Team Relations and Role Perceptions During Anesthesia Crisis Management in Magnetic-Resonance Imaging Settings: A Mixed Methods Exploration.

BACKGROUND: An increasing number of procedures are performed in non-operating room anesthesia (NORA) settings, including magnetic resonance imaging (MRI) suites. Patient care in NORA is accomplished by interprofessional ad hoc teams (anesthesia clinicians, imaging technologists, and others), who do not regularly work together otherwise. The authors aimed to explore team relations and role perceptions during crisis situations in MRI settings among such ad hoc teams. METHODS: This mixed methods study used a convergent parallel design: The Relational Coordination Index (RCI) and a survey about role perceptions were administered to anesthesia and non-anesthesia personnel working in MRI settings, and semistructured interviews were conducted among a purposive sample. After descriptive statistics and thematic analysis, the authors integrated quantitative and qualitative findings to identify and describe overlapping and mismatched perceptions between the two groups. RESULTS: A total of 67 surveys (response rate 74.4%) and 17 interviews were analyzed. RCI ratings revealed moderate relational coordination between the anesthesia and non-anesthesia groups. Anesthesia and non-anesthesia respondents agreed that the anesthesia clinician assumes leadership during crisis management while non-anesthesia personnel assist. There were nuanced differences in expectations about the role of non-anesthesia personnel in calling for help, understanding specific equipment needs, and performing patient care actions. Many anesthesia clinicians felt unsure about crisis-relevant skills of their non-anesthesia colleagues. MRI technologists emphasized attention to magnetic safety as integral to their role, which was infrequently mentioned by anesthesia personnel. CONCLUSION: Nuanced mismatches in role expectations within the interprofessional care team exist, which may hinder effective crisis management in MRI settings.

Anaesthesia clinicians' perception of safety, workload, anxiety, and stress in a remote hybrid suite compared with the operating room.

BACKGROUND: Anaesthesia care outside of the standard operating room (OR) can be challenging. This prospective matched case-pair study describes the difference in anaesthesia clinicians' perception of safety, workload, anxiety, and stress in two settings by comparing similar neurosurgical procedures performed in either the OR or a remote hybrid room with intraoperative MRI (MRI-OR). METHODS: A visual numeric scale for safety perception and validated instruments for workload, anxiety, and stress were administered to enrolled anaesthesia clinicians after induction of anaesthesia and at the end of eligible cases. The difference in outcomes reported by the same clinician for unique pairs of similar operations performed in both settings (OR vs MRI-OR) was compared using the Student t-test with the general bootstrap algorithm to address the presence of clusters. RESULTS: Over 15 months, 37 clinicians provided data for 53 case pairs. Working in the remote MRI-OR vs OR was associated with lower perceived safety (7.3 [2.0] vs 8.8 [0.9]; P<0.001), higher scores in the workload subdomains effort and frustration (41.6 [24.1] vs 31.3 [21.6]; P=0.006 and 32.4 [22.9] vs 20.7 [17.2]; P=0.002, respectively), and higher anxiety (33.6 [10.1] vs 28.4 [9.2]; P=0.003) at the end of the case. Stress was rated higher in the MRI-OR after induction of anaesthesia (26.5 [15.5] vs 20.9 [13.4]; P=0.006). Effect sizes (Cohen's D) were moderate to good. CONCLUSIONS: Anaesthesia clinicians reported lower perceived safety and higher workload, anxiety, and stress in a remote MRI-OR compared with a standard OR. Improving non-standard work settings should benefit clinician well-being and patient safety. CLINICAL TRIAL REGISTRATION: .

Epidemiology of Surgical Procedures, Anesthesia, and Imaging Studies by Gestational Age during the First Year of Life in Medicaid-Insured Infants.

OBJECTIVES: To evaluate the rate of surgical procedures, anesthetic use, and imaging studies by prematurity status for the first year of life we analyzed data for Texas Medicaid-insured newborns. STUDY DESIGN: We developed a retrospective population-based live birth cohort of newborn infants insured by Texas Medicaid in 2010-2014 with 4 subcohorts: extremely premature, very premature, moderate/late premature, and term. RESULTS: In 1 102 958 infants, surgical procedures per 100 infants were 135.9 for extremely premature, 35.4 for very premature, 15.5 for moderate/late premature, and 6.5 for term. Anesthetic use was 62.0 for extremely premature, 20.8 for very premature, 11.1 for moderate/late premature, and 5.6 for the term subcohort. The most common procedures in the extremely premature were neurosurgery, intubations, and procedures that facilitated caloric intake (gastrostomy tubes and fundoplications). The annual rates for the first year of life for chest radiograph ranged from 15.0 per year for the extremely premature cohort to 0.6 for term infants and for magnetic resonance imaging (MRI) from 0.3 to 0.01. MRI was the most common imaging study with anesthesia support in all maturity levels. MRIs were done in extremely premature without anesthesia in over 90% and in term infants in 57.2%. CONCLUSIONS: Surgical procedures, anesthetic use, and imaging studies in infants are common and more frequent with higher a degree of prematurity while the use of anesthesia is lower in more premature newborns. These findings can provide direction for outcome studies of surgery and anesthesia exposure.

