Publications by authors named "Joseph D Tobias"

625 Publications

Acute Hepatic Dysfunction Related to Chronic Acetaminophen Administration.

J Pediatr Pharmacol Ther 2021 28;26(5):497-501. Epub 2021 Jun 28.

Toxicity related to acetaminophen is most encountered with the acute ingestion of large doses. However, toxicity may also result from chronic ingestion, even when recommended doses are administered over a prolonged period of time. We present the case of a 20-month-old female toddler who received therapeutic recommended doses of acetaminophen (oral or intravenous) following multiple surgical interventions for treatment of a tracheo-esophageal fistula following ingestion of a button battery. The potential role of chronic acetaminophen administration in the etiology of hepatoxicity is discussed and prevention strategies are presented.
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http://dx.doi.org/10.5863/1551-6776-26.5.497DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8244954PMC
June 2021

Update on Local Anesthetic Toxicity, Prevention and Treatment During Regional Anesthesia in Infants and Children.

J Pediatr Pharmacol Ther 2021 28;26(5):445-454. Epub 2021 Jun 28.

Local anesthetic agents play a key role in the treatment and prevention of pain in children. Although generally safe and effective, as with any pharmacologic agent, adverse effects may occur with the administration of these medications. Systemic absorption or inadvertent systemic injection during bolus dosing or continuous infusion can result in local anesthetic systemic toxicity with life-threatening neurological and cardiac complications. The following article reviews the pharmacology of local anesthetic agents, outlines previous reports of systemic toxicity during regional anesthesia, and discusses prevention and treatment algorithms.
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http://dx.doi.org/10.5863/1551-6776-26.5.445DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8244955PMC
June 2021

Successful management of an aorto-esophageal fistula following button battery ingestion: A case report and review of the literature.

Saudi J Anaesth 2021 Apr-Jun;15(2):193-198. Epub 2021 Apr 1.

Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio, USA.

Foreign body ingestion is a common event among pediatric patients, especially in children less than 6 years of age. Although most cases are relatively benign, with the foreign body passing spontaneously or requiring a brief endoscopic procedure for removal, button battery ingestion is known to cause significant morbidity with the potential for mortality. Although aorto-esophageal fistula (AEF) is a rare complication following button battery ingestion, its clinical manifestations are significant and outcomes are poor. Early diagnosis and aggressive treatment are key in preventing fatal complications. We describe the successful management of an AEF which presented with hematemesis 8 days after removal of a button battery in a 17-month-old female. The literature regarding button battery ingestion and AEF is reviewed and treatment options including intraoperative anesthetic care discussed.
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http://dx.doi.org/10.4103/sja.sja_1040_20DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8191253PMC
April 2021

Continuous epidural chloroprocaine after abdominal surgery is associated with lower postoperative opioid exposure in NICU infants.

J Pediatr Surg 2021 May 29. Epub 2021 May 29.

Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA; Department of Anesthesiology & Pain Medicine, The Ohio State University College of Medicine, Columbus, OH, USA.

Background: Epidural anesthesia in infants undergoing open abdominal surgery has the potential to reduce opioid consumption, lower pain scores, and expedite tracheal extubation. We evaluated associations between use of continuous epidural chloroprocaine and improved intra- and post-operative outcomes.

Methods: This matched retrospective cohort study first identified 24 patients who between April 2018 through December 2019 were treated with a caudal catheter and epidural chloroprocaine infusion for a laparotomy at postnatal age of 6 months or less. A matched comparator group of 24 patients was derived based on age and type of surgery. Exclusion criteria were the presence of a preoperative opioid infusion, comorbidities that would preclude appropriate pain assessment, or a recent surgical procedure. Primary outcomes included opioid consumption and pain scores; we secondarily analyzed intraoperative anesthetic requirements, other systemic analgesic use, vital signs, tracheal extubation time, and procedural times.

Results: Treatment with epidural anesthesia was associated with lower 5-day total postoperative opioid consumption (3.2 mg/kg vs. 19.7 mg/kg in the respective epidural vs. systemic groups, p = 0.001) and time to tracheal extubation (1.3 days vs. 3.2 days, p = 0.005). Any statistically significant differences in pain scores were not clinically meaningful. There were no differences in mean arterial pressure or intraoperative inhaled anesthetic doses.

Conclusion: Continuous infusion of epidural chloroprocaine in infants following open abdominal surgery may limit exposure to systemic opioid medications while providing adequate postoperative analgesia and shortening time to tracheal extubation.
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http://dx.doi.org/10.1016/j.jpedsurg.2021.05.015DOI Listing
May 2021

In Response.

Anesth Analg 2021 06;132(6):e118-e119

Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, The Ohio State University, Columbus, Ohio,

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http://dx.doi.org/10.1213/ANE.0000000000005535DOI Listing
June 2021

The Time to Seriously Reassess the Use and Misuse of Neuromuscular Blockade in Children Is Now.

Anesth Analg 2021 06;132(6):1514-1517

From the Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, Florida.

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http://dx.doi.org/10.1213/ANE.0000000000005488DOI Listing
June 2021

Unequal rates of postoperative complications in relatively healthy bariatric surgical patients of white and black race.

Surg Obes Relat Dis 2021 Jul 20;17(7):1249-1255. Epub 2021 Apr 20.

Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio.

Background: Racial disparities in postsurgical complications are often presumed to be due to a higher preoperative co-morbidity burden among patients of black race, although being relatively healthy is not a prerequisite for a complication-free postoperative course.

Objectives: To examine the association of race with short-term postbariatric surgery complications in seemingly healthy patients.

