BACKGROUND: Intravenous lidocaine therapy (IVLT) is often used in perioperative multimodal analgesia due to its analgesic, anti-hyperalgesic, and anti-inflammatory effects. In adults, IVLT doses of 1-2 mg/kg/h produce pl...BACKGROUND: Intravenous lidocaine therapy (IVLT) is often used in perioperative multimodal analgesia due to its analgesic, anti-hyperalgesic, and anti-inflammatory effects. In adults, IVLT doses of 1-2 mg/kg/h produce plasma concentrations of 1-2 μg/mL, within the presumed therapeutic range of 1-5 μg/mL. The dose range, expected plasma concentrations, and presumed therapeutic range are not well defined in children. We aimed to review available pharmacokinetic data in pediatric patients receiving IVLT. METHODS: We searched MEDLINE, EMBASE, and CINAHL databases for studies reporting pharmacokinetic data for IVLT in healthy 1-18-year-olds, with plasma lidocaine or metabolite levels collected post-infusion, excluding studies involving non-therapeutic infusions or children with comorbidities affecting lidocaine metabolism. Bias was assessed using validated tools. We conducted narrative data synthesis due to reporting variability and summarized plasma lidocaine and/or metabolite levels and the incidence of reported adverse events. RESULTS: Four studies comprising 174 children were included. A study (n = 22) using a 1.5 mg/kg bolus over 30 min followed by a 1 mg/kg/h infusion for 6 h post-surgery achieved highest mean drug concentrations of 2.82 ± 0.65 μg/mL immediately following surgery. Another study (n = 46) utilized a 1.5 mg/kg bolus over 5 min followed by a 2 mg/kg/h infusion and achieved peak concentrations of 4 to < 5 μg/mL. Two studies (n = 106) utilized a 1.5 mg/kg bolus and 1.5 mg/kg/h infusion until transfer to the post-operative anesthesia care unit or six hours post-operatively achieved concentrations that were detectable and < 5 μg/mL. The only adverse event reported was a single participant who experienced transient sensory disturbances. CONCLUSION: Existing pharmacokinetic data for pediatric IVLT is extremely limited. Reported plasma concentrations were detectable and lower than presumed toxic levels with one reported adverse event. Large-scale, multicenter research is needed to determine optimal pediatric dosing, elucidate dose response curves, and ensure safe and effective use of IVLT in the pediatric population. TRIAL REGISTRATION: Prospective Register of Systematic Reviews (PROSPERO): CRD42025636554.
BACKGROUND: Pain is a common experience for pediatric patients, yet it remains inadequately managed, particularly in low-resource settings. Pediatric palliative care (PPC) services are underdeveloped in many low- and mid...BACKGROUND: Pain is a common experience for pediatric patients, yet it remains inadequately managed, particularly in low-resource settings. Pediatric palliative care (PPC) services are underdeveloped in many low- and middle-income countries, including Nigeria. This scoping review examines pediatric pain management (across acute, procedural, and chronic pain types in various care settings) and palliative care in Nigeria, evaluating barriers, facilitators, and implementation gaps. METHODS: A comprehensive search was conducted for literature on pediatric pain management and palliative care in Nigeria across PubMed, Scopus, African Journals Online, and Google Scholar up to December 2024. Eligible studies were screened using Rayyan QCRI (a web-based systematic review platform) and analyzed with NVivo 12 (qualitative analysis software) for qualitative synthesis. Data on healthcare provider knowledge, pain management practices, palliative care services, and patient outcomes were extracted. The review followed PRISMA-ScR guidelines (Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews), with findings synthesized narratively due to study design heterogeneity. RESULTS: Eleven studies met the inclusion criteria (surveys of healthcare providers, audits of practices, and one RCT). Healthcare providers exhibited poor knowledge and suboptimal practices in pediatric pain management; only 30% could name three non-pharmacological pain management methods, and 52% had never prescribed morphine. Acute pain management practices in major centres relied heavily on basic analgesics but lacked advanced modalities. Two-thirds of pediatric anesthetists reported no institutional guidelines for pediatric pain, only ~5% of surgeons used any formal pain assessment tool, and no neonates received morphine post-operatively in one survey. Pediatric palliative care services were limited, with only 10 dedicated centres serving a small fraction of children in need, and most children with life-limiting illnesses were managed in general wards without specialist palliative input. Children with life-limiting illnesses suffered significant symptom burdens, including pain-over 50% of pediatric cancer patients in one study reported pain as frequent and distressing. Caregivers of these children also experienced high psychological stress, correlating with the child's symptom burden. CONCLUSIONS: Pediatric pain management and palliative care in Nigeria are in early stages. Gaps in provider training, guideline implementation, and service availability hinder progress. Strengthening education (including integration of pediatric pain/palliative care into curricula), improving opioid access (e.g., implementing national pain guidelines), and expanding dedicated palliative care services are critical to meeting the needs of children in Nigeria.
