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Amr Elhamrawy,1 Josiane Kerbage,2 Giorgio Veneziano,3,4 David P Martin,3,4 Joseph D Tobias3,4 1Department of Anesthesiology, Detroit Medical Center/ Wayne State University School of Medicine, Detroit, MI, USA; 2Department of Internal Medicine, Hurley Medical Center, Flint, MI, USA; 3Department of Anesthesiology & Pain Medicine, Nationwide Children’s Hospital, Columbus, OH, USA; 4Department of Anesthesiology & Pain Medicine, the Ohio State University College of Medicine, Columbus, OH, USACorrespondence: Amr Elhamrawy, Department of Anesthesiology, Detroit Medical Center, Wayne State University, 4160 John R St, Detroit, Michigan, 48201, USA, Email Amrelhamrawy89@gmail.comAbstract: Hip disorders in infants and children may result from congenital, infectious, developmental, inflammatory, neoplastic, and traumatic etiologies. Postoperative pain management associated with hip pathologies can be challenging especially due to complex innervation of the hip and surrounding structures. Given the adverse effect profile of systemic opioids, regional anesthesia offers an excellent alternative with more beneficial adverse effect profile. Various peripheral regional anesthetic techniques have been reported with variable results regarding analgesia and differing adverse effect profiles. The pericapsular nerve group (PENG) block is a novel motor-sparing regional anesthetic technique where the local anesthetic agent is deposited in the musculofascial plane between the psoas tendon and the pubic ramus. The main target is the genicular branches of the femoral, obturator, and accessory obturator nerve, which innervate the hip capsule. The anatomy involved with PENG block is reviewed and previous reports of PENG block in pediatric-aged patients, including single shot or continuous catheter techniques, are reviewed.Keywords: regional anesthesia, orthopedic surgery, pediatric anesthesiology, pericapsular nerve group block, lateral femoral cutaneous nerve block

Remimazolam is a novel ultrashort‐acting benzodiazepine, which like midazolam, results in sedation, anxiolysis, and amnesia through its agonistic effects on the gamma‐amino butyric acid A receptor. As opposed to midazolam, its unique metabolism is via tissue esterases, which results in a rapid elimination with a limited context sensitive half‐life and prompt dissipation of its effect when administration is discontinued. Remimazolam received FDA approval for use in adults in 2020. In preliminary and initial clinical trials, its efficacy and safety has been suggested in the adult population, both as a primary agent for procedural sedation or as an adjunct to general anesthesia. There are limited data regarding the use of remimazolam in infants and children and its use in this population remains off label as it does not hold FDA‐approval in pediatric‐aged patients. This narrative outlines the pharmacologic properties of this unique medication, reviews previous published reports of its role in pediatric‐aged patients, and discusses dosing parameters and clinical use in this population. [ABSTRACT FROM AUTHOR]

Introduction. Massive perioperative blood loss that accompanies major surgical interventions is a specific critical condition, the pathogenesis of which is dominated by severe hypovolemia, anemia, and threatening coagulopathy in combination with powerful shockogenic sympathoadrenal stress. Both massive blood loss itself and massive transfusion are associated with a significant risk of serious complications, including death. It is worth noting that information on the survival of patients after replacement of several circulating blood volume (CBV) is limited, and most of the articles are devoted to adult patients with highly traumatic surgical interventions.The objective was to present the experience in managing the patient with blood loss of more than 5.5 CBV according to the MT protocol adopted at the Research Institute of Pediatric Oncology and Hematology. The 3-year-old patient underwent surgical intervention in the following volume: median laparotomy, nephradrenalectomy on the right (lesion 10–15–20 cm in size), paracaval and aortocaval lymph node dissection (conglomerate 7–8 cm in size), resection of S5-S6-S7 liver segments, resection of the right domes of the diaphragm. During the surgical intervention of 440 minutes (7.3 hours), the total blood loss was 5.5 CBV (5.500 ml).Results. After surgery, he was transferred to prolonged assisted ventilation of the lungs, the duration of which was 2 days. On the 3rd day after the operation, adjuvant polychemotherapy was started. 17 days after the operation, the patient was transferred to the specialized department for further treatment. The patient was alive for a year after surgery.Conclusion. Maintenance of homeostasis, normothermia, normocoagulation through basic infusion therapy with balanced crystalloid solutions, targeted transfusion therapy with the introduction of fresh frozen plasma, transfusion of donor platelets and donor erythrocytes/autoerythrocytes during anesthesia in the child with extremely massive blood loss, contributed to early post-anesthetic rehabilitation, provided the opportunity to continue special treatment in the intensive care unit.

Succinic semialdehyde dehydrogenase (SSADH) defi- ciency is an uncommon autosomal recessive disorder that affects the degradation of gamma-aminobutyric acid (GABA) within the central nervous system (CNS). Clin- ical manifestations generally present during infancy in- cluding hypotonia, developmental delay, cognitive im- pairment, expressive language deficits, and ataxia. Sei- zures are a hallmark of the disorder, being present in ap- proximately half of affected individuals. Given the multi- system involvement of these patients with a high inci- dence of associated seizures, anesthetic care may be re- quired for diagnostic imaging or therapeutic interven- tions. We present a 23-year-old woman with SSADH de- ficiency who required anesthetic care during dental sur- gery. The basic pathophysiology and inheritance of SSADH is presented, clinical manifestations and end-or- gan involvement reviewed, and potential anesthetic im- plications outlined.

Background: mivacurium is the shortest-acting non-depolarizing neuromuscular blocking agent (NmBA) with a rapid onset of action that is mainly used for short procedures. Despite the fact that mivacurium has a very favorable average 6-minute recovery index after its infusion in comparison to the approximately 15-30 minutes for atracurium, mivacurium is still not really popular among practicing anesthesiologists. many new studies showing the potential further benefits of implementing mivacurium into daily practice are still being published. Aim of the study: This study aimed to focus on spreading the common knowledge about the detailed pharmacokinetic and pharmacodynamic properties of mivacurium as a medication that has yet to be used widely by practicing anesthesiologists. Material and methods: The literature review was conducted using the common sources of original articles such as pubmed and google Scholar from 1975 to September 2022. Results: Based on the literature review, we observed that mivacurium at a dosage of 6μg produces a lower impact on hemodynamics, shorter intubation and extubation times, faster postoperative recovery, absence of the accumulation of neuromuscular blockade, higher safety, and no significant increase in allergic related adverse events in comparison with other NmBAs. Conclusions: mivacurium is a muscle relaxant medication that is particularly suited for short-lasting surgical procedures. however, it is important to remember that existing mutations in the butyrylcholinesterase enzyme (BChe) may prolong the effect of the neuromuscular blockade due to significantly reducing plasma cholinesterase activity. Therefore, it is advised to stay cautious during its use as more research needs to be done to be able to thoroughly assess the potential advantages and disadvantages of mivacurium introduction in particular patients. [ABSTRACT FROM AUTHOR]

