The role of WhatsApp™ in pediatric difficult airway management: A study from the PeDI Collaborative
Section Editor: Britta S von Ungern-Sternberg
Abstract
Background
Management of the pediatric difficult airway can present unique clinical challenges. The Pediatric Difficult Intubation Collaborative (PeDI-C) is an international collaborative group engaging in quality improvement and research in children with difficult airways. The PeDI-C established a WhatsApp™ group to facilitate real-time discussions around the management of the difficult airway in pediatric patients. The goals of this study were to evaluate the patterns of use of the WhatsApp™ group, themes on messages posted on pediatric difficult airway management and to assess the perceived usefulness of the WhatsApp™ group by the PeDI-C members.
Method
Following research ethics approval, we performed a database analysis on the archived discussion of the PeDI-C WhatsApp™ group from 2014 to 2019 and surveyed members to assess the perceived usefulness of the PeDI-C WhatsApp™ group.
Results
5781 messages were reviewed with 350 (6.0%) original stems. The three most common original stem types were advice seeking 98 (28%), announcements 85 (24.2%), and clinical case-sharing 78 (22.2%). The median number of responses to original stems was 9 [2–21.3]. Post types associated with increased responses included those seeking advice on medication/equipment (regression coefficient 0.78, 95% CI [0.41–1.16]; p < .0001); seeking advice on patient care (regression coefficient 1.16, 95% CI [0.86–1.45]; p < .0001), sharing advice on medication/equipment availability (regression coefficient 0.87, 95% CI [0.33–1.40], p < .0016), and clinical case-sharing (regression coefficient 1.2547, 95% CI [0.9401–1.5693] p < .0001). 46/64 members of the group responded to the survey. Replies offering advice regarding patient management scenarios were found to be of most interest and 77% of surveyed members found the discussion translatable into their own clinical practice.
Discussion
The PeDI-C WhatsApp™ group has facilitated timely knowledge exchange on pediatric difficult airway management across the world. Participants are satisfied with the role the Whatsapp™ group is playing.
What is already known about this topic?
- The management of the difficult airway in pediatric patients remains a challenge. Experienced personnel and appropriate equipment are paramount to safely managing children with difficult airways.
- Clinicians face real-world clinical situations that are challenging, dynamic and may require advice from or discussion with colleagues and difficult airway experts.
What new information does this study add?
- The study shows that a real-time peer advice PeDI-C WhatsApp™ group has facilitated timely knowledge exchange on pediatric difficult airway management across the world.
- Participants perceive high value and are highly satisfied with the role the WhatsApp™ group is playing in difficult airway clinical care.
1 INTRODUCTION
The management of the difficult airway in pediatric patients remains a challenge. Experienced personnel and appropriate equipment are paramount to safely managing children with difficult airways. Several groups, including the Pediatric Difficult Intubation Collaborative(PeDI-C),1 a special interest group of the Society for Pediatric Anesthesia in the United States (https://pedsanethesia.org), the Difficult Airway Society in the United Kingdom,2 and the American Society for Anesthesiologists,3 have published guidelines on evidence-based and consensus-based techniques for improving outcomes in the pediatric difficult airway population. While these guidelines offer frameworks and algorithms for managing difficult airways in adult3 and pediatric patients,4, 5 clinicians face real-world clinical situations that are challenging and dynamic and may require advice from or discussion with colleagues and difficult airway experts. The PeDI-C group includes 45 hospitals from over five countries with members across several time zones. The group meets twice a year at the spring and fall meetings of the Society of Pediatric Anesthesia to discuss ongoing research initiatives. In addition, in 2014, the PeDI-C established a WhatsApp™ group to facilitate real-time discussions around the management of the difficult airway in pediatric patients. Participants can post a case for discussion or seek advice on strategies to assess, diagnose, and manage upcoming difficult intubation cases and can share pictures and images provided they obtain consent from the patients to do so. Sharing and contacting peers with varied experience and expertise may be essential in advancing the field and disseminating evidence-based information on pediatric difficult airways.
The goals of this study were twofold. First, to evaluate the patterns of use of the WhatsApp™ group, themes on messages posted on pediatric difficult airway management, and second, to assess the perceived usefulness of the WhatsApp™ group by the PeDI-Collaborative members.
2 METHODOLOGY
Following ethics approval (Hospital for Sick Children #1000062868), we performed the study in two parts: (a) analysis of PeDI-C WhatsApp™ data and (b) a survey of PeDI-C WhatsApp™ members.
