Factors Associated With Recovery Room Intravenous Opiate Requirement After Pediatric Outpatient Operations.

BACKGROUND: Many children recovering from anesthesia experience pain that is severe enough to warrant intravenous (IV) opioid treatment within moments of admission to the postanesthesia care unit (PACU). Postoperative pain has several negative consequences; therefore, preventing significant PACU pain in children is both a major clinical goal and a moral/ethical imperative. This requires identifying patient-level and perioperative factors that may be used to predict PACU IV opioid requirement. This should allow for the development of personalized care protocols to prevent clinically significant PACU pain in children. Our objective was to develop prediction models enabling practitioners to identify children at risk for PACU IV opioid requirement after various painful ambulatory surgical procedures. METHODS: After Institutional Review Board approval, clinical, demographic, and anthropometric data were prospectively collected on 1256 children 4-17 years of age scheduled for painful ambulatory surgery (defined as intraoperative administration of analgesia or local anesthetic infiltration). Three multivariable logistic regression models to determine possible predictors of PACU IV opioid requirement were constructed based on (1) preoperative history; (2) history + intraoperative variables; and (3) history + intraoperative variables + PACU variables. Candidate predictors were chosen from readily obtainable parameters routinely collected during the surgical visit. Predictive performance of each model was assessed by calculating the area under the respective receiver operating characteristic curves. RESULTS: Overall, 29.5% of patients required a PACU IV opioid, while total PACU analgesia requirement (oral or IV) was 41.1%. Independent predictors using history alone were female sex, decreasing age, surgical history, and non-Caucasian ethnicity (model area under the receiver operating characteristic curve [AUROC], 0.59 [95% confidence interval {CI}, 0.55-0.63]). Adding a few intraoperative variables improved the discriminant ability of the model (AUROC for the history + intraoperative variables model, 0.71 [95% CI, 0.67-0.74]). Addition of first-documented PACU pain score produced a substantially improved model (AUROC, 0.85 [95% CI, 0.82-0.87]). CONCLUSIONS: Postoperative pain requiring PACU IV opioid in children may be determined using a small set of easily obtainable perioperative variables. Our models require validation in other settings to determine their clinical usefulness.

Racial differences in the pain management of children recovering from anesthesia.

BACKGROUND: When pain management has been studied in settings such as pediatric emergency departments, racial disparities have been clearly identified. To our knowledge, this has not been studied in the pediatric perioperative setting. We sought to determine whether there are differences based on race in the administration of analgesia to children suffering from pain in the postanesthesia care unit. METHODS: This is a prospective, observational, study of 771 children aged 4-17 years who underwent elective outpatient surgery. Racial differences in probability of receiving analgesia for pain in the recovery room were assessed using bivariable and multivariable logistic regression analyses. RESULTS: A total of 294 children (38.2%) received at least one class of analgesia (opioid or nonopioid); while 210 (27.2%) received intravenous (i.v.) opioid analgesia in the recovery room. Overall postanesthesia care unit analgesia utilization was similar between white and minority children (white children 36.8% vs minority children 43.4%, OR 1.3; 95% CI=0.92-1.89; P=.134). We found no significant difference by racial/ethnic group in the likelihood of a child receiving i.v. opioid for severe postoperative pain (white children 76.0% vs 85.7%, OR 1.89; 95% CI=0.37-9.67; P=.437). However, minority children were more likely to receive i.v. opioid analgesia than their white peers (white children 24.5% vs minority children 34.2%, OR 1.5; 95% CI=1.04-2.2; P=.03). On multivariable analysis, minority children had a 63% higher adjusted odds of receiving i.v. opioids in the recovery room (OR=1.63; 95% CI, 1.05-2.62; P=.03). CONCLUSIONS: Receipt of analgesia for acute postoperative pain was not significantly associated with a child's race. Minority children were more likely to receive i.v. opioids for the management of mild pain.

Anaesthetic management and outcomes after noncardiac surgery in patients with hypoplastic left heart syndrome: a retrospective review.

