The implementation of a pectus bar insertion enhanced recovery after surgery pathway: A quality improvement initiative.

BACKGROUND: Pectus excavatum repair is associated with significant discomfort, and pain is a primary contributor to postoperative hospital length of stay. Recent advances in postoperative pain control include the use of intercostal cryoablation techniques that may now make it possible to discharge patients on the day of surgery. Unnecessary variation in patient care and noncompliance with care bundles may be a factor in extended length of stay. The global aim of this quality improvement initiative was to successfully implement an enhanced recovery after surgery (ERAS) pathway on patients undergoing pectus excavatum repair. The SMART aim was to have a greater than 70% compliance for the perioperative bundle elements within 1 year of the pathway implementation. METHODS: Multiple Plan-Do-Study-Act (PDSA) cycles were designed to create and implement an ERAS pathway for patients undergoing a pectus bar insertion procedure. This multidisciplinary pathway was designed, managed, and implemented with key stakeholders from the Departments of Evidence Based Practice, Surgery, Anesthesiology, and Perioperative Nursing. Patient characteristics, outcomes, and compliance with elements of the pathway were measured for analysis for both the baseline and post-intervention groups with monthly automated reports. RESULTS: After implementation of the ERAS pathway, data on the first 50 patients showed a 90% compliance with the perioperative bundle elements. Mean length of stay was significantly decreased from 33 h (95% CI [28.76, 37.31]) to 18 h (95% CI [14.54, 21.70]). There were zero readmissions within 24 hours for patients who were discharged on the day of surgery. CONCLUSION: Employing a multidisciplinary approach in both planning and execution that standardized clinician practices and minimized unnecessary variation in patient care, an ERAS pathway for pectus bar insertion has been successfully established at our institution.

A novel approach to operating room readiness for airborne precautions using simulation-based clinical systems testing.

BACKGROUND: The emergence of the COVID-19 disease as a global pandemic caused major challenges and strained busy operating room environments. This required institutions to rethink current system functioning and urgently develop safe medical practices and protocols. PURPOSE: To use a novel approach combining simulation-based clinical system testing with rapid cycle deliberate practice concepts for identifying latent safety threats presented by newly developed operating room COVID-19 protocols and collecting frontline staff recommendations for mitigation. METHODS: This study design combined a training/education approach with probing the systems function. The primary outcomes were the number of latent safety threats and staff evaluations of this approach for feasibility and utility on immediate and four-month post surveys. Participants started the simulation which took place in the operating room, in the assistant role before graduating to the primary airway manager. Simulation staff members observed the simulations and noted whether elements in the protocols/checklists were followed and whether latent safety threats were present using an observation form. Solutions to latent safety threats were sought during the debriefing period. RESULTS: This approach identified 17 latent safety threats not foreseen during the planning stages and allowed for corrections to the protocols prior to impacting patient outcomes. Post-simulation surveys indicated that the program was well received and all who responded agreed that it was worth the time it took. Fifty-seven percent of respondents to four-month follow-up survey reported using the work products to care for an actual COVID-19 patient. CONCLUSIONS: This study demonstrated a flexible methodology that effectively integrated simulation-based training and systems tests to train staff and detect latent safety threats in the new workflows and provide recommendations for mitigation. While COVID was the specific prompt, this approach can be applicable in diverse clinical settings for training medical staff, testing system function, and mitigating potential latent safety threats.

Vaping Associated Cardiac Arrest at School in a Teenager with Anomalous Left Coronary Artery.

The prevalence of electronic cigarette use is increasing at an astonishing pace, particularly in the teenage population. While at school, a healthy 13-year-old male experienced a sudden cardiac arrest after vaping multiple times throughout the day. Workup revealed an anomalous left coronary artery originating from the right sinus of Valsalva. Given this patient's underlying anomalous left coronary artery, we suspect that sympathoexcitatory and arrhythmogenic effects of high dose nicotine from vaping led to his cardiovascular collapse. This is the first published case report of a vaping associated cardiac arrest in a patient of this age.

Update on the safety of anesthesia in young children presenting for adenotonsillectomy.

Tonsillectomy with and without adenoidectomy is a frequently performed surgical procedure in children. Although a common procedure, it is not without significant risk. It is critical for anesthesiologists to consider preoperative, intraoperative, and postoperative patient factors and events to optimize safety, especially in young children. In the majority of cases, the indication for adenotonsillectomy in young children is obstructive breathing. Preoperative evaluation for patient comorbidities, especially obstructive sleep apnea, risk factors for a difficult airway, and history of recent illness are crucial to prepare the patient for surgery and develop an anesthetic plan. Communication and collaboration with the otolaryngologist is key to prevent and treat intraoperative events such as airway fires or hemorrhage. Postoperative analgesia planning is critical for safe pain control especially for those patients with a history of obstructive sleep apnea and opioid sensitivity. In young children, it is important to also consider the impact of anesthetic medications on the developing brain. This is an area of continuing research but needs to be weighed when planning for surgical treatment and when discussing risks and benefits with patients' families.

