David Notrica | Mayo Clinic (original) (raw)

Papers by David Notrica

Research paper thumbnail of Evaluating the Outcomes of Operative vs Nonoperative Management of Pediatric Blunt Pancreatic Trauma

Journal of the American College of Surgeons, 2016

Research paper thumbnail of Multimodal Anesthesia with the Addition of Methadone is Superior to Epidural Analgesia, A Retrospective Comparison of Intraoperative Anesthetic Techniques and Pain Management for 124 Pediatric Patients Undergoing the Nuss Procedure

Journal of Pediatric Surgery, 2015

The Nuss procedure corrects pectus excavatum by forceful displacement of the sternum with metal b... more The Nuss procedure corrects pectus excavatum by forceful displacement of the sternum with metal bars. Optimal pain management remains a challenge. Mutimodal anesthesia alleviates pain through blockade of multiple nociceptive and inflammatory pain receptors. A retrospective chart review of anesthetic and postoperative mangement of 125 children undergoing the Nuss procedure was conducted. Anesthetic mangement strategies were analyzed in four groups: opioid during general anesthesia (GA), epidural with general anesthesia (Epidural), multimodal anesthesia (MM), and multimodal anesthesia with methadone (MM+M). Data collection included total opioid use (as equivalent milligrams of morphine (Mmg)), pain scores, length of stay (LOS), and adverse effects. Total opioid use varied by group (median, IQR (in Mg)): Epidural 213 [149, 293], GA 179 [134, 298], MM (150 [123, 281]), and MM+M (106 [87, 149]), as did severe pain (in minutes): Epidural (208 [73, 323]), GA (115 [7, 255]), MM (54 [0, 210]), and MM+M (49 [0, 151]). LOS was shortest for the MM+M group (MM+M=3.8+1.0days; MM=4.5+1.3days; GA=4.9+1.4days, Epidural=5.5+2.3days). Multimodal anesthesia is associated with less postoperative pain and shorter LOS compared to epidural or traditional anesthetic techniques for the Nuss procedure. Multimodal anesthesia with a single intraoperative dose of methadone was associated with lowest total opioid use, time with uncontrolled pain, and shortest LOS.

Research paper thumbnail of Pediatric blunt abdominal trauma

Current Opinion in Critical Care, 2015

Nonoperative management of pediatric blunt abdominal injury has changed significantly in the last... more Nonoperative management of pediatric blunt abdominal injury has changed significantly in the last few years. Improved resource utilization in the diagnosis of pediatric abdominal injury has been described. Hemodynamic status, rather than grade of injury, now guides care. Stable patients spend less time in the hospital, return to school upon discharge, and are allowed lower hemoglobin levels prior to transfusion. ICUs are reserved for those with recent or ongoing bleeding, previously unstable patients, or children with concomitant injuries necessitating ICU. Risk factors for failure and evidence for adjuncts to nonoperative management are emerging. Operative management of certain pancreatic injuries may have more favorable outcomes than nonoperative management. Sufficient evidence has become available to radically change the management of pediatric abdominal injury, which is being incorporated into new evidence-based management algorithms.

Research paper thumbnail of Apparatus and Method for Treating Pectus Excavatum

Research paper thumbnail of Outcomes of arterial vascular extremity trauma in pediatric patients

Journal of pediatric surgery, Jan 15, 2016

Vascular trauma in children, although rare, carries significant risk for repair. Here we report o... more Vascular trauma in children, although rare, carries significant risk for repair. Here we report outcomes from a single trauma center for children with extremity vascular trauma, proximal to the digits. Retrospective chart review of patients less than age 18years with an acute, non-iatrogenic traumatic arterial vascular injury of the upper and/or lower extremity between January 2008 and December 2013. Abstracted patient demographics, injury characteristics, surgical management, and disposition were summarized and compared with nonparametric methods. 23 children comprised the study cohort: median age of 8years (IQR: 4.6-12), 61% (n=14) males, 100% survival. Penetrating injuries were the predominate mechanism (n=17, 74%). The median time to presentation was 154min (IQR: 65-330). Acute operations for revascularization included a primary repair (n=15, 65%) or reversed vein graft (n=7, 30%). Fasciotomies were done for 3 (13%) patients. Three amputations were done for failed revascularizat...