Settings: Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database (2015-2018).

Methods: We studied a relatively healthy (American Society of Anesthesiologists physical status 1 or 2), propensity score-matched cohort of adult non-Hispanic black and non-Hispanic white bariatric surgery patients. We compared the risk-adjusted incidences of postoperative complications, serious adverse events, and measures of postoperative resource utilization across racial groups.

Results: We identified 44,090 matched pairs of relatively healthy black and white bariatric surgery patients. Patients of black race were 72% more likely than those of white race to develop 1 or more postoperative complications (.7% versus .4%, respectively; odds ratio [OR], 1.72; 95% confidence interval [CI], 1.32-2.24; P < .01). Measures of postbariatric resource utilization were significantly higher in patients of black race than those of white race, including unplanned reoperations (1.3% versus 1.0%, respectively; OR, 1.28; 95% CI, 1.07-1.52; P = .01), unplanned readmissions (4.5% versus 3.0%, respectively; OR, 1.53; 95% CI, 1.38-1.69; P < .01), unplanned interventions (1.6% versus 1.2%, respectively; OR, 1.36; 95% CI, 1.16-1.60; P < .01), and extended hospital lengths of stay (51.2% versus 42.7%, respectively; OR, 1.41; 95% CI, 1.36-1.46; P < .01).

Conclusion: Even among relatively healthy patients, race appears to be an important determinant of postbariatric surgery complications and resource utilization. Research and interventions aimed at narrowing the racial disparities in bariatric surgery outcomes may need to broaden the focus beyond the racial variation in the preoperative co-morbidity burden.
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http://dx.doi.org/10.1016/j.soard.2021.04.011DOI Listing
July 2021

Perioperative Opioid Consumption is Not Reduced in Cyanotic Patients Presenting for the Fontan Procedure.

Pediatr Cardiol 2021 Jun 19;42(5):1170-1179. Epub 2021 Apr 19.

Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH, USA.

Adequate pain control is a critical component of the perioperative approach to children undergoing repair of congenital heart disease (CHD). The impact of specific anatomic and physiologic disturbances on the management of analgesia has been largely unexplored at the present time. Studies in other pediatric populations have found an association between chronic hypoxemia and an increased sensitivity to the effects of opioid medications. The purpose of this retrospective study was to examine perioperative opioid administration and opioid-associated adverse effects in children undergoing surgical repair of CHD, with a comparison between patients with and without chronic preoperative cyanosis. Patients between the ages of 2 and 5 years whose tracheas were extubated in the operating room were included and were classified in the cyanotic group if they presented for the Fontan completion. The primary outcomes of interest were intraoperative and postoperative opioid administration. Secondary outcomes included pain scores and opioid-related side effects. The study cohort included 156 patients. Seventy-one underwent the Fontan procedure, twelve of which were fenestrated. Fontan patients received fewer opioids intraoperatively (11.33 µg/kg fentanyl equivalents versus 12.56 µg/kg, p = 0.03). However, there were no differences with regards to opioid consumption postoperatively and no correlation between preoperative oxygen saturation and total opioid administration. There were no differences between groups with regards to the respiratory rate nadir, postoperative pain scores, or the incidence of opioid-related side effects. In contrast to other populations with chronic hypoxemia exposure, children with cyanotic CHD did not appear to have increased sensitivity to the effects of opioid medications.
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http://dx.doi.org/10.1007/s00246-021-02598-xDOI Listing
June 2021

Moderating Effects of Race and Preoperative Comorbidity on Surgical Mortality in Infants.

J Surg Res 2021 Aug 10;264:435-443. Epub 2021 Apr 10.

Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio. Electronic address:

Background: We sought to investigate the risk of pediatric surgical mortality associated with the combined effects of key preoperative comorbidities and race.

Methods: We performed a retrospective study that included infants who underwent inpatient surgical procedures between 2012 and 2017 and were entered into the NSQIP-P registry. We assessed additive moderation by estimating the proportion of mortality risk attributable to the combined effects of race and the presence of a preoperative comorbidity (attributable proportion [AP]).

Results: The study group was comprised of 58466 surgical cases, of whom 15711(26.9%) were neonates and 42755(73.1%) older infants. Among neonates, a history of prematurity carried a poorer prognosis in black babies than their white peers (OR:1.53, 95%CI:1.20,1.95). Additionally, there was evidence of additive moderation by race on the association between prematurity and postoperative mortality (AP: 23.9%; 95%CI: 3.8,43.9, P value = 0.020). In older infants, presence of preoperative sepsis carried almost two times higher risk of mortality for black patients than their white counterparts (OR:1.81; 95%CI:1.21,2.73). This explained 38.4% of mortality cases in black patients with preoperative sepsis (95%CI:14.0,62.7; P = 0.002). A history of prematurity also carried a greater risk of mortality in older infants of black race (OR:1.69; 95%CI: 1.27, 2.24), accounting for 24.2% of mortality cases (AP:24.2%; 95%CI:0.90, 47.5, P = 0.041).

Conclusions: We quantified the surgical burden of mortality resulting from the differential impact of key comorbidities on black neonates and infants. Our data suggest that race-specific interventions to mitigate the incidence of the identified comorbidities could narrow the racial disparities in post surgical mortality.
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http://dx.doi.org/10.1016/j.jss.2021.02.036DOI Listing
August 2021

Decrease in heart rate following the administration of sugammadex in adults.

J Anaesthesiol Clin Pharmacol 2020 Oct-Dec;36(4):465-469. Epub 2021 Jan 18.

Department of Anesthesiology, The University of Kansas, Kansas City, Kansas, USA.

