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January - February 2023

This issue of Journal Watch features over 30 reviews collated from the Westmead Children's and Sydney Children's hospitals.

Anaesthesia & Intensive Care Medicine

Submitted July 2023 by Dr Ian Miles

Read by 185 Journal Watch subscribers

This article presents the results of an audit of blank anaesthetic charts from 132 hospitals accredited for training by ANZCA. The charts were evaluated for 17 data fields describing tracheal intubation, supraglottic airway use and bag-mask ventilation, with the intent of assessing how useful the charts might be in documenting which airway techniques worked, and which ones did not. The median number of prompts, of the 17 fields examined, was 7 (range 0 – 15).
The discussion highlighted that the relevant College document (PG06) does not specify what details of airway management should be included on an anaesthetic record. Of the charts audited, the main focus related to tracheal intubation, with less information and details relating to SGA or BMV.

Commentary
While this article is not specifically paediatric in nature, it does provide food for thought on how useful the anaesthetic records of our own institutions are in making it easy to document any airway difficulties experienced and how they were resolved, with an eye to assisting a future anaesthetist caring for the same patient.

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A cohort study

Pediatric Anesthesia

Submitted July 2023 by Dr Ian Miles

Read by 137 Journal Watch subscribers

Report of a single centre, retrospective, case–control study comparing complications after anaesthesia within 90 days of a known positive PCR, as compared to matched controls. The study period was between January 3–October 7, 2020. The complications looked for were at the serious end of the scale (unexplained escalation in care <48hrs post anaesthesia, cardiac, respiratory, thrombotic, and haemorrhagic events within 30 days), in addition to 30- day
mortality and hospital length of stay. The cohort included 114 patients who were PCR positive, and 227 controls matched to age and type of surgery. The risk of postoperative complications was not increased in patients who had a positive PCR test more that 7 days prior to anaesthesia compared to matched controls.

Commentary
The low rate of complications in paediatric patients having anaesthesia more than 7 days after a positive PCR is reassuring. The sample size appears to be too small to assess the risk of the most severe (and rare) complications (e.g. death). Much has changed in terms of circulating variants since this data was collected early in the pandemic.

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19 testing at pediatric institutions - Current practice

Pediatric Anesthesia

Submitted July 2023 by Dr Ian Miles

Read by 138 Journal Watch subscribers

Results of a survey sent to US paediatric institutions to explore the pre-operative testing protocols in use at the time (Feb 2022, repeated June 2022). The results from 27/62 (44%) responding institutions were collated. The major change was a move away from PCR testing only (69% --> 52%) and towards protocols involving both PCR and RAT (27% --> 44%)

Commentary
Now a little old and insufficiently detailed to allow direct comparison with current pre-operative testing protocols here in A&NZ, it does demonstrate that processes have continued to be adapted as testing availability and other associated issues (eg. PPE availability) change. Outcome data relating to these changes are lacking.

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Far from over

The Lancet

Submitted July 2023 by Dr Ian Miles

Read by 122 Journal Watch subscribers

Presents a reasonably current (Jan 2023) perspective from China, detailing the Dec 2022-Jan 2023 rise in COVID infections. Some of the reasons are outline (policy changes dropping most of the previous restrictions, inadequate vaccination rates in vulnerable groups including the elderly (prompting efforts to roll out more vaccines), and anticipated mass internal movement of people for Chinese New Year. The effects on a struggling health system are obvious, but numbers of deaths are hard to come by. The variants common in China now are the same as those circulating in Europe and beyond, in populations having higher levels of immunity. New variants with even higher potential for spread are circulating in the US, although the rates of severe disease so far do not seem to be increasing.

Commentary
Worth reading as brief summary of the current state of COVID infections elsewhere in the world, with the clear message that COVID is not over.

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The Lancet

Submitted January 2023 by Dr Andrew Weatherall

Read by 132 Journal Watch subscribers

The Bottom Line
This editorial adds little to the climate change discussion that any member of the general public has not already had a chance to consider. There is little doubt most readers can find a more productive use of their time, particularly if they are concerned about the need for climate action.

Type of Article
Editorial/comment.

Brief Summary
This article reproduces a large number of facts and figures that will feel familiar to anyone who has read any coverage of a multitude of IPCC reports while browsing a weekend media story. There is nothing new here. There is nothing new about the size of the problem, the urgency to act or potential options that can happen. The deeply disappointing thing is that there is plentiful evidence that seeking to influence the population’s perspective on
climate change by adding more numbers to address a knowledge deficit fails as a science communication strategy.
This is as well established as the science around climate change itself. Given the editorial space in The Lancet, the opportunity has been taken to write an article that will add nothing for those already concerned about climate change, while having no influence on those who do not presently see the urgency to act.

