BACKGROUND: Neostigmine is widely used to reverse nondepolarizing neuromuscular blockade in children, but the optimal dose under total intravenous anesthesia is uncertain. AIMS: The primary aim was to compare the time to...BACKGROUND: Neostigmine is widely used to reverse nondepolarizing neuromuscular blockade in children, but the optimal dose under total intravenous anesthesia is uncertain. AIMS: The primary aim was to compare the time to full neuromuscular recovery (TOF ratio of 1.0) following administration of neostigmine at doses of 0, 10, 20, and 30 μg/kg in children at a TOF count of 3. Secondary objectives were full reversal within 10 min and adverse events. METHODS: This prospective, randomized, double-blind, parallel-group, superiority trial enrolled 120 children (2-10 years; ASA I-II) undergoing tonsillectomy. Participants received 0, 10, 20, or 30 μg/kg neostigmine at a TOF count of 3 measured by quantitative acceleromyography. The primary outcome was the time from TOF count of 3 to full reversal (TOF ratio = 1.0). Secondary outcomes were the proportion of patients achieving full reversal within 10 min and adverse events. Comparisons among active groups used the Kruskal-Wallis test. RESULTS: A total of 118 patients were analyzed. Median [IQR] time to full reversal was 20.2 [14.8-24.1], 14.0 [10.7-16.8], 11.0 [8.2-15.5], and 11.2 [7.9-14.6] min in the 0, 10, 20, and 30 μg/kg groups, respectively. Reversal was significantly slower in the control group compared with all neostigmine doses. However, there was no statistically significant difference among the active doses (Kruskal-Wallis, p = 0.33). At 10 min, full reversal had occurred in 10.7%, 23.3%, 43.3%, and 33.3% of patients in the respective groups. Adverse events were uncommon, occurring in 10 of 118 patients, and consisted exclusively of transient bradycardia and tachycardia, without differences among groups. CONCLUSIONS: At TOF count of 3, neostigmine 10-30 μg/kg shortened reversal compared with no reversal, but doses above 10 μg/kg conferred no additional benefit. Quantitative monitoring remains essential, as fewer than half of patients achieved a TOF ratio of 1.0 within 10 min. TRIAL REGISTRY: https://ensaiosclinicos.gov.br/rg/RBR-4xrx2g3.
Gastric ultrasound (GUS) is an evolving Point-of-Care Ultrasound (POCUS) tool whose applicability is being increasingly studied in pediatric anesthesia. The technique evaluates the gastric antrum, in the right lateral de...Gastric ultrasound (GUS) is an evolving Point-of-Care Ultrasound (POCUS) tool whose applicability is being increasingly studied in pediatric anesthesia. The technique evaluates the gastric antrum, in the right lateral decubitus or supine positions to determine the quality and quantity of stomach contents. The Perlas 3-point grading is a semi-quantitative assessment method, which can be applied to pediatric patients as well. GUS may be potentially useful in situations when a child's fasting status is uncertain or gastric emptying is delayed as an adjunct to clinical decision-making. Although quantitative gastric volume estimation models require further validation and large-scale trials are challenging due to the low incidence of aspiration, GUS holds significant promise. Its routine clinical integration demands further robust studies focused on patient-oriented outcomes.
BACKGROUND: Pediatric inhalational induction with a face mask is a well-recognized source of occupational exposure to waste anesthetic gases. Conventional anesthesia machine scavenging systems are ineffective in capturin...BACKGROUND: Pediatric inhalational induction with a face mask is a well-recognized source of occupational exposure to waste anesthetic gases. Conventional anesthesia machine scavenging systems are ineffective in capturing extra-circuit leaks occurring at the patient-mask interface. Urinary hexafluoroisopropanol (HFIP), a metabolite of sevoflurane, is a sensitive biomarker of systemic exposure. METHODS: In this prospective randomized parallel-group study, 20 anesthesiologists performing pediatric mask inductions with sevoflurane in an induction anesthesia room were allocated to work either with or without an additional external active gas scavenger positioned near the patient's face. Urine samples were collected before exposure and the following morning. HFIP concentrations were quantified by chromatography and normalized to creatinine. Between-group comparisons were performed using Welch's t-test, with a Mann-Whitney U test used as a sensitivity analysis. RESULTS: Urinary HFIP concentrations were significantly higher in anesthesiologists working without the additional scavenger compared with those using the scavenging system (mean ± SD: 0.63 ± 0.30 vs. 0.02 ± 0.04 μg/mL; p = 0.002; Cohen's d = 3.19). HFIP was undetectable or near the analytical detection limit in most samples obtained with scavenging. The observed difference corresponded to a very large effect size, indicating a marked reduction in systemic sevoflurane exposure when the additional scavenger was used. CONCLUSIONS: Use of an additional external scavenging system during pediatric mask induction was associated with a substantial reduction in anesthesiologists' biological exposure to sevoflurane, as assessed by urinary HFIP. These findings provide biological evidence supporting exposure reduction strategies during pediatric inhalational anesthesia, although the clinical significance of the observed differences remains to be established. TRIAL REGISTRATION: ClinicalTrials.gov: NCT06487169.
