Outcomes for 41 260 pediatric surgical patients with opioid-free anesthesia: One center's experience.

BACKGROUND: Opioid use is common and associated with side effects and risks. Consequently, analgesic strategies to reduce opioid utilization have been developed. Regional anesthesia and multimodal strategies are central tenets of enhanced recovery pathways and facilitate reduced perioperative opioid use. Opioid-free anesthesia (OFA) protocols eliminate all intraoperative opioids, reserving opioids for postoperative rescue treatment. Systematic reviews show variable results for OFA. METHODS: In a series of Quality Improvement (QI) projects, multidisciplinary teams developed interventions to test and spread OFA first in our ambulatory surgery center (ASC) and then in our hospital. Outcome measures were tracked using statistical process control charts to increase the adoption of OFA. RESULTS: Between January 1, 2016, and September 30, 2022, 19 872 of 28 574 ASC patients received OFA, increasing from 30% to 98%. Post Anesthesia Care Unit (PACU) maximum pain score, opioid-rescue rate, and postoperative nausea and vomiting (PONV) treatment all decreased concomitantly. The use of OFA now represents our ambulatory standard practice. Over the same timeframe, the spread of this practice to our hospital led to 21 388 of 64 859 patients undergoing select procedures with OFA, increasing from 15% to 60%. Opioid rescue rate and PONV treatment in PACU decreased while hospital maximum pain scores and length of stay were stable. Two procedural examples with OFA benefits were identified. The use of OFA allowed relaxation of adenotonsillectomy admission criteria, resulting in 52 hospital patient days saved. Transition to OFA for laparoscopic appendectomy occurred concomitantly with a decrease in the mean hospital length of stay from 2.9 to 1.4 days, representing a savings of >500 hospital patient days/year. CONCLUSIONS: These QI projects demonstrated that most pediatric ambulatory and select inpatient surgeries are amenable to OFA techniques which may reduce PONV without worsening pain.

Collaborative Multidisciplinary Incident Command at Seattle Children's Hospital for Rapid Preparatory Pediatric Surgery Countermeasures to the COVID-19 Pandemic.

Washington was the first US state to have a patient test positive for COVID-19. Before this, our children's hospital proactively implemented an incident command structure that allowed for collaborative creation of safety measures, policies, and procedures for patients, families, staff, and providers. Although the treatment and protective standards are continuously evolving, this commentary shares our thoughts on how an institution, and specifically, surgical services, may develop collaborative process improvement to accommodate for rapid and ongoing change. Specific changes outlined include early establishment of incident command; personal protective equipment conservation; workforce safety; surgical and ambulatory patient triage; and optimization of trainee education. Please note that the contents of this manuscript are shared in the interest of providing collaborative information and are under continuous development as our regional situation changes. We recognize the limitations of this commentary and do not suggest that our approaches represent validated best practices.

Assessment of muscle oxygenation in children with congenital heart disease.

BACKGROUND: Adaptive responses to congenital heart disease result in altered muscle perfusion and muscle metabolism. Such changes may be detectable using noninvasive spectroscopic monitors. AIMS: In this study we aimed to determine if resting muscle oxygen saturation (MOx) is lower in children with acyanotic or cyanotic congenital heart disease than in healthy children and to identify differences in muscle oxygen consumption in children with cyanotic and acyanotic congenital heart disease. METHODS: Using a custom fiber optic spectrometer system, optical measurements were obtained from the calf or forearm of 49 patients (17 with acyanotic congenital heart disease, 18 with cyanotic congenital heart disease, and 14 control). Twenty additional control patients were used to develop the analytic model. Spectra were used to determine MOx at baseline, during arterial occlusion, and during reperfusion. The rate of muscle desaturation during arterial occlusion was also evaluated. Two-sample t-tests were used to compare each heart disease group with the controls. RESULTS: Patients with acyanotic and cyanotic congenital heart disease had lower baseline MOx than controls. Baseline MOx was 91.3% (CI 85.9%, 96.7%) for acyanotic patients, 91.1% (CI 86.3%, 95.9%) for cyanotic patients, and 98.9% (CI 96.7%, 101.1%) for controls. Similarly, MOx was lower in the acyanotic and cyanotic groups than the controls after reperfusion (84.6% [CI 74.1%, 95.1%] and 82.1% [CI 74.5%, 89.7%] vs 98.9% [96.5%, 101.3%]). The rate of decline in oxygenation was significantly greater in cyanotic patients versus controls (0.46%/s (CI 0.30%, 0.62%/s) vs 0.17%/s (0.13%, 0.21%/s)). CONCLUSION: This study demonstrates that muscle oxygenation is abnormal in children with both cyanotic and acyanotic congenital heart disease. This suggests that noninvasive monitoring of muscle oxygenation may provide valuable information in situations where children with congenital heart disease may be at risk of hemodynamic compromise.

