Implementing PDSA Methodology for Pediatric Appendicitis Increases Care Value for a Tertiary Children's Hospital.

INTRODUCTION: We used the plan-do-study-act (PDSA) framework to develop and implement an evidence-based clinical practice guideline (CPG) within an urban, tertiary children's referral center. METHODS: We developed an evidence-based CPG for appendicitis using iterative PDSA cycles. Similar CPGs from other centers were reviewed and modified for local implementation. Adjuncts included guideline-specific order sets and operative notes in the electronic medical record system. Outcomes included length of stay (LOS), 30-day readmissions, hospital costs, and patient and family experience (PFE) scores. Our team tracked outcome, process, and balancing measures using Statistical Process Charts. Outcome measures were compared over 2 fiscal quarters preimplementation and 3 fiscal quarters postimplementation, using interrupted time series, student t test, and chi-square tests when appropriate. RESULTS: LOS for simple (uncomplicated) appendicitis decreased to 0.87 days (interquartile range [IQR] 0.87-0.94 days) from 1.1 days (IQR 0.97-1.42 days). LOS for complicated appendicitis decreased to 4.96 days (IQR 4.95-6.15) from 5.58 days (IQR 5.16-6.09). This reduction equated to an average cost-savings of $1,122/patient. Thirty-day readmission rates have remained unchanged. PFE scores increased across all categories and have remained higher than national benchmarks. CONCLUSION: Development and Implementation of a CPG for pediatric appendicitis using the PDSA framework adds value to care provided within a large tertiary center.

Reduction in Pediatric Ambulatory Adenotonsillectomy Length of Stay Using Clinical Care Guidelines.

OBJECTIVE: Standardization of postoperative care using clinical care guidelines (CCG) improves quality by minimizing unwarranted variation. It is unknown whether CCGs impact patient throughput in outpatient adenotonsillectomy (T&A). We hypothesize that CCG implementation is associated with decreased postoperative length of stay (LOS) in outpatient T&A. METHODS: A multidisciplinary team was assembled to design and implement a T&A CCG. Standardized discharge criteria were established, including goal fluid intake and parental demonstration of medication administration. An order set was created that included a hard stop for discharge timeframe with choices "meets criteria," "4-hour observation," and "overnight stay." Consensus was achieved in June 2018, and the CCG was implemented in October 2018. Postoperative LOS for patients discharged the same day was tracked using control chart analysis with standard definitions for centerline shift being utilized. Trends in discharge timeframe selection were also followed. RESULTS: Between July 2015 and August 2017, the average LOS was 4.82 hours. This decreased to 4.39 hours in September 2017 despite no known interventions and remained stable for 17 months. After CCG implementation, an initial trend toward increased LOS was followed by centerline shifts to 3.83 and 3.53 hours in March and October 2019, respectively. Selection of the "meets criteria" discharge timeframe increased over time after CCG implementation (R2  = 0.38 P = .003). CONCLUSIONS: Implementation of a CCG with standardized discharge criteria was associated with shortened postoperative LOS in outpatient T&A. Concurrently, surgeons shifted practice to discharge patients upon meeting criteria rather than after a designated timeframe. LEVEL OF EVIDENCE: NA Laryngoscope, 131:2610-2615, 2021.

Standardized Order Set Exhibits Surgeon Adherence to Pain Protocol in Pediatric Adenotonsillectomy.

OBJECTIVES/HYPOTHESIS: To produce a sustained reduction in opioid prescriptions in patients <5 years of age undergoing T&A through utilization of standardized algorithms and electronic health record (EHR) automation tools. STUDY DESIGN: Prospective quality improvement initiative. METHODS: Plan-do-study-act (PDSA) methodology was used to design an age-based postoperative pain regimen in which children <5 years of age received a non-opioid pain regimen, and option to prescribe oxycodone for additional pain relief was given for children >5 years of age. Standardized discharge instructions and automated, age-specific order sets were created to facilitate adherence. Rate of discharge opioid prescription was monitored and balanced against post-discharge opioid prescriptions and returns to the emergency department (ED). RESULTS: In children <5 years of age undergoing T&A, reduction in opioid prescription rates from 65.9% to 30.9% after initial implementation of the order set was noted. Ultimately, reduction of opioid prescribing rates to 3.7% of patients was noted after pain-regimen consensus and EHR order set implementation. Opioid prescriptions in patients >5 years of age decreased from 90.6% to 58.1% initially, and then down 35.9% by the last time point analyzed. Requests for outpatient opioid prescriptions did not increase. There was no significant change in returns to the emergency ED for pain management, or in the number opioids prescribed when patients returned to the ED. CONCLUSIONS: Iterative cycles of improvement utilizing standardized pain management algorithms and EHR tools were effective means of producing a sustained reduction in opioid prescriptions in postoperative T&A patients. Such findings suggest a framework for similar interventions in other pediatric otolaryngology settings. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:E2337-E2343, 2021.

