Setup Uncertainty of Pediatric Brain Tumor Patients Receiving Proton Therapy: A Prospective Study.

This study quantifies setup uncertainty in brain tumor patients who received image-guided proton therapy. Patients analyzed include 165 children, adolescents, and young adults (median age at radiotherapy: 9 years (range: 10 months to 24 years); 80 anesthetized and 85 awake) enrolled in a single-institution prospective study from 2020 to 2023. Cone-beam computed tomography (CBCT) was performed daily to calculate and correct manual setup errors, once per course after setup correction to measure residual errors, and weekly after treatments to assess intrafractional motion. Orthogonal radiographs were acquired consecutively with CBCT for paired comparisons of 40 patients. Translational and rotational errors were converted from 6 degrees of freedom to a scalar by a statistical approach that considers the distance from the target to the isocenter. The 95th percentile of setup uncertainty was reduced by daily CBCT from 10 mm (manual positioning) to 1-1.5 mm (after correction) and increased to 2 mm by the end of fractional treatment. A larger variation existed between the roll corrections reported by radiographs vs. CBCT than for pitch and yaw, while there was no statistically significant difference in translational variation. A quantile mixed regression model showed that the 95th percentile of intrafractional motion was 0.40 mm lower for anesthetized patients (p=0.0016). Considering additional uncertainty in radiation-imaging isocentricity, the commonly used total plan robustness of 3 mm against positional uncertainty would be appropriate for our study cohort.

Perioperative Indications for Gabapentinoids in Pediatrics: A Narrative Review.

In recent years, there has been increased interest in using gabapentinoids (gabapentin and pregabalin) as part of multimodal medication plans or enhanced recovery after surgery protocols to mitigate several perioperative clinical challenges. Outcomes explored in the context of using gabapentinoids perioperatively in children are variable and include acute complications of pain, anxiety, nausea and vomiting, and emergence agitation, as well as the long-term postoperative outcome of chronic postsurgical pain. This narrative review describes the current literature regarding perioperative use of gabapentinoids in pediatric patients and aims to describe the role of gabapentinoids in the perioperative setting for each specific indication.

Independent Double-check of Infusion Pump Programming: An Anesthesia Improvement Effort to Reduce harm.

Introduction: Significant adverse drug events (ADEs) due to anesthesia infusion pump programming errors were reported at our institution. We incorporated independent two-provider infusion pump programming verification, an evidence-supported intervention, into our anesthesia medication infusion process with a goal of reducing associated ADEs to zero in 2 years. Methods: Using the model for improvement, we developed key drivers and interventions and utilized plan-do-study-act (PDSA) cycles. Drivers included education and training, verification process, visual aids, information technology, and safety culture. Interventions included anesthesia provider training, information dissemination, independent two-provider verification process of smart pump programming, verification documentation capability, verification compliance tracking, and visual aids. Our outcome measures were relevant ADEs and near-miss events. Process and balancing measures were the percentage of smart pump programs with independent second verification and delayed case starts due to second provider verification, respectively. Results: During the project period, only one related grade E ADE occurred, and the root cause was not conducting an independent pump programming verification. Thirteen grade B near-miss events were prevented due to independent second verification. Second verification adherence reached 85% and was sustained, and no delayed case starts occurred. Conclusions: With structured quality improvement methods, the process of independent two-provider verification of infusion pump programming during anesthesia can be successfully implemented, and errors in a high-volume setting reduced without negatively affecting case start times. The cultural and organizational factors we report may aid other institutions in gaining project buy-in and sustainment.

A concept mobility device with multi-positional configurations and child-kind restraint for safe perioperative transfer and induction of anaesthesia in children with autistic spectrum disorder - a cross sectional study.

