PURPOSE OF THE REVIEW:Paediatric anaesthesia has achieved remarkable progress over recent decades, yet contemporary data reveal that safety remains unevenly distributed across age groups, institutions, and regions of the world. RECENT FINDINGS:Large observational studies demonstrate persistent perioperative morbidity and mortality, particularly in neonates, infants, and children cared for in resource-limited settings. While these multicentric investigations did not establish a direct causal relationship between anaesthetic management and perioperative morbidity or mortality in paediatric populations, they did reveal a high incidence of critical events related to the conduct of anaesthesia, which, if not diagnosed in time or left uncorrected, could lead to catastrophic outcomes. SUMMARY:The Safe Anaesthesia for Every Tots (SAFETOTS) initiative focuses on the safe conduct of anaesthesia, maintenance of perioperative physiological stability, alongside organisational and child-centred values in perioperative care. This review explores the current state of and challenges in paediatric anaesthesia safety through the perspective of the SAFETOTS initiative.

Introduction: Manikin-based high-fidelity simulation (HFS) is critical in anesthesia for teaching crisis resource management skills in a safe environment. However, HFS is known to result in significant stress, potentially affecting learning. Virtual reality (VR) has emerged as a promising alternative to HFS, but the impact on stress remains unknown. This study compares perceived and physiological stress in anesthesia trainees during VR and HFS, and in high- and low-performing subjects after HFS. Methods: This secondary analysis from a prospective, sequential, randomized controlled trial compares anesthesia trainee volunteers who undergo either VR or HFS scenarios. Perceived stress was measured using the State-Trait Anxiety Inventory (STAI), the Medical Emotion Scale (MES), and the NASA Task Load Index (NASA-TLX). Physiological stress was assessed via heart rate variability standard deviation between successive N-N intervals (SDNN) and the low-frequency/high-frequency (LF/HF) ratio. Trainees’ performance was assessed with the Ottawa Global Rating Scale. Results: Among the 34 volunteers enrolled, both the VR and HFS groups demonstrated similar STAI, MES, and NASA-TLX scores following the scenarios. However, VR elicited lower SDNN values (mean difference, −12, 95% CI, −23 to −1.0, P =0.034), but not the LF/HF ratio. No difference was observed in stress indicators between high-performing and low-performing trainees. Conclusions: Anesthesia trainees experience comparable levels of perceived stress in the form of anxiety, emotional responses, and task load in VR and HFS scenarios. A lower heart rate variability during VR scenarios may indicate greater physiological stress. The relevance and implications of these findings in simulation require further clarification. Study Registration ClinicalTrials.gov (NCT05041049).

Background: In adults, the forces generated during Boyle-Davis Gag suspension correlate with postoperative pain, but no data are available in pediatrics. This study investigates the force metrics and postoperative opioid consumption, pain, emergence delirium (ED), and hypoactive delirium in children. Methods: Children undergoing elective partial or total adenotonsillectomy or adenoidectomy were enrolled. Intraoperative maximum and average forces, suspension time, total impulse (area under the curve of force vs. time), and postoperative opioid consumption, pain, ED, and hypoactive delirium were assessed. Results: Data from 43 children were analyzed. Force metrics were not associated with postoperative opioid consumption, ED, or hypoactive delirium. Compared to no pain, total impulse decreased with mild (mean difference 2.3 kN·s; 95% CI, 3.8 to 4.2; p = 0.02), moderate (mean difference 2.8 kN·s; 95% CI, 5.4 to 3.9; p = 0.011), and severe pain (mean difference 2.3 kN·s; 95% CI, 7.6 to 3.9; p = 0.005). Suspension time was negatively correlated with pain score (r = -0.32, p = 0.041). Conclusions: The force metrics are low and not associated with opioid consumption, ED, or hypoactive delirium. Suspension correlates weakly with postoperative pain in children.

