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To assess the clinical implications of cryoanalgesia for pain management in children undergoing minimally invasive repair of pectus excavatum (MIRPE).MIRPE entails significant pain management challenges, often requiring high postoperative opioid use. Cryoanalgesia, which blocks pain signals by temporarily ablating intercostal nerves, has been recently utilized as an analgesic adjunct. We hypothesized that the use of cryoanalgesia during MIRPE would decrease postoperative opioid use and length of stay (LOS).A multicenter retrospective cohort study of 20 US children's hospitals was conducted of children (age below 18 years) undergoing MIRPE from January 1, 2014, to August 1, 2019. Differences in total postoperative, inpatient, oral morphine equivalents per kilogram, and 30-day LOS between patients who received cryoanalgesia versus those who did not were assessed using bivariate and multivariable analysis. P value0.05 is considered significant.Of 898 patients, 136 (15%) received cryoanalgesia. Groups were similar by age, sex, body mass index, comorbidities, and Haller index. Receipt of cryoanalgesia was associated with lower oral morphine equivalents per kilogram (risk ratio=0.43, 95% confidence interval: 0.33-0.57) and a shorter LOS (risk ratio=0.66, 95% confidence interval: 0.50-0.87). Complications were similar between groups (29.8% vs 22.1, P=0.07), including a similar rate of emergency department visit, readmission, and/or reoperation.Use of cryoanalgesia during MIRPE appears to be effective in lowering postoperative opioid requirements and LOS without increasing complication rates. With the exception of preoperative gabapentin, other adjuncts appear to increase and/or be ineffective at reducing opioid utilization. Cryoanalgesia should be considered for patients undergoing this surgery.

Background/Purpose Comprehensive opioid stewardship programs require collective stakeholder alignment and proficiency. We aimed to determine opioid-related prescribing practices, knowledge, and beliefs among providers who care for pediatric surgical patients. Methods A single-center, cross-sectional survey was conducted of attending physicians, residents, and advanced practice providers (APPs), who managed pediatric surgical patients. Results Of 110 providers surveyed, 75% completed the survey. Over half of respondents (n = 43, 52%) reported always/very often prescribing opioids at discharge, with residents reporting the highest rate (66%). Provider types had varying prescribing patterns, including what types of opioids and non-opioids they prescribed. There was a lack of formal training, particularly among residents, of which only 42% reported receiving formal opioid prescribing education. Finally, although only 28% of providers felt that the opioid epidemic affects children, 48% believed pediatric providers’ prescribing patterns contributed to the opioid epidemic as a whole, and 80% reported changing their prescribing practices in response. Conclusions Significant variability exists in opioid prescribing practices, knowledge, and beliefs among providers who care for pediatric surgical patients. Effective opioid stewardship requires comprehensive policies, pediatric specific guidelines, and education for all providers caring for children to align provider proficiency and optimize prescribing patterns.

We implemented a quality improvement (QI) initiative to safely reduce post-reduction monitoring for pediatric patients with ileocolic intussusception. We hypothesized that there would be decreased length of stay (LOS) and hospital costs, with no change in intussusception recurrence rates.A retrospective cohort study was conducted of pediatric ileocolic intussusception patients who underwent successful enema reduction at a tertiary-care pediatric hospital from January 2015 through June 2020. In September 2017, an intussusception management protocol was implemented, which allowed discharge within four hours of reduction. Pre- and post-QI outcomes were compared for index encounters and any additional encounter beginning within 24 h of discharge. An economic evaluation was performed with hospital costs inflation-adjusted to 2020 United States Dollars ($). Cost differences between groups were assessed using multivariable regression, adjusting for Medicaid and transfer status, P 0.05 significant.Of 90 patients, 37(41%) were pre-QI and 53(59%) were post-QI. Patients were similar by age, sex, race, insurance status, and transfer status. Pre-QI patients had a median LOS of 23.4 h (IQR: 16.1-34.6) versus 9.3 h (IQR 7.4-14.2) for post-QI patients, P 0.001. Mean total costs per patient in the pre-QI group were $3,231 (95% CI, $2,442-$4,020) versus $1,861 (95% CI, $1,481-$2,240) in the post-QI group. The mean absolute cost difference was $1,370 less per patient in the post-QI group (95% CI, [-$2,251]-[-$490]). Five patients had an additional encounter within 24 h of discharge [pre-QI: 1 (3%) versus post-QI: 4 (8%), p = 0.7] with four having intussusception recurrence [pre-QI: 1 (3%) versus post-QI: 3 (6%), p = 0.6].Implementation of a quality improvement initiative for the treatment of pediatric intussusception reduced hospital length of stay and costs without negatively affecting post-discharge encounters or recurrence rates. Similar protocols can easily be adopted at other institutions.Level III.Retrospective comparative treatment study.

