Category: Poster Listing

P99

‘PARA-PREMED’ - ENCOURAGING THE SWITCH FROM INTRAVENOUS TO ORAL PARACETAMOL IN PAEDIATRIC SURGERY

J. E. Dalton, E. Walton, R. Newton

UH Sussex NHS Foundation Trust, Brighton, UK

Intraoperative intravenous paracetamol (IVP) has become the standard route of administration in our paediatric theatres due to its pharmacology and ease of delivery. This poses a significant cost and environmental burden. Best available evidence shows that the efficacy of oral paracetamol is broadly equivalent to the IV route [1]. IVP is associated with greater lifecycle carbon dioxide equivalent emissions (eCO2) when compared with equivalent doses of tablet and oral liquid formulations (12-fold and 4-fold respectively) [2].

The operating departments in University Hospitals Sussex used 90,930g of IVP in 2020-2021 costing £100,000. Oral liquid paracetamol is 50% and tablets are 1% of the cost of IVP. Shortages of IVP in recent months has put strain on use. We aim to encourage the use of an oral paracetamol premed (‘para-premed’) thirty minutes pre-operatively for appropriate paediatric cases.

The PDSA method was used to implement and assess change:

1. Education: formal and informal for anaesthetists and nursing teams in the day case ward and theatres.
2. Prompting: posters on the ward and in anaesthetic rooms with stickers on the front of drug charts prompting anaesthetists to prescribe oral paracetamol.
3. Communication: regular formal (surveys) and informal dialogue with anaesthetists and ward staff to identify challenges and ideas.
4. Audit: to measure change.

After ‘para-premed’ implementation the initial audit captured 137 children. Oral paracetamol was prescribed in 50.4% cases and accepted by the child in 98%. Frequent reasons for not prescribing were prioritisation of anxiolytic premedication, lack of time to administer or unavailable weight. Children undergoing laparoscopic surgery had higher pain scores than expected, and it was hypothesised that this could be due to fewer children receiving intraoperative NSAIDs (often co-administered with IVP).

The second audit captured 53 children. Oral paracetamol was prescribed in 64% of cases and all children accepted the dose. There appeared to be no association in this sample between laparoscopic cases and increased pain scores. There were no concerns from the nursing staff or anaesthetists about safety or efficacy during this audit period.

Procurement records demonstrated an average 22% reduction in procurement of IVP to theatres with an associated increase in procurement of liquid oral paracetamol after the PDSA interventions.  Should this be sustained we expect this to generate a saving of £2500 and 345kg eCO2 per year.

We have challenged the myth of IVP being superior to oral paracetamol and demonstrated scalable financial and carbon savings. There is more progress to be made away from IVP use whilst accepting that there will always be some cases where this is appropriate. Success relies on engagement of all team members. We will aim to introduce this to our adult services.

References:

1. Mallama et al. A systematic review and trial sequential analysis of intravenous vs. oral peri-operative paracetamol.  Anaesthesia.  2021, 76. pp270-276
2. Davies et al. Environmental and financial impacts of perioperative paracetamol use: a multicentre international life-cycle analysis.  BJA.  30 Jan 2024.  URL: https://www.bjanaesthesia.org/article/S0007-0912(23)00725-0/fulltext Accessed online 8.2.24

P98

DECOMMISSIONING THE NITROUS OXIDE MANIFOLD AT A TERTIARY PAEDIATRIC HOSPITAL, LESSONS TO SHARE...

E. C. Allison, P. Branford, P. Hughes

Sheffield Children's Hospital, UK

Background/Context

Healthcare is responsible for 4-5% of the UK’s carbon footprint.

Nitrous oxide is a potent greenhouse gas and accounts for 2% of the entire NHS carbon footprint.

In paediatric anaesthesia, nitrous oxide has long been used alongside volatile anaesthetic agents for inhalation inductions.  Its perceived value lies in its lack of odour and potential second gas effect leading to smoother and more rapid onset of anaesthesia.

Many anaesthetists no longer use nitrous oxide and elimination from clinical practice is one way to move towards NetZero carbon emissions by 2040.

The Nitrous Oxide project, shockingly found that 83-98% of procured nitrous oxide is wasted and lost to the environment.  This is through leakages in manifolds and pipelines, poor stock management and theft.

Problem

Ongoing clinical use of nitrous oxide in a tertiary paediatric hospital with concomitant high wastage and consequential unnecessary carbon emissions.

At our hospital, in one year, we noted at least 83% wastage, translating to >400,000 litres of nitrous oxide, 242 tonnes of C02e.

Strategy for change

Through education and departmental buy-in, to achieve decommissioning of the nitrous oxide manifold and pipelines.

