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Anesthesiology and anesthesiologists have a tremendous opportunity and responsibility to eliminate health disparities and to achieve health equity. We thus examine health disparity and health equity through the lens of anesthesiology and the perspective of anesthesiologists. In this paper, we define health disparity and health care disparities and provide tangible, representative examples of the latter in the practice of anesthesiology. We define health equity, primarily as the desired antithesis of health disparity. Finally, we propose a framework for anesthesiologists, working toward mitigating health disparity and health care disparities, advancing health equity, and documenting improvements in health care access and health outcomes. This multilevel and interdependent framework includes the perspectives of the patient, clinician, group or department, health care system, and professional societies, including medical journals. We specifically focus on the interrelated roles of social identity and social determinants of health in health outcomes. We explore the foundational role that clinical informatics and valid data collection on race and ethnicity have in achieving health equity. Our ability to ensure patient safety by considering these additional patient-specific factors that affect clinical outcomes throughout the perioperative period could substantially reduce health disparities. Finally, we explore the role of medical journals and their editorial boards in ameliorating health disparities and advancing health equity., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2022 International Anesthesia Research Society.)

Background: Cerebrovascular reactivity monitoring has been used to identify the lower limit of pressure autoregulation in adult patients with brain injury. We hypothesise that impaired cerebrovascular reactivity and time spent below the lower limit of autoregulation during cardiopulmonary bypass will result in hypoperfusion injuries to the brain detectable by elevation in serum glial fibrillary acidic protein level., Methods: We designed a multicentre observational pilot study combining concurrent cerebrovascular reactivity and biomarker monitoring during cardiopulmonary bypass. All children undergoing bypass for CHD were eligible. Autoregulation was monitored with the haemoglobin volume index, a moving correlation coefficient between the mean arterial blood pressure and the near-infrared spectroscopy-based trend of cerebral blood volume. Both haemoglobin volume index and glial fibrillary acidic protein data were analysed by phases of bypass. Each patient's autoregulation curve was analysed to identify the lower limit of autoregulation and optimal arterial blood pressure., Results: A total of 57 children had autoregulation and biomarker data for all phases of bypass. The mean baseline haemoglobin volume index was 0.084. Haemoglobin volume index increased with lowering of pressure with 82% demonstrating a lower limit of autoregulation (41±9 mmHg), whereas 100% demonstrated optimal blood pressure (48±11 mmHg). There was a significant association between an individual's peak autoregulation and biomarker values (p=0.01)., Conclusions: Individual, dynamic non-invasive cerebrovascular reactivity monitoring demonstrated transient periods of impairment related to possible silent brain injury. The association between an impaired autoregulation burden and elevation in the serum brain biomarker may identify brain perfusion risk that could result in injury.

Cognitive aids such as checklists are commonly used in modern operating rooms for routine processes, and the use of such aids may be even more important during critical events. The Quality and Safety Committee of the Society for Pediatric Anesthesia (SPA) has developed a set of critical-event checklists and cognitive aids designed for 3 purposes: (1) as a repository of the latest evidence-based and expert opinion-based information to guide response and management of critical events, (2) as a source of just-in-time information during critical events, and (3) as a method to facilitate a shared understanding of required actions among team members during a critical event. Committee members, who represented children's hospitals from across the nation, used the recent literature and established guidelines (where available) and incorporated the expertise of colleagues at their institutions to develop these checklists, which included relevant factors to consider and steps to take in response to critical events. Human factors principles were incorporated to enhance checklist usability, facilitate error-free accomplishment, and ensure a common approach to checklist layout, formatting, structure, and design.The checklists were made available in multiple formats: a PDF version for easy printing, a mobile application, and at some institutions, a Web-based application using the anesthesia information management system. After the checklists were created, training commenced, and plans for validation were begun. User training is essential for successful implementation and should ideally include explanation of the organization of the checklists; familiarization of users with the layout, structure, and formatting of the checklists; coaching in how to use the checklists in a team environment; reviewing of the items; and simulation of checklist use. Because of the rare and unpredictable nature of critical events, clinical trials that use crisis checklists are difficult to conduct; however, recent and future simulation studies with adult checklists provide a promising avenue for future validation of the SPA checklists. This article will review the developmental steps in producing the SPA crisis checklists, including creation of content, incorporation of human factors elements, and validation in simulation. Critical-events checklists have the potential to improve patient care during emergency events, and it is hoped that incorporating the elements presented in this article will aid in successful implementation of these essential cognitive aids.

