Outcomes from wake up safe, the pediatric anesthesia quality improvement initiative.

BACKGROUND: Wake Up Safe, a Patient Safety Organization founded by the Society for Pediatric Anesthesia, collects data on serious adverse events along with demographic data from all pediatric patients receiving anesthesia care at participating institutions. This report reviews all events occurring between 2010 and 2015 and focuses on common adverse events that are anesthesia-related. AIMS: Determine which adverse events were most common from 2010 to 2015 among participating Wake Up Safe institutions. Determine how many anesthesia-related events were deemed to be preventable. METHODS: This is a descriptive report. The Wake Up Safe registry data were queried on September 29, 2017. Institutions were included if they had complete demographic data and at least 5 adverse events per year reported. At that time, 19 out of 29 institutions had complete demographic data for events from 2010 to 2015. This study describes demographic data and adverse events from these nineteen institutions. Descriptive data were extracted, and event rate was calculated for each adverse event category. In events that were assessed as primarily related to anesthesia, further detailed analysis was performed. RESULTS: Of all reported adverse events (2544 events), the most common were cardiac arrests (646, 31.6%), respiratory complications (598, 29.2%), and medication events (345, 16.9%). Of all anesthesia-related events (612 events), medication events were the most common (239, 31.9%), followed by respiratory complications (181, 24.1%), and cardiac arrests (139, 18.5%). Overall, 85% of anesthesia-related serious adverse events were deemed somewhat or almost certainly preventable. CONCLUSIONS: The majority of anesthesia-related serious adverse events reported to the Wake Up Safe database are preventable. Medication events are the most common anesthesia-related adverse events. Innovations aimed at decreasing medication events may be the most impactful.

Identification of perioperative pulmonary aspiration in children using quality assurance and hospital administrative billing data.

BACKGROUND: Perioperative aspiration is a rare but potentially devastating complication, occurring in 1-10 per 10 000 anesthetics based on studies of quality assurance databases. Quality assurance reporting is known to underestimate the incidence of adverse outcomes, but few large studies use supplementary data sources. This study aims to identify the incidence of and risk factors for perioperative aspiration in children using quality assurance data supplemented by administrative billing records, and to examine the utility of billing data as a supplementary data source. METHODS: Aspiration events for children receiving anesthesia at a tertiary care pediatric hospital between 2008 and 2014 were identified using (i) a perioperative quality assurance database and (ii) hospital administrative billing records with International Classification of Diseases, Ninth Revision Clinical Modification coded diagnoses of aspiration. Records were subject to review by pediatric anesthesiologists. Following identification of all aspiration events, the incidence of perioperative aspiration was calculated and risk factors were assessed. RESULTS: 47 272 anesthetic cases were evaluated over 7 years. The quality assurance database identified 20 cases of perioperative aspiration occurring in surgical inpatients, same-day admissions, and outpatients. Using hospital administrative data (which excludes outpatients with shorter than a 24-hour stay), 9 cases of perioperative aspiration were identified of which 6 had not been found through quality assurance data. Overall, International Classification of Diseases, Ninth Revision coding demonstrated a positive predictive value of 94.5% for any aspiration event; however, positive predictive value was <4% for perioperative aspiration. A total incidence of 5.5 perioperative aspirations per 10 000 (95% CI: 3.7-8.0 per 10 000) anesthetics was found. CONCLUSION: Quality assurance data offer an efficient way to measure the incidence of rare events, but may underestimate perioperative complications. International Classification of Diseases, Ninth Revision codes for aspiration used as a secondary data source were nonspecific for perioperative aspiration, but when combined with record review yielded a 30% increase in identified cases of aspiration over quality assurance data alone. The use of administrative data therefore holds potential for supplementing quality assurance studies of rare complications.

Pharmacological Management of Severe Neuropathic Pain in a Case of Eosinophilic Meningitis Related to Angiostrongylus cantonensis.

Angiostrongylus cantonensis, the rat lungworm, is the most common infectious cause of eosinophilic meningitis and can be fatal. The parasite can be found throughout Southeast Asia and Pacific Islands and the global distribution is expanding. We present the case of a fourteen-year-old female who had previously traveled to Hawaii and developed severe neuropathic pain related to A. cantonensis infection refractory to gabapentin and pregabalin monotherapy, who was eventually managed with an ultralow dose ketamine infusion, methadone, and serotonin-norepinephrine reuptake inhibitor.

Mechanisms for Research Support.

During the second day of the Pediatric Anesthesia NeuroDevelopment Assessment (PANDA) symposium 2016, 3 invited speakers focused on future directions for the PANDA group. This session, entitled "The Way Forward," included 3 talks on how other groups have organized through public-private partnerships (ACTTION), obtained NIH funding, and how to better communicate a research message. Dr Robert H. Dworkin spoke on the mission of the Analgesic, Anesthetic, and Addiction Clinical Trial Translations, Innovations, Opportunities and Networks (ACTTION), which is a public-private partnership with the United States Food and Drug Administration that pushes forward research related to pain and analgesics. Dr Tracy King discussed National Institute of Health funding for future studies in neurocognitive development after exposure to anesthetics. Dr Sharon Hertz discussed how the PANDA group might better craft their message to the public regarding effects of analgesics on neurocognitive development. Through their talks, the above speakers provided a clear route for the way forward in regard to research, funding, and messaging for the PANDA group.

Long-Term Intravenous Ketamine for Analgesia in a Child with Severe Chronic Intestinal Graft versus Host Disease.

Ketamine is reported to be an effective adjuvant to opioids in the treatment of refractory cancer pain; however, the use of high doses of ketamine for extended periods in pediatric patients has not been described. We present a five-year-old male with grade IV intestinal GVHD whose abdominal pain required both hydromorphone and ketamine for a period of over four months. There was no evidence of hepatotoxicity, hemorrhagic cystitis, or other adverse effects. Possible withdrawal symptoms were mild and were readily mitigated by gradually weaning ketamine.