Objective Extracorporeal membrane oxygenation, an accepted rescue therapy for refractory cardiopulmonary failure, requires a complex multidisciplinary approach and advanced technology. Little is known about the relationship between a center’s case volume and patient mortality. The purpose of this study was to analyze the relationship between hospital extracorporeal membrane oxygenation annual volume and in-hospital mortality and assess if a minimum hospital volume could be recommended. Design Retrospective cohort study Setting A retrospective cohort admitted to children’s hospitals in the Pediatric Health Information System database from 2004-2011 supported with extracorporeal membrane oxygenation was identified. Indications were assigned based on patient age (neonatal vs. pediatric), diagnosis, and procedure codes. Average hospital annual volume was defined as 0-19, 20-49, or ≥50 cases per year. Maximum likelihood estimates were used to assess minimum annual case volume. Patients A total of 7322 pediatric patients aged 0-18 years of age were supported with extracorporeal membrane oxygenation and had an indication assigned. Interventions None Measurements and Main Results Average hospital extracorporeal membrane oxygenation volume ranged from 1-58 cases per year. Overall mortality was 43% but differed significantly by indication. After adjustment for case-mix, complexity of cardiac surgery, and year of treatment, patients treated at medium (OR 0.86, 95% CI 0.75-0.98) and high (OR 0.75, 95% CI 0.63-0.89) volume centers had significantly lower odds of death compared to those treated at low volume centers. The minimum annual case load most significantly associated with lower mortality was 22 (95% CI 22-28). Conclusion Pediatric centers with low extracorporeal membrane oxygenation average annual case volume had significantly higher mortality and a minimum volume of 22 cases per year was associated with improved mortality. We suggest this threshold be evaluated by additional study.

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Background The use of regional anesthesia (RA) in pediatric patients remains understudied, although evidence suggests benefits over general anesthesia. Questions/Purposes We sought to identify factors associated with RA use in patients under the age of 21 years undergoing ambulatory orthopedic surgery. Methods Patients under the age of 21 who underwent anterior cruciate ligament (ACL) repair or reconstruction, knee arthroscopy (KA), or shoulder arthroscopy (SA) were identified from the NY Statewide Planning and Research Cooperative System (SPARCS) database (2005–2015). Frequencies of RA use (defined by femoral nerve block, spinal, epidural, caudal, or brachial plexus anesthesia) were calculated. Multivariable regression analysis identified patient- and healthcare system–related factors associated with the use of RA. Odds ratios (OR) and 95% confidence intervals (CI) were reported. Results We identified 87,273 patients who underwent the procedures of interest (ACL n = 28,226; SA n = 18,155; KA n = 40,892). In our primary analysis, 14.4% (n = 1404) had RA as their primary anesthetic; this percentage increased for patients who had ACL or KA. When adjusting for covariates, Hispanic ethnicity (OR 0.78; CI 0.65–0.94) and Medicaid insurance (OR 0.75; CI 0.65–0.87) were associated with decreased odds for the provision of RA. Further, we identified increasing age (OR 1.10; CI 1.08–1.11), ACL versus SA (OR 1.91; CI 1.74–2.10), and sports injuries (OR 1.20; CI 1.10–1.31) as factors associated with increased odds of RA use. Conclusion In this analysis, RA was used in a minority of patients under the age of 21 undergoing ambulatory orthopedic surgery. Older age was associated with increased use while Hispanic ethnicity and lower socioeconomic status were associated with lower use.

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BackgroundGiven the steep learning curve for neuraxial and peripheral nerve blocks, utilization of general anesthesia may increase as new house staff begin their residency programs. We sought to determine whether “July effect” affects the utilization of neuraxial anesthesia, peripheral nerve blocks, and opioid prescribing for lower extremity total joint arthroplasties (TJA) in July compared with June in teaching and non-teaching hospitals.MethodsNeuraxial anesthesia, peripheral nerve block use, and opioid prescribing trends were assessed using the Premier database (2006–2016). Analyses were conducted separately for teaching and non-teaching hospitals. Differences in proportions were evaluated via χ2 test, while differences in opioid prescribing were analyzed via Wilcoxon rank-sum tests.ResultsA total of 1 723 256 TJA procedures were identified. The overall proportion of neuraxial anesthesia use in teaching hospitals was 14.4% in both June and July (p=0.940). No significant changes in neuraxial use were seen in non-teaching hospitals (24.5% vs 24.9%; p=0.052). Peripheral nerve block utilization rates did not differ in both teaching (15.4% vs 15.3%; p=0.714) and non-teaching hospitals (10.7% vs 10.5%; p=0.323). Overall median opioid prescribing at teaching hospitals changed modestly from 262.5 oral morphine equivalents (OME) in June to 260 in July (p=0.026) while median opioid prescribing remained at a constant value of 255 OME at non-teaching hospitals (p=0.893).ConclusionUtilization of neuraxial and regional anesthesia techniques was not affected during the initial transition period of new house staff in US teaching institutions. It is feasible that enough resources are available in the system to accommodate periods of turnover and maintain levels of regional anesthetic care including additional attending anesthesiologist oversight.

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