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Lonsdale H, Rodriguez K, Shargo R, Ekblad M, Brown JM, Dolan I, Fierstein JL, Miller A, Dey A, Peck J, Rehman MA, Wilsey MJ. Natural airway as an alternative to intubation for pediatric endoscopic esophageal foreign body removal: A retrospective cohort study of 326 patients. Paediatr Anaesth 2024. [PMID: 38591665 DOI: 10.1111/pan.14888] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 03/07/2024] [Accepted: 03/28/2024] [Indexed: 04/10/2024]
Abstract
BACKGROUND Anesthesia is required for endoscopic removal of esophageal foreign bodies (EFBs) in children. Historically, endotracheal intubation has been the de facto gold standard for airway management in these cases. However, as more elective endoscopic procedures are now performed under propofol sedation with natural airway, there has been a move toward using similar Monitored Anesthesia Care (MAC) for select patients who require endoscopic removal of an EFB. METHODS In this single-center retrospective cohort study, we compared endoscopic EFB removal with either MAC or endotracheal intubation. Descriptive statistics summarized factors stratified by initial choice of airway technique, including intra- and postanesthesia complications and the frequency of mid-procedure conversion to endotracheal intubation in those initially managed with MAC. To demonstrate the magnitude of associations between these factors and the anesthesiologist's choice of airway technique, univariable Firth logistic and quantile regressions were used to estimate odds ratios (95% CI) and beta coefficients (95% CI). RESULTS From the initial search, 326 patients were identified. Among them, 23% (n = 75) were planned for intubation and 77% (n = 251) were planned for MAC. Three patients (0.9%) who were initially planned for MAC required conversion to endotracheal intubation after induction. Two (0.6%) of these children were admitted to the hospital after the procedure and treated for ongoing airway reactivity. No patient experienced reflux of gastric contents to the mouth or dislodgement of the foreign body to the airway, and no patient required administration of vasoactive medications or cardiopulmonary resuscitation. Patients had higher odds that the anesthesiologist chose to utilize MAC if the foreign body was a coin (OR, 3.3; CI, 1.9-5.7, p < .001) or if their fasting time was >6 h. Median total operating time was 15 min greater in intubated patients (11 vs. 26 min, p < .001). CONCLUSIONS This study demonstrates that MAC may be considered for select pediatric patients undergoing endoscopic removal of EFB, especially those who have ingested coins, who do not have reactive airways, who have fasted for >6 h, and in whom the endoscopic procedure is expected to be short and uncomplicated. Prospective multi-site studies are needed to confirm these findings.
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Affiliation(s)
- Hannah Lonsdale
- Division of Pediatric Anesthesiology, Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Kurt Rodriguez
- Department of Gastroenterology, Johns Hopkins All Children's Hospital, St. Petersburg, Florida, USA
| | - Ryan Shargo
- Morsani College of Medicine, University of South Florida, Tampa, Florida, USA
| | - Morgan Ekblad
- Department of Gastroenterology, Johns Hopkins All Children's Hospital, St. Petersburg, Florida, USA
| | - Jerry M Brown
- Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, Florida, USA
| | - Isabella Dolan
- Department of Gastroenterology, Johns Hopkins All Children's Hospital, St. Petersburg, Florida, USA
| | - Jamie L Fierstein
- Epidemiology and Biostatistics Shared Resource, Institute for Clinical and Translational Research Institute, Johns Hopkins All Children's Hospital, St. Petersburg, Florida, USA
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Alexandra Miller
- Epidemiology and Biostatistics Shared Resource, Institute for Clinical and Translational Research Institute, Johns Hopkins All Children's Hospital, St. Petersburg, Florida, USA
| | - Aditi Dey
- Maternal Fetal Neonatal Institute, Johns Hopkins All Children's Hospital, St. Petersburg, Florida, USA
| | - Jacquelin Peck
- Department of Pediatric Anesthesia, Joe DiMaggio Children's Hospital, Hollywood, Florida, USA
| | - Mohamed A Rehman
- Department of Pediatric Anesthesiology and Pain Medicine, Johns Hopkins All Children's Hospital, St. Petersburg, Florida, USA
| | - Michael J Wilsey
- Department of Gastroenterology, Johns Hopkins All Children's Hospital, St. Petersburg, Florida, USA
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Smith AH, Gray GM, Ashfaq A, Asante-Korang A, Rehman MA, Ahumada LM. Using machine learning to predict five-year transplant-free survival among infants with hypoplastic left heart syndrome. Sci Rep 2024; 14:4512. [PMID: 38402363 PMCID: PMC10894293 DOI: 10.1038/s41598-024-55285-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Accepted: 02/22/2024] [Indexed: 02/26/2024] Open
Abstract
Hypoplastic left heart syndrome (HLHS) is a congenital malformation commonly treated with palliative surgery and is associated with significant morbidity and mortality. Risk stratification models have often relied upon traditional survival analyses or outcomes data failing to extend beyond infancy. Individualized prediction of transplant-free survival (TFS) employing machine learning (ML) based analyses of outcomes beyond infancy may provide further valuable insight for families and healthcare providers along the course of a staged palliation. Data from both the Pediatric Heart Network (PHN) Single Ventricle Reconstruction (SVR) trial and Extension study (SVR II), which extended cohort follow up for five years was used to develop ML-driven models predicting TFS. Models incrementally incorporated features corresponding to successive phases of care, from pre-Stage 1 palliation (S1P) through the stage 2 palliation (S2P) hospitalization. Models trained with features from Pre-S1P, S1P operation, and S1P hospitalization all demonstrated time-dependent area under the curves (td-AUC) beyond 0.70 through 5 years following S1P, with a model incorporating features through S1P hospitalization demonstrating particularly robust performance (td-AUC 0.838 (95% CI 0.836-0.840)). Machine learning may offer a clinically useful alternative means of providing individualized survival probability predictions, years following the staged surgical palliation of hypoplastic left heart syndrome.
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Affiliation(s)
- Andrew H Smith
- Division of Cardiac Critical Care Medicine, The Heart Institute, Johns Hopkins All Children's Hospital, 501 6th Avenue South, St. Petersburg, FL, 33701, USA.
| | - Geoffrey M Gray
- Center for Pediatric Data Science and Analytic Methodology, Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA
- Department of Anesthesia and Pain Medicine, Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA
| | - Awais Ashfaq
- Cardiovascular Surgery, Heart Institute, Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA
| | - Alfred Asante-Korang
- Heart Transplantation, Cardiomyopathy and Heart Failure, Heart Institute, Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA
| | - Mohamed A Rehman
- Center for Pediatric Data Science and Analytic Methodology, Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA
- Department of Anesthesia and Pain Medicine, Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA
| | - Luis M Ahumada
- Center for Pediatric Data Science and Analytic Methodology, Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA
- Department of Anesthesia and Pain Medicine, Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA
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Kuo FH, Tudor BH, Gray GM, Ahumada LM, Rehman MA, Watkins SC. Precision Anesthesia in 2050. Anesth Analg 2024; 138:326-336. [PMID: 38215711 DOI: 10.1213/ane.0000000000006688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2024]
Abstract
Over the last few decades, the field of anesthesia has advanced far beyond its humble beginnings. Today's anesthetics are better and safer than ever, thanks to innovations in drugs, monitors, equipment, and patient safety.1-4 At the same time, we remain limited by our herd approach to medicine. Each of our patients is unique, but health care today is based on a one-size-fits-all approach, while our patients grow older and more medically complex every year. By 2050, we believe that precision medicine will play a central role across all medical specialties, including anesthesia. In addition, we expect that health care and consumer technology will continually evolve to improve and simplify the interactions between patients, providers, and the health care system. As demonstrated by 2 hypothetical patient experiences, these advancements will enable more efficient and safe care, earlier and more accurate diagnoses, and truly personalized treatment plans.
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Affiliation(s)
| | - Brant H Tudor
- Center for Pediatric Data Science and Analytic Methodology, Johns Hopkins All Children's Hospital, St Petersburg, Florida
| | - Geoffrey M Gray
- Center for Pediatric Data Science and Analytic Methodology, Johns Hopkins All Children's Hospital, St Petersburg, Florida
| | - Luis M Ahumada
- Center for Pediatric Data Science and Analytic Methodology, Johns Hopkins All Children's Hospital, St Petersburg, Florida
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4
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Gray GM, Ahumada LM, Rehman MA, Varughese A, Fernandez AM, Fackler J, Yates HM, Habre W, Disma N, Lonsdale H. A machine-learning approach for decision support and risk stratification of pediatric perioperative patients based on the APRICOT dataset. Paediatr Anaesth 2023; 33:710-719. [PMID: 37211981 DOI: 10.1111/pan.14694] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Revised: 04/28/2023] [Accepted: 05/09/2023] [Indexed: 05/23/2023]
Abstract
BACKGROUND Pediatric anesthesia has evolved to a high level of patient safety, yet a small chance remains for serious perioperative complications, even in those traditionally considered at low risk. In practice, prediction of at-risk patients currently relies on the American Society of Anesthesiologists Physical Status (ASA-PS) score, despite reported inconsistencies with this method. AIMS The goal of this study was to develop predictive models that can classify children as low risk for anesthesia at the time of surgical booking and after anesthetic assessment on the procedure day. METHODS Our dataset was derived from APRICOT, a prospective observational cohort study conducted by 261 European institutions in 2014 and 2015. We included only the first procedure, ASA-PS classification I to III, and perioperative adverse events not classified as drug errors, reducing the total number of records to 30 325 with an adverse event rate of 4.43%. From this dataset, a stratified train:test split of 70:30 was used to develop predictive machine learning algorithms that could identify children in ASA-PS class I to III at low risk for severe perioperative critical events that included respiratory, cardiac, allergic, and neurological complications. RESULTS Our selected models achieved accuracies of >0.9, areas under the receiver operating curve of 0.6-0.7, and negative predictive values >95%. Gradient boosting models were the best performing for both the booking phase and the day-of-surgery phase. CONCLUSIONS This work demonstrates that prediction of patients at low risk of critical PAEs can be made on an individual, rather than population-based, level by using machine learning. Our approach yielded two models that accommodate wide clinical variability and, with further development, are potentially generalizable to many surgical centers.
