INTRODUCTION: Ambulatory surgery has become the dominant model of surgical care in the United States as surgical procedures increasingly shifted from inpatient to outpatient sites of practice. Similar growth in volumes h...INTRODUCTION: Ambulatory surgery has become the dominant model of surgical care in the United States as surgical procedures increasingly shifted from inpatient to outpatient sites of practice. Similar growth in volumes has been observed in pediatric practice. Investigators have highlighted the challenges and opportunities in this current climate, including increasing medical and procedural complexity, difficulties matching pediatric-specific resources to meet the child's perioperative needs and unique risk profile, and limited availability of pediatric ambulatory surgical and anesthesia guidelines of care. Further, they call out the complete lack of pediatric outcomes data to help inform the creation and modification of national care guidelines. METHODS: To address these challenges, we chose to complete a comprehensive, single center retrospective review of our process, outcome, and balancing metrics contained in our EMR from our free-standing pediatric ambulatory surgery center (ASC) since its opening in July 2010 through December 2024. A commercial software system extracted de-identified, aggregated health data from the system's EMR. The data are processed and presented in statistical process control charts. This methodology allows clinicians to distinguish between common cause and special cause variation. RESULTS: Patient and procedural acuity increased as the system matured via lower age cutoffs and higher ASA physical status scores. This higher acuity was managed with a dynamic and evolving screening process, resulting in no change in unplanned emergency visit or hospital admissions. The COVID-19 pandemic had profound impacts on ASC operations and case mix, including a temporary closure. DISCUSSION: This retrospective, observational assessment created a detailed picture of our ASC practice changes over time. A pediatric-specific ASC with appropriate patient selection processes, practice guidelines, and clinical expertise successfully mitigated the risk of complications. These results are not generalizable to non-academic, community ambulatory facilities due to the unique characteristics of our pediatric-specific academic center.
INTRODUCTION: Pediatric ambulatory surgery has become the dominant model of surgical care in the United States, driven primarily by economic forces. There is variability in regional practice patterns, quality improvement...INTRODUCTION: Pediatric ambulatory surgery has become the dominant model of surgical care in the United States, driven primarily by economic forces. There is variability in regional practice patterns, quality improvement cycles, and outcomes. Opportunity exists to overcome knowledge gaps and provide sustainable pathways of quality improvement. Our unique capability of describing the evolution of our pediatric ambulatory quality improvement practice allows us to contribute a single center's perspective. METHODS: We chose to complete a comprehensive retrospective review of our quality improvement process, outcome, and balancing metrics contained in our electronic health record (EHR) from our free-standing pediatric ambulatory surgery center (ASC) from July 2010 through December 2024. A commercial software system extracted de-identified, aggregated health data from the system's EHR. The data are processed and presented in statistical process control charts. This methodology allows clinicians to distinguish between common cause and special cause variation. RESULTS: Improvement themes (opioid-free anesthesia and stewardship, enhanced recovery, environmental efforts, positive deviance, and learning healthcare system) are described. Improvements in all six domains of quality (effectiveness, efficiency/timeliness, patient experience, equity, and safety) are illustrated with reliable sustainability. Our system achieved approximately a 13-fold increase in quality improvement (QI) project completion rate with self-serve, real-world data access; enabling the team to take on improvement tasks previously deemed too big, lengthy, or risky to complete. DISCUSSION: We provide preliminary evidence that these methods may be generalizable. Requirements include engaged leadership, a standard framework for improvement with experienced leadership or accessible support, and easy access to real-world electronic medical record data (i.e., learning healthcare system [LHS]). Lastly, leaders must create a culture supportive of teamwork, change, and continuous improvement. Systems facilitate adoption and hinder resistance to standards, always with implementation and sustainability in mind. Meaningful, large-scale improvements in healthcare outcomes require collaboration across LHSs.
