All Publications


  • Enhanced Recovery After Cleft Palate Repair: A Quality Improvement Project. Paediatric anaesthesia Esfahanian, M., Marcott, S. C., Hopkins, E., Burkart, B., Khosla, R., Lorenz, H. P., Wang, E., De Souza, E., Algaze-Yojay, C., Caruso, T. J. 2022

    Abstract

    BACKGROUND: Children undergoing cleft palate repair present challenges to postoperative management due to several factors that can complicate recovery. Utilization of multimodal analgesic protocols can improve outcomes in this population. We report experience designing and implementing an enhanced recovery after surgery (ERAS) pathway for cleft palate repair to optimize postoperative recovery.AIMS: The primary aim was to implement an ERAS pathway with >70% bundle adherence to achieve a 30% reduction in postoperative opioid consumption within 12 months. Our secondary aims assessed intraoperative opioid consumption, length of stay (LOS), timeliness of oral intake, and respiratory recovery.METHODS: A multidisciplinary team of perioperative providers developed an ERAS pathway for cleft palate patients. Key drivers included patient and provider education, formal pathway creation and implementation, multimodal pain therapy, and target-based care. Interventions included maxillary nerve blockade and enhanced intra- and postoperative medication regimens. Outcomes were displayed as statistical process control charts.RESULTS: Pathway compliance was 77.0%. Patients during the intervention period (n=39) experienced a 49% reduction in postoperative opioid consumption (p<0.0001) relative to our historical cohort (n=63), with a mean difference of -0.33 ±0.11 mg/kg (95% CI -0.55 to -0.12 mg/kg). Intraoperative opioid consumption was reduced by 36% (p=0.002), with a mean difference of -0.27 ±0.09 mg/kg (95% CI -0.45 to -0.09 mg/kg). Additionally, patients in the intervention group had a 45% reduction in time to first oral intake (p=0.02) relative to our historical cohort, with a mean difference of -3.81 ±1.56 hours (95% CI -6.9 to -0.70). There was no difference in PACU or hospital LOS, but there was a significant reduction in variance of all secondary outcomes.CONCLUSION: Opioid reduction and improved timeliness of oral intake is possible with an ERAS protocol for cleft palate repair, but our protocol did not alter PACU or hospital LOS.

    View details for DOI 10.1111/pan.14541

    View details for PubMedID 35929340

  • Pediatric chronic post-surgical pain prevalence, pain scores, and quality-of-life: results of an exploratory patient survey at a single-center tertiary care children's hospital JOURNAL OF ANESTHESIA Dugan, M. Q., Anderson, T., De Souza, E., Delgado, J. R. 2022

    Abstract

    Twenty percent of children may develop chronic post-surgical pain (CPSP), but studies investigating pediatric CPSP are limited in scope. In an exploratory patient survey, we sought to assess CPSP prevalence among children of all ages, across a wide range of surgeries, and over an extended period of time after surgery.We conducted a survey study, including patients < 19 years of age at the time of their surgery at a single-center, quaternary care academic pediatric hospital. Pediatric patients who underwent surgery from May 2014 to August 2019 were included. Via electronic survey, patients/caregivers were asked whether the child had any pain related to their last surgery at the pediatric hospital. Patients/caregivers who answered yes were asked 11 additional questions about the child's pain and pain-related quality of life. The primary outcome was CPSP prevalence; secondary outcomes were pain scores, quality-of-life scores, and the associations of CPSP with time since surgery, preoperative pain, and patient age.The response rate of completed surveys was 4.0%. 30% of respondents reported CPSP; the median pain score was 4.0 on an 11 point scale (0 to 10). Responses to quality of life questions indicated CPSP negatively impacted many children's lives. Preoperative pain was associated with an odds ratio for CPSP of 1.09 [95% confidence interval (CI): 0.58, 2.04], each year after surgery with an odds ratio of 0.94 (95% CI 0.80, 1.10), and each year of age at surgery with an odds ratio of 1.07 (95% CI 1.02, 1.12).While limited by a low response rate, results from this exploratory survey suggest that CPSP is a considerable problem for children who undergo surgery across many specialties, with marked effects on patient well-being even years after surgery.

