Postoperative Hematocrit and Adverse Outcomes in Pediatric Cardiac Surgery Patients: A Cross-Sectional Study From the Society of Thoracic Surgeons and Congenital Cardiac Anesthesia Society Database Collaboration.

BACKGROUND: We sought to examine potential associations between pediatric postcardiac surgical hematocrit values and postoperative complications or mortality. METHODS: A retrospective, cross-sectional study from the Society of Thoracic Surgeons Congenital Heart Surgery Database (STS-CHSD) and Congenital Cardiac Anesthesia Society Database Module (2014-2019) was completed. Multivariable logistic regression models, adjusting for covariates in the STS-CHSD mortality risk model, were used to assess the relationship between postoperative hematocrit and the primary outcomes of operative mortality or any major complication. Hematocrit was assessed as a continuous variable using linear splines to account for nonlinear relationships with outcomes. Operations after which the oxygen saturation is typically observed to be <92% were classified as cyanotic and ≥92% as acyanotic. RESULTS: In total, 27,462 index operations were included, with 4909 (17.9%) being cyanotic and 22,553 (82.1%) acyanotic. For cyanotic patients, each 5% incremental increase in hematocrit over 42% was associated with a 1.31-fold (95% confidence interval [CI], 1.10-1.55; P = .003) increase in the odds of operative mortality and a 1.22-fold (95% CI, 1.10-1.36; P < .001) increase in the odds of a major complication. For acyanotic patients, each 5% incremental increase in hematocrit >38% was associated with a 1.45-fold (95% CI, 1.28-1.65; P < .001) increase in the odds of operative mortality and a 1.21-fold (95% CI, 1.14-1.29; P < .001) increase in the odds of a major complication. CONCLUSIONS: High hematocrit on arrival to the intensive care unit (ICU) is associated with increased operative mortality and major complications in pediatric patients following cardiac surgery.

Neonatal intensive care unit patients recovering in the post anesthesia care unit: An observational analysis of postextubation complications.

BACKGROUND: Neonatal patients are at higher risk in the perioperative period than older infants and children. Extubation as an early goal for noenatal intensive care unit patients presenting for surgery is undergoing a renaissance period, and an exploration of adverse events following selection for extubation immediately after general anesthesia has not specifically been undertaken in this population. AIMS: The objective of this study is to determine the adverse events most commonly encountered in neonatal intensive care unit patients recovering from anesthesia in the post anesthesia care unit, quantify the risk of event occurrence, and identify risk factors that may increase the risk of postoperative adverse events. METHODS: All neonatal intensive care unit patients presenting to the operating room 6/1/2014-5/31/2018 who recovered in the  post anesthesia care unit were included for analysis. Univariate analyses were conducted utilizing the Wilcoxon rank-sum test or Fisher exact test. Due to the low event rate, a small-sample generalized estimating equation model was created with a major event composite as the outcome and explanatory variables with P values < .1 on univariate analysis. Statistically significant continuous variables were then dichotomized based on Youden index. RESULTS: There were 707 operative cases in 607 patients. There were 81 total events recorded, and 64/81 were considered to be major events; all of which were respiratory. The risk of any postoperative event was 11.5%, major respiratory event requiring intervention by a nurse or provider was 9.1%, and reintubation was 0.8%. Birth weight < 1.58 kg (OR 3.71; 95% CI 2.11-6.53; P < .001) and postmenstrual age at surgery <41 weeks (OR 3.20; 95% CI 1.54-6.63; P < .001) were strongly associated with an increased risk of a major postoperative respiratory event. CONCLUSION: The most important factors associated with major events in the post anesthesia care unit following extubation of neonatal intensive care unit patients were birth weight < 1.58 kg and postmenstrual age at surgery < 41 weeks. A patient with both features has a 7-fold increase in the odds of a major respiratory event in the post anesthesia care unit. Careful consideration of the postoperative ventilation and monitoring strategy must be given to patients with low birth weight (<1.58 kg) or who are <41 weeks postmenstrual age at the time of surgery.

Complications in Pediatric Regional Anesthesia: An Analysis of More than 100,000 Blocks from the Pediatric Regional Anesthesia Network.

WHAT WE ALREADY KNOW ABOUT THIS TOPIC: WHAT THIS ARTICLE TELLS US THAT IS NEW: BACKGROUND:: Complications in pediatric regional anesthesia are rare, so a large sample size is necessary to quantify risk. The Pediatric Regional Anesthesia Network contains data on more than 100,000 blocks administered at more than 20 children's hospitals. This study analyzed the risk of major complications associated with regional anesthesia in children. METHODS: This is a prospective, observational study of routine clinical practice. Data were collected on every regional block placed by an anesthesiologist at participating institutions and were uploaded to a secure database. The data were audited at multiple points for accuracy. RESULTS: There were no permanent neurologic deficits reported (95% CI, 0 to 0.4:10,000). The risk of transient neurologic deficit was 2.4:10,000 (95% CI, 1.6 to 3.6:10,000) and was not different between peripheral and neuraxial blocks. The risk of severe local anesthetic systemic toxicity was 0.76:10,000 (95% CI, 0.3 to 1.6:10,000); the majority of cases occurred in infants. There was one epidural abscess reported (0.76:10,000, 95% CI, 0 to 4.8:10,000). The incidence of cutaneous infections was 0.5% (53:10,000, 95% CI, 43 to 64:10,000). There were no hematomas associated with neuraxial catheters (95% CI, 0 to 3.5:10,000), but one epidural hematoma occurred with a paravertebral catheter. No additional risk was observed with placing blocks under general anesthesia. The most common adverse events were benign catheter-related failures (4%). CONCLUSIONS: The data from this study demonstrate a level of safety in pediatric regional anesthesia that is comparable to adult practice and confirms the safety of placing blocks under general anesthesia in children.

