Management of Cerebrospinal Fluid Leak After Intrathecal Baclofen Pump Procedures in Adolescents With Cerebral Palsy: A Retrospective Study.

STUDY OBJECTIVE:  Epidural blood patches (EBPs) are frequently performed in children with cerebral palsy (CP) to manage post-dural puncture headache (PDPH) due to cerebrospinal fluid (CSF) leak after intrathecal baclofen pump (ITBP) placement or replacement procedures. The purpose of our study was to review the incidence and management of CSF leak following ITBP placement or replacement procedures in children with CP. The study was a retrospective review of 245 patients representing 310 surgical cases of baclofen pump insertion (n=141) or reinsertion (n=169) conducted at a 125-bed children's hospital with prominent specialty orthopedics surgical cases. MEASUREMENTS:  Demographic and clinical information was obtained from the anesthesia pain service database on all new ITBP placement and subsequent replacements over an eight-year period. MAIN RESULTS:  The overall incidence of CSF leak in our population was 16% (50 of 310) and 18% (25 of 141) with a new ITBP placement. Children with diplegia were associated with a threefold risk of developing CSF leak. Of patients who developed CSF leak (n=50), 68% (n=34) were successfully treated conservatively, while 32% (n=16) required EBPs. EBPs were successful in 87.5% (14 of 16) of patients at relieving PDPH on the first attempt.  Conclusions: CSF leak is a known problem after ITBP placement and replacement. Most patients were successfully treated with conservative management and EBPs were successful in patients failing conservative therapy. Diagnosing PDPH in non-verbal patients can be challenging.

A Comparative Evaluation of Unilateral and Bilateral Sequential Lung Isolation for Vertebral Body Tethering: A Retrospective Propensity Matched Analysis.

BACKGROUND: Vertebral body tethering (VBT) requires a thoracoscopic approach to visualize the vertebral bodies. Lung collapse and re-expansion have the potential to cause acute lung injury, resulting in increased oxygen and ventilation requirements. AIMS: We compared the intraoperative ventilator management, intra- and postoperative blood gas determinations, and hospital stay information between adolescents undergoing unilateral versus bilateral lung isolation for vertebral body tethering. METHODS:  A study cohort of 132 propensity-matched cases (66 unilateral and 66 bilateral) was derived from 351 consecutive VBT cases. Patient demographic information, case information, fluid administration, ventilatory settings data, blood gas parameters, and complete blood count and differential data were entered into a datasheet. Derived parameters included values calculated from the alveolar gas equation to develop an oxygen cascade and measures of inflammatory response. Chi-square was used for categorical data, and independent samples and t-tests were used for continuous data. RESULTS: The double lung isolation group required higher peak inspiratory pressures (SL 29±5 vs. DL 31±5, p=0.026), resulting in higher tidal volume (SL 246±63 vs. DL 334±101, p<0.001) and tidal volume per kg (SL 5.6±1.4 vs. DL 6.9±2, p<0.001) as compared to the single lung group. The double lung group required a higher partial pressure of inspired and alveolar oxygen as well as a higher alveolar to arterial oxygen tension gradient (SL 417±126 vs. DL 485±96, p=0.001) to achieve optimal arterial oxygen tension. Patients with double lung isolation had similar intensive care lengths of stay but a longer hospital stay than single lung isolation patients. CONCLUSION: Patients undergoing double lung isolation required greater ventilatory support and had more evidence of acute lung injury, as evidenced by a higher postoperative alveolar to arterial oxygen gradient; however, these healthy adolescents tolerated the procedure well and only differed in the hospital length of stay by a day.

Pediatric CYP2D6 metabolizer status and post-tonsillectomy nausea and vomiting after ondansetron.

