Critical incidents in paediatric anaesthesia: an audit of 10 000 anaesthetics in Singapore

Wake Up Safe in the USA & International Patient Safety

Patient safety is the most important aspect of anesthetic care. For both healthcare professionals and patients, the ideal would be no significant morbidity or mortality under anesthesia. Lessons from harm during healthcare can be shared to reduce harm and to increase safety. Many nations and individual institutions have developed robust safety systems to improve the quality and safety of patient care. Large registries that collect rare events, analyze them, and share findings have been developed. The approach, the funding, the included population, support from institutions and government and the methods of each vary. Wake Up Safe (WUS) is a patient safety organization accredited by Agency for Healthcare Research and Quality. Wake Up Safe was established in the United States in 2008 by the Society for Pediatric Anesthesia. The initiative aims to gather data on adverse events, analyze these incidents to gain insights, and apply this knowledge to ultimately reduce their occurrence. The purpose of this review is to describe the patient safety approaches in the USA. Through a national patient safety database WUS. Similar approaches either through WUS international or independent safety approaches have been described in Australia-New Zealand, India, and Singapore. We examine the patient safety processes across the four countries, evaluating their incident review process and the distribution of acquired knowledge. Our focus is on assessing the potential benefits of a WUS collaboration, identifying existing barriers, and determining how such a collaboration would integrate with current incident review databases or systems.

The Incidence of Postoperative Complications Following Lumbar and Bone Marrow Punctures in Pediatric Anesthesia: Insights From APRICOT

OBJECTIVE

Bone marrow aspiration and lumbar puncture are procedures frequently performed in pediatric oncology. We aimed at assessing the incidence and risk factors of perioperative complications in children undergoing these procedures under sedation or general anesthesia.

METHODS

Based on the APRICOT study, we performed a secondary analysis, including 893 children undergoing bone marrow aspiration and lumbar puncture. The primary outcome was the incidence of perioperative complications. Secondary outcomes were their risk factors.

RESULTS

We analyzed data of 893 children who underwent 915 procedures. The incidence of severe adverse events was 1.7% and of respiratory complications was 1.1%. Prematurity (RR 4.976; 95% CI 1.097-22.568; P = 0.038), intubation (RR: 6.80, 95% CI 1.66-27.7; P =0.008), and emergency situations (RR 3.99; 95% CI 1.14-13.96; P = 0.030) increased the risk for respiratory complications. The incidence of cardiovascular instability was 0.4%, with premedication as risk factor (RR 6.678; 95% CI 1.325-33.644; P =0.021).

CONCLUSION

A low incidence of perioperative adverse events was observed in children undergoing bone marrow aspiration or lumbar puncture under sedation and/or general anesthesia, with respiratory complications being the most frequent. Careful preoperative assessment should be undertaken to identify risk factors associated with an increased risk, allowing for appropriate adjustment of anesthesia management.

Pediatric neuroanesthesia experiences: A single center retrospective cohort study

Background/Aim: Pediatric neuroanesthesia is a special field that requires significant experience and infrastructure because of anatomical, neurological, and pharmacological differences in the pediatric patient population. Although technological improvements provide more effective and safer neuroanesthesiological management, the principles of neuroanesthesia, neurocognitive development, and the effects of anesthetic agents on central nervous system development are well-known. The majority of pediatric neuroanesthesia articles in the literature are reviews; however, retrospective/prospective case series and controlled research are limited. In this retrospective cohort study, we aimed to contribute to the existing literature by reviewing and analyzing our single-center 10-year experiences and results addressing pediatric neuroanesthesia management. Methods: After ethical committee approval, anesthetic and surgical reports from 1165 pediatric neurosurgical cases over ten years were collected. Demographic data, intra-operative vascular management, anesthesia techniques, airway management, patient positions, analgesia methods, and complications were evaluated in this retrospective cohort study. The available surgical intervention, patient positions, intra-operative neuromonitorization (IONM), and intra-operative magnetic resonance imaging (IOMR) records were also analyzed. Results: Six-hundred forty-six (55.4%) girls and 519 (44.5%) boys were included in the study. The median age was 60 (0–216) months. Cranial interventions were performed in 842 (72.3%) patients, and spinal interventions were performed in 323 (27.7%) patients. Patients’ American Society of Anesthesiologists (ASA) physical scales grouped as I, II, III, and IV were 718 (61.6%), 360 (30.9%), 82 (7%), and 5 (0.4%), respectively. Sevoflurane (40.3%), propofol (37.2%), and sodium thiopental (2.5%) were used for anesthetic induction. Neuromuscular block was performed with rocuronium (56.7%) and atracurium (14.4%). Neuromuscular blocking agents were not used in 337 patients (28.9%). A blood transfusion was required in 120 patients (10.3%), and 40% of these patients underwent surgery for craniosynostosis. Two-hundred twenty-two (19.1%) were monitored with IONM, and IOMR was carried out in 124 (10.6%) of the cases. The anesthesia-related complication rate was 5.15% (60 patients). Conclusion: Although pediatric neurosurgical interventions involve high risks, they are becoming increasingly common in our daily practice. Neuroanesthesiologists should know the procedures, techniques, and advances for safe and effective management of pediatric neurosurgical cases. We think that these data may be helpful as a guide for the anesthetic management of pediatric neurosurgical cases.

Retrospective Survey and Analysis of Anaesthesia and Outcomes in Paediatric Cleft Lip or Palate Surgery in a Tertiary Care Center, Portugal

INTRODUCTION

Orofacial clefts are the most common craniofacial abnormalities, affecting approximately one in 700 newborns each year. The anaesthetic management of these patients is challenging, including difficulties in airway approach and respiratory complications that have direct implications in the final outcome.

AIM

The present study aimed to characterize the anesthetic approach to paediatric patients undergoing cleft palate or lip surgical repair and review the perioperative anesthetic complications in a tertiary Portuguese hospital.

METHODS

Data were collected from a retrospective review of the patient records which included anaesthesia perioperative notes of paediatric patients submitted to cleft surgery repair during a five-year period (2016 to 2021). Demographic, pre-anaesthetic characteristics, anaesthetic management and perioperative complications were recorded.

RESULTS

A total of 102 patients were included, with a median age of 1.5 years. Congenital syndromes were present in 14 (13.7%) of the children included. Inhalational induction of anaesthesia with sevoflurane was the preferred approach in 86 cases (84.3%), with neuromuscular blockade being used in 59 cases (57.8%). Intubation was achieved at first attempt in 91 (89.2%) cases with four (3.9%) patients needing three or more attempts. Intraoperative respiratory-related complications were the most frequent, occurring in 22 (21.6%) cases. These include multiple attempts to intubation, desaturation due to bronchospasm or laryngospasm. The average length of stay was two days. Postoperative complications were recorded in 17 (16.7%) of patients.

DISCUSSION

The predominance of airway and respiratory complications occurring in cleft is consistent with previous studies. Care must be taken in order to avoid such complications in the perioperative period by following protocols, having skilled personnel, appropriate monitoring equipment and airway devices available during cleft surgeries to minimise morbidity.

Comparison of nonoperative versus operative management in pediatric gustilo-anderson type I open tibia fractures

BACKGROUND

Recent studies suggest pediatric Gustilo-Anderson type I fractures, especially of the upper extremity, may be adequately treated without formal operative debridement, though few tibial fractures have been included in these studies. The purpose of this study is to provide initial data suggesting whether Gustilo-Anderson type I tibia fractures may be safely treated nonoperatively.

METHODS

Institutional retrospective review was performed for children with type I tibial fractures managed with and without operative debridement from 1999 through 2020. Incomplete follow-up, polytrauma, and delayed diagnosis of greater than 12 h since the time of injury were criteria for exclusion. Data including age, sex, mechanism of injury, management, time-to-antibiotic administration, and complications were recorded.

