97.19 Mortality in Children with Necrotizing Enterocolitis Totalis: A Review of the Literature

Posted on January 31, 2019

K. Dukleska1, A. E. Martin1,2, J. Miller3,4, K. M. Sullivan3,4, C. Levy3,4, S. Prestowitz2, K. Flathers2, C. D. Vinocur1,2, L. Berman1,2  1Thomas Jefferson University,Surgery,Philadelphia, PA, USA 2Nemours/Alfred I. duPont Hospital for Children,Surgery,Wilmington, DE, USA 3Nemours/Alfred I. duPont Hospital for Children,Pediatrics,Wilmington, DE, USA 4Thomas Jefferson University,Pediatrics,Philadelphia, PA, USA

Introduction:
Necrotizing enterocolitis totalis (NEC-T) was once thought to be uniformly fatal, and is generally accepted to have poor outcomes. This perception may lead to limitation of the options that are offered for infants with this condition. Therefore, we sought to better understand how NEC-T is defined in the literature and quantify reported mortality in these patients.

Methods:
A systematic literature review was conducted in accordance to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A web-based search was performed to identify studies reporting outcomes on necrotizing enterocolitis. Identified abstracts were screened independently in triplicate and a consensus was required for inclusion. Results were pooled, definitions used for NEC-T were captured, and outcomes were described.

Results:
A total of 766 abstracts were screened, of which 166 met inclusion criteria for review of the full article. From the reviewed articles, 35 included data on a total of 501 patients with NEC-T. There was no consensus regarding the nomenclature or definition of NEC-T. The most common terms used were total involvement of the small bowel (29.4%) and pan-intestinal involvement, which denoted involvement of small and large bowel (20.6%). Length of viable bowel or whether or not the ileocecal valve remained was not standardly captured, even in more contemporary reports. Operative interventions performed for NEC-T included exploratory surgery, placement of peritoneal drains, and, very infrequently, bowel resections. The aggregate reported mortality rate was 345/400 patients (86.3%), with limited details on long-term outcomes.

Conclusion:
NEC-T mortality is high, and the aggressiveness of surgical intervention appears to be low. As advances are made in maintaining long-term durable intravenous access and preventing parenteral nutrition-related liver failure, it is likely that survival prospects for these patients will improve. This study highlights the importance of establishing a standardized definition for NEC-T and prospectively tracking outcomes in these patients. A better understanding of the range of possible outcomes will facilitate more informed decision-making for patients with NEC-T.

97.18 Survey on Post-procedural Opioid Prescribing in Children

Posted on January 31, 2019

E. A. Hedges1, M. Browne2, K. P. Moriarty4, M. V. Raval6, D. H. Rothstein5, D. Wakeman1  1University Of Rochester,Division Of Pediatric Surgery,Rochester, NY, USA 2Lehigh Valley Health Network,Division Of Pediatric Surgery,Allentown, PA, USA 4University Of Massachusetts Medical School-Baystate,Division Of Pediatric Surgery,Springfield, MA, USA 5State University Of New York At Buffalo,Division Of Pediatric Surgery,Buffalo, NY, USA 6Children’s Hospital of Chicago,Division Of Pediatric Surgery,Chicago, IL, USA

Introduction:
North America is in the midst of an opioid epidemic. Deaths from synthetic opioids have risen dramatically in the last several years and have been the focus of significant policy changes in adults. However, the role that children’s surgeons play remains incompletely understood. We conducted a survey of surgeons and proceduralists that care for children to better understand post-procedural opioid prescribing patterns in the pediatric population. We hypothesized that opioid prescribing was common, but varied by patient age.

Methods:
After Institutional Board Review approval, we performed an online survey of 1903 pediatric surgeons and proceduralists (General, Plastic, Urologic, Orthopedic, Otolaryngologic, Ophthalmologic, Cardiac, and Oral Health) who are active members in the American Academy of Pediatrics. The survey inquired about post-procedural prescribing patterns of opioid and non-narcotic pain medications. Perceptions about the magnitude of the opioid epidemic and the role of children’s surgeons were also queried.

Results:
The response rate was 10%. Two-thirds of respondents prescribe opioids themselves. Less than a third of providers utilize a tool to check for prior controlled substance prescriptions routinely. Most respondents utilize acetaminophen (86%) and ibuprofen (80%) post-procedurally > 75% of the time, while gabapentin [25% rarely (<25% of the time), 67% never] and lidocaine transdermal patches (14% rarely, 68% never) are infrequently prescribed. Opioid prescribing increases with age after outpatient and inpatient procedures (see figure). 81.6% of respondents believe the opioid epidemic is a major problem nationally, while only 31.4% believe that pediatric surgical specialists have a major role in helping to control the opioid epidemic.

Conclusion:
Opioid prescribing following surgery in the pediatric population is common. Surgeons are more likely to prescribe opioids post-procedurally as patient get older. While children’s surgeons report the opioid epidemic to be a major problem nationally, fewer believe they have a major role to curb it. Given the magnitude of the opioid epidemic in North America, further efforts are needed to reduce access to opioids in all patient populations. 
 

97.17 Utilization and Accuracy of Appendicitis Imaging at Pediatric and Non-pediatric Facilities

Posted on January 31, 2019

R. Jones1, K. M. Gee1, S. Preston1, A. Beres1  1University of Texas Southwestern Medical Center,Division Of Pediatric Surgery, Department Of Surgery,Dallas, TX, USA

Introduction:
Diagnostic imaging in pediatric appendicitis may decrease rates of negative appendectomy and identify alternate pathologies. Many children with abdominal pain are initially evaluated at non-pediatric facilities, and subsequently transferred to dedicated pediatric centers for surgical management once a diagnosis of appendicitis is established. We compared imaging practices for children transferred from non-pediatric facilities versus directly admitted to our tertiary children’s hospital for appendicitis, and assessed the diagnostic accuracy in each population based upon final pathologic diagnosis.

Methods:
After IRB approval, we retrospectively reviewed all cases of laparoscopic appendectomy at our children’s hospital during 2015. Demographic and clinical data were collected, including age, transfer status, imaging studies performed, and diagnostic accuracy. Imaging studies included computed tomography (CT) and ultrasound. Diagnostic accuracy was defined by confirmed appendicitis on pathology report. Descriptive and comparative statistics were performed. 

