APSA 2018 Practice Gaps

The first, the first topic is we are going to do a review of the top things from last year's event in case you missed it. Uh, so with that we have, uh, the pediatric surgery fellows at Akron Children's and Cincinnati Children's, uh, Dr. Alex Gibbons, Dr. Ray Hanky, and Dr. Alejandro Cassar, uh, and they are gonna go through quickly what was what you missed last year. So, Alex. So, uh, the process that practice gaps identified by the pediatric, uh, surgery practice, uh, development professional development committee last year were very popular. They're also very popular in social media and you've seen our videos. Number 10 for last year was restrictive transfusion protocols, using a target hemoglobin of seven for transfusions, instead of eight or nine or 10, like some institutional protocols did, and it showed that there's no difference in mortality. They also recommended to be aware of the risk of DVT using blood transfusions. Just so you know, Just two days ago, I had a baby that I was operating on, and because you taught me this, the hemoglobin, they were they were going to transfuse up to a hematocrite of 30. I said, no, I learned from the PDC, we don't have to do that anymore. Transfused clinically. Transfused clinically. Okay. So we want to ask a question. Have your has your practice changed, uh, since last year when we presented this? So the poll should be loading and you can start participating. Does any who here, see, you guys don't count because you you're you're skewed. You guys are ahead of everybody else. Because you're the PDC. But has anyone here still transfused to a hematocrite of 30 or a hemoglobin of 10? So I was the only one. It's so embarrassing every year. It's always year. Every year. Yeah, every year. Only exception would be sickle cell disease. Okay. So sickle cell disease, there's some poor evidence to suggest that, uh, their hematocrite needs to be around 30 or you need to measure their sickle cell fraction and make sure that the HBSS is below. I think what is it, 50 or 60%? Um, to make sure that they, they can go through easily. That's good. That's a great point. 60% of you were doing it already. That's awesome. 20% have converted and 20 didn't know. So pay attention to the gaps this year so you'll know for next year. Here we go. Yeah, that's why we're reviewing it this year. So number nine was, uh, enteral nutrition in pancreatitis. So what the PDC emphasized what is that early feeding decreases morbidity, infectious complications and overall mortality. Um, they found that nasogastric is equal to nasojenal, um, feeding. It's equally tolerated, which I found fascinating because it's always been NJ feeds, um, for my training. Um, and then operate early for gallstone pancreatitis. So question for you all, are you enterally feeding children with pancreatitis early on? I remember in last year's update course, one of the like highlight reels of this Dr. Rusty Jennings saying that this single teaching point made the whole update course worth it because he didn't realize this and it totally changed his practice. Yep. He had like a Tad Ponowski like mind-blown moment. This yeah, this, I mean, this is one of those things I was doing wrong again. Um, I would wait until their symptoms were improving. I I wasn't following lipase and amalyse, but I was waiting for their symptoms to improve. And now you don't have to do that. You just feed feed right away if they can tolerate it. So the uh eighth one, uh to paraphrase the rapper childish Gambino, uh it's like an accent mark. It was all about the ovaries. So, uh, this was uh referring to ovarian torsion specifically, and uh the points that the PDC wanted to emphasize were one, that ultrasound is not a great tool to be using for diagnosis at this stage. So, um, really don't be basing your clinical judgment off of that. And then two, when you go in to detorts, um even if the ovary looks black and dead, you leave it in place because they can still have recovery afterwards and it helps uh preserve fertility. Uh, number seven, we have, uh, VTE prophylaxis and high risk trauma patients. And the learning gap was that for uh low bleeding risk, we should be doing SCDs and low molecular weight heparin, and for high bleeding risk, we should be doing SCDs until the patients are ambulatory, and then do a screening ultrasound on ICU day seven. The question was, are you using low molecular weight heparin and SCDs in low risk trauma patients? So, first of all, what age is this? Any age or is this a certain age we should start using low molecular weight heparin? I don't know. Does anyone know? We'll have to look that up because I don't know, do you have to do this in a five year old or is this only a teenager? Who is it that you need to give low molecular weight heparin? Do you guys know? I don't know. No. What do you do? What do you do in your practice? Sorry, institution policy is uh 12 and over. 12 and over. Yes sir. And you do both SCDs and low molecular happen if they don't have a head bleed. Correct. Well, if if they're high risk, they get both. If they're low risk, they get just SCDs. And high risk would be solid organ injury or is that not high risk? Femur fractures, cervical