BACKGROUND:Pulmonary hypertension (PHTN) causes significant morbidity and mortality in patients with congenital diaphragmatic hernia (CDH). Currently, there is no routinely obtained prenatal prognostic marker to reliably predict postnatal CDH-associated PHTN severity. METHODS:The CDH Study Group (CDHSG) registry was queried for infants born from 2015 to 2021 with a graded (1-4) PHTN diagnosis. Fetal observed-to-expected lung volume to head circumference ratio (o/e LHR), percent predicted lung volume (PPLV), and total lung volume (TLV) were classified by severity. RESULTS:Of 4056 patients, 1047 and 785 infants had prenatal ultrasound or magnetic resonance imaging, respectively. Both moderate and severe o/e LHR were associated with increased odds of postnatal development of moderate (OR 2.913) and severe PHTN (OR 4.924). CONCLUSIONS:In infants with CDH, prenatal predictor severity was associated with higher severity of PHTN and increased ECLS usage. Overall, patients with worse prenatal prognostic indicators were less likely to receive pulmonary vasodilator treatment.

Mangat, Sabrina BS; Gaber, Charles MPH; Strassle, Paula D. MSPH; Marzinsky, Amy RN, BSN, OCN; Phillips, Michael MD; McLean, Sean E. MD, FACS Author Information

Umbilical vein catheters (UVC) are commonly used for vascular access in neonates. Despite their routine use, complications frequently arise, often because the catheters are placed without imaging guidance. Correct positioning of the UVC involves the catheter traveling from the umbilical vein, through the left portal vein, across the ductus venosus (DV), and into the inferior vena cava. Because UVC are usually placed at the bedside without image guidance, it is not uncommon for these catheters to be incorrectly positioned – including insertion into the right portal vein, superior mesenteric vein, left atrium, and even the pulmonary vein (Fig. 1), requiring either repositioning or removal of the catheter.1 Necrotizing enterocolitis (NEC) is a serious and potentially fatal condition and remains a significant cause of morbidity and mortality in neonates, with an incidence ranging from 1 to 3/1000 live births. However, the exact etiology of NEC is poorly understood. Several risk factors are known to contribute to NEC, including bacterial colonization, formula feeding, prematurity, and intestinal ischemia. Alteration of the intestinal microbiome, genetic variants, or aberrant inflammatory signaling may play important roles.2 Neonatal NEC has been found to occur in patients after UVC placement.3 One of the factors in the multifactorial etiology of NEC is the potential for increased portal pressure leading to relative bowel ischemia. DV occlusion in near-term lambs was shown to lead to transient portal hypertension associated with cellular damage and intestinal mucosal inflammation.4 We hypothesize that UVC complications in premature infants may affect the closure of the DV and transiently increase portal venous pressure, leading to relative bowel ischemia and possibly NEC. We performed a retrospective review of infants born <1500 g, admitted to the Newborn Critical Care Center with a UVC inserted between January 1, 2012 and December 31, 2012. Demographic data were collected, including gender, gestational age, and birthweight. UVC complications were defined as failed attempt at placement or malposition. Malposition was defined as UVC catheter tip in the inferior vena cava proximal to the level of the ninth thoracic vertebrae, or tip not in the inferior vena cava. Daily X-rays after UVC placement were analyzed to assess for UVC malposition. Malpositioned catheters were either repositioned or removed. The presence or absence of NEC was recorded, along with degree of severity based on the Bell’s criteria, encompassing clinical and radiographic findings. Approval for the study was obtained from the University of North Carolina Institutional Review Board. Statistical analysis was performed with standard software packages (Excel, Microsoft Corp., Redmond, WA; STATA 14, Timberlake Consultants, Limited, London). A total of 58 patients were studied; 28 (48.3%) patients were male. The average gestational age was 26.4 ± 1.7 weeks. The average birthweight was 850 ± 220 g. Average Appearance, Pulse, Grimace, Activity, and Respiration scores at 1, 5, and 10 minutes were 3.8 ± 2.4, 5.6 ± 2.4, and 6.3 ± 1.8, respectively. At 48 hours of life, 32 (56.1%) patients were using nasal cannula or continuous positive airway pressure for respiratory support, compared with 25 (43.9%) patients that were sustained on mechanical ventilation. Forty-four (75.9%) patients had a UVC placed, whereas 10 (17.2%) patients had an attempt at an UVC placement that failed. The remaining four patients ultimately did not have an UVC placed. Thirty-six (66.7%) patients were deemed to have an UVC complication, which was defined as either a failed or malpositioned UVC. On average, UVCs were removed after 5.5 ± 4.1 days. Nine (15.8%) patients were found Address correspondence and reprint requests to Sang Lee, M.D., Department of Surgery, Division of Pediatric Surgery, University of North Carolina, Chapel Hill, NC 27599, CB #7223. E-mail: sang_lee@med.unc.edu.

The role of preoperative bowel prep in the pediatric surgical population is uncertain. We performed a randomized prospective study to evaluate noninferiority between the presence or absence of a preoperative bowel prep in elective pediatric bowel surgery on postoperative outcomes. Patients aged three months to 18 years were recruited and randomized to the bowel prep group or the no bowel prep group. Patients were evaluated in-hospital and at postoperative clinic visits. Thirty-two patients were recruited; 18 in the bowel prep group and 14 in the no bowel prep group. There was no statistical difference (P > 0.05) in complications between the groups. Complications were observed in five patients in each group (27.8% and 35.7%, respectively). In the bowel prep group, two (11.1%) had wound infection (vs three, 21.4%), 0 had an intra-abdominal abscess (vs one, 7.1%), one (5.6%) had sepsis (vs one, 7.1%), one (5.6%) had an anastomotic leak (vs 0), and three (16.7%) had a bowel obstruction (vs one, 7.1%). There were no extra-abdominal complications. There were no significant differences in complications between the two groups. Further research is warranted, but may require a multi-institutional trial to recruit sufficient numbers to make conclusions about the significance of the need for bowel prep.

