Distribution and outcomes of paediatric anaesthesia services in Sweden: an epidemiological study.

BACKGROUND: Centralisation of perioperative care for small children to a limited number of specialised paediatric centres has many theoretical advantages, but neither the optimal balance nor the current distribution of paediatric anaesthesia on a national scale are well elucidated. The aim of this study was to describe the distribution, adverse events, and mortality in children undergoing anaesthesia in Sweden. METHODS: In this cohort study, data from all paediatric anaesthesia procedures registered in Sweden during the years 2019-22 were extracted from the Swedish Perioperative Register (SPOR). Data were analysed according to hospital level of care and ASA physical status. RESULTS: Data from 81 hospitals were analysed. During the 4-yr period, 214,964 procedures were registered. Most procedures in neonates and infants were managed in paediatric (73%) and other university hospitals (21%). Adverse events occurred in 2.71% of cases and severe adverse events in 0.067%. The all-cause 24-h mortality rate was 6.6:10,000 anaesthetics and the all-cause 30-day mortality was 14.7:10,000 anaesthetics. The 30-day all-cause estimated mortality was highest in paediatric hospitals (95% confidence interval [CI] 30-39) compared with other university hospitals (95% CI 6.1-12), county (95% CI 1.9-4.8), district (95% CI 0.07-2.2), and smaller hospitals (95% CI 0.0-22). CONCLUSIONS: Most procedures in neonates and infants were performed in tertiary centres, with county hospitals managing mainly older children, in accordance with national recommendations. Mortality was more common in tertiary centres, reflecting increased comorbidity and centralisation of anaesthesia of neonates and infants.

Incidence of emergence delirium after homeostasis-guided pediatric anesthesia for ear-nose-throat surgery.

BACKGROUND: Emergence delirium is a complication of pediatric anesthesia during the early recovery period. Children undergoing ear, nose, and throat surgery are at high risk. The Pediatric Assessment of Emergence Delirium (PAED) scale is used for diagnosis and founded to specify the degree of emergence delirium. However, there is no consensus regarding a threshold value for emergence delirium diagnosis. Homeostasis-guided pediatric general anesthesia aims to maintain physiological parameters within normal ranges. In this prospective, observational study we evaluated the incidence of emergence delirium in children undergoing elective ear, nose, and throat surgery under standardized homeostasis-guided general anesthesia. Secondarily, we identified risk factors associated with an increased PAED score. METHODS: In children aged 0-6 years, we collected data from standard monitoring, depth of anesthesia, and preoperative glucose and ketone body levels. These variables were studied as risk or protective factors for increased PAED >0 scores using multivariate logistic regression. RESULTS: Of the 105 children analyzed, only five children (4.7%) had emergence delirium according to a threshold PAED score ≥10, while 37 children (35%) had PAED scores >0. Statistical analysis of the PAED outcome identified two significant positive associations with pain (P<0.001) and preoperative blood glucose levels (P=0.006) and one negative association with preoperative ketone body levels (P<0.001). CONCLUSIONS: Our cohort observed a lower incidence of emergence delirium than in the literature. Higher pain intensity and lower blood glucose levels were risk factors for PAED > 0, whereas preoperative ketone body levels were protective.

[Chinese expert consensus on pediatric anesthesia assessment and perioperative risk prediction (2024 edition)].

The incidence of perioperative adverse events in children aged 0 to 15 years was 5.2%. Preoperative scientific and accurate anesthesia assessment is a crucial step in ensuring the safety of pediatric surgery. Perioperative risk prediction is a digital quantitative evaluation of the level of perioperative risk, which classifies the degree of danger. In order to further standardize the methods of anesthesia assessment and identify risk factors, Chinese Society of Anesthesiology organized experts in anesthesiology from children's specialty hospitals and general hospitals, along with statisticians from public health colleges, to jointly draft the "Chinese expert consensus on pediatric anesthesia assessment and perioperative risk prediction (2024 edition)".The anesthesia assessment includes history collection, physical examination, laboratory examination, American Society of Anesthesiologists physical status, difficult airway assessment, and identification and assessment of critically sick children. Perioperative risk prediction includes preoperative anxiety, perioperative respiratory adverse events, regurgitation and aspiration, emergence delirium, postoperative nausea and vomiting, postoperative ICU admission, postoperative acute kidney injury, perioperative mortality, and risk prediction for in-hospital mortality in children with congenital heart disease undergoing non-cardiac surgery.This consensus has formulated a total of 16 recommendations, aiming to promote anesthesiologists' familiarity with the content of pediatric anesthesia assessment, identify risk factors for adverse events during the perioperative period, and take targeted measures to reduce the occurrence of adverse events and improve the safety of children during the perioperative period.