2.1 PeDI-C WhatsApp™ data analysis
Data posted on the PeDI-C WhatsApp™ chat between January 2014 and January 2019 were downloaded onto a Microsoft Excel spreadsheet (Microsoft Inc.). Using methods previously described by Carmona et al. (2018),6 the content was analyzed to provide insights into the following: characteristics of users and patterns of usage, type of content shared (text only, images, videos, weblinks, and file attachments). Also, we performed a thematic analysis of content and categorized this into four themes: advice seeking, clinical case sharing, educational content, administrative content, and miscellaneous content that did not fit the above four categories.
In each category, the initial message or question was coded as an “original stem” and assigned a unique identification number. The thematic subject of the stem was coded using one of the four categories above. All responses or comments related to the stem were coded as “replies” and counted. Uninterrupted comments made by a single individual were counted as one “reply.” We also calculated the time duration between the stem and the final reply.
2.2 Survey of PeDI-C WhatsApp™ members
To gather information on the perceived benefits and utility of the PeDI-C WhatsApp™ group, we conducted an online survey of members. We adapted the survey instrument used by Carmona et al. 2018,6 and as per similar surveys, we formally tested using a convenience sample of three pediatric anesthesia fellows and three pediatric anesthesiologists, members of the PeDI-C WhatsApp™ group.7-12 The survey did not require changes following feedback. We identified survey participants from the members of the PeDI-C WhatsApp™ group and the PeDI-C Google™ group collaborative email list. Eligible members were invited to complete the survey via an initial post to the WhatsApp™ group. The post included a link to an online survey hosted at the Hospital for Sick Children's Redcap Server.13, 14 A first reminder to complete the survey was posted after 2 weeks, and a final reminder 2 weeks later. The online survey remained open for 2 weeks after the final reminder. Similar posts were made via email sent to the PeDI-C mailing list. All survey responses were anonymous.
With a membership of 64 at the time of the study, all members were invited to complete the survey. The completion of the survey implied consent. We performed a thematic analysis of the WhatsApp™ data and categorized each original stem into one of the following categories: advice seeking (clinical or equipment), clinical case sharing, educational content, administrative content, and miscellaneous.
2.3 Statistical analysis
Data were analyzed following procedures that were determined a priori.
Categorical variables are presented as frequency and percentages. According to the results of the Kolmogorov–Smirnov test, normally and nonnormally distributed variables were presented as the mean (SD) and the median [1st–3rd Quartiles], respectively. Multiple linear regression models were performed to assess the relationship between the independent predictors and responses to link the stem after considering the effect within each unique user correlation. A standard model building approach was used to fit the multiple linear regression models. The interaction and confounding factors were adjusted during the model building stages. The outcome variable was transformed using the cubic root function to assess the normality assumption. The statistical significances were defined as p-value ≤ .05 with a two-tailed test. Statistical analyses were conducted using SAS (version 9.4 SAS Institute Inc.).
3 RESULTS
3.1 Analysis of PeDi WhatsApp™ Data
3.1.1 Type and frequency of content shared
5781 messages were archived in the PeDI-C WhatsApp group, from September 30, 2014 to March 23, 2019. These dates spanned 1636 days, averaging 3.5 posts per day. During the study period, there were a total of 71 participants joined the PeDI-C WhatsApp group with seven participants leaving the group resulting in 64 members. 350/5781 (6.1%) messages were original stems (Table 1). Of these original stems, 125/350 (35.7%) included one or more media files. The three most common original stem types were advice seeking 98/350 (28%) announcements 85/350 (24.2%), and clinical case sharing 78/250 (22.2%) (Table 1).
| Message (N = 5781) | n (%) | Responses per stem type |
|---|---|---|
| Original stem | 350 (6.0) | |
| First-generation response | 2360 (40.8) | |
| Second-generation response | 1284 (22.2) | |
| Third-generation response | 712 (12.3) | |
| >Third-generation response | 930 (16.0) | |
| Administrative content | 145 (2.5) | |
| Original stem theme (n = 350) | n (%) | |
| Advice seeking | 98 (28) | 15 (6.8–29, [1, 94]) |
| Patient related (n = 68) | 17.5 (8.3–33, [1, 94]) | |
| Medications/equipment related (n = 30) | 8 (6–19.5, [1, 90]) | |
| Advice sharing | 19 (5.4) | 6 (3–15, [2, 69]) |
| Patient related (n = 4) | 6 (2–10, [2, 10]) | |
| Medications/equipment related (n = 15) | 6 (3–21, [2, 69]) | |
| Clinical case sharing | 78 (22.3) | 18.5 (9–36, [0, 170]) |
| Educational content | 27 (7.7) | 3 (1–9, [0, 25]) |
| Announcements | 85 (24.3) | 3 (0–9.5, [0, 30]) |
| Miscellaneous (nonmedical related) | 43 (12.3) | 5 (1–12, [0, 42]) |
- Note: Data are expressed as the mean (SD), median (first quartile to third quartile [range]), or number of responses (proportion).
