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Background: Postoperative nausea and vomiting (PONV) is a significant problem following paediatric surgery, and volatile anaesthetics are an important cause of this phenomenon. BIS-guided anaesthesia, by reducing the consumption of anaesthetics, leads to a decrease in PONV in adult patients. Study objective: Evaluate the role of BIS-guided anaesthesia in reducing the incidence of paediatric PONV. Design: Prospective, randomized, double-blind study. Setting: A single center study in university hospital in Czech republic, from June 2021 to November 2022. Patients: A total of 163 children, aged 3–8 years with ASA I-II who underwent endoscopic adenoidectomy under general anaesthesia were included. Interventions: In the intervention group, the depth of anaesthesia was maintained to values between 40 and 60 of BIS. Main outcome measure: The primary outcome was the incidence of postoperative nausea and vomiting during 24 h after surgery. Results: The use of BIS-guided anaesthesia led to a significant decrease in the incidence of nausea and vomiting compared to the control group [17% vs. 53%; RR (95%CI) 0.48 (0.27–0.86); p < 0.001and 16% vs. 34%; RR (95%CI) 0.33 (0.20–0.54); p = 0.01, respectively]. Conclusions: BIS-guided anaesthesia decreases the incidence of postoperative nausea and vomiting in children undergoing adenoidectomy. Trial registration: Clinicaltrials.gov identifier: NCT04466579. [ABSTRACT FROM AUTHOR]

Background: Although the efficacy and safety of epidural block (EB) are fairly high, complications such as inadvertent dural puncture may limit its use. Ultrasound-guided quadratus lumborum block (QLB) is a relatively new regional technique that provides perioperative somatic and visceral analgesia for pediatric patients. This trial compared the quality of pain relief in pediatric patients undergoing abdominal surgery who received either QLB or EB. Methods: Patients were randomly allocated into two equal groups: Group E(n = 29): received EB; Group QL(n = 29): received QLB. Both groups were injected with 0.25% bupivacaine (0.5 ml/kg). Assessment of total analgesia consumption was the primary outcome measure, whereas the secondary outcome measures were assessment of postoperative analgesic effect by Children's Hospital of Eastern Ontario Pain Scale (CHEOPS) and time of first analgesic request. Results: Our study showed that the mean total fentanyl consumption was comparable between both groups(38.67 ± 5.02 and 36.47 ± 5.13 µg in the E and QL groups, respectively, P = 0.246). Only five patients did not require rescue analgesia (3 in the E group,2 in the QL group, P = 0.378). The mean duration of analgesia showed no significant difference between the two groups (9.9 ± 1.58 and 11.02 ± 1.74 h in the E and QL groups, respectively, P = 0.212). Evaluation of CHEOPS score values immediately in PACU and for the initial 24 h following operation showed no significant difference between the two study groups(P > 0.05). Conclusion: QLB can achieve analgesic effects comparable to those of EB as a crucial part of multimodal analgesia in children undergoing abdominal surgeries. Clinical trial registration number: PACTR202203906027106. [ABSTRACT FROM AUTHOR]

Background: The exact median effective dose (ED50) of intranasal dexmedetomidine combined with oral midazolam sedation for magnetic resonance imaging (MRI) examination in children remains unknow and the aim of this study was to determine the ED50 of their combination. Methods: This is a prospective dose-finding study. A total of 53 children aged from 2 months to 6 years scheduled for MRI examination from February 2023 to April 2023 were randomly divided into group D (to determine the ED50 of intranasal dexmedetomidine) and group M (to determine the ED50 of oral midazolam). The dosage of dexmedetomidine and midazolam was adjusted according to the modified Dixon's up-and-down method, and the ED50 was calculated with a probit regression approach. Results: The ED50 of intranasal dexmedetomidine when combined with 0.5 mg∙kg− 1 oral midazolam was 0.39 µg∙kg− 1 [95% confidence interval (CI) 0.30 to 0.46 µg∙kg− 1] while the ED50 of oral midazolam was 0.17 mg∙kg− 1 (95% CI 0.01 to 0.29 mg∙kg− 1) when combined with 1 µg∙kg− 1 intranasal dexmedetomidine. The sedation onset time of children with successful sedation in group D was longer than in group M (30.0[25.0, 38.0]vs 19.5[15.0, 35.0] min, P < 0.05). No other adverse effects were observed in the day and 24 h after medication except one dysphoria. Conclusion: This drug combination sedation regimen appears suitable for children scheduled for MRI examinations, offering a more precise approach to guide the clinical use of sedative drugs in children. Trial registration: Chinese Clinical Trial Registry, identifier: ChiCTR2300068611(24/02/2023). [ABSTRACT FROM AUTHOR]

Background: There is limited research on the combined use of propofol and esketamine for anesthesia induction during flexible laryngeal mask airway (FLMA) in pediatric patients, and the effective dosage of propofol for FLMA smooth insertion remains unclear. We explored the effective dose of propofol combined with intravenous esketamine for the smooth insertion of FLMA in two distinct age groups of preschool children. Methods: This is a prospective, observer-blind, interventional clinical study. Based on age, preschool children scheduled for elective surgery were divided into group A (aged 1–3 years) and group B (aged 3–6 years). Anesthesia induction was started with intravenous administration of esketamine (1.0 mg.kg− 1) followed by propofol administration. The FLMA was inserted 2 min after propofol administration at the target dose. The initial dose of propofol in group A and group B was 3.0 mg.kg− 1 and 2.5 mg.kg− 1, respectively. The target dose of propofol was determined with Dixon's up-and-down method, and the dosing interval of propofol was 0.5 mg.kg− 1. If there was smooth insertion of FLMA in the previous patient, the target dose of propofol for the next patient was reduced by 0.5 mg.kg− 1; otherwise, it was increased by 0.5 mg.kg− 1. The median 50% effective dose (ED50) for propofol was estimated using Dixon's up-and-down method and Probit analysis, while the 95% effective dose (ED95) was estimated through Probit analysis. Vital signs and adverse events during induction were recorded. Results: Each group included 24 pediatric patients. Using Dixon's up-and-down method, the ED50 of propofol combined with esketamine for smooth insertion of FLMA in group A was 2.67 mg.kg− 1 (95%CI: 1.63–3.72), which was higher than that in group B (2.10 mg. kg− 1, 95%CI: 1.36–2.84) (p = 0.04). Using Probit analysis, the ED50 of propofol was calculated as 2.44 (95% CI: 1.02–3.15) mg.kg− 1 in group A and 1.93 (95% CI: 1.39–2.32) mg.kg− 1 in group B. The ED95 of propofol was 3.72 (95%CI: 3.07–15.18) mg.kg− 1 in group A and 2.74 (95%CI: 2.34–5.54) mg.kg− 1 in group B. In Group B, one pediatric patient experienced laryngospasm. Conclusion: The effective dose of propofol when combined with intravenous esketamine for smooth insertion of FLMA in children aged 1–3 years is 2.67 mg.kg− 1, which is higher than that in children aged 3–6 years (2.10 mg. kg− 1). Trial registration: Chinese Clinical Trial Registry Center (Registration Number: ChiCTR2100044317; Registration Date: 2021/03/16) [ABSTRACT FROM AUTHOR]

