Publications by authors named "David Faraoni"

129 Publications

Association Between Intraoperative Remifentanil Dosage and Postoperative Opioid Consumption in Adolescent Idiopathic Spine Surgery: A Retrospective Cohort Study.

Anesth Analg 2021 Feb 5. Epub 2021 Feb 5.

From the Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, Toronto, Canada.

Background: Adolescent idiopathic scoliosis (AIS) surgery is associated with significant postoperative pain. Remifentanil is a short-acting opioid that is often used as a component of total intravenous anesthesia. Remifentanil has been implicated in acute opioid tolerance and opioid-induced hyperalgesia, resulting in increased postoperative pain and opioid consumption. This retrospective study sought to investigate the relationship between the dose of intraoperative remifentanil and cumulative postoperative opioid consumption through 72 hours following surgery for pediatric AIS patients.

Methods: We performed a retrospective chart review of adolescent patients undergoing posterior spine instrumentation under total intravenous general anesthesia at a single major pediatric center between January 2015 and October 2017. The relationship between intraoperative cumulative weight-adjusted remifentanil dose and logarithmic transformation of cumulative weight-adjusted opioid consumption through 72 hours following surgery was examined by regression analysis. A priori determined potential confounding variables were collected, including demographic data, perioperative analgesic agents (ie, ketamine, dexmedetomidine, and acetaminophen), surgical duration, vertebrae instrumented, and blood transfusion. Multivariable linear regression analysis was used to adjust for these possible confounding variables.

Results: Eighty-nine patients met inclusion criteria, of which 78 had complete data for analysis. Univariable linear regression analysis revealed no association between remifentanil dose and opioid consumption through 72 hours following surgery (slope = 0.79 [95% confidence interval [CI], 0.61-0.98; R2 = 0.0039; P = .588]). After adjustment for possible confounding factors, no relationship between remifentanil dose (regression coefficient (coeff.) -0.08; 95% CI, -1.59 to 1.43; P = .912) and opioid consumption through 72 hours was found (slope =0.90 [95% CI, -0.65 to 2.46]; R2 = 0.1634). Similar results were obtained when the model was repeated for opioid consumption in postanesthesia care unit (PACU).

Conclusions: In this study examining adolescent patients undergoing surgery for idiopathic scoliosis, no association was found between the dose of intraoperative remifentanil and postoperative opioid consumption in the context of a propofol-based total intravenous anesthetic and multimodal analgesia. These results provide direction for future prospective controlled studies to further evaluate this relationship.
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http://dx.doi.org/10.1213/ANE.0000000000005395DOI Listing
February 2021

General medical publications during COVID-19 show increased dissemination despite lower validation.

PLoS One 2021 2;16(2):e0246427. Epub 2021 Feb 2.

Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada.

Background: The COVID-19 pandemic has yielded an unprecedented quantity of new publications, contributing to an overwhelming quantity of information and leading to the rapid dissemination of less stringently validated information. Yet, a formal analysis of how the medical literature has changed during the pandemic is lacking. In this analysis, we aimed to quantify how scientific publications changed at the outset of the COVID-19 pandemic.

Methods: We performed a cross-sectional bibliometric study of published studies in four high-impact medical journals to identify differences in the characteristics of COVID-19 related publications compared to non-pandemic studies. Original investigations related to SARS-CoV-2 and COVID-19 published in March and April 2020 were identified and compared to non-COVID-19 research publications over the same two-month period in 2019 and 2020. Extracted data included publication characteristics, study characteristics, author characteristics, and impact metrics. Our primary measure was principal component analysis (PCA) of publication characteristics and impact metrics across groups.

Results: We identified 402 publications that met inclusion criteria: 76 were related to COVID-19; 154 and 172 were non-COVID publications over the same period in 2020 and 2019, respectively. PCA utilizing the collected bibliometric data revealed segregation of the COVID-19 literature subset from both groups of non-COVID literature (2019 and 2020). COVID-19 publications were more likely to describe prospective observational (31.6%) or case series (41.8%) studies without industry funding as compared with non-COVID articles, which were represented primarily by randomized controlled trials (32.5% and 36.6% in the non-COVID literature from 2020 and 2019, respectively).

Conclusions: In this cross-sectional study of publications in four general medical journals, COVID-related articles were significantly different from non-COVID articles based on article characteristics and impact metrics. COVID-related studies were generally shorter articles reporting observational studies with less literature cited and fewer study sites, suggestive of more limited scientific support. They nevertheless had much higher dissemination.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0246427PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7853485PMC
February 2021

Effective tranexamic acid concentration for 95% inhibition of tissue-type plasminogen activator-induced hyperfibrinolysis in full-term pregnant women: a prospective interventional study.

Blood Coagul Fibrinolysis 2021 Jan 19. Epub 2021 Jan 19.

Department of Anaesthesiology, CHU Brugmann, Université Libre de Bruxelles, Brussels, Belgium Division of Cardiac Anaesthesia, Department of Anaesthesia and Pain Medicine, The Hospital for Sick Children, University of Toronto, Toronto, Canada.