spine fracture, intubated. Anyone do anything different? No. Okay. There was data presented at uh Appsa this year, uh by the group, um I think the Tomac group and and their subsidiaries. They presented some data on that, uh trying to adopt um VTE prophylaxis protocols. Um, so they're doing more and more prophylaxis. And it's mostly the teenagers as Liz mentioned who who have uh ambulation issues and and and they are supposed to be at high risk. No one knows what that risk is though. Okay. The the other group that's at high risk are kids with IBD. Really? They're they're probably the most at risk group for deep venous thrombosis. Okay. All right, what's next? So, number six, uh the PDC called attention to the topic of physician wellness. They reviewed that burnout, it directly impacts patient care and outcomes, and emphasized the importance of establishing support systems that are established during education as well as practice. And this is something that needs to be proactive so that surgeons don't necessarily have to go out. When you're burnt out, you're not likely to seek out help. Um, it's not necessarily in our mentality, it's not our norm. Um, so that was another point that they emphasized. So, let me while we put put your poll up. Okay I want to ask. So, have you talked to your hospital system about a proactive physician wellness program or participating in one yourself? So, my answer to that is C. Uh, well, it's it's not that I'm not convinced, I just haven't. Um, let me ask the leadership here, people that are in leadership positions, which are I think all are all of you. Uh, what have have you done anything at your hospitals officially or formally for this? Mark Woken says yes, come up here. Well we yeah. No, that's okay. Um, no, we have a very formal program. Uh, most people know uh my partner Kurt Heiss, who has set up the whole second victim program, but we're also our wellness committee looks uh really extensively at burnout. We we pulled the uh medical staff about burnout and then we try to do things to help with that. Dan? I would say uh we also have a similar program, but I think it's also important to recognize that it's not just physicians who have this burnout issue in healthcare. And so we have uh representatives from patient services and from HR for the staff for uh issues of burnout. And you know, we we have a a approach where we do acute interventions for things like we had a couple of kids uh pass away in the emergency department a while back very close to each other and so there were interventions made to help the staff down there deal with those sorts of issues. But it is a real issue. Great point. Yeah, that's actually a great point. And I'm curious for the international community, um we'd love to hear if this is everywhere. Is this just a a big United States thing right now or is this is this uh happening all over the world? So please leave your comments and tell us if it's happening in your neck of the woods. All right, what's next? So next one is also um a more US specific one. It was looking at uh firearm injury prevention. Um, and referring to the gun violence is a public health issue and an epidemic really. An apsa just uh in the um most recent GPS issue for July, had uh position statements that they had and one was for non-accidental trauma and the other one was for firearm injuries. A fantastic position uh paper, so definitely recommend everybody take a look at that. Um, but uh this practice gap was also addressing that and just emphasizing that uh physicians should be talking to their patients about whether there's a firearm in the home. Um and if there is, uh whether it's safely stored. Um and then the other aspect of it was kind of uh emphasizing advocacy and um pushing for uh better um policies that really help address the problem of gun violence. All right, I need some help here. So I don't get where where we fall into the politics arena. Um, I have never talked to a patient about firearms ever. And I so I'm the one that needs to get into that mode, but I am I don't know how this works. How does apsa, how do pediatric surgeons? Are we allowed to take a political stance on something? So this this erupted into a big political controversy in Florida, uh recently. The American Academy of Pediatrics wanted to include this as a question that physicians should feel comfortable asking all parents. And as a matter of fact, they wanted to say that physicians should ask it. And and put it on their list of things they should ask. And it became a huge controversy and the legislation uh legislation, they they basically um at in Talihasi, they they shut that down and they did not want that to go through as that. So I think the the as soon as you bring up a question like this and try to formalize it, you enter into the political arena with both feet. And so I think if you're going to do this, you have to be prepared to do that. What are we supposed to do, Celine? It says do you ask them, okay, do you have firearms in the house? Yes. Is it that we're supposed to tell them do you have safety mechanisms? Correct. Okay. So do you if do you have firearms in the house? If the answer is yes, uh how do you store them? Uh are you