Anesthesiology Performance Improvement and Reporting Exchange (ASPIRE)

Pediatric Subcommittee Meeting Minutes – June 1, 2026

Attendance:

Albert Lin, Children's Hospital NY

Mary Lyn Stein, Boston Children's

Alexander Hoffman, University of Michigan

Megan Charette, MPOG

Amber Franz, Seattle Children's

Megan Dewey, Riley Children’s

Archana Singaravelu Ramesh, Mass General Brigham

Melanie Herren, MPOG

Ashka Shah, University of Utah

Meridith Wade, MPOG

Brady Still, UChicago Medicine

Michelle Huntington, Helen Devos Children's

Cathie Jones, Boston Children's

Morgan Brown, Boston Children's

Diana O'Dell, MPOG

Nicole Horn, Riley Children's

Eva Lu-Boettcher, UW Health - Wisconsin

Nirav Shah, MPOG

Frances Guida Smiatacz, MPOG

Peter Bow, MPOG

Jane Carpenter, University of Michigan

Rahul Koka, Johns Hopkins

John Huntington, Helen Devos Children's

Rob Coleman, MPOG

Jurgen de Graaff, Weill Cornell

Robert Brustowicz, Boston Children's

Kate Buehler, MPOG

Stephanie Kahntroff, University of Maryland

Katie O'Conor, Johns Hopkins

Tiffany Malenfant, MPOG

Kirsten Groody, University of Michigan

Theodora Wingert, UCLA Mattel Children’s

Lauren Madoff, Boston Children's

Vikas O'Reilly-Shah, Seattle Children's

Marla Ferschl, UCSF

*Denotes participant from non-active MPOG Institution

Start: 1601

Minutes from March 2, 2026 meeting approved - minutes, slides and recording posted on the MPOG

website for review

Announcements & General Updates

Pediatric participation in MPOG

• MPOG now includes 32 pediatric hospitals, reflecting continued growth in pediatric representation

across the country, with smaller community and larger academic institutions both participating.

• The MPOG database now contains approximately 3.9 million pediatric anesthetic cases, providing

the numbers needed to examine subgroups that are not well represented in other datasets.

2026 Meeting Schedule

• Three Pediatric Committee meetings are planned for 2026: March 1, June 1, and October 16. The

October meeting will be held in person at the MPOG Retreat in San Diego, CA at 7am Pacific (held

the same day as the SPA meeting), with a virtual/Zoom option available.

• The Pediatric Cardiac Workgroup will reconvene in September as a virtual meeting to update

members on the recently launched pediatric cardiac renal (AKI) outcome measure and to discuss

the next cardiac measure target.

New Measure Update – Patient Blood Management (TRAN-06-Peds, Preoperative

Anemia)

Background

Patient blood management encompasses three commonly described pillars (Goobie, Faraoni 2025

narrative review): (1) screening for, diagnosing, and appropriately treating anemia; (2) minimizing

surgical, procedural, and iatrogenic blood loss; and (3) managing coagulopathic bleeding. The

subcommittee has chosen to target the first pillar (anemia).

TRAN-06-Peds is being developed as a process measure — the percentage of cases in which a patient

had preoperative anemia — focused on major non-cardiac cases at risk of possible blood transfusion

rather than the entire MPOG cohort.

Rationale and cohort development

• Morgan Brown (Boston Children's) explained that the team initially considered defining the cohort

by surgical CPT codes, but there are thousands of them, and they change year to year, making

them difficult to group. Instead, the build uses specific anesthesia CPT codes grouped into

predictably higher-risk categories: neurosurgery, head & neck, thoracic, abdominal, genitourinary,

spine, orthopedic (open hip), and soft tissue.

• Using approximately one and a half years of data (1/1/2025–4/1/2026), the refined cohort

showed an overall transfusion rate of 8.45% (cited by Morgan as ~8.5%), which the committee

considered a reasonable, appropriately high-risk cohort. Transfusion rates varied widely by

procedure — highest for intraperitoneal/liver resection (00792) at 43.1%, esophagus (00500)

30.5%, and tracheobronchial reconstruction (00539) 27.5% — with several neurosurgical

procedures also showing notable rates.

• Anemia (by WHO 2024 hemoglobin cutoffs) was common across age groups: infants <1 year

50.1%, toddlers 1–4 years 40.2%, children 5–11 years 31.1%, and teenagers 12–18 years 33.1%.

Because there is limited agreement on cutoffs for the smallest patients, a hemoglobin threshold of

11 g/dL is being used for all patients between 30 days and 5 years.

Proposed measure specification (TRAN-06-Peds)

• Description: percentage of pediatric patients undergoing elective major non-cardiac surgery who

were anemic preoperatively.

• Inclusions: pediatric patients undergoing major non-cardiac procedures, defined by the listed

anesthesia CPT codes.

• Exclusions: age >18 years; neonates <30 days; ASA 6 (including organ procurement); emergency

procedures; cardiac surgery; anesthesia duration <60 minutes; surgery duration <45 minutes;

TEE/cardioversions; liver, lung, and kidney transplant; burn debridement (CPT 01953); and missing

preoperative hemoglobin within 30 days of the procedure.

• Success: the most recent preoperative hemoglobin within 30 days of anesthesia start is above the

age-based WHO anemia threshold.

• Provider attribution: none — informational measure only.

Discussion

No questions or objections were raised when the update was presented. Morgan Brown emphasized the

measure is intended as an informational, departmental tool rather than an individual feedback measure

— sites can use it to demonstrate to surgeons and hospital leadership how much potentially modifiable

preoperative anemia exists.

Next Steps

• The MPOG Coordinating Center is building out the metric. Once built, the committee will review it,

solicit site-level feedback, and expects further cohort refinement before formal implementation.

Measure Review – Intraoperative Normothermia (TEMP-04-Peds)

Presented by Dr. Lauren Madoff (Boston Children's), the MPOG quality champion at Boston Children's

Hospital. TEMP-04-Peds_Measure Review_2026

Background

TEMP-04-Peds is the percentage of pediatric patients <18 years old with a median core/near-core body

temperature >36°C (96.8°F) during the procedure (threshold 90%). It was last reviewed in March 2023,

when changing from a median temperature to a percentage of time and increasing the minimum case

duration to >60 minutes were discussed, but the majority voted not to change the criteria; the

preoperative hypothermia/hyperthermia exclusion was added in July 2023.

Rationale (literature review, post-2023)

• A single-center retrospective cohort (<12 years) found intraoperative hypothermia (<36°C)

associated with increased hospital and ICU length of stay; risk factors included younger age, higher

ASA status, intra-abdominal or intracranial surgery, and longer surgery.

