Registries in pediatric anesthesiology: A brief history and a new way forward.

Clinical registries are multicenter prospective observational datasets that have been used to examine current perioperative practices in pediatric anesthesia. These datasets have proven useful in quantifying the incidence of rare adverse outcomes. Data from registries can highlight associations between severe patient safety events and patient and procedure-related risk factors. Registries are an effective tool to delineate practices and outcomes in niche patient populations. They have been used to quantify uncommon complications of medications and procedures. Registries can be used to generate knowledge and to support quality improvement. Multicenter engagement can promote best clinical practices and foster professional networks. Registries are limited by their observational nature, which entails a lack of randomization as well as selection and treatment bias. The maintenance of registries over time can be challenging due to difficulties in modifying the included variables, collaborator fatigue, and continued outlay of resources to maintain the database and onboard new sites. These latter issues can lead to decreased data quality. In this article, we discuss key insights from several pediatric anesthesia registries and propose a new type of registry that addresses some shortcomings of the current paradigm.

Comparing the Effectiveness of a Clinical Decision Support Tool in Reducing Pediatric Opioid Dose Calculation Errors: PediPain App vs. Traditional Calculators - A Simulation-Based Randomised Controlled Study.

Wrong dose calculation medication errors are widespread in pediatric patients mainly due to weight-based dosing. PediPain app is a clinical decision support tool that provides weight- and age- based dosages for various analgesics. We hypothesized that the use of a clinical decision support tool, the PediPain app versus pocket calculators for calculating pain medication dosages in children reduces the incidence of wrong dosage calculations and shortens the time taken for calculations. The study was a randomised controlled trial comparing the PediPain app vs. pocket calculator for performing eight weight-based calculations for opioids and other analgesics. Participants were healthcare providers routinely administering opioids and other analgesics in their practice. The primary outcome was the incidence of wrong dose calculations. Secondary outcomes were the incidence of wrong dose calculations in simple versus complex calculations; time taken to complete calculations; the occurrence of tenfold; hundredfold errors; and wrong-key presses. A total of 140 residents, fellows and nurses were recruited between June 2018 and November 2019; 70 participants were randomized to control group (pocket calculator) and 70 to the intervention group (PediPain App). After randomization two participants assigned to PediPain group completed the simulation in the control group by mistake. Analysis was by intention-to-treat (PediPain app = 68 participants, pocket calculator = 72 participants). The overall incidence of wrong dose calculation was 178/576 (30.9%) for the control and 23/544 (4.23%) for PediPain App, P < 0·001. The risk difference was - 32.8% [-38.7%, -26.9%] for complex and - 20.5% [-26.3%, -14.8%] for simple calculations. Calculations took longer within control group (median of 69 Sects. [50, 96]) compared to PediPain app group, (median 48 Sects. [38, 63]), P < 0.001. There were no differences in other secondary outcomes. A weight-based clinical decision support tool, the PediPain app reduced the incidence of wrong doses calculation. Clinical decision support tools calculating medications may be valuable instruments for reducing medication errors, especially in the pediatric population.

Patient and Process Outcomes among Pediatric Patients Undergoing Appendectomy during the COVID-19 Pandemic: An International Retrospective Cohort Study.