What is the point? If you are deeply concerned that urgent global action is needed, why keep communicating using methods that we know perpetually fail?

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A call to action

The Lancet

Submitted January 2023 by Dr Andrew Weatherall

Read by 137 Journal Watch subscribers

The Bottom Line
It is likely that paediatric anaesthetists are already on board with the message that more effort is required to address the needs of children with disabilities across the global health space and this is well written. It may lead to a momentary feeling of ‘yes, that is an excellent way of arguing for this important thing’ but it is unlikely to result in a change in what the reader does – unless the reader is part of the World Bank Group who are at the core of the
appeal for action.

Type of Article
Editorial/comment.

Brief Summary
This is an informative editorial comment piece that provides solid data and context to demonstrate the huge gap between global health efforts to address the needs of children with disabilities and the actual commitments required to deal with the issue. The data chosen is comprehensive and provides a well-rounded perspective including highlighting the importance of education as part of the mix. The authors clearly display their expertise, are members of the Global Research on Developmental Disabilities Collaborators and have lived experience of disability.

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An educational review and a call to action

Pediatric Anesthesia

Submitted January 2023 by Dr Andrew Weatherall

Read by 132 Journal Watch subscribers

The Bottom Line
This is a comprehensive summary of an important topic that provides concrete steps for the practitioner to consider to enhance patient safety.

Type of Article
Educational review.

Summary
This educational review provides a broad review of a significant issue followed by specific recommendations for measures that can be taken to improve medication safety. There is a clear summary of the contributors to medication error in the anaesthesia context, and the review specifically addresses the contributors to a higher risk of medication error in the paediatric setting.

Suggested targets for improving safety cover a range of steps in medication administration including ordering, preparation of medications, standardisation, and delivery of infusions. There is also a section covering human factors which is valuable but less able to describe specific measures that have a strong evidence-base.

If there is one issue with some of the suggestions it is that many of the examples are likely to be more available in higher resource institutions but impractical for many settings. Solutions such as point-of-care barcode scanning, smart library infusion pumps and centralised pharmacy preparation may seem a distant shadow on the horizon for some. However, the authors are upfront about this and the underlying principles are sound. There is plenty to chew on in this read.

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A Retrospective Cohort Study.

Anesthesia Analgesia

Submitted January 2023 by Dr David Sainsbury

Read by 132 Journal Watch subscribers

This was a retrospective matched cohort study examining the prevalence of opioid use disorder (OUD) in 10 to 18-year-olds and the association with post-operative outcomes over a 15-year period from 2004-2019. The study extracted data from the ‘pediatric health information system’ which is an administrative hospital database used in
over 50 not-for-profit, US tertiary-care paediatric hospitals. Patients were identified as having opioid use disorder using a previously identified algorithm based on ICD-9 and ICD-10 coding.

The primary outcome was inpatient mortality with secondary outcomes including a range of post-operative outcomes including surgical complications, infections, ICU admission and prolonged length of stay. The study found that OUD had continued to increase year on year over the 15-year period despite increased awareness of opioid misuse in the US. The study also found that while mortality was not increased, multiple other outcomes were worse in the OUD cohort. These include ICU admission (RR 2.66 95%CI 2.07-3.40), surgical complications (RR 1.57 95%CI 1.24-2.00), post-operative infection (RR 2.02 95%CI 1.62-2.51), ventilation (RR 3.45 95%CI 2.71-4.40) and increased LOS with RR 2.53 95%CI 1.89-3.38).

Discussion
The authors identify the limitations of this type of retrospective study but accurately acknowledge that there are limited alternative approaches for this kind of clinical question. This is particularly true when examining a condition which is quite rare. Again, the numbers of patients they could examine was impressive with over a half a million patients included in this study. They also acknowledge that this approach likely underrepresents the true prevalence of OUD and that it doesn’t differentiate between misuse, dependence and addiction but the authors have understandably needed to be pragmatic in their approach.
These peri-operative risks are likely comparable for all patients with chronic opioid use and are not insignificant.

There have been similar findings in adult studies. The take home message is that we should be identifying these patients pre-operatively to cease or at least reduce their opioids before surgery not only to improve pain management but to mitigate their surgical risk. We should also ensure that we are factoring this elevated risk into decisions about peri-operative management and disseminating this information to our surgical and intensive care
colleagues.

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About

Journal Watch is a community of SPANZA members who work to identify and review articles of interest in the paediatric anaesthesia literature.


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