Error traps in Pediatric Patient Blood Management in the Perioperative Period.

Patient blood management is a patient-centered evidence-based approach to improve patient outcomes by harnessing the patient's own hematopoietic system to optimize blood health while promoting patient safety and empowerment. Perioperative patient blood management is a standard of care in adult medicine, yet it is not commonly accepted in pediatrics. Raising awareness may be the first step in improving perioperative care for the anemic and/or bleeding child. This article highlights five preventable perioperative blood conservation error traps for children. The goal is to provide practical clinical guidance to improve preoperative diagnosis and treatment of anemia, facilitate recognition and treatment of massive hemorrhage, reduce unnecessary allogeneic blood transfusions, and decrease associated complications of anemia and blood component transfusions utilizing a patient/family-centered informed consent and shared decision-making approach.

Immediate extubation following pediatric liver transplantation.

BACKGROUND: Immediate extubation (IE) following pediatric liver transplantation is being increasingly performed. The aim of this study was to characterize the rate of IE at our institution and identify recipient factors predictive of IE. METHODS: All pediatric liver transplants performed at our institution between January 1, 2015 and December 31, 2020 were reviewed. Retransplants and multi-organ transplants were excluded. IE was defined as extubation in the operating room following transplant. Backward stepwise logistic regression at a p-value threshold of .05 was performed to identify variables associated with IE. RESULTS: IE was achieved in 58 (72%) of the 81 pediatric liver transplants. The IE cohort had significantly shorter ICU length of stay and overall hospital length of stay, though IE was not an independent predictor of posttransplant length of stay. Age <2 years, preoperative mechanical ventilation, and total intraoperative epinephrine and dopamine infusion requirements were significant, independent risk factors against IE. This multivariable model was highly predictive of IE (area under the curve = 0.89). CONCLUSIONS: We describe the highest rate of IE postpediatric liver transplantation that has been reported to date and identified significant risk factors against successful IE.

Anesthetic Management and Outcomes of Patients With Epidermolysis Bullosa: Experience at a Tertiary Referral Center.

BACKGROUND: Epidermolysis bullosa (EB) is a group of rare epithelial disorders caused by abnormal or absent structural proteins at the epidermal-dermal junction. As a result, patients experience blisters and wounds from mild shearing forces. Some forms of EB are complicated by resultant scarring and contractures. The perioperative anesthetic management of patients with EB is complex and requires a systems-based approach to limit harm. We reviewed our experience with providing general anesthesia to patients at our tertiary EB referral center, including adverse events related to anesthetic care, outcomes in the immediate perioperative period, and details of anesthetic management. METHODS: We retrospectively reviewed the charts of all patients with EB anesthetized at the Children's Hospital Colorado between January 2011 and December 2016. A subset of pediatric anesthesiologists cared for all patients using a standardized clinical care pathway. Patient demographics, detailed anesthetic methods, immediate perioperative outcomes, and adverse events were characterized. RESULTS: Over a 6-year period, 37 patients underwent 202 general anesthetics. Most patients (75.7%) had dystrophic EB (DEB). Female patients comprised 48.6%. The majority (56.7%) traveled >50 miles to receive care, and many (35.1%) traveled >150 miles for their care. Common adaptations to care included avoidance of electrocardiogram leads (88.6%) and temperature probes (91.6%). Nasal fiberoptic intubation (n = 160) was performed, or natural airway/mask (n = 27) was maintained for most patients. Supraglottic devices were not used for airway management during any of the anesthetics. Anesthesia preparation time was longer (average 25.8 minutes [standard deviation {SD} = 12.7]) than our average institutional time (14 minutes). Succinylcholine was never used, and nondepolarizing muscle relaxants were used in only 1.5% of patient encounters. Blood was transfused in 16.3% of cases and iron infused in 24.8%. Average length of stay in the postanesthesia care unit was comparable to our institutional average (average 40.1 [SD = 28.6] vs 39 minutes). New skin or mucosal injury occurred in 8 encounters (4%), and desaturation occurred in 43 cases (21.3%). There were no major adverse events. CONCLUSIONS: By using a specialized team and a standardized clinical care pathway, our institution was able to minimize adverse events caused by the anesthetic and surgical care of patients with EB. We recommend natural airway or nasal fiberoptic airway management, meticulous avoidance of shear stress on the skin, and a multidisciplinary approach to care. Supportive therapy such as perioperative blood transfusions and iron infusions are feasible for the treatment of chronic anemia in this population.

