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The severe acute respiratory syndrome coronavirus 2 (coronavirus disease 2019 [COVID-19]) pandemic has challenged medical systems and clinicians globally to unforeseen levels. Rapid spread of COVID-19 has forced clinicians to care for patients with a highly contagious disease without evidence-based guidelines. Using a virtual modified nominal group technique, the Pediatric Difficult Intubation Collaborative (PeDI-C), which currently includes 35 hospitals from 6 countries, generated consensus guidelines on airway management in pediatric anesthesia based on expert opinion and early data about the disease. PeDI-C identified overarching goals during care, including minimizing aerosolized respiratory secretions, minimizing the number of clinicians in contact with a patient, and recognizing that undiagnosed asymptomatic patients may shed the virus and infect health care workers. Recommendations include administering anxiolytic medications, intravenous anesthetic inductions, tracheal intubation using video laryngoscopes and cuffed tracheal tubes, use of in-line suction catheters, and modifying workflow to recover patients from anesthesia in the operating room. Importantly, PeDI-C recommends that anesthesiologists consider using appropriate personal protective equipment when performing aerosol-generating medical procedures in asymptomatic children, in addition to known or suspected children with COVID-19. Airway procedures should be done in negative pressure rooms when available. Adequate time should be allowed for operating room cleaning and air filtration between surgical cases. Research using rigorous study designs is urgently needed to inform safe practices during the COVID-19 pandemic. Until further information is available, PeDI-C advises that clinicians consider these guidelines to enhance the safety of health care workers during airway management when performing aerosol-generating medical procedures. These guidelines have been endorsed by the Society for Pediatric Anesthesia and the Canadian Pediatric Anesthesia Society.

Purpose of Review: The evidence regarding the efficacy of analgesics available to guide postoperative pain treatment in pediatric patients is limited. Opioid medications are very often an important component of pediatric postoperative pain treatment but have been associated with perioperative complications. We will focus on initiatives aiming to provide effective treatment minimizing the use of opioids and preventing the long-term consequences of pain., Recent Findings: Interpatient variability in postoperative pain is currently managed by applying protocols or by trial and error, thus often leading to patients being either undertreated or overtreated. Few evidence-based reports are available to guide the use of opioid medications in children, including the prescription of opioids after hospital discharge. Using combinations of nonopioid analgesics in a multimodal approach may limit the need for opioids, thus decreasing the risk of toxicity and dose-related side effects. There is a lack of adequate research in this field, and more specifically on identifying which patient is at higher risk of poor postoperative pain management., Summary: Treatment options have evolved in recent years, including the combinations of multimodal regimens and regional anesthetic techniques. Using combinations of nonopioid analgesics in a multimodal approach may limit the need for opioids.

Background: There is no consensus on the concentration or type of local anesthetic used for initiation of epidural anesthesia. The aim of this randomized, double-blind, controlled trial was to compare the clinical effectiveness of epidural administration of both levobupivacaine and bupivacaine in 0.2% and 0.25% concentrations in pediatric patients undergoing abdominal and urological surgery., Methods: One hundred and forty-one children scheduled for lower abdominal and urological surgery were randomized to receive 0.4-0.6 ml.kg(-1) epidural, 0.25% bupivacaine, 0.2% bupivacaine, 0.25% levobupivacaine or 0.2% levobupivacaine. Initial epidural volumes, onset times; hemodynamic consequences, postoperative pain scores and degree of residual postoperative motor block were all recorded., Results: There were no significant differences in the proportion of children with effective analgesia after incision [0.20% bupivacaine 97%, 0.25% bupivacaine 94%, 0.20% levobupivacaine 91%, 0.25% levobupivacaine 92% (P=0.73)] when a median volume of 0.55 ml.kg(-1) was used. There was no association between the volume used for thoracic, lumbar, or sacral epidural anesthesia and the effectiveness of the agents used. There was a significantly greater incidence of pain on awakening with the 0.2% solutions compared with the 0.25% solutions, but no differences in the incidence of residual motor block between groups., Conclusions: While there is no difference in the proportion of effective surgical anesthesia, the lower incidence of pain and distress with the 0.25% solutions suggests that this concentration has clinical advantages over the 0.2% solutions for pediatric epidural anesthesia.