The goal of this study was to determine whether CYP2D6 metabolizer status within the ondansetron-treated pediatric tonsillectomy population is associated with risk of postoperative nausea and vomiting (PONV) in the post-anesthesia care unit. We conducted a retrospective cohort study of pediatric patients (<18 years) who underwent tonsillectomy and received ondansetron on the day of the procedure. Data were obtained from BioVU, an institutional biobank that links DNA to de-identified electronic health record data. Subjects were tested for 10 CYP2D6 allelic variants and copy number variation, and genotype data translated into CYP2D6 metabolizer status. The cohort included 652 individuals, 105 (16.1%) of whom had PONV. Rates of PONV were similar across groups: ultrarapid metabolizers (UMs), 1 of 9 (11.1%); normal metabolizers (NMs), 64 of 354 (18.1%); intermediate metabolizers (IMs), 33 of 234 (14.1%); poor metabolizers (PMs), 6 of 39 (15.4%); and ambiguous phenotypes, 1 of 16 (6.3%). In multivariable analysis adjusted for age, sex, and time under anesthesia, CYP2D6 metabolizer status was not associated with PONV, with an odds ratio of 1.37 (95% confidence interval 0.9, 2.1) when comparing PM/IM versus NM/UM. In this large pediatric population, no significant differences were detected for PONV based on CYP2D6 metabolizer status. Further investigation is needed to determine mechanisms for ondansetron inefficacy in children.

Predictors of postoperative systemic inflammatory response syndrome after scoliosis surgery in adolescents with cerebral palsy: A retrospective analysis.

Background: Systemic inflammatory response syndrome (SIRS) is known to complicate postsurgical intensive care patients. We noticed that roughly half children with cerebral palsy who undergo posterior spinal fusion (PSF) for neuromuscular scoliosis developed SIRS in the intensive care unit. There is a paucity of literature detailing the impact of intraoperative causes of postoperative SIRS and downstream consequences in these patients. Study purpose was to understand the factors associated with SIRS in children who undergo PSF for neuromuscular scoliosis. Methods: This retrospective, case control study included children who underwent PSF for neuromuscular scoliosis. Patients with idiopathic scoliosis, osteogenesis imperfecta, and tracheotomy were excluded. Subjects were divided into two study groups based on the diagnosis of SIRS in the intensive care unit. Descriptive statistical analysis was used to identify factors associated with SIRS; a regression analysis was used to further evaluate the independent and significant influence of these factors. Results: There was no significant difference in the demographic and other preoperative variables. However, total blood products (ml/kg) administered was significantly higher among the SIRS group compared with the non-SIRS group (54.4±41.0 vs 34.1±21.5 P <0.034). Percent of patients remaining intubated was greater in the SIRS group compared with the non-SIRS group (44.1% vs 7.0%, P < 0.001). The regression model revealed that the odds to develop SIRS in patients who were not extubated were 7.467-fold higher (CI: 1.534-36.347) compared with those who were extubated (p=0.013). Conclusions: The incidence of SIRS is significantly higher among the patients who were not extubated at the end of PSF surgery. Further prospective studies are needed to look at the factors that impede the ability to extubate these patients at the end of surgery.

Endobronchial Blocker Placement for Lung Isolation in Children: A Simple Head Turn Technique.

Endobronchial blockers are frequently used for lung isolation in children <8 years of age. The aim of our report is to highlight the problem that we have encountered with the wire-guided endobronchial blocker (WEB), where the wire loop used to couple the blocker and the fiberoptic scope (FOS) may straddle the carina. We describe the "uncoupled head turn technique" that we have adopted to avoid this problem. If the coupled technique is deemed necessary, a method to keep the wire loop snug around the FOS is described to avoid the straddling problem.

Comparative evaluation of one-handed versus two-handed mask holding techniques in children during inhalational induction of anesthesia: A randomized crossover study.

BACKGROUND: We aimed to evaluate if two-handed mask airway is superior to one-handed mask airway during inhalational induction of anesthesia in children. METHODS: A randomized, two period, crossover study was performed on 60 children aged 1-8 years, with obstructive sleep apnea due to adenotonsillar hypertrophy, scheduled for adenotonsillectomy. Children were assigned to two study sequences and one control sequence of 20 subjects each. A control sequence was added to evaluate the effect of anesthetic depth. Sequence 1: One-handed followed by two-handed airway, 30 seconds each; Sequence 2: two-handed followed by one-handed airway, 30 seconds each and Sequence 3: two-handed airway, for 60 seconds. The work of breathing indices, phase angle, and labored breathing index were recorded using respiratory inductance plethysmography. Additional outcome measures were tidal volume, minute ventilation, and respiratory rate. A straight comparison and a crossover analysis was performed. RESULTS: The initial comparison revealed that one-handed airway had greater phase angle (mean diff. 17.4; 95% confidence interval [CI] 1.07-33.68; P = .034), greater labored breathing index (mean diff. 0.56; 95% CI 0.16-1.04; P = .004),lower minute ventilation (mean diff. -1567; 95% CI -2695 to -5.4; P = .004),and lower tidal volume (mean diff. -39; 95% CI -2.7 to -5.4; P = .02) than two-handed airway. On crossover analysis, within-subject difference in the phase angle was greater during one-handed than two-handed airway (34.3; 95% CI 8.46-60.14; P = .01) as was labored breathing index (mean diff. 1.2; 95% CI 0.39-2.00; P < .0046).Minute ventilation was lower during one-handed than two-handed airway (mean diff. -3359; 95% CI -4363 to -2355, P < 0.0001) as was tidal volume(mean diff. -78; 95% CI -110.4 to -45.8; P < .0001). CONCLUSION: In children with obstructive sleep apnea due to adenotonsillar hypertrophy, two-handed airway provides superior airway patency that was not influenced by the anesthetic depth.

