Simulation in pediatric anesthesiology: current state and visions for the future.

PURPOSE OF REVIEW: Simulation is a well established practice in medicine. This review reflects upon the role of simulation in pediatric anesthesiology in three parts: training anesthesiologists to care for pediatric patients safely and effectively; evaluating and improving systems of care for children; and visions for the future. RECENT FINDINGS: Simulation continues to prove a useful modality to educate both novice and experienced clinicians in the perioperative care of infants and children. It is also a powerful tool to help analyze and improve upon how care is provided to infants and children. Advances in technology and computational power now allow for a greater than ever degree of innovation, accessibility, and focused reflection and debriefing, with an exciting outlook for promising advances in the near future. SUMMARY: Simulation plays a key role in developing and achieving peak performance in the perioperative care of infants and children. Although simulation already has a great impact, its full potential is yet to be harnessed.

Advances in pediatric perioperative care using artificial intelligence.

PURPOSE OF THIS REVIEW: This article explores how artificial intelligence (AI) can be used to evaluate risks in pediatric perioperative care. It will also describe potential future applications of AI, such as models for airway device selection, controlling anesthetic depth and nociception during surgery, and contributing to the training of pediatric anesthesia providers. RECENT FINDINGS: The use of AI in healthcare has increased in recent years, largely due to the accessibility of large datasets, such as those gathered from electronic health records. Although there has been less focus on pediatric anesthesia compared to adult anesthesia, research is on- going, especially for applications focused on risk factor identification for adverse perioperative events. Despite these advances, the lack of formal external validation or feasibility testing results in uncertainty surrounding the clinical applicability of these tools. SUMMARY: The goal of using AI in pediatric anesthesia is to assist clinicians in providing safe and efficient care. Given that children are a vulnerable population, it is crucial to ensure that both clinicians and families have confidence in the clinical tools used to inform medical decision- making. While not yet a reality, the eventual incorporation of AI-based tools holds great potential to contribute to the safe and efficient care of our patients.

Overcoming Obstacles: The Legacy of Fidel Pagés, Founder of the Epidural, 100 Years After His Passing.

Fidel Pagés, a Spanish surgeon, tragically died in 1923 at the age of 37, just 2 years after his publication "Anestesia Metamérica," the first description of human thoracolumbar epidural anesthesia. In the intervening 100 years, epidural anesthesia has faced countless obstacles, starting with the dissemination of his initial report, which was not widely read nor appreciated at the time. However, the merits of the technique have fueled innovations to meet these challenges over the years. Even today, while epidural anesthesia is widely embraced, particularly in obstetric and chronic pain medicine, the pressures of the operating room for efficiency and a low tolerance for failure, pose modern-day challenges. Here, we revisit Pagés' original report and highlight the key innovations that have allowed for the evolution of this essential anesthesia technique.

From Brobdingnag to Lilliput: Gulliver's travels in airway management guidelines.

Neonatal airway management comes with exclusive anatomical, physiological, and environmental complexities, and probably higher incidences of accidents and complications. No dedicated airway management guidelines were available until the recently published first joint guideline released by a task force supported by the European Society of Anaesthesiology and Intensive Care and the British Journal of Anaesthesia and focused on airway management in children under 1 yr of age. The guideline offers a series of recommendations based on meticulous methodology including multiple Delphi rounds to complement the sparse and scarce available evidence. Getting back from Brobdingnag, the land of giants with many guidelines available, this guideline represents a foundational cornerstone in the land of Lilliput.

Integration of simulation-based education in anaesthesiology specialist training: Synthesis of results from an Utstein Meeting.

BACKGROUND: Despite its importance in education and patient safety, simulation-based education and training (SBET) is only partially or poorly implemented in many countries, including most European countries. The provision of a roadmap may contribute to the development of SBET for the training of anaesthesiologists. OBJECTIVE: To develop a global agenda for the integration of simulation into anaesthesiology specialist training; identify the learning domains and objectives that are best achieved through SBET; and to provide examples of simulation modalities and evaluation methods for these learning objectives. DESIGN: Utstein-style meeting where an expert consensus was reached after a series of short plenary presentations followed by small group workshops, underpinned by Kern's six-step theoretical approach to curriculum development. SETTING: Utstein-style collaborative meeting. PARTICIPANTS: Twenty-five participants from 22 countries, including 23 international experts in simulation and two anaesthesia trainees. RESULTS: We identified the following ten domains of expertise for which SBET should be used to achieve the desired training outcomes: boot camp/initial training, airway management, regional anaesthesia, point of care ultrasound, obstetrics anaesthesia, paediatric anaesthesia, trauma, intensive care, critical events in our specialty, and professionalism and difficult conversations. For each domain, we developed a course template that defines the learning objectives, instructional strategies (including simulation modalities and simulator types), and assessment methods. Aspects related to the practical implementation, barriers and facilitators of this program were also identified and discussed. CONCLUSIONS: We successfully developed a comprehensive agenda to facilitate the integration of SBET into anaesthesiology specialist training. The combination of the six-step approach with the Utstein-style process proved to be extremely valuable in supporting content validity and representativeness. These results may facilitate the implementation and use of SBET in several countries. TRIAL REGISTRATION: Not applicable.

