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Summary Opioids have long held a prominent role in the management of perioperative pain in adults and children. Published reports concerning the appropriate, and inappropriate, use of these medications in pediatric patients have appeared in various publications over the last 50 years. For this document, the Society for Pediatric Anesthesia appointed a taskforce to evaluate the available literature and formulate recommendations with respect to the most salient aspects of perioperative opioid administration in children. The recommendations are graded based on the strength of the available evidence, with consensus of the experts applied for those issues where evidence is not available. The goal of the recommendations was to address the most important issues concerning opioid administration to children after surgery, including appropriate assessment of pain, monitoring of patients on opioid therapy, opioid dosing considerations, side effects of opioid treatment, strategies for opioid delivery, and assessment of analgesic efficacy. Regular updates are planned with a re‐release of guidelines every 2 years.

BACKGROUND Persistent postoperative pain is a significant problem for many children, particularly for those undergoing major surgery such as posterior spine fusion. More than two-thirds report persistent pain after spine fusion, yet factors that may contribute to poorer outcomes remain poorly understood. AIMS This prospective, longitudinal study examined how psychologic and somatic symptoms cluster together in children aged 10-17 years with idiopathic scoliosis, and tested the hypothesis that a higher psychological and somatic symptom cluster would predict worse pain outcomes 1 year after fusion. METHODS Otherwise healthy children with idiopathic scoliosis completed preoperative surveys measuring recent pain intensity, pain location(s), somatic symptom severity, painDETECT (neuropathic-type pain symptoms), pain interference, fatigue, depression, anxiety, and pain catastrophizing. Pain outcome data were collected during hospitalization, and at 1 year after surgery. RESULTS Ninety-five children completed baseline surveys and a cluster analysis differentiated 28 (30%) with a high symptom profile that included; higher depression, fatigue, pain interference, catastrophizing, and painDETECT scores. High symptom cluster membership independently predicted higher pain interference at 1 year (β 9.92 [95% CI 6.63, 13.2], P

Summary Background and Objectives There are limited data on pediatric emergency tracheal intubation on inpatient units and in the emergency department by anesthesiologists. This retrospective cohort study was designed to describe the frequency of difficult intubation and adverse events associated with emergency tracheal intubation performed by pediatric anesthesiologists in a large children's hospital. Methods All emergency tracheal intubation on inpatient units and the emergency department performed by pediatric anesthesiologists over a 7-year period in children

SummaryBackground Intrathecal (IT) opioid administration has been associated with postoperative benefits including reduced pain and opioid use in children. However, the postoperative benefits and risks of IT opioid administration during major urologic surgery in children remain unclear. Aim The aim of this study was to compare postoperative pain and adverse event outcomes among children who received IT vs intravenous (IV) opioids during major urologic surgery. Methods We reviewed the medical records of children 3–17 years of age who underwent ureteroneocystostomy or pyeloplasty between 2006 and 2012. Electronically captured anesthetic and surgical data, postanesthesia care recovery unit (PACU) and nursing flowsheets, and daily progress notes through hospital discharge were reviewed. Analgesic techniques (i.e., IT or IV patient/nurse controlled opioids), all analgesic drugs and doses were recorded. Outcome measures included pain scores, need for rescue analgesics, opioid-related adverse events, and their treatments. Results Seventy-seven children received IT opioids and 51 received IV opioids. More children in the IV group required rescue analgesics and had higher pain scores at PACU discharge. Children in the IV group required rescue opioids more frequently than the IT group from 0 to 8 h and 8 to 16 h after PACU discharge, but rates were similar by 16–24 h 70% of children in IT group transitioned directly to oral opioids. Seven IT placements were considered as failed due to early need for rescue opioids. Four (8%) of the IV group and seven (9%) of the IT group experienced oxygen desaturation. Two of these, both in IT group required naloxone and one was admitted to ICU for observation. The IT group experienced a higher incidence of pruritus, constipation and hypotension. Conclusion We observed better postoperative pain control in children who received IT vs IV opioids for the first 16 h with no discernible difference thereafter. The intrathecal group experienced higher incidences of pruritus, constipation, and hypotension.

