A simple screening test of filtration efficiency for protecting the gas sampling line from coronavirus using fluorescent microspheres.

BACKGROUND: During the coronavirus pandemic, preventing contamination of the anesthesia machine, critical to avoid cross-contamination between patients, has proven challenging when treating premature infants and neonates. While attaching a HEPA filter to the endotracheal tube will protect the anesthesia machine and the gas sampling line from contamination, this contribution to the dead space makes ventilation of these small patients challenging. Direct filtration of the gas sampling line eliminates this problem; however, appropriate filters are not readily available. AIMS: Identify a small filter capable of filtering out particles of a size similar to the SARS-CoV-2 virus for the gas sampling line. METHODS: We used fluorescence microspheres suspended in a solution for a challenge test to determine the filtration efficiency of various filters. The microspheres varied in diameter (0.02 µm, 0.042 µm, 0.109 µm, and 0.989 µm). A fluorescence plate reader was used to evaluate the degree of fluorescence intensity in the flow-through from various filters and referenced to the fluorescence intensity of the input. RESULTS: AHEPA filter, as recommended as an anti-viral filter, effectively filtered all the particles tested. The B. Braun PERIFIX Flat Epidural Filter was the second most effective filter, filtering particles larger than 0.042 µm. Other filters tested did not filter fluorescence microspheres equivalent in size to a single coronavirus particle (0.07 µm). CONCLUSIONS: Although the Food and Drug Administration (FDA) has not approved the Flat Epidural Filter for use as an anesthesia machine gas filter, our simple challenge test suggests that it could be used to effectively filter the anesthesia gas sampling line.

Team Approach: The Perioperative Management of Reconstructive Hip Surgery for the Non-Ambulatory Child with Cerebral Palsy and Spastic Hip Disease.

Cerebral palsy (CP) is the leading cause of physical disability in children. Although physical disability is the hallmark of CP, children with CP also often have complex medical comorbidities. Spastic hip subluxation is the second most common orthopaedic deformity in children with CP, and the incidence increases with the severity of CP. Hip surveillance should be implemented in children with CP to monitor hip stability over time. A reconstructive surgical procedure is recommended when the migration percentage is >40%. Perioperative care of children undergoing a hip reconstructive surgical procedure is a multidisciplinary endeavor requiring the expertise of professionals with different backgrounds. The core team should comprise orthopaedic surgeons, nurses, nurse practitioners, pediatricians, nurse case managers, anesthesiologists, and physical therapists. Additional team members include nutritionists, clinical pharmacists, social workers, child life therapists, and consulting specialty services. This review describes the team approach to the perioperative care of non-ambulatory children with spastic hip subluxation undergoing a reconstructive hip surgical procedure, utilizing a case scenario of a 7-year old girl with CP and complex associated medical comorbidities.

Adverse Perioperative Events in Children with Complex Congenital Heart Disease Undergoing Operative Scoliosis Repair in the Contemporary Era.

Scoliosis is common in children with congenital heart disease (CHD) and may have deleterious effects on quality of life and hemodynamics. Relatively little is known about the outcomes of spinal fusion for scoliosis repair in children with complex CHD. We reviewed all cases of children with CHD undergoing first time spinal fusion excluding those with minor CHD between 1995 and 2015. Seventy-eight patients were identified and included in the study. 97.4% of patients included had undergone prior cardiac surgery and sixteen patients had single ventricle circulations. 17.9% of patients experienced a significant perioperative event defined as an aggregate of the presence of any of the following: need for early unanticipated reoperation, neurologic deficit, postoperative bleeding requiring intervention, end organ dysfunction, or death. There were no deaths in our cohort. 38.5% of patients experienced any adverse event, the majority of which were related to perioperative fluid shifts. Larger preoperative Cobb angle and longer length of spinal fusion were associated with increased risk of significant perioperative event while larger preoperative Cobb angle and longer length of spinal fusion, older age at time of surgery, single ventricle circulation, cyanosis and patients taking cardiac medications at the time of surgery were more likely to experience any adverse event. Operative repair of scoliosis in children with complex CHD has been performed without mortality over a 20-year period in a single institution, albeit with a higher rate of perioperative complication than is seen in the general pediatric population. Patients with large preoperative Cobb angles and cyanotic single ventricle circulations appear to be at the highest risk for perioperative complications.

Tranexamic Acid Is Efficacious at Decreasing the Rate of Blood Loss in Adolescent Scoliosis Surgery: A Randomized Placebo-Controlled Trial.

