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IntroductionRegional techniques are a key component of multimodal analgesia and help decrease opioid use perioperatively, but some techniques may not be suitable for all patients, such as those with spina bifida. We hypothesized peripheral regional catheters would reduce postoperative opioid use compared with no regional analgesia without increasing pain scores in pediatric patients with spina bifida undergoing major urological surgery.MethodsA retrospective review of a multicenter database established for the study of enhanced recovery after surgery was performed of patients from 2009 to 2021 who underwent bladder augmentation or creation of catheterizable channels. Patients without spina bifida and those receiving epidural analgesia were excluded. Opioids were converted into morphine equivalents and normalized to patient weight.Results158 patients with pediatric spina bifida from 7 centers were included, including 87 with and 71 without regional catheters. There were no differences in baseline patient factors. Anesthesia setup increased from median 40 min (IQR 34–51) for no regional to 64 min (IQR 40–97) for regional catheters (pDiscussionContinuous regional analgesia following major urological surgery in children with spina bifida was associated with a 70% intraoperative and 78% postoperative reduction in opioids without higher pain scores. This approach should be considered for similar surgical interventions in this population.Trial registration numberNCT03245242.

Background: Difficult facemask ventilation is perilous in children whose tracheas are difficult to intubate. We hypothesised that certain physical characteristics and anaesthetic factors are associated with difficult mask ventilation in paediatric patients who also had difficult tracheal intubation. Methods: We queried a multicentre registry for children who experienced “difficult” or “impossible” facemask ventilation. Patient and case factors known before mask ventilation attempt were included for consideration in this regularised multivariable regression analysis. Incidence of complications, and frequency and efficacy of rescue placement of a supraglottic airway device were also tabulated. Changes in quality of mask ventilation after injection of a neuromuscular blocking agent were assessed. Results: The incidence of difficult mask ventilation was 9% (483 of 5453 patients). Infants and patients having increased weight, being less than 5th percentile in weight for age, or having Treacher-Collins syndrome, glossoptosis, or limited mouth opening were more likely to have difficult mask ventilation. Anaesthetic induction using facemask and opioids was associated with decreased risk of difficult mask ventilation. The incidence of complications was significantly higher in patients with “difficult” mask ventilation than in patients without. Rescue placement of a supraglottic airway improved ventilation in 71% (96 of 135) of cases. Administration of neuromuscular blocking agents was more frequently associated with improvement or no change in quality of ventilation than with worsening. Conclusions: Certain abnormalities on physical examination should increase suspicion of possible difficult facemask ventilation. Rescue use of a supraglottic airway device in children with difficult or impossible mask ventilation should be strongly considered.

Point-of-care hemoglobin testing devices play an important role in intraoperative anesthetic management where significant hemorrhage is anticipated; however, the reliability of these devices has not been examined in the context of pediatric liver transplantation. In this retrospective observational study, we aimed to determine whether 95% of results from two point-of-care hemoglobinometers, the HemoCue and iSTAT, would fall within a difference of ±1 g/dl, our a priori-defined clinically acceptable level of agreement, of the hemoglobin measures on a core laboratory complete blood count.We retrospectively collected data from 70 patients presenting for a liver transplant at a single center, tertiary care pediatric hospital over a 3.5-year period. We analyzed 92 contemporaneous pairs of hemoglobin values from the HemoCue and complete blood count, and 252 pairs of hemoglobin values from the iSTAT and complete blood count. Agreement between the point-of-care devices and complete blood count was assessed using Bland-Altman analysis, which was the primary outcome. Secondary analyses included an error grid analysis and Cohen's kappa statistic.Both point-of-care devices underestimated complete blood count hemoglobin values and neither device satisfied our a priori-defined clinically acceptable level of agreement that 95% of values would fall within ±1 g/dl of the complete blood count measurement. The mean difference [limits of agreement] of the HemoCue was 0.4 g/dl (p .001) [-0.9 to 1.6 g/dl] and of the iSTAT was 0.6 g/dl (p .001) [-1.4 to 2.6 g/dl]. Secondary error grid analysis revealed that neither device performed well enough to replace a complete blood count at critical thresholds of hemoglobin values.While the HemoCue and iSTAT contribute information in a timely manner during dynamic intraoperative situations, there is significant imprecision compared to the gold standard complete blood count. If clinical stability allows, the results of these point-of-care hemoglobinometers should be confirmed with a complete blood count, rather than being used as the sole factor in determining transfusion needs during pediatric liver transplantation.

