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Tracheal intubation is one of the most frequently performed medical procedures in neonatal intensive care units. Younger children, pre-term and full-term infants are at the highest risk of respiratory and traumatic complications when securing the airway. A difficult airway implies a clinical situation in which difficult airway management occurs by an experienced specialist. It is recommended to apply an adequate depth of sedation or general anesthesia with muscle relaxation in neonates and infants during the airway management in order to ensure the comfort and safety of the patients. The use of a videolaryngoscope with standard blades (Macintosh and Miller) is recommended for securing the airway, especially in neonates and infants. Use of passive oxygenation during tracheal intubation prolongs the safe duration of apnea, increases functional residual capacity and reduces the incidence of hypoxemia. The use of supraglottic airway device for rescue ventilation and oxygenation is advised if tracheal intubation has failed and ventilation with a face mask is inadequate. Limiting the number of tracheal intubation attempts is recommended. If two or fewer laryngoscopies are unsuccessful, operator should switch to indirect methods for intubation. After four attempts, intubators should stop and wake the child. It is advised to immediately check the position of the tube simultaneously with clinical signs and the appearance of sustainable carbon dioxide curve. Assessment of clinical indicators is necessary to predict successful awake extubation. A tidal volume greater than 5 ml/kg may indicate readiness for extubation.

Background: Caudal epidural anaesthesia is commonly used in pediatric patients undergoing lower abdominal surgery. The choice of local anesthetic plays a crucial role in determining the efficacy and safety of this technique. This study aimed to compare the effects of ropivacaine and bupivacaine for caudal epidural anaesthesia in children undergoing lower abdominal surgery. Methods: A prospective, randomized, double-blinded study was conducted on 100 children aged 1-10 years scheduled for lower abdominal surgery. The patients were randomly assigned to two groups: Group R (ropivacaine) and Group B (bupivacaine). Caudal epidural anaesthesia was administered using either 0.2% ropivacaine or 0.25% bupivacaine, based on the group assignment. The primary outcome measures included the onset and duration of sensory and motor block, hemodynamic stability, and adverse events. Secondary outcome measures included postoperative pain scores, rescue analgesia requirement, and overall satisfaction. Results: Both ropivacaine and bupivacaine groups exhibited comparable demographic characteristics. The onset of sensory and motor block was similar in both groups (p > 0.05). However, the duration of sensory and motor block was significantly longer in the ropivacaine group compared to the bupivacaine group (p < 0.001). Hemodynamic stability was similar between the two groups, and no significant adverse events were observed. Postoperative pain scores were significantly lower in the ropivacaine group compared to the bupivacaine group (p < 0.001). The ropivacaine group also required less rescue analgesia and showed higher overall satisfaction scores. Conclusions: Ropivacaine and bupivacaine are both effective and safe choices for caudal epidural anaesthesia in children undergoing lower abdominal surgery. However, ropivacaine demonstrated a longer duration of sensory and motor block, superior postoperative pain control, decreased rescue analgesia requirement, and higher overall satisfaction. Therefore, ropivacaine may be considered as a preferable option for caudal epidural anaesthesia in this patient population. Further research is warranted to explore the long-term effects and potential complications associated with ropivacaine use in pediatric patients. [ABSTRACT FROM AUTHOR]

