MPOG Pediatric Committee Meeting
June 23, 2025
Agenda
Announcements and Updates
Dr. Vikas O’Reilly-Shah, Chair, MPOG Pediatrics Committee
Measure Review: SUS-05-Peds
Dr. Brady Still, University of Chicago
Dr. Eva Lu-Boettcher, University of Wisconsin
Measure Reviews: Patient Blood Management
TRAN-03 and TRAN-04
Dr. Jeanna Havidich, Vanderbilt
Dr. Aman Kalsi, Vanderbilt
Upcoming
Meetings
Pediatric Committee Meeting
Monday at 4pm Eastern
• Monday, December 1
st
@ 4pm ET
MPOG Retreat at ASA
San Antonio, TX
● Friday, October 10
th
Upcoming MPOG Pediatric Research Proposal
PCRC 302 - July 14, 2025 @ 10am Eastern
Practice patterns of inotropic medication use in pediatric
cardiac surgery
Primary Authors: Jakob Wollborn and Julian Hubrich
Lead Institution: Brigham and Women's
Anyone from an active MPOG site is invited to attend.
Email mpog-research@med.umich.edu if interested in attending
Updates from MPOG Quality Committee
All non-pediatric specific sustainability measures were reviewed and
voted on in May 2025
• Minimize Average Fresh Gas Flow: SUS-01 (≤ 3L), SUS-04 (≤ 2L)
– Add exclusion for ASA 5&6
– New Measure Approved: SUS-08 (≤ 1L, Maintenance)
– New Measure Approved: SUS-09 (≤ 6L, Induction)
• Global Warming Footprint: SUS-02 (maintenance), SUS-03
(induction)
– Modify to use GWP20 vs. GWP 100 values for inhaled agents
– New Measure Approved: SUS-10 (Carbon Footprint, Cuveele method)
NEW! Pediatric Comorbidity Phenotypes
Pediatric Comorbidity: Cardiovascular Disorders
Pediatric Comorbidity: Congenital Genetic Disorders
Pediatric Comorbidity: GI Disorders
Pediatric Comorbidity: Hematologic / Immunologic Disorders
Pediatric Comorbidity: Malignancy Disorders
Pediatric Comorbidity: Metabolic Disorders
Pediatric Comorbidity: Miscellaneous Disorders
Pediatric Comorbidity: Neonatal Disorders
Pediatric Comorbidity: Neurologic / Neuromuscular Disorders
Pediatric Comorbidity: Renal Disorders
Pediatric Comorbidity: Respiratory
Pediatric Comorbidity: Transplant Disorders
MPOG Pediatrics Committee Leadership
Chair
Vice Chair
● Dr. Morgan Brown will assume the Chair role starting January 2026
● Seeking interested faculty from an active MPOG site to serve as MPOG
Peds Committee Vice Chair for a 2 year term.
?
March Meeting Recap
● Peds Committee voted to Modify NMB-03
● Specific Modifications Proposed
○ Update success criteria to mg/kg/hr threshold: Cumulative NMB dose during…
■ Anesthesia Duration?
■ Procedure Room Duration?
■ Measure Duration: Anesthesia Start → Extubation?
■ First NMB Dose → Extubation?
○ Exclusions
■ Case Duration > 180 minutes
■
Emergency Cases
■ Patients with full stomach considerations
● Pyloromyotomy cases
● Short Gut (ICD10 K90.82)
Case Example: 14mo, 9.9kg, Anes Duration = 5hrs 48min
● Induction Dose = 4.04 mg/kg
● Normalized Dose = 0.8 mg/kg/hr
Should this case pass? or be
flagged for review?
Poll Questions for NMB-03-Peds
1. Measure Definition
a. Continue to measure initial NMB dose but
Exclude cases > 180 minutes
b. Continue to include longer cases but flag cases with a normalized dose > 0.5 mg/kg/hr
Rationale: if a case is expected to last longer, you may intentionally use a higher initial dose, given
that higher dosing might be justified. No clear cutoff for safe dosing over time, however one study
found doses > 0.5 mg/kg/hr were associated with higher rates of residual blockade
2. Additional Exclusions
a. Emergency Cases
b. Patients with GI Comorbidities
Rationale: Full stomach considerations for patients with pyloromyotomy and short gut
Measure Review: SUS-05-Peds
Dr. Brady Still (UChicago Medicine)
Dr. Eva Lu-Boettcher (University of Wisconsin)
SUS-05-Peds: Nitrous oxide avoided, induction
Measure Type: Process
Threshold: 90%
Description: Percentage of pediatric patients < 18 years old where nitrous oxide
was avoided during induction of general anesthesia.