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.

Complications in Pediatric Regional Anesthesia: An Analysis of More than 100,000 Blocks from the Pediatric Regional Anesthesia Network.

WHAT WE ALREADY KNOW ABOUT THIS TOPIC: WHAT THIS ARTICLE TELLS US THAT IS NEW: BACKGROUND:: Complications in pediatric regional anesthesia are rare, so a large sample size is necessary to quantify risk. The Pediatric Regional Anesthesia Network contains data on more than 100,000 blocks administered at more than 20 children's hospitals. This study analyzed the risk of major complications associated with regional anesthesia in children. METHODS: This is a prospective, observational study of routine clinical practice. Data were collected on every regional block placed by an anesthesiologist at participating institutions and were uploaded to a secure database. The data were audited at multiple points for accuracy. RESULTS: There were no permanent neurologic deficits reported (95% CI, 0 to 0.4:10,000). The risk of transient neurologic deficit was 2.4:10,000 (95% CI, 1.6 to 3.6:10,000) and was not different between peripheral and neuraxial blocks. The risk of severe local anesthetic systemic toxicity was 0.76:10,000 (95% CI, 0.3 to 1.6:10,000); the majority of cases occurred in infants. There was one epidural abscess reported (0.76:10,000, 95% CI, 0 to 4.8:10,000). The incidence of cutaneous infections was 0.5% (53:10,000, 95% CI, 43 to 64:10,000). There were no hematomas associated with neuraxial catheters (95% CI, 0 to 3.5:10,000), but one epidural hematoma occurred with a paravertebral catheter. No additional risk was observed with placing blocks under general anesthesia. The most common adverse events were benign catheter-related failures (4%). CONCLUSIONS: The data from this study demonstrate a level of safety in pediatric regional anesthesia that is comparable to adult practice and confirms the safety of placing blocks under general anesthesia in children.

Neuraxial Anesthesia in Children With Ventriculoperitoneal Shunts.

Neuraxial anesthesia has been demonstrated to be safe and effective for children undergoing subumbilical surgery. There is limited evidence regarding the safety of neuraxial anesthesia in pediatric patients with a ventriculoperitoneal shunt. We evaluated a series of 25 patients with indwelling ventriculoperitoneal shunts for complications within 30 days of any procedure performed with a neuraxial technique. One patient required a ventriculoperitoneal shunt revision 5 days after a lumbar catheter placement. The neurosurgeon determined the revision to be likely unrelated to the patient's lumbar catheter. Concerns about the use of neuraxial anesthesia in patients with an indwelling ventriculoperitoneal shunt may be overstated.

Neural preservation underlies speech improvement from auditory deprivation in young cochlear implant recipients.

Although cochlear implantation enables some children to attain age-appropriate speech and language development, communicative delays persist in others, and outcomes are quite variable and difficult to predict, even for children implanted early in life. To understand the neurobiological basis of this variability, we used presurgical neural morphological data obtained from MRI of individual pediatric cochlear implant (CI) candidates implanted younger than 3.5 years to predict variability of their speech-perception improvement after surgery. We first compared neuroanatomical density and spatial pattern similarity of CI candidates to that of age-matched children with normal hearing, which allowed us to detail neuroanatomical networks that were either affected or unaffected by auditory deprivation. This information enables us to build machine-learning models to predict the individual children's speech development following CI. We found that regions of the brain that were unaffected by auditory deprivation, in particular the auditory association and cognitive brain regions, produced the highest accuracy, specificity, and sensitivity in patient classification and the most precise prediction results. These findings suggest that brain areas unaffected by auditory deprivation are critical to developing closer to typical speech outcomes. Moreover, the findings suggest that determination of the type of neural reorganization caused by auditory deprivation before implantation is valuable for predicting post-CI language outcomes for young children.

