Papers by ALEXANDER FELIZ
Seminars in Pediatric Surgery, 2021
Pediatric peripheral vascular trauma is a rare but highly morbid injury in children and is freque... more Pediatric peripheral vascular trauma is a rare but highly morbid injury in children and is frequently associated with concomitant orthopedic injuries. These children require multidisciplinary care by pediatric, vascular, and orthopedic surgery. In this review, we describe elements of the complex care required for children with peripheral vascular trauma.
Current Opinion in Pediatrics, 2020
Purpose of review The purpose of this review is to describe education, training, certification of... more Purpose of review The purpose of this review is to describe education, training, certification of fellows in pediatric surgical critical care (PSCC). PSCC is a small but unique specialty within surgery. Education curricula focus on pediatric intensive care, neonatal intensive care, surgical intensive care, and pediatric surgical acute care. Attention is focused on the current state of SCC certification via the American Board of Surgery and future possibilities that could be implemented. Recent findings Because of the uniqueness of the specialty, the little literature that exists focuses on fellow experience including carrier plans, curricula at different programs and how the training is used in practice. There has been debate over the need for the development of a unified process to train, test, and certify critical care physicians of all programs. This could lead to a common ‘test’ that serves as the basis for critical care medicine certification from the myriad of American Medical Specialty Boards. Summary Training in PSCC offers surgeons a unique skill set to treat the most critically ill and injured children in our society. These surgeons can make large contributions to children's hospitals and to adult trauma centers that take care of injured children.
Pediatric Surgery International, 2018
Purpose Review current practices and expert opinions on contraindications to extracorporeal membr... more Purpose Review current practices and expert opinions on contraindications to extracorporeal membrane oxygenation (ECMO) in congenital diaphragmatic hernia (CDH) and contraindications to repair of CDH following initiation of ECMO. Methods Modified Delphi method was employed to achieve consensus among members of the American Pediatric Surgical Association Critical Care Committee (APSA-CCC). Results Overall response rate was 81% including current and former members of the APSA-CCC. An average of 5-15 CDH repairs were reported annually per institution; 26-50% of patients required ECMO. 100% of respondents would not offer ECMO to a patient with a complex or unrepairable cardiac defects or lethal chromosomal abnormality; 94.1% would not in the setting of severe intracranial hemorrhage (ICH). 76.5% and 72.2% of respondents would not offer CDH repair to patients on ECMO with grade III-IV ICH or new diagnosis of lethal genetic or metabolic abnormalities, respectively. There was significant variability in whether or not to repair CDH if unable to wean from ECMO at 4-5 weeks. Conclusions Significant variability in practice pattern and opinions exist regarding contraindications to ECMO and when to offer repair of CDH for patients on ECMO. Ongoing work to evaluate outcomes is needed to standardize management and minimize potentially futile interventions. Level of evidence V (expert opinion).
Seminars in Pediatric Surgery, 2019
Sepsis is a life-threatening condition that requires aggressive, timely, and multidisciplinary ca... more Sepsis is a life-threatening condition that requires aggressive, timely, and multidisciplinary care. Understanding the changes in national guidelines regarding definitions, diagnosis and the management of pediatric sepsis is critical for the pediatric surgeon participating in the care of these patients. The purpose of this article is to review the essential steps for the timely management of pediatric sepsis, including fluid resuscitation, antibiotics, vasopressors, and steroids. This includes a description of the key adjunct modalities of treatment, including renal replacement therapy and extracorporeal life support (ECLS).
Pediatric critical care medicine : a journal of the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies, Oct 1, 2018
Evaluate trends in method of access (percutaneous cannulation vs open cannulation) for pediatric ... more Evaluate trends in method of access (percutaneous cannulation vs open cannulation) for pediatric extracorporeal membrane oxygenation and determine the effects of cannulation method on morbidity and mortality. Retrospective cohort study. The Extracorporeal Life Support Organization's registry was queried for pediatric patients on extracorporeal membrane oxygenation for respiratory failure from 2007 to 2015. None. Of 3,501 patients identified, 77.2% underwent open cannulation, with the frequency of open cannulation decreasing over the study period from approximately 80% to 70% (p < 0.001). Percutaneous cannulation patients were more commonly male (24.2% vs 21.5%; p = 0.01), older (average 7.6 vs 4.5 yr; p < 0.001), and heavier (average 33.0 vs 20.2 kg; p < 0.001). Subset analysis of patients on venovenous extracorporeal membrane oxygenation revealed higher rates of mechanical complications due to blood clots (28.9% vs 22.6%; p = 0.003) or cannula problems (18.9% vs 12.7%;...
