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This clinical report addresses the topic of preexisting do-not-resuscitate (DNR) orders for children undergoing anesthesia and surgery. Pertinent issues addressed include the rights of children, surrogate decision-making, the process of informed consent, and the roles of surgeons and anesthesiologists. The reevaluation process of DNR orders called 'required reconsideration' can be incorporated into the process of informed consent for surgery and anesthesia. Care should be taken to distinguish between goal-directed and procedure-directed approaches to DNR orders. By giving parents or other surrogates and clinicians the option of deciding from among full resuscitation, limitations based on procedures, or limitations based on goals, the child's needs are individualized and better served. [ABSTRACT FROM AUTHOR]

The Children's Surgery Verification Program of the American College of Surgeons began in 2016 based on the standards created by the Task Force for Children's Surgery. This program seeks to improve the surgical care of children by assuring the appropriate resources and robust performance improvement programs at participating centers. Three levels of centers with defined scopes of practice and matching resources are defined. Since its inception more than 50 center have been verified. A specialty hospital program was launched in 2019. The standards for all hospitals were revised in 2021 based on lessons learned. In this article the leaders of the program discuss the development, areas of greatest impact and future directions of the program., (Copyright © 2023. Published by Elsevier Inc.)

Background: Pediatric perioperative cardiac arrest (CA) is a rare but catastrophic event. This case-control study aims to analyze the causes, incidence, and outcomes of all pediatric CA reported to Wake Up Safe. Factors associated with CA and mortality after arrest are examined and possible strategies for improving outcomes are considered., Methods: CA in children was identified from the Wake Up Safe Pediatric Anesthesia Quality Improvement Initiative, a multicenter registry of adverse events in pediatric anesthesia. Incidence, demographics, underlying conditions, causes of CA, and outcomes were extracted. Descriptive statistics and logistic regression were used to study the above factors associated with CA and mortality after CA., Results: A total of 531 cases of CA occurred during 1,006,685 anesthetics. CA was associated with age (odds ratio [95% confidence interval] comparing ≥6 vs <6 months of 0.26 [0.22-0.32]; P = .014), American Society of Anesthesiologists physical status (ASA PS III-V versus I-II, 9.24, 7.23-11.8; P < .001), and emergency status (3.55, 2.88-4.37; P < .001). Higher ASA PS was associated with increased mortality (ASA PS III-V versus I-II, 3.25, 1.20-8.81; P = .02) but anesthesia-related arrests were correlated with lower mortality (0.44, 0.26-0.74; P = .002). ASA emergency status (1.83, 1.05-3.19; P = .03) and off hours (night and weekend versus weekday, 2.17, 1.22-3.86; P = .008) were other factors associated with mortality after CA., Conclusions: The Wake Up Safe data validate single-institution studies' findings regarding incidence, factors associated with arrest, and outcomes of pediatric perioperative CA. However, CA occurring during the off hours had significantly worse outcomes, independent of patient physical status or emergency surgery. This suggests an opportunity for improved outcomes.

A task force of pediatric surgical specialists with the support of The American College of Surgeons recently launched a verification program for pediatric surgery, the Children's Surgery Verification quality improvement program, with the goal of improving pediatric surgical, procedural, and perioperative care. Included in this program are specific standards for the delivery of pediatric anesthesia care across a variety of practice settings. We review the background, available evidence, requirements for verification, and verification process and its implications for the practice of pediatric anesthesia across the country. In addition, we have included a special roundtable interview of 3 recently Children's Surgery Verification-verified program directors to provide an up-to-date real-world perspective of this children's surgery quality improvement program.

Background: Health-care worker (HCW) hand hygiene (HH) is the cornerstone of efforts to reduce hospital infections but remains low. Real-time mitigation of failures can increase process reliability to > 95% but has been challenging to implement for HH., Objective: To sustainably improve HCW HH to > 95%., Methods: A hospital-wide quality improvement initiative to improve HH was initiated in February 2012. HCW HH behavior was measured by covert direct observation utilizing multiple-trained HCW volunteers. HH compliance was defined as correct HH performed before and after contact with the patient or the patient's care area. Interventions focusing on leadership support, HCW knowledge, supply availability, and culture change were implemented using quality improvement science methodology. In February 2014, the hospital began the Speaking Up for Safety Program, which trained all HCWs to identify and mitigate HH failures at the moment of occurrence and addressed known barriers to speaking up., Results: Between January 1, 2012, and January 31, 2016, there were 30,514 HH observations, averaging 627 observations per month (9% attending physicians, 12% resident physicians, 46% nurses, 33% other HCW types). HCW HH gradually increased from 75% to > 90% by December 2014. After the Speaking Up for Safety Program, HCW HH has been > 95% for 20 months. Physician HH compliance has been above 90% for over a year., Conclusion: Creating a specific process for staff to speak up and prevent HH failures, as part of a multimodal improvement effort, can sustainably increase HCW HH above 95%.

Purpose of Review: The Task Force for Children's Surgical Care, an ad-hoc multidisciplinary group of invited leaders in pediatric perioperative medicine, was assembled in May 2012 to consider approaches to optimize delivery of children's surgical care in today's competitive national healthcare environment. Over the subsequent 3 years, with support from the American College of Surgeons (ACS) and Children's Hospital Association (CHA), the group established principles regarding perioperative resource standards, quality improvement and safety processes, data collection, and verification that were used to develop an ACS-sponsored Children's Surgery Verification and Quality Improvement Program (ACS CSV)., Recent Findings: The voluntary ACS CSV was officially launched in January 2017 and more than 125 pediatric surgical programs have expressed interest in verification. ACS CSV-verified programs have specific requirements for pediatric anesthesia leadership, resources, and the availability of pediatric anesthesiologists or anesthesiologists with pediatric expertise to care for infants and young children., Summary: The present review outlines the history of the ACS CSV, key elements of the program, and the standards specific to pediatric anesthesiology. As with the pediatric trauma programs initiated more than 40 years ago, this program has the potential to significantly improve surgical care for infants and children in the United States and Canada.

