Effect of Preemptive Acetaminophen Administered Within 1 Hour of General Anesthesia on Gastric Residual Volume and pH in Children.

PURPOSE: Determine whether preoperative oral acetaminophen increases gastric residual volume and lowers gastric pH. DESIGN: Prospective, randomized. METHODS: Healthy children, 1 to 14 years, having elective magnetic resonance imaging (MRI) were randomized to oral acetaminophen within 1 hour of induction versus fasting. Gastric volume and pH were measured immediately after intubation. Adverse events were documented from induction through 72 hours post MRI. FINDINGS: Thirty-seven children completed the study (16 treatment, 21 control). Gastric residual volume between groups was not significantly different. The acetaminophen group had significantly higher pH than control group (1.86 ± 0.42 vs 1.56 ± 0.34; P ≤ .044). Three children in the control and 6 in the treatment group experienced minor adverse events. CONCLUSIONS: Findings suggest administering oral acetaminophen prior to induction of anesthesia is not associated with increased gastric residual volume and increases the gastric pH. Further study is needed to examine outcomes such as aspiration pneumonitis risk.

Evaluation of emergency pediatric tracheal intubation by pediatric anesthesiologists on inpatient units and the emergency department.

BACKGROUND AND OBJECTIVES: There are limited data on pediatric emergency tracheal intubation on inpatient units and in the emergency department by anesthesiologists. This retrospective cohort study was designed to describe the frequency of difficult intubation and adverse events associated with emergency tracheal intubation performed by pediatric anesthesiologists in a large children's hospital. METHODS: All emergency tracheal intubation on inpatient units and the emergency department performed by pediatric anesthesiologists over a 7-year period in children <18 years were identified by querying our perioperative clinical information system. Medical records were comprehensively reviewed to describe the emergency intubation process and outcomes. RESULTS: One hundred and thirty-two intubations from 120 children (median age 3.3 years) were eligible. The majority of emergency tracheal intubations were successful with 1-2 laryngoscopy attempts, while 14 (10.6%) were difficult. Despite grade 3 view in 3/14 cases, the airway was secured after multiple direct laryngoscopy attempts. Eleven required use of an alternative airway device to secure the airway. A preexisting airway abnormality or craniofacial abnormality was present in 57% of cases with difficult intubation including half with micrognathia or retrognathia. Major intubation-related adverse events such as aspiration, occurred in 5 (3.8%) emergency tracheal intubations. Mild-to-moderate intubation-related adverse events occurred in 23 (17.4%) emergency tracheal intubations including mainstem bronchus intubation (13.6%). CONCLUSION: A significant rate of difficult intubation and mild-to-moderate intubation-related adverse events were found in emergency tracheal intubations on inpatient units and the emergency department in children performed by a pediatric anesthesiology emergency airway team. Difficult intubation was observed frequently in children with preexisting airway and craniofacial abnormalities and often required the use of an alternative airway device to successfully secure the airway.

Narcotic-only Epidural Infusion for Posterior Spinal Fusion Patients: A Single-Center, Retrospective Review.

BACKGROUND: Adequate and safe postoperative analgesia for patients with idiopathic scoliosis undergoing posterior spinal fusion (PSF) remains challenging and controversial. A past adverse event in this patient population triggered a change of our institution's practice from epidurals containing bupivacaine and has resulted in use of epidurals containing solely narcotic (hydromorphone) for postoperative analgesia. This retrospective review looks at our experiences with hydromorphone patient-controlled epidural analgesia for postoperative analgesia in this patient population. METHODS: Electronic medical records of all children with a diagnosis of idiopathic scoliosis who underwent PSF surgery at our institution during the period of January 2011 to October 2011 were reviewed from the time they entered the PACU through the first 72 hours following PACU discharge. Specifically, the charts were reviewed for pain scores, sedation scores, narcotic use, use of adjuvant medications, antiemetics, antipruritics, hours to first ambulation, hours to first oral intake, respiratory rate, SpO2 values, need for any respiratory interventions, length of stay, and any adverse events. RESULTS: Fifty-six patients were enrolled. Three patients had their epidurals removed within the first 24 hours (5.4% failure rate). Highest mean pain scores ranged from 5.6±2.3 to 5.8±2.2 with median pain scores ranging from 4 to 6. There were no respiratory or neurological adverse events. Ambulation occurred on either postoperative day 1 or 2. The incidence of vomiting in this study was 34% in the first 24 hours post-PACU discharge and during this period, 61% of patients received ondansetron, for either nausea or pruritus. The mean length of stay for our patients was 3.95 days, with a median of 4 days. CONCLUSIONS: This retrospective review suggests that hydromorphone epidurals used for pain control in postoperative PSF patients are a reasonable alternative to IV-PCA, in terms of analgesia, side-effect profile, and length of stay. LEVEL OF EVIDENCE: Level III-retrospective study.

