Changes in cerebral and renal oxygenation during laparoscopic pyloromyotomy

Although a laparoscopic approach may be preferred over open procedures for abdominal surgery, there are limited data on the effect of laparoscopic procedures on cerebral and renal oxygenation in neonates and young infants. Here, we evaluated the effect in neonates and infants. In this two-center prospective observational study, we evaluated changes in cerebral and renal regional oxygen saturation (rSO₂) in infants during laparoscopic pyloromyotomy. Intraoperative hemodynamic and respiratory parameters and rSO₂ were recorded. For the primary outcome, these parameters were compared at incision and at the end of pneumoperitoneum. The study cohort included 25 infants with a mean age of 40 ± 10 days and weight of 4.0 ± 0.6 kg. IAP at the beginning of laparoscopy was 10 ± 2 mmHg (range 7-15 mmHg). Although both cerebral and renal rSO₂ decreased from incision compared to the end of laparoscopy, the decrease reached statistical significance only for cerebral rSO₂ (81 ± 12 to 76 ± 16, p = 0.033). Similarly, the increase in fractional tissue oxygen extraction (FTOE) was only statistically significant for cerebral FTOE (0.18 ± 0.12 to 0.23 ± 0.16, p = 0.037). No change in hemodynamic or respiratory parameters was found. Although there was a decrease in cerebral rSO₂ and increase in cerebral FTOE during pneumoperitoneum, the values did not decrease below those noted before anesthetic induction.

Pediatric chronic pain and caregiver burden in a national survey

Background and aims Caring for children with chronic pain incurs burdens of cost and time for families. We aimed to describe variation in caregiver burden among parents of adolescents with chronic pain who responded to a nationally-representative survey. Our secondary aim was to identify child and parent characteristics associated with increased caregiver burden. Methods We used de-identified, publicly-available data from the 2016 National Survey of Children's Health (NSCH), designed to be representative of non-institutionalized children in the United States. We analyzed data for households where an adolescent age 12-17 years old was reported by a parent to have chronic pain. Outcomes included the parent's time spent on the child's health needs, reduced labor force participation, and out-of-pocket medical costs. Results Data on 1,711 adolescents were analyzed. For adolescents with chronic pain, 15% of parents reported spending at least 1 h/week on their child's health care, 14% reported cutting back on paid work, and 36% reported spending ≥$500 on their child's health care in the past 12 months. Adolescents' general health status and extent of specialized health care needs predicted increased caregiver burden across the three measures. Conversely, no consistent differences in caregiver burden were noted according to demographic or socioeconomic characteristics. Conclusions Among adolescents with chronic pain identified on a nationally-representative survey, parents frequently reported reducing work participation and incurring out-of-pocket expenses in providing health care for their child. Caregiver burdens increased with indicators of greater medical complexity (e.g. presence of comorbidities, need for specialized health care) and poorer overall adolescent health status. Implications We add a national-level perspective to studies previously performed in clinical samples addressing caregiver burden in pediatric chronic pain. Initiatives to reduce the burden of caring for children with chronic pain, described in prior work, may be especially beneficial for families with adolescents whose chronic pain is accompanied by other health problems or requires coordination of care among multiple providers.

Age-Dependent Impact of Pre-Transplant Intensive Care Unit Stay on Mortality in Heart Transplant Recipients

Background

Heart transplantation (HTx) is a treatment option for refractory end-stage heart failure. Severe illness requiring pre-transplant intensive care unit (ICU) stay may be a risk factor for diminished post-transplant survival, but this association is surprisingly inconsistent in recent studies. To clarify the significance of ICU stay as a risk factor for heart transplant outcomes, we aimed to define if patient age was a factor in which ICU stay was predictive of survival after HTx.

Methods

De-identified data were obtained on isolated first-time HTx performed during the years 2006 - 2015 from the UNOS Registry. Nine age groups were defined. The primary outcome was 1-year post-transplant mortality. Cox proportional hazard regression estimated unadjusted and adjusted hazard ratio (HR) associated with pre-transplant ICU stay in each age group.

