Multicenter Population Pharmacokinetics of Fentanyl in Neonatal Surgical Patients Using Dried Blood Spot Specimen Collection Demonstrates Maturation of Elimination Clearance.

BACKGROUND: Fentanyl is widely used for analgesia and sedation in neonates, but pharmacokinetic (PK) analysis in this population has been limited by the relatively large sample volumes required for plasma-based assays. METHODS: In this multicenter observational study of fentanyl kinetics in neonates up to 42 weeks of postmenstrual age (PMA) who received fentanyl boluses and continuous infusions, dried blood spots were used for small-volume sampling. A population PK analysis was used to describe fentanyl disposition in term and preterm neonates. Covariates for the model parameters, including body weight, PMA, birth status (preterm or term), and presence of congenital cardiac disease, were assessed in a stepwise manner. RESULTS: Clearance was estimated to be greater than adult clearance of fentanyl and varied with weight. Covariate selection did not yield a significant relationship for age as a continuous or dichotomous variable (term or preterm, the latter defined as birth with PMA of <37 weeks) and clearance. CONCLUSIONS: A supra-allometric effect on clearance was determined during covariate analyses (exponential scaling factor for body weight >0.75), as has been described in population PK models that account for maturation of intrinsic clearance (here, predominantly hepatic microsomal activity) in addition to scaling for weight, both of which impact clearance in this age group.

Population Pharmacokinetics of Single Bolus Dose Fentanyl in Obese Children.

BACKGROUND: Childhood obesity is a significant problem. Obesity may alter the pharmacokinetics (PKs) of medications. Fentanyl is commonly used for procedural sedation, but there is a paucity of bolus dose fentanyl PK data in obese children. Better understanding of fentanyl PK in obese children would facilitate dosing recommendations. We conducted a study involving children with and without obesity to assess the potential differences in bolus dose fentanyl PK between the 2 groups. METHODS: We enrolled children 2 to 12 years of age with and without obesity, defined as >95th percentile body mass index (BMI) for age and sex, undergoing elective tonsillectomy ± adenoidectomy. After induction, subjects had 2 intravenous (IV) lines placed in 2 different extremities: 1 for medications and IV fluids and 1 for obtaining blood aliquots for fentanyl concentration analysis. After administration of 1 mcg/kg of fentanyl based on total body weight (TBW), blood sample collections for fentanyl concentration analysis were attempted at 5, 15, 30, 60, 90, and 120 minutes. Five-minute fentanyl concentrations were compared between obese and nonobese cohorts. Population PK analysis to examine the differences between obese and nonobese children was performed and included various body size descriptors, such as TBW, BMI, and fat-free mass (FFM), to examine their influence on model parameters. RESULTS: Half of the 30 subjects were obese. Mean fentanyl concentrations at 5 minutes were 0.53 ng/mL for the nonobese group and 0.88 ng/mL for the obese group, difference 0.35 ng/mL (95% CI, 0.08-0.61 ng/mL; P = .01). Population PK analysis showed that FFM was a significant covariate for the central volume of distribution. The potential clinical effect of an IV bolus dose of fentanyl based on TBW versus FFM in an obese child was assessed in a simulation using our model. 1 mcg/kg fentanyl dose based on TBW resulted in an approximately 60% higher peak fentanyl effect site concentration than dosing based on FFM. CONCLUSIONS: Our data demonstrated higher peak plasma fentanyl concentrations in obese compared to nonobese subjects. Population PK analysis found that FFM was a significant covariate for the central volume of distribution. Model simulation showed dosing of fentanyl in obese children based on TBW resulted in significantly higher peak concentrations than dosing based on FFM. Based on this modeling and the known concentration-effect relationship between fentanyl and adverse effects, our results suggest that bolus dosing of fentanyl in obese children should be based on FFM rather than TBW, particularly for procedures of short duration.

Long-term physical and mental health outcomes of pediatric firearm-injured victims: A prospective cohort study.