INTRODUCTION:Manikin-based high-fidelity simulation (HFS) is critical in anesthesia for teaching crisis resource management skills in a safe environment. However, HFS is known to result in significant stress, potentially affecting learning. Virtual reality (VR) has emerged as a promising alternative to HFS, but the impact on stress remains unknown. This study compares perceived and physiological stress in anesthesia trainees during VR and HFS, and in high- and low-performing subjects after HFS. METHODS:This secondary analysis from a prospective, sequential, randomized controlled trial compares anesthesia trainee volunteers who undergo either VR or HFS scenarios. Perceived stress was measured using the State-Trait Anxiety Inventory (STAI), the Medical Emotion Scale (MES), and the NASA Task Load Index (NASA-TLX). Physiological stress was assessed via heart rate variability standard deviation between successive N-N intervals (SDNN) and the low-frequency/high-frequency (LF/HF) ratio. Trainees' performance was assessed with the Ottawa Global Rating Scale. RESULTS:Among the 34 volunteers enrolled, both the VR and HFS groups demonstrated similar STAI, MES, and NASA-TLX scores following the scenarios. However, VR elicited lower SDNN values (mean difference, -12, 95% CI, -23 to -1.0, P=0.034), but not the LF/HF ratio. No difference was observed in stress indicators between high-performing and low-performing trainees. CONCLUSIONS:Anesthesia trainees experience comparable levels of perceived stress in the form of anxiety, emotional responses, and task load in VR and HFS scenarios. A lower heart rate variability during VR scenarios may indicate greater physiological stress. The relevance and implications of these findings in simulation require further clarification. STUDY REGISTRATION:ClinicalTrials.gov (NCT05041049).

Virtual reality (VR) may offer training advantages over mannequin-based high-fidelity simulation (HFS), but data are lacking. We sought to investigate whether VR is noninferior to HFS in teaching nontechnical skills to anesthesiology trainees. We conducted a sequential randomized controlled noninferiority trial to compare two simulation crisis management scenarios in 31 anesthesiology trainees. Scenario #1 was delivered either as a VR or as HFS. After 3 weeks, all participants underwent scenario #2, delivered only as HFS. We set a noninferiority margin of 0.6 for the overall improvement on the Ottawa Global Rating Scale (O-GRS), a crisis resource management scale, in scenario #2 between the two groups. As secondary outcomes, we compared changes in the Anaesthetists’ Non-technical Skills (ANTS) scale and the Managing Emergencies in Paediatric Anaesthesia Global Rating Scale (MEPA-GRS) between the two groups. We also evaluated the VR module using the VR Sickness Questionnaire (VRSQ), the System Usability Scale (SUS), the Technology Acceptance Model, and a feedback survey. During scenario #2, VR was noninferior to HFS regarding the overall O-GRS improvement (mean difference [upper bound 97.5 NCT05041049 ); first submitted 10 September 2021.

Extended reality, an umbrella term for virtual, augmented, and mixed reality, is increasingly used in health care education as it requires fewer human and logistical resources and offers reduced costs compared with high-fidelity simulations. Nevertheless, the impact of extended reality on education and training in anesthesiology is largely unknown. We aimed to explore the existing extended reality tools and applications in anesthesiology, identify current knowledge gaps, and highlight future research needs in anesthesiology education. We conducted a scoping review of studies published from January 2010 to December 2023 that focused on extended reality training in anesthesiology and included comparative analyses with other methods. We excluded publications investigating topics unrelated to anesthesiology or not involving interaction with extended reality. After screening 5,419 studies, we included 62 manuscripts in the final analysis. The definitions and uses of extended reality in anesthesiology education were very heterogeneous. Thirty-seven studies compared extended reality with other forms of training. Neuraxial procedures, peripheral blocks, central venous catheters, and bronchoscopy were primarily investigated. Extended reality improved technical skills, knowledge retention, confidence, and student satisfaction. Six studies reported at least one negative result related to learning, sense of realism, and usefulness. The results of this scoping review highlight the increasing interest of extended reality in anesthesiology education. Nevertheless, many studies lack objective outcome measures and relevant comparisons with existing standards. In addition, extended reality needs to be consistently defined in anesthesiology education to derive optimal benefit and impact. Future studies should also focus on defining extended reality's learning objectives and clinical assessments of trainees’ performance, which are commonly missing compared with high-fidelity simulation teaching. Open Science Framework ( https://doi.org/10.17605/OSF.IO/PDT2F ); first submitted 28 June 2023.