Results

The analysis included 19,508 patients (9% deceased within 1 year). In the overall cohort, pre-transplant ICU stay was associated with increased hazard of 1-year mortality (HR = 1.3; 95% confidence interval (CI): 1.2 - 1.4; P < 0.001); but further univariate analysis showed a greater hazard of 1-year mortality associated with ICU stay in infants (HR = 2.2; 95% CI: 1.5 - 3.2; P < 0.001). However, the adjusted analysis found that adults ages 40 - 49 had the highest statistically significant hazard of 1-year mortality (HR = 1.5; 95% CI: 1.1 - 2.1; P = 0.011).

Conclusions

Our study established age variation in the association between ICU stay and survival after HTx, with this association being strongest among adults, 40 to 49 years of age, undergoing HTx. Previous data suggesting decreased survival in infants may be related to the increased use of extracorporeal membrane oxygenation as a mechanical cardiac assist rather than ventricular assist devices.

Overnight inpatient admission and revisit rates after pediatric adenotonsillectomy

Objective: Overnight admission may be necessary following adenotonsillectomy (T&A) in pediatric patients. This practice may reduce unplanned revisits following hospital discharge.

Study design: Retrospective cohort study.

Subjects: Children from the PHIS database.

Methods: T&A performed in children during the years 2007–2015 were identified in the Pediatric Health Information System. The primary outcome was 7-day, all-cause readmission or emergency department (ED) revisit. Secondary analysis examined specific revisit types and 30-day revisits. The primary exposure was each institution’s annual rate of overnight stay after T&A.

Results: The analysis included 411,876 procedures at 48 hospitals. Hospitals’ annual rates of overnight stay following T&A ranged from 3% to 100%, and 7-day revisit rates varied from 0% to 15%. The percentage or rate of 7-day revisits did not differ based on the use of overnight stay following T&A. At hospitals with higher overnight admission rates after T&A, 7-day revisits were more likely to take the form of inpatient admission rather than an ED visit.

Conclusions: The current study confirms that pediatric hospitals vary widely in inpatient admission practices following T&A. This variation is not associated with differences in revisit rates at 7 and 30 days related to any cause. Although no mortality was noted in the current study, caution is suggested when deciding on the disposition of patients with comorbid conditions as risks related to various patients, anesthetic, and surgical-related issues exist. Risk stratification with appropriate identification of patients requiring overnight stay may be the most important for preventing acute care revisits after T&A.

Sugammadex for Reversal of Neuromuscular Blockade in a Patient With Renal Failure

Residual neuromuscular blockade following the use of non-depolarizing neuromuscular blocking agents (NMBAs) can lead to postoperative respiratory complications, including oxygen desaturation, atelectasis, and pneumonia. Sugammadex rapidly reverses steroidal NMBAs by encapsulating them in a highly stable water-soluble complex. This NMBA-sugammadex complex then undergoes renal elimination. In patients with renal insufficiency or failure, concern has been expressed regarding the elimination of the NMBA-sugammadex complex. We present a 19-year-old patient with renal failure who received sugammadex for reversal of neuromuscular blockade. The use of sugammadex in patients with renal dysfunction is discussed and safety concerns are reviewed.

Defining a Liver Transplant Benefit Threshold for the Model for End-Stage Liver Disease-Sodium Score

OBJECTIVES

The benefits of transplant are shown as the difference in survival posttransplant versus that shown if the patient had remained on the wait list. Serum sodium was added to improve prediction. We sought to revisit the question of which Model for End-Stage Liver Disease-Sodium score threshold corresponded to a predicted benefit of liver transplant.

MATERIALS AND METHODS

Data on adult patients (≥ 18 years old) were obtained from the United Network for Organ Sharing registry (date range of June 18, 2013 to December 2016). Exclusion criteria were individuals listed for multiple organs or liver retransplant, patients who eventually underwent living-donor liver transplant, and patients with MELD score < 12. We used multivariable Cox proportional hazards regression to determine a time-dependent covariate for undergoing transplant with either MELD or MELD-sodium scores to describe the variability in estimated transplant benefit within 6 months of listing.

RESULTS

Our study included 14 352 patients. There were 902 patients with MELD score of 39 to 40 (6.3%) and 931 patients with MELD-Na score of 39 to 40 (6.5%). Using the original MELD score, we found that 90% of the cohort could derive benefit from transplant compared with 83% when MELD-Na was used. We found that 13% of patients had a predicted transplant benefit when determined using either MELD or MELD-Na but not both. The threshold for transplant benefit was 16 and 17 using MELD and MELD-Na, respectively.

