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Mpody C, Kidwell RC, Willer BL, Nafiu OO, Tobias JD. Preoperative neurologic comorbidity and unanticipated early postoperative reintubation: a multicentre cohort study. Br J Anaesth 2024:S0007-0912(24)00471-9. [PMID: 39304468 DOI: 10.1016/j.bja.2024.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2024] [Revised: 08/12/2024] [Accepted: 08/13/2024] [Indexed: 09/22/2024] Open
Abstract
BACKGROUND The risk of respiratory complications is highest in the first 72 h post-surgery. Postoperative respiratory events can exacerbate pre-existing respiratory compromise and lead to reintubation of the trachea, particularly in patients with neurologic disorders. This study examined the association between neurologic comorbidities and unanticipated early postoperative reintubation in children. METHODS This multicentre, 1:1 propensity score-matched study included 420 096 children who underwent inpatient, elective, noncardiac surgery at National Surgical Quality Improvement Program reporting hospitals in 2012-22. The primary outcome was unanticipated early postoperative reintubation within 72 h after surgery. The secondary outcome was prolonged postoperative mechanical ventilation, defined as ventilator use >72 h. We also evaluated 30-day mortality in patients requiring reintubation. RESULTS Cerebral palsy was associated with the highest risk of early reintubation (adjusted relative risk [RRadj]: 1.97, 95% confidence interval [CI]: 1.44-2.69; P<0.01), followed by seizure disorders (RRadj: 1.87, 95% CI: 1.50-2.34; P<0.01), neuromuscular disorders (RRadj: 1.76, 95% CI: 1.41-2.19; P<0.01), and structural central nervous system abnormalities (RRadj: 1.35, 95% CI: 1.13-1.61; P<0.01). Unanticipated early postoperative reintubation was associated with an eight-times increased risk of 30-day mortality (adjusted hazard ratio: 8.1, 95% CI: 6.0-11.1; P<0.01). Risk of prolonged postoperative mechanical ventilation was also increased with neurologic comorbidities, particularly seizure disorders (RRadj: 1.73, 95% CI: 1.55-1.93; P<0.01). CONCLUSIONS Children with neurologic comorbidities have an increased risk of unanticipated early postoperative reintubation and prolonged mechanical ventilation. Given the high mortality risk associated with these outcomes, children with neurologic comorbidities require heightened monitoring and risk assessment.
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Affiliation(s)
- Christian Mpody
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA; Department of Anesthesiology & Pain Medicine, The Ohio State University College of Medicine, Columbus, OH, USA.
| | - Rachel C Kidwell
- Heritage College of Osteopathic Medicine - Athens Campus, Athens, OH, USA; College of Medicine, Ohio University, Athens, OH, USA
| | - Brittany L Willer
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA; Department of Anesthesiology & Pain Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Olubukola O Nafiu
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA; Department of Anesthesiology & Pain Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Joseph D Tobias
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA; Department of Anesthesiology & Pain Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
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Sjöberg C, Ringdal M, Jildenstål P. Postoperative Recovery in the Youngest: Beyond Technology. CHILDREN (BASEL, SWITZERLAND) 2024; 11:1021. [PMID: 39201955 PMCID: PMC11353086 DOI: 10.3390/children11081021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/11/2024] [Revised: 08/09/2024] [Accepted: 08/19/2024] [Indexed: 09/03/2024]
Abstract
BACKGROUND Measuring and interpreting vital signs in pediatric patients recovering from anaesthesia, particularly those up to 36 months old, is challenging. Nurses' decision-making regarding the level of monitoring must balance patient safety with individualized care. This study aimed to explore the perceptions of critical care nurses and registered nurse anesthetists regarding their experiences and actions when making decisions about vital sign monitoring for children in post-anesthesia care units (PACUs). METHODS A qualitative study utilizing the critical incident technique was conducted. Interviews were performed with a purposeful sample of 17 critical care nurses and registered nurse anaesthetists from two hospitals. RESULTS Nurses reported that the rationale for decisions concerning the need for vital sign monitoring in children was both adequate and inadequate. Actions were taken to adjust the monitoring of vital signs, optimizing conditions for assessment and ensuring the child's safe recovery. CONCLUSIONS The complexity of accurately monitoring children makes it challenging for nurses in the PACU to adhere to guidelines. Evidence-based care and safety are compromised when technology has limitations and is not adapted for paediatric use, leading to a greater reliance on experience and clinical assessment. This reliance on experience is crucial for reliable assessment but also entails accepting greater risks.
