Introduction Acute pain is an expected symptom for adolescents after outpatient surgery. In the USA, postoperative analgesic regimens frequently include prescription opioids. Increasing attention from clinicians, patients and other healthcare leaders has been directed toward non-opioid strategies, such as combining non-steroidal anti-inflammatory drugs (NSAIDs) plus acetaminophen, as potential first-line options for managing postoperative pain. However, the effectiveness and safety of home regimens that include versus exclude opioids for adolescents are unclear. The Comparing Analgesic Regimen Effectiveness and Safety after surgery for Kids study evaluates the effectiveness and safety of NSAIDs plus acetaminophen alone (NSAID regimen) versus NSAIDs and acetaminophen plus a low-dose opioid regimen (opioid regimen).Methods and analysis This study is a pragmatic, multicentre randomised controlled clinical trial recruiting 900 patients aged 12–20 years undergoing three common outpatient surgeries (tonsillectomy, laparoscopic cholecystectomy, knee arthroscopy) across four health systems. We will recruit patients prior to surgery and individuals will be randomised 1:1 with stratification to receive prescriptions for either the NSAID regimen or the opioid regimen. The primary effectiveness outcome is patient-reported pain intensity, while the primary safety outcome is adverse medication-related symptoms both assessed over the first 2 weeks after surgery. Secondary outcomes include quality of recovery, healthcare-related quality of life and rates of problematic substance use and chronic prescription opioid use, assessed up to 1 year after surgery.Ethics and dissemination The study incorporates stakeholder collaboration, including patient partners, surgeons, professional organisations., and health insurance payors, to ensure ethical conduct and relevance. This study is overseen by a single institutional review board with certificate of confidentiality. Findings will be disseminated through academic publications, conferences and community outreach to inform patients, parents, surgical teams and policymakers about optimal pain management strategies for adolescents after surgery.Trial registration number NCT06671002.

Introduction Appendicitis is the most common condition requiring emergency surgery in pediatric patients. Despite this, appendicitis is exceedingly rare in neonatal and infant age groups. Neonatal appendicitis is difficult to diagnose as it mimics other more common abdominal pathologies. Methods A retrospective review from 2004 to 2024 of a quaternary pediatric hospital was conducted and included all infants under 1 y of age who underwent appendectomy and were found to have appendicitis on pathology. Patients were excluded if they had an appendectomy without pathology confirming appendicitis or no documentation of appendicitis. Data extracted included demographics, symptoms, labs, imaging, surgical, and pathological outcomes. Results Seven patients presented with appendicitis with a median age of 14 d (interquartile range 8.5-45d). Five had comorbidities. The most common presentations were abdominal distension, pain, fever, and diarrhea. The average white blood cell count was 12.95 ± 6.42x103 cells/μL. C-reactive protein and procalcitonin were elevated in both patients in which they were completed. Five of the patients had blood cultures, with two of the five positive for Escherichia coli. Most patients had an abdominal x-ray (n = 6) and two had free air. Two underwent abdominal ultrasound and one demonstrated an enlarged appendix. Three of the patients required more than one visit for definitive treatment. Two patients had laparoscopic procedures. Four of the patients had perforations. There was no mortality or complications related to surgery. Conclusions Neonatal and infant appendicitis at our institution was rare. There was no unifying presentation or symptomatology that was consistent across the patient cohort, which makes diagnosis challenging in this patient population.

