Effectiveness of simulation in psychiatry for nursing students, nurses and nurse practitioners: A systematic review and meta-analysis.

AIMS: Mental disorders constitute one of the main causes of disease and disability worldwide. While nurses are often at the frontline of mental health care, they have limited access to dedicated psychiatric training opportunities. Simulation training may foster the development of the appropriate competencies required when supporting people with mental disorders. To evaluate the effectiveness of simulation training in psychiatry for nursing students, nurses and nurse practitioners. DESIGN: Systematic review and meta-analysis. DATA SOURCES: Eight electronic databases, trial registries, key journals and reference lists of selected studies were searched from inception to August 20, 2020 without language restriction. REVIEW METHODS: We included randomized and non-randomized controlled studies and single group pre/post studies. Cochrane Risk of Bias tool 2.0 was used for randomized controlled study appraisal, and the Medical Education Research Study Quality instrument was completed for all other studies. Meta-analysis was restricted to randomized controlled studies. The other studies were synthesized narratively. The main outcomes were based on Kirkpatrick levels. RESULTS: A total of 118 studies (6738 participants) were found. Interventions included simulated patients (n = 55), role-plays (n = 40), virtual reality (n = 12), manikins (n = 9) and voice simulations (n = 9). Meta-analyses based on 11 randomized controlled studies found a significant large effect size on skills at immediate post-test for simulation compared with active control; and a small and medium effect size on learners' attitudes for simulation compared with inactive control, at immediate post-test and at three-month follow-up respectively. Three quarters of non-randomized controlled studies and pre/post-tests assessing attitudes and skills showed significant differences, and three quarters of participants in randomized controlled studies and pre/post-tests showed significant differences in behaviours. Among the few studies assessing people with mental health outcomes, almost all reported significant differences. CONCLUSION: These findings support the effectiveness of simulation training in psychiatric nursing throughout professional development grades, despite heterogeneity in methods and simulation interventions.

Determinants of Work-Related Quality of Life in French Anesthesiologists.

BACKGROUND: Little evidence is available regarding work-related quality of life (WRQoL) for anesthesiologists. We aimed to explore factors associated with WRQoL among French anesthesiologists. METHODS: The study surveyed French anesthesiologists qualified for more than 2 years. The primary objective was the determination of factors associated with WRQoL. Factors analyzed included demographic characteristics, lifestyle, financial status, personality traits, professional relations, management and organization, and occupational tasks when at work. Statistical analyses were performed using a multivariable quantile regression model. RESULTS: Overall, 2040 anesthesiologists responded to the survey and 1922 responses were analyzed. The latter represents 19% of practicing French anesthesiologists. The following factors were independently associated with increased WRQoL: family income, long-term employment, organizational and managerial factors (lesser weekly workload, the belief of providing high quality, safe health care services, team management, and operating theatre organization), human relations (satisfaction with workplace ambiance and relations with hospital management and colleagues), and occupational tasks (participation in team activities). Three personality traits were found to be significantly associated with increased WRQoL: extraversion, conscientiousness, and openness. Neuroticism was associated with reduced WRQoL. CONCLUSIONS: The current study demonstrates exogenous and endogenous factors associated with increased WRQoL in anesthesiologists. Results should be considered as explorative and provide hypotheses for further research in this domain.

Simulation in psychiatry for medical doctors: A systematic review and meta-analysis.

CONTEXT: Most medical doctors are likely to work with patients experiencing mental health conditions. However, educational opportunities for medical doctors to achieve professional development in the field of psychiatry are often limited. Simulation training in psychiatry may be a useful tool to foster this development. OBJECTIVES: The purpose of this study was to assess the effectiveness of simulation training in psychiatry for medical students, postgraduate trainees and medical doctors. METHODS: For this systematic review and meta-analysis, we searched eight electronic databases and trial registries up to 31 August 2018. We manually searched key journals and the reference lists of selected studies. We included randomised and non-randomised controlled studies and single group pre- and post-test studies. Our main outcomes were based on Kirkpatrick levels. We included data only from randomised controlled trials (RCTs) using random-effects models. RESULTS: From 46 571 studies identified, we selected 163 studies and combined 27 RCTs. Interventions included simulation by role-play (n = 69), simulated patients (n = 72), virtual reality (n = 22), manikin (n = 5) and voice simulation (n = 2). Meta-analysis found significant differences at immediate post-tests for simulation compared with active and inactive control groups for attitudes (standardised mean difference [SMD] = 0.52, 95% confidence interval [CI] 0.31-0.73 [I2  = 0.0%] and SMD = 0.28, 95% CI 0.04-0.53 [I2  = 52.0%], respectively), skills (SMD = 1.37, 95% CI 0.56-2.18 [I2  = 93.0%] and SMD = 1.49, 95% CI 0.39-2.58 [I2  = 93.0%], respectively), knowledge (SMD = 1.22, 95% CI 0.57-1.88 [I2  = 0.0%] and SMD = 0.72, 95% CI 0.14-1.30 [I2  = 80.0%], respectively), and behaviours (SMD = 1.07, 95% CI 0.49-1.65 [I2  = 68.0%] and SMD = 0.45, 95% CI 0.11-0.79 [I2  = 41.0%], respectively). Significant differences in terms of patient benefit and doctors' behaviours and skills were found at the 3-month follow-up. CONCLUSIONS: Despite heterogeneity in methods and simulation interventions, our findings demonstrate the effectiveness of simulation training in psychiatry training.

