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The leading cause of mortality among children is trauma. Race and ethnicity are critical determinants of pediatric postsurgical outcomes, with minority children generally experiencing higher rates of postoperative morbidity and mortality than White children. This pattern of poorer outcomes for racial and/or ethnic minority children has also been demonstrated in children with head and limb traumas. While injuries to the abdomen and pelvis are not as common, they can be life-threatening. Racial and/or ethnic differences in outcomes of pediatric abdominopelvic operative traumas have not been examined. Our objective was to determine whether disparities exist in postoperative mortality among children with major abdominopelvic trauma.We performed a retrospective analysis of the Healthcare Cost and Utilization Project Kids' Inpatient Database for 2003, 2006, 2009, and 2012. Patients were included if they were18 years, sustained a major abdominopelvic injury, and underwent subsequent surgical intervention. Our primary outcome was inpatient mortality, comparing children of different race and/or ethnicity.We identified a weighted cohort of 13,955 children, of whom 6765 (48.5%) were White, 3614 (25.9%) Black, and 2647 (19.0%) Hispanic. After adjusting for covariates, Black children were 94% more likely to die than their White peers (3.3% versus 1.6%, adjusted-RR:1.94, 95%CI: 1.33-2.82, P = 0.001). Hispanic children (adjusted-RR:1.99, 95%CI: 1.36-2.91, P0.001) and those of other race and/or ethnicity (adjusted-RR: 2.02, 95%CI:1.20-3.40, P = 0.008) were also more likely to die compared to their White peers.Black and Hispanic children who require operative intervention following major abdominopelvic trauma have a higher risk of postoperative mortality compared with White children.

Foreign body ingestion is a common event among pediatric patients, especially in children less than 6 years of age. Although most cases are relatively benign, with the foreign body passing spontaneously or requiring a brief endoscopic procedure for removal, button battery ingestion is known to cause significant morbidity with the potential for mortality. Although aorto-esophageal fistula (AEF) is a rare complication following button battery ingestion, its clinical manifestations are significant and outcomes are poor. Early diagnosis and aggressive treatment are key in preventing fatal complications. We describe the successful management of an AEF which presented with hematemesis 8 days after removal of a button battery in a 17-month-old female. The literature regarding button battery ingestion and AEF is reviewed and treatment options including intraoperative anesthetic care discussed.

Unplanned postoperative reintubation is a serious complication that may increase postsurgical hospital length of stay and mortality. Although asthma is a risk factor for perioperative adverse respiratory events, its association with unplanned postoperative reintubation in children has not been comprehensively examined. Our aim was to determine the association between a preoperative comorbid asthma diagnosis and the incidence of unplanned postoperative reintubation in children. This was a retrospective cohort study comprising of 194,470 children who underwent inpatient surgery at institutions participating in the National Surgical Quality Improvement Program–Pediatric. The primary outcome was the association of preoperative asthma diagnosis with early, unplanned postoperative reintubation (within the first 72 hours following surgery). We also evaluated the association between bronchial asthma and prolonged hospital length of stay (longer than the 75th percentile for the cohort). The incidence of unplanned postoperative reintubation in the study cohort was 0.5% in patients with a history of asthma compared with 0.2% in patients without the diagnosis (odds ratio [OR]: 2.23, 95% confidence interval [CI]: 1.71–2.89). This association remained significant after controlling for several clinical characteristics (OR: 1.54, 95% CI: 1.17–2.20). Additionally, asthmatic children were more likely to require a hospital length of stay longer than the 75th percentile for the study cohort (adjusted OR: 1.05, 95% CI: 1.01–1.10). Children with preoperative comorbid asthma diagnosis have an increased incidence of early, unplanned postoperative reintubation and prolonged postoperative hospitalization following inpatient surgery. By identifying these patients as having higher perioperative risks, it may be possible to institute strategies to improve their outcomes.

BACKGROUND Pneumonia is a common lower respiratory tract infection (LRI) and the leading cause of pediatric hospitalization in the United States. Given its frequency, children with pneumonia may require surgery during their hospital course. This poses serious anesthetic and surgical challenges because preoperative pulmonary status is among the most important risk factors for postoperative complications. Although recent adult data indicated that preoperative pneumonia was associated with poor surgical outcomes, comparable data in children are lacking. Therefore, our objective was to investigate the association of preoperative pneumonia with postoperative mortality and morbidity in children. METHODS Using the National Surgical Quality Improvement Program database, we assembled a retrospective cohort of children (

Introduction: Anti-N-methyl-D-aspartate (NMDA) receptor encephalitis, an autoimmune disorder resulting from antibodies directed against the NMDA (glutamate) receptor, is the second most frequent cause of immune-mediated encephalitis. To date, the information related to the anesthetic care of children with this disorder is limited to anecdotal reports. Methods: We reviewed the anesthetic care of six patients with anti-NMDA receptor encephalitis who underwent 21 procedures at our institution from 2014 through 2019. Results: The study cohort included six patients, ranging in age from 2 to 18 years, who required anesthetic care during 21 procedures. Airway management included a laryngeal mask airway (n = 8), endotracheal intubation (n = 12), and native airway with spontaneous ventilation (n = 1). Intravenous (IV) induction with propofol was used in 17 procedures for five patients, including three that required rapid sequence intubation using rocuronium or succinylcholine. Inhalation induction with sevoflurane in nitrous oxide (N2O)/oxygen (O2) was chosen for two procedures in two patients. A combination of both induction techniques was used for two patients in two procedures. Maintenance anesthesia was accomplished with a volatile agent, predominantly sevoflurane, for 18 of the 21 procedures; propofol infusion for one procedure; and single dose of propofol was used for two short procedures. N2O was not used for maintenance anesthesia in any of the encounters. None of the patients exhibited adverse events, including hemodynamic instability, thermoregulatory problems, or respiratory events perioperatively. Postoperatively, there was no observed deterioration in clinical status attributed to anesthetic care. Discussion: Multisystem involvement in anti-NMDA receptor encephalitis includes memory loss, behavior irregularity, psychosis, arrhythmias, blood pressure (BP) instability, and hypoventilation. In our study cohort, we noted no intraoperative issues and deterioration in clinical status following the use of volatile anesthetic agents, opioids, dexmedetomidine, and propofol for general anesthesia (GA) or sedation. As ketamine, xenon, and N2O mediate their anesthetic effects, primarily, through antagonism of NMDA receptors, theoretical concerns suggest that they should be avoided.

