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Tubeless upper airway surgery in children is a complex procedure in which surgeons and anaesthetists share the same operating field. These procedures are often interrupted for rescue oxygen therapy. The efficacy of nasal high-flow oxygen to decrease the frequency of rescue interruptions in children undergoing upper airway surgery is unknown. In this multicentre randomised trial conducted in five tertiary hospitals in Australia, children aged 0–16 years who required tubeless upper airway surgery were randomised (1:1) by a web-based randomisation tool to either nasal high-flow oxygen delivery or standard oxygen therapy (oxygen flows of up to 6 L/min). Randomisation was stratified by site and age (<1 year, 1–4 years, and 5–16 years). Subsequent tubeless upper airway surgery procedures in the same child could be included if there were more than 2 weeks between the procedures, and repeat surgical procedures meeting this condition were considered to be independent events. The oxygen therapy could not be masked, but the investigators remained blinded until outcome data were locked. The primary outcome was successful anaesthesia without interruption of the surgical procedure for rescue oxygenation. A rescue oxygenation event was defined as an interruption of the surgical procedure to deliver positive pressure ventilation using either bag mask technique, insertion of an endotracheal tube, or laryngeal mask to improve oxygenation. There were ten secondary outcomes, including the proportion of procedures with a hypoxaemic event (SpO 2 <90%). Analyses were done on an intention-to-treat (ITT) basis. Safety was assessed in all enrolled participants. This trial is registered in the Australian New Zealand Clinical Trials Registry, ACTRN12618000949280, and is completed. From Sept 4, 2018, to April 12, 2021, 581 procedures in 487 children were randomly assigned to high-flow oxygen (297 procedures) or standard care (284 procedures); after exclusions, 528 procedures (267 assigned to high-flow oxygen and 261 assigned to standard care) in 483 children (293 male and 190 female) were included in the ITT analysis. The primary outcome of successful anaesthesia without interruption for tubeless airway surgery was achieved in 236 (88%) of 267 procedures on high-flow oxygen and in 229 (88%) of 261 procedures on standard care (adjusted risk ratio [RR] 1·02, 95% CI 0·96–1·08, p=0·82). There were 51 (19%) procedures with a hypoxaemic event in the high-flow oxygen group and 57 (22%) in the standard care group (RR 0·86, 95% CI 0·58–1·24). Of the other prespecified secondary outcomes, none showed a significant difference between groups. Adverse events of epistaxis, laryngospasm, bronchospasm, hypoxaemia, bradycardia, cardiac arrest, hypotension, or death were similar in both study groups. Nasal high-flow oxygen during tubeless upper airway surgery did not reduce the proportion of interruptions of the procedures for rescue oxygenation compared with standard care. There were no differences in adverse events between the intervention groups. These results suggest that both approaches, nasal high-flow or standard oxygen, are suitable alternatives to maintain oxygenation in children undergoing upper airway surgery. Thrasher Research Fund, the Australian and New Zealand College of Anaesthetists, the Society for Paediatric Anaesthesia in New Zealand and Australia. [ABSTRACT FROM AUTHOR]

Clinical outcomes are measurable changes in health, function, or quality of life that are important for evaluating the quality of care and comparing the efficacy of interventions. However, clinical outcomes and related measurement tools need to be well‐defined, relevant, and valid. In adults, Core Outcome Measures in Effectiveness Trials (COMET) methodology has been used to develop core outcome sets for perioperative care. Systematic literature reviews identified standardized endpoints (StEP) and valid measurement tools, and consensus across a broader range of relevant stakeholders was achieved via a Delphi process to establish Core Outcome Measures in Perioperative and Anaesthetic Care (COMPAC). Core outcome sets for pediatric perioperative care cannot be directly extrapolated from adult data. The type and weighting of endpoints within particular domains can be influenced by age‐dependent differences in the indications for and/or nature of surgery and medical comorbidities, and the validity and utility of many measurement tools vary significantly with developmental stage and age. The involvement of parents/carers is essential as they frequently act as surrogate responders for preverbal and developmentally delayed children, parental response may influence child outcome, and parental and/or child ranking of outcomes may differ from those of health professionals. Here, we describe the formation of the international Pediatric Perioperative Outcomes Group, which aims to identify and create validated, broadly applicable, patient‐centered outcome measures for infants, children, and young people. Methodologies parallel that of the StEP and COMPAC projects, and systematic literature searches have been performed within agreed age‐dependent subpopulations to identify reported outcomes and measurement tools. This represents the first steps for developing core outcome sets for pediatric perioperative care. [ABSTRACT FROM AUTHOR]

