Background: The choice of a central venous catheter (CVC) lumen to connect the central venous pressure (CVP) measurement line varies by facility. However, if the CVP values differ based on the connected CVC lumen, this variation could significantly affect the interpretation of the CVP measurements, raising major concerns regarding circulatory management of the patient.
Aims: This study aimed to determine whether a difference exists in the CVP values between the proximal and distal lumens of the CVC in small pediatric patients undergoing cardiac surgery.
Methods: Seventeen pediatric patients with congenital heart disease, aged 1 to 31 months, who underwent cardiac surgery between November 2022 and November 2023, were included in this study. The CVC was inserted via the right internal jugular vein or right supraclavicular approach. Separate transducers were connected to the proximal and distal lumens. The CVP values from each were recorded simultaneously throughout the surgery. Differences were examined in the following phases: (1) after general anesthesia induction, (2) after initiation of cardiopulmonary bypass (CPB), and (3) after weaning from CPB.
Results: No statistically significant differences were observed in A-wave pressure, X-descent pressure, or mean CVP values measured from the distal and proximal lumens after general anesthesia induction or after weaning from CPB. The distal lumen showed significantly lower pressure than the proximal lumen after CPB initiation.
Conclusions: Our findings revealed no significant difference in the CVP values between the proximal and distal lumens of the CVC in small pediatric patients; moreover, the proximal lumen provided reliable CVP values, even during CPB. These findings support connecting the CVP line to the proximal lumen, offering the great advantage of early detection of CVC slippage through changes in the CVP values and waveforms.
Trial registration: This study was registered in the UMIN Clinical Trials Registry (registration number: UMIN000052944).
Background: Preoperative anxiety is prevalent in children undergoing supernumerary tooth extraction and can exacerbate physiological stress responses. Nonpharmacological interventions like immersive gaming interventions (IGI) offer potential anxiolytic benefits, but robust evidence in pediatric dentistry is limited.
Methods: In this prospective RCT, 102 children aged 4-12 years scheduled for supernumerary tooth extraction under general anesthesia were randomized to IGI (n = 50) or standard care (n = 52). The IGI group received a multicomponent framework comprising structured therapeutic play, role-reversal simulation, and environmental modification. Anxiety-related emotional distress and somatic symptoms were assessed using the SCARED scale, heart rate (HR), and heart rate variability (LF/HF ratio) at baseline (T0), post-intervention (T1), and preoperatively (T2). Treatment compliance (Frankl scale) and parental satisfaction (100-point questionnaire) were secondary outcomes.
Results: IGI demonstrated substantial reduction in emotional distress across all measures, with large interaction effect sizes (partial eta squared range: 0.14-0.26). At the preoperative stage (T2), SCARED scores in the IGI group were significantly lower than controls (Mean Difference [MD]: 18.5, 95% CI: 16.3-20.7; Cohen's d = 3.42). Heart rate and LF/HF ratio also showed clinically meaningful improvements in the IGI group compared to controls (HR MD: 17.5 bpm, 95% CI: 13.9-21.1; LF/HF MD: 1.33, 95% CI: 1.03-1.63). IGI attenuated anxiety-physiology correlations, including a 65% reduction in the SCARED-LF/HF slope at T2 (unstandardized beta-intervention = 0.029 vs. beta-control = 0.082). The intervention group exhibited superior active cooperation (Risk Difference [RD]: 70.2%, 95% CI: 57.0%-83.4%) and higher "very satisfied" parental ratings (RD: 78.6%, 95% CI: 66.8%-90.4%).
Conclusions: IGI effectively alleviates perioperative emotional distress, decouples psychological-physiological stress responses, and improves cooperation in children undergoing supernumerary tooth extraction. It represents a robust nonpharmacological strategy to enhance the pediatric perioperative experience.
Trial registration: ClinicalTrials.gov identifier: NCT07149727.
Background: Acute and postoperative pain in children is often undertreated, with effects on patient comfort and postoperative recovery. Extended reality (XR) interventions offer non-pharmacological pain management by distracting patients from discomfort. While effective for procedural pain, its impact on prolonged pain episodes remains underexplored.
Objectives: To systematically review and meta-analyze findings from previous studies on the efficacy of XR interventions in managing acute and postoperative pain in children, compared to standard care.
Eligibility criteria: Studies involving children (≤ 18 years) with acute or postoperative pain were included if they compared XR interventions to standard care. Studies focusing on procedural or chronic pain were excluded.
