Der frühe Beginn von Reanimationsmaßnahmen ist entscheidend für das Überleben und das neurologische Outcome eines Kindes nach einem Atem-Kreislauf-Stillstand. Für professionelle Ersthelfende ist es essenziell, einen leblosen Patienten früh zu erkennen, rasch zu reagieren sowie Basismaßnahmen konsequent und qualitativ hochwertig durchzuführen: Sicherstellen eines freien Atemwegs, effektive Beatmung und Thoraxkompressionen in hoher Qualität (Frequenz 100–120/min, ausreichende Tiefe mit mindestens einem Dittel des Thoraxdurchmessers, vollständige Entlastung des Thorax, Minimierung von Unterbrechungen). Nach Überprüfung von Bewusstsein und Öffnen der Atemwege wird als Nächstes die Atmung kontrolliert. Wenn keine oder nur insuffiziente Atmung vorliegt, sollen initial 5 Beatmungen erfolgen. Thoraxkompressionen mit Beatmungen im Verhältnis 15:2 schließen sich an. Kann ein Beatmungsbeutel nicht sofort eingesetzt werden, ist unverzüglich mit kontinuierlichen Thoraxkompressionen zu beginnen. Die Beatmungen werden ergänzt, sobald Beutel und passende Beatmungsmaske verfügbar sind. Die erweiterten Reanimationsmaßnahmen umfassen die Analyse des Herzrhythmus, ggf. eine Defibrillation bei pulsloser ventrikulärer Tachykardie oder Kammerflimmern sowie die Medikamentenverabreichung. Da Reanimationen von Kindern und Jugendlichen insgesamt selten sowie mit hoher kognitiver und emotionaler Belastung verbunden sind, ist regelmäßiges Training unerlässlich. Unbedingt sollten auch nichttechnische Fertigkeiten wie Kommunikation, Teamführung und Rollenzuweisung in die Ausbildung integriert werden. Besonders effektiv sind teamorientierte Trainings an Patientensimulatoren, wie sie z. B. in Reanimationskursen des European Resuscitation Council (EPALS/European Paediatric Life Support) angeboten werden.

PURPOSE OF REVIEW:Leadership in paediatric anaesthesia is undergoing rapid transformation as clinical complexity, workforce expectations, and organizational structures evolve. This review synthesizes recent developments and highlights the competencies required for effective leadership in this high-stakes specialty. RECENT FINDINGS:Recent literature emphasizes the shift from individual expertise to team-based performance, supported by advances in technology, simulation, and organizational culture. Studies highlight the importance of psychological safety, diversity, and equitable leadership pathways. Emerging leadership models - such as shared leadership, New Work principles, and Just Culture - are increasingly relevant. Workforce well-being, moral injury, and toxic leadership/followership have become central concerns. Global perspectives and structured leadership development programs are expanding, with growing attention to gender, racial, and generational disparities in leadership roles. SUMMARY:Leadership in paediatric anaesthesia requires adaptability, communication excellence, and a commitment to inclusive, psychologically safe team environments with a robust ethical attitude. Future progress depends on integrating modern leadership frameworks, strengthening mentorship, and fostering sustainable, collaborative models that support clinicians and improve patient outcomes.

BACKGROUND:The German guidelines recommend that intravenous fluid therapy should not be mandatorily performed in children with short fasting times undergoing short anesthesia, but there is a lack of clinical studies including a large number of pediatric patients. Therefore, we performed a prospective non-interventional multicenter observational study to evaluate the perioperative hemodynamic and metabolic stability of children undergoing short anesthesia without intravenous fluid therapy.AIMS:The primary aim was to assess the incidence of hypotension and the secondary aim was to assess the real preoperative fasting times, the incidence of hypoglycemia and the impact on ketone bodies and acid-base balance.METHODS:Children aged 1 month-18 years undergoing short anesthesia (<1 h) without intravenous fluid therapy were enrolled. Patient demographics, the surgical or diagnostic procedure performed, anesthesia, hemodynamic, laboratory data, and adverse events were documented using a standardized case report form.RESULTS:Four hundred and twenty seven children that were investigated at three pediatric centers from July 2021 to June 2022 (mean age 83.4 ± 58.9 months, body weight 27.9 ± 19.8 kg) were included in the analysis. The real preoperative fasting times were 14.2 ± 3.6 h for solids, 7.2 ± 3.5 h for milk and 5 ± 4.8 h for clear fluids. During the course of anesthesia, hypotension (<2.5th percentile) was detected in 3 of 427 cases (0.7%), hypoglycemia (glucose <3.0 mmol L-1) in 1 of 355 cases (0.3%), and ketosis (ketone bodies ≥0.6 mmol L-1) in 51 of 233 cases (21.9%). The occurrence of ketosis was associated with lower body weight (p <.001) and longer fasting times for solids or milk (p =.021), but not for clear fluids (p =.69).CONCLUSIONS:Our study supported the German guidelines recommendation that perioperative intravenous fluid therapy is not mandatory in children beyond the neonatal period with short pre- and postoperative fasting times undergoing short anesthesia (<1 h).

