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OBJECTIVE: Augmented reality devices are increasingly accepted in health care, though most applications involve education and pre-operative planning. A novel augmented reality ultrasound application, HoloUS, was developed for the Microsoft HoloLens 2 to project real-time ultrasound images directly into the user's field of view. In this work, we assessed the effect of using HoloUS on vascular access procedural outcomes. METHODS: A single-center user study was completed with participants with (N = 22) and without (N = 12) experience performing ultrasound-guided vascular access. Users completed a venipuncture and aspiration task a total of four times: three times on study day 1, and once on study day 2 between 2 and 4 weeks later. Users were randomized to use conventional ultrasound during either their first or second task and the HoloUS application at all other times. Task completion time, numbers of needle re-directions, head adjustments and needle visualization rates were recorded. RESULTS: For expert users, task completion time was significantly faster using HoloUS (11.5 s, interquartile range [IQR] = 6.5-23.5 s vs. 18.5 s, IQR = 11.0-36.5 s; p = 0.04). The number of head adjustments was significantly lower using the HoloUS app (1.0, IQR = 0.0-1.0 vs. 3.0, IQR = 1.0-5.0; p < 0.0001). No significant differences were identified in other measured outcomes. CONCLUSION: This is the first investigation of augmented reality-based ultrasound-guided vascular access using the second-generation HoloLens. It demonstrates equivalent procedural efficiency and accuracy, with favorable usability, ergonomics and user independence when compared with traditional ultrasound techniques.

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This article is a review of the highlights of pertinent literature of interest to the congenital cardiac anesthesiologist, and was published in 2022. After a search of the United States National Library of Medicine PubMed database, several topics emerged in which significant contributions were made in 2022. The authors of this manuscript considered the following topics noteworthy to be included in this review-intensive care unit admission after congenital cardiac catheterization interventions, antifibrinolytics in pediatric cardiac surgery, the current status of the pediatric cardiac anesthesia workforce in the United States, and kidney injury and renal protection during congenital heart surgery.

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BACKGROUND: The American Society of Anesthesiologists Physical status classification (ASA-PS) is a simple categorization of a patient's physiological status during the perioperative period. The role of ASA-PS in predicting operative risk and complications following tonsillectomy with or without adenoidectomy (T ± A) has not been studied. The objective of the study was to identify the association of the pre-operative ASA-PS with 30-day complication rates and adverse events following T ± A. STUDY DESIGN: A retrospective analysis was performed using data from the American College of Surgeons' National Surgical Quality Improvement Program database (ACS NSQIP) of patients aged 16 years or older who underwent T ± A between 2005 and 2016. Patients were stratified into ASA-PS Classes I/II and III/IV. Patient demographics, preoperative comorbidities, pre-operative laboratory values, operation-specific variables, and postoperative outcomes in the 30-day period following surgery were compared between the two subsets of ASA-PS groups. RESULTS: On multivariate analysis, patients with ASA class III and IV were more likely to experience an unplanned readmission (OR 1.39, 95 % CI 1.09-1.76; p = 0.007), overall complications (OR 1.49, 95 % CI 1.28-1.72; p < 0.001), major complications (OR 1.52, 95 % CI 1.31-1.77, p ≤ 0.001), reoperation (OR 1.33, 95 % CI 1.04-1.69; p = 0.022), and extended length of stay >1 day (OR 1.78, 95 % CI 1.41-2.25; p < 0.001) following a T ± A. CONCLUSION: Higher ASA-PS classification is an independent predictor of complications following T ± A. Surgeons should aim to optimize the systemic medical conditions of ASA-PS classes III and IV patients prior to T ± A and implement post-operative management protocols specific to these patients to decrease morbidity, complications, and overall health care cost.

