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Unique considerations of virtual reality utilization for perioperative pediatric patients. Paediatric anaesthesia Yuan, J. C., Rodriguez, S., Caruso, T. J. 2021; 31 (3): 377?78
View details for DOI 10.1111/pan.14108

View details for PubMedID 33631038
Alternating Side Programmed Intermittent Repeated (ASPIRe) Bolus Regimen for Delivering Local Anesthetic via Bilateral Interfascial Plane Catheters. Journal of cardiothoracic and vascular anesthesia Tsui, B. C., Brodt, J., Pan, S., Caruso, T. J., Kim, R., Horn, J. L., Boublik, J., Tsui, J. H. 2021
View details for DOI 10.1053/j.jvca.2021.02.036

View details for PubMedID 33731299
Leveraging VR/AR to combat chronic pain in youth: Position paper from the Interdisciplinary Network on Virtual and Augmented (AR/VR) Technologies for Pain (INOVATE-Pain) Management. Journal of medical Internet research Logan, D. E., Simons, L. E., Caruso, T. n., Gold, J. I., Greenleaf, W. n., Griffin, A. n., King, C. n., Menendez, M. n., Olbrecht, V. n., Rodriguez, S. n., Silvia, M. n., Stinson, J. n., Wang, E. n., Williams, S. n., Wilson, L. n. 2021
Abstract

Virtual reality (VR) and augmented reality (AR) interventions are emerging as promising tools in the treatment of pediatric chronic pain conditions, but in this young field there is little consensus to guide the process of engaging in the development and evaluation of targeted VR-based interventions.The INOVATE-Pain consortium aims to advance the field of VR for pediatric chronic pain rehabilitation by providing guidance for best practices in the design, evaluation, and dissemination of VR-based interventions targeting this population.An interdisciplinary meeting of 16 academics, clinicians, industry and philanthropy partners was held in January 2020.Reviewing the state of the field, the consortium identified important directions for research-driven innovation in VR/AR clinical care, highlighted key opportunities and challenges facing the field, and established a consensus on best methodological practices to adopt in future efforts to advance the research and practice of VR/AR in pediatric pain. The consortium also identified important next steps to undertake to continue to advance the work in this promising new area of digital health pain interventions.To realize the promise of this realm of innovation, key ingredients for the success include productive partnerships among industry, academic, and clinical stakeholders, a uniform set of outcome domains and measures for standardized evaluation, and widespread access to the latest opportunities, tools and resources. The INOVATE-Pain collaborative hopes to promote the creation, rigorous yet efficient evaluation, and dissemination of innovative VR-based interventions to reduce pain and improve quality of life for children.

View details for DOI 10.2196/25916

View details for PubMedID 33667177
Virtual reality for pediatric periprocedural care. Current opinion in anaesthesiology Wang, E. n., Thomas, J. J., Rodriguez, S. T., Kennedy, K. M., Caruso, T. J. 2021; 34 (3): 284?91
Abstract

Commercial availability of virtual reality headsets and software has exponentially grown over the last decade as it has become more sophisticated, less expensive, and portable. Although primarily used by the general public for entertainment, virtual reality has been adopted by periprocedural clinicians to improve patient experiences and treatments. The purpose of this review is to explore recently reported evidence for virtual reality effectiveness for pediatric periprocedural care and discuss considerations for clinical implementation.In the preprocedure setting, practitioners use virtual reality to introduce children to periprocedural environments, distract attention from preprocedural vascular access, and increase cooperation with anesthesia induction. Intraprocedure, virtual reality decreases sedation requirements, and in some instances, eliminates anesthesia for minor procedures. Virtual reality also augments pain reduction therapies in the acute and extended rehabilitation periods, resulting in faster recovery and improved outcomes. Virtual reality seems to be well treated for pediatric use, given close clinical care and carefully curated content.Given the multiple clinical applications of virtual reality to supplement pediatric periprocedural care, practitioners should consider developing clinical programs that reliably provide access to virtual reality. Future research should focus on identification of patient characteristics and types of software that yield optimal patient outcomes.

View details for DOI 10.1097/ACO.0000000000000983

View details for PubMedID 33935176
Virtual Reality Facilitates Engagement in Physical Therapy in the Pediatric CVICU. Pediatric physical therapy : the official publication of the Section on Pediatrics of the American Physical Therapy Association Hemphill, S. n., Nguyen, A. n., Kwong, J. n., Rodriguez, S. T., Wang, E. n., Caruso, T. J. 2021; 33 (1): E7?E9
Abstract

The purpose of this report is to demonstrate the successful application of virtual reality to improve physical therapy in the pediatric cardiovascular intensive care unit. Early mobilization and cognitive stimulation improve morbidity of critically ill children. However, maintaining child engagement with these therapies can be challenging, especially during extended intensive care stays.While virtual reality has been successfully used as an analgesic and anxiolytic in the cardiovascular intensive care unit, this report demonstrates its novel use as a tool to augment physical therapy for a child who had been debilitated after heart transplantation. Virtual reality encouraged the child to engage in physical therapy sessions, participate for greater durations, and directly address barriers to discharge.While further studies are needed to define best practice, this report demonstrates that virtual reality can be safely used for carefully selected and monitored children in critical care.

View details for DOI 10.1097/PEP.0000000000000769

View details for PubMedID 33337780
Virtual Reality Augments Movement during Physical Therapy: A Pragmatic Randomized Trial. American journal of physical medicine & rehabilitation Hemphill, S. n., Rodriguez, S. n., Wang, E. n., Koeppen, K. n., Aitken-Young, B. n., Jackson, C. n., Simons, L. n., Caruso, T. J. 2021
Abstract

Virtual reality (VR) facilitates physical therapy (PT) via improved engagement. While shown to benefit specific patient populations, such as stroke patients, it is less established in otherwise healthy adults and children receiving outpatient PT. The primary objective was to compare total PT-guided Movement supplemented with VR (PTMVR) to PT guided Movement alone, without VR (PTM).This pragmatic, randomized, crossover study compared PTMVR to PTM in outpatients (ages 6-80). This community sample had variable PT indications (injury, postoperative, chronic pain) and in preexisting conditions, therefore participants served as their own controls. Participants received 10 minutes of both PTMVR and PTM, separated by five minutes. The primary outcome was differences in aggregate movement of PT guided exercises. Secondary outcomes explored OMNI rating of perceived exertion (RPE) and participant and physical therapist satisfaction. Paired t-tests, chi-squared tests, and regression models were used to analyze differences.The 41 participants (17 pediatric and 24 adult) moved significantly more during PTMVR compared to PTM (1120.88 meters vs 672.65 meters p < 0.001), regardless of which intervention was completed first. PTMVR treatment was associated with more movement of the target limbs, lower-body (p < 0.001), upper-body (p <0.05). OMNI RPE scores did not differ between those who started with PTMVR or PTM, and physical therapist and patient surveys endorsed PTMVR.Patients completed more PT guided movement during PTMVR than PTM and therapists and patients supported its use. Future studies will examine finer tracking of movements.

View details for DOI 10.1097/PHM.0000000000001779

View details for PubMedID 33935153
Virtual Reality in Pain Rehabilitation for Youth With Chronic Pain: Pilot Feasibility Study. JMIR rehabilitation and assistive technologies Griffin, A., Wilson, L., Feinstein, A. B., Bortz, A., Heirich, M. S., Gilkerson, R., Wagner, J. F., Menendez, M., Caruso, T. J., Rodriguez, S., Naidu, S., Golianu, B., Simons, L. E. 2020; 7 (2): e22620
Abstract

BACKGROUND: In the field of pain, virtual reality (VR) technology has been increasingly common in the context of procedural pain management. As an interactive technology tool, VR has the potential to be extended beyond acute pain management to chronic pain rehabilitation with a focus on increasing engagement with painful or avoided movements.OBJECTIVE: We outline the development and initial implementation of a VR program in pain rehabilitation intervention to enhance function in youth with chronic pain.METHODS: We present the development, acceptability, feasibility, and utility of an innovative VR program (Fruity Feet) for pediatric pain rehabilitation to facilitate increased upper and lower extremity engagement. The development team was an interdisciplinary group of pediatric experts, including physical therapists, occupational therapists, pain psychologists, anesthesiologists, pain researchers, and a VR software developer. We used a 4-phase iterative development process that engaged clinicians, parents, and patients via interviews and standardized questionnaires.RESULTS: This study included 17 pediatric patients (13 female, 4 male) enrolled in an intensive interdisciplinary pain treatment (IIPT) program, with mean age of 13.24 (range 7-17) years, completing a total of 63 VR sessions. Overall reports of presence were high (mean 28.98; max 40; SD 4.02), suggestive of a high level of immersion. Among those with multisession data (n=8), reports of pain (P<.001), fear (P=.003), avoidance (P=.004), and functional limitations (P=.01) significantly decreased. Qualitative analysis revealed (1) a positive experience with VR (eg, enjoyed VR, would like to utilize the VR program again, felt VR was a helpful tool); (2) feeling distracted from pain while engaged in VR; (3) greater perceived mobility; and (4) fewer clinician-observed pain behaviors during VR. Movement data support the targeted impact of the Fruity Feet compared to other available VR programs.CONCLUSIONS: The iterative development process yielded a highly engaging and feasible VR program based on qualitative feedback, questionnaires, and movement data. We discuss next steps for the refinement, implementation, and assessment of impact of VR on chronic pain rehabilitation. VR holds great promise as a tool to facilitate therapeutic gains in chronic pain rehabilitation in a manner that is highly reinforcing and fun.