Preoperative malnutrition is associated with increased mortality and adverse outcomes after paediatric cardiac surgery.

BACKGROUND: Malnutrition is common in children with CHD and is likely to place them at an increased risk for adverse surgical outcomes. We sought to evaluate the impact of preoperative malnutrition on outcomes after paediatric cardiac surgery. METHODS: We conducted a retrospective analysis of patients from age 0 to 5 years undergoing cardiac surgery at Seattle Children's Hospital from 2006 to 2015. We used regression modelling to examine the impact of malnutrition on surgical outcomes. RESULTS: We found a non-linear relationship between low height-for-age and weight-for-age z-scores and mortality after surgery. In the range of z-score ⩽-2, each additional unit decrease in height-for-age or weight-for-age z-score was associated with a 2.9 or 2.1% increased risk for mortality, respectively. Each unit decrease in height-for-age z-score was associated with a 1.2% increased risk for cardiac arrest, 1.1% increased risk for infection, and an average of 1.7 additional hours of mechanical ventilation, 6 hours longer ICU stay, and 13 hours longer hospital stay. Each unit decrease in weight-for-age z-score was associated with a 0.7% increased risk for cardiac arrest, 0.8% increased risk for infection, and an average of 1.9 additional hours of mechanical ventilation and 5.3 additional hours of ICU stay. CONCLUSIONS: This study is unique in demonstrating a significant association between malnutrition and 30-day mortality and other adverse outcomes after paediatric cardiac surgery in a mixed population of CHD patients. By evaluating nutritional status as a continuous variable, we were able to clearly distinguish the point at which malnutrition begins to affect mortality.

Perioperative morbidity in children with elastin arteriopathy.

BACKGROUND: Children with elastin arteriopathy (EA), the majority of whom have Williams-Beuren syndrome, are at high risk for sudden death. Case reports suggest that the risk of perioperative cardiac arrest and death is high, but none have reported the frequency or risk factors for morbidity and mortality in an entire cohort of children with EA undergoing anesthesia. AIM: The aim of this study was to present one institution's rate of morbidity and mortality in all children with EA undergoing anesthesia and to examine patient characteristics that pose the greatest risk. METHODS: We reviewed medical records of children with EA who underwent anesthesia or sedation for any procedure at our institution from 1990 to 2013. Cardiovascular hemodynamic indices from recent cardiac catheterization or echocardiography were tabulated for each child. The incidence, type, and associated factors of complications occurring intraoperatively through 48 h postoperatively were examined. RESULTS: Forty-eight patients with confirmed EA underwent a total of 141 anesthetics. There were seven cardiac arrests (15% of patients, 5% of anesthetics) and nine additional intraoperative cardiovascular complications (15% of patients, 6% of anesthetics). Extracorporeal life support was initiated in five cases. There were no perioperative deaths. All children having a cardiac arrest or complication were <3 years old and had biventricular outflow tract obstruction (BVOTO). Subgroup analysis demonstrated high rates of cardiac arrest in two groups: children with BVOTO (44%) and age <3 years old (21%). CONCLUSIONS: We have confirmed that the rate of cardiac arrest and complications is significantly elevated in children with EA undergoing anesthesia. Children <3 years old and with BVOTO were at the greatest risk in our population.

