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Implementation of an electroencephalogram-guided propofol anesthesia practice in a large academic pediatric hospital:
Sheri Jones Oguh1, Rajeev S Iyer1, Ian Yuan1
1Department of Anesthesiology & Critical Care Medicine, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA.
Insights
Implementing electroencephalogram-guided anesthesia in pediatric care significantly increased its adoption from 5% to 75%. This quality improvement project enhanced patient safety by optimizing propofol dosing, demonstrating the effectiveness of targeted training and system modifications.
Area of Science:
- Anesthesiology
- Pediatric Anesthesia
- Quality Improvement
Background:
- Propofol-based total intravenous anesthesia (TIVA) is increasingly used in pediatric anesthesia.
- Electroencephalogram (EEG) monitoring can guide propofol dosing to personalize anesthesia and reduce adverse events.
- Gaps in training regarding EEG interpretation and TIVA pharmacokinetics hinder widespread adoption.
Purpose of the Study:
- To implement and evaluate a quality improvement project to increase the utilization of EEG-guided TIVA in a pediatric setting.
- To achieve an 80% rate of EEG-guided TIVA cases within 18 months.
- To monitor balancing measures including TIVA case volume, emergence times, and perioperative emergencies.
Main Methods:
- A Plan-Do-Study-Act (PDSA) framework was employed, focusing on education, equipment, and electronic health record (EHR) enhancements.
- Educational initiatives included journal articles, lectures, and hands-on training with dedicated faculty.
- EHR modifications involved adding dosing tables and EEG parameters, alongside procuring EEG monitoring devices.
Main Results:
- EEG-guided TIVA cases increased from 5% to 75% and were sustained at 72% post-project.
- No significant changes were observed in TIVA case volume or perioperative emergency activations.
- Emergence times were statistically longer for EEG-guided TIVA but clinically insignificant compared to non-EEG TIVA and sevoflurane anesthesia.
Conclusions:
- Quality improvement strategies are effective for adopting EEG-guided TIVA in pediatric anesthesia practices.
- Key success factors include comprehensive education, intraoperative training, dedicated mentorship, EHR integration, and availability of EEG equipment.
- This approach can be successfully implemented in large academic pediatric anesthesia settings.
Background:
Propofol-based total intravenous anesthesia is gaining popularity in pediatric anesthesia. Electroencephalogram can be used to guide propofol dosing to the individual patient to mitigate against overdosing and adverse events. However, electroencephalogram interpretation and propofol pharmacokinetics are not sufficiently taught in training programs to confidently deploy electroencephalogram-guided total intravenous anesthesia.
Aims:
We conducted a quality improvement project with the smart aim of increasing the percentage of electroencephalogram-guided total intravenous anesthesia cases in our main operating room from 0% to 80% over 18 months. Balancing measures were number of total intravenous anesthesia cases, emergence times, and perioperative emergency activations.
Methods:
The project key drivers were education, equipment, and electronic health record modifications. Plan-Do-Study-Act cycles included: (1) providing journal articles, didactic lectures, intraoperative training, and teaching documents; (2) scheduling electroencephalogram-guided total intravenous anesthesia teachers to train faculty, staff, and fellows for specific cases and to assess case-based knowledge; (3) adding age-based propofol dosing tables and electroencephalogram parameters to the electronic health record (EPIC co, Verona, WI); (4) procuring electroencephalogram monitors (Sedline, Masimo Inc). Electroencephalogram-guided total intravenous anesthesia cases and balancing measures were identified from the electronic health record. The smart aim was evaluated by statistical process control chart.
Results:
After the four Plan-Do-Study-Act cycles, electroencephalogram-guided total intravenous anesthesia increased from 5% to 75% and was sustained at 72% 9 months after project completion. Total intravenous anesthesia cases/mo and number of perioperative emergency activations did not change significantly from start to end of the project, while emergence time for electroencephalogram-guided total intravenous anesthesia was greater statistically but not clinically (total intravenous anesthesia without electroencephalogram [16 ± 10 min], total intravenous anesthesia with electroencephalogram [18 ± 9 min], sevoflurane [17 ± 9 min] p < .001).
Conclusion:
Quality improvement methods may be deployed to adopt electroencephalogram-guided total intravenous anesthesia in a large academic pediatric anesthesia practice. Keys to success include education, in operating room case training, scheduling teachers with learners, electronic health record modifications, and electroencephalogram devices and supplies.
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