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Zlotolow M, Mpody C, Carrillo SA, Elmitwalli I, Nazir W, Nafiu OO, Tobias JD. Association of Previous Cardiac Surgery With Postoperative Pneumonia in Infants Undergoing Abdominal Operations: A Cohort Study. J Pediatr Surg 2024:161676. [PMID: 39244419 DOI: 10.1016/j.jpedsurg.2024.08.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2024] [Revised: 07/10/2024] [Accepted: 08/04/2024] [Indexed: 09/09/2024]
Abstract
BACKGROUND Children with congenital heart disease (CHD) often require other, non-cardiac related surgical procedures following their initial cardiac surgery. After full or partial CHD repair, they remain at increased risk of postoperative complications. We examined the association of previous cardiac intervention (surgery or percutaneous catheterization intervention) with postoperative pneumonia in infants undergoing abdominal general surgery. METHODS A 1:1 propensity score-matched study was conducted using a retrospective cohort of 104,820 infants (<12 months) who had general abdominal surgeries between 2012 and 2022 in U.S. hospitals participating in the National Surgical Quality Improvement Program. The primary outcome was postoperative pneumonia within 30 days. Secondary outcomes included unplanned reintubation, prolonged mechanical ventilation (>72 h), and extended hospital stay (>75th percentile for the study cohort). RESULTS Of the study cohort, 9736 infants (9.3%) had previous cardiac interventions. In the propensity score-matched sample, infants with previous cardiac surgery had increased risks of postoperative pneumonia (1.3% vs 0.8%; adjusted relative risk [RRadj]: 1.64, 95% CI: 1.22, 2.18, p = 0.001), unplanned reintubation (57.8% vs 32.6%; RRadj: 1.77, 95% CI: 1.77, 1.85, p < 0.001), prolonged mechanical ventilation (5.0% vs 2.3%; RRadj: 2.14, 95% CI: 1.83, 2.52, p < 0.001), and prolonged hospital stays (61.0% vs 53.8%; RRadj: 1.13, 95% CI: 1.10, 1.17, p < 0.001). CONCLUSIONS A history of previous cardiac intervention carries an increased risk of postoperative pneumonia, unplanned tracheal reintubation, prolonged mechanical ventilation, as well as longer hospital stays following intra-abdominal surgery. Clinicians should closely monitor these patients for respiratory complications after surgery. LEVEL OF EVIDENCE II.
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Affiliation(s)
- Morgan Zlotolow
- Department of Pediatrics, Nationwide Children's Hospital and the Ohio State University College of Medicine, Columbus, OH, USA
| | - 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
| | - Sergio A Carrillo
- Department of Pediatric Cardiothoracic Surgery, Nationwide Children's Hospital and the Ohio State University College of Medicine, Columbus, OH, USA
| | - Islam Elmitwalli
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA
| | - Wajahat Nazir
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, 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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Mora R, Maze M. The role of cultural competency training to address health disparities in surgical settings. Br Med Bull 2024; 150:42-59. [PMID: 38465857 DOI: 10.1093/bmb/ldae005] [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] [Accepted: 02/16/2024] [Indexed: 03/12/2024]
Abstract
BACKGROUND Disparities in health care delivered to marginalized groups are unjust and result in poor health outcomes that increase the cost of care for everyone. These disparities are largely avoidable and health care providers, have been targeted with education and specialised training to address these disparities. SOURCES OF DATA In this manuscript we have sought out both peer-reviewed material on Pubmed, as well as policy statements on the potential role of cultural competency training (CCT) for providers in the surgical care setting. The goal of undertaking this work was to determine whether there is evidence that these endeavours are effective at reducing disparities. AREAS OF AGREEMENT The unjustness of health care disparities is universally accepted. AREAS OF CONTROVERSY Whether the outcome of CCT justifies the cost has not been effectively answered. GROWING POINTS These include the structure/content of the CCT and whether the training should be delivered to teams in the surgical setting. AREAS TIMELY FOR DEVELOPING RESEARCH Because health outcomes are affected by many different inputs, should the effectiveness of CCT be improvement in health outcomes or should we use a proxy or a surrogate of health outcomes.