Results:
There were 1069 patients who underwent laparoscopic appendectomy for acute appendicitis during the study period. A large subset of our cohort was transferred from non-pediatric facilities (197 patients, 18.4%). Of transferred patients, 71.6% underwent preoperative CT scan, compared to 25.5% of non-transfer patients (p<0.000). Patients who presented directly were more likely to receive multiple imaging studies as compared to patients from outside centers (13.5% versus 5.1%, p=0.001). Of the additional studies performed in directly presenting patients, 91.5% were CT scans which were undertaken after inconclusive ultrasound. Rates of negative appendectomy were similar in non-transfer versus transferred patients (1.6% versus 2.0%, p=0.758). Logistic regression analysis revealed no combined influence initial study choice and transfer status on diagnostic accuracy (p=0.892)

Conclusion:
Our results show that non-pediatric facilities use CT more frequently to diagnose pediatric appendicitis. Contrastingly, CT is employed discriminately after nondiagnostic ultrasound at our tertiary pediatric center. The increased rate of CT use by adult centers does not confer diagnostic advantage as evidenced by equal rates of nontherapeutic surgery in each group. Transferring centers should strive to rely more heavily upon ultrasound, which may require education and development of improved pediatric ultrasound capacity.

 

 

97.16 Using a Standardized Script and Process Further Improves Pediatric OR to ICU Handoffs

Posted on January 31, 2019

K. Sheppard1,4, K. E. Anthony1,4, A. Kubanda4, D. C. Salley4, C. H. Bryndzia3,4, R. R. Jain2,4, N. Wadwha2,4, K. P. Lally1,4, K. Tsao1,4, A. L. Kawaguchi1,4  1McGovern Medical School at UTHealth,Department Of Pediatric Surgery,Houston, TX, USA 2McGovern Medical School at UTHealth,Department Of Anesthesia,Houston, TX, USA 3McGovern Medical School at UTHealth,Department Of Pediatrics,Houston, TX, USA 4Children’s Memorial Hermann Hospital,Houston, TX, USA

Introduction: Medical errors are one of the leading causes of death in the United States and lapses in communication during patient handoffs have been identified as a significant contributor to medicals errors nationwide. We hypothesized that a scripted, standardized handoff protocol for all pediatric surgical patients transferred from the operating room to an intensive care unit will improve team member presence, information exchange, and communication. 

Methods:  A three-staged pre/post intervention observational study was conducted for the handoffs of pediatric patients from the operating room (OR) to the neonatal (NICU) and pediatric (PICU) intensive care units. The pre-intervention group (Group A) did not have a standardized handoff process. The first post-intervention group (Group B) used a standardized handwritten handoff form, while the second post-intervention group (Group C) used a standardized handoff process that included scripted questions developed by a multidisciplinary team of physicians. Team member presence at handoff, length of the handoff, number of distractions, and the transfer of essential patient and procedural information were measured through direct observation. 

Results: Direct observation was done for 24, 36, and 45 handoffs in groups A, B, and C respectively. While the anesthesia team was nearly always present at the handoffs (96, 100, 100%), the surgical (4, 64, 73%) and ICU (38, 86,100%) teams vastly improved their attendance at handoffs. The time required for handoffs did not change significantly in the three groups (3.1 ± 2.8, 4.1 ± 3.0, and 3.5 ± 1.9 minutes, respectively). Patient care distractions during handoffs decreased over the three intervention periods (54%, 22%, and 11% of handoffs, respectively). The transfer of essential patient and procedural information improved with each intervention for the surgical teams (see chart). Anesthesiologists had stable reporting of airway concerns and opioid administration (88, 94, 88% and 87, 97, 95% for groups A, B, and C, respectively). Anesthesiologists showed modest improvements in relaying information about opioid and paralytic administration and dosage (50, 58, 75%, and 58, 86, 95% for groups A, B, and C, respectively). Antibiotic name and dosage were improved, but still missed almost half of the time (21, 44, 59% and 21, 36, 45% for groups A, B, and C, respectively). 

Conclusion: Implementation of a scripted, rather than a written, standardized handoff process improved team member presence, decreased distractions, and further improved the transfer of information during handoffs. Future efforts will focus on improving adherence to the scripted handoff protocol and examining the relationship between handoffs and patient outcomes.

97.15 Routine Chest Radiographs in Children after Image-guided Central Lines Offer Little Diagnostic Value

Posted on January 31, 2019

A. J. Cunningham1, M. Boulos1, K. V. McClellan1, S. Krishnaswami1, N. A. Hamilton1  1Oregon Health And Science University,Division Of Pediatric Surgery, Department Of Surgery,Portland, OR, USA

Introduction:
Technical complications following image-guided central venous line (CVL) placement in children are uncommon, occurring in 1.3-1.6% of cases. Severe complications requiring intervention are even less frequent. Despite this and the accuracy of modern, image-guided line insertion techniques, the practice of routine postoperative chest x-ray to detect occult complications persists. This study aims to investigate the utility of this practice.

Methods:
A retrospective review was conducted of all CVLs placed by 15 pediatric surgeons at 2 institutions from January 1, 2010 through June 30, 2016. Demographic data, vessel accessed, use of intraoperative imaging and technical complications were analyzed. Statistical analysis was performed using analysis of variance as appropriate for demographic data and Fisher’s exact test for the relationship of postoperative imaging to technical complications.

Results:
During the period of analysis, 1102 lines were placed in 937 patients. Demographic data and technical complications are shown in Figure 1. Fluoroscopy was utilized in 1078 lines (97.8%) and 556 were ultrasound-guided, internal jugular placements (50.4%). There were 914 postoperative chest radiographs (82.9%). An abnormality was seen on 44 radiographs (4.8%), with only 28 (3.1%) ultimately identifying any complication. The utilization of a postoperative chest radiograph was independent from complications (p = 0.52). There were 39 (3.5%) postoperative complications occurring in 35 patients, including 12 pneumothoraces (1.1%), 12 hemothoraces (1.1%), 7 malpositioned catheters (0.6%), and 1 mortality (0.09%) in a patient who did not have any findings of a technical complication on autopsy.  Twenty-one of these patients (60%) were managed with observation and a repeat chest radiograph alone. Thirteen (37%) patients required 16 interventions: 7 tube thoracostomies, 7 re-operations and 2 thoracotomies. Of all patients, only 1 complication requiring intervention (0.09%) was identified solely by post-operative chest radiograph without either prior intraoperative recognition or postoperative symptomatology.

Conclusion:
To our knowledge, our data represent the largest analysis of technical complications following image-guided CVL placement in the pediatric population. Routine postoperative chest radiographs offer minimal value in identifying clinically significant pathology. Of abnormal postoperative chest radiographs, more than 2/3 are false positives or can be managed by observation, and the majority of the remainder represent previously identified complications. We recommend abandoning routine postoperative chest x-ray following image-guided CVL placement in favor of a clinical, symptom-driven approach to postoperative imaging.
 

