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OBJECTIVES Both parental and child factors have been previously associated with persistent or recurrent postoperative pain in children. Yet, little is known about the relative contribution of parent factors or whether child symptom factors might impact the association between parent factors and long-term pain. The aim of this study was to explore the associations between parent factors, child symptomology, and the child's long-term pain outcomes after surgery. METHODS This prospective, longitudinal study included parents and their children who were scheduled to undergo spinal fusion for underlying scoliosis. Parents completed baseline surveys about their pain history, pain relief preferences (ie, preference to relieve their child's pain vs avoid analgesic risks), and pain catastrophizing (ie, beliefs about their child's pain). Children were classified previously into high vs low symptom profiles at baseline based on their self-reported pain, catastrophizing, fatigue, depression, and anxiety. Children were assessed 1-year after surgery for their long-term pain interference scores and analgesic use. Serial regression modeling was used to explore whether associations between parent factors and the outcomes were changed when accounting for child factors. RESULTS Seventy-six parent/child dyads completed all surveys. Parental preferences and catastrophizing were atemporally associated with the child's baseline psychological-somatic symptom profile. Though parent and child factors were both associated with the long-term pain outcomes, when all three factors were accounted for, the associations between parent factors and long-term pain was fully attenuated by the child's profile. DISCUSSION These findings suggest that the relationship between parent factors and long-term postoperative pain outcomes may be dependent on the child's symptom profile at baseline. Since there may be bidirectional relationships between parent and child factors, interventions to mitigate long-term pain should address child symptoms as well as parental factors.

SummaryBackground Posterior spinal fusion to correct idiopathic scoliosis is associated with severe postoperative pain. Intrathecal morphine is commonly used for analgesia after adolescent posterior spinal fusion; however, anticipating and managing the increase in pain scores after resolution of analgesic effect of intrathecal morphine analgesia is challenging. In 2014, we developed a clinical protocol detailing both the administration of intrathecal morphine intraoperatively and the transition to routine, scheduled oral analgesics at 18 h postoperatively. The goal of our study was to examine the efficacy of our intrathecal morphine protocol vs epidural hydromorphone for postoperative analgesia after posterior spinal fusion. Methods Following IRB approval, we retrospectively identified developmentally intact children of ages 10–20 years in our electronic database with a diagnosis of idiopathic scoliosis who had undergone elective posterior spinal fusion surgery from June 2014 to April 2015. For the intrathecal morphine group, intrathecal morphine was administered in a dose of 12 μg·kg−1 (max 1000 μg) prior to incision. Postoperatively, all children in the intrathecal morphine group had an order to receive oral oxycodone (0.1 mg·kg−1, max 5 mg) starting at 18 h postintrathecal morphine injection. For the epidural hydromorphone group, catheters were placed by the surgeon and bolused with 5 μg·kg−1 hydromorphone (max 200 μg) and 1 μg·kg−1 fentanyl (max 50 μg), followed by a continuous infusion of 40–60 μg·h−1, and patient-controlled bolus doses of 5 μg with a lockout interval of 30 min. All patients in both groups had postoperative orders for acetaminophen, diazepam, and ketorolac. Results During the study time period, 20 patients received intrathecal morphine and were successfully matched with 20 patients who received epidural hydromorphone. All patients in the intrathecal morphine group were transitioned to oral analgesics on the first postoperative day, without need for intravenous opioids after discharge from the postanesthesia care unit. Compared to the epidural hydromorphone group, the intrathecal morphine group reported lower pain scores in the postanesthesia care unit (difference in means −4.26 [95% CI −6.56, −1.96], P = 0.001) and first 8 h after surgery (difference in means −1.88 [95% CI −3.84, 0.082, P = 0.060) and higher pain scores on the 2nd postoperative day (difference in means 1.60 [95% CI 0.10, 3.10], P = 0.037). The documented time to ambulation and time of Foley catheter removal were statistically earlier in the intrathecal morphine group, and the hospital length of stay was significantly shorter (3.0 ± 0.5 days vs 3.5 ± 0.7 days; P = 0.03). Adverse events did not significantly differ between the groups. Conclusion The efficacy of intraoperative intrathecal morphine for postoperative analgesia in the posterior spinal fusion patient population has been shown previously; however, the pain and analgesic trajectory, including transition to other analgesics, has not previously been studied. Our findings suggest that for many patients, use of intrathecal morphine in addition to routine administration of nonopioid medications facilitates direct transition to oral analgesics in the early postoperative period and earlier routine ambulation and discharge of posterior spinal fusion patients.