BACKGROUND Approximately one-third of all pediatric hospital charges are attributable to the care for children living with neurologic comorbidities. These children often require various surgical procedures and may have an elevated risk of lower respiratory infections because of poor neuromuscular coordination, poor cough, uncoordinated swallowing, and poor oral hygiene. Our objective was to evaluate the risk of pneumonia in children presenting with neurologic comorbidities. METHODS We performed a retrospective study of children ( RESULTS We identified 349 163 children, of whom 2191 developed pneumonia (30-day cumulative incidence: 0.6%). The presence of a preoperative neurologic comorbidity conferred approximately twofold higher risk of postoperative pneumonia (hazard ratio [HR]: 1.91, 95% confidence interval [CI]: 1.73–2.11). We explored the risk of pneumonia conferred by the components of neurologic comorbidity: cerebral palsy (HR: 3.92, 95% CI: 3.38–4.56), seizure disorder (HR: 2.93, 95% CI: 2.60–3.30), neuromuscular disorder (HR: 2.63, 95% CI: 2.32–2.99). The presence of a neurologic comorbidity was associated with a longer length of hospital stay (incidence rate ratio: 1.26, 95% CI: 1.25–1.28). CONCLUSIONS The risk of postoperative pneumonia was almost twofold higher in children with neurologic comorbidity. The magnitude of these associations underscores the need to identify areas of research and preventive strategies to reduce the excess risk of pneumonia in children with preoperative neurologic conditions.

BACKGROUND Despite unparalleled advances in perioperative medicine, surgical outcomes remain poor for racial minority patients relative to their white counterparts. Little is known about the excess costs to the health care system related to these disparities. METHODS We performed a retrospective analysis of data from the Nationwide Inpatient Sample between 2001 and 2018. We included children younger than 18 years admitted with appendicitis who underwent an appendectomy during their hospital stay. We examined the inflation-adjusted hospital costs attributable to the racial disparities in surgical complications and perforation status, focusing on differences between non-Hispanic white patients and non-Hispanic Black patients. RESULTS We included 100 639 children who underwent appendectomy, of whom 89.9% were non-Hispanic white and 10.1% were non-Hispanic Black. Irrespective of perforation status at presentation, surgical complications were consistently higher for Black compared with white children, with no evidence of narrowing of the racial disparity gap over time. Black children consistently incurred higher hospital costs (median difference: $629 [95% confidence interval: $500–$758; P < .01). The total inflation-adjusted hospital costs for Black children were $518 658 984, and $59 372 044 (11.41%) represented the excess because of the racial disparities in perforation rates. CONCLUSIONS Although all patients had a progressive decline in post appendectomy complications, Black children consistently had higher rates of complications and perforation, imposing a significant economic burden. We provide an empirical economic argument for sustained efforts to reduce racial disparities in pediatric surgical outcomes, notwithstanding that eliminating these disparities is simply the right thing to do.

Recent data among pediatric otolaryngology patients showed unexplained higher rates of serious perioperative respiratory adverse events (PRAE) in black children compared to their white peers. We evaluated whether preoperative respiratory comorbidity (PRC) burden contributes to racial disparity in serious PRAE in children undergoing non-otolaryngologic procedures.Rates of serious PRAE (laryngospasm and/or bronchospasm) were compared across racial groups in a retrospective cohort of black and white children (N = 18538; black 10%) who underwent various elective, non-otolaryngologic procedures between 2007 and 2014 at a US tertiary Children's hospital. Self-reported race was the primary exposure while age, gender, recent upper respiratory tract infection, use of endotracheal intubation, PRC burden and an interaction term between PRC and race were covariates.Serious PRAE occurred in 9.6% of black children and 6.6% of white children. Although there was no significant difference in age between the groups, being black (odds ratio (OR) 1.70; 95% confidence interval (CI) 1.11-2.62) was independently associated with serious PRAE. Similarly, baseline PRC was independently linked (p 0.001) with serious PRAE. Notably, there was no significant (p = 0.454) interactions between race and PRC and serious PRAE in our subjects.Race and PRC are important considerations in the risk of serious PRAE and black children are especially at risk compared to their white peers. Children, with PRC (particularly those with SDB and asthma) are also at risk suggesting that due consideration should be given to these factors in the perioperative care of children undergoing elective surgical procedures. Mechanisms underlying these associations deserve further evaluation.

Purpose of review Childhood obesity is a public health emergency that has reached a pandemic level and imposed a massive economic burden on healthcare systems. Our objective was to provide an update on (1) challenges of obesity definition and classification in the perioperative setting, (2) challenges of perioperative patient positioning and vascular access, (3) perioperative implications of childhood obesity, (3) anesthetic medication dosing and opioid-sparing techniques in obese children, and (4) research gaps in perioperative childhood obesity research including a call to action. Recent findings Despite the near axiomatic observation that obesity is a pervasive clinical problem with considerable impact on perioperative health, there have only been a handful of research into the many ramifications of childhood obesity in the perioperative setting. A nuanced understanding of the surgical and anesthetic risks associated with obesity is essential to inform patients' perioperative consultation and their parents' counseling, improve preoperative risk mitigation, and improve patients' rescue process when complications occur. Summary Anesthesiologists and surgeons will continue to be confronted with an unprecedented number of obese or overweight children with a high risk of perioperative complications.

