Anesthesiology Performance Improvement and Reporting Exchange (ASPIRE)
Pediatric Subgroup Meeting Minutes – November 30, 2022
Attendance:
Ben Andrew, Duke University
Diana O’Dell, MPOG Coordinating Center
Meridith Bailey, MPOG Coordinating Center
Vikas O’Reilly-Shah, Seattle Children’s
Nicole Barrios, MPOG Coordinating Center
Uma Parekh, Penn State
Kate Buehler, MPOG Coordinating Center
Vikram Patel, Le Bonheur Children’s Hospital
Morgan Brown, Boston Children’s
Archana Singaravelu Ramesh, Yale
Priti Dalal, Penn State
Lori Riegger, University of Michigan
Olga Eydlin, NYU Langone
Kesavan Sadacharam, Nemours
Lucy Everett, Massachusetts General
Charles Schrock, St. Louis Children’s
Jeff Feldman, CHOP
Ashka Shah, University of Utah
Amber Franz, Seattle Children’s
Nirav Shah, MPOG Coordinating Center
Bishr Haydar, University of Michigan
Ruchik Sharma, University of Virginia
Rebecca Johnson, Metro/Spectrum
Kim Strupp, Children’s Colorado
Tory Lacca, MPOG Coordinating Center
Anna Swenson, University of Minnesota
Eva Lu-Boettcher, University of Wisconsin
Brad Taicher, Duke University
Tiffany Malenfant, MPOG Coordinating Center
Meeting Summary
Announcements
● New Pediatric Subcommittee Chair and Co-Chair: Drs. Brad Taicher (Duke) & Vikas O’Reilly-Shah
(UWashington). Thank you to the outgoing chair: Dr. Bishr Haydar!
● May meeting recap- TRAN03 and TRAN04 will have a per/kg measure, ped sustainability, and
unblinded review to benchmark across MPOG pediatric sites. Any questions, reach out to
Meridith Bailey or Brad Taicher - happy to set up time to discuss what was missed.
● See website for 2023 meeting schedule
State of MPOG Pediatrics
● 27 pediatric sites to date: 2,311,506 pediatric cases. opportunity for an immense amount of
projects with this data.
● Additional pediatric hospitals have recently joined MPOG - Seattle Children’s and Boston
Children’s.
● 5 Pediatric Measures Published in 2022. Most recently published:
○ FLUID-02-Peds: See slide 10 for performance variation by site. Minimizing colloid use in
cardiac and non-cardiac cases.
○ SUS-05-Peds: See slide 12 for performance. Nitrous utilization during induction.
● 2023 Planning
○ Develop 2 new pediatric measures
■ SUS-06-Peds: Weight-based, low FGF during induction. Eva Lu-Boettcher and
Jeffrey Feldman working together on this measure- workgroup meeting in next
few months. CHOP has adopted this as a QI initiative recently and is making
good progress. Suggest to change verbiage to weight based fresh gas flows
rather than low FGF.
● Jeffrey Feldman (CHOP): Re: nitrous, can follow use rate. Maybe trial
unplugging.
● Vikas O’Reilly-Shah (Seattle Children’s): Usage went down, purchasing
remained flat. Maybe go to tank usage? But would need to be
decommissioned and that would be a large undertaking. Considerations
for Dental school.
● Lucy Everett (MGH): working on getting EPIC alert for appropriate
weight based flow for patient.
■ ABX-02-Peds: Antibiotic Timing, Intraop
○ Other Measures of interest?
■ Jeffrey Feldman (CHOP): Comment about flows during induction. Opportunity
for study- follow rate of rise of anesthetic agent concentration to demonstrate
that it doesn’t change. Can be prospective study- when induction starts goal is to
limit rebreathing
■ Kesavan Sadacharam (Nemours): In regard to Nitrous - I would like to hear
about any difference in duration of induction or increased incidence of
laryngospasm without nitrous for induction.
■ Vikas O’Reilly Shah (Seattle Children’s): As far as I've been able to discern we've
had no chance in times to IV placement nor in airway events during induction
since discontinuing nitrous
■ Charles Schrock (St. Louis Children’s) - Behavior of different machines might be a
potential variable to explore. St. Louis Children's now has a fleet of Getinge
Flow-e and Flow-i machines. South African built machines ped neonates- very
happy with them/ Have ability to smartly adjust.
■ Jeffrey Feldman (CHOP): GE is the only FDA approved in USA. Spent money to do
the trials. 18yr and up and older. robust technology, would use. Technology has
been around more than 10 years and used in other parts of the world.