The Pediatric Anesthesia Neuro Development Assessment (PANDA) team at the Anesthesiology Department at Columbia University Medical Center held its fifth biennial symposium to discuss issues regarding potential neurotoxicity of anesthetic agents in pediatric patients. Overall optimal surgical timing as well as a "critical window" for surgery on a specialty specific basis are areas of focus for the American Academy of Pediatrics Surgical Advisory Panel. An ad hoc panel of pediatric surgical experts representing general surgery, urology, neurosurgery, and ophthalmology was assembled for this meeting and provided a dialogue focused on the benefits of early intervention versus potential anesthetic risk, addressing parental concerns, and the need for continued interdisciplinary collaboration in this area.

Background: Direct observation of health care worker (HCW) hand hygiene (HH) remains the gold standard, but implementation is challenging. Our objective was to develop an accurate HH observation program using multiple HCW volunteers., Methods: HH compliance was defined as correct HH performed before and after contact with a patient or a patient's environment. HCW volunteers from each unit at our children's hospital were trained by infection preventionists to covertly collect HH observations during routine care using an electronic tool. Questionnaires sent to observers in February and December 2014 recorded demographic characteristics, observation time, and scenarios assessing accuracy. HCWs were surveyed regarding their awareness that their HH behavior was being recorded., Results: There were 146 HH observers. The majority of observers reported making 1-2 observations per shift (65%) and taking ≤10 minutes recording an observation (85%). Between January 2012 and December 2014 there were 22,484 HH observations (average, 622 per month), including nurses (46%), physicians (21%), and other HCWs (33%). Observers correctly recorded HH behavior more than 90% of the time in 5 of the 6 scenarios. Most HCWs (86%) were unaware they were being observed., Conclusion: A direct observation program staffed by multiple HCW volunteers can inexpensively and accurately collect HCW HH data., (Copyright © 2016 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.)

Background: As pediatric anesthesia has become safer over the years, it is difficult to quantify these safety advances at any 1 institution. Safety analytics (SA) and quality improvement (QI) are used to study and achieve high levels of safety in nonhealth care industries. We describe the development of a multiinstitutional program in the United States, known as Wake-Up Safe (WUS), to determine the rate of serious adverse events (SAE) in pediatric anesthesia and to apply SA and QI in the pediatric anesthesia departments to decrease the SAE rate., Methods: QI was used to design and implement WUS in 2008. The key drivers in the design were an organizational structure; an information system for the SAE; SA to characterize the SAE; QI to imbed high-reliability care; communications to disseminate the learnings; and engaged leadership in each department. Interventions for the key drivers, included Participation Agreements, Patient Safety Organization designation, IRB approval, Data Management Co., membership fee, SAE standard templates, SA and QI workshops, and department leadership meetings., Results: WUS has 19 institutions, 39 member anesthesiologists, 734 SAE, and 736,365 anesthetics as of March, 2013. The initial members joined at year 1, and initial SAE were recorded by year 2. The SAE rate is 1.4 per 1000 anesthetics. Of SAE, respiratory was most common, followed by cardiac arrest, care escalation, and cardiovascular, collectively 76% of SAE. In care escalation, medication errors and equipment dysfunction were 89%. Of member anesthesiologists, 70% were trained in SA and QI by March 2013; virtually, none had SA and QI expertise before joining WUS., Conclusion: WUS documented the incidence and types of SAE nationally in pediatric anesthesiology. Education and application of QI and SA in anesthesia departments are key strategies to improve perioperative safety by WUS.

Pediatric advanced life support training and guidelines are typically designed for first-responders and out-of-hospital resuscitation. Guidelines and scenarios that are more applicable to the perioperative environment would be beneficial for anesthesiologists. The goal of this article is to review resuscitation of pediatric patients during the perioperative period. We use a format that focuses on preresuscitation preparation, resuscitation techniques, and postresuscitation management in the perioperative period. In an effort to provide information of maximum benefit to anesthesiologists, we include common pediatric perioperative arrest scenarios with detailed description of their management. We also provide a section on postresuscitation management and review the techniques for maintaining the child's hemodynamic and metabolic stability. Finally, 3 appendices are included: an example of an intraoperative arrest record that provides feedback for interventions; a table of key medications for pediatric perioperative resuscitation; and a review of defibrillator use and simulation exercises to promote effective defibrillation.

Objectives: Few educational opportunities exist in paediatric cardiac critical care units (PCCUs). We introduced a new educational activity in the PCCU in the form of of patient-specific summaries (TPSS). Our objective was to study the role of TPSS in the provision of a positive learning experience to the multidisciplinary clinical team of PCCUs and in improving patient-related clinical outcomes in the PCCU., Methods: Prospective educational intervention with simultaneous clinical assessment was undertaken in PCCU in an academic children's hospital. TPSS was developed utilizing the case presentation format for upcoming week's surgical cases and delivered once every week to each PCCU clinical team member. Role of TPSS to provide clinical education was assessed using five-point Likert-style scale responses in an anonymous survey 1 year after TPSS provision. Paediatric cardiac surgery patients admitted to the PCCU were evaluated for postoperative outcomes for TPSS provision period of 1 year and compared with a preintervention period of 1 year., Results: TPSS was delivered to 259 clinical team members including faculty, fellows, residents, nurse practitioners, nurses, respiratory therapists and others from the Divisions of Anesthesia, Cardiology, Cardio-Thoracic Surgery, Critical Care, and Pediatrics working in the PCCU. Two hundred and twenty-four (86%) members responded to the survey and assessed the role of TPSS in providing clinical education to be excellent based on mean Likert-style scores of 4.32 ± 0.71 in survey responses. Seven hundred patients were studied for the two time periods and there were no differences in patient demographics, complexity of cardiac defect and surgical details. The length of mechanical ventilation for the TPSS period (57.08 ± 141.44 h) was significantly less when compared with preintervention period (117.39 ± 433.81 h) (P < 0.001) with no differences in length of PCICU stay, hospital stay and mortality for the two time periods., Conclusions: Provision of TPSS in a paediatric cardiac surgery unit is perceived to be beneficial in providing clinical education to multidisciplinary clinical teams and may be associated with improved clinical outcome.