BACKGROUND: Penetrating foriegn bodies extending into brain stem are rare in children and present unique anesthetic and surgical challenges. Airway management is particularly difficult because of restricted oral access,...BACKGROUND: Penetrating foriegn bodies extending into brain stem are rare in children and present unique anesthetic and surgical challenges. Airway management is particularly difficult because of restricted oral access, risk of displacement leading to catastrophic hemorrhage and neurological complications. CASE: We describe the perioperative management of achild who presented in emergency with accidentally impacted foriegn body. The metallic foriegn body occupied the oral cavity significantly limiting the airway access and posing a risk of airway obstruction. A multidisciplinary team involving neurosurgeons, anesthesiologists and otolaryngologists was adopted. Tracheostomy under sevoflurane anesthesia with bag mask ventilation, provisions for major intracranial bleeds (due to proximity to basilar and vertebral vessels), postoperative infection control and a properly planned staged decannulation leds to an uneventful recovery without any major sequelae.
OBJECTIVE: To conduct a meta-analysis of postoperative outcomes following the use of regional anesthesia in pediatric cardiac surgery. DATA SOURCES: We searched PubMed (MEDLINE), Web of Science, CINAHL, CENTRAL, and Scop...OBJECTIVE: To conduct a meta-analysis of postoperative outcomes following the use of regional anesthesia in pediatric cardiac surgery. DATA SOURCES: We searched PubMed (MEDLINE), Web of Science, CINAHL, CENTRAL, and Scopus in December 2024 (PROSPERO: CRD420025635423; registered January 2025). STUDY SELECTION: Two authors screened search results. We included parallel-grouped randomized controlled trials (RCT) regardless of blinding. Studies comparing adjuvant regional anesthesia (excluding neuraxial anesthesia) with general anesthesia in pediatric patients (0-17 years) having cardiac surgery via midline sternotomy were included. DATA EXTRACTION: Two authors independently extracted the data and assessed risk of bias. The main outcome measures were pain relief using any documented pain score and duration of mechanical ventilation. Other outcome measures sought were postoperative opioid consumption, time to first rescue analgesia, time in pediatric intensive care unit (PICU), length of hospital stay, complications, and patient satisfaction. DATA SYNTHESIS: We identified 15 RCTs with 1055 participants for the analysis. Pain scores were lower during the first 24 h postoperatively, with Modified Objective Pain Scale (MOPS) mean difference (MD) being 0.76 less (MD -0.76; CI -1.19 to -0.32). Duration of mechanical ventilation was 48 min shorter in the regional anesthesia group (MD -48; CI -60 to -36). Postoperative cumulative opioid consumption (morphine equivalents) was 0.21 mg/kg lower (MD -0.21; CI -0.30 to -0.11). No complications related to regional anesthesia were reported. CONCLUSIONS: Our meta-analysis demonstrates that regional anesthesia in pediatric cardiac surgery reduces postoperative pain, as measured by pain scores and postoperative opioid consumption, leads to shorter mechanical ventilation and PICU stays.