[Enhance the management of perioperative crisis events, improve the safety and quality of pediatric anesthesia].

Perioperative crisis events refer to unexpected seriously life-threatening when the patient is during or after surgery, and require rapid identification, evaluation, and management by clinical teams to minimize harm. The pediatric anesthesia management during perioperative period is special and challenging for anesthesiologists, requiring professional technical and non-technical skills. The article mainly elaborates on the incidence and risk factors of pediatric anesthesia crisis events during perioperative period and introduces the concept of anesthesia crisis resource management and strategies. The anesthesiologist team needs to adopt a crisis resource management strategy, taking a typical crisis event of malignant hyperthermia as an example, including identification of crisis signs immediately, termination of trigger drugs rapidly, intravenous injection of the special drug dantrolene, physical cooling, and symptomatic support treatment, seeking assistance from other teams actively, recording and feeding back. This study aims to improve the cognitive decision-making ability and teamwork ability of anesthesiologists and their teams, effectively preventing and responding to potential crisis events effectively, and ensuring the safety of pediatric patients during perioperative period.

The delivery and challenges of Pediatric Anesthesia within the humanitarian sector: Médecins Sans Frontières and Mercy Ships.

Access to healthcare is inequitable. Poverty, natural disasters and war disproportionally effect those most vulnerable, including children. Non-governmental organizations (NGO) hold a vital role in providing pediatric care in these contexts. Here we describe the delivery and challenges of Pediatric Anesthesia with two such non-governmental organizations; Médecins Sans Frontières (MSF) and Mercy Ships. Descriptions of both are followed by case studies.

Avoiding pain during propofol injection in pediatric anesthesia: Hypnoanalgesia of the hand versus intravenous lidocaine.

INTRODUCTION: Pain related to injection of propofol during induction of anesthesia decreases from 66.8% without prevention, to 22-31% of cases when lidocaine is associated. Hypnoanalgesia of the hand is currently used for painful procedures in children but has never been evaluated in this indication. The primary aim of this prospective randomized single-blind study was to evaluate the efficacy of hypnoanalgesia of the hand for the prevention of moderate to severe pain during intravenous injection of propofol alone in comparison to lidocaine admixture. The secondary aim was to compare the global satisfaction of children in both methods. PATIENTS AND METHODS: One hundred patients aged 7-14 years, ASA 1-2, admitted for scheduled surgery under general anesthesia were randomized into two groups. Group L received a mixture of 1% propofol (3 mg/kg) and 1% Lidocaine (0.3 mg/kg). Group H received 1% propofol (3 mg/kg) after hypnoanalgesia of the hand realized by a single experimented operator. A video was made in order to evaluate the pain related to propofol injection by a blinded observer using the 4-point score of Cameron (painful ≥ 2). The global satisfaction of children was evaluated in postanesthesia care unit and documented if visual analog score was <7/10. RESULTS: Ninety-six patients were analyzed. The rate of painful patients did not differ significantly between groups (8.5% in group H [n = 47] vs 6.1% in group L [n = 49], OR= 0.70; 95% CI [0.13-3.35], p = 0.65), nor did the rate of nonsatisfied patients (10.6 in group H vs. 12.2% in group L, OR = 0.85; 95% CI [0.19-3.65], p = 1). CONCLUSIONS: Our results suggest that hypnoanalgesia of the hand alone is effective to prevent the pain related to propofol injection in children. No significant difference was found in comparison with lidocaine admixture nor for pain or satisfaction.

Association of dexmedetomidine use with haemodynamics, postoperative recovery, and cost in paediatric anaesthesia: a hospital registry study.

