Quality Improvement Program Pediatric Database Research Articles

Inpatient versus Outpatient Alveolar Bone Grafting: A Nationwide Cost Analysis.

To compare postoperative outcomes and costs between inpatient and outpatient ABG in the United States. Retrospective cohort. Multi-institutional/national. Patients who underwent ABG (n = 6649) were identified in the National Surgical Quality Improvement Program Pediatric database from 2012-2021. Inpatient and outpatient cohorts were matched using coarsened exact matching. Thirty-day readmission, reoperation, and complications. A modified Markov model was developed to estimate the cost difference between cohorts. One-way and probabilistic sensitivity analyses were performed. After matching, 3718 patients were included, of which 1859 patients were in each hospital-setting cohort. The inpatient cohort had significantly higher rates of reoperations (0.6% vs. 0.2%; p = 0.032) and surgical site infections (0.8% vs. 0.2%; p = 0.018). The total cost of outpatient ABG was estimated to be $10,824 vs. $20,955 for inpatient ABG, resulting in $10,131 cost savings per patient. Probabilistic sensitivity analysis revealed that all 10,000 simulations resulted in consistent cost savings for the outpatient cohort that ranged from $8000 to $24,000. Outpatient ABG has become increasingly more popular over the past ten years, with a majority of cases being performed in the ambulatory setting. If deemed safe for the individual patient, outpatient ABG may confer a lower risk of nosocomial complications and offer significant cost savings to the healthcare economy.

Reoperation, Readmission, and Postoperative Bleeding in Pediatric Cerebral Palsy Patients Undergoing Spinal Arthrodesis.

Background Cerebral palsy (CP) is one of the most common neuromuscular disorders in children, and spinal abnormalities are vastly more common in people with CP compared to the general population. Further investigation is needed to improve our understanding of the perioperative factors that place children with CP at greater risk of postoperative complications.This study aims to investigate (1) whether pediatric CP patients have higher rates of postoperative complications after spinal fusion and (2) risk factors for postoperative bleeding, readmission, and reoperation. Methodology The 2019 American College of Surgeons National Surgical Quality Improvement Program Pediatric database was used for this study. Chi-square tests were used to compare patient demographics, frequency of comorbidities, intraoperative factors, and postoperative complications between CP and non-CP patients. Multivariable logistic regression modeling was conducted to determine if CP was an independent risk factor for the composite variable that included postoperative bleeding, readmission, and reoperation. Results A total of 4,445 patients were included in the study, with 606 CP and 3,839 non-CP patients. Several comorbidities were more prevalent in the CP cohort, most notably asthma, gastrointestinal disease, previous cardiac surgery, and hematologic disorders. Multivariable logistic regression modeling revealed that CP, older age, non-Caucasian race, American Society of Anesthesiologists (ASA) class of 3 or higher, posterior surgical approach, previous cardiac surgery, and ostomy were significantly correlated with higher postoperative complications. Conclusions This study demonstrates that CP, older age, non-Caucasian race, ASA class of 3 or higher, posterior approach, previous cardiac surgery, and ostomy are independent risk factors for postoperative complications, including readmission, reoperation, and postoperative bleeding requiring transfusions. Consequently, there is a pressing need for additional research to establish perioperative strategies that reduce postoperative risks for these patients. Spine surgeons should consider the findings of this study when communicating the potential risks of spinal fusion surgery with patients and their families.

Characteristics of and cost of care for children with impaired development and acute appendicitis: A study of 2 national databases

