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Perioperative anxiety and distress are common in pediatric patients undergoing general anesthesia and increase the risk for immediate and long‐term postoperative complications. This concise review outlines key research and clinically‐relevant scales that measure pediatric perioperative affect. Strengths and weaknesses of each scale are highlighted. A literature review identified 11 articles with the following inclusion criteria: patients less than or equal to 18 years, perioperative anxiety or distress, and original studies with reliability or validity data. Although robust research‐based assessment tools to measure anxiety have been developed, such as the Modified Yale Preoperative Anxiety Scale, they are too complex and time‐consuming to complete by clinicians also providing anesthesia. Clinically‐based anxiety measurement scales tend to be easier to use, however they require further testing before widespread standard utilization. The HRAD ± scale (Happy, Relaxed, Anxious, Distressed, with a yes/no answer to cooperation) may be a promising observational anxiety scale that is efficient and includes an assessment of compliance. Further studies are needed to refine a clinically‐relevant anxiety assessment tool and appraise interventions that reduce perioperative distress. [ABSTRACT FROM AUTHOR]

Background: Children undergoing cleft palate repair present challenges to postoperative management due to several factors that can complicate recovery. Utilization of multimodal analgesic protocols can improve outcomes in this population. We report experience designing and implementing an enhanced recovery after surgery (ERAS) pathway for cleft palate repair to optimize postoperative recovery. Aims: The primary aim was to implement an ERAS pathway with >70% bundle adherence to achieve a 30% reduction in postoperative opioid consumption within 12 months. Our secondary aims assessed intraoperative opioid consumption, length of stay, timeliness of oral intake, and respiratory recovery. Methods: A multidisciplinary team of perioperative providers developed an ERAS pathway for cleft palate patients. Key drivers included patient and provider education, formal pathway creation and implementation, multimodal pain therapy, and target‐based care. Interventions included maxillary nerve blockade and enhanced intra‐ and postoperative medication regimens. Outcomes were displayed as statistical process control charts. Results: Pathway compliance was 77.0%. Patients during the intervention period (n = 39) experienced a 49% reduction in postoperative opioid consumption (p <.0001) relative to our historical cohort (n = 63), with a mean difference of −0.33 ± 0.11 mg/kg (95% CI −0.55 to −0.12 mg/kg). Intraoperative opioid consumption was reduced by 36% (p =.002), with a mean difference of −0.27 ± 0.09 mg/kg (95% CI −0.45 to −0.09 mg/kg). Additionally, patients in the intervention group had a 45% reduction in time to first oral intake (p =.02) relative to our historical cohort, with a mean difference of −3.81 ± 1.56 h (95% CI −6.9 to −0.70). There was no difference in PACU or hospital length of stay, but there was a significant reduction in variance of all secondary outcomes. Conclusion: Opioid reduction and improved timeliness of oral intake is possible with an ERAS protocol for cleft palate repair, but our protocol did not alter PACU or hospital length of stay. [ABSTRACT FROM AUTHOR]

Background: Many medical specialties have found publication misrepresentation in residency and fellowship applications, but pediatric anesthesia fellowship application data is lacking. Aims: We sought to determine the prevalence of publication misrepresentation among pediatric anesthesia fellowship applications. Methods: In this retrospective cohort study, fellowship applications to Stanford University's pediatric anesthesiology fellowship program from 2009 to 2019 were reviewed. Only peer‐reviewed journal articles listed as accepted or published were included. Nine additional variables were collected: applicant age, gender, citizenship status, American vs. international medical school, public vs. private medical school, allopathic doctor versus osteopathic doctor, number of years between college and medical school, additional degrees, and application year. The primary outcome was the rate of publication misrepresentation, defined as peer‐reviewed journal citations listed on the application that could not be verified or on which the applicant was not listed as an author. Secondary outcomes were the associations between publication misrepresentation and the additional collected variables. Results: 1280 peer‐reviewed journal publications from 877 applicants were reviewed. 3.4% of all citations listed as peer‐reviewed journal articles were misrepresented and 9.0% of all applicants with at least 1 publication had ≥1 misrepresented publications. 30.2% of publications labelled "misrepresented" were located in our search of databases but did not have the applicant as an author, and 69.8% could not be located using the search databases. Only one of the 9 collected variables (public vs private medical school) was significantly associated with publication misrepresentation. Conclusions: In this single‐center retrospective study, publication misrepresentation was found to occur in one out of 11 pediatric anesthesia fellowship applications with at least one publication. Since residency and fellowship applicant publications may be heavily weighted during the application process, programs may want to include additional inquiries into the accuracy of applicant publications. [ABSTRACT FROM AUTHOR]

