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BackgroundCOVID-19 forced healthcare systems to make unprecedented changes in clinical care processes. The authors hypothesized that the COVID-19 pandemic adversely impacted timely access to care, perioperative processes, and clinical outcomes for pediatric patients undergoing primary appendectomy.MethodsA retrospective, international, multicenter study was conducted using matched cohorts within participating centers of the international PEdiatric Anesthesia COVID-19 Collaborative (PEACOC). Patients younger than 18 yr old were matched using age, American Society of Anesthesiologists Physical Status, and sex. The primary outcome was the difference in hospital length of stay of patients undergoing primary appendectomy during a 2-month period early in the COVID-19 pandemic (April to May 2020) compared with prepandemic (April to May 2019). Secondary outcomes included time to appendectomy and the incidence of complicated appendicitis.ResultsA total of 3,351 cases from 28 institutions were available with 1,684 cases in the prepandemic cohort matched to 1,618 in the pandemic cohort. Hospital length of stay was statistically significantly different between the two groups: 29 h (interquartile range: 18 to 79) in the pandemic cohort versus 28 h (interquartile range: 18 to 67) in the prepandemic cohort (adjusted coefficient, 1 [95% CI, 0.39 to 1.61]; P < 0.001), but this difference was small. Eight centers demonstrated a statistically significantly longer hospital length of stay in the pandemic period than in the prepandemic period, while 13 were shorter and 7 did not observe a statistically significant difference. During the pandemic period, there was a greater occurrence of complicated appendicitis, prepandemic 313 (18.6%) versus pandemic 389 (24.1%), an absolute difference of 5.5% (adjusted odds ratio, 1.32 [95% CI, 1.1 to 1.59]; P = 0.003). Preoperative SARS-CoV-2 testing was associated with significantly longer time-to-appendectomy, 720 min (interquartile range: 430 to 1,112) with testing versus 414 min (interquartile range: 231 to 770) without testing, adjusted coefficient, 306 min (95% CI, 241 to 371; P < 0.001), and longer hospital length of stay, 31 h (interquartile range: 20 to 83) with testing versus 24 h (interquartile range: 14 to 68) without testing, adjusted coefficient, 7.0 (95% CI, 2.7 to 11.3; P = 0.002).ConclusionsFor children undergoing appendectomy, the COVID-19 pandemic did not significantly impact hospital length of stay.Editor’s perspective

BackgroundDifficult facemask ventilation is perilous in children whose tracheas are difficult to intubate. We hypothesised that certain physical characteristics and anaesthetic factors are associated with difficult mask ventilation in paediatric patients who also had difficult tracheal intubation.MethodsWe queried a multicentre registry for children who experienced "difficult" or "impossible" facemask ventilation. Patient and case factors known before mask ventilation attempt were included for consideration in this regularised multivariable regression analysis. Incidence of complications, and frequency and efficacy of rescue placement of a supraglottic airway device were also tabulated. Changes in quality of mask ventilation after injection of a neuromuscular blocking agent were assessed.ResultsThe incidence of difficult mask ventilation was 9% (483 of 5453 patients). Infants and patients having increased weight, being less than 5th percentile in weight for age, or having Treacher-Collins syndrome, glossoptosis, or limited mouth opening were more likely to have difficult mask ventilation. Anaesthetic induction using facemask and opioids was associated with decreased risk of difficult mask ventilation. The incidence of complications was significantly higher in patients with "difficult" mask ventilation than in patients without. Rescue placement of a supraglottic airway improved ventilation in 71% (96 of 135) of cases. Administration of neuromuscular blocking agents was more frequently associated with improvement or no change in quality of ventilation than with worsening.ConclusionsCertain abnormalities on physical examination should increase suspicion of possible difficult facemask ventilation. Rescue use of a supraglottic airway device in children with difficult or impossible mask ventilation should be strongly considered.

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.

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.

This article discusses the global perspectives on pediatric anesthesia and the efforts to improve perioperative and anesthesia care for children worldwide. The themed issue of the journal focuses on three main themes: pediatric anesthesia training, patient safety and quality, and pediatric anesthesia research initiatives. It highlights the challenges and potential solutions in the provision of pediatric anesthesia care, both in low- and middle-income countries (LMICs) and high-income countries (HIC). The article emphasizes the need for standardized training protocols, collaboration, and advocacy to ensure safe and effective anesthesia care for all children, regardless of their geographic location. [Extracted from the article]

Clinical registries are multicenter prospective observational datasets that have been used to examine current perioperative practices in pediatric anesthesia. These datasets have proven useful in quantifying the incidence of rare adverse outcomes. Data from registries can highlight associations between severe patient safety events and patient and procedure‐related risk factors. Registries are an effective tool to delineate practices and outcomes in niche patient populations. They have been used to quantify uncommon complications of medications and procedures. Registries can be used to generate knowledge and to support quality improvement. Multicenter engagement can promote best clinical practices and foster professional networks. Registries are limited by their observational nature, which entails a lack of randomization as well as selection and treatment bias. The maintenance of registries over time can be challenging due to difficulties in modifying the included variables, collaborator fatigue, and continued outlay of resources to maintain the database and onboard new sites. These latter issues can lead to decreased data quality. In this article, we discuss key insights from several pediatric anesthesia registries and propose a new type of registry that addresses some shortcomings of the current paradigm. [ABSTRACT FROM AUTHOR]

