BACKGROUND:It is recognized that the perioperative anesthetic management of children with long QT syndrome may be complex, as they are at risk of life-threatening arrhythmias such as ventricular tachycardia, torsades des pointes, ventricular fibrillation, or severe bradycardia. There is uncertainty regarding the incidence of complications as well as which techniques might be acceptable or preferable in this group of patients. AIMS:In collaboration with the Congenital Cardiac Anesthesia Network, we conducted a prospective audit of the anesthetic management, complications, and outcomes of children with long QT syndrome. METHODS:Following receipt of ethics committee approval and an extensive process of communication within the Congenital Cardiac Anesthesia Network and elsewhere, over approximately a two-year period in the United Kingdom we prospectively collected fully anonymized data relating to the anesthetic management of children with long QT syndrome using an online secure reporting portal. RESULTS:90 episodes of anesthesia for cardiac/cardiological (44) and non-cardiac (46) procedures were reported in 81 patients, with a median age of 6 years and a median weight of 22 kg. 59% were male. In 57 patients (70%), the diagnosis of long QT syndrome had been confirmed by genotyping. Where available, the QTc on a preoperative ECG ranged from 340 to 650 milliseconds. 14 patients had a history of previous out-of-hospital cardiac arrest, and 18 patients had an in situ cardiac pacing/defibrillation system. Three patients had a previous history of major complications under anesthesia, including ventricular tachycardia or ventricular fibrillation. Three patients experienced a significant complication, including intermittent atrioventricular block, ventricular tachycardia, changes in QRS morphology on the electrocardiograph, and bradycardia necessitating cardiopulmonary resuscitation. Both intravenous and inhalational agents were used perioperatively. No patient required unplanned admission to an intensive care unit. In every case, the patient was anesthetized by a consultant. CONCLUSIONS:This complex group of patients has a significant complication rate under general anesthesia. Perioperative management of such patients should be delivered by experienced anesthetists, and in the majority of cases, it is appropriate for this to take place in centers where there is relevant additional cardiological expertise.

BACKGROUND:Considerable importance is attached to the process of training, appointing and retaining highly specialized pediatric anesthetists, such as those with a congenital heart disease practice.AIMS:For the 10-year period from April 2012 to March 2022, we wished to establish changes in the absolute number of consultant pediatric cardiac anesthetic posts in NHS Level 1 Centres, turnover in such posts, and what training appointees had received.METHODS:An email survey was sent to the Centre Representative from the Congenital Cardiac Anesthesia Network in each of the eleven NHS Level 1 Pediatric Congenital Heart Disease Centre. Further follow up was completed in order to confirm accuracy of responses. We defined a pediatric cardiac anesthetist as a consultant with a clinical practice including provision of anesthetic management for children undergoing cardiac surgery incorporating the use of cardiopulmonary bypass.RESULTS:The response rate to our survey was 100%. Over the study period the number of consultants increased from 69 to 81, though three posts were unfilled as at March 2022. There were 55 departures and 65 appointees. Five consultants moved between NHS Units. 52 consultants received formal fellowship training and 13 switched into pediatric cardiac anesthesia from an existing general pediatric anesthetic post, with a period of supplementary training within their institution. Appointees reported extensive additional training variably including fellowships in general pediatric anesthesia, adult cardiac anesthesia and pediatric intensive care, both within and outside the United Kingdom.CONCLUSIONS:There has been both an expansion in the number of posts, as well as considerable turnover in consultant posts in the last 10 years. Training standards which support and guide individuals as they develop a practice in this highly specialized field should reflect different routes into the speciality and could be established with the support and advice of the Congenital Cardiac Anesthesia Network.