Research paper thumbnail of The Impact of Morbid Obesity on Solid Organ Injury in Children Using the ATOMAC Protocol at a Pediatric Level I Trauma Center

Journal of Pediatric Surgery, 2016

Research paper thumbnail of Top to Bottom: A New Method for Assessing Adequacy of Laparoscopic Pyloromyotomy

Journal of laparoendoscopic & advanced surgical techniques. Part A, Jan 17, 2016

Hypertrophic pyloric stenosis is a commonly encountered pediatric surgical issue. Initially treat... more Hypertrophic pyloric stenosis is a commonly encountered pediatric surgical issue. Initially treated with open surgical techniques, many pediatric surgeons have adopted the minimally invasive approach using laparoscopy. However, some concerns exist that the rate of incomplete pyloromyotomy is elevated in laparoscopy. We propose a new technique to assess the adequacy of laparoscopic pyloromyotomy. Adequacy of laparoscopic pyloromyotomy was assessed by confirming that the top of the serosa on one side of the pylorus has adequate freedom to reach the bottom of the muscle on other side. A retrospective review of patients undergoing laparoscopic pyloromyotomy confirmed by this method from March 2012 to January 2016 was conducted. Demographics, laboratory values on admission, and postoperative outcomes were collected. Descriptive statistics was utilized. Thirty-three patients were included. Median age was 30 days (interquartile range [IQR]: 24, 47). Median pylorus length and thickness were...

Research paper thumbnail of Success of Minimally Invasive Pectus Excavatum Procedures (Modified Nuss) in Adult Patients (≥30 Years)

The Annals of thoracic surgery, Jan 7, 2016

Minimally invasive repair of pectus excavatum (MIRPE) has become standard for pediatric and young... more Minimally invasive repair of pectus excavatum (MIRPE) has become standard for pediatric and young adult patients, but its use for older adults is controversial. We retrospectively reviewed electronic medical records of adults (≥18 years of age) who underwent MIRPE from January 1, 2010, through April 30, 2015, and collected demographic data, operative details, and information about outcomes. Cardiac function was measured before and after repair by intraoperative transesophageal echocardiography. We divided patients by age: 18 to 29 years of age and 30 years of age and older. Of 361 patients, 207 were 30 or older (mean, 40 years; range, 30 to 72 years; 71.5% men). Of the older patients, 151 had primary repairs. MIRPE was successfully used in 88.7% of patients older than 30 years of age versus 96.5% of those 18 to 29 years of age. For patients 30 years of age and older, open-cartilage resection, sternal osteotomy, or both was more common with increasing age (mean, 47.8 years versus 39....

Research paper thumbnail of Fate of the Combined Adult and Pediatric Trauma Centers: Impact of Increased Pediatric Trauma Requirements

The American Surgeon, Dec 1, 2014

Research paper thumbnail of Successful Singleton and Twin Pregnancies With the Nuss Bars in Place

The Annals of Thoracic Surgery, 2015

Pectus excavatum (PE) occurs less commonly in women, and the implications on a pregnancy after re... more Pectus excavatum (PE) occurs less commonly in women, and the implications on a pregnancy after repair during the period when support bars are in place are unknown. We present 2 cases: 1 with a successful twin gestation and another with a successful singleton gestation. These women carried the pregnancies to term and delivered their infants with the Nuss bars in place.

Research paper thumbnail of Does restraint status in motor vehicle crash with rollover predict the need for trauma team presence on arrival? An ATOMAC study

Journal of Pediatric Surgery, 2015

Restraint status has not been combined with mechanistic criteria for trauma team activation. This... more Restraint status has not been combined with mechanistic criteria for trauma team activation. This study aims to assess the relationship between motor vehicle crash rollover (MVC-R) mechanism with and without proper restraint and need for trauma team activation. Patients <16years old involved in an MVC-R between November 2007 and November 2012 at 6 Level 1 pediatric trauma centers were included. Restraint status, the need for transfusion or intervention in the emergency department (ED), hospital and intensive care length of stay and mortality were assessed. Of 690 cases reviewed, 48% were improperly restrained. Improperly restrained children were more likely to require intubation (OR 10.24; 95% CI 2.42 to 91.69), receive blood in the ED (OR 4.06; 95% CI 1.43 to 14.17) and require intensive care (ICU) (OR; 3.11; 95% CI 1.96 to 4.93) than the properly restrained group. The improperly restrained group had a longer hospital length of stay (p<0.001), and a higher mortality (3.4% vs. 0.8%; OR 4.09; 95% CI 1.07 to 23.02) than the properly restrained group. Unrestrained children in MVC-R had higher injury severity and were significantly more likely to need urgent interventions compared to properly restrained children. This supports a modification to include restraint status with the rollover criterion for trauma team activation.

Research paper thumbnail of Spontaneous bile duct perforation with cystic fibrosis and meconium ileus

Journal of Pediatric Surgery Case Reports, 2015

Research paper thumbnail of Pediatric Blunt Solid Organ Injury: Beyond the APSA Guidelines

Current Surgery Reports, 2015

ABSTRACT The APSA guidelines were published in 2000 making nonoperative management of pediatric b... more ABSTRACT The APSA guidelines were published in 2000 making nonoperative management of pediatric blunt liver and spleen injury standard for most injured children. A review of recent literature supports significant changes in management of children with liver, spleen, as well as kidney injury. Of the >300 articles on pediatric abdominal injury since the publication of the APSA guidelines, no randomized controlled trials have been conducted. Six prospective studies, however, have been completed, and several large database studies add significant insights into our understanding of pediatric spleen, liver, and kidney injury. Significant decreases in use of resources can be safely applied to children with hemodynamic stability at presentation. Recent studies suggest management based on physiologic criteria rather than injury grade may result in improved resource utilization through shortened hospitalization, abbreviated periods of bedrest, decreased use of intensive care units, earlier return to school, fewer tests, and a lower transfusion threshold. New algorithms are now available to assist in management.

