Food allergy history and reaction to propofol administration in a large pediatric population.

BACKGROUND: Anaphylaxis to propofol is rare; however, providers face a clinical quandary as medication warnings still exist regarding propofol administration to egg-, soy-, and peanut-allergic patients. AIMS: The primary aim evaluated the rate of allergic reactions during propofol-containing anesthesia in patients listed allergic to egg, soy, or peanut compared with nonallergic patients who received propofol. The secondary aim evaluated the relationship between food allergy history and allergy testing data. METHODS: A retrospective chart review conducted between May 2012 and October 2018 identified pediatric patients listed allergic to egg, soy, and/or peanut, who received propofol. Allergy testing and results are presented. Evidence of allergic reaction to propofol during anesthesia was evaluated, and compared with a large nonallergic cohort who received propofol. RESULTS: Of the 232 392 anesthetics administered, 177 360 (76%) included propofol and 11308 (6%) involved a patient listed allergic to at least 1 index food. A large number of patients had no food allergy testing (n = 6153) or negative testing (n = 2198). Of the 3435 patients listed egg-allergic, 976 tested positive; 750 tested negative; and 1709 had no testing. Of the 2011 patients listed soy-allergic, 322 tested positive; 585 tested negative; and 1104 had no testing. Additionally, 5862 patients were listed peanut-allergic; 1659 tested positive; 863 tested negative and 3340 had no testing. One record of proven propofol anaphylaxis occurred; it was in a patient without a history of food allergies. There were 6 other cases of suspected allergy to propofol. One had a peanut and tree nut allergy and was lost to follow-up; one had no testing available, while 4 patients had positive propofol allergy testing and positive allergy tests to other medications. The rate of proven propofol anaphylaxis during anesthesia in the nonallergic cohort was 0.06/10 000, and the rate in egg- and soy-allergic patients was 0/5446. One patient with a listed peanut allergy had a possible reaction to propofol. CONCLUSIONS: In the listed food-allergic cohort, the majority had no allergy testing or negative testing. We found no evidence of a relationship between food allergy history and perioperative propofol reaction. We suggest multiply allergic and atopic patients may have a similar likelihood of propofol reaction as with other medications.

The effect of suprainguinal fascia iliaca block on the recovery of patients after arthroscopic hip surgery.

BACKGROUND: Adolescent and young adult patients undergoing arthroscopic hip surgery experience significant pain in the immediate postoperative period. There is a small body of evidence that indicates suprainguinal fascia iliaca blocks can improve comfort during recovery from this intervention. Our hypothesis was that patients undergoing hip surgery would consume fewer opioids and have less pain in the perioperative time frame if they received the block as part of their analgesic regimen. METHODS: In this study, we evaluated the outcomes of 716 patients, including 275 who received a suprainguinal fascia iliaca block, and 441 who did not have a block. Inclusion criteria included all age groups and American Society of Anesthesiologists, functional classes 1-2. Patients who received other concurrent procedures or those with incomplete data sets were excluded. We utilized a regional anesthesia database that combined data from various repositories into one web-based relational system. The primary outcomes were total opioid consumption and pain scores in the recovery room. Secondary outcomes included opioid side effects, block-related complications, and total recovery room time. Multivariable logistic regression analysis was used to evaluate opioid consumption, side effects, and total recovery times. Pearson chi-square was applied to assess the level of pain between the two groups. RESULTS: Total opioid consumption was significantly less in the block group compared to those not receiving a block (0.28 mg/kg vs 0.35 mg/kg, P < 0.001, 95% CI of difference in medians 0.04-0.10 mg/kg), but there was no statistical difference in pain scores. Patients with the regional block had a lower frequency of emesis in the PACU (0.7% vs 4.3%; P < 0.005, 95% CI of difference: 2-25) and shorter PACU times (93 vs 108 minutes, P < 0.001, 95% CI of difference: 8-23 minutes). CONCLUSION: Our study supports the clinical effectiveness of suprainguinal fascia iliaca blocks in young patients undergoing arthroscopic hip surgery.

The Anesthesia Perioperative "Call for Help"-Experience at a Quaternary Pediatric Medical Center: Analysis of 67,564 Anesthesia Encounters.

BACKGROUND: During the past several decades, anesthesia has become increasingly safe. Truly major adverse events are rare, and anesthesia quality researchers have instituted programs to evaluate "near miss" or less critical adverse events to evaluate the safety of anesthesia delivery. In this study, we aimed to evaluate calls for emergency help in our institution as a surrogate for pending critical events. We hypothesized that calls would be more common in patients with high American Society of Anesthesiologists (ASA) physical status, history of prematurity, and children with recent respiratory illness compared to those without these characteristics. METHODS: We analyzed emergent calls for help initiated by perioperative personnel ("STAT" calls) between August 2011 and September 2015 at Boston Children's Hospital. Our analysis had 2 phases: (1) All 193 STAT calls that occurred during this time period were analyzed for demographic variables (age, ASA physical status, gender) and specific features of the STAT calls (provider who initiated the call, anesthetic phase, presence of recent respiratory illness, location). We further categorized the STAT calls as "complicated" or "uncomplicated" based on an unexpected change in patient disposition, and analyzed how demographic factors and specific features related to the likelihood of a STAT call being complicated. (2) A subset of the total calls (108), captured after introduction of electronic intraoperative medical record in July 2012, were analyzed for the incidence of STAT calls by comparing the number and nature of the STAT calls to the number of surgical/diagnostic procedures performed. RESULTS: Univariable and multivariable analysis of the entire cohort of STAT calls (193 cases) identified several characteristics that were more likely to be associated with a complicated STAT call: higher ASA physical status; history of respiratory illness; cardiac inciting event; occurrence during induction phase of general anesthesia; postanesthesia care unit location; and calls initiated by an attending physician or a pediatric anesthesia fellow. Multivariable analysis of the subset of 108 indicated that age <1 year and a history of prematurity were independent predictors of a higher incidence of STAT calls. Offsite anesthesia services were associated with a lower frequency of STAT calls independent of the other variables. CONCLUSIONS: Our study offers the most comprehensive analysis of emergent perioperative calls for help in pediatric anesthesia to date. We identified several characteristics, independently associated with more complicated and frequent perioperative STAT calls. Further research is required to evaluate the utility of this information in preventing and treating adverse events in children undergoing surgery and anesthesia.

