Pediatric American College of Surgeons National Surgical Quality Improvement Program: feasibility of a novel, prospective assessment of surgical outcomes

Risk factors for complications after abdominal surgery in children with sickle cell disease

BACKGROUND

Abdominal surgery in children with sickle cell disease (SCD) carries an increased risk of postoperative complications. Preoperative transfusions are frequently given to decrease the risk of vasoocclusive events. However, risk factors for postoperative complications are not well-defined in the pediatric population.

METHODS

Pediatric patients with SCD undergoing common abdominal operations were identified from the National Surgical Quality Improvement Program-Pediatric (NSQIP-P) database from 2012 to 2018. Outcomes of interest were the incidence rates of 1) any complication or readmission, and 2) serious SCD-related complications (stroke, new onset seizure, ventilator support >24 h postoperatively, or readmission with SCD crisis within 30 days of surgery). Patients were categorized by transfusion approach (transfusion within 48 h before surgery vs. no transfusion) and preoperative hematocrit (<21.0, 21.0-23.9, 24.0-26.9, 27.0-29.9, ≥30.0). Stratified bivariate analyses and multivariable logistic regression were used to identify independent risk factors for complications.

RESULTS

A total of 813 patients met inclusion criteria. There were 470 cholecystectomy, 251 splenectomy, 39 appendectomy, and 53 combination procedures; 13% of cases were urgent or emergent. Preoperative hematocrit levels were <21.0 in 3%, 21.0-23.9 in 10%, 24.0-26.9 in 17%, 27.0-29.9in 30%, and ≥30.0 in 41% of patients; 52% received perioperative transfusion. The 30-day incidences of any complication/readmission and SCD-related complications were 12% and 4%, respectively. On bivariate analyses, urgent/emergent case status was the only significant predictor of complications, carrying risk of 20% and 8% for overall and SCD-related complications, respectively; this finding persisted on multivariable logistic regression (OR 1.83, 95% CI 1.0.2-3.29, p = 0.04). Neither preoperative transfusion nor preoperative hematocrit level was associated with complication risk, although there was a trend toward higher SCD-related complications in patients with preoperative hematocrit <21.0 (p = 0.07).

CONCLUSION

In this large cohort of pediatric SCD patients undergoing abdominal surgery, there was no clear association between postoperative complications and the transfusion approach or the preoperative hematocrit level within the range above 21.0. Urgent/emergent surgical procedures carried a nearly two-fold higher complication risk compared to elective procedures. Future studies should prospectively evaluate preoperative transfusion approaches and compare immediate and delayed operative management to nonoperative management in this population.

LEVEL OF EVIDENCE

III Retrospective review.

Race and major pulmonary complications following inpatient pediatric otolaryngology surgery

BACKGROUND

Compared to their white peers, black children are more likely to experience serious respiratory complications in the perioperative period. Whether a racial difference exists in the occurrence of late postoperative respiratory complications is largely unknown. Here, we evaluated a multi-institutional cohort of children who underwent various elective otolaryngology procedures to examine the racial differences in major postoperative pulmonary complications.

METHODS

We performed a retrospective analysis of elective inpatient otolaryngology cases from the National Surgical Quality Improvement Program (2012-2018). We used propensity score matching of black to white patients to compare the risk of postoperative pulmonary complications, defined as the occurrence of either pneumonia, unplanned reintubation, or prolonged postoperative mechanical ventilation.

RESULTS

The matched cohort was comprised of 4786 black and white patients (2 393 of each race). Black children were more likely to develop postoperative pulmonary complications compared to white peers (29.3% vs. 24.2%; odds ratio: 1.38; 95% confidence interval: 1.20, 1.59; P-value < .001). Furthermore, black children were almost two times more likely to require unplanned postoperative reintubation, relative to their white peers (2.6% vs. 1.3%; odds ratio: 2.07; 95% confidence interval: 1.33, 3.22; P-value < .001). Similarly, black children were estimated to have 37% relative greater odds of requiring prolonged mechanical ventilation (28.6% vs. 23.7%; 95% confidence interval: 1.19, 1.58; P-value < .001). Finally, being of black race conferred greater odds of requiring prolonged hospital length of stay, relative to being of white race (38.6% vs. 34.5%; odds ratio:1.24; 95% confidence interval: 1.09, 1.42; P-value = .004).

CONCLUSION

Black children undergoing elective otolaryngological surgery are more likely to develop major postoperative pulmonary complications.

Measuring malnutrition and its impact on pediatric surgery outcomes: A NSQIP-P analysis

BACKGROUND

There is a limited understanding of the impact of pediatric malnutrition indicators on post-operative outcomes.

MATERIALS AND METHODS

All pediatric surgical patients captured in the ACS NSQIP-Pediatric database from 2016 to 2018 were included. Multivariable logistic regression was used to estimate odds of 30-day post-operative infection by malnutrition definition (stunted, wasted, requiring nutritional support, pre-operative hypoalbuminemia).

RESULTS

Among pediatric surgery patients (n = 282,056), 19% of patients met one definition of malnutrition, 6% met two, 1% met 3, and <0.1% met all 4. After adjustment, requiring nutritional support (OR 1.47, 95% CI 1.36-1.60), stunting (OR 1.17, 95% CI 1.10-1.25), and hypoalbuminemia (OR 1.17 95% CI 1.04-1.32) were associated with increased odds of post-operative infection while wasting was not. Requiring nutritional support was associated in an increase of 10.17 days (95% CI 9.89-10.44) in time from admission to surgery.

CONCLUSIONS

The metric used to define malnutrition changed the association with post-operative outcomes. Nutritional supplementation, stunting, and hypoalbuminemia were associated with poorer postoperative outcomes. These findings have implications for pre-operative patient level counseling, accurate risk stratification, surgical planning, and patient optimization in pediatric surgery.

LEVEL OF EVIDENCE

III.

Transoral versus Transcervical Drainage of Pharyngeal Abscesses in Children: Post-Operative Complications

INTRODUCTION

The objective of this study was to compare complications and other perioperative outcomes between intraoral and transcervical drainage of both retropharyngeal and parapharyngeal abscesses.

MATERIALS AND METHODS

This was a retrospective study that analyzed data from the 2012 to 2016 National Surgical Quality Improvement Program (NSQIP)-Pediatric public use files. Baseline characteristics and perioperative outcomes including postoperative complications and length of hospital stay (LOS) were compared between intraoral and transcervical drainage groups. Multivariable logistic regression was performed to inspect predictors of having an extended LOS, defined as LOS greater than 3 days.

RESULTS

A total of 1174 patients were included. Mean age was 5.1 ± 3.8 years in the intraoral group (N = 1063) and 4.2 ± 4.3 years in the transcervical group (N = 111, P < .001). There was no significant difference in the rate of post-operative complications between groups (5.7% intraoral vs 8.1% transcervical, P = .316). LOS was significantly longer in the transcervical group (>3 days in 36.2% of intraoral vs 49.5% of transcervical, P = .006). Patients in the transcervical group had 1.59 times the odds of extended LOS, after adjusting for age, pre-operative ventilator support, asthma, structural pulmonary disease, hematologic disorders, and all post-operative complications (P = .024).

CONCLUSION

There does not appear to be a significant difference in the rate of post-operative complications after intraoral versus transcervical drainage for pharyngeal abscesses in children. However, transcervical drainage was associated with an extended hospital stay. Further prospective studies will be needed to determine the reasons for this.

Pediatric Appendectomy: an Analysis of 22,334 Cases from the Pediatric National Surgical Quality Improvement Program Data

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Prognostic profiling of children with serious post-operative complications: A novel probability model for failure to rescue

BACKGROUND

Failure to rescue (FTR), mortality after a major postoperative complication, is a superior surgical quality metric compared to surgical mortality or complications rates alone. Our objective was to develop and validate a novel pediatric profiling to identify high-risk subjects among the subset of children who develop serious post-operative complications.

METHODS

We performed a retrospective study of children who developed one or more serious postoperative complications following inpatient surgery across NSQIP-Pediatric hospitals (2012-2017). We evaluated the rate of FTR according to pre-operative comorbidity burden.

RESULTS

We identified 45,504 surgical cases with major post-operative complications (FTR rates: 2.4%). Surgical cases with greater than six pre-operative comorbidities (n = 12,148;28%) accounted for 80% of FTR events. The expected probability of FTR was 0.1%(95%CI:0.1%-0.2%) among low-risk cases, 3.3%(95%CI:3.0%-3.5%) among intermediate-risk cases, and 22.6%(95%CI:20.9%-24.3%) among high-risk cases. About half of surgical cases in the high-risk profile group died within 48 h of surgery. Comparatively, cases in the intermediate-risk group had a much longer time to mortality (10 days).

CONCLUSION

We propose a prognostic index to accurately identify children at risk for FTR. The use of such an index may provide surgeons with a window of opportunity to implement aggressive monitoring and therapeutic strategies to reduce mortality.

LEVEL OF EVIDENCE

IV.

Early ileal pouch anal anastomosis for ulcerative colitis in children: Similar outcome to delayed pouch construction despite higher comorbidity

BACKGROUND

Children with ulcerative colitis (UC) may undergo a staged approach for restorative proctocolectomy and ileal pouch anal anastomosis (IPAA). Previous studies in adults suggest a decreased morbidity with delayed pouch creation, but pediatric studies are limited. We compared outcomes for delayed versus early pouch construction in children.

METHODS

Patients with UC undergoing IPAA were selected from the National Surgical Quality Improvement Program Pediatric database from 2012 to 2018. Patients were categorized as early (2-stage) or delayed (3-stage) pouch construction based on Current Procedural Terminology codes. Our primary outcome was any adverse event. We used a multivariable logistic regression model to assess the relationship between timing of pouch creation and adverse events.

