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Background: Consensus guidelines for postoperative nausea and vomiting (PONV) prophylaxis recommend a risk-based approach in which the number of antiemetics administered is based on a preoperative estimate of PONV risk. These guidelines have been adapted by the Multicenter Perioperative Outcomes Group (MPOG) to serve as measures of clinician and hospital compliance with guideline-recommended care. However, the impact of this approach on clinical outcomes is not known., Methods: We performed a single-center, retrospective study of adult patients undergoing general anesthesia from 2018 to 2021. Risk factors for PONV were defined using MPOG definitions: female sex, history of PONV or motion sickness, nonsmoker, inhaled anesthesia >60 minutes, high-risk procedure (cholecystectomy, laparoscopic, gynecologic), and age <50 years. Adequate prophylaxis was defined using the MPOG PONV-05 metric: at least 2 agents for patients with 1 to 2 risk factors and at least 3 agents for patients with 3+ risk factors. PONV was defined as documented PONV or receipt of rescue antiemetics. To estimate the association between adequate prophylaxis and PONV, we used Bayesian binomial models with overlap propensity score weighting., Results: We included 76,703 cases (43% receiving adequate prophylaxis) with PONV occurring in 19%. In unadjusted and unweighted comparison, adequate prophylaxis was associated with increased incidence of PONV: median odds ratio 1.21 (95% credible interval [1.16-1.25]). However, after propensity score weighting and multivariable adjustment, adequate prophylaxis was associated with reduced relative and absolute risk for PONV: weighted marginal median odds ratio 0.90 [0.84-0.98] and absolute risk reduction (ARR) 1.6% [0.6%-2.6%]. There was evidence for a differential effect of adequate prophylaxis across the guideline-defined risk spectrum, with benefit seen in patients with 1 to 5 risk factors (conditional probabilities of benefit >0.81), but not in those at high predicted risk. Patient-specific, covariate-adjusted ARR was heterogeneous, with a median patient-specific conditional probability of benefit of 0.84 (95% credible interval, 0.73-0.90)., Conclusions: Guideline-directed PONV prophylaxis is associated with a modest reduction in PONV, although this effect is small and heterogeneous on the absolute scale. We found evidence for a differential association between adequate prophylaxis and PONV across the guideline-defined risk spectrum, with diminution in patients at very high predicted preoperative risk. While patient-specific benefit was heterogenous, most patients had reasonably high predicted probabilities of absolute benefit from a guideline-directed strategy. Further assessment of these associations in a multicenter setting, with more robust investigation of risk prediction methods will allow for better understanding of the optimal approach to PONV prophylaxis., Competing Interests: Conflicts of Interest: See Disclosures at the end of the article., (Copyright © 2024 International Anesthesia Research Society.)

Background: Guidelines for postoperative nausea and vomiting (PONV) prophylaxis in pediatric patients recommend escalation of the number of antiemetics based on a preoperative estimate of PONV risk. These recommendations have been translated into performance metrics, most notably by the Multicenter Perioperative Outcomes Group (MPOG), used at over 25 children's hospitals. The impact of this approach on clinical outcomes is not known., Methods: We performed a single-center, retrospective study of pediatric general anesthetic cases from 2018 to 2021. PONV risk factors were defined using MPOG definitions: age ≥3 years, volatile use ≥30 minutes, PONV history, long-acting opioids, female ≥12 years, and high-risk procedure. Adequate prophylaxis was defined using the MPOG PONV-04 metric: 1 agent for 1 risk factor, 2 agents for 2 risk factors, and 3 agents for 3+ risk factors. PONV was defined as documented postoperative nausea/emesis or administration of a rescue antiemetic. Given the nonrandomized allocation of adequate prophylaxis, we used Bayesian binomial models with propensity score weighting., Results: A total of 14,747 cases were included, with PONV in 11% (9% adequate prophylaxis versus 12% inadequate). Overall, there was evidence for reduced incidence of PONV with adequate prophylaxis: weighted median odds ratio 0.82 (95% credible interval, 0.66-1.02; probability of benefit, 0.97) and weighted marginal absolute risk reduction 1.3% (-0.1% to 3.1%). In unweighted estimates, there was an interaction between sum of risk factors and the association of adequate prophylaxis with PONV, with reduced incidence in patients with 1 to 2 risk factors (probability of benefit 0.96 and 0.95) but increased incidence in patients with 3+ risk factors receiving adequate prophylaxis (probability of benefit 0, 0.01, and 0.03 for 3, 4, and 5 risk factors). This was attenuated by weighting, with persistent benefit in 1 to 2 risk factors (probability of benefit 0.90 and 0.94) but equalization of risk in 3+ risk factors., Conclusions: Guideline-directed PONV prophylaxis is inconsistently associated with incidence of PONV across the guideline-defined risk spectrum. This phenomenon, and its attenuation with weighting, is consistent with 2 points: dichotomous risk-factor summation ignores differential effects of individual components, and prognostic information might exist beyond these risk factors. PONV risk at a given sum of risk factors is not homogeneous, but rather is determined by the unique composition of risk factors and other prognostic attributes. These differences appear to have been identified by clinicians, prompting use of more antiemetics. Even after accounting for these differences, however, addition of a third agent did not further reduce risk., Competing Interests: Conflicts of Interest: See Disclosures at the end of the article., (Copyright © 2023 International Anesthesia Research Society.)

