Diversity, equity, and inclusion within the Society for Pediatric Anesthesia: A mixed methods assessment.

BACKGROUND: Leadership of the Society for Pediatric Anesthesia created the Diversity, Equity, and Inclusion committee in 2018 to prioritize diversity work. The Society for Pediatric Anesthesia-Diversity, Equity, and Inclusion committee implemented a baseline survey of the Society for Pediatric Anesthesia membership in 2020 to assess demographics, equity in leadership, inclusivity, and attitudes toward diversity work. The Society for Pediatric Anesthesia plays a significant role in shaping the future of pediatric anesthesiology and in supporting our diverse pediatric patients. METHODS: This study is an IRB-exempt, cross-sectional survey of the Society for Pediatric Anesthesia membership. Quantitative analysis provided descriptive statistics of demographics, practice characteristics, and involvement within the Society for Pediatric Anesthesia. Qualitative thematic analysis provided an in-depth assessment of perceptions of diversity, challenges faced, and prioritization of Diversity, Equity, and Inclusion efforts within the Society for Pediatric Anesthesia. RESULTS: Out of 3 242 Society for Pediatric Anesthesia members, 1 232 completed the survey representing 38% of overall membership. Respondents were 89.2% United States members, 52.7% female, 55.7% non-Hispanic White, 88.6% heterosexual, 95.7% non-military, 59.2% religious, and 2.1% have an Americans with Disabilities Act recognized disability. All major United States geographical areas were represented equally with 71% practicing in urban areas and 67% in academic settings. Ethnic/racial minorities were more likely to be international medical graduates (p < .001). Among United States members, 41.5% report being fluent in a language other than English, and 23.5% of those fluent in another language are certified to interpret. Compared to men, women are less likely to be in leadership roles (p < .003), but we found no difference in participation and leadership when stratified by race/ethnicity, geography, international medical graduate status, or sexuality. Racial/ethnic minorities (p < .028), women (p < .001), and lesbian, gay, bisexual, transgender, and queer members (p < .044) more frequently hold lower academic rank positions when compared to white, heterosexual, and male members. Half of respondents were unsure whether diversity, equity, and inclusion challenges existed within the Society for Pediatric Anesthesia while the other half demonstrated opposing views. Among those who reported diversity, equity, and inclusion challenges, the themes centered around persistent marginalization, the need for more inclusive policies and increased psychological safety, and lack of leadership diversity. CONCLUSIONS: Compared to the diversity of the pediatric population we serve, there are still significant gaps in demographic representation within the Society for Pediatric Anesthesia. As well, there is no consensus among Society for Pediatric Anesthesia membership regarding perceptions of diversity, equity, and inclusion in pediatric anesthesia in the United States. Among those who reported diversity challenges, opportunities for the Society for Pediatric Anesthesia and Anesthesiology Departments to better support minoritized members included bolstering workforce diversity efforts and awareness via more inclusive policies, improved psychological safety, and increasing diversity in leadership. If pediatric anesthesiology is like other specialties, gaining consensus and improving diversity in the workforce might advance pediatric anesthesia innovation, quality, and safety for children of all backgrounds in the United States.

Off-label use of dexmedetomidine in paediatric anaesthesiology: an international survey of 791 (paediatric) anaesthesiologists.

PURPOSE: The purpose of this international study was to investigate prescribing practices of dexmedetomidine by paediatric anaesthesiologists. METHODS: We performed an online survey on the prescription rate of dexmedetomidine, route of administration and dosage, adverse drug reactions, education on the drug and overall experience. Members of specialist paediatric anaesthesia societies of Europe (ESPA), New Zealand and Australia (SPANZA), Great Britain and Ireland (APAGBI) and the USA (SPA) were consulted. Responses were collected in July and August 2019. RESULTS: Data from 791 responders (17% of 5171 invitees) were included in the analyses. Dexmedetomidine was prescribed by 70% of the respondents (ESPA 53%; SPANZA 69%; APAGBI 34% and SPA 96%), mostly for procedural sedation (68%), premedication (46%) and/or ICU sedation (46%). Seventy-three percent had access to local or national protocols, although lack of education was the main reason cited by 26% of the respondents not to prescribe dexmedetomidine. The main difference in dexmedetomidine use concerned the age of patients (SPA primarily < 1 year, others primarily > 1 year). The dosage varied widely ranging from 0.2-5 µg kg-1 for nasal premedication, 0.2-8 µg kg-1 for nasal procedural sedation and 0-4 µg kg-1 intravenously as adjuvant for anaesthesia. Only ESPA members (61%) had noted an adverse drug reaction, namely bradycardia. CONCLUSION: The majority of anaesthesiologists use dexmedetomidine in paediatrics for premedication, procedural sedation, ICU sedation and anaesthesia, despite the off-label use and sparse evidence. The large intercontinental differences in prescribing dexmedetomidine call for consensus and worldwide education on the optimal use in paediatric practice.