97.14 The Significance of Gasless Abdominal Radiographs in Pediatric Adhesive Small Bowel Obstruction

Posted on January 31, 2019

B. L. Johnson1, J. M. Hyak2, G. A. Campagna2, Z. T. Stone2, B. J. Naik-Mathuria1  1Texas Children’s Hospital,Division Of Pediatric Surgery,Houston, TX, USA 2Baylor College Of Medicine,Houston, TX, USA

Introduction:  In children with adhesive small bowel obstruction (ASBO), abdominal radiographs (KUBs) with gaseous, distended small bowel loops are generally utilized for diagnostic and monitoring purposes. Our purpose was to determine the significance of gasless small bowel loops on the initial KUB in patients who ultimately required operation. 

Methods:  Retrospective chart review of children treated for ASBO who required operation between 2011- 2014 at a tertiary care pediatric hospital. Imaging characteristics, time to operation, operative findings and length of bowel resected were recorded. Data were analyzed using descriptive statistics, chi-square, and non-parametric tests. 

Results: Of 99 patients, the median age was 5 and 69% were male. Almost half (48%) had previous episodes of ASBO. The median time to operation was 27 hours (IQR: 11 – 63 hours). Bowel resection was required in 35%, and 31% had closed loop obstruction. Requirement of bowel resection was similar in patients with or without closed loop obstruction (52% vs 49%, p = 0.096); however, patients with closed loop obstruction lost more bowel length than those without (median 30 cm vs 10 cm, p = 0.032). Prior to operation, the majority of patients (53%) were evaluated with serial KUB only, 36% had KUB and computerized tomography (CT scan), and 7% had KUB and small bowel follow through (SBFT). Initial KUB with a partially or completely gasless (non-visualized) portion of the small intestine was noted in 38% of patients. At operation, the majority (71%) of patients with initial gasless KUB had either closed loop or high-grade obstruction; however, the incidence of gasless KUB was similar in patients with and without closed loop obstruction (58% vs 46%, p = 0.25). Follow-up CT scan was obtained more often in patients with a gasless KUB, compared to KUB with visible gaseous distended loops (68% vs 32%, p = 0.003). Five patients with gasless KUB were further evaluated with a SBFT study. CT was superior to KUB for predicting closed loop obstruction (69% vs 7%, p = <0.001). In patients with closed loop obstruction, more bowel length was resected when CT was not obtained (38 cm KUB only vs 15 cm KUB+CT, p = 0.004). Time to operation was longer when follow-up CT was obtained (20 vs 8 hours, p = 0.111); however when CT was obtained the decision to operate was made faster (16 vs 7 hours p = 0.002).

 

Conclusion: For children with adhesive small bowel obstruction with a partially/completely gasless initial KUB, closed loop obstruction or high-grade obstruction should be considered and obtaining additional imaging with CT or SBFT, rather than following serial KUBs, may hasten time to operation and minimize bowel length loss.

 

97.12 Intraoperative Drain Placement in Pediatric Perforated Appendicitis Increases Complication Rate

Posted on January 31, 2019

D. M. Ferguson1,2, K. T. Anderson1,2, M. A. Bartz-Kurycki1,2, K. Tsao1,2  1McGovern Medical School at UTHealth,Department Of Pediatric Surgery,Houston, TX, USA 2Children’s Memorial Hermann Hospital,Department Of Pediatric Surgery,Houston, TX, USA

Introduction: Despite common use, few data exist regarding the efficacy of intraoperative drain placement for preventing post-operative intra-abdominal abscesses (IAA) in perforated appendicitis. Our aim was to evaluate the efficacy of intraoperative drain placement in pediatric perforated appendicitis patients.

Methods: We performed a retrospective review of a prospective cohort secondary to a quality improvement project. In an effort to reduce IAAs, closed suction drains were placed intraoperatively in pediatric (age <18) perforated appendicitis patients from 2013-2016. These patients were compared to pre- and post-intervention controls from 2013 and 2016. Perforated appendicitis was defined as visualization of a hole in the appendix or intra-abdominal stool. All patients received protocolized pre- and post-operative care, including initiation of intravenous antibiotics at diagnosis and continuation until discharge, preoperative prophylactic antibiotics, standardized discharge criteria and 7 days of oral antibiotics after discharge. Intraoperatively discovered abscesses were managed by suctioning without irrigation. Drain placement was standardized with 2 drains per patient. The primary outcome was a composite of any complication. Secondary outcomes included post-operative IAA, emergency visit, readmission, superficial surgical site infection (SSI), small bowel obstruction (SBO), post-operative computed tomography (CT), post-operative percutaneous drain or aspiration, and length of stay (LOS). Descriptive statistics, chi2, student’s t-test and logistic regression with purposeful selection (p<0.20) were used for analysis.

Results: Patients with drains (n=261) were similar to those without drains (n=291) by gender, race/ethnicity, insurance status, admission white blood cell count, and symptom duration prior to arrival. The drain cohort was significantly younger (mean 9.4±4.0 vs 10.6±4.2 years, p<0.01) and weighed less (mean 40.4±22.2 kg vs 46.0±26.1 kg, p<0.01). The rate of post-operative IAA was not significantly different between the groups. Patients with drains had longer LOS (drain: mean 6.5 days±4.1 vs. no drain: 5.3 days±3.6, p<0.01), more frequent post-operative CT use, and an increased proportion of small bowel obstruction (OR 4.90; 95%CI 1.06-22.71). Adjusting for age did not reduce the proportion of post-operative IAA in patients with drains (OR 1.03, 95% CI 0.97-1.08).

Conclusion: Intraoperative drain placement does not reduce the rate of postoperative IAA in pediatric perforated appendicitis and is associated with increased LOS, imaging, and SBO. Without evidence of benefit, and in light of the suggestion of harm, we do not recommend routine drain placement.

97.11 Are Kids More Than Just Little Adults? A Comparison of Surgical Outcomes.

Posted on January 31, 2019

J. Y. Liu1,2, Q. L. Hu1,3, R. P. Merkow4, K. Y. Bilimoria4, Y. Hu4,5, C. Y. Ko1,3, F. Abdullah4,5, M. V. Raval4,5  1American College of Surgeons,Division Of Research And Optimal Patient Care,Chicago, IL, USA 2Emory University,Department Of Surgery,Atlanta, GA, USA 3David Geffen School of Medicine at University of California Los Angeles,Department Of Surgery,Los Angeles, CA, USA 4Northwestern University,Department Of Surgery,Chicago, IL, USA 5Ann and Robert H. Lurie Children’s Hospital,Division Of Pediatric Surgery,Chicago, IL, USA

Introduction: Approximately 450,000 children undergo surgery annually in the United States.  While the complication rates following surgery in both children and adults have been well described using the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) and NSQIP-Pediatric (NSQIP-P) registries, there have been no direct comparisons of outcomes between adults and children undergoing similar procedures.  Our objective was to describe similarities and differences in postoperative outcomes between children and adults undergoing four common surgical procedures.