Background: Hypothermia in neonatal intensive care unit patients is associated with morbidity. Perioperative normothermia is the standard of care., Aims: We hypothesized that a quality improvement intervention (transport protocol, transport education, ongoing monitoring) would decrease the incidence of perioperative hypothermia. Secondarily, we hypothesized that patients undergoing surgery at a postmenstrual age of <37 weeks or at a weight of <1.5 kg would be at higher risk for perioperative hypothermia., Methods: Lean Six Sigma methodology was used to institute a quality improvement intervention. In a retrospective chart review, we identified 708 cases for which the neonatal intensive care unit was the preoperative and postoperative destination and documented patient characteristics, including postoperative temperature. Cardiac surgical cases and cases with no postoperative temperature record were excluded., Results: Patients in the postintervention group had a statistically significant decrease in hypothermia compared to those in the preintervention group (P < 0.001; OR: 0.17; 95% CI: 0.09-0.31). The absolute risk of hypothermia was 23% in the preintervention group and 6% in the postintervention group. Weight <1.5 kg on day of surgery (P = 0.45; OR: 0.63; 95% CI: 0.16-2.24) and postmenstrual age (P = 0.91; OR: 1.07; 95% CI: 0.33-3.98) were not risk factors. Odds of hypothermia were increased in patients undergoing interventional cardiology procedures (P = 0.003; OR: 17.77; 95% CI: 2.07-125.7)., Conclusions: Perioperative hypothermia is a challenge in the care of neonatal intensive care unit patients; however, a thermoregulation intervention can decrease the incidence with sustained results. Future studies can examine why certain procedures have a tendency toward increased perioperative hypothermia, determine the relative value of quality improvement interventions, and characterize the morbidity and mortality associated with perioperative hypothermia in neonatal intensive care unit patients., (© 2016 John Wiley & Sons Ltd.)

Objectives: Protecting the brain during cardiac surgery is a major challenge. We evaluated associations between nadir oxygen delivery (DO2) during paediatric cardiac surgery and a biomarker of brain injury, glial fibrillary acidic protein (GFAP)., Methods: Blood samples were obtained during a prospective, single-centre observational study of children undergoing congenital heart surgery with cardiopulmonary bypass (CPB) (2010-2011). Remnant blood samples, collected serially prior to cannulation for bypass and until incision closure, were analysed for GFAP levels. Perfusion records were reviewed to calculate nadir DO2. Linear regression analysis was used to assess the association between nadir DO2 and GFAP levels., Results: A total of 116 consecutive children were included, with the median age of 0.75 years (interquartile range: 0.42-8.00) and the median weight of 8.3 kg (5.8-20.0). Single-ventricle anatomy was present in 19 patients (16.4%). Deep hypothermic circulatory arrest (DHCA) was used in 14 patients (12.1%). On univariable analysis, nadir DO2 was significantly associated with GFAP values measured during rewarming on CPB (P = 0.005) and after CPB decannulation (P = 0.02). On multivariable analysis controlling for CPB time, DHCA and procedure risk category, a significant negative relationship remained between nadir DO2 and post-CPB GFAP (P = 0.03)., Conclusions: Lower nadir DO2 is associated with increased GFAP levels, suggesting that diminished DO2 during paediatric heart surgery may be contributing to neurological injury. The DO2-GFAP relationship may provide a useful measure for the implementation of neuroprotective strategies in paediatric heart surgery, including goal-directed perfusion., (© The Author 2016. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Background: Although prior studies support the use of a hemoglobin (Hb) transfusion trigger of 7 to 8 g/dL for most hospitalized adults, there are few studies in pediatric populations. We therefore investigated transfusion practices and Hb triggers in hospitalized children., Study Design and Methods: We performed a historical cohort study comparing transfusion practices in hospitalized children by service within a single academic institution. Blood utilization data from transfused patients (n = 3370) were obtained from electronic records over 4 years. Hb triggers and posttransfusion Hb levels were defined as the lowest and last Hb measured during hospital stay, respectively, in transfused patients. The mean and percentile distribution for Hb triggers were compared to the evidence-based restrictive transfusion threshold of 7 g/dL., Results: Mean Hb triggers were above the restrictive trigger (7 g/dL) for eight of 12 pediatric services. Among all of the services, there were significant differences between the mean Hb triggers (>2.5 g/dL, p<0.0001) and between the posttransfusion Hb levels (>3 g/dL, p < 0.0001). The variation between the 10th and 90th percentiles for triggers (up to 4 g/dL, p < 0.0001) and posttransfusion Hb levels (up to 6 g/dL, p < 0.0001) were significant. Depending on the service, between 25 and 90% of transfused patients had Hb triggers higher than the restrictive range., Conclusions: Red blood cell (RBC) transfusion therapy varies significantly in hospitalized children with mean Hb triggers above a restrictive threshold for most services. Our findings suggest that transfusions may be overused and that implementing a restrictive transfusion strategy could decrease the use of RBC transfusions, thereby reducing the associated risks and costs., (© 2015 AABB.)