This study aimed to identify the prevalence, etiology, and outcomes of extubation failure in children after complete repair for tetralogy of Fallot at a single tertiary-care, academic children's hospital. The secondary aim of this study was to determine the cardiorespiratory effects of the transition from positive-pressure ventilation to spontaneous breathing in children with extubation success and extubation failure. For this study, extubation was defined as the need for reintubation within 96 h after extubation. Demographics as well as pre-, intra-, post-, and periextubation data were collected in a retrospective observational format for patients who underwent complete repair for tetralogy of Fallot during the period January 2001-June 2011. Patients with multiple aortopulmonary collateral arteries or associated complete atrioventricular septal defects were excluded from the study. The cardiorespiratory variables collected before and immediately after extubation included heart rate, respiratory rate, mean arterial blood pressure, central venous pressures, near-infrared spectroscopy, oxygen saturations, and lactate levels. The clinical outcomes evaluated included the success or failure of extubation and the hospital length of stay. Descriptive and univariate statistics were used to compare the group with extubation failure and the group with extubation success. Extubation failure occurred for 7 % (12/164) of the 164 eligible patients during the study period. The median age of the patients at surgery was 200 days (range 98-356 days), and their median weight was 6.8 kg (range 5.2-8.5 kg). For 6 % (10/164) of the patients, intubation was performed before surgery. The median duration of mechanical ventilation was 33 h (range 19.5-73 h), and the median hospital stay was 10 days (range 7-15 days). Of the 12 patients with extubation failure, 2 had extubation failure in first 2 h after extubation, 6 had failure in 2-24 h, 3 had failure in 24-48 h, and 1 had failure in 48-96 h. The patients in the extubation success and extubation failure groups were similar in age, sex, and body weight at the time of surgery. All preexisting conditions also were similar in the two groups. The intraoperative variables and postoperative complications did not differ between the two groups. The hospital stay was longer for the children with extubation failure (p < 0.001). The partial pressure of oxygen in arterial blood (PaO2), tachycardia, mean arterial blood pressure, and inotrope score improved significantly at conversion from positive-pressure ventilation to spontaneous ventilation in the patients with extubation success. This study demonstrated that extubation failure in patients after complete repair for tetralogy of Fallot is low and that the etiology is diverse. The majority of extubation failures in these patients occurred in the first 24 h. Extubation success in the children after repair for tetralogy of Fallot was associated with improvement in PaO2, tachycardia, and mean arterial pressure, with a decrease in inotrope score. Extubation failure is associated with a longer hospital stay.

Purpose: General anesthetics can induce apoptotic neurodegeneration and subsequent maladaptive behaviors in animals. Retrospective human studies suggest associations between early anesthetic exposure and subsequent adverse neurodevelopmental outcomes. The relevance of animal data to clinical practice is unclear and to our knowledge the causality underlying observed associations in humans is unknown. We reviewed newly postulated neurodevelopmental risks of pediatric anesthesia and discuss implications for the surgical care of children., Materials and Methods: We queried the MEDLINE®/PubMed® and EMBASE® databases for citations in English on pediatric anesthetic neurotoxicity with the focus on references from the last decade., Results: Animal studies in rodents and primates demonstrate apoptotic neuropathology and subsequent maladaptive behaviors after exposure to all currently available general anesthetics with the possible exception of α2-adrenergic agonists. Similar adverse pathological and clinical effects occur after untreated pain. Anesthetic neurotoxicity in animals develops only after exposure above threshold doses and durations during a critical neurodevelopmental window of maximal synaptogenesis in the absence of concomitant painful stimuli. Anesthetic exposure outside this window or below threshold doses and durations shows no apparent neurotoxicity, while exposure in the context of concomitant painful stimuli is neuroprotective. Retrospective human studies suggest associations between early anesthetic exposure and subsequent adverse neurodevelopmental outcomes, particularly after multiple exposures. The causality underlying the associations is unknown. Ongoing investigations may clarify the risks associated with current practice., Conclusions: Surgical care of all patients mandates appropriate anesthesia. Neurotoxic doses and the duration of anesthetic exposure in animals may have little relevance to clinical practice, particularly surgical anesthesia for perioperative pain. The causality underlying the observed associations between early anesthetic exposure and subsequent adverse neurodevelopmental outcomes is unknown. Anesthetic exposure may be a marker of increased risk. Especially in young children, procedures requiring general anesthesia should be performed only as necessary and general anesthesia duration should be minimized. Alternatives to general anesthesia and the deferral of elective procedures beyond the first few years of life should be considered, as appropriate. Participation in ongoing efforts should be encouraged to generate further data., (Copyright © 2013 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

The morbidity and mortality conference (M&M) is a long-standing practice in medicine. Originally created to identify errors and improve care, the primary focus of M&M has moved toward an emphasis on education of trainees. A structured format for the M&M conference can help the interdisciplinary team address causes of adverse patient outcomes and identify opportunities for systems improvement., (Copyright © 2012. Published by Elsevier Inc.)

