Developing implementation strategies to adopt Enhanced Recovery After Surgery (ERAS®) guidelines.

BACKGROUND: Strong implementation strategies are critical to the success of Enhanced Recovery after Surgery (ERAS®) guidelines, though little documentation exists on effective strategies, especially in complex clinical situations and unfamiliar contexts. This study outlines the process taken to adopt a novel neonatal ERAS® guideline. METHODS: The implementation strategy was approached in a multi-pronged, concurrent but asynchronous fashion. Between September 2019 and January 2020, healthcare providers from various disciplines and different specialties as well as parents participated in the strategy. Multidisciplinary teams were created to consider existing literature and local contexts including potential facilitators and/or barriers. Task forces worked collaboratively to develop new care pathways. An audit system was developed to record outcomes and elicit feedback for revision. RESULTS: 32 healthcare providers representing 9 disciplines and 5 specialties as well as 8 parents participated. Care pathways and resources were created. Elements recommended for a successful implementation strategy included identification of champions, multidisciplinary stakeholder involvement, consideration of local contexts and insights, patient/family engagement, education, and creation of an audit system. CONCLUSION: A multidisciplinary and structured process following principles of implementation science was used to develop an effective implementation strategy for initiating ERAS® guidelines.

A Narrative Review of Oxygenation During Pediatric Intubation and Airway Procedures.

Hypoxemia is a common complication in the pediatric operating room during endotracheal intubation and airway procedures and is a precursor to serious adverse events. Small children and infants are at greater risk of hypoxemia due to their high metabolic requirements and propensity to alveolar collapse during general anesthesia. To improve the care and safety of this vulnerable population, continued efforts must be directed to mitigate hypoxemia and the risk of subsequent serious adverse events. Apneic oxygenation has been shown to significantly prolong the safe apnea time until desaturation in infants, children, and adults and may reduce the incidence of desaturation during emergency intubation of critically ill patients. Successful apneic oxygenation depends on adequate preoxygenation, patent upper and lower airways, and a source of continuous oxygen delivery. Humidified, high-flow nasal oxygenation systems have been shown to provide excellent conditions for effective apneic oxygenation in adults and children and have the added benefit of providing some carbon dioxide clearance in adults; although, this latter benefit has not been shown in children. Humidified, high-flow nasal oxygenation systems may also be useful during spontaneous ventilation for airway procedures in children by minimizing room air entrainment and maintaining adequate oxygenation allowing for a deeper anesthetic. The use of apneic oxygenation and humidified, high-flow nasal oxygenation systems in the pediatric operating room reduces the incidence of hypoxemia and may be effective in decreasing related complications.

Postexertional supraventricular tachycardia in children with catecholaminergic polymorphic ventricular tachycardia.

Catecholaminergic polymorphic ventricular tachycardia (CPVT) is a severe arrhythmia associated with sudden death in the young. It is caused by defective calcium handling in ventricular myocytes. The association of supraventricular tachycardia (SVT) with CPVT is described in the literature, occurring in the lead-up to ventricular tachycardia during exercise testing. We describe three cases of SVT that were initiated in the recovery period of exercise testing in children with CPVT.