Patient and Process Outcomes among Pediatric Patients Undergoing Appendectomy during the COVID-19 Pandemic: An International Retrospective Cohort Study.

BACKGROUND: COVID-19 forced healthcare systems to make unprecedented changes in clinical care processes. The authors hypothesized that the COVID-19 pandemic adversely impacted timely access to care, perioperative processes, and clinical outcomes for pediatric patients undergoing primary appendectomy. METHODS: A retrospective, international, multicenter study was conducted using matched cohorts within participating centers of the international PEdiatric Anesthesia COVID-19 Collaborative (PEACOC). Patients younger than 18 yr old were matched using age, American Society of Anesthesiologists Physical Status, and sex. The primary outcome was the difference in hospital length of stay of patients undergoing primary appendectomy during a 2-month period early in the COVID-19 pandemic (April to May 2020) compared with prepandemic (April to May 2019). Secondary outcomes included time to appendectomy and the incidence of complicated appendicitis. RESULTS: A total of 3,351 cases from 28 institutions were available with 1,684 cases in the prepandemic cohort matched to 1,618 in the pandemic cohort. Hospital length of stay was statistically significantly different between the two groups: 29 h (interquartile range: 18 to 79) in the pandemic cohort versus 28 h (interquartile range: 18 to 67) in the prepandemic cohort (adjusted coefficient, 1 [95% CI, 0.39 to 1.61]; P < 0.001), but this difference was small. Eight centers demonstrated a statistically significantly longer hospital length of stay in the pandemic period than in the prepandemic period, while 13 were shorter and 7 did not observe a statistically significant difference. During the pandemic period, there was a greater occurrence of complicated appendicitis, prepandemic 313 (18.6%) versus pandemic 389 (24.1%), an absolute difference of 5.5% (adjusted odds ratio, 1.32 [95% CI, 1.1 to 1.59]; P = 0.003). Preoperative SARS-CoV-2 testing was associated with significantly longer time-to-appendectomy, 720 min (interquartile range: 430 to 1,112) with testing versus 414 min (interquartile range: 231 to 770) without testing, adjusted coefficient, 306 min (95% CI, 241 to 371; P < 0.001), and longer hospital length of stay, 31 h (interquartile range: 20 to 83) with testing versus 24 h (interquartile range: 14 to 68) without testing, adjusted coefficient, 7.0 (95% CI, 2.7 to 11.3; P = 0.002). CONCLUSIONS: For children undergoing appendectomy, the COVID-19 pandemic did not significantly impact hospital length of stay.

Effect of Wearing a Face Mask on Hand-to-Face Contact by Children in a Simulated School Environment: The Back-to-School COVID-19 Simulation Randomized Clinical Trial.

Importance: Wearing a face mask in school can reduce SARS-CoV-2 transmission but it may also lead to increased hand-to-face contact, which in turn could increase infection risk through self-inoculation. Objective: To evaluate the effect of wearing a face mask on hand-to-face contact by children while at school. Design, Setting, and Participants: This prospective randomized clinical trial randomized students from junior kindergarten to grade 12 at 2 schools in Toronto, Ontario, Canada, during August 2020 in a 1:1 ratio to either a mask or control class during a 2-day school simulation. Classes were video recorded from 4 angles to accurately capture outcomes. Interventions: Participants in the mask arm were instructed to bring their own mask and wear it at all times. Students assigned to control classes were not required to mask at any time (grade 4 and lower) or in the classroom where physical distancing could be maintained (grade 5 and up). Main Outcomes and Measures: The primary outcome was the number of hand-to-face contacts per student per hour on day 2 of the simulation. Secondary outcomes included hand-to-mucosa contacts and hand-to-nonmucosa contacts. A mixed Poisson regression model was used to derive rate ratios (RRs), adjusted for age and sex with a random intercept for class with bootstrapped 95% CIs. Results: A total of 174 students underwent randomization and 171 students (mask group, 50.6% male; control group, 52.4% male) attended school on day 2. The rate of hand-to-face contacts did not differ significantly between the mask and the control groups (88.2 vs 88.7 events per student per hour; RR, 1.00; 95% CI, 0.78-1.28; P = >.99). When compared with the control group, the rate of hand-to-mucosa contacts was significantly lower in the mask group (RR, 0.12; 95% CI, 0.07-0.21), while the rate of hand-to-nonmucosa contacts was higher (RR, 1.40; 95% CI, 1.08-1.82). Conclusions and Relevance: In this clinical trial of simulated school attendance, hand-to-face contacts did not differ among students required to wear face masks vs students not required to wear face masks; however, hand-to-mucosa contracts were lower in the face mask group. This suggests that mask wearing is unlikely to increase infection risk through self-inoculation. Trial Registration: ClinicalTrials.gov Identifier: NCT04531254.

Impact of COVID-19 Public Health Protocols on Teachers Instructing Children and Adolescents During an In-Person Simulation.