View details for DOI 10.2196/22620

View details for PubMedID 33226346
Transnasal Humidified Rapid-Insufflation Ventilatory Exchange in pediatric bronchoscopy: A prospective pilot study. Journal of clinical anesthesia Caruso, T. J., O'Connell, C., Qian, J., Menendez, M., Fonseca, A., Lawrence, K., Sidell, D. R., Darling, C., Tsui, B. 2020; 68: 110086
View details for DOI 10.1016/j.jclinane.2020.110086

View details for PubMedID 33075630
The virtual visit: Using immersive technology to visit hospitals during social distancing and beyond. Paediatric anaesthesia Dinh, A., Furukawa, L., Caruso, T. J. 2020; 30 (8): 954?56
Abstract

Medical trainees face substantial financial and scheduling burdens during the interview process at various levels of training. With current social distancing and travel restrictions in place, in-person interviews now carry an additional health risk that make it difficult for training programs and applicants to conduct a thorough interview process. Virtual interviews and presentations are some of the technology-driven solutions that have been accelerated in the current social context to mitigate financial burdens and health risks. By utilizing immersive technology to provide virtual tours of training sites, applicants have the opportunity to gain a comprehensive perspective before making the critical decision of where to continue their training. We provide our experiences with creating a 360-degree virtual tour of our children's hospital and the methods for distribution to pediatric anesthesia fellowship applicants. Moving forward, training programs may consider immersive virtual tours as an alternative to face-to-face site visits to not only help alleviate the financial and scheduling burden for applicants but also to protect the well-being of healthcare personnel and patients in the context of a global pandemic.

View details for DOI 10.1111/pan.13922

View details for PubMedID 32959974
A Retrospective Cohort Study of Predictors and Interventionsthat Influence Cooperation with Mask Induction in Children. Paediatric anaesthesia Marquez, J. L., Wang, E., Rodriguez, S. T., O'Connell, C., Munshey, F., Darling, C., Tsui, B., Caruso, J., Caruso, T. J. 2020
Abstract

BACKGROUND: Uncooperative pediatric mask induction is linked to perioperative anxiety. Although some risk factors for uncooperative inductions have been reported, there are no large cohort studies that identify intrinsic patient characteristics associated with cooperation.AIM: The primary aim was to identify patient characteristics associated with cooperative mask inductions. The secondary aim was to determine whether preoperative interventions were associated with increased cooperation.METHODS: This retrospective cohort study included patients 2 -11 years old and ASA class I-IV who underwent mask induction. Our primary outcome of interest was cooperation with mask induction, which was correlated against the Induction Compliance Checklist. The variables analyzed for association with cooperation were age, sex, ASA class, class of surgery, preferred language, and race. Interventions examined for association with induction cooperation included premedication with midazolam, exposure to distraction technology, parental presence, and the presence of a Child Life Specialist. Multivariate mixed effects logistic regression was used to assess the relationship between patient characteristics and cooperation. A separate multivariate mixed effects logistic regression was used to examine the association between preoperative interventions and cooperation.RESULTS: 9,692 patients underwent 23,474 procedures during the study period. 3,372 patients undergoing 5,980 procedures met inclusion criteria. The only patient characteristic associated with increased cooperation was age (OR 1.20, p-value 0.03). Involvement of Child Life Specialists was associated with increased cooperation (OR 4.44, p-value = 0.048) while parental/guardian presence was associated with decreased cooperation (OR 0.38, p-value = 0.002).CONCLUSION: In this cohort, increasing age was the only patient characteristic found to be associated with increased cooperation with mask induction. Preoperative intervention by a Child Life Specialists was the sole intervention associated with improved cooperation.

View details for DOI 10.1111/pan.13930

View details for PubMedID 32452092
A Quality Improvement Project to Reduce Combination Acetaminophen-opioid Prescriptions to Pediatric Orthopedic Patients. Pediatric quality & safety Caruso, T. J., Trivedi, S., Chadwick, W., Gaskari, S., Wang, E., Marquez, J., Lagasse, S., Bailey, M., Shea, K. 2020; 5 (3): e291
Abstract

Background: Acetaminophen-opioid analgesics are among the most commonly prescribed pain medications in pediatric orthopedic patients. However, these combined opioid analgesics do not allow for individual medication titration, which can increase the risk of opioid misuse and hepatoxicity from acetaminophen. The primary aim of this quality improvement project was to alter the prescribing habits of pediatric orthopedic providers at our institution from postoperative acetaminophen-opioid analgesics to independent acetaminophen and opioids.Methods: The study took place in a level 1 trauma center at a children's hospital. A multidisciplinary team of health professionals utilized lean methodology to develop a project plan. Guided by a key driver diagram, we removed acetaminophen-oxycodone products from hospital formulary, implemented a revised inpatient and outpatient electronic order set, and conducted multiple education efforts. Outcomes included inpatient and outpatient percent combined acetaminophen-opioid orders by surgical providers over 27 months.Results: Before the intervention, inpatient acetaminophen-opioid products accounted for an average of 46% of all opioid prescriptions for orthopedic patients. After the intervention and multiple educational efforts, we reported a reduction in the acetaminophen-opioid products to 2.9%. For outpatient prescriptions, combined analgesics accounted for 88% before the intervention, and we reported a reduction to 15% after the intervention.Conclusions: By removing acetaminophen-oxycodone products from hospital formulary, educating the medical staff, and employing revised electronic order sets, the prescribing practice of pediatric orthopedic surgeons changed from the routine use of acetaminophen-opioid analgesics to independent medications.

View details for DOI 10.1097/pq9.0000000000000291

View details for PubMedID 32607456
Retrospective Review of the Safety and Efficacy of Virtual Reality in a Pediatric Hospital. Pediatric quality & safety Caruso, T. J., O'Connell, C., Qian, J. J., Kung, T., Wang, E., Kinnebrew, S., Pearson, M., Kist, M., Menendez, M., Rodriguez, S. T. 2020; 5 (2): e293
Abstract

Introduction: Virtual reality (VR) is an emerging tool for anxiety and fear reduction in pediatric patients. VR use is facilitated by Certified Child Life Specialists (CCLS) at pediatric hospitals. The primary aim of this study was to retrospectively review the safety of VR by analyzing adverse events after the utilization of VR under CCLS supervision. Secondary objectives were to characterize the efficacy of VR in enhancing patient cooperation, describe the integration of VR into Child Life services, and identify interventions that accompanied VR.Methods: The Stanford Chariot Program developed VR applications, customized VR interfaces, and patient head straps, and distributed these to CCLS. Chart review analyzed VR utilization through CCLS patient notes. Inclusion criteria were all patients ages 6 to 18-years-old who received a Child Life intervention.Results: From June 2017 to July 2018, 31 CCLS saw 8,098 patients, 3,696 of which met age criteria with pre- and post-intervention cooperation data. Two hundred thirteen patients received VR with an accompanying intervention, while 34 patients received only VR. Adverse events were rare, and included increased anxiety (3.8%, n=8), dizziness (0.5%, n=1), and nausea (0.5%, n=1). Patients were more likely to be cooperative after receiving VR (99.5%, n=212) compared to pre-intervention (96.7%, n=206, p=0.041). VR use was most common in the perioperative setting (60%, n=128), followed by outpatient clinics (15%, n=32).Conclusion: VR is safe in pediatric patients with appropriate hardware, software, and patient selection. Side effects were rare and self-limited. VR appears to be associated with improvements in cooperation.

View details for DOI 10.1097/pq9.0000000000000293

View details for PubMedID 32426648
Mobilization and calibration of the HTC VIVE for virtual reality physical therapy. Digital health Hemphill, S., Nguyen, A., Rodriguez, S. T., Menendez, M., Wang, E., Lawrence, K., Caruso, T. J. 2020; 6: 2055207620950929
Abstract

Aims: The HTC VIVE virtual reality (VR) system is a potential tool for collecting kinematic data during inpatient and outpatient physical therapy (PT). When validated against research-grade systems, the VIVE has a reported translational error between 1.7mm-2.0cm. Our purpose was to portabilize the VIVE for room to room PT and validate the motion tracking software.Methods: The VIVE was configured on a mobile cart. To validate the motion tracking software, the VIVE sensors (motion tracker, controller, headset) were mounted on a rigid linear track and driven through 10, one-meter translations in the X, Y, and Z axes.Results: The mean translational error for all three sensors was below 4.9cm. While error is greater than that reported for research-grade systems, motion tracking software on the portable VIVE unit appears to be a valid means of tracking aggregate movement.Conclusion: Some therapy may require more precise measurements, however, the advantages of portability and accessibility to patients may outweigh the limitation of reduced precision.

View details for DOI 10.1177/2055207620950929

View details for PubMedID 32963801
From Socrates to Virtual Reality: A Historical Review of Learning Theories and Their Influence on the Training of Anesthesiologists. The journal of education in perioperative medicine : JEPM Caruso, T. J., Qian, J. n., Lawrence, K. n., Armstrong-Carter, E. n., Domingue, B. W. 2020; 22 (2): E638
Abstract

Over the past couple of centuries, the training of American physicians, and anesthesiologists in particular, has undergone a radical transformation. The revolution of medical training has been and continues to be fueled by insights from learning theorists. In this historical review, we discuss the origins of American medical education in the 1700s and continue through the centuries illustrating the impact of learning theories on the education and training of anesthesiologists. In particular, we explore the impact of learning theories of the 1800s and the adult-centered teaching strategies of the 1900s. We also discuss the role of learning theories in molding medical education in the modern technological age.