Background And Aims: Sugammadex is a novel agent for reversal of steroidal neuromuscular blocking agents (NMBAs) with potential advantages over acetylcholinesterase inhibitors. In preclinical trials, there have been rare instances of bradycardia with progression to cardiac arrest. To better define this issue, its incidence and mitigating factors, we prospectively evaluated the incidence of bradycardia after sugammadex administration in adults.

Material And Methods: Patients ≥ 18 years of age who received sugammadex were included in this prospective, open label trial. After administration, heart rate (HR) was continuously monitored. HR was recorded every minute for 15 minutes and then every five minutes for the next 15 minutes or until patient was transferred out of the operating room. Bradycardia was defined as HR less than 60 beats/minute (bpm) or decrease in HR by ≥ 10 beats per minute (bpm) if the baseline HR was <70 bpm.

Results: The study cohort included 200 patients. Bradycardia was observed in 13 cases (7%; 95% confidence interval: 4, 11), occurring a median of 4 minutes after sugammadex administration (IQR: 4, 9, range: 2-25). Among patients developing bradycardia, two (15%) had cardiac comorbid conditions. One patient received treatment for bradycardia with ephedrine. No clinically significant blood pressure changes were noted. On bivariate analysis, patients receiving a higher initial sugammadex dose were more likely to develop bradycardia. On multivariable logistic regression, initial sugammadex dose was not associated with the risk of bradycardia.

Conclusion: The incidence of bradycardia after administration of sugammadex in our study was low and not associated with significant hemodynamic changes.
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http://dx.doi.org/10.4103/joacp.JOACP_346_19DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8022043PMC
January 2021

Cardiac Arrest Following the Administration of Intravenous Diphenhydramine for Sedation to an Infant With Congenital Heart Disease.

J Pediatr Pharmacol Ther 2021 31;26(3):311-314. Epub 2021 Mar 31.

Diphenhydramine (Benadryl) is a first-generation antihistamine that is used primarily to treat allergic reactions including anaphylaxis, urticaria, and allergic rhinitis. Despite its availability as an over-the-counter medication, toxicity may occur with its use especially when administered in large doses or via the intravenous route. We present a 3-month-old infant with Trisomy 21 who suffered a cardiac arrest immediately following administration of a single 1.25 mg/kg dose of intravenous diphenhydramine, prescribed for sedation in the Pediatric ICU setting. The potential cardiovascular and respiratory effects of diphenhydramine are presented, previous reports of life-threatening adverse effects reviewed, and options to limit these effects discussed.
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http://dx.doi.org/10.5863/1551-6776-26.3.311DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8021246PMC
March 2021

Utility of gastric ultrasound in evaluating status in a child.

Saudi J Anaesth 2021 Jan-Mar;15(1):46-49. Epub 2021 Jan 5.

Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA.

Although rare, the aspiration of gastric contents can lead to significant morbidity or even mortality in pediatric patients receiving anesthetic care. For elective cases, routine preoperative practices include the use of standard times to decrease the risk of aspiration. However, patients may fail to adhere to provided NPO guidelines or other patient factors may impact the efficacy of standard NPO times. Gastric point-of-care ultrasound provides information on the volume and quality of gastric contents and may allow improved patient management strategies. We present a 4-year-old patient who presented for bilateral myringotomy with tympanostomy tube insertion, who was found to have evidence of a full stomach during preoperative gastric ultrasound examination. The use of preoperative gastric point-of-care ultrasound in evaluating stomach contents and confirming NPO times is reviewed and its application to perioperative practice discussed.
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http://dx.doi.org/10.4103/sja.SJA_702_20DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8016049PMC
January 2021

Use of cuffed endotracheal tubes in infants less than 5 Kilograms: A retrospective cohort study.

J Pediatr Surg 2021 Mar 4. Epub 2021 Mar 4.

Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio USA; Department of Anesthesiology & Pain Medicine, The Ohio State University College of Medicine, Columbus, Ohio USA. Electronic address:

Background: Improved understanding of airway anatomy and refinement of equipment have led to the increased use of cuffed endotracheal tubes (ETTs) in infants and children. Despite expanded evidence on the potential advantages of cuffed ETTs in pediatric patients, there remains limited data on their use in infants less than 5 kilograms (kg). The current study retrospectively evaluates the perioperative use of cuffed ETTs in infants weighing 2-5 kg.

Methods: This is a retrospective study from a tertiary care children's hospital involving a 3-year period. Data regarding anesthetic care, airway management, and postoperative course were retrospectively retrieved from the electronic medical record.

Results: The study cohort included 1162 patients, 1086 of whom had their tracheas intubated with a cuffed ETT and 76 with an uncuffed ETT. Patients were divided into two groups for analysis: 2 to <3 kg and 3 to 5 kg. In both weight groups, cuffed ETTs resulted in a decreased need for more than one laryngoscopy and a change in ETT size with no increase in postoperative airway effects including stridor.

Conclusions: These data provide additional information regarding the efficacy and safety of cuffed ETTs in neonates and infants.
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http://dx.doi.org/10.1016/j.jpedsurg.2021.02.064DOI Listing
March 2021

Prolonged Postoperative Mechanical Ventilation (PPMV) in children undergoing abdominal operations: An analysis of the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database.

J Pediatr Surg 2021 Jun 21;56(6):1114-1119. Epub 2021 Feb 21.

Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio, USA. Electronic address:

Background: Prolonged postoperative mechanical ventilation (PPMV) increases length of stay, hospitalization costs, and postoperative complications. Independent risk factors associated with PPMV are not well-known for children.

