With the increasing variety of pediatric diagnostic procedures, a growing number of children require sedation for diagnostic examinations. Appropriate sedation protocols guarantee the safety of children during sedation and improve its efficiency. Currently, there are significant differences in pediatric sedation practices across countries, regions, and medical institutions. The Pediatric Anesthesiology Group of the Chinese Society of Anesthesiology organized experts from multiple countries to develop the "Chinese Society of Pediatric Anesthesiology Guideline for Pediatric sedation (2025)" based on evidence-based medicine, considering the safety and efficacy, the preferences of children and parents, and drug accessibility. The guideline provided 28 recommendations addressing 12 clinical issues related to pre-sedation assessment, safety measures for sedation personnel and facilities, sedation protocols, sedation monitoring, and post-sedation recovery. The guideline is planned to be disseminated globally through multiple channels, aiming to standardize the management of pediatric sedation and improve its safety and efficacy.

Quantifying the Effective Cricoid Force to Occlude the Esophageal Entrance in Anesthetized and Muscle-Relaxed Children: A Videolaryngoscopy-Based Assessment.

Comprehensive pain management in children requires a specialized skillset, with a limited number of clinicians possessing the level of expertise required to successfully navigate the complexities of holistic care. The emergence of pediatric anesthesia fellowship programs in sub-Saharan Africa presents an opportunity to embed a pediatric pain curriculum for trainees, improving the availability of specialist skill and knowledge in the field. Existing pain curricula fall short in addressing the sociocultural aspects of pediatric pain identified through research as being unique to the African context, and do not include elements of leadership and advocacy training required to navigate the complexities of resource-constrained healthcare settings. A Delphi survey including literature review, iterative rounds of surveys and expert consensus was used to establish a pediatric pain curriculum for pediatric anesthesia fellows undertaking advanced training in sub-Saharan Africa. The 22-member expert panel included anesthetists, nurses, surgeons, pharmacists, pediatricians, a physiotherapist and a patient-caregiver dyad with a lived experience of pain. After completing three rounds of surveys, a steering committee of five members was assembled to resolve outstanding items to achieve the final curriculum. The process yielded a curriculum containing 20 knowledge items and 23 skills items. Attitudes are a key component of the curriculum and were grouped into six themes. A further aspect of the process was the identification of foundational knowledge with which trainees should enter a fellowship training program. This was termed the foundational curriculum. Using a Delphi method, consensus has been achieved on a pediatric pain curriculum for pediatric anesthesia fellows in sub-Saharan Africa with potential to meet the identified need for transformative pain care in this patient population.

Perspective on Pediatric Anesthesia Patient Safety: Past to Future.

BackgroundThe number of 1-year Accreditation Council for Graduate Medical Education (ACGME) fellowships continues to grow. The ACGME recommends a holistic curriculum with nonclinical areas, inclusive of educational sessions. Given the competing demands between clinical skill development, educational pursuits, and work-hour restrictions, we propose an andragogic curriculum using pediatric anesthesiology as the model fellowship.ObjectiveThe primary objective was to improve fellows’ perceptions of their educational experience during their fellowship year after implementing an andragogic holistic curriculum. Secondary objectives assessed improvements in diversity, equity, and inclusion (DEI) training and resources.MethodsThis was a single-center educational improvement project completed at Lucile Packard Children’s Hospital Stanford. Data were collected between 2014 and 2024. The new curriculum was introduced in 2021‐2022 and involved 12 different teaching modalities rooted in andragogic principles. A statistical process control p-chart was used to analyze the primary outcome based on the ACGME annual program evaluation. Outcomes were analyzed using censored regression modeling or a t test, depending on the presence of ceiling effects.ResultsFrom 2014 to 2024, 58 of 60 pediatric anesthesiology fellows completed the ACGME survey. A break in the statistical process control p-chart for educational content scores occurred during 2021‐2022, when the new curriculum was introduced. The mean difference was 0.89 (P<.001). Scores in DEI improved (mean difference 0.52; P=.03), and no difference was noted in resources (mean difference −0.13; P=.98).ConclusionsIntroduction of an andragogic curriculum into a pediatric anesthesiology fellowship program was associated with more favorable perceptions of educational content and DEI training.

