Ellen Wang, MD is a Clinical Associate Professor of Pediatric Anesthesiology and Medical Director of Clinical Informatics for Perioperative Services at Lucile Packard Children’s Hospital Stanford. She is board-certified in Pediatric Anesthesiology and Clinical Informatics, with particular emphasis on EHR enhancement and optimization projects that support surgical, nursing, and pediatric and obstetric anesthesia workflows. She is also Chief of Operations of the Stanford Chariot Program, combining her interest in clinical care, process improvement, data analytics and research with virtual/augmented reality technologies to advance and evolve standards in patient care.

Clinical Focus

  • Pediatric Anesthesiology
  • Regional Anesthesia
  • Pre-Anesthesia Clinic
  • Clinical Informatics
  • Immersive Technologies
  • Pediatric Anesthesia

Academic Appointments

Administrative Appointments

  • Medical Director of Clinical Informatics, Perioperative Services, Information Services, Stanford Children's Health (2012 - Present)

Professional Education

  • Internship: Alameda Health System Highland Hospital (2004) CA
  • Board Certification: American Board of Preventive Medicine, Clinical Informatics (2017)
  • Fellowship: Stanford University Anesthesiology Residency (2012) CA
  • Board Certification, Clinical Informatics, American Board of Preventative Medicine (2017)
  • Board Certification: American Board of Anesthesiology, Pediatric Anesthesia (2013)
  • Residency: UCLA (2007) CA
  • Medical Education: University of California San Francisco (2003) CA
  • Board Certification: American Board of Anesthesiology, Anesthesia (2008)
  • Fellowship: Children's Hospital Boston (2008) MA

Clinical Trials

  • Transnasal Humidified Rapid-Insufflation Ventilatory Exchange (THRIVE) Use in Pediatric Procedures Not Recruiting

    THRIVE (Transnasal Humidified Rapid-Insufflation Ventilatory Exchange) refers to the use of high-flow nasal cannula to augment the ability to oxygenate and ventilate a patient under general anesthesia. The use of high-flow nasal cannula oxygen supplementation during anesthesia for surgical procedures has been a recent development in the adult population, with limited data analyzing the pediatric population. This study will determine whether high flow nasal cannula oxygen supplementation during surgical or endoscopic procedures can safely prevent desaturation events in children under anesthesia.

    Stanford is currently not accepting patients for this trial. For more information, please contact Thomas J Caruso, M.D., M.Ed., 650-723-5728.

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All Publications

  • Virtual Reality Facilitated Exercise Increases Sympathetic Activity and Reduces Pain Perception: A Randomized Crossover Study. American journal of physical medicine & rehabilitation Rodriguez, S. T., Makarewicz, N., Wang, E. Y., Zuniga-Hernandez, M., Titzler, J., Jackson, C., Suen, M. Y., Rosales, O., Caruso, T. J. 2024


    Both virtual reality (VR) and exercise reduce pain while avoiding the risks of traditional pharmacotherapy. The aim of this study was to assess how VR-facilitated exercise modulates sympathetic activity and pain perception.Healthy adult volunteers were randomized by hand dominance and then subjected to a standardized cold pressor test while experiencing a VR application. After a 5-minute washout, participants were crossed-over and repeated the test on their other hand while undergoing a VR-facilitated exercise application. Sympathetic activation, pain sensation, and pain tolerance data were collected identically during both conditions.110 participants were analyzed. Sympathetic activity increased in both conditions but was higher in the VR-facilitated exercise condition (p < 0.0001). Pain sensation scores were initially higher with VR-facilitated exercise but dropped below the VR-only condition by the end of the intervention (p = 0.0175). There were no differences in pain tolerance between conditions (p = 0.18).The decrease in pain perception with VR-facilitated exercise condition compared to VR alone indicates VR-facilitated exercise can be a useful tool for managing pain. Though this effect did not translate into higher pain tolerance, VR-facilitated exercise may be a useful intervention in the setting of physical therapy or for patients with chronic pain.

    View details for DOI 10.1097/PHM.0000000000002550

    View details for PubMedID 38842101

  • Augmented Reality Improves Pediatric Mask Induction: A Prospective, Matched Case-Control Study. Journal of patient experience Yun, R., He, E. M., Zuniga, M., Guo, N., Wang, E. Y., Ho, F., Pearson, M., Rodriguez, S. T., Caruso, T. J. 2024; 11: 23743735241241146


    Introduction: Pediatric perioperative anxiety is a significant problem during mask induction for general anesthesia. Immersive technologies, such as extended reality headsets, are a promising strategy for alleviating anxiety. Our primary aim was to investigate mask acceptance during inhalational induction utilizing augmented reality (AR). Methods: This was a prospective, matched case-control study at a quaternary academic hospital. Fifty pediatric patients using AR for mask induction were matched to 150 standard-of-care (SOC) controls. The primary outcome was measured with the Mask Acceptance Scale (MAS). Secondary outcomes of cooperation and emergent delirium (ED) were assessed. Results: MAS scores ≥2 occurred at 4% (95% CI [0, 9.4%]) with AR versus 19.3%, (95% CI [13%, 25.7%]) with SOC (RR 0.21, 95% CI [0.05, 0.84], P = .027). Ninety-eight percent of AR patients were cooperative versus 91.3% with SOC (P = .457). Zero percent had ED with AR versus 0.7% with SOC (P = 1.000). Conclusions: AR during mask induction improved mask acceptance compared to SOC. No relationship was observed between AR and cooperation or ED. Future research will investigate the integration of AR into clinical practice as a nonpharmacologic intervention.

    View details for DOI 10.1177/23743735241241146

    View details for PubMedID 38549806

    View details for PubMedCentralID PMC10976515

  • A prospective, observational validation of HRAD±, a novel pediatric affect and cooperation scale. Journal of clinical anesthesia Yun, R., Qian, D., Wang, E., Zuniga, M., Forbes, T., Li, B., Rodriguez, S. T., Jackson, C., Caruso, T. J. 2024; 94: 111410


    STUDY OBJECTIVE: HRAD± was developed to quickly assess pediatric perioperative affect and cooperation. HRAD± represents: Happy, Relaxed, Anxious, Distressed, with a yes/no answer to cooperativity. The primary aim of this study was to investigate the clinical utility of HRAD± as an affect and cooperation assessment tool for inhalational mask induction. Secondary aims examined inter-rater reliability (IRR) of HRAD± and predictive validity of induction HRAD± with emergence delirium.DESIGN: This was a prospective observational investigation.SETTING: We conducted this investigation at Lucile Packard Children's Hospital Stanford, an academic, quaternary care children's hospital in Northern California.PATIENTS: A total of 197 patients were included in this investigation. Children 1-14years of age, who underwent daytime procedures with inhalational induction of anesthesia and American Society of Anesthesiologists physical status I-III were eligible.INTERVENTIONS: During mask induction, two trained research assistants (RAs) independently scored the patient's affect and cooperation. After extubation, the same investigators observed the patient's emergence.MEASUREMENTS: RAs scored each mask induction using the following scales: HRAD±, modified Yale Preoperative Anxiety Scale (mYPAS), Observation Scale of Behavioral Distress (OSBD), and Induction Compliance Checklist (ICC). Correlations were calculated to HRAD±. IRR of HRAD± between the RAs as well as predictive validity of HRAD± to Pediatric Anesthesia Emergence Delirium (PAED), Watcha and Cravero scales were calculated.MAIN RESULTS: HRAD± scores strongly correlated with mYPAS (r=0.840, p<0.0001) with moderate correlation to OSBD (r=0.685, p<0.0001) and ICC (-0.663, p<0.0001). IRR was moderate for the affect and cooperation portion of the HRAD± scale, respectively (kappa=0.595 [p<0.0001], kappa=0.478 [p<0.0001]). A weak correlation was observed with PAED (r=0.134 [p=0.0597]) vs HRAD±. No correlations were observed between Watcha (r=0.013 [p=0.8559]) and Cravero and HRAD± scales (r=0.002 [p=0.9767]).CONCLUSIONS: HRAD± is a clinically useful and simple scale for evaluating pediatric affect and cooperation during inhalational mask induction. Results demonstrate correlation with commonly utilized research assessment scales.

    View details for DOI 10.1016/j.jclinane.2024.111410

    View details for PubMedID 38340678

  • Reducing Preoperative Caregiver Anxiety With Virtual Reality: A Pragmatic, Randomized Controlled Study. Journal of patient experience Fonseca, A., Qian, D., Forbes, T., Li, B. S., Lee, C., Burdsall, K., Rodriguez, S., Jackson, C., Wang, E. Y., Caruso, T. J. 2024; 11: 23743735231220190


    Pediatric patients and their caregivers often experience perioperative anxiety. Interventions reduce caregiver anxiety improve cooperation and contribute to an improved patient experience. This study seeks to evaluate the efficacy of virtual reality (VR)-assisted mindfulness on perioperative caregiver anxiety. Participants were randomized into a standard of care (SOC) group, which included snacks but no technology-based distractions, or a VR group, which included snacks and a VR-guided meditation. Caregiver anxiety was measured before and after the intervention using the Visual Analogue Scale for Anxiety (VAS-A). Secondary aims explored participants' baseline anxiety with the State-Trait Anxiety Inventory (STAI). VR group participants completed a satisfaction survey. Linear regression models of VAS-A and STAI were used to compare group differences. Satisfaction survey results were reported with descriptive statistics. 26 participants were included, with 12 randomized to the SOC group and 14 to the VR group. VAS-A scores in the VR group were lower than those in the SOC group (p = .002). The STAI found no change in participants' state of anxiety in the SOC group (p = .7108), compared to a significant reduction (p = .014) in the VR group when controlling for anxiety traits. 12 of 14 caregivers in the VR group expressed satisfaction or strong satisfaction. This study supports the implementation of VR mindfulness as a method to reduce caregiver anxiety. VR use in the pediatric healthcare setting is safe and inexpensive, and the intervention had a high degree of participant satisfaction.