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Affiliation(s)
- Roberto Mora
- Department of Anesthesia and Perioperative Care, University of California, 1001 Potrero Avenue, San Francisco, CA 94110, USA
| | - Mervyn Maze
- Department of Anesthesia and Perioperative Care, University of California, 1001 Potrero Avenue, San Francisco, CA 94110, USA
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Nicotera DJ, Islam AA, Liu Y, Dunsky K, Lieu JEC. Disparities in the Presentation and Management of Pediatric Retropharyngeal Abscess. Laryngoscope 2024; 134:1907-1912. [PMID: 37698387 DOI: 10.1002/lary.31048] [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: 04/14/2023] [Revised: 08/30/2023] [Accepted: 09/01/2023] [Indexed: 09/13/2023]
Abstract
OBJECTIVES Differences in management and outcomes of otolaryngologic diseases may reflect inequities driven by social determinants of health. This study aimed to investigate disparities in presentation and outcomes of retropharyngeal abscess (RPA) among 231 pediatric patients. METHODS Medical records were searched for pediatric patients with RPA from 2010 to 2021. Charts were reviewed for demographics, clinical features, and treatment decisions. Area deprivation index (ADI) scores for patient zip codes were determined. Chi-square analysis independent samples t-test, and regression analyses were used to investigate associations between variables. RESULTS Among patients presenting for RPA, Black patients were less likely to undergo surgical management than non-Black patients (53.2% vs. 71.6%, p = 0.009). Black patients had a lower rate of treatment with antibiotics prior to hospital admission (19.4% vs. 54.4%, p < 0.001). Among patients who received surgery, Black patients had higher cross-sectional abscess area on CT (6.4 ± 8.4 cm2 > vs. 3.8 ± 3.3 cm2 , p = 0.014), longer length of stay (5.4 ± 3.3 days vs. 3.2 ± 1.5, p < 0.001), and longer time between admission and surgery (2.3 ± 2.1 vs. 0.83 ± 1.1, p < 0.001). Increased ADI was correlated with increased rate of trismus. CONCLUSIONS Lower rates of pre-admission antibiotics and larger abscess area on CT imaging among Black patients may suggest disparities in access to primary care, resulting in presentation to tertiary care at later stages of disease and higher rates of medical management trial prior to surgical intervention. LEVEL OF EVIDENCE 3 (retrospective cohort study) Laryngoscope, 134:1907-1912, 2024.
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Affiliation(s)
- Dante J Nicotera
- Department of Pediatric Otolaryngology, Washington University School of Medicine in St. Louis, St. Louis, Missouri, U.S.A
| | - Aseeyah A Islam
- Department of Pediatric Otolaryngology, Washington University School of Medicine in St. Louis, St. Louis, Missouri, U.S.A
| | - Yupeng Liu
- Department of Pediatric Otolaryngology, Washington University School of Medicine in St. Louis, St. Louis, Missouri, U.S.A
| | - Kate Dunsky
- Department of Pediatric Otolaryngology, Washington University School of Medicine in St. Louis, St. Louis, Missouri, U.S.A
| | - Judith E C Lieu
- Department of Pediatric Otolaryngology, Washington University School of Medicine in St. Louis, St. Louis, Missouri, U.S.A
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Warren J, Gibbs A, Mpody C, Nafiu OO, Tobias JD, Willer BL. Failure to rescue following postoperative pneumonia in pediatrics: Is there a racial disparity? Paediatr Anaesth 2024; 34:220-224. [PMID: 38055569 DOI: 10.1111/pan.14815] [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: 08/08/2023] [Revised: 11/15/2023] [Accepted: 11/19/2023] [Indexed: 12/08/2023]
Abstract
INTRODUCTION Racial disparities in measures of health and healthcare processes are well described. Limited work exists on disparities in failure to rescue - hospital mortality following a major adverse event. Postoperative pneumonia is a serious, potentially preventable adverse event that often leads to death, i.e., failure to rescue. This study examined the association of racial grouping with failure to rescue following postoperative pneumonia. METHODS We utilized the National Surgical Quality Improvement Program-Pediatrics Participant Use Data File to assemble a cohort of children <18 years who underwent inpatient surgery from 2012 to 2022. We included Black and White patients who developed pneumonia following an index surgery. The primary outcome was failure to rescue, defined as mortality following postoperative pneumonia. We used logistic regression models to estimate the odds ratio and 95% confidence intervals of failure to rescue, comparing Black and White children. RESULTS The study cohort included 3139 children <18 years who developed pneumonia following inpatient surgery. Of those, 2333 (74.3%) were White and 806 (25.7%) were Black. Failure to rescue occurred in 117 of the children (3.7%); 82 were White (3.5%) and 35 were Black (4.3%). After adjusting for gender, age, American Society of Anesthesiologists Physical Status classification, emergent/urgent vs. elective case status, year of operation, and pre-existing comorbidities, the odds of failure to rescue for Black children with postoperative pneumonia did not differ from White children (adjusted-Odds Ratio: 1.00; 95% Confidence Interval 0.62-1.61; p-value = .992). CONCLUSION We found no significant difference in the odds of failure to rescue following postoperative pneumonia between Black or White children. To improve postoperative care for all children and to narrow the racial gap in postoperative mortality, future studies should continue to investigate the association of race with failure to rescue following other postoperative complications.