BACKGROUND: COVID-19 forced healthcare systems to make unprecedented changes in clinical care processes. The authors hypothesized that the COVID-19 pandemic adversely impacted timely access to care, perioperative processes, and clinical outcomes for pediatric patients undergoing primary appendectomy. METHODS: A retrospective, international, multicenter study was conducted using matched cohorts within participating centers of the international PEdiatric Anesthesia COVID-19 Collaborative (PEACOC). Patients younger than 18 yr old were matched using age, American Society of Anesthesiologists Physical Status, and sex. The primary outcome was the difference in hospital length of stay of patients undergoing primary appendectomy during a 2-month period early in the COVID-19 pandemic (April to May 2020) compared with prepandemic (April to May 2019). Secondary outcomes included time to appendectomy and the incidence of complicated appendicitis. RESULTS: A total of 3,351 cases from 28 institutions were available with 1,684 cases in the prepandemic cohort matched to 1,618 in the pandemic cohort. Hospital length of stay was statistically significantly different between the two groups: 29 h (interquartile range: 18 to 79) in the pandemic cohort versus 28 h (interquartile range: 18 to 67) in the prepandemic cohort (adjusted coefficient, 1 [95% CI, 0.39 to 1.61]; P < 0.001), but this difference was small. Eight centers demonstrated a statistically significantly longer hospital length of stay in the pandemic period than in the prepandemic period, while 13 were shorter and 7 did not observe a statistically significant difference. During the pandemic period, there was a greater occurrence of complicated appendicitis, prepandemic 313 (18.6%) versus pandemic 389 (24.1%), an absolute difference of 5.5% (adjusted odds ratio, 1.32 [95% CI, 1.1 to 1.59]; P = 0.003). Preoperative SARS-CoV-2 testing was associated with significantly longer time-to-appendectomy, 720 min (interquartile range: 430 to 1,112) with testing versus 414 min (interquartile range: 231 to 770) without testing, adjusted coefficient, 306 min (95% CI, 241 to 371; P < 0.001), and longer hospital length of stay, 31 h (interquartile range: 20 to 83) with testing versus 24 h (interquartile range: 14 to 68) without testing, adjusted coefficient, 7.0 (95% CI, 2.7 to 11.3; P = 0.002). CONCLUSIONS: For children undergoing appendectomy, the COVID-19 pandemic did not significantly impact hospital length of stay.

Difficult or impossible facemask ventilation in children with difficult tracheal intubation: a retrospective analysis of the PeDI registry.

BACKGROUND: Difficult facemask ventilation is perilous in children whose tracheas are difficult to intubate. We hypothesised that certain physical characteristics and anaesthetic factors are associated with difficult mask ventilation in paediatric patients who also had difficult tracheal intubation. METHODS: We queried a multicentre registry for children who experienced "difficult" or "impossible" facemask ventilation. Patient and case factors known before mask ventilation attempt were included for consideration in this regularised multivariable regression analysis. Incidence of complications, and frequency and efficacy of rescue placement of a supraglottic airway device were also tabulated. Changes in quality of mask ventilation after injection of a neuromuscular blocking agent were assessed. RESULTS: The incidence of difficult mask ventilation was 9% (483 of 5453 patients). Infants and patients having increased weight, being less than 5th percentile in weight for age, or having Treacher-Collins syndrome, glossoptosis, or limited mouth opening were more likely to have difficult mask ventilation. Anaesthetic induction using facemask and opioids was associated with decreased risk of difficult mask ventilation. The incidence of complications was significantly higher in patients with "difficult" mask ventilation than in patients without. Rescue placement of a supraglottic airway improved ventilation in 71% (96 of 135) of cases. Administration of neuromuscular blocking agents was more frequently associated with improvement or no change in quality of ventilation than with worsening. CONCLUSIONS: Certain abnormalities on physical examination should increase suspicion of possible difficult facemask ventilation. Rescue use of a supraglottic airway device in children with difficult or impossible mask ventilation should be strongly considered.

Machine Vision and Image Analysis in Anesthesia: Narrative Review and Future Prospects.

Machine vision describes the use of artificial intelligence to interpret, analyze, and derive predictions from image or video data. Machine vision-based techniques are already in clinical use in radiology, ophthalmology, and dermatology, where some applications currently equal or exceed the performance of specialty physicians in areas of image interpretation. While machine vision in anesthesia has many potential applications, its development remains in its infancy in our specialty. Early research for machine vision in anesthesia has focused on automated recognition of anatomical structures during ultrasound-guided regional anesthesia or line insertion; recognition of the glottic opening and vocal cords during video laryngoscopy; prediction of the difficult airway using facial images; and clinical alerts for endobronchial intubation detected on chest radiograph. Current machine vision applications measuring the distance between endotracheal tube tip and carina have demonstrated noninferior performance compared to board-certified physicians. The performance and potential uses of machine vision for anesthesia will only grow with the advancement of underlying machine vision algorithm technical performance developed outside of medicine, such as convolutional neural networks and transfer learning. This article summarizes recently published works of interest, provides a brief overview of techniques used to create machine vision applications, explains frequently used terms, and discusses challenges the specialty will encounter as we embrace the advantages that this technology may bring to future clinical practice and patient care. As machine vision emerges onto the clinical stage, it is critically important that anesthesiologists are prepared to confidently assess which of these devices are safe, appropriate, and bring added value to patient care.

