Factors Associated With Family Decision-Making After Pediatric Out-of-Hospital Cardiac Arrest.

AIM: This study aims to identify demographic factors, area-based social determinants of health (SDOH), and clinical features associated with medical decision-making after pediatric out-of-hospital cardiac arrest (OHCA). METHODS: This is a retrospective, exploratory, descriptive analysis of patients < 18 years old admitted to the pediatric intensive care unit (ICU) after OHCA from 2011 to 2022 (n=217) at an urban tertiary care, free-standing children's hospital. Outcomes of interest included: (1) whether a new advance care plan (ACP) (defined as a written advance directive including do not resuscitate and/or do not intubate) was ordered during hospitalization, and (2) whether the patient was discharged with new medical technology (defined as tracheostomy and/or feeding tube). Logistic regression models identified features associated with these outcomes. RESULTS: Of the 217 patients, 78 patients (36%) had a new ACP placed during their admission. Of the survivors, 26% (27/102) were discharged home with new medical technology. Factors associated with ACP were greater change in Pediatric Cerebral Performance Category (PCPC) score (aOR=1.49, 95% CI [1.28-1.73], p-value <0.001) and palliative care consultation (aOR = 2.39, 95% CI [1.16-4.89], p-value 0.018). Factors associated with new medical technology were lower change in PCPC score (aOR=0.76, 95% C.I. [0.61-0.95], p-value=0.015) and palliative care consultation (aOR = 7.07, 95% CI [3.01-16.60], p-value <0.001). There were no associations between area-based SDOH and outcomes. CONCLUSIONS: Understanding factors associated with decision-making related to ACP after OHCA is critical to optimize counseling for families. Multi-institutional studies are warranted to identify whether these findings are generalizable.

Public Health Informatics and the Perioperative Physician: Looking to the Future.

The role of informatics in public health has increased over the past few decades, and the coronavirus disease 2019 (COVID-19) pandemic has underscored the critical importance of aggregated, multicenter, high-quality, near-real-time data to inform decision-making by physicians, hospital systems, and governments. Given the impact of the pandemic on perioperative and critical care services (eg, elective procedure delays; information sharing related to interventions in critically ill patients; regional bed-management under crisis conditions), anesthesiologists must recognize and advocate for improved informatic frameworks in their local environments. Most anesthesiologists receive little formal training in public health informatics (PHI) during clinical residency or through continuing medical education. The COVID-19 pandemic demonstrated that this knowledge gap represents a missed opportunity for our specialty to participate in informatics-related, public health-oriented clinical care and policy decision-making. This article briefly outlines the background of PHI, its relevance to perioperative care, and conceives intersections with PHI that could evolve over the next quarter century.

The Future of Social Media, Anesthesiology, and the Perioperative Physician.

Social media has rapidly developed in the past decade to become a powerful and influential force for patients, physicians, health systems, and the academic community. While the use of social media in health care has produced many positive changes, such as rapid dissemination of information, crowd-sourced sharing of knowledge, learning, and social interaction, social media in health care has also negative effects. Recent examples of negative impacts of social media include rapid and unchecked information dissemination leading to patient misinformation and inadvertent reputational harm for health care professionals due to engaging in controversial topics on public platforms. Members of the anesthesiology community, like other medical specialties, have rapidly adopted social media at many different levels. However, most anesthesiologists, health systems, and academic communities have little education, preparation, and guidelines on optimizing the use of social media technology while minimizing the risks of social media. Anesthesiology has been and will continue to be impacted by the forces of technology and the cultural influences of social media for the foreseeable future. The purpose of this article was to examine the recent history of social media adoption in anesthesiology and perioperative medicine, understand the current impact of social media across our specialty, and consider how the future development of technology and evolving social and cultural dynamic influences of social media will have on anesthesiology over the next quarter century.

Surgical neonates: A retrospective review of procedures and postoperative outcomes at a quaternary children's hospital.

