Pediatric anesthesia in North America.

BACKGROUND AND OBJECTIVES: This educational review outlines the current landscape of pediatric anesthesia training, care delivery, and challenges across Canada, Barbados, and the United States. DESCRIPTIONS AND CONCLUSIONS: Approximately 5% of Canadian children undergo general anesthesia annually, administered by fellowship-trained pediatric anesthesiologists in children's hospitals, general anesthesiologists in community hospitals, or family practice anesthesiologists in underserved regions. In Canada, the focus is on national-level evaluation and accreditation of pediatric anesthesia fellowship training, addressing challenges arising from workforce shortages, particularly in remote areas. Barbados, a Caribbean nation, lacks dedicated pediatric hospitals but has provided pediatric anesthesia since 1972 through anesthetists with additional training. Challenges in its development, common to low-middle-income countries, include inadequate infrastructure and workforce shortages. Increased awareness of pediatric anesthesia as a sub-specialty could enhance perioperative care for Barbadian children. Pediatric anesthesia encompasses various specialties in the United States, with pediatric anesthesiologists playing a foundational role. Challenges faced include recruitment and retention difficulties, supply-chain shortages, and the proliferation of anesthesia sites, all impacting the delivery of modern, high-quality, and cost-effective patient care. Collaborative efforts at national and organizational levels strive to improve the quality and safety of pediatric anesthesia care in the United States.

Clinical Outcomes Associated With Intranasal Dexmedetomidine Sedation in Children.

OBJECTIVES: We aimed to describe the quality of sedation and additional clinically-meaningful outcomes associated with different intranasal dexmedetomidine-based regimens in children undergoing nonpainful procedures. METHODS: A multicenter prospective observational study of children aged 2 months to 17 years undergoing intranasal dexmedetomidine sedation for MRI, auditory brainstem response testing, echocardiogram, EEG, or computed tomography scan. Regimens varied by dose of dexmedetomidine and use of adjunct sedatives. Quality of sedation was assessed using the Pediatric Sedation State Scale and by determining proportion of children who achieved an acceptable sedation state. Procedure completion, time-based outcomes, and adverse events were assessed. RESULTS: We enrolled 578 children across 7 sites. Median age was 2.5 years (interquartile range 1.6-3) and 37.5% were female. The most common procedures were auditory brainstem response testing (54.3%) and MRI (22.8%). The most common dose was 3 to 3.9 mcg/kg (55%), with 25.1% and 14.2% of children receiving oral or intranasal midazolam, respectively. Acceptable sedation state and procedure completion was achieved in 81.1% and 91.3% of children, and mean time to onset of sedation and total sedation time were 32.3 and 114.8 minutes, respectively. Twelve interventions were performed in 10 patients in response to an event; no patients required a serious airway, breathing, or cardiovascular intervention. CONCLUSIONS: Intranasal dexmedetomidine-based regimens can achieve acceptable sedation states and high rates of procedure completion in children undergoing sedation for nonpainful procedures. Our findings delineate clinical outcomes associated with intranasal dexmedetomidine-based sedation that can be used to guide the implementation and optimization of such regimens.

Pediatric Sedation/Anesthesia for MRI: Results From the Pediatric Sedation Research Consortium.

