MPOG Pediatric
Subcommittee Meeting
December 15, 2021
Agenda
MPOG Peds Update
Dr. Bishr Haydar, Mott Children’s
Postoperative Mortality Rate in Pediatrics across MPOG
Dr. Ruchika Sharma, University of Virginia Children’s
PONV Prophylaxis Guideline Discussion
Dr. Lucy Everett, Massachusetts General Children’s
Normothermia QI Measure Review
Dr. Vikas O’Reilly-Shah, Seattle Children’s
2021 Year in Review
MPOG Peds
MPOG Membership Update
Cases Submitted by Pediatric Hospitals (< 18y)
2021 All
Vanderbilt 26,015 50,797
Univ. Michigan
17,980 255,046
St. Louis Children's 15,753 117,084
UNC 10,776 18,207
Spectrum Health
10,379 10,379
Duke 9,546 38,133
Yale 9,438 19,069
Wake Forest
8,892 50,513
NYU Langone 8,364 76,033
UCSF 8,288 33,172
OHSU 7,993 65,119
Univ. Wisconsin 7,896 13,712
Univ. Oklahoma 7,581 125,400
Mass General 6,426 30,620
Beaumont Royal Oak 5,487 42,157
Univ. Virginia 5,483 68,753
Cleveland Clinic 5,411 65,139
Bronson Health 4,008 88,080
Dartmouth 3,999 22,962
Univ. Chicago 3,919 10,720
MSKCC 3,638 42,861
MD Anderson 2,876 11,914
UCLA 1,820 143,864
Total
191,968 1,399,734
Pediatric Cases in MPOG
1,936,607
Congratulations to Dr. Wes Templeton and team on their recent
publication in Anesthesiology!
QI Measures Vetted for Pediatrics - THANK YOU!!
Reviewed Measures
• TOF Monitoring (NMB-01)
• Neuromuscular Blockade Reversal (NMB-02)
• Transfusion Vigilance (TRAN-01)
• Overtransfusion (TRAN-02)
NEW Measures
• Multimodal Analgesia (PAIN-01)
• PONV Prophylaxis (PONV-04)
OME Pediatric Dashboard
Plans for 2022
MPOG Peds
New Peds Specific Phenotypes Available
• Age (groups)
• BMI Percentile (Pediatric)
• BMI Classification (Pediatric)
• Pediatric Hospital Affiliation
Value Definition
Preterm Neonate The period at birth when child is born before the full gestational period
Term-Neonate 0 - 27 days (0 - 3 weeks)
Infant 28 days to 12 months (4 - 48 weeks)
Toddler 13 months - 23 months
Child (early) 2 to 5 years
Child (middle) 6 to 11 years
Adolescent (early) 12 to 18 years
Adolescent (late) 19 to 21 years
Adult > 21 years
Williams et.al, Pediatrics, 2012
Surgical Site Infection Toolkit
• Plans to update current toolkit with
recent literature
• Develop pediatric specific toolkit and
publish by end of 2022
• Contact Meridith if interested in
collaborating on this project!
2022 Meetings
• Pediatric Subcommittee Meetings
(Wednesdays @ 1pm Eastern)
- February 16
- May 18
- August 17
• MPOG Updates at SPA Q&S
- April 2 (Tampa, FL)
- October 22 (New Orleans, LA)
• MPOG Annual Retreat 2022
- October (New Orleans, LA)
Formation of MPOG Peds Interest Groups
• Member driven component of the MPOG peds subcommittee
• Feature 1-2 projects per meeting
• Goal of fostering collaboration among pediatric anesthesiologists and
sparking ideas of how MPOG data can be useful in projects of
interest
• Projects of Interest thus far:
– Postoperative Mortality Rate
– PONV Guideline Validation
– SSI Prevention
– Minimizing Colloid Use
– One Lung Ventilation
Perioperative mortality in the pediatric
population at the University of Virginia:
A 4-year analysis (2018-2021)
Hollie Humphrey
Eugene McGahren*(Department of Surgery)
George Politis
Ruchik Sharma
Why this study?
• Inspired by the congenital heart surgeons database
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
2014 2015
2016 2017 2018 2019 2020
2021
ANZICS 30-day
mortality
101,885 anesthetics
0.35% overall(0-18 yr)
3.7% neonates
Wilhelmina 30-day
mortality
45,182 anesthetics
0.42% overall(0-18 yr)
3.9% neonates
APRICOT 30-day
mortality
31,127
anesthetics(0-18y)
1% overall
NECTARINE 30-day mortality
6,542 anesthetics(60 wk
PMA)
2% overall
NSQIP 30-day
mortality
103,444 surgeries
0.7% overall
Perioperative hospital mortality at a tertiary
paediatric institution: BJA,115(4):608-15(2015)
• 45,182 anesthetics over 7 years (Jan 2006-Dec 2012)
• 188 deaths within 30 days (59 deaths within 24h, 10 died in OR)
• Attributability (2 surgeons + 3 anesth)
• 165/188 : preoperative condition (congenital anomaly/oncology/infection/coagulopathy)
• 14/188 : preoperative trauma
• 5/188 : Anesthesia management + child condition (descriptive analysis)
• 4/188. : Surgical procedure + child condition (descriptive analysis)
23 references: only 1 other was similar: Anesth Analg 2011;112:1440-7 van der Griend
Postoperative mortality in children after 101,885 anesthetics at a tertiary pediatric hospital
(Handwritten records)
24-hour and 30-day perioperative
mortality in pediatric surgery
Journal of Pediatric Surgery 54(2019)628-630
• ACS NSQIP P ( excludes cardiac/trauma/transplant)
• 103,444 patients, 732 deaths.
