Pediatric Postanesthesia Care Unit Research Articles

Impact of dexmedetomidine use on pediatric PACU length of stay and practice patterns: A single center study

BackgroundDexmedetomidine has been increasingly incorporated in pediatric anesthesia owing to its opioid sparing analgesic effect. In theory, dexmedetomidine may lower the use of intraoperative and postoperative opioids but increase post anesthesia care unit (PACU) patient recovery time. In 2020, the Anesthesia Department of Albany Medical Center implemented an opioid reducing initiative with dexmedetomidine incorporation as a major strategy. As such, we have carried out this retrospective study to examine the effect of dexmedetomidine on pediatric PACU length of stay (LOS) across a blend of invasive surgical procedures requiring general anesthesia. MethodsThe present study is a single-institution, retrospective chart review of children undergoing invasive procedures requiring general anesthesia at an academic center during 2021 and 2022. Convenience sampling of the first 200 patients from each of those years was analyzed (n=400). Here, we compared PACU LOS between patients who did or did not receive dexmedetomidine using the propensity-score matching treatment effects analysis. We also examined changes in perioperative medication patterns between patients who did versus did not receive dexmedetomidine. Results344 patients over the study period met inclusion criteria. The matched cohort consisted of 118 patients without dexmedetomidine administration and 122 patients with dexmedetomidine administration. The average treatment effect for administration of dexmedetomidine was an increase in PACU LOS of 19.4 min (p < 0.001). Dosages and proportion of patients receiving intraoperative or postoperative opioids did not significantly change during the study period. ConclusionsIn our center, dexmedetomidine use in pediatric procedures with general anesthesia was associated with prolonged recovery times, without a corresponding reduction in opioid use. Further investigations are therefore warranted to understand the role of dexmedetomidine as an anesthetic adjunct and in multimodal pain management.

Sustainability of an Operating Room to Pediatric Postanesthesia Care Unit Handoff Tool

The purpose of this quality improvement (QI) project was to reintroduce and assess the feasibility of a standardized, electronic health record (EHR) handoff tool and to evaluate the sustainability of a structured, team-based approach in a pediatric postanesthesia care unit (PACU). This QI project used an observational pre-post design using two separate convenience samples of handoffs and perianesthesia providers. A standardized EHR handoff tool was reintroduced for operating room to pediatric PACU handoff communication. Handoffs between anesthesia providers, surgery team members, and PACU nurses were observed pre- and postreintroduction of the EHR handoff tool. Anesthesia providers and PACU RNs received training for giving and receiving handoffs and were provided directions on locating the EHR handoff tool. A bedside audit of items communicated for the six handoff phases (introductions, situation, background, assessment, recommendations, and questions), handoff duration, team member participation, and handoff tool utilization were performed for 149 handoffs pre- and 146 handoffs postimplementation. To evaluate sustainability, the audits were compared to postimplementation data from the 2014 pilot handoff project. Following reintroduction, EHR handoff tool use increased from 4% to 19%. There was a statistically significant increase in items communicated for three of the six handoff phases when using the EHR tool (P < .05). There was no statistically significant increase in handoff duration (mean=3.66 minutes, SD=1.57 minutes) with the EHR handoff tool. Surgical team member presence for the team-based handoff increased from 90.7% pre to 95.9% post. Provider compliance with the team-based handoff approach, which includes a PACU RN, surgical team member, and anesthesia team member present for handoff, was sustained and increased 6 years postimplementation. Feedback from anesthesia providers and PACU RNs indicated mixed reports of satisfaction with the EHR tool, perceived handoff efficiency, and consistency in both giving and receiving handoff. Adherence to five of the six structured handoff phases, except introductions, was sustained and even improved 6 years following implementation. Evidence-based practice for handoff communication supports the use of a team approach and standardized EHR handoff tools. The reintroduction of a standardized EHR handoff tool improved the completeness of information transfer, yet did not lead to widespread adoption nor improved user satisfaction. There is an ongoing need to identify adoptable and sustainable perioperative handoff methods.

Racial inequities in opioid use disorder management: can the anesthesiologist improve outcomes?

Racial inequities in opioid use disorder management: can the anesthesiologist improve outcomes?