BACKGROUND: Magnetic resonance imaging (MRI) is the most common imaging procedure requiring sedation/anesthesia in children. Understanding adverse events associated with sedation/anesthesia is important in making decisions regarding MRI vs. other imaging modalities. No large studies have evaluated the practice of pediatric sedation/anesthesia for MRI by a variety of pediatric specialists. PURPOSE: Utilize a large pediatric sedation database to characterize the patients and adverse events associated with sedation/anesthesia for pediatric MRI. STUDY TYPE: Retrospective analysis of prospectively collected data. SUBJECTS: The Pediatric Sedation Research Consortium (PSRC) has 109,947 entries for sedations for MRI from November 10, 2011 through December 18, 2017. ASSESSMENT: Patient demographics, sedative medications, interventions, and adverse events are described. Associations with adverse events were assessed. Trends in sedative medications used over time are examined. STATISTICAL TESTS: Descriptive statistics, Chi-Squared and Fisher's Exact tests for categorical variables, logistic regression and assessment of trend using logistic regression and other method. RESULTS: A total of 109,947 MRI-related sedations were examined. Most subjects (66.2%) were 5 years old or younger. Seizure or other neurologic issue prompted MRI in 63.7% of cases. Providers responsible for sedation/anesthesia included intensivists (49.3%), emergency medicine physicians (28.2%), hospitalists (10.2%), and anesthesiologists (9.8%). The most commonly used sedative agent was propofol (89.1%). The most common airway intervention was supplemental oxygen (71.7%), followed by head/airway repositioning (20.6%). Airway-related adverse events occurred in 8.4% of patients. Serious adverse events occurred in only 0.06% of patients, including three cases of cardiac arrest. No mortality was recorded. There was a statistically significant increase in the use of dexmedetomidine over time. DATA CONCLUSIONS: Overall, adverse event rates were low. Sedation/anesthesia with propofol infusion and natural airway was the most common method used by this varied group of sedation providers. The use of dexmedetomidine increased over time. EVIDENCE LEVEL: 4 TECHNICAL EFFICACY: Stage 5.

Predictors of Laryngospasm During 276,832 Episodes of Pediatric Procedural Sedation.

STUDY OBJECTIVE: Laryngospasm is a rare but potentially life-threatening complication of sedation. The objective of this study was to perform a predictor analysis of biologically plausible predictors and the interventions and outcomes associated with laryngospasm. METHODS: Secondary analysis of prospectively collected data from consecutively sedated patients, less than or equal to 22 years of age, at multiple locations at 64 member institutions of the Pediatric Sedation Research Consortium. The primary outcome was laryngospasm. The independent variables in the multivariable model included American Society of Anesthesiologists category, age, sex, concurrent upper respiratory infection, medication regimen, hospital sedation location, whether the procedure was painful, and whether the procedure involved the airway. The analysis included adjusted odds ratios (aORs) and predicted probabilities. RESULTS: We analyzed 276,832 sedations with 913 reported events of laryngospasm (overall unadjusted prevalence 3.3:1,000). A younger age, a higher American Society of Anesthesiologists category, a concurrent upper respiratory infection (aOR 3.94, 2.57 to 6.03; predicted probability 12.2/1,000, 6.3/1,000 to 18.0/1,000), and airway procedures (aOR 3.73, 2.33 to 5.98; predicted probability 9.6/1,000, 5.2/1,000 to 13.9/1,000) were associated with increased risk. Compared with propofol alone, propofol combination regimens had increased risk (propofol+ketamine: aOR 2.52, 1.41 to 4.50; predicted probability 7.6/1,000, 3.1/1,000 to 12/1,000; and propofol+dexmedetomidine: aOR 2.10, 1.25 to 3.52; predicted probability 6.3/1,000, 3.7,/1,000 to 8.9/1,000). Among patients with laryngospasm, the resulting outcomes included desaturation less than 70% for more than 30 seconds (19.7%), procedure not completed (10.6%), emergency airway intervention (10.0%), endotracheal intubation (5.3%), unplanned admission/increase in level of care (2.3%), aspiration (1.1%), and cardiac arrest (0.2%). CONCLUSION: We found increased associations of laryngospasm in pediatric procedural sedation with multiple biologic factors, procedure types, and medication regimens. However, effect estimates showed that the laryngospasm prevalence remained low, and this should be taken into consideration in sedation decisionmaking.

A Single Center Case Series of Gender-Affirming Surgeries and the Evolution of a Specialty Anesthesia Team.

