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Background: Excessive operating room noise impairs communication, distracts from monitoring equipment, and may increase patient and provider stress. Aim: This study investigates the effects of reduced noise on perioperative behavior in children undergoing general anesthesia and on anesthesia provider response time. Methods: Healthy children (the American Society of Anesthesiologists class I-II), 2-8 years of age, and their anesthesia providers were randomized into a control or treatment group exposed to reduced stimulation during induction and emergence. Primary outcomes were patient behavior and provider response time. Secondary outcomes were postoperative pain scores, provider responses exceeding 30 seconds, and median and maximum noise exposure. Results: 64 children (27 females and 37 males) were randomized into a control or treatment group, of whom 32 (50%) underwent tonsillectomy/adenoidectomy and 32 (50%) underwent dental procedures. The average age was 4.6 (SD 1.43) years. Children exposed to reduced noise were less likely to be "fussy about eating" (p=0.042), more "interested in what goes on around them" (p=0.008), and had fewer temper tantrums (p=0.004) on postoperative day one or two and on postoperative day five, six, or seven. No other differences were found between groups in behavioral assessment scores or provider response times. Conclusions: Our study is the first to show that a low-stimulus environment improves postdischarge behavior. Provider response time was unaffected by reduced noise, and the average and peak noise exposure levels did not exceed national safety guidelines. This trial is registered with NCT03507855 and NCT03504553.
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BACKGROUND: The number of adolescents and adults identifying as trans or gender-diverse is increasing. The lesbian, gay, bisexual, transgender, queer, and "other" (LGBTQ+) population is recognized as a marginalized health care population. This retrospective study sought to investigate demographic trends in transgender and gender-diverse (TGD) youth accessing surgical care in the United States. METHODS: Using a multi-institutional dataset from the Pediatric Health Information System (PHIS), we described demographic and periprocedural data for TGD adolescents, ages 10 to 18 years, who underwent a surgical procedure between January 1, 2016 and August 31, 2022. RESULTS: Among 767,224 youth who underwent surgical procedures during the study period, 807 (0.1%, 95% confidence interval [CI], 0.09-0.11) were identified as TGD. The overall prevalence of identified TGD youth increased from 0.02% in 2016 to 0.23% in 2022. TGD youth were mostly (71%) assigned female at birth and 13 to 18 years of age (91%, 733/807) at the time of surgery. A total of 76% of TGD patients were non-Hispanic White, 62% had commercial insurance, and 49% lived in a ZIP code with a median annual income between $39,000 and $63,000. Of the 807 TGD patients identified, 264 (33%) were from the Northeast, 226 (28%) were from the Midwest, 219 (27%) were from the West, and 98 (12%) were from the South census regions. The most common procedures for TGD youth to undergo were breast reduction/augmentation (n = 135), insertion/removal of subcutaneous implant device (n = 98), and orthopedic procedures of the hip and lower extremity (n = 29). CONCLUSIONS: We reported the perioperative characteristics of TGD youth and showed a steady increase in the detected prevalence of TGD adolescents accessing surgical care. Future investigations into specific challenges associated with caring for these patients are warranted.
Subject(s)
Sexual and Gender Minorities , Transgender Persons , Transsexualism , Adolescent , Female , Humans , Retrospective Studies , United States/epidemiology , MaleABSTRACT
AAP guidelines recommend infants less than 6 months of age are monitored for at least 2 hours following surgery. This retrospective study evaluated if adherence to the 2-hour monitoring guideline decreased the risk of adverse events associated with ambulatory procedures in infants younger than 6 months. Methods: We queried the hospital's electronic medical record to identify patients younger than 6 months of age who received anesthetic care from January 2015 to March 2020. Demographic data, intraoperative adverse events, and returns to the emergency department (ED) or urgent care within 7 days were captured for each patient. We calculated the number and frequency for categorical data and median and interquartile range (IQR) for continuous data. Chi-square or Fisher's exact test were used to compare patients who experienced an adverse event to those that did not. Results: One thousand one hundred seventy-seven patients who had 1,261 unique anesthetic encounters were analyzed. Forty-four adverse events were identified, 20 (1.6%) before discharge, including 3 unplanned admissions, and 24 (1.9%) returns to the ED/UC within 7 days postoperatively. We did not observe differences in postoperative recovery time in patients who experienced an adverse event and those who did not (88 min vs. 77 min, respectively, P = 0.078). None of the ED/UC returns would have been avoided by a longer PACU stay. Conclusions: With the appropriate patient selection, once physiological discharge readiness is met, adherence to a strict 2-hour time-based discharge criteria does not increase safety for infants younger than 6 months of age after ambulatory procedures.
