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  • 1
    Online Resource
    Online Resource
    Predicting Postoperative Physiologic Decline After Surgery
    American Academy of Pediatrics (AAP) ; 2019
    In:  Pediatrics Vol. 143, No. 4 ( 2019-04-01)
    Details
    In: Pediatrics, American Academy of Pediatrics (AAP), Vol. 143, No. 4 ( 2019-04-01)
    Abstract: Projecting postoperative recovery in pediatric surgical patients is challenging. We assessed how the patients’ number of complex chronic conditions (CCCs) and chronic medications interacted with active health issues to influence the likelihood of postoperative physiologic decline (PoPD). METHODS: A prospective study of 3295 patients undergoing elective surgery at a freestanding children’s hospital. During preoperative clinical evaluation, active health problems, CCCs, and medications were documented. PoPD (compromise of cardiovascular, respiratory, and/or neurologic systems) was measured prospectively every 4 hours by inpatient nurses. PoPD odds were estimated with multivariable logistic regression. Classification and regression tree analysis distinguished children with the highest and lowest likelihood of PoPD. RESULTS: Median age at surgery was 8 years (interquartile range: 2–15); 2336 (70.9%) patients had a CCC; and 241 (7.3%) used ≥11 home medications. During preoperative evaluation, 1556 (47.2%) patients had ≥1 active health problem. After surgery, 882 (26.8%) experienced PoPD. The adjusted odds of PoPD were 1.2 (95% confidence interval [CI]: 1.0–1.4) for presence versus absence of an active health problem; 1.4 (95% CI: 1.0–1.9) for ≥11 vs 0 home medications; and 2.2 (95% CI: 1.7–2.9) for ≥3 vs 0 CCCs. In classification and regression tree analysis, the lowest rate of PoPD (8.6%) occurred in children without an active health problem at the preoperative evaluation; the highest rate (57.2%) occurred in children with a CCC who used ≥11 home medications. CONCLUSIONS: Greater than 1 in 4 pediatric patients undergoing elective surgery experienced PoPD. Combinations of active health problems at preoperative evaluation, polypharmacy, and multimorbidity distinguished patients with a low versus high risk of PoPD.
    Type of Medium: Online Resource
    ISSN: 0031-4005 , 1098-4275
    URL: Article
    DOI: 10.1542/peds.2018-2042
    Language: English
    Publisher: American Academy of Pediatrics (AAP)
    Publication Date: 2019
    detail.hit.zdb_id: 1477004-0
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  • 2
    Online Resource
    Online Resource
    Does the Current American Society of Anesthesiologists Physical Status Classification Represent the Chronic Disease Burden in Children Undergoing General Anesthesia?
    Ovid Technologies (Wolters Kluwer Health) ; 2019
    In:  Anesthesia & Analgesia Vol. 129, No. 4 ( 2019-10), p. 1175-1180
    Details
    In: Anesthesia & Analgesia, Ovid Technologies (Wolters Kluwer Health), Vol. 129, No. 4 ( 2019-10), p. 1175-1180
    Type of Medium: Online Resource
    ISSN: 0003-2999
    URL: Article
    DOI: 10.1213/ANE.0000000000003911
    RVK:
    XA 22250
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2019
    detail.hit.zdb_id: 2018275-2
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  • 3
    Online Resource
    Online Resource
    Does the Current American Society of Anesthesiologists Physical Status Classification Represent the Chronic Disease Burden in Children Undergoing General Anesthesia?
