Incidence, characteristics, and predictive factors for medication errors in paediatric anaesthesia: a prospective incident monitoring study.

BACKGROUND: Medication errors are not uncommon in hospitalized patients. Paediatric patients may have increased risk for medication errors related to complexity of weight-based dosing calculations or problems with drug preparation and dilution. This study aimed to determine the incidence of medication errors in paediatric anaesthesia in a university paediatric hospital, and to identify their characteristics and potential predictive factors. METHODS: This prospective incident monitoring study was conducted between November 2015 and January 2016 in an exclusively paediatric surgical centre. Children <18 yr undergoing general anaesthesia were consecutively included. For each procedure, an incident form was completed by the attending anaesthetist on an anonymous and voluntary basis. RESULTS: Incident forms were completed in 1400 (73%) of the 1925 general anaesthetics performed during the study period with 37 reporting at least one medication error (2.6%). Drugs most commonly involved in medication errors were opioids and antibiotics. Incorrect dose was the most frequently reported type of error (n=27, 67.5%), with dilution error involved in 7/27 (26%) cases of incorrect dose. Duration of procedure >120 min was the only factor independently associated with medication error [adjusted odds ratio: 4 (95% confidence interval: 2-8); P=0.0001]. CONCLUSIONS: Medication errors are not uncommon in paediatric anaesthesia. Identification of the mechanisms related to medication errors might allow preventive measures that can be assessed in further studies.

The effect of pre-operative gastric ultrasound examination on the choice of general anaesthetic induction technique for non-elective paediatric surgery. A prospective cohort study.

Ultrasound examination of the gastric antrum is a non-invasive tool that allows reliable estimation of gastric contents. We performed this prospective cohort study in non-elective paediatric surgery to assess whether gastric ultrasound may help to determine the best anaesthetic induction technique, whether rapid sequence or routine. The primary outcome was the reduction of inappropriate induction technique. A pre-operative clinical assessment was performed by the attending anaesthetist who made a provisional plan for induction. Gastric ultrasound was performed in the semirecumbent and right lateral decubitus positions for a qualitative assessment of gastric contents, using a 0-2 grading scale. A final induction plan was made based on this assessment. Immediately after tracheal intubation, gastric contents were suctioned through a multi-orifice nasogastric tube; these were defined as above risk threshold for regurgitation and aspiration if there was clear fluid > 0.8 ml.kg-1 , and/or the presence of thick fluid and/or solid particles. Gastric ultrasound was feasible in 130 out of 143 (90%) of children, and led to a change in the planned induction technique in 67 patients: 30 from routine to rapid sequence, and 37 from rapid sequence to routine. An appropriate induction technique was therefore performed in 85% of children, vs. 49% planned after pre-operative clinical assessment alone (p < 0.00001). Our results suggest that gastric ultrasound is a useful guide to the general anaesthetic induction technique with respect to the risk of pulmonary aspiration, in comparison with pre-operative clinical assessment alone.

Children and parental anxiolysis in paediatric ambulatory surgery: a randomized controlled study comparing 0.3 mg kg-1 midazolam to tablet computer based interactive distraction.

BACKGROUND: The operating theatre, anaesthesia induction and separation from parents create fear and anxiety in children. Anxiety leads to adverse behavioral changes appearing and sometimes persisting during the postoperative period. Our aim was to compare the effects of midazolam (0.3 mg kg-1: MDZ) for premedication with age-appropriate tablet game apps (TAB) on children anxiety during and after ambulatory surgery. METHODS: A randomized controlled trial was conducted from May 16th, 2013 to March 25th, 2014 at the Children Hospital of Lyon. The primary outcome of this study was the change in m-YPAS score at the time of anaesthetic mask induction. Anxiety was also assessed in the waiting surgical area, at the time of separation with parents and when back in the ambulatory surgery ward. RESULTS: One hundred and eighteen patients aged four-11 yr were recruited, 60 in the TAB Group and 58 in the MDZ Group. Main endpoint was missing for three patients from the MDZ Group. At the time of mask induction, there was no significant difference between MDZ and TAB Group for the m-YPAS score (40.5 (18.6) vs 41.8 (20.7), P = 0.99). There was no significant correlation between m-YPAS score and its evolution over the four period of time between subjects. CONCLUSIONS: We were not able to show whether TAB is superior to MDZ to blunt anxiety in children undergoing ambulatory surgery. TAB is a non-pharmacological tool which has the capacity in reducing perioperative stress without any sedative effect in this population. CLINICAL TRIAL REGISTRATION: NCT 02192710.

Ultrasonographic measurement of antral area for estimating gastric fluid volume in parturients.

BACKGROUND: The aim of this prospective observational study was to assess the performance of ultrasonographic gastric antral area (GAA) to predict gastric fluid volumes of >0.4, >0.8 and >1.5 ml kg(-1), in fasted women in established labour. METHODS: A first ultrasound examination of the antrum was performed, in order to confirm gastric vacuity by using a qualitative score. Baselines GAA measurements were obtained in both supine and right lateral decubitus positions. Thereafter, parturients were allowed to drink clear fluids only. Measurement of GAA was repeated 15 min after last fluid intake, in both supine and right lateral positions. Receiver operating characteristics (ROC) curves were constructed to determine the accuracy of GAA to diagnose ingested volumes of >0.4, >0.8 and >1.5 ml kg(-1). RESULTS: Data from forty parturients were analysed. The areas under the ROC curves ranged from 80% to 86%. The cut-off value for antral area measured in supine position, to detect a volume >0.4 ml kg(-1), was 387 mm(2), with a sensitivity of 87%, a specificity of 70% and a negative predictive value of 85%. A cut-off value of 608 mm(2) predicted a fluid volume >1.5 ml kg(-1), with a specificity of 94%, a sensitivity of 75% and a negative predictive value of 92%. CONCLUSIONS: This study provides cut-off values for GAA that could be used in addition to the qualitative assessment of the antrum to define a full stomach in labouring patients.