Variation in pediatric local anesthetic dosing for peripheral nerve blocks: an analysis from the Pediatric Regional Anesthesia Network (PRAN).

BACKGROUND: Variation of local anesthetic dosing has been reported for adult peripheral nerve blocks (PNBs) and infant caudal blocks. As higher doses of local anesthetics (LA) are potentially associated with increased risk of complications (eg, local anesthetic systemic toxicity), it is important to understand the source of LA dose variation. Using the Pediatric Regional Anesthesia Network (PRAN) database, we aimed to determine if variation in dosing exists in pediatric single-injection PNBs, and what factors influence that variation.The primary aim of this study was to determine the factors associated with dosing for the 10 most commonly performed PNBs, with the secondary aim of exploring possible factors for variation such as number of blocks performed versus geographic location. METHODS: The PRAN database was used to determine the 10 most common pediatric PNBs, excluding neuraxial regional anesthetics. The 10 most common pediatric PNBs in the PRAN database were analyzed for variation of LA dose and causes for variation. RESULTS: In a cohort of 34 514 children receiving PNBs, the mean age was 10.38 (+/-5.23) years, average weight was 44.88 (+/-26.66) kg and 61.8% were men. The mean bupivacaine equivalent (BE) dose was 0.86 (+/-0.5) mg kg-1 and ropivacaine was used in 65.4% of blocks. Dose decreases with age (estimate -0.016 (-0.017, -0.015; p<0.001)). In all blocks for all age groups, the range of doses that make up the central 80% of all doses exceeds the mean BE dose for the block. Variation is not related to the number blocks performed at an institution (p=0.33 (CI -0.42 to 0.15)). The dose administered for a PNB is driven in order of impact by the institution where the block was performed (Cohen's ƒ=0.45), then by weight (0.31), type of block (0.27), LA used (0.15) and age (0.03). CONCLUSIONS: Considerable variation in dosing exists in all age groups and in all block types. The most impactful driver of local anesthetic dose is the institution where the block was performed, indicating the dosing of a potentially lethal drug is more based on local culture than on evidence.

Improvement in Mortality With Early Fluid Bolus in Sepsis Patients With a History of Congestive Heart Failure.

OBJECTIVE: To determine whether rapid administration of a crystalloid bolus of 30 mL/kg within 3 hours of presentation harms or benefits hypotensive patients with sepsis with a history of congestive heart failure (CHF). PATIENTS AND METHODS: A retrospective cohort study using Medicare claims data enhanced by medical record data from members of the High Value Healthcare Collaborative from July 1, 2013, to June 30, 2015, examining patients with a history of CHF who did (fluid bundle compliant [FBC]) or did not (NFBC) receive a volume bolus of 30 mL/kg within 3 hours of presentation to the emergency department. A proportional Cox hazard model was used to evaluate the association of FBC with 1-year survival. RESULTS: Of the 211 patients examined, 190 were FBC and 21 were NFBC. The FBC patients had higher average hierarchical condition category scores but were otherwise similar to NFBC patients. The NFBC patients had higher adjusted in-hospital and postdischarge mortality rates. The risk-adjusted 1-year mortality rate was higher for NFBC patients (hazard ratio, 2.18; 95% CI, 1.2 to 4.0; P=.01) than for FBC patients. CONCLUSION: In a retrospective claim data-based study of elderly patients with a history of CHF presenting with severe sepsis or septic shock, there is an association of improved mortality with adherence to the initial fluid resuscitation guidelines as part of the 3-hour sepsis bundle.

Economic Burden of Postoperative Neurocognitive Disorders Among US Medicare Patients.

