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Postoperative pneumonia increases the risk of postsurgical mortality, making it a serious healthcare-associated complication. Children with preoperative neuromuscular impairments have a higher risk of postoperative pneumonia. Obesity is also a risk factor for postoperative pulmonary complications, including pneumonia. Moreover, obesity is increasingly prevalent among children living with a neurological diagnosis. Whether obesity increases the risk of postoperative pneumonia among children with neurologic diseases remains largely unknown. Therefore, we assessed the risk of postoperative pneumonia among children with neurologic diagnoses based on their obesity status.We analyzed a retrospective cohort of children ≤18 years from the National Surgical Quality Improvement Program (2012-2019) database who underwent inpatient orthopedic surgery. We used Cox proportional regression model to estimate the hazard ratio for the association between neurologic disorders and postoperative pneumonia. In addition, we included an interaction term between body mass index and neurologic disorders to evaluate the moderating effect of obesity status and then performed stratified analyses to compare the magnitude of hazard ratios across body mass index subgroups.A total of 60 745 children underwent inpatient orthopedic surgery during the study period, of whom 43.6% were healthy weight and 30.8% overweight/obese. The median age was 13 years (Interquartile range: 8-15). The incidence of postoperative pneumonia was higher among healthy weight patients with neurologic disorders than healthy weight patients without any neurologic disorders [Hazard ratio: 3.55 vs. 0.34]. Furthermore, the association between neurologic disorders and postoperative pneumonia was strongest among overweight patients than healthy weight or obese patients [Hazard ratio:11.88 vs. 9.45 vs. 4.40]. This observation was consistent across the various neurologic disorders analyzed.Childhood obesity buffered the association between neurologic disorders and postoperative pneumonia, consistent with an 'obesity paradox'. Further research exploring the underlying mechanisms for the obesity paradox in children with neurologic disorders is warranted.

Acetaminophen is routinely used for perioperative analgesia in children undergoing major surgical procedures. There are few estimates of acetaminophen pharmacokinetic parameters in children with congenital heart disease, especially those with cyanotic heart disease.The current study prospectively investigated differences in acetaminophen pharmacokinetics following surgery using cardiopulmonary bypass in children with cyanotic and acyanotic congenital heart disease.Children (2-6 years, 9-23 kg) presenting for median sternotomy for Fontan palliation (cyanotic patients) or two ventricle surgical repair (acyanotic patients) were eligible for inclusion. A single intravenous dose of acetaminophen (15 mg/kg) was administered at the start of sternal closure after separation from cardiopulmonary bypass. The time-course of acetaminophen concentrations were described using non-linear mixed effects models. One and two-compartment disposition models with first-order elimination were tested. Pharmacokinetic parameter estimates were scaled using allometry and standardized to a 70 kg person.There were 208 acetaminophen concentrations assayed from 30 children, 15 with cyanotic, and 15 with acyanotic heart disease. A 2-compartment model best described acetaminophen PK. Parameter estimates (population parameter variability, PPV%; 95% confidence interval, CI) were clearance CL 15.3 L.h-1.70 kg-1 (22.2%; 13.8-16.7), intercompartment clearance Q 45.4 L.h-1.70 kg-1 (22.4%; 25.2-61.9), central volume of distribution V1 33.5 L.70 kg-1 (23.2%; 25.9-38.8), peripheral volume of distribution V2 32.1 L.70 kgAcetaminophen pharmacokinetics were characterized using a 2-compartment model with first-order elimination following cardiac bypass surgery in children. Population pharmacokinetic parameter estimates were similar to other studies in children. No differences were detected between patients with cyanotic and acyanotic heart disease.

