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OBJECT This study explored antibiotic prophylaxis (AP) in pediatric patients undergoing intrathecal baclofen pump (ITBP) surgery and factors associated with perioperative AP compliance with clinical guidelines. METHODS Data were obtained from the Pediatric Health Information System. The study cohort comprised patients who underwent ITBP surgery within 3 days of admission, between July 1, 2004, and March 31, 2014, with a minimum prior screening period and follow-up of 180 days. Exclusion criteria were prior infection, antibiotic use within 30 days of admission, and/or missing financial data. Chi-square tests and multivariate logistic regressions were used to determine factors associated with compliance with AP guidelines in ITBP surgeries. RESULTS A total of 1,534 patients met the inclusion criteria; 91.5% received AP and 37.6% received dual coverage or more. Overall bundled compliance comprised 2 components: 1) perioperative antibiotic administration and 2) < 24-hour postoperative antibiotic course. The most frequently used antibiotics in surgery were cefazolin (n = 873, 62.2%) and vancomycin (n = 351, 25%). Documented bundled AP compliance rates were 70.2%, 62.0%, 66.0%, and 55.2% in West, South, Midwest, and Northeast regions of the US, respectively. Compared with surgeries in the Northeast, procedures carried out in the West (OR 2.0, 95% C11.4-2.9, p < 0.001), Midwest (OR 1.6, 95% C11.1-2.3, p = 0.007), and South (OR 1.5, 95% C11.1-2.0, p = 0.021) were more likely to have documented AP compliance. Black (OR 0.74, 95% CI 0.55-1.00, p = 0.05) and Hispanic (OR 0.63, 95% CI 0.47-0.86, p = 0.004) patients were less likely to have documented AP compliance in ITBP surgeries than white patients. There were no significant differences in compliance rate by age, sex, type of insurance, and diagnosis. AP process measures were associated with shorter length of stay, lower hospitalization costs, and lower 6-month rates of surgical infection/complication. One of the 2 noncompliance subgroups, missed preoperative antibiotic administration, was correlated with a significantly higher 6-month surgical complication/infection rate (27.03%) compared with bundled compliance (20.00%, p = 0.021). For the other subgroup, prolonged antibiotic use > 24 hours postoperatively, the rate was insignificantly higher (22.00%, p = 0.368). Thus, of direct relevance to practicing clinicians, missed preoperative antibiotics was associated with 48% higher risk of adverse complication/infection outcome in a 6-month time frame. Adjusted hospitalization costs associated with baclofen pump surgery differed significantly (p < 0.001) with respect to perioperative antibiotic practices: 22.83, 29.10, 37.66 (× 1000 USD) for bundled compliance, missed preoperative antibiotics, and prolonged antibiotic administration, respectively. CONCLUSIONS Significant variation in ITBP antibiotic prophylaxis was found. Documented AP compliance was associated with higher value of care, showing favorable clinical and financial outcomes. Of most impact to clinical outcome, missed preoperative antibiotics was significantly associated with higher risk of 6-month surgical complication/infection. Prolonged antibiotic use was associated with significantly higher hospital costs compared with those with overall bundled antibiotic compliance. Future research is warranted to examine factors associated with practice variation and how AP compliance is associated with outcomes and quality, aiming for improving delivery of care to pediatric patients undergoing ITBP procedures.

Upper airway obstruction resulting from overflexion of the craniocervical junction after occipitocervical fusion is a rare but potentially life-threatening complication and is associated with morbidity. The authors retrospectively reviewed the medical records and diagnostic images of 2 pediatrie patients who underwent occipitocervical fusion by the Neuro-Spine Program at Texas Children’s Hospital and experienced dyspnea and/or dysphagia from new upper airway obstruction in the postoperative period. Patient demographics, operative data, and preoperative and postoperative occiput-C2 angles were recorded. A review of the literature for similar complications after occipitocervical fusion was performed. A total of 13 cases of prolonged upper airway obstruction after occipitocervical fusion were analyzed. Most of these cases involved adults with rheumatoid arthritis. To the best of the authors’ knowledge, there have been no previous reports of prolonged upper airway obstruction in children after an occipitocervical fusion. Fixation of the neck in increased flexion (−18° to −5°) was a common finding among these adult and pediatrie cases. The authors’ cases involved children with micrognathia and comparatively large tongues, which may predispose the oropharynx to obstruction with even the slightest amount of increased flexion. Close attention to a satisfactory fixation angle (occiput-C2 angle) is necessary to avoid airway obstruction after an occipitocervical fusion. Children with micrognathia are particularly sensitive to changes in flexion at the craniocervical junction after occipitocervical fixation.

Object There have been no large-scale analyses on cost drivers in CSF shunt surgery for the treatment of pediatric hydrocephalus. The objective of this study was to develop a cost model for hospitalization costs in pediatric CSF shunt surgery and to examine risk factors for increased costs. Methods Data were extracted from the Kids' Inpatient Database (KID) of the Healthcare Cost and Utilization Project. Children with initial CSF shunt placement in the 2009 KID were examined. Patient charge was converted to cost using a cost-to-charge ratio. The factors associated with costs of CSF shunt hospitalizations were examined, including patient demographics, hospital characteristics, and clinical data. The natural log transformation of cost per inpatient day (CoPID) was analyzed. Three multivariate linear regression models were used to characterize the cost. Variance inflation factor was used to identify multicollinearity for each model. Results A total of 2519 patients met the inclusion criteria and were included in study. Average cost and length of stay (LOS) for initial shunt placement were $49,317 ± $74,483 (US) and 18.2 ± 28.5 days, respectively. Cost per inpatient day was $4249 ± $2837 (median $3397, range $80–$22,263). The average number of registered nurse (RN) full-time equivalents (FTEs) per 1000 adjusted inpatient days was 5.8 (range 1.6–10.8). The final model had the highest adjusted coefficient of determination (R2 = 0.32) and was determined to be the best among 3 models. The final model showed that child age, hydrocephalus etiology, weekend admission, number of chronic diseases, hospital type, number of RN FTEs per 1000 adjusted inpatient days, number of procedures, race, insurance type, income level, and hospital regions were associated with CoPID. Conclusions A patient's socioeconomic status, such as race, income level, and insurance, in addition to hospitalrelated factors such as number of hospital RN FTEs, hospital type, and US region, could affect the costs of initial CSF shunt placement, in addition to clinical factors such as hydrocephalus origin and LOS. To create a cost model of initial CSF shunt placement in the pediatric population, consideration of such nonclinical factors may be warranted.