Pediatric Anesthesia Research Articles

Protocol development and feasibility of the PEACH in Asia study: A pilot study on PEri‐anesthetic morbidity in CHildren in Asia

AbstractBackgroundComprehensive 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.AimsThe 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.MethodsThis 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.ResultsThe 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).ConclusionsThe 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.

Back to the Future: Historic Insights and Recent Innovations in Pediatric Regional Anesthesia

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.

Common error traps in anesthesia for neonatal surgical emergencies.

Neonatal surgical emergencies are challenging, often high-risk procedures for the pediatric anesthesiologist. Though each emergency presents different anesthetic challenges, several error traps exist that are common to all procedures in this patient population. These error traps include errors in surgical timing, airway management, maintenance of normothermia and normoglycemia, and recognition of pharmacologic and physiologic differences. In this narrative review, we will discuss each error trap to aid the clinician in recognizing, planning for, and mitigating adverse events.

A Paradigm for Shared Decision-Making in Pediatric Anesthesia Practice for Children with Autism for the Generalist Clinician.

A Paradigm for Shared Decision-Making in Pediatric Anesthesia Practice for Children with Autism for the Generalist Clinician.

Optimizing Pediatric Sedation: Evaluating Remimazolam and Dexmedetomidine for Safety and Efficacy in Clinical Practice.

Daily, children undergo countless investigations and interventions, which require sedation and immobilization to ensure safety and accuracy. This remains associated with a persistent risk of sedation-induced life-threatening events as children are particularly vulnerable to adverse medical events and complications. Consequently, there is an urgent need to increase the safety of pediatric sedation and anesthesia. An ideal approach involves the use of drugs with fewer intrinsic side effects. In this context, on the basis of their pharmacokinetic properties, remimazolam (RMZ) and dexmedetomidine (DEX) were evaluated for their suitability as ideal sedatives. RMZ and DEX, both of which are currently available in pediatric medicine, have shown great promise in initial publications. To date, only very limited data concerning RMZ in small children are available. RMZ is a novel, ultrashort-acting benzodiazepine that is metabolized by tissue esterase, largely independent of organ function. It has a context-sensitive half-life of approximately 10 min, with minimal accumulation even with prolonged use. Its effects can be completely reversed with flumazenil. DEX, an isomer of medetomidine, is a potent α2-receptor-agonist with multiple indications in anesthesia and intensive care medicine. It has coanalgesic potential, allows for 'arousal sedations' and has a low profile for cardiorespiratory side effects. DEX is metabolized in the liver and is predominantly excreted renally. Both drugs show potential in the prevention and treatment of delirium, with DEX having additional neuroprotective effects. DEX and RMZ possess several properties of an optimal sedative, including clinically insignificant main metabolites and a broad dosage range, indicating their potential to reduce the incidence of sedation-related life-threatening events in children. However, further clinical research is necessary to better evaluate their potential risks.

Sugammadex for our little ones: a brief narrative review

Sugammadex, the first noncompetitive antagonist developed for the reversal of neuromuscular blockade (NMB), is one of the few drugs that has revolutionized anesthetic practice. However, the use of sugammadex for children between the ages of 2 and 17 years has only recently been approved and is currently not approved for children under the age of 2 years. Although the precision and reliability of reversal of NMB with sugammadex are of great benefit in pediatric anesthesia, several important questions remain regarding its use in our youngest patients. In this brief narrative review, we aim to provide an overview of the key considerations and potential challenges that anesthesiologists often face when using sugammadex in pediatric patients.

Growing Need for Web-Based Simulation in Low and Middle-Income Countries: A Narrative Review

Web-based simulation programs are poised to offer a productive means of delivering asynchronous training in healthcare professionals’ education. Similarly, web-based simulation programs could also sponsor specialty-specific, web-based fellowships for clinicians of low- and middle-income countries. Web-Based Simulation has been utilized for instruction in critical care fields such as emergency medicine and pediatric anesthesia. Studies have shown that enhanced self-reported knowledge and confidence have been achieved through tele simulation which is in line with in-person simulation. During the COVID-19 pandemic, simulations have helped clinicians hone their use of personal protective equipment and other infection control measures. Additionally, it has helped them in learning new and expanded roles, like processing equipment and assisting infected patients in prone position experiencing respiratory failure. However, web-based simulation programs also have unique challenges that must be satisfied: reliable broadband internet network access, multilingual capability, and programming quality. Studies indicate that cost-effective simulation training can be delivered to learners in remote, low-resource areas worldwide, including South Asia, where access to such education is limited. We aimed to explore the effectiveness, challenges, and strategies for implementing web-based simulation education in low- and middle-income countries, based on a thorough PubMed search focused on web-based simulation programs in medical education.