RESULTS

Thirty-three patients met inclusion criteria and were followed to union. Average age was 9.9 ± 3.7 years. All patients were evaluated in the emergency department and received intravenous antibiotics within 8 h of presentation. Median time-to-antibiotics was 2 h. All patients received cefazolin except one who received clindamycin at an outside hospital and subsequent cephalexin. Three patients (8.8%) received augmentation with gentamicin. Twenty-one patients (63.6%) underwent operative irrigation and debridement (I&D), and of those, sixteen underwent surgical fixation of their fracture. Twelve (36.4%) patients had bedside I&D with saline under conscious sedation, with one requiring subsequent operative I&D and intramedullary nailing. Three infections (14.3%) occurred in the operative group and none in the nonoperative group. Complications among the nonoperative patients include delayed union (8.3%), angulation (8.3%), and refracture (8.3%). Complications among the operative patients include delayed union (9.5%), angulation (14.3%), and one patient experienced both (4.8%). Other operative group complications include leg-length discrepancy (4.8%), heterotopic ossification (4.8%), and symptomatic hardware (4.8%).

CONCLUSION

No infections were observed in a small group of children with type I tibia fractures treated with bedside debridement and antibiotics, and similar non-infectious complication rates were observed relative to operative debridement. This study provides initial data that suggests nonoperative management of type I tibial fractures may be safe and supports the development of larger studies.

Exploring Noncardiac Surgical Needs From Infancy to Adulthood in Patients With Congenital Heart Disease

OBJECTIVES

As life expectancy for patients born with congenital heart disease (CHD) continues to rise, these patients will present increasingly for noncardiac surgery during childhood and adolescence. This study aimed to map the lifespan of noncardiac surgical needs among patients with CHD and explore how these needs may change over time.

DESIGN

All patients with CHD presenting for noncardiac surgery between 2008 and 2014 were selected for review.

SETTING

The study was conducted at a single urban academic tertiary pediatric hospital.

PARTICIPANTS

All patients with CHD presenting for noncardiac surgery during the study period were included and grouped by cardiac diagnosis.

INTERVENTIONS

Descriptive analysis included patient demographics, CHD diagnosis, procedures performed, and clinical data, including baseline saturation and underlying cardiac function.

MEASUREMENTS AND MAIN RESULTS

A total of 3,011 noncardiac surgical procedures were performed on patients with CHD during the study period. The most common CHD diagnoses were patent ductus arteriosus (27.6%), ventricular septal defects (24.7%), and patent foramen ovale (24.3%). The median age was 4 years, 87% of all the patients were ≤10 years, and 41% had associated syndromes. Of the patients, 76% underwent a preoperative echocardiogram, and 10% had depressed cardiac function at the time of surgery. The most common procedures performed were ear, nose, and throat (20%), general surgery (14%), and radiology (11%). Intraoperative events were reported in 488 out of 3,010 encounters (16.2%), with the highest rates reported in patients with single-ventricle physiology (55/179; 30.7%).

CONCLUSIONS

These findings suggested a greater burden of noncardiac surgery in lower age groups, with ear, nose, and throat and general surgery most common in young children and orthopedic and dental procedures increasing in adolescence.

Predictive values of the modified Mallampati test, upper lip bite test, thyromental distance and ratio of height to thyromental distance to predict difficult laryngoscopy in pediatric elective surgical patients 5-12 years old at selected Addis Ababa governmental hospitals, Ethiopia: a multicenter cross-sectional study

BACKGROUND

Maintaining patent airways is vital in pediatric anesthetic management. Failure to manage and anticipate difficult laryngoscopy (DL) preoperatively is the leading cause of morbidity and mortality. Data on the predictive values of screening parameters in predicting DL are limited in children. Therefore, this study aimed to assess the predictive value of the modified Mallampati test (MMT), upper lip bite test (ULBT), thyromental distance (TMD), and ratio of height to thyromental distance (RHTMD) in predicting DL in children aged 5-12 years at selected Addis Ababa governmental hospitals in Ethiopia.

METHODS

A multicenter cross-sectional study was conducted on 141 elective pediatric surgical patients aged 5 to 12 years selected using a systematic random sampling technique at three governmental hospitals from December 1, 2021, to April 30, 2022. The collected data were entered and analysed by SPSS version 26. Chi-square and Fisher's exact tests were used to compare categorical variables. The receiver operating characteristic curve analysis was used to compare the accuracy of MMT, ULBT, TMD, and RHTMD against DL. A P value < 0.05 was considered statistically significant.

RESULTS

The magnitude of DL was 15.6%. MMT has the highest sensitivity (86.4%), specificity (91.6%), and negative predictive value (NPV) (97.3%) compared to other tests. The ULBT also has a high sensitivity (72.7%) and specificity (84%) with comparable diagnostic accuracy (90.8%) with the MMT (P < 0.05). The sensitivity, specificity, positive predictive value (PPV), NPV, and accuracy of TMD were 63.6%, 95.8%, 73.7%, 93.4%, and 82.2%, respectively. The RHTMD has the lowest specificity (63.6%), PPV (22.5%), NPV (91.4%), and accuracy (56.7%) in predicting DL.

CONCLUSION

The MMT and ULBT are good screening tests, followed by the TMD in predicting DL, while the RHTMD was the least accurate predictor. Because no single test has 100% predictive value, a combination of screening tests is advised in pediatrics for predicting DL.

The Development of an Enhanced Recovery Protocol for Kasai Portoenterostomy

Balancing post-operative adequate pain control, respiratory depression, and return of bowel function can be particularly challenging in infants receiving the Kasai procedure (hepatoportoenterostomy). We performed a retrospective chart review of all patients who underwent the Kasai procedure from a single surgeon at Children’s Healthcare of Atlanta from 1 January 2018, to 1 September 2022. 12 patients received the Kasai procedure within the study period. Average weight was 4.47 kg and average age was 7.4 weeks. Most patients received multimodal pain management including dexmedetomidine and/or ketorolac along with intravenous opioids. A balance of colloid and crystalloids were used for all patients; 57% received blood products as well. All patients were extubated in the OR and transferred to the general surgical floor without complications. Return of bowel function occurred in all patients by POD2, and enteral feeds were started by POD3. One patient had a presumed opioid overdose while admitted requiring a rapid response and brief oxygen supplementation. Simultaneously optimizing pain control, respiratory safety, and bowel function is possible in infants receiving the Kasai procedure. Based on our experience and the current pediatric literature, we propose an enhanced recovery protocol to improve patient outcomes in this fragile population. Larger, prospective studies implementing an enhanced recovery protocol in the Kasai population are required for stronger evidence and recommendations.

Ultrasound-guided epidural anesthesia and sedation for open transvesical Cohen ureteric reimplantation surgery in 20 consecutive children: a prospective case series and proof-of-concept study

BACKGROUND

Epidural anesthesia is usually combined with general anesthesia (GA) for children undergoing sub-umbilical surgery and GA in children is associated with a potential for respiratory events. Aiming to reduce airway manipulation and the use of GA drugs, we designed a study of transvesical Cohen ureteteric reimplantion under epidural anesthesia in sedated, spontaneously breathing children.

METHODS

We enrolled 20 children (3-83 months, 6.3-25.0 kg) scheduled for open transvesical abdominal surgery with Pfannenstiel incision. Sedation was followed by ultrasound-guided epidural anesthesia. Increases in heart rate by > 15% and or patient movements upon skin incision were rated as block deficiencies. Intubation equipment for advanced airway management was kept on standby. The primary study endpoint was successful blockade, meaning that no sequential airway management was required for the spontaneous breathing patients during surgery. Secondary endpoints included any use of fentanyl/propofol intraoperatively and of postoperative analgesics in the recovery room.

RESULTS

All 20 blocks were successful, with no block deficiencies upon skin incision, no need for sequential airway management, and stable SpO2 levels (97-100%). Surgery took a median of 120.5 minutes (IQR: 89.3-136.5) and included one bolus of fentanyl in one patient 120 minutes into a protracted operation. No more systemic analgesia had to be provided in the recovery room.