BACKGROUND: Tranexamic acid (TXA) is an antifibrinolytic drug that reduces surgical blood loss. Evidence supporting its efficacy in surgery for adolescent idiopathic scoliosis is not robust. This trial was designed to validate the clinical efficacy of TXA in surgery for adolescent idiopathic scoliosis. METHODS: This institutional review board-approved prospective double-blinded trial involved 111 patients with adolescent idiopathic scoliosis who were randomized to receive either a placebo or TXA (50-mg/kg loading dose and 10-mg/kg/h infusion). Power analysis indicated that 50 patients per group would provide power to detect a >20% difference in blood loss. Two-way analysis of variance (ANOVA) was applied to compare blood loss rates (slopes) using the group-by-time interaction F test. RESULTS: The risk of clinically relevant blood loss (>20 mL/kg) was more than twice as high in the placebo group than in the TXA group (44% versus 21%, relative risk = 2.1, 95% confidence interval = 1.2 to 3.7). Compared with the placebo group, the TXA group had a 27% reduction in intraoperative blood loss, a significantly lower rate of intraoperative bleeding per hour (mean and standard deviation, 190 ± 73 versus 230 ± 80 mL, p = 0.01; F = 9.77, p < 0.001) and per fused spinal level (82 ± 32 versus 110 ± 40 mL, p < 0.001), less intraoperative blood loss (836 ± 373 versus 1,031 ± 484 mL, p = 0.02), and less postoperative bleeding (in the drain) (498 ± 228 versus 645 ± 318 mL, p = 0.009). Six patients who received a placebo and no patient who received TXA required an allogenic blood transfusion. No perioperative adverse events, including thromboembolic events or seizures, were observed. Three independent factors were predictive of blood loss: TXA administration, duration of surgery, and number of levels fused. Greater intraoperative blood loss was the only independent variable predictive of a longer hospital stay. CONCLUSIONS: Use of TXA in patients undergoing surgery for adolescent idiopathic scoliosis significantly reduced blood loss, by 27%, compared with that in the placebo group. The rate of intraoperative blood loss per hour and per level fused and the amount of postoperative blood loss were significantly lower in the TXA group. More placebo-treated patients received allogenic blood. Patients with greater intraoperative blood loss spent a longer time in the hospital. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Medication errors in a pediatric anesthesia setting: Incidence, etiologies, and error reduction strategies.

STUDY OBJECTIVE: The objective of the study was to: a) characterize the frequency, type, and outcome of anesthetic medication errors spanning an 8.5-year period, b) describe the targeted error reduction strategies and c) measure the effects, if any, of a focused, continuous, multifaceted Medication Safety Program. DESIGN: Retrospective analysis. SETTING: All anesthetizing locations (57). PATIENTS: All anesthesia patients at all Boston Children's Hospital anesthetizing locations from January 2008 to June 2016 were included. INTERVENTIONS: Medication libraries, zero-tolerance philosophy, independent verification, trainee education, standardized dosing; retrospective study. MEASUREMENTS: Number and type of medication errors. MAIN RESULTS: 105 medication errors were identified among the 287,908 cases evaluated during the study period. Incorrect dose (55%) and incorrect medication (28%) were the most frequently observed errors. Beginning within 3 years of the implementation of the 2009 Medication Safety Program, the incidence declined to an average of 3.0 per 10,000 cases in the years from 2010 to 2016 (57% reduction) and declined to an average of only 2.2 per 10,000 cases since 2012 (69% reduction). Logistic regression indicated a 13% reduction per year in the odds of a medication error over the time period (odds ratio = 0.87, 95% CI: 0.79-0.95, P = 0.004). CONCLUSIONS: Although medication errors persisted, there was a statistically significant reduction in errors during the study period. Formalized Medication Safety Programs should be adopted by other departments and institutions; these Programs could help prevent medication errors and decrease their overall incidence.

A Shared Opportunity for Improving Electronic Medical Record Data.

With the recent rapid adoption of electronic medical records (EMRs), studies reporting results based on EMR data have become increasingly common. While analyzing data extracted from our EMR for a retrospective study, we identified various types of erroneous data entries. This report investigates the root causes of the incompleteness, inconsistency, and inaccuracy of the medical records analyzed in our study. While experienced health information management professionals are well aware of the many shortcomings with EMR data, the aims of this case study are to highlight the significance of the negative impact of erroneous EMR data, to provide fundamental principles for managing EMRs, and to provide recommendations to help facilitate the successful use of electronic health data, whether to inform clinical decisions or for clinical research.

Anesthesiologist- and System-Related Risk Factors for Risk-Adjusted Pediatric Anesthesia-Related Cardiac Arrest.

BACKGROUND: Pediatric anesthesia-related cardiac arrest (ARCA) is an uncommon but potentially preventable adverse event. Infants and children with more severe underlying disease are at highest risk. We aimed to identify system- and anesthesiologist-related risk factors for ARCA. METHODS: We analyzed a prospectively collected patient cohort data set of anesthetics administered from 2000 to 2011 to children at a large tertiary pediatric hospital. Pre-procedure systemic disease level was characterized by ASA physical status (ASA-PS). Two reviewers independently reviewed cardiac arrests and categorized their anesthesia relatedness. Factors associated with ARCA in the univariate analyses were identified for reevaluation after adjustment for patient age and ASA-PS. RESULTS: Cardiac arrest occurred in 142 of 276,209 anesthetics (incidence 5.1/10,000 anesthetics); 72 (2.6/10,000 anesthetics) were classified as anesthesia-related. In the univariate analyses, risk of ARCA was much higher in cardiac patients and for anesthesiologists with lower annual caseload and/or fewer annual days delivering anesthetics (all P < 0.001). Anesthesiologists with the highest academic rank and years of experience also had higher odds of ARCA (P = 0.02). After risk adjustment for ASA-PS ≥ III and age ≤ 6 months, however, the association with lower annual days delivering anesthetics remained (P = 0.03), but the other factors were no longer significant. CONCLUSIONS: Case-mix explained most associations between higher risk of pediatric ARCA and anesthesiologist-related variables at our institution, but the association with fewer annual days delivering anesthetics remained. Our findings highlight the need for rigorous adjustment for patient risk factors in anesthesia patient safety studies.