Objective:This study aimed to evaluate respiratory parameters during percutaneous internal ring suturing (PIRS) for inguinal hernia repair in two different-aged pediatric patients in whom the airway is provided with a laryngeal mask or endotracheal tube for general anaesthesia.Methods:After local ethics committee and parental consent, 180 ASAI-II children were randomly allocated to 4 groups; according to their age (0-24 months / 25-144 months) and airway device laryngeal mask (LMA) / endotracheal tube (ETT) used for general anaesthesia (45 children each) for laparoscopic inguinal hernia repair. Standard anaesthesia induction was done with lidocaine, propofol, and fentanyl, and 0.6 mg kg-1 rocuronium was added to the ETT groups. Sevoflurane is used for maintenance. Hemodynamic parameters, peak airway pressure, end-tidal carbon dioxide (EtCO2), and peripheric oxygen saturation (SpO2) values were recorded after induction, before, and during pneumoperitoneum. The duration of anaesthesia, surgery, recovery time, and surgical satisfaction was recorded. Airway complications (cough, laryngospasm, bronchospasm, desaturation, and aspiration) were recorded.Results:Hundred and eighty patients (45 in each group) were analyzed. Duration of surgery and surgical satisfaction were similar in all groups. Duration of anaesthesia and recovery times were significantly shorter in the LMA groups. Peak airway pressure and EtCO2 levels were significantly lower in the LMA groups. Rare airway complications were observed without significance.Conclusion:In laparoscopic inguinal hernia repair with the PIRS technique, LMA offered comparable operating conditions and surgical satisfaction.

Fryns syndrome cases with variable characteristics require careful preoperative evaluation and have challenges for airway management. Craniofacial anomalies can complicate both ventilation and intubation. Extubation can also be problematic because of limited pulmonary reserves.

Objective: This study aimed to evaluate respiratory parameters during percutaneous internal ring suturing (PIRS) for inguinal hernia repair in two different-aged pediatric patients in whom the airway is provided with a laryngeal mask or endotracheal tube for general anaesthesia. Methods: After local ethics committee and parental consent, 180 ASAI-II children were randomly allocated to 4 groups; according to their age (0-24 months / 25-144 months) and airway device laryngeal mask (LMA) / endotracheal tube (ETT) used for general anaesthesia (45 children each) for laparoscopic inguinal hernia repair. Standard anaesthesia induction was done with lidocaine, propofol, and fentanyl, and 0.6 mg kg-1 rocuronium was added to the ETT groups. Sevoflurane is used for maintenance. Hemodynamic parameters, peak airway pressure, end-tidal carbon dioxide (EtCO2), and peripheric oxygen saturation (SpO2) values were recorded after induction, before, and during pneumoperitoneum. The duration of anaesthesia, surgery, recovery time, and surgical satisfaction was recorded. Airway complications (cough, laryngospasm, bronchospasm, desaturation, and aspiration) were recorded. Results: Hundred and eighty patients (45 in each group) were analyzed. Duration of surgery and surgical satisfaction were similar in all groups. Duration of anaesthesia and recovery times were significantly shorter in the LMA groups. Peak airway pressure and EtCO2 levels were significantly lower in the LMA groups. Rare airway complications were observed without significance. Conclusion: In laparoscopic inguinal hernia repair with the PIRS technique, LMA offered comparable operating conditions and surgical satisfaction. [ABSTRACT FROM AUTHOR]

Fryns syndrome cases with variable characteristics require careful preoperative evaluation and have challenges for airway management. Craniofacial anomalies can complicate both ventilation and intubation. Extubation can also be problematic because of limited pulmonary reserves. [ABSTRACT FROM AUTHOR]

Objective: Millions of children are exposed to anaesthetic drugs every day; however, the possible adverse effects of these agents on the central nervous system remain controversial. This study evaluated anaesthesiologists' and pediatric surgeons' knowledge and daily practices regarding anaesthesia-induced neurotoxicity. Methods: A survey consisting of 12 questions was sent to members of the Turkish Anaesthesiology and Reanimation Association and the Turkish Pediatric Surgery Association via the Google forms program. Results: A total of 202 anaesthesiologists and 51 pediatric surgeons participated in this survey. The results demonstrate that anaesthesiologists and surgeons are aware of the risk of anaesthesia-related neurotoxicity and are willing to take action. Approximately, half of the anaesthesiologists and pediatric surgeons expected to postpone operations lasting at least 3 hours for patients <3 years of age. Also, one-third of the anaesthesiologists would seek feasible and more reliable alternative anaesthetic strategies. Conclusions: More than two-thirds of the participants knew about the US Food and Drug Administration neurotoxicity warning; however, uncertainty about anaesthesia-related neurotoxicity is ongoing. Many questions remain unanswered. The results of large-scale prospective randomized studies to evaluate the effect of anaesthetics and surgery on the cognitive development of pediatric patients are needed. [ABSTRACT FROM AUTHOR]

