BACKGROUND:Socioeconomic status and geography create healthcare inequalities in children. Geographical areas in the United Kingdom are ranked by deprivation, which confers a higher risk for specific diseases that necessitate procedures under anesthesia. AIMS:To examine the relationship between the geographical indices of deprivation and the odds of children presenting for procedures involving anesthesia at a specialist children's referral hospital in Northwest England and Wales, UK. METHODS:A retrospective cross-sectional analysis linking electronic patient records of patients presenting for anesthesia from 2016 to 2024 to population data. Multivariate mixed-effects logistic regression was conducted for the odds of having a procedure requiring anesthesia. RESULTS:71 613 episodes were included in the final analysis, confined to areas with a higher proportion of children having a procedure at our hospital and only one episode per child in each year. The adjusted odds ratio for having a procedure according to deprivation was 1.15 (95% CI: 1.13-1.17, p < 0.001), with children from a deprived area being more likely to undergo treatment. The odds of undergoing a procedure were higher for most specialities, for children from a deprived area. It was the greatest for dental procedures. When analyzed by the 10 deciles of IMD, the strongest effect was for children from the most deprived areas. CONCLUSION:Children living in deprived areas are more likely to present for procedures involving anesthesia at our hospital, which serves a large area: Northwest England and Wales. This is true for most specialities. Sensitivity analysis to address study design limitations did not change the general conclusion. Further research is needed to clarify this phenomenon. Our study emphasizes the importance of preventive interventions to reduce inequalities in child health due to socioeconomic deprivation and geography.
BACKGROUND:Remimazolam is a novel ultra-short-acting benzodiazepine used for general anesthesia. Compared with propofol, it offers reversibility with flumazenil and lacks injection pain. However, its optimal bolus dose for anesthesia induction in pediatric patients remains unclear. The aim of this study was to determine the effective dose of remimazolam for loss of consciousness during anesthesia induction in children aged 2 to 14 years. METHODS:A prospective, randomized, controlled trial using the Dixon up-and-down sequential design was conducted. It comprised two separate, parallel dose-finding studies, in which a total of fifty children undergoing elective surgery were randomly allocated to receive either remimazolam or propofol for anesthesia induction, respectively. The primary outcome was the ED50 and ED95 of each drug. Secondary outcomes included bispectral index (BIS) values, hemodynamic changes, and adverse events within 5 min after drug administration. RESULTS:The ED50 and ED95 of remimazolam were 0.17 mg/kg (95% CI 0.16-0.19) and 0.26 mg/kg (95% CI 0.23-0.29). Both drugs effectively reduced BIS values, with a significant group-time interaction. Heart rate was more stable in the remimazolam group. No respiratory depression, hypotension, or other serious adverse events were observed in either group. CONCLUSION:Using a sequential up-and-down design, this study provides the first determination of the ED50 (0.17 mg/kg) of a single intravenous bolus of remimazolam for inducing loss of consciousness in pediatric patients aged 2-14 years. These findings offer a practical dosing reference for remimazolam induction in children. TRIAL REGISTRATION:Chinese Clinical Trial Registry: ChiCTR 2200067112.
INTRODUCTION:Pediatric patients undergoing liver transplantation (LT) often require postoperative mechanical ventilation, which can increase the risk of complications such as ventilator-associated pneumonia (VAP) and higher intensive care unit (ICU) resource utilization. Advances in perioperative care have made immediate intraoperative extubation (IE) and early extubation (EE) feasible and safe; however, evidence in pediatric LT remains limited, and standardized extubation criteria are lacking. This study aimed to evaluate the incidence, outcomes, and predictors of successful IE/EE after pediatric LT at a high-volume North American center. METHOD:Perioperative data were retrospectively reviewed for patients aged ≤ 18 years who underwent isolated LT between January 1, 2013, and December 31, 2021. Patients undergoing combined liver-bowel transplantation, retransplantation, or liver autotransplantation were excluded. Recipients were categorized into three groups based on extubation timing: IE, EE (≤ 24 h), and delayed extubation (DE; > 24 h). Multivariable logistic regression was used to identify independent predictors of IE/EE. RESULTS:Of 245 patients, 33 underwent IE and 110 underwent EE, with no cases of reintubation. Over the study period, rates of IE and EE increased steadily. The IE/EE cohort had significantly shorter ICU and hospital lengths of stay compared to the DE group. Multivariable analysis identified age, preoperative care setting, and use of regional anesthesia as significant independent predictors of successful IE/EE. The predictive model demonstrated good discrimination (C-statistic 0.82; 95% CI 0.77-0.88). CONCLUSION:IE/EE after pediatric LT is increasingly common and has been associated with a high degree of safety and favorable outcomes. Recipient age, preoperative care setting, and intraoperative regional anesthesia are significant predictors of success. Over 9 years, growing experience was associated with higher IE/EE rates, reduced ICU stays, and shorter hospital length of stay, supporting earlier recovery and optimized resource utilization.