Research paper thumbnail of Primary cutaneous mucormycosis in infants and neonates: Case report and review of the literature

Journal of Pediatric Surgery, 2002

A case of angioinvasive cutaneous mucormycosis in a premature infant, eventually requiring extrac... more A case of angioinvasive cutaneous mucormycosis in a premature infant, eventually requiring extracorporeal membrane oxygenation therapy, is described. The fungal infection began at the site of a brachial artery catheter that had been covered with an adhesive dressing in the left antecubital fossa. The infection progressed rapidly over a 5-day period, and a left arm amputation was required. Fungal hyphae were present at the margins of resection. The patient eventually had disseminated mucormycosis and died. A second case of cutaneous mucormycosis in another premature infant also is presented. This infant had the infection at an intravenous catheter site. Rapid initiation of surgical debridement of the wound and amphotericin B therapy resulted in patient survival. Eighteen reported cases of cutaneous mucormycosis in neonates were found and are reviewed. Prematurity, low birth weight, broad-spectrum antibiotics, corticosteroid therapy, and local trauma to the skin site were common risk factors. Only 7 of the 18 patients survived. Therapy consisted of local debridement and intravenous amphotericin B. High index of suspicion, early diagnosis, and rapid institution of therapy can improve survival rate. The key to prevention appears to be appropriate skin care.

Research paper thumbnail of Nonoperative management of blunt liver and spleen injury in children

Journal of Trauma and Acute Care Surgery, 2015

Nonoperative management of liver and spleen injury should be achievable for more than 95% of chil... more Nonoperative management of liver and spleen injury should be achievable for more than 95% of children. Large national studies continue to show that some regions fail to meet these benchmarks. Simultaneously, current guidelines recommend hospitalization for injury grade + 2 (in days). A new treatment algorithm, the ATOMAC guideline, is in clinical use at many centers but has not been prospectively validated. A literature review conducted through MEDLINE identified publications after the American Pediatric Surgery Association guidelines using the search terms blunt liver trauma pediatric, blunt spleen trauma pediatric, and blunt abdominal trauma pediatric. Decision points in the new algorithm generated clinical questions, and GRADE [Grading of Recommendations, Assessment, Development, and Evaluations] methodology was used to assess the evidence supporting the guideline. The algorithm generated 27 clinical questions. The algorithm was supported by six 1A recommendations, two 1B recommendations, one 2B recommendation, eight 2C recommendations, and ten 2D recommendations. The 1A recommendations included management based on hemodynamic status rather than grade of injury, support for an abbreviated period of bed rest, transfusion thresholds of 7.0 g/dL, exclusion of peritonitis from a guideline, accounting for local resources and concurrent injuries in the management of children failing to stabilize, as well as the use of a guideline in patients with multiple injuries. The use of more than 40 mL/kg or 4 U of blood to define end points for the guideline, and discharging stable patients before 24 hours received 1B recommendations. The original American Pediatric Surgery Association guideline for pediatric blunt solid organ injury was instrumental in improving care, but sufficient evidence now exists for an updated management guideline. Expert opinion, guideline, grades I to IV.

Research paper thumbnail of Management of Occult Traumatic Pneumothorax in the Pediatric Patient: a Multicenter Study

Purpose: An occult pneumothorax (OPTX) represents air within the pleural space not visible on con... more Purpose: An occult pneumothorax (OPTX) represents air within the pleural space not visible on conventional chest radiographs. Many of these OPTX are now identified on computed tomography (CT) and present a management challenge in the pediatric patient. The increased use of CT in children has lead to a rapid increase in the detection of these OPTX and optimal management has not yet been defined. Methods: As part of a prospective, multicenter study evaluating management of OPTX at major trauma centers, we performed a subgroup analysis of pediatric patients (age less than 18 years). OPTX size was measured as the length perpendicular to the chest wall at the largest size seen on a single CT axial image. A descriptive analysis of patients, pneumothorax size, management outcome, and associated risk factors were used to identify the pediatric patients with OPTX who can be safely managed without tube thoracostomy. Results: A total of 52 OPTX (mean ± SD: 7.3 ± 6.2 mm) in 51 patients under 18...