Financial and Clinical Ramifications of Introducing a Novel Pediatric Enhanced Recovery After Surgery Pathway for Pediatric Complex Hip Reconstructive Surgery.

BACKGROUND: Enhanced recovery after surgery pathways confer significant perioperative benefits to patients and are currently well described for adult patients undergoing a variety of surgical procedures. Robust data to support enhanced recovery pathway use in children are relatively lacking in the medical literature, though clinical benefits are reported in targeted pediatric surgical populations. Surgery for complex hip pathology in the adolescent patient is painful, often requiring prolonged courses of opioid analgesia. Postoperative opioid-related side effects may lead to prolonged recovery periods and suboptimal postoperative physical function. Excessive opioid use in the perioperative period is also a major risk factor for the development of opioid misuse in adolescents. Perioperative opioid reduction strategies in this vulnerable population will help to mitigate this risk. METHODS: A total of 85 adolescents undergoing complex hip reconstructive surgery were enrolled into an enhanced recovery after surgery pathway (October 2015 to December 2018) and were compared with 110 patients undergoing similar procedures in previous years (March 2010 to September 2015). The primary outcome was total perioperative opioid consumption. Secondary outcomes included hospital length of stay, postoperative nausea, intraoperative blood loss, and other perioperative outcomes. Total cost of care and specific charge sectors were also assessed. Segmented regression was used to assess the effects of pathway implementation on outcomes, adjusting for potential confounders, including the preimplementation trend over time. RESULTS: Before pathway implementation, there was a significant downward trend over time in average perioperative opioid consumption (-0.10 mg total morphine equivalents/90 days; 95% confidence interval [CI], -0.20 to 0.00) and several secondary perioperative outcomes. However, there was no evidence that pathway implementation by itself significantly altered the prepathway trend in perioperative opioid consumption (ie, the preceding trend continued). For postanesthesia care unit time, the downward trend leveled off significantly (pre: -5.25 min/90 d; 95% CI, -6.13 to -4.36; post: 1.04 min/90 d; 95% CI, -0.47 to 2.56; Change: 6.29; 95% CI, 4.53-8.06). Clinical, laboratory, pharmacy, operating room, and total charges were significantly associated with pathway implementation. There was no evidence that pathway implementation significantly altered the prepathway trend in other secondary outcomes. CONCLUSIONS: The impacts of our pediatric enhanced recovery pathway for adolescents undergoing complex hip reconstruction are consistent with the ongoing improvement in perioperative metrics at our institution but are difficult to distinguish from the impacts of other initiatives and evolving practice patterns in a pragmatic setting. The ERAS pathway helped codify and organize this new pattern of care, promoting multidisciplinary evidence-based care patterns and sustaining positive preexisting trends in financial and clinical metrics.

Comparative Evaluation of Tube First Versus Video Laryngoscope First Techniques in a Normal and Simulated Difficult Airway Model: A Randomized Controlled Trial.