Summary: All commonly used general anesthetics have been shown to cause neurotoxicity in animal models, including nonhuman primates. Opinion, however, remains divided over how cumulative evidence from preclinical and human studies in this field should be interpreted and its translation to current practices in pediatric anesthesia and surgery. A group of international experts in laboratory and clinical sciences recently convened in Genoa, Italy, to evaluate the current state of both laboratory and clinical research and discuss future directions for basic, translational, and clinical studies in this field. This paper describes those discussions and conclusions. A central goal identified was the importance of continuing to pursue laboratory research efforts to better understand the biological pathways underlying anesthesia neurotoxicity. The distinction between basic and translational experimental designs in this field was highlighted, and it was acknowledged that it will be important for future animal research to try to causally link structural changes with long‐term cognitive abnormalities. While inherent limitations will continue to affect the ability of even large observational cohorts to determine if anesthesia impacts neurodevelopment or behavioral outcomes, the importance of conducting further large well‐designed cohort studies was also emphasized. Adequately powered cohorts could clarify which populations are at increased risk, provide information on environmental and healthcare‐related risk modifiers, and guide future interventional trials. If anesthetics cause structural or functional adverse neurological effects in young children, alternative or mitigating strategies need to be considered. While protective or mitigating strategies have been repeatedly studied in animals, there are currently no human data to support alternative anesthetic strategies in clinical practice. Lastly, it was noted that there is still considerable debate over the clinical relevance of anesthesia neurotoxicity, and the need to evaluate the impact of other aspects of perioperative care on neurodevelopment must also be considered. [ABSTRACT FROM AUTHOR]

Background Near-infrared spectroscopy ( NIRS) provides an assessment of cerebral oxygenation and tissue hemoglobin concentration. Aim The aim of this study was to investigate whether the cerebral oxygenation and hemoglobin concentration measured with NIRS could predict outcomes after pediatric cardiac surgery. Method We conducted a retrospective observational study in 399 patients who underwent pediatric cardiac surgery. Associations were determined between postoperative outcome and preoperative and postoperative cerebral tissue oxygenation index ( TOI), postoperative normalized tissue hemoglobin index ( nTHI), concentration changes in oxygenated hemoglobin (Δ[HbO2]) and deoxygenated hemoglobin (Δ[ HHb]). Results Thirty-nine children had major postoperative morbidity and 12 died. Using Spearman's correlation analysis, postoperative lower TOI and higher Δ[ HHb] were associated with longer stays in the Intensive Care Unit ( ICU) ( r = −0.48, P < 0.001, r = 0.31, P < 0.001, respectively) and longer duration of intubation ( r = −0.48, P < 0.001, r = 0.31, P < 0.001, respectively) and higher probability of death determined by the Risk Adjusted Classification for Congenital Heart Surgery ( RACHS-1) ( r = −0.39, P < 0.001, r = 0.23, P < 0.001, respectively). In multivariate regression analysis, postoperative TOI was independently associated with major morbidity and mortality and Δ[ HHb] was independently associated with major morbidity. In receiver operating characteristic analysis, postoperative TOI and Δ[ HHb] predicted major morbidity (Area under the curve [ AUC] = 0.72, 0.68, respectively) and mortality ( AUC = 0.81, 0.69, respectively). Conclusion Lower TOI or higher [ HHb] at the end of surgery and higher RACHS-1 category predicted worse outcomes. [ABSTRACT FROM AUTHOR]

Background Several clinical and surgical factors can influence the occurrence of allogeneic blood transfusion ( ABT) during oncologic neurosurgery. Objectives To identify the potential predictive factors of ABT during craniotomy for the removal of brain tumors in children and the potential impact of intraoperative ABT on early postoperative outcome. Methods A retrospective study was performed in all pediatric patients younger than 18 years who underwent craniotomy for brain tumor removal from December 2009 to December 2012 in our institution. Pre-, intra-, and postoperative data were collected from medical and stored electronic anesthesia records. The predictors of intraoperative ABT were determined using multivariate logistic regression. Results A total of 110 patients were included. Twenty-seven patients (25%) received intraoperative ABT with a volume of 16 ± 8 ml·kg−1. On multivariate analysis, an age <4 years, a duration of surgery >270 min, and a preoperative hemoglobin <12.2 g·dl−1 were independently associated with the need for intraoperative ABT. We did not show any significant difference concerning postoperative early outcome and length of stay between the transfused and non-transfused patients except for the duration of postoperative mechanical ventilation that was significantly higher in the transfused group ( P = 0.04). Conclusion In children, craniotomy for brain tumor removal is at risk of intraoperative ABT. An age <4 years, a duration of surgery >270 min, and a preoperative hemoglobin <12.2 g·dl−1 are the main factors associated with intraoperative ABT during this surgery. [ABSTRACT FROM AUTHOR]