    View details for DOI 10.1177/23743735231220190

    View details for PubMedID 38188533

    View details for PubMedCentralID PMC10771051

  • A Quality Improvement Project to Improve the Utilization of an Intraoperative Rapid Response System. Pediatric quality & safety Rama, A., Qian, D., Forbes, T., Wang, E., Knight, L., Berg, M., Caruso, T. J. 2023; 8 (6): e686


    Rapid response teams (RRTs) improve morbidity by reducing the incidence of cardiac arrests. Although providers commonly activate RRTs on acute care wards, they are infrequently used perioperatively. At our institution, two intraoperative calls for help exist: staff assists (SAs) and code blues (CBs). The SA functions analogously to an RRT, and the CB indicates cardiopulmonary arrest. Given the success of RRTs, this project aimed to increase the use of the SA system. Our primary goal was to increase the ratio of SA to CB alerts by 50% within 6 months.A quality improvement team led this project at an academic pediatric hospital in Northern California. The team analyzed the current state and identified an achievable goal. After developing key drivers, they implemented monthly simulations to teach providers the signs of clinical deterioration and to practice activating the SA system. In addition to measuring the ratio of SA to CB alerts, the team surveyed the etiologies of SA and measured process satisfaction.Before the introduction of this initiative, the ratio of SA to CB alerts were 1:13.3. These improvements efforts led to an increase of SA to CB alerts to 1.5:1 (P = 0.0003). Twenty-three anesthesiologists provided etiologies for SA, reporting laryngospasm as the most common reason (30.4%). Nineteen nurses completed the SA survey and reported high satisfaction.This project successfully increased the utilization of a rapid response protocol in a pediatric perioperative setting using improvement methodologies and a simulation-based educational program.

    View details for DOI 10.1097/pq9.0000000000000686

    View details for PubMedID 38089833

    View details for PubMedCentralID PMC10715782

  • Perioperative Regional Anesthesia Pain Outcomes in Children: A Retrospective Study of 3,160 Regional Anesthetics in Routine Practice. The Clinical journal of pain Xie, J., De Souza, E., Perez, F., Suárez-Nieto, M. V., Wang, E., Anderson, T. A. 2023


    Randomized controlled trials indicate regional anesthesia (RA) improves postoperative outcomes with reduced pain and opioid consumption. Therefore, we hypothesized children who received RA, regardless of technique, would have reduced pain/opioid use in routine practice.Using a retrospective cohort, we assessed the association of RA with perioperative outcomes in everyday practice at our academic pediatric hospital. Patients ≤18 years undergoing orthopedic, urologic, or general surgeries with and without RA from 5/2014 to 9/2021 were categorized as single-shot, catheter-based, or no-block. Outcomes included: intraoperative opioid exposure and dose, pre-incision anesthesia time, post anesthesia care unit (PACU) opioid exposure and dose, PACU antiemetic/antipruritic administration, PACU/inpatient pain scores, PACU/inpatient lengths of stay, and cumulative opioid exposure. Regression models estimated the adjusted association of RA with outcomes, controlling for multiple variables.11,292 procedures with 3,160 RAs were included. Compared to no-block group, single-shot and catheter-based blocks were associated with opioid-free intraoperative anesthesia and opioid-free PACU stays. Post-PACU (i.e. while inpatient), single-shot blocks were not associated with improved pain scores or reduced opioid use. Catheter-based blocks were associated with reduced PACU and inpatient opioid use until 24 hours post-op, no difference of opioid use from 24 to 36 hours, and higher probability of use from 36 to 72 hours. RA was not associated with reduced cumulative opioid consumption.Despite adjustment for confounders, the association of RA with pediatric pain/opioid use outcomes was mixed. Further investigation is necessary to maximize the benefits of RA.

    View details for DOI 10.1097/AJP.0000000000001172

    View details for PubMedID 37942728

  • Effect of an electronic medical record nudge to improve quality improvement program tracking of neuraxial catheter replacements in obstetric patients. BMJ open quality Fedoruk, K., Xie, J., Wang, E., Fowler, C., Riley, E., Carvalho, B. 2023; 12 (4)


    Monitoring complications associated with medical procedures requires reliable and accurate record keeping. Nudge reminders executed by way of electronic medical record (EMR) alerts influence clinician behaviour. We hypothesised that the introduction of an EMR nudge would improve documentation of replaced neuraxial blocks by obstetric anaesthesiologists at our institution.We developed an EMR nudge that would alert the physician to a replaced neuraxial block if two or more neuraxial procedure notes in a single patient encounter were detected. The nudge encouraged physicians to document neuraxial block replacements in our institution's quality improvement database. We assessed the rate of physician adherence to replaced neuraxial block charting prior to the introduction of the nudge (January 2019-September 2019) and after the implementation (October 2019-December 2020).494 encounters during the chart review period, January 2019-December 2020, required a neuraxial block replacement, representing an actual neuraxial replacement rate of 6.3% prior to the introduction of the nudge in October 2019. This rate was largely unchanged (6.2%) after the introduction of the nudge (0.1% difference, 95% CI: -0.0119 to 0.0099). Prior to the introduction of the nudge, the proportion of correctly charted failed/replaced blocks in our quality improvement database was 80.0%, and after nudge introduction, the rate was 96.2% (p value <0.00001, OR=6.32, 95% CI: 3.15 to 12.66). A p-chart of the monthly adherence rate demonstrated sustained improvement over time.EMR nudge technology significantly improved adherence with quality metric monitoring of neuraxial catheter replacement in obstetric patients. The results imply that data collection for quality metric databases of neuraxial block failures and replacements that rely on clinician memory without a nudge are likely under-reporting neuraxial block failures and replacements. This study supports widespread implementation of nudges in EMRs to improve quality metric reporting.

    View details for DOI 10.1136/bmjoq-2022-002240

    View details for PubMedID 37903567

  • Predicting pediatric healthcare provider use of virtual reality using a technology acceptance model. JAMIA open Wang, E. Y., Kennedy, K. M., Zhang, L., Qian, D., Forbes, T., Zuniga-Hernandez, M., Li, B. S., Domingue, B., Caruso, T. J. 2023; 6 (3): ooad076


    The primary aim of this study was to apply a novel technology acceptance model (TAM) for virtual reality (VR) in healthcare. The secondary aim was to assess reliability of this model to evaluate factors that predict the intentions of pediatric health providers' use of VR as an anxiolytic for hospitalized pediatric patients.Healthcare providers that interacted with pediatric patients participated in a VR experience available as anxiolysis for minor procedures and then completed a survey evaluating attitudes, behaviors, and technology factors that influence adoption of new technologies.Reliability for all domain measurements were good, and all confirmatory factor analysis models demonstrated good fit. Usefulness, ease of use, curiosity, and enjoyment of the VR experience all strongly predict intention to use and purchase VR technologies. Age of providers, past use, and cost of technology did not influence future purchase or use, suggesting that VR technologies may be broadly adopted in the pediatric healthcare setting.Previous VR-TAM models in non-healthcare consumers formulated that age, past use, price willing to pay, and curiosity impacted perceived ease of use. This study established that age, past use, and cost may not influence use in healthcare. Future studies should be directed at evaluating the social influences and facilitating conditions within healthcare that play a larger influence on technology adoption.The VR-TAM model demonstrated validity and reliability for predicting intent to use VR in a pediatric hospital.

    View details for DOI 10.1093/jamiaopen/ooad076

    View details for PubMedID 37693368

    View details for PubMedCentralID PMC10483581

  • Virtual reality facilitated exercise improves pain perception: A crossover study. Journal of clinical anesthesia Rodriguez, S. T., Makarewicz, N., Wang, E. Y., Zuniga-Hernandez, M., Titzler, J., Jackson, C., Suen, M. Y., Rosales, O., Caruso, T. J. 2023; 91: 111257


    STUDY OBJECTIVE: Both virtual reality (VR) and exercise are recognized for their analgesic and anxiolytic properties. The purpose of this study is to evaluate the ability of VR-facilitated exercise to modulate pain.DESIGN: Within-subject cross-over clinical trial.SETTING: The Stanford Chariot Program conducted this study at Lucile Packard Children's Hospital Stanford (LCPHS).PATIENTS: Healthy participants meeting inclusion criteria were recruited by volunteer solicitation from LCPHS.INTERVENTIONS: Participants were randomized by hand dominance and subjected to a standardized cold pressor test with no VR or exercise. After a 5-min wash-out period, participants repeated the test on their other hand while experiencing a VR-facilitated exercise condition. Pain sensitivity, pain tolerance, and sympathetic activation data were collected during both conditions.MEASUREMENTS: Pain sensitivity was scored 0-10 and collected every 30s. Pain tolerance was recorded as the duration a participant could endure the painful stimuli. Sympathetic activation was measured by skin conductance response density (SCRD) and recorded in 30s epochs by a biosensor. In all analyses, data were nested by participant.MAIN RESULTS: Forty-one participants completed both interventions. Pain sensitivity was reduced in the VR-facilitated exercise condition (p<0.0001). There was no difference in pain tolerance between conditions. While both conditions resulted in an increase in sympathetic activity, SCRD was higher at all time points in the VR-facilitated exercise condition.CONCLUSIONS: The reduction in pain sensitivity indicates VR-facilitated exercise results in improved pain perception. VR-facilitated exercise may be especially useful for patients with chronic pain or other conditions requiring physical therapy, where pain may be exacerbated by exercise.

