Anesthesia is increasingly acknowledged as a neglected priority in global health, and pediatric anesthesia is especially important due to the high proportion of children in the least developed countries with a large unme...Anesthesia is increasingly acknowledged as a neglected priority in global health, and pediatric anesthesia is especially important due to the high proportion of children in the least developed countries with a large unmet burden of surgical disease. Pediatric anesthesiologists involved in global health may encounter several common "error traps" that could either lead to missed opportunities to build on recent advancements in global anesthesia or potentially cause harm. We present a number of these "traps" based on the literature and our experience from both sides of global health partnerships in East and Southern Africa, India, and the Caribbean. These error traps include failing to appreciate the public health "big picture"; failing to consider a health-systems approach, prioritizing quantity-based outcomes at the expense of quality, having priorities driven by partners in the "Global North"; failing to make programs sustainable, failing to invest in the retention of anesthesia providers, not realizing that not all global health is international health, and unethical practices. Our goal is to spark debate on ongoing controversies and to inform pediatric anesthesiologists who are working or considering a career in this field.
BACKGROUND: Needle-related procedures are among the most frequent and distressing experiences for children. The Buzzy device, which combines cold and vibration, has emerged as one of the best non-pharmacological tools to...BACKGROUND: Needle-related procedures are among the most frequent and distressing experiences for children. The Buzzy device, which combines cold and vibration, has emerged as one of the best non-pharmacological tools to reduce procedural pain and anxiety. However, its effectiveness may vary substantially across age groups, a factor not consistently addressed in prior literature. This stands in sharp contrast to pain assessment, where age-specific tools are routinely applied, while comparable rigor is lacking for non-pharmacological interventions. METHODS: We conducted a Bayesian reanalysis of the most recent systematic review and meta-analysis on the Buzzy device in pediatrics, including sixteen randomized controlled trials reporting pain outcomes and six reporting anxiety outcomes. Bayesian hierarchical random-effects models were applied, and study-level covariates were examined through meta-regression. Posterior distributions, credible intervals (CrIs), and Bayes factors (BFs) served to quantify the strength of evidence. RESULTS: Buzzy significantly reduces pain (SMD -1.05, 95% CrI -1.41 to -0.70) and anxiety (SMD -1.59, 95% CrI -2.65 to -0.54). Age emerged as a significant moderator of pain reduction: children aged 7 years or older showed stronger benefit (posterior probability = 97.9%; BF = 13.9). In contrast, no meaningful associations were observed with sex distribution, procedure type, or risk of bias. For anxiety, the age effect was inconclusive, reflecting limited study numbers and wide credible intervals. CONCLUSION: This Bayesian reanalysis confirms the effectiveness of Buzzy for pediatric procedural pain while highlighting age as a key determinant. The device appears more beneficial in children aged 7 years or older, supporting its preferential use in school-aged populations, where the greatest clinical benefit is observed.
BACKGROUND: Single ventricle congenital heart disease patients palliated to Fontan physiology lack a ventricle to generate pulmonary blood flow. Positive pressure mechanical ventilation reduces pulmonary blood and theref...BACKGROUND: Single ventricle congenital heart disease patients palliated to Fontan physiology lack a ventricle to generate pulmonary blood flow. Positive pressure mechanical ventilation reduces pulmonary blood and therefore cardiac output as compared to regular, negative pressure ventilation. There is controversy as to whether lower or higher tidal volumes are optimal for mechanical ventilation. AIM: This crossover trial aimed to determine whether higher versus lower tidal volumes would be optimal for systemic cardiac output. METHODS: The authors recruited Fontan patients < 18 years old presenting for cardiac catheterization who would require intubation and positive pressure ventilation. Patients were randomized to begin in either a high (10 mL/kg) or low (6 mL/kg) tidal volume strategy. Pressures and blood gases were obtained, the patient was transitioned to the alternate ventilation strategy, and the catheterization procedures were repeated. The authors derived a clinically significant difference of 0.7 L/min/m. Paired comparisons of systemic cardiac index, pulmonary blood flow, and vascular resistances were made between the high and low tidal volume conditions. RESULTS: Thirty patients underwent the complete study protocol. Three out of nine (33%) patients who had a higher cardiac index in the high tidal volume strategy met the significant difference threshold compared to 8/19 (42%) of those who had a higher cardiac index in the low tidal volume strategy (Cohen's h = 0.186). There was no statistically significant difference in cardiac index between low (3.19 L/min/m, 95% CI 2.76-3.62 L/min/m) and high (2.96 L/min/m, 95% CI 2.53-3.39 L/min/m) tidal volume strategies, p = 0.062. CONCLUSION: While there was no significant difference in cardiac index between the two ventilation strategies in the direct comparison, we did obtain data showing lower tidal volume may be favorable for maintaining cardiac index for some Fontan patients requiring positive pressure ventilation.