Although neuraxial techniques such as caudal and epidural anesthesia were initially the predominant regional anesthetic technique used to provide postoperative analgesia in children, there has been a transition to the use of peripheral nerve blockade such as the quadratus lumborum block (QLB). We present preliminary experience with QL catheters for continuous postoperative analgesia in a cohort of pediatric patients following colorectal surgery.After institutional review board (IRB) approval, we retrospectively reviewed the records of patients who underwent major colorectal surgery and received QL catheters for postoperative analgesia. The postoperative pain control data consisted of QL catheter characteristics, anesthetic agents, adjuncts, pain scores, and opioid consumption during the postoperative period.The study cohort included eight pediatric patients, ranging in age from 1 to 19 years (median age 11.8 years). The QL catheters were placed in the operating room after the induction of anesthesia. Comorbid conditions in the cohort that were contraindications to neuraxial anesthesia included spinal/vertebral malformations, presence of a ventriculoperitoneal (VP) shunt, anal atresia, tracheo-esophageal fistula (VACTERL) association, and coagulation disturbances. All patients underwent complex colorectal or genito-urologic procedures. Bilateral QL catheters were placed in six patients, and unilateral catheters were placed in two patients. Four patients received 0.5% ropivacaine and four patients received 0.2% ropivacaine of an initial bolus. The local anesthetic used for continuous infusion was 0.2% ropivacaine in five patients, 0.1% ropivacaine in two patients, and 1.5% chloroprocaine in one patient, with a median infusion rate of 0.11 mL/kg/h. QL catheter infusions were supplemented with intravenous opioids delivered by patient-controlled or nurse-controlled analgesia. The median opioid requirements in oral morphine milligram equivalents (MME) were 1.2, 1.0, 1.1, 0.5, and 0.6 MME/kg on postoperative days 1 - 5. Daily median pain scores were ≤ 2 during the 5-day postoperative course. All catheters functioned successfully and were in place for a median of 79.3 h. Other than early inadvertent removal of two catheters, no adverse effects were noted.Although our preliminary data suggest the efficacy of QL catheters in providing prolonged postoperative analgesia for up to 3 - 5 days following colorectal procedures, attention needs to be directed at measures to ensure that the catheter is secured to avoid inadvertent removal.

Severe obesity, defined as body mass index (BMI) ≥ 40 kg/mWe assembled a retrospective cohort of patients ≥ 65 years who underwent inpatient surgical procedures and were either severely obese or normal weight (BMI 18.6 - 24.9 kg/mWe studied 34,936 patients who were ≥ 65 years of age. The incidence of PPMV was 2.0% (624/31,700) in normal weight patients and 2.8% (92/3,236) in severely obese patients (odds ratio (OR): 1.46; 95% confidence interval (CI): 1.17 - 1.82, P = 0.001). Multivariable analysis, controlling for confounders, estimated a 56% relative increase in the risk of PPMV in severely obese patients, relative to their normal weight peers (OR: 1.56; 95% CI: 1.22 - 1.99, P = 0.001). In normal weight patients, the risk of mortality was multiplied by 23 times in patients who required PPMV (39.6% vs. 2.64%; OR: 23.10; 95% CI: 18.96 - 28.16; P0.001). In severely obese patients, PPMV multiplied the risk of mortality by 25 times (30.4% vs. 1.6%; OR: 25.26, 95% CI: 13.44 - 47.50; P0.001).Severe obesity increased the odds of PPMV. Although the incidence of PPMV was low, its requirement conferred up to 25 times greater risk of postoperative mortality, underscoring the need for perioperative mitigation strategies to minimize PPMV risk in elderly patients undergoing vascular surgery.

Delirium is associated with increased length of stay, duration of mechanical ventilation, in-hospital mortality, and cost. Independent predictors of delirium include age2 years, developmental delay, severity of illness, mechanical ventilation, and administration of benzodiazepines and anticholinergic medications. Although patients receiving noninvasive ventilation (NIV) may have been included in prior studies, there are no data specifically focusing on delirium in children receiving NIV. Our primary aim was to investigate the prevalence of delirium in patients on NIV in the pediatric intensive care unit (PICU) and evaluate potentially modifiable risk factors for delirium.This was a single-center, retrospective study evaluating the prevalence of delirium as established by the Cornell Assessment of Pediatric Delirium (CAPD). We evaluated PICU patients ≤ 18 years old with respiratory insufficiency requiring ≥ 48 h of NIV. Patients receiving invasive mechanical ventilation were excluded from the analysis.There were 202 patients that received ≥ 48 h of NIV during the study period. Of these patients, 43 patients had at least one CAPD score documented while on NIV. There were a total of 143 days on NIV and 137 days with CAPD documentation. The prevalence of delirium, defined as a CAPD score ≥ 9, was 67.4% (29 of 43 patients). Sixty-nine percent of the patients who experienced delirium received benzodiazepines, compared with 14% who did not experience delirium (P = 0.001). Most patients (83.7%) in this cohort received dexmedetomidine. Of patients who received dexmedetomidine and had delirium, 68% received benzodiazepines compared to 25% in the non-delirious group (P = 0.046).Delirium is common in young pediatric patients receiving NIV. As previously shown in the invasive mechanical ventilation population, benzodiazepine exposure continues to be a potentially modifiable risk factor for delirium.