INTRODUCTION: Pediatric ambulatory anesthesia has rapidly evolved as the predominant model for surgical care in the United States, yet variability in practice standards and outcomes persists. This final installment of a...INTRODUCTION: Pediatric ambulatory anesthesia has rapidly evolved as the predominant model for surgical care in the United States, yet variability in practice standards and outcomes persists. This final installment of a four-part series addresses the gaps that remain between research and real-world practice, highlighting the limitations of traditional research models and existing registries in translating evidence into improved universal care and creation of benchmarks. METHODS: Through a review of selected pediatric databases and registries, this paper examines their contributions, strengths, and challenges in generating actionable knowledge and standardizing care. RESULTS: The discussion emphasizes the impact of unwarranted variation, the slow adoption of clinical guidelines, and the need for more robust, inclusive data sources that reflect the realities of community-based practice, where most children receive their care rather than the experience of large, academic centers. DISCUSSION: To address these challenges, we propose the need to create a multicenter, collaborative Learning Health System (LHS) consortium, leveraging real-world electronic medical record data, continuous quality improvement, and implementation science focused on improving quality of care and outcomes in ambulatory Pediatric Anesthesia practice. This model prioritizes adaptive methodologies, inclusive participation across diverse practice settings, and iterative, data-driven improvements. One of the greatest challenges is the ability to capture data from a range of care settings, and not just tertiary and quaternary children's hospitals. We delve into a possible solution to overcome this limitation by extending its reach beyond safety. This proposed LHS consortium offers the possibility of a pragmatic and sustainable pathway to accelerate the development and dissemination of standards and best practices in Pediatric Anesthesia. By fostering collaboration, embracing positive deviance, and bridging the gap between research and practice, this approach ensures that every child benefits from the highest standards of safety, quality, and innovation-regardless of where their care is delivered.
BACKGROUND: Melatonin may have several beneficial clinical effects in the perioperative setting. In children, it has been studied for preoperative anxiety, postoperative pain, and emergence delirium. Melatonin's pharmaco...BACKGROUND: Melatonin may have several beneficial clinical effects in the perioperative setting. In children, it has been studied for preoperative anxiety, postoperative pain, and emergence delirium. Melatonin's pharmacokinetic profile is well-known in adults, but data in young children are sparse. We aimed to investigate the pharmacokinetic parameters of an intravenous intraoperative bolus of melatonin in pediatric surgical patients. METHODS: We enrolled 20 participants aged 1-6 years undergoing general anesthesia for elective surgery to receive an intravenous melatonin dose of 0.15 mg·kg before end of surgery. A total of six blood samples were drawn from each participant at the following time points: baseline, 0, 15, 30, 60, and 90 min post-injection. Plasma melatonin concentrations were determined with High-Performance Liquid Chromatography with Fluorescence Detection (HPLC-FLD). Pharmacokinetic parameters were estimated with non-compartmental analysis. Clinical outcomes were recorded. RESULTS: We included 98 samples in the pharmacokinetic analysis. We found a maximum plasma concentration (C) of 416 298 [IQR 322 230-508 006] pg·mL and an elimination half-life (t) of 35.2 (SD 8.4) minutes. Clearance (CL) was 0.0183 (SD 0.0039) L·min·kg and volume of distribution (V) 0.92 (SD 0.27) L·kg. There were no cases of emergence delirium, mean maximum pain (FLACC) score was 1.3 (SD 2.0), and time to awakening and discharge readiness averaged one and two hours, respectively. Adverse events could be attributed to routine postoperative symptoms. CONCLUSION: Administering intravenous melatonin in a dose of 0.15 mg·kg in 1-6-year-olds yielded pharmacokinetic characteristics comparable to those reported in adults. The observed postoperative events were consistent with expected perioperative findings. These data support dose selection for trials investigating the perioperative use of melatonin in children. TRIAL REGISTRATION:CTIS: EU CT 2024-517592-20. CLINICALTRIALS: gov: NCT05541276 (registered 12/09-2022).