• Newborns show only minimal perioperative dynamic in EEG frequency bands. • EEGs of infants are characterized by a dominating relative δ-power with a mean of around 80%. • Infants aged 6–12 months show an increase of faster frequency bands from baseline to induction of general anaesthesia. The electroencephalographic derived indices have been developed for adult patients, however these monitors have not been validated for infants. Frontal EEGs were recorded in 115 infants aged <1 year [0–3-months (N = 27), 4–6-months (N = 30), 7–9-months (N = 29) and 10–12-months (N = 29)] who received general anaesthesia with sevoflurane. Total power (µV2) and relative β-, α-, θ-, δ-power (%) were analyzed. Additionally, in 20 EEGs event marker were added (baseline, loss of consciousness, intraoperative situation, extubation) to assess perioperative EEG dynamics. Newborns show a mean relative δ-power at 80% in intraoperative EEG compared to infants (10–12 months) showing 47.5%. Relative β-power and α-power are low in newborns (mean 3.2% and 4.6%; respectively), with a marked increase in the older infants (4–6 months) (mean 10.9% and 14.4%; respectively). EEG dynamic in newborns from baseline (relative δ-power of 88%) to the intraoperative situation (80.5%) are discrete. In contrast infants >6-months have a strong reduction of relative δ-power from baseline to the intraoperative situation, which corresponds to an increase of faster frequencies. Age dependent perioperative EEG signatures can be demonstrated in infants younger than one year. We demonstrate significant differences in EEG readouts between newborns and infants which questions our monitoring systems in paediatric anaesthesia. [ABSTRACT FROM AUTHOR]

Temporomandibular joint (TMJ) ankylosis is a form of TMJ condition that causes mouth opening limitation, ranging from partial reduction to total immobilization of the jaw. Bony and fibrous ankylosis is most commonly caused by trauma, although it can also happen as a result of surgery, local or systemic infections, or systemic diseases. Childhood TMJ produces facial deformities, which increase with growth and have a major detrimental impact on the patient's psychological development. Each patient with TMJ ankylosis must have a history, physical examination, and radiographic examination in order to determine a definitive diagnosis, severity, involvement of surrounding tissues, and, ultimately, treatment planning. Technical challenges and a high recurrence rate make treating TMJ ankylosis challenging. Intubating a young child with TMJ ankylosis is a difficult job, which is exacerbated by limited mouth opening. This case report describes a five-year-old boy who reported an inability to open his mouth, diagnosed as TMJ ankylosis, and managed in the absence of an appropriately sized tracheostomy tube., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2024, Patel et al.)

Radiotherapy of the whole body is called total body irradiation (TBI). It is a well-established component of conditioning regimens before stem cell transplantation in juvenile leukemia. The patient was a three-year-old child with a diagnosis of B-cell acute lymphoblastic leukemia and planned for stem cell transplantation. He was given TBI under anesthesia for three consecutive days prior to the bone marrow transplantation under general anesthesia. The important concerns were related to neutropenia/immune suppression, parental consent for repeated anesthesia, nothing per oral guidelines for the TBI treatment, the possibility of high-grade fever, high chance of respiratory tract infections with repeated anesthesia exposure, etc. Proper preparation, teamwork, and collaborative efforts and the child's parents made this treatment possible with intended success., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2024, Butt et al.)