BACKGROUND: Dexmedetomidine utilisation in paediatric patients is increasing. We hypothesised that intraoperative use of dexmedetomidine in children is associated with longer postanaesthesia care unit length of stay, higher healthcare costs, and side-effects. METHODS: We analysed data from paediatric patients (aged 0-12 yr) between 2016 and 2021 in the Bronx, NY, USA. We matched our cohort with the Healthcare Cost and Utilization Project-Kids' Inpatient Database (HCUP-KID). RESULTS: Among 18 104 paediatric patients, intraoperative dexmedetomidine utilisation increased from 51.7% to 85.7% between 2016 and 2021 (P<0.001). Dexmedetomidine was dose-dependently associated with a longer postanaesthesia care unit length of stay (adjusted absolute difference [ADadj] 19.7 min; 95% confidence interval [CI]: 18.0-21.4 min; P<0.001, median length of stay of 122 vs 98 min). The association was magnified in children aged ≤2 yr undergoing short (≤60 min) ambulatory procedures (ADadj 33.3 min; 95% CI: 26.3-40.7 min; P<0.001; P-for-interaction <0.001). Dexmedetomidine was associated with higher total hospital costs of USD 1311 (95% CI: USD 835-1800), higher odds of intraoperative mean arterial blood pressure below 55 mm Hg (adjusted odds ratio [ORadj] 1.27; 95% CI: 1.16-1.39; P<0.001), and higher odds of heart rate below 100 beats min-1 (ORadj 1.32; 95% CI: 1.21-1.45; P<0.001), with no preventive effects on emergence delirium requiring postanaesthesia i.v. sedatives (ORadj 1.67; 95% CI: 1.04-2.68; P=0.034). CONCLUSIONS: Intraoperative use of dexmedetomidine is associated with unwarranted haemodynamic effects, longer postanaesthesia care unit length of stay, and higher costs, without preventive effects on emergence delirium.

Advances in pediatric anesthesia services over the past 10 years in French-speaking sub-Saharan Africa.

INTRODUCTION: To improve and maintain quality and safety in anesthesia, standards have been proposed regarding human resources, facilities and equipment, medications and intravenous fluids, monitoring, and the conduct of anesthesia. Compliance with these standards remains a challenge in French-speaking sub-Saharan Africa (SSA) and results in high morbidity and mortality particularly in children. This aim of this study was to assess the progress made in improving the pediatric anesthesia infrastructures, human resources, education, medications, and equipment in French-speaking SSA over the past 10 years (2013-2022). METHODS: This is a descriptive, multicenter, cross-sectional study with retrospective data collection, conducted from September 1 to November 5, 2023. Comparative data from 2012 to 2022 were collected through an online survey. Descriptive statistics were used to summarize data. RESULTS: Data were obtained from 12 countries out of 14. The number of hospitals providing pediatric surgery and anesthesia rose from 94 in 2012 to 142 in 2022 (+51%). The total number of physician anesthesiologists rose from 293 (0.1 physician anesthesiologists/100 000 inhabitants) in 2012 to 597 (0.2 physician anesthesiologists/100 000 inhabitants) in 2022 (+103.7%). Five (0.006 physician anesthesiologists/100 000 children) had completed a fellowship in pediatric anesthesia and intensive care in 2012, and 15 (0.01 physician anesthesiologists/100 000 children) in 2022 (+200%). Five physician anesthesiologists had an exclusive pediatric anesthesia practice in 2012, whereas they were 32 in 2022 (+540%). There is no specialized training in pediatric anesthesia and intensive care in any of these countries. Halothane was always available in 81.5% of the hospitals in 2012, and in 50.4% of the hospitals in 2022. Sevoflurane was always available in 5% of the hospitals in 2012, and in 36.2% in 2022. Morphine was always available in 32.2% in 2012, whereas it was available in 52.9% of them in 2022. Pediatric pulse oximeter sensors were available in 36% of the hospitals in 2012, and in 63.4% in 2022. Capnography was available in 5.3% of the hospitals in 2012, and in 48% in 2022. CONCLUSION: Progress have been made over the last 10 years in French-speaking SSA to improve infrastructures, human resources, education, medications, and equipment for pediatric anesthesia in French-speaking SSA. However, major efforts must be continued. Standards adapted to the local context should be formulated.

The Incidence of Postoperative Complications Following Lumbar and Bone Marrow Punctures in Pediatric Anesthesia: Insights From APRICOT.