• A single-center prospective cross-sectional study (<18 years, axillary temperature before

extubation) found hypothermia associated with large fluid volumes (≥500 cc) and longer

surgery/anesthesia times, and noted core temperature drops sharply in the first 40–60 minutes of

anesthesia (literature range 30–90 minutes).

• A risk-scoring-system study found surgery and anesthesia >2 hours associated with much higher

hypothermia risk and reaffirmed preoperative hypothermia as a contributing factor.

• Dr. Madoff found no studies that used a median temperature to define hypothermia; published

studies use a single time point or a duration of hypothermia.

Proposed changes (Dr. Madoff)

1. Clarify the inclusion criteria to explicitly state patients <18 years of age (no change to who is

captured, added for consistency).

2. Change the success criterion from a median core temperature <36°C to a duration of hypothermia

(temperature <36°C for a specified period; ~30 minutes suggested).

3. Increase the minimum case duration from >30 minutes to >60 minutes. No change proposed to

provider attribution.

Discussion

• Cathie Jones (Boston Children's) noted the ASA standard historically required temperature

monitoring for cases >60 minutes but now bases it on when significant temperature changes are

expected; she supported lengthening the threshold, noting that quick cases (e.g., ear tubes) that

unexpectedly run long can fall out of bounds. She also asked whether the measure counts any

temperature or only true core values, since axillary/skin readings can misrepresent.

• Vikas O'Reilly-Shah (Seattle Children's), who performed the original review, explained the median

was chosen as a compromise given case-length issues (a percentage-of-case approach penalizes

longer cases with time to recover) and the absence of literature on whether rewarming mitigates

harm or whether any hypothermic exposure is the critical factor. He noted evidence linking

hypothermia to SSI was thin — citing an older study suggesting hypothermia was protective

against SSI and the Wagner paper finding unintended perioperative hypothermia inversely

associated with SSI — whereas hyperthermia showed directionally positive association, prompting

the hyperthermia exclusion.

• Kate Buehler (MPOG) noted this same discussion (60 minutes, area under the curve) occurred at

the prior review but pivoted to hyperthermia, which was addressed first; area under the curve

was difficult to implement. The recurring sticking point is tying the measure to outcomes given

limited evidence, though newer studies in today's review may make reanalysis worthwhile.

• Robert Brustowicz (Boston Children's) suggested a retrospective analysis of existing data to see

whether changing the criteria would cause a large divergence in which cases are flagged. Morgan

Brown agreed and proposed testing on a small sample.

• Nirav Shah (MPOG) asked which construct — median, percentage, or duration of time — would

be most intuitive for a provider or quality champion reviewing their own data, leaning toward

time or percentage over the median.

o Lauren Madoff and Morgan Brown both favored a defined duration of time over a

percentage, since a percentage is difficult to interpret across cases of very different lengths.

• Katie O'Conor (Johns Hopkins) raised area under the curve as potentially the most scientifically

valid option (combining duration and severity) but the least intuitive to describe to non-

statisticians. Morgan Brown agreed it has advantages but would be computationally difficult to

build de novo and is well suited to a research project.

o Morgan Brown encouraged sites to submit combined NSQIP pediatric data (capturing

surgical site infections) to enable an MPOG outcome study on hypothermia; Boston

Children's and Seattle Children's already do so.

• John Huntington (Helen Devos Children's) asked via chat whether a proposed hypothermia

duration would be cumulative or based on any single hypothermic episode.

o Morgan Brown indicated the hypothermia duration would be cumulative, to avoid errors

from a temperature probe falling out.

• Eva Lu-Boettcher (UW Health - Wisconsin) commented via chat that she favored extending to 60-

minute cases, since many ENT procedures fall between 30 and 60 minutes at her institution.

Decision

• A live poll was conducted; Morgan Brown reported that the vote favored adopting Dr. Madoff's

proposed modifications (clarify <18-year inclusion; change the success criterion from median

temperature to a duration of hypothermia <36°C; and increase the minimum case duration from

>30 to >60 minutes), pending the Coordinating Center's review of votes (one per site) and posting

of the final decision on Basecamp.

Next Steps

• The Coordinating Center will tally votes (one per site) and post the decision on Basecamp.

• The team will consider a retrospective sample comparing flagged cases under the current versus

proposed criteria to confirm whether the change alters which cases are captured.

Measure Review – Multimodal Analgesia (PAIN-01-Peds)

Presented by Dr. Morgan Brown (Boston Children's). PAIN-01-Peds_Measure Review_2026

Background

PAIN-01-Peds is the percentage of pediatric patients <18 years old who undergo a procedure and

receive at least one non-opioid adjunct preoperatively or intraoperatively (threshold 90%). Qualifying

adjuncts include acetaminophen, NSAIDs, ketamine, clonidine, and dexmedetomidine, as well as local,

regional block, caudal, or epidural techniques; dexamethasone given alone is not counted, and IV

lidocaine infusion currently counts as an alternative to a regional technique.

Rationale (literature review)

• Olejnik et al. (JAMA Pediatrics 2025), a network meta-analysis of acute pain in children, showed

benefit in pain scores for NSAIDs, opioids, and ketamine, but little benefit for acetaminophen or

tramadol; NSAIDs were most efficacious at reducing both opioid use and the need for rescue

medication.

• Ali et al. (JAMA 2026), two randomized trials in children's musculoskeletal injury, found the

ibuprofen arm gave the most benefit; adding acetaminophen or hydromorphone provided no

further pain reduction.

• Paterson et al. (JAMA 2025), an adult colonic-surgery trial of IV lidocaine using functional gut-

recovery outcomes, found no benefit and no change in intraoperative or postoperative opioid use.

• Hua et al. (Pain Physician 2025) found some benefit to preoperative acetaminophen in children,

though Dr. Brown noted the study quality was low and the literature sparse.

• Raval et al. (ENRICH-US stepped-wedge cluster RCT) found poor adherence to pediatric ERAS order

sets despite EHR integration — preoperative analgesics in only 33% of cases and regional blocks in

44% — but a significant reduction in length of stay and complications when ≥13 components were

delivered.

• Summary: multimodal analgesia remains strongly supported in principle but the data is only

moderate, and not all adjuncts are equal. NSAIDs are most efficacious; ketamine reduces pain

scores but not rescue-medication need; dexmedetomidine is tempered by increased PACU stay

and unclear benefit; IV lidocaine was not helpful in the new adult trial; magnesium, gabapentin,

and clonidine have limited data (gabapentin falling out of favor); regional anesthesia reduces

opioid consumption; and ERAS works when actually implemented. Limitations include reliance on

opioid-consumption outcomes, single-agent-versus-placebo designs, a narrow set of studied

procedures (tonsillectomy, scoliosis, inguinal), little neonatal/infant data, and little polypharmacy

side-effect data.

