Wallis T. Muhly

Ambulatory continuous peripheral nerve blocks in children and adolescents: a longitudinal 8-year single center study.

BACKGROUND:Although the role of regional anesthesia in pediatric patients has been increasing over the last few years, there are only a few small case series that describe the use of ambulatory continuous peripheral nerve blocks (CPNBs) in this patient population. In this report, we describe our experience with the use of ambulatory CPNBs in 1285 children. METHODS:Data were collected for consecutive children who had a CPNB placed between January 2005 and December 2011 at The Children’s Hospital of Philadelphia from the departmental regional anesthesia database. Data collected included demographics, the site of catheter placement and technique of nerve block, presence of sensory/motor blockade, use of perioperative opioids, and any complications related to CPNBs. RESULTS:Continuous infusions of local anesthetics were administered via the catheters in 1285 outpatients. The mean duration of the CPNB was 50.7 ± 14.4 hours (mean ± SD). Among patients discharged home with the CPNBs, 969 (75.4%) of the patients required either no supplemental opioids or oral opioids only on an “as needed” basis in the postoperative period (confidence interval, 73.0%–77.8%). Two patients were readmitted for IV pain management after they were discharged home with the CPNB catheters. No neurological deficit related to the CPNBs was identified in any of the patients at their 6-month follow-up with the orthopedic surgeon (confidence interval, 0%–0.29%). CONCLUSION:This audit of 1285 children shows ambulatory CPNBs can provide postoperative analgesia and may reduce the need for inpatient parenteral opioid therapy.

Pain management following the Nuss procedure: a survey of practice and review

Pectus excavatum is the most common congenital chest wall deformity. The Nuss procedure is frequently used for surgical correction and this technique has been associated with severe and prolonged post‐operative pain. At the present time, the optimal analgesic strategy for managing patients following this procedure has not been determined.

Rapid Recovery Pathway After Spinal Fusion for Idiopathic Scoliosis.

BACKGROUND: Posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS) is associated with significant pain and prolonged hospitalization. There is evidence that early mobilization and multimodal analgesia can accelerate functional recovery and reduced length of stay (LOS). Using these principles, we implemented a quality improvement initiative to enable earlier functional recovery in our AIS–PSF population. METHODS: We designed and implemented a standardized rapid recovery pathway (RRP) with evidence-based management recommendations for children aged 10 to 21 years undergoing PSF for AIS. Our primary outcome, functional recovery, was assessed using statistical process control charts for LOS and average daily pain scores. Our process measures were medication adherence and order set utilization. The balancing measure was 30-day readmission rate. RESULTS: We included 322 patients from January 1, 2011 to June 30, 2015 with 134 (42%) serving as historical controls, 104 (32%) representing our transition population, and 84 (26%) serving as our RRP population. Baseline average LOS was 5.7 days and decreased to 4 days after RRP implementation. Average daily pain scores remained stable with improvement on postoperative day 0 (3.8 vs 4.9 days) and 1 (3.8 vs 5 days) after RRP implementation. In the second quarter of 2015, gabapentin (91%) and ketorolac (95%) use became routine and order set utilization was 100%. Readmission rates did not increase as a result of this pathway. CONCLUSIONS: Implementation of a standardized RRP with multimodal pain management and early mobilization strategies resulted in reduced LOS without an increase in reported pain scores or readmissions.

Continuous perineural infusion after lower extremity osteotomies in children: a feasibility and safety analysis

1 Fertleman CR, Ferrie CD, Aicardi J, et al. Paroxysmal extreme pain disorder (previously familial rectal pain syndrome). Neurology 2007; 69: 586–95. 2 Fertleman CR, Baker MD, Parker KA, et al. SCN9A mutations in paroxysmal extreme pain disorder: allelic variants underlie distinct channel defects and phenotypes. Neuron 2006; 52: 767–74. 3 Dib-Hajj S, Estacion M, Jarecki BW, et al. Paroxysmal extreme pain disorder M1627K mutation in human Nav1.7 renders DRG neurons hyperexcitable. Mol Pain 2008; 4: 37.

