Center,Miami, FL, USA

Introduction: In the pediatric population, ingested foreign bodies are a common cause for emergency department visits. While esophageal foreign bodies may require immediate intervention, gastrointestinal foreign bodies (GIFB) have distinct factors contributing to longer and more costly hospitalizations.

Methods: Patients with ingested foreign bodies were identified using ICD-9-CM 935.2, 936, 937, 938 within the Kids’ Inpatient Database (1997-2009). Ordinal logistic regression models were used to identify predictors of resource utilization. Esophageal ingested foreign bodies (935.1) were excluded from this cohort. Cases were weighted to project national estimates.

Results: Overall, 7,480 cases were identified. Most GIFB patients were ≥5 years of age (56%), male (54%), and Caucasian (57%) with a median (IQR) length of stay (LOS) 2 (3) days, and total charges (TC) 9,295 (14,049). A total of 2,506 procedures were performed, most commonly GI surgery (56%) followed by GI endoscopy (24%), esophagoscopy (11%), and bronchoscopy (9%). A total of 5,110 patients (68% of the cohort) did not have surgery or endoscopy and were not transferred. Psychiatric/cognitive disorders (18%) and self-inflicted/suicidal (5%) were the most common diagnoses. Intestinal perforation (1%) was rare, but intestinal obstruction (5%) was more common.

On multivariate analysis, LOS increased when cases were associated with psychiatric/cognitive disorder (OR=1.9), self-inflicted/suicidal (OR=1.6), intestinal obstruction (OR=1.7), esophageal perforation (OR=40.0), intestinal perforation (OR=4.4), exploratory laparotomy (OR=1.9), and gastric (OR=2.9), small bowel (OR=1.5), or colon surgery (OR=2.5), all p<0.02. Children admitted to hospitals in the Western U.S. had the lowest LOS vs. all other regions, while small bedsize hospitals had higher LOS (OR=1.4), p<0.05.

Higher TC were associated with intestinal obstruction (OR=2.0), endoscopy of esophagus (OR=1.8), stomach (OR=2.1), or colon (OR=3.3), and exploratory laparotomy (OR=3.6) or surgery of stomach (OR=5.6), small bowel (OR=6.4), or colon (OR=3.4), all p<0.001. Hospital mortality was 0.06% (n=5). Western U.S. hospitals had the highest TC vs. all other regions, while small bedsize hospitals had lower TC (OR=0.7), p<0.001.

Conclusion: GIFB affect older children and most do not require surgery or endoscopy. Associated psychiatric disorder or intent to self-harm is seen in over 20% GIFB patients, and surgical or endoscopic procedures are needed in one third of cases. Nevertheless, resource utilization is determined heavily by associated diagnoses and treatment procedures.

12.04 Helicopter Transport in Pediatric Trauma Patients: Are There Improved Outcomes?

Posted on December 22, 2014

S. M. Farach1, L. Bendure1, P. D. Danielson1, E. Amankwah2, N. M. Chandler1, N. E. Walford1  1All Children’s Hospital Johns Hopkins Medicine,Pediatric Surgery,Saint Petersburg, FLORIDA, USA 2All Children’s Hospital Johns Hopkins Medicine,Clinical And Translational Research Organization,Saint Petersburg, FLORIDA, USA

Introduction:  Studies have shown that survival after trauma is improved by the timely transfer of injured patients to a trauma center. There is conflicting data to support the routine use of helicopter transport for trauma patients. The purpose of this study is to evaluate outcomes for trauma patients transported via helicopter to a regional pediatric trauma center.

Methods:  The institutional trauma registry was queried for all trauma patients presenting from January 2000 through March 2012. Of 9119 patients, 1709 patients who presented from the scene were selected for further evaluation. This cohort was stratified into helicopter transport (HT) versus ground transport (GT) for analysis. Significance was defined at p ≤ 0.05.

Results: Table 1 describes select demographic and outcomes data between the groups. There were no differences between the groups with regards to age or gender. Patients arriving by HT had a higher injury severity score (ISS), lower Glasgow Coma Scale (GCS), were less likely to undergo surgery within 24 hours, were more likely to present after motorized trauma, and had longer intensive care unit (ICU) and hospital length of stay.  When controlled for ISS, patients arriving by HT had a higher rate of pre-hospital intubation, had significantly higher ICU admissions, and longer hospital length of stay. There was no difference in 30 day mortality compared to patients arriving by GT. Patients presenting from less than 20 miles were more likely to arrive by GT while those presenting from distances greater than 20 miles were more likely to arrive by HT. When controlled for ISS, there was no significant difference noted from time of injury to hospital arrival between the two transport groups at distances less than 40 miles. 