BackgroundCharacteristics of children with impaired development who have acute appendicitis are not well described in the literature. MethodsWe reviewed the National Surgical Quality Improvement Program-Pediatric and the multicenter Pediatric Health Information System for patients with acute appendicitis. Comparisons for demographics, clinical outcomes, and hospital charges between children with impaired development versus neurotypical children were made using independent t test or Wilcoxon rank sum tests. The multivariable logistic regression model estimated the odds of complicated acute appendicitis in impaired development patients. Based on correlation analyses, hierarchical linear modeling was used to examine the extent to which impaired development influenced resource use. ResultsPatients with impaired development were younger, had higher comorbidities, and were more commonly male sex. In the National Surgical Quality Improvement Program-Pediatric database, impaired development was associated with higher rates of complicated acute appendicitis (33.6% vs 27.5, P < .001), particularly in older children, and higher usage of computed tomography at National Surgical Quality Improvement Program-Pediatric hospitals (23.1% vs 15.1%, P < .001). In the Pediatric Health Information System database, the adjusted odds of complicated acute appendicitis were significantly higher in patients with impaired development (1.20 [1.09–1.31]), low childhood opportunity level (1.39 [95% confidence interval: 1.31–1.47]), and Black race (1.25 [1.17–1.33]). Hierarchical adjusted linear modeling showed that impaired development was associated with significantly higher hospital charges (9% increase). ConclusionManagement of acute appendicitis in children with impaired development remains a challenge to clinicians, as evidenced by the higher rate of perforated appendicitis in older children, diagnostic computed tomography use at National Surgical Quality Improvement Program-Pediatric hospitals, postoperative computed tomography use, and increased costs.

Sociodemographic Disparities and Postoperative Outcomes Following Cranial Vault Remodeling for Craniosynostosis: Analysis of the 2012 to 2021 NSQIP-Pediatric Database.

The objective of this study was to assess whether race and ethnicity are independent predictors of inferior postoperative clinical outcomes, including increased complication rates, extended length of stay (LOS), and unplanned 30-day readmission following cranial vault repair for craniosynostosis. A retrospective cohort study was performed using the American College of Surgeons National Surgical Quality Improvement Program-Pediatric database. Pediatric patients under 2 years of age undergoing cranial vault repair for craniosynostosis between 2012 and 2021 were identified using the International Classification of Diseases-9/10 and Current Procedural Terminology codes. Patients were dichotomized into 4 cohorts: non-Hispanic White (NHW), non-Hispanic Black (NHB), Hispanic, and other. Only patients with available race and ethnicity data were included in this study. Patient demographics, comorbidities, surgical variables, postoperative adverse events, and hospital resource utilization were assessed. Multivariate logistic regression analysis was used to assess the impact of race on complications, extended LOS, and unplanned readmissions. In our cohort of 7764 patients, 72.80% were NHW, 8.44% were NHB, 15.10% were Hispanic, and 3.67% were categorized as "other." Age was significantly different between the 4 cohorts (P<0.001); NHB patients were the oldest, with an average age of 327.69±174.57 days old. Non-Hispanic White experienced the least adverse events while NHB experienced the most (P=0.01). Total operative time and hospital LOS were shorter for NHW patients (P<0.001 and P<0.001, respectively). Rates of unplanned 30-day readmission, unplanned reoperation, and 30-day mortality did not differ significantly between the 4 cohorts. On multivariate analysis, race was found to be an independent predictor of extended LOS [NHB: adjusted odds ratio: 1.30 (1.04-1.62), P=0.021; other: 2.28 (1.69-3.04), P=0.005], but not of complications or readmission. Our study demonstrates that racial and ethnic disparities exist among patients undergoing cranial vault reconstruction for craniosynostosis. These disparities, in part, may be due to delayed age of presentation among non-Hispanic, non-White patients. Further investigations to elucidate the underlying causes of these disparities are necessary to address gaps in access to care and provide equitable health care to at-risk populations.

The Impact of Higher BMI on Wound Complications Following Adolescent Breast Reduction: A Retrospective Study of 1215 Cases.