Summary Background Children with symptoms of sleep-disordered breathing (SDB) appear to be at risk for perioperative respiratory events (PRAE). Furthermore, these children may be more sensitive to the respiratory-depressant effects of opioids compared with children without SDB. Aims The aim of this prospective observational study was to confirm that otherwise healthy children with symptoms of SDB are at greater risk for PRAE compared with children with no symptoms and to determine if these children are also at increased risk for postoperative opioid-related adverse events (ORAE). Methods Six hundred and seventy-eight parents of children scheduled for surgery completed the Snoring, Trouble Breathing, and Un-Refreshed (STBUR) questionnaire preoperatively. Data regarding the incidence of PRAE were collected prospectively. Postoperative pulse oximetry desaturation alarm events were downloaded from the institutional secondary alarm notification system. Results Children with symptoms of SDB per STBUR (≥3 symptoms) had a two-fold increased likelihood of PRAE compared with children without SDB (52.8% vs 27.9% respectively, LR+ = 2.00, 95% CI = 1.60–2.49, P = 0.0001). A subset analysis of children undergoing airway procedures requiring hospital admittance (n = 179) showed that those with SDB were given the same postoperative opioid doses as children without SDB. However, children with SDB symptoms generated a greater number of postoperative oxygen desaturation alarms (14.14 ± 29.3 vs 7.12 ± 13.2, mean difference = 7.02, 95% CI = 0.39–13.64, P = 0.038) and more frequently required escalation of care (15.3% vs 7.1%, LR+ = 1.67, 95% CI = 1.22–2.16, P = 0.001) compared with children with no SDB symptoms. Conclusions Children presenting for surgery with SDB symptoms are at increased risk for PRAE. Children undergoing airway-related procedures also appear to be at increased risk for ORAE. Furthermore, regardless of the preoperative assessment of risk using the STBUR questionnaire, children received the same doses of opioids postoperatively. Given the increased incidence of postoperative oxygen desaturations among children with SDB symptoms, it would seem prudent to consider titration of opioid doses according to identified risk.

SummaryBackground Urethrocutaneous fistula is a well-known complication of hypospadias surgery. A recent prospective study by Kundra et al. (Pediatr Anesth 2012) has suggested that caudal anesthesia may increase the risk of fistula formation. We sought to evaluate this possible association and determine if any other novel factors may be associated with fistula formation. Methods Children who underwent primary hypospadias repair between January 1, 1994 and March 31, 2013 at our tertiary care center were included in this study. Reviewed surgical data included repair type, duration of procedure, use of local anesthetic infiltration, and subcutaneous epinephrine. Analgesic factors included use of caudal and/or penile block, opioid usage, postoperative pain scores, and nausea/vomiting. Postoperative surgical complications and estimates of family household median income by zip code were also reviewed. Results Fistula occurrence was not associated with caudal or penile block, severity of postoperative pain, or surgeon experience. A more proximal location of the urethral meatus, longer operating time, and use of subcutaneous epinephrine were significantly more common in patients who developed fistula. As assessed by home address zip code, distance of more than 100 miles and median household income in the bottom 25th percentile of our study population were not associated with fistula, as compared to closer distance or higher income. Conclusion In this series, we found no association between the use of caudal regional anesthesia and fistula formation. Location of the starting urethral meatus, prolonged surgical duration, and subcutaneous epinephrine use were associated with fistula formation. Our findings call into question the routine use of epinephrine in hypospadias repair.

