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Racial disparities in health care have been extensively documented. Although race is a recognized determinant of the incidence and outcome of disease, few studies have examined the role of race in the delivery of pediatric perianesthesia care. Whereas racial differences in health outcomes may not be easy to modify, disparities in health care delivery are modifiable. The authors examined literature to determine whether racial disparities exist in the delivery of pediatric anesthesia. They explored putative contributors to disparities at the provider, patient, and systems level and propose ideas to address potential causes of disparities in the practice of pediatric anesthesia.

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.

Pediatric anesthesia-related cardiac arrest is an uncommon but catastrophic adverse event which has been, in a previous study, associated with anesthesiologist-related factors such as number of days per year providing pediatric anesthesia. We aimed to replicate this and assess other anesthesiologist-related risk factors for anesthesia-related cardiac arrest after adjusting for known underlying risk factors present in the case mix.We analyzed a large retrospectively collected patient cohort of anesthetics administered from 2006 to 2016 to children at a tertiary pediatric hospital. Three reviewers independently reviewed cardiac arrests and categorized whether they appeared to be related to anesthesia care. Anesthesiologist-related factors including academic rank, experience, recent case mix, and days per year delivering pediatric anesthesia were assessed for association with anesthesia-related cardiac arrest after adjustment for underlying case mix.Cardiac arrest occurred in 240 of 109 775 anesthetics (incidence 22/10 000 anesthetics); 82 (7/10 000 anesthetics) were classified as anesthesia-related. In univariable analyses, anesthesia-related cardiac arrest was associated with age, (infants ≤180 days, p .001) American Society of Anesthesiologists Physical Status, (2, p .001) American Society of Anesthesiologists Physical Status Emergency, (p = .0035) cardiac surgery, (p .001) operating room location, (p = .0066) and resident/fellow supervision, (p = .009) but none of the anesthesiologist factors. Even after adjusting for age and American Society of Anesthesiologist Status, none of the anesthesiologist factors were associated with anesthesia-related cardiac arrest.Case mix explained all associations between higher risk of pediatric anesthesia-related cardiac arrest and anesthesiologist-related variables at our institution.

Many children recovering from anesthesia experience pain that is severe enough to warrant intravenous (IV) opioid treatment within moments of admission to the postanesthesia care unit (PACU). Postoperative pain has several negative consequences; therefore, preventing significant PACU pain in children is both a major clinical goal and a moral/ethical imperative. This requires identifying patient-level and perioperative factors that may be used to predict PACU IV opioid requirement. This should allow for the development of personalized care protocols to prevent clinically significant PACU pain in children. Our objective was to develop prediction models enabling practitioners to identify children at risk for PACU IV opioid requirement after various painful ambulatory surgical procedures.After Institutional Review Board approval, clinical, demographic, and anthropometric data were prospectively collected on 1256 children 4-17 years of age scheduled for painful ambulatory surgery (defined as intraoperative administration of analgesia or local anesthetic infiltration). Three multivariable logistic regression models to determine possible predictors of PACU IV opioid requirement were constructed based on (1) preoperative history; (2) history + intraoperative variables; and (3) history + intraoperative variables + PACU variables. Candidate predictors were chosen from readily obtainable parameters routinely collected during the surgical visit. Predictive performance of each model was assessed by calculating the area under the respective receiver operating characteristic curves.Overall, 29.5% of patients required a PACU IV opioid, while total PACU analgesia requirement (oral or IV) was 41.1%. Independent predictors using history alone were female sex, decreasing age, surgical history, and non-Caucasian ethnicity (model area under the receiver operating characteristic curve [AUROC], 0.59 [95% confidence interval {CI}, 0.55-0.63]). Adding a few intraoperative variables improved the discriminant ability of the model (AUROC for the history + intraoperative variables model, 0.71 [95% CI, 0.67-0.74]). Addition of first-documented PACU pain score produced a substantially improved model (AUROC, 0.85 [95% CI, 0.82-0.87]).Postoperative pain requiring PACU IV opioid in children may be determined using a small set of easily obtainable perioperative variables. Our models require validation in other settings to determine their clinical usefulness.

