Pediatric Subcommittee Minutes 05.19.21

Anesthesiology Performance Improvement and Reporting Exchange (ASPIRE)

Pediatric Subgroup Meeting Minutes – May 19, 2021

Attendance:

Alina Bodas, Cleveland Clinic

Lucy Everett, Mass General Hospital

Amber Franz, Seattle Children’s

Lori Reigger, Michigan Medicine

Anshuman Sharma, Washington University

Lora Gibbs, Michigan Medicine

Bob Brustowicz, Boston Children’s

Morgan Brown, Boston Children’s

Brooke Szymanski-Bogart, MPOG

Meridith Bailey, MPOG Pediatric Program Lead

Carrie Menser, Vanderbilt

Olga Eydlin, NYU Langone

Cheryl Gooden, Yale University

Nirav Shah, MPOG Associate Director

Dave Moore, Vanderbilt

Priti Dalal, Penn State University

David Waisel, Yale University

R.J. Ramamurthi, Stanford

James Xie, Stanford

Shobha Malviya, Michigan Medicine

Jerri Heiter, St. Joseph Mercy Ann Arbor

Stephanie Kahntroff, University of Maryland

Jessica Wren, Henry Ford Health System

Tory Lacca, MPOG

Joe Cravero, Boston Children’s

Vikas O’Reilly-Shah, Seattle Children’s

Jonathan Halem, Penn State Children’s

Vivian Onyewuche, Henry Ford Detroit

Kate Buehler, MPOG

Wilson Chimbira, Michigan Medicine

Laura Downey, Emory University

Wes Templeton, Wake Forest

Liem Pham, NYU Langone

Agenda & Notes

I. Announcements

a. 2021 Pediatric Subcommittee Meetings

i. August 18

ii. October 9

(In person @ SPA if possible)

iii. December 15

b. MPOG Annual Retreat 2021 (virtual version will also be offered for those

unable to travel)

i. October 8

(In person in San Diego, CA, if possible)

ii. Everyone is invited to this meeting regardless of MPOG member

status

II. February 17 Meeting Recap

a. Measure Discussion: PONV Prophylaxis in Pediatrics

i. PONV 02 Inclusion/Exclusion Criteria Updated

1. Inclusion: Patient ages 3-17 years old (no longer require

GA only or >/= 2 risk factors)

2. Exclusion:

a. Patients <3 or > 17 years old

b. Patients transferred directly to ICU

c. ASA 5 or 6

d. Labor Epidural Cases

e. Diagnostic Imaging procedures

3. Discussion:

a. Lucy Everett (MGH): Should patients undergoing

radiation be excluded from PONV 03 given that

they are on chronic antiemetics?

b. Bob Brustowicz (Boston Children’s): How about

patients receiving LP's for chemotherapy? They are

on chronic antiemetics.

c. Wes Templeton (Wake Forest): I think it makes the

most sense to exclude these patients using

CPT/ICD-9 codes. Going to be a relatively small

number of patients…

d. Nirav Shah (ASPIRE Director): Okay! We will work

on adding that exclusion to the PONV 03 measure

specification

4. Risk factors updated:

a. Post-pubertal females (≥12yo)

b. Inhaled anesthetic duration ≥30 minutes

(halogenated or nitrous)

c. Hx of PONV (personal or first degree relative)

d. At Risk Surgery

i. Strabismus

ii. Adenotonsillectomy

iii. Tympanoplasty/otoplasty

e. Postoperative long-acting opioids (administered

after induction)

5. Discussion:

a. Vikas O’Reilly-Shah (Seattle Children’s): I'd only

worry about validity across sites of risk factor data.

b. Nirav Shah (ASPIRE Director): Yes- we have done a

lot of data cleaning in recent years so we are pretty

confident but this is always a potential issue.

6. Success Criteria

a. Low (0 risk factors): Receives at least one

prophylactic antiemetic

b. Medium (1-2 risk factors): Receives at least 2

prophylactic antiemetics from different classes

c. High (≥2 risk factors): Receives three prophylactic

antiemetics

7. Choice of Antiemetics and Frequency: Graphs of

antiemetic use for both prophy and rescue shared with the

group- see PPT slides for more information

8. Discussion:

a. James Xie via chat (Stanford): Our oncologists are

increasingly using Aloxi (palonosetron) which lasts

days and might not be documented intraop

b. Vikas O’Reilly Shah via chat (Seattle CHildrnes): I

sent you an email about atypical antipsychotics and

the growing literature there. Would be given

preop, not intraop. Unsure if amisulpride has a

pediatric indication

c. Priti Dalal via chat (Penn State Children’s): We are

also using Aloxi for hemonc

d. Wes Templeton via chat (Wake Forest): Haldol?