    View details for DOI 10.1016/j.jclinane.2023.111257

    View details for PubMedID 37708601

  • Effectiveness of an early operating room start time in managing pediatric trauma. World journal of orthopedics Kym, D., Kaur, J., Pham, N. S., Klein, E., Langner, J. L., Wang, E., Vorhies, J. S. 2023; 14 (7): 516-525


    The timing of operative treatment for pediatric supracondylar humerus fractures (SCHF) and femoral shaft fractures (FSF) remains controversial. Many fractures previously considered to be surgical emergencies, such as SCHF and open fractures, are now commonly being treated the following day. When presented with an urgent fracture overnight needing operative treatment, the on-call surgeon must choose whether to mobilize resources for a late-night case or to add the case to an elective schedule of the following day.To describe the effect of a program allowing an early operating room (OR) start for uncomplicated trauma prior to an elective day of surgery to decrease wait times for surgery for urgent fractures admitted overnight.Starting in October 2017, patients were eligible for the early slot in the OR at the discretion of the surgeon if they were admitted after 21:00 the previous night and before 05:00. We compared demographics and timing of treatment of SCHF and FSF treated one year before and after implementation as well as the survey responses from the surgical team.Of the 44 SCHF meeting inclusion criteria, 16 received treatment before implementation while 28 were treated after. After implementation, the mean wait time for surgery decreased by 4.8 h or 35.4% (13.4 h vs 8.7 h; P = 0.001). There were no significant differences in the operative duration, time in the post anesthesia care unit, and wait time for discharge. Survey results demonstrated decreased popularity of the program among nurses and anesthesiologists relative to surgeons. Whereas 57% of the surgeons believed that the program was effective, only 9% of anesthesiologists and 16% of nurses agreed. The program was ultimately discontinued given the dissatisfaction.Our findings demonstrate significantly reduced wait times for surgery for uncomplicated SCHF presenting overnight while discussing the importance of shared decision-making with the stakeholders. Although the program produced promising results, it also created new conflicts within the OR staff that led to its discontinuation at our institution. Future implementations of such programs should involve stakeholders early in the planning process to better address the needs of the OR staff.

    View details for DOI 10.5312/wjo.v14.i7.516

    View details for PubMedID 37485431

    View details for PubMedCentralID PMC10359751

  • Prehospital Pediatric Emergency Training Using Augmented Reality Simulation: A Prospective, Mixed Methods Study. Prehospital emergency care Friedman, N., Zuniga-Hernandez, M., Titzler, J., Suen, M. Y., Wang, E., Rosales, O., Graham, J., D'Souza, P., Menendez, M., Caruso, T. J. 2023: 1-18


    ObjectivePediatric emergencies are high-stakes yet low-volume clinical encounters for emergency medical services (EMS) clinicians, necessitating innovative approaches to training. We sought to explore the acceptability, usability, and ergonomics of a novel augmented reality (AR) software for EMS crisis management training.MethodsThis was a prospective, mixed-methods study employing qualitative and quantitative analyses. We enrolled emergency medical technicians (EMTs) and paramedics at a municipal fire service in Northern California. We ran the Chariot Augmented Reality Medical simulation software (#details_redacted_for_peer_review) on the ML1 headset (Magic Leap, Inc., Plantation, FL), which enabled participants to view an AR image of a patient overlaid with real-world training objects. Participants completed a simulation of a pediatric hypoglycemia-induced seizure and cardiac arrest. Participants subsequently engaged in structured focus group interviews assessing acceptability, which we coded and thematically analyzed. We evaluated the usability of the AR system and ergonomics of the ML1 headset using previously validated scales, and we analyzed findings with descriptive statistics.ResultsTwenty-two EMS clinicians participated. We categorized focus group interview statements into seven domains after an iterative thematic analysis: general appraisal, realism, learning efficacy, mixed reality feasibility, technology acceptance, software optimization, and alternate use cases. Participants valued the realism and the mixed reality functionality of the training simulation. They reported that AR could be effective for practicing pediatric clinical algorithms and task prioritization, building verbal communication skills, and promoting stress indoctrination. However, participants also noted challenges with integrating AR images with real-world objects, the learning curve required to adapt to the technology, and areas for software improvement. Participants favorably evaluated the ease of use of the technology and comfortability of wearing the hardware; however, most participants reported that they would need technical support.ConclusionParticipants positively evaluated the acceptability, usability, and ergonomics of an AR simulator for pediatric emergency management training, and participants identified current technological limitations and areas for improvement. AR simulation may serve as an effective training adjunct for prehospital clinicians.

    View details for DOI 10.1080/10903127.2023.2224876

    View details for PubMedID 37318845

  • Automated Alert System of Second-Line Uterotonic Drug Administration. A&A practice Abir, G., Riley, E. T., Oakeson, A. M., Judy, A., Wang, E., Carvalho, B. 2023; 17 (5): e01687


    Multidisciplinary team management of postpartum hemorrhage (PPH) is needed to optimize care and improve outcomes. Lucile Packard Children's Hospital, Stanford, is a tertiary referral center with 4600 deliveries/y (>70% high-risk deliveries), and there have been times when the obstetric anesthesia team was alerted late or not at all for PPHs. Introduction of an automated alert process to the obstetric anesthesia team when a second-line uterotonic drug was administered has ensured prompt evaluation. Utilization of this automated drug alert system has improved communication and reduced failure to inform the obstetric anesthesiology team of PPH after vaginal and cesarean deliveries.

    View details for DOI 10.1213/XAA.0000000000001687

    View details for PubMedID 37222414

  • Keeping an Open Mind About Open Notes: Sharing Anesthesia Records With Patients. Anesthesia and analgesia Ramaswamy, P., Xie, J., Marsiglio, A. M., Burgart, A. M., Schmiesing, C. A., Cohen, N. H., Robinowitz, D. L., Wang, E. 2022; 135 (4): 697-703


    ADDENDUM: Please note that in the interim since this paper was accepted for publication, new governmental regulations, pertinent to the topic, have been approved for implementation. The reader is thus directed to this online addendum for additional relevant information:

    View details for DOI 10.1213/ANE.0000000000005800

    View details for PubMedID 36108183

  • 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


    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

  • Communication Skills Training Using Remote Augmented Reality Medical Simulation: a Feasibility and Acceptability Qualitative Study. Medical science educator Hess, O., Qian, J., Bruce, J., Wang, E., Rodriguez, S., Haber, N., Caruso, T. J. 2022: 1-10


    Introduction: Augmented reality (AR) has promise as a clinical teaching tool, particularly for remote learning. The Chariot Augmented Reality Medical (CHARM) simulator integrates real-time communication into a portable medical simulator with a holographic patient and monitor. The primary aim was to analyze feedback from medical and physician assistant students regarding acceptability and feasibility of the simulator.Methods: Using the CHARM simulator, we created an advanced cardiovascular life support (ACLS) simulation scenario. After IRB approval, preclinical medical and physician assistant students volunteered to participate from August to September 2020. We delivered augmented reality headsets (Magic Leap One) to students before the study. Prior to the simulation, via video conference, we introduced students to effective communication skills during a cardiac arrest. Participants then, individually and remotely from their homes, synchronously completed an instructor-led ACLS AR simulation in groups of three. After the simulation, students participated in a structured focus group using a qualitative interview guide. Our study team coded their responses and interpreted them using team-based thematic analysis.Results: Eighteen medical and physician assistant students participated. We identified four domains that reflected trainee experiences: experiential satisfaction, learning engagement, technology learning curve, and opportunities for improvement. Students reported that the simulator was acceptable and enjoyable for teaching trainees communication skills; however, there were some technical difficulties associated with initial use.Conclusion: This study suggests that multiplayer AR is a promising and feasible approach for remote medical education of communication skills during medical crises.Supplementary Information: The online version contains supplementary material available at 10.1007/s40670-022-01598-7.

    View details for DOI 10.1007/s40670-022-01598-7

    View details for PubMedID 35966166

  • Assessing Pediatric Life Support Skills Using Augmented Reality Medical Simulation With Eye Tracking: A Pilot Study. The journal of education in perioperative medicine : JEPM Qian, J., Rama, A., Wang, E., Wang, T., Hess, O., Khoury, M., Jackson, C., Caruso, T. J. 2022; 24 (3): E691


    Background: Augmented reality (AR) and eye tracking are promising adjuncts for medical simulation, but they have remained distinct tools. The recently developed Chariot Augmented Reality Medical (CHARM) Simulator combines AR medical simulation with eye tracking. We present a novel approach to applying eye tracking within an AR simulation to assess anesthesiologists during an AR pediatric life support simulation. The primary aim was to explore clinician performance in the simulation. Secondary outcomes explored eye tracking as a measure of shockable rhythm recognition and participant satisfaction.Methods: Anesthesiology residents, pediatric anesthesiology fellows, and attending pediatric anesthesiologists were recruited. Using CHARM, they participated in a pediatric crisis simulation. Performance was scored using the Anesthesia-centric Pediatric Advanced Life Support (A-PALS) scoring instrument, and eye tracking data were analyzed. The Simulation Design Scale measured participant satisfaction.Results: Nine each of residents, fellows, and attendings participated for a total of 27. We were able to successfully progress participants through the AR simulation as demonstrated by typical A-PALS performance scores. We observed no differences in performance across training levels. Eye tracking data successfully allowed comparisons of time to rhythm recognition across training levels, revealing no differences. Finally, simulation satisfaction was high across all participants.Conclusions: While the agreement between A-PALS score and gaze patterns is promising, further research is needed to fully demonstrate the use of AR eye tracking for medical training and assessment. Physicians of multiple training levels were satisfied with the technology.