Background: Emergence agitation (EA) is a prevalent complication in children following general anesthesia. Several studies have assessed the relationship between melatonin or its analogs and the incidence of pediatric EA, yielding conflicting results. This meta-analysis aims to assess the effects of premedication with melatonin or its analogs on preventing EA in children after general anesthesia. Methods: PubMed, EMBASE, the Cochrane Library, ProQuest Dissertations & Theses Global, Web of Science, CNKI, Wanfang Data, clinicaltrials.gov, and WHO International Clinical Trials Registry Platform were searched until 25 November 2022. We included randomized controlled trials that assessed EA in patients less than 18 years old who underwent general anesthesia. We excluded studies that did not use a specific evaluation to assess EA. Results: Nine studies (951 participants) were included in this systematic review. Melatonin significantly reduced the incidence of EA compared with placebos (risk ratio 0.40, 95% CI 0.26 to 0.61, P < 0.01) and midazolam (risk ratio 0.48, 95% CI 0.32 to 0.73, P < 0.01). Dexmedetomidine remarkably decreased the incidence of EA compared with melatonin (risk ratio 2.04, 95% CI 1.11 to 3.73, P = 0.02). Conclusions: Melatonin premedication significantly decreases the incidence of EA compared with placebos and midazolam. Dexmedetomidine premedication has a stronger effect than melatonin in preventing EA. Nevertheless, further studies are warranted to reinforce and validate the conclusion on the efficacy of melatonin premedication in mitigating EA in pediatric patients. [ABSTRACT FROM AUTHOR]

Background: Tetralogy of Fallot (TOF) is a common cyanotic congenital heart malformation that carries a high risk of right-to-left shunting. Anemia is characterized by decreased hemoglobin (Hb) levels that can affect tissue oxygen delivery and impact postoperative recovery in patients. Chronic hypoxia caused by right-to-left shunting of TOF could lead to compensatory increases in Hb to maintain systemic oxygen balance. This study aims to investigate whether preoperative Hb and blood oxygen saturation (SpO2) can predict adverse outcomes in children undergoing corrective surgery for TOF. Methods: This retrospective study included patients under 18 years of age who underwent corrective surgery for TOF at Fuwai Hospital between January 2016 and December 2018. Adverse outcomes, including in-hospital death, extracorporeal membrane oxygenation implantation, ICU stay > 30 days, and severe complications, were considered as the primary outcome. Univariable and multivariable logistic analyses were performed to identify independent risk factors for adverse outcomes. Propensity score-matched (PSM) analysis was also conducted to minimize the confounding factors. Results: A total of 596 children were included in the study, of which 64 (10.7%) experienced adverse outcomes. Hb*SpO2 < aaHb was identified as an independent risk factor for adverse outcomes (OR = 2.241, 95% CI = 1.276–3.934, P = 0.005) after univariable and multivariable logistic analyses. PSM analysis further confirmed the association between Hb*SpO2 < aaHb and adverse outcomes. Patients with Hb*SpO2 < aaHb had a significantly higher incidence of postoperative adverse outcomes, longer time of mechanical ventilation, and hospital stay, as well as higher in-hospital costs. Conclusions: Hb*SpO2 < aaHb is significantly associated with adverse outcomes in children undergoing corrective surgery for TOF. Clinicians can use this parameter to early identify high-risk children and optimize their postoperative management. [ABSTRACT FROM AUTHOR]

Background: After pediatric cardiosurgical interventions, postoperative delirium can occur, which can be associated with undesirable consequences during and after the hospital stay. It is therefore important to avoid any factors causing delirium as far as possible. Electroencephalogram (EEG) monitoring can be used during anesthesia to individually adjust dosages of hypnotically acting drugs. It is necessary to gain knowledge about the relationship between intraoperative EEG and postoperative delirium in children. Methods: In a dataset comprising 89 children (53 male, 36 female; median age: 0.99 (interquartile range: 0.51, 4.89) years) undergoing cardiac surgery involving use of a heart–lung machine, relationships between depth of anesthesia as measured by EEG (EEG index: Narcotrend Index (NI)), sevoflurane dosage, and body temperature were analyzed. A Cornell Assessment of Pediatric Delirium (CAP-D) score ≥ 9 indicated delirium. Results: The EEG could be used in patients of all age groups for patient monitoring during anesthesia. In the context of induced hypothermia, EEG monitoring supported individually adjusted sevoflurane dosing. The NI was significantly correlated with the body temperature; decreasing temperature was accompanied by a decreasing NI. A CAP-D score ≥ 9 was documented in 61 patients (68.5%); 28 patients (31.5%) had a CAP-D < 9. Delirious patients with an intubation time ≤ 24 h showed a moderate negative correlation between minimum NI (NImin) and CAP-D (rho = -0.41, 95% CI: -0.70 – -0.01, p = 0.046), i.e., CAP-D decreased with increasing NImin. In the analysis of all patients' data, NImin and CAP-D showed a weak negative correlation (rho = -0.21, 95% CI: -0.40 – 0.01, p = 0.064). On average, the youngest patients had the highest CAP-D scores (p = 0.002). Patients with burst suppression / suppression EEG had a longer median intubation time in the intensive care unit than patients without such EEG (p = 0.023). There was no relationship between minimum temperature and CAP-D score. Conclusions: The EEG can be used to individually adjust sevoflurane dosing during hypothermia. Of the patients extubated within 24 h and classified as delirious, patients with deeper levels of anesthesia had more severe delirium symptoms than patients with lighter levels of anesthesia. [ABSTRACT FROM AUTHOR]

Background: It is believed that negative postoperative behavioral changes (NPOBC) is associated with negative perioperative outcomes in children. The importance of development of a predictive model of NPOBC was noted. This study aims to identify potential risk factors develop a nomogram to predict NPOBC on postoperative day 3 based on a prospective cohort. Methods: A prospective observational study was conducted on children(American Society of Anesthesiologists I ~ III) aged 2 ~ 12 years who underwent selective surgery under general anesthesia between September 2022 and February 2023. The patient's clinical data were analyzed. The method of measuring NPOBC is with the The Posthospital Behaviour Questionnaire (PHBQ), and all of children remained hospitalized at the time of assessment. The enrolled patients were categorized into the NPOBC group and the non-NPOBC group according to if children developed NPOBC on postoperative day 3. Univariate and multivariate logistic regression analyses were performed to identify independent risk factors and develop the nomogram to predict NPOBC. Internal validation was performed using the parametric bootstrapping method. Results: One hundred ninety-two patients were enrolled in the study, 44.8% (86/192 patients) of children developed NPOBC on postoperative day 3. Univariate and multivariate logistic regression analysis demonstrated that the Pediatric Anesthesia Behavior (PAB) score (OR: 1.23, 95%CI: 1.14–1.33), cerebral desaturation (OR: 1.16, 95%CI: 1.02–1.32), and postoperative pain score (OR: 1.07, 95%CI: 1.02–1.13) were independent predictors for NPOBC on postoperative day 3 (P < 0.05). They were used to develop the prediction model. The calibration curve demonstrated satisfied discrimination and calibration of the prediction model. The model presented with good discriminative ability (area under the receiver operating characteristic curve: 0.762 [95%CI: 0.691—0.833]). The decision curve analysis also revealed the great clinical utility of the nomogram. Conclusion: Based on our prospective observational study, pre-anesthesia patients with higher PAB scores, presence of cerebral desaturation, and higher postoperative pain score were more likely to develop NPOBC on postoperative day 3. We established and validated a nomogram for predicting NPOBC, which could help assess patients individually, identify high-risk groups of NPOBC and improve patient prognosis. Trial registration: Chinese Clinical Trial Registry, ChiCTR‐2,200,059,776. Registered 11 May 2022. [ABSTRACT FROM AUTHOR]

