Bishr Haydar

Thoracoscopic vs Open Lobectomy in Infants and Young Children with Congenital Lung Malformations

BACKGROUND Although thoracoscopic lobectomy is a widely accepted surgical procedure in adult thoracic surgery, its role in small children remains controversial. The purpose of this study was to evaluate perioperative outcomes after thoracoscopic and open lobectomy in infants and young children with congenital lung malformations at a single academic referral center. STUDY DESIGN A cohort study of 62 consecutive children who underwent elective pulmonary lobectomy for a congenital lung lesion between 2001 and 2013 was performed. Patient demographics and perioperative outcomes were evaluated in univariate and logistic regression analyses. RESULTS Forty-nine patients underwent thoracoscopy and 13 had a thoracotomy. Six children undergoing thoracoscopy required conversion to thoracotomy (conversion 12.2%). Perioperative outcomes, including median blood loss (2.0 vs 1.1 mL/kg; p = 0.34), chest tube duration (3 vs 3 days; p = 0.33), hospital length of stay (3 vs 3 days; p = 0.42), and morbidity as defined by the Accordion Grading Scale (30.6% vs 30.8%; p = 0.73), were similar between thoracoscopy and thoracotomy, respectively. Although thoracoscopy was associated with increased operative duration compared with thoracotomy (239.9 vs 181.2 minutes, respectively; p = 0.03), thoracoscopy operative times decreased with increasing institutional experience (p = 0.048). Thoracoscopic lobectomy infants younger than 5 months of age had a 2.5-fold higher rate of perioperative adverse outcomes compared with older children (p = 0.048). CONCLUSIONS In small children undergoing pulmonary lobectomy, both thoracoscopy and thoracotomy are associated with similar perioperative outcomes. The cosmetic and musculoskeletal benefits of the thoracoscopic approach must be balanced against institutional expertise and a potentially higher risk for complications in younger patients.

Failure of the laryngeal mask airway unique™ and classic™ in the pediatric surgical patient: A study of clinical predictors and outcomes

Background:Although predictors of laryngeal mask airway failure in adults have been elucidated, there remains a paucity of data regarding laryngeal mask airway failure in children. Methods:The authors performed a retrospective database review of all pediatric patients who received a laryngeal mask anesthetic at their institution from 2006 to 2010. Device brands were restricted to LMA Unique™ (Cardinal Health, Dublin, OH) and LMA Classic™ (LMA North America, San Diego, CA), and primary outcome was laryngeal mask failure, defined as any airway event requiring device removal and tracheal intubation. Potential risk factors were analyzed with both univariate and multivariate techniques and included medical history, physical examination, surgical, and anesthetic characteristics. Results:Of the 11,910 anesthesia cases performed in the study, 102 cases (0.86%) experienced laryngeal mask failure. Common presenting features of laryngeal mask failures included leak (25%), obstruction (48%), and patient intolerance such as intractable coughing/bucking (11%). Failures occurred before incision in 57% of cases and after incision in 43%. Independent clinical associations included ear/nose/throat surgical procedure, nonoutpatient admission status, prolonged surgical duration, congenital/acquired airway abnormality, and patient transport. Conclusions:The findings of the study support the use of the LMA Unique™ and LMA Classic™ as reliable pediatric supraglottic airway devices, demonstrating relatively low failure rates. Predictors of laryngeal mask airway failure in the pediatric surgical population do not overlap with those in the adult population and should therefore be independently considered.

Urethrocutaneous fistula following hypospadias repair: regional anesthesia and other factors

Urethrocutaneous fistula is a well‐known complication of hypospadias surgery. A recent prospective study by Kundra et al. (Pediatr Anesth 2012) has suggested that caudal anesthesia may increase the risk of fistula formation. We sought to evaluate this possible association and determine if any other novel factors may be associated with fistula formation.

Resident characterization of better-than- and worse-than-average clinical teaching.