Background: Albumin continues to be used routinely by cardiac anaesthesiologists perioperatively despite lack of evidence for improved outcomes. The Multicenter Perioperative Outcomes Group (MPOG) data ranked our institution as one of the highest intraoperative albumin users during cardiac surgery. Therefore, we designed a quality improvement project (QIP) to introduce a bundle of interventions to reduce intraoperative albumin use in cardiac surgical patients., Methods: Our institutional MPOG data were used to analyse the FLUID-01-C measure that provides the number of adult cardiac surgery cases where albumin was administered intraoperatively by anaesthesiologists from 1 July 2019 to 30 June 2022. The QIP involved introduction of the following interventions: (1) education about appropriate albumin use and indications (January 2021), (2) email communications reinforced with OR teaching (March 2021), (3) removal of albumin from the standard pharmacy intraoperative medication trays (April 2021), (4) grand rounds presentation discussing the QIP and highlighting the interventions (May 2021) and (5) quarterly provider feedback (starting July 2021). Multivariable segmented regression models were used to assess the changes from preintervention to postintervention time period in albumin utilisation, and its total monthly cost., Results: Among the 5767 cardiac surgery cases that met inclusion criteria over the 3-year study period, 16% of patients received albumin intraoperatively. The total number of cases that passed the metric (albumin administration was avoided), gradually increased as our interventions went into effect. Intraoperative albumin utilisation (beta=-101.1, 95% CI -145 to -56.7) and total monthly cost of albumin (beta=-7678, 95% CI -10712 to -4640) demonstrated significant decrease after starting the interventions., Conclusions: At a single academic cardiac surgery programme, implementation of a bundle of simple and low-cost interventions as part of a coordinated QIP were effective in significantly decreasing intraoperative use of albumin, which translated into considerable costs savings., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: The Paediatric Difficult Intubation Collaborative identified multiple attempts and persistence with direct laryngoscopy as risk factors for complications in children with difficult tracheal intubations and subsequently engaged in initiatives to reduce repeated attempts and persistence with direct laryngoscopy in children. We hypothesised these efforts would lead to fewer attempts, fewer direct laryngoscopy attempts and decrease complications., Methods: Paediatric patients less than 18 years of age with difficult direct laryngoscopy were enrolled in the Paediatric Difficult Intubation Registry. We define patients with difficult direct laryngoscopy as those in whom (1) an attending or consultant obtained a Cormack Lehane Grade 3 or 4 view on direct laryngoscopy, (2) limited mouth opening makes direct laryngoscopy impossible, (3) direct laryngoscopy failed in the preceding 6 months, and (4) direct laryngoscopy was deferred due to perceived risk of harm or poor chance of success. We used a 5:1 propensity score match to compare an early cohort from the initial Paediatric Difficult Intubation Registry analysis (August 6, 2012-January 31, 2015, 785 patients, 13 centres) and a current cohort from the Registry (March 4, 2017-March 31, 2023, 3925 patients, 43 centres). The primary outcome was first attempt success rate between cohorts. Success was defined as confirmed endotracheal intubation and assessed by the treating clinician. Secondary outcomes were eventual success rate, number of attempts at intubation, number of attempts with direct laryngoscopy, the incidence of persistence with direct laryngoscopy, use of supplemental oxygen, all complications, and severe complications., Findings: First-attempt success rate was higher in the current cohort (42% vs 32%, OR 1.5 95% CI 1.3-1.8, p < 0.001). In the current cohort, there were fewer attempts (2.2 current vs 2.7 early, regression coefficient -0.5 95% CI -0.6 to -0.4, p < 0.001), fewer attempts with direct laryngoscopy (0.6 current vs 1.0 early, regression coefficient -0.4 95% CI -0.4 to 0.3, p < 0.001), and reduced persistence with direct laryngoscopy beyond two attempts (7.3% current vs 14.1% early, OR 0.5 95% CI 0.4-0.6, p < 0.001). Overall complication rates were similar between cohorts (19% current vs 20% early). Severe complications decreased to 1.8% in the current cohort from 3.2% in the early cohort (OR 0.55 95% CI 0.35-0.87, p = 0.011). Cardiac arrests decreased to 0.8% in the current cohort from 1.8% in the early cohort. We identified persistence with direct laryngoscopy as a potentially modifiable factor associated with severe complications., Interpretation: In the current cohort, children with difficult tracheal intubations underwent fewer intubation attempts, fewer attempts with direct laryngoscopy, and had a nearly 50% reduction in severe complications. As persistence with direct laryngoscopy continues to be associated with severe complications, efforts to limit direct laryngoscopy and promote rapid transition to advanced techniques may enhance patient safety., Funding: None., Competing Interests: Dr. von Ungern-Sternberg’s work is supported by the Stan Perron Charitable Foundation (00058) and through a National Health and Medical Research Council Investigator Grant (2009322) as well as Perth Children’s Hospital Foundation, WA Health Department, Telethon Trust, Australian and New Zeland College of Anaesthetists, Society of Paediatric Anaesthesia NZ/AUS, Thrasher Research Fund, University of Western Australia. Dr. Kovatsis was a medical advisor to Verathon, Inc to December 2020 and Dr. Hunyady is a medical advisor to Verathon, Inc. Dr. Fiadjoe serves in a leadership or fiduciary role for the American Board and Anesthesiology and the Society for Paediatric Anaesthesia. He reports payment or honoraria from Children’s National Hospital and expert testimony for Nemours Foundation. No other external funding or other competing interests declared., (© 2024 The Author(s).)

