Pediatric Medication Errors and Reduction Strategies in the Perioperative Period.

Anesthesia providers are regularly responsible for assessing, diagnosing, and determining pharmacologic treatment of a problem. This critical workflow often includes medication preparation. Decision making in anesthesia frequently requires rapid intervention, and caring for the pediatric population poses additional challenges, such as needing to quickly calculate the weight-based dosing of medications. The objective of this review article was to identify and describe themes related to pediatric medication errors associated with anesthesia. Additional goals of the review consisted of identifying and comparing various error reduction strategies with a primary goal of communicating the most effective methods to reduce medication errors in the pediatric population. Screening criteria were set, and 17 published scholarly articles meeting inclusion criteria were evaluated using a systematic process. Common themes found leading to medication errors were incorrect dosing, incorrect medication, syringe swap, wrong patient, and wrong dosing interval. The most valuable and sustainable error reduction strategies found were standardized labeling, prefilled syringes, and 2-person medication checks. It is believed that this review will expound on the factors that can be controlled or minimized to decrease the incidence of anesthesia-related pediatric medication errors and facilitate implementation of risk mitigation strategies immediately into clinical practice.

Novel 3D printed integral customized acetabular prosthesis for anatomical rotation center restoration in hip arthroplasty for developmental dysplasia of the hip crowe type III: A Case Report.

RATIONALE: Exact restoration of the rotation center in total hip arthroplasty (THA) is technically challenging in patients with end-stage osteoarthritis due to developmental dysplasia of the hip (DDH), especially in the Crowe type II and III procedures. The technical difficulty is attributable to the complex acetabular changes. In this study, a novel 3-dimensional (3D) printed integral customized acetabular prosthesis for anatomical rotation restoration in THA for DDH Crowe type III was developed using patient-specific Computer-aided design and additive manufacturing (AM) methods. PATIENT CONCERNS: A 69-year-old female patient had developed left hip joint pain and restricted movement for 40 years; the symptoms had increased in the past 5 months. Pain, limited motion of the left hip joint, and lower limb length discrepancy were noted during physical examination. DIAGNOSIS: The patient was diagnosed with left hip end-stage osteoarthritis secondary to DDH (Crowe type III). INTERVENTION: A 3D printed acetabulum model was manufactured and a simulated operation was performed to improve the accuracy of reconstruction of the rotation center and bone defect. A 3D printed titanium alloy integral customized acetabular prosthesis was designed according to the result of simulated operation. The integral customized prothesis was implanted subsequently via the posterolateral approach. Radiography of the pelvis and Harris score assessment were performed during the perioperative period as well as at the 6- and 12-month follow-up. OUTCOMES: The 3D printed integral customized acetabular prosthesis matched precisely with the reamed acetabulum. The rotation center was restored and the bone defect was exactly reconstructed. There were no signs of prosthetic loosening at the 12-month follow-up. The Harris score gradually improved during the follow-up period. LESSONS: Satisfactory results of hip rotation restoration and bone defect reconstruction could be achieved by using 3D printed integral customized acetabular prosthesis, which provides a promising way to reconstruct the acetabulum in patients with DDH anatomically and rapidly for THA.

Recomendaciones para la ejecución de anestesia regional no obstétrica en perioperatorio de pacientes COVID-19 / Recommendations for the execution of non-obstetric regional anesthesia in treatment of COVID-19 patients

En diciembre de 2019, surgió una serie de casos de neumonía causada por un nuevo coronavirus, denominado 2019-nCoV o SARS-CoV2. La propagación del virus ha sido extremadamente rápida y la organización mundial de la salud declaró a la enfermedad COVID-19, causada por 2019-nCoV, como una pandemia. En este contexto la Sociedad de Anestesiología de Chile (SACH) ha elaborado recomendaciones generales para el manejo perioperatorio de los pacientes sospechosos y/o portadores de la enfermedad. Sin embargo, dado que durante el levantamiento de evidencia para la confección de dicha guía se objetivó la ausencia de sugerencias específicas para la ejecución de técnicas de anestesia regional fuera del ambiente obstétrico, se solicitó desde el Comité Científico de SACH al Comité de Anestesia Regional de SACH (CARSACH), representante LASRA (LatinAmerican Society of Regional Anesthesia) en Chile, a través de un grupo de expertos, confeccionar recomendaciones locales en esta materia.