OBJECTIVE: Bone marrow aspiration and lumbar puncture are procedures frequently performed in pediatric oncology. We aimed at assessing the incidence and risk factors of perioperative complications in children undergoing these procedures under sedation or general anesthesia. METHODS: Based on the APRICOT study, we performed a secondary analysis, including 893 children undergoing bone marrow aspiration and lumbar puncture. The primary outcome was the incidence of perioperative complications. Secondary outcomes were their risk factors. RESULTS: We analyzed data of 893 children who underwent 915 procedures. The incidence of severe adverse events was 1.7% and of respiratory complications was 1.1%. Prematurity (RR 4.976; 95% CI 1.097-22.568; P = 0.038), intubation (RR: 6.80, 95% CI 1.66-27.7; P =0.008), and emergency situations (RR 3.99; 95% CI 1.14-13.96; P = 0.030) increased the risk for respiratory complications. The incidence of cardiovascular instability was 0.4%, with premedication as risk factor (RR 6.678; 95% CI 1.325-33.644; P =0.021). CONCLUSION: A low incidence of perioperative adverse events was observed in children undergoing bone marrow aspiration or lumbar puncture under sedation and/or general anesthesia, with respiratory complications being the most frequent. Careful preoperative assessment should be undertaken to identify risk factors associated with an increased risk, allowing for appropriate adjustment of anesthesia management.

Pediatric Anesthesia in the Community.

Pediatric anesthesia is a diverse subspecialty practiced at thousands of hospitals and ambulatory surgery centers across the country. Most unusual and high-risk cases are performed in dedicated children's hospitals. However, the majority of cases and practitioners are based in the community. We present a review of demographics in pediatric anesthesia in the United States across 7 years of data from US Anesthesia Partners, a national anesthesia practice, which covers the full range of hospitals and outpatient facilities.

Fluidoterapia perioperatoria en el paciente pediátrico / Perioperative fluids in pediatric patients

Fluid therapy is the most widely used medical treatment, with indications and risks that are important to know. Its indication in the pediatric perioperative period has continuously changed with the upward understanding of the physiology of newborns, infants and children, as well as in the knowledge of the composition of the different fluids available for use in this patient's population. This is evident in the various existing guidelines on this topic. It is important to consider the preoperative fasting of our patient, which must be decreased to the maximum. We must differentiate the two objectives of fluid therapy: maintenance and replacement fluid therapy. The latest recommendations on maintenance fluid therapy indicate preferring the use of balanced solutions, and if not having these, preferring lactate ringer serum by adding glucose for a concentration of 1-2.5%, especially in patients with a higher risk of hypoglycemia. On the other hand, in replacement fluid therapy, it should always be started with crystalloids preferring isotonic balanced solutions of electrolytes. The use of colloids is controversial given the scarce scientific evidence in pediatric patients. Finally, when indicating blood products, the risks associated with transfusion should always be considered, however, we should also consider the threshold of hematocrit and platelets to transfuse if necessary, and calculate the maximum volume of blood loss allowed to be transfused.

La fluidoterapia es el tratamiento médico más ampliamente utilizado, con indicaciones y riesgos que es importante conocer. Su indicación en el perioperatorio pediátrico ha cambiado continuamente a medida que se avanza en la comprensión de la fisiología de los recién nacidos, lactantes y niños, como también en el conocimiento de la composición de los diferentes fluidos disponibles para su uso en esta población de pacientes. Esto queda en evidencia en las diversas guías existentes respecto al tema. Es importante considerar el ayuno preoperatorio de nuestro paciente, que debe ser disminuido al máximo. Debemos diferenciar los dos objetivos de la fluidoterapia: fluidoterapia de mantención y de reposición. Las últimas recomendaciones sobre fluidoterapia de mantención indican preferir el uso de soluciones balanceadas, y de no disponer de éstas, preferir suero ringer lactato añadiendo glucosa para una concentración de 1%-2,5%, especialmente en pacientes con mayor riesgo de hipoglicemia. Por otro lado, en la fluidoterapia de reposición, se debe iniciar siempre con cristaloides prefiriendo soluciones balanceadas isotónicas de electrolitos. El uso de coloides es controversial dado la escasa evidencia científica en pacientes pediátricos. Por último, al indicar hemoderivados, siempre se deben considerar los riesgos asociados a transfusión, sin embargo, también debemos considerar el umbral de hematocrito y plaquetas para transfundir en caso necesario, y calcular el volumen de pérdida sanguínea máxima permitida para transfundir.