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The leading cause of mortality among children is trauma. Race and ethnicity are critical determinants of pediatric postsurgical outcomes, with minority children generally experiencing higher rates of postoperative morbidity and mortality than White children. This pattern of poorer outcomes for racial and/or ethnic minority children has also been demonstrated in children with head and limb traumas. While injuries to the abdomen and pelvis are not as common, they can be life-threatening. Racial and/or ethnic differences in outcomes of pediatric abdominopelvic operative traumas have not been examined. Our objective was to determine whether disparities exist in postoperative mortality among children with major abdominopelvic trauma.We performed a retrospective analysis of the Healthcare Cost and Utilization Project Kids' Inpatient Database for 2003, 2006, 2009, and 2012. Patients were included if they were18 years, sustained a major abdominopelvic injury, and underwent subsequent surgical intervention. Our primary outcome was inpatient mortality, comparing children of different race and/or ethnicity.We identified a weighted cohort of 13,955 children, of whom 6765 (48.5%) were White, 3614 (25.9%) Black, and 2647 (19.0%) Hispanic. After adjusting for covariates, Black children were 94% more likely to die than their White peers (3.3% versus 1.6%, adjusted-RR:1.94, 95%CI: 1.33-2.82, P = 0.001). Hispanic children (adjusted-RR:1.99, 95%CI: 1.36-2.91, P0.001) and those of other race and/or ethnicity (adjusted-RR: 2.02, 95%CI:1.20-3.40, P = 0.008) were also more likely to die compared to their White peers.Black and Hispanic children who require operative intervention following major abdominopelvic trauma have a higher risk of postoperative mortality compared with White children.

Racial disparities in postsurgical complications are often presumed to be due to a higher preoperative co-morbidity burden among patients of black race, although being relatively healthy is not a prerequisite for a complication-free postoperative course.To examine the association of race with short-term postbariatric surgery complications in seemingly healthy patients.Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database (2015-2018).We studied a relatively healthy (American Society of Anesthesiologists physical status 1 or 2), propensity score-matched cohort of adult non-Hispanic black and non-Hispanic white bariatric surgery patients. We compared the risk-adjusted incidences of postoperative complications, serious adverse events, and measures of postoperative resource utilization across racial groups.We identified 44,090 matched pairs of relatively healthy black and white bariatric surgery patients. Patients of black race were 72% more likely than those of white race to develop 1 or more postoperative complications (.7% versus .4%, respectively; odds ratio [OR], 1.72; 95% confidence interval [CI], 1.32-2.24; P.01). Measures of postbariatric resource utilization were significantly higher in patients of black race than those of white race, including unplanned reoperations (1.3% versus 1.0%, respectively; OR, 1.28; 95% CI, 1.07-1.52; P = .01), unplanned readmissions (4.5% versus 3.0%, respectively; OR, 1.53; 95% CI, 1.38-1.69; P.01), unplanned interventions (1.6% versus 1.2%, respectively; OR, 1.36; 95% CI, 1.16-1.60; P.01), and extended hospital lengths of stay (51.2% versus 42.7%, respectively; OR, 1.41; 95% CI, 1.36-1.46; P.01).Even among relatively healthy patients, race appears to be an important determinant of postbariatric surgery complications and resource utilization. Research and interventions aimed at narrowing the racial disparities in bariatric surgery outcomes may need to broaden the focus beyond the racial variation in the preoperative co-morbidity burden.

