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BACKGROUND Pneumonia is a common lower respiratory tract infection (LRI) and the leading cause of pediatric hospitalization in the United States. Given its frequency, children with pneumonia may require surgery during their hospital course. This poses serious anesthetic and surgical challenges because preoperative pulmonary status is among the most important risk factors for postoperative complications. Although recent adult data indicated that preoperative pneumonia was associated with poor surgical outcomes, comparable data in children are lacking. Therefore, our objective was to investigate the association of preoperative pneumonia with postoperative mortality and morbidity in children. METHODS Using the National Surgical Quality Improvement Program database, we assembled a retrospective cohort of children (

Background The critical question of racial and gender diversity in pediatric anesthesia training programs has not been previously explored. The primary objective of this study was to evaluate trends by race/ethnicity and gender in pediatric anesthesiology fellowship training programs in the United States for the years 2000 to 2018. Methods Demographic data on pediatric anesthesiology fellows and anesthesiology residents were obtained from the self-reported data collected for the Journal of the American Medical Association's annual report on Graduate Medical Education for the years 2000 to 2018. Diversity was assessed by calculating the proportions of trainees per year by gender and racial/ethnic groups in pediatric anesthesiology fellowship and anesthesiology residency programs. Logistic regression equations were developed to estimate the annual growth rate of each racial/ethnic groups. Results The number of pediatric anesthesiology fellows increased from 57 trainees in 2000-2001 to 202 in 2017-2018 at an average rate of 9 fellows per year (95% confidence interval [CI], 8-10). These increases were primarily due to white trainees (54.4%-63.4%) as the proportions of black (7.0%-4.5%), Asian (26.3%-21.3%), and other minority (12.3%-10.9%) trainees have remained low. The number of anesthesiology residents increased from 3950 trainees in 2000-2001 to 5940 in 2017-2018 at an average rate of 99 residents per year (95% CI, 88-111). Within all anesthesiology trainees, these increases were due to white trainees (55.7%-61.3%) as the proportion of black (5.0%-6.0%), Asian (25.8%-24.1%), and other minority trainees (8.2%-8.5%) has remained fairly constant over the time period. Despite the overall lower proportion of female anesthesiology residents (range: 27.0%-37.5%), a steady increase in the number of women in pediatric anesthesiology fellowship programs has reversed the gender imbalance in this population as of 2010. Conclusions While historic gains have been made in gender diversity in pediatric anesthesiology, there is persistent underrepresentation of black and Hispanic trainees in pediatric anesthesiology. It appears that their low numbers in anesthesiology residency programs (the reservoir) may be partly responsible. Efforts to increase ethnic/racial diversity in pediatric anesthesiology fellowship and anesthesiology residency training programs are urgently needed.

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.

BACKGROUND Approximately one-third of all pediatric hospital charges are attributable to the care for children living with neurologic comorbidities. These children often require various surgical procedures and may have an elevated risk of lower respiratory infections because of poor neuromuscular coordination, poor cough, uncoordinated swallowing, and poor oral hygiene. Our objective was to evaluate the risk of pneumonia in children presenting with neurologic comorbidities. METHODS We performed a retrospective study of children ( RESULTS We identified 349 163 children, of whom 2191 developed pneumonia (30-day cumulative incidence: 0.6%). The presence of a preoperative neurologic comorbidity conferred approximately twofold higher risk of postoperative pneumonia (hazard ratio [HR]: 1.91, 95% confidence interval [CI]: 1.73–2.11). We explored the risk of pneumonia conferred by the components of neurologic comorbidity: cerebral palsy (HR: 3.92, 95% CI: 3.38–4.56), seizure disorder (HR: 2.93, 95% CI: 2.60–3.30), neuromuscular disorder (HR: 2.63, 95% CI: 2.32–2.99). The presence of a neurologic comorbidity was associated with a longer length of hospital stay (incidence rate ratio: 1.26, 95% CI: 1.25–1.28). CONCLUSIONS The risk of postoperative pneumonia was almost twofold higher in children with neurologic comorbidity. The magnitude of these associations underscores the need to identify areas of research and preventive strategies to reduce the excess risk of pneumonia in children with preoperative neurologic conditions.

BACKGROUND Despite unparalleled advances in perioperative medicine, surgical outcomes remain poor for racial minority patients relative to their white counterparts. Little is known about the excess costs to the health care system related to these disparities. METHODS We performed a retrospective analysis of data from the Nationwide Inpatient Sample between 2001 and 2018. We included children younger than 18 years admitted with appendicitis who underwent an appendectomy during their hospital stay. We examined the inflation-adjusted hospital costs attributable to the racial disparities in surgical complications and perforation status, focusing on differences between non-Hispanic white patients and non-Hispanic Black patients. RESULTS We included 100 639 children who underwent appendectomy, of whom 89.9% were non-Hispanic white and 10.1% were non-Hispanic Black. Irrespective of perforation status at presentation, surgical complications were consistently higher for Black compared with white children, with no evidence of narrowing of the racial disparity gap over time. Black children consistently incurred higher hospital costs (median difference: $629 [95% confidence interval: $500–$758; P < .01). The total inflation-adjusted hospital costs for Black children were $518 658 984, and $59 372 044 (11.41%) represented the excess because of the racial disparities in perforation rates. CONCLUSIONS Although all patients had a progressive decline in post appendectomy complications, Black children consistently had higher rates of complications and perforation, imposing a significant economic burden. We provide an empirical economic argument for sustained efforts to reduce racial disparities in pediatric surgical outcomes, notwithstanding that eliminating these disparities is simply the right thing to do.

