The Current State of Combined Pediatric Anesthesiology-Critical Care Practice: A Survey of Dual-Trained Practitioners in the United States.

BACKGROUND: Combined practice in pediatric anesthesiology (PA) and pediatric critical care medicine (PCCM) was historically common but has declined markedly with time. The reasons for this temporal shift are unclear, but existing evidence suggests that length of training is a barrier to contemporary trainees. Among current practitioners, restriction in dual-specialty practice also occurs, for reasons that are unknown at present. We sought to describe the demographics of this population, investigate their perceptions about the field, and consider factors that lead to attrition. METHODS: We conducted a cross-sectional, observational study of physicians in the United States with a combined practice in PA and PCCM. The survey was distributed electronically and anonymously to the distribution list of the Pediatric Anesthesia Leadership Council (PALC) of the Society for Pediatric Anesthesia (SPA), directing the recipients to forward the link to their faculty meeting our inclusion criteria. Attending-level respondents (n = 62) completed an anonymous, 40-question multidomain survey. RESULTS: Forty-seven men and 15 women, with a median age of 51, completed the survey. Major leadership positions are held by 44%, and 55% are externally funded investigators. A minority (26%) have given up one or both specialties, citing time constraints and politics as the dominant reasons. Duration of training was cited as the major barrier to entry by 77%. Increasing age and faculty rank and lack of a comparably trained institutional colleague were associated with attrition from dual-specialty practice. The majority (88%) reported that they would do it all again. CONCLUSIONS: The current cohort of pediatric anesthesiologist-intensivists in the United States is a small but accomplished group of physicians. Efforts to train, recruit, and retain such providers must address systematic barriers to completion of the requisite training and continued practice.

Effect of transfusion guidelines on postoperative transfusion in children undergoing craniofacial reconstruction surgery.

OBJECTIVE: To assess the effect of implementation of population-specific postoperative management guidelines on postoperative transfusion in children undergoing cranial vault reconstruction surgery. DESIGN: Retrospective observational study with historical controls. SETTING: Single, large, academic tertiary pediatric hospital. PATIENTS: : Children aged 6 months to 17 yrs undergoing fronto-orbital advancement or posterior cranial vault reconstruction surgery enrolled in our craniofacial surgery perioperative registry from April 14, 2008 to September 7, 2011. INTERVENTION: Postoperative management guidelines for children undergoing cranial vault reconstruction surgery were implemented on December 1, 2009. These management guidelines included projected surgical drain output as well as specific transfusion thresholds for packed red blood cells and hemostatic blood products. MEASUREMENTS AND MAIN RESULTS: We queried our craniofacial surgery perioperative registry for children who underwent cranial vault reconstruction to assess transfusion practices before and after the implementation of the postoperative guidelines. Subjects were divided into a preguideline cohort and a postguideline cohort. Perioperative demographic data and postoperative transfusion data were compared between the two groups. The registry query returned data on 59 procedures in the preguideline cohort and 58 procedures in the postguideline cohort. The immediate postoperative hematocrit and the postoperative blood loss through surgical drains were not statistically different in the two groups. The prevalence of postoperative transfusion of any blood product was significantly less in the postguideline cohort (17% vs. 42%, p = .003). Most of the transfusion reduction was achieved through a reduction in fresh frozen plasma transfusion (5% vs. 25%, p = .002). CONCLUSIONS: In this observational study, the implementation of postoperative management guidelines was associated with a 60% reduction in postoperative transfusion. The use of transfusion thresholds is a simple, inexpensive, and effective strategy for transfusion reduction and should be a first-line approach to perioperative transfusion reduction in this population.

Perioperative management of children undergoing craniofacial reconstruction surgery: a practice survey.