INTRODUCTION: Neonates have a high incidence of respiratory and cardiac perioperative events. Disease severity and indications for surgical intervention often dovetail with an overall complex clinical course and predispose these infants to adverse long-term neurodevelopmental outcomes and increased length of stay. Our aims were to describe severe and nonsevere early postoperative complications to establish a baseline of care outcomes and to identify subgroups of surgical neonates and procedures for future prospective studies. METHODS: Electronic health record data were examined retrospectively for a cohort of patients who had general anesthesia from January 26, 2015 to August 31, 2018. Inclusion criteria were full-term infants with postmenstrual age less than 44 weeks or premature infants less than 60 weeks postmenstrual age undergoing nonimaging, noncardiac surgery. Severe postoperative complications were defined as mortality, reintubation, positive blood culture, and surgical site infection. Nonsevere early postoperative outcomes were defined as hypoglycemia, hyperglycemia, hypothermia, hyperthermia, and readmission within 30 days. RESULTS: About 2569 procedures were performed in 1842 neonates of which 10.9% were emergency surgeries. There were 120 postoperative severe complications and 965 nonsevere postoperative outcomes. Overall, 30-day mortality was 1.8% for the first procedure performed, with higher mortality seen on subgroup analysis for patients who underwent exploratory laparotomy (10.3%) and congenital lung lesion resection (4.9%). Postoperative areas for improvement included hyperglycemia (13.9%) and hypothermia (7.9%). DISCUSSION: The mortality rate in our study was comparable to other studies of neonatal surgery despite a high rate of emergency surgery and a high prevalence of prematurity in our cohort. The early outcomes data identified areas for improvement, including prevention of postoperative glucose and temperature derangements. CONCLUSIONS: Neonates in this cohort were at risk for severe and nonsevere adverse postoperative outcomes. Future studies are suggested to improve mortality and adverse event rates.

Increasing Cefazolin Use for Perioperative Antibiotic Prophylaxis in Penicillin-Allergic Children.

BACKGROUND AND OBJECTIVES: Cefazolin, a first-generation cephalosporin, is the most commonly recommended antibiotic for perioperative prophylaxis to reduce surgical site infections. Children with a reported penicillin allergy often receive an alternative antibiotic because of a common misunderstanding of the cross-reactivity between these antibiotics. This use of alternative antibiotics in surgical populations have been associated with increased infections, antibiotic resistance, and health care costs. We aimed to increase the percentage of patients with nonsevere penicillin-class allergies who receive cefazolin for antibiotic prophylaxis. METHODS: A multidisciplinary team conducted this quality improvement initiative, with a series of 3 plan-do-study-act cycles aimed at children with nonsevere penicillin-class allergies undergoing surgical procedures that require antibiotic prophylaxis. The primary outcome measure was the percentage of surgical encounters among patients with nonsevere penicillin-class allergies who received cefazolin as antibiotic prophylaxis. Statistical process control charts were used to measure improvement over time. RESULTS: Approximately 400 children were involved in this project. There was special cause variation and a shift in the center line from 60% to 80% of eligible patients receiving cefazolin for antibiotic prophylaxis, which was sustained for the duration of the project. In the last month, 90% of eligible patient received cefazolin, surpassing our goal of 85%. This improvement has been sustained in the 5 months after project completion. We had no cases of severe allergic reactions in the operating room. CONCLUSIONS: Our multidisciplinary education-focused interventions were associated with a significant increase in the use of cefazolin for perioperative antibiotic prophylaxis in patient with penicillin allergies.

Achieving Greater Health Equity: An Opportunity for Anesthesiology.

Anesthesiology and anesthesiologists have a tremendous opportunity and responsibility to eliminate health disparities and to achieve health equity. We thus examine health disparity and health equity through the lens of anesthesiology and the perspective of anesthesiologists. In this paper, we define health disparity and health care disparities and provide tangible, representative examples of the latter in the practice of anesthesiology. We define health equity, primarily as the desired antithesis of health disparity. Finally, we propose a framework for anesthesiologists, working toward mitigating health disparity and health care disparities, advancing health equity, and documenting improvements in health care access and health outcomes. This multilevel and interdependent framework includes the perspectives of the patient, clinician, group or department, health care system, and professional societies, including medical journals. We specifically focus on the interrelated roles of social identity and social determinants of health in health outcomes. We explore the foundational role that clinical informatics and valid data collection on race and ethnicity have in achieving health equity. Our ability to ensure patient safety by considering these additional patient-specific factors that affect clinical outcomes throughout the perioperative period could substantially reduce health disparities. Finally, we explore the role of medical journals and their editorial boards in ameliorating health disparities and advancing health equity.