Conclusion: In distances less than 40 miles, transport to the trauma center was not improved by HT. While patients arriving by helicopter are more severely injured and arrive from greater distances, when controlling for ISS, there is no difference in mortality when compared to patients arriving by ground transport.

 

12.05 Timing of Post-Op CT Scans for Abscess in Children with Complicated Appendicitis

Posted on December 22, 2014

J. W. Nielsen1, K. Kurtovic1, B. Kenney1, K. Diefenbach1  1Nationwide Children’s Hospital,Division Of Pediatric Surgery,Columbus, OH, USA

Introduction:   Appendicitis is a common surgical problem in pediatric patients.  Many pediatric patients present to the hospital with gangrenous or ruptured appendicitis and despite surgical and medical management they form intra-abdominal abscesses with associated morbidity.  Although some have suggested that imaging for patients with suspected abscess be delayed until one week the optimal timing is a subject of debate.

Methods:   Our institutional pediatric appendicitis database was reviewed for all complex appendicitis patients (ruptured or gangrenous) who were not discharged before post-op day (POD) #5 from April 2012 to February 2014.  Patients were stratified into 2 groups: those who had a CT scan before POD #7 (Group 1, n=23) and those who did not (Group 2, n=109).   Patients who did not have a CT scan before POD #7 were further stratified into those who were afebrile (<37.5° Celsius)(Group 2a, n=68) or febrile (Group 2b, n=41) at POD #5.  Outcomes including abscess formation, number of additional CT scans, and culture data were compared.

Results: A total of 133 patients were identified who were not discharged before POD #5.  The majority of patients were male (54%) with a mean age of 10.1 years.  The drainage rate was higher for patients who underwent early CT scans: Group 1, 69.6% vs. Group 2b 42.1%, p=0.07.  No difference was found in the rate of culture positivity between Group 1 and Group 2b (73.3% vs. 72.7%, p=1.0).  Of the 23 patients in Group 1 who underwent CT scanning early, 5 patients ended up getting 2 additional CT scans compared to only 4 patients in Group 2b who got 1 additional scan each.  Twenty one of the 41 (51.2%) patients who were still febrile after POD #5 in Group 2b had a resolution of symptoms with antibiotics alone and did not need scanning or drainage.  The 68 patients in Group 2a who were afebrile but still admitted to the hospital due to other symptoms were all discharged with a resolution of symptoms without CT scanning.  In total, 89 of the 109 (81.6%) patients in Group 2 had a resolution of symptoms prior to discharge without needing a CT scan or drainage procedure with readmission of only 3 patients (3.4%) for subsequent abscess development.

Conclusions: CT scanning post-operative appendectomy patients earlier than POD #7 was associated with a higher number of repeat CT scans and an increased number of drainage procedures.  The vast majority of complex appendicitis patients who were still admitted at POD #5 had a resolution of fevers or other symptoms without CT scanning or drainage procedures and they had a low readmission rate.  Our results suggest important patient benefits in decreased CT scans and avoidance of unnecessary procedures from waiting until POD #7 or later before performing a CT scan to look for an abscess.

12.06 Histrelin Implant Treatment of Central Precocious Puberty: A Single Center Experience

Posted on December 22, 2014

S. F. Rosati1, D. Parrish1, J. Haynes2, K. Brown3, M. Poppe3, D. Lanning2  2Virginia Commonwealth University,Division Of Pediatric Surgery,Richmond, VA, USA 3Virginia Commonwealth University,School Of Medicine,Richmond, VA, USA 1Virginia Commonwealth University,Department Of General Surgery,Richmond, VA, USA

Introduction:
 

Precocious puberty is defined as the onset of secondary sexual characteristics before the age of 8 in girls and the age of 9 in boys and is associated with an increase in linear growth velocity, acceleration of bone maturation, and  can result in early epiphyseal closure if untreated. The most common cause of precocious puberty is idiopathic central precocious puberty (CPP), traditionally treated with monthly injections of depot parenteral preparations of gonadotropin-releasing hormone agonists (GnRHa). An alternative treatment is a subcutaneous implant that contains histrelin acetate, which is continuously released over one year; it is then removed or replaced with a new implant.  The aim of this study was to conduct a retrospective review of one surgeon’s experience with the histrelin implant and to examine patient satisfaction in follow-up.    

Methods:
 

After obtaining IRB approval, we conducted a retrospective review of one surgeon’s patients with CPP treated with the histrelin implant. Additionally, parents were contacted by telephone to gather satisfaction with respect to post-operative pain, cosmesis, preference to depot injections, and effectiveness.

