Perioperative clinical practice recommendations for pediatric tonsillectomy: a systematic review.

PURPOSE: Tonsillectomy is one of the most common surgical procedures performed in children. Since most clinical practice guidelines (CPGs) are designed to support surgical decisions, none are specifically designed for the perioperative management of children undergoing tonsillectomy. We aimed to identify and analyze the existing CPGs with recommendations for the perioperative management of children undergoing tonsillectomy by conducting a systematic review. SOURCE: We searched Embase, MEDLINE, MEDLINE ePub Ahead of Print, and CINAHL for relevant articles published from inception to 3 August 2022. The inclusion criteria were: 1) CPG of perioperative recommendations for tonsillectomy under general anesthesia in children, 2) CPG that include at least one evidence-based recommendation, 3) peer-reviewed CPG published in English after 2000. We extracted data on baseline characteristics of each CPG and general recommendations for perioperative interventions or complications. PRINCIPAL FINDINGS: Out of five eligible CPGs, AGREE II and REX confirmed that two CPGs were high quality while only one of the two was recommended for implementation without modifications. Most of the recommendations were for pain management. Acetaminophen was the only medication recommended in all five CPG. Except for the oldest CPG, the CPG all supported of the use of nonsteroidal anti-inflammatory drugs and steroids as a pain adjunct. CONCLUSIONS: Acetaminophen, nonsteroidal anti-inflammatory drugs, and steroids are recommended in the perioperative management of pediatric tonsillectomy. Future CPG should further clarify the safe use of opioids based on severity of obstructive sleep apnea and in the context of opioid-sparing techniques, such as dexmedetomidine, high-dose dexamethasone, and gabapentinoids. STUDY REGISTRATION: PROSPERO (CRD42021253374); first submitted 18 June 2021.

RéSUMé: OBJECTIF: L'amygdalectomie est l'une des interventions chirurgicales les plus courantes pratiquées chez les enfants. Étant donné que la plupart des lignes directrices de pratique clinique sont conçues pour soutenir les décisions chirurgicales, aucune n'est spécifiquement conçue pour la prise en charge périopératoire des enfants bénéficiant d'une amygdalectomie. Notre objectif était d'identifier et d'analyser les lignes directrices de pratique clinique existantes comportant des recommandations pour la prise en charge périopératoire des enfants bénéficiant d'une amygdalectomie en réalisant une revue systématique. SOURCES: Nous avons recherché des articles pertinents dans Embase, MEDLINE, MEDLINE ePub Ahead of Print et CINAHL, publiés depuis la création de ces bases de données jusqu'au 3 août 2022. Les critères d'inclusion étaient les suivants : 1) lignes directrices de pratique clinique comportant des recommandations périopératoires pour l'amygdalectomie sous anesthésie générale chez les enfants, 2) lignes directrices de pratique clinique incluant au moins une recommandation fondée sur des données probantes, et 3) lignes directrices de pratique clinique évaluées par des pairs et publiées en anglais après 2000. Nous avons extrait des données sur les caractéristiques de base de chacune des lignes directrices de pratique clinique et des recommandations générales pour les interventions périopératoires ou les complications. CONSTATATIONS PRINCIPALES: Sur les cinq lignes directrices de pratique clinique admissibles, AGREE II et REX ont confirmé que deux lignes directrices de pratique clinique étaient de haute qualité, tandis qu'une seule des deux a été recommandée pour une mise en œuvre sans modifications. La plupart des recommandations portaient sur la prise en charge de la douleur. L'acétaminophène était le seul médicament recommandé dans les cinq lignes directrices de pratique clinique. À l'exception des lignes directrices de pratique clinique les plus anciennes, les autres ont toutes soutenu l'utilisation d'agents anti-inflammatoires non stéroïdiens et de stéroïdes comme adjuvants pour la douleur. CONCLUSION: L'acétaminophène, les agents anti-inflammatoires non stéroïdiens et les stéroïdes sont recommandés pour la prise en charge périopératoire de l'amygdalectomie pédiatrique. À l'avenir, les lignes directrices de pratique clinique devraient clarifier davantage l'utilisation sécuritaire des opioïdes en fonction de la gravité de l'apnée obstructive du sommeil et dans le contexte des techniques d'épargne des opioïdes, telles que la dexmédétomidine, la dexaméthasone à forte dose et les gabapentinoïdes. ENREGISTREMENT DE L'éTUDE: PROSPERO (CRD42021253374); soumise pour la première fois le 18 juin 2021.

Reducing postoperative pain in children undergoing strabismus surgery: From bundle implementation to clinical decision support tools.

BACKGROUND: Postoperative pain is a significant cause of morbidity in pediatric anesthesia, which can result in delayed discharge and unplanned hospital admission. Children undergoing strabismus surgery are known to be a particularly high-risk group for postoperative pain. AIM: The aim of this project was to reduce the incidence of moderate to severe postoperative pain by 25% over a period of 12 months in children undergoing strabismus surgery. METHODS: This was a multidisciplinary quality improvement project using the Institute for Healthcare Improvement model for improvement and iterative Plan-Do-Study-Act cycles. Baseline data from one hundred patients were collected retrospectively from patient records. Subsequently, iterative interventions introduced comprised: a perioperative bundle (comprising preoperative acetaminophen, intraoperative dexamethasone and ketorolac, a long-acting opioid, and two anti-emetics), email reminders, dissemination of results at departmental rounds, and an intraoperative clinical decision aide. Postoperative pain data were collected as an outcome measure, and length of stay in PACU was monitored as a balancing measure. Statistical process control charts were constructed to monitor bundle compliance and incidence of postoperative pain in the postanesthesia care unit. RESULTS: Postoperative pain and bundle compliance data were collected for 1127 children in total. Baseline mean monthly incidence of moderate to severe postoperative pain was 47.3%. By the conclusion of this project, the incidence of postoperative pain decreased to 21%. Concurrently, mean bundle compliance increased to 78.7%. Mean length of PACU stay for baseline audit patients was 72.5 min compared with 70 min for patients after the introduction of the strabismus macro (November 2018-April 2019, n 91) (mean difference, 2.5; 95% CI, -3.86 to 8.86; P = .439). CONCLUSION: Through the implementation and adoption of an evidence-based bundle of care, we successfully decreased the incidence of moderate to severe postoperative pain for children undergoing strabismus repair. We demonstrated that combining nudge theory with QI methodology can be an effective means of delivering positive results in quality improvement projects.

