Background: Regional anesthetic techniques are safe and effective in reducing pain and the need for opioid analgesia but may be underutilized in neonatal intensive care unit (NICU) patients. We developed an opioid stewardship pathway aimed at reducing the use of opioid analgesia in neonates by increasing caudal block utilization from a baseline of 50%-90% within 18 months. Methods: We used control charts to track intra-operative opioid utilization in morphine milligram equivalents per kilogram (MME/kg) and immediate post-operative extubation rates. Unrelieved pain (defined as two consecutive Neonatal Pain, Agitation & Sedation Scale (NPASS) scores >/ = 4), postoperative opioid use, and reintubation within 24 h were tracked as balancing measures. We ran sample statistical analysis comparing the outcome and balancing measures in surgeries with and without caudal block. Results: There were 125 surgeries in the pre-intervention and 48 in the post-intervention group. Caudal block utilization increased to 63%, while intra-operative opioid utilization decreased (0.230 vs 0.416 MME/kg), and extubation rates increased (75% vs 70%). There were no increases in unrelieved pain or post-operative opioid utilization. Caudal block was associated with decreased intra-operative opioid use (0.000 vs 0.366 MME/kg, p < 0.001) and increased extubation rates (83% vs. 59%, p < 0.001) with no increase in unrelieved pain (23% vs. 22%, p = 0.75) or post-operative opioid use (0.151 vs 0.000 MME/kg, p = 0.35). No patients required reintubation within 24 h. Conclusion: The modest increase in caudal block utilization is associated with a reduction in intraoperative opioid use and increased postoperative extubation rates without compromising pain control. Level of Evidence: Level III. (c) 2024 Elsevier Inc. All rights are reserved, including those for text and data mining, AI training, and similar technologies.

The obesity epidemic has led to an increased number of adolescents requiring metabolic and bariatric surgery (MBS), but there is paucity of data on the impact of implementing all aspects of Enhanced Recovery After Surgery (ERAS) protocols to improve outcomes in this population. We implemented a comprehensive ERAS pathway for adolescents undergoing laparoscopic sleeve gastrectomy (LSG). Key elements included pre-operative fasting with carbohydrate loading in the morning of surgery, comprehensive anti-emetic and analgesic regimens including intra-operative lidocaine infusion (initiated before formal ERAS launch), regional anesthesia, and early goal-directed ambulation. We tracked opioid utilization, rescue anti-emetic use, time to oral intake, and hospital length of stay (HLOS) as outcome measures, and post-operative pain and returns to the system as balancing measures. Eighty-six patients (52 patients pre-ERAS and 34 patients post-ERAS) underwent LSG with no differences in demographics. The post-ERAS group had earlier time to oral intake (3.0 vs. 5.5 h, p = 0.003), used less rescue anti-emetics, (8.0 vs. 16.0 mg, p < 0.001), and had shorter HLOS (33 vs. 54 h, p < 0.001) but no difference in opioid use (0.370 vs. 0.435 MME/kg, p = 0.17), post-operative pain scores or return to the system. Our novel use of bariatric-specific ERAS protocol with intra-operative lidocaine infusion accelerates the time to goal-directed oral intake and decreases HLOS without increasing the rate of returns to the system. This study highlights the feasibility and effectiveness of adapting adult ERAS protocols to the pediatric MBS population. Level III.