Results:
 

Fifty-eight children, average age 8.4 years old (range 7-14) underwent at least one histrelin implant insertion for treatment of CPP. Telephone follow was achieved in 44. All 44 children received local analgesia at implantation; 32 also received conscious sedation.    Thirty-nine children (89%) had at least one implant replacement. Eight children (18%) received injections before undergoing implant insertion; the majority of the parents (88%) preferred the implant.   On average, parents’ satisfaction with the insertion of the implant rated 9.5 on a scale of 1-10 with 10 being most satisfied; parents’ satisfaction with replacement of the implant was also rated highly at 9.5.   The patients’ discomfort after initial surgical insertion was rated on average 3.9 with 10 being the most discomfort (range 1-6); discomfort after replacement and removal was even lower at 2.3 and 2.7, respectively.   Almost all of the parents (95%) stated that they would agree to have their child undergo surgical implantation again, and the majority of children (93%) returned to baseline function within 24 hours.   Parents rated the cosmetic appearance of the scar after surgery on average at 9.1.  There were no surgical complications with the placement, replacement, or removal of the implant.

Conclusion:
 

This study suggests that the using a histrelin subcutaneous implant for control of CPP provides a safe and effective method that, according to parents, is associated with minimal discomfort, allows for a quick return to normal function and activity, and is a preferred method of treating CPP when compared to depot injections in our limited subset analysis.
 

12.07 Surgical Management of Bronchopulmonary Malformations: Comparing Thoracoscopic and Open Approaches.

Posted on December 22, 2014

J. Tashiro1, A. Wagenaar1, A. C. Hirzel2, L. I. Rodriguez3, E. A. Perez1, A. R. Hogan1, H. L. Neville1, J. E. Sola1  1University Of Miami,Division Of Pediatric Surgery, DeWitt Daughtry Family Department Of Surgery,Miami, FL, USA 2University Of Miami,Department Of Pathology,Miami, FL, USA 3University Of Miami,Department Of Anesthesiology,Miami, FL, USA

Introduction: Bronchopulmonary Malformations (BPM) are rare conditions affecting the pediatric population. The spectrum of BPM encompasses congenital cystic adenomatoid malformation (CCAM), pulmonary sequestration (PS), congenital lobar emphysema (CLE), bronchogenic cyst (BC), and hybrid lesions. These focal anatomic anomalies typically arise below the carina and can result in significant morbidity (infection/hemorrhage) and mortality (respiratory failure).

Methods: After IRB approval, all children with BPM surgically treated from 2001-2014 at a tertiary care children’s hospital were identified. Patient demographics, surgical indications, procedure type, estimated blood loss (EBL), pathology, perioperative complications, length of stay (LOS), and outcomes were analyzed using standard statistical methods.

Results: Overall, 41 patients with BPM had surgery (39 thoracic/ 2 abdominal) over the study period (CCAM 19, PS 8, CCAM/PS hybrid 6, CLE 6, BC 5). Our cohort was 51% male with a median age (IQR) at resection of 11 (19) months, weight of 9.1 (5.1) kg. Overall survival was 98% (one CDH/ECMO abdominal BPM expired) but 100% for thoracic lesions. Analysis of thoracic lesions revealed a median (IQR) operative time of 140 (45) minutes, EBL 1.47 (1.90) ml/kg, chest tube (CT) days 4 (4), LOS 5 (5) days, and a complication rate of 26% (21% pulmonary). The left and right lower lobes were most commonly resected (39% and 24%, respectively) and 27% of lesions had a systemic artery. Resections were performed thoracoscopically (38%), thoracoscopy converted to open (23%), and via thoracotomy (38%). Conversions to thoracotomy were due to poor visualization (66%) or inability to tolerate single lung ventilation (33%). There were no conversions due to hemorrhage or blood transfusions in thoracoscopy patients. Patients undergoing thoracoscopic surgery were more likely to have a prenatally diagnosed BPM (OR: 18.2) v. open/converted, p=0.002. Open/converted surgery patients had longer CT days (6.2) vs. thoracoscopic (2.9), p=0.048. BPM with a systemic artery (PS/hybrid) were more commonly resected thoracoscopically (OR: 6.1) than open, p=0.047. Additionally, respiratory distress was a more common indication in patients <4 months old (OR: 28.0) vs. ≥4 months, and patients weighing <6 kg (OR: 40.5) vs. ≥6 kg, p<0.05. Similarly, procedures were started as open resections at a higher rate in patients <4 months old (OR: 8.8) and weighing <6 kg (OR: 24.0) vs. ≥4 months and ≥6 kg, respectively, p<0.05. Operative time was lower for <6 kg vs. ≥6 kg, p=0.035.