To establish a leaner method of nitrous oxide provision for those anaesthetic situations where nitrous oxide has perceived value.

Measure of improvement

To establish the degree of usage of nitrous oxide in a tertiary paediatric hospital and compare with procurement to establish the extent of wastage.

To reduce procurement of nitrous oxide, decommission the manifold and measure the reduction in carbon emissions and cost.

Lessons learnt

Departmental buy-in is key to the successful decommissioning of a nitrous oxide manifold.

Importance of starting with an education piece to clinical and managerial staff and executive teams.

Importance of surveying colleague opinions about the value of nitrous oxide in their practice, their concerns and willingness to change.

Importance of creating a working party with key stakeholders, led by anaesthesia but to include an invested executive member, estates team, pharmacy, clinical engineering, sustainability and theatre leads.

Message for others

Nitrous oxide is a largely unnecessary agent in paediatric anaesthesia.  There are alternatives such as scents in face masks and patient distraction to ensure smooth, compliant inhalation inductions when they are required.

Many of our anaesthetists never use nitrous oxide, but we have created a leaner cylinder system that allows occasional use for those anaesthetists who still feel strongly about its benefits in certain patients.  This is the step-wise compromise until such time that the entire department feel able to stop using nitrous oxide.

To our knowledge, Sheffield Children’s Hospital is the first Children’s Hospital in the UK to decommission its nitrous oxide manifold and we hope others will follow.

Reference:

1. Anaesthetic nitrous oxide system loss mitigation and management. Alifia Chakera, Scottish Government. December 2022

P97

TOTAL PANCREATECTOMY WITH ISLET CELL AUTO-TRANSPLANTATION (TPIAT) IN A 13 YEAR-OLD WITH CHRONIC PANCREATITIS: A CASE REPORT

M. Kellner¹, S. Y. Ong²

¹NHS GGC, Glasgow, UK

²NHS Lothian, Edinburgh, UK

Description:

Chronic pancreatitis (CP) in children is rare, yet can lead to significant morbidity (chronic pain, frequent admissions, poor nutritional state, poor quality of life). [1]

TPIAT is a surgical procedure involving pancreatectomy and auto-transplantation of islet cells into the patient's liver.

We present the youngest reported UK case of TPIAT for CP. Full written consent was obtained to present the case.

The patient was a 13 year-old male with a background of CP, pancreatic insufficiency (gastrostomy fed) and non-verbal autism with significant learning difficulties.

A decision to perform TPIAT was made following local, regional and national MDT discussion.

The patient was premedicated and anaesthetised via inhalational induction with parental presence. IV access was gained and nasal intubation performed. Thoracic epidural, central venous catheter, arterial line and urinary catheter were sited. Maintenance was using TIVA. Intra-operative analgesia comprised of paracetamol, magnesium, thoracic epidural.

Monitoring (standard plus CVP, core temperature, Narcotrend) was supplemented by arterial blood gases hourly for glucose and lactate levels.

An insulin sliding scale was commenced immediately post-pancreatectomy, glucose measured every 15 minutes and sliding scale adjusted accordingly. At end of operation glucose was 7.5.

Post-operatively the patient was transferred to PICU. Analgesia was thoracic epidural, Ketamine and Fentanyl infusions and IV paracetamol. Sedation was Dexmedetomidine and Propofol.

Discussion:

Surgically, this case is similar to adult practice, however anaesthetically there are additional considerations. The patient’s autism/learning difficulties added complexity and affected pre-operative assessment, induction of anaesthesia, airway management, analgesia and post-operative sedation. Significant involvement of the Learning Disability Liaison Nurse, pre-medication and inhalational induction facilitated a smooth induction. Decision for nasal intubation was made to optimise sedation post-operatively.

Tight blood glucose control (4-7) was paramount for the long-term success of the islet auto-transplant. A much higher rate of insulin was required than expected, before it plateaued, to control the glucose. This was done with input from the endocrinologist.

Total anaesthetic time was 18 hours. The time between pancreatectomy and islet cell transplant was almost 9 hours, a long time for both patient and anaesthetist. Theatre teams swapped at their usual shift hours and the surgical team had a prolonged break whilst waiting for islet cells, however the anaesthetists remained throughout the case.

Conclusion:

We present the youngest case of TPIAT in the UK. Autism/learning difficulties can create challenges and alter our approach to intra-operative and post-operative management. Time taken between pancreatectomy and infusion of islet cells was long and may in future warrant an anaesthetic team changeover. Tight glucose control is paramount. We would like to highlight the importance of the MDT approach in the management of this complex paediatric case.

Acknowledgements:

We would like to thank the patient and his family, and the whole multidisciplinary team.

