Brad M. Taicher

Standardizing postoperative PICU handovers improves handover metrics and patient outcomes.

Objectives: To improve handover communication and patient outcomes for postoperative admissions to a multidisciplinary PICU. Design: Prospective cohort study. Setting: Multidisciplinary PICU in a university hospital. Subjects: The multidisciplinary team responsible for postoperative PICU admissions and patient care, including attending, fellow, house staff physicians, and nurses from pediatric critical care medicine, surgery, and anesthesia. Interventions: An online survey distributed to PICU, surgery, and anesthesia providers identified existing barriers and challenges to effective postoperative PICU handovers and guided the formation of a standard protocol. Handovers for postoperative PICU admissions were then directly observed for 3 months pre- and postimplementation of the protocol, with data collected on communication, metrics, and patient outcomes. Observations and data collection, as well as the online provider survey, were repeated approximately 1 year after handover protocol implementation. Measurements and Main Results: Survey data demonstrated increases in provider ratings of handover attendance, communication, and quality after implementation of the handover protocol (p < 0.001). Surgical report errors were eliminated (p = 0.03), and the prevalence of provider attendance for the handover duration increased from 39.3% to 68.2% (p = 0.01). Following protocol implementation, fewer patients experienced antibiotic delays (34.5% to 13.9%; p = 0.03) or required hemodynamic or respiratory interventions within the first 6 hours of PICU admission (24.6% to 9.1%; p = 0.04). Patients received their first dose of analgesia (62.3 to 17.4 min; p = 0.01) and had their admission laboratory studies sent (42.3 to 32.9 min; p = 0.04) more quickly. Data collected at 12 months postimplementation demonstrated sustained reductions in analgesia timing, antibiotic delays, and handover barriers. Conclusions: Postoperative communication and patient outcomes can be improved and sustained over time with implementation of a standardized handover protocol.

Identifying Pediatric Emergence Delirium by Using the PAED Scale: A Quality Improvement Project

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.

The association between caudal anesthesia and increased risk of postoperative surgical complications in boys undergoing hypospadias repair

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.

Perioperative Outcomes and Management in Pediatric Complex Cranial Vault Reconstruction: A Multicenter Study from the Pediatric Craniofacial Collaborative Group

Background: The Pediatric Craniofacial Collaborative Group established the Pediatric Craniofacial Surgery Perioperative Registry to elucidate practices and outcomes in children with craniosynostosis undergoing complex cranial vault reconstruction and inform quality improvement efforts. The aim of this study is to determine perioperative management, outcomes, and complications in children undergoing complex cranial vault reconstruction across North America and to delineate salient features of current practices. Methods: Thirty-one institutions contributed data from June 2012 to September 2015. Data extracted included demographics, perioperative management, length of stay, laboratory results, and blood management techniques employed. Complications and outlier events were described. Outcomes analyzed included total blood donor exposures, intraoperative and perioperative transfusion volumes, and length of stay outcomes. Results: One thousand two hundred twenty-three cases were analyzed: 935 children aged less than or equal to 24 months and 288 children aged more than 24 months. Ninety-five percent of children aged less than or equal to 24 months and 79% of children aged more than 24 months received at least one transfusion. There were no deaths. Notable complications included cardiac arrest, postoperative seizures, unplanned postoperative mechanical ventilation, large-volume transfusion, and unplanned second surgeries. Utilization of blood conservation techniques was highly variable. Conclusions: The authors present a comprehensive description of perioperative management, outcomes, and complications from a large group of North American children undergoing complex cranial vault reconstruction. Transfusion remains the rule for the vast majority of patients. The occurrence of numerous significant complications together with large variability in perioperative management and outcomes suggest targets for improvement.

