1
|
Steinl G, Grabski D, Fleming M, Levin D, McGahren E, McCullough W, Gander J. Implementation of ultrasound and fast magnetic resonance imaging pathway reduces computed tomography utilization in children with suspected appendicitis. Pediatr Surg Int 2023; 39:238. [PMID: 37486585 DOI: 10.1007/s00383-023-05521-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/12/2023] [Indexed: 07/25/2023]
Abstract
PURPOSE Computed tomography (CT) is still used in the imaging diagnosis of acute appendicitis in children at many hospitals. We implemented an ultrasound (US) and fast magnetic resonance imaging (MRI) pathway for suspected appendicitis at our institution with the goal of reducing radiation exposure in children. METHODS All children (< 18 years old) who underwent appendectomy between January 2011 and July 2021 were reviewed. Data were collected on all imaging studies performed. In December 2015, we initiated an imaging pathway for suspected acute appendicitis. US was the initial imaging study, and a rapid protocol MRI was performed if US was equivocal. Those could not tolerate MRI underwent CT. We evaluated the difference in percentage of patients who underwent CT before and after pathway initiation. RESULTS 554 patients who underwent appendectomy did not have prior imaging studies on presentation to our hospital and were included in analysis. After initiating the pathway, the use of abdominal US increased from 87% (220 of 254) to 97% (291 of 300, p < 0.0001) and the use of MRI increased by 100% (0 MRIs pre-protocol, 90 of 300 patients post-protocol, p < 0.0001). CT utilization decreased significantly from 32% (82 of 254) to 2% (6 of 300, p < 0.0001). CONCLUSION Embracing a new US and rapid MRI pathway to evaluate pediatric patients with suspected acute appendicitis resulted in significant reduction in CT utilization and therefore radiation exposure.
Collapse
Affiliation(s)
- Gabrielle Steinl
- Department of Surgery, University of Virginia, Charlottesville, USA
| | - David Grabski
- Department of Surgery, University of Virginia, Charlottesville, USA
| | - Mark Fleming
- Department of Surgery, University of Virginia, Charlottesville, USA
| | - Daniel Levin
- Division of Pediatric Surgery, Department of Surgery, University of Virginia School of Medicine, University of Virginia, 1215 Lee St., Charlottesville, VA, 22904, USA
| | - Eugene McGahren
- Division of Pediatric Surgery, Department of Surgery, University of Virginia School of Medicine, University of Virginia, 1215 Lee St., Charlottesville, VA, 22904, USA
| | - William McCullough
- Department of Radiology, Santa Clara Homestead Medical Center, Santa Clara, CA, USA
| | - Jeffrey Gander
- Division of Pediatric Surgery, Department of Surgery, University of Virginia School of Medicine, University of Virginia, 1215 Lee St., Charlottesville, VA, 22904, USA.
| |
Collapse
|
2
|
Swenson Z, Kinariwala D, Moneme C, McGahren E, Daugherty R. Congenital internal hernia in the neonate: Case series with review of potential comorbidities and imaging findings. Journal of Pediatric Surgery Case Reports 2023. [DOI: 10.1016/j.epsc.2023.102596] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2023] Open
|
3
|
Eubanks AL, Grabski DF, Pollack J, Levin DE, McGahren E, Martin LW, Gander J. A multimodal protocol utilizing liposomal bupivacaine rib blocks leads to opioid reduction in patients undergoing the Nuss procedure. J Thorac Dis 2022; 13:6363-6372. [PMID: 34992816 PMCID: PMC8662494 DOI: 10.21037/jtd-21-1314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Accepted: 10/09/2021] [Indexed: 12/05/2022]
Abstract
Background A major challenge associated with the Nuss procedure for pectus excavatum repair is postoperative pain control. Early Recovery Program (ERP) protocols for the Nuss procedure are becoming common, but there is a paucity of experience using liposomal bupivacaine (LB), a long-acting local anesthetic, for rib blocks in this setting. We investigated whether a protocol utilizing LB rib blocks decreased opioid use after the Nuss procedure while achieving equivalent pain control. Methods All adolescent patients undergoing the Nuss procedure at our institution between January 2013 and January 2021 were included. Patients were divided into a pre-intervention cohort (n=15), a transition cohort (n=4), and a post-intervention cohort (n=13). Patients in all groups received scheduled acetaminophen and non-steroidals postoperatively. The pre-intervention cohort received an opioid patient-controlled analgesia (PCA) pump postoperatively, with a transition to oral opiates. The transition and post-intervention cohorts received scheduled gabapentin in addition to intraoperative bilateral rib blocks with longer-acting local anesthetic. Rib blocks were performed using 0.25% Bupivacaine in the pre-intervention group. In the transition group, epinephrine (1 mg/kg) was added to 0.25% bupivacaine for the rib block. Following approval in patients aged 13–18 years, 1.3% LB (2.25 mg/kg) was given for a rib block in the post-intervention cohort. Results Demographic and clinical variables were equivalent in all groups. Post-intervention patients received 90% fewer opioids [median morphine equivalent (MME) mg/kg] compared to the pre-intervention cohort (0.8 vs. 8.2 MME mg/kg, P<0.0001), with no significant difference in pain scores between groups. Hospital length of stay was decreased among the intervention cohort (3 vs. 4 days, P=0.002). Conclusions Significant decreases in opioid use and length of stay after the Nuss procedure were achieved by the implementation of a multimodal ERP for pain management, without increase in patient-reported pain scores.