Background: Uncooperative pediatric mask induction is linked to perioperative anxiety. Although some risk factors for uncooperative inductions have been reported, there are no large cohort studies that identify intrinsic patient characteristics associated with cooperation. Aim: The primary aim was to identify patient characteristics associated with cooperative mask inductions. The secondary aim was to determine whether preoperative interventions were associated with increased cooperation. Methods: This retrospective cohort study included patients 2‐11 years old and ASA class I‐IV who underwent mask induction. Our primary outcome of interest was cooperation with mask induction, which was correlated against the Induction Compliance Checklist. The variables analyzed for association with cooperation were age, sex, ASA class, class of surgery, preferred language, and race. Interventions examined for association with induction cooperation included premedication with midazolam, exposure to distraction technology, parental presence, and the presence of a Child Life Specialist. Multivariate mixed‐effects logistic regression was used to assess the relationship between patient characteristics and cooperation. A separate multivariate mixed‐effects logistic regression was used to examine the association between preoperative interventions and cooperation. Results: 9692 patients underwent 23 474 procedures during the study period. 3372 patients undergoing 5980 procedures met inclusion criteria. The only patient characteristic associated with increased cooperation was age (OR 1.20, p‐value 0.03). Involvement of Child Life Specialists was associated with increased cooperation (OR 4.44, p‐value = 0.048) while parental/guardian presence was associated with decreased cooperation (OR 0.38, p‐value = 0.002). Conclusion: In this cohort, increasing age was the only patient characteristic found to be associated with increased cooperation with mask induction. Preoperative intervention by a Child Life Specialists was the sole intervention associated with improved cooperation. [ABSTRACT FROM AUTHOR]

Background: Vascular access is a minor procedure that is associated with reported pain and fear in pediatric patients, often resulting in procedural incompliance. Virtual reality has been shown to be effective in adult populations for reducing pain and anxiety in various medical settings, although large studies are lacking in pediatrics. Aims: The primary aim was to determine whether pain would be reduced in pediatric patients using virtual reality undergoing vascular access. The four secondary aims measured patient fear, procedural compliance, satisfaction, and adverse events. Methods: A prospective, randomized, controlled trial was completed at a pediatric hospital, enrolling children 7‐18 years old undergoing vascular access in a variety of clinical settings, randomized to virtual reality or standard of care. Pain scores were measured using a numeric pain faces scale. The secondary outcomes of patient fear, procedural compliance, satisfaction, and adverse events were measured with the Child Fear Scale, modified Induction Compliance Checklist, and satisfaction surveys, respectively. Chi‐squared, t tests, and regression models were used to analyze the results. Results: The analysis included 106 patients in the virtual reality group and 114 in the control. There were no significant differences in postprocedure pain (VR group estimated 0.11 points lower, 95% confidence interval: 0.50 points lower to 0.28 points greater, P =.59), postprocedure fear (VR group estimated 0.05 points lower, 95% confidence interval: 0.23 points lower to 0.13 points greater), or compliance (adjusted odds ratio 2.31, 95% confidence interval: 0.96‐5.56). Children in the virtual reality group were satisfied with the intervention. There were no adverse events. Conclusion: This study demonstrates no reduction in pain while using Virtual reality (VR) across a heterogeneous pediatric inpatient population undergoing vascular access. [ABSTRACT FROM AUTHOR]

This case series examines interactive AR during minor otolaryngologic procedures. Although VR has been successfully used for pediatric vascular access, removing children from comforting people in the real world has resulted in patient anxiety. AR offers a potential advantage, utilizing distracting holographic images when patients maintain eye contact with parents. The primary objective was to determine the effect of AR on fear during pediatric otolaryngologic procedures. Secondary objectives included evaluating pain; procedure compliance; and patient, parent and physician attitudes toward AR, as well as assessing the feasibility of adding AR to a busy outpatient otolaryngologic clinic. Laryngoscope, 131:E1342–E1344, 2021 [ABSTRACT FROM AUTHOR]