Purpose: The purpose of this quality improvement (QI) project was to reintroduce and assess the feasibility of a standardized, electronic health record (EHR) handoff tool and to evaluate the sustainability of a structured, team-based approach in a pediatric postanesthesia care unit (PACU)., Design: This QI project used an observational pre-post design using two separate convenience samples of handoffs and perianesthesia providers., Methods: A standardized EHR handoff tool was reintroduced for operating room to pediatric PACU handoff communication. Handoffs between anesthesia providers, surgery team members, and PACU nurses were observed pre- and postreintroduction of the EHR handoff tool. Anesthesia providers and PACU RNs received training for giving and receiving handoffs and were provided directions on locating the EHR handoff tool. A bedside audit of items communicated for the six handoff phases (introductions, situation, background, assessment, recommendations, and questions), handoff duration, team member participation, and handoff tool utilization were performed for 149 handoffs pre- and 146 handoffs postimplementation. To evaluate sustainability, the audits were compared to postimplementation data from the 2014 pilot handoff project., Findings: Following reintroduction, EHR handoff tool use increased from 4% to 19%. There was a statistically significant increase in items communicated for three of the six handoff phases when using the EHR tool (P < .05). There was no statistically significant increase in handoff duration (mean = 3.66 minutes, SD = 1.57 minutes) with the EHR handoff tool. Surgical team member presence for the team-based handoff increased from 90.7% pre to 95.9% post. Provider compliance with the team-based handoff approach, which includes a PACU RN, surgical team member, and anesthesia team member present for handoff, was sustained and increased 6 years postimplementation. Feedback from anesthesia providers and PACU RNs indicated mixed reports of satisfaction with the EHR tool, perceived handoff efficiency, and consistency in both giving and receiving handoff. Adherence to five of the six structured handoff phases, except introductions, was sustained and even improved 6 years following implementation., Conclusions: Evidence-based practice for handoff communication supports the use of a team approach and standardized EHR handoff tools. The reintroduction of a standardized EHR handoff tool improved the completeness of information transfer, yet did not lead to widespread adoption nor improved user satisfaction. There is an ongoing need to identify adoptable and sustainable perioperative handoff methods., (Copyright © 2023 American Society of PeriAnesthesia Nurses. Published by Elsevier Inc. All rights reserved.)