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BACKGROUND: Resuscitation with blood products is often required for pediatric cardiac surgery patients following cardiopulmonary bypass. However, data suggest that blood product transfusion is an independent predictor of adverse outcomes. Most studies have specifically found detrimental effects of overall transfusion of red blood cells in particular, but few have analyzed outcomes by the other specific blood product components. AIMS: The objective of this study is to analyze adverse outcomes associated with intraoperative transfusion of specific blood product components. METHODS: A retrospective review was performed on 643 pediatric patients who underwent cardiac surgery requiring cardiopulmonary bypass to evaluate the risk of selected adverse outcomes associated with intraoperative blood product transfusion. Adverse outcomes included thrombotic complications, stroke, acute kidney injury, prolonged mechanical ventilation, and death. Univariate logistic and linear regression analyses were performed to explore the association between various blood products and the occurrence of postoperative complications. Multiple logistic and linear regression analyses were performed adjusting for age, cyanotic status, The Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery Score (STAT score), and cardiopulmonary bypass time. RESULTS: Unadjusted analysis using univariate logistic and linear regressions showed statistically significant associations of almost all blood components (per 10 mL/kg dose increments) with multiple postoperative complications, including mortality, thrombotic complications, stroke, and days of mechanical ventilation. After adjusting for patient age, cyanotic status, STAT score, and cardiopulmonary bypass time, multivariable logistic and linear regression analyses revealed no association between transfusion of blood products with acute kidney injury and stroke. Administration of red blood cells was the only category significantly correlated with increased days of mechanical ventilation (0.5 days increase in mechanical ventilation per 10 mL/kg transfusion of red blood cells). The only blood product to show complete lack of a statistically significant association with any of the studied outcomes was cryoprecipitate. CONCLUSIONS: Transfusion of blood products following cardiopulmonary bypass is associated with postoperative adverse outcomes. Future studies aimed at strategies to reduce intraoperative bleeding and decrease the amount of blood products administered are warranted.

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PURPOSE: Microsoft HoloLens is a pair of augmented reality (AR) smart glasses that could improve the intraprocedural visualization of ultrasound-guided procedures. With the wearable HoloLens headset, an ultrasound image can be virtually rendered and registered with the ultrasound transducer and placed directly in the practitioner's field of view. METHODS: A custom application, called HoloUS, was developed using the HoloLens and a portable ultrasound machine connected through a wireless network. A custom 3D-printed case with an AR-pattern for the ultrasound transducer permitted ultrasound image tracking and registration. Voice controls on the HoloLens supported the scaling and movement of the ultrasound image as desired. The ultrasound images were streamed and displayed in real-time. A user study was performed to assess the effectiveness of the HoloLens as an alternative display platform. Novices and experts were timed on tasks involving targeting simulated vessels using a needle in a custom phantom. RESULTS: Technical characterization of the HoloUS app was conducted using frame rate, tracking accuracy, and latency as performance metrics. The app ran at 25 frames/s, had an 80-ms latency, and could track the transducer with an average reprojection error of 0.0435 pixels. With AR visualization, the novices' times improved by 17% but the experts' times decreased slightly by 5%, which may reflect the experts' training and experience bias. CONCLUSION: The HoloUS application was found to enhance user experience and simplify hand-eye coordination. By eliminating the need to alternately observe the patient and the ultrasound images presented on a separate monitor, the proposed AR application has the potential to improve efficiency and effectiveness of ultrasound-guided procedures.

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OBJECTIVE: To compare the incidence and severity of acute kidney injury (AKI) after cardiac surgery with cardiopulmonary bypass and the administration of exogenous nitric oxide in children. DESIGN: A retrospective cohort study. SETTING: A single institution, university hospital. PARTICIPANTS: All children younger than 18 years of age who underwent surgery with cardiopulmonary bypass. INTERVENTIONS: Medical records of all eligible patients between January 4, 2017, and June 28, 2019, were reviewed. Patients were divided into two groups based on whether they received exogenous nitric oxide. MEASUREMENTS AND MAIN RESULTS: The primary endpoint was a change in serum creatinine level, defined as the difference between the preoperative creatinine and peak postoperative creatinine. The secondary endpoint was the incidence and severity of postoperative AKI. A difference-in-difference method using fixed-effect multiple linear regression was carried out to compare the difference in maximum serum creatinine changes between the control and intervention groups. Five hundred ninety-one patients were included in the analysis: 298 (50.5%) in the control group and 293 (49.5%) in the intervention group. Control and intervention groups did not vary significantly in terms of baseline characteristics except for bypass time. After adjusting for all baseline variables, there was no statistically significant difference in the increase in serum creatinine between the control and the intervention groups (0.01 [95% CI: -0.03, 0.05], p = 0.545). CONCLUSIONS: This single-center, retrospective, cohort study found no change in the incidence and severity of postoperative AKI after the administration of nitric oxide into the cardiopulmonary bypass circuit in children.