Methods:  Utilizing data from NSQIP and NSQIP-P from 2013 – 2017, we identified patients undergoing laparoscopic appendectomy, laparoscopic cholecystectomy, thyroidectomy, and colectomy.  Propensity score matching on gender, race, ASA class, surgical indication using ICD9/10 diagnosis codes, and procedure type was performed resulting in matched cohorts of children and adults.  Outcomes of interest included surgical site infection (SSI), readmission rates, mortality, and hospital length of stay (LOS), and were analyzed utilizing χ2 and student’s t-test with statistical significance defined as p<0.05.

Results: Among 79,866 patients from 812 hospitals, there were significant differences in postoperative outcomes evaluated in all procedure types (Table 1).  Compared to adults, children had higher rates of SSI following laparoscopic appendectomy (4.12% vs 1.40%), SSI following laparoscopic cholecystectomy (0.96% vs 0.66%), readmission following laparoscopic appendectomy (4.26% vs 2.47%), and longer LOS in all procedure types (Table 1).  In adults, 30-day mortality was higher following laparoscopic appendectomy (0.03% vs 0.00%) and colectomy (1.77% vs 0.59%) than in children. 

Conclusion: Compared to adults undergoing similar surgical procedures, children demonstrate different complication and outcome profiles, illustrating the unique needs of children undergoing surgery.  Simultaneously, our results demonstrate that adult focused quality improvement efforts through SSI prevention bundles and enhanced recovery protocols aimed at reducing postoperative LOS need to be proactively expanded to children’s surgery.

 

97.10 Setting a Threshold for Discharge Antibiotics for Children with Perforated Appendicitis

Posted on January 31, 2019

C. Dekonenko1, L. A. Benedict1, J. Sujka1, J. Sobrino1, R. M. Dorman1, D. Ostlie2, P. Aguayo1, S. D. St. Peter1, T. A. Oyetunji1  1Children’s Mercy Hospital- University Of Missouri Kansas City,Surgery,Kansas City, MO, USA 2Phoenix Children’s Hospital,Surgery,Phoenix, AZ, USA

Introduction: We previously developed an institutional protocol to address antibiotic overutilization in children with perforated appendicitis. At the time of hospital discharge, children with a normal leukocyte count for age are sent home without oral antibiotics. Whether a normal leukocyte count sufficiently discriminates the risk of abscess remains unknown. The purpose of our study is to assess the effectiveness of this protocol by determining which children may still benefit from additional oral antibiotics at discharge even in the setting of a normal leukocyte count for age.

Methods: A retrospective review of prospectively collected data was conducted. Children undergoing a laparoscopic appendectomy at our freestanding children’s hospital between August 2011-December 2013 and December 2015-July 2017 were included. Patients with perforated appendicitis and discharged home without oral antibiotics were classified according to whether they re-presented with a post-operative abscess or not. Demographic data, post-operative length of stay and discharge leukocyte counts were abstracted from patient medical records. Comparative analysis was performed in STATA with a p value <.05 determined as significant.

Results: A total of 361 children were included, with 7% (n=25) re-presenting with a post-operative abscess following discharge.  Among those who developed a post-operative abscess, the median leukocyte count at discharge was 10.5 (IQR: 8.7, 12.5) compared to 8.7 for the children who did not develop a post-operative abscess (IQR: 7.2, 10.4, p=.005).  Furthermore, children with a post-operative abscess were older (11.8, IQR: 10.9, 14) compared to children who did not develop an abscess (9.1, IQR: 6.4, 12.5, p=.006).  The receiver operator characteristic (ROC) curve for a leukocyte count greater than 10 had an area of .63.

Conclusion: Children with a leukocyte count greater than 10 at discharge, as opposed to normal for age, may benefit from oral antibiotics at discharge following laparoscopic appendectomy for perforated appendicitis.

 

97.09 Safety of Laparoscopic Gastrostomy in Children Receiving Peritoneal Dialysis

Posted on January 31, 2019

R. M. Dorman1, L. A. Benedict1, J. Sujka1, J. Sobrino1, C. D. Dekonenko1, W. Andrews1,4, B. Warady2,4, T. A. Oyetunji1,4, R. Hendrickson1,4  1Children’s Mercy Kansas City,Department Of General And Thoracic Surgery,Kansas City, MO, USA 2Children’s Mercy Kansas City,Division Of Pediatric Nephrology,Kansas City, MO, USA 4University of Missouri – Kansas City School of Medicine,Department Of Pediatrics,Kansas City, MO, USA

Introduction:   The preferred method of dialysis for children is chronic peritoneal dialysis (CPD), and these children may require delayed gastrostomy tube (GT) placement. Investigators have reported a high risk of fungal peritonitis (26%), early bacterial peritonitis (37% at <7 days), and overall post-GT peritonitis rate (1.5 events/patient-year) when percutaneous endoscopic gastrostomy (PEG) is performed children already undergoing CPD.  Current ISPD guidelines recommend only open GT for these patients (post-GT peritonitis rate 1.4 events/patient-year).  We sought to report the safety of laparoscopic GT (LGT) among children already receiving CPD. 

Methods: We conducted a retrospective chart review of children who had initiated CPD prior to GT placement between 2010 and 2017 at our pediatric hospital.  Demographic data, clinical details, and peritonitis rates were recorded.  Peritonitis was defined as peritoneal WBC count > 100 /mm3, >50% neutrophils, and a positive peritoneal culture. 

Results: Twenty-three subjects had both undergone CPD and had a GT placed in the study period.  Of these, 13 had a GT placed after CPD had been initiated.  One of these was excluded for open technique and another excluded due to no overlap of GT and PD catheter, leaving 11 for analysis. Median age at the time of LGT was 1.32 (range 0.21 – 17.23) years and median weight for age z-score was -1.86 (IQR -2.9, -1.3). Median days to PD catheter and GT use after GT placement were 2 (range 0-12) and 1 (range 0-4).  Median weight z-score change at 90 days was +0.5 (IQR 0.0, 0.9). All patients received antifungal and antibiotic coverage at time of GT placement.  No subjects developed fungal peritonitis or early bacterial peritonitis, although two developed bacterial peritonitis within 30 days. The overall rate of peritonitis after LGT was 0.41 (95% CI 0.16, 0.85) events/patient-year.  This was similar to a rate of 0.34 (95% CI 0.07, 1.00) during CPD prior to LGT in the same patients. Four subjects required periods of HD, two of which were due PDC removal due to infection. One of the latter resumed CPD and the other continued HD until renal transplant, both after 6 months.

Conclusions: We found that, in children already receiving CPD, laparoscopic gastrostomy is similar in safety profile and technical principle to open gastrostomy, and is superior in safety to PEG.  Laparoscopic gastrostomy is therefore an appropriate and safe alternative to open gastrostomy in this setting. 