BACKGROUND: Firearms are a leading cause of injury among US youth. There is little research describing outcomes after pediatric firearm injuries, particularly past 1 year. OBJECTIVE: This study aimed to assess long-term physical and mental health outcomes among nonfatal firearm versus motor vehicle collision (MVC)-injured victims and versus a standard population. METHODS: We retrospectively identified firearm and MVC-injured pediatric patients seen at one of our four trauma centers (January 2008 to October 2020) and prospectively assessed outcomes using validated patient-reported outcome measures. Eligible patients were English speaking, injured ≥5 months before study start, younger than 18 years at time of injury, and 8 years or older at study start. All firearm patients were included; MVC patients were matched 1:1 with firearm patients for Injury Severity Score (dichotomized <15 or ≥15), age range (±1 year), and year of injury. We conducted structured interviews of patients and parents using validated tools (Patient-Reported Outcomes Measurement Information System tools, Children's Impact of Event Scale for younger than 18 years and parent proxies). Patient-Reported Outcomes Measurement Information System scores are reported on a T score metric (mean [SD], 50 [10]); higher scores indicate more of the measured domain. We used paired t tests, Wilcoxon signed-rank tests, and McNemar's test to compare demographics, clinical characteristics, and outcomes. RESULTS: There were 24 participants in each of the MVC and firearm-injured groups. Compared with MVC-injured patients, firearm-injured patients younger than 18 years had similar scores, and firearm-injured patients 18 years or older had higher anxiety scores (59.4 [8.3] vs. 51.2 [9.4]). Compared with a standard population, patients younger than 18 years had worse global health scores (mean [SD], 43.4 [9.7]), and participants 18 years or older reported increased fatigue (mean [SD], 61.1 [3.3]) and anxiety (mean [SD], 59.4 [8.3]). CONCLUSION: Long-term effects of firearm-injured patients were poorer than matched MVC and the standard population in few domains. Further study in a larger, prospectively recruited cohort is warranted to better characterize physical and mental health outcomes.

Paid Family Caregiving for Children With Medical Complexity.

OBJECTIVES: We evaluated Colorado's paid family caregiver certified nursing assistant (CNA) program by assessing stakeholders' perceptions of the model's strengths and potential areas for improvement. METHODS: A professional bilingual research assistant conducted key informant interviews of English- and Spanish-speaking certified nursing assistant (CNA) family caregivers (FCs), primary care providers, and pediatric home health administrators of children with medical complexity in the family caregiver CNA program. Interview questions focused on the program's benefits, drawbacks, and implications for the child and caregiver's quality of life. Transcripts were coded and analyzed, and themes summarizing program benefits and disadvantages were identified. RESULTS: Semistructured interviews were completed by phone with 25 FCs, 10 home health administrators, and 10 primary care providers between September 2020 and June 2021. Overall, the program was highly valued and uniformly recommended for prospective families. Perceived benefits included: (1) fulfilling the desire to be a good parent, (2) providing stable and high-quality home health care, (3) benefitting the child's health and wellbeing, and (4) enhancing family financial stability. Perceived drawbacks included: (1) FCs experiencing mental and physical health burdens, (2) difficult access for some community members, (3) extraneous training requirements, and (4) low program visibility. CONCLUSIONS: Given the perceived benefits of the family CNA program, the model may be considered for future dissemination to other communities. However, additional research and program improvements are needed to help make this a more equitable and sustainable home health care model for children with medical complexity.

Anesthesia for Maternal-Fetal Interventions: A Survey of Fetal Therapy Centers in the North American Fetal Therapy Network.

INTRODUCTION: A wide range of fetal interventions are performed across fetal therapy centers (FTCs). We hypothesized that there is significant variability in anesthesia staffing and anesthetic techniques. METHODS: We conducted an online survey of anesthesiology directors at every FTC within the North American Fetal Therapy Network (NAFTNet). The survey included details of fetal interventions performed in 2018, anesthesia staffing models, anesthetic techniques, fetal monitoring, and postoperative management. RESULTS: There was a 92% response rate. Most FTCs are located within an adult hospital and employ a small team of anesthesiologists. There is heterogeneity when evaluating anesthesiology fellowship training and staffing, indicating there is a multidisciplinary specialty team-based approach even within anesthesiology. Minimally invasive fetal interventions were the most commonly performed. The majority of FTCs also performed ex utero intrapartum treatment (EXIT) and open mid-gestation procedures under general anesthesia (GA). Compared to FTCs only performing minimally invasive procedures, FTCs performing open fetal procedures were more likely to have a pediatric surgeon as director and performed more minimally invasive procedures. CONCLUSIONS: There is considerable variability in anesthesia staffing, caseload, and anesthetic techniques among FTCs in NAFTNet. Most FTCs used maternal sedation for minimally invasive procedures and GA for EXIT and open fetal surgeries.