Anuranjan Ghimire,1 Gregory S Maves,1,2 Stephani S Kim,1,2 Vidya T Raman,1,2 Joseph D Tobias1,2 1Department of Anesthesiology & Pain Medicine, Nationwide Children’s Hospital, Columbus, OH, USA; 2Department of Anesthesiology & Pain Medicine, the Ohio State University College of Medicine, Columbus, OH, USACorrespondence: Anuranjan Ghimire, Department of Anesthesiology & Pain Medicine, Nationwide Children’s Hospital, 700 Children’s Dr, Columbus, OH, 43235, USA, Tel +1 614-722-4200, Fax: +1 614-722-4203, Email Anuranjan.Ghimire@nationwidechildrens.orgIntroduction: Cancellation of surgery or delay on the day of service is a huge burden for the patient, family, and healthcare system. Preventable delays impact efficiency and workflow, which may increase costs due to overtime and idle rooms during peak hours. Non-compliance to nil per os (NPO) guidelines remains one of the most common preventable causes for surgical cancellations. The current study sought to investigate and understand patient factors that may be associated with non-compliance to NPO guidelines.Methods: After IRB approval, a retrospective review of completed and cancelled pediatric procedures requiring the use of anesthesia over a 5-year period was performed. Emergency procedures and inpatient surgeries were excluded. Data regarding patient demographics and surgical service were extracted from the electronic medical records for comparison. A logistic regression model was used to identify factors associated with cancellations due to NPO non-compliance.Results: There were 825 cancellations due to NPO non-compliance of 144,049 cases for an incidence of 0.57% over the 5-year period. Patients in the 6– 12 year old age range and those who self-identified as non-White or non-English speaking had a higher incidence of cancelling due to NPO non-compliance. Compared to ear, nose, and throat (ENT) procedures, cancellations due to NPO non-compliance were more likely in radiology, dental, and urology procedures.Discussion: Many factors may impact a family’s compliance with NPO guidelines. Patient-related factors included those who self-identified as non-White or non-English speaking. Patients having ENT surgery were less likely to have NPO non-compliance than those having radiologic procedures, dental surgery, or urologic surgery. Future interventions focused on these groups may be most effective in limiting day of surgery cancellations.Keywords: nil per os, pediatric anesthesia, cancellation

Pneumonia is the third most common surgical complication after urinary tract infection and wound infections. In addition to increased mortality, patients who develop postoperative pneumonia have a higher risk of prolonged hospital stay, intensive care unit (ICU) admissions, and higher healthcare costs. Obesity and chronic obstructive pulmonary disease (COPD) are both independent risk factors for the development and severity of postoperative pneumonia, although the combined effect of these comorbidities is unknown. Therefore, we evaluated whether the combination of severe obesity and COPD is associated with an increased risk of postoperative pneumonia.We performed a multicenter retrospective cohort study of 365,273 patients aged 18 - 64 years who were either severely obese (body mass index (BMI) ≥ 40 kg/mThe co-occurrence of severe obesity and COPD appeared to have a protective effect on the risk of postoperative pneumonia. In the presence of COPD, patients with severe obesity were 14% less likely to develop pneumonia compared to their normal-weight counterparts (2.9% vs. 4.4%; adjusted relative risk (RR): 0.76; 95% confidence interval (CI): 0.60, 0.95). In addition, in the presence of COPD, severe obesity conferred a lower risk for requiring an extended length of stay (37.6% vs. 47.9%; adjusted RR: 0.83; 95% CI: 0.78, 0.89).Counterintuitively, the co-occurrence of severe obesity with COPD appeared to buffer the negative impact of COPD on postoperative pneumonia, unplanned tracheal reintubation, and prolonged hospital stay after noncardiac surgery. These findings are consistent with the obesity paradox and warrant further investigations.

