Factors affecting need for blood transfusion in paediatric patients undergoing open surgery for hip dysplasia.

BACKGROUND AND OBJECTIVES: The management of intraoperative blood loss in the surgical treatment of paediatric hip dysplasia is resource intensive. There are numerous clinical factors that impact the need for intraoperative transfusion. Identification of patient and surgical factors associated with increased blood loss may reduce the unnecessary use of resources. This study aimed to identify factors predictive of intraoperative transfusion in children undergoing hip dysplasia surgery. MATERIALS AND METHODS: This is a single-centre retrospective review of patients undergoing surgery for hip dysplasia from 1 January 2012 to 15 April 2021. Patient demographic factors, anaesthetic, surgical and transfusion histories were reviewed. Multivariable logistic regression analysis was performed to identify factors predictive of allogeneic red blood cell transfusion requirements during the intraoperative period. RESULTS: This study includes 595 patients who underwent open surgery for hip dysplasia, including 297 (52.6%) classified as developmental dysplasia (DD) and 268 (47.3%) as neuromuscular (NM) with a mean age of 9.1 years (interquartile range 3-14). Intraoperative allogeneic transfusion was identified in 26/297 (8.8%) DD and 73/268 (27.2%) NM patients. Adjusted factors associated with increased odds of intraoperative transfusion were NM (odds ratio [OR] = 2.96, 95% confidence interval [CI] [1.76, 5.00]) and the number of osteotomies performed (OR = 1.82/osteotomy, 95% CI [1.40, 2.35]). Adjusted factors that reduced the odds of transfusion were the use of antifibrinolytics (OR = 0.35, 95% CI [0.17, 0.71]) and regional anaesthesia (OR = 0.52, 95% CI [0.29, 0.94]). CONCLUSION: For children undergoing surgery for hip dysplasia, the number of osteotomies performed is predictive of the need for allogeneic blood transfusion. Antifibrinolytics and regional anaesthesia are associated with reduced risk for allogeneic blood transfusion. Blood management initiatives, such a preoperative optimization of haemoglobin and the use of antifibrinolytics, could target patients at increased risk of intraoperative bleeding and transfusion.

Association of Analgesic Block With the Incidence of Complications Following Hypospadias Surgery; A Meta-Analysis.

To examine the association between type of analgesic block and incidence of complications following primary hypospadias correction. Data sources included MEDLINE, Embase, Web of Science and the Cochrane Library, inception-01/2021. Randomized clinical trials, cohort and case control studies reporting original data for patients <18 years of age undergoing primary hypospadias correction with either a penile or caudal block for which outcomes (urethrocutaneous fistula or glans dehiscence) were reported. Two researchers independently extracted data and assessed quality for inclusion. The primary outcome was the incidence of complication within six-months postoperatively based on block performed. Ten studies (3201 patients; range: 54-983) were included. Six studies (cumulative weight 28.6%) favored penile block while 4 studies (cumulative weight 71.4%) favored caudal block. Compared to the reference group of penile blocks, caudal blocks had no significant association with development of complications following primary hypospadias correction (relative risk 1.11, 95% CI (0.88, 1.41); P = .38). When adjusting for meatal location (distal vs proximal) there was no significant association with development of fistulae or glanular dehiscence following primary hypospadias correction with caudal blocks in comparison to the reference group, penile blocks for distal, (relative risk 1.46, 95%CI (0.98, 2.17); P = .065) and proximal (relative risk 0.95, 95% CI (0.58, 1.54); P = .823). The type of analgesic block is not associated with the risk of developing complications following primary hypospadias correction in children. Caudal block should be considered for these urological interventions.

Preventing Home Medication Administration Errors.

Medication administration errors that take place in the home are common, especially when liquid preparations are used and complex medication schedules with multiple medications are involved; children with chronic conditions are disproportionately affected. Parents and other caregivers with low health literacy and/or limited English proficiency are at higher risk for making errors in administering medications to children in their care. Recommended strategies to reduce home medication errors relate to provider prescribing practices; health literacy-informed verbal counseling strategies (eg, teachback and showback) and written patient education materials (eg, pictographic information) for patients and/or caregivers across settings (inpatient, outpatient, emergency care, pharmacy); dosing-tool provision for liquid medication measurement; review of medication lists with patients and/or caregivers (medication reconciliation) that includes prescription and over-the-counter medications, as well as vitamins and supplements; leveraging the medical home; engaging adolescents and their adult caregivers; training of providers; safe disposal of medications; regulations related to medication dosing tools, labeling, packaging, and informational materials; use of electronic health records and other technologies; and research to identify novel ways to support safe home medication administration.

