OBJECTIVES:Prolonged pleural effusion/chylothorax (PPE/C) is a less investigated complication following paediatric cardiac surgery, and its true incidence, risk factors and impact on postoperative outcomes are not well described. We aim to address these gaps in knowledge using data from a prospective, multicentre study. METHODS:Data on 9 post-operative morbidities (unplanned reinterventions, extracorporeal life support, necrotising enterocolitis, PPE/C, renal replacement therapy, major adverse events, acute neurological events, feeding issues and postsurgical infection) were prospectively collected at 5 UK centres between 2015 and 2017, following paediatric cardiac surgery. Incidence of PPE/C, associations with procedure types, and risk factors were described. Mortality (30-day and 6-month) and hospital length of stay (HLoS) were compared between those with isolated PPE/C, single non-PPE/C morbidity, no morbidity, multimorbidity PPE/C and non-PPE/C multimorbidity. RESULTS:A total of 3090 procedures (2861 patients) were included (median age, 228 days). There were 202 PPE/C (incidence of 6.5%), occurring at a median of 6 days postoperatively (interquartile range: 3-10). PPE/C was associated with excess early mortality only when complicating scenarios where at least 2 other post-operative morbidities occurred. On average PPE/C is associated with 8 more HLoS days, but the relative impact is greatest when comparing isolated PPE/C with no morbidity (P < 0.001), whereas in multimorbidity scenarios, PPE/C does not significantly contribute to an increase of HLoS. CONCLUSIONS:Addition of PPE/C increases mortality but not HLoS in multimorbidity and HLoS only in single morbidity scenarios. This reinforces the important role of prevention, early detection and management of PPE/C in complex situations.

We previously selected and defined nine important post-operative morbidities linked to paediatric cardiac surgery, and prospectively measured their incidence following 3090 consecutive operations. Our aim was to study the impact of these morbidities on family functioning and parental quality of life over 6 months in a subset of cases. As part of a prospective case matched study in five of the ten children’s cardiac centers in the UK, we compared outcomes for parents of children who had a ‘single morbidity’, ‘multiple morbidities’, ‘extracorporeal life support (ECLS)’ or ‘no morbidity’. Outcomes were evaluated using the PedsQL Family impact module (FIM) at 6 weeks and 6 months post-surgery. Outcomes were modelled using mixed effects regression, with adjustment for case mix and clustering within centers. We recruited 340 patients with morbidity (60% of eligible patients) and 326 with no morbidity over 21 months. In comparison to the reference group of ‘no morbidity’, after adjustment for case mix, at 6 weeks parent health-related quality of life (HRQoL) and total FIM sores were lower (worse) only for ECLS ( p < 0.005), although a higher proportion of parents in both the ECLS and multi-morbidity groups had low/very low scores ( p < .05). At 6 months, parent outcomes had improved for all groups but parent HRQoL and total score for ECLS remained lower than the ‘no morbidity’ group ( p < .05) and a higher proportion of families had low or very low scores in the ECLS (70%) group ( p < .01). Post-operative morbidities impact parent HRQoL and aspects of family functioning early after surgery, with this impact lessening by 6 months. Families of children who experience post-operative morbidities should be offered timely psychological support.

The set of guidelines for good clinical research practice in pharmacodynamic studies of neuromuscular blocking agents was developed following an international consensus conference in Copenhagen in 1996 (Viby-Mogensen et al., Acta Anaesthesiol Scand 1996, 40, 59-74); the guidelines were later revised and updated following the second consensus conference in Stockholm in 2005 (Fuchs-Buder et al., Acta Anaesthesiol Scand 2007, 51, 789-808). In view of new devices and further development of monitoring technologies that emerged since then, (e.g., electromyography, three-dimensional acceleromyography, kinemyography) as well as novel compounds (e.g., sugammadex) a review and update of these recommendations became necessary. The intent of these revised guidelines is to continue to help clinical researchers to conduct high-quality work and advance the field by enhancing the standards, consistency, and comparability of clinical studies. There is growing awareness of the importance of consensus-based reporting standards in clinical trials and observational studies. Such global initiatives are necessary in order to minimize heterogeneous and inadequate data reporting and to improve clarity and comparability between different studies and study cohorts. Variations in definitions of endpoints or outcome variables can introduce confusion and difficulties in interpretation of data, but more importantly, it may preclude building of an adequate body of evidence to achieve reliable conclusions and recommendations. Clinical research in neuromuscular pharmacology and physiology is no exception.

From the Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh School of Medicine, University of Pittsburgh Medical Center Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania. Accepted for publication May 21, 2021. Funding: None. The authors declare no conflicts of interest. K. Nguyen and P. J. Davis contributed equally to the study. Reprints will not be available from the authors. Address correspondence to Peter J. Davis, MD, Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh School of Medicine, UPMC Children’s Hospital of Pittsburgh, 4401 Penn Ave, Suite 5643, Pittsburgh, PA 15224. Address e-mail to [email protected].