Background: Orotracheal intubation of infants using direct laryngoscopy can be challenging. We aimed to investigate whether video laryngoscopy with a standard blade done by anaesthesia clinicians improves the first-attempt success rate of orotracheal intubation and reduces the risk of complications when compared with direct laryngoscopy. We hypothesised that the first-attempt success rate would be higher with video laryngoscopy than with direct laryngoscopy. Methods: In this multicentre, parallel group, randomised controlled trial, we recruited infants without difficult airways abnormalities requiring orotracheal intubation in operating theatres at four quaternary children's hospitals in the USA and one in Australia. We randomly assigned patients (1:1) to video laryngoscopy or direct laryngoscopy using random permuted blocks of size 2, 4, and 6, and stratified by site and clinician role. Guardians were masked to group assignment. The primary outcome was the proportion of infants with a successful first attempt at orotracheal intubation. Analysis (modified intention-to-treat [mITT] and per-protocol) used a generalised estimating equation model to account for clustering of patients treated by the same clinician and institution, and adjusted for gestational age, American Society of Anesthesiologists physical status, weight, clinician role, and institution. The trial is registered at ClinicalTrials.gov, NCT03396432. Findings: Between June 4, 2018, and Aug 19, 2019, 564 infants were randomly assigned: 282 (50%) to video laryngoscopy and 282 (50%) to direct laryngoscopy. The mean age of infants was 5·5 months (SD 3·3). 274 infants in the video laryngoscopy group and 278 infants in the direct laryngoscopy group were included in the mITT analysis. In the video laryngoscopy group, 254 (93%) infants were successfully intubated on the first attempt compared with 244 (88%) in the direct laryngoscopy group (adjusted absolute risk difference 5·5% [95% CI 0·7 to 10·3]; p=0·024). Severe complications occurred in four (2%) infants in the video laryngoscopy group compared with 15 (5%) in the direct laryngoscopy group (–3·7% [–6·5 to –0·9]; p=0·0087). Fewer oesophageal intubations occurred in the video laryngoscopy group (n=1 [

Background The success rates and related complications of various techniques for intubation in children with difficult airways remain unknown. The primary aim of this study is to compare the success rates of fiber-optic intubation via supraglottic airway to videolaryngoscopy in children with difficult airways. Our secondary aim is to compare the complication rates of these techniques. Methods Observational data were collected from 14 sites after management of difficult pediatric airways. Patient age, intubation technique, success per attempt, use of continuous ventilation, and complications were recorded for each case. First-attempt success and complications were compared in subjects managed with fiber-optic intubation via supraglottic airway and videolaryngoscopy. Results Fiber-optic intubation via supraglottic airway and videolaryngoscopy had similar first-attempt success rates (67 of 114, 59% vs. 404 of 786, 51%; odds ratio 1.35; 95% CI, 0.91 to 2.00; P = 0.16). In subjects less than 1 yr old, fiber-optic intubation via supraglottic airway was more successful on the first attempt than videolaryngoscopy (19 of 35, 54% vs. 79 of 220, 36%; odds ratio, 2.12; 95% CI, 1.04 to 4.31; P = 0.042). Complication rates were similar in the two groups (20 vs. 13%; P = 0.096). The incidence of hypoxemia was lower when continuous ventilation through the supraglottic airway was used throughout the fiber-optic intubation attempt. Conclusions In this nonrandomized study, first-attempt success rates were similar for fiber-optic intubation via supraglottic airway and videolaryngoscopy. Fiber-optic intubation via supraglottic airway is associated with higher first-attempt success than videolaryngoscopy in infants with difficult airways. Continuous ventilation through the supraglottic airway during fiber-optic intubation attempts may lower the incidence of hypoxemia.

SummaryBackground When pain management has been studied in settings such as pediatric emergency departments, racial disparities have been clearly identified. To our knowledge, this has not been studied in the pediatric perioperative setting. We sought to determine whether there are differences based on race in the administration of analgesia to children suffering from pain in the postanesthesia care unit. Methods This is a prospective, observational, study of 771 children aged 4-17 years who underwent elective outpatient surgery. Racial differences in probability of receiving analgesia for pain in the recovery room were assessed using bivariable and multivariable logistic regression analyses. Results A total of 294 children (38.2%) received at least one class of analgesia (opioid or nonopioid); while 210 (27.2%) received intravenous (i.v.) opioid analgesia in the recovery room. Overall postanesthesia care unit analgesia utilization was similar between white and minority children (white children 36.8% vs minority children 43.4%, OR 1.3; 95% CI=0.92-1.89; P=.134). We found no significant difference by racial/ethnic group in the likelihood of a child receiving i.v. opioid for severe postoperative pain (white children 76.0% vs 85.7%, OR 1.89; 95% CI=0.37-9.67; P=.437). However, minority children were more likely to receive i.v. opioid analgesia than their white peers (white children 24.5% vs minority children 34.2%, OR 1.5; 95% CI=1.04-2.2; P=.03). On multivariable analysis, minority children had a 63% higher adjusted odds of receiving i.v. opioids in the recovery room (OR=1.63; 95% CI, 1.05-2.62; P=.03). Conclusions Receipt of analgesia for acute postoperative pain was not significantly associated with a child's race. Minority children were more likely to receive i.v. opioids for the management of mild pain.

