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Elmitwalli I, Abdelhady E, Kalsotra S, Gehred A, Tobias JD, Olbrecht VA. Use of high-flow nasal cannula versus other noninvasive ventilation techniques or conventional oxygen therapy for respiratory support following pediatric cardiac surgery: A systematic review and meta-analysis. Paediatr Anaesth 2024; 34:519-531. [PMID: 38389199 DOI: 10.1111/pan.14866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2023] [Revised: 02/09/2024] [Accepted: 02/13/2024] [Indexed: 02/24/2024]
Abstract
INTRODUCTION Noninvasive respiratory support may be provided to decrease the risk of postextubation failure following surgery. Despite these efforts, approximately 3%-27% of infants and children still experience respiratory failure after tracheal extubation following cardiac surgery. This systematic review evaluates studies comparing the efficacy of high-flow nasal cannula to conventional oxygen therapy such as nasal cannula and other noninvasive ventilation techniques in preventing postextubation failure in this patient population. METHODS A systematic and comprehensive search was conducted in major databases including MEDLINE, EMBASE, Web of Science, and Central. The search encompassed articles focusing on the prophylactic use of high-flow nasal cannula following tracheal extubation in pediatric patients undergoing cardiac surgery for congenital heart disease. The inclusion criteria for this review consisted of randomized clinical trials as well as observational, cohort, and case-control studies. RESULTS A total of 1295 studies were screened and 12 studies met the inclusion criteria. These 12 studies included a total of 1565 children, classified into three groups: seven studies compared high-flow nasal cannula to noninvasive ventilation techniques, four studies compared high-flow nasal cannula to conventional oxygen therapy, and one observational single-arm study explored the use of high-flow nasal cannula with no control group. There was no significant difference in the incidence of tracheal reintubation between high-flow nasal cannula and conventional oxygen therapy (risk ratio [RR] = 0.67, 95% confidence interval [CI]: 0.24-1.90, p = .46). However, there was a lower incidence of tracheal reintubation in patients who were extubated to high-flow nasal cannula versus those extubated to noninvasive ventilation techniques (RR = 0.45, 95% CI: 0.32-0.63, p < .01). The high-flow nasal cannula group also demonstrated a lower mortality rate compared to the noninvasive ventilation techniques group (RR = 0.31, 95% CI: 0.16-0.61, p < .01) as well as a shorter postoperative length of stay (mean difference = -8.76 days, 95% CI: -13.08 to -4.45, p < .01) and shorter intensive care length of stay (mean difference = -4.63 days, 95% CI: -9.16 to -0.11, p = .04). CONCLUSION High-flow nasal cannula is more effective in reducing the rate of postextubation failure compared to other forms of noninvasive ventilation techniques following surgery for congenital heart disease in pediatric-aged patients. high-flow nasal cannula is also associated with lower mortality rates and shorter length of stay. However, when comparing high-flow nasal cannula to conventional oxygen therapy, the findings were inconclusive primarily due to a limited number of scientific studies available on this specific comparison. Future study is needed to further define the benefit of high-flow nasal cannula compared to conventional oxygen therapy and various types of noninvasive ventilation techniques.
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Affiliation(s)
- Islam Elmitwalli
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio, USA
| | | | - Sidhant Kalsotra
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Alison Gehred
- Grant Morrow III Library, Nationwide Children's Hospital and The Ohio State University, Columbus, Ohio, USA
| | - Joseph D Tobias
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio, USA
- Department of Anesthesiology and Pain Medicine, The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Vanessa A Olbrecht
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio, USA
- Department of Anesthesiology and Pain Medicine, The Ohio State University College of Medicine, Columbus, Ohio, USA
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Bonanno J, Grannell T, Maves G, Tobias JD. Perioperative Care of a Child With Hyperthyroidism. J Med Cases 2024; 15:49-54. [PMID: 38646421 PMCID: PMC11027768 DOI: 10.14740/jmc4197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Accepted: 04/03/2024] [Indexed: 04/23/2024] Open
Abstract
In pediatric-aged patients, hyperthyroidism generally results from the autoimmune disorder, Graves' disease (GD). Excessive levels of thyroid hormones (triiodothyronine and thyroxine) result in irritability, emotional lability, nervousness, tremors, palpitations, tachycardia, and arrhythmias. The risk of morbidity and mortality is increased when surgical intervention is required in patients with hyperthyroidism due to the potential for the development of thyroid storm (TS). A 3-year, 1-month-old child with a past medical history of GD presented for total thyroidectomy when pharmacologic control with methimazole was not feasible due to intolerance following development of a serum sickness-like illness. Prior to surgery, his thyrotoxicosis symptoms worsened with fever, tachycardia, diaphoresis, and hypertension. He subsequently developed TS and was admitted to the pediatric intensive care unit where management included hydrocortisone, potassium iodide, and β-adrenergic blockade with esmolol and propranolol. Thyroid studies improved prior to surgery, and a total thyroidectomy was successfully completed. Corticosteroid therapy was slowly tapered as an outpatient, and he was discharged home on hospital day 9. Following discharge, his signs and symptoms of thyrotoxicosis resolved, and he was started on oral levothyroxine replacement therapy. The remainder of his postoperative and post-discharge course were unremarkable. Only two case reports of perioperative pediatric TS have been published in the past 20 years. Our case serves as an important reminder of the signs of TS in children and to outline the treatment options in a pediatric patient, especially in those unable to tolerate first-line pharmacologic therapies such as methimazole or propylthiouracil.
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Affiliation(s)
- Joseph Bonanno
- The Ohio State University College of Medicine, Columbus, OH, USA
| | - Timothy Grannell
- Department of Anesthesiology & Pain Medicine, Nationwide Children’s Hospital, Columbus, OH, USA
| | - Gregory Maves
- 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
- The Ohio State University College of Medicine, Columbus, OH, USA
- Department of Anesthesiology & Pain Medicine, Nationwide Children’s Hospital, Columbus, OH, USA
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Espinal LM, Kalsotra S, Rice-Weimer J, Kitio SAY, Tobias JD. Tolerance to preoperative placement of electrodes for neuromuscular monitoring using the Tetragraph™. Saudi J Anaesth 2024; 18:205-210. [PMID: 38654867 PMCID: PMC11033887 DOI: 10.4103/sja.sja_864_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Accepted: 10/29/2023] [Indexed: 04/26/2024] Open
Abstract
Background Quantitative train-of-four (TOF) monitoring has recently been shown to be feasible in infants and children using a novel electromyography (EMG)-based monitor with a pediatric-sized self-adhesive sensor. However, placement of the sensor and initiation of TOF monitoring may require additional time in the operating room (OR), delaying workflow and the time to induction of anesthesia. The current study evaluates the feasibility of placing the self-adhesive sensor in the preoperative holding area in pediatric patients before arrival to the OR. Methods Consented pediatric patients undergoing inpatient surgery requiring the administration of NMBAs were enrolled. The EMG electrode was placed along the ulnar nerve on the volar aspect of the distal forearm to provide neurostimulation. After the induction of anesthesia, monitoring was initiated and TOF recording started before the administration of the NMBA. A Likert score (0-10) was used to assess ease of placement, tolerability of the monitor during the preoperative period, and its ability to generate a recorded response in the OR. Results The final study cohort included 40 patients with a median age of 3.7 years. Fourteen patients (35%) pulled off the sensor before arrival to the OR and 26 patients (65%) arrived at the OR with the sensor intact and functioning. Older children were more likely to maintain the sensor until arrival to the OR compared to younger patients (median age of 5.24 versus 1 year, P = 0.0521). A median age of 3.7 years correlated with an 80% chance of arriving in the OR with the sensor intact. Application ease and tolerance of the sensor were higher in the group that maintained the sensor until OR arrival. Conclusion In patients more than 4 years of age, placement of the self-adhesive sensor for EMG-based TOF monitoring may be feasible. However, in younger patients, additional interventions may be required to achieve a similar success rate.
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Affiliation(s)
- Leah M. Espinal
- Heritage College of Osteopathic Medicine - Dublin Campus, Dublin, Ohio and Ohio University, Athens, Ohio, USA
| | - Sidhant Kalsotra
- Department of Anesthesiology and Pain Medicine, Nationwide Children’s Hospital, Columbus, Ohio, USA
| | - Julie Rice-Weimer
- Department of Anesthesiology and Pain Medicine, Nationwide Children’s Hospital, Columbus, Ohio, USA
| | - Sibelle A. Yemele Kitio
- Department of Anesthesiology and Pain Medicine, Nationwide Children’s Hospital, Columbus, Ohio, USA
| | - Joseph D. Tobias
- Department of Anesthesiology and Pain Medicine, Nationwide Children’s Hospital, Columbus, Ohio, USA
- Department of Anesthesiology and Pain Medicine, The Ohio State University College of Medicine, Columbus, Ohio, USA
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Elhamrawy A, Syed A, Smith T, Veneziano G, Tobias JD. Management of Post-Dural Puncture Headaches in Pediatric Patients with Epidural Blood or Saline Patch: An Educational Focused Review. J Pain Res 2024; 17:1197-1207. [PMID: 38524695 PMCID: PMC10960508 DOI: 10.2147/jpr.s444381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 03/15/2024] [Indexed: 03/26/2024] Open
Abstract
Post-dural puncture headache (PDPH) is a common adverse outcome following puncture of the dura. It can occur after inadvertent dural puncture during epidural catheter placement or following diagnostic or therapeutic LP. The incidence of PDPH in pediatric patients has been estimated at 1-15% depending on patient factors (age, gender, body mass index) and needle factors (size and needle bevel/point type). The larger the needle gauge, the higher the incidence of PDPH. Various options have been proposed to treat PDPH including observation, bed rest, hydration, caffeine, and epidural blood/saline patch. The current manuscript provides a review of the use of epidural blood/saline patch in pediatric-aged patients with PDPH.
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Affiliation(s)
- Amr Elhamrawy
- Department of Anesthesiology & Pain Medicine, Nationwide Children’s Hospital, Columbus, OH, USA
| | - Ahsan Syed
- 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
| | - Timothy Smith
- 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
| | - Giorgio Veneziano
- 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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Mpody C, Patel AB, Smoyer WE, Tobias JD, Nafiu OO. Metabolomic profiling of pediatric post-tonsillectomy pain: A proof-of-concept study. Paediatr Anaesth 2024. [PMID: 38466029 DOI: 10.1111/pan.14876] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Revised: 02/13/2024] [Accepted: 02/22/2024] [Indexed: 03/12/2024]
Abstract
INTRODUCTION Tonsillectomies are among the most common surgical procedures in children, with over 500 000 cases annually in the United States. Despite universal administration of intraoperative opioid analgesia, three out of five children undergoing tonsillectomy report moderate-to-severe pain upon recovering from anesthesia. The underlying molecular mechanisms of post-tonsillectomy pain are not well understood, limiting the development of targeted treatment strategies. Our study aimed to identify candidate serum metabolites associated with varying severity of post-tonsillectomy pain. METHODS Venous blood samples and pain scores were obtained from 34 children undergoing tonsillectomy ± adenoidectomy, and metabolomic analysis was performed. Supervised orthogonal projections to latent structures discriminant analysis were employed to identify differentially expressed metabolites between children with severe and mild pain, as well as between moderate and mild pain. RESULTS Pain scores differentiated children as mild (n = 6), moderate (n = 14), or severe (n = 14). Four metabolites (fatty acid 18:0(OH), thyroxine, phosphatidylcholine 38:5, and branched fatty acids C27H54O3) were identified as candidate biomarkers that differentiated severe vs. mild post-tonsillectomy pain, the combination of which yielded an AUC of 0.91. Similarly, four metabolites (sebacic acid, dicarboxylic acids C18H34O4, hydroxy fatty acids C18H34O3, and myristoleic acid) were identified as candidate biomarkers that differentiated moderate vs. mild post-tonsillectomy pain, with AUC values ranging from 0.85 to 0.95. CONCLUSION This study identified novel candidate biomarker panels that effectively differentiated varying severity of post-tonsillectomy pain. Further research is needed to validate these data and to explore their clinical implications for personalized pain management in children undergoing painful surgeries.