Reference:

[1] Ellery KM, Uc A. Recurrent Pancreatitis in Children: Past, Present, and Future. Journal of Pediatric Gastroenterology and Nutrition. 70(4):p 413-416, April 2020. DOI: 10.1097/MPG.0000000000002619

P96

THE USE OF ARTIFICIAL INTELLIGENCE FOR SIZING OF PAEDIATRIC TRACHEAL TUBES

R. Vaughan, T. Kong Kam Wa, C. Holmes

CHI at Temple Street, Dublin, Ireland

Introduction and Aims

The appropriate size and type of tracheal tubes is important in paediatric anaesthesia. Under- or over- sizing can lead to complications, and repeated airway interventions increase the risk of airway trauma and aerosolisation exposure (1). Traditional sizing methods are known to be imprecise in practice with tracheal tube exchange rates in paediatric anaesthesia being reported as high as 31% (2). Our primary aim was to establish and back-test a bespoke tracheal tube sizing model using collected data and artificial intelligence to reflect our own population.  Secondary aim was to observe our own institutional practice in tracheal tube selection.

Methods

Data from 508 consecutive paediatric intubations was gathered, including tracheal tube type (cuffed vs uncuffed), sizes and the nature of any changes required for satisfactory airway intubation. The final tracheal tube size used was assumed to be a correct size for the patient. Data validation was performed by Alteryx™, an integrated analytics automation platform, with removal of 11 outliers. This dataset was then analysed using an artificial intelligence program, DataRobot™ to model an algorithm designed to accurately predict tracheal tube sizing. The accuracy of the artificial intelligence derived method was compared to other traditional formulae (Khine (0 – 8 years), Motoyama (greater than 2 years), Cole and Penlington (all ages)) for this same cohort.

Results

For our primary aim, DataRobot™ produced a Support Vector Machine (SVM) regressor model with specifically determined weightings of two main variables – age and weight – to produce our best fit model. The artificial intelligence model was then applied to our 508 intubation dataset. It retrospectively predicted the final size with an accuracy of 51% in cuffed and 55% in uncuffed tracheal tubes. This was higher compared to Motoyama 48%, Khine 23%, Penlington 46% and Cole 43%. For our secondary aim, the data set showed 3.9% of our cuffed tracheal tubes initially attempted required a further reintubation due to incorrect sizing, compared to 20.5% of uncuffed tracheal tubes.

Discussion and Conclusion

All tracheal tubes sizing models used exhibited lower than expected accuracy, likely due to retrospective application with the assumption of only one single size as satisfactory.  Nevertheless, superior accuracy of AI model prediction suggests that use of artificial intelligence can aid correct first-time size selection of paediatric tracheal tubes. Additionally, using an uncuffed tracheal tube increased the likelihood of requiring reintubation with an alternative tracheal tube more than 5-fold.

References:

1. Gálvez JA, Acquah S, Ahumada L, Cai L, Polanski M, Wu L, et al. Hypoxemia, Bradycardia, and Multiple Laryngoscopy Attempts during Anesthetic Induction in Infants: A Single-center, Retrospective Study. Anesthesiology. 2019 Oct;131(4):830–9.

 

2. Weiss M, Dullenkopf A, Fischer JE, Keller C, Gerber AC, European Paediatric Endotracheal Intubation Study Group. Prospective randomized controlled multi-centre trial of cuffed or uncuffed endotracheal tubes in small children. Br J Anaesth. 2009 Dec;103(6):867–73.

P95

AN EVALUATION OF ANAESTHETIC TECHNIQUE AND OUTCOMES FOLLOWING NEONATAL AND INFANT PERIPHERALLY INSERTED CENTRAL CATHETER (PICC) LINE INSERTIONS

D. Vadivel¹, Z. A. Burton²

¹Sheffield Teaching Hospitals NHS Foundation Trust, UK

²Sheffield Children's NHS Foundation Trust, UK

Background

Peripherally Inserted Central Catheter (PICC) line insertion is performed regularly in hospitalised neonates and infants for venous access, nutrition, drug administration and blood sampling. Multiple venous access attempts owing to difficult venous anatomy can cause significant distress to children and their carers. PICC line insertions may be performed under general anaesthesia (GA), awake with local anaesthesia (LA) or under sedation. Dexmedetomidine is a potent alpha-2 agonist commonly used for procedural sedation and has been successfully used as a sole sedative for paediatric radiological procedures such as MRI scans (1).

Problem

GA provides the best conditions for PICC line insertions in neonates and infants but may be complicated by comorbidity, subglottic stenosis, pneumonia, risk of hypotension, hypothermia and long-term neurological deficits or neurotoxicity (2). In our institution, neonatal and infant PICC line insertions performed awake did not always involve anaesthetic presence, potentially leading to suboptimal procedural conditions, repeated theatre visits, unplanned general anaesthesia, hypothermia and hypoglycaemia.

