Combined erector spinae plane block with surgical intercostal nerve cryoablation for Nuss procedure is associated with decreased opioid use and length of stay.

BACKGROUND AND OBJECTIVES: Pain management for patients undergoing the Nuss procedure for treatment of pectus excavatum can be challenging. In an effort to improve pain management, our institution added bilateral single injection erector spinae plane (ESP) blocks to surgeon placed intercostal nerve cryoablation. We aimed to assess the efficacy of this practice change. METHODS: Retrospective clinical data from a single academic medical center were evaluated. Due to an institutional change in clinical management, we were able to perform a before and after study. Twenty patients undergoing Nuss procedure who received bilateral ultrasound-guided single-shot T6 level ESP blocks and intercostal nerve cryoablation were compared with a historical control cohort of 20 patients who underwent Nuss procedure with intercostal nerve cryoablation alone. The primary outcome variables included postoperative pain scores, total hospital opioid use, and hospital length of stay. RESULTS: Median total hospital intravenous morphine milligram equivalents was lower for the ESP group than for the control group (0.60 (IQR 0.35-0.88) vs 1.15 mg/kg (IQR 0.74-1.68), p<0.01). There was no difference in postoperative pain scores between the two groups. Mean hospital length of stay was 2.45 (SD 0.69) days for the control group and 1.95 (SD 0.69) days for the ESP group (p=0.03). No adverse events related to block placement were identified. CONCLUSIONS: In a single-center academic practice, the addition of bilateral single injection ESP blocks at T6 to surgeon performed cryoablation reduced opioid consumption without a change in subjectively reported pain scores. The results from this pilot study can provide effect size estimates to guide the design of future randomized trials.

Paediatric patients in mass casualty incidents: a comprehensive review and call to action.

The paediatric population is disproportionately affected during mass casualty incidents (MCIs). Several unique characteristics of children merit special attention during natural and man-made disasters because of their age, physiology, and vulnerability. Paediatric anaesthesiologists play a critical part of MCI care for this population, yet there is a deficit of publications within the anaesthesia literature addressing paediatric-specific MCI concerns. This narrative review article analyses paediatric MCI considerations and compares differing aspects between care provision in Australia, the UK, and the USA. We integrate some of the potential roles for anaesthesiologists with paediatric experience, which include preparation, command consultation, in-field care, pre-hospital transport duties, and emergency department, operating theatre, and ICU opportunities. Finally, we propose several methods by which anaesthesiologists can improve their contribution to paediatric MCI care through personal education, training, and institutional involvement.

Age-Related Changes in Upper Airway Anatomy Via Ultrasonography in Pediatric Patients.

PURPOSE: Ultrasonography is a portable, noninvasive tool that may be used to evaluate the upper airway. The purpose of our study was to present a systematic approach to identify salient features of the pediatric airway and determine whether ultrasonography can identify anatomical changes that occur with growth and development. METHODS: We present a prospective, observational trial where patients included were between 1 day and 10 years of age presenting for elective surgery who had no known history of unfavorable airway pathology. We sequentially obtained 5 ultrasound views under anesthesia: (1) sagittal sternal notch view of the trachea, (2) sagittal longitudinal view of trachea (LT), (3) axial view at the level of the vocal cords (AVC), (4) axial view at the level of the cricoid membrane (AC), and (5) sagittal longitudinal submental space view (SM). A broadband linear array transducer was used to identify airway structures and perform measurements. RESULTS: Eighty-four percent of enrolled patients underwent airway imaging and were analyzed using multiple regression and Spearman correlation (ρ). In view 1, tracheal diameter via sagittal sternal notch view was immeasurable because of air disturbance. In the LT view, the distance from the skin to the cricothyroid membrane (LT1) did not statistically increase with age in days (P = 0.06); however, the distance from the cricoid to thyroid cartilage (LT2) did correlate to age (P < 0.001; 99% confidence interval [CI], 1.8 × 10-5, 7.7 × 10-5; ρ = 0.77, P = 0.001). We found a statistically significant relationship between age and the distance between the anterior and posterior commissures (AVC2; P < 0.001; 99% CI, 1.0 × 10-4, 1.7 × 10-4; ρ = 0.80, P < 0.001), the distance from the skin to the posterior commissure (AVC3; P < 0.001; 99% CI, 9.6 × 10-5, 2.0 × 10-4; ρ = 0.73, P < 0.001), the distance to the cricoid cartilage (AC; P < 0.001; 99% CI, 2.0 × 10-5, 7.7 × 10-5; ρ = 0.66, P < 0.001), and the distance from the tongue base to the soft palate (SM2; P < 0.001; 9% CI, 1.8 × 10-4, 3.9 × 10-4; ρ = 0.85, P < 0.001). There were no significant relationships between age and AVC1 (P = 0.16) and SM1 (P = 0.44). CONCLUSIONS: Airway ultrasound is a feasible tool to evaluate the pediatric airway in children younger than 10 years; however, the detection of age-related changes of certain structures is limited to select measurements.