    View details for DOI 10.46374/volxxiv_issue3_qian

    View details for PubMedID 36274998

  • 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


    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

  • Quantifying virtual reality pain modulation in healthy volunteers: A randomized, crossover study. Journal of clinical anesthesia Neiman, N. R., Falkson, S. R., Rodriguez, S. T., Wang, E. Y., Hemphill, S. F., Khoury, M. E., Kist, M. N., Jackson, C. D., Caruso, T. J. 2022; 80: 110876


    STUDY OBJECTIVE: Virtual reality (VR) is an emerging tool to reduce pain and anxiety during procedures. Although VR's clinical benefits are reported, biometric data quantifying VR's effect on pain tolerance is lacking. We used time-lapse, subjective, and biometric data to evaluate VR's effect on modulating pain.DESIGN: Randomized, controlled crossover within-subject clinical trial.SETTING: This study was conducted in the Chariot Lab at Lucile Packard Children's Hospital and outdoors at Stanford University School of Medicine.PATIENTS: 156 healthy volunteers were included.INTERVENTIONS: Participants underwent pain-inducing ice immersions while connected to biometric sensors. Participants were randomized to immerse their dominant or non-dominant hand with VR or control (no VR) for one immersion, and then crossed-over to the other hand for the second immersion. We instructed participants to submerge their hand until they reached their pain tolerance or until four minutes elapsed.MEASUREMENTS: Outcomes included ice immersion duration, perceived pain scores, and skin conductance response density (SCRD), a marker of sympathetic arousal. We used survival analysis and mixed effects models to compare measurements with and without VR.MAIN RESULTS: 153 participants were included in the analysis. Participants with VR were 64% less likely to remove their hands from the ice bath throughout the immersion's duration compared to control (P<0.001). Participants with VR reported significantly lower pain scores after controlling for dominant hand treatment assignment, VR vs. no VR treatment order, and gender (P<0.001). SCRD increased as time progressed for both VR and control groups (P=0.047 combined), with no significant mean group differences.CONCLUSIONS: Participants with VR were more likely to survive the 4-min ice bath challenge longer and with lower levels of pain perception, supporting VR's effectiveness as a distraction tool during painful procedures. We observed no differences in sympathetic response when comparing VR to no VR.

    View details for DOI 10.1016/j.jclinane.2022.110876

    View details for PubMedID 35525050

  • Novel Utilization of Strand-Specific Reverse Transcription Polymerase Chain Reaction in Perioperative Clinical Decision Making for SARS-CoV-2 Polymerase Chain Reaction Positive Patients. Paediatric anaesthesia Jette, C. G., Wang, T., Wang, E., Man, J. Y., Mireles, S., Maass, B., Mathew, R., Pinsky, B. A., Claure, R., D'Souza, G. 2022


    In order to prevent in-hospital transmission and potential complications related to SARS-CoV-2 in the perioperative patient, most healthcare institutions require preoperative testing for SARS-CoV-2 prior to proceeding with elective surgery. The Centers for Disease Control and Prevention (CDC) recommends a time and symptom-based duration of isolation for the presumed infectious period. The guidance to avoid retesting of asymptomatic patients in the 90days following a positive reverse transcription polymerase chain reaction (RT-PCR) test is because of the possibility of detection of non-infectious viral shedding. When to reschedule asymptomatic patients who test RT-PCR positive for SARS-CoV-2 preoperatively is of considerable debate, both from the perspective of ensuring a patient's full preoperative fitness, as well as reducing the risk of viral transmission within the hospital. We describe the novel perioperative use of a strand-specific assay to detect minus strand ribonucleic acid (RNA) in a clinical decision-making algorithm to determine optimal timing of elective surgery after a patient tests RT-PCR positive for SARS-CoV-2. This is the first description in the literature of an attempt to further stratify patients who repeatedly test positive for SARS-CoV-2 into infectious versus non-infectious for perioperative planning.

    View details for DOI 10.1111/pan.14448

    View details for PubMedID 35338765

  • A Pilot Quality Improvement Project to Reduce Intraoperative MRI Hypothermia in Neurosurgical Patients. Pediatric quality & safety Wong, B. J., Rama, A., Caruso, T. J., Lee, C. K., Wang, E., Chen, M. 2022; 7 (2): e531


    Intraoperative hypothermia increases patient morbidity, including bleeding and infection risk. Neurosurgical intraoperative magnetic resonance imaging (iMRI) can lead to hypothermia from patient exposure and low ambient temperature in the MRI suite. This quality improvement project aimed to reduce the risk of hypothermia during pediatric neurosurgery laser ablation procedures with iMRI. The primary aim was to increase the mean lowest core temperature in pediatric patients with epilepsy during iMRI procedures by 1 °C from a baseline mean lowest core temperature of 34.2 ± 1.2 °C within 10 months and sustain for 10 months.Methods: This report is a single-institution quality improvement project from March 2019 to June 2021, with 21 patients treated at a pediatric hospital. After identifying key drivers, temperature-warming interventions were instituted to decrease hypothermia among patients undergoing iMRI during neurosurgery procedures. A multidisciplinary team of physicians, nurses, and MRI technologists convened for huddles before each case. Interventions included prewarmed operating rooms (ORs), blanket coverings, MRI table and room; forced-air blanket warming, temperature monitoring in the OR and iMRI environments; and the MRI fan turned off.Results: Data were analyzed for five patients before and nine patients after the institution of the temperature-warming elements. The sustainment period included 15 patients. The mean lowest intraoperative temperature rose from 34.2 ± 1.3 °C in the preintervention period to 35.5 ± 0.6 °C in sustainment (P = 0.004).Conclusion: Hybrid OR and MRI procedures increase hypothermia risk, which increases patient morbidity. Implementation of a multidisciplinary, multi-item strategy for patient warming mitigates the risk.

    View details for DOI 10.1097/pq9.0000000000000531

    View details for PubMedID 35369418

  • 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


    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

  • Real-time reorientation and cognitive load adjustment allow for broad application of virtual reality in a pediatric hospital. Journal of clinical and translational research Caruso, T. J., Fonseca, A., Barreau, A., Khoury, M., Menendez, M., Wang, E., Lawrence, K., Jackson, C., Rodriguez, S. 1800; 7 (6): 750-753


    Background: With a new generation of affordable portable virtual reality (VR), clinicians are discovering more utility for VR, while also identifying opportunities for improvement, such as the inability to reorient the horizon line during repositioning or transport, or modulate cognitive load in real time.Aim: At our institution, this lack of functionality prohibited or decreased VR usage in some clinical scenarios such as dressing changes with dynamic positioning. The purpose of this brief report is to describe the development and use of a VR application that is optimized for the healthcare setting and report historical effects of patients who utilized VR as supplement to Child Life procedures. Eligible affects per chart review included Happy, Relaxed, Anxious, Distressed, Unable to Assess.Materials and Methods: Given the need for real-time reorientation and cognitive load modulation, we created the Space Pups VR application. The experience was launched as part of the Stanford Chariot Program in the summer of 2017, and its usage was tracked through the electronic medical record and a VR application dashboard. Chart review was queried from 3 January 2018 to 9 August 2021 for pediatric patients who used VR with real-time reorientation and cognitive load modulation as a supplement to their Child Life interventions.Results: The Space Pups experience has been successfully used in a variety of settings, including perioperative care, vascular access, wound care, and ENT clinic, a total of 1696 times. Patients ranged from 6 years to 18-year old, with no reports of side effects. Significant results (P<0.001) were observed pre- and post-VR use for affect improvements in Happy, Relaxed, and Anxious, but not for Distressed.Conclusions: The ability to reorient VR experiences in real time has increased functionality where other applications have failed.Relevance for Patients: While more studies are needed to quantify the anxiolytic and pain-reducing effect of Space Pups, our report demonstrates the feasibility of this VR experience as a non-pharmacological modality to safely increase patient cooperation in a wide variety of clinical settings.