Sequential effects in response time reveal learning mechanisms and event representations.

Binary choice tasks, such as 2-alternative forced choice, show a complex yet consistent pattern of sequential effects, whereby responses and response times depend on the detailed pattern of prior stimuli going back at least 5 trials. We show this pattern is well explained by simultaneous incremental learning of 2 simple statistics of the trial sequence: the base rate and the repetition rate. Both statistics are learned by the same basic associative mechanism, but they contribute different patterns of sequential effects because they entail different representations of the trial sequence. Subtler aspects of the data that are not explained by these 2 learning processes alone are explained by their interaction, via learning from joint error correction. Specifically, the cue-competition mechanism that has explained classic findings in animal learning (e.g., blocking) appears to operate on learning of sequence statistics. We also find that learning of the base rate and repetition rate are dissociated into response and stimulus processing, respectively, as indicated by event-related potentials, manipulations of stimulus discriminability, and reanalysis of past experiments that eliminated stimuli or prior responses. Thus, sequential effects in these tasks appear to be driven by learning the response base rate and the stimulus repetition rate. Connections are discussed between these findings and previous research attempting to separate stimulus- and response-based sequential effects, and research using sequential effects to determine mental representations. We conclude that sequential effects offer a powerful means for uncovering representations and learning mechanisms.

The persistent impact of incidental experience.

As we perform daily activities--driving to work, unlocking the office door, or grabbing a coffee cup--our actions seem automatic and preprogrammed. Nonetheless, routine, well-practiced behavior is continually modulated by incidental experience: In repetitive experimental tasks, recent (~4) trials reliably influence performance and action choice. Psychological theories downplay the significance of sequential effects, explaining them as rapidly decaying perturbations of behavior, with no long-term consequences. We challenged this traditional perspective in two experiments designed to probe the impact of more distant experience, finding evidence for effects spanning up to a thousand intermediate trials. We present a normative theory in which these persistent effects reflect optimal adaptation to a dynamic environment exhibiting varying rates of change. The theory predicts a heavy-tailed decaying influence of past experience, consistent with our data, and suggests that individual incidental experiences are catalogued in a temporally extended memory utilized in order to optimize subsequent behavior.

Sequential dependencies in driving.

The effect of recent experience on current behavior has been studied extensively in simple laboratory tasks. We explore the nature of sequential effects in the more naturalistic setting of automobile driving. Driving is a safety-critical task in which delayed response times may have severe consequences. Using a realistic driving simulator, we find significant sequential effects in pedal-press response times that depend on the history of recent stimuli and responses. Response times are slowed up to 100 ms in particular cases, a delay that has dangerous practical consequences. Further, we observe a significant number of history-related pedal misapplications, which have recently been noted as a cause for concern in the automotive safety community. By anticipating these consequences of sequential context, driver assistance systems could mitigate the effects of performance degradations and thus critically improve driver safety.

An integrative, experience-based theory of attentional control.

Although diverse, theories of visual attention generally share the notion that attention is controlled by some combination of three distinct strategies: (1) exogenous cuing from locally contrasting primitive visual features, such as abrupt onsets or color singletons (e.g., L. Itti, C. Koch, & E. Neiber, 1998), (2) endogenous gain modulation of exogenous activations, used to guide attention to task-relevant features (e.g., V. Navalpakkam & L. Itti, 2007; J. Wolfe, 1994, 2007), and (3) endogenous prediction of likely locations of interest, based on task and scene gist (e.g., A. Torralba, A. Oliva, M. Castelhano, & J. Henderson, 2006). However, little work has been done to synthesize these disparate theories. In this work, we propose a unifying conceptualization in which attention is controlled along two dimensions: the degree of task focus and the contextual scale of operation. Previously proposed strategies-and their combinations-can be viewed as instances of this one mechanism. Thus, this theory serves not as a replacement for existing models but as a means of bringing them into a coherent framework. We present an implementation of this theory and demonstrate its applicability to a wide range of attentional phenomena. The model accounts for key results in visual search with synthetic images and makes reasonable predictions for human eye movements in search tasks involving real-world images. In addition, the theory offers an unusual perspective on attention that places a fundamental emphasis on the role of experience and task-related knowledge.