CONCLUSIONS

Sedation and epidural anesthesia emerged as a useful alternative to GA from our consecutive case series.

Assessing and conveying risks and benefits of imaging in neonates using ionizing radiation and sedation/anesthesia

Neonates represent a unique subset of the pediatric population that requires special attention and careful thought when implementing advanced cross-sectional imaging with CT or MRI. The ionizing radiation associated with CT and the sedation/anesthesia occasionally required for MRI present risks that must be balanced against the perceived benefit of the imaging examination in the unique and particularly susceptible neonatal population. We review the perceived risks of ionizing radiation and the more concrete risks of sedation/anesthesia in term and preterm neonates in the context of an imaging paradigm. When the expected diagnostic yield from CT and MRI is similar, and sedation is required for MRI but not for CT, CT likely has the higher benefit-to-risk ratio in the neonate. However, despite the risks, the most appropriate imaging modality should always be chosen after thoughtful consideration is given to each unique patient and informed discussions including radiology, anesthesia, neonatology and the parents/caregivers are pursued.

Anesthetic considerations in children with asthma

Due to the high prevalence of asthma and general airway reactivity, anesthesiologists frequently encounter children with asthma or asthma-like symptoms. This review focuses on the epidemiology, the underlying pathophysiology, and perioperative management of children with airway reactivity, including controlled and uncontrolled asthma. It spans from preoperative optimization to optimized intraoperative management, airway management, and ventilation strategies. There are three leading causes for bronchospasm (1) mechanical (eg, airway manipulation), (2) non-immunological anaphylaxis (anaphylactoid reaction), and (3) immunological anaphylaxis. Children with increased airway reactivity may benefit from a premedication with beta-2 agonists, non-invasive airway management, and deep removal of airway devices. While desflurane should be avoided in pediatric anesthesia due to an increased risk of bronchospasm, other volatile agents are potent bronchodilators. Propofol is superior in blunting airway reflexes and, therefore, well suited for anesthesia induction in children with increased airway reactivity.

Developmental respiratory physiology

Various developmental aspects of respiratory physiology put infants and young children at an increased risk of respiratory failure, which is associated with a higher rate of critical incidents during anesthesia. The immaturity of control of breathing in infants is reflected by prolonged central apneas and periodic breathing, and an increased risk of apneas after anesthesia. The physiology of the pediatric upper and lower airways is characterized by a higher flow resistance and airway collapsibility. The increased chest wall compliance and reduced gas exchange surface of the lungs reduce the pulmonary oxygen reserve vis-à-vis a higher metabolic oxygen demand, which causes more rapid oxygen desaturation when ventilation is compromised. This review describes the various developmental aspects of respiratory physiology and summarizes anesthetic implications.

Risk assessment and optimization strategies to reduce perioperative respiratory adverse events in pediatric anesthesia-Part 1 patient and surgical factors

Pediatric surgery cases are increasing worldwide. Within pediatric anesthesia, perioperative respiratory adverse events are the most common precipitant leading to serious complications. They can have intraoperative impact on the surgical procedure itself, lead to premature case termination and in addition may have postoperative impact resulting in longer hospitalization stays and costs. Although most perioperative respiratory adverse events can be promptly detected and managed, and will not lead to any sequelae, the risk of life-threatening progression remains. The incidence of respiratory adverse events increases in children with comorbid respiratory and/or nonrespiratory illnesses. Optimized perioperative patient care, risk-stratified care level choice, and practitioners with appropriate training allow for risk mitigation. This review will discuss patient and surgical risk factors with a focus on common patient comorbid illnesses and review scoring systems to quantify risk.

A novel nomogram for predicting respiratory adverse events during transport after interventional cardiac catheterization in children

OBJECTIVE

The rate and predictors of respiratory adverse events (RAEs) during transport discharged from operating room after interventional cardiac catheterization in children remain unclear. This study aimed to investigate the incidence and predictors, and to construct a nomogram for predicting RAEs during transport in this pediatric surgical treatment.

METHODS

This prospective cohort study enrolled 290 consecutive pediatric patients who underwent ventricular septal defects (VSD), atrial septal defects (ASD), and patent ductus arteriosus (PDA) between February 2019 and December 2020. Independent predictors were used to develop a nomogram, and a bootstrap resampling approach was used to conduct internal validation. Composite RAEs were defined as the occurrence of at least 1 complication regarding laryngospasm, bronchospasm, apnea, severe cough, airway secretions, airway obstruction, and oxygen desaturation.

RESULTS

The rate of RAEs during transport was 23.1% (67 out of 290). Multivariate analysis identified age (vs. ≤3 years, adjusted odds ratio (aOR) = 0.507, 95% confidence interval (CI), 0.268-0.958, P = 0.036), preoperative upper respiratory tract infections (URI, aOR = 2.335, 95% CI, 1.223-4.460, P = 0.01), type of surgery (vs. VSD, for ASD, aOR =  2.856, 95% CI, 1.272-6.411, P = 0.011; for PDA, aOR = 5.518, 95% CI, 2.425-12.553, P < 0.001), morphine equivalent (vs. ≤0.153 mg/kg, aOR = 2.904, 95% CI, 1.371-6.150, P = 0.005), atropine usage (aOR = 0.463, 95% CI, 0.244-0.879, P = 0.019), and RAEs during extubation to transport (aOR = 5.004, 95% CI, 2.633-9.511, P < 0.001) as independent predictors of RAEs during transport. These six candidate predictors were used to develop a nomogram, which showed a C-statistic value of 0.809 and good calibration (P = 0.844). Internal validation revealed similarly good discrimination (C-statistic, 0.782; 95% CI, 0.726-0.837) and calibration. Decision curve analysis (DCA) also demonstrated the clinical usefulness of the nomogram.

CONCLUSION

The high rate of RAEs during transport reminds us of the need for more medical care and attention. The proposed nomogram can reliably identify pediatric patients at high risk of RAEs during transport and guide clinicians to make proper transport plans. Our findings have important and meaningful implications for RAEs risk prediction, clinical intervention and healthcare quality control.

Should I irradiate with computed tomography or sedate for magnetic resonance imaging?

In the context of pediatric cross-sectional imaging, the risk of ionizing radiation for CT and the potential adverse effects associated with sedation/anesthesia for MRI continue to provoke lively discussions in the pediatric literature and lay press. This is particularly true for issues relating to the risks of ionizing radiation for CT, which has been a topic of discussion for nearly two decades. In addition to understanding these potential risks and the importance of minimizing individual pediatric patient exposure to ionizing radiation, it is equally important for radiologists to be able to frame these risks with respect to the potential for adverse outcomes associated with the use of anesthesia for cross-sectional imaging in the pediatric population. Notably, before such risks can be estimated and compared, one should always consider the potential utility of each imaging modality for a given diagnosis. If one cross-sectional imaging modality is likely to be far superior to the other for a specific clinical question, every effort must be made to safely image the child, even if sedation/anesthesia is required.

A prospective observational study on the feasibility of subumbilical laparoscopic procedures under epidural anesthesia in sedated spontaneously breathing infants with a natural airway

BACKGROUND

Laparoscopic procedures are usually performed under general anesthesia with a secured airway including endotracheal intubation or supraglottic airways.

AIMS

This is a prospective study of the feasibility of subumbilical laparoscopic procedures under epidural anesthesia in sedated, spontaneous breathing infants with a natural airway.

METHODS

We consecutively enrolled 20 children <3 years old with nonpalpable testes scheduled for diagnostic laparoscopy with or without an ensuing orchidopexy, inguinal revision, or Fowler-Stephens maneuver. Inhalational induction for venous access was followed by sedation with propofol and ultrasound-guided single-shot epidural anesthesia via the caudal or thoracolumbar approach using 1.0 or 0.5 ml kg^-1 ropivacaine 0.38%, respectively. The primary outcome measure was block success, defined as no increase in heart rate by >15% or other indicators of pain upon skin incision.