Background. Most children now survive cardiac surgery, and the focus of quality improvement initiatives has shifted toward more complex outcome measures. The aim of this investigation was to study the impact of early postoperative morbidities on parent-reported patient quality of life and parental anxiety or depression over 6 months. Methods. This prospective case-matched cohort study was conducted in 5 UK children's cardiac centers. Measures of impact for patient categories of "single morbidity," "multiple morbidities," and "extracorporeal life support (ECLS)" were compared with "no morbidity." The measures used were the Pediatric Quality of Life Inventory (PedsQL) and the 4-item Patient Health Questionnaire (PHQ-4) at 6 weeks and 6 months postoperatively. The study modeled the outcomes using mixed effects regression, adjusting for case mix and clustering within centers. Results. The study included 666 patients who underwent operation at a median age of 81 days (interquartile range, 10 to 325 days). At 6-week follow-up, significant adjusted differences to the reference group with no morbidity were found for total PedsQL scores, which were lower in patients with ECLS (P [.01), multiple morbidities (P <.001), and a single morbidity (P[.04), as well as the proportion of parents with anxiety and depression, which were higher in the group with multiple morbidities (P [.04 and P [.01, respectively). At 6 months, measures had improved in all morbidity groups. The only significant adjusted difference in the reference group was for physical PedsQL scores in ECLS (P [.04) and multiple morbidities (P <.01). Conclusions. Patient and parent well-being are strongly influenced by postoperative morbidities early after surgery, with improvement by 6 months. Family psychological support and holistic rehabilitation are vital for children who experience postoperative morbidities. (C) 2021 by The Society of Thoracic Surgeons.

Background Rapid reviews (RRs) and safety huddles were introduced in a tertiary children’s hospital in 2017 in order to improve the rapid assessment and expectant management of unwell patients across the hospital and prevent unrecognised deterioration on the wards. RRs gather an experienced team of clinicians (PICU and high dependency registrars and critical care outreach team) together at the bedside of a child felt to be deteriorating or at risk of deterioration if not reviewed. Clinicians should attend within 15 minutes, an ongoing plan must be agreed upon and documented following assessment, and a high dependency or paediatric intensive care consultant is informed about every call. Hospital wide data was collected in both 2018 and 2019 looking in detail at RR calls made, and any effect of these measures on unplanned admissions to Paediatric Intensive Care Unit (PICU) as part of a Trust wide patient safety initiative. Primary: Examine rates, outcomes and overall trends of RRs in 2019 Review unplanned PICU admissions and their involvement in the RR process Comparison of 2018 and 2019 data after presentation of 2018 findings Secondary: Identification of opportunities for quality improvement in the RR process and local paperwork. Methods All unplanned admissions to PICU were identified through the PICAnet database, and RR calls were identified through local switchboard and Datix submission data. Data was collected from electronic notes looking at timings of calls, locations, and subsequent escalation of care. Unplanned PICU admissions were reviewed looking at eventual outcome and whether there had been rapid review calls or emergency calls prior to admission to intensive care. Results Documentation of RR calls improved between 2018 and 2019. There were no documented cardiac arrests on the ward outside of PICU in 2019. Number of RR calls peaked in November in both years studied. Larger proportion of RR calls in 2019 were made from HDU areas compared with 2018 As expected, the majority of RR calls were made out of hours. Larger proportion of RR calls in 2019 remained on the ward compared with 2018 – suggesting improved awareness of their early use in preventing emergency PICU/HDU admissions. 9% of unplanned PICU admissions in 2019 were not preceded by a RR or MET call- the majority of these occurring after direct consultant discussion in hours with a RR not required for appropriate escalation. Conclusions Since their introduction, RR calls have become ingrained within the hospital and awareness of their use has risen. The number of calls increased from 2018 to 2019 with higher proportion of patients able to remain in a ward or HDU environment following RR. A number of changes to the RR paperwork were actioned as a result of the project to make outcomes of the reviews and ongoing plans clearer and easier to identify in the notes. We recommend ongoing audit of RR activity to continue to assess their impact on patient care and associated rates of unplanned PICU admissions within the hospital.

Background Deaths in children and young people (CYP) following SARS-CoV-2 infection are rare. Quantifying the risk of mortality is challenging because of high relative prevalence of asymptomatic and non-specific disease manifestations. Therefore, it is important to differentiate between CYP who have died of SARS-CoV-2 and those who have died of an alternative disease process but coincidentally tested positive. Methods During the pandemic, the mandatory National Child Mortality Database (NCMD) was linked to Public Health England (PHE) testing data to identify CYP (<18 years) who died with a positive SARS-CoV-2 test. A clinical review of all deaths from March 2020 to February 2021 was undertaken to differentiate between those who died of SARS-CoV-2 infection and those who died of an alternative cause but coincidentally tested positive. Then, using linkage to national hospital admission data, demographic and comorbidity details of CYP who died of SARS-CoV-2 were compared to all other deaths. Absolute risk of death was estimated where denominator data were available. Findings 3105 CYP died from all causes during the first pandemic year in England. 61 of these deaths occurred in CYP who tested positive for SARS-CoV-2. 25 CYP died of SARS-CoV-2 infection; 22 from acute infection and three from PIMS-TS. 99.995% of CYP with a positive SARS-CoV-2 test survived. The 25 CYP who died of SARS-CoV-2 equates to a mortality rate of 2/million for the 12,023,568 CYP living in England. CYP >10 years, of Asian and Black ethnic backgrounds, and with comorbidities were over-represented compared to other children. Interpretation SARS-CoV-2 is very rarely fatal in CYP, even among those with underlying comorbidities. These findings are important to guide families, clinicians and policy makers about future shielding and vaccination.