INTRODUCTION: Although enhanced recovery pathways (ERP) provide a safe and effective way to improve the recovery of children undergoing bladder reconstruction, ERPs have not been widely adopted in pediatric urology. We describe a quality improvement initiative and outcomes after implementing a 24-element ERP at a single, freestanding children’s hospital. STUDY DESIGN: Multiple stakeholder meetings were planned and executed, initially with pediatric practitioners with ERP experience to understand potential implementation barriers then with anesthesiologists, nurses, case managers, and other ancillary staff to draft our institution-specific ERP. A standardized order set was generated to improve ERP adherence. ERP adherence audits and cyclic performance evaluations held every 6–9 months facilitated continuous pathway refinement. Patient outcomes were compared with a pre-ERP historic cohort. RESULTS: Time from initial ERP planning to first implementation was 7 months. ERP was implemented in twenty consecutive patients undergoing bladder reconstruction (median age 11.3 years, range 4.1–21.1) who were compared to twenty consecutive pre-ERP patients (median age 11.4 years, range 7.7–25.1). Median post-operative length of stay (LOS) significantly decreased from 9 days (range 2–31) pre-ERP to 4 days (range 3–29) post-ERP (p

Background Preoperative pulmonary function tests are routinely obtained in children with scoliosis undergoing posterior spinal fusion despite unclear benefits as a perioperative risk assessment tool and frequent inability of patients to provide acceptable results. The goal of this study was to determine whether preoperative pulmonary function test results are associated with the need for postoperative intubation or intensive care unit admission after posterior spinal fusion. Methods The electronic medical records of patients who underwent posterior spinal fusion at a pediatric tertiary hospital between June 2012 and August 2017 were reviewed. Pulmonary function tests were consistently ordered for all patients, unless the patient was deemed unable to perform the test due to cognitive disability. Cases were categorized as primary or secondary scoliosis.Demographic data, preoperative bilevel positive airway pressure use, Cobb angle, intraoperative allogeneic blood transfusion, and ability to produce acceptable pulmonary function test results were collected for each patient. In patients with satisfactory pulmonary function test results, forced vital capacity and maximum inspiratory pressure were collected. Primary outcomes for analysis were postoperative intubation and intensive care unit admission. Univariable logistic regression models were used to assess the association between each variable of interest and the primary outcomes. Results The study sample included 433 patients, 288 with primary scoliosis and 145 with secondary scoliosis. Among patients with primary scoliosis, 90% were able to produce acceptable pulmonary function test results, zero remained intubated postoperatively, and 6 were admitted to the intensive care unit. Among patients with secondary scoliosis, 44% could not attempt pulmonary function tests. Among those who did attempt the test, 30% were unable to produce meaningful results. Forced vital capacity and maximum inspiratory pressure were not found to be associated with postoperative intubation or intensive care unit admission. Weight, Cobb angle, intraoperative blood transfusion, American Society of Anesthesiologists physical status classification, and preoperative bilevel positive airway pressure use were associated with patient outcomes. Among 357 total patients who attempted pulmonary function tests, 37 had high-risk results. Only 1 of these 37 patients remained intubated postoperatively. Conclusions Patients undergoing posterior spinal fusion, especially those with secondary scoliosis, are frequently unable to adequately perform pulmonary function tests. Among patients with interpretable pulmonary function tests, there was no association between results and postoperative intubation or intensive care unit admission. Routine pulmonary function testing for all patients with scoliosis may not be indicated for purposes of risk assessment before posterior spinal fusion. Clinicians should consider a targeted approach and limit pulmonary function tests to patients for whom results may guide preoperative optimization as this may improve outcomes and reduce inefficiencies and costs.