Development and Usability Testing of the Society for Pediatric Anesthesia Pedi Crisis Mobile Application.

When life-threatening, critical events occur in the operating room, the fast-paced, high-distraction atmosphere often leaves little time to think or deliberate about management options. Success depends on applying a team approach to quickly implement well-rehearsed, systematic, evidence-based assessment and treatment protocols. Mobile devices offer resources for readily accessible, easily updatable information that can be invaluable during perioperative critical events. We developed a mobile device version of the Society for Pediatric Anesthesia 26 Pediatric Crisis paper checklists-the Pedi Crisis 2.0 application-as a resource to support clinician responses to pediatric perioperative life-threatening critical events. Human factors expertise and principles were applied to maximize usability, such as by clustering information into themes that clinicians utilize when accessing cognitive aids during critical events. The electronic environment allowed us to feature optional diagnostic support, optimized navigation, weight-based dosing, critical institution-specific phone numbers pertinent to emergency response, and accessibility for those who want larger font sizes. The design and functionality of the application were optimized for clinician use in real time during actual critical events, and it can also be used for self-study or review. Beta usability testing of the application was conducted with a convenience sample of clinicians at 9 institutions in 2 countries and showed that participants were able to find information quickly and as expected. In addition, clinicians rated the application as slightly above "excellent" overall on an established measure, the Systems Usability Scale, which is a 10-item, widely used and validated Likert scale created to assess usability for a variety of situations. The application can be downloaded, at no cost, for iOS devices from the Apple App Store and for Android devices from the Google Play Store. The processes and principles used in its development are readily applicable to the development of future mobile and electronic applications for the field of anesthesiology.

Perioperative hypothermia in neonatal intensive care unit patients: effectiveness of a thermoregulation intervention and associated risk factors.

BACKGROUND: Hypothermia in neonatal intensive care unit patients is associated with morbidity. Perioperative normothermia is the standard of care. AIMS: We hypothesized that a quality improvement intervention (transport protocol, transport education, ongoing monitoring) would decrease the incidence of perioperative hypothermia. Secondarily, we hypothesized that patients undergoing surgery at a postmenstrual age of <37 weeks or at a weight of <1.5 kg would be at higher risk for perioperative hypothermia. METHODS: Lean Six Sigma methodology was used to institute a quality improvement intervention. In a retrospective chart review, we identified 708 cases for which the neonatal intensive care unit was the preoperative and postoperative destination and documented patient characteristics, including postoperative temperature. Cardiac surgical cases and cases with no postoperative temperature record were excluded. RESULTS: Patients in the postintervention group had a statistically significant decrease in hypothermia compared to those in the preintervention group (P < 0.001; OR: 0.17; 95% CI: 0.09-0.31). The absolute risk of hypothermia was 23% in the preintervention group and 6% in the postintervention group. Weight <1.5 kg on day of surgery (P = 0.45; OR: 0.63; 95% CI: 0.16-2.24) and postmenstrual age (P = 0.91; OR: 1.07; 95% CI: 0.33-3.98) were not risk factors. Odds of hypothermia were increased in patients undergoing interventional cardiology procedures (P = 0.003; OR: 17.77; 95% CI: 2.07-125.7). CONCLUSIONS: Perioperative hypothermia is a challenge in the care of neonatal intensive care unit patients; however, a thermoregulation intervention can decrease the incidence with sustained results. Future studies can examine why certain procedures have a tendency toward increased perioperative hypothermia, determine the relative value of quality improvement interventions, and characterize the morbidity and mortality associated with perioperative hypothermia in neonatal intensive care unit patients.

Elevated prothrombin time on routine preoperative laboratory results in a healthy infant undergoing craniosynostosis repair: Diagnosis and perioperative management of congenital factor VII deficiency.