The median [IQR] number of responses to original stems was 9 [2–21.3]. All content of the chat was analyzed and dealt primarily with difficult airway management but also contained miscellaneous content such as announcements. The three original stem categories that generated the most responses were advice seeking, median of 15 responses, IQR [6.8–29]; advice sharing, median of 6 responses, IQR [3–15], and clinical case sharing, median of 18.5 responses, IQR [9–36] (Table 2). When seeking advice, patient-related queries generated more responses (median 17.5 responses [8.3–33]) than seeking advice on medications/equipment (median 8 responses [6–19.5]). The post with the highest response of 170 was one sharing experiences from a clinical case.
| Original stem factors | Regression coefficient (95% CI) | p-Value |
|---|---|---|
| Advice seeking medication/equipment availability (not related to a case under discussion) | 0.78 (0.41 to 1.16) | <.0001 |
| Advice-seeking patient care | 1.16 (0.86 to 1.45) | <.0001 |
| Advice sharing non-medical related | 0.47 (−0.43 to 1.38) | .3066 |
| Advice sharing-medication/equipment availability | 0.87 (0.33 to 1.40) | .0016 |
| Clinical case sharing | 1.25 (0.94 to 1.57) | <.0001 |
| Educational content | 0.55 (0.08 to 1.01) | .02 |
| Emoji | −0.29 (−0.92 to 0.33) | .354 |
| Image attached/linked | 0.08 (−0.42 to 0.59) | .7502 |
| Image/video depicts Colleagues | 0.09 (−0.52 to 0.70) | .7619 |
| Image/video depicts is Equipment focused image | −0.39 (−1.16 to 0.38) | .3185 |
| Image/video depicts patient/case | −0.13 (−0.72 to 0.45) | .6539 |
| Link to website | −0.83 (−1.38 to −0.28) | .0031 |
| Link to article | −0.84 (−1.39 to −0.29) | .0029 |
| Link to social media | −0.89 (−1.68 to −0.09) | .0293 |
| Miscellaneous objects depicted in the photo | −0.09 (−0.88 to 0.71) | .8281 |
| Miscellaneous—nonmedical related | 0.18 (−0.15 to 0.51) | .2781 |
| Video attached/linked | −0.5 (−1.38 to 0.34) | .2341 |
A total of 447 responses in the chat included media. Most media responses were images, 382/447 (85.0%), with videos attached in 27/447 (6.0%) of media responses. An image or video that featured a patient was included in 155/447 (37.9%) of media responses, and those that featured equipment were included in 62/447 (15.1%). Only 38/447 (8.5%) of the posts included a link to a website/article/social media.
3.1.2 Influence of chat on clinical decision-making and management
In 49/350 (14.0%) of original stems, the original poster did indeed acknowledge all comments with a final post but did not make explicit or implied changes to their practice (Table S1). There were 29/350 (8.2%) original stems where the original poster provided an update, suggesting that they used the advice provided in the chat to influence their management.
3.1.3 Factors influencing responses to the original stem
In the multiple linear regression analysis, the following post types were associated with increased responses included those seeking advice on medication/equipment (regression coefficient 0.78, 95% CI [0.41–1.16]; p < .0001) seeking advice on patient care (regression coefficient 1.16, 95% CI [0.86–1.45]; p < .0001); and those sharing advice on medication/equipment availability (regression coefficient 0.87, 95% CI [0.33–1.40], p < .0016), and clinical case-sharing (regression coefficient 1.25, 95% CI [0.94–1.57] p < .0001) (Table 2).
3.2 Survey of PeDI-C WhatsApp Members
3.2.1 Demographics of responders
There were 46/64 survey respondents, with an overall completion rate of 71.9%. Responders were from a total of 14 countries, with 26/46 (56.8%) responders from the United States (Figure 1; Table 3). The majority of responders identified their sites as tertiary, teaching pediatric hospitals 28/46 (60.9%), or tertiary teaching mixed pediatric/adult hospitals 13/46 (28.2%). The academic designation of responders was split between lecturer 11/46 (23.9%) and assistant professor 11/46 (23.9%) (Table 3).