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Abstract Title Comparative study between intravenous dexmedetomidine and clonidine as premedication in pediatric patients undergoing spinal anesthesia. Background Many techniques and drug regimens, with partial or greater success, have been tried from time to time to eliminate the anxiety component and to prolong the postoperative analgesia during regional anesthesia. In pediatric patients, anxiety and lack of cooperativeness for the regional procedure is the major problem in providing spinal anaesthesia. Alpha2-adrenergic agonists have both analgesic and sedative properties, when used as an adjuvant to regional anesthesia. They eliminate the anxiety, provide conscious sedation, lower the level of agitation and improve patient satisfaction. We designed a prospective, randomized, double-blind study, to evaluate and compare the efficacy of intravenous dexmedetomidine with clonidine as a premedication drug during spinal anaesthesia using intrathecal bupivacaine. Materials and methods In this prospective, randomized, double-blind study, 60 pediatric patients 4–10 years of age of the American Society of Anesthesiologists status I, scheduled for uro-genital surgery under spinal anesthesia, were randomly allocated into two groups of 30 each. Group DE received dexmedetomidine 1 μg kg−1 and group CL received clonidine 1 μg kg−1 diluted in 20 ml of normal saline intravenously over 10 min, 40 min before subarachnoid anaesthesia with 0.5% hyperbaric bupivacaine. The patients were monitored every 5 min for 1st 20 min and then every 10 min interval vitals were noted. Acceptable sedation score, parental separation anxiety level and degree of mask acceptance were assessed. Highest level of sensory blockade, time of two segment regression and time of first request of analgesic were also noted. Data was analyzed using Fisher's exact test or Chi-square test and the value of P < 0.05 was considered statistically significant. Results Group DE and CL had comparable sedation score (p > 0.05). However, parental separation anxiety score and mask acceptance score, were better in DE than CL group (p < 0.05). There was no significant haemodynamic differences between the groups (p > 0.05). Duration of analgesia was also prolonged in DE group. Conclusion Dexmedetomidine is superior to clonidine as a premedication drug in pediatric patients undergoing spinal anesthesia. [ABSTRACT FROM AUTHOR]

Myasthenia gravis (MG) is a rare autoimmune disease characterized by muscle weakness and fatigability that can be generalized with respiratory muscle involvement. The anaesthetic management of these patients poses significant challenges not only because of the nature of the disease and its possible interactions with anaesthetic drugs but also because of the risk of developing a life-threatening myasthenic crisis. We report the case of a child with generalized refractory MG and pneumonia, worsening his chronic respiratory insufficiency, proposed for an urgent thoracocentesis and chest drain placement, that was successfully managed under sedation with ketamine and dexmedetomidine, allowing to avoid a general anaesthesia, preserve the patient's respiratory drive, and protect his airway. The present report highlights the potential applicability of this novel drug association in MG patients, regarding its safety and efficacy in maintaining respiratory drive and haemodynamic stability in these patients., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2023, Grenho et al.)

Introduction Many clinical indicators for tracheal intubation in children using sevoflurane without muscle relaxant have been used. None of the study showed 100% excellent intubating conditions. A single large study showing 80% excellent intubating conditions, noticed that persistence of spontaneous ventilation before intubation had very poor intubating conditions. So, our study aimed to achieve apnea based on induction time using sevoflurane before intubation and observe the intubating conditions and hemodynamic variations in one hundred and fifty ASA I and II patients aged between one year to six years posted for ophthalmic procedures under general anaesthesia. Methods Based on the results of pilot study, all patients were induced with sevoflurane in 100% oxygen with 7 L/min flow via facemask. Glycopyrrolate 0.06 mg/kg, fentanyl 1 mcg/kg was given intravenously. Induction was done in slow incremental manner upto 8 vol% for 4.5 min (0 vol% to 8 vol% over 2.5 to 3 minutes). Propofol 1 mg/kg was given intravenously at 4.5 min. Ventilation was controlled after achieving apnea on their own based on capnography and respiratory pattern by positive pressure mask ventilation. Laryngoscopy and tracheal intubation was performed at 5.5 minutes. Intubating conditions were assessed using Steyn's modification of Helbo-Hansen scoring system and hemodynamic parameters were measured at 0, 3, 4.5, 5.5 and 6.5 minutes after induction. Results 96 out of 150 patients achieved apnea at 4.5 min and all 150 patients achieved apnea after giving propofol 1 mg/kg. Intubating conditions were excellent in all the cases without any complications. There was decrease in HR at 5.5 min compared to 3 min. There was decrease in Systolic and Diastolic blood pressure at 3, 4.5 and 5.5 minute intervals when compared to baseline value at 0 min (at 5.5 minutes was 15.58% and 12.75% compared to baseline respectively. Conclusions Apnea was achieved and excellent intubating conditions were observed in all the patients without any complications during induction with sevoflurane of 8 vol% by 5.5 minutes beforelaryngoscopy and tracheal intubation. [ABSTRACT FROM AUTHOR]