Background: Difficult facemask ventilation is perilous in children whose tracheas are difficult to intubate. We hypothesised that certain physical characteristics and anaesthetic factors are associated with difficult mask ventilation in paediatric patients who also had difficult tracheal intubation., Methods: We queried a multicentre registry for children who experienced "difficult" or "impossible" facemask ventilation. Patient and case factors known before mask ventilation attempt were included for consideration in this regularised multivariable regression analysis. Incidence of complications, and frequency and efficacy of rescue placement of a supraglottic airway device were also tabulated. Changes in quality of mask ventilation after injection of a neuromuscular blocking agent were assessed., Results: The incidence of difficult mask ventilation was 9% (483 of 5453 patients). Infants and patients having increased weight, being less than 5th percentile in weight for age, or having Treacher-Collins syndrome, glossoptosis, or limited mouth opening were more likely to have difficult mask ventilation. Anaesthetic induction using facemask and opioids was associated with decreased risk of difficult mask ventilation. The incidence of complications was significantly higher in patients with "difficult" mask ventilation than in patients without. Rescue placement of a supraglottic airway improved ventilation in 71% (96 of 135) of cases. Administration of neuromuscular blocking agents was more frequently associated with improvement or no change in quality of ventilation than with worsening., Conclusions: Certain abnormalities on physical examination should increase suspicion of possible difficult facemask ventilation. Rescue use of a supraglottic airway device in children with difficult or impossible mask ventilation should be strongly considered., (Copyright © 2023 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Objective: This article describes the methodology used for the Pediatric Craniofacial Collaborative Group (PCCG) Consensus Conference., Design: This is a novel Consensus Conference of national experts in Pediatric Craniofacial Surgery and Anesthesia, who will follow standards set by the Institute of Medicine and using the Research and Development/University of California, Los Angeles appropriateness method, modeled after the Pediatric Critical Care Transfusion and Anemia Expertise Initiative. Topics related to pediatric craniofacial anesthesia for open cranial vault surgery were divided into twelve subgroups with a systematic review of the literature., Setting: A group of 20 content experts met virtually between 2019 and 2020 and will collaborate in their selected topics related to perioperative management for pediatric open cranial vault surgery for craniosynostosis. These groups will also identify where future research is needed., Conclusions: Experts in pediatric craniofacial surgery and anesthesiology are developing recommendations on behalf of the Pediatric Craniofacial Collaborative Group for perioperative management of patients undergoing open cranial vault surgery for craniosynostosis and identifying future research priorities., (© 2020 John Wiley & Sons Ltd.)

Intravenous administration of acetaminophen is an alternative to the oral and rectal routes, which may be contraindicated in particular clinical settings. This randomized, placebo-controlled study of intravenous acetaminophen (Ofirmev, Mallinckrodt Pharmaceuticals, Bedminster, New Jersey) in neonate and infant patients with acute postoperative pain assessed pharmacokinetics (PK) and safety, in addition to efficacy and pharmacodynamics of repeated doses administered over 24 hours. Neonate and infant patients (<2 years of age) who were undergoing surgery or had experienced a traumatic injury and were expected to need pain management for at least 24 hours were enrolled. Subjects were randomly assigned to receive intravenous acetaminophen low dose, intravenous acetaminophen high dose, or placebo. A population PK model of intravenous acetaminophen was updated by combining 581 samples from the current study of 158 neonate and infant subjects with results from a previously developed model. The individual predicted-versus-observed concentrations plots showed that the structural PK model fit the blood and plasma acetaminophen concentration-versus-time profiles in the active and placebo groups. Terminal elimination half-life was prolonged in neonates and younger infants and in intermediate and older infants similar to values in adults. When compared with placebo, total rescue opioid consumption was similar and significantly fewer intravenous acetaminophen patients prematurely discontinued because of treatment-emergent adverse events (P < .01). For intravenous acetaminophen, neonates receiving 12.5 mg/kg every 6 hours had PK profiles similar to younger, intermediate, and older infants, adolescents, and adults weighing <50 kg receiving 15 mg/kg every 6 hours and adults ≥ 50 kg receiving 1000 mg every 6 hours., (© 2019 Mallinckrodt. The Journal of Clinical Pharmacology published by Wiley Periodicals, Inc. on behalf of American College of Clinical Pharmacology.)