A retrospective description of anesthetic medication dosing in overweight and obese children.

INTRODUCTION: Pediatric obesity is a major health concern in the United States and as many as 34% of those who require general anesthesia are overweight or obese (OW). The lack of data and recommendations for dosing medications in obese children leaves significant gaps in the understanding of correct dosing in the clinical setting. OBJECTIVE: To determine whether OW children were more likely to receive doses of medications outside the recommended range. METHODS: Following IRB approval, patient medical records were queried to identify children 2 through 17 years who underwent noncardiac surgeries and received at least one medication of interest. Children with hepatic disease, renal disease, neurological impairment, sleep-disordered breathing, or missing height or weight measurements were excluded. Children were stratified into weight categories based on age and gender percentiles as per CDC guidelines. Those ≥85th percentile were classified as overweight/obese. Ideal and lean weight (for age, gender) were calculated. Drug doses were stratified as under-dosed (>10% below minimum recommended dose), overdosed (>10% above maximum recommended dose), or within recommended dose (dose ± 10%). Actual doses were compared to recommended doses as per actual, ideal, or lean weight (as recommended for specific drugs) in the overweight/obese groups vs the control weight (CW) group. RESULTS: Ten thousand five hundred and nine doses were reviewed. Overweight/obese children were more likely to receive doses outside the recommended dose range than the CW group. CONCLUSIONS: Overweight/obese children were more likely to receive doses of common anesthetic medications outside the recommended doses potentially adding risk of adverse outcomes in these children.

Early adjuvant use of nonopioids associated with reduced odds of serious postoperative opioid adverse events and need for rescue in children.

OBJECTIVES: Examine factors associated with opioid adverse drug events (ADE) in children. SPECIFIC AIMS: Examine whether adjuvant nonopioid use is associated with a decreased probability of opioid-ADEs and need for rescue. BACKGROUND: Opioid-ADEs contribute to serious preventable harm for hospitalized children. Adjuvant nonopioid use may mitigate opioid risk postoperatively, yet few studies support this notion. METHOD: This nested case-control study included children who required intervention or rescue from opioid-ADEs and procedure-matched controls. Data were recorded from medical records and primary outcomes included serious opioid-ADEs (over-sedation and respiratory depression) and need for rescue (e.g., naloxone, rapid response team). Hierarchical logistic regression (HLR) models examined relationships between factors and opioid-ADEs. Early clinical signs and symptoms of deterioration were examined. RESULTS: Twenty five children with opioid-ADEs and 98 children without events were included. ASA-PS remained an independent risk factor (odds ratio, 2.56 [1.09, 6.03]; P = 0.031), while adjuvant nonopioids a risk reduction factor for opioid-ADEs (OR, 0.16 [0.05, 0.47]; P = 0.001) and need for rescue (0.14 [0.04, 0.47]; P = 0.001). Supplemental oxygen use at PACU discharge was associated with an increased odds of opioid-ADEs (OR, 3.72 [1.35, 10.23]; P = 0.007) and need for rescue (5.5 [1.7, 17.82]; P = 0.002). CONCLUSIONS: Findings from this study suggest that strategies such as early use of adjuvant nonopioids may reduce risk of opioid-ADEs postoperatively. Furthermore, children who require supplemental oxygen early postoperatively may be at heightened risk of later events.

Effects of a New York Medicaid Care Management Program on Substance Use Disorder Treatment Services and Medicaid Spending: Implications for Defining the Target Population.