| Demographics | n (%) |
|---|---|
| Age (n = 44) | |
| 21–29 | 1 (2.2) |
| 30–49 | 30 (68.1) |
| 50–59 | 7 (15.9) |
| >60 | 6 (13.6) |
| Gender (n = 44) | |
| Male | 21 (47.7) |
| Female | 22 (50.0) |
| Other | 1 (2.2) |
| Hospital designationa (n = 43) | |
| Tertiary, teaching pediatric hospital | 27 (62.8) |
| Tertiary teaching mixed pediatric/adult hospital | 12 (27.9) |
| Nontertiary, nonteaching pediatric hospital | 1 (2.3) |
| Nontertiary, nonteaching mixed pediatric/adult hospital | 3 (6.9) |
| Academic Designation (n = 44) | |
| Lecturer | 11 (25.0) |
| Assistant Professor | 11 (25.0) |
| Associate Professor | 7 (15.9) |
| Full Professor | 8 (18.1) |
| Professor Emeritus | 0 (0) |
| No academic affiliation | 7 (15.9) |
- Note: Data are represented or number of respondents (proportion), n = 35, unless otherwise stated.
- a Frequency is presented as the proportion of the 44 survey respondents, except for hospital designation where 43 replies were received.
3.2.2 WhatsApp PeDi group chat participation
The majority of respondents, 28/46 (60.9%), reported posting in the group. 18/46 (39.1%) of respondents reported not posting on the PeDI-C WhatsApp™ group. The most frequently reported reason for not posting was “I don't like participating in mass chat groups, but I enjoy reading the discussions that take place” 9/18 (45.0%) (Table S2).
3.2.3 Perceptions regarding the advice offered on the PeDi Collaborative WhatsApp group
27/35 (77.1%) responders either agreed or strongly agreed that they find it easy to translate the discussion into their own clinical practice (Table 4). 16 /35(45.7%) responders agreed or strongly agreed that they had changed a plan based on the advice provided. 32/35 (91.4%) responders agreed or strongly agreed with each statement that the group informed them of the variance in practice across the globe and that the group chat is professional. 29/35 (85.2%) responders agreed or strongly agreed that they feel connected to peers via the group, 33/35 (94.2%) that they will continue to be a part of the group, and 33/35 (94.2%) that they will recommend others to join the group. The majority of responders, 31/35 (88.5%) either agreed or strongly agreed that the advice in the chat is high quality, 31/35 (88.5%) and is evidence based, 25/35 (71.5%) (Table 4).
| Opinions in the PeDi Collaborative WhatsApp™ group | n = 35(%) |
|---|---|
| I find it easy to translate the discussion into my own clinical practice | 27 (77.1) |
| I have changed a plan based on the advice provided in this group | 16 (45.7) |
| I have instituted a change in my practice/group practice as a result of discussions in this group | 15 (42.8) |
| Has informed me of the variance in practice across the globe | 32 (91.4) |
| I find the group's etiquette to be professional | 32 (91.4) |
| The group helps disseminate new practice guidelines | 23 (65.7) |
| I feel connected to peers via this WhatsApp group | 29 (85.2) |
| I will continue to be a part of this WhatsApp group | 33 (94.2) |
| I will recommend others to join this WhatsApp group | 33 (94.2) |
| I do not have another way of getting timely advice outside of this group | 4 (11.4) |
| I like this group as I get responses almost immediately no matter the time of day | 25 (71.4) |
| I have experienced academic benefits from participating in this WhatsApp group (publications, presentations, collaborations) | 18 (51.4) |
| Opinions on advice in the PeDi Collaborative WhatsApp™ group | |
| The advice is high quality | 31 (88.5) |
| The advice is evidence based, n = 34 | 25 (73.5) |
| The advice is translatable to my clinical practice, n = 34 | 28 (82.3) |
| The advice is well balanced | 28 (80.0) |
- Note: Data are represented or number of respondents (proportion), n = 35, unless otherwise stated. Respondents were allowed to skip questions.
4 DISCUSSION
This study analyzed the use of a WhatsApp™ group by the Pediatric Difficult Intubation Collaborative (PeDI-C) and assessed its perceived usefulness by its members. Our findings indicate that the PeDI-C WhatsApp™ group is a valuable resource for advice seeking, clinical case sharing, and educational content across several geographical areas. The survey results also suggest that the majority of the group members find the advice provided in the chat to be of high quality and useful for their clinical practice.
The PeDI-C group demonstrates the value of WhatsApp™ groups for the sharing of information on managing pediatric difficult airways among this closed international group. The high proportion of advice seeking and clinical case sharing posts reflects the group's primary purpose to facilitate discussions around the management of difficult airways in pediatric patients. Instant messaging applications have been used to share medical knowledge and improve patient safety and delivery of care across a wide range of disciplines.6, 15-18 Clinical collaboration in maternal-fetal medicine has been reported using a closed international group on WhatsApp™ with responses influencing specialist patient care and promoting education.6, 15 Bakshi et al. report on the use of Whatsapp™ to complement a formal acute pain teaching program with positive student feedback.16 Timely communication via messaging platforms can be a powerful tool to help seek clinical advice when triaging patients to the appropriate healthcare service, in particular, in remote locations and this is relevant to seeking advice on pediatric difficult airways.17 Astarcioglu et al. reported reduction in time to re-perfusion after STEMI when standard clinical care was paired with the use of real-time messaging by increasing access to senior clinical advice and influencing emergency team planning and efficiency.18 Our findings also reveal that patient-related queries generated more responses than medication-/equipment-related queries, indicating a stronger focus on patient care among the group members. This aligns with the group's overall goal of improving patient outcomes.
