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Background: A lack of anesthesia and surgical capacity leaves approximately 1.7 billion children per annum without access to surgical and anesthetic care. Review: Over the past 50 years, the predominant strategy to address this lack of access has been to provide surgical capacity primarily from high‐income countries (HICs) to low and middle‐income countries (LMICs) in the form of short‐term surgical missions. More recently, the international medical community has recognized the need to build sustainable surgical capacity in resource‐constrained settings. This article reviews three models of surgical aid: the vertical model (short‐term surgical missions); the horizontal model (system‐wide capacity building); and the diagonal model, which is a hybrid of the first two. At their core, medical aid interventions exist on a spectrum ranging from providing surgical capacity to building surgical capacity. Discussion: The skills, attitudes, and behaviors that drive success in providing medical capacity are fundamentally different from those that drive success in building medical capacity. The root cause of this difference is a shift in the moral duty of the visiting physician from a duty solely to the patient in front of them (based on the primacy of the doctor–patient relationship) to include a duty to the local physicians and the local medical system, and by extension to the next 10 000 patients in need of care. Conclusion: Failure to address the conflicts engendered by this fundamental moral shift risks undermining capacity‐building efforts in all models of medical aid. [ABSTRACT FROM AUTHOR]

Australia and New Zealand are two countries in the Southern Pacific region. They share many pediatric anesthesia similarities in terms of medical organizational systems, education, training, and research, however there are important differences between the two nations in relation to geography, the First Nations populations and the history of colonization. While the standards for pediatric anesthesia and the specialty training requirements are set by the Australian and New Zealand College of Anesthetists and the Society for Pediatric Anesthesia in New Zealand and Australia, colonization has created distinct challenges that each nation now faces in order to improve the anesthetic care of its pediatric population. Australia generally has a high standard of living and good access to health care; disparities exist for First Nations People and for those living in rural or remote areas. Two influences have shaped training within New Zealand over the past 40 years; establishment of a national children's hospital in 1990 and, more importantly, acknowledgement that the First Nations people of New Zealand (Māori) have suffered because of failure to recognize their rights consequent to establishing a partnership treaty between Māori and the British Crown in 1840. Health inequities among Māori in New Zealand and First Nations People in Australia have implications for the health system, culturally appropriate approaches to treatment, and the importance of having an appreciation of First Nations people's history and culture, language, family structure, and cultural safety. Trainees in both countries need to be adequately supported in these areas in order for the sub‐specialty of pediatric anesthesia to develop further and improve the anesthetic and surgical outcomes of our children. [ABSTRACT FROM AUTHOR]

Background: Pediatric airway management requires careful clinical evaluation and experienced execution due to anatomical, physiological, and developmental considerations. Video laryngoscopy in pediatric airways is a developing area of research, with recent data suggesting that video laryngoscopes are better than standard Macintosh blades. Specifically, there is a paucity of literature on the advantages of the C‐MAC D‐blade compared to the McCoy direct laryngoscope. Methods: After Ethics Committee approval, 70 American Society of Anesthesiologists physical status 1 and 2 children aged 4–12 years scheduled for elective surgery under general anesthesia were recruited. Patients were randomly allocated to intubation using a C‐MAC video laryngoscope size 2 D‐blade (Group 1) and a McCoy laryngoscope size 2 blade (Group 2). The Intubation Difficulty Scale (IDS) for ease of intubation was the primary outcome, while Cormack–Lehane grades, duration of laryngoscopy and intubation, hemodynamic responses, and incidence of any airway complications were secondary outcomes. Results: Both groups were comparable in terms of patient characteristics. The median (IQR) Intubation Difficulty Scale (IDS) score was better but was statistically nonsignificant with C‐MAC (0 [0–0] vs. 0 [0–2], p =.055). The glottic views were superior (CL grade I in 32/35 vs. 23/35, p =.002), and the time to best glottic view (6 s [5–7] vs. 8.0 s [6–10], p =.006) was lesser in the C‐MAC D‐blade group while the total duration of intubation was comparable (20 s [16–22] vs. 18 s [15–22], p =.374). All the patients could be successfully intubated on the first attempt. None of the patients had any complications. Conclusion: The C‐MAC video laryngoscope size 2 D‐blade provided faster and better glottic visualization but similar intubation difficulty compared to McCoy size 2 laryngoscope in children. The shorter time to achieve glottic view demonstrated with the C‐MAC failed to translate into a shorter total duration of intubation when compared to the McCoy laryngoscope attributable to a pronounced curvature of the D‐blade. [ABSTRACT FROM AUTHOR]

Background: Children in hospital experience significant pain, either inherent with their pathology, or caused by diagnostic/therapeutic procedures. Little is known about pediatric pain practices in sub‐Saharan Africa. This survey aimed to gain insight into current pain management practices among specialist physician anesthetists in four sub‐Saharan African countries. Methods: A survey was sent to 365 specialist physician anesthetists in Nigeria, South Africa, Uganda and Zambia. Content analysis included descriptive information about the respondents and their work environment. Thematic analysis considered resources available for pediatric pain management, personal and institutional pain practices. Results: One hundred and sixty‐six responses were received (response rate 45.5%), with data from 141 analyzed; Nigeria (27), South Africa (52), Uganda (41) and Zambia (21). Most respondents (71.83%) worked at tertiary/national referral hospitals. The majority of respondents (130/141, 91.55%) had received teaching in pediatric pain management. Good availability was reported for simple analgesia, opioids, ketamine, and local anesthetics. Just over half always/often had access to nurses trained in pediatric care, and infusion pumps for continuous drug delivery. Catheters for regional anesthesia techniques and for patient‐controlled analgesia were largely unavailable. Two thirds (94/141, 66.67%) did not have an institutional pediatric pain management guideline, but good pharmacological pain management practices were reported, in line with World Health Organization recommendations. Eighty‐eight respondents (62.41%) indicated that they felt appropriate pain control in children was always/often achieved in their setting. Conclusion: This survey provides insight into pediatric pain practices in these four countries. Good availability of a variety of analgesics, positive pain prescription practices, and utilization of some non‐pharmacological pain management strategies are encouraging, and suggest that achieving good pain control despite limited resources is attainable. Areas for improvement include the development of institutional guidelines, routine utilization of pain assessment tools, and access to regional anesthesia and other advanced pain management techniques. [ABSTRACT FROM AUTHOR]

Patient positioning interacts with a number of body systems and can impact clinically important perioperative outcomes. In this educational review, we present the available evidence on the impact that patient positioning can have in the pediatric perioperative setting. A literature search was conducted using search terms that focused on pediatric perioperative outcomes prioritized by contemporary research in this area. Several key themes were identified: the effects of positioning on respiratory outcomes, cardiovascular outcomes, enteral function, patient and carer‐centered outcomes, and soft issue injuries. We encountered considerable heterogeneity in research in this area. There may be a role for lateral positioning to reduce respiratory adverse outcomes, head elevation for intubation and improved oxygenation, and upright positioning to reduce peri‐procedural anxiety. [ABSTRACT FROM AUTHOR]

Background Aims Methods Results Conclusions Children undergoing diagnostic and interventional radiology procedures often require sedation to achieve immobility and analgesia if the procedure is painful. In the past decades, leading scientific organizations have developed evidence‐based guidelines for procedural sedation and analgesia in children outside of the operating room. Their recommendations are being applied to procedural sedation in radiology. However, some questions remain open regarding specific aspects contextualized to the radiology setting, such as elective prone sedation, the urgency of the procedure, when venous access or airway protection is required, and others.To address the unresolved issues of procedural sedation and analgesia in pediatric diagnostic and interventional radiology.An expert panel of pediatricians, pediatric anesthesiologists, intensivists, and neuroradiologists selected topics representative of current controversies and formulated research questions. Statements were developed by reviewing the literature for new evidence, comparing expertise and experience, and expressing opinions. Panelists' agreement with the statements was collected anonymously using the DELPHI method.Twelve evidence‐based or expert opinion incorporate are presented, considering risks, benefits, and applicability.This consensus document, developed by a multidisciplinary panel of experts involved in the field, provides statements to improve the quality of decision‐making practice in procedural sedation and analgesia in pediatric radiology. [ABSTRACT FROM AUTHOR]