Telemedicine is a critical military medicine capability in austere, remote, and denied environments where prolonged casualty care and knowledge gaps exist. Despite significant military investment in telemedicine, the literature lacks detailed lessons from real-world cases. U.S. Air Force Pararescue missions between 1 January 2010 and 31 December 2020 that included telemedicine consultation were reviewed. Participating flight surgeons (FS) and Pararescuemen (PJ) were interviewed, and available after-action reports were analyzed. Mission parameters, outcomes, and technical or human factors affecting communication were evaluated. Across 13 telemedicine consultations, the 28 patients experienced: cave entrapment (13), trauma (7), burns (4), and illness (4). Consultations were from PJ to FS (11), U.S. Coast Guard to FS (1), and FS to neurosurgery (1). Secondary consultations (7) were from FS to dental (1), dermatology, burn/critical care, orthopedics (2), pediatric anesthesiology, and thoracic surgery specialists. Missions used voice over mobile or satellite phone, text, and email. Recommendations commonly involved medication selection (6), advisement against mission launch (3), and burn care (2). Consultation effectiveness was impacted by unclear directions (3) and degraded communications (2). Telemedicine is valuable to PJs during complicated cases and rarely performed procedures, but cannot replace pre-deployment medical exposure and training. Rehearsals may optimize telemedicine, and training should focus on synchronizing a shared mental model of the patient using well-understood patient report and evaluation tools (ATMIST and MARCH PAWS). Telemedicine may reduce human error, give medics the confidence to take action, and limit the psychological impact of difficult care decisions.

BackgroundAlthough large language models (LLMs) show potential for patient education, their accuracy, usability, and comprehensibility lack validation in high-risk pediatric anesthesia. Rigorous evaluation is therefore essential prior to widespread clinical use in perioperative parental anesthesia education.ObjectiveThis study aims to evaluate the accuracy, reliability, and readability of responses generated by 5 LLMs to parental inquiries regarding pediatric anesthesia, and to assess their suitability for clinical use in perioperative caregiver education.MethodsTwo expert anesthesiologists identified 33 parental questions on pediatric anesthesia by screening authoritative resources and Google Trends. On December 14, 2025, these questions were submitted to 5 LLMs (DeepSeek-V3.2, ChatGPT-5, Gemini 2.5 Flash, Copilot, and Perplexity) via official web interfaces with default settings and zero-shot prompting, with each query in a separate conversation. Responses were standardized for blinded assessment. Two pediatric anesthesiologists with ≥10 years of clinical experience independently evaluated accuracy and reliability using the 4-point Likert accuracy scale, DISCERN, Ensuring Quality Information for Patients (EQIP), Journal of the American Medical Association (JAMA) benchmark, and Global Quality Score (GQS). After text preprocessing, readability was evaluated using 6 algorithms (Automated Readability Index [ARI], Flesch Reading Ease Score [FRES], Gunning Fog Index [GFI], Flesch-Kincaid Grade Level [FKGL], Coleman-Liau Index [CL], and the Simple Measure of Gobbledygook [SMOG]) via an online calculator. Interrater reliability was analyzed using the intraclass correlation coefficient (ICC); differences across models were assessed with the Kruskal-Wallis H test; and deviations from the sixth-grade benchmark were evaluated using 1-sample Wilcoxon signed-rank tests (P<.05 considered significant).ResultsAll 5 LLMs demonstrated high clinical accuracy (>90%; P=.12), with Gemini reaching 100%. Nevertheless, safety risks and content hallucinations were still observed. Excluding Gemini and Copilot, the remaining 3 models (ChatGPT, DeepSeek, and Perplexity) each produced unsafe content in 3.03% (n=1) of the 33 queries. Hallucinations were detected in all models except Gemini, with DeepSeek and Perplexity showing the highest hallucination rate (3/33, 9.09%). Furthermore, Perplexity showed superior reliability on DISCERN (median 41; P<.05), yet no model achieved a “good” rating. Gemini achieved the highest EQIP (median 66.67%; P<.05) despite lower GQS (median 3). Transparency was universally poor (JAMA median ≤1), with DeepSeek and ChatGPT showing a “floor effect.” ChatGPT had superior readability, but all models exceeded the recommended 6-grade complexity level.ConclusionsIn this study, 5 LLMs generally provided clinically accurate information when responding to parental questions about pediatric anesthesia. However, limitations were also identified, including hallucinated content, safety-related deficiencies, limited source transparency, and readability levels exceeding recommended standards. Therefore, LLM-generated information should be interpreted with caution and should not replace clinician guidance.