Summary Objectives: Examine factors associated with opioid adverse drug events (ADE) in children. Specific Aims: Examine whether adjuvant nonopioid use is associated with a decreased probability of opioid-ADEs and need for rescue. Background: Opioid-ADEs contribute to serious preventable harm for hospitalized children. Adjuvant nonopioid use may mitigate opioid risk postoperatively, yet few studies support this notion. Method: This nested case–control study included children who required intervention or rescue from opioid-ADEs and procedure-matched controls. Data were recorded from medical records and primary outcomes included serious opioid-ADEs (over-sedation and respiratory depression) and need for rescue (e.g., naloxone, rapid response team). Hierarchical logistic regression (HLR) models examined relationships between factors and opioid-ADEs. Early clinical signs and symptoms of deterioration were examined. Results: Twenty five children with opioid-ADEs and 98 children without events were included. ASA-PS remained an independent risk factor (odds ratio, 2.56 [1.09, 6.03]; P = 0.031), while adjuvant nonopioids a risk reduction factor for opioid-ADEs (OR, 0.16 [0.05, 0.47]; P = 0.001) and need for rescue (0.14 [0.04, 0.47]; P = 0.001). Supplemental oxygen use at PACU discharge was associated with an increased odds of opioid-ADEs (OR, 3.72 [1.35, 10.23]; P = 0.007) and need for rescue (5.5 [1.7, 17.82]; P = 0.002). Conclusions: Findings from this study suggest that strategies such as early use of adjuvant nonopioids may reduce risk of opioid-ADEs postoperatively. Furthermore, children who require supplemental oxygen early postoperatively may be at heightened risk of later events.

Summary Acute kidney injury (AKI) is a serious complication that occurs commonly following cardiopulmonary bypass (CPB) in infants and children. Underlying risk factors for AKI remain unclear, given changes in CPB practices during recent years. This retrospective, case–control study examined the relationships between patient, perioperative factors, AKI, and kidney failure in children who underwent CPB. Methods: Cohorts of children with and without AKI were identified from the cardiac perfusion and nephrology consult databases. Demographic, perioperative, and postoperative outcome data were extracted from the databases and from medical records. Children were stratified into groups based on the Acute Dialysis Quality Initiative’s RIFLE definitions for acute kidney risk or injury (AKI-RI) and kidney failure. Results: The study groups included 308 controls (no AKI-RI or failure), 161 with AKI-RI, and 89 with failure. Young age, preoperative need for mechanical ventilation, milrinone, or gentamicin; intraoperative use of milrinone and furosemide; durations of CPB and anesthesia; multiple cross-clamp and transfusion of blood products were significantly associated with AKI or failure. Young age, perioperative use of milrinone, multiple cross-clamps, extracorporeal membrane oxygenation, cardiac failure, neurological complications, sepsis, and failure significantly increased the odds of mortality. Conclusion: This study identified multiple perioperative risk factors for AKI-RI, failure, and mortality in children undergoing CPB. In addition to commonly known risk factors, perioperative use of milrinone, particularly in young infants, and furosemide were independently predictive of poor renal outcomes in this sample. Findings suggest a need for the development of protocols aimed at renal protection in specific at risk patients.