Addressing Perinatal Mental Health Risk within a Fetal Care Center.

Diagnosis of a fetal anomaly in pregnancy increases the risk for perinatal mental health difficulties, including anxiety, depression, and traumatic stress among expectant parents. Common emotional challenges include uncertainty about the diagnosis/prognosis, anticipated neonatal course, fears of fetal or neonatal demise, loss of a typical, uncomplicated pregnancy and postpartum course, and disruption of family roles due to medical care-related activities and restrictions. Psychologists in multidisciplinary fetal care centers are uniquely positioned to assess mental health risks and address the needs of expectant parents. Psychologists bring additional expertise in screening and assessment, clinical interventions to promote coping and symptom reduction while preparing for birth and a complicated neonatal course, consultation and effective communication, and programmatic development. This review paper provides an overview of the challenges and behavioral health risks for expectant parents carrying a fetus with a birth defect and the unique role psychologists play to support patients and families within fetal care settings.

A comprehensive examination of the immediate recovery of children following tonsillectomy and adenoidectomy.

OBJECTIVES: Using multiple well-validated measures and a large sample size, the goal of this paper was to describe the immediate clinical and behavioral recovery of children following tonsillectomy with or without an adenoidectomy (T&A) during the first two weeks following surgery. STUDY DESIGN: Observational, longitudinal study. SETTING: Four major pediatric hospitals in the U.S. consisting of Children's Hospital of Orange County, Children's Hospital of Los Angeles, Lucile Packard Children's Hospital, and Children's Hospital Colorado. SUBJECTS: and Methods: Participants included 827 patients between 2 and 15 years of age who underwent tonsillectomy with or without adenoidectomy surgery. Baseline and demographic information were gathered prior to surgery, and measures of clinical, behavioral, and physical recovery were recorded immediately following and up through two weeks after surgery. RESULTS: Pain following T&A was clinically significant through the first post-operative week and nearly resolved by the end of the second week. Negative behavioral changes were highly prevalent after surgery (75.6% of children at Day 0) through the first week (63.9% at Week 1), and over 20% of children continued to evidence new onset negative behavioral changes at two weeks post-operatively. Children were rated as experiencing significant functional impairment in the immediate three days following surgery and most children returned to baseline functioning by the end of the second week. CONCLUSIONS: Results of this study suggest that children show immediate impairment in functioning and experience clinically significant pain throughout the first week following T&A, and new onset maladaptive behavioral changes persisting even up to the two-week assessment period.

Pain Management for Pediatric Burns in the Outpatient Setting: A Changing Paradigm?

Childhood burns are common and distressing for children and their parents. Pain is the most common complaint and often thought to be undertreated, which can negatively influence the child's care and increase the risk of posttraumatic stress disorder. There is limited literature on the role of opioids and multimodal therapy in the treatment of pediatric outpatient burns. We sought to evaluate the current use of opioids (including the use of multimodal therapies), storage, and disposal of opioids in this patient population. Parents of burn-injured children 8 months to 18 years old, who were seen in an outpatient setting within 2 weeks of their burn injury, were queried from April to December 2019 regarding their child's pain control, opioid medication use, over-the-counter pain medication use, opioid storage, and disposal. A total of 142 parents of burn-injured children and their parents were surveyed. The median age of the burn-injured children was 2.7 years old and the majority (54.2%; 77/142) were male. The mean total body surface area (TBSA) was 1.8% and half sustained burn injuries to one or both hands. The most frequently used regimens for constant and/or breakthrough pain control were acetaminophen (62.7%) and nonsteroidal anti-inflammatory drugs (NSAIDs; 68.3%). Less than one fifth (26/142;18%) of patients were prescribed opioids and 88% filled their prescription. The median number of doses of opioids prescribed was eight doses, with a median of four doses of opioids unused. Only three patients used all of their prescribed opioids and no patient ≥12 years old used their entire prescription. Burns greater than 3% TBSA, irrespective of burn injury location, were associated with opioid prescription (P = .003). Approximately 40% (10/26) of parents who filled their child's opioid prescription stored the opioid in a locked area. Fewer than one third (7/26) of patients were educated on how to dispose of excess opioid pain medication. Overall, most pediatric outpatient burn injuries can be successfully managed with over-the-counter medications. Providers, who care for burn-injured children ≤ 12 years old with burns that cover ≥3% TBSA in the outpatient setting, should consider no more than four opioid doses for initial pain control. This guideline, coupled with family and provider-centered education on multimodal therapy at the time of initial presentation and safe use of opioids, are important first steps to minimizing the use of opioids in the management of small area burns in children.

