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Background:. No study has contextualized the excess mortality attributable to racial and ethnic disparities in surgical outcomes. Further, not much effort has been made to quantify the effort needed to eliminate these disparities. Objective:. We examined the current trends in mortality attributable to racial or ethnic disparities in the US postsurgical population. We then identified the target for mortality reduction that would be necessary to eliminate these disparities by 2030. Methods:. We performed a population-based study of 1,512,974 high-risk surgical procedures among adults (18–64 years) performed across US hospitals between 2000 and 2020. Results:. Between 2000 and 2020, the risk-adjusted mortality rates declined for all groups. Nonetheless, Black patients were more likely to die following surgery (adjusted relative risk 1.42; 95% CI, 1.39–1.46) driven by higher Black mortality in the northeast (1.60; 95% CI, 1.52–1.68), as well as the West (1.53; 95% CI, 1.43–1.62). Similarly, mortality risk remained consistently higher for Hispanics compared with White patients (1.21; 95% CI, 1.19–1.24), driven by higher mortality in the West (1.26; 95% CI, 1.21–1.31). Overall, 8364 fewer deaths are required for Black patients to experience mortality on the same scale as White patients. Similar figures for Hispanic patients are 4388. To eliminate the disparity between Black and White patients by 2030, we need a 2.7% annualized reduction in the projected mortality among Black patients. For Hispanics, the annualized reduction needed is 0.8%. Conclusions:. Our data provides a framework for incorporating population and health systems measures for eliminating disparity in surgical mortality within the next decade.

Introduction. Almost all pediatric orthotopic liver transplant (OLT) recipients require mechanical ventilation in the early postoperative period. Prolonged postoperative mechanical ventilation (PPMV) may be a marker of severe disease and may be associated with morbidity and mortality. We determined the incidence and risk factors for PPMV in children who underwent OLT. Methods. This was a retrospective analysis of data collected on 128 pediatric OLT recipients. PPMV was defined as postoperative ventilation ≥ 4 days. Perioperative characteristics were compared between cases and control groups. Multivariable logistic regression analysis was used to calculate odds ratios for PPMV after controlling for relevant cofactors. Results. An estimated 25% (95% CI, 17.4%–32.6%) required PPMV. The overall incidence of PPMV varied significantly by age group with the highest incidence among infants. PPMV was associated with higher postoperative mortality (p=0.004) and longer intensive care unit (p

Foreign body ingestion is a common event among pediatric patients, especially in children less than 6 years of age. Although most cases are relatively benign, with the foreign body passing spontaneously or requiring a brief endoscopic procedure for removal, button battery ingestion is known to cause significant morbidity with the potential for mortality. Although aorto-esophageal fistula (AEF) is a rare complication following button battery ingestion, its clinical manifestations are significant and outcomes are poor. Early diagnosis and aggressive treatment are key in preventing fatal complications. We describe the successful management of an AEF which presented with hematemesis 8 days after removal of a button battery in a 17-month-old female. The literature regarding button battery ingestion and AEF is reviewed and treatment options including intraoperative anesthetic care discussed.