BACKGROUND:Many children undergoing anesthesia commonly exhibit distress behaviors such as anxiety, crying, and physical resistance. Assessment of this behavior is important as it could lead to postoperative behavioral changes and delayed recovery. AIM:The aim of this study was to evaluate the content validity, construct validity, internal consistency, and inter-observer reliability of the Turkish version of the Induction Compliance Checklist (ICC), which was developed to assess compliance behaviors in children during anesthesia induction. METHODS:The study was planned as a prospective observational study. Following translation of the original ICC, content validity was examined using the Davis technique with the opinions of 10 experts. Next, Turkish ICC was applied simultaneously and independently by three independent observers during mask induction to 184 children (ASA I-III) aged 1-7 years undergoing anesthesia and surgery. Inter-observer reliability was evaluated with Intraclass Correlation Coefficient (ICC) and Fleiss Kappa/Gwet's AC1; internal consistency with KR-20 and McDonald's omega; and construct validity with single-factor confirmatory factor analysis (WLSMV). Item analysis was performed with a tetrachoric correlation matrix, floor and ceiling effects. RESULTS:Content validity was excellent (I-CVI 0.90-1.00, S-CVI≈0.99). Inter-observer reliability for the total score was excellent: InCC (1, 2) = 0.92 (95% CI: 0.90-0.94), InCC (2, 3) = 0.97 (95% CI: 0.96-0.98). At the item level, Gwet's AC1 values ranged from 0.81 to 0.97, while Kappa values were generally 0.75-0.90 except for M11. Internal consistency was at an acceptable level with KR-20 0.49-0.52 and McDonald's omega 0.66-0.82. These results are low due to the floor effect caused by premedication. Confirmatory factor analysis moderately supported the single-factor structure (best fit in Observer Surgeon: CFI = 0.927, TLI = 0.907). High floor effect was prominent especially in rarely observed severe behaviors (M7-M11); strong correlation was observed between M9-M10 (0.89-0.94). CONCLUSIONS:Following rigorous analysis, we found that the Turkish ICC is a reliable and valid tool that can assess children's compliance behaviors during pediatric anesthesia induction. Excellent inter-observer agreement and high content validity support its suitability for clinical and research use. The Turkish Induction Compliance Checklist is a reliable and valid measurement tool in the Turkish pediatric population. It can contribute to standardized evaluation of child behaviors during anesthesia induction and help improve the quality of perioperative care.
BACKGROUND:Neuromuscular blocking agents are recommended by the European Society of Anaesthesiology and Intensive Care (ESAIC) and European Society of Paediatric Anaesthesia (ESPA) for facilitating tracheal intubation in children. Despite these recommendations, real-world data on how neuromuscular blocking agents are used, monitored, and reversed remain scarce. AIMS:To identify and characterize self-reported neuromuscular blocking agent practice patterns across European and non-European countries, in the period preceding publication of the joint ESAIC and ESPA guidelines. METHODS:We conducted an anonymous, cross-sectional survey between 12 November and 12 December 2025, targeting members of the ESAIC, ESPA, and the French and Spanish national pediatric anesthesiology societies involved in pediatric airway management across 43 countries. RESULTS:The survey was accessed by 904 persons, and 874 responses were included in the analysis. Most participants were from Europe (83.5%) and worked in mixed pediatric anesthesia and intensive care settings (71.2%). Rocuronium was the most frequently used neuromuscular blocking agent for both routine tracheal intubation (68%; 95% CI 65%-71%) and rapid sequence intubation (67%; 95% CI 64%-70%). Neuromuscular blocking agents were used "always" or "mostly" before routine intubation in 47% of neonates (≤ 30 days) and 50% of infants (< 1 year), whereas "rarely" or "never" use was reported in 30% and 24%, respectively. Most respondents (56%) assessed adequacy of neuromuscular block using a fixed time interval after neuromuscular blocking agent administration. Reversal was administered "always" before extubation by 27% of respondents, while 9.3% reported "rarely" and 2.9% "never." Only half of participants used quantitative neuromuscular monitoring to guide reversal. Sugammadex was used by 47%. CONCLUSIONS:Self-reported clinical practice regarding neuromuscular blocking agent use in pediatric patients remains heterogeneous. Children are frequently intubated without neuromuscular blocking agents and extubated without consistent reversal. Quantitative neuromuscular monitoring remains uncommon. These practice patterns raise concerns for patient safety.