Prolonged postoperative mechanical ventilation (PPMV) increases length of stay, hospitalization costs, and postoperative complications. Independent risk factors associated with PPMV are not well-known for children.We identified children (18 years) in the ACS NSQIP-P database who underwent a general surgical abdominal operation. We excluded children with preoperative ventilator dependence and mortality within 48 h of surgery. PPMV was defined as cumulative postoperative mechanical ventilation exceeding 72 h. A multivariable logistic regression model identified independent predictors of PPMV.We identified 108,392 children who underwent a general surgical abdominal operation in the ACS NSQIP-P database from 2012 to 2017. We randomly divided the population into a derivation cohort of 75,874(70%) and a validation cohort of 32,518(30%). In the derivation cohort, we identified PPMV in 1,643(2.2%). In the multivariable model, the strongest independent predictor of PPMV was neonatal age (OR:20.66; 95%CI:16.44-25.97). Other independent risk factors for PPMV were preoperative inotropic support (OR:10.56; 95%CI:7.56-14.77), an operative time longer than 150 min (OR:4.30; 95%CI:3.72-4.52), and an American Society of Anesthesiologists classification3 (OR:12.16; 95%CI:10.75-13.75).Independent preoperative risk factors for PPMV in children undergoing a general surgical operation were neonatal age, preoperative ionotropic support, duration of operation, and ASA classification3.

Racial disparities in health care have been extensively documented. Although race is a recognized determinant of the incidence and outcome of disease, few studies have examined the role of race in the delivery of pediatric perianesthesia care. Whereas racial differences in health outcomes may not be easy to modify, disparities in health care delivery are modifiable. The authors examined literature to determine whether racial disparities exist in the delivery of pediatric anesthesia. They explored putative contributors to disparities at the provider, patient, and systems level and propose ideas to address potential causes of disparities in the practice of pediatric anesthesia.

Recent data among pediatric otolaryngology patients showed unexplained higher rates of serious perioperative respiratory adverse events (PRAE) in black children compared to their white peers. We evaluated whether preoperative respiratory comorbidity (PRC) burden contributes to racial disparity in serious PRAE in children undergoing non-otolaryngologic procedures.Rates of serious PRAE (laryngospasm and/or bronchospasm) were compared across racial groups in a retrospective cohort of black and white children (N = 18538; black 10%) who underwent various elective, non-otolaryngologic procedures between 2007 and 2014 at a US tertiary Children's hospital. Self-reported race was the primary exposure while age, gender, recent upper respiratory tract infection, use of endotracheal intubation, PRC burden and an interaction term between PRC and race were covariates.Serious PRAE occurred in 9.6% of black children and 6.6% of white children. Although there was no significant difference in age between the groups, being black (odds ratio (OR) 1.70; 95% confidence interval (CI) 1.11-2.62) was independently associated with serious PRAE. Similarly, baseline PRC was independently linked (p 0.001) with serious PRAE. Notably, there was no significant (p = 0.454) interactions between race and PRC and serious PRAE in our subjects.Race and PRC are important considerations in the risk of serious PRAE and black children are especially at risk compared to their white peers. Children, with PRC (particularly those with SDB and asthma) are also at risk suggesting that due consideration should be given to these factors in the perioperative care of children undergoing elective surgical procedures. Mechanisms underlying these associations deserve further evaluation.

With increasing improvement in perioperative care, post-surgical complication and mortality rates have continued to decline in the United States. Nonetheless, not all racial groups have benefitted equally from this transformative improvement in postoperative outcomes. We tested the hypothesis that among a cohort of "sick" (ASA physical status 4 or 5) Black and White children, there would be no systematic difference in the incidence of postoperative morbidity and mortality.Retrospective cohort study.Institutions participating in the National Surgical Quality Improvement Program-Pediatric (2012-2019).Black and White children who underwent inpatient operations and were assigned ASA physical status 4 or 5.risk adjusted odds ratios for 30-day postoperative mortality and complications using multivariable logistic regression models, controlling for various baseline covariates.There were 16,097 children included in the analytic cohort (77.0% White and 23.0% Black). After adjusting for baseline covariates, Black children were estimated to be 20% more likely than their White counterparts to die within 30 days after surgery (9.3% vs. 7.2%, adjusted-OR: 1.20, 95% CI: 1.05-1.38, P = 0.007). Black children were also more likely to develop pulmonary complications compared to their White peers (52.1% vs. 44.6%, adjusted-OR: 1.13, 95%CI: 1.04, 1.23, P = 0.005). Being Black also conferred an estimated 28% relative greater odds of developing cardiovascular complications (4.6% vs. 3.3%, 95%CI: 1.06, 1.54, P = 0.010). Finally, being Black conferred an estimated 33% relative greater odds of requiring an extended LOS compared to Whites (50.7% vs. 38.7%, adjusted-OR: 1.33, 95% CI: 1.22-1.46, P 0.001).In this cohort of children with high ASA physical status, Black children compared to their White peers experienced significantly higher rates of 30-day postoperative morbidity and mortality. These findings suggest that racial differences in postoperative outcomes among the sickest pediatric surgical patients may not be entirely explained by preoperative health status.

