Complications Associated With the Anesthesia Transport of Pediatric Patients: An Analysis of the Wake Up Safe Database BACKGROUND: Transporting patients under anesthesia care incurs numerous potential risks, especially for those with critical illness. The purpose of this study is to identify and report all pediatric anesthesia transport-associated adverse events from a preexisting database of perioperative adverse events. METHODS: An extract of the Wake Up Safe database was obtained on December 14, 2017, and screened for anesthesia transport-associated complications. This was defined as events occurring during or immediately after transport or movement of a pediatric patient during or in proximity to their care by anesthesiologists, including repositioning and transfer to recovery or an inpatient unit, if the cause was noted to be associated with anesthesia or handover. Events were excluded if the narrative clearly states that an event was ongoing and not impacted by anesthesia transport, such as a patient who develops cardiac arrest that then requires emergent transfer to the operating room. The search methodology included specific existing data elements that indicate transport of the patient, handover or intensive care status preoperatively as well as a free-text search of the narrative for fragments of words indicating movement. Screened events were reviewed by 3 anesthesiologists for inclusion, and all data elements were extracted for analysis. RESULTS: Of 2971 events in the database extract, 63.8% met screening criteria and 5.0% (148 events) were related to transport. Events were primarily respiratory in nature. Nearly 40% of all reported events occurred in infants age ≤6 months. A total of 59.7% of events were at least somewhat preventable and 36.4% were associated with patient harm, usually temporary. Of the 86 reported cardiac arrests, 50 (58.1%) had respiratory causes, of which 74% related to anesthesia or perioperative team factors. Respiratory events occurred at all stages of care, with 21.4% during preoperative transport and 75.5% postoperatively. Ninety-three percent of unplanned extubations occurred in patients 6 months and younger. Ten medication events were noted, 2 of which resulted in cardiac arrest. Root causes in all events related primarily to provider and patient factors, with occasional references to verbal miscommunication. CONCLUSIONS: Five percent of reported pediatric anesthesia adverse events are associated with transport. Learning points highlight the risk of emergence from anesthesia during transport to recovery or intensive care unit (ICU). ICU patients undergoing anesthesia transport face risks relating to transitions in providers, equipment, sedation, and physical positioning. Sedation and neuromuscular blockade may be necessary for transport in some patients but has been associated with adverse events in others. Accepted for publication August 6, 2019. Funding: Departmental. The authors declare no conflicts of interest. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (www.anesthesia-analgesia.org). Reprints will not be available from the authors. Address correspondence to Bishr Haydar, MD, Section of Pediatric Anesthesia, Department of Anesthesiology, Michigan Medicine, 4–911 Mott Hospital, 1540 E Hospital Dr SPC 4245, Ann Arbor, MI 48109. Address e-mail to bhaydar@med.umich.edu. © 2019 International Anesthesia Research Society

Prevention of Early Postoperative Decline: A Randomized, Controlled Feasibility Trial of Perioperative Cognitive Training Background: Postoperative delirium and postoperative cognitive dysfunction (POCD) are common after cardiac surgery and contribute to an increased risk of postoperative complications, longer length of stay, and increased hospital mortality. Cognitive training (CT) may be able to durably improve cognitive reserve in areas deficient in delirium and POCD and, therefore, may potentially reduce the risk of these conditions. We sought to determine the feasibility and potential efficacy of a perioperative CT program to reduce the incidence of postoperative delirium and POCD in older cardiac surgery patients. Methods: Randomized controlled trial at a single tertiary care center. Participants included 45 older adults age 60–90 undergoing cardiac surgery at least 10 days from enrollment. Participants were randomly assigned in a 1:1 fashion to either perioperative CT via a mobile device or a usual care control. The primary outcome of feasibility was evaluated by enrollment patterns and adherence to protocol. Secondary outcomes of postoperative delirium and POCD were assessed using the Confusion Assessment Method and the Montreal Cognitive Assessment, respectively. Patient satisfaction was assessed via a postoperative survey. Results: Sixty-five percent of eligible patients were enrolled. Median (interquartile range [IQR]) adherence (as a percentage of prescribed minutes played) was 39% (20%–68%), 6% (0%–37%), and 19% (0%–56%) for the preoperative, immediate postoperative, and postdischarge periods, respectively. Median (IQR) training times were 245 (136–536), 18 (0–40), and 122 (0–281) minutes for each period, respectively. The incidence of postoperative delirium (CT group 5/20 [25%] versus control 3/20 [15%]; P = .69) and POCD (CT group 53% versus control 37%; P = .33) was not significantly different between groups for either outcome in this limited sample. CT participants reported a high level of agreement (on a scale of 0–100) with statements that the program was easy to use (median [IQR], 87 [75–97]) and enjoyable (85 [79–91]). CT participants agreed significantly more than controls that their memory (median [IQR], 75 [54–82] vs 51 [49–54]; P = .01) and thinking ability (median [IQR], 78 [64–83] vs 50 [41–68]; P = .01) improved as a result of their participation in the study. Conclusions: A CT program designed for use in the preoperative period is an attractive target for future investigations of cognitive prehabilitation in older cardiac surgery patients. Changes in the functionality of the program and enrichment techniques may improve adherence in future trials. Further investigation is necessary to determine the potential efficacy of cognitive prehabilitation to reduce the risk of postoperative delirium and POCD. Accepted for publication August 27, 2019. Funding: The conduct of this trial was performed with support from a Beth Israel Deaconess Medical Center (BIDMC) Department of Anesthesia Internal Research Award (John Hedley-White Award, via Harvard Medical School’s Eleanor and Miles Shore Foundation). A portion of this work was conducted while Dr B.P.O.’G. was a member of the Harvard Anesthesia National Institutes of Health (NIH) T32 program (NIH T32GM007592-38). Research subscriptions to the training program were provided free of charge by Lumos Labs, Inc. Conflicts of Interest: See Disclosures at the end of the article. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (www.anesthesia-analgesia.org). The sponsor had no role in the design/conduct of the study, data collection or analysis, interpretation of the data, manuscript preparation and review, or decision to submit the manuscript for publication. Clinical Trial Registration: Clinicaltrials.gov # NCT02908464 https://clinicaltrials.gov/ct2/show/NCT02908464. Reprints will not be available from the authors. Address correspondence to Brian P. O’Gara, MD, MPH, Department of Anesthesia, Beth Israel Deaconess Medical Center, 1 Deaconess Rd, Rosenberg 470, Boston, MA 02215. Address e-mail to bpogara@bidmc.harvard.edu. © 2019 International Anesthesia Research Society

