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Ciccozzi A, Pizzi B, Vittori A, Piroli A, Marrocco G, Della Vecchia F, Cascella M, Petrucci E, Marinangeli F. The Perioperative Anesthetic Management of the Pediatric Patient with Special Needs: An Overview of Literature. CHILDREN (BASEL, SWITZERLAND) 2022; 9:children9101438. [PMID: 36291372 PMCID: PMC9600107 DOI: 10.3390/children9101438] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Revised: 09/11/2022] [Accepted: 09/17/2022] [Indexed: 06/01/2023]
Abstract
The perioperative management of pediatric patients with psycho-physical disorders with related relational and cognitive problems must be carefully planned, in order to make the entire hospitalization process as comfortable and as less traumatic as possible. This article reports an overview of the anesthetic management of non-cooperative patients between 6 and 14 years old. The pathologies most frequently responsible for psycho-physical disorders can be summarized into three groups: (1) collaboration difficulties (autism spectrum disorders, intellectual impairment, phobia); (2) motor dysfunction (cerebral palsy, epilepsy, other brain pathologies, neuromuscular disorders), and (3) craniofacial anomalies (Down syndrome, other genetic syndromes). Anesthesia can be performed safely and successfully due to careful management of all specific problems of these patients, such as a difficult preoperative evaluation (medical history, physical examination, blood sampling, evaluation of vital parameters and predictive indices of difficult airway) and the inapplicability of a "standard" perioperative path (timing and length of the hospitalization, anesthetic premedication, postoperative management). It is necessary to ensure a dedicated perioperative process that is safe, comfortable, tailored to specific needs, and as less traumatic as possible. At the same time, all necessary precautions must be taken to minimize possible complications.
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Affiliation(s)
- Alessandra Ciccozzi
- Department of Life, Health and Environmental Sciences, University of L’Aquila, 67100 L’Aquila, Italy
| | - Barbara Pizzi
- Department of Anesthesia and Intensive Care Unit, SS Filippo and Nicola Academic Hospital of Avezzano, 67051 L’Aquila, Italy
| | - Alessandro Vittori
- Department of Anesthesia and Critical Care, ARCO ROMA, Ospedale Pediatrico Bambino Gesù IRCCS, 00165 Rome, Italy
| | - Alba Piroli
- Department of Life, Health and Environmental Sciences, University of L’Aquila, 67100 L’Aquila, Italy
| | - Gioele Marrocco
- Department of Life, Health and Environmental Sciences, University of L’Aquila, 67100 L’Aquila, Italy
| | - Federica Della Vecchia
- Department of Life, Health and Environmental Sciences, University of L’Aquila, 67100 L’Aquila, Italy
| | - Marco Cascella
- Department of Anesthesia and Critical Care, Istituto Nazionale Tumori—IRCCS, Fondazione Pascale, 80131 Naples, Italy
| | - Emiliano Petrucci
- Department of Anesthesia and Intensive Care Unit, San Salvatore Academic Hospital of L’Aquila, 67100 L’Aquila, Italy
| | - Franco Marinangeli
- Department of Life, Health and Environmental Sciences, University of L’Aquila, 67100 L’Aquila, Italy
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Mimmo L, Harrison R, Travaglia J, Hu N, Woolfenden S. Inequities in quality and safety outcomes for hospitalized children with intellectual disability. Dev Med Child Neurol 2022; 64:314-322. [PMID: 34562021 PMCID: PMC9293445 DOI: 10.1111/dmcn.15066] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Revised: 07/26/2021] [Accepted: 09/01/2021] [Indexed: 01/06/2023]
Abstract
AIM To investigate if there are inequities in quality and safety outcomes for children with intellectual disability admitted to two tertiary paediatric hospitals. METHOD A cross-sectional study of 1367 admissions for 1018 randomly selected patients admitted for more than 23 hours to one of two tertiary children's hospitals in Sydney, Australia (1st January-31st December 2017). Electronic medical records were manually interrogated to identify children with intellectual disability (including developmental delay). Data extracted included patient demographics, length of stay, number of admissions, and reported clinical incidents. RESULTS In total, 12.3% (n=125) of children admitted during the study period had intellectual disability, which represented 13.9% (n=190) of admissions. Sex and age at admission in children with and without intellectual disability were similar: 83 (43.7%) vs 507 (43.1%) females and 107 (56.3%) vs 670 (56.9%) males, p=0.875; median age 3 years (0-18y) vs 4 years (0-18y), p=0.122. Children with intellectual disability had significantly greater median length of stay (100.5h vs 79h, p<0.001) and cost of admission (A$11 596.38 vs A$8497.96) than their peers (p=0.001). Children with intellectual disability had more admissions with at least one incident compared to children without intellectual disability (14.7% vs 9.7%); this was not statistically significant (p=0.06). INTERPRETATION Children with intellectual disability experience inequitable quality and safety outcomes in hospital. Engaging children and families in clinical incident reporting may enhance understanding of safety risks for children with intellectual disability in hospital.