The influence of resident and faculty gender on assessments in anesthesia competency-based medical education.

PURPOSE: Competency-based medical education (CBME) relies on frequent workplace-based assessments of trainees, providing opportunities for conscious and implicit biases to reflect in these assessments. We aimed to examine the influence of resident and faculty gender on performance ratings of residents within a CBME system. METHODS: This retrospective cohort study took place from August 2017 to January 2021 using resident assessment data from two workplace-based assessments: the Anesthesia Clinical Encounter Assessment (ACEA) and Entrustable Professional Activities (EPAs). Self-reported gender data were also extracted. The primary outcome-gender-based differences in entrustment ratings of residents on the ACEA and EPAs-was evaluated using mixed-effects logistic regression, with differences reported through odds ratios and confidence intervals (α = 0.01). Gender-based differences in the receipt of free-text comments on the ACEA and EPAs were also explored. RESULTS: In total, 14,376 ACEA and 4,467 EPA assessments were analyzed. There were no significant differences in entrustment ratings on either assessment tool between men and women residents. Regardless of whether assessments were completed by men or women faculty, entrustment rates between men and women residents were not significantly different for any postgraduate year level. Additionally, men and women residents received strengths-related and actions-related comments on both assessments at comparable frequencies, irrespective of faculty gender. CONCLUSION: We found no gender-based differences in entrustment ratings for both the ACEA and EPAs, which suggests an absence of resident gender bias within this CBME system. Given considerable heterogeneity in rater leniency, future work would be strengthened by using rater leniency-adjusted scores rather than raw scores.

RéSUMé: OBJECTIF: La formation médicale fondée sur les compétences (FMFC) repose sur des évaluations fréquentes des stagiaires en milieu de travail, ce qui donne l'occasion de refléter les préjugés conscients et implicites dans ces évaluations. Notre objectif était d'examiner l'influence du genre des résident·es et des professeur·es sur les évaluations de la performance des résident·es au sein d'un système de FMFC. MéTHODE: Cette étude de cohorte rétrospective s'est déroulée d'août 2017 à janvier 2021 à l'aide des données d'évaluation des résident·es provenant de deux évaluations en milieu de travail : L'évaluation de l'anesthésie clinique par événement (ACEA ­ Anesthesia Clinical Encounter Assessment) et les Actes professionnels non supervisés (APNS). Des données autodéclarées sur le genre ont également été extraites. Le critère d'évaluation principal, soit les différences fondées sur le genre dans les cotes de confiance des résident·es sur l'ACEA et les APNS, a été évalué à l'aide d'une régression logistique à effets mixtes, les différences étant rapportées par les rapports de cotes et les intervalles de confiance (α = 0,01). Les différences fondées sur le genre dans la réception des commentaires en texte libre sur l'ACEA et les APNS ont également été explorées. RéSULTATS: Au total, 14 376 évaluations ACEA et 4467 évaluations APNS ont été analysées. Il n'y avait pas de différences significatives dans les cotes de confiance obtenues avec l'un ou l'autre des outils d'évaluation entre les résidents et les résidentes. Indépendamment du genre de la personne réalisant l'évaluation, les taux de confiance entre les résidentes et les résidents n'étaient pas significativement différents pour toutes les années de formation postdoctorale. De plus, les résident·es ont reçu des commentaires liés à leurs forces et leurs actes sur les deux évaluations à des fréquences comparables, quel que soit le genre du corps professoral. CONCLUSION: Nous n'avons constaté aucune différence fondée sur le genre dans les cotes de confiance telles qu'évaluées par les ACEA et les APNS, ce qui suggère une absence de préjugés genrés envers les résident·es au sein de ce système de FMFC. Compte tenu de l'hétérogénéité considérable en matière de clémence des évaluateurs et évaluatrices, les travaux futurs seraient plus fiables s'ils utilisaient des scores ajustés en fonction de ladite clémence plutôt que des scores bruts.

Standardized Anesthesia InductioN Tool (SAINT) - The development and international adoption of an integrated electronic tool for documenting the induction of anesthesia in children.