Evaluation of a Formal Wellness Curriculum to Reduce Burnout in Anesthesia Residents: A Pilot Study.

BACKGROUND: Long-term exhaustion and chronic occupational stress often result in physician burnout, which can have adverse consequences for patients, physicians, their families, and society. We hypothesized that increased engagement with a wellness curriculum would reduce the level of burnout, as measured by the Maslach Burnout Inventory Human Services Survey (MBI-HSS). METHODS: We created a yearlong multifaceted pilot wellness curriculum for anesthesia residents at our institution. All residents could experience the wellness curriculum regardless of enrollment in the study. Residents completed the MBI-HSS three times during the year and indicated the number of wellness events attended via web survey. We assessed the influence of different curriculum components and time on the trajectory of three MBI-HSS subscales: emotional exhaustion, depersonalization, and personal accomplishment. RESULTS: Thirty-nine of 43 residents consented to participate in the study and completed at least one survey. Residents showed high levels of emotional exhaustion (mean 29.6; SD 11.14), depersonalization (12.8; 4.49), and personal accomplishment (45.0; 6.50) at baseline. Only personal accomplishment showed a significant increase over time (P < .036). Off-campus, wellness group sessions significantly decreased depersonalization (P = .001) and showed no difference in emotional exhaustion (P = .090). However, didactic workshops and wellness-related grand rounds failed to improve our measure of physician burnout, underscoring the need for alternative interventions to reduce this problem. CONCLUSIONS: A formal wellness curriculum that used classic didactic teaching methods was ineffective at decreasing resident burnout scores. Only wellness group meetings significantly reduced burnout measures. Our findings have important implications for planning future resident wellness interventions.

Children and their parents' assessment of postoperative surgical pain: Agree or disagree?

OBJECTIVE: The purpose of this study is to compare postoperative pain scores between children undergoing tonsillectomy and adenoidectomy (T&A) surgery and their parents, identify potential predictors for this disagreement, and determine possible impact on analgesic administration. METHODS: This is a prospective longitudinal study conducted with children undergoing outpatient T&A in 4 major tertiary hospitals and their parents. Children and their parents were enrolled prior to surgery and completed baseline psychological instruments assessing parental anxiety (STAI), parental coping style (MBSS), child temperament (EAS) and parental medication administration attitude questionnaire (MAQ). Postoperatively, parents and children completed at-home pain severity ratings (Faces Pain Scale-Revised, children; Numeric Rating Scale, parents) on postoperative recovery days 1, 2, and 3, reflecting an overall pain level for the past 24 h. Parents also completed a log of analgesic administration. Based on postoperative pain scores, parent-child dyads were classified as overestimators (i.e., parents rated their child's pain higher than children rated their own pain), in agreement (i.e., rating in agreement), or underestimators (i.e., parents rated their child's pain lower than children rated their own pain). RESULTS: A significant proportion of parent-child pairs disagreed on pain ratings on postoperative days 1-3 (30.05%-35.95%). Of those pairs in disagreement, the majority of parents overestimated their child's pain on all three postoperative days, specifically such that a total of 24-26% parents overestimated their child's pain on postoperative days 1, 2, and 3. Repeated measures ANOVA demonstrated that parents in the overestimator group administered higher, though still within safe limits, amounts of ibuprofen and oxycodone (mg/day) than did the underestimator or agreement groups. Multiple regression models showed hospital site as the only independent predictor for postoperative pain rating disagreement between children and parents. CONCLUSIONS: Since parents overestimate their child's postoperative pain and may administer more analgesics to their child, it is essential to develop a standardized method of child pain assessment and a tailored recommended postoperative analgesic regimen amongst medical providers for children undergoing T&A.

Indomethacin Dosing and Constriction of the Ductus Arteriosus During Open Fetal Surgery for Myelomeningocele Repair.