Coronavirus disease 2019 and pediatric anesthesia.

PURPOSE OF REVIEW: The purpose of this review is to provide the latest evidence for delivering safe and effective anesthesia care for pediatric patients with coronavirus disease 2019 (COVID-19) and to highlight continuing gaps in the literature. RECENT FINDINGS: Safe and efficient care of pediatric patients with COVID-19 can be delivered with the proper planning, coordination, supplies, and staff preparation. From the start of the pandemic, pediatric anesthesiologists from around the world contributed important insights and shared experience as to how best to adapt anesthesia care for children with COVID-19 requiring general anesthesia and sedation. Although initial efforts focused on creating safe airway management processes, the role of anesthesiologists as perioperative leaders quickly extended to ensuring well-coordinated management of COVID-19 patients throughout the hospital for procedures, including preprocedure testing, patient transport, operating room setup, and ensuring the safety of staff. Several important areas remain not well studied including, the timing of rescheduling elective procedures following COVID-19 infection, the perioperative implications of re-infection, and future considerations of managing vaccinated children. SUMMARY: Pediatric anesthesia care can be safely delivered to children with COVID-19 and after COVID-19 infection. More attention needs to be focused on the perioperative management of COVID-19 children in recovery requiring anesthesia.

A Qualitative Assessment of Factors That Children, Parents, and Clinicians Prioritize in the Setting of Elective Anesthesia and Surgery.

BACKGROUND: Assessing the postoperative recovery of pediatric patients is challenging as there is no validated comprehensive patient-centered recovery assessment tool for this population. A qualitative investigative approach with in-depth stakeholder interviews can provide insight into the recovery process and inform the development of a comprehensive patient-centered postoperative assessment tool for children. METHODS: We conducted open-ended, semistructured interviews with children 6-12 years old undergoing elective surgery (n = 35), their parents (n = 37), and clinicians (n = 23) who commonly care for this population (nurses, anesthesiologists, and surgeons). A codebook was developed and analyzed using NVivo 12 Plus. The codebook was iteratively developed using a qualitative content analysis approach with modifications made throughout to refine codes. We report the results of this thematic analysis of patient, parent, and clinician transcripts. RESULTS: Postoperative recovery priorities/concerns overlapped and also diverged across the 3 groups. Topics prioritized by children included mobility and self-care, as well as access to a strong social support network following surgery. The majority of children reported feeling anxious about the surgery and separating from their parents, as well as sadness about their inability to participate in activities while recovering. Although children highly valued familial support during recovery, there was variable awareness of the impact of surgery on family members and support network. In contrast, parents focused on the importance of clear and open communication among themselves and the health care team and being equipped with appropriate knowledge and resources on discharge. The immediate repercussions of the child's surgery, such as pain, confusion, and nausea, appeared to be a primary focus of both parents and clinicians when describing recovery. Clinicians had a comprehensive awareness of the possible psychological impacts of surgery in children, while parents reported varying degrees of awareness or concern regarding longer-term or more latent impacts of surgery and anesthesia (eg, anxiety and depression). Prior experience with pediatric surgery emerged as a distinguishing characteristic for parents and clinicians as parents without prior experience expressed less understanding of or comfort with managing a child's recovery following surgery. CONCLUSIONS: A patient-centered qualitative investigative approach yielded insights regarding the importance of various aspects of recovery in pediatric patients, their parents, and members of the health care team. Specifically, this investigation highlighted the importance of clear communication providing anticipatory guidance for families presenting for elective surgery in an effort to optimize patient recovery. This information will be used in the development of a patient-centered recovery assessment tool.