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Affiliation(s)
- Jalen Warren
- Ohio University Heritage College of Osteopathic Medicine, Dublin Campus and Ohio University, Athens, Ohio, USA
| | - Anna Gibbs
- The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Christian Mpody
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital and the Department of Anesthesiology, The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Olubukola O Nafiu
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital and the Department of Anesthesiology, The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Joseph D Tobias
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital and the Department of Anesthesiology, The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Brittany L Willer
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital and the Department of Anesthesiology, The Ohio State University College of Medicine, Columbus, Ohio, USA
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Willer BL, Mpody C, Nafiu O, Tobias JD. Racial Disparities in Pediatric Mortality Following Transfusion Within 72 Hours of Operation. J Pediatr Surg 2023; 58:2429-2434. [PMID: 37652843 DOI: 10.1016/j.jpedsurg.2023.07.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Revised: 07/24/2023] [Accepted: 07/30/2023] [Indexed: 09/02/2023]
Abstract
BACKGROUND Postoperative bleeding and transfusion are correlated with mortality risk. Furthermore, postoperative bleeding may often initiate the cascade of complications that leads to death. Given that minority children have increased risk of surgical complications, this study aimed to investigate the association of race with pediatric surgical mortality following postoperative transfusion. METHODS We used the NSQIP-P PUF to assemble a retrospective cohort of children <18 who underwent inpatient surgery during 2012-2021. We included White, Black, Hispanic, and 'Other' children who received a transfusion within 72 h of surgery. The primary outcome was defined as all-cause mortality within 30 days following the primary surgical procedure. Using logistic regression models, we estimated the risk-adjusted odds ratio (aOR) and 95% confidence intervals (CI) of mortality, comparing each racial/ethnic cohort to White children. RESULTS A total of 466,230 children <18 years of age underwent inpatient surgical procedures from 2012 to 2021. Of these, 46,200 required transfusion and were included in our analysis. The majority of patients were non-Hispanic White (64.6%, n = 29,850), while 18.9% (n = 8752) were non-Hispanic Black, 11.7% (n = 5387) were Hispanic, and 4.8% (n = 2211) were 'Other' race. The overall rate of mortality following transfusion was 2.5%. White children had the lowest incidence of mortality (2.0%), compared to children of 'Other' race (2.5%), Hispanic children (3.1%), and Black children (3.6%). After adjusting for sex, age, comorbidities, case status, preoperative transfusion within 48 h, and year of operation, we found that Black children experienced 1.24 times the odds of mortality following a postoperative transfusion compared to a White child (aOR: 1.24; 95%CI, 1.03-1.51; P = 0.025). Hispanic children were also significantly more likely to die following a postoperative transfusion than White children (aOR: 1.19; 95%CI, 1.02-1.39; P = 0.027). CONCLUSION We found that minority children who required a postoperative transfusion had a higher odds of death than White children. Future studies should explore adverse events following postoperative transfusion and the differences in their management by race that may contribute to the higher mortality rate for minority children. LEVEL OF EVIDENCE Level II. CLINICAL TRIAL NUMBER AND REGISTRY Not applicable.
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Affiliation(s)
- Brittany L Willer
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA.
| | - Christian Mpody
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA
| | | | - Joseph D Tobias
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA
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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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Burton BN, Wall PV, Le D, Milam AJ, Gabriel RA. Racial Differences in 30-Day Reintubation After Head and Neck Surgery. Cureus 2023; 15:e35280. [PMID: 36968936 PMCID: PMC10038682 DOI: 10.7759/cureus.35280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/21/2023] [Indexed: 02/25/2023] Open
Abstract
Background This study aimed to examine the association of race and ethnicity with 30-day unplanned reintubation following head and neck surgery. Methodology A retrospective analysis of head and neck surgery patients aged greater than or equal to 18 years was extracted from the American College of Surgeons National Surgical Quality Improvement Program database from 2015 to 2020. Patient demographics, comorbidities, and 30-day reintubation were included in the analysis. Pearson's chi-square and independent samples t-test were used to compare reintubation cohorts. Multivariable logistic regression was used to identify the association of race and ethnicity with 30-day reintubation. Results Of the total 108,442 head and neck surgery cases included, 74.9% of patients were non-Hispanic White, 17.3% were non-Hispanic Black, and 7.7% were Hispanic. The overall 30-day reintubation rate was 0.33%. After adjusting for age, body mass index, sex, and comorbidities, non-Hispanic Black patients had increased 30-day reintubation compared to non-Hispanic White patients (odds ratio [OR] = 2.14, 95% confidence interval [CI] 1.70-2.69, and P < 0.0001). There was no difference in 30-day reintubation for Hispanic patients compared to non-Hispanic White patients (OR = 1.08, 95% CI 0.67-1.65, and P = 0.747). Conclusions This analysis showed that non-Hispanic Black patients disproportionately had higher odds of 30-day reintubation following head and neck surgery. Hispanic ethnicity was not associated with increased odds of 30-day reintubation. More studies are needed to investigate the reasons for these racial differences.
