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Background: Induction of anesthesia can be stressful: Up to 60% of children suffer significant anxiety immediately before surgery. Anxiety is associated with higher postoperative analgesia requirements, higher incidence of emergence delirium, and detrimental effects on sleep and behavior. Child Life preparation includes role‐play, expectation‐setting, and teaching coping strategies. Aim : The aim of this trial was to determine whether preoperative Child Life preparation reduces anxiety prior to intravenous induction of anesthesia. Methods: Children aged 3‐10 years, with no known preexisting anxiety and no preoperative anxiolytics, undergoing elective day surgery lasting ≤ 2 hours, were enrolled in a randomized controlled trial. Each child's baseline anxiety was assessed in the anesthetic care unit, using the modified Yale Preoperative Anxiety Scale—Short Form (mYPAS‐SF, observational scores from 22.9, minimal anxiety, to 100, maximal anxiety) as the primary outcome. The child was randomly assigned to intervention (minimum 15 minutes Child Life preparation) or control (standard practice without Child Life preparation). Participants entered the operating room with one parent. A researcher (blinded to group allocation) scored the child's operating room anxiety using mYPAS‐SF, up to the first attempt at intravenous cannulation. Results: Fifty‐nine children completed the study, aged median [interquartile range] 5 [3‐7] years. Baseline mYPAS‐SF anxiety was 29.2 [22.9‐37.5] for all children, and operating room anxiety was 29.2 [22.9‐49.0]. Operating room anxiety was higher than baseline in 16/31 (52%) children in the control group and 6/28 (21%) in the Child Life preparation group. ANCOVA revealed a significant effect of baseline mYPAS‐SF anxiety and group on operating room anxiety (F = 10.31, P <.001, adjusted R2 =.24); individual parameter estimates indicated that Child Life preparation reduced operating room anxiety by 13.8 (95% CI 4.4‐23.1) points compared to control, P =.005. Conclusion: A brief, targeted Child Life preparation session had a statistically significant effect on reducing preoperative anxiety prior to intravenous induction of anesthesia in young children, with no known preexisting anxiety. This effect may be clinically important and suggests that Child Life can be a valuable component of pediatric surgical care. Further research is required in specific populations. [ABSTRACT FROM AUTHOR]

Background: Preoperative fasting is performed to reduce aspiration risk during general anesthesia. Recommendations are that patients should fast for 6 hours from solids and nonhuman milk, 4 hours from breast milk, and 2 hours from clear fluids. However, previous studies have shown that children fast far in excess of these times, which can result in perioperative complications and unnecessary discomfort for the child. Aims: This prospective, mixed‐methods study aims to explore the experiences of pediatric patients undergoing preoperative fasting in Leeds General Infirmary. It also aims to investigate fasting durations of these patients and factors which influence these. Methods: Over 2 weeks, surveys were distributed to all parents of elective pediatric patients and completed prior to their child being called to theater. Children over the age of six were offered a child survey, which had been specifically developed for the study, with visual Likert scales and an area for free text. The gathering of children's comments about their experience of preoperative fasting is unique to this study. Results: Seventy‐one parent surveys and 48 child surveys were completed, with a mean patient age of 8.3 years (SD 4.1). The mean preoperative fasting time for food was 11.7 hours (SD 4.4) and 6.9 hours (SD 5.0) for fluids. Fasting times were far in excess of the minimums recommended, negatively impacting patient experience with 34% reporting being hungry/very hungry and 19% thirsty/very thirsty. Most children's comments suggested that they coped well with the fasting; however, several children reported feelings of sadness and anxiety. Conclusion: Preoperative fasting times in pediatric patients far exceed the durations set by international guidelines. Given that many children reported extreme feelings of hunger and thirst or emotional effects from the fast, these durations need to be optimized in order to improve patient experience. [ABSTRACT FROM AUTHOR]

