BACKGROUND:Glucagon-like peptide-1 receptor agonists (GLP1-RAs) are approved in patients aged ≥10 yr for type 2 diabetes mellitus and aged ≥12 yr for obesity. We examined the effect of GLP1-RAs on the retention of gastric contents in fasting adolescents. METHODS:This prospective cohort study examined adolescent patients (10-18 yr) at a single institution between June 2023 and November 2024. Three groups were compared: a GLP1-RA group; a group at-risk for delayed gastric emptying not on GLP1-RAs; and a healthy control group. All patients fasted 8 h for solids and 1 h for clears liquid. Gastric contents were examined utilising gastric ultrasound qualitatively on a 3-point scale, and quantitatively. The primary outcome was the number of adolescents on GLP1-RAs with residual gastric contents (presence of solids or gastric fluid volume ≥1.5 ml kg-1). RESULTS:In total, 67 patients were analysed: 20 in the GLP1-RA group; 27 in the at-risk group; and 20 in the control group. The median age was 14.8 (interquartile range [IQR] 13.2-16.6) yr, and median fasting durations for solids and clears were 13 h (IQR 12-14) and 12 h (IQR 3.5-13), respectively. In the GLP1-RA group, 16/20 patients (80%) had solids present on gastric ultrasound, compared with 17/27 patients (63%) in the at-risk group and 1/20 patient (5%) in the control group (unadjusted P <0.001; adjusted P <0.02, with propensity score adjustment for age, body mass index, sex, race, and NPO time). CONCLUSIONS:We observed that 80% of adolescents on GLP1-RAs had solids on gastric ultrasound despite having fasted for over 12 h.

BACKGROUND:The upper and lower respiratory tracts feature distinct environments and responses affecting microbial colonization but investigating the relationship between them is technically challenging. We aimed to identify relationships between taxa colonizing the nasopharynx and trachea across childhood. METHODS:We employed V4 16S rRNA gene sequencing to profile nasopharyngeal swabs and tracheal aspirates collected from 172 subjects between 20 weeks and 18 years of age. These samples were collected prior to elective procedures over the course of 20 weeks in 2020 from subjects enrolled in a cross-sectional study. After extraction, sequencing, and quality control, we studied the remaining 147 of 172 nasopharyngeal swabs and 95 of 172 tracheal aspirates, including 80 subject-matched pairs of samples. RESULTS:Sequencing data revealed that the nasopharynx is colonized by few, often highly abundant taxa, while the tracheal aspirates feature greater diversity. The patterns of colonization identified in the nasopharynx correlate with subject age across childhood. CONCLUSION:Our data suggests that there are relatively few species that colonize both the nasopharyngeal tract and the trachea. Furthermore, we observe a pattern of change in the nasopharyngeal microbiota that is correlated with age, suggesting a possible developmental progression of the nasopharyngeal microbiota across childhood. IMPACT:The airway microbiota in childhood plays important roles in respiratory health and immune development. In this work, we report on paired nasopharyngeal swab and tracheal aspirate samples from a cross-sectional cohort of children from infancy to 18 years. We find that the upper and lower airway microbiota are unlikely to share taxa and do not correlate in terms of diversity. We show that the composition of the upper airway microbiota is strongly correlated with age, with a stereotypic developmental trajectory during childhood and adolescence. Our results inform our understanding of airway microbiota assembly and may be used to predict airway disease in young children.

Fetal surgery is an expanding domain in which the developing fetus receives therapeutic interventions aimed at reducing mortality and/or morbidity. It presents unique challenges to the anesthesiologist, as it involves managing two simultaneous patients and necessitates the integration of both obstetric and pediatric anesthesia. Fetal therapies range from minimally invasive techniques to open mid-gestation procedures to near-term procedures performed with the fetus partially delivered while on placental circulation. In this overview, we delineate the indications for fetal surgery, review the principles for administering anesthesia in these cases, and outline the anesthetic strategies for minimally invasive, open mid-gestation, and ex utero intrapartum treatment (EXIT) procedures.

BACKGROUND:Obstructive sleep apnoea (OSA) has been thought to increase the risk of respiratory depression from opioids. The primary aim of this study was to assess whether preoperative hypoxaemia by sleep study pulse oximetry imparts greater opioid sensitivity. METHODS:A multicentre observational cohort study with in-cohort dose randomisation was performed in children 2-8 yr of age with OSA undergoing adenotonsillectomy. Ninety patients were assigned to one of two Spo2 cohorts by preoperative sleep study Spo2 nadir of < or ≥85% to receive fentanyl 1.0 or 1.5 μg kg-1 (maximum 25 μg) after sevoflurane induction. The primary outcome was the extent of opioid-induced central ventilatory depression over time by Spo2 status as defined by the differences in tidal volume, respiratory rate, end-tidal CO2, and minute ventilation for 10 min after fentanyl administration when compared with pre-fentanyl baseline values. Secondary outcomes included assessment of body mass index, fentanyl dose, sex, age, and race on opioid-induced central ventilatory depression. Intention-to-treat and per protocol analysis were performed. RESULTS:Ninety patients underwent in-cohort randomisation (Spo2 <85%; n=47 and Spo2 ≥85%; n=43). Final per protocol analysis included 73 subjects, fentanyl 1.0 μg kg-1 (Spo2 <85%; n=36 and Spo2 ≥85%; n=37) and 15 subjects, fentanyl 1.5 μg kg-1 (Spo2 <85%; n=9 and Spo2 ≥85%; n=6). Multivariable mixed effect model for the primary outcomes (tidal volume, respiratory rate, end-tidal CO2, and minute ventilation) from baseline to 10 min (as % change per minute) were not different between groups by Spo2 nadir (< or ≥85%) and fentanyl dose for the intention-to-treat and per protocol analyses. CONCLUSIONS:Single-dose fentanyl ventilatory effects in paediatric OSA patients during sevoflurane anaesthesia were not associated with preoperative nocturnal hypoxaemia nadir. Fentanyl dosing in children with OSA should not be determined by sleep study Spo2 nadir. CLINICAL TRIAL REGISTRATION:NCT05051189.

