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Background: Optimal ventilation strategies and use of neuromuscular blocking agents (NMBAs) in neonates and small infants undergoing anaesthesia remain unclear. We examined the association of perioperative ventilation strategies and administration of NMBAs on respiratory adverse events in the NEonate-Children sTudy of Anaesthesia pRactice IN Europe (NECTARINE) cohort., Methods: We performed a secondary analysis of NECTARINE, which included infants up to 60 weeks' postmenstrual age undergoing anaesthesia for surgical or diagnostic procedures. The primary endpoint was the association between ventilation mode and intraoperative respiratory adverse events. Secondary endpoints were use of NMBA, and 30-day postoperative pulmonary complications (PPCs)., Results: The dataset comprised 5609 patients undergoing 6542 procedures. Pressure-controlled ventilation was the primary ventilation modality, accounting for 52.4% (n=3428) of cases. The incidence of intraoperative respiratory critical events was 20.7% (95% confidence interval [CI] 19.7-21.7%), while PPCs were observed in 17% of cases (95% CI 16.0-18.1%). Preanaesthesia respiratory conditions and NMBA use after tracheal intubation were associated with higher incidence of PPCs. Of the children receiving NMBAs, reversal was reported in 29.8%. The absence of reversal was associated with a higher incidence of PPCs, with a relative risk of 1.50 (95% CI 1.17-1.93). Conversely, NMBA reversal was associated with a reduced relative risk of 0.43 (95% CI 0.26-0.70)., Conclusions: Regardless of ventilation strategy used, mechanical ventilation and baseline respiratory conditions were risk factors for a greater incidence of adverse respiratory events and PPCs. Reversal of NMBAs before tracheal extubation was significantly associated with reduced PPCs in neonates and should be routine clinical practice., Clinical Trial Registration: ClinicalTrials.gov (NCT02350348)., Competing Interests: Declaration of interest TE is a member of the associate editorial board of the British Journal of Anaesthesia. The other authors declare that they have no conflicts of interest., (Copyright © 2025 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Big data in paediatric anaesthesia allows the evaluation of morbidity and mortality of anaesthesia in a large population, but also the identification of rare critical events and of their causes. This is a major step to focus education and design clinical guidelines. Moreover, they can help trying to determine normative data in a population with a wide range of ages and body weights. The example of blood pressure under anaesthesia will be detailed. Big data studies should encourage every department of anaesthesia to collect its own data and to benchmark its performance by comparison with published data. The data collection processes are also an opportunity to build collaborative research networks and help researchers to complete multicentric studies. Up to recently, big data studies were only performed in well developed countries. Fortunately, big data collections have started in some low and middle income countries and truly international studies are ongoing., Competing Interests: Declaration of competing interest None., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Airway management is required during general anaesthesia and is essential for life-threatening conditions such as cardiopulmonary resuscitation. Evidence from recent trials indicates a high incidence of critical events during airway management, especially in neonates or infants. It is important to define the optimal techniques and strategies for airway management in these groups. In this joint European Society of Anaesthesiology and Intensive Care (ESAIC) and British Journal of Anaesthesia (BJA) guideline on airway management in neonates and infants, we present aggregated and evidence-based recommendations to assist clinicians in providing safe and effective medical care. We identified seven main areas of interest for airway management: i) preoperative assessment and preparation; ii) medications; iii) techniques and algorithms; iv) identification and treatment of difficult airways; v) confirmation of tracheal intubation; vi) tracheal extubation, and vii) human factors. Based on these areas, Population, Intervention, Comparison, Outcomes (PICO) questions were derived that guided a structured literature search. GRADE (Grading of Recommendations, Assessment, Development and Evaluation) methodology was used to formulate the recommendations based on those studies included with consideration of their methodological quality (strong '1' or weak '2' recommendation with high 'A', medium 'B' or low 'C' quality of evidence). In summary, we recommend: 1. Use medical history and physical examination to predict difficult airway management (1C). 2. Ensure adequate level of sedation or general anaesthesia during airway management (1B). 3. Administer neuromuscular blocker before tracheal intubation when spontaneous breathing is not necessary (1C). 4. Use a videolaryngoscope with an age-adapted standard blade as first choice for tracheal intubation (1B). 5. Apply apnoeic oxygenation during tracheal intubation in neonates (1B). 6. Consider a supraglottic airway for rescue oxygenation and ventilation when tracheal intubation fails (1B). 7. Limit the number of tracheal intubation attempts (1C). 8. Use a stylet to reinforce and preshape tracheal tubes when hyperangulated videolaryngoscope blades are used and when the larynx is anatomically anterior (1C). 9. Verify intubation is successful with clinical assessment and end-tidal CO 2 waveform (1C). 10. Apply high-flow nasal oxygenation, continuous positive airway pressure or nasal intermittent positive pressure ventilation for postextubation respiratory support, when appropriate (1B)., (Copyright © 2023 British Journal of Anaesthesia, European Society of Anaesthesiology and Intensive Care. Published by Elsevier Ltd.. All rights reserved.)