Preoperative Fluid Fasting Times and Postinduction Low Blood Pressure in Children: A Retrospective Analysis.

BACKGROUND: Children are required to fast before elective general anesthesia. This study hypothesized that prolonged fasting causes volume depletion that manifests as low blood pressure. This study aimed to assess the association between fluid fasting duration and postinduction low blood pressure. METHODS: A retrospective cohort study was performed of 15,543 anesthetized children without preinduction venous access who underwent elective surgery from 2016 to 2017 at Children's Hospital of Philadelphia. Low blood pressure was defined as systolic blood pressure lower than 2 standard deviations below the mean (approximately the 2.5th percentile) for sex- and age-specific reference values. Two epochs were assessed: epoch 1 was from induction to completion of anesthesia preparation, and epoch 2 was during surgical preparation. RESULTS: In epoch 1, the incidence of low systolic blood pressure was 5.2% (697 of 13,497), and no association was observed with the fluid fasting time groups: less than 4 h (4.6%, 141 of 3,081), 4 to 8 h (6.0%, 219 of 3,652), 8 to 12 h (4.9%, 124 of 2,526), and more than 12 h (5.0%, 213 of 4,238). In epoch 2, the incidence of low systolic blood pressure was 6.9% (889 of 12,917) and varied across the fasting groups: less than 4 h (5.6%, 162 of 2,918), 4 to 8 h (8.1%, 285 of 3,531), 8 to 12 h (5.9%, 143 of 2,423), and more than 12 h (7.4%, 299 of 4,045); after adjusting for confounders, fasting 4 to 8 h (adjusted odds ratio, 1.33; 95% CI, 1.07 to 1.64; P = 0.009) and greater than 12 h (adjusted odds ratio, 1.28; 95% CI, 1.04 to 1.57; P = 0.018) were associated with significantly higher odds of low systolic blood pressure compared with the group who fasted less than 4 h, whereas the increased odds of low systolic blood pressure associated with fasting 8 to 12 h (adjusted odds ratio, 1.11; 95% CI, 0.87 to 1.42; P = 0.391) was nonsignificant. CONCLUSIONS: Longer durations of clear fluid fasting in anesthetized children were associated with increased risk of postinduction low blood pressure during surgical preparation, although this association appeared nonlinear.

A Visual Analytics Dashboard to Summarize Serial Anesthesia Records in Pediatric Radiation Treatment.

BACKGROUND: Young children who undergo radiation therapy may require general anesthesia to remain still during weeks of radiation sessions. On a typical day at our hospital, an anesthesia team will care for 10 patients in the radiation therapy suite, and each patient will have multiple prior anesthetic records. Daily review of prior anesthesia records is important to maintain anesthetic consistency and to identify potential improvement, yet our electronic health record (EHR) made such review time-consuming and cumbersome. OBJECTIVES: This article aims to design a visual analytics interface that simultaneously displays data from multiple anesthesia encounters to support clinical consistency in medications and airway management. METHODS: Documentation from the EHR is available in the clinical data warehouse following daily backups. A visual analytics interface was built to aggregate important components of multiple anesthesia encounters in pediatric radiation oncology on a single screen. The application was embedded in the EHR's anesthesia module and updated daily. RESULTS: Each anesthesia encounter was represented by a vertical line with the date at the bottom of the screen. Each vertical line was divided into sections corresponding to the medications, type of airway device, type of radiation oncology procedure, days between treatments, and recovery score and time. Information about the medications, airways, and procedures was shown with icon legends. This layout enabled users to quickly see the key components of multiple anesthetics and make inferences between, for example, the medications used and the recovery score. CONCLUSION: The dashboard provides a high-level summary of all radiation therapy anesthesia records for children receiving recurrent treatments. In this clinical scenario, it is desirable to replicate an optimal anesthetic approach for daily or near-daily treatments or adjust the anesthetic based on observed patterns.

Hypoxemia, Bradycardia, and Multiple Laryngoscopy Attempts during Anesthetic Induction in Infants: A Single-center, Retrospective Study.