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Affiliation(s)
- Laurel Mimmo
- School of Population HealthFaculty of MedicineUniversity of New South WalesSydneyNew South WalesAustralia,Clinical Governance UnitThe Sydney Children’s Hospitals NetworkSydneyNew South WalesAustralia
| | - Reema Harrison
- Health Management ProgramsFaculty of MedicineSchool of Population HealthUniversity of New South WalesSydneyNew South WalesAustralia
| | - Joanne Travaglia
- Faculty of HealthCentre for Health Services ManagementUniversity of Technology SydneySydneyNew South WalesAustralia
| | - Nan Hu
- Faculty of MedicineSchool of Women’s and Children’s HealthUniversity of New South WalesSydneyNew South WalesAustralia
| | - Susan Woolfenden
- Faculty of MedicineSchool of Women’s and Children’s HealthUniversity of New South WalesSydneyNew South WalesAustralia,Community Child HealthSydney Children’s Hospital, RandwickSydneyNew South WalesAustralia
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Murphy Salem S, Graham RJ. Chronic Illness in Pediatric Critical Care. Front Pediatr 2021; 9:686206. [PMID: 34055702 PMCID: PMC8160444 DOI: 10.3389/fped.2021.686206] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Accepted: 04/21/2021] [Indexed: 11/24/2022] Open
Abstract
Children and Youth with Special Healthcare Needs (CYSHCN), children with medical complexity (CMC), and children with chronic, critical illness (CCI) represent pediatric populations with varying degrees of medical dependance and vulnerability. These populations are heterogeneous in underlying conditions, congenital and acquired, as well as intensity of baseline medical needs. In times of intercurrent illness or perioperative management, these patients often require acute care services in the pediatric intensive care (PICU) setting. This review describes epidemiologic trends in chronic illness in the PICU setting, differentiates these populations from those without significant baseline medical requirements, reviews models of care designed to address the intersection of acute and chronic illness, and posits considerations for future roles of PICU providers to optimize the care and outcomes of these children and their families.