AIMS: We examined the effects of a statewide New York (NY) care management (CM) program for substance use disorder (SUD), Managed Addiction Treatment Services (MATS), on SUD treatment services' utilization and spending among patients with a recent history of high Medicaid spending and among those for whom a predictive algorithm indicates a higher probability of outlier spending in the following year. METHODS: We applied difference-in-difference analyses with propensity score matching using NY Medicaid claims data and a state registry of SUD-treatment episodes from 2006 to 2009. A total of 1263 CM enrollees with high SUD treatment spending (>$10K) in the prior year and a matched comparison group were included in the analysis. Crisis care utilization for SUD (detoxification and hospitalizations), outpatient SUD treatment, and Medicaid spending were examined over 12 months among both groups. CM effects among predicted high-future-spending patients (HFS) were also analyzed. RESULTS: CM increased outpatient SUD treatment visits by approximately 10.5 days (95% CI = 0.9, 20.0). CM crisis care and spending outcomes were not statistically different from comparison since both conditions had comparable pre-post declines. Conversely, CM significantly reduced SUD treatment spending by approximately $955 (95% CI = -1518, -391) and reduced days of detox utilization by about 1.0 days (95% CI = -1.9, -0.1) among HFS. CONCLUSION: Findings suggest that CM can reduce SUD treatment spending and utilization when targeted at patients with a greater likelihood of high future spending, indicating the potential value of predictive models to select CM patients.

Do 0-10 numeric rating scores translate into clinically meaningful pain measures for children?

BACKGROUND: Self-reported pain scores are used widely in clinical and research settings, yet little is known about their interpretability in children. In this prospective, observational study we evaluated the relationship between 0 to 10 numerical rating scale (NRS) pain scores and other self-reported, clinically meaningful outcomes, including perceived need for medicine (PNM), pain relief (PR), and perceived satisfaction (PS) with treatment in children postoperatively. METHODS: This study included children ages 7 to 16 years undergoing surgery associated with postoperative pain. One to 4 observations were recorded in each child within the first 24 hours postoperatively. At each assessment, children rated their pain with the NRS, stated their PNM, and rated their satisfaction with pain management. Assessments were repeated within 1 to 2 hours, and children additionally rated their PR as the same, better, or worse in comparison with the earlier assessment. Receiver operator characteristic curves were developed to examine potential NRS cut-points for PNM and PS, and the minimum clinically significant difference (MCSD) in pain score associated with PR was calculated. RESULTS: Three hundred ninety-seven observations (including 189 pairs) were recorded in 113 children. NRS scores associated with PNM were significantly higher than "no need" (median 6 vs. 3; P < 0.001). NRS scores >4 had good sensitivity (0.81) and specificity (0.70) to discriminate PNM, but with a large number of false positives and negatives (e.g., 42% of children with scores >4 did not need analgesia). The MCSD in NRS scores was -1 (95% confidence interval [CI] -0.5 to 1) or +1 (CI 0.5 to 2.7) in relation to feel "a little better" or "worse," respectively (P < 0.001 vs. the same). NRS scores >6 had a sensitivity of 0.82 and specificity of 0.76 in discriminating dissatisfaction with treatment, yet 46% and 24% of children with scores >6, respectively, were somewhat to very satisfied with their analgesia. CONCLUSIONS: This study provides important information regarding the clinical interpretation of NRS pain scores in children. Data further support the NRS as a valid measure of pain intensity in relation to the child's PNM, PR, and PS in the acute postoperative setting. However, the variability in scores in relation to other clinically meaningful outcomes suggests that application of cut-points for individual treatment decisions is inappropriate.

Prevalence of habitual snoring in children and occurrence of peri-operative adverse events.