The influence of the WhatsApp™ group on clinical decision-making and management was evident in the 29 stems where the original poster used the advice provided to guide their practice. However, it is important to note that this number may not fully represent the impact of the group on clinical practice, as some members might not explicitly report changes in their approach.
While most responders found that advice received was high quality, slightly less than half of the responders reported that they changed their management based on advice provided. One explanation is that some of the feedback received was support or agreement from other PeDI-Collaborative members, serving to validate a participant's clinical plan.
Most of the survey respondents agreed that the advice provided in the chat is high quality, evidence-based, and easy to translate into their own clinical practice. This suggests that the PeDI-C WhatsApp™ group is an effective platform for disseminating information and promoting best practices in pediatric difficult airway management. However, it is possible that some members may use the platform for self-promotion. The group's international composition enables members to gain insights into global variance in practice, fostering a sense of connection among peers. A high percentage of respondents reported their intention to continue participating in the group and recommending it to others, demonstrating the perceived value of the group.
Limitations of instant messaging platforms need to be considered carefully in clinical medicine. Privacy and data protection should be paramount, and precautions taken to avoid disclosing any patient identifying information as the PeDi-C group have done. Expert medical groups using this technology as a form of communication need to review how to communicate appropriately outside of the remit of clinical care to ensure professionalism. Concerns around data security, the ownership of the data shared, and the duration of which it is kept by a platform should all be considered. WhatsApp™ uses end-to-end encryption and stores data for 30 days or less on their servers. Nonetheless, despite patient consent some regional privacy protection policies prohibit sharing of patient data of any sort over platforms like WhatsAppTM. This may limit certain users' degree of participation in the group, in particular, when they would appreciate international expert input on specific patient cases. Anesthesiologists will need to take into consideration local rules and policies on data privacy as determined by their jurisdictions. Exploring a platform that conforms to privacy policies on an international scale is an appealing step forward toward increasing participant engagement. Further, participants need to be wary of unrecognized biases in response patterns, which may influence the discussion and viewpoints, as well as unsolicited publicity shared via external links.
Last, it is key to maintain perspective on how users engage with instant messaging platforms, as we found some experts find active engagement in discussion helpful and others prefer passive information gathering. The current study was unable to explore the influence of factors such as the participants' experience, and academic affiliation as the archive data was de-identified as per ethics approval and study protocol.
However, it is important to recognize some users may not feel comfortable to actively participate in clinical discussions as demonstrated in our study. In addition, it is possible for advice that is inaccurate or not clinically sound to potentially lead to patient harm. While none of the respondents specifically reported harm occurring as a result of advice given, there was no obligation to report outcomes to the group. There is certainly potential for negative outcomes being underreported, considering the issues of stigma and legal consequences of discussing patient harm in an open forum. Further, most responses referenced existing evidence. Since the study, the PeDi-C WhatsApp™ group membership has grown to 125 members and the opinions of the new members have not been captured.
Our study has several limitations. The study was performed on the WhatsApp™ platform so is limited in analysis to this platform. It is possible that other groups may exist on the same platform or other social networks; the interactions on these platforms were not captured in this study.19-23 The COVID pandemic may have changed the perceptions and patterns of use of WhatsApp™ or social media among pediatric anesthesiologists, and its impact has yet to be determined.
However, current usage of the PeDi-C WhatsApp™ suggests a doubling in members since the pandemic started and continued discussions. Nevertheless, our survey was able to provide additional context on the use of the Pedi-C WhatsApp™ chat group. Future studies could explore the impact of such communication platforms on specific clinical outcomes and the potential for their application in other areas of medical practice.
5 CONCLUSIONS
In conclusion, the PeDI-C WhatsApp™ group offers a valuable platform for pediatric anesthesiologists to discuss and seek advice on difficult airway management in children. The PeDI-C WhatsApp™ group's ability to facilitate the exchange of experiences, techniques, and best practices among experts from different countries is crucial in advancing the field and may improve patient outcomes.