Macromastia is a physically and psychologically distressing condition for adolescents. While reduction mammaplasty is often the best treatment, risk factors for adolescent wound complications remain unclear. This study aims to investigate the impact of obesity and other predictors of postoperative wound complications following adolescent reduction mammaplasty using a national database. The 2012-2019 National Surgical Quality Improvement Program Pediatric (NSQIP-P) databases were reviewed to identify primary reduction mammaplasty encounters. World Health Organization Body Mass Index (BMI), alongside patient and case characteristics, were assessed for association for 30-day wound disruption or surgical site complications. Statistical analyses were performed to identify independent predictors for complications and determine a potential BMI cutoff for risk stratification. There were 1215 patients with an average age of 16.6 years. The average BMI was 30.7 kg/m2, and 593 (48.8%) patients were nonobese while 622 (51.2%) were obese. The incidence of complications was 5.27%. Independent predictors of complications included a BMI 35-39.9, BMI > 40, and an American Society of Anesthesiologists (ASA) Classification > 3. A receiver operating characteristic curve determined that a BMI of 34.6 can be a potential cutoff for increased complication risk. Higher obesity increases risk of wound complications; however, complication rates remain low. A BMI of 34.6 is a potential screening metric for counseling and monitoring patients. Reduction mammaplasty should remain a viable option as it can significantly improve quality of life. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to Table of Contents or the online Instructions to Authors www.springer.com/00266 .

802 Increase in Surgical Burn Management During the COVID-19 Pandemic

Abstract Introduction The COVID-19 pandemic has had a profound impact on healthcare systems worldwide. This study explores the consequences of the pandemic on pediatric burn management, specifically focusing on whether the pandemic contributed to a surge in the volume of pediatric burns requiring surgical interventions. Methods All surgical cases that had a post-operative ICD-10 diagnosis of a burn was collected from the National Surgical Quality Improvement Program Pediatric database. Patient demographics, procedure codes, and postoperative complications was collected. Results From 2018 to 2021, there was a total of 872 pediatric burns that required surgical intervention. The median age of the patients was 5.4 years. There was an 8.7% increase in volume of these cases from 2019 to 2020. The overall rate of complications was 8.4%. The predominant surgical approach employed in the majority of cases was the utilization of split-thickness autograft. Conclusions There was an increase in pediatric surgical burn treatment volume during the COVID-19 pandemic. Further investigation into the underlying causes and implications of this surge is warranted. Applicability of Research to Practice This analysis provides more information on the incidence of pediatric burns managed by surgical treatment and how it was affected by the COVID-19 pandemic.

8. National Trends of Gynecologic Surgery Across Pediatric Hospitals: A National Surgical Quality Improvement Program Pediatric (NSQIP-P) Database Analysis

8. National Trends of Gynecologic Surgery Across Pediatric Hospitals: A National Surgical Quality Improvement Program Pediatric (NSQIP-P) Database Analysis

Machine learning for enhanced prognostication: predicting 30-day outcomes following posterior fossa decompression surgery for Chiari malformation type I in a pediatric cohort.

Chiari malformation type I (CM-I) is a congenital disorder occurring in 0.1% of the population. In symptomatic cases, surgery with posterior fossa decompression (PFD) is the treatment of choice. Surgery is, however, associated with peri- and postoperative complications that may require readmission or renewed surgical intervention. Given the associated financial costs and the impact on patients' well-being, there is a need for predictive tools that can assess the likelihood of such adverse events. The aim of this study was therefore to leverage machine learning algorithms to develop a predictive model for 30-day readmissions and reoperations after PFD in pediatric patients with CM-I. This was a retrospective study based on data from the National Surgical Quality Improvement Program-Pediatric database. Eligible patients were those undergoing PFD (Current Procedural Terminology code 61343) for CM-I between 2012 and 2021. Patients undergoing surgery for tumors or vascular lesions were excluded. Unplanned 30-day readmission and unplanned 30-day reoperation were the main study outcomes. Additional outcome data considered included the length of hospital stay, 30-day complications, discharge disposition, and 30-day mortality. Training and testing samples were randomly generated (80:20) to study the 30-day readmission and reoperation using logistic regression, decision tree, random forest (RF), K-nearest neighbors, and Gaussian naive Bayes algorithms. A total of 7106 pediatric patients undergoing PFD were included. The median age was 9.2 years (IQR 4.7, 14.2 years). Most of the patients were female (56%). The 30-day readmission and reoperation rates were 7.5% and 3.4%, respectively. Headaches (32%) and wound-related complications (30%) were the most common reasons for 30-day readmission, while wound revisions and evacuation of fluid or blood (62%), followed by CSF diversion-related procedures (28%), were the most common reasons for 30-day reoperation. RF classifiers had the highest predictive accuracy for both 30-day readmissions (area under the curve [AUC] 0.960) and reoperations (AUC 0.990) compared with the other models. On feature importance analysis, sex, developmental delay, ethnicity, respiratory disease, premature birth, hydrocephalus, and congenital/genetic anomaly were some of the variables contributing the most to both RF models. Using a large-scale nationwide dataset, machine learning models for the prediction of both 30-day readmissions and reoperations were developed and achieved high accuracy. This highlights the utility of machine learning in risk stratification and surgical decision-making for pediatric CM-I.

