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Author(s): Rekha Varghese [1]; Geethu Sebastian [1]; Dimple E. Thomas [1]; Lakshmi Kumar (corresponding author) [1] Dear Editor, Ex-utero intrapartum therapy (EXIT) allows the survival of children with congenital high [...]

The analysis of survey data is a frequently arising issue in clinical trials, particularly when capturing quantities which are difficult to measure. Typical examples are questionnaires about patient's well‐being, pain, or consent to an intervention. In these, data is captured on a discrete scale containing only a limited number of possible answers, from which the respondent has to pick the answer which fits best his/her personal opinion. This data is generally located on an ordinal scale as answers can usually be arranged in an ascending order, for example, "bad", "neutral", "good" for well‐being. Since responses are usually stored numerically for data processing purposes, analysis of survey data using ordinary linear regression models are commonly applied. However, assumptions of these models are often not met as linear regression requires a constant variability of the response variable and can yield predictions out of the range of response categories. By using linear models, one only gains insights about the mean response which may affect representativeness. In contrast, ordinal regression models can provide probability estimates for all response categories and yield information about the full response scale beyond the mean. In this work, we provide a concise overview of the fundamentals of latent variable based ordinal models, applications to a real data set, and outline the use of state‐of‐the‐art‐software for this purpose. Moreover, we discuss strengths, limitations and typical pitfalls. This is a companion work to a current vignette‐based structured interview study in pediatric anesthesia. [ABSTRACT FROM AUTHOR]

ABSTRACT Background Aims Methods Results Conclusions The field of pediatric anesthesiology faces an impending shortage of fellowship‐trained physicians. Despite this projection, fewer anesthesiology residents are opting to pursue a fellowship. To better understand the current perspective and motivation of trainees to pursue a career in pediatric anesthesiology, we surveyed anesthesiology residents across the United States.Our primary aims were to assess the understanding of the current workforce shortage as well as explore the impact of both exposure and characteristics of the anesthesia resident rotation on the decision to pursue pediatric anesthesiology fellowship.A 25‐question Qualtrics survey was distributed to members of the Pediatric Anesthesia Leadership Council and Education Committee within the Society for Pediatric Anesthesia and to anesthesiology residency program directors based in the United States.The survey received 201 responses. Of the respondents, 29% were in Clinical Anesthesia Year 3, 25% in Year 2, 19% in Year 1, and 10% in their intern year. The analysis revealed that self‐reported adequate exposure to high‐acuity cases and advanced procedures (arterial lines, central lines, and nerve blocks) significantly increased the likelihood of planning to pursue pediatric anesthesiology fellowship (adjusted Odd Ratio 8.47, 95% Confidence Interval, 1.65–43.4). Perceptions of faculty teaching, mentor availability, planned practice environment, and the presence of fellowship programs at the institution were not significantly associated with intentions to pursue pediatric anesthesiology fellowship.The journey toward specializing in pediatric anesthesiology is influenced by a complex interplay of factors. Among these, enhanced exposure to challenging cases and advanced procedures during the residency phase is emerging as a critical element. Such exposure not only equips residents with the necessary skills and confidence to handle complex pediatric anesthesia cases but also plays a pivotal role in attracting more trainees to this essential subspecialty. [ABSTRACT FROM AUTHOR]

ABSTRACT Background Aims Methods Results Conclusions Clinical Implications Transgender and gender‐diverse individuals experience higher burdens of health disparities compared to their cisgender counterparts. Contributing factors include decreased access and denial of care, experiences and fear of medical violence, and increasing legislative barriers. These patients often report having to educate healthcare professionals due to lack of expertise of transgender and gender‐diverse issues within the medical community, with training deficits observed at all levels of medical training.We surveyed pediatric anesthesiology fellowship directors in the United States and Canada with an aim to describe the current state of transgender and gender‐diverse topics within diversity, equity, and inclusion curricular content across pediatric anesthesiology fellowship training programs.A 25‐question descriptive, cross‐sectional, electronic survey was created and distributed to all pediatric anesthesiology fellowship program directors in the United States and Canada investigating the inclusion of transgender and gender‐diverse topics within diversity, equity, and inclusion curriculum (if present) for pediatric anesthesiology fellows.A total of 33 responses were collected from 69 total invited programs. Diversity, equity, and inclusion curricula were present in 93.5% (29/31) of fellowship programs but only 29% (9/31) of programs included content specific to transgender and gender‐diverse populations. Just 17% (5/29) of program directors thought their curriculum adequately prepared their graduates to care for transgender and gender‐diverse patients. However, 69% (20/29) expressed a desire to see more educational content included in the future. Lack of knowledgeable faculty educators and time were the most chosen perceived barriers to inclusion.To our knowledge, this study is the first to evaluate pediatric anesthesiology fellowship curricula for inclusion of transgender and gender‐diverse topics within diversity, equity, and inclusion curriculum. As the population of known transgender and gender‐diverse youth increases, all pediatric anesthesiologists must be equipped to treat this population with appropriate clinical and cultural sensitivity. Future endeavors must include robust sexual orientation and gender identity data collection, access to educational materials from content experts, recruitment and empowerment of LGBTQ+ anesthesiologists, and increased dedicated time toward diversity, equity, and inclusion education, specifically in regard to the transgender and gender‐diverse population.Lack of physician education on the care of transgender and gender‐diverse patients is one of several factors contributing to the health disparities seen in this population; training deficits in the care of transgender and gender‐diverse patients have been observed in all levels of medical training. Our data show a critical deficiency of transgender and gender‐diverse topics within diversity, equity, and inclusion curricular content in pediatric anesthesiology fellowships in the United States and Canada and identify potential barriers to the inclusion of such content. [ABSTRACT FROM AUTHOR]

Aim While bradycardia in children with Down syndrome (DS) during inhalation induction of anesthesia is characteristic, its mechanism is not well understood. This study investigated sympathetic failure as a potential (and modifiable) mechanism of bradycardia. Materials and Methods Ninety-three children with DS and 102 typically developing (TD) children underwent inhalation induction of anesthesia. These children were monitored for sympathetic activity, exposed to sevoflurane anesthetic and were observed for the development of bradycardia. The primary outcome was sympathetic failure in the context of normoxic bradycardia within the first 300 seconds of induction. Secondary outcome measures included hypotension and parasympathetic excess. Results During the first 300 seconds of induction, 54 DS children became bradycardic (54/93, 58%) while 22 TD children became bradycardic (22/102, 22%). In the DS group, 23 experienced hypotension (23/80, 29%). Of those who experienced hypotension, 15 also experienced sympathetic failure (15/28, 54%). Conclusion More than half of children with DS undergoing inhalation anesthesia induction with sevoflurane experienced bradycardia. Bradycardia and hypotension were associated with sympathetic failure. Sympathetic activity therefore appears to be a modifiable target in the prevention of bradycardia in children with DS. Keywords:Down syndrome, pediatric anesthesia, autonomic nervous system diseases, sevoflurane: [ABSTRACT FROM AUTHOR]

Background: Cuffed endotracheal tubes (cETT) pose the potential advantage of an infrequent need for reintubation in pediatric patients compared to uncuffed tubes. The aim of this study was to investigate tube exchange rates using second generation Microcuff® pediatric endotracheal tubes (PET) with an adapted sizing recommendation in a large single institution cohort of children and to identify potential variables associated with an elevated risk of tube exchange. Methods: Patient data obtained from the electronic patient data management system of the Department of Anesthesia, University Children's Hospital Zurich, Switzerland, were retrospectively assessed for demographic and anthropometric information, size of the internal tube diameter used for positive pressure ventilation and divergence from the size recommendation chart. Results: Data from 14,188 children younger than 16 years (median 5.3 years) and weighing at least 3 kg who underwent oral or nasal tracheal intubation using second generation Microcuff® PET between 2009 and 2015 were included. Of 13,219 oral tracheal intubations 12,049 (84.9%) were performed according to the manufacturer's size recommendation and 1170 with divergent endotracheal tubes. The odds ratio (OR) of oral reintubation was 0.13% (95% confidence interval 0.08–0.22%) for cases using the manufacture's size recommendation correctly and 22.74% (95% confidence interval 20.42–25.23%) for patients intubated with a not recommended tube (p < 0.0001). Conclusion: These findings indicate that the second generation Microcuff® PETs can be reliably used with low tube exchange rates across the entire pediatric age range when the tube size is selected according to the manufacturer's size recommendation chart. Adherence to the manufacturer's tube size recommendation is urgently advised. [ABSTRACT FROM AUTHOR]

The article discusses the considerations and challenges in planning anesthesia for children with trisomy 21, highlighting the increased risk of complications due to their unique anatomical and physiological characteristics. Topics include airway management challenges, the use of sevoflurane and its associated risks, and the importance of preoperative assessment and emergency readiness when planning anesthesia for these children.

