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Background: We investigated how syndromic versus nonsyndromic forms of micrognathia impacted difficult intubation outcomes in children. Primary outcome was the first‐attempt success rate of tracheal intubation, secondary outcomes were number of intubation attempts and complications. We hypothesized that syndromic micrognathia would be associated with lower first‐attempt success rate. Methods: In micrognathic patients enrolled in the Pediatric Difficult Intubation Registry (08/2012–03/2019) we retrospectively compared demographic and clinical characteristics between children with nonsyndromic and syndromic micrognathia using standardized mean differences (SMD) and assessed the association of the presence of syndrome with the primary and secondary outcomes using propensity score matching analysis with and without matching for airway assessment findings. Results: Nonsyndromic patients (628) were less likely to have additional airway abnormalities. Syndromic patients (216) were less likely to have unanticipated difficult intubation (2% vs. 20%, SMD 0.59). First‐attempt success rates of intubation were: 38% in the syndromic versus 34% in the nonsyndromic group (odds ratio [OR] 1.18; 95% confidence intervals [95% CI] 0.74, 1.89; p =.478), and 37% versus 37% (OR 0.99; 95% CI 0.66, 1.48; p =.959). Median number of intubation attempts were 2 (interquartile range [IQR]: 1, 3; range: 1, 8) versus 2 (IQR: 1, 3; range 1, 12) (median regression coefficient = 0; 95% CI: −0.7, 0.7; p =.999) and 2 (IQR: 1, 3; range: 1, 12) versus 2 (IQR: 1, 3; range 1, 8) (median regression coefficient = 0; 95% CI: −0.5, 0.5; p =.999). Complication rates were 14% versus 22% (OR 0.6; 95% CI 0.34, 1.04; p =.07) and 16% versus 21% (OR 0.71; 95% CI 0.43, 1.17; p =.185). Conclusions: Presence of syndrome was not associated with lower first‐attempt success rate on intubation, number of intubation attempts, or complication rate among micrognathic patients difficult to intubate, despite more associated craniofacial abnormalities. Nonsyndromic patients were more likely to have unanticipated difficult intubations, first attempt with direct laryngoscopy. [ABSTRACT FROM AUTHOR]

Background: Leadership of the Society for Pediatric Anesthesia created the Diversity, Equity, and Inclusion committee in 2018 to prioritize diversity work. The Society for Pediatric Anesthesia‐Diversity, Equity, and Inclusion committee implemented a baseline survey of the Society for Pediatric Anesthesia membership in 2020 to assess demographics, equity in leadership, inclusivity, and attitudes toward diversity work. The Society for Pediatric Anesthesia plays a significant role in shaping the future of pediatric anesthesiology and in supporting our diverse pediatric patients. Methods: This study is an IRB‐exempt, cross‐sectional survey of the Society for Pediatric Anesthesia membership. Quantitative analysis provided descriptive statistics of demographics, practice characteristics, and involvement within the Society for Pediatric Anesthesia. Qualitative thematic analysis provided an in‐depth assessment of perceptions of diversity, challenges faced, and prioritization of Diversity, Equity, and Inclusion efforts within the Society for Pediatric Anesthesia. Results: Out of 3 242 Society for Pediatric Anesthesia members, 1 232 completed the survey representing 38% of overall membership. Respondents were 89.2% United States members, 52.7% female, 55.7% non‐Hispanic White, 88.6% heterosexual, 95.7% non‐military, 59.2% religious, and 2.1% have an Americans with Disabilities Act recognized disability. All major United States geographical areas were represented equally with 71% practicing in urban areas and 67% in academic settings. Ethnic/racial minorities were more likely to be international medical graduates (p <.001). Among United States members, 41.5% report being fluent in a language other than English, and 23.5% of those fluent in another language are certified to interpret. Compared to men, women are less likely to be in leadership roles (p <.003), but we found no difference in participation and leadership when stratified by race/ethnicity, geography, international medical graduate status, or sexuality. Racial/ethnic minorities (p <.028), women (p <.001), and lesbian, gay, bisexual, transgender, and queer members (p <.044) more frequently hold lower academic rank positions when compared to white, heterosexual, and male members. Half of respondents were unsure whether diversity, equity, and inclusion challenges existed within the Society for Pediatric Anesthesia while the other half demonstrated opposing views. Among those who reported diversity, equity, and inclusion challenges, the themes centered around persistent marginalization, the need for more inclusive policies and increased psychological safety, and lack of leadership diversity. Conclusions: Compared to the diversity of the pediatric population we serve, there are still significant gaps in demographic representation within the Society for Pediatric Anesthesia. As well, there is no consensus among Society for Pediatric Anesthesia membership regarding perceptions of diversity, equity, and inclusion in pediatric anesthesia in the United States. Among those who reported diversity challenges, opportunities for the Society for Pediatric Anesthesia and Anesthesiology Departments to better support minoritized members included bolstering workforce diversity efforts and awareness via more inclusive policies, improved psychological safety, and increasing diversity in leadership. If pediatric anesthesiology is like other specialties, gaining consensus and improving diversity in the workforce might advance pediatric anesthesia innovation, quality, and safety for children of all backgrounds in the United States. [ABSTRACT FROM AUTHOR]