Monochromic light reduces emergence delirium in children undergoing adenotonsillectomy; a double-blind randomized observational study.

BACKGROUND: Emergence delirium (ED) is common in pediatric anesthesia. This dissociative state in which the patient is confused from their surroundings and flailing can be self-injurious and traumatic for parents. Treatment is by administration of sedatives which can prolong recovery. The aim of this study was to determine if exposure to monochromatic blue light (MBL) in the immediate phase of recovery could reduce the overall incidence of emergence delirium in children following general inhalational anesthesia. METHODS: This double blinded randomized controlled study included patients ages 2-6 undergoing adenotonsillectomy. Postoperatively, 104 patients were randomization (52 in each group) for exposure to sham blue or MBL during the first phase (initial 30 min) of recovery. The primary outcome was the incidence of emergence delirium during the first phase. We also examined Pediatric Anesthesia Emergence Delirium (PAED) scores throughout the first phase. RESULTS: Emergence Delirium was reported in 5.9% of MBL patients versus 33.3% in the sham group, p = 0.001. Using logistic regression adjusting for age, weight, gender, ASA classification and PAED scores provided an adjusted relative risk ratio of 0.18; 95% CI (0.06, 0.54); p = 0.001 for patients in the MBL group. 23.5% of MBL patients versus 52.9% of sham patients had either ED or PAED scores of 12 or more throughout the first phase of recovery, p = 0.002. This produced an adjusted relative risk of 0.46, 95% CI (0.29, 0.75), p = 0.001. CONCLUSIONS: Monochromatic blue light represents a non-pharmacologic method to reduce the incidence of emergence delirium and PAED scores in children. TRIAL REGISTRATION: #NCT03285243 registered on 15/09/2017.

Incidence of Difficult Laryngoscopy in Adult Congenital Heart Disease Patients: A Retrospective Cohort Study.

OBJECTIVE: To identify the incidence of difficult intubation in patients with adult congenital heart disease (ACHD) undergoing cardiac surgery or catheterization. DESIGN: A retrospective cohort study. SETTING: A single-center academic quaternary pediatric hospital. PARTICIPANTS: All patients were >18 years of age with ACHD undergoing endotracheal intubation within the Heart Center at Texas Children's Hospital between January 2012 and December 2019. INTERVENTIONS: None. MEASUREMENT AND MAIN RESULTS: A retrospective chart review was performed, including patient demographics, preoperative airway assessment and intraoperative airway management characteristics. Airways were categorized as difficult using the Pediatric Difficult Intubation registry operational definitions. For patients classified as having a difficult airway, the preoperative airway examination findings were recorded in addition to factors associated with difficult airway in the adult. The study authors identified 1,029 patients with ACHD who underwent procedures with anesthesia at their institution and were analyzed for the presence of difficult airway. In total, 878 patients were intubated, with 4.3% (n = 38) identified to have difficult airway. The presence of concomitant syndromes was greater in patients with difficult intubations and those who were not intubated compared with those who were not difficult intubations (23.7% and 17.2 v 7.5; p < 0.001), respectively. Most patients did not have typical signs associated with difficult intubation. CONCLUSIONS: The study authors identified an incidence of difficult laryngoscopy in their cohort of ACHD patients to be 4.3%. Their incidences of difficult laryngoscopy were fewer than that reported in adult patients with noncongenital heart disease. Most importantly, the risk factors associated with difficult laryngoscopy in the normal adult may be different from those presenting with ACHD, necessitating further investigation.

An assessment of opioids on respiratory depression in children with and without obstructive sleep apnea.