BACKGROUND: The bispectral index (BIS) represents a promising tool for monitoring the depth of hypnosis. However, its utility in guiding sevoflurane administration during general anesthesia in pediatric patients is not w...BACKGROUND: The bispectral index (BIS) represents a promising tool for monitoring the depth of hypnosis. However, its utility in guiding sevoflurane administration during general anesthesia in pediatric patients is not well known. METHODS: We performed a systematic review and meta-analysis of randomized controlled trials comparing BIS-guided versus standard practice sevoflurane administration in pediatric patients. PubMed/MEDLINE, Embase, and the Cochrane Central Register of Clinical Trials were searched for trials published up to May 2025. Analyses were conducted using RevMan 5.4.1., and heterogeneity was assessed using the I statistic. RESULTS: We included nine studies randomizing a total of 730 pediatric patients, of whom 359 (49.2%) were managed with BIS monitoring. BIS-guided anesthesia was associated with significantly lower mean end-tidal sevoflurane concentrations, both during the maintenance phase (MD -0.46; 95% CI: -0.62 to -0.29; p < 0.00001) and at the end of surgery (MD -0.31; 95% CI: -0.47 to -0.14; p = 0.0003). Furthermore, the BIS-guided group experienced a shorter time to airway removal (MD -1.69 min; 95% CI: -2.84 to -0.55 min; p = 0.004) and a shorter time to post-anesthesia care unit discharge (MD -11.82 min; 95% CI: -17.80 to -5.84 min; p = 0.0001). No significant difference was observed in Pediatric Anesthesia Emergence Delirium score between groups (MD -0.35; 95% CI: -1.90 to 1.19; p = 0.65). CONCLUSIONS: BIS-guided monitoring offers a strategy to reduce end-tidal sevoflurane concentrations, shortening time to airway removal and post-anesthesia care unit discharge in pediatric patients undergoing sevoflurane anesthesia. STUDY REGISTRATION: PROSPERO, review no. CRD420251067409.
Banchs RJ, Barawi K, Banchs BA
… +1 more, Kratunova E
Paediatr Anaesth
· 2026 Feb · PMID 41263419
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BACKGROUND: Dental rehabilitation under general anesthesia (GA) is often required for children who are unable to cooperate during standard dental procedures. Accurately estimating the duration of these cases is challengi...BACKGROUND: Dental rehabilitation under general anesthesia (GA) is often required for children who are unable to cooperate during standard dental procedures. Accurately estimating the duration of these cases is challenging, particularly when preoperative X-rays are unavailable. Efficient scheduling and optimal operating room (OR) utilization rely on precise time predictions; however, existing predictive models, including EPIC's analytics, frequently overlook patient- and case-specific factors, resulting in suboptimal OR efficiency. AIMS: This study aimed to identify preoperative, patient-specific factors that influence the duration of pediatric dental rehabilitation under GA and to develop an age-based predictive equation to improve procedure time estimation. METHODS: A retrospective review was conducted on 255 dental rehabilitation cases performed under general anesthesia (GA) between January 2022 and December 2023. Collected data included patient demographics, treatment details, availability of radiographs, and operating room (OR) time metrics. Statistical analysis was performed to assess the influence of preoperative factors on procedure duration. An age-based fitted equation was developed, and its predictive accuracy compared with that of EPIC's analytics system. RESULTS: Age was the strongest patient-specific predictor of procedure duration (p < 0.001, R = 50.73%), correlating with both dentition type and the extent of dental restoration required. The age-based fitted equation substantially outperformed EPIC's analytics, particularly in the 3-5 and 13-18 age groups, improving prediction accuracy by 42% and 114%, respectively. The fitted equation was Y = 84-4.5X + 0.6X, where Y represents procedure time and X represents age. Other patient-specific variables, including weight, BMI, and ASA classification, demonstrated minimal influence. CONCLUSIONS: Developing an age-specific fitted equation based on site-specific operating room (OR) data improves procedure time prediction for pediatric dental rehabilitation under GA. This model supports more precise scheduling, better resource allocation, and improved patient access to care, providing a valuable framework for efficiency in the OR.