Incidence of Emergence Delirium in the Pediatric PACU: Prospective Observational Trial.

Emergence delirium (ED) is a postoperative complication in pediatric anesthesia characterized by perception and psychomotor disorder and has a negative impact on morbidity in the form of maladaptive behavior, which can last weeks after anesthesia. Patients with developed ED present with psychomotor anxiety, agitation, and are at higher risk of unintentional extraction of an intravenous cannula, self-harm and nausea and vomiting. The described incidence of ED varies between 25–80%, with a higher prevalence among children younger than 6 years of age. We aimed to determine the incidence of ED in pediatric patients (>1 month) after general anesthesia in the post-anesthesia care unit (PACU), using Paediatric Anaesthesia Emergence Delirium (PAED) score, Watcha score and Richmond agitation and sedation scale (RASS). The incidence of ED was the highest in the PAED score with cutoff ≥10 points (89.0%, n = 1088). When using PAED score >12 points, ED incidence was 19.3% (n = 236). The lowest incidence was described by Watcha and RASS scores, 18.8% (n = 230) vs. 18.1% (n = 221), respectively. The threshold for PAED ≥10 points seems to give false-positive results, whereas the threshold >12 points is more accurate. RASS scale, although intended primarily for estimation of the depth of sedation, seems to have a good predictive value for ED.

Initiating a Validated Pediatric Post-Anesthesia Emergence Delirium Scale in the Pediatric Post-Anesthesia Care Unit

<h3>Introduction</h3> Emergence Delirium(ED) is a frequent occurrence in the pediatric PACU. The PAED scale is a research validated tool that has been shown to help nurses and anesthesiologists recognize and appropriately treat ED. <h3>Identification of the problem</h3> OurPACU was currently not using a measuring tool. After learning about the scales already in place at a national conference, I discussed with the unit manager and she agreed that a PAED scale would be a valuable tool. The anesthesiologist that agreed to be physician support recommended that we carry this out as a research project. <h3>Purpose of the study</h3> The aim of this study is to assess our PACU nurse's current knowledge of delirium, implement education, as well as encourage documentation of the PAED score. The potential benefits of the study include benefiting future pediatric patients and their nurses by improving how our institution approaches pediatric post-anesthesia delirium. <h3>Methods</h3> IRBapproval was obtained. A survey was constructed to measure 2 things: 1) nurses knowledge of PAED pre and post education and implementation of a PAED scale 2) nurses confidence and satisfaction with several aspects of PAED pre and post education and implementation. An invitation email with a link to the online survey was sent to all nurses who worked in the pediatric PACU. Consent was in the email. The prospective participant can elect to participate in the survey or not participate. The consent described the anonymity of the survey by including the statement "Identifiers will be removed and the de-identified information may be used for future research without additional informed consent from the subject." Pre-interventiondata was collected via survey answers. Training for the PAED scale was implemented in concurrence with pediatric emergence delirium training by anesthesia. One month post intervention, the survey was re-sent. A final six-month post intervention survey was repeated. Each survey knowledge question was scored and results were analyzed using the T-test. <h3>Outcomes/Results</h3> A total of 15 PACU nurses participated. 14 responded to the one month survey and 7 responded to the 6 month survey. The most significant increase was knowledge of the PAED scale (↑ 58.3%, p < 0.0001)) as well as knowledge about patient risk factors (↑ 13.3%, p = 0.01) and dispelling common myths surrounding PAED (↑ 14.6%, p = 0.01). It is unclear at this time if the education initiative was ineffective in regards to the other goals of PAED knowledge, or if our pediatric PACU nurses simply pre-possessed much of this knowledge prior to implementation. Nursing confidence and satisfaction also increased with the largest gains being seen in their satisfaction with the tools they have at their disposal (↑28.8%) and the responsiveness of anesthesiologists (↑26.5%). The anesthesiologists were not included in the education sessions; therefore the increase in satisfaction is likely due to either a change in nursing perception or a change in anesthesiologist behavior due to nurses reporting the PAED score. A six-month follow-up survey was distributed to see how these gains change over time. The complete results are pending analysis. <h3>Discussion</h3> ThePAED scale is a research-validated tool that is easy to use to quickly identify and discern if emergence delirium is present. The nursing education initiative and implementation was successful in increasing knowledge of the PAED scale as well as increasing knowledge about patient risk factors and dispelling common myths surrounding PAED. The documentation piece has taken several months to get built as we have 3^rd party vendors to develop most of our screens. Currently we are waiting for the screen to be included in our assessment options. During the study, a verbal reporting of the score was provided to the anesthesia provider. Further studies to determine documentation compliance would be helpful. <h3>Conclusion</h3> The findings have demonstrated that the pediatric PACU nurses are more confident in identifying true ED. Additionally, it showed that they are more aware of the tool used to score delirium and what intervention(s) are the best to implement. <h3>Implications for perianesthesia nurses and future research</h3> The PAED scale chosen for this study promotes quick and easy scoring. Identifying emergence delirium quickly in pediatric patients is crucial to implementing the appropriate intervention(s). Future research desired is to determine if having the parent at bedside before onset of delirium would decrease the intensity and/or longevity of ED.