OBJECTIVE: To describe the prevalence of habitual snoring and examine its association with peri-operative adverse events in children undergoing elective non-cardiac surgery--a relationship that has not been previously characterised. METHODS: Using a prospective observational design, we studied children aged 6-18 years undergoing elective non-cardiac surgeries at our institution. Trained research assistants collected clinical (including peri-operative adverse events) and anthropometric data on all individuals. Patients were stratified into two classes, habitual snorers and non-snorers. Subsequently, univariate factors associated with snoring were explored and then odds ratios for the occurrence of peri-operative adverse events were calculated from logistic regression after controlling for clinically relevant cofactors. RESULTS: Among 1102 patients, the prevalence of habitual snoring was 27.3% (28.2% for boys vs. 26.3% for girls). All the measured anthropometric parameters (BMI, waist circumference and neck circumference) were significantly higher in habitual snorers compared with non-snorers. The overall respiratory complication rate was 11.1%. Respiratory adverse events were more frequent in habitual snorers compared with non-snorers (16.9 vs. 8.9%; P < 0.001). Additionally, habitual snoring was associated with longer post-anaesthesia care unit (PACU) stay (114.0 ± 49.6 vs. 103.6 ± 48.9 min; P = 0.002) even after controlling for the occurrence of adverse respiratory events. CONCLUSION: The prevalence of habitual snoring was high in this cohort of paediatric surgical patients. Habitual snoring was associated with some peri-operative adverse events and prolonged PACU stay and should be considered an important symptom in the pre-operative review of children.

Early postoperative outcomes in children after adenotonsillectomy.

Children undergoing tonsillectomy remain at risk for postoperative pain, respiratory depression, and postoperative nausea and vomiting (PONV), presenting unique challenges for the postanesthesia nurse. This prospective, observational study examined the relationships between and factors contributing to these outcomes in 102 children after tonsillectomy. All children received an intraoperative opioid and one or more antiemetics. The majority (67%) experienced moderate to severe pain, 27% experienced a respiratory event, and 7% had PONV. Children with moderate to severe pain received similar intraoperative opioid dosages, increased postoperative opioids (P < 0.05), and had longer PACU stays (P < 0.05) compared to those with no to mild pain. Respiratory events were not associated with age, sleep-disordered breathing, or opioid use. This study suggests that children undergoing tonsillectomy experience significant pain and respiratory events. Further study examining nonopioid treatments are warranted to determine the best practices for this high-risk group of children.

Predictive validity of the New York State Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) for continuous engagement in treatment among individuals recommended for outpatient care.

BACKGROUND: The New York State (NYS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) was launched in 2015 to determine the most appropriate level of care for individuals seeking addiction treatment. However, research has not studied its predictive validity. We examined the predictive validity of the LOCADTR recommendation for outpatient treatment by determining whether those who entered a level of care (LOC) concordant with the LOCADTR recommendation differed in continuous engagement in treatment compared to those who entered a discordant LOC. METHODS: The study combined data from two NYS administrative sources, the LOCADTR database and a treatment registry. The study examined characteristics of the clients who entered concordant and discordant LOCs as well as tested for differences in continuous engagement of clients who entered discordant care compared to a propensity score-matched comparison group of clients who entered the concordant LOC. RESULTS: Among clients for whom the LOCADTR recommended the outpatient LOC, concordant clients who entered the outpatient LOC were more likely to be retained in care than discordant clients who entered the inpatient LOC (aOR = 0.53; 95% CI = 0.36, 0.77). We did not observe statistical differences in continuous engagement among clients who were recommended for outpatient and entered that LOC versus those who entered the outpatient rehabilitation LOC instead (aOR = 1.08; 95% CI = 0.90, 1.30). CONCLUSION: This study provides support for predictive validity of recommendations stemming from the LOCADTR. Clients, treatment providers, and payers benefited from a tool that provides clear guidance and predictively valid recommendations for treatment placement. The study found that clients were more likely to be retained in treatment for 6 months or longer if admitted to outpatient care, as recommended by the LOCADTR algorithm, rather than to inpatient treatment. One factor accounting for the longer engagement in outpatient care is the low level of continuity of care among patients being discharged from inpatient treatment.

Using community pharmacies and team observed structured clinical encounters (TOSCEs) for interprofessional education and training.

