Building the Case for Quality Improvement.

Great improvements have been made by quality improvement teams. National trends towards using quality and value metrics in reimbursement suggest that physicians and advanced practitioners caring for children and adolescents will benefit from knowing and using quality improvement methods. These methods will also help as transparency of quality data becomes more commonplace.

Etiology of postanesthetic and postsedation events on the inpatient ward: data from a rapid response team at a tertiary care children's hospital.

INTRODUCTION: The goal of this study was to identify the etiology of events and demographics of patients that experience complications requiring activation of the Rapid Response Team (RRT) during the first 24 h following anesthetic care. METHODS: We performed a retrospective review of the Quality Improvement database from the Department of Anesthesiology & Pain Medicine at Nationwide Children's Hospital. The database was searched to identify those patients who had a RRT evaluation activated within 24 h of receiving anesthesia or procedural sedation. These patients' charts were reviewed to obtain demographic information, etiology of the RRT call, and outcomes. RESULTS: The study cohort included 106 RRT calls that were made over a 3-year period. Six patients were excluded from analysis due to incomplete datasets. One hundred patients remained for analysis including 60 males and 40 females. Patients ranged in age from 0.08 to 31.21 years (7.8 ± 7.7 years, median 5.3 years). Seventy-one patients were American Society of Anesthesiologists' (ASA) status 3 or 4 and 29 patients were ASA status 1 or 2. Five calls were made for patients who had undergone procedural sedation while the other 95 were on patients who received general anesthesia. The average time to the RRT call after the end of anesthetic care was 11.4 ± 6.6 h. Respiratory concern was the most common reason for RRT initiation, accounting for 71 of the 100 calls. Forty-nine patients had a recent respiratory illness, chronic respiratory-related disease, or history of preterm birth. Fifty patients (50%) were transferred to a higher level of care following the RRT consult. There was no significant difference between age, gender, ASA status, or etiology of the event for patients transferred vs. those who were not. A significant difference was noted in the Pediatric Early Warning Score of patients transferred to a higher level of care in comparison to patients who remained on the floor (4 ± 2 vs. 3 ± 2, P = 0.0097). CONCLUSION: RRT calls were most common for respiratory concerns. High ASA status, general anesthesia administration, and the presence of acute or chronic conditions prior to anesthetic administration predispose a patient to perioperative complications resulting in the need for an RRT call.

A comparison of functional magnetic resonance imaging findings in children with and without a history of early exposure to general anesthesia.

BACKGROUND: Functional magnetic resonance imaging (fMRI) has been used to evaluate the long-term consequences of early exposure to neurotoxic agents. fMRI shows that different patterns of brain activation occur in ethanol-exposed subjects performing a go/no-go response inhibition task. Pharmacologically, ethanol and general anesthetics have similar receptor-level activity in the brain. This study utilizes fMRI to examine brain activation patterns in children exposed to general anesthesia and surgery during early brain development. METHODS: After obtaining Nationwide Children's Hospital IRB approval, a surgical database was utilized to identify children aged 10-17 years with a history of at least 1 h of exposure to general anesthetics and surgery when they were between 0 and 24 months of age. Age- and gender-matched children without anesthesia exposure were recruited as a control group. All subjects were scanned while being presented with a go/no-go response inhibition task. Reaction time and accuracy data were acquired, and the blood-oxygen-level-dependent (BOLD) fMRI signal was measured as a biomarker for regional neuronal activity. RESULTS: There were no differences in terms of performance accuracy and response time. The analysis did not reveal any significant activation differences in the primary region of interest (prefrontal cortex and caudate nucleus); however, activation differences were seen in other structures, including the cerebellum, cingulate gyrus, and paracentral lobule. CONCLUSIONS: Early anesthetic exposure and surgery did not affect accuracy, response time, or activation patterns in the primary region of interest during performance of the task. Intergroup differences in activation patterns in other areas of the brain were observed, and the significance of these findings is unknown. fMRI appears to be a useful tool in evaluating the long-term effects of early exposure to general anesthesia.