Research paper thumbnail of Duodenal injuries in the very young

Journal of Trauma and Acute Care Surgery, 2013

Duodenal injuries in children are uncommon but have been specifically linked with child abuse in ... more Duodenal injuries in children are uncommon but have been specifically linked with child abuse in case reports. Owing to the rarity of the diagnosis, few studies to date have looked at the association between duodenal injuries and mechanism in younger child. We hypothesize that duodenal injuries in the very young are significantly associated with child abuse. This investigation is a retrospective cohort study of patients admitted with duodenal injuries at one of six Level I pediatric trauma centers. All institutions had institutional review board approval. The trauma registries were used to identify children aged 0 year to 5 years from 1991 to 2011. Multiple variables were collected and included age, mechanism of injury, type of duodenal injury, additional injuries, mortality, and results of abuse investigation if available. Relationships were analyzed using Fischer's exact test. We identified 32 patients with duodenal injuries with a mean age of 3 years. Duodenal injuries included duodenal hematomas (44%) and perforations/transections (56%). Of all duodenal injuries, 53% resulted in operation, 53% had additional injuries, and 12.5% resulted in death. Of the 32 children presenting with duodenal injuries, 20 were child abuse patients (62.5%). All duodenal injuries in children younger than 2 years were caused by child abuse (6 of 6, p = 0.06) and more than half of the duodenal injuries in children older than 2 years were caused by child abuse (14 of 26). Child abuse-related duodenal injuries were associated with delayed presentation (p = 0.004). There was a significant increase in child abuse-related duodenal injuries during the time frame of the study (p = 0.002). Duodenal injuries are extremely rare in the pediatric population. This multi-institutional investigation found that child abuse consistently associated with duodenal injuries in children younger than 2 years. The evidence supports a child abuse investigation on children younger than 2 years with duodenal injury. Epidemiological study, level III.

Research paper thumbnail of Blunt Traumatic Occult Pneumothorax: Is Observation Safe?—Results of a Prospective, AAST Multicenter Study

The Journal of Trauma: Injury, Infection, and Critical Care, 2011

Background: An occult pneumothorax (OPTX) is found incidentally in 2% to 10% of all blunt trauma ... more Background: An occult pneumothorax (OPTX) is found incidentally in 2% to 10% of all blunt trauma patients. Indications for intervention remain controversial. We sought to determine which factors predicted failed observation in blunt trauma patients. Methods: A prospective, observational, multicenter study was undertaken to identify patients with OPTX. Successfully observed patients and patients who failed observation were compared. Multivariate logistic regression was used to identify predictors of failure of observation. OPTX size was calculated by measuring the largest air collection along a line perpendicular from the chest wall to the lung or mediastinum. Results: Sixteen trauma centers identified 588 OPTXs in 569 blunt trauma patients. One hundred twenty-one patients (21%) underwent immediate tube thoracostomy and 448 (79%) were observed. Twenty-seven patients (6%) failed observation and required tube thoracostomy for OPTX progression, respiratory distress, or subsequent hemothorax. Fourteen percent (10 of 73) failed observation during positive pressure ventilation. Hospital and intensive care unit lengths of stay, and ventilator days were longer in the failed observation group. OPTX progression and respiratory distress were significant predictors of failed observation. Most patient deaths were from trau-matic brain injury. Fifteen percentage of patients in the failed observation group developed complications. No patient who failed observation developed a tension PTX, or experienced adverse events by delaying tube thoracostomy. Conclusion: Most blunt trauma patients with OPTX can be carefully monitored without tube thoracostomy; however, OPTX progression and respiratory distress are independently associated with observation failure.

Research paper thumbnail of Sternal elevation before passing bars: A technique for improving visualization and facilitating minimally invasive pectus excavatum repair in adult patients

The Journal of Thoracic and Cardiovascular Surgery, 2014

FIGURE 2. A, Stab incisions are placed on either side of the sternal defect, and the perforating ... more FIGURE 2. A, Stab incisions are placed on either side of the sternal defect, and the perforating tips of a bone clamp (Lewin Spinal Perforating Forceps, V. Mueller NL6960; CareFusion, Inc, San Diego, Calif) are inserted through the incision into the sternum. B, The Rultract Retractor (Rultract Inc, Cleveland, Ohio) with extension arm is attached to the bed at the level of the axilla on the left side. The cable is then attached to the clamp, and the sternum is elevated anteriorly. Surgical Technique 2

Research paper thumbnail of Current Management of Pectus Excavatum: A Review and Update of Therapy and Treatment Recommendations

The Journal of the American Board of Family Medicine, 2010

Pectus excavatum (PE) is a posterior depression of the sternum and adjacent costal cartilages and... more Pectus excavatum (PE) is a posterior depression of the sternum and adjacent costal cartilages and is frequently seen by primary care providers. PE accounts for >90% of congenital chest wall deformities. Patients with PE are often dismissed by physicians as having an inconsequential problem; however, it can be more than a cosmetic deformity. Severe cases can cause cardiopulmonary impairment and physiologic limitations. Evidence continues to present that these physiologic impairments may worsen as the patient ages. Data reports improved cardiopulmonary function after repair and marked improvement in psychosocial function. More recent consensus by both the pediatric and thoracic surgical communities validates surgical repair of the significant PE and contradicts arguments that repair is primarily cosmetic. We performed a review of the current literature and treatment recommendations for patients with PE deformities. (J Am Board Fam Med 2010;23:230 -239.)

