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Author(s): Rekha Varghese [1]; Geethu Sebastian [1]; Dimple E. Thomas [1]; Lakshmi Kumar (corresponding author) [1] Dear Editor, Ex-utero intrapartum therapy (EXIT) allows the survival of children with congenital high [...]

Purpose: The incidence of hemodynamic instability associated with dexmedetomidine (DEX) sedation has been reported to exceed 50%, with substantial inter-individual variability in response. Genetic factors have been suggested to contribute significantly to such variation. The aim of this study was to identify the clinical, pharmacokinetic, and genetic factors associated with DEX-induced hemodynamic instability in pediatric anesthesia patients. Methods: A cohort of 270 pediatric patients scheduled for elective interventional surgery received an intranasal dose of 3 mcg·kg-1 of dexmedetomidine, and subsequent propofol induction was conducted when patients had a UMSS of 2–4. The primary endpoint was hemodynamic instability—defined as a composite of hypotension and/or bradycardia, which is characterized by a 20% reduction from age-specific baseline values. Plasma concentrations of dexmedetomidine were determined, and single-nucleotide polymorphisms (SNPs) were genotyped. A validated population pharmacokinetic model was used to estimate pharmacokinetic parameters. LASSO regression was used to identify significant factors, and a Cox's proportional hazards model-derived nomogram for hemodynamic instability was developed. Results: Hemodynamic instability was observed in 52 out of 270 patients (209 events), resulting in a cumulative incidence of 16.30% at 90 min, as estimated by Kaplan–Meier estimation, and it was associated with a median time to event of 35 min. The interval time between DEX initiation and propofol induction was 16 min (IQR: 12–22 min). The cumulative incidence was 8.2% within 22 min after DEX initiation. The identified significant risk factors for DEX-associated hemodynamic instability included weight, DEX clearance, concomitant propofol use, and the following gene variants UGT2B10 rs1841042 (hazard ratio (HR):1.41, 95% confidence interval (CI): 1.12–1.79), CYP2A6 rs8192733 (HR:0.28, 95%CI:0.09–0.88), ADRA2B rs3813662 (HR:1.39,95%CI:1.02–1.89), CACNA2D2 rs2236957 (HR:1.46, 95%CI:1.09–1.96), NR1I2 rs3814057 (HR:0.64, 95%CI:0.43–0.95), and CACNB2 rs10764319 (HR:1.40,95%CI:1.05–1.87). The areas under the curve for the training and test cohorts were 0.881 and 0.762, respectively. The calibration curve indicated excellent agreement. Conclusion: The predictive nomogram, which incorporates genetic variants (UGT2B10, CYP2A6, ADRA2B, CACNA2D2, NR1I2 , and CACNB2) along with clinical factors such as weight, DEX clearance, and propofol use, may help prevent DEX-associated hemodynamic instability. Delayed hemodynamic instability is likely to occur after 35-min DEX initiation in patients with lower DEX clearance after propofol induction. [ABSTRACT FROM AUTHOR]

Introduction: We determined the median effective dose and 95% confidence interval (CI) of remimazolam required to inhibit laryngeal mask airway (LMA) insertion reactions combined with sufentanil 0.3 μg/kg in pediatric anesthesia. Methods: Children scheduled to undergo elective laryngeal mask anesthesia were divided into the preschool (age: 3–6 years) and school-age (6–12 years) groups. The timer was started after intravenous remimazolam was administered; thereafter, 0.3 μg/kg sufentanil was injected intravenously. The laryngeal mask was placed 3 min after remimazolam was finished. If a positive response to LMA insertion, such as movement, swallowing, coughing, hiccups, or other reactions, was observed during the insertion, the dose was increased by 0.03 mg/kg for the next patient; if there was no response, the dose was decreased by 0.03 mg/kg instead. The trial officially commenced after the first LMA was successfully inserted and continued until alternating positive and negative responses formed seven crossover points. Thereafter, probit regression was performed to calculate the median effective dose (ED50) and 95% effective dose (ED95) with the corresponding 95% CIs. The time from remimazolam administration to the disappearance of the eyelash reflex was recorded. Heart rate and mean arterial pressure were recorded before (T1, baseline values) and 3 min after (T2) intravenous remimazolam administration. Adverse reactions were also noted. Results: Overall, 52 children were included; 25 belonged to the preschool group and 27 to the school-age group. In the preschool group, the ED50 and ED95 for remimazolam and their 95% CIs were 0.476 (0.447–0.517) mg/kg and 0.554 (0.515–0.688) mg/kg, respectively. In the school-age group, the ED50 and ED95 for remimazolam and corresponding 95% CIs were 0.427 (0.399–0.463) mg/kg and 0.504 (0.467–0.635) mg/kg, respectively. The dosage for the preschool group was significantly higher than that for the school-age group (p = 0.003). Conversely, the time from remimazolam administration to the disappearance of the eyelash reflex; LMA insertion success rate; or incidence of coughing, movement, swallowing, and hiccups did not differ significantly between the two groups. Conclusion: Remimazolam can be safely used for laryngeal mask anesthesia induction in pediatric patients. Clinical Trial Registration: https://www.chictr.org.cn/, identifier ChiCTR2400087333. [ABSTRACT FROM AUTHOR]

ABSTRACT Background Aims Methods Results Conclusions Clinical Implications Trial Registration In pediatric patients, the use of processed EEG monitoring may reduce the amount of anesthesia administered while maintaining adequate depth of anesthesia.The primary aim of this study was to evaluate whether use of a BIS monitor to guide sevoflurane administration might reduce the average end tidal sevoflurane concentration used in children 4–18 years of age.Participants in three age groups (4–8, 9–12, and 13–18 years) were randomized to either the BIS guided group or the control group. Use of sevoflurane as the primary maintenance anesthetic was the only requirement in both arms. In the BIS guided group, sevoflurane was titrated to achieve a target BIS value of 45–60 during the maintenance period. In the control arm, clinicians were blinded to the BIS value. Primary outcome was mean end‐tidal sevoflurane concentration during maintenance phase of anesthesia. Secondary assessments included time to discharge and the readiness and quality of recovery as assessed by the Pediatric Anesthesia Emergence Delirium scale, the modified Aldrete Score, and the Wong–Baker FACES scale. An intention‐to‐treat analysis was used to analyze and compare groups.A total of 180 participants were randomized. Following randomization, 10 participants did not undergo any study procedures, leaving 84 participants in the BIS guided group and 86 participants in the control group. Across all age groups, the average end‐tidal sevoflurane concentration was less in the BIS guided group compared to control (4–8 years: 2.2% ± 0.3% vs. 2.4% ± 0.4%, −0.3% [−0.4%, −0.1%]; 9–12 years: 1.7% ± 0.5% vs. 2.1% ± 0.6%, −0.4% [−0.7%, −0.1%]; 13–18 years: 1.6% ± 0.4% vs. 1.9% ± 0.5%, −0.3% [−0.5%, −0.1%]). No differences in recovery outcomes between treatment groups were observed.In pediatric participants, the BIS guided group reported a lower average end‐tidal sevoflurane concentration compared to control, though no significant differences in recovery profile were noted.The Bispectral Index (BIS) is a processed EEG tool that can be used to titrate general anesthesia to achieve desired anesthetic depth. Brain monitoring with BIS resulted in lower average end‐tidal sevoflurane concentrations in children aged 4–18 years undergoing general anesthesia.ClinicalTrials.gov identifier: NCT04810481 [ABSTRACT FROM AUTHOR]

The muscular dystrophies or muscle-wasting diseases include a diverse group of genetic disorders, which result in progressive degeneration of skeletal muscles, progressive muscle weakness, and comorbid multi-system involvement. Duchenne muscle dystrophy is the most common type of muscular dystrophy with a reported incidence of 1 in every 3500–6000 male live births in the United States. Given the progressive nature of these disorders, skeletal muscle weakness frequently progresses to loss of the ability to ambulate and perform functions of daily life. In addition to affecting the skeletal musculature, many muscular dystrophies have effects on both cardiac and smooth muscles. As respiratory muscles are one of the most frequently affected muscles in patients with muscular dystrophies, progressive respiratory insufficiency may occur with dependance on non-invasive forms of respiratory support. Given the progressive multi-system involvement associated with the muscular dystrophies, perioperative care and the use of general anesthetic agents and opioids may result in postoperative respiratory failure. In an effort to avoid the deleterious effects of anesthetic agents and opioids on hemodynamic and respiratory functions, regional anesthesia may be used as an adjunct to or instead of general anesthesia. This manuscript provides a literature review and educational summary regarding the use of regional anesthetic techniques in pediatric-aged patients with muscular dystrophies. [ABSTRACT FROM AUTHOR]

