Nathalia Jimenez

An update on pediatric anesthesia liability: a closed claims analysis.

BACKGROUND:Respiratory complications were associated with half of pediatric malpractice claims from the 1970s to 1980s in the ASA Closed Claims Database. Advances in pediatric anesthesia practice have occurred in the 1980s and 1990s and may be reflected in liability trends. METHODS:We reviewed 532 pediatric (age ≤16 yr) malpractice claims from our database over three decades (1973–2000), using logistic regression analysis to evaluate trends over time. Claims from 1990 to 2000 (1990s) were reviewed in detail to determine damaging events and injuries. Multiple logistic regression analysis evaluated factors associated with claims for death/brain damage (BD) compared with claims for less severe injuries. RESULTS:From 1973 to 2000, there was a decrease in the proportion of claims for death/BD (P = 0.002) and respiratory events (P < 0.001), particularly for inadequate ventilation/oxygenation (P < 0.001). However, claims for death (41%) and BD (21%) remained the dominant injuries in pediatric anesthesia claims in the 1990s. Half of the claims in 1990–2000 involved patients 3 yr or younger and one-fifth were ASA 3–5. Cardiovascular (26%) and respiratory (23%) events were the most common damaging events. Factors associated with claims for death/BD in the 1990s when compared with claims for less severe injuries were cardiovascular events (odds ratio [OR] = 6.6, 95% confidence interval [CI] = 2.5–17.8), respiratory events (OR = 3.7, 95% CI = 1.5–9.4), and ASA status 3–5 (OR = 3.1, 95% CI = 1.3–7.8). CONCLUSIONS:Death/BD remained the dominant injuries in pediatric anesthesia malpractice claims in the 1990s. Cardiovascular events joined respiratory events as the major sources of liability.

A Review of the Experience, Epidemiology, and Management of Pain among American Indian, Alaska Native, and Aboriginal Canadian Peoples

UNLABELLED Substantial literature suggests that diverse biological, psychological, and sociocultural mechanisms account for differences by race and ethnicity in the experience, epidemiology, and management of pain. Many studies have examined differences between Whites and minority populations, but American Indians (AIs), Alaska Natives (ANs), and Aboriginal peoples of Canada have been neglected both in studies of pain and in efforts to understand its biopsychosocial and cultural determinants. This article reviews the epidemiology of pain and identifies factors that may affect clinical assessment and treatment in these populations. We searched for peer-reviewed articles focused on pain in these populations, using PubMed, CINAHL, Cochrane, and the University of New Mexico Native Health Database. We identified 28 articles published 1990 to 2009 in 3 topic areas: epidemiology of pain, pain assessment and treatment, and healthcare utilization. A key finding is that AI/ANs have a higher prevalence of pain symptoms and painful conditions than the U.S. general population. We also found evidence for problems in provider-patient interactions that affect clinical assessment of pain, as well as indications that AI/AN patients frequently use alternative modalities to manage pain. Future research should focus on pain and comorbid conditions and develop conceptual frameworks for understanding and treating pain in these populations. PERSPECTIVE We reviewed the literature on pain in AI/ANs and found a high prevalence of pain and painful conditions, along with evidence of poor patient-provider communication. We recommend further investigation of pain and comorbid conditions and development of conceptual frameworks for understanding and treating pain in this population.

Is ethnicity associated with morphine's side effects in children? morphine pharmacokinetics, analgesic response and side effects in children having tonsillectomy

Objectives/Aims:  To examine whether morphine pharmacokinetics (PK) and/or genetic polymorphisms in opioid‐related genes, underlie differences in analgesic response and side effects to morphine in Latino (L) vs non‐Latino Caucasian (NL) children.

Disparities in Disability After Traumatic Brain Injury Among Hispanic Children and Adolescents

OBJECTIVE: To compare the extent of disability in multiple areas of functioning after mild, moderate, and severe traumatic brain injury (TBI) between Hispanic and non-Hispanic white (NHW) children. METHODS: This was a prospective cohort study of children aged <18 years treated for a TBI between March 1, 2007, and September 30, 2008. Hispanic (n = 74) and NHW (n = 457) children were included in the study. Outcome measures were disability in health-related quality of life, adaptive skills, and participation in activities 3, 12, 24, and 36 months after injury compared with preinjury functioning. We compared change in outcome scores between Hispanic and NHW children at each follow-up time. All analyses were adjusted for age, gender, severity and intent of injury, insurance, family function at baseline, parental education, and income. RESULTS: The health-related quality of life for all children was lower at all follow-up times compared with baseline. Although NHW children showed some improvement during the first 3 years after injury, Hispanic children remained significantly impaired. Significant differences were also observed in the domains of communication and self-care abilities after TBI. Differences between groups in scores for participation in activities were also present but were only significant 3 months after injury. CONCLUSIONS: Hispanic children with TBI report larger and long-term reductions in their quality of life, participation in activities, communication, and self-care abilities compared with NHW children. The reasons for these differences need to be better understood and interventions implemented to improve the outcomes of these children.

Perioperative Analgesic Treatment in Latino and non-Latino Pediatric Patients

Purpose. Adult studies suggest pain treatment is influenced by patients race/ ethnicity. The present study aims to evaluate the effect of the patients race/ethnicity on pain treatment in children. Methods. Retrospective cohort study comparing perioperative analgesic administration for tonsillectomy and adenoidectomy (T&A) surgery in Latino and Caucasian patients younger than 18 years of age. Results. Ninety-four (94) patients were included (47 Latino, 47 Caucasian), mean age 8.44 yrs (SD 3.45), 43% female. Administration of non-opioid analgesics and intraoperative opioids was similar in both groups. Early post-operative administration of opioid analgesics was significantly different between groups. Latino subjects received 30% less opioid analgesics than Caucasians; median amount in morphine equivalents was 0.05 (0–0.14) vs. 0.07 (0–0.90) mg/kg for Latino and Caucasian patients respectively (p5.02). Conclusion. This study suggests that perioperative pain treatment in children is correlated with the patients ethnicity. The cause of this difference is unknown and prospective studies are necessary to elucidate the reasons.