Objective: As a result of the COVID-19 pandemic, public health agencies and school boards across Canada enacted new protocols, including face masks, physical distancing and enhanced hygiene, to support the safe reopening of in-person school. This study explored the experiences and perceptions of teachers instructing children and adolescents in person during a two-day school simulation. Method: This study was part of a large school simulation exercise conducted in Toronto, Ontario. Kindergarten to grade 12 teachers taught in classrooms with either masked students, or students who were un-masked or only masked when physical distancing was not possible. A qualitative descriptive phenomenology approach was utilized, and data were collected via virtual focus groups. Qualitative data analysis involved multiple rounds of inductive coding to generate themes. Results: The sample included 14 teachers (92.9% female; 85.7% White), with a median of 9.5 years teaching experience. Three primary themes emerged: 1) learning to navigate public health measures, 2) needing to adapt teaching strategies and 3) striving to manage conflicting priorities. The majority of teachers reported that mask-wearing and physical distancing impacted their classroom teaching, communication and connection with students. Conclusions: As schools transition to in-person instruction, teachers will be required to play dual roles in education and public health, with implications on safety, teaching and professional identity. Public health agencies and school boards are encouraged to engage teachers in ongoing conversations regarding in-person school planning and operations. Furthermore, evidence-based interventions, including increased teaching development programs, are recommended to support teachers during the COVID-19 pandemic.

Objectif: Conséquemment à la pandémie de la COVID-19, les organismes de santé publique et les conseils scolaires de tout le Canada ont mis en œuvre de nouveaux protocoles, notamment des masques, une distanciation physique et une hygiène accrue, afin de soutenir la réouverture prudente de l'école en personne. La présente étude a exploré les expériences et les perceptions des professeurs instruisant les enfants et les adolescents en personne durant une simulation scolaire de deux jours. Méthode: La présente étude faisait partie d'un grand exercice de simulation scolaire mené à Toronto, Ontario. Les professeurs de la maternelle à la 12e année enseignaient dans des classes où les élèves étaient soit masqués, soit non masqués, soit seulement masqués quand la distanciation physique n'était pas possible. Une approche de phénoménologie qualitative descriptive a été utilisée, et les données ont été recueillies par des groupes de discussion virtuels. L'analyse des données qualitatives impliquait de multiples rondes de codage inductif pour générer des thèmes. Résultats: L'échantillon comportait 14 professeurs (92,9 % de sexe féminin; 85,7 % Blancs), avec une moyenne de 9,5 années d'expérience d'enseignement. Trois principaux thèmes ont émergé : 1) apprendre à naviguer les mesures de santé publique, 2) la nécessité d'adapter les stratégies d'enseignement et 3) s'efforcer de gérer les priorités conflictuelles. La majorité des professeurs a déclaré que le port du masque et la distanciation physique influaient sur leur enseignement en classe, sur la communication et la connexion avec les élèves. Conclusions: Tandis que les écoles font la transition à l'enseignement en personne, les professeurs devront assumer des doubles rôles en éducation et en santé publique, impliquant la sécurité, l'enseignement et l'identité professionnelle. Les organismes de santé publique et les conseils scolaires sont invités à faire participer les professeurs à des conversations actuelles relativement à la planification et aux activités de l'école en personne. En outre, les interventions fondées sur des données probantes, notamment les programmes accrus de développement de l'enseignement, sont recommandées pour soutenir les professeurs durant la pandémie de la COVID-19.

Return to school and mask-wearing in class during the COVID-19 pandemic: Student perspectives from a school simulation study.

Objectives: This study examined children's perspectives about returning to in-person school following lockdown due to the pandemic and about mask-wearing in class, as well as the mental health of children and parents during the pandemic. Methods: This cross-sectional study was part of a 2-day school simulation exercise that randomized students to different masking recommendations. Parent-report of mental health and post-simulation child-report of COVID-19-related anxiety and mask-wearing were analyzed using descriptive and multiple regression analyses. Semi-structured focus groups were conducted with older students to supplement questionnaire data. Results: Of 190 students in this study, 31% were in grade 4 or lower 95% looked forward to returning to in-person school. Greater child anxiety about COVID-19 was predicted by increased parent/caregiver anxiety (ß=0.67; P<0.001), and lower parental educational attainment (ß=1.86; P<0.002). Older students were more likely than younger students to report that mask-wearing interfered with their abilities to interact with peers (χ2(1)=31.16; P<0.001) and understand the teacher (χ2(1)=13.97; P<0.001). Students in the group that did not require masks were more likely than students in the masking group to report worries about contracting COVID-19 at school (χ2(1)=10.07; P<0.05), and anticipated difficulty wearing a mask (χ2(1)=18.95; P<0.001). Conclusions: For children anxious about COVID-19, parental anxiety and education about COVID-19 may be targets for intervention. Future research should examine the impact of prolonged implementation of public health mitigation strategies in school on academic achievement and children's mental health.