Tonsillectomy is one of the most common surgical procedures in childhood. While generally safe, it often is associated with a difficult early recovery phase with poor oral intake, dehydration, difficult or painful swallowing, postoperative bleeding, infection and/or otalgia. Better pain management and the availability of more child friendly medications are within the top consumer priorities in perioperative medicine, highlighting the importance of alternative pain treatments. This review focuses on the potential role of honey in the postoperative setting, its effects, and mechanisms of action. While the application of honey post‐tonsillectomy may offer analgesic and healing benefits, it may also reduce postoperative bleeding. A systematic search was carried out using the search terms honey, tonsillectomy. Filters were applied to human studies and English. No other search terms were used or age filters applied to yield a broader range of results. Seven pediatric, four adult, and two studies of mixed pediatric and adult patients with sample sizes ranging from 8 to 52 patients were included in this review. Effect sizes ranged from small to huge across the studies. While the application of honey post‐tonsillectomy may offer analgesic and healing benefits, it may also reduce postoperative bleeding. However, while there are potential benefits based on the chemical composition of honey, the current literature is of variable quality and there is need for high quality clinical trials. [ABSTRACT FROM AUTHOR]

Background: Posterior spinal fusion is the most common surgical procedure performed for correction of adolescent idiopathic scoliosis in the United States. Intraoperative methadone has been shown to improve pain control in adult patients undergoing complex spine surgery, and current pediatric studies show encouraging results; however, prospective randomized‐controlled trials are lacking in the pediatric literature. Aims: We conducted a single‐center double‐blind randomized‐controlled trial to compare intraoperative use of methadone to morphine in pediatric patients undergoing posterior spinal fusion. Methods: A total of 47 adolescents undergoing posterior spinal fusion were randomized (stratified by sex) to either a methadone (n = 25) or morphine (n = 22) group. The primary outcome was postoperative opioid consumption. Secondary outcomes included postoperative pain severity, opioid‐related side effects, and ratio of patient‐controlled analgesia injections: attempts as a behavioral index of uncontrolled pain. Results: Patients in the methadone group consumed less total opioid postoperatively (median [interquartile range], 0.3 mg/kg [0.1, 0.5]) than patients in the morphine group (0.3 mg/kg [0.2, 0.6]), median difference [95% confidence interval] −0.07 [−0.2 to 0.02]; (p =.026). Despite the lower amount of opioid used postoperatively, pain scores for the methadone group (3.5 [3.0, 4.3]) were not significantly different from those in the morphine group (4.0 [3.2, 5.0]; p =.250). Groups did not differ on opioid‐related side effects. Conclusions: A two‐dose intraoperative methadone regimen resulted in decreased opioid consumption compared to morphine. Although the clinical significance of these results may be limited, the analgesic equipoise without increased opioid‐related side effects and potential for a lower incidence of chronic pain may tip the balance in favor of routine methadone use for adolescents undergoing posterior spinal fusion. [ABSTRACT FROM AUTHOR]

Background: Emergence agitation is a complex syndrome of altered consciousness after emergence from anesthesia. It can result in injury to patients and staff and is associated with other postoperative complications. Sevoflurane has been associated with emergence agitation, potentially due to low tissue solubility and therefore speed of emergence. Prior meta‐analyses comparing emergence agitation incidence between sevoflurane and isoflurane anesthetics did not demonstrate a statistically significant difference. Given the publication of additional relevant studies not included in prior meta‐analyses as well as improved diagnosis of emergence agitation, we aim to perform an updated, comprehensive meta‐analysis comparing emergence agitation incidence between sevoflurane and isoflurane anesthetics in children. Methods: We conducted an updated systematic review and meta‐analysis of clinical trials comparing sevoflurane to isoflurane in children <18 years of age, reporting emergence agitation as an outcome, published before July 2023 using databases and registers. Our primary outcome was the incidence of emergence agitation. Secondary outcomes were time to extubation, awakening time, and length of stay in the postanesthetic care unit. We assessed the risk of bias using the Cochrane Risk of Bias tool version 2. We pooled the effect size for the outcomes using the fixed effects model if we had low heterogeneity, otherwise, we used a random‐effects model. Results: Eight randomized controlled trials (523 children) were included in the final analysis. The incidence of emergence agitation after isoflurane was significantly lower compared to sevoflurane (risk ratio: 0.62 (95% CI: [0.46–0.83]; I2 = 40.01%, p <.001)). Time to extubation, awakening times, and postanesthetic care unit duration were not significantly different. The protective effect of isoflurane compared to sevoflurane remained significant in subgroups of patients who received premedication or intraoperative systemic analgesics (risk ratios: (0.48 [0.28–0.82]; I2 = 60.78%, p =.01), (0.52 [0.37–0.75]; I2 = 0.00%, p <.001), respectively). Conclusion: The risk of emergence agitation in children after maintenance anesthesia with sevoflurane is significantly greater than with isoflurane; we did not find evidence of prolonged emergence or postanesthetic length of stay. When possible, isoflurane should be considered for maintenance anesthesia over sevoflurane in patients at high risk of emergence agitation. [ABSTRACT FROM AUTHOR]

Patients with type 1 diabetes mellitus (T1D) require insulin administration at all times to maintain euglycemia and metabolic stability. Insulin administration in the perioperative period is complicated by fasting requirements and perioperative stressors that can change the patient's insulin needs. In addition, many anesthesia providers are not familiar with insulin dosing strategies and technology, such as insulin pumps and continuous glucose monitors (CGMs), that are commonly used by patients with T1D. Errors in perioperative insulin administration can lead to hypoglycemia, hyperglycemia, and diabetic ketoacidosis. This article reviews common errors of associated with the perioperative management of patients with T1D, including failure to assess and coordinate patient care preoperatively; failure to understand diabetes management and technology; failure to monitor blood glucose and recognize dysglycemia; and failure to appropriately administer basal insulin. [ABSTRACT FROM AUTHOR]

Since the introduction of Fascial Plane Blocks in 2007 there has been an enormous interest and application of Fascial Plane Blocks, evidenced by substantially more than 1000 PubMed items. Despite this gigantic number of publications, also including randomized controlled trials and meta‐analyses in children, there is still no clear‐cut insight into how much of the purported effect is in fact due to the blockade of nerve structures and how much is merely adding the well‐known analgesic and anti‐inflammatory effects of the plasma levels of local anesthetics that are achieved with these techniques. Furthermore, Fascial Plane Blocks appear useful only if compared to conventional multi‐modal analgesia (no block or placebo) and Fascial Plane Blocks lack the potency to provide surgical anesthesia on their own and appear only to be of value when used for minor‐moderate surgery. Despite the huge literature, there has so far not emerged any clinical situations where Fascial Plane Blocks have definitively been shown to be the block of choice, being decisively more effective than other established regional blocks. Lastly, Fascial Plane Blocks may appear as virtually free of complications, but case reports are emerging that point to a real risk for causing local anesthetic systemic toxicity when using Fascial Plane Blocks. This text aims to synthesize the current knowledge base regarding the Fascial Plane Blocks that are relevant to use in the pediatric context. In summary, there does currently not exist any convincing scientific evidence for the continued support for the use of Fascial Plane Blocks in children, except for the rectus sheath block and possibly also the transmuscular quadratus lumborum block. [ABSTRACT FROM AUTHOR]

Fasting for surgery is a routine step in the preoperative preparation for surgery. There have however been increasing concerns with regard to the high incidence of prolonged fasting in children, and the subsequent psycho‐social distress and physiological consequences that this poses. Additionally, the past few years have yielded new research that has shown significant inter‐individual variation in gastric emptying regardless of the length of the fast, with some patients still having residual gastric contents even after prolonged fasts. Additionally, multiple large‐scale studies have shown no long‐term sequalae from clear fluid aspiration, although two deaths from aspiration have been reported within the large Wake Up Safe cohort. This has led to a change in the recommended clear fluid fasting times in multiple international pediatric societies; similarly, many societies continue to recommend traditional fasting times. Multiple fasting strategies exist in the literature, though these have mostly been studied and implemented in the adult population. This review hopes to summarize the recent updates in fasting guidelines, discuss the issues surrounding prolonged fasting, and explore potential tolerance strategies for children. [ABSTRACT FROM AUTHOR]