Postpartum haemorrhage is the leading cause of maternal mortality and morbidity worldwide. Tranexamic acid (TXA) has been shown to reduce blood loss and blood product transfusion requirements. Despite clinical evidence, further studies are needed to better define the pharmacokinetic and pharmacodynamic characteristics of TXA in pregnant women. The objective of our prospective observational ex-vivo study was to define the effective TXA concentration required to inhibit 95% (EC95) of tissue-type plasminogen activator (t-PA)-induced fibrinolysis in full-term pregnant women. Hyperfibrinolysis was induced by adding supraphysiologic concentration of t-PA to blood samples obtained from 30 full-term pregnant women and 10 healthy nonpregnant female volunteers. Increasing TXA concentrations (0--40 μg/ml) were then spiked into the blood samples and inhibition of fibrinolysis was assessed using the lysis index at 30 min of the ROTEM measured on EXTEM and NATEM tests. Effective TXA concentrations required to achieve EC95 were extrapolated using nonlinear regression. EC95 were compared between groups using an extra sum-of-squares F test. EC95 in pregnant women was 14.7 μg/ml (95% CI 12.4--17.5 μg/ml) on EXTEM and 11.2 μg/ml (95% CI 8.3--15.1 μg/ml) on NATEM tests. These values were significantly higher than those obtained in volunteers: 8.7 μg/ml (95% CI 5.5--13.9 μg/ml) and 6.8 μg/ml (95% CI 5.3--8.8 μg/ml), respectively (both P < 0.001). Our results suggest a higher fibrinolytic potential in pregnant women compared with nonpregnant women.
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http://dx.doi.org/10.1097/MBC.0000000000001015DOI Listing
January 2021

Trends in mortality rate in patients with congenital heart disease undergoing noncardiac surgical procedures at children's hospitals.

Sci Rep 2021 Jan 15;11(1):1543. Epub 2021 Jan 15.

Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA, 02115, USA.

Advances made in pediatric cardiology, cardiac surgery and critical care have significantly improved the survival rate of patients with congenital heart disease (CHD) leading to an increase in children with CHD presenting for noncardiac surgical procedures. This study aims (1) to describe the trend and perioperative mortality rates in patients with CHD undergoing noncardiac surgical procedures at children's hospitals over the past 5 years and (2) to describe the patient characteristics and the most common type of surgical procedures. The Pediatric Health Information System (PHIS) is an administrative database that contains inpatient, observation, and outpatient surgical data from 52 freestanding children's hospitals. Thirty-nine of the 52 hospitals submitted data on all types of patient encounters for the duration of the study from 2015 to 2019. The total numbers of non-cardiac surgical encounters among patients with history of a CHD diagnosis significantly increased each year from 38,272 in 2015 to 45,993 in 2019 (P < 0.001). Despite the increase in case numbers, there has been a significant decline in mortality rates to the most recent incidence of 1.06% in 2019. Careful patient selection and medical optimization of patients aligned with specific expertise at dedicated children's hospitals may lead to improvement in mortality rate. Future studies comparing the outcomes of patients with cardiac disease based on hospital type and volume as well as type of providers may help determine the future of care including potential need for regionalization of noncardiac care for this vulnerable patient population.
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http://dx.doi.org/10.1038/s41598-021-81161-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7810725PMC
January 2021

Optimal Tranexamic Acid Dosing Regimen in Cardiac Surgery: What Are the Missing Pieces?

Anesthesiology 2021 02;134(2):143-146

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http://dx.doi.org/10.1097/ALN.0000000000003637DOI Listing
February 2021

Abstract of the Scientific Literature.

Authors:
David Faraoni

Pediatr Dent 2020 Nov;42(6):416

Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, 555 University Ave, Toronto, ON M5G 1X8, Canada;, Email:

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November 2020

Management of Perioperative Iron Deficiency in Cardiac Surgery: A Modified RAND Delphi Study.

Ann Thorac Surg 2020 Dec 17. Epub 2020 Dec 17.

Department of Cardiothoracic and Vascular Diseases, Yavapai Regional Medical Center, Prescott, AZ.

Background: Over the last decade, preoperative anemia has become recognized as a clinical condition in need of management. Although the etiology of preoperative anemia can be multifactorial, two-thirds of anemic elective surgical patients have iron deficiency anemia. At the same time, one-third of non-anemic elective surgical patients are also iron deficient.

Methods: Modified-RAND Delphi methodology was employed to identify areas of consensus among an expert panel regarding the management of iron deficiency in patients undergoing cardiac surgery. A list of statements was sent to panel members to respond to using a five-point Likert Scale. All panel members subsequently attended a face-to-face meeting. The initial survey was presented and discussed, and panel members responded to each statement on the Likert scale again. Based on the second survey, the panel came to a consensus on recommendations.

