Papers by Ellen Rawlinson
Pediatric Anesthesia, 2020
This is the author manuscript accepted for publication and has undergone full peer review but has... more This is the author manuscript accepted for publication and has undergone full peer review but has not been through the copyediting, typesetting, pagination and proofreading process, which may lead to differences between this version and the Version of Record. Please cite this article as
Pediatric Anesthesia, 2020
Clinical outcomes are measurable changes in health, function, or quality of life that are importa... more Clinical outcomes are measurable changes in health, function, or quality of life that are important for evaluating the quality of care and comparing the efficacy of interventions. However, clinical outcomes and related measurement tools need to be well-defined, relevant and valid. In adults, Core Outcome Measures in Effectiveness Trials (COMET) methodology has been used to develop core outcome sets for perioperative care. Systematic literature reviews identified Standardized Endpoints (StEP) and valid measurement tools, and consensus across a broader range of relevant stakeholders was achieved via a Delphi process to establish Core Outcome Measures in Perioperative and Anaesthetic Care (COMPAC). Core outcome sets for pediatric perioperative care cannot be directly extrapolated from adult data. The type and weighting of endpoints within particular domains can be influenced by age-dependent differences in the indications for and/or nature of surgery and medical co-morbidities, and the validity and utility of many measurement tools vary significantly with developmental stage and age. Involvement of parents/carers is essential as they frequently act as surrogate responders for preverbal and developmentally delayed children, parental response may influence child outcome, and parental and/or child ranking of outcomes may differ from those of health professionals. Here we describe formation of the international Pediatric Perioperative Outcomes Group, which aims to identify and create validated, broadly applicable, patient-centered outcome measures for infants, children and young people. Methodologies parallel that of the StEP and COMPAC projects, and systematic literature searches have been performed within agreed age-dependent subpopulations to identify reported outcomes and measurement tools. This represents the first steps for developing core outcome sets for pediatric perioperative care. 1 THE NEED FOR CORE OUTCOME SETS FOR PEDIATRIC PERIOPERATIVE CARE 1.1 Rationale for consensus in outcome reporting Clinical outcomes are measurable changes in health, function or quality of life which, in conjunction with the structures (settings, qualifications of providers, administrative systems for care) and processes (components of care) surrounding care delivery, are important in evaluating the quality of health care in adults 1,2 and children. 3,4 However, clinical outcomes and related measurement tools need to be well-defined, relevant and valid to contribute to quality improvement 5 and to enable comparative trials to assess the clinical efficacy of different interventions. 6 A number of worldwide initiatives have been established to improve the relevance and consistency of selection of clinical outcomes and their measurement. The Core Outcome Measures in Effectiveness Trials (COMET) initiative 7,8 supports the development of agreed standardized core outcome sets that can be consistently reported across all trials to: reliably discriminate between beneficial, ineffective or harmful interventions; 9 allow combination of data in high-quality systematic reviews and meta analyses; 10 compare efficacy of different interventions; 6 inform evidence-based practice; and drive improvements in care. 7,8 In addition, standardized and clearly-defined endpoints should be of significance to key stakeholders, relevant to the patient, clinically important, and valid to ensure subsequent impact on health care delivery or policy. 11 COMET resources include details of standardized methodology, 8,12 a database of current and completed projects, 7 and updated reviews. 13 A core outcome set (COS) is defined as a minimum set of outcomes to be measured and reported in clinical trials for a specific condition. However, core outcome sets can also be used for research designs other than randomized controlled trials, and for quality improvement projects. 12 Quality improvement initiatives related to surgical and perioperative care, such as the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) 14 and the Perioperative Quality Improvement Programme in the United Kingdom 15 focus on adult practice, but similar approaches are also relevant for pediatric surgery 3,16 and perioperative care. 4,17-19 1.2 Core outcome sets in adult perioperative care Determining which outcomes should be used to measure success is a research priority for anesthesia and perioperative care. 20 COMET methodology 8,12 is being utilized to develop core outcome sets for perioperative care in adults (age ³ 18 years). 21,22 Systematic reviews have extracted reported outcomes, and expert interpretation and consensus identified Standardized Endpoints (StEP) for Perioperative Medicine, valid measurement tools, and clinically-important times for assessment. In parallel to this 'top-down approach', a 'bottom up' approach to achieve consensus across a broader range of relevant stakeholders that includes patients and carers is achieved via a Delphi process.
Pediatric Anesthesia, 2012
Objectives and aims: To review the anesthetic management of children requiring surgical interven... more Objectives and aims: To review the anesthetic management of children requiring surgical intervention for pericardial effusion, determine the nature and frequency of complications and define risk factors that predict perioperative risk. Background: Anesthesia in the presence of a pericardial effusion may be associated with significant hemodynamic compromise particularly during induction. However, the literature specifically concerning children is limited to a single-case report. Methods: A retrospective case review of children undergoing general anesthesia for surgical treatment for pericardial effusion between 1999 and 2008 at a single institution. Results: Sixty-five children underwent 79 general anesthetics for surgical treatment for pericardial effusion. Median age was 4 years (2 weeks-16 years), and median weight 15 kg (range, 2.5-96 kg). Fifty-five children (84%) developed effusions following cardiac surgery. The commonest induction agent was ketamine (25/65, 38%), and the majority of children (52/65, 80%) were intubated and ventilated for the procedure. Seven children (11%) suffered from eight major complications, and 14 children (22%) suffered from a minor complication. Major complications were more common in children with preoperative tachypnoea (P = 0.01) and cardiac tamponade on preoperative echocardiogram (ECHO) (P = 0.001). Preoperative hypoxia had a sensitivity of 92% and a positive likelihood ratio of 5.2 (95% CI 1.5-17.5) for predicting all complications. Conclusions: Anesthesia for pericardial effusion in children was associated with an adverse physiological event in one-third of children. Major complications may be predicted by preoperative tachypnoea and cardiac tamponade on preoperative ECHO, and all complications may be predicted by preoperative hypoxia. The anesthetic technique included a variety of induction agents, and we cannot recommend a particular approach.
Anaesthesia, 2011
Investigators from Bristol described a fentanyl-and diclofenac-based analgesic technique for tons... more Investigators from Bristol described a fentanyl-and diclofenac-based analgesic technique for tonsillectomy with low postoperative nausea and vomiting rates and low pain scores. This study compared the effectiveness of a modified Bristol technique with a codeine-based regimen with respect to PONV and analgesia. Sixty-five children, ASA 1-2, were randomly assigned to either the Bristol group (fentanyl 1-2 lg.kg)1 and diclofenac 1-2 mg.kg)1) or codeine group (codeine 1.5 mg.kg)1). All children received paracetamol 15 mg.kg)1 and dexamethasone 0.1 mg.kg)1. Postoperative nausea and vomiting and pain scores were recorded hourly, and fitness for discharge was assessed at 4 h. The overall incidence of postoperative nausea and vomiting was 21% with no difference between groups (Bristol group 8 ⁄ 30, codeine group 5 ⁄ 32, p = 0.29). Children in the Bristol group required analgesia earlier than those in the codeine group (p < 0.005), but maximum pain scores were not different (Bristol group median (IQR [range) 4.5 (3-5 [0-5]), codeine group 4.0 (2-5 [1-5]), p = 0.15). Twenty-three per cent of children were assessed as not fit for discharge at 4 h. The codeine-based regimen may have a small advantage over the Bristol regimen, but neither technique seems ideally suited for a day-case service without a longer period of observation.
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Papers by Ellen Rawlinson