Mixed reality simulation for peripheral intravenous catheter placement training.

BACKGROUND: Despite the advantages of simulation-based training, trainees are typically unable to view internal anatomical structures. This limitation can be overcome by using mixed reality (MR) wherein 3-D virtual anatomical images can be projected. This study was designed to evaluate the efficacy of an MR trainer for peripheral intravenous catheter (PIVC) placement. METHODS: Sixty-two participants used projected images of arm veins to place a PIVC in a mannequin arm. Participants were evaluated using a checklist on their ability to successfully place the PIVC. Participants completed a survey to elicit demographic information and perceptions of the trainer. A follow-up survey at two-weeks assessed clinical experiences with PIVC placement since using the MR trainer. RESULTS: First attempt catheter placement was successful in 48 (77.4%) cases. Only 11 (17.7%) and 3 (4.8%) of participants caused 'extravasation' and 'hematoma' formation on their first attempt, respectively. Fifty-nine participants (95.2%) agreed that ability to see internal structures was useful, and 58 (93.5%, respectively) agreed that the interactivity promoted learning and that MR should be included in training. CONCLUSIONS: Results of this study showed that use of a novel MR trainer for PIVC placement appears to provide an environment conducive to successful learning. Most participants were successful at PIVC placement on their first attempt and an overwhelming number found it helpful in identifying landmarks and confirming correct needle angles for insertion. Given the increasing emphasis on simulation training, highly immersive MR tools appear to offer promise to close the gap between classroom instruction and clinical experience.

Survey Research.

Surveys provide evidence on practice, attitudes, and knowledge. However, conducting good survey research is harder than it looks. The authors aim to provide guidance to both researchers and readers in conducting and interpreting survey research. Like all research, surveys should have clear research question(s) using the smallest possible number of high-quality, essential, survey questions (items) that will interest the target population. Both researchers and readers should put themselves in the position of the respondents. The survey questions should provide reproducible results (reliable), measure what they are supposed to measure (valid), and take less than 10 min to answer. Good survey research reports provide results with valid and reliable answers to the research question with an adequate response rate (at least 40%) and adequate precision (margin of error ideally 5% or less). Possible biases among those who did not respond (nonresponders) must be carefully analyzed and discussed. Quantitative results can be combined with qualitative results in mixed-methods research to provide greater insight.

Mothers' Decisions About Donating Newborns' Blood Spots for Research: A Qualitative Study.

Residual dried blood spots from millions of newborns are being stored and used for research. The state of Michigan proactively developed a broad consent process for research use of newborns' blood spots. However, the extent to which mothers make informed choices about this research is unclear. A descriptive, qualitative study was conducted examining this issue. Twenty-nine observations of the consent process and 20 semistructured interviews were conducted with mothers on the postpartum unit of a large, academic hospital in Michigan. Content analysis of the transcripts was conducted. While most mothers agreed to donate the blood spots (n = 14/20; 70%), findings indicated that most decisions were uninformed (n = 16/20; 80%), as mothers lacked knowledge of biobanking research. Misunderstandings about anonymity, the consenter's credentials, and entity conducting the research seemed to influence decision making. Suggestions for improving the consent process include (1) changing the venue of blood spot education and consent from the postpartum period to the perinatal period, (2) strengthening the depth of information and delivery of information provided about the topic, including ethical and values clarification, and (3) increasing consenter education and training. Implementation may help increase the proportion of informed decisions.

Consent Obtained by Residents: Informed by the Uninformed?

Informed consent is central to the bioethical principle of respect for persons, a process that involves a discussion between the physician and patient with disclosure of information sufficient to allow the patient to make an informed decision about her or his care. However, despite the importance of informed consent in clinical practice, the process is often ritualized, perfunctory, and performed by individuals with little or no training in the consent process. This article discusses the lack of medical students' and residents' training in informed consent and questions the practice of allowing untrained residents and surrogates to obtain consent from patients.

Effect of Preemptive Acetaminophen Administered Within 1 Hour of General Anesthesia on Gastric Residual Volume and pH in Children.