Background: Childhood obesity and asthma have reached national epidemic proportions and an increasing number of children requiring anesthesia and surgery would be either obese or asthmatic. Obesity and asthma have a clear proclivity for disturbing pulmonary physiology; and they have both been shown to be risk factors for acute perioperative respiratory adverse events. What is currently unknown is whether the separate or joint presence of obesity and asthma increases the risk of postoperative pneumonia. Our objective was to examine the association of obesity and asthma with postoperative pneumonia in a cohort of children …

Background/Purpose: Prolonged postoperative mechanical ventilation (PPMV) can lead to poor outcomes including pneumonia, ventilator-associated lung injury, prolonged hospital length of stay, increased postoperative mortality, and overall increased cost of surgical care. Our objective was to identify independent risk factors for PPMV in pediatric general surgery patients undergoing abdominal operations. Method: Utilizing the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) …

Background We sought to investigate the risk of pediatric surgical mortality associated with the combined effects of key preoperative comorbidities and race. Methods We performed a retrospective study that included infants who underwent inpatient surgical procedures between 2012 and 2017 and were entered into the NSQIP-P registry. We assessed additive moderation by estimating the proportion of mortality risk attributable to the combined effects of race and the presence of a preoperative comorbidity (attributable proportion [AP]). Results The study group was comprised of 58466 surgical cases, of whom 15711(26.9%) were neonates and 42755(73.1%) older infants. Among neonates, a history of prematurity carried a poorer prognosis in black babies than their white peers (OR:1.53, 95%CI:1.20,1.95). Additionally, there was evidence of additive moderation by race on the association between prematurity and postoperative mortality (AP: 23.9%; 95%CI: 3.8,43.9, P value = 0.020). In older infants, presence of preoperative sepsis carried almost two times higher risk of mortality for black patients than their white counterparts (OR:1.81; 95%CI:1.21,2.73). This explained 38.4% of mortality cases in black patients with preoperative sepsis (95%CI:14.0,62.7; P = 0.002). A history of prematurity also carried a greater risk of mortality in older infants of black race (OR:1.69; 95%CI: 1.27, 2.24), accounting for 24.2% of mortality cases (AP:24.2%; 95%CI:0.90, 47.5, P = 0.041). Conclusions We quantified the surgical burden of mortality resulting from the differential impact of key comorbidities on black neonates and infants. Our data suggest that race-specific interventions to mitigate the incidence of the identified comorbidities could narrow the racial disparities in post surgical mortality.

OBJECTIVE: To characterize the impact, on failure to rescue, of cerebrovascular accident as a first postoperative complication after thoracic endovascular aortic aneurysm repair (TEVAR). DESIGN: A retrospective cohort study using of National Surgical Quality Improvement Program Participants User File. SETTING: United States hospitals taking part in the National Surgical Quality Improvement Program. PARTICIPANTS: Patients >18 years, who underwent TEVAR for nonruptured thoracic aortic aneurysm between 2005 and 2018, and developed one or more major postoperative complications within 30 days after surgery. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Out of 3,937 patients who underwent TEVAR for nonruptured thoracic aneurysm, 1,256 (31.9%) developed major postoperative complications (stroke incidence: 11.4% [143/1256]). In adults

BACKGROUND: That African American (AA) patients have poorer surgical outcomes compared with their white peers is established. The prevailing presumption is that these disparities operate within the context of a higher preoperative comorbidity burden among AA patients. Whether these racial differences in outcomes exist among apparently healthy children (traditionally expected to have low risk of postsurgical complications) has not been previously investigated. METHODS: We performed a retrospective study by analyzing the National Surgical Quality Improvement Program–Pediatric database from 2012 through 2017 and identifying children who underwent inpatient operations and were assigned American Society of Anesthesiologists physical status 1 or 2. We used univariable and risk-adjusted logistic regression to estimate the odds ratios and their 95% confidence intervals (CIs) of postsurgical outcomes comparing AA to white children. RESULTS: Among 172 549 apparently healthy children, the incidence of 30-day mortality, postoperative complications, and serious adverse events were 0.02%, 13.9%, and 5.7%, respectively. Compared with their white peers, AA children had 3.43 times the odds of dying within 30 days after surgery (odds ratio: 3.43; 95% CI: 1.73–6.79). Compared with being white, AA had 18% relative greater odds of developing postoperative complications (odds ratio: 1.18; 95% CI: 1.13–1.23) and 7% relative higher odds of developing serious adverse events (odds ratio: 1.07; 95% CI: 1.01–1.14). CONCLUSIONS: Even among apparently healthy children, being AA is strongly associated with a higher risk of postoperative complications and mortality. Mechanisms underlying the established racial differences in postoperative outcomes may not be fully explained by the racial variation in preoperative comorbidity.

BACKGROUND Bronchial asthma is the most pervasive chronic disease among children in the United States. Pneumonia, an acute pulmonary disorder, is also quite common, affecting individuals with chronic respiratory conditions. Despite the widespread recognition of bronchial asthma as a common, potentially life-threatening disease, its impact on the risk of serious pulmonary infections such as postoperative pneumonia is under-appreciated. We examined the association of bronchial asthma with postoperative pneumonia in a matched cohort of children who underwent inpatient surgical procedures. METHOD We assembled a propensity score-matched retrospective cohort of children (

Background Failure to rescue (FTR), mortality after a major postoperative complication, is a superior surgical quality metric compared to surgical mortality or complications rates alone. Our objective was to develop and validate a novel pediatric profiling to identify high-risk subjects among the subset of children who develop serious post-operative complications. Methods We performed a retrospective study of children who developed one or more serious postoperative complications following inpatient surgery across NSQIP-Pediatric hospitals (2012–2017). We evaluated the rate of FTR according to pre-operative comorbidity burden. Results We identified 45,504 surgical cases with major post-operative complications (FTR rates: 2.4%). Surgical cases with greater than six pre-operative comorbidities (n = 12,148;28%) accounted for 80% of FTR events. The expected probability of FTR was 0.1%(95%CI:0.1%–0.2%) among low-risk cases, 3.3%(95%CI:3.0%–3.5%) among intermediate-risk cases, and 22.6%(95%CI:20.9%–24.3%) among high-risk cases. About half of surgical cases in the high-risk profile group died within 48 h of surgery. Comparatively, cases in the intermediate-risk group had a much longer time to mortality (10 days). Conclusion We propose a prognostic index to accurately identify children at risk for FTR. The use of such an index may provide surgeons with a window of opportunity to implement aggressive monitoring and therapeutic strategies to reduce mortality. Level of evidence IV