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Affiliation(s)
- Sinead Murphy Salem
- Department of Anesthesiology, Boston Children's Hospital, Critical Care and Pain Medicine and Harvard Medical School, Boston, MA, United States
| | - Robert J Graham
- Department of Anesthesiology, Boston Children's Hospital, Critical Care and Pain Medicine and Harvard Medical School, Boston, MA, United States
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Mimmo L, Harrison R, Hinchcliff R. Patient safety vulnerabilities for children with intellectual disability in hospital: a systematic review and narrative synthesis. BMJ Paediatr Open 2018; 2:e000201. [PMID: 29637187 PMCID: PMC5843001 DOI: 10.1136/bmjpo-2017-000201] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Revised: 11/20/2017] [Accepted: 01/06/2018] [Indexed: 12/18/2022] Open
Abstract
PURPOSE Adults and children with intellectual disability (ID) are vulnerable to preventable morbidity and mortality due to poor quality healthcare. While poor quality care has been commonly identified among children with ID, evidence of the patient safety outcomes for this group is lacking and therefore explored in this review. DATA SOURCES Systematic searches of six electronic bibliographic research databases were undertaken from January 2000 to October 2017, in addition to hand searching. STUDY SELECTION Keywords, subject headings and MeSH terms relating to the experience of iatrogenic harm during hospitalisation for children with ID were used. Potentially relevant articles were screened against the eligibility criteria. Non-English language papers were excluded. DATA EXTRACTION Data regarding: author(s), publication year, country, sample, health service setting, study design, primary focus and main findings related to measures of quality and safety performance were extracted. RESULTS OF DATA SYNTHESIS Sixteen studies met the inclusion criteria, with three themes emerging: the impact of the assumptions of healthcare workers (HCWs) about the child with ID on care quality and associated safety outcomes; reliance on parental presence during hospitalisation as a protective factor; and the need for HCWs to possess comprehensive understanding of the IDs experienced by children in their care, to scientifically deduce how hospitalisation may compromise their safety, care quality and treatment outcomes. CONCLUSION When HCWs understand and are responsive to children's individual needs and their ID, they are better placed to adjust care delivery processes to improve care quality and safety during hospitalisation for children with ID.
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Affiliation(s)
- Laurel Mimmo
- Clinical Governance Unit, Sydney Children's Hospitals Network, Sydney, New South Wales, Australia
| | - Reema Harrison
- School of Public Health and Community Medicine, Faculty of Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Reece Hinchcliff
- Centre for Health Services Research, University of Technology Sydney, Ultimo, New South Wales, Australia
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Marr C, Leonard H, Torode I, Downs J. Spinal fusion in girls with Rett syndrome: post-operative recovery and family experiences. Child Care Health Dev 2015; 41:1000-9. [PMID: 25752500 PMCID: PMC4564372 DOI: 10.1111/cch.12243] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/08/2015] [Indexed: 12/14/2022]
Abstract
BACKGROUND Rett syndrome is a severe neurodevelopmental disorder mainly affecting females and scoliosis is a common co-morbidity. Spinal fusion may be recommended if the scoliosis is progressive. This qualitative study investigated recovery of girls with Rett syndrome during the first 12 post-operative months and explored family perspectives and coping around the time of surgery. METHOD Parents registered with the population-based Australian Rett Syndrome Database were recruited to this study if their daughter had a confirmed pathogenic MECP2 mutation and spinal fusion between 2006 and 2012. Twenty-five interviews were conducted to determine their daughter's recovery and parental stresses and coping. Themes in the interview data were identified with content analysis, and the regaining of gross motor skills over the first 12 post-operative months was described with time-to-event (survival) analysis. RESULTS Pain and energy levels, appetite, mood and coinciding health issues influenced their daughter's post-operative recovery. The majority of girls recovered preoperative sitting (88%), standing (81%) and walking (80%) by 12 months. The decision to proceed with surgery was associated with feelings of fear, obligation, relief and guilt for families. Development of complications, poor support and feelings of isolation increased their emotional burden whereas adequate information and discharge preparation, confidence in self and staff, and balancing personal needs with their daughter's care relieved this burden. INTERPRETATION Our study identified clinical practice issues in relation to families whose daughter with Rett syndrome undergoes spinal fusion, issues that are also relevant to other severe disabilities. Return of wellness and gross motor skills following spinal fusion in girls with Rett syndrome occurred within the first 12 post-operative months in most cases. Parents require information and practical support to alleviate their emotional burden.