IMPROVEMENT IN THE perioperative management of children undergoing congenital heart surgery continues to be a common goal of all programs regardless of geographic location or program size. Historically, fast-track programs in pediatric cardiac surgery have focused on early extubation.1Mittnacht AJC Holllinger I Fast-tracking in pediatric cardiac surgery – the current standing.Ann Card Anaesth. 2010; 13: 92-101Crossref PubMed Scopus (64) Google Scholar,2Akhtar MI Momeni M Szekely A et al.Multicenter international survey on the clinical practice of ultra-fast-track anesthesia with on-table extubation in pediatric congenital cardiac surgery.J Cardiothorac Vasc Anesth. 2019; 33: 406-415Abstract Full Text Full Text PDF PubMed Scopus (19) Google Scholar However, more recently, enhanced recovery after pediatric cardiac surgery (ERAS-cardiac) has emerged as a concept that expands beyond fast-track. Enhanced recovery after pediatric cardiac surgery is a patient-centered approach to the surgical encounter involving the entire multidisciplinary perioperative team. Many, anecdotally, seem to think that this is only a change in a “name” (personal communications). In this editorial, the authors want to justify the importance of the ERAS-cardiac concept and encourage programs that have not considered or adopted ERAS-cardiac to consider doing so. ‘Fast-track’ anesthesia was primarily based on an agreement between the pediatric cardiac surgeon and the anesthesiologist, or, in some cases, the intensivist, in which a patient would be extubated at the conclusion of surgery or very shortly thereafter, thus avoiding a significant period of mechanical ventilation in the cardiac intensive care unit (ICU). Fast-track programs generally aim to discharge patients relatively more quickly from the hospital. Extubation is an important driver for many aspects of clinical care that impact ICU and hospital length of stay. Undoubtedly, much expertise, skill, and refinement of anesthetic technique go into the successful, sustained extubation of a wide range of pediatric cardiac surgical patients. There are much data supporting the safety and practicability of early extubation in pediatric cardiac surgery.3Priesman S Lembersky H Yusim Y et al.A randomized trial of outcomes of anesthetic management directed to very early extubation after cardiac surgery in children.J Cardiothorac Vasc Anesth. 2009; 23: 348-357Abstract Full Text Full Text PDF PubMed Scopus (56) Google Scholar, 4Bates KE Mahle WT Bush L et al.Variation in implementation and outcomes of early extubation practices after infant cardiac surgery.Ann Thorac Surg. 2019; 107: 1434-1440Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar, 5Butt W Extubation After neonatal and pediatric cardiac surgery: Where and when?.Pediatr Crit Care Med. 2020; 21: 910-911Crossref PubMed Scopus (1) Google Scholar, 6Rooney SR Mastropietro CW Benneyworth B et al.Influence of early extubation location on outcomes following pediatric cardiac surgery.Pediatr Crit Care Med. 2020; 21: e915-e921Crossref PubMed Scopus (9) Google Scholar It is recognized that intubation and mechanical ventilation are risk factors for several complications, including ventilator-acquired pneumonia, and they mandate concurrent sedation associated with further complications. However, the focus on early extubation is not sufficient or the sole important aspect of an overall excellent outcome for an individual patient. In fact, there are few data that convincingly demonstrate that on-table extubation is clinically superior to early extubation in an ICU within the first few hours of arrival.7Alghamdi AA Singh SK Hamilton BCS et al.Early extubation after pediatric cardiac surgery: Systematic review, meta-analysis, and evidence-based recommendations.J Card Surg. 2010; 25: 586-595Crossref PubMed Scopus (103) Google Scholar,8Harris KC Holowachuk S Pitfield S et al.Should early extubation be the goal for children after congenital cardiac surgery?.J Thorac Cardiovasc Surg. 2014; 148: 2642-2647Abstract Full Text Full Text PDF PubMed Scopus (94) Google Scholar In a follow-up study from the Pediatric Heart Network Collaborative Learning Study, success with early extubation in infants declined over time, with no differences in ICU or hospital lengths of stay.9Gaies M Pasquali SK Banerjee M et al.Improvement in pediatric cardiac surgical outcomes through interhospital collaboration.J Am Coll Cardiol. 2019; 74: 2786-2795Crossref PubMed Scopus (51) Google Scholar In addition to extubation, ERAS-cardiac programs focus on the entire care process and the perioperative workflow. It includes preoperative optimization (nutritional status, fasting times, medications) and intraoperative guidelines, including pain control, nausea and vomiting prophylaxis, transfusion management, and early extubation. Significant focus is directed toward the entire postoperative period, given that this makes up most of the time during which the patient is hospitalized. Aspects addressed include sedation and pain management (with attempts to minimize exposure to opiates), early nutrition, mobilization, delirium management, standardized chest tube and pacemaker wire removal, and optimizing sleep. Enhanced recovery after pediatric cardiac surgery programs also involve the child's family as part of the care team through perioperative education rather than relying on medical providers as the sole drivers of care. Enhanced recovery after pediatric cardiac surgery programs are still being developed in many institutions, with few data published. Some programs have demonstrated clinical benefit, mostly in terms of ICU length of stay10Roy N Parra MF Brown ML et al.Initial experience introducing an enhanced recovery program in congenital cardiac surgery.J Thorac Cardiovasc Surg. 2020; 160: 1313-1321Abstract Full Text Full Text PDF PubMed Scopus (31) Google Scholar,11Murphy T Sale SM Gonzalez Barlatay F et al.Initial results from an enhanced recovery program for pediatric cardiac surgical patients.Pediatr Anesth. 