OBJECTIVE(S):Fetal pleural effusion is a rare condition that may significantly impact fetal and neonatal outcomes. Currently, no universal standardized approach exists for diagnosing and managing primary fetal pleural effusions. This study aimed to develop structured, expert-based clinical guidelines for the diagnosis, monitoring, management, and follow-up care of primary fetal pleural effusion. METHODS:A Delphi method was employed to achieve consensus among an international panel of experts in fetal medicine. Experts were selected based on their clinical expertise, affiliations, and relevant publications. A three-round anonymous electronic survey was sent to the full panel. In the initial two rounds, participants rated each statement on a Likert scale (1-5) and provided suggestions for modifications. Statements with a median score of five and no suggested changes were accepted as consensus. Statements with a median score below four were rejected. Statements scoring a median of four were revised according to suggestions and reconsidered in the subsequent round. In the final round, participants indicated their agreement or disagreement with the remaining statements. Consensus was defined as agreement from more than 70% of participants with no suggestions for further changes. RESULTS:A total of 101 expert clinicians accepted the invitation and completed the first round with 73 (72%) completing all three rounds. Consensus statements were achieved on aspects of diagnosis, monitoring, intervention, post-intervention management, and delivery. Key recommendations concerning the diagnosis of primary fetal pleural effusion include the use of ultrasound as the primary modality for identifying fetal pleural effusion and excluding secondary causes through detailed genetic, infectious, and metabolic evaluations. Management strategies emphasized thoracoamniotic shunting as the preferred intervention in hydropic fetuses with primary pleural effusion. Experts reached consensus that shunt placement could be offered as early as 16 weeks. No consensus was reached for isolated effusion without hydrops, as management was considered case-dependent. The importance of ultrasonographic monitoring of fetal status at least weekly post-intervention was strongly endorsed. CONCLUSION(S):The Delphi method facilitated the development of a consensus-based protocol for diagnosing and managing primary fetal pleural effusion. These standardized guidelines are intended to enhance clinical practice across various settings, improve perinatal outcomes, and serve as a foundation for future research for this high-risk fetal condition.

IntroductionGeneralized arterial calcification of infancy (GACI) is a rare, difficult to recognize, autosomal recessive disorder with high neonatal mortality due to vascular calcification and cardiopulmonary collapse.Case ReportWe report a term female presenting with persistent pulmonary hypertension requiring venoarterial extracorporeal life support within 24 h of life. Despite initial stabilization, she developed progressive neurologic deterioration. Imaging revealed diffuse vascular calcification including severe carotid involvement. GACI was suspected and later genetically confirmed.DiscussionWhile ECLS effectively bridged to diagnosis, the case was complicated by extensive cerebrovascular calcification, resulting in irreversible neurologic injury. This represents the utility of ECLS as bridge to diagnosis and subsequent identification of the first case of GACI with catastrophic carotid involvement.ConclusionOur report highlights the role of ECLS as bridge to diagnosis in GACI and potential for characterization of previously unrecognized processes in this disease.

Introduction Ergonomic injuries pose significant risks to surgeons, affecting health, productivity, care access, and retirement age. Despite unique challenges in pediatric surgery, including varied patient sizes and operations, little is known about pediatric surgeons' ergonomics. This study aimed to assess ergonomic practices and associated injuries among pediatric surgeons. Methods A cross-sectional survey was distributed to the American Pediatric Surgical Association regular members and fellows. Data collected included demographics, physical health, surgical practices, operating habits, discomfort, injuries, interventions, and outcomes. Associations with injury were analyzed using Fisher's exact test, Pearson's Chi-squared test, and Wilcoxon rank-sum tests. Results One hundred seventeen (11%) surgeons responded, 53% were male with a median of 15 y in practice (interquartile range: 6-25). Regarding operating habits, 76% did not take regular breaks, 48% double-gloved, and 51% used loupes regularly. Notably, 90% experienced discomfort or pain, and 30% sustained injuries from operating, primarily affecting the neck and cervical spine (53%). White-identifying pediatric surgeons (80%) reported significantly more ergonomic injuries than other races (P < 0.01). Only 18% of respondents received ergonomic training. Ergonomics training and operating with a resident or co-surgeon were associated with less injury (P < 0.05). Among those experiencing discomfort or injury, 13% underwent a procedure, 63% experienced sleep disturbance, 74% reported contribution to burnout, and 88% used pain medications. Conclusions Ergonomic-related discomfort and injuries occurred in nearly 90% of pediatric surgeons who responded. Few had ergonomic training and most reported an impact on well-being. Modifiable ergonomic factors for pediatric surgeons, along with targeted interventions to reduce injuries, can improve surgeon well-being.