PURPOSE: Determine whether preoperative oral acetaminophen increases gastric residual volume and lowers gastric pH. DESIGN: Prospective, randomized. METHODS: Healthy children, 1 to 14 years, having elective magnetic resonance imaging (MRI) were randomized to oral acetaminophen within 1 hour of induction versus fasting. Gastric volume and pH were measured immediately after intubation. Adverse events were documented from induction through 72 hours post MRI. FINDINGS: Thirty-seven children completed the study (16 treatment, 21 control). Gastric residual volume between groups was not significantly different. The acetaminophen group had significantly higher pH than control group (1.86 ± 0.42 vs 1.56 ± 0.34; P ≤ .044). Three children in the control and 6 in the treatment group experienced minor adverse events. CONCLUSIONS: Findings suggest administering oral acetaminophen prior to induction of anesthesia is not associated with increased gastric residual volume and increases the gastric pH. Further study is needed to examine outcomes such as aspiration pneumonitis risk.

A cluster of high psychological and somatic symptoms in children with idiopathic scoliosis predicts persistent pain and analgesic use 1 year after spine fusion.

BACKGROUND: Persistent postoperative pain is a significant problem for many children, particularly for those undergoing major surgery such as posterior spine fusion. More than two-thirds report persistent pain after spine fusion, yet factors that may contribute to poorer outcomes remain poorly understood. AIMS: This prospective, longitudinal study examined how psychologic and somatic symptoms cluster together in children aged 10-17 years with idiopathic scoliosis, and tested the hypothesis that a higher psychological and somatic symptom cluster would predict worse pain outcomes 1 year after fusion. METHODS: Otherwise healthy children with idiopathic scoliosis completed preoperative surveys measuring recent pain intensity, pain location(s), somatic symptom severity, painDETECT (neuropathic-type pain symptoms), pain interference, fatigue, depression, anxiety, and pain catastrophizing. Pain outcome data were collected during hospitalization, and at 1 year after surgery. RESULTS: Ninety-five children completed baseline surveys and a cluster analysis differentiated 28 (30%) with a high symptom profile that included; higher depression, fatigue, pain interference, catastrophizing, and painDETECT scores. High symptom cluster membership independently predicted higher pain interference at 1 year (ß 9.92 [95% CI 6.63, 13.2], P < 0.001). Furthermore, children in this high symptom cluster reported significantly higher pain intensity and painDETECT scores, and had a 50% higher probability of continued analgesic use at 1 year compared to those in the Low Symptom Cluster (95% CI 21.3-78.5, P = 0.001). CONCLUSION: Findings from this exploratory study suggest a need to comprehensively assess children with scoliosis for preoperative signs and symptoms that may indicate an underlying vulnerability for persistent pain. This, in turn may help guide a comprehensive perioperative treatment strategy to mitigate the potential for long-term pain trajectories.

A High Preoperative Pain and Symptom Profile Predicts Worse Pain Outcomes for Children After Spine Fusion Surgery.

BACKGROUND: Preoperative pain predicts persistent pain after spine fusion, yet little is understood about the nature of that pain, related symptoms, and how these symptoms relate to postoperative pain outcomes. This prospective study examined children's baseline pain and symptom profiles and the association between a high symptom profile and postoperative outcomes. METHODS: Seventy children (aged 10-17 years) scheduled for correction of idiopathic scoliosis completed pain and symptom surveys during their preoperative visit (ie, pain intensity [0-10 numeric rating scores], a pediatric version of the 2011 fibromyalgia survey criteria [including pain locations and symptom severity scale], neuropathic pain symptoms [painDETECT], and Patient-Reported Outcome Measurement System measures of fatigue, depression, function, pain interference, and pain catastrophizing). Pain intensity and total analgesic use were recorded daily postoperatively and for 2 weeks after discharge. A 2-step cluster analysis differentiated a high and low pain and symptom profile at baseline, and a multivariate main effects regression model examined the association between pain profile and posthospital discharge pain and analgesic outcomes. RESULTS: The cluster analysis differentiated 2 groups of children well characterized by their baseline symptom reporting. Thirty percent (95% confidence interval [CI], 20.2%-41.8%) had a high symptom profile with higher depression, fatigue, pain interference, a pediatric version of the fibromyalgia survey criteria symptoms, neuropathic pain, and catastrophizing. Girls were more likely than boys to be clustered in the high symptom profile (odds ratio [OR], 5.76 [95% CI, 1.20-27.58]; P = .022) as were those with preoperative pain lasting >3 months (OR, 3.42 [95% CI, 1.21-9.70]; P = .018). Adjusting for sex, age, and total in-hospital opioid consumption, high cluster membership was independently associated with higher self-reported pain after discharge (mean difference +1.13 point [97.5% CI, 0.09-2.17]; P = .015). Children in the high symptom cluster were more likely to report ongoing opioid use at 2 weeks compared with the low symptom group (87% vs 50%; OR, 6.5 [95% CI, 1.30-33.03]; P = .015). At 6 months, high symptom cluster membership was associated with higher pain intensity, higher pain interference, and ongoing analgesic use (P ≤ .018). CONCLUSIONS: A behavioral pain vulnerable profile was present preoperatively in 30% of children with idiopathic scoliosis and was independently associated with poorer and potentially long-lasting pain outcomes after spine fusion in this setting. This high symptom profile is similar to that described in children and adults with chronic and centralized pain disorders and was more prevalent in girls and those with long-standing pain. Further study is needed to elucidate the potential mechanisms behind our observations.