Background: Propofol is the most commonly used drug for procedural sedation during gastroscopy. However, independent use of propofol can lead to increased dosage and additional side effects. Esketamine was found to be exceptional in combination with propofol for painless gastroscopy. No studies have calculated the median effective dose (ED50) of esketamine combined with propofol in pediatric painless gastroscopy. Here, we designed a research to study the ED50 of esketamine combined with propofol using the Dixon and Massey up-and-down sequential method for inhibiting the response of gastroscope insertion. Methods: Children who met the inclusion and exclusion criteria were included in this study. Propofol and esketamine were used as anesthetics for painless gastroscopy in children. To explore the ED50, the initial propofol dose was set at 3 mg/kg in all children. The first child was given an esketamine dose of 0.1 mg/kg, followed by 30 s of slow bolus injection propofol. If anesthesia induction failed (coughing or body movement of children during gastroscope insertion), the esketamine dose was elevated in the next child, with a interval difference of 0.05 mg/kg. Otherwise, if the anesthesia induction was successful, the next dosage was reduced by 0.05 mg/kg. The study was stopped if nine crossover inflection points were reached. The ED50 of esketamine was calculated using probit regression, and the blood pressure, pulse oxygen saturation, heart rate, recovery time, and side effects were recorded in all children. Results: A total of 26 children were included in this study. The ED50 of esketamine combined with 3 mg/kg propofol was 0.143 mg/kg (95% CI 0.047–0.398 mg/kg). The total consumption of propofol was 16.04 ± 5.37 mg. The recovery time was 16.38 ± 8.70 min. Adverse effects recorded were delayed awakening in two cases and increased oral secretions of another child during the examination inducing cough and hypoxemia (86% was the lowest). Discussion: The ED50 of esketamine was 0.143 mg/kg when combined with 3 mg/kg propofol for successful sedation in pediatric gastroscope insertion. This sub-anaesthetic dose of esketamine was safe and efficacious with few complications in pediatric painless gastroscopy. Trial registration: The study was registered at the Chinese Clinical Trial Registry (www.chictr.org.cn; registration number: ChiCTR2100052830 on 06/11/2021). [ABSTRACT FROM AUTHOR]

Background: Atelectasis during general anesthesia is a risk for perioperative complications. EIT measurements were performed in mechanically ventilated healthy children during elective surgery to demonstrate the changes in ventilation distribution during general anesthesia. The ventilation distribution was quantified by calculating the Global Inhomogeneity index (GI). Methods: EIT measurements were performed in 23 children (9 weeks—10 years) without lung disease to detect changes in regional ventilation during elective surgery. Three previously defined time points were marked during the measurement: after intubation and start of pressure-controlled ventilation (PCV), change to pressure support ventilation (PSV), and after extubation (spontaneous breathing—SB). Ventilation distribution based on regions of interest (ROI) and changes in end-expiratory volume (∆EELV) were collected at these time points and compared. The Global Inhomogeneity index was calculated at the beginning of pressure-controlled ventilation (PCV). Results: With increasing spontaneous breathing, dorsal recruitment of atelectasis occurred. The dorsal ventilation fraction increased over the time of general anesthesia with increasing spontaneous breathing, whereas the ventral fraction decreased relatively (Difference ± 5.5 percentage points respectively; 95% CI; 3.5—7.4; p < 0.001). With the onset of spontaneous breathing, there was a significant reduction in end-expiratory volume (Difference: 105 ml; 95% CI, 75–135; p < 0.001). The GI of the lung-healthy ventilated children is 47% (SD ± 4%). Conclusion: Controlled ventilation of healthy children resulted in increased ventilation of the ventral and collapse of the dorsal lung areas. Restart of spontaneous breathing after cessation of surgery resulted in an increase in ventilation in the dorsal with decrease in the ventral lung areas. By calculating the GI, representing the ratio of more to less ventilated lung areas, revealed the presumed homogeneous distribution of ventilation. Trial registration: ClinicalTrials.gov Registration ID: NCT04873999. First registration: 05/05/2021. [ABSTRACT FROM AUTHOR]

Background: High mobility group box 1 (HMGB1) protein is one of the main risk factors for pediatric acute respiratory distress syndrome (PARDS) after living donor liver transplantation (LDLT). However, studies of the relationship between HMGB1 and PARDS are lacking. We evaluated the link between anomalies of intraoperative serum HMGB1 and PARDS in pediatric LDLT recipients with biliary atresia during the first week after transplant. Methods: Data for 210 pediatric patients with biliary atresia who underwent LDLT between January 2018 and December 2021 were reviewed retrospectively. The main measure was serum HMGB1 levels 30 min after reperfusion, while the outcome was early PARDS after LDLT. Data including pretransplant conditions, laboratory indexes, variables of intraoperation, clinical complications, and outcomes after LDLT were analyzed for each patient. Univariate analysis of PARDS and multivariate logistic regression analyses of serum HMGB1 levels at 30 min in the neohepatic phase in the presence of PARDS were conducted to examine the potential associations. Subgroup interaction analyses and linear relationships between intraoperative serum HMGB1 levels and PARDS were also performed. Results: Among the participants, 55 had PARDS during 7 days after LDLT, including four in the first HMGB1 tertile (4.3–8.1 pg/mL), 18 in the second tertile (8.2–10.6 pg/mL), and 33 in the third tertile (10.6–18.8 pg/mL). The nonadjusted association between intraoperative HMGB1 levels and PARDS was positive (odds ratio 1.41, 95% confidence intervals 1.24–1.61, P < 0.0001). The association remained unchanged after adjustment for age, weight, pretransplant total bilirubin, albumin, graft cold ischemia time, and intraoperative blood loss volume (odds ratio 1.28, 95% confidence interval 1.10–1.49, P = 0.0017). After controlling for potential confounders, the association between intraoperative HMGB1 levels and PARDS remained positive, as well as in the subgroup analyses. Conclusions: Serum HMGB1 levels at 30 min after reperfusion were positively associated with early PARDS among pediatric patients with biliary atresia who had undergone LDLT. Identifying such patients early may increase the efficacy of perioperative respiratory management. [ABSTRACT FROM AUTHOR]