PURPOSE OF REVIEW:To discuss considerations surrounding the use of point-of-care ultrasound (POCUS) in pediatric anesthesiology.RECENT FINDINGS:POCUS is an indispensable tool in various medical specialties, including pediatric anesthesiology. Credentialing for POCUS should be considered to ensure that practitioners are able to acquire images, interpret them correctly, and use ultrasound to guide procedures safely and effectively. In the absence of formal guidelines for anesthesiology, current practice and oversight varies by institution. In this review, we will explore the significance of POCUS in pediatric anesthesiology, discuss credentialing, and compare the specific requirements and challenges currently associated with using POCUS in pediatric anesthesia.SUMMARY:Point-of-care ultrasound is being utilized by the pediatric anesthesiologist and has the potential to improve patient assessment, procedure guidance, and decision-making. Guidelines increase standardization and quality assurance procedures help maintain high-quality data. Credentialing standards for POCUS in pediatric anesthesiology are essential to ensure that practitioners have the necessary skills and knowledge to use this technology effectively and safely. Currently, there are no national pediatric POCUS guidelines to base credentialing processes on for pediatric anesthesia practices. Further work directed at establishing pediatric-specific curriculum goals and competency standards are needed to train current and future pediatric anesthesia providers and increase overall acceptance of POCUS use.

BACKGROUND:Point-of-care ultrasound is an invaluable bedside tool for anesthesiologists and has been integrated into anesthesiology residency training and board certification in the United States. Little is known about point-of-care ultrasound training practices in pediatric anesthesia fellowship programs.AIMS:To describe the current state of point-of-care ultrasound education in pediatric anesthesia fellowship programs in the United States.METHODS:We conducted a cross-sectional survey study distributed to 60 American Accreditation Council for Graduate Medical Education-accredited pediatric anesthesia fellowship programs. Two programs were in their initial accreditation period and were excluded due to lack of historical data. Program directors or associate program directors were invited to complete this 23-item survey.RESULTS:Thirty-three of fifty-eight programs (57%) completed the survey. Of those, 15 programs (45%) reported having a point-of-care ultrasound curriculum. Programs with ≤3 fellows per year were less likely to have an ultrasound curriculum compared to programs with ≥4 fellows per year (30% programs 0-3 fellows/year vs. 69% programs ≥4 fellows/year, odds ratio 0.19 [95% confidence intervals 0.04-0.87]; p = .03). Program directors and associate program directors rated point-of-care ultrasound training as highly valuable to fellows' education. Barriers to use most commonly included lack of experience (64%), lack of oversight/interpretive guidance (58%), and lack of time (45%). Programs without point-of-care ultrasound training had significantly higher odds of listing lack of ultrasound access as a primary barrier (50% programs without vs. 13% programs with, odds ratio 6.5, [95% confidence intervals 1.3-50]; p = .04).CONCLUSIONS:This observational survey-based study suggests that fewer than half of pediatric anesthesia training programs in the United States offer point-of-care ultrasound education. Additional research is needed to optimize this education and training in pediatric anesthesia fellowship programs.

Background The upper (URT) and lower (LRT) respiratory tract feature distinct environments and responses affecting microbial colonization but investigating the relationship between them is technically challenging. We aimed to identify relationships between taxa colonizing the URT and LRT and explore their relationship with development during childhood. Methods We employed V4 16S rDNA sequencing to profile nasopharyngeal swabs and tracheal aspirates collected from 183 subjects between 20 weeks and 18 years of age. These samples were collected prior to elective procedures at the Children's Hospital of Philadelphia over the course of 20 weeks in 2020, from otherwise healthy subjects enrolled in a study investigating potential reservoirs of SARS-CoV-2. Findings After extraction, sequencing, and quality control, we studied the remaining 124 nasopharyngeal swabs and 98 tracheal aspirates, including 85 subject-matched pairs of samples. V4 16S rDNA sequencing revealed that the nasopharynx is colonized by few, highly-abundant taxa, while the tracheal aspirates feature a diverse assembly of microbes. While no taxa co-occur in the URT and LRT of the same subject, clusters of microbiomes in the URT correlate with clusters of microbiomes in the LRT. The clusters identified in the URT correlate with subject age across childhood development. Interpretations The correlation between clusters of taxa across sites may suggest a mutual influence from either a third site, such as the oropharynx, or host-extrinsic, environmental features. The identification of a pattern of upper respiratory microbiota development across the first 18 years of life suggests that the patterns observed in early childhood may extend beyond the early life window. Funding Research reported in this publication was supported by NIH T32 GM007200 (AJH), F30 DK127584 (AJH), NIH/NIAID R21AI154370 (AOJ, ALK), NIH/NICHD R01HD109963 (AOJ, ALK), and NIH/NICHD R33HD105594 (AOJ). Dr. John is an Investigator in the Pathogenesis of Infectious Diseases of the Burroughs Welcome Fund.