Are caudal blocks for pain control safe in children? an analysis of 18,650 caudal blocks from the Pediatric Regional Anesthesia Network (PRAN) database.

BACKGROUND: The caudal block is the most commonly performed regional anesthesia technique in pediatric patients undergoing surgical procedures, but safety concerns raised by previous reports remain to be addressed. Our main objective in current investigation was to estimate the overall and specific incidence of complications associated with the performance of caudal block in children. METHODS: This was an observational study using the Pediatric Regional Anesthesia Network database. A complication after a caudal block was defined by the presence of at least 1 of the following: block failure, vascular puncture, intravascular test dose, dural puncture, seizure, cardiac arrest, sacral pain, or neurologic symptoms. In addition, if a complication was also coded, the presence of temporary or permanent sequelae was evaluated. Additional exploratory analyses were performed to identify patterns of local anesthetic dosage. RESULTS: Eighteen thousand six hundred-fifty children who received a caudal block were included in the study. The overall estimated incidence (95% confidence interval [CI]) of complications after caudal blocks was 1.9% (1.7%-2.1%). Patients who developed complications were younger, median (interquartile range) of 11 (5-24) months, compared to those who did not develop any complications, 14 (7-29) months, P = 0.001. The most common complications were block failure, blood aspiration, and intravascular injection. No cases of temporary or permanent sequelae were identified leading to an estimated incidence (95% CI) of 0.005% (- % to 0.03%). Four thousand four hundred-six of 17,867 (24.6%; 95% CI, 24%-25.2%) subjects received doses (>2 mg of bupivacaine equivalents/kg) that could be potentially unsafe. CONCLUSIONS: Safety concerns should not be a barrier to the use of caudal blocks in children assuming an appropriate selection of local anesthetic dosage.

Corticosteroid and Anesthetic Injections for Muscle Strains and Ligament Sprains in the NFL.

BACKGROUND: Administering local anesthetic or corticosteroid injections in professional athletes to allow return to play is common but has traditionally been viewed as suspect and taboo. The skepticism surrounding therapeutic injections stems predominantly from anecdotal experience as opposed to scientific data. QUESTIONS/PURPOSES: The purpose of this paper is to evaluate the current use of corticosteroid injections for muscle strains and ligaments sprains in the National Football League to document player's ability to return to play and possible adverse effects. PATIENTS AND METHODS: Athletes from a single National Football League team who received at least one corticosteroid or anesthetic injection for either a muscle strain or ligament sprain during three consecutive seasons were retrospectively reviewed. Thirty-seven injections were given over the three seasons. Injections were either performed blindly or by using ultrasound guidance. RESULTS: Twice as many defensive players were injected than offensive players. The average number of days of conservative treatment before injection was 6.5 days. All players returned to play after injection. There were no complications from any of the injections. Seventeen (55%) players did not miss a single game, and nine (30%) did not miss a single day. Quadriceps strains were associated with the most missed games (four) and the most missed days (36.5). Proximal hamstring strains were second with an average of three missed games and 28 missed days. CONCLUSION: Corticosteroid injections are a safe and effective therapeutic intervention for treating muscle strains and ligament sprains in order to enable athletes to return to competition earlier.

Transversus abdominis plane block in children: a multicenter safety analysis of 1994 cases from the PRAN (Pediatric Regional Anesthesia Network) database.

