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Access to healthcare is inequitable. Poverty, natural disasters and war disproportionally effect those most vulnerable, including children. Non-governmental organizations (NGO) hold a vital role in providing pediatric care in these contexts. Here we describe the delivery and challenges of Pediatric Anesthesia with two such non-governmental organizations; Médecins Sans Frontières (MSF) and Mercy Ships. Descriptions of both are followed by case studies., (© 2024 John Wiley & Sons Ltd.)

Pediatric hypnosis is an extremely valuable adjuvant therapeutic tool to reduce pain and ameliorate anxiety in children undergoing procedures and pediatric anesthesia. This perspective summarises; why Integrating hypnosis into practice has this potential, some techniques that are particularly useful in this setting, the training oppurtunities to learn more, and recommendations for future pediatric anesthesia hypnotic research. There is definite capacity for change by Integrating hypnosis into our practice. Not only will this ensure more capable, confident children who present for peri-operative care but also reduce costs and the environmental impact of the pharmaceutical agents we currently employ for sedation and anxiolysis., (© 2024 John Wiley & Sons Ltd.)

Purpose of Review: Simulation is a well established practice in medicine. This review reflects upon the role of simulation in pediatric anesthesiology in three parts: training anesthesiologists to care for pediatric patients safely and effectively; evaluating and improving systems of care for children; and visions for the future., Recent Findings: Simulation continues to prove a useful modality to educate both novice and experienced clinicians in the perioperative care of infants and children. It is also a powerful tool to help analyze and improve upon how care is provided to infants and children. Advances in technology and computational power now allow for a greater than ever degree of innovation, accessibility, and focused reflection and debriefing, with an exciting outlook for promising advances in the near future., Summary: Simulation plays a key role in developing and achieving peak performance in the perioperative care of infants and children. Although simulation already has a great impact, its full potential is yet to be harnessed., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Pakistan is a lower middle-income country located in South Asia with a population of nearly 208 million. Sindh is its second largest province. The aim of this survey was to identify the current setup of pediatric services, staffing, equipment, and training infrastructure in the teaching hospitals of Sindh., Methods: The survey was conducted between June 2018 and September 2018. A questionnaire was designed with input from experts and pretested. One faculty coordinator from each of 12 of the 13 teaching hospitals (7 government and 5 private) completed the form. Information was exported into Statistical Package for the Social Sciences (SPSS) version 22. Frequency and percentages were computed for all variables. Confidentiality was ensured by anonymizing the data., Results: Anesthesia services are provided by consultants with either membership or fellowship in anesthesia of the College of Physicians and Surgeons of Pakistan (CPSP). All drugs on the World Health Organization (WHO) essential medication list were available, although narcotic supply was often inconsistent. Weak areas identified were absence of standardization of practice regarding premedication, preoperative laboratory testing, pain assessment, and management. No national practice guidelines exist. Pulse oximeters and capnometers were available in all private hospitals but in only 86% and 44% of the government hospitals, respectively. Some training centers were not providing the training as outlined by the CPSP criteria., Conclusions: Several gaps have been identified in the practice and training infrastructure of pediatric anesthesia. There is a need for national guidelines, standardization of protocols, provision of basic equipment, and improved supervision of trainees. One suggestion is to have combined residency programs between private and government hospitals to take advantage of the strengths of both. Recommendations by this group have been shared with all teaching hospitals and training bodies., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2021 International Anesthesia Research Society.)

