Comprehensive Risk Assessment of Morbidity in Pediatric Patients Undergoing Noncardiac Surgery: An Institutional Experience

Advances in pediatric perioperative care using artificial intelligence

PURPOSE OF THIS REVIEW

This article explores how artificial intelligence (AI) can be used to evaluate risks in pediatric perioperative care. It will also describe potential future applications of AI, such as models for airway device selection, controlling anesthetic depth and nociception during surgery, and contributing to the training of pediatric anesthesia providers.

RECENT FINDINGS

The use of AI in healthcare has increased in recent years, largely due to the accessibility of large datasets, such as those gathered from electronic health records. Although there has been less focus on pediatric anesthesia compared to adult anesthesia, research is on- going, especially for applications focused on risk factor identification for adverse perioperative events. Despite these advances, the lack of formal external validation or feasibility testing results in uncertainty surrounding the clinical applicability of these tools.

SUMMARY

The goal of using AI in pediatric anesthesia is to assist clinicians in providing safe and efficient care. Given that children are a vulnerable population, it is crucial to ensure that both clinicians and families have confidence in the clinical tools used to inform medical decision- making. While not yet a reality, the eventual incorporation of AI-based tools holds great potential to contribute to the safe and efficient care of our patients.

A systematic review of neurological airway respiratory cardiovascular other-surgical severity (NARCO-SS) score as a pediatric perioperative scoring system

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.

Retrospective analysis of neurological findings in esophageal atresia: Allostatic load of disease complexity, cumulative sedation, and anesthesia exposure

BACKGROUND

There is limited knowledge regarding the impact of perioperative critical care on frequency of neurological imaging findings following esophageal atresia (EA) repair.

METHODS

This is a retrospective study of infants (n = 70) following EA repair at a single institution (2009-2020). Sex, gestational age at birth, type of surgical repair, underlying disease severity, and frequency of neurologic imaging findings were obtained. We quantified the length of postoperative pain/sedation treatment and anesthesia exposure in the first year of life. Data were presented as numerical sums and percentages, while associations were measured using Spearman's Rho.

RESULTS

Vertebral/spinal cord imaging was performed in all infants revealing abnormalities in 44% (31/70). Cranial/brain imaging findings were identified in 67% (22/33) of infants in the context of clinically indicated imaging (47%; 33/70). Long-gap EA patients (n = 16) received 10 times longer postoperative pain/sedation treatment and twice the anesthesia exposure compared with short-gap EA patients (n = 54). The frequency of neurologic imaging findings did not correlate with underlying disease severity scores, length of pain/sedation treatment, or cumulative anesthesia exposure. Lack of associations between clinical measures and imaging findings should be interpreted with caution given possible underestimation of cranial/brain findings.

CONCLUSIONS

We propose that all infants with EA undergo brain imaging in addition to routine spinal imaging given the high burden of abnormal brain/cranial findings in our cohort. Quantification of pain/sedation and anesthesia exposure in long-gap EA patients could be used as indirect markers in future studies assessing the risk of neurological sequelae as evidenced by early abnormalities on brain imaging.

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.

Use of artificial intelligence in paediatric anaesthesia: a systematic review

Objectives

Although the development of artificial intelligence (AI) technologies in medicine has been significant, their application to paediatric anaesthesia is not well characterised. As the paediatric operating room is a data-rich environment that requires critical clinical decision-making, this systematic review aims to characterise the current use of AI in paediatric anaesthesia and to identify barriers to the successful integration of such technologies.

Methods

This review was registered with PROSPERO (CRD42022304610), the international registry for systematic reviews. The search strategy was prepared by a librarian and run in five electronic databases (Embase, Medline, Central, Scopus, and Web of Science). Collected articles were screened by two reviewers. Included studies described the use of AI for paediatric anaesthesia (<18 yr old) within the perioperative setting.

Results

From 3313 records identified in the initial search, 40 were included in this review. Identified applications of AI were described for patient risk factor prediction (24 studies; 60%), anaesthetic depth estimation (2; 5%), anaesthetic medication/technique decision guidance (2; 5%), intubation assistance (1; 2.5%), airway device selection (3; 7.5%), physiological variable monitoring (6; 15%), and operating room scheduling (2; 5%). Multiple domains of AI were discussed including machine learning, computer vision, fuzzy logic, and natural language processing.