Enhanced recovery after surgical correction of adolescent idiopathic scoliosis.

BACKGROUND: Few publications in the literature examine enhanced recovery after scoliosis surgery (ERAS) in children, despite significant scientific interest in adults. The objective of the current study was to describe an ERAS protocol for surgical correction of adolescent idiopathic scoliosis (AIS) and its results. METHODS: ERAS outcomes were measured in two patient cohorts. Historical controls and ERAS groups were selected from patients managed for scoliosis surgery in 2015 and 2018, respectively. The ERAS protocol included fasting minimization, carbohydrate loading, the avoidance of background morphine infusions, perioperative opioid-sparing protocols, the use of a cooling brace, early physiotherapy, feeding and oral medications, and the early removal of urinary catheters and surgical drains. The main outcome of the study was hospital length of stay. RESULTS: Overall, 82 controls and 81 ERAS patients were recruited. ERAS protocols were observed in over 80% of patients for almost items. Median length of hospital stay was significantly lower in the ERAS group (- 3 [95% confidence interval: -2; -4] days). Median morphine consumption was reduced by 25% and 35% on days 2 and 3, respectively. The incidence of PONV did not differ between the two groups, and the incidence of constipation decreased slightly but significantly in the ERAS group on day 2. Pain intensity at rest and movement were lower in the ERAS group at day 2 and 3. CONCLUSIONS: The current study suggests an ERAS protocol after adolescent idiopathic scoliosis surgery is associated with reduced hospital length of stay and improved postoperative care.

Personal recovery of young adults with severe anorexia nervosa during adolescence: a case series.

PURPOSE: Despite the emergence of a growing qualitative literature about the personal recovery process in mental disorders, this topic remains little understood in anorexia nervosa (AN), especially severe AN during adolescence. This cases series is a first step that aims to understand recovery after severe AN among adolescents in France, from a first-person perspective. METHODS: This cases series applied the interpretative phenomenological analysis (IPA) method to data collected in semi-structured face-to-face interviews about the recovery process of five young women who had been hospitalized with severe AN 10 years earlier during adolescence. RESULTS: A model of recovery in four stages (corseted, vulnerable, plastic, and playful) crossing seven dimensions (struggle and path of initiation; work on oneself; self-determination and help; body; family; connectedness; and timeline) emerged from the analysis. New features of the AN personal recovery process were characterized: bodily well-being and pleasure of body; stigmatization; the role of the group; relation to time; and importance of narratives. We suggest a new shape to model the AN recovery process, one that suggests several tipping points. Recruitment must now be widened to different AN contexts. CONCLUSIONS: The personal recovery paradigm may provide a new approach to care, complementary to medical paradigm. REGISTRATION OF CLINICAL TRIAL: No. NCT03712384. Our study was purely observational, without assignment of medical intervention. As a consequence, this clinical trial was registered retrospectively. LEVEL OF EVIDENCE: Level V, descriptive study.

A survey of the anesthetic management of pediatric kidney transplantation in France.