2022; 32: 647-653Crossref PubMed Scopus (2) Google Scholar or decreasing opioid use.12Roy N Brown ML Parra MF et al.Bilateral erector spinae blocks decrease perioperative opioids use after pediatric cardiac surgery.J Cardiothorac Vasc Anesth. 2021; 35: 2082-2087Abstract Full Text Full Text PDF PubMed Scopus (22) Google Scholar,13Franz AM Martin LD Liston DE et al.In pursuit of an opioid-free pediatric ambulatory surgery center: A quality improvement initiative.Anesth Analg. 2021; 132: 788-797Crossref PubMed Scopus (30) Google Scholar However, ERAS-cardiac aims to decrease perioperative stress by defining a range of desirable and specific outcomes, the achievement of which is important to both providers and patient families. These may include avoidance of delirium, early mobilization, excellent pain control, and overall patient satisfaction. More data will be needed to guide protocols and guidelines as existing programs continue to mature and new programs start implementing ERAS in pediatric cardiac surgery. The recently published statement by the American Association for Thoracic Surgery14Fuller S Kumar SR Roy N et al.The American Association for Thoracic Surgery Congenital Cardiac Surgery Working Group 2021 consensus document on a comprehensive perioperative approach to enhanced recoveryafter pediatric cardiac surgery.J Thorac Cardiovasc Surg. 2021; 162: 931-954Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar points clinicians in the right direction, but also highlights the lack of high-quality data on which to guide clinical decision-making in the entire perioperative period. There are more data published on adult cardiac surgery than on pediatric cardiac surgery, but ultimately there needs to be more research on the actual benefits of nutrition, mobilization, nausea prevention, and the minimization of opioids in children. The concept of blood management and conservation and management of cardiopulmonary bypass was notably absent in the American Association for Thoracic Surgery guidelines, and needs more data on these patient populations. Unnecessary variation can be eliminated by working to standardize the overall clinical care using the best available evidence. One question frequently asked is how to implement a program of enhanced recovery. One recommendation is for institutions to begin their ERAS-cardiac program with more simple cases and have relatively strict inclusion/exclusion criteria. Once the program has gained the trust of all parties involved and is perceived to be beneficial, then the program can expand within the institution. Examples of such initial criteria are shown in Table 1.Table 1Two Examples of Potential Inclusion Criteria for a Newly-Established Pediatric ERAS-Cardiac ProgramInclusion CriteriaExample #1Example #2Age>30 d>6 moWeightNo set lower limit of weight≥5 kgSurgical proceduresSTAT 1-3Some STAT 4 procedures may be suitable15Jacobs JP O'Brien SM Pasquali SK et al.Variation in outcomes for risk-stratified pediatric cardiac surgical operations: An analysis of the STS Congenital Heart Surgery Database.Ann Thorac Surg. 2012; 94: 564-571Abstract Full Text Full Text PDF PubMed Scopus (103) Google ScholarCPB <120 min, expectation of normal cardiac systolic function on separation from CPBMinimum temperature on CPBNo set temperature criterion≥32°CCPB, cardiopulmonary bypass; ERAS, enhanced recovery after surgery; STAT, Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery. Open table in a new tab CPB, cardiopulmonary bypass; ERAS, enhanced recovery after surgery; STAT, Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery. Ultimately, there must be a multidisciplinary group that can work through systems issues to coordinate the best care. The following 3 conditions must be met for a successful implementation: support by the institution's leadership and cardiac programs; a champion provider who is passionate and dedicated to developing, launching, and maintaining a program; and a perception that the significant effort and time spent establishing the program are worthwhile. In summary, although the concept of enhanced recovery after pediatric cardiac surgery is slowly building momentum, there are undoubtedly some subtle barriers to its wider acceptance and implementation. There must be institutional agreement that ‘an endotracheal tube management strategy’ is only one small part of care, and that addressing all of the care processes in a consistent and evidence-based way is critical to be able to successfully implement an ERAS-cardiac program. The authors represent 2 of the programs that have published their experience with ERAS-cardiac, and they encourage colleagues to sponsor or support ERAS-cardiac in their institutions and add to the evidence base of these programs. The authors report no conflicts of interest other than VN who is an associate editor for this journal. This work received no external funding.