Human dissection for anesthesiology resident training augments anatomical knowledge and clinical skills.

Anatomy is an essential component of clinical anesthesiology. The use of simulated patients and alternative materials, including embalmed human bodies, have become increasingly common during resident physician training due to the deemphasis on anatomical education during undergraduate medical training. In this report, the need for a more extensive review of relevant anatomy for the practice of anesthesiology was addressed by the design, evaluation, and dissemination of a human dissection course for procedural training of anesthesiology residents. The course utilized "freedom art" embalmed human bodies that allowed trainees to perform ultrasound-based regional and neuraxial techniques followed by detailed dissections of critical anatomy. One hundred and four residents participated in workshops and small group discussions and were evaluated using pre- and post-course assessments. A variety of clinical techniques were performed on the bodies, including regional blocks and neuraxial catheter placement. Insertion of peripheral/neuraxial catheters was successful, with dissections demonstrating the expected placement. Assessment scores improved following the course (pre-course mean 52.7%, standard deviation (σ) 13.1%; post-course mean 72.2%, σ 11.6%; t-test p < 0.0001) and feedback highlighted the usefulness and clinical relevance of course content. The ability to correlate ultrasound imaging with subsequent dissections of the "blocked" area and visualization of dye staining was extremely relevant for spatial understanding of the anatomy relevant for the clinical practice of these techniques. This manuscript demonstrates successful implementation of a comprehensive course for anesthesiology resident physicians to address gaps in undergraduate anatomical education and suggests that broader adoption of dissection courses may be beneficial for training anesthesiologists.

Recommendations from the Brazilian Society of Anesthesiology (SBA) for difficult airway management in adults.

Difficult airway management represents a major challenge, requiring a careful approach, advanced technical expertise, and accurate protocols. The task force of the Brazilian Society of Anesthesiology (SBA) presents a report with updated recommendations for the management of difficult airway in adults. These recommendations were developed based on the consensus of a group of expert anesthesiologists, aiming to provide strategies for managing difficulties during tracheal intubation. They are based on evidence published in international guidelines and opinions of experts. The report underlines the essential steps for proper difficult airway management, encompassing assessment, preparation, positioning, pre-oxygenation, minimizing trauma, and maintaining arterial oxygenation. Additional strategies for using advanced tools, such as video laryngoscopy, flexible bronchoscopy, and supraglottic devices, are discussed. The report considers recent advances in understanding crisis management, and the implementation seeks to further patient safety and improve clinical outcomes. The recommendations are outlined to be uncomplicated and easy to implement. The report underscores the importance of ongoing education, training in realistic simulations, and familiarity with the latest technologies available.

Recommendations from the Brazilian Society of Anesthesiology (SBA) for difficult airway management in pediatric care.

Difficult airway management in pediatrics during anesthesia represents a major challenge, requiring a careful approach, advanced technical expertise, and accurate protocols. The task force of the Brazilian Society of Anesthesiology (SBA) presents a report containing updated recommendations for the management of difficult airways in children and neonates. These recommendations have been developed based on the consensus of a panel of experts, with the objective of offering strategies to overcome challenges during airway management in pediatric patients. Grounded in evidence published in international guidelines and expert opinions, the report highlights crucial steps for the appropriate management of difficult airways in pediatrics, encompassing assessment, preparation, positioning, pre-oxygenation, minimizing trauma, and, paramountly, the maintenance of arterial oxygenation. The report also delves into additional strategies involving the use of advanced tools, such as video laryngoscopy, flexible intubating bronchoscopy, and supraglottic devices. Emphasis is placed on the simplicity of implementing the outlined recommendations, with a focus on the significance of continuous education, training through realistic simulations, and familiarity with the latest available technologies. These practices are deemed essential to ensure procedural safety and contribute to the enhancement of anesthesia outcomes in pediatrics.

Lowering the statistical significance threshold of randomized controlled trials in three major general anesthesiology journals.