A key step in the Nuss procedure, placement of a curved bar that lifts sternum in pectus excavatum, is fixation of the bar to the chest to stabilize the sternum in an anterior position. Complications of bar position and fixation are among the major complications of the Nuss procedure. Numerous techniques have been described in an effort to reduce the risk of bar displacement, including the use of bar stabilizers at one or both ends of the bar, encircling the bar and adjacent rib with suture or wire, and using two bars at different levels of the chest.1 To help determine an optimal technique of bar fixation, we reviewed our group’s experience with the Nuss procedure. The University of North Carolina Institutional Review Board approved review of records of patients aged 0 to 18 years undergoing Nuss procedure for pectus excavatum over a 5-year period from January 2009 through December 2013. The data collected included details of operation (including type of suture used for fixation, number of Nuss bars placed, use of bar stabilizers) and clinical outcome (length of hospital stay, postoperative complications, and reoperations). Statistical analysis was performed with the standard software packages (Excel, Microsoft Corp., Redmond, WA; STATA 14, Timberlake Consultants, Limited, London, UK). During the period we cared for 61 patients, 51 boys (83.6%) and 10 girls (16.4%). Overall, the mean age was 15.3 ± 3.6 years and the mean duration of followup was 2.2 ± 1.1 years after Nuss bar placement. Mean length of hospital stay was 5.8 ± 2.1 days. There were no deaths. A number of measures were taken to stabilize the bar, and several had more than one measure employed. Bar stabilizers were used in 54 (88.5%) patients, with 6 (11.1%) patients receiving bilateral stabilizers. Twothirds (41, 67.2%) patients had two Nuss bars placed at the time of operation. Suture fixation was common, 11 (18%) with wire and 37 (60.7%) with nonabsorbable suture. Complications occurred in one-fourth of patients (15, 24.5%), a rate comparable to that reported in a recent multi-institutional review of more than 30 centers.1 Six (9.8%) had a complication related to bar fixation and position. Five (8.2%) patients had broken wires, three requiring an operative procedure: two because of pain, the third for a late pneumothorax (one month postoperatively) caused by the sharp end of the wire protruding into the pleural cavity (Fig 1). Three broken wires that had not caused overt problems or symptoms were found incidentally at the time of bar removal at the end of the period of surgical fixation. A sixth patient required repositioning of bar migration. The bar had been fixed with nonabsorbable suture. Other complications included three postoperative wound infections (4.9%), two intraoperative trocar injuries (3.3%), two (3.3%) patients had severe pain, one with a large postoperative pleural effusion (1.6%), and one recurrent pectus excavatum (1.6%). Our results confirm measures to prevent bar migration are major causes of complications of the Nuss procedure. Although stabilization of the bar is necessary to maintain the desired position of the sternum and configuration of the chest, we found that complications from wire fixation (5, 8.2%) occurred more frequently than bar migration requiring operative repositioning (1, 1.6%). The use of steel wires to fix the Nuss bar to the adjacent rib reliably secures the bar and minimizes bar migration.2 Our experience confirms the observation

Background: Critically ill pediatric patients frequently require hemoglobin monitoring. Accurate noninvasive Hb (SpHb) would allow practitioners to decrease anemia from repeated blood draws, traumatic blood draws, and a decreased number of laboratory Hb (LabHb) medical tests. The Food and Drug Administration has approved the Masimo Pronto SpHb and associated Rainbow probes; however, its use in the pediatric intensive care unit (PICU) is controversial. In this study, we define the degree of agreement between LabHb and SpHb using the Masimo Pronto SpHb Monitor and identify clinical and demographic conditions associated with decreased accuracy.Materials and methods: We performed a prospective, observational study in a large PICU at an academic medical center. Fifty-three pediatric patients (30-d and 18-y-old), weighing >3 kg, admitted to the PICU from January-April 2013 were examined. SpHb levels measured at the time of LabHb blood draw were compared and analyzed.Results: Only 83 SpHb readings were obtained in 118 attempts (70.3%) and 35 readings provided a result of "unable to obtain." The mean LabHb and SpHb were 11.1 g/dL and 11.2 g/dL, respectively. Bland-Altman analysis showed a mean difference of 0.07 g/dL with a standard deviation of +/- 2.59 g/dL. Pearson correlation is 0.55, with a 95% confidence interval between 0.38 and 0.68. Logistic regression showed that extreme LabHb values, increasing skin pigmentation, and increasing body mass index were predictors of poor agreement between SpHb and LabHb (P < 0.05). Separately, increasing body mass index, hypoxia, and hypothermia were predictors for undetectable readings (P < 0.05).Conclusions: The Masimo Pronto SpHb Monitor provides adequate agreement for the trending of hemoglobin levels in critically ill pediatric patients. However, the degree of agreement is insufficient to be used as the sole indicator for transfusion decisions and should be used in context of other clinical parameters to determine the need for LabHb in critically ill pediatric patients. (C) 2015 Elsevier Inc. All rights reserved.