Lessons from COVID-19: A reflection on the strengths and weakness of early consensus recommendations for pediatric difficult airway management during a respiratory viral pandemic using a modified Delphi method.

BACKGROUND: The authors recognized a gap in existing guidelines and convened a modified Delphi process to address novel issues in pediatric difficult airway management raised by the COVID-19 pandemic. METHODS: The Pediatric Difficult Intubation Collaborative, a working group of the Society for Pediatric Anesthesia, assembled an international panel to reach consensus recommendations on pediatric difficult airway management during the COVID-19 pandemic using a modified Delphi method. We reflect on the strengths and weaknesses of this process and ways care has changed as knowledge and experience have grown over the course of the pandemic. RECOMMENDATIONS: In the setting of the COVID-19 pandemic, the Delphi panel recommends against moving away from the operating room solely for the purpose of having a negative pressure environment. The Delphi panel recommends supplying supplemental oxygen and using videolaryngoscopy during anticipated difficult airway management. Direct laryngoscopy is not recommended. If the patient meets extubation criteria, extubate in the OR, awake, at the end of the procedure. REFLECTION: These recommendations remain valuable guidance in caring for children with anticipated difficult airways and infectious respiratory pathology when reviewed in light of our growing knowledge and experience with COVID-19. The panel initially recommended minimizing involvement of additional people and trainees and minimizing techniques associated with aerosolization of viral particles. The demonstrated effectiveness of PPE and vaccination at reducing the risk of exposure and infection to clinicians managing the airway makes these recommendations less relevant for COVID-19. They would likely be important initial steps in the face of novel respiratory viral pathogens. CONCLUSIONS: The consensus process cannot and should not replace evidence-based guidelines; however, it is encouraging to see that the panel's recommendations have held up well as scientific knowledge and clinical experience have grown.

Coronavirus disease 2019 and pediatric anesthesia.

PURPOSE OF REVIEW: The purpose of this review is to provide the latest evidence for delivering safe and effective anesthesia care for pediatric patients with coronavirus disease 2019 (COVID-19) and to highlight continuing gaps in the literature. RECENT FINDINGS: Safe and efficient care of pediatric patients with COVID-19 can be delivered with the proper planning, coordination, supplies, and staff preparation. From the start of the pandemic, pediatric anesthesiologists from around the world contributed important insights and shared experience as to how best to adapt anesthesia care for children with COVID-19 requiring general anesthesia and sedation. Although initial efforts focused on creating safe airway management processes, the role of anesthesiologists as perioperative leaders quickly extended to ensuring well-coordinated management of COVID-19 patients throughout the hospital for procedures, including preprocedure testing, patient transport, operating room setup, and ensuring the safety of staff. Several important areas remain not well studied including, the timing of rescheduling elective procedures following COVID-19 infection, the perioperative implications of re-infection, and future considerations of managing vaccinated children. SUMMARY: Pediatric anesthesia care can be safely delivered to children with COVID-19 and after COVID-19 infection. More attention needs to be focused on the perioperative management of COVID-19 children in recovery requiring anesthesia.

Pediatric Airway Management in Times of COVID-19-a Review of the Evidence and Controversies.

PURPOSE OF REVIEW: This review summarizes and provides a comprehensive narrative synthesis of the current evidence on pediatric airway management during the COVID-19 pandemic. RECENT FINDINGS: The safe care of children undergoing airway management is a primary concern for pediatric anesthesiologists. The COVID-19 pandemic has brought challenges related to airway management and the use of personal protective equipment, aerosol barriers, and the need for simulation and intubation teams. The risk of COVID-19 transmission to the health care worker may be lower in children due to the smaller volume of aerosol dispersal. The implementation of vaccinations may further reduce the risk to health care workers. Evidence demonstrating the impact of COVID-19 on airway outcomes in children is necessary to inform their care. SUMMARY: This review shows that pediatric airway management can be a safe procedure for both the patient and provider in the right setting. The use of appropriate personal protective equipment, particularly focusing on protection from aerosolized particles, is paramount to reduce infection risk. However, there are opportunities for future research.

Pediatric laryngoscopy and bronchoscopy during the COVID-19 pandemic: A four-center collaborative protocol to improve safety with perioperative management strategies and creation of a surgical tent with disposable drapes.

Aerosolization procedures during the COVID-19 pandemic place all operating room personnel at risk for exposure. We offer detailed perioperative management strategies and present a specific protocol designed to improve safety during pediatric laryngoscopy and bronchoscopy. Several methods of using disposable drapes for various procedures are described, with the goal of constructing a tent around the patient to decrease widespread contamination of dispersed droplets and generated aerosol. The concepts presented herein are translatable to future situations where aerosol generating procedures increase risk for any pathogenic exposure. This protocol is a collaborative effort based on knowledge gleaned from clinical and simulation experience from Children's Hospital Colorado, Children's Hospital of Philadelphia, The Hospital for Sick Children in Toronto, and Boston Children's Hospital.

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

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