In patients with difficult airways, there can be difficulty with advancing the endotracheal tube into the airway even with a good view of the glottis using video laryngoscopy. The purpose of this study was to determine if the time required to intubate an airway and the number of gaze changes by the laryngoscopist could be decreased by using a novel video laryngoscope technique. Sixteen experienced Certified Registered Nurse Anesthetists were recruited to intubate a manikin with a normal or difficult airway using both the laryngoscope first technique and a new endotracheal tube first technique (4 intubations total) in a randomized sequence. The data were analyzed with the Mann-Whitney (U) test to compare the differences between the normal and difficult airway conditions. Although no significant difference was noted in the time to intubation between intubation techniques, the number of gaze changes was found to be significantly fewer in the tube first technique (P=.0009). A steep learning curve, associated with the accommodation of the manikin, was demonstrated by a decrease in time and gaze changes with subsequent intubations. Incorporating the endotracheal tube first technique into an education curriculum could increase patient safety by decreasing the time to secure a difficult airway.

Preoperative Blood Transfusions and Morbidity in Neonates Undergoing Surgery.

BACKGROUND: Blood transfusions in the neonatal patient population are common, but there are no established guidelines regarding transfusion thresholds. Little is known about postoperative outcomes in neonates who receive preoperative blood transfusions (PBTs). METHODS: Using the American College of Surgeons National Surgical Quality Improvement Program-Pediatric Participant Use Data Files from 2012 to 2015, we identified all neonates who underwent surgery. Mortality and composite morbidity (defined as any postoperative complication) in neonates who received a PBT within 48 hours of surgery were compared with that in neonates who did not receive a transfusion. RESULTS: A total of 12 184 neonates were identified, of whom 1209 (9.9%) received a PBT. Neonates who received a PBT had higher rates of preoperative comorbidities and worse postoperative outcomes when compared with those who did not receive a transfusion (composite morbidity: 46.2% vs 16.2%; P < .01). On multivariable regression analysis, PBTs were independently associated with increased 30-day morbidity (odds ratio [OR] = 1.90; 95% confidence interval [CI]: 1.63-2.22; P < .01) and mortality (OR = 1.98; 95% CI: 1.55-2.55; P < .01). In a propensity score-matched analysis, PBTs continued to be associated with increased 30-day morbidity (OR = 1.53; 95% CI: 1.29-1.81; P < .01) and mortality (OR = 1.58; 95% CI: 1.24-2.01; P = .01). CONCLUSIONS: In a propensity score-matched model, PBTs are independently associated with increased morbidity and mortality in neonates who undergo surgery. Prospective data are needed to better understand the potential effects of a red blood cell transfusion in this patient population.

State of the art in clinical decision support applications in pediatric perioperative medicine.

PURPOSE OF REVIEW: The goal of this review is to describe the recent improvements in clinical decision tools applied to the increasingly large and complex datasets in the pediatric ambulatory and inpatient setting. RECENT FINDINGS: Clinical decision support has evolved beyond simple static alerts to complex dynamic alerts for: diagnosis, medical decision-making, monitoring of physiological, laboratory, and pharmacologic inputs, and adherence to institutional and national guidelines for both the patient and the healthcare team. Artificial intelligence and machine learning have enabled advances in predicting outcomes, such as sepsis and early deterioration, and assisting in procedural technique. SUMMARY: With more than a decade of electronic medical data generation, clinical decision support tools have begun to evolve into more sophisticated and complex algorithms capable of transforming large datasets into succinct, timely, and pertinent summaries for treatment and management of pediatric patients. Future developments will need to leverage patient-generated health data, integrated device data, and provider-entered data to complete the continuum of patient care and will likely demonstrate improvements in patient outcomes.

Fresh frozen plasma-to-red blood cell ratio is an independent predictor of blood loss in patients with neuromuscular scoliosis undergoing posterior spinal fusion.

PURPOSE: In major trauma with massive blood loss, higher fresh frozen plasma (FFP)-to-red blood cell (RBC) ratios have been associated with improved morbidity and mortality. Our population of patients with neuromuscular scoliosis undergoing posterior spinal fusion (PSF) often lose volumes of blood considered massive, that is, half a blood volume in 3 hours. In this retrospective cohort study, we examined the association of FFP ratio with blood loss in this elective surgical population. METHODS: Patients with neuromuscular scoliosis undergoing PSF with unit rod fixation were identified from our anesthesia cases database. The patients were divided into two groups: the low FFP group received FFP-to-RBC≤0.5, and the high FFP group received FFP-to-RBC>0.5. After controlling for a false discovery rate in the univariate analysis, a logistic and linear regression was performed to understand the contribution of the significant factors associated with increased blood loss. RESULTS: Risk estimation showed that patients in the low FFP group were more likely to lose >120% blood volume (odds ratio, 3.87; 95% confidence interval, 2.03-7.38). Linear regression revealed that each unit of increase in FFP-to-RBC ratio was associated with a 27.5% (95% confidence interval, -43.12-11.89) mean reduction in blood volume loss. CONCLUSIONS: In our retrospective study, we found that FFP-to-RBC ratio was significant independent predictor of blood loss in this group of complex spine patients undergoing PSF. Thus, in patients with neuromuscular scoliosis undergoing posterior spine fusion, use of higher ratio of FFP to RBC may decrease blood loss.