Conclusion: BPM resections are procedures with high overall survival over a 14-year experience at a large tertiary care children’s hospital. Chest tube days are shorter among thoracoscopic patients but conversion to thoracotomy for poor visualization avoids hemorrhage and need for transfusion. Size and respiratory distress limit use of thoracoscopy in young infants with BPM.

12.08 Pectus Excavatum-To Randomize or Not To Randomize

Posted on December 22, 2014

B. G. Dalton1, K. W. Schnell1, A. A. Desai1, S. W. Sharp1, S. D. St. Peter1  1Children’s Mercy Hospital- University Of Missouri Kansas City,Pediatric Surgery,Kansas City, MO, USA

Introduction:  Minimally invasive bar repair for pectus patients produces substantial pain which dictates the post-operative hospital course.  We conducted a randomized trial comparing epidural catheter placement to patient controlled analgesia and second trial comparing these 2 strategies is under way.  The purpose of this study was to compare the outcomes of patients who were enrolled in the trials to those did not participate in the trials. 

Methods:  A retrospective chart review was performed on patients not enrolled in the trials to compare to the prospective datasets from October 2006 to June 2014.  Perioperative outcomes including length of stay (LOS), pain scores, time to PO diet, operative time and complication rate were examined.  Pain scores were calculated with a visual analog system (VAS).  Findings are reported in mean ± standard deviations.  Comparative analysis was performed using student t test

Results: There were 135 patients in a study protocol (IS) and 195 patients that were not enrolled in a study (OS).  Of the IS patients, 23.4% (n=15 of 64) had epidural failure for pain control compared to 45.9% (n=17 of 37) of OS patients (p<0.01).  In the PCA groups LOS was less in the IS group vs OS group (4.5d vs 4.1d, p=0.02).  Comparing the entire IS and OS groups, LOS was less in the IS group, as was time to PO diet. Average pain scores, operative time and complication rates, including bar malposition, bar infection and wound infection, were not significantly different between the groups (table).

Conclusion: 

There are clear clinical benefits derived from participating in our randomized trials comparing epidural to patient controlled analgesia after bar placement for pectus excavatum regardless of which arm is utilized.  

 

12.09 Same Day Discharge of Pediatric Laparoscopic Cholecystectomy Patients

Posted on December 22, 2014

B. G. Dalton1, K. W. Schnell1, E. M. Knott1, S. D. St. Peter1, P. Aguayo1  1Children’s Mercy Hospital- University Of Missouri Kansas City,Pediatric Surgery,Kansas City, MO, USA

Introduction:  Although historically thought to be a fairly uncommon problem in the pediatric population, gallbladder disease, symptomatic cholelithiasis (SC) and biliary dyskinesia (BD) in particular, is being increasingly diagnosed in the pediatric population.  In the United States, the accepted surgical approach for symptomatic gallbladder disease in both adults and in children has been laparoscopy.  While the safety of same day discharge (SDD) after laparoscopic cholecystectomy (LC) in adults has been well documented in the literature, the same data in the pediatric population is lacking.  We have recently instituted a protocol for SDD after LC for SC and BD and this study is an analysis of our initial experience.  

Methods:  A retrospective chart review of all patients who underwent laparoscopic cholecystectomy for BD and SC in our institution from January 2011 to July 2014 was performed. Time from operation to discharge, reason for overnight stay, complications, readmissions, and follow-up prior to scheduled appointment were analyzed. The Student t test was used for statistical analysis. 

Results: A total of 227 laparoscopic cholecystectomies were performed for SC and BD during the study period.  Approximately 25% (n=57) of patients were discharged on the day of surgery.  The remaining 75% (n=170) of patients were admitted at least one night for the following reasons:  medical 16.5% (n=28), surgery ending too late 4.1% (n=7) or clinical care habits 79.4% (n=135).   Comparing patients that were discharged the same day with patients that stayed overnight, no differences were found in complication rate (3.5% vs 5.8%, P=0.44), readmissions (5.3% vs 1%, P=0.12) or follow up prior to scheduled appointment (3.5% vs 2.9%, P=0.84).  Length of stay was significantly less for the SDD group than the inpatient group (4.1h vs 26.8h, p<.01).   A trend for more SDDs was observed as time elapsed from initiation of the protocol.  From January 2013 (the month of the first SDD) through September 2013, 34% (18/53) of pts undergoing LC  were discharged the same day.  October 2013 through July 2014, 55% (36/69) of patients were sent home the same day.  Also, earlier completion of surgery trended toward SDD (figure).

Conclusion:  Same day discharge appears safe for pediatric patients undergoing laparoscopic cholecystectomy for BD or SC.  The main obstacles to discharge were time of surgery completion and clinical care habits, both of which improved as comfort level with SDD grew among the staff.