A 4 year quality improvement initiative reducing post-operative nausea and vomiting in children undergoing strabismus surgery at a quaternary paediatric hospital.

BACKGROUND: Post-operative nausea and vomiting is a significant cause of morbidity in pediatric anesthesia. As well as patient discomfort, post-operative nausea and vomiting can also result in dehydration, delayed discharge and unplanned hospital admission. Children undergoing strabismus surgery are known to be a particularly high risk group for post-operative nausea and vomiting. AIMS: The aim of this project was to reduce post-operative nausea and vomiting by 50% over a period of 12 months. METHODS: This was a single centre retrospective observational study, with prospective observational follow up. A driver diagram was constructed and smart aim established. The Plan-Do-Study-Act method of quality improvement was used for this project. Benchmark data from one hundred patients was collected retrospectively from patient records. After this, interventions were introduced and serial data was prospectively collected. Statistical process control charts were constructed to monitor percentage bundle compliance and incidence of post-operative nausea and vomiting in the post anesthetic care unit. RESULTS: Post-operative nausea and vomiting data was collected for 1079 children in total. Baseline incidence of post-operative nausea and vomiting was 18%. After 4 years this was reduced to 4.72%. At the conclusion of the project there was no significant difference over the previous six months between the incidence of post-operative nausea and vomiting in the strabismus population and the general post anesthetic care unit population. CONCLUSION: Using quality improvement methodology, we were able to sustainably reduce the incidence of post-operative nausea and vomiting for children undergoing strabismus repair. We demonstrated using an evidence based therapeutic bundle can reduce incidence of post-operative nausea and vomiting in the high risk surgical strabismus population to a level comparable to the average post-operative nausea and vomiting incidence in our post anesthetic care unit population.

Development of a five point enhanced recovery protocol for pectus excavatum surgery.

PURPOSE: We implemented and evaluated an Enhanced Recovery after Surgery (ERAS) protocol for Nuss procedures consisting of patient education, bowel management, pre/post-operative transitional pain service involvement, serratus anterior plane blocks and intercostal nerve cryoablation. METHODS: A 5-point ERAS protocol was implemented using multiple plan-do-study-act (PDSA) cycles. Data was collected prospectively for patients in the full ERAS protocol and retrospectively for previous patients. The primary outcome was length of stay (LOS). Secondary outcomes were opioid consumption, pain scores, protocol compliance and patient satisfaction. The impact of PDSA cycles and the ERAS protocol was quantified using statistical process control charts and Mann Whitney U test. RESULTS: A total of 53 patients were identified, 13 within the ERAS protocol and 40 prior to introduction. There was no difference in age, sex, or Haller index between the two cohorts. The median LOS was decreased by 3 days in the ERAS cohort (P = 0.00001). There was decreased opioid consumption on post-operative day 1 (1.47 vs 1.96 MME/kg, p = 0.009) and overall (3.12 vs 6.35 MME/kg, p = 0.0042) in the ERAS cohort. Median pain scores did not differ between cohorts. ERAS bundle element compliance was: education 92%, bowel management 100%, transitional pain involvement 100%, serratus block 100% and cryoablation 100%. The 1-month survey revealed that 92% of patients were satisfied with their experience. CONCLUSION: Our results demonstrate significant reduction in LOS and a trend to decreasing opioid consumption in hospital following ERAS protocol implementation and support the further application of ERAS protocols in pediatrics. LEVEL OF EVIDENCE: III - Retrospective comparative study.

LPS induced hypothermia in pregnant rats: a regulated thermoregulatory response.

Intraperitoneal administration of E. coli LPS in doses that elicit half-maximal (EC50 - 20 ug/kg) and maximal (EC100 - 160 ug/kg) febrile responses in nonpregnant rats produce hypothermia in near-term pregnant rats. The present experiments have been carried out to determine if the hypothermia results from a "regulated" or "forced" thermoregulatory response. Chronically-instrumented pregnant rats were allocated to one of two experimental groups depending upon whether they were studied in an experimental apparatus configured as a metabolic chamber with a uniform ambient temperature of 25 degrees C or configured as a thermocline with a linear temperature gradient ranging from 10 degrees C to 40 degrees C. The pregnant rats developed hypothermia following intraperitoneal administration of 160 ug/kg of E. coli LPS when they were studied in the thermal gradient as well as when they were studied in the uniform thermoneutral environment. They did not attempt to prevent the hypothermia following administration of bacterial pyrogen by moving to a warmer region of the thermocline. Thus, our data provide evidence that the hypothermia which occurs following intraperitoneal administration of an EC100 dose of E. coli LPS results from a regulated rather than a forced thermoregulatory response. The mechanism and consequences of this pregnancy-induced thermoregulatory response to bacterial pyrogen are unknown.