RESULTS

We identified 371 children who underwent IPAA: 157 (42.3%) had early pouch creation and 214 (57.6%) had a delayed pouch. Those with an early pouch creation were more likely to have exposure to immunosuppressants (11% vs. 5%, p = 0.017) and steroids (30% vs. 10%, p < 0.001) at the time of surgery. After controlling for patient characteristics, there were no significant differences in adverse events between the two groups.

CONCLUSIONS

Children undergoing early pouch creation have increased exposure to steroids and immune suppressants; nevertheless, no differences in adverse events were identified.

LEVEL OF EVIDENCE

II.

Validation of an Electronic Surveillance Algorithm to Identify Patients With Post-Operative Surgical Site Infections Using National Surgical Quality Improvement Program Pediatric Data

BACKGROUND

Surgical site infections (SSIs) are common, but data related to these infections maybe difficult to capture. We developed an electronic surveillance algorithm to identify patients with SSIs. Our objective was to validate our algorithm by comparing it with our institutional National Surgical Quality Improvement Program Pediatric (NSQIP Peds) data.

METHODS

We applied our algorithm to our institutional NSQIP Peds 2015-2017 cohort. The algorithm consisted of the presence of a diagnosis code for post-operative infection or the presence of 4 criteria: diagnosis code for infection, antibiotic administration, positive culture, and readmission/surgery related to infection. We compared the algorithm's SSI rate to the NSQIP Peds identified SSI. Algorithm performance was assessed using sensitivity, specificity, negative predictive value (NPV), positive predictive value (PPV), and Cohen's kappa. The charts of discordant patients were reviewed to understand limitations of the algorithm.

RESULTS

Of 3879 patients included, 2.5% had SSIs by NSQIP Peds definition and 1.9% had SSIs by our algorithm. Our algorithm achieved a sensitivity of 44%, specificity of 99%, NPV of 99%, PPV of 59%, and Cohen's kappa of 0.5. Of the 54 false negatives, 37% were diagnosed/treated as outpatients, 31% had tracheitis, and 17% developed SSIs during their post-operative admission. Of the 30 false positives, 33% had an infection at index surgery and 33% had SSIs related to other surgeries/procedures.

CONCLUSIONS

Our algorithm achieved high specificity and NPV compared with NSQIP Peds reported SSIs and may be useful when identifying SSIs in patient populations that are not actively monitored for SSIs.

Primary Stroke and Failure-to-Rescue Following Thoracic Endovascular Aortic Aneurysm Repair

OBJECTIVE

To characterize the impact, on failure to rescue, of cerebrovascular accident as a first postoperative complication after thoracic endovascular aortic aneurysm repair (TEVAR).

DESIGN

A retrospective cohort study using of National Surgical Quality Improvement Program Participants User File.

SETTING

United States hospitals taking part in the National Surgical Quality Improvement Program.

PARTICIPANTS

Patients >18 years, who underwent TEVAR for nonruptured thoracic aortic aneurysm between 2005 and 2018, and developed one or more major postoperative complications within 30 days after surgery.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Out of 3,937 patients who underwent TEVAR for nonruptured thoracic aneurysm, 1,256 (31.9%) developed major postoperative complications (stroke incidence: 11.4% [143/1256]). In adults <65 years old, the occurrence of stroke as the primary complication, relative to the occurrence of other complications, was associated with ten times greater risk of failure to rescue (29.4% v 4.6%; odds ratio [OR]: 10.10; 95% confidence interval [CI] 2.45-41.56; p < 0.001). The effect size was relatively lower when stroke occurred but was not the primary complication (20.0% v 4.6%; OR: 7.55; 95% CI 1.37-41.71; p = 0.020). In patients ≥65 years, the occurrence of stroke as the primary complication did not carry the similar prognostic value.

CONCLUSION

Younger patients who developed stroke were up to ten times more likely to die, relative to patients who developed other major complications. Survival was substantially reduced when stroke was the primary complication. The authors' findings imply that to maximize the survival of patients undergoing TEVAR, efforts may be needed to predict and prevent stroke occurrence as a primary postoperative morbidity event.

Reducing resource utilization for patients with uncomplicated appendicitis through use of same-day discharge and elimination of postoperative antibiotics

BACKGROUND

There is controversy over certain aspects of post-appendectomy care for children with uncomplicated appendicitis. Some institutions have embraced the practice of same-day discharge after appendectomy, while others are hesitant due to concerns about increased readmissions or emergency department (ED) visits. Similarly, some surgeons have transitioned to treating gangrenous appendicitis with a single perioperative dose, while others are concerned about increased risk of infection in this population.

METHODS

We developed a pathway for the management of patients undergoing appendectomy for uncomplicated acute appendicitis which included same-day discharge and elimination of postoperative antibiotics for patients with gangrenous appendicitis. We compared outcomes for children treated at our institution before and after implementation of the protocol.

RESULTS

We identified 575 patients undergoing appendectomy for uncomplicated appendicitis (307 pre- and 268 post-protocol). We observed a significant decrease in postoperative length-of stay (10.6 to 2.6 h, p < 0.0001). There were no increases in postoperative complications, such as superficial (2.6% vs 1.1%, p = 0.19) or organ-space surgical-site infection (1.6% vs 0.4%, p = 0.14), percutaneous drain placement (1.3% vs 0%, p = 0.06), postoperative ED visits (5.5% vs 5.2%, p = 0.87) or readmission (3.3% vs 1.5%, p = 0.17).

CONCLUSIONS

These findings suggest that incorporating same-day discharge for simple appendicitis and eliminating postoperative antibiotics for children with gangrenous appendicitis does not increase complication rates. Implementation of similar pathways across institutions has the potential to significantly reduce resource utilization for children undergoing appendectomy for uncomplicated appendicitis.

TYPE OF STUDY

Retrospective comparative study.

LEVEL OF EVIDENCE

Level III.

Expanding antimicrobial stewardship strategies for the NICU: Management of surgical site infections, perioperative prophylaxis, and culture negative sepsis

OBJECTIVE

To review antibiotic stewardship strategies for neonatal intensive care units (NICU) in the areas of management of surgical site infections, perioperative prophylaxis and culture negative late onset sepsis.

FINDING

Review of local microbiology, stratification of surgical procedures by risk of contamination of the surgical site, and adherence to evidence-based principles of perioperative antibiotic administration (targeted therapy, effective dosing, appropriate timing and limiting duration post-operatively) can help to minimize unnecessary antibiotic use for neonatal surgery. Creating a late onset sepsis case definition, appropriate collection and interpretation of blood cultures, and instituting antibiotic time-outs can minimize the overuse of antibiotics for culture negative sepsis.

CONCLUSION

Effective implementation of these antimicrobial stewardship strategies in the NICU can reduce unnecessary antimicrobial use and limit the emergence of resistant pathogens.

Risk assessment of postoperative pneumonia among children undergoing otolaryngologic surgery: Derivation and validation of a preoperative risk profiling

BACKGROUND

Postoperative pneumonia is a serious complication because it may be associated with morbidity, mortality and substantially increased cost of surgical care. Risk of postoperative pneumonia varies across surgical specialties, although its incidence and risk factors in pediatric otolaryngology have not been comprehensively elucidated.

OBJECTIVE

To identify factors associated with postoperative pneumonia and determine whether a subset of children with a disproportionate risk of pneumonia can be identified.

METHODS

Using the National Surgical Quality Improvement- Pediatric (NSQIP-P) database, we first selected children (N = 17,776; age under 18 years) who underwent inpatient pediatric otolaryngology procedures between 2012 and 2017. Using a random subset of 80% of the study population (derivation cohort), we next developed a multivariable logistic regression model to identify independent risk factors for postoperative pneumonia. We then divided children into risk groups and evaluated whether the Pareto principle applied to distribution of postoperative pneumonia across the risk groups.

RESULTS

Among the 12,443 children in the derivation cohort, 177 (1.4%) developed postoperative pneumonia. A multivariable risk model identified patients who developed postoperative pneumonia with good accuracy in both the derivation and validation cohorts. Stratification of patients into five mutually exclusive risk groups showed that 71% of postoperative pneumonia occurred in the highest risk group representing 20% the study cohort. Children who developed postoperative pneumonia were 18 times more likely to require an extended hospital length of stay (OR: 18.6; 95%CI: 12.3-28.2), and 7 times more likely to die compared to children without pneumonia (OR: 7.40, 95%CI: 3.53-15.48).

CONCLUSIONS

We identified key preoperative risk factors for postoperative pneumonia in children undergoing otolaryngology surgery. A small proportion (20%) of high-risk patients accounted for a large proportion (71%) of postoperative pneumonia indicating an underlying Pareto distribution and underscoring the need for targeted interventions for this "vital few". Postoperative pneumonia in pediatric otolaryngology surgical inpatients was associated with longer hospital stay and a higher risk of mortality.

CLINICAL TRIAL NUMBER AND REGISTRY

Not applicable.

Preoperative Blood Transfusions and Morbidity in Neonates Undergoing Surgery

BACKGROUND

Blood transfusions in the neonatal patient population are common, but there are no established guidelines regarding transfusion thresholds. Little is known about postoperative outcomes in neonates who receive preoperative blood transfusions (PBTs).

METHODS

Using the American College of Surgeons National Surgical Quality Improvement Program-Pediatric Participant Use Data Files from 2012 to 2015, we identified all neonates who underwent surgery. Mortality and composite morbidity (defined as any postoperative complication) in neonates who received a PBT within 48 hours of surgery were compared with that in neonates who did not receive a transfusion.