Most minors and young transgender persons wishing to undergo gender-affirming surgery need to seek specialists affiliated with gender affirmation programs in adult hospitals. Research suggests gender affirmation surgery has been established as an effective and medically indicated treatment for gender dysphoria. Although most data on gender-affirming surgeries are from adult populations, there is growing literature establishing their effectiveness in adolescents and young adults. Therefore, it is critical to evaluate the perioperative outcomes for gender-diverse youth to deliver safe and affirming care. The primary objective of this retrospective case series is to examine the perioperative characteristics and outcomes of patients with gender identity disorders (International Classification of Diseases [ICD]-10-code F64) who underwent chest reconstruction (mastectomy) and genital surgery (phalloplasty, metoidioplasty, and vaginoplasty) in a pediatric academic hospital. The secondary aim is to evaluate the value of a specialized anesthesia team for improving clinical outcomes, interdisciplinary communication, and further advancing the transgender perioperative experience. We identified 204 gender affirmation surgical cases, 177 chests/top surgeries, and 27 genital/bottom surgeries. These findings indicate gender-diverse individuals who underwent life-changing surgery at our institution had a median age of 18 years old, with many patients identifying as transmen. Our data suggests that postoperative pain was significant, but adverse events were minimal. The evolution of a specialty anesthesia team and initiatives (anesthesia management guidelines, scheduling, continuity, and education) necessitate direct care coordination and multidisciplinary planning for gender affirmation surgery in transgender youth.

Standardizing Opioid Prescribing in a Pediatric Hospital: A Quality Improvement Effort.

BACKGROUND: Opioids are indicated for moderate-to-severe pain caused by trauma, ischemia, surgery, cancer and sickle cell disease, and vaso-occlusive episodes (SCD-VOC). There is only limited evidence regarding the appropriate number of doses to prescribe for specific indications. Therefore, we developed and implemented an opioid prescribing algorithm with dosing guidelines for specific procedures and conditions. We aimed to reach and sustain 90% compliance within 1 year of implementation. METHODS: We conducted this quality improvement effort at a pediatric academic quaternary care institution. In 2018, a multidisciplinary team identified the need for a standard approach to opioid prescribing. The algorithm guides prescribers to evaluate the medical history, physical examination, red flags, pain type, and to initiate opioid-sparing interventions before prescribing opioids. Opioid prescriptions written between January 2015 and September 2020 were included. Examples from 2 hospital departments will be highlighted. Control charts for compliance with guidelines and variability in the doses prescribed are presented for selected procedures and conditions. RESULTS: Over 5 years, 83 037 opioid prescriptions in 53 804 unique patients were entered electronically. The encounters with ≥1 opioid prescription decreased from 48% to 25% between 2015 and 2019. Compliance with the specific guidelines increased to ∼85% for periacetabular osteotomies and SCD-VOC and close to 100% for anterior-cruciate ligament surgery. In all 3 procedures and conditions, variability in the number of doses prescribed decreased significantly. CONCLUSION: We developed an algorithm, guidelines, and a process for improvement. The number of opioid prescriptions and variability in opioid prescribing decreased. Future evaluation of specific initiatives within departments is needed.

Assessing and conveying risks and benefits of imaging in neonates using ionizing radiation and sedation/anesthesia.

Neonates represent a unique subset of the pediatric population that requires special attention and careful thought when implementing advanced cross-sectional imaging with CT or MRI. The ionizing radiation associated with CT and the sedation/anesthesia occasionally required for MRI present risks that must be balanced against the perceived benefit of the imaging examination in the unique and particularly susceptible neonatal population. We review the perceived risks of ionizing radiation and the more concrete risks of sedation/anesthesia in term and preterm neonates in the context of an imaging paradigm. When the expected diagnostic yield from CT and MRI is similar, and sedation is required for MRI but not for CT, CT likely has the higher benefit-to-risk ratio in the neonate. However, despite the risks, the most appropriate imaging modality should always be chosen after thoughtful consideration is given to each unique patient and informed discussions including radiology, anesthesia, neonatology and the parents/caregivers are pursued.

Should I irradiate with computed tomography or sedate for magnetic resonance imaging?