BACKGROUND: Currently, there is not enough evidence to support the safety of the transversus abdominis plane (TAP) block when used to ameliorate postoperative pain in children. Safety concerns have been repeatedly mentioned as a major barrier to performing large randomized trials in children. The main objective of the current investigation was to determine the incidence of overall and specific complications resulting from the performance of the TAP block in children. In addition, we evaluated patterns of local anesthetic dosage selection in the same population. METHODS: This was an observational study using the Pediatric Regional Anesthesia Network database. A complication from the TAP block was defined by the presence of at least one of the following intraoperative and/or postoperative factors: puncture of the peritoneum or organs, vascular puncture, cardiovascular, pulmonary and/or neurological symptoms/signs, hematoma, and infection. Additional analyses were performed to identify patterns of local anesthetic dosage. RESULTS: One thousand nine hundred ninety-four children receiving a TAP block were included in the analysis. Only 2 complications were reported: a vascular aspiration of blood before local anesthetic injection and a peritoneal puncture resulting in an overall incidence of complications (95% CI) of 0.1% (0.02%-0.3%) and a specific incidence of complications (vascular aspiration or peritoneal puncture) of 0.05% (0.0054%-0.2000%). Neither of these complications resulted in additional interventions or sequelae. The median (95% range) for the local anesthetic dose per weight for bilateral TAP blocks was 1.0 (0.47-2.29) mg of bupivacaine equivalents per kilogram; however, subjects' weights were not sufficient to explain much of the variability in dose. One hundred thirty-five of 1944 (6.9%; 95% CI, 5.8%-8.1%) subjects received doses that could be potentially toxic. Subjects who received potentially toxic doses were younger than subjects who did not receive potentially toxic doses, 64 (19-100) months and 108 (45-158) months, respectively (P < 0.001). CONCLUSIONS: The upper incidence of overall complications associated with the TAP block in children was 0.3%. More important, complications were very minor and did not require any additional interventions. In contrast, the large variability of local anesthetic dosage used can not only minimize potential analgesic benefits of the TAP block but also result in local anesthetic toxicity. Safety concerns should not be a major barrier to performing randomized trials to test the efficacy of the TAP block in children as long as appropriate local anesthetic dose regimens are selected.

The effect of mechanical load on tendon-to-bone healing in a rat model.

BACKGROUND: Joint motion is commonly prescribed after tendon repair surgeries such as rotator cuff repairs; however, the ideal rehabilitation program to optimize tendon-to-bone healing is unknown. HYPOTHESES: (1) Delayed loading would result in a mechanically stronger and better organized tendon-to-bone interface compared with prolonged immobilization or immediate loading. (2) Low-magnitude load would lead to superior healing compared with high-magnitude load. STUDY DESIGN: Controlled laboratory study. METHODS: A total of 192 rats underwent unilateral patellar tendon detachment and repair followed by placement of a custom external fixator. Rats were assigned to immobilization, immediate postoperative loading, or delayed-onset loading (4- or 10-day delay). Loading was controlled using a specially designed motorized device to apply constant strain until 3 N (low load) or 6 N (high load) of axial tensile force was reached through the healing bone-tendon complex for 50 cycles per day. Rats were sacrificed at 4, 10, 21, or 28 days postoperatively for histomorphometric, immunohistochemical, radiographic, molecular, and biomechanical analyses. RESULTS: The load to failure was significantly higher in the immobilized group compared with the immediate and delayed loading groups (P < .05). Compared with loaded specimens, the immobilized specimens had significantly less fibrocartilage (at 4, 10, and 28 days), significantly better collagen fiber organization (at 4, 10, and 21 days), decreased expression of matrix metalloproteinase-13 (at 10, 21, and 28 days), and significantly fewer apoptotic cells (at 21 and 28 days). Micro-computed tomographic analyses showed that the 3-N immediate load group had significantly less total volume (P = .012), bone volume (P = .012), and bone mineral density (P = .023) for cortical bone, and the immobilized group had significantly more specimens with new bone formation at the enthesis (100%; P = .001). CONCLUSION: Immobilization results in a stronger tendon-bone complex, with less scar tissue and a more organized tendon-bone interface compared with all loading regimens in this study. CLINICAL RELEVANCE: Given the relatively high rate of failure after rotator cuff and other tendon-to-bone repairs, identification of optimal rehabilitation programs postoperatively is an important research goal.

Pediatric pain management.

Regional anesthesia has become an integral part of adult anesthesia. Although not routinely used in children because of the need for general anesthesia that is necessary to keep the patients from moving and cooperating with the operator, regional anesthesia has been gaining immense popularity in the last decade. Although there is not much objective evidence, large prospective databases and expert opinion have favored administering regional anesthesia in the asleep child safely because major neural damage has not been reported in children. This review discusses a comprehensive approach to acute pain management in infants, children, and adolescents using regional anesthesia.

The effect of dynamic femoroacetabular impingement on pubic symphysis motion: a cadaveric study.

