Leadership in paediatric anaesthesia is undergoing rapid transformation as clinical complexity, workforce expectations, and organizational structures evolve. This review synthesizes recent developments and highlights the competencies required for effective leadership in this high-stakes specialty. Recent literature emphasizes the shift from individual expertise to team-based performance, supported by advances in technology, simulation, and organizational culture. Studies highlight the importance of psychological safety, diversity, and equitable leadership pathways. Emerging leadership models - such as shared leadership, New Work principles, and Just Culture - are increasingly relevant. Workforce well-being, moral injury, and toxic leadership/followership have become central concerns. Global perspectives and structured leadership development programs are expanding, with growing attention to gender, racial, and generational disparities in leadership roles. Leadership in paediatric anaesthesia requires adaptability, communication excellence, and a commitment to inclusive, psychologically safe team environments with a robust ethical attitude. Future progress depends on integrating modern leadership frameworks, strengthening mentorship, and fostering sustainable, collaborative models that support clinicians and improve patient outcomes.
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To investigate the safety and feasibility of deep sedation and general anaesthesia for cardiovascular magnetic resonance imaging in paediatric patients with congenital or acquired cardiac diseases. This retrospective study included all consecutive patients less than 18 years of age who had deep sedation for cardiovascular magnetic resonance examination at the University Hospital Schleswig-Holstein (Kiel, Germany) between 2010 and 2020 and cardiovascular magnetic resonance examination under general anaesthesia at the Royal Brompton Hospital (London, United Kingdom) between 2013 and 2022. Five-hundred twenty-two patients were in the deep sedation group and 171 in general anaesthesia group. Most of the patients had CHD (86% in deep sedation and 70% in general anaesthesia group). There were overall 14 adverse events (2%); 8 (1.5%) in the deep sedation group and 6 (3.5%) in the general anaesthesia group. This difference was not statistically significant (p = 0.122). Complications in the deep sedation group included mild anaphylactic reactions in three patients, a severe coughing fit in one patient, increasing cyanosis in three single-ventricle patients, and suspected aspiration in one patient. In the general anaesthesia group, hypotension requiring some intervention was present in three patients (four scans). One patient (0.6%) had inadvertent endobronchial intubation. Both deep sedation and general anaesthesia can be used for cardiovascular magnetic resonance scans in paediatric patients with a low rate of complications. This, however, requires highly skilled teams who adhere strongly to the safety policies and guidelines set up by each hospital.
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. 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. 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.
Preclinical studies have shown that volatile anaesthetics, particularly sevoflurane, can disrupt neurodevelopment by inducing neuronal apoptosis, neuroinflammation and altered synaptic plasticity during critical periods of brain maturation. Whether these mechanisms translate into long-term neurobehavioral risk in children remains uncertain. To compare the long-term risk of attention-deficit/hyperactivity disorder (ADHD) following paediatric anaesthesia with sevoflurane versus propofol in a large, multinational real-world cohort. We conducted a large, multinational, retrospective cohort study using real-world electronic health record data from more than 150 healthcare organisations across North America, Europe and Asia. Children and adolescents (0-18 years) who underwent a single surgical procedure under general anaesthesia between 2005 and 2025 were included. Patients with ADHD or multiple anaesthetic exposures were excluded. The primary exposure was sevoflurane versus propofol as the main anaesthetic. The primary outcome was new-onset ADHD identified by International Classification of Diseases, Ninth or Tenth Revision codes after surgery. Propensity-score matching (1:1), subgroup, sensitivity and positive/negative control analyses were performed to ensure robustness. Among 54 102 matched children (27 051 per group), the cumulative incidence of ADHD was 5.63% after sevoflurane and 2.95% after propofol, corresponding to incidence rates of 134.9 and 105.4 per 10 000 person-years. Sevoflurane exposure was associated with a higher risk of ADHD (hazard ratio 1.21; 95% confidence interval 1.11-1.31; p < 0.001). Findings were consistent across subgroups and sensitivity analyses; mortality was rare and similar between groups. In this multinational cohort, sevoflurane exposure during paediatric anaesthesia was associated with an increased long-term risk of ADHD compared with propofol. These findings suggest that anaesthetic choice may have enduring neurobehavioral consequences and that prospective validation is warranted to guide safer paediatric anaesthesia practice.