Background:Children commonly experience high levels of anxiety prior to surgery. This distress is associated with postoperative maladaptive behaviors. Virtual reality (VR) is an innovative tool for reducing anxiety and pain during various medical procedures. Previous randomized controlled trials have demonstrated its efficacy in reducing children's anxiety in the preoperative waiting room or during induction. Objective:The primary aim of this study was to examine the feasibility of VR distraction throughout the perioperative period, from the waiting room until the induction of general anesthesia (GA). Secondary aims were to assess its clinical utility, tolerability, and initial clinical efficacy. Methods:A mixed methods, concurrent triangulation feasibility trial was piloted at the Shriners Hospitals for Children-Canada. Participants played an interactive VR game throughout the perioperative period, starting from the waiting room until induction. Feasibility was examined with the duration of the VR intervention, recording the number of interruptions, and taking field notes. Clinical utility was assessed using a perception questionnaire. Tolerability was evaluated by the Child Simulator Sickness Questionnaire (CSSQ). Initial clinical efficacy was assessed by the Faces Pain Scale-Revised, Faces Anxiety Scale, Graphic Rating Scale for multidimensional pain, the Induction Compliance Checklist, and the Pediatric Anesthesia Emergence Delirium scale. Quantitative data were supported with field notes and semistructured interviews with patients and parents. Quantitative and qualitative themes were compared via the triangulation protocol to produce final themes. Results:A total of 39 patients, with a mean age of 11.9 (SD 2.8) years, undergoing elective surgery under GA participated in the study. Stakeholders, including patients, parents, and health care providers, were receptive and willing to adapt to VR. Of the 39 patients, 19 (49%) continued to use VR during transportation and 6 (15%) were induced with VR. Barriers to feasibility included (1) interruptions to VR in 92% (36/39) of patients by health care professionals, (2) unpredictable surgery delays prolonging the duration of the VR intervention (mean 23.1, SD 24.4 minutes; range 5-150 minutes), and (3) discontinuation of VR before induction due to mask seal (n=3) and discomfort with supine positioning (n=2). Patients were generally satisfied with VR, deemed it acceptable and easy to use, and would recommend it to others. VR was tolerable with no self-reported simulator sickness (CSSQ: mean 0.01, SD 0.1). The mean Faces Anxiety Score was 1.5 (SD 1.1) at baseline and 0.7 (SD 0.9) during VR. Conclusions:While VR demonstrated good clinical utility and was well tolerated in the broad perioperative setting, this study highlighted important feasibility barriers in the waiting room and especially during induction of anesthesia, both at the organizational and technical levels. This study highlights several considerations that should be carefully addressed for the successful implementation of perioperative VR.

Introduction: Congenital heart disease (CHD) is one of the most common birth defects. Cerebral (cStO2) and renal (rStO2) saturations measured by near-infrared spectroscopy (NIRS) and the corresponding fractional tissue oxygen extraction (FTOE) during the first week of life in neonates with CHD are described comparing those with and without diastolic steal. METHODS:Single-center prospective cohort study (Montreal Children's Hospital, Montreal, QC, Canada) was conducted, including neonates >34 weeks with CHD without chromosomal anomalies. CStO2/rStO2 was monitored from enrollment until day 7 of life. FTOE was calculated using systemic saturation (SpO2) as [SpO2 - (cStO2 or rStO2)]/SpO2. Daily echocardiography was performed during the monitoring period. Random mixed-effects models were constructed to assess the association between NIRS/FTOE and the presence of retrograde postductal aortic flow on last available echocardiography. RESULTS:Among 49 included neonates, 27 (55%) exhibited retrograde flow in the postductal aorta on the last day of monitoring. Prostaglandin exposure was 100% in the retrograde group vs. 27% in the non-retrograde group. CStO2/rStO2 progressively declined in neonates with CHD over the first week of life. Retrograde aortic flow was associated with negative cStO2 (β = -9.1%, 95% CI [-14.3; -3.8]) and rStO2 (β = -8.4%, 95% CI [-14.5; -2.3]). Cerebral FTOE was lower in the non-retrograde group, while renal FTOE was similar between groups. CONCLUSION:During the first week of life, neonates with CHD who displayed retrograde aortic flow exhibited lower cStO2 and rStO2 as well as higher cerebral FTOE. Future studies should evaluate whether these markers in neonates with CHD are modifiable factors that could influence cerebral or renal injury when addressed. .

