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Background: Pediatric anesthesia has evolved to a high level of patient safety, yet a small chance remains for serious perioperative complications, even in those traditionally considered at low risk. In practice, prediction of at‐risk patients currently relies on the American Society of Anesthesiologists Physical Status (ASA‐PS) score, despite reported inconsistencies with this method. Aims: The goal of this study was to develop predictive models that can classify children as low risk for anesthesia at the time of surgical booking and after anesthetic assessment on the procedure day. Methods: Our dataset was derived from APRICOT, a prospective observational cohort study conducted by 261 European institutions in 2014 and 2015. We included only the first procedure, ASA‐PS classification I to III, and perioperative adverse events not classified as drug errors, reducing the total number of records to 30 325 with an adverse event rate of 4.43%. From this dataset, a stratified train:test split of 70:30 was used to develop predictive machine learning algorithms that could identify children in ASA‐PS class I to III at low risk for severe perioperative critical events that included respiratory, cardiac, allergic, and neurological complications. Results: Our selected models achieved accuracies of >0.9, areas under the receiver operating curve of 0.6–0.7, and negative predictive values >95%. Gradient boosting models were the best performing for both the booking phase and the day‐of‐surgery phase. Conclusions: This work demonstrates that prediction of patients at low risk of critical PAEs can be made on an individual, rather than population‐based, level by using machine learning. Our approach yielded two models that accommodate wide clinical variability and, with further development, are potentially generalizable to many surgical centers. [ABSTRACT FROM AUTHOR]

Background: While non‐invasive assessment of macro‐ and micro‐circulation has the promise to optimize anesthesia management, evidence is lacking for the relationship between invasive and non‐invasive measurements of cardiac output and microcirculatory indices. Aims: We aimed to compare the abilities of non‐invasive techniques to detect changes in macro‐ and micro‐circulation following deep anesthesia and subsequent restoration of the compromised hemodynamic by routinely used vasopressors in a randomized experimental study. Methods: A 20%–25% drop in mean arterial pressure was induced by sevoflurane in anesthetized mechanically ventilated just‐weaned piglets (n = 12) prior to the administration of vasopressors in random order (dopamine, ephedrine, noradrenaline, and phenylephrine). Simultaneous transpulmonary thermodilution cardiac output assessment with the invasive pulse index continuous contour (PiCCO) method was compared with non‐invasive estimates obtained with electrical conductivity (ICON) and echo Doppler (Cardio Q). Changes in microcirculation were characterized by sublingual red blood cell velocity, jugular cerebral venous oxygen saturation, and arterial lactate. Main outcome measures: Cardiac output indices obtained by invasive and non‐invasive methods. Results: Changes in cardiac output measured invasively and non‐invasively correlated significantly after sevoflurane (r =.78, p =.003 and r =.76, p =.006 between PiCCO and ICON or Cardio Q, respectively). Following the administration of vasopressors, invasive and non‐invasive cardiac output assessments were unrelated with significant correlations observed only between PiCCO and ICON after dopamine and ephedrine. Sevoflurane‐induced hypotension decreased jugular cerebral venous oxygen saturation significantly and was recovered by all vasopressors. Sevoflurane and vasopressors had no effect on red blood cell velocity, which increased only after dopamine. No consistent changes in lactate were observed during the study period. Conclusions: The results of this study suggest that non‐invasive cardiac output measurements may not accurately reflect changes in macrocirculation after hemodynamic optimization by vasopressors. Due to the incoherence between macro‐ and micro‐circulation, monitoring microcirculation is essential to guide patient management. [ABSTRACT FROM AUTHOR]