Background: The Nociception Level Index has shown benefits in estimating the nociception/antinociception balance in adults, but there is limited evidence in the pediatric population. Evaluating the index performance in children might provide valuable insights to guide opioid administration. Aims: To evaluate the Nociception Level Index ability to identify a standardized nociceptive stimulus and the analgesic effect of a fentanyl bolus. Additionally, to characterize the pharmacokinetic/pharmacodynamic relationship of fentanyl with the Nociception Level Index response during sevoflurane anesthesia. Methods: Nineteen children, 5.3 (4.1–6.7) years, scheduled for lower abdominal or urological surgery, were studied. After sevoflurane anesthesia and caudal block, a tetanic stimulus (50 Hz, 60 mA, 5 s) was performed in the forearm. Following the administration of fentanyl 2 μg/kg intravenous bolus, three similar consecutive tetanic stimuli were performed at 5‐, 15‐, and 30‐min post‐fentanyl administration. Changes in the Nociception Level Index, heart rate, mean arterial pressure, and bispectral index were compared in response to the tetanic stimuli. Fentanyl plasma concentrations and the Nociception Level Index data were used to elaborate a pharmacokinetic/pharmacodynamic model using a sequential modeling approach in NONMEM®. Results: After the first tetanic stimulus, both the Nociception Level Index and the heart rate increased compared to baseline (8 ± 7 vs. 19 ± 10; mean difference (CI95) −12(−18–−6) and 100 ± 10 vs. 102 ± 10; −2(−4–−0.1)) and decrease following fentanyl administration (19 ± 10 vs. 8 ± 8; 12 (5–18) and 102 ± 10 vs. 91 ± 11; 11 (7–16)). In subsequent tetanic stimuli, heart rate remained unchanged, while the Nociception Level Index progressively increased within 15 min to values similar to those before fentanyl. An allometric weight‐scaled, 3‐compartment model best characterized the pharmacokinetic profile of fentanyl. The pharmacokinetic/pharmacodynamic modeling analysis revealed hysteresis between fentanyl plasma concentrations and the Nociception Level Index response, characterized by plasma effect‐site equilibration half‐time of 1.69 (0.4–2.9) min. The estimated fentanyl C50 was 1.93 (0.73–4.2) ng/mL. Conclusion: The Nociception Level Index showed superior capability compared to traditional hemodynamic variables in discriminating different nociception‐antinociception levels during varying fentanyl concentrations in children under sevoflurane anesthesia. [ABSTRACT FROM AUTHOR]

Background: Children undergoing outpatient surgery are at risk of inadequate postoperative pain control. Methadone has a long duration of action and an intraoperative dose may provide stable analgesia throughout the postoperative period. Intraoperative methadone has been shown to improve pain control in adolescents but its use for postoperative pain in pediatric patients undergoing outpatient surgery has not been studied before. Therefore, we conducted a double‐blind randomized placebo‐controlled trial to investigate the effects of a single dose of intraoperative methadone in children aged less than 5 years undergoing orchiopexy for undescended testis. Methods: A total of 68 children were randomized to receive either methadone (0.1 mg/kg) or isotonic saline following induction of anesthesia. Exclusion criteria included preterm birth, previous scrotal surgery, and parents' inability to consent. Primary outcomes were opioid requirements (first primary outcome) and pain intensity in the post‐anesthesia care unit. Secondary outcomes included episodes of desaturation and time until readiness to discharge from the post‐anesthesia care unit, sleep on the first postoperative night, pain intensity, and opioid requirements at home until the evening on the first postoperative day. Follow‐up was 4 days. Results: Sixty children completed the study (age, mean ± SD, 26.2 ± 13.9 months), 29 children received methadone, and 31 children received placebo. Eighteen children required opioids in the post‐anesthesia care unit, five children in the methadone group (proportion = 0.17, 95% confidence interval (CI): 0.07, 0.36) compared to thirteen patients in the placebo group (0.42, 95% CI: 0.26, 0.60) (mean difference = −0.24 and 95% CI: −0.03, −0.47) (p = 0.037). Five children in the methadone group (0.17, 95% CI: 0.03, 0.31) versus ten in the placebo group (0.32, 95% CI: 0.16, 0.49) had a face, legs, activity, cry, consolability score of ≥5 in the post‐anesthesia care unit (mean difference = −0.15, 95% CI: −0.36, 0.06) (p =.179). More children in the placebo group woke up due to pain the first night following surgery (seven children vs. one child). The methadone group had a longer stay in the post‐anesthesia care unit. There were no differences between the two groups regarding the other secondary outcomes. Conclusion: A single dose of intraoperative methadone reduces short‐term postoperative opioid requirements in children after orchiopexy for nondescended testes but prolongs the duration of their stay in the post‐anesthesia care unit. [ABSTRACT FROM AUTHOR]

Background: Dexmedetomidine, an α2‐adrenergic agonist, reduces propofol and remifentanil requirements when used as an adjunct to total intravenous anesthesia in adults, but studies in a pediatric population are sparse. This study investigates the magnitude of dose‐sparing effects of a postinduction dexmedetomidine bolus on propofol and remifentanil requirements during pediatric surgery. Methods: In this randomized, double‐blind, controlled trial, children aged 2–10 years undergoing elective dental surgery were assigned to one of four groups: placebo, 0.25 mcg/kg dexmedetomidine, 0.5 mcg/kg dexmedetomidine, and 1 mcg/kg dexmedetomidine. Maintenance with fixed‐ratio propofol and remifentanil total intravenous anesthesia followed a bispectral index (BIS)‐guided algorithm designed to maintain a stable depth of anesthesia. The primary outcomes were time‐averaged maintenance infusion rates of propofol and remifentanil. Secondary outcomes in the postanesthetic care unit included sedation scores, pain scores, and time to discharge. Results: Data from 67 patients were available for analysis. The median [interquartile range] propofol infusion rate was lower in the 1 mcg/kg dexmedetomidine group (180 [164–185] mcg/kg/min) versus placebo (200 [178–220] mcg/kg/min): percent change −10.0%; 95% CI −2.4 to −19.8; p = 0.013. The remifentanil infusion rate was also lower in the 1 mcg/kg dexmedetomidine group (0.089 [0.080, 0.095] mcg/kg/min) versus placebo (0.103 [0.095, 0.106] mcg/kg/min): percent change, −13.7%; 95% CI −5.47 to −21.0; p =.022. However, neither propofol nor remifentanil infusion rates were significantly different in the 0.25 or 0.5 mcg/kg dexmedetomidine groups. In the postanesthesia care unit, there were no differences in pain or sedation scores, and time to discharge was not significantly prolonged in any dexmedetomidine group. Conclusion: Dexmedetomidine 1 mcg/kg reduced the propofol and remifentanil requirements during maintenance of anesthesia in children when administered as a postinduction bolus. Trials Registration: ClinicalTrials.gov: NCT03422978, date of registration 2018‐02‐06. [ABSTRACT FROM AUTHOR]