BACKGROUND: The induction of anesthesia in children poses a challenge for the anesthesiologist, the parent and child. Anxiety and negative behaviours and strategies that effectively mitigate should be documented accurately and be available for future patient encounters. To address the need for a structured and standardized electronic documentation tool. AIMS: Our aim was to develop a comprehensive electronic tool to capture and report behaviours during induction of anesthesia. METHODS: We performed a literature search on existing validated tools for documenting behaviours during anesthesia induction. We used the nominal group technique to achieve agreement on the components to include. We used Agile software development techniques to design and review the integrated electronic tool. Twelve international hospitals informed the development of the tool. RESULTS: We developed an electronic tool, the Standardized Anesthesia InductioN Tool (SAINT). SAINT incorporates validated scales for documenting key stages of the anesthesia induction journey (separation from caregivers, mask acceptance, induction behaviour, parental presence, the use of adjuncts and their effectiveness). In addition, the standardised data elements used in SAINT allow for local reporting, quality metrics and can assist in data across multi-centre trials. To date the tool has been adopted by 133 institutions across four countries and is freely available. CONCLUSION: We show that collaborative development and rapid adoption of the comprehensive induction tool SAINT has led to its rapid adoption in the routine practice of pediatric anesthesiology across several countries. Further studies on how the SAINT is being used for quality improvement or research are warranted.

The role of WhatsApp™ in pediatric difficult airway management: A study from the PeDI Collaborative.

BACKGROUND: Management of the pediatric difficult airway can present unique clinical challenges. The Pediatric Difficult Intubation Collaborative (PeDI-C) is an international collaborative group engaging in quality improvement and research in children with difficult airways. The PeDI-C established a WhatsApp™ group to facilitate real-time discussions around the management of the difficult airway in pediatric patients. The goals of this study were to evaluate the patterns of use of the WhatsApp™ group, themes on messages posted on pediatric difficult airway management and to assess the perceived usefulness of the WhatsApp™ group by the PeDI-C members. METHOD: Following research ethics approval, we performed a database analysis on the archived discussion of the PeDI-C WhatsApp™ group from 2014 to 2019 and surveyed members to assess the perceived usefulness of the PeDI-C WhatsApp™ group. RESULTS: 5781 messages were reviewed with 350 (6.0%) original stems. The three most common original stem types were advice seeking 98 (28%), announcements 85 (24.2%), and clinical case-sharing 78 (22.2%). The median number of responses to original stems was 9 [2-21.3]. Post types associated with increased responses included those seeking advice on medication/equipment (regression coefficient 0.78, 95% CI [0.41-1.16]; p < .0001); seeking advice on patient care (regression coefficient 1.16, 95% CI [0.86-1.45]; p < .0001), sharing advice on medication/equipment availability (regression coefficient 0.87, 95% CI [0.33-1.40], p < .0016), and clinical case-sharing (regression coefficient 1.2547, 95% CI [0.9401-1.5693] p < .0001). 46/64 members of the group responded to the survey. Replies offering advice regarding patient management scenarios were found to be of most interest and 77% of surveyed members found the discussion translatable into their own clinical practice. DISCUSSION: The PeDI-C WhatsApp™ group has facilitated timely knowledge exchange on pediatric difficult airway management across the world. Participants are satisfied with the role the Whatsapp™ group is playing.

Validity evidence for the Anesthesia Clinical Encounter Assessment (ACEA) tool to support competency-based medical education.

