<p><strong>BACKGROUND: </strong>Children routinely undergo inhalational induction of general anesthesia. Intravenous line placement typically occurs after induction of anesthesia and can be challenging, particularly in infants and young children.</p>

<p><strong>AIMS: </strong>We conducted a retrospective observational study to determine whether there was an association between clear liquid fasting time and the number of peripheral intravenous catheter insertion attempts in anesthetized children. The secondary aim was to identify factors associated with multiple attempts to insert intravenous lines.</p>

<p><strong>METHODS: </strong>After institutional research board approval, we retrieved a data set of all children between 0 months and 18 years who received general anesthesia at our hospital between January 1, 2016, and September 30, 2017. Data included age, gender, weight, race, ASA status, gestational age, number of peripheral intravenous catheter insertion attempts, any assistive device for insertion, and insertion site. Inclusion criteria were mask induction, ASA status 1 or 2, non-emergency, ambulatory surgical procedures and placement of a single intravenous line during the anesthetic.</p>

<p><strong>RESULTS: </strong>9,693 patients were included in the study. 8,869 patients required one insertion attempt and 824 underwent multiple insertion attempts. 50% of patients in the single insertion attempt group had clear liquid fasting time less than 6.9 hours compared to 51.8% of patients requiring multiple attempts. Logistic regression model adjusted for age, ASA status, gender and BMI did not find an association between duration of clear liquid fasting time and rate of multiple insertion attempts for intravenous catheters (OR 0.99, 95% CI 0.98-1.01, P = 0.47).</p>

<p><strong>CONCLUSIONS: </strong>Clear liquid fasting time was not associated with multiple insertion attempts for intravenous line insertion in children receiving general anesthesia. Factors such as patient age, ethnicity, time of day of induction of anesthesia and American Society of Anesthesiologists Physical Status classification show a greater association with the risk of multiple intravenous line insertion attempts.</p>

<p><strong>BACKGROUND: </strong> Hospitals use antibiograms to guide optimal empiric antibiotic therapy, reduce inappropriate antibiotic usage, and identify areas requiring intervention by antimicrobial stewardship programs. Creating a hospital antibiogram is a time-consuming manual process that is typically performed annually.</p>

<p><strong>OBJECTIVE: </strong> We aimed to apply visual analytics software to electronic health record (EHR) data to build an automated, electronic antibiogram ("e-antibiogram") that adheres to national guidelines and contains filters for patient characteristics, thereby providing access to detailed, clinically relevant, and up-to-date antibiotic susceptibility data.</p>

<p><strong>METHODS: </strong> We used visual analytics software to develop a secure, EHR-linked, condition- and patient-specific e-antibiogram that supplies susceptibility maps for organisms and antibiotics in a comprehensive report that is updated on a monthly basis. Antimicrobial susceptibility data were grouped into nine clinical scenarios according to the specimen source, hospital unit, and infection type. We implemented the e-antibiogram within the EHR system at Children's Hospital of Philadelphia, a tertiary pediatric hospital and analyzed e-antibiogram access sessions from March 2016 to March 2017.</p>

<p><strong>RESULTS: </strong> The e-antibiogram was implemented in the EHR with over 6,000 inpatient, 4,500 outpatient, and 3,900 emergency department isolates. The e-antibiogram provides access to rolling 12-month pathogen and susceptibility data that is updated on a monthly basis. E-antibiogram access sessions increased from an average of 261 sessions per month during the first 3 months of the study to 345 sessions per month during the final 3 months.</p>

<p><strong>CONCLUSION: </strong> An e-antibiogram that was built and is updated using EHR data and adheres to national guidelines is a feasible replacement for an annual, static, manually compiled antibiogram. Future research will examine the impact of the e-antibiogram on antibiotic prescribing patterns.</p>

<p><strong>BACKGROUND: </strong>Children with congenital heart disease (CHD) often require noncardiac surgery. We compared outcomes following open and laparoscopic intraabdominal surgery among children with and without CHD.</p>

<p><strong>METHODS: </strong>We performed a retrospective cohort study using the 2013-2015 National Surgical Quality Improvement Project-Pediatrics. We matched 45,012 children &lt;18years old who underwent laparoscopic surgery to 45,012 children who underwent open surgery. We determined the associations between laparoscopic (versus open) surgery and 30-day mortality, in-hospital mortality, 30-day morbidity, and postoperative length-of-stay.</p>

<p><strong>RESULTS: </strong>Among children with minor CHD, laparoscopic surgery was associated with lower 30-day mortality (Odds Ratio [OR] 0.34 [95% Confidence Interval 0.15-0.79]), inhospital mortality (OR 0.42 [0.22-0.81]) and 30-day morbidity (OR 0.61 [0.50-0.73]). As CHD severity increased, this benefit of laparoscopic surgery decreased for 30-day morbidity (ptrend=0.01) and in-hospital mortality (ptrend=0.05), but not for 30-day mortality (ptrend=0.27). Length-of-stay was shorter for laparoscopic approaches for children at cost of higher readmissions. On subgroup analysis, laparoscopy was associated with lower odds of postoperative blood transfusion in all children.</p>