Recognition of a Kawasaki disease shock syndrome.

OBJECTIVE: We sought to define the characteristics that distinguish Kawasaki disease shock syndrome from hemodynamically normal Kawasaki disease. METHODS: We collected data prospectively for all patients with Kawasaki disease who were treated at a single institution during a 4-year period. We defined Kawasaki disease shock syndrome on the basis of systolic hypotension for age, a sustained decrease in systolic blood pressure from baseline of > or =20%, or clinical signs of poor perfusion. We compared clinical and laboratory features, coronary artery measurements, and responses to therapy and analyzed indices of ventricular systolic and diastolic function during acute and convalescent Kawasaki disease. RESULTS: Of 187 consecutive patients with Kawasaki disease, 13 (7%) met the definition for Kawasaki disease shock syndrome. All received fluid resuscitation, and 7 (54%) required vasoactive infusions. Compared with patients without shock, patients with Kawasaki disease shock syndrome were more often female and had larger proportions of bands, higher C-reactive protein concentrations, and lower hemoglobin concentrations and platelet counts. Evidence of consumptive coagulopathy was common in the Kawasaki disease shock syndrome group. Patients with Kawasaki disease shock syndrome more often had impaired left ventricular systolic function (ejection fraction of <54%: 4 of 13 patients [31%] vs 2 of 86 patients [4%]), mitral regurgitation (5 of 13 patients [39%] vs 2 of 83 patients [2%]), coronary artery abnormalities (8 of 13 patients [62%] vs 20 of 86 patients [23%]), and intravenous immunoglobulin resistance (6 of 13 patients [46%] vs 32 of 174 patients [18%]). Impairment of ventricular relaxation and compliance persisted among patients with Kawasaki disease shock syndrome after the resolution of other hemodynamic disturbances. CONCLUSIONS: Kawasaki disease shock syndrome is associated with more-severe laboratory markers of inflammation and greater risk of coronary artery abnormalities, mitral regurgitation, and prolonged myocardial dysfunction. These patients may be resistant to immunoglobulin therapy and require additional antiinflammatory treatment.

Delayed diagnosis by physicians contributes to the development of coronary artery aneurysms in children with Kawasaki syndrome.

BACKGROUND: A diagnosis of Kawasaki syndrome is based on clinical criteria with nonspecific laboratory findings, and there is a substantial risk of coronary artery aneurysms if treatment with intravenous immunoglobulin is delayed. In this study, we examined the contributions of sociodemographic factors and parent and physician behavior to the development of coronary artery aneurysms in children with Kawasaki syndrome. METHODS: We performed a retrospective, case-control chart review of Kawasaki syndrome patients treated at our institution during an 11-year period (1991-2002). Of 324 patients, 21 patients had coronary artery aneurysms and were matched with 81 Kawasaki syndrome control patients without coronary artery aneurysms. RESULTS: Patients who developed coronary artery aneurysms were more likely to have had their diagnosis established after 10 days of fever as a result of a delay in physician recognition of Kawasaki syndrome. In addition, these patients were also more likely to have been hospitalized at an outside facility with an erroneous diagnosis, to have had a greater number of healthcare visits before diagnosis, to have sought medical care in Mexico, to lack medical insurance and to speak Spanish as a primary language. Independent predictors of delayed diagnosis included incomplete clinical signs of Kawasaki syndrome, seeking health care in Mexico, and being hospitalized at an outside facility with a different diagnosis. CONCLUSIONS: Increased risk of coronary artery aneurysms is associated with a delay in diagnosis by physicians and not with a delay in seeking medical consultation by parents. Sociodemographic factors influence the likelihood that patients will have a delayed diagnosis.