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PURPOSE: To review experience with outpatient spinal anesthesia (SA) from a single center in infants ≤6 months of age. METHODS: Retrospective review of all SAs performed in the ambulatory setting in the outpatient surgery centers in infants ≤6 months of age from 2016 to 2020, focusing on success rate, adverse events, post-anesthesia care unit (PACU) times, and emergency department (ED) or urgent care (UC) returns within 7 days of the operation. RESULTS: The study cohort included 175 SAs performed on 173 patients ≤6 months of age. One hundred and sixty-two patients (93%) were able to undergo their respective surgical procedures under SA without conversion to general anesthesia. One hundred and thirty-six patients (78%) did not require additional sedation or analgesic agents. The median time from entering the operating room until the start of surgical procedure was 17 min. One hundred and twenty-six patients (72%) were able to bypass Phase I of the PACU. One hundred and forty-seven patients (86%) were discharged in less than two hours postoperatively. Only one complication related to SA was noted. This was a patient who returned on postoperative day 2 with a possible CSF leak noted by ultrasound. After overnight hospital floor admission, he was discharged the next day after receiving intravenous fluids without further sequelae. CONCLUSIONS: SA is a viable option for anesthetic care in infants ≤6 months of age presenting for outpatient surgery. Advantages included the ability to bypass PACU Phase I and facilitation of hospital discharge. LEVEL OF EVIDENCE: IV. Retrospective cohort treatment study.
Subject(s)
Anesthesia, Spinal , Ambulatory Surgical Procedures/adverse effects , Anesthesia, General/adverse effects , Anesthesia, Spinal/adverse effects , Cohort Studies , Humans , Infant , Male , Retrospective StudiesABSTRACT
Anesthesiology is a medical specialty well known for its work in patient safety, allowing the field to show a dramatic decrease in perioperative morbidity and mortality in both adults and children since the 1950s. Currently, anesthesia-related mortality is close to zero in healthy children, with deaths occurring primarily in children ASA physical status ≥4. Survival during anesthesia today represents the expectation and standard of care, rather than a marker of quality. Several programs and organizations have created measures to assess safety in pediatric anesthesia-yet none are universally accepted as safety metrics or bundled to evaluate specific aspects of care. In addition, collection of this nonstandardized data in individual centers requires a significant investment of resources and personnel limiting access to only large, "resource-rich" institutions. In this perspective paper, we provide an overview of the efforts made to enhance quality of care across medical specialties with a specific emphasis on pediatric anesthesiology. We discuss the need for standardization of metrics to establish targets and benchmarks for the delivery of high-quality care to children and adolescents mainly in North America. The time has come to move beyond mortality and establish universally accepted minimum outcome standards in pediatric anesthesia. We believe this will ultimately improve confidence in the quality of pediatric anesthesia care offered to children, no matter where they are receiving that care.
Subject(s)
Anesthesia , Anesthesiology , Adolescent , Adult , Benchmarking , Child , Humans , North America , Patient SafetyABSTRACT
OBJECTIVES: General anesthesia or sedation can facilitate the completion of diagnostic radiological studies in children. We evaluated the incidence, predictors, and causes of adverse events (AEs) when general anesthesia is provided for diagnostic radiological imaging. METHODS: Deidentified data from 24 pediatric tertiary care hospitals participating in the Wake-Up Safe registry during 2010-2015 were obtained for analysis. Children 18 years or younger receiving general anesthesia for radiological procedures were identified using Current Procedural Terminology codes, and reported AEs were analyzed if they were associated with anesthetic care at magnetic resonance imaging or computed tomography locations. Logistic regression was used to determine predictors of AE occurrence in cases with complete covariate data. RESULTS: We identified 175,486 anesthetics for diagnostic radiological exams, compared with 83 AEs in magnetic resonance imaging or computed tomography locations (AE incidence of 0.05%). In multivariable analysis, AEs were more likely among patients with American Society of Anesthesiologists physical status IV compared with American Society of Anesthesiologists physical status I patients (adjusted odds ratio, 8.9; 95% confidence interval, 2.8-28.0; P < 0.001). Twenty-three AEs resulted in harm to the patient, whereas 32 AEs required unplanned hospital or intensive care unit admission. Anesthetic complications or issues were the most common cause of AEs (n = 52). CONCLUSIONS: Anesthesia provided for pediatric radiological studies is very safe and with an overall low AE incidence. The contribution of anesthetic complications to reported AEs suggests opportunities for further process improvement in this setting.