 

10.01 Characteristics and Resource Utilization in Pediatric Blunt and Penetrating Trauma

Posted on December 22, 2014

J. W. Nielsen1, J. Shi2, K. Wheeler2, H. Xiang2, B. D. Kenney1  1Nationwide Children’s Hospital,Division Of Pediatric Surgery,Columbus, OH, USA 2Nationwide Children’s Hospital,Center For Injury Research And Policy At The Research Institute,Columbus, OH, USA

Introduction:  Trauma is a leading cause of pediatric morbidity and mortality.  Children suffer both from blunt and penetrating injuries but the differences in resource utilization based on cause is not well studied.

Methods:  The National Trauma Data Bank (NTDB) was analyzed for all patients 0-18 years of age with ICD-9 external-cause-of-injury codes for blunt and penetrating trauma from 2007-2012.  Demographics, causes, treatments, complications, and outcomes were assessed.   T-test for continuous variables, and Chi-square tests for categorical variables were performed with a significance level of p<0.05.

Results: A total of 748,347 pediatric trauma patients were assessed.  Blunt trauma was identified as the cause in 601,898 (80.43%) patients compared to 55,597 (7.4%) patients with penetrating trauma.  Blunt trauma patients were younger on average (10.2 years vs. 14.7 years, p<0.001) and more likely to be female (34.5% vs. 16.4%, p<0.001).   Despite having only a slightly higher mean ISS (injury severity score) (7.9 vs. 7.6, p<0.001), blunt trauma patients had shorter lengths of stay (LOS) in the hospital (2.9 vs. 4.3 days, p<0.001), fewer complications (34.8% vs. 38.6%, p<0.001), and a much lower mortality rate (1.3% vs. 7.1%, p<0.001).  Penetrating trauma patients were more likely to receive transfusions (5.5% vs. 1.8%, p<0.001) and to undergo exploratory laparotomy (9.4% vs. 0.9%, p<0.001) and thoracotomy (1.7% vs. 0.07%, p<0.001).  Blunt trauma patients were more likely to undergo CT scanning (23.4% vs. 13.0%, p<0.001).  African American mortality was higher than Caucasians for both penetrating (7.9% vs. 5.2%, p<0.001) and blunt (1.3% vs. 1.1%, p<0.001) trauma.

Conclusion:   Blunt trauma is much more common than penetrating trauma among pediatric patients. Blunt trauma patients have shorter LOS, less complications, and lower mortality than penetrating trauma patients.  Penetrating trauma patients are more likely to need operative intervention and blood transfusions.  Racial disparities in outcome exist.

 

10.02 Identification of risk factors for cervical spine injury from pediatric trauma registry

Posted on December 22, 2014

A. S. Chaudhry1, S. Bloom1, J. McGinn1, C. Fasanya1, J. Schulz1, M. Price1  1North Shore University And Long Island Jewish Medical Center,Staten Island University Hospital/ Surgery,Manhasset, NY, USA

Cervical spine injuries (CSI) are rare in children. A vast majority is related to blunt trauma, occurring in less than 1% of those evaluated. So far, there is no established standardized protocol in the pediatric population to clear the cervical spine. Exposing children to harmful radiations due to excessive CT scan runs a risk of malignancy, that is 25% higher in the exposed group. The Canadian C-Spine rule and National Emergency X-Radiography Utilization Study (NEXUS) criteria for adults are more than 99% sensitive for identifying cervical spine injuries in adults.  The purpose of this study is to evaluate certain risk stratification strategies for identification of cervical spine injury (CSI) in pediatric trauma patients. 

Methods

With IRB approval we retrospectively reviewed the records of Pediatric Trauma Registries from two state designated level 1 pediatric trauma centers for 11 years (January 2002 and June 2013),inclusive. Patients age 1 month to 17 years who had a CT of the C-spine and evaluated for Cervical Spine Injury (CSI). We identified variables associated with increasing incidence of CSI in the literature and evaluated all patients as per these variables. The Age, Gender, Injury severity score (ISS), Glasgow coma score (GCS), LOC (Loss of consciousness), neck tenderness, significant injuries, and mechanism of injuries were examined for differences based on the presence or absence of cervical spine Injuries (CSI).

Results

A total of 220 cases were reviewed 46 (21%) were positive for CSI and 174(79%) were negative for CSI. Patients with a positive CSI were male (p=0.0261) had ISS > 25 (p=0.00076) and presented with neck tenderness (p=0.0001). The most common mechanism of injury was motor vehicle crashes (39%). LOC unexpectadly was not associated with having CSI (p=0.0003). Upper CSI (C1-C4) were more prevalent inyounger age group (0-8yrs) i.e (82.35%), while lower CSI (C5-C8) were more common in older children (9-16yrs) i.e (44.83%). However this result was not statistically significant (p=0.0617). There was statistically no significant association between CSI and Age, GCS, other significant injuries, or mechanism of injury.