BACKGROUND: Children with congenital heart disease (CHD) frequently undergo cardiac magnetic resonance imaging (MRI) under anesthesia. Although these procedures lack surgical stimulus, patients remain physiologically vul...BACKGROUND: Children with congenital heart disease (CHD) frequently undergo cardiac magnetic resonance imaging (MRI) under anesthesia. Although these procedures lack surgical stimulus, patients remain physiologically vulnerable, and the incidence of perioperative cardiovascular instability in this setting is poorly defined. We aimed to determine the incidence and predictors of intraoperative cardiac events during pediatric cardiac MRI using a recently proposed composite framework of intraoperative cardiovascular instability. METHODS: This single-center retrospective cohort study analyzed patients ≤ 18 years undergoing cardiac MRI under anesthesia from 2013 to 2025. The primary outcome was intraoperative cardiac events, defined as ≥ 5 cumulative minutes with mean arterial pressure > 2 standard deviations below age- and sex-adjusted reference values, vasopressor administration, or severe adverse cardiac events. Multivariable logistic regression identified independent predictors. Thirty-day mortality was evaluated descriptively. RESULTS: Among 330 cases, intraoperative cardiac events occurred in 29.7% (98/330). Hypotension was most common (24.2%), followed by vasopressor administration (9.7%); no severe adverse cardiac events were observed. Thirty-day mortality was 1.8% (6/330). Independent predictors included increasing age (OR 1.13 per year, 95% CI: 1.04-1.21), and higher-acuity preoperative location, including neonatal intensive care unit (ICU) (OR 4.42, 95% CI: 1.86-10.52) and pediatric ICU (OR 4.84, 95% CI: 1.91-12.26). Sensitivity analyses demonstrated consistent findings across model specifications. CONCLUSIONS: Intraoperative cardiac events, primarily hypotension of unknown significance, were common during pediatric cardiac MRI under anesthesia; no severe adverse cardiac events occurred. Our findings highlight the physiologic complexity of this population and support the need for thoughtful perioperative risk stratification and management.
BACKGROUND: Tonsillectomy is one of the most frequently performed pediatric surgeries; however, little evidence guides the choice of intraoperative opioids in a population at an elevated risk for perioperative respirator...BACKGROUND: Tonsillectomy is one of the most frequently performed pediatric surgeries; however, little evidence guides the choice of intraoperative opioids in a population at an elevated risk for perioperative respiratory complications. This study tested the hypothesis that fewer children who received hydromorphone during tonsillectomy would require postoperative "rescue" opioids compared to children who received fentanyl. METHODS: We conducted a triple-blind, randomized, controlled trial to compare intravenous hydromorphone versus fentanyl in pediatric patients undergoing tonsillectomy. Children aged 2-15 years undergoing bilateral tonsillectomy or adenotonsillectomy were assigned (1:1) to receive hydromorphone (10 mcg/kg) or fentanyl (1 mcg/kg) intraoperatively. The primary endpoint was the number of patients who required rescue intravenous opioid analgesia following endotracheal extubation. Secondary endpoints included pain scores, pulse oximetry saturations, postoperative nausea, time in the recovery room, morphine milligram equivalents in the post-anesthesia care unit, and adverse events. RESULTS: A total of 188 children underwent randomization, and 180 were analyzed (90 in each group). The median age was 5 years (interquartile range: 3-7 years). Rescue intravenous opioid was administered to 48 (53%) children who received intraoperative hydromorphone and 66 (73%) children who received intraoperative fentanyl (difference, 20.0 percentage points; 95% confidence interval, 6.2-33.8) (p = 0.005). Children who received hydromorphone also had lower mean pain scores for the first 15 min postoperatively and lower median morphine milligram equivalents. The incidence of adverse events was similar between the two groups. CONCLUSIONS: This study in children undergoing tonsillectomy found that intraoperative hydromorphone resulted in improved analgesia in the recovery room compared to fentanyl. TRIAL REGISTRATION: ClinicalTrials.gov: NCT04230681.