INTRODUCTION: Collaborative practice improves patient outcomes and is a needed student skill. An interprofessional education and collaborative practice (IPECP) program was developed using community pharmacies, clinics, and emergency departments. This study's purpose was to assess student pharmacists' team attitudes and skill development after the IPECP using team observed structured clinical encounters (TOSCEs). METHODS: Nineteen pairs of fourth-year pharmacy and second-year physician assistant students practiced together in a community pharmacy (two days) and clinic or emergency department (two days). They completed TeamSTEPPS training and two team modules. Assessments included TOSCEs and pre/post attitude surveys. RESULTS: Students significantly increased all TOSCE domain skills with pre- to post-mean score (SD) of: team communications 3.0 (0.5) to 4.1 (0.5), collaboration 2.8 (0.6) to 4.0 (0.5), roles and responsibilities 2.4 (0.4) to 3.8 (0.5), patient-centered care 2.8 (0.5) to 4.1 (0.6), conflict management 2.8 (0.5) to 4.1 (0.6), team functioning 2.7 (0.6) to 3.9 (0.6), and global performance 2.8 (0.6) to 4.0 (0.5). Afterwards, students reported positive attitudes about team-based patient care. All students stated the experience increased patient and healthcare professional communication skills and understanding of patient problems, and decreased errors. Most students (84%) agreed team care increased interventions compared to individually provided care. Most students (84%) thought the experience was worthwhile, and 68% agreed the IPECP program should be continued. CONCLUSIONS: This study supports that IPECP can be conducted in a community pharmacy and clinic or emergency department to improve student team skills as evidenced by documented team skills development during TOSCEs.

Anesthesia induction, emergence, and postoperative behaviors in children with attention-deficit/hyperactivity disorders.

BACKGROUND/AIM: Given the increasing prevalence of attention-deficit and attention-deficit hyperactivity disorders (ADHD), anesthesiologists are now presented with a greater number of children who are diagnosed with these conditions. This prospective, observational study was designed to compare anesthesia induction, emergence, and postoperative behaviors in children with and without ADHD. METHODS/MATERIALS: The sample included 268 children, 4-17 years of age undergoing elective surgery with a confirmed diagnosis of ADHD. A cohort of children without ADHD, matched for age, gender, and procedure served as controls. Preoperative cooperation, induction, and emergence behaviors were measured using established scales. Postoperative maladaptive behaviors were measured using a modified Post-Hospital Behavioral Questionnaire that was administered via telephone 1 week after surgery. RESULTS: Children with ADHD were significantly less cooperative at induction of anesthesia compared with controls (20.9% vs 10.6% respectively, P = 0.001). Although some control children exhibited an increase in maladaptive behaviors postoperatively, these behaviors were significantly greater among children with ADHD. In particular, relative to their normal behaviors, children with ADHD had greater difficulties in concentration and decision-making; were more disobedient, impulsive, fidgety, had poor appetite; were difficult to talk to; and exhibited an increase in temper tantrums following surgery. CONCLUSIONS: This is the first prospective study to our knowledge that has examined the perioperative and postoperative behaviors of children with ADHD compared to those without this disorder. These results are important in alerting anesthesiologists, parents, and teachers to the potential for difficulties during induction of anesthesia and postoperative behavioral problems at home and in school, respectively.

Comparing peripheral venous access between obese and normal weight children.

INTRODUCTION: Intravenous (i.v.) access is sometimes a difficult, time-consuming, and highly frustrating procedure. Obesity is widely believed to be associated with difficult peripheral intravenous access (PIV) placement. This study examined the relationship between body mass index (BMI) and ease of venous access in children undergoing noncardiac surgical procedures. METHODS: We prospectively collected data on children aged 2-18 years undergoing elective noncardiac surgery at our institution. A trained research assistant (RA) was present for PIV placement in all patients and noted the following: age, gender, ethnicity, weight, height, and BMI. We also collected data on i.v. insertion site, number of attempts, number of operators, and the number of i.v. cannula used. The main outcome variable was success or failure of i.v. placement on first attempt. Sample size calculation indicated a need for 40 obese and 40 control patients. RESULTS: A total of 103 (56 lean and 47 obese) patients comprised the study population. PIV cannulation was achieved on the first attempt in 55.2% while 39.6% of patients had 2-3 attempts before successful cannulation. Obese children were more likely to have failed attempt at first cannulation than lean controls (P < 0.001). Similarly, obese children were more likely to require two or more attempts at cannulation than lean children (P < 0.001). CONCLUSION: These data indicate that i.v. placement is more difficult in obese children than their lean peers and that the most likely site for successful placement in obese children after a failed attempt on the dorsum of the hand is the volar surface of the hand. Knowledge of potential sites for successful i.v. access could help to improve the success rate for i.v. placement.

