How the Wake Up Safe pediatric anesthesia collaborative increased quality improvement capability and collaboration.

Wake Up Safe is a patient safety organization consisting of 40 institutions with a mission to improve the processes of care and outcomes for newborns, infants, and children having anesthesia for surgery and medical procedures. It was recognized that the level of quality improvement (QI), knowledge, and experience varied greatly between member institutions. In Fiscal Year 2015, the group's leadership created a subcommittee on QI and education in efforts to provide member institutions with the skills and resources to use QI methodology to improve care at their own institution. This subcommittee developed a program to improve members' knowledge in safety analytics and QI science and to help members implement change in their own institutions. This review describes the development and implementation of this initiative. As a result of this initiative, significant progress was made improving the QI capability of the collaborative over a two-year period. This educational and support program included workshops, an online discussion forum, site visits, and project presentations.

A retrospective study of multimodal analgesic treatment after laparoscopic appendectomy in children.

BACKGROUND: Laparoscopic appendectomy is a common emergency pediatric surgery procedure accompanied by substantial pain (pain scores >4 for >60% of the time) in 33% of these patients. We introduced a bundle of pain management interventions including local anesthetic infiltration at the incision site, intravenous (IV) opioids by patient-controlled analgesia (PCA), and scheduled doses of IV ketorolac and oral acetaminophen/hydrocodone. OBJECTIVES: To evaluate the effect of these pain management interventions on pain control after laparoscopic appendectomy. METHODS: We retrospectively studied pain in 206 children above 7 years of age undergoing laparoscopic appendectomy from December 2011 to February 2012 at our institution. We extracted data on patient demographics, duration of anesthesia and surgery, intraoperative opioids, local anesthetic infiltration, surgical procedure reports, along with pain scores, postoperative PCA use, and opioid-related complications and hospital stays. Patients were divided into two groups - simple appendicitis without peritonitis and appendicitis with generalized peritonitis. RESULTS: The incidence of substantial pain when the multimodal regimen was used was 12%, which is significantly lower than earlier reports (Fisher's exact test P < 0.001). Patients with generalized peritonitis experienced more pain, consumed more opioids, had more unmet PCA demands, and a higher incidence of respiratory depression compared with those with simple appendicitis. CONCLUSION: The multimodal regimen of local anesthetic infiltration, opioid by PCA, NSAIDs, and oral acetaminophen/hydrocodone reduced the incidence of substantial pain. Additional studies are required to identify subgroups of patients with minimal opioid requirements who can benefit from modifications of this regimen.

The effect of obesity on the ED(95) of propofol for loss of consciousness in children and adolescents.

INTRODUCTION: Anesthesiologists face a dilemma in determining appropriate dosing of anesthetic drugs in obese children. In this study we determined the dose of propofol that caused loss of consciousness in 95% (ED(95)) of obese and nonobese children as determined by loss of eye lash reflex. METHODS: Forty obese (body mass index [BMI] > 95th percentile for age and gender) and 40 normal weight (BMI 25th to 84th percentile) healthy ASA 1 to 2 children ages 3 to 17 years presenting for surgical procedures were studied using a biased coin design. The primary endpoint was loss of lash reflex at 20 seconds after propofol administration. The first patient in each group received 1.0 mg/kg of IV propofol, and subsequent patients received predetermined propofol doses based on the lash reflex response in the previous patient. If the lash reflex was present, the next patient received a dose increment of 0.25 mg/kg. If the lash reflex was absent, the next patient was randomized to receive either the same dose (95% probability) or a dose decrement of 0.25 mg/kg (5% probability). The ED(95) and 95% confidence intervals (CI) were calculated using isotonic regression and bootstrapping methods respectively. RESULTS: The ED(95) of propofol for loss of lash reflex was significantly lower in obese pediatric patients (2.0 mg/kg, approximate 95% CI, 1.8 to 2.2 mg/kg) in comparison with nonobese patients (3.2 mg/kg, approximate 95% CI, 2.7 to 3.2 mg/kg), P ≤ 0.05. DISCUSSION: A simple approach to deciding what dose of propofol should be used for induction of anesthesia in children ages 3 to 17 years is to first establish the child's BMI on readily available gender-specific charts. Obese children (BMI >95th percentile for age and gender) require a lower weight-based dose of propofol for induction of anesthesia, than do normal-weight children.