PURPOSE: The primary objective of our study was to determine how lowering a P value threshold from 0.05 to 0.005 would affect the statistical significance of previously published randomized controlled trials (RCTs) in major anesthesiology journals. METHODS: We searched the PubMed database for studies electronically published in 2020 within three major general anesthesiology journals as indexed by both Google Metrics and Scimago Journal & Country Rank. Studies included were RCTs published in 2020 in Anesthesiology, Anesthesia & Analgesia, and the British Journal of Anaesthesia; had a primary endpoint, and used a P value threshold to determine the effect of the intervention. We performed screening and data extraction in a masked duplicate fashion. RESULTS: Ninety-one RCTs met inclusion criteria. The most frequently studied type of intervention was drugs (44/91, 48%). From the 91 trials, 99 primary endpoints, and thus P values, were obtained. Fifty-eight (59%) endpoints had a P value < 0.05 and 41 (41%) had a P value ≥ 0.05. Of the 58 primary endpoints previously considered statistically significant, 21 (36%) P values would maintain statistical significance at P < 0.005, and 37 (64%) would be reclassified as "suggestive." CONCLUSIONS: Lowering a P value threshold of 0.05 to 0.005 would have altered one third of significance interpretations of RCTs in the surveyed anesthesiology literature. Thus, it is important for readers to consider post hoc probabilities when evaluating clinical trial results. Although the present study focused on the anesthesiology literature, we suggest that our results warrant further research within other fields of medicine to help avoid clinical misinterpretation of RCT findings and improve quality of care.

RéSUMé: OBJECTIF: L'objectif principal de notre étude était de déterminer comment l'abaissement d'un seuil de valeur P de 0,05 à 0,005 affecterait la signification statistique des études randomisées contrôlées (ERC) précédemment publiées dans certaines des principales revues d'anesthésiologie. MéTHODE: Nous avons réalisé des recherches dans la base de données PubMed pour trouver des études publiées électroniquement en 2020 dans trois des principales revues d'anesthésiologie générale et indexées par Google Metrics et Scimago Journal & Country Rank. Les études incluses étaient des ERC publiées en 2020 dans les revues Anesthesiology, Anesthesia & Analgesia, et le British Journal of Anaesthesia, qui avaient un critère d'évaluation principal et utilisaient un seuil de valeur P pour déterminer l'effet de l'intervention. Nous avons effectué la sélection et l'extraction des données de manière dupliquée masquée. RéSULTATS: Quatre-vingt-onze ERC remplissaient les critères d'inclusion. Le type d'intervention le plus fréquemment étudié était de nature médicamenteuse (44/91, 48 %). Sur les 91 études, 99 critères d'évaluation principaux, et donc valeurs P, ont été obtenus. Cinquante-huit (59 %) critères d'évaluation avaient une valeur P < 0,05 et 41 (41 %) avaient une valeur P ≥ 0,05. Sur les 58 critères d'évaluation principaux précédemment considérés comme statistiquement significatifs, 21 (36 %) valeurs P maintiendraient leur signification statistique à P < 0,005, et 37 (64 %) seraient reclassées comme étant « suggestives ¼. CONCLUSION: Le fait d'abaisser le seuil de valeur P de 0,05 à 0,005 aurait modifié un tiers des interprétations de signification des ERC dans la littérature anesthésiologique étudiée. Il est donc important que les lectrices et lecteurs tiennent compte des probabilités post hoc lors de l'évaluation des résultats d'études cliniques. Bien que la présente étude se soit concentrée sur la littérature en anesthésiologie, nous suggérons que nos résultats justifient des recherches supplémentaires dans d'autres domaines de la médecine afin d'éviter une mauvaise interprétation clinique des résultats des ERC et d'améliorer la qualité des soins.

Impact of female sex on anaesthetic awareness, depth, and emergence: a systematic review and meta-analysis.

BACKGROUND: Suggested anaesthetic dose ranges do not differ by sex, likely because of limited studies comparing sexes. Our objective was to systematically synthesise studies with outcomes of unintended anaesthesia awareness under anaesthesia, intraoperative connected consciousness, time to emergence from anaesthesia, and dosing to achieve adequate depth of anaesthesia, and to compare between females and males. METHODS: Studies were identified from MEDLINE, Embase, and the Cochrane library databases until August 2, 2022. Controlled clinical trials (randomised/non-randomised) and prospective cohort studies that reported outcomes by sex were included. Results were synthesised by random effects meta-analysis where possible, or narrative form. RESULTS: Of the 19 749 studies identified, 64 (98 243 participants; 53 143 females and 45 100 males) were eligible for inclusion, and 44 citations contributed to meta-analysis. Females had a higher incidence of awareness with postoperative recall (33 studies, odds ratio 1.38, 95% confidence interval [CI] 1.09-1.75) and connected consciousness during anaesthesia (three studies, OR 2.09, 95% CI 1.04-4.23) than males. Time to emergence was faster in females, including time to eye-opening (10 studies, mean difference -2.28 min, 95% CI -3.58 to -0.98), and time to response to command (six studies, mean difference -2.84 min, 95% CI -4.07 to -1.62). Data on depth of anaesthesia were heterogenous, limiting synthesis to a qualitative review which did not identify sex differences. CONCLUSIONS: Female sex was associated with a greater incidence of awareness under general anaesthesia, and faster emergence from anaesthesia. These data suggest reappraisal of anaesthetic care, including whether similar drug dosing for females and males represents best care. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42022336087.