Postoperative Pain Management in Children, Parental English Proficiency, and Access to Interpretation

BACKGROUND AND OBJECTIVE Patients with limited English proficiency (LEP) are at risk for undertreated pain. The goal of this study was to examine the association between parental language proficiency, interpreted care, and postsurgical pediatric pain management. METHODS This was a retrospective matched cohort study among children <18 years of age. Children of LEP and English-proficient (EP) parents were matched according to age group, surgical procedure, and admission date. Mean number of daily pain assessments and mean daily pain scores were compared between language groups. We also compared the association between pain scores and type of medication given (opioid versus nonopioid). Within the LEP group, similar analyses compared pain assessment and treatment of children whose families received ≥ 2 professional interpretations per day versus those who received lower rates of interpretation. RESULTS A total of 474 children (237 LEP and 237 EP) were included in the study. Children of LEP parents had fewer pain assessments (mean: 7 [95% confidence interval: 2-13] vs 9 [95% confidence interval: 4-15]; P = .012), and higher levels of pain recorded before receiving opioid analgesics, compared with children of EP parents (P = .003). Within the LEP group, children with ≥ 2 interpretations per day had lower pain scores after medication administration (P < .05) and were more likely to receive opioids at pain levels similar to those of EP families. CONCLUSIONS Children of LEP parents received fewer pain assessments and were less likely to receive opioid analgesics for similar levels of pain compared with children of EP parents. More frequent use of professional interpreters when assessing pain may aid in reducing the gap in pain management between LEP and EP pediatric patients.

Two-agent analgesia versus acetaminophen in children having bilateral myringotomies and tubes surgery

Objectives:  The objective of this study was to determine whether the incidence of emergence agitation (EA) can be reduced by adding an additional, faster onset, non‐IV analgesic, intranasal fentanyl or intramuscular (im) ketorolac to rectal acetaminophen.

Attitudes, Patterns of Recommendation, and Communication of Pediatric Providers About Complementary and Alternative Medicine in a Large Metropolitan Children’s Hospital

The authors conducted an Email survey of their medical staff to explore the attitudes, patterns of recommendation, and communication of pediatric providers about complementary and alternative medicine (CAM) in a large metropolitan children’s hospital. Two thirds of the respondents reported awareness about their patients’ CAM therapy use (65%) and recommended CAM therapy to their patients (67%). Providers who reported personal use of CAM (71%) were more likely to recommend CAM to their patients compared with those who do not (76% vs 45%; P < .05). One half of pediatric providers reported occasional consultation with their patient’s CAM provider, but bidirectional communication was rare (4%). Specific changes in care based on a CAM provider’s recommendations were also unusual (4%). Despite the positive attitudes about and willingness to recommend CAM by pediatric providers, communication between these clinicians and CAM providers may be less than ideal.

Availability of Outpatient Rehabilitation Services for Children After Traumatic Brain Injury: Differences by Language and Insurance Status.

ObjectiveThe objective of this study was to explore associations between English proficiency, insurance status, outpatient rehabilitation service availability, and travel time for children with traumatic brain injury. DesignThe authors used an ecologic cross-sectional design. Data were analyzed from a cohort of 82 children with moderate to severe traumatic brain injury and rehabilitation providers in Washington State. Main measures included availability and travel time to services. ResultsLess than 20% of providers accepted children with Medicaid and provided language interpretation. Mental health services were most limited. Adjusted for median household income, multilingual service availability was lowest in counties with greater language diversity; for every 10% increase in persons older than 5 yrs speaking a language other than English at home, there was a 34% decrease in availability of multilingual services (prevalence ratio, 0.66; 95% confidence interval, 0.48–0.90). Adjusted for education and Medicaid status, children from Spanish-speaking families had significantly longer travel times to services (mean, 16 additional minutes to mental health; 9 to other therapies). ConclusionsChildren in households with limited English proficiency and Medicaid faced significant barriers in availability and proximity of outpatient rehabilitation services. Innovative service strategies are needed to equitably improve availability of rehabilitation for children with traumatic brain injury. Similar studies in other regions will inform one’s understanding of the scope of these disparities.

Personalizing pediatric pain medicine: using population-specific pharmacogenetics, genomics, and other -omics approaches to predict response.

Personalized medicine is the science of individualized prevention and therapy. The notion that “one size fits all” has been replaced by the idea of patient-tailored health care. Within this paradigm, the research community has turned to examine genetic predictors of disease and treatment responses. Pain researchers have produced genetic studies over the last decade that evaluate the association of genetic variability with pain sensitivity and analgesic response. While most of these studies have been conducted among cohorts of subjects of European descent, some have included other racial and ethnic groups, providing evidence of variable responses to analgesics. Simultaneously, there is an increased recognition regarding the complexity of pain research, acknowledging the additional role of epigenetic, transcriptomic, proteomic, and metabolomic factors in the development, experience, and treatment of pain. This article provides an introduction to population-specific pharmacogenetics, proteomics and other “–omics” technologies to predict drug response to pain medications in children. It aims to provide anesthesiologists with the basic knowledge to understand the potential implications of genetic and epigenetic factors managing the pain of pediatric patients.