Background:Clinical teachers and trainees share a common view of what constitutes excellent clinical teaching, but associations between these behaviors and high teaching scores have not been established. This study used residents’ written feedback to their clinical teachers, to identify themes associated with above- or below-average teaching scores. Methods:All resident evaluations of their clinical supervisors in a single department were collected from January 1, 2007 until December 31, 2008. A mean teaching score assigned by each resident was calculated. Evaluations that were 20% higher or 15% lower than the resident’s mean score were used. A subset of these evaluations was reviewed, generating a list of 28 themes for further study. Two researchers then, independently coded the presence or absence of these themes in each evaluation. Interrater reliability of the themes and logistic regression were used to evaluate the predictive associations of the themes with above- or below-average evaluations. Results:Five hundred twenty-seven above-average and 285 below-average evaluations were evaluated for the presence or absence of 15 positive themes and 13 negative themes, which were divided into four categories: teaching, supervision, interpersonal, and feedback. Thirteen of 15 positive themes correlated with above-average evaluations and nine had high interrater reliability (Intraclass Correlation Coefficient >0.6). Twelve of 13 negative themes correlated with below-average evaluations, and all had high interrater reliability. On the basis of these findings, the authors developed 13 recommendations for clinical educators. Conclusions:The authors developed 13 recommendations for clinical teachers using the themes identified from the above- and below-average clinical teaching evaluations submitted by anesthesia residents.

Pediatric Cardiopulmonary Arrest in the Postanesthesia Care Unit, Rare but Preventable: Analysis of Data From Wake Up Safe, The Pediatric Anesthesia Quality Improvement Initiative.

BACKGROUND: Nearly 20% of anesthesia-related pediatric cardiac arrests (CAs) occur during emergence or recovery. The aims of this case series were to use the Wake Up Safe database to describe the following: (1) the nature of pediatric postanesthesia care unit (PACU) CA and subsequent outcomes and (2) factors associated with harm after pediatric PACU CA. METHODS: Pediatric CAs in the PACU were identified from the Wake Up Safe Pediatric Anesthesia Quality Improvement Initiative, a multicenter registry of adverse events in pediatric anesthesia. Demographics, underlying conditions, cause of CA, and outcomes were extracted. Descriptive statistics were used to characterize data and to assess risk of harm in those suffering CA. RESULTS: A total of 26 CA events were included: 67% in children <5 years, and 30% in infants (<1 year); 18 (69%) were deemed likely or almost certainly preventable. All preventable CAs were respiratory in nature and most (67%) had purported root causes that included provider judgment or inexperience, inadequate supervision, and competing priorities. CAs of cardiac origin were associated with increased level of harm (temporary or greater), whereas those of respiratory origin were associated more often with no harm. CONCLUSIONS: PACU CA events are rare and generally survivable, with better outcomes for respiratory-based events, but most were deemed preventable, suggesting a need for further vigilance in the early postoperative period. Maintenance of monitoring during patient transport to PACU and continuing care by anesthesia care providers until emergence from anesthesia may further reduce the preventable arrest rate. The root cause analyses conducted by individual institutions reporting these data to the Wake Up Safe provided only limited insight, so multicenter collaborative approaches may allow for greater insight into effective CA-prevention strategies.

Caudal clonidine and apnea risk

SIR—I read with interest the challenging editorial by Dr. L€ onnqvist on the use of adjuncts with regional anesthesia (1). As with his previous work on the subject, I commend his forward thinking and crisp review, although I disagree with one specific recommendation. In Table 1, he recommends the use of clonidine as an adjunct to local anesthesia in a caudal epidural block in ex-premature babies, neonates, and infants, and cites five articles to support this practice. ‘Only one relevant case report exists linking the use of adjunct clonidine to postoperative apnea following awake caudal blockade in an ex-premature baby’, he wrote (1). For ex-premature infants and neonates, perioperative respiratory events including apnea present the greatest perioperative risk. Of the five citations listed to support clonidine use in this population, four did not concern the use of clonidine in humans. The fifth, a metaanalysis by Engelman, includes no patients under age 6 months; and many of the studies with infants under 1 year failed to capture perioperative respiratory events (2). The case report he notes may be the only case he finds relevant; however, it is common practice to use caudal analgesia in conjunction with general anesthesia. A decade ago, Dr. Hansen found three cases concerning for caudal clonidine-induced apnea (3). The case noted by Dr. L€ onnqvist detailed the use of two procedures, both using caudal blocks, in the same patient; one contained clonidine and one did not. This patient developed multiple apneas following caudal clonidine, causing a prolonged hospital stay, and had no apneas with the clonidine-free caudal block. Caudal clonidine is increasingly being viewed as safe for outpatient use for older children (4). A casual reader may choose to give caudal clonidine to a patient at high risk for apnea based on a cursory reading of Dr. L€ onnqvist’s editorial. In view of the cases noted by Dr. Hansen, the safety profile for patients at high risk of apnea, such as ex-premature babies and neonates, should be demonstrated before it is routinely recommended. In fact, Dr. L€ onnqvist has previously supported this general view. In an editorial he authored in 2005, he admonished readers not to use untested drugs in children’s neuraxial space (5). While there are multiple studies on the use of intrathecal clonidine in this population, I submit that his recommendation of the use of caudal clonidine in neonates and ex-premature infants is premature and should be withdrawn. My concern also stems from personal experience, as I attended a bradycardic cardiac arrest in an ex-premature infant on the inpatient ward. This arrest was caused by and preceded by numerous apneas. This patient had received 1 lg kg 1 caudal clonidine and general anesthesia hours earlier, and no other causal factor could readily be found.