Introduction: This international survey explored the ongoing impact of COVID‐19 on pediatric anesthesiology. It assessed COVID‐19's impact on the practice of pediatric anesthesiology, staffing, job satisfaction, and retention at the beginning of 2022 and addressed what should be done to ameliorate COVID‐19's impact and what initiatives hospitals had implemented. Methods: This survey focused on five major domains: equipment/medication, vaccination/testing, staffing, burnout, and economic repercussions. Pilot testing for questionnaire clarity was conducted by members of the Pediatric Anesthesia COVID‐19 Collaborative. The survey was administered by e‐mail to a representative of the 72 collaborative centers. Respondents were instructed to answer based on their institution's practice from February through April of 2022. Descriptive statistics with 95% confidence intervals are reported. Results: Seventy of seventy‐two institutions participated in this survey (97% response rate). Fifty‐nine (84%) were from the United States, and 11 (16%) included other countries. The majority experienced equipment (68%) and medication (60%) shortages. Many institutions reported staffing shortages in nursing (37%), perioperative staff (27%), and attending anesthesiologists (11%). Sixty‐two institutions (89%) indicated burnout was a frequent topic of conversation among pediatric anesthesiologists. Forty‐three institutions (61%) reported anesthesiologists leaving current practice and 37 (53%) early retirement. Twenty‐eight institutions (40%) canceled elective cases. The major suggestions for improving job retention included improving financial compensation (76%), decreasing clinical time (67%), and increasing flexibility in scheduled clinical time (66%). Only a minority of institutions had implemented the following initiatives: improving financial compensation (19%), increased access to mental health/counseling services (30%), and assistance with child or elder care (7%). At the time of the survey, 34% of institutions had not made any changes. Conclusion: Our study found that COVID‐19 has continued to impact pediatric anesthesiology. There are major discrepancies between what anesthesiologists believe are important for job satisfaction and faculty retention compared to implemented initiatives. Data from this survey provide insight for institutions and departments for addressing these challenges. [ABSTRACT FROM AUTHOR]

Objective: In children, neuromuscular blockers may have different effects with various inhalation agents and incomplete reversal of the blockade continues to be a problem. The aim of the study is to observe the effects of sugammadex on reversing the blockade by a single dose of rocuronium, the peak inspiratory pressure, hemodynamic parameters in children under sevoflurane and desflurane anesthesia. Materials and Methods: One hundred forty-eight children aged 2-10 years old, to be operated under shortterm general anesthesia, were enrolled in this prospective randomized controlled trial. After induction, the patients were intubated at the end of TOF (Train-of-four) ratio of 1.0-0. The time taken until TOF reached 0.25 was recorded, and 2 mg/kg sugammadex was administered to the patients. The period until the TOF was at least 0.9 and in the first 10 minutes after sugammadex injection, peak inspiratory pressure, the systolic- diastolic arterial pressure, and the heart rate were monitored and possible side effects were observed in the recovery room. Results: Following the injection of sugammadex, the time taken for TOF of 0.25 to reach >0.9 was signifi- cantly shorter in the 2-4-year-old age group under sevoflurane anesthesia. After sugammadex injection, a small but statistically significant increase in peak inspiratory pressure values was observed in Group D at the 2nd, 5th, and 10th minutes. Conclusion: Rapid and complete recovery was achieved from the block induced by a single dose of 0.6 mg/ kg rocuronium by the use of sugammadex which did not give rise to any side effects. [ABSTRACT FROM AUTHOR]

Background: As illicit substance use can present several perioperative concerns, effective means to identify such practices are necessary to ensure patient safety. Identification of illicit substance use in pediatric patients may be problematic as screening may rely on parental reporting. Aims: The current study compares answers regarding use of illicit substances between a survey completed by the patient and the preoperative survey completed by parents or guardians. Methods: The study included patients presenting for surgery at Nationwide Children's Hospital, ranging in age from 12 to 21 years. After consent, patients completed a survey of six drop‐down questions using an iPad. The six questions involved the patient's history of alcohol, tobacco, marijuana, vaping, and opioid use. The results were compared to the answers obtained from the parents during a preoperative phone call. Results: The study cohort included surveys from 250 patients with a median age of 16 years. Survey data showed a statistically higher reporting of substance use or abuse from the patient study survey in comparison to the routine parental preoperative survey. Alcohol report rates were highest with 69 (27.6%) patients reporting use compared to only 5 parental reports (2%). There was a similar discrepancy in reported rates of vaping use (40 patient reports, 16.0% vs. 11 parental reports, 4.4%) and illicit substance use including marijuana (52 patient reports, 20.8% vs. 11 parental reports, 4.4%). Reported rates of tobacco use were lowest among the survey responses with 12 patient reports (4.8%) and 5 parental reports (2.0%). Conclusions: Identifying illicit substance and tobacco use via a phone survey of parents is inaccurate and does not allow for proper identification of use of these substances in patients ≤21 years of age presenting for surgery. An anonymous 2‐min survey completed by the patient more correctly identifies these issues. [ABSTRACT FROM AUTHOR]

Kabuki syndrome (KS) is a rare genetic disorder associ- ated with unique facial features, developmental delay, and multiple end-organ abnormalities. Specific pheno- typic findings include long palpebral fissures, eversion of the lateral third of the lower eyelid, arched eyebrows with sparseness of the lateral one-third, a short columella with a depressed nasal tip, and prominent ears. Patients with KS frequently have associated skeletal deformities, short stature, cleft lip and palate, dental anomalies, joint laxity, cardiovascular abnormalities, renal malformations, re- current pneumonia, recurrent otitis media, and hearing loss. Given the potential for end-organ involvement and congenital malformations, surgical intervention may be required to address these concerns. We present a patient with Kabuki syndrome who required anesthetic care dur- ing two operative interventions: laryngoscopy and supra- glottoplasty at 5 months of age and open reduction for hip dislocation at 9 months of age. Previous reports of anes- thetic care for patients with Kabuki syndrome are re- viewed with discussion of perioperative concerns and op- tions for anesthesia.