Introduction Even though respiratory support is a common intervention in paediatric critical care, there is no randomised controlled trial (RCT) evidence regarding the effectiveness of two commonly used modes of non-invasive respiratory support (NRS), continuous positive airway pressure (CPAP) and high-flow nasal cannula therapy (HFNC). FIRST-line support for assistance in breathing in children is a master protocol of two pragmatic non-inferiority RCTs to evaluate the clinical and cost-effectiveness of HFNC (compared with CPAP) as the first-line mode of support in critically ill children. Methods and analysis We will recruit participants over a 30-month period at 25 UK paediatric critical care units (paediatric intensive care units/high-dependency units). Patients are eligible if admitted/accepted for admission, aged >36 weeks corrected gestational age and <16 years, and assessed by the treating clinician to require NRS for an acute illness (step-up RCT) or within 72 hours of extubation following a period of invasive ventilation (step-down RCT). Due to the emergency nature of the treatment, written informed consent will be deferred to after randomisation. Randomisation will occur 1:1 to CPAP or HFNC, stratified by site and age (<12 vs ≥12 months). The primary outcome is time to liberation from respiratory support for a continuous period of 48 hours. A total sample size of 600 patients in each RCT will provide 90% power with a type I error rate of 2.5% (one sided) to exclude the prespecified non-inferiority margin of HR of 0.75. Primary analyses will be undertaken separately in each RCT in both the intention-to-treat and per-protocol populations. Ethics and dissemination This master protocol received favourable ethical opinion from National Health Service East of England—Cambridge South Research Ethics Committee (reference: 19/EE/0185) and approval from the Health Research Authority (reference: 260536). Results will be disseminated via publications in peer-reviewed medical journals and presentations at national and international conferences. Trial registration number ISRCTN60048867

This paper reviews the past 50 years of liver transplantation in children from the perspective of patient demographics, perioperative patient management, surgical techniques, immunosuppression and patient outcomes.

Purpose of review Over the last 3 years and for the first time in 60 years, life expectancy in the United States has declined across all racial groups primarily because of drug overdoses, alcohol abuse, and suicide. A public health response to the opioid crisis must expand its focus to more broadly include children, adolescents, and young adults while increasing efforts toward preventing new cases of opioid addiction, early identification of individuals with opioid-abuse disorder, and ensuring access to effective opioid addiction treatment, while simultaneously continuing to safely meet the needs of patients experiencing pain. Recent findings Although a multimodal approach to pain management is fundamental in current practice, opioids remain an essential building block in the management of acute and chronic pain and have been for over 5000 years as they work. Left over, unconsumed opioids that were appropriately prescribed for pain have become the gateway for the development of opioid use disorder, particularly in the vulnerable adolescents and young adult patient populations. How to reduce the amount of opioids dispensed, improve methods of disposal in an environmentally safe way, and proactively make naloxone, particularly nasal spray, readily available to patients (and their families) receiving prescription opioids or who are at risk of opioid use disorder are highlighted in this review. We describe the historical use of opioids and the scope of the current opioid crisis, review the differences between dependence and addiction, and the private and public sectors response to pain management and highlight the issue of adolescent vulnerability. We conclude with a proposal for future directions that address both public and patient health needs.

Purpose of review Over the last 3 years and for the first time in 60 years, life expectancy in the United States has declined across all racial groups primarily because of drug overdoses, alcohol abuse, and suicide. A public health response to the opioid crisis must expand its focus to more broadly include children, adolescents, and young adults while increasing efforts toward preventing new cases of opioid addiction, early identification of individuals with opioid-abuse disorder, and ensuring access to effective opioid addiction treatment, while simultaneously continuing to safely meet the needs of patients experiencing pain. Recent findings Although a multimodal approach to pain management is fundamental in current practice, opioids remain an essential building block in the management of acute and chronic pain and have been for over 5000 years as they work. Left over, unconsumed opioids that were appropriately prescribed for pain have become the gateway for the development of opioid use disorder, particularly in the vulnerable adolescents and young adult patient populations. How to reduce the amount of opioids dispensed, improve methods of disposal in an environmentally safe way, and proactively make naloxone, particularly nasal spray, readily available to patients (and their families) receiving prescription opioids or who are at risk of opioid use disorder are highlighted in this review. Summary We describe the historical use of opioids and the scope of the current opioid crisis, review the differences between dependence and addiction, and the private and public sectors response to pain management and highlight the issue of adolescent vulnerability. We conclude with a proposal for future directions that address both public and patient health needs.