<p><strong>CONCLUSIONS: </strong>Intraabdominal laparoscopic surgery compared to open surgery is associated with decreased morbidity in patients with no CHD and lower morbidity and mortality in patients with minor CHD, but not in those with more severe CHD.</p>

<p><strong>LEVEL-OF-EVIDENCE: </strong>Level III: Treatment Study.</p>

<p><strong>BACKGROUND: </strong>Intraoperative hypotension may be associated with adverse outcomes in children undergoing surgery. Infants and neonates under 6 months of age have less autoregulatory cerebral reserve than older infants, yet little information exists regarding when and how often intraoperative hypotension occurs in infants.</p>

<p><strong>AIMS: </strong>To better understand the epidemiology of intraoperative hypotension in infants, we aimed to determine the prevalence of intraoperative hypotension in a generally uniform population of infants undergoing laparoscopic pyloromyotomy.</p>

<p><strong>METHODS: </strong>Vital sign data from electronic records of infants who underwent laparoscopic pyloromyotomy with general anesthesia at a children's hospital between January 1, 1998 and October 4, 2013 were analyzed. Baseline blood pressure (BP) values and intraoperative BPs were identified during eight perioperative stages based on anesthesia event timestamps. We determined the occurrence of relative (systolic BP &lt;20% below baseline) and absolute (mean arterial BP &lt;35 mmHg) intraoperative hypotension within each stage.</p>

<p><strong>RESULTS: </strong>A total of 735 full-term infants and 82 preterm infants met the study criteria. Relative intraoperative hypotension occurred in 77%, 72%, and 58% of infants in the 1-30, 31-60, and 61-90 days age groups, respectively. Absolute intraoperative hypotension was seen in 21%, 12%, and 4% of infants in the 1-30, 31-60, and 61-90 days age groups, respectively. Intraoperative hypotension occurred primarily during surgical prep and throughout the surgical procedure. Preterm infants had higher rates of absolute intraoperative hypotension than full-term infants.</p>

<p><strong>CONCLUSIONS: </strong>Relative intraoperative hypotension was routine and absolute intraoperative hypotension was common in neonates and infants under 91 days of age. Preterm infants and infants under 61 days of age experienced the highest rates of absolute and relative intraoperative hypotension, particularly during surgical prep and throughout surgery.</p>

<p>Children are a vulnerable population in the operating room, and are particularly at risk of complications from unanticipated hemorrhage. The decision to prepare blood products prior to surgery varies depending on the personal experience of the clinician caring for the patient. We present the first application of a data visualization technique to study large datasets in the context of blood product transfusions at a tertiary pediatric hospital. The visual analytical interface allows real-time interaction with datasets from 230 000 procedure records. Clinicians can use the visual analytical interface to analyze blood product usage based on procedure- and patient-specific factors, and then use that information to guide policies for ordering blood products.</p>

<p><strong>OBJECTIVE: </strong>To develop and evaluate an electronic dashboard of hospital-wide electronic health record medication alerts for an alert fatigue reduction quality improvement project.</p>

<p><strong>METHODS: </strong>We used visual analytics software to develop the dashboard. We collaborated with the hospital-wide Clinical Decision Support committee to perform three interventions successively deactivating clinically irrelevant drug-drug interaction (DDI) alert rules. We analyzed the impact of the interventions on care providers' and pharmacists' alert and override rates using an interrupted time series framework with piecewise regression.</p>

<p><strong>RESULTS: </strong>We evaluated 2 391 880 medication alerts between January 31, 2011 and January 26, 2014. For pharmacists, the median alert rate prior to the first DDI deactivation was 58.74 alerts/100 orders (IQR 54.98-60.48) and 25.11 alerts/100 orders (IQR 23.45-26.57) following the three interventions (p&lt;0.001). For providers, baseline median alert rate prior to the first round of DDI deactivation was 19.73 alerts/100 orders (IQR 18.66-20.24) and 15.11 alerts/100 orders (IQR 14.44-15.49) following the three interventions (p&lt;0.001). In a subgroup analysis, we observed a decrease in pharmacists' override rates for DDI alerts that were not modified in the system from a median of 93.06 overrides/100 alerts (IQR 91.96-94.33) to 85.68 overrides/100 alerts (IQR 84.29-87.15, p&lt;0.001). The medication serious safety event rate decreased during the study period, and there were no serious safety events reported in association with the deactivated alert rules.</p>

<p><strong>CONCLUSIONS: </strong>An alert dashboard facilitated safe rapid-cycle reductions in alert burden that were temporally associated with lower pharmacist override rates in a subgroup of DDIs not directly affected by the interventions; meanwhile, the pharmacists' frequency of selecting the 'cancel' option increased. We hypothesize that reducing the alert burden enabled pharmacists to devote more attention to clinically relevant alerts.</p>