Nemergut, Michael E.

BACKGROUND: Transfusion-related acute lung injury (TRALI) and transfusion-associated circulatory overload (TACO) are the leading causes of transfusion-related fatalities. While these transfusion-related pulmonary complications (TRPCs) have been well detailed in adults, their burden in pediatric subsets remains poorly defined. We sought to delineate the incidence and epidemiology of pediatric TRPCs after intraoperative blood product transfusion. METHODS: In this retrospective cohort study, we evaluated all consecutive pediatric patients receiving intraoperative blood product transfusions during noncardiac surgeries between January 2010 and December 2014. Exclusion criteria were cyanotic heart disease, preoperative respiratory insufficiency, extracorporeal membrane oxygenation, and American Society of Anesthesiologists physical status VI. Medical records were electronically screened to identify those with evidence of hypoxemia, and in whom a chest x-ray was obtained within 24 hours of surgery. Records were then manually reviewed by 2 physicians to determine whether they met diagnostic criteria for TACO or TRALI. Disagreements were adjudicated by a third senior physician. RESULTS: Of 19,288 unique pediatric surgical patients, 411 were eligible for inclusion. The incidence of TRPCs was 3.6% (95% confidence interval [CI], 2.2–5.9). TACO occurred in 3.4% (95% CI, 2.0–5.6) of patients, TRALI was identified in 1.2% (95% CI, 0.5–2.8), and 1.0% (95% CI, 0.4–2.5) had evidence for both TRALI and TACO. Incidence was not different between males (3.4%) and females (3.8%; P = .815). Although a trend toward an increased incidence of TRPCs was observed in younger patients, this did not reach statistical significance ( P = .109). Incidence was comparable across subsets of transfusion volume ( P = .184) and surgical specialties ( P = .088). Among the 15 patients experiencing TRPCs, red blood cells were administered to 13 subjects, plasma to 3, platelets to 3, cryoprecipitate to 2, and autologous blood to 3. Three patients with TRCPs were transfused mixed blood components. CONCLUSIONS: TRPCs occurred in 3.6% of transfused pediatric surgical patients, with the majority of cases attributable to TACO, congruent with adult literature. The frequency of TRPCs was comparable between genders and across surgical procedures and transfusion volumes. The observed trend toward increased TRPCs in younger children warrants further consideration in future investigations. Red blood cell administration was the associated component for the majority of TRPCs, although platelets demonstrated the highest risk per component transfused. Mitigation of perioperative risk associated with TRPCs in pediatric patients is reliant on further multiinstitutional studies powered to examine patterns and predictors of this highly morbid entity.

Each year millions of young children undergo procedures requiring sedation or general anesthesia. An increasing proportion of the anesthetics used are provided to optimize diagnostic imaging studies such as magnetic resonance imaging. Concern regarding the neurotoxicity of sedatives and anesthetics has prompted the US Food and Drug Administration to change labeling of anesthetics and sedative agents warning against repeated or prolonged exposure in young children. This review aims to summarize the risk of anesthesia in children with an emphasis on anesthetic-related neurotoxicity, acknowledge the value of pediatric neuroimaging, and address this call for conversation.

BACKGROUND: Arthrogryposis syndromes are a heterogeneous group of disorders characterized by congenital joint contractures often requiring multiple surgeries during childhood to address skeletal and visceral abnormalities. Previous reports suggest that these children have increased perioperative risk, including hypermetabolic events discrete from malignant hyperthermia, difficult airway management, isolated hyperthermia, and difficult IV line placement. We sought to compare children with arthrogryposis multiplex congenita (AMC) versus the less severe, distal arthrogryposis syndromes (DAS) and to evaluate possible intraoperative hyperthermia of patients with AMC. We hypothesized that children with AMC had a greater incidence of intraoperative hyperthermia and more difficulty with airway management and IV access. METHODS: Children aged 0 to 25 years with arthrogryposis syndromes who underwent anesthesia from 1972 to 2013 were identified. The medical records were reviewed for demographics, arthrogryposis type, and anesthetic complications. AMC subjects were compared with DAS subjects. To evaluate the probability of hyperthermia and hypermetabolic responses of patients with AMC, we performed a post hoc case–control analysis. Patients with AMC were matched in a 1:2 ratio to patients without arthrogryposis to evaluate the primary outcome of maximum intraoperative temperature. RESULTS: Forty-five patients with AMC and 16 patients with DAS underwent 264 and 105 unique anesthetics, respectively. There was no significant difference in intraoperative hyperthermia or hypermetabolic events (odds ratio [OR], 0.94; 95% confidence interval [CI], 0.36–2.47; P = .90). Children with AMC were more likely to have difficult IV access (OR, 7.1; 95% CI, 1.81–27.90; P = .005). Additional evidence suggested that difficult airway management (OR, 4.06; 95% CI, 1.01–16.39; P = .049) and hemodynamic instability (OR, 4.22; 95% CI, 1.03–17.26; P = .045) were more likely in children with AMC. From post hoc case–control analysis, there was no significant difference in the mean maximum intraoperative temperature (estimated difference +0.04°C; 95% CI, −0.14 to +0.22; P = .64) or odds of intraoperative hyperthermia (OR, 1.49; 95% CI, 0.78–2.82; P = .223) for patients with AMC compared with control subjects. CONCLUSIONS: Children with arthrogryposis syndromes present challenges to the anesthesia and surgical teams, including greater neuromuscular disease burden and challenging peripheral IV placement, with additional evidence suggesting difficult airway management and intraoperative hemodynamic instability. Although more definitive studies are warranted, we did not find evidence of increased odds of intraoperative hyperthermia or hypermetabolic responses.