RESULTS

A total of 12 184 neonates were identified, of whom 1209 (9.9%) received a PBT. Neonates who received a PBT had higher rates of preoperative comorbidities and worse postoperative outcomes when compared with those who did not receive a transfusion (composite morbidity: 46.2% vs 16.2%; P < .01). On multivariable regression analysis, PBTs were independently associated with increased 30-day morbidity (odds ratio [OR] = 1.90; 95% confidence interval [CI]: 1.63-2.22; P < .01) and mortality (OR = 1.98; 95% CI: 1.55-2.55; P < .01). In a propensity score-matched analysis, PBTs continued to be associated with increased 30-day morbidity (OR = 1.53; 95% CI: 1.29-1.81; P < .01) and mortality (OR = 1.58; 95% CI: 1.24-2.01; P = .01).

CONCLUSIONS

In a propensity score-matched model, PBTs are independently associated with increased morbidity and mortality in neonates who undergo surgery. Prospective data are needed to better understand the potential effects of a red blood cell transfusion in this patient population.

Association of childhood asthma with postoperative pneumonia

BACKGROUND

Bronchial asthma is the most pervasive chronic disease among children in the United States. Pneumonia, an acute pulmonary disorder, is also quite common, affecting individuals with chronic respiratory conditions. Despite the widespread recognition of bronchial asthma as a common, potentially life-threatening disease, its impact on the risk of serious pulmonary infections such as postoperative pneumonia is under-appreciated. We examined the association of bronchial asthma with postoperative pneumonia in a matched cohort of children who underwent inpatient surgical procedures.

METHOD

We assembled a propensity score-matched retrospective cohort of children (<18 years of age) who underwent inpatient surgery between 2012 and 2015, in hospitals participating in the National Surgical Quality Improvement Program. Our primary outcome was the incidence of postoperative pneumonia. We used Fine-Gray sub-distributional hazard regression to estimate the hazard ratio of postoperative pneumonia, while accounting for the competing risk by mortality.

RESULTS

The unmatched cohort comprised of 93 061 children who met the eligibility criteria, of whom 7.8% (n = 7237) had a preoperative diagnosis of bronchial asthma. The cumulative incidence of pneumonia was 4.5% (95% confidence interval: 2.8%, 8.3%) among children without bronchial asthma and 8.5% (95% confidence interval: 5.8%, 11.8%) among those with bronchial asthma. Throughout the 30-day postoperative period, the risk of pneumonia almost doubled among children with bronchial asthma compared to their nonasthmatic peers (hazard ratio: 1.71; 95% confidence interval: 1.24, 2.35; P = .001).

CONCLUSION

Children with bronchial asthma had a significantly greater risk of postoperative pneumonia. Further studies are needed to understand the mechanisms underlying these associations and determine if perioperative interventions can mitigate this association.

Outcomes of Pediatric Central Venous Access Device Placement With Concomitant Surgical Procedures

BACKGROUND

Children frequently undergo placement of a tunneled central venous catheter or port (CVAD) concomitantly with other surgical procedures (CVAD-CP), but the risk factors for early CVAD complications with this practice are unclear.

METHODS

Children undergoing CVAD-CP were identified from the National Surgical Quality Improvement Program-Pediatric 2012-2016 database. Predictor variables included demographics, CP characteristics, malignancy, and CVAD type. Outcome variables were CVAD-associated bloodstream infection (CLABSI) or new deep venous thrombosis (nDVT) within 30 d. Patients with and without CLABSI or nDVT were compared, and the temporal relationship of nDVT and CLABSI was investigated. Multivariable logistic regression modeling was used to assess independent risk factors for CLABSI.

RESULTS

Of 2036 patients included, median age was 1.5 y, 35% had malignancy, and 40% had a clean concomitant procedure. Overall, 1.3% developed CLABSI and 0.7% developed nDVT. Multivariable regression modeling revealed higher risk of CLABSI with clean CPs (odds ratio [OR] 2.4, 95% confidence interval [CI] 1.06-5.34, P = 0.035), tunneled catheters (OR 3.2, 95% CI 1.18-8.56, P = 0.022), and longer anesthesia duration (OR 1.02 per 10 min, 95% CI 1.00-1.04, P = 0.042). nDVT was strongly associated with CLABSI (21% CLABSI among those with DVT, 0.5% among those without, P ≤ 0.0001). In all cases of nDVT with CLABSI, the diagnosis of DVT preceded diagnosis of CLABSI, by a median of 7 d.

CONCLUSIONS

The type of CVAD and characteristics of the concomitant procedure influence early CLABSI after CVAD-CP. The unexpected finding of higher CLABSI rates among clean concomitant procedures suggests that perioperative prophylactic antibiotics should not be withheld in this setting, but requires prospective validation. nDVT is frequently diagnosed prior to CLABSI, suggesting a possible role for antibiotics in the treatment of postoperative DVT after CVAD placement.

From Clinic to Computer and Back Again: Practical Considerations When Designing and Implementing Machine Learning Solutions for Pediatrics

Purpose of review

Machine learning (ML), a branch of artificial intelligence, is influencing all fields in medicine, with an abundance of work describing its application to adult practice. ML in pediatrics is distinctly unique with clinical, technical, and ethical nuances limiting the direct translation of ML tools developed for adults to pediatric populations. To our knowledge, no work has yet focused on outlining the unique considerations that need to be taken into account when designing and implementing ML in pediatrics.

Recent findings

The nature of varying developmental stages and the prominence of family-centered care lead to vastly different data-generating processes in pediatrics. Data heterogeneity and a lack of high-quality pediatric databases further complicate ML research. In order to address some of these nuances, we provide a common pipeline for clinicians and computer scientists to use as a foundation for structuring ML projects, and a framework for the translation of a developed model into clinical practice in pediatrics. Throughout these pathways, we also highlight ethical and legal considerations that must be taken into account when working with pediatric populations and data.

Summary

Here, we describe a comprehensive outline of special considerations required of ML in pediatrics from project ideation to implementation. We hope this review can serve as a high-level guideline for ML scientists and clinicians alike to identify applications in the pediatric setting, generate effective ML solutions, and subsequently deliver them to patients, families, and providers.

Racial Disparities in Pediatric Endoscopic Sinus Surgery

OBJECTIVE

To determine the impact of race and ethnicity on 30-day complications following pediatric endoscopic sinus surgery (ESS).

STUDY DESIGN

Cross-sectional cohort study.

SUBJECTS AND METHODS

Patients ≤ 18 years of age undergoing ESS from 2015 to 2017 were identified in the Pediatric National Surgical Improvement Program-Pediatric database. Patient demographics, comorbidities, surgical indication, and postoperative complications were extracted. Patient race/ethnicity included non-Hispanic black, non-Hispanic white, Hispanic, and other. Multivariable logistic regression was performed to determine if race/ethnicity was a predictor of postoperative complications after ESS.

RESULTS

A total of 4,337 patients were included in the study. The median age was 10.9 (interquartile range: 14.5-6.7) years. The cohort was comprised of 68.3% non-Hispanic white, 13.9% non-Hispanic black, 9.7% Hispanic, and 2.1% other. The 30-day complication rate was 3.2%, and the mortality rate was 0.3%. The rate of reoperation was 3.8%, and readmission was 4.1%. Black and Hispanic patients had higher rates of urgent operations (P = .003 and P < .001, respectively), and black patients had a higher incidence of emergent operations (P < .001) compared to their white peers. For elective ESS cases, multivariable analysis adjusting for sex, age, comorbidities, and surgical indication indicated that children of Hispanic ethnicity had increased postoperative complications (odds ratio: 1.57, 95% confidence interval: 1.04-2.37).

CONCLUSION

This analysis demonstrated that black and Hispanic children disproportionately undergo more urgent and emergent ESS. Hispanic ethnicity was associated with increased 30-day complications following elective pediatric ESS. Further studies are needed to elucidate potential causes of these disparities and identify areas for improvement.

LEVEL OF EVIDENCE

3 Laryngoscope, 131:E1369-E1374, 2021.

Synergistic effects of sepsis and prematurity on neonatal postoperative mortality

INTRODUCTION

Compared with term neonates, preterm babies are more likely to die from sepsis. However, the combined effects of sepsis and prematurity on neonatal postoperative mortality are largely unknown. Our objective was to quantify the proportion of neonatal postoperative mortality that is attributable to the synergistic effects of preoperative sepsis and prematurity.

METHODS

We performed a multicentre, propensity-score-weighted, retrospective, cohort study of neonates who underwent inpatient surgery across hospitals participating in the United States National Surgical Quality Improvement Program-Pediatric (2012-2017). We assessed the proportion of the observed hazard ratio of mortality and complications that is attributable to the synergistic effect of prematurity and sepsis by estimating the attributable proportion (AP) and its 95% confidence interval (CI).

RESULTS

We identified 19 312 neonates who realised a total of 321 321 person-days of postsurgical observations, during which 683 died (mortality rate: 2.1 per 1000 person-days). The proportion of mortality risk that is attributable to the synergistic effect of prematurity and sepsis was 50.5% (AP=50.5%; 95% CI, 28.8-72.3%; P < 0.001). About half of mortality events among preterm neonates with sepsis occurred within 24 h after surgery. Just over 45% of postoperative complications were attributable to the synergistic effect of prematurity and sepsis when both conditions were present (AP=45.8; 95% CI, 13.4-78.1%; P<0.001).