Summary: Background: Accurate measurement of preoperative anxiety is important for pediatric surgical patients' care as well as for monitoring anxiety‐reducing interventions. The modified Yale Preoperative Anxiety Scale‐short form is well validated for this purpose in children aged 2 years and above, but not in younger children. Aims: We aimed to validate the Dutch version of the modified Yale Preoperative Anxiety Scale‐short form for measuring preoperative anxiety in children less than 2 years old. Methods: Two investigators independently assessed infants' anxiety at the holding area and during induction of anesthesia with the modified Yale Preoperative Anxiety Scale‐short form and the COMFORT‐Behavior scale—live and from video observations. Construct validity and responsiveness of both scales were tested with Pearson correlation coefficient. Internal consistency of the modified Yale Preoperative Anxiety Scale‐short form was assessed using Cronbach's α, and inter‐rater reliability and intra‐rater reliability were tested using the intraclass correlation coefficient and Cohen's linearly weighted kappa. Hypotheses for sufficient inter‐rater reliability (r > 0.60) and validity (r > 0.65) had been formulated a priori in line with the COSMIN guidelines. Results: Behavior of 129 infants (89.1% male) with a median age of 6.5 months (range 0.9‐16.5 months) was observed. The correlations between the modified Yale Preoperative Anxiety Scale‐short form and COMFORT‐Behavioral scale were strong at the holding area and at induction of anesthesia, as were the correlation of change scores between the holding area and induction. Internal consistency of the modified Yale Preoperative Anxiety Scale‐short form was excellent at both the holding area and at induction of anesthesia. Inter‐rater reliability was good to excellent on scale level and moderate to good on item level. Conclusion: These findings support the validity and reliability of the Dutch version of the modified Yale Preoperative Anxiety Scale‐short form in children less than 2‐years‐old. [ABSTRACT FROM AUTHOR]

Background Children often starve for longer than recommended by current preoperative fasting guidelines. Aims We studied the effects of implementing a more lenient fasting regimen on the duration of clear fluid fasting, as well as the incidence of extended fasting in children. Methods Preoperative duration of clear fluid fasting was recorded for patients scheduled for procedures in a unit applying the standard 6-4-2 fasting regimen. This group was compared with a cohort in the same unit 1 year after transitioning to a 6-4-0 fasting regimen. The latter includes no limitations on clear fluid intake until the child is called to theater. A third cohort from a unit in which the 6-4-0 fasting regimen has been implemented for over a decade was also studied for comparison. Results Patients fasting according to the 6-4-2 fasting regimen (n = 66) had a median fasting time for clear fluids of 4.0 h and a 33.3% incidence of fasting more than 6 h. After transitioning to the 6-4-0 fasting regimen (n = 64), median duration of fasting for clear fluids decreased to 1.0 h, and the incidence of fasting more than 6 h decreased to 6.3%. In the second unit (n = 73), median fasting time was 2.2 h and the proportion of patients fasting more than 6 h was 21.9%. Conclusion The introduction and implementation of the 6-4-0 fasting regimen reduces median fluid fasting duration and the number of children subjected to extended fasting. [ABSTRACT FROM AUTHOR]

Background Information transfer to patients is an integral part of modern medicine. Internet-based alternatives represent a new and attractive way for information transfer. Methods The study used a prospective observer-blinded design. Children (3-12 years) and parents were instructed to get further preoperative information either through an interactive web-based platform, the Anaesthesia-Web, or conventional brochure material until day of outpatient surgery. On the day of surgery, children and parents were separately asked six different questions. The primary end-point was to compare the total question score in children between the two information options (maximum score = 36). Secondary aims were the total question score for parents and the influence of age, sex, and time between the preoperative visit and day of surgery. Results A total of 125 children were recruited, of which 103 were included in the final analysis (the Anaesthesia-Web group, n = 49; the brochure material group, n = 54). At the predetermined interim analysis, the total question score in children was found to be substantially higher in the Anaesthesia-Web group than in the brochure material group (median score: 27; IQR: 16.5-33 and median score: 19.5; IQR: 11.25-27.75, respectively, P = 0.0076). The median difference in score was 6; 95% CI: 0-9. The total question score in parents was also higher in the Anaesthesia-Web group than in the brochure material group. Increasing child age was associated with a higher total question score in both groups. Sex did not influence the total question score in the Anaesthesia-Web group, whereas girls scored better than boys in the brochure material group. Conclusions Children in the age range 3-12 years of age as well as their parents do better attain preoperative information from an interactive web-based platform compared to conventional brochure material. [ABSTRACT FROM AUTHOR]