Sleep disordered breathing (SDB) symptoms are associated with increased rates of opioid-induced respiratory depression as well as enhanced nociception. Consequently, practitioners often withhold or administer lower intraoperative doses of opioids out of concern for postoperative respiratory depression. Therefore, SDB may be a critical determinant of analgesic requirement in the post-anesthesia care unit (PACU). We investigated whether preoperative SDB classification was independently associated with need for PACU analgesic intervention in a cross-sectional sample of 985 children who underwent elective, painful ambulatory surgical procedures.Using prospectively collected data, children aged 4-17yr were grouped into two categories based on whether or not they had symptoms of SDB. Perioperative variables were compared between the exposed and control groups using Chi-squared test for categorical or t-test for continuous variables. Logistic regression analysis was used to assess the association between SDB and the odds of requiring PACU IV opioids.Children with preoperative SDB symptoms (N = 325) compared with the reference group of children who did not have these symptoms had higher rates of PACU analgesic intervention (47.1% vs. 37.4%; p = 0.004) and higher mean arousal pain scores (3.7 ± 3.5 vs.1.9 ± 2.9; p 0.001). In our primary multivariable logistic regression model adjusted for a number of variables, preoperative SDB symptoms was associated with a two-fold increased odds of receiving PACU intravenous opioid (OR = 2.01, 95%CI, 1.29-3.12; p = 0.002).These results suggest that preoperative SDB symptoms in children undergoing ambulatory surgery, exerts a significant influence on PACU pain behavior and analgesic requirement. Mechanisms underlying this enhanced pain experience deserve further elucidation.

Noncardiac surgery in patients with hypoplastic left heart syndrome has been associated with significant morbidity and mortality in case reports and small series.A retrospective study to review the anaesthetic care and outcomes of patients with hypoplastic left heart syndrome undergoing noncardiac surgery.The medical records of patients undergoing anaesthesia for noncardiac surgery were reviewed, including anaesthesiology records, operative notes, admission history, physical examination records and discharge summaries. Data were collected on patient characteristics, co-morbidities, surgical procedure, anaesthetic and monitoring techniques, intraoperative and postoperative complications and admission status.A tertiary medical centre with a high volume of congenital heart disease.Seventy-three procedures performed in 40 patients with hypoplastic left heart syndrome undergoing noncardiac surgery between July 2002 and May 2008.Thirty-three procedures were performed on an outpatient basis without invasive monitoring or complications. Adverse events occurred in 11 (15%) cases, including cardiovascular and respiratory instability, airway obstruction and postoperative stridor, with 13 (18%) patients admitted to the ICU postoperatively.Given the high incidence of adverse events in this patient population, it is imperative that perioperative care be individualised based on the presence of known risk factors such as the stage of palliation, residual cardiac disease and severity of planned surgery.

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.

OBJECTIVE To describe the prevalence of habitual snoring and examine its association with peri-operative adverse events in children undergoing elective non-cardiac surgery--a relationship that has not been previously characterised. METHODS Using a prospective observational design, we studied children aged 6-18 years undergoing elective non-cardiac surgeries at our institution. Trained research assistants collected clinical (including peri-operative adverse events) and anthropometric data on all individuals. Patients were stratified into two classes, habitual snorers and non-snorers. Subsequently, univariate factors associated with snoring were explored and then odds ratios for the occurrence of peri-operative adverse events were calculated from logistic regression after controlling for clinically relevant cofactors. RESULTS Among 1102 patients, the prevalence of habitual snoring was 27.3% (28.2% for boys vs. 26.3% for girls). All the measured anthropometric parameters (BMI, waist circumference and neck circumference) were significantly higher in habitual snorers compared with non-snorers. The overall respiratory complication rate was 11.1%. Respiratory adverse events were more frequent in habitual snorers compared with non-snorers (16.9 vs. 8.9%; P < 0.001). Additionally, habitual snoring was associated with longer post-anaesthesia care unit (PACU) stay (114.0 ± 49.6 vs. 103.6 ± 48.9 min; P = 0.002) even after controlling for the occurrence of adverse respiratory events. CONCLUSION The prevalence of habitual snoring was high in this cohort of paediatric surgical patients. Habitual snoring was associated with some peri-operative adverse events and prolonged PACU stay and should be considered an important symptom in the pre-operative review of children.