Background: Although some prior studies have provided evidence to question the historical belief that pulmonary vascular resistance index ⩾6 Wood Units×m2 should be a contraindication to heart transplantation in children, no national analyses specific to the modern area have addressed this question., Methods: Data were analysed for paediatric heart transplant recipients from 1 January, 2002 to 1 September, 2012 (n=699). The relationship between pulmonary vascular resistance and all-cause 30-day mortality was evaluated using univariate and multivariate analyses., Results: The 30-day mortality included 10 patients (1.43%), which is lower than in the previous analyses. Receiver operating curve analysis of pulmonary vascular resistance index as a predictor of mortality yielded a cut-off value of 3.37 Wood Units×m2, but the area under the curve and specificity of this threshold was weaker than in previous analyses. Whereas pulmonary vascular resistance index treated as a dichotomised variable was a significant predictor of mortality in univariate (odds ratio 4.92, 95% confidence interval 1.04-23.33, p=0.045) and multivariate (odds ratio 5.26, 95% confidence interval 1.07-25.80, p=0.041) analyses, pulmonary vascular resistance index treated as a continuous variable was not a significant predictor of mortality in univariate (p=0.12) or multivariate (p=0.11) analyses., Conclusions: The relationship between pulmonary vascular resistance and post-heart transplant mortality in children is less convincing in this analysis of a comprehensive, contemporary database than in previous series. This suggests the possibility that modern improvements in the management of post-transplant right ventricular dysfunction have mitigated the contribution of pulmonary hypertension to early mortality.

Background: Unnecessary testing for and ordering of blood products adds to overall healthcare costs., Objectives: Determine intraoperative red blood cell (RBC) product utilization for pediatric procedures and costs associated with perioperative testing and ordering., Methods: A retrospective chart review captured perioperative blood testing and intraoperative transfusion data for patients <19 years of age who underwent noncardiac surgery over a 13-month period at one tertiary care hospital. The main outcome measure was cost associated with testing for blood products in patients undergoing procedures that had a zero rate of transfusion., Results: The intraoperative transfusion rate for 8620 noncardiac pediatric procedures was 2.78%. Of 8380 nontransfused patients, 707 (8.4%) had type and screen, and of those, 420 (5%) were crossmatched for RBC products in preparation for surgery. The 10 surgical procedures that had the highest perioperative blood testing but no instances of transfusion were as follows: colostomy or ileostomy takedown, spinal cord untethering, tunneled catheter placement, laparoscopic Nissen fundoplication, elbow reduction and fixation, lumbar puncture, suboccipital craniectomy, hip arthrogram, percutaneous intravascular central line, and tonsillectomy and adenoidectomy. Procedures with low transfusion probability and high crossmatch testing were ventriculoperitoneal shunt revision and growing rod distraction. For all nontransfused patients, the cost of obtaining type and screen was $31,815, and the cost for crossmatch was $25,200., Conclusion: Patients may undergo preoperative type and screen or crossmatch for procedures rarely associated with transfusion. Historic transfusion probability may be used to predict need for transfusion for specific surgical procedures and reduce unnecessary perioperative testing and associated costs., (© 2013 John Wiley & Sons Ltd.)