A Feedback and Evaluation System That Provokes Minimal Retaliation by Trainees

Background: Grade inflation is pervasive in educational settings in the United States. One driver of grade inflation may be faculty concern that assigning lower clinical performance scores to trainees will cause them to retaliate and assign lower teaching scores to the faculty member. The finding of near-zero retaliation would be important to faculty members who evaluate trainees. Methods: The authors used a bidirectional confidential evaluation and feedback system to test the hypothesis that faculty members who assign lower clinical performance scores to residents subsequently receive lower clinical teaching scores. From September 1, 2008, to February 15, 2013, 177 faculty members evaluated 188 anesthesia residents (n = 27,561 evaluations), and 188 anesthesia residents evaluated 204 faculty members (n = 25,058 evaluations). The authors analyzed the relationship between clinical performance scores assigned by faculty members and the clinical teaching scores received using linear regression. The authors used complete dyads between faculty members and resident pairs to conduct a mixed effects model analysis. All analyses were repeated for three different epochs, each with different administrative attributes that might influence retaliation. Results: There was no relationship between mean clinical performance scores assigned by faculty members and mean clinical teaching scores received in any epoch (P ≥ 0.45). Using only complete dyads, the authors’ mixed effects model analysis demonstrated a very small retaliation effect in each epoch (effect sizes of 0.10, 0.06, and 0.12; P ⩽ 0.01). Conclusions: These results imply that faculty members can provide confidential evaluations and written feedback to trainees with near-zero impact on their mean teaching scores.

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Failure of the Laryngeal Mask Airway Unique™ and Classic™ in the Pediatric Surgical Patient: A Study of Clinical Predictors and Outcomes

Background: Although predictors of laryngeal mask airway failure in adults have been elucidated, there remains a paucity of data regarding laryngeal mask airway failure in children. Methods: The authors performed a retrospective database review of all pediatric patients who received a laryngeal mask anesthetic at their institution from 2006 to 2010. Device brands were restricted to LMA UniqueTM (Cardinal Health, Dublin, OH) and LMA ClassicTM (LMA North America, San Diego, CA), and primary outcome was laryngeal mask failure, defined as any airway event requiring device removal and tracheal intubation. Potential risk factors were analyzed with both univariate and multivariate techniques and included medical history, physical examination, surgical, and anesthetic characteristics. Results: Of the 11,910 anesthesia cases performed in the study, 102 cases (0.86%) experienced laryngeal mask failure. Common presenting features of laryngeal mask failures included leak (25%), obstruction (48%), and patient intolerance such as intractable coughing/bucking (11%). Failures occurred before incision in 57% of cases and after incision in 43%. Independent clinical associations included ear/nose/ throat surgical procedure, nonoutpatient admission status, prolonged surgical duration, congenital/acquired airway abnormality, and patient transport. Conclusions: The findings of the study support the use of the LMA UniqueTM and LMA ClassicTM as reliable pediatric supraglottic airway devices, demonstrating relatively low failure rates. Predictors of laryngeal mask airway failure in the pediatric surgical population do not overlap with those in the adult population and should therefore be independently considered.