Evaluation of Gabapentin and Clonidine Use in Children Following Spinal Fusion Surgery for Idiopathic Scoliosis: A Retrospective Review.

BACKGROUND: Opioids are the mainstay of therapy for pain relief following posterior spinal fusion (PSF) surgery. Various adjunctive medications are being used to augment analgesia and to reduce opioid-related side effects. At our institution, we have sequentially added 2 adjuncts to a standard morphine patient-controlled analgesia (PCA) regimen. The goal of our study was to evaluate pain control and the benefit of gabapentin and the combination of gabapentin and clonidine, whereas morphine PCA was in use in children following PSF surgery. METHODS: Following Institutional Review Board approval, data were collected retrospectively from the charts of 127 patients who underwent PSF for idiopathic scoliosis. Children were divided into the 3 following groups: group P, morphine PCA only (42 patients), group G, morphine PCA+gabapentin (45 patients), and group C, morphine PCA+gabapentin+clonidine (40 patients). RESULTS: Addition of gabapentin to our regimen improved the outcome, but the addition of transdermal clonidine and gabapentin together were found to be significantly better in some aspects. Children in group G and C used less morphine on postoperative day 1 following surgery, had more PCA demand-free hours, were able to take orals, were able to ambulate sooner, and had a shorter hospital stay than group P. There were no differences in side effects or sedation between the 3 groups. CONCLUSIONS: In conclusion, additions of postoperative transdermal clonidine and perioperative oral gabapentin together were found to improve functional outcomes following PSF surgery. Group G and C had reduced opioid use and shorter hospital stay than group P. Addition of these adjuncts together was found to be better since group C patients made fewer PCA attempts to obtain morphine over the first 10-hour period postoperatively and were able to ambulate sooner than group G. The PCA pump usage pattern provides useful information about patient comfort and efficacy of adjunctive medications. LEVEL OF EVIDENCE: Level II-retrospective study.

Critical Airway Stenosis in an Adolescent Male With Pompe Disease and Thoracic Lordosis: A Case Report.

An adolescent male with late-onset Pompe disease (glycogen storage disease type II) presented with a history of restrictive airway disease and a near-cardiorespiratory arrest during anesthesia for a liver biopsy initially thought to be due to bronchospasm. During a subsequent posterior spinal fusion procedure, he suffered cardiorespiratory arrest resulting in the procedure being aborted. Bronchoscopy performed shortly after resuscitation revealed an undiagnosed narrowing of the distal trachea and bronchi. This is the first description of a patient with late-onset Pompe disease with undiagnosed critical tracheal stenosis due to the progression of thoracic lordosis, which was ultimately relieved by posterior spinal fusion.

Toward Better Pain Management: The Development of a "Pain Stewardship Program" in a Tertiary Children's Hospital.

OBJECTIVE: Despite increased focus on pediatric pain, uncontrolled pain is still a problem for hospitalized pediatric inpatients. A program was designed to find patients with uncontrolled pain and develop a framework to oversee their pain management. This report details the development of a pain stewardship program with data from the first year of its activity. METHODS: Hospitalized inpatients in a tertiary care pediatric center in the mid-Atlantic region were included in the study. Pain scores are recorded every 4 hours in the hospital electronic health record. A report was constructed to find all patients with an average pain score ≥7 in the preceding 12 hours. The charts of these patients were reviewed by our anesthesia pain service, and all patients were grouped into 1 of the following action categories: (1) no action required; (2) telephone call to the patient's attending physician; (3) one-time consultation; (4) consultation with ongoing management; or (5) patient was already on the anesthesia pain service. Demographic data, pain regimens, and outcomes were recorded in a prospectively collected database. RESULTS: There were 843 records on 441 unique patients. Only 22% required action to be taken by the anesthesia pain service. The pain stewardship database revealed that patients with sickle cell disease or abdominal pain required more frequent attention. CONCLUSIONS: An electronic health record-based pain stewardship program is an important step in identifying all children in the hospital with undermanaged pain, and it provides a warning system that may improve patient care, outcomes, and satisfaction.