Assessing anesthesiology residents' out-of-the-operating-room (OOOR) emergent airway management.

BACKGROUND: At many academic institutions, anesthesiology residents are responsible for managing emergent intubations outside of the operating room (OOOR), with complications estimated to be as high as 39%. In order to create an OOOR training curriculum, we evaluated residents' familiarity with the content and correct adherence to the American Society of Anesthesiologists' Difficult Airway Algorithm (ASA DAA). METHODS: Residents completed a pre-simulation multiple-choice survey measuring their understanding and use of the DAA. Residents then managed an emergent, difficult OOOR intubation in the simulation center, where two trained reviewers assessed performance using checklists. Post-simulation, the residents completed a survey rating their behaviors during the simulation. The primary outcome was comprehension and adherence to the DAA as assessed by survey responses and behavior in the simulation. RESULTS: Sixty-three residents completed both surveys and the simulation. Post-survey responses indicated a shift toward decreased self-perceived familiarity with the DAA content compared to pre-survey responses. During the simulation, 22 (35%) residents were unsuccessful with intubation. Of these, 46% placed an LMA and 46% prepared for cricothyroidotomy. Nineteen residents did not attempt intubation. Of these, only 31% considered LMA placement, and 26% initiated cricothyroidotomy. CONCLUSIONS: Many anesthesiology residency training programs permit resident autonomy in managing emergent intubations OOOR. Residents self-reported familiarity with the content of and adherence to the DAA was higher than that observed during the simulation. Curriculum focused on comprehension of the DAA, as well as improving communication with higher-level physicians and specialists, may improve outcomes during OOORs.

Development of a consensus operational definition of child assent for research.

BACKGROUND: There is currently no consensus from the relevant stakeholders regarding the operational and construct definitions of child assent for research. As such, the requirements for assent are often construed in different ways, institutionally disparate, and often conflated with those of parental consent. Development of a standardized operational definition of assent would thus be important to ensure that investigators, institutional review boards, and policy makers consider the assent process in the same way. To this end, we describe a Delphi study that provided consensus from a panel of expert stakeholders regarding the definitions of child assent for research. METHODS: Based on current guidelines, a preliminary definition of assent was generated and sent out for review to a Delphi panel including pediatric bioethicists and researchers, Institutional Review Board members, parents, and individuals with regulatory/legal expertise. For each subsequent review, the process of summarizing and revising responses was repeated until consensus was achieved. Panelists were also required to rank order elements of assent that they believed were most important in defining the underlying constructs of the assent process (e.g., capacity for assent, disclosure). In providing these rankings, panelists were asked to frame their responses in the contexts of younger (≤ 11 yrs) and adolescents/older children (12-17 yrs) in non-therapeutic and therapeutic trials. Summary rankings of the most important identified elements were then used to generate written construct definitions which were sent out for iterative reviews by the expert panel. RESULTS: Consensus regarding the operational definition was reached by 14/18 (78%) of the panel members. Seventeen (94%) panelists agreed with the definitions of capacity for assent, elements of disclosure for younger children, and the requirements for meaningful assent, respectively. Fifteen (83%) members agreed with the elements of disclosure for adolescents/older children. CONCLUSIONS: It is hoped that this study will positively inform and effect change in the way investigators, regulators, and IRBs operationalize the assent process, respect children's developing autonomy, and in concert with parental permission, ensure the protection of children who participate in research.