BACKGROUND Ultrasound-based diaphragmatic assessments are becoming more common in pediatric acute care, but baseline pediatric diaphragm thickness and contractility values remain unknown. METHODS We conducted a prospective, observational study of healthy children aged <18 years undergoing elective surgery. Diaphragm thickness at end-expiration (Tdi-exp), thickening fraction (DTF) and excursion were measured by ultrasound during spontaneous breathing and during mechanical ventilation. Diaphragm strain and peak strain rate were ascertained post hoc. Measurements were compared across a priori specified age groups (<1 year, 1 to <3, 3 to <6, 6 to <12, and 12 to <18 years) and with versus without mechanical ventilation. RESULTS Fifty subjects were evaluated (n = 10 per age group). Baseline mean Tdi-exp was 0.19 ± 0.04 cm, DTF 0.19 ± 0.09, excursion 1.69 ± 0.97 cm, strain -10.3 ± 4.9, peak strain rate -0.48 ± 0.21 s-1 . No significant difference in Tdi-exp or DTF was observed across age groups (p > .05). Diaphragm excursion increased with age (p < .0001). Diaphragm strain was significantly greater in the 12-17-year age group (-14.3 ± 6.4), p = .048, but there were no age-related differences in peak strain rate (p = .08). During mechanical ventilation, there were significant decreases in DTF 0.12 ± 0.04 (p < .0001), excursion 1.08 ± 0.31 cm (p < .0001), strain -4.60 ± 1.93 (p < .0001), and peak strain rate -0.20 ± 0.10 s-1 (p < .0001) while there was no change in Tdi-exp 0.18 ± 0.03 cm (p = .25) when compared to baseline values. CONCLUSION Pediatric Tdi-exp, DTF, and diaphragm peak strain rate were similar across age groups. Diaphragm excursion and strain varied across age groups. All measures of diaphragm contractility were diminished during mechanical ventilation.

INTRODUCTION:Micrognathic neonates are at risk for upper airway obstruction, and many require intubation in the delivery room. Ex-utero intrapartum treatment is one technique for managing airway obstruction but poses substantial maternal risks. Procedure requiring a second team in the operating room is an alternative approach to secure the obstructed airway while minimizing maternal risk. The aim of this study was to describe the patient characteristics, airway management, and outcomes for micrognathic neonates and their mothers undergoing a procedure requiring a second team in the operating room at a single quaternary care children's hospital.METHODS:This was a retrospective descriptive study. Subjects had prenatally diagnosed micrognathia and underwent procedure requiring a second team in the operating room between 2009 and 2021. Collected data included infant characteristics, delivery room airway management, critical events, and medications. Follow-up data included genetic testing and subsequent procedures within 90 days. Maternal data included type of anesthetic, blood loss, and incidence of transfusion.RESULTS:Fourteen deliveries were performed via procedure requiring a second team in the operating room during the study period. 85.7% were male, and 50% had a genetic syndrome. Spontaneous respiratory efforts were observed in 93%. Twelve patients (85.7%) required an endotracheal tube or tracheostomy. Management approaches varied. Medications were primarily a combination of atropine, ketamine, and dexmedetomidine. Oxygen desaturation was common, and three patients experienced bradycardia. There were no periprocedural deaths. Follow-up at 90 days revealed that 78% of patients underwent at least one additional procedure, and one patient died due to an unrelated cause. All mothers underwent cesarean deliveries under neuraxial anesthesia. Median blood loss was 700 mL [IQR 700 mL, 800 mL]. Only one mother required a blood transfusion for pre-procedural placental abruption.DISCUSSION:Procedure requiring a second team in the operating room is a safe and effective approach to manage airway obstruction in micrognathic neonates while minimizing maternal morbidity.CONCLUSIONS:Though shown to be safe and effective, more data are needed to support the use of procedure requiring a second team in the operating room as an alternative to ex-utero intrapartum treatment for micrognathia outside of highly specialized maternal-fetal centers.

Introduction: Fetoscopic selective laser photocoagulation (FSLPC) and selective cord occlusion with radiofrequency ablation (RFA) can improve fetal outcomes when vascular anastomoses between fetuses cause twin-to-twin transfusion syndrome (TTTS) or selective fetal growth restriction (sFGR) in multiple gestation pregnancies with monochorionic placentation. This study analyzed perioperative maternal-fetal complications and anesthetic management in a high-volume fetal therapy center over a 4-year period. Methods: Included patients received MAC for minimally invasive fetal procedures for complex multiple gestation pregnancies between January 1, 2015, and September 20, 2019. Maternal and fetal complications, intraoperative maternal hemodynamics, medication usage, and reasons for conversion to general anesthesia, if applicable, were analyzed. Results: A total of 203 (59%) patients underwent FSLPC and 141 (41%) had RFA. Four patients (2%; rate 95% CI: 0.00039, 0.03901) undergoing FSLPC had conversion to general anesthesia. No conversions to general anesthesia occurred in the RFA group. The incidence of maternal complications was higher in those who underwent FSLPC. No aspiration or postoperative pneumonia events were observed. Medication usage was similar in FSLPC and RFA groups. Conclusion: A low rate of conversion to general anesthesia and no serious adverse maternal events were observed in patients receiving MAC.

