Etiology of postanesthetic and postsedation events on the inpatient ward: data from a rapid response team at a tertiary care children's hospital

Tracheostomy, Feeding-Tube, and In-Hospital Postoperative Mortality in Children: A Retrospective Cohort Study

BACKGROUND

Neuromuscular/neurologic disease confers increased risk of perioperative mortality in children. Some patients require tracheostomy and/or feeding tubes to ameliorate upper airway obstruction or respiratory failure and reduce aspiration risk. Empiric differences between patients with and without these devices and their association with postoperative mortality have not been previously assessed.

METHODS

This retrospective cohort study using the Pediatric Health Information System measured 3- and 30-day in-hospital postsurgical mortality among children 1 month to 18 years of age with neuromuscular/neurologic disease at 44 US children's hospitals, from April 2016 to October 2018. We summarized differences between patients presenting for surgery with and without these devices using standardized differences. Then, we calculated 3- and 30-day mortality among patients with tracheostomy, feeding tube, both, and neither device, overall and stratified by important exposures, using Fisher exact test to test whether differences were significant.

RESULTS

There were 43,193 eligible patients. Unadjusted 3-day mortality was 1.3% (549/43,193); 30-day mortality was 2.7% (1168/43,193). Most (79.1%) used neither a feeding tube or tracheostomy, 1.2% had tracheostomy only, 15.5% had feeding tube only, and 4.2% used both devices. Compared to children with neither device, children using either or both devices were more likely to have multiple CCCs, dysphagia, chronic pulmonary disease, cerebral palsy, obstructive sleep apnea, or malnutrition, and a prolonged intensive care unit (ICU) stay within the previous year. They were less likely to present for high-risk surgeries (33% vs 57%). Having a feeding tube was associated with decreased 3-day mortality overall compared to having neither device (0.9% vs 1.3%, P = .003), and among children having low-risk surgery, and surgery during urgent or emergent hospitalizations. Having both devices was associated with decreased 3-day mortality among children having low-risk surgery (0.8% vs 1.9%; P = .013), and during urgent or emergent hospitalizations (1.6% vs 2.9%; P = .023). For 30-day mortality, having a feeding tube or both devices was associated with lower mortality when the data were stratified by the number of CCCs.

CONCLUSIONS

Patients requiring tracheostomy, feeding tube, or both are generally sicker than patients without these devices. Despite this, having a feeding tube was associated with lower 3-day mortality overall and lower 30-day mortality when the data were stratified by the number of CCCs. Having both devices was associated with lower 3-day mortality in patients presenting for low-risk surgery, and surgery during urgent or emergent hospitalizations.

Rapid response team activation after major hip surgery: A case series

Introduction

We describe the demographic, preoperative, surgical, anesthetic, and postoperative characteristics of patients who required a rapid response team (RRT) activation after major hip surgery. We determined the characteristics and outcomes of patients that require RRTs after major hip surgery, and their associations with mortality.

Presentation of cases

We retrospectively reviewed adult patients undergoing major hip surgery in a university teaching hospital. We included patients who had an RRT or “code blue” activation post-surgery and within the index hospital admission. We extracted patient, surgical, anesthetic, and postoperative variables. We explored differences between patients who survived their index hospital stay and those who died.

Discussion

187 (9%) patients had a postoperative RRT activation. The median age was 84.0 (78–90) years; 125 (67%) were female, and most patients had significant comorbidities. The median Charlson Comorbidity Index (CCI) was 5.0 (4.0–7.0). Patients were frail (68%), ASA physical status ≥Class 3 (91%) and underwent emergency surgery (88%). Death after RRT activation occurred in 1 in 7 patients. Compared to patients who survived RRT activation, those who died had a higher mean CCI (6.5 [1.8] vs. 5.5 [2.1], P = 0.02), were more frail (80.1% vs. 56.5%, OR = 3.2, 95% CI: 1.2,8.1; P = 0.03), and received less intraoperative opioids (intravenous morphine equi-analgesia: median = 5.8 (0.1–8.20 vs. 11.7 (3.7–19.0) mg, P = 0.03).

Conclusion

Mortality after RRT activation is associated with non-modifiable patients factors rather than surgical or anesthesia factors. Our findings provide opportunities for the implementation of strategies aimed at improving postoperative outcomes.

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Major hip surgery poses a significant physiological challenge to patients.

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Almost one in ten patients had a postoperative rapid response team activation.

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Mortality rate was one in seven patients following rapid response team activation.

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Advanced age, frailty and emergency surgery were associated with RRT activation.

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Death post RRT activation was not associated with surgical or anesthesia factors.

Navigating Uncertainty in Respiratory Assessment: The Interaction of Culture and Technology During Phase I Postanesthetic Recovery

PURPOSE

To explore postanesthesia care unit (PACU) nurses' interactions with technology during the critical Phase I recovery period.

DESIGN

Interpretive description was used to understand nurses' experiences.

METHODS

Nine PACU nurses were recruited from three mid-sized hospitals within the same health authority in a Western Canadian province. Nurse participants were interviewed using a semistructured interview guide.

FINDINGS

Nurses' interactions with technology were significantly influenced by PACU culture, as they constantly navigated a level of uncertainly about their patient's respiratory status. Three themes from the study are described. Theme 1 described nurses' confidence and trust in a visual sensory respiratory assessment process and the influence of anesthesia providers. Theme 2 described PACU nurses' guarded trust or rationalized mistrust in technology. Theme 3 highlighted the contextual influences, which sustained nurses' approach to respiratory assessment.

