In Pursuit of an Opioid-Free Pediatric Ambulatory Surgery Center: A Quality Improvement Initiative.

BACKGROUND: Opioids have been a central component of routine adult and pediatric anesthesia for decades. However, the long-term effects of perioperative opioids are concerning. Recent studies show a 4.8%-6.5% incidence of persistent opioid use after surgery in older children and adults. This means that >2 million of the 50 million patients undergoing elective surgeries in the United States each year are likely to develop persistent opioid use. With this in mind, anesthesiologists at Bellevue Clinic and Surgery Center assembled an interdisciplinary quality improvement team focused on 2 goals: (1) develop effective anesthesia protocols that minimize perioperative opioids and (2) add value to clinical services by maintaining or improving perioperative outcomes while reducing costs. This article describes our project and findings but does not attempt to make inferences or generalizations about populations outside our facility. METHODS: We performed a large-scale implementation of opioid-sparing protocols at our standalone pediatric clinic and ambulatory surgery facility, based in part on the prior success of our previously published tonsillectomy and adenoidectomy protocol. Multiple Plan-Do-Study-Act cycles were performed using data captured from the electronic medical record. The percentage of surgical patients receiving intraoperative opioids and postoperative morphine preintervention and postintervention were compared. The following measures were evaluated using statistical process control charts: maximum postoperative pain score, postoperative morphine rescue rate, total postanesthesia care unit minutes, total anesthesia minutes, and postoperative nausea and vomiting rescue rate. Intraoperative analgesic costs were calculated. RESULTS: Between January 2017 and June 2019, 10,948 surgeries were performed at Bellevue, with 10,733 cases included in the analyses. Between December 2017 and June 2019, intraoperative opioid administration at our institution decreased from 84% to 8%, and postoperative morphine administration declined from 11% to 6% using analgesics such as dexmedetomidine, nonsteroidal anti-inflammatory drugs, and regional anesthesia. Postoperative nausea and vomiting rescue rate decreased, while maximum postoperative pain scores, total anesthesia minutes, and total postanesthesia care unit minutes remained stable per control chart analyses. Costs improved. CONCLUSIONS: By utilizing dexmedetomidine, nonsteroidal anti-inflammatory drugs, and regional anesthesia for pediatric ambulatory surgeries at our facility, perioperative opioids were minimized without compromising patient outcomes or value.

The pudendal nerve block for ambulatory urology: What's old is new again. A quality improvement project.

INTRODUCTION: Caudal epidural analgesia (CEA) is a common analgesic technique performed for pediatric penile surgeries; however, it has associated morbidity. The pudendal nerve block (PNB) has been described as an effective analgesic alternative to CEA. OBJECTIVE: In this quality improvement study, we aim to assess the efficacy of PNB as compared to CEA within our ambulatory surgery center (ASC). We demonstrate our initial experience employing PNB for ambulatory pediatric urology procedures. STUDY DESIGN: Using retrospective, non-randomized, time-series, observational data, a comparative effectiveness study of CEA and PNB was performed. Patients less than three years old, who underwent circumcision, hypospadias repair, congenital chordee repair, correction of penile angulation/torsion, and buried penis repair with or without scrotoplasty, between January 1, 2015-September 9, 2019 with either CEA or PNB in an ASC at a single institution were included. Standard protocols for local and postoperative analgesia were used. Outcome measures were post anesthesia care unit (PACU) pain scores, morphine rescue rates, and PACU length of stay (LOS). These were analyzed using statistical process control (SPC) charts; standard SPC rules were used to detect special cause variation. RESULTS: A total of 999 patients were identified; 746 (74.7%), 172 (17.2%) and 81 (8.1%) received CEA, ultrasound guided PNB (US-PNB) and landmark directed PNB (LD-PNB), respectively. Demographic data was comparable between the three cohorts. There was no special cause variation in the outcome measures between the CEA, US-PNB and LD-PNB cohorts for maximum pain score, morphine rescue rates and PACU LOS. DISCUSSION: Pain outcomes and PACU LOS were similar between the CEA, US-PNB and LD-PNB cohorts, suggesting equivalent postoperative pain control between these techniques within our cohort. Previous published data has reported lower postoperative pain scores with PNB as compared to CEA for patients undergoing circumcision and hypospadias repair. CONCLUSION: PNB is non-inferior to CEA for analgesia for pediatric penile surgery, with LD-PNB being as effective as US-PNB. Given the simplicity and documented lower risk profile, PNB may be preferred to CEA for ambulatory pediatric urology procedures.

Explainable machine-learning predictions for the prevention of hypoxaemia during surgery.

Although anaesthesiologists strive to avoid hypoxemia during surgery, reliably predicting future intraoperative hypoxemia is not currently possible. Here, we report the development and testing of a machine-learning-based system that, in real time during general anaesthesia, predicts the risk of hypoxemia and provides explanations of the risk factors. The system, which was trained on minute-by-minute data from the electronic medical records of over fifty thousand surgeries, improved the performance of anaesthesiologists when providing interpretable hypoxemia risks and contributing factors. The explanations for the predictions are broadly consistent with the literature and with prior knowledge from anaesthesiologists. Our results suggest that if anaesthesiologists currently anticipate 15% of hypoxemia events, with this system's assistance they would anticipate 30% of them, a large portion of which may benefit from early intervention because they are associated with modifiable factors. The system can help improve the clinical understanding of hypoxemia risk during anaesthesia care by providing general insights into the exact changes in risk induced by certain patient or procedure characteristics.

Promoción de la investigación en anestesiología pediátrica / Promoting research in pediatric anesthesiology

RESUMEN En los últimos 2 años ha habido un interés creciente por promover la investigación como parte integral de la práctica académica en anestesiología en Colombia. El Simposio Colombiano de Investigación en Anestesiología, organizado por la Sociedad Colombiana de Anestesiología y Reanimación y la Sociedad Antioqueña de Anestesiología, formuló y publicó guías para promover este esfuerzo. Infortunadamente y a pesar de estos esfuerzos, la investigación en anestesia pediátrica aún es muy escasa. En este artículo de opinión discutimos por qué y cómo promover la investigación en anestesia pediátrica en Colombia.

ABSTRACT Over the past two years there has been increased interest in promoting research in anesthesia as an integral part of academic anesthesia practice in Colombia. The Colombian Symposium on Research in Anesthesia (organized by the Colombian Society of Anesthesiology and the Society of Anesthesiology and Reanimation of Antioquia) formulated and published guidelines to promote this effort. Despite these efforts, pediatric anesthesia is still a subspecialty in which very little research is done. In this opinion article we discuss why and how to promote research in pediatric anesthesia in Colombia.