Sugammadex is a novel agent for the reversal of neuromuscular blockade; it acts by encapsulating rocuronium or vecuronium, eliminating the active compound from the circulation, thereby providing rapid and complete recovery even with profound or complete neuromuscular blockade. Clinical advantages, including reduced incidence of residual blockade, decreased nausea and vomiting, decreased dry mouth, less change in heart rate, and reduced pulmonary complications, have been demonstrated when comparing sugammadex to conventional agents, such as neostigmine, that inhibit acetylcholinesterase. Although generally safe and effective, anaphylactoid and allergic reactions have been reported with sugammadex. The potential for hypersensitivity reactions with sugammadex and previous reports from the literature, as well as diagnostic and treatment strategies, are presented in 3 pediatric cases. [ABSTRACT FROM AUTHOR]

Background: Leadership of the Society for Pediatric Anesthesia created the Diversity, Equity, and Inclusion committee in 2018 to prioritize diversity work. The Society for Pediatric Anesthesia‐Diversity, Equity, and Inclusion committee implemented a baseline survey of the Society for Pediatric Anesthesia membership in 2020 to assess demographics, equity in leadership, inclusivity, and attitudes toward diversity work. The Society for Pediatric Anesthesia plays a significant role in shaping the future of pediatric anesthesiology and in supporting our diverse pediatric patients. Methods: This study is an IRB‐exempt, cross‐sectional survey of the Society for Pediatric Anesthesia membership. Quantitative analysis provided descriptive statistics of demographics, practice characteristics, and involvement within the Society for Pediatric Anesthesia. Qualitative thematic analysis provided an in‐depth assessment of perceptions of diversity, challenges faced, and prioritization of Diversity, Equity, and Inclusion efforts within the Society for Pediatric Anesthesia. Results: Out of 3 242 Society for Pediatric Anesthesia members, 1 232 completed the survey representing 38% of overall membership. Respondents were 89.2% United States members, 52.7% female, 55.7% non‐Hispanic White, 88.6% heterosexual, 95.7% non‐military, 59.2% religious, and 2.1% have an Americans with Disabilities Act recognized disability. All major United States geographical areas were represented equally with 71% practicing in urban areas and 67% in academic settings. Ethnic/racial minorities were more likely to be international medical graduates (p <.001). Among United States members, 41.5% report being fluent in a language other than English, and 23.5% of those fluent in another language are certified to interpret. Compared to men, women are less likely to be in leadership roles (p <.003), but we found no difference in participation and leadership when stratified by race/ethnicity, geography, international medical graduate status, or sexuality. Racial/ethnic minorities (p <.028), women (p <.001), and lesbian, gay, bisexual, transgender, and queer members (p <.044) more frequently hold lower academic rank positions when compared to white, heterosexual, and male members. Half of respondents were unsure whether diversity, equity, and inclusion challenges existed within the Society for Pediatric Anesthesia while the other half demonstrated opposing views. Among those who reported diversity, equity, and inclusion challenges, the themes centered around persistent marginalization, the need for more inclusive policies and increased psychological safety, and lack of leadership diversity. Conclusions: Compared to the diversity of the pediatric population we serve, there are still significant gaps in demographic representation within the Society for Pediatric Anesthesia. As well, there is no consensus among Society for Pediatric Anesthesia membership regarding perceptions of diversity, equity, and inclusion in pediatric anesthesia in the United States. Among those who reported diversity challenges, opportunities for the Society for Pediatric Anesthesia and Anesthesiology Departments to better support minoritized members included bolstering workforce diversity efforts and awareness via more inclusive policies, improved psychological safety, and increasing diversity in leadership. If pediatric anesthesiology is like other specialties, gaining consensus and improving diversity in the workforce might advance pediatric anesthesia innovation, quality, and safety for children of all backgrounds in the United States. [ABSTRACT FROM AUTHOR]

Klippel-Trénaunay syndrome with associated primary intestinal lymphangiectasia is a rare entity in pediatrics. It presents with edema due to hypoproteinemia, and in some cases with ascites. The objective is to present a clinical case whose diagnosis was certified by intestinal esdoscopy and biopsy. For refractary ascities, the treatment was surgical, performing peritoneal venous bypass. The anesthetic management of this type of patients has been described in limited reports, so in the present case we emphasize supportive therapy with albumin infusion as the proposed symptomatic treatment for patients with massive drainage of ascities. [ABSTRACT FROM AUTHOR]

Grant Heydinger,1,2 Shabana Z Shafy,1 Colin O’Connor,1 Olubukola Nafiu,1,2 Joseph D Tobias,1,2 Ralph J Beltran1,2 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: Grant Heydinger, Email grant.heydinger@nationwidechildrens.orgBackground: Various criteria exist for defining difficult intravenous access (DIVA) in infants and children. The current study evaluated the factors associated with DIVA in a prospective cohort of over 1000 infants and children presenting for anesthetic care.Methods: This was a prospective, observational study of patients aged 0 to 18 years undergoing elective surgical or radiologic procedures under general anesthesia. Prior to the initial attempt at peripheral intravenous (PIV) cannulation, the anticipated difficulty of PIV catheter placement was determined by the provider using a visual analogue scale (VAS) from 1 to 10. The number of attempts was recorded as well as the time required to achieve PIV access. DIVA was defined as requiring three or more attempts. After successful cannulation, the actual difficulty of the PIV placement was assessed by the provider and recorded using the same VAS. Patient characteristics, including age, race, body mass index (BMI), American Society of Anesthesiologists (ASA) physical classification, and history of difficult PIV placement, were evaluated as covariates.Results: In our cohort of 1002 pediatric patients, 78% of patients were successfully cannulated in a single attempt and 91% of patients were successfully cannulated in two or fewer attempts. Factors associated with requiring three or more PIV attempts included younger age (OR 8.73; 95% CI: 3.38, 22.6 for age < 1 year and OR 4.93; 95% CI: 2.05, 11.8 for age 1– 3 years), higher ASA physical classification (OR 1.95; 95% CI: 1.10, 3.46 for ASA II), and prior history of difficult PIV placement (OR 3.46; 95% CI: 1.70, 7.08). BMI, racial category or gender were not independent predictors of DIVA.Conclusion: We found that approximately 9% of patients required three or more attempts at IV placement in the operating room. Patients that required multiple PIV attempts were more likely to be younger, have a higher ASA classification or a history of difficult PIV placement.Keywords: intravenous cannulation, pediatric anesthesiology, vascular access, peripheral intravenous catheter