Comprehensive assessment of a physician workforce can help identify emerging challenges in the marketplace and strategically prepare an organization for change. Effective allocation of a physician workforce can also increase efficiency, productivity, and effectiveness by ensuring that there is an adequate supply of physicians with the skills, knowledge, and experience required to achieve their strategic objectives. Workforce assessment is a particularly challenging exercise in subspecialty areas of medicine such as pediatric anesthesiology. Muffly et al1,2 have embraced this challenge in previous publications, and in this issue of Anesthesia & Analgesia, they add to our understanding of the pediatric anesthesiology workforce with an analysis of the shifting landscape of inpatient perioperative pediatric care in California over a 16-year period. In the United States, pediatric care occurs in a variety of settings that are associated with general hospitals (GH) and children’s hospitals (tertiary care children’s hospitals, children’s units within [GH], general [adult] hospitals, and ambulatory surgery centers). The authors sought to describe inpatient surgery demographics in children 5 years old or younger. Historically, low complexity procedures in children were as likely to occur in adult GH as they were in pediatric tertiary care centers.3 This pattern appears to be evolving. The authors documented that for 20 of the most common inpatient pediatric surgical procedures, volume appears to be shifting to pediatric tertiary care facilities for both complex and simple procedures. Importantly, while procedural volume is increasing in the tertiary care centers, overall inpatient pediatric procedural volume is declining statewide. This shift is occurring ahead of the American College of Surgeons Children’s Surgical Verification (ACS CSV) Quality Improvement Program which defines the resources required of a medical center to provide a specific complexity of pediatric care. The information in this study has potentially important implications for the pediatric anesthesiology workforce and for pediatric anesthesiology education. To put the authors’ current findings into context, it is important to appreciate their previous study on the determinants of pediatric anesthesiology workforce supply and demand. The primary supply of pediatric anesthesiologists is the number of fellow graduates produced from US fellowships. The current rate is approximately 220 fellows per year. This has increased significantly over the past 20 years. The authors predicted that there will be a 50% increase in the number of pediatric anesthesiologists by 20354 if we continue on our current path of increasing the number of fellows trained every year. Even if the number of graduating fellows is held constant, growth of pediatric anesthesiology workforce will continue because the per annum number of retiring anesthesiologists is smaller than the number of new graduates added to the workforce. As it stands now, these data suggest that we may be training too many pediatric anesthesiologists. However, there are other important determinants of supply that complicate the picture. Fullor part-time practice patterns of pediatric anesthesiologists will Hospitalization Patterns for Inpatient Pediatric Surgery and Procedures in California: The Ground Is Shifting

Background The FIRST-ABC trial comprises of two pragmatic, multicentre, parallel groups, non-inferiority randomised clinical trials designed to evaluate the clinical non-inferiority of first-line use of high flow nasal cannula (HFNC) to continuous positive airway pressure (CPAP) in critically ill children who require non-invasive respiratory support (NRS). Objectives To describe the pre-specified statistical and health economic analysis for the FIRST-ABC trial before completion of patient recruitment and data collection. Methods The statistical analysis plan was designed by the chief investigators and statisticians. We define the primary and secondary outcomes, summarise methods for data collection and safety monitoring, and present a detailed description of the planned statistical and health economic analysis. Results The primary clinical outcome is time to liberation from respiratory support. The primary effect estimate will be the adjusted hazard ratio, reported with a 95% confidence interval. As a sensitivity analysis, the primary analysis will be repeated using time to start weaning of NRS. Subgroup analyses will be performed to test for interactions between the effect of allocated treatment group and pre-specified baseline covariates. The health economic analysis will follow the intention-to-treat principle and report the mean (95% confidence interval) incremental costs, quality-adjusted life years (QALYs) and cost-effectiveness up to 6 months. All analyses will be performed separately for each of the two trials, and any results will not be combined. Conclusion The FIRST-ABC trial will assess the non-inferiority of HFNC compared to CPAP in two parallel trials with shared infrastructure (step-up RCT and step-down RCT). We have developed a pre-specified statistical and health economics analysis plan for the FIRST-ABC study before trial completion to minimise analytical bias. Trial registration ISRCTN ISRCTN60048867 . Registered on 19 June 2019.