BACKGROUND:Blood pressure measurement is a standard of monitoring during general anesthesia. Invasive measurement is considered the gold standard but is less commonly used than non-invasive. Automated oscillometric blood pressure devices measure the mean arterial pressure (MAP) and use an algorithm to determine the systolic and diastolic pressures. Few devices have been validated in children, particularly during anesthesia. Few studies have assessed the agreement between invasive and non-invasive blood pressure measurements in children.METHODS:This was a multi-center prospective observational study of children under 16 years undergoing cardiac catheterization with general anesthesia. Paired invasive and non-invasive blood pressure measurements were recorded for each patient during stable periods of the procedure. Correlation within and between sites was assessed with Pearson's correlation coefficient, and agreement was examined using Bland-Altman methodology to determine bias. Agreement during episodes of hypotension and for age and weight was also determined. Bias greater than 5 mmHg and standard deviation greater than 8 mmHg was considered clinically significant. The primary end point was agreement of MAP measurements.RESULTS:A total of 683 paired blood pressure values were collected from 254 children in three pediatric hospitals. Median [IQR] age and weight were 3 [1-7] years and 13.9 [8-23] Kg. The overall bias (SD) for mean arterial pressure values was 7.2 (11.4) mmHg. During hypotension (190 readings), the bias (SD) was 15 (11.0) mmHg. The non-invasive MAP was frequently higher than invasive MAP during infancy, and lower in older children.CONCLUSION:Automated oscillometric blood pressure measurement is unreliable in anesthetized children during cardiac catheterization. Invasive pressure measurement should be considered for high-risk cases.

Background: Perioperative trans-esophageal echocardiography ('TEE') is widely used for the assessment of anatomy/repair of congenital cardiac defects. It is recognised that there are risks associated with its use. Aims: We wished, by means of a contemporaneous prospective national audit over a six-month period, to establish what proportion of TEE studies in children are complicated by major upper gastrointestinal or upper aerodigestive tract trauma. Methods: After obtaining appropriate local institutional ethics committee approval, a national prospective audit of the rate and severity of gastrointestinal complications of trans-esophageal echocardiography studies in anaesthetised adult cardiology and cardiac surgical patients was conducted by the Association of Cardiothoracic Anaesthesia and Critical Care in the United Kingdom and Ireland during the twelve months of 2017. During the second six months of the audit, the Congenital Cardiac Anaesthesia Network (an organisation including anaesthetists with a paediatric cardiac anaesthetic practice in all the United Kingdom cardiac surgical centres) prospectively audited the incidence of such complications of TEE studies in children. Results: A total of 1,059 studies were included in this six-month paediatric audit. There were no reports of the specified major complication. Statistical Analysis: The zero incidence of the major complication is consistent with a worst possible incidence of five per thousand TEE examinations. Conclusions: Such potentially reassuring information could be included in discussions with patients or families about the risk of trans-esophageal studies in children.

