Predictors of postoperative systemic inflammatory response syndrome after scoliosis surgery in adolescents with cerebral palsy: A retrospective analysis.

Background: Systemic inflammatory response syndrome (SIRS) is known to complicate postsurgical intensive care patients. We noticed that roughly half children with cerebral palsy who undergo posterior spinal fusion (PSF) for neuromuscular scoliosis developed SIRS in the intensive care unit. There is a paucity of literature detailing the impact of intraoperative causes of postoperative SIRS and downstream consequences in these patients. Study purpose was to understand the factors associated with SIRS in children who undergo PSF for neuromuscular scoliosis. Methods: This retrospective, case control study included children who underwent PSF for neuromuscular scoliosis. Patients with idiopathic scoliosis, osteogenesis imperfecta, and tracheotomy were excluded. Subjects were divided into two study groups based on the diagnosis of SIRS in the intensive care unit. Descriptive statistical analysis was used to identify factors associated with SIRS; a regression analysis was used to further evaluate the independent and significant influence of these factors. Results: There was no significant difference in the demographic and other preoperative variables. However, total blood products (ml/kg) administered was significantly higher among the SIRS group compared with the non-SIRS group (54.4±41.0 vs 34.1±21.5 P <0.034). Percent of patients remaining intubated was greater in the SIRS group compared with the non-SIRS group (44.1% vs 7.0%, P < 0.001). The regression model revealed that the odds to develop SIRS in patients who were not extubated were 7.467-fold higher (CI: 1.534-36.347) compared with those who were extubated (p=0.013). Conclusions: The incidence of SIRS is significantly higher among the patients who were not extubated at the end of PSF surgery. Further prospective studies are needed to look at the factors that impede the ability to extubate these patients at the end of surgery.

Financial and Clinical Ramifications of Introducing a Novel Pediatric Enhanced Recovery After Surgery Pathway for Pediatric Complex Hip Reconstructive Surgery.

BACKGROUND: Enhanced recovery after surgery pathways confer significant perioperative benefits to patients and are currently well described for adult patients undergoing a variety of surgical procedures. Robust data to support enhanced recovery pathway use in children are relatively lacking in the medical literature, though clinical benefits are reported in targeted pediatric surgical populations. Surgery for complex hip pathology in the adolescent patient is painful, often requiring prolonged courses of opioid analgesia. Postoperative opioid-related side effects may lead to prolonged recovery periods and suboptimal postoperative physical function. Excessive opioid use in the perioperative period is also a major risk factor for the development of opioid misuse in adolescents. Perioperative opioid reduction strategies in this vulnerable population will help to mitigate this risk. METHODS: A total of 85 adolescents undergoing complex hip reconstructive surgery were enrolled into an enhanced recovery after surgery pathway (October 2015 to December 2018) and were compared with 110 patients undergoing similar procedures in previous years (March 2010 to September 2015). The primary outcome was total perioperative opioid consumption. Secondary outcomes included hospital length of stay, postoperative nausea, intraoperative blood loss, and other perioperative outcomes. Total cost of care and specific charge sectors were also assessed. Segmented regression was used to assess the effects of pathway implementation on outcomes, adjusting for potential confounders, including the preimplementation trend over time. RESULTS: Before pathway implementation, there was a significant downward trend over time in average perioperative opioid consumption (-0.10 mg total morphine equivalents/90 days; 95% confidence interval [CI], -0.20 to 0.00) and several secondary perioperative outcomes. However, there was no evidence that pathway implementation by itself significantly altered the prepathway trend in perioperative opioid consumption (ie, the preceding trend continued). For postanesthesia care unit time, the downward trend leveled off significantly (pre: -5.25 min/90 d; 95% CI, -6.13 to -4.36; post: 1.04 min/90 d; 95% CI, -0.47 to 2.56; Change: 6.29; 95% CI, 4.53-8.06). Clinical, laboratory, pharmacy, operating room, and total charges were significantly associated with pathway implementation. There was no evidence that pathway implementation significantly altered the prepathway trend in other secondary outcomes. CONCLUSIONS: The impacts of our pediatric enhanced recovery pathway for adolescents undergoing complex hip reconstruction are consistent with the ongoing improvement in perioperative metrics at our institution but are difficult to distinguish from the impacts of other initiatives and evolving practice patterns in a pragmatic setting. The ERAS pathway helped codify and organize this new pattern of care, promoting multidisciplinary evidence-based care patterns and sustaining positive preexisting trends in financial and clinical metrics.