Characterizing antibiotic prophylaxis practices in pediatric deformity spinal surgery and impact on 30-day postoperative infection: an NSQIP pediatric database study.

The aim of this study was to characterize antibiotic prophylaxis practices in pediatric patients who have received posterior arthrodesis for spinal deformity and understand how these practices impact 30-day postoperative infection rates. This was a retrospective cohort study using the National Surgical Quality Improvement Program Pediatric database for year 2021. Patients 18years of age or younger who received posterior arthrodesis for scoliosis or kyphosis correction were included. The outcome of interest was 30-day postoperative infection. Fisher's exact test and multivariable regression analysis were used to analyze the impact of intravenous antibiotic prophylaxis, intraoperative intravenous antibiotic redosing after 4h, postoperative antibiotic prophylaxis, intraoperative topical antibiotics on 30-day postoperative infection, and various antibiotic prophylaxis regimens. A total of 6974 patients were included in this study. The 30-day infection rate was 2.9%. Presurgical intravenous antibiotic (11.5% vs. 2.7%, p = 0.005), postoperative antibiotic (5.7% vs. 2.4%, p < 0.01), and intraoperative topical antibiotic (4.0% vs. 2.7%, p = 0.019) were associated with significantly reduced infection rates. There was no significant difference in infection rates between patients that received cefazolin versus vancomycin versus clindamycin. The addition of Gram-negative coverage did not result in significant differences in infection rates. Multivariable regression analysis found postoperative intravenous antibiotics and intraoperative topical antibiotics to reduce infection rates. We found the use of presurgical intravenous antibiotics, postoperative intravenous antibiotics, and intraoperative topical antibiotics to significantly reduce infection rates. Results from this study can be applied to future research on implementation of standardized infection prevention protocols. Level II.

A 10-Year Nationwide Analysis of Risk Factors of Readmission and the Implications of Same-Day Discharge Following Velopharyngeal Insufficiency Correcting Surgery.

To investigate risk factors for readmission and the implications of same-day discharge for surgical management of velopharyngeal insufficiency (VPI). Retrospective cohort. Multi-institutional/national. Patients who underwent VPI-correcting surgery (n = 4479) were identified in the National Surgical Quality Improvement Program Pediatric database from 2012-2021. 30-day unplanned readmission. A total of 3878 (86.6%) patients were admitted inpatient following surgical intervention, while 601 (13.4%) were discharged on the same day. Thirty-day readmission rate was 1.7% across all patients. Based on multivariate logistic regression, patient factors identified as significant predictors of 30-day readmission included ASA class 4 (OR 11.22 [95% CI 1.01-124.91]; p = 0.049), steroid use (OR 7.30 [95% CI 2.22-23.97]; p = 0.001), and gastrointestinal disease (OR 2.48 [95% CI 1.22-5.00]; p = 0.012). Upon interaction analysis, patients with cardiac or neuromuscular disease who were discharged on the same day of surgery were associated with a higher readmission rate than those admitted to the hospital (cardiac disease RR 6.72 [95% CI 1.41-32.06]; p = 0.017) and (neuromuscular disease RR 12.39 [95% CI 1.64-93.59]; p = 0.015). Approximately 90% of VPI-correcting procedures are completed inpatient nationwide. Cardiac and/or neuromuscular disease significantly increased the patients' readmission risk when discharged on the same day of surgery. The inpatient setting should remain the best practice as adequate resources are available to mitigate life-threatening complications.