Compared with term neonates, preterm babies are more likely to die from sepsis. However, the combined effects of sepsis and prematurity on neonatal postoperative mortality are largely unknown. Our objective was to quantify the proportion of neonatal postoperative mortality that is attributable to the synergistic effects of preoperative sepsis and prematurity.We performed a multicentre, propensity-score-weighted, retrospective, cohort study of neonates who underwent inpatient surgery across hospitals participating in the United States National Surgical Quality Improvement Program-Pediatric (2012-2017). We assessed the proportion of the observed hazard ratio of mortality and complications that is attributable to the synergistic effect of prematurity and sepsis by estimating the attributable proportion (AP) and its 95% confidence interval (CI).We identified 19 312 neonates who realised a total of 321 321 person-days of postsurgical observations, during which 683 died (mortality rate: 2.1 per 1000 person-days). The proportion of mortality risk that is attributable to the synergistic effect of prematurity and sepsis was 50.5% (AP=50.5%; 95% CI, 28.8-72.3%; P0.001). About half of mortality events among preterm neonates with sepsis occurred within 24 h after surgery. Just over 45% of postoperative complications were attributable to the synergistic effect of prematurity and sepsis when both conditions were present (AP=45.8; 95% CI, 13.4-78.1%; P0.001).Approximately half of postsurgical mortality and complications were attributable to the combined effect of sepsis and prematurity among neonates with both exposures. These neonates typically died within a few days after surgery, indicating a very narrow window of opportunity to predict and prevent mortality.Not applicable.

Studies utilizing ideal body weight (IBW) dosing of perioperative medications are being increasingly published (1–3). One major reason for the increasing interest in weight-based medication dose adjustment is the relentless surge in obesity prevalence across every age spectrum in the United States (US) and many Western Countries (4). Current estimates are that about 12 million (approximately 16.9%) children in the US are obese, defined as age and gender-specific body mass index (BMI) ≥95th percentile using the year 2000 Centers for Disease Control and Prevention (CDC) growth charts (5). A predictable result of the secular trend in childhood obesity prevalence is that an increasing proportion of patients undergoing non-bariatric surgery are overweight, obese or severely obese (6). Since weight-based dosing is used for virtually every medication in children (7), the potential for dosing errors in obese patients is enormous. Because many anesthetic drugs are administered intravenously, overdose of these drugs could cause significant side effects, especially in children with lower internal reserves to buffer dosing errors. Conversely, under-dose of anesthetic medications could cause insufficient anesthesia, pain, suffering during, and long after surgery. The overarching question that perioperative clinicians ask on a fairly regular basis is: should actual body weight be used to select perioperative drug doses in obese individuals? The relative dearth of standardized dosing recommendations in obese individuals (children and adults) and a near absence of clear guidelines regarding optimal dosing of anesthetic medications for obese patients is a critical source of concern (7).

BACKGROUND Many of the common equations used for body surface area determination were either introduced before the widespread prevalence of childhood obesity, contained very few children in their sample, or have not been assessed in overweight/obese children. Therefore, we compared 6 body surface area formulae to determine their performance across body mass index categories using cross-sectional anthropometric data of children who underwent elective cardiac procedures. METHODS We selected 6 formulae from the literature that included data from pediatric subjects in their derivation. We then substituted measured height and weight into each equation to compute body surface area data for the study subjects. The average values of the 6 formulae were calculated for each patient and used as reference for comparison. Comparisons between each formula and the reference standard were made with the 1-way ANOVA, Pearson correlation coefficient (measure of precision), the Lin concordance correlation coefficient (measure of bias and precision), and the Bland-Altman limit-of-agreement. All comparisons were made across age, sex, and body mass index categories. RESULTS Among the 1000 (mostly Caucasian: 76.1%) subjects, 16.7% were overweight, while 14.1% were obese and 51.2% were girls. All calculated body surface area data showed a strong positive correlation with each other and the derived reference body surface area values (0.99-1.00; P < .001). Calculated body surface area values for all the formulae were significantly higher in overweight and obese children across every age group. CONCLUSIONS Obesity status is a critical factor in the determination of body surface area values in children undergoing elective cardiac procedures. We caution that indexed hemodynamic and other therapeutic interventions may be inappropriate if limitations of body surface area formulae and the effect of obesity are not taken into consideration when caring for overweight and obese children. Body surface area studies utilizing accurate contemporary techniques that include sufficient number of overweight and obese children of various races are urgently needed.

Background Although noninvasive blood pressure (NIBP) monitoring during anesthesia is a standard of care, reference ranges for blood pressure in anesthetized children are not available. We developed sex- and age-specific reference ranges for NIBP in children during anesthesia and surgery. Methods In this retrospective observational cohort study, we included NIBP data of children with no or mild comorbidity younger than 18 yr old from the Multicenter Perioperative Outcomes Group data set. Sex-specific percentiles of the NIBP values for age were developed and extrapolated into diagrams and reference tables representing the 50th percentile (0 SD), +1 SD, −1 SD, and the upper (+2 SD) and lower reference ranges (−2 SD). Results In total, 116,362 cases from 10 centers were available for the construction of NIBP age- and sex-specific reference curves. The 0 SD of the mean NIBP during anesthesia varied from 33 mmHg at birth to 67 mmHg at 18 yr. The low cutoff NIBP (2 SD below the 50th percentile) varied from 17 mmHg at birth to 47 mmHg at 18 yr old. Conclusions This is the first study to present reference ranges for blood pressure in children during anesthesia. These reference ranges based on the variation of values obtained in daily care in children during anesthesia could be used for rapid screening of changes in blood pressure during anesthesia and may provide a consistent reference for future blood pressure–related pediatric anesthesia research.

Background. Since most people are aware of their clothing size (CS), this prospective study explored the potential utility of CS as a proxy for body size and as a predictor of incident obesity-related health conditions in children. Methods. This was a prospective, cross-sectional study of 725 children aged 6–18 yr. We collected clinical, anthropometric, and sartorial data on all study subjects. Parents reported their children’s usual CS. This was compared with US clothing chart for children. Based on this we determined whether a child’s CS was appropriate or large for age. Results. The prevalence of overweight/obese was 31.4%. Among the study subjects, 36% usually wore large CS. Children who wore large CS were more likely to be overweight/obese compared to those in the normal CS group (OR = 5.6; 95% CI = 4.0–8.0, ). Similarly, large CS was associated with higher rates of incident asthma (), obstructive sleep apnea (), habitual snoring (), and elevated preoperative blood pressure (). Conclusion. CS in children is associated with higher indices of adiposity and increased rates of obesity-related comorbidities.