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Affiliation(s)
- Geoffrey M Gray
- Center for Pediatric Data Science and Analytics Methodology, Johns Hopkins All Children's Hospital, St. Petersburg, Florida, USA
| | - Luis M Ahumada
- Center for Pediatric Data Science and Analytics Methodology, Johns Hopkins All Children's Hospital, St. Petersburg, Florida, USA
| | - Mohamed A Rehman
- Department of Anesthesia, Pain and Perioperative Medicine, Johns Hopkins All Children's Hospital, St. Petersburg, Florida, USA
| | - Anna Varughese
- Department of Anesthesia, Pain and Perioperative Medicine, Johns Hopkins All Children's Hospital, St. Petersburg, Florida, USA
| | - Allison M Fernandez
- Department of Anesthesia, Pain and Perioperative Medicine, Johns Hopkins All Children's Hospital, St. Petersburg, Florida, USA
| | - James Fackler
- Department of Anesthesia, Division of Pediatric Anesthesia, Vanderbilt University School of Medicine, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee, USA
| | - Hannah M Yates
- Department of Anesthesia, Pain and Perioperative Medicine, Johns Hopkins All Children's Hospital, St. Petersburg, Florida, USA
| | - Walid Habre
- Department of Anaesthesia, Pharmacology and Intensive Care, University Hospitals of Geneva, Switzerland
| | - Nicola Disma
- Unit for Research & Innovation, Department of Anesthesia, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Hannah Lonsdale
- Department of Anesthesia, Division of Pediatric Anesthesia, Vanderbilt University School of Medicine, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee, USA
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Affiliation(s)
- Hannah Lonsdale
- From the Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Hospital, Baltimore, Maryland
| | | | - Luis M Ahumada
- Center for Pediatric Data Science and Analytics Methodology
| | - Hannah M Yates
- Department of Anesthesia and Pain Medicine, Johns Hopkins All Children's Hospital, St Petersburg, Florida
| | - Anna Varughese
- Department of Anesthesia and Pain Medicine, Johns Hopkins All Children's Hospital, St Petersburg, Florida
| | - Mohamed A Rehman
- Department of Anesthesia and Pain Medicine, Johns Hopkins All Children's Hospital, St Petersburg, Florida
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McAteer C, Sullivan R, McRory C, O’Domhnaill O, Murphy DE, Rehman MA, Muller T, Gallagher M, Miranda J, Parihar V, Mulpeter K. 95 DOCUMENTATION OF URINARY CATHETER INDICATION AND INSERTION PROCEDURE FOR MEDICAL INPATIENTS AT A UNIVERSITY TEACHING HOSPITAL. Age Ageing 2021. [DOI: 10.1093/ageing/afab219.95] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/25/2023] Open
Abstract
Abstract
Background
Approximately 25% of inpatients have urinary catheters at some point during their hospital stay; over half are deemed inappropriate. This is significant as catheter-associated urinary tract infections (CAUTI) increase morbidity, mortality and length of hospitalisation. Lack of medical documentation and clinician awareness of catheters have been identified as risk factors for inappropriate catheterisation. The aim of this audit was to assess inpatient urinary catheter use among medical inpatients to determine if the indication and insertion procedure were clearly documented.
Methods
The audit was conducted over one day and included all medical inpatients aged 18 years and above. Emergency Department and High Dependency patients were excluded. Data was collected using standardised data collection sheets and involved a review of medical/nursing notes. Data was benchmarked against Health Service Executive guidelines.
Results
27 of 132 medical inpatients (20%) had a urinary catheter in situ on the day of audit. 37% (n = 10) had long-term urinary catheters in situ prior to admission and are not considered further. Of the remaining 63% (n = 17), 9 were female (53%), 8 were male (47%), and the average age was 75 years. Indication was documented in nursing notes for 76% and in medical notes for 53%. Indications included monitoring urinary output (29%), urinary retention (24%), sepsis (18%), comfort (6%) and haematuria (6%). Catheter insertion procedure was documented in nursing notes for 59% and in medical notes for 12%.
Conclusion
One fifth of medical inpatients had urinary catheters on the day of audit. 63% of these patients did not have a catheter prior to admission. Overall medical documentation of catheter indication and insertion procedure is poor. Better documentation would likely improve clinician awareness of their patient’s catheters and prompt earlier review of appropriateness. Education sessions, insertion proforma stickers and catheter review reminder systems are suggested to improve documentation.
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Affiliation(s)
- C McAteer
- Letterkenny University Hospital , Letterkenny, Co. Donegal, Ireland
| | - R Sullivan
- Letterkenny University Hospital , Letterkenny, Co. Donegal, Ireland
| | - C McRory
- Letterkenny University Hospital , Letterkenny, Co. Donegal, Ireland
| | - O O’Domhnaill
- Letterkenny University Hospital , Letterkenny, Co. Donegal, Ireland
| | - D E Murphy
- Letterkenny University Hospital , Letterkenny, Co. Donegal, Ireland
| | - M A Rehman
- Letterkenny University Hospital , Letterkenny, Co. Donegal, Ireland
| | - T Muller
- Letterkenny University Hospital , Letterkenny, Co. Donegal, Ireland
| | - M Gallagher
- Letterkenny University Hospital , Letterkenny, Co. Donegal, Ireland
| | - J Miranda
- Letterkenny University Hospital , Letterkenny, Co. Donegal, Ireland
| | - V Parihar
- Letterkenny University Hospital , Letterkenny, Co. Donegal, Ireland
| | - K Mulpeter
- Letterkenny University Hospital , Letterkenny, Co. Donegal, Ireland
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Hussain K, Abbas RZ, Abbas A, Rehman MA, Raza MA, Rehman T, Hussain R, Mahmood MS, Imran M, Zaman MA, Sindhu ZD, Khan MK, Ali S. Anticoccidial and Biochemical Effects of Artemisia Brevifolia Extract in Broiler Chickens. Braz J Poult Sci 2021. [DOI: 10.1590/1806-9061-2020-1377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- K Hussain
- Muhammad Nawaz Sharif University of Agriculture, Pakistan
| | - RZ Abbas
- University of Agriculture, Pakistan
| | - A Abbas
- Muhammad Nawaz Sharif University of Agriculture, Pakistan
| | | | - MA Raza
- Muhammad Nawaz Sharif University of Agriculture, Pakistan
| | - T Rehman
- The Islamia University of Bahawalpur, Pakistan
| | - R Hussain
- The Islamia University of Bahawalpur, Pakistan
| | | | - M Imran
- University of Agriculture, Pakistan
| | - MA Zaman
- University College of Veterinary and Animal Sciences, Pakistan
| | | | - MK Khan
- University of Agriculture, Pakistan
| | - S Ali
- University of Agriculture, Pakistan
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Saeed M, Khan MI, Arshad R, Farooq MA, Rehman MA, Ishaque A. Exploring the anti-cancerous and anti-inflammatory potential of bovine meat by-product hydrolysates. J BIOL REG HOMEOS AG 2020; 34:1875-1878. [PMID: 33161696 DOI: 10.23812/20-175-l] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Affiliation(s)
- M Saeed
- University Institute of Diet and Nutritional Sciences, The University of Lahore, Gujrat Campus, Gujrat, Pakistan
| | - M I Khan
- National Institute of Food Science and Technology, University of Agriculture, Faisalabad, Pakistan
| | - R Arshad
- University Institute of Diet and Nutritional Sciences, The University of Lahore, Gujrat Campus, Gujrat, Pakistan
| | - M A Farooq
- School of Food Science and Engineering, South China University of Technology, Guangzhou China
| | - M A Rehman
- Ruth Pfau College of Nutrition Sciences, Lahore Medical and Dental College, Lahore, Pakistan
| | - A Ishaque
- University Institute of Diet and Nutritional Sciences, The University of Lahore, Gujrat Campus, Gujrat, Pakistan
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Ahmed N, Ali M, Rafiq M, Khan I, Nisar KS, Rehman MA, Ahmad MO. A numerical efficient splitting method for the solution of two dimensional susceptible infected recovered epidemic model of whooping cough dynamics: Applications in bio-medical engineering. Comput Methods Programs Biomed 2020; 190:105350. [PMID: 32078958 DOI: 10.1016/j.cmpb.2020.105350] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/27/2019] [Revised: 01/04/2020] [Accepted: 01/19/2020] [Indexed: 06/10/2023]
Abstract
Background and Objective The positivity property of the non-linear dynamical systems is one of the essential features in different fields of bio-medical engineering, science and many more. The state variables, involving in the models, describing the natural phenomenon such as concentration, density and population size etc. must be positive. Therefore, the computing techniques used to solve the system of non-linear differential equations must be consisted with the continuous nature of the models. But, unfortunately there are some existing techniques in the literature that do not preserve the positivity property, especially for the multi-space dimensional models. So there is a gap in the literature that should be filled up, by constructing the positivity preserving numerical algorithms. In this study, we consider a susceptible-infected-recovered (SIR) reaction diffusion epidemic model in two space dimensions from biomedical engineering and solved numerically to observe the behavior of the model. Since the state variables involved in this system are population densities therefore we design a novel computational method which is time efficient because of its splitting structure and holds the positivity as well as other important structure of epidemic system. Methods Three different computational techniques are designed to examine the numerical solution of SIR model of infectious disease. Two approaches are well-known existing computing methods named as forward Euler finite difference (FD) method and backward Euler operator splitting finite difference (OS-FD) method. The third approach is operator splitting nonstandard finite difference (OS-NSFD) method which is devised by using the NSFD rules. Results The proposed OS-NSFD technique retains efficiently the stability of equilibria as well as the positivity. Graphical behavior depicts that the existing computing methods can not get success to preserve the structure of the epidemic system of whooping cough dynamics. At the same time OS-NSFD computing method is proven to be reliable and suitable for the system of bio-medical engineering mathematically and graphically. Conclusion A reliable and novel computing technique is developed for the solution of two dimensional reaction diffusion problem. This technique preserves all the imperative characteristics of the model under study. Also the time efficiency of this method makes it easy to find the solution of physical system in two space dimension. The comparison with other techniques shows the efficacy and reliability of the designed technique.