Interesting…more than droperidol…?

e. Vikas O’Reilly-Shah via chat (Seattle Children’s):

Droperidol only recently (re)started manufacture in

the US, I believe.

https://www.prnewswire.com/news-

releases/american-regent-re-introduces-

droperidol-injection-usp-ap-rated-and-

therapeutically-equivalent-to-inapsine1-

300796783.html

f. Wes Templeton via chat (Wake Forest): We use

droperidol at Wake Forest

g. Bob Brustowicz via chat (Boston Children’s): Is the

Propofol rescue an infusion or a bolus?

h. Meridith Bailey via chat (MPOG Coordinating

Center): Infusion

III. Measure Review: Transfusion Measures

a. Graph of current performance across pediatric sites shared for both TRAN

01 and TRAN 02 (see PPT slides)

b. Transfusion Vigilance Measure (TRAN 01)

i. Description: Percentage of cases with a blood transfusion that

have a hemoglobin or hematocrit value documented prior to

transfusion.

1. Transfusion is defined as packed red blood cells or whole

blood

2. Prior to the first transfusion, a hgb/hct of any value should

be checked in a time period of 0 to 90 minutes before the

transfusion, or the most recent documented hgb/hct was

<8/24 within 36 hours before the transfusion

ii. Responsible Provider: Provider(s) who administered the

transfusion

iii. See measure TRAN 01 specification for current inclusion/exclusion

criteria

iv. Proposed Pediatric Inclusion/Exclusion Criteria:

1. Inclusions: All patients who receive a transfusion between

anesthesia start and anesthesia end

2. Exclusions:

a. Patients ≤ 6 months or ≥ 18 years of age

b. ASA 5 & 6

c. Patients with cyanosis preoperatively AND

congenital heart disease

d. Patients with transfused volume or EBL > 40cc/kg.

e. Patients on ECMO

f. Burn Debridement Cases?

g. All Obstetric procedures

3. Discussion:

a. Vikas O’Reilly-Shah via chat (Seattle Children’s):

what about cases where there a strong a priori

expectation of transfusion e.g. we typically just

start blood at the beginning of the case for our

craniosynostosis cases

i. Laura Downey via chat (Emory): We

discussed such cases, but shouldn’t you still

have a Hematocrit or Hb prior to that type

of case?

ii. Nirav Shah (ASPIRE Director): This is our

thought as well. Should have a hgb/hct for

those cases

b. Morgan Brown (Boston Children’s): What about

cardiopulmonary bypass cases in which the pump is

primed with blood product?

i. Nirav Shah (ASPIRE Director): Should we

exclude this time period? Interested in

hearing your opinion

ii. Morgan Brown (Boston Children’s): This is a

complex decision making process in which

we are tracking these patients closely and

deciding to transfuse. I don’t think we want

to focus on those cases. I worry that we’ll

have a hard time excluding based on

congenital heart disease ICD 9/10 codes

alone

iii. Nirav Shah (ASPIRE Director): Some may be

covered under the massive transfusion or

high EBL exclusion but broadly decided to

include cardiac cases at the Quality

Committee level and just exclude units

given while on bypass. Need to review this

from a pediatric standpoint

iv. Morgan Brown (Boston Children’s): May

just lead to excessive blood testing since

these are complicated cases

c. Vikas O’Reilly-Shah via chat (Seattle Children’s):

that also gets to my point. don't think I would

cancel a case if I didn't have a preop hgb for a kid

i'm sure I was going to transfuse. would probably

just send an early lab h/h and trend poct

d. Lori Reigger (Michigan Medicine): If PRBC are

added to the pump circuit by the perfusionist and

documented in anesthetic record, then those cases

would be flagged if there is a not a hct/hgb

documented.

i. Nirav Shah (ASPIRE Director): Yes, that’s

true.

e. Meridith Bailey (MPOG Coordinating Center): Does

it make sense to write a separate measure for

cardiac cases relative to transfusion?

i. Morgan Brown (Boston Children’s): I think I

would just recommend excluding the

cardiac bypass cases

ii. Lori Reigger (Michigan Medicine): I would

agree with that.

iii. Shoba Malviya (Michigan Medicine): Can we

do that reliably?

1. Nirav Shah (ASPIRE Director): Yes,

we have created sophisticated logic

using both CPT code and other

elements of the case

f. RJ Ramamurthi via chat (Stanford): iSTAT Hct is

acceptable for this measure or need lab tested

Hct?

i. Meridith Bailey (MPOG Coordinating

Center): Yes, iSTAT is acceptable

ii. Nirav Shah (ASPIRE Director): As long as

those iSTAT values are uploaded to the lab

system and come over with the lab extract

(not manually documented as a note)

g. Vikas O’Reilly-Shah via chat (Seattle Children’s):

date time ‘preop’ would count if…?

h. Nirav Shah (ASPIRE Director): Okay excluding OB

cases?

i. Wilson Chimbira (Michigan Medicine): Yes

agree

ii. Wes Templeton: Yes – okay with excluding

OB cases

iii. Vikas: Agree

i. Wes Templeton (Wake Forest): why exclude burn

patients…this is a highly transfused population

which may/may not be at risk for over

transfusion…maybe should be separated.

i. Nirav Shah (ASPIRE Director): I believe the

Quality Committee feedback for burn

patients was related to access and reliability

to draw samples intraop; also, oozing so not

always checking in between. If folks feel

differently, let’s discuss

ii. Wes Templeton (Wake Forest): but I

thought you just had to check a

hgb…doesn’t have to be low. These kids will

have a hgb.

iii. Nirav Shah (ASPIRE Director): More about

not being able to check intraop due to their

burn status, not so much what the value

would be

j. Bob Brustowicz (Boston Children’s): What about

intraoperative blood salvage? These patients often

get their blood back without any additional labs.

i. Nirav Shah (ASPIRE Director): Decided years

ago that the risk of transfusion with your

own blood is less and so those instances are

excluded. Thoughts from the group on this?