Results: The panel recommended all patients undergoing cardiac surgery be evaluated for iron deficiency, whether or not anemia is present. Evaluation should include iron studies and reticulocyte hemoglobin content. If iron deficiency is present, with or without anemia, patients should receive parenteral iron. Erythropoietin stimulating agents may be appropriate for some patients.

Conclusions: Consensus of an expert panel resulted in a standardized approach to diagnosing and managing iron deficiency in patients undergoing cardiac surgery.
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http://dx.doi.org/10.1016/j.athoracsur.2020.11.031DOI Listing
December 2020

Viscoelastic testing in pediatric patients.

Transfusion 2020 Oct;60 Suppl 6:S75-S85

Division of Cardiac Anesthesia, Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada.

A tailored transfusion algorithm based on viscoelastic testing in the perioperative period or in trauma patients is recommended by guidelines for bleeding management. Bleeding management strategies in neonates and children are mostly extrapolated from the adult experience, as published evidence in the youngest age group is scarce. This manuscript is intended to give a structured overview of what has been published on the use of viscoelastic testing to guide bleeding management in neonates and children. Several devices that use either the traditional viscoelastic method or resonance viscoelastography technology are on the market. Reference ranges for children have been evaluated in only some of them. As most of the hemostasis maturation processes can be observed during the first year of life, adult reference ranges for viscoelastic testing could be applied over the age of 1 year. The majority of the published trials in children are based on retrospective analyses describing the correlation between viscoelastic testing and standard laboratory testing or focusing on the prediction of bleeding. Clinically more relevant studies in pediatric patients undergoing cardiac surgery have demonstrated that the implementation of a transfusion algorithm based on viscoelastic testing has significantly reduced transfusion requirements and that this approach has enabled a rapid detection of coagulation disorders in the presence of excessive bleeding. Although further studies are urgently needed, experts have reviewed the use of a transfusion algorithm based on viscoelastic testing in children as a feasible approach, as it has been shown to improve bleeding management and rationalize blood product transfusion.
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http://dx.doi.org/10.1111/trf.16076DOI Listing
October 2020

Comprehensive Risk Assessment of Morbidity in Pediatric Patients Undergoing Noncardiac Surgery: An Institutional Experience.

Anesth Analg 2020 11;131(5):1607-1615

From the Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts.

Background: 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 = 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.
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http://dx.doi.org/10.1213/ANE.0000000000005157DOI Listing
November 2020

Predicting Perioperative Respiratory Adverse Events in Children With Sleep-Disordered Breathing.

Anesth Analg 2020 Sep 23. Epub 2020 Sep 23.

From the Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada.

Background: No evidence currently exists to quantify the risk and incidence of perioperative respiratory adverse events (PRAEs) in children with sleep-disordered breathing (SDB) undergoing all procedures requiring general anesthesia. Our objective was to determine the incidence of PRAEs and the risk factors in children with polysomnography-confirmed SDB undergoing procedures requiring general anesthesia.

Methods: Retrospective review of all patients with polysomnography-confirmed SDB undergoing general anesthesia from January 2009 to December 2013. Demographic and perioperative outcome variables were compared between children who experienced PRAEs and those who did not. Generalized estimating equations were used to build a predictive model of PRAEs.

Results: In a cohort of 393 patients, 51 PRAEs occurred during 43 (5.6%) of 771 anesthesia encounters. Using generalized estimating equations, treatment with continuous positive airway pressure or bilevel positive airway pressure (odds ratio, 1.63; 95% confidence interval [CI], 1.05-2.54; P = .031), outpatient (odds ratio, 1.37; 95% CI, 1.03-1.91; P = .047), presence of severe obstructive sleep apnea (odds ratio, 1.63; 95% CI, 1.09-2.42; P = .016), use of preoperative oxygen (odds ratio 1.82; 95% CI, 1.11-2.97; P = .017), history of prematurity (odds ratio, 2.31; 95% CI, 1.33-4.01; P = .003), and intraoperative airway management with endotracheal intubation (odds ratio, 3.03; 95% CI, 1.79-5.14; P < .001) were associated with PRAEs.

Conclusions: We propose the risk factors identified within this cohort of SDB patients could be incorporated into a preoperative risk assessment tool that might better to identify the risk of PRAE during general anesthesia. Further investigation and validation of this model could contribute to improved preoperative risk stratification, decision-making (postoperative admission and level of monitoring), and health care resource allocation.
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http://dx.doi.org/10.1213/ANE.0000000000005195DOI Listing
September 2020

Integration of the Intrinsic Surgical Risk With Patient Comorbidities and Severity of Congenital Cardiac Disease Does Not Improve Risk Stratification in Children Undergoing Noncardiac Surgery.

Anesth Analg 2020 10;131(4):1083-1089

Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts.

Background: The objective of this study is to estimate the surgical risk of noncardiac procedures on the incidence of 30-day mortality in children with congenital heart disease.