The Society for Pediatric Anesthesia launched the Women's Empowerment and Leadership Initiative (WELI) in 2018 to empower highly productive women pediatric anesthesiologists to achieve equity, promotion, and leadership. WELI is focused on six career development domains: promotion and leadership, networking, conceptualization and completion of projects, mentoring, career satisfaction, and sense of well‐being. We sought feedback about whether WELI supported members' career development by surveys emailed in November 2020 (baseline), May 2021 (6 months), and January 2022 (14 months). Program feedback was quantitatively evaluated by the Likert scale questions and qualitatively evaluated by extracting themes from free‐text question responses. The response rates were 60.5% (92 of 152) for the baseline, 51% (82 of 161) for the 6‐month, and 52% (96 of 185) for the 14‐month surveys. Five main themes were identified from the free‐text responses in the 6‐ and 14‐month surveys. Members reported that WELI helped them create meaningful connections through networking, obtain new career opportunities, find tools and projects that supported their career advancement and promotion, build the confidence to try new things beyond their comfort zone, and achieve better work–life integration. Frustration with the inability to connect in‐person during the coronavirus‐19 pandemic was highlighted. Advisors further stated that WELI helped them improve their mentorship skills and gave them insight into early career faculty issues. Relative to the baseline survey, protégés reported greater contributions from WELI at 6 months in helping them clarify their priorities, increase their sense of achievement, and get promoted. These benefits persisted through 14 months. Advisors reported a steady increase in forming new meaningful relationships and finding new collaborators through WELI over time. All the members reported that their self‐rated mentoring abilities improved at 6 months with sustained improvement at 14 months. Thus, programs such as WELI can assist women anesthesiologists and foster gender equity in career development, promotion, and leadership. [ABSTRACT FROM AUTHOR]

• What is currently known about this topic? • Racial disparities in outcomes of pediatric surgery have been previously documented; however, differences in receipt of pediatric surgical care in the United States have not been analyzed. • What new information is contained in this article? • Among children less than 19 years old, analysis from a large, national survey of health reveals an association between minority race/ethnicity and decreased odds of receiving surgery despite adjustment for relevant covariates. It is unknown whether racial/ethnic disparities exist in surgical utilization for children. The aim, therefore, was to evaluate the odds of surgery among children in the US by race/ethnicity to test the hypothesis that minority children have less surgery. Cross-sectional data were analyzed on children 0–18 years old from the 1999 to 2018 National Health Interview Survey, a large, nationally representative survey. The primary outcome was odds of surgery in the prior 12 months for non Latino African-American, Asian, and Latino children, compared with non Latino White children, after adjustment for relevant covariates. The National Surgical Quality Improvement Program Pediatric Dataset was used to analyze the odds of emergent/urgent surgery by race/ethnicity. Data for 219,098 children were analyzed, of whom 10,644 (4.9%) received surgery. After adjustment for relevant covariates, African-American (AOR, 0.54; 95% CI, 0.50–0.59), Asian (AOR, 0.39; 95% CI, 0.33–0.46), and Latino (AOR, 0.62; 95% CI, 0.57–0.67) children had lower odds of surgery than White children. Latino children were more likely to require emergent or urgent surgery (AOR, 1.71; 95% CI, 1.68–1.74). Latino, African-American, and Asian children have significantly lower adjusted odds of having surgery than White children in America, and Latino children were more likely to have emergent or urgent surgery. These racial/ethnic differences in surgery may reflect disparities in healthcare access which should be addressed through further research, ongoing monitoring, targeted interventions, and quality-improvement efforts. II. Prognosis study. [ABSTRACT FROM AUTHOR]

Background Lung resection is a complex surgical procedure performed in children to address various pulmonary conditions. The success of this surgical intervention in these patients lies in a multidisciplinary approach, with anesthetic management playing a critical role in ensuring the safety and efficacy of the procedure. Methods After approval by the local ethics committee, clinical data of 17 pediatric patients who underwent lung resection in our hospital from January 2012 to December 2022 were retrospectively analyzed. Results  A total of 16 patients underwent video-assisted thoracoscopic surgery (VATS), and only one patient underwent open thoracotomy. Most indications for this type of procedure are linked to cystic disease at a stage where respiratory function is not severely compromised. Lung resection procedures were conducted under general anesthesia and invasive blood pressure monitoring in all patients. Various methods, such as double-lumen endotracheal tubes (DLTs), bronchial blockers (BBs), and specialized endobronchial devices, were employed to selectively collapse the lung undergoing resection while maintaining ventilation in the contralateral lung. A multimodal analgesia regimen, combining systemic analgesia with regional anesthesia techniques (epidural or regional trunk blocks), was employed. Conclusions Thorough preoperative preparation is critical for a desirable outcome in pediatric patients undergoing lung resection. The need for one-lung ventilation (OLV) presents challenges, especially in younger ages, where this surgery is more commonly performed. The use of BBs is often necessary, along with the likelihood of their extraluminal application. In recent years, to reduce the risks associated with thoracic epidural analgesia, regional trunk blocks have been described as a safe and effective alternative in pain management., Competing Interests: Human subjects: Consent for treatment and open access publication was obtained or waived by all participants in this study. The institutional ethics committee of Centro Hospitalar de São João issued approval CE-274-22. Approval was granted on December 22, 2022. Subsequently, the database related to the surgical procedures targeted for the study during the specified period was provided to the authors. Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Gonçalves et al.)

Immunoglobulin (Ig) A deficiency is characterized by undetectable levels of serum IgA and normal levels of other immunoglobulins (IgG, IgM) in patients more than 4 years of age. Although generally asymptomatic, patients are at risk for anaphylactic reactions when receiving allogeneic blood products from non-IgA deficient donors. We present a 35-year-old male with IgA deficiency who required anesthetic care during posterior spinal fusion. The basic principles of IgA deficiency are reviewed, general techniques to avoid allogeneic blood products presented, and specific care of the IgA deficient patient discussed including techniques to allow the use of allogeneic blood products if needed. [ABSTRACT FROM AUTHOR]