Background: Neonates and infants requiring anaesthesia are at risk of physiological instability and complications, but triggers for peri-anaesthetic interventions and associations with subsequent outcome are unknown., Methods: This prospective, observational study recruited patients up to 60 weeks' postmenstrual age undergoing anaesthesia for surgical or diagnostic procedures from 165 centres in 31 European countries between March 2016 and January 2017. The primary aim was to identify thresholds of pre-determined physiological variables that triggered a medical intervention. The secondary aims were to evaluate morbidities, mortality at 30 and 90 days, or both, and associations with critical events., Results: Infants (n=5609) born at mean (standard deviation [sd]) 36.2 (4.4) weeks postmenstrual age (35.7% preterm) underwent 6542 procedures within 63 (48) days of birth. Critical event(s) requiring intervention occurred in 35.2% of cases, mainly hypotension (>30% decrease in blood pressure) or reduced oxygenation (SpO 2 <85%). Postmenstrual age influenced the incidence and thresholds for intervention. Risk of critical events was increased by prior neonatal medical conditions, congenital anomalies, or both (relative risk [RR]=1.16; 95% confidence interval [CI], 1.04-1.28) and in those requiring preoperative intensive support (RR=1.27; 95% CI, 1.15-1.41). Additional complications occurred in 16.3% of patients by 30 days, and overall 90-day mortality was 3.2% (95% CI, 2.7-3.7%). Co-occurrence of intraoperative hypotension, hypoxaemia, and anaemia was associated with increased risk of morbidity (RR=3.56; 95% CI, 1.64-7.71) and mortality (RR=19.80; 95% CI, 5.87-66.7)., Conclusions: Variability in physiological thresholds that triggered an intervention, and the impact of poor tissue oxygenation on patient's outcome, highlight the need for more standardised perioperative management guidelines for neonates and infants., Clinical Trial Registration: NCT02350348., (Copyright © 2021 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: Critical respiratory events are common in children in the peri-anaesthetic period and are caused by airway and ventilation management difficulties. We aimed to analyse current European paediatric airway management practices and identify the incidence and potential consequences of difficult airway management., Methods: We performed a secondary analysis of airway and ventilation management details of the European multicentre observational trial (Anaesthesia PRactice in Children Observational Trial, APRICOT) of children from birth to 15 yr of age. The primary endpoint was the incidence of difficult airway management. Secondary endpoints were the associations between difficult airway management, known pre-existing respiratory risk factors, and the occurrence of critical respiratory events., Results: Details for 31 024 anaesthetic procedures were available for analysis. Three or more tracheal intubation attempts were necessary in 120 children (0.9%) and in 40 children (0.4%) for supraglottic airways insertions. The incidence (95% confidence interval) for failed tracheal intubation and failed supraglottic airway insertions was 8/10 000 (0.08%; 0.03-0.13%) and 8.2/10 000 (0.08%; 0.03-0.14%) children, respectively. Difficulties in securing the airway increased the risk for a critical respiratory event for tracheal tube (2.1; 1.3-3.4) and supraglottic airway (4.3; 1.9-9.9) placement. History of pre-existing respiratory risk factors was significantly associated with critical respiratory events independently of the airway device used., Conclusions: Airway management practices vary widely across Europe. Multiple airway device insertion attempts and pre-existing respiratory risk factors increase the likelihood of critical respiratory events in children and require further stratification during preoperative assessment and planning. This study highlights areas where education, research, and training may improve perioperative care., Clinical Trial Registration: NCT01878760., (Copyright © 2018. Published by Elsevier Ltd.)