Safety of Secretin Administration in Children.

OBJECTIVE: The aim of this study was to compare the hemodynamic parameters from the anesthesia records of children who underwent upper gastrointestinal endoscopy (esophagogastroduodenoscopy [EGD]) with and without secretin pancreatic function tests (sPFTs). METHODS: The hemodynamic parameters were retrieved from an electronic anesthesia database. The secretin group consisted of 186 children, and the age- and sex-matched control group included 136 patients who did not have sPFTs. RESULTS: There was no difference in the demographic parameters (age and sex) between the 2 groups. The secretin group had a lower height and body mass index. The sPFT resulted in an average 3-minute extension of the endoscopic procedure. The heart rate increased during the EGD in both groups and was higher (averaged 7 beats per minute) in the secretin group than the EGD-only group. There were mild elevations on the systolic and diastolic blood pressures. None of these changes were clinically significant. There were no complications reported during the anesthesia and procedures in the 2 groups. CONCLUSIONS: Secretin PFT is a safe procedure. It only slightly prolongs the total procedure and anesthesia time. There were no clinically significant changes in the vital parameters in the secretin group, and there were no adverse effects recorded.

Continuous chest wall ropivacaine infusion for analgesia in children undergoing Nuss procedure: a comparison with thoracic epidural.

BACKGROUND: Pain following Nuss procedure is severe and its management is challenging. Many different pain treatment modalities are currently being used, but none of them have been found to be ideal. AIM: In this retrospective review, we compare our current multimodal approach, which involves continuous ropivacaine infusion through chest wall catheters (CWC), intravenous patient-controlled analgesia (IV-PCA), and adjunctive medications (gabapentin and clonidine), with the technique that we used in the past, the thoracic epidural catheter (TEC). METHODS: Following IRB approval, we performed a retrospective analysis of data on 32 patients who underwent the Nuss procedure at our institution. All children were divided into two groups: TEC group: 0.2% ropivacaine and hydromorphone 10 mcg·ml(-1) epidural infusion (n = 15) and CWC group (with IV-PCA and adjuncts [gabapentin + clonidine]): 0.2% ropivacaine infusion and hydromorphone PCA, oral gabapentin, and transdermal clonidine patch (n = 17). RESULTS: Both the groups were demographically similar. Average numeric pain scores were higher in the CWC group only on the day of surgery (mean ± sd: 3.79 ± 1.58 vs 2.68 ± 1.30; 95% CI: -2.16 to -0.05). Pain scores on postoperative day 1 (mean ± sd: 3.40 ± 1.59 vs 3.35 ± 1.32; 95% CI: -1.11 to 1.01), day 2 (mean± sd: 3.39 ± 1.79 vs 2.99 ± 1.06; 95% CI: -1.50 to 0.70), and on the day of discharge (DOD) (mean± sd: 3.25 ± 1.84 vs 3.99 ± 1.28; 95% CI: -0.42 to 1.89) were comparable between the groups. The CWC group needed fewer changes in the therapeutic regimen to maintain acceptable pain relief, had lower incidence of nausea and vomiting, had shorter anesthesia time, total OR time, and hospital length of stay. CONCLUSION: TEC provided better analgesia following the Nuss procedure only on the day of surgery. On the subsequent days until discharge, pain scores were comparable. However, CWC offered other advantages: it was less labor intensive and had fewer side effects, shorter OR time, and shorter hospital stay.

Effect of 90° counterclockwise rotation of the endotracheal tube on its advancement through the larynx during nasal fiberoptic intubation in children: a randomized and blinded study.