Introduction: Postoperative agitation is a common complication of sevoflurane anesthesia in children and might lead to self-harm and recovery disruption. This study aimed to compare the prophylactic effect of dexmedetomidine and remifentanil on postoperative agitation after anesthesia with sevoflurane. Methods: In this clinical trial, 60 children aged 2 to 7 years with ASA class І, II, candidates for elective strabismus surgery, were randomly assigned to three groups using block randomization. Patients in the first group D received 0.5 µgr/kg dexmedetomidine, the second group R received 0.1 µgr/kg remifentanil, and another group C received normal saline at the end of anesthesia. Children's agitation degree was measured by the Pediatric Anesthesia Emergence Delirium (PAED) scales and the 4-point agitation scale at the time of extubation, entering the recovery room, 10, 20, and 30 minutes after entrance. Data analysis was performed using descriptive and inferential statistical tests. Results: The postoperative agitation and pain were significantly lower among children who received dexmedetomidine compared with those in remifentanil and the control group (p <.001). It was observed that the administration of dexmedetomidine at the end of anesthesia significantly decreased the incidence of postoperative agitation (p <.001). None of the patients in group D had a PAED score of over 12. Conclusion: Based on PAED and the 4-point scales, none of the cases in group D had experienced postoperative agitation; this made a significant statistical difference compared with groups C and R (p-value <. 001). Although both dexmedetomidine and remifentanil can prevent and attenuate postoperative agitation, dexmedetomidine administration seems significantly more effective. [ABSTRACT FROM AUTHOR]

ABSTRACT Background Aim Methods Results Conclusion Emergence delirium is a well‐known and common problem in children recovering from anesthesia. The five‐item Pediatric Anesthesia Emergence Delirium scale is one of the most commonly used instruments for assessing this condition, but the scale has been questioned regarding its latent structure, i.e., whether its items cover just one underlying construct. It has been suggested that the scale's first three items might identify emergence delirium better than the last two.The aim of this study was to evaluate the measurement properties of the Pediatric Anesthesia Emergence Delirium scale with a focus on its latent structure and cutoff scores, using appropriate statistical methods for ordinal data.A total of 350 children under 7 years of age, undergoing adenoidectomy, with or without additional tonsillotomy or minor procedures like paracentesis, tongue‐tie release, or cerumen removal, were enrolled in the study. At the recovery unit, emergence delirium and pain were registered.The confirmatory factor analyses demonstrated that the two‐factor model, including emergence delirium‐specific behaviors (first three items) and emergence delirium‐nonspecific behaviors (last two items), established an excellent model fit according to the χ2 goodness‐of‐fit statistics, Root Mean Square Error of Approximation, Comparative Fit Index, Tucker‐Lewis Index, and Standardized Root Mean Square Residual. The ordinal alpha of 0.98 and the ordinal omega of 0.96 supported the internal consistency reliability of the emergence delirium‐specific behaviors. The convergent validity was supported due to a strong correlation between emergence delirium‐nonspecific behaviors and the Face, Legs, Activity, Cry, and Consolability scale. The receiver‐operating characteristic curve analyses resulted in two tentative cutoff scores for emergence delirium‐specific behaviors¸ ≥ 6 and ≥ 8.The Pediatric Anesthesia Emergence Delirium scale's first three items are a more valid and reliable measure of emergence delirium than its original five items. [ABSTRACT FROM AUTHOR]

ABSTRACT Enhanced recovery after surgery (ERAS) pathways have been shown to improve patient outcomes, increase patient satisfaction, and decrease costs. First created and implemented in the adult population, these pathways are now commonplace and continue to expand in the pediatric realm. While there are many proven benefits to ERAS pathways, there continue to be challenges to their proper implementation and long‐term success. This article aims to explore common challenges in pediatric ERAS development and implementation, along with strategies to avoid potential pitfalls. Key themes include departmental and institutional support, stakeholder engagement, awareness of pathways, data management and dissemination, and long‐term maintenance including Plan‐Do‐Study‐Act (PDSA) cycles. Pathway development teams should be aware of these considerations and potential pitfalls, and focusing on them can promote long‐term success for a well‐designed pathway. [ABSTRACT FROM AUTHOR]

Pediatric regional anesthesia is evolving with new peripheral nerve blocks and techniques aimed at improving perioperative pain management. While caudal blocks have long been standard due to their simplicity and low complication rates, newer fascial plane blocks offer comparable efficacy with enhanced nerve coverage tailored to specific surgeries. Moreover, adjuncts like dexmedetomidine and dexamethasone have shown promise in prolonging block duration and enhancing post-operative pain relief and patient satisfaction. The integration of these advancements into clinical practice has yielded significant benefits, including reduced intraoperative fluid requirements, decreased reliance on opioids postoperatively, earlier initiation of enteral nutrition, lower readmission rates, shorter hospital stays, and decreased overall hospital costs. Our review underscores the technical progress and expanding literature supporting the rapid adoption of these impactful regional anesthesia techniques in pediatric care. [ABSTRACT FROM AUTHOR]

Background Aims Methods Results Conclusions Comprehensive data on pediatric anesthesia outcomes, particularly severe critical events (SCEs), are scarce in Asia. This highlights the need for standardized research to assess anesthesia safety and quality in the diverse settings.The PEACH in Asia pilot study aimed to test the feasibility of a standardized protocol for investigating SCEs in anesthesia practices across Asia, evaluate the data acquisition processes, and determine the sample size for a main study.This multicenter pilot study involved ten institutions across nine Asian countries, including children from birth to 15 years undergoing diagnostic or surgical procedures. Data on SCEs were collected using standardized definitions. The study assessed the feasibility and estimated the sample size needed for the main study.The pilot study enrolled 330 patients, with a SCE incidence of 12.4% (95% CI: 9.2–16.4%). Respiratory events were observed in 7.0% of cases, cardiovascular instability in 4.9%, and drug errors in 0.6%. Based on the SCE incidence observed in the pilot study, the estimated sample size required for the main study is at least 10 958 patients. The pilot study demonstrated the feasibility of the study protocol but identified several challenges, particularly in resource‐limited settings. These challenges included a significant burden associated with data collection, technical issues with electronic case report forms (e‐CRFs), variability in patient enrollment across institutions (ranging from 4 to 86 patients per site), and incomplete data acquisition (24.8% of height data and 9.7% of disposition data were missing).The PEACH in Asia pilot study successfully validated a protocol for investigating SCEs in pediatric anesthesia across Asia. Addressing the challenges identified in the pilot study will be crucial for generating robust data to improve pediatric anesthesia safety in the region. Key issues to address include improving data collection methods, resolving e‐CRF technical difficulties, and ensuring consistent institutional support. [ABSTRACT FROM AUTHOR]

Background: The drug volume to be used in caudal in pediatric patients has remained an unmet issue since long. We determined the minimum drug volume required to reach T10 level in pediatric patients using ultrasonography and compared it with the already established volume by Armitage formula. Aim: To determine the minimum effective caudal local anesthetic dose using ultrasound guidance. Methods: Study was performed at two centres and at each centre, 50 pediatric patients (Total 100 patients), aged 1 to 3 years, undergoing below umbilical surgeries were included and randomised into two groups of 25 each (Total 50) to receive ultrasound guided drug volume vs. Armitage formula based volume. The volume required to reach T10 level was assessed with ultrasound in one group. Also, maximum height achieved, cutaneous level achieved after 15 min, FLACC scores 30 min post extubation and parental satisfaction scores were noted. Results: The mean drug volume required to reach T10 level in Group U was 0.755 ± 0.053 ml/kg with a P value < 0.001. (Compared to the drug volume of 1 ml/kg using one sample t test). The highest level achieved in both groups were calculated as the mode value of T8 and T7 in Group U and Group A respectively. The highest cutaneous level achieved after 15 min was also calculated as the mode value of T4 in both groups. FLACC scores at 30 min were also comparable. Satisfaction scores were comparable in both groups. Conclusion: A volume of 0.7 ml/kg of local anaesthetic in pediatric caudal block is sufficient to achieve a target of T10 level for infraumblical surgeries. [ABSTRACT FROM AUTHOR]

