Wake Up Safe in the USA & International Patient Safety.

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

Preventing perioperative hypothermia in children through implementation of customised guidelines.

INTRODUCTION: Perioperative hypothermia (PH) is common in children and associated with adverse clinical outcomes. Guidelines to prevent PH are mainly developed for adults and differ among institutions. We aimed to evaluate the effectiveness of customised guidelines in reducing PH in our paediatric population and the impact of cost considerations on physician practice. METHODS: Patients aged ≤16 years undergoing general anaesthesia in our tertiary paediatric hospital were prospectively recruited in this cohort study. Patient demographics, surgical procedures, anaesthesia details and temperature control measures were recorded. Data collection occurred over four phases: Phases 1 and 2 comprised standard management, while Phases 3 and 4 occurred following guidelines implementation. Sensors for continuous core temperature monitoring were provided free to patients during Phases 1 and 3, but were charged during Phases 2 and 4. The main outcome was occurrence of PH, defined as core temperature <36°C at any point from induction of anaesthesia to discharge from the postanaesthetic care unit. The impact of guidelines implementation and cost considerations influencing physician practice on PH outcomes was also analysed. RESULTS: Data from 3917 patients was analysed (1766 in Phase 1, 679 in Phase 2, 706 in Phase 3 and 766 in Phase 4). Guidelines implementation decreased PH incidence from 11.0% to 6.79% (odds ratio [OR] 0.63, 95% confidence interval [CI] 0.50-0.80, P = 0.0002). Free sensors increased the odds of detecting PH (OR 1.48, 95% CI 1.17-1.88, P = 0.001). With guidelines implementation, there was greater reduction in PH with free sensors (OR 0.64, 95% CI 0.47-0.88, P = 0.0055) compared to chargeable sensors (OR 0.75, 95% CI 0.50-1.11, P = 0.1471). CONCLUSIONS: Customised guidelines facilitated a sustained reduction of hypothermia in our paediatric surgical patients, although its impact was reduced by cost considerations.

Association between maternal labour epidural analgesia and autistic traits in offspring.

STUDY OBJECTIVE: Studies investigating associations between maternal epidural analgesia (MEA) and autism spectrum disorder (ASD) in the offspring are conflicting and lack prospective neurobehavioral follow-up assessments for autistic traits. We aim to prospectively investigate associations between MEA and autistic traits in the offspring. DESIGN: Prospective neurobehavioral observational cohort study. SETTING: Singaporean tertiary healthcare institutions. PATIENTS: Participants recruited were singleton non-IVF children, >36 weeks gestation, delivered via normal vaginal delivery by mothers >18 years of age, delivered in Singapore from June 2009-September 2010 and followed up over 7 years. INTERVENTIONS: Exposure to maternal epidural analgesia during delivery. MEASUREMENTS: The primary outcome is an abnormal Social Responsiveness Scale (SRS) T score at 7 years (≥60 points). Secondary outcomes include the diagnosis of ASD and abnormal scores for autistic traits assessed via a neurobehavioral battery comprising: CBCL (child behavioural checklist), Q-CHAT (Quantitative Checklist for Autism in Toddlers), and Bayley-III. Multivariable analyses adjusting for maternal and offspring characteristics were performed. MAIN RESULTS: 704 out of 769 mother-child dyads recruited fulfilled the criteria for analysis. 365/704 mothers received MEA. The incidence of an abnormal SRS score at 7 years in offspring exposed to MEA was 19.9%, and 26.1% in non-exposed offspring (p = 0.154). Multivariable analysis did not demonstrate a significant association between MEA and abnormal SRS scores at 7 years (O.R.0.726, 95% C·I. 0.394-1.34, p = 0.305). After adjustment for maternal and fetal demographics, exposure to MEA was not significantly associated with an abnormal screen in all other tests for autistic traits. The clinical incidence of ASD was 1.76% in children without exposure to MEA, and 2.32% in children with MEA exposure (p = 0.506). CONCLUSIONS: MEA is not significantly associated with the development of ASD and autistic traits in offspring, assessed over 7 years. Results should be taken into perspective given our wide confidence intervals and small cohort size.