 

Conclusion:

In our study significant CSI is related to male gender, higher ISS and neck tenderness. Patients with significant ISS and those with neck tenderness require diagnostic imaging appropriate for patients who have a higher likelihood of CSI. We propose a protocol for cervical spine injury clearance in children based on this data. Those patients who do not need the above criteria may be saved from undergoing excessive CT scans, in an effort to lower children radiation exposuretion:

 

10.03 Predictors of Mortality Following Pediatric Burns: a 20-year Review of an ABA-verified Burn Center

Posted on December 22, 2014

J. P. Meizoso1, C. J. Allen1, J. J. Ray1, C. M. Thorson1, L. R. Pizano1, N. Namias1, K. G. Proctor1, J. E. Sola2, C. I. Schulman1  1University Of Miami,Trauma, Surgical Critical Care, And Burns,Miami, FL, USA 2University Of Miami,Pediatric And Adolescent Surgery,Miami, FL, USA

Introduction:  Although trauma is the leading cause of death and morbidity in children in the US, pediatric burns continue to represent a large source of morbidity with an estimated 30,000 children requiring inpatient admission every year for treatment. In addition, children account for approximately 25% of burn deaths each year. The objective of this study is to identify major predictors of mortality in the pediatric burn population at a large American Burn Association verified burn center.

 

Methods:  A retrospective review of all pediatric burn patients (≤ 17y) from January 1993 to December 2013 were surveyed. Demographics, laboratory studies, total body surface area (TBSA) burn, need for emergent procedures, length of stay (LOS), and survival were obtained. Univariate analysis was performed to identify factors significantly associated with mortality. A multiple logistic regression model was used to identify independent predictors of mortality. Data are expressed as M±SD if normally distributed or median (interquartile range) if not.

 

Results: 943 patients evaluated at our center were average age 4.9±5 years, 63% male, 44% black, 33% white, and 21% Hispanic, TBSA 8%(28), base deficit -2 mEq/L(8), Glasgow Coma Scale (GCS) 15(0), scene GCS 15(0), and hospital LOS 3(30) days. The vast majority of burns occurred at home (95%). Only 14% of patients had a TBSA burn >20%. Intubation was required in 6.7% of patients. Overall mortality was 2.3%. Initial base deficit [-8(11) vs -2(8), p<0.001], bicarbonate level (18±5 vs 23±3, p<0.001), hematocrit (46±11 vs 34±12, p=0.012), pCO2 (49±21 vs 41±10, p=0.013), pH (7.24±0.15 vs 7.36±0.09, p<0.001), scene GCS [3(12) vs 15(0), p<0.001], hospital GCS [3(12) vs 15(0), p<0.001], TBSA [50(55) vs 7(25), p<0.001], and the need for intubation (67% vs 5.4%, p<0.001) were significantly associated with mortality on univariate analysis. The logistic regression model identified TBSA burn [odds ratio (OR): 1.09, confidence interval (CI): 1.03-1.15] and scene GCS (OR: 0.83, CI: 0.68-0.99) as significant independent predictors for mortality (area under receiver operator characteristic curve: 0.979).

 

Conclusion: Pediatric burn patients are typically young and male with predominantly small burns (<20% TBSA) that occur in the home. Overall mortality over a 20-year period in our burn center was 2.3%. Independent risk factors for mortality included TBSA burn and Glasgow Coma Scale at the scene of the incident. This suggests pre-hospital determinants such as GCS might serve as an indicator for poor outcome in the pediatric burn patient.

 

10.04 Outcomes in Pediatric Trauma Patients: ‘Alerted’ vs. 'Non- Alerted’

Posted on December 22, 2014

C. G. Dessaigne1, K. J. Caldwell1, S. D. Larson1, J. A. Taylor1, D. W. Kays1, S. Islam1  1University Of Florida,Gainesville, FL, USA

Introduction:  Trauma centers and the triage or ‘alert’ system has been shown to save lives. There remain issues with both over and under triage however, and that may result in significant expense to the hospital, or potentially increased morbidity to the patient. The purpose of this study was to compare the presentation and outcomes in children with trauma that presented after an alert or not. 

Methods:  IRB approval was obtained and data collected for a retrospective cohort analysis of all pediatric trauma patients (less than 16 years of age) between May 2010 and August 2013. Data regarding demographics, trauma details, ED and hospital course, and outcomes were collected. Patients were in either the ‘alerted’ or ‘non alerted’ groups, and an age and ISS matched cohort was selected for comparison. 