Surgeons of all specialties are impacted by health policies, primarily written and executed by nonmedical parties. The sequelae of policy change may limit the patient-physician relationship across numerous surgical disciplines, including general and acute care surgery, OB/GYN surgery, pediatric and fetal surgery, and others. The discordance between a surgeon's imperative to provide excellent patient care and legislative limitations that hinder patient care can impact surgeon wellness, career longevity, and attrition as well as reduce access and outcomes for patients, across specialties. Limited literature addresses this presage to physician wellness and patient outcomes. Combatting moral distress requires a framework that considers a multifactorial approach including open communication and respect among colleagues, free discussion of challenges related to health policy, resources for coaching and therapeutic counseling, and organizational actions promoting surgeon wellness. In this article, we present strategies, curated and executed by our subspecialty advocacy group, for navigating moral challenges secondary to health policy. This framework may be implemented across specialties to promote discussion of controversial or difficult topics in the professional setting and help prevent distress and attrition.

Congenital diaphragmatic hernia (CDH) is a rare yet serious congenital condition marked by a diaphragmatic defect, pulmonary hypoplasia, and often pulmonary hypertension. While surgical repair is essential for survival, many controversies remain regarding its timing, approach, and techniques. Delayed repair after physiological stabilization is the current standard, though optimal timing varies. Earlier repair within 24-48 h may reduce hospital stay in some cases, while others benefit from extended stabilization. CDH patients on extracorporeal life support (ECLS) pose additional challenges, balancing bleeding risks against potential survival benefits when surgery is done on ECLS. Open surgical repair remains the gold standard, especially for large defects, with laparotomy preferred over thoracotomy. Minimally invasive surgery (MIS), although associated with better cosmetic and recovery outcomes, has higher recurrence rates and a steep learning curve. MIS is generally suited for smaller defects, though recent experience shows promising outcomes even in complex cases with patch repairs. Repair technique depends on defect size. Primary repair is preferred for small defects, while larger defects require synthetic or biological patches with emphasis on a tension-free repair for all defects. Synthetic patches offer strength but carry infection risks, whereas biological materials may lack durability. Muscle flap techniques offer an alternative, especially for recurrent or large defects. Recurrence remains a major concern, especially with large defects and patch repairs. Open reoperation is standard for recurrences, with MIS reserved for select cases. Prevention strategies include tension-free repair, appropriate patch choice, and meticulous technique. Emerging strategies, such as regenerative medicine, composite patches, and tissue engineering, show promise but are not yet widely available. Multicenter research, individualized care, and standardized reporting are essential to optimize outcomes and guide future innovations in CDH management.

OBJECTIVE:Neonates transfused with adult donor blood (rich in HbA) have a precipitous drop in fetal hemoglobin (HbF) levels. This study evaluates the feasibility of collection and storage of placental cord blood. METHODS:Prospective study patients with uncomplicated term pregnancies undergoing scheduled cesarean section were recruited from July 2022-December 2023. Cord blood was collected after delivery for processing and storage in our institutional blood bank. Samples were analyzed at 0, 7, 14, and 21 days. RESULTS:Thirty patients were recruited (55 % Caucasian with median maternal age 34 years, gestational age 39 weeks, birth weight 3.48 kg). Median collection volume was 83 mL; 8 collections were excluded due to inadequate volume. The median hemolysis was 0.10 % on Day 0 and 0.23 % on Day 21 with median loss 2.5 %. Median biochemical storage lesion at 21 days was within expectations (24.5 mmol/L potassium, 71.2 mg/dL free hemoglobin, pH 6.38, LDH 191 IU/L). All day 21 blood cultures were negative. Hemoglobin fractions remained unchanged between 0 and 21 days (16.2-17.8 % HbA and 83.8-82.2 % HbF). CONCLUSION:Placental cord blood can be safely collected, processed, and stored for 21 days as a potential autologous blood product for neonates. TYPE OF STUDY:Level II, Prospective Cohort.