BACKGROUND: Preoperative anxiety is a significant stressor for children and is associated with negative postoperative outcomes. Although the incidence of difficult inductions during a single anesthetic encounter is well...BACKGROUND: Preoperative anxiety is a significant stressor for children and is associated with negative postoperative outcomes. Although the incidence of difficult inductions during a single anesthetic encounter is well documented, the longitudinal trajectory of anxiety behaviors in children undergoing repeated anesthesia remains poorly characterized. It is unclear whether repeated inductions lead to habituation (reduced difficult inductions) or sensitization (increased difficult inductions). METHODS: We conducted a secondary analysis of a large multicenter retrospective observational study involving data from six pediatric hospitals between 2019 and 2022. The cohort consisted of children under 18 years of age. The primary outcome was the trajectory of difficult induction, defined as a Child Induction Behavioral Assessment (CIBA) score of 3. Secondary outcomes included mask acceptance and trends in anxiolytic interventions. We employed mixed effects logistic regression models to analyze anxiety trajectories, adjusting for age, parental presence, and behavioral diagnoses. Lorenz curves were used to assess the concentration of anesthetic burden within the population. RESULTS: The study included 102 017 unique patients, of whom 24 564 (24%) underwent multiple encounters. The prevalence of difficult induction remained stable during the initial visits but decreased significantly after the fifth encounter, with the odds of difficult induction decreasing by at least 30% compared to the index visit. This "learning effect" was setting-dependent: children aged 1-12 years undergoing Nonoperating room anesthesia (NORA) demonstrated significant habituation, whereas difficult induction rates in the operating room (OR) remained static regardless of visit frequency. Additionally, high-frequency utilizers in NORA settings exhibited a pragmatic shift in anxiolytic strategy, transitioning from pharmacological premedication to increased incidence of parental presence at induction of anesthesia. CONCLUSIONS: In this secondary analysis, we found that repeated anesthetic exposure did not inherently lead to sensitization. Instead, children-particularly in NORA settings-exhibited habituation, characterized by decreasing anxiety behaviors over time. This divergence suggests that the less hostile physical environment and absence of surgical pain in NORA facilitate desensitization, whereas the OR environment maintains a higher baseline threat level. Clinicians should consider these distinct trajectories and prioritize environmental adaptations or parental involvement for high-frequency patients.