Summary Introduction High blood pressure (BP) in childhood is associated with left ventricular hypertrophy and abnormal vascular reactivity even in apparently healthy children. This study examined the prevalence of high BP in children undergoing elective noncardiac operations. We also determined the association of preoperative high BP with preincision hypotension (PIH). Methods This was a retrospective cohort study that used clinical and anthropometric data on children aged 3–17 years who underwent elective, noncardiac operations from January 2006 to January 2014. Preoperative blood pressure (BP) was used to stratify children into three categories: normal BP (systolic and diastolic BP below the 90th percentile), prehypertension (systolic and/or diastolic BP ≥90th percentile but

Background Although the risk of hypoxemia is greatest during the first 72 h after surgery, little is known of the incidence of respiratory failure during this period. The authors studied the incidence and predictors of unanticipated early postoperative intubation (within 3 days) and its role in mortality. Methods A total of 222,094 adult patients undergoing nonemergent, noncardiac surgery in the American College of Surgeons-National Surgical Quality Improvement Program database were studied to determine the incidence and independent predictors of unanticipated early postoperative intubation. A risk-class model was developed and subsequently validated in 109,636 patients. Results Overall, 2,828 of 5,725 (49.4%) unanticipated tracheal intubations in a period of 30 days occurred within the first 3 days after surgery. The incidence of unanticipated early postoperative intubation was 0.83-0.9% in the derivation and validation cohorts. Independent predictors of unanticipated early postoperative intubation included current ethanol use, current smoker, dyspnea, chronic obstructive pulmonary disease, diabetes mellitus needing insulin therapy, active congestive heart failure, hypertension requiring medication, abnormal liver function, cancer, prolonged hospitalization, recent weight loss, body mass index less than 18.5 or ≥ 40 kg/m, medium-risk surgery, high-risk surgery, very-high-risk surgery, and sepsis. Unanticipated early postoperative intubation was an independent predictor of 30-day mortality, with an adjusted odds ratio of 9.2. Higher risk classes were associated with increasing incidence of unanticipated early postoperative intubation and death. Conclusions One half of unanticipated tracheal intubations in a period of 30 days occurred within the first 3 days after nonemergent, noncardiac surgery and were independently associated with a 9-fold increase in mortality. The authors present a validated perioperative risk class index for determining risk of unanticipated early postoperative intubation.

OBJECTIVE: The purpose of this investigation was to examine the association of neck circumference (NC) with perioperative respiratory adverse events in children undergoing elective noncardiac surgery, a relationship that has not been previously characterized. METHODS: Using a prospective, observational design, we studied children aged 6 to 18 years undergoing elective noncardiac surgeries at our institution. Trained research assistants collected clinical (including perioperative adverse events) and anthropometric data from all subjects. Patients were stratified into 2 classes: high NC versus low NC on the basis of age- and gender-specific receiver operating characteristic curve analysis. Subsequently, univariate factors associated with high NC were explored, and odds ratios for the occurrence of perioperative adverse events were then calculated from logistic regression after controlling for clinically relevant cofactors. RESULTS: Among the 1102 patients, the prevalence of high NC was 24.3%. NC was positively correlated with age and other anthropometric parameters. Children with high NC were more likely to be loud snorers and have a history of bronchial asthma, hypertension, and type 2 diabetes. Composite adverse airway events were more frequent in children with a large NC. There was no significant association between high NC and difficult laryngoscopy in our study population. CONCLUSIONS: NC was positively correlated with other indices of obesity in children, and large NC (indicative of central obesity) was associated with some adverse respiratory events in these children undergoing noncardiac surgery. NC could be a useful clinical screening tool for the occurrence of perioperative adverse respiratory events in children.

INTRODUCTION childhood obesity is a risk factor for many perioperative complications. Hypotension is a well described complication of general anaesthesia in both adults and children. This observational study compared the incidence of preincision hypotension (PIH) between children with high BMI and lean controls. METHODS children aged 2-17 years undergoing noncardiac procedures were classified into high or normal BMI groups. The incidence of PIH was then compared between the two groups using SBP data abstracted from our electronic anaesthesia monitoring system. Binary logistic regression was used to examine factors associated with the likelihood of PIH. RESULTS the study population was 19 400 children (54% boys) with a mean (SD) age of 8.3 ± 4.7 years and BMI of 19.3 ± 5.7 kg m(-2). Most (94.7%) of the patients were elective American Society of Anesthesiology I-II (79.7%) procedures. Single episode of PIH occurred in 36.8% of patients, whereas 8.3% had at least three episodes of PIH. PIH was more frequent in children with high BMI than their lean peers (40.9 vs. 31.4%, P < 0.001). Independent predictors of PIH were high BMI, high American Society of Anesthesiology status, propofol coinduction, baseline hypotension, age and preincision duration. CONCLUSION these results imply that children with high BMI have a higher incidence of hypotension than their lean peers following induction of anaesthesia for noncardiac procedures.

OBJECTIVES: Overweight in children is most commonly described by using BMI. Because BMI does not adequately describe regional (central) adiposity, other indices of body fatness are being explored. Neck circumference (NC) is positively associated with obstructive sleep apnea, diabetes, and hypertension in adults. NC also has positive correlation with BMI in adults. The possible role of NC in screening for high BMI in children is not well characterized. The aims of this investigation were to examine the correlation between BMI and NC in children and to determine the best NC cutoff that identifies children with high BMI. METHODS: Children who were aged 6 to 18 years and undergoing elective noncardiac surgeries were the subjects of this study. Trained research assistants collected clinical and anthropometric data from all patients. We calculated Pearson correlation coefficients between NC and other indices of obesity. We then determined by receiver operating characteristic analyses the optimal NC cutoff for identifying children with high BMI. RESULTS: Among 1102 children, 52% were male. NC was significantly correlated with age, BMI, and waist circumference in both boys and girls, although the correlation was stronger in older children. Optimal NC cutoff indicative of high BMI in boys ranged from 28.5 to 39.0 cm. Corresponding values in girls ranged from 27.0 to 34.6 cm. CONCLUSIONS: NC is significantly correlated with indices of adiposity and can reliably identify children with high BMI. NC is a simple technique that has good interrater reliability and could be used to screen for overweight and obesity in children.