Objective: Emergence delirium is frequently observed in pediatric patients. With advancements in video-based interventions, such as cartoons, video games, and virtual reality, these modalities may contribute to a reduced incidence of emergency delirium among children. However, robust evidence supporting their efficacy remains necessary. Methods: The authors conducted a systematic search across multiple databases, including Embase, MEDLINE, and Cochrane Library, to identify all randomized controlled trials comparing video-based interventions with control treatments in pediatric emergence delirium. Data were aggregated and analyzed using Review Manager 5.4 to evaluate the effectiveness of video-based interventions. Results: The analysis included eight randomized controlled trials comprising 872 children. The intervention group showed a trend toward lower Pediatric Anesthesia Emergence Delirium scores (p = 0.10) and fewer emergence delirium events (p = 0.52). Seven studies demonstrated that video-based interventions significantly reduced preoperative anxiety, as indicated by decreased scores on the modified Yale Pre-operative Anxiety Scale (p < 0.00001). Anesthesia duration did not significantly differ between the intervention and control groups (p = 0.16). Notably, subgroup analyses revealed a significant reduction in Pediatric Anesthesia Emergence Delirium scores among children under seven years of age (p = 0.001). Conclusions: Video-based interventions were linked to lower Pediatric Anesthesia Emergence Delirium scores and a decreased incidence of emergence delirium events. However, these results did not reach statistical significance across the broader sample. Notably, in children under seven, these interventions significantly reduced the scores. [ABSTRACT FROM AUTHOR]

The analysis of survey data is a frequently arising issue in clinical trials, particularly when capturing quantities which are difficult to measure. Typical examples are questionnaires about patient's well‐being, pain, or consent to an intervention. In these, data is captured on a discrete scale containing only a limited number of possible answers, from which the respondent has to pick the answer which fits best his/her personal opinion. This data is generally located on an ordinal scale as answers can usually be arranged in an ascending order, for example, "bad", "neutral", "good" for well‐being. Since responses are usually stored numerically for data processing purposes, analysis of survey data using ordinary linear regression models are commonly applied. However, assumptions of these models are often not met as linear regression requires a constant variability of the response variable and can yield predictions out of the range of response categories. By using linear models, one only gains insights about the mean response which may affect representativeness. In contrast, ordinal regression models can provide probability estimates for all response categories and yield information about the full response scale beyond the mean. In this work, we provide a concise overview of the fundamentals of latent variable based ordinal models, applications to a real data set, and outline the use of state‐of‐the‐art‐software for this purpose. Moreover, we discuss strengths, limitations and typical pitfalls. This is a companion work to a current vignette‐based structured interview study in pediatric anesthesia. [ABSTRACT FROM AUTHOR]

Background/Objectives: In 2021, the Food and Drug Administration approved liposomal bupivacaine injectable suspension for single-dose infiltration in patients ≥ 6 years of age. Liposomal bupivacaine and bupivacaine hydrochloride admixtures may also be administered off-label for pediatric regional anesthesia including peripheral nerve blocks (PNBs). This single-injection, long-acting technique is not well described in pediatrics but may have benefits over traditional continuous catheter-based systems. The purpose of this investigation was to examine an adolescent cohort who received liposomal bupivacaine/bupivacaine hydrochloride PNBs for orthopedic surgery. Methods: Patient, surgical, anesthetic, block characteristics, and post-anesthesia care unit (PACU) outcomes were retrospectively reviewed from February 2020 to June 2024. From February to December 2022, a short follow-up survey was conducted to assess post-discharge patient-reported outcomes. Results: There were 524 liposomal bupivacaine/bupivacaine hydrochloride PNBs (106 upper-extremity and 418 lower-extremity) performed in 374 patients with a mean (standard deviation, range) age of 16 (1.2, 11–17) years. Two unilateral PNBs were performed in 150 (40%) patients to ensure an adequate sensory neural blockade. The interscalene (n = 81, 15%) and adductor canal (n = 140, 27%) blocks were the most common upper- and lower-extremity PNBs, respectively. Intraoperatively, the majority of the cohort (n = 258, 69%) underwent monitored anesthesia care (MAC). No patient required conversion from MAC to general anesthesia due to pain. In PACU, 288 (77%) patients reported no pain. Mild and moderate pain were reported by 56 (15%) and 30 (8%) patients, respectively. No patients developed local anesthetic toxicity. The survey results (n = 66) indicate that the majority of patients (96%) were satisfied with block analgesia postoperatively. Conclusion: Liposomal bupivacaine/bupivacaine hydrochloride PNBs were used successfully in adolescents undergoing a variety of orthopedic surgeries. [ABSTRACT FROM AUTHOR]

Background/Objectives: Postoperative delirium is a frequent complication in children undergoing general anesthesia. It has been suggested that inflammation and oxidative stress contribute to the pathophysiology of delirium. The aim of our study was to investigate the relationship between inflammatory markers and delirium. Methods: A total of 221 children in the ASA 1–3 risk group who underwent adenoidectomy, tonsillectomy, and/or ventilation tube application were included in our single-center, prospective, and observational study approved by the Ethics Committee, numbered E1-23-3197. Patients whose parental consent was obtained were either premedicated with oral midazolam preoperatively or taken to surgery without premedication, depending on the anesthesiologist's preference. After induction with sevoflurane, rocuronium and fentanyl were administered intravenously. Sevoflurane and infusion of remifentanil were administered for maintenance. At the end of the operation, patients were transferred to the recovery unit and followed up for 30 min. They were evaluated with the Face, Legs, Activity, Cry, and Consolability (FLACC) Scale and Pediatric Anesthesia Emergence Delirium (PAED) Scale. Results: Delirium was observed in 80 patients. There was no significant difference between patients with and without delirium in terms of neutrophil/lymphocyte ratio, mean platelet volume, or platelet distribution volume. Lymphocyte count, PAED score, and FLACC score were statistically higher in patients with delirium (W = 4407.5, p-value = 0.006997; W = 0, p-value < 2.2 × 10−16; W = 9489, p-value < 2.2 × 10−16, respectively). Conclusions: No statistically significant relationship was found between hematologic inflammatory markers and delirium. Controlled studies with larger sample sizes are needed to determine whether these markers have strong predictive value. [ABSTRACT FROM AUTHOR]

ABSTRACT Background Aims Methods Results Conclusions The field of pediatric anesthesiology faces an impending shortage of fellowship‐trained physicians. Despite this projection, fewer anesthesiology residents are opting to pursue a fellowship. To better understand the current perspective and motivation of trainees to pursue a career in pediatric anesthesiology, we surveyed anesthesiology residents across the United States.Our primary aims were to assess the understanding of the current workforce shortage as well as explore the impact of both exposure and characteristics of the anesthesia resident rotation on the decision to pursue pediatric anesthesiology fellowship.A 25‐question Qualtrics survey was distributed to members of the Pediatric Anesthesia Leadership Council and Education Committee within the Society for Pediatric Anesthesia and to anesthesiology residency program directors based in the United States.The survey received 201 responses. Of the respondents, 29% were in Clinical Anesthesia Year 3, 25% in Year 2, 19% in Year 1, and 10% in their intern year. The analysis revealed that self‐reported adequate exposure to high‐acuity cases and advanced procedures (arterial lines, central lines, and nerve blocks) significantly increased the likelihood of planning to pursue pediatric anesthesiology fellowship (adjusted Odd Ratio 8.47, 95% Confidence Interval, 1.65–43.4). Perceptions of faculty teaching, mentor availability, planned practice environment, and the presence of fellowship programs at the institution were not significantly associated with intentions to pursue pediatric anesthesiology fellowship.The journey toward specializing in pediatric anesthesiology is influenced by a complex interplay of factors. Among these, enhanced exposure to challenging cases and advanced procedures during the residency phase is emerging as a critical element. Such exposure not only equips residents with the necessary skills and confidence to handle complex pediatric anesthesia cases but also plays a pivotal role in attracting more trainees to this essential subspecialty. [ABSTRACT FROM AUTHOR]