Background: The onset of the COVID19 pandemic drove the rapid development and adoption of physical barriers intended to protect providers from aerosols generated during airway management. We report our initial experience with aerosol barrier devices in pediatric patients and raise concerns that they may increase risk to patients., Methods: In March 2020, we developed and implemented simulation training and use of plastic aerosol barrier devices as a component of our perioperative COVID-19 workflow. As part of our quality improvement process, we obtained detailed feedback via a web-based survey after cases were performed while using these aerosol barriers., Results: Between March and June 2020, 36 pediatric patients age 1mo-18years with anatomically normal airways and either PCR confirmed or suspected COVID-19 were intubated under an aerosol barrier as part of urgent or emergent anesthetic care at our institution. Experienced providers had more difficulty than expected in six (16.7%) of the cases with four cases requiring multiple attempts to secure the airway and two cases involving pronounced difficulty in a single attempt. The aerosol barrier was perceived as a contributing factor to difficulty in all cases., Conclusion: The use of barriers may result in unanticipated difficulties with airway management, particularly in pediatric patients, which could lead to hypoxemia or other patient harm. Our initial experience in pediatric patients is the first such report in patients and provides clinical data which corroborates the simulation data prompting the FDA to withdraw support of barriers., (© 2020 John Wiley & Sons Ltd.)

The severe acute respiratory syndrome coronavirus 2 (coronavirus disease 2019 [COVID-19]) pandemic has challenged medical systems and clinicians globally to unforeseen levels. Rapid spread of COVID-19 has forced clinicians to care for patients with a highly contagious disease without evidence-based guidelines. Using a virtual modified nominal group technique, the Pediatric Difficult Intubation Collaborative (PeDI-C), which currently includes 35 hospitals from 6 countries, generated consensus guidelines on airway management in pediatric anesthesia based on expert opinion and early data about the disease. PeDI-C identified overarching goals during care, including minimizing aerosolized respiratory secretions, minimizing the number of clinicians in contact with a patient, and recognizing that undiagnosed asymptomatic patients may shed the virus and infect health care workers. Recommendations include administering anxiolytic medications, intravenous anesthetic inductions, tracheal intubation using video laryngoscopes and cuffed tracheal tubes, use of in-line suction catheters, and modifying workflow to recover patients from anesthesia in the operating room. Importantly, PeDI-C recommends that anesthesiologists consider using appropriate personal protective equipment when performing aerosol-generating medical procedures in asymptomatic children, in addition to known or suspected children with COVID-19. Airway procedures should be done in negative pressure rooms when available. Adequate time should be allowed for operating room cleaning and air filtration between surgical cases. Research using rigorous study designs is urgently needed to inform safe practices during the COVID-19 pandemic. Until further information is available, PeDI-C advises that clinicians consider these guidelines to enhance the safety of health care workers during airway management when performing aerosol-generating medical procedures. These guidelines have been endorsed by the Society for Pediatric Anesthesia and the Canadian Pediatric Anesthesia Society.

COVID-19 was first identified in Wuhan, China and is caused by the novel coronavirus SARS-CoV 2. It has now spread rapidly to over 190 countries and territories around the world and has been declared a global pandemic by the World Health Organization. The virus is spread through droplet transmission and currently has a mortality rate of over 4% globally. The pediatric population has been found to be less susceptible to the disease with the majority of children having milder symptoms and only one pediatric death being reported globally so far. Despite this, strategies need to be put in place to prevent further spread of the virus. We present a summary of the general measures implemented at a large adult and pediatric tertiary hospital in Singapore (National University Hospital) as well as the specific strategies in place for the operating room and pediatric intensive care unit., (© 2020 John Wiley & Sons Ltd.)

Pediatric anesthetists have an important role to play in the management of patients suspected or confirmed to have COVID-19. In many institutions, the COVID-19 intubation teams are staffed with anesthetists as the proceduralists working throughout the hospitals also in the ICU and Emergency Departments. As practitioners who perform aerosol generating procedures involving the airway, we are at high risk of exposure to the virus SARS-CoV-2 and need to ensure we are well prepared and trained to manage such cases. This article reviews the relevant pediatric literature surrounding COVID-19 and summarizes the key recommendations for anesthetists involved in the care of children during this pandemic., (© 2020 John Wiley & Sons Ltd.)