Background: Little is known about the incidence of severe critical events in children undergoing general anaesthesia in Europe. We aimed to identify the incidence, nature, and outcome of severe critical events in children undergoing anaesthesia, and the associated potential risk factors., Methods: The APRICOT study was a prospective observational multicentre cohort study of children from birth to 15 years of age undergoing elective or urgent anaesthesia for diagnostic or surgical procedures. Children were eligible for inclusion during a 2-week period determined prospectively by each centre. There were 261 participating centres across 33 European countries. The primary endpoint was the occurence of perioperative severe critical events requiring immediate intervention. A severe critical event was defined as the occurrence of respiratory, cardiac, allergic, or neurological complications requiring immediate intervention and that led (or could have led) to major disability or death. This study is registered with ClinicalTrials.gov, number NCT01878760., Findings: Between April 1, 2014, and Jan 31, 2015, 31 127 anaesthetic procedures in 30 874 children with a mean age of 6·35 years (SD 4·50) were included. The incidence of perioperative severe critical events was 5·2% (95% CI 5·0-5·5) with an incidence of respiratory critical events of 3·1% (2·9-3·3). Cardiovascular instability occurred in 1·9% (1·7-2·1), with an immediate poor outcome in 5·4% (3·7-7·5) of these cases. The all-cause 30-day in-hospital mortality rate was 10 in 10 000. This was independent of type of anaesthesia. Age (relative risk 0·88, 95% CI 0·86-0·90; p<0·0001), medical history, and physical condition (1·60, 1·40-1·82; p<0·0001) were the major risk factors for a serious critical event. Multivariate analysis revealed evidence for the beneficial effect of years of experience of the most senior anaesthesia team member (0·99, 0·981-0·997; p<0·0048 for respiratory critical events, and 0·98, 0·97-0·99; p=0·0039 for cardiovascular critical events), rather than the type of health institution or providers., Interpretation: This study highlights a relatively high rate of severe critical events during the anaesthesia management of children for surgical or diagnostic procedures in Europe, and a large variability in the practice of paediatric anaesthesia. These findings are substantial enough to warrant attention from national, regional, and specialist societies to target education of anaesthesiologists and their teams and implement strategies for quality improvement in paediatric anaesthesia., Funding: European Society of Anaesthesiology., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Introduction: The authors modified an adult jet ventilation injector (Hunsaker Mon-Jet Ventilation Tube(®)) to be able to provide transglottal high-frequency jet ventilation (HFJV) in small children undergoing laryngeal procedures with CO2 laser., Methods and Material: Retrospective review of the anesthetic records of all children younger than 2years undergoing transglottal HFJV for CO2 laser laryngeal procedures using this modified adult injector between 2006 and 2013., Results: Nine children (5 boys, 4 girls) were identified who underwent a total of 20 procedures. Mean age was 7.4 ± 6.9months, and mean weight was 6 ± 2.8 kg. No complications were observed with the use of HFJV or this modified injector., Conclusion: In experienced hands, this modified injector ensures excellent visibility and field access to the surgeon as well as adequate ventilation during laryngeal laser surgery in infants., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Regarding immediate post-anaesthesia problems, one must distinguish slow awakening and the apparition of neurologic or behavioural problems. Post-anaesthesia delirium, an usual cause of transient agitation in the recovery room following halogenated-based anaesthetic, is not included in this discussion. There are two false causes of slow awakening: residual curarization and a total spinal. Slow awakening is usually caused by overdose, either absolute or relative. Regarding the occurrence of neurologic or behavioural problems, one must consider situations at risk, patients at risk, the consequences of iatrogenicity but also the unknown cerebral tumour or metabolic disorder., (Copyright © 2013 Société française d’anesthésie et de réanimation (Sfar). Published by Elsevier SAS. All rights reserved.)

