Tag Archive for: circumcision

MRI scan of human lumbar spine

Improving outcomes of infant spinal anesthesia through new intervention program

MRI scan of human lumbar spine

New intervention program could help improve outcomes of infant spinal anesthesia.

Spinal anesthesia has a long history as an effective and safe technique to avoid general anesthesia (GA) in infants undergoing surgery. However, adverse effects of GA on infants — children younger than 1 year of age — include respiratory complications, delayed postanesthesia care unit (PACU) discharge and unplanned hospital admissions. In addition, while some reassuring studies have demonstrated the safety of anesthetic agents on the developing brain, the data are still inconclusive, particularly for patients with longer, more frequent anesthetic exposures.

The big picture

In a recent study published in the journal of Pediatric Quality and Safety, Sophie Rose Pestieau, M.D., anesthesiologist at Children’s National Hospital and senior author of the study, and other experts, created a healthcare improvement program aimed to increase the percentage of successful spinal placements as the primary anesthetic in infants undergoing circumcision, open orchidopexy or hernia repair from 11% to 50% by the end of 2019 and sustain that rate for 6 months.

What it means

The interdisciplinary team created a key driver diagram and implemented the following interventions: education of nurses, surgeons and patient families; focused anesthesiologist training on the infant spinal procedure; premedication; availability of supplies; and surgical schedule optimization.

The team collected data retrospectively by reviewing electronic medical records. The primary outcome was the percentage of infants undergoing circumcision, open orchidopexy or hernia repair who received a successful spinal as the primary anesthetic. The team tracked this measure and evaluated using a statistical process control chart.

“We were able to move the needle and successfully offer this technique to many more infants as we educated families on the benefits of spinal anesthesia, as well as other surgical colleagues and the perioperative nursing staff,” Dr. Pestieau said.

Why it matters

Before this quality improvement project, 11% of the circumcisions, open orchidopexies and inguinal hernia repairs were performed in infants using spinal anesthesia as the primary anesthetic. Between August 1, 2018, and February 29, 2020, 470 infants underwent circumcision, open orchidopexy or inguinal hernia repair (235 preintervention and 235 postintervention). Of these infants, 132 underwent a successful spinal anesthetic (26 preintervention and 106 postintervention). Following the interventions, spinal placements increased from 11% to 45%, and the success rate of infant spinal anesthesia increased from 73% to 89%.

This quality improvement project successfully increased the percentage of patients receiving spinal anesthesia for specific surgical procedures by increasing the number of patients who underwent successful spinal anesthesia placement.

“We continue to grow the program by expanding the use of spinal anesthesia to other surgical procedures,” Dr. Pestieau concluded.

The project aimed to increase the number of urological procedures successfully performed under spinal anesthesia in children less than 1 year of age. The interventions increased the number of patients who underwent spinal anesthesia placement. They also increased the success rate of spinal anesthesia placements. Further quality improvement efforts may increase the number of infants considered for infant spinal anesthesia as primary anesthesia for their procedure, beyond circumcision, open orchidopexy and inguinal hernia repair.

DNA Molecule

Decoding cellular signals linked to hypospadias

DNA Molecule

“By advancing our understanding of the genetic causes and the anatomic differences among patients, the real goal of this research is to generate knowledge that will allow us to take better care of children with hypospadias,” Daniel Casella, M.D. says.

Daniel Casella, M.D., a urologist at Children’s National, was honored with an AUA Mid-Atlantic Section William D. Steers, M.D. Award, which provides two years of dedicated research funding that he will use to better understand the genetic causes for hypospadias.

With over 7,000 new cases a year in the U.S., hypospadias is a common birth defect that occurs when the urethra, the tube that transports urine out of the body, does not form completely in males.

Dr. Casella has identified a unique subset of cells in the developing urethra that have stopped dividing but remain metabolically active and are thought to represent a novel signaling center. He likens them to doing the work of a construction foreman. “If you’re constructing a building, you need to make sure that everyone follows the blueprints.  We believe that these developmentally senescent cells are sending important signals that define how the urethra is formed,” he says.

His project also will help to standardize the characterization of hypospadias. Hypospadias is classically associated with a downward bend to the penis, a urethra that does not extend to the head of the penis and incomplete formation of the foreskin. Still, there is significant variability among patients’ anatomy and to date, no standardized method for documenting hypospadias anatomy.

“Some surgeons take measurements in the operating room, but without a standardized classification system, there is no definitive way to compare measurements among providers or standardize diagnoses from measurements that every surgeon makes,” he adds. “What one surgeon may call ‘distal’ may be called ‘midshaft’ by another.” (With distal hypospadias, the urethra opening is near the penis head; with midshaft hypospadias, the urethra opening occurs along the penis shaft.)

“By advancing our understanding of the genetic causes and the anatomic differences among patients, the real goal of this research is to generate knowledge that will allow us to take better care of children with hypospadias,” he says.

Parents worry about lingering social stigma, since some boys with hypospadias are unable to urinate while standing, and in older children the condition can be associated with difficulties having sex. Surgical correction of hypospadias traditionally is performed when children are between 6 months to 1 year old.

When reviewing treatment options with family, “discussing the surgery and postoperative care is straight forward. The hard part of our discussion is not having good answers to questions about long-term outcomes,” he says.

Dr. Casella’s study hopes to build the framework to enable that basic research to be done.

“Say we wanted to do a study to see how patients are doing 15-20 years after their surgery.  If we go to their charts now, often we can’t accurately describe their anatomy prior to surgery.  By establishing uniform measurement baselines, we can accurately track long-term outcomes since we’ll know what condition that child started with and where they ended up,” he says.

Dr. Casella’s research project will be conducted at Children’s National under the mentorship of Eric Vilain, M.D., Ph.D., an international expert in sex and genitalia development; Dolores J. Lamb, Ph.D., HCLD, an established leader in urology based at Weill Cornell Medicine; and Marius George Linguraru, DPhil, MA, MSc, an expert in image processing and artificial intelligence.