A Narrative Review Illustrating the Clinical Utility of Electroencephalogram-Guided Anesthesia Care in Children.

The major therapeutic end points of general anesthesia include hypnosis, amnesia, and immobility. There is a complex relationship between general anesthesia, responsiveness, hemodynamic stability, and reaction to noxious stimuli. This complexity is compounded in pediatric anesthesia, where clinicians manage children from a wide range of ages, developmental stages, and body sizes, with their concomitant differences in physiology and pharmacology. This renders anesthetic requirements difficult to predict based solely on a child's age, body weight, and vital signs. Electroencephalogram (EEG) monitoring provides a window into children's brain states and may be useful in guiding clinical anesthesia management. However, many clinicians are unfamiliar with EEG monitoring in children. Young children's EEGs differ substantially from those of older children and adults, and there is a lack of evidence-based guidance on how and when to use the EEG for anesthesia care in children. This narrative review begins by summarizing what is known about EEG monitoring in pediatric anesthesia care. A key knowledge gap in the literature relates to a lack of practical information illustrating the utility of the EEG in clinical management. To address this gap, this narrative review illustrates how the EEG spectrogram can be used to visualize, in real time, brain responses to anesthetic drugs in relation to hemodynamic stability, surgical stimulation, and other interventions such as cardiopulmonary bypass. This review discusses anesthetic management principles in a variety of clinical scenarios, including infants, children with altered conscious levels, children with atypical neurodevelopment, children with hemodynamic instability, children undergoing total intravenous anesthesia, and those undergoing cardiopulmonary bypass. Each scenario is accompanied by practical illustrations of how the EEG can be visualized to help titrate anesthetic dosage to avoid undersedation or oversedation when patients experience hypotension or other physiological challenges, when surgical stimulation increases, and when a child's anesthetic requirements are otherwise less predictable. Overall, this review illustrates how well-established clinical management principles in children can be significantly complemented by the addition of EEG monitoring, thus enabling personalized anesthesia care to enhance patient safety and experience.

Early Neurodevelopmental Outcomes Following Exposure to General Anesthesia in Infancy: EGAIN, a Prospective Cohort Study.

BACKGROUND: General anesthesia (GA) is known to worsen neural outcomes in animals, but human research assessing early-life GA exposure and neurodevelopment show inconsistent findings. We investigated the effects of a single GA exposure for minor surgery on the neurodevelopment of healthy children at multiple time-points, using clinical assessments along with behavioral and neurophysiological measures rarely used in human research. METHODS: GA-exposed children were a prospective cohort of 250 full-term, healthy infants who underwent GA for minor surgery before 15 months. Nonexposed children were from a separate cohort of similar age, sex, ethnicity, and maternal education. In both cohorts, clinical measures (Bayley Scales of Infant and Toddler Development-III [BSID-III] and Child Behavior Checklist [CBCL1½-5]) were assessed at 24 months, and experimental tests (memory and attentional) and neurophysiology (event-related potentials) at 6 and 18 months. RESULTS: At 24 months, there were no differences between GA-exposed and nonexposed children in the cognitive, language, motor, and socioemotional domains of the BSDI-III; however, GA-exposed children had poorer parental-reported scores in BSID-III general adaptability (94.2 vs. 99.0 [mean difference, 4.77; 97.3% confidence interval, -9.29, -0.24]; P =0.020) and poorer internalizing behavior scores on CBCL1½-5 (52.8 vs. 49.4 [mean difference, 3.35; 97.3% confidence interval, 0.15-6.55]; P =0.021). For experimental measures, GA-exposed children showed differences in 4 tests at 6 and 18 months. CONCLUSIONS: GA-exposed children did not differ from unexposed children in cognitive, language or motor outcomes at 24 months, but exhibited poorer parent-reported behavior scores. Differences in infant behavior and neurophysiology were detected at 6 and 18 months. Neurophysiological assessments may complement clinically relevant assessments to provide greater insights into neurodevelopment following early GA exposure.

Development of local guidelines to prevent perioperative hypothermia in children: a prospective observational cohort study.