Background: Epidural analgesia is considered optimal for postoperative pain management after major abdominal surgery. The potential to decrease anesthetic and opioid exposure is particularly desirable for infants, given their vulnerability to respiratory depression and concern for anesthetic neurotoxicity. We reviewed our experience with infants undergoing major abdominal surgery to determine if epidural catheter use decreased anesthetic and opioid exposure and improved postoperative analgesia. Methods: This retrospective cohort study included infants (<12 months) who underwent exploratory laparotomy, ureteral reimplantation, or bladder exstrophy repair between November 2011 and November 2014. Primary outcomes of anesthetic exposure (mean endtidal sevoflurane) and intraoperative opioid administration were compared between infants who received epidural catheters and those who did not. Secondary outcomes included postoperative pain and sedation scores and morphine equivalents administered 0‐24 and 24‐48 hours after surgery. Results: Of 158 eligible infants, 82 were included and 47 received epidurals. Patients with epidurals underwent bladder exstrophy repair (N = 9), ureteral reimplantation (N = 8), and exploratory laparotomy (N = 30). Infants with epidurals received less intraoperative fentanyl (2.6 mcg/kg (0,4.5) vs 3.3 mcg/kg (2.4,5.8), P = 0.019) and morphine (6% (3/47) vs 26% (9/35), P = 0.014) in univariate analysis. After controlling for age and emergency surgery, differences in long‐acting opioid administration persisted, with significantly less morphine given in the epidural group (OR 0.181; 95% CI 0.035‐0.925; P = 0.040). Mean endtidal sevoflurane concentrations were similar between groups. There was no significant difference in postoperative median morphine equivalents. Conclusion: Placement of epidural catheters in infants undergoing major abdominal surgery is associated with decreased long‐acting opioid requirements intraoperatively. Epidural placement does not preclude opioid exposure however, as opioids may be administered for indications other than nociceptive pain in the difficult‐to‐assess postoperative infant. Further prospective studies are warranted to better quantify the effect of epidural analgesia on intraoperative anesthetic exposure in infants. [ABSTRACT FROM AUTHOR]