Comparative evaluation of one-handed versus two-handed mask holding techniques in children during inhalational induction of anesthesia: A randomized crossover study.

BACKGROUND: We aimed to evaluate if two-handed mask airway is superior to one-handed mask airway during inhalational induction of anesthesia in children. METHODS: A randomized, two period, crossover study was performed on 60 children aged 1-8 years, with obstructive sleep apnea due to adenotonsillar hypertrophy, scheduled for adenotonsillectomy. Children were assigned to two study sequences and one control sequence of 20 subjects each. A control sequence was added to evaluate the effect of anesthetic depth. Sequence 1: One-handed followed by two-handed airway, 30 seconds each; Sequence 2: two-handed followed by one-handed airway, 30 seconds each and Sequence 3: two-handed airway, for 60 seconds. The work of breathing indices, phase angle, and labored breathing index were recorded using respiratory inductance plethysmography. Additional outcome measures were tidal volume, minute ventilation, and respiratory rate. A straight comparison and a crossover analysis was performed. RESULTS: The initial comparison revealed that one-handed airway had greater phase angle (mean diff. 17.4; 95% confidence interval [CI] 1.07-33.68; P = .034), greater labored breathing index (mean diff. 0.56; 95% CI 0.16-1.04; P = .004),lower minute ventilation (mean diff. -1567; 95% CI -2695 to -5.4; P = .004),and lower tidal volume (mean diff. -39; 95% CI -2.7 to -5.4; P = .02) than two-handed airway. On crossover analysis, within-subject difference in the phase angle was greater during one-handed than two-handed airway (34.3; 95% CI 8.46-60.14; P = .01) as was labored breathing index (mean diff. 1.2; 95% CI 0.39-2.00; P < .0046).Minute ventilation was lower during one-handed than two-handed airway (mean diff. -3359; 95% CI -4363 to -2355, P < 0.0001) as was tidal volume(mean diff. -78; 95% CI -110.4 to -45.8; P < .0001). CONCLUSION: In children with obstructive sleep apnea due to adenotonsillar hypertrophy, two-handed airway provides superior airway patency that was not influenced by the anesthetic depth.

Comparative Evaluation of Tube First Versus Video Laryngoscope First Techniques in a Normal and Simulated Difficult Airway Model: A Randomized Controlled Trial.

In patients with difficult airways, there can be difficulty with advancing the endotracheal tube into the airway even with a good view of the glottis using video laryngoscopy. The purpose of this study was to determine if the time required to intubate an airway and the number of gaze changes by the laryngoscopist could be decreased by using a novel video laryngoscope technique. Sixteen experienced Certified Registered Nurse Anesthetists were recruited to intubate a manikin with a normal or difficult airway using both the laryngoscope first technique and a new endotracheal tube first technique (4 intubations total) in a randomized sequence. The data were analyzed with the Mann-Whitney (U) test to compare the differences between the normal and difficult airway conditions. Although no significant difference was noted in the time to intubation between intubation techniques, the number of gaze changes was found to be significantly fewer in the tube first technique (P=.0009). A steep learning curve, associated with the accommodation of the manikin, was demonstrated by a decrease in time and gaze changes with subsequent intubations. Incorporating the endotracheal tube first technique into an education curriculum could increase patient safety by decreasing the time to secure a difficult airway.

Preoperative Blood Transfusions and Morbidity in Neonates Undergoing Surgery.