CONCLUSIONS

Transition to MELD-Na did not define a more precise range at which patients benefited from transplant, and a similar percentage of patients was expected to derive benefit. Future revisions of donor liver allocation may allow better discrimination of expected transplant benefits among candidates currently assigned a high priority for donor livers.

Timing of Palliative Consultation for Children During a Fatal Illness

BACKGROUND

The American Academy of Pediatrics recommends palliative care for children at the diagnosis of serious illness. Yet few children who die receive specialty palliative care consultation, and when it is provided, palliative care consultation tends to occur after >75% of the time from diagnosis until death. Focusing on the timing of palliative consultation in relation to the date of diagnosis, we evaluated factors predicting earlier receipt of pediatric palliative care in a cohort of decedents.

METHODS

We retrospectively identified patients diagnosed with a life-limiting disease who died at our hospital in 2015-2017 after at least 1 inpatient palliative medicine consultation. Our primary outcome was time from palliative-qualifying diagnosis to earliest receipt of specialty palliative care. A survival analysis was used to describe factors associated with earlier receipt of palliative care.

RESULTS

The analysis included 180 patients (median age at diagnosis <1 month [interquartile range (IQR): 0-77]). The median time to first palliative consultation was 7 days after diagnosis (IQR: 2-63), compared with a median of 50 days between diagnosis and death (IQR: 7-210). On the multivariable analysis, palliative consultation occurred earlier for patients who had cardiovascular diagnoses, had private insurance, and were of African American race.

CONCLUSIONS

In a cohort of decedents at our institution, palliative consultation occurred much earlier than has been previously reported. We also identify factors associated with delayed receipt of palliative care among children who are dying that reveal further opportunities to improve access to specialty palliative care.

Prediction of mortality following pediatric heart transplant using machine learning algorithms

BACKGROUND

Optimizing transplant candidates' priority for donor organs depends on the accurate assessment of post-transplant outcomes. Due to the complexity of transplantation and the wide range of possible serious complications, recipient outcomes are difficult to predict accurately using conventional multivariable regression. Therefore, we evaluated the utility of 3 ML algorithms for predicting mortality after pediatric HTx.

METHODS

We identified patients <18 years of age receiving HTx in 2006-2015 in the UNOS Registry database. Mortality within 1, 3, or 5 years was predicted using classification and regression trees, RFs, and ANN. Each model was trained using cross-validation, then validated in a separate testing set. Model performance was primarily evaluated by the area under the receiver operating characteristic (AUC) curve.

RESULTS

The training set included 2802 patients, whereas 700 were included in the testing set. RF achieved the best fit to the training data with AUCs of 0.74, 0.68, and 0.64 for 1-, 3-, and 5-year mortality, respectively, and performed best in the testing data, with AUCs of 0.72, 0.61, and 0.60, respectively. Nevertheless, sensitivity was poor across models (training: 0.22-0.58; testing: 0.07-0.49).

DISCUSSION

ML algorithms demonstrated fair predictive utility in both training and testing data, but the sensitivity of these algorithms was generally poor. With the registry missing data on many determinants of long-term survival, the ability of ML methods to predict mortality after pediatric HTx may be fundamentally limited.

The peer review process

The peer review process provides a foundation for the credibility of scientific findings in medicine. The following article discusses the history of peer review in scientific and medical journals, the process for the selection of peer reviewers, and how journal editors arrive at a decision on submitted manuscripts. To aid authors who are invited to revise their manuscripts for further consideration, we outline steps for considering reviewer comments and provide suggestions for organizing the author's response to reviewers. We also examine ethical issues in peer review and provide recommendations for authors interested in becoming peer reviewers themselves.

Evaluation of postoperative analgesia in pediatric patients after hip surgery: lumbar plexus versus caudal epidural analgesia

Background:There continues to be focus on the value of regional and neuraxial anesthetic techniques when combined with general anesthesia to improve postoperative analgesia. The reported advantages include decreased postoperative opioid requirements, decreased medication-related adverse effects, decreased hospital length of stay, and increased patient satisfaction. Orthopedic procedures of the hip may be amenable to such techniques as there is significant postoperative pain with the requirement for hospital admission and the administration of parenteral opioids. Given the surgical site, various regional anesthetic techniques may be used to provide analgesia including caudal epidural anesthesia (CEA) or lumbar plexus blockade (LPB).