    View details for PubMedID 34988325

  • Development and assessment of an efficient pediatric affect and cooperation scale. Journal of clinical anesthesia Kennedy, K., Wang, E., Rodriguez, S. T., Qian, J., Khoury, M., Kist, M. N., Jackson, C., Yun, R., Caruso, T. J. 2021; 76: 110569


    STUDY OBJECTIVE: HRAD± was developed to quickly evaluate pediatric preprocedural affect and cooperativity during mask induction of anesthesia and peripheral intravenous (PIV) placement. HRAD± represents: Happy, Relaxed, Anxious, Distressed, with a yes/no answer to cooperativity. The primary aim of this study was to compare HRAD± to previously published scales.DESIGN: We conducted an observational study.SETTING: Videos of pediatric patients were collected in the perioperative environment.PATIENTS: Twenty-four children, twenty-one pediatric anesthesiologists and twenty pediatric perioperative providers were included.INTERVENTIONS: To assess the reliability of HRAD±, standard patient videos were created. Children underwent mask induction or PIV placement, and these interventions were video recorded. Mask induction and PIV placement videos were rated by pediatric anesthesiologists and perioperative non-physician providers respectively using HRAD±.MEASUREMENTS: Two trained researchers provided the modified Yale Preoperative Anxiety Scale (mYPAS), Observation Scale of Behavioral Distress (OSBD), and Induction Compliance Checklist (ICC) scores, and we calculated correlations to HRAD±, inter-rater reliability, and intra-rater reliability.MAIN RESULTS: HRAD± scores strongly correlated with mYPAS (r=0.846, p<0.0001) and OSBD scores (r=0.723, p<0.0001). Cooperativity scores correlated strongly with ICC scores in the mask induction group (r=-0.715, p<0.0001) and in the PIV group (r=-0.869, p<0.0001). HRAD± inter-rater reliability for mask induction was 0.414 (p<0.0001) and for PIV assessment was 0.378 (p<0.0001). Inter-rater reliability for cooperativity on mask induction was 0.797 (p<0.0001) and PIV assessment was 0.683 (p<0.0001). Intra-rater reliability for mask induction was 0.675 and PIV assessments was 0.678. Intra-rater reliability for cooperativity for mask induction was 0.894 and for PIV assessments was 0.765.CONCLUSIONS: HRAD± is an efficient and reliable scale that serves as a practical alternative for measuring pediatric affect during mask induction and PIV placement. The results demonstrate strong correlation with commonly utilized yet more complex affect scales.

    View details for DOI 10.1016/j.jclinane.2021.110569

    View details for PubMedID 34739949

  • Pre-operative fasting times for clear liquids at a tertiary children's hospital; what can be improved? Anesthesia and pain medicine Schmidt, A. R., Fehr, J., Man, J., D'Souza, G., Wang, E., Claure, R., Mendoza, J. 2021


    Background: The goal of preoperative fasting is to prevent pulmonary aspiration during general anesthesia. Fasting times are often prolonged leading to patient discomfort and risk for adverse events. This retrospective quality improvement survey evaluated effective nil-per-os (NPO) times and causes for prolonged NPO times with the aim to suggest improvement strategies by a newly founded fasting task force.Methods: Data from all electronic anesthesia records from 2019 at our institution were reviewed for fasting times. Our NPO instructions follow American Society of Anesthesiology guidelines and are calculated based on the patient's arrival time (90 min before operating room [OR] time). Primary outcome was the effective NPO time for clear liquids, secondary outcomes were incidence of delays and the parental compliance with the NPO instructions. Data are presented as median (interquartile range).Results: In total 9,625 cases were included in the analysis. NPO time was documented in 72.1% with a median effective NPO time of 7:13 h (7:36). OR in room times were documented in 72.8%, 2,075 (29.5%; median time 0:10 h [0:21]) were earlier and 4,939 (70.5%; median time 0:29 h [0:54]) were later than scheduled. Parental NPO compliance showed a median deviation for clear liquid intake of 0:55 h (8:30).Conclusions: This study revealed that effective NPO times were longer than current ASA guidelines. Contributing causes include case delays and parental non-compliance to NPO instructions. Thus, task force recommendations include change NPO instruction calculations to scheduled OR time versus arrival time, and encourage parents to give their child clear liquids at the instructed time.

    View details for DOI 10.17085/apm.21025

    View details for PubMedID 34289299

  • Integrated eye tracking on Magic Leap One during augmented reality medical simulation: a technical report BMJ SIMULATION & TECHNOLOGY ENHANCED LEARNING Caruso, T. J., Hess, O., Roy, K., Wang, E., Rodriguez, S., Palivathukal, C., Haber, N. 2021; 7 (5): 431-434
  • Association between regional anesthesia and analgesic outcomes: a single-center retrospective study of 2,761 pediatric regional anesthetics Xie, J. J., De Souza, B., Perez, F. D., Suarez-Nieto, M. V., Wang, E., Anderson, T. A. LIPPINCOTT WILLIAMS & WILKINS. 2021: 934-936
  • Transnasal Humidified Rapid-Insufflation Ventilatory Exchange (THRIVE) Use During Microdirect Laryngoscopy and Bronchoscopy: Initial Data from a Randomized, Prospective, Multi-Collaborative Trial Swanger, A., Yun, R., Olbrecht, V., Winograd, V., Evans, M. A., Stein, M., Ravula, N., Menendez, M., Wang, E., Sidell, D., Caruso, T. LIPPINCOTT WILLIAMS & WILKINS. 2021: 784-785
  • Modeling Intraoperative Opioid Administration Variation: A Single-Center Retrospective Cohort Study of Children Safranek, C., Poole, S., De Souza, B., Hong, T., Wang, E., Scheinker, D., Anderson, T. A. LIPPINCOTT WILLIAMS & WILKINS. 2021: 795-797
  • Integrated eye tracking on Magic Leap One during augmented reality medical simulation: a technical report. BMJ simulation & technology enhanced learning Caruso, T. J., Hess, O., Roy, K., Wang, E., Rodriguez, S., Palivathukal, C., Haber, N. 2021; 7 (5): 431-434


    Augmented reality (AR) has been studied as a clinical teaching tool, however eye-tracking capabilities integrated within an AR medical simulator have limited research. The recently developed Chariot Augmented Reality Medical (CHARM) simulator integrates real-time communication into a portable medical simulator. The purpose of this project was to refine the gaze-tracking capabilities of the CHARM simulator on the Magic Leap One (ML1). Adults aged 18 years and older were recruited using convenience sampling. Participants were provided with an ML1 headset that projected a hologram of a patient, bed and monitor. They were instructed via audio recording to gaze at variables in this scenario. The participant gaze targets from the ML1 output were compared with the specified gaze points from the audio recording. A priori investigators planned to iterative modifications of the eye-tracking software until a capture rate of 80% was achieved. Two consecutive participants with a capture rate less than 80% triggered software modifications and the project concluded after three consecutive participants' capture rates were greater than 80%. Thirteen participants were included in the study. Eye-tracking concordance was less than 80% reliable in the first 10 participants. The investigators hypothesised that the eye movement detection threshold was too sensitive, thus the algorithm was adjusted to reduce noise. The project concluded after the final three participants' gaze capture rates were 80%, 80% and 80.1%, respectively. This report suggests that eye-tracking technology can be reliably used with the ML1 enabled with CHARM simulator software.

    View details for DOI 10.1136/bmjstel-2020-000782

    View details for PubMedID 35515734

    View details for PubMedCentralID PMC8936533

  • Leveraging VR/AR to combat chronic pain in youth: Position paper from the Interdisciplinary Network on Virtual and Augmented (AR/VR) Technologies for Pain (INOVATE-Pain) Management. Journal of medical Internet research Logan, D. E., Simons, L. E., Caruso, T. n., Gold, J. I., Greenleaf, W. n., Griffin, A. n., King, C. n., Menendez, M. n., Olbrecht, V. n., Rodriguez, S. n., Silvia, M. n., Stinson, J. n., Wang, E. n., Williams, S. n., Wilson, L. n. 2021


    Virtual reality (VR) and augmented reality (AR) interventions are emerging as promising tools in the treatment of pediatric chronic pain conditions, but in this young field there is little consensus to guide the process of engaging in the development and evaluation of targeted VR-based interventions.The INOVATE-Pain consortium aims to advance the field of VR for pediatric chronic pain rehabilitation by providing guidance for best practices in the design, evaluation, and dissemination of VR-based interventions targeting this population.An interdisciplinary meeting of 16 academics, clinicians, industry and philanthropy partners was held in January 2020.Reviewing the state of the field, the consortium identified important directions for research-driven innovation in VR/AR clinical care, highlighted key opportunities and challenges facing the field, and established a consensus on best methodological practices to adopt in future efforts to advance the research and practice of VR/AR in pediatric pain. The consortium also identified important next steps to undertake to continue to advance the work in this promising new area of digital health pain interventions.To realize the promise of this realm of innovation, key ingredients for the success include productive partnerships among industry, academic, and clinical stakeholders, a uniform set of outcome domains and measures for standardized evaluation, and widespread access to the latest opportunities, tools and resources. The INOVATE-Pain collaborative hopes to promote the creation, rigorous yet efficient evaluation, and dissemination of innovative VR-based interventions to reduce pain and improve quality of life for children.

    View details for DOI 10.2196/25916

    View details for PubMedID 33667177

  • Virtual reality for pediatric periprocedural care. Current opinion in anaesthesiology Wang, E. n., Thomas, J. J., Rodriguez, S. T., Kennedy, K. M., Caruso, T. J. 2021; 34 (3): 284–91


    Commercial availability of virtual reality headsets and software has exponentially grown over the last decade as it has become more sophisticated, less expensive, and portable. Although primarily used by the general public for entertainment, virtual reality has been adopted by periprocedural clinicians to improve patient experiences and treatments. The purpose of this review is to explore recently reported evidence for virtual reality effectiveness for pediatric periprocedural care and discuss considerations for clinical implementation.In the preprocedure setting, practitioners use virtual reality to introduce children to periprocedural environments, distract attention from preprocedural vascular access, and increase cooperation with anesthesia induction. Intraprocedure, virtual reality decreases sedation requirements, and in some instances, eliminates anesthesia for minor procedures. Virtual reality also augments pain reduction therapies in the acute and extended rehabilitation periods, resulting in faster recovery and improved outcomes. Virtual reality seems to be well treated for pediatric use, given close clinical care and carefully curated content.Given the multiple clinical applications of virtual reality to supplement pediatric periprocedural care, practitioners should consider developing clinical programs that reliably provide access to virtual reality. Future research should focus on identification of patient characteristics and types of software that yield optimal patient outcomes.