Many children recovering from anesthesia experience pain that is severe enough to warrant intravenous (IV) opioid treatment within moments of admission to the postanesthesia care unit (PACU). Postoperative pain has several negative consequences; therefore, preventing significant PACU pain in children is both a major clinical goal and a moral/ethical imperative. This requires identifying patient-level and perioperative factors that may be used to predict PACU IV opioid requirement. This should allow for the development of personalized care protocols to prevent clinically significant PACU pain in children. Our objective was to develop prediction models enabling practitioners to identify children at risk for PACU IV opioid requirement after various painful ambulatory surgical procedures.After Institutional Review Board approval, clinical, demographic, and anthropometric data were prospectively collected on 1256 children 4-17 years of age scheduled for painful ambulatory surgery (defined as intraoperative administration of analgesia or local anesthetic infiltration). Three multivariable logistic regression models to determine possible predictors of PACU IV opioid requirement were constructed based on (1) preoperative history; (2) history + intraoperative variables; and (3) history + intraoperative variables + PACU variables. Candidate predictors were chosen from readily obtainable parameters routinely collected during the surgical visit. Predictive performance of each model was assessed by calculating the area under the respective receiver operating characteristic curves.Overall, 29.5% of patients required a PACU IV opioid, while total PACU analgesia requirement (oral or IV) was 41.1%. Independent predictors using history alone were female sex, decreasing age, surgical history, and non-Caucasian ethnicity (model area under the receiver operating characteristic curve [AUROC], 0.59 [95% confidence interval {CI}, 0.55-0.63]). Adding a few intraoperative variables improved the discriminant ability of the model (AUROC for the history + intraoperative variables model, 0.71 [95% CI, 0.67-0.74]). Addition of first-documented PACU pain score produced a substantially improved model (AUROC, 0.85 [95% CI, 0.82-0.87]).Postoperative pain requiring PACU IV opioid in children may be determined using a small set of easily obtainable perioperative variables. Our models require validation in other settings to determine their clinical usefulness.

To examine whether there are racial and ethnic differences in postoperative complications after nonobstetric surgery during pregnancy in the United States.We conducted a secondary analysis of the prospective ACS NSQIP (American College of Surgeons National Surgical Quality Improvement) program from 2005 to 2012. We assessed pregnant women 18-50 years without prior surgery in the preceding 30 days who underwent a nonobstetric surgery. Race and ethnicity were categorized as non-Hispanic Black, Hispanic, and non-Hispanic White (reference). The primary outcome was a composite of 30-day major postoperative complications inclusive of cardiovascular, pulmonary, and infectious complications, reoperation, unplanned readmission, blood transfusion, and death. We used modified Poisson regression to estimate the relative risk of complications.Among 3,093 pregnant women, 18% were non-Hispanic Black, 20% Hispanic, and 62% non-Hispanic White. The most common surgeries were appendectomy (36%) and cholecystectomy (19%). Black women (18%) were more likely to be assigned American Society of Anesthesiologists (ASA) physical status class III or higher than their White (12%) or Hispanic (9%) peers. Non-Hispanic Black pregnant women had a higher risk of 30-day major postoperative complications compared with their White peers (9% vs 6%; adjusted relative risk [aRR] 1.41, 95% CI 1.11-1.99). This difference persisted when limiting the analysis to apparently healthy women (ASA class I or II) (7% vs 4%; aRR 1.64, 95% CI 1.08-2.50), those who underwent appendectomy (10% vs 3%; aRR 2.36, 95% CI 1.13-4.96), and when appendectomy and cholecystectomy were performed by laparoscopy (7% vs 3%; aRR 2.62, 95% CI 1.22-5.58). Hispanic pregnant women were not at an increased risk of complications compared with non-Hispanic pregnant White women.Pregnant non-Hispanic Black women were at higher risk of major postoperative complications after nonobstetric surgery compared with their White counterparts.

Background We sought to investigate the risk of pediatric surgical mortality associated with the combined effects of key preoperative comorbidities and race. Methods We performed a retrospective study that included infants who underwent inpatient surgical procedures between 2012 and 2017 and were entered into the NSQIP-P registry. We assessed additive moderation by estimating the proportion of mortality risk attributable to the combined effects of race and the presence of a preoperative comorbidity (attributable proportion [AP]). Results The study group was comprised of 58466 surgical cases, of whom 15711(26.9%) were neonates and 42755(73.1%) older infants. Among neonates, a history of prematurity carried a poorer prognosis in black babies than their white peers (OR:1.53, 95%CI:1.20,1.95). Additionally, there was evidence of additive moderation by race on the association between prematurity and postoperative mortality (AP: 23.9%; 95%CI: 3.8,43.9, P value = 0.020). In older infants, presence of preoperative sepsis carried almost two times higher risk of mortality for black patients than their white counterparts (OR:1.81; 95%CI:1.21,2.73). This explained 38.4% of mortality cases in black patients with preoperative sepsis (95%CI:14.0,62.7; P = 0.002). A history of prematurity also carried a greater risk of mortality in older infants of black race (OR:1.69; 95%CI: 1.27, 2.24), accounting for 24.2% of mortality cases (AP:24.2%; 95%CI:0.90, 47.5, P = 0.041). Conclusions We quantified the surgical burden of mortality resulting from the differential impact of key comorbidities on black neonates and infants. Our data suggest that race-specific interventions to mitigate the incidence of the identified comorbidities could narrow the racial disparities in post surgical mortality.

BACKGROUND: That African American (AA) patients have poorer surgical outcomes compared with their white peers is established. The prevailing presumption is that these disparities operate within the context of a higher preoperative comorbidity burden among AA patients. Whether these racial differences in outcomes exist among apparently healthy children (traditionally expected to have low risk of postsurgical complications) has not been previously investigated. METHODS: We performed a retrospective study by analyzing the National Surgical Quality Improvement Program–Pediatric database from 2012 through 2017 and identifying children who underwent inpatient operations and were assigned American Society of Anesthesiologists physical status 1 or 2. We used univariable and risk-adjusted logistic regression to estimate the odds ratios and their 95% confidence intervals (CIs) of postsurgical outcomes comparing AA to white children. RESULTS: Among 172 549 apparently healthy children, the incidence of 30-day mortality, postoperative complications, and serious adverse events were 0.02%, 13.9%, and 5.7%, respectively. Compared with their white peers, AA children had 3.43 times the odds of dying within 30 days after surgery (odds ratio: 3.43; 95% CI: 1.73–6.79). Compared with being white, AA had 18% relative greater odds of developing postoperative complications (odds ratio: 1.18; 95% CI: 1.13–1.23) and 7% relative higher odds of developing serious adverse events (odds ratio: 1.07; 95% CI: 1.01–1.14). CONCLUSIONS: Even among apparently healthy children, being AA is strongly associated with a higher risk of postoperative complications and mortality. Mechanisms underlying the established racial differences in postoperative outcomes may not be fully explained by the racial variation in preoperative comorbidity.