CONCLUSION

Approximately half of postsurgical mortality and complications were attributable to the combined effect of sepsis and prematurity among neonates with both exposures. These neonates typically died within a few days after surgery, indicating a very narrow window of opportunity to predict and prevent mortality.

CLINICAL TRIAL NUMBER AND REGISTRY

Not applicable.

National Patterns in Surgical Management of Syndactyly: A Review of 956 Cases

Purpose: Being one of the most common congenital hand malformations, syndactyly is repaired by orthopedic, plastic, and fellowship-trained general surgeons. Limited multi-institutional outcomes analyses regarding incidence, timing, and type of repair exist. Methods: All syndactyly cases performed over a 5-year period from 2012-2016 were isolated from the National Surgical Quality Improvement Program Pediatric database. Patient demographics, surgical factors, perioperative outcomes, and risk factors were analyzed using χ², Fisher exact, and t-test analysis. Results: A total of 956 patients who underwent syndactyly repair were identified. Most cases were simple syndactyly with nearly even case distribution among plastic and orthopedic surgeons. Most patients were men and Caucasian. Mean age at the time of surgery was 2.6 years. Most cases were performed as outpatient surgery. Patients of plastic surgeons had significantly more airway abnormalities and shorter operative times. Patients with complex syndactyly had significantly more ventilator dependence, tracheostomy, and comorbidities when compared with those with simple syndactyly. Cases with complex syndactyly also had longer operative times and a higher rate of superficial surgical site infections. Conclusions: Syndactyly repair is a safe procedure with few major or minor reconstructive complications regardless of the surgical specialty or syndactyly type. Patients with complex syndactyly have significantly more preoperative comorbidities with comparable outcomes. orthopedic surgeons have significantly longer operative times than plastic surgeons, likely due to caring for increased number of patients with complex syndactyly.

Development and Implications of an Evidence-based and Public Health-relevant Definition of Complicated Appendicitis in Children

OBJECTIVE

To characterize the influence of intraoperative findings on complications and resource utilization as a means to establish an evidence-based and public health-relevant definition for complicated appendicitis.

SUMMARY OF BACKGROUND DATA

Consensus is lacking surrounding the definition of complicated appendicitis in children. Establishment of a consensus definition may have implications for standardizing the reporting of clinical research data and for refining reimbursement guidelines.

METHODS

This was a retrospective cohort study of patients ages 3 to 18 years who underwent appendectomy from January 1, 2013 to December 31, 2014 across 22 children's hospitals (n = 5002). Intraoperative findings and clinical data from the National Surgical Quality Improvement Program-Pediatric Appendectomy Pilot Database were merged with cost data from the Pediatric Health Information System Database. Multivariable regression was used to examine the influence of 4 intraoperative findings [visible hole (VH), diffuse fibrinopurulent exudate (DFE) extending outside the right lower quadrant (RLQ)/pelvis, abscess, and extra-luminal fecalith] on complication rates and resource utilization after controlling for patient and hospital-level characteristics.

RESULTS

At least 1 of the 4 intraoperative findings was reported in 26.6% (1333/5002) of all cases. Following adjustment, each of the 4 findings was independently associated with higher rates of adverse events compared with cases where the findings were absent (VH: OR 5.57 [95% CI 3.48-8.93], DFE: OR 4.65[95% CI 2.91-7.42], abscess: OR 8.96[95% CI 5.33-15.08], P < 0.0001, fecalith: OR 5.01[95% CI 2.02-12.43], P = 0.001), and higher rates of revisits (VH: OR 2.02 [95% CI 1.34-3.04], P = 0.001, DFE: OR 1.59[95% CI 1.07-2.37], P = 0.02, abscess: OR 2.04[95% CI 1.2-3.49], P = 0.01, fecalith: OR 2.31[95% CI 1.06-5.02], P = 0.04). Each of the 4 findings was also independently associated with increased resource utilization, including longer cumulative length of stay (VH: Rate ratio [RR] 3.15[95% CI 2.86-3.46], DFE: RR 3.06 [95% CI 2.83-3.13], abscess: RR 3.94 [95% CI 3.55-4.37], fecalith: RR 2.35 [95% CI 1.87-2.96], P =  < 0.0001) and higher cumulative hospital cost (VH: RR 1.97[95% CI 1.64-2.37], P < 0.0001, DFE: RR 1.8[95% CI 1.55-2.08], P =  < 0.0001, abscess: RR 2.02[95% CI 1.61-2.53], P < 0.0001, fecalith: RR 1.49[95% CI 0.98-2.28], P = 0.06) compared with cases where the findings were absent.

CONCLUSION AND RELEVANCE

The presence of a visible hole, diffuse fibrinopurulent exudate, intra-abdominal abscess, and extraluminal fecalith were independently associated with markedly worse outcomes and higher cost in children with appendicitis. The results of this study provide an evidence-based and public health-relevant framework for defining complicated appendicitis in children.

Lateral cervical abscesses: NSQIP-P perspective on length of stay, readmission, and reoperation

OBJECTIVES

Identify risk factors and determine perioperative sequelae of children undergoing lateral cervical abscess incision and drainage.

METHODS

Pediatric patients who underwent lateral cervical abscess incision and drainage aged 1-18 years were retrospectively queried via ACS-NSQIP-P (2012-2016) utilizing CPT code 21501. Analyzed outcomes include age, time to surgery, operative time, total length of stay, readmission, and reoperation.

RESULTS

A total of 1917 children were identified, with a mean age at time of surgery of 4.05 years (95% CI 3.86-4.25). The mean number of days from hospital admission to operative intervention was 1.24 days (95% CI 1.16-1.31), with a mean total length of stay of 3.64 days (95% CI 3.46-3.82). The mean number of days from hospital admission to surgery was significantly lengthened in younger children (P = .0001) and pediatric patients of non-Caucasian origin (P < 0.001). Children with positive septic parameters not only had a prolonged time to surgery but also a significantly prolonged total length of stay (P < 0.001). Finally, a persistent requirement for postoperative mechanical ventilation and prolonged operative time (P = 0.003) was found to be related to reoperation.

CONCLUSION

Younger children are more likely to have delays from hospital admission to definitive surgical intervention, but this does not appear to affect total length of stay. Recognition of pertinent clinical factors may assist in optimizing perioperative risk assessment and promote timely procedural planning in the pediatric subpopulation.

Ceftriaxone Combined With Metronidazole is Superior to Cefoxitin Alone in the Management of Uncomplicated Appendicitis in Children: Results from a Multicenter Collaborative Comparative Effectiveness Study

OBJECTIVE

To compare rates of surgical site infection between the 2 most commonly utilized narrow-spectrum antibiotic regimens in children with uncomplicated appendicitis (ceftriaxone with metronidazole and cefoxitin alone).

SUMMARY OF BACKGROUND DATA

Narrow-spectrum antibiotics have been found to be equivalent to extended-spectrum (antipseudomonal) agents in preventing surgical site infection (SSI) in children with uncomplicated appendicitis. The comparative effectiveness of different narrow-spectrum agents has not been reported.

METHODS

This was a multicenter retrospective cohort study using clinical data from the Pediatric National Surgical Quality Improvement Program Appendectomy Collaborative Pilot database merged with antibiotic utilization data from the Pediatric Health Information System database from January 2013 to June 2015. Multivariable logistic regression was used to compare outcomes between antibiotic treatment groups after adjusting for patient characteristics, surrogate measures of disease severity, and clustering of outcomes within hospitals.

RESULTS

Eight hundred forty-six patients from 14 hospitals were included in the final study cohort with an overall SSI rate of 1.3%. A total of 56.0% of patients received ceftriaxone with metronidazole (hospital range: 0%-100%) and 44.0% received cefoxitin (range: 0%-100%). In the multivariable model, ceftriaxone with metronidazole was associated with a 90% reduction in the odds of a SSI compared to cefoxitin [0.2% vs 2.7%; odds ratio: 0.10 (95% confidence interval 0.02-0.60); P = 0.01].

CONCLUSIONS

Ceftriaxone combined with metronidazole is superior to cefoxitin alone in preventing SSIs in children with uncomplicated appendicitis.

A Retrospective Analysis of Intervention for Testicular Torsion: Searching for a Hallmark of High Reliability

Supplemental Digital Content is available in the text.

Consistent delivery of high-quality care is a marker of health-care system reliability. Although clinically abstracted outcome databases have revolutionized surgical quality improvement efforts for many high-volume procedures, their utility in aiding the improvement of time-sensitive processes is less clear. The purpose of this study was to determine whether process measures surrounding the delivery of timely surgical care could delineate the variability in the outcome of patients with testicular torsion. Our secondary aim was to use the data to drive quality improvement efforts locally.

National Database Reported Outcomes Following Craniosynostosis Reconstruction

BACKGROUND

While there has been ample interest and literature published regarding craniosynostosis surgical technique, there are few reports on adverse hospital and health system outcomes. The purpose of this study was to describe rate of and risk factors for complications, and adverse outcomes following craniosynostosis reconstruction.

METHODS

This study retrospectively reviewed the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) Pediatric database and identified all patients undergoing craniosynostosis repair from 2012 to 2016. Univariate logistic regression analysis was used to identify significant associations between preoperative risk factors and adverse outcomes. Multivariate logistic regression analysis was then used to identify independent risk factors and causes of prolonged operative times, transfusions, reoperation, prolonged length of hospital stays, and readmission.

RESULTS

There were 3924 patients included who underwent craniosynostosis repair, of whom 1732 underwent frontoorbital advancement and 2192 underwent cranial vault remodeling. Transfusion was the most common NSQIP reportable outcome, occurring for 66.5% of all patients. The incidence of reoperation was 2.4% and readmission was 3.0%.