Intraoperative hypotension is a common perioperative complication in pediatric anesthesia. Oscillometric blood pressure measurement is therefore an essential part of standard perioperative monitoring in pediatric anesthesia. The optimum measurement site is the upper arm. Attention must be paid to the correct cuff size. Blood pressure should be measured before induction. In children undergoing major surgery or in critically ill children, invasive blood pressure measurement is still the gold standard. Continuous noninvasive measurement methods could be an alternative in the future. Threshold values to define hypotension remain unknown, even in awake children. There are also little data on hypotension thresholds in the perioperative setting. The most reliable measurement parameter for estimating hypotension is the mean arterial pressure. The threshold values for intraoperative hypotension are 40 mm Hg in newborns, 45 mm Hg in infants, 50 mm Hg in young children and 65 mm Hg in adolescents. Treatment should be initiated at a deviation of 10% and intensified at a deviation of 20%. Bolus administration of isotonic balanced crystalloid solutions, vasopressors and/or catecholamines are used as treatment options. Consistent and rapid intervention in the event of hypotension appears to be crucial. So far there is no evidence as to whether this leads to an improvement in outcome parameters. [ABSTRACT FROM AUTHOR]

Introduction: This quality improvement initiative is a continued pursuit to optimize outcomes by iteratively improving our opioid sparing anesthesia protocol for tonsillectomy with or without adenoidectomy at our pediatric ambulatory surgical center through data driven Plan‐Do‐Study‐Act cycles. Methods: From 1/2015 through 12/2023, our standardized tonsillectomy protocol underwent nine procedure‐specific perioperative Plan‐Do‐Study‐Act cycles, three procedure‐specific postoperative prescription Plan‐Do‐Study‐Act cycles, and four general ambulatory surgical center enhanced recovery Plan‐Do‐Study‐Act cycles. We analyzed data from the medical record using statistical process control charts. The primary outcome measure was the percent of patients requiring intravenous opioid in the post anesthesia care unit. Secondary outcomes included maximum post anesthesia care unit pain score, the percent of patients requiring treatment for nausea and/or vomiting in the post anesthesia care unit, and the number of postoperative opioid prescription dosages. Balancing measures were average post anesthesia care unit length of stay, percent of patients with prolonged Post Anesthesia Care Unit length of stay (>120 min), and 30‐day reoperation rate. Results: A total of 5654 tonsillectomy with or without adenoidectomy cases were performed at our ambulatory surgical center from 2015 to 2023. The incidence of intravenous opioid administered in the post anesthesia care unit initially rose with opioid free anesthesia launch, but subsequently decreased below the target of 10%. Maximum post anesthesia care unit pain scores rose from mean 3.6 to 4.5, but subsequently returned to the baseline of 3.5, while the incidence of postoperative nausea and/or vomiting improved. The average post anesthesia care unit length of stay increased by 10 min with opioid free anesthesia; however, prolonged post anesthesia care unit stay and 30‐day reoperation rates were unchanged. Conclusions: The continued refinement of our opioid sparing anesthesia protocol has led to reduced perioperative and home opioid use, stable maximum post anesthesia care unit pain scores, and improved postoperative nausea and vomiting rates, with only a slight increase in mean post anesthesia care unit length of stay. [ABSTRACT FROM AUTHOR]

Patients with congenital heart disease are living longer due to improved medical and surgical care. Congenital heart disease encompasses a wide spectrum of defects with varying pathophysiology and unique anesthetic challenges. These patients often present for noncardiac surgery before or after surgical repair and are at increased risk for perioperative morbidity and mortality. Although there is no singular safe anesthetic technique, identifying potential error traps and tailoring perioperative management may help reduce morbidity and mortality. In this article, we discuss five error traps based on the collective experience of the authors. These error traps can occur when providing perioperative care to patients with congenital heart disease for noncardiac surgery and we present potential solutions to help avoid adverse outcomes. [ABSTRACT FROM AUTHOR]

Introduction: Atelectasis is a well-documented complication in pediatric patients undergoing general anesthesia. Its incidence varies significantly based on surgical procedures and anesthesia techniques. Inhalation induction, commonly used to avoid the discomfort of venipuncture, is suspected to cause higher rates of respiratory complications, including atelectasis, compared to intravenous induction. This study aimed to evaluate the impact of inhalation versus intravenous anesthesia induction on atelectasis formation in pediatric patients, as assessed by lung ultrasound (LUS). Methods: This propensity score-matched observational study was conducted at a tertiary pediatric hospital in Milan, Italy. Inclusion criteria were children ≤ 18 years undergoing elective surgery with general anesthesia. Patients were divided into inhalation and intravenous induction groups. LUS was performed before and after anesthesia induction to assess lung aeration. The primary endpoint was the global LUS score post-induction, with secondary endpoints including the incidence and distribution of atelectasis. Results: Of the 326 patients included, 65% underwent inhalation induction and 35% intravenous induction. The global LUS score was significantly higher in the inhalation group (12.0 vs. 4.0, p < 0.001). After propensity score matching (for age, presence of upper respiratory tract infection, duration of induction, and PEEP levels at induction), average treatment effect (ATE) of mask induction was 5.89 (95% CI, 3.21–8.58; p < 0.001) point on LUS global score and a coefficient of 0.35 (OR 1.41) for atelectasis. Discussion: Inhalation induction is associated with a higher incidence of atelectasis in pediatric patients also when we adjusted for clinically relevant covariates. Trial registration: ClinicalTrials.gov identifier: NCT06069414. [ABSTRACT FROM AUTHOR]

Introduction: Nonoperating room anesthesia is a growing field of medicine that can have an increased risk of complications, particularly in low‐ and middle‐income countries. Aims: The aim of this study was to describe the incidence of complications after pediatric nonoperating room anesthesia and investigate its risk factors. Methods: In this prospective observational study, we included all children aged less than 5 years who were sedated or anesthetized in the radiology setting of a university hospital in a low‐ and middle‐income country. Patients were divided into two groups: complications or no‐complications groups. Then, we compared both groups, and univariable and multivariable logistic regression models were used to investigate the main risk factors for complications. Results: We included 256 children, and the incidence of complications was 8.6%. The main predictors of nonoperating room anesthesia‐related morbidity were: critically‐ill children (aOR = 2.490; 95% CI: 1.55–11.21), predicted difficult airway (aOR = 5.704; 95% CI: 1.017–31.98), and organization insufficiencies (aOR = 52.6; 95% CI:4.55–613). The preanesthetic consultation few days before NORA protected against complications (aOR = 0.263; 95%CI: 0.080–0.867). Conclusions: The incidence of complications during NORA among children in our radiology setting remains high. Investigating predictors for morbidity allowed high‐risk patient selection, which allowed taking precautions. Several improvement measures were taken to address the organization's insufficiencies. [ABSTRACT FROM AUTHOR]

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]

Pediatric patients who undergo spinal corrective surgery often require multiple blood product transfusions. The use of antifibrinolytics, especially tranexamic acid (TXA), to mitigate intraoperative blood loss has increased in popularity. The goal of this quality improvement project was to evaluate provider compliance with a TXA dosing protocol during pediatric corrective spine procedures. A retrospective chart review was conducted to compare pre- and postimplementation data on cell saver and packed red blood cell (PRBC) administration and dose of antifibrinolytic administered. A total of 486 patients (68% idiopathic and 32% neuromuscular) were evaluated over a 9-year period. Following implementation of the protocol, patients of idiopathic origin experienced a 20% reduction in cell saver administration, a 10% reduction in PRBC administration, and a 37% increase in provider compliance with the dosing protocol. Patients of neuromuscular origin experienced a 53% increase in provider compliance with the recommended TXA dosing protocol; however, this patient population did not experience a statistically significant reduction in transfusion requirements. Implementation of an antifibrinolytic protocol can facilitate compliance with recommended TXA dosing parameters and potentially decrease intraoperative blood loss, reducing blood product transfusion requirements. [ABSTRACT FROM AUTHOR]