Summary Introduction: Intravenous (i.v.) access is sometimes a difficult, time-consuming, and highly frustrating procedure. Obesity is widely believed to be associated with difficult peripheral intravenous access (PIV) placement. This study examined the relationship between body mass index (BMI) and ease of venous access in children undergoing noncardiac surgical procedures. Methods: We prospectively collected data on children aged 2–18 years undergoing elective noncardiac surgery at our institution. A trained research assistant (RA) was present for PIV placement in all patients and noted the following: age, gender, ethnicity, weight, height, and BMI. We also collected data on i.v. insertion site, number of attempts, number of operators, and the number of i.v. cannula used. The main outcome variable was success or failure of i.v. placement on first attempt. Sample size calculation indicated a need for 40 obese and 40 control patients. Results: A total of 103 (56 lean and 47 obese) patients comprised the study population. PIV cannulation was achieved on the first attempt in 55.2% while 39.6% of patients had 2–3 attempts before successful cannulation. Obese children were more likely to have failed attempt at first cannulation than lean controls (P

Background This prospective, non-randomised study examined the frequency and severity of post dural puncture headache in 96 Ghanaian women who consented to spinal anaesthesia for caesarean section at the Korle Bu Teaching Hospital, Accra, Ghana. Method Spinal anaesthesia was performed using 22-gauge ( n =22), 25-gauge ( n =46) or 26-gauge ( n =38) Quincke needles. Patients were followed up to determine the incidence and severity of post spinal headache. Result The overall incidence of post dural puncture headache was 8.3%, but was significantly higher (33%) in patients in whom 22-gauge Quincke needles were used than in the other two groups (4% and 5% respectively: P =0.003). Most patients rated their headache as mild to moderate on a 10-cm visual analogue scale. Conclusions In view of the high incidence of headache and the need for treatment associated with the use of the 22-gauge Quincke needle, we recommend that this should not be used in the obstetric population. We are also aware that the incidence of post dural puncture headache could be further reduced by the use of small calibre pencil-point needles but these are currently very expensive and many obstetric units in developing countries may not be able to afford them.

We describe the occurrence of postdural puncture headache (PPDH) in an adolescent with idiopathic intracranial hypertension (IIH) and its successful management with an epidural blood patch. PPDH is a very rare occurrence in patients with intracranial hypertension and is described as a paradoxical situation in the literature. There are only two previous case reports (in adults) of the possible association. A 15-year-old obese patient with a diagnosis of IIH had an uneventful diagnostic spinal tap using a 22G Quincke needle in the pediatric emergency department but returned 24 h later with PPDH. After a failed trial of conservative management, she had an uneventful but curative epidural blood patch with 15 ml of autologous venous blood and was able to return to school the day after the blood patch. Follow-up review by her neuro-ophthalmologist shows resolution of her headaches, considerable improvement in her visual field defect and resolution of papilledema. This is the first report of PPDH and its successful management with an epidural blood patch in a pediatric patient with IIH.

BACKGROUND Many of the common equations for weight estimation in children were either introduced before the widespread prevalence of childhood obesity or have not been assessed in overweight/obese children. Therefore, we assessed the accuracy of 3 common age-based weight estimation formulae (Advanced Pediatric Life Support, Luscombe, and Theron) for predicting the weight of children undergoing elective, noncardiac operations. We also developed and validated a new age-based weight estimation formula. METHODS We used preoperative anthropometric and clinical data on 13,933 children aged 2 to 12 years to evaluate the performance of 3 pediatric age-based weight estimation formulae. Ability of the formulae to predict measured weights was assessed in a derivation cohort (75% randomly selected from the study sample). We also developed and validated a new age-based formula (the Michigan formula) that could be used to estimate the weight of contemporary American children. RESULTS Among the 10,488 children in the derivation cohort, 31.8% were overweight or obese while 55.7% were boys. The accuracy of the formulae varied considerably. The Luscombe formula demonstrated the lowest mean bias of 3.4 kg (95% confidence interval, 3.2-3.5 kg) and 89.7% of estimates within 10% of measured weight. Our derived linear regression equation the "Michigan Formula" demonstrated the highest accuracy compared with the existing formulae with a bias of 4.6 kg (95% confidence interval, = 4.36-4.84 kg) and 92% of estimates within 10% of measured weights. CONCLUSIONS Accuracies of current weight estimation formulae varied greatly. Our derived equation (Michigan formula: weight (kg) = 3 x age (yr) + 10) demonstrated high accuracy when compared with existing formulae and may be more applicable for estimating the weight of contemporary American children.

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

Childhood high body mass index (BMI) and sleep disordered breathing (SDB) are increasingly prevalent and both are associated with perioperative respiratory complications. Laryngospasm is one of the more serious respiratory complications with potentially devastating consequences. It is presently unclear whether high BMI and incident SDB in children significantly amplifies the risks of perioperative laryngospasm. This study examined the hypothesis that compared to controls; children with high BMI and SDB at the time of surgery have higher rates of perioperative laryngospasm.Children (6-18 yr) who underwent elective, non-cardiac operations at a tertiary care center were the subjects of this cross-sectional study. Rates of perioperative laryngospasm were compared between normal controls and children who were overweight/obese and had clinical history of SDB at the time of surgery. Stepwise logistic regression analysis was performed to identify independent predictors of perioperative laryngospasm (dependent variable) using high BMI/SDB as the primary predictor variable.Among 642 children, those who were overweight/obese and had incident SDB (N = 197) were younger, and had higher indexes of central adiposity. Children with high BMI and SDB had 3.8 times higher unadjusted odds of developing intraoperative laryngospasm (OR = 3.8; 95% CI = 2.1-6.9, p0.001). After adjusting for several relevant covariates, the following factors were found to be independent predictors of perioperative laryngospasm: high BMI + SDB, male sex and increasing neck circumference.High BMI and incident SDB in children is associated with increased rates of perioperative laryngospasm. The mechanism(s) underlying this propensity to laryngospasm deserve further elucidation.