    View details for DOI 10.1007/s00540-022-03089-w

    View details for Web of Science ID 000824516800001

    View details for PubMedID 35829912

  • Association of Race and Ethnicity with Pediatric Postoperative Pain Outcomes. Journal of racial and ethnic health disparities Rosenbloom, J. M., De Souza, E., Perez, F. D., Xie, J., Suarez-Nieto, M. V., Wang, E., Anderson, T. A. 2022

    Abstract

    INTRODUCTION: Inequitable variability in healthcare practice negatively affects patient outcomes. Children of color may receive different analgesic medications in the perioperative period, resulting in different outcomes.METHODS: Medical records of children 0 to≤18years old from May 2014 to August 2019 were reviewed. The exposure was racial or ethnic groups: Asian, Black, Hispanic, Pacific Islander, and White non-Hispanic (reference).PRIMARY OUTCOME: post-anesthesia care unit mean pain score.SECONDARY OUTCOMES: inpatient mean pain score; opioid, antiemetic, and antipruritic administration in the post-anesthesia care unit and inpatient ward. The association of race or ethnicity with outcomes was modeled using multilevel logistic regression, adjusting for confounders and covariates.RESULTS: Twenty-nine thousand six hundred fourteen cases are included. In the post-anesthesia care unit, Black, Hispanic, and Pacific Islander children had no significant difference in the odds of receiving opioids or having moderate-severe pain as compared to White non-Hispanic patients; Asian children had lower odds of receiving opioids and lower odds of having a moderate-severe mean pain score. In the inpatient setting, Black, Hispanic, and Pacific Islander children had no significant difference in the odds of receiving opioids or having moderate severe-pain as compared to White non-Hispanic children, but Asian children had lower odds of receiving opioids and of having a moderate-severe mean pain score.CONCLUSIONS: Asian children had lower odds of receiving opioids and having moderate-severe pain postoperatively compared to the White non-Hispanic children. These differences may be a function of variation in patient/caregivers culture or healthcare provider care and warrant further investigation.

    View details for DOI 10.1007/s40615-022-01327-1

    View details for PubMedID 35622316

  • Health Care Burden Associated with Pediatric Prolonged Opioid Use After Surgery Anderson, T. A., Joyner, A., King, M. R., Safranek, C., Parvathinathan, G., De Souza, B. LIPPINCOTT WILLIAMS & WILKINS. 2022: 380
  • Visualizing Opioid-Use Variation in a Pediatric Perioperative Dashboard. Applied clinical informatics Safranek, C. W., Feitzinger, L., Joyner, A. K., Woo, N., Smith, V., Souza, E. D., Vasilakis, C., Anderson, T. A., Fehr, J., Shin, A. Y., Scheinker, D., Wang, E., Xie, J. 2022; 13 (2): 370-379

    Abstract

    BACKGROUND: Anesthesiologists integrate numerous variables to determine an opioid dose that manages patient nociception and pain while minimizing adverse effects. Clinical dashboards that enable physicians to compare themselves to their peers can reduce unnecessary variation in patient care and improve outcomes. However, due to the complexity of anesthetic dosing decisions, comparative visualizations of opioid-use patterns are complicated by case-mix differences between providers.OBJECTIVES: This single-institution case study describes the development of a pediatric anesthesia dashboard and demonstrates how advanced computational techniques can facilitate nuanced normalization techniques, enabling meaningful comparisons of complex clinical data.METHODS: We engaged perioperative-care stakeholders at a tertiary care pediatric hospital to determine patient and surgical variables relevant to anesthesia decision-making and to identify end-user requirements for an opioid-use visualization tool. Case data were extracted, aggregated, and standardized. We performed multivariable machine learning to identify and understand key variables. We integrated interview findings and computational algorithms into an interactive dashboard with normalized comparisons, followed by an iterative process of improvement and implementation.RESULTS: The dashboard design process identified two mechanisms-interactive data filtration and machine-learning-based normalization-that enable rigorous monitoring of opioid utilization with meaningful case-mix adjustment. When deployed with real data encompassing 24,332 surgical cases, our dashboard identified both high and low opioid-use outliers with associated clinical outcomes data.CONCLUSION: A tool that gives anesthesiologists timely data on their practice patterns while adjusting for case-mix differences empowers physicians to track changes and variation in opioid administration over time. Such a tool can successfully trigger conversation amongst stakeholders in support of continuous improvement efforts. Clinical analytics dashboards can enable physicians to better understand their practice and provide motivation to change behavior, ultimately addressing unnecessary variation in high impact medication use and minimizing adverse effects.