Purpose: The objective of this study was to assess the effectiveness of LPB versus CEA as an analgesic thechnique for patients undergoing elective hip surgery from the opioid consumption and pain scores perspective.

Patients and methods: The current study retrospectively reviews our experience with CEA and LPB for postoperative analgesia after hip surgery in the pediatric population. Regional anesthesia technique was reviewed as well as opioid requirements and pain scores.

Results: The study cohort included 61 patients, 29 who received an LPB and 32 who received CEA. No difference was noted in the demographics between the two groups. Intraoperative opioid use was 0.7 (IQR: 0.5, 1.1) mg/kg of oral morphine equivalents (MEs) in the LPB group compared to 0.6 (IQR: 0.5, 0.9) in the CEA group (p=0.479). Postoperative opioid use over the first 48 hrs was 4 (IQR: 1, 6) mg/kg of oral ME in the LPB group, compared to 2 (interquartile range [IQR]: 1, 3) in the CEA group (p=0.103). Over the first 24 hrs after surgery, the median pain score in the LPB group was 5 (IQR: 1–6), compared to 3 (IQR: 0, 5) in the CEA group (p=0.014).Conclusion: These retrospective data suggest a modest postoperative benefit of CEA when compared to LPB following hip surgery in the pediatric population. Postoperative pain scores were lower in patients receiving CEA; however, no difference in the intraoperative or postoperative opioid requirements was noted between the two groups.

Are There Missed Opportunities to Maximize Organ Donation Registrations? An Examination of Driver’s License Applications Across the United States

Introduction:

With 116 000 people waiting for transplants and 8000 patients dying annually on waiting lists, the United States has a considerable organ shortage. An insufficient number of Americans have registered to become organ donors when obtaining driver’s licenses or ID cards. Across states, there is considerable variability in organ donor registration rates as well as driver’s license applications.

Methods:

The purpose of this project was to describe the variability in the phrasing of the organ donor registration question by state bureaus of motor vehicles as well as other application questions that might influence this decision. In particular, the frequency of states employing empirically supported messages to increase donor registrations was ascertained. The content and phrasing of 46 different driver’s license applications was coded in regard to seeking organ donor registrations.

Findings:

No states used the empirically supported strategies of reciprocity, descriptive norms, or loss/gain framing from the interdisciplinary field of behavioral economics. Twelve states used injunctive norms to signify social approval for organ donation. Many state applications had lengthy organ donation sections and health questions that could discourage donor registrations.

Discussion:

There is an extremely low use of empirically supported messages to increase organ donation registrations in driver’s license applications in the United States. Opportunities exist for thoughtful consideration of the wording of driver’s license applications. States interested in exploring ways to increase donations could undertake controlled variation of applications to test the effects of message framing on registration rates.

Population-based study of congenital heart disease and revisits after pediatric tonsillectomy

Objective

Accurate assessment of risk factors such as congenital heart disease (CHD) can aid in risk stratification of children presenting for surgery. Risk stratification is especially important in tonsillectomy ± adenoidectomy (T/A), a common pediatric procedure that is usually performed electively, but that has a high rate of adverse events. In this study, we examined the association of CHD with revisits after T/A.

Methods

We identified children who underwent T/A at hospitals and hospital‐owned facilities during 2010 to 2014 using the State Inpatient Databases and State Ambulatory Surgery and Services Databases of Florida, Georgia, Iowa, New York, and Utah. We evaluated the association between CHD severity and the occurrence of an unplanned hospital readmission or ED visit within 30 days following discharge using multivariable logistic regression.

Results

The analysis included 244,598 patients, of whom 858 had minor or major CHD. In multivariable analysis, CHD was not associated with an increased risk of 30‐day revisits (minor OR = 1.1; 95% CI: 0.8, 1.5; P = .65; major OR = 1.2; 95% CI: 0.9, 1.6; P = .34). Other comorbidities, including chromosomal anomalies (OR = 1.4; 95% CI: 1.2, 1.6; P < .001), congenital airway anomalies (OR = 1.3; 95% CI: 1.03, 1.7; P = .03), and neuromuscular impairment (OR = 1.4; 95% CI: 1.2, 1.7; P < .001) predicted an increased likelihood of revisits.