The STBUR questionnaire for identifying children at risk for sleep-disordered breathing and postoperative opioid-related adverse events.

BACKGROUND: Children with symptoms of sleep-disordered breathing (SDB) appear to be at risk for perioperative respiratory events (PRAE). Furthermore, these children may be more sensitive to the respiratory-depressant effects of opioids compared with children without SDB. AIMS: The aim of this prospective observational study was to confirm that otherwise healthy children with symptoms of SDB are at greater risk for PRAE compared with children with no symptoms and to determine if these children are also at increased risk for postoperative opioid-related adverse events (ORAE). METHODS: Six hundred and seventy-eight parents of children scheduled for surgery completed the Snoring, Trouble Breathing, and Un-Refreshed (STBUR) questionnaire preoperatively. Data regarding the incidence of PRAE were collected prospectively. Postoperative pulse oximetry desaturation alarm events were downloaded from the institutional secondary alarm notification system. RESULTS: Children with symptoms of SDB per STBUR (≥3 symptoms) had a two-fold increased likelihood of PRAE compared with children without SDB (52.8% vs 27.9% respectively, LR(+) = 2.00, 95% CI = 1.60-2.49, P = 0.0001). A subset analysis of children undergoing airway procedures requiring hospital admittance (n = 179) showed that those with SDB were given the same postoperative opioid doses as children without SDB. However, children with SDB symptoms generated a greater number of postoperative oxygen desaturation alarms (14.14 ± 29.3 vs 7.12 ± 13.2, mean difference = 7.02, 95% CI = 0.39-13.64, P = 0.038) and more frequently required escalation of care (15.3% vs 7.1%, LR(+) = 1.67, 95% CI = 1.22-2.16, P = 0.001) compared with children with no SDB symptoms. CONCLUSIONS: Children presenting for surgery with SDB symptoms are at increased risk for PRAE. Children undergoing airway-related procedures also appear to be at increased risk for ORAE. Furthermore, regardless of the preoperative assessment of risk using the STBUR questionnaire, children received the same doses of opioids postoperatively. Given the increased incidence of postoperative oxygen desaturations among children with SDB symptoms, it would seem prudent to consider titration of opioid doses according to identified risk.

Survey research: it's just a few questions, right?

While most anesthesiologists and other physician- or nurse-scientists are familiar with traditional descriptive, observational, and interventional study design, survey research has typically remained the preserve of the social scientists. To that end, this article provides a basic overview of the elements of good survey design and offers some rules of thumb to help guide investigators through the survey process.

A comparison of the postoperative pain experience in children with and without attention-deficit hyperactivity disorder (ADHD).

BACKGROUND: Children with attention-deficit hyperactivity disorder (ADHD) may experience pain differently compared to other children, yet the evidence is equivocal regarding whether pain is heightened or dampened. This prospective observational study, therefore, was designed to compare the postoperative pain experiences in children with and without ADHD. METHODS: Children aged 7-17 years with a diagnosis of ADHD (n = 119) who were scheduled for a surgical procedure requiring postoperative pain management and a matched cohort of children without ADHD were recruited (n = 122). Postoperative pain scores and analgesic use were recorded for 1 week, as was parents' estimate of their child's return to normal activity. RESULTS: There were no differences in highest pain scores between children with ADHD (3.3 ± 2.5, 0-10 numerical rating scale) and those without (2.8 ± 1.9). Postoperative opioid use was also similar on day 1 following surgery (0.12 ± 0.3 mg·kg(-1) vs 0.08 mg·kg(-1 ) ± 0.1 morphine equivalents, respectively). Children with ADHD, however, had a significantly longer return to normal activity (4.9 ± 3.8 vs 3.8 ± 3.0 days; P < 0.05). CONCLUSIONS: Results suggest that there were no differences in the postoperative pain experiences of children with and without ADHD. However, the observation that children with ADHD took longer to return to baseline activity will be important in educating parents regarding their child's postoperative experience.