View details for DOI 10.46374/volxxii-issue2-Caruso

View details for PubMedID 32939366

View details for PubMedCentralID PMC7485431
Introduction of the EMR-integrated I-PASS ICU Handoff Tool. Pediatric quality & safety Caruso, T. J., Su, F. n., Wang, E. n. 2020; 5 (4): e334
View details for DOI 10.1097/pq9.0000000000000334

View details for PubMedID 32766505

View details for PubMedCentralID PMC7382550
Using Augmented Reality to Reduce Fear and Promote Cooperation During Pediatric Otolaryngologic Procedures. The Laryngoscope Caruso, T. J., Madill, M. n., Sidell, D. n., Meister, K. n., Wang, E. n., Menendez, M. n., Kist, M. N., Rodriguez, S. n. 2020
Abstract

This case series examines interactive AR during minor otolaryngologic procedures. Although VR has been successfully used for pediatric vascular access, removing children from comforting people in the real world has resulted in patient anxiety. AR offers a potential advantage, utilizing distracting holographic images when patients maintain eye contact with parents. The primary objective was to determine the effect of AR on fear during pediatric otolaryngologic procedures. Secondary objectives included evaluating pain; procedure compliance; and patient, parent and physician attitudes toward AR, as well as assessing the feasibility of adding AR to a busy outpatient otolaryngologic clinic. Laryngoscope, 2020.

View details for DOI 10.1002/lary.29098

View details for PubMedID 32886794
Systemic Absorption of Lidocaine from Continuous Erector Spinae Plane Catheters After Congenital Cardiac Surgery: A Retrospective Study. Journal of cardiothoracic and vascular anesthesia Caruso, T. J., Lin, C. n., O'Connell, C. n., Weiss, D. n., Md, G. B., Wu, M. n., Kwiatkowski, D. n., Maeda, K. n., Tsui, B. C. 2020
Abstract

To examine postoperative serum lidocaine levels in patients with intermittent lidocaine bolus erector spinae plane block (ESPB) catheters after cardiac surgery with or without cardiopulmonary bypass (CPB).A retrospective study.Single-center pediatric quaternary teaching hospital.Patients who received ESPB catheters after congenital cardiac surgery from April 2018 to March 2019.Postoperative serum lidocaine levels were extracted from the record.Twenty-seven of 40 patients were included in the final analyses (19 with CPB and 8 with no CPB, age 1-47 years, undergoing congenital heart repair). Patients who received ropivacaine or were missing data were excluded. The initial intraoperative bolus of lidocaine ranged from 0- to- 3.72 mg/kg, and the range of postoperative intermittent lidocaine boluses ranged from 0.35- to- 0.83 mg/kg, which were administered every hour. Serum lidocaine levels were measured by the hospital laboratory and ranged from <0.05- to- 3.0 ?g/mL in the CPB group and from <0.05- to- 3.2 ?g/mL in the no- CPB group. CPB was not associated with differences in lidocaine levels when controlling for time (P?=?0.529). Lidocaine concentrations ranged from 0.50- to- 1.68 ?g/mL in the CPB group and 0.86- to- 2.07 ?g/mL in the no- CPB group. There was a normally distributed overall mean peak level of 1.818 � standard deviation of 0.624 ?g/mL, with 95% confidence interval of 0.57- to- 3.06 ?g/mL. No patients had clinical signs of toxicity.Postoperative serum lidocaine concentrations did not appreciably differ due to CPB. Serum lidocaine concentrations did not reach near- toxic doses despite the presence of additional lidocaine in the cardioplegia. The results suggested that lidocaine for ESPBs after cardiac surgery is below systemic toxic range at the doses described.

View details for DOI 10.1053/j.jvca.2020.05.040

View details for PubMedID 32622712
Near Miss in Intraoperative Magnetic Resonance Imaging: A Case for In Situ Simulation. Pediatric quality & safety Rama, A., Knight, L. J., Berg, M., Chen, M., Gonzales, R., Delhagen, T., Copperman, L., Caruso, T. J. 2019; 4 (6): e222
Abstract

Pediatric patients in intraoperative magnetic resonance imaging (iMRI) settings are at high risk for morbidity should an adverse event occur. We describe an experience in the iMRI scanner where no harm occurred, yet revealed an opportunity to improve the safety of patients utilizing the iMRI. The perioperative quality improvement team, resuscitation team, and radiology nurse leadership collaborated to understand the process better through in situ simulation.Methods: After a problem analysis, the team planned an in situ, high-fidelity simulation with predefined learning objectives to identify previously overlooked opportunities for improvement. The iMRI simulation had unique considerations, including the use of a magnetic resonance imaging (MRI)-compatible mannequin and ensuring participants' safety. Audiovisual equipment was placed in strategic locations to record the MRI and operating room (OR) segments of the simulation, and trained health-care simulation experts provided debriefing.Results: After completion of the iMRI simulation, the quality improvement team solicited feedback from participants and reviewed the video-recorded simulation. Several opportunities for improvement surrounding staff responsibilities and unique aspects of the iMRI environment were identified.Conclusions: iMRI in situ simulation has not been previously described. It presents unique challenges given the integration of personnel from OR and radiology environments, anesthetized patients, and risks from the high-powered MRI magnet. Other institutions utilizing hybrid ORs with iMRI may consider conducting in situ simulations using the described methods.

View details for DOI 10.1097/pq9.0000000000000222

View details for PubMedID 32010849
A Pilot Quality Improvement Project to Reduce Preoperative Fasting Duration in Pediatric Inpatients. Pediatric quality & safety Nye, A., Conner, E., Wang, E., Chadwick, W., Marquez, J., Caruso, T. J. 2019; 4 (6): e246
Abstract

Despite guidelines allowing clear liquids up to 2 hours before anesthesia, preoperative fasting for pediatric inpatients is often unnecessarily prolonged. This delay can lead to prolonged recovery time and increased postoperative pain. Efforts to reduce fasting duration in pediatric surgical patients is an evolving standard in pediatric anesthesiology. The primary aim of this quality improvement project was to reduce the average inpatient fasting duration undergoing anesthesia by 25% within a year of our pilot intervention. Secondary aims included measuring the adoption rate of the intervention and comparing aspiration rates as a balancing measure.Methods: At an academic pediatric hospital, we created the preanesthesia diet order, a standardized, clear liquid diet for eligible inpatients undergoing anesthesia to decrease preoperative fasting duration. After implementation in January 2018, a statistical process control chart was used to measure the fasting duration of all eligible inpatients by month, and the Wilcoxon rank-sum test assessed differences. A Poisson test was used to determine differences in aspiration rates.Results: Over the first year of our pilot intervention, 127 inpatients received the preanesthesia diet. The average fasting duration before its implementation was 12.5 and 5.7 hours postimplementation. The average adoption rate for eligible inpatients was 17.6%, and there was no difference in aspiration rates.Conclusion: This quality improvement project demonstrated that a standardized, clear liquid diet on the morning of surgery could reduce preoperative fasting times among pediatric inpatients. The adoption of this pilot intervention was limited, highlighting the challenges of implementing a practice change.

View details for DOI 10.1097/pq9.0000000000000246

View details for PubMedID 32010870
Virtual reality successfully provides anxiolysis to laboring women undergoing epidural placement. Journal of clinical anesthesia Kist, M., Bekemeyer, Z., Ralls, L., Carvalho, B., Rodriguez, S. T., Caruso, T. J. 2019: 109635
View details for DOI 10.1016/j.jclinane.2019.109635

View details for PubMedID 31662229
Regional anesthesia for cardiac surgery. Current opinion in anaesthesiology Caruso, T. J., Lawrence, K., Tsui, B. C. 2019
Abstract

PURPOSE OF REVIEW: Anesthesia for cardiac surgery has traditionally utilized high-dose opioids to blunt the sympathetic response to surgery. However, recent data suggest that opioids prolong postoperative intubation, leading to increased morbidity. Given the increased risk of opioid dependency after in-hospital exposure to opioids, coupled with an increase in morbidity, regional techniques offer an adjunct for perioperative analgesia. The aim of this review is to describe conventional and emerging regional techniques for cardiac surgery.RECENT FINDINGS: Well-studied techniques such as thoracic epidurals and paravertebral blocks are relatively low risk despite lack of widespread adoption. Benefits include reduced opioid exposure after paravertebral blocks and reduced risk of perioperative myocardial infarction after epidurals. To further lower the risk of epidural hematoma and pneumothorax, new regional techniques have been studied, including parasternal, pectoral, and erector spinae plane blocks. Because these are superficial compared with paravertebral and epidural blocks, they may have even lower risks of hematoma formation, whereas patients are anticoagulated on cardiopulmonary bypass. Efficacy data have been promising, although large and generalizable studies are lacking.SUMMARY: New regional techniques for cardiac surgery may be potent perioperative analgesic adjuncts, but well-designed studies are needed to quantify the effectiveness and safety of these blocks.