Subject(s)
Anesthesia , Anesthesia/adverse effects , Child , Hospitalization , Humans , Incidence , Registries , Risk FactorsABSTRACT
BACKGROUND: Anaphylactic reactions to antigens in the perioperative environment are uncommon, but they have a potential to lead to serious morbidity and/or mortality. The incidence of anaphylactic reactions is 1:37 000 pediatric anesthetics, and substantially less than the 1:10 000 to 1:20 000 incidence in the adult population. Neuromuscular blocking agents, latex, and antibiotics are the most frequently cited triggers. To date, there is no comprehensive report on perioperative anaphylactic reactions in children in the United States. Using the Wake-up Safe database, we examined the incidence and consequences of reported perioperative anaphylaxis events. METHODS: We reviewed the Wake-up Safe database from 2010 to 2017 and identified all reported instances of anaphylaxis. The triggering agent, timing, and location of the registered event, severity of patient harm, and preventability were identified. Narrative review of free-text comments entered by reporting centers was performed to determine presenting symptoms, and interventions required. Type of case was identified from procedure codes provided in mandatory fields. RESULTS: Among 2 261 749 cases reported to the Wake-up Safe database during the study period, perioperative anaphylactic reactions occurred in 1:36 479 (0.003%). Antibiotics, neuromuscular blocking agents, and opioid analgesics were the main triggers. Forty-nine cases (79%) occurred in the operating room, and 13 cases (21%) occurred in off-site locations. Seven (11%) patients required cardiopulmonary resuscitation following the onset of symptoms. Thirty-five (57%) patients were treated with epinephrine or epinephrine plus other medications, whereas 5% were managed only with phenylephrine. Most cases (97%) required escalation of care after the event. Regarding case preventability, 91% of cases were marked as either "likely could not have been prevented" or "almost certainly could not have been prevented." CONCLUSION: The estimated incidence of anaphylaxis and inciting agents among the pediatric population in this study were consistent with the most recent published studies outside of the United States; however, new findings included need for cardiopulmonary resuscitation in 11% of cases, and estimated fatality of 1.6%. The management of perioperative anaphylaxis could be improved for some cases as epinephrine was not administered, or its administration was delayed. Fewer than half of reported cases had additional investigation to formally identify the responsible agent.
Subject(s)
Anaphylaxis , Anesthesia , Anesthetics , Drug Hypersensitivity , Neuromuscular Blocking Agents , Adult , Anaphylaxis/epidemiology , Child , Drug Hypersensitivity/epidemiology , Humans , Neuromuscular Blocking Agents/adverse effects , United States/epidemiologyABSTRACT
BACKGROUND: Various criteria exist for defining difficult peripheral intravenous (DPIV) cannulation in infants and children. With the help of a survey tool, the characteristics perceived to increase the likelihood of DPIV cannulation amongst anesthesia providers were assessed. METHODS: An individualized survey regarding DPIV which included pediatric anesthesiology faculty and certified registered nurse anesthetists at Nationwide Children's Hospital and anesthesiology faculty members of Wake-up Safe was conducted. Anesthesia provider, patient, and procedural characteristics were expressed as a count and percentage, and compared according to group (faculty, certified registered nurse anesthetists, Wake-up Safe faculty) using analysis of variance. RESULTS: Of the 48 local respondents, 33 (69%) reported age as a contributing factor to DPIV, and 32 (67%) reported weight as a factor. Of the 22 Wake-up Safe respondents, 14 (63%) reported age, and 16 (73%) reported weight as a factor. Patient and procedural characteristics perceived to increased likelihood of DPIV cannulation did not differ by respondent role. The factors most commonly mentioned by local respondents as contributing to DPIV included trisomy 21, neuromuscular disorders, and history of many prior IV cannulations. Among the Wake-up Safe faculty respondents, the most commonly mentioned factors were neuromuscular disorders, trisomy 21, and skin injuries or conditions. CONCLUSION: Age and weight were the two most commonly reported factors from both groups of respondents. Other factors contributing to DPIV included prior history of DPIV, neuromuscular disorders, trisomy 21 and American Society of Anesthesiology status ≥4. Patient and procedural characteristics were perceived to increase the likelihood of DPIV cannulation with no difference among respondents.