CONTEXT: Noncardiac surgery in patients with hypoplastic left heart syndrome has been associated with significant morbidity and mortality in case reports and small series. OBJECTIVE: A retrospective study to review the anaesthetic care and outcomes of patients with hypoplastic left heart syndrome undergoing noncardiac surgery. DESIGN: The medical records of patients undergoing anaesthesia for noncardiac surgery were reviewed, including anaesthesiology records, operative notes, admission history, physical examination records and discharge summaries. Data were collected on patient characteristics, co-morbidities, surgical procedure, anaesthetic and monitoring techniques, intraoperative and postoperative complications and admission status. SETTING: A tertiary medical centre with a high volume of congenital heart disease. PARTICIPANTS: Seventy-three procedures performed in 40 patients with hypoplastic left heart syndrome undergoing noncardiac surgery between July 2002 and May 2008. RESULTS: Thirty-three procedures were performed on an outpatient basis without invasive monitoring or complications. Adverse events occurred in 11 (15%) cases, including cardiovascular and respiratory instability, airway obstruction and postoperative stridor, with 13 (18%) patients admitted to the ICU postoperatively. CONCLUSION: Given the high incidence of adverse events in this patient population, it is imperative that perioperative care be individualised based on the presence of known risk factors such as the stage of palliation, residual cardiac disease and severity of planned surgery.

Prevalence of habitual snoring in children and occurrence of peri-operative adverse events.

OBJECTIVE: To describe the prevalence of habitual snoring and examine its association with peri-operative adverse events in children undergoing elective non-cardiac surgery--a relationship that has not been previously characterised. METHODS: Using a prospective observational design, we studied children aged 6-18 years undergoing elective non-cardiac surgeries at our institution. Trained research assistants collected clinical (including peri-operative adverse events) and anthropometric data on all individuals. Patients were stratified into two classes, habitual snorers and non-snorers. Subsequently, univariate factors associated with snoring were explored and then odds ratios for the occurrence of peri-operative adverse events were calculated from logistic regression after controlling for clinically relevant cofactors. RESULTS: Among 1102 patients, the prevalence of habitual snoring was 27.3% (28.2% for boys vs. 26.3% for girls). All the measured anthropometric parameters (BMI, waist circumference and neck circumference) were significantly higher in habitual snorers compared with non-snorers. The overall respiratory complication rate was 11.1%. Respiratory adverse events were more frequent in habitual snorers compared with non-snorers (16.9 vs. 8.9%; P < 0.001). Additionally, habitual snoring was associated with longer post-anaesthesia care unit (PACU) stay (114.0 ± 49.6 vs. 103.6 ± 48.9 min; P = 0.002) even after controlling for the occurrence of adverse respiratory events. CONCLUSION: The prevalence of habitual snoring was high in this cohort of paediatric surgical patients. Habitual snoring was associated with some peri-operative adverse events and prolonged PACU stay and should be considered an important symptom in the pre-operative review of children.

Computational modeling and prototyping of a pediatric airway management instrument.

BACKGROUND: Anterior retraction of the tongue is used to enhance upper airway patency during pediatric fiberoptic intubation. This can be achieved by the use of Magill forceps as a tongue retractor, but lingual grip can become unsteady and traumatic. Our objective was to modify this instrument using computer-aided engineering for the purpose of stable tongue retraction. METHODS: We analyzed the geometry and mechanical properties of standard Magill forceps with a combination of analytical and empirical methods. This design was captured using computer-aided design techniques to obtain a 3-dimensional model allowing further geometric refinements and mathematical testing for rapid prototyping. RESULTS: On the basis of our experimental findings we adjusted the design constraints to optimize the device for tongue retraction. Stereolithography prototyping was used to create a partially functional plastic model to further assess the functional and ergonomic effectiveness of the design changes. To reduce pressure on the tongue by regular Magill forceps, we incorporated (1) a larger diameter tip for better lingual tissue pressure profile, (2) a ratchet to stabilize such pressure, and (3) a soft molded tip with roughened surface to improve grip. CONCLUSION: Computer-aided engineering can be used to redesign and prototype a popular instrument used in airway management. On a computational model, our modified Magill forceps demonstrated stable retraction forces, while maintaining the original geometry and versatility. Its application in humans and utility during pediatric fiberoptic intubation are yet to be studied.