Acute post-operative pain is one of the most common adverse effects of surgery experienced by children following herniotomy. Methods of managing this adverse effect include the use of caudal block, pre-incisional field block, and parenteral analgesics. We therefore sought to determine the incidence of complications and parental satisfaction following caudal block versus combination of pre-incisional field block and rectal diclofenac suppository for post-herniotomy analgesia. This was a randomised single-blind controlled clinical trial carried out in the Modular theatre of the Jos University Teaching Hospital. Fifty-eight children aged 1-6 years scheduled for elective day case open unilateral inguinal herniotomy with an American society of anesthesiologists of I and II were recruited and randomised into groups A and B; 1 mL/kg of 0.25% plain bupivacaine was administered caudally to group A, while 1 mL/kg of 0.25% plain bupivacaine and 1 mg/kg of diclofenac suppository were administered via pre-incisional field block to group B. Presence of complications such as nausea, vomiting, and pain was noted. Parental satisfaction with post-operative analgesia was assessed using a 5-point Likert item. Data collected were analysed using the SPSS. Patients in the two study groups were comparable with respect to the measured parameters. Two (6.9%) patients in the caudal block group experienced vomiting, while three (10.3%) patients in both study groups had hypotension. Twenty-six (89.7%) and 19 (65.5%) parents in the caudal block group and field block with diclofenac suppository group were, respectively, "very satisfied" (P = 0.0001). No parent was either dissatisfied or extremely dissatisfied. Both caudal block with plain bupivacaine and pre-incisional field block with plain bupivacaine plus diclofenac suppository showed comparable efficacy in the incidence of minimal complications. No parent was either dissatisfied or extremely dissatisfied with the techniques.
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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% confidence interval], -0.4 [0.5]). Likewise, the VR and HFS groups showed no significant differences in ANTS and MEPA-GRS during scenario #2. In scenario #1, the VR and HFS groups' O-GRS, ANTS, and MEPA-GRS scores were comparable. The VR module reported a low VRSQ score (median [interquartile range (IQR)], 8.3 [4.2-15.8]), high-marginal SUS (median [IQR], 65 [62.5-80.0]), and feedback comparable to HFS. Virtual reality was noninferior to HFS in teaching anesthesiology nontechnical skills, and it was well tolerated and perceived. ClinicalTrials.gov ( NCT05041049 ); first submitted 10 September 2021. RéSUMé: OBJECTIF: La réalité virtuelle (RV) pourrait offrir des avantages pédagogiques par rapport à la simulation haute fidélité (SHF) sur mannequin, mais les données demeurent limitées. Nous avons cherché à déterminer si la RV est non inférieure à la SHF pour l’enseignement des compétences non techniques à des personnes en formation en anesthésiologie. MéTHODE: Nous avons mené une étude randomisée contrôlée séquentielle de non-infériorité comparant deux scénarios de gestion de crise en simulation auprès de 31 personnes en formation en anesthésiologie. Le scénario 1 a été administré soit en RV, soit en SHF. Après trois semaines, l’ensemble des participants et participantes ont réalisé le scénario 2, administré uniquement en SHF. Une marge de non-infériorité de 0,6 a été fixée pour l’amélioration globale au score Ottawa Global Rating Scale (O-GRS), une échelle de gestion des ressources en situation de crise, lors du scénario 2 entre les deux groupes. Comme critères d’évaluation secondaires, nous avons comparé les variations des scores à l’échelle Anaesthetists’ Non-technical Skills (ANTS) et à la Managing Emergencies in Paediatric Anaesthesia Global Rating Scale (MEPA-GRS) entre les groupes. Nous avons également évalué le module de RV à l’aide du VR Sickness Questionnaire (VRSQ), de la System Usability Scale (SUS), du Technology Acceptance Model et d’un questionnaire de rétroaction. RéSULTATS: Lors du scénario 2, la RV s’est avérée non inférieure à la SHF en ce qui concerne l’amélioration globale du score O-GRS (différence moyenne [limite supérieure de l’intervalle de confiance à 97,5 %]: −0,4 [0,5]). De même, aucune différence significative n’a été observée entre les groupes RV et SHF pour les scores ANTS et MEPA-GRS lors du scénario 2. Dans le scénario 1, les scores O-GRS, ANTS et MEPA-GRS étaient comparables entre les groupes RV et SHF. Le module de RV a présenté un score VRSQ faible (médiane [écart interquartile (ÉIQ)] : 8,3 [4,2–15,8]), un score SUS marginalement élevé (médiane [ÉIQ]: 65 [62,5–80,0]) et une rétroaction comparable à celle de la SHF. CONCLUSION: La réalité virtuelle s’est révélée non inférieure à la SHF pour l’enseignement des compétences non techniques en anesthésiologie. Elle a été bien tolérée et favorablement perçue. ENREGISTREMENT DE L’éTUDE: ClinicalTrials.gov ( NCT05041049 ); première soumission le 10 septembre 2021.