BACKGROUND: The infant airway is particularly vulnerable to trauma from repeated laryngoscopy attempts. Complications associated with elective tracheal intubations in anesthetized infants may be underappreciated. We conducted this study of anesthetized infants to determine the incidence of multiple laryngoscopy attempts during routine tracheal intubation and assess the association of laryngoscopy attempts with hypoxemia and bradycardia. METHODS: We conducted a retrospective cross-sectional cohort study of anesthetized infants (age less than or equal to 12 months) who underwent direct laryngoscopy for oral endotracheal intubation between January 24, 2015, and August 1, 2016. We excluded patients with a history of difficult intubation and emergency procedures. Our primary outcome was the incidence of hypoxemia or bradycardia during induction of anesthesia. We evaluated the relationship between laryngoscopy attempts and our primary outcome, adjusting for age, weight, American Society of Anesthesiologists status, staffing model, and encounter location. RESULTS: A total of 1,341 patients met our inclusion criteria, and 16% (n = 208) had multiple laryngoscopy attempts. The incidence of hypoxemia was 35% (n = 469) and bradycardia was 8.9% (n = 119). Hypoxemia and bradycardia occurred in 3.7% (n = 50) of patients. Multiple laryngoscopy attempts were associated with an increased risk of hypoxemia (adjusted odds ratio: 1.78, 95% CI: 1.30 to 2.43, P < 0.001). There was no association between multiple laryngoscopy attempts and bradycardia (adjusted odds ratio: 1.23, 95% CI: 0.74 to 2.03, P = 0.255). CONCLUSIONS: In a quaternary academic center, healthy infants undergoing routine tracheal intubations had a high incidence of multiple laryngoscopy attempts and associated hypoxemia episodes.

STBUR: Sleep trouble breathing and unrefreshed questionnaire: Evaluation of screening tool for postanesthesia care and disposition.

BACKGROUND: The Snoring, Trouble Breathing, and Un-Refreshed (STBUR) questionnaire is a five-question screening tool for pediatric sleep-disordered breathing and risk for perioperative respiratory adverse events in children. The utility of this questionnaire as a preoperative risk-stratification tool has not been investigated. In view of limited availability of screening tools for preoperative pediatric sleep-disordered breathing, we evaluated the questionnaire's performance for postanesthesia adverse events that can impact postanesthesia care and disposition. METHODS: The retrospective study protocol was approved by the institutional research board. The data were analyzed using two different definitions for a positive screening based on a five-point scale: low threshold (scores 1 to 5) and high threshold (score of 5). The primary outcome was based on the following criteria: (a) supplemental oxygen therapy following postanesthesia care unit (PACU) stay until hospital discharge, (b) greater than two hours during phase 1 recovery, (c) anesthesia emergency activation in the PACU, and (d) unplanned hospital admission. RESULTS: About 6025 patients completed the questionnaire during the preoperative evaluation. And 1522 patients had a low threshold score and 270 had a high-threshold score. We found statistically significant associations in three outcomes based on the low threshold score: supplemental oxygen therapy (negative-predictive value [NPV] 0.97, 95% CI 0.97-98), PACU recovery time (NPV 0.99, 95% CI 0.99-0.99) and escalation of care (NPV 0.98, 95% CI 0.97-0.98). Positive-predictive values were statistically significant for all outcomes except anesthesia emergency in the PACU. CONCLUSION: The Snoring, Trouble Breathing, and Un-Refreshed questionnaire identified patients at higher risk for prolonged phase 1 recovery, oxygen therapy requirement, and escalation of care. The questionnaire's high-negative predictive value and specificity may make it useful as a screening tool to identify patients at low risk for prolonged stay in PACU.

Care Standardization Reduces Blood Donor Exposures and Transfusion in Complex Cranial Vault Reconstruction.