Objectives: The inferior vena cava collapsibility index (IVCCI) has been used to assess the respiratory variation of the inferior vena cava (IVC) diameter and hence intravascular volume. The sub‐xiphoid view (SXV) is the standard view to evaluate the IVC. The right lateral transabdominal view (RLV) has been shown in adults to be an alternative view to evaluate the IVC when the SXV is not feasible. The aim of the study was to compare IVC dimensions from these two views and thus determine whether the RLV view can be used instead of the SXV in pediatric patients. Methods: We conducted a single‐center prospective observational crossover study. Study subjects were ASA physical status 1–2 children, 1–12 years of age scheduled for elective surgery under general anesthesia. Anesthesia was maintained by mask with spontaneous ventilation with end‐tidal sevoflurane at 2%–5% after the induction of anesthesia. IVCCI was measured using M‐mode in both the SXV and RLV. Results: The study cohort included 50 children with a mean age of 5.1 years. The median value for the IVCCI‐sx was 0.45 (IQR: 0.28–0.70) while the IVCCI‐rl was 0.30 (0.19–0.5). The mean difference between the two groups was 0.12 (95% CI: 0.177–0.066, p <.001, two‐tailed paired t‐test). Spearman's rank correlation coefficient was 0.66. The univariate linear regression model was IVCCIsx = 0.21 + 0.77 × IVCCIrl. Conclusions: IVCCIrl was lower than IVCCIsx. IVCCI measured from the right lateral view tended to overestimate the patient's fluid‐responsiveness and therefore these two values are not interchangeable. [ABSTRACT FROM AUTHOR]

The potential anesthetic neurotoxicity on the neonate is an important focus of research investigation in the field of pediatric anesthesiology. It is essential to understand how these anesthetics may affect the development and growth of neonatal immature and vulnerable brains. Functional magnetic resonance imaging (fMRI) has suggested that using anesthetics result in reduced functional connectivity may consider as core sequence for the neurotoxicity and neurodegenerative changes in the developed brain. Anesthetics either directly impact the primary structures and functions of the brain or indirectly alter the hemodynamic parameters that contribute to cerebral blood flow (CBF) in neonatal patients. We hypothesis that anesthetic agents may either decrease the brain functional connectivity in neonatal patients or animals, which was observed by fMRI. This review will summarize the effect and mechanism of anesthesia on the rapid growth and development infant and neonate brain with fMRI through functional connectivity. It is possible to provide the new mechanism of neuronal injury induced by anesthetics and objective imaging evidence in animal developing brain. [ABSTRACT FROM AUTHOR]

• Largest cohort to date evaluating cuffed endotracheal tube use in patients ≤5 kg. • Cuffed endotracheal tubes decreased need for tube exchange and repeat laryngoscopy. • Cuffed endotracheal tubes did not increase incidence of stridor or reintubation. 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 to <3 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. [ABSTRACT FROM AUTHOR]

Mohammed Hakim,1 Shabana Zainab Shafy,1 Joshua C Uffman,1,2 Julie Rice,1 Vidya T Raman,1,2 Joseph D Tobias,1,2 Ralph J Beltran1,2 1Department of Anesthesiology and Pain Medicine, Nationwide Children’s Hospital, Columbus, OH, USA; 2Department of Anesthesiology and Pain Medicine, The Ohio State University College of Medicine, Columbus, OH, USACorrespondence: Mohammed HakimDepartment of Anesthesiology and Pain Medicine, Nationwide Children’s Hospital, 700 Children’s Drive, Columbus, OH 43205, USATel +1 614 680-2552Fax +1 614 722-4203Email mushtaqahmedhakim.2@osu.eduBackground: Various criteria exist for defining difficult peripheral intravenous (DPIV) cannulation in infants and children. With the help of a survey tool, the characteristics perceived to increase the likelihood of DPIV cannulation amongst anesthesia providers were assessed.Methods: An individualized survey regarding DPIV which included pediatric anesthesiology faculty and certified registered nurse anesthetists at Nationwide Children’s Hospital and anesthesiology faculty members of Wake-up Safe was conducted. Anesthesia provider, patient, and procedural characteristics were expressed as a count and percentage, and compared according to group (faculty, certified registered nurse anesthetists, Wake-up Safe faculty) using analysis of variance.Results: Of the 48 local respondents, 33 (69%) reported age as a contributing factor to DPIV, and 32 (67%) reported weight as a factor. Of the 22 Wake-up Safe respondents, 14 (63%) reported age, and 16 (73%) reported weight as a factor. Patient and procedural characteristics perceived to increased likelihood of DPIV cannulation did not differ by respondent role. The factors most commonly mentioned by local respondents as contributing to DPIV included trisomy 21, neuromuscular disorders, and history of many prior IV cannulations. Among the Wake-up Safe faculty respondents, the most commonly mentioned factors were neuromuscular disorders, trisomy 21, and skin injuries or conditions.Conclusion: Age and weight were the two most commonly reported factors from both groups of respondents. Other factors contributing to DPIV included prior history of DPIV, neuromuscular disorders, trisomy 21 and American Society of Anesthesiology status ≥ 4. Patient and procedural characteristics were perceived to increase the likelihood of DPIV cannulation with no difference among respondents.Keywords: peripheral intravenous cannulation, pediatric anesthesiology, difficult peripheral intravenous cannulation

The potential anesthetic neurotoxicity on the neonate is an important focus of research investigation in the field of pediatric anesthesiology. It is essential to understand how these anesthetics may affect the development and growth of neonatal immature and vulnerable brains. Functional magnetic resonance imaging (fMRI) has suggested that using anesthetics result in reduced functional connectivity may consider as core sequence for the neurotoxicity and neurodegenerative changes in the developed brain. Anesthetics either directly impact the primary structures and functions of the brain or indirectly alter the hemodynamic parameters that contribute to cerebral blood flow (CBF) in neonatal patients. We hypothesis that anesthetic agents may either decrease the brain functional connectivity in neonatal patients or animals, which was observed by fMRI. This review will summarize the effect and mechanism of anesthesia on the rapid growth and development infant and neonate brain with fMRI through functional connectivity. It is possible to provide the new mechanism of neuronal injury induced by anesthetics and objective imaging evidence in animal developing brain.