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Affiliation(s)
- Nauman Ahmed
- Department of Mathematics, University of Management and Technology, Lahore, Pakistan; Department of Mathematics and Statistics, University of Lahore, Lahore, Pakistan
| | - Mubasher Ali
- School of Engineering and Digital Arts, University of Kent, Canterbury Kent, United Kingdom
| | - M Rafiq
- Faculty of Engineering, University of Central Punjab, Lahore, Pakistan
| | - Ilyas Khan
- Faculty of Mathematics and Statistics, Ton Duc Thang University, Ho Chi Minh City 72915 Vietnam.
| | - Kottakkaran Sooppy Nisar
- Department of Mathematics, College of Arts and Science at Wadi Aldawaser, Prince Sattam bin Abdulaziz University, Alkharj 11991, Kingdom of Saudi Arabia
| | - M A Rehman
- Department of Mathematics, University of Management and Technology, Lahore, Pakistan
| | - M O Ahmad
- Department of Mathematics and Statistics, University of Lahore, Lahore, Pakistan
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10
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Ahmed N, Wei Z, Baleanu D, Rafiq M, Rehman MA. Spatio-temporal numerical modeling of reaction-diffusion measles epidemic system. Chaos 2019; 29:103101. [PMID: 31675795 DOI: 10.1063/1.5116807] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Accepted: 09/09/2019] [Indexed: 06/10/2023]
Abstract
In this work, we investigate the numerical solution of the susceptible exposed infected and recovered measles epidemic model. We also evaluate the numerical stability and the bifurcation value of the transmission parameter from susceptibility to a disease of the proposed epidemic model. The proposed method is a chaos free finite difference scheme, which also preserves the positivity of the solution of the given epidemic model.
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Affiliation(s)
- Nauman Ahmed
- Department of Mathematics, University of Management and Technology, Lahore 54770, Pakistan
| | - Zhouchao Wei
- School of Mathematics and Physics, China University of Geosciences, Wuhan 430074, China
| | - Dumitru Baleanu
- Department of Mathematics, Faculty of Arts and Sciences, Cankaya University, 06530 Ankara, Turkey
| | - M Rafiq
- Faculty of Engineering, University of Central Punjab, Lahore 54770, Pakistan
| | - M A Rehman
- Department of Mathematics, University of Management and Technology, Lahore 54770, Pakistan
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Affiliation(s)
- Allan F Simpao
- Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA 19104, USA.
| | - Mohamed A Rehman
- Department of Anesthesiology, Johns Hopkins All Children's Hospital, 501 6th Avenue South, St Petersburg, FL 33701, USA
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12
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Simpao AF, Rehman MA. Dyeing to Find Out How an "AWEsim" Bundle Can Impact Anesthesia Work Environment Contamination. Anesth Analg 2019; 127:594-595. [PMID: 30113973 DOI: 10.1213/ane.0000000000003323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Allan F Simpao
- From the Department of Anesthesiology and Critical Care, Perelman School of Medicine at the University of Pennsylvania and Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Mohamed A Rehman
- Department of Anesthesiology, Johns Hopkins All Children's Hospital, St Petersburg, Florida
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13
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Galvez JA, Yaport M, Maeder-Chieffo S, Simpao AF, Tan JM, Wasey JO, Lingappan AM, Jablonka DH, Subramanyam R, Ahumada LM, Song B, Wu L, Dubow S, Rehman MA. STBUR: Sleep trouble breathing and unrefreshed questionnaire: Evaluation of screening tool for postanesthesia care and disposition. Paediatr Anaesth 2019; 29:821-828. [PMID: 31124263 DOI: 10.1111/pan.13660] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Revised: 04/19/2019] [Accepted: 05/05/2019] [Indexed: 11/28/2022]
Abstract
BACKGROUND The Snoring, Trouble Breathing, and Un-Refreshed (STBUR) questionnaire is a five-question screening tool for pediatric sleep-disordered breathing and risk for perioperative respiratory adverse events in children. The utility of this questionnaire as a preoperative risk-stratification tool has not been investigated. In view of limited availability of screening tools for preoperative pediatric sleep-disordered breathing, we evaluated the questionnaire's performance for postanesthesia adverse events that can impact postanesthesia care and disposition. METHODS The retrospective study protocol was approved by the institutional research board. The data were analyzed using two different definitions for a positive screening based on a five-point scale: low threshold (scores 1 to 5) and high threshold (score of 5). The primary outcome was based on the following criteria: (a) supplemental oxygen therapy following postanesthesia care unit (PACU) stay until hospital discharge, (b) greater than two hours during phase 1 recovery, (c) anesthesia emergency activation in the PACU, and (d) unplanned hospital admission. RESULTS About 6025 patients completed the questionnaire during the preoperative evaluation. And 1522 patients had a low threshold score and 270 had a high-threshold score. We found statistically significant associations in three outcomes based on the low threshold score: supplemental oxygen therapy (negative-predictive value [NPV] 0.97, 95% CI 0.97-98), PACU recovery time (NPV 0.99, 95% CI 0.99-0.99) and escalation of care (NPV 0.98, 95% CI 0.97-0.98). Positive-predictive values were statistically significant for all outcomes except anesthesia emergency in the PACU. CONCLUSION The Snoring, Trouble Breathing, and Un-Refreshed questionnaire identified patients at higher risk for prolonged phase 1 recovery, oxygen therapy requirement, and escalation of care. The questionnaire's high-negative predictive value and specificity may make it useful as a screening tool to identify patients at low risk for prolonged stay in PACU.
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Affiliation(s)
- Jorge A Galvez
- Department of Anesthesiology & Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,Department of Anesthesiology & Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Miguel Yaport
- Department of Anesthesiology & Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Susan Maeder-Chieffo
- Department of Anesthesiology & Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Allan F Simpao
- Department of Anesthesiology & Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,Department of Anesthesiology & Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Jonathan M Tan
- Department of Anesthesiology & Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,Department of Anesthesiology & Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Jack O Wasey
- Department of Anesthesiology & Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Arul M Lingappan
- Department of Anesthesiology & Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,Department of Anesthesiology & Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Denis H Jablonka
- Department of Anesthesiology & Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,Department of Anesthesiology & Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Rajeev Subramanyam
- Department of Anesthesiology & Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,Department of Anesthesiology & Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Luis M Ahumada
- Enterprise Analytics and Reporting, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Bo Song
- Department of Anesthesiology & Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,College of Computing & Informatics, Drexel University, Philadelphia, Pennsylvania
| | - Lezhou Wu
- Department of Anesthesiology & Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,Department of Biomedical and Health Informatics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Scott Dubow
- Department of Anesthesiology & Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,Department of Anesthesiology & Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Mohamed A Rehman
- Department of Anesthesiology & Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,Department of Anesthesiology & Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
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Simpao AF, Obsekov V, Gálvez JA, Isserman RS, Rehman MA, Schwartz ES. A retrospective study of the impact of supraglottic airway devices on the appearance of neck masses in children undergoing serial magnetic resonance imaging. Paediatr Anaesth 2018; 28:1123-1128. [PMID: 30298970 DOI: 10.1111/pan.13510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2018] [Revised: 08/29/2018] [Accepted: 09/17/2018] [Indexed: 11/28/2022]
Abstract
BACKGROUND General anesthesia and sedation are used routinely for magnetic resonance imaging (MRI) studies in children to optimize image quality. Airway devices such as supraglottic airways (SGAs) can alter the appearance of cervical soft tissue regions on an MRI and increase the risk of misdiagnosis. This phenomenon has not been well described in vivo. AIMS We conducted this retrospective study to determine how often SGAs affected the appearance of neck masses in children who received multiple anesthetics for MRIs with and without an SGA. METHODS We retrieved data on children 17 years old and younger who had multiple MRIs between January 2005 and January 2015. Inclusion criteria were patients with neck masses who had a SGA for at least one MRI and either a natural airway or endotracheal tube (ETT) for another MRI. We reviewed MRI images and imaging reports to determine if SGAs affected the appearance of neck masses. RESULTS Twelve of the 921 patients who received anesthesia for neck MRIs during the study period met the inclusion criteria. SGAs affected the appearance of the neck mass in 11 of the 12 patients. CONCLUSIONS Supraglottic airways can significantly alter the appearance of neck masses in children undergoing MRIs and affect radiologists' ability to assess those masses. Communication with the radiologist prior to the induction of anesthesia is crucial when using supraglottic devices in this patient population. It may be more prudent to use a different airway device and/or anesthetic technique when MRIs of these neck masses are undertaken.
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Affiliation(s)
- Allan F Simpao
- Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania.,Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Vladislav Obsekov
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Jorge A Gálvez
- Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania.,Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Rebecca S Isserman
- Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania.,Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Mohamed A Rehman
- Department of Anesthesiology, Johns Hopkins All Children's Hospital, St. Petersburg, Florida
| | - Erin S Schwartz
- Department of Radiology, University of Pennsylvania Perelman School of Medicine and Children's Hospital Of Philadelphia, Philadelphia, Pennsylvania
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Gurnaney HG, Cook-Sather SD, Shaked A, Olthoff KM, Rand EB, Lingappan AM, Rehman MA. Extubation in the operating room after pediatric liver transplant: A retrospective cohort study. Paediatr Anaesth 2018; 28:174-178. [PMID: 29316006 DOI: 10.1111/pan.13313] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/05/2017] [Indexed: 11/29/2022]
Abstract
BACKGROUND Early extubation immediately following liver transplantation is increasingly common in adult practice. Some pediatric institutions have begun to adopt this strategy. Careful patient selection is essential in minimizing risk. METHODS This retrospective cohort study evaluated infants and children who underwent liver transplantation between July 2011 and December 2014. Our primary objective was to determine early extubation rate. Secondary objectives were to identify clinical factors associated with successful early extubation compared with delayed extubation and to examine significant postoperative complications, intensive care unit length of stay, and hospital length of stay. RESULTS The early extubation rate was 57.8% (37/64, confidence interval [CI] 44.8%-70.1%) over this 3.5-year period, increasing from 42% in 2012 to 58% by the end of 2014. The patients in the early extubation group were more likely to be older than the delayed extubation group (mean [SD], 7 [5.3] years vs 3.5 [5.5] years, difference between the mean [95% CI], 3.5 [0.8, 6.2] years); were to have come from home on the day of surgery (78.4% vs 25.9%); and were less likely to be listed as United Network for Organ Sharing status 1A (2.7% vs 25.9%). The early extubation group received less packed red blood cell volume (mean [SD], 9 [13.2] mL/kg vs 40.6 [48.5] mL/kg, difference between the mean [95% CI], 31.6 [95% CI 14.9, 48.3] mL/kg) and fresh-frozen plasma (mean 2.7 [SD 9.5] vs 13.3 [SD15.1], difference between the mean [95% CI], 10.5 [4.4,16.7] mL/kg). None of the patients in the early extubation group required reintubation in the first 24 hours following transplant and none experienced hepatic artery thrombosis. The early extubation group had a shorter average postoperative PICU stay (mean 3.8 [SD 2.1] days vs 17.6 [SD 31.3] days, difference between the mean [95% CI], 9.5 [4.3, 14.7] days) and a shorter postoperative hospital stay overall (mean 10.7 [SD 4.3] days vs 29.7 [SD 43.1] days, difference between the mean [95% CI], 19.1 [8.6, 29.6] days). CONCLUSION More than half of our pediatric liver transplant patients were successfully extubated in the operating room immediately following surgery. We believe early extubation to be safe when employed in selected subpopulations of pediatric patients undergoing liver transplantation.