Importance: Postoperative neurocognitive disorders (PNDs) after surgical procedures are common and may be associated with increased health care expenditures. Objective: To quantify the economic burden associated with a PND diagnosis in 1 year following surgical treatment among older patients in the United States. Design, Setting, and Participants: This retrospective cohort study used claims data from the Bundled Payments for Care Improvement Advanced Model from 4285 hospitals that submitted Medicare Fee-for-service (FFS) claims between January 2013 and December 2016. All Medicare patients aged 65 years or older who underwent an inpatient hospital admission associated with a surgical procedure, did not experience a PND before index admission, and were not undergoing dialysis or concurrently enrolled in Medicaid were included. Data were analyzed from October 2019 and May 2020. Exposures: PND, defined as an International Classification of Diseases, Ninth or Tenth Revision, diagnosis of delirium, mild cognitive impairment, or dementia within 1 year of discharge from the index surgical admission. Main Outcomes and Measures: The primary outcome was total inflation-adjusted Medicare postacute care payments within 1 year after the index surgical procedure. Results: A total of 2 380 473 patients (mean [SD] age, 75.36 (7.31) years; 1 336 736 [56.1%] women) who underwent surgical procedures were included, of whom 44 974 patients (1.9%) were diagnosed with a PND. Among all patients, most were White (2 142 157 patients [90.0%]), presenting for orthopedic surgery (1 523 782 patients [64.0%]) in urban medical centers (2 179 893 patients [91.6%]) that were private nonprofits (1 798 749 patients [75.6%]). Patients with a PND, compared with those without a PND, experienced a significantly longer hospital length of stay (mean [SD], 5.91 [6.01] days vs 4.29 [4.18] days; P < .001), were less likely to be discharged home (9947 patients [22.1%] vs 914 925 patients [39.2%]; P < .001), and had a higher incidence of mortality at 1 year after treatment (4580 patients [10.2%] vs 103 767 patients [4.4%]; P < .001). After adjusting for patient and hospital characteristics, the presence of a PND within 1 year of the index procedure was associated with an increase of $17 275 (95% CI, $17 058-$17 491) in cost in the 1-year postadmission period (P < .001). Conclusions and Relevance: The findings of this cohort study suggest that among older Medicare patients undergoing surgical treatment, a diagnosis of a PND was associated with an increase in health care costs for up to 1 year following the surgical procedure. Given the magnitude of this cost burden, PNDs represent an appealing target for risk mitigation and improvement in value-based health care.

Variation Between and Within Hospitals in Single Injection Caudal Local Anesthetic Dose: A Report From the Pediatric Regional Anesthesia Network.

BACKGROUND: Given that variation exists in health care utilization, expenditure, and medical practice, there is a paucity of data on variation within the practice of anesthesia. The Pediatric Regional Anesthesia Network (PRAN) data lend itself to explore whether different medical practice patterns exist and if there are nerve blocks with more local anesthetic dosing variation than others. The primary aim of this study was to quantify variation in single injection caudal block dosing, and the secondary aim was to explore possible causes for variation (eg, number of blocks performed versus geographic location). METHODS: We queried the PRAN database for single injection caudal blocks in children <1 year of age. Data were analyzed for local anesthetic dose, variation within and across institutions, and possible causes. RESULTS: Mean dose of bupivacaine equivalents per kilogram (BE·kg) among sites ranged from 1.39 to 2.22 with an interdecile range (IDR) containing the mid 80% of all doses ranging from 0.21 to 1.48. Mean dose (BE·kg) was associated with site, age, weight, and local anesthetic used (all P < .0001). Cohen's F effect size estimate was 10 times higher for site (0.65) than for age (0.05) or weight (0.02). Variation (IDR) was not related to number of blocks done at each site (P = .23). Mean volume per kilogram was 0.9± ± 0.2 (mean ± ±standard deviation) and was more strongly associated with site (Cohen's F 0.3) than age (0.04) or weight (0.07). CONCLUSIONS: Wide variation in caudal local anesthetic dosing and administered volume exists. This variation is independent of the number of cases performed at each center but rather is determined by study site (ie, variation between centers) with considerable additional variation within study centers, suggesting additional variability dependent on individual practitioners. While there are legitimate reasons to vary dosing, the current approach is inconsistent and not supported by strong evidence over giving a standardized dose.

Thoracic caudal epidural catheter localization using ultrasound guidance.