Method: We identified children (<18 years) in the ACS NSQIP-P database who underwent a general surgical abdominal operation. We excluded children with preoperative ventilator dependence and mortality within 48 h of surgery. PPMV was defined as cumulative postoperative mechanical ventilation exceeding 72 h. A multivariable logistic regression model identified independent predictors of PPMV.

Results: We identified 108,392 children who underwent a general surgical abdominal operation in the ACS NSQIP-P database from 2012 to 2017. We randomly divided the population into a derivation cohort of 75,874(70%) and a validation cohort of 32,518(30%). In the derivation cohort, we identified PPMV in 1,643(2.2%). In the multivariable model, the strongest independent predictor of PPMV was neonatal age (OR:20.66; 95%CI:16.44-25.97). Other independent risk factors for PPMV were preoperative inotropic support (OR:10.56; 95%CI:7.56-14.77), an operative time longer than 150 min (OR:4.30; 95%CI:3.72-4.52), and an American Society of Anesthesiologists classification >3 (OR:12.16; 95%CI:10.75-13.75).

Conclusion: Independent preoperative risk factors for PPMV in children undergoing a general surgical operation were neonatal age, preoperative ionotropic support, duration of operation, and ASA classification >3.
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http://dx.doi.org/10.1016/j.jpedsurg.2021.02.022DOI Listing
June 2021

Sugammadex to Reverse Neuromuscular Blockade Prior to Withdrawal of Life Support.

J Pain Symptom Manage 2021 Aug 5;62(2):438-442. Epub 2021 Mar 5.

Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital and The Ohio State University College of Medicine, Columbus, Ohio, USA.

In certain end-of-life scenarios, pharmacologic reversal of neuromuscular blockade may be indicated. However, given the depth of blockade frequently necessitated in the ICU setting, rapid reversal of neuromuscular blockade is generally not feasible with conventional reversal agents such as neostigmine that inhibit acetylcholinesterase. Sugammadex is a novel pharmacologic agent for the reversal of neuromuscular blockade that acts by directly encapsulating steroidal neuromuscular blocking agents and providing effective 1:1 binding of rocuronium or vecuronium. This unique mechanism of action is rapid and allows for complete reversal and recovery of neuromuscular function. We report the use of sugammadex to reverse neuromuscular blockade prior to compassionate extubation in three pediatric patients. Its clinical use in children is reviewed, potential applications in the palliative care arena discussed, and dosing algorithms presented.
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http://dx.doi.org/10.1016/j.jpainsymman.2021.03.001DOI Listing
August 2021

Response to the case submitted by Bellapukonda .- Can intubate but cannot ventilate! An unexpected event in a child with stridor after accidental aspiration of the potassium permanganate solution.

Saudi J Anaesth 2020 Oct-Dec;14(4):570-572. Epub 2020 Sep 24.

Department of Anesthesiology and Pain Medicine, Nationtionwide Children's Hospital, Columbus, Ohio, USA.

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http://dx.doi.org/10.4103/sja.SJA_413_20DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7796733PMC
September 2020

Comparison of the skin-to-epidural space distance at the thoracic and lumbar levels in children using magnetic resonance imaging.

Saudi J Anaesth 2020 Oct-Dec;14(4):493-497. Epub 2020 Sep 24.

Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio, USA.

Background: Several studies have attempted to estimate the approximate distance from the skin-to-epidural space using different imaging modalities (computed tomography [CT], ultrasound, and magnetic resonance imaging [MRI]) and direct needle measurements. The objective of our study was to compare the distance from the skin to the epidural space (SED) at multiple levels, focusing on T, T, and L using MRI.

Methods: After institutional review board (IRB) approval, sagittal T2-weighted MRI images of the spine of 108 children in the age group ranging from 3 months to 8 years undergoing radiological evaluation in the supine position at our institution were analyzed. The SED at T and T levels (straight and inclined) and SED at L (straight) were determined and compared using repeated-measures ANOVA and paired -tests with a Bonferroni correction for 10 pairwise comparisons ( < 0.005 was considered statistically significant).

Results: The average SED (measured straight and inclined) was 18.2 mm and 21.6 mm at T; 18.3 mm and 20.5 mm at T; and 21.8 mm (straight) at L. The repeated-measures ANOVA F-test indicated significant variability in SED ( < 0.001) among the 5 measurements obtained. At the < 0.005 significance level, corrected for multiple comparisons, the SED (straight) at T straight was shorter than the other measured distances.

Conclusion: The distance from the skin to the epidural space is not constant at various vertebral levels. At the levels measured, it was greatest at the lumbar level and at least at the thoracic level of T. A single predictive formula was not applicable for calculating the approximate SED at all vertebral levels.
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http://dx.doi.org/10.4103/sja.SJA_292_20DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7796762PMC
September 2020

Methadone: applications in pediatric anesthesiology and critical care medicine.

Authors:
Joseph D Tobias

J Anesth 2021 02 12;35(1):130-141. Epub 2021 Jan 12.

Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital and The Ohio State University, 700 Children's Drive, Columbus, OH , 43205, USA.