BACKGROUND:Fluid administration in children undergoing surgery requires precision, however, determining fluid responsiveness can be challenging. Ultrasound has been used widely in the emergency department and intensive care units as a noninvasive, bedside manner of determining volume status, but the intraoperative period presents unique challenges as often the chest and abdomen are inaccessible for ultrasound. We investigate whether carotid artery ultrasound, specifically carotid flow time, can be used to determine fluid responsiveness in children under general anesthesia. METHODS:Prospective observational study of 87 children ages 1-12 years who were scheduled for elective noncardiac surgery. Ultrasound of the carotid artery and heart was performed at three time points: (1) after inhalational induction of anesthesia with the subject spontaneously breathing, (2) during positive pressure ventilation through endotracheal tube or supraglottic airway with tidal volume set at 8 ml/kg with PEEP of 10 cmH2 O, and (3) after a 10 ml/kg fluid bolus. Carotid flow time and cardiac output were measured from saved images. RESULTS:Corrected carotid flow time (FTc) increased with initiation of positive pressure ventilation in both fluid responders and nonresponders (352.7 vs. 365.3 msec, p = .005 in fluid responders; 348.3 vs. 365.2 msec, p = .001 in nonresponders). FTc increased after fluid bolus in both responders and nonresponders (365.3 vs. 397.6 msec, p < .001 in fluid responders; 365.2 vs. 397.2 msec, p < .001 in nonresponders). However, baseline FTc during spontaneous ventilation or positive pressure ventilation prior to fluid bolus was not associated with fluid responsiveness. DISCUSSION:Flow time increases with initiation of positive pressure ventilation and after administration of a fluid bolus. FTc may serve as an indicator of fluid status but does not predict fluid responsiveness in children under general anesthesia.

Pediatric AnesthesiaVolume 32, Issue 10 p. 1172-1174 SHORT REPORT Early elective surgery in children with mild COVID-19 does not increase pulmonary complications: A retrospective cohort study David R. Lee, David R. Lee orcid.org/0000-0002-4040-0143 Division of Pediatric Otolaryngology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USASearch for more papers by this authorGrace L. Banik, Grace L. Banik Division of Pediatric Otolaryngology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USASearch for more papers by this authorTerri Giordano, Terri Giordano Division of Pediatric Otolaryngology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USASearch for more papers by this authorKen Kazahaya, Ken Kazahaya Division of Pediatric Otolaryngology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USASearch for more papers by this authorElaina E. Lin, Corresponding Author Elaina E. Lin [email protected] orcid.org/0000-0002-4451-8448 Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA Correspondence Elaina E. Lin, Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Suite 9329, Philadelphia, PA 19104, USA. Email: [email protected]Search for more papers by this author David R. Lee, David R. Lee orcid.org/0000-0002-4040-0143 Division of Pediatric Otolaryngology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USASearch for more papers by this authorGrace L. Banik, Grace L. Banik Division of Pediatric Otolaryngology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USASearch for more papers by this authorTerri Giordano, Terri Giordano Division of Pediatric Otolaryngology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USASearch for more papers by this authorKen Kazahaya, Ken Kazahaya Division of Pediatric Otolaryngology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USASearch for more papers by this authorElaina E. Lin, Corresponding Author Elaina E. Lin [email protected] orcid.org/0000-0002-4451-8448 Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA Correspondence Elaina E. Lin, Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Suite 9329, Philadelphia, PA 19104, USA. Email: [email protected]Search for more papers by this author First published: 16 July 2022 https://doi.org/10.1111/pan.14528 Section Editor: Britta S. von Ungern-Sternberg Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat No abstract is available for this article. CONFLICT OF INTEREST The authors have no conflicts of interest. Open Research DATA AVAILABILITY STATEMENT The data that support the findings of this study are available from the corresponding author upon reasonable request. Volume32, Issue10October 2022Pages 1172-1174 RelatedInformation

Background: Animal studies have shown evidence of neurotoxicity from inhalational anesthesia, yet clinical studies have been less conclusive. While ongoing studies investigate the clinical significance of anesthesia-associated neurodevelopmental changes in young children, reducing anesthetic exposure in pediatric orthopaedic surgery is prudent. The primary objective of this study is to determine if local anesthetic injection before surgical incision versus after surgical release decreased inhalational anesthetic exposure in children undergoing unilateral trigger thumb release. The secondary objectives were to determine if the timing of local anesthetic injection affected postoperative pain or length of stay. Methods: This was a single-center randomized controlled trial of pediatric patients (4 y and below) undergoing unilateral trigger thumb release. Subjects were randomized into preincision or postrelease local anesthesia injection groups. The surgeon was aware of the treatment group, while the anesthesiologist was blinded. Patient demographics, operative times, cumulative sevoflurane dose, and postoperative anesthesia care unit recovery characteristics were collected. The χ2, Fisher exact, and Mann-Whitney U tests were conducted. Results: A total of 24 subjects were enrolled, with 13 randomized to the preincision injection group and 11 to the postprocedure injection group. There was no significant difference in age, sex, operative time, or tourniquet time between groups. There was a significant difference in the cumulative sevoflurane dose between the preincision injection group (23.2 vol%; interquartile range: 21.7 to 27.6) and the postprocedure injection group (28.1 vol%; interquartile range: 27 to 30) (P=0.03), with a 21% reduction in cumulative dose. There were no significant differences in postoperative pain scores, use of rescue pain medications, the incidence of nausea, or time to discharge between groups. Conclusions: Administering local anesthesia before incision versus at the end of the procedure significantly decreased cumulative sevoflurane dose for unilateral trigger thumb release. The results of this study suggest that local anesthetic injection before the incision is a low risk, easy method to reduce general anesthesia requirements during trigger thumb release and could decrease sevoflurane exposure more substantially in longer procedures and mitigate risks of neurotoxicity. Preincision injection with local anesthetic should be incorporated into routine clinical practice. Level of Evidence: Level I.