Conclusion

Neither minor nor major CHD was independently associated with an increased risk of 30‐day revisits among children undergoing T/A. Other characteristics, particularly non‐cardiac comorbidities, socioeconomic status, and geographic region may be of greater utility for predicting revisit risk following pediatric T/A.

Level of Evidence

2b

Implications of Pediatric Palliative Consultation for Intensive Care Unit Stay

Background: The impact of specialty pediatric palliative care (PPC) on intensive care unit (ICU) length of stay for children is unclear. Objective: To estimate the impact of PPC consultation by analyzing ICU stay as a dynamic outcome over the course of hospitalization. Patients and Methods: Retrospective cohort study of children hospitalized with diagnoses suggested as referral triggers for PPC at a large academic children's hospital. We assessed ICU stay according to PPC consultation and, using a patient-day analysis, applied multivariable mixed effects logistic regression to predict the odds of being in the ICU on a given day. Results: The analytic sample included 777 admissions (11,954 hospital days), of which 100 admissions (13%) included PPC consultation. Principal patient demographics were age 8 ± 6 years, 55% male sex, 71% white race, and 52% commercial insurance. Cardiac diagnoses were most frequent (29%) followed by gastrointestinal (22%) and malignant (20%) conditions. Although total ICU stay was longer for admissions, including PPC consultation (compared to admissions where PPC was not consulted), the odds of being in the ICU on a given day were reduced by 79% after PPC consultation (odds ratio [OR] = 0.21; 95% confidence interval [CI]: 0.13-0.34; p < 0.001) for children with cancer and 85% (OR = 0.15; 95% CI: 0.08-0.26; p < 0.001) for children with nononcologic conditions. Conclusions: Among children hospitalized with a diagnosis deemed eligible for specialty PPC, the likelihood of being in the ICU on a given day was strongly reduced after PPC consultation, supporting the value of PPC.

Hemodynamic and pharmacokinetic analysis of oxymetazoline use during nasal surgery in children

OBJECTIVES/HYPOTHESIS

Oxymetazoline is an α-adrenergic agonist that is commonly used as a topical hemostatic agent in the operating room during ear, nose, and throat surgery. There are limited data on oxymetazoline pharmacokinetics in children who undergo general anesthesia. We assessed the hemodynamic effects and systemic absorption of topically applied oxymetazoline in children undergoing various nasal procedures.

STUDY DESIGN

Prospective trial.

METHODS

Children ages 2 to 17 years undergoing functional endoscopic sinus surgery, turbinate resection, or adenoidectomy were enrolled. The surgeon placed oxymetazoline-soaked pledgets (1.5 mL of 0.05% solution) according to our usual clinical practice. Blood samples for oxymetazoline assay were drawn at 5, 10, 20, 45, 90, and 150 minutes, and hemodynamic data were recorded at 5-minute intervals. Data analysis included mixed-effects regression and population pharmacokinetic/pharmacodynamic modeling.

RESULTS

The analysis included 27 patients, age 7 ± 4 years, who received between 2 and 12 pledgets (3-18 mL) of oxymetazoline. Relative bioavailability compared to the spray formulation was 2.3 (95% confidence interval [CI]: 1.6-3.2), with slow absorption from the mucosal surface (absorption half-life 64 minutes; 95% CI: 44-90). Mean arterial pressure did not increase with oxymetazoline instillation at the observed oxymetazoline serum concentrations (0.04-7.6 μg/L).

CONCLUSIONS

Despite concerns regarding oxymetazoline administration to mucosal membranes, we found that hemodynamic changes were clinically negligible with our usual clinical use of pledgets soaked in oxymetazoline. Compared to data on oxymetazoline in spray formulation, bioavailability was increased twofold with pledgets, but systemic absorption was very slow, contributing to low serum concentrations and limited hemodynamic effects.

LEVEL OF EVIDENCE

1b. Laryngoscope, 129:2775-2781, 2019.

Chronic opioid use and clinical outcomes in lung transplant recipients: A single-center cohort study

INTRODUCTION

Chronic opioid use is common after organ transplantation, and has been associated with poor outcomes in transplantation of abdominal organs. However, little is known about possible influences of chronic opioid use on outcomes of lung transplantation (LTx).

OBJECTIVES

We assessed whether long-term chronic opioid use influenced clinical outcomes among LTx recipients at our program.