Methods: Children with congenital heart disease undergoing noncardiac surgery from 2012 to 2016 and included in the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) Pediatric database were included in the derivation cohort, while the 2017 database was used as a validation cohort. Intrinsic surgical risk quartiles were built utilizing 30-day mortality rates for each Current Procedural Terminology code and relative value units to create 2 groups defined as low surgical risk (quartiles 1-3) and high surgical risk procedures (quartile 4). We used multivariable logistic regression to determine the predictors for 30-day mortality including patient comorbidities and intrinsic surgical risk. A partially external validation of the model was performed using the 2017 version of the database.

Results: We included 37,658 children with congenital heart disease undergoing noncardiac surgery with an incidence of overall 30-day mortality of 1.7% in the derivation cohort and 1.5% in the validation cohort (n = 13,129). Intrinsic surgical risk of procedures represented by Current Procedural Terminology procedural codes and relative value units risk quartiles was significantly associated with 30-day mortality (unadjusted P < .001). Predicted probability of 30-day mortality ranges from 0.2% (95% confidence interval [CI], 0.2-0.2) with no comorbidities to 39.6% (95% CI, 23.2-56.0) when all comorbidities were present among high surgical risk procedures and from 0.3% (95% CI, 0.3-0.3) to 54.8% (95% CI, 39.4-70.1) among low surgical risk procedures. An excellent discrimination was reported for the multivariable model with area under the curve (AUC) of 0.86 (95% CI, 0.85-0.88). High surgical risk was not associated with increased odds of 30-day mortality after adjustment for all other predictors (adjusted odds ratio [OR]: 0.75, 95% CI, 0.62-0.91). We also estimated the discriminative ability of a model that does not include the surgical risk (0.86 [95% CI, 0.84-0.88], with P value for the direct comparison of the AUC of the 2 models = 0.831). The multivariable model obtained from an external validation cohort reported an optimism corrected AUC of 0.88 (95% CI, 0.85-0.91).

Conclusions: Our study demonstrates that integration of intrinsic surgical risk to comorbidities and severity of cardiac disease does not improve prediction of 30-day mortality in children undergoing noncardiac surgery. In children with congenital heart disease, patient comorbidities, and severity of the cardiac lesion are the predominant predictors of 30-day mortality.
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http://dx.doi.org/10.1213/ANE.0000000000004906DOI Listing
October 2020

Network meta-analysis of isolated patient blood management interventions leads to uncertain interpretation. Comment on Br J Anaesth 2020; https://doi.org/10.1016/j.bja.2020.04.087.

Br J Anaesth 2021 01 21;126(1):e1-e2. Epub 2020 Aug 21.

Department of Anesthesiology, Critical Care and Hyperbaric Medicine, TeamHealth, Englewood Health, Englewood, NJ, USA.

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http://dx.doi.org/10.1016/j.bja.2020.07.021DOI Listing
January 2021

Association between preoperative hemoglobin levels after iron supplementation and perioperative blood transfusion requirements in children undergoing scoliosis surgery.

Paediatr Anaesth 2020 10 29;30(10):1077-1082. Epub 2020 Aug 29.

Department of Anesthesiology and Pain Medicine, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada.

Background And Aims: In this study, we assessed the association between preoperative hemoglobin and red blood cell transfusion in children undergoing spine surgery after the implementation of our preoperative iron supplementation protocol.

Method: We performed a retrospective analysis of patients who underwent posterior spinal fusion surgery between January 2013 and December 2017 and received preoperative iron supplementation. We used uni- and multivariable logistic regression to determine the association between preoperative hemoglobin level and red blood cell transfusion in patients receiving iron supplementation.

Results: A total of 382 patients treated with preoperative oral iron were included. Of these, 175 (45.5%) patients were transfused intraoperatively. Multivariable logistic regression analysis revealed nonidiopathic etiology of the scoliosis (OR 4.178 [95% CI: 2.277-7.668], P < .001), the Cobb angle (OR 1.025 [95% CI: 1.010-1.040], P = .001), and number of vertebrae fused (OR 1.169 [95% CI: 1.042-1.312], P = .008) were associated with red blood cell transfusion. In addition, patients with a preoperative hemoglobin ≥ 140 g/L (OR 0.157 [95% CI: 0.046-0.540], P = .003), and hemoglobin between 130 and 140 g/L (OR 0.195 [95% CI: 0.057-0.669], P = .009) were less likely to be transfused compared with patients with preoperative hemoglobin between 120 and 130 g/L (OR 0.294 [95% CI: 0.780-1.082], P = .066) or <120 g/L (reference).

Conclusion: Our study suggests that higher preoperative hemoglobin levels (>130 g/L) are associated with a reduced need for red blood cell transfusion in pediatric patients who have received iron supplementation before undergoing posterior spinal fusion in our institution. The effect of iron supplementation, the optimal dosing, and duration of supplemental iron therapy remains unclear at this time.
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http://dx.doi.org/10.1111/pan.13987DOI Listing
October 2020

Efficacy and safety of decontamination for N95 respirator reuse: a systematic literature search and narrative synthesis.