Moustaqim-Barrette M, Riehm L, Parra D
… +1 more, Munshey F
Paediatr Anaesth
· 2026 Feb · PMID 41222005
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Ultrasound (US) guidance has become an essential skill for peripheral intravenous (PIV) placement in children. It may be used as a primary approach or as a rescue technique after failed attempts, particularly in children...Ultrasound (US) guidance has become an essential skill for peripheral intravenous (PIV) placement in children. It may be used as a primary approach or as a rescue technique after failed attempts, particularly in children with difficult intravenous access (DiVA). An increasing amount of literature shows the benefit of using US guidance for PIV placement in children with DiVA. With more consistent availability of US machines across many institutions, their use for PIV placement is becoming commonplace, with several types of clinicians performing the procedure. Novice proceduralists and those in training may encounter technical challenges that may impede successful PIV cannulation. Having strategies to avoid, troubleshoot, and overcome technical challenges is essential for improving the technique of US guidance for PIV access. The purpose of this review was to summarize the literature around the most common technical challenges that arise when performing US-guided PIV placement in children and practical strategies that may improve cannulation success. We also highlight US-guided PIV placement considerations specific to special populations, including premature neonates, pediatric burns, epidermolysis bullosa, and those receiving bleomycin sclerotherapy.
Weba ETP, de Sousa GS, de Mesquita Ipácio AP
… +7 more, Fukunaga CK, Silva RAS, Teixeira MAF, Filardi RM, Costa CM, Carlos RV, von Ungern-Sternberg BS
Paediatr Anaesth
· 2026 Feb · PMID 41216993
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INTRODUCTION: Lidocaine is widely used in pediatric anesthesia for airway topicalization to modulate undesirable airway and circulatory reflexes, yet its effectiveness remains unclear. Therefore, we aimed to perform a me...INTRODUCTION: Lidocaine is widely used in pediatric anesthesia for airway topicalization to modulate undesirable airway and circulatory reflexes, yet its effectiveness remains unclear. Therefore, we aimed to perform a meta-analysis evaluating the impact of topical lidocaine on respiratory adverse events in children undergoing airway management. METHODS: PubMed, Embase, and Cochrane databases were systematically searched for studies comparing topical lidocaine with placebo, no intervention, or intravenous lidocaine for pediatric airway management. Statistical analysis was performed using R (version 4.4.1). Odds ratios (ORs) were used for binary outcomes and mean differences for continuous outcomes, with 95% confidence intervals (CIs) computed using a random-effects model. RESULTS: Fourteen randomized controlled trials comprising 1937 pediatric patients were included, of whom 917 (47%) received airway topicalization. In those receiving topical lidocaine, there was a significant reduction in the incidence of laryngospasm (OR 0.50; 95% CI 0.27 to 0.95; p = 0.033), desaturation (OR 0.49; 95% CI 0.25 to 0.98; p = 0.043), and sore throat (OR 0.31; 95% CI 0.16 to 0.58; p < 0.001). However, no significant differences were observed for bronchospasm (OR 0.50; 95% CI 0.11 to 2.35; p = 0.382), cough (OR 0.56; 95% CI 0.28 to 1.11; p = 0.099), severe cough (OR 1.30; 95% CI 0.18 to 9.51; p = 0.793), hoarseness (OR 1.41; 95% CI 0.17 to 11.96; p = 0.754), vomiting (OR 1.95; 95% CI 0.47 to 7.99; p = 0.355), and heart rate (beats/min) (MD 0.08; 95% CI -6.31 to 6.47; p = 0.98). CONCLUSION: Our findings suggest that topical lidocaine may reduce the incidence of undesirable airway reflexes such as laryngospasm, desaturation, and sore throat in children undergoing airway management. However, its benefit for other perioperative respiratory adverse events requires further investigation, especially in high-risk populations. TRIAL REGISTRATION: PROSPERO registration number: CRD42024614863.
"Cannot Intubate, Cannot Oxygenate" is a rare but life-threatening situation that requires immediate recognition, advanced airway management, and ultimately emergency front-of-neck access. All airway practitioners caring..."Cannot Intubate, Cannot Oxygenate" is a rare but life-threatening situation that requires immediate recognition, advanced airway management, and ultimately emergency front-of-neck access. All airway practitioners caring for children should be prepared to face these situations. The aim of this review was to provide a concise summary of the latest evidence and to propose a streamlined protocol for pediatric emergency front-of-neck access in the intensive care setting. The strength of our protocol is that we have set explicit time limits for front-of-neck access attempts and incorporated extracorporeal membrane oxygenation to achieve the best possible survival and neurological outcomes. No evidence-based consensus exists on the best practice, although organization of local protocols and equipment, as well as regular and comprehensive training, is crucial to bolster clinician confidence and improve patient outcomes.