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BACKGROUND: That African American (AA) patients have poorer surgical outcomes compared with their white peers is established. The prevailing presumption is that these disparities operate within the context of a higher preoperative comorbidity burden among AA patients. Whether these racial differences in outcomes exist among apparently healthy children (traditionally expected to have low risk of postsurgical complications) has not been previously investigated. METHODS: We performed a retrospective study by analyzing the National Surgical Quality Improvement Program-Pediatric database from 2012 through 2017 and identifying children who underwent inpatient operations and were assigned American Society of Anesthesiologists physical status 1 or 2. We used univariable and risk-adjusted logistic regression to estimate the odds ratios and their 95% confidence intervals (CIs) of postsurgical outcomes comparing AA to white children. RESULTS: Among 172 549 apparently healthy children, the incidence of 30-day mortality, postoperative complications, and serious adverse events were 0.02%, 13.9%, and 5.7%, respectively. Compared with their white peers, AA children had 3.43 times the odds of dying within 30 days after surgery (odds ratio: 3.43; 95% CI: 1.73-6.79). Compared with being white, AA had 18% relative greater odds of developing postoperative complications (odds ratio: 1.18; 95% CI: 1.13-1.23) and 7% relative higher odds of developing serious adverse events (odds ratio: 1.07; 95% CI: 1.01-1.14). CONCLUSIONS: Even among apparently healthy children, being AA is strongly associated with a higher risk of postoperative complications and mortality. Mechanisms underlying the established racial differences in postoperative outcomes may not be fully explained by the racial variation in preoperative comorbidity.
Subject(s)
Black or African American/statistics & numerical data , Postoperative Complications/mortality , Surgical Procedures, Operative/mortality , White People/statistics & numerical data , Databases, Factual , Emergencies , Female , Hospitalization , Humans , Infant , Infant, Newborn , Intubation, Intratracheal/statistics & numerical data , Logistic Models , Male , Operative Time , Recurrence , Reoperation/statistics & numerical data , Retrospective Studies , Sex Factors , United States/epidemiologyABSTRACT
INTRODUCTION: Anti-N-methyl-D-aspartate (NMDA) receptor encephalitis, an autoimmune disorder resulting from antibodies directed against the NMDA (glutamate) receptor, is the second most frequent cause of immune-mediated encephalitis. To date, the information related to the anesthetic care of children with this disorder is limited to anecdotal reports. METHODS: We reviewed the anesthetic care of six patients with anti-NMDA receptor encephalitis who underwent 21 procedures at our institution from 2014 through 2019. RESULTS: The study cohort included six patients, ranging in age from 2 to 18 years, who required anesthetic care during 21 procedures. Airway management included a laryngeal mask airway (n = 8), endotracheal intubation (n = 12), and native airway with spontaneous ventilation (n = 1). Intravenous (IV) induction with propofol was used in 17 procedures for five patients, including three that required rapid sequence intubation using rocuronium or succinylcholine. Inhalation induction with sevoflurane in nitrous oxide (N2O)/oxygen (O2) was chosen for two procedures in two patients. A combination of both induction techniques was used for two patients in two procedures. Maintenance anesthesia was accomplished with a volatile agent, predominantly sevoflurane, for 18 of the 21 procedures; propofol infusion for one procedure; and single dose of propofol was used for two short procedures. N2O was not used for maintenance anesthesia in any of the encounters. None of the patients exhibited adverse events, including hemodynamic instability, thermoregulatory problems, or respiratory events perioperatively. Postoperatively, there was no observed deterioration in clinical status attributed to anesthetic care. DISCUSSION: Multisystem involvement in anti-NMDA receptor encephalitis includes memory loss, behavior irregularity, psychosis, arrhythmias, blood pressure (BP) instability, and hypoventilation. In our study cohort, we noted no intraoperative issues and deterioration in clinical status following the use of volatile anesthetic agents, opioids, dexmedetomidine, and propofol for general anesthesia (GA) or sedation. As ketamine, xenon, and N2O mediate their anesthetic effects, primarily, through antagonism of NMDA receptors, theoretical concerns suggest that they should be avoided.