Vaping and E-Cigarette Use in Children and Adolescents: Implications on Perioperative Care From the American Society of Anesthesiologists Committee on Pediatric Anesthesia, Society for Pediatric Anesthesia, and American Academy of Pediatrics Section on Anesthesiology and Pain Medicine.

Electronic cigarettes (e-cigarettes) or vaping use in adolescents has emerged as a public health crisis that impacts the perioperative care of this vulnerable population. E-cigarettes have become the most commonly used tobacco products among youth in the United States. Fruit and mint flavors and additives such as marijuana have enticed children and adolescents. E-cigarette, or vaping, product use-associated lung injury (EVALI) is a newly identified lung disease linked to vaping. Clinical presentation of EVALI can be varied, but most commonly includes the respiratory system, gastrointestinal (GI) tract, and constitutional symptoms. Clinical management of EVALI has consisted of vaping cessation and supportive therapy, including supplemental oxygen, noninvasive ventilation, mechanical ventilation, glucocorticoids, and empiric antibiotics, until infectious causes are eliminated, and in the most severe cases, extracorporeal membrane oxygenation (ECMO). Currently, although there is an insufficient evidence to determine the safety and the efficacy of e-cigarettes for perioperative smoking cessation, EVALI clearly places these patients at an increased risk of perioperative morbidity. Given the relatively recent introduction of e-cigarettes, the long-term impact on adolescent health is unknown. As a result, the paucity of postoperative outcomes in this potentially vulnerable population does not support evidence-based recommendations for the management of these patients. Clinicians should identify "at-risk" individuals during preanesthetic evaluations and adjust the risk stratification accordingly. Our societies encourage continued education of the public and health care providers of the risks associated with vaping and nicotine use and encourage regular preoperative screening and postoperative outcome studies of patients with regard to smoking and vaping use.

Temporal variation of the leak pressure of uncuffed endotracheal tubes following pediatric intubation: an observational study.

PURPOSE: Uncuffed endotracheal tubes are still preferred over cuffed tubes in certain situations in pediatric anesthesia. Inaccurately sized uncuffed endotracheal tubes may lead to inadequate ventilation or tracheal mucosal damage during anesthesia. Endotracheal tube size in children is usually assessed by measuring the audible leak pressure; if the fit of the tube and the leak pressure decrease significantly with time, reintubation during surgery as a result of inability to ventilate effectively may be challenging, and could lead to patient morbidity. There is no evidence to indicate whether leak pressure increases or decreases with time following endotracheal intubation with uncuffed tubes in children. METHODS: We measured leak pressure for 30 min following tracheal intubation in 46 ASA I children age 0-7 years after excluding factors known to modify leak pressure. RESULTS: The largest mean change in leak pressure occurred between time points 0 and 15 min, an increase of 3.5 cmH2O. Endotracheal tube size and type of procedure were associated with the leak pressure. In the final linear mixed model, there were no statistically significant variations in leak pressure over time (P = 0.129) in this group of children. CONCLUSIONS: We did not identify a consistent change in leak pressure within 30 min following tracheal intubation with uncuffed endotracheal tubes in this group of children.

Respiratory complications associated with ketamine anesthesia for ophthalmic procedures following intraocular pressure measurement in children.