Bleeding caused by coagulopathy is common in children undergoing cardiac surgery and causes adverse outcomes. Coagulation testing assists selection of treatments to stop bleeding but has an uncertain role for predicting bleeding. We aimed to evaluate how well prospective coagulation testing predicted excessive bleeding during and after cardiac surgery compared to prediction using clinical characteristics alone. The study was a single-center, prospective cohort study in children having a range of cardiac surgery procedures with coagulation testing at anesthetic induction and immediately after cardiopulmonary bypass. The primary outcome was clinical concern about bleeding (CCB), a composite of either administration of prohemostatic treatments in response to bleeding or a high chest drain volume after surgery. In 225 children, CCB occurred in 26 (12%) during surgery and in 68 (30%) after surgery. Multivariable fractional polynomial models using the clinical characteristics of the children alone predicted CCB during surgery (c-statistic 0.64; 95% confidence interval 0.53, 0.76) and after surgery (0.74; 0.67, 0.82). Incorporating coagulation test results into these models improved prediction (c-statistics 0.79; 0.70, 0.87, and 0.80; 0.74, 0.87, respectively). However, this increased the overall proportion of children classified correctly as CCB or not CCB during surgery by only 0.9% and after surgery by only 0.4%. Incorporating coagulation test results into predictive models had no effect on prediction of blood transfusion or postoperative complications. Prospective coagulation testing marginally improves prediction of CCB during and after cardiac surgery but the clinical impact of this is small when compared to prediction using clinical characteristics.

BACKGROUND:Over recent years, a number of enhanced recovery programs have appeared in first, adult colorectal surgery, and subsequently many other adult surgical specialties. Increasing interest in this approach to perioperative management in children culminated in the recent development of the first enhanced recovery pathway for pediatric intestinal surgery, endorsed by Enhanced Recovery after Surgery Society (ERAS®). In parallel, there has been increasing interest in the refinement of perioperative management of selected pediatric cardiac surgical patients, invariably referred to as "fast track" management. Initiatives have largely focused on duration of postoperative ventilation rather than on a much wider range of perioperative interventions to optimize recovery and ensure timely discharge after surgery. In our institution, a "Level 1" pediatric cardiac surgical center, we assembled a multidisciplinary team to design a comprehensive enhanced recovery pathway, based on ERAS® methodology, for selected cardiac surgical patients. After a lengthy period of planning, staff education, and preparation, we implemented the pathway at the end of November 2019.METHODS:We conducted a prospective audit of the perioperative management and outcomes of the first 88 patients managed according to this enhanced recovery pathway over a 25-month period in our institution.RESULTS:The mean age of the patients was 5.8 years (range 0.5-17.9), and the mean weight was 22.4 kg (range 6.6-57.2). Sixty-eight of the 88 patients were cardiopulmonary bypass cases. A total of 54% of patients received all four defined intraoperative anesthetic interventions (intravenous paracetamol, non-steroidal anti-inflammatory drug, antiemetic if aged more than 4 years, and use of a local anesthetic technique). A total of 89% of patients met the target extubation time of 6 h after administration of protamine. Median postoperative intensive care unit length of stay was 23.5 h (range 15.2-89.5). When compared to a historic control group, this represented a 22% reduction in median intensive care unit stay, although the total hospital length of stay remained unchanged. A total of 83% of patients met the target hospital discharge target of the fifth postoperative day.CONCLUSIONS:These preliminary results suggest that enhanced recovery pathway implementation for selected pediatric cardiac surgical patients is feasible, with acceptable outcomes. They suggest areas for further development and the potential for wider implementation.

We read with interest the article by Li et al1Li L Jiang Y Zhang W. Sugammadex for Fast-track surgery in children undergoing cardiac surgery: A randomized controlled study.J Cardiothorac Vasc Anesth. 