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Background and Purpose: Tonsillectomy procedures are commonly performed worldwide. At our academic tertiary care facility, we perform approximately 1000 tonsillectomy procedures annually. We have found inconsistent pain management strategies in pediatric tonsillectomy patients have contributed to variability in postoperative complications and the number and types of postoperative pain medications required in the Post Anesthesia Care Unit (PACU). This project aimed to assess the impact of implementing a standardized perioperative pain management protocol on reducing postoperative complications in pediatric patients who underwent a tonsillectomy procedure. Methods: A pre‐post‐intervention design was utilized, comparing characteristics and outcomes of pediatric patients for whom a standardized perioperative pain management protocol was implemented over a 12‐week period compared to those who did not. The standardized perioperative pain management protocol was utilized intraoperatively by the anesthesiologists, nurse anesthetists, and residents. A Qualtrics survey was used by the Post Anesthesia Care Unit (PACU) nurses to gather data as they cared for patients who underwent tonsillectomy. Four outcomes were measured: (1) postoperative pain medication administration, (2) rate of postoperative respiratory complications, (3) rate of adherence, and (4) usability of a standardized pain management protocol. Data were compared between pre and post‐implementation groups. Results: During the quality improvement project, 180 children underwent tonsillectomy, with 81 in the control group and 99 in the intervention group. The median age did not differ between groups. The control group had higher postoperative opioid medication usage (93.8% vs. 54.5%) and a higher number of opioids administered in the recovery room. Postoperative IV fentanyl was reduced in the intervention group (49.4% vs. 28.3% in the intervention, p =.004). Respiratory interventions were more frequent in the control group (24.7% vs. 7.1%), with increased respiratory team activation. Respiratory team activation in the Post Anesthesia Care Unit (PACU) includes a 511 page for anesthesia provider assistance. Respiratory interventions included bag‐mask ventilation, lidocaine, propofol or succinylcholine administration, and reintubation. The intervention group had 100% adherence to the pain management protocol, and providers found it easy to use. Conclusion: The quality improvement project highlighted notable improvements in the intervention group for whom a standardized perioperative pain management protocol was used, including reduced opioid medication administration, lower incidence of respiratory interventions, and high adherence to the pain management protocol. These findings underscore the effectiveness and feasibility of standardized protocols in enhancing patient outcomes. [ABSTRACT FROM AUTHOR]

Background Although serious complications during pediatric anesthesia are less common than they were 20 years ago, serious airway events continue to occur. Based on Quality Improvement ( QI) data from our institution, a QI project was designed to reduce the incidence of serious airway events and airway cardiac arrests. Methods A quality improvement team consisting of members of the Department of Anesthesia was formed and QI data from previous years were analyzed. The QI team developed a Smart Aim, Key Driver Diagram, and specific Interventions that focused on the accessibility of emergency drugs, the use of nondepolarizing muscle relaxants for endotracheal intubation in children 2 years and younger, and the presence of anesthesia providers until emergence from anesthesia in high-risk patients. Results The percentage of cases where muscle relaxants were utilized in children 2 years and younger for endotracheal intubation and where atropine and succinylcholine were readily available increased at both our base and outpatient facilities. Over the 2.5-year study period, the incidence of serious airway events and airway cardiac arrests was reduced by 44% and 59%, respectively compared to the previous 2-year period. Conclusion We utilized QI methodology to design and implement a project which led to greater standardization of clinical practice within a large pediatric anesthesia group. Based on an understanding of system issues impacting our clinical practice, we designed and tested interventions that led to a significant reduction in the incidence of serious airway events and airway cardiac arrests. [ABSTRACT FROM AUTHOR]

Background Rate of perioperative respiratory complications between tracheal intubation ( TI) and laryngeal mask airway remains unclear during pediatric anesthesia. Objectives The aim of the present meta-analysis was to compare the perioperative respiratory complications between laryngeal mask airway and TI. Methods A meta-analysis of available controlled studies comparing laryngeal mask airway to TI was conducted. Studies including patients with airway infection were excluded. Data from each trial were combined to calculate the pooled odds ratios ( OR) or mean difference ( MD) and 95% confidence intervals. Results The meta-analysis was performed on 19 studies. In 12 studies, patients were given muscle relaxation, and in 16 studies, ventilation was controlled. During recovery from anesthesia, the incidence of desaturation ( OR = 0.34 [0.19-0.62]), laryngospasm ( OR = 0.34 [0.2-0.6]), cough ( OR = 0.18 [0.11-0.27]), and breath holding (0.19 [0.05-0.68]) was lower when laryngeal mask airway was used to secure the airway. Postoperative incidences of sore throat ( OR = 0.87 [0.53-1.44]), bronchospasm ( OR = 0.56 [0.25-1.25]), aspiration (1.33 [0.46-3.91]) and blood staining on the device ( OR = 0.62 [0.21-1.82]) did not differ between laryngeal mask airway and TI. Results were homogenous across the studies, with the exceptions of blood staining on the device. Conclusions This meta-analysis found that the use of laryngeal mask airway in pediatric anesthesia results in a decrease in a number of common postanesthetic complications. It is therefore a valuable device for the management of the pediatric airway. [ABSTRACT FROM AUTHOR]