Background : Epidural anesthesia in infants undergoing open abdominal surgery has the potential to reduce opioid consumption, lower pain scores, and expedite tracheal extubation. We evaluated associations between use of continuous epidural chloroprocaine and improved intra- and post-operative outcomes. Methods : This matched retrospective cohort study first identified 24 patients who between April 2018 through December 2019 were treated with a caudal catheter and epidural chloroprocaine infusion for a laparotomy at postnatal age of 6 months or less. A matched comparator group of 24 patients was derived based on age and type of surgery. Exclusion criteria were the presence of a preoperative opioid infusion, comorbidities that would preclude appropriate pain assessment, or a recent surgical procedure. Primary outcomes included opioid consumption and pain scores; we secondarily analyzed intraoperative anesthetic requirements, other systemic analgesic use, vital signs, tracheal extubation time, and procedural times. Results : Treatment with epidural anesthesia was associated with lower 5-day total postoperative opioid consumption (3.2 mg/kg vs. 19.7 mg/kg in the respective epidural vs. systemic groups, p = 0.001) and time to tracheal extubation (1.3 days vs. 3.2 days, p = 0.005). Any statistically significant differences in pain scores were not clinically meaningful. There were no differences in mean arterial pressure or intraoperative inhaled anesthetic doses. Conclusion : Continuous infusion of epidural chloroprocaine in infants following open abdominal surgery may limit exposure to systemic opioid medications while providing adequate postoperative analgesia and shortening time to tracheal extubation.

Improved understanding of airway anatomy and refinement of equipment have led to the increased use of cuffed endotracheal tubes (ETTs) in infants and children. Despite expanded evidence on the potential advantages of cuffed ETTs in pediatric patients, there remains limited data on their use in infants less than 5 kilograms (kg). The current study retrospectively evaluates the perioperative use of cuffed ETTs in infants weighing 2-5 kg.This is a retrospective study from a tertiary care children's hospital involving a 3-year period. Data regarding anesthetic care, airway management, and postoperative course were retrospectively retrieved from the electronic medical record.The study cohort included 1162 patients, 1086 of whom had their tracheas intubated with a cuffed ETT and 76 with an uncuffed ETT. Patients were divided into two groups for analysis: 2 to3 kg and 3 to 5 kg. In both weight groups, cuffed ETTs resulted in a decreased need for more than one laryngoscopy and a change in ETT size with no increase in postoperative airway effects including stridor.These data provide additional information regarding the efficacy and safety of cuffed ETTs in neonates and infants.

Various factors may lead to coagulation disturbances following cardiopulmonary bypass and surgery for congenital heart disease. In addition to the risks associated with the administration of allogeneic blood products, persistent disturbances in coagulation function and ongoing bleeding may lead to prolonged surgical times, hemodynamic alterations, intracranial hemorrhage, and even mortality. In most clinical scenarios, coagulation disturbances are treated by targeted blood product therapy including fresh frozen plasma, platelet transfusions, or the administration of cryoprecipitate. When routine blood product therapy fails, coagulation adjuncts such as activated recombinant factor VII or prothrombin complex concentrates (PCCs) may be an option to rapidly replenish depleted coagulation factors and correct coagulation disturbances. The PCC formulations including three-factor PCC, four-factor PCC, and factor eight-inhibitor bypass activator (FEIBA) have been used mainly in the adult population with sporadic case series and anecdotal reports in the pediatric population. The following manuscript discusses the various PCC products available for clinical use, reviews previous reports of their use in infants and children with an emphasis on their role following surgery for congenital heart disease, and outlines their potential role in these clinical scenarios.

To review the results of a postoperative respiratory pathway for patients with muscular dystrophy (MD) and spinal muscular atrophy (SMA) undergoing spinal surgery.With IRB approval, a retrospective review was done on all patients with SMA and MD undergoing spinal surgery on a neuromuscular protocol. Baseline demographics, perioperative results, and long-term outcomes were collected. Per the protocol, patients remained intubated after surgery and were transported to the intensive care unit (ICU) for extubation. We present the results of protocol implementation and compare patients with MD to those with SMA.Twenty-four patients were treated using the protocol. Average age was 13.1 years. Severe restrictive lung disease was present in 75% of patients. Nocturnal BiPAP was required in 68% of patients. Average number of instrumented levels was 17. All patients were immediately extubated upon entering the ICU. There were three respiratory complications and only was patient was re-intubated. Average ICU stay was 1.8 days and average hospital length of stay was 6.7 days. No differences in postoperative inspiratory or expiratory positive airway pressures were observed between the MD and SMA groups.Through a multidisciplinary neuromuscular protocol, excellent clinical outcomes were achieved in patients with neuromuscular scoliosis and restrictive lung disease, with complication rates and length of stay significantly lower than previously published data.IV.