Nasopharyngeal reverse-transcriptase polymerase chain reaction assay for SARS-CoV-2 is considered the gold standard for diagnosing COVID-19 infections. However, multiple reports in adults with acute COVID-19 have shown positive tracheobronchial reverse-transcriptase polymerase chain reaction for SARS-CoV-2 despite initial negative nasopharyngeal testing.1–5 Furthermore, viral nucleic acid appears to persist longer in the lower respiratory tract than in the upper respiratory tract in adults, suggesting that the lower respiratory tract may be a more accurate sampling site later in the course of infection.6Children with COVID-19 generally have less severe symptoms than adults, including significantly fewer cases of respiratory compromise and an increased likelihood of asymptomatic infection.7–9 Lack of symptoms is insufficient to rule out lower respiratory tract disease, and characteristic ground glass opacities have been observed on chest computed tomography in asymptomatic children.10 However, it is unclear whether children can harbor virus in their lower respiratory tract with a negative nasopharyngeal test. Understanding the SARS-CoV-2 viral reservoir in children is important for diagnostic and infection prevention control reasons and has hospital and public health implications. The aim of this study is to determine the concordance of upper and lower respiratory samples for SARS-CoV-2 in asymptomatic children presenting for surgery.The institutional review board at The Children's Hospital of Philadelphia (Philadelphia, Pennsylvania) approved the study, and consent was obtained from guardians. A convenience sample of asymptomatic pediatric patients less than or equal to 18 yr old, undergoing procedures for which endotracheal intubation or diagnostic bronchoalveolar lavage were planned, were enrolled between July 10 and November 24, 2020. The study was conducted at a tertiary care children's hospital.After general anesthesia was induced and subjects were unconscious, tracheal aspirate or bronchoalveolar lavage samples were collected by clinicians (anesthesiologist or pulmonologist). At the time of lower respiratory tract sample collection, nasopharyngeal swabs were also obtained. All samples were tested with an in-house–developed reverse-transcriptase polymerase chain reaction laboratory assay, which, like most commercially available reverse-transcriptase polymerase chain reaction assays, uses the same N2 primer and probe as the assay developed by the Centers for Disease Control and Prevention (Atlanta, Georgia). The cycle threshold (number of cycles needed to amplify viral RNA to a detectable level) was 40. Electronic medical records were reviewed for demographics and clinical symptoms.Statistical analyses were performed using STATA 14.2 (StataCorp LP, USA). Concordance was determined between nasopharyngeal and lower respiratory tract samples with the Fisher exact test. A data analysis and statistical plan was written and filed with the institutional review board before data were accessed.Three hundred sixty subjects were enrolled. Two subjects had insufficient lower respiratory tract samples, leaving 358 subjects with evaluable upper and lower respiratory sample pairs. Three hundred twenty-two tracheal aspirates and 36 bronchoalveolar lavage samples were collected. The median age was 6 yr old (range, 6 days to 18 yr). Sex, race, ethnicity, and procedure types are described in table 1. Among the 358 lower respiratory tract samples, all were negative for SARS-CoV-2. Of 358 nasopharyngeal samples, 2 of 358 (0.6%) were positive for SARS-CoV-2, with 99.4% concordance between upper and lower respiratory tract samples (P = 0.008; table 2). The SARS-CoV-2–positive nasopharyngeal samples had cycle thresholds of 39.86 and 39.11. Neither of the SARS-CoV-2–positive subjects reported symptoms of COVID-19.In our cohort, the two cases of discordance were in subjects with positive nasopharyngeal swab and negative tracheal aspirate. Both nasopharyngeal-positive subjects had cycle thresholds that were very close to the limit for detection, indicating low viral loads. Our data suggest that in asymptomatic pediatric patients, nasopharyngeal samples are more sensitive for detecting SARS-CoV-2 than tracheal aspirate or bronchoalveolar lavage samples, and that false negative results are extremely rare.There are several limitations to our study. Our cohort included few SARS-CoV-2 polymerase chain reaction–positive patients because all patients at our hospital are tested before surgery, and if positive, surgery was postponed unless emergent. Similarly, all subjects were asymptomatic with respect to SARS-CoV-2 infection. These data should also be interpreted in the setting of community prevalence. During the study period, our pediatric healthcare network-wide SARS-CoV-2 reverse-transcriptase polymerase chain reaction test positivity rate for pediatric patients was 1.1 to 8.7%.As pediatric specialists determine how to safely care for patients in the setting of COVID-19, understanding viral reservoirs and the accuracy of test sampling sites in children is vital. The results of this systematic study are reassuring to providers who perform aerosol-generating procedures in children. The results support the preprocedure use of upper respiratory sample testing as a safe and accurate screening test. Further studies in symptomatic children, in children known to be SARS-CoV-2–positive, and in special populations (e.g., immunocompromised patients) are required to determine if these findings are generalizable to these populations.Dr. Odom John is supported by National Institutes of Health/National Institute for Allergy and Infectious Diseases (Bethesda, Maryland) grant Nos. R01-AI103280, R21-AI123808, and R21-AI130584, and she is an investigator in the Pathogenesis of Infectious Diseases of the Burroughs Wellcome Fund (Durham, North Carolina).Dr. Odom John reports funding from the National Institutes of Health (Bethesda, Maryland) and the Burroughs Wellcome Fund (Durham, North Carolina). Dr. John is on the scientific advisory board of Pluton Biosciences (St. Louis, Missouri). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. The remaining authors declare no competing interests.