Severely displaced distal radial fractures are among the most common and controversial injuries in children. Despite observational evidence of reliable remodelling with growth in younger children, their alarming radiographic appearance-particularly when completely displaced (off-ended)-has driven routine surgical reduction and fixation. The Children's Radius Acute Fracture Fixation Trial (CRAFFT) aimed to evaluate the clinical and cost-effectiveness of surgical reduction compared with non-surgical casting. This pragmatic, multicentre, randomised, non-inferiority trial included participants (aged 4-10 years) with a severely displaced distal radial fracture from 49 hospitals in the UK. Recruiting centres were secondary or tertiary care hospitals providing acute paediatric trauma care. Participants were randomly assigned to either non-surgical casting or surgical reduction, using a minimisation algorithm with a random element and stratification factors were centre, age group, fracture location, and displacement severity. Participants and their parents and carers could not be masked to treatment. Surgical reduction was performed under general anaesthesia or conscious sedation, to restore anatomical alignment, with fixation permitted at the discretion of the surgeon. Non-surgical care involved immobilisation of the fracture in a plaster cast without general anaesthesia or sedation, and without purposeful manipulation of the fracture position. Immobilisation of the fracture beyond 6 weeks post-randomisation was not recommended. The primary outcome was upper limb function at 3 months, measured using the Patient Report Outcomes Measurement System (PROMIS) Upper Extremity Score for Children in the intention-to-treat population, which included all participants in the groups to which they were randomly assigned, irrespective of treatment received. The non-inferiority margin was conservatively set at -2·5 points for the main trial population. A prespecified subgroup analysis was powered to assess whether non-surgical casting could exclude a larger more clinically relevant margin of -5 points among children with completely off-ended fractures. Complications and serious adverse events were summarised in a safety (as-treated) population defined by treatment received. A within-trial economic evaluation was undertaken from the perspective of the UK National Health Service (NHS) and Personal Social Services over a 12-month time period. The trial was registered with the ISRCTN registry, ISRCTN10931294, recruitment is complete and extended follow-up to 3-years post-randomisation is ongoing. Between Aug 11, 2020, and May 30, 2024, 1227 children were screened for eligibility across 49 UK hospitals. 477 children were excluded (54 met exclusion criteria and 423 did not enter the study, the majority for lack of clinical or parental equipoise). 750 participants were randomly assigned, 375 to the non-surgical casting group and 375 to the surgical reduction group. 456 (61%) participants were male, 294 (39%) were female, and the median age of participants was 7·9 years (IQR 6·5-9·5). 329 (44%) of the 750 participants had completely off-ended fractures. Primary outcome data were collected from 640 (85%) participants. At 3 months post-randomisation, the mean PROMIS Upper Extremity score was 44·9 (SD 8·7) in the non-surgical casting group and 46·6 (8·8) in the surgical reduction group (adjusted mean difference -1·64 [95% CI -2·84 to -0·44]), with the confidence interval favouring surgical reduction but extending beyond the prespecified non-inferiority margin of -2·5 points. In children with completely off-ended fractures, findings were consistent with non-inferiority against the wider, prespecified margin for this group. Most complications within 8 weeks occurred in the surgical reduction