Can J Anaesth 2020 Dec 27;67(12):1814-1823. Epub 2020 Jul 27.

Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, 555 University Ave, Toronto, ON, M5G 1X8, Canada.

Purpose: Under times of supply chain stress, the availability of some medical equipment and supplies may become limited. The current pandemic involving severe acute respiratory syndrome coronavirus 2 has highlighted limitations to the ordinary provision of personal protective equipment (PPE). For perioperative healthcare workers, N95 masks provide a stark example of PPE in short supply necessitating the creation of scientifically valid protocols for their decontamination and reuse.

Methods: We performed a systematic literature search of MEDLINE, Embase, Cochrane CENTRAL databases, and ClinicalTrials.gov to identify peer-reviewed articles related to N95 mask decontamination and subsequent testing for the integrity of mask filtration and facial seal. To expand this search, we additionally surveyed the official statements from key health agencies, organizations, and societies for relevant citations.

Results: Our initial database search resulted in five articles that met inclusion criteria, with 26 articles added from the expanded search. Our search did not reveal any relevant randomized clinical trials or cohort studies. We found that moist mask heating (65-80°C at 50-85% relative humidity for 20-30 min) and vaporous hydrogen peroxide treatment were supported by the literature to provide consistent viral decontamination without compromising mask seal and filtration efficiency. Other investigated decontamination methods lacked comprehensive scientific evidence for all three of these key criteria.

Conclusions: N95 mask reprocessing using either moist heat or vaporous hydrogen peroxide is recommended to ensure healthcare worker safety.
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http://dx.doi.org/10.1007/s12630-020-01770-wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7384726PMC
December 2020

The effect of dexmedetomidine on motor-evoked potentials during pediatric posterior spinal fusion surgery: a retrospective case-control study.

Can J Anaesth 2020 Oct 22;67(10):1341-1348. Epub 2020 Jul 22.

Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, ON, M5G 1X8, Canada.

Purpose: Motor-evoked potentials (MEPs) are frequently used in pediatric posterior spinal fusion surgery (PSFS) to detect spinal cord ischemia. Dexmedetomidine is increasingly being used as an adjunct to total intravenous anesthesia, but its effect on MEP amplitude has been variably reported. The purpose of this study was to evaluate the effect of an infusion of dexmedetomidine on the amplitude of MEPs.

Methods: We performed a retrospective case-control study of 30 pediatric patients who received a 0.5 µg·kg·hr infusion of dexmedetomidine, ten patients who received 0.3 µg·kg·hr dexmedetomidine, and 30 control patients who did not receive dexmedetomidine during PSFS. Two neurophysiologists reviewed the MEP amplitudes in six muscle groups at three time points: when the patient was turned prone (baseline; T1), one hour after incision (T2), and after exposure of the spine but before insertion of the first screw (T3).

Results: In all muscles tested, the mean MEP amplitude was reduced by T3 when dexmedetomidine was infused at 0.5 µg·kg·hr. The greatest reduction from baseline MEP amplitude was 829 µV (95% confidence interval, 352 to 1230; P < 0.001) seen in first right dorsus interosseous. When dexmedetomidine was infused at 0.3 µg·kg·hr, there was a significant reduction in MEP amplitude in four of the six muscles tested at T3 compared with the control group.

Conclusions: Dexmedetomidine at commonly used infusion rates of 0.3 µg·kg·hr or 0.5 µg·kg·hr causes a significant decrease in MEP amplitude during pediatric PSFS. We suggest that dexmedetomidine should be avoided in children undergoing PSFS so as not to confuse the interpretation of this important neurophysiological monitor.
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http://dx.doi.org/10.1007/s12630-020-01758-6DOI Listing
October 2020

Pro: Early Extubation After Pediatric Cardiac Surgery.

J Cardiothorac Vasc Anesth 2020 Sep 27;34(9):2539-2541. Epub 2020 May 27.

Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Canada; Department of Anesthesia and Pain Management, University Health Network - Toronto General Hospital, Toronto, Canada.

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http://dx.doi.org/10.1053/j.jvca.2020.05.025DOI Listing
September 2020

Considerations for Pediatric Heart Programs During COVID-19: Recommendations From the Congenital Cardiac Anesthesia Society.

Anesth Analg 2020 08;131(2):403-409

Division of Cardiac Anesthesia, Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts.

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http://dx.doi.org/10.1213/ANE.0000000000005015DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7273948PMC
August 2020

Essential Role of Patient Blood Management in a Pandemic: A Call for Action.

Anesth Analg 2020 07;131(1):74-85

Institute of Anesthesiology, University of Zurich and University Hospital Zurich, Zurich, Switzerland.

