Prevalence of COVID-19 and Risk Factors for Infection Among Pediatric Anesthesia Patients: A Report From the PEACOC Research Network.

BACKGROUND: The Pediatric Anesthesia COVID-19 Collaborative (PEACOC) is a research network to advance the care of children during the pandemic. Here we calculate the prevalence of coronavirus disease 2019 (COVID-19) among children undergoing anesthesia, look at prevalence in the population data from the Centers for Disease Control and Prevention (CDC), and assess independent risk factors for infection. METHODS: This was a multicenter, retrospective, observational study. Children aged 28 days to 18 years scheduled for anesthesia services at 12 centers requiring universal COVID-19 testing from March 29, 2020 to June 30, 2020 were included. COVID-19 positivity rates among those tested were plotted and trends were assessed using the Cochran Armitage test of trend. Independent risk factors were explored using multivariable logistic regression. RESULTS: Data were collected and analyzed on 33,320 anesthesia encounters including 265 children with COVID-19. Over the study period, the rates of infections in the pediatric anesthesia population did not demonstrate a significant trend. In the general population, there was a significant downward trend in infection rates ( P < .001). In exploratory analysis, multivariable risk factors for a COVID-19 positive test were Black/African American race, Hispanic ethnicity, American Society of Anesthesiologists (ASA) physical status III or above, overweight and obese body mass index (BMI), orthopedic cases, abdominal cases, emergency cases, absence of injury and trauma, and West region (all P < .05). CONCLUSIONS: Rates of COVID-19 in pediatric anesthesia patients were consistently lower than in the general population. Independent risk factors of a positive test for children were identified. This is the first time universal testing for a single infectious disease was undertaken on a wide scale. As such, the association of infection with surgical case type or emergency case status is unprecedented.

Diversity, equity, and inclusion within the Society for Pediatric Anesthesia: A mixed methods assessment.

BACKGROUND: Leadership of the Society for Pediatric Anesthesia created the Diversity, Equity, and Inclusion committee in 2018 to prioritize diversity work. The Society for Pediatric Anesthesia-Diversity, Equity, and Inclusion committee implemented a baseline survey of the Society for Pediatric Anesthesia membership in 2020 to assess demographics, equity in leadership, inclusivity, and attitudes toward diversity work. The Society for Pediatric Anesthesia plays a significant role in shaping the future of pediatric anesthesiology and in supporting our diverse pediatric patients. METHODS: This study is an IRB-exempt, cross-sectional survey of the Society for Pediatric Anesthesia membership. Quantitative analysis provided descriptive statistics of demographics, practice characteristics, and involvement within the Society for Pediatric Anesthesia. Qualitative thematic analysis provided an in-depth assessment of perceptions of diversity, challenges faced, and prioritization of Diversity, Equity, and Inclusion efforts within the Society for Pediatric Anesthesia. RESULTS: Out of 3 242 Society for Pediatric Anesthesia members, 1 232 completed the survey representing 38% of overall membership. Respondents were 89.2% United States members, 52.7% female, 55.7% non-Hispanic White, 88.6% heterosexual, 95.7% non-military, 59.2% religious, and 2.1% have an Americans with Disabilities Act recognized disability. All major United States geographical areas were represented equally with 71% practicing in urban areas and 67% in academic settings. Ethnic/racial minorities were more likely to be international medical graduates (p < .001). Among United States members, 41.5% report being fluent in a language other than English, and 23.5% of those fluent in another language are certified to interpret. Compared to men, women are less likely to be in leadership roles (p < .003), but we found no difference in participation and leadership when stratified by race/ethnicity, geography, international medical graduate status, or sexuality. Racial/ethnic minorities (p < .028), women (p < .001), and lesbian, gay, bisexual, transgender, and queer members (p < .044) more frequently hold lower academic rank positions when compared to white, heterosexual, and male members. Half of respondents were unsure whether diversity, equity, and inclusion challenges existed within the Society for Pediatric Anesthesia while the other half demonstrated opposing views. Among those who reported diversity, equity, and inclusion challenges, the themes centered around persistent marginalization, the need for more inclusive policies and increased psychological safety, and lack of leadership diversity. CONCLUSIONS: Compared to the diversity of the pediatric population we serve, there are still significant gaps in demographic representation within the Society for Pediatric Anesthesia. As well, there is no consensus among Society for Pediatric Anesthesia membership regarding perceptions of diversity, equity, and inclusion in pediatric anesthesia in the United States. Among those who reported diversity challenges, opportunities for the Society for Pediatric Anesthesia and Anesthesiology Departments to better support minoritized members included bolstering workforce diversity efforts and awareness via more inclusive policies, improved psychological safety, and increasing diversity in leadership. If pediatric anesthesiology is like other specialties, gaining consensus and improving diversity in the workforce might advance pediatric anesthesia innovation, quality, and safety for children of all backgrounds in the United States.