Study objective This study assessed whether implementation of an enhanced recovery-based pathway decreased length of stay without increasing readmissions among patients with adolescent idiopathic scoliosis undergoing posterior spinal fusion. Design Retrospective observational before-and-after study. Setting A tertiary children's hospital. Patients A total of 117 patients were studied, 78 in the pre-intervention group and 39 in the post-intervention group. All patients underwent posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS) in the same institution with one of two spine surgeons. Age, sex, American Society of Anesthesiologists physical status, and Cobb angle were comparable between the two groups. Interventions Between the pre- and post-intervention groups an enhanced recovery protocol was developed. The pathway included standardized use of nonopioid analgesics, proactive transition to oral analgesics, scheduled antiemetics, plans for diet advancement, and specific physical therapy goals. Measurements Outcome measurements included hospital length of stay, cumulative opioid doses in the first two postoperative days, and time to discontinuation of urinary catheter and patient-controlled analgesia. Postoperative emergency department visits, hospital readmissions and chronic pain management referrals were also measured. Pain scores on postoperative days one through four were recorded. Main results Hospital length of stay decreased from 4.6 days to 3.8 days. Patient-controlled analgesia (PCA) was discontinued one day earlier on average following pathway implementation. Average cumulative postoperative opioid use, in morphine equivalents, decreased in the first two postoperative days from 2.5 to 2.2 mg/kg. There was no change in hospital readmission rate or postoperative chronic pain referral. Conclusions Patients undergoing PSF for AIS experienced shorter hospital stays without increased readmissions following the implementation of an enhanced recovery pathway. Development of this pathway required buy-in from multiple stakeholders and significant coordination among services. The principles used to develop this pathway may be applied in other institutions and to other patient populations using the model outlined here.

Summary Introduction Enhanced Recovery Pathways (ERPs), also known as ERAS® pathways, are standardized pathways composed of 21–24 perioperative elements designed to improve post-surgical recovery. ERP has been shown to be safe and effective in children undergoing bladder reconstruction but has not been widely utilized. Objective The aim of this study was to assess utilization of ERPs in pediatric urology and identify barriers to establishing these standardized pathways. Study design Pediatric urologists who were members of the Societies for Pediatric Urology (SPU) were surveyed regarding their familiarity with standardized ERPs, current use of ERP elements, and encountered or perceived barriers to standardized ERP implementation. Willingness to implement ERP elements in a child undergoing bladder reconstruction was assessed with a 5-point Likert scale. Descriptive analysis was performed; Fisher's exact test was performed to assess associations between respondent demographics and ERP familiarity. Results Of 714 distributed surveys, 113 (16%) valid responses were collected. 69% of respondents were male, 58% practiced at academic institutions, and 57% performed 1–5 bladder reconstructions a year. 61% were somewhat familiar or not familiar with standardized ERP. While 54% currently utilize individual ERP elements, only 20% have standardized pathways. Out of 24 possible ERP elements, a median of 15 elements (range 0–24) were implemented by the respondents whether they reported they were implementing ERP elements or had standardized pathways in place. 15 of 24 ERP elements were found to be nearly universally acceptable, with greater than 90% of respondents being somewhat or very willing to implement them in the presented case scenario (Summary Figure). 62% and 56% of those who currently implement ERP elements and experienced barriers noted lack of administrative/leadership support and inability to achieve consensus among pediatric colleagues, respectively, as common barriers in standardization. For those who have not attempted standardization, the most common perceived barrier was pathway unfamiliarity (48%). Discussion Over half of respondents were not familiar with enhanced recovery pathways but were willing to implement a majority of the pathway elements, suggesting potential for ERP standardization in pediatric urology. Buy-in from colleagues and leadership would be necessary to overcome perceived barriers of standardized pathway development. Conclusion Administrative support and more widespread knowledge of ERP amongst pediatric urologists are necessary to facilitate further implementation in children undergoing bladder reconstruction. Download : Download high-res image (691KB) Download : Download full-size image Summary Figure .

Continuous regional analgesia techniques for ambulatory management of postoperative thoracic and abdominal wall pain are limited. We report the placement of an erector spinae plane (ESP) catheter in a pediatric patient who underwent rib resection for slipping rib syndrome and was discharged on postoperative day 1 with an elastomeric pump for continued regional analgesia in the ambulatory setting. The patient required minimal opioids while the catheter was in place and experienced a functional level that surpassed her preoperative state. Ambulatory ESP peripheral nerve catheters are a feasible and potentially effective option for the treatment of acute postsurgical pain in children.