RESULTS

Of the 20 children (median age: 10 months; IQR: 8.3-12), 17 (85%) were anesthetized through a caudal and 3 (15%) through a direct thoracolumbar epidural, 18 (90%) underwent a surgical procedure and 2 (10%) diagnostic laparoscopy only. Five patients (25%) received block augmentation using an intravenous bolus of fentanyl (median dose: 0.9 µg kg^-1 ; IQR: 0.8-0.95) after the initial prick test and before skin incision. There was no additional need for systemic pain therapy in the operating theater or recovery room. No events of respiratory failure or aspiration were observed.

CONCLUSIONS

In experienced hands, given our success rate of 100%, epidural anesthesia performed in sedated spontaneously breathing infants with a natural airway can be an alternative strategy for subumbilical laparoscopic procedures.

Difficult tracheal intubation and perioperative outcomes in patients with congenital heart disease: A retrospective study

BACKGROUND AND OBJECTIVE

Management of difficult tracheal intubation during induction of anesthesia in children with congenital heart disease is challenging. The aim of this study is to evaluate the incidence of difficult tracheal intubation in patients with congenital heart disease and compare the incidence of perioperative complications and outcomes in patients with and without difficult tracheal intubation.

DESIGN

Retrospective cohort study.

SETTING

Tertiary Children's Hospital.

PARTICIPANTS

6858 patient-encounters including cardiac diagnostic, interventional or surgical procedures from 2012 to 2018 were reviewed.

EXCLUSION CRITERIA

age > 18 years, endotracheal tube or tracheostomy in-situ.

METHODS/INTERVENTIONS

Patients' demographics, number and methods of intubation, peri-intubation hemodynamics, intensive care unit and postoperative hospital length of stay were recorded. Multivariable mixed-effects median, logistic, ordinal, and multinomial regression modeling were implemented to analyze outcomes in the matched sets.

RESULTS

Of the 6014 encounters examined in the study, the incidence of DTI was 0.96% and all 58 difficult tracheal intubations (DTI) were matched using 1:2 propensity score matching to 116 non-DTI encounters. Number of intubation attempts was significantly higher among patients with difficult tracheal intubation (ordinal logistic regression odds ratio = 2; 95% CI; 1.3, 2.7; P < 0.001). No significant differences in peri-intubation hemodynamic stability were noted. Patients with difficult tracheal intubation had longer postoperative hospital length of stay (median = 12.1 vs 7.9 days, coef. = 4; 95% CI: 1.3, 6.8; P = 0.004) than patients without.

CONCLUSION

Despite a higher number of intubation attempts, our study shows no major differences in the peri-intubation hemodynamics in patients with and without difficult tracheal intubation. This risk can be mitigated by a good understanding of cardiac physiology, management of hemodynamics, and early use of an indirect intubation technique to maximize first attempt success.

It's Not Over Till It's Over: A Prospective Cohort Study and Analysis of "Anesthesia Stat!" Emergency Calls in the Pediatric Post-Anesthesia Care Unit (PACU)

Background

Emergency "Anesthesia Stat!" (AS!) calls remain a common practice in medical centers even when advanced communication infrastructures are available. We hypothesize that the analysis of post-procedure "AS!" calls will lead to actionable insights which may enhance patient safety.

Methods

After institutional review board approval, we prospectively collected data from April 2015 through May 2018 on "AS!" calls throughout the pediatric operating rooms (OR), off-site locations, and post-anesthesia care unit (PACU) at a tertiary university medical center. Data recorded included demographic information, location, time of the event, event duration, vital signs, medications, anesthesia staff, attending anesthesiologist, and staff responding to the call. A narrative account of the event was also documented.

Results

A total of 82 "AS!" calls occurred, with ages ranging from 11 days old to 17 years old. Forty-nine of the 82 calls (60%) occurred at emergence. Seventy-one of the 82 calls (87%) were solely respiratory-related. Thirty-five of 49 emergence calls (71%) occurred in the PACU. Further, 34 of 35 PACU calls (97%) were respiratory-related, with 30 of 35 PACU calls (86%) associated with desaturation requiring intervention by anesthesia staff. Finally, 31 of 35 PACU calls (89%) occurred within 30 minutes of patient arrival to PACU.

Conclusion

Analysis of "AS!" events from our PACU continues to support the need for the prompt and continuous availability of at least one staff member with advanced airway management skills. Further, pediatric patients undergoing general anesthesia and surgery should likely be monitored for a minimum of 30 minutes following arrival in the PACU.

Intranasal dexmedetomidine premedication in children with recent upper respiratory tract infection undergoing interventional cardiac catheterisation: A randomised controlled trial

BACKGROUND

Recent upper respiratory tract infection (URI) is a risk factor for the occurrence of peri-operative respiratory adverse events (PRAE). This risk may be higher in children with congenital heart disease (CHD), particularly in those undergoing interventional cardiac catheterisation. It is therefore essential to adapt the anaesthetic strategy in these children to prevent from the occurrence of PRAE.

OBJECTIVE

To determine whether intranasal dexmedetomidine (DEX) premedication can reduce the incidence of PRAE in children with recent URI undergoing interventional cardiac catheterisation.

DESIGN

Randomised controlled trial.

SETTING

Single-centre study based at a tertiary care centre in Shanghai, China.

PATIENTS

A total of 134 children with CHD aged 0 to 16 years with recent URI undergoing interventional cardiac catheterisation.

INTERVENTIONS

Children were randomised to receive either intranasal DEX 1.5 μg kg (DEX group) or intranasal saline (Placebo group) 30 to 45 min before anaesthesia induction.

MAIN OUTCOME MEASURES

The incidence of PRAE.

RESULTS

Intranasal DEX significantly reduced the incidence of PRAE (P = 0.001), particularly oxygen desaturation (P = 0.012). Most PRAE were observed during the emergence phase. The incidence of PRAE was comparable among the three types of left-right shunt CHD children in both groups. In children aged less than 3 years, the incidence of PRAE was significantly lower in the DEX group (P = 0.003). In contrast, the incidence of PRAE was comparable between the two groups in children aged at least 3 years. No differences in the incidence of emergence agitation, fever and vomiting between the two groups were noted.

CONCLUSION

Administration of intranasal DEX 1.5 μg kg 30 to 45 min before induction led to a reduction in the incidence of PRAE in children aged less than 3 years with recent URI undergoing interventional cardiac catheterisation.

TRIAL REGISTRATION

chictr.org.cn identifier: ChiCTR-RRC-17012519.

Incidence of post-anesthetic respiratory complications in pediatrics. Observational, single-center study in Medellin, Colombia

Introduction: Post-anesthetic complications, particularly respiratory complications, continue to be a source of concern due to their high frequency, particularly in pediatrics. Objective: To describe the incidence of respiratory complications in the post-anesthesia care unit of an intermediate complexity center during a six-month period, and to explore the variables associated with major respiratory complications. Materials and Methods: Retrospective cohort study based on clinical record reviews. The records of the post-anesthesia care unit of an intermediate complexity pediatric institution located in Medellin, Colombia, were reviewed. This center uses a nursing-based care model that includes patient extubation in the post-anesthesia care unit. Results: The records of 1181 patients were analyzed. The cumulative incidences of major complications were bronchospasm 1.44%, laryngospasm 0.68% and respiratory depression 0.59%. There were no cases of cardiac arrest or acute pulmonary edema. A history of respiratory infection less than 15 days before the procedure, rhinitis and female sex were associated with major respiratory complications. Conclusions: A low frequency of respiratory complications was found during care provided by nursing staff trained in anesthesia recovery and pediatric airway in the post-anesthesia care unit.

