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Graber TJ, Baskin PL, Soria C, Greenberg M, Gabriel RA, Brzenski A. An assessment of perioperative respiratory adverse events and difficult intubation in pediatric patients with Trisomy 21. Paediatr Anaesth 2021; 31:410-418. [PMID: 33484030 DOI: 10.1111/pan.14138] [Citation(s) in RCA: 3] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 12/20/2020] [Accepted: 01/13/2021] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Several prior studies have demonstrated an association between trisomy 21 and airway-related anesthetic complications. However, there is a paucity of large clinical studies characterizing the airway challenges associated with trisomy 21. In this analysis, we examine anesthetic-related airway complications in children with trisomy 21 and compare our findings to well-matched controls. METHODS A chart review of all general anesthetics occurring between 2011 and 2017 at a single pediatric hospital was performed. Children with trisomy 21 were identified. Matched controls were created using a 1:1 propensity score and controlling for patient sex, patient age, surgical specialty, airway management, and anesthetic induction technique. The primary outcomes were the numbers of difficult intubations and perioperative respiratory adverse events. Secondary outcomes included the number of intubation attempts and the Cormack-Lehane grade in each cohort. RESULTS/DATA ANALYSIS A total of 2702 anesthetic records were reviewed. Propensity score matching resulted in adequately matched control groups as indicated by a standard mean difference below 0.2 in each case. Logistic regression analysis between trisomy 21 patients and matched controls demonstrated that the trisomy 21 cohort had a higher incidence of perioperative respiratory adverse events (OR 2.04, 95% CI 1.34-3.09, p = .0008) due largely to a higher incidence of airway obstruction (1.7% vs. 0.2%, p = .0005). The trisomy 21 group had a lower rate of difficult intubation (OR 0.26, 95% CI 0.07-0.91, p = .034). There was no association between trisomy 21 and the number of intubation attempts (RR 0.99, 95% CI 0.88-1.13, p = .92) or Cormack-Lehane grade (RR 0.95, 95% CI 0.87-1.05, p = .35). DISCUSSION The trisomy 21 cohort had an increased incidence of perioperative respiratory adverse events compared to matched controls, largely secondary to a higher rate of obstructed ventilation, but without statistically different rates of laryngospasm, bronchospasm, postextubation stridor, or other desaturation events. Our trisomy 21 cohort had a decreased incidence of difficult intubation. There was no association between trisomy 21 and number of attempts required to successfully place an endotracheal tube or a less favorable CL grade. CONCLUSIONS Compared to matched controls, children with trisomy 21 have a lower incidence of difficult intubation and a higher incidence of perioperative respiratory adverse events, largely due to increased rate of airway obstruction.
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Affiliation(s)
- Taylor J Graber
- Department of Anesthesiology, University of California, San Diego, CA, USA
| | | | - Claire Soria
- Department of Anesthesiology, University of California, San Diego, CA, USA.,Rady Children's Hospital San Diego, San Diego, CA, USA
| | - Mark Greenberg
- Department of Anesthesiology, University of California, San Diego, CA, USA.,Rady Children's Hospital San Diego, San Diego, CA, USA
| | - Rodney A Gabriel
- Department of Anesthesiology, University of California, San Diego, CA, USA
| | - Alyssa Brzenski
- Department of Anesthesiology, University of California, San Diego, CA, USA.,Rady Children's Hospital San Diego, San Diego, CA, USA
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Frugoni B, Gabriel RA, Rafaat K, Abanobi M, Rantael B, Brzenski A. A predictive model for prolonged hospital length of stay in surgical burn patients. Burns 2020; 46:1565-1570. [PMID: 32430185 DOI: 10.1016/j.burns.2020.04.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [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: 10/28/2019] [Accepted: 04/15/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Improvement in the care of burn patients has led to decreased mortality. Length of stay (LOS) has been used as a marker for quality of care in this population. However, the historical association of LOS as correlating only with % burn surface area (BSA) injury has been questioned with retrospective data suggesting other factors may also be associated with LOS. A model to predict prolonged LOS does not exist but could provide important information for clinicians and patients. METHODS Data from January 2014 to December 2016 was used to develop a predictive model utilizing multivariable logistic regression. Prolonged hospital LOS was the outcome used with multiple covariates utilized to identify various associations. Odds ratios (OR) and their associated 95% confidence interval (CI) were reported for each covariate in the final regression model. Model performance in both the training and validation sets was evaluated using area under the receiver operating characteristic (ROC) curve (AUC) for discrimination and the Hosmer-Lemeshow (HL) test for goodness-of-fit. RESULTS A total of 441 patients was included in the final analysis, 296 (67.1%) of which were in the training set. Within the training set, the median hospital LOS was 14 days with a range of 4 to 205 days. Patient age (in decades), hypertension, total BSA, involvement of perineum, and abnormal white blood cell count were independent risk factors for prolonged hospital length of stay. When using this separate dataset, the model had an AUC of 0.81 (95% CI 0.74-0.88) and had good calibration based on the HL-test (p=0.10). CONCLUSIONS Prolonged hospitalization following burns is predicted by patient age (in decades), TBSA, hypertension, perineal involvement, and abnormal white blood cell count.