Background: A continuous epidural infusion of morphine is the pain treatment modality for children undergoing selective dorsal rhizotomy (SDR) in our institution. The aim of the study was to evaluate the impact of having an organized acute pain service (APS) on postoperative pain management of these children. Methods: We conducted a retrospective cohort study using anesthetic records and the APS database to compare the postoperative pain management of children undergoing SDR before and after the introduction of the APS at the Montreal Children’s Hospital in April 2001. Ninety-two consecutive children who had their surgery between January 1997 and July 2006 were included. We collected data regarding postoperative pain, opioid-induced side effects, complications (sedation, desaturations < 92%), and hospital length of stay. Results: Pain scores were documented more frequently after the implementation of the APS (61% vs 48.5%). Sedation scores were documented only after the implementation of the APS. Postoperative desaturation was significantly more frequent in the pre-APS group compared to the APS group (45.5% vs 6.8%, P < 0.001). Despite the fact that the epidural catheter was in place for the same duration for both groups [median of 3 days (3–3 25–75%ile)], the duration of hospitalization was 1 day shorter in the APS group compared to the pre-APS group [median of 5 (5–5 25–75%ile) vs 6 (5–6 25–75%ile) days, P < 0.001]. Conclusions: Although we recognize that it is possible that there were changes in care not related specifically to the introduction of a dedicated APS that occurred in our institution that resulted in improvements in general postoperative care and in length of stay, our study did show that having an organized APS allowed to significantly decrease the incidence of postoperative oxygen desaturation and to decrease the hospital length of stay by 1 day. [ABSTRACT FROM AUTHOR]

Background: Premedication with β-2 agonists (e.g. salbutamol) is effective in preventing increases in total respiratory resistance and in decreasing the incidence of perioperative bronchospasm in asthmatic children. Because children with recent respiratory tract infection (RTI) exhibit bronchial hyperreactivity similar to that observed in asthmatic children, the use of salbutamol in children with RTI has become popular among pediatric anesthetists for the prevention of perioperative respiratory adverse events (PRAE). In a prospective observational study, we therefore assessed the usefulness of salbutamol premedication on the occurrence of PRAE. Methods: Results from 600 children (0–16 years) undergoing general anesthesia were analyzed: 200 children with a recent RTI who received preoperative salbutamol 10–30 min prior to surgery, 200 children with a recent RTI without salbutamol premedication, and 200 children without a RTI during the last 4 weeks. All PRAE (laryngospasm, bronchospasm, oxygen desaturation [<95%], severe coughing) were recorded. Results: Children with a recent RTI who received salbutamol demonstrated a significantly reduced incidence of perioperative bronchospasm (5.5% vs 11%, P = 0.0270) and severe coughing (5.5% vs 11.5%, P = 0.0314) compared with children who had an RTI but did not receive salbutamol. However, healthy children presented with the lowest rate (bronchospasm 1.5%, severe coughing 4.5%) of respiratory complications compared with children with a recent RTI independent whether or not they received salbutamol preoperatively. Conclusions: The results from this audit suggest that children with a history of a recent RTI have significantly less PRAE following a premedication with salbutamol compared with no premedication. Therefore, premedication with salbutamol might be considered in children with recent RTI. [ABSTRACT FROM AUTHOR]

Adverse respiratory events remain one of the major causes of morbidity during anaesthesia, especially in children. The purpose of this prospective study was to determine the incidence of perioperative respiratory adverse events (PRAE) during elective paediatric surgery and to identify the risk factors for these events. Potential risk factors (atopy, eczema, rhinitis, food allergy, previous allergic tests, pollens or animal allergy, passive smoking, obstructive sleep disorders) were assessed using the International Society on Allergy and Asthma (ISAAC) questionnaire, which was submitted to the parents during preoperative anaesthetic assessment. Anaesthetic and surgical conditions were systematically recorded. A multivariate logistic regression explaining PRAE was developed in 800 children. The intraoperative incidence of respiratory adverse events was 21% and the incidence in the postanesthetic care unit was 13%. According to the multivariate analysis, children not anaesthetized by a specialist paediatric anaesthesiologist have 1.7 increased risk to present PRAE (95% CI = 1.13–2.57). Children anaesthetized for ear, nose, throat (ENT) surgery had a 1.57-fold higher risk of PRAE compared with other procedures (95% CI = 1.01–2.44). Furthermore, there was a synergistic interaction when two risk factors: residents and ENT surgery, were concomitant: the odds ratio (OR) of PRAE during non-ENT surgical procedures was 1.43 (95% CI = 0.91–2.24), but increased to 2.74-fold (95% CI = 1.15–4.32) for ENT surgery. The risk of PRAE was significantly lower when the anaesthetic technique included tracheal intubation with relaxants (OR = 0.6, 95% CI = 0.45–0.95) and decreased by 8% with each increasing year of age. This study demonstrates a high incidence of PRAE in paediatric surgical patients without respiratory tract infections, which appears to be primarily determined by the age of the child and the anaesthetic care rather than by the child's medical history. [ABSTRACT FROM AUTHOR]