Introduction: Timing of repair for infants with congenital diaphragmatic hernia (CDH) requiring extracorporeal life support (ECLS) remains controversial. Approaches include early repair on ECLS, late repair on ECLS, or repair after ECLS decannulation; all have potential risks and benefits. To mitigate risk and maximize benefit, our group developed an individualized hybrid model in 2016 in which approach is based on prenatal risk stratification. Here we report the outcomes of this model. Methods: This is a single-institution retrospective review (2002-2023) of infants diagnosed with CDH requiring ECLS, grouping patients according to temporal protocols: Delayed Repair (DR; 2002-2009), Early Repair (ER; 2010-2016), and Hybrid Model (HM; 2017-2023). Demographics, disease characteristics, and outcomes were analyzed. Chi-squared/Fisher's exact/Kruskal-Wallis tests were used, with significance of p < 0.05. Results: 103 infants were included- 35 (34 %) with DR, 32 (31 %) with ER, and 36 (35 %) using HM. Patient demographics and markers of prenatal severity were similar among groups. Median ECLS duration was significantly less in patients treated with HM (10 days; IQR: 5,17) compared to DR (12 days, IQR: 6,17) and ER (17 days, IQR: 11,22) [p 1 / 4 0.019]. Survival to discharge was highest using the HM (78 %) compared to DR (69 %) and ER (34 %) groups [p < 0.001]. Subgroup analysis of the HM cohort demonstrated prenatal predictors differed significantly based on timing selected for repair. Conclusion: We demonstrate a physiologic spectrum across infants with CDH requiring ECLS, suggesting utility of a hybrid model. This individualized approach may be beneficial in discerning patients of moderate severity who could be decannulated prior to repair to mitigate bleeding complications. Level of Evidence: III. (c) 2024 Elsevier Inc. All rights are reserved, including those for text and data mining, AI training, and similar technologies.

INTRODUCTION:There are limited data regarding long-term outcomes in patients with congenital diaphragmatic hernia (CDH) who require tracheostomy with chronic ventilator dependence. The aim of this study is to describe the characteristics of these patients and their associated long-term outcomes in our institutional cohort. METHODS:Retrospective chart review was performed on all patients with CDH at our institution who underwent tracheostomy during their initial admission, from January 1, 2004 through October 31, 2024. Patients were excluded if they had tracheostomy creation during a subsequent admission. Demographic and clinical data were collected. RESULTS:Out of 308 newborn CDH patients treated at our institution over the study period, 8 (2.6%) were discharged with tracheostomy and mechanical ventilation. Two (25%) were born preterm, 2 (25%) had chromosomal anomalies, and 5 (62.5%) had cardiac anomalies. Four (50%) patients underwent extracorporeal life support, all prior to CDH repair. Seven (87.5%) patients required medical therapy for pulmonary hypertension during hospitalization, with 4 (50%) discharged on antipulmonary hypertensive medication. All patients were treated for viral or bacterial pneumonia during their index admission and all patients were diagnosed with variable degrees of tracheobronchomalacia. At the time of review, 2 (25%) patients were deceased-both living a total of 9 mo-while 3 (37.5%) had been successfully decannulated and 3 (37.5%) remain on ventilator support. CONCLUSIONS:Requiring tracheostomy with home mechanical ventilation is rare in CDH patients. In this small series, we noted an association of home ventilation with both pneumonia and tracheobronchomalacia.