Anesthesia for Potts Shunt in a Child with Severe Refractory Idiopathic Pulmonary Arterial Hypertension.

Childhood idiopathic pulmonary arterial hypertension is a progressive and fatal disease. When pulmonary artery pressures become suprasystemic and refractory to medical management, atrial septostomy can be recommended for bridging patients to lung transplantation. Recently, a surgical Potts shunt has been recommended as an alternative rescue therapy, and initial outcome data are promising. The placement of a Potts shunt converts the child to Eisenmenger physiology, which is anticipated to provide an improved quality and duration of life. We present the first description of anesthetic management of a child undergoing surgical Potts shunt for pulmonary arterial hypertension and summarize the multiple, unique intraoperative considerations.

Perioperative and Anesthetic Considerations in Ebstein's Anomaly.

Ebstein's anomaly is a complex and heterogeneous form of congenital heart disease characterized by malformation and apical displacement of the tricuspid valve leaflets. Patients may present at any time from the neonatal period to adulthood with symptoms ranging from cardiac failure and cyanosis to paroxysmal arrhythmias. Depending on the timing of presentation, various surgical options are available for the management of symptomatic patients. This review will discuss the perioperative and anesthetic management of patients with Ebstein's anomaly with reference to the more common surgical approaches.

Anesthetic Considerations and Management of Transposition of the Great Arteries.

Transposition of the great arteries was once an almost uniformly fatal disease in infancy. Six decades of advances in surgical techniques, intraoperative care, and perioperative management have led to at least 90% of patients reaching adulthood, most with a good quality of life. This review summarizes medical and surgical decision making during the neonatal perioperative period, with a special emphasis on factors pertinent to the anesthetic evaluation and care during primary surgical repair of transposition of the great arteries. A review is also provided of anesthetic considerations for noncardiac surgery later in childhood or adulthood, for those survivors of the arterial switch operation, Rastelli procedure, Nikaidoh procedure, and the réparation á l'étage ventriculaire procedure.

Video observation of anesthesia practice: a useful and reliable tool for quality improvement initiatives.

AIMS: Patients with central venous catheters who are transferred out of the Intensive Care Unit to the care of an anesthesiology team for an operation or interventional radiology procedure had excessive rates of catheter associated blood stream infection (CABSI). METHODS: We convened a multi-disciplinary team to audit anesthesia practice and to develop countermeasures for those aspects of practice that were thought to be contributing to CABSI's. It was noted that provider behavior changed in the presence of an auditor (Hawthorne effect) and so videorecordings were used, in the hope that this Hawthorne effect would be reduced. Clips were chosen from the hours of video (without audio) recordings that showed medication administration, airway management and touching the anesthesia cart of equipment/supplies. RESULTS: These clips were viewed by three observers and measurements were made to assess intra-rater and inter-rater reliability. The clips were then viewed to quantify differences in practice before and after our bundle of "best practices" was introduced. CONCLUSIONS: Although video recording has been used to evaluate adherence to resuscitation protocols in both trauma and in neonatal resuscitation, (Pediatric Emergency Care, 26, 2010, 803; Pediatrics, 117, 2006, 658; Pediatrics, 106, 2000, 654) we believe this is the first time that video has been used to record before and after behaviors for an anesthesia quality improvement initiative.

Modification of anesthesia practice reduces catheter-associated bloodstream infections: a quality improvement initiative.