ABSTRACT Background Aims Methods Results Conclusions Clinical Implications Transgender and gender‐diverse individuals experience higher burdens of health disparities compared to their cisgender counterparts. Contributing factors include decreased access and denial of care, experiences and fear of medical violence, and increasing legislative barriers. These patients often report having to educate healthcare professionals due to lack of expertise of transgender and gender‐diverse issues within the medical community, with training deficits observed at all levels of medical training.We surveyed pediatric anesthesiology fellowship directors in the United States and Canada with an aim to describe the current state of transgender and gender‐diverse topics within diversity, equity, and inclusion curricular content across pediatric anesthesiology fellowship training programs.A 25‐question descriptive, cross‐sectional, electronic survey was created and distributed to all pediatric anesthesiology fellowship program directors in the United States and Canada investigating the inclusion of transgender and gender‐diverse topics within diversity, equity, and inclusion curriculum (if present) for pediatric anesthesiology fellows.A total of 33 responses were collected from 69 total invited programs. Diversity, equity, and inclusion curricula were present in 93.5% (29/31) of fellowship programs but only 29% (9/31) of programs included content specific to transgender and gender‐diverse populations. Just 17% (5/29) of program directors thought their curriculum adequately prepared their graduates to care for transgender and gender‐diverse patients. However, 69% (20/29) expressed a desire to see more educational content included in the future. Lack of knowledgeable faculty educators and time were the most chosen perceived barriers to inclusion.To our knowledge, this study is the first to evaluate pediatric anesthesiology fellowship curricula for inclusion of transgender and gender‐diverse topics within diversity, equity, and inclusion curriculum. As the population of known transgender and gender‐diverse youth increases, all pediatric anesthesiologists must be equipped to treat this population with appropriate clinical and cultural sensitivity. Future endeavors must include robust sexual orientation and gender identity data collection, access to educational materials from content experts, recruitment and empowerment of LGBTQ+ anesthesiologists, and increased dedicated time toward diversity, equity, and inclusion education, specifically in regard to the transgender and gender‐diverse population.Lack of physician education on the care of transgender and gender‐diverse patients is one of several factors contributing to the health disparities seen in this population; training deficits in the care of transgender and gender‐diverse patients have been observed in all levels of medical training. Our data show a critical deficiency of transgender and gender‐diverse topics within diversity, equity, and inclusion curricular content in pediatric anesthesiology fellowships in the United States and Canada and identify potential barriers to the inclusion of such content. [ABSTRACT FROM AUTHOR]

Background: Dexmedetomidine and Midazolam were utilized as adjuvants for extending the duration of analgesia; the most common local anesthetic used globally for Caudal anesthesia (CA) is a single dose of plain bupivacaine. To achieve adequate post-operative analgesia, we aimed to compare bupivacaine-dexmedetomidine and bupivacaine-midazolam in caudal anesthesia in pediatric hypospadias surgeries. Methods: We conducted a prospective randomized double-blind controlled clinical study on 51 patients who were scheduled for hypospadias surgery aged from 3 to 8 years; they were allocated randomly into three equal groups (17 patients in each group): Group C (Control): received bupivacaine 0.25% total volume 1ml/kg only, Group D: who received bupivacaine 0.25% in addition to dexmedetomidine 1µg/kg total volume 1ml/kg, Group M: received bupivacaine 0.25% in addition to midazolam 50µg/kg total volume 1ml/kg. The postoperative vital signs, adverse events and duration of the caudal analgesia were assessed utilizing the pediatrics observational Face, Legs, Activity, Cry, Consolability scale (FLACC) pain scale. Results: Group D had the lowest significant FLACC pain score, followed by Group M, then Group C (P=0.00), Duration of Caudal block was the highest in Group D [14 hours, 95% CI(13.26-14.7)] followed by Group M [10 hours, 95% CI(9.6-10.36)] then Group C [4 hours, 95% CI(3.5-4.49)]. Time to first request analgesics was the highest in Group D [14 hours, 95% CI(12.2-14.7)] followed by Group M [10 hours, 95% CI(9.22-10.7)] then Group C [4 hours, 95% CI(5.23 - 6.77)], with statistically significant differences between the 3 groups (P<0.001). Conclusion: Combining bupivacaine with dexmedetomidine or midazolam dramatically extends the time of postoperative analgesia, which in turn increases the time until the patient requires another analgesic. Compared to a mixture of midazolam and bupivacaine, the analgesic profile of the dexmedetomidine plus bupivacaine combination was superior, and there were no significant side effects or disturbances in hemodynamic parameters. [ABSTRACT FROM AUTHOR]

Aim While bradycardia in children with Down syndrome (DS) during inhalation induction of anesthesia is characteristic, its mechanism is not well understood. This study investigated sympathetic failure as a potential (and modifiable) mechanism of bradycardia. Materials and Methods Ninety-three children with DS and 102 typically developing (TD) children underwent inhalation induction of anesthesia. These children were monitored for sympathetic activity, exposed to sevoflurane anesthetic and were observed for the development of bradycardia. The primary outcome was sympathetic failure in the context of normoxic bradycardia within the first 300 seconds of induction. Secondary outcome measures included hypotension and parasympathetic excess. Results During the first 300 seconds of induction, 54 DS children became bradycardic (54/93, 58%) while 22 TD children became bradycardic (22/102, 22%). In the DS group, 23 experienced hypotension (23/80, 29%). Of those who experienced hypotension, 15 also experienced sympathetic failure (15/28, 54%). Conclusion More than half of children with DS undergoing inhalation anesthesia induction with sevoflurane experienced bradycardia. Bradycardia and hypotension were associated with sympathetic failure. Sympathetic activity therefore appears to be a modifiable target in the prevention of bradycardia in children with DS. Keywords:Down syndrome, pediatric anesthesia, autonomic nervous system diseases, sevoflurane: [ABSTRACT FROM AUTHOR]

Background: Cuffed endotracheal tubes (cETT) pose the potential advantage of an infrequent need for reintubation in pediatric patients compared to uncuffed tubes. The aim of this study was to investigate tube exchange rates using second generation Microcuff® pediatric endotracheal tubes (PET) with an adapted sizing recommendation in a large single institution cohort of children and to identify potential variables associated with an elevated risk of tube exchange. Methods: Patient data obtained from the electronic patient data management system of the Department of Anesthesia, University Children's Hospital Zurich, Switzerland, were retrospectively assessed for demographic and anthropometric information, size of the internal tube diameter used for positive pressure ventilation and divergence from the size recommendation chart. Results: Data from 14,188 children younger than 16 years (median 5.3 years) and weighing at least 3 kg who underwent oral or nasal tracheal intubation using second generation Microcuff® PET between 2009 and 2015 were included. Of 13,219 oral tracheal intubations 12,049 (84.9%) were performed according to the manufacturer's size recommendation and 1170 with divergent endotracheal tubes. The odds ratio (OR) of oral reintubation was 0.13% (95% confidence interval 0.08–0.22%) for cases using the manufacture's size recommendation correctly and 22.74% (95% confidence interval 20.42–25.23%) for patients intubated with a not recommended tube (p < 0.0001). Conclusion: These findings indicate that the second generation Microcuff® PETs can be reliably used with low tube exchange rates across the entire pediatric age range when the tube size is selected according to the manufacturer's size recommendation chart. Adherence to the manufacturer's tube size recommendation is urgently advised. [ABSTRACT FROM AUTHOR]

The article discusses the considerations and challenges in planning anesthesia for children with trisomy 21, highlighting the increased risk of complications due to their unique anatomical and physiological characteristics. Topics include airway management challenges, the use of sevoflurane and its associated risks, and the importance of preoperative assessment and emergency readiness when planning anesthesia for these children.