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INTRODUCTION: Laparoscopic Nissen fundoplication with gastrostomy tube (LPNF-GT) placement is often indicated in children with congenital cardiac diseases (CCDs) for nutritional optimization. This study aims to evaluate institutional outcomes of LPNF-GT, with a team-based approach in operative management. METHODS: Five years of an institutional database at a tertiary care children's hospital was queried for LPNF-GT in children with CCDs. Descriptive analyses were performed. A national comparison was performed utilizing the 2012-2013 Pediatrics NSQIP database, using propensity score matching. Outcome measures of interest were operative-time, unplanned readmission, and 30-day mortality. RESULTS: A team-based approach was utilized in 51 cases. Median operative time was 68.5 (IQR: 48-89) minutes. All patients tolerated tube feeds postoperatively. All patients survived 30 days post surgery. When compared to 136 similarly matched children nationally, the risk-adjusted operative time with a team-based approach was 47.38 (12.43-82.33) minutes shorter (P < .05). There were no statistically significant differences in the likelihood of being in the hospital past 30 days, unplanned readmissions, and mortality (P > .05). CONCLUSION: LPNF-GT can be safely performed in children with CCDs. A team-based approach demonstrates improved operative time and achieved similar outcomes when compared nationally.

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BACKGROUND: The benefits of cardiac magnetic resonance imaging (MRI) in the pediatric population must be balanced with the risk and cost of anesthesia. Segmented imaging using multiple averages attempts to avoid breath-holds requiring general anesthesia; however, cardiorespiratory artifacts and prolonged scan times limit its use. Thus, breath-held imaging with general anesthesia is used in many pediatric centers. The advent of free-breathing, motion-corrected (MOCO) cines by real-time re-binned reconstruction offers reduced anesthesia exposure without compromising image quality. OBJECTIVE: This study evaluates sedation utilization in our pediatric cardiac MR practice before and after clinical introduction of free-breathing MOCO imaging for cine and late gadolinium enhancement. MATERIALS AND METHODS: In a retrospective study, patients referred for a clinical cardiac MR who would typically be offered sedation for their scan (n=295) were identified and divided into two eras, those scanned before the introduction of MOCO cine and late gadolinium enhancement sequences and those scanned following their introduction. Anesthesia use was compared across eras and disease-specific cohorts. RESULTS: The incidence of non-sedation studies performed in children nearly tripled following the introduction of MOCO imaging (25% [pre-MOCO] to 69% [post-MOCO], P<0.01), with the greatest effect in patients with simple congenital heart disease. Eleven percent of the post-MOCO cohort comprised infants younger than 3 months of age who could forgo sedation with the combination of MOCO imaging and a "feed-and-bundle" positioning technique. CONCLUSION: Implementation of cardiac MR with MOCO cine and late gadolinium enhancement imaging in a pediatric population is associated with significantly decreased sedation utilization.