Perioperative Point of Care Ultrasound for Hemodynamic Assessment: A Narrative Review.

While transesophageal echocardiography (TEE) has traditionally been used in perioperative care, there is growing evidence supporting point of care ultrasound (POCUS) for the anesthesiologist in guiding patient care. It is a quick way to non-invasively evaluate hemodynamically unstable patients and ascertain their state of shock, determine volume status, and guide resuscitation in cardiac arrest. In addition, through use of POCUS, the anesthesiologist is able to identify signs of chronic heart disease to provide a more tailored and safer approach to perioperative care.

Current status of point of care ultrasonography for the perioperative care of trauma patients.

PURPOSE OF REVIEW: The incorporation of point of care ultrasound into the field of anesthesiology and perioperative medicine is growing at rapid pace. The benefits of this modality align with the acuity of patient care and decision-making in anesthetic care of a trauma patient. RECENT FINDINGS: Cardiac ultrasound can be used to diagnose cardiac tamponade or investigate the inferior vena cava to assess volume status in patients who may suffer from hemorrhagic shock. Thoracic ultrasound may be used to rapidly identify pneumothorax or hemothorax in a patient suffering chest wall trauma. In addition, investigators are exploring the utility of ultrasonography in traumatic airway management and elevated intracranial pressure. In addition, the utility of gastric ultrasound on trauma patients is briefly discussed. SUMMARY: Incorporation of point of care ultrasound techniques into the practice of trauma anesthesiology is important for noninvasive, mobile and expeditious assessment of trauma patients. In addition, further large-scale studies are needed to investigate how point of care ultrasound impacts outcomes in trauma patients.

Pediatric Preanesthesia Anxiety and Factors of Family Satisfaction.

PURPOSE: Pediatric patients scheduled for procedures with anesthesia experience stress and feelings of anxiety, but frequently lack the opportunity to report their feelings. Pediatric patient anxiety may be related to internal (patient perceptions/emotions) or external (demographic/family knowledge/satisfaction) factors. The purpose of the study was to explore patient reports of anxiety in young school-age through adolescent ages, and factors of family satisfaction before a scheduled procedure with anesthesia. DESIGN: Cross-sectional, descriptive, and correlational. METHODS: A voluntary survey including family-report of patient age and past anesthesia, type of procedure, family satisfaction factors (knowledge of anesthesia; perioperative concerns), and patient-report of anxiety with a visual analog scale (0-10) was offered to eligible families at their preanesthesia clinic appointment. FINDINGS: Completed surveys from 80 families (mean age of patient = 12 years; range 7-17 years) showed legally authorized guardians (LAGs) felt the preanesthesia visit helped them understand anesthesia information, but they also had concerns, such as complications and pain. Patient anxiety ratings ranged from 0 to 10 (M = 3.3, SD = 3.1), and were slightly higher for patients 11 years and younger (M = 3.8; SD = 3.4). Anxiety ratings were not significantly correlated with other factors measured. CONCLUSIONS: Pediatric patients, ages 7-17, report preanesthesia anxiety levels ranging from "not at all" to "worst imaginable," unrelated to demographic or family factors. Family members have perioperative concerns that need to be addressed before scheduled procedures. There is an impetus for improvement in psychosocial assessment and health care team collaboration to meet needs in a family-centered preanesthesia care model.

Guidelines for treatment of acute pain in children - the consensus statement of the Section of Paediatric Anaesthesiology and Intensive Therapy of the Polish Society of Anaesthesiology and Intensive Therapy.