In the context of pediatric cross-sectional imaging, the risk of ionizing radiation for CT and the potential adverse effects associated with sedation/anesthesia for MRI continue to provoke lively discussions in the pediatric literature and lay press. This is particularly true for issues relating to the risks of ionizing radiation for CT, which has been a topic of discussion for nearly two decades. In addition to understanding these potential risks and the importance of minimizing individual pediatric patient exposure to ionizing radiation, it is equally important for radiologists to be able to frame these risks with respect to the potential for adverse outcomes associated with the use of anesthesia for cross-sectional imaging in the pediatric population. Notably, before such risks can be estimated and compared, one should always consider the potential utility of each imaging modality for a given diagnosis. If one cross-sectional imaging modality is likely to be far superior to the other for a specific clinical question, every effort must be made to safely image the child, even if sedation/anesthesia is required.

Free-breathing radial stack-of-stars three-dimensional Dixon gradient echo sequence in abdominal magnetic resonance imaging in sedated pediatric patients.

BACKGROUND: There is a strong need for improvements in motion robust T1-weighted abdominal imaging sequences in children to enable high-quality, free-breathing imaging. OBJECTIVE: To compare imaging time and quality of a radial stack-of-stars, free-breathing T1-weighted gradient echo acquisition (volumetric interpolated breath-hold examination [VIBE]) three-dimensional (3-D) Dixon sequence in sedated pediatric patients undergoing abdominal magnetic resonance imaging (MRI) against conventional Cartesian T1-weighed sequences. MATERIALS AND METHODS: This study was approved by the institutional review board with informed consent obtained from all subjects. Study subjects included 31 pediatric patients (19 male, 12 female; median age: 5 years; interquartile range: 5 years) undergoing abdominal MRI at 3 tesla with a free-breathing T1-weighted radial stack-of-stars 3-D VIBE Dixon prototype sequence, StarVIBE Dixon (radial technique), between October 2018 and June 2019 with previous abdominal MR imaging using conventional Cartesian T1-weighed imaging (traditional technique). MRI component times were recorded as well as the total number of non-contrast T1-weighted sequences. Two radiologists independently rated images for quality using a scale from 1 to 5 according to the following metrics: overall image quality, hepatic edge sharpness, hepatic vessel clarity and respiratory motion robustness. Scores were compared between the groups. RESULTS: Mean T1-weighted imaging times for all subjects were 3.63 min for radial exams and 8.01 min for traditional exams (P<0.001), and total non-contrast imaging time was 32.7 min vs. 43.9 min (P=0.002). Adjusted mean total MRI time for all subjects was 60.2 min for radial exams and 65.7 min for traditional exams (P=0.387). The mean number of non-contrast T1-weighted sequences performed in radial MRI exams was 1.0 compared to 1.9 (range: 0-6) in traditional exams (P<0.001). StarVIBE Dixon outperformed Cartesian methods in all quality metrics. The mean overall image quality (scale 1-5) was 3.95 for radial exams and 3.31 for traditional exams (P<0.001). CONCLUSION: Radial stack-of-stars 3-D VIBE Dixon during free-breathing abdominal MRI in pediatric patients offers improved image quality compared to Cartesian T1-weighted imaging techniques with decreased T1-weighted and total non-contrast imaging time. This has important implications for children undergoing sedation for imaging.

Risk of Hypoxemia by Induction Technique Among Infants and Neonates Undergoing Pyloromyotomy.