Compared with term neonates, preterm babies are more likely to die from sepsis. However, the combined effects of sepsis and prematurity on neonatal postoperative mortality are largely unknown. Our objective was to quantify the proportion of neonatal postoperative mortality that is attributable to the synergistic effects of preoperative sepsis and prematurity.We performed a multicentre, propensity-score-weighted, retrospective, cohort study of neonates who underwent inpatient surgery across hospitals participating in the United States National Surgical Quality Improvement Program-Pediatric (2012-2017). We assessed the proportion of the observed hazard ratio of mortality and complications that is attributable to the synergistic effect of prematurity and sepsis by estimating the attributable proportion (AP) and its 95% confidence interval (CI).We identified 19 312 neonates who realised a total of 321 321 person-days of postsurgical observations, during which 683 died (mortality rate: 2.1 per 1000 person-days). The proportion of mortality risk that is attributable to the synergistic effect of prematurity and sepsis was 50.5% (AP=50.5%; 95% CI, 28.8-72.3%; P0.001). About half of mortality events among preterm neonates with sepsis occurred within 24 h after surgery. Just over 45% of postoperative complications were attributable to the synergistic effect of prematurity and sepsis when both conditions were present (AP=45.8; 95% CI, 13.4-78.1%; P0.001).Approximately half of postsurgical mortality and complications were attributable to the combined effect of sepsis and prematurity among neonates with both exposures. These neonates typically died within a few days after surgery, indicating a very narrow window of opportunity to predict and prevent mortality.Not applicable.

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.

SummaryBackground When pain management has been studied in settings such as pediatric emergency departments, racial disparities have been clearly identified. To our knowledge, this has not been studied in the pediatric perioperative setting. We sought to determine whether there are differences based on race in the administration of analgesia to children suffering from pain in the postanesthesia care unit. Methods This is a prospective, observational, study of 771 children aged 4-17 years who underwent elective outpatient surgery. Racial differences in probability of receiving analgesia for pain in the recovery room were assessed using bivariable and multivariable logistic regression analyses. Results A total of 294 children (38.2%) received at least one class of analgesia (opioid or nonopioid); while 210 (27.2%) received intravenous (i.v.) opioid analgesia in the recovery room. Overall postanesthesia care unit analgesia utilization was similar between white and minority children (white children 36.8% vs minority children 43.4%, OR 1.3; 95% CI=0.92-1.89; P=.134). We found no significant difference by racial/ethnic group in the likelihood of a child receiving i.v. opioid for severe postoperative pain (white children 76.0% vs 85.7%, OR 1.89; 95% CI=0.37-9.67; P=.437). However, minority children were more likely to receive i.v. opioid analgesia than their white peers (white children 24.5% vs minority children 34.2%, OR 1.5; 95% CI=1.04-2.2; P=.03). On multivariable analysis, minority children had a 63% higher adjusted odds of receiving i.v. opioids in the recovery room (OR=1.63; 95% CI, 1.05-2.62; P=.03). Conclusions Receipt of analgesia for acute postoperative pain was not significantly associated with a child's race. Minority children were more likely to receive i.v. opioids for the management of mild pain.

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 Many of the common equations used for body surface area determination were either introduced before the widespread prevalence of childhood obesity, contained very few children in their sample, or have not been assessed in overweight/obese children. Therefore, we compared 6 body surface area formulae to determine their performance across body mass index categories using cross-sectional anthropometric data of children who underwent elective cardiac procedures. METHODS We selected 6 formulae from the literature that included data from pediatric subjects in their derivation. We then substituted measured height and weight into each equation to compute body surface area data for the study subjects. The average values of the 6 formulae were calculated for each patient and used as reference for comparison. Comparisons between each formula and the reference standard were made with the 1-way ANOVA, Pearson correlation coefficient (measure of precision), the Lin concordance correlation coefficient (measure of bias and precision), and the Bland-Altman limit-of-agreement. All comparisons were made across age, sex, and body mass index categories. RESULTS Among the 1000 (mostly Caucasian: 76.1%) subjects, 16.7% were overweight, while 14.1% were obese and 51.2% were girls. All calculated body surface area data showed a strong positive correlation with each other and the derived reference body surface area values (0.99-1.00; P < .001). Calculated body surface area values for all the formulae were significantly higher in overweight and obese children across every age group. CONCLUSIONS Obesity status is a critical factor in the determination of body surface area values in children undergoing elective cardiac procedures. We caution that indexed hemodynamic and other therapeutic interventions may be inappropriate if limitations of body surface area formulae and the effect of obesity are not taken into consideration when caring for overweight and obese children. Body surface area studies utilizing accurate contemporary techniques that include sufficient number of overweight and obese children of various races are urgently needed.

Although noninvasive blood pressure (NIBP) monitoring during anesthesia is a standard of care, reference ranges for blood pressure in anesthetized children are not available. We developed sex- and age-specific reference ranges for NIBP in children during anesthesia and surgery.In this retrospective observational cohort study, we included NIBP data of children with no or mild comorbidity younger than 18 yr old from the Multicenter Perioperative Outcomes Group data set. Sex-specific percentiles of the NIBP values for age were developed and extrapolated into diagrams and reference tables representing the 50th percentile (0 SD), +1 SD, -1 SD, and the upper (+2 SD) and lower reference ranges (-2 SD).In total, 116,362 cases from 10 centers were available for the construction of NIBP age- and sex-specific reference curves. The 0 SD of the mean NIBP during anesthesia varied from 33 mmHg at birth to 67 mmHg at 18 yr. The low cutoff NIBP (2 SD below the 50th percentile) varied from 17 mmHg at birth to 47 mmHg at 18 yr old.This is the first study to present reference ranges for blood pressure in children during anesthesia. These reference ranges based on the variation of values obtained in daily care in children during anesthesia could be used for rapid screening of changes in blood pressure during anesthesia and may provide a consistent reference for future blood pressure-related pediatric anesthesia research.

