Safe pediatric anesthesia Maria Matuszczak MD Professor of Anesthesiology Division Chief Pediatric Anesthesia Safe pediatric anesthesia ( Summary) A multitude of factors contribute to safe pediatric aesthesia. First of all an appropriate pre-anesthesia assessment to determine if the child is fit for anesthesia and what type of anesthesia should be provided depending on the procedure and on preexisting medical conditions. The anesthesia workplace needs to be prepared and have all necessary monitors available, the anesthesia machine needs to be tested, all needed anesthesia supply needs to be ready for use, medications for induction and emergencies need to be prepared. The operating room needs to be warm especially if the child is very small. The WHO checklist has been shown to decrease perioperative morbidity and mortality and should be adapted for the children's OR and adhered to. A crisis management pamphlet should be available, simulation training has been shown to improve performance during a crisis and should be part of the continuous education of the OR team. The planning of the post anesthesia care is entire part of a safe pediatric anesthesia and handoff tool should be used when a patient is transferred to another caregiver team and communication is extremely important. Another concern that has been brought to our attention in the last 5 years is the potential neurotoxicity of anesthesia for the developing brain. Several animal studies confirm repeatedly that most of the drugs we use cause apoptosis in the developing brain. Retrospective studies in children show conflicting results but do not eliminate the existing concerns. Future studies are needed and we need to be vigilant and stay informed.

Nothing to disclose

Objectives Part 1 The preoperative assessment Preparation of the operating room The checklist Crisis management Post anesthesia care Importance of communication Team building Simulation

Objectives Part 2 Neurotoxicity and developing brain Wake-up safe PRAN Pediatric Difficult Airway Registry Data collection, national and international data bank

The preoperative assessment Other then the preop assessment that I presented in my previous talk it is important to make sure parents and children are at ease ! Depending on the age this means adjusting to may different needs.

Preparation of the operating room Pediatric Anesthesia Equipment and Drugs There should be a full selection of equipment available for application to the pediatric patient. This equipment should be easily accessible and wellmaintained. A resuscitation cart with equipment appropriate for pediatric patients of all ages, including pediatric defibrillator paddles, is required. The anesthesiologist should be educated in recognition of cardiac dysrhythmias, have equipment for accurate recording of abnormal cardiac rhythms, and know how to use defibrillators that can deliver pediatric doses of energy accurately.31 Resuscitation cardiac drugs should be available in appropriate pediatric concentrations. A written pediatric dose schedule for these drugs should be immediately available.32–34 Airway equipment for all ages of pediatric patients including ventilation masks, tracheal tubes, oral and nasopharyngeal airways, laryngoscopes with pediatric blades, fiber-optic airway equipment, and bronchoscopes; • A separate, fully stocked “difficult airway cart” containing specialized equipment for management of the difficult pediatric airway by a variety of techniques for airway control, ventilation, and intubation including but not limited to fiber-optic bronchoscopy, and emergency cricothyrotomy; • Positive-pressure ventilation systems appropriate for infants and children; • Devices for the maintenance of normothermia (eg, warming lamps, circulating warm-air devices, room thermal regulation capability, airway humidifiers, and fluid-warming devices); • Intravenous fluid administration equipment in- cluding pediatric volumetric fluid administration devices, intravascular catheters in all pediatric sizes, and devices for intraosseous fluid administration35; • Noninvasive monitoring equipment for the measurement of electrocardiography, blood pressure, pulse oximetry, capnography including anesthetic gas concentrations, temperature, and inhaled oxygen concentration; and • Equipment for the measurement of arterial and central venous pressures in infants and small children

How safe is Healthcare Deaths due to medical errors = 8th cause of death. Deaths due to medical errors > motor vehicle accidents, breast cancer or AIDS Medication errors alone = 7,000 deaths annually Healthcare-associated infections =100,000 deaths Total national costs of preventable adverse events are estimated to be between $17 - $29 billion

Patient safety topics on the WHO website Patient safety resources are categorised using these topic headings:   Abuse/aggression and patient safety Consent, communication, confidentiality Documentation and patient safety (checklists/patient records) Environment and patient safety (cleaning, PEAT) Human factors and patient safety culture (Seven Steps, teamwork, staffing) Medical devices/equipment Medication safety Patient accident (slips, trips and falls) Patient admission, transfer, discharge (patient ID) Patient assessment and diagnosis (tests, scans) Patient treatment/procedure (nutrition) Risk assessment and patient safety    