A machine-learning approach for decision support and risk stratification of pediatric perioperative patients based on the APRICOT dataset.

BACKGROUND: Pediatric anesthesia has evolved to a high level of patient safety, yet a small chance remains for serious perioperative complications, even in those traditionally considered at low risk. In practice, prediction of at-risk patients currently relies on the American Society of Anesthesiologists Physical Status (ASA-PS) score, despite reported inconsistencies with this method. AIMS: The goal of this study was to develop predictive models that can classify children as low risk for anesthesia at the time of surgical booking and after anesthetic assessment on the procedure day. METHODS: Our dataset was derived from APRICOT, a prospective observational cohort study conducted by 261 European institutions in 2014 and 2015. We included only the first procedure, ASA-PS classification I to III, and perioperative adverse events not classified as drug errors, reducing the total number of records to 30 325 with an adverse event rate of 4.43%. From this dataset, a stratified train:test split of 70:30 was used to develop predictive machine learning algorithms that could identify children in ASA-PS class I to III at low risk for severe perioperative critical events that included respiratory, cardiac, allergic, and neurological complications. RESULTS: Our selected models achieved accuracies of >0.9, areas under the receiver operating curve of 0.6-0.7, and negative predictive values >95%. Gradient boosting models were the best performing for both the booking phase and the day-of-surgery phase. CONCLUSIONS: This work demonstrates that prediction of patients at low risk of critical PAEs can be made on an individual, rather than population-based, level by using machine learning. Our approach yielded two models that accommodate wide clinical variability and, with further development, are potentially generalizable to many surgical centers.

Continued challenges in pediatric anesthesia during COVID-19 in 2022: An international survey from the pediatric anesthesia COVID-19 collaborative.

INTRODUCTION: This international survey explored the ongoing impact of COVID-19 on pediatric anesthesiology. It assessed COVID-19's impact on the practice of pediatric anesthesiology, staffing, job satisfaction, and retention at the beginning of 2022 and addressed what should be done to ameliorate COVID-19's impact and what initiatives hospitals had implemented. METHODS: This survey focused on five major domains: equipment/medication, vaccination/testing, staffing, burnout, and economic repercussions. Pilot testing for questionnaire clarity was conducted by members of the Pediatric Anesthesia COVID-19 Collaborative. The survey was administered by e-mail to a representative of the 72 collaborative centers. Respondents were instructed to answer based on their institution's practice from February through April of 2022. Descriptive statistics with 95% confidence intervals are reported. RESULTS: Seventy of seventy-two institutions participated in this survey (97% response rate). Fifty-nine (84%) were from the United States, and 11 (16%) included other countries. The majority experienced equipment (68%) and medication (60%) shortages. Many institutions reported staffing shortages in nursing (37%), perioperative staff (27%), and attending anesthesiologists (11%). Sixty-two institutions (89%) indicated burnout was a frequent topic of conversation among pediatric anesthesiologists. Forty-three institutions (61%) reported anesthesiologists leaving current practice and 37 (53%) early retirement. Twenty-eight institutions (40%) canceled elective cases. The major suggestions for improving job retention included improving financial compensation (76%), decreasing clinical time (67%), and increasing flexibility in scheduled clinical time (66%). Only a minority of institutions had implemented the following initiatives: improving financial compensation (19%), increased access to mental health/counseling services (30%), and assistance with child or elder care (7%). At the time of the survey, 34% of institutions had not made any changes. CONCLUSION: Our study found that COVID-19 has continued to impact pediatric anesthesiology. There are major discrepancies between what anesthesiologists believe are important for job satisfaction and faculty retention compared to implemented initiatives. Data from this survey provide insight for institutions and departments for addressing these challenges.