INTRODUCTION: Emergence agitation (EA) is a postoperative neurobehavioral complication characterized by a transient disturbance in cognition and perception following anesthesia. Neuroinflammation is thought to play a cen...INTRODUCTION: Emergence agitation (EA) is a postoperative neurobehavioral complication characterized by a transient disturbance in cognition and perception following anesthesia. Neuroinflammation is thought to play a central role in its pathophysiology. Preoperative anxiety is the "acute preoperative stress response." This study aimed to evaluate the relationship between hemogram-derived inflammatory markers and the development of preoperative anxiety and EA in pediatric patients. METHODS: This prospective observational study included 350 pediatric patients aged 5-12 years with ASA grade I-II. Preoperative anxiety was assessed in the waiting room using the modified Yale Preoperative Anxiety Scale. Demographic and clinical data, anesthesia/surgical data, and hemogram parameters were recorded. EA was evaluated in the recovery room using the Pediatric Anesthesia Emergence Delirium scale. Pain was assessed at 0, 5, 10, 20, and 30 min using the FLACC scale in children < 7 years and the Visual Analog Scale in those ≥ 7 years. RESULTS: Of the total 350 patients, 130 (37.1%) developed EA. Compared with those without EA, children with EA had significantly higher leukocyte, monocyte, neutrophil, and platelet counts (p = 0.018, 0.005, 0.001, and 0.001, respectively), lower lymphocyte counts (p = 0.042), and elevated monocyte-to-lymphocyte ratio, neutrophil-to-lymphocyte ratio, platelet-to-lymphocyte ratio, and systemic immune inflammatory index (SII) (all p < 0.001). Regression analysis showed that younger age, higher postoperative pain scores, and elevated SII were independently associated with EA. Preoperative anxiety was observed in 103 children (29.4%). These patients had higher white blood cell counts (p = 0.026), and regression analysis identified that younger age, anxious parents, and elevated SII were independently associated with preoperative anxiety. CONCLUSION: Easily obtainable hemogram-derived inflammatory markers, particularly SII, may be useful for identifying children at increased risk of preoperative anxiety and EA in children. These findings suggest that SII may assist anesthesiologists in identifying high-risk patients and implementing preventive strategies to reduce the incidence of EA. TRIAL REGISTRATION: The study was registered at ClinicalTrials.gov (NCT06648122).
BACKGROUND: Objective assessment of sedation depth in children undergoing procedural sedation while maintaining spontaneous breathing and protective reflexes can be challenging. Processed electroencephalogram (pEEG) moni...BACKGROUND: Objective assessment of sedation depth in children undergoing procedural sedation while maintaining spontaneous breathing and protective reflexes can be challenging. Processed electroencephalogram (pEEG) monitoring systems such as the Narcotrend monitor may provide continuous information regarding the depth of sedation. The aim of this study was to investigate the correlation between the Narcotrend Index (NI) and the Pediatric Sedation State Scale (PSSS) during procedural sedation with propofol and fentanyl in children. METHODS: Children and adolescents aged 6 months to 17 years undergoing procedural sedation with propofol and fentanyl in the procedure room of a pediatric intensive care unit were included. Sedation depth was assessed using the Narcotrend monitor and the Pediatric Sedation State Scale. Spearman's rank correlation coefficient was calculated to evaluate the relationship between the NI and PSSS. RESULTS: A total of 311 paired measurements (NI and PSSS) from 29 patients were analyzed. Spearman's rank correlation analysis demonstrated a moderate to good correlation between the NI and PSSS (r = 0.61; 95% CI 0.54-0.68; p < 0.0001). The median NI corresponding to the desired deep sedation level (PSSS 2) was 39 (IQR 30-50), with a 95% confidence interval for the median of 36-42. CONCLUSION: The Narcotrend Index demonstrated an acceptable correlation with the Pediatric Sedation State Scale. Processed EEG monitoring using the Narcotrend Index may therefore represent a useful adjunct to clinical monitoring for avoiding both over-sedation and inadequate sedation in children, particularly for less experienced sedation providers. TRIAL REGISTRATION: German Clinical Trials Register: DRKS00033129.