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Affiliation(s)
- Christian Mpody
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital and The Ohio State University, Columbus, Ohio, USA
| | - Ambrish B Patel
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital and The Ohio State University, Columbus, Ohio, USA
| | - William E Smoyer
- Center for Clinical and Translational Research, Nationwide Children's Hospital and The Ohio State University, Columbus, Ohio, USA
| | - Joseph D Tobias
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital and The Ohio State University, Columbus, Ohio, USA
| | - Olubukola O Nafiu
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital and The Ohio State University, Columbus, Ohio, USA
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Elhamrawy A, Veneziano G, Tobias JD. Regional anesthesia and sickle cell crisis in pediatric patients: An educational-focused review. Paediatr Anaesth 2024; 34:195-203. [PMID: 37983941 DOI: 10.1111/pan.14801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 10/31/2023] [Accepted: 11/01/2023] [Indexed: 11/22/2023]
Abstract
INTRODUCTION Sickle cell disease (SCD) is the most common inherited hemoglobinopathy, affecting approximately 100 000 patients in United States and millions worldwide. Although the mainstay of pain management for VOC remains systemic opioids, given the potential for adverse effects including respiratory depression and hypoxemia, there remains interest in the use of regional anesthetic techniques (neuraxial or peripheral nerve blockade). METHODS A systematic search of pubMed, Scopus, and Google Scholar was conducted using the terms sickle cell disease, sickle cell crisis, pain crisis, vaso-occlusive crisis, regional anesthesia, peripheral nerve blockade, and neuraxial anesthesia. RESULTS We identified 7 publications, all of which were retrospective case series or single case reports, outlining the use of neuraxial anesthesia in a total of 26 patients with SCD. Additionally, we identified 4 publications, including one retrospective case series and 3 single case reports, entailing the use of peripheral blockade in patients with VOC and SCD. DISCUSSION The available literature, albeit all retrospective or anecdotal, suggests the potential utility of regional anesthesia to treat pain in patients with SCD. Additional benefits have included avoidance of the potential deleterious physiologic effects of systemic opioids and in one case series, an improvement in respiratory function as judged by pulse oximetry. The anecdotal and retrospective nature of the available reports with an absence of prospective trials limits the evidence based medicine available from which to develop to guidlines for the optimal local anesthetic agent to use, its concentration, the rate of infusion, and the choice of adjunctive agents.
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Affiliation(s)
- Amr Elhamrawy
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Giorgio Veneziano
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio, USA
- Department of Anesthesiology & Pain Medicine, The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Joseph D Tobias
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio, USA
- Department of Anesthesiology & Pain Medicine, The Ohio State University College of Medicine, Columbus, Ohio, USA
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Heydinger G, Roth C, Kidwell R, Tobias JD, Veneziano G, Jayanthi VR, Whitaker EE, Thung AK. A Single Center's Experience With Spinal Anesthesia for Pediatric Patients Undergoing Surgical Procedures. J Pediatr Surg 2024:S0022-3468(24)00081-2. [PMID: 38418274 DOI: 10.1016/j.jpedsurg.2024.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Revised: 01/28/2024] [Accepted: 02/02/2024] [Indexed: 03/01/2024]
Abstract
PURPOSE To perform a single institution review of spinal instead of general anesthesia for pediatric patients undergoing surgical procedures. Spinal success rate, intraoperative complications, and postoperative outcomes including unplanned hospital admission and emergency department visits within seven days are reported. METHODS Retrospective chart review of pediatric patients who underwent spinal anesthesia for surgical procedures from 2016 until 2022. Data collected included patient demographics, procedure and anesthetic characteristics, intraoperative complications, unplanned admissions, and emergency department returns. RESULTS The study cohort included 1221 patients. Ninety-two percent of the patients tolerated their surgical procedure without requiring conversion to general anesthesia, and 78% of patients that had spinals placed successfully did not receive any sedation following lumbar puncture. The most common intraoperative event was systolic blood pressure below 60 mm Hg (14%), but no cases required administration of vasoactive agents, and no serious intraoperative adverse events were observed. Post-Anesthesia Care Unit Phase I was bypassed in 72% of cases with a median postoperative length of stay of 84 min. Forty-six patients returned to the emergency department following hospital discharge, but no returns were due to anesthetic concerns. CONCLUSIONS Spinal anesthesia is a viable and versatile option for a diversity of pediatric surgical procedures. We noted a low incidence of intraoperative and postoperative complications. There remain numerous potential advantages of spinal anesthesia over general anesthesia in young pediatric patients particularly in the ambulatory setting. LEVEL OF EVIDENCE IV. TYPE OF STUDY Retrospective cohort treatment study.
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Affiliation(s)
- Grant Heydinger
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA; Department of Anesthesiology, The Ohio State University College of Medicine, Columbus, OH, USA.
| | - Catherine Roth
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA
| | - Rachel Kidwell
- Heritage College of Osteopathic Medicine, Dublin Campus (Dublin) and Ohio University, Athens, OH, USA
| | - Joseph D Tobias
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA; Department of Anesthesiology, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Giorgio Veneziano
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA; Department of Anesthesiology, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Venkata R Jayanthi
- Division of Pediatric Urology, Nationwide Children's Hospital and the Department of Urology, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Emmett E Whitaker
- Department of Anesthesiology, University of Vermont Larner College of Medicine, University of Vermont Medical Center, Burlington, VT, USA
| | - Arlyne K Thung
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA; Department of Anesthesiology, The Ohio State University College of Medicine, Columbus, OH, USA
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Willer BL, Tobias JD. Addressing the Minority Pay Gap: Put Your Money Where Your Mouth Is. Anesth Analg 2024; 138:e10-e11. [PMID: 38215722 DOI: 10.1213/ane.0000000000006797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2024]
Affiliation(s)
- Brittany L Willer
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio,
| | - Joseph D Tobias
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio,
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Gillis H, McKee C, Chenault K, Corridore M, Tobias JD. Preliminary Experience With Remimazolam for Procedural Sedation and as an Adjunct to General Anesthesia During Diagnostic and Interventional Cardiac Procedures. Cardiol Res 2024; 15:12-17. [PMID: 38464705 PMCID: PMC10923259 DOI: 10.14740/cr1595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Accepted: 01/12/2024] [Indexed: 03/12/2024] Open
Abstract
Background Remimazolam is a benzodiazepine which, like midazolam, has sedative, anxiolytic, and amnestic properties. Ester metabolism results in a half-life of 5 - 10 min, a limited context sensitive half-life, and rapid recovery when the infusion is discontinued. Methods Following the Institutional Review Board (IRB) approval, we performed a retrospective chart review of patients who received remimazolam in the cardiac catheterization, cardiac magnetic resonance imaging (MRI), and electrophysiology suites. The primary objective was to assess efficacy and safety. The secondary objective was to describe bolus and infusion dosing of remimazolam and the need for adjunctive agents to optimize procedural sedation conditions. Results The study cohort included 26 patients with a median age of 18 years and a total of 33 anesthetic encounters. The most common procedures were endomyocardial biopsy or isolated hemodynamic assessment (right or left heart catheterization). Remimazolam was the primary agent for sedation in 82% of the procedures. The majority of cases (25 encounters, 76%) included a bolus dose of remimazolam prior to the start of an infusion. For those patients who received a starting bolus dose, dosing typically ranged between 30 and 110 µg/kg. Continuous infusion rates of remimazolam varied from 5 to 20 µg/kg/min. No adverse hemodynamic or respiratory effects were noted. Midazolam, fentanyl, and dexmedetomidine were the most frequently used adjunctive agents. One patient required transition to general anesthesia due to the need for a surgical intervention based on the findings of the cardiac catheterization. All other patients were effectively sedated. Conclusions Our preliminary experience demonstrates that remimazolam effectively provided sedation for diagnostic and therapeutic cardiovascular procedures. Future studies are needed to further define dosing parameters for both bolus dosing and continuous infusion as well as to compare remimazolam to other commonly used for procedural sedation in patients with congenital and acquired heart disease.
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Affiliation(s)
- Holly Gillis
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA
| | - Christopher McKee
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA
- Department of Anesthesiology and Pain Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Kristin Chenault
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA
- Department of Anesthesiology and Pain Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Marco Corridore
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA
- Department of Anesthesiology and Pain Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Joseph D Tobias
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA
- Department of Anesthesiology and Pain Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
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Elhamrawy A, Aepli S, Heydinger G, Tobias JD, Beltran RJ. Epidural Abscess Complicating Tunneled Caudal Epidural Catheter in an Infant for Postoperative Pain Management of Open Abdominal Surgery. J Med Cases 2024; 15:7-14. [PMID: 38328807 PMCID: PMC10846496 DOI: 10.14740/jmc4180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Accepted: 01/10/2024] [Indexed: 02/09/2024] Open
Abstract
Regional anesthesia is being used more frequently in pediatric anesthesia practice, including the perioperative care of neonates and infants. Adverse effects may be encountered during epidural needle placement, with catheter advancement, or subsequently during infusion of local anesthetic agents. Despite applying standard practice of care regarding placement of epidural catheter, epidural catheter-related infections may still occur. We present the rare occurrence of an epidural abscess in a 4-month-old infant after placement and subsequent use of a tunneled caudal epidural catheter for postoperative pain management following abdominal surgery. Magnetic resonance imaging (MRI) was the gold standard diagnostic imaging modality and was used to identify the abscess. Management included intravenous antibiotic therapy as well as hemilaminectomy with evacuation of the epidural abscess and hematoma. The patient continued to progress well with no deficits noted on neurological examination. There were no other postoperative concerns. When there is a concern for epidural catheter-related infection, the catheter should be removed immediately. The epidural catheter tip as well as any purulent discharge from the insertion site should be sent for culture and sensitivity. Urgent neurosurgical and infectious disease consultation is suggested to provide opinions regarding surgical intervention and antibiotic therapy.
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Affiliation(s)
- Amr Elhamrawy
- Department of Anesthesiology & Pain Medicine, Nationwide Children’s Hospital, Columbus, OH, USA
| | - Savannah Aepli
- Department of Anesthesiology & Pain Medicine, Nationwide Children’s Hospital, Columbus, OH, USA
| | - Grant Heydinger
- 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
| | - Ralph J. Beltran
- 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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12
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Lysandrou M, Rice-Weimer J, Yemele Kitio SA, Elmitwalli I, Kadado A, Samora W, Corridore M, Tobias JD. Use of a Novel Buffered Hypertonic Saline Solution for Fluid Replacement and Resuscitation During Spinal Surgery in Adolescents. J Clin Med Res 2024; 16:1-7. [PMID: 38327392 PMCID: PMC10846487 DOI: 10.14740/jocmr5059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Accepted: 12/28/2023] [Indexed: 02/09/2024] Open
Abstract
Background During major orthopedic procedures, such as posterior spinal fusion (PSF), isotonic fluids, colloids, starches, or gelatins are commonly used to replace the preoperative fluid deficit and provide ongoing fluid resuscitation. Given recent concerns regarding the potential adverse physiologic effects of albumin solutions, we have modified our intraoperative practice to include the use of a novel 2% buffered hypertonic saline solution during major orthopedic procedures. We present our preliminary clinical experience with this novel fluid for intraoperative resuscitation and its impact on limiting the use of 5% albumin. Methods A retrospective review was performed to identify patients who received 2% buffered hypertonic saline during PSF. The intraoperative course of these patients was compared to case-matched control patients who received standard care with isotonic fluids plus 5% albumin as an adjunct for intravascular resuscitation. Results The study cohort included 23 patients who received 2% buffered hypertonic saline and 25 in the case-matched control group. There was no difference in the volume of intraoperative isotonic crystalloid fluids, estimated blood loss, and urine output between the two groups. In the control cohort, 19 of 25 patients (76%) received 5% albumin compared to only six of 23 patients (26%, P = 0.0005) in the 2% buffered hypertonic saline group. The final pH was higher in the patients that received 2% buffered hypertonic saline than in the control group (7.40 ± 0.03 versus 7.36 ± 0.06, P = 0.0131). Additionally, the starting and final serum sodium values were higher in the patients that received 2% buffered hypertonic saline, although no difference was noted in the mean change from the starting value (average increase of 2 mEq/L in both groups). Conclusion Use of a novel 2% buffered hypertonic saline solution for intraoperative resuscitation during major orthopedic procedures decreases the need for 5% albumin while avoiding the development of hyperchloremic metabolic acidosis which may occur with standard sodium chloride solutions.
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Affiliation(s)
- Maria Lysandrou
- The Ohio State University College of Medicine, Columbus, OH, USA
| | - Julie Rice-Weimer
- Department of Anesthesiology & Pain Medicine, Nationwide Children’s Hospital, Columbus, OH, USA
| | | | - Islam Elmitwalli
- Department of Anesthesiology & Pain Medicine, Nationwide Children’s Hospital, Columbus, OH, USA
| | - Allen Kadado
- Division of Pediatric Orthopedic Surgery, Nationwide Children’s Hospital and The Ohio State University, Columbus, OH, USA
| | - Walter Samora
- Division of Pediatric Orthopedic Surgery, Nationwide Children’s Hospital and The Ohio State University, Columbus, OH, USA
| | - Marco Corridore
- Division of Pediatric Orthopedic Surgery, Nationwide Children’s Hospital and The Ohio State University, Columbus, OH, USA
- Department of Anesthesiology & Pain Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Joseph D. Tobias
- Division of Pediatric Orthopedic Surgery, Nationwide Children’s Hospital and The Ohio State University, Columbus, OH, USA
- Department of Anesthesiology & Pain Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
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13
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Ghimire A, Moharir A, Yamaguchi Y, Tram NK, Tobias JD. Preoperative gastric point-of-care ultrasound in nonelective surgical procedures in pediatric-aged patients. Saudi J Anaesth 2024; 18:17-22. [PMID: 38313729 PMCID: PMC10833037 DOI: 10.4103/sja.sja_379_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Accepted: 05/10/2023] [Indexed: 02/06/2024] Open
Abstract
Background Airway management for nonelective surgical procedures in the setting of trauma, pain, and opioid use can be complicated by the potential for aspiration due to delayed gastric emptying. Point-of-care ultrasound (POCUS) remains a useful tool for evaluating gastric content and volume in various clinical settings. The authors evaluated gastric volume and content in children scheduled for urgent and semi-urgent procedures to assess their aspiration risk. Methods After obtaining consent, gastric POCUS was performed in the preoperative holding area for pediatric patients scheduled for both elective and nonelective surgery. Qualitative and quantitative measurements of the gastric antrum were taken, and the risk of gastric aspiration was calculated. Additional data collected included patient demographics, the type of surgery, nil per os (NPO) status at the time of surgery, NPO status at the time of injury, and administration of opioids. Results The study cohort included 100 patients ranging in age from 3 to 17 years old (mean age 9.2 years). Out of these 100 patients, gastric scanning was successfully conducted in 98 patients. Sixteen of fifty-nine nonelective patients (27%) had received opioids for pain control prior to surgery. Among the 34 patients who had suffered an acute injury, 7 (21%) had been NPO for <8 hours at the time of the injury. Ninety-nine out of hundred patients had been NPO for at least 6 hours at the time of the gastric ultrasound. Based on our gastric ultrasound findings, all patients who were appropriately NPO had either Grade 0 or Grade 1 risk for aspiration, indicating a low risk of aspiration. Conclusions The preliminary data show that when patients presenting for nonelective surgery are appropriately NPO, they may have a low risk of aspiration. This information may help guide the choice of anesthetic induction technique, particularly when concerns exist about the safety of a rapid sequence induction. It allows for a more stable and controlled induction of anesthesia.
