BACKGROUND: There is difficulty completing outpatient procedures in children with complex developmental and behavioral diagnoses. These visits may require increased personnel and incur delays. AIMS: We sought to evaluate...BACKGROUND: There is difficulty completing outpatient procedures in children with complex developmental and behavioral diagnoses. These visits may require increased personnel and incur delays. AIMS: We sought to evaluate if an interdisciplinary team of providers, nurses, and a clinical pharmacist dedicated to advanced preparation (e.g., discussing patient, reviewing concerns with procedure completion, understanding medication needs) and the development of a pre-appointment plan can streamline outpatient visits. METHODS: Pediatric patients with complex behavioral disorders requiring a procedure at an outpatient visit were evaluated retrospectively using pre- and post-implementation data. Outcomes assessed were duration of outpatient appointment and procedural sedation times, procedure success, and description of pharmacist interventions as part of the team. Data are reported descriptively. RESULTS: Thirty-five patients were included: 17 pre- and 18 post-implementation of the team. Median appointment and sedation times were reduced in the post- compared to the pre-implementation group, 133 min (IQR 98-178) vs. 173 min (IQR 153-190) (p = 0.08) and 40 min (IQR 30-54) vs. 75 min (IQR 45-100) (p = 0.02), respectively. There was no difference in procedure success, and 15 pharmacist interventions were made in six patients in the post-implementation group related to drug-drug interactions, premedication selection, and dose recommendations. CONCLUSIONS: An interdisciplinary sedation team focused on pre-appointment planning for complex pediatric behavioral patients requiring a procedure in the outpatient setting was associated with reduced appointment and sedation times, a clinically and statistically significant finding, respectively. Future studies should focus on resource utilization and patient and caregiver satisfaction.
There exists, across the world, significant variation in pre-operative pediatric fasting guidance for breast, formula, and cow's milk. Alongside recent shifts toward liberal clear liquid intake in response to prolonged f...There exists, across the world, significant variation in pre-operative pediatric fasting guidance for breast, formula, and cow's milk. Alongside recent shifts toward liberal clear liquid intake in response to prolonged fasts, there is also a trend emerging toward more liberal milk fasts. This narrative review aims to shed light on the following questions on the topic of pre-operative fasting of milks in children: What current published guidelines exist, what do they recommend and why? What benefits might reduced fasting times provide? Is there evidence that shorter fasting rules are as safe as longer fasting rules? What is the physiology of gastric emptying for milks? What is the evidence that gastric emptying differs for cow's, formula, or breast milk, and does age have an influence? The extent to which we are currently able to answer these questions aims to both better inform those formulating perioperative fasting guidelines and to stimulate standardized research into gastric emptying and pre-operative fasting of milk in children.
BACKGROUND: It is recognized that the perioperative anesthetic management of children with long QT syndrome may be complex, as they are at risk of life-threatening arrhythmias such as ventricular tachycardia, torsades de...BACKGROUND: It is recognized that the perioperative anesthetic management of children with long QT syndrome may be complex, as they are at risk of life-threatening arrhythmias such as ventricular tachycardia, torsades des pointes, ventricular fibrillation, or severe bradycardia. There is uncertainty regarding the incidence of complications as well as which techniques might be acceptable or preferable in this group of patients. AIMS: In collaboration with the Congenital Cardiac Anesthesia Network, we conducted a prospective audit of the anesthetic management, complications, and outcomes of children with long QT syndrome. METHODS: Following receipt of ethics committee approval and an extensive process of communication within the Congenital Cardiac Anesthesia Network and elsewhere, over approximately a two-year period in the United Kingdom we prospectively collected fully anonymized data relating to the anesthetic management of children with long QT syndrome using an online secure reporting portal. RESULTS: 90 episodes of anesthesia for cardiac/cardiological (44) and non-cardiac (46) procedures were reported in 81 patients, with a median age of 6 years and a median weight of 22 kg. 59% were male. In 57 patients (70%), the diagnosis of long QT syndrome had been confirmed by genotyping. Where available, the QTc on a preoperative ECG ranged from 340 to 650 milliseconds. 14 patients had a history of previous out-of-hospital cardiac arrest, and 18 patients had an in situ cardiac pacing/defibrillation system. Three patients had a previous history of major complications under anesthesia, including ventricular tachycardia or ventricular fibrillation. Three patients experienced a significant complication, including intermittent atrioventricular block, ventricular tachycardia, changes in QRS morphology on the electrocardiograph, and bradycardia necessitating cardiopulmonary resuscitation. Both intravenous and inhalational agents were used perioperatively. No patient required unplanned admission to an intensive care unit. In every case, the patient was anesthetized by a consultant. CONCLUSIONS: This complex group of patients has a significant complication rate under general anesthesia. Perioperative management of such patients should be delivered by experienced anesthetists, and in the majority of cases, it is appropriate for this to take place in centers where there is relevant additional cardiological expertise.