Extraordinary progress has been made during the past few decades in the development of anesthesia machines and ventilation techniques. With unprecedented precision and performance, modern machines for pediatric anesthesia can deliver appropriate mechanical ventilation for children and infants of all sizes and with ongoing respiratory diseases, ensuring very small volume delivery and compensating for circuit compliance. Along with highly accurate monitoring of the delivered ventilation, modern ventilators for pediatric anesthesia also have a broad choice of ventilation modalities, including synchronized and assisted ventilation modes, which were initially conceived for ventilation weaning in the intensive care setting. Despite these technical advances, there is still room for improvement in pediatric mechanical ventilation. There is a growing effort to minimize the harm of intraoperative mechanical ventilation of children by adopting the protective ventilation strategies that were previously employed only for prolonged mechanical ventilation. More than ever, the pediatric anesthesiologist should now recognize that positive‐pressure ventilation is potentially a harmful procedure, even in healthy children, as it can contribute to both ventilator‐induced lung injury and ventilator‐induced diaphragmatic dysfunction. Therefore, careful choice of the ventilation modality and its parameters is of paramount importance to optimize gas exchange and to protect the lungs from injury during general anesthesia. The present report reviews the novel ventilation techniques used for children, discussing the advantages and pitfalls of the ventilation modalities available in modern anesthesia machines, as well as innovative ventilation modes currently under development or research. Several innovative strategies and devices are discussed. These novel modalities are likely to become part of the armamentarium of the pediatric anesthesiologist in the near future and are particularly relevant for challenging ventilation scenarios. [ABSTRACT FROM AUTHOR]

Background: Recently, the European prospective observational multicenter cohort study, APRICOT, reported anesthesia techniques and complications in more than 31 000 pediatric procedures. The main objective of this study was to analyze the current practice in regional anesthesia in the 33 countries that participated to APRICOT. Methods: Data on regional anesthesia techniques were extracted from the database of APRICOT (261 centers across 33 European countries). All children, aged from birth to 16 years old, were eligible for inclusion during a 2‐week period. Type of regional anesthesia, whether used awake or with sedation or general anesthesia, techniques of guidance, and the drugs administered were analyzed. Results: Regional anesthesia was used in 4377 pediatric surgical procedures. The large majority was performed under general anesthesia with central blocks and truncal blocks, representing, respectively, 42.6% and 41.8% of performed techniques. Caudal blocks represented 76.9% of all central blocks. The penile and ilioinguinal/iliohypogastric blocks were the most commonly performed truncal blocks. Anesthetists used mainly anatomical landmarks; ultrasound guidance was applied in only 23.8% of cases. A wide variability of practices was observed in terms of regional anesthesia techniques and local anesthetics among the participating European countries. No serious complications were reported. Conclusion: These data show a large predominance of central and truncal blocks in APRICOT study. Ultrasound guidance was mainly used for peripheral nerve blocks while central blocks were performed using landmark techniques. [ABSTRACT FROM AUTHOR]

Background: Premedication with β-2 agonists (e.g. salbutamol) is effective in preventing increases in total respiratory resistance and in decreasing the incidence of perioperative bronchospasm in asthmatic children. Because children with recent respiratory tract infection (RTI) exhibit bronchial hyperreactivity similar to that observed in asthmatic children, the use of salbutamol in children with RTI has become popular among pediatric anesthetists for the prevention of perioperative respiratory adverse events (PRAE). In a prospective observational study, we therefore assessed the usefulness of salbutamol premedication on the occurrence of PRAE. Methods: Results from 600 children (0–16 years) undergoing general anesthesia were analyzed: 200 children with a recent RTI who received preoperative salbutamol 10–30 min prior to surgery, 200 children with a recent RTI without salbutamol premedication, and 200 children without a RTI during the last 4 weeks. All PRAE (laryngospasm, bronchospasm, oxygen desaturation [<95%], severe coughing) were recorded. Results: Children with a recent RTI who received salbutamol demonstrated a significantly reduced incidence of perioperative bronchospasm (5.5% vs 11%, P = 0.0270) and severe coughing (5.5% vs 11.5%, P = 0.0314) compared with children who had an RTI but did not receive salbutamol. However, healthy children presented with the lowest rate (bronchospasm 1.5%, severe coughing 4.5%) of respiratory complications compared with children with a recent RTI independent whether or not they received salbutamol preoperatively. Conclusions: The results from this audit suggest that children with a history of a recent RTI have significantly less PRAE following a premedication with salbutamol compared with no premedication. Therefore, premedication with salbutamol might be considered in children with recent RTI. [ABSTRACT FROM AUTHOR]