Incidence and risk factors for preincision hypotension in a noncardiac pediatric surgical population.

BACKGROUND: Routine monitoring of blood pressure is an essential part of perioperative care in adults and children. It is however not known whether intraoperative hypotension (IOH) is clinically important in the 'healthy' pediatric patient. This may be partly due to the lack of data on the incidence and consequences of IOH in this group of patients. We utilized the Brain Trauma Foundation definition of hypotension to describe the incidence of preincision hypotension (PIH) in a large pediatric noncardiac surgical population and identified risk factors for the occurrence PIH. METHODS: We examined the electronic perioperative records of all children aged 1-17 years undergoing general anesthesia for noncardiac surgeries between January 2005 and June 2007 in our institution. Frequency and factors associated with PIH were computed. Binary logistic regression with forward step-wise algorithm was used to examine factors associated with PIH. RESULTS: There were 22,263 children of whom 57.6% were males. Most (94.9%) cases were elective, American Society of Anesthesiologists (ASA) I-II (79.5%) procedures. Inhalational induction was predominantly used in this cohort (67%) although 33% of patients had propofol either as a sole induction agent or as part of a 'co-induction' regime. Single or multiple episodes of PIH occurred in 35.8% of patients. PIH was more common in patients with ASA > or = III (P < 0.001); those with preoperative hypotension (P < 0.001); and following intravenous induction (P < 0.001) as well as propofol co-induction (P < 0.001). On multivariate analysis the following were significant predictors of PIH: baseline hypotension, propofol co-induction, age, ASA > or = III, and long preincision period. CONCLUSION: Preincision hypotension is common in the pediatric surgical population undergoing general anesthesia. Factors independently predictive of PIH included high ASA status, pre-existing hypotension, propofol co-induction prolonged preincision period and adolescent age group. The importance of blood pressure monitoring, prompt recognition of hypotension and use of appropriate intervention is emphasized.

How do pediatric anesthesiologists define intraoperative hypotension?

INTRODUCTION: Although blood pressure (BP) monitoring is a recommended standard of care by the ASA, and pediatric anesthesiologists routinely monitor the BP of their patients and when appropriate treat deviations from 'normal', there is no robust definition of hypotension in any of the pediatric anesthesia texts or journals. Consequently, what constitutes hypotension in pediatric anesthesia is currently unknown. We designed a questionnaire-based survey of pediatric anesthesiologists to determine the BP ranges and thresholds used to define intraoperative hypotension (IOH). METHODS: Members of the Society of Pediatric Anesthesia (SPA) and the Association of Paediatric Anaesthetists (APA) of Great Britain and Ireland were contacted through e-mail to participate in this survey. We asked a few demographic questions and five questions about specific definitions of hypotension for different age groups of patients undergoing inguinal herniorraphy, a common pediatric surgical procedure. RESULTS: The overall response rate was 56% (483/860), of which 76% were SPA members. Majority of the respondents (72%) work in academic institutions, while 8.9% work in institutions with fewer than 1000 annual pediatric surgical caseload. About 76% of respondents indicated that a 20-30% reduction in baseline systolic blood pressure (SBP) indicates significant hypotension in children under anesthesia. Most responders (86.7%) indicated that they use mean arterial pressure or SBP (72%) to define IOH. The mean SBP values for hypotension quoted by SPA members was about 5-7% lower across all pediatric age groups compared to values quoted by APA members (P = 0.001 for all age groups). CONCLUSIONS: There is great variability in the BP parameters used and the threshold used for defining and treating IOH among pediatric anesthesiologists. The majority of respondents considered a 20-30% reduction from baseline in SBP as indicative of significant hypotension. Lack of a consensus definition for a common clinical condition like IOH could have implications for patient care as well as future clinical research.