The Use of Neuraxial Catheters for Postoperative Analgesia in Neonates: A Multicenter Safety Analysis from the Pediatric Regional Anesthesia Network.

BACKGROUND: Currently, there is limited evidence to support the safety of neuraxial catheters in neonates. Safety concerns have been cited as a major barrier to performing large randomized trials in this population. The main objective of this study is to examine the safety of neuraxial catheters in neonates across multiple institutions. Specifically, we sought to determine the incidence of overall and individual complications encountered when neuraxial catheters were used for postoperative analgesia in neonates. METHODS: This was an observational study that used the Pediatric Regional Anesthesia Network database. Complications and adverse events were defined by the presence of at least 1 of the following intraoperative and/or postoperative factors: catheter malfunction (dislodgment/occlusion), infection, block abandoned (unable to place), block failure (no evidence of block), vascular (blood aspiration/hematoma), local anesthetic systemic toxicity, excessive motor block, paresthesia, persistent neurologic deficit, and other (e.g., intra-abdominal misplacement, tremors). Additional analyses were performed to identify the use of potentially toxic doses of local anesthetics. RESULTS: The study cohort included 307 neonates with a neuraxial catheter. There were 41 adverse events and complications recorded, resulting in an overall incidence of complications of 13.3% (95% confidence interval, 9.8%-17.4%). Among the complications, catheter malfunction, catheter contamination, and vascular puncture were common. None of the complications resulted in long-term complications and/or sequelae, resulting in an estimated incidence of any serious complications of 0.3% (95% confidence interval, 0.08%-1.8%). There were 120 of 307 patients who received intraoperative and/or postoperative infusions consistent with a potentially toxic local anesthetic dose in neonates. The incidence of potentially toxic local anesthetic infusion rates increased over time (P = 0.008). CONCLUSIONS: Neuraxial catheter techniques for intraoperative and postoperative analgesia appear to be safe in neonates. Further studies to confirm our results and to establish the efficacy of these techniques across different surgical procedures are required. We suggest that each center that uses neuraxial anesthesia techniques in neonates closely evaluate the dose limits for local anesthetic agents and develop rigorous quality assurance methods to ensure potentially toxic doses are not used.

Transversus abdominis plane block in children: a multicenter safety analysis of 1994 cases from the PRAN (Pediatric Regional Anesthesia Network) database.

BACKGROUND: Currently, there is not enough evidence to support the safety of the transversus abdominis plane (TAP) block when used to ameliorate postoperative pain in children. Safety concerns have been repeatedly mentioned as a major barrier to performing large randomized trials in children. The main objective of the current investigation was to determine the incidence of overall and specific complications resulting from the performance of the TAP block in children. In addition, we evaluated patterns of local anesthetic dosage selection in the same population. METHODS: This was an observational study using the Pediatric Regional Anesthesia Network database. A complication from the TAP block was defined by the presence of at least one of the following intraoperative and/or postoperative factors: puncture of the peritoneum or organs, vascular puncture, cardiovascular, pulmonary and/or neurological symptoms/signs, hematoma, and infection. Additional analyses were performed to identify patterns of local anesthetic dosage. RESULTS: One thousand nine hundred ninety-four children receiving a TAP block were included in the analysis. Only 2 complications were reported: a vascular aspiration of blood before local anesthetic injection and a peritoneal puncture resulting in an overall incidence of complications (95% CI) of 0.1% (0.02%-0.3%) and a specific incidence of complications (vascular aspiration or peritoneal puncture) of 0.05% (0.0054%-0.2000%). Neither of these complications resulted in additional interventions or sequelae. The median (95% range) for the local anesthetic dose per weight for bilateral TAP blocks was 1.0 (0.47-2.29) mg of bupivacaine equivalents per kilogram; however, subjects' weights were not sufficient to explain much of the variability in dose. One hundred thirty-five of 1944 (6.9%; 95% CI, 5.8%-8.1%) subjects received doses that could be potentially toxic. Subjects who received potentially toxic doses were younger than subjects who did not receive potentially toxic doses, 64 (19-100) months and 108 (45-158) months, respectively (P < 0.001). CONCLUSIONS: The upper incidence of overall complications associated with the TAP block in children was 0.3%. More important, complications were very minor and did not require any additional interventions. In contrast, the large variability of local anesthetic dosage used can not only minimize potential analgesic benefits of the TAP block but also result in local anesthetic toxicity. Safety concerns should not be a major barrier to performing randomized trials to test the efficacy of the TAP block in children as long as appropriate local anesthetic dose regimens are selected.