Quadratus lumborum block is an efective truncal block for postoperative analgesia in patients undergoing abdominal surgeries. We aimed to compare the analgesic efficacy of caudal block versus ultrasonography-guided quadratus lumborum block in pediatric patients undergoing open pyeloplasty. Fifty patients weighing ) 16 kg (age ) 4 years) with ASA physical status I-II scheduled for elective open pyeloplasty under general anesthesia were randomized into caudal block or transmuscular quadratus lumborum block groups. Fifty patients were included in the analysis. The mean duration of postoperative analgesia in the caudal group was 6.85 ± 1.99 hr, and for the quadratus lumborum block group it was 11.27 ± 3.74 hr (P < .001). There was no significant diference between the groups in terms of perioperative fentanyl requirement. However, there was a significant diference in postoperative paracetamol requirement between the groups (P = .005). There was a significant diference in postoperative pain score between the groups at 30 min, 1 hr, 1.5 hr, 2 hr, 8 hr, and 24 hr (P < .05). Mean heart rate and mean arterial pressure were comparable. No complications were recorded. Quadratus lumborum block was more efective than caudal block in terms of duration of postoperative analgesia and postoperative analgesic consumption. [ABSTRACT FROM AUTHOR]

Emergence delirium remains a clinically significant issue, often leading to short-term distress among pediatric patients, parents, and staff, and potentially resulting in postoperative maladaptive behaviors persisting for weeks to months. Although several diagnostic tools are available, the Pediatric Anesthesia Emergence Delirium Scale is most often utilized. Many risk factors contributing to the likelihood of a pediatric patient developing emergence delirium have been identified; however, its accurate prediction remains challenging. Recently, intraoperative electroencephalographic monitoring has been used to improve the prediction of emergence delirium. Similarly, it may also prevent emergence delirium if the anesthesiologist ensures that the at-risk patient rouses only after the onset of appropriate electroencephalogram patterns, thus indicating a change to natural sleep. Prediction of at-risk patients is crucial; preventing emergence delirium may begin early during patient preparation by using non-pharmacological methods (i.e., the ADVANCE program). Intraoperative electroencephalographic monitoring can predict emergence delirium. This review also discusses a range of pharmacological treatment options which may assist the anesthesiologist in preventing emergence delirium among at-risk patients. [ABSTRACT FROM AUTHOR]

In pediatric anesthesia, respiratory adverse events often occur during emergence from anesthesia and at the time of endotracheal tube or supraglottic device removal. The removal of airway devices and extubation are conducted either while patients are deeply anesthetized or when patients awaken from anesthesia and have regained consciousness. The airways of children are easily irritated by external stimuli and are structurally prone to collapse, and the timing of both methods of airway device removal is similarly associated with various airway complications, including upper airway obstruction, coughing, or serious adverse events such as laryngospasm and desaturation. In current practice in pediatric anesthesia, the choice of the timing and method of extubation is made by anesthesiologists. To achieve a smooth and safe recovery from anesthesia, understanding the unique characteristics of pediatric airways and the factors likely to contribute to an increased risk of perioperative complications remains essential. These factors include patient age, comorbidities, and physical conditions. The level of anesthesia and readiness for removal of airway devices should be evaluated carefully for each patient, and quick identification of airway problems and intervention is required if patients fail to maintain the airway and sufficient ventilation after removal of airway devices. [ABSTRACT FROM AUTHOR]

Pediatric regional anesthesia (RA) has emerged as a rapidly advancing dimension within pediatric anesthesia, demanding a continual commitment to knowledge acquisition. This review underscores the contemporary significance of this specialty, focusing on its application in neonates and infants. The primary objective of RA is to address perioperative pain effectively while preserving the delicate physiological balance, thereby enhancing overall patient care. This review explores the advantages offered by RA in this age group. Furthermore, conventional, and recently introduced techniques of RA are examined by exploring the advantages and disadvantages of these methods. The aim is to provide clinicians with a nuanced understanding of their applicability in different clinical scenarios. Additionally, the review elucidates the unique considerations associated with pediatric RA, acknowledging pediatric patients’ distinctive anatomical and physiological characteristics. The exceptional cases of congenital anomalies and their implications for the choice of RA are considered. An aspect of the review is its focus on dosages of local anesthetics and the volumes required for various blocks in neonates and infants. The dosages for continuous infusion and practical issues with infusions are considered. Complications associated with RA are described, along with their prevention and treatment. The review offers pragmatic insights into the selection criteria for various regional blocks, aiding anesthesiologists in making informed decisions tailored to individual patient needs. [ABSTRACT FROM AUTHOR]

Neuromuscular blocking agents (NMBAs), a cornerstone of pediatric anesthesia, facilitate intubation and muscle relaxation during surgery. However, NMBAs can also lead to serious complications including respiratory depression, residual paralysis, and prolonged recovery. Neuromuscular monitoring (NMM) in pediatric patients is therefore essential, as it is in adults, to ensure adequate paralysis during surgery and prompt recovery from NMBA-induced paralysis. This article aimed to provide a comprehensive overview of NMM in pediatric anesthesia including the various available methods, their advantages and disadvantages, and the importance of a standardized NMM approach. [ABSTRACT FROM AUTHOR]

Early extubation after pediatric cardiac surgery has come full circle from being practiced in the early days of pediatric cardiac surgery, falling out of favor with opioid-heavy cardiostable anesthesia, and resurfacing again in more recent times as part of enhanced recovery after surgery practice. Early extubation is variably defined, but is mostly accepted as extubation that occurs within 6–8 h from the end of surgery. In recent years, the debate has shifted from early extubation in the intensive care unit to immediate extubation in the operating theatre. In this review, we examined the benefits and pitfalls of early and immediate extubation, factors that influence the success of early extubation, and potential guidelines for practice and implementation. [ABSTRACT FROM AUTHOR]

Purpose: The effects of general anesthesia on neurodevelopment in children remain controversial. We explored the relationship between general anesthesia and neurodevelopment in children participating in the Japan Environment and Children's Study (JECS). Methods: This study enrolled children born between 37 and 41 weeks of pregnancy via single-vaginal delivery to pregnant women registered in the JECS between January 2011 and March 2014. Data were collected from mother-completed questionnaires and medical transcripts. Neurodevelopment in five domains was assessed every 6 months between 12 and 48 months of age, using the Ages and Stages Questionnaires. The associations between general anesthesia exposure during early childhood and neurodevelopment in children were evaluated at each time point. Adjusted odds ratios and 95% confidence intervals were estimated after covariate adjustment using logistic regression models. Results: Children who received general anesthesia before age 1 year had higher risks of neurodevelopmental delay in all five domains throughout the observational period. The largest risk was for gross motor delay at 18 months (adjusted odds ratio: 3.51; 95% confidence interval: 2.75–4.49). The effects on the incidence of neurodevelopmental delays after age 3 were not observed except for problem solving at 48 months. The risk of neurodevelopmental delay in children who first received general anesthesia after age 1 was considerably small. Conclusions: This study suggests that general anesthesia administration before age 1 is associated with neurodevelopmental delay during 1–4 years of age. The risk of general anesthesia after age 1 may be small. [ABSTRACT FROM AUTHOR]