Background: Collaborative and toolkit approaches have gained traction for improving quality in health care., Objective: To determine if a quality improvement virtual collaborative intervention would perform better than a toolkit-only approach at preventing central line-associated bloodstream infections (CLABSIs) and ventilator-associated pneumonias (VAPs)., Design and Setting: Cluster randomized trial with the Intensive Care Units (ICUs) of 60 hospitals assigned to the Toolkit (n=29) or Virtual Collaborative (n=31) group from January 2006 through September 2007., Measurement: CLABSI and VAP rates. Follow-up survey on improvement interventions, toolkit utilization, and strategies for implementing improvement., Results: A total of 83% of the Collaborative ICUs implemented all CLABSI interventions compared to 64% of those in the Toolkit group (P = 0.13), implemented daily catheter reviews more often (P = 0.04), and began this intervention sooner (P < 0.01). Eighty-six percent of the Collaborative group implemented the VAP bundle compared to 64% of the Toolkit group (P = 0.06). The CLABSI rate was 2.42 infections per 1000 catheter days at baseline and 2.73 at 18 months (P = 0.59). The VAP rate was 3.97 per 1000 ventilator days at baseline and 4.61 at 18 months (P = 0.50). Neither group improved outcomes over time; there was no differential performance between the 2 groups for either CLABSI rates (P = 0.71) or VAP rates (P = 0.80)., Conclusion: The intensive collaborative approach outpaced the simpler toolkit approach in changing processes of care, but neither approach improved outcomes. Incorporating quality improvement methods, such as ICU checklists, into routine care processes is complex, highly context-dependent, and may take longer than 18 months to achieve., (Copyright © 2011 Society of Hospital Medicine.)

Recent animal and human studies have raised concern that exposure to anesthetic agents in children may cause neuronal damage and be associated with adverse neurodevelopmental outcomes. Exposure of young animals to anesthetic agents above threshold doses and durations during a critical neurodevelopmental window in the absence of concomitant painful stimuli causes widespread neuronal apoptosis and subsequent abnormal behaviors. The relevance of such animal data to humans is unknown. Untreated neonatal pain and stress also are associated with enhanced neuronal death and subsequent maladaptive behaviors, which can be prevented by exposure to these same anesthetic agents. Retrospective observational human studies have suggested a dose-dependent association between multiple anesthetic exposures in early childhood and subsequent learning disability, the causality of which is unknown. Ongoing prospective investigations are underway, the results of which may clarify if and what neurodevelopmental risks are associated with pediatric anesthesia. No change in current practice is yet indicated.

Context: Bureaucratic organisational culture is less favourable to quality improvement, whereas organisations with group (teamwork) culture are better aligned for quality improvement., Objective: To determine if an organisational group culture shows better alignment with patient safety climate., Design: Cross-sectional administration of questionnaires. Setting 40 Hospital Corporation of America hospitals., Participants: 1406 nurses, ancillary staff, allied staff and physicians., Main Outcome Measures: Competing Values Measure of Organisational Culture, Safety Attitudes Questionnaire (SAQ), Safety Climate Survey (SCSc) and Information and Analysis (IA)., Results: The Cronbach alpha was 0.81 for the group culture scale and 0.72 for the hierarchical culture scale. Group culture was positively correlated with SAQ and its subscales (from correlation coefficient r = 0.44 to 0.55, except situational recognition), ScSc (r = 0.47) and IA (r = 0.33). Hierarchical culture was negatively correlated with the SAQ scales, SCSc and IA. Among the 40 hospitals, 37.5% had a hierarchical dominant culture, 37.5% a dominant group culture and 25% a balanced culture. Group culture hospitals had significantly higher safety climate scores than hierarchical culture hospitals. The magnitude of these relationships was not affected after adjusting for provider job type and hospital characteristics., Conclusions: Hospitals vary in organisational culture, and the type of culture relates to the safety climate within the hospital. In combination with prior studies, these results suggest that a healthcare organisation's culture is a critical factor in the development of its patient safety climate and in the successful implementation of quality improvement initiatives.

Context: Patient misidentification continues to be a quality and safety issue. There is a paucity of US data describing interventions to reduce identification band error rates., Setting: Monroe Carell Jr Children's Hospital at Vanderbilt., Key Measures: Percentage of patients with defective identification bands., Strategies for Change: Web-based surveys were sent, asking hospital personnel to anonymously identify perceived barriers to reaching zero defects with identification bands. Corrective action plans were created and implemented with ideas from leadership, front-line staff and the online survey. Data from unannounced audits of patient identification bands were plotted on statistical process control charts and shared monthly with staff. All hospital personnel were expected to "stop the line" if there were any patient identification questions., Effects of Change: The first audit showed a defect rate of 20.4%. The original mean defect rate was 6.5%. After interventions and education, the new mean defect rate was 2.6%., Lessons Learnt: (a) The initial rate of patient identification band errors in the hospital was higher than expected. (b) The action resulting in most significant improvement was staff awareness of the problem, with clear expectations to immediately stop the line if a patient identification error was present. (c) Staff surveys are an excellent source of suggestions for combating patient identification issues. (d) Continued audit and data collection is necessary for sustainable staff focus and continued improvement. (e) Statistical process control charts are both an effective method to track results and an easily understood tool for sharing data with staff.