A retrospective comparison of ropivacaine and 2-chloroprocaine continuous thoracic epidural analgesia for management of postthoracotomy pain in infants.

Continuous thoracic epidural analgesia is useful in the management of infants following thoracotomy. Concerns about drug accumulation and toxicity limit the amount of amide local anesthetics that can be delivered. Continuous epidural infusions of the ester local anesthetic chloroprocaine result in little drug accumulation allowing for higher infusion rates. We retrospectively compared patients managed with 1.5% 2‐ chloroprocaine or 0.1% ropivacaine epidural infusions to determine if the increased infusion rate resulted in similar or improved analgesia.

Safety of pediatric continuous interscalene block catheters placed under general anesthesia: a single center's experience.

The use of interscalene catheters is an effective treatment strategy for children and adolescents undergoing shoulder surgery. Although placement of interscalene catheters in the awake child is challenging, some have cautioned against performing regional anesthesia in the patient under general anesthesia. We present a case series of 154 interscalene catheters placed in pediatric patients under general anesthesia and managed in the outpatient setting.

A retrospective comparison of thoracic epidural infusion and multimodal analgesia protocol for pain management following the minimally invasive repair of pectus excavatum

Pain management following minimally invasive repair of pectus excavatum is variable. We recently adopted a comprehensive multimodal analgesic protocol that standardizes perioperative analgesic management. We hypothesized that patients managed with this protocol would use more opioids postoperatively, have similar pain control, and shorter length of stay compared to patients managed with thoracic epidural infusion.

Regional anesthesia for pediatric knee surgery: a review of the indications, procedures, outcomes, safety, and challenges.

The indications for surgery on the knee in children and adolescents share some similarity to adult practice in that there are an increasing number of sports-related injuries requiring surgical repair. In addition, there are some unique age-related conditions or congenital abnormalities that may present as indications for orthopedic intervention at the level of the knee. The efficacy and safety of peripheral nerve blocks (PNBs) for postoperative analgesia following orthopedic surgery has been well established in adults. Recent studies have also demonstrated earlier functional recovery after surgery in patients who received PNBs. In children, PNB is gaining popularity, and increasing data are emerging to demonstrate the feasibility, efficacy, and safety in this population. In this paper, we will review some of the most common indications for surgery involving the knee in children and the anatomy of knee, associated dermatomal and osteotomal innervation, and the PNBs most commonly used to produce analgesia at the level of the knee. We will review the evidence in support of regional anesthesia in children in terms of both the quality conferred to the immediate postoperative care and the role of continuous PNBs in maintaining effective analgesia following discharge. Also we will discuss some of the subtle challenges in utilizing regional anesthesia in the pediatric patient including the use of general anesthesia when performing regional anesthesia and the issue of monitoring for compartment syndrome. Finally, we will offer some thoughts about areas of practice that are in need of further investigation.

Preoperative fasting in children: is there room for improvement?