CONCLUSION

This study provides a large descriptive analysis of craniosynostosis repair throughout the United States. Largely nonmodifiable patient risk factors lead to worse health system metrics, with young age, gastrointestinal comorbidities, American Society of Anesthesiologist scores of 3 and greater, reoperation, and a prolonged length of stay as independent risk factors for readmission. This analysis can be used to identify the standard of practice in synostosis care and enhance the implementation of ancillary care services to provide safe and cost-effective care for patients undergoing craniosynostosis repair.

Comparison of Military Health System Data Repository and American College of Surgeons National Surgical Quality Improvement Program-Pediatric

Background

Given the rarity of pediatric surgical disease, it is important to consider available large-scale data resources as a means to better study and understand relevant disease-processes and their treatments. The Military Health System Data Repository (MDR) includes claims-based information for > 3 million pediatric patients who are dependents of members and retirees of the United States Armed Services, but has not been externally validated. We hypothesized that demographics and selected outcome metrics would be similar between MDR and the previously validated American College of Surgeons National Surgical Quality Improvement Program-Pediatric (NSQIP-P) for several common pediatric surgical operations.

Methods

We selected five commonly performed pediatric surgical operations: appendectomy, pyeloplasty, pyloromyotomy, spinal arthrodesis for scoliosis, and facial reconstruction for cleft palate. Among children who underwent these operations, we compared demographics (age, sex, and race) and clinical outcomes (length of hospital stay [LOS] and mortality) in the MDR and NSQIP-P, including all available overlapping years (2012–2014).

Results

Age, sex, and race were generally similar between the NSQIP-P and MDR. Specifically, these demographics were generally similar between the resources for appendectomy (NSQIP-P, n = 20,602 vs. MDR, n = 4363; median age 11 vs. 12 years; female 40% vs. 41%; white 75% vs. 84%), pyeloplasty (NSQIP-P, n = 786 vs. MDR, n = 112; median age 0.9 vs. 2 years; female 28% vs. 28%; white 71% vs. 80%), pyloromyotomy, (NSQIP-P, n = 3827 vs. MDR, n = 227; median age 34 vs. < 1 year, female 17% vs. 16%; white 76% vs. 89%), scoliosis surgery (NSQIP-P, n = 5743 vs. MDR, n = 95; median age 14.2 vs. 14 years; female 75% vs. 67%; white 72% vs. 75%), and cleft lip/palate repair (NSQIP-P, n = 6202 vs. MDR, n = 749; median age, 1 vs. 1 year; female 42% vs. 45%; white 69% vs. 84%). Length of stay and 30-day mortality were similar between resources. LOS and 30-day mortality were also similar between datasets.

Conclusion

For the selected common pediatric surgical operations, patients included in the MDR were comparable to those included in the validated NSQIP-P. The MDR may comprise a valuable clinical outcomes research resource, especially for studying infrequent diseases with follow-up beyond the 30-day peri-operative period.

Extended Versus Narrow-spectrum Antibiotics in the Management of Uncomplicated Appendicitis in Children: A Propensity-matched Comparative Effectiveness Study

OBJECTIVE

The aim of this study was to compare the effectiveness of extended versus narrow spectrum antibiotics in preventing surgical site infections (SSIs) and hospital revisits in children with uncomplicated appendicitis.

SUMMARY OF BACKGROUND DATA

There is a paucity of high-quality evidence in the pediatric literature comparing the effectiveness of extended versus narrow-spectrum antibiotics in the prevention of SSIs associated with uncomplicated appendicitis.

METHODS

Clinical data from the ACS NSQIP-Pediatric Appendectomy Pilot Project were merged with antibiotic utilization data from the Pediatric Health Information System database for patients undergoing appendectomy for uncomplicated appendicitis at 17 hospitals from January 1, 2013 to June 30, 2015. Patients who received piperacillin/tazobactam (extended spectrum) were compared with those who received either cefoxitin or ceftriaxone with metronidazole (narrow spectrum) after propensity matching on demographic and severity characteristics. Study outcomes were 30-day SSI and hospital revisit rates.

RESULTS

Of the 1389 patients included, 39.1% received piperacillin/tazobactam (range by hospital: 0% to 100%), and the remainder received narrow-spectrum agents. No differences in demographics or severity characteristics were found between groups following matching. In the matched analysis, the rates of SSI were similar between groups [extended spectrum: 2.4% vs narrow spectrum 1.8% (odds ratio, OR: 1.05, 95% confidence interval, 95% CI 0.34-3.26)], as was the rate of revisits [extended spectrum: 7.9% vs narrow spectrum 5.1% (OR: 1.46, 95% CI 0.75-2.87)].

CONCLUSIONS

Use of extended-spectrum antibiotics was not associated with lower rates of SSI or hospital revisits when compared with narrow-spectrum antibiotics in children with uncomplicated appendicitis. Our results challenge the routine use of extended-spectrum antibiotics observed at many hospitals, particularly given the increasing incidence of antibiotic-resistant organisms.

Risk Factors for Readmission After Cleft Lip Repair

BACKGROUND

Cleft lip is the most common craniofacial malformation with an incidence of 1 in 700 live births. Our study sought to evaluate incidences and risk factors readmission following CLP repair using a well-validated national surgical database.

METHODS

All cleft lip repairs performed between 2012 and 2016 were identified in the American College of Surgeons National Surgical Quality Improvement Program Pediatric Database. Patient demographics, surgical variables, and reasons for readmission were analyzed and identified. A binary logistic regression was performed to identify factors independently associated with readmission following cleft lip repair.

RESULTS

The 4550 cleft lip repairs were identified with a thirty-day readmission rate of 3.8% (173 patients). A higher incidence of readmission was identified among patients with developmental delay (P ≤0.001), seizure disorder (P <0.001), structural central nervous system abnormality (P ≤0.001), steroid use within 30 days (P ≤0.001), a requirement for nutritional support (P <0.001), and ASA of 3 or higher (17.3% vs 9.9%, P <0.001). Readmitted patients were more likely to have deep incisional surgical site infections (P <0.001), deep wound dehiscence (P = 0.002), reoperation (P <0.001), pneumonia (P <0.001), and unplanned intubation (P <0.001).Multivariate regression identified seizure disorder (OR = 3.3; 95% CI = 1.3-8.3; P = 0.012) and steroid use within 30 days (OR = 3.8; 95% CI = 1.1-12.2; P = 0.030) as independently associated with readmission. The mean time of readmission was 9 days after operation.

CONCLUSION

Patients with seizure disorder and steroid use were significantly more likely to be readmitted. Physicians should be cautious with management of patients with these risk factors.

Preoperative laboratory testing before pediatric neurosurgery: an NSQIP-Pediatrics analysis

OBJECTIVES

The goal of this study was to evaluate clinical predictors of abnormal preoperative laboratory values in pediatric neurosurgical patients.

METHODS

Data obtained in children who underwent a neurosurgical operation were extracted from the prospective National Surgical Quality Improvement Program-Pediatrics (NSQIP-P, 2012-2013) registry. Multivariable logistic regression evaluated predictors of preoperative laboratory values that might require further evaluation (white blood cell count < 2000/μl, hematocrit < 24%, platelet count < 100,000/μl, international normalized ratio > 1.4, or partial thromboplastin time > 45 seconds) or a preoperative transfusion (within 48 hours prior to surgery). Variables screened included patient demographics; American Society of Anesthesiologists (ASA) physical designation classification; comorbidities; recent steroid use, chemotherapy, or radiation therapy; and admission type. Predictive score validation was performed using the NSQIP-P 2014 data.

RESULTS

Of the 6556 patients aged greater than 2 years, 68.9% (n = 5089) underwent laboratory testing, but only 1.9% (n = 125) had a critical laboratory value. Predictors of a laboratory abnormality were ASA class III-V; diabetes mellitus; hematological, hypothrombotic, or oncological comorbidities; nutritional support; recent chemotherapy; systemic inflammatory response syndrome; and a nonelective hospital admission. These 9 variables were used to create a predictive score, with a single point assigned for each predictor. The prevalence of critical values in the validation population (NSQIP-P 2014) of patients greater than 2 years of age was 0.3% with a score of 0, 1.0% in those with a score of 1, 1.6% in those with a score of 2, and 6.2% in those with a score ≥ 3. Higher score was predictive of a critical value (OR 2.33, 95% CI 1.91-2.83, p < 0.001, C-statistic 0.76) and with the requirement of a perioperative transfusion (intraoperatively or within 72 hours postoperatively; OR 1.42, 95% CI 1.22-1.67, p < 0.001) in the validation population. Moreover, when the same score was applied to children aged 2 years or younger, a greater score was predictive of a critical value (OR 2.47, 95% CI 2.15-2.84, p < 0.001, C-statistic 0.76).

CONCLUSIONS

Critical laboratory values in pediatric neurosurgical patients are largely predicted by clinical characteristics, and abnormal preoperative laboratory results are rare in patients older than 2 years of age without comorbidities who are undergoing elective surgery. The NSQIP-P critical preoperative laboratory value scale is proposed to indicate patients with the highest odds of an abnormal value. The scale can assist with triaging preoperative testing based on the surgical risk, as determined by the treating surgeon and anesthesiologist.

Embracing change: the era for pediatric ERAS is here

The concept of Enhanced Recovery After Surgery (ERAS) has increasingly been embraced by our adult surgical colleagues, but has been slow to crossover to pediatric surgical subspecialties. ERAS^® improves outcomes through multiple, incremental steps that act synergistically throughout the entire surgical journey. In practice, ERAS^® is a strategy of perioperative management that is defined by strong implementation and ongoing adherence to a patient-focused, multidisciplinary, and multimodal approach. There are increasing numbers of surgical teams exploring ERAS^® in children and there is mounting evidence that this approach may improve surgical care for children across the globe. The first World Congress in Pediatric ERAS^® in 2018 has set the stage for a new era in pediatric surgical safety.