Background Although some studies have investigated the potential predictors of perioperative mortality, there are few specifically for pediatrics. Objective The aim of the retrospective study was to analyze potential preoperative risk factors and to develop a pediatric preoperative risk prediction score ( PRPS), and to predict postoperative ICU admission and the incidence of perioperative death in pediatric patients. Methods Patients who postoperatively admitted to ICU or died (occurred within 30 days after the surgery) from 263 607 pediatric surgical patients with age from 1 day to 14 years old in eight centers in China from October 2010 to September 2013 were retrospectively analyzed. About 5500 non- ICU admission and death patients were randomly selected from those 263 607 patients as controls for analysis comparison. Independent risk factors and a risk model were derived from these analyses, and were further assessed with the likelihood ratio test and the area under the receiver operating characteristic ( ROC) curve. Results There were 1812 ICU admission or death patients but 187 patients' records are incomplete. There were 487 patients with incomplete records among 5500 controls. Collectively, data from 6626 patients were enrolled in final analyses. With multiple logistic regression analysis, age, ASA physical status, SpO2, prematurity, and unfasted status were found to be independent predictors for critical patients. The AUC value of 0.905 indicated excellent predictive performance between critical and noncritical predictors. Conclusions Our study revealed that age, ASA physical status, SpO2, prematurity, and unfasted status are risk factors to predict postoperative ICU admission and death in pediatric patients. [ABSTRACT FROM AUTHOR]

Down syndrome is a common chromosome disorder affecting all body systems. This creates unique physiologic concerns that can affect safety during anesthesia and surgery. Little consensus exists, however, on the best way to evaluate children with Down syndrome in preparation for surgery. We review a number of salient topics affecting these children in the perioperative period, including cervical spine instability, cardiovascular abnormalities, pulmonary hypertension, upper airway obstruction, hematologic disturbances, prematurity, low birth weight, and the use of supplements and alternative therapies. Recommendations include obtaining a complete blood count to detect an increased risk for bleeding or stroke, and cardiology evaluation to identify patients with pulmonary hypertension, as well as undiagnosed or residual heart disease. Pediatric cardiac anesthesiologists and intensivists should be involved as needed. The potential for cervical spine instability should be considered, and the anesthesiologist may wish to have several options available both for the medications and equipment used. The child's family should always be asked if he or she is on any nutritional supplements, as some products marketed to families may have secondary effects such as inhibition of platelet function. Using this evaluation in presurgical planning will allow physicians to better consider the individual circumstances for their patients with Down syndrome. Our goal was to optimize patient safety by choosing the most appropriate setting and perioperative personnel, and to mitigate those risk factors amenable to intervention. [ABSTRACT FROM AUTHOR]

Background/Aim: Malignant hyperthermia susceptible patients may experience a fatal reaction to volatile anesthetic gases. This study sought to determine the washout characteristics of desflurane, sevoflurane, and isoflurane from the Aisys®, Avance®, and Aestiva® anesthesia machines. (GE Healthcare, Madison, WI, USA). Methods: All machines were inspected by a GE Healthcare engineer prior to testing. The machines were primed with desflurane 7 vol%, sevoflurane 2.5 vol%, and isoflurane 1.2 vol% on three separate occasions for 2 h each with each gas. The Aisys® and Avance® were tested with and without an Advanced Breathing System (ABS™, GE Healthcare, Madison, Wl, USA). The Aestiva® was tested without modification to its breathing system. Additionally, the Aisys was evaluated with desflurane 1.2 vol% and the Avance with a preflushed fresh gas line was tested with an autoclaved ABS. After priming, disposable components of the patient breathing system were replaced. The fresh gas flow was increased to 15 1pm. Gas measurements were recorded until the concentration was 4 parts per million (p.p.m). Results: The fastest median washout time was achieved by the Avance in 3 min or less without an ABS or with an autoclaved ABS. The longest median time was 35 min for the Aestiva®. Clearance of desflurane was the most time consuming for all machines. Conclusion: This study demonstrates that saturated vapor pressure and priming concentration exert a greater effect on washout times than gas solubility. The Aisys utilizes an electronic vaporizer system that may expose the breathing system to retained saturated vapor. The breathing systems for all machines may hinder washout of gases. [ABSTRACT FROM AUTHOR]