BACKGROUND: Workplace-based assessment (WBA) is key to a competency-based assessment strategy. Concomitantly with our programme's launch of competency-based medical education, we developed an entrustment-based WBA, the Anesthesia Clinical Encounter Assessment (ACEA), to assess readiness for independent practice of competencies essential to perioperative patient care. This study aimed to examine validity evidence of the ACEA during postgraduate anaesthesiology training. METHODS: The ACEA comprises an eight-item global rating scale (GRS), an overall independence rating, an eight-item checklist, and case details. ACEA data were extracted for University of Toronto anaesthesia residents from July 2017 to January 2020 from the programme's online assessment portal. Validity evidence was generated following Messick's validity framework, including response process, internal structure, relations with other variables, and consequences. RESULTS: We analysed 8664 assessments for 137 residents completed by 342 assessors. From generalisability analysis, 10 independent observations (two assessments each from five assessors) were sufficient to achieve a reliability threshold of ≥0.70 for in-training assessments. A composite GRS score of 3.65/5 provided optimal sensitivity (93.6%) and specificity (90.8%) for determining entrustment on receiver operator characteristic curve analysis. Test-retest reliability was high (intraclass correlation coefficient [ICC2,1]=0.81) for matched assessments within 14 days of each other. Composite GRS scores differed significantly between residents based on their training level (P<0.0001) and correlated highly with overall independence (0.91, P<0.001). The internal consistency of the GRS (α=0.96) was excellent. CONCLUSIONS: This study supports the validity of the ACEA for assessing the competence of residents performing perioperative care and supports its use in competency-based anaesthesiology training.

Chest trauma in children-what an anesthesiologist should know.

Injury is the leading cause of death in children, with chest trauma accounting for 25% of this mortality. In addition, these patients often present with multiple system injuries, which require simultaneous management. These concurrent injuries can lead to challenges when prioritizing tasks in the resuscitation room and during anesthetic management. In addition, changes from spontaneous ventilation to positive pressure ventilation can impact lung physiology. Therefore, a clear communication plan with careful monitoring and vigilance is needed for intubation and ventilation in these children. These injuries also require specific strategies to prevent barotrauma which could lead to complications such as respiratory failure, pneumonia, sepsis, and acute respiratory distress syndrome. This educational review aims to guide clinicians managing pediatric chest trauma through some of the critical decision-making regarding intubation, ventilation, and subsequent management of injuries.

Lung and airway ultrasound in pediatric anesthesia.

Perioperative lung ultrasound is a continuously evolving modality with numerous applications for the pediatric anesthesiologist. Lung ultrasound can be used at the bedside, including intraoperatively, to augment traditional physical examination methods of assessing cardiopulmonary structures and identifying the presence of specific and clinically significant pathology. With regard to the lungs, ultrasound has been shown to be highly sensitive at identification of pulmonary pathologies, particularly those of interest in the acute care setting (eg, pleural effusion, pneumothorax). With its relative ease of performance, lung ultrasound should be considered in the initial evaluation of intraoperative hypoxemia particularly when traditional modes of evaluation are nonexplanatory. This educational review introduces the basic concepts of lung ultrasound as they relate to pediatric anesthesia patients.

Risk assessment and optimization strategies to reduce perioperative respiratory adverse events in Pediatric Anesthesia-Part 2: Anesthesia-related risk and treatment options.

Perioperative respiratory adverse events are the most common cause of critical events in children undergoing anesthesia and surgery. While many risk factors remain unmodifiable, there are numerous anesthetic management decisions which can impact the incidence and impact of these events, especially in at-risk children. Ongoing research continues to improve our understanding of both the influence of risk factors and the effect of specific interventions. This review discusses anesthesia risk factors and outlines strategies to reduce the rate and impact of perioperative respiratory adverse events with a chronologic based inquiry into anesthetic management decisions through the perioperative period from premedication to postoperative disposition.

Risk assessment and optimization strategies to reduce perioperative respiratory adverse events in pediatric anesthesia-Part 1 patient and surgical factors.

Pediatric surgery cases are increasing worldwide. Within pediatric anesthesia, perioperative respiratory adverse events are the most common precipitant leading to serious complications. They can have intraoperative impact on the surgical procedure itself, lead to premature case termination and in addition may have postoperative impact resulting in longer hospitalization stays and costs. Although most perioperative respiratory adverse events can be promptly detected and managed, and will not lead to any sequelae, the risk of life-threatening progression remains. The incidence of respiratory adverse events increases in children with comorbid respiratory and/or nonrespiratory illnesses. Optimized perioperative patient care, risk-stratified care level choice, and practitioners with appropriate training allow for risk mitigation. This review will discuss patient and surgical risk factors with a focus on common patient comorbid illnesses and review scoring systems to quantify risk.

Safe in the first attempt: teaching neonatal airway management.