Transgender describes a variety of identities in which an individual's gender identity is different from expected based on the sex assigned at birth. In the United States, it is estimated that over 1 million adults and 150 000 youth identify as transgender, with increasing numbers being seen in healthcare and surgical settings. These numbers will continue to rise as visibility and acceptance grow. Current guidelines recommend transition-related surgeries be reserved for older adolescents and adults. However, this is not the only circumstance in which the pediatric anesthesiologist may find themselves caring for a transgender patient. In order to provide the safest and most affirming care, it is crucial that the pediatric anesthesiologist develop a working knowledge of this unique and vulnerable population, including the potential impacts of gender-affirming treatment on their perioperative care., (© 2020 John Wiley & Sons Ltd.)

Background: Peri-operative critical events are still a major problem in paediatric anaesthesia care. Access to more experienced healthcare teams might reduce the adverse event rate and improve outcomes., Objective: The current study analysed incidences of peri-operative paediatric cardiac arrest before and after implementation of a specialised paediatric anaesthesia team and training programme., Design: Retrospective cohort study with before-and-after analysis., Setting: Department of Anaesthesiology and Intensive Care Medicine, University Hospital of Cologne, Germany., Patients: A total of 36 243 paediatric anaesthetics (0 to 18 years) were administered between 2008 and 2016., Intervention: Implementation of a specialised paediatric anaesthesia team and training programme occurred in 2014 This included hands-on supervised training in all fields of paediatric anaesthesia, double staffing for critical paediatric cases and a 24/7 emergency team. A logistic regression analysis with risk factors (age, ASA physical status, emergency) was used to evaluate the impact of implementation of the specialised paediatric anaesthesia team., Main Outcome Measures: Incidences of peri-operative paediatric cardiac arrest and anaesthesia-attributable cardiac arrest before and after the intervention., Results: Twelve of 25 paediatric cardiac arrests were classified as anaesthesia-attributable. The incidence of overall peri-operative paediatric cardiac arrest was 8.1/10 000 (95% CI 5.2 to 12.7) in the period 2008 to 2013 and decreased to 4.6/10 000 (95% CI 2.1 to 10.2) in 2014 to 2016. Likewise, the incidence of anaesthesia-attributable cardiac arrest was lower after 2013 [1.6/10 000 (95% CI 0.3 to 5.7) vs. 4.3/10 000 (95% CI 2.3 to 7.9)]. Using logistic regression, children anaesthetised after 2013 had nearly a 70% lower probability of anaesthesia-attributable cardiac arrest (odds ratio 0.306, 95% CI 0.067 to 1.397; P = 0.1263). For anaesthesia-attributable cardiac arrest, young age was the most contributory risk factor, whereas in overall paediatric cardiac arrest, ASA physical statuses 3 to 5 played a more important role., Conclusion: In this study on incidences of peri-operative paediatric cardiac arrest from a European tertiary care university hospital, implementation of a specialised paediatric anaesthesia team and training programme was associated with lower incidences of peri-operative paediatric cardiac arrest and a reduced probability of anaesthesia-attributable cardiac arrest.

Background: To assess the thoughts of practicing anaesthesiologists about the use of depth of hypnosis monitors in children., Methods: Members of the European Society for Paediatric Anaesthesiology were invited to participate in an online survey about their thoughts regarding the use, applicability and reliability of hypnosis monitoring in children., Results: The survey achieved a response rate of 30% (N = 168). A total of 138 completed surveys were included for further analysis. Sixty-eight respondents used hypnosis monitoring in children (Users) and 70 did not (Non-users). Sixty-five percent of the Users reported prevention of intra-operative awareness as their main reason to apply hypnosis monitoring. Among the Non-users, the most frequently given reason (43%) not to use hypnosis monitoring in children was the perceived lack or reliability of the devices in children. Hypnosis monitoring is used with a higher frequency during propofol anaesthesia than during inhalation anaesthesia. Hypnosis monitoring is furthermore used more frequently in children > 4 years than in younger children. An ideal hypnosis monitor should be reliable for all age groups and any (combination of) anaesthetic drug. We found no agreement in the interpretation of monitor index values and subsequent anaesthetic interventions following from it., Conclusions: Prevention of intraoperative awareness appears to be the most important reason to use hypnosis monitoring in children. The perceived lack of reliability of hypnosis monitoring in children is the most important reasons not to use it. No consensus currently exists on how to adjust anaesthesia according to hypnosis monitor index values in children.