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Affiliation(s)
- Brian Frugoni
- Department of Anesthesiology, University of California, San Diego, La Jolla, CA, United States
| | - Rodney A Gabriel
- Department of Anesthesiology, University of California, San Diego, La Jolla, CA, United States; Division of Biomedical Informatics, University of California, San Diego, La Jolla, CA, United States; Outcomes Research Consortium, Cleveland, OH, United States
| | - Karim Rafaat
- Department of Anesthesiology, University of California, San Diego, La Jolla, CA, United States
| | - Mary Abanobi
- Department of Anesthesiology, University of California, San Diego, La Jolla, CA, United States
| | - Brian Rantael
- Department of Anesthesiology, University of California, San Diego, La Jolla, CA, United States
| | - Alyssa Brzenski
- Department of Anesthesiology, University of California, San Diego, La Jolla, CA, United States
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Fernandez AM, Reddy SK, Gordish-Dressman H, Muldowney BL, Martinez JL, Chiao F, Stricker PA, Abruzzese C, Apuya J, Beethe A, Benzon H, Binstock W, Brzenski A, Budac S, Busso V, Chhabada S, Cladis F, Claypool D, Collins M, Dabek R, Dalesio N, Falcon R, Fernandez P, Fiadjoe J, Gangadharan M, Gentry K, Glover C, Goobie SM, Gosman A, Grap S, Gries H, Griffin A, Haberkern C, Hajduk J, Hall R, Hansen J, Hetmaniuk M, Hsieh V, Huang H, Ingelmo P, Ivanova I, Jain R, Kars M, Kowalczyk-Derderian C, Kugler J, Labovsky K, Lakheeram I, Lee A, Masel B, Medellin E, Meier P, Mitzel Levy H, Muhly WT, Nelson J, Nicholson J, Nguyen KP, Nguyen T, Olutuye O, Owens-Stubblefield M, Ramesh Parekh U, Petersen T, Pohl V, Post J, Poteet-Schwartz K, Prozesky J, Reid R, Ricketts K, Rubens D, Ryan L, Skitt R, Soneru C, Spitznagel R, Singh D, Singhal NR, Sorial E, Staudt S, Stubbeman B, Sung W, Syed T, Szmuk P, Taicher BM, Thompson D, Tretault L, Ungar-Kastner G, Watts R, Wieser J, Wong K, Zamora L. Perioperative Outcomes and Surgical Case Volume in Pediatric Complex Cranial Vault Reconstruction. Anesth Analg 2019; 129:1069-1078. [DOI: 10.1213/ane.0000000000003515] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [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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Goobie S, Zurakowski D, Isaac K, Taicher B, Fernandez P, Derderian C, Hetmaniuk M, Stricker P, Abruzzese C, Apuya J, Beethe A, Benzon H, Binstock W, Brzenski A, Budac S, Busso V, Chhabada S, Chiao F, Cladis F, Claypool D, Collins M, Dabek R, Dalesio N, Falconl R, Fernandez A, Fernandez P, Fiadjoe J, Gangadharan M, Gentry K, Glover C, Goobie SM, Gosman A, Grap S, Gries H, Griffin A, Haberkern C, Hajduk J, Hall R, Hansen J, Hetmaniuk M, Hsieh V, Huang H, Ingelmo P, Ivanova I, Jain R, Kars M, Kowalczyk-Derderian C, Kugler J, Labovsky K, Lakheeram I, Lee A, Martinez JL, Masel B, Medellin E, Meier P, Levy HM, Muhly WT, Muldowney B, Nelson J, Nicholson J, Nguyen KP, Nguyen T, Olutuye O, Owens-Stubblefield M, Parekh UR, Petersen T, Pohl V, Post J, Poteet-Schwartz K, Prozesky J, Reddy S, Reid R, Ricketts K, Rubens D, Ryan L, Skitt R, Soneru C, Spitznagel R, Stricker P, Singh D, Singhal NR, Sorial E, Staudt S, Stubbeman B, Sung W, Syed T, Szmuk P, Taicher BM, Thompson D, Tretault L, Ungar-Kastner G, Watts R, Wieser J, Wong K, Zamora L. Predictors of perioperative complications in paediatric cranial vault reconstruction surgery: a multicentre observational study from the Pediatric Craniofacial Collaborative Group. Br J Anaesth 2019; 122:215-223. [DOI: 10.1016/j.bja.2018.10.061] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Revised: 10/03/2018] [Accepted: 10/15/2018] [Indexed: 11/24/2022] Open