RATIONALE AND SCOPE OF THE GUIDELINES Pain is a subjective unpleasant sensory and emotional experience. Acute pain occurs irrespective of age and has a prevalence of about 5% of the general population. Surgical procedures and painful diagnostic procedures are the main causes of this unpleasant and dangerous phenomenon for hospitalized children. It should be remembered that maintaining homeostasis in a child undergoing surgery is also affected by provision of an adequate level of analgesia and sedation as well as nerve conduction block within the surgical site. Even though both paediatric anaesthesiologists and paediatric surgeons know that the therapeutic activities during the perioperative period should be focused on ensuring sufficient analgesia and haemodynamic stability in surgical patients, as many as 70% of children undergoing surgery may experience moderate to severe pain [1-7]. Moreover, pain management is one of the fundamental human rights, i.e. the right to relief of suffering. According to the declaration of the 13th World Congress on Pain in Montreal (September 2010), this right also includes children [8, 9]. In Poland, the law was amended in 2017, and now each patient is guaranteed the right to relief and treatment of pain (Journal of Laws of 2017, item 836). Unfortunately, this right is not always respected in paediatric patients. Many factors contribute to ineffective analgesia in paediatric patients, mainly insufficient knowledge and lack of experience (concerning the use of opioids in particular), as well as lack of management standards, the negative attitude of the personnel or poor organization [10-13]. In hospitals which, as a result of organizational changes, have implemented analgesic treatment regimens and regularly educate their personnel in these issues, both efficiency and effectiveness of pain relief in children are high [14]. For many years, Polish paediatric anaesthesio-logists have been promoting and streamlining the analgesic management of children, which has led to the development of the present publication. The regimens presented in it are based on both the latest medical reports and many years of the authors' experience. The classes of recommendations and levels of evidence have been prepared (Tables 1 and 2, respectively). The presented recommendations were formulated based on a survey of medical reports published in the last two decades.

Machine learning in anesthesiology: Detecting adverse events in clinical practice.

The credibility of threshold-based alarms in anesthesia monitors is low and most of the warnings they produce are not informative. This study aims to show that Machine Learning techniques have a potential to generate meaningful alarms during general anesthesia without putting constraints on the type of procedure. Two distinct approaches were tested - Complication Detection and Anomaly Detection. The former is a generic supervised learning problem and for this a simple feed-forward Neural Network performed best. For the latter, we used an Encoder-Decoder Long Short-Term Memory architecture that does not require a large manually-labeled dataset. We show this approach to be more flexible and in the spirit of Explainable Artificial Intelligence, offering greater potential for future improvement.

A descriptive appraisal of quality of reporting in a cohort of machine learning studies in anesthesiology.

BACKGROUND: The field of machine learning is being employed more and more in medicine. However, studies have shown that the quality of published studies frequently lacks completeness and adherence to published reporting guidelines. This assessment has not been done in the subspecialty of anesthesiology. METHODS: We appraised the quality of reporting of a convenience sample of 67 peer-reviewed publications sourced from the scoping review by Hashimoto et al. Each publication was appraised on the presence of reporting elements (reporting compliance) selected from 4 peer-reviewed guidelines for reporting on machine learning studies. Results are described in several cross sections, including by section of manuscript (e.g. abstract, introduction, etc.), year of publication, impact factor of journal, and impact of publication. RESULTS: On average, reporting compliance was 64% ± 13%. There was marked heterogeneity of reporting based on section of manuscript. There was a mild trend towards increased quality of reporting with increasing impact factor of journal of publication and increasing average number of citations per year since publication, and no trend regarding recency of publication. CONCLUSION: The quality of reporting of machine learning studies in anesthesiology is on par with other fields, but can benefit from improvement, especially in presenting methodology, results, and discussion points, including interpretation of models and pitfalls therein. Clinicians in today's learning health systems will benefit from skills in appraisal of evidence. Several reporting guidelines have been released, and updates to mainstream guidelines are under development, which we hope will usher in improvement in reporting quality.

Perioperative Brain Health in the Older Adult: A Patient Safety Imperative.

While people 65 years of age and older represent 16% of the population in the United States, they account for >40% of surgical procedures performed each year. Maintaining brain health after anesthesia and surgery is not only important to our patients, but it is also an increasingly important patient safety imperative for the specialty of anesthesiology. Aging is a complex process that diminishes the reserve of every organ system and often results in a patient who is vulnerable to the stress of surgery. The brain is no exception, and many older patients present with preoperative cognitive impairment that is undiagnosed. As we age, a number of changes occur in the human brain, resulting in a patient who is less resilient to perioperative stress, making older adults more susceptible to the phenotypic expression of perioperative neurocognitive disorders. This review summarizes the current scientific and clinical understanding of perioperative neurocognitive disorders and recommends patient-centered, age-focused interventions that can better mitigate risk, prevent harm, and improve outcomes for our patients. Finally, it discusses the emerging topic of sleep and cognitive health and other future frontiers of scientific inquiry that might inform clinical best practices.