Solan T, Sabato S, Alkhouri H
… +18 more, Dinh M, Reeves K, Tagg A, Forsyth N, McCarthy B, Loughhead E, Lawton B, Gorman M, Furyk J, Kinnear F, Brainard A, Borland ML, George S, Kochar A, Craig S, Babl FE, Long E, A collaboration between the Paediatric Research in Emergency Departments International Collaborative (PREDICT) network and the Australian and New Zealand Emergency Department Airway Registry (ANZEDAR)
BACKGROUND: Airway management in the Emergency Department (ED) can be challenging, particularly in children. Difficult laryngoscopy reduces first-pass success and increases complications, but pediatric ED data remain lim...BACKGROUND: Airway management in the Emergency Department (ED) can be challenging, particularly in children. Difficult laryngoscopy reduces first-pass success and increases complications, but pediatric ED data remain limited. METHODS: We conducted a prospective, observational study of pediatric intubations recorded in the Australian and New Zealand Emergency Department Airway Registry (ANZEDAR) between 2012 and 2025, including 25 Pediatric Research in Emergency Departments International Collaborative (PREDICT) sites. The primary outcome was the incidence of difficult laryngoscopy. Secondary outcomes were the impact of difficult laryngoscopy on First-Pass Success (FPS) and adverse events. The main exposure variable was laryngoscopic grade, defined as difficult when a Cormack-Lehane Grade 3 or 4 view was encountered on the first attempt. Patient, procedural, and operator characteristics were assessed as potential confounders. RESULTS: Of 946 pediatric ED intubations recorded across 55 sites (including 25 PREDICT pediatric sites) between 2012 and 2025, 865 were included in the analysis after exclusion of cases with missing laryngoscopic grade. The median age was 3.5 years. Difficult laryngoscopy (Cormack-Lehane grade 3-4) was observed in 65 cases (7.5%). FPS was significantly lower in patients with a difficult view compared with those with a non-difficult view (41.5% vs. 87.9%; OR 0.10, 95% CI 0.06-0.17). Adverse events were more frequent in the difficult-view group, including hypoxaemia (38.5% vs. 11.5%; OR 4.81, 95% CI 2.79-8.29) and esophageal intubation (15.4% vs. 1.3%; OR 14.36, 95% CI 5.73-35.98). CONCLUSION: Difficult laryngoscopy in pediatric ED intubations is relatively infrequent but associated with reduced FPS and increased complications. These findings emphasize the importance of ongoing quality improvement and may help inform training and escalation strategies. Continued registry participation is valuable to capture these low-frequency events and better understand their consequences.
OBJECTIVE: To evaluate the effects of perioperative music interventions on emotional outcomes (preoperative anxiety, postoperative fear, emergence delirium) and related physiological parameters in children and adolescent...OBJECTIVE: To evaluate the effects of perioperative music interventions on emotional outcomes (preoperative anxiety, postoperative fear, emergence delirium) and related physiological parameters in children and adolescents undergoing surgery, and to examine potential effect modifiers. METHODS: Nine databases were searched from inception to February 2026. Randomized controlled trials comparing music versus no-music control in pediatric surgical patients (≤ 18 years) were included. Risk of bias was assessed with RoB 2.0. Random-effects meta-analyzes were performed for preoperative anxiety, postoperative pain, heart rate, and blood pressure. Subgroup analyzes were conducted for age, music selection method, intervention timing, and surgery type. The certainty of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework. RESULTS: Seventeen RCTs (1871 children) were included. Music significantly reduced preoperative anxiety (SMD = -2.03; 95% CI -3.19 to -0.86; I = 97%), postoperative pain (SMD = -0.64; 95% CI -1.01 to -0.27; I = 62%), heart rate (MD = -12.92 bpm; 95% CI -19.07 to -6.77; I = 88%), and mean arterial pressure (MD = -8.41 mmHg; 95% CI -10.07 to -6.76; I = 66%). Effects on systolic blood pressure were not significant. Anxiolytic effects were significant in both children (≤ 12 years) and adolescents (≥ 13 years) with no subgroup difference. Self-selected and pre-selected music were both effective. Sensitivity analyzes confirmed robustness. GRADE assessment indicated very low to low certainty of evidence for all outcomes, primarily due to high heterogeneity, risk of bias, and imprecision. CONCLUSIONS: Perioperative music was associated with reduced anxiety and pain, but evidence certainty was very low to low. Pending stronger evidence, music may be considered a low-risk adjunct to standard care.