BACKGROUND:Transition periods within surgical education are characterized by heightened stress and a sense of under-preparedness. We evaluated the self-reported knowledge and preparedness of new surgical residents for pediatric rotations, and the impact of a pediatric surgery fundamentals boot camp on the same. METHODS:An annual full-day pediatric surgery boot camp, consisting of didactic and interactive lectures, was created in 2020 as part of a 4-week surgical boot camp for new residents in general surgery, plastic surgery, neurosurgery, cardiac surgery, urology, orthopedics, otorhinolaryngology, maxillofacial surgery, and obstetrics and gynecology, delivered each July. The topics focused exclusively on pediatric surgical and anesthetic perioperative care. An anonymous on-line evaluation was completed by trainees in 2021, 2022, and 2023, assessing their baseline pediatric surgical preparedness, knowledge, and confidence, and the impact of the boot camp on these areas. RESULTS:Of 114 trainees who attended the boot camp over the three years, 79 (69 %) provided evaluations. Trainees characterized their baseline knowledge of perioperative management of pediatric patients as average (46, 58 %) or weak/very weak (31, 39 %). The program increased the confidence of 57 trainees (72 %) for starting their pediatric rotations and improved understanding of both pediatric surgical perioperative and anesthesia issues in 70 (89 %) and 65 (82 %) participants, respectively. A majority (69, 87 %) concurred that the course significantly justified the time invested. CONCLUSION:New surgical trainees report baseline weak to average levels of knowledge of perioperative pediatric surgical care. A pediatric surgery fundamentals boot camp was well received by trainees, and substantially improved their self-reported knowledge and readiness.

OBJECTIVES:To describe the incidence and survival of extracorporeal membrane oxygenation (ECMO) deployment in the operating room (OR) for failure to wean from cardiopulmonary bypass (CPB) after surgery for congenital heart disease (CHD). DESIGN:Retrospective, quaternary children's hospital. PARTICIPANTS:Children supported with ECMO in the OR after cardiac surgery during the 2000 to 2023 period. MEASUREMENTS AND MAIN RESULTS:In total, 123 children (0.8% of cardiac surgical cases in the study period) had ECMO initiated in the OR. Children supported with ECMO in the OR had a median age of 1.6 months (interquartile range [IQR], 0.2-10.0) and underwent complex cardiac surgery (Risk Adjustment in Cardiac Surgery 1, categories 3-6 [N = 108; 88%]). Seventy-seven patients (63%) had 2-ventricle circulation, 38 patients (31%) had single-ventricle circulation, and 8 (5%) patients had cavopulmonary circulation. The median CPB time was 253 minutes (IQR, 188-348) with an aortic cross-clamp time of 109 minutes (IQR, 71-172). ECMO duration for all patients was 5 days (IQR, 3-9). Sixty-one patients (50%) underwent cardiac catheterization, and 41 patients (34%) required surgery while on ECMO. Bleeding was common in all patients on ECMO. There were cardiac complications in 21% and neurologic complications in 24%. Eleven patients (9%) needed a heart transplant or transition to a ventricular assist device. Fifty-five (45%) of the patients survived to discharge. CONCLUSION:While ECMO continues to be a life-saving intervention, children requiring ECMO in the OR after cardiac surgery for CHD face high mortality. The need for prolonged ECMO support, suggesting irreversible myocardial failure and neurologic injury, is associated with increased mortality.

Neonates with congenital heart disease (CHD) are at high risk for systemic steal, hypoperfusion, and organ dysfunction due to abnormal cardiac anatomy and persistent shunts. Understanding these physiological changes is crucial for optimizing management strategies and improving outcomes. To evaluate longitudinal ultrasonographic (US) estimators of systemic blood flow during the postnatal transition in neonates with CHD using Doppler measurements of the aorta (Ao) during the first week of life. This prospective observational single-center study recruited neonates born at ≥34 weeks' gestation between 2018 and 2021 with CHD requiring NICU admission. Infants with significant genetic anomalies were excluded. Daily Aortic (Ao) ultrasounds were performed until day 7 of life, discharge, or cardiac intervention. Pulse-wave Doppler measurements were obtained from the suprasternal (ascending, preductal and postductal descending Ao) and subcostal views (postductal Ao). Key measurements included velocity-time integral (VTI), peak systolic velocity (PSV), end-diastolic velocity (EDV), and mean velocity (VM). Temporal changes and associations with retrograde flow were analyzed using mixed-effects models to assess systemic blood flow dynamics during the postnatal transition. Of the 62 enrolled neonates, data from 22 were analyzed (work in progress). CHD types in this cohort are detailed in Table 1. Over the first week, heart rate significantly increased (Table 2). VTI at the ascending aorta increased over time (β = 0.004, p = 0.03), and VM increased at both the ascending (β = 0.02, p = 0.009) and preductal sites (β = 0.02, p = 0.009), suggesting compensatory mechanisms to maintain cerebral perfusion (while PVR is dropping). Retrograde flow was linked to significant HR increases (Table 2) and VM decreases at the subcostal (β = –0.12, p = 0.02) and postductal sites (β = –0.2, p < 0.001). EDV at the subcostal site became more negative with retrograde flow (β = –0.19, p = 0.005). Preliminary data suggest neonates with CHD undergo significant hemodynamic changes during the early postnatal period, including increased HR and differencial flow velocity time evolution in pre and post ductal Aorta, reflecting compensatory mechanisms for maintaining cerebral and systemic perfusion. These findings emphasize the value of hemodynamic monitoring to provide real-time insights not always evident through standard assessments, aiding in optimizing clinical management.