Results: We found 359 ‘alerted’ and 1004 ‘non-alerted’ patients during the study period. Overall, the mean ISS, median GCS was higher in the ‘alerts’.  After selecting an age and ISS matched cohort of ‘non alerts’, we performed Univariate analyses. Physiologic parameters of heart rate and systolic/diastolic BP, and respiratory rate were statistically higher in the alerted patients, but clinically not different.  Median GCS was equivalent. The mortality rate was not different (3.6 vs. 1.6%), and there were no missed injuries in the non-alerted group. The ICU and overall hospital LOS was slightly greater in the alerted group, with an equivalent number of procedures and consults being done (table). In addition, we noted that 26% of the ‘alerts’ were based on the criteria of paramedic discretion. Separate analysis of this group noted that 62% were admitted to the floor, 6% were discharged home after being downgraded from an alert, and there was only one patient with a GCS less than 13. This reduced the discriminating power of a trauma 'alert'.

Conclusion: We noted a 25% rate of trauma alerts during the study period. The alerted patients presented with minimal physiologic change compared to the non alerts, and the outcomes were not significantly different including mortality. This suggests that the triage system may need to be adjusted. Education of paramedics would be helpful in reducing the number of unnecessary alerts and improve the cost efficiency of the system. 

 

10.05 Epidemiology and Cause-Specific Outcome of Facial Fracture in Hospitalized Children in the US.

Posted on December 22, 2014

T. Soleimani1, T. M. Bell2, Y. Tahiri1, R. Sood1, R. L. Flores1, N. Nosrati1, S. S. Tholpady1  1Indiana University School Of Medicine,Plastic Surgery,Indianapolis, IN, USA 2Indiana University School Of Medicine,Surgery,Indianapolis, IN, USA

Introduction:
Facial fractures in the pediatric population, although less common than in adults, have a significant impact on public health and the US economy. Although some demographic data exists regarding the overall epidemiology of facial fractures in adults and children, little attention has been paid to the patterns of facial fractures based on the etiology of the trauma. This study was designed to provide a more thorough analysis via a large dataset.

Methods:
The KID (Kid Inpatient Database) was used to analyze pediatric facial fractures. Data from years 2000-2009 was studied. 21,533 patients aged 0-17 were identified using ICD-9 diagnosis codes for facial fractures. National estimates of incidence and distribution of pediatric facial fracture by mechanism were obtained. Association of demographics with mortality and length of stay (LOS) as the outcomes of interest was assessed by bivariate analysis using SAS.

Results:
The incidence of facial fractures increased with age and 49% of patients were 15 to 17 years old. 70% of the patients were male. 59% of patients were white, 18% were African-American, and 15.6% were Hispanic. The most frequent primary payer was private insurance (54%) followed by Medicaid (25%). Most of the patients were admitted at large (68%), urban (94%), teaching (75%) hospitals. The top 4 trauma mechanisms were motor vehicle accident (MVA) (43%), intentional trauma (IT) (17%), falls (11%) and non-intentional trauma (NIT) (9%). Compared to other trauma mechanism groups, patients in the IT group were more likely to be older, male, African-American, low income, covered by Medicaid, and treated in northeastern hospitals. 47% of patients had concomitant injuries including skull fracture, intracranial injuries, and cervical spine injuries. The overall mortality rate was 2.0%. Mortality was highest in the MVA group (3.4%) followed by IT group (0.6%). Having concomitant injury was associated with a higher mortality. In MVA, IT, and NIT groups, younger age was associated with higher rate of concomitant injury. Compared to male patients, female patients were more likely to have concomitant injury and mortality in IT and NIT groups. They were less likely to have concomitant injury in MVA group. In all four groups, mortality rate decreased by age and longer LOS was associated with African-American race, Medicaid payer, and receiving treatment at urban, teaching, and public hospitals.

Conclusion:
This study shows that the epidemiology and pattern of pediatric facial fracture differs based on the etiology of the trauma. Increasing incidence of facial trauma by age suggests increased vulnerability of the face in older children and higher risk-taking behavior in this group. The analysis demonstrated young female victims have a greater risk of mortality and that LOS increases with African-American race. Because poor outcomes are more likely in vulnerable populations, further analysis of the causes of increased mortality and LOS is warranted.
 