Caudal epidural catheters provide exceptional analgesia while avoiding or minimizing opioids. Historically, the catheter tip location (dermatomal level) was estimated or verified via epidurogram. According to the Pediatric Regional Anesthesia Database, the majority of caudal-to-thoracic epidural catheters are placed without imaging guidance or verification of the position of the catheter tip. Ponde et al demonstrated that catheter insertion depth was longer when using ultrasound guidance than when estimated by external measurement. We report a simple yet novel ultrasound approach for catheter localization.

Settled science or unwarranted variation in local anesthetic dosing? An analysis from an International Registry of Regional Anesthesiology.

BACKGROUND: Variation in clinical practice is often considered unwarranted when it does not reflect patient preference or evidence-based medicine. Complications from regional anesthesia such as nerve injury and systemic toxicity are dose dependent. It is currently unclear if there is significant variation with the dosing of local anesthetics (LA) in the context of the modern practice of peripheral regional anesthesia. METHODS: We analyzed data from the International Registry of Regional Anesthesia that include prospective data on peripheral regional anesthesia procedures from 21 centers located around the world. Using data from years 2011 to 2017, our primary aim was to characterize the degree of variation in dosing of LA for the top 10 most commonly performed single injection peripheral nerve blocks. Our secondary aim was to identify potential drivers of this variation. RESULTS: Among the 26 457 peripheral blocks performed, mean (±SD) LA dose per block in ropivacaine equivalents was 125.1±51.2 mg and 1.6±0.7 for mg/kg. There was large variation across all block types, with the highest variation (measured by interdecile range) in axillary blocks (143.8 mg) and lowest in interscalene blocks (83.3 mg). In a regression analysis, dose was primarily associated with the hospital (Cohen's f=0.37) where the block was administered and block type (f=0.38), less so with age (f=0.02), weight (f=0.12), gender (f=0.05) or LA (f=0.17) used. Hospital site had strong impact on variation in LA dose (f=0.88). Variation was not significantly associated with number of blocks performed by hospital site. CONCLUSIONS: Large variation in dosing for regional blocks exists within and among hospitals, which is unlikely to be warranted. For many blocks, the variation of dosing is larger than the mean dose. Hospital site had strong impact on variation in LA dose and moderate impact on mean LA dose.

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.

Safety in Acute Pain Medicine-Pharmacologic Considerations and the Impact of Systems-Based Gaps.

Objective: In the setting of an expanding prevalence of acute pain medicine services and the aggressive use of multimodal analgesia, an overview of systems-based safety gaps and safety concerns in the setting of aggressive multimodal analgesia is provided below. Setting: Expert commentary. Methods: Recent evidence focused on systems-based gaps in acute pain medicine is discussed. A focused literature review was conducted to assess safety concerns related to commonly used multimodal pharmacologic agents (opioids, nonsteroidal anti-inflammatory drugs, gabapentanoids, ketamine, acetaminophen) in the setting of inpatient acute pain management. Conclusions: Optimization of systems-based gaps will increase the probability of accurate pain assessment, improve the application of uniform evidence-based multimodal analgesia, and ensure a continuum of pain care. While acute pain medicine strategies should be aggressively applied, multimodal regimens must be strategically utilized to minimize risk to patients and in a comorbidity-specific fashion.

The Afferent Limb of Rapid Response Systems: Continuous Monitoring on General Care Units.

The prevention of adverse events continues to be the focus of patient safety work. Although rapid response systems have improved the efferent limb of the patient's rescue, the detection of the patient's deterioration (the afferent limb) has not been solved. This article provides an overview of the complex issues surrounding patient surveillance by addressing the principal considerations of continuous monitoring as they relate to implementation, choice of sensors and physiologic variables, notification, and alarm balancing, as well as future research opportunities.

Characteristics of Desaturation and Respiratory Rate in Postoperative Patients Breathing Room Air Versus Supplemental Oxygen: Are They Different?