 Strategy for change

We hypothesised that the increased use of dexmedetomidine for PICC line insertions in spontaneously ventilating neonates and infants may improve procedural conditions with improved likelihood of success, negating the need for GA and its potential associated complications (3).  At Sheffield Children’s Hospital, we conducted a retrospective analysis of data collected over a 3-year period from patients <1 year of age undergoing PICC insertions. Mechanically ventilated patients were excluded from the analysis.

Measure of improvement

We used success rate (%) of PICC line insertion as our primary measure to compare three procedural subgroups; dexmedetomidine sedation, insertion awake with LA or under GA. Possible outcomes included successful PICC, conversion to GA, re-booking of procedure under GA, abandonment, or insertion of alternative peripheral or Broviac lines.

 Lessons Learnt

148 patients underwent PICC line insertions between October 2019 and October 2022. Three infants were excluded due to unavailable data. Mean age and weight were 10.4 weeks 4.2kg (range 1.6-11.2 kg) respectively. Indications for PICC line insertions included long term antibiotics (n=70), total parenteral nutrition (n=50), long-term IV access (n=25). As hypothesised, PICC insertions using dexmedetomidine sedation showed a higher success rate (92.5%) than insertions awake with LA (87.5%; Table 1). In the GA group, PICC success rates appeared lower (83.8%) due to this being a more complex cohort who may have had multiple previous venous access attempts and hence much higher rates of conversion to Broviac lines (n=13).

 Message for others

In our institution, dexmedetomidine sedation provides a good balance of optimal cannulation conditions and maintenance of spontaneous ventilation. This is a potential means of reducing exposure to GA risks amongst a vulnerable cohort of neonates and infants. Anaesthetic presence helps to ensure adequate vigilance during procedures, with particular attention to normothermia and normoglycaemia.

References:

1. Mason KP, Zurakowski D, Zgleszewski SE, Robson CD, Carrier M, Hickey PR, et al. High dose dexmedetomidine as the sole sedative for paediatric MRI. Pediatric Anesthesia. 2008 May;18(5):403–11
2. Ing C, Jackson WM, Zaccariello MJ, Goldberg TE, McCann ME, Grobler A, et al. Prospectively assessed neurodevelopmental outcomes in studies of anaesthetic neurotoxicity in children: a systematic review and meta-analysis. British Journal of Anaesthesia. 2021 Feb;126(2):433–44.
3. Lu Y, Peng C, Xie L, Wu Y, Gu L, Li S. Nasal drip of dexmedetomidine for optimal sedation during PICC insertion in paediatric burn care. Medicine [Internet]. 2023 Feb 10 [cited 2024 Feb 8];102(6):e32831.

P94

DECISION-MAKING AND MULTIDISCIPLINARY TEAM APPROACH FOR COMPLEX AIRWAY MANAGEMENT IN MORQUIO A SYNDROME: EXPERIENCE FROM A NATIONAL REFERRAL SERVICE

J. J. Kenth¹, E. Maughan², S. Wilkinson¹, M. de Kruijf¹, S. Jones¹, C. Butler², I. A. Bruce¹, R. Hewitt², R. Nandi²

¹The Royal Manchester Children's Hospital, UK

²Great Ormond Street Hospital for Children, London, UK

Background/Context

Mucopolysaccharidosis type IVA (MPS IVA or Morquio A Syndrome) is rare lysosomal storage disease associated with progressive, multi-level central airway obstruction due to tracheomalacia, stenosis, and tortuosity.  In severe phenotypes, disease progression culminates in near fatal, airway obstructions, which is the leading cause of death in this cohort [1,2].  Traditional management strategies have been palliative, focusing on symptom relief through non-invasive ventilation (NIV). We aimed to explore the critical role of multidisciplinary team (MDT) decision-making for a novel surgical approach (tracheal resection combined with partial upper manubriectomy) to ameliorate critical airway obstruction in children with MPS IVA [3].

Problem

Patients who progress to critical airway obstruction despite enzyme-replacement-therapy (ERT) lack definitive treatment options, with palliative care being the primary approach. This gap necessitates a novel surgical solution to manage the profound multi-level airway disease and improve quality of life.