How are Substance Use Disorder Treatment Programs Adjusting to Value-Based Payment? A Statewide Qualitative Study.

Healthcare systems are implementing value-based payment (VBP) arrangements in efforts to incentivize cost-effective, high quality of care. These arrangements represent a major shift for substance use disorder (SUD) treatment providers who may need to make changes to their clinical and business operations to meet new demands for quality under value-based contracts. This qualitative study was conducted in the context of New York State's efforts to implement VBP among SUD treatment providers to understand their experiences, challenges, and needs. Five focus groups were conducted across the State with a total of 68 treatment professionals. Content analysis was conducted and five themes emerged. First, competing demands, limited workforce and technology infrastructure, and perceived lack of information were leading to overwhelmed administrators. Second, confusion and financial fear was being driven by the need for new clinical roles, business practices, and external partnerships. Third, providers were undertaking a number of measures to address workforce needs. Fourth, providers were building new business models and clinical practices. Fifth, providers desired more support and information. As VBP models are being adopted, healthcare systems should identify ways to mitigate challenges and support SUD treatment providers that may have limited resources to address complex workforce, client, and infrastructure needs.

The incidence of intraoperative awareness in children: childhood awareness and recall evaluation.

BACKGROUND: There is a considerable discrepancy between the reported incidences of awareness under anesthesia in children (0.2%-2.7%). In this prospective, observational, cohort study we evaluated 1) the incidence of awareness during general anesthesia in children across three settings, 2) factors contributing to awareness, and 3) short-term psychological effects of awareness. METHODS: Children (aged 5-15 yr) who underwent general anesthesia were included, and all perioperative data including anesthetic drugs were collected prospectively. Children were interviewed three times postoperatively using a semistructured questionnaire. All cases of possible or probable awareness were discussed with the child's care providers to confirm or refute the memories. Internal consensus among investigators across sites was reached, and these cases and a random selection of others were reviewed by three external reviewers. For the purpose of this study, possible/probable awareness was defined as cases with agreement between the internal consensus and at least two of the three external reviewers. RESULTS: One thousand seven hundred eighty-four children completed at least one interview. Thirty-two cases were coded as possible or probable awareness by at least one entity (i.e., either the internal consensus or one of the external reviewers). Fourteen of these cases met the definition for possible/probable awareness, making the incidence of awareness 0.8%. Six of the 14 children with awareness (43%) remembered feeling scared during their surgery and three (21%) reported hurting. Two children in this group (14%) said they would feel worse if they had to have surgery again, which was not significantly different from reports of children with no recall (15%). None of the children with awareness required psychological follow-up. Endoscopic procedures were associated with a higher risk for awareness (relative risk = 4.5 [confidence interval 1.5-13.6]). CONCLUSIONS: Although 0.8% of children experienced possible/probable awareness in this study, none experienced short-term psychological distress.

Epidural analgesia compared with intravenous analgesia after pediatric posterior spinal fusion.