Proposed changes (Dr. Brown)

1. Remove the cardiac (open cardiac) exclusion — extubated cardiac patients should still receive

multimodal analgesia (patients who remain intubated and go to the ICU remain excluded).

2. Consider removing IV lidocaine as a qualifying adjunct, given the negative adult trial and because

patients on a lidocaine infusion are highly likely to receive another adjunct anyway.

3. Leave the remaining criteria unchanged for now while watching the literature, particularly

regarding intraoperative acetaminophen (costly, with uncertain benefit).

Discussion

• Morgan Brown noted that most sites already perform well on this metric (above the 90%

benchmark), raising the question of its ongoing value and reinforcing the need for an outcome-

based pain measure (e.g., PACU pain score or rescue opioid) — a topic for the next meeting.

• Cathie Jones (Boston Children's) asked about patients with known kidney issues that limit

options, noting potential problems for the tonsillectomy population if acetaminophen were ever

removed.

o Morgan Brown clarified that acetaminophen would not be removed in the near future and

that the measure currently does not exclude for comorbidity, as it is designed to capture as

many patients as possible.

• Cathie Jones asked via chat what period counts as preoperative, given fracture patients who

arrive having recently received Tylenol and ibuprofen.

o Kate Buehler (MPOG) responded via chat that the preoperative window is defined by the

MPOG Preop Start Time phenotype.

• Eva Lu-Boettcher (UW Health - Wisconsin) commented via chat that the strongest opioid-sparing

evidence for acetaminophen comes from the PCA population in pediatrics;

o Morgan Brown acknowledged she had not examined that area specifically.

• Cathie Jones asked why central lines are excluded and whether that includes ports, since oncology

patients frequently receive them and can have postoperative pain.

o Morgan Brown, Meridith Wade, and Nirav Shah (MPOG) explained the exclusion originated

from a site request (similar to lumbar punctures) for minor anesthesia-only procedures and

is likely a remnant from the adult side, where central lines were considered minor and

confounded pain scores; it was not intended to exclude surgical procedures such as ports or

tunneled lines.

o Cathie Jones agreed that excluding LPs is reasonable but noted pediatric patients undergo

many tunneled lines with tunnel-site pain.

Decision

• A live poll was conducted (continue / modify / retire; >50% required to retire; one vote per site).

Morgan Brown reported that the vote was likely to favor adopting the proposed modifications

(remove the cardiac exclusion; remove IV lidocaine as a qualifying adjunct)

Next Steps

• The team will examine the central-line exclusion to determine whether ports and tunneled lines

are being captured and whether they should be included.

• The committee will pursue an outcome-based pediatric pain measure (PACU pain score / rescue

opioid) at the October meeting.

Next Steps (Overall)

• TRAN-06-Peds: Coordinating Center to complete the build; committee to review and refine the

cohort and solicit site feedback once available.

• TEMP-04-Peds and PAIN-01-Peds: votes to be tallied (one per site) and final decisions posted on

Basecamp.

• Next Pediatric Committee meeting: October 16, 2026, in person at the MPOG Retreat (Zoom

available); Pediatric Cardiac Workgroup in September (virtual).

• Measure-review volunteers sought; quality champions may be contacted directly if none come

forward.

Adjourned: 1700

Full Transcript

00:06 – Morgan Brown (Boston Children's):

Perfect. All right, thanks, everybody, for joining us today. It is our second meeting of the year, and we

have another one coming up, but I'm glad everyone could make it. Next slide, Meridith, if you don't

mind — thank you. So our agenda today will be a few announcements; we'll give you a little update on

where we are with the metric we discussed in the last two meetings; and then we have two measures

for review. Dr. Lauren Madoff, one of my colleagues here at Boston Children's, will present one, and

then I'm going to review two different metrics, TEMP-04 and PAIN-01, and hopefully stimulate some

discussion. Good news: we are slowly but surely getting bigger and getting more pediatric

representation, which is wonderful. It's now 32 pediatric hospitals — you can see they're outlined here

on the map. We've still got to get to the Midwest, but it looks pretty good otherwise. Next slide. And the

overall number of cases is pretty significant now — there are 3.9 million cases in here. The more recent

data is probably going to be more robust, but it gives us the numbers to look at subgroups that either

aren't well represented in other datasets or that we just don't have access to for some rare conditions.

So it's good news overall. Thanks to everybody for all the work you put into mapping and keeping the

data coming over to MPOG, because it's a lot of work, as we all know. Next slide.

00:08 – Morgan Brown (Boston Children's):

As I was saying, we had one committee meeting in March, we have one today, and then we're going to

have one in person — hopefully with a Zoom link — in October at the MPOG Retreat. It's a nice chance

to get together and have a little face-to-face discussion. I think we'll hold it first thing in the morning, so

if you happen to be going to a different meeting, like the SPA meeting, which is always the same day,

you could come to this first and then head over to SPA and have a chance to network with everybody.

The other thing we're going to do, which we haven't done for a little while because it's been busy — and

the MPOG site has been very busy doing all this work for us — is reconvene our cardiac subgroup in

September. That will be a virtual meeting, and we'll update people on where we are with the renal

outcome we just launched in the spring, and also talk about where we want to target next for the next

metric. All right, next slide.

00:09 – Morgan Brown (Boston Children's):

So, the pediatric blood management metric. As a refresher: in patient blood management there are

multiple nice reviews, and from one of them we took the three pillars or principles of patient blood

management. We decided to target the first one, which is really making sure we're screening for,

diagnosing, and appropriately treating anemia. Our metric goal is a process metric — the percentage of

patients who actually had preoperative anemia. For this metric, we decided that looking at the entire

MPOG cohort would not be that helpful, so we wanted to target major non-cardiac cases at risk of

possible blood transfusion. We had a lot of discussion last time about what that means and who those

patients are, so I'll update you on where we are. Next slide, Meridith — thank you.

00:10 – Morgan Brown (Boston Children's):

We went through a lot of iterations and discussion about the best way to approach this. We were

initially interested in using surgical CPT codes, but we soon realized there are thousands of them and

they change year to year, which would make grouping them pretty challenging. So instead we looked at

specific anesthesia CPT codes. They fall into fairly predictable areas that we'd all agree are likely at risk:

neurosurgery cases, some of the bigger head and neck procedures, thoracics, major abdominal surgery,

some of the bigger GU procedures, major spine, open hip procedures for orthopedics, and then some

that are often called soft tissue, which is a little more generic. Next slide, Meridith — thank you.

