Diversity, equity, and inclusion within the Society for Pediatric Anesthesia: A mixed methods assessment

BACKGROUND

Leadership of the Society for Pediatric Anesthesia created the Diversity, Equity, and Inclusion committee in 2018 to prioritize diversity work. The Society for Pediatric Anesthesia-Diversity, Equity, and Inclusion committee implemented a baseline survey of the Society for Pediatric Anesthesia membership in 2020 to assess demographics, equity in leadership, inclusivity, and attitudes toward diversity work. The Society for Pediatric Anesthesia plays a significant role in shaping the future of pediatric anesthesiology and in supporting our diverse pediatric patients.

METHODS

This study is an IRB-exempt, cross-sectional survey of the Society for Pediatric Anesthesia membership. Quantitative analysis provided descriptive statistics of demographics, practice characteristics, and involvement within the Society for Pediatric Anesthesia. Qualitative thematic analysis provided an in-depth assessment of perceptions of diversity, challenges faced, and prioritization of Diversity, Equity, and Inclusion efforts within the Society for Pediatric Anesthesia.

RESULTS

Out of 3 242 Society for Pediatric Anesthesia members, 1 232 completed the survey representing 38% of overall membership. Respondents were 89.2% United States members, 52.7% female, 55.7% non-Hispanic White, 88.6% heterosexual, 95.7% non-military, 59.2% religious, and 2.1% have an Americans with Disabilities Act recognized disability. All major United States geographical areas were represented equally with 71% practicing in urban areas and 67% in academic settings. Ethnic/racial minorities were more likely to be international medical graduates (p < .001). Among United States members, 41.5% report being fluent in a language other than English, and 23.5% of those fluent in another language are certified to interpret. Compared to men, women are less likely to be in leadership roles (p < .003), but we found no difference in participation and leadership when stratified by race/ethnicity, geography, international medical graduate status, or sexuality. Racial/ethnic minorities (p < .028), women (p < .001), and lesbian, gay, bisexual, transgender, and queer members (p < .044) more frequently hold lower academic rank positions when compared to white, heterosexual, and male members. Half of respondents were unsure whether diversity, equity, and inclusion challenges existed within the Society for Pediatric Anesthesia while the other half demonstrated opposing views. Among those who reported diversity, equity, and inclusion challenges, the themes centered around persistent marginalization, the need for more inclusive policies and increased psychological safety, and lack of leadership diversity.

CONCLUSIONS

Compared to the diversity of the pediatric population we serve, there are still significant gaps in demographic representation within the Society for Pediatric Anesthesia. As well, there is no consensus among Society for Pediatric Anesthesia membership regarding perceptions of diversity, equity, and inclusion in pediatric anesthesia in the United States. Among those who reported diversity challenges, opportunities for the Society for Pediatric Anesthesia and Anesthesiology Departments to better support minoritized members included bolstering workforce diversity efforts and awareness via more inclusive policies, improved psychological safety, and increasing diversity in leadership. If pediatric anesthesiology is like other specialties, gaining consensus and improving diversity in the workforce might advance pediatric anesthesia innovation, quality, and safety for children of all backgrounds in the United States.

Modes of ventilation for pediatric patients under anesthesia: A Pro/Con conversation

The development of sophisticated modes of ventilation for pediatric patients undergoing anesthesia is ongoing; what remains a challenge for the pediatric anesthesiologist is thoughtful selection of the mode(s) of ventilation for a particular patient in the context of the surgical procedure and the goals of the anesthetic. This article provides some historical accounting of a variety of modes of ventilation, defines the terminology of modern ventilatory modes, and reviews in detail the benefits and pitfalls of the specific modes of ventilation and their applicability to the practice of pediatric anesthesiology. In an attempt to debate the Pros and Cons of different modes of ventilation, and to finally resolve the debate "spontaneous vs. controlled ventilation," we share with you a thoughtful conversation of the continuum of modes of ventilation and their applicability to our pediatric anesthesia population.