The severe acute respiratory syndrome coronavirus 2 (coronavirus disease 2019 [COVID-19]) pandemic has challenged medical systems and clinicians globally to unforeseen levels. Rapid spread of COVID-19 has forced clinicians to care for patients with a highly contagious disease without evidence-based guidelines. Using a virtual modified nominal group technique, the Pediatric Difficult Intubation Collaborative (PeDI-C), which currently includes 35 hospitals from 6 countries, generated consensus guidelines on airway management in pediatric anesthesia based on expert opinion and early data about the disease. PeDI-C identified overarching goals during care, including minimizing aerosolized respiratory secretions, minimizing the number of clinicians in contact with a patient, and recognizing that undiagnosed asymptomatic patients may shed the virus and infect health care workers. Recommendations include administering anxiolytic medications, intravenous anesthetic inductions, tracheal intubation using video laryngoscopes and cuffed tracheal tubes, use of in-line suction catheters, and modifying workflow to recover patients from anesthesia in the operating room. Importantly, PeDI-C recommends that anesthesiologists consider using appropriate personal protective equipment when performing aerosol-generating medical procedures in asymptomatic children, in addition to known or suspected children with COVID-19. Airway procedures should be done in negative pressure rooms when available. Adequate time should be allowed for operating room cleaning and air filtration between surgical cases. Research using rigorous study designs is urgently needed to inform safe practices during the COVID-19 pandemic. Until further information is available, PeDI-C advises that clinicians consider these guidelines to enhance the safety of health care workers during airway management when performing aerosol-generating medical procedures. These guidelines have been endorsed by the Society for Pediatric Anesthesia and the Canadian Pediatric Anesthesia Society.

The treatment of pediatric patients with diabetes is frequently orchestrated within a multidisciplinary framework at tertiary, specialized institutions. In situations where emergent surgery is indicated or when a procedure is scheduled in a facility devoid of an endocrinology service, the onus of managing perioperative glycemic levels may rest with the attending anesthesiologist. The objective of this review is to furnish a comprehensive examination of the anesthetic considerations and perioperative governance of pediatric patients with diabetes. Furthermore, this paper delineates a streamlined protocol for perioperative glycemic control, tailored to both major and minor surgical interventions. [ABSTRACT FROM AUTHOR]

Chronic postsurgical pain (CPSP) affects a significant proportion of children and adolescents after major surgery and is a detriment to both short- and long-term recovery outcomes. While clinical characteristics and psychosocial risk factors for developing CPSP in children and adults are well established in the literature, there has been little progress on the prevention and management of CPSP after pediatric surgery. Limited evidence to support current pharmacologic approaches suggests a fundamentally new paradigm must be considered by clinicians to both conceptualize and address this adverse complication. This narrative review provides a comprehensive evaluation of both the known and emerging mechanisms that support our current understanding of CPSP. Additionally, we discuss the importance of optimizing perioperative analgesic strategies to mitigate CPSP based on individual patient risks. We highlight the importance of postoperative pain trajectories to identify those most at risk for developing CPSP, the early referral to multi-disciplinary pain clinics for comprehensive evaluation and treatment of CPSP, and additional work needed to differentiate CPSP characteristics from other chronic pain syndromes in children. Finally, we recognize ongoing challenges associated with the universal implementation of available knowledge about pediatric CPSP into practically useful care plans for clinicians. [ABSTRACT FROM AUTHOR]

Postoperative hyperglycemia is an independent risk factor for postoperative complications. In adults, perioperative hyperglycemia is influenced by prolonged fasting, but data in children are lacking. The Glycemic Stress Index (GSI) has been shown to predict prolonged Pediatric Intensive Care Unit (PICU) stays in neurosurgical patients. This study aimed to confirm the correlation between GSI and duration of intubation, PICU stay, and postoperative complications in infants undergoing elective open heart surgery. The correlation between preoperative fasting and GSI was also investigated. Methods: A retrospective chart review of 85 infants ≤ 6 months undergoing elective open heart surgery was performed. GSI values ≥ 3.9 and 4.5 were tested to determine whether they carried a higher incidence of postoperative complications (metabolic uncoupling, kidney injury, ECMO, and death). The correlation between GSI and the length of intubation, PICU stay, and duration of fasting were also investigated. Perioperative factors such as age, weight, blood gas analysis, use of inotropes, and risk adjustment for congenital heart surgery were also analyzed as possible predictors. Results: GSI correlated with the duration of intubation and PICU stay. A GSI ≥ 4.5, but not 3.9, was associated with a higher incidence of metabolic uncoupling. GSI was not influenced by preoperative fasting. None of the preoperative patient factors analyzed was associated with prolonged intubation, PICU stay, or PICU complications. An abnormal creatinine before surgery increased the risk of developing acute kidney injury postoperatively. Conclusions: GSI may be valuable to predict prolonged intubation, PICU stay, and metabolic derangement in infants undergoing cardiac surgery. Fasting does not appear to affect GSI. [ABSTRACT FROM AUTHOR]