Objective: The United States is currently in the midst of a hospital construction boom. An increasing number of hospitals are being designed using the principles of evidence-based design to improve patient safety and patient satisfaction. Few studies have examined the impact of new hospital design models on providers' attitudes or work performance. The goal of this study was to determine how providers' attitudes at one children's hospital changed over a 2-year period. It was hypothesized that clinicians' attitudes about their work environment would be significantly more positive 2 years after opening., Background: In 2004 a children's hospital within a hospital was replaced with a free-standing facility, which was designed on the theme of family-centered care. The hospital quality improvement team developed and administered the Environment of Work survey to measure providers' initial impressions of the hospital design on job function, patient safety, and personal well-being. The survey was readministered approximately 2 years later to measure changes in providers' perceptions about the same issues., Methods: A 25-item survey was administered to a convenience sample of clinical staff to measure their attitudes about the effects of family-centered hospital design on providers and patients. Chi-square tests were used to compare subjective ratings collected from the two surveys on pooled samples and on samples stratified by clinical unit., Results: Surveys were collected from 270 clinicians (a 25% response rate) in 2004 and 544 clinicians (a 51% response rate) in 2006. Nurses accounted for a higher percentage of total respondents (78% versus 57%). Most domain areas garnered improved and overall positive ratings from clinicians in 2006. Providers' ratings of elevated mental fatigue, physical fatigue, and walking burden remained high in 2006 despite improvements. Ratings of noise levels increased on all units except the neonatal intensive care unit. Fewer respondents rated the new hospital "somewhat to much better" than the former hospital., Conclusions: Moving into a new healthcare facility is a stressful event for healthcare providers and adapting to a new work environment requires a lengthy period of transition. Providers' initial ratings of a new workspace are likely to change over time as they adjust their work practices to the physical environment.

Purpose: Clinical practices are increasingly proposing health related quality of life measures for informed treatment decisions. Dismembered pyeloplasty is an accepted standard therapy for ureteropelvic junction obstruction. This study evaluates health related quality of life in patients with ureteropelvic junction obstruction undergoing pyeloplasty. Patients have perceived it helpful in communicating health care needs to physicians. We believe this is the first study to use child self and parent reports prospectively in ureteropelvic junction obstruction. The goals of the study were to document baseline preoperative health related quality of life assessments, differences between parent and child assessments at given intervals, differences in preoperative and postoperative assessments, and overall clinical outcomes., Materials and Methods: Patients younger than 18 years (mean 9.1 years) with ureteropelvic junction obstruction were included in the study. Demographic survey and validated health related quality of life questionnaire (Pediatric Quality of Life Inventory 4.0) were used preoperatively and postoperatively. The questionnaire documented subjective health related quality of life (physical, social, emotional and school functioning, and psychosocial health). Clinical outcomes were generated following the office visit. Questionnaire subscales were scored with algorithms provided. Paired t test evaluated differences in parent and child scores of less than 0.05 were statistically significant. Tests were 2-tailed., Results: Response rate was 100%. Preoperatively emotional functioning (81.8) and psychosocial health (80.9) child scores were significantly higher than parent scores (70.7 and 73.9, respectively). Overall child score of the study population (80.9) was similar to that of healthy children (85). However, parent scores of physical functioning (78.3), psychosocial health (73.9), emotional functioning (70.7) and school functioning (65.5) were significantly lower than the general population. At postoperative week 6 child emotional functioning (91.7) and physical functioning (90.3) showed significant improvement (p <0.05). Parent scores of physical functioning (88.4), psychosocial health (82.2) and emotional functioning (80.8) were also significantly higher than preoperative scores. Longer followup demonstrated that child scores of physical functioning (96.9), psychosocial health (96.5), emotional functioning (95.4) and social functioning (97.1) were significantly higher than preoperatively. Postoperatively parents reported significantly higher health related quality of life scores compared to preoperative scores. There was no significant difference at 6 months between parent and child scores. Clinically all patients did well following pyeloplasty., Conclusions: Preoperatively children recorded higher health related quality of life than parents/guardians. At postoperative week 6 children and parents recorded higher health related quality of life compared to preoperative scores. At 6 months overall child health related quality of life was significantly higher than preoperative reports, and no significant difference was seen between parent and child scores. Health related quality of life evaluations enabled us to monitor patient recovery and progress postoperatively. Prospective evaluations at regular intervals helped us to document improvement in overall quality of life in these children.

Background: Ventilator-associated pneumonia (VAP) is widely recognized as a serious and common complication associated with high morbidity and high costs. Given the complexity of caring for heterogeneous populations in the intensive care unit (ICU), however, there is still uncertainty regarding how to diagnose and manage VAP., Objective: We recently conducted a national collaborative aimed at reducing health care-associated infections in ICUs of hospitals operated by the Hospital Corporation of America (HCA). As part of this collaborative, we developed algorithms for diagnosing and treating VAP in mechanically ventilated patients. In the current article, we (1) review the current evidence for diagnosing VAP, (2) describe our approach for developing these algorithms, and (3) illustrate the utility of the diagnostic algorithms using clinical teaching cases., Design: This was a descriptive study, using data from a national collaborative focused on reducing VAP and catheter-related bloodstream infections., Setting: The setting of the study was 110 ICUs at 61 HCA hospitals., Intervention: None., Measurements and Results: We assembled an interdisciplinary team that included infectious disease specialists, intensivists, hospitalists, statisticians, critical care nurses, and pharmacists. After reviewing published studies and the Centers for Disease Control and Prevention VAP guidelines, the team iteratively discussed the evidence, achieved consensus, and ultimately developed these practical algorithms. The diagnostic algorithms address infant, pediatric, immunocompromised, and adult ICU patients., Conclusions: We present practical algorithms for diagnosing and managing VAP in mechanically ventilated patients. These algorithms may provide evidence-based real-time guidance to clinicians seeking a standardized approach to diagnosing and managing this challenging problem.

