Pediatric Anesthesia最新文献

Background: Single ventricle congenital heart disease patients palliated to Fontan physiology lack a ventricle to generate pulmonary blood flow. Positive pressure mechanical ventilation reduces pulmonary blood and therefore cardiac output as compared to regular, negative pressure ventilation. There is controversy as to whether lower or higher tidal volumes are optimal for mechanical ventilation.

Aim: This crossover trial aimed to determine whether higher versus lower tidal volumes would be optimal for systemic cardiac output.

Methods: The authors recruited Fontan patients < 18 years old presenting for cardiac catheterization who would require intubation and positive pressure ventilation. Patients were randomized to begin in either a high (10 mL/kg) or low (6 mL/kg) tidal volume strategy. Pressures and blood gases were obtained, the patient was transitioned to the alternate ventilation strategy, and the catheterization procedures were repeated. The authors derived a clinically significant difference of 0.7 L/min/m². Paired comparisons of systemic cardiac index, pulmonary blood flow, and vascular resistances were made between the high and low tidal volume conditions.

Results: Thirty patients underwent the complete study protocol. Three out of nine (33%) patients who had a higher cardiac index in the high tidal volume strategy met the significant difference threshold compared to 8/19 (42%) of those who had a higher cardiac index in the low tidal volume strategy (Cohen's h = 0.186). There was no statistically significant difference in cardiac index between low (3.19 L/min/m², 95% CI 2.76-3.62 L/min/m²) and high (2.96 L/min/m², 95% CI 2.53-3.39 L/min/m²) tidal volume strategies, p = 0.062.

Conclusion: While there was no significant difference in cardiac index between the two ventilation strategies in the direct comparison, we did obtain data showing lower tidal volume may be favorable for maintaining cardiac index for some Fontan patients requiring positive pressure ventilation.

Background: The bispectral index (BIS) represents a promising tool for monitoring the depth of hypnosis. However, its utility in guiding sevoflurane administration during general anesthesia in pediatric patients is not well known.

Methods: We performed a systematic review and meta-analysis of randomized controlled trials comparing BIS-guided versus standard practice sevoflurane administration in pediatric patients. PubMed/MEDLINE, Embase, and the Cochrane Central Register of Clinical Trials were searched for trials published up to May 2025. Analyses were conducted using RevMan 5.4.1., and heterogeneity was assessed using the I² statistic.

Results: We included nine studies randomizing a total of 730 pediatric patients, of whom 359 (49.2%) were managed with BIS monitoring. BIS-guided anesthesia was associated with significantly lower mean end-tidal sevoflurane concentrations, both during the maintenance phase (MD -0.46; 95% CI: -0.62 to -0.29; p < 0.00001) and at the end of surgery (MD -0.31; 95% CI: -0.47 to -0.14; p = 0.0003). Furthermore, the BIS-guided group experienced a shorter time to airway removal (MD -1.69 min; 95% CI: -2.84 to -0.55 min; p = 0.004) and a shorter time to post-anesthesia care unit discharge (MD -11.82 min; 95% CI: -17.80 to -5.84 min; p = 0.0001). No significant difference was observed in Pediatric Anesthesia Emergence Delirium score between groups (MD -0.35; 95% CI: -1.90 to 1.19; p = 0.65).

Conclusions: BIS-guided monitoring offers a strategy to reduce end-tidal sevoflurane concentrations, shortening time to airway removal and post-anesthesia care unit discharge in pediatric patients undergoing sevoflurane anesthesia.

Study registration: PROSPERO, review no. CRD420251067409.

Background: Dental rehabilitation under general anesthesia (GA) is often required for children who are unable to cooperate during standard dental procedures. Accurately estimating the duration of these cases is challenging, particularly when preoperative X-rays are unavailable. Efficient scheduling and optimal operating room (OR) utilization rely on precise time predictions; however, existing predictive models, including EPIC's analytics, frequently overlook patient- and case-specific factors, resulting in suboptimal OR efficiency.

Aims: This study aimed to identify preoperative, patient-specific factors that influence the duration of pediatric dental rehabilitation under GA and to develop an age-based predictive equation to improve procedure time estimation.

Methods: A retrospective review was conducted on 255 dental rehabilitation cases performed under general anesthesia (GA) between January 2022 and December 2023. Collected data included patient demographics, treatment details, availability of radiographs, and operating room (OR) time metrics. Statistical analysis was performed to assess the influence of preoperative factors on procedure duration. An age-based fitted equation was developed, and its predictive accuracy compared with that of EPIC's analytics system.