The leading cause of mortality among children is trauma. Race and ethnicity are critical determinants of pediatric postsurgical outcomes, with minority children generally experiencing higher rates of postoperative morbidity and mortality than White children. This pattern of poorer outcomes for racial and/or ethnic minority children has also been demonstrated in children with head and limb traumas. While injuries to the abdomen and pelvis are not as common, they can be life-threatening. Racial and/or ethnic differences in outcomes of pediatric abdominopelvic operative traumas have not been examined. Our objective was to determine whether disparities exist in postoperative mortality among children with major abdominopelvic trauma.We performed a retrospective analysis of the Healthcare Cost and Utilization Project Kids' Inpatient Database for 2003, 2006, 2009, and 2012. Patients were included if they were18 years, sustained a major abdominopelvic injury, and underwent subsequent surgical intervention. Our primary outcome was inpatient mortality, comparing children of different race and/or ethnicity.We identified a weighted cohort of 13,955 children, of whom 6765 (48.5%) were White, 3614 (25.9%) Black, and 2647 (19.0%) Hispanic. After adjusting for covariates, Black children were 94% more likely to die than their White peers (3.3% versus 1.6%, adjusted-RR:1.94, 95%CI: 1.33-2.82, P = 0.001). Hispanic children (adjusted-RR:1.99, 95%CI: 1.36-2.91, P0.001) and those of other race and/or ethnicity (adjusted-RR: 2.02, 95%CI:1.20-3.40, P = 0.008) were also more likely to die compared to their White peers.Black and Hispanic children who require operative intervention following major abdominopelvic trauma have a higher risk of postoperative mortality compared with White children.

Pharmacologic management of chemotherapy-induced peripheral neuropathy (CIPN) in pediatric patients remains a challenge. Without effective treatment to control pain from CIPN in children, reduction or discontinuation of life-saving chemotherapeutic medications may be required. Various combinations of medications are available, but none have been thoroughly evaluated for their effectiveness in managing CIPN in the pediatric population. We present the clinical management of severe CIPN in a 3-year-old child with pre-B acute lymphoblastic lymphoma that was refractory to a regiment that included high-dose gabapentin and opioids. Therapy was subsequently adjusted to include amitriptyline, eliminating the need for opioids with complete resolution of symptoms. The potential combination pharmacotherapies for pediatric CIPN are discussed and mechanisms accounting for inadequate response with monotherapy are presented.

Joanne Du,1 Catherine Roth,2 Sujana Dontukurthy,3 Joseph D Tobias,2,4 Giorgio Veneziano2,4 1The Ohio State University College of Medicine, Columbus, OH, USA; 2Department of Anesthesiology & Pain Medicine, Nationwide Children’s Hospital, Columbus, OH, USA; 3Department of Anesthesiology, Valley Children’s Hospital, Madera, CA, USA; 4Department of Anesthesiology & Pain Medicine, The Ohio State University College of Medicine, Columbus, OH, USACorrespondence: Giorgio Veneziano, Department of Anesthesiology & Pain Medicine, Nationwide Children’s Hospital, 700 Children’s Dr, Columbus, OH, 43205, USA, Tel + 1 614-722-4200, Email Giorgio.Veneziano@nationwidechildrens.orgPurpose: Awake spinal anesthesia continues as an alternative to general anesthesia for infants. Standard clinical practice includes the manual palpation of surface landmarks to identify the desired intervertebral space for lumbar puncture (LP). The current study investigates the accuracy of manual palpation for identifying the intended intervertebral site for LP, using ultrasonography for confirmation and to determine the interspace where the conus medullaris ends.Patients and Methods: After informed parental consent, patients less than one year of age undergoing spinal anesthesia for lower abdominal, urologic, or lower extremity surgical procedures were included. Patients were held in the seated position and an attending pediatric anesthesiologist or pediatric anesthesiology fellow declared the vertebral interspace intended for needle insertion, palpated surface landmarks, and placed a mark at the site. A research anesthesiologist then determined the actual vertebral interspace of the marked site and the location of the conus medullaris using ultrasonography. The time to complete both techniques (manual palpation and ultrasonography) was recorded.Results: The study cohort included 50 infants (median age of 7 months). Sixteen vertebral interspaces (32%) were inaccurately marked. One was marked two spaces higher than intended, ten were marked one space higher than intended, and five were marked one space lower than intended. In one patient, the intended vertebral interspace for the lumbar puncture overlaid the conus medullaris. The median time required was 25 seconds (IQR 14.3, 32) for palpation and 39 seconds (IQR 29, 63.8) for ultrasonography.Conclusion: Manual palpation of surface landmarks to determine the correct interspace for LP for spinal anesthesia in infants is inaccurate. The time required to perform spinal ultrasonography in infants for determination of the optimal site for LP is brief and may be useful in ensuring accurate identification of the correct interspace and the location of the conus medullaris.Keywords: spinal anesthesia, infant, ultrasonography, palpation, lumbar puncture, conus medullaris