INTRODUCTION: Congenital factor VII deficiency is a rare bleeding disorder with high phenotypic variability. It is critical that children with congenital Factor VII deficiency be identified early when high-risk surgery is planned. Cranial vault surgery is common for children with craniosynostosis, and these surgeries are associated with significant morbidity mostly secondary to the risk of massive blood loss. PRESENTATION OF CASE: A two-month old infant who presented for elective craniosynostosis repair was noted to have an elevated prothrombin time (PT) with a normal activated partial thromboplastin time (aPTT) on preoperative labs. The infant had no clinical history or reported family history of bleeding disorders, therefore a multidisciplinary decision was made to repeat the labs under general anesthesia and await the results prior to incision. The results confirmed the abnormal PT and the case was canceled. Hematologic workup during admission revealed factor VII deficiency. The patient underwent an uneventful endoscopic strip craniectomy with perioperative administration of recombinant Factor VIIa. DISCUSSION: Important considerations for perioperative laboratory evaluation and management in children with factor VII deficiency are discussed. Anesthetic and surgical management of the child with factor VII deficiency necessitates meticulous planning to prevent life threatening bleeding during the perioperative period. CONCLUSION: A thorough history and physical examination with a high clinical suspicion are vital in preventing hemorrhage during surgeries in children with coagulopathies. Abnormal preoperative lab values should always be confirmed and addressed before proceeding with high-risk surgery. A multidisciplinary discussion is essential to optimize the risk-benefit ratio during the perioperative period.

Airway management complications in children with difficult tracheal intubation from the Pediatric Difficult Intubation (PeDI) registry: a prospective cohort analysis.

BACKGROUND: Despite the established vulnerability of children during airway management, remarkably little is known about complications in children with difficult tracheal intubation. To address this concern, we developed a multicentre registry (Pediatric Difficult Intubation [PeDI]) to characterise risk factors for difficult tracheal intubation, establish the success rates of various tracheal intubation techniques, catalogue the complications of children with difficult tracheal intubation, and establish the effect of more than two tracheal intubation attempts on complications. METHODS: The PeDI registry consists of prospectively collected tracheal intubation data from 13 children's hospitals in the USA. We established standard data collection methods before implementing the secure web-based registry. After establishing standard definitions, we collected and analysed patient, clinician, and practice data and tracheal intubation outcomes. We categorised complications as severe or non-severe. FINDINGS: Between August, 2012, and January, 2015, 1018 difficult paediatric tracheal intubation encounters were done. The most frequently attempted first tracheal intubation techniques were direct laryngoscopy (n=461, 46%), fibre-optic bronchoscopy (n=284 [28%]), and indirect video laryngoscopy (n=183 [18%]) with first attempt success rates of 16 (3%) of 461 with direct laryngoscopy, 153 (54%) of 284 with fibre-optic bronchoscopy, and 101 (55%) of 183 with indirect video laryngoscopy. Tracheal intubation failed in 19 (2%) of cases. 204 (20%) children had at least one complication; 30 (3%) of these were severe and 192 (19%) were non-severe. The most common severe complication was cardiac arrest, which occurred in 15 (2%) patients. The occurrence of complications was associated with more than two tracheal intubation attempts, a weight of less than 10 kg, short thyromental distance, and three direct laryngoscopy attempts before an indirect technique. Temporary hypoxaemia was the most frequent non-severe complication. INTERPRETATION: More than two direct laryngoscopy attempts in children with difficult tracheal intubation are associated with a high failure rate and an increased incidence of severe complications. These results suggest that limiting the number of direct laryngoscopy attempts and quickly transitioning to an indirect technique when direct laryngoscopy fails would enhance patient safety. FUNDING: None.

Improved vitamin D supplementation in hospitalized breastfed infants through electronic order modification and targeted provider education.