Inguinal hernia surgery is one of the most common electively performed surgeries in infants. The common nature of inguinal hernia combined with the high‐risk population involving a predominance of preterm infants makes this a particular area of interest for those concerned with their perioperative care. Despite a large volume of literature in the area of infant inguinal hernia surgery, there remains much debate amongst anesthetists, surgeons and neonatologists regarding the optimal perioperative management of these patients. The questions asked by clinicians include; when should the surgery occur, how should the surgery be performed (open or laparoscopic), how should the anesthesia be conducted, including regional versus general anesthesia and airway devices used, and what impact does anesthesia choice have on the developing brain? There is a paucity of evidence in the literature on the concerns, priorities or goals of the parents or caregivers but clearly their opinions do and should matter. In this article we review the current clinical surgical and anesthesia practice and evidence for infants undergoing inguinal hernia surgery to help clinicians answer these questions. [ABSTRACT FROM AUTHOR]

Introduction: Bleeding and transfusion remain important concerns during surgical correction of scoliosis even when multiple conservative strategies, such as preoperative recombinant erythropoietin and/or antifibrinolytic agents, are used. The current work aimed to determine the impact of other potential risk factors, especially the volume of intraoperative fluid intake, on the perioperative risk of allogenic transfusion during surgical correction of adolescent idiopathic scoliosis. Methods: This prospective study included all cases of adolescent idiopathic scoliosis operated in a single center during 2 years (2018–2020). Predictors analyzed were as follows: body mass index, preoperative hemoglobin concentration, thoracoplasty, preoperative halo‐gravity, volume of intraoperative crystalloid administration, use of esophageal Doppler (for goal‐directed fluid therapy), and duration of surgery. Statistical analyses were performed using a multivariable logistic regression model. Results: Two hundred patients were included in the analysis. Multivariable analysis found: an increased volume of intraoperative crystalloid administration as a significant predictor of allogenic blood transfusion. Receiving operator characteristics analysis found the model exhibiting an area under the curve of 0.85 (95% confidence interval: 0.75–0.95). Optimizing stroke volume using esophageal Doppler was associated with a decrease in intraoperative crystalloid intake. Conclusion: These results indicate a statistical association between the increase in crystalloid intake and the risk of allogenic blood transfusion during surgical correction of adolescent idiopathic scoliosis. Controlled studies are needed to address the causative relation between intraoperative fluid intake and the risk of allogenic transfusion. [ABSTRACT FROM AUTHOR]

Post‐dural puncture headache is a distressing complication that may occur after lumbar puncture or unintentional dural puncture. Risk factors in the pediatric population have not been well elicited, and the true incidence is unknown. Conservative management includes conservative physical measures and medical therapies. Epidural blood patch remains the gold standard for managing severe refractory headache, but greater occipital nerve blocks and sphenopalatine ganglion blocks have been used with success. Sphenopalatine ganglion blocks are easy to perform, minimally invasive and, in the postoperative setting where epidural analgesia is utilized, provide an alternative that should be considered. [ABSTRACT FROM AUTHOR]

Background: Ornithine transcarbamylase deficiency is an X‐linked genetic disorder that induces accumulation of ammonia in the liver and is the most common urea cycle disorder. The clinical manifestation of ornithine transcarbamylase deficiency is hyperammonemia that causes irreversible neurological damage. Liver transplantation is a curative therapy for ornithine transcarbamylase deficiency. The aim of this study is to suggest, from our previous experience, an anesthesia management protocol of liver transplantation for ornithine transcarbamylase deficiency, particularly focused on liver transplantation for cases with uncontrolled hyperammonemia. Method: We retrospectively reviewed our anesthesia‐related experience in all cases of liver transplantation for ornithine transcarbamylase deficiency in our center. Results: Twenty‐nine liver transplantation cases for ornithine transcarbamylase deficiency were found between November 2005 and March 2021 in our center. Of these, 25 cases were stable through the perioperative period. However, 2 cases with carrier donor graft had hyperammonemia after liver transplantation. Another two cases had uncontrolled hyperammonemia before liver transplantation, even with continuous hemodialysis. They underwent life‐saving liver transplantation. Their metabolic status stabilized after the anhepatic phase. Conclusion: Liver transplantation for cases with uncontrolled hyperammonemia can be performed with proper management. Second, liver transplantation with carrier donors should be avoided because of the risk of postoperative recurrence. [ABSTRACT FROM AUTHOR]

Background: Emergence agitation or delirium can occur in pediatric patients after anesthesia. Dexmedetomidine is known to reduce the impairment of postoperative cognitive function. Aims: This study aimed to identify the role of intranasal administration of dexmedetomidine in lowering the development of emergence agitation or emergence delirium in pediatric patients after general anesthesia. Methods: Electronic databases, including PubMed, EMBASE, CENTRAL, Scopus, and Web of Science, were searched to identify studies. The primary outcome was the proportion of patients who underwent emergence agitation or emergence delirium after the surgery. Secondary outcomes included emergence time and incidence of postoperative nausea and/or vomiting. We estimated the odds ratio and mean difference with 95% confidence intervals for the determination of effect size using a random‐effects model. Results: In total, 2103 pediatric patients from 20 randomized controlled trials were included in the final analysis. The incidence of emergence agitation or emergence delirium was 13.6% in the dexmedetomidine group and 33.2% in the control group. The pooled effect size revealed that intranasal dexmedetomidine administration significantly reduced the incidence of postoperative emergence agitation or emergence delirium in pediatric patients undergoing surgery under general anesthesia (odds ratio 0.25, 95% confidence interval 0.18–0.34; p =.0000; I2 = 37.74%). Additionally, significant difference was observed in emergence time between the two groups (mean difference 2.42, 95% confidence interval 0.37–4.46; p =.021; I2 = 98.40%). Children in the dexmedetomidine group had a significantly lower incidence of postoperative nausea and/or vomiting than those in the control group (odds ratio 0.39, 95% confidence interval 0.24–0.64; p =.0002; I2 = 0.00%). Conclusions: Intranasal dexmedetomidine reduced the incidence of emergence agitation or emergence delirium in pediatric patients after general anesthesia. [ABSTRACT FROM AUTHOR]

Patient blood management is a patient‐centered evidence‐based approach to improve patient outcomes by harnessing the patient's own hematopoietic system to optimize blood health while promoting patient safety and empowerment. Perioperative patient blood management is a standard of care in adult medicine, yet it is not commonly accepted in pediatrics. Raising awareness may be the first step in improving perioperative care for the anemic and/or bleeding child. This article highlights five preventable perioperative blood conservation error traps for children. The goal is to provide practical clinical guidance to improve preoperative diagnosis and treatment of anemia, facilitate recognition and treatment of massive hemorrhage, reduce unnecessary allogeneic blood transfusions, and decrease associated complications of anemia and blood component transfusions utilizing a patient/family‐centered informed consent and shared decision‐making approach. [ABSTRACT FROM AUTHOR]

Background: There has been a recent focus among anesthesiologists on reducing the use of perioperative opioids in favor of multimodal analgesic regimens. Gabapentin has played an integral role in this evolution of practice. This comprehensive review assesses the current clinical evidence on the efficacy of perioperative gabapentin regarding postoperative pain and opioid requirements among the pediatric surgery population. Data Sources: Pubmed, CINAHL, Embase, Scopus, and Web of Science Review. Methods: This scoping review of the above databases includes all studies examining the use of gabapentin perioperatively in pediatric patients and its association with postoperative pain intensity and postoperative opioid consumption through July 2021. The inclusion criteria encompassed all studies evaluating gabapentin in the perioperative pediatric population through randomized controlled trials (RCTs) and retrospective studies. Relevant metadata from each study were abstracted and descriptive statistics were used to summarize the results. Results: Fifteen papers met the inclusion criteria for this review, including 11 RCTs and 4 retrospective studies. Sample sizes ranged from 20 to 144 patients. Administered doses varied widely, mainly between 5 and 20 mg/kg. The studies included primarily orthopedic (10) and neck surgery cases (3). Seven papers had gabapentin provided preoperatively only, two postoperative only, and six both pre‐ and postoperatively. Of the studies assessing postoperative pain, 6/11 studies saw a decrease in postoperative pain in at least one period for the gabapentin group. Of the studies considering opioid requirements, 6/10 reported a reduction, 1/10 an increase, and 3/10 no difference in opioid requirements for the gabapentin groups. Yet, most of these pain and opioid requirement findings were only significant at one to two time points in the study follow‐up periods, and the actual decreases had minimal clinical significance. Conclusions: The current data on perioperative gabapentin in pediatric patients are insufficient to support the routine use of gabapentin in pediatric patients. Additional high‐quality RCTs with more standardized protocols for gabapentin administration and outcome measures are necessary to provide more definitive conclusions. [ABSTRACT FROM AUTHOR]

