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.

An assessment of perioperative respiratory adverse events and difficult intubation in pediatric patients with Trisomy 21.

INTRODUCTION: Several prior studies have demonstrated an association between trisomy 21 and airway-related anesthetic complications. However, there is a paucity of large clinical studies characterizing the airway challenges associated with trisomy 21. In this analysis, we examine anesthetic-related airway complications in children with trisomy 21 and compare our findings to well-matched controls. METHODS: A chart review of all general anesthetics occurring between 2011 and 2017 at a single pediatric hospital was performed. Children with trisomy 21 were identified. Matched controls were created using a 1:1 propensity score and controlling for patient sex, patient age, surgical specialty, airway management, and anesthetic induction technique. The primary outcomes were the numbers of difficult intubations and perioperative respiratory adverse events. Secondary outcomes included the number of intubation attempts and the Cormack-Lehane grade in each cohort. RESULTS/DATA ANALYSIS: A total of 2702 anesthetic records were reviewed. Propensity score matching resulted in adequately matched control groups as indicated by a standard mean difference below 0.2 in each case. Logistic regression analysis between trisomy 21 patients and matched controls demonstrated that the trisomy 21 cohort had a higher incidence of perioperative respiratory adverse events (OR 2.04, 95% CI 1.34-3.09, p = .0008) due largely to a higher incidence of airway obstruction (1.7% vs. 0.2%, p = .0005). The trisomy 21 group had a lower rate of difficult intubation (OR 0.26, 95% CI 0.07-0.91, p = .034). There was no association between trisomy 21 and the number of intubation attempts (RR 0.99, 95% CI 0.88-1.13, p = .92) or Cormack-Lehane grade (RR 0.95, 95% CI 0.87-1.05, p = .35). DISCUSSION: The trisomy 21 cohort had an increased incidence of perioperative respiratory adverse events compared to matched controls, largely secondary to a higher rate of obstructed ventilation, but without statistically different rates of laryngospasm, bronchospasm, postextubation stridor, or other desaturation events. Our trisomy 21 cohort had a decreased incidence of difficult intubation. There was no association between trisomy 21 and number of attempts required to successfully place an endotracheal tube or a less favorable CL grade. CONCLUSIONS: Compared to matched controls, children with trisomy 21 have a lower incidence of difficult intubation and a higher incidence of perioperative respiratory adverse events, largely due to increased rate of airway obstruction.

Endoscopic Versus Open Repair for Craniosynostosis in Infants Using Propensity Score Matching to Compare Outcomes: A Multicenter Study from the Pediatric Craniofacial Collaborative Group.

BACKGROUND: The North American Pediatric Craniofacial Collaborative Group (PCCG) established the Pediatric Craniofacial Surgery Perioperative Registry to evaluate outcomes in infants and children undergoing craniosynostosis repair. The goal of this multicenter study was to utilize this registry to assess differences in blood utilization, intensive care unit (ICU) utilization, duration of hospitalization, and perioperative complications between endoscopic-assisted (ESC) and open repair in infants with craniosynostosis. We hypothesized that advantages of ESC from single-center studies would be validated based on combined data from a large multicenter registry. METHODS: Thirty-one institutions contributed data from June 2012 to September 2015. We analyzed 1382 infants younger than 12 months undergoing open (anterior and/or posterior cranial vault reconstruction, modified-Pi procedure, or strip craniectomy) or endoscopic craniectomy. The primary outcomes included transfusion data, ICU utilization, hospital length of stay, and perioperative complications; secondary outcomes included anesthesia and surgical duration. Comparison of unmatched groups (ESC: N = 311, open repair: N = 1071) and propensity score 2:1 matched groups (ESC: N = 311, open repair: N = 622) were performed by conditional logistic regression analysis. RESULTS: Imbalances in baseline age and weight are inherent due to surgical selection criteria for ESC. Quality of propensity score matching in balancing age and weight between ESC and open groups was assessed by quintiles of the propensity scores. Analysis of matched groups confirmed significantly reduced utilization of blood (26% vs 81%, P < .001) and coagulation (3% vs 16%, P < .001) products in the ESC group compared to the open group. Median blood donor exposure (0 vs 1), anesthesia (168 vs 248 minutes) and surgical duration (70 vs 130 minutes), days in ICU (0 vs 2), and hospital length of stay (2 vs 4) were all significantly lower in the ESC group (all P < .001). Median volume of red blood cell administered was significantly lower in ESC (19.6 vs 26.9 mL/kg, P = .035), with a difference of approximately 7 mL/kg less for the ESC (95% confidence interval for the difference, 3-12 mL/kg), whereas the median volume of coagulation products was not significantly different between the 2 groups (21.2 vs 24.6 mL/kg, P = .73). Incidence of complications including hypotension requiring treatment with vasoactive agents (3% vs 4%), venous air embolism (1%), and hypothermia, defined as <35°C (22% vs 26%), was similar between the 2 groups, whereas postoperative intubation was significantly higher in the open group (2% vs 10%, P < .001). CONCLUSIONS: This multicenter study of ESC versus open craniosynostosis repair represents the largest comparison to date. It demonstrates striking advantages of ESC for young infants that may result in improved clinical outcomes, as well as increased safety.

Left mainstem bronchial intubation at an extremely short incisor-to-carina distance in a patient with severe ascites.