2021; 35: 1388-1392Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar describing the use of Sugammadex for ‘fast-track’ pediatric cardiac surgical patients. In November 2019, we established an enhanced recovery program for selected cardiac surgical patients at our institution and have comparable experience and some comments to offer. Li et al's definition of fast-track anesthesia included ‘extubation within six hours postoperatively’; this is very similar to our own target for extubation, although extubation in the operating room (OR) is permitted at the discretion of the anesthesiologist. We agree that mobilization and timely hospital discharge, in an effort to decrease hospitalization costs, are some, but not all, of the objectives of an enhanced recovery program. Li et al's study included two well-matched groups of 30 children between one and six years of age undergoing repair of atrial or ventricular septal defects, whom were randomized to receive either Sugammadex or Neostigmine/Atropine for the reversal of neuromuscular blockade in the intensive care unit (ICU). The sample size calculation was not described clearly, but the inclusion and exclusion criteria appear reasonable, and no patients assessed for eligibility subsequently were excluded from the analysis. In contrast with a sequential bolus technique used in our institution, Li et al. employed continuous neuromuscular junction monitoring while maintaining paralysis with a rocuronium infusion. No patients in their study were extubated in the OR. The results of the study demonstrated a significant difference in extubation time after the administration of the drug between the Sugammadex group and the Atropine/Neostigmine group (31 v 125.5 minutes, p < 0.01). This difference in extubation time was reported to translate into earlier discharge from the ICU (1.2 v 1.6 days, or 580 minutes) and shorter hospital stay (5.8 v 6.5 days, or slightly more than 1,000 minutes). It is difficult to understand how an intervention that shortens ventilation by only approximately 90 minutes translates into such a large difference in ICU and hospital stay. Our results suggest that there was no statistically significant difference in either ICU or total hospital length of stay between those extubated in the OR versus in the ICU.2Murphy T, Sale S, Gonzalez Barlatay F, et al. Initial results from an Enhanced Recovery Programme for pediatric cardiac surgical patients. Manuscript submitted to Pediatric Anesthesia.Google Scholar Li et al. stated that ‘the investigators and surgeons were blinded to the groupings in the study,’ but it would be useful to know if ICU and hospital discharge was decided by team members who were similarly blinded. There was also a significant difference in the incidence of atelectasis between the two groups—defined as the presence of ‘high-density images and reduction of lung volumes on x-ray’. It would be interesting to know the timing of these x-rays and, again, if they were reported by someone blinded to the patient treatment allocation. The discussion stated that there were no significant differences in hypoxemia between the two groups, which begs the question ‘was the atelectasis of clinical significance? For example, were the saturations the same between the two groups only because the latter group was treated with oxygen and or physiotherapy (and for what period?). None. Sugammadex for Fast-Track Surgery in Children Undergoing Cardiac Surgery: A Randomized Controlled StudyJournal of Cardiothoracic and Vascular AnesthesiaVol. 35Issue 5PreviewObjective: The purpose of this study was to evaluate the safety and efficacy of sugammadex for fast-track surgery in children undergoing cardiac surgery.Design: This was a prospective, randomized, controlled clinical study.Setting: University hospital.Participants: The study comprised 60 children undergoing cardiac surgery.Interventions: The children in group S received sugammadex, 4 mg/kg, for reversal of neuromuscular block, and the children in group N received neostigmine, 30 µg/kg, and atropine, 15 µg/kg. Full-Text PDF

Pediatric AnesthesiaVolume 30, Issue 4 p. 390-391 EDITORIAL In defense of common sense Tim Murphy, Corresponding Author tim.murphy@uhbristol.nhs.uk orcid.org/0000-0002-2744-0976 Department of Paediatric Anaesthesia, Bristol Children's Hospital, Bristol, UK Correspondence Tim Murphy, Department of Paediatric Anaesthesia, Bristol Children's Hospital, Upper Maudlin Street, Bristol BS2 8BJ, UK. Email: tim.murphy@uhbristol.nhs.ukSearch for more papers by this author Tim Murphy, Corresponding Author tim.murphy@uhbristol.nhs.uk orcid.org/0000-0002-2744-0976 Department of Paediatric Anaesthesia, Bristol Children's Hospital, Bristol, UK Correspondence Tim Murphy, Department of Paediatric Anaesthesia, Bristol Children's Hospital, Upper Maudlin Street, Bristol BS2 8BJ, UK. Email: tim.murphy@uhbristol.nhs.ukSearch for more papers by this author First published: 22 April 2020 https://doi.org/10.1111/pan.13812Read 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 onEmailFacebookTwitterLinked InRedditWechat No abstract is available for this article. Volume30, Issue4April 2020Pages 390-391 RelatedInformation

This article reviews the evidence for anesthetist-delivered perioperative transesophageal echocardiography for children undergoing cardiac surgery. It addresses the additional issues of training, developing practice, accreditation, and the requirement for collaboration with pediatric cardiologists, surgeons and other members of the perioperative team. Finally an overview of the potential structure of an anesthetist-delivered perioperative transesophageal echocardiography service is presented.

