INTRODUCTION: Periacetabular osteotomy, commonly performed for prearthritic hip dysplasia, was identified as a procedure that could benefit from an enhanced recovery after surgery pathway due to wide variation in multimo...INTRODUCTION: Periacetabular osteotomy, commonly performed for prearthritic hip dysplasia, was identified as a procedure that could benefit from an enhanced recovery after surgery pathway due to wide variation in multimodal pain management and regional anesthesia practices at our institution. The global aim of this project was to implement an enhanced recovery after surgery pathway for patients undergoing periacetabular osteotomy. Our SMART aim was to achieve greater than 70% compliance for the intraoperative medication bundle elements during the first PDSA cycle. METHODS: A multidisciplinary pathway was designed and implemented with key stakeholders from the Departments of Evidence Based Practice, Anesthesiology, Orthopedic Surgery, and Perioperative Nursing. Patient data from all patients undergoing periacetabular osteotomy from 2018 to the present were analyzed, which included the baseline cohort as well as outcomes from two Plan-Do-Study-Act cycles. RESULTS: After ERAS implementation and two subsequent Plan-Do-Study-Act cycles, we observed a decrease in hospital length of stay from 3.34 days (95% CI [2.95, 3.72]) to 2.37 days (95% CI [2.00, 2.74]) and an intraoperative medication bundle compliance of 90%. These gains occurred with minimal change in average postoperative pain scores and no hospital readmissions within 30 days of surgery. CONCLUSIONS: Multidisciplinary enhanced recovery after surgery pathways continue to play a critical role in standardizing perioperative care, reducing unwarranted variation, and promoting faster recovery across paediatric populations.
INTRODUCTION: Intraoperative hypothermia remains a frequent and under-recognized complication in neonates undergoing surgery despite standard preventive measures. Low-flow anesthesia, by increasing rebreathing and conser...INTRODUCTION: Intraoperative hypothermia remains a frequent and under-recognized complication in neonates undergoing surgery despite standard preventive measures. Low-flow anesthesia, by increasing rebreathing and conserving heat and humidity, may offer a thermo-protective effect. In this study, we compare the incidence of intraoperative hypothermia between low-flow (1 L/min) vs. routine-flow (2 L/min) anesthesia in neonates undergoing abdominal surgery. METHODS: After obtaining written informed consent from parents or legal guardians, 160 neonates scheduled for elective or emergency abdominal surgery were randomized into two groups: Group L (low-flow, 1 L/min) and Group C (control, 2 L/min). Core temperature was continuously monitored intraoperatively. The primary outcome was the incidence of intraoperative hypothermia (core temperature < 36°C). Secondary outcomes included changes in core temperature, minimum and maximum intraoperative temperature, percentage of surgical time spent under hypothermia, time to extubation, blood loss, transfusion requirements, use of inotropes, and postoperative ventilation. RESULTS: The incidence of intraoperative hypothermia was significantly lower in group L compared to group C (75% vs. 90%, p = 0.01). The median (IQR) drop in core temperature from baseline was smaller in group L as compared to group C [0.80°C (0.60-1.10) vs. 1.20°C (0.90-1.50), p < 0.001]. Minimum core temperature was higher in group L [35.5°C (35.20-35.90) vs. 35°C (34.80-35.40), p < 0.001]. The percentage of surgical time spent under hypothermia (< 36°C) was significantly lower in group L [50.3% (95% CI: 43.3-57.3)] compared to group C [65.6% (95% CI: 58.6-72.6), p = 0.003]. While intraoperative blood loss was slightly higher in the low-flow group, the clinical impact was minimal. Other outcomes, including extubation time, inotrope use, and hypoxia incidence, were comparable between groups. CONCLUSION: Low-flow anesthesia technique at 1 L/min is a safe and effective approach for reducing the incidence and duration of intraoperative hypothermia in neonates undergoing abdominal surgery. TRIAL REGISTRATION: Clinical Trial Registry of India (www.ctri.nic.in): CTRI/2022/11/047532.