Background: Electronic decision support tools in anesthesiology practice have great value, including the potential for mobile applications to simplify delivery of best-practice guidelines., Aims: We sought to combine demographics with usage information to elucidate important patterns in the rate of use of the Society of Pediatric Anesthesia Critical Events Checklist, as measured by in-app accesses of the checklist via the freely available anesthesia calculator app anesthesiologist., Methods: We performed a retrospective analytic observational case-control study using analytics and survey data collected from the app. Users of the app were classified on the basis of whether or not they had accessed the checklist. This classification was used to perform logistic regression against a number of independent variables, including frequency of app use, country income level, professional role, rating of app importance, length of time in practice, group size, practice model, community served, and primary practice environment., Results: Individual app users practicing in low- and middle-income countries have a significantly higher rate of Society for Pediatric Anesthesia Critical Events Checklist utilization as compared with high-income countries. Rural practitioners had higher utilization of the checklist. Practice size did not affect the utilization of the checklist. The checklist was used for both provider learning and for just-in-time patient care., Conclusion: mHealth apps are invaluable resource in everyday clinical practice. Mobile app analytics and in-app survey data reveal variable penetration and applicability of such technology worldwide. mHealth apps may be particularly impactful in limited-resource areas, such as lower-income environments and rural communities., (© 2017 John Wiley & Sons Ltd.)

Background: Appropriate supervision has been shown to reduce medical errors in anesthesiology residents and other trainees across various specialties. Nonetheless, supervision of pediatric anesthesiology fellows has yet to be evaluated. The main objective of this survey investigation was to evaluate supervision of pediatric anesthesiology fellows in the United States. We hypothesized that there was an indirect association between perceived quality of faculty supervision of pediatric anesthesiology fellow trainees and the frequency of medical errors reported., Methods: A survey of pediatric fellows from 53 pediatric anesthesiology fellowship programs in the United States was performed. The primary outcome was the frequency of self-reported errors by fellows, and the primary independent variable was supervision scores. Questions also assessed barriers for effective faculty supervision., Results: One hundred seventy-six pediatric anesthesiology fellows were invited to participate, and 104 (59%) responded to the survey. Nine of 103 (9%, 95% confidence interval [CI], 4%-16%) respondents reported performing procedures, on >1 occasion, for which they were not properly trained for. Thirteen of 101 (13%, 95% CI, 7%-21%) reported making >1 mistake with negative consequence to patients, and 23 of 104 (22%, 95% CI, 15%-31%) reported >1 medication error in the last year. There were no differences in median (interquartile range) supervision scores between fellows who reported >1 medication error compared to those reporting ≤1 errors (3.4 [3.0-3.7] vs 3.4 [3.1-3.7]; median difference, 0; 99% CI, -0.3 to 0.3; P = .96). Similarly, there were no differences in those who reported >1 mistake with negative patient consequences, 3.3 (3.0-3.7), compared with those who did not report mistakes with negative patient consequences (3.4 [3.3-3.7]; median difference, 0.1; 99% CI, -0.2 to 0.6; P = .35)., Conclusions: We detected a high rate of self-reported medication errors in pediatric anesthesiology fellows in the United States. Interestingly, fellows' perception of quality of faculty supervision was not associated with the frequency of reported errors. The current results with a narrow CI suggest the need to evaluate other potential factors that can be associated with the high frequency of reported errors by pediatric fellows (eg, fatigue, burnout). The identification of factors that lead to medical errors by pediatric anesthesiology fellows should be a main research priority to improve both trainee education and best practices of pediatric anesthesia.