PURPOSE: Perioperative hypothermia (PH) is defined as core body temperature < 36°C during the perioperative period. The incidence of PH is not well established in children because of variations in perioperative temperature monitoring and control measures. We sought to 1) establish the incidence of pediatric PH, 2) assess its adverse outcomes, and 3) identify risk factors in our pediatric population to develop local guidelines for prevention of PH. METHODS: We conducted a prospective observational cohort study at a single tertiary hospital (KK Women's and Children's Hospital, Singapore) from June 2017 to December 2017 based on existing institutional practice. We recruited patients aged ≤ 16 yr undergoing surgery and determined the incidence and adverse outcomes of hypothermia. We identified risk factors for PH using univariate and multiple logistic regression analysis and used these to develop local guidelines. RESULTS: Of 1,766 patients analyzed, 213 (12.1%; 95% confidence interval, 10.6 to 13.7) developed PH. Among these cases of PH, only 4.5% would have been detected by a single measurement in the postanesthesia care unit (PACU). Adverse outcomes included a longer stay in the PACU (47 vs 39 min; P < 0.01), a higher incidence of shivering (7.1 vs 2.6%; P = 0.01), and more discomfort (3.8 vs 1.4%; P = 0.02) compared with normothermic patients. Risk factors for PH included preoperative temperature < 36°C, surgery duration > 60 min, ambient operating room temperature < 23.0°C, and several "high-risk" surgeries. Guidelines were developed based on these risk factors and customized according to clinical and workflow considerations. CONCLUSIONS: Perioperative hypothermia was a common problem in our pediatric population and was associated with significant adverse outcomes. Guidelines developed based on risk factors identified in the local context can facilitate workflow and implementation within the institution.

RéSUMé: OBJECTIF: L'hypothermie périopératoire (HP) est définie par une température corporelle centrale < 36 °C pendant la période périopératoire. L'incidence de l'HP chez les enfants n'est pas connue avec précision en raison des variations dans le suivi de la température périopératoire et des mesures de contrôle. Nous avons cherché à (1) déterminer l'incidence de l'HP pédiatrique, (2) évaluer ses effets préjudiciables et (3) identifier les facteurs de risque dans notre population pédiatrique afin d'élaborer des lignes directrices locales pour la prévention de l'HP. MéTHODES: Nous avons mené une étude de cohorte observationnelle prospective dans un seul hôpital de niveau tertiaire (KK Women's and Children's Hospital, Singapour) de juin 2017 à décembre 2017 sur la base des pratiques existantes dans l'établissement. Nous avons recruté des patients âgés de 16 ans ou moins subissant une intervention chirurgicale et nous avons déterminé l'incidence et les effets secondaires de l'hypothermie. Nous avons identifié les facteurs de risque de l'HP en utilisant des analyses de régression logistique monofactorielle et multifactorielle qui nous ont servi à élaborer ces lignes directrices locales. RéSULTATS: Parmi les 1 766 cas de patients analysés, 213 (12,1 %; intervalle de confiance à 95 % : 10,6 à 13,7) ont développé une HP. Parmi ceux-ci, seulement 4,5 % auraient été détectés par une mesure unique dans l'unité de soins post anesthésie (salle de réveil). Les événements indésirables ont inclus un séjour plus long en salle de réveil (47 contre 39 minutes; P < 0,01), une plus grande incidence de tremblements (7,1 % contre 2,6 %; P = 0,01) et plus d'inconfort (3,8 % contre 1,4 %; P = 0,02), comparativement aux patients normothermiques. Les facteurs de risque d'HP étaient, notamment, une température préopératoire < 36 °C, la durée de la chirurgie > 60 min, la température de la salle d'opération < 23,0°C et plusieurs chirurgies à « risque élevé ¼. Des lignes directrices ont été élaborées à partir de ces facteurs de risque et adaptées en tenant compte de considérations cliniques et des flux de travail. CONCLUSIONS: L'hypothermie périopératoire était un problème fréquent dans notre population pédiatrique et a été associée à des effets secondaires significatifs. Des lignes directrices élaborées en fonction de facteurs de risque dans un contexte local peuvent faciliter le flux de travail et leur mise en œuvre au sein d'un établissement.

Sevoflurane requirements during electroencephalogram (EEG)-guided vs standard anesthesia Care in Children: A randomized controlled trial.