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Affiliation(s)
- Harshad G Gurnaney
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia and Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Scott D Cook-Sather
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia and Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Abraham Shaked
- The Department of Surgery, Division of Transplant Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Kim M Olthoff
- The Department of Surgery, Division of Transplant Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Elizabeth B Rand
- Division of Gastroenterology, Hepatology, and Nutrition, The Children's Hospital of Philadelphia and Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Arul M Lingappan
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia and Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Mohamed A Rehman
- Department of Anesthesiology and Pain Medicine, Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA
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Simpao AF, Ahumada LM, Larru Martinez B, Cardenas AM, Metjian TA, Sullivan KV, Gálvez JA, Desai BR, Rehman MA, Gerber JS. Design and Implementation of a Visual Analytics Electronic Antibiogram within an Electronic Health Record System at a Tertiary Pediatric Hospital. Appl Clin Inform 2018; 9:37-45. [PMID: 29342478 DOI: 10.1055/s-0037-1615787] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
BACKGROUND Hospitals use antibiograms to guide optimal empiric antibiotic therapy, reduce inappropriate antibiotic usage, and identify areas requiring intervention by antimicrobial stewardship programs. Creating a hospital antibiogram is a time-consuming manual process that is typically performed annually. OBJECTIVE We aimed to apply visual analytics software to electronic health record (EHR) data to build an automated, electronic antibiogram ("e-antibiogram") that adheres to national guidelines and contains filters for patient characteristics, thereby providing access to detailed, clinically relevant, and up-to-date antibiotic susceptibility data. METHODS We used visual analytics software to develop a secure, EHR-linked, condition- and patient-specific e-antibiogram that supplies susceptibility maps for organisms and antibiotics in a comprehensive report that is updated on a monthly basis. Antimicrobial susceptibility data were grouped into nine clinical scenarios according to the specimen source, hospital unit, and infection type. We implemented the e-antibiogram within the EHR system at Children's Hospital of Philadelphia, a tertiary pediatric hospital and analyzed e-antibiogram access sessions from March 2016 to March 2017. RESULTS The e-antibiogram was implemented in the EHR with over 6,000 inpatient, 4,500 outpatient, and 3,900 emergency department isolates. The e-antibiogram provides access to rolling 12-month pathogen and susceptibility data that is updated on a monthly basis. E-antibiogram access sessions increased from an average of 261 sessions per month during the first 3 months of the study to 345 sessions per month during the final 3 months. CONCLUSION An e-antibiogram that was built and is updated using EHR data and adheres to national guidelines is a feasible replacement for an annual, static, manually compiled antibiogram. Future research will examine the impact of the e-antibiogram on antibiotic prescribing patterns.
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Gálvez JA, Jalali A, Ahumada L, Simpao AF, Rehman MA. Neural Network Classifier for Automatic Detection of Invasive Versus Noninvasive Airway Management Technique Based on Respiratory Monitoring Parameters in a Pediatric Anesthesia. J Med Syst 2017; 41:153. [PMID: 28836107 DOI: 10.1007/s10916-017-0787-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2017] [Accepted: 07/20/2017] [Indexed: 01/09/2023]
Abstract
Children undergoing general anesthesia require airway monitoring by an anesthesia provider. The airway may be supported with noninvasive devices such as face mask or invasive devices such as a laryngeal mask airway or an endotracheal tube. The physiologic data stored provides an opportunity to apply machine learning algorithms distinguish between these modes based on pattern recognition. We retrieved three data sets from patients receiving general anesthesia in 2015 with either mask, laryngeal mask airway or endotracheal tube. Patients underwent myringotomy, tonsillectomy, adenoidectomy or inguinal hernia repair procedures. We retrieved measurements for end-tidal carbon dioxide, tidal volume, and peak inspiratory pressure and calculated statistical features for each data element per patient. We applied machine learning algorithms (decision tree, support vector machine, and neural network) to classify patients into noninvasive or invasive airway device support. We identified 300 patients per group (mask, laryngeal mask airway, and endotracheal tube) for a total of 900 patients. The neural network classifier performed better than the boosted trees and support vector machine classifiers based on the test data sets. The sensitivity, specificity, and accuracy for neural network classification are 97.5%, 96.3%, and 95.8%. In contrast, the sensitivity, specificity, and accuracy of support vector machine are 89.1%, 92.3%, and 88.3% and with the boosted tree classifier they are 93.8%, 92.1%, and 91.4%. We describe a method to automatically distinguish between noninvasive and invasive airway device support in a pediatric surgical setting based on respiratory monitoring parameters. The results show that the neural network classifier algorithm can accurately classify noninvasive and invasive airway device support.
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Affiliation(s)
- Jorge A Gálvez
- Section of Biomedical Informatics, Department of Anesthesiology & Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, 19104, USA.
| | - Ali Jalali
- Section of Biomedical Informatics, Department of Anesthesiology & Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, 19104, USA
| | - Luis Ahumada
- Enterprise Analytics and Reporting, The Children's Hospital of Philadelphia, Philadelphia, PA, 19104, USA
| | - Allan F Simpao
- Section of Biomedical Informatics, Department of Anesthesiology & Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, 19104, USA
| | - Mohamed A Rehman
- Section of Biomedical Informatics, Department of Anesthesiology & Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, 19104, USA
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Weintraub AY, Deutsch ES, Hales RL, Buchanan NA, Rock WL, Rehman MA. Using High-Technology Simulators to Prepare Anesthesia Providers Before Implementation of a New Electronic Health Record Module: A Technical Report. Anesth Analg 2017; 124:1815-1819. [PMID: 28207594 DOI: 10.1213/ane.0000000000001775] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Learning to use a new electronic anesthesia information management system can be challenging. Documenting anesthetic events, medication administration, and airway management in an unfamiliar system while simultaneously caring for a patient with the vigilance required for safe anesthesia can be distracting and risky. This technical report describes a vendor-agnostic approach to training using a high-technology manikin in a simulated clinical scenario. Training was feasible and valued by participants but required a combination of electronic and manual components. Further exploration may reveal simulated patient care training that provides the greatest benefit to participants as well as feedback to inform electronic health record improvements.
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Affiliation(s)
- Ari Y Weintraub
- From the Departments of *Anesthesiology and Critical Care Medicine; ‡Center for Simulation, Advanced Education and Innovation; §Biomedical Engineering, the Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; and †ECRI Institute, Plymouth Meeting, Pennsylvania
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Chua P, Hill-Kayser C, Ahumada LM, Jalal A, Simpao AF, Lingappan AM, Jawad A, Rehman MA, Gálvez JA. Visual analytics dashboard to explore the relationship of unscheduled treatment interruptions and variations in airway management for children undergoing external beam radiation therapy. Pract Radiat Oncol 2017; 7:e339-e344. [PMID: 28428018 DOI: 10.1016/j.prro.2017.01.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2016] [Revised: 11/23/2016] [Accepted: 01/16/2017] [Indexed: 11/27/2022]
Affiliation(s)
- Pandora Chua
- University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Christine Hill-Kayser
- Department of Radiation Oncology, University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Luis M Ahumada
- Enterprise Reporting & Analytics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Ali Jalal
- Department of Mechanical Engineering, Villanova University, Villanova, Pennsylvania; Department of Anesthesiology & Critical Care Medicine, The Children's Hospital of Philadelphia, Pennsylvania
| | - Allan F Simpao
- Department of Anesthesiology & Critical Care Medicine, The Children's Hospital of Philadelphia, Pennsylvania
| | - Arul M Lingappan
- Department of Anesthesiology & Critical Care Medicine, The Children's Hospital of Philadelphia, Pennsylvania
| | - Abbas Jawad
- Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Mohamed A Rehman
- Department of Anesthesiology & Critical Care Medicine, The Children's Hospital of Philadelphia, Pennsylvania
| | - Jorge A Gálvez
- Department of Anesthesiology & Critical Care Medicine, The Children's Hospital of Philadelphia, Pennsylvania.
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Simpao AF, Ahumada LM, Gálvez JA, Bonafide CP, Wartman EC, Randall England W, Lingappan AM, Kilbaugh TJ, Jawad AF, Rehman MA. The timing and prevalence of intraoperative hypotension in infants undergoing laparoscopic pyloromyotomy at a tertiary pediatric hospital. Paediatr Anaesth 2017; 27:66-76. [PMID: 27896911 DOI: 10.1111/pan.13036] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/11/2016] [Indexed: 11/28/2022]
Abstract
BACKGROUND Intraoperative hypotension may be associated with adverse outcomes in children undergoing surgery. Infants and neonates under 6 months of age have less autoregulatory cerebral reserve than older infants, yet little information exists regarding when and how often intraoperative hypotension occurs in infants. AIMS To better understand the epidemiology of intraoperative hypotension in infants, we aimed to determine the prevalence of intraoperative hypotension in a generally uniform population of infants undergoing laparoscopic pyloromyotomy. METHODS Vital sign data from electronic records of infants who underwent laparoscopic pyloromyotomy with general anesthesia at a children's hospital between January 1, 1998 and October 4, 2013 were analyzed. Baseline blood pressure (BP) values and intraoperative BPs were identified during eight perioperative stages based on anesthesia event timestamps. We determined the occurrence of relative (systolic BP <20% below baseline) and absolute (mean arterial BP <35 mmHg) intraoperative hypotension within each stage. RESULTS A total of 735 full-term infants and 82 preterm infants met the study criteria. Relative intraoperative hypotension occurred in 77%, 72%, and 58% of infants in the 1-30, 31-60, and 61-90 days age groups, respectively. Absolute intraoperative hypotension was seen in 21%, 12%, and 4% of infants in the 1-30, 31-60, and 61-90 days age groups, respectively. Intraoperative hypotension occurred primarily during surgical prep and throughout the surgical procedure. Preterm infants had higher rates of absolute intraoperative hypotension than full-term infants. CONCLUSIONS Relative intraoperative hypotension was routine and absolute intraoperative hypotension was common in neonates and infants under 91 days of age. Preterm infants and infants under 61 days of age experienced the highest rates of absolute and relative intraoperative hypotension, particularly during surgical prep and throughout surgery.