97.08 Does Subspecialty Care Impact Outcomes in Adolescents Undergoing Laparoscopic Appendectomies?

Posted on January 31, 2019

A. A. Shah1,3, A. Badillo3, P. Guzzetta3, T. Kane3, A. Sandler3, M. Petrosyan2,3  1Howard University College Of Medicine,Surgery,Washington, DC, USA 2George Washington University School Of Medicine And Health Sciences,Surgery,Washington, DC, USA 3Children’s National Medical Center,Surgery,Washington, DC, USA

Introduction: A majority of adolescent patients with appendicitis initially present to hospitals that do not uniquely care for children. The initial treatment is frequently by general surgeons. This study aims to examine the differences in outcomes in such patients when treated by either a pediatric or general surgeon.

Methods: The 2012-2013 American College of Surgeons Pediatric NSQIP was queried for adolescent patients(age>10) undergoing a laparoscopic appendectomy. Patients with an operative-time greater than the 75% percentile of the average operative-time were excluded. The population was subdivided into those treated by general surgeons and those treated by pediatric subspecialists. Propensity-score matching was utilized to match across baseline parameters such as age, race/ethnicity and sex prior to multivariable logistic and linear regression analysis. Outcomes of interest were operative-time, total length of hospital stay (LOS), complications, unplanned readmission, reoperation, and conversion to open.

Results: Of 7,272 laparoscopic appendectomies, 238 were performed by general surgeons. 60.2% were males and the average age was 12.9(+2.4)years. General surgeons treated slightly older patients (14.0y vs 12.8y,p<0.05). Median operative-time was 38(IQR: 29-46)minutes. Median LOS was 1(IQR: 1-2)days. Rates of complications, unplanned readmissions, reoperations and conversion to open were 3.0%, 3.0%, 0.8% and 3.4%, respectively. Matched multivariable regression analysis revealed no differences (Table) in operative-times, LOS, complications, unplanned readmissions, reoperations and rates of conversion between pediatric and general surgeons (p>0.05).

Conclusion: There were no differences in outcomes when appendectomies were performed by either pediatric or general surgeons for adolescents with acute appendicitis. Adolescent patients can effectively undergo surgery at non-pediatric designated hospitals.

97.07 Does Microscopic Hematuria After Blunt Abdominal Trauma in Children Indicate Clinically Significant Injury?

Posted on January 31, 2019

C. Casson1, A. Beres1,2  1University of Texas at Southwestern,Dallas, TX, USA 2Children’s Health,Dallas, TX, USA

Introduction:
Children are more likely than adults to have urinary system injury following blunt abdominal trauma (BAT) due to several anatomical vulnerabilities. Urinalysis is often performed during initial evaluation to screen for injury. The purpose of this study was to determine how often the finding of microscopic hematuria after BAT leads to further testing and whether this finding indicates a clinically significant injury. 

Methods:
A retrospective chart review of children who were evaluated for BAT at Children’s Health from 2013-2017 was performed. Patients included had microscopic hematuria leading to further workup. Data collected included demographics, mechanism and types of injuries, laboratory and imaging data, and outcomes. Data was analyzed using descriptive statistics, Chi-square, and Wilcoxin test.

Results:
248 patients had microscopic hematuria following BAT. Most patients had UA results after imaging was completed. 45 patients were found to have microscopic hematuria leading to additional workup: CT abdomen/pelvis (82%), renal ultrasound (13%), XR/CT cystogram (29%), repeat urinalysis (76%). Of these 45 patients, the majority (82%) had a urinalysis performed as a part of an initial trauma workup without any symptoms of urinary system injury. Eight patients had a negative CT scan prior to finding hematuria, but still went on to have XR/CT cystograms. 17 patients were scanned solely due to the finding of microscopic hematuria on screening urinalysis. 9 patients were found to have a urinary system injury: 6 low grade renal and 3 patients with bladder wall. 2/8 patients with urology consults required any outpatient follow-up and no patients were taken to the OR.

Conclusion:
Microscopic hematuria on screening urinalysis after BAT leads to extensive workup, regardless of the presence of symptoms. Urinary system injury presenting solely with microscopic hematuria is uncommon, with all injuries in this study being clinically non-significant.

97.06 Surgical Safety Checklist Adherence Improves Outcomes in Pediatric Patients

Posted on January 31, 2019

M. A. Bartz-Kurycki1,2, K. T. Anderson1,2, D. M. Ferguson1,2, M. E. Curbo1,2, J. Bach1,2, A. A. Childs1,2, T. D. Parker1,2, A. L. Kawaguchi1,2, M. T. Austin1,2, L. S. Kao1, M. E. Matuszczak2,3, R. R. Jain2,3, K. P. Lally1,2, K. Tsao1,2  1McGovern Medical School at UTHealth,Department Of Pediatric Surgery,Houston, TX, USA 2Children’s Memorial Hermann Hospital,Department Of Pediatric Surgery,Houston, TX, USA 3McGovern Medical School at UTHealth,Department Of Anesthesiology,Houston, TX, USA

Introduction: The surgical safety checklist (SSC) is a 3-phase tool created to reduce morbidity and mortality. Adult studies have demonstrated improved outcomes associated with SSC utilization. However, the pediatric surgical population has very low morbidity and mortality, therefore the association between SCC adherence and outcomes has been difficult to establish. The purpose of this study was to evaluate whether SSC adherence was associated with improved 30-day post-operative outcomes in pediatric patients. 

Methods: An observational study of non-emergent pediatric surgical cases performed in a children’s hospital was conducted by trained observers (2017-2018). Degree of adherence (verbalization and confirmation by 2 or more parties) was defined as the proportion of checklist items completed. Pre-induction, pre-incision and debriefing phases were observed. Total adherence score was the proportion of items completed from all 3 phases combined. Thirty-day outcomes were determined by retrospective chart review and included surgical site infection, wound dehiscence, readmission, emergency department (ED) visits, unplanned reoperations, pneumonia, and urinary tract infection. The primary outcome was a composite of any complication. Logistic regression was used for analysis. 

Results: 510 cases were observed for SSC adherence. Patients had a median age of 4.1 years (IQR 1.1-9.8 years). Most observed cases were performed by Pediatric General Surgery (26.9%), Otorhinolaryngology (24.9%), and Urology (21.6%). The median operative time was 33.9 minutes (IQR 19.7-68.8 minutes). Median total adherence score was 86.2 (IQR 66.7-96.0). SSC adherence differed by phase. Pre-incision phase adherence was greatest at 100% (IQR 96-100), followed by debriefing (90.9%, IQR 72.7- 100), then pre-induction (84.6%, IQR 53.8-100). Complications occurred in 57 patients (11.2%); ED visits were most common (64.9%), followed by readmission (38.6%), and SSI (19.3%). Operative time and age were not associated with presence of a post-operative complication. However, surgical specialty, greater pre-induction adherence, and greater total adherence were associated with reduced likelihood of any complication on univariate regression. After adjusting for age, case length, specialty and total adherence to the SSC, only greater total adherence and greater pre-induction adherence remained associated with decreased post-operative complications (Table).