Methods: A systematic search was conducted on January 23, 2025, in MEDLINE, EMBASE, Web of Science, CINAHL, and PsycINFO for studies evaluating XR interventions for acute and postoperative pain in children, using validated pain measures. Pain outcomes were extracted for an exploratory meta-analysis, with self-report as the primary and observer-report as the secondary outcome. Two reviewers independently extracted data and assessed study quality using CONSORT and TREND.
Results: From 1793 records, nine studies were included, all evaluating virtual reality (VR) interventions. Seven focused on postoperative pain, two on acute pain. The primary meta-analysis (n = 6) showed a moderate but nonsignificant effect in self-reported pain (SMD = -0.61; 95% CI, -1.58 to 0.36). The secondary meta-analysis (n = 6) for observer-reported pain showed a large but nonsignificant effect (SMD = -1.04; 95% CI, -2.18 to 0.11).
Conclusion: This meta-analysis found no significant analgesic effect of VR on acute or postoperative pain in children. However, moderate effect sizes were observed, but the lack of statistical significance indicates that XR interventions require further investigation in pediatric pain management. Future research should prioritize pain as a primary endpoint and assess the effects of VR type, timing, and age on acute pain using validated measures.
Background: The medical comorbidities associated with trisomy 21 (T21) often necessitate multiple surgical and imaging procedures requiring general anesthesia, with perioperative complications occurring at a higher frequency than their age-matched peers. Combining multiple procedures by unrelated specialists under a single anesthetic is often suggested as a method to reduce anesthetic risks during induction, airway manipulation and emergence, in addition to potentially decreasing health care costs and time burdens on patients and families, but the safety advantage of this strategy has not been demonstrated.
Aim: To evaluate the association of multispecialty case strategies with perioperative safety events in children with T21.
Result: At Children's Wisconsin, we performed 219 626 anesthesia cases in 120 299 patients over a span of 9.6 years, compared to 3873 cases in 995 patients with T21. Of this cohort, 2871 cases were single specialty in nature while 1002 (17.5%) cases were multispecialty. Compared to the whole anesthesia population, the T21 cohort had a notably higher likelihood of multiple anesthetics per patient (OR = 8.02 [95% CI 7.11-9.04] p < 0.001), multispecialty care (OR = 3.95 [95% CI 3.6-4.3] p < 0.001), and risk of perioperative safety events (OR = 5.65 [95% CI 4.51-7.08] p < 0.001). The T21 cohort had lower age and weight, higher ASA-PS, more organ-based pathology, longer anesthesia case times, more cases, and higher multispecialty exposure per case. Detailed demographic comparison of the T21 cohort to the anesthesia population is shown in Table S2. Multivariable logistic regression identified independent risk factors associated with perioperative events as ASA-PS 4 (OR = 4.5 [95% CI 1.4-14.5]) or 5 (OR = 85.5 [95% CI 22.8-320.3]), Black or African American race (OR = 1.98 [95% CI 1.2-3.3]), anesthesia time (OR = 1.22 [95% CI 1.1-1.3]), and multispecialty case (OR = 2.6 [95% CI 1.6-4.3]); however, there was no increased risk with number of anesthetics per patient. No attempts were made to evaluate whether the families perceived benefit of either practice.
Conclusion: Multispecialty care is a highly utilized method of providing care for children with T21 within our institution, often used to ease the scheduling burden and risk of these children and families. Understanding the risk associated with this practice by parents and care providers may lead to a more thoughtful scheduling practice. With this understanding, patients in need of multispecialty care may benefit by either considering a single specialty case or limit multispecialty scheduling to a 4-h duration.
Background: Albeit the numerous guidelines on pre-operative fasting in pediatric patients, clinical practice varies. Prolonged fasting can result in several complications, hypoglycemia being one of them. This systematic review and meta-analysis (SRMA) was conducted to assess the effect of prolonged pre-operative fasting on the incidence of hypoglycemia in pediatric patients posted for elective surgery.
Materials and methods: Relevant studies (observational and randomized controlled studies [RCTs]) with fasting duration and incidence of hypoglycemia were identified from data sources (Medline, Scopus, Cochrane Library, Google Scholar) using a systematic search strategy. A pooled relative risk (RR) of hypoglycemia and ketosis due to prolonged fasting was calculated from the RCTs.
