The role of collaboration in educating the global pediatric anesthesia workforce.

An estimated 1.7 billion children and adolescents do not have access to safe and affordable surgical care, and the vast majority of these are located in low-middle-income countries (LMICs). Pediatric anesthesia, a specialized field that requires a diverse set of knowledge and skills, has seen various advancements over the years and has become well-established in upper-middle and high-income countries. However, in LMICs, due to a multitude of factors including severe workforce shortages, this has not been the case. Collaborations play a vital role in increasing the capacity of pediatric anesthesiology educators and training the pediatric anesthesia workforce. These efforts directly increase access for children who require surgical intervention. Collaboration models can be operationalized through bidirectional knowledge sharing, training, resource allocation, research and innovation, quality improvement, networking, and advocacy. This article aims to highlight a few of these collaborative efforts. Specifically, the role that the World Federation of Societies of Anaesthesiologists, the Safer Anesthesia from Education program, the Asian Society of Pediatric Anaesthesiologists, Pediatric Anesthesia Training in Africa, the Paediatric Anaesthesia Network New Zealand, the Safe Pediatric Anesthesia Network and two WhatsApp™ groups (global ped anesthesia and the Pediatric Difficult Intubation Collaborative) have played in improving anesthesiology care for children.

Incidence of sodium-glucose cotransporter-2 inhibitor-associated perioperative ketoacidosis in surgical patients: a prospective cohort study.

PURPOSE: Sodium-glucose cotransporter 2 inhibitors (SGLT2is) are commonly prescribed anti-diabetic medications with various beneficial effects; however, they have also been associated with ketoacidosis. The aim of this study was to determine the incidence of SGLT2i-associated perioperative ketoacidosis (SAPKA) in surgical patients. METHODS: We conducted a multicenter, prospective cohort study across 16 centers in Japan, enrolling surgical patients with diabetes who were prescribed SGLT2is between January 2021 and August 2022. Patients were monitored until the third postoperative day to screen for SAPKA, defined as urine ketone positivity with a blood pH of < 7.30 and HCO3 level ≤ 18.0 mEq/L, excluding cases of respiratory acidosis. RESULTS: In total, 759 of the 762 evaluated patients were included in the final analysis. Among these, three patients (0.40%) had urine ketones with a blood pH of < 7.30; however, blood gas analysis revealed respiratory acidosis in all three, and none of them was considered to have SAPKA. The estimated incidence of SGLT2i-associated postoperative ketoacidosis was 0% (95% confidence interval, 0%-0.4%). CONCLUSIONS: The observed incidence of SAPKA in our general surgical population was lower than expected. However, given that the study was observational in nature, interpretation of study results warrants careful considerations for biases.

Sodium-glucose cotransporter 2 inhibitor-associated perioperative ketoacidosis: a systematic review of case reports.

Although the recommended preoperative cessation period for sodium-glucose cotransporter 2 inhibitors (SGLT2is) changed in 2020 (from 24 h to 3-4 days preoperatively) to reduce the risk of SGLT2i-associated perioperative ketoacidosis (SAPKA), the validity of the new recommendation has not been verified. Using case reports, we assessed the new recommendation effectiveness and extrapolated precipitating factors for SAPKA. We searched electronic databases up to June 1, 2022 to assess SAPKA (blood pH < 7.3 and blood or urine ketone positivity within 30 days postoperatively in patients taking SGLT2i). We included 76 publications with 99 cases. The preoperative SGLT2i cessation duration was reported for 59 patients (59.6%). In all cases with available cessation periods, the SGLT2is were interrupted < 3 days preoperatively. No SAPKA cases with > 2-day preoperative cessation periods were found. Many case reports lack important information for estimating precipitating factors, including preoperative SGLT2i cessation period, body mass index, baseline hemoglobin A1c level, details of perioperative fluid management, and type of anesthesia. Our study suggested that preoperative SGLT2i cessation for at least 3 days could prevent SAPKA. Large prospective epidemiologic studies are needed to identify risk factors for SAPKA.

Effect of forced-air warming by an underbody blanket on end-of-surgery hypothermia: a propensity score-matched analysis of 5063 patients.