Association of sleep disordered breathing symptoms with early postoperative analgesic requirement in pediatric ambulatory surgical patients.

INTRODUCTION: Sleep disordered breathing (SDB) symptoms are associated with increased rates of opioid-induced respiratory depression as well as enhanced nociception. Consequently, practitioners often withhold or administer lower intraoperative doses of opioids out of concern for postoperative respiratory depression. Therefore, SDB may be a critical determinant of analgesic requirement in the post-anesthesia care unit (PACU). We investigated whether preoperative SDB classification was independently associated with need for PACU analgesic intervention in a cross-sectional sample of 985 children who underwent elective, painful ambulatory surgical procedures. METHODS: Using prospectively collected data, children aged 4-17yr were grouped into two categories based on whether or not they had symptoms of SDB. Perioperative variables were compared between the exposed and control groups using Chi-squared test for categorical or t-test for continuous variables. Logistic regression analysis was used to assess the association between SDB and the odds of requiring PACU IV opioids. RESULTS: Children with preoperative SDB symptoms (N = 325) compared with the reference group of children who did not have these symptoms had higher rates of PACU analgesic intervention (47.1% vs. 37.4%; p = 0.004) and higher mean arousal pain scores (3.7 ± 3.5 vs.1.9 ± 2.9; p < 0.001). In our primary multivariable logistic regression model adjusted for a number of variables, preoperative SDB symptoms was associated with a two-fold increased odds of receiving PACU intravenous opioid (OR = 2.01, 95%CI, 1.29-3.12; p = 0.002). CONCLUSION: These results suggest that preoperative SDB symptoms in children undergoing ambulatory surgery, exerts a significant influence on PACU pain behavior and analgesic requirement. Mechanisms underlying this enhanced pain experience deserve further elucidation.

Airway management complications in children with difficult tracheal intubation from the Pediatric Difficult Intubation (PeDI) registry: a prospective cohort analysis.

BACKGROUND: Despite the established vulnerability of children during airway management, remarkably little is known about complications in children with difficult tracheal intubation. To address this concern, we developed a multicentre registry (Pediatric Difficult Intubation [PeDI]) to characterise risk factors for difficult tracheal intubation, establish the success rates of various tracheal intubation techniques, catalogue the complications of children with difficult tracheal intubation, and establish the effect of more than two tracheal intubation attempts on complications. METHODS: The PeDI registry consists of prospectively collected tracheal intubation data from 13 children's hospitals in the USA. We established standard data collection methods before implementing the secure web-based registry. After establishing standard definitions, we collected and analysed patient, clinician, and practice data and tracheal intubation outcomes. We categorised complications as severe or non-severe. FINDINGS: Between August, 2012, and January, 2015, 1018 difficult paediatric tracheal intubation encounters were done. The most frequently attempted first tracheal intubation techniques were direct laryngoscopy (n=461, 46%), fibre-optic bronchoscopy (n=284 [28%]), and indirect video laryngoscopy (n=183 [18%]) with first attempt success rates of 16 (3%) of 461 with direct laryngoscopy, 153 (54%) of 284 with fibre-optic bronchoscopy, and 101 (55%) of 183 with indirect video laryngoscopy. Tracheal intubation failed in 19 (2%) of cases. 204 (20%) children had at least one complication; 30 (3%) of these were severe and 192 (19%) were non-severe. The most common severe complication was cardiac arrest, which occurred in 15 (2%) patients. The occurrence of complications was associated with more than two tracheal intubation attempts, a weight of less than 10 kg, short thyromental distance, and three direct laryngoscopy attempts before an indirect technique. Temporary hypoxaemia was the most frequent non-severe complication. INTERPRETATION: More than two direct laryngoscopy attempts in children with difficult tracheal intubation are associated with a high failure rate and an increased incidence of severe complications. These results suggest that limiting the number of direct laryngoscopy attempts and quickly transitioning to an indirect technique when direct laryngoscopy fails would enhance patient safety. FUNDING: None.