BACKGROUND: Renal transplantation is the best available therapeutic option for end-stage renal failure in both children and adults. However, little is known about anesthetic practice during pediatric renal transplantation. MATERIAL AND METHODS: The study consisted of a national survey about anesthetic practice during pediatric renal transplantation in France. French tertiary pediatric centers performing renal transplants were targeted, and one physician from each team was asked to complete the survey. The survey included patient data, preoperative assessment and optimization data, and intraoperative anesthesia data (drugs, ventilation, and hemodynamic interventions). RESULTS: Twenty centers performing kidney transplantation were identified and contacted to complete the survey, and eight responded. Surveyed centers performed 96 of the 122 pediatric kidney transplantations performed in France in 2017 (79%). Centers consistently performed echocardiography and ultrasound examinations of the great veins preoperatively and consistently employed esophageal Doppler cardiac output estimation and vasopressors intraoperatively. All other practices were found to be heterogeneous. Central venous pressure was monitored in six centers, and dopamine was administered perioperatively in two centers. CONCLUSIONS: The current study provides a snapshot of the perioperative management of pediatric kidney transplantation in France. Results emphasize the need for both standardization of practice and awareness of recent evidence against the use of CVP monitoring and dopamine infusions.

Correction to: Efficacy of the Game Ready® cooling device on postoperative analgesia after scoliosis surgery in children.

Unfortunately, one co-author name was incorrectly published in the original publication. The complete correct name of the co-author is given below.

Efficacy of the Game Ready® cooling device on postoperative analgesia after scoliosis surgery in children.

PURPOSE: The aim of this study was to investigate the opioid-sparing effect of a cooling brace after surgical correction of idiopathic surgery in children. METHODS: We compared two consecutive cohorts of patients before and after introducing this technique in our institution. Management of patients was standardized. The primary objective of the study was to investigate the morphine consumption during the first postoperative day. Secondary outcomes were opioid consumption at day 3, pain intensity (at days 1 and 3), the mobilization in the standing position and duration of hospitalization. RESULTS: This study included 23 and 22 patients in the control and the cooling cohorts. Cooling brace was associated with a significant decrease in morphine consumption at day 1 (1.7 [0.9, 3.3] versus 1.2 [0.5, 3.2] mg kg-1, P = 0.02) and day 3 (2.5 [0.5, 6.7] versus 1.2 [0.9, 2.5] mg kg-1, P = 0.003), and a reduction in duration of hospitalization (4 [3, 6] versus 3 [3, 4] days, P = 0.004). However, no difference was found on the pain intensity or the percentage of patient mobilized in the standing position. Number of level fused and intraoperative opioid consumption were also different between the two cohorts. However, multivariate analysis found only the use of the cooling brace as significantly associated with opioid consumption at day 1. CONCLUSION: The use of this cooling brace allows decreasing the opioid use after surgical correction of idiopathic surgery in children. The current results strongly suggest an interest of this technique in the postoperative management of patients. These slides can be retrieved under Electronic Supplementary Material.

Does Staphylococcus aureus nasal decontamination affect the rate of early surgical site infection in adolescent idiopathic scoliosis surgery?

PURPOSE: Surgical site infection (SSI) is a main complication after adolescent idiopathic scoliosis (AIS) surgery. Nasal colonization with S. aureus is a known risk factor for developing nosocomial infections in cardiac surgery. However, the risk in orthopedic surgery remains unclear, especially in spine surgery. This study aims to report the efficacy of a preoperative nasal decontamination program in S. aureus carriers on the incidence of early SSI after AIS posterior surgery. METHODS: Between January 2014 and July 2017, all AIS patients were screened preoperatively with nasal swabs and decontaminated if positive 5 days before surgery. Early SSI was identified, and microorganisms findings were analyzed within nasal carriage and compared to a previous series published before the decontamination program (2007-2011). RESULTS: Among the 331 AIS posterior fusion performed during the study period, incidence of positive nasal swab was 23% (n = 75). Those were preoperatively decontaminated. In comparison with the period before the nasal decontamination program, incidence of S. aureus early SSI significantly decreased from 5.1 to 1.3%, p < 0.05. None of those S. aureus decontaminated patients had an early S. aureus SSI. In all cases of S. aureus infections, S. aureus nasal screening was negative with a mean delay of 315 days (± 115) before surgery, which was significantly different from the global cohort (104 days ± 67, p < 0.05). CONCLUSIONS: Preoperative S. aureus nasal decontamination was associated with a significant decrease in S. aureus SSI. Optimal delay of nasal screening needs to be optimized in order to diagnose intermittent S. aureus carriers. These slides can be retrieved under Electronic Supplementary Material.

Description of typical personality factors and events that lead to anxiety at induction of anesthesia in French children.