group, including pressure damage (n=2), wound infections (n=6), scarring (n=5), and nerve irritation (n=1). During the 12-months of follow-up, refracture occurred in 13 participants (nine after non-surgical casting and four after surgical reduction). From an NHS and Personal Social Services perspective, non-surgical casting was associated with a significant reduction in mean cost per patient of £1665 (95% CI 1487 to 1843) and a marginal incremental reduction in quality-adjusted life-years (QALYs; -0·023 [95% CI -0·037 to -0·009]). The probability of non-surgical casting being cost-effective at the £20 000 and £30 000 per QALY threshold was 100%, indicating that the small short-term functional advantage of surgical reduction was not cost-effective. The CRAFFT trial did not demonstrate non-inferiority of non-surgical casting at 3 months against a conservative margin; however, the observed difference in favour of surgical reduction was small, below thresholds that families considered meaningful, and did not persist beyond early recovery. Surgical reduction was associated with higher costs, early procedural complications, and only a modest improvement in cosmetic appearance, supporting consideration of a cast-first strategy for most children. National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (17/22/02) and the NIHR Oxford Biomedical Research Centre.
Although urolithiasis is relatively common, urethral stones are rare, with an incidence of less than 0.3%. They are particularly uncommon in children, occurring 20 times less frequently than in adults, and are rarely seen in females as compared to males. The presence of an obstructing urethral stone resulting in acute urinary retention constitutes a urological emergency and requires immediate intervention. We present an unusual case of impacted urethral stones in a female child who presented to the Paediatric surgery emergency department at Mayo hospital, Lahore on 22nd October 2024. The diagnosis was established based on clinical history and examination, and the stones were retrieved under general anaesthesia. Further evaluation identified no underlying metabolic or anatomical abnormalities, suggesting that the stones originated from the primary urinary source. This case underscores the importance of considering urethral stones in the differential diagnosis of paediatric urinary tract obstruction, despite its rarity.
To investigate the impact of different tourniquet pressures and application durations on venous diameter and compliance in children, in order to optimise conditions for peripheral intravenous catheter insertion. This non-randomised clinical study included 21 healthy children aged 6-10 years. Vein diameter was measured using ultrasound. The force required to fully compress the vein was measured with a pressure-sensing device. Tourniquet pressures of 20-100 mmHg were applied for 60 s, with measurements every 10 s. Data were analyzed using non-parametric methods to assess changes over time and correlations between variables. Vein diameter changed significantly over time at all applied pressures. All tourniquet pressures showed a significant reduction in venous compliance. Substantial interindividual variation was observed in the pressure and timing that yielded optimal changes in vein diameter and compliance. Vein diameters ranged from 1 to 5 mm, with no consistent correlation with age or body weight. Paediatric tourniquet application markedly increases venous diameter and reduces venous compliance. The substantial interindividual variation in these responses motivates individualised rather than universal approaches. Future research should aim to develop practical techniques to assess and optimise venous conditions, thereby improving the success rate of paediatric intravenous catheter insertion.