    Ovid Technologies (Wolters Kluwer Health) ; 2018
    In:  Anesthesia & Analgesia ( 2018-11), p. 1-
    Details
    In: Anesthesia & Analgesia, Ovid Technologies (Wolters Kluwer Health), ( 2018-11), p. 1-
    Type of Medium: Online Resource
    ISSN: 0003-2999
    URL: Article
    DOI: 10.1213/00000539-900000000-96367
    RVK:
    XA 22250
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2018
    detail.hit.zdb_id: 2018275-2
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  • 4
    Online Resource
    Online Resource
    One Size Does Not Fit All: A Perspective on the American Society of Anesthesiologists Physical Status Classification for Pediatric Patients
    Ovid Technologies (Wolters Kluwer Health) ; 2020
    In:  Anesthesia & Analgesia Vol. 130, No. 6 ( 2020-06), p. 1685-1692
    Details
    In: Anesthesia & Analgesia, Ovid Technologies (Wolters Kluwer Health), Vol. 130, No. 6 ( 2020-06), p. 1685-1692
    Abstract: The American Society of Anesthesiologists physical status (ASA-PS) classification system is used worldwide to classify patients based on comorbid conditions before general anesthesia. Despite its popularity, the ASA-PS classification system has been shown to have poor interrater reliability due to its subjective definitions, especially when applied to the pediatric population. We hypothesized that the clarification of ASA-PS definitions to better reflect pediatric conditions would improve the accuracy of ASA-PS applied to this population. METHODS: A stratified, randomized sample of 120 pediatric surgical cases was collected from a tertiary-care pediatric hospital. A team of senior anesthesiologists reclassified ASA-PS within this patient sample using the suggested pediatric-specific ASA-PS definitions. Interrater reliability was measured using intraclass correlation (ICC) and Fleiss κ statistic. In addition, a qualitative study component using small focus groups of senior anesthesiologists identified areas of ambiguity within the ASA-PS system. RESULTS: Among the 90 reclassifications within each ASA-PS group, 42.2% (n = 38) of ASA-PS I were upgraded to ASA-PS II, and 36.7% (n = 33) of ASA-PS II were upgraded to ASA-PS III. In addition, 28.9% (n = 26) of ASA-PS III were upgraded to ASA-PS IV, and 24.4% (n = 22) of ASA-PS IV were downgraded to III. ICC across the reclassified ASA-PS categories was 0.77 (95% confidence interval [CI], 0.71–0.83; P 〈 .001) demonstrating strong overall agreement. Fleiss κ statistic was lowest in ASA-PS II and III patients (κ = 0.41 and κ = 0.30, respectively) indicating lower agreement beyond chance within these subgroups. Focus groups revealed common themes such as active sequelae of disease, active versus well-controlled presence of comorbidities, and the possible inclusion of functional limitations as important considerations. CONCLUSIONS: The ASA-PS classification system has several benefits including ease-of-use, simplicity, and flexibility. However, revising the ASA-PS system to provide better guidance for pediatric patients could be valuable. While this study demonstrates good interrater reliability with the included ASA-PS pediatric definitions, further work is needed to clarify accurate assignment of ASA-PS within the midrange of the scale (ASA-PS II and III) and explore its implementation in other institutions.