Padiyath F, O'Brien EM, Nam J
… +15 more, Hu P, Mehta N, Parris M, Alexander A, Hodges A, Chiang G, Quintão VC, Carlos RV, de Sousa GS, Padiyath A, Nicolson SC, Fiadjoe J, Jackson OA, Lee LK, Garcia-Marcinkiewicz AG
BACKGROUND: Patients undergoing palatoplasty experience perioperative adverse events. Identifying risk factors for perioperative adverse events and escalation of care may improve outcomes. METHODS: Pediatric patients und...BACKGROUND: Patients undergoing palatoplasty experience perioperative adverse events. Identifying risk factors for perioperative adverse events and escalation of care may improve outcomes. METHODS: Pediatric patients undergoing primary palatoplasty were included in this retrospective observational study performed at two academic children's hospitals from 2014 to 2020. RESULTS: Four hundred fifty-nine patients with a median age of 12 months (IQR: 10-17) and median weight of 9.3 kg (IQR: 8.3-10.9) were included. A perioperative adverse event occurred in 15% (69/459) patients. Multiple (> 1) perioperative adverse events occurred in 18 patients. Hypoxemia (42 events, 9.2%) was the most common perioperative adverse event, followed by upper airway obstruction (29 events, 6.3%), vomiting (11 events, 2.4%), hypoventilation (10 events, 2.2%), and bleeding (7 events, 1.5%). Two events required a rapid response team, and there was 1 cardiac arrest. Forty percent of perioperative adverse events occurred in the post-anesthesia recovery area, and 24% occurred within 12 h of arriving to the floor. Prolonged emergence time (OR 1.04 [95% CI 1.02-1.06], p < 0.001) and nasal stent placement (OR 6.02 [95% CI 2.7-13.6], p < 0.001) were significantly associated with perioperative adverse events and increased odds of unanticipated admission to the pediatric intensive care unit (OR 1.02 [95% CI, 1.01-1.04], p < 0.001) and (OR 3.39 [95% CI, 1.19-8.83], p = 0.016), respectively. The occurrence of any perioperative adverse event (OR 8.47 [95% CI, 4.06-18], p < 0.001) and increasing number of perioperative adverse events (OR 1.75 [95% CI, 1.41-2.24], p < 0.001) were also associated with increased odds of unanticipated PICU admission. CONCLUSIONS: Patients undergoing palatoplasty are at risk of perioperative adverse events, particularly in post-operative recovery areas, which may result in unanticipated escalation of care. Recognizing the risk factors associated with the development of perioperative adverse events may improve planning of post-operative care and outcomes.
BACKGROUND: As medical education shifts toward holistic competence, integrating values-based education-including ethical reasoning, professionalism, and humanistic values-into early clinical exposure (ECE) clerkships has...BACKGROUND: As medical education shifts toward holistic competence, integrating values-based education-including ethical reasoning, professionalism, and humanistic values-into early clinical exposure (ECE) clerkships has become essential. However, scalable and effective tools to embed these components into foundational clinical training remain limited. This paper addresses the need for a structured, technology-enhanced approach to values-based learning in early clinical settings. METHODS: The authors synthesized principles from instructional design, clinical pedagogy, and educational technology to develop a conceptual and technological framework for web-based case repositories. The methodology includes a systematic architecture comprising needs analysis, multidisciplinary case authoring, technical infrastructure design, and alignment with blended learning curricula. Application strategies for authentic ECE contexts-such as facilitation techniques, learner engagement, and competency assessment-were also analyzed, alongside critical examination of implementation challenges. RESULTS: The proposed framework yields a scalable, immersive digital repository that supports values-based education through realistic, ethically nuanced cases. Key components include a user-centered technical platform, collaborative case authoring workflows, integration pathways with existing ECE-blended learning models, and assessment tools for values-related competencies. The analysis identifies technological barriers, faculty development needs, and evaluation complexities as major implementation challenges, while suggesting future directions such as AI-driven personalized learning and interoperable resource-sharing standards. CONCLUSIONS: This conceptual framework provides a comprehensive foundation for developing web-based case repositories that cultivate ethically grounded, reflective practitioners from the outset of clinical training. Although empirical evidence in this specific area is nascent, the proposed model offers actionable guidance for educators and technologists. Future empirical research is needed to validate the framework's effectiveness in real-world ECE contexts.