Conclusion

There is an emerging literature regarding applications of AI for paediatric anaesthesia, and their clinical integration holds potential for ultimately improving patient outcomes. However, multiple barriers to their clinical integration remain including a lack of high-quality input data, lack of external validation/evaluation, and unclear generalisability to diverse settings.

Systematic review protocol

CRD42022304610 (PROSPERO).

Risk factors associated with unplanned ICU admissions following paediatric surgery: A systematic review

Background

Unplanned admissions to the intensive care unit (ICU) have important implications in the general management of patients. Research in this area has been conducted in the adult and non-surgical population. To date, there is no systematic review addressing risk factors in the paediatric surgical population.

Objectives

To synthesise the information from studies that explore the risk factors associated with unplanned ICU admissions following surgery in children through a systematic review process.

Methods

We conducted a systematic review of published literature (PROSPERO registration CRD42020163766), adhering to the Preferred Reporting of Observational Studies and Meta-Analysis (PRISMA) statement. The Population, Exposure, Comparator, Outcome (PECO) strategy used was based on: population – paediatric population, exposure – risk factors, comparator – other, and outcome – unplanned ICU admission. Data that reported on unplanned ICU admissions following paediatric surgery were extracted and analysed. Quality of the studies was assessed using the Newcastle-Ottawa Scale.

Results

Seven studies were included in the data synthesis. Four studies were of good quality with the Newcastle-Ottawa Scale score ≥7 points. The pooled prevalence (95% confidence interval) estimate of unplanned ICU stay was 2.69% (0.05 - 8.6%) and ranged between 0.06% and 8.3%. Significant risk factors included abnormal sleep studies and the presence of comorbidities in adenotonsillectomy surgery. In the general surgical population, younger age, comorbidities and general anaesthesia were significant. Abdominal surgery and ear, nose and throat (ENT) surgery resulted in a higher risk of unplanned ICU admission. Owing to the heterogeneity of the data, a meta-analysis with risk prediction could not be performed.

Conclusion

Significant patient, surgical and anaesthetic risk factors associated with unplanned ICU admission in children following surgery are described in this systematic review. A combination of these factors may direct planning toward anticipation of the need for a higher level of postoperative care. Further work to develop a predictive score for unplanned ICU stay is desirable.

Contributions of the study

Unplanned admissions to the intensive care unit (ICU) have been acknowledged as an overall marker of safety.^[1] Awareness of this concept has encouraged research to determine the incidence and risk factors of these occurrences. This research has been interrogated in a systematic review process with beneficial conclusions drawn; however, these studies included adults and non-surgical patients.^[2–4] To date, we have not been able to find a systematic review addressing the risk factors associated with unplanned ICU admissions in paediatric surgical patients.

Patients With Congenital Heart Disease Undergoing Noncardiac Procedures at Hospitals With and Without a Cardiac Surgical Program

Background

The type and location of hospitals where patients with congenital heart disease (CHD) undergo noncardiac procedures have not been investigated. This study aimed to describe (1) the characteristics of these patients, (2) the distribution of procedures among hospitals with and without a cardiac surgical program and travel distances, (3) the characteristics determining the distribution, and (4) mortality rates.

Methods and Results

This is a retrospective cohort analysis of inpatient data from the Center for Healthcare Information and Analysis of the Commonwealth of Massachusetts, Texas Healthcare Information Collection, and Health Care Cost and Utilization Project State Inpatient Database. Children <18 years old with CHD who underwent noncardiac procedures were included. Distances were calculated using the Haversine formula. Logistic regression was performed to evaluate the odds of a procedure at a hospital with a cardiac program. There were 7435 encounters at 235 hospitals analyzed. Most procedures (87.8%) occurred at hospitals with a cardiac program. Patients at a hospital without a cardiac program had simple CHD (72.4%) with <1% with single ventricle disease. At hospitals with a cardiac program, 56.8% had simple CHD, 35.4% complex CHD, and 7.8% single ventricle disease. The median distance traveled was 25.2 miles (interquartile range, 10.3–73.8 miles) to a hospital with a cardiac program and 14.6 miles (interquartile range, 6.2–37.4 miles) to a hospital without a cardiac program (P<0.001). Single ventricle disease (adjusted odds ratio [aOR], 16.25 [95% CI, 7.22–36.61]) and ≥6 chronic conditions (aOR, 1.81 [95% CI, 1.57–2.09]) were associated with performance at a hospital with a cardiac program. Mortality rate was 3.8%.