Economic evaluation of cell salvage in pediatric surgery.

BACKGROUND: Red blood cells are a scarce resource with demand outstripping supply. Use of intraoperative red cell salvage (CS) - the process of collecting shed blood during surgery and reinfusing it to patients - is often used as an effective blood conservation strategy. However, little is known about the economic impact of CS during pediatric surgery. METHODS: A decision tree model was used to estimate the transfusion-related costs per patient (2010 USD) from a healthcare system perspective of four transfusion strategies among children undergoing elective orthopedic or cardiac surgery: (i) CS followed by allogeneic transfusion, (ii) CS followed by autologous transfusion, (iii) allogeneic transfusion alone, and (iv) autologous transfusion alone. RESULTS: Cell salvage and allogeneic transfusion was the least expensive strategy (USD 883.3) followed by CS and autologous blood transfusion (USD 1,269.7), allogeneic transfusion alone (USD 1,443.0), and autologous transfusion alone (USD 1,824.7). Savings associated with CS use persisted in separate analyses of orthopedic and cardiac surgery, as well as in one-way and probabilistic sensitivity analyses. CONCLUSIONS: Use of CS, particularly along with allogeneic blood transfusion, appears cost-saving and cost-effective in pediatric surgery.

Tranexamic acid reduces intraoperative blood loss in pediatric patients undergoing scoliosis surgery.

BACKGROUND: Excessive bleeding often occurs during pediatric scoliosis surgery and is attributed to numerous factors, including accelerated fibrinolysis. The authors hypothesized that administration of tranexamic acid would reduce bleeding and transfusion requirements during scoliosis surgery. METHODS: Forty-four patients scheduled to undergo elective spinal fusion were randomly assigned to receive either 100 mg/kg tranexamic acid before incision followed by an infusion of 10 mg . kg . h during surgery (tranexamic acid group) or 0.9% saline (placebo group). General anesthesia was administered according to a standard protocol. Blood loss, transfusion requirements, coagulation parameters, and complications were assessed. RESULTS: In the tranexamic acid group, blood loss was reduced by 41% compared with placebo (1,230 +/- 535 vs. 2,085 +/- 1,188 ml; P < 0.01). The amount of blood transfused did not differ between groups (615 +/- 460 vs. 940 +/- 718 ml; P = 0.08). Administration of tranexamic acid was a multivariate predictor of blood loss, as was American Society of Anesthesiologists physical status and preoperative platelet count. No apparent adverse drug effects occurred in any patient. CONCLUSION: Intraoperative administration of tranexamic acid significantly reduces blood loss during spinal surgery in children with scoliosis.

The bispectral index and explicit recall during the intraoperative wake-up test for scoliosis surgery.

UNLABELLED: In this prospective study, we evaluated the bispectral index (BIS) and postoperative recall during the intraoperative wake-up examination in 34 children and adolescents undergoing scoliosis surgery. Each anesthesiologist was blinded to BIS values throughout surgery and the wake-up test. The BIS, mean arterial blood pressure, and heart rate were compared at: before starting the wake-up test, patient movement to command, and after the patient was reanesthetized. The anesthetic technique for Group 1 was small-dose isoflurane, nitrous oxide, fentanyl, and midazolam and for Group 2 was nitrous oxide, fentanyl, and midazolam. Controlled hypotension was used for all cases. At patient movement to command, the patients were told a specific color to remember (teal) and on the second postoperative day were interviewed for explicit recall of the color and other intraoperative events. A total of 37 wake-up tests were performed in 34 patients. There was a significant increase in both groups of BIS (P < 0.001), mean arterial blood pressure (P < 0.001), and heart rate (P < 0.01) at the time of purposeful patient movement followed by a significant decline in BIS after reintroduction of anesthesia (P < 0.01). No patient recalled intraoperative pain, one patient recalled the wake-up test but not the color, and five patients recalled the specified color. We conclude that BIS may be a useful clinical monitor for predicting patient movement to command during the intraoperative wake-up test, particularly when controlled hypotension is used and hemodynamic responses to emergence of anesthesia are blunted. IMPLICATIONS: The relationship between bispectral index (BIS) and purposeful intraoperative patient movement is consistent with previous BIS utility studies. We conclude that BIS may be a useful clinical monitor for predicting patient movement to command during the intraoperative wake-up test, particularly when controlled hypotension is used and hemodynamic responses to emergence of anesthesia are blunted.