BACKGROUND: Blood transfusions in the neonatal patient population are common, but there are no established guidelines regarding transfusion thresholds. Little is known about postoperative outcomes in neonates who receive preoperative blood transfusions (PBTs). METHODS: Using the American College of Surgeons National Surgical Quality Improvement Program-Pediatric Participant Use Data Files from 2012 to 2015, we identified all neonates who underwent surgery. Mortality and composite morbidity (defined as any postoperative complication) in neonates who received a PBT within 48 hours of surgery were compared with that in neonates who did not receive a transfusion. RESULTS: A total of 12 184 neonates were identified, of whom 1209 (9.9%) received a PBT. Neonates who received a PBT had higher rates of preoperative comorbidities and worse postoperative outcomes when compared with those who did not receive a transfusion (composite morbidity: 46.2% vs 16.2%; P < .01). On multivariable regression analysis, PBTs were independently associated with increased 30-day morbidity (odds ratio [OR] = 1.90; 95% confidence interval [CI]: 1.63-2.22; P < .01) and mortality (OR = 1.98; 95% CI: 1.55-2.55; P < .01). In a propensity score-matched analysis, PBTs continued to be associated with increased 30-day morbidity (OR = 1.53; 95% CI: 1.29-1.81; P < .01) and mortality (OR = 1.58; 95% CI: 1.24-2.01; P = .01). CONCLUSIONS: In a propensity score-matched model, PBTs are independently associated with increased morbidity and mortality in neonates who undergo surgery. Prospective data are needed to better understand the potential effects of a red blood cell transfusion in this patient population.

Evaluation of Gabapentin and Clonidine Use in Children Following Spinal Fusion Surgery for Idiopathic Scoliosis: A Retrospective Review.

BACKGROUND: Opioids are the mainstay of therapy for pain relief following posterior spinal fusion (PSF) surgery. Various adjunctive medications are being used to augment analgesia and to reduce opioid-related side effects. At our institution, we have sequentially added 2 adjuncts to a standard morphine patient-controlled analgesia (PCA) regimen. The goal of our study was to evaluate pain control and the benefit of gabapentin and the combination of gabapentin and clonidine, whereas morphine PCA was in use in children following PSF surgery. METHODS: Following Institutional Review Board approval, data were collected retrospectively from the charts of 127 patients who underwent PSF for idiopathic scoliosis. Children were divided into the 3 following groups: group P, morphine PCA only (42 patients), group G, morphine PCA+gabapentin (45 patients), and group C, morphine PCA+gabapentin+clonidine (40 patients). RESULTS: Addition of gabapentin to our regimen improved the outcome, but the addition of transdermal clonidine and gabapentin together were found to be significantly better in some aspects. Children in group G and C used less morphine on postoperative day 1 following surgery, had more PCA demand-free hours, were able to take orals, were able to ambulate sooner, and had a shorter hospital stay than group P. There were no differences in side effects or sedation between the 3 groups. CONCLUSIONS: In conclusion, additions of postoperative transdermal clonidine and perioperative oral gabapentin together were found to improve functional outcomes following PSF surgery. Group G and C had reduced opioid use and shorter hospital stay than group P. Addition of these adjuncts together was found to be better since group C patients made fewer PCA attempts to obtain morphine over the first 10-hour period postoperatively and were able to ambulate sooner than group G. The PCA pump usage pattern provides useful information about patient comfort and efficacy of adjunctive medications. LEVEL OF EVIDENCE: Level II-retrospective study.

Critical Airway Stenosis in an Adolescent Male With Pompe Disease and Thoracic Lordosis: A Case Report.

An adolescent male with late-onset Pompe disease (glycogen storage disease type II) presented with a history of restrictive airway disease and a near-cardiorespiratory arrest during anesthesia for a liver biopsy initially thought to be due to bronchospasm. During a subsequent posterior spinal fusion procedure, he suffered cardiorespiratory arrest resulting in the procedure being aborted. Bronchoscopy performed shortly after resuscitation revealed an undiagnosed narrowing of the distal trachea and bronchi. This is the first description of a patient with late-onset Pompe disease with undiagnosed critical tracheal stenosis due to the progression of thoracic lordosis, which was ultimately relieved by posterior spinal fusion.

Safety of Secretin Administration in Children.