AUTHOR CONTRIBUTIONS
Evelina Pankiv, MD, implemented the study, performed data analysis, and wrote and edited the manuscript. Kira Achaibar, MBBS, performed data analysis and wrote and edited the manuscript. Alomgir Hassan MBChB, performed the analysis and reviewed and edited the manuscript. John E. Fiadjoe MD, implemented the study and reviewed and edited the manuscript. Clyde T. Matava, MBCHB, MMed, MHSC, conceived the study, implemented the study, performed data analysis, and wrote and edited the manuscript.
FUNDING INFORMATION
This work was funded from institutional resources.
CONFLICT OF INTEREST STATEMENT
John F. Fiadjoe is Associate Editor at the journal Pediatric Anesthesia. Clyde T. Matava is Section Editor at the journal Pediatric Anesthesia. The remaining authors have no disclosures.
ETHICAL APPROVAL
This study received Human Ethics Committee approval.
APPENDIX: PeDI Collaborative investigators to be indexed on PubMed
The following collaborators do not meet all authorship criteria but meet those for nonauthor contributors and are members of the PeDI Collaborative.
From the Department of Anesthesiology, Alberta Children's Hospital, Calgary, Alberta, Canada:
David Lardner, M.B.B.S., contributed as an investigator, collected data, and provided care for study patients.
From the Department of Anesthesia and Pain Management, Perth Children's Hospital, Nedlands, Western Australia, Australia:
Britta S. von Ungern-Sternberg, M.D., Ph.D., contributed as an investigator, collected data, and provided care for study patients.
David Sommerfield, M.D., contributed as an investigator, collected data, and provided care for study patients.
From the Department of Anesthesia and Pain Management, Royal Children's Hospital, Melbourne, Victoria, Australia:
Chris Holmes, M.D., contributed as an investigator, collected data, and provided care for study patients.
Stefano Sabato, M.D., contributed as an investigator, collected data, and provided care for study patients.
From the Department of Anesthesiology and Pain Medicine, UC Davis Children's Hospital, Davis, California:
Niroop Ravula, M.D., contributed as an investigator, collected data, and provided care for study patients.
From the Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University.
Medical Center, Stanford, California:
Christine Jette, M.D., contributed as an investigator, collected data, and provided care for study patients.
Sam Mireles, M.D., contributed as an investigator, collected data, and provided care for study patients.
From the Department of Anesthesia, Hospital for Sick Children, Toronto, Ontario, Canada:
Julia Olsen, M.D., contributed as an investigator, collected data, and provided care for study patients.
Eric Greenwood, M.D., contributed as an investigator, collected data, and provided care for study patients.
From the Department of Anesthesiology, Pharmacology and Therapeutics, British Columbia Children's Hospital, Vancouver, British Columbia, Canada:
Simon Whyte, M.B.B.S., F.R.C.A., F.R.C.P.C., contributed as an investigator, collected data, and provided care for study patients.
From the Department of Anesthesia, School of Medicine, Pontifical Catholic University of Chile, Santiago, Chile:
Eduardo Vega, M.D., contributed as an investigator, collected data, and provided care for study patients.
From the Department of Anesthesiology and Perioperative Care, West China Medical Center of Sichuan University, Chengdu, China:
Lei Yang, M.D., contributed as an investigator, collected data, and provided care for study patients.
From the Department of Anesthesiology, Instituto de Ortopedia Infantil Roosevelt, Bogotá, Colombia:
Piedad Echeverry-Marin, M.D., contributed as an investigator, collected data, and provided care for study patients.
Carolina Pérez-Pradilla, M.D., contributed as an investigator, collected data, and provided care for study patients.
From the Department of Pediatric Anesthesiology, Ann and Robert H. Lurie Children's Hospital of Chicago, Feinberg School of Medicine, Northwestern University, Chicago, Illinois:
Narasimhan Jagannathan, M.D., M.B.A., contributed as an investigator, collected data, and provided care for study patients.
Nicholas E. Burjek, M.D., contributed as an investigator, collected data, and provided care for study patients.
From the Department of Anesthesiology, Children's Hospital of Colorado, Aurora, Colorado:
David Polaner, M.D., contributed as an investigator, collected data, and provided care for study patients.
Elizabeth Starker, M.D., contributed as an investigator, collected data, and provided care for study patients.
Judit Szolnoki, M.D., contributed as an investigator, collected data, and provided care for study patients.
Melissa Brooks-Peterson, M.D., contributed as an investigator, collected data, and provided care for study patients.
From the Department of Anesthesiology, Pain and Perioperative Medicine, Children's National Medical Center, Washington, D.C.:
Angela Lee, M.D., contributed as an investigator, collected data, and provided care for study patients.
Eugenie Heitmiller, M.D., contributed as an investigator, collected data, and provided care for study patients.