Autism spectrum disorder ( ASD) is now diagnosed in more than 1 in 100 children, so it is not surprising that anesthetists are increasingly providing care for children with this diagnosis. The diagnostic classification for ASD has recently changed and our understanding of the causes and management of ASD are also changing rapidly. This review provides a timely update to increase understanding and awareness of the problems that children with ASD experience, and to minimize perioperative problems. Current literature on premedication and the increasing use of alpha-2 agonists such as clonidine and dexmedetomidine as well as the use of old favorites midazolam and ketamine is reviewed. Some simple strategies that will improve care and decrease anxiety, like social stories, the use of tablet computers, other comfort items or games for distraction, and using favorite drinks to disguise the bitter taste of medications, are described. Remember, the parents are their child's expert and will know what agitates and settles them. Talking to them prior to the day of the procedure is ideal. The importance of staff training and having a clinical practice guideline available at every institution cannot be overstated. [ABSTRACT FROM AUTHOR]

Background Anesthetic depth is an important parameter to monitor during surgery, yet remains difficult to quantify, particularly in young children where developmental changes influence the electroencephalogram. A more fundamental physiological response to stimulation is the increase in cerebral blood flow secondary to increased metabolic demand, referred to as flow-metabolism coupling ( FMC) and measurable using near-infrared spectroscopy ( NIRS). Little is known about the effect of anesthesia on FMC; therefore, we studied visually evoked hemodynamic responses ( VEHRs) using NIRS in children undergoing general anesthesia for minor surgical procedures. Method We recruited 23 children (aged 2-5 years), undergoing surgery requiring general anesthesia. VEHRs were measured for 30 min using NIRS, including 5 min of baseline recording after anesthetic induction. Parameters recorded using NIRS included the concentrations of oxygenated (oxy), deoxygenated (deoxy), and total hemoglobin (Hb), which were separated into epochs for evoked response analysis after filtration of motion artifact and baseline drift. Goodness-of-fit statistics and classification rules were used to determine the existence of evoked responses, and a modified Gaussian equation was used to model each evoked response. Results Near-infrared spectroscopy data were recorded in 20/23 children, of whom nine showed a VEHR. No responses were seen in the baseline control data. When examining the relationship between VEHR and anesthetic agents, we noted that for 8/10 patients in whom preoperative or intraoperative fentanyl were administered and VEHRs were absent. Conclusion We have shown that VEHRs can be detected using NIRS in some anesthetized children. Administration of fentanyl was associated with an absence of VEHRs. The mechanism underlying this association is unclear. [ABSTRACT FROM AUTHOR]

Background The use of isotonic electrolytic solutions for the intraoperative fluid management in children is largely recognized, but the exact composition still needs to be defined. Objectives The primary objective of this randomized controlled open trial was to compare the changes in chloride plasma concentration using two intraoperative isotonic fluid regimens (Sterofundin vs normal saline, both added with 1% of glucose) in children undergoing major surgery. Secondary objectives were to compare changes in other electrolytes, renal function, and the occurrence of hypoglycemia. Methods Children aged between 1 and 36 months, scheduled for major surgery, were randomized to receive Sterofundin or saline during the intraoperative time. Children with preoperative electrolyte abnormalities, hemodynamic instability, and severe renal or hepatic dysfunction were excluded. The primary outcome was the Δ of Cl− (Δ = change in plasma concentration between post- and pre-infusion), and secondary outcomes included Δ of other electrolytes and intraoperative hypoglycemia. Results A total of 240 patients were included in the two study sites and randomized to receive Sterofundin plus 1% glucose or normal saline plus 1% glucose, in a open fashion (229 were finally analyzed). Δ of Cl− and Mg++ was statistically less relevant in patients who received intraoperative Sterofundin, and Δ of the other electrolytes was comparable between the two study groups. Relative risk of hyperchloremia was significantly higher when large volumes were infused (over than 46.7 ml·kg−1), regardless of type of crystalloid infused. Hypoglycemia occurred in two of 229 patients. Conclusions Sterofundin is safer than normal saline in protecting young children undergoing major surgery against the risk of increasing plasma chlorides and the subsequent metabolic acidosis. [ABSTRACT FROM AUTHOR]