Background: The light reflex, which reflects central nervous system dysfunction, can also be affected by anesthetic agents. Aims: We evaluated whether these effects differed according to the anesthetic agent in pediatric patients. Methods: Twenty children aged 3–12 years who were scheduled to undergo elective surgery under general anesthesia were randomly allocated to propofol and sevoflurane groups and underwent pupillometric assessments at five points during anesthesia: T1, after confirming loss of consciousness; T2, after endotracheal intubation; T3, at the time of skin incision; T4, 1 h after skin incision; and T5, before endotracheal extubation. The primary outcome was the Neurological Pupil index at T4, and the secondary outcomes were other pupillometric parameters, including pupil diameter, percentage of change in pupil diameter, dilation velocity, and constriction velocity. Results: At T4, the Neurological Pupil index was significantly lower in the sevoflurane group (median difference, 0.30; 95% CI, 0.00 to 0.70; p =.036). Furthermore, the Neurological Pupil index at all time points was lower in the sevoflurane group. The time‐and‐group interaction effects on constriction velocity and dilation velocity were significantly different [F(1, 4) = 16.68, p =.002; F(1, 4) = 14.78, p =.008, respectively] but were not different on the Neurological Pupil index, pupil diameter, and percentage of change in pupil diameter. No intergroup differences were observed in the baseline characteristics, the flow rate of remifentanil at each time point, and total infused remifentanil. Conclusion: The Neurological Pupil index value in pediatric patients under general anesthesia is affected by the anesthetic agent used; this factor requires consideration in evaluations of the Neurological Pupil index during general anesthesia. [ABSTRACT FROM AUTHOR]

Background: Modern pediatric anesthetic encounters occur in operating rooms and non‐operating room settings. Most anesthesia providers have cared for children in radiology, endoscopy, and other interventional settings at some point in their training and career. There is an absence of published data on the frequency, timing, and demographics of these pediatric anesthesia encounters. Aims: The primary goal of our study is to present data spanning a variety of institutions and practice settings in the United States to define the percentage of non‐operating room anesthetic encounters in children. We also set out to characterize the frequency of the most common procedures in the non‐operating room setting within the United States. Methods: Using the National Anesthesia Clinical Outcomes Registry data from 2015–2019, we analyzed and reported data on current trends in non‐operating room anesthesia including patient demographics, encounter setting, procedure type, and the time at which anesthetic encounters occurred. Results: 2 236 788 pediatric anesthetic encounters (patient age <18 y.o.) were analyzed revealing that 22.7% of all pediatric anesthetics occur in non‐operating room settings. Patients were more likely to have higher American Society of Anesthesiologists Physical Status classifications in the non‐operating room anesthesia group. Gastroenterological suites are the most common setting reported for pediatric non‐operating room anesthesia. Conclusions: Non‐operating room anesthesia in the United States is a prominent segment of pediatric anesthetic practice. Pediatric patients encountered in the non‐operating room setting have more comorbidities, though further studies are needed to characterize the implication of this finding. [ABSTRACT FROM AUTHOR]

Background: Resuscitation with blood products is often required for pediatric cardiac surgery patients following cardiopulmonary bypass. However, data suggest that blood product transfusion is an independent predictor of adverse outcomes. Most studies have specifically found detrimental effects of overall transfusion of red blood cells in particular, but few have analyzed outcomes by the other specific blood product components. Aims: The objective of this study is to analyze adverse outcomes associated with intraoperative transfusion of specific blood product components. Methods: A retrospective review was performed on 643 pediatric patients who underwent cardiac surgery requiring cardiopulmonary bypass to evaluate the risk of selected adverse outcomes associated with intraoperative blood product transfusion. Adverse outcomes included thrombotic complications, stroke, acute kidney injury, prolonged mechanical ventilation, and death. Univariate logistic and linear regression analyses were performed to explore the association between various blood products and the occurrence of postoperative complications. Multiple logistic and linear regression analyses were performed adjusting for age, cyanotic status, The Society of Thoracic Surgeons‐European Association for Cardio‐Thoracic Surgery Score (STAT score), and cardiopulmonary bypass time. Results: Unadjusted analysis using univariate logistic and linear regressions showed statistically significant associations of almost all blood components (per 10 mL/kg dose increments) with multiple postoperative complications, including mortality, thrombotic complications, stroke, and days of mechanical ventilation. After adjusting for patient age, cyanotic status, STAT score, and cardiopulmonary bypass time, multivariable logistic and linear regression analyses revealed no association between transfusion of blood products with acute kidney injury and stroke. Administration of red blood cells was the only category significantly correlated with increased days of mechanical ventilation (0.5 days increase in mechanical ventilation per 10 mL/kg transfusion of red blood cells). The only blood product to show complete lack of a statistically significant association with any of the studied outcomes was cryoprecipitate. Conclusions: Transfusion of blood products following cardiopulmonary bypass is associated with postoperative adverse outcomes. Future studies aimed at strategies to reduce intraoperative bleeding and decrease the amount of blood products administered are warranted. [ABSTRACT FROM AUTHOR]

Postoperative pain control is essential to optimizing patient outcomes, improving satisfaction, and allowing patients to resume their baseline functional activities. Methadone, a synthetic mu‐opioid agonist, has multiple pharmacologic properties that may be optimal for perioperative use. Compared to other opioids, methadone has a longer duration of action, rapid onset, extended dosing intervals, high oral bioavailability, low cost, lack of active metabolites, and action on multiple receptors. The current literature examining the use of methadone in the perioperative care of children and adolescents is limited and most often reported within the context of spine or cardiothoracic surgery. Overall, these studies support the hypothesis that perioperative methadone in pediatric patients may decrease postoperative pain, opioid consumption, length‐of‐stay, and the incidence of some opioid‐related side effects, like constipation and urinary retention. A variety of protocols for the perioperative use of methadone have been described, including a single intraoperative dose as well as multiple small doses within multimodal pain protocols. The superiority of these protocols has not been established. Like all opioids, methadone has a side effect profile which includes nausea, vomiting, reduced GI motility, sedation, and respiratory depression at high doses. There is also a concern that it can cause QTc prolongation in patients. The primary aim of this educational review is to examine the pharmacologic data, published perioperative protocols, dosing considerations, and risks and benefits associated with inclusion of methadone in analgesic regimens for surgical patients. A secondary aim is to introduce opportunities for research around the perioperative use of methadone in children and adolescents. Based on our review, we would prioritize establishing optimal procedure‐specific methadone protocols, determining generalizability for use in routine pediatric surgeries, and investigating methadone safety and efficacy prospectively as the primary opioid for pain management in the postanesthesia care unit or postsurgical floors. [ABSTRACT FROM AUTHOR]

This article discusses the continued use of halothane as an anesthetic, particularly in Africa, despite its removal from most high-income countries due to safety concerns. The author, a practitioner in Cameroon, acknowledges the dangers associated with halothane but highlights its affordability compared to other options. The article explores the complications and adaptations made to ensure safe use of halothane, including the management of myocardial depression and liver toxicity. The author also discusses the longer induction and emergence times of halothane and its advantages in certain surgical procedures. The article concludes by emphasizing the need for better healthcare financing and prioritization to switch to safer alternatives. [Extracted from the article]

Background: Consumer‐driven research is increasingly being prioritized. Aim: Our aim was to partner with consumers to identify the top 10 research priorities for pediatric anesthesia and perioperative medicine. The ACORN (Anesthesia Consumer Research Network) was formed to collaborate with children and families across Australia. Methods: A prospective online survey was developed to generate research ideas from consumers. The survey was developed in Qualtrics, a survey research platform. Consumers were invited to participate through poster advertising, social media posts, via consumer networks at participating hospitals and in addition 35 national consumer/patient representative organizations were approached. We also conducted a similar idea generating survey for clinicians through email invitation and via Twitter. A second round of surveys was conducted to prioritize the long list of research questions and a shortlist of priorities developed. A single consensus meeting was held, and a final consensus list of top 10 priorities emerged. Results: A total of 281 research ideas were submitted between 356 consumers in the idea generating survey and from four consumer/patient representative groups. Seventy‐five clinicians responded to the clinician idea generation survey. This was consolidated into 20 research ideas/themes for the second survey for each group. 566 responses were received to the consumer prioritization top 10 survey and 525 responses to the clinician survey. The consensus meeting produced the final 10 consumer research priorities. Conclusion: This study has given Australian consumers the opportunity to shape the anesthesia and perioperative medicine research agenda for pediatric patients both nationally and internationally. [ABSTRACT FROM AUTHOR]