Objective: Patient safety is challenging for health systems around the world, particularly in low-and middleincome countries such as Guatemala. The goal of this report is to summarize a strategic planning process for a national patient safety plan in Guatemala., Methods: This strategic planning process involved multiple stakeholders, including representatives of the Guatemala Ministry of Health and Social Assistance, medical leadership from across the public health system, and academic experts from Guatemala and the United States of America. We used mixed methods (quantitative and qualitative surveys) and a nominal group technique at a national symposium to prioritize patient safety challenges across Guatemala, and subsequent meetings to develop a national patient safety plan., Results: This national patient safety plan outlines four domains to advance patient safety across the public hospital system over a five-year period in Guatemala: leadership and governance, training and awareness, safety culture, and outcome metrics. For each domain, we developed a set of goals, activities, outputs, and benchmarks to be overseen by the Ministry of Health., Conclusions: With this national patient safety plan, Guatemala has made a long-term commitment to improving patient safety across the public hospital system of Guatemala. Future efforts will require its extension to all levels of the Guatemalan health system., Competing Interests: Conflicts of interest. None declared.

Purpose: Pediatric patients undergoing complex cranial vault reconstruction (CCVR) are at risk of significant perioperative blood loss requiring blood product transfusion. Minimizing allogeneic blood product transfusion is an important goal because of the associated risks and cost. The impact of patient and surgical variables on transfusion is unknown in this population. Our primary aim was to examine relationships between demographic and perioperative variables and blood product transfusion outcomes in CCVR., Methods: The multicentre Pediatric Surgery Perioperative Registry was checked for children undergoing CCVR between June 2012 and September 2016. Univariable and multivariable analyses were performed examining patient, procedure, and blood conservation variables and their relationship to three outcomes: intraoperative red blood cell-containing product (RBC-CP) transfusion, total perioperative blood donor exposures, and transfusion-free hospitalization., Results: The registry search returned data from 1,814 cases. Age and surgical duration were the only variables significantly associated with all three outcomes studied. Predictors of reduced RBC-CP transfusion included lower American Society of Anesthesiologists (ASA) physical status and antifibrinolytic administration. Total cranial vault reconstruction, intraoperative vasoactive infusion, and presence of a tracheostomy predicted increased donor exposures. Increased body weight, higher preoperative hematocrit, and utilization of intraoperative cell saver and transfusion protocols were associated with transfusion-free hospitalization., Conclusion: Clinical factors associated with increased allogeneic blood product transfusion in pediatric CCVR include: age ≤ 24 months, ASA status ≥ III, preoperative anemia, prolonged surgical duration, lack of intraoperative antifibrinolytic use, lack of intraoperative cell saver use, and the lack of transfusion protocols.

Background: The current incidence of major complications in paediatric craniofacial surgery in North America has not been accurately defined. In this report, the Pediatric Craniofacial Collaborative Group evaluates the incidence and determines the independent predictors of major perioperative complications using a multicentre database., Methods: The Pediatric Craniofacial Surgery Perioperative Registry was queried for subjects undergoing complex cranial vault reconstruction surgery over a 5-year period. Major perioperative complications were identified through a structured a priori consensus process. Logistic regression was applied to identify predictors of a major perioperative complication with bootstrapping to evaluate discrimination accuracy and provide internal validity of the multivariable model., Results: A total of 1814 patients from 33 institutions in the US and Canada were analysed; 15% were reported to have a major perioperative complication. Multivariable predictors included ASA physical status 3 or 4 (P=0.005), craniofacial syndrome (P=0.008), antifibrinolytic administered (P=0.003), blood product transfusion >50 ml kg -1 (P<0.001), and surgery duration over 5 h (P<0.001). Bootstrapping indicated that the predictive algorithm had good internal validity and excellent discrimination and model performance. A perioperative complication was estimated to increase the hospital length of stay by an average of 3 days (P<0.001)., Conclusions: The predictive algorithm can be used as a prognostic tool to risk stratify patients and thereby potentially reduce morbidity and mortality. Craniofacial teams can utilise these predictors of complications to identify high-risk patients. Based on this information, further prospective quality improvement initiatives may decrease complications, and reduce morbidity and mortality., (Copyright © 2018 British Journal of Anaesthesia. Published by Elsevier Ltd. All rights reserved.)