OBJECTIVE: The aim of this study was to compare the hemodynamic parameters from the anesthesia records of children who underwent upper gastrointestinal endoscopy (esophagogastroduodenoscopy [EGD]) with and without secretin pancreatic function tests (sPFTs). METHODS: The hemodynamic parameters were retrieved from an electronic anesthesia database. The secretin group consisted of 186 children, and the age- and sex-matched control group included 136 patients who did not have sPFTs. RESULTS: There was no difference in the demographic parameters (age and sex) between the 2 groups. The secretin group had a lower height and body mass index. The sPFT resulted in an average 3-minute extension of the endoscopic procedure. The heart rate increased during the EGD in both groups and was higher (averaged 7 beats per minute) in the secretin group than the EGD-only group. There were mild elevations on the systolic and diastolic blood pressures. None of these changes were clinically significant. There were no complications reported during the anesthesia and procedures in the 2 groups. CONCLUSIONS: Secretin PFT is a safe procedure. It only slightly prolongs the total procedure and anesthesia time. There were no clinically significant changes in the vital parameters in the secretin group, and there were no adverse effects recorded.

Continuous chest wall ropivacaine infusion for analgesia in children undergoing Nuss procedure: a comparison with thoracic epidural.

BACKGROUND: Pain following Nuss procedure is severe and its management is challenging. Many different pain treatment modalities are currently being used, but none of them have been found to be ideal. AIM: In this retrospective review, we compare our current multimodal approach, which involves continuous ropivacaine infusion through chest wall catheters (CWC), intravenous patient-controlled analgesia (IV-PCA), and adjunctive medications (gabapentin and clonidine), with the technique that we used in the past, the thoracic epidural catheter (TEC). METHODS: Following IRB approval, we performed a retrospective analysis of data on 32 patients who underwent the Nuss procedure at our institution. All children were divided into two groups: TEC group: 0.2% ropivacaine and hydromorphone 10 mcg·ml(-1) epidural infusion (n = 15) and CWC group (with IV-PCA and adjuncts [gabapentin + clonidine]): 0.2% ropivacaine infusion and hydromorphone PCA, oral gabapentin, and transdermal clonidine patch (n = 17). RESULTS: Both the groups were demographically similar. Average numeric pain scores were higher in the CWC group only on the day of surgery (mean ± sd: 3.79 ± 1.58 vs 2.68 ± 1.30; 95% CI: -2.16 to -0.05). Pain scores on postoperative day 1 (mean ± sd: 3.40 ± 1.59 vs 3.35 ± 1.32; 95% CI: -1.11 to 1.01), day 2 (mean± sd: 3.39 ± 1.79 vs 2.99 ± 1.06; 95% CI: -1.50 to 0.70), and on the day of discharge (DOD) (mean± sd: 3.25 ± 1.84 vs 3.99 ± 1.28; 95% CI: -0.42 to 1.89) were comparable between the groups. The CWC group needed fewer changes in the therapeutic regimen to maintain acceptable pain relief, had lower incidence of nausea and vomiting, had shorter anesthesia time, total OR time, and hospital length of stay. CONCLUSION: TEC provided better analgesia following the Nuss procedure only on the day of surgery. On the subsequent days until discharge, pain scores were comparable. However, CWC offered other advantages: it was less labor intensive and had fewer side effects, shorter OR time, and shorter hospital stay.

Outpatient outcomes and satisfaction in pediatric population: data from the postoperative phone call.

BACKGROUND: Quality and patient/parent satisfaction are goals for pediatric perioperative services. As part of the implementation of our operating room electronic medical record (EMR), a postoperative phone call questionnaire was developed to assess patients discharged after outpatient surgery. The goal of this initiative was to determine the rate of common postoperative complications and understand reasons for patient/parent dissatisfaction. METHODS: Institutional Review Board approval was obtained for chart review. The postoperative phone call survey was attempted by our postanesthesia care unit nursing staff on all pediatric outpatients. The call was attempted for 3 days. From 2009 to 2013, more than 37 000 phone records existed in our EMR, Epic Optime (Epic Systems, Verona, WI). These data were extracted to a business intelligence (BI) program, QlikView (Qliktech, Radnor, PA, USA). A BI dashboard was constructed to obtain phone call results for any given time frame from monthly to spanning several years. Complications were logged as 4-point severity rating scales (none, mild, moderate, severe) with descriptions for each level. The BI dashboard calculated the overall and rates by severity for the following: (i) nausea, (ii) vomiting, (iii) pain, (iv) bleeding, (v) hoarseness, and (vi) difficulty eating. RESULTS: Of 42 688 outpatient cases, 37 620 postoperative phone calls were completed for an overall response rate of 88%. Pain, at 11.1%, was the highest reported postoperative complication. The rate of dissatisfaction was reported to be 0.31%. Most patients reporting dissatisfaction (62%) did not report any complications. Contingency coefficient showed that there was little relationship between satisfaction and presence of complications. CONCLUSION: A postoperative phone survey is cost-effective and appreciated by patients. We found that satisfaction with our perioperative services was not related to the rates of reported complications. Although reducing complications is of utmost importance, improvements in wait times and other operational issues would yield greater improvements in satisfaction.