BACKGROUND: A major strategic hospital goal is the prevention of catheter associated bloodstream infections (CABSI). In 2009, at our institution, the CABSI rate for patients who traveled out of the ICU to the operating room and other procedural areas under the care of an anesthesiologist was increased compared to patients who remained on the unit. AIMS: Our objective was to develop countermeasures to improve intraoperative cleanliness by anesthesia providers, minimize contamination of intravenous access points, and ultimately reduce CABSIs. MATERIALS & METHODS: A multidisciplinary team identified barriers to following best practices for reducing contamination of intravenous line entry-ports. Using Continuous Performance Improvement (CPI) or Lean techniques, staff directly impacted by the changes developed countermeasures to improve anesthesia practice. Compliance with the new "best practices" improved with coaching and feedback. RESULTS: Postimplementation, CABSI rates for patients traveling off the ICU with anesthesiology providers decreased from 14.1 per thousand trips off the ICU preintervention in 2009 to 9.7 per 1000 trips in 2010 and to 0 per 1000 trips in 2011 postintervention. Hospital-wide CABSI rates decreased from 3.5 per 1000 central line days preintervention to 2.2 per 1000 central line days after. CONCLUSION: Practice modification by anesthesiology providers in the operating room can decrease workspace contamination and is associated with decreased CABSI rates.

Striving for a zero-error patient surgical journey through adoption of aviation-style challenge and response flow checklists: a quality improvement project.

AIMS: We describe our aim to create a zero-error system in our pediatric ambulatory surgery center by employing effective teamwork and aviation-style challenge and response 'flow checklists' at key stages of the patient surgical journey. These are used in addition to the existing World Health Organization Surgical Safety Checklists (Ann Surg, 255, 2012 and 44). BACKGROUND: Bellevue Surgery Center is a freestanding ambulatory surgery center affiliated with Seattle Children's Hospital, WA, USA. Approximately three thousand ambulatory surgeries are performed each year across a variety of surgical disciplines. METHODS: Key points in the patient surgical journey were identified as high risk (different time points from the WHO safer surgery checklists). These were moments when the team, patient, and equipment have to been reconfigured to maximize patient safety. These points were departure from induction room, arrival in the operating room, departure from operating room, and arrival in the postanesthesia care unit. Traditionally, the anesthesiologist has memorized a list of 'do-not-forget items' for each of these stages. We recognized the potential for error to occur if the process was solely the responsibility of one individual and their memory. So we created 'flow checklists' executed by the team at every one of these high-risk points. We adopted a challenge and response system for these flow checklists as this is a tried and tested system widely used in aviation for critical tasks such as configuring an aircraft pretakeoff and prelanding. RESULTS: A staff survey with a 72% response rate (n = 29) showed that the team valued the checklists and thought they contributed to patient safety. To date, we have had zero incidence of omitting any of the 24 items listed on the four flow checklists. CONCLUSIONS: We have created a reproducible model of care involving multiple checklists at high-risk points in the patient surgical journey. The model is reliable and has a high degree of staff engagement. It promotes patient safety by ensuring the patient, team and equipment are correctly configured at every key transition stage in the surgical journey. We have been able to achieve this with no measurable increase in turnover times or reduction in operating room efficiency.

The Response of Hemostatic Marker Levels to Activated Factor VII in a Neonate following Cardiopulmonary Bypass.

The primary function of recombinant activated factor VII (rFVIIa) is to increase thrombin formation which leads to increased fibrin and less "bleeding." As a result, most of literature utilizes "bleeding" as the outcome measure with respect to rFVIIa. However, we report the actual effect of rFVIIa on changes in hemostatic markers such as prothrombin activation peptide F1.2, thrombin antithrombin complex (TAT), D-dimer, tissue plasminogen activator (tPA), and plasminogen activator inhibitor (PAI) in a neonate after cardiopulmonary bypass. A single dose of rFVIIa caused a 5.5-fold increase in F1.2, 3.5-fold increase in TAT, and a small increase in d-dimer compared to only a 1.5-fold increase, no increase, and a decrease, respectively, in two neonates undergoing the same procedure having not received rFVIIa. The patterns of change for tPA and PAI were similar.

Anesthesia-related cardiac arrest in children: update from the Pediatric Perioperative Cardiac Arrest Registry.

