Optimizing anticonvulsant administration for children before anesthesia: a quality improvement project

Anesthetic Care of a Child Harboring the KCNH2 Gene

Epilepsy is a heterogeneous group of disorders characterized by recurrent and generally unprovoked seizures. Genetic mutations may play an important role in the etiology of epilepsy. Over the past few years, genetic mutations in various genes have been identified in patients with epilepsy. One of the more common mutations responsible for seizures involves the KCNH2 gene. The KCNH2 gene encodes the Kv11.1 protein, which involves the pore-forming subunit of a rapidly activating-delayed rectifier potassium channel. This channel plays an essential role in phases 2 and 3 of the cardiac action potential involving cardiac repolarization as well as being expressed in various parts of the central nervous system where it regulates neuronal function. As such, patients presenting with this gene mutation may be at risk not only for seizures, but also abnormalities in cardiac repolarization leading to lethal arrhythmias. We present an 11-year-old girl who required general anesthesia for magnetic resonance imaging as part of her evaluation for non-convulsive status epilepticus. An epilepsy gene panel evaluated revealed a KCNH2 gene mutation. End-organ involvement of KCNH2 gene mutations is presented, previous reports of anesthetic care for these patients are reviewed, and options for anesthetic care are discussed.

Perioperative Care of a Child With Cri Du Chat Syndrome

Cri du chat syndrome (CdCS) is a chromosomal disorder resulting from a deletion in the short arm of chromosome 5. Anatomical abnormalities of the larynx result in a distinctive high-pitched, cat-like cry for which the disorder is named. Typical findings of the syndrome involve the upper airway, cardiovascular, and central nervous system (CNS). Of particular concern during anesthetic care is the potential for airway abnormalities leading to difficulties with endotracheal intubation as well as the presence of congenital heart disease (CHD). We present a 15-month-old child with CdCS who required anesthetic care during direct laryngoscopy and supraglottoplasty. The perioperative concerns of such patients are discussed, and previous reports of anesthetic care reviewed.

Medication Discrepancy Risk Factors for Pediatric Patients With Epilepsy at Hospital Admission

BACKGROUND

Children with epilepsy are at increased risk of medication errors due to disease complexity and administration of time-sensitive medication. Errors frequently occur during transitions of care between home and hospital, a time when accuracy of medication history lists is difficult to ascertain. Adverse events likely from medication discrepancies underscore the importance of improving medication reconciliation upon inpatient intake. This quality improvement project was designed to evaluate and optimize the current medication history process in epileptic patients upon hospital admission at a pediatric academic hospital.

METHODS

A retrospective chart review was conducted on 30 patients with epilepsy admitted in during April, July, and October 2018 to identify unintentional medication discrepancies among 6 sources: documented medication history, inpatient orders from the electronic medical record, outpatient clinic notes, inpatient history and admission document, phone message records, and external insurance claims.

RESULTS

A total of 63% percent of patients had at least 1 unintentional medication discrepancy. Most discrepancies occurred with daily maintenance anticonvulsants (63%). The most common types were omission of medication history (31%) and inpatient order omissions (27%). The number of medication histories completed with at least 1 discrepancy varied across pharmacists, nurses, and physicians, yet differences were not statistically significant.

CONCLUSIONS

Our study found a higher incidence of anticonvulsant discrepancies compared with previous studies. This quality improvement initiative identified the absence of a standardized process as the root cause for the high incidence of anticonvulsant discrepancies in pediatric patients with epilepsy at hospital admission.

Anesthetic care for patients with anti-NMDA receptor encephalitis

Introduction

Anti-N-methyl-D-aspartate (NMDA) receptor encephalitis, an autoimmune disorder resulting from antibodies directed against the NMDA (glutamate) receptor, is the second most frequent cause of immune-mediated encephalitis. To date, the information related to the anesthetic care of children with this disorder is limited to anecdotal reports.

Methods

We reviewed the anesthetic care of six patients with anti-NMDA receptor encephalitis who underwent 21 procedures at our institution from 2014 through 2019.

