Journal of Pediatric Surgical Nursing

Each year, numerous children undergo surgery and require oral opioids during their postoperative recovery. Little is known about when children who have been on a nothing-by-mouth diet after surgery can tolerate oral opioids. Although oral opioids offer advantages over the intravenous route, healthcare professionals have differing opinions regarding how much oral intake (liquids or solids) a patient needs to tolerate before starting oral opioids. This could lead to inconsistencies in practice, which could impact patients' comfort, length of stay, and, ultimately, healthcare costs. The primary purpose of this study was to identify current practice regarding initiation of oral opioids in pediatric patients recovering from an appendectomy for ruptured appendicitis. On the basis of this data, our team aimed to provide a best practice recommendation for this population.

A retrospective chart review was conducted from a sample of 43 children recovering from an appendectomy secondary to ruptured appendicitis. Data included time from surgery to ingestion of clear liquids, administration of oral opioids, and occurrence of emesis in relation to either of these administrations.

Children received from 30 ml to an average of 354 ml of clear liquids before taking oral opioids, and no patients had emesis documented regardless of the volume of clear liquids they ingested before administration of oral opioids.

Results suggest that pediatric patients may be able to tolerate oral opioids regardless of the amount of clear liquids they tolerate beforehand. Although more studies are needed to support these results, such results could mean earlier transition from intravenous to oral opioids, which could decrease healthcare costs and potentially decrease length of stay.

Perforated appendicitis is a high-volume diagnosis managed by advanced practice nurses (APNs) in the general pediatric surgery department at an urban hospital in the northeast. This APN-led quality improvement project aimed to determine the impact of APN phone follow-up to prevent unplanned return visits and readmission.

Before June 2015, all patients with perforated appendicitis discharged home on antibiotic therapy were provided with APN phone follow-up. The patients were followed for 30-day outcomes regarding unplanned returns to care. The goal was to attempt to identify patients at a higher risk for returns based on symptom analysis so that preventative measures may be instituted. The process of phone follow-up for patients with perforated appendicitis changed in June 2015 because of the decreased number of patients discharged home on intravenous antibiotic therapy, and therefore the phone follow-up was discontinued. This allowed the data from the first cohort (December 2014 to May 2015) to be reviewed by a retrospective chart review and analyzed.

The preliminary data between the two cohorts, which have comparable patient volumes and return rates, have revealed that the APN phone follow-up did not necessarily change the rate of unplanned return-to-care visits after patient discharge, perhaps because of the call being conducted too soon after discharge. Our findings suggested that the APN phone follow-up call may have been more impactful in reducing unplanned return-to-care visits if completed after the 48-hour time frame.

Neonatal sacrococcygeal teratoma is rare occurring in approximately one in 35,000 live births with a female predominance (3:1–4:1 ratio). It is an unusual tumor that develops before birth and arises from embryologically multipotent cells from the Hensen node, which is located in the coccyx. Sacrococcygeal teratomas generally present in two distinct fashions: newborns with large predominately external masses, which are noted in utero or at the time of delivery and are rarely malignant, and older infants and young children presenting with tumors predominately confined to the pelvis with a much higher rate of malignancy. Most sacrococcygeal teratomas are now diagnosed prenatally because of the routine obstetric ultrasonagraphy. An abnormally sized uterus is typically the first sign that a sacrococcygeal teratoma may be present. The increased-sized uterus can be due to a massive tumor or polyhydramnios. Less common presentations include maternal preeclampsia. Newborns generally present with the mass protruding from the sacral region. If detected prenatally, the neonate should be considered for abdominal delivery if the mass is greater than 5 cm in size. In addition, some develop in utero high-output cardiac failure resulting in fetal hydrops and may be candidates for in utero resection. When a prenatally diagnosed sacrococcygeal teratoma is associated with fetal hydrops, the tumor can become life-threatening to both mother and baby.

A classification system has been devised by Altman et al. in 1974 and is still used today. Sacrococcygeal teratomas are categorized according to their location and severity. Type I tumors are predominately external. Type II tumors present with both internal and external components. Type III tumors are predominately hidden in the pelvis with a very small external portion. Type IV tumors are entirely hidden within the pelvis.