Background: Management of the pediatric difficult airway can present unique clinical challenges. The Pediatric Difficult Intubation Collaborative (PeDI‐C) is an international collaborative group engaging in quality improvement and research in children with difficult airways. The PeDI‐C established a WhatsApp™ group to facilitate real‐time discussions around the management of the difficult airway in pediatric patients. The goals of this study were to evaluate the patterns of use of the WhatsApp™ group, themes on messages posted on pediatric difficult airway management and to assess the perceived usefulness of the WhatsApp™ group by the PeDI‐C members. Method: Following research ethics approval, we performed a database analysis on the archived discussion of the PeDI‐C WhatsApp™ group from 2014 to 2019 and surveyed members to assess the perceived usefulness of the PeDI‐C WhatsApp™ group. Results: 5781 messages were reviewed with 350 (6.0%) original stems. The three most common original stem types were advice seeking 98 (28%), announcements 85 (24.2%), and clinical case‐sharing 78 (22.2%). The median number of responses to original stems was 9 [2–21.3]. Post types associated with increased responses included those seeking advice on medication/equipment (regression coefficient 0.78, 95% CI [0.41–1.16]; p <.0001); seeking advice on patient care (regression coefficient 1.16, 95% CI [0.86–1.45]; p <.0001), sharing advice on medication/equipment availability (regression coefficient 0.87, 95% CI [0.33–1.40], p <.0016), and clinical case‐sharing (regression coefficient 1.2547, 95% CI [0.9401–1.5693] p <.0001). 46/64 members of the group responded to the survey. Replies offering advice regarding patient management scenarios were found to be of most interest and 77% of surveyed members found the discussion translatable into their own clinical practice. Discussion: The PeDI‐C WhatsApp™ group has facilitated timely knowledge exchange on pediatric difficult airway management across the world. Participants are satisfied with the role the Whatsapp™ group is playing. [ABSTRACT FROM AUTHOR]

BackgroundThe use of the Internet to search for medical and health-related information is increasing and associated with concerns around quality and safety. ObjectiveWe investigated the current use and perceptions on reliable websites for children’s health information by parents. MethodsFollowing institutional ethics approval, we conducted a survey of parents/guardians of children presenting for day surgery. A 20-item survey instrument developed and tested by the investigators was administered. ResultsNinety-eight percent of respondents reported that they used the Internet to search for information about their child’s health. Many respondents reported beginning their search at public search engines (80%); less than 20% reported starting their search at university/hospital-based websites. Common conditions such as colds/flu, skin conditions and fever were the most frequently searched, and unique conditions directly affecting the child were second. Despite low usage levels of university/hospital-based websites for health information, the majority of respondents (74%) regarded these as providing safe, accurate, and reliable information. In contrast, only 24% of respondents regarded public search engines as providing safe and reliable information. Fifty percent of respondents reported that they cross-checked information found on the internet with a family physician. ConclusionsAn unprecedented majority of parents and guardians are using the Internet for their child’s health information. Of concern is that parents and guardians are currently not using reliable and safe sources of information. Health care providers should begin to focus on improving access to safe, accurate, and reliable information through various modalities including education, designing for multiplatform, and better search engine optimization.

Pediatric surgery cases are increasing worldwide. Within pediatric anesthesia, perioperative respiratory adverse events are the most common precipitant leading to serious complications. They can have intraoperative impact on the surgical procedure itself, lead to premature case termination and in addition may have postoperative impact resulting in longer hospitalization stays and costs. Although most perioperative respiratory adverse events can be promptly detected and managed, and will not lead to any sequelae, the risk of life‐threatening progression remains. The incidence of respiratory adverse events increases in children with comorbid respiratory and/or nonrespiratory illnesses. Optimized perioperative patient care, risk‐stratified care level choice, and practitioners with appropriate training allow for risk mitigation. This review will discuss patient and surgical risk factors with a focus on common patient comorbid illnesses and review scoring systems to quantify risk. [ABSTRACT FROM AUTHOR]

Perioperative respiratory adverse events are the most common cause of critical events in children undergoing anesthesia and surgery. While many risk factors remain unmodifiable, there are numerous anesthetic management decisions which can impact the incidence and impact of these events, especially in at‐risk children. Ongoing research continues to improve our understanding of both the influence of risk factors and the effect of specific interventions. This review discusses anesthesia risk factors and outlines strategies to reduce the rate and impact of perioperative respiratory adverse events with a chronologic based inquiry into anesthetic management decisions through the perioperative period from premedication to postoperative disposition. [ABSTRACT FROM AUTHOR]

Perioperative lung ultrasound is a continuously evolving modality with numerous applications for the pediatric anesthesiologist. Lung ultrasound can be used at the bedside, including intraoperatively, to augment traditional physical examination methods of assessing cardiopulmonary structures and identifying the presence of specific and clinically significant pathology. With regard to the lungs, ultrasound has been shown to be highly sensitive at identification of pulmonary pathologies, particularly those of interest in the acute care setting (eg, pleural effusion, pneumothorax). With its relative ease of performance, lung ultrasound should be considered in the initial evaluation of intraoperative hypoxemia particularly when traditional modes of evaluation are nonexplanatory. This educational review introduces the basic concepts of lung ultrasound as they relate to pediatric anesthesia patients. [ABSTRACT FROM AUTHOR]

Injury is the leading cause of death in children, with chest trauma accounting for 25% of this mortality. In addition, these patients often present with multiple system injuries, which require simultaneous management. These concurrent injuries can lead to challenges when prioritizing tasks in the resuscitation room and during anesthetic management. In addition, changes from spontaneous ventilation to positive pressure ventilation can impact lung physiology. Therefore, a clear communication plan with careful monitoring and vigilance is needed for intubation and ventilation in these children. These injuries also require specific strategies to prevent barotrauma which could lead to complications such as respiratory failure, pneumonia, sepsis, and acute respiratory distress syndrome. This educational review aims to guide clinicians managing pediatric chest trauma through some of the critical decision‐making regarding intubation, ventilation, and subsequent management of injuries. [ABSTRACT FROM AUTHOR]