Exclusion Criteria
• Age ≥ 18 years
• Patients who did not receive general anesthesia (determined by Anesthesia
Technique: General value codes > 0)
Nitrous Avoided Compliance by Institution
MPOG Hospitals, past 12 months
Nitrous Avoided Compliance by Age Group
MPOG Pediatric Hospitals, past 12 months
Sustainability Workgroup Met on April 28th
SUS-05-Peds
● The group is considering excluding standard IV inductions given to
minimize score inflation (nitrous oxide is less likely to be used during
induction for IV inductions)
Example cases that resulted as IV Induction and Flagged for SUS-05
Risk of hypoxemia
Cumin D, Baker PA, Anderson BJ. Incidence of post-induction hypoxemia in children and the effect of induction gas composition. Paediatr Anaesth. 2021
Jul;31(7):763-769. doi: 10.1111/pan.14161. Epub 2021 Mar 17. PMID: 33615619.
Summary of Proposed Modifications: SUS-05
Rationale
Recommendation: addition of the sentence, “In addition to its greenhouse warming
potential, N2O reduces the FiO2 used during preoxygenation, decreasing safe ‘
apneic time.”
Definition
Current: Percentage of pediatric patients < 18 years old where nitrous oxide was
avoided during induction of general anesthesia.
Recommendation: ……where nitrous oxide was avoided during inhalational
induction of general anesthesia.
Inclusion Criteria
Current: Pediatric patients undergoing general anesthesia
Recommendation: Pediatric patients undergoing general anesthesia with
inhalational induction
MPOG Measure Review
TRAN-03-Peds
TRAN-04-Peds
Jeana E. Havidich, MD, MS
Aman Kalsi, MBBS
June 23, 2025
Agenda
• Review Measures
• Discuss the Importance of Pediatric Patient Blood Management
• Review Current Dashboard
• Evaluate Current Metrics
• Discussion Points
• Recommendations
Patient Blood Management
PBM is defined as a
Patient-centered, systematic,
evidence-based approach to
improve patient outcomes by
managing and preserving a
patient’s own blood while promoting
patient safety and empowerment
Shander, A. , Hardy, J. , Ozawa, S. , Farmer, S. , Hofmann, A. , Frank, S. ,
Kor, D. , Faraoni, D. & Freedman, J.(2022).A Global Definition of Patient
Blood Management.Anesthesia & Analgesia,135(3),476-488.
Pillars of PBM
Pillar I: Optimize RBC mass and
avoid iatrogenic anemia
Pillar II: Minimize blood loss and
coagulopathy
Pillar III: Optimize tissue
oxygenation and tolerance of
anemia and coagulopathy
Association for the Advancement of Blood and
Biotherapies (AABB) Guidelines for Children
Recommendation 3
For critically ill children and those at
risk of critical illness who are
hemodynamically stable and
without a hemoglobinopathy,
cyanotic cardiac condition, or
severe hypoxemia, the panel
recommends a restrictive
transfusion strategy (transfuse Hb <
7 g/dl)
Recommendation 4
For hemodynamically stable
children with congenital heart
disease, the panel suggests a
transfusion threshold that is based
on the cardiac abnormality and
stage of surgical repair
Carson JL, et al. Red Blood Cell Transfusion: 2023 AABB International Guidelines. JAMA. 2023;330(19):1892–1902
Biventricular Repair Hemoglobin 7g/dl
Single Ventricle
Palliation
Hemoglobin 9 g/dl
Uncorrected
Congenital Heart
Disease
Hemoglobin 7 to 9 g/dl
Carson JL, et al. Red Blood Cell Transfusion: 2023 AABB International Guidelines. JAMA. 2023;330(19):1892–1902
AABB Recommendations based on Age and Stability: Neonates
Goobie, S. M., & Faraoni, D. (2025). Perioperative paediatric patient blood management: A narrative
review. British Journal of Anaesthesia, 134(1), 168-179
.