STUDY OBJECTIVES: Intra-operative electroencephalographic (EEG) monitoring utilizing the spectrogram allows visualization of children's brain response during anesthesia and may complement routine cardiorespiratory monitoring to facilitate titration of anesthetic doses. We aimed to determine if EEG-guided anesthesia will result in lower sevoflurane requirements, lower incidence of burst suppression and improved emergence characteristics in children undergoing routine general anesthesia, compared to standard care. DESIGN: Randomized controlled trial. SETTING: Tertiary pediatric hospital. PATIENTS: 200 children aged 1 to 6 years, ASA 1 or 2, undergoing routine sevoflurane anesthesia for minor surgery lasting 30 to 240 min. INTERVENTIONS: Children were randomized to either EEG-guided anesthesia (EEG-G) or standard care (SC). EEG-G group had sevoflurane titrated to maintain continuous slow/delta oscillations on the raw EEG and spectrogram, aiming to avoid burst suppression and, as far as possible, maintain a patient state index (PSI) between 25 and50. SC group received standard anesthesia care and the anesthesia teams were blinded to EEG waveforms. MEASUREMENTS: The primary outcomes were the average end-tidal sevoflurane concentration during induction and maintenance of anesthesia. Secondary outcomes include incidence and duration of intra-operative burst suppression and Pediatric Anesthesia Emergence Delirium (PAED) scores. RESULTS: The EEG-G group received lower end-tidal sevoflurane concentrations during induction [4.80% vs 5.67%, -0.88% (-1.45, -0.31) p = 0.003] and maintenance of anesthesia [2.23% vs 2.38%, -0.15% (-0.25, -0.05) p = 0.005], and had a lower incidence of burst suppression [3.1% vs 10.9%, p = 0.044] compared to the SC group. PAED scores were similar between groups. Children <2 years old required higher average end-tidal sevoflurane concentrations, regardless of group. CONCLUSIONS: EEG-guided anesthesia care reduces sevoflurane requirements in children undergoing general anesthesia, possibly lowering the incidence of burst suppression, without altering emergence characteristics. EEG monitoring allows direct visualization of brain responses in real time and allows clearer appreciation of varying sevoflurane requirements in children of different ages.

An unusual case of a foreign body: A child's tongue entrapped in a soft drink bottle.

Young children often present at the emergency department (ED) with foreign bodies in their mouths, including the occasional bottles and cans. Previous reports of tongue entrapment have presented cases where bottles were mostly made of glass or metal. A 4-year-old girl presented to the ED with her tongue entrapped in a uniquely designed plastic bottle. Attempts at conservative methods of removal such as gentle traction, breaking of the vacuum seal and use of lubricants were unsuccessful. The child was brought to the operating theatre for further management. Anaesthesia induction with a facemask was not possible as the plastic bottle was protruding from the tongue and would not allow an adequate seal around the nose and mouth. To overcome such challenges of a shared airway and workspace, the child was placed under intravenous propofol sedation initially until the prompt removal of foreign body allowed subsequent mask placement and oral intubation. The foreign body was eventually removed by sectioning the inflexible plastic into two pieces with a water-cooled high speed dental diamond bur. The child remained stable intra-operatively and subsequent post-operative recovery was uneventful. This report highlights the importance of multidisciplinary coordination to reduce delays when liberating the entrapped tongue so as to minimize potential complications from the injury.

Novel Conformal Skin Patch with Embedded Thin-Film Electrodes for Early Detection of Extravasation.

Extravasation is a complication of intravenous (IV) cannulation in which vesicant drugs leak from a vein into the surrounding subcutaneous tissue. The severity of extravasation depends on the type, concentration, and volume of drugs that accumulate in the subcutaneous tissue. Rapid detection of extravasation can facilitate prompt medical intervention, minimizing tissue damage, and preventing adverse events. In this study, we present two portable sensor patches, namely gold- and carbon-based sensing patches, for early detection of extravasation. The gold-based sensor patch detected extravasated fluid of volume as low as 2 mL in in vivo animal models and human clinical trials; the patch exhibited a resistance change of 41%. The carbon-based sensor patch exhibited a resistance change of 51% for 2 mL of extravasated fluid, and fabrication throughput and cost-effectiveness are superior for this patch compared with the gold-based sensing patch.

