MPOG Pediatric Committee Meeting
March 10, 2025
Agenda
Announcements and Updates
Measure Review: NMB-03-Peds
Dr. Chuck Schrock, St. Louis Children’s Hospital
Hyperglycemia Management in Pediatrics
Dr. Ruchika Gupta, University of Michigan
Upcoming
Meetings
2025 Pediatric Committee Meetings
Mondays at 4pm Eastern
• March 10
th
• June 23
rd
• December 1
st
2025 Pediatric QI Measure Reviews
March - NMB Initial Dosing
● NMB-03-Peds Dr. Chuck Schrock, WashU
May - Sustainability
● SUS-06-Peds Dr. Eva Lu-Boettcher, UWisconsin
● SUS-05-Peds Dr. Brady Still, UChicago Medicine
June - Transfusion Vigilance / Overtransfusion
● TRAN-03-Peds Dr. Jeana Havidich, Vanderbilt
● TRAN-04-Peds Dr. Amanpreet Kalsi, Vanderbilt
Peds Cardiac Workgroup Updates
● Last met February 2025
○ Reviewed new peds cardiac procedure phenotype
○ Can now separate cases with or without bypass
● New Measure Build - AKI-03-Peds
○ Percentage of cases with AKI after
congenital cardiac surgery requiring
cardiopulmonary bypass
Pediatric Committee Meeting Recap - November 2024
PONV-04-Peds Measure Review
● Update success criteria to at least a single agent for all patients (0 risk factors), with
combination therapy of two agents for those at higher risk (≥ 1 risk factor).
● Modify definition of opioid risk factor to Multiple doses of any opioid between induction
and PACU end.
● Consider Hydrocortisone IV as an antiemetic
● Add Anticholinesterase administration intraop as a risk factor
● Update age inclusion of Infants (*pending MPOG central data analysis)
Decision: Will send out poll for MPOG pediatric site champions to vote after 2025 Consensus
guidelines are published.
Preterm Neonate
Term Neonate
Amongst Failures
Amongst Failures
Infants (28d - 12m)
Amongst Failures
Toddlers (13m - 23m)
Amongst Failures
Children (24m - 3y)
Amongst Failures
Measure Review: NMB-03-Peds
Dr. Chuck Schrock (WashU, St. Louis Children’s)
• Review of what NMB-03 measures
• How the performance measure was recently updated
• Why NMB monitoring matters
• Literature
• Data from SLCH
• Open discussion
• How have institutions achieved high success with this measure
The outcome measured
• Percentage of pediatric patients <= 5 years who receive appropriate
initial dose of non-depolarizing NMB
• Rationale:
•Infants should receive lower doses than older children
•Lower doses produce similar onset time and efficacy
•Benefits of larger doses are questionable
•Consequences of larger doses potentially greater
•Adequate monitoring can be more challenging
First Rocuronium Dose mg/kg
12 month period, n=560
136 of 560 passed = 24%
All under age 5 years
Infants, <12 months
NMB Dosing, All under 5y
NMB Dosing, Infants < 12m
Are we good at NMB monitoring?
•Half of the included (extubated) neonates had any
recorded TOF value
NMB Reversal
TOF Monitoring
NMB Dosing
R
2
=0.18
More Roc, Less monitoring
More Roc, More monitoring
Less Roc, Less monitoring
Less Roc, More monitoring
Does NMB dose correlate with NMB monitoring?
Increasing likelihood to record TOF (percentile rank)
Increasing rocuronium dose (percentile rank)
Are we monitoring neonates sufficiently?
NICU observational study.
10 infants following Rocuronium bolus, 1.5mg/kg
9 infants following Vecuronium infusion
Outcome measure, time for recovery of 70% twitch height
Are we monitoring neonates closely enough?
% of infants with TOF <70%
Roc bolus group:
-Median 11 days old
-Weight 3.6 kg
-Convenience sample of
patients who would
remain intubated after
surgery
Average Rocuronium Mg/kg
Fraction Reversed With Sugammadex
Does paralytic dose matter?