Chronic pain is usually underestimated in children, due to lack of knowledge and its specific signs. In addition to suffering, chronic pain causes a physical, psychological, emotional, social, and financial burden for the child and his family. Practitioners may find themselves in a situation of failure with depletion of medical resources. Some types of chronic pain are refractory to conventional systemic treatment and may require the use of regional anesthesia. Cancer pain is common in children and its medical management is sometimes insufficient. It is accessible to neuroaxial or peripheral techniques of regional anesthesia if it is limited to an area accessible to one of these techniques and no contraindications (e.g., thrombopenia) are present. Complex regional pain syndrome 1 is not rare in children and adolescents, but it often goes undiagnosed. Regional anesthesia may contribute to the treatment of complex regional pain syndrome 1, mainly in case of recurrence, because it provides rapid effective analgesia and allows rapid implementation of intensive physiotherapy. These techniques have also shown interest in phantom limb pain after limb amputation, but they remain controversial for erythromelalgia pain or chronic abdominopelvic pain. Finally, the treatment of postdural puncture headache due to cerebrospinal fluid leak can be treated by performing an epidural injection of the patient's blood, called a blood-patch. Finally, the management of children with chronic pain should be multidisciplinary (pediatrician, physiotherapist, psychologist, surgeon, anesthesiologist) to support the child and her problem in its entirety., (Copyright © 2013. Published by Elsevier SAS.)

This paper critically reviews the new devices that can be used on the operating room to monitor the oxygenation and the haemodynamics of the child undergoing general anaesthesia., (Copyright © 2011 Société française d’anesthésie et de réanimation (Sfar). Published by Elsevier SAS. All rights reserved.)

Objective: In order to reduce the risk of postoperative apnoea, awake spinal anaesthesia or awake caudal anaesthesia are recommended for hernia surgery in newborn babies and former premature infants aged less than 60 weeks of amenorrhoea. However, additional sedation is sometimes necessary. Our working hypothesis was that a general anaesthesia with a face mask (sevoflurane) with no opiates nor neuromuscular blocking agents, maintaining the infant's spontaneous breathing and combined with a caudal anaesthesia, could provide a safe and effective alternative., Study Design: The epidemiological and technical data about the patient and the anaesthesia, as well as any per- and postoperative complications, were collected prospectively and analysed retrospectively., Patients and Methods: Ninety-eight infants undergoing hernia surgery were included during the period from 2003 to 2008., Results: Caudal anaesthesia proved successful at first attempt in 69% of the infants (term or premature). Three attempts were needed in 8% of the infants born at term and 2% of the infants born prematurely. One failure was recorded. Seven patients presented one episode of peroperative apnoea; they were easily taken care of by means of brief face mask ventilation. The follow-up of these seven infants did not reveal any reappearance of postoperative apnoea/bradypnoea., Conclusion: The technique proposed is an effective alternative to the awake locoregional anaesthesia techniques: it provides excellent conditions for surgery and presents similar perioperative morbidity and risk of postoperative apnoea., (Copyright © 2011 Société française d’anesthésie et de réanimation (Sfar). Published by Elsevier SAS. All rights reserved.)

Up to recently, inserting venous or arterial 'lines' in the neonate was essentially based on clinical skill and experience. The recent advent of portable ultrasound (US) machines with paediatric probes has resulted in the development of new approaches that, if correctly learned and used, should allow quicker and safer vascular access in this population. Both classic and new techniques are reviewed on the basis of literature and authors' experience.

The real place of tramadol in the armatarium of postoperative analgesics in children remains to be defined. This paper presents a synthetic review of the present knowledge regarding the efficacy, dosage and possible routes of administration of tramadol to children in the postoperative period. The intravenous and oral routes are the most used. The perinervous routes (epidural, around peripheral nerves, skin infiltration) are controversial. Tramadol is a good alternative to NSAIDs and to morphine for moderate pain but its efficacy is variable due to the genetic polymorphism of its metabolism and possible drug interactions.

Background: Central venous cannulation in infants remains challenging even for experienced paediatric anaesthesiologists. Ultrasound (US)-guidance techniques are proven to be safer for internal jugular vein catheterization. But the subclavian vein (SCV) is often the preferred site for long-term central venous catheterization in children. We describe a novel US-guided approach for SCV cannulation in infants and children., Methods: The principle of this technique is to place the US probe at the supraclavicular level to obtain a longitudinal view of the SCV, and to gain access to the vein via the usual infraclavicular route to cannulate it under ultrasonic control. Details and pitfalls of this technique are described. The prospectively collected results of our first 25 punctures are reported., Results: Patients' weight and age range were 2.2-27 kg and 1 day to 9 yr, respectively: 76% of the children weighed less than 10 kg. The success rate at the first attempt was 84% and 100% after two attempts. An asymptomatic thrombus in the SCV could also be detected with this technique., Conclusions: This US-guided approach of the SCV offers a new possibility for central venous catheterization in children. This technique seems promising for children less than 10 kg and probably also for older children. It provides good quality needle guidance and allows to check the vessel patency before puncture.