• 2012-2015
• Overall 30 day mortality: 0.7%
NEC highest 30-day mortality of 19%
CDH came second at 5.2%
• 13 references: 4 were CHD based, rest were NEC-surgical and medical
literature.
NECTARINE Morbidity and mortality after anaesthesia in early life: results of the European prospective multicentre
observational study, neonate and children audit of anaesthesia practice in Europe (NECTARINE) BJA2021
• 6542 anesthetics in infants less than 60wk PMA
• 3.2 % overall mortality (90 day. 2% 30-day mortality)
APRICOT Incidence of severe critical events in paediatric anaesthesia (APRICOT): a prospective multicentre
observational study in 261 hospitals in Europe Lancet Respir Med 2017; 5: 412–25
• 31,127 anesthetics from birth to 15 years
• 1% overall mortality
MPOG-P
• Intraoperative database
• 21 participants
• Date of start
• Anesthesia encounter specific
(all inclusive!)
NSQIP-P
• Preop variables(18) and Postop
outcomes(9)
• 127 participants
• Date of Start
• Surgery specific (excludes
trauma/transplant)
Predicting postoperative Physiologic decline
after elective surgery Pediatrics (2019) 143 (4)
• Predicting Mortality after Pediatric surgery (non cardiac surgery):
PRAM score from NSQIP 2012/2013/2014(derivation and validation cohorts)
• Development of a Pediatric Risk Assessment Score to Predict
Perioperative Mortality in Children Undergoing Noncardiac Surgery.
Nasr VG, DiNardo JA, Faraoni D.Anesth Analg. 2017 May;124(5):1514-1519
• Prospective External Validation of the Pediatric Risk Assessment Score
in Predicting Perioperative Mortality in Children Undergoing
Noncardiac Surgery. Valencia E, Staffa SJ, Faraoni D, DiNardo JA, Nasr VG.Anesth Analg. 2019 Oct;129(4):1014-1020
PONV Prophylaxis Measure Discussion
Lucy Everett, MD
Massachusetts General Hospital
PONV Measures
Outcome measure (PONV-03) applies to both adults and peds
Prophylaxis measures
• Being revised to match update PONV consensus guidelines
• PONV 01/05 - Adult measure uses Apfel criteria
• PONV 02/04 - Pediatric measure uses age, hx PONV in pt/parents/sib, certain
procedures
PONV-02 (March 2018) PONV-04 (August 2021)
Inclusion
Ages 3-17
GA with volatile maintenance
2+ risk factors for POV
Ages 3 - 17
Patients with 1+ risk factors for PONV
Risk Factors
Age > 3 years
Hx POV or PONV in patient, parent, sibling
Strabismus surgery
Procedure > 30 minutes
Age > 3 years
Female > 12 years
Hx POV or PONV in patient, parent, sibling
Strabismus, T&A, tympanoplasty
Volatile > 30 minutes
Administration of long-acting opioid intraop
Exclusion
- ICU admit, lung/liver transplant, neck,
intrathoracic, lower abdominal procedures,
endoscopy, labor epidural
- Cases where volatile used only for induction
ICU admit
Labor epidural
Radiology procedures
ECT
Success
Patient receives at least 2 antiemetics of different
classes
Antiemetic matched to number of risks (1, 2, or 3 if >2
risks). Propofol infusion is an antiemetic.
Pediatric PONV Prophylaxis: Source Reference
Summary of population/anesthetic technique:
• 1250 pediatric patients having surgery (only 43 had “diagnostic” procedures and no endoscopy noted).
• All received oral midazolam.
• 77% of their patients had an IV induction and nearly half of those had thiopental.
• 55% received a non-depolarizer but there is no data regarding reversal agents used (publication is from 2004 so
pre-sugammadex)
• Only 20% had propofol maintenance
Prospective validation by same group in 673 surgical patients - oral midaz, sevo or propofol
induction, volatile/opioid maintenance
Graphic from
revised guidelines;
based on Eberhart
Anesth Analg 2004;
99:1630–7
PONV 04 - PONV Prophylaxis in Pediatrics
• At November ASPIRE meeting, revised adult PONV prophylaxis measure
(PONV-05) was discussed. It was decided to include only patients who meet the
MPOG general anesthesia phenotype.