This study evaluated whether an objective tool would provide a more reliable and valid assessment of perioperative risk compared with the ASA-physical status (ASA-PS) in children.A system-based risk assessment tool was developed using these categories: Neurological, Airway, Respiratory, Cardiovascular, and Other (NARCO) with a subcomponent grading surgical severity (SS). Anaesthesiologists reviewed the preoperative assessments and assigned NARCO, SS, and ASA-PS scores independently. Perioperative outcomes were recorded by trained observers. Validity and reliability of the tools were evaluated.NARCO correlated with ASA-PS (ρ=0.664; P0.01) supporting its criterion validity. Inter-rater reliability of the measures was supported (intraclass correlation coefficients 0.71-0.96; κ 0.43-0.87) except for the Airway category. Measures of exact agreement were slightly better for NARCO compared with ASA-PS. NARCO, SS, and ASA-PS scores correlated significantly with perioperative escalation of care, adverse events (AE), hospital length of stay, and admission status. Correlations between NARCO and ASA-PS and outcomes improved when SS was factored into their coding. There were significant, but low, correlations between all measures and mortality. The odds of having escalation of care, AE, and mortality were 5-47 times greater among children with higher risk scores.Findings suggest that all measures of outcome have acceptable to excellent reliability with a slight improvement in agreement for the NARCO compared with the ASA-PS. This study supports the validity of both the NARCO and the ASA-PS in predicting perioperative risk in children with a slight improvement in correlations when combined with the SS score.

Background Patients with effective repair of D-transposition of the great arteries (D-TGA) increasingly present for non-cardiac surgery. These patients may be predisposed to heart failure, arrhythmias, and sudden death, especially after the atrial switch repair. This retrospective study was undertaken to review the care and outcomes of patients with D-TGA who presented for non-cardiac surgery. Methods Records for patients with surgically corrected D-TGA undergoing general anaesthesia for non-cardiac surgery between October 2000 and April 2008 were reviewed. The anaesthesiology records, operative note, admission history and physical examination records, and discharge summaries of these patients were reviewed and the following data collected: patient characteristics; comorbidities; surgical procedure; anaesthetic and monitoring techniques; intra- and postoperative complications; and admission status. Results Fifty procedures, including 43 in the paediatric setting and seven in the adult setting, comprised the final sample. The majority of these patients received anaesthesia on an outpatient basis in the paediatric hospital, without invasive monitoring and without complication. There were four adverse events including a significant bradycardia, failed extubation after two of the procedures, and postoperative bleeding requiring return to the operating theatre in another. Conclusions Data suggest that the majority of patients with surgically corrected D-TGA can safely undergo general anaesthesia, often as outpatients, with no invasive monitoring. However, given the incidence of adverse events, it remains imperative that the perioperative care be individualized based on the presence of comorbidities, type of repair, residual cardiac disease, severity of planned surgery, and experience of the provider.

Summary Introduction: Although blood pressure (BP) monitoring is a recommended standard of care by the ASA, and pediatric anesthesiologists routinely monitor the BP of their patients and when appropriate treat deviations from ‘normal’, there is no robust definition of hypotension in any of the pediatric anesthesia texts or journals. Consequently, what constitutes hypotension in pediatric anesthesia is currently unknown. We designed a questionnaire-based survey of pediatric anesthesiologists to determine the BP ranges and thresholds used to define intraoperative hypotension (IOH). Methods: Members of the Society of Pediatric Anesthesia (SPA) and the Association of Paediatric Anaesthetists (APA) of Great Britain and Ireland were contacted through e-mail to participate in this survey. We asked a few demographic questions and five questions about specific definitions of hypotension for different age groups of patients undergoing inguinal herniorraphy, a common pediatric surgical procedure. Results: The overall response rate was 56% (483/860), of which 76% were SPA members. Majority of the respondents (72%) work in academic institutions, while 8.9% work in institutions with fewer than 1000 annual pediatric surgical caseload. About 76% of respondents indicated that a 20–30% reduction in baseline systolic blood pressure (SBP) indicates significant hypotension in children under anesthesia. Most responders (86.7%) indicated that they use mean arterial pressure or SBP (72%) to define IOH. The mean SBP values for hypotension quoted by SPA members was about 5–7% lower across all pediatric age groups compared to values quoted by APA members (P = 0.001 for all age groups). Conclusions: There is great variability in the BP parameters used and the threshold used for defining and treating IOH among pediatric anesthesiologists. The majority of respondents considered a 20–30% reduction from baseline in SBP as indicative of significant hypotension. Lack of a consensus definition for a common clinical condition like IOH could have implications for patient care as well as future clinical research.