BACKGROUND: In patients presenting for pyloromyotomy, most practitioners prioritize rapid securement of the airway due to concern for aspiration. However, there is a lack of consensus and limited evidence on the choice between rapid sequence induction (RSI) and modified RSI (mRSI). METHODS: The medical records of all patients presenting for pyloromyotomy from May 2012 to December 2018 were reviewed. The risk of hypoxemia (peripheral oxygen saturation [Spo2], <90%) during induction was compared between RSI and mRSI cohorts for all patients identified as well as in the neonate subgroup by univariate and multivariable logistic regression analysis. Complications (aspiration, intensive care unit admission, bradycardia, postoperative stridor, and hypotension) and initial intubation success for both cohorts were also compared. RESULTS: A total of 296 patients were identified: 181 in the RSI and 115 in the mRSI cohorts. RSI was associated with significantly higher rates of hypoxemia than mRSI (RSI, 30% [23%-37%]; mRSI, 17% [10%-24%]; P = .016). In multivariable logistic regression analysis of all patients, the adjusted odds ratio (OR) of hypoxemia for RSI versus mRSI was 2.8 (95% confidence interval [CI], 1.5-5.3; P = .003) and the OR of hypoxemia for multiple versus a single intubation attempt was 11.4 (95% CI, 5.8-22.5; P < .001). In multivariable logistic regression analysis of neonatal subgroup, the OR of hypoxemia for RSI versus mRSI was 6.5 (95% CI, 2.0-22.2; P < .001) and the OR of hypoxemia for multiple intubation versus single intubation attempts was 18.1 (95% CI, 4.7-40; P < .001). There were no induction-related complications in either the RSI and mRSI cohorts, and the initial intubation success rate was identical for both cohorts (78%). CONCLUSIONS: In infants presenting for pyloromyotomy, anesthetic induction with mRSI compared with RSI was associated with significantly less hypoxemia without an observed increase in aspiration events. In addition, the need for multiple intubation attempts was a strong predictor of hypoxemia. The increased risk of hypoxemia associated with RSI and multiple intubation attempts was even more pronounced in neonatal patients.

Aerosol barriers in pediatric anesthesiology: Clinical data supports FDA caution.

BACKGROUND: The onset of the COVID19 pandemic drove the rapid development and adoption of physical barriers intended to protect providers from aerosols generated during airway management. We report our initial experience with aerosol barrier devices in pediatric patients and raise concerns that they may increase risk to patients. METHODS: In March 2020, we developed and implemented simulation training and use of plastic aerosol barrier devices as a component of our perioperative COVID-19 workflow. As part of our quality improvement process, we obtained detailed feedback via a web-based survey after cases were performed while using these aerosol barriers. RESULTS: Between March and June 2020, 36 pediatric patients age 1mo-18years with anatomically normal airways and either PCR confirmed or suspected COVID-19 were intubated under an aerosol barrier as part of urgent or emergent anesthetic care at our institution. Experienced providers had more difficulty than expected in six (16.7%) of the cases with four cases requiring multiple attempts to secure the airway and two cases involving pronounced difficulty in a single attempt. The aerosol barrier was perceived as a contributing factor to difficulty in all cases. CONCLUSION: The use of barriers may result in unanticipated difficulties with airway management, particularly in pediatric patients, which could lead to hypoxemia or other patient harm. Our initial experience in pediatric patients is the first such report in patients and provides clinical data which corroborates the simulation data prompting the FDA to withdraw support of barriers.

Bilateral Erector Spinae Blocks Decrease Perioperative Opioid Use After Pediatric Cardiac Surgery.

OBJECTIVE: The present study examined the feasibility and efficacy of continuous bilateral erector spinae blocks for post-sternotomy pain in pediatric cardiac surgery. DESIGN: Prospective cohort study; patients were retrospectively matched 1:2 to control patients. Conditional logistic regression was used to compare dichotomous outcomes, and generalized linear models were used for continuous measures, both accounting for clusters. SETTING: Quaternary children's hospital, university setting. PARTICIPANTS: The study comprised 10 children ages five-to-17 years undergoing elective cardiac surgery requiring cardiopulmonary bypass. INTERVENTIONS: Ultrasound-guided bilateral erector spinae blocks at the conclusion of the cardiac surgical procedure, with postoperative infusion of ropivacaine until chest tube removal. Postoperative management otherwise followed standardized guidelines. MEASUREMENTS AND MAIN RESULTS: Patient characteristics were similar in the two groups. The median time to completion of the bilateral blocks was 16.0 minutes (interquartile range [IQR] 14.8-19.3), and no major adverse events were identified. Pain scores were low in both groups. Postoperative opioid use at 48 hours, rendered as oral morphine equivalents, was significantly reduced in the patients receiving the blocks. Cluster-adjusted squared-root-transformed means ± standard error were 0.89 ± 0.06 mg/kg for patients receiving the blocks versus 1.05 ± 0.06 mg/kg for control patients (p = 0.04; raw medians 0.81 [IQR 0.41-1.04] v 1.10 [IQR 0.78-1.35] mg/kg, respectively). There were no differences in recovery metrics, length of stay, or complications. CONCLUSIONS: Bilateral erector spinae blocks were associated with a reduction in opioid use in the first 48 hours after pediatric cardiac surgery compared with a matched cohort from the enhanced recovery program. Larger studies are needed to determine whether this can result in an improvement in recovery and patient satisfaction.