Pain control is challenging after minimally invasive repair of pectus excavatum (MIRPE). Cryoanalgesia, which temporarily ablates peripheral nerves, improves pain control and may accelerate post-operative recovery. We hypothesized that cryoanalgesia would be associated with shorter length of stay (LOS) in children undergoing MIRPE.A matched cohort study was conducted of children (18 years) who underwent MIRPE 2016-2018, using the National Surgical Quality Improvement Program-Pediatric database. Each patient who received cryoanalgesia during MIRPE was matched to four controls (no cryoanalgesia). Univariate and multilevel regression analyses were performed.Thirty-five patients who received cryoanalgesia during MIRPE were matched to 140 controls. Patients who received cryoanalgesia had a LOS reduction with similar secondary outcomes (operative time, rates of complication, reoperation, and readmission). On multilevel regression adjusted for matched groups, cryoanalgesia was associated with a 1.3-day reduction in LOS (95% CI -1.8 to -0.8, p 0.001). On sensitivity analysis excluding patients with complications, cryoanalgesia remained associated with a LOS reduction.Cryoanalgesia is a promising adjunct in the care of pediatric patients undergoing MIRPE. Utilization is associated with a shorter LOS without an increase in operative time or complications. Cryoanalgesia should be considered for inclusion in enhanced recovery strategies for patients undergoing MIRPE.

Purpose Repetitive painful stimuli and early exposure to opioids places neonates at risk for neurocognitive delays. We aimed to understand opioid utilization for neonates with gastroschisis. Methods We performed a retrospective review of infants with gastroschisis at a tertiary children's hospital (2017–2019). Multivariate linear regression was performed to analyze variations in opioid use. Results Among 30 patients with gastroschisis, 33% were managed by primary suture-less closure, 7% by primary sutured closure, 40% by spring silo, and 20% by handsewn silo. The proportion of pain medication used was: morphine (89%), acetaminophen (8%), and fentanyl (3%). Opioids were used for a median of 6.5 days (range 0–20) per patient. Median total opioid administered across all patients was 2.2 morphine milligram equivalents (MME)/kg (IQR 0.7–3.3). Following definitive closure, median opioid use was 0.2 MME/kg (IQR 0.1–0.8). With multivariate regression, 45% of the variation in MME use was associated with the type of surgery after adjusting for weight, gestational age, and gender, p = 0.02. After definitive fascial closure, there was no significant variations in opioid use. Conclusion There is a significant variation in the utilization of opioid, primarily prior to fascial closure. Understanding pain needs and standardization may improve opioid stewardship in infants with gastroschisis. 197/200 Level of Evidence Level III

Clinical practice guidelines (CPGs) have been associated with improved patient outcomes. We aimed to evaluate institutional CPG adherence and hypothesized that adherence would be associated with fewer complications in pediatric appendicitis.A retrospective review was conducted of pediatric (18 y) appendicitis patients who underwent appendectomy (6/1/2017-5/30/2018). Patients were managed using an institutional pediatric appendicitis CPG. The primary outcome was CPG adherence, defined as receipt of preoperative antibiotics at diagnosis, surgical prophylaxis before incision, and, in perforated/gangrenous appendicitis, continued postoperative antibiotics, and prescription for discharge antibiotics. Univariate and multivariate analyzes were performed.Among 399 patients, the baseline characteristics were similar between CPG-adherent and nonadherent patients. Overall CPG adherence was low at 55% (n = 221). Only 58% of patients received preoperative antibiotics per protocol (n = 233). Patients with simple appendicitis were more likely to proceed to surgery without receiving any preoperative antibiotics (35% vs. 21%, P = 0.004). Surgical prophylaxis compliance was high at 97% (n = 389). CPG violation was associated with reoperation (n = 5 versus 0, P = 0.02). After adjusting for age and admission white blood cell count, the association between CPG adherence and postoperative surgical site infection or intra-abdominal abscess remained nonsignificant (OR: 1.2, 95% CI: 0.5-2.5).Despite a long-standing pediatric appendicitis CPG, adherence with antibiotic components of the CPG was poor. CPG violation was significantly associated with reoperation, but was not associated with other postoperative complications. Regular audits of CPG adherence are necessary to ascertain reasons for noncompliance and identify ways to improve adherence.