PURPOSE OF REVIEW: Quick and precise facemask ventilation and tracheal intubation are critical clinical skills in neonatal airway management. In addition, this vulnerable population requires a thorough understanding of developmental airway anatomy and respiratory physiology to manage and anticipate potential airway mishaps. Neonates have greater oxygen consumption, increased minute ventilation relative to functional residual capacity, and increased closing volumes compared to older children and adults. After a missed airway attempt, this combination can quickly lead to dire consequences, such as cardiac arrest. Keeping neonates safe throughout the first attempt of airway management is key. RECENT FINDINGS: Several techniques and practices have evolved to improve neonatal airway management, including improvement in neonatal airway equipment, provision of passive oxygenation, and closer attention to the management of anesthetic depth. The role of nontechnical skills during airway management is receiving more recognition. SUMMARY: Every neonatal intubation should be considered a critical event. Below we discuss some of the challenges in neonatal airway management, including anatomical and physiological principles which must be understood to approach the airway. We then follow with a description of current evidence for best practices and training.

Return to school and mask-wearing in class during the COVID-19 pandemic: Student perspectives from a school simulation study.

Objectives: This study examined children's perspectives about returning to in-person school following lockdown due to the pandemic and about mask-wearing in class, as well as the mental health of children and parents during the pandemic. Methods: This cross-sectional study was part of a 2-day school simulation exercise that randomized students to different masking recommendations. Parent-report of mental health and post-simulation child-report of COVID-19-related anxiety and mask-wearing were analyzed using descriptive and multiple regression analyses. Semi-structured focus groups were conducted with older students to supplement questionnaire data. Results: Of 190 students in this study, 31% were in grade 4 or lower 95% looked forward to returning to in-person school. Greater child anxiety about COVID-19 was predicted by increased parent/caregiver anxiety (ß=0.67; P<0.001), and lower parental educational attainment (ß=1.86; P<0.002). Older students were more likely than younger students to report that mask-wearing interfered with their abilities to interact with peers (χ2(1)=31.16; P<0.001) and understand the teacher (χ2(1)=13.97; P<0.001). Students in the group that did not require masks were more likely than students in the masking group to report worries about contracting COVID-19 at school (χ2(1)=10.07; P<0.05), and anticipated difficulty wearing a mask (χ2(1)=18.95; P<0.001). Conclusions: For children anxious about COVID-19, parental anxiety and education about COVID-19 may be targets for intervention. Future research should examine the impact of prolonged implementation of public health mitigation strategies in school on academic achievement and children's mental health.

Lessons from COVID-19: A reflection on the strengths and weakness of early consensus recommendations for pediatric difficult airway management during a respiratory viral pandemic using a modified Delphi method.

BACKGROUND: The authors recognized a gap in existing guidelines and convened a modified Delphi process to address novel issues in pediatric difficult airway management raised by the COVID-19 pandemic. METHODS: The Pediatric Difficult Intubation Collaborative, a working group of the Society for Pediatric Anesthesia, assembled an international panel to reach consensus recommendations on pediatric difficult airway management during the COVID-19 pandemic using a modified Delphi method. We reflect on the strengths and weaknesses of this process and ways care has changed as knowledge and experience have grown over the course of the pandemic. RECOMMENDATIONS: In the setting of the COVID-19 pandemic, the Delphi panel recommends against moving away from the operating room solely for the purpose of having a negative pressure environment. The Delphi panel recommends supplying supplemental oxygen and using videolaryngoscopy during anticipated difficult airway management. Direct laryngoscopy is not recommended. If the patient meets extubation criteria, extubate in the OR, awake, at the end of the procedure. REFLECTION: These recommendations remain valuable guidance in caring for children with anticipated difficult airways and infectious respiratory pathology when reviewed in light of our growing knowledge and experience with COVID-19. The panel initially recommended minimizing involvement of additional people and trainees and minimizing techniques associated with aerosolization of viral particles. The demonstrated effectiveness of PPE and vaccination at reducing the risk of exposure and infection to clinicians managing the airway makes these recommendations less relevant for COVID-19. They would likely be important initial steps in the face of novel respiratory viral pathogens. CONCLUSIONS: The consensus process cannot and should not replace evidence-based guidelines; however, it is encouraging to see that the panel's recommendations have held up well as scientific knowledge and clinical experience have grown.