Machine Learning Applied to Registry Data: Development of a Patient-Specific Prediction Model for Blood Transfusion Requirements During Craniofacial Surgery Using the Pediatric Craniofacial Perioperative Registry Dataset.

BACKGROUND: Craniosynostosis is the premature fusion of ≥1 cranial sutures and often requires surgical intervention. Surgery may involve extensive osteotomies, which can lead to substantial blood loss. Currently, there are no consensus recommendations for guiding blood conservation or transfusion in this patient population. The aim of this study is to develop a machine-learning model to predict blood product transfusion requirements for individual pediatric patients undergoing craniofacial surgery. METHODS: Using data from 2143 patients in the Pediatric Craniofacial Surgery Perioperative Registry, we assessed 6 machine-learning classification and regression models based on random forest, adaptive boosting (AdaBoost), neural network, gradient boosting machine (GBM), support vector machine, and elastic net methods with inputs from 22 demographic and preoperative features. We developed classification models to predict an individual's overall need for transfusion and regression models to predict the number of blood product units to be ordered preoperatively. The study is reported according to the Transparent Reporting of a multivariable prediction model for Individual Prognosis Or Diagnosis (TRIPOD) checklist for prediction model development. RESULTS: The GBM performed best in both domains, with an area under receiver operating characteristic curve of 0.87 ± 0.03 (95% confidence interval) and F-score of 0.91 ± 0.04 for classification, and a mean squared error of 1.15 ± 0.12, R-squared (R) of 0.73 ± 0.02, and root mean squared error of 1.05 ± 0.06 for regression. GBM feature ranking determined that the following variables held the most information for prediction: platelet count, weight, preoperative hematocrit, surgical volume per institution, age, and preoperative hemoglobin. We then produced a calculator to show the number of units of blood that should be ordered preoperatively for an individual patient. CONCLUSIONS: Anesthesiologists and surgeons can use this continually evolving predictive model to improve clinical care of patients presenting for craniosynostosis surgery.

A survey of the global impact of COVID-19 on the practice of pediatric anesthesia: A study from the pediatric anesthesia COVID-19 Collaborative Group.

BACKGROUND: Pediatric anesthesiology has been greatly impacted by COVID-19 in the delivery of care to patients and to the individual providers. With this study, we sought to survey pediatric centers and highlight the variations in care related to perioperative medicine during the COVID-19 pandemic, including the availability of protective equipment, the practice of pediatric anesthesia, and economic impact. AIM: The aim of the survey was to determine how COVID-19 directly impacted pediatric anesthesia practices during the study period. METHODS: A survey concerning four major domains (testing, safety, clinical management/policy, economics) was developed. It was pilot tested for clarity and content by members of the Pediatric Anesthesia COVID-19 Collaborative. The survey was administered by email to all Pediatric Anesthesia COVID-19 Collaborative members on September 1, 2020. Respondents had six weeks to complete the survey and were instructed to answer the questions based on their institution's practice during September 1 - October 13, 2020. RESULTS: Sixty-three institutions (100% response rate) participated in the COVID-19 Pediatric Anesthesia Survey. Forty-one hospitals (65%) were from the United States, and 35% included other countries. N95 masks were available to anesthesia teams at 91% of institutions (n = 57) (95% CI: 80%-96%). COVID-19 testing criteria of anesthesia staff and guidelines to return to work varied by institution. Structured simulation training aimed at improving COVID-19 safety and patient care occurred at 62% of institutions (n = 39). Pediatric anesthesiologists were economically affected by a reduction in their employer benefits and restriction of travel due to employer imposed quarantine regulations. CONCLUSION: Our data indicate that the COVID-19 pandemic has impacted the testing, safety, clinical management, and economics of pediatric anesthesia practice. Further investigation into the long-term consequences for the specialty is indicated.

Perioperative Outcomes and Surgical Case Volume in Pediatric Complex Cranial Vault Reconstruction: A Multicenter Observational Study From the Pediatric Craniofacial Collaborative Group.