View details for DOI 10.1097/ACO.0000000000000769

View details for PubMedID 31356362
Varying Screen Size for Passive Video Distraction During Induction of Anesthesia in Low Risk Children: A Pilot Randomized Controlled Trial. Paediatric anaesthesia Rodriguez, S., Jang, O., Hernandez, J. M., George, A. J., Caruso, T. J., Simons, L. 2019
Abstract

BACKGROUND: Preoperative anxiety affects up to 65% of children who undergo anesthesia induction and often results in uncooperative behaviour. Electronic devices have been used to distract children to reduce anxiety and create a more enjoyable preoperative experience. Few studies have compared the effects of different video delivery systems on preoperative anxiety.AIM: The primary aim was to determine if a large projection based video screen mounted to a patient's bed decreased anxiety when compared to a tablet during mask induction of anesthesia in children from 4-10 years of age.METHODS: We performed a prospective, randomized trial to determine differences in our primary outcome, preoperative anxiety, between the large Bedside Entertainment and Relaxation Theater (BERT) and a smaller tablet screen. Secondary outcomes included 1) induction compliance, 2) child fear, 3) frequency of emergence delirium, and 4) satisfaction.RESULTS: In examining the primary outcome for 52 patients, there was a main effect for time on mYPAS scores, f(2, 51)=13.18, p<0.01. mYPAS scores significantly increased across time for both groups. The interaction for time (T0, T1 or T2) x group (BERT vs. Tablet) was not significant, f(2, 51)=1.96, p=0.15; thus changes in mYPAS scores across time did not differ by group status. There was no significant difference in induction compliance, child fear, emergence delirium, or satisfaction between the two groups.CONCLUSION: In a low risk population, preoperative anxiety was low and induction compliance was high when pairing screen based distraction interventions, regardless of size, with parental presence at induction of anesthesia. This article is protected by copyright. All rights reserved.

View details for PubMedID 30916447
Toward Opioid-Free Fast Track for Pediatric Congenital Cardiac Surgery. Journal of cardiothoracic and vascular anesthesia Esfahanian, M., Caruso, T. J., Lin, C., Kuan, C., Purkey, N. J., Maeda, K., Tsui, B. C. 2019
View details for DOI 10.1053/j.jvca.2019.02.003

View details for PubMedID 30852093
Transnasal Humidified Rapid Insufflation Ventilatory Exchange (THRIVE) augments oxygenation in children with cyanotic heart disease during microdirect laryngoscopy and bronchoscopy. Journal of clinical anesthesia Caruso, T. J., Sidell, D. R., Lennig, M., Menendez, M., Fonseca, A., Rodriguez, S. T., Tsui, B. 2019; 56: 53?54
View details for PubMedID 30690312
Speeding the Detection of Vessel Cannulation: An In-Vitro Stimulation Study. Anesthesia and analgesia Muffly, M. K., Ku, A., Drover, D. R., Rodriguez, S., Caruso, T. J., Ku, A., Tsui, B. C. 2019
Abstract

BACKGROUND: Some practitioners "prime" small IV angiocatheter needles with 0.9% sodium chloride-claiming this modification speeds visual detection of blood in the angiocatheter flash chamber on vessel cannulation.METHODS: We compared the time required for human blood to travel the length of saline-primed and saline-unprimed 24- and 22-gauge angiocatheter needles (Introcan Safety IV Catheter; B. Braun, Bethlehem, PA). A syringe pump (Medfusion 4000, Cary, NC) advanced each angiocatheter needle through the silicone membrane of an IV tubing "t-piece" (Microbore Extension Set, 5 Inch; Hospira, Lake Forest, IL) filled with freshly donated human blood. When the angiocatheter needle contacted the blood, an electrical circuit was completed, illuminating a light-emitting diode. We determined the time from light-emitting diode illumination to visual detection of blood in the flash chamber by video review. We tested 105 saline-primed angiocatheters and 105 unprimed angiocatheters in the 24- and 22-gauge angiocatheter sizes (420 catheters total). We analyzed the median time to visualize the flash using the nonparametric Wilcoxon rank sum test in R (http://www.R-project.org/). The Stanford University Administrative Panel on Human Subjects in Medical Research determined that this project did not meet the definition of human subjects research and did not require institutional review board oversight.RESULTS: In the 24-gauge angiocatheter group, the median (and interquartile range) time for blood to travel the length of the unprimed angiocatheter needle was 1.14 (0.61-1.47) seconds compared with 0.76 (0.41-1.20) seconds in the saline-primed group (P = 0.006). In the 22-gauge catheter group, the median (interquartile range) time for blood to travel the length of the unprimed angiocatheter needle was 1.80 (1.23-2.95) seconds compared with 1.46 (1.03-2.54) seconds in the saline-primed group (P = .046).CONCLUSIONS: These results support the notion that priming small angiocatheter needles, in particular 24-gauge catheters, with 0.9% sodium chloride may provide earlier detection of vessel cannulation than with the unprimed angiocatheter.

View details for PubMedID 30633054
Operating Room Codes Redefined: A Highly Reliable Model Integrating the Core Hospital Code Team. Pediatric quality & safety Caruso, T. J., Rama, A. n., Knight, L. J., Gonzales, R. n., Munshey, F. n., Darling, C. n., Chen, M. n., Sharek, P. J. 2019; 4 (3): e172
Abstract

Typically, multidisciplinary teams manage cardiac arrests occurring outside of the operating room (OR). This approach results in reduced morbidity. However, arrests that occur in the OR are usually managed by OR personnel alone, missing the benefits of out-of-OR hospital code teams. At our institution, there were multiple pathways to activate codes, each having different respondents, depending on time and day of the week. This improvement initiative aimed to create a reliable intraoperative emergency response system with standardized respondents and predefined roles.A multidisciplinary improvement team led this project at an academic pediatric hospital in California. After simulations performed in the OR (in situ), the team identified a valuable key driver-a consistent activation process that initiated standard respondents, 24 hours a day, 7 days a week. By utilizing core hospital code members routinely available outside of the OR during days, nights, and weekends, respondents were identified to augment OR personnel. Code roles were preassigned. After education, we conducted in situ simulations that included the perioperative and out-of-OR code team members. We administered a knowledge assessment to perioperative staff.The knowledge assessment for perioperative staff (n = 52) had an average score of 96%. Review of subsequent OR codes reflects an improved initiation process and management.The process for activating the emergency response system and roles for intraoperative code respondents were standardized to ensure a predictable code response, regardless of time or day of the week. Ongoing simulations with perioperative personnel continue to optimize the process.

View details for DOI 10.1097/pq9.0000000000000172

View details for PubMedID 31579871

View details for PubMedCentralID PMC6594783
Intraoperative Methadone Is Associated with Decreased Perioperative Opioid Use Without Adverse Events: A Case-Matched Cohort Study. Journal of cardiothoracic and vascular anesthesia Robinson, J. D., Caruso, T. J., Wu, M. n., Kleiman, Z. I., Kwiatkowski, D. M. 2019
Abstract

To determine if there is an association of intraoperative methadone use and total perioperative opioid exposure in patients undergoing congenital heart surgeries.Retrospective, case-match cohort study.Single center quaternary care teaching hospital.Seventy-four patients with congenital heart disease (CHD) undergoing surgical repair or palliative surgery.Thirty-seven patients undergoing CHD surgeries receiving intraoperative methadone were matched to 37 patients based upon age and procedure who did not receive intraoperative methadone. The primary study outcome was to evaluate total opioid use in intravenous milligrams of morphine equivalents per kilogram (mg ME/kg) within the first 36-hours postoperatively. Mann-Whitney U test was used to compare total opioid exposure.The total opioid use was compared between groups. The methadone cohort required less opioids intraoperatively, in the first 12 hours postoperatively, and during the first 36 hours postoperatively (2.51 v 4.39 mg ME/kg, p < 0.001; 0.43 v 1.28 mg ME/kg, p?=?0.001; and 0.83 v 1.91 mg ME/kg, p < 0.001) compared with the matched control cohort. There were no differences in clinical outcomes or adverse events. A dose-dependent reduction in opioid consumption in high- versus low-dose groups also was not observed.Intraoperative methadone use was associated with a decrease in perioperative opioid exposure in patients undergoing congenital heart surgery and was not associated with adverse events or prolonged durations of mechanical ventilation or ICU stay.

View details for DOI 10.1053/j.jvca.2019.09.033

View details for PubMedID 31699597
A Sustainable and Effective Mentorship Model for Graduate Medical Education Programs. Journal of graduate medical education Caruso, T. J., Kung, T. n., Piro, N. n., Li, J. n., Katznelson, L. n., Dohn, A. n. 2019; 11 (2): 221?25
Abstract

Mentorship models rarely seek generalizability across training programs at the graduate medical education (GME) level.We examined the sustainability and effectiveness of an intervention to increase the number and usefulness of trainee mentorship.A 0.20 full-time equivalent GME faculty adviser position (MD, MEd) implemented mentorship programs in residencies and fellowships. In group 1, 6 GME programs implemented the mentorship strategies prior to 2014, which were used to measure whether the number of mentor relationships were longitudinally sustained. In group 2, 10 different GME programs implemented the mentorship strategies in 2016, which were used to measure whether the intervention immediately increased the number of mentor relationships. To measure mentorship usefulness, trainees rated mentors' ability to promote clinical skills and personal and professional development. The remaining programs were the comparison. Responses from the 2014 and 2016 annual institutional trainee survey were analyzed.The incidence of group 1 reporting mentor relationships in 2014 compared to the incidence of group 1 in 2016 were 89% (41 of 46) and 95% (42 of 44), respectively, suggesting that the intervention was sustained for 2 years (P = .26). Group 2 showed a higher proportion of trainees reporting mentors in 2016 (88%, 149 of 170) compared to preintervention (66%, 71 of 108; P = .00001). Groups 1 and 2 reported significant increases in mentorship usefulness.A GME initiative to enhance mentoring across specialties in 16 GME training programs was self-sustaining and effective.