Anesthesiologists are important components of volunteer teams which perform congenital cardiac surgery in low-resource settings throughout the world, but limited data exist to characterize the nature and breadth of their work. A survey of Congenital Cardiac Anesthesia Society (CCAS) members was conducted with the objective of understanding the type of voluntary care being provided, its geographic reach, the frequency of volunteer activities, and factors which may encourage or limit anesthesiologists’ involvement in this work. The survey was completed by 108 participants. Respondents reported a total of 115 volunteer trips during the study period, including work in 41 countries on 5 continents. Frequent motivating factors to begin volunteering included invitations from charitable groups, encouragement from senior colleagues, and direct connections to individual locations. Discouraging factors included familial responsibilities, the need to use vacation time, and a lack of support from home institutions. The year 2020 saw a marked decrease in reported volunteer activity, and respondents reported multiple pandemic-related factors which might discourage future volunteer activities. The results of this study demonstrate the global reach of anesthesiologists in providing care for children having cardiac surgery. It also offers insights into the challenges faced by interested individuals, many of which are related to a lack of institutional support. These challenges have only mounted under the COVID-pandemic, leading to a dramatic downturn in volunteer activities. Finally, the survey reinforces the need for better coordination of volunteer activities to optimize clinical impact.

Waardenburg syndrome is a genetic disorder, resulting in defective control of the division and migration of neural crest cells including the melanocyte lineage during embryonic development. Primary involvement of melanocytes results in the characteristic phenotypic involvement including a white forelock, vitiligo, and heterochromia. Involvement of the organ of Corti leads to sensorineural hearing loss. Involvement of the craniofacial mesenchyme results in abnormal facial features, airway abnormality, and upper limb involvement malformations. Given the potential for end-organ involvement, surgical intervention may be required. Specific concerns during anesthetic care include the potential for difficulties with endotracheal intubation, tracheal involvement, impairment of communication related to deafness, and associated congenital heart disease.

Introduction For surgical procedures involving the hip and femur, various regional anesthetic techniques may be used to provide analgesia. Although there has been an increase in the use of lumbar plexus block (LPB), the technique may be time consuming and associated with complications. Suprainguinal fascia iliaca compartment block (FICB) is a potentially easier and safer alternative. The current study prospectively compares LPB with suprainguinal FICB. Methods This prospective, double-blinded, randomized, study included patients undergoing elective orthopedic procedures of the hip and/or femur. All study patients received general anesthesia with randomization to either an LPB or suprainguinal FICB using 0.5% ropivacaine with epinephrine and dexamethasone. Postoperative pain control was achieved with intravenous hydromorphone delivered by patient-controlled analgesia with scheduled acetaminophen and ketorolac. Outcome data included time to perform the block, perioperative opioid consumption, postoperative pain scores (VAS) and hospital length of stay. Results The study cohort included 15 patients between the ages of 7 and 16 years (LPB N = 7, FICB N = 8). The median block time was 6 minutes (IQR: 4.11) for the LPB group and 3 minutes (IQR: 3.6) for the FICB group (p = 0.107). Median postoperative pain scores were 4 (IQR: 0.6) for the LPB group and 2 (IQR: 0.5) for the FICB group (p = 0.032). There were no differences in the intraoperative or postoperative opioid and NSAID use between the two groups. Discussion The suprainguinal FICB provides analgesia that is at least as effective as a LPB following hip and femur surgery. Time to perform the block was shorter with the FICB due to the supine patient position and limited needle trajectory. Although we noted no adverse effects, the superficial needle trajectory of the FICB offers a less invasive approach and the potential for decreased risks of adverse effects.