BACKGROUND: Complex cranial vault reconstruction (CCVR) performed to treat craniosynostosis can be associated with significant blood loss, transfusion, and perioperative complications. The aim of this study was to examine the effect of CCVR surgical case volume on perioperative outcomes. We hypothesized that surgical case volume is not associated with differences in perioperative outcomes. The study primary outcome was total perioperative blood donor exposures. Secondary outcomes included the total perioperative transfusion volume, major complications, and intensive care unit and hospital length of stay. METHODS: The multicenter Pediatric Surgery Perioperative Registry was queried for infants and children undergoing CCVR between June 2012 and September 2016. Institutions were categorized into low, middle, or high surgical case volume groups based on tertiles of the average number of cases performed per month. Primary and secondary outcomes were analyzed with respect to these groupings. RESULTS: The query yielded 1814 CCVR cases from 33 institutions. Demographics were similar among the 3 study groups. An inverse relationship between surgical case volume and total perioperative blood donor exposures was observed (P < .001). The low-volume group had higher perioperative transfusion volumes (P = .02 versus middle; P = .01 versus high). There was no significant relationship between surgical case volume and the incidence of major postoperative complications or hospital length of stay. CONCLUSIONS: In this study, low surgical case volumes were associated with increased total blood donor exposures and increased perioperative transfusion volumes. Hospital length of stay was homogeneous in the 3 groups, suggesting a limited overall clinical impact of the observed transfusion outcome differences.

Coagulative function assessed preoperatively via the clot formation and lysis assay as a prognostic factor for blood loss in adolescents undergoing posterior spinal fusion for idiopathic scoliosis.

BACKGROUND: Posterior spinal fusion for adolescent idiopathic scoliosis is a complex surgery often associated with clinically significant blood loss leading to perioperative blood transfusion. Knowledge of risk factors for blood loss and transfusion stems mostly from retrospective studies. AIM: We sought to prospectively investigate putative prognostic factors for intraoperative blood loss and perioperative blood transfusion in adolescent idiopathic scoliosis patients undergoing posterior spine fusion, including clinical characteristics, surgical factors, and preoperative assessment of overall coagulative and fibrinolytic functions in plasma using the clot formation and lysis (CloFAL) assay. METHODS: Following Internal Review Board approval, adolescents 10 to <21 years old with idiopathic scoliosis undergoing posterior spine fusion were enrolled preoperatively in a single-institutional prospective cohort and biobanking study. Clinical data were collected on patient characteristics, surgical approach, perioperative management, intraoperative estimated blood loss, and blood transfusion through hospital discharge. Coagulative and fibrinolytic functions in plasma were measured on preoperative samples by CloFAL assay (Coagulation Index and modified Fibrinolytic Index). Univariate linear regression and multivariable linear regression were performed to identify predictors of weight-indexed intraoperative estimated blood loss EBL (EBL/kg). RESULTS: The final study population included 74 patients. Median age was 14.8 years (SD = 2.2). After adjustment for other putative prognostic factors via multivariable linear regression, coagulative function as determined preoperatively by CloFAL Coagulation Index was an independent predictor of intraoperative (EBL)/kg. Specifically, each 10% increase in CloFAL CI was associated with 3% decrease in the geometric mean of EBL/kg (OR 0.97, 95%CI 0.94-0.99, P = .01). CONCLUSION: In adolescents undergoing posterior spinal fusion for idiopathic scoliosis, increased coagulative function measured preoperatively using the CloFAL assay is independently associated with decreased intraoperative blood loss. Future studies should expand upon these investigations of plasma coagulative and fibrinolytic capacities in combination with clinical factors, to guide precise preventive strategies against blood loss and blood transfusion in this patient population.

Perioperative outcomes and management in midface advancement surgery: a multicenter observational descriptive study from the Pediatric Craniofacial Collaborative Group.

BACKGROUND/AIMS: The evolution of Le Fort III and Monobloc procedures with utilization of distraction devices has resulted in shortened surgical times, greater facial advancements, and decreased transfusion requirements. The aim of this observational study was to utilize data from the multicenter Pediatric Craniofacial Surgery Perioperative Registry to present and compare patient characteristics and outcomes in children undergoing midface advancement with distraction osteogenesis. METHODS: We queried the Pediatric Craniofacial Surgery Perioperative Registry for children undergoing midface advancement involving distractor application from June 2012 to September 2016. Data extracted included demographics, perioperative management, complications, fluid and transfusion volumes, and length of stay. The extracted patient characteristics and perioperative variables were summarized and compared. RESULTS: The query yielded 72 cases from 11 institutions: 49 children undergoing Le Fort III and 23 undergoing Monobloc procedures. Monobloc patients were younger, weighed less, and more likely to have tracheostomies along with elevated intracranial pressure. Greater transfusion was observed in the Monobloc group for nearly all of the transfusion outcomes evaluated. Median ICU and hospital length of stay were 2 and 3 days longer, respectively, in the Monobloc group. Perioperative complications were not uncommon, occurring in 18% of patients in the Le Fort III group and 30% in the Monobloc group. CONCLUSION: Monobloc procedures were associated with greater transfusion and longer ICU and hospital length of stay. Perioperative complications were more prevalent in the Monobloc group.