Summary Introduction High blood pressure (BP) in childhood is associated with left ventricular hypertrophy and abnormal vascular reactivity even in apparently healthy children. This study examined the prevalence of high BP in children undergoing elective noncardiac operations. We also determined the association of preoperative high BP with preincision hypotension (PIH). Methods This was a retrospective cohort study that used clinical and anthropometric data on children aged 3–17 years who underwent elective, noncardiac operations from January 2006 to January 2014. Preoperative blood pressure (BP) was used to stratify children into three categories: normal BP (systolic and diastolic BP below the 90th percentile), prehypertension (systolic and/or diastolic BP ≥90th percentile but

Background Although the risk of hypoxemia is greatest during the first 72 h after surgery, little is known of the incidence of respiratory failure during this period. The authors studied the incidence and predictors of unanticipated early postoperative intubation (within 3 days) and its role in mortality. Methods A total of 222,094 adult patients undergoing nonemergent, noncardiac surgery in the American College of Surgeons-National Surgical Quality Improvement Program database were studied to determine the incidence and independent predictors of unanticipated early postoperative intubation. A risk-class model was developed and subsequently validated in 109,636 patients. Results Overall, 2,828 of 5,725 (49.4%) unanticipated tracheal intubations in a period of 30 days occurred within the first 3 days after surgery. The incidence of unanticipated early postoperative intubation was 0.83-0.9% in the derivation and validation cohorts. Independent predictors of unanticipated early postoperative intubation included current ethanol use, current smoker, dyspnea, chronic obstructive pulmonary disease, diabetes mellitus needing insulin therapy, active congestive heart failure, hypertension requiring medication, abnormal liver function, cancer, prolonged hospitalization, recent weight loss, body mass index less than 18.5 or ≥ 40 kg/m, medium-risk surgery, high-risk surgery, very-high-risk surgery, and sepsis. Unanticipated early postoperative intubation was an independent predictor of 30-day mortality, with an adjusted odds ratio of 9.2. Higher risk classes were associated with increasing incidence of unanticipated early postoperative intubation and death. Conclusions One half of unanticipated tracheal intubations in a period of 30 days occurred within the first 3 days after nonemergent, noncardiac surgery and were independently associated with a 9-fold increase in mortality. The authors present a validated perioperative risk class index for determining risk of unanticipated early postoperative intubation.

OBJECTIVE: The purpose of this investigation was to examine the association of neck circumference (NC) with perioperative respiratory adverse events in children undergoing elective noncardiac surgery, a relationship that has not been previously characterized. METHODS: Using a prospective, observational design, we studied children aged 6 to 18 years undergoing elective noncardiac surgeries at our institution. Trained research assistants collected clinical (including perioperative adverse events) and anthropometric data from all subjects. Patients were stratified into 2 classes: high NC versus low NC on the basis of age- and gender-specific receiver operating characteristic curve analysis. Subsequently, univariate factors associated with high NC were explored, and odds ratios for the occurrence of perioperative adverse events were then calculated from logistic regression after controlling for clinically relevant cofactors. RESULTS: Among the 1102 patients, the prevalence of high NC was 24.3%. NC was positively correlated with age and other anthropometric parameters. Children with high NC were more likely to be loud snorers and have a history of bronchial asthma, hypertension, and type 2 diabetes. Composite adverse airway events were more frequent in children with a large NC. There was no significant association between high NC and difficult laryngoscopy in our study population. CONCLUSIONS: NC was positively correlated with other indices of obesity in children, and large NC (indicative of central obesity) was associated with some adverse respiratory events in these children undergoing noncardiac surgery. NC could be a useful clinical screening tool for the occurrence of perioperative adverse respiratory events in children.

INTRODUCTION childhood obesity is a risk factor for many perioperative complications. Hypotension is a well described complication of general anaesthesia in both adults and children. This observational study compared the incidence of preincision hypotension (PIH) between children with high BMI and lean controls. METHODS children aged 2-17 years undergoing noncardiac procedures were classified into high or normal BMI groups. The incidence of PIH was then compared between the two groups using SBP data abstracted from our electronic anaesthesia monitoring system. Binary logistic regression was used to examine factors associated with the likelihood of PIH. RESULTS the study population was 19 400 children (54% boys) with a mean (SD) age of 8.3 ± 4.7 years and BMI of 19.3 ± 5.7 kg m(-2). Most (94.7%) of the patients were elective American Society of Anesthesiology I-II (79.7%) procedures. Single episode of PIH occurred in 36.8% of patients, whereas 8.3% had at least three episodes of PIH. PIH was more frequent in children with high BMI than their lean peers (40.9 vs. 31.4%, P < 0.001). Independent predictors of PIH were high BMI, high American Society of Anesthesiology status, propofol coinduction, baseline hypotension, age and preincision duration. CONCLUSION these results imply that children with high BMI have a higher incidence of hypotension than their lean peers following induction of anaesthesia for noncardiac procedures.