BACKGROUND: Preventive strategies are available to reduce preoperative anxiety in children, the ideal time for implementing such strategies remains poorly determined. AIMS: The aim of this study was to determine psychological factors and events involved in the development of preoperative anxiety in children. METHODS: This study consisted of prospective evaluations of anxiety trait and state during the preoperative period. Attendance at a preanesthetic consultation is obligatory for all patients undergoing surgery in France. Anxiety trait and state assessments were quantified in mothers and children before and after the preanesthetic consultation using visual analog and faces numerical scales. Preoperative anxiety in children was assessed immediately before induction of anesthesia using an analog scale. Other data recorded included demographic and medical data and type of hospital stay. Univariate and multivariate logistic regression analyses were used. RESULTS: Overall 111 consecutive patients were included. The following factors emerged leading to anxiety state at induction of anesthesia: maternal anxiety state before the preanesthetic consultation, a feeling of not being reassured by the anesthesiologist, maternal anxiety state after the consultation, and anxiety trait in the child. Logistic regression found this combination of factors (OR = 4 [1.4 -12]) and inpatient stay (OR = 3 [1.4-7]), predicting anxiety with an accuracy of 69%. CONCLUSION: The present study identified a combination of psychological factors and events associated with the development of anxiety at induction of anesthesia in children. Parental anxiety impacts upon children and occurs before the preanesthetic consultation. This result may assist clinicians to prescribe personalized preventive strategies against anxiety.

Safety and efficacy of peri-operative administration of hydroxyethyl starch in children undergoing surgery: A systematic review and meta-analysis.

BACKGROUND: Hydroxyethyl starch (HES) solutions have shown their efficiency for intravascular volume expansion. A safety recommendation limiting their use in adult patients has recently been made. OBJECTIVE: To assess the efficacy and adverse effects of HES when administered intra-operatively to paediatric patients. DESIGN: Systematic review with meta-analyses. Data were analysed using classical mean differences [and their 95% confidence intervals (CIs)] and trial sequential analysis. A Grading of Recommendations Assessment, Development and Evaluation (GRADE) classification was performed for all outcomes. Reviewers extracted valid data, including perioperative total fluid intakes, mortality, renal function, coagulation tests, blood loss and length of hospital and ICU stay. DATA SOURCES: Searches were performed in databases (Pubmed, Embase, Cochrane central register of controlled trials), clinical trials register, and open access journals not indexed in major databases. ELIGIBILITY CRITERIA: Randomised controlled trials (RCTs) published before December 2016 involving paediatric patients who received 6% low molecular weight HES. RESULTS: Nine RCTs involving 530 peri-operative paediatric patients were analysed. Compared with other fluids, HES did not significantly modify the amount of peri-operative fluid administered [mean difference 0.04; 95% CI (-1.76 to 1.84) ml kg], urine output [mean difference -33; 95% CI (-104 to 38) ml kg] or blood loss [mean difference -0.09; (-0.32 to 0.15) ml kg]. Trial sequential analysis determined that the outcomes for peri-operative fluid and urine output were underpowered. All results were graded as very low quality of evidence. CONCLUSION: Intravascular volume expansion with low molecular weight 6% HES did not appear to modify renal function, blood loss or transfusion when administered to children during the peri-operative period. However, given the lack of statistical power and the very low GRADE quality of evidence, more high-quality RCTs are needed to explore these outcomes.

Intraoperative hemodynamic factors predicting early postoperative renal function in pediatric kidney transplantation.

BACKGROUND: The anesthetic management of kidney transplantation in children remains somewhat empirical. The goal of the present study was to investigate intraoperative hemodynamic factors affecting posttransplantation kidney function. METHODS: We performed a retrospective analysis of data from patients undergoing kidney transplantation in our pediatric teaching hospital from 2000 to 2014. Data collected included: donor and recipient demographic data, recipient comorbidities, fluids administered intraoperatively, and intraoperative blood pressure and central venous pressure. The main outcome of the study was the creatinine clearance at day 1 corrected to a body surface area of 1.73 m². Analysis was performed using Classification Tree Analysis with 10-fold cross-validation. RESULTS: One hundred and two patients were included. The following predictors of increased postoperative creatinine clearance at day 1 were identified: decreasing recipient weight, mean blood pressure-to-weight ratio 10 minutes after reperfusion, reduced cold ischemia duration, and increased intraoperative albumin infusion. Increased creatinine clearance was observed when mean blood pressure-to-weight ratio 10 minutes after reperfusion was ≥4.3 in patients weighing 13-21 kg and ≥2.5 in those ≥22 kg. Overall, the model explained 64% (and at cross-validation 60%) of creatinine clearance variability at day 1. CONCLUSION: Intraoperative hemodynamics during kidney transplantation should be optimized in order to increase mean blood pressure according to values indicated by our analyses. Cold ischemia duration should be shortened as far as possible.