Background: Hyperkalemic cardiac arrest is a potential complication of massive transfusion in children. Our objective was to identify risk factors and potential preventive measures by reviewing the literature on transfusion-associated hyperkalemic cardiac arrest (TAHCA) in the pediatric population., Study Design and Methods: Literature searches were performed in MEDLINE and the Cochrane Database of Systematic Reviews., Results: We identified nine case reports of pediatric patients who had experienced cardiac arrest during massive transfusion. Serum potassium concentration was reported in eight of those reports; the mean was 9.2 ± 1.8 mmol/L. Risk factors for TAHCA noted in the case reports included infancy (n = 6); age of red blood cells (RBCs; n = 5); site of transfusion (n = 5); and the presence of comorbidities such as hyperkalemia, hypocalcemia, acidemia, and hypotension (n = 9). We also identified 13 clinical studies that examined potassium levels associated with transfusion. Of those 13, five studied routine transfusion, two were registries, and six examined massive transfusion., Conclusions: Key points identified from this literature search are as follows: 1) Case reports are skewed toward infants and neonates in particular and 2) the rate of blood transfusion, more so than total volume, cardiac output, and the site of infusion, are key factors in the development of TAHCA. Measures to reduce the risk of TAHCA in young children include anticipating and replacing blood loss before significant hemodynamic compromise occurs, using larger-bore (>23-gauge) peripheral intravenous catheters rather than central venous access, checking and correcting electrolyte abnormalities frequently, and using fresher RBCs for massive transfusion., (© 2013 American Association of Blood Banks.)

Health care quality and value are leading issues in medicine today for patients, health care professionals, and policy makers. Outcome, safety, and service-the components of quality-have been used to define value when placed in the context of cost. Health care organizations and professionals are faced with the challenge of improving quality while reducing health care related costs to improve value. Measurement of quality is essential for assessing what is effective and what is not when working toward improving quality and value. However, there are few tools currently for assessing quality of care, and clinicians often lack the resources and skills required to conduct quality improvement work. In this article, we provide a brief review of quality improvement as a discipline and describe these efforts within pediatric anesthesiology.

Pediatric advanced life support training and guidelines are typically designed for first-responders and out-of-hospital resuscitation. Guidelines and scenarios that are more applicable to the perioperative environment would be beneficial for anesthesiologists. The goal of this article is to review resuscitation of pediatric patients during the perioperative period. We use a format that focuses on preresuscitation preparation, resuscitation techniques, and postresuscitation management in the perioperative period. In an effort to provide information of maximum benefit to anesthesiologists, we include common pediatric perioperative arrest scenarios with detailed description of their management. We also provide a section on postresuscitation management and review the techniques for maintaining the child's hemodynamic and metabolic stability. Finally, 3 appendices are included: an example of an intraoperative arrest record that provides feedback for interventions; a table of key medications for pediatric perioperative resuscitation; and a review of defibrillator use and simulation exercises to promote effective defibrillation.

Background: Moyamoya syndrome carries a high risk of cerebral ischemia, and impaired cerebrovascular autoregulation may play a critical role. Autoregulation indices derived from near-infrared spectroscopy (NIRS) may clarify hemodynamic goals that conform to the limits of autoregulation., Objectives: The aims of this pilot study were to determine whether the NIRS-derived indices could identify blood pressure ranges that optimize autoregulation and whether autoregulatory function differs between anatomic sides in patients with unilateral vasculopathy., Methods: Pediatric patients undergoing indirect surgical revascularization for moyamoya were enrolled sequentially. NIRS-derived autoregulation indices, the cerebral oximetry index (COx) and the hemoglobin volume index (HVx), were calculated intraoperatively and postoperatively to measure autoregulatory function. The 5-mmHg ranges of optimal mean arterial blood pressure (MAPOPT ) with best autoregulation and the lower limit of autoregulation (LLA) were identified., Results: Of seven enrolled patients (aged 2-16 years), six had intraoperative and postoperative autoregulation monitoring and one had only intraoperative monitoring. Intraoperative MAPOPT was identified in six (86%) of seven patients with median values of 60-80 mmHg. Intraoperative LLA was identified in three (43%) patients with median values of 55-65 mmHg. Postoperative MAPOPT was identified in six (100%) of six patients with median values of 70-90 mmHg. Patients with unilateral disease had higher intraoperative HVx (P = 0.012) on side vasculopathy., Conclusions: NIRS-derived indices may identify hemodynamic goals that optimize autoregulation in pediatric moyamoya., (© 2013 Blackwell Publishing Ltd.)