Supplemental Digital Content is available in the text., Introduction: We used the plan-do-study-act (PDSA) framework to develop and implement an evidence-based clinical practice guideline (CPG) within an urban, tertiary children’s referral center. Methods: We developed an evidence-based CPG for appendicitis using iterative PDSA cycles. Similar CPGs from other centers were reviewed and modified for local implementation. Adjuncts included guideline-specific order sets and operative notes in the electronic medical record system. Outcomes included length of stay (LOS), 30-day readmissions, hospital costs, and patient and family experience (PFE) scores. Our team tracked outcome, process, and balancing measures using Statistical Process Charts. Outcome measures were compared over 2 fiscal quarters preimplementation and 3 fiscal quarters postimplementation, using interrupted time series, student t test, and chi-square tests when appropriate. Results: LOS for simple (uncomplicated) appendicitis decreased to 0.87 days (interquartile range [IQR] 0.87–0.94 days) from 1.1 days (IQR 0.97–1.42 days). LOS for complicated appendicitis decreased to 4.96 days (IQR 4.95–6.15) from 5.58 days (IQR 5.16–6.09). This reduction equated to an average cost-savings of $1,122/patient. Thirty-day readmission rates have remained unchanged. PFE scores increased across all categories and have remained higher than national benchmarks. Conclusion: Development and Implementation of a CPG for pediatric appendicitis using the PDSA framework adds value to care provided within a large tertiary center.

Children may experience acute pain for a variety of reasons, including surgical procedures, oncologic processes, and sickle cell vaso-occlusive episodes. A thoughtful analgesia plan must consider the source of pain, patient developmental level, prior opioid use, ability to tolerate oral medications, and patient comorbidities. Opioid pain medications are effective at treating acute pain, but are associated with significant side effects at higher doses. Multimodal analgesia is a strategy that utilizes multiple nonopioid medications working synergistically at different locations along the pain pathway to achieve better pain control with an improved side effect profile compared to opioids alone.

We analysed data from the Paediatric Difficult Intubation Registry examining the use of direct laryngoscopy and GlideScope® videolaryngoscopy.Data collected by a multicentre, paediatric difficult intubation registry from 1295 patients were analysed. Rates of success and complications between direct laryngoscopy and GlideScope videolaryngoscopy were analysed.Initial (464/877 = 53% vs 33/828 = 4%, Z-test = 22.2, P 0.001) and eventual (720/877 = 82% vs. 174/828 = 21%, Z-test = 25.2, P 0.001) success rates for GlideScope were significantly higher than direct laryngoscopy. Children weighing10 kg had lower success rates with the GlideScope than the group as a whole. There were no differences in complication rates per attempt between direct laryngoscopy and GlideScope. The direct laryngoscopy group had more complications associated with the greater number of attempts needed to intubate. There were no increased risks of hypoxia or trauma with GlideScope use. Each additional attempt at intubation with either device resulted in a two-fold increase in complications (odds ratio: 2.0, 95% confidence interval: 1.5-2.5, P 0.001).During difficult tracheal intubation in children, direct laryngoscopy is an overly used technique with a low chance of success. GlideScope use was associated with a higher chance of success with no increased risk of complications. GlideScope use in children with difficult tracheal intubation has a lower success rate than in adults with difficult tracheal intubation. Children weighing less than 10 kilograms had lower success rates with either device. Attempts should be minimized with either device to decrease complications.

Background The success rates and related complications of various techniques for intubation in children with difficult airways remain unknown. The primary aim of this study is to compare the success rates of fiber-optic intubation via supraglottic airway to videolaryngoscopy in children with difficult airways. Our secondary aim is to compare the complication rates of these techniques. Methods Observational data were collected from 14 sites after management of difficult pediatric airways. Patient age, intubation technique, success per attempt, use of continuous ventilation, and complications were recorded for each case. First-attempt success and complications were compared in subjects managed with fiber-optic intubation via supraglottic airway and videolaryngoscopy. Results Fiber-optic intubation via supraglottic airway and videolaryngoscopy had similar first-attempt success rates (67 of 114, 59% vs. 404 of 786, 51%; odds ratio 1.35; 95% CI, 0.91 to 2.00; P = 0.16). In subjects less than 1 yr old, fiber-optic intubation via supraglottic airway was more successful on the first attempt than videolaryngoscopy (19 of 35, 54% vs. 79 of 220, 36%; odds ratio, 2.12; 95% CI, 1.04 to 4.31; P = 0.042). Complication rates were similar in the two groups (20 vs. 13%; P = 0.096). The incidence of hypoxemia was lower when continuous ventilation through the supraglottic airway was used throughout the fiber-optic intubation attempt. Conclusions In this nonrandomized study, first-attempt success rates were similar for fiber-optic intubation via supraglottic airway and videolaryngoscopy. Fiber-optic intubation via supraglottic airway is associated with higher first-attempt success than videolaryngoscopy in infants with difficult airways. Continuous ventilation through the supraglottic airway during fiber-optic intubation attempts may lower the incidence of hypoxemia.