Background: The Nociception Level Index has shown benefits in estimating the nociception/antinociception balance in adults, but there is limited evidence in the pediatric population. Evaluating the index performance in children might provide valuable insights to guide opioid administration. Aims: To evaluate the Nociception Level Index ability to identify a standardized nociceptive stimulus and the analgesic effect of a fentanyl bolus. Additionally, to characterize the pharmacokinetic/pharmacodynamic relationship of fentanyl with the Nociception Level Index response during sevoflurane anesthesia. Methods: Nineteen children, 5.3 (4.1–6.7) years, scheduled for lower abdominal or urological surgery, were studied. After sevoflurane anesthesia and caudal block, a tetanic stimulus (50 Hz, 60 mA, 5 s) was performed in the forearm. Following the administration of fentanyl 2 μg/kg intravenous bolus, three similar consecutive tetanic stimuli were performed at 5‐, 15‐, and 30‐min post‐fentanyl administration. Changes in the Nociception Level Index, heart rate, mean arterial pressure, and bispectral index were compared in response to the tetanic stimuli. Fentanyl plasma concentrations and the Nociception Level Index data were used to elaborate a pharmacokinetic/pharmacodynamic model using a sequential modeling approach in NONMEM®. Results: After the first tetanic stimulus, both the Nociception Level Index and the heart rate increased compared to baseline (8 ± 7 vs. 19 ± 10; mean difference (CI95) −12(−18–−6) and 100 ± 10 vs. 102 ± 10; −2(−4–−0.1)) and decrease following fentanyl administration (19 ± 10 vs. 8 ± 8; 12 (5–18) and 102 ± 10 vs. 91 ± 11; 11 (7–16)). In subsequent tetanic stimuli, heart rate remained unchanged, while the Nociception Level Index progressively increased within 15 min to values similar to those before fentanyl. An allometric weight‐scaled, 3‐compartment model best characterized the pharmacokinetic profile of fentanyl. The pharmacokinetic/pharmacodynamic modeling analysis revealed hysteresis between fentanyl plasma concentrations and the Nociception Level Index response, characterized by plasma effect‐site equilibration half‐time of 1.69 (0.4–2.9) min. The estimated fentanyl C50 was 1.93 (0.73–4.2) ng/mL. Conclusion: The Nociception Level Index showed superior capability compared to traditional hemodynamic variables in discriminating different nociception‐antinociception levels during varying fentanyl concentrations in children under sevoflurane anesthesia. [ABSTRACT FROM AUTHOR]

Background: Children undergoing outpatient surgery are at risk of inadequate postoperative pain control. Methadone has a long duration of action and an intraoperative dose may provide stable analgesia throughout the postoperative period. Intraoperative methadone has been shown to improve pain control in adolescents but its use for postoperative pain in pediatric patients undergoing outpatient surgery has not been studied before. Therefore, we conducted a double‐blind randomized placebo‐controlled trial to investigate the effects of a single dose of intraoperative methadone in children aged less than 5 years undergoing orchiopexy for undescended testis. Methods: A total of 68 children were randomized to receive either methadone (0.1 mg/kg) or isotonic saline following induction of anesthesia. Exclusion criteria included preterm birth, previous scrotal surgery, and parents' inability to consent. Primary outcomes were opioid requirements (first primary outcome) and pain intensity in the post‐anesthesia care unit. Secondary outcomes included episodes of desaturation and time until readiness to discharge from the post‐anesthesia care unit, sleep on the first postoperative night, pain intensity, and opioid requirements at home until the evening on the first postoperative day. Follow‐up was 4 days. Results: Sixty children completed the study (age, mean ± SD, 26.2 ± 13.9 months), 29 children received methadone, and 31 children received placebo. Eighteen children required opioids in the post‐anesthesia care unit, five children in the methadone group (proportion = 0.17, 95% confidence interval (CI): 0.07, 0.36) compared to thirteen patients in the placebo group (0.42, 95% CI: 0.26, 0.60) (mean difference = −0.24 and 95% CI: −0.03, −0.47) (p = 0.037). Five children in the methadone group (0.17, 95% CI: 0.03, 0.31) versus ten in the placebo group (0.32, 95% CI: 0.16, 0.49) had a face, legs, activity, cry, consolability score of ≥5 in the post‐anesthesia care unit (mean difference = −0.15, 95% CI: −0.36, 0.06) (p =.179). More children in the placebo group woke up due to pain the first night following surgery (seven children vs. one child). The methadone group had a longer stay in the post‐anesthesia care unit. There were no differences between the two groups regarding the other secondary outcomes. Conclusion: A single dose of intraoperative methadone reduces short‐term postoperative opioid requirements in children after orchiopexy for nondescended testes but prolongs the duration of their stay in the post‐anesthesia care unit. [ABSTRACT FROM AUTHOR]

Background: Dexmedetomidine, an α2‐adrenergic agonist, reduces propofol and remifentanil requirements when used as an adjunct to total intravenous anesthesia in adults, but studies in a pediatric population are sparse. This study investigates the magnitude of dose‐sparing effects of a postinduction dexmedetomidine bolus on propofol and remifentanil requirements during pediatric surgery. Methods: In this randomized, double‐blind, controlled trial, children aged 2–10 years undergoing elective dental surgery were assigned to one of four groups: placebo, 0.25 mcg/kg dexmedetomidine, 0.5 mcg/kg dexmedetomidine, and 1 mcg/kg dexmedetomidine. Maintenance with fixed‐ratio propofol and remifentanil total intravenous anesthesia followed a bispectral index (BIS)‐guided algorithm designed to maintain a stable depth of anesthesia. The primary outcomes were time‐averaged maintenance infusion rates of propofol and remifentanil. Secondary outcomes in the postanesthetic care unit included sedation scores, pain scores, and time to discharge. Results: Data from 67 patients were available for analysis. The median [interquartile range] propofol infusion rate was lower in the 1 mcg/kg dexmedetomidine group (180 [164–185] mcg/kg/min) versus placebo (200 [178–220] mcg/kg/min): percent change −10.0%; 95% CI −2.4 to −19.8; p = 0.013. The remifentanil infusion rate was also lower in the 1 mcg/kg dexmedetomidine group (0.089 [0.080, 0.095] mcg/kg/min) versus placebo (0.103 [0.095, 0.106] mcg/kg/min): percent change, −13.7%; 95% CI −5.47 to −21.0; p =.022. However, neither propofol nor remifentanil infusion rates were significantly different in the 0.25 or 0.5 mcg/kg dexmedetomidine groups. In the postanesthesia care unit, there were no differences in pain or sedation scores, and time to discharge was not significantly prolonged in any dexmedetomidine group. Conclusion: Dexmedetomidine 1 mcg/kg reduced the propofol and remifentanil requirements during maintenance of anesthesia in children when administered as a postinduction bolus. Trials Registration: ClinicalTrials.gov: NCT03422978, date of registration 2018‐02‐06. [ABSTRACT FROM AUTHOR]

Introduction: Postoperative agitation is a common complication of sevoflurane anesthesia in children and might lead to self-harm and recovery disruption. This study aimed to compare the prophylactic effect of dexmedetomidine and remifentanil on postoperative agitation after anesthesia with sevoflurane. Methods: In this clinical trial, 60 children aged 2 to 7 years with ASA class І, II, candidates for elective strabismus surgery, were randomly assigned to three groups using block randomization. Patients in the first group D received 0.5 µgr/kg dexmedetomidine, the second group R received 0.1 µgr/kg remifentanil, and another group C received normal saline at the end of anesthesia. Children's agitation degree was measured by the Pediatric Anesthesia Emergence Delirium (PAED) scales and the 4-point agitation scale at the time of extubation, entering the recovery room, 10, 20, and 30 minutes after entrance. Data analysis was performed using descriptive and inferential statistical tests. Results: The postoperative agitation and pain were significantly lower among children who received dexmedetomidine compared with those in remifentanil and the control group (p <.001). It was observed that the administration of dexmedetomidine at the end of anesthesia significantly decreased the incidence of postoperative agitation (p <.001). None of the patients in group D had a PAED score of over 12. Conclusion: Based on PAED and the 4-point scales, none of the cases in group D had experienced postoperative agitation; this made a significant statistical difference compared with groups C and R (p-value <. 001). Although both dexmedetomidine and remifentanil can prevent and attenuate postoperative agitation, dexmedetomidine administration seems significantly more effective. [ABSTRACT FROM AUTHOR]