CONCLUSIONS

PACU nurses practiced their intuitive sensory assessments with a projected strong sense of expert practice and minimal dependence on technology. PACU nurses expressed frustrations with current PACU bedside technology, particularly the respiratory module and described some experiences with delayed identification of hypoventilation and hypoxia. Rationalized behaviors with technology and alarm suppression were commonplace. Workplace culture sustained PACU nurses' respiratory assessment practices.

Incidence and risk factors for adverse events during monitored anaesthesia care for gastrointestinal endoscopy in children: A prospective observational study

BACKGROUND

Better understanding of risk factors for adverse events during monitored anaesthesia care (MAC) for paediatric gastrointestinal endoscopy may improve outcome in children.

OBJECTIVES

To identify the prevalence and predictors of adverse events during MAC for paediatric endoscopy.

DESIGN

An observational study.

SETTING

Tertiary university hospital, single-centre cohort, from January 2010 to August 2016.

PATIENTS

The prospectively collected electronic anaesthetic records of 3435 children aged up to 16 years who underwent diagnostic gastrointestinal endoscopy under MAC were analysed retrospectively. Children with an American Society of Anesthesiologists' physical status at least 4, and those requiring mechanical ventilation and therapeutic or urgent endoscopy were excluded.

MAIN OUTCOME MEASURES

The prevalence and predictors of adverse events during MAC for paediatric gastrointestinal endoscopy, with particular reference to the use of different anaesthetic or sedative agents.

RESULTS

Mean ± SD age of the children was 8.5 ± 4.4 years. The incidences of adverse events and adverse respiratory events were 3.4 and 3.3%, respectively. Multivariate analysis identified 12 independent predictors: age [odds ratio (OR) 0.92, P = 0.002], children's size for example underweight (OR 1.78, P = 0.039), overweight (OR 2.20, P = 0.039), (morbid) obesity (OR 4.25, P = 0.006), presence of respiratory comorbidities (OR 8.18, P < 0.001), recent respiratory infection (OR 23.55, P < 0.001) or both (OR 17.46, P < 0.001), neurological comorbidities (OR 2.18, P = 0.007), upper gastrointestinal endoscopy (OR 5.66, P < 0.001), propofol co-administration with ketamine (OR 10.34, P < 0. 001) or after sevoflurane induction (OR 44.95, P < 0.001), and propofol induction dose (OR 18.97, P < 0.001). Posthoc secondary analyses revealed a significantly higher risk of adverse events (OR 3.9, P < 0.0001) and also significantly more respiratory comorbidities and respiratory infections (P < 0.0001) in children aged less than 2 years when compared with children aged at least 2 years. No cardiovascular events were observed and outcome was uneventful.

CONCLUSION

The present cohort demonstrated the feasibility and safety of MAC for paediatric gastrointestinal endoscopy by an experienced team. Although adverse events occurred rarely, their predictive factors were clinically identifiable. Applying this information in risk assessment and modifying anaesthetic management accordingly could improve outcome.

TRIAL REGISTRATION

ISRCTN70362666.

Rapid Response Team activation for pediatric patients on the acute pain service

INTRODUCTION

Untreated pain or overly aggressive pain management may lead to adverse physiologic consequences and activation of the hospital's Rapid Response Team. This study is a quality improvement initiative that attempts to identify patient demographics and patterns associated with Rapid Response Team consultations for patients on the acute pain service.

METHODS

A retrospective review of all patients on the acute pain service from February 2011 until June 2015 was cross-referenced with inpatients requiring consultation from the Rapid Response Team. Two independent practitioners reviewed electronic medical records to determine which events were likely associated with pain management interventions.

RESULTS

Over a 4-year period, 4872 patients were admitted to the acute pain service of whom 135 unique patients required Rapid Response Team consults. There were 159 unique Rapid Response Team activations among 6538 unique acute pain service consults. A subset of 27 pain management-related Rapid Response Team consultations was identified. The largest percentage of patients on the acute pain service were adolescents aged 12-17 (36%). Compared to this age group, the odds of Rapid Response Team activation were higher among infants <1 year old (odds ratio = 2.85; 95% confidence interval: 1.59, 5.10; P < .001) and adults over 18 years (odds ratio = 1.68; 95% confidence interval: 1.01, 2.80; P = .046).

DISCUSSION

Identifying demographics and etiologies of acute pain service patients requiring Rapid Response Team consultations may help to identify patients at risk for clinical decompensation.

The Simulation-Based Assessment of Pediatric Rapid Response Teams

OBJECTIVE

To create scenarios of simulated decompensating pediatric patients to train pediatric rapid response teams (RRTs) and to determine whether the scenario scores provide a valid assessment of RRT performance with the hypothesis that RRTs led by intensivists-in-training would be better prepared to manage the scenarios than teams led by nurse practitioners.

STUDY DESIGN

A set of 10 simulated scenarios was designed for the training and assessment of pediatric RRTs. Pediatric RRTs, comprising a pediatric intensive care unit (PICU) registered nurse and respiratory therapist, led by a PICU intensivist-in-training or a pediatric nurse practitioner, managed 7 simulated acutely decompensating patients. Two raters evaluated the scenario performances and psychometric analyses of the scenarios were performed.

RESULTS

The teams readily managed scenarios such as supraventricular tachycardia and opioid overdose but had difficulty with more complicated scenarios such as aortic coarctation or head injury. The management of any particular scenario was reasonably predictive of overall team performance. The teams led by the PICU intensivists-in-training outperformed the teams led by the pediatric nurse practitioners.

CONCLUSIONS

Simulation provides a method for RRTs to develop decision-making skills in managing decompensating pediatric patients. The multiple scenario assessment provided a moderately reliable team score. The greater scores achieved by PICU intensivist-in-training-led teams provides some evidence to support the validity of the assessment.