Research paper thumbnail of Evaluating the Outcomes of Operative vs Nonoperative Management of Pediatric Blunt Pancreatic Trauma

Journal of the American College of Surgeons, 2016

Research paper thumbnail of Multimodal Anesthesia with the Addition of Methadone is Superior to Epidural Analgesia, A Retrospective Comparison of Intraoperative Anesthetic Techniques and Pain Management for 124 Pediatric Patients Undergoing the Nuss Procedure

Journal of Pediatric Surgery, 2015

The Nuss procedure corrects pectus excavatum by forceful displacement of the sternum with metal b... more The Nuss procedure corrects pectus excavatum by forceful displacement of the sternum with metal bars. Optimal pain management remains a challenge. Mutimodal anesthesia alleviates pain through blockade of multiple nociceptive and inflammatory pain receptors. A retrospective chart review of anesthetic and postoperative mangement of 125 children undergoing the Nuss procedure was conducted. Anesthetic mangement strategies were analyzed in four groups: opioid during general anesthesia (GA), epidural with general anesthesia (Epidural), multimodal anesthesia (MM), and multimodal anesthesia with methadone (MM+M). Data collection included total opioid use (as equivalent milligrams of morphine (Mmg)), pain scores, length of stay (LOS), and adverse effects. Total opioid use varied by group (median, IQR (in Mg)): Epidural 213 [149, 293], GA 179 [134, 298], MM (150 [123, 281]), and MM+M (106 [87, 149]), as did severe pain (in minutes): Epidural (208 [73, 323]), GA (115 [7, 255]), MM (54 [0, 210]), and MM+M (49 [0, 151]). LOS was shortest for the MM+M group (MM+M=3.8+1.0days; MM=4.5+1.3days; GA=4.9+1.4days, Epidural=5.5+2.3days). Multimodal anesthesia is associated with less postoperative pain and shorter LOS compared to epidural or traditional anesthetic techniques for the Nuss procedure. Multimodal anesthesia with a single intraoperative dose of methadone was associated with lowest total opioid use, time with uncontrolled pain, and shortest LOS.

Research paper thumbnail of Pediatric blunt abdominal trauma

Current Opinion in Critical Care, 2015

Nonoperative management of pediatric blunt abdominal injury has changed significantly in the last... more Nonoperative management of pediatric blunt abdominal injury has changed significantly in the last few years. Improved resource utilization in the diagnosis of pediatric abdominal injury has been described. Hemodynamic status, rather than grade of injury, now guides care. Stable patients spend less time in the hospital, return to school upon discharge, and are allowed lower hemoglobin levels prior to transfusion. ICUs are reserved for those with recent or ongoing bleeding, previously unstable patients, or children with concomitant injuries necessitating ICU. Risk factors for failure and evidence for adjuncts to nonoperative management are emerging. Operative management of certain pancreatic injuries may have more favorable outcomes than nonoperative management. Sufficient evidence has become available to radically change the management of pediatric abdominal injury, which is being incorporated into new evidence-based management algorithms.

Research paper thumbnail of Apparatus and Method for Treating Pectus Excavatum

Research paper thumbnail of Outcomes of arterial vascular extremity trauma in pediatric patients

Journal of pediatric surgery, Jan 15, 2016

Vascular trauma in children, although rare, carries significant risk for repair. Here we report o... more Vascular trauma in children, although rare, carries significant risk for repair. Here we report outcomes from a single trauma center for children with extremity vascular trauma, proximal to the digits. Retrospective chart review of patients less than age 18years with an acute, non-iatrogenic traumatic arterial vascular injury of the upper and/or lower extremity between January 2008 and December 2013. Abstracted patient demographics, injury characteristics, surgical management, and disposition were summarized and compared with nonparametric methods. 23 children comprised the study cohort: median age of 8years (IQR: 4.6-12), 61% (n=14) males, 100% survival. Penetrating injuries were the predominate mechanism (n=17, 74%). The median time to presentation was 154min (IQR: 65-330). Acute operations for revascularization included a primary repair (n=15, 65%) or reversed vein graft (n=7, 30%). Fasciotomies were done for 3 (13%) patients. Three amputations were done for failed revascularizat...

Research paper thumbnail of The Impact of Morbid Obesity on Solid Organ Injury in Children Using the ATOMAC Protocol at a Pediatric Level I Trauma Center

Journal of Pediatric Surgery, 2016

Research paper thumbnail of Top to Bottom: A New Method for Assessing Adequacy of Laparoscopic Pyloromyotomy

Journal of laparoendoscopic & advanced surgical techniques. Part A, Jan 17, 2016

Hypertrophic pyloric stenosis is a commonly encountered pediatric surgical issue. Initially treat... more Hypertrophic pyloric stenosis is a commonly encountered pediatric surgical issue. Initially treated with open surgical techniques, many pediatric surgeons have adopted the minimally invasive approach using laparoscopy. However, some concerns exist that the rate of incomplete pyloromyotomy is elevated in laparoscopy. We propose a new technique to assess the adequacy of laparoscopic pyloromyotomy. Adequacy of laparoscopic pyloromyotomy was assessed by confirming that the top of the serosa on one side of the pylorus has adequate freedom to reach the bottom of the muscle on other side. A retrospective review of patients undergoing laparoscopic pyloromyotomy confirmed by this method from March 2012 to January 2016 was conducted. Demographics, laboratory values on admission, and postoperative outcomes were collected. Descriptive statistics was utilized. Thirty-three patients were included. Median age was 30 days (interquartile range [IQR]: 24, 47). Median pylorus length and thickness were...