Introduction: The aim of the study was to explore the relationship between near-infrared spectroscopy parameters (cerebral saturation [CSat] and corresponding cerebral fractional tissue oxygen extraction [cFTOE]) with resistive (RI) and pulsatility indices (PI) of the anterior cerebral artery (ACA) obtained simultaneously in neonates with congenital heart defect (CHD) during the first week of life. METHODS:Prospective observational study on neonates ≥35 weeks with CHD was conducted. Cerebral FTOE was based on concomitant pre-ductal oxygen saturation (SpO2) during CSat measurement. ACA was assessed via Doppler ultrasound (US). Continuous CSat/SpO2 monitoring was collected during the first week of life. Daily ACA Doppler was obtained from day 1-7. RESULTS:A total of 142 concomitant measurements of NIRS and US parameters during the first week of life were collected in 34 neonates with various CHD. Mixed effect models showed significant association between CSat/cFTOE and time-corresponding RI-ACA (p = 0.02 and 0.005) and PI-ACA (p = 0.006 and 0.002), respectively. A 0.1-point increase in RI was associated to a 2.3% decrease in CSat and a 3-point increase in cFTOE. A 0.1-point increase in PI was associated to a 0.9% decrease in CSat and 1.1-point increase in cFTOE. CONCLUSIONS:In neonates with CHD during their first week of life, lower CSat and higher cerebral FTOE were associated with elevated RI and PI values of the ACA obtained simultaneously. Future research should assess whether a multimodal bedside approach to monitoring cerebrovascular hemodynamics can facilitate early detection of cerebral hypoperfusion and prevent brain injury, as well as adverse neurodevelopmental outcomes in this vulnerable population. .

Children recovering from anesthesia commonly experience early postoperative negative behaviour, caused by pain and emergence delirium. Differentiating the two is challenging in young children. Perioperative pain influences the heart rate variability-derived Newborn Infant Parasympathetic Evaluation (NIPE) index and may also affect emergence delirium. We sought to investigate whether the perioperative NIPE index can discriminate between mild, moderate, or severe pain levels and can detect emergence delirium. This prospective observational study enrolled children aged three years or younger undergoing elective adenotonsillectomy, tonsillectomy, or adenoidectomy. The NIPE index, the Faces, Legs, Activity, Cry, Consolability (FLACC) score, and the Pediatric Anesthesia Emergence Delirium (PAED) score were recorded in the postanesthesia care unit (PACU). The primary aim was to investigate the relationship between the postoperative NIPE index and postoperative pain severity. The secondary aims were to evaluate the association between the NIPE index and emergence delirium (PAED ≥ 10) and its delirium-specific (ED-I) and pain-specific (ED-II) components. Sixty-nine children were recruited. In the PACU, the mean (standard deviation [SD]) NIPE values in children experiencing moderate and severe pain were 50 (12) and 49 (14), respectively. These values were significantly lower than the mean (SD) value of 64 (13) observed in children with mild pain (mean difference moderate vs no/mild pain, −14; 95 NCT04909060 ); first submitted 26 May 2021.

The authors have no conflict of interest to declare. Data sharing is not applicable for this article as no new data were created or analyzed in this study.

Portable ultrasound has resulted in the creation of clinical protocols for rapid bedside diagnosis and interventions, commonly referred to as point-of-care ultrasound (POCUS). In pediatric perioperative care, POCUS allows evaluation of basic physiological functions and assessment of the clinical patient status. The majority of critical incidences in pediatric anesthesia are airway-related, but the role of ultrasound in pediatric airway management has not yet been fully explored. This narrative review discusses a structured airway examination to facilitate pediatric airway management. In addition, it explores how ultrasound examinations can be implemented into a pediatric airway POCUS algorithm.