View details for DOI 10.4300/JGME-D-18-00650.2

View details for PubMedID 31024657

View details for PubMedCentralID PMC6476078
Virtual Reality during Pediatric Vascular Access: A Pragmatic, Prospective Randomized, Controlled Trial. Paediatric anaesthesia Caruso, T. J., George, A. n., Menendez, M. n., De Souza, E. n., Khoury, M. n., Kist, M. N., Rodriguez, S. T. 2019
Abstract

Vascular access is a minor procedure that is associated with reported pain and fear in pediatric patients, often resulting in procedural incompliance. Virtual reality has been shown to be effective in adult populations for reducing pain and anxiety in various medical settings, although large studies are lacking in pediatrics.The primary aim was to determine if pain would be reduced in pediatric patients using virtual reality undergoing vascular access. The four secondary aims measured patient fear, procedural compliance, satisfaction, and adverse events.A prospective, randomized, controlled trial was completed at a pediatric hospital, enrolling children 7-18 years old undergoing vascular access in a variety of clinical settings, randomized to virtual reality or standard of care. Pain scores were measured using a numeric pain faces scale. The secondary outcomes of patient fear, procedural compliance, satisfaction, and adverse events were measured with the Child Fear Scale, modified induction compliance checklist, and satisfaction surveys, respectively. Chi-squared, t-tests, and regression models were used to analyze the results.The analysis included 106 patients in the virtual reality group and 114 in the control. There were no significant differences in post-procedure pain (VR group estimated 0.11 points lower, 95% confidence interval: 0.50 points lower to 0.28 points greater, p=0.59), post-procedure fear (VR group estimated 0.05 points lower, 95% confidence interval: 0.23 points lower to 0.13 points greater) or compliance (adjusted odds ratio 2.31, 95% confidence interval: 0.96 to 5.56). Children in the virtual reality group were satisfied with the intervention. There were no adverse events.This study demonstrates no reduction in pain while using VR across a heterogeneous pediatric inpatient population undergoing vascular access.

View details for DOI 10.1111/pan.13778

View details for PubMedID 31785015
Accreditation Improves Quality of Oncology Education in Low- and Middle-Income Countries: Perspectives of African Oncologists. Journal of cancer education : the official journal of the American Association for Cancer Education Hammad, N. n., Stockley, D. n., Hastings-Truelove, A. n., Vanderpuye, V. n., Rubagumya, F. n., Caruso, T. n. 2019
Abstract

The purpose of this study is to understand the perspectives of African Oncologists on the role of accreditation and on global standards. We developed a survey that addressed African oncologists' opinions on the role of accreditation. The survey also included 187 standards from World Federation of Medical Education Postgraduate medical education (PGME) standards, American Council of Graduate Medical Education (ACGME)-I standards for hematology/oncology, and the Royal College of Physician and Surgeons of Canada Medical Oncology standards. A 3-point scale was employed for each standard: 1 = not important, 2 = important but not essential, 3 = essential. The survey was sent to 79 physicians, 38 responded. Eighty-seven percent agreed that accreditation ensures quality. Forty-five percent agreed it will not increase migration of qualified doctors. Twenty-two individuals who completed the entire survey were analyzed for the standards. Five standards received the highest ratings of 3 (essential) from all respondents. One standard received a rating of
View details for DOI 10.1007/s13187-019-01497-3

View details for PubMedID 30806905
A multifaceted quality improvement project improves intraoperative redosing of surgical antimicrobial prophylaxis during pediatric surgery. Paediatric anaesthesia Colletti, A. A., Wang, E. n., Marquez, J. L., Schwenk, H. T., Yeverino, C. n., Sharek, P. J., Caruso, T. J. 2019
Abstract

Accurate intraoperative antibiotic redosing contributes to prevention of surgical site infections in pediatric patients. Ensuring compliance with evolving national guidelines of weight-based, intraoperative redosing of antibiotics is challenging to pediatric anesthesiologists.Our primary aim was to increase compliance of antibiotic redoses at the appropriate time and appropriate weight-based dose to 70%. Secondary aims included a subset analysis of time compliance and dose compliance individually, and compliance based on order entry method of the first dose (verbal or electronic).At a freestanding, academic pediatric hospital, we reviewed surgical cases between May 1, 2014 and October 31, 2017 requiring antibiotic redoses. After an institutional change in cefazolin dosing in May 2015, phased interventions to improve compliance included electronic countermeasures to display previous and next dose timing, an alert five minutes prior to next dose, and weight-based dose recommendation (September 2015). Physical countermeasures include badge cards, posting of guidelines, and updates to housestaff manual (September 2015). Statistical process control charts were used to assess overall antibiotic redose compliance, time compliance, and dose compliance. The chi-square test was used to analyze group differences.3,015 antibiotic redoses were administered during 2,341 operative cases between May 1, 2014 and October 31, 2017. Mean monthly compliance with redosing was 4.3% (May 2014-April 2015) and 73% (November 2015-October 2017) (p < 0.001). Dose-only compliance increased from 76% to 89% (p < 0.001) and time-only compliance increased from 4.9 to 82% (p < 0.001). After implementation of countermeasures, electronic order entry compared with verbal order was associated with higher dose compliance, 90% vs. 86% (p = 0.015).This quality improvement project, utilizing electronic and physical interventions, was effective in improving overall prophylactic antibiotic redosing compliance in accordance with institutional redosing guidelines. This article is protected by copyright. All rights reserved.

View details for PubMedID 31034725
Crowd Sourced Assessment of Ureteroscopy with Laser Lithotripsy video feed does not correlate with Trainee Experience. Journal of endourology Conti, S. L., Brubaker, W., Chung, B. I., Sofer, M., Hsi, R. S., Shinghal, R., Elliott, C. S., Caruso, T., Leppert, J. T. 2018
Abstract

OBJECTIVES: We sought to validate the use of crowd sourced surgical video evaluation in the evaluation of flexible ureteroscopic laser lithotripsy videos using a modified global assessment scale previously validated for ureteroscopic skills.METHODS: We collected video feeds from 30 intra-renal ureteroscopic laser lithotripsy cases where residents post graduate year(PGY) 2 through 6 handled the ureteroscope. The video feeds were annotated to represent the overall performance and to contain the parts of the procedure being scored. The videos were submitted to a commercially available surgical video evaluation platform. We used a validated ureteroscopic laser lithotripsy global assessment tool that was modified to account for the fact that this scoring system looked at the video feed only. Videos were evaluated by crowd workers recruited using Amazon's Mechanical Turk as well as 5 Endourology trained experts. Mean scores were calculated and intraclass correlation coefficients(ICCs) were computed for the expert domain and total scores. The ICCs were estimated using a linear mixed-effects model. Spearman rank correlation coefficients were calculated as a measure of the strength of the relationships between the crowd mean and the expert average scores.RESULTS: 30 videos were reviewed 2,488 times by 487 crowd workers and five expert endourologists. ICCs between expert raters were all below accepted levels of correlation(0.30) with the overall score having an ICC of .000. Overall the crowd scores did not correlate with expert scores except for the stone retrieval domain (0.60 p = 0.015). Crowd sourced scores had a negative correlation with PGY level(-0.44 p=0.019).CONCLUSIONS: Given the poor agreement between experts and poor correlation between expert and crowd scores when evaluating video feeds of ureteroscopic laser lithotripsy, assessment of skills using intraoperative video feeds may not be reliable. This is further supported by the inverse correlation between crowd scores and PGY level.

View details for PubMedID 30450963
The erector spinae plane (ESP) block: A pooled review of 242 cases. Journal of clinical anesthesia Tsui, B. C., Fonseca, A., Munshey, F., McFadyen, G., Caruso, T. J. 2018; 53: 29?34
Abstract

STUDY OBJECTIVE: The erector spinae plane block (ESPB) was first described in 2016 as a regional block for thoracic neuropathic pain. Given its short history, there are a paucity of controlled clinical trials, yet an abundance of case reports. The primary aim of this review is to examine pooled clinical data from published literature to gain an understanding of ESPB characteristics.DESIGN: A PubMed search was conducted to identify all ESPB related publications. Inclusion criteria included reports of ESP single shot, continuous infusion, intermittent bolus, human and cadaveric studies. Only publications obtained in English were included. Measures included type of publication, year and country of publication, journal of publication, block technique, anatomic location, age, opioid and adjunct pain medication use, sensory and motor changes, side effects and adverse events. Qualitative statistics were used.MAIN RESULTS: The initial search yielded 201 publications. After application of inclusion and exclusion criteria, 85 publications from 21 journals were included in the pooled review which yielded 242 reported cases between 2016 and 2018. The majority of publications reported single shot techniques (80.2%), followed by intermittent boluses (12.0%) and continuous infusions (7.9%). 90.9% reported use of multimodal analgesia in addition to the ESPB and 34.7% reported sensory changes from ESPB. A reduction in opioid use was reported in 34.7% of cases. One adverse event involving a pneumothorax was reported.CONCLUSIONS: To our knowledge, this is the first review providing a pooled review of ESPB characteristics. The ESPB appears to be a safe and effective option for multiple types thoracic, abdominal, and extremity surgeries.