Results: Age was the strongest patient-specific predictor of procedure duration (p < 0.001, R² = 50.73%), correlating with both dentition type and the extent of dental restoration required. The age-based fitted equation substantially outperformed EPIC's analytics, particularly in the 3-5 and 13-18 age groups, improving prediction accuracy by 42% and 114%, respectively. The fitted equation was Y = 84-4.5X + 0.6X², where Y represents procedure time and X represents age. Other patient-specific variables, including weight, BMI, and ASA classification, demonstrated minimal influence.

Conclusions: Developing an age-specific fitted equation based on site-specific operating room (OR) data improves procedure time prediction for pediatric dental rehabilitation under GA. This model supports more precise scheduling, better resource allocation, and improved patient access to care, providing a valuable framework for efficiency in the OR.

"Cannot Intubate, Cannot Oxygenate" is a rare but life-threatening situation that requires immediate recognition, advanced airway management, and ultimately emergency front-of-neck access. All airway practitioners caring for children should be prepared to face these situations. The aim of this review was to provide a concise summary of the latest evidence and to propose a streamlined protocol for pediatric emergency front-of-neck access in the intensive care setting. The strength of our protocol is that we have set explicit time limits for front-of-neck access attempts and incorporated extracorporeal membrane oxygenation to achieve the best possible survival and neurological outcomes. No evidence-based consensus exists on the best practice, although organization of local protocols and equipment, as well as regular and comprehensive training, is crucial to bolster clinician confidence and improve patient outcomes.

Anesthesia is increasingly acknowledged as a neglected priority in global health, and pediatric anesthesia is especially important due to the high proportion of children in the least developed countries with a large unmet burden of surgical disease. Pediatric anesthesiologists involved in global health may encounter several common "error traps" that could either lead to missed opportunities to build on recent advancements in global anesthesia or potentially cause harm. We present a number of these "traps" based on the literature and our experience from both sides of global health partnerships in East and Southern Africa, India, and the Caribbean. These error traps include failing to appreciate the public health "big picture"; failing to consider a health-systems approach, prioritizing quantity-based outcomes at the expense of quality, having priorities driven by partners in the "Global North"; failing to make programs sustainable, failing to invest in the retention of anesthesia providers, not realizing that not all global health is international health, and unethical practices. Our goal is to spark debate on ongoing controversies and to inform pediatric anesthesiologists who are working or considering a career in this field.

Introduction: Proton beam therapy (PBT) is becoming the radiotherapeutic modality of choice for children with curable cancer. A significant proportion require anesthetic care to facilitate precise positioning and immobility, and such patients undergo repetitive episodes of general anesthesia, 5 days a week for up to 8 weeks. Patients with central nervous tumors and those undergoing concurrent chemotherapy form a large proportion of referrals. Although X-ray therapy and PBT demonstrate similarities, factors including younger patient age, longer session length and a need for rigid immobilization, means that providing anesthetic care for PBT is more complex as compared to X-ray therapy. We present a case series of three patients who failed to complete PBT due to problems relating to anaesthesia. Our objective is to highlight specific PBT-related challenges in the pediatric population, because although serious complications are uncommon, there can still be significant risk.

Methods: We retrospectively reviewed the patient records of the three pediatric cases that failed to complete PBT at our outpatient regional center between January 2020 and December 2022.

Results: Two cases failed to complete PBT due to respiratory adverse events, including one that required admission to intensive care. Both of these cases had central nervous tumours. The third case developed neutropenic typhlitis relating to concurrent chemotherapy making the patient unfit for ongoing anesthesia.

Discussion: All three cases demonstrate that the risk of adverse events cannot be reliably predicted in this patient group. Detailed assessment must be performed prior to proceeding with anesthesia including regular review of blood tests, observations, and examining patients for any signs and symptoms of subclinical infection. The decision to proceed with anesthesia on a daily basis will require an anesthetic team that is highly skilled and familiar with their environment.

Conclusion: Anesthetic care for PBT is more complex as compared to X-ray therapy. A small group of children, particularly those with central nervous system tumors or altered respiratory control, may be at increased and sometimes unpredictable risk. Safe and sustainable care for PBT is possible with careful history taking, planning, and identification of patients at a higher risk of adverse events.