BACKGROUND: Pain management remains challenging for pediatric patients after posterior spinal fusion (PSF). This study compares the effectiveness of hydromorphone and bupivacaine administered through patient-controlled epidural analgesia (PCEA) with hydromorphone patient-controlled intravenous analgesia (IV-PCA) in this population. METHODS: Patients aged 8 to 18 years undergoing PSF for idiopathic scoliosis were randomized to receive either PCEA (0.1% bupivacaine plus hydromorphone 10 mcg/mL at 8 mL/h plus bolus dosing) or IV-PCA (hydromorphone 2 mcg/kg/h continuous infusion; 2 mcg/kg bolus dose). Pain scores, severity of muscle spasms, and analgesic doses were recorded for 3 postoperative days (PODs). Adverse events were followed until discharge. RESULTS: Thirty-eight patients were included (19 PCEA and 19 IV-PCA). Seven in the PCEA group (37%) experienced early epidural failure, and 2 in the IV-PCA group remained intubated, sedated, and ventilated for several hours postoperatively; these patients were included in the intention-to-treat analysis. All data are presented as "per protocol" unless otherwise specified. Pain scores were significantly lower on days 2 and 3 (P < or = 0.042). Eight percent of the patients who received PCEA experienced moderate-to-severe spasms through POD 3 compared with 35% of those in the IV-PCA group (P=NS). Seven (58%) patients in the PCEA group and 17 (100%) in the IV-PCA group required diazepam (P=0.007). CONCLUSIONS: Epidural catheters provide modestly improved analgesia in patients after PSF for idiopathic scoliosis. However, the high failure rate in this population emphasizes a need for a close assessment for adequate blockade early in the recovery period. This study provides an excellent platform on which to build future trials that could include increased baseline dosing for the epidural medications, radiographic confirmation of catheter placement, and dual catheter techniques toward the goal of improving pain control in these patients. LEVEL OF EVIDENCE: Level 2, randomized, controlled trial.

Parental presence on emergence: effect on postanesthesia agitation and parent satisfaction.

This prospective, randomized study compared the incidence and duration of postanesthetic agitation in children whose parents were present or absent during emergence from anesthesia. Findings demonstrated that there was no difference in agitation between groups; however, more parents who were present believed they were present at "the right time," in contrast to those reunited later, who more often said they arrived "too late." Furthermore, these parents were comfortable in the setting and reported a high degree of helpfulness in comforting their child. Findings from this study suggest that although parental presence at emergence did not decrease agitation in young children, there was significant psychosocial benefit to the parents. Perioperative and perianesthesia nurses should consider these potential benefits when planning reunion of parents with their children after surgery.

Development and Testing of an Addiction Treatment Level of Care Determination Tool.

Two studies examined inter-rater reliability and content-related validity of an addiction treatment level of care determination tool currently in use in New York, the LOCADTR 3.0. The studies occurred after tool implementation. In study 1, 139 providers used the LOCADTR 3.0 to determine level of care for four case vignettes. Inter-rater reliability coefficients were calculated. In study 2, 387,338 state records from existing data were analyzed to determine how often providers opted to override the LOCADTR 3.0 level of care determination by choosing an alternative level of care. In study 1, an acceptable inter-rater reliability (IRR = .57-.59) was found. Good indication of content-related validity was also found; participants chose the same level of care the study team chose for each vignette 80% of the time. In study 2, the override option was selected only 10% of the time, further establishing the content validity of the tool. These studies provide evidence for acceptable preliminary reliability and validity of the LOCADTR 3.0.

Incidence and risk factors for perioperative adverse respiratory events in children who are obese.

BACKGROUND: Consistent with the increasing prevalence of obesity in the United States and many countries worldwide, anesthesiologists are now presented with a greater number of adult and pediatric patients who are significantly overweight. This prospective study was designed to examine the relation between age-adjusted body mass index, preoperative comorbidities, and perioperative outcome in children. METHODS: Children aged 2-18 yr undergoing noncardiac elective procedures were classified as overweight or obese based on their age- and sex-adjusted body mass index. Information was elicited regarding patient demographics, presence of comorbidities, and anesthetic technique. Data regarding the incidence and severity of perioperative adverse events were collected prospectively. RESULTS: Two thousand twenty-five children comprised the sample (1,380 normal weight, 351 overweight, and 294 obese). Obese children had a significantly higher prevalence of comorbidities than nonobese children, including asthma, hypertension, sleep apnea, and type II diabetes. Furthermore, obese children had a higher incidence of difficult mask ventilation, airway obstruction, major oxygen desaturation (>10% of baseline), and overall critical respiratory adverse events. Logistic regression analysis revealed several risk factors for adverse events, including procedures involving the airway, obesity, age younger than 10 yr, and a history of obstructive sleep apnea. CONCLUSIONS: These results suggest that children presenting for elective surgical procedures who are obese have a greater prevalence of preexisting comorbid medical conditions and an increased incidence of perioperative adverse respiratory events compared with normal-weight children. Identification and awareness of risk factors for perioperative complications will be important in optimizing the anesthetic management of these children.