Background Practitioners rely on the Pediatric Risk of Mortality (PRISM) Score as the standard for assessing neonatal illness severity. Clinicians also may use the Clinical Risk Index for Babies (CRIB) score, the American Society of Anesthesiology (ASA) patient classification system, length of hospitalization, patient weight, and the anecdotal Patient Chart-to-Patient Weight Ratio (PCPWR). This study aims to determine whether parent-provided possessions at the patient bedside might also accurately reflect neonatal illness severity. Methods The study is prospective observational trial conducted on tertiary surgical Neonatal Intensive Care Unit (NICU) servicing 250 000 km² in Australia with a culturally diverse population. Participants are all neonates admitted to our surgical NICU within a 12-week period. Primary and secondary outcomes measures: Investigators determined weekly PRISM and CRIB scores, ASA classifications, and patient and case note weights. Additionally, investigators catalogued private possessions in, around, and attached to patients' cribs, placing each possession into "soft toys", "spiritual amulets" or "other items" categories. Results Investigators followed 102 neonates, collecting 249 observations. PRISM scores correlated best with the "spiritual amulets" category (R²=0.82). The TOI (Tokens and Ornaments Index), calculated by combining all possessions in the "soft toys", "spiritual amulets", and "other items" categories, correlated next best (R²=0.71). The CRIB Score (R²=0.63), ASA classification (R²=0.61), and "soft toys" category (R²=0.39) all correlated to lesser degrees than TOI. Birth and current weight, post-conceptual age, NICU days and PCPWR each demonstrated insignificant correlations. Conclusions Private bedside possessions reliably reflected PRISM scores and, by extension, neonatal illness severity. Specifically, the number of spiritual items and TOI correlated well and may therefore serve as independent indica of clinical status. This may have potential for also identifying anaesthetic risk. Despite the widespread belief of an association between application of PCPWR and illness severity, this study found no support for its validity. [ABSTRACT FROM AUTHOR]

Medical migration is damaging health systems in developing countries and anesthesia delivery is critically affected, particularly in sub-Saharan Africa. ‘Within country’ postgraduate anesthesia training needs to be supported to encourage more doctors into the specialty. Open-ended training programs to countries that do not share the same spectrum of disease should be discouraged. Donor agencies have an important role to play in supporting sustainable postgraduate training programs. [ABSTRACT FROM AUTHOR]