    Type of Medium: Online Resource
    ISSN: 0003-2999
    URL: Article
    DOI: 10.1213/ANE.0000000000004277
    RVK:
    XA 22250
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2020
    detail.hit.zdb_id: 2018275-2
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  • 5
    Online Resource
    Online Resource
    The Pediatric-Specific American Society of Anesthesiologists Physical Status Score: A Multicenter Study
    Ovid Technologies (Wolters Kluwer Health) ; 2021
    In:  Anesthesia & Analgesia Vol. 132, No. 3 ( 2021-03), p. 807-817
    Details
    In: Anesthesia & Analgesia, Ovid Technologies (Wolters Kluwer Health), Vol. 132, No. 3 ( 2021-03), p. 807-817
    Abstract: When applied to the pediatric population, the American Society of Anesthesiologists physical status (ASA-PS) classification has exhibited poor reliability due to its subjective and adult-focused definitions. This study was done to measure interrater agreement of a pediatric-adapted ASA-PS classification and to solicit multicenter perspectives to optimize the pediatric ASA-PS classification. METHODS: A prospective, mixed-methods study of 197 pediatric anesthesiologists from 13 academic pediatric hospitals in the United States, Europe, and Australia surveyed in May and July 2019. Participants assigned ASA-PS scores (I to V) for 15 pediatric cases with a heterogeneous mix of acute and chronic health conditions undergoing a variety of surgical and related procedures. Pediatric-adapted definitions of ASA-PS were provided. The intraclass correlation coefficient (ICC) was used to assess interrater reliability of ASA-PS scores. The ICC was estimated using 2-way mixed-effects modeling, accounting for multiple raters assigning scores for the same set of cases. Qualitative feedback on the pediatric-adapted ASA-PS classification was analyzed with line-by-line coding. RESULTS: The survey response rate was 83.8% (165 of 197). The ICC agreement among participants on ASA-PS scoring across all 15 clinical cases was 0.58 (95% confidence interval [CI], 0.42–0.77). ICC did not vary significantly by years of anesthesiology practice. ICC varied across hospitals (range: 0.34; 95% CI, 0.12–0.63 to 0.79; 95% CI, 0.66–0.91). The highest level of agreement occurred with cases most often scored as ASA-PS I, IV, and V; the lowest agreement occurred with cases most often scored ASA-PS II and III. Clarification of how well a chronic condition was controlled and presence of an acute illness were 2 common themes suggested to optimize the validity of the pediatric-adapted ASA-PS definitions. CONCLUSIONS: The pediatric-adapted ASA-PS classification had moderate interrater reliability among pediatric anesthesiologists. The lower reliability of scoring for ASA-PS II and III cases, in particular, supports the need for further ASA-PS definition refinement for pediatric populations.
    Type of Medium: Online Resource
    ISSN: 0003-2999
    URL: Article
    DOI: 10.1213/ANE.0000000000005025
    RVK:
    XA 22250
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2021
    detail.hit.zdb_id: 2018275-2
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  • 6
    Online Resource
    Online Resource
    Comprehensive Risk Assessment of Morbidity in Pediatric Patients Undergoing Noncardiac Surgery: An Institutional Experience
    Ovid Technologies (Wolters Kluwer Health) ; 2020
    In:  Anesthesia & Analgesia Vol. 131, No. 5 ( 2020-11), p. 1607-1615
    Details
    In: Anesthesia & Analgesia, Ovid Technologies (Wolters Kluwer Health), Vol. 131, No. 5 ( 2020-11), p. 1607-1615
    Abstract: Utilizing the intrinsic surgical risk (ISR) and the patient’s chronic and acute conditions, this study aims to develop and validate a comprehensive predictive model of perioperative morbidity in children undergoing noncardiac surgery. METHODS: Following institutional review board (IRB) approval at a tertiary care children’s hospital, data for all noncardiac surgical encounters for a derivation dataset from July 2017 to December 2018 including 16,724 cases and for a validation dataset from January 2019 to December 2019 including 9043 cases were collected retrospectively. The primary outcome was a composite morbidity score defined by unplanned transfer to an intensive care unit (ICU), acute respiratory failure requiring intubation, postoperative need for noninvasive or invasive positive pressure ventilation, or cardiac arrest. Internal model validation was performed using 1000 bootstrap resamples, and external validation was performed using the 2019 validation cohort. RESULTS: A total of 1519 surgical cases (9.1%) experienced the defined composite morbidity. Using multivariable logistic regression, the Risk Assessment of Morbidity in Pediatric Surgery (RAMPS) score was developed with very good predictive ability in the derivation cohort (area under the curve [AUC] = 0.805; 95% confidence interval [CI] , 0.795–0.816), very good internal validity using 1000 bootstrap resamples (bias-corrected Nagelkerke R 2 = 0.21 and Brier score = 0.07), and good external validity (AUC = 0.783; 95% CI, 0.770–0.797). The included variables are age 〈 5 years, critically ill, chronic condition indicator (CCI) ≥3, significant CCI ≥2, and ISR quartile ≥3. The RAMPS score ranges from 0 to 10, with the risk of composite morbidity ranging from 1.8% to 42.7%. CONCLUSIONS: The RAMPS score provides the ability to identify a high-risk cohort of pediatric patients using a 5-component tool, and it demonstrated good internal and external validity and generalizability. It also provides an opportunity to improve perioperative planning with the intent of improving both individual-patient outcomes and the appropriate allocation of health care resources.