Trimmed central venous catheters in pediatric cardiac surgery: Does height or weight correlate with the amount trimmed?

BACKGROUND: Due to excess catheter length, pediatric patients undergoing cardiac surgery frequently have the tip of the central venous catheter trimmed while on bypass to obtain optimal catheter positioning. AIMS: We sought to determine if there is a correlation between the patient's height or weight and the length of catheter removed. Our secondary aim compared the instances of central line-associated bloodstream infections and venous thromboembolisms between the trimmed and untrimmed catheters. METHODS: This retrospective study included patients having undergone cardiac surgery over a 3-year period who had an 8 cm central venous catheter placed in the right internal jugular vein. Hospital lists of central line-associated bloodstream infections and venous thromboembolisms that occurred were cross referenced with our study patients. RESULTS: There were 147 cases where the 8 cm central venous catheter was trimmed, which represents 35% of the cases. Of the catheters that were cut, on average 2.17 cm was removed. There is negligible correlation between the length of catheter removed and patient height (r = -.19, p = .021). There is negligible correlation between the length of catheter removed and patient weight (r = -.17, p = .039). There were no instances of central line-associated bloodstream infections or venous thromboembolisms attributed to the trimmed catheters. Of the 273 untrimmed catheters, there were no instances of an infection and one instance of a venous thromboembolism. CONCLUSION: Right internal jugular 8 cm central venous catheters are trimmed during pediatric cardiac surgery, and there is minimal correlation between the length removed and the patient height or weight. Due to the difficulty in estimating the proper length of a central venous catheter in smaller pediatric patients, placing an 8 cm long catheter in these patients and then trimming the distal tip while on bypass may be the most accurate way to properly position a catheter.

Epidural versus PCA Pain Management after Pectus Excavatum Repair: A Multi-Institutional Prospective Randomized Trial.

INTRODUCTION: Postoperative pain control remains the primary reason for inpatient stay after minimally invasive repair of pectus excavatum. In a previous study, our group reported that early pain control was better in patients managed with a thoracic epidural, while late pain control was better in patients managed with patient-controlled analgesia (PCA). After revising our epidural transition and modifying the PCA protocol, we conducted a multi-institutional prospective randomized trial to evaluate these two pain control strategies. MATERIALS AND METHODS: Patients were randomized to epidural or PCA following minimally invasive repair of pectus excavatum with standard protocols for each arm. Primary outcome was length of stay with secondary variables including mean patient pain scores, complications, and parental satisfaction. Scores were pooled for the two groups and reported as means with standard deviation. Results were compared using t-tests and one-way analysis of variance with p-value < 0.05 determining significance. RESULTS: Sixty-five patients were enrolled, 32 epidural and 33 PCA. Enrollment was stopped early when we developed an alternative strategy for controlling these patients' pain. There was no difference in length of stay in hours between the two arms; epidural 111.3 ± 18.5 versus PCA 111.4 ± 51.4, p = 0.98. Longer operative time was found in the epidural group. Nine patients in the epidural group (28%) required a PCA in addition to epidural for adequate pain control. Mean pain scores were lower on postoperative day 0 in the epidural group compared with the PCA groups, but were otherwise similar. CONCLUSION: In our prospective randomized trial, PCA is just as effective as thoracic epidural in decreasing early postoperative pain scores after minimally invasive repair of pectus excavatum.

Does Intravenous Acetaminophen Improve Postoperative Pain Control after Laparoscopic Appendectomy for Perforated Appendicitis? A Prospective Randomized Trial.

INTRODUCTION: The recent increased awareness of the dangers of opioids in the United States has highlighted the need to minimize narcotics and identify nonopioid options for pain control after surgery. With evidence suggesting that intravenous acetaminophen (IVA) can be an opioid sparing option, we conducted a prospective, randomized trial that evaluated the effect of IVA on the postoperative pain course of children with perforated appendicitis. MATERIALS AND METHODS: After IRB approval, children with perforated appendicitis were randomized to receive postoperative IVA with the standard patient/nurse-controlled analgesia (PCA) or to receive the PCA alone. All patients were treated according to an evidence-based treatment protocol. The primary outcome was duration of time on PCA. RESULTS: Eighty-two patients were analyzed from 7/14 to 11/15. There was no statistically significant difference in the time to transition from the PCA to oral pain medications for children given IVA compared with children not receiving IVA (76.4 ± 32.5 versus 86.7 ± 49.3 hours; p = 0.73). Children in the IVA group had no statistically significant difference in intravenous narcotics delivered and pain scores compared with the non-IVA group. There was no significant difference in the amount of oral narcotics between both groups (2.8 ± 2.4 versus 2.9 ± 2.5; p = 0.88). Patients who received IVA had higher medication charges ($3752.7 ± 1618.3 vs. $1198.19 ± 521.51; p < 0.01), but not total hospital charges ($53842.0 ± 19409.2 vs. $50501.03 ± 16223.32; p = 0.76). CONCLUSION: Children given IVA showed no difference in the transition time off the PCA and to oral pain medications after laparoscopic appendectomy for perforated appendicitis.