Background: There is increasing evidence for the use of multilevel epidural catheter-guided blood patches to treat spontaneous cerebrospinal fluid leaks in adults. Yet, there are scarce data for their use in children. Furthermore, higher level epidural blood patches are uncommon in both adult and pediatric populations.Case Presentation: An adolescent boy with multilevel cerebrospinal fluid leaks associated with status migrainosus failed conservative pain management treatment. As he remained severely symptomatic, epidural blood patches were required to mitigate his symptoms. Given his multilevel leaks, a catheter-guided blood patch approach was used to treat multiple cervicothoracic and thoracolumbar leaks. After three separate uneventful blood patch procedures, the patient was free of symptoms. Other than some rebound intracranial hypertension, the patient maintained full neurological capacity without further complications. Following the resolution of treatment, he has not sought help for pain since his last blood patch over a year ago.Conclusions: Multilevel catheter-guided blood patches have the potential to be administered to higher level spinal regions to the pediatric population suffering from multiple spontaneous cerebrospinal fluid leaks. [ABSTRACT FROM AUTHOR]

Epidermolysis Bullosa is a dermatologic condition characterized by skin fragility and the formation of painful blisters all over the body. The course of this chronic hereditary disorder involves multiple painful procedures for which adequate analgesia is an ongoing challenge. This case report follows a previously‐described pediatric patient with the Dowling‐Meara variant of Epidermolysis Bullosa who was treated with at‐home nitrous oxide for daily procedural analgesia. We report on the long‐term effectiveness of this treatment in addition to any side effects encountered as a result of this treatment. [ABSTRACT FROM AUTHOR]

Epidermolysis bullosa comprises a range of conditions characterized by fragile skin with painful blistering induced by minor trauma and friction. The Dowling-Meara variant is a severe form characterized by disseminated painful blistering requiring lifelong skin and wound care. The natural history of the disease is characterized by a chronic course that tends to improve with advancing age. Various multimodal analgesic strategies have been proposed for painful procedures in children with epidermolysis bullosa. In this case report, we describe the use of nitrous oxide for pain control at home of blister treatments in a 4-year-old child with the Dowling-Meara variant. [ABSTRACT FROM AUTHOR]

Background: Monitoring of anesthesia depth is difficult clinically, particularly in children. The aim of this study was to assess the correlation existing between CSI (Cerebral State Index), or AAI (A-line ARX) and a clinical sedation scale such as UMSS (University of Michigan Sedation Scale), during deep sedation with propofol in children undergoing diagnostic procedures. Methods: Twenty ASA I and II children, scheduled to undergo deep sedation for magnetic resonance imaging (MRI) or Esophagogastroduodenoscopy (EGDS), were enrolled. The patients were randomly assigned to receive depth of anesthesia monitoring with CSI or AAI. The anesthetist administered repeated doses of propofol every 10 s to a UMSS score of 3–4. An attending anesthetist, not involved in drug administration, recorded time and doses of sedation medications, vital signs, UMSS score and CSI or AAI score. All the evaluations were recorded at awake state (baseline), every 10 s until an UMSS score of 3–4 and every 3 min until the children were awake. Results: We enrolled 13 males and seven females ranging in age from 8 months to 7 years. After induction of anesthesia CSI and AAI scores decreased and from the end of the procedure to emergence the two scores increased. The CSI data showed a strong correlation with the UMSS scores ( r = −0.861; P < 0.0001); we found a similar correlation between the AAI data and the UMSS scores ( r = −0.823; P < 0.0001). Conclusions: Our study suggests that CSI and AAI may be two, real-time and objective tools to assess induction and emergence during propofol sedation in children undergoing EGDS and MRI. [ABSTRACT FROM AUTHOR]

Abstract: This study describes the minimum incidence of pediatric complex regional pain syndrome (CRPS), clinical features, and treatments recommended by pediatricians and pain clinics in Canada. Participants in the Canadian Paediatric Surveillance Program reported new cases of CRPS aged 2 to 18 years monthly and completed a detailed case reporting questionnaire from September 2017 to August 2019. Descriptive analysis was completed, and the annual incidence of CRPS by sex and age groupings was estimated. A total of 198 cases were reported to the Canadian Paediatric Surveillance Program, and 168 (84.8%) met the case definition. The minimum Canadian incidence of CRPS is estimated at 1.14/100,000 (95% confidence interval 0.93-1.35/100,000) children per year. Incidence was highest among girls 12 years and older (3.10, 95% confidence interval 2.76-3.44/100,000). The mean age of CRPS diagnosis was 12.2 years (SD = 2.4), with the mean time from symptom onset to diagnosis of 5.6 months (SD = 9.9) and no known inciting event for 19.6% of cases. Most cases had lower limb involvement (79.8%). Nonsteroidal anti-inflammatory drugs (82.7%) and acetaminophen (66.0%) were prescribed more commonly than antiepileptic drugs (52.3%) and antidepressants (32.0%). Referrals most commonly included physical therapy (83.3%) and multidisciplinary pain clinics (72.6%); a small number of patients withdrew from treatment because of pain exacerbation (5.3%). Pain education was recommended for only 65.6% of cases. Treatment variability highlights the need for empiric data to support treatment of pediatric CRPS and development of treatment consensus guidelines. [ABSTRACT FROM AUTHOR]