See Article, p 469 This month, the Pediatric Difficult Intubation (PeDI) Collaborative brings us its latest article discussing the management of difficult pediatric airways.1 The PeDI registry is an international, multicenter registry created in 2012 by the Society for Pediatric Anesthesia special interest group now called the PeDI Collaborative. Difficult tracheal intubations are rare in pediatric anesthesia practice. Previous data from the PeDI collaborative suggest that approximately 2–5 in 1000 intubations are difficult, with 80% of those anticipated in advance.2 The Anesthesia PRactice In Children Observational Trial (APRICOT), a prospective study involving more than 30,000 anesthetics over a 2-week period performed at 261 institutions from 33 countries with well-defined criteria for difficult laryngoscopy and intubation and supraglottic airway (SGA) insertion, found the incidence of failed intubation and SGA insertion was 8 out of 10,000 and 8.2 out of 10,000, respectively.3 In a previous PeDI registry publication, on more than 1000 patients with known difficult airways, a significant 2% intubation failure rate was noted, with 20% having at least 1 complication and 2% having a cardiac arrest.2 In addition to quantifying the incidence of difficult airway, these articles have also shed light on the pediatric risk factors associated with complications, namely, >2 tracheal intubation attempts, weight <10 kg, micrognathia, and 3 direct laryngoscopy attempts before switching to an indirect method.2,3 What is not known is the impact of anesthetic agents and ventilation method on the rate and type of complications. Standard wisdom in the management of any difficult airway is to ensure air movement, whether spontaneous ventilation by the patient or effective bag-mask/SGA ventilation. Previously, there was no objective evidence supporting a superior strategy; management choices are based on individual or local experience and opinion, and for the most part, the use of a neuromuscular blocking drug (NMBD) in the management of the difficult airway is controversial. If one ultimately needs to cross the river or return safely to shore, burning the bridge (in the case of airway management, administering an NMBD) intuitively seems questionable. The study by Garcia-Marcinkiewicz et al1 from the PeDI Collaborative, “A Retrospective Analysis of Neuromuscular Blocking Drug Use and Ventilation Technique on Complications in the Pedi Registry Using Propensity Score Matching,” appearing in this issue of the Journal, evaluates the effect of spontaneous versus controlled ventilation on airway management and complications in children with known difficult airways.1 This study provides some evidence to help guide decision-making for pediatric patients with known difficult airways, but the findings of the article also pose additional questions. The present study represents data from 16 institutions: 1289 intubations of children ≤18 years of age with anticipated difficult intubation, mask ventilation, or both. Spontaneous ventilation was used to manage 507 of the intubations, 453 involved controlled ventilation with an NMBD, and 329 were managed with controlled ventilation without an NMBD. The study reports an overall complication rate of 18.8%, with 16.9% and 1.9% nonsevere and severe complications, respectively. Although the incidence of severe complications was similar among all groups, when corrected for confounding factors, patients managed with spontaneous ventilation had greater odds of complications (odds ratio [OR], 2.07, 95%, CI, 1.36–3.15, P = .001, n = 770) than those managed with controlled ventilation. However, when adjusting for airway reactivity, this difference disappeared. Although spontaneous ventilation is traditionally viewed as a lifeline for patients with difficult airways, the preservation of spontaneous ventilation may make intubation more difficult. In a recent meta-analysis of patients >14 years of age, Lundstrøm et al4 reported that avoiding an NMBD was associated with an increased risk of upper airway discomfort (risk ratio [RR] = 1.37, 95% CI, 1.09–1.74, P = .008, Trial Sequential Analysis [TSA]--adjusted CI, 1.00–1.86) and difficult laryngoscopy (RR = 2.54, 95% CI, 1.53–4.21, P = .0003, TSA-adjusted CI, 0.27–21.75) compared with patients intubated without the benefit of an NMBD. However, the role neuromuscular blocking agents play in pediatric patients with difficult airways has not yet been assessed. It is not clear how generalizable and relevant the concept of administering NMBDs to pediatric patients with difficult airways is in view of the wide variability of pediatric diseases and syndromes that underlie and/or affect the pediatric difficult airway. In addition, the real possibility of converting a spontaneous ventilating patient into one who cannot be intubated or ventilated would make a bad situation worse with no possibility of recovery other than escalation to a surgical airway. The current article suggests that there may be a benefit to using NMBDs for some of these patients, and that an adequate depth of anesthesia is an important principle in the management of these challenging cases. However, an acknowledged shortcoming of the paper was that the database was not robust enough to ascertain why a particular ventilation strategy was chosen for a given patient, what anesthetic technique (inhalational anesthesia versus total intravenous anesthesia) was used, and whether sugammadex was available. How the anesthesiologist approaches the airway depends on a number of factors, including patient disease, previous successful and unsuccessful intubation attempts from previous anesthetics, available equipment and drugs, physician experience and comfort with a given tool or technique, and availability of backup. The authors included propensity score matching in their analysis; nonetheless, the choice of spontaneous ventilation for airway management by a particular physician may itself be a marker of anticipated degree of difficulty. Equally important in their findings was that when airway reactivity was adjusted for, the increase in complications with spontaneous ventilation disappeared. Airway reactivity is a known risk factor for pediatric perioperative respiratory events.5 Airway reactivity is an ever-present danger when managing pediatric airways. The registry cannot delineate how the anesthetics were managed, what agents were used, or how adequate depth of anesthesia was assured and maintained both during and between intubation attempts, which limits some of the findings. It may be that certain agents or combinations thereof perform better than others to suppress airway reflexes while maintaining respiratory drive. Certainly, as the authors conclude, ensuring adequate depth of anesthesia to safely manage the airway and maintain hemodynamic stability is critical for patient safety. The main value of the current article by Garcia-Marcinkiewicz et al1 is that it reinforces previous concepts regarding the difficult pediatric airway, namely utilizing indirect intubation techniques, minimizing the use of direct laryngoscopy in pediatric patients with known difficult airways, and minimizing the number of attempts to secure the airway. It may be that as anesthesiologists focus on the technical aspects of airway management, maintenance of sufficient anesthetic depth is deprioritized. This article also calls into question the utility of NMBDs in securing the pediatric difficult airway. Conventional wisdom suggests that one should never burn bridges, especially in airway management. Although burning the airway bridge may be unsettling, especially if the spontaneously ventilated patient may become a “cannot-intubate, cannot-ventilate” patient, there may be a safety net, as evidenced by the case report by Wołoszczuk-Gębicka et al6 on the use of sugammadex as a rescue drug in 2 pediatric patients.6 Important lessons can be learned from this article as well as the previous articles of the PeDI Collaborative. Teaching trainees that successful and safe airway management is very much coupled with the adequacy of anesthetic depth, along with techniques for administration and titration of intravenous and inhalational anesthesia to levels that both maintain spontaneous ventilation and allow airway instrumentation is as essential as learning the mechanical skill of securing the airway. Reinforcing the concept that repetitive direct laryngoscopy leads to complications is also critical. Instituting early, indirect laryngoscopy and not repeating the same failed techniques cannot be overstated. Finally, NMBDs may play a role in patients who can be ventilated to possibly decrease reactivity-related complications. NMBDs might be incorporated into the difficult airway algorithm for this specific situation in which burning the bridge may indeed help successfully cross the river. DISCLOSURES Name: K. Karisa Walker, MD, MEd. Contribution: This author helped write and edit the article. Conflicts of Interest: None. Name: Peter J. Davis, MD. Contribution: This author helped write and edit the article. Conflicts of Interest: P. J. Davis is a consultant for Octapharma. This manuscript was handled by: James A. DiNardo, MD, FAAP.