High blood pressure (BP) and overweight/obesity are increasingly prevalent in children. We examined the associations of excess weight indicators including neck circumference (NC) and body mass index (BMI) with high BP in children. We hypothesized that high NC is associated with elevated BP. We utilized cross-sectional anthropometric and BP data on 1058 children aged 6-18 years. Patients were classified into weight and NC categories according to published guidelines. Prehypertension was defined as systolic or diastolic BP levels between 90th and 95th percentile for gender, age and height. Hypertension signifies systolic and/or diastolic BP levels ≥ 95th percentile for age, gender and height. The prevalence of elevated BP was 29.2% (prehypertension=10.1%, hypertension=19.1%). The prevalence of overweight and obesity was 19.0 and 18.7%, respectively. Rates of wide NC increased progressively with BMI categories by 8.8, 29.4 and 68.7% among normal weight, overweight and obese children, respectively. Within each BMI category, the unadjusted odds ratio for elevated BP was significantly higher in children with wide NC than those with normal NC (normal weight OR=1.78 (1.0-3.1), P=0.04); overweight OR=2.74 (1.5-5.2), P=0.001); obese OR=2.44 (1.3-4.6), P=0.006)). Increasing NC and BMI are associated with elevated BP in children. Joint presence of wide NC and high BMI is associated with significantly high rates of elevated BP. NC measurement may be a helpful tool to detect the presence of elevated BP in children.

Waist circumference (WC), a measure of abdominal obesity, is associated with several chronic disorders. Less is known about the association between WC and acute perioperative adverse events. The purpose of the present investigation was to test the hypothesis that abdominal obesity increases the occurrence of perioperative adverse events in children undergoing elective, noncardiac surgeries.Prospective observational study.We studied the association between WC and perioperative adverse events in children aged 6 to 18 years who underwent elective noncardiac surgeries at our institution. Patients were considered to have abdominal obesity if WC was 90th percentile or greater for age and gender. Subsequently, univariate factors associated with abdominal obesity were explored and then odds ratios for the occurrence of perioperative respiratory adverse events were calculated from logistic regression after controlling for clinically pertinent covariates.Among 1,102 patients, the prevalence of abdominal obesity was 23.1%. WC was positively correlated with age and measured anthropometric parameters. Composite perioperative adverse events were more frequent in children with abdominal obesity. After adjusting for several clinically relevant risk factors, abdominal obesity independently predicted increased relative odds of respiratory adverse events (OR = 2.35, 95% CI = 1.6 to 3.5, P.001). Abdominal obesity was also associated with prolonged postanesthesia care unit (PACU) length of stay.WC, a measure of abdominal obesity, is an independent predictor of perioperative respiratory adverse events in children undergoing elective noncardiac surgery. Furthermore, abdominal obesity was associated with prolonged PACU length of stay.

The purpose of this investigation was to determine whether there is an association between high body mass index (BMI) in children and the occurrence of early post-tonsillectomy pain (PTP). The hypothesis tested was that high BMI is associated with increased severity of early PTP.We extracted data on all children aged 3-17 years that underwent adeno-tonsillectomy (TA) over a 2-year period from our anesthesia clinical information system. Patients were classified into normal or high BMI group and early PTP scores were compared between the groups. Clinically significant (moderate-severe) early PTP was defined as pain score ≥ 4 within the first 15 min of admission to the post-anesthesia care unit (PACU).Among 462 patients, 35.1% were overweight or obese. The overall incidence of moderate to severe early PTP was 23.6%. All the patients received at least one or more intraoperative opioid (morphine 94.2% and fentanyl 21.9%). Compared to those in the normal BMI group, children with moderate-severe PTP were older, female and more likely to be overweight or obese. Children with high BMI had significantly higher unadjusted odds of having moderate-severe early post-tonsillectomy pain (48.9% vs. 14.1%, OR=7.01, 95% CI=3.9-12.8, p0.001). After controlling for several clinically relevant covariates, high BMI was the most consistent risk factor for moderate to severe early PTP in this cohort of children.These results indicate that high BMI in children is associated with increased early PTP. The mechanism(s) underlying this association deserve further elucidation.

Obesity is disproportionately prevalent among minority patients, yet very little has been written about its effect on surgical outcome in this group.We investigated the association of body mass index (BMI) category with perioperative complications and resource utilization.Data from the American College of Surgeons National Surgical Quality improvement Program Participant Use Data File was used to calculate the BMI (kg/m2) of all minority patients undergoing inpatient surgery from 2005 to 2008. Patients were stratified into 4 BMI classes, ranging from normal weight to severely obese. Postoperative length of stay (LOS) was used as the main proxy for resource utilization. Stepwise logistic regression was used to calculate odds ratios for prolonged LOS after controlling for clinically relevant cofactors.Among 73978 patients, 28% were in the normal BMI category, 28.9% were overweight, 28.2% were obese, and 14.9% were severely obese. Morbidity and mortality distribution varied significantly by BMI category, with the highest proportion of cases occurring in the normal-BMI group and the lowest in the severely obese patients. Postoperative LOS was longer for patients in the normal-BMI group than for severely obese patients. Other markers of resource utilization also followed the same pattern with progressive decrease from normal-BMI patients to the severely obese group.Postoperative morbidity and mortality and markers of hospital resource consumption were highest in the normal-BMI patients and decreased progressively to the severely obese group. This group appears to enjoy a paradoxical protection from perioperative complications and so utilize fewer hospital resources.