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Affiliation(s)
- Anuranjan Ghimire
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio, Japan
| | - Alok Moharir
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio, Japan
- Department of Anesthesiology and Pain Medicine, The Ohio State University College of Medicine, Columbus, Ohio, Japan
| | - Yoshikazu Yamaguchi
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio, Japan
- Department of Anesthesiology, Yokohama Municipal Citizen's Hospital, Yokohama, Japan
| | - Nguyen K. Tram
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio, Japan
- Department of Anesthesiology and Pain Medicine, The Ohio State University College of Medicine, Columbus, Ohio, Japan
| | - Joseph D. Tobias
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio, Japan
- Department of Anesthesiology and Pain Medicine, The Ohio State University College of Medicine, Columbus, Ohio, Japan
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14
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Drapeau AI, Mpody C, Gross MA, Lemus R, Tobias JD, Nafiu O. Factors Associated With Unplanned Post-Craniotomy Re-intubation in Children: A NSQIP-Pediatric ® Analysis. J Neurosurg Anesthesiol 2024; 36:37-44. [PMID: 36136605 DOI: 10.1097/ana.0000000000000871] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 08/15/2022] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Most children undergoing craniotomy with general endotracheal anesthesia are extubated postoperatively, but some require unplanned postoperative intubation (UPI). We sought to determine the incidence of UPI and identify associated factors and related postoperative mortality. METHODS The National Surgical Quality Improvement Program for Pediatrics (2012-2018) was used to retrospectively identify patients less than 18 years old who underwent craniotomy for epilepsy, tumor, and congenital/cyst procedures. Perioperative factors associated with UPI were identified with logistic regression models. RESULTS We identified 15,292 children, of whom 144 (0.94%) required UPI. Ninety-two (0.60%) children required UPI within the first 3 days after surgery. Postoperative mortality was higher among children with UPI within 3 days than in those with UPI later or not at all (8.0 vs. 2.2 vs. 0.3%, respectively; P <0.001). Posterior fossa procedures trended towards an increased odds of UPI (odds ratio [OR], 1.50; 95% confidence interval [CI] 0.99 to 2.27; P =0.05). Five preoperative factors were independently associated with UPI: age ≤ 12 months (OR, 2.78; 95% CI, 1.29 to 5.98), ASA classification ≥3 (OR, 1.92; 95% CI, 1.12 to 3.29), emergent case status (OR, 2.06; 95% CI, 1.30 to 3.26), neuromuscular disease (OR, 1.87; 95% CI, 1.01 to 3.47), and steroid use within 30 days (OR, 1.79; 95% CI 1.14 to 2.79). Long operative times were independently associated with UPI (200 to 400 vs. <200 min OR, 1.92; 95% CI 1.18 to 3.11 and ≥400 vs. <200 min OR, 4.66; 95% CI 2.70 to 8.03). CONCLUSION Although uncommon, UPI in children who underwent craniotomy was associated with an elevated risk of postoperative mortality. The presence of identifiable risk factors may be used for preoperative counseling and risk profiling in these patients.
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Affiliation(s)
| | - Christian Mpody
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, and The Ohio State University College of Medicine
| | - Michael A Gross
- Heritage College of Osteopathic Medicine, Dublin Campus, Ohio University, Dublin, OH
| | - Rafael Lemus
- Department of Pediatrics, Nationwide Children's Hospital, Columbus
| | - Joseph D Tobias
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, and The Ohio State University College of Medicine
| | - Olubukola Nafiu
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, and The Ohio State University College of Medicine
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15
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Holladay JD, McKee C, Nafiu OO, Tobias JD, Beltran RJ. Continuous Erector Spinae Plane Block for Pain Management Following Thoracotomy for Aortic Coarctectomy. J Med Cases 2024; 15:26-30. [PMID: 38328811 PMCID: PMC10846499 DOI: 10.14740/jmc4177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Accepted: 01/17/2024] [Indexed: 02/09/2024] Open
Abstract
Pain following thoracotomy is one of the most severe forms of postoperative pain. Post-thoracotomy pain may increase the risk of post-surgical pulmonary complications, postoperative mortality, prolong hospitalization, and increase utilization of healthcare resources. To mitigate these effects, anesthesia providers commonly employ continuous epidural infusions, paravertebral blocks, and systemic opioids for pain management and improvement of pulmonary mechanics. We report the use of a continuous erector spinae plane block (ESPB) via a peripheral nerve catheter for postoperative pain management of an 18-year-old patient who underwent complex aortic coarctation repair via lateral thoracotomy, aided by cardiopulmonary bypass. Continuous ESPB proved to be an acceptable alternative for postoperative pain control, producing a substantial multi-dermatomal sensory block, resulting in adequate pain control, reduced opioid consumption, and a potentially shorter hospital stay.
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Affiliation(s)
- Jay D. Holladay
- Department of Anesthesiology and Pain Medicine, Nationwide Children’s Hospital, Columbus, OH 43205, USA
| | - Christopher McKee
- Department of Anesthesiology and Pain Medicine, Nationwide Children’s Hospital, Columbus, OH 43205, USA
- Department of Anesthesiology and Pain Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Olubukola O. Nafiu
- Department of Anesthesiology and Pain Medicine, Nationwide Children’s Hospital, Columbus, OH 43205, USA
- Department of Anesthesiology and Pain Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Joseph D. Tobias
- Department of Anesthesiology and Pain Medicine, Nationwide Children’s Hospital, Columbus, OH 43205, USA
- Department of Anesthesiology and Pain Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Ralph J. Beltran
- Department of Anesthesiology and Pain Medicine, Nationwide Children’s Hospital, Columbus, OH 43205, USA
- Department of Anesthesiology and Pain Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
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16
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Elhamrawy A, Syed A, Tobias JD. Anesthetic Care During Exploratory Laparotomy and Excision of a Fetus-in-Fetu With a Combined General-Regional Anesthetic Technique Using a Caudal Epidural Catheter. J Med Cases 2023; 14:393-399. [PMID: 38186560 PMCID: PMC10769655 DOI: 10.14740/jmc4164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Accepted: 11/20/2023] [Indexed: 01/09/2024] Open
Abstract
Fetus-in-fetu (FIF) is a rare, congenital anomaly involving the presence of one of a pair of twins within the body of the other. It is postulated that this pathology occurs during embryogenesis of a diamniotic-monochorionic twin pregnancy with unequal division of the blastocele, which results in monozygotic, monochorionic, and diamniotic twins of unequal sizes. Presentation as an abdominal mass during the neonatal period or infancy is most common, although late diagnosis during the adult years may also occur. We report a 1-day-old, full-term female neonate who presented for exploratory laparotomy and excision of a FIF. We present the use of a combined general-regional technique using caudal epidural anesthesia. The etiology, presentation, appropriate workup, and treatment of FIF are presented. Previous anecdotal reports of anesthetic care for excision of FIF are reviewed.
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Affiliation(s)
- Amr Elhamrawy
- Department of Anesthesiology & Pain Medicine, Nationwide Children’s Hospital, Columbus, OH, USA
| | - Ahsan Syed
- 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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17
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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18
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Kerbage J, Dairo OO, Ketchum L, Smith C, Tobias JD. Pulseless Electrical Activity and Perioperative Cardiac Arrest Due to Undiagnosed and Asymptomatic Hypothyroidism During Outpatient Surgery in an Adolescent. Cardiol Res 2023; 14:468-471. [PMID: 38187514 PMCID: PMC10769615 DOI: 10.14740/cr1605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Accepted: 12/23/2023] [Indexed: 01/09/2024] Open
Abstract
Commonly identified risk factors for perioperative cardiac arrest in pediatric-aged patients include cardiac surgery, younger age, comorbid conditions including pulmonary hypertension and cyanotic congenital heart disease, and emergency surgery. Although medication-related etiologies formerly predominated, the elimination of halothane from anesthetic care has resulted in a shift in etiology to hemodynamic events related to blood loss or hyperkalemia associated with the rapid administration of blood products. Rarely, cardiac arrest can be sudden and unexpected without an identified pre-existing etiology in an otherwise apparently healthy patient. We present an 18-year-old adolescent who experienced pulseless electrical activity (PEA) and cardiac arrest following anesthetic care for an outpatient orthopedic procedure, who was eventually diagnosed with hypothyroidism. The potential etiologies of PEA and cardiac arrest during anesthesia are reviewed, components of successful resuscitation discussed, and an outline for the investigative workup presented.
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Affiliation(s)
- Josiane Kerbage
- Department of Anesthesiology & Pain Medicine, Nationwide Children’s Hospital, Columbus, OH, USA
| | - Olamide O. Dairo
- 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
| | - Lauren Ketchum
- Department of Anesthesiology & Pain Medicine, Nationwide Children’s Hospital, Columbus, OH, USA
| | - Craig Smith
- Department of Orthopedic Surgery, Nationwide Children’s Hospital, 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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19
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Mpody C, Best AF, Lee CN, Stahl DL, Raman VT, Urman RD, Tobias JD, Nafiu OO. Current Trends in Mortality Attributable to Racial or Ethnic Disparities in Post-Surgical Population in The United States: A Population-Based Study. Ann Surg Open 2023; 4:e342. [PMID: 38144482 PMCID: PMC10735112 DOI: 10.1097/as9.0000000000000342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2023] [Accepted: 08/17/2023] [Indexed: 12/26/2023] Open
Abstract
Background No study has contextualized the excess mortality attributable to racial and ethnic disparities in surgical outcomes. Further, not much effort has been made to quantify the effort needed to eliminate these disparities. Objective We examined the current trends in mortality attributable to racial or ethnic disparities in the US postsurgical population. We then identified the target for mortality reduction that would be necessary to eliminate these disparities by 2030. Methods We performed a population-based study of 1,512,974 high-risk surgical procedures among adults (18-64 years) performed across US hospitals between 2000 and 2020. Results Between 2000 and 2020, the risk-adjusted mortality rates declined for all groups. Nonetheless, Black patients were more likely to die following surgery (adjusted relative risk 1.42; 95% CI, 1.39-1.46) driven by higher Black mortality in the northeast (1.60; 95% CI, 1.52-1.68), as well as the West (1.53; 95% CI, 1.43-1.62). Similarly, mortality risk remained consistently higher for Hispanics compared with White patients (1.21; 95% CI, 1.19-1.24), driven by higher mortality in the West (1.26; 95% CI, 1.21-1.31). Overall, 8364 fewer deaths are required for Black patients to experience mortality on the same scale as White patients. Similar figures for Hispanic patients are 4388. To eliminate the disparity between Black and White patients by 2030, we need a 2.7% annualized reduction in the projected mortality among Black patients. For Hispanics, the annualized reduction needed is 0.8%. Conclusions Our data provides a framework for incorporating population and health systems measures for eliminating disparity in surgical mortality within the next decade.