Pediatric Airway Management in COVID-19 Patients: Consensus Guidelines From the Society for Pediatric Anesthesia's Pediatric Difficult Intubation Collaborative and the Canadian Pediatric Anesthesia Society

The severe acute respiratory syndrome coronavirus 2 (coronavirus disease 2019 [COVID-19]) pandemic has challenged medical systems and clinicians globally to unforeseen levels. Rapid spread of COVID-19 has forced clinicians to care for patients with a highly contagious disease without evidence-based guidelines. Using a virtual modified nominal group technique, the Pediatric Difficult Intubation Collaborative (PeDI-C), which currently includes 35 hospitals from 6 countries, generated consensus guidelines on airway management in pediatric anesthesia based on expert opinion and early data about the disease. PeDI-C identified overarching goals during care, including minimizing aerosolized respiratory secretions, minimizing the number of clinicians in contact with a patient, and recognizing that undiagnosed asymptomatic patients may shed the virus and infect health care workers. Recommendations include administering anxiolytic medications, intravenous anesthetic inductions, tracheal intubation using video laryngoscopes and cuffed tracheal tubes, use of in-line suction catheters, and modifying workflow to recover patients from anesthesia in the operating room. Importantly, PeDI-C recommends that anesthesiologists consider using appropriate personal protective equipment when performing aerosol-generating medical procedures in asymptomatic children, in addition to known or suspected children with COVID-19. Airway procedures should be done in negative pressure rooms when available. Adequate time should be allowed for operating room cleaning and air filtration between surgical cases. Research using rigorous study designs is urgently needed to inform safe practices during the COVID-19 pandemic. Until further information is available, PeDI-C advises that clinicians consider these guidelines to enhance the safety of health care workers during airway management when performing aerosol-generating medical procedures. These guidelines have been endorsed by the Society for Pediatric Anesthesia and the Canadian Pediatric Anesthesia Society.

Diurnal variations in recovery times after general anaesthesia in children

BACKGROUND

Circadian rhythms coordinate almost all physiological functions and are implicated in major disease development. Even though circadian rhythms have a major impact on human health, little is known about how they affect general anaesthesia. The purpose of this study was to understand if the time of day affects the length of time a child needs to achieve readiness for discharge after general anaesthesia for brain MRI.

METHODS

A retrospective analysis over a 3 yr period (2013-5) on the length of stay in the postanaesthesia care unit (PACU) before discharge was performed for children (age <18 yr) undergoing brain magnetic resonance imaging as outpatients. PACU duration was correlated to either morning vs afternoon or to time clusters for discharge times (<9 AM, >9 AM <12 PM, >12 PM <3 PM, >3 PM <6 PM, >6 PM).

RESULTS

Data from 2340 procedures in children, with median age [inter-quartile range (range)] of 4.7 [2.3-7.25 (0.5-17.8)] yr were available for analysis. The length of stay in the PACU significantly increased over the course of the day with an observed maximum increase of 18 or 19 min (<9 AM vs >6 PM) in children older than 3 or 5 yr, respectively. Subgroup analysis suggested time of day dependent PACU time increase was independent of sex, co-medications, or obstructive sleep apnoea.

CONCLUSION

The time of day significantly affects PACU recovery times in children of both genders having brain imaging under general anaesthesia. Children younger than 3 yr might not be affected. Further validation of these findings may guide future strategies to reduce discharge times.

Improving operative flow during pediatric airway evaluation: a quality-improvement initiative

IMPORTANCE

Microlaryngoscopy and bronchoscopy procedures (MLBs) are short-duration, high-acuity procedures that carry risk. Poor case flow and communication exacerbate such potential risk. Efficient operative flow is critical for patient safety and resource expenditure.

OBJECTIVES

To identify areas for improvement and evaluate the effectiveness of a multidisciplinary quality-improvement (QI) initiative.

DESIGN, SETTING, AND PARTICIPANTS

A QI project using the "Plan-Do-Study-Act" (PDSA) cycle was implemented to assess MLBs performed on pediatric patients in a tertiary academic children's hospital. Forty MLBs were audited using a QI evaluation tool containing 144 fields. Each MLB was evaluated for flow, communication, and timing. Opportunities for improvement were identified. Subsequently, QI interventions were implemented in an iterative cycle, and 66 MLBs were audited after the intervention.