00:11 – Morgan Brown (Boston Children's):

As a reminder, here are the exclusions we have right now. It's only pediatric patients, so we've excluded

patients over 18. We excluded neonates, because neonates having major surgery usually can't wait, so

there's little possibility of intervening on anemia even if we found it — and there's also the problem of

defining what anemia is in that age group. We eliminated ASA 6 patients, such as our organ donors, and

anything that's an emergency. We removed cardiac surgery, because that just gets more complicated.

We excluded very short cases — anesthesia less than 60 minutes or surgery less than 45 minutes. We

removed a few specific case types where there's really no opportunity to intervene: liver, lung, and

kidney transplant — you obviously have to go when the donor becomes available — and burn

debridement, which may not be listed as an emergency but can't be well planned ahead. And we had to

exclude cases missing a hemoglobin value; we decided you had to have a hemoglobin value within 30

days of surgery to make it meaningful. Next slide.

00:12 – Morgan Brown (Boston Children's):

The MPOG site is now building out the metric, but to make sure what we were getting was really what

we wanted, we looked at patients over about the last year and a half — and thanks, Meridith, for doing

all this. With those inclusions and exclusions, the rate of blood transfusion is 8.5%, which is pretty

reasonable, and so far we're happy with it; this looks like a pretty high-risk cohort. You can see there's

variation: the green dots are the number of cases and the bars are the transfusion rate. For a liver

resection or a similarly major case the transfusion rate is 43%, which is probably what your experience

would tell you if you do those cases. But there are other cases with significant transfusion rates too,

including a lot of our neurosurgical procedures. So I think we're looking pretty good. Once the metric is

built and we can show it to you, there will surely be further refinements needed on the big cohort, but

so far it's promising as a high-risk group. Next slide, Meridith.

00:14 – Morgan Brown (Boston Children's):

When we looked at that year-and-a-half group to get a sense of whether patients are actually anemic —

whether we're really looking at a problem — we took the WHO definitions for hemoglobin levels. Of

note, there's not a lot of agreement about exactly what to use in our smallest patients, those less than

one year of age, so we've elected to use 11 for all patients between 30 days and 5 years. This metric,

when you get it, is only going to be informational. It's not something you'd get in an individual email

making you feel badly about how a patient wasn't treated; rather, as a site you can use it to go to your

surgeons and hospitals and say, look how much anemia we have that we're not doing anything about,

and use it to improve care.

00:15 – Morgan Brown (Boston Children's):

When we looked at this group of patients, just to confirm there's a problem, the rates of anemia are

quite high. About a third of our children and teenagers — patients who could certainly receive some

intervention — are coming to the operating room anemic in this MPOG group. The toddlers are at 40%,

and our infants, the kids less than a year old, it's half of them. So we'll see once the metric is built; we'll

be looking for lots of feedback, with people examining their own sites and telling us what's gone well

and where we can improve. Hopefully this will be useful going forward, especially for those interested in

patient blood management. Does anybody have any questions about this? Then we'll go on to our

measure reviews.

00:16 – Morgan Brown (Boston Children's):

Okay, great. If you think of something, you can always put it in the chat, or we can talk about it later. All

right, so we'll start with Dr. Madoff, who has very kindly agreed to do the TEMP-04 review. She's the

quality champion here at Boston Children's Hospital. Take it away, Lauren.

00:17 – Meridith Wade (MPOG) (via chat):

Posted a link to the TEMP-04-Peds measure review document (Google Doc).

00:17 – Lauren Madoff (Boston Children's):

Okay, thanks, Morgan, and thank you all for having me and giving me the opportunity to present. As

Morgan mentioned, I'm going to review the TEMP-04-Peds metric. Next slide, please, Meridith. Just to

refresh everyone's memory: TEMP-04-Peds is the percentage of pediatric patients less than 18 years old

who have a median core or near-core body temperature greater than 36 degrees Celsius during the

procedure. The threshold for passing is 90%. The inclusion criteria is defined as pediatric patients

requiring anesthesia care. Next slide, please.

00:17 – Lauren Madoff (Boston Children's):

Here are the exclusion criteria: age greater than 18, ASA 5 and 6 cases, cases less than 30 minutes, cases

without a temperature documented, and preoperative hypothermia and hyperthermia — that last one is

new, added the last time this measure was reviewed in 2023. MAC cases are excluded, and then there

are the procedure types listed; the GI procedures, endoscopy, and ERCP were also added back in 2023

when this measure was last reviewed. Next slide, please, Meridith.

00:18 – Lauren Madoff (Boston Children's):

I wanted to briefly review what was discussed three years ago, the last time this measure was

addressed. The background articles referenced, not surprisingly, showed that hypothermia can lead to

adverse events — mostly SSIs were discussed. It was also noted that hyperthermia can be detrimental;

one study referenced the problems with a temperature greater than 38. They also discussed that

preoperative temperature may be a contributing factor, which is why preoperative hypothermia and

hyperthermia were added to the exclusion criteria. There were variable outcomes reported across these

studies, which led to a big discussion about the median temperature being problematic for this

measure. At the time there was discussion about changing from a median temperature of 36 to a

percentage of the total intraoperative time, and about increasing the included procedure duration to

greater than 60 minutes rather than greater than 30. There was a vote, and the largest percentage

voted not to change the criteria — but looking at the percentages, there was quite a lot of variable

interest in changing some of these things. So I'm going to readdress some of these again as I go through

the updated data. Can we go to the Google Doc, Meridith, please? Thank you.

00:20 – Lauren Madoff (Boston Children's):

When I did a literature search, oddly enough most of what came up first were the studies referenced

three years ago, so some of what we referenced before is still the core driving this metric. I looked at

studies from 2023 and newer. The first study was a single-center retrospective cohort of patients less

than 12 years of age who had one or more episodes of intraoperative hypothermia — a temperature

less than 36. They found this hypothermia was associated with increased hospital length of stay and

increased ICU length of stay. Risk factors tended to be younger age, higher ASA status, certain surgeries

— intra-abdominal or intracranial — and longer duration of surgery; I'll reference that again, because I

think it'll be important in our discussion.

00:21 – Lauren Madoff (Boston Children's):

The next study was a single-center prospective cross-sectional study of patients less than 18. They took

a single axillary temperature prior to extubation and found that patients who tended to be hypothermic

were those who received large amounts of fluid — 500 cc's or more — and that longer surgery and

longer anesthesia times were more likely to lead to hypothermia. They also noted that core body

temperature drops sharply in the first 40 to 60 minutes of anesthesia; in the literature I've seen

anywhere from the first 30 to 90 minutes. That can be a factor in our discussion later. The last study I

pulled up was a group trying to develop a scoring system to assess risk factors for intraoperative

hypothermia. Similar to the others, they found that surgery greater than two hours and anesthesia

longer than two hours was associated with much higher risk of intraoperative hypothermia, and they

noted that preoperative hypothermia was also a contributing factor — strengthening the evidence we

saw three years ago.