Strategy for Change

In a collaborative effort to address near fatal airway obstruction in Morquio Syndrome, Royal Manchester Children's Hospital (RMCH), a leading European centre for metabolic disorders, partnered with Great Ormond Street Hospital (GOSH), home to the national tracheal service. A MDT approach was initiated to develop a referral-to-surgery pathway. This involved setting up a framework for pre-procedural planning, patient selection, and decision-making, leveraging the combined expertise of RMCH and GOSH. The strategy sought to refine the identification of surgical candidates and streamline the process from referral to surgery, optimising the timing for intervention

Measure of Improvement

The effectiveness of the new pathway was evaluated by measuring the referral-to-surgery time (4-6motnhs), postoperative improvements in respiratory function through spirometry, and enhanced quality of life via PedsQL(v4) questionnaires. Improvements were also sought in the consistency of MDT decision-making and the clarity of communication with referring centres and patients.

Lessons Learnt

The initiative demonstrated the critical importance of a centralised expertise and the benefits of a collaborative MDT approach. The robust referral pathway facilitated the surgical management of nine patients across the UK, with significant improvements noted postoperatively, validating the effectiveness of the strategy.

Message for Others

The centralised approach and shared decision making serve as a model for the management of rare diseases requiring highly specialised care. This QI project illustrates how pooling resources and knowledge within a national framework can lead to better patient outcomes and serve as a guide for similar high-risk interventions in other rare diseases.

Conclusion

This QI initiative underscores the value of a national referral pathway and MDT approach in managing complex airway diseases in Morquio A Syndrome. The collaborative efforts between RMCH and GOSH have not only improved patient outcomes but have also set the groundwork for the management of complex medical conditions, promoting a model that can be replicated for other rare diseases.

References:

1. Broomfield A, Kenth J, Bruce IA, Tan HL, Wilkinson S. Respiratory complications of metabolic disease in the paediatric population: A review of presentation, diagnosis and therapeutic options. Paediatric Respiratory Reviews. 2019 Nov;32:55–65.
2. Kenth JJ, Thompson G, Fullwood C, Wilkinson S, Jones S, Bruce IA. The characterisation of pulmonary function in patients with mucopolysaccharidoses IVA: A longitudinal analysis. Mol Genet Metab Rep. 2019 Sep;20:100487.
3. Frauenfelder C, Maughan E, Kenth J, Nandi R, Jones S, Walker R, et al. Tracheal Resection for Critical Airway Obstruction in Morquio A Syndrome. Case Reports in Pediatrics. 2023 May 3;2023:e7976780.

P93

MULTIDISCIPLINARY ERAS PROTOCOL SHORTENS LENGTH OF STAY AND EARLIER MOBILISATION AFTER AIS CORRECTION AND FUSION SURGERY

R. J. Morris, J. Morgan, R. Jayasuriya

Sheffield Children’s Hospital, UK

Introduction:

Enhanced Recovery After Surgery (ERAS) is a multidisciplinary evidence-based approach to perioperative care to improve patient outcomes which has been well described across a range of surgical specialties (1). A systematic review looking at the use of ERAS in scoliosis surgery showed a significant reduction in length of stay (LOS) without any increase in complication or readmission rate. Early mobilisation, multimodal analgesia and early removal of drains/ urinary catheters were common to all reported protocols (2).

We introduced a multidisciplinary ERAS program for patients with adolescent idiopathic scoliosis (AIS) with the aim of improving patient reported outcomes and reducing LOS.

Method:

Qualitative patient feedback survey of patients undergoing surgery for AIS highlighted the need for a goal directed, multidisciplinary approach to recovery in our hospital. This feedback, along with an ERAS proposal was presented to engage stakeholders at the spine MDT.

A jointly produced patient information leaflet was given to families to guide expectations. Awareness of the new pathway was raised in governance meetings and education provided for staff prior to its introduction. Comments and opinions regularly sought through multidisciplinary forums to ensure effective pathway delivery, with repeated PDSA cycles allowing refinement of the protocol. A patient flip chart with daily aims in partnership with physiotherapy was produced to empower patients and staff, allowing easy communication and highlighting where more support was needed.

Prospective audit of compliance to ERAS targets was carried out. Length of stay data was compared with data from 2013 to assess impact.

Results: 

During a 12-month period in 2013, 32 patients underwent scoliosis correction surgery for AIS with a median LOS of 7 days. Following the introduction of the ERAS pathway, 46 patients underwent surgery in a 12-month period with a median LOS of 4 days.

ERAS targets and outcomes: 

Drinking on day 0 achieved by 78%, with 84% eating on day 1. PCA stopped by day 2 was achieved by 83%, with IVI discontinued by day 2 in 67% and catheter removed in 57%. Physiotherapy targets included sitting by day 1 (achieved by 91%) and walking by day 3 (89%).

Discussion:

Introduction of ERAS for this cohort of patients has significantly reduced median LOS from 7 to 4 days.