Background: Children with congenital heart disease (CHD) often require other, non-cardiac related surgical procedures following their initial cardiac surgery. After full or partial CHD repair, they remain at increased risk of postoperative complications. We examined the association of previous cardiac intervention (surgery or percutaneous catheterization intervention) with postoperative pneumonia in infants undergoing abdominal general surgery., Methods: A 1:1 propensity score-matched study was conducted using a retrospective cohort of 104,820 infants (<12 months) who had general abdominal surgeries between 2012 and 2022 in U.S. hospitals participating in the National Surgical Quality Improvement Program. The primary outcome was postoperative pneumonia within 30 days. Secondary outcomes included unplanned reintubation, prolonged mechanical ventilation (>72 h), and extended hospital stay (>75th percentile for the study cohort)., Results: Of the study cohort, 9736 infants (9.3%) had previous cardiac interventions. In the propensity score-matched sample, infants with previous cardiac surgery had increased risks of postoperative pneumonia (1.3% vs 0.8%; adjusted relative risk [RRadj]: 1.64, 95% CI: 1.22, 2.18, p = 0.001), unplanned reintubation (57.8% vs 32.6%; RRadj: 1.77, 95% CI: 1.77, 1.85, p < 0.001), prolonged mechanical ventilation (5.0% vs 2.3%; RRadj: 2.14, 95% CI: 1.83, 2.52, p < 0.001), and prolonged hospital stays (61.0% vs 53.8%; RRadj: 1.13, 95% CI: 1.10, 1.17, p < 0.001)., Conclusions: A history of previous cardiac intervention carries an increased risk of postoperative pneumonia, unplanned tracheal reintubation, prolonged mechanical ventilation, as well as longer hospital stays following intra-abdominal surgery. Clinicians should closely monitor these patients for respiratory complications after surgery., Level of Evidence: II., Competing Interests: Conflict of interest The authors have no potential conflicts of interest to disclose. All authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Introduction Weight-based dosing combined with variable patient weights in pediatric anesthesia can lead to significant medication excess and waste from single-use medication vials packaged for dosing in adults. Medication aliquots have been proposed as a strategy to decrease waste and therefore expense when using high-cost medications such as sugammadex. Appropriate dosing of sugammadex to antagonize neuromuscular block is based on the results of quantitative monitoring, though the use of these monitors is not routine. In this quality improvement project, we demonstrate cost savings from aliquoting sugammadex from large, single-use vials and using quantitative monitoring to guide accurate and appropriate dosing.  Methods After institutional review and approval, patients receiving rocuronium neuromuscular block during their anesthetic care between October 10 and December 9, 2022, were included for analysis. Sugammadex aliquots were prepared under sterile conditions in the operating room pharmacy according to current compounding guidelines. Quantitative neuromuscular monitoring with electromyography-based monitors was used to guide accurate sugammadex dosing. Cost analysis included the actual savings achieved when aliquots were used instead of single-use vials, the potential savings if aliquots had been used as opposed to single-use vials, and the actual savings achieved when quantitative monitoring indicated that adequate spontaneous recovery was reached and sugammadex administration was not needed. Results A total of 200 patients were included in the analysis. In 73 patients, a 200 mg/2 ml vial of sugammadex was utilized, while 86 patients received sugammadex from pre-filled aliquot syringes of 50 mg/0.5 ml. Forty-one patients did not require sugammadex antagonism as they achieved spontaneous recovery to a train-of-four ratio ≥90%. Conclusion Administration of sugammadex from aliquots rather than manufacturer-packaged single-use vials, with dosing guided by quantitative neuromuscular monitoring, produced a net cost savings of approximately $46 per case and projected net annual cost savings of nearly $370,000 in our institution. Forty percent of the net cost savings came from confirmation by quantitative monitoring of adequate spontaneous recovery to a train-of-four ratio ≥90%., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. Children's Hospital Colorado Organizational Research Risk and Quality Improvement Review Panel issued approval ORRQIRP #2208-3. Institutional review and approval were obtained for this quality improvement project. Informed consent was waived. Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Haberkorn et al.)

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Remimazolam is a novel benzodiazepine with sedative, anxiolytic, and amnestic properties similar to midazolam. Metabolism by tissue esterases results in a short clinical half-life of 5 - 10 min and a limited context sensitive half-life. We present initial retrospective clinical experience with the use of remimazolam as an intraoperative adjunct to sedation during awake craniotomy in a cohort of three adolescent patients. A remimazolam infusion was added to a combination of dexmedetomidine and remifentanil to deepen the level of sedation during surgical incision, craniotomy, duraplasty, and surgical dissection for exposure of the seizure foci. The remimazolam infusion was discontinued 30 min prior to the planned awake assessments and electrophysiology testing. The patients emerged calmly and were able to follow commands for intraoperative testing. Our anecdotal experience supports the efficacy of remimazolam for awake craniotomy and tumor resection using a standard asleep-awake-asleep technique. We noted adequate sedation, maintenance of spontaneous respiration, rapid awakening, and no limitations to intraoperative neuromonitoring or awake assessment in our three patients., Competing Interests: None to declare., (Copyright 2024, Smith et al.)

Technology improvements have rapidly advanced medicine over the last few decades. New approaches are constantly being developed and utilized. Anesthesiology strongly relies on technology for resuscitation, life-support, monitoring, safety, clinical care, and education. This manuscript describes a reverse engineering process to confirm the fit of a medical device in a pediatric patient. The method uses virtual reality and three-dimensional printing technologies to evaluate the feasibility of a complex procedure requiring one-lung isolation and one-lung ventilation. Based on the results of the device fit analysis, the anesthesiology team confidently proceeded with the operation. The approach used and described serves as an example of the advantages available when coupling new technologies to visualize patient anatomy during the procedural planning process. [ABSTRACT FROM AUTHOR]

Summary: Recent decades have seen an unprecedented leap in digital innovation, with far‐reaching implications in healthcare. Anesthesiologists have historically championed the adoption of new technologies. However, the rapid evolution of these technologies has outpaced attempts at studying their potential impact on healthcare providers' well‐being. This document introduces several categories of workplace technologies commonly encountered by the anesthesiologist. We examine examples of novel technology and the impact of these digital interventions on the anesthesiologist's well‐being. We also review popular personalized technology aimed at improving wellness and the impact on well‐being examined. Finally, technology acceptance models are introduced to improve technology adoption, which, when appropriately applied, may minimize the negative impacts of technology on anesthesiologists' well‐being. Incorporating quantitative, serial assessments of well‐being as part of technology implementation are proposed as a future direction for examining the wellness impact of technology on anesthesiologists. [ABSTRACT FROM AUTHOR]

Promoting and retaining junior faculty are major challenges for many medical schools. High clinical workloads often limit time for scholarly projects and academic development, especially in anesthesiology. To address this, we created the East/West Visiting Scholars in Pediatric Anesthesia Program (ViSiPAP). The program's goal is to help "jumpstart" academic careers by providing opportunities for national exposure and recognition through invited lectures and collaborative opportunities. East/West ViSiPAP benefits the participating scholars, the home and hosting anesthesia departments, and pediatric anesthesia fellowship training programs. By fostering a sense of well‐being and inclusion in the pediatric anesthesia community, East/West ViSiPAP has the potential to increase job satisfaction, help faculty attain promotion, and reduce attrition. Faculty and trainees are exposed to new expertise and role models. Moreover, ViSiPAP provides opportunities for women and underrepresented in medicine faculty. This program can help develop today's junior faculty into tomorrow's leaders in pediatric anesthesia. We advocate for expanding the concept of ViSiPAP to other institutions in academic medicine. [ABSTRACT FROM AUTHOR]