00:23 – Lauren Madoff (Boston Children's):

Considering all that, I wanted to readdress a couple of issues raised at the last meeting in 2023. I did not

find any studies that used a median temperature to determine hypothermia; most studies look either at

a single point in time or at an amount of time the patient is hypothermic. So it's unclear to me how a

median temperature relates to patient outcomes based on the published data. The other factor worth

discussing is that most studies show longer surgical and anesthesia times put patients at higher risk for

hypothermia, so I'm wondering whether it's worth looking at longer procedures rather than procedures

less than 30 minutes.

00:24 – Lauren Madoff (Boston Children's):

In terms of inclusion criteria, currently it's defined just as pediatric patients requiring anesthesia care.

While I believe the full definition infers patients less than 18, it's not explicitly stated, so for consistency I

think it would be worth changing the inclusion criteria to say patients under 18 years of age — it

wouldn't change what goes into or out of the metric, just provide clarity. For the exclusion criteria,

currently cases less than or equal to 30 minutes are excluded, but given that longer procedures are

associated with more hypothermia and more adverse events, I wanted to discuss increasing this to cases

less than or equal to 60 minutes. And for the success criteria, currently it looks at a median core

temperature of 36; in light of the studies, I wanted to discuss changing from a median core temperature

to a duration of hypothermia — a duration of time the patient is less than 36 degrees Celsius. I was

considering 30 minutes of hypothermia, but we could discuss that as a group. I had nothing to change

about provider attribution.

00:26 – Lauren Madoff (Boston Children's):

So in summary, I propose three changes: first, change the inclusion criteria to say patients less than 18

years of age, just for consistency; second, measure a temperature below 36 degrees for a specified

period of time rather than the median temperature; and third, change the criteria to include cases

greater than 60 minutes rather than 30 minutes. I'd like to open it up for discussion.

00:26 – Morgan Brown (Boston Children's):

Great, thanks, Lauren. Let's open it up to everybody. I saw Kathy had put a comment in the chat — I

don't know if she's free to comment in person.

00:27 – Cathie Jones (Boston Children's):

Historically, the ASA standard had been that cases greater than 60 minutes needed temperature

monitoring; now they just say monitoring is needed when you're expecting significant changes in

temperature — which is why I deleted my chat comment. I don't think we expect significant changes in a

lot of these, but many places still might have, say, an ear tube case that's difficult and suddenly runs

long. I'm not typically monitoring temp during an ear tube, so a case you expected to be quick suddenly

becomes an over-30-minute case and you're out of bounds. So I think these changes are reasonable.

00:27 – Morgan Brown (Boston Children's):

Thanks, Kathy. If you want to speak up, please put it in the chat or raise your hand so I can see you.

Meridith — do you know why we chose median? Was it due to issues with data quality and getting a

temperature for a duration, or was it just something we discussed before that I've forgotten?

00:28 – Meridith Wade (MPOG):

That's a great question.

00:28 – Vikas O'Reilly-Shah (Seattle Children's):

I did the review last time — and my last name is misspelled there. We chose the median because of the

case-length issues: if you use a percentage of the case, then in a longer case versus a shorter case you

sort of penalize the cases where you have time to catch up on the temperature. The median doesn't

help that much with that either, but it was the best compromise. There also wasn't really any literature

to support, for example, whether — if you were hypothermic for part of the case and then warmed back

up — it was okay that you warmed back up, or whether the hypothermic exposure itself was the critical

thing. That's maybe a study we'd do in MPOG with sufficient data, but I just don't think we have the

literature to support the percentage question or the rewarming question, which is why we went with

the median.

00:29 – Morgan Brown (Boston Children's):

Thank you — I'm glad you could remember that, because I'd just forgotten. Any other thoughts? Forgive

me, my patients are usually cold because I do cardiac, but there's been a lot of work, often in spine

procedures, to avoid ever getting hypothermic, based on the theory that any hypothermia was bad. If

you went with time, then warming them up quickly enough — or never getting cold — would be good,

but staying pretty cold for a while would at least be a trigger for people looking at this issue in their

patients. I don't know what everyone else thinks.

00:30 – Vikas O'Reilly-Shah (Seattle Children's):

My recollection from the review was that the evidence for hypothermia was actually pretty thin for SSI.

If you scroll up, you'll see one paper that said hypothermia appeared to provide protection against SSI in

that patient population — obviously an older study — and the Wagner paper also found that

unintended perioperative hypothermia was inversely associated with SSI. That's why we added the

hyperthermia piece, because hyperthermia did seem to have directionally positive evidence that it was

associated with SSI. That was my review at the time.

00:31 – Lauren Madoff (Boston Children's):

Morgan, I don't think it's completely clear which is the best way to go. If you look at the survey results

after that review, it wasn't much different between people who wanted to keep the median and people

who wanted to change to a percentage or a duration of time. It's controversial because we just don't

have great data showing what's best — as Dr. O'Reilly-Shah said, what is the end result of the

hypothermia: is it the amount of time, or is it any hypothermia? I could see it going either way. I'm

suggesting changing it just because I haven't seen any studies using the median, whereas there are some

that show hypothermia over a period of time.

00:31 – John Huntington (Helen Devos Children's) (via chat):

If you are proposing a duration of hypothermia, is this a cumulative, or any single hypothermic episode

of a particular duration?

00:32 – Kate Buehler (MPOG):

This exact discussion — the 60 minutes, the area under the curve, all of it — was discussed last time, but

Dr. O'Reilly-Shah is correct that the conversation pivoted to hyperthermia, so we chose to remedy that

first. Dealing with area under the curve was tricky; we weren't exactly sure how to do it. Moving to 60

minutes seems like we're repeating history — which is fine, because apparently this is a conversation

that needs to be had — so maybe this time we modify it based on this feedback, at least skewing toward

including longer cases.

00:32 – Kate Buehler (MPOG) (via chat):

Posted a link to the March 2023 Peds meeting summary.

00:33 – Morgan Brown (Boston Children's):

Maybe the other interesting thing — I think the question is whether this would really change much.

Even if we change it, are we going to get the same cases? The people who are cold are actually cold,

whether you look at the median temperature or at 30 minutes. Meridith, do you think it might be

possible to take a small sample of cases and show that? We could potentially vote on lengthening the

time now, but show at the next meeting whether it really changes anything and whether it's worth

pursuing.