AIMS: Preoperative anemia is a potentially modifiable risk factor in children undergoing surgery, but contemporary data describing its prevalence and associated outcomes in high-income settings are limited. We aimed to d...AIMS: Preoperative anemia is a potentially modifiable risk factor in children undergoing surgery, but contemporary data describing its prevalence and associated outcomes in high-income settings are limited. We aimed to determine the prevalence of anemia in a pediatric major-surgery surgical cohort, identify associated demographic and clinical factors, and examine relationships with perioperative outcomes. METHODS: We conducted a retrospective observational study of children undergoing major surgery at an Australian tertiary children's hospital. Patients with a hemoglobin measurement within 3 months prior to surgery were included. Anemia was defined according to the World Health Organization 2024 thresholds. Demographic variables, comorbidities, surgical characteristics, transfusion, and postoperative outcomes were extracted. Logistic regression was used to evaluate independent associations between preoperative anemia, red cell transfusion, and postoperative infection. RESULTS: Of 786 eligible patients, 582 (74%) were included. Anemia was present in 123 children (21.1%, 95% CI 18.0-24.6). Anemia was more common in females, higher ASA classification, emergency surgery, and those with chronic comorbidities. In multivariable analyses, anemia was independently associated with red cell transfusion (aOR 2.77, 95% CI 1.74-4.41), and with postoperative infection (aOR 1.89, 95% CI 1.15-3.09). Other postoperative outcomes were not significantly associated with preoperative anemia. Anemia remained common in elective surgical patients, a group in whom preoperative screening and optimization are feasible. CONCLUSION: Preoperative anemia affects one in five children undergoing major surgery in this Australian cohort and is independently associated with red cell transfusion and postoperative infection. These findings support further evaluation of strategies to identify and manage preoperative anemia in pediatric surgical patients. The observed prevalence and outcome associations in this cohort should be interpreted in the context of missing preoperative hemoglobin data, which may bias estimates toward higher risk patients.
In pediatric-aged patients, distributive (vasoplegic) shock is commonly caused by sepsis, anaphylaxis, or the humoral/immunologic response following cardiopulmonary bypass. In general, the first-line vasoactive agent for...In pediatric-aged patients, distributive (vasoplegic) shock is commonly caused by sepsis, anaphylaxis, or the humoral/immunologic response following cardiopulmonary bypass. In general, the first-line vasoactive agent for children is epinephrine or norepinephrine. In cases of fluid-refractory shock requiring escalating doses of catecholamines, adjunct therapies such as vasopressin, hydrocortisone, hydroxycobalamin-ascorbic acid, and methylene blue may be introduced. In 2017, the FDA approved a synthetic human angiotensin II (AT-II) infusion preparation for treating adult patients with refractory vasodilatory shock. The following educational review examines the role of AT-II as a vasoactive agent in the treatment of distributive shock with a focus on pediatric patients. A systematic search of the literature was performed to identify key publications regarding the therapeutic use of AT-II for the treatment of distributive shock in adult and pediatric patients. Prospective studies in adult patients demonstrate the efficacy of AT-II to treat refractory vasodilatory shock when escalating doses of conventional vasoactive agents (norepinephrine ≥ 0.2-0.3 μg/kg/min) have failed. In these scenarios, AT-II has been added as the third or fourth medication. There are limited trials evaluating AT-II as the primary agent for vasodilatory shock in adults. The majority of studies have shown an improvement in mean arterial pressure (MAP); however, there has been limited impact on long-term survival. Pediatric evidence to date has included 5 case reports and two larger retrospective case series encompassing a total of 44 patients. Although AT-II was generally effective in increasing the MAP, given the non-randomized and non-prospective nature of these studies, information regarding the impact on long-term outcomes is not available. Both adult and pediatric reports have outlined the potential utility of AT-II in treating vasodilatory shock as primarily a rescue agent when conventional vasoactive agents fail or dose requirements escalate. To date, evidence-based medicine demonstrates an increase in MAP with the ability to wean other vasoactive agents. The current studies do not appear to uniformly and clearly define a survival benefit. Future studies should focus on the potential survival impact of this novel vasoactive agent, further define dosing strategies, and more clearly outline its role as a primary agent or when other vasoactive agents fail.