• Should PONV-04 be similarly limited until better evidence is available?
• Additional Revisions/Discussion points
– Exclude LP/Chemo/rad onc patients
– Surgical CPT 96450; Radiation oncology room tag
– How to handle cases w/o IV? *question during last quality committee meeting
Normothermia Measure Review
Vikas O’Reilly-Shah, MD
Seattle Children’s Hospital
TEMP-01: Thermoregulation Vigilance (Active Warming)
Description: Percentage of cases where active warming was
applied OR at least one temperature ≥ 36 C within 30 minutes
of case end.
Active Warming includes:
● Convective warming: forced air
● Conductive warming: water mattress
● Endovascular warming: heat exchange catheter
● Radiant Heaters
Exclusions:
● ASA 5 & 6
● Cases with a duration < 60min
● Procedure Types
○ Diagnostic
○ Obstetric
○ Radiology
TEMP-02: Core Temperature Monitoring
Description: Percentage of cases with at least one core temperature
documented between Anesthesia Start → Patient out of room.
Core or Near Core Temperature Monitoring Includes:
● Pulmonary Artery
● Distal Esophageal
● Nasopharyngeal
● Tympanic Membrane
● Bladder
● Rectal
● Axillary
● Oral
● Zero-Flux Thermometer
Exclusions:
● ASA 5 & 6
● Cases with neuraxial or regional anesthesia as the primary technique
● MRI Procedures
● Cases with duration ≤ 30 min
● Labor Epidurals
TEMP-04-Peds: Intraoperative Hypothermia
Description: Percentage of patients <18yo who undergo a
procedure >30 min and have a median core/near core body
temperature >36 C (96.8F)
Measure Period: Patient in Room → Patient out of Room
Exclusions:
● ASA 5 & 6
● Patients ≥ 18yo
● Procedure Types
○ Obstetric non-operative
○ Cardiac
○ MRI/Radiology
● Cases without a temperature route documented
TEMP-03: Postoperative Hypothermia
Description: Percentage of general and/or neuraxial cases with
at least one body temperature ≤36 C within 30 minutes
immediately before or 15 minutes after Anesthesia End.
Success: Documentation of a TOF
Exclusions:
● ASA 5 & 6
● Cases with a duration < 60min
● MAC cases
● Procedure Types
○ Cardiac
○ Obstetric non-operative
○ Emergent cases
● Cases with Intentional hypothermia
TEMP-03: Possible updates
Modify temperature target? (36.0 vs 36.5 for neonates and infants; in May 2019 target was
raised for all comers from 35.5 to 36.0)
- WHO Definition for neonates (age < 1mo) is 36.5
- World Health Organization. Thermal protection of the newborn: a practical guide. Report No.: WHO/RHT/MSM/97.2. Geneva, Switzerland: World Health Organization; 1997.
- 2015 guideline of care for prevention of perioperative hypothermia targets 36.5.
Evidence IIb: normal core temp age < 5yr is 36.5 to 38.0. Evidence IIb, Grade A
recommendation: up to age 2, core temp recommended.
- Torossian A, Bräuer A, Höcker J, Bein B, Wulf H, Horn E-P. Preventing inadvertent perioperative hypothermia. Dtsch Arztebl Int [Internet]. 2015 Mar 6;112(10):166–72.
- 36.5 as a threshold for neonates
- Trevisanuto D, Testoni D, de Almeida MFB. Maintaining normothermia: Why and how? Semin Fetal Neonatal Med [Internet]. 2018 Oct;23(5):333–9.
- STEPP-IN (Safe Transitions & Euthermia in the Perioperative Period in Infants &
Neonates - wide multicenter QI effort) used 36.0
- Brozanski BS, Piazza AJ, Chuo J, Natarajan G, Grover TR, Smith JR, et al. STEPP IN: Working Together to Keep Infants Warm in the Perioperative Period. Pediatrics [Internet].
2020 Apr;145(4).
- https://app.ihi.org/extranetng/content/7fb00eb3-84ae-4097-bec5-9a453c15ee6a/d3267c79-33ad-45c3-a0ec-1fdbcffd5471/STEPP%20IN%20Project%20Overview.pdf
-
TEMP-03: Possible updates
Temperature - site of measurement?
- In general, approach has been to reject skin temps
- Sahin SH, Duran R, Sut N, Colak A, Acunas B, Aksu B. Comparison of temporal artery, nasopharyngeal, and axillary temperature
measurement during anesthesia in children. J Clin Anesth [Internet]. 2012 Dec;24(8):647–51.
- Summary: Small study examining temperature measurement site during anesthesia. Axillary temperature was significantly
lower and less well correlated with core temperature than temporal artery or nasopharyngeal temperature.
- Handling of temps with no site recorded? (EMR issue)
- Failure to measure?
Thank You!