Bhettay A, Gray R, Parker R
… +22 more, Allorto N, Amponsah AK, Anderson B, Baranzila L, Carapinha C, Carolus S, Green-Thompson L, Higgins O, Kolman S, Kyololo OB, Lamacraft G, Laycock H, Matula S, Mutlhobogwa K, Modack S, Modack I, Mwiti T, Ndikontar R, Oshikoya K, Salloo A, Thomas J, Maswime S
Paediatr Anaesth
· 2026 Jul · PMID 41981888
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BACKGROUND: Comprehensive pain management in children requires a specialized skillset, with a limited number of clinicians possessing the level of expertise required to successfully navigate the complexities of holistic...BACKGROUND: Comprehensive pain management in children requires a specialized skillset, with a limited number of clinicians possessing the level of expertise required to successfully navigate the complexities of holistic care. The emergence of pediatric anesthesia fellowship programs in sub-Saharan Africa presents an opportunity to embed a pediatric pain curriculum for trainees, improving the availability of specialist skill and knowledge in the field. Existing pain curricula fall short in addressing the sociocultural aspects of pediatric pain identified through research as being unique to the African context, and do not include elements of leadership and advocacy training required to navigate the complexities of resource-constrained healthcare settings. METHODS: A Delphi survey including literature review, iterative rounds of surveys and expert consensus was used to establish a pediatric pain curriculum for pediatric anesthesia fellows undertaking advanced training in sub-Saharan Africa. The 22-member expert panel included anesthetists, nurses, surgeons, pharmacists, pediatricians, a physiotherapist and a patient-caregiver dyad with a lived experience of pain. After completing three rounds of surveys, a steering committee of five members was assembled to resolve outstanding items to achieve the final curriculum. RESULTS: The process yielded a curriculum containing 20 knowledge items and 23 skills items. Attitudes are a key component of the curriculum and were grouped into six themes. A further aspect of the process was the identification of foundational knowledge with which trainees should enter a fellowship training program. This was termed the foundational curriculum. CONCLUSION: Using a Delphi method, consensus has been achieved on a pediatric pain curriculum for pediatric anesthesia fellows in sub-Saharan Africa with potential to meet the identified need for transformative pain care in this patient population.
Stancliff H, Basilious MM, Yoder LR
… +3 more, Krawiec C, Murphy T, Dalal PG
Paediatr Anaesth
· 2026 Jul · PMID 41964314
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BACKGROUND: Elective pediatric upper airway procedures are generally safe; however, some patients require unplanned pediatric intensive care unit admission, increasing care complexity. AIMS: To identify perioperative ris...BACKGROUND: Elective pediatric upper airway procedures are generally safe; however, some patients require unplanned pediatric intensive care unit admission, increasing care complexity. AIMS: To identify perioperative risk factors associated with unplanned pediatric intensive care unit admission following elective pediatric upper airway surgery. METHODS: We performed a retrospective case-control study at a single tertiary care center, identifying all unplanned pediatric intensive care unit admissions between January 2017 and June 2022. Among 151 such admissions, 29 followed elective upper airway surgery; of these, 22 cases were successfully matched on procedure type, age, and date of surgery in a 1:2 ratio to controls without unplanned pediatric intensive care unit admission based on procedure type, age, and date of surgery. Demographic, clinical, and perioperative variables were compared between cases and controls. RESULTS: The unplanned pediatric intensive care unit admission (n = 22) and control (n = 44) groups were comparable with respect to age and weight; however, median apnea-hypopnea index was higher in the unplanned pediatric intensive care unit cohort (12.7 [IQR 7.9-33.7] vs. 6.6 [IQR 3.7-25.2] events/h; p = 0.033). In unadjusted conditional logistic regression analyses, American Society of Anesthesiologists physical status > 2 was associated with increased odds of unplanned pediatric intensive care unit admission (OR 7.92, 95% CI 2.25-27.92; p = 0.001), as were prior neonatal intensive care unit admission (OR 23.19, 95% CI 3.03-177.38; p = 0.003), chronic lung disease (OR 14.00, 95% CI 1.72-113.79; p = 0.014), and longer operative duration (OR 1.03 per minute, 95% CI 1.003-1.058; p = 0.032). Apnea-hypopnea index, analyzed using multiple imputed values, was not significant (OR 1.03 per unit increase, 95% CI 0.996-1.069; p = 0.082). In a multivariable conditional logistic regression model, only prior neonatal intensive care unit admission remained independently associated with unplanned pediatric intensive care unit admission (adjusted OR 14.65, 95% CI 1.23-175.05; p = 0.034). CONCLUSION: Several clinical factors were seen to be associated with increased risk of unplanned pediatric intensive care unit admission after upper airway surgery including American Society of Anesthesiologists physical status > 2, chronic lung disease, prior neonatal intensive care unit admission, and longer operative duration. Controlling for these clinical factors, prior neonatal intensive care unit admission best predicted the need for unplanned pediatric intensive care unit admission. Recognition of these risk factors may help inform perioperative risk stratification and postoperative resource planning.
