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Background: Airway management procedures are critical for emergency medicine (EM) physicians, but rarely performed skills in pediatric patients. Worldwide experience with respect to frequency and confidence in performing airway management skills has not been previously described. Objective(s): Our aims were 1) to determine the frequency with which emergency medicine physicians perform airway procedures including: bag-mask ventilation (BMV), endotracheal intubation (ETI), laryngeal mask airway (LMA) insertion, tracheostomy tube change (TTC), and surgical airways, and 2) to investigate predictors of procedural confidence regarding advanced airway management in children. Method(s): A web-based survey of senior emergency physicians was distributed through the six research networks associated with Pediatric Emergency Research Network (PERN). Senior physician was defined as anyone working without direct supervision at any point in a 24-h cycle. Physicians were queried regarding their most recent clinical experience performing or supervising airway procedures, as well as with hands on practice time or procedural teaching. Reponses were dichotomized to within the last year, or >= 1 year. Confidence was assessed using a Likert scale for each procedure, with results for ETI and LMA stratified by age. Response levels were dichotomized to "not confident" or "confident." Multivariate regression models were used to assess relevant associations. Result(s): 1602 of 2446 (65%) eligible clinicians at 96 PERN sites responded. In the previous year, 1297 (85%) physicians reported having performed bag-mask ventilation, 900 (59%) had performed intubation, 248 (17%) had placed a laryngeal mask airway, 348 (23%) had changed a tracheostomy tube, and 18 (1%) had performed a surgical airway. Of respondents, 13% of physicians reported the opportunity to supervise but not provide ETI, 5% for LMA and 5% for BMV. The percentage of physicians reporting "confidence" in performing each procedure was

BACKGROUND: Children rarely experience critical illness, resulting in low exposure of emergency physicians (EPs) to critical procedures. Our primary objective was to describe senior EP confidence, most recent performance, and/or supervision of critical nonairway procedures. Secondary objectives were to compare responses between those who work exclusively in PEM and those who do not and to determine whether confidence changed for selected procedures according to increasing patient age. METHOD(S): Survey of senior EPs working in 96 emergency departments (EDs) affiliated with the Pediatric Emergency Research Networks. Questions assessed training, performance, supervision, and confidence in 11 nonairway critical procedures, including cardiopulmonary resuscitation (CPR), vascular access, chest decompression, and cardiac procedures. RESULT(S): Of 2446 physicians, 1503 (61%) responded to the survey. Within the previous year, only CPR and insertion of an intraosseous needle had been performed by at least 50% of respondents: over 20% had performed defibrillation/direct current cardioversion. More than 50% of respondents had never performed or supervised ED thoracotomy, pericardiocentesis, venous cutdown, or transcutaneous pacing. Self-reported confidence was high for all patient age groups for CPR, needle thoracocentesis, tube thoracostomy, intraosseous needle insertion, and defibrillation/DC cardioversion. Confidence levels increased with increasing patient age for central venous and arterial line insertion. Respondents working exclusively in PEM were more likely to report being at least somewhat confident in defibrillation/DC cardioversion, intraosseous needle insertion, and central venous line insertion in particular age groups; however, they were less likely to be at least somewhat confident in ED thoracotomy and transcutaneous pacing. CONCLUSION(S): Cardiopulmonary resuscitation and intraosseous needle insertion were the only critical nonairway procedures performed by a

Objective To describe senior paediatric emergency clinician perspectives on the optimal frequency of and preferred modalities for practising critical paediatric procedures. Methods Multicentre multicountry cross-sectional survey of senior paediatric emergency clinicians working in 96 EDs affiliated with the Pediatric Emergency Research Network. Results 1332/2446 (54%) clinicians provided information on suggested frequency of practice and preferred learning modalities for 18 critical procedures. Yearly practice was recommended for six procedures (bag valve mask ventilation, cardiopulmonary resuscitation (CPR), endotracheal intubation, laryngeal mask airway insertion, defibrillation/direct current (DC) cardioversion and intraosseous needle insertion) by at least 80% of respondents. 16 procedures were recommended for yearly practice by at least 50% of respondents. Two procedures (venous cutdown and ED thoracotomy) had yearly practice recommended by <40% of respondents. Simulation was the preferred learning modality for CPR, bag valve mask ventilation, DC cardioversion and transcutaneous pacing. Practice in alternative clinical settings (eg, the operating room) was the preferred learning modality for endotracheal intubation and laryngeal mask insertion. Use of models/mannequins for isolated procedural training was the preferred learning modality for all other invasive procedures. Free-text responses suggested the utility of cadaver labs and animal labs for more invasive procedures (thoracotomy, intercostal catheter insertion, open surgical airways, venous cutdown and pericardiocentesis). Conclusions Paediatric ED clinicians suggest that most paediatric critical procedures should be practised at least annually. The preferred learning modality depends on the skill practised; alternative clinical settings are thought to be most useful for standard airway manoeuvres, while simulation-based experiential learning is applicable for most other procedures.Copyright © Author(s) (