BACKGROUND: Underbody blankets have recently been launched and are used by anesthesiologists for surgical patients. However, the forced-air warming effect of underbody blankets is still controversial. The aim of this study was to determine the effect of forced-air warming by an underbody blanket on body temperature in anesthetized patients. METHODS: We retrospectively analyzed 5063 surgical patients. We used propensity score matching to reduce the bias caused by a lack of randomization. After propensity score matching, the change in body temperature from before to after surgery was compared between patients who used underbody blankets (Under group) and those who used other types of warming blankets (Control group). The incidence of hypothermia (i.e., body temperature < 36.0 °C at the end of surgery) was compared between the two groups. A p value < 0.05 was considered to indicate statistical significance. RESULTS: We obtained 489 propensity score-matched pairs of patients from the two groups, of whom 33 and 63 had hypothermia in the Under and Control groups, respectively (odds ratio: 0.49, 95% confidence interval: 0.31-0.76, p = 0.0013). CONCLUSIONS: The present study suggests that the underbody blanket may help reduce the incidence of intraoperative hypothermia and may be more efficient in warming anesthetized patients compared with other types of warming blankets. TRIAL REGISTRATION: UMIN Clinical Trials Registry (Identifier: UMIN000022909 ; retrospectively registered on June 27, 2016).

Lower incidence of emergence agitation in children after propofol anesthesia compared with sevoflurane: a meta-analysis of randomized controlled trials.

BACKGROUND: Emergence agitation (EA) from general anesthesia has been reported as an adverse effect of sevoflurane in children. We describe a meta-analysis of randomized controlled trials that compared the incidence of EA between children who underwent sevoflurane anesthesia and those who underwent propofol anesthesia. METHODS: A literature search was conducted to identify clinical trials that met our inclusion criteria. Prospective randomized trials comparing sevoflurane and propofol anesthesia in children less than 15 years of age were included in the meta-analysis. Data from each trial were combined using the random effects model to calculate pooled odds ratios (ORs) and their corresponding 95 % confidence intervals (CIs). The heterogeneity of data was assessed by Cochran's Q and I (2) tests. Sensitivity analysis was conducted for study quality, patient age, and type of surgical procedure. RESULTS: The meta-analysis included 14 studies, in which 560 patients received sevoflurane and 548 received propofol. The pooled OR for EA was 0.25 with a 95 % CI of 0.16-0.39 (P = 0.000), which indicates that propofol anesthesia resulted in a lower incidence of EA. The heterogeneity of data was not statistically supported (P = 0.191). All sensitivity analyses strengthened the evidence for the lower incidence of EA with propofol. CONCLUSIONS: Our meta-analysis demonstrated that EA in children is less likely to occur after propofol anesthesia compared with sevoflurane anesthesia.

[Efficacy of Pentax-AWS in difficult airways: a meta-analysis of randomized controlled trials].

BACKGROUND: Increased evidence indicates that the Pentax-AWS (AWS) is useful for difficult airways. The aim of this meta-analysis was to assess the efficacy of the AWS in difficult airways, comparing that of Macintosh laryngoscopy. METHODS: The systematic search, data extraction, critical appraisal, and pooled analysis were performed according to the PRISMA statement. The relative risk (RR), mean difference (MD), and their corresponding 95% confidence intervals (CIs) were calculated by the Comprehensive Meta-analysis version 2.2.040 software for dichotomous and continuous outcomes, respectively. RESULTS: Eighteen randomized controlled trials, performed in simulated difficult airways (published between 2006, October and 2012, May), included 981 tracheal intubations by AWS and 986 tracheal intubations by Macintosh laryngoscopy. AWS showed higher success rate (RR: 1.220, 95% CI: 1.126 to 1.322, P < 0.00001) and shorter duration for instrumentation (MD: -10.319 s, 95% CI: -14.309 s to -6.328 s, P < 0.00001). CONCLUSIONS: There is considerable evidence that AWS has an advantage over Macintosh laryngoscope in difficult airways.

[Glidescope cobalt videolaryngoscope].

GlideScope Cobalt video laryngoscope is a novel indirect laryngoscope for tracheal intubation. It consists of a reusable high-resolution miniature video camera and light source, and a disposable transparent sheath that enshrouds the video camera, thereby preventing contact with the patient. To evaluate the per- formance of GlideScope Cobalt, endotracheal intubation was performed in 100 consecutive patients requiring tracheal intubation for surgery. The time to complete instrumentation, the visualization of the glottis by the Cormack-Lehane grade and optimizing procedures were recorded. GlideScope Cobalt allowed successful intubation in all patients examined, including two patients with difficult airway with the Macintosh laryngoscope. Endotracheal intubation was performed within one minute in 83 cases. GlideScope Cobalt provided Cormack-Lehane grade 1 or 2 visualization of the glottis in 100 patients. It was easily handled not only by experienced anesthetists but also by novice personnel. GlideScope Cobalt could be an effective aid to airway management in surgical patients.