Research paper thumbnail of Success of Minimally Invasive Pectus Excavatum Procedures (Modified Nuss) in Adult Patients (≥30 Years)

The Annals of thoracic surgery, Jan 7, 2016

Minimally invasive repair of pectus excavatum (MIRPE) has become standard for pediatric and young... more Minimally invasive repair of pectus excavatum (MIRPE) has become standard for pediatric and young adult patients, but its use for older adults is controversial. We retrospectively reviewed electronic medical records of adults (≥18 years of age) who underwent MIRPE from January 1, 2010, through April 30, 2015, and collected demographic data, operative details, and information about outcomes. Cardiac function was measured before and after repair by intraoperative transesophageal echocardiography. We divided patients by age: 18 to 29 years of age and 30 years of age and older. Of 361 patients, 207 were 30 or older (mean, 40 years; range, 30 to 72 years; 71.5% men). Of the older patients, 151 had primary repairs. MIRPE was successfully used in 88.7% of patients older than 30 years of age versus 96.5% of those 18 to 29 years of age. For patients 30 years of age and older, open-cartilage resection, sternal osteotomy, or both was more common with increasing age (mean, 47.8 years versus 39....

Research paper thumbnail of Fate of the Combined Adult and Pediatric Trauma Centers: Impact of Increased Pediatric Trauma Requirements

The American Surgeon, Dec 1, 2014

Research paper thumbnail of Successful Singleton and Twin Pregnancies With the Nuss Bars in Place

The Annals of Thoracic Surgery, 2015

Pectus excavatum (PE) occurs less commonly in women, and the implications on a pregnancy after re... more Pectus excavatum (PE) occurs less commonly in women, and the implications on a pregnancy after repair during the period when support bars are in place are unknown. We present 2 cases: 1 with a successful twin gestation and another with a successful singleton gestation. These women carried the pregnancies to term and delivered their infants with the Nuss bars in place.

Research paper thumbnail of Does restraint status in motor vehicle crash with rollover predict the need for trauma team presence on arrival? An ATOMAC study

Journal of Pediatric Surgery, 2015

Restraint status has not been combined with mechanistic criteria for trauma team activation. This... more Restraint status has not been combined with mechanistic criteria for trauma team activation. This study aims to assess the relationship between motor vehicle crash rollover (MVC-R) mechanism with and without proper restraint and need for trauma team activation. Patients <16years old involved in an MVC-R between November 2007 and November 2012 at 6 Level 1 pediatric trauma centers were included. Restraint status, the need for transfusion or intervention in the emergency department (ED), hospital and intensive care length of stay and mortality were assessed. Of 690 cases reviewed, 48% were improperly restrained. Improperly restrained children were more likely to require intubation (OR 10.24; 95% CI 2.42 to 91.69), receive blood in the ED (OR 4.06; 95% CI 1.43 to 14.17) and require intensive care (ICU) (OR; 3.11; 95% CI 1.96 to 4.93) than the properly restrained group. The improperly restrained group had a longer hospital length of stay (p<0.001), and a higher mortality (3.4% vs. 0.8%; OR 4.09; 95% CI 1.07 to 23.02) than the properly restrained group. Unrestrained children in MVC-R had higher injury severity and were significantly more likely to need urgent interventions compared to properly restrained children. This supports a modification to include restraint status with the rollover criterion for trauma team activation.

Research paper thumbnail of Spontaneous bile duct perforation with cystic fibrosis and meconium ileus

Journal of Pediatric Surgery Case Reports, 2015

Research paper thumbnail of Pediatric Blunt Solid Organ Injury: Beyond the APSA Guidelines

Current Surgery Reports, 2015

ABSTRACT The APSA guidelines were published in 2000 making nonoperative management of pediatric b... more ABSTRACT The APSA guidelines were published in 2000 making nonoperative management of pediatric blunt liver and spleen injury standard for most injured children. A review of recent literature supports significant changes in management of children with liver, spleen, as well as kidney injury. Of the >300 articles on pediatric abdominal injury since the publication of the APSA guidelines, no randomized controlled trials have been conducted. Six prospective studies, however, have been completed, and several large database studies add significant insights into our understanding of pediatric spleen, liver, and kidney injury. Significant decreases in use of resources can be safely applied to children with hemodynamic stability at presentation. Recent studies suggest management based on physiologic criteria rather than injury grade may result in improved resource utilization through shortened hospitalization, abbreviated periods of bedrest, decreased use of intensive care units, earlier return to school, fewer tests, and a lower transfusion threshold. New algorithms are now available to assist in management.