Influence of body mass index and antibiotic dose on the risk of surgical site infections in pediatric clean orthopedic surgery.

OBJECTIVE: To evaluate body mass index (BMI) and antimicrobial dose as risk factors for surgical site infections in pediatric patients. PATIENTS AND METHODS: Children between 2 and 19 years of age undergoing clean orthopedic procedures and receiving at least one dose of perioperative antibiotics (cefazolin, vancomycin, or clindamycin) were studied. The retrospective case-controlled study was conducted at the Alfred I. duPont Hospital for Children, a 180-bed tertiary-care academic pediatric hospital in Wilmington, DE. Data were collected from January 1, 2002, to December 31, 2005. RESULTS: Underweight children had a higher risk for SSIs than overweight and normal-weight children. American Society of Anesthesiologists classes II and greater were associated with a greater risk of SSI. Longer procedures were also associated with a higher risk of SSI, specifically, duration of surgery >2 h. Children weighing ≥70 kg who received a standard dose of cefazolin (maximum of 1 g) had a higher risk of SSI caused by methicillin-sensitive Staphylococcus aureus (MSSA). CONCLUSIONS: Being underweight and undergoing an operation lasting >2 h created significant risks for SSI. Children weighing ≥70 kg receiving a standard 1-g dose of cefazolin had a greater risk of MSSA SSIs than children weighing <70 kg who received an appropriate weight-based dose of this antibiotic.

Carbon dioxide embolism in a 3-week-old neonate during laparoscopic pyloromyotomy: a case report.

Laparoscopic pyloromyotomy has gained popularity in the treatment of hypertrophic pyloric stenosis. This is the first case report of carbon dioxide embolism during laparoscopic pyloromyotomy. We describe a case of carbon dioxide embolism in a 3-week-old neonate during laparoscopic pyloromyotomy by injection of carbon dioxide into a patent umbilical vein. The diagnosis of carbon dioxide embolism was made on the basis of the abrupt decrease in end-tidal CO(2), sudden decreased Spo(2), hypotension, and cyanosis. Portable x-ray with the clinical presentation was sufficient for a diagnosis of carbon dioxide embolism. Treatment included termination of CO(2) insufflation, placing the patient in Durant's position, and adequate resuscitation as necessary. Despite the fact that the insufflation pressure was in the recommended range, a carbon dioxide embolism was thought to be caused by injection of carbon dioxide into a patent umbilical vein. Although laparoscopic pyloromyotomy has demonstrated to be a safe and effective procedure, this is a serious and rare complication causing prolonged length of stay and skewed hospital charges.

Anesthesia for pediatric obesity.

This article discusses the unique anesthetic implications of obesity, with an emphasis on children and adolescents. It also touches on the issues surrounding bariatric surgery in the morbidly obese adolescent population. Adolescent bariatric surgery is moving to the forefront as a treatment modality because weight-loss programs alone are not keeping pace with the growth of the problem. Bariatric surgery offers the potential to achieve the weight reductions necessary to reverse the debilitating and costly comorbidities of obesity.

Herbal and homeopathic medication use in pediatric surgical patients.

