MPOG Pediatric
Subcommittee Meeting
November 30, 2022
Pediatric Subcommittee Leadership
Chair
Vice Chair
THANK YOU Dr. Haydar for your many contributions over the past two years
as chair and for your continued participation as a member of the MPOG
pediatric subcommittee!
MPOG is pleased to announce Drs. Brad Taicher (Duke University) and Vikas O’Reilly-Shah
(Seattle Children’s) as the new pediatric subcommittee leadership team.
May Meeting Recap
• Review of new MPOG pediatric blood
management measures
– TRAN-03: Transfusion vigilance
– TRAN-04: Overtransfusion
• Pediatric sustainability workgroup update and
measure proposals
• Unblinded data review - Benchmark across MPOG
pediatric sites
– TEMP-03: Postoperative Hypothermia
– TEMP-04: Intraoperative Normothermia
Agenda
Announcements & State of MPOG Pediatrics
Dr. Brad Taicher, Duke University
Evaluation of PONV Consensus Guidelines in Pediatrics
using MPOG data
Dr. Lucy Everett, Mass General Hospital
Pediatric Postoperative Mortality Project
Dr. Ruchika Sharma, University of Virginia
Open Discussion: Hot Topics in Pediatric Anesthesia
Dr. Vikas O’Reilly-Shah, Seattle Children’s
2023 Meetings
• Pediatric Subcommittee Meetings
- March
- June
- December
• MPOG Updates at SPA Q&S
- March & October
• MPOG Annual Retreat 2023
- October (San Francisco, CA)
State of MPOG
Pediatrics
MPOG Membership - 27 Pediatric Sites!
Pediatric Cases in MPOG
2,311,506
Age Group Case Count
-- Preterm Neonate 5,583
0 - 27d Term Neonate 37,746
28d - 12mo. Infant 253,672
13 mo. - 23mo. Toddler 173,475
2 - 5y Child (Early) 582,180
6-11y Child (Middle) 531,513
12-18y Adolescent (Early) 727,337
5 Pediatric Measures Published in 2022!
FLUID-02-Peds (cardiac and non-cardiac)
Minimizing Colloid Use
Description: Percentage of pediatric cases where colloids were avoided intraoperatively
Measure Time Period: Patient in room to Patient out of room
Inclusions:
• FLUID-02-NC: Patients < 18y who undergo a non-cardiac procedure
• FLUID-02-C: Patients < 18y who undergo an open cardiac procedure (as defined by the MPOG Cardiac phenotype)
Exclusions:
● Patients ≥ 18 years of age
● ASA 5 & 6
● Massive Transfusion or blood loss: Defined as volume of 40 mL/kg
● Patients that are in prone or trendelenburg position for ≥ 4 hours
● Patients with ascites
SUS-05-Peds
Nitrous utilization during induction
Description: Percentage of pediatric cases where nitrous oxide gas was used during induction of anesthesia.
Measure Time Period: Induction Start to Intubation. If not available, then Induction End
Inclusions: Patients < 18yo who undergo general anesthesia
Exclusions: Patients > 18yo
Success Criteria: Nitrous oxide was not administered during the induction period of anesthesia
Other Measure Details:
Values for flows and inhalational agents will be assessed and considered as artifact if inside the following ranges:
● Nitrous Oxide Flows: <0.2 L/min
● Nitrous Oxide Insp % <20%
Plans for 2023…
Measures In Progress
SUS-06: Weight based, Low fresh gas flow
during induction
ABX-02: Antibiotic Timing, intraop
Other Measures of interest?