BACKGROUND: We compared respiratory complications (RCs) in children who received intramuscular (IM) versus intravenous (IV) or no ketamine for intraocular pressure (IOP) measurement to test our observation that IM ketamine is associated with higher incidence of RCs. MATERIALS AND METHODS: We analyzed 149 eye examinations under anesthesia with ketamine in 27 patients and 263 non-ketamine examinations under anesthesia in 81 patients using a mixed effects logistic regression model. RESULTS: IM KETAMINE WAS STRONGLY ASSOCIATED WITH INCREASED ODDS OF RCS COMPARED TO NO KETAMINE (ODDS RATIO (OR): 20.23, P < 0.0001) and to IV ketamine (OR: 6.78, P = 0.02), as were higher American Society of Anesthesiologists (ASA) classification (OR: 2.60, P = 0.04), and the use of volatile agents (OR: 3.32, P = 0.02). CONCLUSION: Further studies should be conducted to confirm our observation of increased RCs with IM ketamine.

The 'dark' side of sedation: 12 years of office-based pediatric deep sedation for electroretinography in the dark.

OBJECTIVES: Analyze pediatric ERG data for adverse events, interventions, and outcomes of propofol sedations performed in near-complete darkness. AIM: To demonstrate that deep sedation with propofol for ERG can be performed efficiently and safely in children in near-total darkness. BACKGROUND: Full-field electroretinography (ERG) is a valuable tool for the diagnosis of vision loss in children. The ERG measures the electrical activity of the retina. In children, ERG quality significantly improves with deep sedation by allowing easier eye electrode placement and decreasing motion artifacts. As this procedure must be performed in darkness, administering sedation imposes unique challenges. METHODS AND MATERIALS: ERGs are performed outside of the operating room in our hospital's electrophysiology suite. IVs are placed, and patients are allowed to adapt to complete darkness. An anesthesiologist then administers propofol sedation in the dark with the aid of a red-filter light source and monitor light shields. Data were collected on 379 patients (411 ERGs) performed from 1996 to 2008. These records were reviewed and analyzed for demographic, medical, and anesthetic data. RESULTS: Propofol sedation resulted in an ERG completion rate of 99.5%. During sedation, 8.5% (35) of patients experienced minor respiratory complications such as airway obstruction that resulted in an oxygen saturation <90%. A total of 9.7% (40) of patients required minor airway interventions such as a chin lift. CONCLUSIONS: We demonstrated that pediatric sedation is a safe, efficient, and a cost-effective method for measuring ERGs in a challenging environment. The incidence of minor complications is low and appears similar to other studies of propofol sedation.

Randomized controlled trial of acupuncture to prevent emergence delirium in children undergoing myringotomy tube placement.

BACKGROUND: Myringotomy tube placement is a pediatric procedure frequently performed under inhalational anesthesia without intravenous line placement. Emergence delirium is common following sevoflurane anesthesia, and can lead to patient harm and escalation of nursing care. Our goal was to determine if intraoperative acupuncture, compared to standard of care, reduces emergence delirium in children undergoing myringotomy tube placement. METHODS: Single center, randomized, controlled trial at a university hospital, including children ages 1-6 years with ASA physical status 1-3 scheduled for myringotomy tube placement. Participants were stratified based on midazolam premedication and randomized to intraoperative acupuncture (AC, N.=49) or standard anesthesia care (SC, N.=50). Acupuncture needles were placed in bilateral Heart 7 (HT7) and ear Shen Men points after anesthesia induction. A blinded observer in the PACU assessed emergence delirium using the Pediatric Anesthesia Emergence Delirium (PAED) scale. Endpoints were highest PAED score in the recovery room and post-discharge agitation and sleep quality. RESULTS: Patient baseline characteristics were similar between treatment groups. With midazolam premedication, the highest PAED score was 11.6 in patients receiving AC and 12.0 for SC. Without midazolam premedication, the highest PAED was 11.8 in patients receiving AC and 10.7 for SC. The overall PAED score difference between AC and SC groups was 0.33 (95% CI -1.5, 2.2, P=0.723). CONCLUSIONS: Intraoperative acupuncture at HT7 and ear Shen Men did not reduce PAED scores after myringotomy tube placement. Based on these data, it is therefore unlikely that a larger study of the same design would demonstrate a significant effect of intraoperative acupuncture on emergence delirium after brief sevoflurane anesthesia. However, other acupuncture points or techniques could be considered.

Cardiac arrest in the neonate during laparoscopic surgery.