Intraoperative dextrose rate during exploratory laparotomies in neonates and the incidence of postoperative hyperglycemia: A retrospective observational study

INTRODUCTION

Compared with the older pediatric population, neonates have greater perioperative morbidity and mortality. Difficulty with glucose regulation may be a contributing modifiable risk factor during perioperative anesthetic management. To mitigate the risk of hyperglycemia in neonates, some providers empirically halve the preoperative rate of dextrose-containing infusions during surgery.

AIM

To assess the association between halving the preoperative maintenance dextrose rate and postoperative euglycemia in neonatal intensive care unit patients undergoing exploratory laparotomies.

METHODS

Neonatal intensive care unit patients who underwent exploratory laparotomy under general anesthesia from 1/1/2014 to 11/21/2019 were included in this analysis. Hyperglycemia and hypoglycemia were defined as >150 mg/dL and <46 mg/dL. A calculated dextrose ratio was utilized to categorize patients into full and half intraoperative dextrose rate cohorts. Univariate analyses were performed with Fisher's exact test, the Wilcoxon rank sum test, or Spearman's correlation. Multivariable analyses with regression models were conducted after graphical evaluation of a predetermined set of independent variables.

RESULTS

107 patients were included in the full dextrose rate cohort and 96 patients in the half dextrose rate cohort with postoperative hyperglycemia occurring in 47 and 28 patients, respectively. On univariate analysis, halving the preoperative dextrose rate was associated with decreased postoperative hyperglycemia (odds ratio: 0.53; 95% CI: 0.28-0.98, P = 0.041). This association continued in the regression model (adjusted odds ratio: 0.49; 95% CI: 0.25-0.80, P = 0.008) after controlling for preoperative dextrose rate, preoperative serum glucose, preoperative pH, surgical duration, postmenstrual age at surgery, and the presence of necrotizing enterocolitis. Only one patient was hypoglycemic postoperatively, and they were in the full dextrose cohort.

CONCLUSION

Halving of preoperative dextrose rates intraoperatively during exploratory laparotomy in neonatal intensive care unit patients was associated with a decreased risk of postoperative hyperglycemia without substantially increasing the occurrence of postoperative hypoglycemia. The practice of halving preoperative dextrose rates may be an effective empirical approach for intraoperative glucose management in the high-risk neonatal population when blood glucose monitoring is challenging.

Best practice & research clinical anesthesiology: Safety and quality in perioperative anesthesia care. Update on safety in pediatric anesthesia

Pediatric anesthesia is large part of anesthesia clinical practice. Children, parents and anesthesiologists fear anesthesia because of the risk of acute morbidity and mortality. Modern anesthesia in otherwise healthy children above 1 year of age in developed countries has become very safe due to recent advance in pharmacology, intensive education, and training as well as centralization of care. In contrast, anesthesia in these children in low-income countries is associated with a high risk of mortality due to lack of basic resources and adequate training of health care providers. Anesthesia for neonates and toddlers is associated with significant morbidity and mortality. Anesthesia-related (near) critical incidents occur in 5% of anesthetic procedures and are largely dependent on the skills and up-to-date knowledge of the whole perioperative team in the specific needs for children. An investment in continuous medical education of the perioperative staff is required and international standard operating protocols for common procedures and critical situations should be defined.

Outcomes from wake up safe, the pediatric anesthesia quality improvement initiative

BACKGROUND

Wake Up Safe, a Patient Safety Organization founded by the Society for Pediatric Anesthesia, collects data on serious adverse events along with demographic data from all pediatric patients receiving anesthesia care at participating institutions. This report reviews all events occurring between 2010 and 2015 and focuses on common adverse events that are anesthesia-related.

AIMS

Determine which adverse events were most common from 2010 to 2015 among participating Wake Up Safe institutions. Determine how many anesthesia-related events were deemed to be preventable.

METHODS

This is a descriptive report. The Wake Up Safe registry data were queried on September 29, 2017. Institutions were included if they had complete demographic data and at least 5 adverse events per year reported. At that time, 19 out of 29 institutions had complete demographic data for events from 2010 to 2015. This study describes demographic data and adverse events from these nineteen institutions. Descriptive data were extracted, and event rate was calculated for each adverse event category. In events that were assessed as primarily related to anesthesia, further detailed analysis was performed.

RESULTS

Of all reported adverse events (2544 events), the most common were cardiac arrests (646, 31.6%), respiratory complications (598, 29.2%), and medication events (345, 16.9%). Of all anesthesia-related events (612 events), medication events were the most common (239, 31.9%), followed by respiratory complications (181, 24.1%), and cardiac arrests (139, 18.5%). Overall, 85% of anesthesia-related serious adverse events were deemed somewhat or almost certainly preventable.

CONCLUSIONS

The majority of anesthesia-related serious adverse events reported to the Wake Up Safe database are preventable. Medication events are the most common anesthesia-related adverse events. Innovations aimed at decreasing medication events may be the most impactful.

The safety profile and effectiveness of propofol-remifentanil mixtures for total intravenous anesthesia in children

BACKGROUND

Total intravenous anesthesia is used in less than 10% of operations in the UK. Many pediatric anesthetists in the UK and Ireland administer total intravenous anesthesia to children using a mixture of propofol and remifentanil in the same syringe. This unlicensed drug has not been studied clinically, because of lack of Medicines and Healthcare products Regulatory Agency (UK) or Food and Drug Administration (US) approval to undertake such studies.

AIM

The aim of this service evaluation was to assess the safety profile and effectiveness of propofol-remifentanil mixtures in the pediatric population undergoing a variety of surgical procedures.

METHODS

Pediatric Anesthetists in the UK and Ireland who regularly used propofol-remifentanil mixtures for total intravenous anesthesia were invited to submit data. This data were analyzed to assess the effectiveness of anesthesia and the incidence and nature of any complications that occurred.

RESULTS

Usable data were collected from 873 patients. Mixtures were most commonly administered in gastroenterology and ear, nose, and throat procedures. Two-thirds of patients were less than 10 years old, and their mean weight was 28.7 kg. Anesthesia using the mixture alone was successful in all but 3 patients. The commonest nonserious complication was coughing (4.6%), followed by movement (3.3%). The overall incidence of serious, related, unexpected adverse events requiring intervention was 1.7%. These included desaturation (5 patients), apnea (3), abdominal/chest rigidity (2), cough requiring paralysis (2), ventilatory problems (2), and hypotension (1). Most occurred at induction, were attributable to the properties of the drugs being administered and not directly related to the use of the mixture. No life-threatening adverse events were recorded. Complications were less common if a ≤5 μg mL^-1 concentration of remifentanil was used.

CONCLUSION

These data demonstrate that effective anesthesia can be administered to pediatric patients undergoing a wide range of procedures using mixtures of propofol and remifentanil. Serious, related, unexpected adverse events requiring intervention had a low incidence and were largely due to predictable effects of the drugs being administered. A ≤5 μg mL^-1 remifentanil concentration is associated with proportionately less complications.

Comprehensive Risk Assessment of Morbidity in Pediatric Patients Undergoing Noncardiac Surgery: An Institutional Experience

BACKGROUND

Utilizing the intrinsic surgical risk (ISR) and the patient's chronic and acute conditions, this study aims to develop and validate a comprehensive predictive model of perioperative morbidity in children undergoing noncardiac surgery.

METHODS

Following institutional review board (IRB) approval at a tertiary care children's hospital, data for all noncardiac surgical encounters for a derivation dataset from July 2017 to December 2018 including 16,724 cases and for a validation dataset from January 2019 to December 2019 including 9043 cases were collected retrospectively. The primary outcome was a composite morbidity score defined by unplanned transfer to an intensive care unit (ICU), acute respiratory failure requiring intubation, postoperative need for noninvasive or invasive positive pressure ventilation, or cardiac arrest. Internal model validation was performed using 1000 bootstrap resamples, and external validation was performed using the 2019 validation cohort.