A goal directed; multidisciplinary approach was key to successful implementation. Regular multidisciplinary meetings enabled swift identification of problems faced on the ward and barriers to early mobilisation, enabling ongoing adaptation.

Introduction of patient orientated, goal-directed flash cards encouraged active engagement and enabled effective communication between all members of the MDT. Following the successful implementation of this ERAS program for AIS patients its use will be expanded to all ambulatory non-AIS scoliosis patients.

References:

1. Ljungqvist O, Scott M, Fearon KC. Enhanced recovery after surgery: a review. JAMA Surg. 2017;152:292–298. doi: 10.1001/jamasurg.2016.4952
2. Gadyia A, Koch J et al. Enhanced recovery after surgery (ERAS) in adolescent idiopathic scoliosis (AIS) : a meta-analysis and systematic review Spine Deform 2021; 9(4):893-904

P92

APPLICATION & DOCUMENTATION OF 2023 PAEDIATRIC PERIOPERATIVE VTE PROPHYLAXIS PRESCRIBING AT ELCH

L. C. Barwell¹, L. Almasri¹, H. B. Ahmed¹, C. Johnstone², D. Philpott³, R. Sabaratnam³, K. E. Nicholson³

¹King's College London, UK

²St Thomas' Hospital, Guy's & St Thomas' NHS Trust, London, UK

³Evelina London Children's Hospital, London, UK

Background/Context

Venous Thromboembolism (VTE) is an uncommon peri-operative risk in children, occurring in 0.04-8.9% of surgical cases (Mets et al., 2020) but can cause significant morbidity.  Royal College of Anaesthetists (RCoA) Guidelines for the Provision of Anaesthetic Services (GPAS) have mandated that paediatric anaesthesia services have a VTE guideline (GPAS, 2024).  National Institute for Health and Care Excellence (NICE) state that patients 16 years plus require VTE assessment within 24 hours (NICE, 2023).  Association of Paediatric Anaesthetists of Great Britain and Ireland (APAGBI) published paediatric VTE guidelines in 2017 (APAGBI, 2017).  Services need a consistent way to assess and document VTE risk for paediatric surgical patients to minimise events.

Problem

Baseline data from Evelina London Children’s Hospital (ELCH) - a tertiary NHS hospital - revealed no VTE guidelines. A retrospective 3-month case review using modified APAGBI criteria (age 13-18yrs, weight >40kg) in Autumn 2022, found 345 patients eligible for VTE assessment. 30 (8.12%) met criteria for further assessment, revealing 29 were having orthopaedic or spinal surgery, and deemed eligible for prophylaxis, yet only 10 (2.89%) received any.  Documentation justifying this decision was limited.  This revealed a population needing assessment and appropriate documentation and decision tools were required.

Strategy for Change

Two Plan-Do-Study-Act (PDSA) cycles were developed.

PDSA Cycle 1 (9 spinal & orthopaedic patients)

Implementation of approved paediatric VTE guideline for patients aged <16yrs (NICE mandate adult guidelines >16yrs). Targeted implementation was spinal and orthopaedic patients as most eligible.  Hospital guideline mandates further VTE assessment for patients aged between 13-16, >40kg and immobile for >48hrs, compared to their baseline.

PDSA Cycle 2 (14 spinal & orthopaedic patients)

Introduction of a logic based VTE assessment & documentation tool into the electronic patient record. This was restricted to anaesthetists only.

Improvement Measures

The electronic assessment tool was not used, which was disappointing.  Despite this, most of the patients received correct VTE measures (which was no prophylaxis), but there was no documentation indicating an assessment had taken place.  It is also possible that no assessment was done. One patient was prescribed VTE prophylaxis which the audit team felt was not guideline indicated, but the surgeon wrote free text justification for the prescribing in notes. We felt hopeful about the documentation tool but it seemed unsuccessful.  This may have been due to rapid implementation to anaesthetists only, or not enough verbal and written communications.

Message for Others

Electronic solutions do not provide imminent fixes. Running this parallel to continued education is required. Moving forward, establishing whose responsibility documentation of VTE prophylaxis is, is essential for maintaining continuity. Exploring assessment and prescribing for the older age group patient, e.g. >16 years, will provide interesting opportunities to expand in this important landscape.