The checklist This Patient Safety Alert alerts healthcare organisations to the release of a World Health Organization (WHO) Surgical Safety Checklist for use in any operating theatre environment. It is a tool for the relevant clinical teams to improve the safety of surgery by reducing deaths and complications.   In June 2008, WHO launched a second Global Patient Safety Challenge, ‘Safe Surgery Saves Lives’, to reduce the number of surgical deaths across the world. The checklist is part of this initiative. The National Reporting and Learning Service (NRLS) in collaboration with an expert reference group, has adapted the checklist for use in England and Wales. It contains the core content but can be adapted locally or for specific specialties through usual clinical governance procedures. In England and Wales, 129,419 incidents relating to surgical specialties were reported to the NRLS in 2007 with a range of degrees of harm, including 271 deaths. Organisations are required to: Ensure an executive and a clinical lead are identified in order to implement the surgical safety checklist within the organisation.  Ensure the checklist is completed for every patient undergoing a surgical procedure (including local anaesthesia).  Ensure that the use of the checklist is entered in the clinical notes or electronic record by a registered member of the team. BMJ Quality and safety Changes in safety attitude and relationship to decreased postoperative morbidity and mortality following implementation of a checklist-based surgical safety intervention Conclusions: Improvements in postoperative outcomes were associated with improved perception of teamwork and safety climate among respondents, suggesting that changes in these may be partially responsible for the effect of the checklist. Clinicians held the checklist in high regard and the overwhelming majority would want it used if they were undergoing surgery themselves. Gawande A. The checklist manifesto: how to get things right. New York: Metropolitan Books, 2010.

The checklist This Patient Safety Alert alerts healthcare organisations to the release of a World Health Organization (WHO) Surgical Safety Checklist for use in any operating theatre environment. It is a tool for the relevant clinical teams to improve the safety of surgery by reducing deaths and complications.   In June 2008, WHO launched a second Global Patient Safety Challenge, ‘Safe Surgery Saves Lives’, to reduce the number of surgical deaths across the world. The checklist is part of this initiative. The National Reporting and Learning Service (NRLS) in collaboration with an expert reference group, has adapted the checklist for use in England and Wales. It contains the core content but can be adapted locally or for specific specialties through usual clinical governance procedures. In England and Wales, 129,419 incidents relating to surgical specialties were reported to the NRLS in 2007 with a range of degrees of harm, including 271 deaths. Organisations are required to: Ensure an executive and a clinical lead are identified in order to implement the surgical safety checklist within the organisation.  Ensure the checklist is completed for every patient undergoing a surgical procedure (including local anaesthesia).  Ensure that the use of the checklist is entered in the clinical notes or electronic record by a registered member of the team.

14 cases of wrong-side thoracenteses are identified. Contributing factors: failure to perform a time-out (n=12), missing indication of laterality on the patient’s consent form (n=10), absence of a site mark on the patient’s skin , absent verification of medical images (n=7). Complications included: pneumothoraces (n=4), hemorrhage (n=3), and death directly attributable to the wrong-side thoracentesis (n=2). Teamwork and communication failure, unawareness of existing policy, and a deficit in training and education were the most common root causes of wrong-side thoracentesis. Fourteen cases of wrong-side thoracenteses are identified. Contributing factors included failure to perform a time-out (n=12), missing indication of laterality on the patient’s consent form (n=10), absence of a site mark on the patient’s skin within the sterile field (n=12), and absent verification of medical images (n=7). Complications included pneumothoraces (n=4), hemorrhage (n=3), and death directly attributable to the wrong-side thoracentesis (n=2). Teamwork and communication failure, unawareness of existing policy, and a deficit in training and education were the most common root causes of wrong-side thoracentesis. Prevention of wrong-site procedures and accompanying patient harm outside the operating room requires adherence to the Universal Protocol and time-outs, effective teamwork, training and education, mentoring, and patient assessment for early detection of complications. The time-outs provide protected time and place for error detection and recovery.

Crisis management SPA’s Pediatric Critical Events Checklists are freely available on the SPA website at http://www.pedsanesthesia.org/newnews/Critical_Event_Checklists.pdf. SPA’s Pediatric Critical Events Checklists are freely available on the SPA website at http://www.pedsanesthesia.org/newnews/Critical_Event_Checklists.pdf.

Crisis management Arriaga AF, Bader AM, Wong JM, et al. Simulation-Based Trial of Surgical-Crisis Checklists. N Engl J Med 2013; 368: 245-53.

Post-Anesthesia Care Unit Nursing Staff Postanesthesia recovery nurses with pediatric education and experience who are knowledgeable in intraoperative pediatric anesthesia management are required. Training and experience in pediatric airway management and basic resuscitation techniques, as well as the ability to recognize a child in distress and provide immediate assistance while calling for support staff/resuscitation team, are necessary. Pediatric Advanced Life Support Course certification should be required. Anesthesiologist/Physician Staff An anesthesiologist or other physician trained and experienced in pediatric perioperative care including the management of postoperative complications and the provision of pediatric cardiopulmonary resuscitation should be immediately available to evaluate and treat any child in distress. Pediatric Advanced Life Support or Advanced Pediatric Life Support certification is recommended. Pediatric Anesthesia Equipment and Drugs The pediatric anesthesia equipment and drugs specified in “Operating Room” above should be available for patients in the Postanesthesia Care Unit. Every child admitted to the postanesthesia care unit should have his/her vital signs monitored. Suction equipment and oxygen should be available at each bedside. A respiratory oxygen delivery system should be available for use in the transport of infants and children from the operating room to the postanesthesia care and/or postoperative intensive care unit when medically indicated.