Song X, Lei D, Cui Y
… +37 more, Du Z, Jia Y, Jin Y, Tian H, Xu Y, Yang L, Zhang J, Zheng J, Zuo Y, Zhong L, Zhong J, Osazuwa M, Drum E, Kurth CD, Huang Y, Huang Q, Liu H, Liu W, Ma R, Wang D, Wang T, Wang Z, Wei S, Yang L, Zhou R, Chen L, Yu W, Li J, Zhang M, Zhang L, Qu S, Pan S, Wei R, Cheng L, Chen Y, Li X, Tang Z
Paediatr Anaesth
· 2026 Jul · PMID 41960732
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BACKGROUND: With the increasing variety of pediatric diagnostic procedures, a growing number of children require sedation for diagnostic examinations. Appropriate sedation protocols guarantee the safety of children durin...BACKGROUND: With the increasing variety of pediatric diagnostic procedures, a growing number of children require sedation for diagnostic examinations. Appropriate sedation protocols guarantee the safety of children during sedation and improve its efficiency. Currently, there are significant differences in pediatric sedation practices across countries, regions, and medical institutions. METHODS: The Pediatric Anesthesiology Group of the Chinese Society of Anesthesiology organized experts from multiple countries to develop the "Chinese Society of Pediatric Anesthesiology Guideline for Pediatric sedation (2025)" based on evidence-based medicine, considering the safety and efficacy, the preferences of children and parents, and drug accessibility. RESULTS: The guideline provided 28 recommendations addressing 12 clinical issues related to pre-sedation assessment, safety measures for sedation personnel and facilities, sedation protocols, sedation monitoring, and post-sedation recovery. CONCLUSIONS: The guideline is planned to be disseminated globally through multiple channels, aiming to standardize the management of pediatric sedation and improve its safety and efficacy.
BACKGROUND: Adequate intravenous (IV) access is a key component of anesthetic care, but this concept is often discussed in qualitative rather than quantitative terms, particularly within the pediatric subspecialty. AIMS:...BACKGROUND: Adequate intravenous (IV) access is a key component of anesthetic care, but this concept is often discussed in qualitative rather than quantitative terms, particularly within the pediatric subspecialty. AIMS: We propose a concept termed relative resuscitation capacity as a framework to standardize IV catheter sizes across patients of different sizes. METHODS: Manufacturer-reported IV catheter flow rates were used to calculate time to replace estimated blood volume (EBV). A short 16G catheter in an adult was defined to have a relative resuscitation capacity of 1, which serves as a reference point. Equivalent calculations were performed across a range of pediatric ages and catheter sizes and were normalized to this adult reference. RESULTS: The following catheter-age pairings have a relative resuscitation capacity near 1, indicating a similar time to replace EBV compared to a 16G catheter in an adult: 6-month-old with 24G, 1-year-old with 22G, 6-year-old with 20G, 10-year-old with 18G. CONCLUSIONS: Relative resuscitation provides a practical framework to equate IV catheter selection across patients of all ages. This approach helps to translate adult-based heuristics to pediatric practice and to define large-bore access quantitatively.