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 BACKGROUND: 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. METHODS: 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). RESULTS: 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. CONCLUSIONS: 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. Accepted for publication August 22, 2019. Funding: Work by J.M.R. was supported by a National Institutes of Health grant (T32 GM007592; Research Training for Anesthetists). All other support was provided from institutional and/or departmental sources. The authors declare no conflicts of interest. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (www.anesthesia-analgesia.org). This work was presented in part at the Society for Pediatric Anesthesia-American Academy of Pediatrics Pediatric Anesthesiology Meeting, March 15–17, 2019, Houston, Texas. Reprints will not be available from the authors. Address correspondence to T. Anthony Anderson, PhD, MD, Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, 300 Pasteur Dr, MC5640, Stanford, CA 94305. Address e-mail to tanders0@stanford.edu. © 2019 International Anesthesia Research Society

Anesthetic Management for the Pediatric Airway: Advanced Approaches and Techniques No abstract available

Risk of Major Complications After Perioperative Norepinephrine Infusion Through Peripheral Intravenous Lines in a Multicenter Study BACKGROUND: Continuous infusions of norepinephrine to treat perioperative hypotension are typically administered through a central venous line rather than a peripheral venous catheter to avoid the risk of localized tissue necrosis in case of drug extravasation. There is limited literature to estimate the risk of skin necrosis when peripheral norepinephrine is used to counteract anesthesia-associated hypotension in elective surgical cases. This study aimed to estimate the rate of occurrence of drug-related adverse effects, including skin necrosis requiring surgical management when norepinephrine peripheral extravasation occurs. METHODS: This retrospective cohort study used the perioperative databases of the University Hospitals in Amsterdam and Utrecht, the Netherlands, to identify surgical patients who received norepinephrine peripheral intravenous infusions (20 µg/mL) between 2012 and 2016. The risk of drug-related adverse effects, including skin necrosis, was estimated. Particular care was taken to identify patients who needed plastic surgical or medical attention secondary to extravasation of dilute, peripheral norepinephrine. RESULTS: A total of 14,385 patients who received norepinephrine peripheral continuous infusions were identified. Drug extravasation was observed in 5 patients (5/14,385 = 0.035%). The 95% confidence interval (CI) for infusion extravasation was 0.011%–0.081%, indicating an estimated risk of 1–8 events per every 10,000 patients. There were zero related complications requiring surgical or medical intervention, resulting in a 95% CI of 0%–0.021% and indicating a risk of approximately 0–2 events per 10,000 patients. CONCLUSIONS: In the current database analysis, no significant association was found between the use of peripheral intravenous norepinephrine infusions and adverse events. Accepted for publication August 15, 2019. Funding: Departmental. The authors declare no conflicts of interest. Reprints will not be available from the authors. Address correspondence to Carlo Pancaro, MD, Department of Anesthesiology, University of Michigan, 1500 Medical Center Dr, Ann Arbor, MI 48109. Address e-mail to cpancaro@med.umich.edu. © 2019 International Anesthesia Research Society