Background: The frequency that ED attending physicians perform or supervise these invasive procedures is poorly described. A description of the the invasive procedure experiences of attendings working in the ED would inform EM residency programs regarding expectations related to pediatric training. Objective(s): To describe experiences with and confidence in performing invasive pediatric procedures by attending ED physicians internationally. To compare experience and confidence between EM and paediatrics/pediatric EM physicians. Method(s): Web-based survey of self-reported experience and confidence performing 19 invasive procedures. Disseminated through eight existing research networks. Result(s): Response rate 64% (N=1603), 43% male, mean age: 42 years (26-69), mean clinical hours/week: 26 hours (0-90). Country: 49% US, 9% CA, 5% AU, 23% UK 12% EU, 3% South America. Training: EM (25%), Pediatric EM (48%), Pediatrics (27%) Performance of procedure on a patient < 18 years-old in last 12 months: Airway: 91% bag-valve mask, 73% intubation, 27% tracheostomy change, 22% laryngeal mask airway Chest: 78% CPR, 34% defibrillation/ cardioversion, 18% needle thoracentesis, 6% pacing, 3% pericardiocentesis Access: 75% intraosseous, 27% central line, 22% arterial line, 1% venous cut-down EM physicians were less likely than pediatric/pediatric EM physicians to have performed bag valve mask, intubation, CPR and central lines in the last 12 months. Providers reporting NEVER performing procedures on any patient < 18 years-old: Airway: 2% bag-valve mask,6% intubation, 40% tracheostomy change, 31% laryngeal mask airway, 95% surgical airway Chest: 4% CPR, 28% defibrillation/cardioversion, 48% needle thoracentesis, 72% pacing, 77% pericardiocentesis, 88% thoracotomy Access: 8% intraosseous, 22% central line, 23% arterial line, 81% venous cut-down Confidence: EM physicians were more likely to be confident (> 3 on 5-point Likert) than pediatric/pediatric EM physicians in surgical airways

Despite current recommendations on the management of pre-operative anaemia, there is no pragmatic guidance for the diagnosis and management of anaemia and iron deficiency in surgical patients. A number of experienced researchers and clinicians took part in an expert workshop and developed the following consensus statement. After presentation of our own research data and local policies and procedures, appropriate relevant literature was reviewed and discussed. We developed a series of best-practice and evidence-based statements to advise on patient care with respect to anaemia and iron deficiency in the peri-operative period. These statements include: a diagnostic approach for anaemia and iron deficiency in surgical patients; identification of patients appropriate for treatment; and advice on practical management and follow-up. We urge anaesthetists and peri-operative physicians to embrace these recommendations, and hospital administrators to enable implementation of these concepts by allocating adequate resources.

In major surgery, the implementation of multidisciplinary, multimodal and individualized strategies, collectively termed Patient Blood Management, aims to identify modifiable risks and optimise patients' own physiology with the ultimate goal of improving outcomes. Among the various strategies utilized in Patient Blood Management, timely detection and management of preoperative anaemia is most important, as it is in itself a risk factor for worse clinical outcome, but also one of the strongest predisposing factors for perioperative allogeneic blood transfusion, which in turn increases postoperative morbidity, mortality and costs. However, preoperative anaemia is still frequently ignored, with indiscriminate allogeneic blood transfusion used as a 'quick fix'. Consistent with reported evidence from other medical specialties, this imprudent practice continues to be endorsed by non-evidence based misconceptions, which constitute serious barriers for a wider implementation of preoperative haemoglobin optimisation. We have reviewed a number of these misconceptions, which we unanimously consider should be promptly abandoned by health care providers and replaced by evidence-based strategies such as detection, diagnosis and proper treatment of preoperative anaemia. We believe that this approach to preoperative anaemia management may be a viable, cost-effective strategy that is beneficial both for patients, with improved clinical outcomes, and for health systems, with more efficient use of finite health care resources.