Background: The efficacy of analgesia with bilateral infraorbital nerve block and intravenous (i.v.) fentanyl were compared for cleft lip surgery in children. Methods: Eighty-two children aged 3 months to 10 years undergoing cleft lip repair were prospectively randomized to one of two groups: bilateral infraorbital nerve block (Group B), or i.v. fentanyl (Group F). Group B ( n = 41) received bilateral infraorbital injection of 1 ml 0.25% bupivacaine and 2 ml i.v. saline as control. Group F ( n = 41) received 2 μg·kg−1 i.v. fentanyl, and bilateral infraorbital injection of 1 ml saline as control. Pain was evaluated by the incidence of tachycardia, hypertension, and/or modified pain score ≥4. The time to awakening, time to first cry and time to feeding were noted. Results: Thirty four children (82.9%) in Group B had adequate analgesia compared with 15 (36.6%) in Group F ( P < 0.0001, RR of failure 0.27 for Group B). Group B had a mean time to awakening of 5.65 ± 2.52 min (Group F: 9.37 ± 4.50 min; P < 0.0001), time to first cry 32.14 ± 18.22 min (Group F: 28.00 ± 16.27 min; P = 0.3), time to feed 62.05 ± 20.06 min (Group F: 72.44 ± 17.72; P = 0.015), and pain score 2.81 ± 1.38 (Group F: 4.71 ± 1.89; P < 0.0001). There were no major complications. Conclusions: Bilateral infraorbital block is superior to fentanyl in terms of analgesia, and time to awakening and feeding. [ABSTRACT FROM AUTHOR]

Emergence distress commonly occurs in children recovering from the immediate effects of general anaesthesia. This study was performed to (1) examine whether parental presence in the operating room during emergence from anaesthesia reduces the incidence or severity of emergence distress behaviour, and (2) assess psychosocial risk factors, including child temperament and sleep behaviour, for development of emergence distress. A randomized and controlled trial of parental presence at emergence was conducted in 100 ASA class I and II children having general anaesthesia for inguinal or penile surgery. Children in the study group had a parent present at induction and emergence of anaesthesia, while children in the control group had a parent present only at induction. Emergence and postanaesthesia care unit (PACU) behaviour was monitored using both the Operating Room Behaviour Rating Scale (ORBRS) and a 7-point Likert type cooperation scale. One-way anovas showed no significant differences between the control group and the study group on emergence distress behaviour. The frequency of negative postoperative behavioural changes at 1 and 4 weeks postsurgery was low in both groups. Children described as clingy/dependent ( χ2 = 5.57, P < 0.06) and children with frequent temper tantrums ( χ2 = 7.44, P < 0.02) were more likely to have emergence distress behaviour. Parental presence during emergence from anesthesia did not decrease the incidence or severity of emergence distress behaviour in children. Young children and children with a history of temper tantrums or separation anxiety may be more likely to develop such behaviour. [ABSTRACT FROM AUTHOR]

Copyright of Anaesthesist is the property of Springer Nature and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Copyright of Anaesthesist is the property of Springer Nature and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Atelectasis is one of the most common respiratory complications in pediatric patients after open-heart surgery, and may lead to weaning failure and increased morbidity. We report the use of an original, minimally invasive approach to refractory left lung atelectasis after repair of an aortic coarctation in a 2 month-old infant, in which a CPAP system connected to a flexible endobronchial tube resolved the atelectasis., (Copyright © 2020 Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor. Publicado por Elsevier España, S.L.U. All rights reserved.)

Introduction: Parents feel fear and anxiety before surgery is performed on their child, and those feelings could obstruct their preparation for the surgery. Preoperative information could relieve those feelings., Objective: To determine the preoperative information needs of parents of children undergoing elective surgery., Patients and Method: A study was conducted on the parents of children who underwent elective surgery. Demographic data of parents were recorded. Preoperative information received or would like to have received was assessed in terms of contents, methods, opportunity, place and informant. Descriptive statistics were used., Results: Thirteen hundred parents were surveyed. More than 80% of them want preoperative information about anaesthesia, surgery, preoperative fasting, drugs and anaesthetic complications, monitoring, intravenous line management, pain treatment, postoperative feeding, anxiety control, hospitalisation room, recovery room, and entertainment in recovery room. Most want to be informed verbally, one to two weeks in advance and not on the same day of surgery. The informant should be the surgeon and in his office. In addition, they want information through leaflets, videos and simulation workshops, or guided tours., Conclusions: Parents need complete preoperative information about anesthesia, surgery and postoperative care, received verbally and in advance., (Copyright © 2015 Sociedad Chilena de Pediatría. Publicado por Elsevier España, S.L.U. All rights reserved.)