Conclusions: This is the first study to demonstrate that increased SCC adherence is associated with improved patient outcomes in pediatric surgery. The data suggest that improving pre-induction checklist adherence may help prevent patient harm.

97.05 Effect of Volume on Outcomes of Children Treated for Esophageal Atresia/Tracheoesophageal Fistula

Posted on January 31, 2019

L. C. Pruitt1, D. E. Skarda1, D. C. Barnhart1, E. R. Scaife1, B. T. Bucher1  1University Of Utah,Division Of Pediatric Surgery, Department Of Surgery, School Of Medicine,Salt Lake City, UT, USA

Introduction:
We sought to determine the effect of hospital volume on the outcomes of children treated for esophageal atresia and tracheoesophageal fistula (EA/TEF) at children’s hospitals in the United States.

Methods:
We performed a retrospective cohort study using the PHIS database of children treated at 51 freestanding children’s hospitals from 2007-2017. Children who were admitted under seven days of age with an ICD9/10 for EA/TEF and an ICD9/10 or CPT code for an EA/TEF repair were included. Hospitals were divided into quartiles based on the average annual number of EA/TEF repair operations. Our primary outcome was operation for recurrent TEF within the first year following initial EA/TEF repair. Our secondary outcome was multiple (≥2) esophageal dilations in the first year following surgery. We used generalized linear models to calculate the effect of hospital volume on our primary and secondary outcomes after adjusting for salient patient characteristics.

Results:
There were 1648 patients initially admitted in the first seven days of life who underwent EA/TEF repair in the 10-year period of our study. The mean birth weight was 2528 g with a range of 300g to 6900g. The average annual EA/TEF repair volume by hospital ranged from 0.6-20.1. Redo repair in the first year after EA/TEF repair was rare in the entire cohort (117/1648, 7.1%). 20 patients required a third repair within the first year and three patients required four or more repairs in the first year. The number of dilations per patient ranged from 0-17; 254 (15.4%) patients required two or more dilations in the first year following EA/TEF repair. After adjusting for patient and hospital characteristics, there was no significant association between low- and high-volume hospitals (quartile 1 vs. 4) and need for reoperation in the first year after EA/TEF repair (OR = 1.63, CI = 0.68-4.8, p =0.32), and the occurrence of multiple esophageal dilations (OR= 0.9, CI = 0.6-1.6, p=0.54). There was no significant correlation between the frequency of reoperations and the frequency of recurrent dilations at a given hospital (Figure) (r= 0.20, p = 0.16).

Conclusion:
Our study demonstrated no significant volume-outcome relationship in children treated for EA/TEF at freestanding children’s hospitals, however our primary outcome was rare in our entire cohort.
 

97.04 Participation of Pediatric Surgery Departments in Fertility Preservation Initiatives

Posted on January 31, 2019

C. J. Harris1,2, K. S. Corkum1,2, E. E. Rowell1,2  1Feinberg School Of Medicine – Northwestern University,Surgery,Chicago, IL, USA 2Ann and Robert H. Lurie Children’s Hospital of Chicago,Pediatric Surgery,Chicago, IL, USA

Introduction:

Significant reduction in overall childhood cancer mortality over several decades has allowed for greater emphasis on efforts to improve quality of life issues affecting survivors, including fertility preservation (FP). Unfortunately, many benign and malignant conditions require gonadotoxic treatments that may threaten a child’s future fertility. Currently the only FP options for prepubertal children are testicular tissue cryopreservation (TTC) and ovarian tissue cryopreservation (OTC), which involve surgical removal of gonadal tissue. The American Academy of Pediatrics (AAP) recommends that a board-certified pediatric surgeon should be responsible for the surgical care of pediatric patients 0-12 years old who require minimally invasive procedures. Many FP programs utilize pediatric and adolescent gynecologists and urologists to carry out FP procedures. This study sought to evaluate the participation of pediatric surgery departments in FP and the exposure of pediatric surgery fellows to adnexal and testicular cases. 

Methods:

An electronic survey was distributed to pediatric surgery fellowship program directors in the United States and Canada via email. Questions were related to participation in FP initiatives and procedures, limitations to participation, and involvement of fellows in adnexal and testicular surgery.  

Results:

Survey participation was 49% (28/57). Of respondents, 43% (12/28) of programs report participation in FP initiatives. Of departments with FP programs, the most common procedure for males was TTC (58%, 7/12) and testicular sperm extraction (42%, 5/12), however only 50% (6/12) of programs reported performing at least one FP procedure for males in the last year. For female infertility, the most common procedures were surgical transposition of the ovaries (83%, 10/12) and laparoscopic OTC (67%, 8/12). Over the last year, 75% (9/12) of programs performed at least one procedure for female FP. Of departments without a FP program, the most commonly cited limitations were that FP was another department’s responsibility (50%, 8/16) and lack of multidisciplinary team (31%, 5/16). Additionally, one program cited lack of funding. Notably, lack of tissue handling (6%, 1/16) and lack of experience with benign ovarian and testicular procedures (0%, 0/16) were not common limitations. All programs, regardless of participation in FP, noted 100% exposure of their fellows to benign and malignant adnexal cases. During fellowship, most trainees logged greater than ten adnexal cases (39% performed 11-20 cases and 25% performed 21-30 cases). 

Conclusion:

The only options for FP in prepubertal patients are OTC and TTC, which require surgical removal of gonadal tissue for cryopreservation. The AAP currently recommends that pediatric surgeons operate on this age group of children. Even with these recommendations pediatric surgery departments have a low participation in FP, despite adequate training of fellows to perform these procedures.

97.03 Audit and Feedback Accelerates Reduction in Opioid Prescriptions in Pediatric Surgical Patients

Posted on January 31, 2019

J. B. Bach1, K. T. Anderson1,2, D. M. Ferguson1,2, M. A. Bartz-Kurycki1,2, A. L. Kawaguchi1,2, M. T. Austin1,2, K. P. Lally1,2, K. Tsao1,2  1McGovern Medical School at UTHealth,Department Of Pediatric Surgery,Houston, TX, USA 2Children’s Memorial Hermann Hospital,Department Of Pediatric Surgery,Houston, TX, USA

Introduction:  Opioid prescriptions, commonly written for post-operative pain, are an important component of the opioid epidemic. While physician awareness of excessive opioid prescribing has increased, few surgeon-level interventions for prescription reduction have been described. The aim of this study was to evaluate the impact of a simple audit and feedback intervention on pediatric surgeon opioid prescriptions in post-operative appendectomy patients at discharge.