OBJECTIVES: Overweight in children is most commonly described by using BMI. Because BMI does not adequately describe regional (central) adiposity, other indices of body fatness are being explored. Neck circumference (NC) is positively associated with obstructive sleep apnea, diabetes, and hypertension in adults. NC also has positive correlation with BMI in adults. The possible role of NC in screening for high BMI in children is not well characterized. The aims of this investigation were to examine the correlation between BMI and NC in children and to determine the best NC cutoff that identifies children with high BMI. METHODS: Children who were aged 6 to 18 years and undergoing elective noncardiac surgeries were the subjects of this study. Trained research assistants collected clinical and anthropometric data from all patients. We calculated Pearson correlation coefficients between NC and other indices of obesity. We then determined by receiver operating characteristic analyses the optimal NC cutoff for identifying children with high BMI. RESULTS: Among 1102 children, 52% were male. NC was significantly correlated with age, BMI, and waist circumference in both boys and girls, although the correlation was stronger in older children. Optimal NC cutoff indicative of high BMI in boys ranged from 28.5 to 39.0 cm. Corresponding values in girls ranged from 27.0 to 34.6 cm. CONCLUSIONS: NC is significantly correlated with indices of adiposity and can reliably identify children with high BMI. NC is a simple technique that has good interrater reliability and could be used to screen for overweight and obesity in children.

Summary Introduction: Intravenous (i.v.) access is sometimes a difficult, time-consuming, and highly frustrating procedure. Obesity is widely believed to be associated with difficult peripheral intravenous access (PIV) placement. This study examined the relationship between body mass index (BMI) and ease of venous access in children undergoing noncardiac surgical procedures. Methods: We prospectively collected data on children aged 2–18 years undergoing elective noncardiac surgery at our institution. A trained research assistant (RA) was present for PIV placement in all patients and noted the following: age, gender, ethnicity, weight, height, and BMI. We also collected data on i.v. insertion site, number of attempts, number of operators, and the number of i.v. cannula used. The main outcome variable was success or failure of i.v. placement on first attempt. Sample size calculation indicated a need for 40 obese and 40 control patients. Results: A total of 103 (56 lean and 47 obese) patients comprised the study population. PIV cannulation was achieved on the first attempt in 55.2% while 39.6% of patients had 2–3 attempts before successful cannulation. Obese children were more likely to have failed attempt at first cannulation than lean controls (P

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.

BACKGROUND Many of the common equations for weight estimation in children were either introduced before the widespread prevalence of childhood obesity or have not been assessed in overweight/obese children. Therefore, we assessed the accuracy of 3 common age-based weight estimation formulae (Advanced Pediatric Life Support, Luscombe, and Theron) for predicting the weight of children undergoing elective, noncardiac operations. We also developed and validated a new age-based weight estimation formula. METHODS We used preoperative anthropometric and clinical data on 13,933 children aged 2 to 12 years to evaluate the performance of 3 pediatric age-based weight estimation formulae. Ability of the formulae to predict measured weights was assessed in a derivation cohort (75% randomly selected from the study sample). We also developed and validated a new age-based formula (the Michigan formula) that could be used to estimate the weight of contemporary American children. RESULTS Among the 10,488 children in the derivation cohort, 31.8% were overweight or obese while 55.7% were boys. The accuracy of the formulae varied considerably. The Luscombe formula demonstrated the lowest mean bias of 3.4 kg (95% confidence interval, 3.2-3.5 kg) and 89.7% of estimates within 10% of measured weight. Our derived linear regression equation the "Michigan Formula" demonstrated the highest accuracy compared with the existing formulae with a bias of 4.6 kg (95% confidence interval, = 4.36-4.84 kg) and 92% of estimates within 10% of measured weights. CONCLUSIONS Accuracies of current weight estimation formulae varied greatly. Our derived equation (Michigan formula: weight (kg) = 3 x age (yr) + 10) demonstrated high accuracy when compared with existing formulae and may be more applicable for estimating the weight of contemporary American children.

SummaryIntroduction: Pediatric obesity is a major health concern in the United Statesand as many as 34% of those who require general anesthesia are overweightor obese (OW). The lack of data and recommendations for dosing medica-tions in obese children leaves significant gaps in the understanding of correctdosing in the clinical setting.Objective: To determine whether OW children were more likely to receivedoses of medications outside the recommended range.Methods: Following IRB approval, patient medical records were queried toidentify children 2 through 17 years who underwent noncardiac surgeries andreceived at least one medication of interest. Children with hepatic disease,renal disease, neurological impairment, sleep-disordered breathing, or missingheight or weight measurements were excluded. Children were stratified intoweight categories based on age and gender percentiles as per CDC guidelines.Those ≥85th percentile were classified as overweight/obese. Ideal and leanweight (for age, gender) were calculated. Drug doses were stratified as under-dosed (>10% below minimum recommended dose), overdosed (>10% abovemaximum recommended dose), or within recommended dose (dose 10%).Actual doses were compared to recommended doses as per actual, ideal, orlean weight (as recommended for specific drugs) in the overweight/obesegroups vs the control weight (CW) group.Results: Ten thousand five hundred and nine doses were reviewed. Over-weight/obese children were more likely to receive doses outside the recom-mended dose range than the CW group.Conclusions: Overweight/obese children were more likely to receive doses ofcommon anesthetic medications outside the recommended doses potentiallyadding risk of adverse outcomes in these children.IntroductionPediatric obesity is a major public health concern in theUnited States (1), with up to 34% of school-age childrenand adolescents being overweight [body mass index(BMI) ≥85th percentile] or obese (BMI ≥95th percen-tile). Indeed, childhood obesity prevalence has increasedup to threefold over the last three decades (1,2). RecentCenters for Disease Control and Prevention (CDC) data(2010) suggest that a slight decrease in obesity and mor-bid obesity in poor, preschool, nonnative American orAlaskan populations have decreased slightly during theprevious 7 years (3). However, obesity continues to be atroubling attribute of America’s young people. Further-more, more than 30% of pediatric patients presentingfor surgery in one large pediatric setting were foundto be overweight or obese (OW) (4). These trends sug-gest a need to address specific healthcare needs of this