OBJECTIVE: To examine effectiveness of an intervention promoting vitamin D supplementation in hospitalized breastfed infants. METHODS: Our urban tertiary care hospital instituted a 2-part intervention: brief education for providers on vitamin D guidelines and insertion of an opt-in order for vitamin D supplements into electronic admission order sets. Data downloads on admissions of patients aged <1 year were obtained. We excluded those not breastfed, with a dietary restriction, or admitted to intensive care. Intervention effects were compared from 6 months postintervention to the 6 same months 1 year earlier. We applied χ2 and logistic regression, including the patient as a random effect to adjust for repeated admissions. RESULTS: Data on 471 exclusively or partially breastfed admissions (441 infants) were analyzed (221 preintervention, 250 postintervention). Admission characteristics did not differ by period: 55.0% boys; 40.6% Medicaid; 63.7% hospitalized ≤2 days; 72.0% on a general medical service; 16.6% received nutritionist consultation. In-hospital vitamin D prescribing rates significantly increased postintervention (19.5% vs 44.4%; P<.001). Postintervention admissions were more than twice as likely to receive vitamin D supplementation (adjusted odds ratio 2.3, 95% confidence interval 1.6-3.2). Other associated factors included vitamin D as a medication used before admission (adjusted odds ratio 14.3, 95% confidence interval 4.9-41.6), nutritionist consultation during admission, hospitalization≥3 days, and admission to a general medical service. Prescribing of vitamin D at discharge increased significantly (9.0% vs 19.6%; P<.001). CONCLUSIONS: Medical provider education and modification of electronic ordering templates significantly increased use of vitamin D supplementation in hospitalized breastfed infants.

Pediatric preoperative blood ordering: when is a type and screen or crossmatch really needed?

BACKGROUND: Unnecessary testing for and ordering of blood products adds to overall healthcare costs. OBJECTIVES: Determine intraoperative red blood cell (RBC) product utilization for pediatric procedures and costs associated with perioperative testing and ordering. METHODS: A retrospective chart review captured perioperative blood testing and intraoperative transfusion data for patients <19 years of age who underwent noncardiac surgery over a 13-month period at one tertiary care hospital. The main outcome measure was cost associated with testing for blood products in patients undergoing procedures that had a zero rate of transfusion. RESULTS: The intraoperative transfusion rate for 8620 noncardiac pediatric procedures was 2.78%. Of 8380 nontransfused patients, 707 (8.4%) had type and screen, and of those, 420 (5%) were crossmatched for RBC products in preparation for surgery. The 10 surgical procedures that had the highest perioperative blood testing but no instances of transfusion were as follows: colostomy or ileostomy takedown, spinal cord untethering, tunneled catheter placement, laparoscopic Nissen fundoplication, elbow reduction and fixation, lumbar puncture, suboccipital craniectomy, hip arthrogram, percutaneous intravascular central line, and tonsillectomy and adenoidectomy. Procedures with low transfusion probability and high crossmatch testing were ventriculoperitoneal shunt revision and growing rod distraction. For all nontransfused patients, the cost of obtaining type and screen was $31,815, and the cost for crossmatch was $25,200. CONCLUSION: Patients may undergo preoperative type and screen or crossmatch for procedures rarely associated with transfusion. Historic transfusion probability may be used to predict need for transfusion for specific surgical procedures and reduce unnecessary perioperative testing and associated costs.

Ultrasound use in the pediatric airway: the time has come.

Advancements in ultrasonography and increasing familiarity with its use in the operating room (vascular access and regional neural blockade) suggest its feasibility as an adjunct in pediatric airway evaluation and intervention. We report 3 cases demonstrating the usefulness of ultrasound techniques in this setting. We show key elements of airway anatomy, noninvasive observation of vocal cord motion, and percutaneous periglottic steroid injection via the cricothyroid membrane in 3 different patients. This report reveals the possible usefulness of ultrasound imaging in clinical anesthesia care, specifically airway management, in children.

Rainy days for the Society for Pediatric Anesthesia.

Members of the Society for Pediatric Anesthesia (SPA) perceive the 47% rain rate has burdened its national meetings more than would be expected. We compared weather conditions on the first day of each national SPA meeting since 1987 with historical data using the day, month, and location of each meeting. Using a generalized estimating equations model, the odds ratio of rain comparing meeting and nonmeeting days was 2.63 (P value 0.006, 95% confidence interval 1.32-5.22). These results confirm a significantly higher frequency of rain at national SPA meetings than would be anticipated.

Impact of perioperative RSV or influenza infection on length of stay and risk of unplanned ICU admission in children: a case-control study.