Injury, 2017
Non-powder guns (NPG) are viewed as toys for children by the general public. Literature on firear... more Non-powder guns (NPG) are viewed as toys for children by the general public. Literature on firearm injuries in the pediatric population is increasing, however there are still large gaps in the published literature regarding NPG. We intended to identify and compare the epidemiology, circumstances of injury and outcomes of children with NPG versus powder-gun injuries (GSW). We performed a 6-year retrospective analysis of children 0-14 years old treated for NPG and GSW injuries at our level one pediatric trauma center. Mann-Whitney U test and Pearson's X(2) were used to compare continuous and categorical variables, respectively. There were 43 NPG and 112 GSWs. Patients were predominantly male (36 children; 84%) NPG vs. 92 children; 82% GSW) with a median age in both groups of 11 years. Analysis of residential zip codes showed that 74% (32 children) NPG injuries and 85% (95 children) GSW lived in regions with higher poverty than the national level. Children with NPG injuries were mo...
The Journal of Pediatrics, 2017
The American Journal of Surgery, 2017
Background: Firearm injuries have the highest case-fatality rate among pediatric trauma related d... more Background: Firearm injuries have the highest case-fatality rate among pediatric trauma related deaths. We sought to determine whether demographics, mechanism of injury, and outcomes were age specific. Methods: We performed a 5 year retrospective analysis of patients 0-19 years old with firearm related injuries. Children were divided into two cohorts based on age. Mann-Whitney and Pearson's X 2 were used to compare continuous and categorical variables, respectively. Significance was established at p <0.05. Data: Compared to their younger counterparts, children >15 years old were more likely to be male (82% vs. 90%, p=0.02), African-American (71% vs 89%, p<0.0001), and injured due to assault (76.9% vs 44.6%, p<0.0001). Mortality rates for children <14 was 1.4 times the national average (10.7% vs. 7.5%) while the rate for children >15 was 3.9 times the national average (12.4% vs. 3.2%). Conclusion: Firearm injuries continue to be a prevalent public health concern greatly affecting African-American adolescent males. Prevention strategies and trauma related healthcare resource utilization should target this group in order to reduce the risk of injury and improve outcomes and case-fatality in our population.
The Annals of Thoracic Surgery, 2016
The American Journal of Surgery, 2017
BACKGROUND This study investigates whether health disparities exist in infants with hypertrophic ... more BACKGROUND This study investigates whether health disparities exist in infants with hypertrophic pyloric stenosis (HPS), to identify factors affecting definitive treatment, and if more morbidity occurs. METHODS A 6-year retrospective analysis was performed on infants with HPS. Analysis of variance was used to evaluate the impact of socioeconomic factors on disease severity and hospitalization. General linear models were used to assess the impact of risk factors on the outcomes. RESULTS There were a total of 584 infants. African-American's had lower serum chloride (P < .001), higher bicarbonate (P = .001), and sodium levels (P = .006), adding to longer hospitalization than whites (P = .03). Uninsured infants had lower sodium and chloride (P < .001) and higher bicarbonate (P < .001), resulting in a longer time to operation (P = .05) than privately insured infants. In multivariable analyses, African-American's were associated with chloride (P = .002) and higher bicarbonate (P = .009), and uninsured status remained significantly associated with all electrolyte abnormalities. CONCLUSIONS African-American and poorly insured infants with HPS had greater risk of metabolic derangements. This required more time to correct dehydration and electrolytes, adding to longer hospitalizations.
Journal of Trauma and Acute Care Surgery, 2016
Hemorrhage is a major cause of preventable death secondary to traumatic injury. Diagnosis often r... more Hemorrhage is a major cause of preventable death secondary to traumatic injury. Diagnosis often requires multiple blood draws, which are psychologically stressful in pediatric patients. The Pronto device is a pulse co-oximeter that measures the total hemoglobin level using multiple wavelengths of light. The purpose of this study was to evaluate the accuracy of the noninvasive hemoglobin measurements relative to current invasive and point of care testing methods in pediatric trauma patients. METHODS: We performed a prospective observational trial involving patients younger than 17 years presenting to a Level I pediatric trauma center. Following admission, blood was sampled from each patient for testing using an i-Stat device (point-of-care hemoglobin) and a complete blood count within our core laboratory (invasive hemoglobin). Noninvasive hemoglobin analysis was performed within 15 minutes of phlebotomy. Data were evaluated using Spearman correlation and Bland-Altman analysis. RESULTS: Over 2 years, 114 patients had attempted noninvasive hemoglobin measurements, with a success rate of 89%. Mean ± SD age was 9.2 ± 5.1 years. Ninety percent of admissions were for blunt injury, 3% penetrating, 5% near drowning, and 1% burns. Mean invasive hemoglobin was 12.6 ± 1.9 g/dL, mean point-of-care hemoglobin was 12.2 ± 2.0 g/dL, and mean noninvasive hemoglobin was 12.3 ± 1.6 g/dL. Noninvasive hemoglobin values were strongly correlated with both invasive and point of care measurements (R = 0.672 and R = 0.645, respectively; p < 0.001). Bland-Altman analysis comparing noninvasive to point-of-care and invasive hemoglobin levels resulted in an estimated bias of −0.39 and −0.49, respectively. CONCLUSION: Noninvasive hemoglobin values had excellent correlation with both invasive and point-of-care hemoglobin measurements, although the device was not successful for all patients. Given the rapid availability of results and the lack of requirement of venipuncture, noninvasive hemoglobin monitoring may be a valuable adjunct in the initial evaluation and monitoring of pediatric trauma patients.