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Affiliation(s)
- Carina Sjöberg
- Department of Medicine and Health Sciences, Lund University, 223 62 Lund, Sweden;
- Department of Anaesthesiology, Surgery and Intensive Care, Sahlgrenska University Hospital, 413 45 Gothenburg, Sweden
| | - Mona Ringdal
- Institute of Health and Care Sciences, Sahlgrenska Academy, University of Gothenburg, 413 46 Gothenburg, Sweden;
- Department of Anestesiology and Critical Care, West Hospital, 442 34 Kungälv, Sweden
| | - Pether Jildenstål
- Department of Medicine and Health Sciences, Lund University, 223 62 Lund, Sweden;
- Department of Anaesthesiology, Surgery and Intensive Care, Sahlgrenska University Hospital, 413 45 Gothenburg, Sweden
- Institute of Health and Care Sciences, Sahlgrenska Academy, University of Gothenburg, 413 46 Gothenburg, Sweden;
- Department of Anaesthesiology and Intensive Care, Örebro University Hospital and School of Medical Sciences, Örebro University, 701 82 Örebro, Sweden
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Sjöberg C, Ringdal M, Lundqvist P, Jildenstål P. How to Achieve Highly Professional Care in the Postoperative Ward: The Care of Infants and Toddlers. J Perianesth Nurs 2024:S1089-9472(24)00115-1. [PMID: 38958626 DOI: 10.1016/j.jopan.2024.03.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Revised: 03/26/2024] [Accepted: 03/28/2024] [Indexed: 07/04/2024]
Abstract
PURPOSE The purpose of this study was to describe the experiences of critical care nurses (CCNs) and registered nurse anesthetists (RNAs) when monitoring and observing infants and toddlers recovering from anesthesia. DESIGN A qualitative design with a critical incident approach. METHODS Semistructured individual interviews were conducted with a purposeful sample of CCNs and RNAs (n = 17) from postanesthesia care units at two hospitals. The critical incident technique approach was used to guide the interviews, and data were analyzed inductively using thematic analysis. FINDINGS The main finding was the CCNs' and RNAs' description of how they "watch over the children and stay close" to provide emotional and physical safety. CCNs' and RNAs' experiences of observing and managing the children's small, immature airways were reflected in the theme "using situation awareness of the small, immature airways." The theme "understanding emergence agitation" describes the challenge that arises when children are anxious, feel insecure, and have pain, and the theme "having parents nearby" shows the necessity and value of involving parents in their children's care. CONCLUSIONS Findings from this study suggest that caring for infants and toddlers recovering from anesthesia requires experience and both technical and nontechnical skills. These are prerequisites for achieving readiness for planning, setting priorities, and adapting one's behavior if an adverse event occurs. Alertness and the ability to solve acute problems and make quick decisions are essential because of the risks associated with children's small, immature airways, as is the ability to understand and respond to emergence agitation. Having parents nearby is equally important for creating the conditions for compassionate child- and family-centered care.
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Affiliation(s)
- Carina Sjöberg
- Department of Medicine and Health Sciences, Lund University, Lund, Sweden; Department of Anaesthesiology, Surgery and Intensive Care, Sahlgrenska University Hospital, Gothenburg, Sweden.