BACKGROUND: Off-label medicine use is the administration of a medication in any manner that is not included in the approved package insert for that medication. The off label use of medicines is common in pediatric anesth...BACKGROUND: Off-label medicine use is the administration of a medication in any manner that is not included in the approved package insert for that medication. The off label use of medicines is common in pediatric anesthesia due to the limited number of drugs that are specifically approved for use in children. This is due to the lack of clinical drug trials involving children, resulting in the absence of safety and efficacy data for this population of patients. This may lead to an increased risk of adverse events when these medicines are used in pediatric patients and expose anesthesia practitioners to the risk of litigation. AIMS: This paper describes an approach and principles for decision making for anesthesia practitioners around use of medicines in pediatric patients undergoing anesthesia. CONCLUSION: The decision to use a medication off label should be rational, clinically appropriate and based on a balance of benefit versus risk.
Analgesic effect from codeine is from its metabolite, morphine. Morphine is formed by the O-demethylation of codeine and that enzyme is controlled by the cytochrome P450 2D6. More than 60 alleles in the CYP2D6 gene have...Analgesic effect from codeine is from its metabolite, morphine. Morphine is formed by the O-demethylation of codeine and that enzyme is controlled by the cytochrome P450 2D6. More than 60 alleles in the CYP2D6 gene have been identified. This spectrum of polymorphism can be categorized into four groups: poor (PM), intermediate (IM), normal (NM), and ultra-rapid (UR) metabolizers. Codeine is rarely used in children because of fears that those with the UR genotype may suffer respiratory depression from increased morphine production. There is also concern that postpartum women medicated with codeine and who are UR metabolizers may have enough morphine in breastmilk to cause respiratory depression in a breastfed neonate. A pharmacokinetic compartment model was used to explore this assumption. There are five issues to consider in the pharmacological pathway from maternal ingestion of codeine to neonatal morphine plasma concentration: maternal morphine concentration that is dependent on genotype, milk to plasma concentration ratio, neonatal codeine and morphine exposure from breastmilk, codeine metabolism to morphine in the neonate, and morphine clearance in the neonate. The compartment model confirmed the implausibility of neonatal opioid toxicity from breastfeeding. Currently, short-term maternal use of prescription opioids (other than codeine) is considered safe and infrequently presents a hazard to the newborn. Postpartum women are denied codeine for analgesia and yet predicted neonatal morphine concentrations are lower than 1 μg/L, regardless of genotype. Maternal opioids are used with caution, especially after multiple doses, and neonates younger than 46 weeks postmenstrual age are observed for drowsiness and respiratory depression. The maternal use of codeine requires similar considerations and the current ban on codeine use in postpartum women who are breastfeeding requires review.