A systematic review of outcomes reported inpediatric perioperative research: A report from the Pediatric Perioperative Outcomes Group.

The Pediatric Perioperative Outcomes Group (PPOG) is an international collaborative of clinical investigators and clinicians within the subspecialty of pediatric anesthesiology and perioperative care which aims to use COMET (Core Outcomes Measures in Effectiveness Trials) methodology to develop core outcome setsfor infants, children and young people that are tailored to the priorities of the pediatric surgical population.Focusing on four age-dependent patient subpopulations determined a priori for core outcome set development: i) neonates and former preterm infants (up to 60 weeks postmenstrual age); ii) infants (>60 weeks postmenstrual age - <1 year); iii) toddlers and school age children (>1-<13 years); and iv) adolescents (>13-<18 years), we conducted a systematic review of outcomes reported in perioperative studies that include participants within age-dependent pediatric subpopulations. Our review of pediatric perioperative controlled trials published from 2008 to 2018 identified 724 articles reporting 3192 outcome measures. The proportion of published trials and the most frequently reported outcomes varied across pre-determined age groups. Outcomes related to patient comfort, particularly pain and analgesic requirement, were the most frequent domain for infants, children and adolescents. Clinical indicators, particularly cardiorespiratory or medication-related adverse events, were the most common outcomes for neonates and infants < 60 weeks and were the second most frequent domain at all other ages. Neonates and infants <60 weeks of age were significantly under-represented in perioperative trials. Patient-centered outcomes, heath care utilization, and bleeding/transfusion related outcomes were less often reported. In most studies, outcomes were measured in the immediate perioperative period, with the duration often restricted to the post-anesthesia care unit or the first 24 postoperative hours. The outcomes identified with this systematic review will be combined with patient centered outcomes identified through a subsequent stakeholder engagement study to arrive at a core outcome set for each age-specific group.

Postoperative pain and psychological outcomes following minimally invasive pectus excavatum repair: A report from the Society for Pediatric Anesthesia Improvement Network.

BACKGROUND: Minimally invasive repair of pectus excavatum (MIRPE) is associated with less tissue trauma; however, it may result in increased postoperative pain. Pain experience is a known risk factor for the development of posttraumatic stress symptoms, though there are little data on its relationship with long-term psychological outcomes following major surgery in pediatric patients. AIMS: In this study, we examined the relationship between immediate postoperative pain and psychological outcomes at 2 weeks and three months after discharge in a cohort of pediatric patients who underwent MIRPE. We sought to determine whether immediate postoperative pain levels were associated with ongoing distress related to aspects of surgery at both time points. We were also interested in how psychological symptoms related to persistent pain concerns. METHODS: Data on patients undergoing MIRPE across 14 institutions were collected as part of the Society for Pediatric Anesthesia Improvement Network (SPAIN). Patients were contacted at 2 weeks and three months following discharge to track pain levels and assess psychological distress using a self-report questionnaire. Patients were grouped into cohorts based on self-report of distress related to aspects of surgery, nonsurgical distress, or absence of distress. RESULTS: Analysis revealed that a higher proportion of children reporting ongoing distress related to surgery at both 2 weeks and 3 months experienced higher immediate postoperative pain levels. A subset of patients with complete data sets for 2 weeks and 3 months (N = 76) was further examined. Among the 47 patients who endorsed surgical distress at 2 weeks, 25 (53.2%) continued to endorse surgical distress at 3 months. Additionally, report of surgical distress at 3 months was associated with longer-term postoperative pain. CONCLUSIONS: Our data suggest that, in patients undergoing MIRPE, the presence of distress at 2 weeks and 3 months may be associated with higher immediate postoperative pain levels.

Trends in Outpatient Procedural Sedation: 2007-2018.