Background: Universal protocol implementation can be challenging in low-income or middle-income countries, particularly when providers work together across language barriers. The aim of this quality improvement initiative was to test the implementation of a colour-coded universal protocol in a Guatemalan hospital staffed by US and Guatemalan providers., Methods: From 2013 to 2016, a US and Guatemalan team implemented a universal protocol at a Guatemalan surgical centre for children undergoing general surgical or urologic procedures. The protocol was a two-step patient identification and documentation checklist, with the first step of all chart element verification in the preoperative area, after which a blue hat was placed on the patient as a visual cue that this was completed. The second step included checklist confirmation in the operating room prior to the procedure. We tested protocol implementation over three phases, identifying implementation barriers and modifying clinical workflow after each phase. We measured the error rate in documentation or other universal protocol steps at each phase and made modifications based on iterative analysis., Results: Over the course of programme implementation, we substantially decreased the rate of errors in documentation or other universal protocol elements. After the first phase, 30/51 patients (58.8%) had at least one error. By the third phase, only 2/43 patients (4.6%) had any errors. All errors were corrected prior to surgery with no adverse outcomes., Conclusions: Care teams of providers from different countries pose potential challenges with patient safety. Implementation of a colour-coded universal protocol in this setting can prevent and reduce errors that could potentially lead to patient harm., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Background: Infants with congenital heart disease often require feeding tube placement to supplement oral intake. Gastrostomy tubes may be placed by either surgical or percutaneous endoscopic methods, but there is currently no data comparing outcomes of these procedures in this population., Aims: The aim of our retrospective study was to investigate the perioperative outcomes between the 2 groups to determine if there are clinically significant differences., Methods: We reviewed the charts of all infants with congenital heart disease at a single academic institution having isolated surgical or percutaneous endoscopic gastrostomy tube placement from January 2011 to December 2015. Anesthetic time, defined by cumulative minimum alveolar concentration hours of exposure to volatile anesthetic, was the primary outcome. Operative time, intraoperative complications, and postoperative intensive care admissions were secondary outcomes., Results: One hundred and one infants with congenital heart disease were included in this study. Anesthetic exposure was shorter in the endoscopic group than the surgical group (0.20 MAC-hours vs 0.56 MAC-hours, 95% confidence interval 0.23, 0.49, P < .001). Average operative times were also shorter in the endoscopic gastrostomy vs the surgical group (8 ± 0.7 minutes vs 35 ± 1.3 minutes, 95% confidence interval 23.7, 31.0, P < .001). Adjusting for prematurity and preoperative risk category, the surgical group was associated with a 3.45 fold increase in the likelihood of a higher level of care postoperatively (95% confidence interval 1.20, 9.90, P = .02)., Conclusion: In infants with congenital heart disease, percutaneous endoscopic gastrostomy placement is associated with reduced anesthetic exposure and fewer postoperative intensive care unit admissions compared to surgical gastrostomy., (© 2018 John Wiley & Sons Ltd.)

Introduction: Surgical correction of pediatric scoliosis is associated with significant blood loss. Minimizing estimated blood loss and blood transfusion is beneficial as transfusions have been associated with increased morbidity, including risk of surgical site infections, longer hospitalizations, and increased cost. Although there is evidence that African-American or Black adults are more likely to require intraoperative blood transfusion compared with Caucasian or White adults, the reasons for this difference are unclear., Methods: The electronic records for all patients <18 y/o undergoing primary corrective scoliosis surgery by a single pediatric orthopedic surgeon at a single academic medical center between 2013 and 2015 were collected and reviewed. Multivariate models were performed to assess the association between Black race and blood loss/transfusion in primary pediatric scoliosis surgery., Results: In a multivariate model, Black race was independently associated with 1.61 times higher estimated blood loss than White race (P < .01; 95% CI = 1.16-2.23). Additionally, compared to a White patient, the odds a Black patient received blood transfusion was 6.25 times higher (P = .03; 95% CI = 1.56-25.06) and among the patients who received blood transfusion, Black race was independently associated with 2.61 times greater volume of blood transfusion than White race (P < .01; 95% CI = 1.54-4.41)., Conclusion: Black race was independently associated with increased estimated blood loss, increased rate of blood transfusion, and increased amount of blood transfused during surgical correction of pediatric scoliosis. Further investigation is needed to better understand the etiology of the disparity and assess opportunities for improving outcomes., (© 2018 John Wiley & Sons Ltd.)