    View details for DOI 10.1055/s-0042-1744387

    View details for PubMedID 35322398

  • Pediatric Perioperative Methadone Dosing Trial: An Illustration of the Challenges in Conducting High-Quality Pediatric Anesthesia Research ANESTHESIA AND ANALGESIA De Souza, E., Anderson, T. 2021; 133 (2): 324-326

    View details for DOI 10.1213/ANE.0000000000005453

    View details for Web of Science ID 000670745100018

    View details for PubMedID 34257193

  • Prediction of Prolonged Opioid Use After Surgery in Adolescents: Insights From Machine Learning. Anesthesia and analgesia Ward, A., Jani, T., De Souza, E., Scheinker, D., Bambos, N., Anderson, T. A. 2021

    Abstract

    BACKGROUND: Long-term opioid use has negative health care consequences. Patients who undergo surgery are at risk for prolonged opioid use after surgery (POUS). While risk factors have been previously identified, no methods currently exist to determine higher-risk patients. We assessed the ability of a variety of machine-learning algorithms to predict adolescents at risk of POUS and to identify factors associated with this risk.METHODS: A retrospective cohort study was conducted using a national insurance claims database of adolescents aged 12-21 years who underwent 1 of 1297 surgeries, with general anesthesia, from January 1, 2011 to December 30, 2017. Logistic regression with an L2 penalty and with a logistic regression with an L1 lasso (Lasso) penalty, random forests, gradient boosting machines, and extreme gradient boosted models were trained using patient and provider characteristics to predict POUS (≥1 opioid prescription fill within 90-180 days after surgery) risk. Predictive capabilities were assessed using the area under the receiver-operating characteristic curve (AUC)/C-statistic, mean average precision (MAP); individual decision thresholds were compared using sensitivity, specificity, Youden Index, F1 score, and number needed to evaluate. The variables most strongly associated with POUS risk were identified using permutation importance.RESULTS: Of 186,493 eligible patient surgical visits, 8410 (4.51%) had POUS. The top-performing algorithm achieved an overall AUC of 0.711 (95% confidence interval [CI], 0.699-0.723) and significantly higher AUCs for certain surgeries (eg, 0.823 for spinal fusion surgery and 0.812 for dental surgery). The variables with the strongest association with POUS were the days' supply of opioids and oral morphine milligram equivalents of opioids in the year before surgery.CONCLUSIONS: Machine-learning models to predict POUS risk among adolescents show modest to strong results for different surgeries and reveal variables associated with higher risk. These results may inform health care system-specific identification of patients at higher risk for POUS and drive development of preventative measures.

    View details for DOI 10.1213/ANE.0000000000005527

    View details for PubMedID 33939656

  • Association Between Race and Ethnicity with Intraoperative Analgesic Administration and Initial Recovery Room Pain Scores in Pediatric Patients: a Single-Center Study of 21,229 Surgeries. Journal of racial and ethnic health disparities Jette, C. G., Rosenbloom, J. M., Wang, E., De Souza, E., Anderson, T. A. 2020

    Abstract

    INTRODUCTION: Perioperative pain may have deleterious effects for all patients. We aim to examine disparities in pain management for children in the perioperative period to understand whether any racial and ethnic groups are at increased risk of poor pain control.METHODS: Medical records from children ≤18years of age who underwent surgery from May 2014 to May 2018 were reviewed. The primary outcome was total intraoperative morphine equivalents. The secondary outcomes were intraoperative non-opioid analgesic administration and first conscious pain score. The exposure was race and ethnicity. The associations of race and ethnicity with outcomes of interest were modeled using linear or logistic regression, adjusted for preselected confounders and covariates. Bonferroni corrections were made for multiple comparisons.RESULTS: A total of 21,229 anesthetics were included in analyses. In the adjusted analysis, no racial and ethnic group received significantly more or less opioids intraoperatively than non-Hispanic (NH) whites. Asians, Hispanics, and Pacific Islanders were estimated to have significantly lower odds of receiving non-opioid analgesics than NH whites: odds ratio (OR)=0.83 (95% confidence interval (CI): 0.70, 0.97); OR=0.84 (95% CI: 0.74, 0.97), and OR=0.53 (95% CI: 0.33, 0.84) respectively. Asians were estimated to have significantly lower odds of reporting moderate-to-severe pain on awakening than NH whites: OR=0.80 (95% CI: 0.66, 0.99).CONCLUSIONS: Although children of all races and ethnicities investigated received similar total intraoperative opioid doses, some were less likely to receive non-opioid analgesics intraoperatively. Asians were less likely to report moderate-severe pain upon awakening. Further investigation may delineate how these differences lead to disparate patient outcomes and are influenced by patient, provider, and system factors.

