Paediatric anaesthesia最新文献

Historical and current methodologies in patient safety are based on a deficit-based model, defining safety as the absence of harm. This model is aligned with the human innate negativity bias and the general philosophy of health care: to diagnose and cure illness and to relieve suffering. While this approach has underpinned measurable progress in healthcare outcomes, a common narrative in the healthcare literature indicates that this progress is stalling or slowing. It is important to learn from and improve poor outcomes, but the deficit-based approach has some theoretical limitations. In this article, we discuss some of the theoretical limitations of the prevailing approach to patient safety and introduce emerging, complementary approaches in this field of practice. Safety-II and resilience engineering represent a new paradigm of safety, characterized by focusing on the entirety of work, with a system-wide lens, rather than single incidents of failure. More overtly positive approaches are available, specifically focusing on success-both outstanding success and everyday success-including exnovation, appreciative inquiry, learning from excellence and positive deviance. These approaches are not mutually exclusive. The new methods described in this article are not intended as replacements of the current methods, rather they are presented as complementary tools, designed to allow the reader to take a balanced and holistic view of patient safety.

Background: Operating room noise levels may hinder staff communication and cause distractions for providers, endangering patient safety. Owing to concerns of unacceptable noise levels during emergence from general anesthesia, our institution developed a quality improvement project. The SMART aim of this initiative was to decrease the average decibel noise level measured during emergence from general anesthesia in our operating rooms from 65.65 to 63 decibels and the maximum decibel noise level from 81.64 to 75 decibels over approximately 3 months.

Methods: A multidisciplinary team completed this project utilizing improvement science methodology from The Model for Improvement, including interventions tested via Plan-Do-Study-Act cycles. Data were measured, collected manually, and entered in an Excel spreadsheet. Data were analyzed using statistical process control methods, including a Run Chart. Our measures were the average and maximum decibel noise levels during emergence from general anesthesia.

Results: Several interventions were associated with a decrease in the average and maximum decibel noise levels. Interventions included educational presentations to perioperative staff; the operating room nurse taking the role of pausing any music; and the utilization of an audible and visual decibel alarm meter to sound and blink lights when the noise level is too high. During the initiative, the average (and maximum) decibel noise levels during emergence from general anesthesia in our operating rooms decreased from 65.65 (81.84) to 61.5 (76.44).

Conclusions: This improvement project was associated with a decrease in decibel noise levels during emergence. We enhanced a process and encouraged culture change at an academic pediatric hospital to enhance the safety of our care.

Making data more accessible and understandable in quality improvement requires a diversity of approaches beyond formal teaching in technical skills of measurement. Improvement practitioners might co-opt the wider skillset of analyst, designer, and storyteller in tailoring the team strategy needed to make best use of the data used to inform decision-making at the point of care. Data literacy levels, negative prior experiences, or limited access to technology might influence the ability of teams to engage in measurement. Co-designing the experience ensures that the data are meaningful, that it is framed in inclusive language, and that the process is manageable. Being mindful about intrinsic motivators when designing measurement strategies can improve the collective approach to data analysis and the sustainability of the project. Thoughtful data visualization takes account of the inherent perceptual challenges of comprehending data and complex images. Establishing a routine of simplification-removing redundant elements and distractions-and amplifying aspects that aid understanding can bring clarity to the important concepts within a chart. Story-telling techniques can help wider audiences engage with data by carefully shaping analytical and emotional content around a central narrative-always mindful of the limitations of working memory, and the emotional momentum needed to inspire change.

Background: Propofol total intravenous anesthesia (TIVA) is increasingly popular in pediatric anesthesia, but education on its use is variable and over-dosage adverse events are not uncommon. Recent work suggests that electroencephalogram (EEG) parameters can guide propofol dosing in the pediatric population. This education quality improvement project aimed to implement a standardized EEG TIVA training program over 12 months in a large pediatric anesthesia division.