Published Measures - Due for Review
Call for MPOG Pediatric Research
PCRC Date
Presented
Institution First Author Research Proposal Status
02/2020 Wake Forest Miller
An Assessment of Procedural and Patient Risk Factors for Hypoxemia in Pediatric
Patients Less than 3 years of age Undergoing One-Lung Ventilation and Thoracic
Surgery Using the MPOG Database
Published in
Anesthesiology
11/2017 U. Michigan Riegger
Risk Factors for Perioperative Hypoglycemia in Children and Adults: A Report From
the Multicenter Perioperative Outcomes Group (MPOG)
Published in A&A
02/2014 Utrecht de Graaff
Development of reference ranges for vital signs for children during anesthesia Published in
Anesthesiology
Evaluation of Pediatric PONV
Prophylaxis Using the MPOG Database
Dr. Lucy Everett (Mass General Hospital)
PONV-04 (Pediatric Prophylaxis)
Inclusion
Ages 3 - 17
Patients with 1+ risk factors for PONV
Risk Factors
Age > 3 years
Female > 12 years
Hx PONV in patient, parent, sibling
High-risk Surgery (Strabismus, T&A, tympanoplasty)
Volatile > 30 minutes
Administration of long-acting opioid in OR or PACU
Exclusion
ICU admit; ASA 5 or 6
Labor epidural
Radiology/radiation oncology procedures
ECT
Sedation/MAC
Success
Antiemetic matched to number of risks (1, 2, or 3 if >2 risks).
Propofol infusion is an antiemetic.
Anesthetic technique not comparable to current (thiopental, neostigmine, all premedicated)
Minimal numbers for diagnostic procedures/endoscopy
We had questions….
Are the findings generalizable?
How much does provider bias impact practice?
Should the factors have equal weight?
Can we build a better score?
Lucy Everett MGH
Brad Taicher Duke
Lisa Vitale Michigan Medicine
Meridith Bailey MPOG
Vikas O’Reilly-Shah Seattle Children’s
Wes Templeton Wake Forest
Ben Andrew Duke
Tim Houle (statistician) MGH
Arielle Mueller MGH
Pedi PONV Research Proposals
PCRC 0145: Pedi PONV Descriptive
Aims to evaluate pediatric practice related to recommendations for PONV prophylaxis in the
recent Consensus Guidelines (used to construct PONV-04).
We hypothesize that prophylaxis practice varies depending on case type and specific risk
factors rather than just the number of risk factors.
PCRC 0180: Pedi PONV Outcomes
Aims to evaluate the correlation between compliance with PONV prophylaxis and outcomes.
We hypothesize that outcome as measured by the surrogate endpoint of rescue med in
PACU does not correlate with compliance with prophylaxis recommendations.
Aspirational Questions (possible secondary analysis):
• Can we validate the previously identified risk factors
• Can we validate the inclusions/exclusions (case type, etc)?
• Can we assign any weight based on the MPOG data?
• Can we identify other specific risk factors that impact outcome?
Potential Data Limitations
• Incomplete identification of risk factors (personal/family hx of PONV and
motion sickness)
• Incomplete documentation of PACU PONV
• Inability to tease out multiple factors that impact PONV
• Impact of feedback emails
• Impact of using measure for compensation
Pilot Data - Descriptive
Center A Center B
Site description Large academic hospital with all
peds except ENT/ophth
Large academic hospital with all peds
Variability by provider 77.5 - 93.8% success 46.2-73.3% success
Impact of emails/comp
measure
PONV-04 success improved from
73% to 87%
N/A
Observations
All patients have age 3-17
Majority had volatiles > 30 min
Additional risk of hx PONV much
more likely to pass than second risk
of female gender (>12)
For 1 risk factor, compliance 82%
For 2 or 3 risks, higher success if risks
were surgical procedure or hx PONV
Pilot Data - Outcomes
• Success on the prophylaxis measure did not correlate with success on the
outcome measure at either pilot center.
• At Center A, data was examined before and after feedback emails. Although
prophylaxis rates improved, the incidence of documented PACU vomiting also
rose between the two periods (likely related to efforts to improve
documentation) and the incidence of rescue antiemetic administration rose a
small amount.
Discussion
Pediatric Postoperative Mortality
Dr. Ruchika Sharma (University of Virginia)
MORT-01
30 Day In-Hospital Mortality
Description: Percentage of patients with in hospital
death reported within 30 days after procedure
Exclusions: ASA 6
Numerator: Flagged cases
Denominator:
• Passed - No known death or known death > 30 days
• Excluded - Death within 30 days, Not index case
• Flagged - Death within 30 days, Index case
Mortality Project
Part A: Raw POMR
• UVA Pilot study of unadjusted 24h, 30d POMR in 2019, 2020, 2021
• Descriptive analysis of our individual cases
*abstract submitted to SPA 2023
Part B: Risk Adjusted POMR
• STS-CCAS database: participating program outcomes are open to public.