In pediatric-aged patients, hyperthyroidism generally results from the autoimmune disorder, Graves' disease (GD). Excessive levels of thyroid hormones (triiodothyronine and thyroxine) result in irritability, emotional lability, nervousness, tremors, palpitations, tachycardia, and arrhythmias. The risk of morbidity and mortality is increased when surgical intervention is required in patients with hyperthyroidism due to the potential for the development of thyroid storm (TS). A 3-year, 1-month-old child with a past medical history of GD presented for total thyroidectomy when pharmacologic control with methimazole was not feasible due to intolerance following development of a serum sickness-like illness. Prior to surgery, his thyrotoxicosis symptoms worsened with fever, tachycardia, diaphoresis, and hypertension. He subsequently developed TS and was admitted to the pediatric intensive care unit where management included hydrocortisone, potassium iodide, and β-adrenergic blockade with esmolol and propranolol. Thyroid studies improved prior to surgery, and a total thyroidectomy was successfully completed. Corticosteroid therapy was slowly tapered as an outpatient, and he was discharged home on hospital day 9. Following discharge, his signs and symptoms of thyrotoxicosis resolved, and he was started on oral levothyroxine replacement therapy. The remainder of his postoperative and post-discharge course were unremarkable. Only two case reports of perioperative pediatric TS have been published in the past 20 years. Our case serves as an important reminder of the signs of TS in children and to outline the treatment options in a pediatric patient, especially in those unable to tolerate first-line pharmacologic therapies such as methimazole or propylthiouracil., Competing Interests: None to declare., (Copyright 2024, Bonanno et al.)

Background: Resident education in pediatric anesthesiology is challenging. Traditional curricula for anesthesiology residency programs have included a combination of didactic lectures and mentored clinical service, which can be variable. Limited pediatric medical knowledge, technical inexperience, and heightened resident anxiety further challenge patient care. We developed a pediatric anesthesia simulation‐based curriculum to address crises related to hypoxemia and dysrhythmia management in the operating room as an adjunct to traditional didactic and clinical experiences. Aims: The primary objective of this trial was to evaluate the impact of a simulation curriculum designed for anesthesiology residents on their performance during the management of crises in the pediatric operating room. A secondary objective was to compare the retention of learned knowledge by assessment at the eight‐week time point during the rotation. Methods: In this prospective, observational trial 30 residents were randomized to receive simulation‐based education on four perioperative crises (Laryngospasm, Bronchospasm, Supraventricular Tachycardia (SVT), and Bradycardia) during the first week (Group A) or fifth week (Group B) of an eight‐week rotation. Assessment sessions that included two scenarios (Laryngospasm, SVT) were performed in the first week, fifth week, and the eighth week of their rotation for all residents. The residents were assessed in real time and by video review using a 7‐point checklist generated by a modified Delphi technique of senior pediatric anesthesiology faculty. Results: Residents in Group A showed improvement between the first week and fifth week assessment as well as between first week and eighth week assessments without decrement between the fifth week and eighth week assessments for both the laryngospasm and SVT scenarios. Residents in Group B showed improvement between the first week and eighth week assessments for both scenarios and between the fifth week and eighth week assessment for the SVT scenario. Conclusion: This adjunctive simulation‐based curriculum enhanced the learner's management of laryngospasm and SVT management and is a reasonable addition to didactic and clinical curricula for anesthesiology residents. [ABSTRACT FROM AUTHOR]

Purpose: The optimal sedative regime that provides the greatest comfort and the lowest risk for procedural sedation in young children remains to be determined. The aim of this randomized, blinded, controlled, parallel-design trial was to evaluate the efficacy of intranasal ketamine and midazolam as the main component of the behavioral guidance approach for preschoolers during dental treatment. Materials and methods: Children under seven years of age, with caries and non-cooperative behavior, were randomized into three groups: (KMIN) intranasal ketamine and midazolam; (KMO) oral ketamine and midazolam; or (MO) oral midazolam. The dental sedation appointments were videotaped, and the videos were analyzed using the Ohio State University Behavioral Rating Scale (OSUBRS) to determine the success of the sedation in each group. Intra- and postoperative adverse events were recorded. Data analysis involved descriptive statistics and non-parametric tests (P < 0.05, IBM SPSS). Results: Participants were 84 children (28 per group; 43 boys), with a mean age of 3.1 years (SD 1.2). Children’s baseline and the dental sedation session characteristics were balanced among groups. The success of the treatment as assessed by the dichotomous variable ‘quiet behavior for at least 60% of the session length’ was: KMIN 50.0% (n = 14; OR 2.10, 95% CI 0.71 to 6.30), KMO 46.4% (n = 13; OR 1.80, 95% CI 0.62 to 5.40), MO 32.1% (n = 9) (P = 0.360). Adverse events were minor, occurred in 37 of 84 children (44.0%), and did not differ among groups (P = 0.462). Conclusion: All three regimens provided moderate dental sedation with minor adverse events, with marked variability in the behavior of children during dental treatment. The potential benefit of the ketamine–midazolam combination should be further investigated in studies with larger samples. Trial registration: , identifier: . Registered on 11 May 2015, named “Midazolam and Ketamine Effect Administered Through the Nose for Sedation of Children for Dental Treatment (NASO).” [ABSTRACT FROM AUTHOR]

Introduction: Although the administration of rectal thiopental for sedation during magnetic resonance imaging (MRI) has been well described, there are limited data regarding its intravenous (IV) use in this clinical scenario. The aim of this study was to investigate the efficiency of IV thiopental for sedation during MRI in the pediatric population. Methods: A retrospective review was conducted over a 12-month period of pediatric patients who received IV thiopental for sedation during MRI. Data collected included the procedure length, the induction dose, the time to sedation, recovery time, total sedation time, and adverse events. The parents were telephoned and questioned regarding any adverse effect after discharge and their satisfaction (yes = satisfied; no = not satisfied) regarding the sedation process. Results: A total of 300 (American Society of Anesthesiology I–II status) pediatric patients received IV thiopental for sedation during MRI. The average age of the patients was 4.7 ± 3 years. Thiopental was administered as an initial IV bolus dose of 3 mg/kg, followed by additional bolus doses of thiopental (1 mg/kg) as needed to achieve a Ramsay sedation score of 4. The average procedure length was 20.7 ± 11.9 min. The average total dose of thiopental during the procedure was 5.6 ± 0.9 mg/kg. Patients recovered in an average time of 11 ± 5.6 min after a total sedation time of 31.7 ± 14.2 min. None of the patients had oxygen desaturation, adverse effects before or after discharge, and no patient required unplanned hospital admission. All parents were satisfied with the sedation process. Conclusion: IV thiopental is an effective, safe, and inexpensive medication for the sedation of children undergoing MRI.