Association of neck circumference with perioperative adverse respiratory events in children.

OBJECTIVE: The purpose of this investigation was to examine the association of neck circumference (NC) with perioperative respiratory adverse events in children undergoing elective noncardiac surgery, a relationship that has not been previously characterized. METHODS: Using a prospective, observational design, we studied children aged 6 to 18 years undergoing elective noncardiac surgeries at our institution. Trained research assistants collected clinical (including perioperative adverse events) and anthropometric data from all subjects. Patients were stratified into 2 classes: high NC versus low NC on the basis of age- and gender-specific receiver operating characteristic curve analysis. Subsequently, univariate factors associated with high NC were explored, and odds ratios for the occurrence of perioperative adverse events were then calculated from logistic regression after controlling for clinically relevant cofactors. RESULTS: Among the 1102 patients, the prevalence of high NC was 24.3%. NC was positively correlated with age and other anthropometric parameters. Children with high NC were more likely to be loud snorers and have a history of bronchial asthma, hypertension, and type 2 diabetes. Composite adverse airway events were more frequent in children with a large NC. There was no significant association between high NC and difficult laryngoscopy in our study population. CONCLUSIONS: NC was positively correlated with other indices of obesity in children, and large NC (indicative of central obesity) was associated with some adverse respiratory events in these children undergoing noncardiac surgery. NC could be a useful clinical screening tool for the occurrence of perioperative adverse respiratory events in children.

Does high BMI influence hospital charges in children undergoing adenotonsillectomy?

BACKGROUND: Obesity is a highly prevalent chronic problem with health and fiscal consequences. Data from adults and nonsurgical pediatric patients suggest that obesity has serious implications for the US economy. OBJECTIVE: Our goal was to describe the impact of BMI on hospital charges in children undergoing adenotonsillectomy (AT). METHODS AND PROCEDURES: We carried out a retrospective comparative analysis of the electronic anesthesia record and the charges from billing data from a large tertiary institution on children aged 3-18 years who had AT during the year 2005-2007. The main outcome measures were mean total hospital charges, likelihood of admission, and length of hospital stay (LOS). RESULTS: Of 1,643 children, 68.9% were aged <10 years, 76% were whites, and 74.1% had private commercial insurance. Most (75.3%) children were discharged on the day of surgery. Obese and overweight children were more likely to be admitted than their normal-weight peers (X(2)=26.3, P<0.001). Among those admitted, BMI showed a positive correlation with LOS (r=0.20, P<0.001). Obese and overweight patients had significantly higher total hospital charges than their healthy-weight counterparts (P=0.001). Anesthesia, postanesthesia care unit (PACU), and pharmacy and laboratory charges were also higher for obese than normal-weight children (P<0.05). DISCUSSION: Overweight and obese children undergoing AT accrued higher hospital charges and had longer postoperative LOS than their healthy-weight peers. If these findings are extendable to other surgical procedures, they could have far-reaching implications for the US economy.

Childhood body mass index and perioperative complications.