INTERVENTIONS

Specific QI interventions addressed issues of personnel frequently exiting the operating room (OR) and poor preoperative preparation, identified during QI audit as areas for improvement. Interventions included (1) conducting "huddles" between surgeon and OR staff to discuss needed equipment; (2) implementing improvements to surgeon case ordering and preference cards review; (3) posting an OR door sign to limit traffic during airway procedures; and (4) discouraging personnel breaks during airway procedures.

MAIN OUTCOMES AND MEASURES

Operating room exiting behavior of OR personnel, preoperative preparation, and case timing were assessed and compared before and after the QI intervention.

RESULTS

Personnel exiting the OR during the MLB was identified as a preintervention issue, with the surgical technologist, circulator, or surgeon exiting the room in 55% of cases (n = 22). The surgical technologist and circulator left the room to retrieve equipment in 40% of cases (n = 16), which indicated the need for increased preoperative preparation to improve case timing and operative flow. The QI interventions implemented to address these concerns included education regarding break timing, improvements in communication, and improvements in ordering and preparation of equipment. After the QI intervention, the surgical technologist exiting rate decreased from 20% (n = 8) to 8% (n = 5), and the circulator exiting rate decreased from 38% (n = 15) to 27% (n = 17). In addition, the rate of surgeon exiting decreased significantly (from 25% [n = 10 of 40] to 9% [n = 6 of 66]) (P = .03). The surgical technologist and circulating nurse remaining in the room were significantly associated with decreased operating time (1.84-minute decrease for surgical technologist [P = .04] and 1.95-minute decrease for circulating nurse [P = .001]).

CONCLUSIONS AND RELEVANCE

Gains were made in personnel exiting behavior and case timing after implementation of the QI interventions, potentially leading to decreased risk. This process is easily reproduced and is widely accepted by stakeholders.

Design and implementation of a near-miss reporting system at a large, academic pediatric anesthesia department

BACKGROUND

Current incident reporting systems encourage retrospective reporting of morbidity and mortality and have low participation rates. A near miss is an event that did not cause patient harm, but had the potential to. By tracking and analyzing near misses, systems improvements can be targeted appropriately, and future errors may be prevented.

METHODS

An electronic, web based, secure, anonymous reporting system for anesthesiologists was designed and instituted at The Children's Hospital, Denver. This portal was compared to an existing hospital incident reporting system.

RESULTS

A total of 150 incidents were reported in the first 3 months of operation, compared to four entered in the same time period 1 year ago.

CONCLUSION

An anesthesia-specific anonymous near-miss reporting system, which eases and facilitates data entry and can prospectively identify processes and practices that place patients at risk, was implemented at a large, academic, freestanding children's hospital. This resulted in a dramatic increase in reported events and provided data to target and drive quality and process improvement.

[Malignant rhabdoid tumour in the liver]

The authors describe the case of a 6-months-old child with liver tumour. The newborn was healthy until 6 months of age. Prior to hospitalization meteorism and remarkably enlarged liver were observed. A tumour occupying the right lobe of the liver was found with ultrasound and computer tomography, which proved to be inoperable. Intraoperative liver biopsy and few days later the autopsy histology showed a malignant rhabdoid tumour. Authors describe the clinical and morphological features of a rare case of primary hepatic rhabdoid tumour.

The cellular electrophysiologic effect of a new amiodarone like antiarrhythmic drug GYKI 16638 in undiseased human ventricular muscle: comparison with sotalol and mexiletine

The cellular electrophysiologic effect of GYKI 16638, a new antiarrhythmic compound was studied and compared with that of sotalol and mexiletine in undiseased human right ventricular muscle preparation by applying the conventional microelectrode technique. GYKI 16638 (5 microM), at stimulation cycle length of 1000 ms, lengthened action potential duration (APD(90)) from 338.9 +/- 28.6 ms to 385.4 +/- 24 ms (n = 9, p > 0.05). This APD lengthening effect, unlike that of sotalol (30 microM), was rate-independent. GYKI 16638, contrary to sotalol and like mexiletine (10 microM), exerted a use-dependent depression of the maximal rate of depolarization (V(max)) which amounted to 36.4 +/- 11.7% at cycle length of 400 ms (n = 5, p < 0.05) and was characterised with an offset kinetical time constant of 298.6 +/- 70.2 ms. It was concluded that GYKI 16638 in human ventricular muscle shows combined Class IB and Class III antiarrhythmic properties, resembling the electrophysiological manifestation seen after chronic amiodarone treatment.