Like morphine, methadone is a pure agonist at the µ opioid receptor. However, in distinction to morphine which has an elimination half-life of 2-3 h, methadone has an elimination half-life of 24-36 h. In addition to its effects at the µ opioid receptor, methadone is an antagonist at the N-methyl-D-aspartate (NMDA) receptor and also inhibits the reuptake of the neurotransmitters, serotonin and norepinephrine, in the central nervous system. Given its long half-life and high oral bioavailability, methadone has had a primary role in the outpatient treatment of patients with a history of opioid abuse or addiction. However, its unique pharmacology and cellular effects make it a valuable agent in the treatment of both acute and chronic pain of various etiologies. The following manuscript reviews the pharmacologic properties of methadone and discusses its clinical applications in the practice of pediatric anesthesiology and pediatric critical care medicine.
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http://dx.doi.org/10.1007/s00540-020-02887-4DOI Listing
February 2021

Primary Stroke and Failure-to-Rescue Following Thoracic Endovascular Aortic Aneurysm Repair.

J Cardiothorac Vasc Anesth 2021 Aug 2;35(8):2338-2344. Epub 2020 Dec 2.

Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, OH. Electronic address:

Objective: To characterize the impact, on failure to rescue, of cerebrovascular accident as a first postoperative complication after thoracic endovascular aortic aneurysm repair (TEVAR).

Design: A retrospective cohort study using of National Surgical Quality Improvement Program Participants User File.

Setting: United States hospitals taking part in the National Surgical Quality Improvement Program.

Participants: Patients >18 years, who underwent TEVAR for nonruptured thoracic aortic aneurysm between 2005 and 2018, and developed one or more major postoperative complications within 30 days after surgery.

Interventions: None.

Measurements And Main Results: Out of 3,937 patients who underwent TEVAR for nonruptured thoracic aneurysm, 1,256 (31.9%) developed major postoperative complications (stroke incidence: 11.4% [143/1256]). In adults <65 years old, the occurrence of stroke as the primary complication, relative to the occurrence of other complications, was associated with ten times greater risk of failure to rescue (29.4% v 4.6%; odds ratio [OR]: 10.10; 95% confidence interval [CI] 2.45-41.56; p < 0.001). The effect size was relatively lower when stroke occurred but was not the primary complication (20.0% v 4.6%; OR: 7.55; 95% CI 1.37-41.71; p = 0.020). In patients ≥65 years, the occurrence of stroke as the primary complication did not carry the similar prognostic value.

Conclusion: Younger patients who developed stroke were up to ten times more likely to die, relative to patients who developed other major complications. Survival was substantially reduced when stroke was the primary complication. The authors' findings imply that to maximize the survival of patients undergoing TEVAR, efforts may be needed to predict and prevent stroke occurrence as a primary postoperative morbidity event.
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http://dx.doi.org/10.1053/j.jvca.2020.11.061DOI Listing
August 2021

Racial Disparities in Failure to Rescue Following Unplanned Reoperation in Pediatric Surgery.

Anesth Analg 2021 03;132(3):679-685

From the Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital and The Ohio State University, Columbus, Ohio.

Background: Failure to rescue (FTR) and unplanned reoperation following an index surgical procedure are key indicators of the quality of surgical care. Given that differences in unplanned reoperation and FTR rates among racial groups may contribute to persistent disparities in postsurgical outcomes, we sought to determine whether racial differences exist in the risk of FTR among children who required unplanned reoperation following inpatient surgical procedures.

Methods: We used the National Surgical Quality Improvement database (2012-2017) to assemble a cohort of children (<18 years), who underwent inpatient surgery and subsequently returned to the operating room within 30 days of the index surgery. We used logistic regression models to estimate the odds ratio (OR) and 95% confidence interval (CI) of FTR, comparing African American (AA) to White children. We estimated the risk-adjusted odds ratio (aOR) for FTR by controlling the analyses for demographic characteristics, surgical profile, and preoperative comorbidities. We further evaluated the racial differences in FTR by stratifying the analyses by the timing of unplanned reoperation.

Results: Of 276,917 children who underwent various inpatient surgical procedures, 10,425 (3.8%) required an unplanned reoperation, of whom 2016 (19.3%) were AA and 8409 (80.7%) were White. Being AA relative to being White was associated with a 2-fold increase in the odds of FTR (aOR: 2.03; 95% CI, 1.5-2.74; P < .001). Among children requiring early unplanned reoperation, AAs were 2.38 times more likely to die compared to their White peers (8.9% vs 3.4%; aOR: 2.38; 95% CI, 1.54-3.66; P < .001). In children with intermediate timing of return to the operating room, the risk of FTR was 80% greater for AA children compared to their White peers (2.2% vs 1.1%; aOR: 1.80; 95% CI, 1.07-3.02; P = .026). Typically, AA children die within 5 days (interquartile range [IQR]: 1-16) of reoperation while their White counterparts die within 9 days following reoperation (IQR: 2-26).

Conclusions: Among children requiring unplanned reoperation, AA patients were more likely to die than their White peers. This racial difference in FTR rate was most noticeable among children requiring early unplanned reoperation. Time to mortality following unplanned reoperation was shorter for AA than for White children. Race appears to be an important determinant of FTR following unplanned reoperation in children and it should be considered when designing interventions to optimize unplanned reoperation outcomes.
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http://dx.doi.org/10.1213/ANE.0000000000005329DOI Listing
March 2021

Use of viscoelastic monitoring and prothrombin complex concentrate in a paediatric patient with polytrauma and severe traumatic brain injury.

BMJ Case Rep 2020 Dec 13;13(12). Epub 2020 Dec 13.

Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio, USA.