View details for PubMedID 30292068
Programmed Intermittent Bolus Regimen for Erector Spinae Plane Blocks in Children: A Retrospective Review of a Single-Institution Experience. Anesthesia and analgesia Munshey, F., Caruso, T. J., Wang, E. Y., Tsui, B. C. 2018
Abstract

With few published reports on erector spinae plane block use in children, limited guidance on perioperative local anesthetic dosing exists. We present a series of 22 patients who received erector spinae plane catheters with programmed intermittent bolus for various surgeries. Median loading dose of 0.4 mL/kg (interquartile range [IQR], 0.1 mL/kg) ropivacaine 0.5%, intraoperative bolus of 0.3 mL/kg/h (IQR, 0.1 mL/kg) ropivacaine 0.2%, and a postoperative programmed intermittent bolus regimen of maximum 0.6 mg/kg/h resulted in highest pain scores on postoperative day 1 with a median score of 1.7 of 10 (IQR, 1.8) and highest morphine equivalents consumed on postoperative day 2 with a median score of 0.16 mg/kg up to 120 hours after surgery.

View details for DOI 10.1213/ANE.0000000000003817

View details for PubMedID 30252704
Safety Stop: A Valuable Addition to the Pediatric Universal Protocol JOINT COMMISSION JOURNAL ON QUALITY AND PATIENT SAFETY Caruso, T. J., Munshey, F., Aldorfer, B., Sharek, P. J. 2018; 44 (9): 552?56
Abstract

The World Health Organization (WHO) guidelines and Joint Commission requirements state that the time-out component of the Universal Protocol for Preventing Wrong Site, Wrong Procedure, and Wrong Person Surgery? must be performed just prior to incision. A mock Joint Commission survey at one institution revealed that the time-out was performed prior to preparation and draping (P&D) of the patient, not afterward, representing both a patient and regulatory risk.The multidisciplinary perioperative quality improvement team at a freestanding, quaternary care, academic pediatric hospital led the development of a new time-out process. An enhanced pediatric Universal Protocol, which included a new component, the safety stop, was created. The safety stop occurred just prior to P&D of the patient, and the time-out was performed just prior to incision, aligning with WHO recommendations. After electronic correspondence and several perioperative leadership meetings, the enhanced pediatric Universal Protocol was initiated. Compliance audits were performed to demonstrate comprehensive adoption.In seven operating room locations, 60 audits were completed in four weeks, with 96.7% (58/60) demonstrating compliance with the new policy. During a subsequent Joint Commission accreditation survey, the enhanced pediatric Universal Protocol with inclusion of the safety stop was highlighted as a leading practice.Although initially it was believed that moving the time-out from prior to P&D to just prior to incision would be a simple solution, flow mapping the complete time-out process identified significant risk of wrong-site or wrong-patient surgery with this solution. This risk was exacerbated by the small body size of pediatric patients being obscured by draping on a typical operating room table.

View details for PubMedID 30166039
The successful application of high flow nasal oxygen during microdirect laryngoscopy and bronchoscopy in patients under 7?kg. Journal of clinical anesthesia Caruso, T. J., Gupta, A., Sidell, D. R., Darling, C., Rodriguez, S., Fonseca, A., Tsui, B. 2018; 52: 27?28
View details for PubMedID 30153541
A Retrospective Review of a Bed-mounted Projection System for Managing Pediatric Preoperative Anxiety. Pediatric quality & safety Caruso, T. J., Tsui, J. H., Wang, E., Scheinker, D., Sharek, P. J., Cunningham, C., Rodriguez, S. T. 2018; 3 (4): e087
Abstract

Introduction: Most children undergoing anesthesia experience significant preoperative anxiety. We developed a bedside entertainment and relaxation theater (BERT) as an alternative to midazolam for appropriate patients undergoing anesthesia. The primary aim of this study was to determine if BERT was as effective as midazolam in producing cooperative patients at anesthesia induction. Secondary aims reviewed patient emotion and timeliness of BERT utilization.Methods: We conducted a retrospective cohort study of pediatric patients undergoing anesthesia at Lucile Packard Children's Hospital Stanford between February 1, 2016, and October 1, 2016. Logistic regression compared induction cooperation between groups. Multinomial logistic regression compared patients' emotion at induction. Ordinary least squares regression compared preoperative time.Results: Of the 686 eligible patients, 163 were in the BERT group and 150 in the midazolam. Ninety-three percentage of study patients (290/313) were cooperative at induction, and the BERT group were less likely to be cooperative (P = 0.04). The BERT group was more likely to be "playful" compared with "sedated" (P < 0.001). There was a reduction of 14.7 minutes in preoperative patient readiness associated with BERT (P = 0.001).Conclusions: Although most patients were cooperative for induction in both groups, the midazolam group was more cooperative. The BERT reduced the preinduction time and was associated with an increase in patients feeling "playful."

View details for PubMedID 30229198
Improving Satisfaction with Pediatric Pain Management by Inviting the Conversation. Joint Commission journal on quality and patient safety Caruso, T. J., Kung, T. H., Good, J. n., Taylor, K. n., Ashland, M. n., Cunningham, C. n., Gonzalez, E. n., Wood, M. n., Sharek, P. n. 2018; 44 (4): 227?32
Abstract

Patient satisfaction with pain management is associated with improved patient adherence to medical management and efficient service utilization. Pediatric pain control is challenging, given the inability to elicit reliable histories, particularly in younger patients. Several studies have suggested that communication surrounding pain management can improve satisfaction, although there are limited data describing structured interventions with measurable outcomes. A quality improvement project was conducted to determine if reliably asking families about pain management was associated with improved patient satisfaction with pain management.In an academic pediatric hospital, nurse manager rounds were used to invite a conversation about pain management. The question, "Pain management is very important to us. Has your child's pain been well controlled?" was added to the established standard questions asked during nurse manager rounds. Effectiveness was measured using the preexisting Press Ganey survey question, "How well was your child's pain controlled?" Responses were compared between those patients who were and were not exposed to the rounding question.Data for 1,032 patients were used to establish baseline satisfaction with pain management scores. In the intervention period, 328 patients received nurse manager rounds and 121 did not. The median of the weighted mean patient survey satisfaction scores were baseline, 91.5%; receiving intervention, 94.2%; and not receiving intervention, 90.0%. Patients who received the intervention reported higher satisfaction with pain management than those who did not (p?<0.0001).Hospitals seeking to improve satisfaction with pain management should encourage health care providers to reliably discuss pain control with pediatric patients.

View details for DOI 10.1016/j.jcjq.2017.10.003

View details for PubMedID 29579448
A Postoperative Care Bundle Reduces Surgical Site Infections in Pediatric Patients Undergoing Cardiac Surgeries. Joint Commission journal on quality and patient safety Caruso, T. J., Wang, E. Y., Schwenk, H. n., Marquez, J. L., Cahn, J. n., Loh, L. n., Schaffer, J. n., Chen, K. n., Wood, M. n., Sharek, P. J. 2018
Abstract

Pediatric patients undergoing cardiac surgeries are at an increased surgical site infection (SSI) risk, given prolonged cardiopulmonary bypasses and delayed sternal closures. At one institution, the majority of cardiac patients developed SSIs during prolonged recoveries in the cardiovascular intensive care unit (CVICU). Although guidelines have been published to reduce SSIs in the perioperative period, there have been few guidelines to reduce the risk during prolonged hospital recoveries. The aim of this project was to study a postoperative SSI reduction care bundle, with a goal of reducing cardiac SSIs by 50%, from 3.4 to 1.7 per 100 procedures.This project was conducted at a quaternary, pediatric academic center with a 20-bed CVICU. Historical control data were recorded from January 2013 through May 2015 and intervention/sustainment data from June 2015 through March 2017. A multidisciplinary SSI reduction team developed five key drivers that led to implementation of 11 postoperative SSI reduction care elements. Statistical process control charts were used to measure process compliance, and Pearson's chi-square test was used to determine differences in SSI rates.Prior to implementation, there were 27 SSIs in 799 pediatric cardiac surgeries (3.4 SSIs per 100 surgeries). After the intervention, SSIs significantly decreased to 5 in 570 procedures (0.9 SSIs per 100 surgeries; p?=?0.0045).This project describes five key drivers and 11 elements that were dedicated to reducing the risk of SSI during prolonged CVICU recoveries from pediatric cardiac surgery, with demonstrated sustainability.

View details for DOI 10.1016/j.jcjq.2018.05.009

View details for PubMedID 30170753
Intraoperative antibiotic redosing compliance and the extended postoperative recovery period: often overlooked areas that may reduce surgical site infections. Paediatric anaesthesia Caruso, T. J., Wang, E. n., Colletti, A. A., Sharek, P. J. 2018
Abstract

It was with great interest that we read Compliance with perioperative prophylaxis guidelines and the use of novel outcome measures by Morse, et�al.1 The authors should be applauded for presenting a well-balanced review of the rationale behind the use of prophylactic antibiotics, data supporting dosing intervals, and potential outcome measures. This article is protected by copyright. All rights reserved.