Introduction: The Plethysmographic Variability Index can be measured by both finger and forehead probes. Vasoconstriction may jeopardize the reliability of finger PVI measurements in pediatric patients undergoing surgery. However, forehead vasculature exhibits more marked resistance to alterations in the vasomotor tonus. Objective: Our aim was to compare the Plethysmographic Variability Index measured via finger or forehead probes in mechanically ventilated pediatric surgery patients in terms of their ability to predict fluid responsiveness as well as to determine the best cut‐off values for these two measurements. Materials and Methods: A total of 50 pediatric patients undergoing minor elective surgery were included after provision of parental consent and ethics committee approval. Perfusion index measured at the finger or forehead and Plethysmographic Variability Index monitoring comprised the primary assessments. Hemodynamic parameters monitored included perfusion index, Plethysmographic Variability Index, and cardiac output. A ≥ 15% increase in cardiac output following passive leg raise maneuver was considered to show fluid responsiveness. Two groups were defined based on fluid responsiveness: Group R (responsive) and Group NR (non‐responsive). Student's t‐test, Mann–Whitney U test, DeLong test, and ROC were used for statistical analysis. Results: The area under curve for finger and forehead Plethysmographic Variability Index prior to passive leg raise maneuver were 0.699 (p =.011) and 0.847 (p <.001), respectively. The sensitivity for finger and forehead measurements at a cut‐off value of ≤14% was 92.9% and 96.4%, and 45.4% and 72.7%, respectively. Conclusion: Although forehead and finger Plethysmographic Variability Index monitoring were similarly sensitive in predicting fluid responsiveness in pediatric surgical patients, the former method provided higher specificity. The best cut‐off value for PVI measurements with forehead and finger probes was found to be 14%. [ABSTRACT FROM AUTHOR]

Background: Point‐of‐care hemoglobin testing devices play an important role in intraoperative anesthetic management where significant hemorrhage is anticipated; however, the reliability of these devices has not been examined in the context of pediatric liver transplantation. In this retrospective observational study, we aimed to determine whether 95% of results from two point‐of‐care hemoglobinometers, the HemoCue and iSTAT, would fall within a difference of ±1 g/dl, our a priori‐defined clinically acceptable level of agreement, of the hemoglobin measures on a core laboratory complete blood count. Methods: We retrospectively collected data from 70 patients presenting for a liver transplant at a single center, tertiary care pediatric hospital over a 3.5‐year period. We analyzed 92 contemporaneous pairs of hemoglobin values from the HemoCue and complete blood count, and 252 pairs of hemoglobin values from the iSTAT and complete blood count. Agreement between the point‐of‐care devices and complete blood count was assessed using Bland–Altman analysis, which was the primary outcome. Secondary analyses included an error grid analysis and Cohen's kappa statistic. Results: Both point‐of‐care devices underestimated complete blood count hemoglobin values and neither device satisfied our a priori‐defined clinically acceptable level of agreement that 95% of values would fall within ±1 g/dl of the complete blood count measurement. The mean difference [limits of agreement] of the HemoCue was 0.4 g/dl (p <.001) [−0.9 to 1.6 g/dl] and of the iSTAT was 0.6 g/dl (p <.001) [−1.4 to 2.6 g/dl]. Secondary error grid analysis revealed that neither device performed well enough to replace a complete blood count at critical thresholds of hemoglobin values. Conclusions: While the HemoCue and iSTAT contribute information in a timely manner during dynamic intraoperative situations, there is significant imprecision compared to the gold standard complete blood count. If clinical stability allows, the results of these point‐of‐care hemoglobinometers should be confirmed with a complete blood count, rather than being used as the sole factor in determining transfusion needs during pediatric liver transplantation. [ABSTRACT FROM AUTHOR]

Background: Pain may be a modifiable risk factor for lower health‐related quality of life after pediatric critical illness. Aim: To evaluate the association between severe pain experienced in the (pediatrc intensive care unit) and postdischarge health‐related quality of life. Methods: This was a retrospective cohort study. Children aged 1 month to 18 years admitted to the pediatric intensive care unit and enrolled in the Seattle Children's Hospital Outcomes Assessment Program were included. Pain was assessed every 2 h by bedside nursing staff using a behavioral pain scale or numeric pain scale. A day of severe pain was defined as a pediatric intensive care unit day with ≥25% of pain scores ≥7/10. Baseline (preadmission) and postdischarge (median 6 weeks) health‐related quality of life was assessed by the Pediatric Quality of Life Inventory (PedsQL™) or the Stein Jessop Functional Status II‐R (FS II‐R, for children with developmental disability). The cohort was stratified by diagnosis category (surgical vs. medical), and associations were measured using linear regression models. Results: Among 546 patients, 11.9% experienced ≥1 day of severe pain. In multivariable linear regression, each day of severe pain was independently associated with a lower postdischarge health‐related quality of life score by 3.6 points (95% CI −6.3 to −0.9) adjusted for baseline health‐related quality of life score, age, baseline cognitive function, days with multi‐organ dysfunction, pediatric intensive care unit length of stay, and decline in overall function. This association was stronger among surgical patients than medical patients with each day of severe pain resulting in a lower postdischarge health‐related quality of life score by 5.3 points (95% CI −9.6 to −0.9) versus 2.6 points (95% CI −5.8 to 0.6). Surgical patients had lower postdischarge emotional functioning than physical functioning subdomain scores. Conclusions: Children who experience severe pain in the pediatric intensive care unit have lower postdischarge health‐related quality of life adjusting for baseline health‐related quality of life, particularly among children who have undergone surgery. Attention to pain management may be important to improve postdischarge health‐related quality of life. [ABSTRACT FROM AUTHOR]

Background: Intravenous acetaminophen and opioid analgesics are routinely given concurrently to children after major surgery, where intravenous access can be limited. There is limited information about the compatibility of acetaminophen with opioid analgesics and ketamine in concentrations commonly used in pediatric setting. Aims: We aimed to determine the physical and chemical compatibility in mixtures of intravenous acetaminophen 10 mg/mL with morphine (0.025, 0.05, 0.1, 0.2, 1, and 2 mg/ml), fentanyl (0.5, 0.75, 1, 1.5, 2, and 5 mcg/ml) and ketamine (0.01, 0.1, 0.5, 1, 1.5, and 3 mg/ml). Methods: Acetaminophen was mixed with all 18 solutions and was examined at time 0, 15, 30, and 60 min. In Phase one of the study, we used a colorimetric method to assess preliminary feasibility and acetaminophen recovery. In Phase two study, we used high‐performance liquid chromatography to evaluate the recovery of all components of the mixtures. Results: All solutions tested, for both acetaminophen and the three analgesics, had more than 90% of the drug recovery, up to 60 min after mixing. Conclusion: Our data demonstrated the stability of acetaminophen, in combination with fentanyl, morphine, and ketamine at clinical concentrations used in acute pediatric pain setting. [ABSTRACT FROM AUTHOR]

Background: Previous studies have shown Proseal LMA and I gel similar to endotracheal intubation in ventilatory ability in pediatric laparoscopic surgeries. Aims: The primary aim of this study was to assess whether there is a significant difference in the oropharyngeal leak pressure between Ambu Auragrain, I‐gel, and Proseal LMA during pediatric laparoscopic surgery. Methods: In this randomized controlled trial, 90 male patients of American Society of Anesthesiologists physical status I aged between 6 months and 10 years who were scheduled for laparoscopic single‐sided inguinal hernia repair were recruited and randomly allocated to three groups in which airway was secured with Ambu Auragain, I gel, or Proseal LMA. The primary outcome was oropharyngeal leak pressure. The secondary outcomes were peak pressures before and after pneumoperitoneum, fiberoptic view, insertion attempts, insertion time, manipulations, perioperative and postoperative anesthesia‐related problems. Continuous variables were compared using the one‐way analysis of variance or the Kruskal–Wallis test with post hoc Turkey analysis. Categorical and ordinal data were compared using the chi‐square test or Fisher's exact test. Results: Oropharyngeal leak pressure before pneumoperitoneum was higher with I gel as compared to Ambu Auragain (27.36 ± 5.72 cm of H2O vs 23.56 ± 5.72 cm of H2O) (p =.021) and PLMA (27.36 ± 5.72 cm of H2O vs 23.24 ± 4.35 cm of H2O) (p =.011). Oropharyngeal leak pressure after pneumoperitoneum was also higher with I gel as compared to Ambu Auragain (31.58 ± 4.35 cm of H2O vs 26.83 ± 5.00 cm of H2O) (p =.001) and Proseal LMA (31.58 ± 4.35 cm of H2O vs 27.03 ± 3.80 cm of H2O) (p =.002). Oropharyngeal leak pressures of Ambu Auragain and Proseal LMA were comparable. Postoperative complications were similar in all the supraglottic airway devices. No regurgitation or aspiration‐related problem was observed in our study. Conclusion: I gel had a higher oropharyngeal leak pressure than the other two supraglottic airway devices and therefore may represent a better choice in situations where higher ventilatory pressures may be necessary, for example, in extremes of weight trendelenburg position, etc. Clinical Trial Identifier: Clinical trial registry of India (CTRI/2018/11/016445). [ABSTRACT FROM AUTHOR]