Anaesthesia for radiotherapy in paediatric oncology-a retrospective observational study in an Asian population.

BACKGROUND: Immobilisation in radiotherapy treatment is especially important as many paediatric tumours are located near critical organs. Although the external beam radiotherapy treatment process itself is painless, the immobilization devices used may cause anxiety and discomfort in children who are too young to understand and co-operate. Hence, anaesthesia or sedation is unavoidable in such cases. This descriptive study aims to evaluate the demographics, methods and outcomes of paediatric radiotherapy patients in our Asian context. METHODS: This is a single-institution, retrospective observational study in a tertiary hospital with more than a decade of experience in paediatric radiotherapy. Data collected include age, gender, race, ASA status, oncology diagnosis, site of radiotherapy, position of patient during procedure, need for sedation or anaesthesia, anaesthetic drugs used, airway devices, use of premedications, use of antiemetics, and incidence and type of complications. We also analysed the association between various factors (e.g., age, radiotherapy treatment site) and usage of anaesthesia. Statistical analysis was carried out using a multivariable model. RESULTS: Between January 2006 and December 2017, 434 paediatric patients underwent radiotherapy, with a total of 10,357 discrete radiotherapy sessions. In 1,276 radiotherapy sessions (11.8%) either general anaesthesia or sedation was required. The need for anaesthesia was highly age-dependent-all patients under 3 years of age required anaesthesia, whereas anaesthesia was rarely needed in patients above 7 years of age. Our institution had a higher prevalence of inhalational agent usage as opposed to intravenous agent usage. Complication rate was relatively low. CONCLUSIONS: This is the first retrospective review performed in our country on paediatric patients receiving anaesthesia during radiotherapy, evaluating patients' demographic data, and type of anaesthesia and radiotherapy techniques used. We found that patients' requirement for anaesthesia decreases in an age-dependent fashion, in line with existing literature. Our reported complication rate during anaesthesia sessions was low, testament to the high standards and safety of our techniques.

The COVID-19 Pandemic: Effects on Low- and Middle-Income Countries.

Coronavirus disease 2019 (COVID-19) is spreading rapidly around the world with devastating consequences on patients, health care workers, health systems, and economies. As it reaches low- and middle-income countries, its effects could be even more dire, because it will be difficult for them to respond aggressively to the pandemic. There is a great shortage of all health care providers, who will be at risk due to a lack of personal protection equipment. Social distancing will be almost impossible. The necessary resources to treat patients will be in short supply. The end result could be a catastrophic loss of life. A global effort will be required to support faltering economies and health care systems.

An open label pilot study of a dexmedetomidine-remifentanil-caudal anesthetic for infant lower abdominal/lower extremity surgery: The T REX pilot study.

BACKGROUND: Concern over potential neurotoxicity of anesthetics has led to growing interest in prospective clinical trials using potentially less toxic anesthetic regimens, especially for prolonged anesthesia in infants. Preclinical studies suggest that dexmedetomidine may have a reduced neurotoxic profile compared to other conventional anesthetic regimens; however, coadministration with either anesthetic drugs (eg, remifentanil) and/or regional blockade is required to achieve adequate anesthesia for surgery. The feasibility of this pharmacological approach is unknown. The aim of this study was to determine the feasibility of a remifentanil/dexmedetomidine/neuraxial block technique in infants scheduled for surgery lasting longer than 2 hours. METHODS: Sixty infants (age 1-12 months) were enrolled at seven centers over 18 months. A caudal local anesthetic block was placed after induction of anesthesia with sevoflurane. Next, an infusion of dexmedetomidine and remifentanil commenced, and the sevoflurane was discontinued. Three different protocols with escalating doses of dexmedetomidine and remifentanil were used. RESULTS: One infant was excluded due to a protocol violation and consent was withdrawn prior to anesthesia in another. The caudal block was unsuccessful in two infants. Of the 56 infants who completed the protocol, 45 (80%) had at least one episode of hypertension (mean arterial pressure >80 mm Hg) and/or movement that required adjusting the anesthesia regimen. In the majority of these cases, the remifentanil and/or dexmedetomidine doses were increased although six infants required rescue 0.3% sevoflurane and one required a propofol bolus. Ten infants had at least one episode of mild hypotension (mean arterial pressure 40-50 mm Hg) and four had at least one episode of moderate hypotension (mean arterial pressure <40 mm Hg). CONCLUSION: A dexmedetomidine/remifentanil neuraxial anesthetic regimen was effective in 87.5% of infants. These findings can be used as a foundation for designing larger trials that assess alternative anesthetic regimens for anesthetic neurotoxicity in infants.