BACKGROUND: Intraoperative opioid use during pediatric tonsillectomy is commonly avoided to reduce the risk of postoperative respiratory adverse events (PRAEs). Avoidance of perioperative opioids may contribute to increa...BACKGROUND: Intraoperative opioid use during pediatric tonsillectomy is commonly avoided to reduce the risk of postoperative respiratory adverse events (PRAEs). Avoidance of perioperative opioids may contribute to increased early postoperative pain, which can result in patients receiving rescue doses of opioids in the postanesthesia care unit (PACU). AIMS: The aim of this project was to reduce moderate to severe pain in PACU for pediatric tonsillectomy/adenotonsillectomy patients by 50% within 12 months. METHODS: Pilot data was collected on the intraoperative care and PACU pain outcomes of patients between June 2018 and June 2020. A six-item toolkit was designed, then implemented from April 2021, with identical data points collected for comparison. Postintervention patients were categorized into toolkit compliance groups: (1) Standard of care (< 5 of 6 items delivered), (2) Partial Toolkit (5 of 6 items delivered), and (3) Toolkit (100% adherence). Statistical process control charts were used for data analysis. RESULTS: Data was collected for 420 patients. Baseline data reported 65.8% of patients experienced moderate-severe pain in PACU. In the first 12 months of toolkit implementation (2021-2022), the incidence of moderate to severe pain decreased to 47.1% in the 100% adherence group (28% reduction). In subsequent years (2022-2024), this measure decreased further to 31% (53% reduction overall). Pretoolkit, 69% of patients received rescue opioids in PACU. In the first 12 months of toolkit implementation (2021-2022), the incidence of rescue opioids in PACU decreased to 35% in the 100% toolkit adherence group (49% reduction). From 2022 to 2024, this decreased to 45% (35% reduction). CONCLUSION: Through the implementation of the tonsillectomy toolkit, we helped reduce early postoperative pain by 28% in the first year. Continued data collection showed the intervention to be sustainable and delivered subsequent decreases in moderate to severe pain by a factor of 53%. These improvements were achieved without increasing PRAEs, postoperative nausea/vomiting incidence, or PACU length of stay.
Bardol M, Sheng Y, Baarslag M
… +20 more, Ceci A, Dörje F, Ilmoja ML, Larsson P, Lönnqvist PA, Methsvat T, Pokorna P, Rascher W, van Rosmalen J, Schroth M, Simonetti A, Tibboel D, Toni I, Tuleu C, Völkl TMK, Anderson BJ, Wimmer S, Standing JF, Neubert A, CloSed Consortium
Paediatr Anaesth
· 2025 Dec · PMID 41045026
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BACKGROUND: Clonidine and midazolam are routinely used in the pediatric intensive care unit for pain and sedation management, but target concentration and optimal dose are poorly defined for both drugs. The CloSed study...BACKGROUND: Clonidine and midazolam are routinely used in the pediatric intensive care unit for pain and sedation management, but target concentration and optimal dose are poorly defined for both drugs. The CloSed study is a multicenter, double-blind, randomized, active-controlled noninferiority trial with a 1:1 randomization between clonidine and midazolam. AIMS: Data from the prematurely terminated CloSed trial were used to study the population pharmacokinetic-pharmacodynamic relationships for clonidine and midazolam to inform the optimal use of both drugs in mechanically ventilated children. METHODS: Twenty-eight patients (0-6 years) were included; 13 received midazolam, and 15 received clonidine. Morphine was administered to all patients as background analgesia. A total of 317 and 306 observed COMFORT-B scores for midazolam and clonidine, respectively, were available to build the pharmacokinetic-pharmacodynamic model. Pharmacokinetic models were developed using findings from previously published pharmacokinetic studies to augment the trial data. A one-compartment model described clonidine pharmacokinetics, while a single compartment for midazolam and its metabolite described its pharmacokinetics. A joint inhibitory sigmoid model that included a postanesthesia effect was used to describe the concentration-effect relationship, using the COMFORT-B score as the pharmacodynamic endpoint. RESULTS: The final models adequately described the observed data. Simulations based on the final models showed that a clonidine dose of 4 μg/kg loading dose followed by a 3 μg/kg/h infusion, and a midazolam dose of 200 μg/kg loading dose followed by a 200 μg/kg/h infusion would be required to achieve adequate sedation. CONCLUSION: The CloSed data suggest that higher doses of clonidine and midazolam than are commonly used in clinical practice should be considered to provide adequate sedation in critically ill children.