BACKGROUND: Pediatric anesthesia training varies widely across Ibero-America, and many anesthesiologists care for children without formal specialized preparation. AIMS: To describe training patterns, clinical exposure, a...BACKGROUND: Pediatric anesthesia training varies widely across Ibero-America, and many anesthesiologists care for children without formal specialized preparation. AIMS: To describe training patterns, clinical exposure, and practice characteristics in pediatric anesthesia across the region. METHODS: A cross-sectional online survey was distributed to anesthesiologists in 21 Ibero-American countries. Data on training, clinical experience, case volume, and use of pediatric anesthesia techniques were analyzed. RESULTS: Among 1416 respondents, only 27.8% reported formal fellowship training in pediatric anesthesia, while 72.2% developed pediatric skills through routine practice. Most (56.6%) had < 10 years of pediatric anesthesia experience, and 41% dedicated ≤ 20% of clinical time to pediatric cases. Fellowship-trained anesthesiologists performed higher pediatric case volumes and used more advanced techniques. CONCLUSIONS: Pediatric anesthesia practice in Ibero-America shows marked heterogeneity and limited structured training. Expanding fellowship programs and increasing opportunities for sustained pediatric clinical exposure are needed to support safe anesthesia care for children.
BACKGROUND AND OBJECTIVES: Epidural analgesia is an effective analgesic method for children throughout the postoperative phase. The post-operative urinary retention affects the post-operative recovery immensely. Many stu...BACKGROUND AND OBJECTIVES: Epidural analgesia is an effective analgesic method for children throughout the postoperative phase. The post-operative urinary retention affects the post-operative recovery immensely. Many studies look at post-operative urinary retention in adults who receive epidural analgesia, while there is a paucity of data in children. This is a study that addresses the question of post-operative urinary retention in children in whom epidural analgesia is employed. METHODOLOGY: This is a prospective study undertaken in the pediatric surgery department of Christian Medical College in Vellore. Children enrolled in the trial got epidural analgesia both during and after surgery. They weren't catheterized before the surgery. Those who had urinary retention were identified with ultrasound and were catheterized. Data were prospectively collected and analyzed. RESULTS: A total of 157 children participated in this study. Epidural bolus and infusate were either Ropivacaine or Bupivacaine. Sixteen children developed post-operative urinary retention, yielding an overall incidence of 10.2%. Children who were below 2 years of age had no postoperative urinary retention (95% CI: 0.0%-10.9%). Those aged 2 years and above had an incidence of 12.8% (95% CI: 8.0%-19.8%). The likelihood of voiding is 1.15 times higher in children under the age of 2 than in those 2 years and above (Relative Risk (RR): 1.15, 95% CI: 1.07 to 1.23). The incidence of POUR was 13.2% in girls and 7.9% in boys (RR: 1.68, 95% CI: 0.66-4.29, p = 0.270). POUR was observed by 9.6% of the group without the opioid additive and 11.1% of the group with the opioid additive (RR: 0.862, 95% CI: 0.338-2.19). The rate of POUR increased with surgical duration, from 6.1% in procedures < 120 min to 10.8% in procedures with 120 to 180 min and 16.0% in those exceeding 180 min. The bolus used at induction, the Bupivacaine group had 13 out of 124 patients (10.5%) with POUR, and the Ropivacaine group had 3 out of 33 patients (9.1%) with POUR (RR: 1.15, 95% CI: 0.349 to 3.81). The level of epidural placement was not found to be a significant predictor in this study. CONCLUSION: This study found a rising trend in POUR incidence with age, signifying that older children are more likely to have POUR. This supports a selective, age-guided approach to bladder catheterization in pediatric epidural practice, though larger prospective studies are needed to establish evidence-based thresholds.