Tetanus is a potentially fatal infectious disease caused by the toxins produced by the anaerobic bacterium, Clostridium tetani. Of major concern during the perioperative care of these patients is control of muscle spasms, skeletal rigidity, and autonomic dysfunction. Several of the modern sedative and opioid agents including remifentanil have not been fully evaluated in managing tetanus. We present the intraoperative use of remifentanil in a 75-year-old woman with generalized tetanus who required anesthetic care during placement of a tracheostomy. The end-organ involvement of tetanus is presented, previous reports of anesthetic care reviewed, and the potential utility of remifentanil explored.

Severing of the pilot balloon of an endotracheal tube (ETT) results in cuff deflation and may lead to complications including inadequate patient ventilation, increased risk of aspiration and infection, and operating room air pollution with anesthetic gases. In situations where ETT exchange or reintubation may pose a significant risk to the patient, temporary repair of the severed cuff tubing can be helpful until it is safe to address the problem with replacing the ETT. Simple and effective repair methods can be achieved using readily available materials in the operating room, including intravenous cannulas, hypodermic syringes, and epidural clamp connectors. However, choosing which technique or method depends mainly on personal preference, equipment availability, and provider comfort and experience. We present a 12-year-old adolescent who presented for anesthetic care for extensive burn injury. During removal of the dressing around the head and face, the tubing of the pilot balloon of the ETT was inadvertently cut. Options for dealing with such problems are discussed, including techniques to allow for temporary repair and re-inflation of the deflated cuff.

Alok Moharir,1,2 Joseph D Tobias1,2 1Department of Anesthesiology & Pain Medicine, Nationwide Children’s Hospital, Columbus, OH, USA; 2Department of Anesthesiology & Pain Medicine, The Ohio State University College of Medicine, Columbus, OH, USACorrespondence: Alok MoharirDepartment of Anesthesiology & Pain Medicine, Nationwide Children’s Hospital, 700 Children’s Drive, Columbus, OH, 43205, USATel +1 614 722-4200Fax +1 614 722-4203Email Alok.Moharir@Nationwidechildrens.orgAbstract: Point-of-care ultrasound is a growing field within anesthesiology as well as several other medical and surgical specialties. The recent development of handheld ultrasound devices has the potential to expand the use or this technology by decreasing the cost and increasing accessibility for the healthcare provider. These handheld devices may be used to assist with education, training, and even direct patient care. We outline our process for using a handheld ultrasound device, the Lumify, to assist in the completion of a point-of-care ultrasound certificate program offered by the American Society of Anesthesiologists. We outline the unique advantages of this device as it relates to cost, portability, and applicability of its web-based technology compared to a traditional standalone ultrasound machine for the completion of this course.Keywords: ultrasound, point-of-care ultrasound, POCUS, hand-held

Although the prevalence of obesity in the general population and its perioperative implications among children undergoing inpatient surgeries are well known, little is known about obesity prevalence among children scheduled for ambulatory surgery.Here, we report the trends of obesity and severe obesity among children who underwent ambulatory surgery across multiple centers in the United States and explore the association of obesity status with admission following elective ambulatory surgery.Using data from the American College of Surgeons National Surgical Quality Improvement Program-Pediatric (2012-2019), we selected children 2-18 years old who underwent outpatient surgical procedures under general anesthesia and had documented height, weight, and body mass index (BMI) data. We estimated the prevalence of overweight, obesity (class 1), and severe obesity (class 2 and class 3) patients and explored their association with same-day hospital admission, defined as hospital length of stay ≥1 day.Data from 152 918 children (mean age: 9.7 ± 4.7 years) were analyzed. Of these, 16.4% (n = 25 007) were overweight, 13.8% (n = 21 085) were class 1 obese, 5.2% (n = 7879) were class 2 obese, and 3.0% (n = 4623) were class 3 obese. From 2012 to 2019, class 2 or 3 obesity prevalence increased by 26.7% and 32.5%, respectively. Overweight and obese children had relatively higher odds of same-day hospital admission compared to healthy weight children (overweight odds ratio [95% confidence interval]: 1.05 [1.02, 1.08]; class 1 obesity: 1.04 [1.00, 1.07]; class 2 obesity: 1.09 [1.02, 1.16]; class 3 obesity: 1.20 [1.11, 1.30]).The burden of obesity continues to increase in children scheduled for ambulatory surgery. Children with class 2 and class 3 obesity have higher rates of same-day hospital admission following elective ambulatory surgery compared to healthy weight children, a factor that should be considered in scheduling these patients.