Muscle relaxation for tracheal intubation during paediatric anaesthesia: A meta-analysis and trial sequential analysis.

BACKGROUND: Muscle relaxation for tracheal intubation during paediatric anaesthesia remains a subject of debate. OBJECTIVE: The aim of the current meta-analysis was to investigate the effect of muscle relaxants (MR) compared with opioids on intubation conditions in children. DESIGN: Meta-analysis of randomised controlled studies. DATA SOURCES: Exhaustive literature analysis. ELIGIBILITY CRITERIA: Clinical trials, with no high-risk bias, that examined the effect of MR in comparison with opioids on intubation conditions (excellent: primary outcome, acceptable: secondary outcome) in children were included. RESULTS: Excellent intubation conditions were not significantly different in their occurrence between children receiving MR or opioids, risk ratio [95% Confidence Interval]  = 1.17 [0.96, 1.43], I = 36%, number of studies = 5, number of patients = 226. However, trial sequential analysis indicated the lack of power of this result and the need for more trials to provide certainty for this outcome (81 patients needed in future trials). Acceptable intubation conditions were more frequent when administering MR, risk ratio = 1.25 [1.06, 1.47], I = 70%, number of studies = 6, number of patients = 362. This effect was confirmed using the trial sequential analysis. Grading of Recommendations Assessment, Development and Evaluation analysis found a low and moderate quality of evidences for excellent and acceptable intubation conditions, respectively. CONCLUSION: The current meta-analysis shows that the use of MR during tracheal intubation might improve the quality of intubation conditions. Further studies, including at least 81 children, are required to confirm this and determine the impact of MR on complications related to intubation.

Intraoperative changes in blood pressure associated with cerebral desaturation in infants.

BACKGROUND: Intraoperative hypotension has been linked to poor postoperative neurological outcomes. However, the definition of hypotension remains controversial in children. We sought to determine arterial blood pressure threshold values associated with cerebral desaturation in infants. METHODS: After ethics committee approval, infants younger than 3 months were included in this prospective observational study. Cerebral saturation was assessed using near-infrared spectroscopy. The primary goal of the study was to determine percentage reductions in intraoperative systolic blood pressure (SBP) and mean blood pressure (MBP) associated with decreases in cerebral blood oxygen saturation of >20%, when compared to baseline. Analyses were performed using a bootstrap receiving operator characteristic (ROC) curves with determination of the gray zone. RESULTS: Sixty patients were recruited and 960 measurement points were recorded. Fifty-nine data points (6.1%) recorded cerebral desaturation of >20% when compared to baseline. The areas under the ROC curves were 0.79 (0.74-0.84) and 0.67 (0.6-0.75) for percentage decreases in SBP and MBP, respectively. Gray zone values with false-positive and negative rates <10% were SBP decreases of 20.5% and 37.5%, respectively, and MBP decreases of 15.5% and 44.5%, respectively. CONCLUSION: Our results indicate that falls in noninvasive systolic blood pressure of <20% from baseline are associated with a <10% chance of cerebral desaturation in neonates and infants <3 months of age undergoing noncardiac surgery. As such, maintaining systolic blood pressure above this threshold value appears a valid clinical target.

Supraglottic airway devices vs tracheal intubation in children: a quantitative meta-analysis of respiratory complications.