Purpose Open temporomandibular joint (TMJ) arthroplasty with discectomy has been described as a primary surgical treatment and as a secondary treatment when minimally invasive procedures have failed. The aim of the present study was to compare TMJ discectomy with a fat graft versus TMJ discectomy with a temporalis graft using the pain score and maximal interincisal opening (MIO). Patients and Methods We performed a retrospective study of patients who had undergone TMJ arthroplasty and discectomy with an abdominal fat graft or an interpositional temporalis flap at the University of Michigan from 1999 to 2014. The predictor variable was the type of surgical intervention. The main outcome variables were the pain score and MIO. Additional outcome variables were diet, medication use, the presence of myofascial pain, and occlusal outcomes. The statistical analysis included the mean ± standard deviation, a 1-way analysis of variance for continuous data, and Pearson's χ2 test for categorical variables. Results The study cohort included 50 patients, of whom 30 had undergone discectomy with a fat graft and 20 had undergone discectomy with a temporalis myofascial graft. The mean pain scores were decreased by 78.3% in the myofascial flap group and 52.8% in the fat graft group. Changes in MIO showed a statistically significant increase in the fat graft group but only approached statistical significance in the myofascial flap group. Conclusions The patients who had undergone TMJ arthroplasty and discectomy with a temporalis myofascial flap showed significantly greater improvement in pain scores and marginal improvement in the MIO compared with patients who had received an abdominal fat graft.

Sleep disordered breathing (SDB) symptoms are associated with increased rates of opioid-induced respiratory depression as well as enhanced nociception. Consequently, practitioners often withhold or administer lower intraoperative doses of opioids out of concern for postoperative respiratory depression. Therefore, SDB may be a critical determinant of analgesic requirement in the post-anesthesia care unit (PACU). We investigated whether preoperative SDB classification was independently associated with need for PACU analgesic intervention in a cross-sectional sample of 985 children who underwent elective, painful ambulatory surgical procedures.Using prospectively collected data, children aged 4-17yr were grouped into two categories based on whether or not they had symptoms of SDB. Perioperative variables were compared between the exposed and control groups using Chi-squared test for categorical or t-test for continuous variables. Logistic regression analysis was used to assess the association between SDB and the odds of requiring PACU IV opioids.Children with preoperative SDB symptoms (N = 325) compared with the reference group of children who did not have these symptoms had higher rates of PACU analgesic intervention (47.1% vs. 37.4%; p = 0.004) and higher mean arousal pain scores (3.7 ± 3.5 vs.1.9 ± 2.9; p 0.001). In our primary multivariable logistic regression model adjusted for a number of variables, preoperative SDB symptoms was associated with a two-fold increased odds of receiving PACU intravenous opioid (OR = 2.01, 95%CI, 1.29-3.12; p = 0.002).These results suggest that preoperative SDB symptoms in children undergoing ambulatory surgery, exerts a significant influence on PACU pain behavior and analgesic requirement. Mechanisms underlying this enhanced pain experience deserve further elucidation.