Peace in the PACU

<h3>Introduction</h3> Open-bay Post Anesthesia Care Unit (PACU) environments can be loud and overstimulating for patients, caregivers, and healthcare workers. Literature describes noise interferes with the patient's surgical recovery and increases the need for analgesia. In patients and healthcare workers, physiologic (increased heart rate, blood pressure) and psychologic (sleeplessness, stress) changes are associated with increased noise levels as well as medical errors, miscommunication, and surgical site infections. <h3>Identification of the Problem</h3> Reports of a noisy, loud pediatric PACU environment has been identified as an area of improvement by healthcare workers, patients, and caregivers. <h3>Purpose of the Study</h3> Evaluate the effects of noise-reducing curtains on PACU noise level and noise perception by caregivers. <h3>Methodology</h3> Institutional Review Board approval was obtained. A pre/post- intervention study design was employed to evaluate the effectiveness of noise-reducing curtains on noise level and caregiver perception. Noise decibels were measured with calibrated dosimeters. An acoustical assessment was performed and caregiver perception of noise was measured by anonymous surveys. <h3>Results</h3> Following noise-reducing curtain installation no statistical significance in overall decibel levels was observed, however intrusive noise was reduced by 35% - 50%. Additionally, 54.7% of caregivers reported the area around the bay was never quiet before installation compared to 15.5% after noise-reducing curtain installation. <h3>Discussion</h3> This study was done to validate results from a 2019 study in the same PACU where a statistically significant reduction in decibel levels was observed following noise-reducing curtain installation. This study did not validate an improvement in decibel levels likely due to pandemic-related effects such as decreased surgical volumes and an intentional reduction of caregivers and healthcare workers at the bedside. However, this study does validate the use of noise-reducing curtains to improve noise perception. <h3>Conclusion</h3> Noise and sound are multi-dimensional. Though a statistically significant reduction in noise levels was not observed, sound transmission, speech privacy, and reverberation measurements revealed statistically significant reduction in noise perception. Caregiver surveys supported the use of noise-reducing curtains in providing a more therapeutic environment. <h3>Implications for perianesthesia nurses & future research</h3> Literature describes noisy hospital environments lead to negative outcomes for patients, caregivers, and healthcare workers. Noise-reducing curtains are an evidence-based intervention that can improve noise perception in PACUs.

Feasibility, implementation, and outcomes of in situ simulation-based curriculum to manage common emergencies in the pediatric post-anesthesia care unit

PurposeStudies have shown that most critical events that occur in the post-anesthesia care unit (PACU), including cardiac arrests, are preventable and respiratory in origin. Admission to the PACU necessitates transfer of care from anesthesiology staff to PACU nurses. The aim of the study is to assess a) feasibility in implementing an in-situ curriculum for PACU nurses to manage common pediatric emergencies, b) the effectiveness of the curriculum in improving self-confidence of the PACU nurses in performing essential skills c) nurses’' perception of such an offering. Design and methodsThis was a single center curricular evaluation study. Anonymous surveys were used to assess curriculum effectiveness by comparing self-reported confidence in the execution of key technical skills and application of knowledge in a real clinical environment at three time points: baseline, immediately post-simulation, and 3 months later. ResultsOf 50 PACU nurses, 80%, 98% and 58% responded to the targeted needs assessment, post-simulation and follow up (at 3 months) survey respectively. Self-reported confidence levels for most of the essential skills were significantly increased immediately after simulation and at 3 months. Most of the participants responded that the simulation training helped them improve care of hypoxic (83%) and hypotensive (62%) patients in the PACU. ConclusionImplementation of in situ curriculum for PACU nurses was feasible. The self-reported confidence in performing essential skills increased significantly and the nurses could apply these skills in real clinical environment. Practice implicationsInterprofessional simulation should be implemented in all high risk units to optimize safety of children.