The World Health Organization (WHO) has declared coronavirus disease 2019 (COVID-19), the disease caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), a pandemic. Global health care now faces unprecedented challenges with widespread and rapid human-to-human transmission of SARS-CoV-2 and high morbidity and mortality with COVID-19 worldwide. Across the world, medical care is hampered by a critical shortage of not only hand sanitizers, personal protective equipment, ventilators, and hospital beds, but also impediments to the blood supply. Blood donation centers in many areas around the globe have mostly closed. Donors, practicing social distancing, some either with illness or undergoing self-quarantine, are quickly diminishing. Drastic public health initiatives have focused on containment and "flattening the curve" while invaluable resources are being depleted. In some countries, the point has been reached at which the demand for such resources, including donor blood, outstrips the supply. Questions as to the safety of blood persist. Although it does not appear very likely that the virus can be transmitted through allogeneic blood transfusion, this still remains to be fully determined. As options dwindle, we must enact regional and national shortage plans worldwide and more vitally disseminate the knowledge of and immediately implement patient blood management (PBM). PBM is an evidence-based bundle of care to optimize medical and surgical patient outcomes by clinically managing and preserving a patient's own blood. This multinational and diverse group of authors issue this "Call to Action" underscoring "The Essential Role of Patient Blood Management in the Management of Pandemics" and urging all stakeholders and providers to implement the practical and commonsense principles of PBM and its multiprofessional and multimodality approaches.
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http://dx.doi.org/10.1213/ANE.0000000000004844DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7173035PMC
July 2020

Tranexamic Acid for Acute Hemorrhage: When Is Enough Evidence Enough?

Anesth Analg 2019 12;129(6):1459-1461

Departments of Anesthesiology, Critical Care, and Surgery, Duke University School of Medicine, Durham, North Carolina.

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http://dx.doi.org/10.1213/ANE.0000000000004481DOI Listing
December 2019

Improving Pediatric Risk Stratification: Reply.

Anesthesiology 2020 01;132(1):213-214

Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts (V.G.N.).

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http://dx.doi.org/10.1097/ALN.0000000000003035DOI Listing
January 2020

Patient Blood Management in Pediatric Complex Cranial Vault Reconstruction: Time for Some Action.

Authors:
David Faraoni

Anesth Analg 2019 10;129(4):912-914

From the Division of Cardiac Anesthesia, Department of Anesthesia and Pain Medicine, University of Toronto, Toronto, Ontario, Canada.

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http://dx.doi.org/10.1213/ANE.0000000000003645DOI Listing
October 2019

Patient Blood Management is not about blood transfusion: it is about patients' outcomes.

Blood Transfus 2019 09 18;17(5):331-333. Epub 2019 Jul 18.

Network for the Advancement of Patient Blood Management, Haemostasis and Thrombosis (NATA), Paris, France.

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http://dx.doi.org/10.2450/2019.0126-19DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6774929PMC
September 2019

Association Between Cyanosis, Transfusion, and Thrombotic Complications in Neonates and Children Undergoing Cardiac Surgery.

J Cardiothorac Vasc Anesth 2020 Feb 13;34(2):349-355. Epub 2019 Jul 13.

Department of Anesthesia and Pain Medicine, Hospital for Sick Children, University of Toronto, Toronto, Canada; Division of Cardiac Anesthesia, Labatt Family Heart Centre, Hospital for Sick Children, University of Toronto, Toronto, Canada. Electronic address:

Objective: Children with congenital heart defects are at increased risk for perioperative bleeding and postoperative thrombosis. In this study, the authors sought to develop a predictive model for postoperative thrombotic complications that integrates intraoperative bleeding and the requirement for allogenic blood products in addition to known patient and surgical characteristics.

Design: Retrospective cohort.

Setting: Pediatric hospital.

Participants: Neonates and children who underwent surgery with cardiopulmonary bypass (CPB).

Interventions: None MEASUREMENTS AND MAIN RESULTS: Demographic, laboratory, point-of-care coagulation, surgical, and perioperative transfusion data were collected. Among the 369 participants included in the study, 67 (18%) developed postoperative thrombotic complications. From multivariable logistic regression analyses, preoperative oxygen saturation <85% (odds ratio [OR] 2.06, 95% confidence interval [CI] 1.10-3.85; p = 0.024), surgery in the neonatal period (OR 2.16, 95% CI 1.02-4.55; p = 0.044), use of preoperative antiplatelet or anticoagulation therapy (OR 3.34, 95% CI 1.61-6.96; p = 0.001), and the volume of blood product transfused post-CPB (>80 mL/kg [OR 5.72, 95% CI 1.73-18.91; p = 0.004] and 15-80 mL/kg [OR 3.06, 95% CI 1.24-7.53; p = 0.015]) were independently associated with an increased incidence of thrombotic complications. No statistical differences were observed in available preoperative coagulation tests between children who developed postoperative thrombosis and those who did not.

Conclusion: This observational cohort study found that cyanosis, surgery in neonates, preoperative anticoagulation or antiplatelet therapy, and the volume of post-CPB transfusion are important predictors of postoperative thrombotic complications in children undergoing cardiac surgery. Additional studies are required to explore the relationship between hypoxia, coagulopathy, and postoperative thrombosis.
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http://dx.doi.org/10.1053/j.jvca.2019.07.123DOI Listing
February 2020

Ischemic limb necrosis in septic shock: What is the role of high-dose vasopressor therapy?