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BACKGROUND: Perioperative aspiration, while rare, is a serious complication of anesthetic care. Consequences of aspiration may include physical obstruction, wheezing, and pneumonia, resulting in mild to severe hypoxemia and even death. AIM: We used a multi-institutional registry of pediatric patients to identify factors that influence the rate and resulting harm of perioperative pulmonary aspiration. METHODS: The Wake Up Safe registry was queried for all severe adverse events reported from 29 institutions from 2010 to 2017. Aspiration events were identified through the "respiratory adverse event" data entry form or through free text search. Multivariable regression was used to predict aspiration events, and contributory factors were identified by reviewing free text case comments. RESULTS: Analysis included 2 440 810 anesthetics administered involving patients ≤18 years of age. There were 135 pulmonary aspiration events, for an incidence of 0.006%. Within these 135 cases, 110 cases (82%) resulted in escalation of care and 51 (38%) resulted in patient harm, including 2 deaths (1.5%). In multivariable analysis, patients undergoing emergency surgery (OR 2.0 [1.2-3.5]) or with higher ASA status were more likely to experience aspiration (ASA 3 (OR 5.0 [2.6-9.1]); ASA ≥ 4 (OR 5.5 [3.8-16.8])). Noted causes of aspiration included gastrointestinal comorbid conditions (19%), postcoughing event or laryngospasm (14%), nil per os (NPO) violation (11%), blood or secretions in the airway following or during the procedure (6%), and oral premedication reaction (3%). CONCLUSION: Although infrequent, death was reported as a consequence of perioperative aspiration in two patients. The frequency with which NPO violations were identified as a potential cause of aspiration highlights the struggles institutions face with adherence to NPO regulations, as these cases may be preventable. Furthermore, preventive measures may be needed to address other common causes of aspiration, such as gastrointestinal comorbid conditions.
Subject(s)
Anesthesia , Anesthetics , Respiration Disorders , Child , Databases, Factual , Humans , Incidence , Respiration Disorders/epidemiologyABSTRACT
PURPOSE: Batten disease or neuronal ceroid lipofuscinosis is the most prevalent neurodegenerative disorder of childhood. Previously reported perioperative complications in children with Batten disease have come mainly from single case reports. The primary aim of the current study was to investigate perioperative complications of patients with Batten disease in the largest cohort known to date. The secondary objective was to characterize the anesthetic management including the use of propofol and to assess its association with adverse events. METHOD: We conducted a single center, retrospective descriptive study by querying the hospital's electronic medical record to identify patients with a diagnosis of Batten disease or ICD10 E75.4 who received anesthetic care from December 2014 to May 2019. RESULTS: Thirty-five patients who underwent a total of 93 anesthetic encounters (range 1-11) were included in the analysis. A total of 29 adverse events were identified. Hypotension (N = 6, 6.5%) and bradycardia (N = 7, 7.5%) requiring treatment with medications were the most common adverse events. Other adverse events include oxygen desaturation (N = 4, 4.3%), seizures (N = 4, 4.3%), unanticipated hospital or ICU admission (N = 1, 1.1%), PACU phase 1 stay > 120 min (N = 2, 2.2%), hypothermia (N = 4, 4.3%), agitation (N = 1, 1.1%), and laryngospasm requiring treatment (N = 1, 1.1%). The number of preoperative anti-epileptic drugs (AEDs) had a positive correlation with the rate of perioperative adverse events. There was no statistical relationship of adverse events with intraoperative use of propofol (odds ratio 1.03, 95% CI 0.42-2.51). CONCLUSIONS: The majority of these patients were managed without clinically significant perioperative complications. As previously reported, bradycardia, hypotension, and hypothermia were the most common adverse events. Routine avoidance of propofol in patients with Batten disease does not appear warranted.