A 3-year-old boy of North African decent was seen in the anaesthetic preoperative clinic prior to a scheduled adenoidectomy. His history revealed that his older brother suffered from an unknown form of muscular dystrophy. On clinical exam, no signs of muscular dystrophy were present. However in light of the patient's family history a blood sample for CPK was taken. This was found to be elevated and a neurological consultation was obtained. The patient was diagnosed with a deltasarcoglycanopathy, a rare form of limb girdle muscular dystrophy. A non triggering anaesthetic technique was used, avoiding halogenated anaesthetics and succinylcholine. The preoperative evaluation for a child with a suspected myopathy and the implications for its anaesthetic management are reviewed in this article.

We report a case of respiratory distress in the post anesthesia care unit following general anaesthesia for a dilatation and curettage related to miscarriage in a 32-year-old woman. The preoperative physical examination showed no abnormalities except for the presence of dry cough during the preceding two or three days. A few minutes after her arrival in the PACU, the patient developed hyperthermia till 40.6 degrees C, cough, polypnea and oxygen desaturation (SpO(2): 82% on FiO(2): 40%). A thoraco-abdominal angioscanner showed pulmonary basal condensations and a thrombosis of the right ovarian vein. The patient had to be transferred to the intensive care unit where she remained intubated and ventilated during 13 days because of a Haemophilus influenzae pneumonia.

We report the anaesthetic management of a patient suffering from an ischaemic arteriopathy of the CADASIL (cerebral autosomal dominant arteriopathy with subcortical infarcts and leucoencephalopathy) type. The anaesthetic implications of this pathology are discussed. By analogy with other cerebral arteriopathies, the aim of our management was to keep mean arterial blood pressure and end-tidal carbon dioxide so as to prevent any cerebral ischaemic or vasospastic phenomenon. We preserved the cerebral venous return by avoiding excessive head-down position. We used a balanced anaesthetic technique because it allows easier titration of the depth of anaesthesia with regard to mean arterial pressure. There is no contraindication to the use of loco-regional anaesthesia.

Simple techniques of local analgesia applicable in children either in the medical office or in the emergency room by non-specialist practitioners are described: infiltration of the skin, topical anaesthesia of the skin, whether intact or damaged, topical anaesthesia of the mucosae.... In addition safety rules, early signs and treatment of local anaesthetics intoxication are underlined.

Study Objectives: To compare the clinical and management aspects of tracheobronchial aspirated foreign body (AFB) removal in children and adults; to assess the influence of the operator's experience on the outcome of the procedure., Design: A retrospective review of a 20-year experience (from 1976 to 1996)., Setting: A 900-bed university hospital., Patients: Eighty-four children up to 8 years old (the child group) and 28 adult patients (the adult group)., Results: The peak incidence of foreign body aspiration occurred during the second year of life in the child group and during the sixth decade in the adult group. The symptoms at presentation were similar in both age groups, but the diagnosis was significantly delayed in the adults. The AFBs were lodged preferentially in the right bronchial tree only in the adults; a central location was predominant (but not at all exclusive) in the children. Atelectasis was more common in the adults, and air trapping was more common in the children. The most frequent procedure was rigid bronchoscopy; when a flexible bronchoscope was used, it was always in the adult patients. When the operator was less experienced, a failed first attempt at bronchoscopy and the need for a second procedure were significantly more frequent., Conclusions: At presentation, the symptoms seen with AFBs do not differ according to the age of the patient; however, the delay to diagnosis, the location of the AFBs, and the radiographic images differ between child and adult populations. The removal of AFBs in patients of all ages can be performed by the same operators. Because the outcome associated with these procedures improves when the operator is experienced, the removal of AFBs should be performed in medical centers that are capable of acquiring and maintaining the necessary expertise.