How long do your patients fast prior to surgery? Do they align with your institution’s fasting policy? Are they even close? Are your patients fasting longer than they need to because they do not understand their preoperative instructions and do not want their procedure canceled? The day of surgery can be long, confusing, and stressful for children and their families. We are all familiar with the scenario of a hungry and cranky child who has had nothing to eat or drink since dinnertime the day before and her frustrated parents. Would this scenario be improved with a cup of juice on arrival to the preoperative check-in? Would such a simple intervention translate to more stable hemodynamics and easier venous access? In this issue, Newton and colleagues begin to answer some of these questions, and more importantly, they show us how to investigate this in our patient populations. Aspiration of gastric contents in otherwise healthy fasting children is a rare occurrence. The most recent American Society of Anesthesiologists practice guidelines for preoperative fasting recommend the provision of clear liquids up to 2 hours prior to anesthetic induction in most children undergoing elective surgery. Although there is compelling evidence based on a surrogate of aspiration risk (gastric fluid volume) that 1-hour clear fluid fasting times are likely also safe, we know through both personal experience and published research that children often fast longer than necessary. In addition to the discomfort and dissatisfaction prolonged fasting creates for children and their families, these children are more prone to hemodynamic instability on induction, a sequence of events that can be prevented with preoperative fluid optimization. Thus, there remains a chasm between evidence and practice for preoperative fasting. Where such chasms exist, physicians have increasingly turned to quality improvement (QI) methodologies to integrate evidence-based medicine into clinical practice. The balance between risks and benefits of fasting times in the preoperative arena is very real and needs to take into consideration clinical experience and evidence. Both clinical research and QI share the goal of improving patient care and outcomes. Although research provides facts, data, and foundational knowledge, QI methodology is dynamic, adaptable, and addresses the granular real-world obstacles faced when implementing practice changes to improve patient care. Newton et al. have shown us how they tackled the preoperative fasting question using QI methodology. They first delineated the problem of preoperative fasting at their institution. Despite having a 2-hour clear fasting fluid policy, they found that only 19% of children received clear fluids within 4 hours of induction with a mean clear fluid fast time of 6.3 hours. We suspect that this type of discrepancy would be present at many tertiary pediatric institutions. They then created a multidisciplinary team that included nurses, anesthetists, a dietician, administrators, and a data analyst. This team set about trying to solve this common clinical problem through structured Plan-Do-Study-Act cycles with sequential changes in patient education, preoperative phone calls, and, finally, administration of an age-based volume of clear fluids following arrival at the hospital. These changes ultimately resulted in a remarkable improvement, more than tripling the number of children receiving a clear fluid within 4 hours of induction (72%), combined with a reduction of the mean clear fluid fasting time by more than half (3.1 hours). For the pediatric anesthesia community, this work is valuable both for the new clinical evidence it contains and the example it provides about how to put this type of change into practice. Rather than evaluating the effect of implementing a 1-hour clear fluid fasting rule in the context of hypothesis-driven research, we instead have a potentially more useful report that includes outcome data on the safety of an envelope-pushing fasting policy in over 6800 patients. Although the nuances of implementation would likely be different at other institutions, the QI framework presented appears broadly applicable. Of note, Newton and colleagues do not report on surrogate end points or outcomes. Instead, the authors focus on clinical outcomes that matter: actual fasting times and aspiration events. The absence of an increased risk of aspiration events in the context of a shortened 1-hour clear fluid fasting time is consistent with a recent large population study of aspiration events in pediatric patients undergoing procedural sedation/anesthesia where aspiration was rare (0.7 events per 10 000) and was not increased in patients who were not nil per os. What remains to be seen is whether 1-hour clear fluid fasting practices lead to improvements in patient/ family satisfaction, compliance with induction, hemodynamic stability, and vascular access. So what’s a pediatric anesthesiologist to do? Here in the US, do we follow published practice guidelines, which recommend that children be fasted for 2 hours for clear liquids, or do we implement something similar to what Newton and colleagues have done, while continuing to track the safety of this practice? Based on our read of the data, we would argue for the latter. Change begins when we acknowledge that there is a problem. The data presented in this issue of the journal add to the rising tide of evidence that it is time to reevaluate our clear fluid fasting practices. In the era of the electronic health record, we should know how long our patients fast, and if there is a problem, we owe it to our patients to address it. Our colleagues at Great Ormond Street DOI: 10.1111/pan.13166

Pediatric perioperative outcomes group: Defining core outcomes for pediatric anesthesia and perioperative medicine