PURPOSE OF REVIEW:This review gives an overview of the safety aspects for paediatric procedural sedation and a discussion of possibilities for optimizing structure, processes and outcomes.RECENT FINDINGS:Procedural sedation in paediatric patients is performed by providers of different specialties and compliance with safety standards is a basic requirement regardless of provider specialty. This includes preprocedural evaluation, monitoring, equipment and profound expertise of sedation teams. The choice of sedative medications and the possibility of incorporating nonpharmacological methods play an important role for optimal outcome. In addition, an ideal outcome from the patient's perspective includes optimized processes and clear and empathetic communication.SUMMARY:Institutions providing paediatric procedural sedation must ensure the comprehensive training of sedations teams. Furthermore, institutional standards for equipment, processes and optimal choice of medication depending on performed procedure and comorbidities of the patient must be established. At the same time, organizational and communication aspects should be considered.

Physical and mental disabilities resulting froma child's cardiac arrest are of exceptional family and social concern. Recent studies showed that the quality of pediatric resuscitation often does not meet recommended standards. Implementation of these 10 evidence-based measures published here can help improve survival rates and morbidity in resuscitated children. These 10 theses are intended to focus on the broad range of issues surrounding resuscitation of children and adolescents. It begins with improved prevention and recognition of life-threatening events in children to prevent respiratory and circulatory arrest. In the case of resuscitation, it can only be effective if consistent and sustained training is provided. Learning from each patient is the most important thing. The quality of resuscitation and the postresuscitation phase must be measured and evaluated to identify aspects for optimization. Structured collection of treatment and outcome data in a centralized, mandatory registry offers the opportunity to identify strengths of in-hospital and out-of-hospital care and to develop concepts for quality improvement. These theses and basic principles are also supported by the Austrian, German, and Swiss Resuscitation Councils and have already been published in Frontiers in Pediatrics.

INTRODUCTION:Modified fluid gelatin 4% is approved for use in children, but there is still a surprising lack of clinical studies including large numbers of pediatric patients. Therefore, we performed a European prospective noninterventional multicenter study to evaluate the use of a modified fluid gelatin 4% in saline (sal-GEL) or an acetate-containing balanced electrolyte solution (bal-GEL) in children undergoing major pediatric surgery.AIMS:The primary aim was to assess the indications and dosing of modified fluid gelatin, and the secondary aim was to assess the safety and efficacy, focusing, in particular, on routinely collected clinical parameters.METHODS:Children aged up to 12 years with ASA risk scores of I-III receiving sal-GEL or bal-GEL were followed perioperatively. Demographic data, surgical procedures performed, anesthesia, hemodynamic and laboratory data, adverse events, and adverse drug reactions were documented using a standardized case report form.RESULTS:601 children that were investigated at 13 European pediatric centers from May 2015 to March 2020 (sal-GEL 20.1%, bal-GEL 79.9%; mean age 29.1 ± 38.6 (range 0-144) months; body weight 12.1 ± 10.5 (1.4-70) kg) were included in the analysis. The most frequent indications for GEL infusion were hemodynamic instability without bleeding (76.0%), crystalloids alone not being sufficient for hemodynamic stabilization (55.7%), replacement of preoperative deficit (26.0%), and significant bleeding (13.0%). Mean infused GEL volume was 13.0 ± 5.3 (2.4-37.5) ml kg-1 . The total dose was affected by age, with higher doses in younger patients. After gelatin infusion, mean arterial pressure increased (mean change 8.5 ± 7.3 [95% CI: 8 to 9.1] mmHg), and the hemoglobin concentrations decreased significantly (mean change -1.1 ± 1.8 [95% CI: -1.2 to -0.9] g·dL-1 ). Acid-base parameters were more stable with bal-GEL. No serious adverse drug reactions directly related to gelatin (i.e., anaphylactoid reaction, clotting disorders, and renal failure) were observed.CONCLUSION:Moderate doses up to 20 ml kg-1 of modified fluid gelatin were infused most frequently to improve hemodynamic stability in children undergoing major pediatric surgery. The acid-base balance was more stable when gelatin in a balanced electrolyte solution was used instead of saline. No serious adverse drug reactions associated with gelatin were observed.