BACKGROUND: Children with viral respiratory infections who undergo general anesthesia are at increased risk of respiratory complications. We investigated the impact of RSV and influenza infection on perioperative outcomes in children undergoing general anesthesia. METHODS: We performed a retrospective case-control study. All patients under the age of 18 years who underwent general anesthesia at our institution with confirmed RSV or influenza infection diagnosed within 24 hours following induction between October 2002 and September 2008 were identified. Controls were randomly selected and were matched by surgical procedure, age, and time of year in a ratio of three controls per case. The primary outcome was postoperative length of stay (LOS). RESULTS: Twenty-four patients with laboratory-confirmed RSV or influenza who underwent general anesthesia prior to diagnosis of viral infection were identified and matched to 72 controls. Thirteen cases had RSV and 11 had influenza. The median postoperative LOS was three days (intra-quartile range 1 to 8 days) for cases and two days (intra-quartile range 1 to 5 days) for controls. Patients with influenza had a longer postoperative LOS (p < 0.001) and patients with RSV or influenza were at increased risk of unplanned admission to the PICU (p = 0.04) than matched controls. CONCLUSIONS: Our results suggest that children with evidence of influenza infection undergoing general anesthesia, even in the absence of symptoms previously thought to be associated with a high risk of complications, may have a longer postoperative hospital LOS when compared to matched controls. RSV and influenza infection was associated with an increased risk of unplanned PICU admission.

Activity and dietary habits of mothers and children: close ties.

OBJECTIVE: To examine associations between activity and dietary habits reported by mothers for themselves and their children aged 2 to 11 years. DESIGN/METHODS: Cross-sectional, consecutive samples of parents at 13 primary care practices were surveyed on health behaviors. Survey questions were used to define 5 "healthy" habits: low-fat milk choice; low fast food use; low weekend screen time; low juice/sweet drinks intake; and high-frequency physical activity. Mixed-effects logistic regression models were applied. RESULTS: Responses from a socioeconomically diverse group of 2115 mothers were analyzed. For each healthy behavior self-reported by the mother, the odds of the healthy behavior being reported for the child were significantly higher (range: odds ratio [OR] = 3.2 for high-frequency physical activity to OR = 19.7 for low-fat milk choice). CONCLUSIONS: Mothers and children often have similar health habits. The impact of clinician counseling for children may be strengthened by promotion of healthy habits for their mothers.

Anesthetic considerations for the pediatric oncology patient--part 1: a review of antitumor therapy.

The anesthesiologist who cares for children with cancer or for survivors of childhood cancer should possess a basic understanding of cancer treatment. While this is an ever-changing field, a basic knowledge of chemotherapeutic drugs, radiation therapy, and the toxicities of each is necessary to prepare a safe anesthetic plan. Such an understanding also assists the anesthesiologist as the perioperative specialist for these children in consultation with the surgeon and oncologist. This article, which is the first of a three-part review series, will review current principles of cancer therapy and the general mechanisms of toxicity to the child. Although this article is not intended to comprehensively review the fundamentals of chemotherapy and radiation therapy, the consequences of anticancer therapy that impact perioperative care and decision making are presented for the anesthesiologist.

Anesthetic considerations for the pediatric oncology patient--part 2: systems-based approach to anesthesia.

One of the prices paid for chemo- and radiotherapy of cancer in children is damage to the vulnerable and developing healthy tissues of the body. Such damage can exist clinically or subclinically and can become apparent during active antineoplastic treatment or during remission decades later. Furthermore, effects of the tumor itself can significantly impact the physiologic state of the child. The anesthesiologist who cares for children with cancer or for survivors of childhood cancer should understand what effects cancer and its therapy can have on various organ systems. In part two of this three-part review, we review the anesthetic issues associated with childhood cancer. Specifically, this review presents a systems-based approach to the impact from both tumor and its treatment in children, followed by a discussion of the relevant anesthetic considerations.

Anesthetic considerations for the pediatric oncology patient--part 3: pain, cognitive dysfunction, and preoperative evaluation.

In part three of this three-part review, we continue with discussion of the effects of tumor and its therapy as they impact neurocognitive functioning, psychosocial issues of the patient and family, and the mechanisms and experience of pain in the child with cancer. A discussion of preanesthetic testing and evaluation in this patient population is next presented for the reader, focusing on the factors which pose the commonest and greatest risks to the child undergoing surgery. Lastly, an algorithmic approach to evaluating and managing key components of the medical history of pediatric patients is presented.

Need for emergency surgical airway reduced by a comprehensive difficult airway program.