Sleep-Disordered Breathing--Not Just for Grownups Anymore.

Previous research on SDB in children has focus edprimarily on OSA, whereas there is an increasing body of evidence to suggest that children with a spectrum of SDB symptoms may be at risk for perioperative and postoperative adverse events. To this end, it is imperative that these children are identified before surgery so that anesthesia and postoperative pain management plans can be optimized to mitigate risk. Although PSG remains the gold standard as a means to screen for SDB preoperatively,there are now clinically valid tools that can be used as part of the preanesthetic interview to identify children at risk. However, although recent work suggests that implementation of such screening tools may be important in identifying at-risk children and reducing perioperative adverse events through changes in anesthetic management, there is still much to be done with respect to changing the culture of standard postoperative opioid dosing. Perianesthesia nurses are thus in a unique position to help encourage a culture in which SDB in children is recognized asa significant risk for both perioperative and potentially deadly postoperative sequelae.

Informed consent for anesthesia: a review of practice and strategies for optimizing the consent process.

PURPOSE: Patients must receive information in a manner that promotes understanding so they can make informed decisions about anesthesia and other medical interventions. Unfortunately, history is replete with examples of the negative consequences of inadequate disclosure of information and lack of patient understanding. While obtaining consent for anesthesia poses unique challenges, the ability of the anesthesiologist to engage the patient in meaningful discussion is critical as a means to ensure that the patient is truly informed. This narrative review aims to: 1) discuss the process of informed consent as it applies to anesthesia practice; 2) describe the salient issues related to patient capacity, disclosure, understanding, decision-making, and documentation of the informed consent process; and 3) discuss current strategies to improve the presentation and understanding of consent information. SOURCE: Review of the extant literature, including the authors' own research. PRINCIPAL FINDINGS: Despite the ethical imperative of informed consent, many decision-makers have limited understanding of medical information. The reasons for this are multifactorial but often result from incomplete disclosure and presentation of generic information that does not take into account differences in information needs, values, and preferences of individual patients. Several simple strategies are available, however, that can enhance decision-makers' understanding of both written and verbal information. CONCLUSIONS: Despite the unique challenges of obtaining consent for anesthesia on the day of surgery, attention to the manner in which information for anesthesia care is provided and adoption of simple strategies to enhance understanding can go a long way to ensure that decision-makers are appropriately informed.

Retrospective evaluation of antimicrobial prophylaxis in prevention of surgical site infection in the pediatric population.

BACKGROUND AND OBJECTIVES: Few studies have been conducted in pediatric patients evaluating efficacy of prophylactic antibiotics for prevention of surgical site infection (SSI). This retrospective study was undertaken to determine the effect of antibiotic prophylaxis in the prevention of SSI in children. METHODS: With IRB approval, our perioperative electronic clinical information database was queried. Pediatric patients (≤18 years) undergoing general surgery, cardiac surgery, and spinal surgery at Mott Children's Hospital from January 2000 to April 2010 were included. Demographics and preoperative data were obtained from the Centricity Intraoperative Database, and any episodes of SSI were obtained by review of the infection control records. RESULTS: A total 5023 pediatric patients underwent surgery from January 2000 to April 2010. The average age of the children in the sample was 4.16 ± 5.5 years, and of these, 57% were boys. Overall, 119 (2.37%) cases of SSI were identified. There were no associations between the various patient factors and the development of SSIs. Children for whom antibiotics were administered incorrectly had a 1.7-fold increased risk of SSIs compared with children who received antibiotics within the recommended guidelines (P < 0.02). Children who received antibiotics were more likely to suffer an SSI compared with those who did not. CONCLUSIONS: Proper administration of preoperative antibiotics in pediatric patients is one of the few modifiable and significant factors in prevention of SSI.

The STBUR questionnaire for predicting perioperative respiratory adverse events in children at risk for sleep-disordered breathing.