BACKGROUND: Objective neuromuscular monitoring is essential to prevent residual neuromuscular block in patients receiving neuromuscular blocking agents. However, the small size of pediatric hands and the lack of appropri...BACKGROUND: Objective neuromuscular monitoring is essential to prevent residual neuromuscular block in patients receiving neuromuscular blocking agents. However, the small size of pediatric hands and the lack of appropriately sized neuromuscular equipment have made quantitative neuromuscular monitoring at the ulnar nerve (UN) difficult. In such cases, the tibial nerve (TN) can serve as an alternative site. This study aimed to compare train-of-four (TOF) monitoring using acceleromyography (AMG) and electromyography (EMG) at the TN and UN in children aged 3-24 months. We hypothesized that the time to reach a train-of-four ratio (TOFR) ≥ 0.9 would be shorter with AMG compared to EMG. METHODS: In this observational study, a total of 107 pediatric patients scheduled to elective surgery under general anesthesia with rocuronium 0.6 mg/kg were included. Patients were allocated to either bilateral tibial nerve (TN) or bilateral ulnar nerve (UN) monitoring using AMG and EMG. The primary outcome was time to TOFR ≥ 0.9. Other outcomes were time to TOFC = 0 (onset); reappearance of post tetanic count (PTC) = 1, TOFC = 1, TOFC = 2, and symptoms of residual neuromuscular block. RESULTS: Fifty patients were bilaterally monitored at TN and 50 patients were bilaterally monitored at UN. At TN time to TOFR ≥ 0.9 was 81 min (SD 29) with AMG and 112 min (SD 34) with EMG with a mean difference of 34 min (95% CI: 29-39; p < 0.0001). At UN time to TOFR ≥ 0.9 was 71 min (SD 29) with AMG and 82 min (SD 28) with EMG, with a mean difference of 11 min (95% CI: 6-15; p < 0.0001). Seventeen patients exhibited symptoms of residual neuromuscular block. CONCLUSION: Time to TOFR ≥ 0.9 after rocuronium 0.6 mg/kg in children aged 3-24 months was significantly shorter with AMG compared to EMG at both the UN and TN. AMG may underestimate the duration of action. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT06409260.
BACKGROUND: Epidural analgesia is commonly used for pain control after major lower-limb orthopedic surgery in children, but it is associated with a risk of postoperative urinary retention. Consequently, urinary catheters...BACKGROUND: Epidural analgesia is commonly used for pain control after major lower-limb orthopedic surgery in children, but it is associated with a risk of postoperative urinary retention. Consequently, urinary catheters are often placed and left in situ for the full duration of epidural analgesia, despite the potential risks of prolonged catheterization, including discomfort, ward reinsertion, and urinary tract infection. AIMS: To assess the impact of implementing a standardized institutional urinary catheter management protocol on postoperative urinary catheter outcomes in children less than age 18 years, undergoing major lower-limb orthopedic surgery with postoperative epidural analgesia. METHODS: Single-center, retrospective, observational study on children who met the above criteria in the study period before (1/2019-6/2021) and after (7/2021-7/2023) initiation of a urinary catheter management protocol. The protocol mandated intra-operative urinary catheter placement and early removal on postoperative day 1, while continuing epidural analgesia as long as 5 days. RESULTS: A total of 93 children were included in this study: 47 before and 46 after initiation of the protocol. Demographic data were similar. Children treated according to the new protocol required significantly fewer ward urinary catheter insertions (2.2% vs. 19.1% respectively, p = 0.003) and had significantly faster removal of urinary catheter (1 [1-1] vs. 3 [2-3] days, p < 0.001) without subsequent urinary catheter insertion despite similar epidural analgesia duration. There was no difference in occurrence of urinary tract infection. CONCLUSIONS: Implementation of a standardized institutional urinary catheter management protocol, mandating intraoperative catheter placement and removal on postoperative day 1, despite ongoing epidural analgesia, was associated with reduced urinary catheter duration and fewer postoperative ward catheter insertions in pediatric patients undergoing major lower-limb orthopedic surgery.