Summary Background Children with attention-deficit hyperactivity disorder (ADHD) may experience pain differently compared to other children, yet the evidence is equivocal regarding whether pain is heightened or dampened. This prospective observational study, therefore, was designed to compare the postoperative pain experiences in children with and without ADHD. Methods Children aged 7–17 years with a diagnosis of ADHD (n = 119) who were scheduled for a surgical procedure requiring postoperative pain management and a matched cohort of children without ADHD were recruited (n = 122). Postoperative pain scores and analgesic use were recorded for 1 week, as was parents’ estimate of their child's return to normal activity. Results There were no differences in highest pain scores between children with ADHD (3.3 ± 2.5, 0–10 numerical rating scale) and those without (2.8 ± 1.9). Postoperative opioid use was also similar on day 1 following surgery (0.12 ± 0.3 mg·kg−1 vs 0.08 mg·kg−1 ± 0.1 morphine equivalents, respectively). Children with ADHD, however, had a significantly longer return to normal activity (4.9 ± 3.8 vs 3.8 ± 3.0 days; P

Summary While most anesthesiologists and other physician- or nurse-scientists are familiar with traditional descriptive, observational, and interventional study design, survey research has typically remained the preserve of the social scientists. To that end, this article provides a basic overview of the elements of good survey design and offers some rules of thumb to help guide investigators through the survey process.

SummaryIntroduction: Pediatric obesity is a major health concern in the United Statesand as many as 34% of those who require general anesthesia are overweightor obese (OW). The lack of data and recommendations for dosing medica-tions in obese children leaves significant gaps in the understanding of correctdosing in the clinical setting.Objective: To determine whether OW children were more likely to receivedoses of medications outside the recommended range.Methods: Following IRB approval, patient medical records were queried toidentify children 2 through 17 years who underwent noncardiac surgeries andreceived at least one medication of interest. Children with hepatic disease,renal disease, neurological impairment, sleep-disordered breathing, or missingheight or weight measurements were excluded. Children were stratified intoweight categories based on age and gender percentiles as per CDC guidelines.Those ≥85th percentile were classified as overweight/obese. Ideal and leanweight (for age, gender) were calculated. Drug doses were stratified as under-dosed (>10% below minimum recommended dose), overdosed (>10% abovemaximum recommended dose), or within recommended dose (dose 10%).Actual doses were compared to recommended doses as per actual, ideal, orlean weight (as recommended for specific drugs) in the overweight/obesegroups vs the control weight (CW) group.Results: Ten thousand five hundred and nine doses were reviewed. Over-weight/obese children were more likely to receive doses outside the recom-mended dose range than the CW group.Conclusions: Overweight/obese children were more likely to receive doses ofcommon anesthetic medications outside the recommended doses potentiallyadding risk of adverse outcomes in these children.IntroductionPediatric obesity is a major public health concern in theUnited States (1), with up to 34% of school-age childrenand adolescents being overweight [body mass index(BMI) ≥85th percentile] or obese (BMI ≥95th percen-tile). Indeed, childhood obesity prevalence has increasedup to threefold over the last three decades (1,2). RecentCenters for Disease Control and Prevention (CDC) data(2010) suggest that a slight decrease in obesity and mor-bid obesity in poor, preschool, nonnative American orAlaskan populations have decreased slightly during theprevious 7 years (3). However, obesity continues to be atroubling attribute of America’s young people. Further-more, more than 30% of pediatric patients presentingfor surgery in one large pediatric setting were foundto be overweight or obese (OW) (4). These trends sug-gest a need to address specific healthcare needs of this