OBJECTIVE/AIMS: To assess current practices in the management of children undergoing craniofacial surgery and identify areas of significant practice variability with the intent to direct future research. BACKGROUND: The perioperative management of infants and children undergoing craniofacial reconstruction surgery can be challenging because of the routine occurrence of significant blood loss with associated morbidity. A variety of techniques have been described to improve the care for these children. It is presently unknown to what extent these practices are currently employed. METHODS: A web-based survey was sent to representatives from 102 institutions. One individual per institution was surveyed to prevent larger institutions from being over-represented in the results. RESULTS: Requests to complete the survey were sent to 102 institutions; 48 surveys were completed. The survey was composed of two parts: management of infants undergoing strip craniectomies, and management of children undergoing major craniofacial reconstruction. CONCLUSIONS: Significant variability exists in the management of children undergoing these procedures; further study is required to determine the optimal management strategies. Clinical trials assessing the utility of central venous pressure and other hemodynamic monitoring modalities would enable evidence-based decision-making for monitoring in these children. The development of institutional transfusion thresholds should be encouraged, as there exists a body of evidence supporting their efficacy and safety.

Fluoroscopic-assisted endobronchial intubation for single-lung ventilation in infants.

OBJECTIVE: Review our institutional experience with an alternative to fiberoptic-guided endobronchial intubation. AIM: The aim of this retrospective cohort study was to present our experience with the use of fluoroscopy to facilitate endobronchial lung isolation in infants undergoing thoracoscopic procedures. BACKGROUND: Anesthesiologists are more frequently being asked to anesthetize infants and small children for thoracoscopic surgery. Typically, endobronchial intubation or bronchial blockers are utilized to achieve lung isolation during these procedures. However, sometimes small and complicated anatomy can make this challenging. METHODS: Respective chart review over a 13-month period of infants undergoing thoracoscopic excision of congenital lung lesions at the Children's Hospital of Philadelphia. Rate of success in achieving lung isolation along with time of fluoroscopy exposure were recorded. RESULTS: Twenty infants had thoracoscopic lung surgery attempted during the period of the review. Lung isolation was successfully achieved in all of the patients. The average exposure to fluoroscopy was 83.7 s (range 20-320 s). CONCLUSIONS: Fluoroscopic aided lung isolation is a reliable and effective alternative method to the use of fiberoptic bronchoscope for endobronchial intubation in infants.

Rapid Recovery Pathway After Spinal Fusion for Idiopathic Scoliosis.

BACKGROUND: Posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS) is associated with significant pain and prolonged hospitalization. There is evidence that early mobilization and multimodal analgesia can accelerate functional recovery and reduced length of stay (LOS). Using these principles, we implemented a quality improvement initiative to enable earlier functional recovery in our AIS-PSF population. METHODS: We designed and implemented a standardized rapid recovery pathway (RRP) with evidence-based management recommendations for children aged 10 to 21 years undergoing PSF for AIS. Our primary outcome, functional recovery, was assessed using statistical process control charts for LOS and average daily pain scores. Our process measures were medication adherence and order set utilization. The balancing measure was 30-day readmission rate. RESULTS: We included 322 patients from January 1, 2011 to June 30, 2015 with 134 (42%) serving as historical controls, 104 (32%) representing our transition population, and 84 (26%) serving as our RRP population. Baseline average LOS was 5.7 days and decreased to 4 days after RRP implementation. Average daily pain scores remained stable with improvement on postoperative day 0 (3.8 vs 4.9 days) and 1 (3.8 vs 5 days) after RRP implementation. In the second quarter of 2015, gabapentin (91%) and ketorolac (95%) use became routine and order set utilization was 100%. Readmission rates did not increase as a result of this pathway. CONCLUSIONS: Implementation of a standardized RRP with multimodal pain management and early mobilization strategies resulted in reduced LOS without an increase in reported pain scores or readmissions.

Cavernous sinus thrombosis complicating sinusitis.

BACKGROUND: Septic cavernous sinus thrombosis is a rare complication of paranasal sinusitis. OBJECTIVE: To familiarize the clinician with the pathogenesis, diagnosis, and appropriate management of septic cavernous sinus thrombosis. DESIGN: Case report and literature review. SETTING: Pediatric intensive care unit in a university hospital. PATIENT: We present a 12-yr-old female with a 1 wk history of an upper respiratory tract infection with worsening dyspnea, cough, and swelling of the left eye progressing to adult respiratory distress syndrome. Secondary to the need for significant mechanical ventilatory support, venovenous extracorporeal membrane oxygenation was initiated. Computed tomography scan of the head and neck with contrast revealed bilateral cavernous sinus thrombosis. After broad-spectrum intravenous antibiotics and aggressive supportive care in conjunction with surgical intervention (maxillary sinus lavage and right orbital exploration) and anticoagulation therapy, the patient recovered. Blood cultures were positive for Viridans streptococcus. At discharge 3 wks later, the patient had improved, but had right-eye blindness. CONCLUSIONS: The diagnosis of septic cavernous sinus thrombosis requires a high index of suspicion and confirmation by imaging; early diagnosis and surgical drainage of the underlying primary source of infection in conjunction with long-term intravenous antibiotic therapy are critical for an optimal clinical outcome.