Rehabilitación multimodal en cirugía bariátrica / Enhanced recovery after bariatric surgery

Los protocolos de rehabilitación multimodal o recuperación intensificada (PRI) son programas de cuidado del paciente basados en la evidencia científica y orientados a mejorar su recuperación postoperatoria. Abarcan todos los aspectos implicados en el cuidado del paciente y requieren un manejo multidisciplinar, en el que intervienen varios especialistas. La aplicación de estos protocolos se está extendiendo ampliamente por diferentes tipos de cirugías abdominales y extraabdominales, incluyendo la cirugía bariátrica. Facultativos de diferentes especialidades, con experiencia en el tratamiento de pacientes obesos mórbidos, han formado parte del grupo de trabajo que desarrolló este protocolo. Para evaluar la evidencia científica actualizada, se realizó una búsqueda bibliográfica sobre PRI en cirugía bariátrica en diferentes bases de datos, estableciendo los niveles de calidad de evidencia y el grado de recomendación según la metodología GRADE. Se agruparon las actuaciones incluidas en la matriz temporal en 3 etapas: preoperatorio, perioperatorio y postoperatorio

Enhanced recovery after surgery (ERAS) protocols are care programs based on scientific evidence and focused on postoperative recovery. They encompass all aspects of patient care and require multidisciplinary management, with the participation of diverse specialists. The implementation of these protocols is being extended to several abdominal and extra-abdominal surgeries, including bariatric approaches. Diverse specialists with wide experience in the management of morbidly obese patients have taken part in the working group that developed this protocol. A bibliographic search about ERAS in bariatric surgery in several databases was performed to evaluate the current scientific evidence, establishing evidence levels and recommendations according to the GRADE methodology. The items included in this protocol are separated into preoperative, perioperative and postoperative guidelines

A Change in Focus: Shifting From Treatment to Prevention of Perioperative Pressure Injuries.

Hospital-acquired pressure injuries are a patient safety concern and can be costly for health care organizations. A multidisciplinary team of senior leaders, managers, nurses, and educators from departments that care for perioperative patients created an evidence-based perioperative pressure injury prevention bundle that includes skin and risk assessments, visual and electronic health record cues, prophylactic protection of at-risk skin, communication among providers and leaders regarding patient risk and injury throughout hospitalization, staff member education, compliance audits, root cause analyses, and wound care team follow-up. The prevention bundle resulted in a 50% reduction in perioperative pressure injuries the first calendar year after implementation and a zero-incidence rate for perioperative pressure injuries for at least a two-year period. This article discusses hospital-acquired pressure injuries related to the perioperative setting and outlines the full perioperative pressure injury prevention bundle.

Thermal Suit or Forced Air Warming in Prevention of Perioperative Hypothermia: A Randomized Controlled Trial.

PURPOSE: To prevent perioperative hypothermia, forced air warming blanket was compared with a passive insulation suit. DESIGN: Prospective, open, randomized controlled trial. METHODS: Thirty patients were scheduled for orthopedic spinal surgery. The intervention group (group TS) received the thermal suit T-Balance before premedication and throughout the perioperative period, whereas the control group (group C) received forced air warming (FAW) during surgery. FINDINGS: No statistically significant difference (ns) was found between the groups for core temperature 30 minutes after induction of general anesthesia. Perioperative hypothermia occurred in 10 (66.7%) patients in group TS and 6 (40%) in group C (ns). For hypothermic patients, re-establishment of normothermia took significantly longer in group TS, mean 108 ± 111 minutes, than in group C, 33 ± 59.5 minutes (P = .03). CONCLUSIONS: The thermal suit did not prevent hypothermia in this study. FAW was significantly more efficient in re-establishing normothermia.

Enhanced recovery after bariatric surgery. / Rehabilitación multimodal en cirugía bariátrica.