Renal function in pediatric urologic surgical patients: Insight from the National Surgical Quality Improvement Program—Pediatric cohort

Abstract Background Renal protection is a frequent indication for urological surgery in pediatric patients; however, preoperative assessment is not routinely performed. We assessed the rates of preoperative renal function testing and stratified outcomes after major pediatric urological surgery. Pediatric urology patients, specifically high-risk patients undergoing genitourinary surgeries, are likely to have an underdiagnosis of renal dysfunction after surgery. Materials and methods Cases were identified from the 2012 to 2019 National Surgical Quality Improvement Program—Pediatric database. Patients who underwent major urological surgery on an inpatient basis were included in this study. Abnormal renal function was defined as a creatinine (Cr) level of ≥0.5 mg/dL (younger than 2 years) and a glomerular filtration rate of &lt;90 mL/min (2 years or older). Glomerular filtration rate was calculated using the bedside Schwartz equation (2 years or older): estimated glomerular filtration rate = 0.413 × (height/Cr). Results A total of 17,315 patients were included, of whom 3792 (21.9%) had documented Cr values. Based on the defined criteria, abnormal renal function was found in 7.3% of infants (younger than 2 years), 33.6% of children (2–9 years), and 52.5% of adolescents (10–18 years). Patients with abnormal preoperative renal function values were significantly (p &lt; 0.001) more likely to experience readmission (10.2% vs. 5.8%), reoperation (3.7% vs. 1.6%), surgical organ/space infection (0.9% vs. 0.4%), transfusion (1.5% vs. 0.6%), renal insufficiency (1.6% vs. 0.4%), or urinary tract infection (5.1% vs. 3.6%). Conclusions In this pediatric population, 21.9% of the patients had documented preoperative Cr values before major urological surgery. Patients with documented abnormal preoperative renal function tests experienced higher complication rates. These patients have higher rates of progressive renal insufficiency and acute renal failure than those with normal renal function. The introduction of a standardized and unbiased risk assessment tool has the potential to offer patients benefits by pinpointing individuals with a heightened risk of complications. Further investigation is necessary to enhance the precise categorization of at-risk patients.

Ethnic disparities in pediatric appendicitis: the impact of hispanic ethnicity on presentation, complications, and postoperative outcomes

PurposeOur study investigates ethnic disparities in pediatric appendicitis, focusing on the impact of Hispanic ethnicity on presentation, complications, and postoperative outcomes.MethodsWe conducted a retrospective analysis of pediatric patients undergoing appendectomy for acute appendicitis from 2015 to 2020 using the National Surgical Quality Improvement Program-Pediatric database. We compared 30-day postoperative complications, postoperative length of stay, and postoperative interventions between Hispanic and non-Hispanic White patients.Results65,976 patients were included, of which 23,462 (35.56%) were Hispanic and 42,514 (64.44%) non-Hispanic White. Hispanic children were more likely to present to the hospital with complicated appendicitis (31.75% vs. 25.15%, P < 0.0001) and sepsis (25.22% vs. 19.02%, P < 0.0001) compared to non-Hispanic White. Hispanics had higher rates of serious complications (4.06% vs. 3.55%, P = 0.001) but not overall complications (5.37% vs. 5.09%, P = 0.12). However, after multivariate analysis, Hispanic ethnicity was not associated with an increased rate of serious postoperative complications (OR 0.93, CI 0.85–1.01, P = 0.088); it was associated with less overall complications (OR 0.88, CI 0.81–0.96, P = 0.003) but a longer postoperative length of stay (OR 1.09, CI 1.04–1.14, P < 0.0001).ConclusionHispanic children are more likely to present with complicated appendicitis, contributing to increased postoperative complications. Notably, upon adjustment for the impact of complicated appendicitis, our findings suggest potentially favorable outcomes for Hispanic ethnicity. This emphasizes the need to understand delays in presentation to improve outcomes in the Hispanic population.

Frequency and predictors of complication clustering within 30days of spinal fusion surgery: a study of children with neuromuscular scoliosis.