Methods: The division consisted of 63 faculty, 11 clinical fellows, 32 residents, and 28 nurse anesthetists at the Children's Hospital of Philadelphia. The program was assessed for effectiveness (a significant improvement in EEG knowledge scores), scalability (training 50% of fellows and staff), and sustainability (recurring EEG lectures for 80% of rotating residents and 100% of new fellows and staff). The key drivers included educational content development (lectures, articles, and hand-outs), training a cohort of EEG TIVA trainers, intraoperative teaching (teaching points and dosing tables), decision support tools (algorithms and anesthesia electronic record pop-ups), and knowledge tests (written exam and verbal quiz during cases).

Results: Over 12 months, 78.5% of the division (62/79) completed EEG training and test scores improved (mean score 38% before training vs 59% after training, p < .001). Didactic lectures were given to 100% of the fellows, 100% (11/11) of new staff, and 80% (4/5 blocks) of rotating residents.

Conclusion: This quality improvement education project successfully trained pediatric anesthesia faculty, staff, residents, and fellows in EEG-guided TIVA. The training program was effective, scalable, and sustainable over time for newly hired faculty staff and rotating fellows and residents.

With continued political support and increased health financing, China has achieved great progress in medical and health quality during the two decades. The strategy to improve health in China is built on reliable cross-sectoral information and data sharing along with quality improvement science and safety analytics balancing equitability, accessibility, quality outcomes, and safety in healthcare for everyone. As part of the healthcare system, pediatric anesthesiology has made great efforts to align with the China healthcare strategy to achieve quality outcomes, accessibility, and patient safety, but it still faces many problems such as unbalanced regional development, lack of awareness and relevant knowledge, and increased workload due to insufficient number of anesthesiologists. To address these problems, the Chinese Society of Anesthesiology and Chinese Society for Pediatric Anesthesiology supported by the Chinese hospital associations are strengthening interregional cooperation and international collaboration. In our experience, quality improvement can be successfully implemented at major centers through collaboration with experienced international institutions. In turn, the major centers educate and collaborate with the district hospitals to empower local improvements in safety and quality. Since the science in QI and patient safety is relatively new to anesthesiology in China, such collaborations must be greatly scaled up to reach the large geography and patient population in China. While the future is promising, there is still a long way to go.

We describe a two-year-old boy with Dravet syndrome, a severe genetic epilepsy, who developed a generalized tonic-clonic seizure immediately following an intravenous bolus of lidocaine given for propofol pain amelioration during induction of anesthesia for emergency gastroscopy. Although lidocaine has not specifically been reported as potentiating seizures in Dravet syndrome, it is well-established that sodium channel blockers can worsen seizures in this population.

Study objective: This study's purpose was to determine if ondansetron can prevent pruritus after administration of intrathecal morphine in children, as has been demonstrated in adults.

Design: A double-blinded, randomized placebo-controlled trial.

Setting: Operating room and first 24 h postoperative inpatient stay at an academic children's hospital.

Patients: Forty-six children aged 3-17 years, who received 4-5 mcg/kg intrathecal morphine for urological or orthopedic procedures were included.

Interventions: Children were randomized to receive intravenous ondansetron (treatment) or saline placebo (placebo), prior to intrathecal morphine administration, and q6H for 24 h thereafter. Intraoperative anti-emetics and postoperative rescue treatments for pruritus and nausea were standardized.

Measurements: Patients were interviewed q6H for scored pruritus, nausea, and pain, using standardized scales.

Main results: The trial was terminated for futility after interim analysis. Forty-six children were recruited and 45 completed data collection. No significant difference was found between both groups for incidence of pruritus (requiring treatment) [relative risk (RR) 0.9, 95% CI: 0.7, 1.2], during the first postoperative 24 h. Notably, the incidence of pruritus was 84% overall, much higher than rates in previously published studies. Intravenous ondansetron significantly reduced the incidence of nausea, compared with the placebo group [RR 0.5, 95% CI: 0.3, 0.9].

Conclusions: This study found no evidence for intravenous ondansetron as an effective preventative for pruritus following intrathecal morphine in children. However, this RCT did find that the rate of pruritus following intrathecal morphine administration may be significantly higher than previously thought. Nausea and vomiting (a secondary outcome) were reduced significantly in the treatment group. The negative findings of this study reinforce the potential dangers of extrapolating the drug effects seen in adults onto pediatric patients.