Summary Introduction: Although blood pressure (BP) monitoring is a recommended standard of care by the ASA, and pediatric anesthesiologists routinely monitor the BP of their patients and when appropriate treat deviations from ‘normal’, there is no robust definition of hypotension in any of the pediatric anesthesia texts or journals. Consequently, what constitutes hypotension in pediatric anesthesia is currently unknown. We designed a questionnaire-based survey of pediatric anesthesiologists to determine the BP ranges and thresholds used to define intraoperative hypotension (IOH). Methods: Members of the Society of Pediatric Anesthesia (SPA) and the Association of Paediatric Anaesthetists (APA) of Great Britain and Ireland were contacted through e-mail to participate in this survey. We asked a few demographic questions and five questions about specific definitions of hypotension for different age groups of patients undergoing inguinal herniorraphy, a common pediatric surgical procedure. Results: The overall response rate was 56% (483/860), of which 76% were SPA members. Majority of the respondents (72%) work in academic institutions, while 8.9% work in institutions with fewer than 1000 annual pediatric surgical caseload. About 76% of respondents indicated that a 20–30% reduction in baseline systolic blood pressure (SBP) indicates significant hypotension in children under anesthesia. Most responders (86.7%) indicated that they use mean arterial pressure or SBP (72%) to define IOH. The mean SBP values for hypotension quoted by SPA members was about 5–7% lower across all pediatric age groups compared to values quoted by APA members (P = 0.001 for all age groups). Conclusions: There is great variability in the BP parameters used and the threshold used for defining and treating IOH among pediatric anesthesiologists. The majority of respondents considered a 20–30% reduction from baseline in SBP as indicative of significant hypotension. Lack of a consensus definition for a common clinical condition like IOH could have implications for patient care as well as future clinical research.

Summary Background: Few articles have addressed the issue of the child who refuses anesthesia or sedation for surgery. A survey of members of the Society for Pediatric Anesthesia in the USA was conducted regarding their experience with pediatric refusal and assent for surgery. Methods: Structured response and open-end questions were used in a confidential postal survey to assess the following: details of cancellations, the use of, and attitudes to, physical restraint at induction, premedication, the management of a hypothetical case of child refusal and individual techniques used for uncooperative children. Results: Surveys were received from 453/852 anesthesiologists for a 57% response rate. Nine percent and 45% of respondents had cancelled one or more cases for child refusal in the past year and during their entire career respectively. Forty-four percent of respondents used restraint in the majority of children 11 years. Respondents were more uncomfortable with restraint in older children and less likely to proceed with induction. Twelve years was the median age when respondents would respect the child’s refusal to proceed. Conclusions: Cancellation of planned surgery because of child refusal is not uncommon. It is important to recognize the potentially uncooperative child, particularly older children with developmental delay or a lack of understanding. Discussion with child and parents, selective use of premedication and different induction agents, distraction, play techniques, gentle restraint and the option of cancellation and review should all be considered.

Summary Background: Emergence agitation (EA) is a common postoperative problem in young children who have received sevoflurane and isoflurane for general anesthesia. This randomized, double-blinded study evaluated the efficacy of intraoperative clonidine in reducing EA, and describes its recovery profile. Methods: With Institutional Review Board approval and informed consent, children undergoing brief, minimally painful procedures were studied. All children received preemptive analgesia with acetaminophen and ketorolac, sevoflurane for induction, and isoflurane for maintenance of anesthesia. Children received either 2 lgAEkg )1 clonidine or placebo intravenously (i.v.) following induction of anesthesia. Children were observed postoperatively for behavior and side effects, and their parents were telephoned the next day to determine postdischarge recovery characteristics. Results: One hundred and twenty children were included in this study: 59 of whom received clonidine, and 61 placebo; 41% of those in the placebo group exhibited moderate–severe EA compared with only 22% of those in the clonidine group (P < 0.03). Compared with those who received placebo, children who received clonidine awakened more slowly (22 min vs 14 min), had a longer postanesthesia care unit stay (57 min vs 46 min), and experienced sleepiness more frequently after discharge (75% vs 39%; all comparisons significant at P < 0.03). There were no adverse cardiorespiratory events in either group. Conclusions: Findings demonstrate that i.v. clonidine administered after induction of anesthesia significantly reduces the incidence of EA in young children, but is associated with sleepiness postoperatively.