    View details for DOI 10.1097/ACO.0000000000000983

    View details for PubMedID 33935176

  • Virtual Reality Augments Movement during Physical Therapy: A Pragmatic Randomized Trial. American journal of physical medicine & rehabilitation Hemphill, S. n., Rodriguez, S. n., Wang, E. n., Koeppen, K. n., Aitken-Young, B. n., Jackson, C. n., Simons, L. n., Caruso, T. J. 2021


    Virtual reality (VR) facilitates physical therapy (PT) via improved engagement. While shown to benefit specific patient populations, such as stroke patients, it is less established in otherwise healthy adults and children receiving outpatient PT. The primary objective was to compare total PT-guided Movement supplemented with VR (PTMVR) to PT guided Movement alone, without VR (PTM).This pragmatic, randomized, crossover study compared PTMVR to PTM in outpatients (ages 6-80). This community sample had variable PT indications (injury, postoperative, chronic pain) and in preexisting conditions, therefore participants served as their own controls. Participants received 10 minutes of both PTMVR and PTM, separated by five minutes. The primary outcome was differences in aggregate movement of PT guided exercises. Secondary outcomes explored OMNI rating of perceived exertion (RPE) and participant and physical therapist satisfaction. Paired t-tests, chi-squared tests, and regression models were used to analyze differences.The 41 participants (17 pediatric and 24 adult) moved significantly more during PTMVR compared to PTM (1120.88 meters vs 672.65 meters p < 0.001), regardless of which intervention was completed first. PTMVR treatment was associated with more movement of the target limbs, lower-body (p < 0.001), upper-body (p <0.05). OMNI RPE scores did not differ between those who started with PTMVR or PTM, and physical therapist and patient surveys endorsed PTMVR.Patients completed more PT guided movement during PTMVR than PTM and therapists and patients supported its use. Future studies will examine finer tracking of movements.

    View details for DOI 10.1097/PHM.0000000000001779

    View details for PubMedID 33935153

  • Virtual Reality Facilitates Engagement in Physical Therapy in the Pediatric CVICU. Pediatric physical therapy : the official publication of the Section on Pediatrics of the American Physical Therapy Association Hemphill, S. n., Nguyen, A. n., Kwong, J. n., Rodriguez, S. T., Wang, E. n., Caruso, T. J. 2021; 33 (1): E7–E9


    The purpose of this report is to demonstrate the successful application of virtual reality to improve physical therapy in the pediatric cardiovascular intensive care unit. Early mobilization and cognitive stimulation improve morbidity of critically ill children. However, maintaining child engagement with these therapies can be challenging, especially during extended intensive care stays.While virtual reality has been successfully used as an analgesic and anxiolytic in the cardiovascular intensive care unit, this report demonstrates its novel use as a tool to augment physical therapy for a child who had been debilitated after heart transplantation. Virtual reality encouraged the child to engage in physical therapy sessions, participate for greater durations, and directly address barriers to discharge.While further studies are needed to define best practice, this report demonstrates that virtual reality can be safely used for carefully selected and monitored children in critical care.

    View details for DOI 10.1097/PEP.0000000000000769

    View details for PubMedID 33337780

  • 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; 131 (4): 1237-1248


    Long-term opioid use has negative health care consequences. Opioid-naïve 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.Using a national administrative claims database, we identified 175,878 surgical visits by opioid-naïve 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.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.Some patient characteristics and surgeries are positively and negatively associated with prolonged opioid use in opioid-naïve 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 32925345

  • 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


    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

  • A Retrospective Cohort Study of Predictors and Interventionsthat Influence Cooperation with Mask Induction in Children. Paediatric anaesthesia Marquez, J. L., Wang, E., Rodriguez, S. T., O'Connell, C., Munshey, F., Darling, C., Tsui, B., Caruso, J., Caruso, T. J. 2020


    BACKGROUND: Uncooperative pediatric mask induction is linked to perioperative anxiety. Although some risk factors for uncooperative inductions have been reported, there are no large cohort studies that identify intrinsic patient characteristics associated with cooperation.AIM: The primary aim was to identify patient characteristics associated with cooperative mask inductions. The secondary aim was to determine whether preoperative interventions were associated with increased cooperation.METHODS: This retrospective cohort study included patients 2 -11 years old and ASA class I-IV who underwent mask induction. Our primary outcome of interest was cooperation with mask induction, which was correlated against the Induction Compliance Checklist. The variables analyzed for association with cooperation were age, sex, ASA class, class of surgery, preferred language, and race. Interventions examined for association with induction cooperation included premedication with midazolam, exposure to distraction technology, parental presence, and the presence of a Child Life Specialist. Multivariate mixed effects logistic regression was used to assess the relationship between patient characteristics and cooperation. A separate multivariate mixed effects logistic regression was used to examine the association between preoperative interventions and cooperation.RESULTS: 9,692 patients underwent 23,474 procedures during the study period. 3,372 patients undergoing 5,980 procedures met inclusion criteria. The only patient characteristic associated with increased cooperation was age (OR 1.20, p-value 0.03). Involvement of Child Life Specialists was associated with increased cooperation (OR 4.44, p-value = 0.048) while parental/guardian presence was associated with decreased cooperation (OR 0.38, p-value = 0.002).CONCLUSION: In this cohort, increasing age was the only patient characteristic found to be associated with increased cooperation with mask induction. Preoperative intervention by a Child Life Specialists was the sole intervention associated with improved cooperation.

    View details for DOI 10.1111/pan.13930

    View details for PubMedID 32452092

  • A Quality Improvement Project to Reduce Combination Acetaminophen-opioid Prescriptions to Pediatric Orthopedic Patients. Pediatric quality & safety Caruso, T. J., Trivedi, S., Chadwick, W., Gaskari, S., Wang, E., Marquez, J., Lagasse, S., Bailey, M., Shea, K. 2020; 5 (3): e291


    Background: Acetaminophen-opioid analgesics are among the most commonly prescribed pain medications in pediatric orthopedic patients. However, these combined opioid analgesics do not allow for individual medication titration, which can increase the risk of opioid misuse and hepatoxicity from acetaminophen. The primary aim of this quality improvement project was to alter the prescribing habits of pediatric orthopedic providers at our institution from postoperative acetaminophen-opioid analgesics to independent acetaminophen and opioids.Methods: The study took place in a level 1 trauma center at a children's hospital. A multidisciplinary team of health professionals utilized lean methodology to develop a project plan. Guided by a key driver diagram, we removed acetaminophen-oxycodone products from hospital formulary, implemented a revised inpatient and outpatient electronic order set, and conducted multiple education efforts. Outcomes included inpatient and outpatient percent combined acetaminophen-opioid orders by surgical providers over 27 months.Results: Before the intervention, inpatient acetaminophen-opioid products accounted for an average of 46% of all opioid prescriptions for orthopedic patients. After the intervention and multiple educational efforts, we reported a reduction in the acetaminophen-opioid products to 2.9%. For outpatient prescriptions, combined analgesics accounted for 88% before the intervention, and we reported a reduction to 15% after the intervention.Conclusions: By removing acetaminophen-oxycodone products from hospital formulary, educating the medical staff, and employing revised electronic order sets, the prescribing practice of pediatric orthopedic surgeons changed from the routine use of acetaminophen-opioid analgesics to independent medications.

    View details for DOI 10.1097/pq9.0000000000000291

    View details for PubMedID 32607456

  • Augmented Reality as a Tool to Reduce Fear and Promote Cooperation During Pediatric Nasal Endoscopy Madill, M., Caruso, T. J., Sidell, D., Meister, K., Wang, E., Menendez, M., Rodriguez, S. LIPPINCOTT WILLIAMS & WILKINS. 2020
  • Association Of Race and Ethnicity with Postoperative Analgesic Administration and Pain Scores in Pediatric Patients: A Single-Center Study of 29,614 Surgical Cases Perez, F. D., De Souza, B., Wang, E., Rosenbloom, J. M., Anderson, T. A. LIPPINCOTT WILLIAMS & WILKINS. 2020: 680–81
  • Quantifying Virtual Reality Pain Modulation in Healthy Volunteers through Ice Immersion Neiman, N., Hemphill, S., Lawrence, K., Khoury, M., Kist, M., Menendez, M., Rodriguez, S., Wang, E., Caruso, T. LIPPINCOTT WILLIAMS & WILKINS. 2020: 585–86
  • Reducing Anxiety, Fear, and Pain with Virtual Reality in Pediatric Outpatient Orthopedic Clinic Kist, M., Neiman, N., Khoury, M., Hastings, K., Menendez, M., Wang, E., Caruso, T., Rodriguez, S. LIPPINCOTT WILLIAMS & WILKINS. 2020: 707
  • Association between regional anesthesia and analgesic outcomes: a single-center retrospective study of 2038 pediatric regional anesthetics Xie, J. J., De Souza, B., Wang, E., Anderson, T. A. LIPPINCOTT WILLIAMS & WILKINS. 2020: 862–63
  • Retrospective Review of the Safety and Efficacy of Virtual Reality in a Pediatric Hospital. Pediatric quality & safety Caruso, T. J., O'Connell, C., Qian, J. J., Kung, T., Wang, E., Kinnebrew, S., Pearson, M., Kist, M., Menendez, M., Rodriguez, S. T. 2020; 5 (2): e293