Background: Surgical repair of inguinal hernia is one of the most common day case surgeries in the pediatric population. This study compared the postoperative analgesic effects of transversalis fascia plane block (TFB) versus quadratus lumborum block (QLB) in children scheduled for open unilateral inguinal herniotomy. Methods: In this prospective, randomized, double-blind, controlled non-inferiority study, 76 eligible patients were recruited. Patients were randomly allocated to either the TFB or QLB group. The primary outcome measure was the proportion of patients who needed rescue analgesia during the first postoperative 12 h. The secondary outcomes were, the time needed to perform the block, the postoperative FLACC score, intraoperative heart rate (HR) and mean arterial pressure (MAP). Results: The proportion of patients who required a rescue analgesic was comparable (p = 1.000) between the TFB group (7/34, 20.5%) and the QLB group (6/34, 17.6%). The median [Q1-Q3] time needed to perform the block (min) was significantly longer (p < 0.001) in the QLB group (5[5]) compared with the TFB group. The postoperative FLACC pain scale was comparable between the two groups at all-time points of assessment. There is no difference regarding the heart rate and mean arterial blood pressure values at the time points that the values were recorded. (P > 0.005). Conclusions: Both TFB and QLB similarly provide good postoperative analgesia by reducing the proportion of patients who required rescue analgesia, pain scores and analgesic consumption. Moreover, TFB is technically easier than QLB. [ABSTRACT FROM AUTHOR]

Backgrounds: To preliminary evaluate the application of novel SaCoVLM video laryngeal mask -guided intubation for anesthetized children. Methods: One hundred twenty-four children with microtia (ages 5-15 years,) who required general intubation anaesthesia, were enrolled in the study. After induction of general anesthesia,guided tracheal intubation under direct vision of the SaCoVLM was performed. Our primary outcome was first-pass success rate of guided tracheal tube placement. Secondary outcome included glottic visualization grades, the first-attempt success rate of LMA placement, the time for LMA placement and time to endotracheal intubation as well as the time for LMA removal after successful intubation, the fiberoptic grade of laryngeal view, the baseline and postinduction hemodynamic parameters were also recorded,and the incidence 24 h complications after operation. Results: The first-pass success rate of guided tracheal tube placement was 91.1% (95%CI = 1.04–1.14), the status of glottic visualization was classified: grade 1 in 27cases, grade 2 in 36 cases, grade 3 in 41 cases and grade 4 in 20 cases. The first success rate of LMA placement was 92.7% (95%CI = 1.03–1.13), the time for LMA insertion was 15.7 (±9.1) s, intubation time was 30.9 (±17.6) s and withdrawl time was 24.9 (±9.3) s. The incidence of postoperative sore throat at 2 h was 29%, and 16.1% at 24 h, without dysphagia and hypoxia. Conclusion: The SaCoVLM video laryngeal mask-guided intubation is feasible in children, with a high success rate, could be a new promising device to guide intubation in airway management. Trial registration: This study was approved by the University's Institutional Review Board and written informed consent was obtained from all subjects participating in the trial. The trial was registered prior to patient enrollment at clinicaltrials.gov (ChiCTR2200061481, http://www.chictr.org.cn. Principal investigator: Juan Zhi; Date of registration: 26/06/2022. [ABSTRACT FROM AUTHOR]

Background: Assessement of the pattern of admission and treatment outcomes of critically ill pediatrics admitted to pediatric intensive care units (PICU) in developing countries is crucial. In these countries with resource limitations, it may help to identify priorities for resource mobilization that may improve patient service quality. The PICU mortality rate varies globally, depending on the facilities of the intensive care unit, availability of experties, and admission patterns. This study assessed the admission pattern, treatment outcomes, and associated factors for children admitted to the PICU. Methods: A retrospective cross-sectional study was implemented on 406 randomly selected pediatrics patients admitted to the PICU of Tikur Anbessa Specialized Hospital from 1-Oct-2018 to 30-Sept-2020. The data were collected with a pretested questionnaire. A normality curve was used to check for data the distribution. Both bivariable and multivariable analyses were used to see association of variables. A variable with a p-value of < 0.2 in the bivariable model was a candidate for multivariate analysis. The strength of association was shown by an adjusted odds ratio (AOR) with a 95% Confidence interval (CI), and a p-value of < 0.05 was considered statistically significant. Frequency, percentage,and tables were used to present the data. Results: A total of 361 (89% response rate) patient charts were studied, 197 (54.6%) were male, and 164(45.4%) were female. The most common pattern for admission was a septic shock (27.14%), whereas the least common pattern was Asthma 9(2.50%). The mortality rate at the pediatric intensive care unit was 43.8%. Moreover, mechanical ventilation need (AOR = 11.2, 95%CI (4.3–28.9), P < 0.001), need for inotropic agents (AOR = 10.7, 95%CI (4.1–27.8), P < 0.001), comorbidity (AOR =8.4, 95%CI (3.5–20.5), P < 0.001), length of PICU stay from 2 to 7 days (AOR = 7.3, 95%CI (1.7–30.6), P = 0.007) and severe GCS (< 8) (AOR = 10.5, 95%CI (3.8–29.1), P < 0.001) were independent clinical outcome predictors (mortality). Conclusion: The mortality rate at the PICU was 43.8%. Septic shock, and meningitis were the common cause of death and the largest death has happened in less than 7 days of admission. [ABSTRACT FROM AUTHOR]

Background: Propofol, a widely used sedative in endoscopic procedures, sometimes causes cardiopulmonary complications. Intravenous lidocaine can diminish visceral pain and decrease the dose of propofol. The purpose of this study was to assess the efficacy and safety of intravenous lidocaine in reducing propofol dosage during paediatric colonoscopy. Methods: Forty children who underwent colonoscopy were divided into two groups. Lidocaine hydrochloride (1.5 mg/kg induction and 2 mg/kg/h maintenance) was given intravenously to the lidocaine group, and the same amount of saline was given to the control group after they received lidocaine induction. Propofol initial plasma concentration of 5 μg/mL was targeted, and the procedure was performed after the bispectral index value reached 55. The primary outcome was propofol requirement. Results: The propofol requirement in the lidocaine group was decreased by 35.5% (128.6 ± 30.4 mg vs. 199.4 ± 57.6 mg; p < 0.001; 95%CI: − 100.60, − 41.02). The incidence of involuntary body movements was significantly lower in the lidocaine group (p = 0.028; OR = 0.17; 95%CI: 0.03, 0.92). The awakening time (p < 0.001; 95%CI: − 7.67, − 5.13) and recovery times (p < 0.001; 95%CI: − 7.45, − 4.35) were significantly lower in the lidocaine group. Pain was significantly less at 30 min and 60 min after the procedure in the lidocaine group (0 [0–4] vs. 3 [0–5], p < 0. 001; 0 [0–2] vs. 1 [0–3], p = 0.001). There was no difference in the incidence of bradycardia, hypotension, or hypoxia between the two groups. Conclusions: For colonoscopy procedures in paediatric patients, intravenous lidocaine reduces the amount of propofol needed, provides better sedation and postprocedural pain management, as well as a reduction in recovery time. Trial registration: The trial was registered on November 6, 2020 at China Clinical Trials Registration Center (www.chictr.org.cn) ref.: ChiCTR 2,000,039,706. [ABSTRACT FROM AUTHOR]