Reduction of Preoperative Anxiety Using Virtual Reality vs Midazolam: A Randomized Controlled Trial

More than 50% of pediatric patients experience significant stress and anxiety prior to surgery.1 High anxiety can result in increased postoperative pain, analgesic consumption, and delayed recovery.2 To reduce this preoperative anxiety, multiple therapeutic modalities have been developed, including the use of distraction, such as playing video games, watching movies, and listening to music. In severe cases of anxiety, anxiolytic and sedative medications like midazolam are used. However, given the acknowledged drawbacks of medications, including the risk of paradoxical reactions to the drug, alternatives to medication for reducing preoperative anxiety in patients may be useful. We aim to compare the use of virtual reality (VR) to midazolam in reducing preoperative anxiety in surgical patients and assess differences in induction compliance, emergence delirium, pain scores, and opioid use in VR vs. midazolam-treated patients. Methods This study was approved by the Phoenix Children’s Hospital Institutional Review Board. First-time surgical patients (N = 36) between the ages of 5 and 11 years undergoing tonsillectomy or tonsillectomy/adenoidectomy procedures were randomly assigned to either receive midazolam (0.5 mg/kg up to 25 mg) or play an interactive underwater-themed game using VR. The Modified Yale Preoperative Anxiety Scale (mYPAS) was administered by a single child life specialist preoperatively, and only patients who reached a threshold of >40 on mYPAS scoring were enrolled (scale range: 23 - 100). Additional anxiety measurement was tested using the adult and child State-Trait Anxiety Inventory (STAI). Midazolam or VR was administered prior to transport to the OR, and mYPAS was scored again at the time of separation from the family. The Induction Compliance Checklist (ICC) was utilized for assessment at the time of anesthesia induction. The VR-treated patients continued use of the VR headset through mask induction. A standardized anesthesia induction protocol was used for all patients. The Pediatric Anesthesia Emergence Delirium (PAED) scale was administered at emergence, postoperatively. Postoperative nurses scored pain and administered IV pain medication as needed. Group means and standard deviations were reported and compared with two-sided t tests. Results Interim results show the mYPAS anxiety scores dropped 20.1 ± 11.7 points following midazolam treatment (p<0.001) and dropped 28.3 ± 7.3 points following VR treatment (p < 0.001). There was a significant difference in mYPAS scores between groups following treatment (midazolam = 32.0 ± 4.9; VR = 25.4 ± 4.7; p = 0.04). There were no significant differences between midazolam- and VR-treated groups in the Induction Compliance Checklist, PAED scale, peak postoperative pain scores, and medication use for pain control postoperatively. This study is currently ongoing. Conclusion VR appears to reduce preoperative anxiety similarly to midazolam in anxious first-time surgical pediatric patients. Limitations include patient population. Further studies should be conducted for greater generalizability.

The Utility of Electroencephalograhy in Guiding General Anesthesia in Children.