Subject(s)
Anesthetics , Hypothermia , Neuronal Ceroid-Lipofuscinoses , Bradycardia/chemically induced , Bradycardia/epidemiology , Child , Humans , Retrospective StudiesABSTRACT
This study evaluated progress to publication of pediatric quality improvement (QI) projects initially presented as national conference abstracts, according to project findings and other characteristics. QI abstracts were identified among presentations at the 2010-2015 American Academy of Pediatrics National Conference & Exhibition, and publications were tracked through June 2018. Positive findings (improvement on at least 1 quantitative project outcome), interventions, and analyses were correlated with journal publication. Of 142 abstracts, 128 (90%) reported positive findings. Forty-nine positive abstracts and 3 abstracts reporting negative results resulted in publication (38% vs 21%, respectively; P = .256). Median time to publication was 1.2 years for projects with positive findings, compared to >3 years for abstracts with negative findings (P = .029). Ninety percent of abstracts reported positive findings, and these abstracts progressed to publication more quickly. Overcoming publication bias for pediatric QI projects may enhance selection of promising interventions as new projects are designed.
Subject(s)
Congresses as Topic/statistics & numerical data , Pediatrics/statistics & numerical data , Publication Bias/statistics & numerical data , Quality Improvement/statistics & numerical data , Bibliometrics , HumansABSTRACT
INTRODUCTION: Atelectasis is a problem in sedated pediatric patients undergoing cross-sectional imaging, impairing the ability to accurately interpret chest computed tomography (CT) imaging for the presence of malignancy, often leading to additional maneuvers and/or repeat imaging with additional radiation exposure. METHODS: A quality improvement team established a best-practice protocol to improve the quality of thoracic CT imaging in young patients with suspected primary or metastatic pulmonary malignancy. The specific aim was to increase the percentage of chest CT scans obtained for the evaluation of pulmonary nodules with acceptable atelectasis scores (0-1) in patients aged 0-5 years with malignancy, from a baseline of 45% to a goal of 75%. RESULTS: A retrospective cohort consisted of 94 patients undergoing chest CT between February 2014 and January 2015 before protocol implementation. The prospective cohort included 195 patients imaged between February 2015 and April 2018. The baseline percentage of CT scans that were scored 0 or 1 on the atelectasis scale was 44.7%, which improved to 75% with protocol implementation. The mean atelectasis score improved from 1.79 (±0.14) to 0.7 (±0.09). Sedation incidence decreased substantially from 73.2% to 26.5% during the study period. CONCLUSIONS: Using quality improvement methodology including standardization of care, the percentage of children with atelectasis scores of 0-1 undergoing cross-sectional thoracic imaging improved from 45% to 75%. Also, eliminating the need for sedation in these patients has further improved image quality, potentially allowing for optimal detection of smaller nodules, and minimizing morbidity.
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Objectives This study classified patterns of discontinuous health insurance coverage, including change in coverage type and gaps in coverage, and described their associations with children's access to health care. Methods Using the 2011-2013 National Health Interview Survey data, we determined children's insurance coverage over the past year, and whether children had a usual source of care, had to delay getting care, or had unmet health care needs. Using multivariable logistic regression, we compared measures of access to care across insurance coverage patterns, classified as continuous private coverage; continuous public coverage; continuous lack of coverage; change in coverage type (public versus private) without gaps in coverage; and any gap in coverage. A subgroup analysis repeated this comparison for children with a caregiver-reported chronic physical illness. Results The analysis included 34,105 children, of whom 7% had a gap in coverage and 1% had a change in coverage type. On multivariable analysis, gaps in coverage were associated with increased likelihood of unmet health care needs, compared to continuous private (OR 6.9; 95% CI 5.9, 8.0) or continuous public coverage (OR 5.1; 95% CI 4.4, 6.0). Seamless changes in coverage were also associated with greater likelihood of unmet health care needs [OR vs. private: 3.8 (95% CI 2.3, 6.1); OR vs. public: 2.8 (95% CI 1.8, 4.6); all p < 0.001]. Results were similar for other study outcomes, and among children with chronic physical illness. Conclusions for Practice Both gaps in coverage and seamless changes between coverage types were associated with limited health care access for children.