Background: Informed consent for pediatric anesthesia is unique because it is (1) obtained from surrogates (ie, parents) rather than from the patient and (2) sought after parents have authorized the surgical intervention. There are limited data on how pediatric anesthesia informed and consent discussions are conducted. The purpose of this study was to characterize the content of preanesthesia informed consent discussions and assess their impact on parent recall and understanding., Methods: We conducted a cross-sectional observational study at a tertiary pediatric hospital. We audio-recorded and transcribed preanesthesia consent discussions between pediatric anesthesia providers and parents of children undergoing elective surgery. Parents were recruited on the day of surgery and completed a survey postdiscussion to assess their recall and perceived understanding. We used directed content analysis to identify 7 informed consent elements: (i) description of the plan; mention of (ii) alternatives, (iii) risks, and (iv) benefits; (v) discussion of uncertainties; (vi) assessment of comprehension; and (vii) solicitation of a decision. We used multivariable logistic regression to explore the association between discussions that included 3 informed consent elements (description of plan, mention of risks, and mention of benefits) and parent recall and understanding of these elements., Results: We analyzed 97 discussions involving 41 different anesthesia providers. The element most frequently included in preanesthesia discussions was a description of the plan (100%); the least frequently included was decision solicitation (18%). Seventy-one percent of discussions included ≥5 informed consent elements and 70% included a description of the plan, mention of risks, and mention of benefits. Parental recall of these 3 informed consent elements was associated with their inclusion in the preanesthesia discussion (75% vs 34%), and more parents understood all 3 elements if they had reported (vs not reported) recall of all 3 elements (97% vs 53%)., Conclusion: Most pediatric preanesthesia discussions include ≥5 informed consent elements and describe the plan, mention risks, and mention benefits. Inclusion of these latter 3 consent elements was associated with parental recall of these elements but not understanding., (© 2017 John Wiley & Sons Ltd.)

This educational review presents an overview of opioid use disorder, misuse and overdose among adolescents, and the clinical implications for anesthesiologists. It provides definitions, discusses the epidemiology worldwide, (focusing on North America), and emphasizes the clinical implications of patients with chronic opioid exposure, including perioperative pain management, as well as opioid overdose and prolonged use of opioids after acute exposure. In the USA, opioid use disorder and negative outcomes related to opioids rose dramatically from 1999-2010; concomitantly heroin use and fatal overdoses have increased as heroin use is associated with the disordered use of licit opioids. Among adolescents and young adults, opioid use disorder is significant, with continued increases in disordered use specifically among young adults. Acute opioid intoxication may have multiple medical implications in addition to respiratory depression, and children are susceptible to acute intoxication via accidental ingestion of prescription opioids. Novel opioid formulations, such as acetyl fentanyl, with unpredictable pharmacology may also be present in acute intoxication. Chronically, opioid use presents challenges for safe and adequate pain management, in the presence of opioid-induced hyperalgesia and differential tolerance as well as mental health issues including depression and anxiety. Predictors of prolonged opioid use in adolescents and adults after surgery is an area of ongoing research. Young patients encountered by pediatric anesthesiologists may be involved in diversion and disordered use of opioids. Increased awareness among anesthesiologists is important, as perioperative discussions often provide an opportunity to detect at risk patients., (© 2017 John Wiley & Sons Ltd.)

Healthcare-associated infections are an important source of morbidity and mortality in pediatric patients. Anesthesiologists have a unique role in infection prevention. Hand hygiene and anesthesia workspace decontamination decrease infection rates in surgical patients. Standard protocols exist for insertion and handling of central lines, arterial lines, and regional procedures, which should be strictly adhered to in order to prevent infectious complications. Temperature control and timely administration of antibiotics contribute to the prevention of surgical site infections. Education, culture shift, staff engagement, and effective change management are necessary for successful implementation of infection prevention strategies., (© 2017 John Wiley & Sons Ltd.)

Pediatric cardiac anesthesia has developed over the past eight decades into a specialty delivering complex clinical care and contributing remarkable scientific progress. The history of this development can be traced through journal articles that mark the strides of the specialty. This article discusses journal articles, chosen by the author, that he considers had a significant impact on the practice of pediatric cardiac anesthesia or are of historical interest., (© 2016 John Wiley & Sons Ltd.)