Singh M, Anilkumar A, Vondivillu Srinivasan R
… +3 more, Jabbar JA, Malaichamy N, Jayaraman R
Paediatr Anaesth
· 2026 Jul · PMID 41949292
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OBJECTIVE: To evaluate the efficacy and safety of prophylactic dexmedetomidine in preventing Junctional Ectopic Tachycardia (JET) and its impact on postoperative recovery in pediatric congenital heart surgery, restrictin...OBJECTIVE: To evaluate the efficacy and safety of prophylactic dexmedetomidine in preventing Junctional Ectopic Tachycardia (JET) and its impact on postoperative recovery in pediatric congenital heart surgery, restricting analysis to prospective trials. METHODS: We systematically searched PubMed, Scopus, and CENTRAL through October 16, 2025, for prospective randomized and quasi-randomized trials. Retrospective cohorts were excluded. The primary outcome was postoperative JET incidence. Secondary outcomes included mechanical ventilation duration, ICU length of stay (LOS), Vasoactive-Inotropic Score (VIS), and safety. Data were synthesized using random-effects models and certainty of evidence was assessed using the GRADE framework. RESULTS: Five prospective trials (n = 639) met the inclusion criteria. Prophylactic dexmedetomidine was associated with a significant reduction in postoperative JET incidence (OR 0.37; 95% CI 0.23-0.58; p < 0.0001; I = 0%), supported by moderate-certainty evidence. For secondary outcomes, pooled analyses suggested reductions in mechanical ventilation (MD -4.80 h) and ICU LOS (MD -19.83 h), but these were characterized by substantial clinical heterogeneity and low to very-low certainty of evidence. A significant reduction in VIS emerged only in the sensitivity analysis; these findings remain hypothesis-generating. No significant differences were observed for mortality or hypotension. CONCLUSIONS: In prospective pediatric cardiac surgery trials, prophylactic dexmedetomidine was associated with reduced postoperative JET, supported by moderate-certainty evidence. While dexmedetomidine may help facilitate earlier recovery, its impact on secondary outcomes remains suggestive rather than definitive due to low evidence certainty. Future large-scale, multicenter randomized trials are required to confirm if these potential benefits translate into consistent clinical improvements.
BACKGROUND: Intravenous dexmedetomidine is a safe and effective adjunct in propofol-based sedation. Dexmedetomidine is typically administered as a loading dose, followed by continuous infusion or not. Whether the additio...BACKGROUND: Intravenous dexmedetomidine is a safe and effective adjunct in propofol-based sedation. Dexmedetomidine is typically administered as a loading dose, followed by continuous infusion or not. Whether the addition of a maintenance infusion of dexmedetomidine after a loading dose in propofol-based sedation for pediatric magnetic resonance imaging (MRI) can be beneficial in terms of propofol consumption or adverse events is not clear. AIMS: We aimed to study whether maintaining dexmedetomidine infusion after loading dose can help reduce propofol consumption and minimize airway and cardiovascular interventions during sedation. METHODS: We retrospectively reviewed 884 medical records of pediatric sedation for MRI using both propofol and dexmedetomidine, performed at a single tertiary hospital between May 2021 and January 2023. We compared patients who received dexmedetomidine loading + maintenance (group LM) and dexmedetomidine loading only (group L) as an adjunct to propofol-based sedation. The consumption of propofol and time to recovery were measured. We also compared the incidence of airway rescue maneuver and hypotension requiring intervention during sedation. RESULTS: Overall, 695 patients were included in the analysis (group LM, n = 351, group L, n = 344). The total sedation duration was similar between the two groups (52 vs. 50 min, p = 0.255). Group LM showed significantly less total propofol consumption (6.62 vs. 7.63 mg·kg·h, p = 0.001). The incidence of airway rescue maneuver did not differ significantly between the two groups (0.9 vs. 1.5%, p = 0.501); however, the incidence of hypotension requiring intervention was lower in group LM than in group L (4.3 vs. 8.1%, p = 0.040). The recovery time did not differ significantly between the two groups (34 vs. 34 min, p = 0.932). CONCLUSION: In propofol-based sedation for pediatric MRI, maintenance infusion of dexmedetomidine after a loading dose reduces total propofol consumption and hemodynamic instability requiring intervention without prolonging recovery time, compared with dexmedetomidine bolus without maintenance.