There is limited information on the clustering or co-occurrence of complications after spinal fusion surgery for neuromuscular disease in children. We aimed to identify the frequency and predictive factors of co-occurring perioperative complications in these children. In this retrospective database cohort study, we identified children (ages 10-18years) with neuromuscular scoliosis who underwent elective spinal fusion in 2012-2020 from the National Surgical Quality Improvement Program-Pediatric database. The rates of co-occurring complications within 30days were calculated, and associated factors were identified by logistic regression analysis. Correlation between a number of complications and outcomes was assessed. Approximately 11% (709/6677 children with neuromuscular scoliosis undergoing spinal fusion had co-occurring complications: 7% experienced two complications and 4% experienced ≥ 3. The most common complication was bleeding/transfusion (80%), which most frequently co-occurred with pneumonia (24%) and reintubation (18%). Surgical time ≥ 400min (odds ratio (OR) 1.49 [95% confidence interval (CI) 1.25-1.75]), fusion ≥ 13 levels (1.42 [1.13-1.79]), and pelvic fixation (OR 1.21 [1.01, 1.44]) were identified as procedural factors that independently predicted concurrent complications. Clinical risk factors for co-occurring complications included an American Society of Anesthesiologist physical status classification ≥ 3 (1.73 [1.27-2.37]), structural pulmonary/airway abnormalities (1.24 [1.01-1.52]), impaired cognitive status (1.80 [1.41-2.30]), seizure disorder (1.36 [1.12-1.67]), hematologic disorder (1.40 [1.03-1.91], preoperative nutritional support (1.34 [1.08-1.72]), and congenital malformations (1.20 [1.01-1.44]). Preoperative tracheostomy was protective against concurrent complications (0.62 [0.43-0.89]). Significant correlations were found between number of complications and length of stay, non-home discharge, readmissions, and death. Longer surgical time (≥ 400min), fusion ≥ 13 levels and pelvic fixation are surgical risk factors independently associated with co-occurring complications, which were associated with poorer patient outcomes. Recognizing identified nonmodifiable risk factors might also be important for preoperative planning and risk stratification of children with neuromuscular scoliosis requiring spinal fusion. Level IV evidence.

Tracheotomy in children older than two years: Analysis of discharge trends from 2015 to 2020

ObjectiveIn light of increasingly complex patients being discharged with tracheostomies, we aimed to evaluate discharge trends over time in pediatric tracheotomy patients. We hypothesized that there would be delays in discharge from increased focus on preparing families for at-home care of critically ill pediatric patients. Materials and methodsWe conducted a cross-sectional analysis of pediatric patients who underwent tracheotomy (Current Procedural Terminology code 31600) between 2015 and 2020 using the American College of Surgeons National Surgical Quality Improvement Program Pediatric database (ACS NSQIP-P). Univariate and multivariate regression analyses were performed to assess patient demographics, comorbidities, perioperative factors, postoperative complications, and discharge information. Data were analyzed using Stata 15. ResultsA total of 1552 patients were identified. There were 868 (56 %) males and 684 (44 %) females with a mean age of 7.3 ± 5.7 years. At least one comorbidity was seen in 1282 (83 %) patients, with 907 (58 %) having impaired cognitive status or developmental delay. Thirty-six (2.3 %) patients experienced mortality within 30 days, while 710 (46 %) were still in the hospital at 30 days. The odds of remaining in the hospital after 30 days were positively correlated with the year (p=.001). Other factors associated with an increased likelihood of remaining in the hospital after 30 days included younger patient age (p <.001), any complication (p <.001), and a higher American Society of Anesthesiologists classification (p <.001). ConclusionAs years have progressed, fewer children were discharged from the hospital after 30 days following tracheotomy. Further research may identify socioeconomic factors contributing to the increasing length of hospital stays associated with a need for tracheotomy.