BACKGROUND: Obstructive sleep apnea is a risk factor for respiratory depression following opioid administration as well as opioid-induced hyperalgesia. Little is known on how obstructive sleep apnea status is associated with central ventilatory depression in pediatric surgical patients given a single dose of fentanyl. METHODS: This was a single-center, prospective trial in children undergoing surgery requiring intubation and opioid administration. Sixty patients between the ages of 2-8 years presenting for surgery at Texas Children's Hospital were recruited. Twenty non-obstructive sleep apnea controls and 30 patients with moderate to severe obstructive sleep apnea met inclusion criteria. Following induction of general anesthesia and establishment of steady-state ventilation, participants received 1 mcg/kg intravenous fentanyl. Ventilatory variables (tidal volume, respiratory rate, end-tidal CO2 , and minute ventilation) were assessed each minute for 10 min. The primary outcome was the extent of opioid-induced central ventilatory depression over time by obstructive sleep apnea status when compared with baseline values. Secondary aims assessed the impact of demographics and SpO2 nadir on ventilatory depression. RESULTS: We found no significant difference in percent decrease in respiratory rate (38.1% and 37.1%; p = .950), tidal volume (6.4% and 5.4%; p = .992), and minute ventilation (35.0 L/min and 35.0 L/min; p = .890) in control and obstructive sleep apnea patients, respectively. Both groups experienced similar percent increases in end-tidal CO2 (4.0% vs. 2.2%; p = .512) in control and obstructive sleep apnea patients, respectively. CONCLUSIONS: In pediatric surgical patients, obstructive sleep apnea status was not associated with significant differences in central respiratory depression following a single dose of fentanyl (1 mcg/kg). These findings can help determine safe opioid doses in future pediatric obstructive sleep apneapatients.

The Association of Dexmedetomidine on Perioperative Opioid Consumption in Children Undergoing Adenotonsillectomy With and Without Obstructive Sleep Apnea.

BACKGROUND: Dexmedetomidine is used to reduce opioid consumption in pediatric anesthesia. However, there is conflicting evidence in pediatric adenotonsillectomy literature regarding the total perioperative opioid-sparing effects of dexmedetomidine. The aim of this study was to examine the association between dexmedetomidine and total perioperative opioid consumption in children undergoing adenotonsillectomy. METHODS: This was a retrospective cohort study of the children undergoing adenotonsillectomy surgery at Texas Children's Hospital between November 2017 and October 2018. Intraoperative dexmedetomidine was the exposure of interest. The primary outcome was total perioperative opioid consumption calculated as oral morphine equivalents (OME). Secondary outcomes of interest included opioid consumption and pain scores based on presence and absence of obstructive sleep apnea (OSA) and postanesthesia care unit (PACU) duration. We used multivariable linear regression to estimate the association of dexmedetomidine on the outcomes. RESULTS: A total of 941 patients met inclusion criteria, 697 (74.1%) received intraoperative dexmedetomidine. For every 0.1 µg/kg increase in intraoperative dexmedetomidine, the total perioperative OME (mg/kg) decreases by 0.021 mg/kg (95% CI, -0.027 to -0.015; P < .001). Pain scores did not significantly vary by OSA status. PACU duration increased by 1.14 minutes (95% CI, 0.30-1.99; P = .008) for each 0.1 µg/kg of intraoperative dexmedetomidine. CONCLUSIONS: Dexmedetomidine is associated with an overall perioperative opioid-sparing effect in children undergoing adenotonsillectomy and a small but statistically significant increase in PACU duration. Additionally, children with OSA did not have reduced perioperative opioid consumption.

"You can't make me!" Managing adolescent dissent to anesthesia.

When adolescents require health care, the need to obtain consent from the parent/legal guardian and assent from the patient can create the potential for an ethical dilemma when these two parties are not in agreement. Here, we describe a representative and common case scenario in which both parent and adolescent patient gave consent and assent, respectively, with a full understanding of the risks and benefits of the procedure and anesthetic. At the time of anesthetic induction, however, the patient expresses that she no longer wishes to have the procedure. We identify a number of considerations that inform the ethical analysis of such cases and offer recommendations about the most appropriate path forward for a practitioner faced with a difficult decision about how to respond.

Effect of Caudal vs. Penile Block on the Incidence of Hypospadias Complications Following Primary Repairs: A Retrospective Cohort Study.