Background: Pain control during dental procedures is one of the most important topics related to behavior management in children. This study aims to compare the pain perception associated with a needle-free system (Comfort-In™) and the dental needle method during filling and pulpotomy treatments in children. Methods: The study included teeth that required treatment (pulpotomy or filling treatment) in 56 patients aged 4 to 11 years with no systemic problems or history of allergy. Patients were randomly divided into the needle-free system group (filling treatment, n = 13; pulpotomy, n = 15) and dental needle method group (filling treatment, n = 14; pulpotomy, n = 14). For pulpotomy and filling treatment performed with 0.3 mL anesthesia, the active ingredient of which is 2% lidocaine and 1/80000 epinephrine. The patients' behavior before the procedure was evaluated by a pediatric dentist using the Frankl Behavior Scale. The pain intensity was assessed Immediately after injection (induction), during treatment (treatment), and at the end of the treatment (post treatment) by the Wong-Baker Faces Pain Scale. Results: The median (IQR-InterQuartile Range) induction pain value was 6[3-8] and 2[0-4] in dental needle method and needle-free system respectively, p < 0.001). In filling and pulpotomy treatment group, no difference between the needle and needle-free group for treatment and post-treatment pain values. Conclusions: For pulpotomy and filling treatment, needle-free system performed with 0.3 mL anesthesia was found as effective as infiltrative anesthesia with a dental needle method. Trial registration: ClinicalTrials.gov, NCT04653974. Registered 4 December 2020 – Retrospectively registered. [ABSTRACT FROM AUTHOR]

Background: Emergence delirium (ED) is common in pediatric patients undergoing general anesthesia with sevoflurane. Preoperative sleep quality is associated with the risk factors for ED. However, research on the relationship between sleep quality and ED is limited. We aimed to investigate the relationship between ED and preoperative sleep quality in pediatric patients undergoing strabismus surgery. Methods: This clinical trial included pediatric patients aged 4–12 years who underwent elective strabismus surgery. The patients and their parents were questioned about the patients' preoperative sleep quality using the Pittsburgh Sleep Quality Index (PSQI) questionnaire. For anesthesia induction, thiopental (5 mg/kg) and rocuronium (0.6 mg/kg) were used, and anesthesia was maintained with sevoflurane (minimum alveolar concentration, 1–1.5). After administration of a reversal drug, extubation was performed, and the patients were transferred to a post-anesthesia recovery unit. At 10 min after extubation, the degree of ED was measured using the pediatric anesthesia emergence delirium (PAED) and Watcha scale scores. Results: Of the 62 enrolled patients, three pediatric patients were excluded. The overall incidence of ED was 22%. A total of 59 patients were divided into the two groups. The ED group and the non-ED group comprised 13 and 46 patients. Age, height and weight were significantly lower in the ED group than in the non-ED group. Preoperative PSQI and Watcha scale score were significantly higher in the ED group than in the non-ED group. Multivariate analysis showed that age (adjusted OR [95% CI]: 0.490 [0.290–0.828], p = 0.008) and preoperative PSQI score (adjusted OR [95% CI]: 2.149[1.224–3.771], p = 0.008) was associated with ED. In sub-group analysis, PAED scale and Watcha scale scores showed a moderate correlation with preoperative sleep quality in preschool-age patients. Conclusion: In conclusion, the incidence of ED tended to be higher in younger age and poorer preoperative sleep quality in pediatric patients. In particular, the poorer sleep quality score was associated with higher incidence of ED in the preschool-age. Large-scale clinical studies and long-term follow-up studies on ED and sleep quality are required. Trial registration: This study was registered with Clinicaltrials.gov (NCT03332407) at November 5th 2017. [ABSTRACT FROM AUTHOR]

Background: Continuous infusion of propofol has been used to achieve sedation in children. However, the relationship between the effect-site concentration (Ce) of propofol and sedation scale has not been previously examined. The objective of this study was to investigate the relationship between the Ce of propofol and the University of Michigan Sedation Scale (UMSS) score in children with population pharmacodynamic modeling. Methods: A total of 30 patients (aged 3 to 6 years) who underwent surgery under general anesthesia with propofol and remifentanil lasting more than 1 h were enrolled in this study. Sedation levels were evaluated using the UMSS score every 20 s by a 1 μg/mL stepwise increase in the Ce of propofol during the induction of anesthesia. The pharmacodynamic relationship between the Ce of propofol and UMSS score was analyzed by logistic regression with nonlinear mixed-effect modeling. Results: The estimated Ce50 (95% confidence interval) of propofol to yield UMSS scores equal to or greater than n were 1.84 (1.54–2.14), 2.64 (2.20–3.08), 3.98 (3.66–4.30), and 4.78 (4.53–5.03) μg/mL for n = 1, 2, 3, and 4, respectively. The slope steepness for the relationship of the Ce versus sedative response to propofol (95% confidence interval) was 5.76 (4.00–7.52). Conclusions: We quantified the pharmacodynamic relationship between the Ce of propofol and UMSS score, and this finding may be helpful to predict the sedation score at the target Ce of propofol in children. Trial registration: http://www.clinicaltrials.gov (No.: NCT03195686, Date of registration: 22/06/2017). [ABSTRACT FROM AUTHOR]

Background: Megaloblastic anemia or bone marrow changes could occur after prolonged nitrous oxide inhalation via vitamin B12 inactivation related DNA synthesis impairment. Previous researches have studied hematological changes with nitrous oxide exposure, but only in adults or adolescents. Pre-school age children with active hematopoietic red bone marrow are more vulnerable to potential side effects of nitrous oxide and might experience growth impairment. The purpose of our study was to analyze red blood cell morphology changes under nitrous oxide anesthesia in pre-school age children. Methods: One hundred thirty-six children under 5 years old scheduled for hemivertebra resection were analyzed. According to fresh gas type in anesthesia records, 71 children who received nitrous oxide in oxygen during anesthesia maintenance were categorized into the nitrous oxide group and the other 65 who received air in oxygen were the air group. Complete blood counts in perioperative period were assessed for anemia, macrocytosis, microcytosis, anisocytosis, hyperchromatosis and hypochromatosis. The peak value and change percentage were calculated for mean corpuscular volume and red cell distribution width. Results: Forty-two children in the air group (64.6%) and 30 in the nitrous oxide group (42.3%) developed anemia (P = 0.009). None developed macrocytosis in both groups. Postoperative mean corpuscular volume peaked (mean [95% confidence interval]) at 83.7(82.9–84.4) fL, and 83.2(82.4–83.9) fL and postoperative red cell distribution width at 13.8% (13.4–14.2%), and 13.9% (13.6–14.2%) for the air group and the nitrous oxide group. Both the relative change of mean corpuscular volume (P = 0.810) and red cell distribution width (P = 0.456) were similar between the two groups. Conclusions: No megaloblastic red blood cell changes were observed with nitrous oxide exposure for 4 h in pre-school age children undergoing hemivertebra resection. [ABSTRACT FROM AUTHOR]