We describe a case of intraoperative neonatal cardiac arrest during attempted laparoscopic surgery. Circulatory collapse occurred before peritoneal insufflation, initially obscuring the diagnosis. Emergent transthoracic echocardiography during resuscitation demonstrated intracardiac gas bubbles consistent with venous gas embolism. The site of entrainment was probably a bleeding umbilical vein transected by the umbilical trocar. Greater awareness of this complication in neonates will facilitate early diagnosis and encourage preventive measures, such as the avoidance of umbilical vessels, use of an open instead of closed access technique, and ligation of bleeding vessels after peritoneal access.

Use of oxcarbazepine to treat a pediatric patient with resistant complex regional pain syndrome.

UNLABELLED: We describe a 12-year-old patient with severe, protracted complex regional pain syndrome type I. His pain did not respond to gabapentin, amitriptyline, physical therapy, opioids, or nonsteroidal drugs. Sympathetic or regional block was not attempted because of persistent bacteremia and severe local sepsis. His pain responded dramatically to the addition of oxcarbazepine, with rapid improvement in his symptoms and functional status. We suggest that oxcarbazepine might be a useful adjunct in the treatment of gabapentin-resistant complex regional pain syndrome type I in children and should be considered. PERSPECTIVE: Oxcarbazepine's antinociceptive effect is mediated via sodium channel inhibition in neuropathic models and by inhibition of substance P and prostaglandins in anti-inflammatory models. The efficacy of oxcarbazepine in this patient might be attributable to these mechanisms or possibly to synergism with either gabapentin or the anti-inflammatory effects produced by amitriptyline.

Intravenous sedation vs general anesthesia for pediatric otolaryngology procedures.

OBJECTIVE: To compare efficacy, safety, and hospital charges for common pediatric otolaryngology procedures with the use of intravenous sedation (IVS) vs general anesthesia (GA). DESIGN: Retrospective chart study. SETTING: Hospital-based pediatric otolaryngology practice. PATIENTS: Patients younger than 18 years who underwent tympanostomy tube removal and/or patch myringoplasty with absorbable gelatin sponge, nasal ciliary biopsy, fine-needle aspiration, or other minor procedures between September 1, 1998, and August 31, 2001. INTERVENTIONS: Procedures performed in 2 settings: outpatient clinic with IVS or operating room with GA. MAIN OUTCOME MEASURES: Procedure completion rate, tympanic membrane perforation rate after ear procedures, complications, and hospital charges. RESULTS: Of 103 procedures, 54 were performed with IVS and 49 with GA. Within the GA group, 32 of 49 patients had additional operations performed and were excluded from analysis of safety and hospital charges. Procedure completion rate was 100% in both groups. The most common procedure was tympanostomy tube removal with patch myringoplasty (IVS, 52 ears; GA, 42 ears). The rate of persistent tympanic membrane perforation was similar between these groups (IVS, 7 [16%] of 45 ears; GA, 5 [15%] of 33; P =.96). All complications were minor and occurred at similar rates (IVS, 10 [19%] of 54 ears; GA, 3 [18%] of 17; P =.94). These events included hypoxia, airway obstruction, and bradycardia, all of which resolved spontaneously or responded to noninvasive interventions such as oxygen or repositioning. Average hospital charges were significantly higher for the GA group (IVS, $356.22; GA, $1516.55; P<.001). CONCLUSION: Various procedures can be performed safely, effectively, and with decreased hospital charges with the use of IVS administered by a pediatric sedation service.

The laryngeal mask airway for pediatric adenotonsillectomy: predictors of failure and complications.