PURPOSE: Primary repair of hypospadias is associated with risk of complications, specifically urethrocutaneous fistula and glanular dehiscence. Caudal block may potentially increase the risk of these complications. Therefore, we studied the incidence of hypospadias complications in children who underwent correction at our institution having received either penile or caudal block. MATERIALS AND METHODS: We analyzed all primary hypospadias repair cases from December 2011 through December 2018 at Texas Children's Hospital with a minimum of 1-year followup for the presence of complications: urethrocutaneous fistula and glanular dehiscence. Surgical (surgeon, operative time, block type, local anesthetic, meatal position) and patient (age at correction, prematurity) factors were additionally analyzed. RESULTS: For the primary aim, 983 patients underwent primary hypospadias correction with a minimum of 1 year of postoperative followup data. There were 897 patients (91.3%) in which no complications were identified and 86 (8.7%) with either urethrocutaneous fistula (81) or glanular dehiscence (5). Of the 86 identified complications, 45/812 (5.5%) were distal, 41/171 (24%) were proximal (p <0.001) with a complication. Rate of complications was not associated with caudal block (OR 0.67, 95% CI 0.41-1.09; p=0.11). On univariable analysis, age (OR 1.12, 95% CI 1.04-1.20; p=0.04), surgical duration (OR 1.02; 95% CI 1.01-1.02; p <0.001), prematurity <32 weeks (OR 4.38, 95% CI 1.54-4.11 p <0.001) and position of meatus as proximal (OR 5.38 95% CI 3.39-8.53; p <0.001) were associated with an increased rate of complications. However, on multivariable analysis, associations of age (OR 1.13, 95% CI 1.05-1.22; p=0.001), surgery duration (OR 1.01, 95% CI 1.01-1.02; p <0.001) and meatal position (OR 3.85, 95% CI 2.32-6.39; p <0.001) were associated with increased rate of complications. CONCLUSIONS: Our data suggest that meatal location, older age, extreme prematurity and surgical duration are associated with increased incidence of complications (urethrocutaneous fistula and glanular dehiscence) following hypospadias correction. Analgesic block was not associated with increased hypospadias complication risk.

Intermittent Hypoxia and Effects on Early Learning/Memory: Exploring the Hippocampal Cellular Effects of Pediatric Obstructive Sleep Apnea.

This review provides an update on the neurocognitive phenotype of pediatric obstructive sleep apnea (OSA). Pediatric OSA is associated with neurocognitive deficits involving memory, learning, and executive functioning. Adenotonsillectomy (AT) is presently accepted as the first-line surgical treatment for pediatric OSA, but the executive function deficits do not resolve postsurgery, and the timeline for recovery remains unknown. This finding suggests that pediatric OSA potentially causes irreversible damage to multiple areas of the brain. The focus of this review is the hippocampus, 1 of the 2 major sites of postnatal neurogenesis, where new neurons are formed and integrated into existing circuitry and the mammalian center of learning/memory functions. Here, we review the clinical phenotype of pediatric OSA, and then discuss existing studies of OSA on different cell types in the hippocampus during critical periods of development. This will set the stage for future study using preclinical models to understand the pathogenesis of persistent neurocognitive dysfunction in pediatric OSA.

Pediatric obstructive sleep apnea revisited: Perioperative considerations for the pediatric Anesthesiologist.

Pediatric obstructive sleep apnea presents in up to 7% of children and represents a constellation from nasal turbulence to cessation in gas exchange. There are numerous end organ sequelae including neurocognitive morbidity associated with persistent OSA. Adenotonsillectomy (AT), the first line therapy for pediatric OSA, has not been demonstrated to reduce all end organ morbidity, specifically neurological and behavioral morbidity. Furthermore, certain at-risk populations are at higher risk from neurocognitive morbidity. Precise knowledge and perioperative planning is required to ensure optimal evidence-based practices in children with OSA. This comprehensive review covers the seminal perioperative implications of OSA, including preoperative polysomnography, pharmacotherapeutics, and postoperative risk stratification.

Analysis of 1478 Cases of Hypospadias Repair: The Incidence of Requiring Repeated Anesthetic Exposure as Well as Exploration of the Involvement of Trainees on Case Duration.