Keywords: acute; chronic; induction of anesthesia; PAIN EN acute chronic induction of anesthesia PAIN 1276 1277 2 11/14/22 20221201 NES 221201 INTRODUCTION The recent meta-analysis by Van Eijk et al. is a welcome addition to the rapidly expanding knowledge regarding the usefulness of virtual reality (VR) for the treatment of pediatric pain and anxiety. Despite these recurring opportunities in VR research, those that regularly use these technologies (these authors included) can attest to the dramatic, and sometimes transformative impact of VR when paired with the "right" patient in the "right" clinical context. [Extracted from the article]

Background: Accurate intraoperative antibiotic redosing contributes to prevention of surgical site infections in pediatric patients. Ensuring compliance with evolving national guidelines of weight‐based, intraoperative redosing of antibiotics is challenging to pediatric anesthesiologists. Aims: Our primary aim was to increase compliance of antibiotic redoses at the appropriate time and appropriate weight‐based dose to 70%. Secondary aims included a subset analysis of time compliance and dose compliance individually, and compliance based on order entry method of the first dose (verbal or electronic). Methods: At a freestanding, academic pediatric hospital, we reviewed surgical cases between May 1, 2014, and October 31, 2017 requiring antibiotic redoses. After an institutional change in cefazolin dosing in May 2015, phased interventions to improve compliance included electronic countermeasures to display previous and next dose timing, an alert 5 minutes prior to next dose, and weight‐based dose recommendation (September 2015). Physical countermeasures include badge cards, posting of guidelines, and updates to housestaff manual (September 2015). Statistical process control charts were used to assess overall antibiotic redose compliance, time compliance, and dose compliance. The chi‐square test was used to analyze group differences. Results: A total of 3015 antibiotic redoses were administered during 2341 operative cases between May 1, 2014, and October 31, 2017. Mean monthly compliance with redosing was 4.3% (May 2014‐April 2015) and 73% (November 2015‐October 2017) (P < 0.001). Dose‐only compliance increased from 76% to 89% (P < 0.001), and time‐only compliance increased from 4.9% to 82% (P < 0.001). After implementation of countermeasures, electronic order entry compared with verbal order was associated with higher dose compliance, 90% vs 86% (P = 0.015). Conclusion: This quality improvement project, utilizing electronic and physical interventions, was effective in improving overall prophylactic antibiotic redosing compliance in accordance with institutional redosing guidelines. [ABSTRACT FROM AUTHOR]

Summary: Background: Preoperative anxiety affects up to 65% of children who undergo anesthesia induction and often results in uncooperative behavior. Electronic devices have been used to distract children to reduce anxiety and create a more enjoyable preoperative experience. Few studies have compared the effects of different video delivery systems on preoperative anxiety. Aims: The primary aim was to determine if a large projection‐based video screen mounted to a patient's bed decreased anxiety when compared to a tablet during mask induction of anesthesia in children from 4‐10 years of age. Methods: We performed a prospective, randomized trial to determine differences in our primary outcome, preoperative anxiety, between the large Bedside Entertainment and Relaxation Theater (BERT) and a smaller tablet screen. Secondary outcomes included (a) induction compliance; (b) child fear; (c) frequency of emergence delirium; and (d) satisfaction. Results: In examining the primary outcome for 52 patients, there was a main effect for time on mYPAS scores, f(2, 51) = 13.18, P < 0.01. mYPAS scores significantly increased across time for both groups. The interaction for time (T0, T1 or T2) × group (BERT vs Tablet) was not significant, f(2, 51) = 1.96, P = 0.15; thus changes in mYPAS scores across time did not differ by group status. There was no significant difference in induction compliance, child fear, emergence delirium, or satisfaction between the two groups. Conclusion: In a low‐risk population, preoperative anxiety was low and induction compliance was high when pairing screen‐based distraction interventions, regardless of size, with parental presence at induction of anesthesia. [ABSTRACT FROM AUTHOR]

Medical trainees face substantial financial and scheduling burdens during the interview process at various levels of training. With current social distancing and travel restrictions in place, in‐person interviews now carry an additional health risk that make it difficult for training programs and applicants to conduct a thorough interview process. Virtual interviews and presentations are some of the technology‐driven solutions that have been accelerated in the current social context to mitigate financial burdens and health risks. By utilizing immersive technology to provide virtual tours of training sites, applicants have the opportunity to gain a comprehensive perspective before making the critical decision of where to continue their training. We provide our experiences with creating a 360‐degree virtual tour of our children's hospital and the methods for distribution to pediatric anesthesia fellowship applicants. Moving forward, training programs may consider immersive virtual tours as an alternative to face‐to‐face site visits to not only help alleviate the financial and scheduling burden for applicants but also to protect the well‐being of healthcare personnel and patients in the context of a global pandemic. [ABSTRACT FROM AUTHOR]