Summary Background: Difficulty with pain assessment in individuals whocannot self-report their pain poses a significant barrier to effective painmanagement. However, available assessment tools lack consistentreliability as pain measures in children with cognitive impairment(CI). This study evaluated the validity and reliability of the revisedand individualized Face Legs Activity Cry and Consolability (FLACC)behavioral pain assessment tool in children with CI.Methods: Children with CI scheduled for elective surgery werestudied. The FLACC was revised to include specific descriptors andparent-identified, unique behaviors for individual children. Thechild’s ability to self-report pain was evaluated. Postoperatively, twonurses scored pain using the revised FLACC scale before and afteranalgesic administration, and, children self-reported a pain score, ifable. Observations were videotaped and later viewed by experiencednurses blinded to analgesic administration.Results: Eighty observations were recorded in 52 children aged4–19 years. Twenty-one parents added individualized pain behaviorsto the revised FLACC. Interrater reliability was supported by excellentintraclass correlation coefficients (ICC, ranging from 0.76 to 0.90) andadequate j statistics (0.44–0.57). Criterion validity was supported bythe correlations between FLACC, parent, and child scores (q ¼ 0.65–0.87; P < 0.001). Construct validity was demonstrated by the decreasein FLACC scores following analgesic administration (6.1 ± 2.6 vs1.9 ± 2.7; P < 0.001).Conclusions: Findings support the reliability and validity of theFLACC as a measure of pain in children with CI.Keywords: pain assessment; developmentally delayed children; facelegs activity cry and consolability pain tool

Summary: Obstetric complications such as spontaneous abortion, preterm labour, preterm delivery, low birth weight and congenital anomalies may be associated with exposure to anaesthetic gases. We hypothesized that female anaesthesiologists practicing primarily paediatric anaesthesia, with increased exposure to trace anaesthetic agents, experience a greater prevalence of obstetric complications than female anaesthesiologists performing primarily adult anaesthesia. Methods: Questionnaires were sent to all female Society for Pediatric Anesthesia (SPA) members and to an equal number of randomly selected female American Society of Anesthesiologists (ASA) members. Subjects were asked to answer questions regarding their pregnancy outcomes, work history and personal habits. Parametric data were analysed by unpaired t-tests. Nonparametric data were analysed by chi-square, Fisher’s exact test and Mann–Whitney U-test as appropriate. Results: Paediatric anaesthesiologists were defined as those having >75% paediatric practice. Paediatric anaesthesiologists were older and had greater operating room exposure during their pregnancies than nonpaediatric anaesthesiologists. There was a significantly higher prevalence of spontaneous abortion among paediatric anaesthesiologists than nonpaediatric anaesthesiologists. In an exploratory analysis, the following factors were found to be significantly associated with the development of spontaneous abortion: age >35 years, gravida >1, exercise during pregnancy, percentage of inhalational anaesthetics >75% and paediatric anaesthesia practice >75%. Independent risk factors for spontaneous abortion among anaesthesiologists included exercise (>1 time/week) and age. Conclusion: Our results suggest a higher prevalence of spontaneous abortion in anaesthesiologists whose practice is >75% paediatrics.

Summary Background: Willingness to pay (WTP) surveys have proven to be useful tools in determining patient preferences though relatively few pediatric studies have utilized them. Studies in the adult surgical population have used such methods to assess patients’ perspectives regarding the avoidance of anesthesia side effects or outcomes. The purpose of this survey was to assess parental preferences, using a relative WTP model, for the avoidance of anesthesia side effects in their children undergoing surgery. Methods: The survey was distributed to 150 parents of children who were undergoing surgery. Parents were asked to rank order (1 = most unwanted to 7 = least troublesome) six stated potential anesthesia side effects and to allocate a fixed dollar percentage of a $100 toward prevention of each. A total of 142 surveys were returned (95% response rate). Results: Parents ranked vomiting as the least desirable side effect for their child (rank order = 1.9) and pain as second (rank order = 2.14). However, parents allocated $33.48 to prevent pain compared with $28.89 for vomiting as a relative dollar amount. Conclusions: This study suggests that targeting management toward the prevention of these adverse outcomes may improve parental satisfaction with anesthesia care of their children.