BACKGROUND: A link between femoroacetabular impingement and athletic pubalgia has been reported clinically. One proposed origin of athletic pubalgia is secondary to repetitive loading of the pubic symphysis, leading to instability and parasymphyseal tendon and ligament injury. Hypothesis/ PURPOSE: The purpose of this study was to investigate the effect of simulated femoral-based femoroacetabular impingement on rotational motion at the pubic symphysis. The authors hypothesize that the presence of a cam lesion leads to increased relative symphyseal motion. STUDY DESIGN: Controlled laboratory study. METHODS: Twelve hips from 6 fresh-frozen human cadaveric pelvises were used to simulate cam-type femoroacetabular impingement. The hips were held in a custom jig and maximally internally rotated at 90° of flexion and neutral adduction. Three-dimensional motion of the pubic symphysis was measured by a motion-tracking system for 2 states: native and simulated cam. Load-displacement plots were generated between the internal rotational torque applied to the hip and the responding motion in 3 anatomic planes of the pubic symphysis. RESULTS: As the hip was internally rotated, the motion at the pubic symphysis increased proportionally with the degrees of the rotation as well as the applied torque measured at the distal femur for both states. The primary rotation of the symphysis was in the transverse plane and on average accounted for more than 60% of the total rotation. This primary motion caused the anterior aspect of the symphyseal joint to open or widen, whereas the posterior aspect narrowed. At the torque level of 18.0 N·m, the mean transverse rotation in degrees was 0.89° ± 0.35° for the native state and 1.20° ± 0.41° for cam state. The difference between cam and the native groups was statistically significant (P < .03). CONCLUSION: Dynamic femoroacetabular impingement as caused by the presence of a cam lesion causes increased rotational motion at the pubic symphysis. CLINICAL RELEVANCE: Repetitive loading of the symphysis by cam impingement is thought to lead to increased symphyseal motion, which is one possible precursor to athletic pubalgia.

Functional outcome after repair of proximal hamstring avulsions.

BACKGROUND: Rupture of the proximal origin of the hamstrings leads to pain, weakness, and a debilitating decrease in physical activity. Repair of these injuries should be based on the expectation that these deficits can be addressed. The goal of this study was to objectively evaluate the efficacy of repair of proximal hamstring avulsions. METHODS: Thirty-four patients were identified retrospectively to have a complete rupture of the proximal origin of the hamstrings based on the presence of a bowstring sign and the results of magnetic resonance imaging (MRI).Patients were contacted for follow-up evaluation to fill out a subjective questionnaire, to undergo functional testing, and to undergo isokinetic testing on a Cybex dynamometer. Twenty-three patients were evaluated. RESULTS: There were nine acute and fourteen chronic repairs, and the average period of follow-up was 43.3 months. Twenty-one of twenty-three patients reported returning to activity at an average of 95% of their pre-injury activity level at an average of 9.8 months. Eighteen patients reported excellent results; four, good results; and one, fair results. Hamstring strength was an average of 93% and 90% of that in the uninvolved limb at 240° per second and 180° per second, respectively. The hamstrings-to-quadriceps ratio was 56% for 240° per second and 48% at 180° per second. Hamstring endurance was an average of 81% and 91% of the nonoperative limb at 240° per second and 180° per second, respectively. Postoperative quadriceps strength and endurance were positively correlated with return to pre-injury level of activity (r = 0.6, p < 0.05; and r = 0.6, p < 0.05) and negatively correlated with time to return to sport (r = -0.5, p < 0.05; and r = -0.5, p < 0.05). There was no significant effect associated with age or time from injury. CONCLUSIONS: Repair of a symptomatic and displaced ruptured proximal hamstring tendon yields good subjective and objective functional results with minimal complications. Overall, patients are satisfied with surgical repair and experience return of functional activity with minimal postoperative weakness.

Children with spinal dysraphism: transversus abdominis plane (TAP) catheters to the rescue!

Transversus abdominis plane (TAP) block catheters may offer an alternative to a central neuraxial blockade for patients undergoing major abdominal surgery (Paediatr Anaesth 19: 2009; 296). This case series consists of two children with spinal dysraphism in whom bilateral TAP block catheters were placed for postoperative pain relief. Administration of low dose, low concentration local anesthetic provided both children with excellent postoperative analgesia.