RESULTS

A total of 1519 surgical cases (9.1%) experienced the defined composite morbidity. Using multivariable logistic regression, the Risk Assessment of Morbidity in Pediatric Surgery (RAMPS) score was developed with very good predictive ability in the derivation cohort (area under the curve [AUC] = 0.805; 95% confidence interval [CI], 0.795-0.816), very good internal validity using 1000 bootstrap resamples (bias-corrected Nagelkerke R = 0.21 and Brier score = 0.07), and good external validity (AUC = 0.783; 95% CI, 0.770-0.797). The included variables are age <5 years, critically ill, chronic condition indicator (CCI) ≥3, significant CCI ≥2, and ISR quartile ≥3. The RAMPS score ranges from 0 to 10, with the risk of composite morbidity ranging from 1.8% to 42.7%.

CONCLUSIONS

The RAMPS score provides the ability to identify a high-risk cohort of pediatric patients using a 5-component tool, and it demonstrated good internal and external validity and generalizability. It also provides an opportunity to improve perioperative planning with the intent of improving both individual-patient outcomes and the appropriate allocation of health care resources.

Non-operative versus operative management of open fractures in the paediatric population: A systematic review and meta-analysis of the adverse outcomes

Open fractures are at greater risk of infection and delayed bone healing. Guidelines to reduce these risks exist for adult open fracture management but not for paediatric open fractures, where there is considerable practice variability. This systematic review evaluates the quality of the evidence and clinical outcomes for paediatric open fractures treated non-operatively versus operatively. A PROSPERO-registered, PRISMA-compliant systematic review and meta-analysis. Databases searched were MEDLINE, Embase and Web of Science (WoS) up to March 2019. Clinical studies reporting adverse outcomes of both non-operative and operative management of paediatric open fractures were included. Data extracted included demographics, treatment methods and outcomes. The primary outcome was infection (osteomyelitis and/or wound infection). Secondary outcomes were abnormalities of bone healing (delayed union, malunion and nonunion) and re-fracture. The ROBINS-I tool was used to assess risk of bias. Seventeen studies reporting 1093 open fractures were included. Non-operatively managed injuries had a lower risk of osteomyelitis (RR 0.33 [95%CI 0.12-0.86]), wound infection (RR 0.47 [95%CI 0.22-0.97]) and nonunion (RR 0.27 [95%CI 0.09-0.80]). Gustilo-Anderson (GA) III injuries had the highest incidence of osteomyelitis (10.7%) with no difference in outcome between operative and non-operative groups (RR 0.67 [95%CI 0.22-2.03]). Tibial GA III fractures were associated with a lower risk of osteomyelitis than femoral fractures: adverse effects were seen in the operative group. All studies were retrospective, observational and at high risk of bias. The quality of the evidence relating to paediatric open fractures is low, and findings are limited by significant methodological flaws in the literature. GA I and II fractures were commonly managed non-operatively and associated with a lower infection rate. Operative intervention was more frequent in GA III fractures, where the risk of infection was highest. Operative management of GA III fractures was not associated with a lower infection risk compared to non-operative management. Robust prospective multi-centre studies are needed to explore further the most effective management of paediatric open fractures and to inform guideline development.

Recognizing Risks and Optimizing Perioperative Care to Reduce Respiratory Complications in the Pediatric Patient

There have been significant advancements in the safe delivery of anesthesia as well as improvements in surgical technique; however, the perioperative period can still be high risk for the pediatric patient. Perioperative respiratory complications (PRCs) are some of the most common critical events that can occur in pediatric surgical patients and they can lead to increased length of hospitalization, worsened patient outcomes, and higher hospital and postoperative costs. It is important to determine the various factors that put pediatric patients at increased risk of PRCs. This will allow for more detailed and accurate informed consent, optimized perioperative management strategy, improved allocation of clinical resources, and, hopefully, better patient experience. There are only a few risk prediction models/scoring tools developed for and validated in the pediatric patient population, but they have been useful in helping identify the key factors associated with a high likelihood of developing PRCs. Some of these factors are patient factors, while others are procedure-related factors. Some of these factors may be modified such that the patient’s clinical status is optimized preoperatively to decrease the risk of PRCs occurring perioperatively. Fore knowledge of the factors that are not able to be modified can help guide allocation of perioperative clinical resources such that the negative impact of these non-modifiable factors is buffered. Additional training in pediatric anesthesia or focused expertise in pediatric airway management, vascular access and management of massive hemorrhage should be considered for the perioperative management of the less than 3 age group. Intraoperative ventilation strategy plays a key role in determining respiratory outcomes for both adult and pediatric surgical patients. Key components of lung protective mechanical ventilation strategy such as low tidal volume and moderate PEEP used in the management of acute respiratory distress syndrome (ARDS) in pediatric intensive care units have been adopted in pediatric operating rooms. Adequate post-operative analgesia that balances pain control with appropriate mental status and respiratory drive is important in reducing PRCs.

A Multivariable Model Predictive of Unplanned Postoperative Intubation in Infant Surgical Patients

BACKGROUND

Unplanned postoperative intubation is an important quality indicator, and is associated with significantly increased mortality in children. Infant patients are more likely than older pediatric patients to experience unplanned postoperative intubation, yet the literature provides few characterizations of this outcome in our youngest patients. The objective of this study was to identify risk factors for unplanned postoperative intubation and to develop a scoring system to predict this complication in infants undergoing major surgical procedures.

METHODS

In this retrospective cohort study, The National Surgical Quality Improvement Program-Pediatric database was surveyed for all infants who underwent noncardiac surgery between January 1, 2012 and December 31, 2015 (derivation cohort, n = 56,962) and between January 1 and December 31, 2016 (validation cohort, n = 20,559). Demographic and perioperative clinical characteristics were examined in association with our primary outcome of unplanned postoperative intubation within 30 days of surgery. Risk factors were analyzed in the derivation cohort (2012-2015 data) using multivariable logistic regression with stepwise selection. Parameters from the final model were used to create a scoring system for predicting unplanned postoperative intubation. Data from the validation cohort were utilized to assess the performance of the scoring system using the area under the receiver operating characteristic curve.

RESULTS

In the derivation cohort, 2.2% of the infants experienced unplanned postoperative intubation within 30 days of surgery. Of the 14 risk factors identified in multivariable analysis, 10 (age, prematurity, American Society of Anesthesiologists physical status, inpatient status, operative time >120 minutes, cardiac disease, malignancy, hematologic disorder, oxygen supplementation, and nutritional support) were included in the final multivariable logistic regression model to create the risk score. The area under the receiver operating characteristic curve of the final model was 0.86 (95% CI, 0.85-0.87) for the derivation cohort and 0.83 (95% CI, 0.82-0.85) for the validation cohort.

CONCLUSIONS

About 1 in 50 infants undergoing major surgical procedures experiences unplanned postoperative intubation. Our scoring system based on routinely collected perioperative assessment data can predict risk in infants with good accuracy. Further investigation should assess the clinical utility of the scoring system for risk stratification and improvement in perioperative care quality and patient outcomes.

Pediatric Thyroidectomy: NSQIP-P Analysis of Adverse Perioperative Outcomes

Background:

This study identifies risk factors and 30-day adverse outcomes of pediatric patients undergoing thyroidectomy.

Methods:

Retrospective analysis utilizing the American College of Surgeons National Surgical Quality Improvement–Pediatric Database (2015-2016). Study population includes pediatric patients (≤18 years) who underwent hemithyroidectomy (HT), total thyroidectomy (TT), and total thyroidectomy with central neck dissection (TT+ND).

Results:

A total of 720 cases were identified; mean age at time of surgery was 14.1 years, with a female-to-male ratio of 3.4:1. Following hospital discharge, there were 10 related readmissions, with 1 patient requiring reoperation for neck hematoma evacuation. Regression analysis revealed anesthesia time had a significant impact on total length of stay ( P = .0020).