Background The 5-year survival for pediatric acute lymphoblastic leukemia (ALL) is greater than 90%. One late effect of pediatric ALL associated with numerous long-term difficulties is neurocognitive deficits. The experience at our institution, as well as conversations with oncologists at other institutions, suggests an increase in the use of sedation during lumbar punctures (LPs) for treatment of pediatric ALL. Among the most common Children's Oncology Group (COG) ALL protocols, approximately 30 LPs are performed over 2-3 years. Studies in animals reveal that sedation drugs may harm the developing brain. Gaps in knowledge exist regarding their use in children, particularly repeated exposures. The purpose of this study is to summarize sedation practices for LPs related to the treatment of ALL at COG institutions. Methods Responsible Individuals (RIs) of the Cancer Control Committee of COG were invited to complete an internet-based survey about sedation practices at their institutions. Results Surveys were sent to 103 RIs with a 62% response rate (N = 64). A combined 2018 new patients with ALL were seen each year (mean = 31.5, range = 3-110) at the participating institutions. The majority (96%) of children with ALL received sedation for LPs. While there was considerable variability across institutions in the type of sedation given, the most common was propofol alone (n = 36, 56%). Conclusions A substantial number of children with ALL receive sedation for LPs; however, there is variation in the medication used. Better understanding of sedation practices in children with ALL may inform future research to investigate which methods are the safest, with an emphasis on long-term neurocognitive late effects.

