Update on Management and Outcomes of Congenital Diaphragmatic Hernia

Infants with congenital diaphragmatic hernia (CDH) benefit from comprehensive multidisciplinary teams that have experience in caring for the unique and complex issues associated with CDH. Despite prenatal referral to specialized high-volume centers, advanced ventilation strategies and pulmonary hypertension management, and extracorporeal membrane oxygenation, mortality and morbidity remain high. These infants have unique and complex issues that begin in fetal and infant life, but persist through adulthood. Here we will review the literature and share our clinical care pathway for neonatal care and follow up. While many advances have occurred in the past few decades, our work is just beginning to continue to improve the mortality, but also importantly the morbidity of CDH.

Reducing the environmental impact of mask inductions in children: A quality improvement report

BACKGROUND

Inhalational anesthetic agents are potent greenhouse gases with global warming potential that far exceed that of carbon dioxide. Traditionally, pediatric inhalation inductions are achieved with a volatile anesthetic delivered to the patient in oxygen and nitrous oxide at high fresh gas flows. While contemporary volatile anesthetics and anesthesia machines allow for a more environmentally conscious induction, practice has not changed. We aimed to reduce the environmental impact of our inhalation inductions by decreasing the use of nitrous oxide and fresh gas flows.

METHODS

Through a series of four plan-do-study-act cycles, the improvement team used content experts to demonstrate the environmental impact of the current inductions and to provide practical ways to reduce this, by focusing on nitrous oxide use and fresh gas flows, with visual reminders introduced at point of delivery. The primary measures were the percentage of inhalation inductions that used nitrous oxide and the maximum fresh gas flows/kg during the induction period. Statistical process control charts were used to measure improvement over time.

RESULTS

33 285 inhalation inductions were included over a 20-month period. nitrous oxide use decreased from 80% to <20% and maximum fresh gas flows/kg decreased from a rate of 0.53 L/min/kg to 0.38 L/min/kg, an overall reduction of 28%. Reduction in fresh gas flows was greatest in the lightest weight groups. Induction times and behaviors remained unchanged over the duration of this project.

CONCLUSIONS

Our quality improvement group decreased the environmental impact of inhalation inductions and created cultural change within our department to sustain change and foster the pursuit of future environmental efforts.

Medication safety in pediatric anesthesia: An educational review and a call to action

Children presenting for anesthesia are at high risk for medication error during their care. In this educational review, we address the rates of medication error in pediatric patients undergoing anesthesia, why they are at higher risk than adults, and why reporting chronically underestimates the number of medication errors incurred during the anesthetic care of children. We also introduce the Anesthesia Patient Safety Foundation and Wake Up Safe, two safety organizations that have led the call to decrease medication errors. We discuss various tools to increase medication safety, as championed by Anesthesia Patient Safety Foundation and Wake Up Safe, including human factors research and highlight a few studies that have evaluated and addressed medication safety in the anesthesia environment.

Increasing Cefazolin Use for Perioperative Antibiotic Prophylaxis in Penicillin-Allergic Children

BACKGROUND AND OBJECTIVES

Cefazolin, a first-generation cephalosporin, is the most commonly recommended antibiotic for perioperative prophylaxis to reduce surgical site infections. Children with a reported penicillin allergy often receive an alternative antibiotic because of a common misunderstanding of the cross-reactivity between these antibiotics. This use of alternative antibiotics in surgical populations have been associated with increased infections, antibiotic resistance, and health care costs. We aimed to increase the percentage of patients with nonsevere penicillin-class allergies who receive cefazolin for antibiotic prophylaxis.

METHODS

A multidisciplinary team conducted this quality improvement initiative, with a series of 3 plan-do-study-act cycles aimed at children with nonsevere penicillin-class allergies undergoing surgical procedures that require antibiotic prophylaxis. The primary outcome measure was the percentage of surgical encounters among patients with nonsevere penicillin-class allergies who received cefazolin as antibiotic prophylaxis. Statistical process control charts were used to measure improvement over time.

RESULTS

Approximately 400 children were involved in this project. There was special cause variation and a shift in the center line from 60% to 80% of eligible patients receiving cefazolin for antibiotic prophylaxis, which was sustained for the duration of the project. In the last month, 90% of eligible patient received cefazolin, surpassing our goal of 85%. This improvement has been sustained in the 5 months after project completion. We had no cases of severe allergic reactions in the operating room.

CONCLUSIONS

Our multidisciplinary education-focused interventions were associated with a significant increase in the use of cefazolin for perioperative antibiotic prophylaxis in patient with penicillin allergies.