BACKGROUND: Our aim was to describe the incidence of quality assurance events between overweight/obese and normal weight children. METHODS: This is a retrospective review of the quality assurance database of the Mott Children's Hospital, University of Michigan for the period January 2000 to December 2004. Using directly measured height and weight, we computed the body mass index (BMI) in 6094 children. Overweight and obesity were defined using age and gender-specific cut off according to the National Center for Health Statistics (NCHS)/Centers for Disease Control and Prevention (CDC) (2000) growth charts. Frequency of quality assurance events were compared between normal weight, overweight, and obese children. RESULTS: There were 3359 males (55.1%) and 2735 females (44.9%). The mean age for the entire population was 11.9 +/- 5.2 while the mean BMI was 21.6 +/- 6.7 kg x m(-2). The overall prevalence of overweight and obesity was 31.6%. Obesity was more prevalent in boys than girls (P = 0.016). Preoperative diagnoses of hypertension, type II diabetes, and bronchial asthma were more common in overweight and obese than normal weight children (P = 0.0001 for hypertension, P = 0.001 for diabetes and P = 0.014 for bronchial asthma). Difficult airway, upper airway obstruction in the postanesthesia care unit (PACU) and PACU stay longer than 3 h and need for two or more antiemetics were more common in overweight and obese than normal weight children (P = 0.001). There was no significant difference in the incidence of unplanned hospital admission following an outpatient surgical procedure between normal weight and overweight/obese children. DISCUSSION: Studies on perioperative aspects of childhood overweight and obesity are rare. Our report shows a high prevalence of overweight and obesity in this cohort of pediatric surgical patients. Certain perioperative morbidities are more common in overweight and obese than in normal weight children. There is a need for prospective studies of the impact of childhood overweight and obesity on anesthesia and surgical outcome.

Increased respiratory symptoms following surgery in children exposed to environmental tobacco smoke.

OBJECTIVE: The aim of this study was to determine if children exposed to environmental tobacco smoke (ETS) via parental smoking (ETS+) developed more respiratory symptoms resulting in longer recovery times following surgical outpatient procedures compared with children of nonsmoking parents (ETS-). METHODS: One hundred and forty six children (4.9 +/- 3 years) undergoing inguinal hernia repair were prospectively studied. Parental smoking behaviour was determined by survey and urine analysis. Seven respiratory symptoms were evaluated during induction and emergence from anaesthesia and during the recovery room (RR) stay. RESULTS: Fifty-seven (39%) families admitted a smoking history while 89 (61%) denied it. This strongly correlated with the cotinine/creatinine ratio (Pearson correlation coefficient = 0.76; P = 0.01). ETS exposure was associated with an increased frequency of RR symptoms (ETS+: 56%; ETS-: 31%; P = 0.007). CONCLUSIONS: In children undergoing general anaesthesia for inguinal hernia repair, ETS exposure was associated with an increased frequency of respiratory symptoms during emergence from anaesthesia and during postoperative recovery.

Pentobarbital vs chloral hydrate for sedation of children undergoing MRI: efficacy and recovery characteristics.

BACKGROUND: Chloral hydrate (CH) sedation for magnetic resonance imaging (MRI) is associated with significant failure rates, adverse events and delayed recovery. Pentobarbital (PB), reportedly produces successful sedation in 98% of children undergoing diagnostic imaging. This study compared the efficacy, adverse events and recovery characteristics of CH vs PB in children undergoing MRI. METHODS: With Institutional Review Board approval and written consent, children were randomly assigned to receive intravenous (i.v.) PB (maximum 5 mg x kg(-1) in incremental doses) or oral CH (75 mg x kg(-1)) prior to MRI. Sedation was augmented with 0.05 mg x kg(-1) doses of i.v. midazolam (maximum 0.1 mg x kg(-1)) as necessary. Adverse effects, including hypoxaemia, failed sedation, paradoxical reactions and behavioural changes, the return of baseline activity, and parental satisfaction were documented. The quality of MRI scans was evaluated by a radiologist blinded to the sedation technique. RESULTS: PB facilitated an earlier onset of sedation (P = 0.001), higher sedation scores (P = 0.01), and less need for supplemental midazolam compared with CH. Severe hypoxaemia occurred in two children (6%) in the PB group. Fourteen per cent of the PB group experienced a paradoxical reaction, 9% sedation failure and 11% major motion artefact, compared with 0% (P = 0.05), 3 and 2% (P = NS), respectively, in the CH group. CH and PB were both associated with a high incidence of motor imbalance, and agitation. However, children who received PB had a slower return to baseline activity (P = 0.04). CONCLUSIONS: Although PB facilitated a quicker sedation onset and reduced the requirement for supplemental sedation, it produced a higher incidence of paradoxical reaction and prolonged recovery with a similar failure rate compared with CH.