BACKGROUND: Complex cranial vault reconstruction (CCVR) often requires a large-volume transfusion of blood products. We implemented a series of improvement interventions to reduce blood donor exposures (BDE) and transfusion requirements in CCVR. METHODS: We implemented interventions over 4 epochs: (E1) reconstituted blood (1:1 ratio of donor-matched red blood cells and fresh-frozen plasma) for intraoperative transfusions, (E2) reconstituted blood plus postoperative transfusion guidelines, (E3) reconstituted blood plus intraoperative antifibrinolytics and postoperative guidelines, and (E4) fresh whole blood for intraoperative transfusion, antifibrinolytics, and postoperative guidelines. Primary outcomes, BDE, and total volume of blood products transfused are presented by using statistical process control charts, with statistical comparisons between each epoch and baseline data. RESULTS: We included 347 patients <72 months old who underwent CCVR between 2008 and 2016 (E1: n = 50; E2: n = 41; E3: n = 87; and E4: n = 169). They were compared with a baseline sample group of 138 patients who were managed between 2001 and 2006. Compared with our baseline group, patients in each epoch had a significant reduction in BDE (P = .02-<.0001). Conversely, compared with the baseline group, we observed an increase the volume of blood products transfused in E1 (P = .004), no difference in E2 (P = .6) or E3 (P = .46), and a reduction in the volume of blood products transfused in E4 (P < .0001). CONCLUSIONS: The implementation of sequential clinical improvement strategies resulted in a sustained reduction in BDE whereas only the use of whole blood resulted in a significant reduction in the total volume of blood products transfused in children undergoing CCVR.

One Laryngospasm, 2 Realities: A Case Report Highlighting the Impact of Data Granularity on Post Hoc Analysis of Perioperative Events.

We present the case of a laryngospasm event in a 21-month-old child in which the changes in pulse oximetry and end-tidal carbon dioxide were recorded by both our Anesthesia Information Management System and middleware medical device integration platform. When this case was analyzed retrospectively, we noted that the 2 systems recorded the event very differently with respect to pulse oximetry. This case report illustrates the impact of data sampling rates on post hoc analysis of perioperative events and highlights the importance of understanding data collection processes when using electronically recorded data.

Outcomes of laparoscopic and open surgery in children with and without congenital heart disease.

BACKGROUND: Children with congenital heart disease (CHD) often require noncardiac surgery. We compared outcomes following open and laparoscopic intraabdominal surgery among children with and without CHD. METHODS: We performed a retrospective cohort study using the 2013-2015 National Surgical Quality Improvement Project-Pediatrics. We matched 45,012 children <18years old who underwent laparoscopic surgery to 45,012 children who underwent open surgery. We determined the associations between laparoscopic (versus open) surgery and 30-day mortality, in-hospital mortality, 30-day morbidity, and postoperative length-of-stay. RESULTS: Among children with minor CHD, laparoscopic surgery was associated with lower 30-day mortality (Odds Ratio [OR] 0.34 [95% Confidence Interval 0.15-0.79]), inhospital mortality (OR 0.42 [0.22-0.81]) and 30-day morbidity (OR 0.61 [0.50-0.73]). As CHD severity increased, this benefit of laparoscopic surgery decreased for 30-day morbidity (ptrend=0.01) and in-hospital mortality (ptrend=0.05), but not for 30-day mortality (ptrend=0.27). Length-of-stay was shorter for laparoscopic approaches for children at cost of higher readmissions. On subgroup analysis, laparoscopy was associated with lower odds of postoperative blood transfusion in all children. CONCLUSIONS: Intraabdominal laparoscopic surgery compared to open surgery is associated with decreased morbidity in patients with no CHD and lower morbidity and mortality in patients with minor CHD, but not in those with more severe CHD. LEVEL-OF-EVIDENCE: Level III: Treatment Study.

Mortality and Morbidity after Laparoscopic Surgery in Children with and without Congenital Heart Disease.