Objectives Artificial colloids, frequently used to prevent hemorrhagic shock in children, may induce serious renal side effects in critically ill adult patients. The impact of perioperative colloid infusion on the renal function in adults and children remains unclear. Aim To determine the impact of single doses of artificial colloids on renal function tests, we conducted an experimental animal study. We hypothesized that neither the infusion of moderate doses of 6% hydroxyethyl starch ( HES) nor of 4% gelatin ( GEL) would have a serious impact on the renal function of healthy piglets. Methods Fifteen sedated piglets were randomly assigned to receive an infusion of either 20 ml·kg−1 HES or GEL or a balanced electrolyte solution ( BS, control group) over 30 min. Before and 7 days after infusion, serum and urine renal function tests were recorded and renal biopsies were taken. Results Serum and urine renal function tests (e.g., creatinine, urea, cystatin C, and neutrophil gelatinase-associated lipocalin) were within normal ranges, and a microscopic examination of the renal tissue in all groups revealed no major alterations such as tubular necrosis, interstitial bleeding, interstitial inflammation, or vacuoles. Conclusions In this pediatric animal model, the infusion of moderate doses of artificial colloids was not found to have any relevant impact on renal function. Further clinical investigations are necessary to provide a conclusive assessment of the risk for renal impairment after HES and GEL administration during major pediatric surgery. [ABSTRACT FROM AUTHOR]

Background Currently, very little information is known regarding the research education of pediatric anesthesia fellows. Objective The main objective of the current investigation was to evaluate the status of research training in pediatric anesthesia fellowship programs in the United States. Methods Survey responses were solicited from forty-six pediatric anesthesia fellowship directors. Questions evaluated department demographic information, the extent of faculty research activity, research resources and research funding in the department, the characteristics of fellow research education and fellow research productivity, departmental support for fellow research, and perceived barriers to fellow research education. Results Thirty-six of forty-six fellowship directors responded to the survey, for a response rate of 78%. Eight of fourteen (57%) programs with a structured curriculum had more than 20% of graduating fellows publish a peer-reviewed manuscript compared with only five of twenty-two (23%) programs, which did not have a structured research curriculum ( P = 0.03). While the majority of program directors (thirty of thirty-six (83%)) did not think that fellows are adequately trained to pursue research activities, only a minority of program directors (7 of 36 (19%)) thought that an extra year of fellowship dedicated to research should become a requirement. Conclusion Structured research curriculum is associated with increased research productivity during pediatric anesthesia fellowship. Important barriers to fellows' research education include high clinical demands and lack of research time for faculty. Despite acknowledging the poor research education, a small minority of fellowship directors supports the addition of an extra year exclusively dedicated to research. [ABSTRACT FROM AUTHOR]

Pain following ambulatory surgery is often poorly managed at home. Certain procedures, such as tonsillectomy, cause high levels of pain for at least 1 week postoperatively. This impacts significantly on recovery and postoperative morbidity with regards to oral intake, sleep, and behavior. Barriers to effective postoperative pain management at home following discharge have been investigated and incorporate: parental factors, such as the ability to recognize and assess their child's pain, and misconceptions about analgesics; child factors, such as refusal to take medication; medication factors, such as ineffective medication or inadequate formulation or dose of analgesics; and system factors, such as poor discharge instructions, difficulty in obtaining medication and lack of information provision. A number of interventions have been suggested and trialled in an effort to address these barriers, which encompass educational strategies, improved information provision, improved medication regimens, and the provision of tools to aid parents in the pain management of their children. All in all, improvements in pain outcomes have been minor, and a more holistic approach, that appreciates the complex and multifaceted nature of pain management at home, is required. [ABSTRACT FROM AUTHOR]

Regional anesthesia in children is an evolving technique with many advantages in perioperative management. Although most regional anesthesia techniques are sufficiently described in the literature, the implementation of these techniques into daily clinical practice is still lacking. The main problems associated with pediatric regional anesthesia ( PRA) include the appropriate selection of blockade, the management around the block, and how to teach these techniques in an optimal manner. This review article provides an overview of these 'hot' topics in PRA. [ABSTRACT FROM AUTHOR]