BACKGROUND: Congenital long QT syndrome (LQTS) and Catecholaminergic Polymorphic ventricular Tachycardia (CPVT) are inherited arrhythmogenic disorders leading to an increased risk of life-threatening arrhythmias. Left ca...BACKGROUND: Congenital long QT syndrome (LQTS) and Catecholaminergic Polymorphic ventricular Tachycardia (CPVT) are inherited arrhythmogenic disorders leading to an increased risk of life-threatening arrhythmias. Left cardiac sympathetic denervation (LCSD), currently performed by video-assisted thoracoscopic surgery (VATS) is a well-established treatment for patients not fully protected by drugs. Peri-operative pain management represents a challenge. AIM: To assess the impact of a multimodal approach for perioperative pain management including combined regional anesthesia on postoperative pain scores, opioid requirements and neuropathic pain incidence in pediatric LQTS and CPVT patients undergoing VATS-LCSD. METHODS: A retrospective analysis was conducted on consecutive children undergoing VATS-LCSD at a single center from 2021 to March 2025. Per protocol, they all received Erector Spinae Plane (ESP) and Serratus Plane (SP) block. A perifascial catheter was placed following ESP for continuous local anesthetic infusion. RESULTS: 15 patients were enrolled (median age 6.9 years, IQR 4.3-9.8, median weight 24 kg, IQR 18.3-35.5). Most (13, 87%) had LQTS and almost one third had a high-risk genotype. There were no major complications. There was only 1 case (7%) of accidental removal of the ESP catheter, in whom prophylactic morphine was used. Pain scores, as assessed by VAS, were below 2 in all patients; none needed additional doses of opioids nor ketorolac or developed neuropathic pain postoperatively. CONCLUSIONS: Our results support the use of a combined regional anesthesia protocol for peri-operative pain management in pediatric channelopathy patients undergoing VATS-LCSD. This approach may improve overall quality of care for this vulnerable population.
Paediatr Anaesth
· 2026 Feb · PMID 41189402
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The field of pediatric cardiac anesthesia faces a critical workforce shortage. Survival of children with congenital heart disease (CHD) has improved dramatically, increasing both lifetime procedural demand and case compl...The field of pediatric cardiac anesthesia faces a critical workforce shortage. Survival of children with congenital heart disease (CHD) has improved dramatically, increasing both lifetime procedural demand and case complexity. At the same time, the supply of fellowship-trained pediatric cardiac anesthesiologists is shrinking due to an aging workforce, declining fellowship recruitment, financial disincentives, and concerns about work-life balance and professional culture. The resulting mismatch between demand and supply threatens access to care and risks moral injury and attrition within the specialty. At our institution, workforce pressures necessitated the redistribution of some CHD care to general pediatric anesthesiologists through the Special Cardiac Care Anesthesia (SCCA) model. As this team expanded, members themselves recognized a pressing need for structured education in congenital cardiac physiology and anesthetic implications. In response, the Cardiac Basics curriculum was developed to provide accessible, foundational cardiac content for anesthesiologists, fellows, advanced practice providers, and intensivists. The program was designed with three goals: (1) to provide essential cardiac knowledge, (2) to deliver material in a format accessible to diverse learners, and (3) to foster a psychologically safe environment where all participants could ask questions and engage openly. The curriculum uses weekly topic guides, brief interactive didactic sessions, and case-based reinforcement. It has been well received, with strong participation across learner groups and overwhelmingly positive feedback highlighting clarity, brevity, and clinical applicability. Educational innovations such as Cardiac Basics represent a pragmatic and scalable strategy to address the pediatric cardiac anesthesia workforce crisis. By equipping a broader group of providers with the skills to care safely for selected CHD patients, such curricula can serve as a critical "force multiplier" while longer term solutions-fellowship recruitment, pipeline repair, and cultural change-are pursued.