Venous thromboembolism following inpatient pediatric surgery: Analysis of 153,220 patients

PURPOSE

To evaluate venous thromboembolism (VTE) rates and risk factors following inpatient pediatric surgery.

METHODS

153,220 inpatient pediatric surgical patients were selected from the 2012-2015 NSQIP-P database. Demographic and perioperative variables were documented. Primary outcome was VTE requiring treatment within 30 postoperative days. Secondary outcomes included length of stay (LOS) and 30-day mortality. Prediction models were generated using logistic regression. Mortality and time to VTE were assessed using Kaplan-Meier survival analysis.

RESULTS

305 patients (0.20%) developed 296 venous thromboses and 12 pulmonary emboli (3 cooccurrences). Median time to VTE was 9 days. Most VTEs (81%) occurred predischarge. Subspecialties with highest VTE rates were cardiothoracic (0.72%) and general surgery (0.28%). No differences were seen for elective vs. urgent/emergent procedures (p = 0.106). All-cause mortality VTE patients was 1.2% vs. 0.2% in patients without VTE (p < 0.001). After stratifying by American Society of Anesthesiologists (ASA) class, no mortality differences remained when ASA < 3. Preoperative, postoperative, and total LOSs were longer for patients with VTE (p < 0.001 for each). ASA ≥ 3, preoperative sepsis, ventilator dependence, enteral/parenteral feeding, steroid use, preoperative blood transfusion, gastrointestinal disease, hematologic disorders, operative time, and age were independent predictors (C-statistic = 0.83).

CONCLUSIONS

Pediatric postsurgical patients have unique risk factors for developing VTE.

LEVEL OF EVIDENCE

Level II.

Laparoscopic Splenectomy: Has It Become the Standard Surgical Approach in Pediatric Patients?

BACKGROUND

Splenectomy is often required in the pediatric population as part of the treatment of hematologic disorders and can be performed laparoscopically or open. We evaluated the comparative effectiveness of laparoscopic (LS) and open (OS) splenectomies using the American College of Surgeons National Surgical Quality Improvement Program Pediatric (NSQIP-P) data set.

METHODS

The NSQIP-P data set was used to identify children who underwent elective splenectomy between January 2012 and December 2016. Thirty-day outcomes between OS and LS, and LS alone and concurrent LS and cholecystectomy were compared using univariate and multivariate analysis.

RESULTS

Most of the splenectomies (91%) were performed laparoscopically. There was no difference in overall complications between OS (n = 60) and LS (n = 613), although OS had a higher risk of perioperative transfusion (OR 3.19, 95% CI 1.52-6.69). LS was associated with a shorter median hospital length of stay (2 versus 4 d, P < 0.001) and similar mean operative times compared to OS (120 versus 133 min, P = 0.559). There was no difference in outcomes of children undergoing LS versus LS and concurrent cholecystectomy (n = 129).

CONCLUSIONS

LS has become the standard approach for elective splenectomies in the pediatric population and has minimal morbidity, and when indicated, concurrent cholecystectomies do not increase the risk of complications.

LEVELS OF EVIDENCE

III.

Impact of patient handover structure on neonatal perioperative safety

OBJECTIVE

To compare the incidence, severity, preventability, and contributing factors of non-routine events-deviations from optimal care based on the clinical situation-associated with team-based, nurse-to-nurse, and mixed handovers in a large cohort of surgical neonates.

STUDY DESIGN

A prospective observational study and one-time cross-sectional provider survey were conducted at one urban academic children's hospital. 130 non-cardiac surgical cases in 109 neonates who received pre- and post-operative NICU care.

RESULTS

The incidence of clinician-reported NREs was high (101/130 cases, 78%) but did not differ significantly across acuity-tailored neonatal handover practices. National Surgical Quality Improvement-Pediatric occurrences of major morbidity were significantly higher (p < 0.001) in direct team handovers than indirect nursing or mixed handovers.

CONCLUSIONS

NREs occur at a high rate and are of variable severity in neonatal perioperative care. NRE rates and contributory factors were homogenous across handover types. Surveyed clinicians recommend structured handovers for all patients at every transfer point regardless of acuity.

Impact of Cardiac Risk Factors on Complications Following Cranial Vault Remodeling: Analysis of the 2012 to 2016 National Safety Quality Improvement Program-Pediatric Database

Congenital cardiac malformations have been reported in 8% of patients with craniosynostosis undergoing cranial vault remodeling (CVR), but associations with surgical outcomes are unknown. This study evaluated postoperative complications in patients who underwent CVR for craniosynostosis with or without cardiac risk factors (CRF) using the National Safety Quality Improvement Program-Pediatric (NSQIP-P) database. NSQIP-P database was queried for patients <2 years with craniosynostosis who underwent CVR from 2012 to 2016 based on diagnosis and procedure codes. The primary outcome was a composite of available NSQIP-P complications. Analysis compared patients with craniosynostosis based on the presence or absence of CRF. Univariate and multiple logistic regression identified risk factors associated with postoperative complications. A total of 3293 patients met inclusion criteria (8% with CRF). Two-thirds of patients experienced at least 1 complication, though patients with CRF experienced a greater proportion (74% vs 66%, P = 0.001). Univariate analysis identified associations between post-operative complications and age, ASA class, supplemental oxygen, neuromuscular disorders, preoperative nutritional supplementation, interventricular hemorrhage, and CRF. On multivariate regression, only older age (OR 1.17, 95% CI 1.01-1.36) and longer operative duration (OR 1.01, 95% CI 1.01-1.01) were associated with greater odds of postoperative complications. The most common complication in patients with craniosynostosis who undergo CVR is bleeding requiring transfusion. Older age and longer operative duration were associated with postoperative complications. Although patients with CRF have more postoperative complications, CRF was not a risk factor on adjusted analysis.

Room for "quality" improvement? Validating National Surgical Quality Improvement Program-Pediatric (NSQIP-P) appendectomy data

INTRODUCTION

Accurate data are essential for the validity of clinical registries. This study aimed to validate NSQIP-P data, assess representativeness, and evaluate risk-adjusted predictive ability at a single institution.

METHODS

A prospective appendectomy-specific pediatric surgery research database (RD) maintained by clinical researchers was compared to the NSQIP-P data for appendectomies performed in 2016 at a tertiary children's hospital. NSQIP-P sampled data collected by trained surgical clinical reviewers (SCRs) were compared to matched RD patients. Both datasets used NSQIP-P definitions. Using χ², datasets were compared by patient demographics, disease severity (simple vs. complicated), and outcomes.

RESULTS

458 appendectomies for acute appendicitis were performed in 2016, of which 250 (55%) were abstracted by SCRs and matched to RD patients. Patient demographics were similar between datasets. Disease severity (NSQIP-P:50% complicated vs RD:31% complicated) and composite morbidity (NSQIP-P:6.0% vs RD:14.4%) were significantly different (both p < 0.01). Demographics and outcomes were similar between matched (n = 250) and unsampled patients in the RD (n = 208). NSQIP-P's risk-adjusted predicted morbidity was significantly lower than morbidity observed in all (n = 458) RD patients (NSQIP-P:9.9% vs RD:14.2%, p < 0.01).

CONCLUSIONS

Though constituting a representative sample, NSQIP-P appendectomy data were inconsistent with department data. Discrepancies appear to be the result of underreporting of outcome variables and disease misclassification.

TYPE OF STUDY

Retrospective comparative review.

LEVEL OF EVIDENCE

Level III.

Integrating intraoperative physiology data into outcome analysis for the ACS Pediatric National Surgical Quality Improvement Program

BACKGROUND

The Pediatric National Surgical Quality Improvement Program (P-NSQIP) samples surgical procedures for benchmarking and quality improvement. While generally comprehensive, P-NSQIP does not collect intraoperative physiologic data, despite potential impact on outcomes.

AIMS

The aims of this study were (a) to describe a methodology to augment P-NSQIP with vital signs data and (b) demonstrate its utility by exploring relationships that intraoperative hypothermia and hypotension have with P-NSQIP outcomes.

METHODS

Vital signs from 2012 to 2016 were available in a research databank. Episodes of hypotension and hypothermia were extracted and recorded alongside local P-NSQIP data. Multivariable regression analyses were performed to explore associations with undesired outcomes, including: surgical site infection, wound disruption, unplanned return to the operating room, and blood transfusion. Model variables were selected with the Akaike information criterion using 2012-2014 as the training set and validated with receiver operating characteristics analysis using 2015-2016 as the testing set.

RESULTS

Data from 6737 patients were analyzed, with 43.9% female, median [interquartile range] age 5.8 [1.3-12.4] years, undergoing procedures lasting 118 [75-193] minutes. Hypothermia, observed in 45% of cases, was associated with wound disruption (odds ratio 1.75, 95% CI 1.1-2.83). Hypotension, observed in 60% of cases, was associated with unplanned returns (odds ratio 1.58, 95% CI 1.02-2.51), and transfusions (odds ratio 1.95, 95% CI 1.14-3.52). Surgical site infection, wound disruption, unplanned return, and transfusion models had areas under the receiver operating characteristic curve of 0.69/0.67, 0.59/0.63, 0.78/0.79, and 0.92/0.93 for validation models including hypothermia/hypotension respectively.