BACKGROUND: There remains a critical shortage of pediatric organ donors and there is a gap in understanding of optimal perioperative management to optimize donor organ outcomes for this valuable resource. AIMS: To survey...BACKGROUND: There remains a critical shortage of pediatric organ donors and there is a gap in understanding of optimal perioperative management to optimize donor organ outcomes for this valuable resource. AIMS: To survey practice patterns for intraoperative management of pediatric (age < 18 years) brain-dead donors during organ recovery procedures. METHODS: This retrospective observational study included organ recovery cases from 24 centers included in the Multicenter Perioperative Outcomes Group (MPOG) cohort in the United States from 2014 to 2020. Practice variation was evaluated using descriptive statistics, Fleiss' kappa, and logistic regression for between-group comparisons for volume-based analysis (case volume < 10 or ≥ 10) without adjustment for multiple comparisons. RESULTS: A total of 231 cases were included in this analysis. The median case volume for the Higher-Volume (≥ 10 cases) group was 25 [IQR 17, 46] cases and 7 [IQR 3, 8] cases for the Lower-Volume (< 10 cases) group. Descriptive analyses identified differences in case volume, race, and administration of steroids and vasoactives (bolus and infusion). The Fleiss' kappa scores were negative across all medications administered, suggesting a lack of within-group agreement. The odds ratio for steroid administration in the Lower-Volume group was 0.319 (95% CI: 0.116-0.745, p = 0.014). CONCLUSIONS: This study found substantial practice variation across MPOG centers grouped based on case volume frequency for organ recovery procedures in pediatric donation after brain death. A major limitation of this study is the inability to correlate perioperative management with organ recipient outcomes. The main takeaway is an opportunity to improve consistency in perioperative management for brain-death donors from case classification to medication administration that reflects an understanding of brain death physiology.
Taverner FJ, Stepanovic B, Roberts CT
… +2 more, von Ungern-Sternberg BS, Morris S
Paediatr Anaesth
· 2025 Dec · PMID 41025574
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INTRODUCTION: There is a paucity of data on the chosen anesthesia management for infant inguinal hernia surgery. We aimed to characterize self-reported anesthetic practice in Australia and New Zealand. We also aimed to i...INTRODUCTION: There is a paucity of data on the chosen anesthesia management for infant inguinal hernia surgery. We aimed to characterize self-reported anesthetic practice in Australia and New Zealand. We also aimed to identify the outcomes that matter to both anesthetists and to parents and carers. METHODS: Two separate surveys were administered, one for anesthetists and the other for parents and carers of infants who had undergone an inguinal hernia operation. RESULTS: Eighty-nine surveys were completed by anesthetists. The most common preferred anesthetic technique was general anesthesia for both preterm 55 (61.8%) and term infants 79 (91%). Anesthetists reported that an infant's gestational age at birth and health factors influence their choice of anesthetic, as well as their personal and institutional experience. The highest priority of anesthetists was "avoiding intraoperative critical events." Eighty-three surveys were completed by parents or carers. 48 (57.8%) reported their infant born preterm, and 50 (62.7%) spent time in the neonatal intensive care unit. The highest ranked priority for parents was "minimising impact on baby's brain." CONCLUSION: The most common anesthetic type reported by parents and anesthetists for both preterm and term infants undergoing inguinal hernia surgery in Australia and New Zealand is general anesthesia. Many anesthetists do not feel confident in performing neuraxial blocks in infants; however, regional techniques are more likely to be preferred for preterm infants. In this study, anesthetists' top-ranked priority was avoiding intraoperative critical events, and parents and carers' top-ranked priority was minimizing impact on their baby's brain. Differences in the priorities of anesthetists and consumers indicate the need to ensure clinicians discuss issues relevant to parents in preoperative counseling. The need to involve consumers in future research directions and study design is highlighted. Data on anesthetic outcomes following hernia surgery in an Australian and New Zealand context are needed.