Pediatric AnesthesiaVolume 27, Issue 8 p. 789-790 EDITORIAL How should training in Pediatric Cardiac Anesthetic Training be undertaken—And in what sort of centers? Tim Murphy, Tim Murphy Paediatric Anaesthesia, Bristol Royal Hospital for Children, Bristol, UKSearch for more papers by this authorIan A. Jenkins, Ian A. Jenkins Ian.Jenkins@UHBristol.nhs.uk orcid.org/0000-0003-3908-5948 Paediatric Cardiac Anaesthesia & Intensive Care, Bristol Royal Hospital for Children, Bristol, UKSearch for more papers by this author Tim Murphy, Tim Murphy Paediatric Anaesthesia, Bristol Royal Hospital for Children, Bristol, UKSearch for more papers by this authorIan A. Jenkins, Ian A. Jenkins Ian.Jenkins@UHBristol.nhs.uk orcid.org/0000-0003-3908-5948 Paediatric Cardiac Anaesthesia & Intensive Care, Bristol Royal Hospital for Children, Bristol, UKSearch for more papers by this author First published: 07 July 2017 https://doi.org/10.1111/pan.13193Citations: 2Read 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.Citing Literature Volume27, Issue8August 2017Pages 789-790 RelatedInformation

In this issue, El-Boghdadly et al. report their series of 600 patients undergoing awake fibreoptic intubation (AFOI) [1]. They make observations on procedural practice, outcome and training, but reveal unanswered questions about contemporary practice which merit analysis and discussion. The backdrop to their study is the technology-driven evolution in airway management that anaesthetists are in the process of adopting. Acquisition and maintenance of expertise to effectively manage AFOI takes time [2]. The procedure necessitates simultaneous endoscopy, with variable use of: sedation; provision of oxygen; and applied topical local anaesthetic to the airway, tailored to each individual patient. However, it also takes time to acquire and maintain every one of the skills needed to manage an airway in easy and challenging conditions. There are guidelines, such as those published by the Difficult Airway Society [3, 4], with which to become familiar. Specific techniques for the management of the obese patient, the parturient [5], or the child, need to be understood, learned and put into regular safe practice as appropriate. There is increasing emphasis on assuring the quality of training in airway management, which may take place in the operating room, in the simulation laboratory and elsewhere. Technological advancement brings with it an increasing array of new pieces of equipment and familiarity and confidence in their use should be acquired [6]. Modern departments of anaesthesia should have a lead clinician for airway management to assist in achieving this important objective for all members of an anaesthetic department [7, 8]. Placing particular emphasis on any individual component of the pathway to becoming an expert in airway management risks losing sight of the bigger picture. Data collected during the 2week 4th National Audit Project (NAP4) [9] census period reveal that intubation was expected to be difficult in 2.2% of cases. Amongst these potentially difficult airways, 90% were managed after induction of anaesthesia; AFOI was performed in 10% of reported cases. By extrapolation, there are approximately 7000 AFOIs performed in the 335 Departments of Anaesthesia in the UK each year. The distribution of AFOI frequency among those departments is likely to be very wide, and in some departments, AFOI may be a relatively rare event. For example, NAP4 data showed that no AFOIs were performed in children with an anticipated difficult airway – it was most commonly secured after inhalational induction of anaesthesia. Total loss of an airway during AFOI, with life-threatening consequences, is likely to be a very rare event. It would be extremely difficult to construct a scientific study to prove one technique of AFOI is superior to another once the airway was ‘lost’. Finally, to make matters more complicated, it is acknowledged that anaesthetists may lack accuracy in their ability to predict difficulty in intubation [10]. In the light of the above, the paper by El-Boghdadly et al. in this issue is timely. They state that “contemporary data regarding procedural practice, training provision and outcome data for AFOI in the UK is lacking”. By means of a prospective observational audit of clinical practice conducted over a 39-month period in one teaching hospital, the authors report on the management of 600 AFOIs in adults. This represented 1.71% of all tracheal intubations in their hospital during the study period – significantly above the average for NHS hospitals in the UK. Around 86% of the This editorial accompanies an article by El-Boghdadly et al., Anaesthesia 2017; 72: 694–703.