References:

1. Mets EJ, McLynn RP, Grauer JN. Venous thromboembolism in children undergoing surgery: Incidence, risk factors and related adverse events. World Journal of Pediatric Surgery. 2020 Apr 14;3(1). doi:10.1136/wjps-2019-000084
2. National Institute for Health and Care Excellence (NICE). Overview: Venous thromboembolism in over 16s: Reducing the risk of hospital-acquired deep vein thrombosis or pulmonary embolism: Guidance [Internet]. 2018 [cited 2024 Feb 8]. Available from: https://www.nice.org.uk/guidance/NG89
3. Association of Paediatric Anaesthetists of Great Britain and Ireland (APAGBI). Prevention of peri operative venous - APAGBI [Internet]. 2017 [cited 2024 Feb 8]. Available from: https://www.apagbi.org.uk/sites/default/files/inline-files/APA%20Thromboprophylaxis%20guidelines%20final.pdf
4. The Royal College of Anaesthetists. Chapter 10: Guidelines for the provision of paediatric anaesthesia services 2024 [Internet]. 2023 [cited 2024 Feb 8]. Available from: https://rcoa.ac.uk/gpas/chapter-10

P91

IMPROVING AWARENESS & KNOWLEDGE OF 2023 PAEDIATRIC PERIOPERATIVE VTE PROPHYLAXIS GUIDELINES AMONGST ELCH ANAESTHETISTS

L. Almasri¹, L. C. Barwell¹, H. B. Ahmed¹, R. Sabaratnam², K. E. Nicholson²

¹King's College London, UK

²Evelina London Children's Hospital, London, UK

Background

Venous Thromboembolism (VTE) is an uncommon perioperative risk in children, occurring in 0.04-8.9% of surgical cases (Mets et al., 2020), that causes significant morbidity. Royal College of Anaesthetists (RCoA) Guidelines for the Provision of Anaesthetic Services (GPAS) have mandated that paediatric anaesthesia services have a VTE guideline (GPAS, 2024). National Institute for Health and Care Excellence (NICE) state that patients older than or equal to 16 years old require VTE assessment within 24 hours (NICE, 2023). Association of Paediatric Anaesthetists of Great Britain and Ireland (APAGBI) published paediatric VTE guidelines in 2017 (APAGBI, 2017). Staff involved in the perioperative care of children require appropriate knowledge and skills to minimise their risk of VTE.

Problem

An initial survey at Evelina London Children’s Hospital (ELCH) - a tertiary NHS hospital – demonstrated that:

• 72% of anaesthetists rated their knowledge of paediatric VTE prophylaxis ‘average’ or ‘poor’.
• 53% felt ‘neutral’ or ‘not confident’ correctly prescribing VTE prophylaxis.
• 76% knew patients >13 years old should be assessed for VTE prophylaxis.

Strategy for Change

To provide knowledge-based education to the clinical team alongside launch of 2023 approved prophylaxis guideline and ensure accessibility to appropriate protocols:

1)         Educational email to relevant clinical staff with results from initial survey and information regarding guidelines.

2)         Display of paediatric VTE guidelines to trust VTE guidelines app (GSTT Thrombosis App) in collaboration with app committee for smartphone-friendly access.

3)         Reminder posters in all operating theatres to prompt assessment and documentation of eligibility and decision making, with QR codes linking Thrombosis App.

4)         Presentation at trust paediatric anaesthetics clinical governance meeting.

Improvement Measures

A second survey was circulated following our initial educational intervention to assess change in clinical knowledge and confidence.

The results showed:

• 77% of anaesthetists rated their knowledge ‘average’ or ‘poor’.
• 62% felt confident prescribing VTE prophylaxis to the correct population.
• 82% were not aware of or used the Thrombosis app.

Lessons Learnt

• Follow-up survey after educational interventions demonstrated slightly improved confidence in identifying and prescribing VTE prophylaxis, but the educational interventions did not result in improvement of reported knowledge levels amongst respondents.
• Smartphone-friendly means of access (Thrombosis app) was not utilised by clinicians as predicted, despite efforts to guide towards app through poster and presentation interventions.

Message for Others

Our results show that emails alone are insufficient in achieving successful education. Information should be widely communicated and regularly shared. Data gathering and continuous feedback cycling should be used as a way of frequently assessing intervention impact and progress towards aims. The responding group of clinicians also displayed a low uptake of this app – this should also be borne in mind when deciding to invest in a supportive app for clinicians, but further demonstrates need for a multi-dimensional educational approach.