Subject(s)
Health Services Accessibility/standards , Insurance Coverage/trends , Adolescent , Child , Child Health Services/statistics & numerical data , Child, Preschool , Female , Health Services Accessibility/statistics & numerical data , Humans , Infant , Insurance Coverage/standards , Insurance, Health/statistics & numerical data , Logistic Models , Male , Medically Uninsured/statistics & numerical data , OhioABSTRACT
PURPOSE: We prospectively investigated contamination of high-contact surfaces in the operating room (OR) using adenosine triphosphate (ATP) monitoring. We tested whether contamination would increase from morning (AM) to afternoon (PM), despite cleaning between cases. Second, we compared the degree of OR contamination to non-OR control sites. METHODS: ORs with high case volumes were selected for the study. Ten sites in each OR were swabbed using the AccuPoint® HC ATP Sanitation Monitoring device, which provided a numerical measure of contamination (relative light units, RLUs). According to the manufacturer, surfaces are considered clean at ≤ 400 RLUs. AM measurements were taken before the start of surgical cases and PM measurements were taken after cases were completed. RESULTS: Eighty morning and 70 afternoon samples were obtained from 8 ORs. Apart from the OR floor, laryngoscope handles had the highest level of morning contamination (1204 RLUs, interquartile range 345, 2603), with 75% of AM samples and 100% of PM samples exceeding 400 RLUs. This contamination was comparable to hospital toilet seats (87% of samples exceeding 400 RLUs). No sites showed statistically significant increases in contamination from AM to PM. CONCLUSION: Apart from the OR floors, laryngoscope handles emerged as a key OR site where improved cleaning practices may reduce cross-contamination risk. While some sites showed increased contamination over the course of the day, none of these met statistical significance thereby offering tentative evidence that current cleaning practices during case turnover are effective for most sites.
Subject(s)
Adenosine Triphosphate/analysis , Luminescent Measurements , Operating Rooms , Humans , Prospective StudiesABSTRACT
BACKGROUND: Anesthesia services are frequently provided outside of the traditional operating room environment for children. It is unclear if adverse events which occur in off-site anesthetizing locations result in more severe outcomes compared to events in traditional operating rooms. AIM: We used a multi-institutional registry of pediatric patients to compare outcomes of perioperative adverse events between location types. METHODS: De-identified data from 24 pediatric tertiary care hospitals participating in the Wake Up Safe registry during 2010-2015 were analyzed. Peri-procedural adverse events occurring in operating rooms or off-site locations were included. The primary outcome was whether the adverse event was severe, defined as requiring escalation of care or resulting in temporary or significant harm. Multivariable logistic regression was used to compare location type (operating room vs. off-site) and the likelihood of a severe outcome among reported events. RESULTS: There were 1594 adverse events, of which 362 were associated with off-site anesthetizing locations. In multivariable logistic regression, off-site location was associated with greater odds of severe adverse event outcome (adjusted odds ratio, 1.31; 95% confidence interval: 1.01, 1.69; P = 0.044). Comparing adverse events in cardiac catheterization suites to events in operating rooms confirmed higher odds of severe outcome in the former group (adjusted odds ratio = 1.48; 95% confidence interval: 1.05, 2.08; P = 0.025), while this difference was not found for other off-site locations. CONCLUSION: Multivariable analysis of a large registry revealed a greater likelihood of severe outcome for adverse events occurring in cardiac catheterization suites (but not other out of the OR sites), compared to adverse events occurring in the operating room. Additional prospective studies are needed which better control for patient and environmental characteristics and their effect on severe outcomes after anesthesia.