SummaryBackgroundIt is important that postoperative analgesic management after thoracotomy is very effective in order to optimize postoperative recovery. A regional technique such as an epidural or a paravertebral catheter with an infusion of local anesthetic may be supplemented with systemically administered analgesic drugs in order to achieve satisfactory analgesia.ObjectiveThe objective of this observational study was to evaluate whether a paravertebral infusion of local anesthetic delivered via a surgically placed catheter together with systemic analgesics is associated with low pain scores and satisfactory analgesia after thoracotomy for decortication in children.MethodsWe performed a retrospective analysis of the notes and charts of 83 children admitted with empyema thoracis and managed with thoracotomy and decortication. We collected data on the doses of analgesic drugs (morphine, paracetamol, and ibuprofen) and details of paravertebral infusions, together with postoperative pain scores for the first 48 h after surgery, or earlier if the paravertebral infusion was stopped within 48 h of surgery. Poor quality analgesia was defined as a score of 7 or more on the Visual Analog/Smiley Faces Scale (‘VAS/SF’).ResultsA total of 81 children were ASA 1 status and two were ASA 3 status. Analgesia comprised intravenous morphine at a mean dose of 20 μg·kg−1·h−1, together with oral paracetamol (62.5 mg·kg−1/24 h) and ibuprofen (14.2 mg·kg−1/24 h). The mean paravertebral bupivacaine dose was 0.29 mg·kg−1·h−1. Sixty‐four patients (77.1%) had good quality analgesia, 17 (20.5%) patients had moderate quality analgesia, and only two patients (2.4%) had poor quality analgesia.ConclusionAnalgesic outcomes with this regimen appear to be very satisfactory. It compares favorably with an epidural‐based regimen.

Sir—We read with interest the paper by Shah et al. entitled ‘Retrospective evaluation of antimicrobial prophylaxis in prevention of surgical site infection in the pediatric population’ 1. This paper raises some interesting questions about the relationship between the use of antibiotic therapy in the perioperative period and the incidence of postoperative surgical site infections (‘SSI’). The authors defined incorrect antibiotics as the administration of an incorrectly low dose of the relevant drug, or administration at an incorrect time (either too early or too late). The authors concluded ‘proper administration of preoperative antibiotics in pediatric patients is one of the few modifiable and significant factors in prevention of SSI’. We have examined the authors' data and have reached a different conclusion. We agree with the authors that the lower rate of SSI in the 1261 children who did not receive prophylactic antibiotics is likely to reflect absence of indication due to the low SSI risk of the procedure. We argue that these patients should not be included in the ‘incorrect antibiotic administration’ group as described in Table 3. Of the 3762 patients that did receive a prophylactic antibiotic, 844 had ‘incorrect’ administration. A two-by-two table can be constructed containing the number of patients who received incorrect versus correct antibiotics, and the incidence of SSIs as follows: From this data, among all patients who received antibiotic prophylaxis, there was no statistically significant difference in the rate of SSI whether ‘correct’ or ‘incorrect’ antibiotics were administered (OR 1.34 [95% CI 0.88–2.1], P = 0.2). Similar to previous studies, this study does not provide evidence to support the theory that failure to provide appropriate antibiotic prophylaxis increases the risk of SSI. We agree that the role of antibiotics in the prevention of SSI needs to be investigated in larger prospective trials that are adequately powered to answer this important question. No funding was received for this letter. No conflicts of interest declared.

Background When intubating a child's trachea with an uncuffed tracheal tube (TT), it is current practice in anesthesia and intensive care to use the leak test to assess TT fit. The aim of this study is to compare three measures of assessing leak around uncuffed tracheal tubes in the PICU. Methods We obtained institutional ethical permission and written informed consent, prior to any clinical investigation, from the parents of 135 children who had surgery for cardiac defects. On admission to the PICU, we measured leak by audible assessment, fractional volume loss, and leak conductance for each patient. Measurements of fractional volume loss and leak conductance were repeated every 4 h thereafter until extubation. Results On admission to the PICU, calculated values of leak conductance were significantly different between each grade of audible leak (P < 0.001). Values of fractional volume loss were not significantly different between no leak and small leak grades of leak. Throughout the PICU stay, a significant correlation between mean leak conductance and mean fractional volume loss was found (0.86, 95% CI, 0.810.90). Significant agreement within time series of leak conductance and fractional volume recorded for each patient occurred in 47/128 cases (37%). Conclusions On admission to the PICU, values of leak conductance are more strongly associated with audible assessment than with fractional volume loss. Throughout PICU stay, leak conductance is associated with fractional volume loss. This study demonstrates that leak conductance, calculated from routinely available pressure and flow signals, has the potential to represent the characteristics of the leak interface between a TT and the trachea.