Summary Background Despite the established vulnerability of children during airway management, remarkably little is known about complications in children with difficult tracheal intubation. To address this concern, we developed a multicentre registry (Pediatric Difficult Intubation [PeDI]) to characterise risk factors for difficult tracheal intubation, establish the success rates of various tracheal intubation techniques, catalogue the complications of children with difficult tracheal intubation, and establish the effect of more than two tracheal intubation attempts on complications. Methods The PeDI registry consists of prospectively collected tracheal intubation data from 13 children's hospitals in the USA. We established standard data collection methods before implementing the secure web-based registry. After establishing standard definitions, we collected and analysed patient, clinician, and practice data and tracheal intubation outcomes. We categorised complications as severe or non-severe. Findings Between August, 2012, and January, 2015, 1018 difficult paediatric tracheal intubation encounters were done. The most frequently attempted first tracheal intubation techniques were direct laryngoscopy (n=461, 46%), fibre-optic bronchoscopy (n=284 [28%]), and indirect video laryngoscopy (n=183 [18%]) with first attempt success rates of 16 (3%) of 461 with direct laryngoscopy, 153 (54%) of 284 with fibre-optic bronchoscopy, and 101 (55%) of 183 with indirect video laryngoscopy. Tracheal intubation failed in 19 (2%) of cases. 204 (20%) children had at least one complication; 30 (3%) of these were severe and 192 (19%) were non-severe. The most common severe complication was cardiac arrest, which occurred in 15 (2%) patients. The occurrence of complications was associated with more than two tracheal intubation attempts, a weight of less than 10 kg, short thyromental distance, and three direct laryngoscopy attempts before an indirect technique. Temporary hypoxaemia was the most frequent non-severe complication. Interpretation More than two direct laryngoscopy attempts in children with difficult tracheal intubation are associated with a high failure rate and an increased incidence of severe complications. These results suggest that limiting the number of direct laryngoscopy attempts and quickly transitioning to an indirect technique when direct laryngoscopy fails would enhance patient safety. Funding None.

We compared the incidence and duration of false alarms (FA)and the sensitivity of conventional pulse oximetry (CPO) with Masimo Signal Extraction Technology (Masimo SET; Masimo Corporation, Irvine, CA) in children in the postanesthesia care unit. Disposable oximeter sensors were placed on separate digits of one extremity. Computerized acquisition of synchronous data included electrocardiograph heart rate, SpO(2), and pulse rate via CPO and Masimo SET. Patient motion, respiratory, and other events were simultaneously documented. SpO(2) tracings conflicting with clinical observations and/or documented events were considered false. These were defined as 1) Data dropout, complete interruption in SpO(2) data; 2) False negative, failure to detect SpO(2)/= 90% detected by another device or based on observation/intervention; 3) FA, SpO(2)/= 90% considered artifactual; and 4) True alarm (TA), SpO(2)/= 90% considered valid. Seventy-five children were monitored for 35 +/- 22 min/patient (42 h total). There were 27 TAs, all of which were identified by Masimo SET and only 16 (59%) were identified by CPO (P0.05). There was twice the number of FAs with CPO (10 vs 4 Masimo SET; P0.05). The incidence and duration of data dropouts were similar between Masimo SET and CPO. Masimo SET reduced the incidence and duration of FAs and identified a more frequent incidence of TAs compared with CPO.Pulse oximetry that incorporates Masimo Signal Extraction Technology (Masimo Corporation, Irvine, CA) may offer an advantage over conventional pulse oximetry by reducing the incidence of false alarms while identifying a higher number of true alarms in children in the postanesthesia care unit.

In a canine puppy model, pulmonary artery stenosis was created by banding the left pulmonary artery to 30-40% of its original diameter. Animals underwent right heart catheterization and angiography 1-2 mo later, and Palmaz P308 stents were implanted. Stent redilation was performed 3-5 mo later. One mo postredilation, the animals were restudied and sacrificed. Coarctations of the aorta were created by transverse aortic incision and longitudinal repair. P308 stent implantation was performed 2-3 mo later. Stent redilation was performed after 6-10 mo, and the animals were restudied and sacrificed 1-2 mo later. Stent implantation was performed in 6 puppies with pulmonary artery stenosis, as 2 animals developed postoperative pulmonary arterial hypoplasia, precluding stenting. The stenosis diameter increased from 4.8 +/- 0.5 mm to 7.4 +/- 0.6 mm (mean +/- SE) following stenting (P = 0.005), and increased further to 9.2 +/- 0.7 mm following redilation (P < 0.001). There were no significant vessel tears or ruptures. Coarctation stenting was performed in 8 animals. The coarctation was dilated from 5.8 +/- 0.9 mm to 9.8 +/- 0.6 mm (P < 0.001), and to 13.5 +/- 0.5 mm at redilation (P = 0.002). Redilation could not be performed in 1 animal. Aortic rupture and death occurred in 2 of 7 animals at redilation. Stent implantation and redilation in experimental pulmonary artery stenosis appears safe and effective. Though stent implantation for coarctation of the aorta appears safe, there was a 28% aortic rupture rate at stent redilation in this model.

To evaluate fluoroscopically guided percutaneous feeding tube placement in pediatric patients.Sixty-one procedures were performed. Periprocedural care protocol was changed after patient nine. Forty-eight-hour and 30-day outcomes were assessed.Almost 97% of procedures were successful. The 48-hour major and minor complication rates were 1.9% and 9.6%, respectively, after the initial nine procedures. Risk factors for early complications were the use of the initial care protocol (P.01) and patient weight below the 50th percentile (P.05). Major and minor 30-day complication rates were 8.3% and 12.0%, respectively. Risk factors for delayed complications were placement of a gastrojejunostomy tube rather than a gastrostomy tube (P.05) and immunosuppression (P.05).Percutaneous feeding tubes can be placed in children with a high rate of technical success. Optimal results require attention to periprocedural care. Morbidity is common during the first month of tube use.