00:34 – Kate Buehler (MPOG):

I think the issue was tying it to outcomes — that's what comes up over and over. Say we go for longer

cases and require 30 minutes of hypothermia: then what? Are the outcomes worse? That's where the

conversation landed last time — there's just not enough evidence. It does look like there are some

newer studies identified in today's review, so maybe it's worth doing that analysis. I'm just curious about

tying it back to the actual outcome — is there some way we could do that?

00:34 – Morgan Brown (Boston Children's):

Well — a little sidebar — submit your NSQIP data, because they have surgical site infections, and then

we could actually do that. We just did it here, and I know Seattle has, and a few other places, so if you're

interested in doing that, it would be a great opportunity to get more data in. And I hear you, Kate. What

I was thinking is that, granted, I'd love someone to do a research project on this, but inherently we all

believe that being cold is probably not good for these kids. So without conclusive proof of exactly what

matters, what's the easiest way for people to use this information? Does it make sense to get a report of

cases where your median temperature was cold, or does it make more sense to get a report of cases

where you were cold for a longer period of time? What would make people want to change themselves,

or go to their colleagues and say this is not okay?

00:34 – Vikas O'Reilly-Shah (Seattle Children's) (via chat):

We need peds centers to submit combined NSQIP peds data! That's how we get a good MPOG study on

this question.

00:36 – Nirav Shah (MPOG):

I see a couple of folks have their hands up — Dr. Jones and Dr. Brustowicz — and then I have one

comment related to that as well, so I'll put my hand up.

00:36 – Morgan Brown (Boston Children's):

Perfect. Why don't we go — Dr. Brustowicz, you go for it.

00:36 – Robert Brustowicz (Boston Children's):

Oh, thank you, but I think Kathy was actually in front of me.

00:36 – Morgan Brown (Boston Children's):

Sure — then go, Kathy.

00:36 – Cathie Jones (Boston Children's):

My concern about leaving it at 30 minutes is that even if they're cold, you have limited opportunity to

actually warm them, so what are we showing? We're showing that pre-op needs to do something

differently — which we can probably impact in some ways — but that says less about the anesthetic and

more about cold rooms, pre-op, and what your kids are wearing. So I'd be in favor of lengthening it,

because then we have an opportunity to improve the temperature. Also, is this measuring any

temperature, or only a true core temperature? We have a lot of skin temps that get measured, or non-

core like an axillary, where once they hit 36 I figure they're probably 37.

00:36 – Eva Lu-Boettcher (UW Health - Wisconsin) (via chat):

I am in favor of extending to 60-minute cases, since a lot of ENT procedures fall between 30 and 60

minutes, at least at our institution.

00:37 – Meridith Wade (MPOG):

Yeah.

00:37 – Morgan Brown (Boston Children's):

It depends how you label it, Kathy. If you have it properly labeled as skin, it goes in as skin and doesn't

get counted. If you have it labeled as something else, it's considered core, because almost everything

else is considered core.

00:37 – Cathie Jones (Boston Children's):

Okay.

00:37 – Robert Brustowicz (Boston Children's):

What I was going to ask is whether it would be possible to go back and look — if you changed the

criteria — to see if there was a large divergence in the cases that were flagged. In other words, go

retrospective, since we already have the information, and see how our current criteria would differ from

the proposed criteria, and whether that's significant.

00:38 – Morgan Brown (Boston Children's):

Yeah, that's what I was getting at, Bob — is there a way to do just a small piece of it, because obviously

everything is effort for the MPOG team. But that's definitely something we could think about doing. I

can't see everybody's faces for some reason, so I'm missing all these hands — I'll work on that — but

why don't you go ahead, Nirav?

00:38 – Nirav Shah (MPOG):

Thanks, everyone. I wanted to follow up on your point, Morgan: if you were a provider or quality

champion looking at this, what would be most meaningful? If I immediately saw that my median

temperature was, say, 35.6, would I have to do some processing to understand that my patients are

hypothermic — versus knowing that my patients were hypothermic for more than 30 minutes, or more

than 25% of the case? So I wanted to ask the group: if you were reviewing this for your own institution

or your own data, which would be the most intuitive hypothermia construct to understand — a

percentage, a median value, or the amount of time? I agree it's probably either the amount of time or a

percentage; between those two I don't know that one is better than the other, but I'm curious whether

others have thoughts.

00:39 – Morgan Brown (Boston Children's):

I asked the question because I'm a little biased personally — I think the time is the one I'd respond best

to. But I don't know what others think. What do you think, Lauren? You posed the question, so what

would you prefer?

00:40 – Lauren Madoff (Boston Children's):

When I consider percentages — if I did a bunch of 35-minute cases and we're looking at a percentage,

those kids might only have a low temperature reading for five minutes, whereas if I'm doing a bunch of

spines or long cases, that percentage is a much longer period of time. So for me, a defined period of

time would be more helpful, because a percentage doesn't tell me how much time that really is across

all the different cases I do.

00:40 – Morgan Brown (Boston Children's):

That's a really good point — you'd be pretty biased if you're doing a bunch of little cases versus long

cases. Okay, anyone else like to comment? Otherwise we can go ahead and vote on the proposed

changes.

00:41 – Katie O'Conor (Johns Hopkins):

I just wanted to add — we alluded to it but didn't really talk about the area-under-the-curve option. It's

probably the least intuitive using that language, but in a way it may be the one that's most scientifically

valid — it's the combination of the amount of time and the badness of the hypothermia. It's not going to

resonate easily, but if anyone has an idea of how to describe it in a way that makes more sense to a non-

statistician, that may be another option that actually captures the most scientifically valid measure. We

spent the most time on it last time. I just wanted to throw it out there.

00:42 – Morgan Brown (Boston Children's):

Thanks, Katie — you're cutting out a little, but I think we got the idea that area under the curve would

probably provide several advantages. The biggest disadvantage from an MPOG Central standpoint is

that doing that de novo would be computationally difficult — there are going to be errors — and I don't

know if anyone has tried anything like this with temperature; they probably haven't. Again, this is ripe

for a research project if someone is so inclined, which would then support using the area under the

curve.

00:43 – Morgan Brown (Boston Children's):

Did you want to show the current benchmark data, Lauren and Meridith, just so you can see it? This is

the TEMP-04 as it stands, by de-identified site. The good thing about this metric — which I'll contrast

with the next one — is that you can see a fair bit of variation, and no one is perfect, which is always

good for a quality metric because it gives you somewhere to shoot for. But let's go ahead and vote.

00:43 – Meridith Wade (MPOG):

I just launched the poll, so it looks like there are some votes coming in.

00:43 – Morgan Brown (Boston Children's):

Perfect, we'll let that sit for a minute. Meridith and everyone will review all the votes — each site is only

able to vote once — and then she'll announce on Basecamp what the decision was on this metric.

Thanks, everybody, that was a great discussion, and thank you again, Lauren, for doing that.