The preinduction checklist, part of the three-phase surgical safety checklist, is performed before induction of anesthesia. Our previous research demonstrated higher checklist adherence by perioperative staff when parents were engaged in the preinduction checklist. We hypothesized that use of a parent-centered script (PCS) during the preinduction checklist would increase parent engagement and checklist adherence.A single-center, prospective, observational study was conducted in which parents of children (18 y) undergoing nonemergent surgeries (June 2018-July 2019) were observed before and after PCS implementation. The PCS, developed by the health care team, engaged parents by directly asking them to contribute information relevant to parent knowledge. Parent engagement was rated using a five-point Likert scale, and adherence was scored for each relevant checkpoint completed.Of 270 checklists, 154 (57%) occurred before and 116 (43%) after PCS implementation. Groups were similar by primary language, patient age, and type of surgery, but more postimplementation children had a prior surgery. The overall parent engagement score did not improve with the PCS (P = 0.8); however, there was an improvement in eye contact by parents. After introduction of the PCS, checklist adherence decreased from a median score of 6 (interquartile range 5-6) to 4 (interquartile range 4-5) (P 0.001).Use of a PCS did not improve parent engagement during the preinduction checklist and an unexpected decline in checklist adherence was observed. Further research, with parent and staff input, is necessary to determine how best to engage parents while ensuring high checklist adherence.

Based on limited evidence, the American Pediatric Surgical Association recommends 5-7 d of postoperative antibiotics in perforated appendicitis for preventing intra-abdominal abscess (IAA). In 2015, our institutional clinical practice guideline was modified to standardize prescription for 7 additional days of oral antibiotics after discharge. We hypothesized that prescribing oral antibiotics after discharge would be associated with fewer complications in perforated appendicitis.A retrospective cohort study was conducted of pediatric (younger than 18 y) patients who underwent laparoscopic appendectomy for perforated appendicitis (August 1, 2012-April 30, 2019). Patients diagnosed with IAA before discharge or with a postoperative length of stay ≥8 d were excluded. Patient outcomes were compared prestandardization and poststandardization of discharge antibiotics.Of 617 patients, 212 (34.5%) were admitted prestandardization and 404 (65.5%) poststandardization. Overall, 409 patients (66.3%) received discharge antibiotics. The median total postoperative antibiotic duration was 4 d (interquartile range, 3-5) prestandardization versus 11 d (interquartile range, 10-12) poststandardization (P 0.001). Prestandardization patients had a higher rate of IAA (8.9% versus 4.5%, P = 0.03) and were readmitted more frequently (13.1% versus 6.4%, P = 0.005). On adjusted analysis, admission poststandardization was associated with reduced odds of IAA (odds ratio, 0.51; 95% confidence interval, 0.25-1.06), but the relationship was imprecise. Admission poststandardization was significantly associated with reduced adjusted odds of readmission (odds ratio, 0.46; 95% confidence interval, 0.25-0.85).Prescription for seven additional days of oral antibiotics after discharge was associated with reduced odds of readmission in pediatric perforated appendicitis. This population may benefit from a longer postoperative antibiotic course than currently recommended.

Background The relative influences of baseline risk factors for pediatric nonaccidental burns have not been well described. We evaluated baseline characteristics of pediatric nonaccidental burn patients and their primary caretakers. Methods A single-center retrospective cohort study was conducted of pediatric (age, Highlights • Non-Hispanic black children had higher rates of Child Protective Services referral. • Non-Hispanic black children had higher rates of nonaccidental burn diagnosis. • Caretaker history with Child Protective Services correlated with nonaccidental burns. • Patient non-Hispanic black race/ethnicity was associated with nonaccidental burn.

