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Antifibrinolytics such as tranexamic acid and epsilon-aminocaproic acid are effective at reducing blood loss and transfusion in pediatric patients having craniofacial surgery. The Pediatric Craniofacial Collaborative Group has previously reported low rates of seizures and thromboembolic events (equal to no antifibrinolytic given) in open craniofacial surgery.To query the Pediatric Craniofacial Collaborative Group database to provide an updated antifibrinolytic safety profile in children given that antifibrinolytics have become recommended standard of care in this surgical population. Additionally, we include the population of younger infants having minimally invasive procedures.Patients in the Pediatric Craniofacial Collaborative Group registry between June 2012 and March 2021 having open craniofacial surgery (fronto-orbital advancement, mid and posterior vault, total cranial vault remodeling, intracranial LeFort III monobloc), endoscopic cranial suture release, and spring mediated cranioplasty were included. The primary outcome is the rate of postoperative complications possibly attributable to antifibrinolytic use (seizures, seizure-like activity, and thromboembolic events) in infants and children undergoing craniosynostosis surgery who did or did not receive antifibrinolytics.Forty-five institutions reporting 6583 patients were included. The overall seizure rate was 0.24% (95% CI: 0.14, 0.39%), with 0.20% in the no Antifibrinolytic group and 0.26% in the combined Antifibrinolytic group, with no statistically reported difference. Comparing seizure rates between tranexamic acid (0.22%) and epsilon-aminocaproic acid (0.44%), there was no statistically significant difference (odds ratio = 2.0; 95% CI: 0.6, 6.7; p = .257). Seizure rate was higher in patients greater than 6 months (0.30% vs. 0.18%; p = .327), patients undergoing open procedures (0.30% vs. 0.06%; p = .141), and syndromic patients (0.70% vs. 0.19%; p = .009).This multicenter international experience of pediatric craniofacial surgery reports no increase in seizures or thromboembolic events in those that received antifibrinolytics (tranexamic acid and epsilon-aminocaproic acid) versus those that did not. This report provides further evidence of antifibrinolytic safety. We recommend following pharmacokinetic-based dosing guidelines for administration.

Pediatric intravenous catheter insertion can be difficult in the operating room due to the technical challenges of small diameter vessels and the need to rapidly gain intravenous access in anesthetized children. Few studies have examined factors associated with difficult vascular access in the operating room, especially accounting for the increased possibility to use ultrasound guidance.The primary aim of the study was to identify factors associated with pediatric difficult vascular access in the operating room. Our primary hypothesis was that Black race, Hispanic ethnicity, and ultrasound use would be associated with pediatric difficult vascular access.We performed a retrospective analysis of prospectively collected data from a cohort of pediatric patients who had intravenous catheters inserted in the operating room at an academic tertiary care children's hospital from March 2020 to February 2021. We measured associations among patients who were labeled as having difficult vascular access (2 attempts at access) with demographic, clinical, and hospital factors.12 728 intravenous catheter insertions were analyzed. Multivariable analysis showed significantly higher odds of difficult vascular access with Black non-Hispanic race (1.43, 95% CI: 1.06-1.93, p = .018), younger age (0.93, 95% CI: 0.89-0.98, p = .005), overweight (1.41, 95% CI: 1.04-1.90, p = .025) and obese body mass index (1.56, 95% 95% CI: 1.12-2.17, p = .008), and American Society of Anesthesiologists physical status III (1.54, 95% CI:1.11-2.13, p = .01). The attending anesthesiologist compared to all other practitioners (certified registered nurse anesthetist: (0.41, 95% CI: 0.31-0.56, p .001, registered nurse: 0.25, 95% CI: 0.13-0.48, p .001, trainee: 0.21, 95% CI: 0.17-0.28, p-value.001 with attending as reference variable) and ultrasound use (2.61, 95% CI: 1.85-3.69, p .001) were associated with successful intravenous catheter placement.Black non-Hispanic race/ethnicity, younger age, obese/overweight body mass index, American Society of Anesthesiologists physical status III, and ultrasound were all associated with pediatric difficult vascular access in the operating room.

The career of Dr Nishan Goudsouzian spanned half a century of pediatric anesthesia. His 50 years saw seminal contributions to the use of neuromuscular blocking agents in children, the development of proton beam therapy and magnetic resonance imaging for pediatric cancer, the introduction of the laryngeal mask airway, an explosion in the volume and depth of knowledge about pediatric anesthesia, the expansion of formal training in pediatric anesthesia, and the widening of academic efforts to improve anesthetic care for children worldwide. Based on interviews with Dr Goudsouzian, this article reviews the contributions of this Robert M. Smith Award winner to the development of pediatric anesthesia.

Mechanical ventilation of the anesthetized infant requires careful attention to equipment and ventilator settings to assure optimal gas exchange and minimize the potential for lung injury. Apparatus dead space, defined as dead space resulting from devices placed between the endotracheal tube and the Y-piece of the breathing circuit, is the primary source of dead space controlled by the clinician. Due to the small tidal volumes required by infants and neonates, it is easy to create excessive apparatus dead space resulting in unintended hypercarbia or increased minute ventilation in an effort to achieve a desirable PCO2 . The goal of this review was to evaluate the apparatus that are commonly added to the breathing circuit during anesthesia care, and develop recommendations to guide the clinician in selecting apparatus that are best matched to the clinical goals and the patient's size. We include specific recommendations for apparatus that are best suited for different size pediatric patients, with a particular focus on patients