Objectives: To investigate the prevalence trend of gastroschisis in the United States between 2014 and 2022. Methods: A cross-sectional retrospective analysis of the Centers for the United States live births between 2014 and 2022. Pregnancies and neonatal singleton live births with documented isolated gastroschisis were included. Neonates with other major congenital anomalies and known chromosomal abnormalities were excluded. Prevalence per 10,000 live births along with 95% confidence intervals was estimated. Results: Among 32,088,301 singleton live births, 6804 cases of isolated gastroschisis were identified (Point prevalence: 2 in 10,000 live births). A significant decline in gastroschisis prevalence was observed, decreasing from 2.86 per 10,000 live births in 2014-1.55 per 10,000 live births in 2022 (P < 0.001). The risk of gastroschisis was significantly higher in teen and nulliparous gravidae, with prepregnancy tobacco use, and among socially vulnerable populations (underweight, < 12th-grade education, Medicaid, non-Hispanic Indigenous Americans). The drop in gastroschisis births from 2014 to 2022, compared to non-gastroschisis births, is more significant in maternal age <20 years, nulliparous, BMI <18.5, and in smokers prior to pregnancy than in the overall population (P = 0.02, 0.0008, <0.0001, <0.0001, and 0.01 respectively). All of the associated maternal factors had a significant decline in prevalence (P < 0.001), which may influence the decreasing trend of gastroschisis. There was no perceived considerable impact of the COVID-19 pandemic on gastroschisis trends. Conclusions: The study highlights a notable decline in gastroschisis prevalence mostly attributable to a declining birth rate in the highest at-risk strata, suggesting recent increases in birth rates among these at-risk gravidae may reverse the trend of declining gastroschisis disease prevalence. These findings support the need for ongoing further research to understand effective means of sustaining this decreasing trend.

BACKGROUND:Women have long been underrepresented in surgical fields, including pediatric general surgery (PGS), one of the most competitive subspecialties. This study examined trends in gender representation in PGS. METHODS:We identified all PGS graduates from U.S. and Canadian programs between 1919 and 2025 using validated sources. Gender was determined, and male-to-female ratios were analyzed by year. National leadership roles were reviewed for their representation of females. Chi-square tests were used to assess statistical significance (p ​< ​0.05). RESULTS:Seventy-nine programs produced 2235 graduates: 1675 (75 ​%) men and 560 (25 ​%) women. Female representation increased steadily, with gender parity emerging around 2020. Although women entered leadership roles in PGS earlier than in General Surgery, they still lag behind men in overall leadership representation. CONCLUSIONS:PGS has made significant progress toward gender equity in training, with recent parity among graduates. However, leadership remains an area for continued improvement to ensure equitable representation at all levels.

Objective To describe our experience utilizing epoprostenol for pulmonary hypertension (PH) in infants with congenital diaphragmatic hernia (CDH) requiring extracorporeal life support (ECLS). Study design We retrospectively reviewed infants diagnosed with CDH who required ECLS at our institution from 2013-2023. Data collected included demographics, disease characteristics, medication administration patterns, and hospital outcomes. We first compared infants who received intravenous epoprostenol and those who did not. Among infants who received epoprostenol, we compared survivors and non-survivors. Chi-square/Fisher’s exact and Mann-Whitney tests were used, with significance p<0.05. Results Fifty-seven infants were included; 40 (70.2%) received epoprostenol. Infants receiving epoprostenol had lower observed/expected total fetal lung volume (O/E TFLV) on MRI (20 vs. 26.2%, p=0.042) as well as higher prenatal frequency of liver-up (90 vs 64.7%, p=0.023) and “severe” classification (67.5 vs 35.3%, p=0.007). Survival with and without epoprostenol was comparable (60% vs. 64%, p=0.23). Of those receiving epoprostenol, both survivors and non-survivors had similar prenatal indicators of disease severity. Most (80%) of hernia defects were classified as Type C/D and 68% were repaired <72 hours after ECLS cannulation. The median age at initiation of epoprostenol was day of life 6 (IQR: 4, 7) in survivors and 8 (IQR: 7, 16) in non-survivors (p=0.012). Survivors had shorter ECLS duration (11 vs 20 days, p=0.049). Of non-survivors, refractory PH was the cause of death for 13 infants (81%). Conclusion In infants with CDH requiring ECLS, addition of epoprostenol appears promising and earlier initiation may affect survival.