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Affiliation(s)
- Caitlin Marr
- School of Physiotherapy and Exercise Science, Curtin University, Perth, Australia
| | - Helen Leonard
- Telethon Kids Institute, University of Western Australia, Perth, Australia
| | - Ian Torode
- Department of Orthopaedics, Royal Children’s Hospital, Melbourne, Australia
| | - Jenny Downs
- School of Physiotherapy and Exercise Science, Curtin University, Perth, Australia and Telethon Kids Institute, University of Western Australia, Perth, Australia
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Wang YC, Lin IH, Huang CH, Fan SZ. Dental anesthesia for patients with special needs. ACTA ACUST UNITED AC 2012; 50:122-5. [DOI: 10.1016/j.aat.2012.08.009] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2012] [Revised: 06/19/2012] [Accepted: 06/22/2012] [Indexed: 10/27/2022]
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Landsman IS, Mitzel HM, Peters SU, Bichell TJ. Are children with Angelman syndrome at high risk for anesthetic complications? Paediatr Anaesth 2012; 22:263-7. [PMID: 21801274 DOI: 10.1111/j.1460-9592.2011.03661.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVES/AIMS To review seven children with Angelman syndrome (AS) undergoing 16 general anesthetics for both invasive and noninvasive procedures to determine if these children are at greater risk for anesthetic-related complications than the general population. BACKGROUND Children with AS may exhibit unpredictable responses to GABA agonists because of abnormal GABA receptors. These abnormal receptors may affect AS patients' responses to sedation and general anesthesia. METHODS The study design was a retrospective chart review of seven patients with AS who underwent a total of 16 general anesthetics for a variety of invasive and noninvasive procedures between the years 4/25/2005 and 12/31/2010. We reviewed the preoperative orders, anesthesia record and PACU records for preoperative medication orders and intraoperative and PACU adverse events. RESULTS We could not find documentation of complications attributed to the delivery of general anesthesia regardless of chromosomal defect, the use of GABA activating drugs, or a history of seizures. Six patients received a propofol-based anesthetic while 10 patients received potent inhalation agent for anesthetic maintenance. There were no statistical differences between the PACU lengths of stay (LOS) for AS patients as compared to the average PACU LOS for the 60 969 postprocedure patients cared for between 1/1/06 through 12/31/10. CONCLUSIONS We found no data to suggest that these patients demonstrate exaggerated responses to GABA stimulating drugs. In fact, it appears that regardless of the anesthetic agent, the perioperative course was unremarkable.
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Affiliation(s)
- Ira S Landsman
- Anesthesiology and Pediatrics, Vanderbilt University Medical Center, Nashville, TN, USA.
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Current world literature. Curr Opin Anaesthesiol 2010; 23:283-93. [PMID: 20404787 DOI: 10.1097/aco.0b013e328337578e] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Graham RJ, Athiraman U, Laubach AE, Sethna NF. Anesthesia and perioperative medical management of children with spinal muscular atrophy. Paediatr Anaesth 2009; 19:1054-63. [PMID: 19558636 DOI: 10.1111/j.1460-9592.2009.03055.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To describe the perioperative medical care, anesthetic considerations, and the risk of postanesthetic respiratory failure in patients with pediatric spinal muscular atrophy (SMA). METHODS There is a retrospective chart review carried out at an urban, tertiary care pediatric hospital. All patients with ICD-9 codes corresponding to SMA diagnoses were identified, and records screened for anesthetic and perioperative medical management. Medical records were reviewed for demographic, clinical, and outcome data. MAIN RESULTS Twenty-five children with SMA (10 type I, 8 type II, 7 type III) accounted for 56 general and regional anesthetic cases. Twenty-one (38%) cases had preexisting ventilator dependence. Total intravenous anesthesia with nitrous oxide was provided in 14 (25%) cases, balanced anesthesia with inhalational agents and epidural or systemic opioids were used in 41 (84%) cases, and one infant received a spinal anesthesia. Intraoperative and postoperative complications occurred in 2 (4%) and 2 (4%) cases respectively. One case required an unplanned postanesthetic intensive care unit admission, and there were two late deaths with redirection of care. CONCLUSIONS Perioperative care can be provided for children with SMA safely and effectively with total intravenous or inhaled anesthetics along with the judicious use of opioids to improve patient comfort without increased morbidity. Further prospective studies of standardized anesthetic and perioperative respiratory medical management in this population are required to minimize the decompensation of tenuous preoperative respiratory function.
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Affiliation(s)
- Robert J Graham
- Division of Critical Care Medicine, Children's Hospital Boston, Boston, MA 02115-5724, USA.
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