    View details for DOI 10.1007/s40615-020-00811-w

    View details for PubMedID 32621098

  • Non-Opioid Analgesic Usage Among Pediatric Anesthesiologists: A Survey of Society for Pediatric Anesthesia Members. Paediatric anaesthesia King, M. R., Wu, R. L., De Souza, E., Newton, M. A., Anderson, T. A. 2020

    Abstract

    There is growing evidence to support the perioperative use of non-opioid analgesic medications in the pediatric population,1 but the use of, and attitudes toward, these agents among pediatric anesthesiologists is unknown. In order to characterize utilization of opioid-sparing agents in pediatric anesthesia, we designed a survey to study usage patterns for several non-opioid adjuncts by members of the Society for Pediatric Anesthesia (SPA) during and in the 24 hours following procedures.

    View details for DOI 10.1111/pan.13891

    View details for PubMedID 32323361

  • Incidence of and Factors Associated With Prolonged and Persistent Postoperative Opioid Use in Children 0-18 Years of Age. Anesthesia and analgesia Ward, A., De Souza, E., Miller, D., Wang, E., Sun, E. C., Bambos, N., Anderson, T. A. 2020

    Abstract

    BACKGROUND: Long-term opioid use has negative health care consequences. Opioid-naive adults are at risk for prolonged and persistent opioid use after surgery. While these outcomes have been examined in some adolescent and teenage populations, little is known about the risk of prolonged and persistent postoperative opioid use after common surgeries compared to children who do not undergo surgery and factors associated with these issues among pediatric surgical patients of all ages.METHODS: Using a national administrative claims database, we identified 175,878 surgical visits by opioid-naive children aged ≤18 years who underwent ≥1 of the 20 most common surgeries from each of 4 age groups between December 31, 2002, and December 30, 2017, and who filled a perioperative opioid prescription 30 days before to 14 days after surgery. Prolonged opioid use after surgery (filling ≥1 opioid prescription 90-180 days after surgery) was compared to a reference sample of 1,354,909 nonsurgical patients randomly assigned a false "surgery" date. Multivariable logistic regression models were used to estimate the association of surgical procedures and 22 other variables of interest with prolonged opioid use and persistent postoperative opioid use (filling ≥60 days' supply of opioids 90-365 days after surgery) for each age group.RESULTS: Prolonged opioid use after surgery occurred in 0.77%, 0.76%, 1.00%, and 3.80% of surgical patients ages 0-<2, 2-<6, 6-<12, and 12-18, respectively. It was significantly more common in surgical patients than in nonsurgical patients (ages 0-<2: odds ratio [OR] = 4.6 [95% confidence interval (CI), 3.7-5.6]; ages 2-<6: OR = 2.5 [95% CI, 2.1-2.8]; ages 6-<12: OR = 2.1 [95% CI, 1.9-2.4]; and ages 12-18: OR = 1.8 [95% CI, 1.7-1.9]). In the multivariable models for ages 0-<12 years, few surgical procedures and none of the other variables of interest were associated with prolonged opioid use. In the models for ages 12-18 years, 10 surgical procedures and 5 other variables of interest were associated with prolonged opioid use. Persistent postoperative opioid use occurred in <0.1% of patients in all age groups.CONCLUSIONS: Some patient characteristics and surgeries are positively and negatively associated with prolonged opioid use in opioid-naive children of all ages, but persistent opioid use is rare. Specific pediatric subpopulations (eg, older patients with a history of mood/personality disorder or chronic pain) may be at markedly higher risk.