Background: Intraoperative hypercapnia and hypocapnia are common during pediatric anesthesia, and the cerebral blood flow and intracranial pressure may be affected by the partial pressure of arterial carbon dioxide. Transorbital ultrasound measurement of the optic nerve sheath diameter is a simple and non‐invasive method for intracranial pressure assessment. The objective of this study was to evaluate the effect of end‐tidal carbon dioxide (ETCO2) on optic nerve sheath diameter in a healthy anesthetized pediatric population. Methods: Pediatric patients scheduled for elective surgery under general anesthesia and mechanical ventilation in the supine position were enrolled and divided into four subgroups; age <2 years, 2–6 years, 6–12 years, and 12–18 years. Mechanical ventilation was adjusted to achieve target ETCO2 levels in a randomized sequence (40–35–45–40 mmHg or 40–45–35–40 mmHg). Three minutes after reaching each target ETCO2 level, transorbital ultrasound images of optic nerve sheath diameter were obtained and analyzed. The primary outcome was the optic nerve sheath diameter at each ETCO2 level. Results: Sixty‐four pediatric patients were enrolled and analyzed. At ETCO2 = 40 mmHg, the optic nerve sheath diameter was 5.6 ± 0.6 mm, 6.4 ± 0.5 mm, 6.8 ± 0.6 mm, and 7.1 ± 0.5 mm in children aged <2 years, 2–6 years, 6–12 years, and 12–18 years, respectively. The overall percent decreases in the optic nerve sheath diameter was −5.6 ± −4.3% (95% CI; −6.7 to −4.5%) at ETCO2 = 35 mmHg while the overall percent increases of optic nerve sheath diameter (ONSD) was 4.9 ± 5.1% (95% CI; 3.6 to 6.1%) at ETCO2 = 45 mmHg compared with those at ETCO2 = 40 mmHg. Spearman rank correlation analysis indicated that there were weak to moderate correlation between ETCO2 and the optic nerve sheath diameter (correlation coefficient [p‐value] =.355 [.004],.318 [.014],.373 [<.001], and.420 [<.001] in children aged <2 years, 2–6 years, 6–12 years, and 12–18 years, respectively). Conclusions: The optic nerve sheath diameter measured by transorbital ultrasound showed rapid reactivity from ETCO2 35 to 45 mmHg in healthy pediatric patients under inhalation general anesthesia. [ABSTRACT FROM AUTHOR]

Background: Worldwide, pediatric sedation for magnetic resonance imaging is a standard practice; however, there are few studies on its trends and patterns. Aims: This study aimed to investigate the trends and patterns of pediatric sedation for magnetic resonance imaging in Japan and determine the incidence of and risk factors for adverse events/interventions. Methods: This longitudinal descriptive study assessed children (age < 15 years) who underwent sedation for magnetic resonance imaging between April 2012 and December 2019 in Japan using a nationwide claims database. We assessed the patients' demographic characteristics, time trends in sedatives, sedative patterns by age, and adverse events/interventions within two post‐sedation days. Further, we used multivariable logistic regression models to explore factors related to the incidence of adverse events/interventions. Results: We identified 29 187 cases (median age, 2.0 years; 55.2% males). The most common sedative was triclofos sodium (n = 18 812, 51.7%). There was an increasing trend in barbiturate use (17.0% [2012] to 25.0% [2019]) and decreasing trends in the use of triclofos sodium (56.4% [2012] to 47.7% [2019]) and chloral hydrate (15.6% [2012] to 10.8% [2019]). We identified 534 adverse events/interventions in 460 cases (1.5%). Multivariable logistic regression analyses revealed that the incidence of adverse events/interventions mainly increased with the number of sedatives (≥3; adjusted odds ratio, 5.10; 95% confidence interval, 3.67–7.10) and unscheduled setting (adjusted odds ratio, 6.28; 95% confidence interval, 4.85–8.61); further, it decreased with high hospital procedure volume (adjusted odds ratio, 0.62; 95% confidence interval, 0.49–0.78). Conclusions: Based on a Japanese real‐world setting, there is an increasing trend in barbiturate use and decreasing trends in the use of triclofos sodium and chloral hydrate in pediatric sedation for magnetic resonance imaging. Low hospital procedure volumes were associated with an increased risk of adverse events/interventions. [ABSTRACT FROM AUTHOR]

In this educational article, we summarize the changes in the new European Resuscitation Council guidelines for Pediatric Life Support, emphasizing the most important aspects for the anesthesiologist. Among these are: the use of two‐thumb‐encircling technique for thorax compressions in infants, 10 ml/kg as the standard volume fluid bolus and ventilation after intubation at an age‐dependent rate. Using a fictitious case, we present a point‐by‐point summary of the changes and briefly mention some of the evidence behind them, referring the reader to the full guidelines for further evidence. We also give a summary of the incidence, causes, challenges, treatment, and prognosis of pediatric cardiac arrest in the operating room. [ABSTRACT FROM AUTHOR]

Background: Perioperative central venous catheters are required but may be associated with various complications. Aims: The purpose of our study was to assess the incidence and perioperative risk factors for catheter‐related internal jugular vein thrombosis in pediatric surgical patients. Methods: This prospective observational study included children under 6 years of age who were scheduled to undergo central venous catheterization of the right internal jugular vein under general anesthesia. A central venous catheter was inserted under real‐time ultrasound guidance. An investigator examined for thrombosis using ultrasonography at predetermined time points. The primary aim was the incidence of catheter‐related thrombosis from insertion until the 5th day postoperatively or the removal of the central venous catheter. The secondary aim was the determination of the risk factors for thrombosis. Results: Eighty patients completed the study. Internal jugular vein thrombi were found in 31 patients (38.8%, 95% CI 28.0–49.4). On multiple logistic regression analyses, the number of insertion attempts was the only influencing factor for catheter‐related thrombosis (p <.001). More than two insertion attempts increased the risk of thrombosis (odds ratio 5.6; 95% CI 1.7 – 18.7, p =.004). Anesthesia time (p =.017; mean difference 166.4 min; 95% CI 55.7–277.1), intraoperative red blood cell transfusion (p =.001; median difference 21.1 ml kg−1; 95% CI 6.6–34.4), and intensive care unit stay (p =.001; median difference 100.0 h; 95% CI 48–311) differed between patients with transient thrombosis and those with thrombosis lasting for more than 3 days. Conclusion: Internal jugular vein thrombosis was frequently detected by ultrasound following central venous catheterization in pediatric surgical patients. Multiple insertion attempts may be associated with the incidence of thrombosis. The clinical relevance of thrombi detected via ultrasound surveillance has not been determined. [ABSTRACT FROM AUTHOR]