BACKGROUND: Recently, there has been significant focus on the effects of anesthesia on the developing brain. Concern is heightened in children <3 years of age requiring lengthy and/or multiple anesthetics. Hypospadias correction is common in otherwise healthy children and may require both lengthy and repeated anesthetics. At academic centers, many of these cases are performed with the assistance of anesthesia and surgical trainees. We sought to identify both the incidence of these children undergoing additional anesthetics before age 3 as well as to understand the effect of trainees on duration of surgery and anesthesia and thus anesthetic exposure (AE), specifically focusing on those cases >3 hours. METHODS: We analyzed all cases of hypospadias repair from December 2011 through December 2018 at Texas Children's Hospital. In all, 1326 patients undergoing isolated hypospadias repair were analyzed for anesthesia time, surgical time, provider types involved, AE, caudal block, and additional AE related/unrelated to hypospadias. RESULTS: For the primary aim, a total of 1573 anesthetics were performed in children <3 years of age, including 1241 hypospadias repairs of which 1104 (89%) were completed with <3 hours of AE. For patients with <3 hours of AE, 86.1% had a single surgical intervention for hypospadias. Of patients <3 years of age, 17.3% required additional nonrelated surgeries. There was no difference in anesthesia time in cases performed solely by anesthesia attendings versus those performed with trainees/assistance (16.8 vs 16.8 minutes; P = .98). With regard to surgery, cases performed with surgical trainees were of longer duration than those performed solely by surgical attendings (83.5 vs 98.3 minutes; P < .001). Performance of surgery solely by attending surgeon resulted in a reduced total AE in minimal alveolar concentration (MAC) hours when compared to procedures done with trainees (1.92 vs 2.18; P < .001). Finally, comparison of patients undergoing initial correction of hypospadias with subsequent revisions revealed a longer time (117.7 vs 132.2 minutes; P < .001) and AE during the primary stage. CONCLUSIONS: The majority of children with hypospadias were repaired within a single AE. In general, most children did not require repeated AE before age 3. While presence of nonattending surgeons was associated with an increase in AE, this might at least partially be due to differences in case complexity. Moreover, the increase is likely not clinically significant. While it is critical to maintain a training environment, attempts to minimize AE are crucial. This information facilitates parental consent, particularly with regard to anesthesia duration and the need for additional anesthetics in hypospadias and nonhypospadias surgeries.

Universal Screening for COVID-19 in Children Undergoing Orthopaedic Surgery: A Multicenter Report.

BACKGROUND: The COVID-19 pandemic has substantially altered the typical process around performing surgery to ensure protection of health care workers, patients, and their families. One safety precaution has been the implementation of universal preoperative screening for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). This study examines the results of universal screening on children undergoing orthopaedic surgery. METHODS: This is a retrospective cohort study evaluating the incidence and symptomatology of COVID-19 in all patients presenting for orthopaedic surgery at 3 pediatric tertiary care children's hospitals during the COVID-19 pandemic (March to June 2020). All patients underwent universal screening with a nasopharyngeal swab to detect presence of SARS-CoV-2. Bivariate and multivariate logistic regression analysis was performed to identify risk factors for positive COVID-19 screening. RESULTS: In total, 1198 patients underwent preoperative screening across all 3 institutions and 7 (0.58%) had detection of SARS-CoV-2. The majority of patients (1/7, 86%) were asymptomatic. Patients that tested positive were significantly more likely to be Hispanic (P=0.046) and had greater number of medical comorbidities (P=0.013), as scored on the American Society of Anesthesiologists (ASA) physical status score. A known COVID-19 positive contact was found to be a significant risk factor in the multivariate analysis (P=0.004). CONCLUSIONS: Early results of universal preoperative screening for COVID-19 demonstrates a low incidence and high rate of asymptomatic patients. Health care professionals, especially those at higher risk for the virus, should be aware of the challenges related to screening based solely on symptoms or travel history and consider universal screening for patients undergoing elective surgery. LEVEL OF EVIDENCE: Level II.

Perioperative Considerations for the Fontan Patient Requiring Noncardiac Surgery.

Children and adults with congenital heart disease undergoing noncardiac surgery are at higher risk of perioperative adverse events. Patients have significant comorbidities and syndromic associations that increase perioperative risk further. The complexity of congenital heart disease requires a thorough understanding of lesion-specific pathophysiology in order to provide safe care. Comprehensive multidisciplinary planning and the use of skilled and experienced teams achieve the best outcomes. The anesthesiologist is a perioperative physician charged with providing safe anesthesia care, instituting appropriate hemodynamic monitoring, and determining appropriate postoperative disposition on an individual basis.

Pediatric Obstructive Sleep Apnea and Neurocognition.

Pediatric obstructive sleep apnea affects a large number of children and has multiple end-organ sequelae. Although many of these have been demonstrated to be reversible, the effects on some of the organ systems, including the brain, have not shown easy reversibility. Progress in this area has been hampered by lack of a preclinical model to study the disease. Therefore, perioperative and sleep physicians are tasked with making a number of difficult decisions, including optimal surgical timing to prevent disease evolution, but also to keep the perioperative morbidity in a safe range for these patients.