View details for PubMedID 30592343
Lumbar erector spinae plane catheter via a thoracic approach for iliac crest autograft in a pediatric patient. Journal of clinical anesthesia Darling, C. E., Lin, C. n., Caruso, T. J., Tsui, B. C. 2018; 54: 164?65
View details for DOI 10.1016/j.jclinane.2018.12.008

View details for PubMedID 30554043
Augmented reality for intravenous access in an autistic child with difficult access. Paediatric anaesthesia Rodriguez, S. n., Munshey, F. n., Caruso, T. J. 2018; 28 (6): 569?70
View details for DOI 10.1111/pan.13395

View details for PubMedID 29878540
Cervical erector spinae plane block catheter using a thoracic approach: an alternative to brachial plexus blockade for forequarter amputation. Canadian journal of anaesthesia = Journal canadien d'anesthesie Tsui, B. C., Mohler, D. n., Caruso, T. J., Horn, J. L. 2018
View details for PubMedID 29868941
Bilateral automatized intermittent bolus erector spinae plane analgesic blocks for sternotomy in a cardiac patient who underwent cardiopulmonary bypass: A new era of Cardiac Regional Anesthesia. Journal of clinical anesthesia Tsui, B. C., Navaratnam, M. n., Boltz, G. n., Maeda, K. n., Caruso, T. J. 2018; 48: 9?10
View details for DOI 10.1016/j.jclinane.2018.04.005

View details for PubMedID 29684728
Successful directional thoracic erector spinae plane block after failed lumbar plexus block in hip joint and proximal femur surgery. Journal of clinical anesthesia Darling, C. E., Pun, S. Y., Caruso, T. J., Tsui, B. C. 2018; 49: 1?2
View details for PubMedID 29775780
A quality improvement initiative to optimize dosing of surgical antimicrobial prophylaxis. Paediatric anaesthesia Caruso, T. J., Wang, E., Schwenk, H. T., Scheinker, D., Yeverino, C., Tweedy, M., Maheru, M., Sharek, P. J. 2017; 27 (7): 702-710
Abstract

The risk of surgical site infections is reduced with appropriate timing and dosing of preoperative antimicrobials. Based on evolving national guidelines, we increased the preoperative dose of cefazolin from 25 to 30 mg�kg(-1) . This quality improvement project describes an improvement initiative to develop standard work processes to ensure appropriate dosing.The primary aim was to deliver cefazolin 30 mg�kg(-1) to at least 90% of indicated patients. The secondary aim was to determine differences between accuracy of cefazolin doses when given as an electronic order compared to a verbal order.Data were collected from January 1, 2012 to May 31, 2016. A quality improvement team of perioperative physicians, nurses, and pharmacists implemented a series of interventions including new electronic medical record order sets, personal provider antibiotic dose badges, and utilization of pharmacists to prepare antibiotics to increase compliance with the recommended dose. Process compliance was measured using a statistical process control chart, and dose compliance was measured through electronic analysis of the electronic medical record. Secondary aim data were displayed as percentage of dose compliance. An unpaired t-test was used to determine differences between groups.Between January 1, 2012 and May 31, 2016, cefazolin was administered to 9086 patients. The mean compliance of cefazolin at 30 mg�kg(-1) from May 2013 to March 2014 was 40%, which prompted initiation of this project. From April 2014 to May 2016, a series of interventions were deployed. The mean compliance from September 2015 to May 2016 was 93% with significantly reduced variation and no special cause variation, indicating that the process was in control at the target primary aim. There were 649 cefazolin administrations given verbally and 1929 given with an electronic order between October 1, 2014 and May 31, 2016. During this time period, the rate of compliance of administering cefazolin at 30 mg�kg(-1) was significantly higher when given after an electronic order than when given verbally, 94% vs 76%.This comprehensive quality improvement project improved practitioner compliance with evidence-based preoperative antimicrobial dosing recommendations to reduce the risk of surgical site infections.

View details for DOI 10.1111/pan.13137

View details for PubMedID 28321988
Standardized ICU to OR handoff increases communication without delaying surgery. International journal of health care quality assurance Caruso, T. J., Marquez, J. L., Gipp, M. S., Kelleher, S. P., Sharek, P. J. 2017; 30 (4): 304-311
Abstract

Purpose No studies have examined preoperative handoffs from the intensive care unit (ICU) to OR. Given the risk of patient harm, the authors developed a standardized ICU to OR handoff using a previously published handoff model. The purpose of this paper is to determine whether a standardized ICU to OR handoff process would increase the number of team handoffs and improve patient transport readiness. Design/methodology/approach The intervention consisted of designing a multidisciplinary, face-to-face handoff between sending ICU providers and receiving anesthesiologist and OR nurse, verbally presented in the I-PASS format. Anticipatory calls from the OR nurse to the ICU nurse were made to prepare the patient for transport. Data collected included frequency of handoff, patient transport readiness, turnover time between OR cases, and anesthesia provider satisfaction. Findings In total, 57 audits were completed. The frequency of handoffs increased from 25 to 86 percent ( p<0.0001) and the frequency of patient readiness increased from 61 to 97 percent ( p=0.001). There were no changes in timeliness of first start cases and no significant change in turnover times between cases. Anesthesia provider satisfaction scores increased significantly. Practical implications A standardized, team based ICU to OR handoff increased the frequency of face-to-face handoffs, patient readiness and anesthesia provider satisfaction within increasing turnover between cases. Originality/value Although studies have identified the transition of patients from the ICU to the OR as a period of increased harm, the development of a preoperative ICU to OR handoff had not been described. This intervention may be used in other institutions to design ICU to OR transitions of care.

View details for DOI 10.1108/IJHCQA-02-2016-0015

View details for PubMedID 28470134
Pediatric Postoperative Pulse Oximetry Monitoring During Transport to the Postanesthesia Care Unit Reduces Frequency of Hypoxemia. Joint Commission journal on quality and patient safety Caruso, T. J., Mokhtari, T. E., Coughlan, M. J., Wu, D. S., Marquez, J. L., Duan, M. n., Freeman, H. n., Giustini, A. n., Tweedy, M. n., Sharek, P. J. 2017; 43 (3): 146?50
Abstract

The standard use of pulse oximetry during the transport of postoperative patients from the operating room (OR) to the postanesthesia care unit (PACU) is not routinely practiced. A study was conducted to determine if the frequency of hypoxemia on admission to the PACU decreased after implementation of routine use of transport pulse oximeters for postoperative patients being transferred to the PACU.In this prospective cohort study, which was conducted at an academic pediatric hospital, the primary outcome measure was the frequency of hypoxemic events on arrival to the PACU.A total of 506 patients in the preintervention phase and 597 in the postintervention phase met the inclusion criteria. Six hypoxemic events on arrival to the PACU were identified in preintervention phase versus zero in the postintervention period, p?=?0.009. Use of oxygen monitors during transport from the OR to the PACU increased from 0% to 100%, p?
View details for DOI 10.1016/j.jcjq.2016.12.001

View details for PubMedID 28334593
Provider-controlled virtual reality experience may adjust for cognitive load during vascular access in pediatric patients. Canadian journal of anaesthesia = Journal canadien d'anesthesie Yuan, J. C., Rodriguez, S. n., Caruso, T. J., Tsui, J. H. 2017
View details for PubMedID 28861855
Caution with the Posey(�) Cufflator? cuff pressure manometers. Paediatric anaesthesia Kiberd, M. B., Swenson-Schalkwyk, A. K., Caruso, T. J. 2017; 27 (12): 1279?80
View details for PubMedID 29110434
Interactive video game built for mask induction in pediatric patients. Canadian journal of anaesthesia = Journal canadien d'anesthesie Rodriguez, S. n., Tsui, J. H., Jiang, S. Y., Caruso, T. J. 2017
View details for PubMedID 28646461
Bedside Entertainment and Relaxation Theater: size and novelty does matter when using video distraction for perioperative pediatric anxiety. Paediatric anaesthesia Rodriguez, S. n., Caruso, T. n., Tsui, B. n. 2017; 27 (6): 668?69
View details for DOI 10.1111/pan.13133

View details for PubMedID 28474813
A Strategic Approach to Implementation of Medical Mentorship Programs. Journal of graduate medical education Caruso, T. J., Steinberg, D. H., Piro, N., Walker, K., Blankenburg, R., Rassbach, C., Marquez, J. L., Katznelson, L., Dohn, A. 2016; 8 (1): 68-73
Abstract

Mentors influence medical trainees' experiences through career enhancement and psychosocial support, yet some trainees never receive benefits from involved mentors.Our goals were to examine the effectiveness of 2 interventions aimed at increasing the number of mentors in training programs, and to assess group differences in mentor effectiveness, the relationship between trainees' satisfaction with their programs given the presence of mentors, and the relationship between the number of trainees with mentors and postgraduate year (PGY).In group 1, a physician adviser funded by the graduate medical education department implemented mentorships in 6 residency programs, while group 2 involved a training program with funded physician mentoring time. The remaining 89 training programs served as controls. Chi-square tests were used to determine differences.Survey responses from group 1, group 2, and controls were 47 of 84 (56%), 34 of 78 (44%), and 471 of 981 (48%, P?=?.38), respectively. The percentages of trainees reporting a mentor in group 1, group 2, and the control group were 89%, 97%, and 79%, respectively (P?=?.01). There were no differences in mentor effectiveness between groups. Mentored trainees were more likely to be satisfied with their programs (P?=?.01) and to report that faculty supported their professional aspirations (P?=?.001). Across all programs, fewer first-year trainees (59%) identified a mentor compared to PGY-2 through PGY-8 trainees (84%, P?
View details for DOI 10.4300/JGME-D-15-00335.1

View details for PubMedID 26913106

View details for PubMedCentralID PMC4763391
Implementation of a standardized postanesthesia care handoff increases information transfer without increasing handoff duration. Joint Commission journal on quality and patient safety / Joint Commission Resources Caruso, T. J., Marquez, J. L., Wu, D. S., Shaffer, J. A., Balise, R. R., Groom, M., Leong, K., Mariano, K., Honkanen, A., Sharek, P. J. 2015; 41 (1): 35-42
Abstract

In the transition of a patient from the operating room (OR) to the postanesthesia care unit (PACU), it was hypothesized that (1) standardizing the members of sending and receiving teams and (2) requiring a structured handoff process would increase the overall amount of patient information transferred in the OR-to-PACU handoff process.A prospective cohort study was conducted at a 311-bed freestanding academic pediatric hospital in Northern California. The intervention, which was conducted in February-March 2013, consisted of (1) requiring the sending team to include a surgeon, an anesthesiologist, and a circulating nurse, and the receiving team to include the PACU nurse; (2) standardizing the content of the handoff on the basis of literature-guided recommendations; and (3) presenting the handoff verbally in the I-PASS format. Data included amount of patient information transferred, duration of handoff, provider presence, and nurse satisfaction.Forty-one audits during the preimplementation phase and 45 audits during the postimplementation phase were analyzed. Overall information transfer scores increased significantly from a mean score of 49% to 83% (p < .0001). Twenty-two PACU nurse satisfaction surveys were completed after the preimplementation phase and 14 surveys were completed in the postimplementation phase. Paired mean total satisfaction scores increased from 36 to 44 (p =. 004). The duration of the handoffs trended downward from 4.1 min to 3.5 min (p = 0.10).A standardized, team-based approach to OR-to-PACU handoffs increased the quantity of patient information transferred, increased PACU nurse satisfaction, and did not increase the handoff duration.