Höök A, Hylén M, Björk M
… +8 more, Nilsson S, Bai J, Berlin H, Hansson H, Kristjánsdóttir G, Roxner R, Stenström P, Castor C
Paediatr Anaesth
· 2025 Dec · PMID 40977637
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BACKGROUND: Pain in children is undertreated. An assessment scale co-designed with children, parents, and health care professionals could lead to more effective pain assessments and treatment strategies aimed at reducing...BACKGROUND: Pain in children is undertreated. An assessment scale co-designed with children, parents, and health care professionals could lead to more effective pain assessments and treatment strategies aimed at reducing pain and pain-related symptoms. There are analogue scales validated for self-report of pain in children, but today, children regularly use digital technology, which healthcare should align with. The newly developed electronic Faces Thermometer Scale is a digital assessment scale that needs further validation before it may be recommended for self-reporting pain intensity. AIMS: The study aimed to determine the convergent and discriminant validity of a new digital pain assessment scale in a pediatric postoperative setting. METHODS: The study was performed at a pediatric surgery department in southern Sweden. A total of 88 children were included, generating 716 assessments. Convergent validity was established by comparing the well-validated Colored Analogue Scale and Faces Pain Scale Revised with the electronic Faces Thermometer Scale. Pain assessments were conducted at three different time points: one before surgery, one once the participant became alert and aware, and one 30-45 min after the second time point. A p-value of 0.05 was considered statistically significant. Discriminant validity was established by comparing a potential non-painful situation with a painful situation using the electronic Faces Thermometer Scale. RESULTS: The agreement between the scales at different time points, as well as across different ages and gender, showed a statistically significant correlation: Kendall's Tau B correlation coefficient varied between 0.61 and 0.79 at different time points. The electronic Faces Thermometer Scale was able to discriminate pain across different age groups and genders. There was a statistically significant difference between pre- and postoperative assessments, and the Clopper-Pearson proportion ranged from 0.70 to 0.90. CONCLUSIONS: The electronic Faces Thermometer Scale provides a valid digital scale for self-report of pain within pediatric postoperative care.
Wang EY, Castro S, Zhang L
… +14 more, Suen MY, Parris M, Marks A, Weser V, Longhini AB, Strupp KM, Hernandez MR, Libaw JS, Kupiec-Weglinski S, Lockhart TJ, Olbrecht VA, Lau LL, CHARM Consortium, Caruso TJ
BACKGROUND: The infrequent occurrence of resuscitating critically ill pediatric patients poses educational challenges for pediatric anesthesiology residents developing competence. Traditional medical simulations, despite...BACKGROUND: The infrequent occurrence of resuscitating critically ill pediatric patients poses educational challenges for pediatric anesthesiology residents developing competence. Traditional medical simulations, despite their utility, incur significant costs due to the need for monitors, mannequins, and personnel. Augmented reality (AR) medical simulation shows promise as an alternative clinical teaching tool. The Technology Acceptance Model (TAM) assesses usefulness, ease of use, and attitudes toward new technologies, offering insights into their adoption. Following successful application with other healthcare innovations, the TAM can also assess innovations in pediatric anesthesiology resident education, including AR medical simulation. AIMS: The primary aim identified factors that influenced acceptance of AR for medical simulation in pediatric anesthesiology using a TAM. The secondary aims assessed the model's reliability, usability, and ergonomics. METHODS: This prospective, multi-site study was carried out across nine academic children's hospitals around the United States and Hong Kong. We recruited anesthesiology residents with a minimum of two weeks of pediatric anesthesia experience, excluding those with severe motion sickness, seizures, or who wore corrective glasses. Using Magic Leap 1 headsets, participants underwent a simulated AR pediatric resuscitation scenario. Data were collected via electronic surveys, evaluating TAM factors, usability (System Usability Scale), and ergonomics (ISO 9241-400 standard). RESULTS: A total of 101 participants completed the study. The AR TAM model indicated that perceived ease of use and computer self-efficacy predicted perceived usefulness. Behavioral intention to use the AR system was influenced by perceived usefulness and perceived ease of use. System usability scores showed 83% agreement on ease of use. Ergonomic assessments indicated minimal physical discomfort. CONCLUSION: AR simulations are highly acceptable and usable for pediatric resuscitation training, with perceived ease of use and computer self-efficacy influencing AR adoption. These findings align with previous TAM studies, supporting AR's potential to supplement traditional simulations and enhance accessibility.