Subject(s)
Anesthesia/methods , Intraoperative Complications/epidemiology , Perioperative Period/adverse effects , Anesthesia/adverse effects , Anesthesia/statistics & numerical data , Anesthetics/administration & dosage , Cardiac Catheterization , Child , Child, Preschool , Databases, Factual , Female , Humans , Male , Operating Rooms , Prospective Studies , Risk Assessment , Risk FactorsABSTRACT
Socioeconomic disparities in access to care coordination have been noted among children with special health care needs (CSHCN). Following recent policy developments and technological innovation, care coordination has become more widespread, possibly leading to reduced disparity in care coordination access. This study investigates whether child and household characteristics remain associated with unmet need for care coordination among CSHCN. CSHCN (aged <18 years) requiring ≥2 types of health services in the past year were identified in the 2016 National Survey of Children's Health (NSCH). Care coordination was defined as help with arranging the child's care among different doctors or services. Children were classified as not needing care coordination, receiving sufficient care coordination (met need), or needing but not receiving care coordination (unmet need). Weighted multinomial logistic regression examined the association of child characteristics with this outcome. The analysis included 5622 children with no need for care coordination, 1466 with a met need, and 980 with unmet needs. Children with mental health conditions were more likely to have unmet rather than met needs for care coordination (odds ratio = 4.1; 95% confidence interval: 2.7, 6.1; P < 0.001). After multivariable adjustment, race/ethnicity, income, family structure, insurance coverage, place of birth, and use of English in the home were not associated with having unmet rather than met needs for care coordination. Among CSHCN, the latest data from NSCH reveal no evidence of previously described socioeconomic disparities in access to care coordination. Nevertheless, unmet needs for care coordination remain prevalent, especially among children with mental health conditions.
Subject(s)
Child Health Services/statistics & numerical data , Continuity of Patient Care/statistics & numerical data , Disabled Children , Health Services Needs and Demand , Mental Disorders/therapy , Mental Health Services/statistics & numerical data , Adolescent , Child , Female , Health Services Accessibility , Humans , Male , Needs Assessment , United StatesABSTRACT
INTRODUCTION: Anesthesiologists use sugammadex to reverse neuromuscular blockade (NMB) produced by rocuronium and vecuronium. Its mechanism involves encapsulation of the neuromuscular blocking agent. Sugammadex dosing is based on the depth of NMB, assessed by measuring the train-of-four (TOF). METHODS: We retrospectively reviewed procedures under general anesthesia in patients older than 1 year of age if they included sugammadex reversal of rocuronium-induced NMB. Documentation of TOF monitoring before and after reversal was noted, along with the dose of sugammadex administered. TOF was considered correctly documented if the anesthesia provider recorded the number of twitches before and after NMB reversal, or if they recorded 4 twitches before NMB reversal. We defined appropriate sugammadex dosing if it was within 10% of the recommended dose for the depth of NMB. We repeated this review after staff education and creating a reminder in the electronic health record system. RESULTS: We included 100 patients in the preintervention analysis, of whom 30% had correct TOF documentation. Among patients with TOF assessment before sugammadex administration, the dose was appropriate in 34 of 40 cases. In the postintervention analysis, we reviewed 75 cases and found that correct documentation improved to 45% (P = 0.024). Among postintervention cases with TOF documented before sugammadex administration, sugammadex dosing was appropriate in 62 patients. CONCLUSION: Documentation of TOF was low (30%) before intervention and improved to only 45% after the interventions, suggesting that additional interventions are needed. Even before the intervention, with or without TOF documentation, the dose of sugammadex was generally consistent with recommendations.
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PURPOSE: Few data exist on combining pediatric surgical procedures under a single general anesthetic encounter (general anesthesia). We compared perioperative outcomes of combining dental surgical procedures with tonsillectomy during one anesthetic vs separate encounters. METHODS: We classified elective tonsillectomy ± adenoidectomy and restorative dentistry as combined (group C) or separate (group S). Outcomes included anesthesia time, recovery duration, the need for overnight hospital stay, and postoperative complications. RESULTS: Patients aged 4±1 years underwent tonsillectomy and dental surgery in combination (n=7) or separately (n=27). No differences were noted in total anesthesia time (C: median: 150, interquartile range [IQR]: 99, 165 vs S: median: 109, IQR: 92, 132; 95% CI of difference in median: -58, +10 minutes; P=0.115) and total recovery time (C: median: 54, IQR: 40, 108 vs S: median: 72, IQR: 58, 109; 95% CI of difference in median: -16, +48 minutes; P=0.307). The need for overnight stay (C: 4 of 7, S: 20 of 27; P=0.394) did not differ between the groups. No postoperative complications were noted in either group. CONCLUSION: These preliminary data support the potential feasibility of combining dental procedures with tonsillectomy during a single anesthetic encounter. Such care may not only reduce costs but also limit parental work absences and increase convenience for patient families. When compared with procedures performed separately, combined procedures did not result in increased morbidity or significant changes in postoperative outcomes.