The description of our fellowship DEI course sequence may serve as a template for other fellowships seeking to establish a formal course sequence within their own fellowship curriculum. Curriculum, diversity, education, equity, fellowship, inclusion Keywords: curriculum; diversity; education; equity; fellowship; inclusion EN curriculum diversity education equity fellowship inclusion 487 488 2 02/16/22 20220301 NES 220301 DATA AVAILABILITY STATEMENT Data sharing is not applicable to this article as no new data were created or analyzed in this study. [Extracted from the article]

Background The risk of surgical site infections is reduced with appropriate timing and dosing of preoperative antimicrobials. Based on evolving national guidelines, we increased the preoperative dose of cefazolin from 25 to 30 mg·kg−1. This quality improvement project describes an improvement initiative to develop standard work processes to ensure appropriate dosing. Aims The primary aim was to deliver cefazolin 30 mg·kg−1 to at least 90% of indicated patients. The secondary aim was to determine differences between accuracy of cefazolin doses when given as an electronic order compared to a verbal order. Methods Data were collected from January 1, 2012 to May 31, 2016. A quality improvement team of perioperative physicians, nurses, and pharmacists implemented a series of interventions including new electronic medical record order sets, personal provider antibiotic dose badges, and utilization of pharmacists to prepare antibiotics to increase compliance with the recommended dose. Process compliance was measured using a statistical process control chart, and dose compliance was measured through electronic analysis of the electronic medical record. Secondary aim data were displayed as percentage of dose compliance. An unpaired t-test was used to determine differences between groups. Results Between January 1, 2012 and May 31, 2016, cefazolin was administered to 9086 patients. The mean compliance of cefazolin at 30 mg·kg−1 from May 2013 to March 2014 was 40%, which prompted initiation of this project. From April 2014 to May 2016, a series of interventions were deployed. The mean compliance from September 2015 to May 2016 was 93% with significantly reduced variation and no special cause variation, indicating that the process was in control at the target primary aim. There were 649 cefazolin administrations given verbally and 1929 given with an electronic order between October 1, 2014 and May 31, 2016. During this time period, the rate of compliance of administering cefazolin at 30 mg·kg−1 was significantly higher when given after an electronic order than when given verbally, 94% vs 76%. Conclusion This comprehensive quality improvement project improved practitioner compliance with evidence-based preoperative antimicrobial dosing recommendations to reduce the risk of surgical site infections. [ABSTRACT FROM AUTHOR]

By thoughtfully selecting VR content and appropriately screening patients, providers can diminish negative VR experiences that may lead to adverse psychological and behavioral events. For children who elect to experience VR, clinicians should offer a carefully curated VR library. Virtual reality (VR) has been used as a nonpharmacologic adjunct to mitigate anxiety through distraction during uncomfortable procedures, as well as preoperatively by providing mental rehearsals and guided imagery. [Extracted from the article]

Summary There are approximately 10 000 pediatric burn survivors in the United States each year, many of whom will present for reconstructive surgery after severe burns in the head and neck (1). These recovered burn victims, who are beyond the acute phase of injury, often have significant scarring and contractures in the face, mouth, nares, neck, and chest, which can make airway management challenging and potentially lead to a 'cannot intubate, cannot ventilate' scenario (2). Although numerous cases have been presented in the literature on this topic (3-17), there are no comprehensive review articles on the unique challenges of airway management in the recovered pediatric burn patient with distorted airway anatomy. This article aims to provide a comprehensive review of airway management in such patients, focusing on challenges encountered during mask ventilation and tracheal intubation, as well as the role of surgical release of neck contractures to facilitate tracheal intubation. Lessons learned from all reported cases identified in a thorough literature search are incorporated into this review. [ABSTRACT FROM AUTHOR]

The article discusses the measurement of cuff pressure after placement of an endotracheal tube (ETT) is standard practice for most pediatric anesthesiologists and low cuff pressures increase the risk of aspiration and ventilator-associated pneumonia. It mentions complications from under or over-pressurizing ETT cuffs and manometer that is applied to the pilot balloon to measure the ETT cuff pressure. It also offers information on Cufflator cuff pressure manometers from Posey.