Introduction Postoperative pain control remains the primary reason for inpatient stay after minimally invasive repair of pectus excavatum. In a previous study, our group reported that early pain control was better in patients managed with a thoracic epidural, while late pain control was better in patients managed with patient-controlled analgesia (PCA). After revising our epidural transition and modifying the PCA protocol, we conducted a multi-institutional prospective randomized trial to evaluate these two pain control strategies. Materials and Methods Patients were randomized to epidural or PCA following minimally invasive repair of pectus excavatum with standard protocols for each arm. Primary outcome was length of stay with secondary variables including mean patient pain scores, complications, and parental satisfaction. Scores were pooled for the two groups and reported as means with standard deviation. Results were compared using t-tests and one-way analysis of variance with p-value < 0.05 determining significance. Results Sixty-five patients were enrolled, 32 epidural and 33 PCA. Enrollment was stopped early when we developed an alternative strategy for controlling these patients' pain. There was no difference in length of stay in hours between the two arms; epidural 111.3 ± 18.5 versus PCA 111.4 ± 51.4, p = 0.98. Longer operative time was found in the epidural group. Nine patients in the epidural group (28%) required a PCA in addition to epidural for adequate pain control. Mean pain scores were lower on postoperative day 0 in the epidural group compared with the PCA groups, but were otherwise similar. Conclusion In our prospective randomized trial, PCA is just as effective as thoracic epidural in decreasing early postoperative pain scores after minimally invasive repair of pectus excavatum.

Children given IVA showed no difference in the transition time off the PCA and to oral pain medications after laparoscopic appendectomy for perforated appendicitis.

Background The emergence of the COVID‐19 disease as a global pandemic caused major challenges and strained busy operating room environments. This required institutions to rethink current system functioning and urgently develop safe medical practices and protocols. Purpose To use a novel approach combining simulation‐based clinical system testing with rapid cycle deliberate practice concepts for identifying latent safety threats presented by newly developed operating room COVID‐19 protocols and collecting frontline staff recommendations for mitigation. Methods This study design combined a training/education approach with probing the systems function. The primary outcomes were the number of latent safety threats and staff evaluations of this approach for feasibility and utility on immediate and four‐month post surveys. Participants started the simulation which took place in the operating room, in the assistant role before graduating to the primary airway manager. Simulation staff members observed the simulations and noted whether elements in the protocols/checklists were followed and whether latent safety threats were present using an observation form. Solutions to latent safety threats were sought during the debriefing period. Results This approach identified 17 latent safety threats not foreseen during the planning stages and allowed for corrections to the protocols prior to impacting patient outcomes. Post‐simulation surveys indicated that the program was well received and all who responded agreed that it was worth the time it took. Fifty‐seven percent of respondents to four‐month follow‐up survey reported using the work products to care for an actual COVID‐19 patient. Conclusions This study demonstrated a flexible methodology that effectively integrated simulation‐based training and systems tests to train staff and detect latent safety threats in the new workflows and provide recommendations for mitigation. While COVID was the specific prompt, this approach can be applicable in diverse clinical settings for training medical staff, testing system function, and mitigating potential latent safety threats.

Tonsillectomy with and without adenoidectomy is a frequently performed surgical procedure in children. Although a common procedure, it is not without significant risk. It is critical for anesthesiologists to consider preoperative, intraoperative, and postoperative patient factors and events to optimize safety, especially in young children. In the majority of cases, the indication for adenotonsillectomy in young children is obstructive breathing. Preoperative evaluation for patient comorbidities, especially obstructive sleep apnea, risk factors for a difficult airway, and history of recent illness are crucial to prepare the patient for surgery and develop an anesthetic plan. Communication and collaboration with the otolaryngologist is key to prevent and treat intraoperative events such as airway fires or hemorrhage. Postoperative analgesia planning is critical for safe pain control especially for those patients with a history of obstructive sleep apnea and opioid sensitivity. In young children, it is important to also consider the impact of anesthetic medications on the developing brain. This is an area of continuing research but needs to be weighed when planning for surgical treatment and when discussing risks and benefits with patients’ families.