BACKGROUND: The initial findings from the Pediatric Perioperative Cardiac Arrest (POCA) Registry (1994-1997) revealed that medication-related causes, often cardiovascular depression from halothane, were the most common. Changes in pediatric anesthesia practice may have altered the causes of cardiac arrest in anesthetized children. METHODS: Nearly 80 North American institutions that provide anesthesia for children voluntarily enrolled in the Pediatric Perioperative Cardiac Arrest Registry. A standardized data form for each perioperative cardiac arrest in children

Effect of polymer coating (poly 2-methoxyethylacrylate) of the oxygenator on hemostatic markers during cardiopulmonary bypass in children.

OBJECTIVE: Heparin and other oxygenator coatings have been used in attempts to reduce hemostatic activation during cardiopulmonary bypass (CPB). This study evaluated whether an oxygenator coated with poly 2-methoxyethylacrylate (PMEA) (X-coating; Terumo Corporation, Tokyo, Japan) would cause less activation of coagulation and fibrinolytic systems during CPB in children than a noncoated oxygenator. DESIGN: Observational study. SETTING: University-affiliated children's hospital. PATIENTS: Twenty-six patients, 3 months to 5 years old, who underwent congenital heart surgery for repair of a ventricular septal defect, atrial septal defect, or both. INTERVENTIONS: Patients were divided into 2 age-matched groups based on the type of oxygenator used: a noncoated oxygenator (group NC) versus a PMEA-coated oxygenator (group C). MEASUREMENTS AND MAIN RESULTS: Blood samples for coagulation and fibrinolytic markers were compared before, during, and after CPB. Despite increases in thrombin generation markers (F1.2 and TAT) at certain times during CPB in group C compared to group NC, a comparison over all times during CPB were not statistically different between groups. Overall D-dimer concentrations during CPB were elevated in group C compared to group NC (p = 0.02). Active tPA and active PAI-1 were not different between groups during or after CPB. Group C had higher platelet counts (181,000 +/- 29,000) during CPB than group NC (155,000 +/- 57,000, p = 0.04) but not postoperatively. Twelve hours postoperatively, chest tube outputs were 8.8 +/- 3 mL/kg in group C and 19.1 +/- 12 mL/kg in group NC (p = 0.003). The corresponding outputs 24 hours after surgery were 12.4 +/- 3 mL/kg and 24 +/- 11 mL/kg, respectively (p = 0.005). CONCLUSIONS: Except for a somewhat higher platelet count during CPB, there was no indication that PMEA coating resulted in less activation of coagulation and fibrinolytic systems. The lower postoperative chest tube output observed after CPB with PMEA-coated oxygenators needs to be studied further.

The effects of common airway maneuvers on airway pressure and flow in children undergoing adenoidectomies.

UNLABELLED: Obstruction of the upper airway occurs frequently in anesthetized, spontaneously breathing children, especially in those with adenoidal hyperplasia. To improve airway patency, maneuvers such as chin lift (CL), jaw thrust (JT), and continuous positive airway pressure (CPAP) are often used. In this study, we examined the comparative efficacy of these maneuvers in children scheduled to undergo adenoidectomy. Sixteen children aged 2-9 yr were anesthetized with sevoflurane. During spontaneous breathing, the flows and pressures in the mask (ma), oropharynx (op), and esophagus (es) were measured simultaneously, and maximal pressure differences during inspiration (DeltaP) were calculated. After baseline recording, CL and JT maneuvers were performed in random order without and with CPAP (5 cm H(2)O). The observed DeltaP(ma) - P(es) of 12.3 +/- 3.4 cm H(2)O at baseline decreased with all airway maneuvers (P < 0.05). This resulted from decreases of DeltaP(ma) - P(op) (P < 0.05) and DeltaP(op) - P(es) (P < 0.05) in all interventions except CL, in which DeltaP(ma) - P(op) remained similar. In contrast, significant improvements of minute ventilation and maximal inspiratory peak flow (P > 0.05) were observed only with JT (with and without CPAP). We conclude that CL may improve airway patency and ventilation, whereas JT with or without CPAP was the most effective maneuver to overcome airway obstruction in children with adenoidal hyperplasia. IMPLICATIONS: Airway maneuvers are often used in anesthetized children to relieve airway obstruction during spontaneous ventilation. Compared with chin lift and continuous positive airway pressure, the jaw thrust maneuver was the most effective to improve airway patency and ventilation in children undergoing adenoidectomy.