Current practices regarding codeine administration among pediatricians and pediatric subspecialists.

Pharmacogenomic studies have revealed a wide variation in the metabolism of codeine to its active metabolite, morphine. A particular subset of patients, known as ultrarapid metabolizers, possesses multiple copies of the CYP2D6 gene responsible for codeine metabolism. This has been linked to serious morbidity and mortality in pediatric patients leading to considerable debate regarding the use of codeine for analgesia in the pediatric population. The current study surveyed the current practice of codeine prescription in pediatric health care providers from a single tertiary care pediatric hospital. Of the 298 responders, 43.3% (129 of 298) continue to prescribe codeine for pain management in children. The vast majority of codeine prescribers were primary health care providers (89.1%). Most of the primary care practitioners were in office-based (42.6%) or hospital-based (45.7%) group practices. There was no significant difference in codeine use based on years of experience. Given the risks associated with this practice, increased education targeting this group appears warranted.

Perioperative hypothermia in the pediatric population: a quality improvement project.

There are limited data in the pediatric population regarding the incidence of, risk factors for, and means to prevent perioperative hypothermia. The Institute for Healthcare Improvement Model for quality improvement (QI) methodology was used to bundle the most effective techniques to prevent hypothermia. A multidisciplinary QI team was assembled with the goal to decrease the incidence of perioperative hypothermia by 50%. The baseline incidence of hypothermia was determined and causes identified using a flowchart and a cause-and-effect diagram. Pareto charts were formed and opportunities to decrease the incidence of perioperative hypothermia were trialed. The baseline incidence of hypothermia was 8.9%. Implementation of a standardized temperature management bundle in the operating rooms decreased the incidence to 4.2%. The QI methodology was useful to bundle the most effective techniques to prevent hypothermia, resulting in standardized perioperative care and a sustained reduction in the incidence of perioperative hypothermia.

Severe intraoperative hypertension after induction of anesthesia in a child with a neuroblastoma.

Neuroblastomas are the most common, non-central nervous system tumor of childhood. Similar to pheochromocytomas, they are derived from neural crest cells and therefore retain the potential to synthesize catecholamines. Unlike pheochromocytomas, however, perioperative issues related to blood pressure instability with hypertension are uncommon. We report details of a 3-year-old child with a neuroblastoma who developed severe hypertension and end-organ effects after induction of anesthesia. The association of such problems with neuroblastoma is reviewed and options for perioperative care presented.

A randomized trial comparing sevoflurane and propofol in children undergoing MRI scans.

OBJECTIVES: We compared three primary outcomes of pausing the magnetic resonance imaging (MRI) scan, emergence quality and respiratory complications. AIM: To measure and compare the quality between sevoflurane and propofol in children undergoing MRI scans. BACKGROUND: No randomized controlled trial exists comparing the quality between sevoflurane and propofol for MRI. METHODS/MATERIALS: Two hundred unpremedicated children (18 months to 7 years) scheduled for brain MRI scans were recruited. After induction with sevoflurane, children were randomized to receive sevoflurane [general anesthesia with sevoflurane (GAS)] via laryngeal mask airway (LMA) or propofol [general anesthesia with propofol (GAP)] bolus and infusion for their scan. The three primary outcomes of pausing the MRI scan (P), agitation (A), and respiratory complications (R) were compared. Timeliness of care was also measured. RESULTS: No MRI scan pauses were found in 92% and 80% in the GAS and GAP groups. The median and interquartile A scores were 3 (0, 7) in GAS and 0 (0, 4) in GAP groups respectively. There was no difference in respiratory complications between GAS and GAP (P = 0.62). The median and interquartile postanesthesia care unit (PACU) times were 25 (18, 34) for GAS and 31 (25, 44) for GAP (P = 0.0001). The median and interquartile total times were 78 (69, 90) for GAS and 88 (78, 100) for GAP (P = 0.0002). CONCLUSION: Our study compared the three primary outcomes of pausing, agitation, and respiratory complications between the two groups, and we found no difference in respiratory complications. However, the GAP group had more pausing and less agitation than the GAS group.