Enhanced recovery after surgery (ERAS) protocols are care programs based on scientific evidence and focused on postoperative recovery. They encompass all aspects of patient care and require multidisciplinary management, with the participation of diverse specialists. The implementation of these protocols is being extended to several abdominal and extra-abdominal surgeries, including bariatric approaches. Diverse specialists with wide experience in the management of morbidly obese patients have taken part in the working group that developed this protocol. A bibliographic search about ERAS in bariatric surgery in several databases was performed to evaluate the current scientific evidence, establishing evidence levels and recommendations according to the GRADE methodology. The items included in this protocol are separated into preoperative, perioperative and postoperative guidelines.

Inadvertent Perioperative Hypothermia Risks and Postoperative Complications: A Retrospective Study.

Inadvertent perioperative hypothermia is a widely known patient condition that is associated with postoperative complications. This retrospective comparative study of 298 surgical patients was conducted at a single hospital site in the midwestern United States. Our aims were to describe risk factors and outcomes associated with perioperative hypothermia. We compared the type and frequency of patient factors, clinical factors, and postoperative complications during the inpatient stay of the sample patients to determine whether there were factors or complications associated with perioperative hypothermia. Significant factors associated with the occurrence of perioperative hypothermia included older age and type of surgery. Hypothermia in patients was associated with a higher rate of postoperative complications when compared with normothermic patients. Nurses and perioperative leaders should understand the risk factors and complications associated with perioperative hypothermia to collaboratively develop and test evidence-based initiatives, improve care, and promote optimal patient outcomes.

The Society for Pediatric Anesthesia recommendations for the use of opioids in children during the perioperative period.

Opioids have long held a prominent role in the management of perioperative pain in adults and children. Published reports concerning the appropriate, and inappropriate, use of these medications in pediatric patients have appeared in various publications over the last 50 years. For this document, the Society for Pediatric Anesthesia appointed a taskforce to evaluate the available literature and formulate recommendations with respect to the most salient aspects of perioperative opioid administration in children. The recommendations are graded based on the strength of the available evidence, with consensus of the experts applied for those issues where evidence is not available. The goal of the recommendations was to address the most important issues concerning opioid administration to children after surgery, including appropriate assessment of pain, monitoring of patients on opioid therapy, opioid dosing considerations, side effects of opioid treatment, strategies for opioid delivery, and assessment of analgesic efficacy. Regular updates are planned with a re-release of guidelines every 2 years.

Fast-track surgery for acute appendicitis in children: a systematic review of protocol-based care.

BACKGROUND: 'Fast-track' surgery protocols aim to standardize and rationalize post-operative care, with evidence of safety and efficacy in both uncomplicated and complicated childhood appendicitis. Generalization for broader adoption has been limited by variation in protocol design, including specific antibiotic choice, discharge criteria, post-operative monitoring and patient selection. METHODS: A systematic review of the literature was performed to evaluate the current evidence underpinning fast-track protocols for childhood appendicitis and identify areas of consensus and controversy. RESULTS: About 33 studies met the inclusion criteria, including four prospective observational studies, 20 case-control studies, seven cohort studies and two randomized controlled trials studying uncomplicated (n = 9), complicated (n = 18) and mixed cohorts (n = 6). Reduction in length of hospital stay was almost universally reported, with equivalent or improved complication rates. Key themes of protocols included antibiotic choice and duration, discharge criteria and post-operative laboratory and radiographic testing. Rationalized analgesia is an underexplored aspect of protocol design, and a standardized definition of complicated appendicitis remains elusive. CONCLUSION: Standardized care of childhood appendicitis has been shown to be safe and effective in several local and international centres. Next steps include investigation of a complicated appendicitis protocol that integrates rationalized analgesia in appendicectomy recovery, and development of a consistent classification scheme for complicated disease to aid in identification of amenable cohorts.

Evaluation of Warming Effectiveness on Physiological Indices of Patients Undergoing Laparoscopic Cholecystectomy Surgery: A Randomized Controlled Clinical Trial.