BACKGROUND: Rate of perioperative respiratory complications between tracheal intubation (TI) and laryngeal mask airway remains unclear during pediatric anesthesia. OBJECTIVES: The aim of the present meta-analysis was to compare the perioperative respiratory complications between laryngeal mask airway and TI. METHODS: A meta-analysis of available controlled studies comparing laryngeal mask airway to TI was conducted. Studies including patients with airway infection were excluded. Data from each trial were combined to calculate the pooled odds ratios (OR) or mean difference (MD) and 95% confidence intervals. RESULTS: The meta-analysis was performed on 19 studies. In 12 studies, patients were given muscle relaxation, and in 16 studies, ventilation was controlled. During recovery from anesthesia, the incidence of desaturation (OR = 0.34 [0.19-0.62]), laryngospasm (OR = 0.34 [0.2-0.6]), cough (OR = 0.18 [0.11-0.27]), and breath holding (0.19 [0.05-0.68]) was lower when laryngeal mask airway was used to secure the airway. Postoperative incidences of sore throat (OR = 0.87 [0.53-1.44]), bronchospasm (OR = 0.56 [0.25-1.25]), aspiration (1.33 [0.46-3.91]) and blood staining on the device (OR = 0.62 [0.21-1.82]) did not differ between laryngeal mask airway and TI. Results were homogenous across the studies, with the exceptions of blood staining on the device. CONCLUSIONS: This meta-analysis found that the use of laryngeal mask airway in pediatric anesthesia results in a decrease in a number of common postanesthetic complications. It is therefore a valuable device for the management of the pediatric airway.

Association of severe postpartum hemorrhage and development of psychological disorders: Results from the prospective and multicentre HELP MOM study.

OBJECTIVE: Post-partum hemorrhage (PPH) is the leading preventable cause of worldwide maternal morbidity and mortality. Risk factors for psychological disorders following PPH are currently unknown. HELP-MOM study aimed to determine the incidence and identify risk factors for psychological disorders following PPH. METHODS: HELP-MOM study was a prospective, observational, national, and multicentre study including patients who experienced severe PPH requiring sulprostone. The primary endpoint was the occurrence of psychological disorders (anxiety and/or post-traumatic disorder and/or depression) following PPH, assessed at 1, 3, and 6 months after delivery using HADS, IES-R, and EPDS scales. RESULTS: Between November 2014 and November 2016, 332 patients experienced a severe PPH and 236 (72%) answered self-questionnaires at 1, 3, and 6 months. A total of 161 (68%) patients declared a psychological disorder following severe PPH (146 (90.1%) were screened positive for anxiety, 96 (58.9%) were screened positive for post-traumatic stress disorder, and 94 (57.7%) were screened positive for post-partum depression). In multivariable analysis, the use of intra-uterine tamponnement balloon was associated with a lower risk to be screened positive for psychological disorder after severe PPH (OR = 0.33 [IC95% 0.15-0.69], p = 0.004, and after propensity score matching (OR=0.34 [IC95% 0.12-0.94], p = 0.04)). Low hemoglobin values during severe PPH management were associated with a higher risk of being screened positive for psychological disorders. Finally, we did not find differences in desire or pregnancy between patients without or with psychological disorders occurring in the year after severe PPH. DISCUSSION: Severe PPH was associated with significant psychosocial morbidity including anxiety, post-traumatic disorder, and depression. This should engage a psychological follow-up. Large cohorts are urgently needed to confirm our results. REGISTRATION: ClinicalTrials.gov under number NCT02118038.

Plethysmographic variability index (PVI) accuracy in predicting fluid responsiveness in anesthetized children.

INTRODUCTION: Plethysmographic Variability Index (PVI) has been shown to accurately predict responsiveness to fluid loads in adults. The goal of this study was to evaluate PVI accuracy when predicting fluid responsiveness during noncardiac surgery in children. MATERIAL AND METHODS: Children aged 2-10 years scheduled for noncardiac surgery under general anesthesia were included. PVI was assessed concomitantly with stroke volume index (SVI). A response to fluid load was defined by an SVI increase of more than 15%. A 10 ml·kg(-1) normal saline intravenous fluid challenge was administered before surgical incision and after anesthetic induction. After incision, fluid challenges were administered when SVI values decreased by more than 15% or where judged necessary by the anesthesiologist. Statistical analyses include receiving operator characteristics (ROC) analysis and the determination of gray zone method with an error tolerance of 10%. RESULTS: Fifty-four patients were included, 97 fluid challenges administered and 45 responses recorded. Area under the curve of ROC curves was 0.85 [0.77-0.93] and 0.8 [0.7-0.89] for baseline PVI and SVI values, respectively. Corresponding gray zone limits were [10-17%] and [22-31 ml·m(-2)], respectively. PVI values exhibited different gray zone limits for pre-incision and postincision fluid challenges, whereas SVI values were comparable. PVI value percentages in the gray zone were 34% overall and 44% for challenges performed after surgical incision. DISCUSSION: This study found both PVI and prechallenge SVI to be accurate when used to predict fluid load response during anesthetized noncardiac surgery in children. However, a third of recorded PVI values were inconclusive.