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PURPOSE OF REVIEW: To review the perioperative applications of point-of-care ultrasound (POCUS). RECENT FINDINGS: The role of point-of-care ultrasonography for perioperative care is expanding with respect to perioperative application. The imaging approach can complement the physical exam and provide additional information for decision-making in pediatric perioperative medicine. This review will focus on applications in the following organ systems: airway, cardiac, pulmonary and gastric. Specifically, POCUS of the airway has been used to optimize endotracheal tube depth, aid in tube size selection and predict difficulty with laryngoscopy and intubation. Lung POCUS has been used to assess for causes hypoxemia as well as to optimize ventilatory mechanics. Cardiac POCUS has been used for assessment of hemodynamics, valvular and ventricular function. Gastric ultrasound has emerged as an evaluative mechanism of gastric content in the setting of fasting as well as to confirm placement of gastric tubes. The applications of POCUS in the perioperative setting continue to evolve as a reliable diagnostic tool that can assist in timely diagnosis, improve procedural safety and has the potential to improve patient outcomes. SUMMARY: The utility of perioperative POCUS has been well demonstrated, specifically for examination of the airway, stomach and cardiopulmonary system. It is advisable for the novice sonographer to perform POCUS within the guidelines set by the American Society of Echocardiography regarding basic POCUS. As with all diagnostic modalities, understanding the limitations of ultrasound and POCUS as well as continuous self-assessment is crucial.

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INTRODUCTION: There is a myriad of factors that can lead to temperature derangements in anesthetized children undergoing magnetic resonance imaging (MRI). Temperature abnormalities in pediatric patients are associated with increased morbidity and mortality. Although some reports have looked at this topic, to our knowledge, no studies have continuously monitored temperature throughout the MRI scan. The purpose of this study is to determine the impact of MRI on body temperature for anesthetized children undergoing MRI using continuous temperature measurement, identify patient risk factors to develop temperature abnormalities, and determine the effect of temperature derangements on perianesthetic complications. METHODS: This retrospective, single-center study evaluated 285 pediatric outpatients from January 1, 2018, to March 31, 2018, who were less than 8 years old and underwent anesthesia for an MRI scan. Temperature, postanesthesia care unit length of stay, and demographic data were collected retrospectively using chart review and data extraction from electronic medical records. Statistical analyses included unpaired t test, chi-square test, and simple and multiple linear regressions. RESULTS: Sixty-three percent (179/285) of children in our study had a median temperature less than 36°C during their MRI scan. There were no patients who had a median temperature greater than 38°C during their MRI scan. There were no identifiable patient risk factors for the development of hypothermia. Those who developed hypothermia did not have an increased rate of perianesthetic complications. CONCLUSION: MRI in anesthetized children is associated with hypothermia but does not correlate with any significant perianesthetic complications.

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Cardiac catheterization is an integral part of medical management for pediatric patients with congenital heart disease. Owing to age and lack of cooperation in children who need this procedure, general anesthesia is typically required. These patients have increased anesthesia risk secondary to cardiac pathology. Furthermore, multiple catheterization procedures result in exposure to harmful ionizing radiation. Magnetic resonance imaging-guided right-heart catheterization offers decreased radiation exposure and diagnostic imaging benefits over traditional fluoroscopy but potentially increases anesthetic complexity and risk. We describe our early experience with anesthetic techniques and challenges for pediatric magnetic resonance imaging-guided right-heart catheterization.

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BACKGROUND: The intra-extracardiac (IE) Fontan modification has advantages over the lateral tunnel modification. A direct comparison of IE to the extracardiac (EC) modification so far has not been done. This study compared IE to EC Fontan with respect to early postoperative outcomes. METHODS: We retrospectively compared outcomes of the Fontan operation using the IE or EC conduit modification between January 2012 and December 2016. IE and EC groups were compared using univariate and multivariable regression analysis. To eliminate the confounding effects of fenestration, repeat intergroup comparison was performed after excluding nonfenestrated patients. RESULTS: There were 81 patients grouped according to Fontan modification into the IE group (n = 43) or EC group (n = 38). The Fontan was fenestrated in 100% of the IE group but in only 55% of the EC group (p < 0.001). Cardiopulmonary bypass time was shorter for the IE group (74 vs 103, p < 0.001) The IE patients had median cross-clamp time of 34 minutes, whereas only 2 patients in the EC group required cross-clamping (35 and 95 minutes; p < 0.001). The IE group had significantly shorter median duration of pleural effusion (8 days vs 11 days, p = 0.007) and hospital length of stay (9 days vs 13 days, p = 0.001) than the EC group. Multivariable linear regression analysis revealed that the IE modification was independently associated with reduced duration of pleural effusion (p = 0.004) and hospital length of stay (p = 0.003). Presence of any unfavorable hemodynamics on preoperative assessment was also associated with longer duration of pleural effusion and hospital length of stay for patients with fenestration. CONCLUSIONS: The IE Fontan modification may be associated with reduced duration of postoperative pleural effusion and hospital length of stay compared with the EC modification.