BACKGROUND: While randomized trials show standard blade video laryngoscopy (SVL) improves first attempt tracheal intubation success in neonates and infants, data on outcomes following adoption in routine clinical practic...BACKGROUND: While randomized trials show standard blade video laryngoscopy (SVL) improves first attempt tracheal intubation success in neonates and infants, data on outcomes following adoption in routine clinical practice are limited. We hypothesized that SVL use would increase over time and would be associated with higher first attempt success, fewer difficult intubations, and less hypoxemia during induction. AIMS: Our primary aims were to report first attempt success and incidence of difficult intubation. Secondary aims included evaluation of temporal trends in SVL use and association of modifiable factors with hypoxemia at induction. METHODS: Following IRB approval, we retrospectively reviewed anesthetics with tracheal intubation for noncardiac procedures in neonates and infants < 2 months of age at our institution from August 2012 to May 2024. Group comparisons were made using Fisher's exact test or the Chi-square test. Trends over time were analyzed using the Cochran-Armitage test of trend. Multivariable logistic regression identified factors independently associated with airway outcomes. RESULTS: First attempt tracheal intubation success was 80.4% (2994/3724); incidence of difficult intubation was 5.0% (186/3724). Hypoxemia at induction occurred in 5.5% (205/3724), and airway-related cardiac arrest occurred in 0.2% (6/3724). First attempt success increased over time, paralleling increased SVL use. SVL use was associated with increased odds of first attempt success (85.9%,1381/1607 SVL vs. 76.2%,1613/2117 direct laryngoscopy (DL), aOR 1.77 95% CI 1.48, 2.12, p < 0.001) and decreased odds of difficult intubation (3.1%, 49/1607 SVL vs. 6.5%, 137/2117 DL, aOR 0.47, 95% CI 0.33, 0.66, p < 0.001). Each additional intubation attempt was strongly associated with hypoxemia at induction. CONCLUSIONS: We found clinically important improvements in first attempt tracheal intubation over time. These changes occurred in the context of increased SVL use in conjunction with other practice changes in airway management. We advocate routine SVL use in neonates and young infants with the goal of minimizing the number of intubation attempts, a key target for reducing hypoxemia at induction.
BACKGROUND: Neuromuscular blocking agents are essential for safe pediatric anesthesia but remain a frequent source of preventable morbidity when misused, inadequately monitored, or incompletely reversed. Children, partic...BACKGROUND: Neuromuscular blocking agents are essential for safe pediatric anesthesia but remain a frequent source of preventable morbidity when misused, inadequately monitored, or incompletely reversed. Children, particularly neonates and infants, are especially vulnerable to residual neuromuscular block due to developmental pharmacological variability and limited physiological reserve. AIMS: To describe common and preventable "error traps" in pediatric neuromuscular block management and to highlight strategies to improve safety across the perioperative continuum. METHODS: This narrative review synthesizes current evidence and clinical practice patterns to identify recurrent pitfalls in the use, monitoring, reversal, and postoperative management of neuromuscular blocking agents in children. RESULTS: Four major error traps were identified: omission of neuromuscular blocking agents when optimal intubating conditions are required; failure to use quantitative neuromuscular monitoring; inappropriate or mistimed pharmacological reversal; and failure to recognize and treat residual paralysis. These errors contribute to a persistently high incidence of residual neuromuscular block and are associated with increased risk of postoperative respiratory complications. Developmental pharmacokinetic and pharmacodynamic variability further amplifies these risks in pediatric populations. CONCLUSIONS: Avoidance of these error traps requires systematic application of evidence-based practices, including routine use of quantitative neuromuscular monitoring and objective confirmation of recovery with a train-of-four ratio ≥ 0.9 prior to extubation. Embedding these principles into clinical practice is essential to improving safety in pediatric anesthesia.
BACKGROUND: Emergence delirium (ED) is a common phenomenon in pediatric populations and is characterized by altered consciousness, manifesting as either agitation or a hypoactive state. While the link between socioeconom...BACKGROUND: Emergence delirium (ED) is a common phenomenon in pediatric populations and is characterized by altered consciousness, manifesting as either agitation or a hypoactive state. While the link between socioeconomic status and chronic stress has been well studied and linked to poor health outcomes, no research to date has explored the impact that socioeconomic status has on ED in pediatric populations. AIMS: This study investigated how socioeconomic status impacts ED in pediatric patients undergoing common outpatient procedures. METHODS: We conducted an analysis of pediatric patients at one tertiary care center who received one of three common, stimulating, outpatient procedures: venting myringotomy, intestinal endoscopy, or dermatologic laser surgery. The Modified Yale Pediatric Anxiety Scale (mYPAS) and Pediatric Anesthesia Emergence Delirium (PAED) screening tools were administered, and demographic factors were collected for each patient. Socioeconomic status was determined using each patient's address and the Area Deprivation Index (ADI), a validated metric created by the University of Wisconsin. Statistical analysis was performed using logistic regression with an outcome of emergence delirium and with ADI as a three-category categorical variable. RESULTS: Patients in the highest ADI group had a significantly higher probability of experiencing emergence delirium compared to patients in the lowest ADI group, adjusting for age and postoperative pain score. CONCLUSIONS: This data suggests that children from low socioeconomic backgrounds are more likely to experience emergence delirium. This is the first study tying socioeconomic status to emergence delirium, or any anesthesia complication, in pediatric patients. Future studies should investigate strategies to mitigate emergence delirium and explore associations between socioeconomic status and other anesthesia complications.