Background: The aim of our study was to identify the factors associated with unplanned reoperations among neonates who had undergone primary repair of gastrointestinal disorders. Methods: A retrospective chart review was conducted for neonates who underwent primary gastrointestinal surgery between July 2018 and September 2020. The neonates were divided into two cohort, depending on whether they had an unplanned reoperation. The primary outcome was the occurrence of unplanned reoperation. The risk factors that associated the occurrence of unplanned reoperation were examined. Main results: Two hundred ninety-six neonates fulfilled the eligibility criteria. The incidence of unplanned reoperation was 9.8%. Analyses of all patients with respect of developing unplanned reoperation showed that the length of operative time was an independent risk factor [Odds Ratio 1.02; 95% confidence interval 1.00, 1.04; p = 0.03]. Patients with unplanned reoperation had a longer postoperative hospital length-of-stay [19.9 ± 14.7 vs. 44.1 ± 32.1 days; p<0.01]. Conclusion: The current study is the first analysis of risk factors associated with an unplanned reoperation in neonates undergoing primary repair of gastrointestinal disorders. The length of operative time is the only risk factor for an unplanned reoperation, and the unplanned reoperation can directly prolong the postoperative hospital length-of-stay. Trial registration: This study was registered at http://www.chictr.org.cn/index.aspx with No. ChiCTR2000040260. [ABSTRACT FROM AUTHOR]

Background: Infection is a major complication following cerebral spinal fluid (CSF) diversion procedures for hydrocephalus. However, pediatric risk factors for surgical site infection (SSI) are currently not well defined. Because a SSI prevention bundle is increasingly introduced, the purpose of this study was to evaluate risk factors associated with SSIs following CSF diversion surgeries following a SSI bundle at a single quaternary care pediatric hospital. Methods: We performed a retrospective cohort study of patients undergoing CSF diversion procedures from 2017 to 2019. SSIs were identified prospectively through continuous surveillance. We performed unadjusted logistic regression analyses and univariate analyses to determine an association between SSIs and patient demographics, comorbidities and perioperative factors to identify independent risk factors for SSI. Results: We identified a total of 558 CSF diversion procedures with an overall SSI rate of 3.4%. The SSI rates for shunt, external ventricular drain (EVD) placement, and endoscopic third ventriculostomy (ETV) were 4.3, 6.9 and 0%, respectively. Among 323 shunt operations, receipt of clindamycin as perioperative prophylaxis and presence of cardiac disease were significantly associated with SSI (O.R. 4.99, 95% C.I. 1.27–19.70, p = 0.02 for the former, and O.R. 7.19, 95% C.I. 1.35–38.35, p = 0.02 for the latter). No risk factors for SSI were identified among 72 EVD procedures. Conclusion: We identified receipt of clindamycin as perioperative prophylaxis and the presence of cardiac disease as risk factors for SSI in shunt procedures. Cefazolin is recommended as a standard antibiotic for perioperative prophylaxis. Knowing that unsubstantiated beta-lactam allergy label is a significant medical problem, efforts should be made to clarify beta-lactam allergy status to maximize the number of patients who can receive cefazolin for prophylaxis before shunt placement. Further research is needed to elucidate the mechanism by which cardiac disease may increase SSI risk after shunt procedures. [ABSTRACT FROM AUTHOR]

Background: Patient blood management programs should be applied to the pediatric population, but little is known about the current transfusion practice of pediatric burn injury patients. This retrospective study was performed to evaluate the practice of red blood cell (RBC) transfusion in children with burn injury, their predictive factors, and adherence to the German transfusion guideline. Methods: We reviewed the RBC transfusion practice of all children younger than 8 years with burn injury who were operated during a four-year period in a German university medical center. We analyzed the data associated with transfusion and guideline conformity of transfusion triggers for RBCs from the beginning to the end of hospital stay using logistic regression. Results: During the four-year period, 138 children (median age 21 months, minimum-maximum 9–101 months) with burn injury needed surgery, 31 children were transfused with RBCs. During their hospital stay, the median hemoglobin concentrations (Hb) of transfused and non-transfused children were 8 g/dL (6.3–11.3 g/dL) and 10.7 (7–13.8 g/dL), respectively. Total body surface area burned (TBSA) (OR = 1.17 per % TBSA, 95% CI = [1.05; 1.30], p = 0.0056), length of surgery (OR = 1.016 per minute, 95% CI = [1.003; 1.028], p = 0.0150), and Hb (OR = 0.48 per 1 g/dl in Hb, 95% CI = [0.24; 0.95], p = 0.0343) were associated with transfusion while other factors (age, gender, ASA, and catecholamines) did not show notable association. Length of stay was mainly influenced by TSBA (+ 1.38 days per %, p < 0.0001), age (+ 0.21 days per month, p = 0.0206), and administering of catecholamines (+ 14.3 days, p = 0.0118), but not by RBC transfusion. The decision to transfuse was in 23% too restrictive and in 74% too liberal according to the German guidelines. Conclusions: Amount of TBSA, length of surgery, and Hb influenced the RBC transfusion rate in burned children. However, age and length of stay were not affected by transfusion of RBCs. In clinical practice of burned children, physicians follow a more liberal transfusion strategy than the proposed in guidelines. [ABSTRACT FROM AUTHOR]

Background: Children require anesthesia for MRI to maintain immobility and reduce discomfort; clear indications about the best anesthesiologic management are lacking and each center developed its own protocol. Moreover, children with neuropsychiatric disorders more likely require sedation and are described in literature as more prone to general and respiratory complications. Aim of this study was to analyze the applicability of a sevoflurane-based approach, to describe general and respiratory complications and to identify risk factors in a pediatric neuropsychiatric population. Methods: Retrospective cohort study, university Hospital (January 2007–December 2016). All the 1469 anesthesiologic records of children addressed from Neuropsychiatric Unit to undergo MRI under general anesthesia were analyzed; 12 patients equal or older than 18-year-old were excluded. We identified post-hoc nine macro-categories: static encephalopathies, metabolic/evolutive encephalopathies, epileptic encephalopathies, neuromuscular diseases, autistic spectrum disorders, migraine, psychiatric disorders, intellectual disabilities, others. A logistic regression model for events with low frequency (Firth's penalized likelihood approach) was carried out to identify the mutually adjusted effect among endpoints (complications) and the independent variables chosen on the basis of statistical significance (univariate analysis, p ≤ 0.05) and clinical judgment. Results: Of 1457 anesthesiologic records (age 4.0 (IQR 2.0 to 7.0) year-old, males 891 (61.2%), weight 17.0 (IQR 12.0 to 24.9) kg), 18 were cancelled for high anesthesiologic risk, 50 were cooperative, 1389 were anesthetized. A sevoflurane-based anesthesia was feasible in 92.3%; these patients required significantly less mechanical ventilation (8.6 vs. 16.2%; p = 0.012). Complications' rate was low (6.2%; 3.1% respiratory). The risk for general complications increases with ASA score > 1 (OR 2.22, 95 CI% 1.30 to 3.77, p = 0.003), male sex (OR 1.73, 95% CI 1.07 to 2.81, p = 0.025), multi-drug anesthesia (OR 2.98, 95 CI% 1.26 to 7.06, p = 0.013). For respiratory complications, it increases with ASA score > 1 (OR 2.34, 95 CI% 1.19 to 4.73, p = 0.017), autumn-winter (OR 2.01, 95 CI% 1.06 to 3.78, p = 0.030), neuromuscular disorders (OR 3.18, 95 CI% 1.20 to 8.41, p = 0.020). We had no major complications compromising patients' outcome or requiring admission to ICU. Conclusions: Sevoflurane anesthesia is feasible and safe for children affected by neuropsychiatric disorders undergoing MRI. Specific risk factors for general and respiratory complications should be considered. [ABSTRACT FROM AUTHOR]