keeping them under a lock and key and are they loaded or are they kept unloaded? Is the ammunition kept separate from the guns or is it right next to them? And and who has access to them? So that is what primary care physicians especially are supposed to do. Um, and when, you know, I've kind of done it a few times when there's been a trauma situation. It's kind of after the horse has already left the barn in a lot of ways. Um, but but yeah. By the way, I have two friends, one this past week, uh know someone who uh uh injured themselves by cleaning their gun. And apparently this happens a lot. It's cleaning the gun, there's a stray bullet. You either shoot yourself or someone else in the house. So, uh, that's something else to keep in mind. Uh, interesting uh uh variation there in the answers. Next. Practice gap number four. This one was really interesting last year because everyone said they knew about it and probably like 90% of people were still not doing it. Uh, so this is a transition from before, where uh isotonic fluids would be switched to hypotonic fluids for uh maintenance in resuscitation to the current, uh, strategy that should be to continue isotonic fluids throughout. And this decreases the risk of hyponatremia, and it had similar more mortality otherwise. All right. Let's see what the poll says. So, comments on this. So I was blown away by this. I have always go, okay, first day, resuscitate them. The next day, put them on maintenance fluid at a hypotonic solution. I said, oh my God. Okay, now I need to keep everybody on isotonic and I can't do it. A lot of it's because of our epic, um, Protocols? What? Order sets. Order sets that I'd have to go change the whole epic order set. So, even though I tried, we still end up giving switching over. It's too it's been too hard of a mountain to push. What about everyone here? Do you switch? At our institution, we switched the order sets. You did switch them. Yes. You guys like do everything right. It was it was at the push of the pediatricians. So all the order sets throughout the institution were changed. Amazing. At our institution, we had a lots of education with the residents. particularly surgery residents, neurosurgery residents that take care of kids. The pediatricians were doing this, but we we had to do that to make the change. Stephen, not babies, right? What about pylorics? Do you keep I switched for pyic. For them too? Yes. Because last year that was unclear when we talked about what about babies? It was a bit unclear at what age this starts, but you do it in everybody. Okay. Celine? I agree. It's it's the biggest thing was almost like a culture change. Um, because when we were teaching medical students, we were teaching them that this is we're basing their fluid requirements on their sodium requirement on a daily basis. And so that's what we we were traditionally teaching them in and in in lectures and everything. So it was a overcoming that. Um, and once the pediatricians uh kind of convince were convinced, then that helped us as well because the the floors then wanted to do it. So we we've switched over. Okay. So once again, what is that? Question nine, I'm still the only one who's getting everyone wrong. Okay. Let's keep going. Well, it seems like 46% of people were already doing this. 38 have converted and 15 didn't know. Just I'm just curious at your hospitals, um, the one here, CEO on camera, but is anyone, did you guys all switch to this? This is uh Dr. Fred Rescorla who we haven't introduced yet, uh from Indiana. So, uh we switched for many of our patients. We had a big discussion with our peeslogy division, and they actually didn't want us to switch on everybody. We're starting a protocol of following lights on some of these kids, but they didn't think it was quite as big of a deal. Um and they thought this was kind of a quick jump on the pediatric group. It's interesting. So a little bit of a more tailored measured approach. Okay. All right. Okay, so practice gap number three. Um, they identified violations of the Wilms tumor protocol. So a few things, um, that we highlighted were, remember to take the nodes every time every operation because if you don't it automatically up stage upstages your kids. Um, remember that there's local and systemic staging, and um that pulmonary metastasis doesn't preclude doing a primary nephrectomy. So, I have two questions for the uh the audience. So first, have you been short to remove these nodes in in your kids when you're operating for a Wilms tumor? Okay, so a comment about this. I think people know you're supposed to. Yeah. I I'm guessing what happens is you're patting yourselves on the back that you took out the tumor. like, okay, sweat, let's close. And and I think it's it's a a lapse because you were focused on the tumor. So it might be a good trick to uh tell the the the the staff in the operating room, make sure you remind me to get nodes. Put it on the whiteboard on the timeout. Uh, make sure people you have a hemistat to something and say remind me to get the nodes. Maybe I think that might be part of it. Anyone comments? So Liz, um question again here is, this is for sampling of nodes and it's for primarily staging