Unintentional left mainstem bronchial intubation after direct laryngoscopy is less common than unintentional right mainstem bronchial intubation, having only been referenced 3 times outside of the anesthesia literature. We report a case of unintentional left mainstem intubation at an extremely short incisor-to-carina distance. We hypothesize that the left mainstem intubation occurred because of a distortion of the anatomy of the tracheal bifurcation, caused by the patient's severe ascites, hepatomegaly, and collapsed right lower lobe, thus creating a shallower angle of the left mainstem bronchus from midline. The short incisor-to-carina distance can be explained by ascites-induced cephalad shift of the mediastinum.

Recommendations for developing clinical care protocols during pandemics: From theory and practice.

In 2019, a novel coronavirus called the severe acute respiratory syndrome coronavirus 2 led to the outbreak of the coronavirus disease 2019, which was deemed a pandemic by the World Health Organization in March 2020. Owing to the accelerated rate of mortality and utilization of hospital resources, health care systems had to adapt to these major changes. This affected patient care across all disciplines and specifically within the perioperative services. In this review, we discuss the strategies and pitfalls of how perioperative services in a large academic medical center responded to the initial onset of a pandemic, adjustments made to airway management and anesthesia specialty services - including critical care medicine, obstetric anesthesiology, and cardiac anesthesiology - and strategies for reopening surgical caseload during the pandemic.

A predictive model for prolonged hospital length of stay in surgical burn patients.

BACKGROUND: Improvement in the care of burn patients has led to decreased mortality. Length of stay (LOS) has been used as a marker for quality of care in this population. However, the historical association of LOS as correlating only with % burn surface area (BSA) injury has been questioned with retrospective data suggesting other factors may also be associated with LOS. A model to predict prolonged LOS does not exist but could provide important information for clinicians and patients. METHODS: Data from January 2014 to December 2016 was used to develop a predictive model utilizing multivariable logistic regression. Prolonged hospital LOS was the outcome used with multiple covariates utilized to identify various associations. Odds ratios (OR) and their associated 95% confidence interval (CI) were reported for each covariate in the final regression model. Model performance in both the training and validation sets was evaluated using area under the receiver operating characteristic (ROC) curve (AUC) for discrimination and the Hosmer-Lemeshow (HL) test for goodness-of-fit. RESULTS: A total of 441 patients was included in the final analysis, 296 (67.1%) of which were in the training set. Within the training set, the median hospital LOS was 14 days with a range of 4 to 205 days. Patient age (in decades), hypertension, total BSA, involvement of perineum, and abnormal white blood cell count were independent risk factors for prolonged hospital length of stay. When using this separate dataset, the model had an AUC of 0.81 (95% CI 0.74-0.88) and had good calibration based on the HL-test (p=0.10). CONCLUSIONS: Prolonged hospitalization following burns is predicted by patient age (in decades), TBSA, hypertension, perineal involvement, and abnormal white blood cell count.

A population-based study of sociodemographic and clinical factors among children and adolescents with opioid overdose.

STUDY OBJECTIVE: An upsurge of high-risk opioid misuse has contributed to the epidemic of opioid overdose in the United States. The primary aim was to report the rate of opioid overdose among the pediatric population and to report demographic and medical differences among POD versus IOD populations. DESIGN: Retrospective descriptive analysis of opioid overdose using the largest pediatric inpatient database in the United States. We performed a Pearson chi-square and Wilcoxon rank sum test to compare differences between cohorts. SETTING: Multi-institutional. PATIENTS: Data were obtained from the Kids' Inpatient Database of the Healthcare Cost and Utilization Project. We used the International Classification of Disease, Ninth Revision codes to extract records of pediatric patients who were admitted for POD or IOD from 2000 to 2012. INTERVENTIONS: None. MEASUREMENTS: None. MAIN RESULTS: The final analysis included 15,884 patients admitted to a United States hospitals with opioid overdose. The rate of POD and IOD has increased steadily from 2000 to 2012. Black, Asian or Pacific Islander, Native American, Multi-race, and Unknown race had higher proportion of POD versus IOD (p < 0.001). Compared to POD, the rate of IOD was highest in Northeast (29.2% versus 14.3%, p < 0.001) and Midwest (31.6%versus 26.1%, (p < 0.001) regions of the country. CONCLUSIONS: Our findings reinforce existing studies that report a continued rise in opioid morbidity and mortality while providing new insights into sociodemographic patterns and comorbidities associated with POD versus IOD.

The sensitivity and specificity of the digital rectal examination for detecting spinal cord injury in adult patients with blunt trauma.

STUDY OBJECTIVES: The digital rectal examination (DRE) may assist physicians in detecting spinal cord injury in patients with blunt trauma. However, the test characteristics of the DRE for detecting spinal cord injury are unknown. METHODS: We conducted a retrospective review of consecutive adult patients with blunt trauma over a 2-year period. The DRE result was compared with the presence or absence of spinal cord injury at discharge. RESULTS: A total of 1032 adult patients with blunt trauma had a DRE. Of these, 54 (5.2%) had diagnoses consistent with spinal cord injury. Ninety-nine patients had decreased rectal tone, 27 of whom also had spinal cord injuries. The sensitivity, specificity, positive predictive value, and negative predictive values were 50%, 93%, 27%, and 97%, respectively. CONCLUSION: The DRE is insensitive to spinal cord injury and has a poor positive predictive value. The high specificity must be balanced against the large number of false-positive results.