Congenital high airway obstruction syndrome (CHAOS) is one indication for the ex utero intrapartum treatment (EXIT), which is used to secure the fetal airway, while fetal oxygenation is maintained by uteroplacental circulation. We report a successful EXIT procedure in a twin gestation in which one child had CHAOS while the other was a healthy child without any congenital abnormalities. After version of Twin B to allow for delivery of Twin A, Twin B underwent airway evaluation and tracheostomy for laryngeal atresia prior to delivery., (Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.)

Background: Many drugs used for anesthesia and analgesia in children are administered "off-label." We undertook an audit of drugs commonly used for pediatric anesthesia to determine which drugs have United States Food and Drug Administration (FDA) labeling for pediatric use, which drugs are age-restricted, and which have no labeling for pediatric use., Methods: We identified drugs administered during anesthesia to pediatric patients from the operating room pharmacy. FDA approval and indications were determined by using the Thomson Micromedex® online database. Drugs without FDA approval for pediatric use were further examined for strength of evidence and strength of recommendation for their listed indications in the database. We then examined the rate of off-label drug administration to patients younger than the age of 18 years between July 1, 2010, and August 31, 2011., Results: One hundred six drugs were identified. Thirty-six (34%) were not FDA-labeled for use in any pediatric age group, 40 (38%) were FDA-labeled for use in all pediatric age groups, and 30 (28%) were FDA-labeled for use in only specific age groups. Drugs were administered off-label in 73.4% of cases. Of those not labeled for any pediatric age group, some were among the most commonly used drugs in pediatric anesthesia, including neostigmine, hydromorphone, and dopamine., Conclusions: Many drugs used for children during anesthesia continue to lack FDA labeling for pediatric use. Off-label use of these drugs is an accepted practice that is considered superior to the alternative of withholding needed medications. Studies are still needed to determine the safety and efficacy of drugs that lack FDA labeling for this vulnerable patient population.

Checklists have established themselves as a key safety process in the operating room environment. This paper describes the background and context of how checklists have evolved in medicine. It also highlights ongoing challenges with particular attention to the importance of nontechnical skills or human factors training with relation to checklist design, testing and implementation and ongoing coaching., (© 2012 Blackwell Publishing Ltd.)

Far too many patients suffer preventable harm from medical errors that add to needless suffering and cost of care. Underdeveloped residency training programmes in patient safety are a major contributor to preventable harm. Consequently, the Institute of Medicine has called for health professionals to reform their educational programmes to advance health-care safety and quality. Additionally, the Accreditation Council for Graduate Medical Education (ACGME) now requires education in 'systems-based practice' and 'practice-based learning and improvement' as core competencies of residency training programmes. The specific aim of this article is to describe the implementation of a novel programme designed to enhance residency education, meet ACGME core competencies and improve quality and safety education in one residency programme at an academic medical institution., (Copyright © 2011 Elsevier Ltd. All rights reserved.)

Background: Hyperkalemia is a serious complication of rapid and massive blood transfusion due to high plasma potassium (K) in stored red blood cell (RBC) units. A potassium adsorption filter (PAF) was developed in Japan to remove K by exchanging with sodium (Na). We performed an in vitro evaluation of its efficacy and feasibility of use., Study Design and Methods: Three AS-3 RBC units were filtered by each PAF using gravity; 10 PAFs were tested. Blood group, age, flow rate, and irradiation status were recorded. Total volume, K, Na, Cl, Mg, total Ca (tCa), RBC count, hemoglobin (Hb), hematocrit (Hct), and plasma Hb were measured before and after filtering each unit. Ionized Ca (iCa), pH, and glucose were measured for some units., Results: After filtration, the mean decrease in K was 97.5% in the first RBC unit, 91.2% in the second unit, and 64.4% in the third unit. The mean increases in Na, Mg, and tCa were 33.0, 151.4, and 116.1%, respectively. iCa and pH remained low; glucose was unchanged. RBC count, Hb, and Hct decreased slightly after filtration of first units; plasma Hb was unchanged. After filtration, there was no visual evidence of increased hemolysis or clot formation., Conclusion: The PAF decreased K concentration in stored AS-3 RBC units to minimal levels in the first and second RBC units. Optimally, one filter could be used for 2 RBC units. Although Na increased, the level may not be clinically significant. PAF may be useful for at-risk patients receiving older units or blood that has been stored after gamma irradiation., (© 2010 American Association of Blood Banks.)