In light of consumers' and regulators' increasing focus on infection prevention, infection control practices and resources were surveyed at 134 hospitals owned by the Hospital Corporation of America. Infection control practices and resources varied substantially among hospitals, and many facilities reported difficulty acquiring the data they needed to report infection rates.

In December 2004, the Institute for Healthcare Improvement launched a campaign to save 100,000 lives by implementing evidence-based interventions in six areas, five of which are relevant to children. Working collaboratively, the Child Health Corporation of America, National Associate of Children's Hospitals and Related Institutions, and National Initiative for Children's Health Care Quality provided a series of Web-enabled seminars on how the campaign initiatives might be adapted for pediatric settings. Ventilator-associated pneumonia (VAP) is an example of how interventions based on evidence in adult settings may need to be tailored in pediatric settings. The authors describe how assessing and implementing parts of the VAP bundle led to reduction in VAP in two children's hospitals.

Purpose: Spina bifida, the most frequent permanently debilitating birth defect, results in major urological problems of voluntary bladder control and bowel function, which may impair quality of life. We prospectively assessed quality of life in patients with spina bifida using child and parent reports simultaneously. This study had 3 goals, that is to 1) document baseline health related quality of life in patients with spina bifida preoperatively, 2) study health related quality of life, reporting differences between parents and children, and 3) study changes in health related quality of life prospectively at preoperative and postoperative intervals., Materials and Methods: Patients with spina bifida who were 2 to 18 years old and required reconstructive urological surgery in 2004 were included in the study. Demographic survey and the validated PedsQL 4.0 health related quality of life questionnaire were used preoperatively and postoperatively. A clinical outcomes data set was completed after the clinician saw the patient. PedsQL 4.0 subscales were scored using the algorithms provided., Results: The response rate was 100%. Mean participant age was 10.3 years. Preoperatively child physical and psychosocial health and school functioning were significantly higher than parent reports (p <0.001). Overall health related quality of life in patients with spina bifida was lower than in healthy children (62.4 vs 85, p <0.001). Six weeks postoperatively significant differences in health related quality of life reporting between parents and children had lowered. Six months postoperatively child emotional and social functioning scores were higher than parent scores (p <0.001). No correlation was found between health related quality of life, and clinical and demographic factors due to insufficient sample size., Conclusions: Children with spina bifida recorded higher health related quality of life scores than parents/guardians. This health related quality of life study addresses concerns that impact daily quality of life in patients with spina bifida. Future health related quality of life studies in patients with spina bifida should use child self-reports.

Objective: To describe the use of inhaled isoflurane in a series of children with life-threatening asthma., Design: Retrospective case series., Setting: Pediatric intensive care unit of a tertiary-care children's hospital. Ten children ranging in age from 1 to 16 years with 11 episodes of severe asthma requiring invasive mechanical ventilation in the pediatric intensive care unit over a 5-year period., Results: Isoflurane resulted in an improvement in arterial pH and a reduction in partial pressure of arterial carbon dioxide (PaCO(2)) in all the 11 instances. This effect was sustained in 10 cases and led to clinical improvement and rapid weaning from mechanical ventilation. One child failed to show sustained response and was placed on veno-venous extracorporeal membrane oxygenation. One child died secondary to anoxic brain injury sustained prior to hospitalization. Hypotension was the major side effect, and occurred in 8 children necessitating vasopressor support., Conclusions: Isoflurane improves arterial pH and reduces partial pressure of arterial carbon dioxide in mechanically ventilated children with life-threatening status asthmaticus who are not responsive to conventional management.

The demand for safe and effective procedural sedation for children is rapidly increasing because of the increased awareness about procedure-related anxiety even in young infants and children. The development of short-acting sedatives, improved monitoring, and new regulatory requirements have led to the evolution of new paradigms of safe, effective, and resource-efficient systems for providing procedural sedation outside the operating rooms by anesthesiologists and nonanesthesiologists.

Pediatric anesthesiology has made a significant contribution to child health and will be necessary for progress in the health sciences and outcomes related to child health in the future. It is likely that the practice of pediatric anesthesiology will remain an interesting and rewarding but demanding profession for the next generations of physicians. Despite this favorable professional profile, stiff competition for resources will come from other segments of the health care community. This article outlines a multidimensional strategy for pediatric anesthesiology to sustain its progress as a profession and contribute to the health of our children.

Background: Timely prophylactic antibiotic administration aids in preventing postoperative superficial surgical site infections. However, during lengthy surgical procedures, redosing of prophylactic antibiotics may be unintentionally omitted. We assessed the utility of a computerized reminder as part of the anesthesia charting system to increase the rate of timely intraoperative prophylactic antibiotic redosing., Methods: A retrospective observational analysis was performed on consecutive patients undergoing non-cardiac surgical procedures at a university-affiliated hospital prior to and after the institution of a computerized reminder system. The reminder system presented the clinician with a series of on-screen dialog boxes prior to the redose time for the specific prophylactic antibiotic administered preoperatively. Antibiotic redosing was defined as appropriate if it occurred within 30 min prior to or after the due time, calculated as twice the half-life of the specific antibiotic. Patients were excluded if the case duration was less than twice the half-life of the administered prophylactic antibiotic, or if no prophylactic antibiotic was given., Results: A total of 287 cases were included in the study (148 pre-intervention, 139 post-intervention). Patient age, case length, and American Society of Anesthesiologists (ASA) score stratification did not differ between the groups. Use of the reminder system resulted in an increase in the appropriate redosing of antibiotics from 20% prior to institution of the reminder to 58% after institution (p < 0.001)., Conclusions: A computerized reminder system is an effective tool to assist in appropriate intraoperative redosing of prophylactic antibiotics during lengthy surgical procedures.