From the Department of Anesthesia, Johns Hopkins All Children's Hospital, St. Petersburg, Florida:
Mohamed Rehman, M.D., contributed as an investigator, collected data, and provided care for study patients.
Allison Fernandez, M.D., contributed as an investigator, collected data, and provided care for study patients.
From the Department of Anesthesiology, Spectrum Health Partners Maine, South Portland, Maine:
Jonathan Meserve, M.D., contributed as an investigator, collected data, and provided care for study patients.
Charles (Ted) Lord, M.D., contributed as an investigator, collected data, and provided care for study patients.
From the Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland:
John McCloskey, M.D., contributed as an investigator, collected data, and provided care for study patients.
Nicholas Dalesio, M.D., M.P.H., contributed as an investigator, collected data, and provided care for study patients.
Rahul Koka, M.D., M.P.H., contributed as an investigator, collected data, and provided care for study patients.
Robert Greenberg, M.D., contributed as an investigator, collected data, and provided care for study patients.
From the Department of Anesthesiology, Perioperative and Pain Medicine, Children's Hospital of Boston, Harvard Medical School, Boston, Massachusetts:
Raymond Park, M.D., contributed as an investigator, collected data, and provided care for study patients.
James Peyton, M.B.Ch.B., M.R.C.P., F.R.C.A., contributed as an investigator, collected data, and provided care for study patients.
Mary Lyn Stein, M.D., contributed as an investigator, collected data, and provided care for study patients.
Chinyere Egbuta, M.D., contributed as an investigator, collected data, and provided care for study patients.
Stephen Flynn, M.D., contributed as an investigator, collected data, and provided care for study patients.
From the Department of Anesthesia, Critical Care and Pain, Massachusetts General Hospital, Boston, Massachusetts:
Somaletha Bhattacharya, M.B.B.S., contributed as an investigator, collected data, and provided care for study patients.
From the Department of Pediatric Anesthesiology, University of Michigan Health Center, Ann Arbor, Michigan:
Paul Reynolds, M.D., contributed as an investigator, collected data, and provided care for study patients.
Ian Lewis, M.D., contributed as an investigator, collected data, and provided care for study patients.
Bishr Haydar, M.D., contributed as an investigator, collected data, and provided care for study patients.
From the Department of Anesthesiology, National Institute of Pediatrics, Mexico City, Mexico:
Lina Sarmiento, M.D., contributed as an investigator, collected data, and provided care for study patients.
From the Department of Anesthesiology, University of Minnesota, Minneapolis, Minnesota:
Martina Richtsfeld, M.D., contributed as an investigator, collected data, and provided care for study patients.
Kumar Belani, M.D., contributed as an investigator, collected data, and provided care for study patients.
From the Department of Anesthesiology, University of Mississippi Medical Center, Jackson, Mississippi:
Sara Robertson, M.D., contributed as an investigator, collected data, and provided care for study patients.
Madhankumar Sathyamoorthy, M.D., contributed as an investigator, collected data, and provided care for study patients.
From the Department of Anesthesiology, Washington University School of Medicine in St. Louis, St. Louis, Missouri:
Charles Schrock, M.D., contributed as an investigator, collected data, and provided care for study patients.
From the Department of Anesthesia, Erasmus Medical Center Sophia's Children Hospital Rotterdam, Rotterdam, The Netherlands:
Jurgen C. de Graaff, M.D. Ph.D., contributed as an investigator, collected data, and provided care for study patients.
From the Department of Anesthesiology, University of New Mexico, Albuquerque, New Mexico:
Codruta Soneru, M.D., contributed as an investigator, collected data, and provided care for study patients.
From the Department of Anesthesiology, Perioperative Care and Pain Medicine, New York University School of Medicine, New York, New York:
Neeta Singh, D.O., contributed as an investigator, collected data, and provided care for study patients.
From the Department of Anesthesiology, New York Presbyterian Hospital–Weill Cornell Medical College, New York, New York:
Franklin Chiao, M.D., contributed as an investigator, collected data, and provided care for study patients.
From the Department of Anesthesiology, Duke University, Durham, North Carolina:
Brad Taicher, D.O., contributed as an investigator, collected data, and provided care for study patients.
From the Department of Anesthesiology, Wake Forest School of Medicine, Wake Forest, North Carolina:
Thomas Templeton, M.D., contributed as an investigator, collected data, and provided care for study patients.
From the Department of Anesthesiology and Pain Management, Children's Hospital of Cleveland Clinic, Cleveland, Ohio:
Pilar Castro, M.D., contributed as an investigator, collected data, and provided care for study patients.