BACKGROUND: Pediatric subspecialists routinely provide procedural sedation outside the operating room. No large study has reported trends in outpatient pediatric procedural sedation. Our purpose in this study was to identify significant trends in outpatient procedural sedation using the Pediatric Sedation Research Consortium. METHODS: Prospectively collected data from 2007 to 2018 were used for trending procedural sedation. Patient characteristics, medications, type of providers, serious adverse events, and interventions were reported. The Cochran-Armitage test for trend was used to explore the association between the year and a given characteristic. RESULTS: A total of 432 842 sedation encounters were identified and divided into 3 4-year epochs (2007-2011, 2011-2014, and 2014-2018). There was a significant decrease in infants <3 months of age receiving procedural sedation (odds ratio = 0.97; 95% confidence interval, 0.96-0.98). A large increase was noticed in pediatric hospitalists providing procedural sedation (0.6%-9.5%; P < .001); there was a decreasing trend in sedation by other providers who were not in emergency medicine, critical care, or anesthesiology (13.9%-3.9%; P < .001). There was an increasing trend in the use of dexmedetomidine (6.3%-9.3%; P < .001) and a decreasing trend in the use of chloral hydrate (6.3%-0.01%; P < .001) and pentobarbital (7.3%-0.5%; P < .001). Serious adverse events showed a nonsignificant increase overall (1.35%-1.75%). CONCLUSIONS: We report an increase in pediatric hospitalists providing sedation and a significant decrease in the use of chloral hydrate and pentobarbital by providers. Further studies are required to see if sedation services decrease costs and optimize resource use.

Measuring behavioral and emotional changes in children following hospitalization: Limitations and future directions.

Psychological and behavioral changes have been observed and documented in children following medical interventions/hospitalizations. The Posthospital Behavior Questionnaire (PHBQ) was created to assess for such changes in youth. Over the past several decades, researchers have used this measure to examine rates and duration of behavior changes as well as relevant risk factors. However, certain limitations to the PHBQ exist that may interfere with its utility. This article advocates for creating an optimized measure with an underlying theoretical framework, clinical cutoffs, and developmental sensitivity in order to better identify and track significant emotional and behavioral changes in youth following hospitalization and surgery.

The effect of suprainguinal fascia iliaca block on the recovery of patients after arthroscopic hip surgery.

BACKGROUND: Adolescent and young adult patients undergoing arthroscopic hip surgery experience significant pain in the immediate postoperative period. There is a small body of evidence that indicates suprainguinal fascia iliaca blocks can improve comfort during recovery from this intervention. Our hypothesis was that patients undergoing hip surgery would consume fewer opioids and have less pain in the perioperative time frame if they received the block as part of their analgesic regimen. METHODS: In this study, we evaluated the outcomes of 716 patients, including 275 who received a suprainguinal fascia iliaca block, and 441 who did not have a block. Inclusion criteria included all age groups and American Society of Anesthesiologists, functional classes 1-2. Patients who received other concurrent procedures or those with incomplete data sets were excluded. We utilized a regional anesthesia database that combined data from various repositories into one web-based relational system. The primary outcomes were total opioid consumption and pain scores in the recovery room. Secondary outcomes included opioid side effects, block-related complications, and total recovery room time. Multivariable logistic regression analysis was used to evaluate opioid consumption, side effects, and total recovery times. Pearson chi-square was applied to assess the level of pain between the two groups. RESULTS: Total opioid consumption was significantly less in the block group compared to those not receiving a block (0.28 mg/kg vs 0.35 mg/kg, P < 0.001, 95% CI of difference in medians 0.04-0.10 mg/kg), but there was no statistical difference in pain scores. Patients with the regional block had a lower frequency of emesis in the PACU (0.7% vs 4.3%; P < 0.005, 95% CI of difference: 2-25) and shorter PACU times (93 vs 108 minutes, P < 0.001, 95% CI of difference: 8-23 minutes). CONCLUSION: Our study supports the clinical effectiveness of suprainguinal fascia iliaca blocks in young patients undergoing arthroscopic hip surgery.