A Wellness Program to Decrease Pediatric Postanesthesia Care Unit Staff Compassion Fatigue.

Health care workers, especially those in pediatrics, have a high risk for compassion fatigue (CF). A wellness program (WP) might help decrease CF and increase compassion satisfaction (CS). This project implemented and evaluated a WP in a pediatric postanesthesia care unit at a large children's hospital. The project evaluated the effectiveness of a WP using pre- and post-WP surveys, which assessed CF (i.e., burnout and secondary traumatic stress), CS, and overall satisfaction with the WP. Overall results demonstrated decreases in CF and increases in CS, self-care, healthy behaviors, and knowledge of CF. The perceived level of teamwork, morale, recognition, social support, and positive coworker interactions also increased. Overall, 77% of the respondents thought the WP helped decrease CF. Implementing a WP that incorporates social support, education, and healthy behaviors had significant benefits, including a reduction in CF.

It's Not Over Till It's Over: A Prospective Cohort Study and Analysis of "Anesthesia Stat!" Emergency Calls in the Pediatric Post-Anesthesia Care Unit (PACU).

BackgroundEmergency "Anesthesia Stat!" (AS!) calls remain a common practice in medical centers even when advanced communication infrastructures are available. We hypothesize that the analysis of post-procedure "AS!" calls will lead to actionable insights which may enhance patient safety.MethodsAfter institutional review board approval, we prospectively collected data from April 2015 through May 2018 on "AS!" calls throughout the pediatric operating rooms (OR), off-site locations, and post-anesthesia care unit (PACU) at a tertiary university medical center. Data recorded included demographic information, location, time of the event, event duration, vital signs, medications, anesthesia staff, attending anesthesiologist, and staff responding to the call. A narrative account of the event was also documented.ResultsA total of 82 "AS!" calls occurred, with ages ranging from 11 days old to 17 years old. Forty-nine of the 82 calls (60%) occurred at emergence. Seventy-one of the 82 calls (87%) were solely respiratory-related. Thirty-five of 49 emergence calls (71%) occurred in the PACU. Further, 34 of 35 PACU calls (97%) were respiratory-related, with 30 of 35 PACU calls (86%) associated with desaturation requiring intervention by anesthesia staff. Finally, 31 of 35 PACU calls (89%) occurred within 30 minutes of patient arrival to PACU.ConclusionAnalysis of "AS!" events from our PACU continues to support the need for the prompt and continuous availability of at least one staff member with advanced airway management skills. Further, pediatric patients undergoing general anesthesia and surgery should likely be monitored for a minimum of 30 minutes following arrival in the PACU.