INTRODUCTION: Proton beam therapy (PBT) is becoming the radiotherapeutic modality of choice for children with curable cancer. A significant proportion require anesthetic care to facilitate precise positioning and immobil...INTRODUCTION: Proton beam therapy (PBT) is becoming the radiotherapeutic modality of choice for children with curable cancer. A significant proportion require anesthetic care to facilitate precise positioning and immobility, and such patients undergo repetitive episodes of general anesthesia, 5 days a week for up to 8 weeks. Patients with central nervous tumors and those undergoing concurrent chemotherapy form a large proportion of referrals. Although X-ray therapy and PBT demonstrate similarities, factors including younger patient age, longer session length and a need for rigid immobilization, means that providing anesthetic care for PBT is more complex as compared to X-ray therapy. We present a case series of three patients who failed to complete PBT due to problems relating to anaesthesia. Our objective is to highlight specific PBT-related challenges in the pediatric population, because although serious complications are uncommon, there can still be significant risk. METHODS: We retrospectively reviewed the patient records of the three pediatric cases that failed to complete PBT at our outpatient regional center between January 2020 and December 2022. RESULTS: Two cases failed to complete PBT due to respiratory adverse events, including one that required admission to intensive care. Both of these cases had central nervous tumours. The third case developed neutropenic typhlitis relating to concurrent chemotherapy making the patient unfit for ongoing anesthesia. DISCUSSION: All three cases demonstrate that the risk of adverse events cannot be reliably predicted in this patient group. Detailed assessment must be performed prior to proceeding with anesthesia including regular review of blood tests, observations, and examining patients for any signs and symptoms of subclinical infection. The decision to proceed with anesthesia on a daily basis will require an anesthetic team that is highly skilled and familiar with their environment. CONCLUSION: Anesthetic care for PBT is more complex as compared to X-ray therapy. A small group of children, particularly those with central nervous system tumors or altered respiratory control, may be at increased and sometimes unpredictable risk. Safe and sustainable care for PBT is possible with careful history taking, planning, and identification of patients at a higher risk of adverse events.
Billstein C, Schenk A, Vergnat M
… +5 more, Jakobs P, Frede S, Putensen CP, Muders T, Schindler E
Paediatr Anaesth
· 2026 Jan · PMID 41131794
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BACKGROUND: Respiratory arrest during cardiopulmonary bypass (CPB) in pediatric cardiac surgery risks lung dysfunction including derecruitment, atelectasis, and inflammation. Continuous positive airway pressure (CPAP) an...BACKGROUND: Respiratory arrest during cardiopulmonary bypass (CPB) in pediatric cardiac surgery risks lung dysfunction including derecruitment, atelectasis, and inflammation. Continuous positive airway pressure (CPAP) and lung-protective ventilation (LPV) during aortic cross-clamping show inconsistent results in mitigating these risks. AIMS: To investigate whether LPV during aortic cross-clamping under CPB affects postoperative respiratory mechanics and ventilation inhomogeneity compared to apnea or CPAP. METHODS: This prospective, randomized pilot study compared three ventilation strategies during aortic cross-clamping under CPB: apnea, CPAP (5 mbar), and LPV. LPV was standardized using pressure-controlled ventilation at a positive end-expiratory pressure of 5 mbar, individualized driving pressure (20% of the pre-cross clamp inspiratory pressure), and age-adjusted respiratory rate. Recruitment maneuvers were applied at the end of CPB. Respiratory mechanics were assessed. Ventilation distribution was measured preoperatively and postoperatively under spontaneous breathing and mechanical ventilation using Electrical Impedance Tomography. Blood was analyzed pre- and postoperatively for pulmonary and systemic inflammatory markers. Feasibility of LPV was assessed. Statistical analysis used linear mixed-effects models. RESULTS: Driving pressure increased (11.8 (2.6) to 12.9 (2.6) mbar) and dynamic compliance decreased (9.9 (7.3) to 8.5 (7.4) Pa L) statistically significantly preoperatively to postoperatively. The number of ventilated pixels increased statistically significantly from spontaneous breathing (408.2 (77.2)) to mechanical ventilation (495.1 (44.9)) and returned toward baseline postoperatively (433.9 (72.6)). The Center of Ventilation shifted statistically significantly ventrally during mechanical ventilation (0.491 (0.039) to 0.442 (0.027)) and normalized afterward (0.485 (0.037)). These changes were unaffected by the ventilation strategy. Biomarker analysis showed no statistically significant changes between groups. LPV during aortic cross-clamping was feasible. CONCLUSION: In this pilot study, ventilation strategies did not differ in their effect on ventilation distribution, respiratory mechanics, or inflammatory markers when recruitment maneuvers were uniformly applied after CPB. LPV was feasible. TRIAL REGISTRATION: German Clinical Trials Register: DRKS00030219; https://drks.de/search/de/trial/DRKS00030219.