Introduction: Minimally invasive surgery (MIS) is gaining traction as a first-line approach to repair congenital anomalies. This study aims to evaluate outcomes for neonates undergoing open versus MIS repairs for esophageal atresia/tracheoesophageal fistula (EA/TEF). Methods: In this retrospective study, neonates undergoing EA/TEF repair from 2013 to 2020 were identified using the National Surgical Quality Improvement Program-Pediatric database. Proportions of operative approach (open vs. MIS) over time were analyzed. A propensity score-matched analysis using preoperative characteristics was performed and outcomes were compared including composite morbidity and reintervention rates (overall, major [thoracoscopy, thoracotomy], and minor [chest/ feeding tube placement, endoscopy]) between operative approaches. Pearson's chi-square or Fisher's exact tests were used as appropriate. Results: We identified 1738 neonates who underwent EA/TEF repair. MIS utilization increased over time. Pre-match, neonates undergoing open repair were more likely to be premature, lower weight, ventilator dependent, and have cardiac risk factors with higher severity. Post-match, the groups were similar and included 340 neonates per group. MIS repair was associated with longer median operative time (209 vs. 174 min, p < 0.001) and increased overall post-operative intervention rates (7.6% vs. 2.9%, p = 0.01). There were no differences in composite morbidity (24.4% vs. 25.0%, p = 0.86) outside of reintervention. Conclusion: MIS approach for neonates with EA/TEF appears to be associated with a higher rate of reinterventions. Further studies evaluating MIS approaches for the repair of EA/TEF are needed to better define short- and long-term outcomes. Type of Study: Retrospective comparative study. Level of Evidence: Level III. (c) 2024 Elsevier Inc. All rights are reserved, including those for text and data mining, AI training, and similar technologies.

Abstract Purpose This study analyzes the implementation of the routine use of quadratus lumborum blocks (QLBs) on postoperative pain and opioid consumption among children undergoing laparoscopic appendectomy compared to those not receiving regional anesthesia. Methods Children undergoing laparoscopic appendectomy within a multi-hospital children’s healthcare system were retrospectively reviewed from 2017 through 2021. Patients were stratified by appendicitis type (uncomplicated vs. complicated). Pain scores and opioid consumption in the post-anesthesia care unit (PACU) and within the first 24 hours postoperatively were compared by block status (no block [NB] vs. QLB) and appendicitis type. Results 2033 patients were reviewed, and 610 received a QLB. The frequency of rescue opioid use was reduced in the PACU (uncomplicated: QLB 46.6% vs. NB 54.6%, p = 0.005; complicated: QLB 28.5% vs. NB 39.9%, p = 0.01) and postoperatively (complicated: QLB 33.7% vs. NB 52.9%, p < 0.001) for those who received a QLB. This resulted in reduced opioid consumption as measured by morphine milligram equivalents per kilogram postoperatively. Conclusion QLBs can be safely administered in children and provide improvements in opioid consumption postoperatively. QLBs should remain a strongly favored regional anesthetic technique because of their wide applicability for abdominal surgeries in order to minimize rescue opioid analgesic use. Level of Evidence: Level III

Background: Pediatric intestinal failure (IF) often requires central venous catheter (CVC) placement for home parenteral nutrition (PN), with attendant risks for infectious and mechanical complications.Numerous strategies have been attempted to reduce these risks including ethanol lock therapy and various dressings to maintain line integrity, yet altering the tunnel location has not been identified in the literature as an alternative option.The purpose of this study was to evaluate altering the CVC tunneling location and its effect on line-associated complications due to limiting the ability of children to manipulate the CVC. Methods:We retrospectively analyzed all CVCs placed in patients >1-year-old followed by our intestinal rehabilitation program (IRP) between January 2014 and June 2021.Lines tunneled onto the back were compared to those tunneled onto the anterior chest wall.Percentages of lines with at least one central line-associated bloodstream infection (CLABSI) or mechanical complication were compared using tests on proportions.Rates of CLABSI and mechanical complications per 1000 catheter-days were compared using Fisher′s exact and Mann-Whitney U tests.Kaplan-Meier analysis with a log-rank test was utilized to compare the 2-year longevity of CVCs.Results: A total of 34 lines were tunneled anteriorly and 15 posteriorly.Median line longevity was 228.5 days and 219 days for anterior and posterior lines respectively (p=0.85).CLABSI rates per 1000 catheter-days were 2.41 for anterior lines and 1.03 for posterior lines (p=0.08).Mechanical complication rates per 1000 catheter-days were 4.21 and 2.47 for anterior and posterior lines respectively (p=0.10).On Kaplan-Meier analysis, decreased line longevity trended to anterior compared to posterior lines (5.22% vs. 22.03%, p=0.13,Figure). Conclusion:There was a trend toward decreased complications and increased line longevity based on the tunneling strategy during CVC placement.Using these rates, 14 line repairs and 11 CLABSIs would have been avoided if all lines had been tunneled posteriorly, resulting in a $458,739 decrease in hospital charges using our hospital′s medians for bedside repairs and CLABSI admissions.Further studies with a larger patient cohort are needed to determine the optimal patient selection, evaluate the effects on quality of life, and assess long-term complication rates for posteriorly tunneled CVCs.