Multidisciplinary Approach for a Phase II Pediatric Pandemic Recovery Plan

<h3>Background Information</h3> Phoenix Children's Hospital (PCH) pediatric Post-Anesthesia Care Unit (PACU) is comprised of 16 bays, 4 being isolation rooms. This PACU area serves 10 OR/Endoscopy rooms. The daily census average is 26 patients with a range of acuity. The traditional model was to recover patients in Phase I and Phase II in the same area. The back log of cases from the COVID pandemic presented a challenge where we were seeing an increase in the daily census. Historically we have had challenges when the daily surgical patient census was more than 35 patients. Our multiple rapid, high turnover cases along with a lack of space in PACU, caused delays and a decrease in number of cases performed each day and dissatisfaction among surgeons, staff, and families. <h3>Objectives of Project</h3> Goal was to increase efficiency by freeing up space in the PACU department, create Phase II recovery with cross-trained Acute Care Nurses, maintain a revenue stream, and improve physician, staff, patient and family satisfaction. <h3>Process of Implementation</h3> Utilizing ASPAN's Practice Recommendation and American Society of Anesthesiologists Standards for Post-anesthesia Care, we developed criteria that identified patients who met criteria for transfer to Phase II supported by the Aldrete Scoring System. Through collaboration with nursing leaders, we cross-trained Acute Care nurses to Phase II. Leadership identified hours of Phase II operation, which patients we would send to Phase II, and developed a plan to support the Phase II staff. Department leadership reviewed the schedule one week in advance to determine the most appropriate days for Phase II. <h3>Statement of Successful Practice</h3> Successfully able to accommodate more ENT patients on a daily basis, increase efficiency, prevent delays related to PACU saturation. <h3>Implications for Advancing the Practice of Perianesthesia Nursing</h3> Using resources from multiple areas, AORN/ASPAN, perianesthesia nursing can increase productivity with this practice, by identifying patients that are appropriate to transfer to Phase II. Patient families can be with children earlier. It will decrease the RN's divided attention with a mix of patients and supports the mission of nursing as life-long learners, and improved PACU RN's efficiency with appropriately assessing the Aldrete scoring system.

Incidence of Emergence Agitation in Pediatric Patient after General Anesthesia

Post anesthesia agitation is common problem in pediatric post anesthesia care unit. The incidences range from 10 to 80%. EA has been described as a dissociated state of consciousness in which the child is inconsolable, irritable, and uncooperative typically thrashing, crying, moaning or incoherent. This study was done to determine the incidence of emergence agitation and associated risk factors in pediatric patients who underwent general anesthesia. This descriptive and analytic study was performed on 105 pediatric patient aged 1-12 years that underwent general anesthesia for various elective diagnostic and surgeries at Dr. Soetomo Hospital between January and February 2016. The presence of emergence agitation was recorded using Pediatric Anesthesia Emergence Delirium (PAED) scale. The factors that linked with Emergence Agitation were recorded in a questionnaire. The data were analyzed using SPSS software with logistic regression. p - values less than 0.05 were considered as significant. Forty two (40%) children had Emergence Agitation. Preoperative anxiety (p = 0.006) and Pain (p=0.035) were associated with higher rates of post anesthetic emergence agitation. This study identified preoperative anxiety and pain as risk factors, which are associated with emergence agitation in children. To minimize the incidence of post anesthetic emergence agitation, these risk factors should be considered in the routine care by anesthetist.

Preoperative Administration of Hycet Elixir Reduces Hospital Length of Stay After Pediatric Outpatient Adeno/Tonsillectomy.

Background: Postoperative wound pain is commonly observed in the pediatric postanesthesia care unit (PACU) following tonsillectomy, adenoidectomy, and adenotonsillectomy (adeno/tonsillectomy), which contributes to increased medical care costs and delayed facility discharge. The purpose of this study was to review the benefits of preoperative administration of Hycet elixir (2.5 mg hydrocodone and 108 mg acetaminophen per 5 mL) in a pediatric population aged 1 to 9 years following adeno/tonsillectomy.Methods: Patient demographics, comorbidities, surgical and anesthetic times, need for postoperative rescue therapies, and PACU recovery and length of stay times were measured in pediatric patients who received preoperative administration of Hycet elixir (0.2 mg/kg hydrocodone) for adeno/tonsillectomy in an outpatient setting compared to a control group.Results: The Hycet elixir group had significant reductions in PACU and hospital lengths of stay and significant reductions in the need for postoperative rescue analgesics. No significant differences were observed in emergence times or in the incidences of unplanned hospital admission between the control and Hycet elixir groups.Conclusion: These data show that the preoperative administration of Hycet elixir is well tolerated in the pediatric patient population undergoing adeno/tonsillectomy and appears to significantly reduce the need for postoperative rescue analgesics and postoperative care times. These data support the use of preoperative administration of Hycet elixir in this patient population.