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Affiliation(s)
- Christian Mpody
- From the Department of Anesthesiology & Pain Medicine, Nationwide Children’s Hospital, Columbus, OH
- Department of Anesthesiology, The Ohio State University, Columbus, OH
| | - Ana F. Best
- Biostatistics Branch, Biometric Research Program, Division of Treatment and Diagnosis, National Cancer Institute, Bethesda, MD
| | - Clara N. Lee
- Department of Plastic and Reconstructive Surgery, The Ohio State University, Columbus, OH
| | - David L. Stahl
- Department of Anesthesiology, The Ohio State University, Columbus, OH
| | - Vidya T. Raman
- Department of Anesthesiology, The Ohio State University, Columbus, OH
| | - Richard D. Urman
- Department of Anesthesiology, The Ohio State University, Columbus, OH
| | - Joseph D. Tobias
- From the Department of Anesthesiology & Pain Medicine, Nationwide Children’s Hospital, Columbus, OH
- Department of Anesthesiology, The Ohio State University, Columbus, OH
| | - Olubukola O. Nafiu
- From the Department of Anesthesiology & Pain Medicine, Nationwide Children’s Hospital, Columbus, OH
- Department of Anesthesiology, The Ohio State University, Columbus, OH
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20
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Stone K, Rice-Weimer J, Tram NK, Tobias JD. Efficacy of an expanded preoperative survey during perioperative care to identify illicit substance use in teenagers and adolescents. Paediatr Anaesth 2023; 33:808-815. [PMID: 37435702 DOI: 10.1111/pan.14728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Revised: 06/09/2023] [Accepted: 06/27/2023] [Indexed: 07/13/2023]
Abstract
BACKGROUND As illicit substance use can present several perioperative concerns, effective means to identify such practices are necessary to ensure patient safety. Identification of illicit substance use in pediatric patients may be problematic as screening may rely on parental reporting. AIMS The current study compares answers regarding use of illicit substances between a survey completed by the patient and the preoperative survey completed by parents or guardians. METHODS The study included patients presenting for surgery at Nationwide Children's Hospital, ranging in age from 12 to 21 years. After consent, patients completed a survey of six drop-down questions using an iPad. The six questions involved the patient's history of alcohol, tobacco, marijuana, vaping, and opioid use. The results were compared to the answers obtained from the parents during a preoperative phone call. RESULTS The study cohort included surveys from 250 patients with a median age of 16 years. Survey data showed a statistically higher reporting of substance use or abuse from the patient study survey in comparison to the routine parental preoperative survey. Alcohol report rates were highest with 69 (27.6%) patients reporting use compared to only 5 parental reports (2%). There was a similar discrepancy in reported rates of vaping use (40 patient reports, 16.0% vs. 11 parental reports, 4.4%) and illicit substance use including marijuana (52 patient reports, 20.8% vs. 11 parental reports, 4.4%). Reported rates of tobacco use were lowest among the survey responses with 12 patient reports (4.8%) and 5 parental reports (2.0%). CONCLUSIONS Identifying illicit substance and tobacco use via a phone survey of parents is inaccurate and does not allow for proper identification of use of these substances in patients ≤21 years of age presenting for surgery. An anonymous 2-min survey completed by the patient more correctly identifies these issues.
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Affiliation(s)
- Katelynn Stone
- The Ohio State University College of Medicine Columbus, Columbus, Ohio, USA
| | - Julie Rice-Weimer
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Nguyen K Tram
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio, USA
- Department of Anesthesiology and Pain Medicine, The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Joseph D Tobias
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio, USA
- Department of Anesthesiology and Pain Medicine, The Ohio State University College of Medicine, Columbus, Ohio, USA
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21
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Mpody C, Olbrecht V, Tobias JD. Acute Cranial Nerve VI Palsy Following Prolonged Prone Positioning in an Adolescent With Neurofibromatosis Type 1: A Rare Complication of Spinal Surgery in the Prone Position. J Med Cases 2023; 14:317-321. [PMID: 37868328 PMCID: PMC10586333 DOI: 10.14740/jmc4145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 08/31/2023] [Indexed: 10/24/2023] Open
Abstract
The abducens or sixth cranial nerve provides motor innervation to the lateral rectus muscle, which abducts the ipsilateral eye with secondary innervation of the contralateral medial rectus muscle to allow for coordinated movement of both eyes. Various acute and chronic pathologic conditions, most importantly pontine infarctions and increased intracranial pressure, can result in acute sixth cranial nerve palsies. We report the uncommon occurrence of acute abducens nerve palsy following spinal fusion surgery in an 18-year-old male patient with a history of multiple neurological and orthopedic conditions. Postoperatively, the patient presented with symptoms that included left diplopia with restricted upward and downward gaze, indicative of abducens nerve palsy. The anatomy of the sixth cranial nerve is discussed, potential etiologies of sixth nerve palsy presented, and a proposed diagnostic workup reviewed. Our report emphasizes the need for comprehensive exploration of ocular symptoms following spinal surgery, given the various potential etiologies of sixth nerve palsy.
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Affiliation(s)
- Christian Mpody
- Department of Anesthesiology & Pain Medicine, Nationwide Children’s Hospital and The Ohio State University College of Medicine, Columbus, OH, USA
| | - Vanessa Olbrecht
- Department of Anesthesiology & Pain Medicine, Nationwide Children’s Hospital and The Ohio State University College of Medicine, Columbus, OH, USA
| | - Joseph D. Tobias
- Department of Anesthesiology & Pain Medicine, Nationwide Children’s Hospital and The Ohio State University College of Medicine, Columbus, OH, USA
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22
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Uffman JC, Willer BL, Mpody C, Nafiu OO, Tobias JD. Characteristics of Transgender and Gender-Diverse Youth Presenting for Surgery in the United States. Anesth Analg 2023; 137:882-886. [PMID: 37471293 DOI: 10.1213/ane.0000000000006618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/22/2023]
Abstract
BACKGROUND The number of adolescents and adults identifying as trans or gender-diverse is increasing. The lesbian, gay, bisexual, transgender, queer, and "other" (LGBTQ+) population is recognized as a marginalized health care population. This retrospective study sought to investigate demographic trends in transgender and gender-diverse (TGD) youth accessing surgical care in the United States. METHODS Using a multi-institutional dataset from the Pediatric Health Information System (PHIS), we described demographic and periprocedural data for TGD adolescents, ages 10 to 18 years, who underwent a surgical procedure between January 1, 2016 and August 31, 2022. RESULTS Among 767,224 youth who underwent surgical procedures during the study period, 807 (0.1%, 95% confidence interval [CI], 0.09-0.11) were identified as TGD. The overall prevalence of identified TGD youth increased from 0.02% in 2016 to 0.23% in 2022. TGD youth were mostly (71%) assigned female at birth and 13 to 18 years of age (91%, 733/807) at the time of surgery. A total of 76% of TGD patients were non-Hispanic White, 62% had commercial insurance, and 49% lived in a ZIP code with a median annual income between $39,000 and $63,000. Of the 807 TGD patients identified, 264 (33%) were from the Northeast, 226 (28%) were from the Midwest, 219 (27%) were from the West, and 98 (12%) were from the South census regions. The most common procedures for TGD youth to undergo were breast reduction/augmentation (n = 135), insertion/removal of subcutaneous implant device (n = 98), and orthopedic procedures of the hip and lower extremity (n = 29). CONCLUSIONS We reported the perioperative characteristics of TGD youth and showed a steady increase in the detected prevalence of TGD adolescents accessing surgical care. Future investigations into specific challenges associated with caring for these patients are warranted.
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Affiliation(s)
- Joshua C Uffman
- From the Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital and the Department of Anesthesiology & Pain Medicine, Columbus, Ohio
- Department of Anesthesiology & Pain Medicine, The Ohio State University College of Medicine, Columbus, Ohio
| | - Brittany L Willer
- From the Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital and the Department of Anesthesiology & Pain Medicine, Columbus, Ohio
- Department of Anesthesiology & Pain Medicine, The Ohio State University College of Medicine, Columbus, Ohio
| | - Christian Mpody
- From the Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital and the Department of Anesthesiology & Pain Medicine, Columbus, Ohio
| | - Olubukola O Nafiu
- From the Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital and the Department of Anesthesiology & Pain Medicine, Columbus, Ohio
- Department of Anesthesiology & Pain Medicine, The Ohio State University College of Medicine, Columbus, Ohio
| | - Joseph D Tobias
- From the Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital and the Department of Anesthesiology & Pain Medicine, Columbus, Ohio
- Department of Anesthesiology & Pain Medicine, The Ohio State University College of Medicine, Columbus, Ohio
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23
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Lutmer JE, Mpody C, Sribnick EA, Karube T, Tobias JD. Prothrombin Complex Concentrate Utilization in Children's Hospitals. J Pediatr Intensive Care 2023; 12:219-227. [PMID: 37565019 PMCID: PMC10411157 DOI: 10.1055/s-0041-1731686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Accepted: 05/20/2021] [Indexed: 10/20/2022] Open
Abstract
Prothrombin complex concentrates (PCCs) are used to manage bleeding in critically ill children. We performed a repeat cross-sectional study using the Pediatric Health Information System registry to describe PCC utilization in the U.S. children's hospitals over time and determine the relationship between PCC use and specific risk factors for bleeding. We included children < 18 years who received three-factor or four-factor PCC during hospital admission between January 2015 and December 2020 to describe the association between PCC therapy, anticoagulation therapies, and inherited or acquired bleeding diatheses. PCC use steadily increased over the 6-year study period (from 1.3 to 4.6 per 10,000 encounters). Patients exhibited a high degree of critical illness, with 85.0% requiring intensive care unit admission and a mortality rate of 25.8%. PCCs were used in a primarily emergent or urgent fashion (32.6 and 39.3%, respectively) and more frequently in surgical cases (79.0% surgical vs. 21.0% medical). Coding analysis suggested a low rate of chronic anticoagulant use which was supported by review of concomitant anticoagulant medications. PCC use is increasing in critically ill children and does not correlate with specific anticoagulant therapy use or other bleeding risk factors. These findings suggest PCC use is not limited to vitamin K antagonist reversal. Indications, efficacy, and safety of PCC therapy in children require further study.
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Affiliation(s)
- Jeffrey E. Lutmer
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, Ohio, United States
| | - Christian Mpody
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, Ohio, United States
| | - Eric A. Sribnick
- Department of Neurological Surgery, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, Ohio, United States
| | - Takaharu Karube
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, Ohio, United States
| | - Joseph D. Tobias
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, Ohio, United States
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24
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Hughes M, Maves G, Tobias JD. Remimazolam for Sedation During Fiberoptic Intubation in an Adolescent. J Med Cases 2023; 14:289-292. [PMID: 37692369 PMCID: PMC10482594 DOI: 10.14740/jmc4137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Accepted: 08/11/2023] [Indexed: 09/12/2023] Open
Abstract
In specific clinical scenarios, fiberoptic intubation (FOI) may be the preferred technique for airway management and endotracheal intubation. In addition to topical anesthesia of the airway, sedation is frequently necessary, especially in younger patients, to facilitate the procedure. The goal is to facilitate the procedure by providing sedation, anxiolysis, and analgesia with maintenance of spontaneous ventilation. Remimazolam is a novel benzodiazepine with a short half-life and limited context sensitive half-life that can be titrated by continuous infusion. These novel properties may make it a suitable agent for sedation during FOI of the trachea. We report the novel use of a combination of remimazolam and remifentanil infusions to provide sedation during FOI in an adolescent. The basic pharmacology of remimazolam is presented and previous reports of its use for sedation during FOI are reviewed.
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Affiliation(s)
- Mitchell Hughes
- Heritage College of Osteopathic Medicine - Dublin Campus, Dublin, OH, USA
- Ohio University, Athens, OH, USA
| | - Gregory Maves
- 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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25
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Kalsotra S, Rice-Weimer J, Tobias JD. Intraoperative electromyographic monitoring in children using a novel pediatric sensor. Saudi J Anaesth 2023; 17:378-382. [PMID: 37601498 PMCID: PMC10435795 DOI: 10.4103/sja.sja_160_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 03/14/2023] [Indexed: 08/22/2023] Open
Abstract
Background Train-of-four (TOF) monitoring is essential in optimizing perioperative outcomes as a means to assess the depth of neuromuscular blockade and confirm recovery following the administration of neuromuscular blocking agents (NMBAs). Quantitative TOF monitoring has been limited in infants and children primarily due to lack of effective equipment. The current study evaluates a novel electromyography (EMG)-based TOF monitor with a recently developed pediatric-sized self-adhesive sensor in infants and children. Methods Consented pediatric patients undergoing inpatient surgery requiring the administration of NMBAs were enrolled. The EMG electrode was placed along the ulnar nerve on the volar aspect of the distal forearm. The muscle action potentials from the adductor pollicis muscle were recorded throughout surgery at 20-second intervals. Data from the monitor's built-in memory card were later retrieved and analyzed. Results The final study cohort included 51 patients who ranged in age from 0.2 to 7.9 years and in weight from 4.2 to 36.0 kilograms. Thirty patients weighed less than 15 kgs. Supramaximal stimulus current intensity (mA) at a pulse width of 200 μsec was 30 mA in 8%; 40 mA in 29%; 50 mA in 16%; and 60 mA in 20% of the patients. Supramaximal stimulus current intensity (mA) at a pulse width of 300 μsec was 50 mA in 4%; 60 mA in 24%. The muscle action potential baseline amplitude was 8.7 ± 3.3 mV and recovered to 7.2 ± 3.7 mV after antagonism of neuromuscular blockade. The average baseline TOF ratio was 100 ± 3% and recovered to 98 ± 7% after antagonism of neuromuscular blockade. No technical issues were noted with application of the sensor or subsequent use of the monitor. Conclusion Neuromuscular monitoring can be performed intraoperatively in pediatric patients who are less than 8 years of age using a novel commercially available EMG-based monitor with a recently developed pediatric sensor. The novel sensor allows use of an EMG-based monitor in infants and children in whom acceleromyography or subjective (visual) observation of the TOF response may not be feasible. Automatic detection of neuromuscular stimulating parameters (supramaximal current intensity level, baseline amplitude of the muscle action potential) was feasible in pediatric patients of all sizes including those weighing less than 15 kilograms or when there was limited access to the extremity being monitored.