Objective: Perioperative acute kidney injury (AKI) is associated with poor patient outcomes. The epidemiology of perioperative AKI is characterized in children and to a lesser extent in neonates with cardiac disease. We hypothesized that the prevalence of noncardiac perioperative AKI in neonates is higher than in older children. We also hypothesized that certain neonatal characteristics and comorbidities increase the risk of perioperative AKI and hospital mortality. We aimed to characterize the epidemiology and risk factors of perioperative AKI in neonates undergoing noncardiac surgeries and outline the associated mortality risk factors., Study Design: We performed a retrospective study of neonates ≤28 days old who underwent inpatient noncardiac surgery in 46 U.S. children's hospitals participating in the Pediatric Hospital Information System between 2016 and 2021. AKI was evaluated throughout the surgical admission encounter. AKI was defined using the International Classification of Diseases (ICD) versions 9 and 10 codes. Comorbid risk factors are chronic and longstanding diagnoses and were selected using ICD-9 and ICD-10 diagnostic and procedure codes., Results: Perioperative AKI occurred in 10% of neonates undergoing noncardiac surgeries. Comorbidities associated with high risk of perioperative AKI included metabolic, hematologic/immunologic, cardiovascular, and renal disorders. The relative risk of mortality in perioperative AKI was highest in infants with low birthweight (relative risk = 1.49, 1.14-1.94) and those with hematologic (1.46, 1.12-1.90), renal (1.24, 1.01-1.52), and respiratory comorbidities (1.35, 1.09-1.67)., Conclusion: Perioperative AKI is common in neonates undergoing noncardiac surgeries. Infants with high-risk comorbidity profiles for the development of perioperative AKI and mortality may benefit from close surveillance of their kidney function in the perioperative period. Although retrospective, the findings of our study could inform clinicians to tailor neonatal perioperative kidney care to improve short- and long-term outcomes., Key Points: · AKI is common in neonates undergoing noncardiac surgeries.. · Extremely preterm and very low birth weight neonates have the highest rates of perioperative AKI.. · Renal, hematologic, and respiratory comorbidities increase mortality risk in neonates with perioperative AKI.., Competing Interests: None declared., (Thieme. All rights reserved.)

Objective: Most children undergoing craniotomy with general endotracheal anesthesia are extubated postoperatively, but some require unplanned postoperative intubation (UPI). We sought to determine the incidence of UPI and identify associated factors and related postoperative mortality., Methods: The National Surgical Quality Improvement Program for Pediatrics (2012-2018) was used to retrospectively identify patients less than 18 years old who underwent craniotomy for epilepsy, tumor, and congenital/cyst procedures. Perioperative factors associated with UPI were identified with logistic regression models., Results: We identified 15,292 children, of whom 144 (0.94%) required UPI. Ninety-two (0.60%) children required UPI within the first 3 days after surgery. Postoperative mortality was higher among children with UPI within 3 days than in those with UPI later or not at all (8.0 vs. 2.2 vs. 0.3%, respectively; P <0.001). Posterior fossa procedures trended towards an increased odds of UPI (odds ratio [OR], 1.50; 95% confidence interval [CI] 0.99 to 2.27; P =0.05). Five preoperative factors were independently associated with UPI: age ≤ 12 months (OR, 2.78; 95% CI, 1.29 to 5.98), ASA classification ≥3 (OR, 1.92; 95% CI, 1.12 to 3.29), emergent case status (OR, 2.06; 95% CI, 1.30 to 3.26), neuromuscular disease (OR, 1.87; 95% CI, 1.01 to 3.47), and steroid use within 30 days (OR, 1.79; 95% CI 1.14 to 2.79). Long operative times were independently associated with UPI (200 to 400 vs. <200 min OR, 1.92; 95% CI 1.18 to 3.11 and ≥400 vs. <200 min OR, 4.66; 95% CI 2.70 to 8.03)., Conclusion: Although uncommon, UPI in children who underwent craniotomy was associated with an elevated risk of postoperative mortality. The presence of identifiable risk factors may be used for preoperative counseling and risk profiling in these patients., Competing Interests: The authors have no funding or conflicts of interest to disclose., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Various criteria exist for defining difficult intravenous access (DIVA) in infants and children. The current study evaluated the factors associated with DIVA in a prospective cohort of over 1000 infants and children presenting for anesthetic care., Methods: This was a prospective, observational study of patients aged 0 to 18 years undergoing elective surgical or radiologic procedures under general anesthesia. Prior to the initial attempt at peripheral intravenous (PIV) cannulation, the anticipated difficulty of PIV catheter placement was determined by the provider using a visual analogue scale (VAS) from 1 to 10. The number of attempts was recorded as well as the time required to achieve PIV access. DIVA was defined as requiring three or more attempts. After successful cannulation, the actual difficulty of the PIV placement was assessed by the provider and recorded using the same VAS. Patient characteristics, including age, race, body mass index (BMI), American Society of Anesthesiologists (ASA) physical classification, and history of difficult PIV placement, were evaluated as covariates., Results: In our cohort of 1002 pediatric patients, 78% of patients were successfully cannulated in a single attempt and 91% of patients were successfully cannulated in two or fewer attempts. Factors associated with requiring three or more PIV attempts included younger age (OR 8.73; 95% CI: 3.38, 22.6 for age <1 year and OR 4.93; 95% CI: 2.05, 11.8 for age 1-3 years), higher ASA physical classification (OR 1.95; 95% CI: 1.10, 3.46 for ASA II), and prior history of difficult PIV placement (OR 3.46; 95% CI: 1.70, 7.08). BMI, racial category or gender were not independent predictors of DIVA., Conclusion: We found that approximately 9% of patients required three or more attempts at IV placement in the operating room. Patients that required multiple PIV attempts were more likely to be younger, have a higher ASA classification or a history of difficult PIV placement., Competing Interests: The authors report no conflicts of interest in this work., (© 2022 Heydinger et al.)