Research paper thumbnail of Primary cutaneous mucormycosis in infants and neonates: Case report and review of the literature

Journal of Pediatric Surgery, 2002

A case of angioinvasive cutaneous mucormycosis in a premature infant, eventually requiring extrac... more A case of angioinvasive cutaneous mucormycosis in a premature infant, eventually requiring extracorporeal membrane oxygenation therapy, is described. The fungal infection began at the site of a brachial artery catheter that had been covered with an adhesive dressing in the left antecubital fossa. The infection progressed rapidly over a 5-day period, and a left arm amputation was required. Fungal hyphae were present at the margins of resection. The patient eventually had disseminated mucormycosis and died. A second case of cutaneous mucormycosis in another premature infant also is presented. This infant had the infection at an intravenous catheter site. Rapid initiation of surgical debridement of the wound and amphotericin B therapy resulted in patient survival. Eighteen reported cases of cutaneous mucormycosis in neonates were found and are reviewed. Prematurity, low birth weight, broad-spectrum antibiotics, corticosteroid therapy, and local trauma to the skin site were common risk factors. Only 7 of the 18 patients survived. Therapy consisted of local debridement and intravenous amphotericin B. High index of suspicion, early diagnosis, and rapid institution of therapy can improve survival rate. The key to prevention appears to be appropriate skin care.

Research paper thumbnail of Nonoperative management of blunt liver and spleen injury in children

Journal of Trauma and Acute Care Surgery, 2015

Nonoperative management of liver and spleen injury should be achievable for more than 95% of chil... more Nonoperative management of liver and spleen injury should be achievable for more than 95% of children. Large national studies continue to show that some regions fail to meet these benchmarks. Simultaneously, current guidelines recommend hospitalization for injury grade + 2 (in days). A new treatment algorithm, the ATOMAC guideline, is in clinical use at many centers but has not been prospectively validated. A literature review conducted through MEDLINE identified publications after the American Pediatric Surgery Association guidelines using the search terms blunt liver trauma pediatric, blunt spleen trauma pediatric, and blunt abdominal trauma pediatric. Decision points in the new algorithm generated clinical questions, and GRADE [Grading of Recommendations, Assessment, Development, and Evaluations] methodology was used to assess the evidence supporting the guideline. The algorithm generated 27 clinical questions. The algorithm was supported by six 1A recommendations, two 1B recommendations, one 2B recommendation, eight 2C recommendations, and ten 2D recommendations. The 1A recommendations included management based on hemodynamic status rather than grade of injury, support for an abbreviated period of bed rest, transfusion thresholds of 7.0 g/dL, exclusion of peritonitis from a guideline, accounting for local resources and concurrent injuries in the management of children failing to stabilize, as well as the use of a guideline in patients with multiple injuries. The use of more than 40 mL/kg or 4 U of blood to define end points for the guideline, and discharging stable patients before 24 hours received 1B recommendations. The original American Pediatric Surgery Association guideline for pediatric blunt solid organ injury was instrumental in improving care, but sufficient evidence now exists for an updated management guideline. Expert opinion, guideline, grades I to IV.

Research paper thumbnail of Management of Occult Traumatic Pneumothorax in the Pediatric Patient: a Multicenter Study

Purpose: An occult pneumothorax (OPTX) represents air within the pleural space not visible on con... more Purpose: An occult pneumothorax (OPTX) represents air within the pleural space not visible on conventional chest radiographs. Many of these OPTX are now identified on computed tomography (CT) and present a management challenge in the pediatric patient. The increased use of CT in children has lead to a rapid increase in the detection of these OPTX and optimal management has not yet been defined. Methods: As part of a prospective, multicenter study evaluating management of OPTX at major trauma centers, we performed a subgroup analysis of pediatric patients (age less than 18 years). OPTX size was measured as the length perpendicular to the chest wall at the largest size seen on a single CT axial image. A descriptive analysis of patients, pneumothorax size, management outcome, and associated risk factors were used to identify the pediatric patients with OPTX who can be safely managed without tube thoracostomy. Results: A total of 52 OPTX (mean ± SD: 7.3 ± 6.2 mm) in 51 patients under 18...

