Journal Club: Review of 2018 Pediatric Surgery Practice Gaps

Hey guys, so in about 2 months, the 2019 annual update course is coming again. This will be the 7th one. And I know that last year we had APSA come and APSA's PDC, uh, the Practice Development Committee, who helped identify practice gaps for us. Alex, what were these practice gaps? Yeah, so essentially the PDC, uh, they identified, uh, areas that pediatric surgeons don't know about. And the thing is that not only do we not know about them, we don't know that we don't know about them. Gap, and a practice gap is the distance between what is best practices or evidence-based and what you should be doing and what actually happens. So not only do I not know what I don't know, I don't know when I don't know it. This is just kind of their effort to help identify areas that we could improve on and help spread the message that kind of take away key points for those gaps. So I think it was last year it was David Powell, Craig Lillehei, and Chuck Snyder. And they presented some major practice gaps. Number 10 was restrictive transfusion policies and they shared that transfusing to a target hemoglobin of seven instead of nine or ten like some institutions do, actually has no difference in mortality. And in addition to this, they wanted us to remember that blood transfusions increase the risk risk of DVT in patients, so we should be careful with them. That according to the PDC and uh that the restrictive transfusion policy of 7 not 9 or 10, uh, is probably going to have no, it will have no difference in mortality. So Alex, just to clarify, this is not just trauma, this is across the board pediatric patients. Correct. Uh, they made some examples with NICU patients and other general surgery patients as well. Right, because a lot of hospitals when you want to take a NICU baby to the operating room, they mandate that the patient has a hemoglobin of 10. And now we're saying you don't need 10. Yeah, transfuse clinically. If patient's doing well, they can sit there with lower hemoglobin levels. Ray, what's number nine? So, number nine is enteral nutrition and pancreatitis. So, they found early enteral feedings when it's not associated with vomiting, decreases morbidity, infectious risk and mortality. And they also found NG feeds are equally as tolerated as NJ feeds. And we should be operating earlier for gallstone pancreatitis. This is a big change, Ray, because I was always taught, you know, you wait for many, many days, you wait for the amylase and lipase to to get normal, you wait for all their belly pain to go away. And now we're saying you don't need to, you can start feeds early. Yep. Infected pancreatic phlegmon? Sure. Still feed them. Why not? Wow. I got to go back to surgery school. Well this single conversation is totally worth coming to this meeting. Wow, that's a big change. Alex, what was number eight? So uh number eight was a topic near and dear to my heart. It was ovarian torsion and just emphasizing that ultrasounds right now are not very good in terms of ruling out torsion. Is that an ultrasound is a horrible test for torsion. So in a patient with a suspected torsion, you got to go to the operating room. And when you're there, you don't take the ovary out even if it's black. You leave it there, you uh in order to preserve fertility and then you follow serially with ultrasounds in order to, you know, make sure that the ovary is staying healthy. When you reduce that torsion, then what do you do with that ovary? Leave it in. If it's black? It's dead. We we've been trained up. We've been hit by the rolled up newspaper enough that we know what to say now. All right, two questions. Why are ovaries near and dear to your heart? It's it's a research topic of interest to me. So specifically the the ultrasound and lack of sensitivity there and how we can try to improve that. That's great. And so, what about Doppler flow? It shows that it's got, uh, Doppler flow, do you do you still need to go to the operating room? Right now, yeah. Even if there's flow there doesn't mean that there's no torsion, it could be intermittently torsing, there may be a part that has blood flow, some that doesn't. So you still got to go. Okay. Number seven, Alex. So, number seven is Venus thromboembolism prophylaxis in high-risk trauma patients. So they found that for low bleeding risk patients, it's okay to just do, uh, SCDs and low molecular weight heparin. And for high bleeding risk patients, uh, they recommend SCDs on their until they're ambulatory, and then a screening ultrasound on ICU day seven. So basically, if they're high risk for bleeding, you're leaving out the the low molecular weight heparin. Correct. Okay. Great. Number six, Ray. So number six has been a hot topic. It's uh in surgery as a whole, physician wellness. So reviewing, they found burnout directly impacts patient care and establishing support systems should be a focus throughout education and practice. there is somebody that had a bad complication, uh resources get mobilized so that one a one of the leaders goes to that person, not to say, you know, hey, what the heck did you do here, but to say how are you? And we proactively go to them and it needs to be a proactive system because people, there's a lot of stigma around this. So, I actually have to say I loved that they Powell presented this. Um, this is a topic we don't address enough. Burnout's a definite real issue. I love that they talked about it. And I love some of the comments that were made that we have that police officers have training for traumatic experiences, but pediatric surgeons don't. I thought that was a great topic. I completely agree. Number five, Alex. So number five is another passionate area of mine, it was uh firearm injury prevention. Um, and just kind of emphasizing that pediatric