BACKGROUND: Transfer into the operating room, onto the operating table and mask induction of anaesthesia are major challenges faced by children with Autistic Spectrum Disorder (ASD). In a pilot study, parents observed that perioperative transfer becomes unsafe and difficult when children with ASD becomes uncooperative. METHOD: A CHILD-KIND CONCEPT mobility system comprising of multi-positioning seat configurations and restraining module was developed with inputs from multi-disciplinary healthcare professionals and parents with children with ASD. To appeal to children and motivate child-machine interaction, the seat configurations and restraining module are designed to take the form of child-friendly, non-threatening, fun and familiar items. The sitting configuration, sitting to supine transformation, the restraint modules resemble racing-car seat, reclining motion of a home massage chair, safety restraints found in airplanes and amusement rides respectively. Healthcare professionals (HCPs) involved in the perioperative patient care, parents of ASD children and children (neurotypical and ASD) experience the use of the system in a non-clinical environment and participated in a survey study. The acceptance of its functionality (HCPs, parents) for perioperative transfer and induction of anaesthesia, rating of the user experience and likes and dislikes of (parents and children) were obtained. RESULTS: Thirty-two HCPs, 30 parents and 23 children participated. Majority of parents and HCPs opined the use of the system enables improvement in the management of perioperative movement (90.0% parents, 100% HCPs), safe perioperative movement (86.7% parents, 96.9% HCPs) and promotes ease of anaesthesia induction (76.7% parents, 90.6% HCPs) for uncooperative combative ASD children. Overall, 93.8% HCPs and 86.7% parents would recommend its frequent use in their own practice and their ASD children respectively. Attractiveness and multi-functionality are attributes endorsed by parents and children. Children endorse its use for induction of anaesthesia (73.9%), dental chair (82.6%), intra-hospital transfer (95.7%). CONCLUSION: A child-kind mobility device that integrates appeal with functionality of restraint and multi-positional transformation has a potential to promote safe perioperative movement and ease of induction of anaesthesia in anxious uncooperative ASD children.

Perianesthetic neurological adverse events in children: A review of the Wake-Up Safe Database.

BACKGROUND: Perianesthetic neurological adverse events are rare in children and have been studied in detail in the settings of cardiac surgery and regional anesthesia. Our study aims to characterize perianesthetic neurological adverse events in children in the setting of all types of surgery and diagnostic or interventional procedures, to evaluate anesthesia's role, and to identify factors amenable to prevention. METHODS: We conducted a retrospective study by reviewing all the anesthetic encounters reported in the Wake-Up Safe database between January 2010 and December 2017. RESULTS: The rate of perianesthetic neurological adverse events was 0.49 per 10 000 pediatric anesthetic encounters. The odds of NAE were significantly higher in children who were older than 6 months; had American Society of Anesthesiologists physical status (ASA PS) of 3, 4, or 5; or had American Society of Anesthesiologists Emergency (ASA E) status. Seizures were the most common NAE. Overall, 23 (18.1%) children with neurological adverse events died, and 33 (26%) experienced permanent or severe permanent harm. The risk of death was higher in infants and in children with ASA PS of 3, 4, or 5; ASA E status; preexisting neurological abnormality; or preexisting neurological deficit and in events associated with cardiac arrest or trauma. Anesthesia contributed to 24 (18.9%) events; patient disease was the primary causative factor in 95 (74.8%) adverse events, and 37 (29.1%) events were preventable, including 2 deaths. Preventable factors broadly included inadequate preoptimization, complications during airway management and central venous catheter placement, and suboptimal patient positioning. CONCLUSION: Perianesthetic neurological adverse events are rare in children and have a poor outcome. Our study has described pediatric perianesthetic neurological injury in detail and identified contributing factors that can be optimized during various phases of perianesthetic care. This information can be utilized during the informed consent process and to enhance the quality of care in children receiving anesthesia.

Propofol Total Intravenous Anesthesia as an Intervention for Severe Radiation-Induced Phantosmia in an Adolescent with Ependymoma.

Radiation-induced phantosmia has been reported both in children and adults. A fraction of these patients have nausea and vomiting triggered by phantosmia. Radiation-induced phantosmia, although transient, can be distressing enough to prevent a patient from staying still during radiation therapy. To date, specific interventions for radiation-induced phantosmia, including anesthesia, have not been reported. We report for the first time anesthesia as an intervention for transient severe radiation-induced phantosmia, in a 16-year-old girl with ependymoma undergoing proton therapy, and we discuss the pros and cons of techniques for anesthesia and airway management.