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OBJECTIVE: In this single-center, retrospective review, we sought to determine the risk factors associated with the development of severe acquired airway disease (AAD; vocal cord paralysis [VCP] or subglottic stenosis [SGS]) in pediatric patients who had undergone surgery for congenital heart disease (CHD) with cardiopulmonary bypass. All patients who required surgical treatment for CHD using cardiopulmonary bypass at our institution between 2010 and 2015 were reviewed. We defined severe AAD as either clinically significant VCP, SGS, or both, requiring consultation with the otolaryngology (ENT) service for evaluation. The disease was classified as severe because it led to difficulty with intubation or failure to wean mechanical ventilation. This airway disease was not present or was clinically insignificant prior to congenital heart surgery. RESULTS: Over a 5-year period (August 2010 to December 2015), 1395 patients were evaluated. Of these, 25 (1.8%) had significant AAD. Age was the only statistically significant independent predictor of AAD ( P < .001). Those with AAD were younger-3 versus 8 months-and had longer intubation time: 5 (2-18) versus 2 days (1-5). Of those who developed AAD, most (22/25) required some form of additional surgical procedure for its evaluation or management. Only 3 of the 25 patients with severe AAD required tracheostomy. CONCLUSIONS: Children who undergo congenital heart surgery with cardiopulmonary bypass are at risk for developing AAD, most often because of SGS or VCP. AAD can lead to failed extubation in the postoperative setting as well as difficult intubation during subsequent anesthetics. Although it often requires surgical treatment, it responds well to therapy and rarely requires tracheostomy.

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Down syndrome is a common chromosome disorder affecting all body systems. This creates unique physiologic concerns that can affect safety during anesthesia and surgery. Little consensus exists, however, on the best way to evaluate children with Down syndrome in preparation for surgery. We review a number of salient topics affecting these children in the perioperative period, including cervical spine instability, cardiovascular abnormalities, pulmonary hypertension, upper airway obstruction, hematologic disturbances, prematurity, low birth weight, and the use of supplements and alternative therapies. Recommendations include obtaining a complete blood count to detect an increased risk for bleeding or stroke, and cardiology evaluation to identify patients with pulmonary hypertension, as well as undiagnosed or residual heart disease. Pediatric cardiac anesthesiologists and intensivists should be involved as needed. The potential for cervical spine instability should be considered, and the anesthesiologist may wish to have several options available both for the medications and equipment used. The child's family should always be asked if he or she is on any nutritional supplements, as some products marketed to families may have secondary effects such as inhibition of platelet function. Using this evaluation in presurgical planning will allow physicians to better consider the individual circumstances for their patients with Down syndrome. Our goal was to optimize patient safety by choosing the most appropriate setting and perioperative personnel, and to mitigate those risk factors amenable to intervention.

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Since the first description in 1961, several case reports have documented an increased incidence of anesthesia-related cardiac arrest in patients with Williams-Beuren syndrome, commonly known as Williams syndrome (WS). Widespread arteriopathy secondary to an elastin gene defect results in various cardiac defects, including supravalvar aortic stenosis (SVAS) and coronary artery anomalies, which can increase the risk of myocardial ischemia. Even though patients with WS are known to have increased risk of adverse events during anesthesia and sedation, they often undergo several procedures that require anesthesia during their lifetimes, and cases of perianesthetic cardiac arrest continue to be reported. To date, no prospective studies have been reported that quantify anesthetic risk in individual patients with WS. In this article, we review the clinical manifestations of WS, propose a consensus, expert-informed method to estimate anesthetic risk based on the current literature, and provide recommendations for periprocedural management of this patient population.

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