View details for PubMedID 25976722
Images in clinical medicine. Severe vitamin D deficiency--rickets. New England journal of medicine Caruso, T. J., Fuzaylov, G. 2013; 369 (9)
View details for DOI 10.1056/NEJMicm1205540

View details for PubMedID 23984751
Airway management of recovered pediatric patients with severe head and neck burns: a review PEDIATRIC ANESTHESIA Caruso, T. J., Janik, L. S., Fuzaylov, G. 2012; 22 (5): 462-468
Abstract

There are approximately 10,000 pediatric burn survivors in the United States each year, many of whom will present for reconstructive surgery after severe burns in the head and neck (1). These recovered burn victims, who are beyond the acute phase of injury, often have significant scarring and contractures in the face, mouth, nares, neck, and chest, which can make airway management challenging and potentially lead to a 'cannot intubate, cannot ventilate' scenario (2). Although numerous cases have been presented in the literature on this topic (3-17), there are no comprehensive review articles on the unique challenges of airway management in the recovered pediatric burn patient with distorted airway anatomy. This article aims to provide a comprehensive review of airway management in such patients, focusing on challenges encountered during mask ventilation and tracheal intubation, as well as the role of surgical release of neck contractures to facilitate tracheal intubation. Lessons learned from all reported cases identified in a thorough literature search are incorporated into this review.

View details for DOI 10.1111/j.1460-9592.2012.03795.x

View details for Web of Science ID 000302540900009

View details for PubMedID 22260458
Complementary and Alternative Medicine for Pain: An Evidence-based Review CURRENT PAIN AND HEADACHE REPORTS Dhanani, N. M., Caruso, T. J., Carinci, A. J. 2011; 15 (1): 39-46
Abstract

Pain is one of the most prevalent conditions for which patients seek medical attention. Additionally, the number of patients who utilize complementary and alternative medicine as a treatment of pain either in lieu of, or concurrent with, standard conventional treatments continues to grow. While research into the mechanisms, side effect profiles, and efficacies of these alternative therapies has increased in recent years, much more remains unknown and untested. Herein, we review the literature on complementary and alternative medicine for pain, with particular emphasis on evidence-based assessments pertinent to the most common alternative therapies, including acupuncture, herbal therapy, massage therapy, hypnosis, tai chi, and biofeedback.

View details for DOI 10.1007/s11916-010-0158-y

View details for Web of Science ID 000286230400007

View details for PubMedID 21063917
Magnetic resonance Imaging detected renal volume reduction in refluxing and nonrefluxing kidneys JOURNAL OF UROLOGY Chang, S. L., Caruso, T. J., Shortliffe, L. D. 2007; 178 (6): 2550-2554
Abstract

Renal parenchymal damage is a well recognized sequela of urinary tract infection in the setting of vesicoureteral reflux. We investigated renal magnetic resonance imaging as a quantitative modality to detect renal parenchymal damage in children with primary vesicoureteral reflux and urinary tract infection.We retrospectively reviewed the medical records of children with primary vesicoureteral reflux and urinary tract infection who underwent renal magnetic resonance imaging evaluation. Those with other genitourinary pathology were excluded. Controls underwent magnetic resonance imaging for nongenitourinary pathologies. Kidneys were segregated among control, nonrefluxing, and low grade (I to III) and high grade (IV to V) reflux. Size plots (magnetic resonance imaging volume vs age) were drawn for comparison. Gross imaging abnormalities observed were renal scarring and small size.Magnetic resonance imaging was performed in 114 patients with vesicoureteral reflux (228 kidneys, patient age 0.5 to 17.8 years) and 21 controls (42, 0.5 to 12). Higher grades of reflux were associated with smaller volume, and smaller volume was noted in the refluxing and nonrefluxing kidneys of children with vesicoureteral reflux. Kidneys from patients with unilateral or bilateral reflux had significantly decreased renal volume compared to controls (p <0.0001). Kidneys in which vesicoureteral reflux spontaneously resolved had renal volumes similar to control kidneys (p = 0.23).Use of magnetic resonance imaging derived renal volume allows renal comparison and is helpful in evaluating patients with vesicoureteral reflux. In patients with a history of a febrile urinary tract infection and reflux the finding of measurably smaller kidneys appears to be more common than scarring. Whether these findings represent renal atrophy or hypoplasia needs further investigation.

View details for Web of Science ID 000250847900082

View details for PubMedID 17937957
Treatment of naturally acquired common colds with zinc: A structured review CLINICAL INFECTIOUS DISEASES Caruso, T. J., Prober, C. G., Gwaltney, J. M. 2007; 45 (5): 569-574
Abstract

Over the past 20 years, the use of zinc as an over-the-counter alternative therapy for the common cold has vastly grown in popularity. Recent reports of potentially permanent anosmia caused by intranasal zinc therapy warrant careful analysis of the therapeutic effects of zinc.A search of the Medline database (including articles published during 1966-2006) for studies of zinc and the common cold produced 105 published reports. Fourteen were randomized, placebo-controlled studies that examined the effect of zinc lozenges, nasal sprays, or nasal gels on naturally acquired common colds. Eleven features of experimental design affecting signal quality, chance, bias, and blinding were used to evaluate the 14 placebo-controlled studies. These criteria were validated case definition, quantifiable hypothesis, sample size calculation, randomized assignment, double blinding, proof of blinding, measurement of compliance, measurement of dropout rate, analysis by intent to treat, description of methods of analysis, and measurements of probability. Equal weight was given to each criterion, because failure to meet any one could potentially invalidate the findings of a clinical trial.Four studies met all 11 criteria. Three of these studies reported no therapeutic effect from zinc lozenge or nasal spray. One study reported positive results from zinc nasal gel. Of the remaining 10 studies, 6 reported a positive effect and 4 reported no effect. Intent-to-treat analysis was the most common criterion not met.This structured review suggests that the therapeutic effectiveness of zinc lozenges has yet to be established. One well-designed study did report a positive effect of zinc nasal gel.

View details for DOI 10.1086/520031

View details for Web of Science ID 000248557000016

View details for PubMedID 17682990
Efficacy of echinilin for the common cold - Echinacea, vitamin C, the common cold, and blinding - Reply CLINICAL INFECTIOUS DISEASES Caruso, T. J., Gwaltney, J. M. 2005; 41 (5): 763?64
View details for DOI 10.1086/432628

View details for Web of Science ID 000230995600032
Treatment of the common cold with echinacea: A structured review CLINICAL INFECTIOUS DISEASES Caruso, T. J., Gwaltney, J. M. 2005; 40 (6): 807-810
Abstract

Echinacea is a herbal preparation that is frequently used to treat the common cold. Spending on echinacea in the United States has risen to >300 million dollars annually.A total of 322 articles related to echinacea and colds, including 9 placebo-controlled clinical trials, were identified using the Medline and PubMed databases. Eleven features of experimental design that affect the accuracy of the measurement of features of interest, the probability of a chance relationship, bias, and blinding were used to evaluate the 9 placebo-controlled studies. The criteria were validated case definition, quantifiable hypothesis, sample-size calculation, randomized assignment, double blinding, proof of blinding, measurement of compliance, measurement of drop-out rate, analysis by intention to treat, description of the methods of analysis, and measurement of probability. Equal weight was given to each criterion, since failure to meet any one of them could potentially invalidate the findings of a clinical trial.Of the 9 studies, 2 met all 11 criteria. The results of both studies were judged to be negative by the people who performed the studies. Of the remaining 7 studies, 6 were judged to have positive results, and 1 was judged to have negative results. The criterion most commonly not met was proof of blinding.This structured review suggests that the possible therapeutic effectiveness of echinacea in the treatment of colds has not been established.

View details for Web of Science ID 000227492800005

View details for PubMedID 15736012
Evaluating Studies of Echinacea of Treating the Common Cold Contagion Caruso, T. J. 2005; 9: 378-381

Thomas Caruso

Clinical Associate Professor, Anesthesiology, Perioperative and Pain MedicinePh.D. Student in Education, admitted Autumn 2019

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Clinical Associate Professor, Anesthesiology, Perioperative and Pain Medicine
Ph.D. Student in Education, admitted Autumn 2019

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