This secondary analysis of the 2013 United Kingdom National Health Service (NHS) Anaesthesia Activity Survey of the Fifth National Audit Project (of the Royal College of Anaesthetists and Association of Anaesthetists of Great Britain and Ireland) shows pediatric anesthesia activity in detail. A local coordinator (LC) in every NHS hospital collected data on patients undergoing any procedure managed by an anesthetist. Questionnaires had 30 question categories. Each LC was randomized to a 2-day period. The pediatric age groups were infants, (<1 year), preschool age (1-5 year), and school age children (6-15 year). The median questionnaire return rate was 98%. The annual caseload was estimated to be 486 900 children: 36 500 infants, 184 700 preschool age, and 265 800 school age children. Almost 90% of children (1-15 year) were ASA 1 or 2 and the substantial majority underwent routine nonurgent ear nose and throat, dental, orthopaedics, or general surgery procedures; 65% were 'day cases'. One in six children were managed outside operating theater sites compared with one in 12 adults. Forty one per cent was in district general hospitals. Almost all ASA 4 and 5 children (89%) and infants (92%) were managed in specialist hospitals. 'Awake' cases and sedation accounted for only 2% of cases. There were notable differences in demography and anesthetic care compared with adults and between different age groups of children. These data enable analysis of the current state of UK pediatric anesthetic practice and highlight differences between pediatric and adult services., (© 2015 John Wiley & Sons Ltd.)

(Classic) rapid sequence induction and intubation (RSII) has been considered fundamental to the provision of safe anesthesia. This technique consists of a combination of drugs and techniques and is intended to prevent pulmonary aspiration of gastric content with catastrophic outcomes to the patient. This review investigates aspects of this technique and highlights dangers and frauds if this technique is transferred directly into pediatric anesthesia practice. The author recommends a controlled anesthesia induction by trained pediatric anesthesiologist with suitable equipment for the children considered at risk of pulmonary aspiration. RSSI is a dangerous technique if adopted without modification into pediatric anesthesia and has in its 'classic' form no use., (© 2014 John Wiley & Sons Ltd.)

Background: Providing safe anaesthesia to children especially in emergency situations goes hand in hand with instant availability of appropriately sized equipment and monitoring. This is best achieved using a designated paediatric anaesthetic trolley containing essential equipment. Guidance for the contents of such trolleys is neither explicit nor standard. We used a survey and a qualitative enquiry to develop a checklist suitable for standardisation of contents and layout of paediatric anaesthetic trolleys., Methods: We conducted an observational study of our current practice and paediatric anaesthetic trolleys in a tertiary care hospital. We also performed a qualitative enquiry from experienced paediatric anaesthetists and operating department practitioners.We developed an empirical checklist to ensure the minimum 'essential' equipment is available on these trolleys and implemented a standard layout to facilitate its use., Results: We identified 11 areas in our hospital where anaesthesia is provided to children, each with a designated paediatric anaesthetic trolley. There were considerable deficiencies of items in all areas with no standard pattern or layout. Different types of trolleys contributed to the confusion. In addition, overstocking of inappropriate items hindered its efficient use., Conclusion: Standardising the contents and layout of the paediatric anaesthetic trolley is an essential pre-requisite for safer paediatric anaesthetic practice.

The Pediatric Anesthesia NeuroDevelopment Assessment team at Columbia University Medical Center Department of Anesthesiology convened its fourth biennial Symposium to address unresolved issues concerning potential neurotoxic effects of anesthetic agents and sedatives on young children and to assess study findings to date. Dialogue initiated at the third Symposium was continued between anesthesiologists, researchers, and a panel of expert pediatric surgeons representing general surgery and dermatology, orthopedic, and urology specialties. The panel explored the need to balance benefits of early surgery using improved technologies against potential anesthetic risks, practice changes while awaiting definitive answers, and importance of continued interprofessional dialogue.