10.06 Predictors of Mortality in Pediatric Urban Firearm Injuries.

Posted on December 22, 2014

J. Tashiro1, C. J. Allen2, E. A. Perez1, H. L. Neville1, C. I. Schulman2, J. E. Sola1  1University Of Miami,Division Of Pediatric Surgery, DeWitt Daughtry Family Department Of Surgery,Miami, FL, USA 2University Of Miami,Division Of Trauma And Critical Care, DeWitt Daughtry Family Department Of Surgery,Miami, FL, USA

Introduction:
Although firearms account for less than 5% of all pediatric injuries, they have the highest associated case fatality rate. In the U.S., pediatric hospitalizations and deaths from firearms have continued to increase with most of these injuries occurring in metropolitan settings. We sought to examine factors associated with mortality due to firearm injuries in pediatric patients treated at an urban trauma center.

Methods:
We queried the trauma registry at a large, urban, Level 1 trauma center for all patients aged <18 years evaluated for firearm injuries from 1991-2011. Descriptive statistics and risk-adjusted multivariate analyses (MVA) were used.

Results:
Overall, 1085 patients were identified. The cohort had a median (IQR) age of 16 (2) years, LOS 2.4 (4.3) days, and most were male (86%), black (74%), sustained intentional injuries (93%) and were admitted to hospital (68%). The most commonly injured locations were abdomen (20%), extremities (19%), and chest (15%). Immediate operations were performed in 33% (n=358) of patients with most having abdominal surgery (n=214). Survival was 86% (7% expired in emergency department), but higher for blacks (OR=1.92) than for Hispanics (p=0.006). Blacks were more likely to sustain extremity (OR=2.26) and less head (OR=0.36) injuries than Hispanics (p<0.001), see Table. Analysis by injury location showed that head (OR=14.1) had the highest associated mortality followed by multiple major by Abbreviated Injury Scale (AIS) with central nervous system (7.30), chest (OR=2.68), and multiple major by AIS (OR=2.52) compared to abdomen (p<0.02). Most deaths occurred in patients with head (43%) or chest (21%) gunshot wounds. No fatalities occurred following scalp, face, or extremity injuries. MVA demonstrated that white children were 8.06 times more likely to die from a firearm injury than Hispanics (p=0.013). Children admitted with initial pH ≤ 7.15 (OR=21.8), initial hematocrit ≤ 30 (OR=4.69), or Injury Severity Score (ISS) > 15 (OR=7.73) had higher mortality rates (p<0.006).

Conclusion:
Analysis of pediatric firearm injuries treated at an urban trauma center demonstrates that most patients are male, black, teenagers who are more likely to sustain extremity rather than higher mortality head injuries seen more frequently in whites and Hispanics. On risk-adjusted MVA, white children are more likely to die than Hispanics. Initial pH, hematocrit, and ISS are significant independent predictors of mortality following firearm injury in children.

 

10.08 Dysphagia: An Underappreciated Complication in Cervical Spine Injury

Posted on December 22, 2014

J. C. Lee1, A. Vellucci1, B. W. Gross1, K. J. Rittenhouse1, C. Morrison1, F. B. Rogers1  1Lancaster General Hospital,Trauma,Lancaster, PENNSYLVANIA, USA

Introduction: Severe cervical spine (c-spine) injuries requiring rigid immobilization are associated with high rates of dysphagia and complications. Research suggests a geriatric predisposition to this complication. We sought to compare the incidence of dysphagia in the geriatric and general population for patients with c-spine injuries and propose an aggressive screening program that aims to decrease morbidity.

Methods: All trauma admissions to a level II trauma center from January 2010 to April 2014 with c-spine injuries were retrospectively reviewed. C-spine injury was classified as any ligamentous or vertebral body fracture. Patients were considered to have signs of dysphagia if a speech evaluation and/or a barium swallow (VFSS) was conducted, indicating a failure of preliminary bedside nursing assessment. The relationship between dysphagia development and age was assessed using X2 analysis (significance p<0.05). Development of pneumonia was considered a complication.

Results: Over the four-year study period, 537 c-spine injured patients were admitted. Of this, 144 total patients (26.8%) exhibited signs of dysphagia, 105 (72.9%) of which were geriatric and 39 (27.1%) general. Geriatric patients were found to be associated with higher rates of speech evaluation (p<0.001) and barium swallow (p=0.022), while the general population was associated with higher rates of pneumonia (p=0.021) (Table 1).

Conclusion: The high rate of speech evaluation and even higher incidence of formal contrast swallow studies in the geriatric population suggests a significant presence of dysphagic symptoms following c-spine injury. The low prevalence of pneumonia in the geriatric population may reflect the preventative measures taken due to heightened awareness of this susceptible population. Therefore, a formal speech therapy evaluation for dysphagia should be strongly considered in all trauma patients with c-spine injuries, and mandatory for those over the age of 65. 
 
 

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