Conclusion:

Contemporary pediatric thyroidectomy has a low incidence of 30-day general surgical postoperative complications. Future research efforts are necessary once thyroidectomy specific variables are incorporated into ACS-NSQIP-P, which will provide further insights into managing this unique patient population.

Management of Pediatric Type I Open Fractures in the Emergency Department or Operating Room: A Multicenter Perspective

BACKGROUND

The management of pediatric type I open fractures remains controversial. The aim of this study is to compare outcomes in type I open fractures managed with superficial wound debridement and antibiotics in the emergency department (ED) (nonoperative management) to patients managed with operative debridement and antibiotics (operative management).

METHODS

A multicenter retrospective review was performed of all pediatric type I open forearm, wrist, and tibia fractures treated at 4 high volume pediatric centers between 2000 and 2015. Patients with multiple traumatic injuries, immunocompromised patients, or those without final radiographs indicating healing were excluded.

RESULTS

In total, 219 patients met inclusion criteria. A total of 170 fractures were treated operatively (77.6%), 49 fractures were treated nonoperatively (22.4%). There was 1 infection in the nonoperative group (2.0% infection rate), and no infections in the operatively managed group (P=0.062). Cefazolin was the most commonly administered antibiotic (88.1% of patients). Duration of hospital-administered antibiotics was significantly different, with a mean of 10.9 hours in the nonoperative group and 41.6 hours in the operative group (P<0.001). Length of stay averaged 16.3 hours for nonoperative patients and 48.6 hours for the operatively treated patients (P<0.001). In the nonoperative group, 44/49 had documented superficial wound debridement in the ED utilizing, on an average, 1500 mL of irrigant. There were 10 other complications, 9 in the operative group (5.4%) and 2 in the nonoperative group (4.1%, P=0.107), including 2 compartment syndromes and 1 acute carpal tunnel syndrome all requiring immediate surgical release (1.8%) in the operative group.

CONCLUSIONS

There was no significant difference in infection rate or complication rate in those managed with antibiotics and operative debridement versus those managed with superficial wound debridement and antibiotics in the ED. Consideration should be given to the similar safety profiles for these 2 treatment modalities when managing pediatric patients with type I open fractures.

LEVEL OF EVIDENCE

Level III.

Cardiovascular and respiratory physiology in children

Children are at increased risk of perioperative respiratory and cardiovascular complications because of their unique respiratory and cardiovascular physiology compared to adults. Anaesthesia can exaggerate respiratory deterioration in young children because of their inability to control respiration and inherent susceptibility to rapid desaturation, airway obstruction, early respiratory fatigue and lung atelectasis. Premature infants (less than 60 weeks of postconceptional age) can be exposed to the danger of prolonged apnoea and consequent worsening of respiratory function. The transitional phase of circulation is vulnerable to revert to persistent foetal circulation in neonates. Myocardium and autonomic control of the heart is immature and different in neonates and infants compared to older children and adults and are predisposed to inadvertent life-threatening haemodynamic changes during the perioperative period. In this review article, we discuss respiratory and cardiovascular physiology in neonates, infants and younger children and their differences with older children and adults. We mainly focus on transitional physiology of both respiratory and cardiovascular system in newborns and infants and the deleterious changes that may occur during anaesthesia or perioperatively.

Essentials of Pulmonology

Pulmonary complications are a major cause of perioperative morbidity in the pediatric population. Although preexisting pulmonary pathologic processes in children can present significant challenges to anesthetic delivery, a thorough assessment of the problem combined with meticulous anesthetic management allows most children to undergo surgical interventions without long-term adverse sequelae. Asthma, cystic fibrosis and sickle cell disease continue to pose challenges during anesthesiology. Consultation with a pediatric pulmonologist is indicated when appropriate for specific problems as outlined in this chapter; a team approach may markedly improve operative and postoperative outcomes.

Congenital Choanal Atresia Repair: An Analysis of Adverse Perioperative Events

Objectives

To identify risk factors and determine the perioperative morbidity of infants undergoing congenital choanal atresia (CCA) repair.

Study Design

Retrospective analysis of the ACS-NSQIP-P database (American College of Surgeons National Surgical Quality Improvement–Pediatric).

Setting

Tertiary medical center.

Subjects and Methods

Patients who underwent CCA repair at age ≤365 days at the time of surgery were queried via the ACS-NSQIP-P database (2013-2016) via Current Procedural Terminology code 30540. Analyzed outcomes include age, length of stay, medical comorbidities, operative time, readmission, reoperation, and postoperative complications.

Results

A total of 168 patients were identified, 70 of which were within the neonatal period. Preoperatively, gastrointestinal disease ( P < .0001), mechanical ventilation ( P < .0001), and oxygen supplementation ( P = .0040) were significantly greater in frequency among neonates. For all children preoperatively, ASA class ( P < .0001), chronic lung disease ( P = .0019), oxygen supplementation ( P < .0001), and prematurity ( P = .0016) had a significant impact on prolonged length of stay. Neonates had a persistent requirement for postoperative mechanical ventilation ( P < .0001) and a prolonged length of stay ( P < .00001).

Conclusion

Neonates undergoing CCA repair are more likely to have a persistent requirement for postoperative mechanical ventilation and a prolonged length of stay. Recognition of key clinical factors may aid in optimizing perioperative risk assessment, patient counseling, and procedural planning.

An Analysis of Safety and Adverse Events Following Cochlear Implantation in Children Under 12 Months of Age

OBJECTIVE

To determine perioperative morbidity of children ≤12 months undergoing cochlear implantation (CI).

STUDY DESIGN

Retrospective analysis using the American College of Surgeons National Surgical Quality Improvement Program Pediatric Database (ACS-NSQIP-P).

SETTING

General acute care children's hospitals, children's hospitals within larger hospitals, specialty children's hospitals, and general acute care hospitals with a pediatric wing.

PATIENTS

Children who underwent CI were queried using the ACS-NSQIP-P from 2012 to 2015.

INTERVENTION

Cochlear implantation.

MAIN OUTCOME MEASURES

Risk factors analyzed include age, prematurity, and presence of congenital disorders. Outcomes analyzed include operative time, length of stay, general surgical complications, readmissions, and related reoperations.

RESULTS

Over the database accrual period, the percentage of children ≤12 months at the time of surgery increased from 2012 to 2015 (6.08-7.78%, p = 0.0752). Total operative time, length of stay (≥1 d), and readmissions for those ≤12 months were significantly greater compared with those >12 months at the time of surgery (p < 0.001, p = 0.0037, and p < 0.0001, respectively). There were no statistically significant differences in general surgical complications (i.e., superficial incisional surgical site infections, organ/space surgical site infections, and/or unplanned reoperations) in cases ≤12 months. Complications specific to CI such as facial nerve paralysis, cerebrospinal fluid leak, and mastoiditis were not recorded in the ACS-NSQIP-P.

CONCLUSION

Infants had no more general surgical complications in the immediate postoperative period compared with older children, although total operative time, length of stay, and readmissions were found to be significantly greater in frequency.

Inhalational versus Intravenous Induction of Anesthesia in Children with a High Risk of Perioperative Respiratory Adverse Events: A Randomized Controlled Trial

BACKGROUND

Limited evidence suggests that children have a lower incidence of perioperative respiratory adverse events when intravenous propofol is used compared with inhalational sevoflurane for the anesthesia induction. Limiting these events can improve recovery time as well as decreasing surgery waitlists and healthcare costs. This single center open-label randomized controlled trial assessed the impact of the anesthesia induction technique on the occurrence of perioperative respiratory adverse events in children at high risk of those events.

METHODS

Children (N = 300; 0 to 8 yr) with at least two clinically relevant risk factors for perioperative respiratory adverse events and deemed suitable for either technique of anesthesia induction were recruited and randomized to either intravenous propofol or inhalational sevoflurane. The primary outcome was the difference in the rate of occurrence of perioperative respiratory adverse events between children receiving intravenous induction and those receiving inhalation induction of anesthesia.