Pediatric Interventional Radiology (IR) is progressively expanding and gaining popularity as it provides minimally invasive procedures and treatments, with very good outcomes and low adverse event rates. The image-guided...Pediatric Interventional Radiology (IR) is progressively expanding and gaining popularity as it provides minimally invasive procedures and treatments, with very good outcomes and low adverse event rates. The image-guided body procedures include central venous access, gastrointestinal procedures, such as gastrostomy tubes, biopsies of solid organs and tumors, pleural and abdominal drain placements, endovascular procedures, and embolizations. Pediatric patients who require IR are often medically complex and have significant pathophysiological derangements. Pediatric IR intersects with multiple specialties, including Oncology, Transplant, General Surgery, Genetic Metabolic Diseases, Neurology, and Infectious Diseases. Anesthesiologists play a key role in IR, ensuring safe and effective care, often under complex clinical circumstances. The purpose of this review is to outline key practical considerations in the anesthetic management of pediatric IR, in particular body procedures. We present aspects of the pre-procedure evaluation and preparation and an overview of the IR technique, including considerations about agents commonly used in radiology, and we describe peri-operative considerations, anticipated challenges, and potential complications. Anesthesiologists will learn about image-guided body procedures and peculiarities of the anesthetic management, expanding their familiarity, and gaining confidence with pediatric cases in the IR environment.
Mills N, Michalchyshyn E, Parry M
… +11 more, Couper B, Orr A, Mohareb M, Rutherford S, Cosby K, Jarvis A, So J, Lachica M, Domingues A, Robertson J, Matava C
BACKGROUND: Preanesthesia assessment is essential but resource-intensive. Electronic health records (EHRs) are widespread, yet pediatric perioperative screening remains variable. OBJECTIVE: To develop and implement a pre...BACKGROUND: Preanesthesia assessment is essential but resource-intensive. Electronic health records (EHRs) are widespread, yet pediatric perioperative screening remains variable. OBJECTIVE: To develop and implement a preanesthesia triage tool based on patient-administered electronic triage questionnaire (PAC-Q) integrated with the Epic EHR to streamline pediatric preanesthesia assessment. METHODS: Using a quality-improvement framework, we created a preanesthesia triage tool that includes an adapted version of Epic's foundation questionnaire to form a 28-item PAC-Q distributed via MyChart. Responses were weighted (0, 1, or 100) to generate a triage score that, together with surgical risk, routed patients to an RN, NP, or MD for preanesthesia assessment. Implementation was staggered across surgical services. Adoption and outcomes were monitored via Epic dashboards and Power BI. RESULTS: By August 31, 2025, 3993 patients completed the PAC-Q. Of these, 53.7% (2144/3993) were triaged to an RN, 12.3% (492/3993) to an NP, and 6.8% (272/3993) to an MD; 27.1% (1083/3993) were cleared by chart review without further consultation. Comparing April-June 2023 with April-June 2025, completed preanesthesia assessments increased from 71.3% (1182/1659) to 83.8% (1510/1802) (χ = 78.70, p < 0.0001). In otolaryngology, completion rose from 22.9% (65/284) to 82.7% (230/278) (χ = 199.37, p < 0.0001). Providers and families reported high satisfaction and reductions in administrative burden. CONCLUSIONS: The PAC-Q is a scalable, patient-centered digital tool that standardizes pediatric preanesthesia triage, reduces unnecessary visits, and improves screening uptake. It can be adapted to diverse perioperative settings to enhance efficiency and patient experience.