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Affiliation(s)
- Sidhant Kalsotra
- Department of Anesthesiology and Pain Medicine, Nationwide Children’s Hospital, Columbus, OH, USA
| | - Julie Rice-Weimer
- 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
- Department of Anesthesiology and Pain Medicine, The Ohio State University, Columbus, OH, USA
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26
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Amaya S, Kalsotra S, Tobias JD, Olbrecht VA. Clinical experience with the use of inhaled isopropyl alcohol to treat nausea and vomiting: A narrative review. Saudi J Anaesth 2023; 17:383-390. [PMID: 37601520 PMCID: PMC10435785 DOI: 10.4103/sja.sja_151_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2023] [Accepted: 03/09/2023] [Indexed: 08/22/2023] Open
Abstract
Isopropyl alcohol (IA) is a colorless, flammable organic compound that has been used in the manufacturing process of a wide variety of industrial and household chemicals. Inhalation of its vapor has been noted to potentially have antiemetic effects, which may be useful in the treatment of postoperative nausea and vomiting (PONV). However, given the varied study protocols and endpoints assessing its efficacy as antiemetic, clinical trials have yielded mixed results. If effective, inhalation of IA may be a cost-effective, readily available, and inexpensive therapy that can be used for the treatment of PONV with a low risk of adverse effects. The following narrative review explores the available information regarding the mechanism of action of IA in treating PONV, presents clinical information including possible mechanism of action and clinical applications, and reviews the published literature on its efficacy to treat nausea and vomiting with a focus on its use postoperatively. While early studies suggested that inhaled IA may be successful for the short-term treatment of PONV compared with placebo, subsequent studies both in and out of the operating room (OR) have reported conflicting results. In general, studies in the perioperative setting have provided some evidence to support the use of inhaled IA in alleviating or reducing the severity of PONV in adults. In particular, inhaled IA may have a more rapid onset compared with traditional antiemetic agents, but the clinical effect has generally been found to be short-lived. The results outside of the OR and perioperative setting have been somewhat more favorable, generally showing that inhaled IA reduces nausea and vomiting of various etiologies in adults in the emergency department setting. Similarly, it has been shown to reduce the need for rescue antiemetic agents in this area and thus may be considered a cost-cutting strategy with no reported adverse effects. The available literature suggests that inhaled IA may be considered a potential therapy to achieve rapid relief of PONV and assist in the management of nausea and vomiting in adult patients outside of the perioperative setting. There remain insufficient data to determine how inhaled IA may impact PONV in children. Given the mixed results and the limitations of the current studies, additional data are needed to draw firm conclusions regarding the utility of inhaled IA.
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Affiliation(s)
- Sebastian Amaya
- Department of Anesthesiology and Pain Medicine, Nationwide Children’s Hospital, Columbus, Ohio
| | - Sidhant Kalsotra
- 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
- Department of Anesthesiology and Pain Medicine, The Ohio State University College of Medicine, Columbus, Ohio
| | - Vanessa A. Olbrecht
- Department of Anesthesiology and Pain Medicine, Nationwide Children’s Hospital, Columbus, Ohio
- Department of Anesthesiology and Pain Medicine, The Ohio State University College of Medicine, Columbus, Ohio
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27
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Khara B, Tobias JD. Perioperative Care of the Pediatric Patient and an Algorithm for the Treatment of Intraoperative Bronchospasm. J Asthma Allergy 2023; 16:649-660. [PMID: 37384067 PMCID: PMC10295469 DOI: 10.2147/jaa.s414026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Accepted: 06/17/2023] [Indexed: 06/30/2023] Open
Abstract
Asthma remains a common comorbid condition in patients presenting for anesthetic care. As a chronic inflammatory disease of the airway, asthma is known to increase the risk of intraoperative bronchospasm. As the incidence and severity of asthma and other chronic respiratory conditions that alter airway reactivity is increasing, a greater number of patients at risk for perioperative bronchospasm are presenting for anesthetic care. As bronchospasm remains one of the more common intraoperative adverse events, recognizing and mitigating preoperative risk factors and having a pre-determined treatment algorithm for acute events are essential to ensuring effective resolution of this intraoperative emergency. The following article reviews the perioperative care of pediatric patients with asthma, discusses modifiable risk factors for intraoperative bronchospasm, and outlines the differential diagnosis of intraoperative wheezing. Additionally, a treatment algorithm for intraoperative bronchospasm is suggested.
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Affiliation(s)
- Birva Khara
- Department of Anesthesiology, Shree Krishna Hospital, Pramukhswami Medical College and Bhaikaka University, Karamsad, Gujarat, India
| | - Joseph D Tobias
- Department of Anesthesiology & Pain Medicine, Nationwide Children’s Hospital, Columbus, OH, USA
- The Ohio State University College of Medicine, Columbus, OH, USA
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28
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Willer BL, Petkus H, Manupipatpong K, Tram N, Nafiu OO, Tobias JD, Mpody C. Association of Obstructive Sleep Apnea With Unanticipated Admission Following Nonotolaryngologic Pediatric Ambulatory Surgery. Anesth Analg 2023; Publish Ahead of Print:00000539-990000000-00595. [PMID: 37307227 DOI: 10.1213/ane.0000000000006593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
BACKGROUND Approximately 2% of ambulatory pediatric surgeries require unanticipated postoperative admission, causing parental dissatisfaction and suboptimal use of hospital resources. Obstructive sleep apnea (OSA) occurs in nearly 8% of children and is known to increase the risk of perioperative adverse events in children undergoing otolaryngologic procedures (eg, tonsillectomy). However, whether OSA is also a risk for unanticipated admission after nonotolaryngologic surgery is unknown. The objectives of this study were to determine the association of OSA with unanticipated admission after pediatric nonotolaryngologic ambulatory surgery and to explore trends in the prevalence of OSA in children undergoing nonotolaryngologic ambulatory surgery. METHODS We used the Pediatric Health Information System (PHIS) Database to evaluate a retrospective cohort of children (<18 years) undergoing nonotolaryngologic surgery scheduled as ambulatory or observation status from January 1, 2010, to August 31, 2022. We used International Classification of Diseases codes to identify patients with OSA. The primary outcome was unanticipated postoperative admission lasting ≥1 day. Using logistic regression models, we estimated the odds ratio (OR) and 95% confidence intervals (CIs) for unanticipated admission comparing patients with and without OSA. We then estimated trends in the prevalence of OSA during the study period using the Cochran-Armitage test. RESULTS A total of 855,832 children <18 years underwent nonotolaryngologic surgery as ambulatory or observation status during the study period. Of these, 39,427 (4.6%) required unanticipated admission for ≥1 day, and OSA was present in 6359 (0.7%) of these patients. Among children with OSA, 9.4% required unanticipated admission, compared to 5.0% among those without. The odds of children with OSA requiring unanticipated admission were more than twice that in children without OSA (adjusted OR, 2.27; 95% CI, 1.89-2.71; P < .001). The prevalence of OSA among children undergoing nonotolaryngologic surgery as ambulatory or observation status increased from 0.4% to 1.7% between 2010 and 2022 (P trends < .001). CONCLUSIONS Children with OSA were significantly more likely to require unanticipated admission after a nonotolaryngologic surgery scheduled as ambulatory or observation status than those without OSA. These findings can inform patient selection for ambulatory surgery with the goal of decreasing unanticipated admissions, increasing patient safety and satisfaction, and optimizing health care resources related to unanticipated admission.
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Affiliation(s)
- Brittany L Willer
- From the Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital and The Ohio State University, Columbus, Ohio
| | - Holly Petkus
- Heritage College of Osteopathic Medicine-Athens Campus and Ohio University, Athens, Ohio
| | - Katherine Manupipatpong
- From the Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital and The Ohio State University, Columbus, Ohio
| | - Nguyen Tram
- From the Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital and The Ohio State University, Columbus, Ohio
| | - Olubukola O Nafiu
- From the Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital and The Ohio State University, Columbus, Ohio
| | - Joseph D Tobias
- From the Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital and The Ohio State University, Columbus, Ohio
| | - Christian Mpody
- From the Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital and The Ohio State University, Columbus, Ohio
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29
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Olbrecht VA, Engelhardt T, Tobias JD. Beyond mortality: definitions and benchmarks of outcome standards in paediatric anaesthesiology. Curr Opin Anaesthesiol 2023; 36:318-323. [PMID: 36745075 DOI: 10.1097/aco.0000000000001246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW The aim of this study was to review the evolution of safety and outcomes in paediatric anaesthesia, identify gaps in quality and how these gaps may influence outcomes, and to propose a plan to address these challenges through the creation of universal outcome standards and a paediatric anaesthesia designation programme. RECENT FINDINGS Tremendous advancements in the quality and safety of paediatric anaesthesia care have occurred since the 1950 s, resulting in a near absence of documented mortality in children undergoing general anaesthesia. However, the majority of data we have on paediatric anaesthesia outcomes come from specialized academic institutions, whereas most children are being anaesthetized outside of free-standing children's hospitals. SUMMARY Although the literature supports dramatic improvements in patient safety during anaesthesia, there are still gaps, particularly in where a child receives anaesthesia care and in quality outcomes beyond mortality. Our goal is to increase equity in care, create standardized outcome measures in paediatric anaesthesia and build a verification system to ensure that these targets are accomplished. The time has come to benchmark paediatric anaesthesia care and increase quality received by all children with universal measures that go beyond simply mortality.
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Affiliation(s)
- Vanessa A Olbrecht
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital and the Department of Anesthesiology & Pain Medicine, The Ohio State University College of Medicine
- Center for Clinical Excellence, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Thomas Engelhardt
- Department of Paediatric Anaesthesia, Montreal Children's Hospital, McGill University, Montreal, Quebec, Canada
| | - Joseph D Tobias
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital and the Department of Anesthesiology & Pain Medicine, The Ohio State University College of Medicine
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30
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Naguib AN, Carrillo SA, Corridore M, Bigelow AM, Walczak A, Tram NK, Hersey D, Galantowicz M, Tobias JD. A ROTEM-guided algorithm aimed to reduce blood product utilization during neonatal and infant cardiac surgery. J Extra Corpor Technol 2023; 55:60-69. [PMID: 37378438 DOI: 10.1051/ject/2023017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Accepted: 04/24/2023] [Indexed: 06/29/2023]
Abstract
BACKGROUND Neonates and infants undergoing cardiac surgery tend to receive high volumes of blood products. The use of rotational thromboelastometry (ROTEM®) has been shown to reduce the administration of blood products in adults after cardiac surgery. We sought to develop a targeted administration of blood products based on ROTEM® to reduce blood product utilization during and after neonatal and infant cardiac surgery. METHODS We conducted a retrospective review of data from a single center for neonates and infants undergoing congenital cardiac surgery using cardiopulmonary bypass (CPB) from September 2018-April 2019 (control group). Then, using a ROTEM® algorithm, we collected data prospectively between April-November 2021 (ROTEM group). Data collected included age, weight, gender, procedure, STAT score, CPB time, aortic cross-clamp time, volume, and type of blood products administered in the operating room and cardiothoracic intensive care unit (CTICU). In addition, ROTEM® data, coagulation profile in CTICU, chest tube output at 6 and 24 hours, use of factors concentrate, and thromboembolic complications were recorded. RESULTS The final cohort of patients included 28 patients in the control group and 40 patients in the ROTEM group. The cohort included neonates and infants undergoing the following procedures: arterial switch, aortic arch augmentation, Norwood procedure, and comprehensive stage II procedure. There were no differences in the demographics or procedure complexity between the two groups. Patients in the ROTEM® group received fewer platelets (36 ± 12 vs. 49 ± 27 mL/kg, p 0.028) and cryoprecipitate (8 ± 3 vs. 15 ± 10 mL/kg, p 0.001) intraoperatively when compared to the control group. CONCLUSION The utilization of ROTEM® may have contributed to a significant reduction in some blood product administration during cardiac surgery for infants and neonates. ROTEM® data may play a role in reducing blood product administration in neonatal and infant cardiac surgery.