BACKGROUND: Patients who present for surgery may be using herbal or homeopathic preparations; adverse effects of some of these substances include bleeding, cardiovascular changes, and liver dysfunction. Little information is available on the frequency of use in the pediatric surgical population. METHODS: With institutional approval, a survey was conducted to assess the use of vitamins, nutritional supplements, or herbal or homeopathic preparations in children presenting for surgery in five geographically diverse centers in the USA. RESULTS: A total of 894 completed surveys showed that overall, 3.5% of pediatric surgical patients had been given herbal or homeopathic medications in the 2 weeks prior to surgery. Most substances were prescribed by parents. The use of these medications did not differ between children with coexisting diseases and those without; use was also not different among ethnic groups or by residence setting (city, suburban, rural). There was a significant difference between the west coast centers in the study compared with the rest of the country (7.5% of patients in Palo Alto, CA; 5.5% of patients in Seattle, WA; 1.5% of patients in Chicago, IL; and 1.9% in Virginia and Delaware used herbal or homeopathic remedies). The most prevalent substance given to children presenting for elective surgery was Echinacea. CONCLUSIONS: Herbal and homeopathic medications are used by a small percentage of pediatric patients presenting for elective pediatric surgery patients. Use of these substances should be addressed in the preoperative history.

A simplified analysis to determine the impact of surgical procedure time on pediatric anesthesia productivity.

With fee-for-service (FFS) reimbursement, anesthesiologists benefit financially from cases that take longer than expected. Capitation, or fixed anesthesia reimbursement (FAR), might result in financial losses for such inefficient cases. In this investigation, we used the Centers for Medicare and Medicaid Services' average anesthesia times as benchmarks for efficiency and examined case time characteristics for three surgical services: otorhinolaryngology, general surgery, and orthopedics. Our model demonstrated that some inefficient cases would be better billed FAR rather than FFS.

Cytokine release, pancreatic injury, and risk of acute pancreatitis after spinal fusion surgery.

Acute pancreatitis after posterior spinal fusion in children is associated with high intraoperative blood loss. Inflammation, oxidative stress, and pancreatitis markers were assessed during this period. Five of the 17 patients studied developed acute pancreatitis 3-7 days after surgery. Intraoperative blood loss (4850 +/- 2315 vs 1322 +/- 617 ml) and peak tumor necrosis factor alpha levels (15.29 +/- 5.3 vs 8.27 +/- 4.6 pg/ml) in the immediate postoperative period were significantly higher in these five patients than in controls, respectively. No differences were noted in serum interleukin 8, interleukin 6, pancreatis-associated protein, or urine malondialdehyde levels. Urine trypsin-associated peptide, elevated initially in all patients, was significantly higher in the acute pancreatitis group at diagnosis. Length of stay was significantly longer in the acute pancreatitis group. Greater blood loss and peak tumor necrosis factor alpha are associated with subsequent risk of acute pancreatitis, suggesting a role of ischemia-reperfusion injury.

Analysis of efficiency of common otolaryngology operations: comparison of operating room vs short procedure room in a pediatric tertiary hospital.

OBJECTIVE: To compare the operative times of routine otolaryngologic procedures performed with 2 different operating room staffing models: the traditional model with 2 staff, a scrub nurse and a circulator, and the short procedure room (SPR) setting, with a circulator only. DESIGN: Retrospective comparison of operative procedure times. Data were extracted from a prospectively maintained database of electronic medical records. SETTING: All data were from procedures performed at a tertiary care children's hospital operating room suite. PATIENTS OR OTHER PARTICIPANTS: Data for the year 2000 were extracted for all outpatient otolaryngology cases of bilateral myringotomy and tube placement (BMT), tonsillectomy and adenoidectomy (TA), and adenoidectomy alone. MAIN OUTCOME MEASURES: The mean +/- SD operative time intervals (operative procedure times and total operative procedure time), anesthesia start times, surgical preparation times, and anesthesia end times of the 2 sites were compared. These time intervals were also compared for the 3 surgeons performing TAs in both settings. RESULTS: Total operative procedure times were significantly shorter in the SPR setting for TA and BMT, but not for adenoidectomy. For TA procedures, operative procedure times and anesthesia end times were significantly shorter in the SPR setting (P<.05). For BMT procedures, all operative times were significantly shorter in the SPR setting. All 3 surgeons who performed TAs in both settings had significantly shorter total operative procedure times in the SPR setting than in the traditional setting. CONCLUSIONS: Despite fewer assisting staff, the SPR setting showed a statistically significant reduction in total operative procedure times for TA and BMT, and results were similar for adenoidectomy. Reducing operating room personnel costs is possible in addition to achieving modest gains in efficiency.