Intra-abdominal abscess, the most common complication after perforated appendicitis, is associated with considerable economic burden. However, costs of intra-abdominal abscesses in children are unknown. We aimed to evaluate resource utilization and costs attributable to intra-abdominal abscess in pediatric perforated appendicitis.A single-center retrospective analysis was performed of children (18 years) who underwent appendectomy for perforated appendicitis (2013-2019). Hospital costs incurred during the index admission and within 30 postoperative days were obtained from the hospital accounting system and inflated to 2019 USD. Generalized linear models were used to determine excess resource utilization and costs attributable to intra-abdominal abscess after adjusting for confounders.Of 763 patients, 153 (20%) developed intra-abdominal abscesses. Eighty-one patients with intra-abdominal abscesses (53%) underwent percutaneous abscess drainage. Intra-abdominal abscess was independently associated with a nearly 8-fold increased risk of 30-day readmission (adjusted risk ratio, 7.8 [95% confidence interval, 4.7-13.0]). Patients who developed an intra-abdominal abscess required 6.1 excess hospital bed days compared to patients without intra-abdominal abscess (95% confidence interval, 5.3-7.0). Adjusted mean hospital costs for patients with intra-abdominal abscess totaled $27,394 (95% confidence interval, $25,688-$29,101) versus $15,586 (95% confidence interval, $15,102-$16,069) for patients without intra-abdominal abscess. Intra-abdominal abscess was associated with an incremental cost of $11,809 (95% confidence interval, $10,029-$13,588). Hospital room costs accounted for 66% of excess costs.Postoperative intra-abdominal abscess nearly doubled pediatric perforated appendicitis costs, primarily due to more hospital bed days and associated room costs. Intra-abdominal abscesses resulted in estimated excess costs of $1.8 million during the study period. Even small reductions in intra-abdominal abscess rates or hospital bed days could yield substantial health care savings.

BACKGROUND Postoperative pain control is challenging after pectus excavatum repair. We aimed to understand the impact that cryoanalgesia had on opioid utilization and outcomes of pediatric patients undergoing minimally invasive repair of pectus excavatum (MIRPE). METHODS A single-center retrospective cohort study was conducted of all patients (< 18 y) who underwent MIRPE (2011-2019). Patients receiving cryoanalgesia were compared to those who did not. The primary outcome was total postoperative, inpatient, opioid use, measured as milligrams of oral morphine equivalents per kilogram (OME/kg). Univariate and multivariable analyses were performed. RESULTS Of 35 patients, 20 received cryoanalgesia (57%). Baseline characteristics were similar. Patients who received cryoanalgesia had a lower opioid requirement: median 2.3 mg OME/kg (IQR 1.2-3.1), versus 4.9 mg OME/kg (IQR 2.9-5.8), P < 0.001. Accounting for receipt of cryoanalgesia, epidural, and/or patient-controlled analgesia, cryoanalgesia was associated with a 3.3 mg OME/kg reduction in opioid use (P < 0.001). Median length of stay (LOS) was shorter in cryoanalgesia patients: 3.1 d (IQR 2.3-3.4), versus 5.1 d (IQR 4.3-5.4), P < 0.001. Complications within 90 d were similar between groups. CONCLUSIONS Cryoanalgesia is an effective adjunctive pain control modality for patients undergoing MIRPE. Use of cryoanalgesia was associated with lower postoperative opioid requirements and shorter LOS, without increased short-term complications, and should be considered for enhanced recovery after MIRPE.

Introduction: Intra-abdominal abscess (IAA) after perforated appendicitis is associated with increased healthcare costs. In 2016, our center conducted a pilot randomized control trial (RCT) in which 100 children (age 2-17) with perforated appendicitis were randomized to intra-abdominal irrigation with povidone-iodine (PVI) during appendectomy or no irrigation. We observed an 89% probability that PVI irrigation reduced the rate of IAA (Bayesian Relative Risk: 0.72 [95% credible interval (CrI), 0.38-1.23]). We hypothesized …

Prophylactic, intraabdominal drains have been used to prevent intraabdominal abscess (IAA) after perforated appendicitis. We hypothesized that routine drain placement would reduce the IAA rate in pediatric perforated appendicitis.A 27-month quality improvement (QI) initiative was conducted: closed-suction, intraabdominal drains were placed intraoperatively in pediatric (age 18) perforated appendicitis patients. QI patients were compared to controls admitted during the preceding 8 months and following 4 months. The primary outcome was 30-day IAA rate. Univariate and multivariate analyses were performed.Two hundred seventy QI patients were compared to 109 controls. There was 100% compliance during 21 of 27 months of the QI initiative; only 7 QI patients did not receive drains. IAA occurred in 20.0% of QI patients and 22.9% of control (p = 0.52). After adjustment, the QI initiative was not associated with reduced odds of IAA (OR 0.83, 95% CI 0.48-1.44). Median length of stay was longer in QI patients during the index admission (p = 0.03) and over 30 postoperative days (p = 0.03), but these relationships did not persist after adjustment.A QI initiative investigating prophylactic, intraabdominal drain placement in perforated appendicitis did not reduce the IAA rate. We recommend against routine drain placement in pediatric perforated appendicitis.Level III.