Methods:  Pediatric (<18 years) patients who underwent appendectomy for simple appendicitis from October 2016 through May 2018 were included in a retrospective review of discharge opioid prescriptions. Patients were discharged from a tertiary care Children’s Hospital located in a state in which only fully-licensed (primarily attending) physicians can prescribe out-of-hospital opioids. Prescription data were captured from a state prescription monitoring program database. At the end of October 2017, discharge opioid prescriptions for simple appendectomies over the previous 6 months were audited. These data were fed back to attending pediatric surgeons in a 10-minute presentation, providing descriptive statistics of their opioid prescribing patterns as a group. No specific guideline was established regarding opioid prescribing. The Cochran-Armitage test for trend was used to evaluate for prescription trends over time. Student’s t-test, Wilcoxon rank sum and test for trend were used to compare pre- (10/1/16-10/31/17) and post- (11/1/17-5/31/18) intervention dosing.

Results:Amongst the nine attending pediatric surgeons, opioid prescriptions at discharge for pediatric patients with simple appendicitis decreased significantly over time, (p<0.005) from a zenith of 84% of patients receiving a prescription in January 2017 to 0% receiving a prescription in February and March 2018. Morphine milliequivalents per day (mme/d) prescribed also declined significantly in mean dose (20.5 mme/d ± 12.7 pre-intervention vs. 16.5 mme/d ± 13.6 post-intervention, p<0.005) . Number of days for which opioids were prescribed also decreased from a median of 5 days (IQR 3-6) to a median of 3 days (IQR 3-4), p=0.05.

Conclusion: Although the rate of opioid prescription was already falling, a simple educational intervention dramatically accelerated the rate of decline. Audit and feedback of individual or local group prescribing practices may help prescribers recognize their contribution to unnecessary opioid use. 

97.02 A Rapid MRI Protocol for Pediatric Closed Head Injury: An Effort to Reduce Radiation Exposure

Posted on January 31, 2019

R. Appelbaum1, S. Azari1, M. Li4, M. Eischen3, M. Browne2  1Lehigh Valley Health Network,Allentown, PA, USA 2Lehigh Valley Health Network,Lehigh Valley Children’s Hospital And Pediatric Surgery,Allentown, PA, USA 3Lehigh Valley Health Network,LVPG General, Bariatric And Trauma Surgery,Allentown, PA, USA 4Lehigh Valley Health Network,LVPG Neurosurgery,Allentown, PA, USA

Introduction:  Traumatic brain injury is the leading cause of morbidity and mortality for children in the United States. The modality of choice to evaluate closed head injuries in the acute care setting is computed tomography (CT); however, due to the radiation exposure, this imaging modality does not come without long term risks. Advances in imaging to include limited radiation alternatives have emerged with promising results, including rapid brain T2 weighted MRI (rbMRI).  The aim of our study was to establish a guideline to decrease radiation exposure by identifying the patient population who had repeat head CT imaging due to an initial abnormal head CT scan; and identify if a rbMRI could have been used as an effective alternative.

Methods:  We performed a retrospective chart review of all pediatric trauma patients from January 2013 to June 2018 at our institution. Our exclusion criteria included patients who did not sustain a head injury; had no initial head imaging or imaging was from an outside hospital; and children who were primary burns or drownings. This group was then narrowed to patients who obtained initial and repeat CT head imaging within the first 48 hours of injury. Demographics including age, gender, race, and mechanism of injury were reviewed.  Additionally, GCS, number of total head CT scans during initial hospital course, clinical appropriateness of initial and repeat head CT scans; and the possible use of rbMRI imaging were analyzed. Clinical appropriateness of the initial CT scan was based on PECARN criteria; repeat scans were considered indicated for any child with a GCS <13 or altered mental exam with a subarachnoid, epidural, subdural or intraparenchymal hematoma. Possible rbMRI utilization was determined in children who received repeat imaging and did not meet rbMRI guideline contraindications, including patients with rapid neurologic decline, unstable ICPs, recent craniotomy, and retained metal or catheters.   

Results: A total of 416 patients met initial inclusion criteria and 142/416 (34.1%) had an abnormal finding on the initial head CT; 100% following PECARN criteria.  At least one repeat head CT scan was performed in 64/142 (45.1%) patients for re-evaluation of their initial findings.  The average number of repeat head CT scans was 2.1; ranging from 1 to 10. Based on our clinical criteria, 51/64 (79.7%) patients met criteria for re-imaging.  However, 38/51 (74.5%) of these patients could have had a rapid T2 weighted MRI instead of a CT scan to re-evaluate their intracranial process. 

Conclusion: CT head imaging is invaluable in the initial trauma evaluation of pediatric patients; however, it is often over utilized and the radiation exposure may lead to long term deleterious effects. The ability of using other imaging modalities such as rbMRI, does appear to be a possible option and should be considered when developing a radiation reduction guideline for pediatric closed head injury.

97.01 Direct Admission of Children with Outside CT Scans Diagnostic of Appendicitis is Safe and Feasible

Posted on January 31, 2019

C. D. Flores1,2, B. Patel3, J. Bee5, J. McManemy3, D. D’Ambrosio5, M. McPherson4,5, M. A. Lyn3, S. R. Shah1,2  1Texas Children’s Hospital,Pediatric Surgery,Houston, TX, USA 2Baylor College Of Medicine,Pediatric Surgery,Houston, TX, USA 3Texas Children’s Hospital,Emergency Medicine,Houston, TX, USA 4Texas Children’s Hospital,Critical Care,Houston, TX, USA 5Texas Children’s Hospital,Transfer Center,Houston, TX, USA

Introduction: Prior studies have shown that 35 – 50% of appendicitis patients seen at tertiary-care children’s hospitals are diagnosed at outside hospitals (OSH) by CT scan.  We recently initiated a workflow for direct inpatient admission of these patients to prevent a second emergency department (ED) evaluation. The objective of this study was to conduct an early evaluation of the feasibility and outcomes of our direct admission process for appendicitis.

Methods:  A prospective pilot trial of the direct admission process was conducted from 05/13/18 – 08/15/18 at a tertiary-care children’s hospital.  Criteria for direct admission included patients that were ≥ 4 years-old, stable for acute care, and had an OSH CT with appendicitis. The transfer center accepted eligible patients as a direct admission to the surgical service.  Upon arrival, vital signs were collected in ED triage and patients stable for acute care were directly admitted to the surgical service.  Patient characteristics, clinical outcomes, delays in care, escalation of care, and pathway compliance were collected and analyzed. 