Shared experiential learning is critical in the field of pediatric surgery to support the translation of evidence into practice. Surgeons who develop QI interventions in their own institutions based on the best available evidence create work products that can accelerate similar projects in other institutions, rather than continuously reinventing the wheel. The American Pediatric Surgical Association (APSA) Quality and Safety Committee (QSC) toolkit was created to facilitate knowledge-sharing and thereby hasten the development and implementation of QI. The toolkit is an expanding open-access web-based repository of curated QI projects that includes evidence-based pathways and protocols, stakeholder presentations, parent/patient educational materials, clinical decision support (CDS) tools, and other components of successful QI interventions in addition to contact information for the surgeons who developed and implemented them. This resource catalyzes local QI endeavors by showcasing a range of projects that can be adapted to fit the needs of a given institution, and it also serves as a network to connect interested surgeons with successful implementers. As healthcare shifts towards value-based care models, quality improvement becomes increasingly important, and the APSA QSC toolkit will continue to adapt to the evolving needs of the pediatric surgery community.

Purpose: Children undergoing splenectomy for hemolytic anemia often have cholelithiasis, which may or may not be symptomatic. It is unclear whether concurrent cholecystectomy increases length of stay or morbidity after splenectomy. The purpose of this study was to compare morbidity among children undergoing laparoscopic splenectomy alone versus splenectomy with concurrent cholecystectomy in patients with hemolytic anemia. Methods: We retrospectively evaluated children with hemolytic anemia undergoing non-traumatic laparoscopic splenectomy in the National Surgical Quality Improvement Program-Pediatric database (2012 e2020). Outcomes were compared for patients undergoing splenectomy alone (n 1/4 1010) versus splenectomy with cholecystectomy (n 1/4 371). Pearson's Chi-square and Student's t-tests were utilized as appropriate. Propensity score-matching was completed, controlling for eight demographic and clinical variables. Results: 1381 patients were identified, 73.1% undergoing splenectomy alone and 26.9% splenectomy with cholecystectomy. Splenectomy with cholecystectomy patients were older (10.9 years vs. 8.4 years, p<0.01), more likely to have hereditary spherocytosis (56.1% vs. 40.8%, p < 0.01), less likely to have sickle cell disease (12.1% vs. 33.5%, p < 0.01), more likely ASA class 1 or 2 (49.3% vs. 42.1%, p < 0.01), and had similar preoperative hematocrit levels (29.6 vs. 29.3, p 1/4 0.33). The splenectomy with cholecystectomy group was less likely to receive preoperative blood transfusions (13.5% vs. 25.4%, p<0.01). Therewere 360 pairs selected on propensity score-matching, and splenectomy with cholecystectomy was associated with increased operative time (182 min vs.145 min, p< 0.01) and decreased occurrences of a postoperative transfusion (4.2% vs. 8.9%, p 1/4 0.01). Length of stay after surgery (2.5 days vs. 2.3 days, p 1/4 0.13), composite morbidity (3.9% vs. 3.4%, p 1/4 0.69), and 30-day readmission rates (3.3% vs. 7.4%, p 1/4 0.08) were all similar. Conclusions: Splenectomy with cholecystectomy is associated with similar postoperative morbidity, length of stay and readmission rates compared to splenectomy alone. These data support the safety of concurrent cholecystectomy with splenectomy for children with cholelithiasis in the setting of hemolytic anemia. Type of Study: Retrospective Cohort Study. (c) 2023 Elsevier Inc. All rights reserved.