Background: In the absence of formal polysomnography (PSG), many children with symptoms of sleep-disordered breathing (SDB) go unrecognized and thus may be at risk for perioperative respiratory adverse events (PRAE). Objectives: To develop a simple practical tool to identify children with symptoms consistent with SDB who may be at risk for PRAE. Methods: Three-hundred and thirty-seven parents of children scheduled for surgery completed the Sleep-Related Breathing Disorder (SRBD) questionnaire. Data regarding the incidence and severity of PRAE including airway obstruction and laryngospasm, were collected prospectively. Results: Thirty-two (9.5%) children had a confirmed diagnosis of SDB by PSG and 90 (26.7%) had symptoms consistent with SDB based on the SRBD questionnaire. Principal component analysis identified five symptoms from the SRBD questionnaire that were strongly predictive of PRAE and which were incorporated into the STBUR tool (Snoring, Trouble Breathing, Un-Refreshed). The likelihood of PRAE was increased by threefold (positive likelihood ratio 3.06 [1.64–5.96] in the presence of any 3 STBUR symptoms and by tenfold when all five symptoms were present (9.74 [1.35–201.8]). In comparison, the likelihood of PRAE based on a PSG-confirmed diagnosis of SDB was 2.63 (1.17–6.23). Conclusions: Children presenting for surgery with symptoms consistent with SDB may be at risk for PRAE. It is important therefore that anesthesia providers identify these individuals prior to surgery to avoid potential complications. The STBUR questionnaire appears promising as a simple, clinically useful tool for identifying children at risk for PRAE. Further studies to validate the STBUR questionnaire as a diagnostic tool may be warranted.

Summary Background Nearly 20% of anesthesia-related pediatric cardiopulmonary arrests (CPAs) occur during emergence or recovery. The aims of this study were to describe (i) the nature of pediatric postanesthesia care unit (PACU) CPA and subsequent outcomes and (ii) factors associated with mortality. Methods Cardiopulmonary Arrests occurring in PACU in children (

Acute kidney injury (AKI) is a serious complication that occurs commonly following cardiopulmonary bypass (CPB) in infants and children. Underlying risk factors for AKI remain unclear, given changes in CPB practices during recent years. This retrospective, case-control study examined the relationships between patient, perioperative factors, AKI, and kidney failure in children who underwent CPB.Cohorts of children with and without AKI were identified from the cardiac perfusion and nephrology consult databases. Demographic, perioperative, and postoperative outcome data were extracted from the databases and from medical records. Children were stratified into groups based on the Acute Dialysis Quality Initiative's RIFLE definitions for acute kidney risk or injury (AKI-RI) and kidney failure.The study groups included 308 controls (no AKI-RI or failure), 161 with AKI-RI, and 89 with failure. Young age, preoperative need for mechanical ventilation, milrinone, or gentamicin; intraoperative use of milrinone and furosemide; durations of CPB and anesthesia; multiple cross-clamp and transfusion of blood products were significantly associated with AKI or failure. Young age, perioperative use of milrinone, multiple cross-clamps, extracorporeal membrane oxygenation, cardiac failure, neurological complications, sepsis, and failure significantly increased the odds of mortality.This study identified multiple perioperative risk factors for AKI-RI, failure, and mortality in children undergoing CPB. In addition to commonly known risk factors, perioperative use of milrinone, particularly in young infants, and furosemide were independently predictive of poor renal outcomes in this sample. Findings suggest a need for the development of protocols aimed at renal protection in specific at risk patients.

Summary Background/Aim: Given the increasing prevalence of attention-deficit and attention-deficit hyperactivity disorders (ADHD), anesthesiologists are now presented with a greater number of children who are diagnosed with these conditions. This prospective, observational study was designed to compare anesthesia induction, emergence, and postoperative behaviors in children with and without ADHD. Methods/Materials: The sample included 268 children, 4–17 years of age undergoing elective surgery with a confirmed diagnosis of ADHD. A cohort of children without ADHD, matched for age, gender, and procedure served as controls. Preoperative cooperation, induction, and emergence behaviors were measured using established scales. Postoperative maladaptive behaviors were measured using a modified Post-Hospital Behavioral Questionnaire that was administered via telephone 1 week after surgery. Results: Children with ADHD were significantly less cooperative at induction of anesthesia compared with controls (20.9% vs 10.6% respectively, P = 0.001). Although some control children exhibited an increase in maladaptive behaviors postoperatively, these behaviors were significantly greater among children with ADHD. In particular, relative to their normal behaviors, children with ADHD had greater difficulties in concentration and decision-making; were more disobedient, impulsive, fidgety, had poor appetite; were difficult to talk to; and exhibited an increase in temper tantrums following surgery. Conclusions: This is the first prospective study to our knowledge that has examined the perioperative and postoperative behaviors of children with ADHD compared to those without this disorder. These results are important in alerting anesthesiologists, parents, and teachers to the potential for difficulties during induction of anesthesia and postoperative behavioral problems at home and in school, respectively.