4. Definitions/Considerations: see TRAN 01 specification for

current considerations

5. Proposed Pediatric-specific considerations:

a. Massive Transfusion defined as ≥40 cc/kg: No

objections to this change from the group.

b. 1 Unit of Blood for patients ≥12 years

c. Patients less than 12 years: define a ‘unit’ as 15

cc/kg

i. Discussion:

1. Joe Cravero (Boston Children’s):

How rapidly a patient is losing blood

is not considered with this measure;

If a patient is losing blood quickly,

you wouldn’t want to wait for a

H&H– there could be a lot of flags in

these instances

2. Nirav Shah (ASPIRE Director): We

have not seen this historically with

this measure as being an issue. Will

be interesting to see if that presents

as an issue with the pediatric

population

3. Vikas O’Reilly-Shah via chat (Seattle

Children’s): I do worry a bit about

how well your data quality is going

to assure that fallouts/fails are real.

There will be a lot of variability in

e.g. when blood tx is documented,

when EBL is intermittently (or not)

documented, when labs are

documented, whether POCT vs lab

sent h/h are available. Tightening

too much may be counterproductive

d. Cyanosis and CHD

i. Cyanosis: At least two SpO2 readings <90%

(between preop start and Patient in Room)

ii. CHD defined by ICD-9/10 codes

1. Discussion:

a. Meridith Bailey (MPOG

Coordinating Center): I met

with Bishr Haydar (Michigan

Medicine) and Laura Downey

(Emory) earlier this month

and came up with this

definition. Okay with the

group?

b. Morgan Brown (Boston

Children’s): ICD codes aren’t

always great. Fontan patient

with sat of 94% may still

want a higher transfusion

trigger.

6. Success Criteria: see TRAN 01 specification for current

success definition

7. Proposed Pediatric-specific Success Definition:

a. Documentation of hgb/hct prior to transfusion

i. If the most recent Hgb/Hct drawn before

the first transfusion is ≤ 5/16, an additional

15cc/kg could be administered without

rechecking Hgb/Hct between units.

ii. For patients < 12y?

iii. If multiple units are administered,

documentation of a Hgb/Hct value must be

present within 60 minutes before each

transfusion.

1. Morgan Brown (Boston Children’s):

Is there a practical implication for

limiting to 60 minutes rather than 90

minutes? If someone checks it at 64

minutes, rather than 60, does that

matter in terms of transfusion

administration?

2. Nirav Shah (ASPIRE Director): That’s

a great question and one for this

group to consider.

3. Meridith Bailey (MPOG Coordinating

Center): I believe 60min time frame

was suggested due to the total

blood volume of younger patients

4. Morgan Brown: Recommend

adjusting this measure to 60

minutes rather than 90 minutes to

see the impact on performance first

iv. All transfusions administered between

cardiopulmonary bypass start → end will

not be included for determining measure

results for the case.

c. Overtransfusion Measure (TRAN 02)

i. Description: Percentage of cases with a post transfusion hgb/hct

value ≥10/30

1. All hgb/hct labs resulted between the time of last

transfusion and 18 hours after anes end are evaluated.

ii. Responsible provider: Provider(s) who administered the last

transfusion

iii. See TRAN 02 specification for current inclusion/exclusion criteria

iv. Proposed Inclusion Criteria: All patients who receive a transfusion

between anesthesia start/end (no change)

v. Proposed Exclusion criteria:

1. Patients ≤ 6 months or ≥ 18 years old

2. ASA 5 & 6

3. Patients with cyanosis preoperatively and congential heart

disease

4. Patients with transfused volume or EBL>40cc/kg

5. Patients on ECMO

6. Burn Debridement Cases?

7. All Obstetric procedures

vi. Success Criteria: Hgb/hct value documented as ≤ 10/30 within 18

hours after anesthesia end OR if no hgb/hct checked within 18

hours of anesthesia end, the case will pass (should these instances

be excluded or flagged instead?)

1. Discussion:

a. Morgan Brown (Boston Children’s): Seems like you

should check a hct after a transfusion so would

suggest these cases should be flagged. Only other

consideration is that some patients continue to

bleed postop

b. Bob Brustowicz via chat (Boston Children’s):

Flagged for review.

d. Next Steps

i. MPOG Coordinating Center will incorporate your feedback and

update the transfusion metrics as needed or decide if we should

create new pediatric-specific measures

ii. Next meeting: August 18

at 1pm

1. NMB 01/NMB 02 are scheduled to be reviewed next

Meeting adjourned at: 1404