Effect of continuous positive airway pressure on the measurement of thoracoabdominal asynchrony and minute ventilation in children anesthetized with sevoflurane and nitrous oxide.

STUDY OBJECTIVE: s: To quantify thoracoabdominal asynchrony (TAA) in children during anesthesia, and to measure the effect of continuous positive airway pressure (CPAP) on TAA, tidal volume (VT), and minute ventilation (E). DESIGN: Prospective, nonrandomized, controlled study. SETTING: Operating room of a university children's hospital. PARTICIPANTS: Ninety children aged 2 to 9 years scheduled for elective outpatient day surgery who were enrolled prospectively. METHODS: Each subject was anesthetized with sevoflurane 3% in equal parts O2 and N2O while breathing spontaneously through a facemask. Respiratory impedance plethysmography was used to calculate TAA indexes (phase angle [PA], phase relation in inspiration [PhRIB], phase relation in expiration, phase relation in total breath [PhRTB], and ratio of the inspiratory time to the total duration of the respiratory cycle [TI/TTOT]), VT, and E. Tidal gas flows were measured with a dual-hotwire anemometer with the sensor inserted between the facemask and the Y-piece of the anesthetic breathing circuit. This enabled the volume calibration of the respiratory impedance plethysmography equipment. The following conditions were compared: (1) no CPAP, (2) CPAP of 5 cm H2O, and (3) CPAP of 10 cm H2O. RESULTS: Eighty-one children completed the study protocol. All measurements of TAA with an inspiratory component (PA, PhRIB, PhRTB, and TI/TTOT) decreased significantly from baseline with the addition of CPAP to the circuit. Application of CPAP of 10 cm H2O decreased significantly mean VTs and Es compared with CPAP of 5 cm H2O and no CPAP. There were no differences in TAA for all conditions when comparing children scheduled for adenoidectomy with other surgical procedures. CONCLUSIONS: With spontaneously breathing anesthetized children, TAA decreases with the application of CPAP. CPAP of 5 cm H2O was as effective as CPAP of 10 cm H2O in reducing PA, PhRIB, PhRTB, and TI/TTOT. However, CPAP of 10 cm H2O also caused a significant decrease in VT and E.

The effect of chin lift, jaw thrust, and continuous positive airway pressure on the size of the glottic opening and on stridor score in anesthetized, spontaneously breathing children.

UNLABELLED: Chin lift and jaw thrust are two common maneuvers used to improve the patency of the upper airway during general anesthesia. We investigated the effect of these maneuvers combined with continuous positive airway pressure (CPAP) on the size of glottic opening and on stridor score. Forty children, aged 2--9 yr, premedicated with midazolam and spontaneously breathing end-tidal 1% halothane and equal parts of nitrous oxide and oxygen, were studied. A flexible fiberoptic bronchoscope was placed via mask and one nostril to the level of the junction of the soft palate and oropharynx. Video recordings and simultaneous stridor scores were obtained during six conditions: 1) chin unsupported, 2) manual chin lift, 3) chin lift and CPAP 10 cm H(2)O, 4) repeat chin unsupported, 5) manual jaw thrust, and 6) jaw thrust and CPAP 10 cm H(2)O. Videos were analyzed to determine the percentage of glottic opening (POGO) score. POGO score increased (P < 0.05) in Conditions 2, 3, 5, and 6. With increasing POGO score there was a decrease in stridor score (P < 0.05). IMPLICATIONS: Chin lift and jaw thrust maneuvers combined with continuous positive airway pressure improve the view of the glottic opening as viewed by flexible nasal laryngoscopy and decrease stridor in anesthetized, spontaneously breathing children.