Viscoelastic monitoring (VEM) tools, such as rotational thrombelastometry, have been used extensively to measure coagulopathy in adults but have received less attention in paediatric care. The presented case involves a 5-year-old boy who was brought to the emergency department after a motor vehicle collision with a Glasgow Coma Scale score of 6T and extensive injuries, including a subdural hematoma. VEM was used to monitor the patient's coagulopathy and to inform treatment measures by allowing real-time visualisation of the patient's coagulation status. VEM was additionally used to direct blood product replacement in preparation for neurosurgical intervention, and 4-factor prothrombin complex concentrate (PCC) was used to help reverse the coagulopathy. The patient underwent successful hemicraniectomy after improvement of his coagulopathy. In paediatrics, VEM and PCC are increasingly being used for post-trauma coagulopathy, and this case highlights their potential promise and the need for further research.
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http://dx.doi.org/10.1136/bcr-2020-236608DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7737072PMC
December 2020

Opioid-Sparing Anesthetic Technique for Pediatric Patients Undergoing Adenoidectomy: A Pilot Study.

J Pain Res 2020 19;13:2997-3004. Epub 2020 Nov 19.

Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital and the Ohio State University College of Medicine, Columbus, OH, USA.

Introduction: An opioid-sparing anesthetic involves a multi-modal technique with non-opioid medications targeting different analgesic pathways. Such techniques may decrease adverse effects related to opioids. These techniques may be considered in patients at higher risk for opioid-related adverse effects including obstructive sleep apnea or sleep disordered breathing.

Methods: A prospective, pilot study was performed in 10 patients (3-8 years of age), presenting for adenoidectomy. The perioperative regimen included oral dextromethorphan (1 mg/kg) and acetaminophen (15 mg/kg) plus single boluses of intraoperative dexmedetomidine (0.5 μg/kg) and ketamine (0.5 mg/kg). Pain scores were assessed in the post anesthesia care unit (PACU) using the FLACC (Face, Legs, Activity, Cry, Consolability) scale. Patients with a pain score >4 received fentanyl as needed. PACU time, pain scores, and parent satisfaction were recorded. Postoperatively, patients were instructed to use oral acetaminophen or ibuprofen every 6 hours as needed for pain.

Results: The study cohort included 10 patients, 3-8 years of age. All patients had opioid-free anesthetic care. PACU time ranged from 24 to 102 minutes (median: 56 minutes). FLACC pain scores were 0 for all PACU assessments. Nine patients were discharged home and 1 patient had a planned overnight admission. Following hospital discharge, the pain scores were satisfactory during the 72-hour study period and 90% of the patients' guardians were satisfied or highly satisfied with their child's pain control.

Conclusion: This opioid-sparing approach provided safe and effective pain control as well as parental satisfaction following adenoidectomy in children. Additional prospective studies are needed to determine whether this regimen is effective in a larger cohort of patients with and for other otolaryngology procedures.
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http://dx.doi.org/10.2147/JPR.S281275DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7682613PMC
November 2020

Point-of-Care Lung Ultrasound to Evaluate Lung Isolation During One-Lung Ventilation in Children: Narrative Review.

Med Devices (Auckl) 2020 17;13:385-389. Epub 2020 Nov 17.

Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA.

This review focuses on the current technique and evidence regarding the use of point-of-care ultrasound (POCUS) to evaluate lung isolation for thorax surgery in infants and children. Previous reports in infants and children are presented. Figures and high-quality video are used to demonstrate the technique for POCUS in pediatric patients and to highlight differences between pediatric and patients. Lung sliding in B-mode and the seashore sign in M-mode suggest that the lung is ventilated. Pediatric anesthesiologists should be familiar with this technique as it is non-invasive and may also be more accurate when compared with auscultation.
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http://dx.doi.org/10.2147/MDER.S265074DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7680174PMC
November 2020

Metabolic Alkalosis in the Pediatric Patient: Treatment Options in the Pediatric ICU or Pediatric Cardiothoracic ICU Setting.

Authors:
Joseph D Tobias

World J Pediatr Congenit Heart Surg 2020 Nov;11(6):776-782

Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus and The Ohio State University College of Medicine, Columbus, OH, USA.

Metabolic alkalosis is characterized by the primary elevation of the serum bicarbonate concentration with a normal or elevated partial pressure of carbon dioxide. Although there may be several potential etiologies in the critically ill patient in the pediatric or cardiothoracic intensive care unit, metabolic alkalosis most commonly results from diuretic therapy with chloride loss. In most cases, the etiology can be determined by a review of the patient's history and medication record. Although generally innocuous with limited impact on physiologic function, metabolic alkalosis may impair central control of ventilation, especially when weaning from mechanical ventilation. The following manuscript presents the normal homeostatic mechanisms that control pH, reviews the etiology of metabolic alkalosis, and outlines the differential diagnosis. Options and alternatives for treatment including pharmacologic interventions are presented with a focus on these conditions as they pertain to the patient in the pediatric or cardiac intensive care unit.
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http://dx.doi.org/10.1177/2150135120942488DOI Listing
November 2020

Perioperative anaphylaxis in children: A report from the Wake-Up Safe collaborative.

Paediatr Anaesth 2021 02 4;31(2):205-212. Epub 2021 Jan 4.

Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA.

Background: Anaphylactic reactions to antigens in the perioperative environment are uncommon, but they have a potential to lead to serious morbidity and/or mortality. The incidence of anaphylactic reactions is 1:37 000 pediatric anesthetics, and substantially less than the 1:10 000 to 1:20 000 incidence in the adult population. Neuromuscular blocking agents, latex, and antibiotics are the most frequently cited triggers. To date, there is no comprehensive report on perioperative anaphylactic reactions in children in the United States. Using the Wake-up Safe database, we examined the incidence and consequences of reported perioperative anaphylaxis events.