Background Postoperative pneumonia is a serious complication because it may be associated with morbidity, mortality and substantially increased cost of surgical care. Risk of postoperative pneumonia varies across surgical specialties, although its incidence and risk factors in pediatric otolaryngology have not been comprehensively elucidated. Objective To identify factors associated with postoperative pneumonia and determine whether a subset of children with a disproportionate risk of pneumonia can be identified. Methods Using the National Surgical Quality Improvement- Pediatric (NSQIP-P) database, we first selected children (N = 17,776; age under 18 years) who underwent inpatient pediatric otolaryngology procedures between 2012 and 2017. Using a random subset of 80% of the study population (derivation cohort), we next developed a multivariable logistic regression model to identify independent risk factors for postoperative pneumonia. We then divided children into risk groups and evaluated whether the Pareto principle applied to distribution of postoperative pneumonia across the risk groups. Results Among the 12,443 children in the derivation cohort, 177 (1.4%) developed postoperative pneumonia. A multivariable risk model identified patients who developed postoperative pneumonia with good accuracy in both the derivation and validation cohorts. Stratification of patients into five mutually exclusive risk groups showed that 71% of postoperative pneumonia occurred in the highest risk group representing 20% the study cohort. Children who developed postoperative pneumonia were 18 times more likely to require an extended hospital length of stay (OR: 18.6; 95%CI: 12.3–28.2), and 7 times more likely to die compared to children without pneumonia (OR: 7.40, 95%CI: 3.53–15.48). Conclusions We identified key preoperative risk factors for postoperative pneumonia in children undergoing otolaryngology surgery. A small proportion (20%) of high-risk patients accounted for a large proportion (71%) of postoperative pneumonia indicating an underlying Pareto distribution and underscoring the need for targeted interventions for this “vital few”. Postoperative pneumonia in pediatric otolaryngology surgical inpatients was associated with longer hospital stay and a higher risk of mortality. Clinical trial number and registry Not applicable.

This study evaluated whether an objective tool would provide a more reliable and valid assessment of perioperative risk compared with the ASA-physical status (ASA-PS) in children.A system-based risk assessment tool was developed using these categories: Neurological, Airway, Respiratory, Cardiovascular, and Other (NARCO) with a subcomponent grading surgical severity (SS). Anaesthesiologists reviewed the preoperative assessments and assigned NARCO, SS, and ASA-PS scores independently. Perioperative outcomes were recorded by trained observers. Validity and reliability of the tools were evaluated.NARCO correlated with ASA-PS (ρ=0.664; P0.01) supporting its criterion validity. Inter-rater reliability of the measures was supported (intraclass correlation coefficients 0.71-0.96; κ 0.43-0.87) except for the Airway category. Measures of exact agreement were slightly better for NARCO compared with ASA-PS. NARCO, SS, and ASA-PS scores correlated significantly with perioperative escalation of care, adverse events (AE), hospital length of stay, and admission status. Correlations between NARCO and ASA-PS and outcomes improved when SS was factored into their coding. There were significant, but low, correlations between all measures and mortality. The odds of having escalation of care, AE, and mortality were 5-47 times greater among children with higher risk scores.Findings suggest that all measures of outcome have acceptable to excellent reliability with a slight improvement in agreement for the NARCO compared with the ASA-PS. This study supports the validity of both the NARCO and the ASA-PS in predicting perioperative risk in children with a slight improvement in correlations when combined with the SS score.

Background This prospective, non-randomised study examined the frequency and severity of post dural puncture headache in 96 Ghanaian women who consented to spinal anaesthesia for caesarean section at the Korle Bu Teaching Hospital, Accra, Ghana. Method Spinal anaesthesia was performed using 22-gauge ( n =22), 25-gauge ( n =46) or 26-gauge ( n =38) Quincke needles. Patients were followed up to determine the incidence and severity of post spinal headache. Result The overall incidence of post dural puncture headache was 8.3%, but was significantly higher (33%) in patients in whom 22-gauge Quincke needles were used than in the other two groups (4% and 5% respectively: P =0.003). Most patients rated their headache as mild to moderate on a 10-cm visual analogue scale. Conclusions In view of the high incidence of headache and the need for treatment associated with the use of the 22-gauge Quincke needle, we recommend that this should not be used in the obstetric population. We are also aware that the incidence of post dural puncture headache could be further reduced by the use of small calibre pencil-point needles but these are currently very expensive and many obstetric units in developing countries may not be able to afford them.