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Affiliation(s)
- Allan F Simpao
- Department of Anesthesiology and Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania and The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Luis M Ahumada
- Data Analytics and Enterprise Reporting, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Jorge A Gálvez
- Department of Anesthesiology and Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania and The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Christopher P Bonafide
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania and the Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Elicia C Wartman
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - William Randall England
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Arul M Lingappan
- Department of Anesthesiology and Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania and The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Todd J Kilbaugh
- Department of Anesthesiology and Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania and The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Abbas F Jawad
- Department of Biostatistics in Pediatrics, Perelman School of Medicine at the University of Pennsylvania and the Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Mohamed A Rehman
- Department of Anesthesiology and Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania and The Children's Hospital of Philadelphia, Philadelphia, PA, USA
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Schleelein LE, Vincent AM, Jawad AF, Pruitt EY, Kreher GD, Rehman MA, Goebel TK, Cohen DE, Cook-Sather SD. Pediatric perioperative adverse events requiring rapid response: a retrospective case-control study. Paediatr Anaesth 2016; 26:734-41. [PMID: 27198531 DOI: 10.1111/pan.12922] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/10/2016] [Indexed: 11/29/2022]
Abstract
BACKGROUND Perioperative pediatric adverse events have been challenging to study within and across institutions due to varying definitions, low event rates, and incomplete capture. AIM The aim of this study was to determine perioperative adverse event prevalence and to evaluate associated case characteristics and potential contributing factors at an academic pediatric quaternary-care center. METHODS At the Children's Hospital of Philadelphia (CHOP), perioperative adverse events requiring rapid response assistance are termed Anesthesia Now (AN!) events. They have been accurately captured and entered into a quality improvement database since 2010. Adverse events involving open heart and cardiac catheterization cases are managed separately and not included in this database. We conducted a retrospective case-control study utilizing Compurecord (Phillips Healthcare, Andover, MA, USA), EPIC (EPIC, Verona, WI, USA), and Chartmaxx (MedPlus, Mason, OH, USA) systems matching AN! event cases to noncardiac controls (1 : 2) based on surgical date. RESULTS From April 16, 2010 to September 25, 2012, we documented 213 AN! events in the noncardiac perioperative complex and remote sites at our main hospital. AN! prevalence was 0.0043 (1 : 234) with a 95% confidence interval (CI) (0.0037, 0.0049). Respiratory events, primarily laryngospasm, were most common followed by events of cardiovascular etiology. Median age was lower in the AN! group than in controls, 2.86 years (interquartile range 0.94, 10.1) vs 6.20 (2.85, 13.1), P < 0.0001. Odds ratios (with 95% CI) for age, 0.969 (0.941, 0.997); American Society of Anesthesiologists physical status, 1.67 (1.32, 2.12); multiple (≥2) services, 2.27 (1.13, 4.55); nonoperating room vs operating room location, 0.240 (0.133, 0.431); and attending anesthesiologist's experience, 0.976 (0.959, 0.992) were all significant. CONCLUSIONS Decreased age, increased comorbidities, multiple (vs single) surgical services, operating room (vs nonoperating room) location, and decreased staff experience were associated with increased risk of AN! events, which were predominantly respiratory in origin.
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Affiliation(s)
- Laura E Schleelein
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Ariel M Vincent
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Abbas F Jawad
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Eric Y Pruitt
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Genna D Kreher
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Mohamed A Rehman
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Theodora K Goebel
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - David E Cohen
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Scott D Cook-Sather
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
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Simpao AF, Galvez JA, England WR, Wartman EC, Scott JH, Hamid MM, Rehman MA, Epstein RH. A Technical Evaluation of Wireless Connectivity from Patient Monitors to an Anesthesia Information Management System During Intensive Care Unit Surgery. Anesth Analg 2016; 122:425-9. [PMID: 26797553 DOI: 10.1213/ane.0000000000001064] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Surgical procedures performed at the bedside in the neonatal intensive care unit (NICU) at The Children's Hospital of Philadelphia were documented using paper anesthesia records in contrast to the operating rooms, where an anesthesia information management system (AIMS) was used for all cases. This was largely because of logistical problems related to connecting cables between the bedside monitors and our portable AIMS workstations. We implemented an AIMS for documentation in the NICU using wireless adapters to transmit data from bedside monitoring equipment to a portable AIMS workstation. Testing of the wireless AIMS during simulation in the presence of an electrosurgical generator showed no evidence of interference with data transmission. Thirty NICU surgical procedures were documented via the wireless AIMS. Two wireless cases exhibited brief periods of data loss; one case had an extended data gap because of adapter power failure. In comparison, in a control group of 30 surgical cases in which wired connections were used, there were no data gaps. The wireless AIMS provided a simple, unobtrusive, portable alternative to paper records for documenting anesthesia records during NICU bedside procedures.
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Affiliation(s)
- Allan F Simpao
- From the *Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; †The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; and ‡Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania
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Diaz LK, Gaynor JW, Koh SJ, Ittenbach RF, Gerdes M, Bernbaum JC, Zackai EH, Clancy RR, Rehman MA, Pennington JW, Burnham N, Spray TL, Nicolson SC. Increasing cumulative exposure to volatile anesthetic agents is associated with poorer neurodevelopmental outcomes in children with hypoplastic left heart syndrome. J Thorac Cardiovasc Surg 2016; 152:482-9. [PMID: 27183886 DOI: 10.1016/j.jtcvs.2016.03.095] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2015] [Revised: 03/03/2016] [Accepted: 03/17/2016] [Indexed: 12/30/2022]
Abstract
OBJECTIVES Despite improved survival in children with hypoplastic left heart syndrome (HLHS), significant concern persists regarding their neurodevelopmental (ND) outcomes. Previous studies have identified patient factors, such as prematurity and genetic syndromes, to be associated with worse ND outcomes. However, no consistent relationships have been identified among modifiable management factors, including cardiopulmonary bypass strategies, and ND outcomes after cardiac surgery in infancy. Studies in immature animals, including primates, have demonstrated neurodegeneration and apoptosis in the brain after certain levels and extended durations of anesthetic exposure. Retrospective human studies have also suggested relationships between adverse ND effects and anesthetic exposure. METHODS Cumulative minimum alveolar concentration hours (MAC-hrs) of exposure to volatile anesthetic agents (VAA) (desflurane, halothane, isoflurane, and sevoflurane) were collected from an anesthetic database and medical record review for 96 patients with HLHS or variants. ND testing was performed between ages 4 and 5 years, including full-scale IQ, verbal IQ, performance IQ, and processing speed. Four generalized linear modes were hypothesized a priori and tested using a Gaussian (normal) distribution with an identity link. RESULTS Cumulative VAA exposure ranged from 0 to 35.3 MAC-hrs (median 7.5 hours). Using specified covariates identified previously as significant predictors of ND outcomes, statistically significant relationships were identified between total MAC-hrs exposure and worse full-scale IQ and verbal IQ scores (P's < .05) alone and after adjusting for relevant covariates. CONCLUSIONS Increased cumulative MAC-hrs exposure to VAA is associated with worse ND outcomes in certain domains in children with HLHS and variants.
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Affiliation(s)
- Laura K Diaz
- Department of Anesthesia and Critical Care Medicine, The Children's Hospital of Philadelphia, Perelman School of Medicine at The University of Pennsylvania, Philadelphia, Pa
| | - J William Gaynor
- Division of Pediatric Cardiothoracic Surgery, The Children's Hospital of Philadelphia, Perelman School of Medicine at The University of Pennsylvania, Philadelphia, Pa.