Paediatric regional anaesthesia (RA) is a safe and effective modality for peri-operative pain management, associated with improved outcomes and reduced opioid use. However, utilisation remains variable, and defining appropriate benchmarks is challenging. We conducted a 28-day retrospective audit of RA practice in a tertiary paediatric centre. All anaesthesiologist-performed regional blocks were recorded. Surgical cases not typically amenable to RA were excluded. The primary outcome was the proportion of patients receiving RA, with secondary analysis excluding unsuitable procedures. A total of 491 patients underwent surgery, of whom 94 (19.1%) received RA, increasing to 20.8% following case exclusion. A total of 117 blocks were performed, comprising 86 peripheral (73.5%) and 31 central (26.5%) blocks. Peripheral techniques included 42 lower limb (35.9%), 30 truncal/craniofacial (25.6%), and 14 upper limb (12.0%) blocks. Central blocks included 15 caudal (12.8%), 10 epidural (8.5%), and 6 paravertebral (5.2%) blocks. RA utilisation in our institution is consistent with European data. These findings establish a local benchmark and support ongoing audit and quality improvement in paediatric anaesthesia practice.

Emergence agitation (EA) is a postoperative neurobehavioral complication characterized by a transient disturbance in cognition and perception following anesthesia. Neuroinflammation is thought to play a central role in its pathophysiology. Preoperative anxiety is the "acute preoperative stress response." This study aimed to evaluate the relationship between hemogram-derived inflammatory markers and the development of preoperative anxiety and EA in pediatric patients. This prospective observational study included 350 pediatric patients aged 5-12 years with ASA grade I-II. Preoperative anxiety was assessed in the waiting room using the modified Yale Preoperative Anxiety Scale. Demographic and clinical data, anesthesia/surgical data, and hemogram parameters were recorded. EA was evaluated in the recovery room using the Pediatric Anesthesia Emergence Delirium scale. Pain was assessed at 0, 5, 10, 20, and 30 min using the FLACC scale in children < 7 years and the Visual Analog Scale in those ≥ 7 years. Of the total 350 patients, 130 (37.1%) developed EA. Compared with those without EA, children with EA had significantly higher leukocyte, monocyte, neutrophil, and platelet counts (p = 0.018, 0.005, 0.001, and 0.001, respectively), lower lymphocyte counts (p = 0.042), and elevated monocyte-to-lymphocyte ratio, neutrophil-to-lymphocyte ratio, platelet-to-lymphocyte ratio, and systemic immune inflammatory index (SII) (all p < 0.001). Regression analysis showed that younger age, higher postoperative pain scores, and elevated SII were independently associated with EA. Preoperative anxiety was observed in 103 children (29.4%). These patients had higher white blood cell counts (p = 0.026), and regression analysis identified that younger age, anxious parents, and elevated SII were independently associated with preoperative anxiety. Easily obtainable hemogram-derived inflammatory markers, particularly SII, may be useful for identifying children at increased risk of preoperative anxiety and EA in children. These findings suggest that SII may assist anesthesiologists in identifying high-risk patients and implementing preventive strategies to reduce the incidence of EA. The study was registered at ClinicalTrials.gov (NCT06648122).

Introduction Polytrauma is defined by the presence of multiple traumatic injuries and poses a significant global health concern due to its associated morbidity. Clear guidelines or recommendations for the medical or surgical management of pediatric polytrauma patients are currently lacking. Aims National Survey of the Management of Paediatric Polytrauma was conducted to clarify and delineate the current national standards in the care paediatric polytrauma patients. Material and methods We conducted a survey among senior physicians from the Italian Society of Pediatric Surgery and the Italian Society of Pediatric and Neonatal Anesthesia and Intensive Care. The survey focused on the management of pediatric polytrauma and compared practices between pediatric and hybrid hospitals, as well as between high- and low-volume centers. Results A national survey of 52 institutions revealed that 33% were paediatric hospitals and 67% were hybrid institutions treating adult patients. We found that 89% of the institutions had a dedicated paediatric emergency department, and 44% had a senior paediatric surgeon on call. Most hospitals had a dedicated paediatric intensive care unit, 72% had a multidisciplinary trauma team, and 94% had an internal protocol for paediatric polytrauma management. We found no significant differences in the number of second-level paediatric emergency departments, availability of paediatric surgeons, multidisciplinary trauma teams, or imaging modalities. High-volume centres had a higher annual incidence of polytrauma than low-volume centres. Conclusion The study provides important insights into the current state of paediatric polytrauma management in the Italian healthcare system. The study emphasised the crucial need for standardisation, specialised training, and the development of evidence-based guidelines. The proposed national trauma registry will be instrumental in facilitating this process and improving the quality of care for paediatric polytrauma patients in Italy. Further research examining the effect of volume, training, and guideline implementation on patient outcomes will significantly enhance this field.