The efficacy of GlideScope ® videolaryngoscopy compared with direct laryngoscopy in children who are difficult to intubate: An analysis from the paediatric difficult intubation registry

Background We analysed data from the Paediatric Difficult Intubation Registry examining the use of direct laryngoscopy and GlideScope® videolaryngoscopy. Methods Data collected by a multicentre, paediatric difficult intubation registry from 1295 patients were analysed. Rates of success and complications between direct laryngoscopy and GlideScope videolaryngoscopy were analysed. Results Initial (464/877 = 53% vs 33/828 = 4%, Z-test = 22.2, P < 0.001) and eventual (720/877 = 82% vs. 174/828 = 21%, Z-test = 25.2, P < 0.001) success rates for GlideScope were significantly higher than direct laryngoscopy. Children weighing <10 kg had lower success rates with the GlideScope than the group as a whole. There were no differences in complication rates per attempt between direct laryngoscopy and GlideScope. The direct laryngoscopy group had more complications associated with the greater number of attempts needed to intubate. There were no increased risks of hypoxia or trauma with GlideScope use. Each additional attempt at intubation with either device resulted in a two-fold increase in complications (odds ratio: 2.0, 95% confidence interval: 1.5-2.5, P < 0.001). Conclusions During difficult tracheal intubation in children, direct laryngoscopy is an overly used technique with a low chance of success. GlideScope use was associated with a higher chance of success with no increased risk of complications. GlideScope use in children with difficult tracheal intubation has a lower success rate than in adults with difficult tracheal intubation. Children weighing less than 10 kilograms had lower success rates with either device. Attempts should be minimized with either device to decrease complications.

Electronic reminders for intraoperative antibiotic re-dosing

To the Editor, Administration of antibiotics within one hour of surgical incision for qualifying surgeries has become the standard of care for reducing the incidence of surgical-site infections, as described by the United States’ Joint Commission Surgical Care Improvement Project. Interestingly, although re-dosing antibiotics during prolonged surgical cases is also recommended, the dosing interval is often determined by a hospital’s Antimicrobial Stewardship and Evaluation Team (ASET) and may vary by antibiotic and by hospital. Although anesthesia providers at our institution are aware of these recommendations, and compliance with pre-incisional antibiotic dosing is [ 99.9%, a recent convenience sample revealed that our compliance with antibiotic redosing during long cases was sub-optimal [68/88 (77.3%)]. Furthermore, a preliminary review of the 20 cases that failed to re-dose in a timely manner revealed a multitude of reasons. Most commonly, failure to re-dose could be attributed to (1) concurrent intraoperative activities during the anticipated time of re-dosing and (2) failure to recognize the recommended dosing interval for secondline antibiotics in cases where first-line antibiotics were contraindicated, often because of allergy. At least two previous studies have demonstrated the utility of real-time intraoperative electronic reminder systems for increasing compliance of timely prophylactic antibiotic re-dosing during prolonged surgical cases. As a quality improvement endeavor, our hospital implemented such a system in our Anesthesia Information Management System (AIMS) (Epic, Verona, WI, USA) with the intent to achieve a similar increase in compliance with timely redosing of intraoperative prophylactic antibiotics. In this era of frequent messages, reminders, alerts, and advisories from our AIMS, however, it was unclear whether implementation of such a system would result in improved compliance. This preliminary retrospective observational study (deemed exempt for review by our Institutional Review Board, August 2016) aimed to determine whether such a system could improve intraoperative antibiotic re-dosing compliance to[ 90%. A real-time intraoperative electronic reminder system was designed to provide a pop-up message when an antibiotic was recommended to be re-dosed as per intervals set by our ASET guideline. To determine baseline compliance, a convenience sample of all cases in neurosurgical operating suites that required re-dosing of prophylactic antibiotics were examined over a three-month period prior to intervention. In the following nine months, we analyzed the pre-intervention data, formulated a quality improvement plan for automated reminders in our AIMS, presented the plan to an internal Patient Safety and Quality Council, and worked with Epic builders to implement the automated tool. Post-intervention data were collected one month following launch of the tool, which allowed us to mitigate a potential Hawthorne effect. Furthermore, preintervention and post-intervention data were collected during the same academic interval to control for trainee S. K. Smith, MD, PhD G. de Lisle Dear, MA, MB, BChir, FRCA B. M. Taicher, DO, MBA (&) Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA e-mail: Brad.Taicher@duke.edu