Photoinduced inactivation of T7 phage sensitized by symmetrically and asymmetrically substituted tetraphenyl porphyrin: comparison of efficiency and mechanism of action

We investigated the efficiency and the mechanism of action of two--one symmetrically and one asymmetrically substituted--glycoconjugated tetraphenyl porphyrins in their photoreaction with T7 phage as a model of nucleoprotein (NP) complexes. A correlation was found between the dark inactivation of T7 and the binding of porphyrins determined by fluorescence spectroscopy. Both types of porphyrin sensitized the photoinactivation of T7, but the slopes of inactivation kinetics were markedly different. There was no correlation between the dark binding and the photosensitizing efficacy of the two derivatives. Inactivation was moderated by 1,3-diphenylisobenzofuran and 1,3-dimethyl-2-thiourea; however, neither of them inhibited T7 inactivation completely. This result suggests that both Type-I and Type-II reactions play a role in the virus inactivation. Optical melting studies revealed structural changes in the protein part but not in the DNA of the photochemically treated NP complex. Polymerase chain reaction analysis of a 555 bp segment of gene 1 and a 3826 bp segment of genes 3 and 4 failed to demonstrate any DNA damage.

[Ultrasonic follow up of spontaneous regression of neonatal abdominal cystic changes]

Abdominal cyst was diagnosed in 14 babies by ultrasound examination (9 multicystic dysplastic kidneys, 4 ovarian cysts, 1 bowel duplication). The cysts were followed up in 6 patients by ultrasound, and marked reduction of multicystic dysplastic kidneys was observed in 2 patients, and 1 ovarian cyst was disappeared. Their experience and a review of the literature suggest that conservative management with sonographic reevaluation is an acceptable alternative to surgical therapy in uncomplicated cases.

Horizontal transmission of Aujeszky's disease virus from sheep to pigs

Eight 2-month-old merino lambs were inoculated intranasally with different (10(2.0)-10(5.0)TCID50) amounts of Aujeszky's disease virus (ADV). Electron microscopic studies indicated that ADV replicated in extra-neural sites, in the epithelial cells of the mucosa of the upper and lower respiratory tract. Although the virus was excreted continuously in nasal discharges, horizontal transmission to contact lambs failed. The surviving exposed and contact lambs had no demonstrable antibodies against ADV and they were susceptible when challenged by ADV. However, the virus was transmitted to susceptible pigs in contact with the exposed lambs. One of the five contact pigs showed characteristic clinical signs of Aujeszky's disease, developed a nonsuppurative meningoencephalomyelitis and ADV was recovered from the brain, nasal discharge and other organs. Restriction enzyme analysis of DNA from this virus confirmed the sheep origin of the isolate. The other 4 pigs seroconverted. ADV infection in sheep is therefore a possible source of infection for pigs, but the lack of horizontal transmission in sheep was confirmed.

Reflectometric blood glucose determination in the neonatological intensive care: haematocrit dependence

The dependence upon haematocrit of the readings of different methods of reflectometric blood glucose determination ( Eyetone /Dextrostix: Reflomat / Reflotest Hypoglycaemie , Reflomat / Reflotest Glucose, Glucometer /Dextrostix) was studied in blood samples adjusted to haematocrit values between 0.47 and 0.90. In general the reflectometric methods measure lower blood glucose concentration if the haematocrit value is enhanced. There is a clear-cut correlation between the rise in haematocrit and the decrease in blood glucose reading. The critical haematocrit level to reach this effect in the Eyetone and Glucometer is 0.60, and in the Reflomat it is 0.80.