Background: Red blood cell (RBC) product wastage in hospitals is reported to range from 0.1% to 6.7%. Wastage at our institution averaged 4.4% of 63,000 issued RBC products. Data indicated that approximately 87% of wasted RBC units were either individual units that were out of blood bank for more than 30 minutes (dispensed but not administered) or units packed in transport containers that had temperature indicators affixed to each unit. We hypothesized that Lean Sigma methodology could be used to reduce RBC wastage by 50%., Study Design and Methods: An interdisciplinary hospital team (transfusion medicine, nursing, and anesthesiology) used Lean Sigma methodology as a tool to reduce RBC product wastage, with a focus on container wastage, which was determined to yield the largest impact. Using the five-part Lean Sigma process-define, measure, analyze, improve, and control-the team collected baseline wastage data, identified major factors affecting RBC product wastage, and implemented interventions to reduce amount of wastage., Results: Factors identified as contributors to RBC wastage most amenable to improvement were lack of awareness and training of staff ordering and handling RBC products, management of temperature-validated containers, inconsistent interpretation of RBC temperature indicators, and need for accountability when ordering blood products. Overall RBC product wastage decreased from 4.4% to a sustained rate of less than 2%. This reduction decreased the number of RBC units wasted by approximately 4300 per year, savings approximately $800,000 over the 4-year period of the study., Conclusions: Lean Sigma methodology was an effective tool for reducing RBC wastage in a large academic hospital., (© 2010 American Association of Blood Banks.)

Background: Inability to intubate and ventilate patients with respiratory failure is associated with significant morbidity and mortality. A patient is considered to have a difficult airway if an anesthesiologist or other health care provider experienced in airway management is unable to ventilate the patient's lungs using bag-mask ventilation and/or is unable to intubate the trachea using direct laryngoscopy., Methods: We performed a retrospective review of a departmental database to determine whether a comprehensive program to manage difficult airways was associated with a reduced need to secure the airway surgically via cricothyrotomy or tracheostomy. The annual number of unplanned, emergency surgical airway procedures for inability to intubate and ventilate reported for the 4 yr before the program (January 1992 through December 1995) was compared with the annual number reported for the 11 yr after the program was initiated (January 1996 through December 2006)., Results: The number of emergency surgical airways decreased from 6.5 +/- 0.5 per year for 4 yr before program initiation to 2.2 +/- 0.89 per year for the 11-yr period after program initiation (P < 0.0001). During the 4-yr period from January 1992 through December 1995, 26 surgical airways were reported, whereas only 24 surgical airways were performed in the subsequent 11-yr period (January 1996 through December 2006)., Conclusions: A comprehensive difficult airway program was associated with a reduction in the number of emergency surgical airway procedures performed for the inability of an anesthesiologist to intubate and ventilate, a reduction that was sustained over an 11-yr period. This decrease occurred despite an increase in the number of patients reported to have a difficult airway and an overall increase in the total number of patients receiving anesthesia per year.

Obstructive sleep apnea syndrome (OSA) affects 1%-3% of children. Children with OSA can present for all types of surgical and diagnostic procedures requiring anesthesia, with adenotonsillectomy being the most common surgical treatment for OSA in the pediatric age group. Thus, it is imperative that the anesthesiologist be familiar with the potential anesthetic complications and immediate postoperative problems associated with OSA. The significant implications that the presence of OSA imposes on perioperative care have been recognized by national medical professional societies. The American Academy of Pediatrics published a clinical practice guideline for pediatric OSA in 2002, and cited an increased risk of anesthetic complications, though specific anesthetic issues were not addressed. In 2006, the American Society of Anesthesiologists published a practice guideline for perioperative management of patients with OSA that noted the pediatric-related risk factor of obesity, and the increased perioperative risk associated with adenotonsillectomy in children younger than 3 yr. However, management of OSA in children younger than 1 yr-of-age was excluded from the guideline, as were other issues related specifically to the pediatric patient. Hence, many questions remain regarding the perioperative care of the child with OSA. In this review, we examine the literature on pediatric OSA, discuss its pathophysiology, current treatment options, and recognized approaches to perioperative management of these young and potentially high-risk patients.