Objective: No risk prediction model is currently available to measure patient’s probability for readmission to the pediatric intensive care unit (PICU). This retrospective case–control study was designed to assess the applicability of an adult risk prediction score (Stability and Workload Index for Transfer [SWIFT]) and to create a pediatric version (PRediction Of PICU Early Readmissions [PROPER]). Design: Eighty-six unplanned early (<48 hours) PICU readmissions from January 07, 2007, to June 30, 2014, were compared with 170 random controls. Patient- and disease-specific data and PICU workload factors were compared across the 2 groups. Factors statistically significant on multivariate analysis were included in the creation of the risk prediction model. The SWIFT scores were calculated for cases and controls and compared for validation. Results: Readmitted patients were younger, weighed less, and were more likely to be admitted from the emergency department. There were no differences in gender, race, or admission Pediatric Index of Mortality scores. A higher proportion of patients in the readmission group had a Pediatric Cerebral Performance Category in the moderate to severe disability category. Cases and controls did not differ with respect to staff workload at discharge or discharge day of the week; there was a much higher proportion of patients on supplemental oxygen in the readmission group. Only 2 of 5 categories in the SWIFT model were significantly different, and although the median SWIFT score was significantly higher in the readmissions group, the model discriminated poorly between cases and controls (area under the curve: 0.613). A 7-category PROPER score was created based on a multiple logistic regression model. Sensitivity of this model (score ≥12) for the detection of readmission was 81% with a positive predictive value of 0.50. Conclusion: We have created a preliminary model for predicting patients at risk of early readmissions to the PICU from the hospital floor. The SWIFT score is not applicable for predicting the risk for pediatric population.

BACKGROUND AND OBJECTIVES: Ineffective and inefficient patient transfer processes can increase the chance of medical errors. Improvements in such processes are high-priority local institutional and national patient safety goals. At our institution, nonintubated postoperative pediatric patients are first admitted to the postanesthesia care unit before transfer to the PICU. This quality improvement project was designed to improve the patient transfer process from the operating room (OR) to the PICU. METHODS: After direct observation of the baseline process, we introduced a structured, direct OR-PICU transfer process for orthopedic spinal fusion patients. We performed value stream mapping of the process to determine error-prone and inefficient areas. We evaluated primary outcome measures of handoff error reduction and the overall efficiency of patient transfer process time. Staff satisfaction was evaluated as a counterbalance measure. RESULTS: With the introduction of the new direct OR-PICU patient transfer process, the handoff communication error rate improved from 1.9 to 0.3 errors per patient handoff (P = .002). Inefficiency (patient wait time and non–value-creating activity) was reduced from 90 to 32 minutes. Handoff content was improved with fewer information omissions (P &lt; .001). Staff satisfaction significantly improved among nearly all PICU providers. CONCLUSIONS: By using quality improvement methodology to design and implement a new direct OR-PICU transfer process with a structured multidisciplinary verbal handoff, we achieved sustained improvements in patient safety and efficiency. Handoff communication was enhanced, with fewer errors and content omissions. The new process improved efficiency, with high staff satisfaction.

SummaryOver the past decade, numerous preclinical and retrospective human studies have reported that the provision of anesthetic and sedative agents to infants and children may be associated with adverse neurodevelopmental outcomes. These data have gained widespread attention from professional and regulatory agencies, including the public at large. As such, pediatric anesthesiologists are being increasingly questioned by parents about the risks of anesthetic agents on their children's neurocognitive development. To impart a framework from which anesthesiologists may address the apprehensions of parents who actively bring up this issue, we review the data supporting anesthetic neurotoxicity and discuss its strengths and limitations. As many parents are not yet aware and do not actively raise these concerns, we also discuss whether such a conversation should be undertaken as a part of the consent process.