Introduction: Recent reports have suggested that caudal anesthesia may be associated with an increased risk of postoperative surgical complications. We examined our experience with caudal anesthesia in hypospadias repair to evaluate for increased risk of urethrocutaneous fistula or glanular dehiscence., Methods: All hypospadias repairs performed by a single surgeon in 2001-2014 were reviewed. Staged or revision surgeries were excluded. Patient age, weight, hypospadias severity, surgery duration, month and year of surgery, caudal anesthesia use, and postoperative complications were recorded. Bivariate and multivariate statistical analyses were performed., Results: We identified 395 single-stage primary hypospadias repairs. Mean age was 15.6 months; 326 patients had distal (83%) and 69 had proximal (17%) hypospadias. Caudal anesthetics were used in 230 (58%) cases; 165 patients (42%) underwent local penile block at the discretion of the surgeon and/or anesthesiologist. Complications of urethrocutaneous fistula or glanular deshiscence occurred in 22 patients (5.6%) and were associated with caudal anesthetic use (OR 16.5, 95% CI 2.2-123.8, P = 0.007), proximal hypospadias (OR 8.2, 95% CI 3.3-20.0, P < 0.001), increased surgical duration (OR 1.01, 95% CI 1.01-1.02, P < 0.001), and earlier year of practice (OR 3.0, 95% CI 1.2-7.9, P = 0.03 for trend). After adjusting for confounding variables via multivariable logistic regression, both caudal anesthetic use (OR 13.4, 95% CI 1.8-101.8, P = 0.01) and proximal hypospadias (OR 6.8, 95% CI 2.7-16.9, P < 0.001) remained highly associated with postoperative complications., Conclusions: In our experience, caudal anesthesia was associated with an over 13-fold increase in the odds of developing postoperative surgical complications in boys undergoing hypospadias repair even after adjusting for urethral meatus location. Until further investigation occurs, clinicians should carefully consider the use of caudal anesthesia for children undergoing hypospadias repair., (© 2017 John Wiley & Sons Ltd.)

Service dogs are beneficial in providing assistance to people with multiple types of disabilities and medical disorders including visual impairment, physical disabilities, seizure disorders, diabetes, and mental illness. Some service animals have been trained as a screening tool for cancer. We review a case involving a 6-year-old female with a history of mast cell mediator release and immediate hypersensitivity due to the urticaria pigmentosa variant of cutaneous mastocytosis who underwent a cystourethroscopy. Her service dog, JJ, who would alert to mast cell mediator release, was used throughout the perioperative course as a means of anxiolysis and comfort and to monitor for mast cell mediator release. This case presents an example of a service dog used in a family-care model in the field of anesthesiology and provides a unique example of using a service dog as an additional monitor to alert the care team for impending mast cell mediator release.

Mastocytosis includes a spectrum of diseases characterized by abnormal mast cell infiltration in various organs, which can lead to mast cell mediator release and immediate hypersensitivity. We review anesthetic challenges presented by a 6-year-old girl with a history of mast cell mediator release because of the urticaria pigmentosa variant of cutaneous mastocytosis, factor VII deficiency, increasing episodes of urinary tract infections, and pyelonephritis. She underwent spine magnetic resonance imaging, subsequent lumbar laminectomy for fatty filum release, and a cystourethroscopy. Perioperative management included factor VII desensitization, avoidance of triggers, minimizing histamine-releasing medications, mast cell stabilization, and preparation for potential immediate hypersensitivity.