BACKGROUND: Routine monitoring of postoperative patients with pulse oximetry-based surveillance monitoring has been shown to reduce adverse events. However, there is some concern that pulse oximetry is limited in its ability to detect deterioration quickly enough to allow for intervention in patients receiving supplemental oxygen. To address such concerns, this study expands on the current limited knowledge of differences in desaturation and respiratory rate characteristics between patients breathing room air and those receiving supplemental oxygen. METHODS: Pulse oximetry-derived data and patient characteristics were used to examine overnight desaturation patterns of 67 postoperative patients who were receiving either supplemental oxygen or breathing room air. The 2 modalities with respect to the speed of desaturation, in addition to magnitude and duration of desaturation events, are compared. Night-time pulse rate, oxygen saturation, respiratory rate, and the transition times from normal oxygen saturation levels to desaturated states are also compared. The behavior of respiratory rate in proximity to desaturation events is described. Statistical methods included multivariable regression and inverse probability of treatment weighted to adjust for any imbalance in patient characteristics between the oxygen and room air patients and linear mixed effect models to account for clustering by patient. RESULTS: The study included 33 patients on room air and 34 receiving supplemental oxygen. The speed of desaturation was not different for room air versus oxygen for 2 types of desaturation (adjusted % difference, 95% confidence interval [CI]: type I; 22.4%, -51.5% to 209%; P = .67, type II; -17.3%, -53.8% to 47.6%; P = .52). Patients receiving supplemental oxygen had a higher mean oxygen saturation (adjusted difference, 95% CI, 2.4 [0.7-4.0]; P = .006). No differences were found for the average overnight respiratory or pulse rate, or proportion of time in desaturation states between the 2 groups.The time to transition from a normal oxygen saturation (92%) to 88% or below was not longer for supplemental oxygen patients (P = .42, adjusted difference 26.1%: 95% CI, -28.1% to 121%). Respiratory rates did not differ between the overall mean and desaturation or recovery phases or between the oxygen and room air group. CONCLUSIONS: In this study, desaturation characteristics did not differ between patients receiving supplemental oxygen and breathing room air with regard to speed, depth, or duration of desaturation. Transition time for desaturations to reach low oxygen saturation alarms was not different, while respiratory rate remained in the normal range during these events. These findings suggest that pulse oximetry-based surveillance monitoring for deterioration detection can be used equally effectively for patients on supplemental oxygen and for those on room air.

Assessment of continuous acoustic respiratory rate monitoring as an addition to a pulse oximetry-based patient surveillance system.

Technology advances make it possible to consider continuous acoustic respiratory rate monitoring as an integral component of physiologic surveillance systems. This study explores technical and logistical aspects of augmenting pulse oximetry-based patient surveillance systems with continuous respiratory rate monitoring and offers some insight into the impact on patient deterioration detection that may result. Acoustic respiratory rate sensors were introduced to a general care pulse oximetry-based surveillance system with respiratory rate alarms deactivated. Simulation was used after 4324 patient days to determine appropriate alarm thresholds for respiratory rate, which were then activated. Data were collected for an additional 4382 patient days. Physiologic parameters, alarm data, sensor utilization and patient/staff feedback were collected throughout the study and analyzed. No notable technical or workflow issues were observed. Sensor utilization was 57 %, with patient refusal leading reasons for nonuse (22.7 %). With respiratory rate alarm thresholds set to 6 and 40 breaths/min., the majority of nurse pager clinical notifications were triggered by low oxygen saturation values (43 %), followed by low respiratory rate values (21 %) and low pulse rate values (13 %). Mean respiratory rate collected was 16.6 ± 3.8 breaths/min. The vast majority (82 %) of low oxygen saturation states coincided with normal respiration rates of 12-20 breaths/min. Continuous respiratory rate monitoring can be successfully added to a pulse oximetry-based surveillance system without significant technical, logistical or workflow issues and is moderately well-tolerated by patients. Respiratory rate sensor alarms did not significantly impact overall system alarm burden. Respiratory rate and oxygen saturation distributions suggest adding continuous respiratory rate monitoring to a pulse oximetry-based surveillance system may not significantly improve patient deterioration detection.

A Framework for Aligning Data from Multiple Institutions to Conduct Meaningful Analytics.

INTRODUCTION: Health systems can be supported by collaborative networks focused on data sharing and comparative analytics to identify and rapidly disseminate promising care practices. Standardized data collection, quality assessment, and cleansing is a necessary process to facilitate meaningful analytics for operations, quality improvement, and research. We developed a framework for aligning data from health care delivery systems using the High Value Healthcare Collaborative central registry. FRAMEWORK: The centralized data registry model allows for multiple layers of data quality assessment. Our framework uses an iterative approach, starting with clear specifications, maintaining ongoing dialogue with diverse stakeholders, and regular checkpoints to assess data conformance, completeness, and plausibility. LESSONS LEARNED: We found that an iterative communication process is critical for a central registry to ensure: 1) clarity of data specifications, 2) appropriate data quality, and 3) thorough understanding of data source, purpose, and context. Engaging teams from all participating institutions and incorporating diverse stakeholders of clinicians, information technologists, data analysts, operations managers, and health services researchers in all decision making processes supports development of high quality datasets for comparative analytics across multiple institutions. CONCLUSION: A standard data specification and submission process alone does not guarantee aligned data for a collaborative registry. Implementing an iterative data quality improvement framework with extensive communication proved to be effective for aligning data from multiple institutions to support meaningful analytics.