Age-related outcomes after pediatric branchial cleft cyst excision via NSQIP-P

ObjectiveBranchial cleft cysts present at varying ages; sometimes excision is delayed because of concern about operating in small children. Our goal was to determine if outcomes and complications differed among pediatric age groups. Study designRetrospective, cross-sectional. SettingAmerican College of Surgeons’ National Surgical Quality Improvement Pediatric database. MethodsPatients who underwent a branchial cleft cyst excision between 2016 and 2020 were identified in the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) Pediatric database. Patients with CPT code 42,815: ‘excision branchial cleft cyst, vestige, or fistula, extending beneath subcutaneous tissues and/or into the pharynx’ as their primary procedure were included. Variables of interest included patient demographics, comorbidities, pre-operative risk factors and complications. Results2267 patients with median age of 3.9 (IQR: 7.4, range: 0.04–17.9) years were included. The most common pre-operative risk factors were 149 (7 %) patients with prematurity, 136 (6 %) with developmental delay, 135 (6 %) with congenital malformation, and 128 (6 %) with open wound or wound infection. 68 (3 %) patients experienced at least one post-operative complication, with 73 post-operative complications documented in total. Surgical site infections were the most common complications with 49 (67.1 %) superficial infections, 11 (15.1 %) deep infections, and 4 (5.5 %) organ/space infections. Surgical site infections were the most common reason for related readmission. Duration of anesthesia and operative time increased significantly as patient age increased (p < .001 for both). There was no significant correlation between age and complication incidence. ConclusionBranchial cleft cyst excision is a relatively safe operation with a low complication rate, even in young pediatric populations.

Predictors and outcomes of perioperative cardiac arrest in children undergoing noncardiac surgery

BackgroundPerioperative cardiac arrest continues to occur. This study aims to identify risk factors for perioperative cardiac arrest in children presenting for noncardiac surgery and characterise its outcomes. MethodsUsing the National Surgical Quality Improvement Program (NSQIP) Pediatric Database 2019 and 2020, 261 276 patients were included. Patients ≥18 yr and cardiac surgical procedures were excluded. Exploratory multivariable analysis was performed to identify independent predictors of perioperative cardiac arrest and associated outcomes. ResultsThe overall rate of cardiac arrest was 0.1%, with an intraoperative rate of 0.05% and 48-h postoperative rate of 0.06%. Significant risk factors for perioperative cardiac arrest included age <12 months (adjusted odds ratios [aOR] 3.07, P<0.001), American Society of Anesthesiology Physical Status classification (ASA-PS 3 aOR=2.57, P<0.001; ASA-PS 4 aOR=5.27, P<0.001; ASA-PS 5 aOR=13.1, P<0.001), admission through the emergency room (aOR 1.7, P=0.003), inpatient (aOR 2.19, P=0.008), major and severe cardiac disease (aOR 1.58, P=0.008), impaired cognitive status (aOR 1.54, P=0.009), and longer anaesthesia duration (aOR 1.1 per 30 min, P<0.001). Perioperative cardiac arrest was significantly associated with longer hospital length of stay, reoperation, differences in discharge destination, and 30-day mortality. In addition, patients experiencing postoperative cardiac arrest had a significantly higher rate of in-hospital and 30-day mortality than those experiencing intraoperative cardiac arrest. ConclusionsThe incidence of cardiac arrest in this study is higher than previously reported. This may be related to selection bias and the rigorous data collection required by NSQIP. Lower 30-day mortality after intraoperative cardiac arrest could be related to prompt recognition and rapid initiation of intraoperative resuscitation. Identification of perioperative risk factors for cardiac arrest is crucial to improve the safety and quality of patient care.

Preoperative Risk Factors and Postoperative Complications of COVID-Positive Children Requiring Urgent or Emergent Surgical Care