[Efficacy of Glidescope video laryngoscope in difficult airways: a meta-analysis of randomized controlled trials].

BACKGROUND: Increased evidence indicates that the Glidescope video laryngoscope (GVL) is useful for difficult tracheal intubations. The aim of this meta-analysis was to assess the efficacy of the GVL in difficult tracheal intubations, comparing with that of Macintosh laryngoscopy. METHODS: The systematic search, data extraction, critical appraisal, and pooled analysis were performed according to the PRISMA statement. The relative risk (RR), mean difference (MD), and their corresponding 95% confidence intervals (CIs) were calculated by the Comprehensive Meta-analysis version 2.2.040 software for dichotomous and continuous outcomes, respectively. RESULTS: Fifteen randomized controlled trials including 860 tracheal intubations by GVL and 860 tracheal intubations by Macintosh laryngoscopy. GVL showed higher success rate (RR 1.065, 95% CI 1.017-1.117, P < 0.008) than does the Macintosh laryngoscope, whereas no difference was found in the duration for instrumentation. CONCLUSIONS: Our meta-analysis showed that GVL has an advantage over Macintosh laryngoscope in respect to the success rate for difficult tracheal intubations.

[Airtraq for difficult airways: A meta-analysis of randomized controlled trials].

BACKGROUND: Increased evidence indicates that the Airtraq is useful for difficult tracheal intubations. The aim of this meta-analysis was to assess the efficacy of the Airtraq in difficult airways, comparing with that of Macintosh laryngoscopy. METHODS: The systematic search, data extraction, critical appraisal, and pooled analysis were performed according to the PRISMA statement. The relative risk (RR), mean difference (MD), and their corresponding 95% confidence intervals (CIs) were calculated by the Comprehensive Meta-analysis version 2.2.040 software for dichotomous and continuous outcomes, respectively. RESULTS: Sixteen randomized controlled trials included 863 tracheal intubations by Airtraq and 865 tracheal intubations by Macintosh laryngoscopy. Airtraq showed higher success rate (RR 1.242, 95%CI 1.137 to 1.357, P<0.00001) and shorter duration for instrumentation (MD-8.259 s, 95%CI-13.122 s to-3.396 s, P <0.00087). CONCLUSIONS: There is considerable evidence that Airtraq has an advantage over Macintosh laryngoscope in difficult airways.

[Channeled videolaryngoscope: A meta-analysis of randomized controlled trials].

BACKGROUND: The aim of this meta-analysis was to assess the efficacy of the channeled videolaryngoscopes in routine tracheal intubation. METHODS: The systematic search, data extraction, critical appraisal, and pooled analysis were performed according to the PRISMA statement. We included randomized controlled trials in humans comparing Airtraq and Pentax-AWS to Macintosh laryngoscopy regarding the successful first-attempt and time for instrumentation. The relative risk (RR), mean difference (MD), and their corresponding 95% confidence intervals (CIs) were calculated for dichotomous and continuous outcomes, respectively. RESULTS: We included 20 trials with total of 2,370 patients. The channeled videolaryngoscopes showed higher success rate (RR 1.103, 95%CI 1.042 to 1.167, P <0.00069) and shorter duration for instrumentation (MD-10.873 s, 95%CI-18.588 s to-3.158 s, P< 0.0057). In studies examining novice laryngoscopists, successful first-attempt intubation (RR 1.28, 95%CI 1.14 to 1.45, P<0.000067) and time for instrumentation (MD-22.9 s, 95%CI-29.4 to-16.4, P<0.00001) were improved using the channeled videolaryngoscopes. With respect to experts' hands, there was no difference between the two devices in both of these outcomes for non-difficult intubations, while successful first-attempt intubation was improved for difficult intubations (RR 1.09, 95%CI 1.05 to 1.15, P<0.00011). CONCLUSIONS: Compared to the Macintosh laryngoscopy, channeled videolaryngoscopy offers advantages for novice laryngoscopists, while these benefits are not seen with experts' hands in normal airways. Even with skillful hands, channeled videolaryngoscopy improves the successful first-attempt intubation in difficult intubations.

[Efficacy of videolaryngoscopes for nasotracheal intubation: a meta-analysis of randomized controlled trials].