CONCLUSION

Adding intraoperative vital signs to P-NSQIP data allowed identification of two modifiable risk factors: hypothermia was associated with increased wound disruption, and hypotension with increased blood transfusions and unplanned returns to the operating room. These findings may motivate prospective studies and prompt other centers and P-NSQIP to augment outcome data with intraoperative physiological data.

Pediatric Rhinoplasty: A national surgical quality improvement program analysis

OBJECTIVES

Rhinoplasty is commonly performed in children with congenital anomalies and resultant nasal deformity causing airway obstruction. Little is known regarding patient factors or perioperative sequelae. We define demographic characteristics and perioperative complications for children undergoing rhinoplasty within a large national cohort.

STUDY DESIGN

Retrospective cohort study of children aged ≤ 18 years undergoing rhinoplasty utilizing data from the 2012 to 2015 American College of Surgeons National Surgery Quality Improvement Program-Pediatric public use file.

METHODS

All children who underwent rhinoplasty were identified. Postoperative complications were defined as 30-day postoperative infection, unplanned readmission and reoperation, and death. Multivariate logistic regression was used to identify predictors of complications. Subgroup analysis was performed based on child age (age < 5 years vs. 5-13 years vs. ≥ 14 years).

RESULTS

Of 1,378 children undergoing rhinoplasty, 21(1.52%) children experienced complications, with the most common being unplanned readmission. Younger children were more likely to experience complications (3.79% aged < 5 years vs. 0.66% aged ≥ 14 years; P = 0.001). Using multivariate logistic regression analysis, we observed a 61% decreased odds of complication with each age group (odds ratio 0.39, 95% confidence interval 0.19, 0.77; P = 0.007). Younger children were more likely to be male (56.2% male aged < 5 years vs. 46.6% male aged ≥ 14 years; P = 0.011), have developmental delay (11.7% aged < 5 years vs. 3.65% aged ≥ 14 years; P < 0.001), and have craniofacial abnormalities (73.2% aged < 5 years vs. 42.1% aged ≥ 14 years; P < 0.001).

CONCLUSION

Children undergoing rhinoplasty experience few major complications, with the most common being unplanned readmission. Younger children are at greater risk and are more likely to be male with craniofacial abnormalities.

LEVEL OF EVIDENCE

4 Laryngoscope, 129:494-499, 2019.

Publicly Available Databases in Otolaryngology Quality Improvement

The historical context for quality improvement is provided. Important differences are described between the two overarching types of databases: clinical registries and administrative databases. The pros and cons of each are provided as are examples of their utilization in otolaryngology-head and neck surgery.

Readmission and complications within 30 days after intrathecal baclofen pump placement

AIM

To describe 30-day outcomes after intrathecal baclofen (ITB) pump placement in children and identify risk factors for readmission, reoperation, and perioperative complication using the National Surgical Quality Improvement Program-Pediatric (NSQIP-P) database.

METHOD

Patients aged 0 to 18 years who underwent ITB pump placement (2012-2014) comprised the study cohort defined in the database. Multivariate regression analysis was performed using preoperative and perioperative data from the American College of Surgeons' NSQIP-P database. Outcomes of interest within 30 days of surgery were (1) unplanned reoperation; (2) unplanned readmission; and (3) composite postoperative event, including complication, reoperation, and/or readmission.

RESULTS

We identified 423 surgeries; 246 (58.2%) patients were male, 177 (41.8%) patients were female. Median age was 12 years and 11 months. Median operative time was 70 minutes (interquartile range 56-97min). Mean length of stay was 3.8 days. The patient population had a high number of medical comorbidities. The overall readmission rate was 7.3%; mean postoperative admission date was 14.1 days after surgery. Of readmitted patients, 64.5% underwent reoperation. The most common indication for reoperation was surgical site infection. Female sex was associated with decreased risk of readmission (odds ratio [OR] 0.25, 95% confidence interval [CI] 0.09-0.65; p=0.01); American Society of Anesthesiologists Classification of greater than or equal to 3 was associated with decreased risk of unplanned return to surgery (OR 0.26, 95% CI 0.11-0.66; p=0.04); length of stay greater than or equal to 3 days at index surgery was associated with increased risk of composite 30-day perioperative event (OR 2.33, 95% CI 1.29-4.20; p=0.01).

INTERPRETATION

Our data provide national perspectives on 30-day perioperative outcomes for ITB pump placement in children. Results illustrate NSQIP-P database collection methodology and highlight opportunities for quality improvement in clinical practice.

WHAT THIS PAPER ADDS

Seven percent of patients who underwent intrathecal baclofen pump placement required readmission within 30 days. The most common indication for reoperation was surgical site infection.

Incidence and risk factors associated with 30-day post-operative venous thromboembolism: A NSQIP-pediatric analysis

INTRO

Venous thromboembolism (VTE) is a rare event in children, but can cause significant morbidity and mortality. The majority of research on pediatric VTE has been in the trauma and critical care populations. The incidence of VTE after surgery in children is not well-established.

OBJECTIVE

The objective was to evaluate the incidence of VTE in the 30 days after surgery, as well as associated risk factors.

STUDY DESIGN

All cases in the National Surgical Quality Improvement Program Pediatric (NSQIPP) database from 2012 to 2015 were assessed for presence of post-operative VTE. Demographic, clinical, and peri-operative characteristics were collected. Descriptive statistics were performed, and multiple logistic regression models were created to estimate associated risk of VTE.

RESULTS

In a cohort of 267,299 surgical cases, the 30-day incidence of post-operative VTE was 12 per 10,000 cases (0.12%). VTE incidence followed a bi-modal distribution, highest in infants and adolescents (Figure). Malignancy, pre-operative illness, and greater anesthetic times were associated with increased risk of VTE.

DISCUSSION

The incidence of post-operative VTE in NSQIPP is similar to that seen in pediatric trauma and critical care populations. Risk factors are also consistent, including baseline illness, immobility, and prolonged anesthetic time.

CONCLUSION

Post-operative VTE in children occurs infrequently, yet certain individuals are at increased risk and thus guidelines for prophylaxis and treatment are needed.

Short-term outcomes in children undergoing restorative proctocolectomy with ileal-pouch anal anastomosis

INTRODUCTION

Patients with familial adenomatous polyposis (FAP) and ulcerative colitis (UC) commonly undergo restorative proctocolectomy with ileal-pouch anal anastomosis (RP-IPAA). We sought to describe patient characteristics and postoperative outcomes in this patient population.

METHODS

Using the National Surgical Quality Improvement Program-Pediatric Participant Use Files from 2012 to 2015, children who were 6-18years old who underwent RP-IPAA for FAP or UC were identified. Postoperative morbidity, including reoperation and readmission were quantified. Associations between preoperative characteristics and postoperative outcomes were analyzed.

RESULTS

A total of 260 children met the inclusion criteria, of which 56.2% had UC. Most cases were performed laparoscopically (58.1%), and the operative time was longer with a laparoscopic versus open approach (326 [257-408] versus 281 [216-391] minutes, p=0.02). The overall morbidity was 11.5%, and there were high reoperation and readmission rates (12.7% and 21.5%, respectively). On bivariate analysis, preoperative steroid use was associated with reoperation (22.5% versus 10.9%, p=0.04). On multivariable regression analysis, obesity was independently associated with reoperation (odds ratio: 3.34 [95% confidence intervals: 1.08-10.38], p=0.04).

CONCLUSIONS

Children who undergo RP-IPAA have high rates of overall morbidity, reoperation, and readmission. Obesity was independently associated with reoperation. This data can be used by practitioners in the preoperative setting to better counsel families and establish expectations for the postoperative setting.

TYPE OF STUDY

Retrospective Comparative Study.

LEVEL OF EVIDENCE

Level III.

Quality measurement and improvement in liver transplantation

There is growing interest in the quality of health care delivery in liver transplantation. Multiple stakeholders, including patients, transplant providers and their hospitals, payers, and regulatory bodies have an interest in measuring and monitoring quality in the liver transplant process, and understanding differences in quality across centres. This article aims to provide an overview of quality measurement and regulatory issues in liver transplantation performed within the United States. We review how broader definitions of health care quality should be applied to liver transplant care models. We outline the status quo including the current regulatory agencies, public reporting mechanisms, and requirements around quality assurance and performance improvement (QAPI) activities. Additionally, we further discuss unintended consequences and opportunities for growth in quality measurement. Quality measurement and the integration of quality improvement strategies into liver transplant programmes hold significant promise, but multiple challenges to successful implementation must be addressed to optimise value.

Advances in perioperative quality and safety

For decades, safe surgery focused on intraoperative technique and decision-making. The traditional hierarchy placed the surgeon as the leader with ultimate authority and responsibility. Despite the advances in surgical technique and equipment, too many patients have suffered unnecessary complications and suboptimal care. Today, we understand that the conduct of safe and effective surgery requires evidence-based decision-making, multifaceted treatment approaches to prevent complications, and effective communication in and out of the operating room. In this manuscript, we describe three significant advances in quality and safety that have changed the approach to surgical care: the National Surgical Quality Improvement Program, evidence-based bundled prevention of surgical site infections, and the Surgical Safety Checklist.

Impact of outpatient management following appendectomy for acute appendicitis: An ACS NSQIP-P analysis

BACKGROUND

In 2012, a same-day discharge protocol following appendectomy for acute appendicitis was initiated. Our objective was to determine the success of the protocol by reviewing the National Surgical Quality Improvement Program-Pediatric (NSQIP-P) outcomes following protocol development.

METHODS

The 2015 NSQIP-P Participant Use Data File was queried to identify patients with acute appendicitis who underwent appendectomy. Outcomes were compared to institutional outcomes.