OBJECTIVES: We hypothesize that the laryngeal mask airway (LMA) is a safe technique for airway management in pediatric adenotonsillectomy (T&A). METHODS: After institutional review board (I.R.B.) approval, we conducted a retrospective review of 1199 medical records of children who underwent T&A from 2002 to 2006 at Doernbecher Children's Hospital, a teaching institution in Portland, OR. There were no significant demographic differences between the LMA (n=451), endotracheal tube (ETT) (n=715), and failed LMA groups (n=33). Outcome variables were LMA failure (LMA replaced with endotracheal tube), and any complication. We collected demographic and medical data to determine the incidence and predictors of LMA failure, and to characterize the failed LMA group. RESULTS: The incidence of LMA failure was 6.8%. Patients who underwent adenoidectomy had significantly lower odds of LMA failure compared to patients who had a tonsillectomy or adenotonsillectomy (OR 0.28, 95% CI 0.15-0.52, P<0.0001). One of the surgeons (OR 0.46, 95% CI 0.45-0.48, P<0.0001) was also associated with decreased odds of LMA failure. Controlled ventilation (OR 7.17, 95% CI 4.99-10.32, P<0.0001), and younger patients (OR 1.05 for each year decrease in age, 95% CI 1.03-1.07, P ≤ 0.0001) were associated with increased odds of LMA failure. The complication rate was 14.2% in the LMA group and 7.7% in the ETT group. Increased odds of developing any complication were seen in male patients (OR 1.4, 95% CI 1.01-1.7, P=0.04), and in patients with co-morbidities other than obstructive sleep apnea syndrome or upper respiratory tract infection (OR 4.2, 95% CI 1.03-17.2, P=0.04). The odds of developing a complication were lower in the ETT group compared to the LMA group (0.63, 0.46, 0.8, P=0.005). CONCLUSIONS: LMA use for pediatric T&A is associated with a higher incidence of complications, mainly as a result of airway obstruction following insertion of the LMA or McIvor gag placement. Complications were more likely if tonsillectomy was performed when compared to adenoidectomy alone. Appropriate patient selection, careful insertion, and avoidance of controlled ventilation may decrease the incidence of LMA failure, especially if tonsillectomy is performed. The ability of surgeons to work around the LMA can modify the failure rate significantly.

Complications of three deep sedation methods for magnetic resonance imaging.

BACKGROUND: Propofol and pentobarbital are commonly used to sedate children undergoing magnetic resonance imaging (MRI). AIM/OBJECTIVE: TO COMPARE THE SAFETY OF THREE TYPES OF SEDATION: intravenous propofol (PROP), mixed pentobarbital/propofol (PENT), and mixed pentobarbital group requiring supplemental sedation (PENT SUPP) regimens in pediatric patients following deep sedation (DS) for noncardiac MRI. MATERIALS AND METHODS: We conducted a case-control study matching 619 cases with complications with 619 controls using data from our institution's sedation database for children deeply sedated for noncardiac MRI. Cases were defined as patients with any complication and we characterized complications from cases, and used a conditional logistic regression model to assess the association between three DS methods and occurrence of complications after adjusting for confounding variables. RESULTS: We found that complications occurred in association with 794 (10.1%) of the 7,839 DSs performed for MRI between 1998 and 2008. Of the 794 cases, 619 cases met inclusion criteria for the study. Among the 619 cases that met inclusion criteria, 24 (0.3% of 7,839 DSs total) were associated with major complications. Type of sedation was significantly associated with the occurrence of complications, and the PENT group was associated with decreased odds of complications when compared to the PROP regimen (OR 0.68; 95% CI 0.46, 0.98; P=0.040) and compared to the PENT SUPP group (OR 0.60; 95% CI 0.31, 0.89; P<0.0001). CONCLUSIONS: DS with a pentobarbital technique was associated with decreased odds for complications when compared to a propofol-based technique or a pentobarbital technique requiring supplemental sedation.

Office-based deep sedation for pediatric ophthalmologic procedures using a sedation service model.

Aims. (1) To assess the efficacy and safety of pediatric office-based sedation for ophthalmologic procedures using a pediatric sedation service model. (2) To assess the reduction in hospital charges of this model of care delivery compared to the operating room (OR) setting for similar procedures. Background. Sedation is used to facilitate pediatric procedures and to immobilize patients for imaging and examination. We believe that the pediatric sedation service model can be used to facilitate office-based deep sedation for brief ophthalmologic procedures and examinations. Methods. After IRB approval, all children who underwent office-based ophthalmologic procedures at our institution between January 1, 2000 and July 31, 2008 were identified using the sedation service database and the electronic health record. A comparison of hospital charges between similar procedures in the operating room was performed. Results. A total of 855 procedures were reviewed. Procedure completion rate was 100% (C.I. 99.62-100). There were no serious complications or unanticipated admissions. Our analysis showed a significant reduction in hospital charges (average of $1287 per patient) as a result of absent OR and recovery unit charges. Conclusions. Pediatric ophthalmologic minor procedures can be performed using a sedation service model with significant reductions in hospital charges.