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Affiliation(s)
- Aymen N Naguib
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital and The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Sergio A Carrillo
- Department of Cardiothoracic Surgery, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Marco Corridore
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital and The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Amee M Bigelow
- The Heart Center, Nationwide Children's Hospital, Department of Pediatrics, The Ohio State University, Columbus, Ohio, USA
| | - Ashley Walczak
- Department of Cardiothoracic Surgery, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Nguyen K Tram
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital and The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Diane Hersey
- Department of Cardiothoracic Surgery, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Mark Galantowicz
- Department of Cardiothoracic Surgery, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Joseph D Tobias
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital and The Ohio State University College of Medicine, Columbus, Ohio, USA
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31
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Mpody C, Kemper AR, Aldrink JH, Michalsky MP, Tobias JD, Nafiu OO. Trends and Economic Implications of Disparities in Postoperative Pneumonia. Pediatrics 2023; 151:191052. [PMID: 37057490 DOI: 10.1542/peds.2022-058774] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/02/2023] [Indexed: 04/15/2023] Open
Abstract
BACKGROUND Postoperative pneumonia is the third most common surgical complication and can seriously impair surgical rehabilitation and lead to related morbidity and mortality. We evaluated the temporal trends in racial and ethnic disparities in postoperative pneumonia and quantified the economic burden resulting from these inequalities in the United States. METHODS This population-based study includes 195 028 children (weighted to 964 679) admitted for elective surgery across 5340 US hospitals reporting to the Nationwide Inpatient Sample between 2010 and 2018. We estimated the risk-adjusted incidence of postoperative pneumonia, comparing racial and ethnic groups. We also quantified the inflation-adjusted hospital costs attributable to racial and ethnic disparities in postoperative pneumonia. RESULTS The risk-adjusted rates of pneumonia declined across all racial and ethnic categories, with Black children having the lowest annual rate of decline (Black: 0.03 percentage points, Hispanic: 0.05 percentage points, white: 0.05 percentage points). The risk-adjusted rates of pneumonia trended consistently higher for Black and Hispanic children, relative to white children, throughout the study period (Black versus white: relative risk, 1.31 (95% confidence interval, 1.14-1.51), P < .01; Hispanic versus white: relative risk, 1.16 (95% confidence interval, 1.02-1.32), P = .02). These disparities did not narrow significantly over time. During the study period, the excess hospitalization cost attributable to racial and ethnic disparities in postoperative pneumonia was $24 533 458 for Black children and $26 200 783 for Hispanic children (total, $50 734 241). CONCLUSIONS Against the backdrop of decreasing postoperative pneumonia, Black and Hispanic children continue to experience higher rates compared with white children. These persistent disparities in postoperative pneumonia were associated with considerable excess cost of surgical care.
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Affiliation(s)
- Christian Mpody
- Departments of Anesthesiology and Pain Medicine
- Ohio State University College of Medicine, Columbus, Ohio
| | - Alex R Kemper
- Division of Primary Care Pediatrics, Nationwide Children's Hospital, Columbus, Ohio; and
- Ohio State University College of Medicine, Columbus, Ohio
| | - Jennifer H Aldrink
- General Pediatric Surgery
- Ohio State University College of Medicine, Columbus, Ohio
| | - Marc P Michalsky
- General Pediatric Surgery
- Ohio State University College of Medicine, Columbus, Ohio
| | - Joseph D Tobias
- Departments of Anesthesiology and Pain Medicine
- Ohio State University College of Medicine, Columbus, Ohio
| | - Olubukola O Nafiu
- Departments of Anesthesiology and Pain Medicine
- Ohio State University College of Medicine, Columbus, Ohio
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Mpody C, Beltran R, Hayes S, Nafiu OO, Tobias JD. Sugammadex Vial Wastage: Implications for the Cost of Anesthesia Care in Children. Anesthesiology 2023:138037. [PMID: 37027170 DOI: 10.1097/aln.0000000000004551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/08/2023]
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Tram NK, Mpody C, Owusu-Bediako K, Murillo-Deluquez ME, Tobias JD, Nafiu OO. Childhood obesity trends: Association with same-day hospital admission in a National Outpatient Surgical Population. Paediatr Anaesth 2023; 33:312-318. [PMID: 36527422 DOI: 10.1111/pan.14617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Revised: 11/30/2022] [Accepted: 12/13/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND Although the prevalence of obesity in the general population and its perioperative implications among children undergoing inpatient surgeries are well known, little is known about obesity prevalence among children scheduled for ambulatory surgery. AIMS Here, we report the trends of obesity and severe obesity among children who underwent ambulatory surgery across multiple centers in the United States and explore the association of obesity status with admission following elective ambulatory surgery. MATERIALS AND METHODS Using data from the American College of Surgeons National Surgical Quality Improvement Program-Pediatric (2012-2019), we selected children 2-18 years old who underwent outpatient surgical procedures under general anesthesia and had documented height, weight, and body mass index (BMI) data. We estimated the prevalence of overweight, obesity (class 1), and severe obesity (class 2 and class 3) patients and explored their association with same-day hospital admission, defined as hospital length of stay ≥1 day. RESULTS Data from 152 918 children (mean age: 9.7 ± 4.7 years) were analyzed. Of these, 16.4% (n = 25 007) were overweight, 13.8% (n = 21 085) were class 1 obese, 5.2% (n = 7879) were class 2 obese, and 3.0% (n = 4623) were class 3 obese. From 2012 to 2019, class 2 or 3 obesity prevalence increased by 26.7% and 32.5%, respectively. Overweight and obese children had relatively higher odds of same-day hospital admission compared to healthy weight children (overweight odds ratio [95% confidence interval]: 1.05 [1.02, 1.08]; class 1 obesity: 1.04 [1.00, 1.07]; class 2 obesity: 1.09 [1.02, 1.16]; class 3 obesity: 1.20 [1.11, 1.30]). DISCUSION AND CONCLUSION The burden of obesity continues to increase in children scheduled for ambulatory surgery. Children with class 2 and class 3 obesity have higher rates of same-day hospital admission following elective ambulatory surgery compared to healthy weight children, a factor that should be considered in scheduling these patients.
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Affiliation(s)
- Nguyen K Tram
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio, USA.,Department of Anesthesiology & Pain Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Christian Mpody
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio, USA.,Department of Anesthesiology & Pain Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Kwaku Owusu-Bediako
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio, USA
| | | | - Joseph D Tobias
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio, USA.,Department of Anesthesiology & Pain Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Olubukola O Nafiu
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio, USA.,Department of Anesthesiology & Pain Medicine, The Ohio State University, Columbus, Ohio, USA
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Yeh J, McKee C, Chenault K, Tobias JD. Remimazolam as a Primary Agent for Brief Invasive and Noninvasive Procedures: A Case Series. J Clin Med Res 2023; 15:174-180. [PMID: 37035849 PMCID: PMC10079368 DOI: 10.14740/jocmr4870] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Accepted: 03/15/2023] [Indexed: 03/31/2023] Open
Abstract
Remimazolam is a novel benzodiazepine with sedative and amnestic properties similar to midazolam. Ester metabolism results in a half-life of 5 - 10 min and a limited context sensitive half-life. We present preliminary retrospective experience with its use as a primary agent for procedural sedation for brief invasive and noninvasive procedures. The study cohort included seven patients, ranging in age from 14 to 51 years. Remimazolam administration included bolus dosing in two patients and a combination of bolus dosing followed by an infusion in the other five patients. The initial bolus dose of remimazolam ranged from 2.5 to 5 mg. Starting doses for the infusion ranged from 10 to 30 µg/kg/min with titration of the continuous infusion during the procedure, ranging from 10 - 30 µg/kg/min. Median dose infusion requirements were 15 - 20 µg/kg/min. One procedure was completed with remimazolam as the sole anesthetic agent while the other six patients received adjunctive agents. Changes in blood pressure or oxygen saturation were noted which resolved with minimal interventions such as a decrease in remimazolam infusion rate or an increase in supplemental oxygen administration. Our anecdotal experience provides further support for the efficacy of remimazolam as an agent for procedural sedation.
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Affiliation(s)
- Jessica Yeh
- Department of Anesthesiology & Pain Medicine, Nationwide Children’s Hospital, Columbus, OH, USA
| | - Christopher McKee
- 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
| | - Kristin Chenault
- 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
- Corresponding Author: Joseph D. Tobias, Department of Anesthesiology & Pain Medicine, Nationwide Children’s Hospital, Columbus, OH 43205, USA.
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Hall B, Bryant J, Winch P, Tobias JD. Oropharyngeal and Tongue Pulse Oximetry in 2 Critically Ill Pediatric Patients: A Case Report. A A Pract 2023; 17:e01660. [PMID: 36881555 DOI: 10.1213/xaa.0000000000001660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/08/2023]
Abstract
Pulse oximetry has become a standard of care to monitor oxygenation. Absent or inaccurate readings can occur with varied patient states. We present preliminary experience with a modification of a standard pulse oximetry using readily available equipment (oral airway and a tongue blade) to allow for continuous pulse oximetry from the oral cavity and tongue in 2 critically ill pediatric patients when standard application of pulse oximetry was not feasible or nonfunctional. These modifications can assist in the care of critically ill patients, allowing for adaptability in monitoring techniques when other options are unavailable.
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Affiliation(s)
- Brian Hall
- From the Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio
| | - Jason Bryant
- From the Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio
- Department of Anesthesiology & Pain Medicine, The Ohio State University College of Medicine, Columbus, Ohio
| | - Peter Winch
- From the Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio
- Department of Anesthesiology & Pain Medicine, The Ohio State University College of Medicine, Columbus, Ohio
| | - Joseph D Tobias
- From the Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio
- Department of Anesthesiology & Pain Medicine, The Ohio State University College of Medicine, Columbus, Ohio
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Amaya S, Kalsotra S, Tram NK, Tobias JD, Olbrecht VA. Vial-splitting and Repackaging into Aliquot-specific Syringes: A Cost-effective and Waste-decreasing Strategy for Sugammadex. Pediatr Qual Saf 2023; 8:e646. [PMID: 37051405 PMCID: PMC10085484 DOI: 10.1097/pq9.0000000000000646] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Accepted: 03/10/2023] [Indexed: 04/14/2023] Open
Abstract
Sugammadex is a medication that may have cost considerations with the potential for waste of unused product in pediatric patients due to the vial size and its single-use limitation. Therefore, exploring the potential of vial-splitting for perioperative use may be beneficial. Methods The study was a retrospective, quality improvement study using the electronic medical record to identify every sugammadex administration over the last five years in a tertiary care pediatric institution. We divided patients into groups depending on the dose of sugammadex administered. The cost of sugammadex was calculated under three scenarios: (1) only 200-mg vials available; (2) 100-mg aliquots available; and (3) 50-mg aliquots. We then calculated the total money spent per patient in the 3 scenarios. Results 31,063 patients received sugammadex over the study period, of whom 23.6% received 151-200 mg. The greatest percentage of patients received ≤50 mg (32.9%). The average cost per patient was $113.58, $81.61, and $68.83 if 200 mg, 100 mg, and 50 mg doses were available, respectively. Over the last 5 years, $1,390,110.13 could have been saved by having 50 and 100 mg aliquots available. Conclusions Pediatric patients generally receive lower doses of sugammadex due to weight-based dosing, leading to increased waste and cost when using only 200-mg vials. Vial-splitting into smaller aliquots can significantly cut costs for healthcare centers and patients while decreasing waste.
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Affiliation(s)
- Sebastian Amaya
- From the Department of Anesthesiology and Pain Medicine, Nationwide Children’s Hospital, Columbus, Ohio
| | - Sidhant Kalsotra
- From the Department of Anesthesiology and Pain Medicine, Nationwide Children’s Hospital, Columbus, Ohio
| | - Nguyen K. Tram
- From the Department of Anesthesiology and Pain Medicine, Nationwide Children’s Hospital, Columbus, Ohio
| | - Joseph D. Tobias
- From the Department of Anesthesiology and Pain Medicine, Nationwide Children’s Hospital, Columbus, Ohio
- Department of Anesthesiology & Pain Medicine, Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Vanessa A. Olbrecht
- From the Department of Anesthesiology and Pain Medicine, Nationwide Children’s Hospital, Columbus, Ohio
- Department of Anesthesiology & Pain Medicine, Ohio State University Wexner Medical Center, Columbus, Ohio
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Owusu-Bediako K, Mpody C, Iobst C, Tobias JD, Nafiu OO. Risk assessment of postoperative pneumonia in children with neurologic disorders and obesity. Paediatr Anaesth 2023; 33:160-166. [PMID: 36399010 DOI: 10.1111/pan.14593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Revised: 10/26/2022] [Accepted: 10/29/2022] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Postoperative pneumonia increases the risk of postsurgical mortality, making it a serious healthcare-associated complication. Children with preoperative neuromuscular impairments have a higher risk of postoperative pneumonia. Obesity is also a risk factor for postoperative pulmonary complications, including pneumonia. Moreover, obesity is increasingly prevalent among children living with a neurological diagnosis. Whether obesity increases the risk of postoperative pneumonia among children with neurologic diseases remains largely unknown. Therefore, we assessed the risk of postoperative pneumonia among children with neurologic diagnoses based on their obesity status. METHODS We analyzed a retrospective cohort of children ≤18 years from the National Surgical Quality Improvement Program (2012-2019) database who underwent inpatient orthopedic surgery. We used Cox proportional regression model to estimate the hazard ratio for the association between neurologic disorders and postoperative pneumonia. In addition, we included an interaction term between body mass index and neurologic disorders to evaluate the moderating effect of obesity status and then performed stratified analyses to compare the magnitude of hazard ratios across body mass index subgroups. RESULTS A total of 60 745 children underwent inpatient orthopedic surgery during the study period, of whom 43.6% were healthy weight and 30.8% overweight/obese. The median age was 13 years (Interquartile range: 8-15). The incidence of postoperative pneumonia was higher among healthy weight patients with neurologic disorders than healthy weight patients without any neurologic disorders [Hazard ratio: 3.55 vs. 0.34]. Furthermore, the association between neurologic disorders and postoperative pneumonia was strongest among overweight patients than healthy weight or obese patients [Hazard ratio:11.88 vs. 9.45 vs. 4.40]. This observation was consistent across the various neurologic disorders analyzed. CONCLUSION Childhood obesity buffered the association between neurologic disorders and postoperative pneumonia, consistent with an 'obesity paradox'. Further research exploring the underlying mechanisms for the obesity paradox in children with neurologic disorders is warranted.