To examine factors that anesthesiologists consider when making decisions regarding elective surgery cancellation of the pediatric patient with an upper respiratory infection (URI).Questionnaire survey.Anesthesiology departments and/or practices throughout the United States.212 anesthesiologist members of the Society for Pediatric Anesthesia (SPA).A total of 400 questionnaires were mailed to anesthesiologists randomly selected from the membership of the SPA. Of these questionnaires, 212 (54%) were completed and returned. Of these respondents, 71 (34.5%) reported that they seldom (1% to 25% of the time) cancelled cases due to an URI, and 43 (20.9%) stated that they usually (76% to 99% of the time) cancelled in the event of an URI. Two respondents (1%) reported never cancelling due to an URI, and six (2.9%) stated that they always cancelled. Frequency of cancellation was independent of type of practice. However, anesthesiologists who had been in practice for more than 10 years were significantly more likely to cancel than those who had been in practice for less than 10 years (p0.05). Factors that were considered most important in making decisions regarding cancellation included the urgency of the surgery and the presence of asthma. Other important considerations included fear of complications and the anesthesiologist's previous experience anesthetizing children with URIs. Factors related to the economics and inconvenience of cancellation did not influence the decision to cancel surgery. These factors included distance traveled, cost of cancellation, attitude of the parents, fear of litigation, and pressure to complete cases expediently.The results of this survey demonstrate a wide range of opinions and approaches to this enduring clinical dilemma. However, it appears that the practice of cancelling elective surgery for children with URIs may be changing over time, since younger anesthesiologists appear to cancel less often than their more experienced counterparts. It is hoped that this information will be useful to practioners in their evaluation and management of children with colds and will stimulate further investigation into this important clinical problem.

BACKGROUND: Anterior retraction of the tongue is used to enhance upper airway patency during pediatric fiberoptic intubation. This can be achieved by the use of Magill forceps as a tongue retractor, but lingual grip can become unsteady and traumatic. Our objective was to modify this instrument using computer-aided engineering for the purpose of stable tongue retraction. METHODS: We analyzed the geometry and mechanical properties of standard Magill forceps with a combination of analytical and empirical methods. This design was captured using computer-aided design techniques to obtain a 3-dimensional model allowing further geometric refinements and mathematical testing for rapid prototyping. RESULTS: On the basis of our experimental findings we adjusted the design constraints to optimize the device for tongue retraction. Stereolithography prototyping was used to create a partially functional plastic model to further assess the functional and ergonomic effectiveness of the design changes. To reduce pressure on the tongue by regular Magill forceps, we incorporated (1) a larger diameter tip for better lingual tissue pressure profile, (2) a ratchet to stabilize such pressure, and (3) a soft molded tip with roughened surface to improve grip. CONCLUSION: Computer-aided engineering can be used to redesign and prototype a popular instrument used in airway management. On a computational model, our modified Magill forceps demonstrated stable retraction forces, while maintaining the original geometry and versatility. Its application in humans and utility during pediatric fiberoptic intubation are yet to be studied.

Routine monitoring of blood pressure is an essential part of perioperative care in adults and children. It is however not known whether intraoperative hypotension (IOH) is clinically important in the 'healthy' pediatric patient. This may be partly due to the lack of data on the incidence and consequences of IOH in this group of patients. We utilized the Brain Trauma Foundation definition of hypotension to describe the incidence of preincision hypotension (PIH) in a large pediatric noncardiac surgical population and identified risk factors for the occurrence PIH.We examined the electronic perioperative records of all children aged 1-17 years undergoing general anesthesia for noncardiac surgeries between January 2005 and June 2007 in our institution. Frequency and factors associated with PIH were computed. Binary logistic regression with forward step-wise algorithm was used to examine factors associated with PIH.There were 22,263 children of whom 57.6% were males. Most (94.9%) cases were elective, American Society of Anesthesiologists (ASA) I-II (79.5%) procedures. Inhalational induction was predominantly used in this cohort (67%) although 33% of patients had propofol either as a sole induction agent or as part of a 'co-induction' regime. Single or multiple episodes of PIH occurred in 35.8% of patients. PIH was more common in patients with ASAor = III (P0.001); those with preoperative hypotension (P0.001); and following intravenous induction (P0.001) as well as propofol co-induction (P0.001). On multivariate analysis the following were significant predictors of PIH: baseline hypotension, propofol co-induction, age, ASAor = III, and long preincision period.Preincision hypotension is common in the pediatric surgical population undergoing general anesthesia. Factors independently predictive of PIH included high ASA status, pre-existing hypotension, propofol co-induction prolonged preincision period and adolescent age group. The importance of blood pressure monitoring, prompt recognition of hypotension and use of appropriate intervention is emphasized.