BACKGROUND:Post-extubation emergence agitation (EA) is common in pediatric ear, nose, and throat (ENT) procedures and may lead to serious complications. AIMS:To assess the efficacy of low-dose propofol administered before extubation, compared with placebo, for preventing EA, using meta-analysis with trial sequential analysis (TSA). METHODS:We searched PubMed, Embase, and the Cochrane Central Register of Controlled Trials for randomized controlled trials (RCTs) comparing low-dose propofol versus placebo administered before extubation in pediatric ENT procedures. The primary outcomes were laryngospasm, severity of EA, assessed by the Pediatric Anesthesia Emergence Delirium (PAED) scale score, and incidence of EA. Secondary outcomes included post-anesthesia care unit (PACU) length of stay, time to recovery, and time to extubation. Random-effects models were used to pool effect estimates with 95% confidence intervals (CIs). TSA was performed for all outcomes to assess the robustness of the evidence. RESULTS:Ten RCTs were included in the review, of which six (414 pediatric patients) contributed to the meta-analysis. Compared with control, propofol significantly reduced the incidence of EA (risk ratio [RR] = 0.57; 95% CI, 0.42-0.78) and lowered agitation severity (mean difference [MD] = -3.94; 95% CI, -5.74 to -2.13). Time to extubation was slightly longer (MD = 1.8 min; 95% CI, 1.4-2.3), whereas time to recovery (MD = 0.9 min; 95% CI, -1.9 to 3.6) and PACU length of stay (MD = -0.63 min; 95% CI, -3.2 to 1.9) did not differ. TSA confirmed the robustness of the findings for incidence of EA, severity of EA, and time to extubation. However, the certainty of evidence was very low for severity of EA and moderate for EA incidence and time to extubation. Laryngospasm outcomes were not pooled due to substantial heterogeneity. CONCLUSIONS:Our findings suggest that pre-extubation propofol probably reduces the incidence of EA in pediatric ENT surgery, supported by moderate-certainty evidence, and may lower EA severity measured by PAED scale scores, for which the certainty of evidence was very low. Propofol was also associated with a slightly longer time to extubation, with no difference in overall recovery time or PACU length of stay.
BACKGROUND:In pediatric anesthesia, minimum alveolar concentration (MAC) guides inhalational agent dosing but may not accurately reflect anesthetic depth. EEG-guided anesthesia has shown benefits in adults but remains underused in children. AIMS:This study aims to evaluate the effect of EEG-guided anesthesia with SedLine on emergence delirium (ED) and sevoflurane dose in behaviorally noncompliant children undergoing dental procedures under general anesthesia. METHODS:In this prospective, randomized controlled trial, 100 children aged 4-10 years were randomized to standard anesthesia guided by MAC and conventional clinical signs (standard group) or EEG-guided anesthesia titrated to SedLine parameters (primary target: PSI 25-50; secondary parameter: SEF 10-15 Hz) (EEG-S group). Primary outcome was ED incidence assessed by the Pediatric Anesthesia Emergence Delirium Scale (PAEDS). Secondary outcomes included mean EtSevo values, postoperative pain, rescue analgesia, nausea/vomiting, recovery time. RESULTS:Median PAEDS scores during the first 120 min postoperatively were significantly lower in the EEG-S group compared with the Standard group (e.g., upon arrival to PACU: 4 [IQR 4] vs. 8 [IQR 4.5]). In addition, the incidence of ED upon arrival in the recovery room was significantly lower in the EEG-S group (17% vs. 43%) and at 10 min postoperatively (17% vs. 37%). The mean end-tidal sevoflurane concentration was statistically lower in the EEG-S group (maintenance EtSevo 1.88 ± 0.25 vs. 1.98 ± 0.20; mean difference = 0.10, 95% confidence interval: 0.006-0.190; p = 0.036). Postoperative FLACC pain scores were also lower in the EEG-S group, representing a potential confounding factor for ED outcomes. CONCLUSION:EEG-guided anesthesia was associated with lower PAEDS scores and reduced sevoflurane consumption compared with standard management. However, given small EEG-derived differences and potential confounding by postoperative pain, these findings should be interpreted cautiously. Within the applied target ranges, EEG-derived parameters were not independently associated with ED, and specific EEG targets predictive of ED could not be identified. TRIAL REGISTRATION:This study was registered (Protocol Registration Receipt NCT06400706/OKocaturk/May 02 2024) at http://www. CLINICALTRIAL:gov.