Summary Background: Adenotonsillectomy (T&A) is a very common surgical procedure in children. With the rising prevalence of childhood overweight and obesity, our goal was to describe the prevalence of overweight/obesity in children presenting for T&A in our institution. We also sought to compare the frequency of peri-operative complications and the likelihood of being admitted following T&A between overweight/obese and normal weight children. Methods: We examined our peri-operative database and extracted clinical, demographicandanthropometricinformationon2170childrenwhounderwentT&Abetween January 2005 and February 2008. Children were classified into normal weight, overweightandobeseusingpublishedbodymassindex(BMI)criteria.TheincidencesofperioperativecomplicationswerecomparedbetweentheBMIcategories.Wealsoexamined factors contributing to the likelihood of admission following T&A. Results: The overall prevalence of overweight and obese was 20.7%. Overweight/ obese children were more likely to have intra-operative desaturation (p = 0.004), multiple attempts at laryngoscopy (p < 0.001), difficult mask ventilation (p = 0.001), and post-induction and post-anesthesia care unit (PACU) upper airway obstruction (p < 0.001). Additionally, overweight and obese children were more likely to be admitted following T&A. BMI showed a moderate positive correlation with postoperative length of stay (LOS). Multiple logistic regression analysis showed that BMI and presence of medical co-morbidities were independent predictors of LOS. Conclusion: OverweightandobesechildrenpresentingforT&Ahaveahigherincidence of peri-operative complications and are more likely to be admitted and stay for longer than their healthy weight peers. Published by Elsevier Ireland Ltd.

b ackground: Obesity is a highly prevalent chronic problem with health and fiscal consequences. Data from adults and nonsurgical pediatric patients suggest that obesity has serious implications for the US economy. o bjective: Our goal was to describe the impact of BMI on hospital charges in children undergoing adenotonsillectomy (AT). Methods and Procedures: We carried out a retrospective comparative analysis of the electronic anesthesia record and the charges from billing data from a large tertiary institution on children aged 3–18 years who had AT during the year 2005–2007. The main outcome measures were mean total hospital charges, likelihood of admission, and length of hospital stay (LOS). Results: Of 1,643 children, 68.9% were aged

Our aim was to describe the incidence of quality assurance events between overweight/obese and normal weight children.This is a retrospective review of the quality assurance database of the Mott Children's Hospital, University of Michigan for the period January 2000 to December 2004. Using directly measured height and weight, we computed the body mass index (BMI) in 6094 children. Overweight and obesity were defined using age and gender-specific cut off according to the National Center for Health Statistics (NCHS)/Centers for Disease Control and Prevention (CDC) (2000) growth charts. Frequency of quality assurance events were compared between normal weight, overweight, and obese children.There were 3359 males (55.1%) and 2735 females (44.9%). The mean age for the entire population was 11.9 +/- 5.2 while the mean BMI was 21.6 +/- 6.7 kg x m(-2). The overall prevalence of overweight and obesity was 31.6%. Obesity was more prevalent in boys than girls (P = 0.016). Preoperative diagnoses of hypertension, type II diabetes, and bronchial asthma were more common in overweight and obese than normal weight children (P = 0.0001 for hypertension, P = 0.001 for diabetes and P = 0.014 for bronchial asthma). Difficult airway, upper airway obstruction in the postanesthesia care unit (PACU) and PACU stay longer than 3 h and need for two or more antiemetics were more common in overweight and obese than normal weight children (P = 0.001). There was no significant difference in the incidence of unplanned hospital admission following an outpatient surgical procedure between normal weight and overweight/obese children.Studies on perioperative aspects of childhood overweight and obesity are rare. Our report shows a high prevalence of overweight and obesity in this cohort of pediatric surgical patients. Certain perioperative morbidities are more common in overweight and obese than in normal weight children. There is a need for prospective studies of the impact of childhood overweight and obesity on anesthesia and surgical outcome.

Pneumocephalus is a rare complication of epidural block which typically occurs when the loss of resistance to air technique is used to identify the epidural space. We present a case of pneumocephalus with headache in a parturient following apparently uncomplicated labour epidural analgesia.

Video-assisted thoracoscopic surgery has become a common procedure in pediatric surgery. We present a case of accidental intraoperative bronchopleural fistula during a video-assisted thoracoscopic surgery procedure, which was first identified by the anesthesia team. We discuss differential diagnoses including the role of end-tidal carbon dioxide monitoring as an aid to prompt diagnosis.

SIR––We found the survey by Short et al. in the May 2006 issue of Pediatric Anesthesia (1) very interesting and believe it opened some theoretical ‘food for thought’ about the perioperative behavior of the immunized child. However the authors conclusions and recommendations that elective surgery should be postponed for one week after killed vaccine and for three weeks after live-attenuated vaccine administration is a little too strong and the findings of their study cannot support such strong recommendations. The accompanying editorial (2) tried to address some of our concerns; however there is a need to expand on some of the controversies. Vaccinations are among the most successful and costeffective public health tools. Their use has led to the global eradication of diseases such as small pox and near elimination of diseases like measles and polio in the Western hemisphere. The World Health Organization estimates that 2 million childhood deaths were prevented through vaccination in 2003 (3). While the immunoparetic role of anesthesia and surgery are theoretical possibilities, there is incontrovertible evidence that immunization saves lives and childhood mortality in the prevaccination era and in countries with poorly organized immunization programs is appalling. To ask parents to postpone elective surgical procedures for a 3 week period after immunization may not be practical. One fundamental principle of active immunization is that continued exposure to the antigen is needed for adequate immune response hence the need for periodic booster doses (4). For example the ‘triple vaccine’ Diphtheria, Tetanus toxoid and acellular pertussis (DTP) and oral or inactivated polio vaccine are administered to children at 4weekly intervals between age 2–6mo. The recommendation of Short et al. will be impractical in countries that predominantly use the oral (or live-attenuated) polio vaccine. The same arguments will apply to other liveattenuated vaccines such as measles, mumps, rubella (MMR) or Varicella. Another important consideration in live-attenuated vaccine administration is the issue of household contacts. These can easily transmit the altered virus to contacts who can become actively immunized this way and may in fact develop vaccine-related illness (5). Should we then recommend that surgery be postponed in patients with positive contact history? Clearly this recommendation will escalate the number of unnecessary cancellations and more importantly increase the number of unimmunized children. It is not clear from the literature whether the immunopertubation that results from anesthesia and surgery is a dose-effect relationship. Does long duration of surgery and anesthesia cause greater perturbation of the immune system or does short procedures like elective myringotomy, tonsillectomy or herniorrhaphy carry the same risk as say craniofacial reconstruction or open heart surgery? These are issues that need to be addressed before we can recommend postponing surgery in immunized children or postponing immunization in children with impending surgery. Olubukola O Nafiu M D F R C A Ian Lewis M D F R C A Division of Pediatric Anesthesiology, Department of Anesthesiology, University of Michigan Hospital 1500 East Medical Centre Drive, Ann Arbor, MI, USA (email: onafiu@med.umich.edu)