This study analyzes the implementation of the routine use of quadratus lumborum blocks (QLBs) on postoperative pain and opioid consumption among children undergoing laparoscopic appendectomy compared to those not receiving regional anesthesia. Children undergoing laparoscopic appendectomy within a multi-hospital children’s healthcare system were retrospectively reviewed from 2017 to 2021. Patients were stratified by appendicitis type (uncomplicated vs. complicated). Pain scores and opioid consumption in the post-anesthesia care unit (PACU) and within the first 24 h postoperatively were compared by block status (no block [NB] vs. QLB) and appendicitis type. 2033 patients were reviewed, and 610 received a QLB. The frequency of rescue opioid use was reduced in the PACU (uncomplicated: QLB 46.6

Background: Antibiotic overutilization in the neonatal intensive care unit (NICU) has many adverse ef-fects, and necrotizing enterocolitis (NEC) is one of the most common indications for antibiotics in pre-mature infants. Evidence for a preferred antibiotic regimen for NEC is lacking. This project aims to reduce piperacillin-tazobactam use and overall antibiotic duration in neonates with NEC through the imple-mentation of an antibiotic stewardship pathway based on the modified Bell stage classification system. Methods: A multidisciplinary team consisting of neonatology, pharmacy, infectious disease, and surgery developed an antibiotic protocol for the management of NEC based on Bell stage. Recommendations included 48 h of ampicillin/gentamicin (AG) for stage I, 5-10 days of AG for stage II, the addition of metronidazole for stage IIIA, and 7-14 days of piperacillin-tazobactam (PT) for stage IIIB. We evaluated overall antibiotic and PT exposure, progression to surgical NEC, NEC recurrence, antibiotic resistance, bacteremia/fungemia, and mortality 1 year pre-and post-protocol implementation. Results: 27 patients pre-intervention and 44 post-intervention were analyzed. Antibiotic exposure was reduced from a median 119.19 to 80.65 days of therapy (DOT) per 1000 patient days (p = 0.11). PT exposure decreased after protocol implementation (median 68.78 vs. 7.97 DOT per 1000 patient days, p = 0.002). There were no significant differences in morbidity or mortality outcomes. Conclusions: Antibiotic stewardship strategies can be implemented in the NICU without compromising outcomes in patients with NEC. Bell stage stratification appears to be an effective method for antibiotic selection. Further studies are needed in a larger population to optimize regimens and ensure safety. Type of Study: Retrospective comparative study. Level of Evidence: Level III.(c) 2023 Elsevier Inc. All rights reserved.

Purpose: Neonates with duodenal atresia (DA) are often born prematurely and undergo repair soon after birth, while others are delayed to allow for growth until closer to term corrected gestational age (cGA). Premature infants have been demonstrated to experience worse outcomes, but it is unclear whether delaying surgery mitigates the increased morbidity. This study evaluates the association of timing of DA repair with postoperative morbidity. Methods: We retrospectively evaluated neonates undergoing DA repair from the National Surgical Quality Improvement Program-Pediatric database (2015-2020). A multivariable regression analyzed factors associated with composite morbidity, including cGA and age in days of life (DOL) at surgery. A propensity score matched analysis was completed in premature neonates born at <= 35 weeks gestation to compare outcomes at similar birth gestational ages (bGA) and birth weight who underwent early (<7 DOL) versus delayed (>= 7 DOL) repair. Results: 809 neonates were included with a median bGA of 36 weeks (IQR 34-38), birth weight of 2.46 kg (IQR 1.96-2.95), and DOL at surgery of 2 (IQR 1-5). Infants born <= 35 weeks represented 35.23% of the cohort. On multivariable analysis, increasing cGA at surgery was associated with decreased morbidity (OR: 0.91, CI [0.84, 0.99]), and increasing DOL at surgery was associated with increased morbidity (OR: 1.02, CI [1.00, 1.04]). On propensity score matched analysis, delayed repairs were associated with increased postoperative ventilation (6 days vs. 2 days, p < 0.05); however, there were no differences in composite or surgical morbidity between early and delayed repairs. Conclusions: Morbidity after DA repair in neonates <= 35 weeks cGA is primarily driven by non-surgical causes, but delaying surgery does not appear to mitigate the risks associated with prematurity. It seems reasonable to consider repair in neonates around 33-34 weeks gestation without prohibitive risk factors. Optimal timing of DA repair requires a delicate balance between these factors. Level of Evidence: Level III. Type of Study: Retrospective Cohort Study.