• O/E ratios for benchmarking
• 4 surgical risk categories (STAT 1-5)
Papers used for this project…
Perioperative hospital mortality at a tertiary paediatric institution
(de Bruin et al, BJA, 2015)
• Identified causes of death (2A, 2S)- attributability
• 45,182 anesthetics over 7 yrs (2006-2012 @ Netherlands)
• 30d POMR : 41.6/10,000
• Highest POMR in under 1 yr, ASA 3/4, Cardiac surgery, Emergency.
Development of a Pediatric Risk Assessment Score to Predict Perioperative
Mortality in Children Undergoing Noncardiac Surgery (Nasr et al, Anesth Analg, 2017)
Derivation cohort: n=115,229 (2012,2013 NSQIP peds)
0.5% mortality
Validation cohort: n=68,194 (2014 NSQIP peds)
0.4% mortality
Multivariable Regression modelling for in-hospital mortality
PRAm score : Pediatric Risk Assessment of Mortality
PRAm >= 6 increasing POMR
Prospective external validation of the pediatric risk assessment score in
predicting perioperative mortality in children undergoing noncardiac surgery
(Valencia et al, Anesth Analg, 2019)
A PRAm score was prospectively assigned by the primary anesthesia team to children ≤18
years of age undergoing noncardiac surgery between July 2017 and July 2018 at a tertiary
care pediatric hospital. The primary outcome was the PRAm score's ability to predict 30-day
mortality.
13,530 cases included in the external validation cohort, the incidence of 30-day mortality
was 0.21% (29/13,530)
Among the surgical encounters with a PRAm score ≥6, mortality was 2.62% (20/762) as
compared to 0.07% (9/12,768) among the encounters with a PRAm score <6 (P < .001).
PRAm scores of ≥6 and ≤3 are the optimal cutoff points for determining at which threshold
a child’s risk of mortality markedly increases and decreases, respectively
Pediatric Risk Stratification Is Improved by Integrating Both Patient
Comorbidities and Intrinsic Surgical Risk (Nasr et al, Anesthesiology, 2019)
Predicted risk of 30-day mortality ranges from 0% with no comorbidities to 4.7% when all
comorbidities* are present among low-risk surgical procedures and from 0.07 to 46.7%
among high-risk surgical procedures.
Low Risk Surgery: Risk quartile 1 (hypospadias)
Risk quartile 2 (appendicectomy)
High Risk Surgery: Risk quartile 3 (Laparoscopic gastrostomy)
Risk quartile 4 (ex lap, PD cath, trach)
*The 5 Comorbidities: weight <5 kg, ASA 3+, preop vent support, preop inotrope, preop
sepsis
Key
● < 5,000
● 5,000 - 6,000
● 6,000 - 10,000
● > 10,000
Hot Topics in Pediatric Anesthesia
SAFETY
● Intraoperative Cardiac Arrest
● Unplanned reintubation within 24hrs
● Unplanned ICU admission within 24hrs
● Unplanned Hospital readmission for outpatient surgery
● Activation of rapid response team within 24hrs
● Death within 72hrs of anesthesia (MORT-02?)
● Medication Error
EFFECTIVENESS
● PACU length of stay ≥ 120 min
● PONV requiring rescue antiemetic (PONV-03)
● Failed Regional anesthetic
● Duration of postop intubation (cardiac surgery, neonates)
EFFICIENCY
● % On time 1st case starts
● Delayed case start ≥60 min
● Emergence Duration: Surgery end --> extubation
● OR turnover time
● % Same day case cancellation
EQUITY
Consistent outcomes regardless of
● Race
● Ethnicity
● Gender
● Socioeconomic status
TIMELINESS
● % Emergent cases arriving to OR within 60
min
PATIENT-CENTERED
● Patient Satisfaction survey scores (via
MPOG’s survey app - MQUARK)
Thank You!