Background: Knowledge regarding the shape, size, and variability of the cricoid ring is important to properly choose the correct endotracheal tube (ETT) in the pediatric patient. Studies have measured the size of the cricoid ring using methodologies such as moulages, magnetic resonance imaging, and video-bronchoscopy. In the present study, computed tomography (CT) -based images were used to determine the shape, size, and configuration of the cricoid ring in the pediatric population taking into considerations growth and development. Methods: This is a retrospective review using 130 CT images of children ranging in age from 1 month to 10 years undergoing radiological evaluation unrelated to airway symptomatology. The CT scans were obtained in spontaneously breathing patients during either natural sleep or procedural sedation. Anteroposterior (AP) and transverse (T) diameters were measured at the cricoid ring using these images. Results: The cricoid ring is generally round in children older than 1 year with a T/AP ratio ranging between 0.98 and 1.01. However, in infants (1–12 months of age), the cricoid ring is elliptical with the AP dimension an average of 0.31 mm larger than the T dimension with a T/AP ratio of 0.95. A statistically significant difference between the T and AP dimensions was only observed in infancy (P < 0.05). Conclusion: The cricoid ring is round in children older than 1 year of age. In infants, the cricoid shape presents a more elliptical configuration because the T-axis is narrower than the AP dimension. CT is recognized as the most accurate technique to study cricoid ring configuration, and the present data may help clinicians determine the appropriate type, size, and shape of ETTs, particularly in infants.

Background and aims Propofol combined with fentanyl is a commonly used sedative for pediatric upper endoscopies (UEs). The primary aim was to study the association between propofol dose and procedure and sedation time. The secondary aims were to assess the pharmacodynamics of propofol use with fentanyl and evaluate if gastroenterologists' and anesthesiologists' years of experience or the presence of supervised participants (such as students, residents, and fellows) have any influence on the procedure and sedation time. Methods A retrospective study was performed at the Children's Hospital of Michigan on patients under 18 years who underwent UEs with propofol sedation with fentanyl over a two-year period. Results A correlation was found between the propofol amount used expressed per body mass index (BMI)/body surface area (BSA), procedure time, and sedation time (p < 0.0001). Throat pain was the most common post-procedural adverse event (4.48%). The impact of psychoactive drugs on these events was not statistically significant, but attention-deficit/hyperactivity disorder (ADHD) medication use was related to increased post-procedural pain complaints. The use of prescribed psychoactive medications was associated with larger propofol dose usage (p = 0.007) without a significant increase in sedation time. Individual gastroenterologists, their years of experience, and the presence of supervised participants were associated with different procedure times (p <0.0001, <0.0001, 0.01). Fellow participation was associated with a 1.11-minute procedure time increase (p = 0.04). Individual anesthesiologists, their years of experience, and the presence of supervised participants were associated with different sedation times (p <0.0001, <0.0001, 0.01). Conclusion We found a novel correlation between propofol dosing expressed by the BMI/BSA and sedation time. The UE procedure time and sedation time are associated with individual gastroenterologists and anesthesiologists, their years of experience, and the presence of supervised participants., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2024, Manivannan et al.)

Tracheoesophageal fistula (TEF) is an abnormal connection between the trachea and esophagus. This report presents a rare case of a pediatric patient who developed a TEF due to battery ingestion, which was diagnosed during intubation and resulted in cardiac arrest. A 4-year-old child with a two-year history of battery ingestion presented with severe dehydration, weight loss, and recurrent respiratory tract infections. Chest X-ray revealed a radiopaque foreign body in the esophagus. During general anesthesia for central venous line insertion and after endotracheal intubation, some difficulties in ventilation occurred, characterized by the inability to reach tidal volume, absence of capnography, and stomach distention which led to hypoxia and ultimately to cardiac arrest. Prompt resuscitation (CPR) was initiated, and selective right bronchial intubation during CPR improved the patient's condition. Subsequent bronchofibroscopy performed in the ICU confirmed the TEF, which was surgically corrected during the hospital stay. TEF poses challenges in anesthesia and airway management, particularly when positive pressure ventilation is used. In this case, the TEF was diagnosed during intubation, highlighting the critical role of clinical expertise and prompt intervention in managing this unexpected pediatric critical event., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2023, Telo et al.)

Fetus-in-fetu (FIF) is a rare, congenital anomaly involving the presence of one of a pair of twins within the body of the other. It is postulated that this pathology occurs during embryogenesis of a diamniotic-monochorionic twin pregnancy with unequal division of the blastocele, which results in monozygotic, monochorionic, and diamniotic twins of unequal sizes. Presentation as an abdominal mass during the neonatal period or infancy is most common, although late diagnosis during the adult years may also occur. We report a 1-day-old, full-term female neonate who presented for exploratory laparotomy and excision of a FIF. We present the use of a combined general-regional technique using caudal epidural anesthesia. The etiology, presentation, appropriate workup, and treatment of FIF are presented. Previous anecdotal reports of anesthetic care for excision of FIF are reviewed., Competing Interests: None to declare., (Copyright 2023, Elhamrawy et al.)

Commonly identified risk factors for perioperative cardiac arrest in pediatric-aged patients include cardiac surgery, younger age, comorbid conditions including pulmonary hypertension and cyanotic congenital heart disease, and emergency surgery. Although medication-related etiologies formerly predominated, the elimination of halothane from anesthetic care has resulted in a shift in etiology to hemodynamic events related to blood loss or hyperkalemia associated with the rapid administration of blood products. Rarely, cardiac arrest can be sudden and unexpected without an identified pre-existing etiology in an otherwise apparently healthy patient. We present an 18-year-old adolescent who experienced pulseless electrical activity (PEA) and cardiac arrest following anesthetic care for an outpatient orthopedic procedure, who was eventually diagnosed with hypothyroidism. The potential etiologies of PEA and cardiac arrest during anesthesia are reviewed, components of successful resuscitation discussed, and an outline for the investigative workup presented., Competing Interests: None to declare., (Copyright 2023, Kerbage et al.)