High-frequency percussive ventilation and bronchoscopy during extracorporeal life support in children.

Variables affecting duration of pediatric extracorporeal life support (ECLS) are poorly defined. Prior analyses suggested increased mortality risk with prolonged ECLS. Lung recruitment strategies with improved secretion mobilization may shorten ECLS duration. High frequency percussive ventilation (HFPV) has been used, predominantly in inhalational injury, as a mode of ventilation to improve secretion clearance. We describe the application of HFPV and therapeutic bronchoscopies in pediatric ECLS and evaluate outcomes with a same-center historical control population. After May 2011, all children (n = 14) on ECLS were managed with HFPV during extracorporeal support (HFPV cohort). This group's demographics and outcomes were compared with ECLS patients in our unit immediately before the utilization of HFPV (pre-HFPV cohort, n = 22). The HFPV and pre-HFPV cohorts had similar demographics and utilization of venoarterial ECLS. In univariate analysis, the HFPV group underwent more bronchoscopies and experienced more ECLS-free days (days alive and off ECLS) at 30 and 60 days. In multivariate analysis, use of HFPV was independently associated with ECLS-free days. We conclude that use of HFPV and bronchoscopies during ECLS for respiratory failure was associated with an increase in ECLS-free days and that this association should be prospectively evaluated.

Bi-caval dual lumen venovenous extracorporeal membrane oxygenation and high-frequency percussive ventilatory support for postintubation tracheal injury and acute respiratory distress syndrome.

Bi-caval dual lumen venovenous extracorporeal membrane oxygenation (VV-ECMO) as a nonoperative approach to postintubation tracheal injury has not been described. We report the case of a 7-year-old boy who sustained a postintubation tracheal injury, developed acute respiratory distress syndrome from aspiration and viral pneumonitis, and was supported on bi-caval dual lumen VV-ECMO for 16 days until the trachea healed without surgical repair. Before ECMO decannulation, high-frequency percussive ventilation using a volumetric diffusive respiration ventilator was used for lung recruitment and airway clearance without disruption of the healed trachea. The use of ECMO to allow for lower mean airway pressure during initial healing and high-frequency percussive ventilation for lung recruitment and secretion clearance is a promising strategy to allow nonoperative tracheal injury repair in critically ill patients with multiple comorbidities.

Assessment of the prevalence of microaspiration by gastric pepsin in the airway of ventilated children.

AIM: Mechanically ventilated patients are at risk for aspiration of gastric contents. The aim of this observational study was to determine the prevalence of micro-aspiration in children with cuffed and uncuffed endotracheal (ET) tubes and with tracheostomies and to assess the effect of feeding status on aspiration. Micro-aspiration was determined by measuring gastric pepsin in tracheal aspirates. METHODS: We studied 27 children on ventilators in paediatric intensive care unit (PICU) and 10 children undergoing elective surgeries for various indications. Tracheal aspirates were collected from children on ventilatory support in the intensive care unit during medically indicated suctioning and from the group of children undergoing elective surgery in the operation room. Pepsin was detected by enzymatic assay. RESULTS: Overall 70% of cases in PICU were positive for pepsin in at least one of the aspirates. Pepsin positivity was significantly lower in the cuffed group than in the uncuffed and tracheostomy groups. Tube feedings did not significantly influence the prevalence of pepsin positivity. CONCLUSIONS: Measurement of gastric pepsin in tracheobronchial fluid is a sensitive tool to detect aspirations in mechanically ventilated children and to assess the efficacy of preventive measures in PICU settings.