Emergence agitation (EA) is a frequent complication in preschool children following adenotonsillectomy. This study evaluated the efficacy of intravenous nalbuphine versus esketamine for EA prophylaxis in this population. In this randomized, double-blind trial, 98 children (aged 3-7 years) undergoing adenotonsillectomy were analysed via a modified intention-to-treat approach. Patients received esketamine 0.25 mg/kg (Group E, n=33), nalbuphine 0.1 mg/kg (Group N1, n=33), or nalbuphine 0.2 mg/kg (Group N2, n=32) approximately 10 minutes before surgery completion. The primary outcome was EA incidence (maximum Pediatric Anesthesia Emergence Delirium [PAED] score ≥12 within 30 minutes post-extubation). Secondary outcomes included exploratory longitudinal Face, Legs, Activity, Cry, and Consolability (FLACC) scores, haemodynamics, and adverse events. EA incidence was significantly lower in Group N2 (6.25%) than Group E (39.39%) (Relative Risk [RR] = 0.16; 95% CI: 0.04-0.65; Bonferroni-adjusted P = 0.006). The difference between Group N1 (21.21%) and Group E was not statistically significant (RR = 0.54; 95% CI: 0.25-1.18; P = 0.354). Exploratory repeated-measures analyses showed Group N2 provided superior analgesia and more stable heart rates postoperatively compared to Group E (P = 0.004 for FLACC; P = 0.002 for heart rate). Extubation times and adverse event rates were comparable across groups (P = 0.482 and P > 0.999, respectively). Prophylactic nalbuphine (0.2 mg/kg) significantly reduces EA incidence in preschool children undergoing adenotonsillectomy compared with esketamine. Exploratory findings suggest it provides stable analgesia and haemodynamics without delaying recovery. These results may inform paediatric anaesthesia guidelines, warranting further multicentre validation.
To describe the normal heart rate (HR) of healthy newborns ≥35+0 weeks' gestation in the first 10 min after caesarean delivery (CD) with extrauterine placental transfusion, using dry-electrode ECG (NeoBeat). Single-centre, prospective observational study. Norwegian County Hospital. Newborns ≥35+0 weeks' gestation delivered by CD under regional anaesthesia were eligible for inclusion. Newborns delivered by CD under general anaesthesia, or who needed medical intervention, were excluded. NeoBeat was attached to the newborn's chest immediately following delivery. The placenta was delivered without cord clamping after 60-90 s and transferred with the newborn to a resuscitation table. Modified physiology-based cord clamping (PBCC) was performed. HR was recorded every second for 10 min. HR quartiles were calculated. Events possibly influencing HR were annotated using Liveborn Observation App. 89 newborns with a mean (SD) gestational age of 39+3 weeks (10 days) and birth weight of 3649 (536) g were included. Median (IQR) HR was 164 (117-176) and 169 (145-186) beats per minute at 20 s and 30 s, respectively, peaking at 169 (152-183) beats per minute at 4 min and then slowly decreasing to 157 (146-167) beats per minute at 10 min. HR was not significantly affected by intact-cord blood sampling (mean difference=5.4 (95% CI -1.4 to 12.1)), placental delivery (mean difference=0.7 (95% CI -3.5 to 4.9)) or cord clamping (mean difference =-0.6 (95% CI -2.1 to 0.9)). This report describes, for the first time, HR quartiles for healthy newborns ≥350 weeks' gestation from 15 s to 20 s and up to 10 min after CD with extrauterine placental transfusion and PBCC.
Syndromic conditions are frequently associated with congenital heart disease (CHD). Their distribution, recognition and prognostic impact in adults with CHD (ACHD) remain poorly characterised due to limited assessment beyond childhood. We retrospectively analysed 9826 patients with ACHD from a tertiary ACHD centre. Syndromic conditions were identified from clinical records and categorised as chromosomal, single-gene or other syndromes. Clinical characteristics, comorbidities and CHD complexity were compared between syndromic and non-syndromic patients. Multivariable Cox regression was used to evaluate associations with all-cause mortality. Of 9826 patients, 1069 (10.9%) had a syndromic diagnosis. Marfan syndrome (4.1%) and Down syndrome (3.6%) were the most common, followed by Noonan syndrome (0.7%) and 22q11.2 deletion syndrome (0.7%). Syndromic patients were younger (median 34 vs 39 years), had higher rates of pulmonary arterial hypertension (15% vs 5.9%) and sleep apnoea (7.4% vs 2.8%), but fewer traditional cardiovascular risk factors. Down syndrome clustered with atrioventricular septal defect and 22q11.2 deletion with conotruncal defects. In Tetralogy of Fallot, 4.3% had 22q11.2 deletion, mostly diagnosed in childhood; among those without prior diagnosis, most were neither clinically suspected nor tested in adulthood, suggesting under-recognition compared with paediatric cohorts. A syndromic diagnosis was independently associated with higher all-cause mortality (HR 2.06, 95% CI 1.76 to 2.42, p<0.001). We present herewith our institutional ACHD data showing that approximately 1 in 10 patients had a syndromic condition, which was clinically relevant in many respects, cardiovascular or other, including overall mortality. We submit that improved recognition and expanded access to genetic screening may provide additional information relevant to risk stratification and long-term outcome in this growing patient population.