Background: General anesthesia has been linked to impaired brain development in immature animals and young children. In this study the influence of orthopedic surgery under general anesthesia on the intelligence of school age children has been evaluated. Methods: A total of 209 subjects aged 6-12 years were recruited and allocated into 4 groups according to the duration of general anesthesia, including a control group (n = 30), short (< 1 h, n = 49), moderate- (1-3 h, n = 51) and long-duration groups (> 3 h, n = 79), respectively. The intelligence quotient (IQ) of the subjects was measured by the Raven's Standard Progressive Matrices (RSPM) before and after orthopedic surgery under general anesthesia of various durations (vide supra). Results: The IQ score decreased significantly in the long-duration group at 1 month post-operation compared with the pre-operation score (P < 0.001), and IQ did not recover completely at 3 months postoperatively (P < 0.05), but had recovered when measured at the 1-year follow-up. Moreover, this study showed that the development of children's intelligence was affected by the exposure time to anesthetics at a younger age (OR = 5.26, 95% CI:2. 70-8.41, P < 0.001), having a mother with a low education level (OR = 2.71, 95% CI:1.24-6.14, P = 0.014) and premature birth (OR = 2.76, 95% CI:1.34-5.46, P = 0.005). Conclusions: More than 3 h general anesthesia influenced the IQ of school age children for up to 3 months after orthopedic surgery. Beside extended exposure time to anesthetics additional factors for post-operative IQ reduction were younger children age, mothers with low educational levels and premature birth. Trial registration: Chinese Clinical Trial Registry with registration number ChiCTR-OOC-17013497 retrospectively registered on 11/23/2017. [ABSTRACT FROM AUTHOR]

Background: Dexmedetomidine can be used for the prevention of emergence agitation (EA) in children. However, an inadequate dose of dexmedetomidine can induce prolonged sedation and cardiovascular complications. The aim of this study was to evaluate the effective dose of dexmedetomidine for the prevention of EA after desflurane anesthesia for patients undergoing a tonsillectomy or adenoidectomy. Methods: We enrolled 21 unpremedicated children, between 2 and 12 years, undergoing either a tonsillectomy or an adenoidectomy. General anesthesia was induced using sevoflurane and oxygen, and dexmedetomidine was administered before surgery. Anesthesia was maintained using desflurane resulting in a BIS range of 40-60. In the postanesthetic care unit (PACU), EA (agitation measured at level 4 or more at least once) was assessed on arrival in the PACU,15 min later, and 30 min later. The dose of dexmedetomidine for consecutive patients was determined by the response of the previous patient, using an increment or decrement of 0.1 μg/kg. Results: The 50 % effective dose of dexmedetomidine for prevention of EA was 0.25 μg/kg (95 % confidence limits, 0.17-0.33 μg/kg), and the 95 % effective dose was 0.38 μg/kg (95 % confidence limits, 0.29-0.39 μg/kg). Conclusions: For prevention of EA after desflurane anesthesia for 50 % and 95 % of children undergoing tonsillectomies or adenoidectomies, 0.25 μg/kg or 0.38 μg/kg of dexmedetomidine is suggested. Further study is needed to validate the suggested dose of dexmedetomidine to prevent the EA that was identified in the present study. [ABSTRACT FROM AUTHOR]

Background The variation in the rate of intraoperative respiratory events (IRE) over time under anesthesia and the influence of anesthesia-related factors have not yet been described. The objectives of this study were to describe the risk over time and the risk factors for IRE in children at a tertiary care hospital in southern Thailand. Methods The surveillance anesthetic database and chart review of IRE of 14,153 children who received surgery at Songklanagarind Hospital during January 2005 to December 2011 were used to obtain demographic, surgical and anesthesia-related data. Incidence density of IRE per person-time was determined by a Poisson modelling. Risk of IRE over time was displayed using Kaplan Meier survival and Nelson-Aalen curves. Multivariate Cox regression was employed to identify independent predictors for IRE. Adjusted hazard ratios (HR) and their 95% confidence intervals (CI) were obtained from the final Cox model. Results Overall, IRE occurred in 315 out of 14,153 children. The number (%) of desaturation, wheezing or bronchospasm, laryngospasm, reintubation and upper airway obstruction were 235 (54%), 101 (23%), 75 (17%), 21 (5%) and 4 (1%) out of 315 IRE, respectively. The incidence density per 100,000 person-minutes of IRE at the induction period (61.3) was higher than that in the maintenance (13.7) and emergence periods (16.5) (p < 0.001). The risk of desaturation, wheezing and laryngospasm was highest during the first 15, 20 and 30 minutes of anesthesia, respectively. After adjusting for age, history of respiratory disease and American Society of Anesthesiologist (ASA) classification, anesthesia-related risk factors for laryngospasm were assisted ventilation via facemask (HR: 18.1, 95% CI: 6.4-51.4) or laryngeal mask airway (HR: 12.5, 95% CI: 4.6-33.9) compared to controlled ventilation via endotracheal tube (p < 0.001), and desflurane (HR: 11.0, 95% CI: 5.1-23.9) compared to sevoflurane anesthesia (p < 0.001). Conclusions IRE risk was highest in the induction and early maintenance period. Assisted ventilation via facemask or LMA and desflurane anesthesia were anesthesia-related risk factors for laryngospasm. Therefore, anesthesiologists should pay more attention during the induction and early maintenance period especially when certain airway devices incorporated with assisted ventilation or desflurane are used. [ABSTRACT FROM AUTHOR]

Background: The benefits of intraoperative magnesium supplementation have been reported. In this prospective, randomized study, the effects of magnesium supplementation during general anaesthesia on emergence delirium and postoperative pain in children were evaluated. Methods: A total of 66 children aged 2 to 5 years who underwent strabismus surgery were assigned to the magnesium or to the control group. Preoperative anxiety was assessed using the modified Yale Preoperative Anxiety Scale. After anaesthesia induction, the magnesium group received an initial loading dose of 30 mg/kg magnesium sulphate over 10 min and, then, continuous infusion of 10 mg/kg per h until 10 min before the end of the surgery. The control group received an equal volume of normal saline via the same regimen. The Paediatric Anaesthesia Emergence Delirium (PAED) score, pain score, and respiratory events were assessed at the postanaesthetic care unit. Results: Data obtained from 65 children were analyzed. The PAED and pain scores of the two groups did not differ significantly. There were 26 of 33 (78.8%) and 27 of 32 (84.4%) children with emergence delirium in the control and the magnesium groups, respectively (odds ratio 0.69, 95% CI 0.19–2.44; p = 0.561). The preoperative anxiety score was not significantly correlated with the PAED score. The incidence of respiratory events during the emergence period did not differ significantly between the two groups. Conclusions: Magnesium supplementation during anaesthesia had no significant effects on the incidence of emergence delirium or postoperative pain in children undergoing strabismus surgery. Trial registration: ClinicalTrials.gov (NCT03132701). Prospectively registered May 8, 2017. [ABSTRACT FROM AUTHOR]