A prospective, double-blind study was conducted to compare the effect of pressure at the P6 (Neikuan) point with placebo as an antiemetic in children. Sixty-six patients, ages 3-12 yr, undergoing outpatient surgery for correction of strabismus, were allocated randomly to receive either bilateral P6 acupressure or placebo during the perioperative period. The study was designed to detect a 50% difference in the incidence of postoperative vomiting between the two groups, with a 90% power of achieving a statistically significant result at the 5% level (two-tailed). The incidence of postoperative vomiting for the placebo group was 58% before discharge from hospital, 73% at home and 82% in the first 24 h after surgery. The corresponding results for the acupressure group were 58% before discharge, 71% at home and 94% in the first 24 h. These differences were not significant; P6 acupressure did not reduce the incidence of postoperative vomiting in children undergoing strabismus surgery.

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.

Summary Background: The American Society of Anesthesiologists physical status classification (ASA-PS) is used worldwide by anesthesia providers as an assessment of the preoperative physical status of patients. This assessment score has been inconsistently assigned by anesthesia providers among adult surgical patients. This study tested the reliability of assignment of ASA-PS classification among pediatric anesthesia providers. Methods: A postal questionnaire was sent to a randomly selected sample of full members of the Society of Pediatric Anesthesiologists. Participants were asked to assign ASA-PS for 10 clinical case scenarios chosen from regular pediatric surgical cases at the investigators’ institution. Results: The response rate to our mailing was 54%. There was a moderate overall agreement among pediatric anesthesia providers in assigning ASA-PS for pediatric surgical patients (exact agreement 40.5–78.6%; κ = 0.479). Exact agreement improved for combined ASA classifications of I and II (83%), and III and IV (95%). Conclusion: These findings suggest a moderate agreement among pediatric anesthesia providers in assigning ASA-PS classification to selected pediatric case scenarios. Most disagreement, however, represented a tendency of outside care providers to assign a higher ASA physical status for cases. Furthermore, agreement was excellent for low risk (i.e. ASA I and II) as well as high risk (ASA III and IV) cases.

Summary Background: Chloral hydrate (CH) sedation for magnetic resonance imaging (MRI) is associated with significant failure rates, adverse events and delayed recovery. Pentobarbital (PB), reportedly produces successful sedation in 98% of children undergoing diagnostic imaging. This study compared the efficacy, adverse events and recovery characteristics of CH vs PB in children undergoing MRI. Methods: With Institutional Review Board approval and written consent, children were randomly assigned to receive intravenous (i.v.) PB (maximum 5 mgAEkg )1 in incremental doses) or oral CH (75 mgAEkg )1 ) prior to MRI. Sedation was augmented with 0.05 mgAEkg )1 doses of i.v. midazolam (maximum 0.1 mgAEkg )1 ) as necessary. Adverse effects, including hypoxaemia, failed sedation, paradoxical reactions and behavioural changes, the return of baseline activity, and parental satisfaction were documented. The quality of MRI scans was evaluated by a radiologist blinded to the sedation technique. Results: PB facilitated an earlier onset of sedation (P ¼ 0.001), higher sedation scores (P ¼ 0.01), and less need for supplemental midazolam compared with CH. Severe hypoxaemia occurred in two children (6%) in the PB group. Fourteen per cent of the PB group experienced a paradoxical reaction, 9% sedation failure and 11% major motion artefact, compared with 0% (P ¼ 0.05), 3 and 2% (P ¼ NS), respectively, in the CH group. CH and PB were both associated with a high incidence of motor imbalance, and agitation. However, children who received PB had a slower return to baseline activity (P ¼ 0.04). Conclusions: Although PB facilitated a quicker sedation onset and reduced the requirement for supplemental sedation, it produced a higher incidence of paradoxical reaction and prolonged recovery with a similar failure rate compared with CH.

Summary Objective: The aim of this study was to determine if children exposed to environmental tobacco smoke (ETS) via parental smoking (ETS+) developed more respiratory symptoms resulting in longer recovery times following surgical outpatient procedures compared with children of nonsmoking parents (ETS)). Methods: One hundred and forty six children (4.9 ± 3 years) undergoing inguinal hernia repair were prospectively studied. Parental smoking behaviour was determined by survey and urine analysis. Seven respiratory symptoms were evaluated during induction and emergence from anaesthesia and during the recovery room (RR) stay. Results: Fifty-seven (39%) families admitted a smoking history while 89 (61%) denied it. This strongly correlated with the cotinine/ creatinine ratio (Pearson correlation coefficient ¼ 0.76; P ¼ 0.01). ETS exposure was associated with an increased frequency of RR symptoms (ETS+: 56%; ETS) :3 1%; P ¼ 0.007). Conclusions: In children undergoing general anaesthesia for inguinal hernia repair, ETS exposure was associated with an increased frequency of respiratory symptoms during emergence from anaesthesia and during postoperative recovery.