Childhood high body mass index (BMI) and sleep disordered breathing (SDB) are increasingly prevalent and both are associated with perioperative respiratory complications. Laryngospasm is one of the more serious respiratory complications with potentially devastating consequences. It is presently unclear whether high BMI and incident SDB in children significantly amplifies the risks of perioperative laryngospasm. This study examined the hypothesis that compared to controls; children with high BMI and SDB at the time of surgery have higher rates of perioperative laryngospasm.Children (6-18 yr) who underwent elective, non-cardiac operations at a tertiary care center were the subjects of this cross-sectional study. Rates of perioperative laryngospasm were compared between normal controls and children who were overweight/obese and had clinical history of SDB at the time of surgery. Stepwise logistic regression analysis was performed to identify independent predictors of perioperative laryngospasm (dependent variable) using high BMI/SDB as the primary predictor variable.Among 642 children, those who were overweight/obese and had incident SDB (N = 197) were younger, and had higher indexes of central adiposity. Children with high BMI and SDB had 3.8 times higher unadjusted odds of developing intraoperative laryngospasm (OR = 3.8; 95% CI = 2.1-6.9, p0.001). After adjusting for several relevant covariates, the following factors were found to be independent predictors of perioperative laryngospasm: high BMI + SDB, male sex and increasing neck circumference.High BMI and incident SDB in children is associated with increased rates of perioperative laryngospasm. The mechanism(s) underlying this propensity to laryngospasm deserve further elucidation.

High blood pressure (BP) and overweight/obesity are increasingly prevalent in children. We examined the associations of excess weight indicators including neck circumference (NC) and body mass index (BMI) with high BP in children. We hypothesized that high NC is associated with elevated BP. We utilized cross-sectional anthropometric and BP data on 1058 children aged 6-18 years. Patients were classified into weight and NC categories according to published guidelines. Prehypertension was defined as systolic or diastolic BP levels between 90th and 95th percentile for gender, age and height. Hypertension signifies systolic and/or diastolic BP levels ≥ 95th percentile for age, gender and height. The prevalence of elevated BP was 29.2% (prehypertension=10.1%, hypertension=19.1%). The prevalence of overweight and obesity was 19.0 and 18.7%, respectively. Rates of wide NC increased progressively with BMI categories by 8.8, 29.4 and 68.7% among normal weight, overweight and obese children, respectively. Within each BMI category, the unadjusted odds ratio for elevated BP was significantly higher in children with wide NC than those with normal NC (normal weight OR=1.78 (1.0-3.1), P=0.04); overweight OR=2.74 (1.5-5.2), P=0.001); obese OR=2.44 (1.3-4.6), P=0.006)). Increasing NC and BMI are associated with elevated BP in children. Joint presence of wide NC and high BMI is associated with significantly high rates of elevated BP. NC measurement may be a helpful tool to detect the presence of elevated BP in children.

The purpose of this investigation was to determine whether there is an association between high body mass index (BMI) in children and the occurrence of early post-tonsillectomy pain (PTP). The hypothesis tested was that high BMI is associated with increased severity of early PTP.We extracted data on all children aged 3-17 years that underwent adeno-tonsillectomy (TA) over a 2-year period from our anesthesia clinical information system. Patients were classified into normal or high BMI group and early PTP scores were compared between the groups. Clinically significant (moderate-severe) early PTP was defined as pain score ≥ 4 within the first 15 min of admission to the post-anesthesia care unit (PACU).Among 462 patients, 35.1% were overweight or obese. The overall incidence of moderate to severe early PTP was 23.6%. All the patients received at least one or more intraoperative opioid (morphine 94.2% and fentanyl 21.9%). Compared to those in the normal BMI group, children with moderate-severe PTP were older, female and more likely to be overweight or obese. Children with high BMI had significantly higher unadjusted odds of having moderate-severe early post-tonsillectomy pain (48.9% vs. 14.1%, OR=7.01, 95% CI=3.9-12.8, p0.001). After controlling for several clinically relevant covariates, high BMI was the most consistent risk factor for moderate to severe early PTP in this cohort of children.These results indicate that high BMI in children is associated with increased early PTP. The mechanism(s) underlying this association deserve further elucidation.

Obesity is disproportionately prevalent among minority patients, yet very little has been written about its effect on surgical outcome in this group.We investigated the association of body mass index (BMI) category with perioperative complications and resource utilization.Data from the American College of Surgeons National Surgical Quality improvement Program Participant Use Data File was used to calculate the BMI (kg/m2) of all minority patients undergoing inpatient surgery from 2005 to 2008. Patients were stratified into 4 BMI classes, ranging from normal weight to severely obese. Postoperative length of stay (LOS) was used as the main proxy for resource utilization. Stepwise logistic regression was used to calculate odds ratios for prolonged LOS after controlling for clinically relevant cofactors.Among 73978 patients, 28% were in the normal BMI category, 28.9% were overweight, 28.2% were obese, and 14.9% were severely obese. Morbidity and mortality distribution varied significantly by BMI category, with the highest proportion of cases occurring in the normal-BMI group and the lowest in the severely obese patients. Postoperative LOS was longer for patients in the normal-BMI group than for severely obese patients. Other markers of resource utilization also followed the same pattern with progressive decrease from normal-BMI patients to the severely obese group.Postoperative morbidity and mortality and markers of hospital resource consumption were highest in the normal-BMI patients and decreased progressively to the severely obese group. This group appears to enjoy a paradoxical protection from perioperative complications and so utilize fewer hospital resources.

OBJECTIVE: The purpose of this investigation was to examine the association of body mass index (BMI) category with short-term outcomes in minority surgical patients—a relationship that previously has not been well characterized. METHODS: Data from the National Surgical Quality Improvement Program were used to calculate the BMI of minority patients undergoing surgery from 2005 to 2008. Patients were stratified into 5 BMI classes. Stepwise logistic regression was used to calculate odds ratios for mortality after controlling for known clinically relevant covariates. MAIN OUTCOME MEASURES: Morbidity and mortality at 30 days, across all 5 BMI classes. RESULTS: Among 119,619 minority patients studied, 50% were African American, 36% Hispanic, 10% Asian and Pacific Islanders, and 4% American Indian and Alaskan natives. Seventy percent were overweight or obese. Women were more likely to be obese or severely obese. The overall mortality rate was 1.5%, and this varied significantly by BMI class. Distribution of 30-day mortality demonstrated a progressive decrease, with the highest risk of death in the underweight class, and the lowest risk of death in the severely obese class. This relationship was maintained, even in patients with at least 1 major postoperative complication. CONCLUSION: The prevalence of being overweight or obese was high in this nationally representative cohort of minority surgical patients. Although BMI class is a significant predictor of 30-day mortality, the effect appeared paradoxical. The poorest outcomes were in the underweight and normal BMI patients. Severely obese patients had the lowest risk of mortality, even after experiencing a major postoperative complication. Journal of Hospital Medicine 2012; © 2011 Society of Hospital Medicine.