Traditional pediatric anesthetic dosing using pharmacokinetic estimates based on age and weight is often imprecise, frequently leading to oversedation. Intraoperative electroencephalography (EEG) allows visualization of the brain's response to anesthetic agents in real time, facilitating precise titration of anesthetic drug doses optimized for the individual child. The goal of EEG-guided anesthesia management is to maintain an optimal state of hypnosis during various stages of the procedure while minimizing hemodynamic instability and other adverse effects of anesthesia. This is especially important in children with less predictable anesthetic requirements, such as children with atypical neurodevelopment, altered levels of consciousness before anesthesia, or those receiving total intravenous anesthesia, neuromuscular blockers, or a combination of anesthetic agents with different mechanisms of actions. Children with limited cardiorespiratory reserves and those undergoing high-risk procedures such as cardiopulmonary bypass also benefit from EEG guidance as they have a narrower therapeutic window for optimal anesthetic dosing. Various processed EEG (pEEG) monitors are available for intraoperative monitoring in children. These monitors display a pEEG index based on the manufacturer's algorithm, purportedly indicating the patient's hypnotic state. Due to differences in developmental neurophysiology and EEG dynamics in children, pEEG indices may not always reliably indicate the hypnotic state, especially in neonates and infants. Learning to interpret nonproprietary EEG parameters including the raw EEG, spectral-edge frequency 95% (SEF95), and density spectral array can prevent overreliance on pEEG indices. This review provides an overview of the advantages of EEG guidance during clinical anesthesia, including potential reduction in anesthetic dosage, prevention of EEG suppression, and reduction in peri-operative adverse events. We describe the use of nonproprietary EEG parameters in guiding anesthesia in children for various clinical end points including laryngoscopy, surgical incision, and maintenance of anesthesia, as well as sedation. We illustrate these principles with various case examples commonly encountered during pediatric anesthesia. Lastly, we discuss strategies to expand intraoperative EEG monitoring in children through education and training programs, as well as advocate for further research to assess clinical outcomes associated with EEG guidance to support its routine use in clinical care.

Children are not little adults: a special issue on pediatric anesthesia

Children are not little adults: a special issue on pediatric anesthesia

A Brief Introduction on Latent Variable Based Ordinal Regression Models With an Application to Survey Data.

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.

Editor's picks for the Pediatric Anesthesia article of the day: July 2024.

Editor's picks for the Pediatric Anesthesia article of the day: July 2024.

Pediatric Ambulatory Anesthesia: Confronting Challenges, Embracing Opportunities.

Pediatric Ambulatory Anesthesia: Confronting Challenges, Embracing Opportunities.

Acute Adrenal Insufficiency in Childhood: Etiopathogenesis, Clinical Picture, and Intensive Care

Introduction. Acute adrenal insufficiency (AAI) is a severe endocrinopathy whose victims include children and adolescents and which can be life-threatening despite its low incidence. Analysis of issues associated with intensive care of children with this pathology is of vital interest for pediatric anesthesiology and critical care medicine. The aim of this work was to assess current views on the etiopathogenesis, clinical pathology and intensive treatment of pediatric AAI.Materials and methods. The topic was researched by analyzing publications found in the Cochrane Library, PubMed and Medscape using the following search terms: “acute adrenal insufficiency, children and adolescents, intensive therapy, fluid management”, with 65 published sources chosen.Results and discussion. In AAI, caused by a sharp deficiency of cortisol (and mineralocorticoids), which triggers an inflammatory reaction, electrolyte imbalance and hemodynamic disorders. AAI presents with dehydration, nausea and vomiting, feelings of pain, hypotension, tachycardia, seizures and impaired consciousness up to coma. Laboratory tests in children often reveal hyperkalemia, hyponatremia, hypoglycemia and hypercalcemia. Intensive management of AAI in the ICU relies on parenteral corticosteroids (preferably intravenous hydrocortisone). Two or three days later, when the child is stable, they are switched to oral hormones. Meanwhile, fluid management is performed over 2 to 3 days to increase the circulating blood volume and relieve dehydration with crystalloid fluids.Conclusion. A clearer understanding of the etiopathogenesis, clinical manifestations and diagnostic features of AAI, along with knowledge of emergency care algorithms, will improve the quality of intensive therapy of pediatric patients with this condition.

The effect of deep versus awake removal of the laryngeal mask airway on the incidence of emergence delirium in paediatric tonsillectomy: A randomised controlled trial.