RESULTS

There were 154 institutional patients and 4973 from NSQIP-P centers. Institutional rate of outpatient management was higher compared to NSQIP-P (84% vs 48%, p<0.0001). Surgical length of stay was shorter compared to national rates (0.3±0.7 vs 1.1±1.9days, p<0.0001). There was no significant difference in the incidence of superficial (1.9% vs 1.0%, p=0.2), deep (0.6% vs 0.1%, p=0.17) or organ/space surgical site infections (1.3% vs 0.7%, p=0.31). The incidences of other complications (1.3% vs 0.6%, p=0.26) and 30-day readmissions (3.2% vs 2.6%, p=0.61) were similar.

CONCLUSION

Outpatient management following appendectomy in children is possible with low morbidity and readmission rates. Comparison with other NSQIP-Pediatric centers suggests an opportunity to generalize this practice with considerable savings to the health care system.

LEVEL OF EVIDENCE

Prognosis study, level II.

Thirty-day outcomes in pediatric epilepsy surgery

PURPOSE

The aim of this study was to use the multicenter American College of Surgeons National Surgical Quality Improvement Program-Pediatric (NSQIP-P) to evaluate and identify risk factors for 30-day adverse events in children undergoing epilepsy surgery.

METHODS

Using the 2015 NSQIP-P database, we identified children (age 0-18 years) undergoing pediatric epilepsy surgery and analyzed NSQIP-defined complications, unplanned reoperations, and unplanned readmissions. Multivariable logistic regression analysis was performed using perioperative data to identify risk factors for adverse events within 30 days of the index procedure.

RESULTS

Two hundred eight pediatric patients undergoing epilepsy surgery were identified for the year 2015 in the NSQIP-P database. The majority of patients were male (51.8%) and white (72.9%). The median age was 10 years. Neurological and neuromuscular comorbidities were seen in 62.5% of patients. Surgical blood loss and transfusion was the most common overall NSQIP-defined event (15.7%) and was reported in 40% with hemispherectomy. Nineteen patients (6.8%) had an unplanned reoperation and 20 patients (7.1%) had an unplanned readmission. Multivariable logistic regression analysis showed that African American patients (OR 3.26, 95% CI 1.29-8.21, p = 0.01) and hemispherectomy (OR 3.05, 95% CI 1.4-6.65, p = 0.01) were independently associated with NSQIP-defined complications. Patients undergoing hemispherectomy (OR 4.11, 95% CI 1.48-11.42, p = 0.01) were also at significantly higher risk of unplanned readmission after pediatric epilepsy surgery.

CONCLUSIONS

Data from the 2015 NSQIP-P database showed that hemispherectomy was significantly associated with higher perioperative events in children undergoing epilepsy surgery. Quality improvement initiatives for hemispherectomy should target surgical blood loss and wound-related complications. Racial disparities in access to cranial pediatric epilepsy surgery and perioperative complications were also highlighted in the present study.

Early versus delayed closure of bladder exstrophy: A National Surgical Quality Improvement Program Pediatric analysis

INTRODUCTION

Delayed closure of bladder exstrophy has become more popular; however, there is limited the evidence of its success. Existing literature focuses on intermediate and long-term outcomes, and short-term postoperative outcomes are limited by the small number of cases and varying follow-up methods.

OBJECTIVE

The objectives of the current study were to: 1) compare 30-day complications after early and delayed closure of bladder exstrophy, and 2) evaluate practice patterns of bladder exstrophy closure.

STUDY DESIGN

The National Surgical Quality Improvement Program Pediatric (NSQIPP) database from 2012 to 2015 was reviewed for all cases of bladder exstrophy closure. Early closure was defined as surgery at age 0-3 days, and delayed closure was defined as age 4-120 days at time of surgery. Demographic, clinical, and peri-operative characteristics were collected, as were postoperative complications, readmissions, and re-operations up to 30 days. Descriptive statistics were performed, and multivariate linear and logistic regression analyses were performed for salient complications.

RESULTS

Of 128 patients undergoing bladder exstrophy closure, 62 were included for analysis, with 44 (71%) undergoing delayed closure. Mean anesthesia and operative times were greater in the delayed closure group, and were associated with more concurrent procedures, including inguinal hernia repairs and osteotomies. The delayed closure group had a higher proportion of 30-day complications, due to a high rate of blood transfusion (57% vs 11%). Wound dehiscence occurred in 6/44 (14%) delayed closures, as compared with 0/18 (0%) early closures. When compared with prior published reports of national data from 1999 to 2010, delayed closure was performed more frequently in this cohort (71% vs 27%).

DISCUSSION

The NSQIPP provides standardized reporting of peri-operative characteristics and 30-day complications, allowing a comparison of early to delayed closure of bladder exstrophy across multiple institutions. Assessing short-term risks in conjunction with long-term follow-up is crucial for determining optimal management of this rare but complex condition.

CONCLUSION

Delayed closure of bladder exstrophy is performed frequently, yet it carries a high rate of 30-day complications worthy of further investigation. This can be useful in counseling patients and families, and to understand practice patterns across the country.

New anthropometric classification scheme of preoperative nutritional status in children: a retrospective observational cohort study

OBJECTIVE

WHO uses anthropometric classification scheme of childhood acute and chronic malnutrition based on low body mass index (BMI) ('wasting') and height for age ('stunting'), respectively. The goal of this study was to describe a novel two-axis nutritional classification scheme to (1) characterise nutritional profiles in children undergoing abdominal surgery and (2) characterise relationships between preoperative nutritional status and postoperative morbidity.

DESIGN

This was a retrospective observational cohort study.

SETTING

The setting was 50 hospitals caring for children in North America that participated in the American College of Surgeons National Surgical Quality Improvement Program Paediatric from 2011 to 2013.

PARTICIPANTS

Children >28 days who underwent major abdominal operations were identified.

INTERVENTIONS/MAIN PREDICTOR

The cohort of children was divided into five nutritional profile groups based on both BMI and height for age Z-scores: (1) underweight/short, (2) underweight/tall, (3) overweight/short, (4) overweight/tall and (5) non-outliers (controls).

MAIN OUTCOME MEASURES

Multiple variable logistic regressions were used to quantify the association between 30-day morbidity and nutritional profile groups while adjusting for procedure case mix, age and American Society of Anaesthesiologists class.

RESULTS

A total of 39 520 cases distributed as follows: underweight/short (656, 2.2%); underweight/tall (252, 0.8%); overweight/short (733, 2.4%) and overweight/tall (1534, 5.1%). Regression analyses revealed increased adjusted odds of composite morbidity (35%) and reintervention events (75%) in the underweight/short group, while overweight/short patients had increased adjusted odds of composite morbidity and healthcare-associated infections (43%), and reintervention events (79%) compared with controls.

CONCLUSION

Stratification of preoperative nutritional status using a scheme incorporating both BMI and height for age is feasible. Further research is needed to validate this nutritional risk classification scheme for other surgical procedures in children.

Outcomes in Children Undergoing Surgery for Congenital Pulmonary Airway Malformations in the First Year of Life

BACKGROUND

Treatment of congenital pulmonary airway malformations (CPAMs) is generally surgical resection; however, there is controversy regarding the optimal timing of surgical intervention, especially in asymptomatic patients.

STUDY DESIGN

Using the American College of Surgeons National Surgical Quality Improvement Program-Pediatric Participant Use Files from 2012 to 2015, children who underwent lung resection for CPAMs were identified. Outcomes in children who underwent lung resection during the neonatal period were compared with those who underwent resection beyond the neonatal period, but during the first year of life (non-neonates).

RESULTS

A total of 541 patients (20.7% neonates and 79.3% non-neonates) were identified. Neonates had higher rates of preoperative comorbidities and worse postoperative outcomes when compared with non-neonates (morbidity 19.6% vs 5.4%, p < 0.0001). On multivariable regression analysis, the presence of preoperative symptoms (defined as oxygen dependence or ventilatory support) was independently associated with increased morbidity (odds ratio 3.91 [range 1.6 to 9.57], p = 0.003). In a subgroup analysis of asymptomatic neonates compared with asymptomatic non-neonates, there was no difference in overall morbidity (7.4% vs 4.4%, p = 0.33).

CONCLUSIONS

These data suggest that lung resection for CPAMs in the neonatal period in asymptomatic children are not associated with increased 30-day morbidity. The presence of preoperative symptoms was independently associated with increased morbidity in a multivariable regression model. More data are needed to better understand the long-term outcomes and better define the optimal timing of surgery in this patient population.

Review of the enhanced recovery pathway for children: perioperative anesthetic considerations

PURPOSE

Enhanced recovery after surgery (ERAS) pathways have been used for two decades to improve perioperative recovery in adults. Nevertheless, little is known about their effectiveness in children. The purpose of this review was to consider pediatric ERAS pathways, review the literature concerned with their potential benefit, and compare them with adult ERAS pathways.

SOURCE

A PubMed literature search was performed for articles that included the terms enhanced recovery and/or fast track in the pediatric perioperative period. Pediatric patients included those from the neonatal period through teenagers and/or youths.

PRINCIPAL FINDINGS

The literature search revealed a paucity of articles about pediatric ERAS. This lack of academic investigation is likely due in part to the delayed acceptance of ERAS in the pediatric surgical arena. Several pediatric studies examined individual components of adult-based ERAS pathways, but the overall study of a comprehensive multidisciplinary ERAS protocol in pediatric patients is lacking.

CONCLUSION

Although adult ERAS pathways have been successful at reducing patient morbidity, the translation, creation, and utility of instituting pediatric ERAS pathways have yet to be realized.