    Introduction: Virtual reality (VR) is an emerging tool for anxiety and fear reduction in pediatric patients. VR use is facilitated by Certified Child Life Specialists (CCLS) at pediatric hospitals. The primary aim of this study was to retrospectively review the safety of VR by analyzing adverse events after the utilization of VR under CCLS supervision. Secondary objectives were to characterize the efficacy of VR in enhancing patient cooperation, describe the integration of VR into Child Life services, and identify interventions that accompanied VR.Methods: The Stanford Chariot Program developed VR applications, customized VR interfaces, and patient head straps, and distributed these to CCLS. Chart review analyzed VR utilization through CCLS patient notes. Inclusion criteria were all patients ages 6 to 18-years-old who received a Child Life intervention.Results: From June 2017 to July 2018, 31 CCLS saw 8,098 patients, 3,696 of which met age criteria with pre- and post-intervention cooperation data. Two hundred thirteen patients received VR with an accompanying intervention, while 34 patients received only VR. Adverse events were rare, and included increased anxiety (3.8%, n=8), dizziness (0.5%, n=1), and nausea (0.5%, n=1). Patients were more likely to be cooperative after receiving VR (99.5%, n=212) compared to pre-intervention (96.7%, n=206, p=0.041). VR use was most common in the perioperative setting (60%, n=128), followed by outpatient clinics (15%, n=32).Conclusion: VR is safe in pediatric patients with appropriate hardware, software, and patient selection. Side effects were rare and self-limited. VR appears to be associated with improvements in cooperation.

    View details for DOI 10.1097/pq9.0000000000000293

    View details for PubMedID 32426648

  • Mobilization and calibration of the HTC VIVE for virtual reality physical therapy. Digital health Hemphill, S., Nguyen, A., Rodriguez, S. T., Menendez, M., Wang, E., Lawrence, K., Caruso, T. J. 2020; 6: 2055207620950929


    Aims: The HTC VIVE virtual reality (VR) system is a potential tool for collecting kinematic data during inpatient and outpatient physical therapy (PT). When validated against research-grade systems, the VIVE has a reported translational error between 1.7mm-2.0cm. Our purpose was to portabilize the VIVE for room to room PT and validate the motion tracking software.Methods: The VIVE was configured on a mobile cart. To validate the motion tracking software, the VIVE sensors (motion tracker, controller, headset) were mounted on a rigid linear track and driven through 10, one-meter translations in the X, Y, and Z axes.Results: The mean translational error for all three sensors was below 4.9cm. While error is greater than that reported for research-grade systems, motion tracking software on the portable VIVE unit appears to be a valid means of tracking aggregate movement.Conclusion: Some therapy may require more precise measurements, however, the advantages of portability and accessibility to patients may outweigh the limitation of reduced precision.

    View details for DOI 10.1177/2055207620950929

    View details for PubMedID 32963801

  • State of the art in clinical decision support applications in pediatric perioperative medicine. Current opinion in anaesthesiology Wang, E. n., Brenn, B. R., Matava, C. T. 2020


    The goal of this review is to describe the recent improvements in clinical decision tools applied to the increasingly large and complex datasets in the pediatric ambulatory and inpatient setting.Clinical decision support has evolved beyond simple static alerts to complex dynamic alerts for: diagnosis, medical decision-making, monitoring of physiological, laboratory, and pharmacologic inputs, and adherence to institutional and national guidelines for both the patient and the healthcare team. Artificial intelligence and machine learning have enabled advances in predicting outcomes, such as sepsis and early deterioration, and assisting in procedural technique.With more than a decade of electronic medical data generation, clinical decision support tools have begun to evolve into more sophisticated and complex algorithms capable of transforming large datasets into succinct, timely, and pertinent summaries for treatment and management of pediatric patients. Future developments will need to leverage patient-generated health data, integrated device data, and provider-entered data to complete the continuum of patient care and will likely demonstrate improvements in patient outcomes.

    View details for DOI 10.1097/ACO.0000000000000850

    View details for PubMedID 32324659

  • Introduction of the EMR-integrated I-PASS ICU Handoff Tool. Pediatric quality & safety Caruso, T. J., Su, F. n., Wang, E. n. 2020; 5 (4): e334

    View details for DOI 10.1097/pq9.0000000000000334

    View details for PubMedID 32766505

    View details for PubMedCentralID PMC7382550

  • Using Augmented Reality to Reduce Fear and Promote Cooperation During Pediatric Otolaryngologic Procedures. The Laryngoscope Caruso, T. J., Madill, M. n., Sidell, D. n., Meister, K. n., Wang, E. n., Menendez, M. n., Kist, M. N., Rodriguez, S. n. 2020


    This case series examines interactive AR during minor otolaryngologic procedures. Although VR has been successfully used for pediatric vascular access, removing children from comforting people in the real world has resulted in patient anxiety. AR offers a potential advantage, utilizing distracting holographic images when patients maintain eye contact with parents. The primary objective was to determine the effect of AR on fear during pediatric otolaryngologic procedures. Secondary objectives included evaluating pain; procedure compliance; and patient, parent and physician attitudes toward AR, as well as assessing the feasibility of adding AR to a busy outpatient otolaryngologic clinic. Laryngoscope, 2020.

    View details for DOI 10.1002/lary.29098

    View details for PubMedID 32886794

  • A Pilot Quality Improvement Project to Reduce Preoperative Fasting Duration in Pediatric Inpatients. Pediatric quality & safety Nye, A., Conner, E., Wang, E., Chadwick, W., Marquez, J., Caruso, T. J. 2019; 4 (6): e246


    Despite guidelines allowing clear liquids up to 2 hours before anesthesia, preoperative fasting for pediatric inpatients is often unnecessarily prolonged. This delay can lead to prolonged recovery time and increased postoperative pain. Efforts to reduce fasting duration in pediatric surgical patients is an evolving standard in pediatric anesthesiology. The primary aim of this quality improvement project was to reduce the average inpatient fasting duration undergoing anesthesia by 25% within a year of our pilot intervention. Secondary aims included measuring the adoption rate of the intervention and comparing aspiration rates as a balancing measure.Methods: At an academic pediatric hospital, we created the preanesthesia diet order, a standardized, clear liquid diet for eligible inpatients undergoing anesthesia to decrease preoperative fasting duration. After implementation in January 2018, a statistical process control chart was used to measure the fasting duration of all eligible inpatients by month, and the Wilcoxon rank-sum test assessed differences. A Poisson test was used to determine differences in aspiration rates.Results: Over the first year of our pilot intervention, 127 inpatients received the preanesthesia diet. The average fasting duration before its implementation was 12.5 and 5.7 hours postimplementation. The average adoption rate for eligible inpatients was 17.6%, and there was no difference in aspiration rates.Conclusion: This quality improvement project demonstrated that a standardized, clear liquid diet on the morning of surgery could reduce preoperative fasting times among pediatric inpatients. The adoption of this pilot intervention was limited, highlighting the challenges of implementing a practice change.

    View details for DOI 10.1097/pq9.0000000000000246

    View details for PubMedID 32010870

  • A multifaceted quality improvement project improves intraoperative redosing of surgical antimicrobial prophylaxis during pediatric surgery PEDIATRIC ANESTHESIA Colletti, A. A., Wang, E., Marquez, J. L., Schwenk, H. T., Yeverino, C., Sharek, P. J., Caruso, T. J. 2019; 29 (7): 705–11

    View details for DOI 10.1111/pan.13651

    View details for Web of Science ID 000478990900006

  • INCIDENCE OF PERSISTENT OPIOID USE IN CHILDREN AFTER SURGERY Anderson, T. A., Ward, A. T., De Souza, B., Wang, E., Miller, D., Bambos, N. LIPPINCOTT WILLIAMS & WILKINS. 2019: 764–65
  • Intraoperative antibiotic redosing compliance and the extended postoperative recovery period: Often overlooked areas that may reduce surgical site infections PEDIATRIC ANESTHESIA Caruso, T. J., Wang, E. Y., Colletti, A. A., Sharek, P. J. 2019; 29 (3): 290-291

    View details for DOI 10.1111/pan.13568

    View details for Web of Science ID 000459789900014

  • Differential Lung Ventilation Using a Bronchial Blocker in a Pediatric Patient on Extracorporeal Membrane Oxygenation: A Case Report. A&A practice Bhargava, V. n., Arastu, A. n., Darling, C. n., Wang, E. n., Kache, S. n. 2019


    We describe a patient with acute on chronic respiratory failure after a cardiac arrest who was cannulated to venoarterial extracorporeal membrane oxygenation. The patient developed right-sided interstitial emphysema with air leak and left-sided hemothorax with secondary atelectasis. A differential lung ventilation strategy was used in which an endotracheal tube was placed in the left main stem bronchus and a bronchial blocker was placed in the right mainstem bronchus. The patient's overall pulmonary function improved, and he was successfully decannulated from extracorporeal membrane oxygenation. In conclusion, differential lung ventilation may be performed in patients on extracorporeal membrane oxygenation with disparate lung disease as an alternative ventilation strategy.