BACKGROUND: Inability to intubate and ventilate patients with respiratory failure is associated with significant morbidity and mortality. A patient is considered to have a difficult airway if an anesthesiologist or other health care provider experienced in airway management is unable to ventilate the patient's lungs using bag-mask ventilation and/or is unable to intubate the trachea using direct laryngoscopy. METHODS: We performed a retrospective review of a departmental database to determine whether a comprehensive program to manage difficult airways was associated with a reduced need to secure the airway surgically via cricothyrotomy or tracheostomy. The annual number of unplanned, emergency surgical airway procedures for inability to intubate and ventilate reported for the 4 yr before the program (January 1992 through December 1995) was compared with the annual number reported for the 11 yr after the program was initiated (January 1996 through December 2006). RESULTS: The number of emergency surgical airways decreased from 6.5 +/- 0.5 per year for 4 yr before program initiation to 2.2 +/- 0.89 per year for the 11-yr period after program initiation (P < 0.0001). During the 4-yr period from January 1992 through December 1995, 26 surgical airways were reported, whereas only 24 surgical airways were performed in the subsequent 11-yr period (January 1996 through December 2006). CONCLUSIONS: A comprehensive difficult airway program was associated with a reduction in the number of emergency surgical airway procedures performed for the inability of an anesthesiologist to intubate and ventilate, a reduction that was sustained over an 11-yr period. This decrease occurred despite an increase in the number of patients reported to have a difficult airway and an overall increase in the total number of patients receiving anesthesia per year.

Safety and efficacy of patient controlled epidural analgesia following pediatric spinal surgery.

BACKGROUND: Patient controlled epidural analgesia (PCEA) is uncommon in pediatric anesthesia. Because PCEA offers superior pain control compared with continuous epidural infusions in adults, we prospectively evaluated the analgesia efficacy and safety of PCEA in children and adolescents following extensive spinal surgery. METHODS: Following ethics committee approval, 100 consecutive children [age median (range) 14 (6-19) years] undergoing spinal surgery were studied until the seventh postoperative day, and 98 children received a PCEA. One or two epidural catheters were positioned under direct vision by the surgeon based on the number of vertebral segments operated upon. The epidural solution consisted of bupivacaine 0.0625%, fentanyl 1 microg.ml(-1) and clonidine 0.6 microg.ml(-1), delivered at a basal rate of 0.2 ml.kg(-1).h(-1) and a PCEA dose of 0.1 ml.kg(-1).h(-1)(max. 2 h(-1)). On the fourth postoperative day, PCEA was stopped and analgesia was continued with patient controlled analgesia (PCA) with morphine. RESULTS: During the PCEA regimen, the maximal scores of the revized facial scale were below 4 at rest with a very high satisfaction rate (>90%). Pain scores were higher during mobilization on the first postoperative day and when PCEA was switched to PCA. The overall incidence of adverse events was low and consisted primarily of technical problems and postoperative nausea and vomiting. Only two children experienced a complication requiring the discontinuation of the PCEA but there were no consequent adverse sequelae. CONCLUSIONS: The present study demonstrates that PCEA provides excellent pain relief following extensive spinal surgery and is associated with a low incidence of adverse events. The use of PCEA should be encouraged in children and adolescents following extensive spinal surgery.

Case report: full-thickness forehead burn over indwelling titanium hardware resulting from an aberrant intraoperative electrocautery circuit.

OBJECTIVE: This study aims to contextualize an unintended intraoperative electrocautery burn that occurred on our service within the spectrum of all intraoperative electrocautery burns. METHODS: A case report of the incident was drafted, and the relevant literature present in PubMed and industry publications was reviewed. RESULTS: Intraoperative electrocautery burns can be divided into 4 categories: (1) direct contact burns resulting from inappropriate operator use of the active electrode, (2) burns at the grounding electrode site due to improper attachment or placement, (3) burns resulting from electrode heating of pooled solutions, and (4) burns occurring outside the operative field as a result of circuits generated between the active electrode and an alternate grounding source. We herein report an unintended intraoperative electrocautery burn of the fourth category. An aberrant intraoperative circuit utilized previously placed in-dwelling titanium plating in the patient's right brow as the grounding electrode, resulting in 3 x 3-cm full-thickness skin necrosis overlying the site of hardware implantation. CONCLUSIONS: Literature recommendations to reduce this type of electrocautery burn suggest avoiding grounding pad placement on the forearm and lateral thigh, although further investigation is needed to determine optimal grounding electrode placement with respect to known indwelling hardware.