Does anesthesia duration or number of cases per patient predict safety events?

BACKGROUND: The need for dental rehabilitation under general anesthesia is increasing, with varying needs between patients. Mortality has been found to be a rare event in these patients; however other perioperative events can and do occur. Previous studies have established increased incidence of perioperative events with younger, sicker children, and longer anesthetics, however, no studies to date have evaluated if the incidence of perioperative events is more closely associated with one long anesthetic or multiple anesthetics per patient. AIMS: To evaluate the association of perioperative events related to single anesthetic duration or number of anesthetics per patient for dental rehabilitation. METHODS: After Children's Wisconsin Human Research Protection Program determined this quality activity did not meet the definition of human subjects research, we performed an epidemiologic observational evaluation by extracting all dental related cases (dental alone or with oral surgeon vs. dental with other specialties) with an associated general anesthesia encounter from Children's Wisconsin electronic data warehouse from June 1, 2015 to December 31, 2021. These cases occurred at a free-standing children's hospital or associated pediatric-only ambulatory surgery center. The risk of perioperative safety events was analyzed for previously identified risk groups such as American Society of Anesthesiologists Physical Status (ASA-PS), patient age, anesthesia case time with the addition of number of dental cases per patient. RESULTS: In this study, 8468 procedures were performed on 8082 patients. Of this cohort, 7765 patients underwent one procedure for dental care while 317 patients underwent a total of 703 dental-related procedures, ranging from two to five procedures per patient. Multivariable logistic regression identified increased risk of perioperative events in patients with ASA-PS 3 (n = 1459, rate 1.78%, p value .001, OR 5.7, CI 2.1-15.5) and ASA-PS 4 (n = 86, rate 5.8%, p < .001, OR 17.2, CI 4.4-67.3), anesthesia duration (p < .001, OR 1.46, CI 1.21-1.76), but no increased risk with number of anesthetics per patient (p value .54, OR 0.81, CI 0.4-1.61). CONCLUSIONS: Limiting dental care under general anesthesia to multiple short cases may decrease the risk of perioperative events when compared to completing all treatment in one long operative session.

Noise measurements during high-frequency oscillatory and conventional mechanical ventilation.

OBJECTIVE: To evaluate the noise levels with high-frequency oscillatory ventilation and conventional mechanical ventilation. DESIGN: An observational, prospective study. SETTING: Pediatric intensive care unit. SUBJECTS: The caretakers and environment of the pediatric intensive care unit. INTERVENTIONS: High-frequency oscillatory and conventional mechanical ventilation. MEASUREMENTS AND MAIN RESULTS: Caretakers evaluated noise using a visual analog scale. Noise was measured with a decibel meter and an octave band frequency filter. There was twice as much noise perceived by the caretakers and as measured on the decibel A scale. All measures showed significantly greater noise, especially at low frequencies, with high-frequency oscillatory ventilation. CONCLUSIONS: High-frequency oscillatory ventilation exposes the patient to twice as much noise as does the use of conventional mechanical ventilation.

Efficacy of an enteral 10-day methadone wean to prevent opioid withdrawal in fentanyl-tolerant pediatric intensive care unit patients.

OBJECTIVE: To demonstrate the efficacy of a 10-day, single daily dose, enteral methadone weaning protocol for the prevention of opioid withdrawal symptoms in pediatric patients after prolonged fentanyl exposure. DESIGN: Prospective, observational study. SETTING: Twenty-four-bed medical-surgical intensive care unit within a 222-bed pediatric teaching hospital. PATIENTS: Twenty-nine children, aged 1 day to 19.8 yrs, who received methadone to prevent opioid withdrawal after prolonged continuous fentanyl infusion exposure. INTERVENTIONS: Institution of a standardized methadone weaning protocol. MEASUREMENTS AND MAIN RESULTS: All 29 patients had received a continuous fentanyl infusion; duration of exposure was 14.5 +/- 9.2 days, cumulative fentanyl dose was 1.93 +/- 1.53 mg/kg, and peak fentanyl infusion was 9.6 +/- 4.3 microg/kg per hr. Twenty-five (86%) of 29 patients successfully completed the methadone wean in 10 days. Withdrawal complications that required a weaning delay were seen in three patients, and one patient expired before completion. Sixteen patients were discharged to complete their weaning schedule at home without incident. CONCLUSIONS: Opioid withdrawal symptoms in pediatric intensive care unit patients after prolonged fentanyl exposure can be avoided by using an enteral, 10-day, single daily dose methadone weaning protocol.

Cost analysis of ceiling tile replacement for noise abatement.