Anesthetic management of pediatric patients poses several challenges and the optimal anesthetic agent for use in this population is still a matter of debate. We systematically searched PubMed/MEDLINE and Google Scholar from their inception for studies that investigated the role and potential applications of remimazolam, a novel ultra-short-acting benzodiazepine, in pediatric patients. Furthermore, in March 2024, an update of the literature search along with an additional post-hoc search on the EMBASE database were performed. A total of fourteen pertinent studies which spanned the 2021–2023 period explored remimazolam as either the primary or adjuvant hypnotic agent for inducing and/or maintaining general anesthesia or sedation. Preliminary evidence derived from these studies highlighted that remimazolam is a safe and effective option for both sedation and general anesthesia in pediatric patients, particularly those with concurrent mitochondrial disorders, myopathic diseases, or at risk for malignant hyperthermia. Moreover, the current evidence suggested that remimazolam may contribute to reducing preoperative anxiety and postoperative delirium in children. Its favorable pharmacodynamic and pharmacokinetic profile demonstrated potential safety, effectiveness, and ease-of-use in various perioperative pediatric contexts, making it suitable for integration into specific protocols, such as intraoperative monitoring of evoked potentials and management of difficult intubation. Notwithstanding these promising findings, further research is essential to determine optimal dosages, establish conclusive evidence of its superiority over other benzodiazepines, and elucidate the impact of genetic factors on drug metabolism. [ABSTRACT FROM AUTHOR]

Background: Little is known about patients' or carers' reported experiences of dental care provided using dental behaviour support (DBS) techniques. Qualitative literature can provide unique insight into these experiences. Aim: To explore and synthesize qualitative literature related to patient experience of dental behaviour support. Methods: A PROSPERO‐registered systematic review of qualitative articles was undertaken. Studies were identified through MEDLINE, Embase and PsycINFO. Abstracts were screened by two reviewers and data were extracted to summarize the qualitative findings included within them. A thematic summary approach was used to synthesize the qualitative data identified. Results: Twenty‐three studies were included. Studies primarily explored experiences of dental care of children by speaking to their parents (n = 16), particularly regarding paediatric dental general anaesthesia (DGA) (n = 8). Studies of adults' experiences of DBS (n = 7) covered a range of techniques. Nine studies explored broader dental care experiences and did not study specific DBS approaches. A thematic synthesis identified five themes applicable across the studies identified: Trust and the therapeutic alliance supporting effective care delivery; considered information sharing often alleviated anticipatory anxiety; control and autonomy‐reduced anxieties; variations in the perceived treatment successes and failures of DBS techniques; and DBS techniques produced longer positive and negative impacts on patients beyond direct care provision. Conclusion: Qualitative research has been under‐utilized in research on DBS techniques. Care experiences of most DBS techniques outside of paediatric DGA are poorly understood. Building trust with patients and enabling autonomy appear to support positive patient‐reported experiences of care. [ABSTRACT FROM AUTHOR]

Aim: While bradycardia in children with Down syndrome (DS) during inhalation induction of anesthesia is characteristic, its mechanism is not well understood. This study investigated sympathetic failure as a potential (and modifiable) mechanism of bradycardia. Materials and Methods: Ninety-three children with DS and 102 typically developing (TD) children underwent inhalation induction of anesthesia. These children were monitored for sympathetic activity, exposed to sevoflurane anesthetic and were observed for the development of bradycardia. The primary outcome was sympathetic failure in the context of normoxic bradycardia within the first 300 seconds of induction. Secondary outcome measures included hypotension and parasympathetic excess. Results: During the first 300 seconds of induction, 54 DS children became bradycardic (54/93, 58%) while 22 TD children became bradycardic (22/102, 22%). In the DS group, 23 experienced hypotension (23/80, 29%). Of those who experienced hypotension, 15 also experienced sympathetic failure (15/28, 54%). Conclusion: More than half of children with DS undergoing inhalation anesthesia induction with sevoflurane experienced bradycardia. Bradycardia and hypotension were associated with sympathetic failure. Sympathetic activity therefore appears to be a modifiable target in the prevention of bradycardia in children with DS.

Tiffany K Guan,1 Brittany L Willer,2,3 Jack Stevens,4,5 Joseph D Tobias,2,3 Vanessa A Olbrecht2,3 1College of Medicine, The Ohio State University, Columbus, OH, USA; 2Department of Anesthesiology & Pain Medicine, Nationwide Children’s Hospital, Columbus, OH, USA; 3Department of Anesthesiology & Pain Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA; 4Department of Pediatrics, Nationwide Children’s Hospital and The Ohio State University, Columbus, OH, USA; 5Center for Clinical Excellence, Nationwide Children’s Hospital, Columbus, OH, USACorrespondence: Brittany L Willer, Nationwide Children’s Hospital, 700 Children’s Drive, Columbus, Ohio, 43205, USA, Email Brittany.Willer@nationwidechildrens.orgIntroduction: Identification and reporting of severe adverse events (SAEs) during anesthesia care remains critical in identifying areas of improvement in perioperative patient care. Although many healthcare organizations rely on the self-reporting of SAEs, under-reporting may limit the identification of the true incidence of these events. To circumvent these barriers, many healthcare systems leverage the Electronic Medical Record (EMR) by incorporating an Anesthesia Information Management System (AIMS).Methods: We followed the Institute for Healthcare Improvement’s Model of Improvement and implemented behavioral economic-based interventions to our perioperative practice including adding a deliberation-promoting “hard stop” that required the anesthesiologists to report the occurrence or absence of a “notable event” prior to closing a patient’s encounter in the EMR system.Results: At baseline, 53% of SAEs were self-reported. The interventions resulted in a baseline shift to more than 75% self-reporting, a relative increase of 42%.Conclusion: An increase in reporting of SAEs was achieved with simple interventions including modifications of the EMR which were done with limited financial impact or interruption in the work flow.Keywords: adverse events, pediatric anesthesia, intraoperative care, quality and safety

Yanling Liao,1,&ast; Siyu Xie,2,&ast; Yifen Zhuo,3,&ast; Sisi Chen,1 Yuxin Luo,1 Ying Wei,4 Yusheng Yao1 1Department of Anesthesiology, Shengli Clinical Medical College of Fujian Medical University, Fujian Provincial Hospital, Fuzhou, People’s Republic of China; 2Department of Anesthesiology, Longyan First Affiliated Hospital of Fujian Medical University, Longyan, People’s Republic of China; 3Department of Anesthesiology, Xiamen Haicang Hospital, Xiamen, People’s Republic of China; 4Department of Anesthesiology, Fujian Maternity and Child Health Hospital, College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, People’s Republic of China&ast;These authors contributed equally to this workCorrespondence: Ying Wei, Department of Anesthesiology, Fujian Maternity and Child Health Hospital, College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, 18 Daoshan Road, Fuzhou, 350025, People’s Republic of China, Email whm444@fjmu.edu.cn Yusheng Yao, Department of Anesthesiology, Shengli Clinical Medical College of Fujian Medical University, Fujian Provincial Hospital, 134 Dongjie Street, Fuzhou, 350001, People’s Republic of China, Email fjslyys@126.comPurpose: Emergence delirium and postoperative negative behavioral changes (PNBC) are common complications in pediatric anesthesia. This study evaluated whether intranasal premedication combining dexmedetomidine and esketamine more effectively reduces these complications compared to either drug alone in children undergoing tonsillectomy and/or adenoidectomy with sevoflurane anesthesia.Patients and Methods: This randomized, double-blind trial involved 198 children aged 2− 5 years undergoing tonsillectomy and/or adenoidectomy. Participants received intranasal premedication with either dexmedetomidine (2 μg/kg), esketamine (1 mg/kg), or their combination (dexmedetomidine 1 μg/kg plus esketamine 0.5 mg/kg). The primary outcome was the incidence of emergence delirium, defined as a Pediatric Anesthesia Emergence Delirium (PAED) scale score ≥ 10. Secondary outcomes included the incidence of PNBC, sedation depth, easiness of separation from parents, acceptance of the mask for induction, emergence time, postoperative pain score, parental satisfaction, and adverse events.Results: The combination premedication significantly reduced emergence delirium incidence (9.4%) compared to esketamine alone (38.1%; relative risk [RR] 0.25, 95% confidence interval [CI] 0.11– 0.57, p < 0.001), but not compared to dexmedetomidine alone (17.2%; RR 0.55, 95% CI 0.21– 1.39, p = 0.193). PNBC incidence at day 7 was lower with the combination (28.1%) versus dexmedetomidine (48.4%; RR 0.58, 95% CI 0.36– 0.93, p = 0.018), but not significantly different from esketamine alone (20.6%; RR 1.38, 95% CI 0.74– 2.58, p = 0.326). The combination also provided significantly superior sedation, improved ease of separation from parents, better acceptance of the mask for induction, shorter emergence time, and higher parental satisfaction than both monotherapies.Conclusion: In children undergoing tonsillectomy and/or adenoidectomy with sevoflurane anesthesia, intranasal dexmedetomidine-esketamine premedication more effectively reduces emergence delirium compared to esketamine alone and PNBC compared to dexmedetomidine alone. This combination also improves sedation, shortens emergence times, and enhances parental satisfaction compared to monotherapy without significant adverse effects.Trial Registration: The Chinese Clinical Trial Registry, ChiCTR2300076709. Keywords: adenoidectomy, dexmedetomidine, emergence delirium, esketamine, intranasal administration, pediatric anesthesia, postoperative complications, tonsillectomy