BACKGROUND: School reintegration after traumatic brain injuries (TBI) requires school support; however, implementation of services is complex. This study evaluates disparities in receipt of school services for Hispanic children and its effect on academic performance. METHODS: Secondary analyses of school data on receipt of pre‐ and post‐TBI school services. A logistic regression compared receipt of services between Hispanic and non‐Hispanic white (NHW) children, and a linear regression evaluated services' effect on academic performance. RESULTS: The study includes 419 children; 46 Hispanic, 373 NHW. For NHW children there were no differences in receipt of pre‐ and post‐TBI services; Hispanic children had significant increase in receipt of services from 5% to 27% (p < .001). Compared to NHWs, Hispanics had lower grade point average (GPA) at baseline (2.3 [confidence interval, CI: 1.9‐2.7] vs 2.9 [CI: 2.8‐3.0]). No differences in GPA were found between groups after injury among students who received post‐TBI services. CONCLUSIONS: Students who receive post‐TBI school services benefit academically. NHW students maintain their academic performance and Hispanics increase their performance to their NHW peers' level. This highlights the importance of providing post‐TBI school services to ensure better outcomes for all children. [ABSTRACT FROM AUTHOR]

Objectives: To compare health care costs and service utilization associated with mild traumatic brain injury (mTBI) in rural and urban commercially insured children.Data Source: MarketScan Commercial Claims and Encounters Data, 2007-2011.Study Design: We compared health care costs and outpatient encounters for physical/occupational therapy, speech therapy, and psychiatry/psychology encounters 180 days after mTBI among rural versus urban children (<18 years).Principal Findings: A total of 387 846 children had mTBI, with 13 percent residing in rural areas. Adjusted mean total health care costs in the 180 days after mTBI were $2778 (95% CI: 2660-2897) among rural children, compared to $2499 (95% CI: 2471-2528) among urban children (adjusted cost ratio 1.11, 95% CI 1.06-1.16). Rural-urban differences in utilization for specific services were also found.Conclusions: Total health care costs were higher for rural compared to urban children despite lower utilization of certain services. Differences in health service utilization may exacerbate geographic disparities in adverse outcomes associated with mTBI. [ABSTRACT FROM AUTHOR]

This educational review presents an overview of opioid use disorder, misuse and overdose among adolescents, and the clinical implications for anesthesiologists. It provides definitions, discusses the epidemiology worldwide, (focusing on North America), and emphasizes the clinical implications of patients with chronic opioid exposure, including perioperative pain management, as well as opioid overdose and prolonged use of opioids after acute exposure. In the USA, opioid use disorder and negative outcomes related to opioids rose dramatically from 1999-2010; concomitantly heroin use and fatal overdoses have increased as heroin use is associated with the disordered use of licit opioids. Among adolescents and young adults, opioid use disorder is significant, with continued increases in disordered use specifically among young adults. Acute opioid intoxication may have multiple medical implications in addition to respiratory depression, and children are susceptible to acute intoxication via accidental ingestion of prescription opioids. Novel opioid formulations, such as acetyl fentanyl, with unpredictable pharmacology may also be present in acute intoxication. Chronically, opioid use presents challenges for safe and adequate pain management, in the presence of opioid-induced hyperalgesia and differential tolerance as well as mental health issues including depression and anxiety. Predictors of prolonged opioid use in adolescents and adults after surgery is an area of ongoing research. Young patients encountered by pediatric anesthesiologists may be involved in diversion and disordered use of opioids. Increased awareness among anesthesiologists is important, as perioperative discussions often provide an opportunity to detect at risk patients. [ABSTRACT FROM AUTHOR]