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Willer BL, Tobias JD, Suttle ML, Nafiu OO, Mpody C. Trends of Racial/Ethnic Disparities in Pediatric Central Line-Associated Bloodstream Infections. Pediatrics 2022; 150:188786. [PMID: 35979730 DOI: 10.1542/peds.2021-054955] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/20/2022] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Central line-associated bloodstream infections (CLABSIs), eminently preventable nosocomial infections, are a substantial source of morbidity, mortality, and increased resource utilization in pediatric care. Racial or ethnic disparities in health outcomes have been demonstrated across an array of medical specialties and practices in pediatric patients. However, it is unknown whether disparities exist in the rate of CLABSIs. Our objective was to evaluate the trends in racial and ethnic disparities of CLABSIs over the past 5 years. METHODS This is a retrospective cohort study using data from Pediatric Health Information System database collected from tertiary children's hospitals in the United States. Participants included 226 802 children (<18 years) admitted to the emergency department or inpatient ward between 2016 and 2021 who required central venous catheter placement. The primary outcome was risk-adjusted rate of CLABSI, occurring during the same admission, across race and ethnicity. RESULTS Of the 226 802 children, 121 156 (53.4%) were White, 40 589 (17.9%) were Black, and 43 374 (19.1%) were Hispanic. CLABSI rate decreased in all racial/ethnic groups over the study period, with the rates being consistently higher in Black (relative risk [RR], 1.27; 95% confidence interval [CI], 1.17-1.37; P < .01) and Hispanic children (RR, 1.16; 95% CI, 1.08-1.26; P < .01) than in White children. There was no statistically significant evidence that gaps in CLABSI rate between racial/ethnic groups narrowed over time. CONCLUSIONS CLABSI rate was persistently higher among Black and Hispanic children than their White peers. These findings emphasize the need for future exploration of the causes of persistent racial and ethnic disparities in pediatric patients.
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Affiliation(s)
- Brittany L Willer
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital and The Ohio State University, Columbus, Ohio
| | - Joseph D Tobias
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital and The Ohio State University, Columbus, Ohio
| | - Markita L Suttle
- Division of Critical Care Medicine, Nationwide Children's Hospital and The Ohio State University, Columbus, Ohio
| | - Olubukola O Nafiu
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital and The Ohio State University, Columbus, Ohio
| | - Christian Mpody
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital and The Ohio State University, Columbus, Ohio
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Mpody C, Hayes S, Rusin N, Tobias JD, Nafiu OO. Risk Assessment for Postoperative Pneumonia in Children Living With Neurologic Impairments. Pediatrics 2021; 148:peds.2021-050130. [PMID: 34349030 DOI: 10.1542/peds.2021-050130] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/15/2021] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Approximately one-third of all pediatric hospital charges are attributable to the care for children living with neurologic comorbidities. These children often require various surgical procedures and may have an elevated risk of lower respiratory infections because of poor neuromuscular coordination, poor cough, uncoordinated swallowing, and poor oral hygiene. Our objective was to evaluate the risk of pneumonia in children presenting with neurologic comorbidities. METHODS We performed a retrospective study of children (<18 years) who underwent inpatient surgery between 2012 and 2018 in hospitals participating in the National Surgical Quality Improvement Program. Our primary outcome was the time to incident pneumonia within the 30 days after surgery. RESULTS We identified 349 163 children, of whom 2191 developed pneumonia (30-day cumulative incidence: 0.6%). The presence of a preoperative neurologic comorbidity conferred approximately twofold higher risk of postoperative pneumonia (hazard ratio [HR]: 1.91, 95% confidence interval [CI]: 1.73-2.11). We explored the risk of pneumonia conferred by the components of neurologic comorbidity: cerebral palsy (HR: 3.92, 95% CI: 3.38-4.56), seizure disorder (HR: 2.93, 95% CI: 2.60-3.30), neuromuscular disorder (HR: 2.63, 95% CI: 2.32-2.99). The presence of a neurologic comorbidity was associated with a longer length of hospital stay (incidence rate ratio: 1.26, 95% CI: 1.25-1.28). CONCLUSIONS The risk of postoperative pneumonia was almost twofold higher in children with neurologic comorbidity. The magnitude of these associations underscores the need to identify areas of research and preventive strategies to reduce the excess risk of pneumonia in children with preoperative neurologic conditions.
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Affiliation(s)
- Christian Mpody
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio
| | - Seth Hayes
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio
| | - Nathan Rusin
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio
| | - Joseph D Tobias
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio
| | - Olubukola O Nafiu
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio
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