Safety of antifibrinolytics in cranial vault reconstructive surgery: a report from the pediatric craniofacial collaborative group.

BACKGROUND: Antifibrinolytic therapy significantly decreases blood loss and transfusion in pediatric cranial vault reconstructive surgery; however, concern regarding the side effects profile limits clinical use. AIMS: The aim was to utilize the Pediatric Craniofacial Surgery Perioperative Registry database to identify the safety profile of antifibrinolytic therapy for cranial vault reconstructive surgery by reporting the incidence of adverse events as they relate to exposure to tranexamic acid and aminocaproic acid compared to no exposure to antifibrinolytics. METHODS: The database was queried for cases of open cranial vault reconstructive surgery. Less invasive procedures such as neuro-endoscopic and spring-mediated cranioplasties were excluded. The outcomes evaluated included any perioperative neurological adverse event including seizures or seizure-like movements and thromboembolic events. RESULTS: Thirty-one institutions reported a total of 1638 cases from 2010 to 2015. Total antifibrinolytic administration accounted for 59.5% (tranexamic acid, 36.1% and aminocaproic acid, 23.4%), with 40.5% not receiving any antifibrinolytic. The overall incidence of postoperative seizures or seizure-like movements was 0.6%. No significant difference was detected in the incidence of postoperative seizures between patients receiving tranexamic acid and those receiving aminocaproic acid [the odds ratio for seizures being 0.34 (95% confidence interval: 0.07-1.85) controlling for American Society of Anesthesia (ASA) physical class] nor in patients receiving antifibrinolytics compared to those not administered antifibrinolytics (the odds ratio for seizures being 1.02 (confidence interval 0.29-3.63) controlling for ASA physical class). One complicated patient in the antifibrinolytic group with a femoral venous catheter had a postoperative deep venous thrombosis. CONCLUSIONS: This is the first report of an incidence of postoperative seizures of 0.6% in pediatric cranial vault reconstructive surgery. There was no significant difference in postoperative seizures or seizure-like events in those patients who received the tranexamic acid or aminocaproic acid vs those that did not. This report provides evidence of the safety profile of antifibrinolytic in children having noncardiac major surgery. Caution should prevail however in using antifibrinolytic in high-risk patients. Antifibrinolytic dosage regimes should be based on pharmacokinetic data avoiding high doses.

Enhancing recovery after minimally invasive repair of pectus excavatum.

PURPOSE: There are variations in the perioperative management of patients who undergo minimally invasive repair of pectus excavatum (MIRPE). The purpose is to analyze the change in resource utilization after implementation of a standardized practice plan and describe an enhanced recovery pathway. METHODS: A standardized practice plan was implemented in 2013. A retrospective review of patients who underwent MIRPE from 2012 to 2015 was performed to evaluate the trends in resource utilization. A pain management protocol was implemented and a retrospective review was performed of patients who underwent repair before (2010-2012) and after (2014-2015) implementation. RESULTS: There were 71 patients included in the review of resource utilization. After implementation, there was a decrease in intensive care unit length of stay (LOS), and laboratory and radiologic studies ordered. There were 64 patients included in the pain protocol analysis. After implementation, postoperative morphine equivalents (3.3 ± 1.4 vs 1.2 ± 0.5 mg/kg, p < 0.01), urinary retention requiring catheterization (33 vs 14%, p = 0.07), and LOS (4 ± 1 vs 2.8 ± 0.8 days, p < 0.01) decreased. CONCLUSION: The implementation of an enhanced recovery pathway is a feasible and effective way to reduce resource utilization and improve outcomes in pediatric patients who undergo minimally invasive repair of pectus excavatum.

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

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

Washout times of desflurane, sevoflurane and isoflurane from the GE Healthcare Aisys® and Avance®, Carestation®, and Aestiva® anesthesia system.