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Affiliation(s)
- Kwaku Owusu-Bediako
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Christian Mpody
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio, USA.,Department of Anesthesiology & Pain Medicine, The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Christopher Iobst
- Department of Pediatric Orthopedic Surgery, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Joseph D Tobias
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio, USA.,Department of Anesthesiology & Pain Medicine, The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Olubukola O Nafiu
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio, USA.,Department of Anesthesiology & Pain Medicine, The Ohio State University College of Medicine, Columbus, Ohio, USA
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Kalsotra S, Khan S, McKee C, Tobias JD. Remimazolam as the Primary Agent for Sedation During Cardiac Catheterization in Three Patients With Comorbid Cardiac Conduction Abnormalities. Cardiol Res 2023; 14:86-90. [PMID: 36896227 PMCID: PMC9990540 DOI: 10.14740/cr1477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Accepted: 02/16/2023] [Indexed: 02/27/2023] Open
Abstract
General anesthesia or procedural sedation may be required to ensure immobility, facilitate completion of the procedure, and ensure patient comfort during diagnostic or therapeutic procedures in the cardiac catheterization suite. Although propofol and dexmedetomidine are two of the more commonly chosen agents, concerns regarding their impact on inotropic, chronotropic or dromotropic function may limit their applicability based on underlying patient comorbid conditions. We present three patients with comorbid conditions involving pacemaker (natural or implanted) function or cardiac conduction which impacted the choice of agent for procedural sedation during procedures in the cardiac catheterization suite. Remimazolam, a novel ester-metabolized benzodiazepine, was used as the primary agent for sedation in an effort to limit detrimental effects on chronotropic and dromotropic function which may be seen with propofol or dexmedetomidine. Remimazolam's potential utility in procedural sedation is discussed, previous reports of its use are reviewed, and dosing algorithms are presented.
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Affiliation(s)
- Sidhant Kalsotra
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA
| | - Sarah Khan
- 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
| | - Christopher McKee
- 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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Manupipatpong K, Ghimire A, Tram NK, Wood R, Tobias JD, Veneziano G. Quadratus Lumborum Blockade for Postoperative Analgesia in Infants and Children Following Colorectal Surgery. J Clin Med Res 2023; 15:84-89. [PMID: 36895621 PMCID: PMC9990722 DOI: 10.14740/jocmr4833] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Accepted: 02/23/2023] [Indexed: 03/06/2023] Open
Abstract
Background Adult studies have indicated that the quadratus lumborum block (QLB) may provide superior analgesia compared to single-shot neuraxial and other truncal peripheral nerve blocks. The technique is being increasingly used for postoperative analgesia in children undergoing lower abdominal surgery. To date, these pediatric reports have been limited by small sample sizes, which may hinder the interpretation of results and assessment of safety. In this study, we retrospectively examined QLBs performed at a large tertiary care hospital for evidence of effectiveness and safety in the pediatric colorectal surgery population. Methods Patients less than 21 years of age who underwent abdominal surgery and received a unilateral or bilateral QLB over a 4-year period were identified in the electronic medical record. Patient demographics, surgery type, and QLB characteristics were retrospectively examined. Pain scores and opioid consumption were tabulated over the first 72-h postoperative period. QLB procedural complications or adverse events attributable to the regional anesthetic were obtained. Results The study cohort included 204 QLBs in 163 pediatric-aged patients (2 days to 19 years of age, median age of 2.4 years). The most common indication was unilateral blockade for ostomy creation or reversal. The majority of QLBs were performed using ropivacaine 0.2% with a median volume of 0.6 mL/kg. The median opioid requirement in oral morphine milligram equivalents (MMEs) was 0.7, 0.5, and 0.3 MME/kg on the first, second, and third postoperative days, respectively. Median pain scores were less than 2 over each time period. Aside from block failure (incidence 1.2%), there were no complications or postoperative adverse events related to the QLBs. Conclusion This retrospective review in a large cohort of pediatric patients demonstrates that the QLB can be performed safely and efficiently in children undergoing colorectal surgery. The QLB provides adequate postoperative analgesia, has a high success rate, may limit postoperative opioid consumption, and is associated with a limited adverse effect profile.
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Affiliation(s)
- Katherine Manupipatpong
- 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
| | - Anuranjan Ghimire
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA
| | - Nguyen K Tram
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA
| | - Richard Wood
- Department of Pediatric Colorectal & Pelvic Reconstructive Surgery, Nationwide Children's Hospital, 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
| | - Giorgio Veneziano
- 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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Du J, Roth C, Dontukurthy S, Tobias JD, Veneziano G. Manual Palpation versus Ultrasound to Identify the Intervertebral Space for Spinal Anesthesia in Infants. J Pain Res 2023; 16:93-99. [PMID: 36647435 PMCID: PMC9840403 DOI: 10.2147/jpr.s392438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Accepted: 01/04/2023] [Indexed: 01/11/2023] Open
Abstract
Purpose Awake spinal anesthesia continues as an alternative to general anesthesia for infants. Standard clinical practice includes the manual palpation of surface landmarks to identify the desired intervertebral space for lumbar puncture (LP). The current study investigates the accuracy of manual palpation for identifying the intended intervertebral site for LP, using ultrasonography for confirmation and to determine the interspace where the conus medullaris ends. Patients and Methods After informed parental consent, patients less than one year of age undergoing spinal anesthesia for lower abdominal, urologic, or lower extremity surgical procedures were included. Patients were held in the seated position and an attending pediatric anesthesiologist or pediatric anesthesiology fellow declared the vertebral interspace intended for needle insertion, palpated surface landmarks, and placed a mark at the site. A research anesthesiologist then determined the actual vertebral interspace of the marked site and the location of the conus medullaris using ultrasonography. The time to complete both techniques (manual palpation and ultrasonography) was recorded. Results The study cohort included 50 infants (median age of 7 months). Sixteen vertebral interspaces (32%) were inaccurately marked. One was marked two spaces higher than intended, ten were marked one space higher than intended, and five were marked one space lower than intended. In one patient, the intended vertebral interspace for the lumbar puncture overlaid the conus medullaris. The median time required was 25 seconds (IQR 14.3, 32) for palpation and 39 seconds (IQR 29, 63.8) for ultrasonography. Conclusion Manual palpation of surface landmarks to determine the correct interspace for LP for spinal anesthesia in infants is inaccurate. The time required to perform spinal ultrasonography in infants for determination of the optimal site for LP is brief and may be useful in ensuring accurate identification of the correct interspace and the location of the conus medullaris.
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Affiliation(s)
- Joanne Du
- The Ohio State University College of Medicine, Columbus, OH, USA
| | - Catherine Roth
- Department of Anesthesiology & Pain Medicine, Nationwide Children’s Hospital, Columbus, OH, USA
| | - Sujana Dontukurthy
- Department of Anesthesiology, Valley Children’s Hospital, Madera, CA, 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
| | - Giorgio Veneziano
- 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,Correspondence: Giorgio Veneziano, Department of Anesthesiology & Pain Medicine, Nationwide Children’s Hospital, 700 Children’s Dr, Columbus, OH, 43205, USA, Tel + 1 614-722-4200, Email
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Holladay J, Winch P, Morse J, Anderson BJ, McKee CT, Rice-Weimer J, Tobias JD. Acetaminophen pharmacokinetics in infants and children with congenital heart disease. Paediatr Anaesth 2023; 33:46-51. [PMID: 36264219 PMCID: PMC10100048 DOI: 10.1111/pan.14579] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2022] [Revised: 10/11/2022] [Accepted: 10/16/2022] [Indexed: 01/20/2023]
Abstract
BACKGROUND Acetaminophen is routinely used for perioperative analgesia in children undergoing major surgical procedures. There are few estimates of acetaminophen pharmacokinetic parameters in children with congenital heart disease, especially those with cyanotic heart disease. AIMS The current study prospectively investigated differences in acetaminophen pharmacokinetics following surgery using cardiopulmonary bypass in children with cyanotic and acyanotic congenital heart disease. METHODS Children (2-6 years, 9-23 kg) presenting for median sternotomy for Fontan palliation (cyanotic patients) or two ventricle surgical repair (acyanotic patients) were eligible for inclusion. A single intravenous dose of acetaminophen (15 mg/kg) was administered at the start of sternal closure after separation from cardiopulmonary bypass. The time-course of acetaminophen concentrations were described using non-linear mixed effects models. One and two-compartment disposition models with first-order elimination were tested. Pharmacokinetic parameter estimates were scaled using allometry and standardized to a 70 kg person. RESULTS There were 208 acetaminophen concentrations assayed from 30 children, 15 with cyanotic, and 15 with acyanotic heart disease. A 2-compartment model best described acetaminophen PK. Parameter estimates (population parameter variability, PPV%; 95% confidence interval, CI) were clearance CL 15.3 L.h-1.70 kg-1 (22.2%; 13.8-16.7), intercompartment clearance Q 45.4 L.h-1.70 kg-1 (22.4%; 25.2-61.9), central volume of distribution V1 33.5 L.70 kg-1 (23.2%; 25.9-38.8), peripheral volume of distribution V2 32.1 L.70 kg-1 (21.7%; 25.9-38.8). Neither clearance nor volume parameters differed between cyanotic and acyanotic patients. CONCLUSIONS Acetaminophen pharmacokinetics were characterized using a 2-compartment model with first-order elimination following cardiac bypass surgery in children. Population pharmacokinetic parameter estimates were similar to other studies in children. No differences were detected between patients with cyanotic and acyanotic heart disease.
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Affiliation(s)
- Jay Holladay
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Peter Winch
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio, USA.,Department of Anesthesiology & Pain Medicine, The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - James Morse
- Department of Anesthesiology, University of Auckland, Auckland, New Zealand
| | - Brian J Anderson
- Department of Anesthesiology, University of Auckland, Auckland, New Zealand
| | - Christopher T McKee
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio, USA.,Department of Anesthesiology & Pain Medicine, The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Julie Rice-Weimer
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Joseph D Tobias
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio, USA.,Department of Anesthesiology & Pain Medicine, The Ohio State University College of Medicine, Columbus, Ohio, USA
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Beltran RJ, Mpody C, Nafiu OO, Tobias JD. Association of Sugammadex or Neostigmine With Major Postoperative Pulmonary Complications in Children. Anesth Analg 2022; 135:1041-1047. [PMID: 35020682 DOI: 10.1213/ane.0000000000005872] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Recent data in adult patients indicate that the use of sugammadex compared to neostigmine for reversal of neuromuscular block (NMB) was associated with a significant reduction in the risk of composite postoperative pulmonary complications. Despite the clinical significance of pulmonary complications in children, studies exploring the role of NMB reversal in the risk of these complications are currently unavailable. METHOD We performed a propensity score-matched retrospective study using the Pediatric Health Information System (PHIS) dataset spanning the years 2016 and 2020. We studied children <18 years who underwent elective, inpatient, noncardiac surgical procedures and received either neostigmine or sugammadex for reversal of NMB. Our primary outcome was major postoperative pulmonary complication, which we defined as the occurrence of either postoperative pneumonia or respiratory failure. RESULTS Our study included a study population of 33,819 children, of whom 23,312 (68.9%) received neostigmine and 10,507 (31.1%) received sugammadex. After propensity score matching (10,361 matched from each group), we found no evidence of a statistically significant association between the NMB reversal agent and the incidence of pulmonary complications (3.1% vs 3.1%; odds ratio [OR], 0.90; 95% confidence interval [CI], 0.78-1.05; P = .19). The components of pulmonary complications, including respiratory failure and pneumonia, were not statistically associated with the choice of NMB reversal agent. CONCLUSIONS Choice of NMB reversal agent does not appear to impact the incidence of major postoperative pulmonary complications. Further research is needed to determine whether our results carry forth across subpopulations defined by surgical specialty, the presence of complex chronic conditions, and anesthesia technique.
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Affiliation(s)
- Ralph J Beltran
- From the Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio
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Garrett A, Flowers J, Ng V, Tobias JD. Remimazolam for Sedation During Upper Gastrointestinal Endoscopy in an Adolescent. J Med Cases 2022; 13:495-498. [PMID: 36407860 PMCID: PMC9635772 DOI: 10.14740/jmc4013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Accepted: 10/08/2022] [Indexed: 11/05/2022] Open
Abstract
Remimazolam is a short-acting benzodiazepine that has recently received approval from the US Food and Drug Administration (FDA) for procedural sedation in adults. Similar to other benzodiazepines such as midazolam, remimazolam has sedative, anxiolytic, and amnestic properties. Rapid metabolism by plasma esterases results in a half-life of 5 - 10 min and a limited context sensitive half-life. Preliminary data from adult studies have demonstrated favorable hemodynamic stability, no pain on injection, and limited impact on ventilatory function. To date, its use as the primary agent for procedural sedation in pediatric-aged patients has been limited, as previous published reports of its use have detailed its administration as an adjunct to general anesthesia. We report anecdotal experience with the use of remimazolam for procedural sedation during an upper gastrointestinal endoscopy in a 15-year-old adolescent with multiple drug and food allergies. The role of remimazolam in procedural sedation is discussed, previous reports of its use in pediatric-aged patients are reviewed, and dosing algorithms are presented.