Background: The purpose of this study was to review our experience in the early application of extracorporeal membrane oxygenation (ECMO) in patients requiring mechanical assistance after cardiac surgical procedures., Methods: The hospital records of all children requiring ECMO after cardiac operation were retrospectively reviewed, and an analysis of variables affecting survival was performed., Results: Fifty pediatric patients between May 1997 and October 2000 required ECMO for cardiopulmonary support after cardiac operation. Patients ranged in age from 1 day to 11 years (median age, 40 days). Forty-eight patients underwent repair of congenital cardiac lesions and 2 were included after receiving a heart transplant. Twenty-two children could not be weaned from cardiopulmonary bypass and were placed on ECMO in the operating room for circulatory support. Of the 28 children who required ECMO in the intensive care unit, 10 had ECMO instituted after cardiopulmonary arrest (mean cardiopulmonary resuscitation time 42 minutes; range, 5 to 110 minutes). In infants with single-ventricle physiology, survival to discharge was 61% (11 of 18 patients) as compared with 43% (14 of 32 patients) in those with biventricular physiology. Thirty of the 50 patients (60%) were successfully weaned from ECMO, of which 25 (83%) were discharged home. Overall survival to discharge in the entire cohort was 50%. Extracorporeal membrane oxygenation support greater than 72 hours was a grave prognostic indicator. Overall survival in this group was 36% (9 of 25 patients) compared with 56% (14 of 25 patients) in those with ECMO support less than 72 hours (p < 0.05). Univariate analysis revealed the presence of renal failure, extended periods of circulatory support, and a prolonged period of cardiopulmonary resuscitation as risk factors for mortality. The presence of shunt-dependent flow, operative procedure, and institution of ECMO in the intensive care unit did not alter survival., Conclusions: Extracorporeal membrane oxygenation provides effective support for postoperative cardiac and pulmonary failure refractory to medical management. Early institution of ECMO may decrease the incidence of cardiac arrest and end-organ damage, thus increasing survival in these critically ill patients.

Clinical care pathways and case management are strategies utilized by increasing numbers of hospitals to meet the challenges of capitated reimbursement and managed care. A clinical pathway is an outcome-focused tool used to define a multidisciplinary plan of care. A case manager coordinates patient care across an episode of illness or hospitalization. These tools and systems have great potential for use by nurse anesthetists in ensuring that high-quality anesthesia care is delivered in a cost-effective manner.

Nicardipine or nitroprusside was used to induce controlled hypotension in healthy adolescents with idiopathic scoliosis undergoing spinal fusion. Twenty patients were randomly assigned to the nitroprusside (N) or nicardipine (C) group. All patients received a standardized anesthetic. A target mean arterial blood pressure (MAP) of 60 mm Hg was achieved by varying the vasoactive infusions only. Moderate hemodilution (PCV = 25) and intraoperative blood salvage were used in all cases. Hemodynamic variables, blood loss, occurrence of reflex tachycardia, and reversibility of the hypotensive state were compared between the two groups. Significant differences were observed between the two groups in the amount of blood loss and reversibility of the hypotensive state. Group C had less blood loss (761 +/- 199 mL) than Group N (1297.5 +/- 264, P < or = .05). Time to restoration of baseline MAP was longer with Group C (26.8 +/- 4.0 min) than Group N (7.3 +/- 1.1 min, P < or = 0.001). Both drugs rapidly achieved a stable, controlled hypotensive state and an acceptable operating field. There was no statistically significant difference between groups with respect to the amount of crystalloid administered or urine output. These results suggest that nicardipine is a safe, effective drug for controlled hypotension in this population and that it may offer the significant advantage of reduced blood loss in these patients.

We present our experience with pentobarbital for sedation during mechanical ventilation in six infants when fentanyl and midazolam failed. The patients ranged in age from 2 to 17 months and in weight from 3.0 to 11.4 kg. Before the switch to pentobarbital, the maximum doses of fentanyl ranged from 7 to 13 micrograms/kg/hr and the midazolam infusions, from 0.2 to 0.4 mg/kg/hr. Pentobarbital was administered as a bolus dose followed by a continuous infusion. The hourly infusion rates ranged from 1 to 4 mg/kg. Adequate sedation was achieved in all six patients. In the four patients who required neuromuscular blocking agents, their use was discontinued after pentobarbital was given. The antihypertensive agents (diazoxide and nitroprusside) required by the two patients receiving extracorporeal membrane oxygenation were also discontinued after pentobarbital administration. Although we continue to use fentanyl and benzodiazepines as first-line drugs for sedation, pentobarbital may be an effective alternative when these agents fail.

Nicardipine is the first intravenously administered dihydropyridine calcium channel blocker. Its primary physiological actions include vasodilatation with limited effects on the inotropic and dromotropic function of the myocardium. Several reports have documented its use in adult patients for pharmacological control of blood pressure. We present our experience with the perioperative use of nicardipine in children to treat intraoperative hypertension, as an agent for controlled hypotension during spinal fusion and LeFort I maxillary osteotomies and to treat postoperative hypertension. Dosing regimens and possible applications in paediatric anaesthesia are discussed.

The authors prospectively examined the cardiorespiratory changes during brief laparoscopy (less than 15 minutes) in children. Intraoperative ventilatory management included a tidal volume of 12 mL/kg, with the rate adjusted to achieve an end-tidal CO2 (PETCO2) of 30 to 35 mm Hg. The initial rate and tidal volume were not changed during the procedure. Baseline measurements of heart rate, blood pressure, peak inflating pressure (PIP), PETCO2, and oxygen saturation were recorded every minute for 5 minutes before the start of the laparoscopic procedure, and every minute during the laparoscopic procedure. Fifty-five patients were enrolled in the study (age range, 1 month to 7 years; weight range, 5.2 to 31 kg). PIP increased from the baseline value of 20 +/- 2.5 to 23 +/- 3.2 cm H2O (P < .01) during laparoscopy. The increase in PIP was 5 or more in six patients, with a maximum of 7. PETCO2 increased from the baseline value of 32 +/- 3.1 to 35 +/- 4.8 mm Hg (P < .01). The PETCO2 returned to baseline within 10 minutes after completion of the laparoscopy. No increase in ventilatory parameters was required during the brief laparoscopic procedure.