ABSTRACT Enhanced recovery after surgery (ERAS) pathways have been shown to improve patient outcomes, increase patient satisfaction, and decrease costs. First created and implemented in the adult population, these pathways are now commonplace and continue to expand in the pediatric realm. While there are many proven benefits to ERAS pathways, there continue to be challenges to their proper implementation and long‐term success. This article aims to explore common challenges in pediatric ERAS development and implementation, along with strategies to avoid potential pitfalls. Key themes include departmental and institutional support, stakeholder engagement, awareness of pathways, data management and dissemination, and long‐term maintenance including Plan‐Do‐Study‐Act (PDSA) cycles. Pathway development teams should be aware of these considerations and potential pitfalls, and focusing on them can promote long‐term success for a well‐designed pathway. [ABSTRACT FROM AUTHOR]

Pediatric regional anesthesia is evolving with new peripheral nerve blocks and techniques aimed at improving perioperative pain management. While caudal blocks have long been standard due to their simplicity and low complication rates, newer fascial plane blocks offer comparable efficacy with enhanced nerve coverage tailored to specific surgeries. Moreover, adjuncts like dexmedetomidine and dexamethasone have shown promise in prolonging block duration and enhancing post-operative pain relief and patient satisfaction. The integration of these advancements into clinical practice has yielded significant benefits, including reduced intraoperative fluid requirements, decreased reliance on opioids postoperatively, earlier initiation of enteral nutrition, lower readmission rates, shorter hospital stays, and decreased overall hospital costs. Our review underscores the technical progress and expanding literature supporting the rapid adoption of these impactful regional anesthesia techniques in pediatric care. [ABSTRACT FROM AUTHOR]

Background: The drug volume to be used in caudal in pediatric patients has remained an unmet issue since long. We determined the minimum drug volume required to reach T10 level in pediatric patients using ultrasonography and compared it with the already established volume by Armitage formula. Aim: To determine the minimum effective caudal local anesthetic dose using ultrasound guidance. Methods: Study was performed at two centres and at each centre, 50 pediatric patients (Total 100 patients), aged 1 to 3 years, undergoing below umbilical surgeries were included and randomised into two groups of 25 each (Total 50) to receive ultrasound guided drug volume vs. Armitage formula based volume. The volume required to reach T10 level was assessed with ultrasound in one group. Also, maximum height achieved, cutaneous level achieved after 15 min, FLACC scores 30 min post extubation and parental satisfaction scores were noted. Results: The mean drug volume required to reach T10 level in Group U was 0.755 ± 0.053 ml/kg with a P value < 0.001. (Compared to the drug volume of 1 ml/kg using one sample t test). The highest level achieved in both groups were calculated as the mode value of T8 and T7 in Group U and Group A respectively. The highest cutaneous level achieved after 15 min was also calculated as the mode value of T4 in both groups. FLACC scores at 30 min were also comparable. Satisfaction scores were comparable in both groups. Conclusion: A volume of 0.7 ml/kg of local anaesthetic in pediatric caudal block is sufficient to achieve a target of T10 level for infraumblical surgeries. [ABSTRACT FROM AUTHOR]

Intraoperative hypotension is a common perioperative complication in pediatric anesthesia. Oscillometric blood pressure measurement is therefore an essential part of standard perioperative monitoring in pediatric anesthesia. The optimum measurement site is the upper arm. Attention must be paid to the correct cuff size. Blood pressure should be measured before induction. In children undergoing major surgery or in critically ill children, invasive blood pressure measurement is still the gold standard. Continuous noninvasive measurement methods could be an alternative in the future. Threshold values to define hypotension remain unknown, even in awake children. There are also little data on hypotension thresholds in the perioperative setting. The most reliable measurement parameter for estimating hypotension is the mean arterial pressure. The threshold values for intraoperative hypotension are 40 mm Hg in newborns, 45 mm Hg in infants, 50 mm Hg in young children and 65 mm Hg in adolescents. Treatment should be initiated at a deviation of 10% and intensified at a deviation of 20%. Bolus administration of isotonic balanced crystalloid solutions, vasopressors and/or catecholamines are used as treatment options. Consistent and rapid intervention in the event of hypotension appears to be crucial. So far there is no evidence as to whether this leads to an improvement in outcome parameters. [ABSTRACT FROM AUTHOR]

Introduction: This quality improvement initiative is a continued pursuit to optimize outcomes by iteratively improving our opioid sparing anesthesia protocol for tonsillectomy with or without adenoidectomy at our pediatric ambulatory surgical center through data driven Plan‐Do‐Study‐Act cycles. Methods: From 1/2015 through 12/2023, our standardized tonsillectomy protocol underwent nine procedure‐specific perioperative Plan‐Do‐Study‐Act cycles, three procedure‐specific postoperative prescription Plan‐Do‐Study‐Act cycles, and four general ambulatory surgical center enhanced recovery Plan‐Do‐Study‐Act cycles. We analyzed data from the medical record using statistical process control charts. The primary outcome measure was the percent of patients requiring intravenous opioid in the post anesthesia care unit. Secondary outcomes included maximum post anesthesia care unit pain score, the percent of patients requiring treatment for nausea and/or vomiting in the post anesthesia care unit, and the number of postoperative opioid prescription dosages. Balancing measures were average post anesthesia care unit length of stay, percent of patients with prolonged Post Anesthesia Care Unit length of stay (>120 min), and 30‐day reoperation rate. Results: A total of 5654 tonsillectomy with or without adenoidectomy cases were performed at our ambulatory surgical center from 2015 to 2023. The incidence of intravenous opioid administered in the post anesthesia care unit initially rose with opioid free anesthesia launch, but subsequently decreased below the target of 10%. Maximum post anesthesia care unit pain scores rose from mean 3.6 to 4.5, but subsequently returned to the baseline of 3.5, while the incidence of postoperative nausea and/or vomiting improved. The average post anesthesia care unit length of stay increased by 10 min with opioid free anesthesia; however, prolonged post anesthesia care unit stay and 30‐day reoperation rates were unchanged. Conclusions: The continued refinement of our opioid sparing anesthesia protocol has led to reduced perioperative and home opioid use, stable maximum post anesthesia care unit pain scores, and improved postoperative nausea and vomiting rates, with only a slight increase in mean post anesthesia care unit length of stay. [ABSTRACT FROM AUTHOR]

Patients with congenital heart disease are living longer due to improved medical and surgical care. Congenital heart disease encompasses a wide spectrum of defects with varying pathophysiology and unique anesthetic challenges. These patients often present for noncardiac surgery before or after surgical repair and are at increased risk for perioperative morbidity and mortality. Although there is no singular safe anesthetic technique, identifying potential error traps and tailoring perioperative management may help reduce morbidity and mortality. In this article, we discuss five error traps based on the collective experience of the authors. These error traps can occur when providing perioperative care to patients with congenital heart disease for noncardiac surgery and we present potential solutions to help avoid adverse outcomes. [ABSTRACT FROM AUTHOR]

Tiffany K Guan,1 Brittany L Willer,2,3 Jack Stevens,4,5 Joseph D Tobias,2,3 Vanessa A Olbrecht2,3 1College of Medicine, The Ohio State University, Columbus, OH, USA; 2Department of Anesthesiology & Pain Medicine, Nationwide Children’s Hospital, Columbus, OH, USA; 3Department of Anesthesiology & Pain Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA; 4Department of Pediatrics, Nationwide Children’s Hospital and The Ohio State University, Columbus, OH, USA; 5Center for Clinical Excellence, Nationwide Children’s Hospital, Columbus, OH, USACorrespondence: Brittany L Willer, Nationwide Children’s Hospital, 700 Children’s Drive, Columbus, Ohio, 43205, USA, Email Brittany.Willer@nationwidechildrens.orgIntroduction: Identification and reporting of severe adverse events (SAEs) during anesthesia care remains critical in identifying areas of improvement in perioperative patient care. Although many healthcare organizations rely on the self-reporting of SAEs, under-reporting may limit the identification of the true incidence of these events. To circumvent these barriers, many healthcare systems leverage the Electronic Medical Record (EMR) by incorporating an Anesthesia Information Management System (AIMS).Methods: We followed the Institute for Healthcare Improvement’s Model of Improvement and implemented behavioral economic-based interventions to our perioperative practice including adding a deliberation-promoting “hard stop” that required the anesthesiologists to report the occurrence or absence of a “notable event” prior to closing a patient’s encounter in the EMR system.Results: At baseline, 53% of SAEs were self-reported. The interventions resulted in a baseline shift to more than 75% self-reporting, a relative increase of 42%.Conclusion: An increase in reporting of SAEs was achieved with simple interventions including modifications of the EMR which were done with limited financial impact or interruption in the work flow.Keywords: adverse events, pediatric anesthesia, intraoperative care, quality and safety