Objective: Unplanned post-operative intubation (UPI) may be associated with significant morbidity and/or mortality after surgery. The purpose of this investigation was to determine the incidence and predictors of UPI in elderly patients who underwent general and vascular surgical procedures. Methods: Data from the American College of Surgeons National Surgical Quality Improvement Program Participant Use Data File was used to calculate the incidence of UPI in all elderly vascular and general surgery patients undergoing operations from 2005 to 2008. UPI was defined as a requirement for the placement of an endotracheal tube and mechanical or assisted ventilation because of the onset of respiratory or cardiac failure manifested by severe respiratory distress, hypoxia, hypercarbia or respiratory acidosis within 30 days of the index operation. Univariate factors associated with UPI were identified. Multivariate stepwise logistic regression was used to calculate odds ratios (ORs) for UPI after controlling for known clinically relevant cofactors. Main outcome measures: Incidence of UPI as well as morbidity and mortality associated with UPI. Results: Among 115 692 patients, 3.3% required UPI. Univariate predictors of UPI were older age group, chronic obstructive pulmonary disease, low pre-operative functional status as well as emergency operation. UPI was associated with an 18-fold increased risk of death as well as significantly increased hospital length of stay. Multivariate analysis identified several predictors of UPI with re-operation having the greatest odds for UPI (OR = 4.5; 95% confidence interval = 4.29-4.86, P < 0.001). Conclusion: Although the incidence of UPI in this elderly surgical cohort was low, it was associated with significant morbidity and mortality as well as prolonged hospital length of stay, underscoring the need for accurately identifying modifiable risk factors.

Routine monitoring of blood pressure is an essential part of perioperative care in adults and children. It is however not known whether intraoperative hypotension (IOH) is clinically important in the 'healthy' pediatric patient. This may be partly due to the lack of data on the incidence and consequences of IOH in this group of patients. We utilized the Brain Trauma Foundation definition of hypotension to describe the incidence of preincision hypotension (PIH) in a large pediatric noncardiac surgical population and identified risk factors for the occurrence PIH.We examined the electronic perioperative records of all children aged 1-17 years undergoing general anesthesia for noncardiac surgeries between January 2005 and June 2007 in our institution. Frequency and factors associated with PIH were computed. Binary logistic regression with forward step-wise algorithm was used to examine factors associated with PIH.There were 22,263 children of whom 57.6% were males. Most (94.9%) cases were elective, American Society of Anesthesiologists (ASA) I-II (79.5%) procedures. Inhalational induction was predominantly used in this cohort (67%) although 33% of patients had propofol either as a sole induction agent or as part of a 'co-induction' regime. Single or multiple episodes of PIH occurred in 35.8% of patients. PIH was more common in patients with ASAor = III (P0.001); those with preoperative hypotension (P0.001); and following intravenous induction (P0.001) as well as propofol co-induction (P0.001). On multivariate analysis the following were significant predictors of PIH: baseline hypotension, propofol co-induction, age, ASAor = III, and long preincision period.Preincision hypotension is common in the pediatric surgical population undergoing general anesthesia. Factors independently predictive of PIH included high ASA status, pre-existing hypotension, propofol co-induction prolonged preincision period and adolescent age group. The importance of blood pressure monitoring, prompt recognition of hypotension and use of appropriate intervention is emphasized.

Summary Background: Adenotonsillectomy (T&A) is a very common surgical procedure in children. With the rising prevalence of childhood overweight and obesity, our goal was to describe the prevalence of overweight/obesity in children presenting for T&A in our institution. We also sought to compare the frequency of peri-operative complications and the likelihood of being admitted following T&A between overweight/obese and normal weight children. Methods: We examined our peri-operative database and extracted clinical, demographicandanthropometricinformationon2170childrenwhounderwentT&Abetween January 2005 and February 2008. Children were classified into normal weight, overweightandobeseusingpublishedbodymassindex(BMI)criteria.TheincidencesofperioperativecomplicationswerecomparedbetweentheBMIcategories.Wealsoexamined factors contributing to the likelihood of admission following T&A. Results: The overall prevalence of overweight and obese was 20.7%. Overweight/ obese children were more likely to have intra-operative desaturation (p = 0.004), multiple attempts at laryngoscopy (p < 0.001), difficult mask ventilation (p = 0.001), and post-induction and post-anesthesia care unit (PACU) upper airway obstruction (p < 0.001). Additionally, overweight and obese children were more likely to be admitted following T&A. BMI showed a moderate positive correlation with postoperative length of stay (LOS). Multiple logistic regression analysis showed that BMI and presence of medical co-morbidities were independent predictors of LOS. Conclusion: OverweightandobesechildrenpresentingforT&Ahaveahigherincidence of peri-operative complications and are more likely to be admitted and stay for longer than their healthy weight peers. Published by Elsevier Ireland Ltd.

b ackground: Obesity is a highly prevalent chronic problem with health and fiscal consequences. Data from adults and nonsurgical pediatric patients suggest that obesity has serious implications for the US economy. o bjective: Our goal was to describe the impact of BMI on hospital charges in children undergoing adenotonsillectomy (AT). Methods and Procedures: We carried out a retrospective comparative analysis of the electronic anesthesia record and the charges from billing data from a large tertiary institution on children aged 3–18 years who had AT during the year 2005–2007. The main outcome measures were mean total hospital charges, likelihood of admission, and length of hospital stay (LOS). Results: Of 1,643 children, 68.9% were aged