| | - Shannon J Koh
- Division of Pediatric Cardiothoracic Surgery, The Children's Hospital of Philadelphia, Perelman School of Medicine at The University of Pennsylvania, Philadelphia, Pa
| | - Richard F Ittenbach
- Division of Biostatistics and Epidemiology, Cincinnati Children's Medical Center, University of Cincinnati School of Medicine, Cincinnati, Ohio
| | - Marsha Gerdes
- Department of Pediatrics, The Children's Hospital of Philadelphia, Perelman School of Medicine at The University of Pennsylvania, Philadelphia, Pa
| | - Judy C Bernbaum
- Department of Pediatrics, The Children's Hospital of Philadelphia, Perelman School of Medicine at The University of Pennsylvania, Philadelphia, Pa
| | - Elaine H Zackai
- Department of Pediatrics, The Children's Hospital of Philadelphia, Perelman School of Medicine at The University of Pennsylvania, Philadelphia, Pa
| | - Robert R Clancy
- Department of Pediatrics, The Children's Hospital of Philadelphia, Perelman School of Medicine at The University of Pennsylvania, Philadelphia, Pa
| | - Mohamed A Rehman
- Department of Anesthesia and Critical Care Medicine, The Children's Hospital of Philadelphia, Perelman School of Medicine at The University of Pennsylvania, Philadelphia, Pa
| | - Jeffrey W Pennington
- Center for Biomedical Informatics, The Children's Hospital of Philadelphia, Perelman School of Medicine at The University of Pennsylvania, Philadelphia, Pa
| | - Nancy Burnham
- Division of Pediatric Cardiothoracic Surgery, The Children's Hospital of Philadelphia, Perelman School of Medicine at The University of Pennsylvania, Philadelphia, Pa
| | - Thomas L Spray
- Division of Pediatric Cardiothoracic Surgery, The Children's Hospital of Philadelphia, Perelman School of Medicine at The University of Pennsylvania, Philadelphia, Pa
| | - Susan C Nicolson
- Department of Anesthesia and Critical Care Medicine, The Children's Hospital of Philadelphia, Perelman School of Medicine at The University of Pennsylvania, Philadelphia, Pa
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Gurnaney HG, Fiadjoe JE, Levin LS, Chang B, Delvalle H, Gálvez J, Rehman MA. Anesthetic management of the first pediatric bilateral hand transplant. Can J Anaesth 2016; 63:731-6. [PMID: 26951450 DOI: 10.1007/s12630-016-0625-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2015] [Revised: 02/03/2016] [Accepted: 02/25/2016] [Indexed: 12/16/2022] Open
Abstract
PURPOSE The purpose of this case report is to describe the anesthetic and case management of the first vascularized composite allograft pediatric bilateral hand transplant. CLINICAL DETAILS Our patient was an eight-year-old male with a medical history of Staphylococcus aureus sepsis at one year of age that resulted in end-stage renal disease as well as bilateral upper and lower extremity amputations. After referral for bilateral hand transplantation, the transplantation team, with expertise in all aspects of perioperative care (surgery, anesthesiology, nephrology, renal transplantation, pediatric intensive care, and therapeutic pharmacy), was consulted to help develop anesthetic and other perioperative protocols for surgery. Prior to activation of the transplantation team, the lead surgeon evaluated potential donors by comparing a three-dimensional printed model of the recipient's forearm with the donor's upper extremities to ensure an adequate match. The anesthesia team inserted bilateral ultrasound-guided infraclavicular catheters to provide a sympathetic block to facilitate blood flow to the upper extremities and to provide both intraoperative and postoperative pain control. The patient remained in the operating room for 13 hr 37 min for a surgical time of ten hours 39 min. He remained in the hospital for 34 days after the procedure and was then transferred to an inpatient rehabilitation facility for a further 15 days. The patient is currently doing well in a postoperative rehabilitation program. He has demonstrated motor power to the hands using the forearm muscles but is not expected to reach his maximum sensory function for at least one to two years. CONCLUSION This report describes the anesthetic management of the first pediatric bilateral hand transplant. This procedure required considerable preoperative planning and communication between various teams to ensure all resources needed to deliver the care for this complex and novel transplant surgery were readily available.
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Affiliation(s)
- Harshad G Gurnaney
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA, USA.
| | - John E Fiadjoe
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA, USA
| | - L Scott Levin
- Department of Orthopaedic Surgery, Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA, USA
| | - Benjamin Chang
- Department of Plastic and Reconstructive Surgery, Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA, USA
| | - Heather Delvalle
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA, USA
| | - Jorge Gálvez
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA, USA
| | - Mohamed A Rehman
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA, USA
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Fiadjoe JE, Nishisaki A, Jagannathan N, Hunyady AI, Greenberg RS, Reynolds PI, Matuszczak ME, Rehman MA, Polaner DM, Szmuk P, Nadkarni VM, McGowan FX, Litman RS, Kovatsis PG. Airway management complications in children with difficult tracheal intubation from the Pediatric Difficult Intubation (PeDI) registry: a prospective cohort analysis. The Lancet Respiratory Medicine 2016; 4:37-48. [DOI: 10.1016/s2213-2600(15)00508-1] [Citation(s) in RCA: 234] [Impact Index Per Article: 29.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/07/2015] [Revised: 11/25/2015] [Accepted: 11/26/2015] [Indexed: 12/17/2022]
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Gálvez JA, Rothman BS, Doyle CA, Morgan S, Simpao AF, Rehman MA. A Narrative Review of Meaningful Use and Anesthesia Information Management Systems. Anesth Analg 2015; 121:693-706. [PMID: 26287298 DOI: 10.1213/ane.0000000000000881] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The US federal government has enacted legislation for a federal incentive program for health care providers and hospitals to implement electronic health records. The primary goal of the Meaningful Use (MU) program is to drive adoption of electronic health records nationwide and set the stage to monitor and guide efforts to improve population health and outcomes. The MU program provides incentives for the adoption and use of electronic health record technology and, in some cases, penalties for hospitals or providers not using the technology. The MU program is administrated by the Department of Health and Human Services and is divided into 3 stages that include specific reporting and compliance metrics. The rationale is that increased use of electronic health records will improve the process of delivering care at the individual level by improving the communication and allow for tracking population health and quality improvement metrics at a national level in the long run. The goal of this narrative review is to describe the MU program as it applies to anesthesiologists in the United States. This narrative review will discuss how anesthesiologists can meet the eligible provider reporting criteria of MU by applying anesthesia information management systems (AIMS) in various contexts in the United States. Subsequently, AIMS will be described in the context of MU criteria. This narrative literature review also will evaluate the evidence supporting the electronic health record technology in the operating room, including AIMS, independent of certification requirements for the electronic health record technology under MU in the United States.
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Affiliation(s)
- Jorge A Gálvez
- From the Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee; and Coast Anesthesia Medical Group, O'Connor Hospital, San Jose, California
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Simpao AF, Lingappan AM, Ahumada LM, Rehman MA, Gálvez JA. Perioperative Smartphone Apps and Devices for Patient-Centered Care. J Med Syst 2015; 39:102. [PMID: 26265239 DOI: 10.1007/s10916-015-0310-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2015] [Accepted: 08/04/2015] [Indexed: 12/19/2022]
Abstract
Smartphones have grown in ubiquity and computing power, and they play an ever-increasing role in patient-centered health care. The "medicalized smartphone" not only enables web-based access to patient health resources, but also can run patient-oriented software applications and be connected to health-related peripheral devices. A variety of patient-oriented smartphone apps and devices are available for use to facilitate patient-centered care throughout the continuum of perioperative care. Ongoing advances in smartphone technology and health care apps and devices should expand their utility for enhancing patient-centered care in the future.
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Affiliation(s)
- Allan F Simpao
- Department of Anesthesiology and Critical Care, Perelman School of Medicine at the University of Pennsylvania and the Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Suite 9329, Philadelphia, PA, 19104-4399, USA,
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Simpao AF, Janik LS, Hsu G, Schwartz AJ, Heuer GG, Warrington AP, Rehman MA. Transient and reproducible loss of motor-evoked potential signals after intravenous levetiracetam in a child undergoing craniotomy for resection of astrocytoma. ACTA ACUST UNITED AC 2015; 4:26-8. [PMID: 25611003 DOI: 10.1213/xaa.0000000000000107] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Transcranial electrical motor-evoked potential (tceMEP) monitoring is used in complex intracranial and spinal surgeries to detect and prevent neurological injury. We present a case of transient, reproducible loss of tceMEPs after an infusion of levetiracetam during craniotomy and tumor resection in a child. Cessation of the infusion resulted in restoration of baseline tceMEPs. When the infusion was resumed at the end of the procedure, a similar decrease in tceMEPs was seen as before, after the infusion was stopped. The surgery and postoperative course proceeded without incident, and the patient experienced a full recovery.
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Affiliation(s)
- Allan F Simpao
- From the *Department of Anesthesiology and Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia; †Department of Anesthesiology and Critical Care, The Children's Hospital of Philadelphia, Pennsylvania; ‡Department of Neurosurgery, Perelman School of Medicine at the University of Pennsylvania; §Division of Neurosurgery, Children's Hospital of Philadelphia, Pennsylvania; and ‖Medtronic International, Tolochenaz, Switzerland
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Kamath AM, Schwartz AJ, Simpao AF, Lingappan AM, Rehman MA, Galvez JA. Induction of General Anesthesia Is in the Eye of the Beholder--Objective Feedback Through a Wearable Camera. J Grad Med Educ 2015; 7. [PMID: 26221450 PMCID: PMC4512805 DOI: 10.4300/jgme-d-14-00680.1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Affiliation(s)
- Aruna Maria Kamath
- Aruna Maria Kamath, MD, MPHPediatric Anesthesiology Fellow, The Children's Hospital of Philadelphia
| | - Alan Jay Schwartz
- Alan Jay Schwartz, MD, MSEdDirector of Education, Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia Professor of Clinical Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania
| | - Allan F. Simpao
- Allan F. Simpao, MDAssistant Professor of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania
| | - Arul M. Lingappan
- Arul M. Lingappan, MDInstructor of Anesthesiology, The Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania
| | - Mohamed A. Rehman
- Mohamed A. Rehman, MDProfessor of Clinical Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia Professor of Clinical Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania
| | - Jorge A. Galvez
- Jorge A. Galvez, MDAssistant Professor of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania
- Corresponding author: Jorge A. Galvez, MD, The Children's Hospital of Philadelphia, Main Building, 9th Floor, Room 9347, 34th St and Civic Center Blvd, Philadelphia, PA 19104, 215.590.1858, fax 215.590.1415,
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Abstract
Advances in computer technology, patient monitoring systems, and electronic health record systems have enabled rapid accumulation of patient data in electronic form (i.e. big data). Organizations such as the Anesthesia Quality Institute and Multicenter Perioperative Outcomes Group have spearheaded large-scale efforts to collect anaesthesia big data for outcomes research and quality improvement. Analytics--the systematic use of data combined with quantitative and qualitative analysis to make decisions--can be applied to big data for quality and performance improvements, such as predictive risk assessment, clinical decision support, and resource management. Visual analytics is the science of analytical reasoning facilitated by interactive visual interfaces, and it can facilitate performance of cognitive activities involving big data. Ongoing integration of big data and analytics within anaesthesia and health care will increase demand for anaesthesia professionals who are well versed in both the medical and the information sciences.