BACKGROUND: Emergence delirium (ED) is a common postoperative complication in the pediatric population. Although the pathophysiology of ED has not been fully elucidated, an association has been suggested between inflamma...BACKGROUND: Emergence delirium (ED) is a common postoperative complication in the pediatric population. Although the pathophysiology of ED has not been fully elucidated, an association has been suggested between inflammation and the development of the condition. AIMS: The aim of this study was to investigate the associations between the development of ED and preoperative inflammatory indices, primarily the systemic immune inflammation index (SII) and the pan-immune inflammation value (PIV) calculated from complete blood count parameters in pediatric patients undergoing adenoidectomy or adenotonsillectomy. METHODS: This prospective study was conducted with children aged 3-12 years who underwent adenoidectomy or adenotonsillectomy at our hospital. Preoperative inflammatory indices were calculated from complete blood count parameters, including the SII (platelet × neutrophil/lymphocyte), PIV (platelet × neutrophil × monocyte/lymphocyte), neutrophil-to-lymphocyte ratio (NLR), neutrophil-to-monocyte ratio (NMR), monocyte-to-lymphocyte ratio (MLR), platelet-to-lymphocyte ratio (PLR), and platelet-to-monocyte ratio (PMR). ED was assessed using the Pediatric Anesthesia Emergence Delirium (PAED) scale, while the Face, Legs, Activity, Cry, Consolability (FLACC) scale was used to minimize confounding by postoperative pain. Statistical analyses included receiver operating characteristic (ROC) curve analysis and multivariable logistic regression to assess the association between inflammatory indices and emergence delirium. RESULTS: ED occurred in 32 out of 99 patients (32.3%). SII exhibited an AUC of 0.850 with a cut-off value of 412 (sensitivity 81.3%; specificity 86.6%). PIV exhibited an area under the curve of 0.883, with a cut-off value of 289 (sensitivity 75.0%; specificity 92.5%). In the univariable analysis, operative time, SII, and PIV were significantly associated with ED. In the multivariable analysis, operative time, SII and PIV were significantly associated with ED. CONCLUSIONS: SII and PIV values derived from routine complete blood count parameters were observed to be associated with the development of ED in pediatric patients undergoing adenotonsillectomy and may provide useful insights into the potential role of systemic inflammation in the pathophysiology of such delirium.
INTRODUCTION: Total intravenous anesthesia (TIVA) in children has gained popularity due to potential advantages, including decreased respiratory adverse events, postoperative nausea and vomiting, and emergence agitation....INTRODUCTION: Total intravenous anesthesia (TIVA) in children has gained popularity due to potential advantages, including decreased respiratory adverse events, postoperative nausea and vomiting, and emergence agitation. British Columbia Children's Hospital (BCCH) has a reputation for TIVA use, training, and advocacy, including intravenous induction. AIM: To inform practice change and education by exploring how institutional culture impacts TIVA adoption, particularly regarding intravenous cannulation in awake children. METHODS: Current and former BCCH anesthesiologists and trainees were surveyed and interviewed about TIVA practices at BCCH and at their current institutions. The survey covered demographics, practice settings, past and current methods for induction and maintenance of anesthesia, factors contributing to technique selection, TIVA barriers and facilitators, and implementation factors. Semi-structured interviews conducted with a subset of participants were analyzed using deductive and inductive thematic analysis. RESULTS: Twenty-six participants completed the survey: 21 attending physicians, 2 fellows, and 3 residents; 58% with < 10 years' and 23% with > 20 years' anesthesia practice. Most participants (92%) practised in an academic setting, caring for a median [interquartile range] 400 [200-500] children annually. Most (96%) indicated their BCCH experience had changed their practice, with a greater effect on using intravenous anesthesia for maintenance than induction. Changes were influenced by a positive experience (77%), supportive environment (42%), and scientific evidence (42%). Choice of anesthetic technique depended on patient factors (89%), institutional expectations (46%), pharmacology (42%), and patient preference (39%), but not parental preference (15%). Interviews with 11 participants focused on intervention bundles to enable success, expectation-setting, family education, equipment and staff availability, and supportive workflows. CONCLUSION: Training in a TIVA institution can have a profound effect on using TIVA in children and drive changes in anesthetic practice elsewhere. Introducing TIVA requires a supportive culture, appropriate equipment, and the personalization of approaches, and may benefit from understanding factors in change management.