Objective: To determine whether outcomes and costs in children undergoing cardiac surgery are affected by the method of postoperative pain management. Design: Retrospective, case control. Setting: Tertiary care children's hospital in a university setting. Participants: Two groups of children undergoing cardiac surgery for palliation or repair of congenital heart disease over a 21-month period between January 1993 and September 1994. Interventions: Lumbar epidural morphine infusions (LEM) in one group, and IV opioid (IVO) medication in the other for postoperative pain control. Measurements and Main Results: Hospital courses of 27 LEM patients and 27 IVO patients were analyzed. In LEM patients, epidural catheters were placed following anesthetic induction, but before anticoagulation. A bolus of 50 μg/kg of preservative-free morphine sulfate was administered through the catheter, followed by a continuous infusion at 3 to 4 μg/kg/h for 22 to 102 (median, 46) hours postoperatively. The IVO patients received 50 μg/kg, IV, of fentanyl before incision followed by a continuous infusion at 0.3 μg/kg/min. The fentanyl infusion rate was decreased to 0.1 μg/kg/min postoperatively and maintained for 24 hours. Although the LEM group was demographically similar to the IVO group, times to tracheal extubation, transfer from the intensive care unit, and resumption of regular diet were significantly shorter in LEM patients. LEM and IVO patients received similar amounts of fentanyl during surgery (10.4 ± 19.3 μg/kg/h v 13.7 ± 8.1 μg/kg/h, p = 0.4). However, during postoperative recovery, LEM patients who were extubated late received significantly less supplemental opioid medication than IVO patients extubated late during the first 5 postoperative days. No complications related to dural puncture, bleeding into the epidural space, or respiratory depression were encountered. Pruritus and nausea/vomiting were the most commonly reported morbidities in both groups. Fifty-six percent (15/27) of LEM patients and 41% of IVO patients reported pruritus (p = 0.4). There was no significant difference in the incidence of nausea and vomiting between the groups (34% v 30%, respectively). Conclusions: Given the present methodologic limitations, the authors found improved outcomes only in LEM patients extubated late compared with IVO patients. Randomized, prospective studies to evaluate this conclusion and to determine the comparative efficacy and safety of LEM infusions are in progress.

In a prospective, double-blind, randomized study, we have compared i.v. ketorolac and morphine in paediatric outpatients undergoing strabismus surgery. Forty-two ASA I or II children, aged 2-12 yr, were allocated randomly to receive either ketorolac 0.75 mg kg-1 i.v. or morphine 0.1 mg kg-1 i.v. and metoclopramide 0.15 mg kg-1. Anaesthesia was induced with propofol and maintained with propofol and nitrous oxide. Pain was assessed at 15-min intervals until discharge, and the incidence of nausea and vomiting was recorded for the first 24 h. There was no difference in pain behaviour scores or recovery times. The incidence of nausea and vomiting during the first 24 h was 19% in the ketorolac group and 71% in the morphine group (P0.001). We concluded that ketorolac was an effective analgesic for this type of surgery and that it was associated with less postoperative emesis than morphine and metoclopramide.

The present study was intended to evaluate the acute and short-term hemodynamic, angiographic, and pathological response to balloon-expandable stent treatment of experimental coarctation of the aorta. A discrete thoracic coarctation was surgically created in six mongrel dogs (two adults, four puppies). Two months postoperatively all six dogs (8.9-30 kg) underwent left heart catheterization and coarctation stenting performed through a femoral artery cutdown. A Palmaz PS-30 stent was advanced to the coarctation through a IOFrench sheath, and expanded with an angioplasty balloon chosen to equal the diameter of the proximaf aorta (9-12 mm). Sfent implantation was successful in each dog. The systolic pressure gradient decreased from 26.3 ? 9.1 mmHg (mean & SE) to 0.5 c 0.5 mmHg (P = OM), and the coarctation diameter improved from 50 2 6% to 82 c 6% of the diameter of the proximal descending aorta (P < 0.01). Follow-up catheterization 4-7 weeks after stenting documented no stent migration, early restenosis, thrombosis, obstruction of arterial side branches, or aneurysm formation. Pathological evaluation of the explanted segments of stented aorta documented that by 6-7 weeks the stents are covered by a neointima composed of intimal proliferation and fibrosis with an endothelial cell surface. These data suggest that balloon-expandable stainless steel stents provide excellent acute and short-term relief of coarctation in this experimental model. Larger and longerterm studies are needed to better assess the incidence of restenosis or aneurysm formation following stenring of coarctation of the aorta. (J Interven Cardiol 1993; 6: 113-123)