The effects of active (hot-seat) versus observer roles during simulation-based training on stress levels and non-technical performance: a randomized trial.

BACKGROUND: Active 'hands-on' participation in the 'hot-seat' during immersive simulation-based training (SBT) induces stress for participants, which is believed to be necessary to improve performance. We hypothesized that observers of SBT can subsequently achieve an equivalent level of non-technical performance as 'hot-seat' participants despite experiencing lower stress. METHODS: We randomized 37 anaesthesia trainees into two groups to undergo three consecutive SBT scenarios. Eighteen 'hot-seat' trainees actively participated in all three scenarios, and 19 'observer' trainees were directed to observe the first two scenarios and participated in the 'hot-seat' only in scenario 3. Salivary cortisol (SC) was measured at four time points during each scenario. Primary endpoint for stress response was the change in SC (ΔSC) from baseline. Performance was measured using the Anaesthetist's Non-Technical Skills (ANTS) Score. RESULTS: Mean SC increased in all participants whenever they were in the 'hot-seat' role, but not when in the observer role. Hot-seat ΔSC (mcg/dL) for scenarios 1, 2, and 3 were 0.122 (p = 0.001), 0.074 (p = 0.047), and 0.085 (p = 0.023), respectively. Observers ΔSC (mcg/dL) for scenarios 1, 2, and 3 were -0.062 (p = 0.091), 0.010 (p = 0.780), and 0.144 (p = 0.001), respectively. Mean ANTS scores were equivalent between the 'hot-seat' (40.0) and 'observer' (39.4) groups in scenario 3 (p = 0.733). CONCLUSIONS: Observers of SBT achieved an equivalent level of non-technical performance, while experiencing lower stress than trainees repeatedly trained in the 'hot-seat'. Our findings suggest that directed observers may benefit from immersive SBT even without repeated 'hands-on' experience and stress in the hot-seat. The directed observer role may offer a less stressful, practical alternative to the traditional 'hot-seat' role, potentially rendering SBT accessible to a wider audience. TRIAL REGISTRATION: ClinicalTrials.gov Identifier NCT02211378, registered August 5, 2014, retrospectively registered.

The effects of exposure to general anesthesia in infancy on academic performance at age 12.

BACKGROUND: Recent evidence from juvenile animal models has shown that exposure to anesthetic drugs above threshold doses during a critical neurodevelopmental window causes widespread neuronal apoptosis, resulting in irreversible brain damage and subsequent learning difficulties. The relevance of this to human infants having general anesthesia for minor surgery is unknown. In this pilot observational cohort study, we sought to determine whether children exposed to general anesthesia for minor surgery during infancy exhibited differences in academic achievement at age 12 years, as evidenced by (1) lower aggregate scores in the Singapore standardized Primary School Leaving Examination (PSLE) and (2) formally diagnosed learning disability, compared with children who were never exposed to anesthesia or sedation. METHODS: We compared 100 full-term, apparently healthy children aged 12 years who were exposed to general anesthesia for minor surgery before age 1 at our institution with an age-matched cohort of 106 children who were never exposed to anesthesia or sedation. Parents of children completed a 20-minute telephone interview with questions regarding their children's medical history, school environment, and home environment. RESULTS: The difference in mean PSLE aggregate scores (3.0; 95% confidence interval [CI], -8.3 to 14.3) between exposed (197.0; 95% CI, 185.6-208.4) and control groups (194.0; 95% CI, 182.9-205.1) was not statistically significant (P = 0.603). The presence of formally diagnosed learning disability was 15% (15 of 100) in the exposed group compared with 3.77% (4 of 106) in the control group (P < 0.001). The odds ratio for a formal diagnosis of learning disability in those exposed to general anesthesia relative to controls was 4.5 (95% CI, 1.44-14.1). CONCLUSION: The odds of a formal diagnosis of learning disability by age 12 years in apparently healthy children exposed to general anesthesia for minor surgery during infancy were 4.5 times greater than their peers who had never been exposed to anesthesia. However, study precision was inadequate to detect a clinically relevant difference in PSLE scores.

