proactive risk assessment by utilizing 'Healthcare Failure Mode and Effect Analysis' [HFMEA] for safe implementation of peripheral nerve catheters in pediatric patients

In 2011, Nationwide Children's Hospital began using peripheral nerve catheters [PNC] to provide postoperative analgesia to patients undergoing select orthopedic and abdominal surgeries. While PNCs provide a significant improvement in the quality of care that our patients receive, introducing this new technology and process within our hospital presents an inherent risk. In order to assure that our patients received the safest care, we assembled a multi-disciplinary team to complete a proactive risk assessment by utili2ing Healthcare Failure Mode and Effect Analysis [HFMEA]. HFMEA was designed by the VA National Center for Patient Safety to identify potential failure modes within systems, and to study the consequences the failure modes have on customers. The result of this process identified and evaluated 96 failure modes and therefore 19 specific interventions were developed and deployed. The HFMEA process gives us confidence that new pain management techniques and tfieir related processes can be safely and effectively implemented in order to provide the safest and highest quality care to our patients

Peripheral regional anesthesia in infants and children: an update

Peripheral regional anesthesia in children has had a recent surge in popularity among pediatric anesthesia providers. The increased prevalence is at least in part explained by the proliferation of ultrasonography in the perioperative arena. Ultrasound-guided peripheral nerve block techniques have given pediatric anesthesiologists confidence to approach the diminutive structures that are in close approximation to sensitive areas. The three major categories of pediatric peripheral nerve blocks are upper extremity, truncal, and lower extremity. The indications, ultrasound anatomy, ultrasound-guided technique, and potential complications of the nerve blocks in each category are reviewed

retrospective review of interscalene nerve blockade for shoulder surgery in the pediatric population

To retrospectively investigate the efficacy of interscalene nerve blockade in reducing postoperative pain and minimizing inpatient hospital admission after shoulder surgery in the pediatric population. Thirty-four consecutive patients undergoing shoulder surgery under general anesthesia both with and without the addition of an interscalene nerve block were included in the study. After induction of general anesthesia, those patients receiving regional anesthesia had an interscalene nerve block placed using real-time ultrasonographic guidance with the deposition of 20-30 mL of local anesthetic solution into the interscalene groove. Postoperative pain scores, the use of supplemental analgesic medications, post-anesthesia care unit [PACU] length of stay, hospital course, and any acute or non-acute complications were recorded and evaluated. There were no cardiac events, neuropathies, seizures, pneumothoraoes, or other major complications. There was a statistically significant reduction in the pain scores in patients who received an interscalene nerve block versus those who did not. There was also a significant difference found in the need for postoperative inpatient hospital admission. Eleven of the 14 patients [79%] who received a combined general and regional anesthetic technique were discharged home on the day of surgery versus 9 of 20 patients [45%] who did not receive an interscalene block [p = 0.036]. Postoperative opioid requirements were significantly reduced in patients receiving an interscalene block within the first six hours of inpatient hospital admission [p = 0.035]. There was no difference in PACU length of stay or adverse effects [postoperative nausea and vomiting] between the groups. Interscalene nerve block offers a safe and effective method of providing superior postoperative analgesia and minimizing inpatient hospital admissions in pediatric patients undergoing shoulder surgery

case report of a retained and knotted caudal catheter

Caudal catheters advanced to the lumbar and thoracic regions can be used to provide excellent analgesia for pre-term neonates undergoing major abdominal and thoracic procedures. Despite their frequent use, attention to detail is mandatory to avoid complications related to the medications used or the placement technique. We present a 2-day-old, 2 kg, pre-term infant who was born at 32 weeks gestational age with a tracheoesophageal fistula. Following anesthetic induction, a caudal epidural catheter was placed with the intent of threading it to the mid-thoracic level. The intraoperative and post-operative courses were uneventful with the epidural catheter providing adequate analgesia without the need for supplemental intravenous opioids. During catheter removal, resistance was noted and it could not be easily removed. With repositioning and various other maneuvers, the catheter was removed with some difficulty. On examination of the catheter, a complete knot was noted. Options for catheter advancement from the caudal space to the thoracic dermatomes are reviewed and techniques discussed for removal of a retained epidural catheter