BACKGROUND: In the absence of formal polysomnography (PSG), many children with symptoms of sleep-disordered breathing (SDB) go unrecognized and thus may be at risk for perioperative respiratory adverse events (PRAE). OBJECTIVES: To develop a simple practical tool to identify children with symptoms consistent with SDB who may be at risk for PRAE. METHODS: Three-hundred and thirty-seven parents of children scheduled for surgery completed the Sleep-Related Breathing Disorder (SRBD) questionnaire. Data regarding the incidence and severity of PRAE including airway obstruction and laryngospasm, were collected prospectively. RESULTS: Thirty-two (9.5%) children had a confirmed diagnosis of SDB by PSG and 90 (26.7%) had symptoms consistent with SDB based on the SRBD questionnaire. Principal component analysis identified five symptoms from the SRBD questionnaire that were strongly predictive of PRAE and which were incorporated into the STBUR tool (Snoring, Trouble Breathing, Un-Refreshed). The likelihood of PRAE was increased by threefold (positive likelihood ratio 3.06 [1.64-5.96] in the presence of any 3 STBUR symptoms and by tenfold when all five symptoms were present (9.74 [1.35-201.8]). In comparison, the likelihood of PRAE based on a PSG-confirmed diagnosis of SDB was 2.63 (1.17-6.23). CONCLUSIONS: Children presenting for surgery with symptoms consistent with SDB may be at risk for PRAE. It is important therefore that anesthesia providers identify these individuals prior to surgery to avoid potential complications. The STBUR questionnaire appears promising as a simple, clinically useful tool for identifying children at risk for PRAE. Further studies to validate the STBUR questionnaire as a diagnostic tool may be warranted.

Early adjuvant use of nonopioids associated with reduced odds of serious postoperative opioid adverse events and need for rescue in children.

OBJECTIVES: Examine factors associated with opioid adverse drug events (ADE) in children. SPECIFIC AIMS: Examine whether adjuvant nonopioid use is associated with a decreased probability of opioid-ADEs and need for rescue. BACKGROUND: Opioid-ADEs contribute to serious preventable harm for hospitalized children. Adjuvant nonopioid use may mitigate opioid risk postoperatively, yet few studies support this notion. METHOD: This nested case-control study included children who required intervention or rescue from opioid-ADEs and procedure-matched controls. Data were recorded from medical records and primary outcomes included serious opioid-ADEs (over-sedation and respiratory depression) and need for rescue (e.g., naloxone, rapid response team). Hierarchical logistic regression (HLR) models examined relationships between factors and opioid-ADEs. Early clinical signs and symptoms of deterioration were examined. RESULTS: Twenty five children with opioid-ADEs and 98 children without events were included. ASA-PS remained an independent risk factor (odds ratio, 2.56 [1.09, 6.03]; P = 0.031), while adjuvant nonopioids a risk reduction factor for opioid-ADEs (OR, 0.16 [0.05, 0.47]; P = 0.001) and need for rescue (0.14 [0.04, 0.47]; P = 0.001). Supplemental oxygen use at PACU discharge was associated with an increased odds of opioid-ADEs (OR, 3.72 [1.35, 10.23]; P = 0.007) and need for rescue (5.5 [1.7, 17.82]; P = 0.002). CONCLUSIONS: Findings from this study suggest that strategies such as early use of adjuvant nonopioids may reduce risk of opioid-ADEs postoperatively. Furthermore, children who require supplemental oxygen early postoperatively may be at heightened risk of later events.

Sequential Behavioral Analysis: A Novel Approach to Help Understand Clinical Decision-Making Patterns in Extended Reality Simulated Scenarios.

SUMMARY STATEMENT: Extended reality (XR)-based simulation training offers unique features that facilitate collection of dynamic behavioral data and increased immersion/realism while providing opportunities for training health care professionals on critical events that are difficult to recreate in real life. Sequential analysis can be used to summarize learning behaviors by discovering hidden learning patterns in terms of common learning or clinical decision-making sequences. This project describes the use of sequential analysis to examine differential patterns of clinical decision-making behaviors in observed XR scenarios, allowing for new insights when using XR as a method to train for critical events and to trace clinical decision making.