J Thromb Haemost 2019 11 23;17(11):1973-1978. Epub 2019 Jul 23.

Departments of Pathology, Molecular Medicine, and Medicine, McMaster University, Hamilton, ON, Canada.

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http://dx.doi.org/10.1111/jth.14566DOI Listing
November 2019

Prospective External Validation of the Pediatric Risk Assessment Score in Predicting Perioperative Mortality in Children Undergoing Noncardiac Surgery.

Anesth Analg 2019 10;129(4):1014-1020

From the Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts.

Background: Early identification of children at high risk for perioperative mortality could lead to improved outcomes; however, there is a lack of well-validated risk prediction tools. The Pediatric Risk Assessment (PRAm) score is a new model to prognosticate perioperative risk of mortality in pediatric patients undergoing noncardiac surgery. It was derived from the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) Pediatric database. In this study, we aimed to externally validate the PRAm score at 1 large institution.

Methods: A PRAm score was prospectively assigned by the primary anesthesia team to children ≤18 years of age undergoing noncardiac surgery between July 2017 and July 2018 at a tertiary care pediatric hospital. The primary outcome was the PRAm score's ability to predict 30-day mortality. The area under the receiver operating characteristic (ROC) curve was utilized to determine discriminative ability. Sensitivity and specificity at varying cutoffs were considered. Youden J index and the gray zone approach were applied to determine the optimal PRAm cutoff for predicting 30-day mortality.

Results: Among the 13,530 cases included in the external validation cohort, the incidence of 30-day mortality was 0.21% (29/13,530). The PRAm score was found to predict 30-day mortality with an area under the curve (AUC) of 0.956 (95% confidence interval [CI], 0.938-0.974; P < .001). Youden J index determined the optimal PRAm score threshold to be ≥5 with a sensitivity of 86% and a specificity of 91%. The gray zone identified an inconclusive risk of mortality in 6.93% (938/13,530) of patients who had PRAm scores of 4 or 5 (sensitivity or specificity <90%, respectively), therefore refining the optimal cutoff point to be a PRAm score of ≥6. The incidence of mortality for patients with an American Society of Anesthesiologists Physical Status (ASA PS) ≤3 (0.06%, 8/13,530) increased 8-fold for those with an ASA PS of ≤3 and a PRAm score of ≥6.

Conclusions: The PRAm score is a simple and objective tool that has excellent ability to predict perioperative risk of mortality in pediatric patients undergoing noncardiac surgery and can be easily used by clinicians. The application of the PRAm score could have important implications on the safety and quality of care delivered to infants and children and on the resource utilization in the pediatric health care system.
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http://dx.doi.org/10.1213/ANE.0000000000004197DOI Listing
October 2019

Patient Blood Management for Neonates and Children Undergoing Cardiac Surgery: 2019 NATA Guidelines.

J Cardiothorac Vasc Anesth 2019 Dec 20;33(12):3249-3263. Epub 2019 Mar 20.

Thrombosis & Haemophilia Centre, St Thomas' Hospital, London, United Kingdom.

Pediatric cardiac surgery is associated with a substantial risk of bleeding, frequently requiring the administration of allogeneic blood products. Efforts to optimize preoperative hemoglobin, limit blood sampling, improve hemostasis, reduce bleeding, correct coagulopathy, and incorporate blood sparing techniques (including restrictive transfusion practices) are key elements of patient blood management (PBM) programs, and should be applied to the pediatric cardiac surgical population as across other disciplines. Many guidelines for implementation of PBM in adults undergoing cardiac surgery are available, but evidence regarding the implementation of PBM in children is limited to systematic reviews and specific guidelines for the pediatric cardiac population are missing. The objective of the task force from the Network for the Advancement of Patient Blood Management, Haemostasis and Thrombosis (NATA, www.nataonline.com) is to provide evidence-based recommendations regarding anemia management and blood transfusion practices in the perioperative care of neonates and children undergoing cardiac surgery, and to highlight potential areas where additional research is urgently required.
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http://dx.doi.org/10.1053/j.jvca.2019.03.036DOI Listing
December 2019

Pediatric Risk Stratification Is Improved by Integrating Both Patient Comorbidities and Intrinsic Surgical Risk.

Anesthesiology 2019 06;130(6):971-980

From the Division of Cardiac Anesthesia (V.G.N., J.A.D.) Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts (S.J.S., D.Z.) the Division of Cardiac Anesthesia, Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, University of Toronto, Toronto, Ontario Canada (D.F).

What We Already Know About This Topic: Risk stratification models to predict perioperative mortality in pediatric surgical populations are based on patient comorbidities, but do not take into consideration the intrinsic risk of the surgical procedures.