    View details for DOI 10.1213/XAA.0000000000001025

    View details for PubMedID 31162224

  • 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


    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

  • Anesthesiologist Surgery Assignments Using Policy Learning Ward, A., Zhou, Z., Bambos, N., Scheinker, D., Wang, E., IEEE IEEE. 2019
  • Programmed Intermittent Bolus Regimen for Erector Spinae Plane Blocks in Children: A Retrospective Review of a Single-Institution Experience. Anesthesia and analgesia Munshey, F., Caruso, T. J., Wang, E. Y., Tsui, B. C. 2018


    With few published reports on erector spinae plane block use in children, limited guidance on perioperative local anesthetic dosing exists. We present a series of 22 patients who received erector spinae plane catheters with programmed intermittent bolus for various surgeries. Median loading dose of 0.4 mL/kg (interquartile range [IQR], 0.1 mL/kg) ropivacaine 0.5%, intraoperative bolus of 0.3 mL/kg/h (IQR, 0.1 mL/kg) ropivacaine 0.2%, and a postoperative programmed intermittent bolus regimen of maximum 0.6 mg/kg/h resulted in highest pain scores on postoperative day 1 with a median score of 1.7 of 10 (IQR, 1.8) and highest morphine equivalents consumed on postoperative day 2 with a median score of 0.16 mg/kg up to 120 hours after surgery.

    View details for DOI 10.1213/ANE.0000000000003817

    View details for PubMedID 30252704

  • A Retrospective Review of a Bed-mounted Projection System for Managing Pediatric Preoperative Anxiety. Pediatric quality & safety Caruso, T. J., Tsui, J. H., Wang, E., Scheinker, D., Sharek, P. J., Cunningham, C., Rodriguez, S. T. 2018; 3 (4): e087


    Introduction: Most children undergoing anesthesia experience significant preoperative anxiety. We developed a bedside entertainment and relaxation theater (BERT) as an alternative to midazolam for appropriate patients undergoing anesthesia. The primary aim of this study was to determine if BERT was as effective as midazolam in producing cooperative patients at anesthesia induction. Secondary aims reviewed patient emotion and timeliness of BERT utilization.Methods: We conducted a retrospective cohort study of pediatric patients undergoing anesthesia at Lucile Packard Children's Hospital Stanford between February 1, 2016, and October 1, 2016. Logistic regression compared induction cooperation between groups. Multinomial logistic regression compared patients' emotion at induction. Ordinary least squares regression compared preoperative time.Results: Of the 686 eligible patients, 163 were in the BERT group and 150 in the midazolam. Ninety-three percentage of study patients (290/313) were cooperative at induction, and the BERT group were less likely to be cooperative (P = 0.04). The BERT group was more likely to be "playful" compared with "sedated" (P < 0.001). There was a reduction of 14.7 minutes in preoperative patient readiness associated with BERT (P = 0.001).Conclusions: Although most patients were cooperative for induction in both groups, the midazolam group was more cooperative. The BERT reduced the preinduction time and was associated with an increase in patients feeling "playful."

    View details for PubMedID 30229198

  • Intraoperative antibiotic redosing compliance and the extended postoperative recovery period: often overlooked areas that may reduce surgical site infections. Paediatric anaesthesia Caruso, T. J., Wang, E. n., Colletti, A. A., Sharek, P. J. 2018


    It was with great interest that we read Compliance with perioperative prophylaxis guidelines and the use of novel outcome measures by Morse, et al.1 The authors should be applauded for presenting a well-balanced review of the rationale behind the use of prophylactic antibiotics, data supporting dosing intervals, and potential outcome measures. This article is protected by copyright. All rights reserved.

    View details for PubMedID 30592343

  • Enhancing pediatric airway safety using the electronic medical record. The Laryngoscope Rameau, A. n., Wang, E. n., Saraswathula, A. n., Pageler, N. n., Perales, S. n., Sidell, D. R. 2018


    Difficult intubations are not uncommon in tertiary care children's hospitals, and effective documentation of the difficult airway is a fundamental element of safe airway management. The primary goal of our quality improvement initiative was to improve access to airway information via an alert and documentation system within the electronic medical record (EMR).We created a difficult airway alert within the EMR, linking common airway evaluation templates used by specialists involved in airway management. We assessed the time required for different specialists to answer an airway information questionnaire using the electronic charts of patients before and after the EMR modification. Satisfaction with the EMR modification was also surveyed.Questionnaires were administered to 12 participants before the Epic (Epic Systems Corp., Verona, WI) changes were implemented and to 19 participants after they were implemented. Each participant was asked to answer the airway data questionnaire for two patients, for a total of 24 questionnaires before the EMR changes and 38 questionnaires after the changes. Respondents averaged 7.24 minutes to complete the entire airway data questionnaire before the EMR changes and 3.16 minutes following modification (P < 0.0001). Correct airway information was more consistently collected with the modified EMR (98.6% vs 51.4%, P < 0.00001). Satisfaction surveys revealed that participants found the accessibility of airway data to be significantly improved following the EMR changes.An EMR airway alert that provides rapid access to relevant airway information critical tool during urgent and emergent events. Based on our preliminary data, further use of this instrument is expected to continue to improve patient safety and practitioner satisfaction.4. Laryngoscope, 2018.

    View details for PubMedID 30195274

  • A Postoperative Care Bundle Reduces Surgical Site Infections in Pediatric Patients Undergoing Cardiac Surgeries. Joint Commission journal on quality and patient safety Caruso, T. J., Wang, E. Y., Schwenk, H. n., Marquez, J. L., Cahn, J. n., Loh, L. n., Schaffer, J. n., Chen, K. n., Wood, M. n., Sharek, P. J. 2018


    Pediatric patients undergoing cardiac surgeries are at an increased surgical site infection (SSI) risk, given prolonged cardiopulmonary bypasses and delayed sternal closures. At one institution, the majority of cardiac patients developed SSIs during prolonged recoveries in the cardiovascular intensive care unit (CVICU). Although guidelines have been published to reduce SSIs in the perioperative period, there have been few guidelines to reduce the risk during prolonged hospital recoveries. The aim of this project was to study a postoperative SSI reduction care bundle, with a goal of reducing cardiac SSIs by 50%, from 3.4 to 1.7 per 100 procedures.This project was conducted at a quaternary, pediatric academic center with a 20-bed CVICU. Historical control data were recorded from January 2013 through May 2015 and intervention/sustainment data from June 2015 through March 2017. A multidisciplinary SSI reduction team developed five key drivers that led to implementation of 11 postoperative SSI reduction care elements. Statistical process control charts were used to measure process compliance, and Pearson's chi-square test was used to determine differences in SSI rates.Prior to implementation, there were 27 SSIs in 799 pediatric cardiac surgeries (3.4 SSIs per 100 surgeries). After the intervention, SSIs significantly decreased to 5 in 570 procedures (0.9 SSIs per 100 surgeries; p = 0.0045).This project describes five key drivers and 11 elements that were dedicated to reducing the risk of SSI during prolonged CVICU recoveries from pediatric cardiac surgery, with demonstrated sustainability.

    View details for DOI 10.1016/j.jcjq.2018.05.009

    View details for PubMedID 30170753

  • A quality improvement initiative to optimize dosing of surgical antimicrobial prophylaxis. Paediatric anaesthesia Caruso, T. J., Wang, E., Schwenk, H. T., Scheinker, D., Yeverino, C., Tweedy, M., Maheru, M., Sharek, P. J. 2017; 27 (7): 702-710


    The risk of surgical site infections is reduced with appropriate timing and dosing of preoperative antimicrobials. Based on evolving national guidelines, we increased the preoperative dose of cefazolin from 25 to 30 mg·kg(-1) . This quality improvement project describes an improvement initiative to develop standard work processes to ensure appropriate dosing.The primary aim was to deliver cefazolin 30 mg·kg(-1) to at least 90% of indicated patients. The secondary aim was to determine differences between accuracy of cefazolin doses when given as an electronic order compared to a verbal order.Data were collected from January 1, 2012 to May 31, 2016. A quality improvement team of perioperative physicians, nurses, and pharmacists implemented a series of interventions including new electronic medical record order sets, personal provider antibiotic dose badges, and utilization of pharmacists to prepare antibiotics to increase compliance with the recommended dose. Process compliance was measured using a statistical process control chart, and dose compliance was measured through electronic analysis of the electronic medical record. Secondary aim data were displayed as percentage of dose compliance. An unpaired t-test was used to determine differences between groups.Between January 1, 2012 and May 31, 2016, cefazolin was administered to 9086 patients. The mean compliance of cefazolin at 30 mg·kg(-1) from May 2013 to March 2014 was 40%, which prompted initiation of this project. From April 2014 to May 2016, a series of interventions were deployed. The mean compliance from September 2015 to May 2016 was 93% with significantly reduced variation and no special cause variation, indicating that the process was in control at the target primary aim. There were 649 cefazolin administrations given verbally and 1929 given with an electronic order between October 1, 2014 and May 31, 2016. During this time period, the rate of compliance of administering cefazolin at 30 mg·kg(-1) was significantly higher when given after an electronic order than when given verbally, 94% vs 76%.This comprehensive quality improvement project improved practitioner compliance with evidence-based preoperative antimicrobial dosing recommendations to reduce the risk of surgical site infections.

    View details for DOI 10.1111/pan.13137

    View details for PubMedID 28321988

  • A Novel Bed-Mounted Projection System is as Effective as Pharmacologic Modalities to Treat Pediatric Preoperative Anxiety Caruso, T. J., Rodriguez, S., Wang, E., Terajewicz, A., Brockington, D., Cunningham, C., Sharek, P. J., Marquez, J. LIPPINCOTT WILLIAMS & WILKINS. 2017: 23–25