BACKGROUND/AIM: Malignant hyperthermia susceptible patients may experience a fatal reaction to volatile anesthetic gases. This study sought to determine the washout characteristics of desflurane, sevoflurane, and isoflurane from the Aisys® , Avance® , and Aestiva® anesthesia machines. (GE Healthcare, Madison, WI, USA). METHODS: All machines were inspected by a GE Healthcare engineer prior to testing. The machines were primed with desflurane 7 vol%, sevoflurane 2.5 vol%, and isoflurane 1.2 vol% on three separate occasions for 2 h each with each gas. The Aisys® and Avance® were tested with and without an Advanced Breathing System (ABS™ , GE Healthcare, Madison, WI, USA). The Aestiva® was tested without modification to its breathing system. Additionally, the Aisys was evaluated with desflurane 1.2 vol% and the Avance with a preflushed fresh gas line was tested with an autoclaved ABS. After priming, disposable components of the patient breathing system were replaced. The fresh gas flow was increased to 15 lpm. Gas measurements were recorded until the concentration was 4 parts per million (p.p.m). RESULTS: The fastest median washout time was achieved by the Avance in 3 min or less without an ABS or with an autoclaved ABS. The longest median time was 35 min for the Aestiva® . Clearance of desflurane was the most time consuming for all machines. CONCLUSION: This study demonstrates that saturated vapor pressure and priming concentration exert a greater effect on washout times than gas solubility. The Aisys utilizes an electronic vaporizer system that may expose the breathing system to retained saturated vapor. The breathing systems for all machines may hinder washout of gases.

Quality Initiative Using Theory of Change and Visual Analytics to Improve Controlled Substance Documentation Discrepancies in the Operating Room.

BACKGROUND: Discrepancies in controlled substance documentation are common and can lead to legal and regulatory repercussions. We introduced a visual analytics dashboard to assist in a quality improvement project to reduce the discrepancies in controlled substance documentation in the operating room (OR) of our free-standing pediatric hospital. METHODS: Visual analytics were applied to collected documentation discrepancy audit data and were used to track progress of the project, to motivate the OR team, and in analyzing where further improvements could be made. This was part of a seven-step improvement plan based on the Theory of Change with a logic model framework approach. RESULTS: The introduction of the visual analytics dashboard contributed a 24% improvement in controlled substance documentation discrepancy. The project overall reduced documentation errors by 71% over the studied period. CONCLUSION: We used visual analytics to simultaneously analyze, monitor, and interpret vast amounts of data and present them in an appealing format. In conjunction with quality-improvement principles, this led to a significant improvement in controlled substance documentation discrepancies.

Percutaneous ultrasound-guided vs. intraoperative rectus sheath block for pediatric umbilical hernia repair: A randomized clinical trial.

BACKGROUND: Regional anesthesia is commonly used in children. Our hypothesis was that percutaneous ultrasound-guided (PERC) rectus sheath blocks would result in lower postoperative pain scores compared to intraoperative (IO) rectus sheath blocks following umbilical hernia repair. METHODS: A single-institution randomized blinded trial was conducted in pediatric patients undergoing elective umbilical hernia repair. The primary outcome was mean postoperative Wong-Baker pain score. Secondary outcomes included narcotic requirements and length of postoperative stay. RESULTS: Fifty-eight patients were included: 28 PERC and 30 IO. Operating room time was significantly longer in the PERC group (41 vs. 35min, p<0.01). Mean postoperative pain scores (PERC-2.6 vs. IO-3.3, p=0.11), morphine equivalents intraoperatively (PERC-0 vs. IO-0.04mg/kg, p=0.29) and postoperatively (PERC-0.04 vs. IO-0.09mg/kg, p=0.17), time to first postoperative narcotic dose (PERC-30 vs. IO-22min, p=0.33, log-rank test), and postoperative length of stay (PERC-76 vs. IO-80min, p=0.44) were similar. CONCLUSION: Following umbilical hernia repair in children, percutaneous ultrasound-guided and intraoperative rectus sheath blocks resulted in similar mean postoperative pain scores. There were no differences in secondary outcomes such as time to first narcotic, narcotic requirements, and length of stay. The additional resources required to complete a percutaneous ultrasound-guided rectus sheath block may not be warranted. TYPE OF STUDY: Randomized controlled trial. LEVEL OF EVIDENCE: Level I.