Background : The anesthesia manpower shortage in the last few years in the US has limited many hospital pediatric surgical services. We sought to meet an increasing surgical caseload, while providing safe, timely and patient-centered care by instituting a nurse practitioner-assisted preoperative evaluation (NPAPE) program. The strategic goal of this program was to shift anesthesiologists from the preanesthesia clinic to the operating room (OR), while maintaining the quality of preoperative care. Our study sought to evaluate the quality of the NPAPE program. Methods : One thousand five hundred and nine children aged 1 month–18 years, 463 parents, 25 anesthesiologists and 20 preoperative clinic nurses were studied. Indicators of quality were incidence of respiratory complications (apnea/hypopnea, laryngospasm, bronchospasm, and supplemental oxygen use in postanesthesia care unit), patient preoperative preparation time and parent and staff (anesthesiologists and preoperative clinic nurse) satisfaction. These indicators were recorded for 1 week every 3 months for 1 year. The first week (baseline) was an anesthesiologist-only preoperative assessment (three anesthesiologists performing approximately 120 evaluations per day). The subsequent four data collection weeks at 3, 6, 9, and 12 months were nurse practitioner (NP)-aided preoperative assessments (one anesthesiologist with six NPs performing approximately 120 evaluations per day). Results : The incidence of respiratory complications, patient preoperative preparation time, and levels of parental satisfaction did not differ significantly between anesthesiologist-only and NP-aided assessments. However, anesthesiologist and preoperative clinic nurse satisfaction increased significantly postimplementation of the program. Conclusions : Our study revealed that within a year of its implementation, the NPAPE program maintained patient safety, timeliness, and a high level of parent satisfaction as well as increased staff satisfaction, while shifting two anesthesiologists to the OR. A NP-assisted preoperative evaluation program can offer operational advantages without compromising care. [ABSTRACT FROM AUTHOR]

Background: It has been the anecdotal experience in this unit that many parents and guardians of children presenting for day-case surgery also fast along with their child for prolonged periods of time. There have been several episodes of parents feeling dizzy or nauseated on leaving the anesthetic room after induction of anesthesia, and many incidents of fainting in recovery when collecting their child. Our purpose was to investigate this theme further, by auditing the fasting times of caregivers coming to the induction room over a 3-month period. This information has not been previously described in the literature. Methods: We carried out a prospective audit of current practice. Data were collected by questionnaire, which caregivers were requested to complete in the holding area, after the child was checked in for theatre. Results: Two hundred and fifty-seven caregivers fasted for 0–6 h and 223 fasted for >6 h. One hundred and fourteen caregivers fasted for 7–12 h and 109 caregivers fasted between 13 and 19 h. Conclusions: A large proportion of parents choose to fast with their children. Some caregivers fast for long periods. In general, this does not cause any ill effects, although some parents missed routine medications while fasting. [ABSTRACT FROM AUTHOR]

Clonidine is experiencing increasing use in the pediatric population as a sedative and analgesic because of its central α2-adrenergic agonism. We report three cases of preoperative use of intranasal clonidine in pediatric patients, all for different indications. One patient was treated for preoperative agitation and hallucinations associated with oral midazolam. One patient was given clonidine as a premedicant. The third patient was treated for preoperative agitation and hypertension. All three patients had subjective resolution of indicated symptoms and none experienced adverse outcomes. [ABSTRACT FROM AUTHOR]