Operating Room Personnel Determine Efficiency of Pediatric Spinal Fusions for Scoliosis.

STUDY DESIGN: Retrospective chart review. OBJECTIVES: To investigate the effect of different surgeons, anesthesiologists, and cRNAs individually and in teams on various perioperative and operative time intervals in a large, high-volume children's hospital. SUMMARY OF BACKGROUND DATA: Along with individual factors, studies have indicated that team factors play a role in efficiency, with larger teams leading to increased procedure times. An operating room (OR) staff dedicated to orthopedics has been reported to decrease turnover time; however, the characteristics and behaviors of surgical team members, to our knowledge, have not been analyzed as possible factors contributing to pediatric OR efficiency, and limited research has been conducted in the field of orthopedic personnel. METHODS: Chart review identified consecutive pediatric and adolescent patients who had primary posterior spinal fusion (PSF) of ≥7 levels for correction of spinal deformity. Time intervals and delays were recorded based on previous studies looking at OR efficiency and adjusted to the specific time points available in our perioperative nursing records. RESULTS: Adjusted for etiology, osteotomy, fusion levels, distance from hospital, staff switch, and body mass index, there was a significant difference in patient wait time among anesthesiologists, surgeon-anesthesiologist, and anesthesiologist-certified registered nurse anesthetist (cRNA) teams; in surgery prep time and total prep among surgeons and SA teams; and in surgery time and total room time among surgeons. There were no significant differences among cRNAs, individually, in any time interval. CONCLUSIONS: Anesthesiologists have a significant effect before and surgeons have a significant effect after entry into the OR. Identification of this variability provides an opportunity to study the differences in habits and processes of high- and low-efficiency teams, which can then be applied to all teams with the goal of improving performance of all surgical teams. LEVEL OF EVIDENCE: Level IV, case series.

Establishing a surgical outreach program in the developing world: pediatric strabismus surgery in Guatemala City, Guatemala.

PURPOSE: To report our experince in establishing a sustainable pediatric surgical outreach mission to an underserved population in Guatemala for treatment of strabismic disorders. METHODS: A pediatric ophthalmic surgical outreach mission was established. Children were evaluated for surgical intervention by 3 pediatric ophthalmologists and 2 orthoptists. Surgical care was provided at the Moore Pediatric Surgery Center, Guatemala City, over 4 days. Postoperative care was facilitated by Guatemalan physicians during the second year. RESULTS: In year 1, patients 1-17 years of age were referred by local healthcare providers. In year 2, more than 60% of patients were prescreened by a local pediatric ophthalmologist. We screened 47% more patients in year 2 (132 vs 90). Diagnoses included congenital and acquired esotropia, consecutive and acquired exotropia, congenital nystagmus, Duane syndrome, Brown syndrome, cranial nerve palsy, dissociated vertical deviation, and oblique muscle dysfunction. Overall, 42% of the patients who were screened underwent surgery. We performed 21 more surgeries in our second year (58 vs 37), a 57% increase. There were no significant intra- or postoperative complications. CONCLUSIONS: Surgical outreach programs for children with strabismic disorders in the developing world can be established through international cooperation, a multidisciplinary team of healthcare providers, and medical equipment allocations. Coordinating care with local pediatric ophthalmologists and medical directors facilitates best practice management for sustainability.

Phantom limb pain in young cancer-related amputees: recent experience at St Jude children's research hospital.

OBJECTIVES: This study in children and young adults having cancer-related amputation aimed to examine the incidence of phantom limb pain (PLP) in the first year after amputation and also the proportion of patients who had preamputation pain. METHODS: A retrospective review of medical records was undertaken. The proportion of patients with PLP was reported. Fisher exact test was used to examine the association between PLP and the presence of preamputation pain and between PLP and age (≤ 18 y vs. >18 y). RESULTS: Twenty-six amputations were performed on 25 patients. During the year after amputation, 76% of patients had experienced PLP at some time. After 1 year, though, only 10% still had PLP. Preamputation pain was present in 64% of patients. Although both of our patients with PLP at 1 year were young adults (older than or equal to 18 y) and both had preamputation pain, we found no statistically significant associations between age or the presence of preamputation pain with PLP. DISCUSSION: PLP after cancer-related amputation in children and young adults seems to be common but generally short lived in most patients.

Complications of anesthesia for children with malignant infantile osteopetrosis before and after hematopoietic stem cell transplantation.

OBJECTIVES AND AIMS: The primary aim was to determine the frequency of anesthetic-related complications for patients with malignant infantile osteopetrosis (MIOP) before and after hematopoietic stem cell transplant (HSCT). The secondary aims were to describe the types of complications that occurred, to determine whether the risk of anesthetic complications was altered by HSCT, and to determine the frequency of difficult intubation. BACKGROUND: Patients with MIOP undergo HSCT, often in infancy, and anesthesia is frequently required for investigations and procedures associated with transplantation. Although MIOP has adverse implications for anesthetic management, the literature describing the anesthetic management of MIOP patients is limited. METHODS: A retrospective review of medical and anesthetic records was undertaken between November 2000 and March 2008. RESULTS: Eleven patients underwent 127 anesthetics. The overall complication rate was 11%. Before HSCT, there were 12 complications in 62 anesthetics (19.3%). After HSCT, there were two complications in 65 anesthetics (3.2%). This difference was not statistically significant. All of the complications were airway or respiratory events. Of the 26 intubations associated with anesthesia, 23 (88.5%) were easy, 1 (3.8%) was moderately difficult, and 2 (7.7%) were difficult. CONCLUSION: Complications associated with anesthesia for infants and children with MIOP having HSCT are fairly common and are usually airway or respiratory related. Difficult endotracheal intubation is also common.

How well do pediatric anesthesiologists agree when assigning ASA physical status classifications to their patients?

BACKGROUND: The scope and application of the American Society of Anesthesiologists Physical Status (ASA PS) classification has been called into question and interobserver consistency even by specialist anesthesiologists has been described as only fair. Our purpose was to evaluate the consistency of the application of the ASA PS amongst a group of pediatric anesthesiologists. METHODS: We randomly selected 400 names from the active list of specialist members of the Society for Pediatric Anesthesia. Respondents were asked to rate 10 hypothetical pediatric patients and answer four demographic questions. RESULTS: We received 267 surveys, yielding a response rate of 66.8% and the highest number of responses in any study of this nature. The spread of answers was wide across almost all cases. Only one case had a response spread of only two classifications, with the remaining cases having three or more different ASA PS classifications chosen. The most variability was found for a hypothetical patient with severe trauma, who received five different ASA PS classifications. The Modified Kappa Statistic was 0.5, suggesting moderate agreement. No significant difference between the private and academic anesthesiologists was found (P = 0.26). CONCLUSIONS: We present the largest evaluation of interobserver consistency in ASA PS in pediatric patients by pediatric anesthesiologists. We conclude that agreement between anesthesiologists is only moderate and suggest standardizing assessment, so that it reflects the patient status at the time of anesthesia, including any acute medical or surgical conditions.