BACKGROUND Ventilation is critical in airway management, and failure can be fatal. The optimal ventilation approach for endotracheal intubation in children with difficult airways remains controversial. The Pediatric Difficult Intubation (PeDI) Registry is an international multicenter registry that collects intubation data in difficult to intubate children. The registry captures the initial (at induction) and final ventilation technique (at intubation), the use of neuromuscular blocking drugs (NMBDs), airway reactivity during intubation, and complications. We analyzed data in the PeDI Registry to determine the frequency of use of various ventilation techniques and associated complications. Because spontaneously breathing patients ventilate throughout intubation, we hypothesized that spontaneous ventilation would be associated with fewer complications than other approaches. METHODS We queried the PeDI Registry for cases entered between September 2012 and February 2016, from 16 children's hospitals. We categorized the attending anesthesiologist's ventilation plan into 3 groups: spontaneous ventilation, controlled ventilation after administering an NMBD, and controlled ventilation without administering an NMBD. Generalized Estimating Equation (GEE) model, with a binomial family distribution and logit link, was used to determine the association between ventilation technique and the risk of complications, as well as to account for within-site clustering. Propensity score matching was further applied to balance pretreatment characteristics of ventilation groups. RESULTS Of 1289 anticipated difficult intubations, 507 (39%) were managed with spontaneous ventilation, 453 (35%) controlled ventilation with an NMBD, and 329 (26%) controlled ventilation without an NMBD. Complications occurred in 242 (18.8%; 95% confidence interval [CI], 16.6%-20.9%) patients. Of these, 218 (16.9%) were nonsevere, and 24 (1.9%) were severe. The spontaneous ventilation group had 114 (22.5%, standardized residual [Std.Res] = 4.29) nonsevere complications, which was higher than the controlled ventilation with an NMBD 60 (13.3%, Std.Res = -2.58), and controlled ventilation without an NMBD 44 (13.4%, Std.Res = -1.98), P < .001. Nearest neighbor matching with caliper width equal to 0.2 of the standard deviation (SD) of the logit of the propensity score also demonstrated that patients with spontaneous ventilation had greater odds of complications compared to controlled ventilation techniques: odds ratio (OR) = 2.07 (95% CI, 1.36-3.15; P = .001). CONCLUSIONS Spontaneous ventilation is associated with more nonsevere complications, such as hypoxemia and laryngospasm, than controlled ventilation techniques during intubation of children with difficult airways. Inadequate anesthetic depth may contribute to increased complications.

To test the hypothesis that low bispectral index scores and low sedative requirements during therapeutic hypothermia predict poor neurologic outcome.Observational study of a prospectively collected cohort.Cardiovascular ICU.One hundred sixty consecutive cardiac arrest patients treated with therapeutic hypothermia.None.Eighty-four of the 141 subjects (60%) who survived hypothermia induction were discharged from the ICU with poor neurologic outcome, defined as a cerebral performance category score of 3, 4, or 5. These subjects had lower bispectral index (p0.001) and sedative requirements (p0.001) during hypothermia compared with the 57 subjects discharged with good outcome. Early prediction of neurologic recovery was best 7 hours after ICU admission, and median bispectral index scores at that time were 31 points lower in subjects discharged with poor outcome (11 [interquartile range, 4-29] vs 42 [37-49], p0.001). Median sedation requirements decreased by 17% (interquartile range, -50 to 0%) 7 hours after ICU admission in subjects with poor outcome but increased by 50% (interquartile range, 0-142%) in subjects with good outcome (p0.001). Each 10-point decrease in bispectral index was independently associated with a 59% increase in the odds of poor outcome (95% CI, 32-76%; p0.001). The model including bispectral index and sedative requirement correctly reclassified 15% of subjects from good to poor outcome and 1% of subjects from poor to good outcome. The model incorrectly reclassified 1% of subjects from poor to good outcome but did not incorrectly reclassify any from good to poor outcome.Bispectral index scores and sedative requirements early in the course of therapeutic hypothermia improve the identification of patients who will not recover from brain anoxia. The ability to accurately predict nonrecovery after cardiac arrest could facilitate discussions with families, reduce patient suffering, and limit use of ICU resources in futile cases.