Background: Few randomized studies have assessed recovery from rocuronium‐ or vecuronium‐induced moderate or deep neuromuscular blockade with sugammadex in pediatric participants. Aim: To assess sugammadex for reversal of neuromuscular blockade in pediatric participants. Methods: This was a randomized, phase IV, active comparator‐controlled, double‐blind study. Participants aged 2 to <17 years, under moderate or deep neuromuscular blockade, were administered sugammadex (2 or 4 mg/kg) or neostigmine (50 µg/kg; for moderate neuromuscular blockade only). Predefined adverse events of clinical interest, including clinically relevant bradycardia, hypersensitivity, and anaphylaxis, were monitored. The primary efficacy endpoint was time to recovery to a train‐of‐four ratio of ≥0.9 in participants receiving sugammadex 2 mg/kg versus neostigmine for reversal of moderate neuromuscular blockade, analyzed by analysis of variance adjusted for neuromuscular blocking agent and age. Results: Of 288 randomized participants, 272 completed the study and 276 were included in the analyses. Clinically relevant bradycardia was experienced by 2.0%, 1.6%, and 5.9% of participants in the sugammadex 2 mg/kg, sugammadex 4 mg/kg, and neostigmine groups, respectively. No hypersensitivity or anaphylaxis events were observed. Recovery to a train‐of‐four ratio of ≥0.9 with sugammadex 2 mg/kg was faster than neostigmine (1.6 min, 95% CI 1.3 to 2.0 vs. 7.5 min, 95% CI 5.6 to 10.0; p <.0001) and was comparable to sugammadex 4 mg/kg (2.0 min, 95% CI 1.8 to 2.3). Conclusions: Pediatric participants recovered from rocuronium‐ or vecuronium‐induced moderate neuromuscular blockade significantly faster with sugammadex 2 mg/kg than with neostigmine. Time to reversal of deep neuromuscular blockade with sugammadex 4 mg/kg was consistent with that of moderate neuromuscular blockade reversal. No meaningful differences in clinically relevant bradycardia, hypersensitivity, or anaphylaxis were seen with sugammadex vs neostigmine. These results support the use of sugammadex for reversal of moderate and deep rocuronium‐ and vecuronium‐induced neuromuscular blockade in patients aged 2 to <17 years. Clinical Trial Registration: NCT03351608/EudraCT 2017‐000692‐92. [ABSTRACT FROM AUTHOR]

Racial and ethnic disparities in both healthcare management and delivery have been extensively documented in medical literature. For example, patients from non‐White minority backgrounds in the United States have been found to experience worse clinical outcomes after surgery, to receive fewer surgical procedures, and to experience worse perioperative pain management compared with patients from non‐minority backgrounds. A recent NIH‐ACS Symposium on Surgical Disparities Research has identified an urgent need for research aimed at addressing and understanding these disparities. The present review summarizes existing literature describing perioperative pain disparities in children in the United States, as well as highlights the paucity of research in this domain. Specifically, there is a need for randomized control trials and health services research studying pediatric perioperative pain disparities. A multidisciplinary systems‐based approach would help translate findings from scientific research to clinical practice and is a crucial step to ensuring all children of diverse backgrounds receive optimal perioperative care. [ABSTRACT FROM AUTHOR]

Summary: Due to the high prevalence of asthma and general airway reactivity, anesthesiologists frequently encounter children with asthma or asthma‐like symptoms. This review focuses on the epidemiology, the underlying pathophysiology, and perioperative management of children with airway reactivity, including controlled and uncontrolled asthma. It spans from preoperative optimization to optimized intraoperative management, airway management, and ventilation strategies. There are three leading causes for bronchospasm (1) mechanical (eg, airway manipulation), (2) non‐immunological anaphylaxis (anaphylactoid reaction), and (3) immunological anaphylaxis. Children with increased airway reactivity may benefit from a premedication with beta‐2 agonists, non‐invasive airway management, and deep removal of airway devices. While desflurane should be avoided in pediatric anesthesia due to an increased risk of bronchospasm, other volatile agents are potent bronchodilators. Propofol is superior in blunting airway reflexes and, therefore, well suited for anesthesia induction in children with increased airway reactivity. [ABSTRACT FROM AUTHOR]

Pediatric surgery cases are increasing worldwide. Within pediatric anesthesia, perioperative respiratory adverse events are the most common precipitant leading to serious complications. They can have intraoperative impact on the surgical procedure itself, lead to premature case termination and in addition may have postoperative impact resulting in longer hospitalization stays and costs. Although most perioperative respiratory adverse events can be promptly detected and managed, and will not lead to any sequelae, the risk of life‐threatening progression remains. The incidence of respiratory adverse events increases in children with comorbid respiratory and/or nonrespiratory illnesses. Optimized perioperative patient care, risk‐stratified care level choice, and practitioners with appropriate training allow for risk mitigation. This review will discuss patient and surgical risk factors with a focus on common patient comorbid illnesses and review scoring systems to quantify risk. [ABSTRACT FROM AUTHOR]

Perioperative respiratory adverse events are the most common cause of critical events in children undergoing anesthesia and surgery. While many risk factors remain unmodifiable, there are numerous anesthetic management decisions which can impact the incidence and impact of these events, especially in at‐risk children. Ongoing research continues to improve our understanding of both the influence of risk factors and the effect of specific interventions. This review discusses anesthesia risk factors and outlines strategies to reduce the rate and impact of perioperative respiratory adverse events with a chronologic based inquiry into anesthetic management decisions through the perioperative period from premedication to postoperative disposition. [ABSTRACT FROM AUTHOR]

Children with neuromuscular, chronic neurologic, and chest wall diseases are at increased risk of postoperative respiratory complications including atelectasis, pneumonia, and respiratory failure with the possible need for reintubation or even tracheostomy. These complications negatively impact patient outcomes, including increased healthcare resource utilization and increased surgical mortality. In these children, the existing respiratory reserve is often inadequate to withstand the stresses brought on during anesthesia and surgery. A thorough clinical assessment and objective evaluation of pulmonary function and gas exchange can help identify which children are at particular risk for poor postoperative outcomes and thus merit preoperative interventions. These may include initiation and optimization of non‐invasive ventilation and mechanical insufflation‐exsufflation. Furthermore, such an evaluation will help identify children who may require a postoperative extubation plan tailored to neuromuscular diseases. Such strategies may include avoidance of pre‐extubation lung decruitment by precluding continuous positive airway pressure trials, aggressively weaning to room air and directly extubating to non‐invasive ventilation with a high inspiratory to expiratory pressure differential of at least 10 cm H20. Children with cerebral palsy and other neurodegenerative or neurodevelopmental disorders are a more heterogeneous group of children who may share some operative risk factors with children with neuromuscular disease; they may also be at risk of sleep‐disordered breathing, may also require non‐invasive ventilation or mechanical insufflation‐exsufflation, and may have associated chronic lung disease from aspirations that may require perioperative treatment. [ABSTRACT FROM AUTHOR]

Perioperative respiratory adverse events pose a significant risk in pediatric anesthesia, and identifying these risks is vital. Traditionally, this is assessed using history and examination. However, the perioperative risk is multifactorial, and children with complex medical backgrounds such as chronic lung disease or obesity may benefit from additional objective preoperative pulmonary function tests. This article summarizes the utility of available pulmonary function assessment tools as preoperative tests in improving post‐anesthetic outcomes. Currently, there is no evidence to support or discourage any pulmonary function assessment as a routine preoperative test for children undergoing anesthesia. In addition, there is uncertainty about which patients with the known or suspected respiratory disease require preoperative pulmonary function tests, what time period prior to surgery these are required, and whether spirometry or more sophisticated tests are indicated. Therefore, the need for any test should be based on information obtained from the history and examination, the child's age, and the complexity of the surgery. [ABSTRACT FROM AUTHOR]

Bronchoscopy‐guided diagnostic and interventional airway procedures are gaining in popularity and prominence in pediatric surgery. Many of these procedures have been used successfully in the adult population but have not been used in children due to a lack of appropriately sized instruments. Recent technological advances have led to the creation of instruments to enable many more diagnostic and therapeutic procedures to be done under bronchoscopic guidance. These procedures vary significantly in their length and invasiveness and require vastly different anesthetic plans that must be easily adapted to situational and procedural changes. In addition to close communication between the anesthesiology and procedural teams; an understanding of the type of procedure, anesthetic requirements, and potential patient risks is paramount to a successful anesthetic. This review will focus on new rigid bronchoscopic procedures, goals for their respective anesthetic management, and unique tips and trick for how to maintain adequate oxygenation and ventilation in each scenario. [ABSTRACT FROM AUTHOR]

The systemic challenges in providing safe anesthesia, including safe ventilation, to children in resource‐constrained settings are many. For anesthesia providers caring for children, the lack of appropriate equipment, inadequate anesthesia workforce and deficiencies in postoperative care are especially difficult. The clinical decisions made by anesthesia providers around when and how to ventilate a child for surgery are influenced by all of these factors and can result in patient management which may vary significantly from that in a high‐resource setting. This educational review considers the intraoperative ventilation of a small child in a resource‐constrained setting and discusses specific challenges and context‐sensitive solutions. [ABSTRACT FROM AUTHOR]