Emergence delirium, characterised by inconsolable crying, perceptual disturbances and thrashing, occurs in young children during the recovery phase from general anaesthesia. Our aim was to determine whether timing of laryngeal mask airway removal (deeply anaesthetised versus awake) influenced the incidence of emergence delirium in children after tonsillectomy. A single-centre, randomised controlled trial was conducted at Albury Wodonga Health, a regional hospital in Australia. Included patients were two to seven years old, American Society of Anesthesiologists physical status classification 1-2, undergoing elective tonsillectomy (with or without adenoidectomy or grommet insertion) under general anaesthesia. Patients were randomised to have their laryngeal mask removed whilst deeply anaesthetised (in the operating theatre) or after awakening (in the post-anaesthesia care unit (PACU)). Pediatric Anesthesia Emergence Delirium score was determined at 5 and 20 min after eye opening, and frequency of complications (cough, vomiting, excessive salivation, oxygen desaturation and laryngospasm) in the PACU were recorded. Sixty-two patients were randomised to deep laryngeal mask removal and 62 to awake. In the awake versus deep groups, 33 (53%) versus 40 (65%) participants had emergence delirium at 5 min (odds ratio (OR) 0.63, 95% confidence interval (CI) 0.30 to 1.29, P = 0.20). At 20 min, 18 (29%) vs. 19 (31%) participants had emergence delirium (OR 0.93, 95% CI 0.43 to 2.00, P = 0.88). A greater incidence of most PACU complications was observed in the awake versus deep group; cough (24% vs. 8%), vomiting (8% vs. 0%), excessive salivation (23% vs. 8%) and oxygen desaturation (16% vs. 0%). We found no significant difference between the two techniques in terms of preventing emergence delirium. However, other PACU complications were more frequent with awake removal.

Navigating postextubation bronchospasm in pediatric patients with intraoperative inhalation agents: A comprehensive review

Post-extubation bronchospasm poses a considerable challenge in pediatric anesthesia, necessitating effective management strategies to mitigate its potential complications. This review provides an overview of post-extubation bronchospasm, including its etiology, risk factors, and clinical presentation in pediatric patients. We emphasize the critical role of intraoperative inhalation agents in managing bronchospasm, discussing their mechanisms of action and comparative efficacy. Through a comprehensive analysis of existing literature and clinical evidence, we highlight best practices for administering and monitoring inhalation agents during pediatric anesthesia. Furthermore, we present case studies and clinical outcomes to illustrate the practical implications of utilizing these agents in bronchospasm management. Our review underscores the importance of optimizing intraoperative inhalation agents to improve patient outcomes and safety in pediatric anesthesia, emphasizing the need for evidence-based approaches and tailored interventions in clinical practice.

PDOC-02 SUB-SAHARAN AFRICAN EXPERIENCE OF NEUROSURGICAL-ONCOLOGIC CARE: CHALLENGES AND BARRIERS ENCOUNTERED AT 7 CANCER TREATMENT CENTERS

Abstract BACKGROUND Wide disparities in neurosurgical-oncologic care and treatment outcomes exists globally despite recent improvements in diagnostics and cancer therapy. To better understand the challenges to neurosurgical-oncologic care in low resource settings, we collected data on national neurosurgery capacity and hospital diagnostic and treatment capacity across 7 national referral hospitals in 7 countries Sub-Saharan Africa (SSA). METHODS A 42-item self-administered questionnaire was distributed to partner neurosurgeons at the 7 sites via REDCap in April 2023 to provide country and hospital level capacity data on neurosurgical-oncologic care. RESULTS Neurosurgical and neurosurgical-oncologic care was reported to be available in a limited number of provinces/states/regions in 6 out of the 7 countries. The neurosurgery and pediatric neurosurgery workforce density across the 7 countries ranged between 0.03 – 0.67 per 100,000 and 0 – 0.05 per 100,000 respectively. Three hospitals had no pediatric ICU with the remaining four having between 2-8 bed-capacity pediatric ICU. One hospital did not have both CT and MRI scanner available and relied solely on private diagnostic facilities for neuroimaging. Histopathology services were largely limited to basic hematoxylin and eosin (H&E) and/or advanced histopathology staining. Molecular subtyping was available at only one hospital. None of the 7 hospitals had neurocritical care expertise, neuroradiologist, or neuropathologist. Four hospitals had a pediatric anesthesiologist. Only one hospital had a neuro-oncologist, but none had a pediatric neuro-oncologist. Both adjuvant chemotherapy and radiotherapy was unavailable at 3 hospitals. Rehabilitation was largely limited to basic physical and occupational therapy at all 7 hospitals. Although all 7 countries had a multiple health payer system, the payment structure differed across the 7 hospitals for different neurosurgical-oncologic services with patients making out-of-pocket payments for all services in some cases. Financial constraint was reported as a major barrier to care. CONCLUSION System-level interventions are needed to strengthen neurosurgical-oncologic care capacity in SSA.