Decreasing Pediatric PACU Noise Level and Alarm Fatigue: A Quality Improvement Initiative to Improve Safety and Satisfaction

PurposeTo describe how a pediatric postanesthesia care unit used a two-phased approach of bundled interventions to reduce unit noise levels and improve staff perceptions of their work environment. DesignPre/post design. MethodsPostanesthesia care unit sound levels and monitor alarms were measured at baseline and after implementing both project phases. Nursing staff members were surveyed at baseline and after completion of the project. FindingsMonitor alarms were reduced by more than 50% after Phase I. However, noise measurement data did not reflect a difference in sound levels between baseline and intervention phases. Despite this, staff perceived the unit as much quieter. ConclusionsThe reduction in monitor alarms did not cause an appreciable change in sound levels as measured by noise dosimeters in either intervention phase. Despite these findings, nurses perceived a quieter and more pleasant workplace. These impressions might have resulted from subjective expectations versus actual volume levels, or they might owe to the reduction in incidence of alarms themselves, which they had viewed as nuisance sounds.

Incidence of Emergence Agitation in Pediatric Patient after General Anesthesia

Post anesthesia agitation is common problem in pediatric post anesthesia care unit. The incidences range from 10 to 80%. EA has been described as a dissociated state of consciousness in which the child is inconsolable, irritable, and uncooperative typically thrashing, crying, moaning or incoherent. This study was done to determine the incidence of emergence agitation and associated risk factors in pediatric patients who underwent general anesthesia. This descriptive and analytic study was performed on 105 pediatric patient aged 1-12 years that underwent general anesthesia for various elective diagnostic and surgeries at Dr. Soetomo Hospital between January and February 2016. The presence of emergence agitation was recorded using Pediatric Anesthesia Emergence Delirium (PAED) scale. The factors that linked with Emergence Agitation were recorded in a questionnaire. The data were analyzed using SPSS software with logistic regression. p - values less than 0.05 were considered as significant. Forty two (40%) children had Emergence Agitation. Preoperative anxiety (p = 0.006) and Pain (p=0.035) were associated with higher rates of post anesthetic emergence agitation. This study identified preoperative anxiety and pain as risk factors, which are associated with emergence agitation in children. To minimize the incidence of post anesthetic emergence agitation, these risk factors should be considered in the routine care by anesthetist.

Pediatric Post-anesthesia Care Unit Challenges Update

The purpose of this review is to discuss the current management of various challenges the health care provider faces in the pediatric post-anesthesia care unit (PACU). Efforts to ameliorate and manage PACU issues in the pediatric patient continue to evolve as new medications and methods of anesthesia delivery are introduced and incorporated into the perioperative period. In this review, emergence delirium (ED), postoperative nausea and vomiting (PONV), residual neuromuscular blockade, and tracheal extubation in the operating room versus the PACU are addressed. As ED may be self-limited, pharmacologic treatment may only be indicated if there is a concern for patient harm. Midazolam, fentanyl, and propofol have all been shown to be effective in the treatment of emergence delirium. Dexmedetomidine has been shown to decrease the incidence of ED when administered preoperatively or intraoperatively. This has led practitioners to use dexmedetomidine to treat ED in the PACU, though this has not been studied. Postoperative nausea is difficult to assess in the pediatric patient leading to under treatment. In order to capture these children, the BARF score, initially validated for use in oncologic pediatric patients, is validated for use in postoperative pediatric patients 6 years and older. The approach to treating breakthrough PONV in the PACU is guided by the medications administered intraoperatively for prophylactic treatment. Rescue medications from a different class should be selected if fewer than 6 h have passed since the administration of prophylactic antiemetics. Inadequate reversal of neuromuscular blockade intraoperatively results in adverse respiratory events in the PACU. In the past, when maximum doses of reversal agents are administered, the only recourse in the PACU is to provide assisted ventilation. With the introduction of sugammadex, assisted ventilation can be avoided since sugammadex is capable of reversing dense neuromuscular blockade by vecuronium or rocuronium. In the current environment of achieving greater OR efficiency and cost savings, some institutions are moving tracheal extubation from the operating room by trained anesthesiologists to the PACU by trained nurses with physicians immediately available. This practice in two different children’s hospitals is shown to be safe with no greater incidence of adverse respiratory events and with the added benefit of decreasing operating room time. PACU challenges in the pediatric patient continue to occur despite changes in anesthetic practice and introduction of newer medications. It is important to keep abreast of these newer modalities to best manage these PACU conditions.