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Affiliation(s)
- A F Simpao
- Department of Anesthesiology and Critical Care, Perelman School of Medicine at the University of Pennsylvania and the Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, Suite 9329, Philadelphia, PA 19104-4399, USA
| | - L M Ahumada
- Enterprise Analytics and Reporting, The Children's Hospital of Philadelphia, 1300 Market Street, Room W-8006, Philadelphia, PA 19107-3323, USA
| | - M A Rehman
- Department of Anesthesiology and Critical Care, Perelman School of Medicine at the University of Pennsylvania and the Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, Suite 9329, Philadelphia, PA 19104-4399, USA
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Simpao AF, Ahumada LM, Desai BR, Bonafide CP, Gálvez JA, Rehman MA, Jawad AF, Palma KL, Shelov ED. Optimization of drug-drug interaction alert rules in a pediatric hospital's electronic health record system using a visual analytics dashboard. J Am Med Inform Assoc 2014; 22:361-9. [PMID: 25318641 DOI: 10.1136/amiajnl-2013-002538] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE To develop and evaluate an electronic dashboard of hospital-wide electronic health record medication alerts for an alert fatigue reduction quality improvement project. METHODS We used visual analytics software to develop the dashboard. We collaborated with the hospital-wide Clinical Decision Support committee to perform three interventions successively deactivating clinically irrelevant drug-drug interaction (DDI) alert rules. We analyzed the impact of the interventions on care providers' and pharmacists' alert and override rates using an interrupted time series framework with piecewise regression. RESULTS We evaluated 2 391 880 medication alerts between January 31, 2011 and January 26, 2014. For pharmacists, the median alert rate prior to the first DDI deactivation was 58.74 alerts/100 orders (IQR 54.98-60.48) and 25.11 alerts/100 orders (IQR 23.45-26.57) following the three interventions (p<0.001). For providers, baseline median alert rate prior to the first round of DDI deactivation was 19.73 alerts/100 orders (IQR 18.66-20.24) and 15.11 alerts/100 orders (IQR 14.44-15.49) following the three interventions (p<0.001). In a subgroup analysis, we observed a decrease in pharmacists' override rates for DDI alerts that were not modified in the system from a median of 93.06 overrides/100 alerts (IQR 91.96-94.33) to 85.68 overrides/100 alerts (IQR 84.29-87.15, p<0.001). The medication serious safety event rate decreased during the study period, and there were no serious safety events reported in association with the deactivated alert rules. CONCLUSIONS An alert dashboard facilitated safe rapid-cycle reductions in alert burden that were temporally associated with lower pharmacist override rates in a subgroup of DDIs not directly affected by the interventions; meanwhile, the pharmacists' frequency of selecting the 'cancel' option increased. We hypothesize that reducing the alert burden enabled pharmacists to devote more attention to clinically relevant alerts.
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Affiliation(s)
- Allan F Simpao
- Department of Anesthesiology and Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania and the Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Luis M Ahumada
- Department of Enterprise Analytics and Reporting, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Bimal R Desai
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania and the Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Christopher P Bonafide
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania and the Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Jorge A Gálvez
- Department of Anesthesiology and Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania and the Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Mohamed A Rehman
- Department of Anesthesiology and Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania and the Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Abbas F Jawad
- Department of Biostatistics in Pediatrics, Perelman School of Medicine at the University of Pennsylvania and the Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Krisha L Palma
- Department of Pharmacy Services, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Eric D Shelov
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania and the Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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Cook-Sather SD, Li J, Goebel TK, Sussman EM, Rehman MA, Hakonarson H. TAOK3, a novel genome-wide association study locus associated with morphine requirement and postoperative pain in a retrospective pediatric day surgery population. Pain 2014; 155:1773-1783. [PMID: 24909733 DOI: 10.1016/j.pain.2014.05.032] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2013] [Revised: 04/18/2014] [Accepted: 05/30/2014] [Indexed: 01/21/2023]
Abstract
Candidate gene studies have revealed limited genetic bases for opioid analgesic response variability. Genome-wide association studies facilitate impartial queries of common genetic variants, allowing identification of novel genetic contributions to drug effect. Illumina (Illumina Inc, San Diego, CA, USA) single nucleotide polymorphism (SNP) arrays were used to investigate SNP associations with total morphine requirement as a quantitative trait locus and with postoperative pain in a retrospective population of opioid-naïve children ages 4-18years who had undergone day surgery tonsillectomy and adenoidectomy. In an independent replication cohort, significant genome-wide association studies-identified SNPs were assayed using TaqMan probes. Among 617 comprehensively phenotyped children, the 277 subjects of European Caucasian (EC) ancestry demonstrated nominal association between morphine dose and a series of novel SNPs (top rs795484, P=1.01 × 10(-6) and rs1277441, P=2.77 × 10(-6)) at the TAOK3 locus. Age, body mass index, and physical status were included covariates. Morphine requirement averaged 132.4 μg/kg (SD 40.9). Each minor allele at rs795484 (guanine [G]>adenine [A]) contributed +17.6 μg/kg (95% confidence interval [CI] 10.7-24.4) to dose. Effect direction and magnitude were replicated in an independent cohort of 75 EC children (P<0.05). No association with morphine dose was detected in African Americans (AA) (n=241). Postoperative pain scores ≥ 7/10 were associated with rs795484 (G>A) in the EC cohort (odds ratio 2.35, 95% CI 1.56-3.52, P<0.00005) and this association replicated in AA children (odds ratio 1.76, 95% CI 1.14-2.71, P<0.01). Variants in TAOK3 encoding the serine/threonine-protein kinase, TAO3, are associated with increased morphine requirement in children of EC ancestry and with increased acute postoperative pain in both EC and AA subjects.
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Affiliation(s)
- Scott D Cook-Sather
- Department of Anesthesiology and Critical Care, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, USA Center for Applied Genomics, Abramson Research Center, The Children's Hospital of Philadelphia, Philadelphia, PA, USA Department of Pediatrics, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
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Gálvez JA, Ahumada L, Simpao AF, Lin EE, Bonafide CP, Choudhry D, England WR, Jawad AF, Friedman D, Sesok-Pizzini DA, Rehman MA. Visual analytical tool for evaluation of 10-year perioperative transfusion practice at a children's hospital. J Am Med Inform Assoc 2013; 21:529-34. [PMID: 24363319 DOI: 10.1136/amiajnl-2013-002241] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Children are a vulnerable population in the operating room, and are particularly at risk of complications from unanticipated hemorrhage. The decision to prepare blood products prior to surgery varies depending on the personal experience of the clinician caring for the patient. We present the first application of a data visualization technique to study large datasets in the context of blood product transfusions at a tertiary pediatric hospital. The visual analytical interface allows real-time interaction with datasets from 230 000 procedure records. Clinicians can use the visual analytical interface to analyze blood product usage based on procedure- and patient-specific factors, and then use that information to guide policies for ordering blood products.
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Affiliation(s)
- Jorge A Gálvez
- Department of Anesthesiology & Critical Care, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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Simpao AF, Pruitt EY, Cook-Sather SD, Gurnaney HG, Rehman MA. The reliability of manual reporting of clinical events in an anesthesia information management system (AIMS). J Clin Monit Comput 2012; 26:437-9. [PMID: 22618299 DOI: 10.1007/s10877-012-9371-z] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2012] [Accepted: 05/10/2012] [Indexed: 11/24/2022]
Abstract
Manual incident reports significantly under-report adverse clinical events when compared with automated recordings of intraoperative data. Our goal was to determine the reliability of AIMS and CQI reports of adverse clinical events that had been witnessed and recorded by research assistants. The AIMS and CQI records of 995 patients aged 2-12 years were analyzed to determine if anesthesia providers had properly documented the emesis events that were observed and recorded by research assistants who were present in the operating room at the time of induction. Research assistants recorded eight cases of emesis during induction that were confirmed with the attending anesthesiologist at the time of induction. AIMS yielded a sensitivity of 38 % (95 % confidence interval [CI] 8.5-75.5 %), while the sensitivity of CQI reporting was 13 % (95 % CI 0.3-52.7 %). The low sensitivities of the AIMS and CQI reports suggest that user-reported AIMS and CQI data do not reliably include significant clinical events.
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Affiliation(s)
- Allan F Simpao
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, 34th and Civic Center Blvd, Room 9329, Philadelphia, PA, USA.
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Richardson JE, Shah-Hosseini S, Fiadjoe JE, Ash JS, Rehman MA. The effects of a hands-free communication device system in a surgical suite. J Am Med Inform Assoc 2010; 18:70-2. [PMID: 21113074 DOI: 10.1136/jamia.2009.001461] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
This case report describes a qualitative investigation into how a Hands-free Communication Device (HCD) system impacted communication among anesthesia staff in a pediatric surgical suite. The authors recruited a purposive sample that included anesthesiologists, certified registered nurse anesthetists, circulating nurses, a charge nurse, and a postanesthesia care unit nurse. Data were collected using semistructured interviews and observations, then analyzed using a constant comparison approach. The results corroborate and enrich themes that were discovered in a previous qualitative study of HCD systems: (1) communication access, (2) control, (3) training, (4) environment and infrastructure. The results also generated new subthemes and themes: (1) technical control, (2) choosing communication channels, and (3) reliability. The authors conclude that HCD systems profoundly impacted communication in a largely positive way, although reliability of the technology remained an issue. The authors' findings contribute a valuable insight into the growing body of knowledge about implementation and use of HCD systems.
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Affiliation(s)
- Joshua E Richardson
- Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland, Oregon, USA.
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Ehrenfeld JM, Rehman MA. Anesthesia information management systems: a review of functionality and installation considerations. J Clin Monit Comput 2010; 25:71-9. [PMID: 20734117 DOI: 10.1007/s10877-010-9256-y] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2010] [Accepted: 08/06/2010] [Indexed: 12/01/2022]
Abstract
The functionality and rate of implementation of Anesthesia Information Management Systems (AIMS) has markedly risen over the past decade. These systems have now become much more than the generic automated record keepers, originally proposed and developed in the 1980s. AIMS have now become complex integrated systems, which have been shown to improve patient care and, in some cases, the financial performance of a department. Although the underlying technology has improved greatly over the past 5 years, the process of selecting and completing an AIMS installation still presents a number of challenges, and must be approached carefully in order to maximize the benefits provided by these systems.
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Affiliation(s)
- Jesse M Ehrenfeld
- Department of Anesthesia, Critical Care & Pain Medicine, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Jackson 458, Boston, MA 02114-2696, USA.