Effects of simulation versus traditional tutorial-based training on physiologic stress levels among clinicians: a pilot study.

INTRODUCTION: Emotionality and heightened anxiety during medical simulation encounters have been hypothesized to contribute to improved cognition and learning, but the overall stress "dose response curve" of experiential learning remains unclear. We sought to (1) identify the degree and time course of physiologic stress induced in physicians by simulation-based training (SBT), when compared with a traditional tutorial-based interactive-education training (IET) and (2) compare differences in stress responses to simulation activities among pediatric provider groups. METHOD: Twenty-seven gastroenterology physicians were randomized among six crisis resource management courses taught by SBT versus IET. Eleven RNs and four technicians participated in the SBT exercises. Heart rate (HR) and salivary cortisol (SC) levels were measured in all participants at four time points before, during, and after participation in the SBT sessions and at two time points before and after the IET sessions. RESULTS: Physicians who underwent SBT (n = 13) demonstrated increased tachycardia at the end of the session (+17 beats/min), when compared with those in the IET group (n = 14) who demonstrated an overall negative response (-4 beats/min, P = 0.001). Similarly, physicians in the SBT group demonstrated increased SC (+0.140 µg/dL, 70% over baseline), when compared with physicians in the IET group who had a median decrease in SC (-0.015 µg/dL, 20% under baseline, P = 0.001). There were similar increases in HR in all participants after SBT, but technicians experienced a relatively smaller increase in SC compared with physicians and nurses. CONCLUSIONS: After high-fidelity SBT within the gastroenterology suite, clinicians independent of their role demonstrated increased physiologic stress levels-as measured by HR and SC levels-compared with traditional IET sessions. The study provides novel calibration data compared with a traditional baseline for future investigations aimed at further understanding the dose-response curve of simulation-based experiences to optimize emotionality, cognition, and learning.

Effects of preemptive epidural analgesia on post-thoracotomy pain.

OBJECTIVE: The purpose of this study was to determine whether preemptive thoracic epidural analgesia (TEA) initiated before surgical incision would reduce the severity of acute post-thoracotomy pain and the incidence of chronic post-thoracotomy pain. METHOD: Meta-analysis of randomized controlled trials (RCTs). SEARCH STRATEGY: MEDLINE, the Cochrane Central Register of Controlled Trials (CENTRAL) and EMBASE were searched from 1966 to December 2004 for prospective RCTs published in all languages using the following MeSH terms: post-thoracotomy pain, epidural analgesia, chronic pain, and preemptive analgesia. SELECTION CRITERIA: All RCTs that compared thoracic epidural analgesia initiated before surgical incision (preemptive group) versus thoracic epidural analgesia initiated after completion of surgery (control group) in adult patients undergoing unilateral thoracotomy. MEASUREMENTS AND MAIN RESULTS: Three authors reviewed all citations and simultaneously extracted data on sample size, patient characteristics, surgical and analgesic interventions, methods of pain assessment, and pain scores at 24 hours, 48 hours, and 6 months postoperatively. Six studies were included with a total of 458 patients. Pooled analyses indicated that preemptive TEA was associated with a statistically significant reduction in the severity of acute pain on coughing at 24 and 48 hours (weighted mean difference -1.17 [95% confidence interval (CI) -1.50 to -0.83] and -1.08 [95% CI -1.17 to -0.99]), respectively. Acute pain was a good predictor of chronic pain. However, there was no statistically significant difference in the overall incidence of chronic pain at 6 months between the preemptive TEA group (39.6%) and the control group (48.6%). CONCLUSION: Preemptive TEA appeared to reduce the severity of acute pain but had no effect on the incidence of chronic pain.