Purpose of Review: Age-related differences in the surgical lesions, anatomy and physiological responses to surgery and anesthesia underlie the clinically relevant differences between pediatric patients and their adult counterparts. Anesthesiologists need to be aware of the unique challenges in the anesthetic management of the pediatric neurosurgical patient., Recent Findings: Neurosurgeons with subspecialty training in pediatrics have driven advances in intracranial surgery in infants and children. Subspecialization in pediatric neurosurgery and critical care has resulted in more favorable outcomes. Innovations in tumor, epilepsy and endoscopic and cerebrovascular neurosurgery are constantly being adapted to the pediatric patient. The highly specialized nature of these and other pediatric neurosurgical procedures prompt calls for similarly trained anesthesiologists for management of these infants and children., Summary: The aim of this review is to highlight the impact of these techniques on the intraoperative management of the pediatric neurosurgical patient. These issues are essential in minimizing perioperative morbidity and mortality.

The Pediatric Anesthesia NeuroDevelopment Assessment (PANDA) study investigates the potential neurotoxicity of anesthetics in the pediatric population. At a recent symposium, a panel of nonsurgical physicians from the disciplines of radiology, neurology, cardiology, and critical care discussed the role anesthesia plays in their respective practices. To execute diagnostic studies and/or therapeutic interventions in each of these disciplines, general anesthesia is oftentimes required for pediatric patients. Given recent publications in the literature suggesting the potential for neurotoxicity following anesthesia in pediatric patients, physicians, parents, and other stakeholders are now challenged to continue to balance safety with efficacy in caring for children. This paper summarizes the panelist presentations and the ensuing discussion at the 2014 PANDA symposium.

On April 12, 2014, the Pediatric Anesthesia and NeuroDevelopment Assessment (PANDA) study team held its fourth biennial scientific symposium at Morgan Stanley Children's Hospital of New York (MS-CHONY). The symposium was organized by the PANDA study team and co-sponsored by the Morgan Stanley Children's Hospital of New York-Presbyterian and the Department of Anesthesiology of Columbia University. The PANDA symposium has become a platform to review current preclinical and clinical data related to anesthetic neurotoxicity, to discuss relevant considerations in study design and approaches to future research among clinicians and researchers, and finally to engage key stakeholders in this controversial public health topic. Program attendants and speakers represented many of the most active investigators in the area of pediatric anesthetic neurotoxicity as well as stakeholders from many different backgrounds outside of anesthesia that provided their own unique perspectives, concerns, and input regarding anesthetic-related neurotoxicity in children.

Perioperative airway problems frequently result in significant morbidity and mortality in children. Therefore, proficiency in airway management is one of the most important key elements in the safe conduct of paediatric anaesthesia. This review includes important anatomical and physiological aspects of the paediatric airway, challenges encountered, and their management with commonly available resources. The importance of early recognition and treatment of anatomical or functional airway obstruction using locally adapted algorithms is highlighted. Children deemed at risk of aspiration require a controlled rapid sequence induction with sufficiently deep anaesthesia, confirmed complete muscle paralysis and intermittent ventilation prior to tracheal intubation. The benefits of a supraglottic airway device and a cuffed tracheal tube in paediatric airway management are discussed. The primary goal of mastering the paediatric airway is to ensure oxygenation and ventilation. This requires intricate knowledge, regular practice and experience.

Organizational culture underlies every improvement strategy; without a strong culture, a change, even if initially successful, is short lived. Changing culture and improving quality require commitment of leadership, and leaders must play an active and visible role to articulate the vision and create the proper environment. Quality-improvement projects require a consistent framework for outlining a process, identifying problems, and testing, evaluating, and implementing changes. Wake Up Safe is a patient safety organization that strives to use quality improvement to make anesthesia care safer. Root cause analysis is a methodology in safety analytics based on a sequence of events model of safety., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Anesthesiologists are increasingly turning to videolaryngoscopes (VLs) for normal and difficult endotracheal intubations. As children grow the airway is in constant transition. This means that a device that works well in an older child may fail in an infant. Are VLs ideal in all children? What are the pitfalls and strengths of these devices? When are they indicated? How should their efficacy be assessed? Can they play a role in teaching standard laryngoscopy? This article explores these questions and reviews the literature relating to VLs use in children.