INTRODUCTION: The use of perioperative tocolytic agents in fetal surgery is imperative to prevent preterm labor. Indomethacin, a well-known tocolytic agent, can cause ductus arteriosus (DA) constriction. We sought to determine whether a relationship exists between preoperative indomethacin dosing and fetal DA constriction. MATERIALS AND METHODS: This is an IRB-approved, single-center retrospective observational case series of 42 pregnant mothers who underwent open fetal myelomeningocele repair. Preoperatively, mothers received either 1 (QD) or 2 (BID) indomethacin doses. Maternal anesthetic drug exposures and fetal cardiac dysfunction measures were collected from surgical and anesthesia records and intraoperative fetal echocardiography. Pulsatility Index was used to calculate DA constriction severity. Comparative testing between groups was performed using t- and chi-square testing. RESULTS: DA constriction was observed in all fetuses receiving BID indomethacin and in 71.4% of those receiving QD dosing (p = 0.0002). Severe DA constriction was observed only in the BID group (35.7%). QD indomethacin group received more intraoperative magnesium sulfate (p < 0.0001). Minimal fetal cardiac dysfunction (9.5%) and bradycardia (9.5%) were observed in all groups independent of indomethacin dosing. CONCLUSIONS: DA constriction was the most frequent and severe in the BID indomethacin group. QD indomethacin and greater magnesium sulfate dosing was associated with reduced DA constriction.

Continuous local bupivacaine wound infusion with neuraxial morphine reduces opioid consumption after cesarean delivery.

Background: As a part of a quality improvement program, maternal postoperative opioid use and pain scores were compared between those receiving continuous infusion of bupivacaine for local incisional pain control with multimodal pain management and neuraxial morphine versus multimodal pain management with neuraxial morphine alone. Objective: We compared postoperative opioid use and pain scores between the multimodal pain management group with neuraxial morphine and the group receiving multimodal pain management, neuraxial morphine, and continuous infusion of bupivacaine for local incisional pain control. Study design: A retrospective cohort analysis of cesarean deliveries from January of 2015 through March of 2016 was undertaken. Deliveries were grouped by utilization of continuous infusion of bupivacaine for local incisional pain control. For each postoperative day, the average daily opioid use, antiemetic use and pain scores were determined. Patients received 1-2 tablets oxycodone-acetaminophen (5-325 mg) every 4 h as needed with oxycodone 5-10 mg immediate release tablets every 4 h as needed for breakthrough pain in addition to acetaminophen and ibuprofen. Total dose of narcotic, antiemetic use, and pain scores was compared between groups utilizing t-test for continuous variables and chi square for categorical data. A linear mixed model with unstructured covariance was utilized to analyze the daily dose of narcotic and pain scores from postoperative day 1 through day 4. Results: Patients in the standard multimodal group with neuraxial morphine used more opioids versus those receiving continuous wound infusion of bupivacaine in total postoperative dosing (122.79 ± 61.92 mg versus 89.88 ± 51.38 mg, p = .0063). There was a statistically significant difference between the standard group and local infusion of bupivacaine group on postoperative days 1 and 2 (32.79 ± 15.56 mg versus 22.13 ± 15.73 mg, p = .0011 and 40.25 ± 19.84 mg versus 29.13 ± 14.58 mg, p = .0018, respectively). There was no difference in narcotic use for postoperative days 3 and 4. There was a higher mean number of antiemetic doses in the standard group (0.31 ± 0.70 versus 0.10 ± 0.30, p = .0396). Pain scores did not differ between groups, although there was a correlation between opioid dosing and pain scores. The standard group received more IV ketorolac (87.72 ± 42.01 mg versus 64.50 ± 53.3 mg, p = .0165) and more IV acetaminophen (634.89 ± 706.42 mg versus 375.0 ± 490.29 mg, p = .0315) within the first 24 h postoperatively. In addition, the standard group received more oral acetaminophen (6969.67 ± 3230.14 mg versus 5248.75 ± 2711.71 mg, p = .0064). No difference was seen in regard to ibuprofen between groups. These results remained constant when adjusted for differences in gestational age, variation in intraoperative opioid dosing, as well as differences in uterine incision type. Conclusion: We found a significant reduction in postoperative opioid use when continuous infusion of bupivacaine for local incisional pain control was added to our standard pain management with neuraxial morphine after cesarean delivery. As a result of this quality improvement initiative, we have implemented this intervention universally as a part of our multimodal postoperative pain management strategy.

Parental satisfaction of child's perioperative care.