What This Article Tells Us That Is New: Surgical procedures identified by specialty are not independent risk factors for perioperative mortality in pediatric patients. However, in multivariable predictive algorithms, the interaction of patient comorbidities with the intrinsic risk of the surgical procedure strongly predicts 30-day mortality.

Background: Recently developed risk stratification models for perioperative mortality incorporate patient comorbidities as predictors but fail to consider the intrinsic risk of surgical procedures. In this study, the authors used the American College of Surgeons National Surgical Quality Improvement Program Pediatric database to demonstrate the relationship between the intrinsic surgical risk and 30-day mortality and develop and validate an accessible risk stratification model that includes the surgical procedures in addition to the patient comorbidities and physical status.

Methods: A retrospective analysis of the American College of Surgeons National Surgical Quality Improvement Program Pediatric database was performed. The incidence of 30-day mortality was the primary outcome. Surgical Current Procedural Terminology codes with at least 25 occurrences were included. Multivariable logistic regression model was used to determine the predictors for mortality including patient comorbidities and intrinsic surgical risk. An internal validation using bootstrap resampling, and an external validation of the model were performed.

Results: The authors analyzed 367,065 surgical cases encompassing 659 unique Current Procedural Terminology codes with an incidence of overall 30-day mortality of 0.34%. Intrinsic risk of surgical procedures represented by Current Procedural Terminology risk quartiles instead of broad categorization was significantly associated with 30-day mortality (P < 0.001). Predicted risk of 30-day mortality ranges from 0% with no comorbidities to 4.7% when all comorbidities are present among low-risk surgical procedures and from 0.07 to 46.7% among high-risk surgical procedures. Using an external validation cohort of 110,474 observations, the multivariable predictive risk model displayed good calibration and excellent discrimination with area under curve (c-index) equals 0.95 (95% CI, 0.94 to 0.96; P < 0.001).

Conclusions: Understanding and accurately estimating perioperative risk by accounting for the intrinsic risk of surgical procedures and patient comorbidities will lead to a more comprehensive discussion between patients, families, and providers and could potentially be used to conduct cost analysis and allocate resources.
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http://dx.doi.org/10.1097/ALN.0000000000002659DOI Listing
June 2019

Tranexamic acid and perioperative bleeding in children: what do we still need to know?

Curr Opin Anaesthesiol 2019 Jun;32(3):343-352

Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada.

Purpose Of Review: Perioperative bleeding and blood product transfusion are associated with significant morbidity and mortality. Prevention and optimal management of bleeding decreases risk and lowers costs. Tranexamic acid (TXA) is an antifibrinolytic agent that reduces bleeding and transfusion in a broad number of adult and pediatric surgeries, as well as in trauma and obstetrics. This review highlights the current pediatric indications and contraindications of TXA. The efficacy and safety profile, given current and evolving research, will be covered.

Recent Findings: Based on the published evidence, prophylactic or therapeutic TXA administration is a well-tolerated and effective strategy to reduce bleeding, decrease allogeneic blood product transfusion, and improve pediatric patients' outcomes. TXA is now recommended in recent guidelines as an important part of pediatric blood management protocols.

Summary: Based on TXA pharmacokinetics, the authors recommend a dosing regimen of between 10 to 30 mg/kg loading dose followed by 5 to 10 mg/kg/h maintenance infusion rate for pediatric trauma and surgery. Maximal efficacy and minimal side-effects with this dosage regime will have to be determined in larger prospective trials including high-risk groups. Furthermore, future research should focus on determining the ideal TXA plasma therapeutic concentration for maximum efficacy and minimal side-effects.
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http://dx.doi.org/10.1097/ACO.0000000000000728DOI Listing
June 2019

Traditional and non-traditional anticoagulation management during extracorporeal membrane oxygenation.

Ann Cardiothorac Surg 2019 Jan;8(1):129-136

Department of Anesthesia and Pain Medicine, Hospital for Sick Children, University of Toronto, Toronto, Canada.

Unfractionated heparin (UFH) is the anticoagulant of choice during extracorporeal membrane oxygenation (ECMO) support. Despite its favorable pharmacologic properties, management of heparin anticoagulation during ECMO remains a major challenge. To date, little is known about the optimal monitoring strategy or the heparin dose offering the best safety/efficacy profile. Therefore, it remains unclear if the heparin dose should be adapted to target a specific "clotting time" [e.g., activated clotting time (ACT) or activated partial thromboplastin time (aPTT)] or a heparin concentration, measured by coagulation factor anti-Xa assay. In addition, no study has compared the relevance of modern viscoelastic coagulation tests over the single value of a clotting time or heparin concentration value. Although guidelines for anticoagulation during ECMO support have been published, the absence of evidence limits the quality of the recommendations provided, which explains the major intra- and inter-institutional variability observed. Large prospective multicenter trials are urgently needed to investigate the optimal anticoagulation management strategy during ECMO support.
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http://dx.doi.org/10.21037/acs.2018.07.03DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6379198PMC
January 2019