Children 0-10 years of age, N=6,500
Postoperative respiratory complications: resp failure, pul edema, reintubation,
pneumonia
Complex analysis, propensity for NMB use, and confounder adjusted analyses
Results: 1.1% of patients experiences postoperative respiratory complications
Effects of high neuromuscular blocking agent dose on
post‐operative respiratory complications in infants and children
Acta Anaesthesiol Scand, Volume: 64, Issue: 2, Pages: 156-167, First published: 17 September 2019, DOI: (10.1111/aas.13478)
• Neonates undergoing laparoscopy Ladd
• Randomized to zero, 0.45mg/kg, 0.6 mg/kg rocuronium
• Surgeons could not appreciate difference
• Anesthesia airway management benefited from low dose
Eur J Anaesthesiol. 2023 Dec 1;40(12):928-935
weight Total Roc Roc mg/kg Twitches
Package insert
sugammadex
Stoichiometric
Sugammadex
Sug doses Sug mg/kg mg/mg
3.65 7 1.9 4 of 4 7 25 10/5/16 8.5 4.4
4.1 11 2.7 triggering vent 16 40 20/16 8.8 3.3
7.3 20 2.7 triggering vent 28 72 20/15 4.8 1.8
33 40 1.2 3 of 4 65 144 70/70 4.2 3.5
Changes to measure specification
• The calculation for pass/fail now updated to achieve the
original goal of this measure
• Can the measure have an easy means of toggling
between neonates(<12 months) and children(<5 years).
Perhaps both graphs may be displayed simultaneously.
•
Questions for group discussion:
• is anyone using other NMB drugs with any frequency?
• Comments from institutions that have a high pass rates?
NMB-03: NMB Dosing, Pediatrics
1 vote / site
Continue as is/ modify/ retire
Need > 50% to retire measure
Coordinating center will review all votes after meeting to
ensure no duplication
Hyperglycemia Management in
Pediatrics
Dr. Ruchika Gupta (UMich, C.S. Mott Children’s)
Department of Anesthesiology
DEPARTMENT OF ANESTHESIOLOGY
GLU-11: measure details
Department of Anesthesiology
DEPARTMENT OF ANESTHESIOLOGY
Management of Perioperative Glucose
In Children over 12 (GLU-11 & GLU-10)
• GLU-11 measure started as an adult measure
• Expanded to include pediatric pt greater than 12 years old
• Includes cardiac & noncardiac (inpatient > 30 minute & outpatient > 4 hours)
• Diabetic or non-diabetics
• Good protocols to manage pediatric patients with diabetes
• No pediatric protocols to manage non-diabetic hyperglycemia
• No RCT or observational evidence to support treatment in
non-diabetic pediatric patients > 12 years old
• Some evidence to showing very poor outcomes with hypoglycemia
• Hesitancy to treat amongst pediatric anesthesiologists across country
Department of Anesthesiology
DEPARTMENT OF ANESTHESIOLOGY
Department of Anesthesiology
DEPARTMENT OF ANESTHESIOLOGY
Pediatric context
• Prepubertal children are more sensitive to insulin
• We have a varied population (syndromes)
• Pediatric surgery this may include: Neuro, Ortho Spine, Long Bowel
resections, Cardiac
Department of Anesthesiology
DEPARTMENT OF ANESTHESIOLOGY
Recommendations
• EXCLUDE pediatrics for GLU-11 (treatment > 180)
• Focus pediatric QI work on GLU-10 (treatment or recheck of > 180)
• Recheck OR treat within 90 minutes
• Consider diabetic-specific pediatric measure built upon
peer-reviewed recommendations
• Offer more conservative guidelines for treatment but limited data
• Identify evidence supporting non-diabetic pediatric hyperglycemia
management
GLU-11: Hyperglycemia Treatment, Periop
Description: Percentage of patients with perioperative
blood glucose >180 mg/dL with documentation of
treatment within 90 minutes.
EXCLUDE patients 12-18y?
Coordinating center will review all votes after meeting to
ensure no duplication
Participants from outside of MPOG are welcome to
join our pediatric subcommittee!
Next Meeting:
Monday June 23, 2025
4 - 5pm Eastern
Agenda
Measure Reviews:Pediatric Blood Management
Thank You!