| | - Mona Ringdal
- Institute of Health and Care Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Department of Anaesthesiology and Critical Care, Kungälvs Hospital, Kungälv, Sweden
| | - Pia Lundqvist
- Department of Medicine and Health Sciences, Lund University, Lund, Sweden
| | - Pether Jildenstål
- Department of Medicine and Health Sciences, Lund University, Lund, Sweden; Department of Anaesthesiology, Surgery and Intensive Care, Sahlgrenska University Hospital, Gothenburg, Sweden; Institute of Health and Care Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Department of Anaesthesiology and Intensive Care, Örebro University Hospital and School of Medical Sciences, Örebro University, Örebro, Sweden
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Udupa AN, Majmudar AA, Tran L. A systematic review of neurological airway respiratory cardiovascular other-surgical severity (NARCO-SS) score as a pediatric perioperative scoring system. Paediatr Anaesth 2024; 34:396-404. [PMID: 38300020 DOI: 10.1111/pan.14846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2023] [Revised: 12/20/2023] [Accepted: 01/15/2024] [Indexed: 02/02/2024]
Abstract
OBJECTIVE To systematically identify and synthesize the available evidence of the neurological airway respiratory cardiovascular other-surgical severity (NARCO-SS) score as compared to other pediatric specific perioperative scoring systems. DESIGN This systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) statement. All studies in all languages comparing NARCO-SS with pediatric perioperative scoring systems against outcomes were included. Records were screened and data were extracted by three independent reviewers into standardized pilot-tested extraction templates. DATA SOURCES Electronic searches were performed in MEDLINE, Embase, Scopus, and CINAHL (from inception to February 2023). REVIEW METHODS The references were uploaded to a validated software for systematic reviews (Rayyan) and screened against the inclusion criteria. Full text of included studies were reviewed and the available data were tabulated. We conducted Risk of Bias analysis on the included studies using the Prediction model Risk Of Bias ASsessment Tool (PROBAST). RESULTS A meta-analysis could not be performed due to differences in outcome definitions across the included studies. Correlations between NARCO-SS scores, ASA-PS scores and the predefined outcomes of each study were presented as a narrative synthesis. The included studies were determined to have a high risk of bias using the PROBAST. CONCLUSIONS This review has identified a need for high-quality studies assessing NARCO-SS before recommendations for clinical practice can be made. Addressing its limitations and enhancing the NARCO-SS through targeted refinements of its individual descriptive categories could potentially lead to improvement in its overall predictive accuracy and facilitate wider adoption into clinical practice.
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Affiliation(s)
- Ashwin N Udupa
- Queen Elizabeth Hospital, Central Adelaide Local Health Network, Adelaide, South Australia, Australia
- Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia
| | - Ahan A Majmudar
- Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia
- Royal Adelaide Hospital, Central Adelaide Local Health Network, Adelaide, South Australia, Australia
| | - Liem Tran
- Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia
- Royal Adelaide Hospital, Central Adelaide Local Health Network, Adelaide, South Australia, Australia
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Mamaril ME, MacDonald R. Documentation of Assessments and Interventions Using a Pediatric Preoperative Risk Assessment Checklist in the Postanesthesia Care Unit: A Quality Improvement Initiative. J Perianesth Nurs 2023; 38:693-702. [PMID: 37269275 DOI: 10.1016/j.jopan.2023.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2022] [Revised: 12/22/2022] [Accepted: 01/07/2023] [Indexed: 06/05/2023]
Abstract
PURPOSE Describe the impact of the implementation of an evidence-based pediatric preoperative risk assessment (PPRA) checklist on the frequency of postanesthesia care unit (PACU) nursing assessments and interventions in children at risk for respiratory complications during emergence from anesthesia. DESIGN Prospective pre-/postdesign. METHODS Pediatric perianesthesia nurses assessed 100 children preintervention according to current standard. After nurses received pediatric preoperative risk factor (PPRF) education, another 100 children were assessed postintervention using the PPRA checklist. Pre-/postpatients were unmatched for statistical purposes due to two different groups. Frequency of PACU nursing respiratory assessments/interventions was evaluated. FINDINGS Demographic variables, risk factors, frequency of nursing assessments/interventions were summarized in pre-/postinterventions. Significant differences (P < .001) were noted between pre-/postintervention groups with increased frequency of postnursing assessments/interventions that correlated with increased risk factors and weighted risk factors. CONCLUSIONS By identifying total PPRFs, PACU nurses used their plan of care to frequently assess and pre-emptively intervene with children who had increased risk factors to prevent or mitigate respiratory complications on emergence from anesthesia.
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Affiliation(s)
- Myrna E Mamaril
- Perioperative Services, Johns Hopkins Hospital, Baltimore, MD.