Surveillance Monitoring Management for General Care Units: Strategy, Design, and Implementation.

BACKGROUND: The growing number of monitoring devices, combined with suboptimal patient monitoring and alarm management strategies, has increased "alarm fatigue," which have led to serious consequences. Most reported alarm man- agement approaches have focused on the critical care setting. Since 2007 Dartmouth-Hitchcock (Lebanon, New Hamp- shire) has developed a generalizable and effective design, implementation, and performance evaluation approach to alarm systems for continuous monitoring in general care settings (that is, patient surveillance monitoring). METHODS: In late 2007, a patient surveillance monitoring system was piloted on the basis of a structured design and implementation approach in a 36-bed orthopedics unit. Beginning in early 2009, it was expanded to cover more than 200 inpatient beds in all medicine and surgical units, except for psychiatry and labor and delivery. RESULTS: Improvements in clinical outcomes (reduction of unplanned transfers by 50% and reduction of rescue events by more than 60% in 2008) and approximately two alarms per patient per 12-hour nursing shift in the original pilot unit have been sustained across most D-H general care units in spite of increasing patient acuity and unit occupancy. Sample analysis of pager notifications indicates that more than 85% of all alarm conditions are resolved within 30 seconds and that more than 99% are resolved before escalation is triggered. CONCLUSION: The D-H surveillance monitoring system employs several important, generalizable features to manage alarms in a general care setting: alarm delays, static thresholds set appropriately for the prevalence of events in this setting, directed alarm annunciation, and policy-driven customization of thresholds to allow clinicians to respond to needs of individual patients. The systematic approach to design, implementation, and performance management has been key to the success of the system.

Asleep versus awake: does it matter?: Pediatric regional block complications by patient state: a report from the Pediatric Regional Anesthesia Network.

BACKGROUND AND OBJECTIVES: The impact of the patient state at time of placement of regional blocks on the risk of complications is unknown. Current opinion is based almost entirely on case reports, despite considerable interest in the question. Analyzing more than 50,000 pediatric regional anesthesia blocks from an observational prospective database, we determined the rate of adverse events in relation to the patient's state at the time of block placement. Primary outcomes considered were postoperative neurologic symptoms (PONSs) and local anesthetic systemic toxicity (LAST). Secondary outcome was extended hospital stay due to a block complication. METHODS: The Pediatric Regional Anesthesia Network is a multi-institutional research consortium that was created with an emphasis on rigorous, prospective, and complete data collection including a data validation and audit process. For the purpose of the analysis, blocks were divided in major groups by single injection versus continuous and by block location. Rates were determined in aggregate for these groups and classified further based on the patient's state (general anesthesia [GA] without neuromuscular blockade [NMB], GA with NMB, sedated, and awake) at the time of block placement. RESULTS: Postoperative neurological symptoms occurred at a rate of 0.93/1000 (confidence interval [CI], 0.7-1.2) under GA and 6.82/1000 (CI, 4.2-10.5) in sedated and awake patients. The only occurrence of PONSs lasting longer than 6 months (PONSs-L) was a small sensory deficit in a sedated patient (0.019/1000 [CI, 0-0.1] for all, 0.48/1000 [CI, 0.1-2.7] for sedated patients). There were no cases of paralysis. There were 5 cases of LAST or 0.09/1000 (CI, 0.03-0.21). The incidence of LAST in patients under GA (both with and without NMB) was 0.08/1000 (CI, 0.02-0.2) and 0.34/1000 (CI, 0-1.9) in awake/sedated patients. Extended hospital stays were described 18 times (0.33/1000 [CI, 0.2-0.53]). The rate for patients under GA without NMB was 0.29/1000 (CI, 0.13-0.48); GA with NMB, 0.29/1000 (CI, 0.06-0.84); sedated, 1.47/1000 (CI, 0.3-4.3); and awake, 1.15/1000 (CI, 0.02-6.4). CONCLUSIONS: The placement of regional anesthetic blocks in pediatric patients under GA is as safe as placement in sedated and awake children. Our results provide the first prospective evidence for the pediatric anesthesia community that the practice of placing blocks in anesthetized patients should be considered safe and should remain the prevailing standard of care. Prohibitive recommendations based on anecdote and case reports cannot be supported.