N. Ricardo Riveros Perez, M.D., contributed as an investigator, collected data, and provided care for study patients.
From the Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Ohio State University, Columbus, Ohio:
Vidya T. Raman, M.D., contributed as an investigator, collected data, and provided care for study patients.
Ralph Beltran, M.D., contributed as an investigator, collected data, and provided care for study patients.
Tarun Bhalla, M.D., contributed as an investigator, collected data, and provided care for study patients.
From the Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania:
Annery Garcia-Marcinkiewicz M.D., contributed as an investigator, collected data, and provided care for study patients.
Benjamin B. Bruins, M.D., contributed as an investigator, collected data, and provided care for study patients.
Paul Stricker, M.D., contributed as an investigator, collected data, and provided care for study patients.
Justin L. Lockman, M.D., M.S.Ed., contributed as an investigator, collected data, and provided care for study patients.
Brian Struyk, M.D., contributed as an investigator, collected data, and provided care for study patients.
Christopher Ward, M.D., contributed as an investigator, collected data, and provided care for study patients.
Akira Nishisaki, M.D., M.S.C.E., contributed as an investigator, collected data, and provided care for study patients.
Ramesh Kodavatiganti, M.D., contributed as an investigator, collected data, and provided care for study patients.
Rodrigo J. Daly Guris, M.D., contributed as an investigator, collected data, and provided care for study patients.
Mark S. Teen, M.D., contributed as an investigator, collected data, and provided care for study patients.
From the Department of Anesthesiology, Instituto de Ortopedia Infantil Roosevelt, Bogotá, Colombia:
Piedad C. Echeverry Marín, M.D., contributed as an investigator, collected data, and provided care for study patients.
From the Department of Anesthesiology, Vanderbilt University School of Medicine, Nashville, Tennessee:
Scott Watkins, M.D., contributed as an investigator, collected data, and provided care for study patients.
Christy Crockett, M.D., contributed as an investigator, collected data, and provided care for study patients.
John Moore, M.D., contributed as an investigator, collected data, and provided care for study patients.
From the Department of Anesthesiology and Pain Management, University of Texas Southwestern, Dallas, Texas; the Children's Health System of Texas, Dallas, Texas; and the Outcome Research Consortium, Cleveland, Ohio:
Tally Goldfarb, M.D., contributed as an investigator, collected data, and provided care for study patients.
Patrick Olomu, M.D., contributed as an investigator, collected data, and provided care for study patients.
Peter Szmuk, M.D., contributed as an investigator, collected data, and provided care for study patients.
From the Department of Anesthesiology, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas:
Paul Hopkins, M.D., contributed as an investigator, collected data, and provided care for study patients.
Chris Glover, M.D., M.B.A., contributed as an investigator, collected data, and provided care for study patients.
Kim Nguyen, M.D., contributed as an investigator, collected data, and provided care for study patients.
Thomas L. Shaw, M.D., contributed as an investigator, collected data, and provided care for study patients.
Olutoyin Olutoye, M.D., contributed as an investigator, collected data, and provided care for study patients.
From the Department of Anesthesiology, University of Texas Medical School at Houston, Houston, Texas:
Ranu Jain, M.D., contributed as an investigator, collected data, and provided care for study patients.
Maria Matuszczak, M.D., contributed as an investigator, collected data, and provided care for study patients.
From the Department of Anesthesiology and Pain Medicine, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, Washington:
Agnes Hunyady, M.D., contributed as an investigator, collected data, and provided care for study patients.
Adrian Bosenberg, M.D., contributed as an investigator, collected data, and provided care for study patients.
See Tham, M.D., contributed as an investigator, collected data, and provided care for study patients.
Daniel Low, M.D., contributed as an investigator, collected data, and provided care for study patients.
From the Department of Anesthesiology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin:
Guelay Bilen-Rosas, M.D., contributed as an investigator, collected data, and provided care for study patients.
From the Department of Anesthesiology, University of Washington in St. Louis, St. Louis, Missouri:
James Fehr, M.D., contributed as an investigator, collected data, and provided care for study patients.
From the Department of Anesthesia, University of California Los Angeles, Los Angeles, California:
Lisa K. Lee, M.D., contributed as an investigator, collected data, and provided care for study patients.
Ihab Ayad, M.D., contributed as an investigator, collected data, and provided care for study patients.
From the Department of Anesthesiology, Albert Einstein College of Medicine, New York, New York:
Roshan Patel, M.D., contributed as an investigator, collected data, and provided care for study patients.
From the Department of Anesthesiology, Yale New Haven Hospital, New Haven, Connecticut:
Cheryl Gooden, M.D., contributed as an investigator, collected data, and provided care for study patients.
Open Research
DATA AVAILABILITY STATEMENT
The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.