BACKGROUND: Resistance to the passage of the endotracheal tube (ETT) is frequently encountered in children as it is advanced over the fiberoptic scope for placement into the trachea because it gets hung up at the laryngeal inlet. Literature in adults indicates that a 90° counterclockwise rotation (CCR) of the ETT before advancing results in smooth passage. We found no literature in children. OBJECTIVES: Our aim was to study if a 90° counterclockwise rotation (CCR) of the ETT before advancement leads to smooth passage of the ETT into the larynx in children. METHODS: Following IRB approval, we performed this study in two parts: Part 1: An unblinded, observational, pilot study on 20 children scheduled for oral rehabilitation where we concurrently used a fiberoptic scope nasally and GlideScope orally. We visualized the ETT path and observed that 90° CCR allowed smooth passage without hang up. Part 2: A blinded and randomized study on 40 children to confirm if 90° CCR from the outset would improve passage of the ETT during nasal intubation with a fiberoptic scope in children. All children were divided into two groups: group S, ETT bevel facing left; group R, ETT bevel facing down. RESULTS: In Part 1, we observed that the ETT got hung up in 57% of children with standard bevel direction (facing left) and in 0% of children when prerotated. In Part 2, efficacy of prerotation was confirmed; the ETT got hung up in 50% of children in group S but in only 10.5% of children in group R. CONCLUSION: A change in ETT tip orientation from bevel facing left to facing down by 90° CCR, leads to a significantly higher first-attempt success rate by nasal approach in children. We believe the ETT should be rotated before insertion into the nostril to ensure that full 90° CCR of the tip has been accomplished.

Outpatient outcomes and satisfaction in pediatric population: data from the postoperative phone call.

BACKGROUND: Quality and patient/parent satisfaction are goals for pediatric perioperative services. As part of the implementation of our operating room electronic medical record (EMR), a postoperative phone call questionnaire was developed to assess patients discharged after outpatient surgery. The goal of this initiative was to determine the rate of common postoperative complications and understand reasons for patient/parent dissatisfaction. METHODS: Institutional Review Board approval was obtained for chart review. The postoperative phone call survey was attempted by our postanesthesia care unit nursing staff on all pediatric outpatients. The call was attempted for 3 days. From 2009 to 2013, more than 37 000 phone records existed in our EMR, Epic Optime (Epic Systems, Verona, WI). These data were extracted to a business intelligence (BI) program, QlikView (Qliktech, Radnor, PA, USA). A BI dashboard was constructed to obtain phone call results for any given time frame from monthly to spanning several years. Complications were logged as 4-point severity rating scales (none, mild, moderate, severe) with descriptions for each level. The BI dashboard calculated the overall and rates by severity for the following: (i) nausea, (ii) vomiting, (iii) pain, (iv) bleeding, (v) hoarseness, and (vi) difficulty eating. RESULTS: Of 42 688 outpatient cases, 37 620 postoperative phone calls were completed for an overall response rate of 88%. Pain, at 11.1%, was the highest reported postoperative complication. The rate of dissatisfaction was reported to be 0.31%. Most patients reporting dissatisfaction (62%) did not report any complications. Contingency coefficient showed that there was little relationship between satisfaction and presence of complications. CONCLUSION: A postoperative phone survey is cost-effective and appreciated by patients. We found that satisfaction with our perioperative services was not related to the rates of reported complications. Although reducing complications is of utmost importance, improvements in wait times and other operational issues would yield greater improvements in satisfaction.

Development of a computerized monitoring program to identify narcotic diversion in a pediatric anesthesia practice.

PURPOSE: Development of an operational reporting dashboard designed to correlate data from multiple sources to help detect potential drug diversion by automated dispensing cabinet (ADC) users is described. METHODS: A commercial business intelligence platform was used to create a dashboard tool for rapid detection of unusual patterns of ADC transactions by anesthesia service providers at a large pediatric hospital. By linking information from the hospital's pharmacy information management system (PIMS) and anesthesia information management system (AIMS) in an associative data model, the "narcotic reconciliation dashboard" can generate various reports to help spot outlier activity associated with ADC dispensing of controlled substances and documentation of medication waste processing. RESULTS: The dashboard's utility was evaluated by "back-testing" the program with historical data on an actual episode of diversion by an anesthesia provider that had not been detected through traditional methods of PIMS and AIMS data monitoring. Dashboard-generated reports on key metrics (e.g., ADC transaction counts, discrepancies in dispensed versus reconciled amounts of narcotics, PIMS-AIMS documentation mismatches) over various time frames during the period of known diversion clearly indicated the diverter's outlier status relative to other authorized ADC users. CONCLUSION: A dashboard program for correlating ADC transaction data with pharmacy and patient care data may be an effective tool for detecting patterns of ADC use that suggest drug diversion.