Factors affecting parental satisfaction following pediatric procedural sedation.

STUDY OBJECTIVE: To investigate factors affecting parental satisfaction with a pediatric sedation service in a university hospital setting. DESIGN: Prospective, observational study with interviews using a survey instrument. SETTING: Academic university hospital. SUBJECTS: Parents (or legal guardians; hereafter "parents") of 220 children scheduled for sedation with the hospital's pediatric sedation service. INTERVENTIONS AND MEASUREMENTS: Caregivers of children scheduled for sedation were interviewed using a validated survey instrument. The instrument was designed to investigate the quality of communication, environment, care provided, and the overall experience. We followed patients by telephone the day after discharge. Chi-square or linear-by-linear association tests were used to evaluate associations between satisfaction scores and demographic variables; the Mann-Whitney test was used for mean levels of satisfaction in anxious versus non-anxious children. MAIN RESULTS: Of 222 parents approached, 220 agreed to participate (response rate = 99.1%). Significant associations between each area of satisfaction and parents' overall satisfaction existed (P < 0.001). Previous sedations, types of sedation, age of child, or any individual provider were not significantly associated with overall satisfaction. Caregivers of anxious children reported less satisfaction than caregivers of non-anxious children. Parents of children who underwent magnetic resonance imaging reported the lowest mean satisfaction scores. CONCLUSIONS: Overall satisfaction was high, and care provided by anesthesiologists was significantly associated with overall satisfaction. A site in our institution was associated with significantly lower satisfaction as a result of inadequate space and privacy.

Modified orbitozygomatic craniotomy for craniopharyngioma resection in children.

OBJECT: In this study, the authors evaluated the efficacy and safety of modified orbitozygomatic craniotomy for resection of craniopharyngioma in children. METHODS: A prospective, institutional review board-approved database was retrospectively reviewed for pediatric patients undergoing craniopharyngioma resection performed by a single surgeon. RESULTS: Ten patients underwent craniopharyngioma resection surgery between July 2000 and January 2006 (4 girls and 6 boys, ages 1.5-17 years). Nine patients presented to the authors' institution, and 1 patient was referred after surgery and radiation therapy were administered elsewhere. Nine patients presented with visual field deficits (2 with unilateral or bilateral light perception only) and 5 with endocrine dysfunction. Eight patients had large tumors that significantly displaced the optic chiasm and hypothalamus. All patients underwent a modified frontotemporal orbitozygomatic osteotomy in a single piece. The lamina terminalis was opened in 4 patients with third ventricular extension. One patient required a staged transsphenoidal operation to remove residual tumor in the sella turcica, and 1 patient underwent a contralateral subtemporal approach to resect a daughter lesion in the prepontine cistern. Complete radiographic resection was achieved in all patients. Follow-up averaged 55 months (range 12-95 months). Vision was improved in 8 patients and remained stable in 2. All patients had postoperative endocrine dysfunction. One patient experienced transient cranial nerve IV palsy and 1 suffered a small caudate stroke 5 months after surgery without sequelae. Two patients experienced polyphagia and weight gain without other symptoms of hypothalamic dysfunction. There were no other new neurological deficits. CONCLUSIONS: Modified orbitozygomatic craniotomy provides excellent exposure of the suprasellar region with minimal brain retraction, allowing complete resection of craniopharyngiomas with good visual and neurological results.

Office-based dental rehabilitation in children with special healthcare needs using a pediatric sedation service model.