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Thompson DR, Zurakowski D, Haberkern CM, Stricker PA, Meier PM, Bannister C, Benzon H, Binstock W, Bosenberg A, Brzenski A, Budac S, Busso V, Capehart S, Chiao F, Cladis F, Collins M, Cusick J, Dabek R, Dalesio N, Falcon R, Fernandez A, Fernandez P, Fiadjoe J, Gangadharan M, Gentry K, Glover C, Goobie S, Gries H, Griffin A, Groenewald CB, Hajduk J, Hall R, Hansen J, Hetmaniuk M, Hsieh V, Huang H, Ingelmo P, Ivanova I, Jain R, Koh J, Kowalczyk-Derderian C, Kugler J, Labovsky K, Martinez JL, Mujallid R, Muldowney B, Nguyen KP, Nguyen T, Olutuye O, Soneru C, Petersen T, Poteet-Schwartz K, Reddy S, Reid R, Ricketts K, Rubens D, Skitt R, Sohn L, Staudt S, Sung W, Syed T, Szmuk P, Taicher B, Tetreault L, Watts R, Wong K, Young V, Zamora L. Endoscopic Versus Open Repair for Craniosynostosis in Infants Using Propensity Score Matching to Compare Outcomes: A Multicenter Study from the Pediatric Craniofacial Collaborative Group. Anesth Analg 2018; 126:968-975. [PMID: 28922233 DOI: 10.1213/ane.0000000000002454] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND The North American Pediatric Craniofacial Collaborative Group (PCCG) established the Pediatric Craniofacial Surgery Perioperative Registry to evaluate outcomes in infants and children undergoing craniosynostosis repair. The goal of this multicenter study was to utilize this registry to assess differences in blood utilization, intensive care unit (ICU) utilization, duration of hospitalization, and perioperative complications between endoscopic-assisted (ESC) and open repair in infants with craniosynostosis. We hypothesized that advantages of ESC from single-center studies would be validated based on combined data from a large multicenter registry. METHODS Thirty-one institutions contributed data from June 2012 to September 2015. We analyzed 1382 infants younger than 12 months undergoing open (anterior and/or posterior cranial vault reconstruction, modified-Pi procedure, or strip craniectomy) or endoscopic craniectomy. The primary outcomes included transfusion data, ICU utilization, hospital length of stay, and perioperative complications; secondary outcomes included anesthesia and surgical duration. Comparison of unmatched groups (ESC: N = 311, open repair: N = 1071) and propensity score 2:1 matched groups (ESC: N = 311, open repair: N = 622) were performed by conditional logistic regression analysis. RESULTS Imbalances in baseline age and weight are inherent due to surgical selection criteria for ESC. Quality of propensity score matching in balancing age and weight between ESC and open groups was assessed by quintiles of the propensity scores. Analysis of matched groups confirmed significantly reduced utilization of blood (26% vs 81%, P < .001) and coagulation (3% vs 16%, P < .001) products in the ESC group compared to the open group. Median blood donor exposure (0 vs 1), anesthesia (168 vs 248 minutes) and surgical duration (70 vs 130 minutes), days in ICU (0 vs 2), and hospital length of stay (2 vs 4) were all significantly lower in the ESC group (all P < .001). Median volume of red blood cell administered was significantly lower in ESC (19.6 vs 26.9 mL/kg, P = .035), with a difference of approximately 7 mL/kg less for the ESC (95% confidence interval for the difference, 3-12 mL/kg), whereas the median volume of coagulation products was not significantly different between the 2 groups (21.2 vs 24.6 mL/kg, P = .73). Incidence of complications including hypotension requiring treatment with vasoactive agents (3% vs 4%), venous air embolism (1%), and hypothermia, defined as <35°C (22% vs 26%), was similar between the 2 groups, whereas postoperative intubation was significantly higher in the open group (2% vs 10%, P < .001). CONCLUSIONS This multicenter study of ESC versus open craniosynostosis repair represents the largest comparison to date. It demonstrates striking advantages of ESC for young infants that may result in improved clinical outcomes, as well as increased safety.