BACKGROUND: Increased evidence indicates that the videolaryngoscope is useful for nasotracheal intubation. The aim of this meta-analysis is to assess the efficacy of videolaryngoscopes (Glidescope, Airtraq and Pentax-AWS) in nasotracheal intubations, comparing with that of Macintosh laryngoscopy. METHODS: The systematic search, data extraction, critical appraisal, and pooled analysis were performed according to the PRISMA statement. The relative risk (RR), mean difference (MD), and their corresponding 95% confidence intervals (CIs) were calculated by the Comprehensive Meta-analysis version 2.2.040 software for dichotomous and continuous outcomes, respectively. RESULTS: Seven randomized controlled trials included 294 tracheal intubations by videolaryngoscopes and 253 tracheal intubations by Macintosh laryngoscopy. Videolaryngoscopes showed higher success rate (RR 1.116, 95% CI 1.021-1.220, P < 0.0155, I2 : 51%) and shorter intubation time (MD -11.9 sec, 95% CI-18.9(-) -5.0 sec, P < 0.0008, I2 84%) compared with the Macintosh laryngoscope. CONCLUSIONS: Our meta-analysis showed that the videolaryngoscope has an advantage over Macintosh laryngoscope in nasotracheal intubations.

[Procedural sedation: an integral part of tertiary care in pediatrics].

Procedural sedation and analgesia comprise an integral part of high quality tertiary care in pediatrics. All patients undergoing procedural sedation should be evaluated as extensively as in patients receiving general anesthesia, and an appropriate fasting time should also be considered. Since cardio-respiratory side effects are inevitably associated with sedative medications, (1) only medical personnel with an expertise in the use of these medications should manage procedural sedation, and (2) additionally, the choice of medication should be decided on a case-by-case basis as no single sedation recipe has proven superior to others. Analgesics should be introduced during painful procedures in order to reduce the chance of overdose by hypnotics alone. During sedation, medical staff should continuously monitor the patients so that prompt resuscitation can be provided if unexpected critical events occur. Following the procedure, medical staff should also monitor patients until full recovery is achieved. Pediatric anesthesiologists should be involved in the sedation procedure for patients with complicated medical histories. Finally, care should be taken to avoid ferrous equipment when performing sedation in an MRI suite.

Incidence of long-term post-acute sequelae of SARS-CoV-2 infection related to pain and other symptoms: A systematic review and meta-analysis.

BACKGROUND: Persistent symptoms are reported in patients who survive the initial stage of COVID-19, often referred to as "long COVID" or "post-acute sequelae of SARS-CoV-2 infection" (PASC); however, evidence on their incidence is still lacking, and symptoms relevant to pain are yet to be assessed. METHODS: A literature search was performed using the electronic databases PubMed, EMBASE, Scopus, and CHINAL and preprint servers MedRχiv and BioRχiv through January 15, 2021. The primary outcome was pain-related symptoms such as headache or myalgia. Secondary outcomes were symptoms relevant to pain (depression or muscle weakness) and symptoms frequently reported (anosmia and dyspnea). Incidence rates of symptoms were pooled using inverse variance methods with a DerSimonian-Laird random-effects model. The source of heterogeneity was explored using meta-regression, with follow-up period, age and sex as covariates. RESULTS: In total, 38 studies including 19,460 patients were eligible. Eight pain-related symptoms and 26 other symptoms were identified. The highest pooled incidence among pain-related symptoms was chest pain (17%, 95% confidence interval [CI], 11%-24%), followed by headache (16%, 95% CI, 9%-27%), arthralgia (13%, 95% CI, 7%-24%), neuralgia (12%, 95% CI, 3%-38%) and abdominal pain (11%, 95% CI, 7%-16%). The highest pooled incidence among other symptoms was fatigue (44%, 95% CI, 32%-57%), followed by insomnia (27%, 95% CI, 10%-55%), dyspnea (26%, 95% CI, 17%-38%), weakness (25%, 95% CI, 8%-56%) and anosmia (19%, 95% CI, 13%-27%). Substantial heterogeneity was identified (I2, 50-100%). Meta-regression analyses partially accounted for the source of heterogeneity, and yet, 53% of the symptoms remained unexplained. CONCLUSIONS: The current meta-analysis may provide a complete picture of incidence in PASC. It remains unclear, however, whether post-COVID symptoms progress or regress over time or to what extent PASC are associated with age or sex.

Remimazolam as an Adjunct to General Anesthesia in Children: Adverse Events and Outcomes in a Large Cohort of 418 Cases.