Pediatric total intravenous anesthesia (TIVA) with propofol is well-established, safe, and offers advantages over volatile anesthesia. Nevertheless, its use remains limited because of inadequate training and knowledge, l...Pediatric total intravenous anesthesia (TIVA) with propofol is well-established, safe, and offers advantages over volatile anesthesia. Nevertheless, its use remains limited because of inadequate training and knowledge, lack of confidence, perceived complexity, and uncertainty or limited awareness of its benefits. This error traps article explores key principles for the safe and effective use of pediatric TIVA, including pharmacological principles, the role of adjunct agents, practical aspects of drug delivery, electroencephalography-based monitoring, and the use of TIVA in specific populations.
BACKGROUND: Effective pain management during peripherally inserted central catheter placement in neonates and pediatric patients remains challenging, often leading to procedural distress and suboptimal outcomes. AIM: Thi...BACKGROUND: Effective pain management during peripherally inserted central catheter placement in neonates and pediatric patients remains challenging, often leading to procedural distress and suboptimal outcomes. AIM: This randomized controlled trial aimed to evaluate the analgesic efficacy of brachial plexus block compared to local infiltration anesthesia during peripherally inserted central catheter placement. METHODS: Seventy patients were randomized into two groups: brachial plexus block (Group B) and local infiltration anesthesia (Group C). Procedural pain was assessed using the Comfort Neo Scale at T = 0 min (puncture) and T = 30 min (30 min after the procedure). Secondary outcomes included the first-attempt success rate, procedure time, number of puncture attempts, and rescue analgesic use. All interventions were performed under ultrasonographic guidance. Continuous data are expressed as medians [interquartile range (IQR)]. RESULTS: The median Comfort Neo Scale scores at T = 0 were significantly lower in Group B (6 [6-6]) than in Group C (30 [30-30]; difference: -24, 95% CI: -24 to -24, p < 0.0001). At T = 30, the scores remained lower in Group B (6 [6-6]) than in Group C (22 [12-30]; difference: -16, 95% CI: -19 to -10, p < 0.0001). Group B also demonstrated shorter procedure times (30 [20-30] vs. 40 [30-50] min; difference: -10 min, 95% CI: -20 to -10, p < 0.0001), higher first-attempt success rates (61% vs. 38%; odds ratio: 0.08, 95% CI: 0.03-0.26, p < 0.0001), and fewer puncture attempts (1 [1-2] vs. 2 [1-3]; difference: -1, 95% CI: -2 to 0, p < 0.001). Rescue analgesic use and pain-related movements were significantly reduced in Group B (odds ratio for pain-related movement: ∞, 95% CI: 109-∞, p < 0.0001). CONCLUSIONS: Brachial plexus block provides superior pain relief and procedural outcomes compared to local infiltration anesthesia during peripherally inserted central catheter placement in neonates and pediatric patients. Its adoption as a standard pain management approach can enhance patient comfort, improve efficiency, and reduce procedural distress. Future studies should explore the broad applicability and long-term benefits of this approach. TRIAL REGISTRATION: Japan Registry of Clinical Trials (jRCT): jRCT1010220045.