Background/Purpose: As the COVID-19 pandemic continues to spread worldwide, children may account foronly 2 16% of conrmed cases Previous studies may underestimate the true incidence of COVID-19 in childrenas they are more likely to be asymptomatic, and thereby less likely to be tested We aimed to determine theincidence of COVID-19 in pediatric patients presenting for surgery Methods: After universal preoperativescreening for COVID-19 was instituted at the Children's Hospital of Philadelphia, Seattle Children's, and TexasChildren's Hospital, children <19 years age without known COVID-19 were tested using a reverse-transcriptasepolymerase chain reaction (RT-PCR) assay to detect the SARS-CoV-2 virus Patient characteristics wereevaluated to determine factors associated with positive testing Results: 1,295 pediatric surgical patients werescreened (mean age 7 35 years) The overall incidence of COVID-19 was 0 93% (12/1,295), but ranged from0 22% to 2 65% across hospitals (p=0 001) At one institution, 5/9 positive patients presented from a singletownship with a positive risk rate of 55 6% vs 1 51% in all other patients (p=0 001) 50% of COVID-19 patients presented with preoperative symptoms vs 12 24% in negative patients (p=0 002) (Table 1) Fever (25 0% vs 6 7%, p=0 044), rhinorrhea (16 7% vs 2 8%, p=0 005), and known COVID-19 exposure (20 0% vs 1 7%, p=0 014) were more common in COVID-19 patients After multivariate regression, age (OR 1 10, p=0 048) and ASA emergent classication (OR 5 66, p=0 001) were associated with COVID-19 Conclusion: The overall incidence of COVID-19 in children undergoing preoperative universal screening was <1% However, this varied greatly between the regions represented by our hospitals, and even by township within the catchment area of a single hospital The value of universal COVID-19 screening appears greatest in areas with higher prevalence As elective surgery resumes, it will be important to consider universal testing in the context of regional prevalence, local testing capability, and availability of personal protective equipment

