Adverse events in radiation oncology: A case series from wake up safe, the pediatric anesthesia quality improvement initiative.

BACKGROUND: Radiation therapy in pediatric patients often requires anesthesia and poses environmental challenges. Monitoring must be done remotely to limit radiation exposure to the provider. Airway access can be limited by masks or frames. Care is often delivered in relatively inaccessible locations in the hospital. While individual institutions have reported their outcomes, this case series aims to review a multicenter registry of significant adverse events and make recommendations for improved care. METHODS: Wake Up Safe: The Pediatric Quality Improvement Initiative maintains a multisite, voluntary registry of pediatric perianesthetic significant adverse events. This was queried for reports from radiation oncology from January 1, 2010 to May 10, 2018. The database contained 3,379 significant adverse events from approximately 3.3 million anesthetics. All 33 institutions submitted data on a standardized form to a central data repository (Axio Research, Seattle Washington). Prior to each significant adverse events case submission, three anesthesiologists who were not involved in the event analyzed the event using a standardized root cause analysis method to identify the causal or contributing factor(s). RESULTS: Six significant adverse events were identified. In three, incorrect programming of a propofol infusion resulted in overdose. In case one, the 3-year-old female became hypotensive, requiring vasopressors and volume resuscitation. In the second, the 2-year-old female experienced airway obstruction and apnea requiring chin lift. In case three, the child suffered no consequences despite a noted overdose of propofol infusion. In case four, a 2-year-old female with recent respiratory infection suffered laryngospasm during an unmonitored transport to the recovery area. She developed profound oxygen desaturation with bradycardia treated with succinylcholine and chest compressions. In case five, a 6-year-old former premature child suffered laryngospasm at the conclusion of mask creation under general anesthesia with a laryngeal mask airway. The radiation mask delayed recognition of copious secretions. Finally, in case six, a 6-year-old undergoing stereotactic radiosurgery in a head halo suffered bronchospasm and unintended extubation during therapy which required multiple attempts at reintubation by multiple providers ultimately requiring cancellation of the treatment and transport to the intensive care unit. CONCLUSION: There were few radiation oncology significant adverse events, but analysis has led to the identification of several specific opportunities for improvement in pediatric anesthesia for radiation oncology.

Pediatric Perioperative Cardiac Arrest, Death in the Off Hours: A Report From Wake Up Safe, The Pediatric Quality Improvement Initiative.

BACKGROUND: Pediatric perioperative cardiac arrest (CA) is a rare but catastrophic event. This case-control study aims to analyze the causes, incidence, and outcomes of all pediatric CA reported to Wake Up Safe. Factors associated with CA and mortality after arrest are examined and possible strategies for improving outcomes are considered. METHODS: CA in children was identified from the Wake Up Safe Pediatric Anesthesia Quality Improvement Initiative, a multicenter registry of adverse events in pediatric anesthesia. Incidence, demographics, underlying conditions, causes of CA, and outcomes were extracted. Descriptive statistics and logistic regression were used to study the above factors associated with CA and mortality after CA. RESULTS: A total of 531 cases of CA occurred during 1,006,685 anesthetics. CA was associated with age (odds ratio [95% confidence interval] comparing ≥6 vs <6 months of 0.26 [0.22-0.32]; P = .014), American Society of Anesthesiologists physical status (ASA PS III-V versus I-II, 9.24, 7.23-11.8; P < .001), and emergency status (3.55, 2.88-4.37; P < .001). Higher ASA PS was associated with increased mortality (ASA PS III-V versus I-II, 3.25, 1.20-8.81; P = .02) but anesthesia-related arrests were correlated with lower mortality (0.44, 0.26-0.74; P = .002). ASA emergency status (1.83, 1.05-3.19; P = .03) and off hours (night and weekend versus weekday, 2.17, 1.22-3.86; P = .008) were other factors associated with mortality after CA. CONCLUSIONS: The Wake Up Safe data validate single-institution studies' findings regarding incidence, factors associated with arrest, and outcomes of pediatric perioperative CA. However, CA occurring during the off hours had significantly worse outcomes, independent of patient physical status or emergency surgery. This suggests an opportunity for improved outcomes.

Pediatric Cardiopulmonary Arrest in the Postanesthesia Care Unit, Rare but Preventable: Analysis of Data From Wake Up Safe, The Pediatric Anesthesia Quality Improvement Initiative.