Background: Patients undergoing surgery are an important user of red blood cells (RBC). Increasingly, medical staff and patients wish to know the likelihood of RBC transfusion for appropriate resource allocation and to inform preoperative discussions regarding risk. Although some adult data are available, little is known about RBC use in children. Aim: The aim of this study was to describe RBC use in the perioperative period in a large pediatric hospital. Methods: Over a 2-year period the hospital operating theatre database and trauma registry was merged with the blood bank database to identify episodes where RBC units were transfused in association with anesthesia. Incidence of transfusion of RBC units associated with particular procedures was then calculated. Results: A total of 21 441 patients underwent 32 511 anesthetics from January 1, 2006 to December 31, 2007, and 9838 units of RBC were released from the hospital blood bank of which 4070 (41%) were transfused in the perioperative period. Cardiac surgery was the greatest user of RBC units (2359 units). Acute major trauma accounted for only 159 units. Overall 6.3% of anesthetics were associated with a RBC transfusion. The procedures with the greatest frequency of RBC transfusion were cardiac surgery on bypass (79%), cardiac off bypass (55%), liver transplant (87%) and cranioplasty (61%). Conclusion: In a tertiary pediatric hospital surgery accounts for a substantial proportion of total RBC use, with particular procedures accounting for the majority of transfusions. [ABSTRACT FROM AUTHOR]

Background: The characteristics of the electroencephalogram (EEG) during anesthesia in children are poorly described. An understanding of the EEG during anesthesia may help explain and predict the performance of EEG-derived depth of anesthesia monitors in children. This study aims to describe the association between age and some basic characteristics of the EEG during nonstandardized anesthesia in children and infants. Methods: Sixty-four children aged 9 days to 12 years were enrolled in this observational physiological study. Anesthesia was given at the discretion of the anesthetist. EEG was recorded from after induction to emergence using a BRM2 brain monitor ’’BrainZ Instruments, Auckland, New Zealand‘‘ in parietal and frontal montages. For comparison, 90% spectral edge frequency (SEF-90) and power were determined at three points (equilibrium during anesthesia, when the volatile agent was discontinued and at emergence), and children were divided into three age groups (0–6 months, 6–24 months and 2–12 years). Results: Fifty-seven children had artifact-free EEG data. From equilibrium to emergence the mean forehead power decreased substantially in children aged 2–12 years (3171–153 μV2, P < 0.001) and 6–24 months (756–140 μV2, P < 0.001) but no difference was found in infants aged 0–6 months (93–63 μV2, P = 0.4). From equilibrium to emergence mean forehead spectral edge frequency increased in children aged 2–12 years (10.8–13.7 Hz, P = 0.01) but no change was found in children aged 6–24 months (12.7–12.7 Hz, P = 0.9) or 0–6 months (9.45–7.26 Hz, P = 0.08). Throughout emergence, infants demonstrated a discontinuous EEG pattern with intermittent bursts separated with low amplitude. Conclusions: During anesthesia, the EEG in infants is fundamentally different from the EEG in older children. This study supports the need for specific infant-derived algorithms if EEG-derived anesthesia depth monitors are to be used in infants. [ABSTRACT FROM AUTHOR]

An introduction is presented in which the editor discusses articles in the issue on topics including perioperative venous thromboembolism in pediatric patients; pediatric surgery; and pediatric anesthesia.

A correction is presented to the article "Pediatric Anesthesia" which appeared in the previous issue.

The article reports the research in the current issue including the application of ultrasound in the evaluation of pediatric airway, analgesic dosing recommendations and parent participation in addressing pain among children after day surgery, and the significance of near-infrared spectroscopy in surgery among infants.

An introduction is presented focusing on reports on pediatric surgical case duration, attention-deficit hyperactivity disorder in children, and anesthesia.

An introduction is presented in which the author discusses various reports within the issue on topics including intraoperative hypotension, the application of gas induction to children undergoing pyloromyotomy and the psychological impact of surgery on children.

The article focuses on a study regarding emergence delirium in children following desflurane and sevoflurane anesthesia. It mentions the use of the well-recognized PAED score in measuring delirium as well as a comparison of the incidence of emergence delirium following nonpainful imaging and minor surgical procedure. A research which offers strong evidence for or against the role of surgery and presumably pain in delirium is presented.