Importance of communication/handoffs

Culture of safety Team building Awareness Simulation

Objectives Part 2 Neurotoxicity and developing brain Wake-up safe PRAN Pediatric Difficult Airway Registry Data collection, national and international data bank

Neurotoxicity and developing brain Consensus Statement on the Use of Anesthetics and Sedatives in Children December 2012 Each year, millions of young children require surgery and other procedures for serious or life-threatening medical conditions or to improve their quality of life. Anesthetic and sedative drugs are widely used to help ensure the safety, health, and comfort of children undergoing these procedures. However, increasing evidence from research studies suggests the benefits of these agents should be considered in the context of their potential to cause harmful effects. Previous research in young animals and children has raised concerns that exposure to commonly used anesthetics may produce adverse neurobehavioral effects. However, these studies had limitations that prevent experts from drawing conclusions on whether the harmful effects were due to the anesthesia or to other factors, including surgery, hospitalization, or pre-existing conditions. Furthermore, the findings in children have been mixed, with some studies of infants and young children undergoing anesthesia or sedation finding long-term deficits in learning and behavior while others have not. Clearly, additional research is urgently needed to identify any possible risks to young children. In the absence of conclusive evidence, it would be unethical to withhold sedation and anesthesia when necessary. Instead, healthcare providers should do the following: Discuss with parents and other caretakers the risks and benefits of procedures requiring anesthetics or sedatives, as well as the known health risks of not treating certain conditions Stay informed of new developments in this area Recognize that current anesthetics and sedatives are necessary for infants and children who require surgery or other painful and stressful procedures Consensus Statement on the Use of Anesthetics and Sedatives in Children December 2012 Each year, millions of young children require surgery and other procedures for serious or life-threatening medical conditions or to improve their quality of life. Anesthetic and sedative drugs are widely used to help ensure the safety, health, and comfort of children undergoing these procedures. However, increasing evidence from research studies suggests the benefits of these agents should be considered in the context of their potential to cause harmful effects. Previous research in young animals and children has raised concerns that exposure to commonly used anesthetics may produce adverse neurobehavioral effects. However, these studies had limitations that prevent experts from drawing conclusions on whether the harmful effects were due to the anesthesia or to other factors, including surgery, hospitalization, or pre-existing conditions. Furthermore, the findings in children have been mixed, with some studies of infants and young children undergoing anesthesia or sedation finding long-term deficits in learning and behavior while others have not. Clearly, additional research is urgently needed to identify any possible risks to young children. In the absence of conclusive evidence, it would be unethical to withhold sedation and anesthesia when necessary. Instead, healthcare providers should do the following: Discuss with parents and other caretakers the risks and benefits of procedures requiring anesthetics or sedatives, as well as the known health risks of not treating certain conditions Stay informed of new developments in this area Recognize that current anesthetics and sedatives are necessary for infants and children who require surgery or other painful and stressful procedures

Wake-up safe The Goals of Wake up Safe are: To define quality in pediatric anesthesia care. To develop ways of measuring quality in pediatric anesthesia care. To develop robust Quality Improvement Systems within Departments of Pediatric Anesthesia. To provide data to allow research about adverse events in pediatric perioperative care. The Objectives of Wake up Safe are: To develop a registry of adverse events in pediatric perioperative care. To analyze adverse events and to determine common causes for these adverse events. To devise strategies to prevent adverse events. To gather data to allow departments to compare their data with national norms. Although great strides have been made in anesthesia safety, patients continue to experience unintended harm related to anesthesia and surgical care. Because these events of harm are relatively rare, it is difficult for any one institution to learn enough from any single occurrence. Thus, the Society of Pediatric Anesthesia undertook the development of a multi-institutional system for reporting and analyzing these events. Wake Up Safe is the initiative designed to fill these gaps in knowledge and to find ways to reduce or eliminate these harmful events. The Society for Pediatric Anesthesia, the largest professional group for pediatric anesthesiologists in the United States, sponsors Wake Up Safe, which has been certified by the Agency for Healthcare Research and Quality (AHRQ) as a Patient Safety Organization. Wake up Safe contains a registry of serious adverse events reported on a voluntary basis by participating institutions. Names of patients, individuals involved in the event, and institutions will not be identified and are confidential. Each institution reports the event and a structured analysis of why the event occurred. From a review of the reports, we hope to find ways to improve care of children in the perioperative environment through quality improvement initiatives. We are also developing a program of peer visitation where anesthesiologists visit other institutions and critique their processes of care, looking for areas for improvement and trying to find best practices. Findings Hyperkalemia Statement Statement on Preventing Wrong Side Procedures November 29, 2010 - A Wake Up Safe Patient Safety Alert: Decreasing the Risks of Intravenous Medication Errors UPDATE June 22, 2011 - A Wake Up Safe Patient Safety Alert: Decreasing the Risks of Intravenous Medication Errors

PRAN Pediatric regional anesthesia network 14,917 RA, performed on 13,725 patients, from April 1, 2007 through March 31, 2010. No deaths or complications with sequelae lasting >3 months (95% CI 0–2:10,000). 95% of blocks placed while patients were under GA. Widespread use of ultrasound (83% of upper extremity and 69% of lower extremity blocks). December 2012; 115(6) 1352-64

Pediatric Difficult Airway Registry

Conclusion