Introduction Various randomized control trials in the pediatric population have shown no therapeutic advantage of video-assisted thoracoscopic surgery over fibrinolytic therapy (tissue plasminogen activator [tPA]) for empyema management. However, literature detailing changes in practice management and protocol implementation is limited. In 2018, we instituted clinical practice guidelines (CPGs) for empyema management utilizing tissue plasminogen activatorinstillation via a small bore chest tube as initial therapy. Before standardization, surgeon preference drove management. Our aim was to determine differences in management and outcomes following institutional CPG implementation. Methods A single-institution retrospective study (2002-2022) examined patients 0-18 y of age diagnosed with pneumonia and associated empyema (loculated pleural fluid on ultrasound or computed-tomographic scan). The comparison groups were pre- and post-CPG implementation groups. Comparative statistics were performed, and the significance level was set at P < 0.05. Results Sixty-one patients met the inclusion criteria: 33 (54%) preimplementation and 28 (46%) postimplementation. The demographics and diagnostic imaging modalities were similar between groups. There were no significant differences in time to initiate antibiotics, antibiotic duration, intensive care unit length of stay (LOS), or total hospital LOS. The utilization of video-assisted thoracoscopic surgery as initial intervention significantly decreased from 66% to 10% after protocol implementation (P < 0.01); the failure rates of initial therapy choice were similar (12% versus 10%, P = 0.87). Marked reduction in total patients undergoing operative intervention at any point during the course of therapy was observed, 76% preimplementation versus 21% postimplementation (P < 0.01). Conclusions In children treated for empyema, the overall incidence of operative intervention significantly decreased following CPG implementation. The changes in antibiotic usage, intensive care unit/total LOS, and initial therapy failure rates did not differ. In our experience, the implementation of a CPG was instrumental in adherence to national guidelines.

Introduction: Prenatally diagnosed congenital lung malformations (CLMs) are monitored via ultrasound and measured by congenital pulmonary airway malformation volume ratios (CVRs) which can predict postnatal respiratory symptoms. This study compared CVR to postnatal lesion size to help guide prenatal counseling.Methods: A retrospective chart review evaluated the prenatal imaging and postnatal out-comes for patients who were prenatally diagnosed with CLMs and had a postnatal computed tomography (CT) scan at one institution.Results: Fifty-seven patients were included. Four had symptoms requiring urgent resection. The remaining were discharged and had clinic follow-up with CT scan to determine next steps: five had no identified lesions, eight had lesions whose diagnosis did not warrant an operation, and 40 had lesions whose diagnosis rendered size a factor in operative decision-making. Of these 40, 26/40 patients (65%) underwent elective resection (median maximum CVR 0.97; median lesion size 4 cm) and 14/40 patients (35%) were observed without resection (median maximum CVR 0.5; median lesion size 3 cm). There was a positive correlation between prenatal CVR and postnatal lesion size, with R-squared 1/4 0.46. Maximum CVRs were better than last CVRs when predicting whether postnatal CT size would fall above or below our institution's level of recommended resection, with an area under the curve of 0.85 and a CVR cut-point of 0.61.Conclusions: For newborns with asymptomatic CLMs, higher maximum CVRs correlated with larger size on postnatal CT. A maximum CVR <0.6 was correlated with a smaller postnatal CT size that may be eligible for nonoperative management. While these results are not intended to recommend surgery based on higher CVRs alone, this information could potentially be used to reassure expectant parents whose babies' prenatal imaging demonstrate lower maximum CVRs.(c) 2023 Elsevier Inc. All rights reserved.