Summary Background: The purpose of this retrospective study was to examine the benefits, risks and costs associated with aprotinin use in children who underwent repair of an atrial septal defect (ASD). The primary aim was to determine whether the transfusion rate is lower in children who received aprotinin compared with those who did not during ASD repair. The use of aprotinin has been shown to reduce transfusion requirements for children undergoing primary or secondary repair of congenital cardiac anomalies. However, past studies have not reported the benefits of this agent during low complexity procedures such as ASD repair. Methods: All children who underwent ASD repair over 6 years (3 years pre- and postroutine use of aprotinin for all CPB cases in the institution) were identified, and their medical records reviewed. Children with multiple congenital cardiac lesions were excluded. The following data were recorded: demographics and baseline laboratory findings, intraoperative use of aprotinin, cardiopulmonary bypass information including details of ultrafiltration, all intraoperative and postoperative transfusions, postoperative bleeding and relevant laboratory findings. Results: One hundred and fifteen children were included, 66 of whom received aprotinin. Transfusion rates were not different between children who received aprotinin [n = 8 (12%)] and those who did not [n =3( 6%)]. Furthermore, changes in hematocrit were not different between groups. These findings were similar when children £15 kg were compared with those >15 kg. Conclusions: This study suggests that aprotinin use offers no benefit for children undergoing isolated repair of an ASD.

Summary Background: Chloral hydrate (CH) sedation for magnetic resonance imaging (MRI) is associated with significant failure rates, adverse events and delayed recovery. Pentobarbital (PB), reportedly produces successful sedation in 98% of children undergoing diagnostic imaging. This study compared the efficacy, adverse events and recovery characteristics of CH vs PB in children undergoing MRI. Methods: With Institutional Review Board approval and written consent, children were randomly assigned to receive intravenous (i.v.) PB (maximum 5 mgAEkg )1 in incremental doses) or oral CH (75 mgAEkg )1 ) prior to MRI. Sedation was augmented with 0.05 mgAEkg )1 doses of i.v. midazolam (maximum 0.1 mgAEkg )1 ) as necessary. Adverse effects, including hypoxaemia, failed sedation, paradoxical reactions and behavioural changes, the return of baseline activity, and parental satisfaction were documented. The quality of MRI scans was evaluated by a radiologist blinded to the sedation technique. Results: PB facilitated an earlier onset of sedation (P ¼ 0.001), higher sedation scores (P ¼ 0.01), and less need for supplemental midazolam compared with CH. Severe hypoxaemia occurred in two children (6%) in the PB group. Fourteen per cent of the PB group experienced a paradoxical reaction, 9% sedation failure and 11% major motion artefact, compared with 0% (P ¼ 0.05), 3 and 2% (P ¼ NS), respectively, in the CH group. CH and PB were both associated with a high incidence of motor imbalance, and agitation. However, children who received PB had a slower return to baseline activity (P ¼ 0.04). Conclusions: Although PB facilitated a quicker sedation onset and reduced the requirement for supplemental sedation, it produced a higher incidence of paradoxical reaction and prolonged recovery with a similar failure rate compared with CH.