Background: Emergence delirium is a well‐known and common problem in children recovering from anesthesia. The five‐item Pediatric Anesthesia Emergence Delirium scale is one of the most commonly used instruments for assessing this condition, but the scale has been questioned regarding its latent structure, i.e., whether its items cover just one underlying construct. It has been suggested that the scale's first three items might identify emergence delirium better than the last two. Aim: The aim of this study was to evaluate the measurement properties of the Pediatric Anesthesia Emergence Delirium scale with a focus on its latent structure and cutoff scores, using appropriate statistical methods for ordinal data. Methods: A total of 350 children under 7 years of age, undergoing adenoidectomy, with or without additional tonsillotomy or minor procedures like paracentesis, tongue‐tie release, or cerumen removal, were enrolled in the study. At the recovery unit, emergence delirium and pain were registered. Results: The confirmatory factor analyses demonstrated that the two‐factor model, including emergence delirium‐specific behaviors (first three items) and emergence delirium‐nonspecific behaviors (last two items), established an excellent model fit according to the χ2 goodness‐of‐fit statistics, Root Mean Square Error of Approximation, Comparative Fit Index, Tucker‐Lewis Index, and Standardized Root Mean Square Residual. The ordinal alpha of 0.98 and the ordinal omega of 0.96 supported the internal consistency reliability of the emergence delirium‐specific behaviors. The convergent validity was supported due to a strong correlation between emergence delirium‐nonspecific behaviors and the Face, Legs, Activity, Cry, and Consolability scale. The receiver‐operating characteristic curve analyses resulted in two tentative cutoff scores for emergence delirium‐specific behaviors¸ ≥ 6 and ≥ 8. Conclusion: The Pediatric Anesthesia Emergence Delirium scale's first three items are a more valid and reliable measure of emergence delirium than its original five items. [ABSTRACT FROM AUTHOR]

Background: Comprehensive data on pediatric anesthesia outcomes, particularly severe critical events (SCEs), are scarce in Asia. This highlights the need for standardized research to assess anesthesia safety and quality in the diverse settings. Aims: The PEACH in Asia pilot study aimed to test the feasibility of a standardized protocol for investigating SCEs in anesthesia practices across Asia, evaluate the data acquisition processes, and determine the sample size for a main study. Methods: This multicenter pilot study involved ten institutions across nine Asian countries, including children from birth to 15 years undergoing diagnostic or surgical procedures. Data on SCEs were collected using standardized definitions. The study assessed the feasibility and estimated the sample size needed for the main study. Results: The pilot study enrolled 330 patients, with a SCE incidence of 12.4% (95% CI: 9.2–16.4%). Respiratory events were observed in 7.0% of cases, cardiovascular instability in 4.9%, and drug errors in 0.6%. Based on the SCE incidence observed in the pilot study, the estimated sample size required for the main study is at least 10 958 patients. The pilot study demonstrated the feasibility of the study protocol but identified several challenges, particularly in resource‐limited settings. These challenges included a significant burden associated with data collection, technical issues with electronic case report forms (e‐CRFs), variability in patient enrollment across institutions (ranging from 4 to 86 patients per site), and incomplete data acquisition (24.8% of height data and 9.7% of disposition data were missing). Conclusions: The PEACH in Asia pilot study successfully validated a protocol for investigating SCEs in pediatric anesthesia across Asia. Addressing the challenges identified in the pilot study will be crucial for generating robust data to improve pediatric anesthesia safety in the region. Key issues to address include improving data collection methods, resolving e‐CRF technical difficulties, and ensuring consistent institutional support. [ABSTRACT FROM AUTHOR]

Abstract Introduction Atelectasis is a well-documented complication in pediatric patients undergoing general anesthesia. Its incidence varies significantly based on surgical procedures and anesthesia techniques. Inhalation induction, commonly used to avoid the discomfort of venipuncture, is suspected to cause higher rates of respiratory complications, including atelectasis, compared to intravenous induction. This study aimed to evaluate the impact of inhalation versus intravenous anesthesia induction on atelectasis formation in pediatric patients, as assessed by lung ultrasound (LUS). Methods This propensity score-matched observational study was conducted at a tertiary pediatric hospital in Milan, Italy. Inclusion criteria were children ≤ 18 years undergoing elective surgery with general anesthesia. Patients were divided into inhalation and intravenous induction groups. LUS was performed before and after anesthesia induction to assess lung aeration. The primary endpoint was the global LUS score post-induction, with secondary endpoints including the incidence and distribution of atelectasis. Results Of the 326 patients included, 65% underwent inhalation induction and 35% intravenous induction. The global LUS score was significantly higher in the inhalation group (12.0 vs. 4.0, p

Sicong Wang, Yan Li, Fang Chen, Hua-Cheng Liu, Lezhou Pan, Wangning Shangguan Department of Anesthesiology and Perioperative Medicine, The Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University, Key Laboratory of Pediatric Anesthesiology of Ministry of Education, Wenzhou, Zhejiang Province, People’s Republic of ChinaCorrespondence: Wangning Shangguan, Email sgwning@163.comPurpose: This study aimed to estimate the effect of different doses of fentanyl on the median effective dose (ED50) of ciprofol for attenuating the airway and motor response to laryngeal mask airway (LMA) insertion response in healthy children.Patients and Methods: 90 healthy preschool patients undergoing inguinal hernia repair surgery were randomly assigned to one of three groups: C0 (ciprofol+saline), C1 (ciprofol + fentanyl 1μg/kg), C2 (ciprofol + fentanyl 2μg/kg). Anesthesia was induced with either prepared fentanyl or saline, followed by ciprofol. The dose of ciprofol for each patient was determined using the up-and-down sequential study design. The primary outcome was the ED50 of ciprofol required for smooth LMA insertion in the three groups. Additionally, the time to loss of consciousness and any perioperative adverse events were recorded.Results: Compared with the C0 group, the ED50 (95% confidence interval) of ciprofol in the C1 and C2 groups were significantly lower (1.81 [1.73– 1.90]mg/kg versus 0.67 [0.64– 0.71]mg/kg and 0.48 [0.42– 0.54] mg/kg, respectively; P< 0.05). Additionally, the ED50 of ciprofol in the C2 group was lower than that in the C1 group (0.42 [0.42– 0.54] mg/kg vs 0.67 [0.64– 0.71]mg/kg; P< 0.05). Furthermore, the time to loss of consciousness in the C1 and C2 groups decreased by 60% and 53%, respectively, compared to the C0 group. There were no significant differences in the incidence of drug-related hypotension after anesthesia induction among the three groups. No adverse events of hypoxia, bradycardia, or injection pain were observed in any groups.Conclusion: In healthy, non-obese Chinese children undergoing elective inguinal hernia repair surgery, fentanyl 1 μg/kg and 2 μg/kg before ciprofol injection significantly reduced the ED50 of ciprofol for attenuating LMA response, with minimal occurrence of severe side effects.Keywords: ciprofol, laryngeal mask airway, pediatric anesthesia, 50% effective dose