PURPOSE: 1) To review our experience with office-based sedation/anesthesia for children with special healthcare needs who underwent dental rehabilitation at our institution. 2) To compare the cost to comparable patients who underwent similar procedures in the operating room. PATIENTS AND METHODS: Retrospective review of patients' medical records and the sedation service database. Group CL: 114 patients who underwent office-based dental rehabilitation (135 procedures). Group OR: 23 patients who underwent dental rehabilitation under general anesthesia in the operating room for cost comparison. OUTCOMES: 1) EFFICACY (procedure completion rate and unplanned admissions); 2) SAFETY (complications and interventions); 3) Comparison of mean hospital charges billed between groups. RESULTS: Demographics were similar in both groups. The most common specific underlying diagnoses were autism (38%), cerebral palsy/developmental delay (18%) and ADHD (4%) in both groups. EFFICACY: procedure completion rate was 98.5% (2 aborted). There was 1 (0.7%) unplanned postanesthetic care unit admission due to an adverse drug event. SAFETY: 2 (1.5%) patients required invasive airway control. Eighteen (13.3%) patients developed transient hypoxemia. Twenty-three (17%) patients had airway obstruction needing simple intervention, and 1 (0.7%) patient had hypotension. There were no serious complications. Cost: mean total hospital charges were considerably higher in group OR ($6,126), versus group CL ($1,277), even after adjustment for inflation and length of procedure (P<.0001). CONCLUSION: Office-based dental rehabilitation using a pediatric sedation service model in children with special needs is efficient, and can achieve average savings of $4,849 in hospital charges per patient.

Demographics and trends in nonoperating-room anesthesia.

PURPOSE OF REVIEW: Nonoperating-room anesthesia includes sedation or anesthesia for radiological imaging, cardiac catheterization, office-based surgery, and pediatric procedures or investigations, all of which have seen explosive growth over the last decade. This review discusses the factors that are driving this growth and the challenges we face as a profession to accommodate new practice paradigms. RECENT FINDINGS: Many departments have difficulty providing services for nonoperating-room anesthesia. A shortage of providers, insufficient reimbursement, and lack of institutional support have been identified as barriers limiting delivery of pediatric nonoperating-room sedation services. Practitioners from other specialties appear increasingly eager to provide sedation at an institutional level. The use of propofol by nonanesthesiologists is widespread, and the issue of provider credentialing has yet to be fully resolved. The shift to nonoperating-room locations will continue, driven by cost savings and convenience for patients and providers. SUMMARY: Nonoperating-room anesthesia will play a central role in anesthesia practice in the future. Provision of these services requires planning, personnel, and institutional resources. This should be a high priority for anesthesiology departments to ensure delivery of the highest quality of patient care in a cost-effective and organized manner.

Aerophagia and anesthesia: an unusual cause of ventilatory insufficiency in a neonate.

We describe a healthy neonate with abdominal distention, inadequate ventilation, and delayed extubation during anesthesia for minor surgery. Following rectal decompression and successful extubation, extreme abdominal distention recurred postoperatively after ingestion of clear fluids. We elicited a history of frequent and excessive flatus from the parents, and abdominal radiography revealed distended loops of small bowel with small lung volumes suggestive of aerophagia. The differential diagnosis of aerophagia is reviewed, the anesthetic implications discussed, and relevant literature pertaining to this condition summarized.

Pediatric sedation in North American children's hospitals: a survey of anesthesia providers.

BACKGROUND: Information about the existence and organization of pediatric sedation services in North America is not available. We conducted a survey to collect this information from anesthesiologists at pediatric institutions and to identify factors perceived as limiting the development of sedation services. METHOD: We electronically mailed a confidential survey about pediatric sedation practice to an attending anesthesiologist involved in pediatric sedation at 116 children's hospitals in the United States and Canada. We identified the institutions using Internet resources. Electronic mailing addresses were obtained from departmental websites, society membership directories and departmental administrators. Our follow-up for nonresponders was by a second e-mail and a telephone call. RESULTS: A total of 54 completed questionnaires were received, a response rate of 47%. Forty-nine (91%) were received from US hospitals, and the remainder from Canadian. Fifty percent of hospitals had a formal pediatric sedation service. Fifty-four percent utilized a 'mobile' provider model. Hospital credentialing for nonanesthesiologist providers varied between 66 and 76% for 'deep' and 'conscious' sedation, respectively. A nurse-physician provider combination was the most common, utilized in 59% of hospitals. Anesthesiologists were the sole sedation providers in 26% of institutions. Propofol was used regularly by nonanesthesiologists for sedation of nonintubated (42%) and intubated (63%) patients. Eighty-seven percent of institutions reported barriers to development of pediatric sedation services. The most common barrier was a shortage of providers, particularly anesthesiologists. CONCLUSIONS: Propofol use by nonanesthesiologists is common. Addressing the shortage of providers, and allocating resources for credentialing providers will encourage further development of pediatric sedation practice.