Early initiation of resuscitation measures is of enormous importance for the outcome of a child after respiratory failure and cardiac arrest. Therefore, the timely recognition of a critically ill patient, early initiation and effective performance of basic measures, such as securing an open airway, effective ventilation and high-quality thorax compressions (frequency 100-120/min, depth 4-5 cm, full chest recoil, minimization of interruptions) are essential. After assessing consciousness, the airway should be opened and in the case of insufficient or lack of breathing five initial rescue breaths should be given. Subsequently, effective chest compressions should be performed in conjunction with assisted ventilation in a ratio of 15:2. If a bag valve mask is not immediately available, continuous chest compressions should be started immediately and ventilation added as soon as a bag valve mask becomes available. The extended resuscitation measures include the administration of medicaments, heart rhythm analysis and possibly defibrillation. Resuscitation situations in pediatrics are overall rare events and represent a great cognitive challenge and a significant emotional burden for all those involved. Therefore, continuous training measures to learn and refresh basic life support (BLS) and advanced life support (ALS) measures are essential. To this end, special pediatric resuscitation courses of the European Resuscitation Council (European pediatric life support, EPLS; ) are provided. So-called nontechnical skills, such as communication, team leadership and task distribution within the team are becoming increasingly more important and should be integrated into training concepts. In this context, team-oriented training concepts on state-of-the-art patient simulators are increasing in popularity.

Christoph Eich · Karin Becke-Jakob · Katharina Röher 1 Kinderund Jugendkrankenhaus Auf der Bult, Abteilung Anästhesie, Kinderintensivund Notfallmedizin, Hannover, Deutschland 2 Cnopfsche Kinderklinik/Klinik Hallerwiese, Abteilung Anästhesie, Kinderanästhesie und Intensivmedizin, Nürnberg, Deutschland UniversitätsklinikumHamburg-Eppendorf, Zentrum für Anästhesiologie und Intensivmedizin, Klinik und Poliklinik für Anästhesiologie, Hamburg, Deutschland Wissenschaftlicher Arbeitskreis Kinderanästhesie (WAKKA), DGAI, https://www.ak-kinderanaesthesie.de

Der frühzeitige Beginn von Reanimationsmaßnahmen hat enorme Bedeutung für das Outcome eines Kindes nach einem Atem-/Herz-Kreislauf-Stillstand. Daher sind das rechtzeitige Erkennen eines kritisch kranken Patienten, der frühzeitige Beginn sowie die effektive Durchführung von Basismaßnahmen, wie Sicherstellung eines freien Atemwegs, effektive Beatmungen und hochqualitative Thoraxkompressionen (Frequenz 100–120/min, Drucktiefe 4–5 cm, volle Entlastung des Thorax, Minimierung der Unterbrechungen), essenziell. Nach Überprüfung des Bewusstseins sollte der Atemweg geöffnet und bei insuffizienter oder fehlender Atmung sollten 5 initiale Beatmungen verabreicht werden. Anschließend werden Thoraxkompressionen im Wechsel mit den Beatmungen im Verhältnis 15:2 durchgeführt. Sollte ein Beatmungsbeutel nicht direkt verfügbar sein, soll sofort mit kontinuierlichen Thoraxkompressionen begonnen und um Beatmungen ergänzt werden, sobald der Beatmungsbeutel verfügbar ist. Die erweiterten Reanimationsmaßnahmen beinhalten die Gabe von Medikamenten, Herzrhythmusanalyse und eine evtl. Defibrillation. Reanimationssituationen sind in der Pädiatrie insgesamt selten und stellen für alle Beteiligten eine hohe kognitive Herausforderung und eine große emotionale Belastung dar. Daher sind ständige Schulungsmaßnahmen zum Erlernen und zur Auffrischung der Basic-Life-Support(BLS)- und Advanced-Life-Support(ALS)-Maßnahmen erforderlich. Hierfür werden spezielle Kinderreanimationskurse des European Resuscitation Council (European Paediatric Life Support, EPLS; http://www.erc.edu ) angeboten. Sogenannte nichttechnische Fertigkeiten, wie Kommunikation, Teamführung und Aufgabenverteilung im Team, gewinnen zunehmend an Bedeutung und sollten in Trainingskonzepte integriert werden. Hier finden teamorientierte Ausbildungskonzepte an hochmodernen Patientensimulatoren wachsende Verbreitung.