Background. Organ donors supported by extracorporeal membrane oxygenation (ECMO) have historically been considered high-risk and are judiciously utilized. This study examines transplant outcomes using renal allografts from donors supported on ECMO for nondonation purposes. Methods. Retrospective review of the Gift of Life (Pennsylvania, New Jersey, Delaware) organ procurement organization database, cross-referenced to the Organ Procurement and Transplantation Network database, assessed kidney transplants using donors supported on venoarterial (VA) and venovenous (VV) ECMO for nondonation purposes. Transplants using VA- and VV-ECMO donors were compared with Kidney Donor Profile Index (KDPI)-stratified non-ECMO donors. Regression modeling of the entire ECMO and non-ECMO populations assessed ECMO as predictive of graft survival. Additional regression of the ECMO population alone assessed for donor features associated with graft survival. Results. Seventy-eight ECMO donors yielded 128 kidney transplants (VA: 80, VV: 48). Comparing outcomes using these donors to kidney transplants using organs from KDPI-stratified non-ECMO donors, VA- and VV-ECMO donor grafts conferred similar rates of delayed graft function and posttransplant renal function to KDPI-matched non-ECMO counterparts. VA-ECMO kidneys demonstrated superior graft survival compared with the lowest-quality (KDPI 86%–100%) non-ECMO kidneys and similar graft survival to KDPI <85% non-ECMO kidneys. VV-ECMO showed inferior graft survival to all but the lowest-quality (KDPI 86%–100%) non-ECMO kidneys. VV-ECMO, but not VA-ECMO, was associated with increased risk of graft loss on multivariable regression (hazard ratios—VA: 1.02, VV: 2.18). Higher KDPI, advanced age, increased body mass index, hypertension, and diabetes were identified as high-risk features of ECMO donors. Conclusions. Kidney transplantation using appropriately selected ECMO donors can safely expand the donor pool. Ongoing studies are necessary to determine best practice patterns using kidneys from these donors.

Background: Many studies evaluating opioid stewardship interventions' effects on postoperative pain rely on emergency department (ED) visits or readmissions, but patient-reported pain scores represent a more complete picture of the postoperative experience. This study compares patient-reported pain scores after ambulatory pediatric and urologic procedures and the effect of an opioid stewardship intervention that nearly eliminated the use of outpatient narcotics.Methods: This is a retrospective comparative study including 3173 pediatric patients who underwent ambulatory procedures from 2015 to 2019, during which there was an intervention to reduce narcotic prescriptions. Postoperative day one phone calls assessed pain levels using a four-point scale (no pain, mild pain, moderate pain controlled with medication, or severe pain uncontrolled with medication). We quantified the proportion of patients prescribed opioids pre-versus post-intervention and compared pain scores for patients receiving opioid versus non-opioid regimens.Results: Opioid prescription rates demonstrated a 6.5-fold reduction after opioid stewardship efforts. The majority of patients (2838) received non-opioids, with only 335 patients receiving opioids. Opioid patients reported moderate/severe pain slightly more than non-opioid patients (14.1% vs. 10.4%, p 1/4 0.04). On by-procedure analyses, there were no subgroups in which non-opioid patients reported significantly higher pain scores.Conclusions: Non-opioid postoperative pain regimens appear to be effective, with only 10.4% of patients reporting moderate/severe pain after ambulatory procedures. Future studies assessing patient-reported outcomes are necessary to optimize pain control for all patients and to determine whether there is ever an indication for opioid prescription after ambulatory general pediatric or urologic surgery. Type of study: Retrospective comparative study. Level of evidence: Level III.& COPY; 2023 Elsevier Inc. All rights reserved.