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Affiliation(s)
- Douglas R Thompson
- From the Department of Anesthesiology and Pain Medicine, University of Washington-Seattle Children's Hospital, Seattle, Washington
| | - David Zurakowski
- Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Charles M Haberkern
- From the Department of Anesthesiology and Pain Medicine, University of Washington-Seattle Children's Hospital, Seattle, Washington.,Department of Pediatrics (adj.), University of Washington-Seattle Children's Hospital, Seattle, Washington
| | - Paul A Stricker
- Department of Anesthesiology and Critical Care, The Children's Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Petra M Meier
- Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
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Goobie SM, Cladis FP, Glover CD, Huang H, Reddy SK, Fernandez AM, Zurakowski D, Stricker PA, Gries H, Soneru C, Falcon R, Petersen T, Kowalczyk‐Derderian C, Dalesio N, Budac S, Groenewald N, Rubens D, Thompson D, Watts R, Gentry K, Ivanova I, Hetmaniuk M, Hsieh V, Collins M, Wong K, Binstock W, Reid R, Poteet‐Schwartz K, Gries H, Hall R, Koh J, Colpitts K, Scott L, Bannister C, Sung W, Jain R, Chaudhry R, Fernandez A, Tuite GF, Ruas E, Drozhinin O, Tetreault L, Muldowney B, Ricketts K, Fernandez P, Sohn L, Hajduk J, Taicher B, Burkhart J, Wright A, Kugler J, Barajas‐DeLoa L, Gangadharan M, Busso V, Stallworth K, Staudt S, Labovsky K, Glover C, Huang H, Karlberg‐Hippard H, Capehart S, Streckfus C, Nguyen K, Manyang P, Martinez JL, Hansen J, Brzenski A, Chiao F, Ingelmo P, Mujallid R, Bosenberg A, Meier P, Haberkern C, Nguyen T, Benzon H. Safety of antifibrinolytics in cranial vault reconstructive surgery: a report from the pediatric craniofacial collaborative group. Paediatr Anaesth 2017; 27:271-281. [PMID: 28211198 DOI: 10.1111/pan.13076] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [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] [Accepted: 11/14/2016] [Indexed: 11/26/2022]
Abstract
BACKGROUND Antifibrinolytic therapy significantly decreases blood loss and transfusion in pediatric cranial vault reconstructive surgery; however, concern regarding the side effects profile limits clinical use. AIMS The aim was to utilize the Pediatric Craniofacial Surgery Perioperative Registry database to identify the safety profile of antifibrinolytic therapy for cranial vault reconstructive surgery by reporting the incidence of adverse events as they relate to exposure to tranexamic acid and aminocaproic acid compared to no exposure to antifibrinolytics. METHODS The database was queried for cases of open cranial vault reconstructive surgery. Less invasive procedures such as neuro-endoscopic and spring-mediated cranioplasties were excluded. The outcomes evaluated included any perioperative neurological adverse event including seizures or seizure-like movements and thromboembolic events. RESULTS Thirty-one institutions reported a total of 1638 cases from 2010 to 2015. Total antifibrinolytic administration accounted for 59.5% (tranexamic acid, 36.1% and aminocaproic acid, 23.4%), with 40.5% not receiving any antifibrinolytic. The overall incidence of postoperative seizures or seizure-like movements was 0.6%. No significant difference was detected in the incidence of postoperative seizures between patients receiving tranexamic acid and those receiving aminocaproic acid [the odds ratio for seizures being 0.34 (95% confidence interval: 0.07-1.85) controlling for American Society of Anesthesia (ASA) physical class] nor in patients receiving antifibrinolytics compared to those not administered antifibrinolytics (the odds ratio for seizures being 1.02 (confidence interval 0.29-3.63) controlling for ASA physical class). One complicated patient in the antifibrinolytic group with a femoral venous catheter had a postoperative deep venous thrombosis. CONCLUSIONS This is the first report of an incidence of postoperative seizures of 0.6% in pediatric cranial vault reconstructive surgery. There was no significant difference in postoperative seizures or seizure-like events in those patients who received the tranexamic acid or aminocaproic acid vs those that did not. This report provides evidence of the safety profile of antifibrinolytic in children having noncardiac major surgery. Caution should prevail however in using antifibrinolytic in high-risk patients. Antifibrinolytic dosage regimes should be based on pharmacokinetic data avoiding high doses.
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Affiliation(s)
- Susan M Goobie
- Department of Anesthesiology, Critical Care, Perioperative and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Franklyn P Cladis
- Department of Anesthesiology, The Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Chris D Glover
- Department of Anesthesiology, Texas Children's Hospital, Houston, TX, USA
| | - Henry Huang
- Department of Anesthesiology, Texas Children's Hospital, Houston, TX, USA
| | - Srijaya K Reddy
- Division of Anesthesiology, Children's National Health System, Washington, DC, USA
| | - Allison M Fernandez
- Department of Anesthesiology, Johns Hopkins All Children's Hospital, St Petersburg, FL, USA
| | - David Zurakowski
- Department of Anesthesiology, Critical Care, Perioperative and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Paul A Stricker
- Department of Anesthesiology and Critical Care, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
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