Methods: We reviewed the Wake-up Safe database from 2010 to 2017 and identified all reported instances of anaphylaxis. The triggering agent, timing, and location of the registered event, severity of patient harm, and preventability were identified. Narrative review of free-text comments entered by reporting centers was performed to determine presenting symptoms, and interventions required. Type of case was identified from procedure codes provided in mandatory fields.

Results: Among 2 261 749 cases reported to the Wake-up Safe database during the study period, perioperative anaphylactic reactions occurred in 1:36 479 (0.003%). Antibiotics, neuromuscular blocking agents, and opioid analgesics were the main triggers. Forty-nine cases (79%) occurred in the operating room, and 13 cases (21%) occurred in off-site locations. Seven (11%) patients required cardiopulmonary resuscitation following the onset of symptoms. Thirty-five (57%) patients were treated with epinephrine or epinephrine plus other medications, whereas 5% were managed only with phenylephrine. Most cases (97%) required escalation of care after the event. Regarding case preventability, 91% of cases were marked as either "likely could not have been prevented" or "almost certainly could not have been prevented."

Conclusion: The estimated incidence of anaphylaxis and inciting agents among the pediatric population in this study were consistent with the most recent published studies outside of the United States; however, new findings included need for cardiopulmonary resuscitation in 11% of cases, and estimated fatality of 1.6%. The management of perioperative anaphylaxis could be improved for some cases as epinephrine was not administered, or its administration was delayed. Fewer than half of reported cases had additional investigation to formally identify the responsible agent.
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http://dx.doi.org/10.1111/pan.14063DOI Listing
February 2021

Prognostic profiling of children with serious post-operative complications: A novel probability model for failure to rescue.

J Pediatr Surg 2021 Feb 6;56(2):207-212. Epub 2020 Oct 6.

Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, OH. Electronic address:

Background: Failure to rescue (FTR), mortality after a major postoperative complication, is a superior surgical quality metric compared to surgical mortality or complications rates alone. Our objective was to develop and validate a novel pediatric profiling to identify high-risk subjects among the subset of children who develop serious post-operative complications.

Methods: We performed a retrospective study of children who developed one or more serious postoperative complications following inpatient surgery across NSQIP-Pediatric hospitals (2012-2017). We evaluated the rate of FTR according to pre-operative comorbidity burden.

Results: We identified 45,504 surgical cases with major post-operative complications (FTR rates: 2.4%). Surgical cases with greater than six pre-operative comorbidities (n = 12,148;28%) accounted for 80% of FTR events. The expected probability of FTR was 0.1%(95%CI:0.1%-0.2%) among low-risk cases, 3.3%(95%CI:3.0%-3.5%) among intermediate-risk cases, and 22.6%(95%CI:20.9%-24.3%) among high-risk cases. About half of surgical cases in the high-risk profile group died within 48 h of surgery. Comparatively, cases in the intermediate-risk group had a much longer time to mortality (10 days).

Conclusion: We propose a prognostic index to accurately identify children at risk for FTR. The use of such an index may provide surgeons with a window of opportunity to implement aggressive monitoring and therapeutic strategies to reduce mortality.

Level Of Evidence: IV.
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http://dx.doi.org/10.1016/j.jpedsurg.2020.09.054DOI Listing
February 2021

Risk assessment of postoperative pneumonia among children undergoing otolaryngologic surgery: Derivation and validation of a preoperative risk profiling.

Int J Pediatr Otorhinolaryngol 2020 Dec 23;139:110466. Epub 2020 Oct 23.

Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA.

Background: Postoperative pneumonia is a serious complication because it may be associated with morbidity, mortality and substantially increased cost of surgical care. Risk of postoperative pneumonia varies across surgical specialties, although its incidence and risk factors in pediatric otolaryngology have not been comprehensively elucidated.

Objective: To identify factors associated with postoperative pneumonia and determine whether a subset of children with a disproportionate risk of pneumonia can be identified.

Methods: Using the National Surgical Quality Improvement- Pediatric (NSQIP-P) database, we first selected children (N = 17,776; age under 18 years) who underwent inpatient pediatric otolaryngology procedures between 2012 and 2017. Using a random subset of 80% of the study population (derivation cohort), we next developed a multivariable logistic regression model to identify independent risk factors for postoperative pneumonia. We then divided children into risk groups and evaluated whether the Pareto principle applied to distribution of postoperative pneumonia across the risk groups.

Results: Among the 12,443 children in the derivation cohort, 177 (1.4%) developed postoperative pneumonia. A multivariable risk model identified patients who developed postoperative pneumonia with good accuracy in both the derivation and validation cohorts. Stratification of patients into five mutually exclusive risk groups showed that 71% of postoperative pneumonia occurred in the highest risk group representing 20% the study cohort. Children who developed postoperative pneumonia were 18 times more likely to require an extended hospital length of stay (OR: 18.6; 95%CI: 12.3-28.2), and 7 times more likely to die compared to children without pneumonia (OR: 7.40, 95%CI: 3.53-15.48).

Conclusions: We identified key preoperative risk factors for postoperative pneumonia in children undergoing otolaryngology surgery. A small proportion (20%) of high-risk patients accounted for a large proportion (71%) of postoperative pneumonia indicating an underlying Pareto distribution and underscoring the need for targeted interventions for this "vital few". Postoperative pneumonia in pediatric otolaryngology surgical inpatients was associated with longer hospital stay and a higher risk of mortality.

Clinical Trial Number And Registry: Not applicable.
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http://dx.doi.org/10.1016/j.ijporl.2020.110466DOI Listing
December 2020

Clinical Outcomes of a Modified Laryngeal Mask Airway (LMA Gastro™ Airway) During Esophagogastroduodenoscopy in Children and Adolescents: A Randomized Study.