Introduction: Thoracoscopic CDH repair is increasingly performed for Type A and small Type B defects that are amenable to primary repair. However, the thoracoscopic approach is controversial for larger defects necessitating a patch due to technical complexity, intraoperative acidosis, and recurrence risk. We aim to compare clinical outcomes between thoracoscopic and open patch repair of Type B/C defects, using a standardized technique. Methods: This is a single -center retrospective review of thoracoscopic and open CDH patch repairs January 2017-December 2021. We excluded primary repairs, Type D hernias, repairs on ECMO, recurrent repairs. Various preoperative, intraoperative, and postoperative variables were compared. Primary outcome was recurrence rate. Secondary outcomes included intraoperative pH and pCO(2), operative time, and complication rates. Results: Twenty-nine patients met inclusion criteria (open = 13, thoracoscopic = 16). The open cohort had lower o/e total fetal lung volume (29 vs 41.2%, p = 0.042), higher preoperative peak inspiratory pressures (24 vs 20 cm H2O, p = 0.007), were more frequently Type C defects (92.3 vs 31%, p = 0.002) and had liver "up " in left -sided hernias (46 vs 0%, p < 0.0001). Intraoperatively, median lowest pH and highest pCO(2) did not differ; neither did overall median pH or pCO(2). Operative times were similar (153 vs 194 min, p = 0.113). No difference in recurrence rates was identified, however postoperative complications were higher in the open group. There were no mortalities. Conclusions: Although we demonstrate higher disease severity of patients undergoing open repair, thoracoscopic patch repair for Type B/C defects is safe and effective in patients with favorable physiologic status, alleviating concerns for intraoperative acidosis, operative length, and risk of recurrence. Level of Evidence: II. (c) 2023 Elsevier Inc. All rights reserved.

Introduction A radical paradigm shift in the treatment of premature infants failing conventional treatment is to recreate fetal physiology using an extracorporeal Artificial Placenta (AP). The aim of this study is to evaluate the effects of changing fetal hemoglobin percent (HbF%) on physiology and circuit function during AP support in an ovine model. Methods Extremely premature lambs ( n = 5) were delivered by cesarean section at 117-121 d estimated gestational age (EGA) (term = 145d), weighing 2.5 ± 0.35 kg. Lambs were cannulated using 10-14Fr cannulae for drainage via the right jugular vein and reinfusion via the umbilical vein. Lambs were intubated and lungs were filled with perfluorodecalin to a meniscus with a pressure of 5–8 cm H2O. The first option for transfusion was fetal whole blood from twins followed by maternal red blood cells. Arterial blood gases were used to titrate AP support to maintain fetal blood gas values. Results The mean survival time on circuit was 119.6 ± 39.5 h. Hemodynamic parameters and lactate were stable throughout. As more adult blood transfusions were given to maintain hemoglobin at 10 mg/dL, the HbF% declined, reaching 40% by post operative day 7. The HbF% was inversely proportional to flow rates as higher flows were required to maintain adequate oxygen saturation and perfusion. Conclusions Transfusion of adult blood led to decreased fetal hemoglobin concentration during AP support. The HbF% was inversely proportional to flow rates. Future directions include strategies to decrease the priming volume and establishing a fetal blood bank to have blood rich in HbF.

PURPOSE:Despite trends toward equal gender representation among medical school graduates, surgical trainees and fellows, diversity in higher levels of pediatric surgery is largely unstudied. This study aims to quantify gender diversity among leadership of pediatric surgical associations and societies across the globe. METHODS:National and international pediatric surgical organizations were identified from the websites of the American Pediatric Surgical Association (APSA) and World Federation of Associations of Pediatric Surgery (WOFAPS). Compositional gender data of current and past organizational leadership was collected by examining publicly available archives of executive membership rosters. If roster pictures were not available, member names were input into social media sites and other search engines to ensure accurate gender denotation. Univariate analyses of organizational metrics and aggregate data of 5-year time intervals were performed via Fischer's Exact Test with significance of p < 0.05. RESULTS:Nineteen pediatric surgical organizations were included for study analysis. Of 189 current organizational leaders, 50 (26.4%) are women. Eight organizations (42.1%) have less than 20% of leadership positions filled by women members, while two executive boards have no women members. Four organizations (22.2%) have a current woman seated as president/chairperson. Historical gender distribution stratified by organization demonstrates a range of 0-7.8% (p = 0.99), with one organization having yet to elect a woman president/chairperson. Longitudinally, women presidential representation remained consistently low (5-11%) across all time intervals from 1993 to 2022 (p = 0.35). CONCLUSIONS:Despite advances in diversity in medical school graduates, surgical training, and workforce recruitment, there are still significant disparities in gender representation within pediatric surgery societal leadership. LEVEL OF EVIDENCE:IV.