Results: There were 53 patients transferred from an OSH for suspected appendicitis and 33 (62%) had a CT with appendicitis.  There were 27 (51%) patients that underwent direct admission [25 CTs and 2 MRIs with appendicitis].  Of the 25 admitted with a CT, 24 (96%) underwent an appendectomy and one patient was discharged upon further evaluation. Both patients admitted with an MRI underwent appendectomies. Acute appendicitis was confirmed by pathology on all patients who had an appendectomy.  None of these patients required escalation in care and no significant delays were identified during their hospital course.

Of the 26 patients that did not undergo direct admission, there were 8 patients that had an OSH CT with appendicitis.  One patient was appropriately held for resuscitation based on unstable vital signs in ED triage.  This patient ultimately underwent an appendectomy and appendicitis was confirmed by pathology.  The remaining 7 patients were deviations from our new workflow and were eligible for direct admission.  All seven of these patients eventually underwent appendectomies and had confirmed appendicitis on pathology (Fig 1). 

Conclusions: Our data demonstrate that direct admission of children diagnosed with appendicitis by an outside institution CT is safe and feasible at a tertiary-care children’s hospital.  Next steps include increasing compliance with our direct admission workflow for eligible patients, and considering the inclusion of outside institution MRIs diagnostic of appendicitis.

96.20 Prevalence and Significance of Preoperative Bilirubin Testing in Hypertrophic Pyloric Stenosis

Posted on January 31, 2019

R. M. Dorman1, C. D. Dekonenko1, J. A. Sobrino1, J. R. Noel-MacDonnell2,3, T. A. Oyetunji1,4  1Children’s Mercy Hospital- University Of Missouri Kansas City,Department Of General And Thoracic Surgery,Kansas City, MO, USA 2Children’s Mercy Hospital- University Of Missouri Kansas City,Department Of Health Services And Outcomes Research,Kansas City, MO, USA 3University of Kansas Medical Center,Department Of Biostatistics,Kansas City, KS, USA 4University of Missouri – Kansas City School of Medicine,Department Of Pediatrics,Kansas City, MO, USA

Introduction:   Hypertrophic pyloric stenosis (HPS) has historically been associated with the finding of clinical jaundice at presentation in 2-8% of children.  Research has suggested that this usually represents either physiologic neonatal jaundice or the unmasking of Gilbert’s syndrome by the fasting and stress that accompany HPS.  The role of routine bilirubin testing in children presenting with HPS however remains unknown. We sought to determine the prevalence of bilirubin testing in a population of children undergoing pyloromyotomy, what the distribution of these values was, and whether these data might prompt additional care. 

Methods:   The pediatric NSQIP database (2012-2015) was queried for children who had undergone pyloromyotomy and had a postoperative diagnosis of HPS.  Demographic variables and bilirubin values were compared and investigated for their effect on length of stay (LOS) and readmission. Descriptive, comparative, and regression analyses were completed in STATA v15 and Minitab 18. 

Results: Of 5,294 children who met inclusion criteria, 83% were male, 62% were white, median gestational age at birth was 39 weeks (IQR 38, 40), and median age at operation was 35 days (IQR 27, 47). Twenty-five percent of the subjects had a preoperative bilirubin value recorded.  Median total bilirubin was 2.0 mg/dL (IQR 1.0, 4.6).  Only 10% of reported values were >9mg/dL with a maximum of 15.0 mg/mL.  At 4 weeks, where there is overlap with published data from healthy newborns, our 50th and 95th percentiles were 3.5 mg/dL (95% CI 3.1-3.9) and 11.6 mg/dL (95% CI 10.4-12.9), compared with 2.6 and 10.9 mg/dL in the nomogram from Maisels et al (fig). Bilirubin level, controlled for sex and race, was not significantly associated with LOS or readmission. 

Conclusion: We found that one in four children who underwent pyloromyotomy also had a total bilirubin checked.  Based on historical incidence of jaundice in children with HPS, the majority of testing was likely in children without clinical jaundice. Preoperative bilirubin values among those tested decreased exponentially with increased age at operation, paralleling the natural history of physiologic hyperbilirubinemia in other newborns.  Severe hyperbilirubinemia was rare in this population and the degree of bilirubin elevation did not correspond with additional days of care.  A diagnosis of HPS alone in the absence of clinical suspicion does not warrant bilirubin testing, and is probably overused in this population. 

96.19 Inconsistency in Narcotic Prescribing Practices After Pediatric Ambulatory Hernia Surgery

Posted on January 31, 2019

N. Denning2, J. Golden2, B. S. Rich1,2, A. M. Lipskar1,2  1Cohen Children’s Medical Center, Northwell Health,Division Of Pediatric Surgery,New Hyde Park, NY, USA 2Zucker School of Medicine at Hofstra/Northwell,Department Of Surgery,Manhasset, NY, USA

Introduction: Non-medical opioid use is a major public health problem. There is little standardization in narcotic prescribing practices for pediatric ambulatory surgery which can result in patients being prescribed large quantities of narcotics. We have evaluated the variability in post-operative pain medication given to pediatric patients following routine ambulatory pediatric surgical procedures.

Methods: Following IRB approval, pediatric patients undergoing umbilical hernia repair, inguinal hernia repair, hydrocelectomy, and orchiopexy from 2/1/2017 to 2/1/2018 at our tertiary care children’s hospital were retrospectively reviewed. Data collected include operation, surgeon, resident or fellow involvement, utilization of pre-operative analgesia, narcotic prescription on discharge, and patient follow up.

Results: Of 329 patients identified, narcotics were prescribed on discharge to 37.4% of patients (66.3% of umbilical hernia repairs, 20.6% of laparoscopic inguinal hernia repairs, and 33.3% of open inguinal hernia repairs (including hydrocelectomies and orchiopexies)). For each procedure, there was large intra and inter-surgeon variability in the number of narcotic doses prescribed. Narcotic prescription ranged from 0 to 33 doses for umbilical hernia repairs, 0 to 24 doses for laparoscopic inguinal repairs, and 0 to 20 doses prescribed for open inguinal repairs, hydrocele repair, and orchiopexy.  Pediatric surgical fellows were less likely to discharge a patient with a narcotic prescription than surgical resident prescribers (p<0.05).  Additionally, surgical residents were more likely to prescribe more than twelve doses of narcotics than pediatric surgical fellows (p <0.01). Increasing patient age was associated with an increased likelihood of narcotic prescription (p<0.01). There were two phone calls and two clinic visits for pain control issues with equal numbers for those with and without narcotic prescriptions.  

Conclusion: There is significant variation in narcotic prescribing practices after pediatric surgical procedures; increased awareness may help minimize this variability and reduce overprescribing. Training level has an impact on the frequency and quantity of narcotics prescribed. 

 

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