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This consensus- based S1 Guideline for perioperative infusion therapy in children is focused on safety and efficacy. The objective is to maintain or re-establish the child's normal physiological state (normovolemia, normal tissue perfusion, normal metabolic function, normal acid- base- electrolyte status). Therefore, the perioperative fasting times should be as short as possible to prevent patient discomfort, dehydration, and ketoacidosis. A physiologically composed balanced isotonic electrolyte solution (BS) with 1-2.5% glucose is recommended for the intraoperative background infusion to maintain normal glucose concentrations and to avoid hyponatremia, hyperchloremia, and lipolysis. Additional BS without glucose can be used in patients with circulatory instability until the desired effect is achieved. The additional use of colloids (albumin, gelatin, hydroxyethyl starch) is recommended to recover normovolemia and to avoid fluid overload when crystalloids alone are not sufficient and blood products are not indicated. Monitoring should be extended in cases with major surgery, and autotransfusion maneuvers should be performed to assess fluid responsiveness.

Summary Background: Intraosseous (IO) infusion is a well-established intervention to obtain vascular access in pediatric emergency medicine but is rarely used in routine pediatric anesthesia. Methods: In this observational study, we report on a series of 14 children in whom semi-elective IO infusion was performed under inhalational anesthesia after peripheral intravenous (IV) access had failed. Patient and case characteristics, technical details, and estimated timings of IO infusion as well as associated complications were reviewed. Data are median and range. Results: IO infusion was successfully established in fourteen children [age: 0.1–6.00 years (median 0.72 years); weight: 3.5–12.0 kg (median 7.0 kg)]. The majority suffered from chronic cardiac, metabolic, or dysmorphic abnormalities. Estimated time taken from inhalational induction of anesthesia until insertion of an intraosseous needle was 26.5 min (15–65 min). The proximal tibia was cannulated in all patients. The automated EZIO™ IO system was used in eight patients and the manual COOK™ system in six patients. Drugs administered included hypnotics, opioids, neuromuscular blocking agents and reversals, cardiovascular drugs, antibiotics, and IV fluids. The IO cannulas were removed either in the operating theatre (n = 5), in the recovery room (n = 5), or in the ward (n = 4), after 73 min (19–225 min) in situ. There were no significant complications except one accidental postoperative dislocation. Conclusions: IO access represents a quick and reliable alternative for pediatric patients with prolonged difficult or failed IV access after inhalational induction of anesthesia.

The perioperative administration of selective cyclooxygenase-2 (COX-2)-inhibitors to avoid postoperative pain is an attractive option: they show favorable gastro-intestinal tolerability, lack inhibition of blood coagulation, and carry a low risk of asthmatic attacks. The purpose of this study was to determine the cerebrospinal fluid (CSF), plasma, and tissue pharmacokinetics of orally administered etoricoxib and to compare it with effect data, i.e., COX-2-inhibition in patients after hip surgery. The study was performed in a blinded, randomized, parallel group design. A total of 12 adult patients were included who received 120 mg etoricoxib (n = 8) or placebo (n = 4) on day 1 post-surgery. Samples from plasma, CSF, and tissue exudates were collected over a period of 24 h post-dosing and analyzed for etoricoxib and prostaglandin E(2) (PGE(2)) using liquid chromatography-tandem mass spectrometry and immuno-assay techniques. CSF area under the curve (AUC) [AUCs((O-24h))] for etoricoxib amounted to about 5% of the total AUC in plasma (range: 2-7%). Individual CSF lag times with respect to (50%) peak plasma concentration were/=2 h in all but one case (median: 1 h). PGE(2) production in tissue was significantly blocked by the COX-2 inhibitor starting with the appearance of etoricoxib in tissue and lasting for the whole observation period of 24 h (P0.01). In conclusion, etoricoxib reaches the CSF and site of surgery at effective concentrations and reduces PGE(2) production at the presumed site of action.

The intraoperative infusion of isotonic solutions with 1-2.5% glucose in children is considered well established use in Europe and other countries. Unfortunately, a European marketing authorisation of such a solution is currently missing and as a consequence paediatric anaesthetists tend to use suboptimal intravenous fluid strategies that may lead to serious morbidity and even mortality because of iatrogenic hyponatraemia, hyperglycaemia or medical errors. To address this issue, the German Scientific Working Group for Paediatric Anaesthesia suggests a European consensus statement on the composition of an appropriate intraoperative solution for infusion in children, which was discussed during a working session at the 2nd Congress of the European Society for Paediatric Anaesthesiology in Berlin in September 2010. As a result, it was recommended that an intraoperative fluid should have an osmolarity close to the physiologic range in children in order to avoid hyponatraemia, an addition of 1-2.5% instead of 5% glucose in order to avoid hypoglycaemia, lipolysis or hyperglycaemia and should also include metabolic anions (i.e. acetate, lactate or malate) as bicarbonate precursors to prevent hyperchloraemic acidosis. Thus, the underlying intention of this consensus statement is to facilitate the granting of a European marketing authorisation for such a solution with the ultimate goal of improving the safety and effectiveness of intraoperative fluid therapy in children.

We report on a failed epidural puncture for insertion of a catheter during chest wall correction by the minimally invasive procedure according to Nuss in a 16-year-old boy. After insertion of the catheter without any problem and establishment of a symmetrical thoracic analgesia and initiation of general anaesthesia, the catheter was surprisingly observed in the thoracic cavity upon insertion of the endoscopic camera. The catheter was then withdrawn under vision and the operation continued without any further incidents.

On the basis of a case report the prehospital management of a newborn child with deep accidental hypothermia (22oC) is discussed. The child was found in a garbage can. The continuous resuscitation during the transport into the clinic is done in an incubator and the child survives without neurologic damages. The used measures of the resuscitation are discussed on the basis of the therapy.

Most would agree that a flexible application of a variety of endoscopic techniques, even combined in the same patient, provide the best chance for a successful outcome for benign but unresectable airway obstruction. However, concern has been raised concerning the enthusiastic attitude toward endoluminal stents and their preference over surgical repair in the absence of true contraindications. A life-threatening clinical scenario of this attitude is presented here.