References:

1. Mets EJ, McLynn RP, Grauer JN. Venous thromboembolism in children undergoing surgery: Incidence, risk factors and related adverse events. World Journal of Pediatric Surgery. 2020 Apr 14;3(1). doi:10.1136/wjps-2019-000084
2. National Institute for Health and Care Excellence (NICE). Overview: Venous thromboembolism in over 16s: Reducing the risk of hospital-acquired deep vein thrombosis or pulmonary embolism: Guidance [Internet]. 2018 [cited 2024 Feb 8]. Available from: https://www.nice.org.uk/guidance/NG89
3. Association of Paediatric Anaesthetists of Great Britain and Ireland (APAGBI). Prevention of peri operative venous - APAGBI [Internet]. 2017 [cited 2024 Feb 8]. Available from: https://www.apagbi.org.uk/sites/default/files/inline-files/APA%20Thromboprophylaxis%20guidelines%20final.pdf
4. The Royal College of Anaesthetists. Chapter 10: Guidelines for the provision of paediatric anaesthesia services 2024 [Internet]. 2023 [cited 2024 Feb 8]. Available from: https://rcoa.ac.uk/gpas/chapter-10

P90

BUILDING BLOCKS TO ENHANCED RECOVERY IN PAEDIATRIC PATIENTS UNDERGOING COMPLEX MAJOR SURGERY

E. R. Temple-Murray, D. P. D. Nielsen, A. J. Stilwell, C. Vega, C. Hill

King's College Hospital, London, UK

Introductions and Aims

Regional anaesthetic techniques reduce systemic opioid requirements and subsequently associated adverse effects. Our hospital regularly carries out complex major surgery for paediatric patients, including Kasai procedures for biliary atresia1 and congenital pulmonary airway malformation excisions. Traditionally these patients would receive opioid analgesia, including a nurse-controlled analgesic pump (NCA). Numerous adult studies, including a Cochrane review2, demonstrate paravertebral blocks to be equivalent or superior to intravenous opioids in managing post-operative pain3. We aimed to determine the effectiveness and side effect profile of regional anaesthetic blocks in paediatric patients undergoing major surgery.

Methods

This was a retrospective observational study reviewing the post-operative course of children undergoing major surgeries. Two cohorts were compared; standard analgesic methods of systemic opioids, caudal or epidural anaesthesia versus patients receiving regional techniques such as paravertebral block/catheter. The primary outcome was total opioid consumption. Secondary outcomes were length of stay and incidence of post-operative nausea and vomiting (PONV), pruritus, sedation, urinary retention and ileus.

Whether patients received a regional anaesthetic technique was dependent upon the responsible consultant anaesthetist. Data was retrospectively collected from electronic patient records. Data collected included post-operative pain assessments, daily peak pain score, NCA demands and rescue analgesia administered.

Results

An initial pilot study was conducted reviewing paediatric patients undergoing Kasai procedure for biliary atresia between October 2023 and February 2024. 7 patients were identified. 4(57%) patients received a paravertebral nerve block. 1(14%) patient received systemic opioids alone, 1(14%) was supplemented by spinal anaesthesia and 2(28%) patients had wound catheters, with all 3(43%) analysed in the standard care group. There were lower pain scores in the paravertebral group on days 1 and 2 post-operatively compared to the standard care group (median pain score of 0 vs 4 in the standard care group). NCA demands were similar. The pilot study numbers were small and not powered to be significant, but these results have driven the next phase of the study reviewing increased patient numbers and types of surgeries in each arm.

Discussion and conclusion

Peripheral nerve blocks as analgesic adjuncts and anaesthetic sparing techniques are underused in the paediatric population. This is despite demonstrable superiority to central neuraxial techniques and a reassuring safety profile3.

The results of our pilot study demonstrate positive benefits to performing peripheral nerve blocks for paediatric patients undergoing major surgery. These results enabled us to proceed with phase 2 of the study comparing 50 patients from cases over a four-month period. The greater number of patients in phase 2 will enhance reliability in comparison of the primary and secondary outcomes between the two groups. We hope that these results will promote the use of peripheral nerve Plan A and B blocks3 in paediatric patients through demonstrating improved analgesic provision.

References:

1                Matcovici M, Stoica I, Smith K, Davenport M. What Makes A “Successful” Kasai Portoenterostomy “Unsuccessful”? Journal of Pediatric Gastroenterology and Nutrition. 2023 Jan;76(1):66.

2                Yeung JH, Gates S, Naidu BV, Wilson MJ, Smith FG. Paravertebral block versus thoracic epidural for patients undergoing thoracotomy. Cochrane Database of Systematic Reviews [Internet]. John Wiley & Sons, Ltd; 2016 [cited 2024 Feb 7];(2). Available from: https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD009121.pub2/information

3                New blocks on the kids: core basic nerve blocks in paediatric anaesthesia - Pearson - 2023 - Anaesthesia - Wiley Online Library [Internet]. [cited 2024 Feb 7]. Available from: https://associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/abs/10.1111/anae.15876

4                Arroyo AG del, Sanchez J, Patel S, Phillips S, Reyes A, Cubillos C, et al. Role of leucocyte caspase-1 activity in epidural-related maternal fever: a single-centre, observational, mechanistic cohort study. British Journal of Anaesthesia. Elsevier; 2019 Jan 1;122(1):92–102.