METHODS

We retrospectively evaluated chronic opioid use among bilateral LTx recipients ages 12 and older followed at our institution 1-5 years post-transplant. Chronic opioid use was defined as ≥3 months of consecutive prescribed use. Outcomes included survival, hospitalization, emergency department and urgent care visits, forced expiratory volume in one second (FEV1), and allograft rejection.

RESULTS

Twenty-one patients ages 15-50 years met inclusion criteria. On multivariable analysis, initiation of chronic opioid use was followed by increased mortality hazard (hazard ratio=7.1; 95% confidence interval [CI]: 1.1, 45.0, P = 0.037) and decreased FEV1 (-16%; 95% CI: -24%, -7%; P < 0.001), although no differences were observed in risk of acute care visits, inpatient admission, or chronic rejection.

CONCLUSION

This analysis presents the first evidence that late-onset chronic opioid use may be associated with decreased lung function and increased mortality after LTx. Therefore, evaluation of chronic opioid use should be included in the routine monitoring of transplant recipients, to better define the impact of this risk factor on LTx outcomes.

Secondhand smoke alters arachidonic acid metabolism and inflammation in infants and children with cystic fibrosis

BACKGROUND

Mechanisms that facilitate early infection and inflammation in cystic fibrosis (CF) are unclear. We previously demonstrated that children with CF and parental-reported secondhand smoke exposure (SHSe) have increased susceptibility to bacterial infections. SHSe hinders arachidonic acid (AA) metabolites that mediate immune function in patients without CF, and may influence CF immune dysfunction. We aimed to define SHSe's impact on inflammation mediators and infection in children with CF.

METHODS

Seventy-seven children with CF <10 years of age (35 infants <1 year; 42 children 1-10 years) were enrolled and hair nicotine concentrations measured as an objective surrogate of SHSe. AA signalling by serum and macrophage lipidomics, inflammation using blood transcriptional profiles and in vitro macrophage responses to bacterial infection after SHSe were assessed.

RESULTS

Hair nicotine concentrations were elevated in 63% of patients. Of the AA metabolites measured by plasma lipidomics, prostaglandin D₂ (PGD₂) concentrations were decreased in children with CF exposed to SHSe, and associated with more frequent hospitalisations (p=0.007) and worsened weight z scores (p=0.008). Children with CF exposed to SHSe demonstrated decreased expression of the prostaglandin genes PTGES3 and PTGR2 and overexpression of inflammatory pathways. These findings were confirmed using an in vitro model, where SHSe was associated with a dose-dependent decrease in PGD₂ and increased methicillin-resistant Staphylococcus aureus survival in human CF macrophages.

CONCLUSIONS

Infants and young children with CF and SHSe have altered AA metabolism and dysregulated inflammatory gene expression resulting in impaired bacterial clearance. Our findings identified potential therapeutic targets to halt early disease progression associated with SHSe in the young population with CF.

Perioperative Provider and Staff Competency in Providing Culturally Competent LGBTQ Healthcare in Pediatric Setting

INTRODUCTION

Children and adolescents identifying as lesbian, gay, bisexual, transgender, or queer/questioning (LGBTQ) may feel reluctant to seek medical care due to stigma and the possibility of negative interactions with health care providers. Due to the short duration of the perioperative period, the interaction in this setting is limited and providers may not have the time to develop a rapport with the patient. It is imperative that staff are trained to address the patient and family in a culturally competent manner.

METHODS

We undertook surveys before and after a 2 part educational series among the pediatric perioperative staff to understand the impact of providing education and cultural competency training regarding caring for patients who identify as LGBTQ. Providers self-reported their knowledge and comfort on a 1-5 point scale (5 being most knowledgeable or comfortable) in 6 domains of caring for LGBTQ patients. Objective knowledge of LGBTQ issues was assessed using 7 questions based on lecture material. On objective assessment, knowledge of LGBTQ issues improved after cultural competency training.

RESULTS

The analysis included 90 responses. Before training, median ratings of knowledge and comfort were 3 or 4 out of a maximum of 5 for each domain. The pre-training median score on the 7-item test of LGBTQ cultural competency was 5 (IQR: 4, 6). After training, knowledge and comfort self-ratings did not improve, but the score on the objective knowledge test increased to a median of 6 (IQR: 4, 7; p=0.011) of 7 possible points.