BACKGROUND: Nearly 20% of anesthesia-related pediatric cardiac arrests (CAs) occur during emergence or recovery. The aims of this case series were to use the Wake Up Safe database to describe the following: (1) the nature of pediatric postanesthesia care unit (PACU) CA and subsequent outcomes and (2) factors associated with harm after pediatric PACU CA. METHODS: Pediatric CAs in the PACU were identified from the Wake Up Safe Pediatric Anesthesia Quality Improvement Initiative, a multicenter registry of adverse events in pediatric anesthesia. Demographics, underlying conditions, cause of CA, and outcomes were extracted. Descriptive statistics were used to characterize data and to assess risk of harm in those suffering CA. RESULTS: A total of 26 CA events were included: 67% in children <5 years, and 30% in infants (<1 year); 18 (69%) were deemed likely or almost certainly preventable. All preventable CAs were respiratory in nature and most (67%) had purported root causes that included provider judgment or inexperience, inadequate supervision, and competing priorities. CAs of cardiac origin were associated with increased level of harm (temporary or greater), whereas those of respiratory origin were associated more often with no harm. CONCLUSIONS: PACU CA events are rare and generally survivable, with better outcomes for respiratory-based events, but most were deemed preventable, suggesting a need for further vigilance in the early postoperative period. Maintenance of monitoring during patient transport to PACU and continuing care by anesthesia care providers until emergence from anesthesia may further reduce the preventable arrest rate. The root cause analyses conducted by individual institutions reporting these data to the Wake Up Safe provided only limited insight, so multicenter collaborative approaches may allow for greater insight into effective CA-prevention strategies.

MR enterography under the age of 10 years: a single institutional experience.

BACKGROUND: MR enterography (MRE) plays a major role in the imaging of pediatric patients with inflammatory bowel disease (IBD) but can be challenging to perform in young children. OBJECTIVE: To review our institutional experience regarding the performance of MRE in children younger than 10 years of age, including the use of general anesthesia (GA). MATERIALS AND METHODS: Institutional review board approval was obtained. Radiology and anesthesia records were searched to identify MRE exams in children younger than 10 years old between June 2009 and May 2013. The following information was documented: demographics, indications for MRE, use of GA, imaging diagnoses, and documented GA-related side effects or adverse events. Imaging was reviewed to document study length, quality and progression of oral contrast material. RESULTS: One hundred six children (59 boys [56%]) younger than 10 years old underwent 119 MRE examinations (age range: 1 month to 9 years, 11 months). Common indications for MRE included known IBD (42%) and suspected IBD (38%). One hundred ten (92%) examinations were performed under GA. Mean exam length was 52 ± 13 min for GA patients with a range of 31--113 min. Median time under GA was 155 min. Oral contrast material reached the terminal ileum in 31%. Side effects/adverse events associated with GA were uncommon and minor, including transient nausea in 13 children (11%) and emesis in 9 (8%). CONCLUSION: Diagnostic-quality MRE can be performed successfully in young children. The majority of MRE exams were performed under GA, with only occasional minor side effects/adverse events.

Retrospective evaluation of antimicrobial prophylaxis in prevention of surgical site infection in the pediatric population.

BACKGROUND AND OBJECTIVES: Few studies have been conducted in pediatric patients evaluating efficacy of prophylactic antibiotics for prevention of surgical site infection (SSI). This retrospective study was undertaken to determine the effect of antibiotic prophylaxis in the prevention of SSI in children. METHODS: With IRB approval, our perioperative electronic clinical information database was queried. Pediatric patients (≤18 years) undergoing general surgery, cardiac surgery, and spinal surgery at Mott Children's Hospital from January 2000 to April 2010 were included. Demographics and preoperative data were obtained from the Centricity Intraoperative Database, and any episodes of SSI were obtained by review of the infection control records. RESULTS: A total 5023 pediatric patients underwent surgery from January 2000 to April 2010. The average age of the children in the sample was 4.16 ± 5.5 years, and of these, 57% were boys. Overall, 119 (2.37%) cases of SSI were identified. There were no associations between the various patient factors and the development of SSIs. Children for whom antibiotics were administered incorrectly had a 1.7-fold increased risk of SSIs compared with children who received antibiotics within the recommended guidelines (P < 0.02). Children who received antibiotics were more likely to suffer an SSI compared with those who did not. CONCLUSIONS: Proper administration of preoperative antibiotics in pediatric patients is one of the few modifiable and significant factors in prevention of SSI.

Failure of the Laryngeal Mask Airway Unique™ and Classic™ in the pediatric surgical patient: a study of clinical predictors and outcomes.