Adenotonsillectomy is one of the most common elective pediatric surgeries. However, its routine occurrence can mask substantial preventable risks arising from practitioner inexperience, underappreciated comorbidities, ai...Adenotonsillectomy is one of the most common elective pediatric surgeries. However, its routine occurrence can mask substantial preventable risks arising from practitioner inexperience, underappreciated comorbidities, airway proximity to the surgical field, and challenging postoperative pain management. This review highlights common "error traps" that contribute to perioperative adverse events and outlines evidence-based mitigation strategies. Key preoperative challenges include unrecognized moderate-to-severe obstructive sleep apnea (OSA) and recent upper respiratory infections (URIs), both of which markedly increase perioperative respiratory adverse events (PRAEs). Intraoperative hazards include challenging airway management at induction and emergence, risk of airway fire, and excessive opioid administration. Postoperatively, inadequate analgesia and inappropriate disposition planning remain major preventable causes of morbidity. Perioperative management of the child with post-tonsillectomy hemorrhage is uniquely challenging. Structured OSA and URI screening and mitigation strategies, multimodal opioid-sparing analgesia, and institution-specific discharge algorithms are strongly recommended. A systematic, team-based approach emphasizing awareness of cognitive biases, vigilance, protocolized management, and hospital outcome monitoring can significantly reduce preventable complications and improve safety in pediatric adenotonsillectomy.
BACKGROUND: Perioperative hypoglycemia during elective surgery may have serious consequences in neonates; however, infants under 12 months of age have traditionally been assumed to be at lower risk of hypoglycemia and ke...BACKGROUND: Perioperative hypoglycemia during elective surgery may have serious consequences in neonates; however, infants under 12 months of age have traditionally been assumed to be at lower risk of hypoglycemia and ketosis. AIMS: The aim of this multi-centre prospective observational study was to identify the incidence of hypoglycemia and ketosis in children aged 6-12 months having elective surgery. Secondary aims were to identify factors associated with serum glucose concentrations and ketone concentrations at the beginning and end of anesthesia. METHODS: Serum glucose and ketone concentrations were tested at the induction of anesthesia and at the end of anesthesia. For this study, hypoglycemia was defined as glucose < 3.0 mmol/L and ketosis was defined as ketones being > 0.6 mmol/L. Data on types of fluids given, fasting time for fluids, milks and solids, and vital signs were collected. RESULTS: The study enrolled 158 participants between 2019 and 2021 at three tertiary pediatric hospitals in Australia. There were 6 cases of hypoglycemia (3.8%) recorded at induction of anesthesia with only 1 at the end of the case. At induction, 54 (34.6%) patients were ketotic with 76 ketotic (48.7%) at the end of the procedure. At induction there was no evidence for a difference between states with differing fasting guidelines in the incidence of hypoglycemia; The Royal Children's Hospital (RCH) 4 (4.1%), Queensland hospitals 2 (3.6%) risk ratio 1.13, and no evidence for a difference in ketosis; RCH 31 (32%), Queensland hospitals 18 (47.4%) risk ratio 0.76, 95% CI 0.45 to 1.17, p = 0.22. There was also no evidence for a difference in serum glucose concentrations; RCH mean 4.6 mmol/L (SD 0.84), Queensland hospitals' mean 4.7 mmol/L (SD 0.83), differences in mean -0.07 (95% CI -0.35 to 0.20) p = 0.60. However, there was evidence for a difference in ketones with median at RCH at 0.4 (IQR 0.2,0.7), Queensland at 0.6 mmol/L (IQR 0.3,0.9) however it is clinically insignificant. Serum glucose and ketone concentrations are related to milk fasting time. Increasing milk fasting times increases ketone concentrations and decreases serum glucose concentrations. CONCLUSIONS: The study showed that for young children undergoing elective surgery, there is a risk of hypoglycemia and ketosis.