OBJECTIVE: Our purpose was to evaluate the cost and benefit of noise reduction after replacement of acoustic ceiling tile in an open ward neonatal intensive care unit (NICU). STUDY DESIGN: An observational, prospective study evaluated noise in an open ward NICU before and after suspended ceiling tiles were replaced. Noise was rated by a 10-point visual analog scale and measured with a decibel meter. RESULTS: The mean decibel level was 55 before and 53 after renovation (p < 0.05). The median visual analog score was 5 before and 4 after renovation (p = 0.09). The cost of ceiling tile replacement was $2400. CONCLUSIONS: The renovation resulted in a small decrease in the decibel level in the NICU, although this measured decrease was not perceived by observers. With a formal prerenovation noise evaluation, a more efficient ceiling tile might have been selected or the project may have been aborted or modified because of the low levels of noise already present.

Noise analysis of three newborn infant isolettes.

OBJECTIVE: The purpose of this study was to evaluate the noise of three newborn infant isolettes. STUDY DESIGN: An observational, prospective study evaluated noise in three isolettes (Ohmeda, Air Shields, and Drager). The study measured interior isolette noise production during quiet noise situations and isolette noise attenuation of added low- and high-frequency noise. Noise was measured on the decibel A scale and in the 125 Hz and 1000 Hz bands. RESULTS: During quiet conditions the Ohmeda and Drager isolettes had the least noise production on the basis of decibel A levels (p < 0.001). Low-frequency noise on the decibel A scale was attenuated the most by the Drager isolette (p < 0.001), although the overall difference may be clinically insignificant. The Ohmeda isolette attenuated high-frequency noise by 28.4 dB as measured on the decibel A scale, which was greater than values for the Drager (22.8 dB) and Air Shields (14 dB) isolettes (p < 0.001). CONCLUSIONS: High-frequency noise attenuation by the Ohmeda and Drager isolettes is clinically and statistically greater than high-frequency noise attenuation by the Air Shields isolette.

Use of active noise cancellation devices in caregivers in the intensive care unit.

OBJECTIVE: Recent development of noise cancellation devices may offer relief from noise in the intensive care unit environment. This study was conducted to evaluate the effect of noise cancellation devices on subjective hearing assessment by caregivers in the intensive care units. DESIGN: Randomized, double-blind. SETTING: Adult medical intensive care unit and pediatric intensive care unit of a teaching hospital. SUBJECTS: Caregivers of patients, including nurses, parents, respiratory therapists, and nursing assistants from a medical intensive care unit and pediatric intensive care, were enrolled in the study. INTERVENTION: Each participant was asked to wear the headphones, functional or nonfunctional noise cancellation devices, for a minimum of 30 mins. MEASUREMENTS: Subjective ambient noise level was assessed on a 10-point visual analog scale (VAS) before and during headphone use by each participant. Headphone comfort and the preference of the caregiver to wear the headphone were also evaluated on a 10-point VAS. Simultaneously, objective measurement of noise was done with a sound level meter using the decibel-A scale and at each of nine octave bands at each bedspace. RESULTS: The functional headphones significantly reduced the subjective assessment of noise by 2 (out of 10) VAS points (p < 0.05) in environments of equal objective noise profiles, based on decibel-A and octave band assessments. CONCLUSION: Noise cancellation devices improve subjective assessment of noise in caretakers. The benefit of these devices on hearing loss needs further evaluation in caregivers and critically ill patients.

Intraosseous infusion of phenytoin.

In the critically ill child, administration of fluids and medications via the intraosseous route often proves life-saving. The authors describe the case of a child with status epilepticus in whom phenytoin was administered via the intraosseous route, and seizure resolution and therapeutic serum levels were achieved. Intraosseous drug administration should be reserved for the rare critically ill child in whom vascular access proves impossible.

Skin breakdown in children and high-frequency oscillatory ventilation.

OBJECTIVE: To investigate the relationship of high-frequency oscillatory ventilation (HFOV) to skin breakdown on the scalp and ears in mechanically ventilated children. STUDY DESIGN: Retrospective cohort study of 32 patients supported with HFOV paired with 32 patients supported with conventional mechanical ventilation (CV) in a pediatric intensive care unit (PICU). RESULTS: By univariate analysis, more HFOV patients had skin breakdown than did the CV patients (53% vs 12.5%, p=.001); HFOV patients also had greater severity of illness (Pediatric Risk of Mortality scores), higher mortality, and longer durations of neuromuscular blockade, low systolic blood pressure, and time exposed to risk. Life table analysis demonstrated no difference in the rate of skin breakdown between HFOV and CV patients. Multifactorial analysis showed that only PICU time at risk was a risk factor for skin breakdown. CONCLUSIONS: HFOV was not an independent risk factor for the development of skin breakdown. PICU time at risk was the sole risk factor for the development of skin breakdown in all mechanically ventilated patients in the PICU.

