Todd Ponsky: What is new in Pediatric Surgery? Teaser
With Dr. Mike Rubin · hosted by Dr. Todd Ponsky & Dr. Alp Numanoglu
Chapter 1 of 12 · Evidence & Research
Pneumothorax protocol
Introduction and Spontaneous Pneumothorax Management
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What the experts said
Putting in a chest tube for spontaneous pneumothorax is probably an unnecessary step that will eventually be eliminated — either send patients home or go to the operating room.
The preponderance of literature in the last 5 years on post-pyloromyotomy feeding is leading towards ad-lib feeding, though some papers show parents get frustrated because babies vomit more.
A 1950s study showed larger umbilical hernias have a lower spontaneous closure rate, which could justify earlier repair, though waiting until after age 4 is still recommended.
Colorectal surgeons have known about appendectomy's role in ulcerative colitis for a long time, but pediatric surgeons were unaware — an example of knowledge silos between specialties.
The recurrence rate for traditional large excision of pilonidal disease published from Kansas City was 30-40%, showing we are 'very bad at it' with big excisions.
Almost everybody in the US switched to the Gips pilonidal technique after it was presented, and no one the presenter knows personally still does the traditional flaps.
The Gips pilonidal procedure takes 3-5 minutes and has the same recurrence rate as traditional flaps but with less pain and fewer sick days away from school.
The worst thing you could do with someone with reactive airway disease is instrument their airway — it's a high-risk case that makes them worse.
In a study of 133 patients using CT for suspected foreign body, when CT showed a foreign body, findings were confirmed on bronchoscopy 94% of the time.
CT scan for airway foreign body had 98% inter-observer reliability between radiologists, and patients with negative CT who were called years later never had any problems.
Bronchoscopy alone for suspected foreign body is negative 40% of the time (61% positive rate).
For intussusception that reaches the cecum but doesn't fully reduce, a second contrast enema attempt should be performed if there was movement all the way to the ileocecal valve.
Traditional ATLS teaching of giving two 20cc/kg saline boluses before blood is outdated; ATOMAC data supports earlier blood transfusion in pediatric trauma.
Neonatologists are nervous about glycopyrrolate because it slows secretions and could theoretically cause mucus plugs in the airway, though this hasn't been observed to happen yet.
The OR headgear study showed an example where a hospital rule (mandating disposable bouffants) came out with no basis, and when you look at the data, it didn't make any sense — people went back to wearing cloth caps.
ATLS has not yet caught up to ATOMAC protocols, but will probably put out a new edition within the year reflecting the ATOMAC data, since no one else has come close to data of that quality.
Publications are growing at an exponential rate, doubling every 73 days due to open access journals, making it impossible to know what to pay attention to.
A machine learning algorithm for predicting important papers has achieved 85% accuracy after one year of training; data scientists predict 95% accuracy after three years of content.
No one has ever seen a patient become critically ill or develop tension pneumothorax from a spontaneous (non-traumatic) pneumothorax, which is why it's probably safe to send them home.
In the Midwest Pediatric Surgery Consortium prospective trial of spontaneous pneumothorax, 83% of patients who failed aspiration and received a chest tube eventually required VATS procedure.
After aspiration protocol for spontaneous pneumothorax with 6-hour observation, the recurrence rate in patients sent home was 44%, with no episodes of tension pneumothorax.
The recommendation from the pneumothorax study is that patients who fail aspiration should go straight to the operating room, since the need for OR is so high (83%) in chest tube patients.
In the Riley Hospital pyloromyotomy feeding trial, a relaxed (ad-lib) feeding strategy decreased time to goal feeds and overall length of stay without significant differences in post-operative vomiting or readmissions compared to incremental feeding protocol.
After pyloromyotomy, patients with serum chloride less than 100 on admission took significantly longer to reach their feeding goal.
In a multi-state retrospective cohort study, umbilical hernia repair before age 4 had double the recurrence rate and double the readmission rate compared to repair at age 4 or later.
In the Journal of Crohn's and Colitis 2019 multi-center study, appendectomy in patients with refractory ulcerative colitis resulted in sustained symptomatic improvement in 30% of patients.
Appendectomy for refractory ulcerative colitis produced pathologic improvement in 50% of patients and complete endoscopic remission in 17%.
The Gips procedure for pilonidal disease involves coring out pits with a trephine, extracting granulation tissue and hair with a mosquito, curettage through the openings, and flushing with saline then peroxide, leaving holes unpacked and unsutured.
Using CT to screen for airway foreign body eliminates unnecessary bronchoscopies in children who probably just have a respiratory virus, avoiding the risk of worsening reactive airway disease by instrumenting the airway.
Chest CT for suspected airway foreign body has an incredibly high, almost 100% sensitivity for detecting foreign bodies whether radiolucent or not.
The ATOMAC prospective trial from 12 institutions changed pediatric trauma resuscitation: after one 20cc/kg saline bolus without response, give 10-20cc/kg blood rather than a second saline bolus.
In pediatric trauma, if a patient is transfused with 40cc/kg of blood or 4 units total, that is an indication of failure and the patient probably needs to go to the operating room.
In a Kansas City study of 622 fluoroscopy-guided central lines, 504 patients had no chest X-ray and no symptoms, with no adverse outcomes.
Of 25 symptomatic patients after central line placement who received chest X-ray, 4 had pneumothorax managed non-operatively and sent home next day; only 1 patient (symptomatic with pleural effusion) required a chest tube.
Out of 622 central line patients, only 1 required a chest tube, and that patient was symptomatic — conclusion is routine chest X-ray after line placement is not needed if patient is asymptomatic.
In a randomized trial of glycopyrrolate for esophageal anastomotic leak after EA repair, chest tube output was 124mL in treatment group vs. 370mL in placebo group.
Glycopyrrolate for EA anastomotic leak achieved leak resolution in 76% of treatment group vs. 29% of placebo group.
Glycopyrrolate for EA anastomotic leak allowed oral feeding in 71% of treatment group vs. only 14% of placebo group.
In the Riley Hospital OR headgear study, disposable bouffant caps had the highest microbial and particle shedding of all three cap types tested.
Cloth skull caps had the lowest permeability, lowest porous material, and very low shedding compared to disposable bouffant caps.