In 2015, the joint National Institute of Academic Anaesthesia/James Lind Alliance Research Priority Setting Partnership published a top 10 list of research priorities for anesthesia and perioperative care in the UK. These priorities were developed through a systematic process that engaged physicians, patients, and the public with the intent of identifying research questions broadly relevant to pertinent stakeholders. A subsequent editorial in this journal highlighted 4 priorities applicable to the care of children. One of the questions relevant to both adults and children was “What outcomes should we use to measure the ‘success’ of anesthesia and perioperative care?” However, this research priority generates many more questions: What outcomes matter most to our patients and their families? What outcomes are most important to clinicians? What are the fundamental outcomes for clinical researchers? Are these outcomes aligned? Do we and can we routinely measure these outcomes, either in clinical practice or in clinical trials? Core outcome sets have been developed to address these questions across a wide range of medical disciplines. Consensus-based standardized outcomes are defined with the aim of reducing variability in the use and reporting of outcomes in clinical trials. In 2010, The Core Outcome Measures in Effectiveness Trials (COMET) initiative was launched with the goal of fostering core outcome set development throughout medicine, and now provides a resource for core outcome set developers (http://www.comet-initiative.org). The COMET initiative promotes the use of evidence-based review together with clinician, researcher, and patient participation in the development process. Through conscientious engagement of these parties, the COMET methodology ensures that clinically meaningful patient-centered outcomes are identified. Core outcome sets are intended to be a minimum set of outcomes for inclusion in all trials in a given population. As such, the intent is not to narrow the scope of trials to a few preselected outcomes, but rather to ensure that certain fundamental outcomes with standard definitions are included in all trials conducted in that population. It is therefore expected that researchers will include other outcomes relevant to their specific studies. Importantly, core outcome sets are intended not only for use in clinical research but also for incorporation into data systems used in clinical practice to support clinical audits and quality improvement activities. So why do we need core outcome sets? Our ability to compare and synthesize results of clinical trials and investigations is often limited by variability in the outcomes utilized and reported. Even when the same “outcome” is used, variability in how that outcome is defined can make comparison of different trial results difficult. The use of standardized outcomes would greatly enhance the value of individual study results by enabling them to be seamlessly integrated into metaanalyses. The ability to combine results of multiple trials also helps address an ethical obligation of clinical research by enhancing the benefits and generalizability of data derived from human subject participation in research and minimizing unnecessary duplication. Using COMET methodology, a core outcome set for adult perioperative medicine is being developed by a group of perioperative medicine clinicians and researchers. This initiative is described in greater detail elsewhere, but in essence there are 2 parallel projects. COMPAC (Core Outcome Measures for Perioperative and Anesthetic Care) is a collaborative effort that seeks input from patients, care givers, nurses, and physicians to determine what outcome domains should be included in a perioperative core outcome set. The parallel StEP (Standardizing Endpoints in Perioperative medicine) project is an expertbased Delphi consensus-driven effort to define how the specific outcomes within these domains should be measured. Both COMPAC and StEP focus on perioperative care of adults having major surgery, and as such many of the outcomes are more specifically relevant to adult and elderly patients (eg, major adverse cardiac events, stroke, postoperative cognitive decline). While there are some commonalities and overlap of outcomes relevant in both adults and children, it is apparent to anyone who takes care of children that many of the concerns of adult patients are less relevant or do not apply to pediatric populations. For example, for patient comfort outcomes, there are similar clinically relevant endpoints (postoperative nausea and vomiting, pain measurement, quality of recovery) but the measurement scales of adults cannot be applied in children. Age-specific scales and measures are needed for these items. In contrast, cardiovascular adverse events (eg, myocardial injury, arrhythmias, venous thromboembolism), postoperative respiratory complications, and acute kidney injury are much less common in children, whereas others such as acute airway incidents are more specific for children. Recognizing this, an international group of investigators has formed the Pediatric Perioperative Outcomes Group, and taken up the task of pursuing the question “How do we measure/define a successful anesthetic in infants, children, and young people?” Through a process similar to that of our adult counterparts, work has begun to develop a core outcome set applicable to pediatric perioperative care. Currently, investigators from Australia, China, Europe, India, New Zealand, South Africa, the United Kingdom, and the United States are involved, but additional opportunities for clinicians and Pediatric Perioperative Outcomes Group members are in Appendix 1. DOI: 10.1111/pan.13354