BACKGROUND: Satisfaction in the hospital setting is an important component of both hospital funding and patient experience. When it comes to a child's hospital experience, parent satisfaction of their child's perioperative care is also necessary to understand. However, little research has been conducted on the predictors of this outcome. Therefore, the purpose of this current study was to validate a priori selected predictors for parental satisfaction in their child's perioperative process. METHODS: Eight hundred and ten pediatric patients who underwent tonsillectomy and adenoidectomy surgery and their parents were included in this study. The primary outcome was assessed using a 21-item parent satisfaction questionnaire resulting in three satisfaction scores: overall care satisfaction, OR/induction satisfaction, and total satisfaction. RESULTS: Descriptive statistics and correlational analysis found that sedative-premedication, parental presence at anesthesia induction, child social functioning, parental anxiety, and language were all significant predictors of various components of the satisfaction score. Regression models, however, revealed that only parent anxiety and child social functioning remained significant predictors such that parents who reported lower state anxiety (OR/induction satisfaction: OR = 0.975, 95% CI [0.957, 0.994]; total satisfaction: OR = 0.968, 95% CI [0.943, 0.993]) and who had higher socially functioning children (overall care satisfaction: OR = 1.019, 95% CI [1.005, 1.033]; OR/induction satisfaction: OR = 1.011, 95% CI [1.000, 1.022]) were significantly more satisfied with the perioperative care they received. CONCLUSION: Lower parent anxiety and higher child social functioning were predictive of higher parental satisfaction scores.

An evaluation of preoperative anxiety in Spanish-speaking and Latino children in the United States.

BACKGROUND: There is a large body of literature examining factors associated with children's preoperative anxiety; however, cultural variables such as ethnicity and language have not been included. AIMS: The purpose of this investigation was to examine the role of Latino ethnicity and Spanish-speaking families in pediatric preoperative anxiety. METHODS: Participants were 294 children aged 2-15 years of age undergoing outpatient, elective tonsillectomy and/or adenoidectomy surgery and general anesthesia. Participants were recruited and categorized into 3 groups: English-speaking non-Latino White (n = 139), English-speaking Latino (n = 88), and Spanish-speaking Latino (n = 67). Children's anxiety was rated at 2 time points before surgery: the time the child entered the threshold of the operating room (Induction 1) and the time when the anesthesia mask was placed (Induction 2). RESULTS: Results from separate linear regression models at Induction 1 and Induction 2, respectively, showed that being from a Spanish-speaking Latino family was associated with higher levels of preoperative anxiety compared with being from an English-speaking family. In addition, young age and low sociability was associated with higher preoperative anxiety in children. CONCLUSION: Clinicians should be aware that younger, less sociable children of Spanish-speaking Latino parents are at higher risk of developing preoperative anxiety and manage these children based on this increased risk.

Morphine Pharmacokinetics in Children With Down Syndrome Following Cardiac Surgery.

OBJECTIVES: To assess if morphine pharmacokinetics are different in children with Down syndrome when compared with children without Down syndrome. DESIGN: Prospective single-center study including subjects with Down syndrome undergoing cardiac surgery (neonate to 18 yr old) matched by age and cardiac lesion with non-Down syndrome controls. Subjects were placed on a postoperative morphine infusion that was adjusted as clinically necessary, and blood was sampled to measure morphine and its metabolites concentrations. Morphine bolus dosing was used as needed, and total dose was tracked. Infusions were continued for 24 hours or until patients were extubated, whichever came first. Postinfusion, blood samples were continued for 24 hours for further evaluation of kinetics. If patients continued to require opioid, a nonmorphine alternative was used. Morphine concentrations were determined using a unique validated liquid chromatography tandem-mass spectrometry assay using dried blood spotting as opposed to large whole blood samples. Morphine concentration versus time data was modeled using population pharmacokinetics. SETTING: A 16-bed cardiac ICU at an university-affiliated hospital. PATIENTS: Forty-two patients (20 Down syndrome, 22 controls) were enrolled. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The pharmacokinetics of morphine in pediatric patients with and without Down syndrome following cardiac surgery were analyzed. No significant difference was found in the patient characteristics or variables assessed including morphine total dose or time on infusion. Time mechanically ventilated was longer in children with Down syndrome, and regarding morphine pharmacokinetics, the covariates analyzed were age, weight, presence of Down syndrome, and gender. Only age was found to be significant. CONCLUSIONS: This study did not detect a significant difference in morphine pharmacokinetics between Down syndrome and non-Down syndrome children with congenital heart disease.