Objectives/Aims: To examine whether morphine pharmacokinetics (PK) and/or genetic polymorphisms in opioid-related genes, underlie differences in analgesic response and side effects to morphine in Latino (L) vs non-Latino Caucasian (NL) children. Background: Morphine has high interindividual variability in its analgesic response and side effects profile. Earlier studies suggest that morphine response may vary by race and ethnicity. Methods: Prospective cohort study in L and NL children, 3-17 years of age comparing pain scores, occurrence of side effects, plasma morphine, morphine-6- and morphine-3-glucuronide concentrations measured after a single morphine IV bolus administration. Noncompartmental pharmacokinetic analysis and genotyping for 28 polymorphisms in eight genes ( UGT1A8, UGT2B7, ABCB1, COMT, STAT6, MC1R, OPRM1, and ARRB2) were performed. Results: We enrolled 68 children (33 L, 35 NL). There were no differences in pain scores or need for rescue analgesia. Statistically significant differences in the occurrence of side effects were documented: While 58% of L children experienced at least one side effect only 20% of NL did ( P = 0.001). Pruritus was four times ( P = 0.006) and emesis seven times ( P = 0.025) more frequent in L compared with NL. PK parameters were similar between groups. None of the assessed polymorphisms mediated the association between ethnicity and side effects. Conclusions: We found statistically significant differences in the occurrence of side effects after morphine administration between L and NL children. Neither differences in morphine or metabolite concentrations, nor the genetic polymorphisms examined explain these findings. Studies are needed to further investigate reasons for the increase in morphine side effects by Latino ethnicity. [ABSTRACT FROM AUTHOR]

The objective of this study was to determine whether the incidence of emergence agitation (EA) can be reduced by adding an additional, faster onset, non-IV analgesic, intranasal fentanyl or intramuscular (im) ketorolac to rectal acetaminophen. To compare the incidence of EA after analgesia with two agents vs acetaminophen alone in pediatric patients after bilateral myringotomy procedures (BM&T). Anesthesia for BM&T is usually performed with volatile anesthetics as a single agent without securing intravenous access. The anesthetic agent most commonly used is sevoflurane; however, EA has been reported in up to 67% of patients. Emergence agitation is distressing for parents, can impair the ability of nursing staff to adequately monitor the child, and can result in a child injuring him/herself if it is severe. A standardized anesthetic was used with oral midazolam premedication and sevoflurane for induction, and maintenance of anesthesia. All patients received 40 mg·kg rectal acetaminophen, group 1 received acetaminophen alone, group 2 received acetaminophen and 1 mcg·kg of intranasal fentanyl, and group 3 received acetaminophen and 1 mg·kg of intramuscular ketorolac. Incidence of EA was compared using chi-square test between the acetaminophen group alone vs the two-agent analgesia groups combined. There were no differences in demographic and clinical characteristics between the two groups. There were no statistically significant differences between the three groups for the incidence of EA at any time point during recovery from anesthesia nor were there any significant differences in pain scores or side effects. No significant side effects because of the administration of a second analgesic agent were reported. We conclude that two-agent analgesia is not superior to acetaminophen alone for decreasing the incidence of EA after inhalation anesthesia with sevoflurane for BM&T surgery. Our overall incidence of EA was low compared to previous studies, which could potentially have decreased our ability to detect differences between groups. [ABSTRACT FROM AUTHOR]

Trans-esophageal echocardiography ( TEE) and/or central venous pressure ( CVP) monitoring are important in the anesthetic management of spine fusion of pediatric patients with severe muscular weakness. This case highlights an unusual situation of apparent acute right ventricular mechanical obstruction after prone positioning and its prompt recognition with CVP monitoring. The anesthetic management of a patient with congenital muscular dystrophy, an uncommon neuromuscular disorder, is presented. Good communication and planning between the anesthesiology and surgical teams allowed completion of the procedure using a lateral approach. [ABSTRACT FROM AUTHOR]

Tranexamic acid is an anti-fibrinolytic agent frequently used in pediatric surgery. Common side effects include nausea, flushing, and headache, but in rare instances, it may produce anaphylaxis; with only one previously reported case in a 72-year-old man. We report a case of a delayed anaphylactic reaction in a pediatric patient undergoing posterior spine fusion; and discuss the intraoperative management of the acute event, immunologic confirmation, and subsequent anesthetic approach. [ABSTRACT FROM AUTHOR]

A response by Sally Rampersad, Nathalia Jimenez, and Anne Lynn to a letter to the editor regarding their article "Two-agent analgesia versus acetaminophen in children having bilateral myringotomies and tubes surgery."