BACKGROUND:Emergence delirium is a frequent and distressing postoperative complication in children, particularly following sevoflurane-based anesthesia. Despite its clinical importance, the optimal preventive strategy remains under investigation. This study aims to systematically evaluate the efficacy and safety of esketamine in preventing emergence delirium in pediatric patients undergoing sevoflurane-based general anesthesia. METHODS:We systematically searched seven databases and registries through 27 March 2026. Randomized controlled trials that compared esketamine with placebo in children undergoing surgical procedures were included. The primary outcome was the incidence of emergence delirium. Secondary outcomes were postoperative pain scores, extubation time, post-anesthesia care unit stay, and postoperative nausea and vomiting. Data were synthesized using random-effects models, with risk ratios for dichotomous outcomes and mean differences or standardized mean differences for continuous outcomes. Meta-regression and trial sequential analysis were performed. The risk of bias was assessed using the revised Cochrane risk-of-bias tool for randomized trials, and the certainty of the evidence was evaluated using the Grading of Recommendations, Assessment, Development, and Evaluation approach. RESULTS:Eight randomized controlled trials involving 916 patients were included. Esketamine significantly reduced the incidence of emergence delirium versus placebo (risk ratio = 0.35; 95% confidence interval: 0.26-0.48; p < 0.0001). No significant differences were observed between dosing regimens, surgical types, routes of administration, or timing of administration. Pain scores were significantly lower with esketamine (standardized mean difference = -0.58; 95% confidence interval: -0.79 to -0.37; p < 0.0001). Extubation time was modestly prolonged (mean difference = 1.72 min; 95% confidence interval: 0.20-3.24; p = 0.0267). Meta-regression revealed a statistically significant association between emergence delirium risk ratios and anesthesia duration (β = 0.98, p = 0.042), with no other significant associations observed for the other covariates. Post-anesthesia care unit stay showed no statistically significant difference, while postoperative nausea and vomiting was significantly reduced with esketamine (risk ratio = 0.69; 95% confidence interval: 0.49-0.97; p = 0.0304). No study was at high-risk of bias; four studies raised some concerns. Certainty of evidence was moderate, except for extubation time, which was low. CONCLUSIONS:Esketamine demonstrates promising efficacy for preventing emergence delirium and improving postoperative pain in children. PROSPERO:CRD420251230407.
BACKGROUND:Trauma is one of the leading causes of death in children. Trauma patients have been demonstrated to require significant resources, including operating room time. We aimed to describe the characteristics and patterns of access to surgery and outcomes of pediatric major trauma patients at The Hospital for Sick Children. METHODS:We retrospectively collected data from the Hospital for Sick Children trauma registry and the hospital's patient electronic record, from June 01, 2018, to October 31 2020. We analyzed a subset of patients requiring surgery in the operating room. The objective was to describe the distribution of major trauma cases requiring operating room access and their hospital length of stay, blood product use, and mortality rates. We summarized the results into three groups based on operating room access timing: patients with immediate access, within 24 h, and after 24 h. RESULTS:In total, 141 of 721 pediatric major trauma patients (19.6%) underwent surgery and were included. Among these, 67 patients received immediate access to the operating room (47.5%), 37 patients received access within 24 h (26.2%) and 37 patients received access after 24 h (26.2%). The median age was 8 (0-17) years, and 65.2% of patients were male. The median ISS score was 11.5 (1-57). The most frequently involved surgical specialties were orthopedics and neurosurgery. The median hospital length of stay was 6 days (range 1-102). The mortality rate was 1.4%. A multivariable regression analysis showed a correlation between the number of surgical procedures and length of stay (p < 0.01, 95% confidence interval 9.11-11.64). CONCLUSION:Major trauma patients have a significant time impact on the anesthesia department. Further studies are needed to better define the pediatric trauma population and its intra-hospital flow and resource use.
BACKGROUND:Preoperative anxiety is common in children and is associated with emergence delirium-a distressing postoperative complication characterized by agitation and disorientation. Midazolam has long been the drug of choice for preoperative anxiolysis. More recently, α2 adrenoceptor agonists, such as clonidine, have gained popularity for their sedative and analgesic properties. The effect of these agents on the incidence of emergence delirium remains uncertain. This study evaluated whether premedication with clonidine or midazolam is associated with emergence delirium in children undergoing general anesthesia. METHODS:We performed a post hoc analysis of prospectively collected data pooled from 10 clinical studies, comprising data from 4796 general anesthetics in children (0-16 years). The studies were carried out at a tertiary pediatric hospital in Perth, Australia. We assessed the impact of premedication with clonidine or midazolam on the incidence of emergence delirium using validated scales. RESULTS:In this cohort, with a mean age of 6.8 (range: 0.03-16.97), 331 children received clonidine and 731 received midazolam. Overall, the incidence of emergence delirium was 6%. Primary propensity score-matched analyses found no significant association between clonidine (OR 1.19, 95% CI 0.65-2.16) or midazolam (OR 1.23, 95% CI 0.79-1.92) and emergence delirium. In our secondary adjusted logistic regression models, midazolam was associated with increased odds of emergence delirium, whereas clonidine showed no statistically significant association overall. CONCLUSIONS:The overall incidence of emergence delirium was low. While clonidine showed no statistically significant association with emergence delirium, our secondary multivariate analysis suggests midazolam might be associated with an increased risk of emergence delirium.