This tool helps assess factors that positively and negatively contributed to an adverse event, near miss, or inefficiency during an operation-or any procedure.

This tool, which takes one or two minutes to use, provides a structured approach to promote effective interdisciplinary communication and teamwork in the operating room--or any other area, such as an intensive care unit, inpatient unit, or outpatient clinic.

The uses of transesophageal echocardiography have expanded dramatically over the last decade. With advances in technology, this imaging modality has become readily available for evaluation of the complex pediatric population with congenital heart disease. This article discusses the many uses of transesophageal echocardiography in this population, in the outpatient setting, in the peri-operative period, and in the cardiac catheterization laboratory.

The change in the prevalence of esophageal cancer by cell type from predominantly squamous cell carcinoma to adenocarcinoma has been well documented in the USA, UK, and Western Europe. The objective of this study was to determine if this shift in cell type resulted in a change in survival in patients treated by esophagectomy without neoadjuvant therapy. Our study group included 106 consecutive esophageal cancer patients who underwent esophagectomy without neoadjuvant therapy. Cell type was adenocarcinoma in 76, and squamous cell in 30 patients. For stage 1 tumors there was a trend towards survival advantage for patients with adenocarcinoma, but this did not reach significance. For stage 2-4 tumors and overall, there was no statistical difference in survival as a function of cell type. Therefore, the observed shift in cell type to a higher prevalence of adenocarcinoma does not alter expected post-surgical outcome.

The present study evaluates the action of volatile anesthetics on the voltage-dependent Ca2+ channels in isolated rat brain membranes, measured as changes in binding of the Ca2+ channel blocker [3H]isradipine to these membranes. Equilibrium binding studies with increasing concentrations of [3H]isradipine (0.01-1 nM) in the presence of halothane (1.9%), isoflurane (2.3%), and enflurane (4.8%) at 25 degrees C were performed. Only halothane produced a significant depression in the specific binding of isradipine to the brain membranes at 0.5 and 1.0 nM [3H]isradipine (P = 0.028 and 0.018, respectively). Isoflurane and enflurane had such inconsistent effects that the data were inconclusive. Halothane produced a significant dose-dependent inhibition of binding, the maximum inhibition being 44% (P less than 0.005). Nonlinear regression analysis fit of the binding data indicates halothane produced a 48% decrease (P less than 0.05) in the maximal number of binding sites (Bmax) with no effect on the dissociation constant (Kd). As voltage-dependent Ca2+ channels are important in mediating neurotransmission, the marked decrease in channel number (Bmax) associated with halothane exposure suggests that this phenomenon might be related to the mechanism of general anesthesia.

Troponin C has been suggested as a possible target for the negative inotropic action of volatile anesthetics. This study has examined the effect of halothane on the structure and response of isolated cardiac troponin C to Ca2+ and the response of skinned soleus and cardiac muscle fibers to Ca2+. The high-affinity Ca(2+)-binding sites of cardiac troponin C were assessed by measurement of the change in intrinsic tyrosine fluorescence and ultraviolet circular dichroism in response to Ca2+ in the presence and absence of halothane. Halothane (0.9 mM, 1.4%) did not alter the 45% enhancement in intrinsic tyrosine fluorescence that occurs with saturation of the high-affinity sites or change the Ca2+ concentration at which half-maximal enhancement occurred. The molar ellipticity in the far ultraviolet region, a measure of the secondary structure, increased to a similar extent with addition of 10(-6) M Ca2+ in the absence and presence of 1.0 mM (1.6%) halothane. The binding rate of the sulfhydryl reagent, 5,5'-dithiobis (2-nitrobenzoic acid), to troponin C in response to Ca2+ titration was used as a measure of the integrity of the low-affinity Ca(2+)-binding site in troponin C in the presence and absence of 1.0 mM (1.6%) halothane. The rate of reaction was stimulated twofold, and the half maximal effect was observed at pCa 4.8 +/- 0.2 in both control and halothane-treated samples. Halothane (5 mM; 7.8%) did not change the pCa/tension response of skinned soleus fibers; the data were fit to the Hill equation and yielded dissociation constants of 6.2 x 10(-7) M for control and halothane-treated specimens.(ABSTRACT TRUNCATED AT 250 WORDS)