Abstract Introduction Atelectasis is a well-documented complication in pediatric patients undergoing general anesthesia. Its incidence varies significantly based on surgical procedures and anesthesia techniques. Inhalation induction, commonly used to avoid the discomfort of venipuncture, is suspected to cause higher rates of respiratory complications, including atelectasis, compared to intravenous induction. This study aimed to evaluate the impact of inhalation versus intravenous anesthesia induction on atelectasis formation in pediatric patients, as assessed by lung ultrasound (LUS). Methods This propensity score-matched observational study was conducted at a tertiary pediatric hospital in Milan, Italy. Inclusion criteria were children ≤ 18 years undergoing elective surgery with general anesthesia. Patients were divided into inhalation and intravenous induction groups. LUS was performed before and after anesthesia induction to assess lung aeration. The primary endpoint was the global LUS score post-induction, with secondary endpoints including the incidence and distribution of atelectasis. Results Of the 326 patients included, 65% underwent inhalation induction and 35% intravenous induction. The global LUS score was significantly higher in the inhalation group (12.0 vs. 4.0, p

Sicong Wang, Yan Li, Fang Chen, Hua-Cheng Liu, Lezhou Pan, Wangning Shangguan Department of Anesthesiology and Perioperative Medicine, The Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University, Key Laboratory of Pediatric Anesthesiology of Ministry of Education, Wenzhou, Zhejiang Province, People’s Republic of ChinaCorrespondence: Wangning Shangguan, Email sgwning@163.comPurpose: This study aimed to estimate the effect of different doses of fentanyl on the median effective dose (ED50) of ciprofol for attenuating the airway and motor response to laryngeal mask airway (LMA) insertion response in healthy children.Patients and Methods: 90 healthy preschool patients undergoing inguinal hernia repair surgery were randomly assigned to one of three groups: C0 (ciprofol+saline), C1 (ciprofol + fentanyl 1μg/kg), C2 (ciprofol + fentanyl 2μg/kg). Anesthesia was induced with either prepared fentanyl or saline, followed by ciprofol. The dose of ciprofol for each patient was determined using the up-and-down sequential study design. The primary outcome was the ED50 of ciprofol required for smooth LMA insertion in the three groups. Additionally, the time to loss of consciousness and any perioperative adverse events were recorded.Results: Compared with the C0 group, the ED50 (95% confidence interval) of ciprofol in the C1 and C2 groups were significantly lower (1.81 [1.73– 1.90]mg/kg versus 0.67 [0.64– 0.71]mg/kg and 0.48 [0.42– 0.54] mg/kg, respectively; P< 0.05). Additionally, the ED50 of ciprofol in the C2 group was lower than that in the C1 group (0.42 [0.42– 0.54] mg/kg vs 0.67 [0.64– 0.71]mg/kg; P< 0.05). Furthermore, the time to loss of consciousness in the C1 and C2 groups decreased by 60% and 53%, respectively, compared to the C0 group. There were no significant differences in the incidence of drug-related hypotension after anesthesia induction among the three groups. No adverse events of hypoxia, bradycardia, or injection pain were observed in any groups.Conclusion: In healthy, non-obese Chinese children undergoing elective inguinal hernia repair surgery, fentanyl 1 μg/kg and 2 μg/kg before ciprofol injection significantly reduced the ED50 of ciprofol for attenuating LMA response, with minimal occurrence of severe side effects.Keywords: ciprofol, laryngeal mask airway, pediatric anesthesia, 50% effective dose

With the advent of minimally invasive surgeries, robot-assisted techniques have gained popularity because they overcome various shortcomings of standard laparoscopic surgeries. Despite the associated costs and limitations among the pediatric population, surgeon comfort due to the ergonomic design, in combination with enhanced three-dimensional high-fidelity imaging and tissue handling, may offer better surgical and postoperative outcomes. However, robotic surgeries require innovations with regard to patient positioning and the overall arrangement of operative equipment and personnel. Anesthesiologists should become well versed with these changes by learning the basic features of robotic surgical systems to offer appropriate anesthetic care and promote patient safety. In this original case report, we present a 3-year-old child posted for robot-assisted left heminephrectomy and excision of the lower megaureter. It provides instructive significance for anesthesia management, especially taking into account the age of the patient and associated concerns.

This case report delves into pediatric lung isolation challenges and innovations in managing patients with pulmonary alveolar proteinosis undergoing whole lung lavage. The central focus is on a 5-year-old girl who initially encountered intraoperative complications, including bilateral pneumothorax and pulmonary edema. However, a subsequent attempt employing a Foley’s catheter for lung isolation proved successful, with the patient displaying marked postoperative improvements. The case offers valuable insights into the intricate balance of anesthesia, ventilatory parameters, and the novel use of common medical equipment, like the Foley’s catheter, for specialized procedures in pediatric pulmonology.

Extracorporeal membrane oxygenation (ECMO) is a technology used with increasing frequency to support pa- tients in cardiac or respiratory failure refractory to con- ventional therapies. As technologies have improved, the clinical indications for and applications of ECMO have been increased including its use in the peri-operative set- ting. Use of single access, double lumen cannulas have been instrumental in optimizing venous-venous (VV ECMO) for use in the perioperative setting, particularly in the pediatric population. We report the use of VV- ECMO with a dual lumen Avalon® catheter during air- way surgery in two pediatric patients. The potential applications of ECMO in the operating room are re- viewed, options for anesthetic care discussed, and peri- operative concerns reviewed.