Summary: Bronchospasm is a common respiratory adverse event in pediatric anesthesia. First‐line treatment commonly includes inhaled salbutamol. This review focuses on the current best practice to deliver aerosolized medications to awake as well as anesthetized pediatric patients and discusses the advantages and disadvantages of various administration techniques. Additionally, we detail the differences between various airway devices used in anesthesia. We highlight the unmet need for innovation of orally inhaled drug products to deliver aerosolized medications during pediatric respiratory critical events such as bronchospasm. It is therefore important that clinicians remain up to date with the best clinical practice for aerosolized drug delivery in order to prevent and efficiently treat pediatric patients experiencing life‐threatening respiratory emergencies. [ABSTRACT FROM AUTHOR]

With the advent of thoracoscopic surgery, the benefits of lung isolation in children have been increasingly recognized. However, because of the small airway dimensions, equipment limitations in size and maneuverability, and limited respiratory reserve, one‐lung ventilation in children remains challenging. This article highlights some of the most common error traps in the management of pediatric lung isolation and focuses on practical solutions for their management. The error traps discussed are as follows: (1) the failure to take into consideration relevant aspects of tracheobronchial anatomy when selecting the size of the lung isolation device, (2) failure to execute correct placement of the device chosen for lung isolation, (3) failure to maintain lung isolation related to surgical manipulation and isolation device movement, (4) failure to select appropriate ventilator strategies during one‐lung ventilation, and (5) failure to appropriately manage and treat hypoxemia in the setting of one‐lung ventilation. [ABSTRACT FROM AUTHOR]

General anesthesia is associated with development of pulmonary atelectasis. Children are more vulnerable to the development and adverse effects of atelectasis. We review the physiology and risk factors for the development of atelectasis in pediatric patients under general anesthesia. We discuss the clinical significance of atelectasis, the use and value of recruitment maneuvers, and other techniques available to minimize lung collapse. This review demonstrates the value of a recruitment maneuver, maintaining positive end‐expiratory pressure (PEEP) until extubation and lowering FiO2 where possible in the daily practice of the pediatric anesthetist. [ABSTRACT FROM AUTHOR]

Congenital lung lesions are numerous but rare in individual clinical practice. They do require close multidisciplinary collaboration between health care professionals. This educational review will focus on the pathophysiology, clinical manifestations, surgical approaches, and anesthetic management of congenital anomalies of the large intrathoracic airways: congenital tracheal stenosis, tracheal agenesis, tracheal diverticulum, bronchial anomalies (tracheal, esophageal, or bridging bronchus), congenital lung malformations, lung sequestrations and Scimitar syndrome, lobar emphysema, Williams–Campbell syndrome, and pleuropulmonary blastoma. In addition, this review will illustrate common pitfalls and challenges related to the anesthesia management with emphasis on ventilation and correct endotracheal tube positioning. [ABSTRACT FROM AUTHOR]

Background: Accurate insertion depth of endotracheal tube (ETT) in children has been predicted using the demographic variables, such as age, weight, and height. Middle finger length showed good correlation with ETT depth measurement in children aged 4–14 years. Aims: The primary objective was to correlate the actual ETT insertion depth with the depth derived from middle finger length, age, weight, and height formulae in children aged 1–4 years. The secondary objective was to find the most accurate formula for prediction of ETT insertion depth. Methods: This prospective parallel group study was done in 50 american society of anesthesiologists 1 or 2 children aged 1–4 years undergoing elective surgery under general anesthesia. Children with difficult airway, finger anomalies, or syndromic associations were excluded. Age, weight, height, and middle finger length of all children were measured. Depth of orally inserted uncuffed ETT and tracheal length was measured by fiberoptic bronchoscopy. The actual ETT depth was correlated with the depth calculated from different formulae. Results: The mean middle finger length was 4.42 ± 0.50 cm, age was 2.64 ± 1.07 years, weight was 12.28 ± 2.84 kg, and height was 82.89 ± 16.23 cm. The mean tracheal length was 6.42 ± 0.96 cm. The mean depth of ETT was actual depth (12.89 ± 1.09 cm), middle finger depth (13.23 ± 1.53cm; p =.001; 95%CI 0.12–0.50), age‐based depth 1(3.31 ± 0.53 cm; 95%CI 0.37–1.44; p =.001), weight‐based depth (14.14 ± 1.42 cm; 95% CI 0.10–0.51; p =.004), and height‐based depth (13.73 ± 0.94 cm; 95% CI 0.15–0.77; p =.004). Middle finger length and age‐based formulae showed higher number of accurate placements (58% each). Weight‐ (74%) and height (64%)‐derived formulae gave a higher number of distal ETT placements. Conclusion: Formulas based on the demographic variables and middle finger length showed good correlation with the actual ETT depth in children aged 1–4 years. The percentage of accurate ETT depth placements was higher with middle finger length and age‐based formulae. [ABSTRACT FROM AUTHOR]

Background: Pediatric anesthesia‐related cardiac arrest is an uncommon but catastrophic adverse event which has been, in a previous study, associated with anesthesiologist‐related factors such as number of days per year providing pediatric anesthesia. We aimed to replicate this and assess other anesthesiologist‐related risk factors for anesthesia‐related cardiac arrest after adjusting for known underlying risk factors present in the case mix. Methods: We analyzed a large retrospectively collected patient cohort of anesthetics administered from 2006 to 2016 to children at a tertiary pediatric hospital. Three reviewers independently reviewed cardiac arrests and categorized whether they appeared to be related to anesthesia care. Anesthesiologist‐related factors including academic rank, experience, recent case mix, and days per year delivering pediatric anesthesia were assessed for association with anesthesia‐related cardiac arrest after adjustment for underlying case mix. Results: Cardiac arrest occurred in 240 of 109 775 anesthetics (incidence 22/10 000 anesthetics); 82 (7/10 000 anesthetics) were classified as anesthesia‐related. In univariable analyses, anesthesia‐related cardiac arrest was associated with age, (infants ≤180 days, p <.001) American Society of Anesthesiologists Physical Status, (>2, p <.001) American Society of Anesthesiologists Physical Status Emergency, (p =.0035) cardiac surgery, (p <.001) operating room location, (p =.0066) and resident/fellow supervision, (p =.009) but none of the anesthesiologist factors. Even after adjusting for age and American Society of Anesthesiologist Status, none of the anesthesiologist factors were associated with anesthesia‐related cardiac arrest. Conclusions: Case mix explained all associations between higher risk of pediatric anesthesia‐related cardiac arrest and anesthesiologist‐related variables at our institution. [ABSTRACT FROM AUTHOR]

Background: Appropriate size selection of pediatric rigid bronchoscopes is fundamental to avoidance of airway trauma and to a high success rate with the first intubation attempt. The aim of the present study was to compare the outer diameters of pediatric rigid bronchoscopes with the anatomical data on the pediatric airway. Methods: Outer diameters (OD) of pediatric rigid ventilating bronchoscopes as given by the manufacturer were compared with published computed tomography internal diameters (ID) of the cricoid outlet, the trachea as well as the left and right proximal mainstem bronchus, using six published recommendations for age‐related size selection. The ratios between a specific OD and ID were calculated and given as percentage values (%) for lower and upper age ranges. Results: Nominal sized 2.5, 3, 3.5, 3.7, 4, 4.5, 5, and 6 rigid bronchoscopes were included. In five recommendations, the rigid bronchoscopes' OD was larger than the internal cricoid diameter in the upper age range, whereas in one recommendation the ratio (OD rigid bronchoscope to ID of cricoid) ranged between 77% and 90% for the upper age and between 95% and 109% for the lower age range. In only one of the six recommendations was the rigid bronchoscope OD larger than the tracheal ID. Ratios for the left and right proximal mainstem bronchus ranged from 70% to 146% for the upper and from 78% to 156% for the lower age range, with the highest ratios for the left proximal mainstem bronchus. Conclusion: Based on this in vitro study, most of the recommendations analyzed result in a balanced fit of rigid bronchoscopes within the cricoid. Since the left mainstem bronchus is considerably smaller than the cricoid, any insertion on this level will require careful endoscopic guidance to avoid damage to the left mainstem bronchus. [ABSTRACT FROM AUTHOR]