purposes, right? Correct. And so if you have a patient who does have known pulmonary mets, how important is it then to make sure that you take nodes in that situation? If your stage is already four. Well, I think that I mean, that's an excellent question. What's what's the point? But on the other hand, to Todd's statement, if you get into the practice of doing it every time, then you're going to do it every time. Do you want to I think There's also a Go ahead. Go ahead, Dan. Just it's important to still take the nodes because you treat the local disease and it it has an impact on the treatment for the abdominal disease whether they have lung mets or not. So it is important to take the nodes regardless. This was a great discussion. Did you want to make another point, Liz? I'm good. Thanks. That was actually high yield right there. So, separating systemic and local disease and uh some system of doing it regularly so you just don't forget. So the number two practice gap was talking about uh non-operative management of uncomplicated appendicitis. Um, and just emphasizing that this is a a possible treatment option now. So, um, and not only is it possible, but it also has uh decreased days of hospitalization, um decreased days of disability, and uh equal outcome measures otherwise. So, um, I know standard of care is obviously still the appendectomy, but this was emphasizing that this is a viable treatment option. So, um our question for the audience is, uh, are you considering non-operative management of uh acute appendicitis? So while this is polling, of course Dr. Holken has something to say about this. Not surprised. So, um most people here in the United States know that there are a couple of uh prospective trials looking at the efficacy of non-operative management versus operative management for non-perforated appendicitis. To me, the important point in this discussion is not whether or not non-optive management is effective for six months or a year. It's what's going to happen 10 years down the road or 20 years down the road or 40 years down the road. It's hard to believe that the appendix doesn't scar uh somewhat due the inflammation, which may predispose it to developing an obstruction and acute appendicitis later. Mhm. And whether that's again, 10 years or 30 years or whatever, uh that's going to be really important, I think in in trying to determine if non-optive management is really effective. So, the point is that these patients, I hope, will be followed for a long time. This cohort of patients and in these trials, so that we'll really know, you know, 20 or 30 years later if non-optive management truly is effective. Currently, it appears somewhere between 10 and 20% develop uh recurrent appendicitis. Although somewhere between perhaps 20 and 40% develop or have have an operation at some point because they have symptoms that are either similar to appendicitis or their parents are concerned they have appendicitis. So anyway, all all that data is just as important to me at least, whether or not the actual management is effective. Is does the patient get an operation for whatever reason either soon after the non-optive management or 10 or 20 or 30 years down the road. I think that's a great, a great point. We just don't know enough yet. Yeah. Impact trial, which was an adult study mostly based in Finland, uh looked at five years out, five year outcomes. They randomized adults to either get an appendectomy, which in Finland apparently they still do open appendectomies. So it was an open appendectomy to a non-operative management. And at five years when they looked back, 41% of the non-operative group underwent an appendectomy. So, and when it was this was published in Jama earlier this year, and the editorial accompanying that said, uh they consider this a success that non-operative management of pendicitis is is great. I don't know if any surgeon would look at that and go 41% failure rate is a success. So, we would add that um in the adult population, there's a fundend study that is uh multi-institutional based out of Seattle, but we participated in Los Angeles. And part of the the uh ramp up to that, we had to survey parents to see what they would accept as a potential success for non-operative management. And parents actually came up with if there was a 50% chance of being successful, they would enroll in the study. So it just, I think it really shows the differences between what the patient's view and what we view as surgeons. And in addition, you know, where we are in Los Angeles, lots of patients are coming in, families just asking we want non-operative management. And so we have to actually address this head on. So. Yeah, I think my comment to that would be that I think the parents are more focused on the here and now, that is what's happening at that moment in the emergency room, whereas we as their caregivers need to be thinking about what's best for the total life of the patient, whether it's a child or an adult. And that's why I think the long-term follow-up is going to be vitally important for this uh this group of patients. Right. We have them now in a controlled environment versus when they get it the next time, who knows where they'll be and if it's