BackgroundPreoperative COVID-19 testing protocols were widely implemented for children requiring surgery, leading to increased resource consumption and many delayed or canceled operations or procedures. This study using multi-center data investigated the relationship between preoperative risk factors, COVID-positivity, and postoperative outcomes among children undergoing common urgent and emergent procedures. MethodsChildren (<18 years) who underwent common urgent and emergent procedures were identified in the 2021 National Surgical Quality Improvement Program Pediatric database. The outcomes of COVID-positive and non-COVID-positive (negative or untested) children were compared using simple and multivariable regression models. ResultsAmong 40,628 children undergoing gastrointestinal surgery (appendectomy, cholecystectomy), long bone fracture fixation, cerebrospinal fluid shunt procedures, gonadal procedures (testicular detorsion, ovarian procedures), and pyloromyotomy, 576 (1.4%) were COVID-positive. COVID-positive children had higher American Society of Anesthesiologists scores (p ≤ 0.001) and more frequently had preoperative sepsis (p ≤ 0.016) compared to non-COVID-positive children; however, other preoperative risk factors, including comorbidities, were largely similar. COVID-positive children had a longer length of stay than non-COVID-positive children (median 1.0 [IQR 0.0–2.0] vs. 1.0 [IQR 0.0–1.0], p < 0.001). However, there were no associations between COVID-19 positivity and overall complications, pulmonary complications, infectious complications, or readmissions. ConclusionsDespite increased preoperative risk factors, COVID-positive children did not have an increased risk of postoperative complications after common urgent and emergent procedures. However, length of stay was greater for COVID-positive children, likely due to delays in surgery related to COVID-19 protocols. These findings may be applicable to future preoperative testing and surgical timing guidelines related to respiratory viral illnesses in children. Level of EvidenceIII.

Associated Risk Factors for Extended Length of Stay Following Cranial Vault Remodeling for Craniosynostosis: Analysis of the 2012 to 2021 NSQIP-Pediatric Database.

The aim of this study was to identify the factors associated with extended length of stay (LOS) for pediatric patients with craniosynostosis undergoing cranial vault remodeling (CVR). A retrospective cohort study was performed using the 2012 to 2021 American College of Surgeons National Surgical Quality Improvement Program-Pediatric database. Pediatric patients below 2 years old with craniosynostosis who underwent CVR were identified using Current Procedural Terminology and International Classification of Diseases-9/10 codes. Patients were dichotomized according to whether they encountered an extended postoperative hospital LOS, which was defined as LOS greater than the 75th percentile for the entire cohort (4 days). Patient demographics, comorbidities, intraoperative variables, postoperative adverse events, and health care resource utilization were assessed. Multivariate logistic regression analysis was utilized to identify predictors of prolonged LOS. In our cohort of 9784 patients, 1312 (13.4%) experienced an extended LOS. The extended LOS cohort was significantly older than the normal LOS cohort (normal LOS: 225.1±141.8d vs. extended LOS: 314.4±151.7d, P<0.001) and had a smaller proportion of non-Hispanic white patients (normal LOS: 70.0% vs. extended LOS: 61.2%, P<0.001). Overall, comorbidities and adverse events were significantly higher in the extended LOS cohort than the normal LOS cohort. On multivariate logistic regression, independent associations of extended LOS included age, race and ethnicity, weight, American Society of Anesthesiologists classification, impaired cognitive status, structural pulmonary abnormalities, asthma, and neuromuscular disorders. This study demonstrates that age, race, comorbidities, and perioperative complications contribute to extended LOS after CVR for craniosynostosis. Further investigations to further elucidate the risk factors of extended LOS is warranted to optimize patient outcomes.

Concurrent Cholecystectomy Does Not Increase Splenectomy Morbidity in Patients With Hemolytic Anemia: A Pediatric NSQIP Analysis

PurposeChildren 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. MethodsWe retrospectively evaluated children with hemolytic anemia undergoing non-traumatic laparoscopic splenectomy in the National Surgical Quality Improvement Program-Pediatric database (2012–2020). Outcomes were compared for patients undergoing splenectomy alone (n = 1010) versus splenectomy with cholecystectomy (n = 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. Results1381 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 = 0.33). The splenectomy with cholecystectomy group was less likely to receive preoperative blood transfusions (13.5% vs. 25.4%, p < 0.01). There were 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 = 0.01). Length of stay after surgery (2.5 days vs. 2.3 days, p = 0.13), composite morbidity (3.9% vs. 3.4%, p = 0.69), and 30-day readmission rates (3.3% vs. 7.4%, p = 0.08) were all similar. ConclusionsSplenectomy 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 StudyRetrospective Cohort Study. Level of EvidenceLevel III.

Association of Age at Duodenal Atresia Repair With Outcomes: A Pediatric NSQIP Analysis

PurposeNeonates 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. MethodsWe 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. Results809 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. ConclusionsMorbidity 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 EvidenceLevel III. Type of StudyRetrospective Cohort Study.