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Kraemer FW, Stricker PA, Gurnaney HG, McClung H, Meador MR, Sussman E, Burgess BJ, Ciampa B, Mendelsohn J, Rehman MA, Watcha MF. Bradycardia during induction of anesthesia with sevoflurane in children with Down syndrome. Anesth Analg 2010; 111:1259-63. [PMID: 20736433 DOI: 10.1213/ane.0b013e3181f2eacf] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Bradycardia is a complication associated with inhaled induction of anesthesia with halothane in children with Down syndrome. Although bradycardia has been reported after anesthetic induction with sevoflurane in these children, the incidence is unknown. OBJECTIVES In this study we compared the incidence and characteristics of bradycardia after induction of anesthesia with sevoflurane in children with Down syndrome to healthy controls. METHODS We reviewed electronic anesthetic records of 209 children with Down syndrome and 268 healthy control patients who had inhaled induction of anesthesia with sevoflurane over an 8-year period. Data extracted from the medical record included demographics, history of congenital heart disease, heart rate, oxyhemoglobin saturation, expired sevoflurane concentrations, arterial blood pressure, and any treatment of bradycardia during the first 360 seconds after the start of induction of anesthesia. Bradycardia and hypotension were defined as heart rate and arterial blood pressure below the critical limits recommended for activating a pediatric rapid response team to the bedside of a hospitalized child for quick intervention. Factors associated with bradycardia were identified in a univariate analysis. A step-wise backward multiple logistic regression model was used to identify independent factors. Differences between the 2 groups were computed using Fisher's exact test or χ(2) tests for categorical data and t tests for continuous data. RESULTS Univariate analysis demonstrated that Down syndrome, low ASA physical status, congenital heart disease, and mean sevoflurane concentrations were factors associated with bradycardia. However, multivariate analysis showed that only Down syndrome and low ASA physical status remained as independent factors associated with bradycardia. CONCLUSION Bradycardia during anesthetic induction with sevoflurane was common in children with Down syndrome, with and without a history of congenital heart disease.
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Affiliation(s)
- F Wickham Kraemer
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, PA 19104-4399, USA.
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Stricker PA, Budac S, Fiadjoe JE, Rehman MA. Awake laryngeal mask insertion followed by induction of anesthesia in infants with the Pierre Robin sequence. Acta Anaesthesiol Scand 2008; 52:1307-8. [PMID: 18823480 DOI: 10.1111/j.1399-6576.2008.01751.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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41
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Abstract
Prenatally diagnosed sacrococcygeal teratomas (SCT) have higher mortality rates than those diagnosed in the neonatal period. Natural history of SCT varies, and management depends on pathophysiology. Treatment may be minimally invasive or require open surgery. Intervention may take place in the prenatal period, or it may occur within minutes to days after birth. Optimal care requires close follow up and communication between members of a multidisciplinary team. We present a case of prenatally diagnosed SCT and address the evaluation, anesthetic considerations, and mechanisms needed to care for this high risk population.
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Affiliation(s)
- Kha M Tran
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, PA 19104, USA.
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Abstract
Morquio's syndrome is an inherited disorder characterized by excessive excretion of keratan sulphate in the urine. The anaesthetic care of these patients should take into consideration respiratory, craniofacial, cardiac, skeletal, ocular and hepatic abnormalities. We report the case of a child with Morquio's syndrome who presented for stabilization of the cervical spine, and discuss the issues relevant to the anaesthesiologist.
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Affiliation(s)
- Kathleen A Morgan
- Department of Anesthesia and Critical Care, St Christopher's Hospital for Children, Philadelphia, PA 19134, USA
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44
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Abstract
OBJECTIVES The aim of the study was to assess the safety and efficacy of the Amplatzer ductal occluder (ADO) in transcatheter occlusion of patent ductus arteriosus (PDA). BACKGROUND Transcatheter closure of small to moderate sized PDAs is an established procedure. The ADO is a self-expandable device with a number of salutary features, notably its retrievability, ease of delivery via small 5F to 7F catheters and a range of sizes suitable even for the larger PDAs. METHODS Between November 1997 and August 1999, the ADO was successfully implanted in 205 of 209 patients with PDA. The inclusion criteria for this device occlusion method were patients with clinical and echocardiographic features of moderate to large PDA, weighing > or =3.5 kg as well as asymptomatic adolescents and adults with PDA measuring > or =5.0 mm on two-dimensional (2D) echocardiogram. Occlusion was achieved via the antegrade venous approach. Follow-up evaluations were performed with 2D echocardiogram, color-flow mapping and Doppler measurement of the descending aorta and left pulmonary artery velocity at 24 h and 1, 3, 6 and 12 months after implantation. RESULTS Two hundred and five patients had successful PDA occlusion using this device. The patients were between two months and 50 years (median 1.9) and weighed between 3.4 kg and 63.2 (median 8.4). Infants made up 26% of the total patients. The PDA measured from 1.8 to 12.5 mm (mean 4.9) at the narrowest diameter. Forty-four percent of patients achieved immediate complete occlusion. On color Doppler the closure rates at 24 h and 1 month after implant were 66% and 97%, respectively. At 6 and 12 months all except one patient attained complete occlusion. Device embolization occurred in three patients; in two this was spontaneous, and in the other it was due to catheter manipulation during postimplant hemodynamic measurement. Mild aortic narrowing was seen in an infant. CONCLUSIONS Patent ductus arteriosus occlusion using ADO is safe and efficacious. It is particularly useful in symptomatic infants and small children with relatively large PDA. Embolization can be minimized by selection of appropriate sized devices, and caution should be exercised in infants <5 kg.
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Affiliation(s)
- A A Bilkis
- Department of Pediatric Cardiology, Institut Jantung Negara, Kuala Lumpur, Malaysia
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45
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Abstract
A case of somatosensory evoked potential (SSEP) induced electrocardiographic artefact simulating supraventricular tachycardia (SVT) is described in a three year old girl with Goldenhar syndrome, during anterior thoracoscopic discectomy with posterior spinal fusion for scoliosis. Adenosine was administered for this misinterpreted EKG with coincidental cessation of SVT like trace.
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Affiliation(s)
- D K Choudhry
- St. Christopher's Hospital for Children, Department of Anesthesia and Critical Care, Philadelphia, PA 19134-1095, USA
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46
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Abstract
Alagille's syndrome is an inherited disorder affecting multiple organ systems. Most characteristic is the paucity of the interlobular bile ducts with cholestasis. The anaesthetic plan for these patients should be based on careful preoperative preparation and attention to the issues involving hepatobiliary, cardiac, neurodevelopmental, nutritional, haematological, ocular and facial abnormalities. We report the case of a five-and-a-half-year old patient with Alagille's syndrome who sustained a pathological fracture of the femur and was scheduled for closed reduction and application of a hip spica cast. Relevant anaesthetic issues are discussed.
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Affiliation(s)
- D K Choudhry
- Department of Anaesthesia and Critical Care, St. Christopher's Hospital for Children, Philadelphia, PA 19134-1095, USA
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47
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Abstract
Fibreoptic bronchoscopic guided tracheal intubation is often the first choice for clinicians familiar with the technique, when faced with a patient in whom tracheal intubation presents known or possible difficulties. Regardless of the technique chosen, anticipated and unanticipated problems may arise. We report three patients with known difficult airways that illustrate the utility of light wand guided oral and nasotracheal intubation when tracheal intubation with fibreoptic bronchoscopy proved impossible.
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Affiliation(s)
- M A Rehman
- Department of Anesthesia and Critical Care Medicine, St. Christopher's Hospital for Children, Philadelphia, PA 19134, USA
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Rehman MA, al-Sulaiman MH, Mousa DH, al-Hawas FA, Abdalla AH, Rassoul Z, al-Khader AA. Effects of simvastatin in hyperlipidemic renal transplant patients receiving cyclosporine. Transplantation 1995; 60:397-9. [PMID: 7652773 DOI: 10.1097/00007890-199508270-00018] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Affiliation(s)
- M A Rehman
- Department of Nephrology, Riyadh Armed Forces Hospital, Kingdom of Saudi Arabia
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Rassoul Z, Mousa D, Rehman MA, Abdalla AH, Hawas F, Popovich W, Gaisoum M, al-Sulaiman M, Al-Khader A. Serum parathyroid hormone suppression by intravenous 1,25-dihydroxyvitamin D3 in patients on maintenance haemodialysis. Am J Nephrol 1995; 15:507-11. [PMID: 8546173 DOI: 10.1159/000168896] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Secondary hyperparathyroidism in patients with end-stage renal disease is characterised by elevated circulating levels of parathyroid hormone, due to inadequate synthesis of calcitriol, the active metabolite of vitamin D. Recent studies suggest that administration of calcitriol may directly suppress parathyroid (PTH) secretion independent of changes in serum calcium. We have studied the effect of intravenous calcitriol administration on the PTH level in 14 patients on maintenance haemodialysis with serum PTH levels above 2,000 pmol/l over a 16-week period. There was a significant reduction in the PTH level (65%) and a rise of serum calcium to the normal range. There was a significant reduction in serum PTH levels before the serum calcium concentrations increased, suggesting that calcitriol directly inhibits PTH release. In conclusion, intravenous treatment with calcitriol is of clinical importance, because it suppresses hypersecretion of PTH in uraemic patients, with minimal side effects.
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Affiliation(s)
- Z Rassoul
- Department of Nephrology, Riyadh Armed Forces Hospital, Saudi Arabia
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50
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Mousa D, Hamilton D, Miola UJ, al-Sulaiman M, Rassoul Z, Abdalla A, Rehman MA, al-Khader A. The importance of the perfusion index in the evaluation of captopril renography for transplant renal artery stenosis. Nucl Med Commun 1994; 15:949-52. [PMID: 7715893 DOI: 10.1097/00006231-199412000-00005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Severe renal artery stenosis (RAS) is a relatively uncommon complication following renal transplantation but is a curable cause of hypertension which demands reliable early diagnosis to reduce morbidity, mortality and graft loss. Captopril renography has been used for a number of years as a method of detecting RAS mainly in native kidneys, with only a few studies concerning the transplant situation. Controversy still exists as to the diagnostic accuracy of this test and as to the most appropriate interpretation criteria with which to establish a positive result. This paper reports the evaluation of 26 captopril renography investigations on hypertensive renal transplant patients with a suspected diagnosis of RAS. Each renogram study was correlated with an arteriogram as the 'gold standard' which was undertaken within 28 days of the renography. A sensitivity of 92%, a specificity of 86% and an accuracy of 88% were achieved by including a consideration of the change in perfusion to the kidney between pre- and post-challenge studies. It is concluded that captopril renography is a useful screening test for the detection of transplant renal artery stenosis (TRAS).
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Affiliation(s)
- D Mousa
- Department of Renal Medicine, Riyadh Al Kharj Hospital Programme, Kingdom of Saudi Arabia
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