Challenges with PBM Metrics in Pediatrics
• Limited Evidence (expert/panel
opinion)
• Publication Bias (ICU vs OR) and
few institutions publish their results
• Currently not routinely implemented
as a Standard of Care (slow
adoption)
• Heterogeneous population
• Premature neonatesadults
• Specific considerations based on
age, weight, physiology,
comorbidities, postoperative course
• “Tank Up” practice phenomenon
• Relative lack of evidence of
complications in healthy patients
with Hgb level > 10 g/dl
• Knowledge deficit among
providers
• Lack of PBM recommendations in
pediatric hospitals
• Lag time in results may impact
clinical decisions
MPOG TRAN-03-PEDS
Most Institutions succeed
• Case will PASS if
• Hgb and Hct documented before each
transfusion volume of ≥ 15 ml/kg
• Most recent Hgb/Hct ≤ 5/16 and a volume
of < 30ml/kg transfused
• If most recent Hgb/Hct < 8/24 within 36
hours of first transfusion
Recommendations
• Defining Massive Transfusion as ≥ 40
ml/kg
• Consider including ANY transfusion (can
be ≤ 15 ml/kg)
• Clarify definition of unit
• Compliant with Best Practice
• Keep Metric
TRAN-03
Most Organizations achieve or nearly achieve the benchmark
Accessed June 14, 2025
*all ages 6 mo. - 18y
TRAN-03: Transfusion Vigilance
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
TRAN-04-Peds: Elevated Hgb/Hct Post-Transfusion
Measure Type: Outcome
Threshold: 10%
Description: Percentage of pediatric patients ≥ 6 months to 18 years old with a
post transfusion hemoglobin or hematocrit value greater than or equal to 10 g/dL
or 30% within 18 hours of Anesthesia End.
Exclusion Criteria
• ASA 6
• Patients who did not receive at least 15 mL/kg intraop
• Cardiac Bypass cases
• Cases with Massive Transfusion (≥ 40 mL/kg)
*all ages 6 mo. - 18y
A significant number of institutions
Flagged (threshold < 10%)
Comparison of Ages: Infant vs. Adolescent (Accessed June 2025)
Suggests a higher ‘pass’ rate among older children
Recommendations
• Committee to Review TRAN-04
• Consider exclusion criteria: Hemoglobinopathies
• Consider Age Categories
• Determine the cause of the large number of
‘flagged’ cases
• Reconsider if the threshold of hemoglobin of 10
g/dl is appropriate
• Consider the development of metric for neonates
Summary of Proposed Modifications: TRAN-04
PRBC transfusion definition ≥ 15 ml/kg
Recommendation: ≥ 10 ml/kg
OR any transfusion volume
Inclusion Criteria ≥ 6 months < 18y
Recommendation: limit age group to ≥ 6 months < 12y
OR patients < 50kg
Exclusion Criteria
Recommendation:
• Patients with certain cardiac or hematologic comorbidities
• Transplant cases, all cardiac cases, cranial vaults
Success Criteria - Postop Hgb < 10 mg/dl or Hct < 30%
Recommendation
• (no hematologic comorbidities): Postop Hgb < 12 mg/dl or Hct < 40%
• (hematologic comorbidities): Postop Hgb < 14 mg/dl or Hct < 45%
Participants from outside of MPOG are welcome to
join our pediatric subcommittee!
Next Meeting:
Monday December 1, 2025
4 - 5pm Eastern
Appendix
Measure Benchmark Performance
MPOG Pediatric Hospitals, Patients < 18y
April 2024 - May 2025
TRAN-03-Peds
Transfusion Vigilance: Percentage of pediatric patients ≥ 6 months to 18
years old who received a blood transfusion and had a valid hemoglobin
or hematocrit value documented within 90 minutes before each
transfusion.
TRAN-04-Peds
Overtransfusion: Percentage of pediatric patients ≥ 6 months to 18
years old with a post transfusion hemoglobin or hematocrit value
greater than or equal to 10 g/dL or 30%.
TRAN-03 vs. TRAN-04
Overtransfusion based on pre-transfusion lab check compliance
SUS-05-Peds
Avoiding Nitrous, Induction
Neonates
Infants
Toddlers
Children (2-5y)
Children (6-11y)
Adolescents (12-18y)