Summary Background: Children undergoing strabismus surgery have a high incidence of postoperative vomiting (POV). The purpose of this study was to assess the efficacy and safety of dolasetron for the prevention of emesis comparing a single 0.35 mgAEkg )1 or 12.5 mg dose with placebo. Methods: Children aged 2‐12 years with an ASA status of 1 or 2 undergoing strabismus surgery were randomized in a double-blind manner to one of three treatment groups. Patients were excluded with a history of previous postoperative vomiting or motion sickness, allergy to serotonin receptor antagonists or previous antiemetic administration within 24 h prior to enrollment. General anaesthesia was induced with sevoflurane and N2O/O2 and maintained with isoflurane and N2O/O2. The study medication was administered 15 min prior to the end of surgery. Patients experiencing two or more episodes of vomiting were rescued in the postanaesthesia care unit (PACU) with metoclopramide 0.15 mgAEkg )1 . A total of 118 patients were enrolled with documentation of the number and severity of vomiting episodes, time to awakening, PACU length of stay and postoperative agitation. Results: Patients with an acute complete response (ACR), defined as no emetic episodes and no rescue medication within 24 h of study drug administration were 62% (weight dose), 64% (fixed dose) and 33% (placebo, P < 0.05). Conclusions: There was no statistical difference between the 0.35 mgAEkg )1 dose and the fixed 12.5 mg dose of dolasetron with both reducing the incidence of POV.

Summary Background: Disclosure is a key element of the informed consentprocess. This study examines and compares the priorities for disclo-sure of the elements of informed consent between parents ofpaediatric research subjects and investigators.Methods: The study sample comprised 184 parents who had beenapproached for permission to allow their child to participate in aclinical anaesthesia or surgery study. Parents were asked to rank 11elements of informed consent that they believed were most importantfor them to know before allowing their child to participate in aresearch study. In addition, 38 investigators were asked to rank, inorder of importance, the same elements that they felt were mostimportant for parents to know.Results: The results showed that risk was the most important elementconsidered by both parents and investigators. However, parentsplaced significantly greater importance on knowledge of the potentialbenefits to their child (direct) and to other children (indirect)compared with investigators, and less importance on the details of theprotocol and the element of voluntariness.Conclusions: These results demonstrated differences in the prioritiesfor disclosure of the elements of consent between parents andinvestigators. As such, they may be important in directing theinvestigator to focus on the elements that are most important toparents and thus maximize their ability to provide truly informedconsent.Keywords: informed consent; paediatric research; ethics; disclosure

Background: We compared pain assessment and management practices in children with and without cognitive impairment (CI) undergoing spine fusion surgery. Methods: The medical records of 42 children (19 with CI and 23 without) were reviewed and data related to demographics, surgery, pain assessment and management, and side-effects were recorded. Results: Fewer children with CI were assessed for pain on postoperative days (POD) 0–4 compared to those without CI (P

Summary Background: The traditional paternalistic approach to medical decision-making is moving towards a climate of greater patient and/or surrogate involvement. Despite this, there is considerable debate regarding patient preferences for participation in medical decisionmaking and its effect on patient satisfaction and outcome. This study was designed to examine parents’ preferences for participation in decisions regarding their child’s anaesthetic care and to determine if active participation is associated with greater parental satisfaction. Methods: Three hundred and eight parents of children scheduled to undergo elective surgical procedures were asked to complete a questionnaire detailing information regarding their preferences for participation in decisions made regarding their child’s anaesthetic care. Parents were classified as being passive, shared, or active decision makers. Results: Overall, parents evidenced a preference for shared decisionmaking with the anaesthetist. Parents preferred to be passive with respect to intraoperative pain management but active with respect to their presence when their child wakes up. There were no differences between active, shared and passive decision-makers with respect to their satisfaction with anaesthetic care and their participation in decision-making. However, 32.1% of parents stated that they would have preferred more involvement in decision-making. These parents were significantly less satisfied with their child’s care than those who felt that their participation had been adequate. Conclusions: This study highlights specific areas in which parents would prefer a more active role in decision-making and, as such, may serve to focus anaesthetists’ efforts to educate parents with respect to the various options available for their child’s care.