Remimazolam was first approved in 2020 as a general anesthetic for adults and still does not have pediatric labeling. Our study will be the first pilot program that administers remimazolam as an adjunct to a general endotracheal anesthetic in children. Between August 2020 and December 2022, electronic medical records were collected for all children who received remimazolam during anesthesia. The remimazolam dosing regimen was extrapolated from the adult package insert, with intravenous induction doses of 12 mg/kg/h administered until the desired effect was achieved. Subsequent infusions were given at a rate of 1-2 mg/kg/h, accompanied by intermittent boluses of 0.2 mg/kg, with all dosing adjustments made according to the anesthesiologist's clinical discretion. A total of 418 children (mean 4.6 yrs, 68.7% ASA 1 and 2) underwent surgeries which averaged 81.2 min. A total of 75.2% of patients had greater than a 20% change (increase or decrease) in MAP (lowest or highest) from baseline, and 203 (49.3%) patients had greater than a 30% change (increase or decrease) in MAP (lowest or highest) from baseline. A total of 5% received ephedrine to treat unanticipated hemodynamic variability. Discharge criteria were met within an average of 13.8 min after arrival at the post-anesthesia care unit. Remimazolam may offer the benefits of rapid recovery following general endotracheal anesthesia. The risk of hemodynamic variability which necessitates and responds to ephedrine should be anticipated.

Remimazolam for Pediatric Procedural Sedation: Results of an Institutional Pilot Program.

Remimazolam, an ultra-short-acting benzodiazepine sedative, was first approved in 2020 in Japan as a general anesthetic for adults. However, its utilization in pediatric settings remains unexplored and, to date, is confined to isolated case reports due to a lack of specific pediatric labeling. The primary objective of our study was to evaluate the safety profile of remimazolam when used for procedural sedation in children following dosages established in adult protocols. Additional parameters, including dosage per kg of body weight, duration of the procedure, efficacy (measured as successful completion of the procedure), the necessity for supplemental medications, and changes in physiological parameters, such as the heart rate (HR) and mean arterial blood pressure (MAP), were assessed. Our study encompassed 48 children with an average age of 7.0 years. The objective Tracking and Reporting Outcomes of Procedural Sedation tool indicated no adverse events. In our cohort, propofol and ketamine were used as adjunctive treatments in 8 and 39 patients, respectively, with successful completion of all procedures. Notable hemodynamic variability was observed, with 88.4% of patients experiencing a ≥20% change (increase or decrease) and 62.8% experiencing a ≥30% change in MAP. Additionally, a ≥20% change in HR was observed in 54.3% of patients, and a ≥30% change was observed in 34.8% of patients. Nevertheless, none of the patients required pharmacological intervention to manage these hemodynamic fluctuations. Our findings suggest that remimazolam, when supplemented with propofol or ketamine, could offer a safe and effective pathway for administering procedural sedation in pediatric populations.

Epidemiology of adverse events attributed to airway management in paediatric anaesthesia: protocol for the prospective, multicentre, registry-based, cross-sectional Japan Pediatric Difficult Airway in Anesthesia study (J-PEDIA).

INTRODUCTION: Failure to secure an airway during general anaesthesia is a major cause of adverse events (AEs) in children. The safety of paediatric anaesthesia may be improved by identifying the incidence of AEs and their attributed risk factors. The aim of the current study is to obtain real-world data on the incidence of adverse peri-intubation events and assess their association with patient characteristics (including the prevalence of difficult airway features) and choice of anaesthesia management. These data can be used to develop a targeted education programme for anaesthesia providers towards quality improvement activities. METHODS AND ANALYSIS: This prospective, multicentre, registry-based, cross-sectional study will be conducted in four tertiary care hospitals in Japan from June 2022 to May 2025. Children <18 years of age undergoing surgical and/or diagnostic test procedures under general anaesthesia or sedation by anaesthesiologists will be enrolled in this study. Data on patient characteristics, discipline of anaesthesia providers and methodology of airway management will be collected through a standardised verification system. The exposure of interest is the presence of difficult airway features defined based on the craniofacial appearance. The primary and secondary endpoints are all AEs associated with airway management and reduced peripheral capillary oxygen saturation values. Potential confounders are related to the failure to secure the airway and variations in the anaesthesia providers' levels, adjusted using hierarchical multivariable regression models with mixed effects. The sample size was calculated to be approximately 16 000 assuming a 99% probability of obtaining a 95% Wilson CI with±0.3% of the half-width for the 2.0% of the incidence of critical AEs. ETHICS AND DISSEMINATION: The study protocol was approved by the Institutional Review Board at Aichi Children's Health and Medical Center (2021051). The results will be reported in a peer-reviewed journal and a relevant academic conference. TRIAL REGISTRATION NUMBER: UMIN000047351.