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Affiliation(s)
- Alexandrea Garrett
- Department of Anesthesiology & Pain Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Jessie Flowers
- Department of Pediatrics, The Ohio State University College of Medicine and Nationwide Children’s Hospital, Columbus, OH, USA
| | - Vanessa Ng
- Department of Anesthesiology & Pain Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
- Department of Anesthesiology & Pain Medicine, Nationwide Children’s Hospital, Columbus, OH, USA
- Corresponding Author: Vanessa Ng, Department of Anesthesiology & Pain Medicine, Nationwide Children’s Hospital, Columbus, OH 43205, USA.
| | - Joseph D. Tobias
- Department of Anesthesiology & Pain Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
- Department of Anesthesiology & Pain Medicine, Nationwide Children’s Hospital, Columbus, OH, USA
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Pooley R, Veneziano G, Burrier C, Tram NK, Tobias JD. Preliminary Experience With Quadratus Lumborum Catheters for Postoperative Pain Management in Pediatric-Aged Patients With Contraindications to Epidural Anesthesia. J Clin Med Res 2022; 14:425-431. [PMID: 36406942 PMCID: PMC9635806 DOI: 10.14740/jocmr4813] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Accepted: 09/23/2022] [Indexed: 08/30/2023] Open
Abstract
BACKGROUND Although neuraxial techniques such as caudal and epidural anesthesia were initially the predominant regional anesthetic technique used to provide postoperative analgesia in children, there has been a transition to the use of peripheral nerve blockade such as the quadratus lumborum block (QLB). We present preliminary experience with QL catheters for continuous postoperative analgesia in a cohort of pediatric patients following colorectal surgery. METHODS After institutional review board (IRB) approval, we retrospectively reviewed the records of patients who underwent major colorectal surgery and received QL catheters for postoperative analgesia. The postoperative pain control data consisted of QL catheter characteristics, anesthetic agents, adjuncts, pain scores, and opioid consumption during the postoperative period. RESULTS The study cohort included eight pediatric patients, ranging in age from 1 to 19 years (median age 11.8 years). The QL catheters were placed in the operating room after the induction of anesthesia. Comorbid conditions in the cohort that were contraindications to neuraxial anesthesia included spinal/vertebral malformations, presence of a ventriculoperitoneal (VP) shunt, anal atresia, tracheo-esophageal fistula (VACTERL) association, and coagulation disturbances. All patients underwent complex colorectal or genito-urologic procedures. Bilateral QL catheters were placed in six patients, and unilateral catheters were placed in two patients. Four patients received 0.5% ropivacaine and four patients received 0.2% ropivacaine of an initial bolus. The local anesthetic used for continuous infusion was 0.2% ropivacaine in five patients, 0.1% ropivacaine in two patients, and 1.5% chloroprocaine in one patient, with a median infusion rate of 0.11 mL/kg/h. QL catheter infusions were supplemented with intravenous opioids delivered by patient-controlled or nurse-controlled analgesia. The median opioid requirements in oral morphine milligram equivalents (MME) were 1.2, 1.0, 1.1, 0.5, and 0.6 MME/kg on postoperative days 1 - 5. Daily median pain scores were ≤ 2 during the 5-day postoperative course. All catheters functioned successfully and were in place for a median of 79.3 h. Other than early inadvertent removal of two catheters, no adverse effects were noted. CONCLUSIONS Although our preliminary data suggest the efficacy of QL catheters in providing prolonged postoperative analgesia for up to 3 - 5 days following colorectal procedures, attention needs to be directed at measures to ensure that the catheter is secured to avoid inadvertent removal.
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Affiliation(s)
- Rachel Pooley
- Heritage College of Osteopathic Medicine, Dublin Campus, Dublin, Ohio and Ohio University, Athens, OH, USA
| | - Giorgio Veneziano
- 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
| | - Candice Burrier
- 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
| | - Nguyen K. Tram
- 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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Lemus R, Jacobowski NL, Humphrey L, Tobias JD. Applications of Dexmedetomidine in Palliative and Hospice Care. J Pediatr Pharmacol Ther 2022; 27:587-594. [PMID: 36186237 PMCID: PMC9514772 DOI: 10.5863/1551-6776-27.7.587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Accepted: 12/10/2021] [Indexed: 08/30/2023]
Abstract
Although the use of dexmedetomidine is currently approved by the US Food and Drug Administration in the adult population for monitored anesthesia care and sedation during mechanical ventilation, clinical experience suggests the potential application of dexmedetomidine in the palliative care arena. The medication can provide sedation with lower risk of delirium, control or minimize the adverse effects of other medications, and augment analgesia from opioids. We conducted a computerized bibliographic search of the literature regarding dexmedetomidine use for the treatment of pain and provision of sedation during palliative and hospice care in adult and pediatric patients. The objective was to provide a general descriptive account of the physiologic effects of dexmedetomidine and review its potential applications in the field of palliative and hospice care in adult and pediatric patients. The sedative and analgesic effects of dexmedetomidine have been well studied in animal and human models. Published experience from both single case reports and small case series has demonstrated the potential therapeutic applications of dexmedetomidine in palliative and hospice care. In addition to intravenous administration, case reports have demonstrated its successful use by both the intranasal and subcutaneous routes. Although these experiences have suggested its safety and efficacy, larger series and additional clinical experience with prospective comparison to other agents are needed to further define its efficacy and role in palliative and hospice care.
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Affiliation(s)
- Rafael Lemus
- Department of Pediatrics (RL), The Ohio State University College of Medicine, Columbus, OH
| | - Natalie L. Jacobowski
- Department of Psychiatry and Behavioral Health (NLJ), Nationwide Children's Hospital and The Ohio State University College of Medicine, Columbus, OH
- Division of Palliative Care and Advanced Illness Management (NLJ), Nationwide Children's Hospital and Department of Pediatrics, The Ohio State University, Columbus, OH
| | | | - Joseph D. Tobias
- Department of Anesthesiology & Pain Medicine (JDT), Nationwide Children's Hospital and The Ohio State University College of Medicine, Columbus, OH
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Christian CE, Kim SS, Tobias JD. Delirium in Pediatric Patients With Respiratory Insufficiency Requiring Noninvasive Ventilation. J Clin Med Res 2022; 14:357-363. [PMID: 36258841 PMCID: PMC9534187 DOI: 10.14740/jocmr4805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Accepted: 09/10/2022] [Indexed: 11/11/2022] Open
Abstract
Background Delirium is associated with increased length of stay, duration of mechanical ventilation, in-hospital mortality, and cost. Independent predictors of delirium include age < 2 years, developmental delay, severity of illness, mechanical ventilation, and administration of benzodiazepines and anticholinergic medications. Although patients receiving noninvasive ventilation (NIV) may have been included in prior studies, there are no data specifically focusing on delirium in children receiving NIV. Our primary aim was to investigate the prevalence of delirium in patients on NIV in the pediatric intensive care unit (PICU) and evaluate potentially modifiable risk factors for delirium. Methods This was a single-center, retrospective study evaluating the prevalence of delirium as established by the Cornell Assessment of Pediatric Delirium (CAPD). We evaluated PICU patients ≤ 18 years old with respiratory insufficiency requiring ≥ 48 h of NIV. Patients receiving invasive mechanical ventilation were excluded from the analysis. Results There were 202 patients that received ≥ 48 h of NIV during the study period. Of these patients, 43 patients had at least one CAPD score documented while on NIV. There were a total of 143 days on NIV and 137 days with CAPD documentation. The prevalence of delirium, defined as a CAPD score ≥ 9, was 67.4% (29 of 43 patients). Sixty-nine percent of the patients who experienced delirium received benzodiazepines, compared with 14% who did not experience delirium (P = 0.001). Most patients (83.7%) in this cohort received dexmedetomidine. Of patients who received dexmedetomidine and had delirium, 68% received benzodiazepines compared to 25% in the non-delirious group (P = 0.046). Conclusions Delirium is common in young pediatric patients receiving NIV. As previously shown in the invasive mechanical ventilation population, benzodiazepine exposure continues to be a potentially modifiable risk factor for delirium.
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Affiliation(s)
- Claire E. Christian
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Nationwide Children’s Hospital, Columbus, OH, USA
- Corresponding Author: Claire E. Christian, Department of Pediatrics, Division of Pediatric Critical Care Medicine, Nationwide Children’s Hospital, Columbus, OH 43205, USA.
| | - Stephani S. Kim
- Department of Anesthesiology & Pain Medicine, Nationwide Children’s Hospital and The Ohio State University College of Medicine, Columbus, OH, USA
| | - Joseph D. Tobias
- Department of Anesthesiology & Pain Medicine, Nationwide Children’s Hospital and The Ohio State University College of Medicine, Columbus, OH, USA
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Khanna N, Gbadegesin S, Reline T, Tobias JD, Nafiu OO. Severe Obesity and Prolonged Postoperative Mechanical Ventilation in Elderly Vascular Surgery Patients. J Clin Med Res 2022; 14:341-347. [PMID: 36258842 PMCID: PMC9534189 DOI: 10.14740/jocmr4804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Accepted: 09/06/2022] [Indexed: 11/28/2022] Open
Abstract
Background Severe obesity, defined as body mass index (BMI) ≥ 40 kg/m2 is increasingly prevalent in elderly surgical patients. Although older age is associated with prolonged postoperative mechanical ventilation (PPMV), the contribution of obesity to this complication in the elderly has not been explored. We investigated the association of severe obesity with the PPMV and the role of severe obesity on mortality risk in patients requiring PPMV. Methods We assembled a retrospective cohort of patients ≥ 65 years who underwent inpatient surgical procedures and were either severely obese or normal weight (BMI 18.6 - 24.9 kg/m2 (National Surgical Quality Improvement Program (NSQIP) 2015 - 2018). PPMV was defined as requirement of postoperative mechanical ventilation for longer than 48 h following surgery. We examined the association between severe obesity and PPMV, using univariable and multivariable logistic regression. Results We studied 34,936 patients who were ≥ 65 years of age. The incidence of PPMV was 2.0% (624/31,700) in normal weight patients and 2.8% (92/3,236) in severely obese patients (odds ratio (OR): 1.46; 95% confidence interval (CI): 1.17 - 1.82, P = 0.001). Multivariable analysis, controlling for confounders, estimated a 56% relative increase in the risk of PPMV in severely obese patients, relative to their normal weight peers (OR: 1.56; 95% CI: 1.22 - 1.99, P = 0.001). In normal weight patients, the risk of mortality was multiplied by 23 times in patients who required PPMV (39.6% vs. 2.64%; OR: 23.10; 95% CI: 18.96 - 28.16; P < 0.001). In severely obese patients, PPMV multiplied the risk of mortality by 25 times (30.4% vs. 1.6%; OR: 25.26, 95% CI: 13.44 - 47.50; P < 0.001). Conclusions Severe obesity increased the odds of PPMV. Although the incidence of PPMV was low, its requirement conferred up to 25 times greater risk of postoperative mortality, underscoring the need for perioperative mitigation strategies to minimize PPMV risk in elderly patients undergoing vascular surgery.
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Affiliation(s)
- Neha Khanna
- 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
| | - Olubukola O. Nafiu
- Department of Anesthesiology and Pain Medicine, Nationwide Children’s Hospital, Columbus, OH, USA
- Corresponding Author: Olubukola O. Nafiu, Department of Anesthesiology and Pain Medicine, Columbus, OH 43205, USA.
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Petkus H, Willer BL, Tobias JD. Remimazolam in a Pediatric Patient With a Suspected Family History of Malignant Hyperthermia. J Med Cases 2022; 13:386-390. [PMID: 36128061 PMCID: PMC9451561 DOI: 10.14740/jmc3977] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Accepted: 07/20/2022] [Indexed: 11/30/2022] Open
Abstract
Malignant hyperthermia (MH) is an acute hypermetabolic crisis, triggered in susceptible patients by the administration of succinylcholine or a volatile anesthetic agent. When providing anesthetic care for MH-susceptible patients, a total intravenous anesthetic technique with propofol or other sedative hypnotic is frequently chosen. Remimazolam is a novel benzodiazepine which, like midazolam, has sedative, anxiolytic, and amnestic properties. Ester metabolism results in a half-life of 5-10 min and a limited context sensitive half-life. We present anecdotal experience with its use as an adjunct to propofol anesthesia in a patient with a suspected family history of MH. Previous reports of the use of remimazolam in MH-susceptible patients are reviewed and its potential role in such patients discussed.
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Affiliation(s)
- Holly Petkus
- Heritage College of Osteopathic Medicine, Athens Campus and 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
- Corresponding Author: Brittany Willer, Department of Anesthesiology & Pain Medicine, Nationwide Children’s Hospital, Columbus, OH 43205, 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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Couser DF, Veneziano GC, Nafiu OO, Tobias JD, Beltran RJ. Use of a Spinal-Caudal Epidural Technique for Abdominal Surgery in a Newborn With Noonan Syndrome and Severe Hypertrophic Cardiomyopathy. A A Pract 2022; 16:e01611. [DOI: 10.1213/xaa.0000000000001611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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