Background Myringotomy with tympanostomy tube insertion (MTI) is a superficial surgical procedure used to prevent hearing loss in children with serous otitis media. Intravenous anesthesia, often ketamine, is preferred for this procedure because of its ability to induce sedation without compromising airway reflexes. However, ketamine alone may be insufficient and potentially lead to spontaneous movement during surgery. This study evaluated the effectiveness of midazolam and fentanyl as adjuvants to ketamine in reducing spontaneous movement during MTI and enhancing the quality of recovery. Methods This study involved two groups of 30 patients each: one group received intravenous ketamine (1.5 mg/kg) with an equal volume of normal saline (K group), while the other received a combination of midazolam, fentanyl, and ketamine (0.05 mg/kg, 1 μg/kg, and 1.5 mg/kg, respectively; MFK group). We assessed side effects, intraoperative patient movement, surgeon satisfaction, and emergence agitation scores. Results The MFK group exhibited significantly lower scores for patient movement (p

Background: Off-label intranasal administration of injectable dexmedetomidine has been widely applied in the pediatric sedation setting. However, the development of an improved drug delivery system that is easy to use is needed. We developed a novel dexmedetomidine nasal spray that can be administered directly without dilution or configuration for pediatric pre-anesthetic sedation. This nasal spray has a fixed dose and is stable during storage. To the best of our knowledge, this is the first licensed nasal spray preparation of dexmedetomidine worldwide. Objective: To evaluate the pre-anesthetic sedation efficacy and safety of the novel dexmedetomidine nasal spray in children. Methods: The study was conducted at 11 sites in China between 24 November 2021 and 20 May 2022 and was registered in ClinicalTrials.gov (NCT05111431, first registration date: 20/10/2021). Subjects (n = 159) between 2 and 6 years old who were to undergo elective surgery were randomized to the dexmedetomidine group (n = 107) or the placebo group (n = 52) in a 2:1 ratio. The dosage was 30 µg or 50 µg based on the stratified body weight. The primary outcome measure was the proportion of subjects who achieved the desired child-parent separation and Ramsay scale ≥ 3 within 45 min of administration. Safety was monitored via the assessments of adverse events, blood pressure, heart rate, respiratory rate and blood oxygen saturation. Results: The proportion of subjects achieving desired parental separation and Ramsay scale ≥ 3 within 45 min was significantly higher in the dexmedetomidine group (94.4%) vs the placebo group (32.0%) (P < 0.0001). As compared with placebo, dexmedetomidine treatment led to more subjects achieving Ramsay scale ≥ 3 or UMSS ≥ 2, and shorter time to reach desired parental separation, Ramsay scale ≥ 3 and UMSS ≥ 2 (all P < 0.0001). Adverse events were reported in 90.7% and 84.0% of subjects in the dexmedetomidine and placebo groups, respectively, and all the events were mild or moderate in severity. Conclusions: This novel dexmedetomidine nasal spray presented effective pre-anesthetic sedation in children with a tolerable safety profile. [ABSTRACT FROM AUTHOR]

A stay in hospital and an operation are always an exceptional situation for children and their parents, which is accompanied by great uncertainty and fear. The aim of this article is to show what possibilities exist as a caring anesthetist to accompany a child and the parents through the operation and that anesthesia remains a good memory. The effect of communication on a verbal and nonverbal level is discussed. The focus is on dealing with children and their parents, taking the influence of the psychological developmental stages of children into account and on presenting helpful coping strategies in exceptional situations. [ABSTRACT FROM AUTHOR]

Patient safety is the most important aspect of anesthetic care. For both healthcare professionals and patients, the ideal would be no significant morbidity or mortality under anesthesia. Lessons from harm during healthcare can be shared to reduce harm and to increase safety. Many nations and individual institutions have developed robust safety systems to improve the quality and safety of patient care. Large registries that collect rare events, analyze them, and share findings have been developed. The approach, the funding, the included population, support from institutions and government and the methods of each vary. Wake Up Safe (WUS) is a patient safety organization accredited by Agency for Healthcare Research and Quality. Wake Up Safe was established in the United States in 2008 by the Society for Pediatric Anesthesia. The initiative aims to gather data on adverse events, analyze these incidents to gain insights, and apply this knowledge to ultimately reduce their occurrence. The purpose of this review is to describe the patient safety approaches in the USA. Through a national patient safety database WUS. Similar approaches either through WUS international or independent safety approaches have been described in Australia‐New Zealand, India, and Singapore. We examine the patient safety processes across the four countries, evaluating their incident review process and the distribution of acquired knowledge. Our focus is on assessing the potential benefits of a WUS collaboration, identifying existing barriers, and determining how such a collaboration would integrate with current incident review databases or systems. [ABSTRACT FROM AUTHOR]

The article discusses the power and privilege dynamics that exist in pediatric anesthesia care globally. It highlights the disparities in access to safe and high-quality care between different countries, which are influenced by social determinants of health, economic factors, and political causes. The article identifies poverty, healthcare system fragility, geography and rural-urban divide, extremes of age in patients, poor prioritization of surgical care, race, gender, and colonial legacy as factors that perpetuate inequity in pediatric anesthesia care. The authors emphasize the need for collaboration and investment in strengthening healthcare systems to address these disparities and promote equity in pediatric anesthesia care. [Extracted from the article]

Around 1.7 billion children lack access to surgical care worldwide. To reinvigorate the efforts to address these disparities and support work to address global challenges in surgery, anesthesia, emergency, and critical care, the World Health Assembly passed World Health Organization Resolution World Health Assembly 76.2: Integrated emergency, critical and operative care for universal health coverage and protection from health emergencies (ECO) in 2023. This resolution highlights the integral role of surgery, anesthesia, and perioperative care in health systems. However, understanding how best to operationalize this resolution is challenging. We review the ECO resolution and highlight points that the pediatric surgical and anesthesia community can leverage to advocate for its recommendations for operative care. [ABSTRACT FROM AUTHOR]

Access to healthcare is inequitable. Poverty, natural disasters and war disproportionally effect those most vulnerable, including children. Non‐governmental organizations (NGO) hold a vital role in providing pediatric care in these contexts. Here we describe the delivery and challenges of Pediatric Anesthesia with two such non‐governmental organizations; Médecins Sans Frontières (MSF) and Mercy Ships. Descriptions of both are followed by case studies. [ABSTRACT FROM AUTHOR]

Introduction: To improve and maintain quality and safety in anesthesia, standards have been proposed regarding human resources, facilities and equipment, medications and intravenous fluids, monitoring, and the conduct of anesthesia. Compliance with these standards remains a challenge in French‐speaking sub‐Saharan Africa (SSA) and results in high morbidity and mortality particularly in children. This aim of this study was to assess the progress made in improving the pediatric anesthesia infrastructures, human resources, education, medications, and equipment in French‐speaking SSA over the past 10 years (2013–2022). Methods: This is a descriptive, multicenter, cross‐sectional study with retrospective data collection, conducted from September 1 to November 5, 2023. Comparative data from 2012 to 2022 were collected through an online survey. Descriptive statistics were used to summarize data. Results: Data were obtained from 12 countries out of 14. The number of hospitals providing pediatric surgery and anesthesia rose from 94 in 2012 to 142 in 2022 (+51%). The total number of physician anesthesiologists rose from 293 (0.1 physician anesthesiologists/100 000 inhabitants) in 2012 to 597 (0.2 physician anesthesiologists/100 000 inhabitants) in 2022 (+103.7%). Five (0.006 physician anesthesiologists/100 000 children) had completed a fellowship in pediatric anesthesia and intensive care in 2012, and 15 (0.01 physician anesthesiologists/100 000 children) in 2022 (+200%). Five physician anesthesiologists had an exclusive pediatric anesthesia practice in 2012, whereas they were 32 in 2022 (+540%). There is no specialized training in pediatric anesthesia and intensive care in any of these countries. Halothane was always available in 81.5% of the hospitals in 2012, and in 50.4% of the hospitals in 2022. Sevoflurane was always available in 5% of the hospitals in 2012, and in 36.2% in 2022. Morphine was always available in 32.2% in 2012, whereas it was available in 52.9% of them in 2022. Pediatric pulse oximeter sensors were available in 36% of the hospitals in 2012, and in 63.4% in 2022. Capnography was available in 5.3% of the hospitals in 2012, and in 48% in 2022. Conclusion: Progress have been made over the last 10 years in French‐speaking SSA to improve infrastructures, human resources, education, medications, and equipment for pediatric anesthesia in French‐speaking SSA. However, major efforts must be continued. Standards adapted to the local context should be formulated. [ABSTRACT FROM AUTHOR]