Atrial Fibrillation: Current Evidence and Management Strategies During the Perioperative Period Atrial fibrillation (AF) is the most common arrhythmia in the perioperative period. Previously considered a benign and self-limited entity, recent data suggest that perioperative AF is associated with considerable morbidity and mortality and may predict long-term AF and stroke risk in some patients. Despite known risk factors, AF remains largely unpredictable, especially after noncardiac surgery. As a consequence, strategies to minimize perioperative risk are mostly supportive and include avoiding potential arrhythmogenic triggers and proactively treating patient- and surgery-related factors that might precipitate AF. In addition to managing AF itself, clinicians must also address the hemodynamic perturbations that result from AF to prevent end-organ dysfunction. This review will discuss current evidence with respect to causes, risk factors, and outcomes of patients with AF, and address current controversies in the perioperative setting. Accepted for publication September 5, 2019. Funding: None. The authors declare no conflicts of interest. Reprints will not be available from the authors. Address correspondence to Kunal Karamchandani, MD, FCCP, Department of Anesthesiology & Perioperative Medicine, H187, Penn State Health Milton S. Hershey Medical Center, 500 University Dr, Hershey, PA 17033. Address e-mail to kkaramchandani@pennstatehealth.psu.edu. © 2019 International Anesthesia Research Society

Prospective Comparison of Preoperative Predictive Performance Between 3 Leading Frailty Instruments BACKGROUND: Guidelines recommend routine preoperative frailty assessment for older people. However, the degree to which frailty instruments improve predictive accuracy when added to traditional risk factors is poorly described. Our objective was to measure the accuracy gained in predicting outcomes important to older patients when adding the Clinical Frailty Scale (CFS), Fried Phenotype (FP), or Frailty Index (FI) to traditional risk factors. METHODS: This was an analysis of a multicenter prospective cohort of elective noncardiac surgery patients ≥65 years of age. Each frailty instrument was prospectively collected. The added predictive performance of each frailty instrument beyond the baseline model (age, sex, American Society of Anesthesiologists’ score, procedural risk) was estimated using likelihood ratio test, discrimination, calibration, explained variance, and reclassification. Outcomes analyzed included death or new disability, prolonged length of stay (LoS, >75th percentile), and adverse discharge (death or non-home discharge). RESULTS: We included 645 participants (mean age, 74 [standard deviation, 6]); 72 (11.2%) participants died or experienced a new disability, 164 (25.4%) had prolonged LoS, and 60 (9.2%) had adverse discharge. Compared to the baseline model predicting death or new disability (area under the curve [AUC], 0.67; R2, 0.08, good calibration), prolonged LoS (AUC, 0.73; R2, 0.18, good calibration), and adverse discharge (AUC, 0.78; R2, 0.16, poor calibration), the CFS improved fit per the likelihood ratio test (P < .02 for death or new disability, <.001 for LoS, <.001 for discharge), discrimination (AUC = 0.71 for death or new disability, 0.76 for LoS, 0.82 for discharge), calibration (good for death or new disability, LoS, and discharge), explained variance (R2 = 0.11 for death or new disability, 0.22 for LoS, 0.25 for discharge), and reclassification (appropriate directional reclassification) for all outcomes. The FP improved discrimination and R2 for all outcomes, but to a lesser degree than the CFS. The FI improved discrimination for death or new disability and R2 for all outcomes, but to a lesser degree than the CFS and the FP. These results were consistent in internal validation. CONCLUSIONS: Frailty instruments provide meaningful increases in accuracy when predicting postoperative outcomes for older people. Compared to the FP and FI, the CFS appears to improve all measures of predictive performance to the greatest extent and across outcomes. Combined with previous research demonstrating that the CFS is easy to use and requires less time than the FP, clinicians should consider its use in preoperative practice. Accepted for publication September 6, 2019. Funding: This study was funded by the Canadian Frailty Network and the Ottawa Hospital Academic Medical Organization. D.I.M. and M.M.L. receive salary support from the Ottawa Hospital Department of Anesthesiology and Pain Medicine. D.I.M. is supported by the Canadian Anesthesiologists Society Career Scientist Award. The authors declare no conflicts of interest. Reprints will not be available from the authors. Address correspondence to Daniel I. McIsaac, MD, MPH, FRCPC, Department of Anesthesiology and Pain Medicine, Room B311, 1053 Carling Ave, Ottawa, ON, Canada K1Y 4E9. Address e-mail to dmcisaac@toh.ca. © 2019 International Anesthesia Research Society

Cerebral Oximetry and Mean Arterial Pressure: Not a Straight Relationship, the Flow Between? No abstract available

Achieving Gender Parity in Acute Care Medicine Requires a Multidimensional Perspective and a Committed Plan of Action No abstract available

In Response No abstract available