In the perioperative setting, blood-pressure fluctuations can cause adverse outcomes, underscoring the need to identify vulnerable patients preoperatively. Imaging-based cardiovascular diagnostic tests are rapidly evolving, yet few are developed with anaesthesia in mind. This highlights an opportunity to develop techniques that evaluate the cardiovascular response to changes in blood pressure, but early feasibility studies in healthy controls are needed before clinical application. In combination with cardiovascular magnetic resonance (CMR) imaging, the isometric handgrip test has the potential to comprehensively assess how the heart and ascending aorta respond to transiently elevated blood pressure. We investigated the effect of an isometric handgrip exercise on myocardial tissue features with atrial, ventricular, and aortic function and coupling in healthy adults, assessed by CMR. In a single-centre observational study, 45 healthy adults underwent a CMR exam. Following acquisition of non-invasive blood pressure as well as cardiac and aortic rest images, participants sustained a grip of a dynamometer at 30% of their maximal strength. After a 2.5 min adjustment period, identical images were acquired. Myocardial blood volume and oxygenation were measured using parametric mapping and oxygenation-sensitive imaging. Furthermore, aortic function was assessed via vascular strain and flow parameters, while atrial and ventricular function were assessed through long-axis shortening. Coupling was calculated from atrial, ventricular and aortic parameters. The isometric handgrip exercise improved left ventricular and left atrial systolic (-18.4±2.6% to -19.3±3.3%, p < 0.05 and 36.2±6.4% to 39.6±7.9%, p < 0.01) and late diastolic function (4.4 ± 1.7% to 5.1 ± 1.6%, p = 0.04 and -11.5 ± 4.5% to -14.8 ± 5.3%, p < 0.01), assessed by long-axis shortening. Aortic strain, reflecting vascular elasticity, decreased (31.0±11.3% to 26.1±12.3%, p < 0.01). The ventricular-arterial systolic coupling index dropped (31.0 ± 11.3% to 26.1 ± 12.3%, p < 0.01), while atrio-ventricular coupling remained unchanged. While myocardial blood volume did not change (T1: 1193±25ms to 1194±22ms, p = 0.77), myocardial oxygenation decreased (-2.9% [95%CI: -4.4, -1.3], p = 0.02). The isometric handgrip exercise effectively increased afterload and elicited augmented cardiovascular function and myocardial oxygen demand in healthy adults. Our data demonstrate the physiological changes expected from increased afterload in healthy hearts. Future studies in patient cohorts are warranted to investigate if it has potential as diagnostic tool for preoperative stress testing.
Non-operative treatment for acute appendicitis (AA) in children has gained acceptance as an alternative to surgery in selected cases. Accurate preoperative differentiation between perforated and non-perforated AA is increasingly important, as the former requires emergency surgery while the latter may be managed conservatively. Previous research has suggested that low plasma sodium concentration (P-Na) may serve as a reliable predictor of perforation. This study aimed to evaluate the association between P-Na and appendiceal perforation in a prospective, multicentre paediatric cohort. Previously healthy children, aged 1-15 years, presenting with suspected AA who subsequently underwent appendectomy were enrolled at five paediatric surgical centres (Stockholm, Oslo, Berlin, Odense and Cape Town). Blood sampling on admission included concentration of C-reactive protein, plasma sodium concentration, white blood cell count and neutrophil count. 451 children met the inclusion criteria. Mean plasma sodium concentration on admission was lower in children with perforated AA as compared to non-perforated AA, mean 133.6 (standard deviation (SD) 4.0) mmol/l and 138.2 (SD 2.7) mmol/l respectively. A cut-off value of P-Na > 136 mmol/l resulted in an odds ratio of 0.11 (95% CI 0.07-0.17) for perforation. In a multivariate logistic regression analysis CRP and P-Na, respectively, were the strongest predictors of perforation. Combining the two resulted in an area under the curve of (AUC) of 0.86 in discriminating perforated AA from non-perforated AA. In this large, prospective, multicentre study, low P-Na was independently associated with an increased risk of perforated AA in children. The predictive value improved when combined with CRP.