Background: The Jackson Rees breathing system is commonly used for bag and mask ventilation in preschool children, although the lack of a pressure release valve can increase the risk of gastric insufflation. Therefore, we investigated the impact of bag and mask ventilation with a Jackson Rees system on functional residual capacity (FRC) and ventilation homogeneity and evaluated the effect of the level of training of the anesthesiologist in charge. Methods: Functional residual capacity and ventilation homogeneity were measured in 74 children (1–6 years) undergoing general surgery and the level of training of the anesthesiologist was recorded. FRC was measured (i) after intubation and (ii) after gastric emptying. Sixty-four children were ventilated using a Jackson Rees system, whereas 10 children were ventilated using a circle system to compare these two breathing systems in the second phase of the protocol. Results: Functional residual capacity and ventilation homogeneity increased in all patients following gastric emptying with the highest improvement (25%) being observed when nurse students were in charge of the ventilation with the Jackson Rees system. The lowest changes in FRC and ventilation homogeneity were observed when pediatric consultants were in charge, whereas ventilation by the pediatric nurse anesthetists led to significant gastric gas insufflation. However, the circle system was associated with significantly less gastric insufflation than the Jackson Rees system. Conclusions: The efficacy of bag and mask ventilation was highly dependent on the training of the anesthesiologist with consultants demonstrating significantly better skills than any of the other groups. As the circle system is associated with a much steeper learning curve than the Jackson Rees system, its use in daily routine practice may prevent ventilatory impairment induced by gastric insufflation. [ABSTRACT FROM AUTHOR]

Background: The implementation of sevoflurane in pediatric anesthesia practice led to a decrease in the incidence of cardiac arrest previously reported with halothane. Nevertheless, the effects of sevoflurane on cardiac rhythm and function have not been systematically investigated in infants. Thus, we compared cardiac rhythm and left ventricular function at 1 MAC sevoflurane and halothane anesthesia and investigated the potential benefit effect of atropine. Methods: Twenty infants ASA physical status I or II were randomly assigned to have anesthesia induced with either sevoflurane (up to 5%) or halothane (up to 1.5%). After insertion of an i.v. line, anesthesia was maintained at 1 MAC sevoflurane (group S) or 1 MAC halothane (group H) with infants breathing spontaneously in 100% oxygen. Cardiac output and contractility were measured by transthoracic echocardiography. Three sets of hemodynamic parameters were averaged prior to and after administration of 20 μg·kg−1 of i.v. atropine. Results: Infants breathing spontaneously 1 MAC halothane or 1 MAC sevoflurane were found to have comparable hemodynamic parameters. After atropine administration, heart rate and cardiac index (CI) increased significantly in both groups (19.6 ± 7.6% in group H and 21.3 ± 13.1% in group S, 18.6 ± 8.8% in group H and 17.7 ± 12% in group S respectively). Moreover, atropine induced an increase in left ventricular shortening fraction with no difference between groups. In contrast, only infants in group S presented a significant increase in ejection fraction. Conclusions: Indices of left ventricular function were comparable between groups with no clinically significant change following atropine administration. The present study confirms the favorable hemodynamic profile of sevoflurane in infants breathing spontaneously at 1 MAC concentration. [ABSTRACT FROM AUTHOR]

The article assesses the risks involved in pediatric anesthesia. The article states that mortality related to pediatric anesthesia has improved though the incidence of perioperative morbidity is high. The role of anesthesia and preoperative assessment for conducting surgeries in children suffering from several diseases including diabetes, chronic renal failure and allergies are discussed.