    View details for DOI 10.1213/ANE.0000000000004823

    View details for PubMedID 32332289

  • Association Between Race and Ethnicity in the Delivery of Regional Anesthesia for Pediatric Patients: A Single-Center Study of 3189 Regional Anesthetics in 25,664 Surgeries. Anesthesia and analgesia King, M. R., De Souza, E. n., Rosenbloom, J. M., Wang, E. n., Anderson, T. A. 2019

    Abstract

    Racial and ethnic disparities in health care are well documented in the United States, although evidence of disparities in pediatric anesthesia is limited. We sought to determine whether there is an association between race and ethnicity and the use of intraoperative regional anesthesia at a single academic children's hospital.We performed a retrospective review of all anesthetics at an academic tertiary children's hospital between May 4, 2014, and May 31, 2018. The primary outcome was delivery of regional anesthesia, defined as a neuraxial or peripheral nerve block. The association between patient race and ethnicity (white non-Hispanic or minority) and receipt of regional anesthesia was assessed using multivariable logistic regression. Sensitivity analyses were performed comparing white non-Hispanic to an expansion of the single minority group to individual racial and ethnic groups and on patients undergoing surgeries most likely to receive regional anesthesia (orthopedic and urology patients).Of 33,713 patient cases eligible for inclusion, 25,664 met criteria for analysis. Three-thousand one-hundred eighty-nine patients (12.4%) received regional anesthesia. One thousand eighty-six of 8884 (13.3%) white non-Hispanic patients and 2003 of 16,780 (11.9%) minority patients received regional anesthesia. After multivariable adjustment for confounding, race and ethnicity were not found to be significantly associated with receiving intraoperative regional anesthesia (adjusted odds ratios [ORs] = 0.95; 95% confidence interval [CI], 0.86-1.06; P = .36). Sensitivity analyses did not find significant differences between the white non-Hispanic group and individual races and ethnicities, nor did they find significant differences when analyzing only orthopedic and urology patients, despite observing some meaningful clinical differences.In an analysis of patients undergoing surgical anesthesia at a single academic children's hospital, race and ethnicity were not significantly associated with the adjusted ORs of receiving intraoperative regional anesthesia. This finding contrasts with much of the existing health care disparities literature and warrants further study with additional datasets to understand the mechanisms involved.

    View details for DOI 10.1213/ANE.0000000000004456

    View details for PubMedID 31569162

  • Virtual Reality during Pediatric Vascular Access: A Pragmatic, Prospective Randomized, Controlled Trial. Paediatric anaesthesia Caruso, T. J., George, A. n., Menendez, M. n., De Souza, E. n., Khoury, M. n., Kist, M. N., Rodriguez, S. T. 2019

    Abstract

    Vascular access is a minor procedure that is associated with reported pain and fear in pediatric patients, often resulting in procedural incompliance. Virtual reality has been shown to be effective in adult populations for reducing pain and anxiety in various medical settings, although large studies are lacking in pediatrics.The primary aim was to determine if pain would be reduced in pediatric patients using virtual reality undergoing vascular access. The four secondary aims measured patient fear, procedural compliance, satisfaction, and adverse events.A prospective, randomized, controlled trial was completed at a pediatric hospital, enrolling children 7-18 years old undergoing vascular access in a variety of clinical settings, randomized to virtual reality or standard of care. Pain scores were measured using a numeric pain faces scale. The secondary outcomes of patient fear, procedural compliance, satisfaction, and adverse events were measured with the Child Fear Scale, modified induction compliance checklist, and satisfaction surveys, respectively. Chi-squared, t-tests, and regression models were used to analyze the results.The analysis included 106 patients in the virtual reality group and 114 in the control. There were no significant differences in post-procedure pain (VR group estimated 0.11 points lower, 95% confidence interval: 0.50 points lower to 0.28 points greater, p=0.59), post-procedure fear (VR group estimated 0.05 points lower, 95% confidence interval: 0.23 points lower to 0.13 points greater) or compliance (adjusted odds ratio 2.31, 95% confidence interval: 0.96 to 5.56). Children in the virtual reality group were satisfied with the intervention. There were no adverse events.This study demonstrates no reduction in pain while using VR across a heterogeneous pediatric inpatient population undergoing vascular access.

    View details for DOI 10.1111/pan.13778

    View details for PubMedID 31785015