BACKGROUND: Although predictors of laryngeal mask airway failure in adults have been elucidated, there remains a paucity of data regarding laryngeal mask airway failure in children. METHODS: The authors performed a retrospective database review of all pediatric patients who received a laryngeal mask anesthetic at their institution from 2006 to 2010. Device brands were restricted to LMA Unique™ (Cardinal Health, Dublin, OH) and LMA Classic™ (LMA North America, San Diego, CA), and primary outcome was laryngeal mask failure, defined as any airway event requiring device removal and tracheal intubation. Potential risk factors were analyzed with both univariate and multivariate techniques and included medical history, physical examination, surgical, and anesthetic characteristics. RESULTS: Of the 11,910 anesthesia cases performed in the study, 102 cases (0.86%) experienced laryngeal mask failure. Common presenting features of laryngeal mask failures included leak (25%), obstruction (48%), and patient intolerance such as intractable coughing/bucking (11%). Failures occurred before incision in 57% of cases and after incision in 43%. Independent clinical associations included ear/nose/throat surgical procedure, nonoutpatient admission status, prolonged surgical duration, congenital/acquired airway abnormality, and patient transport. CONCLUSIONS: The findings of the study support the use of the LMA Unique™ and LMA Classic™ as reliable pediatric supraglottic airway devices, demonstrating relatively low failure rates. Predictors of laryngeal mask airway failure in the pediatric surgical population do not overlap with those in the adult population and should therefore be independently considered.

Predictors of survival from perioperative cardiopulmonary arrests: a retrospective analysis of 2,524 events from the Get With The Guidelines-Resuscitation registry.

BACKGROUND: Perioperative cardiopulmonary arrests are uncommon and little is known about rates and predictors of in-hospital survival. METHODS: Using the Get With The Guidelines®-Resuscitation national in-hospital resuscitation registry, we identified all patients aged 18 yr or older who experienced an index, pulseless cardiac arrest in the operating room or within 24 h postoperatively. The primary outcome was survival to hospital discharge, and the secondary outcome was neurologically intact recovery among survivors. Multivariable logistic regression models using generalized estimating equation models were used to identify independent predictors of survival and neurologically intact survival. RESULTS: A total of 2,524 perioperative cardiopulmonary arrests were identified from 234 hospitals. The overall rate of survival to discharge was 31.7% (799/2,524), including 41.8% (254/608) for ventricular tachycardia and ventricular fibrillation, 30.5% (296/972) for asystole, and 26.4% (249/944) for pulseless electrical activity. Ventricular fibrillation and pulseless ventricular tachycardia were independently associated with improved survival. Asystolic arrests occurring in the operating room and postanesthesia care unit were associated with improved survival when compared to other perioperative locations. Among patients with neurological status assessment at discharge, the rate of neurologically intact survival was 64.0% (473/739). Prearrest neurological status at admission, patient age, inadequate natural airway, prearrest ventilatory support, duration of event, and event location were significant predictors of neurological status at discharge. CONCLUSION: Among patients with a perioperative cardiac arrest, one in three survived to hospital discharge, and good neurological outcome was noted in two of three survivors.

Anaesthetic management and outcomes after noncardiac surgery in patients with hypoplastic left heart syndrome: a retrospective review.

CONTEXT: Noncardiac surgery in patients with hypoplastic left heart syndrome has been associated with significant morbidity and mortality in case reports and small series. OBJECTIVE: A retrospective study to review the anaesthetic care and outcomes of patients with hypoplastic left heart syndrome undergoing noncardiac surgery. DESIGN: The medical records of patients undergoing anaesthesia for noncardiac surgery were reviewed, including anaesthesiology records, operative notes, admission history, physical examination records and discharge summaries. Data were collected on patient characteristics, co-morbidities, surgical procedure, anaesthetic and monitoring techniques, intraoperative and postoperative complications and admission status. SETTING: A tertiary medical centre with a high volume of congenital heart disease. PARTICIPANTS: Seventy-three procedures performed in 40 patients with hypoplastic left heart syndrome undergoing noncardiac surgery between July 2002 and May 2008. RESULTS: Thirty-three procedures were performed on an outpatient basis without invasive monitoring or complications. Adverse events occurred in 11 (15%) cases, including cardiovascular and respiratory instability, airway obstruction and postoperative stridor, with 13 (18%) patients admitted to the ICU postoperatively. CONCLUSION: Given the high incidence of adverse events in this patient population, it is imperative that perioperative care be individualised based on the presence of known risk factors such as the stage of palliation, residual cardiac disease and severity of planned surgery.

Opening the black box: cognitive strategies in family practice.

PURPOSE: We wanted to describe the cognitive strategies used by family physicians when structuring the decision-making tasks of an outpatient visit. METHODS: This qualitative study used cognitive task analysis, a structured interview method in which a trained interviewer works individually with expert decision makers to capture their stages and elements of information processing. RESULTS: Eighteen family physicians of varying levels of experience participated. Three dominant themes emerged: time pressure, a high degree of variation in task structuring, and varying degrees of task automatization. Based on these data and previous research from the cognitive sciences, we developed a model of novice and expert approaches to decision making in primary care. The model illustrates differences in responses to unexpected opportunity in practice, particularly the expert's use of attentional surplus (reserve capacity to handle problems) vs the novice's choice between taking more time or displacing another task. CONCLUSIONS: Family physicians have specific, highly individualized cognitive task-structuring approaches and show the decision behavior features typical of expert decision makers in other fields. This finding places constraints on and suggests useful approaches for improving practice.