Sustainability Standards in Pediatric Anesthesia: Quality Initiative to Reduce Costly Environmentally Harmful Volatile Anesthetics.

Background: The emission and entrapment of greenhouse gases (GHG) inside the atmosphere is one of the leading causes of global warming. Commonly administered anesthetics have global warming potential up to 2,000 times greater than carbon dioxide. This Quality Improvement (QI) initiative aimed to develop a set of sustainability standards to reduce volatile anesthetic GHG emissions and costs at a children's hospital. Methods: In January 2020, the QI project team implemented education sessions for clinical staff on the environmental impact of volatile anesthetics, bedside clinical reminders, resource guides on sustainable anesthesia practices, preset low-flow gas levels on anesthesia machines, relocated and reduced the number of available vaporizers, and implemented policies to standardize clinical practice. Using hospital pharmacy purchase order data between 2018 and 2022, GHG emissions and costs from three commonly used volatile anesthetics (Isoflurane, Sevoflurane, and Desflurane) were compared using metric ton carbon dioxide equivalents. Results: During 3 years, GHG emissions from volatile anesthetics were significantly reduced by 77%, with most of the reduction attributed to the reduced use and eventual elimination of Desflurane. Purchase costs were also significantly reduced during this period by 41%. Conclusions: This QI project successfully decreased GHG emissions over 3 years by simultaneously reducing the use of costly and environmentally harmful volatile anesthetic, Desflurane, and increasing the use of low-flow anesthesia. This study addresses our anesthesia practices and healthcare system's impact on the pediatric population and proposes simple interventions to mitigate the negative consequences of current practices.

Telemedicine for the pediatric preoperative assessment during the COVID-19 pandemic: Evaluating patient and provider satisfaction.

The COVID-19 pandemic has presented unprecedented challenges in delivering healthcare to surgical patients. To avoid delays in patient care while still minimizing COVID-19 infection risk to patients and providers, anesthesiology preoperative clinics were presented with the opportunity to implement telemedicine to assess patients' risks prior to surgery. This study explores patient and provider satisfaction with video-based telemedicine preoperative clinic visits during the COVID-19 pandemic via a patient and provider satisfaction survey. A vast majority (>93%) of patients expressed overall satisfaction with telemedicine visits. Similarly, >85% of providers agreed with the benefits of and expressed overall satisfaction with the preoperative telemedicine visits. Overall, patient and provider study participants had positive feedback in response to anesthesia preoperative telemedicine visits. Future studies could assess the preference of telemedicine to in-person visits once the fears of COVID-19 spread have been mitigated, as well as an assessment of outcomes comparing telemedicine and in-person visits.

Association between implementation of a coordinated care pathway in idiopathic scoliosis patients and a reduction in perioperative outcome disparities.

BACKGROUND: There are well-documented racial and ethnic disparities in treatment and perioperative outcomes for patients with adolescent idiopathic scoliosis. AIMS: We hypothesize that the implementation of a coordinated care pathway for pediatric patients undergoing posterior spinal fusion for adolescent idiopathic scoliosis may be associated with a reduction in racial and ethnic disparities in perioperative outcomes. METHODS: This is a retrospective pre- and post-test cohort study of patients who underwent posterior spinal fusion for adolescent idiopathic scoliosis at our institution between July 1, 2013 and August 5, 2019. We implemented a coordinated care pathway in March 2015. Patient demographics included age, race, ethnicity, weight, gender, insurance status, ASA class, time between the date surgery was ordered and the date surgery occurred, degree of scoliosis, and the number of spinal levels fused. The primary outcome was length of stay. The secondary outcomes included transfusion rates, pain scores, and postoperative complications. Multivariable regression models compared outcome medians across race/ethnicity. Disparities were defined as the difference in adjusted outcomes by race/ethnicity. RESULTS: Four hundred twenty-four patients underwent posterior spinal fusion for adolescent idiopathic scoliosis at our institution (116 prepathway and 308 postpathway). The median length of stay of Black patients was 1.0 day (95% CI: 0.4, 1.5; p = .006) longer than White patients prepathway. Prepathway patients who self-identified as Other had a 1.2 (95% CI: 0.5, 1.9; p = .004) higher median average pain score on postoperative day 1 compared with White patients. On postoperative day 2, patients who identified as Other had 2.0 (95% CI: 0.8, 3.2; p = .005) higher pain score compared with White patients prepathway. Postpathway, there were no significant differences in outcomes by race/ethnicity. CONCLUSIONS: Our study supports the hypothesis that use of a coordinated care pathway is associated with a reduction in racial and ethnic disparities in length of stay and pain scores in pediatric patients undergoing posterior spinal fusion.

Serratus Anterior Plane Block as a Primary Anesthetic Technique for Video-Assisted Thoracic Surgery in a Child.

Cystic fibrosis (CF) commonly affects those of European descent; however, it can also be found in those of Asian, African, and Caribbean descent. Patients with CF may have significant lung disease, and their perioperative management can be challenging for the anesthesiologist. In this case report, we describe the use of serratus anterior plane block (SAPB) and IV sedation as an alternative to general anesthesia with an endotracheal tube in a patient with CF pulmonary exacerbation presenting to the operating room for a video-assisted thoracic surgery (VATS).

Open wide: Anesthetic management of a child with Hecht-Beals syndrome.

Hecht-Beals syndrome (HBS) is a rare disorder characterized by trismus and deformity of the extremities. The etiology of trismus is unknown; theories suggest invasion of enlarged coronoid processes into the zygomatic bone. Of primary concern is the limited mouth opening and possible difficult airway. Since the syndrome was first described in 1969, there have been several articles in the pediatrics and dental literature but only 6 case reports describing the anesthetic management of these patients. Successful airway approaches have utilized various techniques including blind nasal intubation, fiberoptic intubation, and tracheal tube introducer guidance. In this case report, we discuss a multidisciplinary approach to the anesthetic management of a child with HBS undergoing MRI and outpatient surgery.

Implications of anesthesia and vaccination.

The current COVID-19 pandemic has had a global impact on vaccination rates. Delays in routine healthcare and immunization have led to a rise in concerns about resurgence of vaccine-preventable diseases around the world. With the release and distribution of COVID-19 vaccines, plans to improve immunization rates need to be explored and implemented across disciplines. One approach would be the consideration of perioperative vaccinations; however, the effects of anesthesia and surgery on the immune response and complications associated with vaccination during the perioperative period are still poorly understood, and opinions are divided. To ascertain the value of a perioperative vaccination program, it is important to understand the basics of immunization and common vaccinations; the potential vaccine complications in the pediatric cohort; the implications of anesthesia and surgery on the immune response; and current recommendations. In addition, we believe it is important to discuss the logistics and feasibility of coordinating perioperative immunization should this become a regular opportunity.