Körperliche und geistige Behinderungen, die aus dem überlebten Atem‑/Herz-Kreislauf-Stillstand eines Kindes resultieren, sind von außergewöhnlicher familiärer und gesellschaftlicher Bedeutung. Aktuelle Studien zeigen, dass die Qualität der pädiatrischen Reanimation häufig nicht die empfohlenen Standards erreicht. Die Umsetzung der hier publizierten 10 evidenzbasierten Maßnahmen kann dazu beitragen, die Überlebensraten und die Morbidität reanimierter Kinder zu verbessern. Mit diesen 10 Thesen soll das weite Feld der Themen rund um die Reanimation von Kindern und Jugendlichen fokussiert werden. Es beginnt mit der verbesserten Prävention und Erkennung von lebensbedrohlichen Ereignissen bei Kindern, um einen Atem‑/Herz-Kreislauf-Stillstand zu vermeiden. Im Falle einer Reanimation kann diese nur dann effektiv sein, wenn ein konsequentes und nachhaltiges Training angeboten wird. Von jedem Patienten zu lernen, ist das Wichtigste. Die Qualität der Reanimation und der Postreanimationsphase muss gemessen und ausgewertet werden, um Aspekte zur Optimierung zu identifizieren. Eine strukturierte Sammlung von Behandlungs- und Ergebnisdaten in einem zentralisierten, verpflichtenden Register bietet die Möglichkeit, Stärken der inner- und außerklinischen Versorgung zu identifizieren und Konzepte für Qualitätsverbesserungen zu erstellen. Diese Thesen und Grundprinzipien werden auch vom österreichischen, deutschen und schweizerischen Rat für Wiederbelebung unterstützt und wurden bereits in englischer Sprache in Frontiers in Pediatrics publiziert.

Children often do not receive effective pain therapy in emergency situations! Pain assessment, application and medication dosage are just not as familiar to us as they are to adults. However, since trauma accounts for at least one third of all paediatric emergencies, analgesia is often needed. Prehospital emergency anaesthesia, on the other hand, is very rare and only necessary in the "worst case". If you want to act effectively and safely here, you have to be well-versed and experienced, know the risks and have a plan B in mind!

For many decades, pediatric bronchoscopy has been an integral part of the diagnosis and treatment of acute and chronic pulmonary diseases in children. Rapid technical advances have continuously influenced the performance of the procedure. Over the years, the application of pediatric bronchoscopy has considerably expanded to a broad range of indications. In this comprehensive and up-to-date guideline, the Special Interest Group of the Society for Pediatric Pneumology reviewed the most recent literature on pediatric bronchoscopy and reached a consensus on a safe technical performance of the procedure.

Diesen Leitspruch der Aufklärung hatten die Autoren der Studie „Präoperative Flüssigkeitskarenz – Etablierung eines liberalen Flüssigkeitsregimes mittelsNüchternheitskarten“ vonRüggeberg et al. vielleicht im Sinn, als sie die Umsetzung eines liberalisierten Nüchterngebots auf dessen klinische Praktikabilität und Akzeptanz in ihrem Krankenhaus untersuchten. Ein guter Anlass, gemeinsam einen kurzen Ausflug durch die Geschichte des anästhesiologischen Nüchterngebots zu machen und dann – Stand heute – zu resümieren, wo die Entwicklung in Zukunft hingehen sollte. Mit dem anästhesiologischen Nüchterngebot wird spätestens seit Mitte des 19. Jh. allen Patienten präoperativ eine prolongierte Nahrungsund Flüssigkeitskarenz verordnet. Fast gleichzeitig formuliert der berühmte französische Physiologe Claude Bernard die Bedeutung des Milieu intérieur für die Aufrechterhaltung des Lebens und war damit einer der ersten Protagonisten des Konzepts der Homöostase [1]. Manchen beschleicht gelegentlich der Verdacht, dass für das Nüchterngebot nicht nur Aspekte der evidenzbasierten Medizin eine Rolle spielen könnten. Abgesehen von diagnostischen Aspekten wie Nüchternprobenentnahmen sowie radiologischen, sonographischen und endoskopischen Untersuchungen sollen durch eine Nahrungskarenz die EntleerungdesMagensunddamitdieSicherheit vor Narkosen und Operationen gewährleistet werden. Häufig kommt es dabei zu einer Dysbalance zwischen den Maßnahmen zur Vermeidung von gastraler Regurgitation und pulmonaler Aspiration einerseits und der Berücksichtigung von Homöostase, Wohlbefinden und Stressvermeidung sowie einer reibungslosen OP-Organisation andererseits.