Caudal epidural blockade in adolescents

Various options are available for the provision of analgesia following major surgical procedures including systemic opioids and regional anesthetic techniques. Regional anesthetic techniques offer the advantage of providing analgesia while avoiding the deleterious adverse effects associated with opioids including nausea, vomiting, sedation and respiratory depression. Although used commonly in infants and children, there is a paucity of experience with the use of caudal epidural blockade in adolescents. We retrospectively reviewed the perioperative care of adolescents undergoing major urologic or orthopedic surgical procedures for whom a caudal epidural block was placed for postoperative analgesia. The cohort for the study included 5 adolescents, ranging in age from 13 to 18 years and in weight from 42 to 71 kilograms. Caudal epidural analgesia was accomplished after the induction of anesthesia and prior to the start of the surgical procedure using 20-25 mL of either 0.25% bupivacaine or 0.2% ropivacaine with clonidine [1 micro g/kg]. The patients denied pain the recovery room. The time to first request for analgesia varied from 12 to 18 hours with the patients requiring 1-3 doses of analgesic agents during the initial 24 postoperative hours. Our preliminary experience demonstrates the efficacy of caudal epidural block in providing analgesia following major urologic and orthopedic surgical procedures. The applications of this technique as a means of providing postoperative analgesia are discussed

Transversus abdominis plane block for placement of a paracentesis catheter with failed fontan physiology

Despite the successful palliation of patients with complex CHD, long term consequences may occur related to the chronically elevated venous pressures or failing ventricular function following total cavopulmonary anastomosis in patients with single ventricle anatomy. We present a 33-year-old adult woman with Fontan physiology who presented with recurrent ascites requiring insertion of a tunneled abdominal drain. Given her co-morbid conditions, the procedure was accomplished using a transversus abdominis plane [TAP] block placed with ultrasound guidance. Although generally used for the provision of postoperative analgesia following lower abdominal procedures, the TAP block may also be used in specific scenarios instead of general anesthesia in high risk patients. The anatomy of the TAP block is reviewed, its perioperative applications discussed, and its potential use instead of general anesthesia presented

Anesthesia in a pediatric patient with systemic mastocytosis

Systemic mastocytosis is a rare disorder of mast cells which carries considerable risk in the perioperative period

Unintended release of mast cell mediators has the potential to cause signi! cant hypotension, multi-system organ dysfunction, and death. Many factors have been implicated in mast cell degranulation including heat, stress, and many medications that may be commonly used anesthetic care. We present the case of a 10 year old girl with systemic mastocytosis who required general anesthesia for reduction of a dislocated elbow

The perioperative care of such patients is reviewed and strategies for intraoperative anesthesia are discussed

Bilateral transversus abdominis plane [TAP] catheters for postoperative analgesia in a child with spinal dysraphism

Regional analgesic techniques have become indispensable in the management of adult postoperative pain, and are gaining popularity in the pediatric population. Several case reports have been published describing the use of transversus abdominis plane [TAP] blocks for the provision of analgesia following lower and middle abdominal surgery in the adult population. Although there are several anecdotal reports and a few case series describing TAP blocks in the pediatric population, there are a limited number of reports regarding the use of continuous TAP catheters in the pediatric population. We present our experience with the use of bilateral TAP catheters to provide postoperative analgesia following major abdominal surgery [appendicovesicostomy] in a 5-year old, 17.8 kg pediatric patient with spina bifida. Applications of the technique are discussed and previous reports from the adult and pediatric population regarding the use of TAP catheters are reviewed

Postoperative hypoxemia due to fat embolism

Although the reported incidence of fat embolism syndrome [FES] is low [approximately 1%], it is likely that microscopic fat emboli are showered during manipulation of long bone fractures. Even though there continues to be debate regarding the etiology and proposed mechanism responsible for FES, significant systemic manifestations may occur. Treatment is generally symptomatic based on the clinical presentations. We report a 10-year-old girl who developed hypoxemia following treatment of a displaced Salter-Harris type II fracture of the distal tibia. The subsequent evaluation and hospital course pointed to fat embolism as the most likely etiology for the hypoxemia. We discuss the etiology for FES, review the proposed pathophysiological mechanisms responsible for its clinical manifestations, present currently accepted diagnostic criteria, and discuss its treatment

unusual cause of post-operative orbital edema in a child after general anesthesia

We present an unusual ocular complication during the perioperative period, bilateral orbital edema in an otherwise healthy child after an outpatient surgical procedure. Ocular complications under general anesthesia remain a rare event. When periorbital edema is present, the appropriate work-up includes ruling out the potential for an allergic event by reviewing the medications administered and serum tryptase testing. Ophthalmology consultation should be considered to exclude pathology native to the eye itself. An allergist may assist in confirming a diagnosis and for allergic testing, if indicated. In our patient, the eventual diagnosis of exclusion was that of a localized reaction to the cellophane-based eye tape