● Bishr Haydar (UMich): GE Device is FDA cleared for adults only (18+
years)
■ Vikas O’Reilly-Shah (Seattle Children’s): As far as I've been able to discern we've
had no chance in times to IV placement nor in airway events during induction
since discontinuing nitrous
■ Archana Ramesh (Yale): In your experience have you seen any difference in mask
acceptance since eliminating nitrous oxide?
● Vikas O’Reilly-Shah (Seattle Children’s): Not really. Calm kids go to sleep
just as well, ones prone to getting upset or midazolam. We have a low
rate of premed, high rate of parental presence, child life/distraction, and
use of flavorings in the mask
● Jeffrey Feldman (CHOP)- No difference in mask acceptance in my
practice. Distraction, fragrance are both useful. Caveat, practice at
CHOP has a high percentage of midazolam premedication.
● Amber Franz (Seattle Children’s)-I've noticed it's helpful to have a small
amount of gas flowing when you first hand them the mask (with flavor
in mask) so that they don't notice the change in smell (as they would
when you turn on the gas after they have already smelled the mask)
■ Jeffrey Feldman (CHOP): Have not used nitrous in a long while. Don’t miss it.
APSF/ASA course on Low-Flow anesthesia can be found at the APSF landing
page:
https://www.apsf.org/apsf-technology-education-initiative/low-flow-anesthesia/
● The page has information on the practice of low-flow as well as a link to
the ASA website to access the course. Unique learning platform using
guided simulation and 8 topics taught in 15 minute modules. Free of
charge to all interested. 3 CME hours eligible for MOCA safety credits.
○ 5 Pediatric Measures Due for Review
Evaluation of PONV Consensus Guidelines in Pediatrics using MPOG Data- Dr. Lucy Everett (MGH)
● Two pediatric research studies approved through PCRC evaluating PONV outcomes
○ PCRC 0145: Aims to evaluate pediatric practice related to recommendations for PONV
prophylaxis in the recent Consensus Guidelines (used to construct PONV-04).
○ PCRC 0180: Aims to evaluate the correlation between compliance with PONV
prophylaxis and outcomes.
● Additional Questions:
○ Can we validate the previously identified risk factors or assign weighting to them?
○ 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?
● Results:
○ Descriptive data and pilot data show variability by provider. More than 2 risk factors
including hist of PONV had a higher pass rate.
○ Success on prophylaxis measure did not correlate with success on outcome measure at
either pilot center.
● Discussion:
○ Wes Templeton (Wake Forest) via chat: Another pediatric study (unrelated to PONV) -
PCRC 0143 is basically done…risk factor for hypoxemia and OLV in 4-17 years of age.
Manuscript has finished the review phase…and should be submitted shortly…
Pediatric Postoperative Mortality Project - Dr. Ruchika Sharma (UVA)
● ASPIRE measure: MORT-01: 30 day in-hospital mortality. two part project.
● Mortality Project
○ Part A: Raw POMR - UVA pilot study of unadjusted 24h, 30d POMR in 2019, 2020, 2021
■ Abstract submitted to SPA
■ Data obtained using the MPOG database - pediatric patients < 18 years of age
that underwent surgical procedure with anesthesia between 2019-2021 at the
University of Virginia Health System
■ Primary outcomes:
● Death within 24 hrs → Decision to operate, anesthetic care, ability to
care for a deteriorating patient intraoperatively/postoperatively.
● Death within 30 days → Overall hospital performance
■ Secondary outcomes: risk scores, using the Pediatric Risk Assessment (PRAm)
score
■ Results: Shared during the meeting but omitted from minutes- will be published
after SPA
○ Part B: Risk Adjusted POMR
■ STS-CCAS database: participating program outcomes are open to the public.
■ O/E ratios for benchmarking
■ 4 surgical risk categories (STAT 1-5)
○ See presentation slides 33-37 for literature to support this project
Open Discussion: 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)
● Discussion:
○ Vikas O’Reilly-Shah (UWashington): Should we benchmark quality outcomes for peds
anesthesia care? we see inst rate but not anonymized. would be nice to have that
information benchmarked. What would be interesting targets?
○ Vikas O’Reilly-Shah (UWashington): Have access to gender/sex but not gender identity.
■ Nirav Shah (MPOG Quality Director): As part of PCRC 131, we found that race
and ethnicity are under-reported in the MPOG data. Assuming this is a local
documentation issue or related to patients not being comfortable self-reporting
identity but national level is over 10% but rare for any MPOG to show > 10%.
● Vikas O’Reilly-Shah (UWashington): Is the discrepancy due to mapping
issues or single race as category? self reporting may also be an issue.
○ Nirav Shah: Don’t think the data is collected from sites
○ Brad Taicher (Duke): We find that race is being reported but
ethnicity is not. Many race projects proposed at Duke, not
ethnicity projects, since source cannot be trusted.
Meeting Concluded @ 1606