Our aim was to describe the incidence of quality assurance events between overweight/obese and normal weight children.This is a retrospective review of the quality assurance database of the Mott Children's Hospital, University of Michigan for the period January 2000 to December 2004. Using directly measured height and weight, we computed the body mass index (BMI) in 6094 children. Overweight and obesity were defined using age and gender-specific cut off according to the National Center for Health Statistics (NCHS)/Centers for Disease Control and Prevention (CDC) (2000) growth charts. Frequency of quality assurance events were compared between normal weight, overweight, and obese children.There were 3359 males (55.1%) and 2735 females (44.9%). The mean age for the entire population was 11.9 +/- 5.2 while the mean BMI was 21.6 +/- 6.7 kg x m(-2). The overall prevalence of overweight and obesity was 31.6%. Obesity was more prevalent in boys than girls (P = 0.016). Preoperative diagnoses of hypertension, type II diabetes, and bronchial asthma were more common in overweight and obese than normal weight children (P = 0.0001 for hypertension, P = 0.001 for diabetes and P = 0.014 for bronchial asthma). Difficult airway, upper airway obstruction in the postanesthesia care unit (PACU) and PACU stay longer than 3 h and need for two or more antiemetics were more common in overweight and obese than normal weight children (P = 0.001). There was no significant difference in the incidence of unplanned hospital admission following an outpatient surgical procedure between normal weight and overweight/obese children.Studies on perioperative aspects of childhood overweight and obesity are rare. Our report shows a high prevalence of overweight and obesity in this cohort of pediatric surgical patients. Certain perioperative morbidities are more common in overweight and obese than in normal weight children. There is a need for prospective studies of the impact of childhood overweight and obesity on anesthesia and surgical outcome.

OBJECTIVE: To describe the prevalence of overweight and obesity in a pediatric surgical population from a large teaching hospital in the United States. METHODS AND PROCEDURES: We carried out a retrospective review of the perioperative database for the period January 2000 to December 2004 at the University of Michigan. Using directly measured height and weight, we computed body mass index (BMI) on 6,017 children. Overweight and obesity were defined using age- and gender-specific cut-off according to the National Center for Health Statistics (NCHS)/Centers for Disease Control and Prevention (CDC) (2000) growth charts. We also examined the type of surgical procedures most commonly performed on overweight and obese children, and the distribution of overweight and obese patients by preoperative American Society of Anesthesiologist (ASA) classification. RESULTS: We found a somewhat "heavy" pediatric population with a mean BMI of 21.6kg/m(2). The mean BMI in males was 21.7 kg/m(2) and 21.6 kg/m(2) in females. BMI showed a positive correlation with age overall (r=0.48, p < 0.01), and in both males and females. The overall prevalence of overweight and obesity using age-specific criteria was 14.4% and 17.2%, respectively. Approximately 10% of the children met adult criterion for obesity (BMI > or =30 kg/m(2)). Orthopedic and otolaryngological procedures were the most common surgeries in this cohort of overweight and obese children. We further found that 35.3% of obese and 20.6% of morbidly obese children were classified as ASA I. CONCLUSION: The prevalence of overweight and obesity is high in this pediatric surgical population. Follow-up studies examining the impact of overweight and obesity on perioperative outcome are needed.

We describe the occurrence of postdural puncture headache (PPDH) in an adolescent with idiopathic intracranial hypertension (IIH) and its successful management with an epidural blood patch. PPDH is a very rare occurrence in patients with intracranial hypertension and is described as a paradoxical situation in the literature. There are only two previous case reports (in adults) of the possible association. A 15-year-old obese patient with a diagnosis of IIH had an uneventful diagnostic spinal tap using a 22G Quincke needle in the pediatric emergency department but returned 24 h later with PPDH. After a failed trial of conservative management, she had an uneventful but curative epidural blood patch with 15 ml of autologous venous blood and was able to return to school the day after the blood patch. Follow-up review by her neuro-ophthalmologist shows resolution of her headaches, considerable improvement in her visual field defect and resolution of papilledema. This is the first report of PPDH and its successful management with an epidural blood patch in a pediatric patient with IIH.

Pneumocephalus is a rare complication of epidural block which typically occurs when the loss of resistance to air technique is used to identify the epidural space. We present a case of pneumocephalus with headache in a parturient following apparently uncomplicated labour epidural analgesia.

The purpose of this investigation was to determine whether there is a relation between body mass index (BMI) classes and early postoperative outcomes in elderly patients undergoing vascular surgery. We hypothesized that being overweight or obese increases the risks of surgery.Data from the American College of Surgeons' National Surgical Quality Improvement Program Participant Use Data File was used to identify the BMI (kg/m(2)) and 30-day outcomes of 25,337 patients aged ≥ 65 years undergoing vascular surgery from 2005 to 2007. Patients were stratified into 6 BMI classes: (1) underweight (BMI ≤ 18.5 kg/m(2)), (2) normal (BMI = 18.6-24.9 kg/m(2)), (3) overweight (BMI = 25-29.9 kg/m(2)), (4) obese class I (BMI = 30-34.9 kg/m(2)), (5) obese class II (BMI = 35-39.9 kg/m(2)), and (6) obese class III (BMI ≥ 40 kg/m(2)). Morbidity and mortality rates across all BMI classes were subjected to univariate and multiple logistic regression analyses.Mortality rates varied among the BMI classes: 9.4% underweight, 4.0% normal, 3.0 overweight and obese I, 3.3% obese II, and 4.6% obese III (P0.001). Major postoperative morbidity paralleled the risk of death. Independent preoperative factors associated with mortality included diabetes mellitus, chronic obstructive pulmonary disease, active congestive heart failure, recent weight loss, disseminated cancer, and an inability to function independently. Each of these factors was statistically more important than the BMI alone in defining an increased risk of surgery.Increased BMI alone was not a major factor predicting perioperative 30-day mortality in this cohort of elderly surgical patients; the effect was a nonlinear one with a reversed J-curve response documenting the poorest outcomes in underweight, normal, and a slight increase in excessively obese patients.