The novel technology of robotic-assisted surgery (RAS) has been utilized in children for the past two decades with several potential clinical benefits including reduction of postoperative pain, shortened hospital length of stay, and improved cosmetic outcomes. While associated costs and the limitations regarding instruments for smaller pediatric patients remain relevant issues, surgeon comfort related to ergonomic design in combination with enhanced three-dimensional high-fidelity imaging and tissue handling compared to traditional minimally invasive approached may offer improved surgical and postoperative outcomes. Given that the demand for this innovative technology will likely continue to expand in the field of pediatric surgery, pediatric anesthesiologists will be called upon to provide anesthetic care to patients exposed to this novel surgical technology with its unique features, intraoperative requirements, and potential complications. The current manuscript provides a narrative review of robotic-assisted surgery and discusses important anesthetic considerations and potential complications of these techniques., Competing Interests: Dr Michalsky has received an honorarium from Intuitive Surgical, Inc (Sunnyvale, CA) for professional educational services rendered. Intuitive Surgical, Inc has had no involvement or access to the original content reported in the work. None of the authors have a competing financial interest, and report no other conflicts of interest in this work., (© 2021 Wakimoto et al.)

Introduction: Pediatric obesity is a major health concern in the United States and as many as 34% of those who require general anesthesia are overweight or obese (OW). The lack of data and recommendations for dosing medications in obese children leaves significant gaps in the understanding of correct dosing in the clinical setting., Objective: To determine whether OW children were more likely to receive doses of medications outside the recommended range., Methods: Following IRB approval, patient medical records were queried to identify children 2 through 17 years who underwent noncardiac surgeries and received at least one medication of interest. Children with hepatic disease, renal disease, neurological impairment, sleep-disordered breathing, or missing height or weight measurements were excluded. Children were stratified into weight categories based on age and gender percentiles as per CDC guidelines. Those ≥85th percentile were classified as overweight/obese. Ideal and lean weight (for age, gender) were calculated. Drug doses were stratified as under-dosed (>10% below minimum recommended dose), overdosed (>10% above maximum recommended dose), or within recommended dose (dose ± 10%). Actual doses were compared to recommended doses as per actual, ideal, or lean weight (as recommended for specific drugs) in the overweight/obese groups vs the control weight (CW) group., Results: Ten thousand five hundred and nine doses were reviewed. Overweight/obese children were more likely to receive doses outside the recommended dose range than the CW group., Conclusions: Overweight/obese children were more likely to receive doses of common anesthetic medications outside the recommended doses potentially adding risk of adverse outcomes in these children., (© 2014 John Wiley & Sons Ltd.)