Since the start of the global coronavirus disease 2019 (COVID-19) pandemic in December 2019, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has infected over 93 million people worldwide, with more than 1.9 million deaths.1Johns Hopkins University & Medicine. 2021. Available from: https://coronavirus.jhu.edu (accessed 14 January 2021).Google Scholar In the midst of an unprecedented case surge, there appears to be a glimpse of hope in the battle against SARS-CoV-2 as millions of people around the world start receiving vaccinations. Yet, as vaccinations roll out, healthcare providers will be forced to make difficult decisions over the coming months, specifically with regard to continuation of routine preoperative testing and the use of personal protective equipment (PPE), particularly for asymptomatic paediatric patients. In this issue of the British Journal of Anaesthesia, Colas and colleagues2Colas A.-E. Azale M. Ayanmanesh F. et al.Mandatory preoperative SARS-CoV-2 infection screening policies for paediatric surgery.Br J Anaesth. 2021; 126: e182-e184Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar report on their cohort of paediatric surgical patients screened using a reverse transcriptase–polymerase chain reaction (RT–PCR) assay to detect SARS-CoV-2 at the Robert Debré Hospital in Paris, France. Preoperative universal screening of all surgical patients provides a unique opportunity to examine patients that are otherwise asymptomatic. Specifically, it allows determination of asymptomatic carriers of SARS-CoV-2. In their cohort of 2148 paediatric patients tested before surgery, 29 (1.4%) tested positive for SARS-CoV-2, of which 20 (69%) were asymptomatic.2Colas A.-E. Azale M. Ayanmanesh F. et al.Mandatory preoperative SARS-CoV-2 infection screening policies for paediatric surgery.Br J Anaesth. 2021; 126: e182-e184Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar Recently, Adler and colleagues3Adler A.C. Shah A.S. Blumberg T.J. et al.Symptomatology and racial disparities among children undergoing universal preoperative COVID-19 screening at three US children's hospitals: early pandemic through resurgence.Paediatr Anaesth Adv Access Published November. 2020; 13https://doi.org/10.1111/pan.14074Crossref Scopus (9) Google Scholar reported on a similar cohort of 19 061 paediatric patients having preoperative SARS-CoV-2 screening by RT–PCR assays at three US paediatric hospitals (Children's Hospital of Philadelphia, Texas Children's Hospital, and Seattle Children's Hospital) between March and July of 2020. The multi-institutional SARS-CoV-2 positivity rate was 161/19 061 (0.85%) with the majority being asymptomatic 123/161 (75.9%).3Adler A.C. Shah A.S. Blumberg T.J. et al.Symptomatology and racial disparities among children undergoing universal preoperative COVID-19 screening at three US children's hospitals: early pandemic through resurgence.Paediatr Anaesth Adv Access Published November. 2020; 13https://doi.org/10.1111/pan.14074Crossref Scopus (9) Google Scholar Taken together, the combined positivity rate amongst patients screened for SARS-CoV-2, as reported by Colas and colleagues2Colas A.-E. Azale M. Ayanmanesh F. et al.Mandatory preoperative SARS-CoV-2 infection screening policies for paediatric surgery.Br J Anaesth. 2021; 126: e182-e184Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar and Adler and colleagues,3Adler A.C. Shah A.S. Blumberg T.J. et al.Symptomatology and racial disparities among children undergoing universal preoperative COVID-19 screening at three US children's hospitals: early pandemic through resurgence.Paediatr Anaesth Adv Access Published November. 2020; 13https://doi.org/10.1111/pan.14074Crossref Scopus (9) Google Scholar is 191/21 209 (0.9%) with 143/191 (74.9%) being asymptomatic. These findings, across the two continents, underscore the finding that the majority of children with COVID-19 are asymptomatic. Furthermore, Colas and colleagues2Colas A.-E. Azale M. Ayanmanesh F. et al.Mandatory preoperative SARS-CoV-2 infection screening policies for paediatric surgery.Br J Anaesth. 2021; 126: e182-e184Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar observed that SARS-CoV-2 positivity rates in their paediatric cohort do not necessarily parallel regional adult positivity rates. The week of highest paediatric positivity rate noted in their cohort was at a time of low adult positivity rate. Phase 3 testing of the BNT162b2 vaccine (Pfizer, Pearl River, NY, USA) and mRNA01273 vaccine (Moderna, Cambridge, MA, USA) reports an extremely promising 95% and 94.1% efficacy, respectively, in protection from developing symptomatic COVID-19.4Polack F.P. Thomas S.J. Kitchin N. et al.Safety and efficacy of the BNT162b2 mRNA Covid-19 vaccine.N Engl J Med. 2020; 383: 2603-2615Crossref PubMed Scopus (8459) Google Scholar,5Baden L.R. El Sahly H.M. Essink B. et al.Efficacy and safety of the mRNA-1273 SARS-CoV-2 vaccine.N Engl J Med. 2021; 384: 403-416Crossref PubMed Scopus (5763) Google Scholar Although medical providers are amongst the first to receive the SARS-CoV-2 vaccine, it remains to be established whether vaccinated persons can have asymptomatic infection and are able to transmit disease. The SARS-CoV-2 vaccines have not been approved for administration in children. Although paediatric safety and efficacy studies are underway for these vaccines, it is unlikely that data will be available for several months. Furthermore, the virus is mutating, and there is early concern that new circulating variants with changes in their spike proteins, such as strain 501Y.V2, may be resistant to the current vaccines.6Greanery A.J. Loes A.N. Crawford K.H.D. et al.Comprehensive mapping of mutations to the SARS-CoV-2 receptor-binding domain that affect recognition by polyclonal human serum antibodies.2021Google Scholar Although children are largely spared from severe illness caused by SARS-CoV-2, they remain a source of asymptomatic carriers and may transmit the virus. As an example, the institutions where the authors of this editorial work have a combined annual anaesthetic case volume exceeding 80 000 cases. At current positivity rates, this represents an exposure to approximately 720 SARS-CoV-2-positive patients, of which 549 would be asymptomatic. Universal preoperative SARS-CoV-2 screening, performed within 72 h of a procedure, can be resource intensive, onerous for families, and uncomfortable for the patient. However, until the majority of the population is vaccinated and circulating levels of virus in the community are minimal, universal preoperative testing, and use of PPE remain important, particularly for aerosol-generating procedures. Both authors contributed to writing of this manuscript The authors declare that they have no conflicts of interest. Mandatory preoperative SARS-CoV-2 infection screening policies for paediatric surgeryBritish Journal of AnaesthesiaVol. 126Issue 5PreviewEditor—During the first wave of the coronavirus 2019 (COVID-19) pandemic in France, substantial hospital resources were allocated to the clinical care of patients presenting with severe and critical severe acute respiratory syndrome-related coronavirus-2 (SARS-CoV-2) infection to the detriment of other clinical priorities.1 Such policy is only sustainable for a short period, and unsurprisingly most health systems have increased treatment of non-emergent, non-COVID-19 patients during subsequent waves. Full-Text PDF Open Archive