Results: This SRMA included 42 studies (15 RCTs and 27 observational studies) involving 5121 patients. There was a wide variation in the definition of hypoglycemia, fasting duration, and incidence of hypoglycemia across the studies. The pooled RR for hypoglycemia was 2.0 (95% CI: 0.57-7.03, I2 = 0.00%, p = 0.28) in the prolonged fasting group compared to the non-prolonged fasting group. Although statistical significance was not reached, the direction and magnitude of the pooled effect suggest a clinically meaningful trend toward a lower risk of hypoglycemia with adherence to recommended fasting durations compared with prolonged fasting.
Conclusion: The findings of the review revealed the need for standardized outcome definitions and fasting protocols to enable comparisons across future studies. The meta-analysis revealed a variable relationship between fasting duration and hypoglycemia incidence. Structured interventions to facilitate the implementation of guidelines in clinical practice may mitigate the problem.
Background: Emergence delirium commonly occurs in pediatric patients after general anesthesia, causing distress and potential harm. Remimazolam, an ultra-short-acting benzodiazepine, has recently been introduced in pediatric anesthesia, but its preventive role against emergence delirium remains unclear.
Aims: This systematic review with meta-analysis evaluated the effect of remimazolam on the incidence and severity of emergence delirium in children undergoing general anesthesia.
Methods: PubMed, EMBASE, CENTRAL, Scopus, Web of Science, and Google Scholar were searched for relevant studies. The primary outcome was the incidence of emergence delirium. Secondary outcomes included Pediatric Anesthesia Emergence Delirium score, incidence of hypotension and bradycardia, extubation time, postanesthesia care unit stay, and postoperative nausea and vomiting incidence. Relative risks (RR) or mean difference (MD) with 95% confidence intervals (CI) were calculated using a random-effects model.
Results: Ten randomized controlled trials involving 1231 children were included. Remimazolam significantly reduced the incidence of emergence delirium (RR 0.38, 95% CI 0.23-0.63; p = 0.0002) and Pediatric Anesthesia Emergence Delirium score (MD -1.70, 95% CI -2.77 to -0.63; p = 0.0019). It also decreased bradycardia (RR 0.39, 95% CI 0.21-0.70; p = 0.0018). Although the overall incidence of hypotension did not differ significantly (RR 0.35, p = 0.0991), subgroup analysis showed a lower incidence with remimazolam than with propofol (RR 0.14, p = 0.0376). Overall extubation time was comparable (MD -0.75, p = 0.5088), but shorter with remimazolam than propofol (MD -3.36, p < 0.0001). No significant differences were found in postanesthesia care unit stay or postoperative nausea and vomiting.
Conclusions: Remimazolam may reduce the incidence and severity of emergence delirium in children after general anesthesia, without affecting hemodynamic stability or recovery time.
Trial registration: PROSPERO: CRD420251236789.
Background: Age-specific EEG signatures during anesthesia are described in pediatrics, and perioperative monitoring is increasingly advocated; yet most indices and algorithms derive from adult data and may not generalize to early development.
Aims: The purpose of this study was to characterize perioperative frontal EEGs in young children younger than 8 years.
Methods: A total of 147 frontal EEGs from children ranging from 1 month to 8 years of age were recorded prospectively under general anesthesia at Charité-Campus Virchow Klinik (CVK). For data acquisition, the Narcotrend Monitor was used, and the raw EEG files were further analyzed in their frequency bands. The patient cohort was divided into four age groups (0-5, 6-11, 12-23, and > 24 months), and EEG signatures were compared between the age groups.
Results: Delta activity is the predominant frequency in all age groups already in the awake state before induction of anesthesia, with a step increase at loss of consciousness, which is more pronounced in older children. Intraoperatively, alpha- and beta-activity emerge at the age of 6 months and are greater in the older age groups. Infants (0-5 months) remain with a high amount of Delta activity intraoperatively. With the return of consciousness, the faster frequencies gradually decrease, and the EEG is characterized again by a predominant delta-activity in all age groups.
Conclusions: In this study, we characterized differences in the perioperative EEG signatures of children from 1 month to 8 years from the preoperative awake state during induction and general anesthesia until they regained consciousness from general anesthesia. The EEG readouts differ across age groups, and age-adapted monitoring systems are needed to protect this vulnerable patient group from over- and undersedation.
Trial registration: This study was approved by the Charité-University Medicine Berlin's ethics committee (EA2/027/15) and was registered at clinicaltrials.gov (23rd of June 2015/NCT02481999).
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