Coronavirus disease 2019 and pediatric anesthesia.

PURPOSE OF REVIEW: The purpose of this review is to provide the latest evidence for delivering safe and effective anesthesia care for pediatric patients with coronavirus disease 2019 (COVID-19) and to highlight continuing gaps in the literature. RECENT FINDINGS: Safe and efficient care of pediatric patients with COVID-19 can be delivered with the proper planning, coordination, supplies, and staff preparation. From the start of the pandemic, pediatric anesthesiologists from around the world contributed important insights and shared experience as to how best to adapt anesthesia care for children with COVID-19 requiring general anesthesia and sedation. Although initial efforts focused on creating safe airway management processes, the role of anesthesiologists as perioperative leaders quickly extended to ensuring well-coordinated management of COVID-19 patients throughout the hospital for procedures, including preprocedure testing, patient transport, operating room setup, and ensuring the safety of staff. Several important areas remain not well studied including, the timing of rescheduling elective procedures following COVID-19 infection, the perioperative implications of re-infection, and future considerations of managing vaccinated children. SUMMARY: Pediatric anesthesia care can be safely delivered to children with COVID-19 and after COVID-19 infection. More attention needs to be focused on the perioperative management of COVID-19 children in recovery requiring anesthesia.

Pediatric Airway Management in COVID-19 Patients: Consensus Guidelines From the Society for Pediatric Anesthesia's Pediatric Difficult Intubation Collaborative and the Canadian Pediatric Anesthesia Society.

The severe acute respiratory syndrome coronavirus 2 (coronavirus disease 2019 [COVID-19]) pandemic has challenged medical systems and clinicians globally to unforeseen levels. Rapid spread of COVID-19 has forced clinicians to care for patients with a highly contagious disease without evidence-based guidelines. Using a virtual modified nominal group technique, the Pediatric Difficult Intubation Collaborative (PeDI-C), which currently includes 35 hospitals from 6 countries, generated consensus guidelines on airway management in pediatric anesthesia based on expert opinion and early data about the disease. PeDI-C identified overarching goals during care, including minimizing aerosolized respiratory secretions, minimizing the number of clinicians in contact with a patient, and recognizing that undiagnosed asymptomatic patients may shed the virus and infect health care workers. Recommendations include administering anxiolytic medications, intravenous anesthetic inductions, tracheal intubation using video laryngoscopes and cuffed tracheal tubes, use of in-line suction catheters, and modifying workflow to recover patients from anesthesia in the operating room. Importantly, PeDI-C recommends that anesthesiologists consider using appropriate personal protective equipment when performing aerosol-generating medical procedures in asymptomatic children, in addition to known or suspected children with COVID-19. Airway procedures should be done in negative pressure rooms when available. Adequate time should be allowed for operating room cleaning and air filtration between surgical cases. Research using rigorous study designs is urgently needed to inform safe practices during the COVID-19 pandemic. Until further information is available, PeDI-C advises that clinicians consider these guidelines to enhance the safety of health care workers during airway management when performing aerosol-generating medical procedures. These guidelines have been endorsed by the Society for Pediatric Anesthesia and the Canadian Pediatric Anesthesia Society.

Anesthesia environmental sustainability programs-a survey of Canadian department chiefs and residency program directors.

INTRODUCTION: Anesthesia-related activities contribute to operating room waste impacting climate change. The aim of this study was to ascertain 1) the current existence and scope of department and education programs concerned with anesthesia "green" practice; and 2) perceived barriers to environmental sustainability efforts among Canadian anesthesia department chiefs and residency program directors. METHODS: Association of Canadian University Departments of Anesthesia-affiliated anesthesiology department chiefs (n = 113) were invited to complete an online survey ascertaining current efforts in, and barriers to, environmentally sustainable anesthesia practice. Similarly, Canadian anesthesiology residency program directors (n = 17) were invited to complete an online survey delineating current educational programs on environmental sustainability and identifying interest in, and barriers to, developing a Canada-wide curriculum. RESULTS: The response rates for department chiefs and program directors were 23% (26/113) and 41% (7/17), respectively. Department chiefs indicated that their departments participate in sustainability efforts such as donating medical equipment (65%) and recycling (58%). Despite interest in environmental sustainability, department chiefs identified inadequate funding (72%), lack of a mandate (64%), and inadequate knowledge (60%) as barriers to implementing environmentally sustainable practices. Only 29% of responding Canadian anesthesiology programs include environmental sustainability in their curriculum. Responding residency program directors believe residents would benefit from more teaching on the topic (86%) but identified barriers including a lack of faculty expertise (100%) and time constraints (71%). Respondents (71%) also indicated an interest in developing a Canadian curriculum on the topic. CONCLUSION: Our results highlight current attitudes, gaps, and barriers to environmentally sustainable anesthesiology practice among departmental and educational leadership. Furthermore, this study identifies potential opportunities to develop cross-Canada collaborative educational programs in this field.