The anesthesiological care of children places particular demands on the knowledge and skills of the anesthetist providing care. There is currently no structured further training in this field in Germany. Acurriculum for afellowship program in pediatric anesthesiology was developed through aconsensus procedure. Building on specialist anesthesiology training this program aims to impart specific knowledge and skills for the care of children. The defined final skills were divided into basic and advanced skills. Basic skills are taught at all fellowship sites, while the teaching of advanced skills depends on the structural requirements of the centers. In addition to the acquisition of clinical competencies, the fellowship comprises mandatory supplementary components, such as aquality improvement project, continuing professional development, certified pediatric emergency courses and webinars. The fellows' progress in competencies is monitored through regular, standardized evaluation interviews and documented as part of astructured evaluation. The "Pediatric Anesthesiology Fellowship" is acompetency-based, curriculum-structured training program. Building on specialist anesthesiology training it aims to contribute to the sustainable improvement of patient safety and the quality of care in pediatric anesthesiology.

Early-life sevoflurane exposure is associated with long-term cognitive deficits. Given that hippocampal development relies on precise critical windows, disruption of developmental processes during these periods is likely the origin of these impairments. However, the molecular mechanisms underlying sevoflurane-induced perturbations during critical development periods and their progression to lasting cognitive dysfunction remain elusive. Here, we determined that the first three postnatal weeks are a critical window of vulnerability to early-life sevoflurane exposure. Mechanistically, sevoflurane exposure suppressed the physiological upregulation of activity-regulated cytoskeleton-associated protein (Arc; also known as Arg3.1) during the critical period of hippocampal development, a process driven by glycogen synthase kinase-3 beta (GSK3β)-mediated protein degradation. We demonstrated that transient suppression of Arc via hippocampal injection of Arc antisense oligonucleotide (ASO) during the third postnatal week was sufficient to recapitulate the sevoflurane-induced phenotype, impairing microglial synaptic pruning and causing initial synaptic redundancy. This early pathology subsequently evolved into aberrant microglial phagocytic activation in adolescence and adulthood, resulting in excessive synaptic loss and cognitive deficits. Crucially, restoration of Arc expression specifically during this critical period using a doxycycline (Dox)-inducible Tet-On system successfully reversed this pathological pruning trajectory and prevented long-term cognitive impairment. Our findings highlight that Arc upregulation during this critical period is essential for microglial function and synaptic homeostasis, establishing Arc as a time-sensitive therapeutic target for preventing the developmental neurotoxicity associated with pediatric anesthesia. This diagram illustrates the role of the Arc protein in microglial synaptic pruning and cognitive development under physiological conditions (upper panel, blue; Arc is highly expressed during the critical period) and sevoflurane exposure (lower panel, red; Arc expression during the critical period is downregulated). Under normal conditions, Arc is expressed during the critical period and is localized to synapses, where it facilitates the tagging of redundant synapses for elimination. Synaptic pruning peaks during the critical period, followed by further refinement during adolescence, leading to mature cognitive function in adulthood. Neonatal sevoflurane exposure leads to aberrant activation of GSK3β during the critical period. This promotes Arc degradation, thereby disrupting its synaptic localization. This leads to microglial dysfunction in terms of synaptic engulfment. In adolescence, this disruption leads to excessive microglial phagocytosis and significant synaptic loss, ultimately resulting in cognitive deficits. Graphical elements: GSK3β, green circles; Arc, orange circles; phosphorylation site, pale yellow circle containing the letter "P"; C1q, yellow umbrella shapes.

Regional anaesthesia has well established benefits in paediatric perioperative care and acute pain interventions. This article explores current controversies and emerging evidence in paediatric regional anaesthesia. Despite rates of local anaesthetic systemic toxicity (LAST) remaining low, dosing of local anaesthetics in children remains controversial, particularly in neonates, in whom maximum safe doses can easily be exceeded. Local anaesthetic additives, such as dexamethasone, dexmedetomidine, and clonidine, are commonly used to prolong regional anaesthesia and have demonstrated good efficacy and safety, though best route of administration remains debated. Peripheral nerve catheters prolong analgesia and can be safely managed in ambulatory settings. Enhanced recovery after surgery (ERAS) is rapidly expanding in paediatric anaesthesia, and regional anaesthesia forms a key component. Fear of masking compartment syndrome is not supported by current literature and not a contraindication to regional anaesthesia. Studies exploring the utility of awake regional anaesthesia in children have successfully demonstrated the avoidance of general anaesthesia. Anaesthetic training increasingly demands proficiency in ultrasound-guided regional techniques. Regional anaesthesia is a safe and effective analgesic modality in children, including in trauma patients and as part of ERAS protocols, with good evidence for use of additives and low rates of complications, including LAST.

A one‑year snapshot of pediatric regional anesthesia at a French Tertiary University Hospital.