Yanling Liao,1,&ast; Siyu Xie,2,&ast; Yifen Zhuo,3,&ast; Sisi Chen,1 Yuxin Luo,1 Ying Wei,4 Yusheng Yao1 1Department of Anesthesiology, Shengli Clinical Medical College of Fujian Medical University, Fujian Provincial Hospital, Fuzhou, People’s Republic of China; 2Department of Anesthesiology, Longyan First Affiliated Hospital of Fujian Medical University, Longyan, People’s Republic of China; 3Department of Anesthesiology, Xiamen Haicang Hospital, Xiamen, People’s Republic of China; 4Department of Anesthesiology, Fujian Maternity and Child Health Hospital, College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, People’s Republic of China&ast;These authors contributed equally to this workCorrespondence: Ying Wei, Department of Anesthesiology, Fujian Maternity and Child Health Hospital, College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, 18 Daoshan Road, Fuzhou, 350025, People’s Republic of China, Email whm444@fjmu.edu.cn Yusheng Yao, Department of Anesthesiology, Shengli Clinical Medical College of Fujian Medical University, Fujian Provincial Hospital, 134 Dongjie Street, Fuzhou, 350001, People’s Republic of China, Email fjslyys@126.comPurpose: Emergence delirium and postoperative negative behavioral changes (PNBC) are common complications in pediatric anesthesia. This study evaluated whether intranasal premedication combining dexmedetomidine and esketamine more effectively reduces these complications compared to either drug alone in children undergoing tonsillectomy and/or adenoidectomy with sevoflurane anesthesia.Patients and Methods: This randomized, double-blind trial involved 198 children aged 2− 5 years undergoing tonsillectomy and/or adenoidectomy. Participants received intranasal premedication with either dexmedetomidine (2 μg/kg), esketamine (1 mg/kg), or their combination (dexmedetomidine 1 μg/kg plus esketamine 0.5 mg/kg). The primary outcome was the incidence of emergence delirium, defined as a Pediatric Anesthesia Emergence Delirium (PAED) scale score ≥ 10. Secondary outcomes included the incidence of PNBC, sedation depth, easiness of separation from parents, acceptance of the mask for induction, emergence time, postoperative pain score, parental satisfaction, and adverse events.Results: The combination premedication significantly reduced emergence delirium incidence (9.4%) compared to esketamine alone (38.1%; relative risk [RR] 0.25, 95% confidence interval [CI] 0.11– 0.57, p < 0.001), but not compared to dexmedetomidine alone (17.2%; RR 0.55, 95% CI 0.21– 1.39, p = 0.193). PNBC incidence at day 7 was lower with the combination (28.1%) versus dexmedetomidine (48.4%; RR 0.58, 95% CI 0.36– 0.93, p = 0.018), but not significantly different from esketamine alone (20.6%; RR 1.38, 95% CI 0.74– 2.58, p = 0.326). The combination also provided significantly superior sedation, improved ease of separation from parents, better acceptance of the mask for induction, shorter emergence time, and higher parental satisfaction than both monotherapies.Conclusion: In children undergoing tonsillectomy and/or adenoidectomy with sevoflurane anesthesia, intranasal dexmedetomidine-esketamine premedication more effectively reduces emergence delirium compared to esketamine alone and PNBC compared to dexmedetomidine alone. This combination also improves sedation, shortens emergence times, and enhances parental satisfaction compared to monotherapy without significant adverse effects.Trial Registration: The Chinese Clinical Trial Registry, ChiCTR2300076709. Keywords: adenoidectomy, dexmedetomidine, emergence delirium, esketamine, intranasal administration, pediatric anesthesia, postoperative complications, tonsillectomy

Extracorporeal membrane oxygenation (ECMO) is a technology used with increasing frequency to support pa- tients in cardiac or respiratory failure refractory to con- ventional therapies. As technologies have improved, the clinical indications for and applications of ECMO have been increased including its use in the peri-operative set- ting. Use of single access, double lumen cannulas have been instrumental in optimizing venous-venous (VV ECMO) for use in the perioperative setting, particularly in the pediatric population. We report the use of VV- ECMO with a dual lumen Avalon® catheter during air- way surgery in two pediatric patients. The potential applications of ECMO in the operating room are re- viewed, options for anesthetic care discussed, and peri- operative concerns reviewed.

Emergence delirium remains a clinically significant issue, often leading to short-term distress among pediatric patients, parents, and staff, and potentially resulting in postoperative maladaptive behaviors persisting for weeks to months. Although several diagnostic tools are available, the Pediatric Anesthesia Emergence Delirium Scale is most often utilized. Many risk factors contributing to the likelihood of a pediatric patient developing emergence delirium have been identified; however, its accurate prediction remains challenging. Recently, intraoperative electroencephalographic monitoring has been used to improve the prediction of emergence delirium. Similarly, it may also prevent emergence delirium if the anesthesiologist ensures that the at-risk patient rouses only after the onset of appropriate electroencephalogram patterns, thus indicating a change to natural sleep. Prediction of at-risk patients is crucial; preventing emergence delirium may begin early during patient preparation by using non-pharmacological methods (i.e., the ADVANCE program). Intraoperative electroencephalographic monitoring can predict emergence delirium. This review also discusses a range of pharmacological treatment options which may assist the anesthesiologist in preventing emergence delirium among at-risk patients. [ABSTRACT FROM AUTHOR]

In pediatric anesthesia, respiratory adverse events often occur during emergence from anesthesia and at the time of endotracheal tube or supraglottic device removal. The removal of airway devices and extubation are conducted either while patients are deeply anesthetized or when patients awaken from anesthesia and have regained consciousness. The airways of children are easily irritated by external stimuli and are structurally prone to collapse, and the timing of both methods of airway device removal is similarly associated with various airway complications, including upper airway obstruction, coughing, or serious adverse events such as laryngospasm and desaturation. In current practice in pediatric anesthesia, the choice of the timing and method of extubation is made by anesthesiologists. To achieve a smooth and safe recovery from anesthesia, understanding the unique characteristics of pediatric airways and the factors likely to contribute to an increased risk of perioperative complications remains essential. These factors include patient age, comorbidities, and physical conditions. The level of anesthesia and readiness for removal of airway devices should be evaluated carefully for each patient, and quick identification of airway problems and intervention is required if patients fail to maintain the airway and sufficient ventilation after removal of airway devices. [ABSTRACT FROM AUTHOR]

Pediatric regional anesthesia (RA) has emerged as a rapidly advancing dimension within pediatric anesthesia, demanding a continual commitment to knowledge acquisition. This review underscores the contemporary significance of this specialty, focusing on its application in neonates and infants. The primary objective of RA is to address perioperative pain effectively while preserving the delicate physiological balance, thereby enhancing overall patient care. This review explores the advantages offered by RA in this age group. Furthermore, conventional, and recently introduced techniques of RA are examined by exploring the advantages and disadvantages of these methods. The aim is to provide clinicians with a nuanced understanding of their applicability in different clinical scenarios. Additionally, the review elucidates the unique considerations associated with pediatric RA, acknowledging pediatric patients’ distinctive anatomical and physiological characteristics. The exceptional cases of congenital anomalies and their implications for the choice of RA are considered. An aspect of the review is its focus on dosages of local anesthetics and the volumes required for various blocks in neonates and infants. The dosages for continuous infusion and practical issues with infusions are considered. Complications associated with RA are described, along with their prevention and treatment. The review offers pragmatic insights into the selection criteria for various regional blocks, aiding anesthesiologists in making informed decisions tailored to individual patient needs. [ABSTRACT FROM AUTHOR]

Neuromuscular blocking agents (NMBAs), a cornerstone of pediatric anesthesia, facilitate intubation and muscle relaxation during surgery. However, NMBAs can also lead to serious complications including respiratory depression, residual paralysis, and prolonged recovery. Neuromuscular monitoring (NMM) in pediatric patients is therefore essential, as it is in adults, to ensure adequate paralysis during surgery and prompt recovery from NMBA-induced paralysis. This article aimed to provide a comprehensive overview of NMM in pediatric anesthesia including the various available methods, their advantages and disadvantages, and the importance of a standardized NMM approach. [ABSTRACT FROM AUTHOR]