Influencing Policy to Advance Paediatric Surgery in Africa

My aim in this lecture was to address the critical role of policy in advancing paediatric surgery in Africa. I highlight the policy gaps hindering progress in paediatric surgery, discuss supportive ongoing policy initiatives and outline the short-term impacts of these initiatives. Globally, an estimated 1.7 billion children lack access to safe and timely surgical care. In Nigeria, policy gaps have contributed to significant challenges in paediatric surgical care, including poor access and inequities in the distribution of paediatric surgeons and anaesthesiologists. To address this situation, key innovations including inclusion of children's surgery in Nigeria’s National Surgical, Obstetrics, Anaesthesia, and Nursing Plan (NSOANP) has led to infrastructure improvements, critical care training, and the creation of a birth defects registry. These initiatives have shown significant gains, such as increased surgical volumes and cost-effective infrastructure investments. Efforts to strengthen the workforce for paediatric surgery through mentoring, training, and tasksharing are underway to address the shortage of paediatric surgeons and paediatric anaesthesiologists. Furthermore, children's surgery is gaining emphasis in new policies and plans across Africa, including initiatives such as the Africa Surgical Initiative and Pan African Surgical Healthcare Forum. Paediatric surgeons must actively engage in public health policy and decision-making to create sustainable impacts on global child surgical healthcare. Continued efforts are needed to broaden engagement beyond surgical networks and platforms to achieve lasting improvements in paediatric surgical care.

The impact of current pediatric anesthesiology fellows shortfall on freestanding children's hospitals and practices

The pediatric anesthesiology workforce is currently facing a critical shortage, which will have significant consequences for patient care and the healthcare system as a whole. The workforce is aging, and despite increasing numbers of anesthesiology residents, fewer graduates are entering the field of pediatrics. It should also be noted that fewer medical school graduates are entering pediatrics as well. This situation raises concerns about the availability of specialists and the training of future physicians. To address this shortage, a comprehensive strategy is urgently needed, including outreach, mentorship, financial incentives, and policy changes to attract and retain new talent in pediatric anesthesiology. Immediate intervention is necessary to prevent a severe impact on the availability and quality of pediatric anesthesia care.

Current sedation practices for non-invasive procedures in tertiary maternity and children's hospitals in China: a 5-year update.

Sedation techniques can ease anxiety during medical procedures for children. Our previous report on Chinese sedation practices for non-invasive procedures in 2018 is outdated due to the rapid development of sedation services. This study provides an updated report on sedation practices for non-invasive procedures in China. This is a cross-sectional study. Questionnaires were sent to tertiary maternity and children's hospitals nationwide through the WeChat Mini Program. The survey questioned the location and caseloads of hospitals providing sedation services, support facilities, contraindications, fasting practices, sedation regimens, monitoring practices, staff structure, certification requirements for sedation providers and quality control data. Procedural sedation for non-invasive procedures were provided in 88 of 114 hospitals. These hospitals are located across the country except Heilongjiang province and the Tibet Autonomous Region. Compared with previous reports, significant increases were found in the number of hospitals providing sedation services, dedicated sedation rooms and recovery rooms and full-time sedation providers. Most hospitals advocated the 2-4-6 rule for pre-sedation fasting. Dexmedetomidine was the most used first-choice sedative. Anaesthesiologists remain the primary sedation providers, but nurses are also important. The most mentioned qualification requirements for sedation providers were a professional title of attending doctor, ≥5 years of working experience in paediatric anaesthesia and paediatric advanced life support certification. Sedation service records were used in 83 hospitals, but only 42 and 39 recorded success rates and adverse events, respectively. Sedation services for non-invasive procedures are available in most areas of China. More hospitals now provide sedation services and full-time sedation providers. Supporting facilities and sedation regimens have improved. Non-anaesthesiologist sedation providers are important at current stage, developing training programmes for them may be necessary. Attention should be focused on quality control and improvement of sedation services.