Piloting Medication Histories in a Pediatric Postanesthesia Care Unit

Develop a medication history process for pediatric postanesthesia care unit (PACU) patients to identify discrepancies between home and inpatient medications and prevent medication errors. Pilot an evidence-based practice change to perform PACU medication histories. Inpatients or surgical admissions to general care units at a pediatric tertiary care 348-bed hospital ages 2-18 years were included. Parents/guardians were asked about their child's prescription and over-the-counter medications, allergies, and adherence. Data included patient age, surgery, medication categories, and error classifications. Information was compared to the patient's medical record. From June to July 2016, 75 medication histories were performed, covering 44.6% of eligible cases within the period. Seventy-four discrepancies were found, the most frequent being omission. The medication category with the most errors was vitamins/herbals/supplements. The workflow designed assessed discrepancy frequency and type in surgical patients' medication lists when transitioning from the PACU to general care units.

Humidification of Blow-By Oxygen During Recovery of Postoperative Pediatric Patients: One Unit's Journey

To examine the practice of nebulizer cool mist blow-by oxygen administered to spontaneously breathing postanesthesia care unit (PACU) pediatric patients during Phase one recovery. Existing evidence was evaluated. Informal benchmarking documented practices in peer organizations. An invitro study was then conducted to simulate clinical practice and determine depth and amount of airway humidity delivery with blow-by oxygen. Informal benchmarking information was obtained by telephone interview. Using a three-dimensional printed simulation model of the head connected to a breathing lung simulator, depth and amount of moisture delivery in the respiratory tree were measured. Evidence specific to PACU administration of cool mist blow-by oxygen was limited. Informal benchmarking revealed that routine cool mist oxygenated blow-by administration was not widely practiced. The laboratory experiment revealed minimal moisture reaching the mid-tracheal area of the simulated airway model. Routine use of oxygenated cool mist in spontaneously breathing pediatric PACU patients is not supported.

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

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. 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. 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. 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.

The impact of capnography monitoring among children and adolescents in the postanesthesia care unit: a randomized controlled trial.

Pulse oximetry does not reliably recognize respiratory depression, particularly in the presence of supplemental oxygen. Capnography frequently detects hypoventilation and apnea among children recovering from anesthesia. Although children are routinely monitored with capnography during anesthesia, reducing the rate of adverse events, it is not routinely used in the postanesthesia care unit (PACU), where patients remain at risk for respiratory depression. We hypothesized that children monitored with capnography would have more frequent staff interventions and fewer adverse events than children monitored with pulse oximetry alone. Otherwise healthy children of age 1-20 years undergoing general anesthesia for elective surgery were eligible for enrollment upon entering the pediatric PACU. Subjects were randomized as to whether PACU staff could view the capnography monitor (intervention group) or not (control group). All children received standard monitoring with pulse oximetry. Vital signs and patient interventions were recorded every 30 s by a portable monitor or a research associate. Data from 201 children were analyzed. The rates of hypopneic hypoventilation [5% (95% CI: 2-8%) per minute vs 1% (95% CI: -1% to 3%) per minute, difference 4% (95% CI: 0.2-8%) per minute; P = 0.04] and apnea [11% (95% CI: 8-14%) per minute vs 1.5% (95% CI: -2% to 5%) per minute, difference 9% (5-14%) per minute; P < 0.001] decreased significantly faster in our intervention group as compared to the control group. The rates of bradypnea decreased faster in our control group [5% (95% CI: 2-8%) per minute vs 1% (95% CI: 0-4%) per minute, difference 4% per minute, 95% CI: 0-9%; P = 0.05]. Rates of respiratory events over time between groups were affected by the presence or absence of interventions. There were no differences in rates of hypoxemia between groups over time. Children monitored with capnography have different rates of adverse respiratory events over time than children monitored solely with pulse oximetry. The addition of capnography improved the efficacy of staff interventions, however did not impact rates of oxygen desaturation.

Capnography Monitoring to Reduce Adverse Events in the Pediatric Post-Anesthesia Care Unit

Capnography Monitoring to Reduce Adverse Events in the Pediatric Post-Anesthesia Care Unit