DISCUSSION

Anesthesia providers participating in LGBTQ cultural competency training self-reported high levels of knowledge and comfort with providing care to LGBTQ patients even before formal training was provided. On objective assessment, knowledge of LGBTQ issues improved after cultural competency training.

Severe outcomes of pediatric perioperative adverse events occurring in operating rooms compared to off-site anesthetizing locations in the Wake Up Safe Database

BACKGROUND

Anesthesia services are frequently provided outside of the traditional operating room environment for children. It is unclear if adverse events which occur in off-site anesthetizing locations result in more severe outcomes compared to events in traditional operating rooms.

AIM

We used a multi-institutional registry of pediatric patients to compare outcomes of perioperative adverse events between location types.

METHODS

De-identified data from 24 pediatric tertiary care hospitals participating in the Wake Up Safe registry during 2010-2015 were analyzed. Peri-procedural adverse events occurring in operating rooms or off-site locations were included. The primary outcome was whether the adverse event was severe, defined as requiring escalation of care or resulting in temporary or significant harm. Multivariable logistic regression was used to compare location type (operating room vs. off-site) and the likelihood of a severe outcome among reported events.

RESULTS

There were 1594 adverse events, of which 362 were associated with off-site anesthetizing locations. In multivariable logistic regression, off-site location was associated with greater odds of severe adverse event outcome (adjusted odds ratio, 1.31; 95% confidence interval: 1.01, 1.69; P = 0.044). Comparing adverse events in cardiac catheterization suites to events in operating rooms confirmed higher odds of severe outcome in the former group (adjusted odds ratio = 1.48; 95% confidence interval: 1.05, 2.08; P = 0.025), while this difference was not found for other off-site locations.

CONCLUSION

Multivariable analysis of a large registry revealed a greater likelihood of severe outcome for adverse events occurring in cardiac catheterization suites (but not other out of the OR sites), compared to adverse events occurring in the operating room. Additional prospective studies are needed which better control for patient and environmental characteristics and their effect on severe outcomes after anesthesia.

Acetaminophen pharmacokinetics in severely obese adolescents and young adults

BACKGROUND

Intravenous acetaminophen is commonly administered as an adjunctive to opioids during major surgical procedures, but neither the correct pharmacokinetic size descriptor nor the dose is certain in severely obese adolescents undergoing bariatric surgery.

METHODS

Adolescents, 14-20 years of age, with a body mass index (BMI) ≥95th percentile for age and sex or BMI ≥40 kg·m^-2 , presenting for laparoscopic or robotic assisted or vertical sleeve gastrectomy were administered intravenous acetaminophen (1000 mg) following completion of the surgical procedure. Venous blood was drawn for acetaminophen assay at eight time points, starting 15 minutes after completion of the infusion and up to 12 hours afterward. Time-concentration data profiles were analyzed using nonlinear mixed effects models. Parameter estimates were scaled to a 70-kg person using allometry. Normal fat mass was used to assess the impact of obesity on pharmacokinetic parameters.

RESULTS

The study cohort comprised 11 female patients, age 17 SD 2 years with a weight of 125 SD 19 kg and a mean BMI of 46 SD 5 kg·m^-2 . The plasma acetaminophen serum concentration was 17 (SD 4) μg·mL^-1 at 10-20 minutes after completion of the infusion and 5 (SD 6) μg·mL^-1 at 80-100 minutes. A two-compartment model, used to investigate pharmacokinetics, estimated clearance 10.6 (CV 72%) L·h·70 kg^-1 , intercompartment clearance 37.3 (CV 63%) L·h·70 kg^-1 , central volume of distribution 20.4 (CV 46%) L·70 kg^-1 , and peripheral volume of distribution 16.8 (CV 42%) L·70 kg^-1 . Clearance was best described using total body weight. Normal fat mass with a parameter that accounts for fat mass contribution (Ffat) of 0.88 best described volumes.

CONCLUSION

Current recommendations of acetaminophen to a maximum dose of 1000 mg resulted in serum concentrations below detection limits in all patients within 2 hours after administration. Dose is better predicted using total body mass with allometric scaling.