In light of current opioid-minimization efforts, we aimed to identify factors that predict postoperative opioid requirement in pediatric appendicitis patients.A single-center retrospective cohort study was conducted of children (18 y) who underwent laparoscopic appendectomy for acute appendicitis between January 1, 2018 and April 30, 2019. Patients who underwent open or interval appendectomies were excluded. The primary outcome was morphine milliequivalents (MMEs) per kilogram administered between 2 and 24 h after surgery. Multivariable analyses were performed to evaluate predictors of postoperative opioid use. Clinically sound covariates were chosen a priori: age, weight, simple versus complicated appendicitis, preoperative opioid administration, and receipt of regional or local anesthesia.Of 546 patients, 153 (28%) received postoperative opioids. Patients who received postoperative opioids had a longer median preadmission symptom duration (48 versus 24 h, P 0.001) and were more likely to have complicated appendicitis (55% versus 21%, P 0.001). Patients who received postoperative opioids were more likely to have received preoperative opioids (54% versus 31%, P 0.001). Regional and local anesthesia use was similar between groups. Nearly all patients (99%) received intraoperative opioids. Each preoperative MME per kilogram that a patient received was associated with receipt of 0.29 additional MMEs per kilogram postoperatively (95% confidence interval, 0.19-0.40).Preoperative opioid administration was independently associated with increased postoperative opioid use in pediatric appendicitis. These findings suggest that preoperative opioids may potentiate increased postoperative pain. Limiting preoperative opioid exposure, through strategies such as multimodal analgesia, may be an important facet of efforts to reduce postoperative opioid use.

Background: Syndesmosis injuries are common, with up to 25% of all ankle injuries being reported to involve an associated syndesmosis injury. These injuries are typically treated with cortical screw fixation or suture-button implants when indicated, but the addition of a suture anchor augment implant has yet to be evaluated. The purpose of this study was to evaluate the ability of a suture anchor augment to add sagittal plane translational and transverse plane rotational constraint to suture-button constructs with syndesmosis injuries. We hypothesized that the suture anchor augment oriented in parallel with the fibers of an injured anterior-inferior tibiofibular ligament (AITFL) in addition to a suture-button construct would achieve physiological motion and stability at the syndesmosis through increased rotational and translational constraint of the fibula. Methods: Eleven fresh-frozen cadaver ankles were stressed in external rotation using a custom-made ankle rig. Each ankle had simultaneous recording of ultrasound video, 6 degrees-of-freedom kinematics of the fibula and tibia, and torque as the ankle was stressed by an examiner. The ankles were tested in 6 different states: native uninjured; injured with interosseous ligament and AITFL sectioned; 1× suture button; 2× suture buttons, divergent; 1× suture anchor augment with 2× suture buttons, divergent; and 1× suture anchor augment with 1× suture buttons. Results: Only the suture anchor augment + 2× suture buttons and suture anchor augment + 1× suture-button constructs were found to be significantly different from the injured state ( P = .0003, P = .002) with mean external rotation of the fibula. Conclusion: Overall, the most important finding of this study was that the addition of a suture anchor augment to suture-button constructs provided a mechanism to increase external rotational constraint of the fibula. Clinical Relevance: This study provides a mechanistic understanding of how the combined suture-button and suture anchor augment construct provides an anatomically similar reconstruction of constraints found in the native ankle. However, none of the constructs examined in this study were able to fully restore physiologic motion.

Background/Purpose: Neonates with severe cases of congenital pulmonary airway malformation (CPAM) may require early emergent/urgent surgery for cardiopulmonary compromise. The CPAM volume ratio (CVR) is often utilized for prenatal prognostication; however, the threshold that predicts early surgery is unknown. We hypothesized that a late gestation CVR threshold exists at which neonates with prenatally diagnosised CPAM would require early surgery. Methods: A single-center, retrospective cohort study was conducted of all neonates with …