Pediatric emergence delirium is a postoperative phenomenon characterized by aberrant cognitive and psychomotor behavior, which can place the patient and health care personnel at risk for injury. A common tool for identifying emergence delirium is the Level of Consciousness-Richmond Agitation and Sedation Scale (LOC-RASS), although it has not been validated for use in the pediatric population. The Pediatric Anesthesia Emergence Delirium Scale (PAED) is a newly validated tool to measure emergence delirium in children. We chose to implement and evaluate the effectiveness and fidelity of using the PAED Scale to identify pediatric emergence delirium in one eight-bed postanesthesia care unit in comparison with the traditional LOC-RASS. The overall incidence of pediatric emergence delirium found by using the LOC-RASS with a retrospective chart review (3%) was significantly lower than the incidence found by using the LOC-RASS (7.5%) and PAED Scale (11.5%) during the implementation period. Our findings suggest that the PAED Scale may be a more sensitive measure of pediatric emergence delirium, and, in the future, we recommend that health care personnel at our facility use the PAED Scale rather than the LOC-RASS., (Copyright © 2014 AORN, Inc. Published by Elsevier Inc. All rights reserved.)

Access to pediatric surgical care is limited in low- and middle-income countries. Barriers must be identified before improvements can be made. This pilot study aimed to identify self-reported barriers to pediatric surgical care in Guatemala. We surveyed 78 families of Guatemalan children with surgical conditions who were seen at a pediatric surgical clinic in Guatemala City. Spanish translators were used to complete questionnaires regarding perceived barriers to surgical care. Surgical conditions included hernias, rectal prolapse, anorectal malformations, congenital heart defects, cryptorchidism, soft tissue masses, and vestibulourethral reflux. Average patient age was 8.2 years (range, 1 month to 17 years) with male predominance (62%). Families reported an average symptom duration of 3.7 years before clinic evaluation. Families traveled a variety of distances to obtain surgical care: 36 per cent were local (less than 10 km), 17 per cent traveled 10 to 50 km, and 47 per cent traveled greater than 50 km. Other barriers to surgery included financial (58.9%), excessive wait time in the national healthcare system (10. 2%), distrust of local surgeons (37.2%), and geographic inaccessibility to surgical care (10.2%). The majority of study patients required outpatient procedures, which could improve their quality of life. Many barriers to pediatric surgical care exist in Guatemala. Interventions to remove these obstacles may enhance access to surgery and benefit children in low- and middle-income countries.

Background: Effective communication with patients having limited proficiency in the native language of anesthesia care providers during the perioperative period is often challenging. We describe how we developed, implemented, and evaluated a computerized system to convey frequently used prerecorded phrases related to perioperative anesthesia care in the languages we most often encounter in such patients., Methods: Phrases were chosen through a consensus process among anesthesia department members. These included routine sayings used to inform patients about what they should anticipate, what interventions we are performing, and how they can participate. Common questions requiring a "yes" or "no" answer were also identified. We recorded these phrases using native speakers who were both knowledgeable medically and familiar with the culture of the patients to provide accurate translations. We developed a software application that categorically grouped the phrases and allowed care providers to select a phrase and play the associated sound file to the patient and deployed the program on our touchscreen-enabled anesthesia information management system workstations. A convenience sample of obstetrical patients speaking a Chinese dialect with whom the language program was used were asked to complete an anonymous questionnaire, translated into Chinese, about their experience. Ninety-five percent lower confidence limits (LCLs) were calculated for response proportions., Results: We approached 25 parturients with varying levels of English comprehension, and all agreed to use the language program. Each used it throughout her interaction with the anesthesia care providers during labor and delivery, and all patients completed the survey. Acceptance of the process was high, with all patients indicating that they would like to use it again were they to return for another procedure requiring anesthesia. Eighty-eight percent (LCL = 73%) indicated that having instructions in their native language made them feel more relaxed, whereas the experience was neutral in the remainder. Comprehension of the phrases presented was high, with 96% (LCL = 83%) indicating that they understood all instructions. Ninety-six percent (LCL = 83%) of patients indicated that they would be likely to refer friends and family to our institution based on the availability of this device., Conclusions: Although patient safety likely could be improved by use of a communication device such as the one we developed, our study was insufficiently powered to be able to measure this potential improvement. The process we describe should be useful wherever anesthesia care providers are not able to communicate in the same language as their patients.