Results

The study cohort included six patients, ranging in age from 2 to 18 years, who required anesthetic care during 21 procedures. Airway management included a laryngeal mask airway (n = 8), endotracheal intubation (n = 12), and native airway with spontaneous ventilation (n = 1). Intravenous (IV) induction with propofol was used in 17 procedures for five patients, including three that required rapid sequence intubation using rocuronium or succinylcholine. Inhalation induction with sevoflurane in nitrous oxide (N₂O)/oxygen (O₂) was chosen for two procedures in two patients. A combination of both induction techniques was used for two patients in two procedures. Maintenance anesthesia was accomplished with a volatile agent, predominantly sevoflurane, for 18 of the 21 procedures; propofol infusion for one procedure; and single dose of propofol was used for two short procedures. N₂O was not used for maintenance anesthesia in any of the encounters. None of the patients exhibited adverse events, including hemodynamic instability, thermoregulatory problems, or respiratory events perioperatively. Postoperatively, there was no observed deterioration in clinical status attributed to anesthetic care.

Discussion

Multisystem involvement in anti-NMDA receptor encephalitis includes memory loss, behavior irregularity, psychosis, arrhythmias, blood pressure (BP) instability, and hypoventilation. In our study cohort, we noted no intraoperative issues and deterioration in clinical status following the use of volatile anesthetic agents, opioids, dexmedetomidine, and propofol for general anesthesia (GA) or sedation. As ketamine, xenon, and N₂O mediate their anesthetic effects, primarily, through antagonism of NMDA receptors, theoretical concerns suggest that they should be avoided.

Batten disease and perioperative complications: a retrospective descriptive study

PURPOSE

Batten disease or neuronal ceroid lipofuscinosis is the most prevalent neurodegenerative disorder of childhood. Previously reported perioperative complications in children with Batten disease have come mainly from single case reports. The primary aim of the current study was to investigate perioperative complications of patients with Batten disease in the largest cohort known to date. The secondary objective was to characterize the anesthetic management including the use of propofol and to assess its association with adverse events.

METHOD

We conducted a single center, retrospective descriptive study by querying the hospital's electronic medical record to identify patients with a diagnosis of Batten disease or ICD10 E75.4 who received anesthetic care from December 2014 to May 2019.

RESULTS

Thirty-five patients who underwent a total of 93 anesthetic encounters (range 1-11) were included in the analysis. A total of 29 adverse events were identified. Hypotension (N = 6, 6.5%) and bradycardia (N = 7, 7.5%) requiring treatment with medications were the most common adverse events. Other adverse events include oxygen desaturation (N = 4, 4.3%), seizures (N = 4, 4.3%), unanticipated hospital or ICU admission (N = 1, 1.1%), PACU phase 1 stay > 120 min (N = 2, 2.2%), hypothermia (N = 4, 4.3%), agitation (N = 1, 1.1%), and laryngospasm requiring treatment (N = 1, 1.1%). The number of preoperative anti-epileptic drugs (AEDs) had a positive correlation with the rate of perioperative adverse events. There was no statistical relationship of adverse events with intraoperative use of propofol (odds ratio 1.03, 95% CI 0.42-2.51).

CONCLUSIONS

The majority of these patients were managed without clinically significant perioperative complications. As previously reported, bradycardia, hypotension, and hypothermia were the most common adverse events. Routine avoidance of propofol in patients with Batten disease does not appear warranted.

Preoperative anesthesia evaluation

The preoperative evaluation is the first step in ensuring the safe conduct of anesthetic care in pediatric patients of all ages. Over time, this process has changed significantly from a time when patients were admitted to the hospital the night before surgery to a time when the majority of patients, including those scheduled for major surgical procedures, arrive the day of surgery. For most patients, the preoperative examiantion can be conducted over the phone by a trained nurse or on-line via a survey thereby eliminating the need for a separate visit merely for the preoperative evaluation. Regardless of where or how it occurs, the goals of the preoperative evaluation are to gain information regarding the patient's current status, comorbid conditions, and the intended procedure. This process allows the identification of patients who require additional preoperative testing or those patients who need to be seen by an anesthesiolgoist prior to the day of surgery. During the preopeative evalaution, decisions are made regarding further laboratory or investigative work-up that are required. The preoperative meeting provides an arena to develop the initial parent-physcian rapport, outline anesthetic risks, and discuss the intended anesthetic plan including options for postoperative analgesia. The process facilitates the care of patients during the perioperative period while limiting surgical cancellations resulting from patient-related issues. The following chapter reviews the essential components of the preoperative evaluation including the appropraite use of preoperative laboratory testing and other investigative procedures including radiologic imaging. Key components of the physical examinatino including the airway examination are reviewed.