Surgery in patients with coronavirus disease 2019 (COVID-19) is associated with increased mortality and complications.1 Procedures may generate aerosols or require endotracheal intubation, increasing risk of occupational exposure of health care workers. As medical centers navigate aerosol-generating procedures, preprocedure testing is important for patient and provider safety. Testing for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) immediately before the procedure would yield the most accurate results. However, scheduling logistics and inadequate turnaround times often necessitate preprocedure testing several days in advance. Thus, patients may have negative preprocedure testing results, yet have active viral replication at the time of surgery. Although patients are instructed to monitor for symptoms after testing, symptom reporting is likely to be insensitive in children because most have mild or no symptoms.2–4 The purpose of this study was to determine if preprocedure testing up to 3 days before surgery was concordant with testing performed at the time of surgery in children.Children presenting for surgery at the Children’s Hospital of Philadelphia (CHOP) are required to have a reverse transcriptase polymerase chain reaction (RT-PCR)–based nasopharyngeal SARS-CoV-2 test within 3 days of surgery. From July 10, 2020, to October 9, 2020, a convenience sample of patients aged <18 years who had negative preprocedure testing results and lacked symptoms of COVID-19 had nasopharyngeal samples taken after anesthesia induction. Preprocedural samples taken 1 to 3 days before surgery, as well as at the time of surgery, were analyzed for the presence of SARS-CoV-2 with a CHOP in-house laboratory–developed RT-PCR assay, which has a 6- to 10-hour turnaround time. The N2 primer and probe used in the assay are the same as the Centers for Disease Control–developed assay and authorized by the United States Food and Drug Administration. The cycle threshold for a positive test result was 40. The limit of detection for this assay is ∼20 000 copies per milliliter, and the specificity was 100%, as determined through wet testing against common respiratory pathogens and by in silico analysis. Preprocedural samples taken on the day of surgery were analyzed by our in-house laboratory for the presence of SARS-CoV-2 with the Xpert Xpress SARS-CoV-2 assay from Cepheid Inc (Sunnyvale, CA), an RT-PCR rapid assay with a 45-minute turnaround time. This test is used to target the E and y genes of SARS-CoV-2 and contains an exogenous processing control. It has a limit of detection of 0.01 plaque-forming units per milliliter, with a reported negative percentage agreement of 95.6%.5The study was approved by the institutional review board (IRB 20-017635), and informed consent was obtained from guardians. Race and ethnicity were self-reported by parents and guardians during surgery registration. Race and ethnicity of this cohort is described because minorities have higher reported rates of SARS-CoV-2 infection,6 and racial and ethnic composition may affect overall positivity rates and likelihood of exposure to SARS-CoV-2 between time of preprocedural testing and time of surgery. Time-of-surgery test results were compared with preprocedure results by using Pearson’s χ2 test.Two hundred forty-one pediatric surgical patients were included in this study, with a mean (SD) age of 7.2 (5.5) years (range 7 d–18 y). Sex, race, and ethnicity are described in Table 1. Twelve surgical procedure types were identified. In total, 10.8% of patients had preprocedure testing on day of surgery, 27.4% had it 1 day before, 54.8% had it 2 days before, and 7.1% had it 3 days before surgery (Table 1). There was 100% concordance of testing, with all subjects with negative preprocedure testing results having negative time-of-surgery SARS-CoV-2 RT-PCR results (P < .01).In this cohort of asymptomatic children with negative preprocedure testing, there was 100% concordance with time-of-surgery testing. The vast majority (93%) of subjects had testing performed within 2 days of their surgery. These data should be interpreted in the context of community prevalence.7 With any test, the negative predictive value will decrease with increased prevalence. During the 3-month period of this study, inpatient and outpatient testing positivity rates in our pediatric health care network ranged from 1.1% to 4.5%. In an area of relatively low community transmission, preprocedure testing of children within 2 days of surgery appears to be a reasonable strategy for balancing the safety of patients and staff with logistic testing and surgical scheduling issues.There are several limitations to our study. Because of need for consent and testing resource availability, we retested a subset of patients undergoing surgery. However, we believe we captured a representative cross-section of ages and surgical procedure types. Our study also does not address the sensitivity of nasopharyngeal RT-PCR testing for SARS-CoV-2.As pediatric specialists grapple with how to make procedures safer in the setting of COVID-19, testing guidelines must evolve on the basis of the patient population, community prevalence, and logistic realities. A negative test result cannot rule out SARS-CoV-2 infection, and use of appropriate personal protective equipment remains essential.We acknowledge Allison M. Blatz, MD, and William R. Otto, MD, for their assistance in enrolling subjects for this study. No compensation was received for their role in this investigation.

Purpose of review This review describes maternal and fetal anesthetic management for noncardiac fetal surgical procedures, including the management of lower urinary tract obstruction, congenital diaphragmatic hernia (CDH), myelomeningocele, sacrococcygeal teratoma, prenatally anticipated difficult airway and congenital lung lesions. Recent findings Fetal interventions range from minimally invasive fetoscopic procedures to mid-gestation open surgery, to ex-utero intrapartum treatment procedure. Anesthetic management depends on the fetal intervention and patient characteristics. Anesthesia for most minimally invasive procedures can consist of intravenous sedation and local anesthetic infiltration in clinically appropriate maternal patients. Open fetal and ex-utero intrapartum treatment procedures require maternal general anesthesia with volatile anesthetic and other medications to maintain uterine relaxation. Tracheal balloons are a promising therapy for CDH and can be inserted via minimally invasive techniques. Management of the prenatally anticipated difficult airway during delivery and removal of tracheal balloons from patients with CDH during delivery can be clinically dynamic and require flexibility, seamless communication and a high-functioning, multidisciplinary care team. Maternal and fetal anesthetic management is tailored to the fetal intervention and the underlying health of the fetus and mother.

PURPOSE OF REVIEW This review describes maternal and fetal anesthetic management for noncardiac fetal surgical procedures, including the management of lower urinary tract obstruction, congenital diaphragmatic hernia (CDH), myelomeningocele, sacrococcygeal teratoma, prenatally anticipated difficult airway and congenital lung lesions. RECENT FINDINGS Fetal interventions range from minimally invasive fetoscopic procedures to mid-gestation open surgery, to ex-utero intrapartum treatment procedure. Anesthetic management depends on the fetal intervention and patient characteristics. Anesthesia for most minimally invasive procedures can consist of intravenous sedation and local anesthetic infiltration in clinically appropriate maternal patients. Open fetal and ex-utero intrapartum treatment procedures require maternal general anesthesia with volatile anesthetic and other medications to maintain uterine relaxation. Tracheal balloons are a promising therapy for CDH and can be inserted via minimally invasive techniques. Management of the prenatally anticipated difficult airway during delivery and removal of tracheal balloons from patients with CDH during delivery can be clinically dynamic and require flexibility, seamless communication and a high-functioning, multidisciplinary care team. SUMMARY Maternal and fetal anesthetic management is tailored to the fetal intervention and the underlying health of the fetus and mother.