Jayant K. Deshpande

Cardiorespiratory changes in children during laparoscopy

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.

Effective hemodialysis and hemofiltration driven by an extracorporeal membrane oxygenation pump in infants with hyperammonemia

Two infants with urea cycle disorders had life-threatening hyperammonemia within the first 5 days of life. Both patients were small for dates, poorly oxygenated, and hemodynamically unstable. We employed a combination of extracorporeal oxygenation and hemodialysis to provide high-flow filtration in a controlled system to rapidly detoxify both patients.

Prospective, longitudinal evaluation of health related quality of life in the pediatric spina bifida population undergoing reconstructive urological surgery.

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.

National pediatric anesthesia safety quality improvement program in the United States.

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.

Newly Postulated Neurodevelopmental Risks of Pediatric Anesthesia: Theories That Could Rock Our World

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.

Newly Postulated Neurodevelopmental Risks of Pediatric Anesthesia

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.

Standardization of Case Reviews (Morbidity and Mortality Rounds) Promotes Patient Safety

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.

Cause and effect or conjecture? A call for consensus on defining "anesthesia-related mortality.".

In this issue of the Journal, Dr. van der Griend and colleagues present a report entitled, “Postoperative Mortality in Children After 101,885 Anesthetics at a Tertiary Pediatric Hospital.” This is a very well written retrospective analysis of the anesthetic experience at a single tertiary care institution, the Royal Children’s Hospital (RCH) in Melbourne, Australia. The objective of the study was to determine the incidence and nature of anesthesia-related mortality in pediatric practice at a large tertiary institution. The study population included all cases of children 18 years of age who had an anesthetic between January 1, 2003, and August 30, 2008, at the RCH in Melbourne, Australia. The investigators merged a database of anesthetics performed at the hospital with a regional mortality database. Cases of children dying within 30 days and 24 hours of an anesthetic were identified and the patient history and anesthetic record examined. “Anesthesiarelated deaths were defined as those cases in which a panel of 3 senior anesthesiologists all agreed that anesthesia or factors under the control of the anesthesiologist more likely than not influenced the timing of death.” During the 68-month study period, 101,885 anesthetics were administered to 56,263 children. The authors report an overall 24-hour mortality from any cause after anesthesia as 13.4 per 10,000 anesthetics delivered; the 30-day mortality was 34.5 per 10,000 anesthetics delivered. The incidence of death was highest in children 30 days old. Patients undergoing cardiac surgery had a higher incidence of both 24-hour and 30-day mortality in comparison with noncardiac surgery. There were 10 anesthesia-related deaths, giving an incidence rate of 0.98 cases per 10,000 anesthetics performed (95% confidence interval [CI] 0.5 to 1.8). In all 10 cases, preexisting medical conditions were identified as being a significant factor in the patient’s death. Five of these cases (50%) involved children with pulmonary hypertension. There were no anesthetic-related deaths in children who did not have major comorbidities. The authors conclude that anesthesia-related mortality is higher in children with heart disease and in particular those with pulmonary hypertension. The study results indicate an anesthesia-related mortality that is significantly higher than that reported previously. Prior studies have found an anesthesia-related mortality rate ranging from 0.36 to 2.9 per 10,000 anesthetics, depending on the definitions used. Increased perioperative mortality from any cause in newborns and in children with cardiac disease of all ages has been reported in other studies. This finding is important because it confirms the safety of pediatric anesthesia in healthy children. The present study includes other valuable information for the clinician. The data of the current study corroborate previous studies for children younger than 1 year and younger than 1 month undergoing anesthesia and surgery. The findings of increased risk for children younger than 1 year and especially younger than 1 month point to the need for greater caution when caring for these age groups. The study results reinforce the inherent risk in caring for children with heart disease. The data corroborate the previously published findings of investigators from the Mayo Clinic and the Perioperative Cardiac Arrest (POCA) Registry. Of note for the clinician is that more than half of all deaths occurred outside the operating room. While corroborating important findings of previous investigations, the current study presents a major challenge to the reader because of some methodologic issues. The study is focused only on mortality after anesthesia, excluding many interesting surrogate events (i.e., cardiac arrest) that are precursors. The publication by Odegard et al. from Boston Children’s Hospital provided insight into 41 cardiac arrests in children with heart disease that did not result in a single death. The RCH paper has only 10 anesthesia-related deaths, insufficient to evaluate in a statistically meaningful fashion, or even to build a case control study. However, it would be quite useful for the clinician if the investigators had included a meaningful discussion of potential causes and preventability of these deaths. The present study provides a limited basis for comparison to prior results. Experienced clinicians caring for medically fragile or high-risk patients are already aware that anesthesia involvement may be coincidental to the death of From the Arkansas Children’s Hospital and University of Arkansas for Medical Sciences, Little Rock, Arkansas.

Ondansetron to prevent emesis following N-acetylcysteine for acetaminophen intoxication.

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.

Prospective Evaluation of Health Related Quality of Life for Pediatric Patients With Ureteropelvic Junction Obstruction

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.