PURPOSE: The present study aimed to evaluate the impact of warming on physiological indices of patients undergoing laparoscopic cholecystectomy. DESIGN: The study was a three-group randomized controlled clinical trial. METHODS: In the present study, 96 patients were assigned to three groups: forced-air warming system group; warmed intravenous fluid group; and control group. The intervention was performed immediately after the anesthesia induction. Physiological indices (core body temperature, blood pressure, and heart rate) were evaluated at 15-minute intervals, and postoperative shivering was also recorded. FINDINGS: The mean systolic blood pressure and the mean heart rate were significantly different in each warming group before, during, and after surgery, but the three groups had no significant differences in terms of physiological indices at any time (P > .05). Postoperative shivering was not seen in any group. CONCLUSIONS: Both interventions had similar effects on physiological indices. Therefore, the recommendation is to use the warming method according to patient's other conditions.

STAGES AND FACTORS OF THE "PERIOPERATIVE PROCESS": POINTS IN COMMON WITH THE AERONAUTICAL INDUSTRY.

BACKGROUND: The aeronautical industry is one of the disciplines that most use control systems. Its purpose is to avoid accidents and return safer flights. The flight of an airplane, from its takeoff to its landing is a process divided into stages under strict control. A surgical procedure has the same characteristics. We try to identify and develop the stages of the surgical process using the experience of the aviation industry in order to optimize the results and reduce surgical complications. AIM: To identify and develop the stages of the surgical process so that they could be applied to surgery departments. METHODS: A search, review and bibliographic analysis of the application of aeronautical control and safety to medical practice in general and to surgery, in particular, were carried out. RESULTS: Surgical process comprises the perioperative period. It is composed of Preoperative Stage (it is divided into 2 "sub-steps": hospital admission and control of preoperative studies) Operative Stage (it is divided into 3 "sub-steps": anesthetic induction, surgery, and anesthetic recovery) and Postoperative Stage (it is divided into 2 "sub-steps": control during hospitalization and ambulatory control). Two checkpoints must be developed. Checkpoint #1 would be located between the preoperative and operative stages, and checkpoint #2 would be located between the operative and postoperative stages. Surgical factors are surgeons, instrumental and technology, anesthesiology and operating room environment. CONCLUSION: It is possible and necessary to develop a systematic surgical procedure. Its application in the department of surgery could optimize the results and reduce the complications and errors related to daily practice.

Stages and factors of the "perioperative process": points in common with the aeronautical industry / Etapas e fatores do "processo perioperatório": pontos em comum com a indústria aeronáutica

ABSTRACT Background: The aeronautical industry is one of the disciplines that most use control systems. Its purpose is to avoid accidents and return safer flights. The flight of an airplane, from its takeoff to its landing is a process divided into stages under strict control. A surgical procedure has the same characteristics. We try to identify and develop the stages of the surgical process using the experience of the aviation industry in order to optimize the results and reduce surgical complications. Aim: To identify and develop the stages of the surgical process so that they could be applied to surgery departments. Methods: A search, review and bibliographic analysis of the application of aeronautical control and safety to medical practice in general and to surgery, in particular, were carried out. Results: Surgical process comprises the perioperative period. It is composed of Preoperative Stage (it is divided into 2 "sub-steps": hospital admission and control of preoperative studies) Operative Stage (it is divided into 3 "sub-steps": anesthetic induction, surgery, and anesthetic recovery) and Postoperative Stage (it is divided into 2 "sub-steps": control during hospitalization and ambulatory control). Two checkpoints must be developed. Checkpoint #1 would be located between the preoperative and operative stages, and checkpoint #2 would be located between the operative and postoperative stages. Surgical factors are surgeons, instrumental and technology, anesthesiology and operating room environment. Conclusion: It is possible and necessary to develop a systematic surgical procedure. Its application in the department of surgery could optimize the results and reduce the complications and errors related to daily practice.