Background: It is still unknown whether newborn infant parasympathetic evaluation (NIPE), based on heart rate variability (HRV) as a reflection of parasympathetic nerve tone, can predict the hemodynamic response to a nociception stimulus in children less than 2 years old. Methods: Fifty-five children undergoing elective surgery were analyzed in this prospective observational study. Noninvasive mean blood pressure (MBP), heart rate (HR) and NIPE values were recorded just before and 1 min after general anesthesia with endotracheal intubation as well as skin incision. The predictive performance of NIPE was evaluated by receiver-operating characteristic (ROC) curve analysis. A significant hemodynamic response was defined by a > 20% increase in HR and/or MBP. Results: Endotracheal intubation and skin incision caused HR increases of 22.2% (95% confidence interval [CI] 17.5–26.9%) and 3.8% (2.1–5.5%), MBP increases of 18.2% (12.0–24.4%) and 10.6% (7.7–13.4%), and conversely, NIPE decreases of 9.9% (5.3–14.4%) and 5.6% (2.1–9.1%), respectively (all P < 0.01 vs. pre-event value). Positive hemodynamic responses were observed in 32 patients (62.7%) during tracheal intubation and 13 patients (23.6%) during skin incision. The area under the ROC curve values for the ability of NIPE to predict positive hemodynamic responses at endotracheal intubation and skin incision were 0.65 (0.50–0.78) and 0.58 (0.44–0.71), respectively. Conclusions: NIPE reflected nociceptive events as well as anesthestic induction in children less than 2 years undergoing general anaesthetia. Nevertheless, NIPE may not serve as a sensitive and specific predictor to changes in hemodynamics. Trial registration: This study was registered on May 3, 2018 in the Chinese Clinical Trail Registry; the registration number is (ChiCTR1800015973). [ABSTRACT FROM AUTHOR]

Background: The oculocardiac reflex (OCR), bradycardia that occurs during strabismus surgery is a type of trigemino-cardiac reflex (TCR) is blocked by anticholinergics and enhanced by opioids and dexmedetomidine. Two recent studies suggest that deeper inhalational anesthesia monitored by BIS protects against OCR; we wondered if our data correlated similarly. Methods: In an ongoing, prospective study of OCR/TCR elicited by 10-s, 200 g square-wave traction on extraocular muscles (EOM) from 2009 to 2013, anesthetic depth was estimated in cohorts using either BIS or Narcotrend monitors. The depth of anesthesia was deliberately varied between first and second EOM tested. Results: From 1992 through 2013, 2833 cases of OCR during strabismus surgery were monitored. Excluding re-operations and cases with anticholinergic, OCR from first EOM traction averaged − 20.2 ± 21.8% (S.D.) with a range from − 95 to + 25% in patients aged 0.2 to 90 (median 6.5) years. We did not find correlation between %OCR and brain wave for 97 patients with BIS monitoring and 91 with Narcotrend. With intra-patient controls between first and second muscle, the difference in brain wave did not correlate with difference in %OCR for BIS (r = 0.0002, 95% C. I -0.0002, 0.002, p = 0.30) or for Narcotrend (r = − 0.001, 95% C. I -0.004, 0.001, p = 0.32). Secondary multi-variable analysis demonstrated significant association on %OCR particularly with BIS monitor, opioid, propofol and nitrous oxide concentration in the second EOM tensioned. Sevoflurane concentration correlated better with BIS monitor in second and third EOM tension. %OCR correlated with younger age (p < 0.01). OCR with rapid onset was more profound than those with gradual onset (difference in means 18, 95% C. I 10, 26%). Conclusions: We were unable to confirm a direct correlation between brain wave monitor and OCR when using multifactorial anesthetic agents. The discrepency with other studies probably reflects direct impact of inhalational agent concentration and less deliberate quantification of EOM tension. We found no level of BIS or Entropy EEG monitoring that uniformly prevents OCR. Trial registry: NCT03663413. Data: http://www.abcd-vision.org/OCR/OCR%20Brainwave%20de-identified.pdf. [ABSTRACT FROM AUTHOR]

Background: We aimed to construct a prediction tool for postoperative oxygen therapy and determine predictors of duration of use among children undergoing non-cardiac surgery. Methods: Data from this case-control study was obtained from a database of 9820 children aged < 15 years who underwent general anesthesia between January 2010 and December 2013 at a tertiary care hospital in southern Thailand. The primary outcomes were the use and duration (hours) of postoperative oxygen therapy (cases). Cases were matched with controls on age group and year of surgery in a ratio of 1:4. A negative binomial hurdle model was used to obtain significant predictors of any use and number of hours of oxygen therapy. A risk score was derived from the coefficients of the significant predictors. The risk score, adjusted odds ratio (OR) for any use and count ratio (CR) for duration of postoperative oxygen therapy and 95% confidence interval (CI) were determined. Results: A total of 288 cases and 1152 controls were included. The median (inter-quartile range) duration of oxygen therapy delivered was 17 (9–22) hours. An optimal risk score for predictors of oxygen use was 12 (0–32) giving an area under the receiver operating characteristic curve of 0.93. Predictors of high risk need for oxygen therapy (score ≥ 12) were thoracic surgery (OR = 278, 95% CI = 44.6–1733) and having desaturation perioperatively (OR = 459.8, 95% CI = 169.7–1246). Intermediate risk factors (score 8–11) were having bronchospasm (OR = 92.4, 95% CI = 29.7–287.5) and upper airway obstruction/laryngospasm (OR = 61.5, 95% CI = 14.4–262.4) perioperatively. Significant predictors of duration of oxygen therapy were probably difficult airway (CR = 2.2, 95% CI = 1.4–3.5), history of delayed development (CR = 2.3, 95% CI = 1.5–3.6), airway (CR = 3.0, 95% CI = 1.6–5.8), orthopedic (CR = 2.1, 95% CI = 1.1–4.3), thoracic (CR = 4.9, 95% CI = 2.3–10.1) and abdominal surgery (CR = 4.2, 95% CI = 2.1–8.1), compared to eye surgery. Conclusions: Our risk prediction tool for the use of postoperative oxygen therapy provided a high predictive ability. Children who have thoracic surgery, desaturation, bronchospasm, upper airway obstruction or laryngospasm will most likely need postoperative oxygen therapy, regardless of other factors, while those with a probably difficult airway, history of delayed development, or thoracic/abdominal surgery will most likely need longer duration of oxygen therapy. [ABSTRACT FROM AUTHOR]