00:44 – Lauren Madoff (Boston Children's):

Thank you, Morgan.

00:44 – Morgan Brown (Boston Children's):

You're more than welcome. Let's go to the next one. So, this is pain — and I'm not a pain person, so bear

with me. Hopefully this stimulates discussion, because I may not agree with the group. Next slide. PAIN-

01 is the percentage of pediatric patients less than 18 years old who undergo a procedure and then get

at least one non-opioid adjunct pre-op or intra-op. The threshold is 90%, and it includes all pediatric

patients requiring anesthesia care, except for the exclusion criteria we'll go through.

00:45 – Meridith Wade (MPOG) (via chat):

Posted a link to the PAIN-01-Peds measure review document (Google Doc).

00:45 – Morgan Brown (Boston Children's):

When I went through the literature I went broad, because I don't know this topic very well, and there's a

lot of interesting work coming out — major papers that are a little adjacent to peds anesthesia, but I

think there are lessons to learn. This is a nice meta-analysis published in JAMA Pediatrics last year,

where they went through the evidence for various adjuncts and tried to calculate the amount of benefit.

Note this is pediatrics and acute pain, so it includes a lot of patients with, for example, acute fractures,

but it includes other kinds of papers too. They showed good benefit in pain scores with NSAIDs, opioids,

and ketamine. Interestingly, they didn't find much benefit with acetaminophen or tramadol. So this is

something to think about — and it's one of my later points — that adjuncts are not all created equal,

and we need to start thinking about that in anesthesia. Next slide.

00:46 – Morgan Brown (Boston Children's):

Oh — yeah, no problem. I just thought for a second you were actually talking to me. The next paper is

from JAMA, published last month — a really interesting study out of Canada with two randomized trials

giving patients one or multiple agents to treat acute fracture pain. They found the most benefit from

their ibuprofen arm. Adding Tylenol gave no further benefit in pain scores, which is interesting, and

adding hydromorphone gave no further benefit either. So this is another paper telling us we don't

entirely understand multimodal analgesia as well as we'd like, and hopefully there will be more

anesthesia studies on this. Next slide.

00:47 – Morgan Brown (Boston Children's):

This is also an interesting large randomized trial in JAMA last year — this one in adults, so further from

our pediatric literature, but nice because they looked at IV lidocaine and, rather than surrogate

outcomes, actually looked at functional outcomes of gut recovery. They didn't find any benefit to IV

lidocaine, and no change in intraoperative or postoperative opioid use. It's probably one of the better-

done studies on this topic, really demonstrating it may not be as much help as we thought. Next slide.

This is probably the poorest-quality study I included, published in something called Pain Physician — I

don't know if that's even a reputable journal — looking at Tylenol use in children undergoing surgery.

They found some benefit if Tylenol was given preoperatively, consistent with our current metric, but it

just shows we're missing a lot of studies on where the benefit is, when to give it, and what to give,

because they didn't have many studies to look at. Next slide.

00:49 – Morgan Brown (Boston Children's):

The last paper, because it comes up every time we talk about pain, is the ERAS protocols. This group out

of Lurie Children's ran a stepped-wedge cluster randomized trial that many of us, including us, were sites

in. Even though he's presented it, I still don't fully understand the trial design, but basically they gave

everybody a preset group of orders, put them into everyone's EHR, and saw whether there was benefit.

They found generally poor adherence even with the EHR order sets: the preoperative analgesics they

wanted were given in only 33% of cases — and this is at major pediatric centers — and regional blocks in

only 44%, despite wanting them in most cases. The take-home is that when sites were compliant with

the components, there was a reduction in length of stay and complications, which is what we're trying

to get at with multimodal analgesia and reduced opioids. But you've got to actually do it — you can't

just say you're going to do it. Next slide.

00:50 – Morgan Brown (Boston Children's):

That's all the papers I pulled, because there are tons and a lot are poor quality. My summary is that

multimodal analgesia is still strongly supported in principle — I do it, and I think we've all bought into

the concept — but the data is only moderate at best, and it's becoming clearer that not all adjuncts are

equal. NSAIDs appear most efficacious at both reducing opioid use and the need for rescue medications.

Ketamine decreases pain scores but doesn't reduce the need for rescue medications. Dexmedetomidine,

another adjunct we've included, is tempered by increased PACU stay and unclear benefit. The new adult

trial doesn't show IV lidocaine is helpful. Of the other adjuncts — magnesium, gabapentin, clonidine —

gabapentin is really falling out of favor, even though it was in every ERAS pathway for orthopedics in the

adult world for a long time; it's not showing much help, and there's not a lot of data for clonidine either.

When we get down to pediatrics, there's even less to go by. Regional anesthesia works — we can all

agree — and decreases opioid consumption, and our ERAS protocols likely work if we actually do them.

00:52 – Morgan Brown (Boston Children's):

There are a lot of limitations: linking all this to outcomes is tricky; most pain studies just look at opioid

consumption, not pain relief or functional recovery, because that's harder. Most studies look at a single

drug versus placebo, not groups of medications and how they interact — and those recent Canadian

trials showing you don't get a lot of bang for your buck once you add other things are very intriguing. A

lot of the pediatric studies focus on three procedures — tonsillectomy, scoliosis, or inguinal surgery —

and leave out a lot; there's a little in cardiac surgery, but not much. There's very little data on neonates

or infants, and not a lot on the side effects of polypharmacy. Next slide.

00:53 – Morgan Brown (Boston Children's):

Going back to how our current peds metric is built, we've excluded a lot of cases, which I agree with, and

I can't imagine changing most of these. The only thing I'll suggest, once we get to recommendations, is

that there's no reason cardiac shouldn't be included in this metric. Historically cardiac was high-narcotic

for everybody with no adjuncts, but now that people are extubating patients in the OR, it would be

reasonable to keep the existing exclusion for extubated patients — meaning if you're intubated and go

to the ICU you're not included — but whether those ICU patients should also get multimodal analgesia is

a topic for another day. For today I didn't question that. Next slide.

00:54 – Morgan Brown (Boston Children's):

To succeed on this metric you have to have given a dose of something — acetaminophen, NSAIDs,

ketamine, clonidine, or dexmedetomidine. Dexamethasone is a possible adjunct but was previously

removed, because people often give dexamethasone for nausea and vomiting, which confounds the

metric and would probably give everybody 100% — rewarding, but not the point. The center also went

to a fair bit of work so that IV lidocaine infusion would count as an alternative to a regional technique.

Personally, after reading the adult study, I would remove that, because the data is weak at best and it

was a negative study. Next slide.