Over the past 50 years, the specialty of anesthesiology has spawned 4 entirely new branches of medicine: critical care medicine; pain medicine; quality and safety medicine; and simulation-based medical education. During this same time period, the specialty evolved into recognized subspecialties, and the American Board of Anesthesiology began offering subspecialty certification in 5 fields: pediatrics; critical care; pain; sleep; and hospice and palliative medicine. Pediatric critical care medicine, initially a subspecialty of pediatric anesthesia, was born, like its adult counterparts, from the practice of anesthesiology in the 1970s.1,2 Initially modeled as an extension of the postoperative recovery room, early pediatric intensive care units, like adult surgical intensive care units, were staffed by anesthesiologists for surgical patients, and were designed to support patients with failing ventilation and to provide continuous vital sign monitoring.2,3 The role of anesthesiologists was logical and practical: they ran the postanesthesia care units and were the recognized experts in resuscitation, intubation, airway management, and mechanical ventilation. Over time, these first pediatric intensive care units increasingly cared for medical as well as surgical patients. Consequently, the background and number of intensivists staffing these units dramatically shifted. Pediatric intensive care unit attending physicians and leadership roles in pediatric critical care medicine became dominated by board-certified pediatricians and pediatric subspecialists. Indeed, today, as described in the current issue,4 American pediatric critical care anesthesiologists are an endangered, vanishing species, overshadowed in pediatric intensive care units by pediatric subspecialists (cardiologists and intensivists). How did we get here? Is this situation salvageable, or are we like the woolly mammoth, on the road to, or already at the point of, extinction? And more significantly for the specialty, why is this concern important? In the early 1980s, an attempt was made to form a conjoint Board of Critical Care Medicine representing anesthesiology, internal medicine, surgery, and pediatrics.1,3,5 Unfortunately, the component boards could not agree on training qualifications, and the initiative failed. By 1986, each of the specialty boards created their own training criteria and separate certification examinations, with the only common denominator being a minimum of 5 years of postgraduate training. Thus, the American Board of Anesthesiology, which has a 4-year residency requirement, mandated only 1 year of additional training in critical care medicine. On the other hand, the American Board of Pediatrics, which has a 3-year residency training requirement, exceeded the agreed-upon 5 years of postgraduate training. The American Board of Pediatrics mandated not only 2 years of clinical critical care medicine training, but also an additional mandatory 1 year of research in a pediatric critical care medicine–related area. This total of 6 years of graduate medical education matches the requirements for other fellowship training programs in subspecialties such as pediatric pulmonology, cardiology, neonatology, etc.3 Unfortunately, the American Board of Pediatrics gives no credit for any time spent in an anesthesiology residency or fellowship. Thus, for individuals interested in dual pediatric and anesthesiology residency and fellowship training, this 6-year American Board of Pediatrics training requirement, in addition to 3–4 years of anesthesiology training and a 1-year pediatric anesthesia fellowship, is simply, in the current time of enormous medical school debt, kryptonite. No one, except perhaps the independently wealthy, can realistically be expected to complete 10 or more years of graduate medical education, with college and medical school debts averaging well over $200,000 (and climbing). Further, the more favorable economic and working conditions in operating room anesthesia drive "double-boarded" (really, "quadruple-boarded": anesthesiology, pediatrics, pediatric anesthesia, and pediatric critical care medicine) physicians away from the pediatric intensive care unit toward the operating room. Considering these economic realities, as a profession, we must rethink how we train the next generation of physicians. Anesthesiologists have a long and proud history of investigative endeavors in medicine, biology, physiology, pharmacology, and quality and safety science. And yet, in our current paradigm of postgraduate medical education, much of this is currently very much at risk. Indeed, we are at a crossroads, with fewer and fewer fellowship-trained physicians interested in research and even fewer trained for competitive extramural grant funding. Further, by any measure, our current 1-year American Board of Anesthesiology fellowship training programs in pediatric anesthesiology have failed at producing the next generation of clinician scientists and leaders. The lone exception has been the few programs and individual quadruple-boarded, pediatric critical care anesthesiologists who have a mandatory research year as part of their training. In recent editorials on the advanced pediatric anesthesiology fellowship, McGowan and Davis6 and Andropoulos et al7 outlined the obstacles confronting the academic advancement of the specialty. Most notably, they describe the lack of research training of the specialty, the relative paucity of pediatric anesthesia mentorship, and the inability of programs to commit both time and money to research. Like the Irish monks of the Dark Ages who saved civilization by keeping the tradition of scholarship alive, we believe that the spark of scholarship and leadership in our profession is best being kept alive by the quadruple-boarded pediatric anesthesia intensivists. Indeed, we believe that our very survival as a profession depends on keeping this critical care training track alive and emulating and transferring many of the skill sets to our standard pediatric anesthesia fellowship training pathways. As discussed by Longacre et al,4 an essential element in preventing the extinction of the quadruple-boarded pediatric critical care anesthesiologist is to shorten the training period for these individuals to a maximum of 7 or 8 years. The American Board of Anesthesiology/American Board of Pediatrics–approved combined 5-year residency track approved in 2013 is a good first start. This pathway allows completion of an anesthesia and pediatrics residency in 5 rather than 6 years. We believe that a simple solution to this training duration conundrum would be to creatively change year 5 of the basic residencies and combine the pediatric anesthesia and pediatric critical care fellowships in years 6 and 7. In our revised pathway, year 5 of residency for these individuals would be devoted solely to pediatric anesthesia and critical care medicine. This year would include subspecialty time in pediatric cardiology, pulmonology, pain management, and regional anesthesia, and additional time in the neonatal, adult surgical, and pediatric medical, surgical, and cardiac intensive care units. Year 6, the first fellowship year, would be evenly divided between pediatric anesthesia and pediatric critical care medicine (6 months each). Finally, year 7 would be a hybrid year, with 8 months of research and the rest of the time devoted to clinical responsibilities, including call. By developing and defining specific competencies, professional outcome metrics, and serial levels of supervision for both pediatric anesthesia and pediatric critical care medicine programs, this revised program would meet the training requirements of the Accreditation Council for Graduate Medical Education, the American Board of Pediatrics, and the American Board of Anesthesiology and allow the trainee to be a candidate for board certification in both pediatric anesthesia and pediatric critical care medicine. Further, we believe that the year after completion of this training should be a protected time period, in which institutions that hire these formidably trained individuals should provide them with protected nonclinical time and mentorship in order for them to continue their research and further their faculty development. Because the number of available training positions for the combined 5-year dual training program is limited, and medical students must identify this pathway in their third or the early part of the fourth year of medical school, we believe that our proposed shortened training program can be modified for pediatric residents who choose a career in pediatric anesthesia and critical care medicine during their pediatric residencies. In this paradigm, the combined training program would take 8 rather than 7 years. Years 6 through 8 would be modeled on years 5 through 7, as described above, for those individuals who are in the abbreviated 5-year combined residencies. Because approximately 40%–60% of patients admitted to most pediatric intensive care units are postsurgical, we believe that having a subset of physicians trained in pediatrics and anesthesiology adds significant value to patient care and to the team of physicians and nurses staffing the pediatric intensive care unit. The pediatric critical care anesthesiologist not only can share expertise in airway management, vascular access, pain management, and sedation administration, but can impart his/her experience and understanding of perioperative care. However, once trained, another issue must be addressed: Where will these pediatric anesthesiology intensivists work after their training? Institutions will have to individualize how to incorporate these quadruple-boarded physicians into their coverage and their financial and revenue models. Currently, several successful models of multidisciplinary staffing and financial revenue management exist at some institutions, such as the Johns Hopkins Hospital, the Children's Hospital of Philadelphia, the Children's Hospital of Los Angeles, and the Mayo Clinic. How to incorporate this model into pediatric intensive care units that are administratively managed within departments of pediatrics remains a hurdle that must be overcome or will force many quadruple-boarded, pediatric critical care anesthesiologists away from critical care medicine. Finally, as when one reads a mutual fund prospectus, there is an immediate disclaimer "that past performance is no guarantee of future success." In terms of professional development, we disagree. Indeed, we believe that past performance is the best predictor of future results. It is no accident that 11 of the past 15 presidents of the Society for Pediatric Anesthesia, the largest specialty society of its kind in the world, with more than 3500 members, were all quadruple-boarded, pediatric critical care anesthesiologists. Indeed, 2 of the next 3 members in line for the presidency of the society were similarly trained. Thus, we contend that not only is it necessary to protect the continuing existence of the pediatric critical care anesthesiologist, but the very survival of our specialty may depend on it. DISCLOSURES Name: Myron Yaster, MD. Contribution: This author helped draft the initial manuscript, critically review the final manuscript, and approved the manuscript as submitted. Name: Peter J. Davis, MD. Contribution: This author helped draft the initial manuscript, critically review the final manuscript, and approved the manuscript as submitted. Name: William J. Greeley, MD. Contribution: This author helped draft the initial manuscript, critically review the final manuscript, and approved the manuscript as submitted. This manuscript was handled by: James A. DiNardo, MD, FAAP.