RESUMO Racional: A indústria aeronáutica é uma das disciplinas que mais utiliza sistemas de controle. Sua finalidade é evitar acidentes e retornar voos mais seguros. O voo de um avião, desde a decolagem até a aterrissagem, é processo dividido em etapas com estrito controle. Um procedimento cirúrgico tem as mesmas características. Tentar identificar e desenvolver etapas no processo cirúrgico, utilizando a experiência da indústria aeronáutica, poderá otimizar os resultados e reduzir as complicações cirúrgicas. Objetivo: Identificar e desenvolver etapas no processo cirúrgico para que possam ser aplicadas nos serviços de cirurgia. Métodos: Foram realizadas pesquisas, revisão e análise bibliográfica sobre o controle e segurança aeronáutica e aplicando-as na prática médica em geral e à cirurgia em particular. Resultados: O processo cirúrgico compreende o período perioperatório. É composto de pré-operatório (dividido em duas sub-etapas: admissão hospitalar e controle de estudos pré-operatórios); fase operatória (dividida em três sub-etapas: indução anestésica, operação e recuperação anestésica) e fase pós-operatória (dividida em duas "sub-etapas": controle durante a hospitalização e controle ambulatorial). Dois pontos de verificação devem ser desenvolvidos. O ponto de checagem nº 1 estaria localizado entre os estágios pré-operatório e operatório, e o ponto de checagem nº 2 entre os estágios operatório e pós-operatório. Fatores cirúrgicos são cirurgiões, instrumental e tecnologia, anestesiologia e ambiente de sala de cirurgia. Conclusão: É possível e necessário desenvolver um procedimento cirúrgico sistemático. Sua aplicação no departamento de cirurgia poderia otimizar os resultados e reduzir as complicações e erros relacionados à prática diária.

Perioperative management of an anterior mediastinal teratoma in an infant: one more tool in the toolbox.

Anterior mediastinal masses present a significant challenge in the perioperative period. Standard anaesthetic induction and airway management are often not feasible due to the risk of complete respiratory and/or cardiovascular collapse. Invasive manoeuvres, such as extracorporeal membrane oxygenation, cardiac bypass, or tracheal or bronchial stenting, are sometimes not applicable due to significant anatomic aberration. We present a case of anterior mediastinal mass in a 5-month-old infant where typical management techniques in the treatment algorithm were not possible.

Factors predicting adjacent segment disease after anterior cervical discectomy and fusion treating cervical spondylotic myelopathy: A retrospective study with 5-year follow-up.

The purpose of this study is to explore perioperative factors predicting symptomatic adjacent segment disease (ASD) after anterior cervical discectomy and fusion (ACDF) for patients with cervical spondylotic myelopathy (CSM) at 5-year follow-up.This study included 356 patients who underwent ACDF for CSM from Jan.2011 to Jan.2013. Up to Jan. 2018, 39 patients suffered from ASD and 317 did not. Assessments include: age, sex, body mass index (BMI), diabetes, smoking, alcohol, duration of symptoms, preoperative Cobb angle of C2 to 7, T1 slope, C2 to 7 range of motion (C2-7 range of motion [ROM]), C2 to 7 sagittal vertical axis (C2-7 SVA), fusion level involved, superior fusion segment, high signal intensity on T2-WI of magnetic resonance imaging (MRI), preoperative visual analogue scale (VAS)-neck, VAS-Arm, Neck Disability Index (NDI) and Japanese Orthopaedic Association (JOA). Factors were processed by univariate analysis and multivariate linear regression.Data analyzed by univariate and multivariate analysis shows that age (68.9 years old), duration of symptoms (18.8 months), superior fusion segment, more fusion level involved (2.7), high signal intensity on T2-WI (17 of 39 patients), Cobb angle of C2 to C7 (18.7°), C2 to C7 SVA (31.0 mm), T1 slope (28.4°), preoperative VAS-neck (5.2), VAS-Arm (5.6) and NDI (36.7) in ASD group are significantly higher than those in non-ASD group, however, preoperative JOA (8.2 vs 11.2, P < .001) has an opposite trend in 2 groups.The rate of ASD after ACDF is 10.9% in 5-year follow up. Patients with cervical sagittal imbalance, advanced age and sever state of CSM, which have a positive relation with ASD before surgery should be paid attention for surgeons.

The reasons and clinical treatments of postoperative relapse of Pott's disease.