Liver transplantation continues to face significant organ shortages and efficient utilization of marginal donors is paramount. This study evaluates the practice patterns and outcomes in liver transplantation when utilizing allografts from marginal donors who required extracorporeal membrane oxygenation (ECMO) support. We performed a retrospective review of the Gift of Life (PA, NJ, DE) organ-procuring organization database for transplants performed using donors supported on ECMO for nondonation purposes. These were cross-referenced to the transplant recipients within the Organ Procurement and Transplantation Network database, and the outcomes of liver transplants using donors on ECMO support were compared with those not requiring ECMO. Organ use and nonuse patterns were then evaluated in ECMO-supported donors, identifying the factors associated with nonuse compared with the factors associated with graft failure. Thirty-nine of the 84 ECMO-supported donors contributing at least one intra-abdominal organ for transplant donated a liver. Graft survival and patient survival up to 5 years were comparable between transplants from ECMO and non-ECMO-supported donors, and no cases of primary nonfunction were seen in the ECMO group. ECMO support was not associated with 1-year graft failure on regression modeling. Additional regression analyses within the ECMO donor population identified bacteremia (HR: 19.81) and elevated total bilirubin at donation (HR: 2.44) as predictive of post-transplant graft failure. Livers from donors supported on ECMO before donation appear safe to use in select transplant settings. Better understanding of the impact of predonation ECMO on liver allograft function will help guide the optimal use of these scarcely used donors.

Diverse perspectives are critical components of effective teams in every industry. Underrepresentation of minorities in medicine leads to worse outcomes for minority patients, and efforts to increase diversity in the health care workforce are critical. Presently, about 70% of the pediatric surgery workforce is white, and pediatric surgeons at large do not reflect the racial or ethnic diversity of the populations they serve. Pediatric surgery fellowship training programs are the gateway to the field, and fellow selection processes should be optimized to support diversity and inclusion. The Association of Pediatric Surgery Training Program Directors (APSTPD) Diversity Equity and Inclusion subcommittee compiled best practices for bias mitigation during fellow selection, drawing from published literature and personal experiences in our own programs. A list of concrete recommendations was compiled, which can be implemented in every phase from applicant screening to rank list creation. We present these as a position statement that has been endorsed by the executive committee of the APSTPD. Pediatric surgery fellowship programs can utilize this focused review of best practices to mitigate bias and support diverse applicants.

Bevilacqua, Lisa A. MD; Pace, Devon J. MD; Aka, Allison A. MD; Latona, Jessica MD; Koenig, George J. DO; Marks, Joshua A. MD; Cohen, Murray J. MD; Maley, Warren R. MDAuthor Information

Background: Euglycemic diabetic ketoacidosis (euDKA) is a potential side effect associated with inhibitors of the sodium–glucose cotransporter 2 (SGLT-2). This effect is most often recognized during physiologic stress (i.e., sepsis) or in patients who undergo surgery. Case presentations: Case 1: A 66-year-old woman underwent distal pancreatectomy with en bloc splenectomy after presenting with a biopsy-proven pancreatic adenocarcinoma in the body of the pancreas noted incidentally on a screening magnetic resonance imaging for an ovarian mass. The patient had a history of type 2 diabetes mellitus (T2DM) and used canagliflozin, which she was instructed to hold 24 h before surgery. Case 2: A 75-year-old man underwent a pylorus-preserving pancreaticoduodenectomy after presenting with obstructive jaundice. This patient also had a history of T2DM and was on dapagliflozin, which he was also instructed to hold 24 h before surgery. Postoperatively, both patients were diagnosed with euDKA, which was suspected primarily because of intraoperative and postoperative polyuria. Conclusions: SGLT-2 inhibitors are associated with euDKA that can be potentiated in patients who undergo surgery. This medication side effect can be easily unrecognized and potentially lead to significant morbidity.