Climate change is already disrupting healthcare delivery with perioperative medicine, particularly pediatric anesthesia, being both highly exposed to climate-related shocks and a major contributor to healthcare-related greenhouse gas emissions (GHG). This review examines how mitigation and resilience strategies can be integrated into pediatric anesthetic practice. Sustainability measures in pediatric anesthesia are currently actionable and clinically beneficial. Reducing the use of volatile anesthetics through low-flow techniques, avoiding N2O or desflurane, and increasing the adoption of total intravenous anesthesia lead to substantial reductions in GHG and are associated with better clinical outcomes. EEG-guided anesthesia further reduces unnecessary exposure to anesthetics and improves recovery profiles. The use of reusable warming drapes or the implementation of 10R policies can markedly reduce our footprint without compromising the quality of care. Sustainable pediatric anesthesia is achievable today and aligns with improved clinical outcomes. Translating evidence into routine practice remains a challenge. Patient safety primacy or entrenched clinical habits continue to slow the adoption of sustainable practices, even when supported by robust data. Success will depend on reframing sustainability as a core component of quality and safety, embedding it within guidelines and audit structures, and supporting clinicians, thereby enabling durable behavior change.

Preoperative assessment is a central but increasingly complex component of pediatric anesthetic care. While perioperative safety in children has improved substantially, preventable complications remain prevalent. This review examines current concepts of pediatric preoperative evaluation, highlights emerging trends and controversies, and proposes the concept of anesthesia as a perioperative "navigator", whose guiding function begins with preoperative assessment. Contemporary practice of preoperative assessment increasingly includes structured risk stratification, procedure-specific planning, optimization of modifiable risk factors, and family centered communication. Advances highlight shorter fasting regimens, growing implementation of methods to optimize preexisting or chronic conditions such as pediatric patient blood management, refined strategies to manage upper respiratory tract infections and individualized approaches to manage preoperative anxiety. At the same time, digitalization, remote preassessment models, and delegation of assessment tasks are shaping clinical workflows. Shared decision-making and proactive communication have emerged as key determinants of cooperation for children and their families. Modern pediatric preoperative evaluation should be viewed less as a static medical checkpoint and more as starting for the dynamic process of perioperative "navigation". Integrating medical risk assessment with structured planning and effective communication remains essential to reduce complications and improve both safety and experience in pediatric anesthesia.

Pediatric Anesthesia and Respiratory Complications: Comment.

Paediatric anaesthesia has achieved remarkable progress over recent decades, yet contemporary data reveal that safety remains unevenly distributed across age groups, institutions, and regions of the world. Large observational studies demonstrate persistent perioperative morbidity and mortality, particularly in neonates, infants, and children cared for in resource-limited settings. While these multicentric investigations did not establish a direct causal relationship between anaesthetic management and perioperative morbidity or mortality in paediatric populations, they did reveal a high incidence of critical events related to the conduct of anaesthesia, which, if not diagnosed in time or left uncorrected, could lead to catastrophic outcomes. The Safe Anaesthesia for Every Tots (SAFETOTS) initiative focuses on the safe conduct of anaesthesia, maintenance of perioperative physiological stability, alongside organisational and child-centred values in perioperative care. This review explores the current state of and challenges in paediatric anaesthesia safety through the perspective of the SAFETOTS initiative.

Raising the bar: why paediatric anaesthesia needs specialists, structured training, and strong leaders.

Parents and caregivers play a critical role in the care of their child peri-operatively. Our team undertook previous research with parents/carers, which identified Australian parents' top 10 research priorities for paediatric anaesthesia and peri-operative medicine. While this was an important exercise, it focused on parent-reported experiences rather than the priorities of the children themselves; however, the experiences and concerns of parents/carers may not always reflect those of their child. It has been shown previously how integral it is to listen to each child's own voice to improve and create a more adaptive and safer peri-operative environment. This research prioritisation study was developed for children and used a modified James Lind Alliance method that involved surveys, a youth community conversation and a final consensus-based prioritisation meeting, all of which were conducted online. Participants were children and young people aged 6-18 y living in Australia. In total, we engaged 356 children and young people. We identified the top research priorities for Australian children and young people for paediatric anaesthesia and peri-operative medicine through a rigorous process of consensus. The final top 10 priorities were agreed by consensus after a multi-step process and included how to: reduce anxiety (including needle phobia); make anaesthesia safer; avoid postoperative complications (e.g. pain, sickness, agitation); and improve communication between children and doctors. The resulting priorities differed from those conducted in Australia for adult peri-operative medicine and from the parent/carer and clinician priorities identified previously for paediatric anaesthesia care. These research priorities can help guide future paediatric anaesthesia and peri-operative medicine research directions.