Literature about postoperative relapse of Pott's disease is rare. Accordingly, the risk factors and clinical treatments for postoperative relapse of Pott's disease remain controversial. In order to evaluate the clinical outcomes of surgical treatment of postoperative Pott's disease relapse, and to investigate its optimal therapeutic procedures with respect to focal characteristics, we performed a retrospective review of clinical and radiographic data that were prospectively collected between July 2008 and May 2014 from 753 consecutive spinal tubercular patients including 67 patients who were diagnosed and treated as postoperative relapse of Pott's disease in our hospital. Apart from 9 patients being treated conservatively, the remaining 58 cases received surgery in our series. Specifically, 12 cases underwent anterior debridement, interbody fusion with instrumentation; 15 cases received posterior instrumentation anterior debridement, and bone grafting; 10 cases underwent posterior decompression, bone grafting, and instrumentation; 7 cases with debridement, 5 with debridement and sinus resection. Nine cases received percutaneous drainage and low-dose local continuous chemotherapy. Clinical outcomes before and after treatment were evaluated with statistical analysis based on hematologic and radiographic examinations, bone fusion, and neurologic status. Patients were followed-up for a mean of 39.2 ±â€Š8.2 months (range, 24-60 months). Postoperatively, the erythrocyte sedimentation rate (ESR) became normal within 4-6 months in all patients, and solid bone fusion was achieved within 8 months. Patients exhibited significant improvements in neurological deficits postoperatively, while the visual analog scale for pain showed significant improvements in all patients at final follow-up. The outcomes of follow-up showed that the reasons for postoperative relapse of Pott's disease were multiple. Individualized therapeutic methods should be chosen in accordance with the patient's general condition, recurrence focal characteristic, surgeon's experience, but above all is administration of appropriate chemotherapy.

Low preoperative fibrinogen level is risk factor for neurological complications in acute aortic dissection.

Aortic arch surgery in patients with acute aortic dissection is frequently complicated by neurological complications and coagulopathy. However, the relationship between the coagulation system and neurological complications in patients with acute aortic dissection has not been clarified. Thus, the aim of this study was to investigate the relationship between the coagulation system and neurological complications in patients with acute aortic dissection.From September 2014 to January 2016, a total of 126 patients with acute type A aortic dissection were enrolled. Perioperative characteristics and standard laboratory tests upon admission were analyzed using univariate and multivariate logistic regression analysis in this study. The primary outcome was the correlation between the coagulation system and neurological complications.Univariate logistic regression analysis showed that the neurological complications (+) group underwent more serious and complicated postoperative outcomes. Multivariable logistic regression analysis revealed serum creatinine level (OR, 1.049; 95% CI, 1.011-1.089; P = .01), white blood cell counts (OR, 1.581; 95% CI, 1.216-2.057; P = .001) and fibrinogen concentration upon admission (OR, 0.189; 95% CI, 0.060-0.596; P = .004) as predictors of neurological complications. However, we found that there was no association between the coagulation system and in-hospital mortality.Low preoperative fibrinogen level is the preferred marker for predicting clinical neurological complications in patients with acute type A aortic dissection treated with surgical repair.

Prevention of perioperative venous thromboembolism in pediatric patients: Guidelines from the Association of Paediatric Anaesthetists of Great Britain and Ireland (APAGBI).

The Association of Paediatric Anaesthetists of Great Britain and Ireland (APAGBI) Guidelines Working Group on Thromboprophylaxis in Children has reviewed the literature and where possible provided advice on the care of children in the perioperative period. Areas reviewed include the incidence of perioperative venous thromboembolism (VTE), risk factors, evidence for mechanical and chemical prophylaxis, and complications. Safe practice of regional anesthesia with anticoagulant prophylaxis is detailed. In summary, there are few areas of strong evidence. Routine prophylaxis cannot be recommended for young children. Postpubertal adolescents (approximately 13 years and over) are at a slightly increased risk of VTE and should be assessed for prophylaxis and may warrant intervention if other risk factors are present. However, the incidence of VTE is significantly lower than in the adult population. This special interest review presents a summary and discussion of the key recommendations, a decision-making algorithm and a risk assessment chart. For the full guideline, go to www.apagbi.org.uk/publications/apa-guidelines.