SummaryRopivacaine has a favourable toxicity profile for epidural anaesthesia in adults, so it may also be an appropriate agent for epidural analgesia in children. We therefore designed this study to determine the pharmacokinetic variables of ropivacaine relevant to the risk of toxicity, after caudal administration in children. We studied nine healthy children, aged 1–6 years who received 1 ml.kg-1 of ropivacaine 0.25% for caudal analgesia. Venous blood samples were collected at intervals for 12 h after injection. Total plasma concentration of ropivacaine was assayed by high performance liquid chromatography, and pharmacokinetic descriptors were estimated from the plasma concentration-time data. The median peak venous plasma concentration was 799 μg·l-1 [interquartile range (IQR) 707–1044 μg·l-1], and was reached at a median time of 1.5 h (IQR 0.5–2 h). The mean elimination half-life was 3.9 h (95% CI 2.7–5.0 h), and the mean apparent clearance and volume of distribution were 7.6±1.6 ml·min-1·kg-1 (95% CI 6.1–9.1 ml·min-1·kg-1) and 2.4±0.6 l·kg-1 (95% CI 1.9–3.0 l.kg-1), respectively. Analgesia was satisfactory in all cases and no systemic ropivacaine toxicity was observed. Caudal administration of weight-adjusted doses of ropivacaine to children resulted in systemic exposure similar to that reported for adults. No systemic toxicity was observed. The findings strengthen predictions that the relative systemic safety of epidural ropivacaine in adults will apply to children. However, the pharmacokinetics and safety of epidural ropivacaine need to be studied further in children with circumstances that affect drug disposition and systemic tolerance. [ABSTRACT FROM AUTHOR]

Hyperventilation with large tidal volumes contributes to ventilator-induced lung injury and may also lead to hypocapnia. The issue is complex, with evidence supporting the importance of driving pressure and the subsequent dynamic energy load to the lung in determining the optimal tidal volume in order to decrease the strain on the alveoli.[5] Using a pneumotachometer and respiratory mechanics monitoring likely provide the most reliable measurement of the delivered tidal volume while considering the optimal end-expiratory lung volume and driving pressure. [Extracted from the article]

The article presents an editorial which discusses on the approaches to delivery of sevoflurane, a volatile anesthetic, in the neonates. It includes a solution offering anesthetists a possibility to administer inhalation volatile agents within a built‐on system mounted on a neonatal ventilator that can be used as an alternative to anesthesia ventilators in the operating room.

Background: Although a high inspired oxygen fraction (FiO2) is commonly used in paediatric anaesthesia, the impact on postoperative lung function is unclear. We compared lung volume, ventilation heterogeneity, and respiratory mechanics in anaesthetised children randomised to receive low or high FiO2 intraoperatively.Methods: In a double-blind randomised controlled trial, children scheduled for elective surgery were randomly assigned FiO2 100% (n=29) or FiO2 80% (n=29) during anaesthesia induction and emergence. During maintenance of anaesthesia, participants assigned FiO2=100% at induction/emergence received FiO2=80% (FiO2>0.8 group); those randomised to FiO2=80% at induction/emergence received FiO2=35% intraoperatively (FiO2 [0.8→0.35 group]). During spontaneous breathing, we measured the (i) functional residual capacity (FRC) and lung clearance index (ventilation inhomogeneity) by multiple-breath nitrogen washout; and (ii) airway resistance and respiratory tissue elastance by forced oscillations, before operation, after discharge from the recovery room, and 24 h after operation. Mean (95% confidence intervals) are reported.Results: Fifty eight children (12.9 [12.3-13.5] yr) were randomised; 22/29 (high group) and 21/29 (low group) children completed serial multiple-breath nitrogen washout measurements. FRC decreased in the FiO2>0.8 group after discharge from recovery (-12.0 [-18.5 to -5.5]%; P=0.01), but normalised 24 h later. Ventilation inhomogeneity increased in both groups after discharge from recovery, but persisted in the FiO2>0.8 group 24 h after surgery (6.1 [2.5-9.8%]%; P=0.02). Airway resistance and respiratory elastance did not differ between the groups at any time point.Conclusions: FiO2>0.8 decreases lung volume in the immediate postoperative period, accompanied by persistent ventilation inhomogeneity. These data suggest that FiO2>0.8 should be avoided in anaesthetised children with normal lungs.Clinical Trial Registration: NCT02384616. [ABSTRACT FROM AUTHOR]