Pontocerebellar hypoplasia, malignant hyperthermia, and inappropriate use of secondary references

SIR—We were recently consulted to give an opinion about a 2-year-old female child diagnosed with TSEN34related pontocerebellar hypoplasia (PCH) Type 2 who required general anesthesia for radiologic studies. As per the parents, the child’s neurologist warned that children with PCH are predisposed to the development of malignant hyperthermia (MH) during general anesthesia. We consulted the Malignant Hyperthermia Association of the U.S. (MHAUS) and performed a detailed literature search to confirm this association. PCH is an autosomal recessive neurodegenerative disorder characterized by microcephaly, dyskinesia, seizures, and severe cognitive and language impairment. PCH was considered confined to the central nervous system until 2008 when Barth et al. demonstrated a myopathic component in two patients who developed hyperthermia and rhabdomyolysis (1). The only mention of MH in that paper was the statement: ‘Anesthetic accidents resulting in malignant hyperthermia have not been documented in PCH-2, and also are not known to the authors by experience’. But, this same group then published reviews of PCH in which it was stated that MH was, indeed, an anesthetic risk in these patients (2). No references were cited for these claims. This incorrect association was then furthered by additional authors citing these secondary sources (3). A ‘secondary source’ is an account of a scholarly subject that has been previously published elsewhere in its original form, the primary source. At best, a secondary source can be a comprehensive and accurate summary of a compilation of studies or findings concerning a single subject. In the process of preparing a scholarly article, many authors will rely on secondary sources to avoid the workload of reading and digesting all the possible primary sources, as well as to cut down on references to include in their paper. However, a major limitation of the use of a secondary source is that it presents the primary references from someone else’s viewpoint. This viewpoint is oftentimes helpful, but at times may be incorrect because of inaccurate citation or misinterpretation of the findings of the primary reference. When an author relies on incorrect information from a secondary reference, patients can be harmed. When a patient is deemed to be MH susceptible, it leads to significant alterations in anesthetic and perioperative care. For example, the anesthesia machine has to be specially prepared to purge the system of all anesthetic gases, and the anesthesiologist must only use intravenous anesthetics (e.g., propofol, opioids, midazolam, etc.) and nondepolarizing neuromuscular blockers (e.g., vecuronium, rocuronium, etc.). The disadvantages of using this ‘nontriggering’ technique include not only additional time and expense but also the inability to use succinylcholine, one of the most important anesthetic medications because of its role in the immediate relief of life-threatening upper airway obstruction. For these reasons, the designation of ‘MH susceptible’ is not to be taken lightly. The propagation of misinformation due to inaccurate citations is common in the medical literature (4). In our own specialty of anesthesiology, the citation error rate is estimated to be as high as 56% (5). Many of these errors will be composed of inconsequential mistakes in title, volume, etc., but misinterpretations of findings carry the potential to subsequently alter clinical care. Following detailed discussions with the patient’s parents about the lack of relationship between PCH and MH, the patient successfully received routine general anesthesia for her diagnostic studies without complication. The patient’s neurologist was informed of our findings, and the authors of the secondary references were contacted and asked to alter their recommendations, and we are grateful for their cooperation and support. We call on authors and journal editors to discourage the use of secondary sources whenever possible, as inaccurate citation or interpretation may lead to detriments in clinical care.

Analysis of the impact of race on blood transfusion in pediatric scoliosis surgery

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.

Percutaneous endoscopic gastrostomy vs surgical gastrostomy in infants with congenital heart disease

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.

Implementation of a colour-coded universal protocol safety initiative in Guatemala

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.