Intrathecal Morphine Versus Extended-Release Epidural Morphine for Postoperative Pain Control in Pediatric Patients Undergoing Posterior Spinal Fusion.

BACKGROUND: Posterior spinal fusion for scoliosis is one of the most painful elective pediatric surgeries. Good postoperative pain control allows early ambulation and return of ability to tolerate oral intake. Options for analgesia in this patient population are suboptimal. We hypothesized that extended-release epidural morphine (EREM) would provide better pain control and less adverse effects compared to intrathecal (IT) morphine. METHODS: The primary outcome was total IV morphine consumption during 0-48 hours postoperatively. Secondary outcomes included time until first patient-controlled analgesia (PCA) demand, pain scores, and adverse opioid effects. After institutional review board approval, 71 subjects undergoing posterior spinal fusion for idiopathic scoliosis completed the study. The subjects were randomly allocated to 7.5 µg/kg IT morphine or 150 µg/kg EREM. The final IT morphine and EREM groups contained 37 and 34 subjects, respectively. Postoperative pain was treated with morphine PCA, ketorolac, oral oxycodone, and acetaminophen. Morphine consumption, pain scores, nausea and vomiting, pruritus, and respiratory depression were measured every 4 hours. Parents completed a caregiver questionnaire about their child's pain control regimen after the first postoperative day. RESULTS: There was no difference in total morphine consumption over the first 48 hours between subjects in the EREM and IT morphine groups: median (range) 42.2 (5.5-123.0) and 34.0 (4.5-128.8) mg, respectively (P = .27). EREM and IT morphine groups had no difference in time until first PCA demand. Pain scores were no different between the groups from 8 to 24 hours after surgery. Compared to IT morphine, EREM subjects had lower pain scores from 28 to 36 hours after surgery. The reported incidence of pruritus was lower in the EREM subjects. CONCLUSIONS: There was no difference in total morphine consumption or time until first PCA demand between the EREM and IT morphine groups. EREM provides a longer duration of analgesia after posterior spinal fusion for scoliosis and may be associated with less opioid-induced pruritus.

The Role of Ethnicity and Acculturation in Preoperative Distress in Parents of Children Undergoing Surgery.

This study examined the effects of acculturation on anxiety and stress in Latino and non-Latino white parents of children undergoing outpatient surgery. Participants included 686 parent-child dyads from four major children's hospitals in the United States. Latino parents who grew up in the U.S. reported higher levels of anxiety (p = 0.009) and stress (p < 0.001) compared to parents who grew up in a Latin American country. Additionally, English-speaking Latino parents reported higher anxiety and stress compared to both Spanish-speaking Latino and non-Latino white parents (p's < 0.05), whereas Spanish-speaking Latino and non-Latino white parents reported similar levels of stress and anxiety. Results of the current study were consistent with the immigrant health paradox in that more acculturated Latino parents reported higher levels of anxiety and stress than less acculturated Latino and non-Latino white parents, supporting the need for culturally tailored interventions in the perioperative environment.

First steps in validating the pediatric anesthesia parent satisfaction (PAPS) survey.

BACKGROUND: In the last few decades, patient satisfaction has become a critical component of quality assessment and is being incorporated into payment for performance plans. However, assessment of satisfaction with anesthesia services is problematic and few validated satisfaction tools have been published. Assessing parent satisfaction with pediatric anesthesia services is even more challenging. OBJECTIVE: Our aim was to develop, implement, and start validating a set of survey questions that evaluate parental satisfaction with the pediatric anesthesia services in order to identify strengths and potential areas for improvement. METHODS: The Pediatric Anesthesia Parent Satisfaction (PAPS) survey contained 17 questions adapted from the American Society of Anesthesiologists Committee on Outcomes and Performance Measures. With consent of the hospital quality improvement committee, the PAPS survey was randomly administered on iPads to 250 English-speaking parents in the main operating room and procedure center postanesthesia care units prior to discharge. Statistical analyses including descriptive statistics, exploratory factor analysis, Cronbach's alpha and Raykov's rho coefficients, composite scale creation, correlations between items, composite scores, and overall satisfaction measures were used to provide evidence for a subset of validity and reliability types. RESULTS AND CONCLUSIONS: The PAPS survey is a short and simple tool for evaluation of parent satisfaction with pediatric anesthesia services and provides some evidence for validity and reliability. The majority (greater than 95%) of parents reported were satisfied or very satisfied with the care provided by the pediatric anesthesia department.