The authors describe the way pediatric anesthesia is organized outside the operating theatre in their country. In Germany, children can be anesthetized outside the operating theater in the hospital but also outside the hospital according to the concept of office-based anesthesia. National recommendations have been published and their revision is currently underway. In Quebec, pediatric anesthesia outside the operating theatre is well organized in order to ensure quality of care, patient's safety and efficiency of the system., (Copyright © 2013 Société française d’anesthésie et de réanimation (Sfar). Published by Elsevier SAS. All rights reserved.)

Preoperative assessment and premedication represent important preparatory steps to ensuring a smooth and effective induction of anaesthesia. A thorough review of the child's medical history, previous anaesthetics, medications, allergies and family history is essential to design the optimal anaesthetic for the child and his/her surgery. Risks must be addressed with the parents as appropriate based on the local standards. Preoperative anxiolysis may assume several strategies, with premedication with a pharmacologic agent very common and most successful. This review focuses on the preoperative assessment and premedication for children undergoing elective surgery.

Introduction: This study reports our experience of audit and critical incidents observed by paediatric anaesthetics from 2000 to 2010 at a paediatric teaching hospital in Singapore., Methods: Data pertaining to patient demographics, practices and critical incidents during anaesthesia and in the perioperative period were prospectively collected via an audit form and retrospectively analysed thereafter., Results: A total of 2,519 incidents were noted at the 75,331 anaesthetics performed during the study period. There were nine deaths reported. The majority of incidents reported were respiratory critical incidents (n = 1,757, 69.8%), followed by cardiovascular incidents (n = 238, 9.5%). Risk factors for critical incidents included age less than one year, and preterm and former preterm children., Conclusion: Critical incident reporting has value, as it provides insights into the system and helps to identify active and system errors, thus enabling the formulation of effective preventive strategies. By creating and maintaining an environment that encourages reporting, we have maintained a high and consistent reporting rate through the years. The teaching of analysis of critical incidents should be regarded by all clinicians as an important tool for improving patient safety.

Pediatric regional anesthesia continues to evolve. Education and attention to anatomical detail remain key elements to successful outcomes. New techniques, some adapted from adult practice, provide analgesia for pediatric surgical procedures such cleft palate or congenital hip dysplasia. Despite technological advances a number of controversial issues remain unresolved., (© 2012 Blackwell Publishing Ltd.)

We present a review of smartphone applications (apps) available for pediatric anesthesia., (© 2012 Blackwell Publishing Ltd.)

Objective: There is growing demand for safe and effective procedural sedation in pediatric facilities nationally. Currently, these needs are being met by a variety of providers and sedation techniques, including anesthesiologists, pediatric intensivists, emergency medicine physicians, and pediatric hospitalists. There is currently no consensus regarding the training required by non-anesthesiologists to provide safe sedation. We will outline the training method developed at St. Louis Children's Hospital., Methods: In 2003, the Division of Pediatric Anesthesia at St. Louis Children's Hospital approached the Division of Pediatric Hospitalist Medicine as a resource to provide pediatric sedation outside of the operating room. Over the last seven years, Pediatric Hospitalist Sedation services have evolved into a three-tiered system of sedation providers. The first tier provides sedation services in the emergency unit (EU) and the Center for After Hours Referral for Emergency Services (CARES). The second tier provides sedation throughout the hospital including the EU, CARES, inpatient units, Ambulatory Procedure Center (APC), and Pediatric Acute Wound Service (PAWS); it also provides night/weekend sedation call for urgent needs. The third tier provides sedation in all of the second-tier locations, as well as utilizing propofol in the APC., Results: This training program has resulted in a successful pediatric hospitalist sedation service. Based on fiscal year 2009 billing data, the division performed 2,471 sedations. We currently have 43 hospitalists providing Tier-One sedation, 18 Tier-Two providers, and six Tier-Three providers., Conclusions: A pediatric hospitalist sedation service with proper training and oversight can successfully augment sedation provided by anesthesiologists., (Copyright © 2011 Society of Hospital Medicine.)