An infant fatality following verapamil therapy for supraventricular tachycardia: cardiovascular collapse following intravenous verapamil.

A four-month-old infant with myocarditis and supraventricular tachycardia was given intravenous verapamil (0.1 mg/kg). Immediately following the dosage, the patient developed cardiovascular collapse. Aggressive, appropriate cardiopulmonary resuscitative efforts--including ventricular pacing--failed to reverse verapamil-induced decompensation. Myocarditis may have been responsible for our failure to resuscitate this infant successfully. To our knowledge, this is the first reported pediatric fatality following intravenous verapamil. We suggest that proven or suspected myocarditis should be added to the list of contraindications for intravenous verapamil therapy.

Prospective, randomized comparison of high-frequency oscillatory ventilation and conventional mechanical ventilation in pediatric respiratory failure.

OBJECTIVE: To compare the effectiveness of high-frequency oscillatory ventilation with conventional mechanical ventilation in pediatric patients with respiratory failure. SETTING: Five tertiary care pediatric intensive care units. DESIGN: A prospective, randomized, clinical study with crossover. PATIENTS: Seventy patients with either diffuse alveolar disease and/or airleak syndrome were randomized to receive high-frequency oscillatory ventilation or conventional mechanical ventilation. INTERVENTIONS: Patients randomized to receive high-frequency oscillatory ventilation were managed, using a strategy that consisted of aggressive increases in mean airway pressure to attain the "ideal" lung volume and to achieve an arterial oxygen saturation of > or = 90%, with an FIO2 of < or = 0.6. Patients who were randomized to receive conventional mechanical ventilation were treated with a strategy that utilized increases in end-expiratory pressure and inspiratory time to increase mean airway pressure and to limit increases in peak inspiratory pressure. Target blood gas values were the same for both groups. Crossover to the alternate ventilator was required if the patient met defined criteria for treatment failure. MEASUREMENTS AND MAIN RESULTS: Physiologic data and ventilatory parameters were collected prospectively at predetermined intervals after randomization. Airleak Scores were derived daily, based on the chest radiograph and the patient's clinical condition. In the high-frequency oscillatory ventilation group, the PaO2/PAO2 ratio increased significantly and the oxygenation index (mean airway pressure x FIO2 x 100/PaO2) decreased significantly over time. There were no differences between the groups in duration of mechanical ventilation, frequency of airleak, Airleak Scores, or 30-day survival rates. Significantly fewer patients treated with high-frequency oscillatory ventilation required supplemental oxygenation at 30 days compared with patients managed with conventional ventilation. When ventilatory subgroups were compared, the patients managed with high-frequency oscillation only had significantly better ranked outcomes than patients managed with conventional ventilation only. CONCLUSIONS: Our results indicate that high-frequency oscillatory ventilation, utilizing an aggressive volume recruitment strategy, results in significant improvement in oxygenation compared with a conventional ventilatory strategy designed to limit increases in peak airway pressures. Furthermore, despite the use of higher mean airway pressures, the optimal lung volume strategy used in this study was associated with a lower frequency of barotrauma, as indicated by requirement for supplemental oxygen at 30 days, and improved outcome compared with conventional mechanical ventilation.

Altered skin integrity in children admitted to a pediatric intensive care unit.

As part of a quality improvement study, the incidence and severity of altered skin integrity in a tertiary pediatric intensive care unit (PICU) were investigated in an attempt to identify contributing risk factors. Demographic, severity of illness, and practice variables were collected on 271 of 357 admissions during an 18-week period. Data were analyzed from the date of PICU admission until a change in skin integrity occurred or until PICU discharge. Altered skin integrity occurred in 26 percent of admissions; 7 percent of the cases had skin breakdown. By multivariate analysis, only the Pediatric Risk of Mortality Score and white race were associated with altered skin integrity.

Indications for chest roentgenogram in the febrile young infant.

A combined retrospective and prospective analysis of infants 60 days of age or less evaluated for fever (greater than or equal to 38.3 degrees C) or history of fever who received chest roentgenogram over a one-year period was performed to determine whether clinical characteristics were predictive of pneumonia. Of the 209 patients studied, 115 were reviewed prospectively and 94 retrospectively. Pneumonia was radiographically diagnosed in 16 patients. Individual clinical factors were not found to be highly predictive of pneumonia. However, infants with the following nine factors did not have pneumonia; illness in the summer months; absence of cough, dyspnea, and respiratory distress (grunting/flaring/retracting); respiratory rate less than 60; absence of rales and decreased breath sounds; presence of normal color; and white blood cell count less than 19,000/mm3. We recommend that these clinical characteristics be utilized to determine whether chest roentgenogram is warranted in the young infant evaluated for fever.