Population analysis of predictors of difficult intubation with direct laryngoscopy in pediatric patients with and without thyroid disease.

PURPOSE: There are no data on the prevalence and predictors of difficult intubation (DI) in pediatric patients with thyroid disease. This study (1) assesses the prevalence of DI in patients with thyroid disease undergoing elective operations, (2) identifies other predictors of DI in children, and (3) evaluates the effect of DI on postoperative care and length-of-stay. METHODS: A single-center retrospective cohort analysis of procedures in patients assigned with an ICD-9 code for thyroid disease between June 2012 and February 2016. A comparative group was created which comprised of patients without thyroid disease receiving orthopedic or urologic surgeries to determine differences in DI prevalence. Univariate analyses compared demographics and intubation details between groups, and logistic regression identified independent variables associated with DI. Patients with and without DI were compared based on procedure duration, PACU-LOS, and escalation-of-care. RESULTS: DI prevalence was greater in the thyroid group (4.9%, 51/1046) compared to the non-thyroid group (2.6%, 33/1289) (OR 1.95, 95% CI 1.25-3.05; p = 0.003). DI was associated with younger age, higher American Society of Anesthesiologists (ASA) class, and smaller body habitus (p < 0.001 for all comparisons). Congenital hypothyroidism (OR 2.49, 95% CI 1.44-4.32; p = 0.002)) and acquired hypothyroidism (OR 2.20, 95% CI 1.42-3.41; p < 0.001) were seen in a greater proportion of DI patients. After adjustment for demographic confounders, age and ASA class were independently associated with DI (p < 0.05), while hypothyroidism did not reach statistical significance (p = 0.077). Direct laryngoscopy (DL) was most frequently used as the successful subsequent maneuver in securing the airway in DI patients. A longer PACU length-of-stay was seen after procedures with DI (p < 0.001). CONCLUSION: Elective pediatric surgical patients with thyroid-related diagnoses at our institution had a higher prevalence of DI than those without thyroid disease, but this finding could not be isolated to thyroid pathology. Repeat DL achieves successful intubation in the majority of DI patients. DI patients often require longer recovery times due to prolonged cardiopulmonary monitoring.

Validation of the Pediatric Sedation State Scale.

OBJECTIVES: Development and validation of the Pediatric Sedation State Scale (PSSS) is intended to specifically meet the needs of pediatric procedural sedation providers to measure effectiveness and quality of care. METHODS: The PSSS content was developed through Delphi methods utilizing leading pediatric sedation experts and published guidelines on procedural sedation in children. Video clips were created and presented to study participants, who graded the state of patients during procedures by using the PSSS to evaluate inter- and intrarater reliability by determining the intraclass correlation coefficient. We also compared the PSSS to the Observational Scale of Behavioral Distress-revised during 4 clinically relevant phases of a laceration repair procedure. RESULTS: Six sedation states were defined for the PSSS. Each state was assigned a numerical value with higher numbers for increasing activity states. We included behaviors associated with adequate and inadequate sedation and adverse events associated with excessive sedation. Analysis of interrater and intrarater reliability revealed an intraclass correlation coefficient of 0.994 (95% confidence interval: 0.986-0.998) and 0.986 (95% confidence interval: 0.970-0.995), respectively. Criterion validity was confirmed with respect to the Observational Scale of Behavioral Distress-revised (Spearman r = 0.96). Construct validity was indicated by significant differences in PSSS scores (P < .001) between 4 phases of a procedure, each having a different degree of painful or distressing stimuli. CONCLUSIONS: The PSSS is a 6-point scale that is a valid measure of the effectiveness and quality of procedural sedation in children within the limits of the testing method used in this study.

Creation of an integrated outcome database for pediatric anesthesia.

Outcome analysis is essential to health care quality improvement efforts. Pediatric anesthesia faces unique challenges in analyzing outcomes. Anesthesia most often involves a one-time point of care interaction where work flow precludes detailed feedback to care givers. In addition, pediatric outcome evaluations must take into account patients' age, development, and underlying illnesses when attempting to establish benchmarks. The deployment of electronic medical records, including preoperative, operative, and postoperative data, offers an opportunity for creating datasets large and inclusive enough to overcome these potential confounders. At our institution, perioperative data exist in five distinct environments. In this study, we describe a method to integrate these datasets into a single web-based relational database that provides researchers and clinicians with regular anesthesia outcome data that can be reviewed on a daily, weekly, or monthly basis. Because of its complexity, the project also entailed the creation of a 'dashboard,' allowing tracking of data trends and rapid feedback of measured metrics to promote and sustain improvements. We present the first use of such a database and dashboard for pediatric anesthesia professionals as well as successfully demonstrating its capabilities to perform as described above.