Med Devices (Auckl) 2020 21;13:277-282. Epub 2020 Sep 21.

Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA.

Introduction: During esophagogastroduodenoscopy (EGD), general anesthesia (GA) may be provided using a laryngeal mask airway (LMA) with the endoscope inserted behind the cuff of the LMA into the esophagus. Passage of the endoscope may increase the intracuff of the LMA. We evaluated a newly designed LMA (LMA Gastro™ Airway) which has an internal channel exiting from its distal end to facilitate EGD. The current study compared the change of LMA cuff pressure between this new LMA and a standard clinical LMA (Ambu AuraOnce™) during EGD.

Methods: Patients less than 21 years of age and weighing more than 30 kg were randomized to receive airway management with one of the two LMAs during EGD. After anesthetic induction and successful LMA placement, the intracuff pressure of the LMAs was continuously monitored during the procedure. The primary outcome was the change of intracuff pressure of the LMAs.

Results: The study cohort included 200 patients (mean age 13.6 years and weight 56.6 kg) who were randomized to the LMA Gastro™ Airway (n=100) or the Ambu AuraOnce™ LMA (n=100). Average intracuff pressures during the study period (before and after endoscope insertion) were not different between the two LMAs. Ease of the procedure was slightly improved with the LMA Gastro™ Airway (p<0.001).

Discussion: The LMA Gastro™ Airway blunted, but did not prevent an increase in intracuff pressure during EGD when compared to the Ambu AuraOnce™ LMA. Throat soreness was generally low, and complications were infrequent in both groups. The ease of the procedure was slightly improved with the LMA Gastro™ Airway compared to the Ambu AuraOnce™ LMA.
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http://dx.doi.org/10.2147/MDER.S272557DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7518770PMC
September 2020

Association of Preoperative Pneumonia With Postsurgical Morbidity and Mortality in Children.

Anesth Analg 2021 05;132(5):1380-1388

From the Department of Anesthesiology and Pain Medicine.

Background: Pneumonia is a common lower respiratory tract infection (LRI) and the leading cause of pediatric hospitalization in the United States. Given its frequency, children with pneumonia may require surgery during their hospital course. This poses serious anesthetic and surgical challenges because preoperative pulmonary status is among the most important risk factors for postoperative complications. Although recent adult data indicated that preoperative pneumonia was associated with poor surgical outcomes, comparable data in children are lacking. Therefore, our objective was to investigate the association of preoperative pneumonia with postoperative mortality and morbidity in children.

Methods: Using the National Surgical Quality Improvement Program database, we assembled a retrospective cohort of children (<18 years) who underwent inpatient surgery between 2012 and 2015. Our primary outcome was the time to all-cause 30-day postoperative mortality that we evaluated using Cox proportional hazards regression models. For the secondary outcomes, including 30-day postoperative morbidity events, we used Fine-Gray models to account for competing risk by mortality. We also evaluated the association of preoperative pneumonia with duration of postoperative mechanical ventilation and postoperative hospital length of stay. We used propensity score weighting methods to adjust for potential confounding factors, whose distributions differ across the pneumonia groups.

Results: Among 153,242 children who underwent inpatient surgery, 0.7% (n = 867) had preoperative pneumonia. Compared with those without preoperative pneumonia, children with preoperative pneumonia had a higher risk of mortality throughout the 30-day postoperative period (hazard ratio [HR], 4.10; 95% confidence intervals [CI], 2.42-6.97; P < .001). Although not statistically significant, children with preoperative pneumonia were twice as likely to develop cardiovascular complications compared to children without preoperative pneumonia (HR, 2.10; 95% CI, 1.17-3.75; P = .012). Furthermore, children with preoperative pneumonia had longer duration of postoperative ventilation (incidence rate ratio, 1.47; 95% CI, 1.26-1.71; P < .001). Finally, children with preoperative pneumonia were estimated to be 56% less likely to be discharged within the 30 days following surgery, compared to children without preoperative pneumonia (HR, 0.44; 95% CI, 0.40-0.47; P < .001).

Conclusions: Preoperative pneumonia was strongly associated with increased incidence of postoperative mortality and complications in children. Clinicians should make concerted efforts to screen for preoperative pneumonia and consider whether proceeding with surgery is the most expedient course of action. Our findings may be helpful in preoperative discussions with parents of children with preoperative pneumonia for risk stratification and postoperative resource allocation purposes.
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http://dx.doi.org/10.1213/ANE.0000000000005219DOI Listing
May 2021

Pharmacologic Control of Blood Pressure in Infants and Children.

Pediatr Cardiol 2020 Oct 11;41(7):1301-1318. Epub 2020 Sep 11.

Department of Pediatrics and Division of Pediatric Cardiology, Nationwide Children's Hospital and The Ohio State University, Columbus, OH, USA.

Alterations in blood pressure are common during the perioperative period in infants and children. Perioperative hypertension may be the result of renal failure, volume overload, or activation of the sympathetic nervous system. Concerns regarding end-organ effects or postoperative bleeding may mandate regulation of blood pressure. During the perioperative period, various pharmacologic agents have been used for blood pressure control including sodium nitroprusside, nitroglycerin, β-adrenergic antagonists, fenoldopam, and calcium channel antagonists. The following manuscript outlines the commonly used pharmacologic agents for perioperative BP including dosing regimens and adverse effect profiles. Previously published clinical trials are discussed and efficacy in the perioperative period reviewed.
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http://dx.doi.org/10.1007/s00246-020-02448-2DOI Listing
October 2020
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