    Type of Medium: Online Resource
    ISSN: 0003-2999
    URL: Article
    DOI: 10.1213/ANE.0000000000005157
    RVK:
    XA 22250
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2020
    detail.hit.zdb_id: 2018275-2
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  • 7
    Online Resource
    Online Resource
    Hospital Volumes of Inpatient Pediatric Surgery in the United States
    Ovid Technologies (Wolters Kluwer Health) ; 2021
    In:  Anesthesia & Analgesia Vol. 133, No. 5 ( 2021-11), p. 1280-1287
    Details
    In: Anesthesia & Analgesia, Ovid Technologies (Wolters Kluwer Health), Vol. 133, No. 5 ( 2021-11), p. 1280-1287
    Abstract: Perioperative outcomes of children depend on the skill and expertise in managing pediatric patients, as well as integration of surgical, anesthesiology, and medical teams. We compared the types of pediatric patients and inpatient surgical procedures performed in low- versus higher-volume hospitals throughout the United States. METHODS: Retrospective analysis of 323,258 hospitalizations with an operation for children age 0 to 17 years in 2857 hospitals included in the Agency for Healthcare Research and Quality (AHRQ) Kids’ Inpatient Database (KID) 2016. Hospitals were categorized by their volume of annual inpatient surgical procedures. Specific surgeries were distinguished with the AHRQ Clinical Classification System. We assessed complex chronic conditions (CCCs) using Feudtner and Colleagues’ system. RESULTS: The median annual volume of pediatric inpatient surgeries across US hospitals was 8 (interquartile range [IQR], 3–29). The median volume of inpatient surgeries for children with a CCC was 4 (IQR, 1–13). Low-volume hospitals performed significantly fewer types of surgeries (median 2 vs 131 types of surgeries in hospitals with 1–24 vs ≥2000 volumes). Appendectomy and fixation of bone fracture were among the most common surgeries in low-volume hospitals. As the volume of surgical procedures increased from 1 to 24 to ≥2000, the percentage of older children ages 11 to 17 years decreased (70.9%–32.0% [ P 〈 .001]) and the percentage of children with a CCC increased (11.2%–60.0% [ P 〈 .001]). CONCLUSIONS: Thousands of US hospitals performed inpatient surgeries on few pediatric patients, including those with CCCs who have the highest risk of perioperative morbidity and mortality. Evaluation of perioperative decision making, workflows, and pediatric clinicians in low- and higher-volume hospitals is warranted.
    Type of Medium: Online Resource
    ISSN: 0003-2999
    URL: Article
    DOI: 10.1213/ANE.0000000000005748
    RVK:
    XA 22250
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2021
    detail.hit.zdb_id: 2018275-2
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  • 8
    Online Resource
    Online Resource
    The Role of Chronic Conditions in Outcomes following Noncardiac Surgery in Children with Congenital Heart Disease
    Elsevier BV ; 2022
    In:  The Journal of Pediatrics Vol. 244 ( 2022-05), p. 49-57.e8
    Details
    In: The Journal of Pediatrics, Elsevier BV, Vol. 244 ( 2022-05), p. 49-57.e8
    Type of Medium: Online Resource
    ISSN: 0022-3476
    URL: Article
    DOI: 10.1016/j.jpeds.2022.01.013
    Language: English
    Publisher: Elsevier BV
    Publication Date: 2022
    detail.hit.zdb_id: 2005245-5
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