Early extubation after pediatric cardiac surgery has come full circle from being practiced in the early days of pediatric cardiac surgery, falling out of favor with opioid-heavy cardiostable anesthesia, and resurfacing again in more recent times as part of enhanced recovery after surgery practice. Early extubation is variably defined, but is mostly accepted as extubation that occurs within 6–8 h from the end of surgery. In recent years, the debate has shifted from early extubation in the intensive care unit to immediate extubation in the operating theatre. In this review, we examined the benefits and pitfalls of early and immediate extubation, factors that influence the success of early extubation, and potential guidelines for practice and implementation. [ABSTRACT FROM AUTHOR]

Introduction: Atelectasis is a well-documented complication in pediatric patients undergoing general anesthesia. Its incidence varies significantly based on surgical procedures and anesthesia techniques. Inhalation induction, commonly used to avoid the discomfort of venipuncture, is suspected to cause higher rates of respiratory complications, including atelectasis, compared to intravenous induction. This study aimed to evaluate the impact of inhalation versus intravenous anesthesia induction on atelectasis formation in pediatric patients, as assessed by lung ultrasound (LUS). Methods: This propensity score-matched observational study was conducted at a tertiary pediatric hospital in Milan, Italy. Inclusion criteria were children ≤ 18 years undergoing elective surgery with general anesthesia. Patients were divided into inhalation and intravenous induction groups. LUS was performed before and after anesthesia induction to assess lung aeration. The primary endpoint was the global LUS score post-induction, with secondary endpoints including the incidence and distribution of atelectasis. Results: Of the 326 patients included, 65% underwent inhalation induction and 35% intravenous induction. The global LUS score was significantly higher in the inhalation group (12.0 vs. 4.0, p < 0.001). After propensity score matching (for age, presence of upper respiratory tract infection, duration of induction, and PEEP levels at induction), average treatment effect (ATE) of mask induction was 5.89 (95% CI, 3.21–8.58; p < 0.001) point on LUS global score and a coefficient of 0.35 (OR 1.41) for atelectasis. Discussion: Inhalation induction is associated with a higher incidence of atelectasis in pediatric patients also when we adjusted for clinically relevant covariates. Trial registration: ClinicalTrials.gov identifier: NCT06069414. [ABSTRACT FROM AUTHOR]

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Despite the well-known benefits of spinal anesthesia (SA), this technique remains underutilized among pediatric anesthesiologists. According to the data from the Pediatric Regional Anesthesia Network, SA accounted for less than 5% of all neuraxial techniques. Some of the factors for underutilization of SA include: Limited duration, unfamiliarity with the technique in younger children, and surgeon preference for general anesthesia. The safe and successful use of SA in children involves recognition of anatomical and physiological differences between adults and children owing to differences in bony structures, spinal cord growth and cerebrospinal fluid physiology. Reports on successful use of SA in children for various surgeries have increased. This educational review summarizes what is known about SA in children, reviews the literature from the last decade and provides suggestions for development of SA in children. Technical considerations, role of ultrasound, guidance on dosing, physiological effects, unexplained aspects of the mechanism of action and combined caudal/SA are discussed. [ABSTRACT FROM AUTHOR]

Introduction: Although the subclavian vein offers significant advantages over other approaches for ultrasound-guided central venous access, it is not the first choice in the pediatric population, mainly due to its proximity to the pleura and the subclavian artery. Objective: To assess the sonoanatomical characteristics of the subclavian vein and adjacent structures using the supraclavicular approach in a pediatric population. Materials and methods: Observational, intraoperative, cross-sectional study, between June 2021 and March 2022. The population consisted of ASA I, II and III children taken to non-emergent surgical procedures under general anesthesia. Images were acquired with the patients under general anesthesia, using a high-frequency linear probe to identify the subclavian vein and measure the anatomical landmarks. Results: A total of 67 children were recruited; mean age was 6 years (IQR: 2-12 years), with male sex predominance (61%). Median weight was 22 kg (IQR: 12.2-34 Kg) and median height was 115 cm (IQR: 88-142 cm). Measurements in relation to the vessel showed a mean distance from the skin of 0.70 cm (SD: 0.18 cm), while mean distance from the skin to the pleura was 1.31 cm (SD: 0.28 cm). Mean vein diameter was 0.49 cm (IQR: 0.40-0.63 cm). The mean hypothetical approach angle to the vessel was 22.09 degrees (SD: 4.37 degrees), while the approach angle to the pleura was 39 degrees (SD: 5.31 degrees). No concurrent visualization of the vein and artery was documented in any of the recorded sonoanatomy windows. The tests pointed to an average difference of 0.61 cm in vessel depth in relation to the pleura, and the angle of approach to the vessel was 16.91 degrees smaller when compared with the angle of approach to the pleura (p < 0.001). Conclusions: Using this technique, the supraclavicular approach to the subclavian vein in children is safe and feasible, with an average skin-to-vessel distance of 0.70 cm, minimizing the risk of pleural puncture. Additional studies are required to optimize this technique in the pediatric population. [ABSTRACT FROM AUTHOR]

Introduction: Non-pharmacological distraction using video games (VG) is still under-explored in pediatric surgical patients. Materials and Methods: We conducted this randomized controlled study of 150 children, aged 4–12 years, scheduled for elective surgery in a tertiary care hospital to estimate the distractive effect of VG on immediate preoperative anxiety in children. In the intervention group (I), playing with VG was encouraged till anesthetic induction. The control group (C) received usual care with verbal reassurance. Modified Yale preoperative anxiety scale (mYPAS) score and presence of anxiety (mYPAS >30) were noted in the preoperative area (T1), at parental separation (T2), and anesthetic induction (T3). Parental separation anxiety score (PSAS) >3 was considered unacceptable parental separation. We used the Mann-Whitney test and t-test to find significance of intergroup mean difference of anxiety and logistic regression to find risk factors for immediate preoperative anxiety. Results: The mean m-YPAS (±SD) scores at T1 and T2 were 38 (±10.9) and 52.2 (±18.7) in group C and 46.5 (±13.5) and 33 (IQR: 28.3–65.5) in group I, respectively. The incidence of anxiety at T2 was higher in group C (81.3%) than in group I (59%). More children in group I (53/75) had acceptable separation than in group C (32/75) (P = 0.001). VG led to a 2.32 times lower risk of anxiety at T2 (P = 0.036). In children with acceptable separation, the incidence of anxiety was lower in group I (59%) than in group C (87%). Conclusion: VG-based distraction effectively reduced preoperative anxiety in children undergoing elective surgeries. [ABSTRACT FROM AUTHOR]

Introduction: Nonoperating room anesthesia is a growing field of medicine that can have an increased risk of complications, particularly in low‐ and middle‐income countries. Aims: The aim of this study was to describe the incidence of complications after pediatric nonoperating room anesthesia and investigate its risk factors. Methods: In this prospective observational study, we included all children aged less than 5 years who were sedated or anesthetized in the radiology setting of a university hospital in a low‐ and middle‐income country. Patients were divided into two groups: complications or no‐complications groups. Then, we compared both groups, and univariable and multivariable logistic regression models were used to investigate the main risk factors for complications. Results: We included 256 children, and the incidence of complications was 8.6%. The main predictors of nonoperating room anesthesia‐related morbidity were: critically‐ill children (aOR = 2.490; 95% CI: 1.55–11.21), predicted difficult airway (aOR = 5.704; 95% CI: 1.017–31.98), and organization insufficiencies (aOR = 52.6; 95% CI:4.55–613). The preanesthetic consultation few days before NORA protected against complications (aOR = 0.263; 95%CI: 0.080–0.867). Conclusions: The incidence of complications during NORA among children in our radiology setting remains high. Investigating predictors for morbidity allowed high‐risk patient selection, which allowed taking precautions. Several improvement measures were taken to address the organization's insufficiencies. [ABSTRACT FROM AUTHOR]

The treatment of pediatric patients with diabetes is frequently orchestrated within a multidisciplinary framework at tertiary, specialized institutions. In situations where emergent surgery is indicated or when a procedure is scheduled in a facility devoid of an endocrinology service, the onus of managing perioperative glycemic levels may rest with the attending anesthesiologist. The objective of this review is to furnish a comprehensive examination of the anesthetic considerations and perioperative governance of pediatric patients with diabetes. Furthermore, this paper delineates a streamlined protocol for perioperative glycemic control, tailored to both major and minor surgical interventions. [ABSTRACT FROM AUTHOR]