Conclusions

Patients with CHD are more likely to travel to a hospital with a cardiac program for noncardiac procedures than to a hospital without; especially patients with single ventricle disease, other complex CHD, and with ≥6 chronic conditions.

From the Ground Up: Esophageal Atresia Types, Disease Severity Stratification and Survival Rates at a Single Institution

Esophageal atresia (EA), although a rare congenital anomaly, represents one of the most common gastrointestinal birth defects. There is a gap in our knowledge regarding the impact of perioperative critical care in infants born with EA. This study addresses EA types, disease severity stratification, and mortality in a retrospective cohort at a single institution. Institutional Review Board approved our retrospective cross-sectional study of term-born (n = 53) and premature infants (28–37 weeks of gestation; n = 31) that underwent primary surgical repair of EA at a single institution from 2009–2020. Demographic and clinical data were obtained from the electronic medical record, Powerchart (Cerner, London, UK). Patients were categorized by (i) sex, (ii) gestational age at birth, (iii) types of EA (in relation to respiratory tract anomalies), (iv) co-occurring congenital anomalies, (v) severity of disease (viz. American Society of Anesthesiologists (ASA) and Pediatric Risk Assessment (PRAm) scores), (vi) type of surgical repair for EA (primary anastomosis vs. Foker process), and (vii) survival rate classification using Spitz and Waterston scores. Data were presented as numerical sums and percentages. The frequency of anatomical types of EA in our cohort parallels that of the literature: 9.5% (8/84) type A, 9.5% (8/84) type B, 80% (67/84) type C, and 1% (1/84) type D. Long-gap EA accounts for 88% (7/8) type A, 75% (6/8) type B, and 13% (9/67) type C in the cohort studied. Our novel results show a nearly equal distribution of sex per each EA type, and gestational age (term-born vs. premature) by anatomical EA type. PRAm scoring showed a wider range of disease severity (3–9) than ASA scores (III and IV). The survival rate in our EA cohort dramatically increased in comparison to the literature in previous decades. This retrospective analysis at a single institution shows incidence of EA per sex and gestational status for anatomical types (EA type A-D) and by surgical approach (primary anastomosis vs. Foker process for short-gap vs. long-gap EA, respectively). Despite its wider range, PRAm score was not more useful in predicting disease severity in comparison to ASA score. Increased survival rates over the last decade suggest a potential need to assess unique operative and perioperative risks in this unique population of patients. Presented findings also represent a foundation for future clinical studies of outcomes in infants born with EA.

Reflection on young adult transitional care in the Boston Children's Hospital Perioperative Care Coordination Clinic

THEORETICAL PRINCIPLES

The complexity of pediatric healthcare has increased due to advancement in research and identification of new treatment modalities. With these advancements, life expectancy has increased creating a greater need for young adult transition into adult medical settings and specialty care (Marani et al., 2020). The holistic approach of nursing care is essential in assisting young adults during this transitional period.

PHENOMENON ADDRESSED

Many pediatric hospitals and subspecialties continue to care for young adults ≥18 years of age that have not transitioned to adult care. In the perioperative care coordination clinic at Boston Children's Hospital, pediatric nurses and advanced practice nurse practitioners provide care to patients from infancy to adulthood, throughout many specialties, to ensure safe perioperative care for a medically complex surgical population. The purpose of this paper is to describe the PCCC young adult care coordination process that provides engaging opportunities for the young adult to advocate for oneself and promote autonomy as they proceed through the stages of transition to adult care.

RESEARCH LINKAGES

The perioperative care coordination process at Boston Children's Hospital aligns with the Society of Pediatric Nurses position statement that recommended pediatric nurses utilize a framework (Betz, 2017) and Meleis' middle-range theory of Transitions that identified the nursing role during the transitional process (Meleis et al., 2000). A suggestion for future nursing research includes development of a nursing framework that nurses can utilize when supporting young adults during their progression through the steps of transition from pediatric to adult perioperative programs.