Sleep-disordered breathing and reaction time in children

Background

The incidence of obstructive sleep apnea (OSA) and sleep-disordered breathing (SDB) in children exceeds the availability of polysomnography (PSG) to definitively diagnose OSA and identify children at higher risk of perioperative complications. As sleep deficits are associated with slower reaction times (RTs), measuring RT may be a cost-effective approach to objectively identify SDB symptoms.

Aim

The aim of this study is to compare RT on a standard 10-minute psychomotor vigilance test (PVT) based on children’s history of OSA/SDB.

Methods

Children, 6–11 years of age, were enrolled from two different clinical groups. The SDB group included children undergoing adenotonsillectomy with a clinical history of SDB, OSA, or snoring. The control group included children with no history of SDB, OSA, or snoring who were scheduled for surgery other than adenotonsillectomy. RT was measured via 10-minute PVT (Ambulatory Monitoring Inc., Ardsley, NY, USA). Median RT was calculated for each patient based on all responses to stimuli during the PVT assessment and was compared to published age-sex-specific norms. The proportion of children exceeding RT norms was compared between study groups.

Results

The study included 72 patients (36/36 male/female, median age 7 years), 46 with SDB and 26 without SDB. There was no difference in the RT between the two groups. Fifty-four percent of patients with SDB exceeded norms for median RT vs 42% of control patients (95% CI of difference: – 12, 36; P=0.326).

Conclusion

Approximately half of the patients in both groups exceeded published norms for median RT on PVT. Despite its convenience, measurement of RT did not distinguish between patients with probable SDB/OSA for preoperative risk stratification.

Education and Employment After Lung Transplantation in Adolescents and Young Adults

Pediatric transplant recipients experience barriers to social functioning, including participation in school and work, but our understanding of barriers to these activities is limited by insufficient data collection and standardization. Existing studies rely on cross-sectional surveys of transplant survivors that are subject to survivorship and nonresponse bias, or analyses of large registry data that lack detail on educational progress and work participation. We report our experience using the electronic medical record to retrospectively review work and educational attainment in this population, and identify specific barriers that were encountered and how they were addressed by the patient and care team. We reviewed current literature on post-transplant survey participation and compared questionnaires to our current documentation practice for tracking education and employment progress in the transplant recipient population. Based on this review, we discuss the possibility, barriers, and implications of conducting a standardized assessment to track social participation outcomes of transplantation.

Cardiac Risk Factors and Complications After Spinal Fusion for Idiopathic Scoliosis in Children

BACKGROUND

Cardiac risk factors pose challenges in pediatric posterior spinal fusion (PSF). Differences in risk according to etiology of cardiac disease are unclear. We investigated outcomes of PSF according to presence of congenital heart defect compared to cardiomyopathy.

METHODS

Elective PSF for idiopathic scoliosis in patients aged 0-18 y was identified in the 2012-2015 National Surgical Quality Improvement Program-Pediatric. Cardiac risk factors were classified as: no cardiac risk factors or minor cardiac risk factors without congenital heart defect; minor cardiac risk factors because of congenital heart defect; major cardiac risk factors because of congenital heart defect; major cardiac risk factors because of cardiomyopathy. Multivariable logistic regression compared surgical site infection, wound dehiscence, hospital length of stay ≥30 d, and unplanned readmission across these categories.

RESULTS

The analysis included 5395 girls and 1691 boys, aged 14 ± 2 y. Among these, 140 patients had minor cardiac risk factors because of congenital heart defect, 144 had major cardiac risk factors because of congenital heart defect, and 20 had major cardiac risk factors because of cardiomyopathy. Rates of any complication were significantly higher among patients with cardiomyopathy (40%) compared to patients with major cardiac risk factors because of congenital heart defect (10%), minor cardiac risk factors because of congenital heart defect, or other minor or no cardiac risk factors (5%; chi-square P < 0.001). In multivariable analysis of 6829 patients, cardiomyopathy predicted greater odds of unplanned readmission compared to no or minor cardiac risk factors (OR = 5.9; 95% CI: 1.8, 19.7; P = 0.004) and compared to major cardiac risk factors because of congenital heart defect (OR = 4.5; 95% CI: 1.1, 17.6; P = 0.032).

CONCLUSIONS

Cardiomyopathy is a rare but significant risk factor for complications after pediatric PSF, whereas congenital heart defects did not independently contribute to risk of complications after this procedure.