Management of neonatal difficult airway emergencies in the delivery room

Neonatal airway emergencies in the delivery room are associated with significant morbidity and mortality. Etiologies vary, but often predispose the neonate to life threatening airway obstruction. With the recent expansion of fetal medicine programs, pediatric anesthesiologists are increasingly being asked to care for these patients. In this review, we discuss common etiologies of difficult airway at delivery, management tools and techniques, and surgical approaches.

A retrospective study of the impact of supraglottic airway devices on the appearance of neck masses in children undergoing serial magnetic resonance imaging

BACKGROUND

General anesthesia and sedation are used routinely for magnetic resonance imaging (MRI) studies in children to optimize image quality. Airway devices such as supraglottic airways (SGAs) can alter the appearance of cervical soft tissue regions on an MRI and increase the risk of misdiagnosis. This phenomenon has not been well described in vivo.

AIMS

We conducted this retrospective study to determine how often SGAs affected the appearance of neck masses in children who received multiple anesthetics for MRIs with and without an SGA.

METHODS

We retrieved data on children 17 years old and younger who had multiple MRIs between January 2005 and January 2015. Inclusion criteria were patients with neck masses who had a SGA for at least one MRI and either a natural airway or endotracheal tube (ETT) for another MRI. We reviewed MRI images and imaging reports to determine if SGAs affected the appearance of neck masses.

RESULTS

Twelve of the 921 patients who received anesthesia for neck MRIs during the study period met the inclusion criteria. SGAs affected the appearance of the neck mass in 11 of the 12 patients.

CONCLUSIONS

Supraglottic airways can significantly alter the appearance of neck masses in children undergoing MRIs and affect radiologists' ability to assess those masses. Communication with the radiologist prior to the induction of anesthesia is crucial when using supraglottic devices in this patient population. It may be more prudent to use a different airway device and/or anesthetic technique when MRIs of these neck masses are undertaken.

Risk factors for perioperative mortality and transfusion in sacrococcygeal teratoma resections

BACKGROUND

Sacrococcygeal teratomas are a common congenital tumor. Surgical resection can occur in utero, in the neonatal period, or in the postneonatal period.

AIMS

We describe patient and tumor factors associated with mortality and transfusion in this population.

METHODS

We did a retrospective chart review of patients who underwent sacrococcygeal teratoma resection between January 1998 and March 2016. Demographic data, transfusion data, and tumor characteristics were collected. Descriptive statistics were calculated, and univariate comparisons were performed with chi-square test and Fisher's exact test. Variables significant at univariate level were used in multivariate logistic regression and negative binomial regression.

RESULTS

Of the 112 cases, 6 were in utero repairs, 73 were neonatal repairs, and 33 were repairs at >30 days of life. There was 17%, 1%, and 0% intraoperative mortality and 33%, 5%, and 0% 30-day mortality in the in utero, neonatal, and >30 days of life repairs, respectively. All six patients who died within the first 30 days of life had a postmenstrual age of <32 weeks at time of surgery. All six patients who died had noncystic tumors. Patients with noncystic tumors were more likely to be born prior to 30-week gestation (23/65 vs 6/47; χ² = 7.3; P = 0.007). Gestational age >30 weeks was associated with decreased intraoperative death (0% vs 10%; modified maximum likelihood estimate of OR 0.05; 95% CI 0.002-0.96; P = 0.02). Gestational age >30 weeks (2.4% vs 13.8%; OR 0.15; 95% CI 0.03-0.89; P = 0.04) and cystic morphology (0% vs 9.2%; modified maximum likelihood estimate of OR 0.1; CI 0.01-1.75; P = 0.04) were associated with decreased 30-day mortality and emergent surgery (17.9% vs 1.2%; OR 18; 95% CI 2-162.2; P = 0.004) was associated with increased 30-day mortality. Gestational age >30 weeks (33.7% vs 62.1%; OR 0.27; 95% CI 0.09-0.79; P = 0.02) and Altman class 3-4 (12.1% vs 52.7%; OR 0.1; 95% CI 0.03-0.34; P = 0.0002) were associated with decreased need for transfusion and noncystic tumor was associated with increased transfusion volume (131.6 ml·kg^-1 [95% CI 94-184] vs 63 ml·kg^-1 [95% CI 40-100.1]; P = 0.01).

CONCLUSIONS

Prematurity is associated with increased intraoperative and 30-day mortality. Noncystic tumor morphology was the only significant factor associated with transfusion volume and all six patients who died had transfusion volumes of 240 ml·kg^-1 or greater. In these patients at high risk of mortality due to blood loss, the anesthesia team should be prepared to manage massive transfusion and coagulopathy with blood components and pharmacologic measures.