The authors present their clinical experience with the oral administration of lorazepam, methadone, and pentobarbital to prevent or treat withdrawal symptoms following prolonged sedation in the PICU patient. The 3 patients presented required prolonged sedation for mechanical ventilation. Different agents were used for sedation in the 3 patients including intravenous fentanyl, midazolam, and pentobarbital. The switch to oral agents must take into consideration the differences in potency, half-life, and oral bioavailability between the agents. The authors discuss the appropriate conversion factors for opioids, benzodiazepines, and barbiturates. The switch to oral administration eliminated the need for intravenous access in the 3 patients and allowed for earlier discharge home. All 3 patients were discharged home on an oral, taper schedule. Such an approach may lead to earlier home discharge thereby improving the patient's quality of life as well as saving health care dollars.

Psychological factors are associated with how parents cope during a child's intensive care hospitalization. However, little is known about the role of physiological-stress responses in parents' coping and adaptation to such situations. This study investigates the relationship between parents' psychophysiological-stress responses, as measured by urine catecholamine excretion, and their coping and activities during a child's intensive care experience. Parents who appraised the situation as one that is amenable to change and who used more problem-focused strategies, such as seeking social support, had lower anxiety and lower catecholamine levels. Further, parents who were more problem focused performed more child care activities during the experience. The results of this study provide information for planning interventions to promote parental coping and adjustment to the child's critical care situation.

Preoperative evaluation and preparation are directed toward minimizing the intrinsic risks of anesthesia and surgery by having the child in the healthiest possible condition prior to surgery. The pediatrician can contribute to this goal by understanding the effects of general anesthesia on the physiology of children. This knowledge allows an appreciation of the anesthesiologists' concerns regarding underlying diseases, which may seem "stable" (and, therefore, of little present concern to the pediatrician) but which may have grave consequences during anesthesia. The preoperative evaluation is designed to ensure that the child's preoperative needs may be met by providing the anesthesiologist both qualitative and quantitative information regarding the child's state of health and disease. The relationship between the child, parents, and pediatrician places the pediatrician in an ideal position to prepare families for their children's surgical experience.

Background: The extent and duration of respiratory depression after opioid administration are poorly defined in infants and children., Methods: The disposition and respiratory effects of intrathecal morphine were studied in ten patients (ages 4 months-15 yr) after repair of craniofacial defects. Morphine, 0.02 mg/kg, was administered intrathecally before the end of surgery. Postoperatively, we determined the minute ventilation (VE) in response to increasing partial pressure of end-tidal carbon dioxide (PETCO2) during carbon dioxide rebreathing. The slope (VE/PETCO2) and intercept (VE at PETCO2 60 mmHg, VE 60) of the carbon dioxide response curve were calculated at 6, 12, and 18 h after morphine administration. Cerebrospinal fluid (CSF) and blood were analyzed for morphine concentration by radioimmunoassay., Results: Mean VE/PETCO2 decreased from a preoperative value of 35.1 +/- 3.7 to 16.3 +/- 2.8 ml.kg-1 x min-1 x mmHg-1 at 6 h after morphine, and remained depressed to 23.4 +/- 2.9 and 23.5 +/- 3.3 ml.kg-1 x min-1 x mmHg-1 at 12 h and 18 h, respectively, compared to preoperatively). The infants' (n = 3) VE/PETCO2 at 6 h were 21, 4, and 27 ml.kg-1 x min-1 x mmHg-1. Mean VE 60 decreased from 874 +/- 125 to 276 +/- 32 ml x kg-1 x min-1 at 6 h, but then recovered at 12 and 18 h to 491 +/- 68 and 567 +/- 82 ml.kg-1 x min-1, respectively. The infants' VE 60 at 6 h were 350, 142, and 245 ml.kg-1 x min-1. Mean CSF morphine concentration was 2,860 +/- 540 ng/ml at 6 h, and decreased to 640 +/- 220 and 220 +/- 150 ng/ml at 12 and 18 h, respectively., Conclusions: Intrathecal morphine, 0.02 mg/kg, depressed the ventilatory response to carbon dioxide for up to 18 h concomitant with increased CSF morphine concentrations. Infants (4-12 months of age) did not exhibit greater ventilatory depression than did children (2-15 yr of age).

We present a 17-year-old girl who developed persistent vomiting following acetaminophen overdose. Because of the amount of drug ingested (300 mg/kg acetaminophen) and the four-hour postingestion level (256 micrograms/ml), administration of N-acetylcysteine (NAC) was indicated. Emesis occurred immediately following the first three doses of NAC despite administering the drug by continuous nasogastric drip over one hour. Prior to the next attempt, ondansetron (0.15 mg/kg) was administered intravenously as an antiemetic. Thirty minutes following ondansetron, NAC was tolerated without further emesis. Although several antiemetics may have prevented further emesis, we chose ondansetron since, as a serotonin antagonist, it does not cause extrapyramidal side effects or sedation. In patients with potentially toxic drug ingestions, these side effects may be confused with or mask the adverse effects of the ingested drug, thereby interfering with the ongoing evaluation of the patient. Although not previously administered for this indication, ondansetron has several advantages over other antiemetic agents in the setting of an acute drug ingestion.