RESULTS

Children receiving intravenous propofol were significantly less likely to experience perioperative respiratory adverse events compared with those who received inhalational sevoflurane after adjusting for age, sex, American Society of Anesthesiologists physical status and weight (perioperative respiratory adverse event: 39/149 [26%] vs. 64/149 [43%], relative risk [RR]: 1.7, 95% CI: 1.2 to 2.3, P = 0.002, respiratory adverse events at induction: 16/149 [11%] vs. 47/149 [32%], RR: 3.06, 95% CI: 1.8 to 5. 2, P < 0.001).

CONCLUSIONS

Where clinically appropriate, anesthesiologists should consider using an intravenous propofol induction technique in children who are at high risk of experiencing perioperative respiratory adverse events.

VISUAL ABSTRACT

An online visual overview is available for this article at http://links.lww.com/ALN/B725.

Ionizing radiation from computed tomography versus anesthesia for magnetic resonance imaging in infants and children: patient safety considerations

In the context of health care, risk assessment is the identification, evaluation and estimation of risk related to a particular clinical situation or intervention compared to accepted medical practice standards. The goal of risk assessment is to determine an acceptable level of risk for a given clinical treatment or intervention in association with the provided clinical circumstances for a patient or group of patients. In spite of the inherent challenges related to risk assessment in pediatric cross-sectional imaging, the potential risks of ionizing radiation and sedation/anesthesia in the pediatric population are thought to be quite small. Nevertheless both issues continue to be topics of discussion concerning risk and generate significant anxiety and concern for patients, parents and practicing pediatricians. Recent advances in CT technology allow for more rapid imaging with substantially lower radiation exposures, obviating the need for anesthesia for many indications and potentially mitigating concerns related to radiation exposure. In this review, we compare and contrast the potential risks of CT without anesthesia against the potential risks of MRI with anesthesia, and discuss the implications of this analysis on exam selection, providing specific examples related to neuroblastoma surveillance imaging.

Characteristics of Mandarin Open-set Word Recognition Development among Chinese Children with Cochlear Implants

Background:

Cochlear implants (CIs) can improve speech recognition for children with severe congenital hearing loss, and open-set word recognition is an important efficacy measure. This study examined Mandarin open-set word recognition development among Chinese children with CIs and normal hearing (NH).

Methods:

This study included 457 children with CIs and 131 children with NH, who completed the Mandarin lexical neighborhood test. The results for children at 1–8 years after receiving their CIs were compared to those from the children with NH using linear regression analysis and analysis of variance.

Results:

Recognition of disyllabic easy words, disyllabic hard words, monosyllabic easy words, and monosyllabic hard words increased with time after CI implantation. Scores for cases with implantation before 3 years old were significantly better than those for implantation after 3 years old. There were significant differences in open-set word recognition between the CI and NH groups. For implantation before 2 years, there was no significant difference in recognition at the ages of 6–7 years, compared to 3-year-old children with NH, or at the age of 10 years, compared to 6-year-old children with NH. For implantation before 3 years, there was no significant difference in recognition at the ages of 8–9 years, compared to 3-year-old children with NH, or at the age of 10 years, compared to 6-year-old children with NH. For implantation after 3 years, there was a significant difference in recognition at the age of 13 years, compared to 3-year-old children with NH.

Conclusions:

Mandarin open-set word recognition increased with time after CI implantation, and the age at implantation had a significant effect on long-term speech recognition. Chinese children with CIs had delayed but similar development of recognition, compared to normal children. Early CI implantation can shorten the gap between children with CIs and normal children.

Application of end-tidal carbon dioxide monitoring via distal gas samples in ventilated neonates

BACKGROUND

Previous research has suggested correlations between the end-tidal partial pressure of carbon dioxide (P_ETCO₂) and the partial pressure of arterial carbon dioxide (PaCO₂) in mechanically ventilated patients, but both the relationship between P_ETCO₂ and PaCO₂ and whether P_ETCO₂ accurately reflects PaCO₂ in neonates and infants are still controversial. This study evaluated remote sampling of P_ETCO₂ via an epidural catheter within an endotracheal tube to determine the procedure's clinical safety and efficacy in the perioperative management of neonates.

METHODS

Abdominal surgery was performed under general anesthesia in 86 full-term newborns (age 1-30 days, weight 2.55-4.0 kg, American Society of Anesthesiologists class I or II). The infants were divided into 2 groups (n = 43 each), and carbon dioxide (CO₂) gas samples were collected either from the conventional position (the proximal end) or a modified position (the distal end) of the epidural catheter.

RESULTS

The P_ETCO₂ measured with the new method was significantly higher than that measured with the traditional method, and the difference between P_ETCO₂ and PaCO₂ was also reduced. The accuracy of P_ETCO₂ measured increased from 78.7% to 91.5% when the modified sampling method was used. The moderate correlation between P_ETCO₂ and PaCO₂ by traditional measurement was 0.596, which significantly increased to 0.960 in the modified sampling group. Thus, the P_ETCO₂ value was closer to that of PaCO₂.

CONCLUSION

P_ETCO₂ detected via modified carbon dioxide monitoring had a better accuracy and correlation with PaCO₂ in neonates.

The Efficacy of Lidocaine in Laryngospasm Prevention in Pediatric Surgery: a Network Meta-analysis

Higher incidence and worse outcomes of laryngospasm during general anesthesia in children than adults have been reported for many years, but few prevention measures are put forward. Efficacy of lidocaine in laryngospasm prevention has been argued for many years and we decided to design this network meta-analysis to assess the efficacy of lidocaine. We conducted an electronic search of six sources and finally included 12 Randomized Controlled Trials including 1416 patients. A direct comparison between lidocaine and placebo revealed lidocaine had the effect on preventing laryngospasm in pediatric surgery (RR = 0.46, 95% CI = [0.30, 0.70], P = 0.0002, I² = 0%). Both subgroup analysis and network analysis demonstrated that both intravenous lidocaine (subgroup: RR = 0.39, 95% CI = [0.18, 0.86], P = 0.02, I² = 38%; network: RR = 0.25, 95% CI = [0.04, 0.86]) and topical lidocaine (subgroup: RR = 0.37, 95% CI = [0.19, 0.72], P = 0.003, I² = 0%; network: RR = 0.14, 95% CI = [0.02, 0.55]) was effective in laryngospasm prevention, while no statistical difference was found in a comparison between intravenous and topical lidocaine. In conclusion, both intravenous and topical lidocaine are effective in laryngospasm prevention in pediatric surgery, while a comparison between them needs more evidences.

Intraoperative complications in pediatric neurosurgery: review of 1807 cases

OBJECTIVE Minimal literature exists on the intraoperative complication rate of pediatric neurosurgical procedures with respect to both surgical and anesthesiological complications. The aim of this study, therefore, was to establish intraoperative complication rates to provide patients and parents with information on which to base their informed consent and to establish a baseline for further targeted improvement of pediatric neurosurgical care. METHODS A clinical complication registration database comprising a consecutive cohort of all pediatric neurosurgical procedures carried out in a general neurosurgical department from January 1, 2004, until July 1, 2012, was analyzed. During the study period, 1807 procedures were performed on patients below the age of 17 years. RESULTS Sixty-four intraoperative complications occurred in 62 patients (3.5% of procedures). Intraoperative mortality was 0.17% (n = 3). Seventy-eight percent of the complications (n = 50) were related to the neurosurgical procedures, whereas 22% (n = 14) were due to anesthesiology. The highest intraoperative complication rates were for cerebrovascular surgery (7.7%) and tumor surgery (7.4%). The most frequently occurring complications were cerebrovascular complications (33%). CONCLUSIONS Intraoperative complications are not exceptional during pediatric neurosurgical procedures. Awareness of these complications is the first step in preventing them.