The recommended treatment of a sacrococcygeal teratoma is complete removal of the tumor by surgery performed soon after the birth. Unfortunately, there is a significant recurrence rate of 10%–20% even with complete resection.

Long-term follow-up is needed, as there is a risk of malignancy and reoccurrence. Postoperative follow-up is needed during the first several years of life as bowel and bladder functions can be affected. Children should be followed through potty training to ensure that bowel and bladder functions are normal.

Opioid therapy has long represented the foundation of pain management postoperatively. However, as a significant and concerning increase in prescription-opioid-associated morbidity and mortality has emerged, there is an urgent need to balance adequate postoperative pain management with evidence-based prescription processes and to incorporate the use of multimodal pain management plans to both reduce opioid side effects and decrease the amount of unused opioid prescriptions that are available for diversion. Laparoscopic appendectomy for nonperforated appendicitis is among the most common operation in the pediatric population. There is an opportunity to decrease and even eliminate the use of opioids for this patient population using other modalities of pain control. This study further builds on previous work started in 2013 where we found that patients were taking far less opioids for pain than had been prescribed. This resulted in standardizing the amount of opioids prescribed in this patient population to five doses.

The purpose of the study will be to describe pain control in the pediatric postoperative nonperforated appendectomy population after discharge from the hospital. Our hope is that we can show adequate pain control in this patient population, specifically using nonopioid modalities for pain control including acetaminophen and ibuprofen.

This is a prospective cohort study.

The standard clinical practice regarding the prescription of postoperative medications for pain management will be followed. Patients and their families are instructed to alternate acetaminophen and nonsteroidal anti-inflammatory drugs (Motrin) as necessary after discharge from the hospital. Parents are also offered a prescription for an opioid to fill in the event that their child had breakthrough pain (pain not relieved with acetaminophen or NSAIDs [Motrin]) and instructed to fill the opioid prescription only if they think their child needs an opioid for pain relief. Parents are instructed to keep track on their child's pain medication history on a sheet given to them detailing how many doses of acetaminophen, Motrin, or opioid doses they gave to their child. The medical record will be reviewed retrospectively to determine whether the child received an intraoperative peripheral block. The patients will be approached by the team (surgeon or nurse practitioner) when discharge prescriptions are explained. The study will be described, and the subjects/families will ask if they would participate in this study. If the subject/family consents to participate, they will receive a follow-up telephone call from a member of the team on Postoperative Day 3. In the event that the family cannot be reached on Postoperative Day 3, a follow-up call will be made on Day 4. No other contact will occur after this time. They will be contacted at the best number supplied by the family. The team member will ask about their child's pain experience and about the use of opioid and nonnarcotic pain relievers (acetaminophen and NSAIDs; see Table 1, data collection sheet). Patient education sheets will be provided per usual practice.

Descriptive and correlational statistics will be used for the analysis of this study. This analysis will be used to interpret the appropriateness and efficacy of utilizing this modality of treatment for pain control in this patient population with the outcome of eliminating the use of opioids for pain control.

There has been an increase in the number of children with escalator-related foot injuries. Lim et al. (2010) reviewed the charts of 17 children who sustained escalator foot injuries within a 2-year time span, 13 of them were wearing rubber clogs. Nine of these 13 children sustained severe foot injuries, and one child had an unsalvageable traumatic amputation. The injuries included a traumatic amputation of the great toe and others with fractures, lacerations, and cuts. This abstract and poster is a case study of an escalator injury.

This is a case study of a 7-year-old, Spanish-speaking boy who sustained a right foot traumatic amputation after getting it caught in a moving escalator. He presented to a Level I pediatric trauma center in an urban setting where he was brought emergently to the operating room and admitted under the trauma service. This case study reviews the hospital course including surgical procedures, postoperative care, complications, and outcomes.

Escalator-related traumatic amputations result in severe tissue-mangling injuries that require multiple trips to the operating room and interdisciplinary collaboration. Educating parents and caregivers on escalator safety can help prevent injures and hospitalizations.

The U.S. Consumer Product Safety Commission has published a general interest in safety brochure on escalator injuries; however, it has not reconsidered mandatory standards (accessed on November 11, 2016). By enforcing safety behaviors within the community, there is a potential decrease in the incidence of injuries and, subsequently, hospitalizations.