Journal of Radiotherapy in Practice, 2016
BackgroundAntioxidant therapies to control oxidative damage have already attracted worldwide atte... more BackgroundAntioxidant therapies to control oxidative damage have already attracted worldwide attention in recent years. Extensive studies on phytochemicals in cell culture system and animal models have provided a wealth of information on the mechanism by which such nutraceuticals show their beneficial effect. Nutraceuticals include plant-derived factors (phytochemicals) and factors derived from animal sources as well as from microbial sources. The activities of nutraceuticals are broad and include antioxidation, modulation of enzyme activity and modification of natural hormonal activity (agonist or antagonist) to act as a precursor for one or more beneficial molecules. Antioxidants scavenge free radicals that cause cell damage. Antioxidant consumption during radiotherapy and its effects are still controversial. Some studies suggest that antioxidant supplementation during chemotherapy or radiotherapy may be beneficial and some, harmful. Wheat grass is rich in superoxide dismutase, an...
The American Journal of Surgery, 2016
Journal of the American College of Surgeons, 2015
INTRODUCTION: Pediatric liver transplantation outcomes improve with size-matched donor livers. We... more INTRODUCTION: Pediatric liver transplantation outcomes improve with size-matched donor livers. We hypothesized that graft failure and mortality would be lower when children receive age-matched donor livers. METHODS: The United Network of Organ Sharing database was reviewed for pediatric patients(18 years) undergoing liver transplantation from 1987 to 2013. Primary outcomes examined included rejection, graft failure, and mortality in adult-to-pediatric and pediatric-to-pediatric transplants. Data were analyzed using Fisher's test, Cox regression, and logistic regression. Multivariate analysis (MA) controlled for height, warm (WIT) and cold ischemia time (CIT), and split-liver grafts; p<0.05 was significant. RESULTS: Of 11,256 patients, 3,709 received adult donor livers (ADL), 7,547 got livers from pediatric donors (PDL). Adult donor liver recipients were older (6.9 years vs 4.2 years; p<0.001), and more likely to receive split liver (p<0.001). Cold and warm ischemia times were longer with PDL (p<0.001). The entire cohort showed decreased graft failure and mortality in PDL compared with ADL (p<0.001). Univariate analysis for recipients <13 years old receiving PDL showed lower graft failure (26.49% vs 31.13%, p <0.001) and mortality (13.64% vs 16.41%, p¼0.001). Higher rates of 6-month and 1-year rejection (p<0.001) and vascular thrombosis (p<0.001) were observed with PDL. Of these findings, only graft failure (odds ratio [OR] 0.53; 95% CI 0.41-0.68; p<0.001) and mortality (OR 0.58; 95% CI 0.43-0.80; p<0.001) remained significant on MA. Rejection rates on MA were affected by WIT (p<0.001) and CIT (p<0.001). In recipients aged 13 to 18 years, there was no difference in mortality (p¼0.15), rejection (p¼0.28 to p¼0.31), or vascular thrombosis (p¼0.86) between ADL and PDL. Graft failure was lower with PDL (p¼0.005) for recipients aged 13 to 18 years, but did not maintain significance on MA (OR 0.82; 95% CI, 0.60-1.11; p¼0.21). CONCLUSIONS: Age-matched donor livers in children <13 years are associated with less graft failure and decreased mortality.
Journal of Surgical Research, 2015
Pediatric scald burns result in frequent emergency room visits and hospitalizations. We investiga... more Pediatric scald burns result in frequent emergency room visits and hospitalizations. We investigated whether cooking-related burns produce greater morbidity requiring more extensive care than noncooking burns. We performed a 6-y review at our free-standing children&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s hospital. Children aged &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;18 y admitted for accidental scald burns were included. Demographics, injury pattern, treatment, and outcome (contractures and/or limited mobility and nonhealing and/or infected wounds) data were analyzed comparing cooking versus noncooking burns. The Mann-Whitney U test, a chi-square test, and the negative binomial were used to compare continuous, categorical, and count data between groups. Bivariate analysis was performed to identify risk factors among patients with adverse outcomes. We identified 308 patients; 262 (85%) cooking and 46 (15%) noncooking burns. Most patients were African-American males, with public insurance, and a median age of 2 y. Cooking burns preferentially occurred over the head, neck, and upper body; noncooking burns were distributed over the lower body (P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.02). Median total body surface area was equal for both groups (P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt; 0.11). In subgroup analysis, semisolid and grease burns resulted in increased rates of wound contractures and/or limited mobility when compared with noncooking burns (P = 0.05 and P = 0.008, respectively). Patients with complications were more likely to have third degree burns and required more consults, longer hospitalization, and more surgical debridements and clinic visits. Most accidental scald burns occurred in young children during food preparation. Greater long-term morbidity was found in patients with semisolid and grease burns. This subset of children has a higher injury burden and requires extensive care in the acute and long-term setting.
The Journal of Trauma: Injury, Infection, and Critical Care, 2010
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Papers by ALEXANDER FELIZ