OBJECTIVES: To determine the risk of morbidity and mortality after laparoscopic surgery among children with congenital heart disease (CHD). STUDY DESIGN: Cohort study using the 2013-2014 National Surgical Quality Improvement Program-Pediatrics, which prospectively collected data at 56 and 64 hospitals in 2013 and 2014, respectively. Primary exposure was CHD. Primary outcome was overall in-hospital postoperative mortality. Secondary outcomes included 30-day mortality and 30-day morbidity (any nondeath adverse event). Among 34?543 children who underwent laparoscopic surgery, 1349, 1106, and 266 had minor, major, and severe CHD, respectively. After propensity score matching within each stratum of CHD severity, morbidity and mortality were compared between children with and without CHD. RESULTS: Children with severe CHD had higher overall mortality and 30-day morbidity (OR 12.31, 95% CI 1.59-95.01; OR 2.51, 95% CI 1.57-4.01, respectively), compared with matched controls. Overall mortality and 30-day morbidity were also higher among children with major CHD compared with children without CHD (OR 3.46, 95% CI 1.49-8.06; OR 2.07, 95% CI 1.65-2.61, respectively). Children with minor CHD had similar mortality outcomes, but had higher 30-day morbidity compared with children without CHD (OR 1.71, 95% CI 1.37-2.13). CONCLUSIONS: Children with major or severe CHD have higher morbidity and mortality after laparoscopic surgery. Clinicians should consider the increased risks of laparoscopic surgery for these children during medical decision making.

A systematic review of near real-time and point-of-care clinical decision support in anesthesia information management systems.

Anesthesia information management systems (AIMS) are sophisticated hardware and software technology solutions that can provide electronic feedback to anesthesia providers. This feedback can be tailored to provide clinical decision support (CDS) to aid clinicians with patient care processes, documentation compliance, and resource utilization. We conducted a systematic review of peer-reviewed articles on near real-time and point-of-care CDS within AIMS using the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols. Studies were identified by searches of the electronic databases Medline and EMBASE. Two reviewers screened studies based on title, abstract, and full text. Studies that were similar in intervention and desired outcome were grouped into CDS categories. Three reviewers graded the evidence within each category. The final analysis included 25 articles on CDS as implemented within AIMS. CDS categories included perioperative antibiotic prophylaxis, post-operative nausea and vomiting prophylaxis, vital sign monitors and alarms, glucose management, blood pressure management, ventilator management, clinical documentation, and resource utilization. Of these categories, the reviewers graded perioperative antibiotic prophylaxis and clinical documentation as having strong evidence per the peer reviewed literature. There is strong evidence for the inclusion of near real-time and point-of-care CDS in AIMS to enhance compliance with perioperative antibiotic prophylaxis and clinical documentation. Additional research is needed in many other areas of AIMS-based CDS.

Caudal analgesia and cardiothoracic surgery: a look at postoperative pain scores in a pediatric population.

AIM: Caudal epidural anesthesia has been shown to reduce stress response and shorten the time to extubation in children after cardiac surgery. Combined with general anesthesia, regional anesthesia has been proven to be safe and efficacious in the pediatric population. It is not known, however, whether the use of caudal anesthesia actually reduces postoperative pain scores and decreases postoperative opioid use. METHODS: We retrospectively analyzed the charts of 199 children who underwent repair for atrial septal defect (ASD), ventricular septal defect (VSD), and Tetralogy of Fallot (TOF) at a major academic children's hospital between 2010 and 2013. RESULTS: Eighty-six patients underwent preoperative placement of caudal anesthesia (bupivacaine 0.25% 1 ml·kg-1 up to 20 ml + clonidine 2mcg·kg-1 + Duramorph 40 mcg·kg-1 up to 2.5 mg) and 113 patients did not have a caudal block. Postoperative cardiac intensive care pain scores were analyzed according to standard nurse-recorded patient-appropriate pain scales ranging from 0 to 10 (CRIES for neonates and FLACC for 2 months-7 years). There was no statistical difference between caudal and noncaudal groups with respect to postoperative pain scores or with postoperative opioid requirements. There was a statistical significance with regard to intraoperative opioid use as noncaudal patients invariably received more opioid during the procedure. CONCLUSION: Although regional anesthesia reduced intraoperative opioid usage, there was no difference in postoperative opioid usage or pain scores.