Research paper thumbnail of Duodenal injuries in the very young

Journal of Trauma and Acute Care Surgery, 2013

Duodenal injuries in children are uncommon but have been specifically linked with child abuse in ... more Duodenal injuries in children are uncommon but have been specifically linked with child abuse in case reports. Owing to the rarity of the diagnosis, few studies to date have looked at the association between duodenal injuries and mechanism in younger child. We hypothesize that duodenal injuries in the very young are significantly associated with child abuse. This investigation is a retrospective cohort study of patients admitted with duodenal injuries at one of six Level I pediatric trauma centers. All institutions had institutional review board approval. The trauma registries were used to identify children aged 0 year to 5 years from 1991 to 2011. Multiple variables were collected and included age, mechanism of injury, type of duodenal injury, additional injuries, mortality, and results of abuse investigation if available. Relationships were analyzed using Fischer's exact test. We identified 32 patients with duodenal injuries with a mean age of 3 years. Duodenal injuries included duodenal hematomas (44%) and perforations/transections (56%). Of all duodenal injuries, 53% resulted in operation, 53% had additional injuries, and 12.5% resulted in death. Of the 32 children presenting with duodenal injuries, 20 were child abuse patients (62.5%). All duodenal injuries in children younger than 2 years were caused by child abuse (6 of 6, p = 0.06) and more than half of the duodenal injuries in children older than 2 years were caused by child abuse (14 of 26). Child abuse-related duodenal injuries were associated with delayed presentation (p = 0.004). There was a significant increase in child abuse-related duodenal injuries during the time frame of the study (p = 0.002). Duodenal injuries are extremely rare in the pediatric population. This multi-institutional investigation found that child abuse consistently associated with duodenal injuries in children younger than 2 years. The evidence supports a child abuse investigation on children younger than 2 years with duodenal injury. Epidemiological study, level III.

Research paper thumbnail of Blunt Traumatic Occult Pneumothorax: Is Observation Safe?—Results of a Prospective, AAST Multicenter Study

The Journal of Trauma: Injury, Infection, and Critical Care, 2011

Background: An occult pneumothorax (OPTX) is found incidentally in 2% to 10% of all blunt trauma ... more Background: An occult pneumothorax (OPTX) is found incidentally in 2% to 10% of all blunt trauma patients. Indications for intervention remain controversial. We sought to determine which factors predicted failed observation in blunt trauma patients. Methods: A prospective, observational, multicenter study was undertaken to identify patients with OPTX. Successfully observed patients and patients who failed observation were compared. Multivariate logistic regression was used to identify predictors of failure of observation. OPTX size was calculated by measuring the largest air collection along a line perpendicular from the chest wall to the lung or mediastinum. Results: Sixteen trauma centers identified 588 OPTXs in 569 blunt trauma patients. One hundred twenty-one patients (21%) underwent immediate tube thoracostomy and 448 (79%) were observed. Twenty-seven patients (6%) failed observation and required tube thoracostomy for OPTX progression, respiratory distress, or subsequent hemothorax. Fourteen percent (10 of 73) failed observation during positive pressure ventilation. Hospital and intensive care unit lengths of stay, and ventilator days were longer in the failed observation group. OPTX progression and respiratory distress were significant predictors of failed observation. Most patient deaths were from trau-matic brain injury. Fifteen percentage of patients in the failed observation group developed complications. No patient who failed observation developed a tension PTX, or experienced adverse events by delaying tube thoracostomy. Conclusion: Most blunt trauma patients with OPTX can be carefully monitored without tube thoracostomy; however, OPTX progression and respiratory distress are independently associated with observation failure.

Research paper thumbnail of Sternal elevation before passing bars: A technique for improving visualization and facilitating minimally invasive pectus excavatum repair in adult patients

The Journal of Thoracic and Cardiovascular Surgery, 2014

FIGURE 2. A, Stab incisions are placed on either side of the sternal defect, and the perforating ... more FIGURE 2. A, Stab incisions are placed on either side of the sternal defect, and the perforating tips of a bone clamp (Lewin Spinal Perforating Forceps, V. Mueller NL6960; CareFusion, Inc, San Diego, Calif) are inserted through the incision into the sternum. B, The Rultract Retractor (Rultract Inc, Cleveland, Ohio) with extension arm is attached to the bed at the level of the axilla on the left side. The cable is then attached to the clamp, and the sternum is elevated anteriorly. Surgical Technique 2

Research paper thumbnail of Current Management of Pectus Excavatum: A Review and Update of Therapy and Treatment Recommendations

The Journal of the American Board of Family Medicine, 2010

Pectus excavatum (PE) is a posterior depression of the sternum and adjacent costal cartilages and... more Pectus excavatum (PE) is a posterior depression of the sternum and adjacent costal cartilages and is frequently seen by primary care providers. PE accounts for >90% of congenital chest wall deformities. Patients with PE are often dismissed by physicians as having an inconsequential problem; however, it can be more than a cosmetic deformity. Severe cases can cause cardiopulmonary impairment and physiologic limitations. Evidence continues to present that these physiologic impairments may worsen as the patient ages. Data reports improved cardiopulmonary function after repair and marked improvement in psychosocial function. More recent consensus by both the pediatric and thoracic surgical communities validates surgical repair of the significant PE and contradicts arguments that repair is primarily cosmetic. We performed a review of the current literature and treatment recommendations for patients with PE deformities. (J Am Board Fam Med 2010;23:230 -239.)