00:55 – Morgan Brown (Boston Children's):

If you look at this, people generally do really well on this metric, which raises the question: if everyone's

doing so well, it becomes less valuable. I still think there's some utility at present, but we should think

about this going forward — if everyone gets 100%, we need something different. That's where the topic

of needing an outcome-based metric for pain, which we've talked about briefly, comes in. Next slide. We

can go to the sheet. The suggestions I had for modifications were: remove the cardiac exclusion —

getting extubated after a cardiac case doesn't mean you shouldn't get multimodal analgesia; consider

removing IV lidocaine — and in general, if people are running an IV lidocaine infusion they're highly

likely to give another adjunct, so they'd probably pass anyway; and leave everything else alone for now

but really watch the literature. The most interesting thing will be if someone does a nice study on

intraoperative acetaminophen, because that's costing us a lot of money, and the question is whether it's

actually benefiting our patients. That was all I had, so I'm happy to take questions.

00:55 – Cathie Jones (Boston Children's) (via chat):

What period is considered preop? We have some fracture patients who come having had recent Tylenol

& ibuprofen.

00:55 – Eva Lu-Boettcher (UW Health - Wisconsin) (via chat):

I think the strongest opioid-sparing evidence for Tylenol comes from the PCA population in peds.

00:56 – Kate Buehler (MPOG) (via chat):

Preop Start is defined by the Preop Start Time phenotype (posted the phenotype link).

00:57 – Morgan Brown (Boston Children's):

Eva put in the chat — sorry, Eva put in the chat — that the strongest evidence for Tylenol comes from

the PCA population in peds, which may be true, but I have to say I didn't specifically get into that area.

Pain is obviously an enormous area of research.

00:57 – Cathie Jones (Boston Children's):

What are you doing about patients with known kidney issues, which may limit their options? Are we

excluding them in some way? In our tonsil population, for instance, a lot of them get Acetaminophen so

they probably pass — but if you took Tylenol out as an option in the future, that creates potential

problems.

00:58 – Morgan Brown (Boston Children's):

Yeah, that would be something to think about. It's an interesting question — it's going to take us years

to figure out whether IV Tylenol, at least, is giving us much benefit intraoperatively. I was saying that to

be controversial, Kathy; I don't think we'd take it out in the near future. We currently don't exclude for

any comorbidity — this is one of those metrics that really tries to grab as many of our patients as we

can.

00:59 – Cathie Jones (Boston Children's):

Thanks.

00:59 – Morgan Brown (Boston Children's):

Other thoughts, questions, concerns?

00:59 – Cathie Jones (Boston Children's):

I have a question — why is central line excluded, and does that also include a port? I know the oncology

kids are often the ones getting them, but they do sometimes have pain afterward.

00:59 – Morgan Brown (Boston Children's):

I don't know, Kathy — do you know, Meridith? I'm sorry to keep putting you on the spot for random

items of MPOG history, but why are central lines excluded? Is that just a central line and not a port?

00:59 – Meridith Wade (MPOG):

I believe it was a request — probably not for a formal review — from a site, similar to the lumbar

punctures, where either the patients are already on pain meds or… I think it's both PICC and ports

01:00 – Nirav Shah (MPOG):

I think it was for a bucket of anesthesia-only procedures — LPs, central lines — and this could be a

remnant from the adult population, where it was showing up as a procedure when it was considered a

relatively minor central-line procedure that didn't necessarily require an adjunct, and so it was

confounding some of the pain-performance scores. I know it was excluded on the adult side for that

reason. It may be worth seeing whether things like ports are being included, but it certainly wasn't

meant to include surgical procedures a surgeon would perform — it was mainly meant to exclude

anesthesia-focused ones.

01:00 – Morgan Brown (Boston Children's):

That was a good call-out, Kathy. The one issue with the LPs is that you may not give multimodal during

your brief anesthetic — you might have to give some narcotics — but those kids may be on multimodal

that extends beyond the period we're capturing, so you might get more cases flagged.

01:01 – Cathie Jones (Boston Children's):

Yeah, I agree with excluding LPs, because most of the time when I do them they get a little fentanyl and

have EMLA, and that's it — especially when we do them at the cancer center.

01:01 – Morgan Brown (Boston Children's):

Maybe, Meridith, we could look at the central lines and see what those cases are — whether they're

really the ports — because I think you're right, Kathy, a port would be a more major procedure, and it

would be much more reasonable to consider giving them multimodal.

01:01 – Cathie Jones (Boston Children's):

I think we do a lot of tunneled lines in peds — more than the adult world — where they have more pain,

often from the tunnel site.

01:02 – Meridith Wade (MPOG):

Yeah, I can look into that, definitely.

01:02 – Morgan Brown (Boston Children's):

Other questions or thoughts? We're getting close to five o'clock, so please speak up. Okay.

01:02 – Morgan Brown (Boston Children's):

Well, on that note, I hope this has sparked your interest in talking about pain, because that will be a

topic of our next meeting, where we'll try to review what we want to do with it. For TEMP-04, it looks

like our vote is to go ahead with the modifications as proposed by Lauren — great, thanks, everybody,

for participating. Now let's go ahead and vote for multimodal analgesia.

01:03 – Meridith Wade (MPOG):

Trying to get to the poll — sorry, I've got seven screens open.

01:03 – Meridith Wade (MPOG):

Just going back quickly to the temperature — there was one question from Dr. Huntington about

whether, if the proposal is a duration of hypothermia, it would be cumulative or a single hypothermic

episode.

01:03 – Morgan Brown (Boston Children's):

I think we'd want to do cumulative, because I'd be worried that if it were separated it would be an error

from someone's temperature probe having fallen out. At least, that would be my first inclination.

01:03 – Meridith Wade (MPOG):

Okay.

01:04 – Morgan Brown (Boston Children's):

All right, well, thank you, everybody, again, for coming and participating — we really appreciate

everyone's contributions. As always, reach out to Meridith if you'd like to get on the email list; everyone

at any site is welcome to join us and have these conversations about hypothermia and pain. These aren't

things everyone likes talking about, so it's nice to find other people who are interested. We'll see you

again, and it looks like we're probably going to be going ahead with the pain changes as well. Meridith,

as always, will send out updates through Basecamp, so look for that, and we'll see you in October.

01:04 – Meridith Wade (MPOG):

Thanks, everyone. And thanks, Morgan, for doing that review, and Lauren.

01:04 – Morgan Brown (Boston Children's):

No problem. And for all the quality champions on the line, going forward, if we don't have volunteers,

we're going to be emailing you to get you to volunteer.

01:04 – Meridith Wade (MPOG):

Spoiler alert.

01:05 – Morgan Brown (Boston Children's):

Exactly. It's all good — it's a good chance to review things. All right, thanks, everybody.