BACKGROUND: Hemodynamic instability during vasoactive drug infusion remains a clinical challenge. While macroscopic factors are well-studied, the physical interaction between syringe residual air and vertical pump positi...BACKGROUND: Hemodynamic instability during vasoactive drug infusion remains a clinical challenge. While macroscopic factors are well-studied, the physical interaction between syringe residual air and vertical pump positioning is often overlooked. This study investigates how these factors synergistically disrupt flow stability using a simplified simulation model. METHODS: A simulation model was constructed using a 60 mL syringe, infusion tubing, and two 3-way stopcocks. The system was tested under four conditions: with or without 1 mL of air in the syringe, and with the infusion terminal positioned 25 cm or 50 cm below the syringe level. Droplet formation at the terminal stopcock was quantified over 10 s intervals using a standardized visual scale. Each condition was repeated 30 times (n = 120 trials). Data were analyzed using non-parametric tests. RESULTS: The presence of 1 mL of air significantly increased flow instability, yielding higher droplet counts compared to the no-air group at both 25 cm (median: 0.75 vs. 0.25 drops, p < 0.001) and 50 cm (median: 2.25 vs. 0.75 drops, p < 0.001). Increasing the height from 25 cm to 50 cm also significantly raised droplet output: from 0.25 to 0.75 drops without air (p < 0.001), and from 0.75 to 2.50 drops with 1 mL of air (p < 0.001). The greatest instability occurred under the combined condition of 50 cm height with 1 mL of air. CONCLUSION: Residual syringe air and infusion pump vertical position are critical, interacting factors that disrupt flow continuity during vasoactive drug delivery. Air bubbles induce transient flow variations, while height differences amplify these effects through hydrostatic pressure. Clinical protocols should emphasize meticulous air elimination and consistent pump positioning at the level of the patient's right atrium to minimize avoidable infusion-related hemodynamic instability.
BACKGROUND: Bleeding after cardiopulmonary bypass in pediatric patients undergoing pulmonary artery reconstruction is a major source of morbidity. Factor concentrates have emerged as off-label therapy to achieve hemostas...BACKGROUND: Bleeding after cardiopulmonary bypass in pediatric patients undergoing pulmonary artery reconstruction is a major source of morbidity. Factor concentrates have emerged as off-label therapy to achieve hemostasis while minimizing transfusion. In 2020, our institution implemented a standardized hemostasis management pathway combining factor concentrates. AIMS: This study evaluates the impact of the pathway on blood product transfusion and thromboembolism for patients undergoing pulmonary artery reconstruction with cardiopulmonary bypass. METHODS: We conducted a retrospective propensity score-matched cohort study comparing pediatric patients undergoing pulmonary artery reconstruction before and after pathway implementation. The pre-pathway cohort received activated 4-factor prothrombin complex concentrate for refractory bleeding with variable dosing, whereas the post-pathway cohort received both fibrinogen and activated 4-factor prothrombin complex concentrates in standardized doses. The primary efficacy outcome was total blood product transfused after cardiopulmonary bypass. The primary safety outcome was thromboembolism incidence at seven and 30 days postoperatively. Secondary outcomes included 24-h chest tube output, time to extubation, length of stay, 30-day mortality, and acute kidney injury. RESULTS: A total of 97 pre-pathway patients and 178 post-pathway patients were included in the final data set for statistical analysis. After propensity score matching, 87 patients remained in each cohort. The post-pathway cohort was associated with a statistically significant reduction in total blood products transfused (30.4 mL/kg vs. 47.9 mL/kg, mean difference 17.6 mL/kg, 95% CI [9.82-25.9], p < 0.0001). There was no statistically significant difference in seven-day (11.5% post-pathway vs. 8.0% pre-pathway, OR 1.48, 95% CI 0.51-4.32, p = 0.468) or 30-day (18.4% post-pathway vs. 9.2% pre-pathway, OR 2.23, 95% CI 0.84-5.87, p = 0.106) thromboembolism rates. There were no significant differences in secondary outcomes. CONCLUSIONS: A hemostasis management pathway utilizing combined factor concentrates was associated with significantly reduced post-bypass transfusion requirements in pediatric pulmonary artery reconstruction. We observed a higher incidence of post-operative thromboembolism, with a twofold increase at 30 days, although statistical significance was not reached. The majority of post-operative thromboembolism was associated with indwelling lines. Prospective multicenter studies are needed to validate safety, efficacy and generalizability of utilizing combined factor concentrates in pediatric patients.