RéSUMé: INTRODUCTION: Les activités liées à l'anesthésie contribuent aux déchets de salle d'opération qui ont un impact sur les changements climatiques. L'objectif de cette étude était d'établir 1) l'existence et la portée des programmes départementaux et de formation s'intéressant à une pratique écoresponsable de l'anesthésie; et 2) les obstacles perçus aux efforts en matière de durabilité environnementale parmi les chefs de départements et les directeurs de programmes de résidence en anesthésie canadiens. MéTHODE: Les chefs des départements d'anesthésiologie affiliés à l'Association canadienne universitaire des départements d'anesthésie (ACUDA) (n = 113) ont été invités à remplir un sondage en ligne afin de déterminer les efforts actuels et les obstacles à une pratique durable de l'anesthésie. Les directeurs de programmes de résidence en anesthésiologie canadiens (n = 17) ont également été invités à remplir un sondage en ligne décrivant les programmes de formation actuels portant sur la durabilité environnementale et identifiant l'intérêt pour et les obstacles à la création d'un cursus s'appliquant à tout le Canada. RéSULTATS: Les taux de réponse des chefs de département et des directeurs de programme étaient de 23 % (26/113) et 41 % (7/17), respectivement. Les chefs de département ont indiqué que leurs départements prenaient part aux efforts de durabilité en faisant don des équipements médicaux (65 %) et en recyclant (58 %). Malgré un intérêt pour la durabilité environnementale, les chefs de département ont fait mention d'un financement inadapté (72 %), de l'absence de mandat (64 %), et d'un manque de connaissances (60 %) en tant qu'obstacles à la mise en place de pratiques durables. Seuls 29 % des programmes d'anesthésiologie canadiens ayant répondu comportaient un volet sur la durabilité environnementale dans leur programme. Les directeurs de programmes de résidence ayant répondu étaient d'avis que les résidents bénéficieraient d'une augmentation de l'enseignement à ce sujet (86 %) mais ont identifié divers obstacles, notamment un manque d'expertise du corps enseignant (100 %) et des contraintes de temps (71 %). Les répondants (71 %) ont également indiqué leur intérêt pour la création d'un cursus canadien à ce sujet. CONCLUSION: Nos résultats résument les attitudes, écueils et obstacles actuels à une pratique durable de l'anesthésiologie parmi les directions des départements et des programmes de formation. En outre, cette étude identifie des occasions potentielles de création de programmes éducatifs collaboratifs pancanadiens dans ce domaine.

State of the art in clinical decision support applications in pediatric perioperative medicine.

PURPOSE OF REVIEW: The goal of this review is to describe the recent improvements in clinical decision tools applied to the increasingly large and complex datasets in the pediatric ambulatory and inpatient setting. RECENT FINDINGS: Clinical decision support has evolved beyond simple static alerts to complex dynamic alerts for: diagnosis, medical decision-making, monitoring of physiological, laboratory, and pharmacologic inputs, and adherence to institutional and national guidelines for both the patient and the healthcare team. Artificial intelligence and machine learning have enabled advances in predicting outcomes, such as sepsis and early deterioration, and assisting in procedural technique. SUMMARY: With more than a decade of electronic medical data generation, clinical decision support tools have begun to evolve into more sophisticated and complex algorithms capable of transforming large datasets into succinct, timely, and pertinent summaries for treatment and management of pediatric patients. Future developments will need to leverage patient-generated health data, integrated device data, and provider-entered data to complete the continuum of patient care and will likely demonstrate improvements in patient outcomes.