Collapse
Affiliation(s)
- Alicia L Eubanks
- Department of Surgery, University of Virginia, Charlottesville, VA, USA
| | - David F Grabski
- Department of Surgery, University of Virginia, Charlottesville, VA, USA
| | - Jessica Pollack
- Department of Surgery, University of Virginia, Charlottesville, VA, USA
| | - Daniel E Levin
- Department of Surgery, University of Virginia, Charlottesville, VA, USA
| | - Eugene McGahren
- Department of Surgery, University of Virginia, Charlottesville, VA, USA
| | - Linda W Martin
- Department of Surgery, University of Virginia, Charlottesville, VA, USA
| | - Jeffrey Gander
- Department of Surgery, University of Virginia, Charlottesville, VA, USA
| |
Collapse
|
4
|
Meyer JS, Robinson G, Moonah S, Levin D, McGahren E, Herring K, Poulter M, Waggoner-Fountain L, Shirley DA. Acute appendicitis in four children with SARS-CoV-2 infection. J Pediatr Surg Case Rep 2021; 64:101734. [PMID: 33262930 PMCID: PMC7690274 DOI: 10.1016/j.epsc.2020.101734] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 11/20/2020] [Accepted: 11/22/2020] [Indexed: 02/07/2023] Open
Abstract
We describe 4 children (11-17 years in age) at our institution with acute appendicitis in the setting of SARS-CoV-2 infection, suggesting a possible association. Providers should consider testing for this infection in patients with severe gastrointestinal symptoms, in order to take appropriate transmission based precautions, until more is understood.
Collapse
Key Words
- ACE2, angiotensin-converting enzyme 2
- Appendicitis
- COVID-19
- COVID-19, novel coronavirus disease 2019
- CT, computed tomography
- ED, emergency department
- HEPA, high-efficiency particulate air
- IV, intravenous
- MIS-C, multisystem inflammatory syndrome in children
- NP, nasopharyngeal
- PCR, polymerase-chain-reaction
- SARS-CoV-2
- SARS-CoV-2, severe acute respiratory syndrome coronavirus 2
Collapse
Affiliation(s)
- Jessica S Meyer
- Pediatric Hospital Medicine, Department of Pediatrics, University of Virginia, Charlottesville, VA, USA
| | - Grant Robinson
- Department of Pediatrics, University of Virginia, Charlottesville, VA, USA
| | - Shannon Moonah
- Division of Infectious Diseases & International Health, Department of Medicine, University of Virginia Health System, Charlottesville, VA, USA
| | - Daniel Levin
- Division of Pediatric Surgery, Department of Pediatrics, University of Virginia, Charlottesville, VA, USA
| | - Eugene McGahren
- Division of Pediatric Surgery, Department of Pediatrics, University of Virginia, Charlottesville, VA, USA
| | - Katye Herring
- Division of Pediatric Hematology & Oncology, Department of Pediatrics, University of Virginia, Charlottesville, VA, USA
| | - Melinda Poulter
- Division of Laboratory Medicine/ Clinical Laboratories, Department of Pathology, University of Virginia, Charlottesville, VA, USA
| | - Linda Waggoner-Fountain
- Division of Pediatric Infectious Diseases, Department of Pediatrics, University of Virginia, Charlottesville, VA, USA
| | - Debbie-Ann Shirley
- Division of Pediatric Infectious Diseases, Department of Pediatrics, University of Virginia, Charlottesville, VA, USA
| |
Collapse
|
5
|
Katzenstein HM, Furman WL, Malogolowkin M, Krailo MD, McCarville MB, Towbin A, Tiao G, Finegold M, Ranganathan S, Dunn S, Langham M, McGahren E, Rodriguez-Galindo C, Meyers R. Vincristine/irinotecan upfront window treatment of high-risk hepatoblastoma: A report from the Children’s Oncology Group (COG) AHEP0731 study committee. J Clin Oncol 2016. [DOI: 10.1200/jco.2016.34.15_suppl.10516] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
| | | | | | | | | | | | - Greg Tiao
- Cincinnati Childrens Medical Center, Cincinnati, OH
| | | | | | - Stephen Dunn
- Alfred Dupont Children's Hospital, Wilmington, DE
| | | | | | | | | |
Collapse
|
6
|
Hartman S, Petroze R, McGahren E. Two Cases of Abdominal Pain after Trauma. Pediatr Rev 2016; 37:e16-8. [PMID: 27037109 DOI: 10.1542/pir.2015-0101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
- Stephanie Hartman
- Department of Pediatrics, University of Virginia, Charlottesville, VA
| | - Robin Petroze
- Department of Surgery, University of Virginia, Charlottesville, VA
| | - Eugene McGahren
- Department of Surgery, University of Virginia, Charlottesville, VA
| |
Collapse
|
7
|
Abstract
Although complications of Meckel's diverticula are relatively common, there has not been a reported case, to our knowledge, of foreign bodies impacted within a Meckel's diverticulum. We report herein a case of a 2-year-old child who had two pennies trapped in a Meckel's diverticulum. This case demonstrates that foreign objects in the right lower quadrant that do not progress may be impacted in a Meckel's diverticulum.
Collapse
Affiliation(s)
- V Velanovich
- General Surgery Service, Madigan Army Medical Center, Tacoma, Wash
| | | | | | | | | |
Collapse
|