surgeons need to kind of take an active role in identifying risk factors for this, ask your patients if they have a firearm at home, if they keep it stored safely, and then also for areas of patient advocacy. So states that don't have child access prevention laws like Ohio, maybe pediatric surgeons should be advocating and trying to push for something like that. That the most effective state laws in reducing pediatric firearm injuries are those that hold adult adults criminally liable for negligently storing firearms. Yeah, that was a great um topic because we don't usually talk about advocacy and now this is definitely making its way. And it's and the approach is not one around Second Amendment or politics or anything else. It's about children being shot and children being safe. And and even at Apso, this is becoming a real big presence of Apso's advocacy. Number four, Alex. So number four addresses maintenance fluids and resuscitation. Before the dogma was you switch from isotonic to hypotonic once you reach maintenance space. The new information is that you should continue with isotonic fluids because this uh decreases the risk of hyponatremia without any adverse consequences. So I thought this was huge. I don't know what you guys thought. I have always been trained, start with normal saline or LR and then switch to half normal saline or quarter normal saline. That's the way I've been taught. This whole idea of keeping them on isotonic fluid was a complete new thing to me. What about you guys? It is. It is very practice changing and at the same time, we have the data, there evidence is there, and most people are still reluctant to do this. I still see a lot of people ordering hypotonic fluids on the floor. Okay. Number three was Wilms tumor protocol violations. So one, we need to be sure that we're taking out lymph nodes when we're take doing the nephrectomy because that automatically upstages our patients if we're not taking out the notes. Um, there is a local and systemic staging system that we need to remember. And pulmonary mets do not preclude a primary nephrectomy. Just because you have metastatic disease in the lung, doesn't mean you shouldn't treat the primary with a nephrectomy. Because that changes the whether or not you're going to get radiation therapy as well. So as as Dr. Erlik would point out, there's kind of a local stage for Wilms's tumor and then there's a patient staging for Wilms tumor. All right, Ray, that's huge because I know that that's a major violation that is something that hopefully through education we can start increasing the numbers of people that are doing those node biopsies. Number two, Givens. So number two was talking about non-operative management of appendicitis. Um, so we've known about non-operative management of perforated appendicitis for a long time. Um, but this was just kind of appendicitis in general. And it emphasized that uh treating with antibiotics, uh had kind of equal outcome measures in terms of initial operative management. There was like a 15% risk of recurrence of appendicitis at a one-year follow-up, but otherwise you had decreased hospital stays and decreased the days of disability. So we're not telling you what that that the world changed to non-operative or or operative treatment of appendicitis. All we're saying with this is non-operative management is a is an option. It has some risks and benefits that that need to be taken into account and then make a decision accordingly. You know, my whole take on that was, it's great to see that information. I still think it's dealer's choice. I don't think a flat out recommendation was being made by Apso to start doing non-operative appendicitis. I think it was showing that the data is becoming more clear and it's still dealer's choice on whether people do one versus the other. Right. Alex, what was number one? So the most important one and this is one that also was very popular at the Apso conference this year is the opioid crisis. Uh, but pretty much the recommendations are reduce the total amount of opioids prescribed. And there's studies uh out there that show that you don't need to be giving opioids for incision and drainages or for breast biopsies. Second recommendation is to use non opioid analgesics. They work really well in kids and kids are really comfortable uh taking these. Tylenol plus insets or like Motrin are equally as effective as narcotics. Third recommendation was to use non pharmacological approaches. There's a lot of either heat or warmth, there are other comfort measures that significantly reduce pain. Uh including medication and deep breathing. And the fourth recommendation is to educate patients on the disposal of these unused drugs because the drugs are staying at home and being found either by kids or other family members are and they're continuing to contribute to the opioid uh epidemic in the country. I have to go back and review that to see uh if there's something I can start doing as well. I am really excited for the upcoming course to see what the 10 new uh practice gaps are, but Ray, what what should we be doing with this now? We we hear all these practice gaps. What can pediatric surgeons do around the world to help contribute to these? So I think reflection on your own knowledge gaps, they're ones that you see. If you find them, you can shoot an email over to think@epsa.org um and contribute to the PDC's effort. This is the way it's going to happen. We've got to get worldwide participation in this. This whole effort of education and identifying these gaps is huge and I think we're going to see a a change drastically by doing this. So thank you guys. This is awesome. Thank you for reviewing those and I'm excited for the 2019 update course. It's on August 2nd. We hope everyone's there and we'll do this again next year.