Periacetabular osteotomy, commonly performed for prearthritic hip dysplasia, was identified as a procedure that could benefit from an enhanced recovery after surgery pathway due to wide variation in multimodal pain management and regional anesthesia practices at our institution. The global aim of this project was to implement an enhanced recovery after surgery pathway for patients undergoing periacetabular osteotomy. Our SMART aim was to achieve greater than 70% compliance for the intraoperative medication bundle elements during the first PDSA cycle. A multidisciplinary pathway was designed and implemented with key stakeholders from the Departments of Evidence Based Practice, Anesthesiology, Orthopedic Surgery, and Perioperative Nursing. Patient data from all patients undergoing periacetabular osteotomy from 2018 to the present were analyzed, which included the baseline cohort as well as outcomes from two Plan-Do-Study-Act cycles. After ERAS implementation and two subsequent Plan-Do-Study-Act cycles, we observed a decrease in hospital length of stay from 3.34 days (95% CI [2.95, 3.72]) to 2.37 days (95% CI [2.00, 2.74]) and an intraoperative medication bundle compliance of 90%. These gains occurred with minimal change in average postoperative pain scores and no hospital readmissions within 30 days of surgery. Multidisciplinary enhanced recovery after surgery pathways continue to play a critical role in standardizing perioperative care, reducing unwarranted variation, and promoting faster recovery across paediatric populations.
Enhancing the safety of paediatric patients undergoing surgery is crucial, particularly in settings with limited resources and fragmented health systems. This study focused on investigating perioperative respiratory adverse events in Brazil. To determine the incidence and associated risk factors of perioperative respiratory adverse events in pediatric surgical patients, and develop a predictive model to improve bedside decision. Observational cohort study. Two high complexity public teaching hospitals in Southern Brazil. Patients under 16 years undergoing elective or nonelective procedures between August 2020 and February 2022. The primary outcome was perioperative respiratory adverse events. Patients were prospectively followed during surgery and recovery stay. Preoperative data were collected through interviews with parents and legal guardians, and multilevel logistic regression models were used for analysis. Among 1339 children, 214 (15.9%) experimented perioperative respiratory adverse events. Desaturation was the most frequent respiratory complication, occurring in 111 children (8.3%), followed by laryngospasm (84, 6.3%). The final risk model exhibited good discrimination with an AUROC of 0.71 (95% CI 0.68-0.75) and had superior accuracy (AUROC, 0.69 vs. 0.62; p = 0.004) compared to the COLDS score in patients under 6 years. Variables included in the model were age < 1 year, current upper respiratory infection, history of prematurity, lung or airway disease, and the interaction between tracheal intubation and airway surgery. The study identifies a high incidence of perioperative respiratory adverse events (PRAE) in Brazilian pediatric surgical patients and key risk factors. A novel risk prediction model for children under 16 outperforms existing tools. These findings are vital for resource-limited settings. Future research should validate these results in varied healthcare contexts, develop targeted interventions, and assess the model clinical effectiveness to enhance pediatric surgical care and patient safety. Study registration: UTN code U1111-1274-8584.
Hydatid cyst disease is a parasitic disease induced by Echinococcus granulosus, which is still endemic in northern African countries. We report the case of a late-discovered pulmonary hydatid cyst in a four-year-old boy revealed by recent dyspnoea. The chest X-ray showed a complete white-out of the left hemithorax with mediastinal deviation, and the thoracoabdominal CT scan showed a giant pulmonary hydatid cyst encompassing the entire left lung associated with a hepatic cyst. An emergent superior pulmonary lobe resection was performed under deep general anaesthesia and selective intubation to prevent contralateral lung inundation. The evolution was favourable postoperatively.