BACKGROUND: High-risk substance use is a public health concern among adolescents placing them at increased likelihood for opioid misuse and overdose. However, whether high-risk substance use is associated with increased...BACKGROUND: High-risk substance use is a public health concern among adolescents placing them at increased likelihood for opioid misuse and overdose. However, whether high-risk substance use is associated with increased postoperative opioid use remains poorly described. This study aimed to determine whether preoperative high-risk substance use is associated with increased postoperative opioid use in adolescents. METHODS: This longitudinal study included opioid-naive adolescents undergoing ambulatory orthopedic surgery. Preoperative high-risk substance use was stratified using the Brief Screener for Tobacco, Alcohol, and other Drugs (BSTAD). Postoperative opioid dose use was recorded with an objective electronic medication adherence device. Postoperative pain was reported every 4 h using a smartphone diary. Multivariable regression analyses for cross-sectional data and multivariable mixed modeling for longitudinal data were performed. RESULTS: Participants (n 121) aged 15 years (mean; range 11-19) (49% females) had mostly knee, some shoulder and elbow surgery. Only 13/121 (10.7%) reported high substance use risk, none reported low risk, with the majority (89.3%) reporting no substance intake in the prior 12 months. Patients with high-risk preoperative substance use took twice the postoperative opioid doses compared to those with no use 12.2 (2.7) versus 5.6 (0.6) (p < 0.0001). Multivariate negative binomial regression analysis, controlling for sociodemographic and clinical factors, confirmed high-risk preoperative substance use was associated with increased postoperative opioid dose use (incidence rate ratio 1.96, 95% CI: 1.12-3.43, p = 0.018). Longitudinal analysis over 14 days revealed that while adolescents with high-risk substance use overall used more opioids for their pain, they were also less likely to vary their opioid use in response to lower levels of pain intensity as compared to adolescents without substance use. CONCLUSIONS: High-risk preoperative substance use was associated with increased postoperative opioid use in opioid-naïve adolescents following elective ambulatory orthopedic surgery. These findings, although limited by small sample size, highlight the need for presurgery substance use screening to guide personalized strategies, potentially reduce opioid use, improve pain management, and lower misuse risk.
BACKGROUND: Pediatric anesthesia carries a higher risk of complications than adult anesthesia, yet clinical exposure to pediatric cases is increasingly limited in Japan due to declining birth rates and urban-rural dispar...BACKGROUND: Pediatric anesthesia carries a higher risk of complications than adult anesthesia, yet clinical exposure to pediatric cases is increasingly limited in Japan due to declining birth rates and urban-rural disparities. Although simulation-based education improves clinical competency, no validated program exists in Japan for pediatric anesthesia. AIMS: This study aimed to develop and implement a culturally adapted, simulation-based training program for pediatric anesthesia in Japan, the Japanese version of Managing Emergencies in Pediatric Anesthesia (J-MEPA). METHODS: This study was conducted in two phases. Phase 1 involved the translation, cultural adaptation, and feasibility testing of the original English MEPA course. Phase 2 implemented J-MEPA and evaluated inter-rater reliability, criterion-related validity, and educational effectiveness. All simulations were video-recorded; learners' performance was assessed by trained pediatric anesthesiologists using a revised checklist with added sub-items and behaviorally anchored rating scale (BARS). The reliability of these assessments was evaluated using intraclass correlation coefficients (ICC). Validity was examined by correlations between participants' clinical experience and performance scores. Educational effectiveness, focusing on reaction and learning, was measured using a post-course questionnaire with the Kirkpatrick Model. RESULTS: Forty-four participants completed 209 simulations. Inter-rater reliability was acceptable across scenarios (ICCs ranging from 0.54 to 0.86 for the revised checklist; 0.50 to 0.79 for BARS). We explored criterion-related validity, and the positive correlation between BARS scores and pediatric experience was consistent with preliminary validity evidence, whereas the revised checklist scores were modest. Participants reported high satisfaction, engagement, relevance, and increased confidence and motivation to apply skills learned in the course. CONCLUSIONS: The Japanese version of MEPA was successfully developed and preliminarily evaluated. We observed acceptable inter-rater reliability, initial evidence of criterion-related validity, and positive educational outcomes. J-MEPA offers a feasible, culturally appropriate approach to addressing pediatric anesthesia training gaps in Japan and may serve as a model for adapting simulation-based training to similar healthcare contexts, while warranting further evaluation in larger and more diverse settings. TRIAL REGISTRATION: University Hospital Medical Information Network Clinical Trials Registry (UMIN-CTR), Japan Trial ID: UMIN000040879.