Kinder erhalten in der Notfallsituation häufig keine effektive Schmerztherapie! Schmerzerfassung, Applikation und Medikamentendosierung sind uns eben nicht so vertraut wie bei Erwachsenen. Da jedoch Traumata mindestens ein Drittel aller Kindernotfälle ausmachen, wird eine Analgesie oft benötigt. Die prähospitale Notfallnarkose ist hingegen sehr selten und nur im „worst Case“ erforderlich. Wer hier effektiv und sicher handeln will, muss versiert und erfahren sein, die Risiken kennen und einen Plan B im Hinterkopf haben!

Foreign bodies lodged in the upper esophagus in children may result in life‐threatening complications, especially with button batteries. Rapid removal is essential to prevent complications. Experts report that extraction with a suitable laryngoscope and a forceps is feasible under general anesthesia, but no further data had been available so far.

BACKGROUND:A preliminary national audit of real fasting times including 3324 children showed that the fasting times for clear fluids and light meals were frequently shorter than recommended in current guidelines, but the sample size was too small for subgroup analyses.AIMS:Therefore, the primary aim of this extended study with more participating centers and a larger sample size was to determine whether shortened fasting times for clear fluids or light meals have an impact on the incidence of regurgitation or pulmonary aspiration during general anesthesia in children. The secondary aim was to evaluate the impact of age, emergent status, ASA classification, induction method, airway management or surgical procedure.METHODS:After the Ethics Committee's approval, at least more than 10 000 children in total were planned to be enrolled for this analysis. Patient demographics, real fasting times, anesthetic and surgical procedures, and occurrence of target adverse events defined as regurgitation or pulmonary aspiration were documented using a standardized case report form.RESULTS:At fifteen pediatric centers, 12 093 children scheduled for surgery or interventional procedures were included between October 2018 and December 2019. Fasting times were shorter than recommended in current guidelines for large meals in 2.5%, for light meals in 22.4%, for formula milk in 5.3%, for breastmilk in 10.9%, and for clear fluids in 39.2%. Thirty-one cases (0.26%) of regurgitation, ten cases (0.08%) of suspected pulmonary aspiration, and four cases (0.03%) of confirmed pulmonary aspiration were reported, and all of them recovered quickly without any consequences. Fasting times for clear fluids shortened from 2 hours to 1 hour did not affect the incidence of adverse events (upper limit 95% CI 0.08%). The sample size of the cohort with fasting times for light meals shorter than 6 hours was too small for a subgroup analysis. An age between one and 3 years (odds ratio 2.7,95% CI 1.3 to 5.8%; P < .01) and emergent procedures (odds ratio 2.8,95% CI 1.4 to 5.7;P < .01) increased the incidence of adverse events, whereas ASA classification, induction method, or surgical procedure had no influence. The clear fluid fasting times were shortest under 6/4/0 as compared to 6/4/1 and 6/4/2 fasting regimens, all with an incidence of 0.3% for adverse events.CONCLUSION:This study shows that a clear fluid fasting time shortened from 2 hours to 1 hour does not affect the incidence of regurgitation or pulmonary aspiration, that an age between one and 3 years and emergent status increase the incidence of regurgitation or pulmonary aspiration, and that pulmonary aspiration followed by postoperative respiratory distress is rare and usually shows a quick recovery.

• Quality and outcome of pediatric resuscitation often does not achieve recommended goals. • Quality improvement initiatives with the aim of better survival rates and decreased morbidity of resuscitated children are urgently needed. • These initiatives should include an action framework for a comprehensive, fundamental, and interprofessional reorientation of clinical and organizational structures concerning resuscitation and post-resuscitation care of children. • The authors of this DACH position statement suggest the implementation of 10 evidence-based actions (for out-of-hospital and in-house cardiac arrests) that should improve survival rates and decrease morbidity of resuscitated children with better neurological outcome and quality of life.