e21500 Background: The 5-year survival rate for pediatric acute lymphoblastic leukemia (ALL) is greater than 90%. A common late effect of pediatric ALL is neurocognitive deficits, such as lower IQ. In recent years, the use of sedation during lumbar punctures (LPs) for treatment of pediatric ALL is becoming increasingly widespread. These patients are exposed to repeated doses of sedatives. Among the most common Children’s Oncology Group (COG) ALL protocols, approximately 30 LPs are performed over a period of 2-3 years. Studies in animals (both rodents and primates) have revealed that common sedation drugs cause harm to the developing brain and can negatively affect behavior, learning, and memory. Gaps in knowledge exist regarding their use in children, particularly with repeated exposures. For children with ALL, little is known about sedation practices such as how commonly sedation is used; what medications are most common; and who administers the medications. The purpose of this study is to summarize sedation practices at COG institutions for LPs related to treatment of pediatric ALL. Methods: All Responsible Investigators (RIs) of the Cancer Control Committee (a subcommittee of COG) were invited to complete an internet-based survey about sedation practices for ALL patients at their institution. Results: Surveys were sent out to 103 RIs with a 62.1% response rate ( N = 64). A combined 2018 new patients with ALL were seen each year ( M = 31.5, range = 3-110); of these patients, 95.7% received sedation for LPs. While there was considerable variability across institutions in medications used (general anesthesia, Propofol with opioid and/or Versed, Versed and opioid, other), the most common was Propofol alone ( n = 36, 56.3%). Anesthesiologists administered sedation at the majority of institutions ( n = 36, 56.3%) while trained sedationists, oncologists, and nurses administered sedation at other institutions. Conclusions: A substantial number of pediatric patients with ALL receive sedation for LPs. However, there is much variation in the types of medications administered and who is administering these medications. Better understanding of sedation practices in children with ALL may inform future research to investigate which methods of sedation are safest, with a particular emphasis on its long-term effects.

IntroductionFollowing centralisation of UK paediatric intensive care, specialist retrieval teams were established who travel to general hospitals to stabilise and transport sick children to regional paediatric intensive care units (PICUs). There is national variation among these PICU retrieval teams (PICRTs) in terms of how quickly they reach the patient’s bedside and in the care provided during transport. The impact of these variations on clinical outcomes and the experience of stakeholders (patients, families and healthcare staff) is however unknown. The primary objective of this study is to address this evidence gap.Methods and analysisThis mixed-methods project involves the following: (1) retrospective analysis of linked data from routine clinical audits (2014–2016) to assess the impact of service variations on 30-day mortality and other secondary clinical outcomes; (2) a prospective questionnaire study conducted at 24 PICUs and 9 associated PICRTs in England and Wales over a 12-month period in 2018 to collect experience data from parents of transported children as well as qualitative analysis of in-depth interviews with a purposive sample of patients, parents and staff to assess the impact of service variations on patient/family experience; (3) health economic evaluation analysing transport service costs (and other associated costs) against lives saved and longer term measurements of quality of life at 12 months in transported children and (4) mathematical modelling evaluating the costs and potential impact of different service configurations. A final work stream involves a series of stakeholder workshops to synthesise study findings and generate recommendations.Ethics and disseminationThe study has been reviewed and approved by the Health Research Authority, ref: 2 18 569. Study results will be actively disseminated through peer-reviewed journals, conference presentations, social media, print and broadcast media, the internet and stakeholder workshops.