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Willer BL, Mpody C, Nafiu OO. Racial Inequity in Pediatric Anesthesia. CURRENT ANESTHESIOLOGY REPORTS 2023; 13:108-116. [PMID: 37168831 PMCID: PMC10150147 DOI: 10.1007/s40140-023-00560-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/03/2023] [Indexed: 05/13/2023]
Abstract
Purpose of Review Minority health disparities have received renewed attention in the USA following several highly publicized racial injustices in 2020. Though the focus has been largely on adults, children are not immune to these inequities. By reviewing racial disparities in pediatric perioperative care, we aim to engage the anesthesia community in the fight against systemic racism. Recent Findings Minority children have higher rates of anesthetic and surgical morbidity compared to White children, including respiratory events, length of stay, hospital costs, and even death. These inequities occur across surgical specialties and environments. Summary Racial disparities in the perioperative health and management of children are ubiquitous. Herein, we will summarize recent pediatric health disparity literature, discuss some important contributors to persistent inequities, and propose avenues for anesthesiologists to impact the pursuit of equitable healthcare outcomes.
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Affiliation(s)
- Brittany L. Willer
- Department of Anesthesiology & Pain Medicine, Nationwide Children’s Hospital, 700 Children’s Drive, Columbus, OH 43205 USA
| | - Christian Mpody
- Department of Anesthesiology & Pain Medicine, Nationwide Children’s Hospital, 700 Children’s Drive, Columbus, OH 43205 USA
| | - Olubukola O. Nafiu
- Department of Anesthesiology & Pain Medicine, Nationwide Children’s Hospital, 700 Children’s Drive, Columbus, OH 43205 USA
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Development of an Evidence-Based Pediatric Preoperative Risk Assessment Checklist. J Perianesth Nurs 2022; 37:589-594.e2. [DOI: 10.1016/j.jopan.2020.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2020] [Revised: 12/14/2020] [Accepted: 12/26/2020] [Indexed: 11/18/2022]
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Hii J, Templeton TW, Sommerfield D, Sommerfield A, Matava CT, von Ungern-Sternberg BS. Risk assessment and optimization strategies to reduce perioperative respiratory adverse events in pediatric anesthesia-Part 1 patient and surgical factors. Paediatr Anaesth 2022; 32:209-216. [PMID: 34897906 DOI: 10.1111/pan.14377] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Revised: 12/08/2021] [Accepted: 12/09/2021] [Indexed: 01/22/2023]
Abstract
Pediatric surgery cases are increasing worldwide. Within pediatric anesthesia, perioperative respiratory adverse events are the most common precipitant leading to serious complications. They can have intraoperative impact on the surgical procedure itself, lead to premature case termination and in addition may have postoperative impact resulting in longer hospitalization stays and costs. Although most perioperative respiratory adverse events can be promptly detected and managed, and will not lead to any sequelae, the risk of life-threatening progression remains. The incidence of respiratory adverse events increases in children with comorbid respiratory and/or nonrespiratory illnesses. Optimized perioperative patient care, risk-stratified care level choice, and practitioners with appropriate training allow for risk mitigation. This review will discuss patient and surgical risk factors with a focus on common patient comorbid illnesses and review scoring systems to quantify risk.
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Affiliation(s)
- Justin Hii
- Perioperative Medicine Team, Telethon Kids Institute, Nedlands, Western Australia, Australia.,Department of Anaesthesia, Joondalup Health Campus, Joondalup, Western Australia, Australia
| | - T Wesley Templeton
- Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - David Sommerfield
- Perioperative Medicine Team, Telethon Kids Institute, Nedlands, Western Australia, Australia.,Division of Emergency Medicine, Anaesthesia and Pain Medicine, Medical School, University of Western Australia, Crawley, Western Australia, Australia.,Department of Anaesthesia and Pain Management, Perth Children's Hospital, Nedlands, Western Australia, Australia
| | - Aine Sommerfield
- Perioperative Medicine Team, Telethon Kids Institute, Nedlands, Western Australia, Australia.,Department of Anaesthesia and Pain Management, Perth Children's Hospital, Nedlands, Western Australia, Australia
| | - Clyde T Matava
- Department of Anesthesia and Pain Medicine, Hospital for Sick Children, Toronto, Ontario, Canada.,Department of Anesthesiology and Pain Medicine, Termerty Faculty of Medicine, University of Toronto, Ontario, Canada
| | - Britta S von Ungern-Sternberg
- Perioperative Medicine Team, Telethon Kids Institute, Nedlands, Western Australia, Australia.,Division of Emergency Medicine, Anaesthesia and Pain Medicine, Medical School, University of Western Australia, Crawley, Western Australia, Australia.,Department of Anaesthesia and Pain Management, Perth Children's Hospital, Nedlands, Western Australia, Australia
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