Retrograde autologous priming and venous antegrade priming replace the cardiopulmonary bypass circuit crystalloid with patient blood to mitigate hemodilution. However, their effectiveness in pediatric patients, particularly when analyzed as continuous variables, remains unclear. We aimed to evaluate the effects of autologous priming techniques on blood conservation and patient safety during pediatric cardiac surgery. This retrospective cohort study included 191 patients (age 0-14 years; weight > 6 kg) who underwent repair of ventricular and/or atrial septal defects. The primary endpoint was the correlation between the priming volume reduction rate (proportion of priming solution replaced) and the hematocrit retention ratio (hematocrit immediately after cardiopulmonary bypass initiation divided by pre-bypass hematocrit). Secondary outcomes, including transfusion rates, regional cerebral oxygen saturation, and lactate levels, were compared between a retrograde autologous priming group (n = 144) and a control group (n = 47). All patients underwent venous antegrade priming. The priming volume reduction rate correlated positively with the hematocrit retention ratio (Spearman's ρ = 0.545, p < 0.001). Multiple regression confirmed this independent association: a 0.1 increase in the priming volume reduction rate corresponded to a 0.5% absolute increase in hematocrit at bypass initiation. The retrograde autologous priming group had a significantly higher transfusion-free surgery rate (93.1% vs. 76.6%; relative risk ratio 1.22; p = 0.005). Regarding safety and the postoperative course, no significant intergroup differences were found in trends in regional cerebral oxygen saturation (Time × retrograde autologous priming interaction) or in lactate levels. Similarly, intensive care unit and hospital lengths of stay did not differ significantly between groups. Safety analyses suggested no evidence of cerebral perfusion suppression during retrograde autologous priming. These findings suggest that even partial retrograde autologous priming is effective to mitigate hemodilution and is independently associated with improved hematocrit retention and a significant reduction in transfusion risk after initiation of cardiopulmonary bypass in pediatric patients. This study was registered with the UMIN Clinical Trials Registry, Japan, prior to commencement (Trial ID: R000067879).

Pediatric inhalational induction with a face mask is a well-recognized source of occupational exposure to waste anesthetic gases. Conventional anesthesia machine scavenging systems are ineffective in capturing extra-circuit leaks occurring at the patient-mask interface. Urinary hexafluoroisopropanol (HFIP), a metabolite of sevoflurane, is a sensitive biomarker of systemic exposure. In this prospective randomized parallel-group study, 20 anesthesiologists performing pediatric mask inductions with sevoflurane in an induction anesthesia room were allocated to work either with or without an additional external active gas scavenger positioned near the patient's face. Urine samples were collected before exposure and the following morning. HFIP concentrations were quantified by chromatography and normalized to creatinine. Between-group comparisons were performed using Welch's t-test, with a Mann-Whitney U test used as a sensitivity analysis. Urinary HFIP concentrations were significantly higher in anesthesiologists working without the additional scavenger compared with those using the scavenging system (mean ± SD: 0.63 ± 0.30 vs. 0.02 ± 0.04 μg/mL; p = 0.002; Cohen's d = 3.19). HFIP was undetectable or near the analytical detection limit in most samples obtained with scavenging. The observed difference corresponded to a very large effect size, indicating a marked reduction in systemic sevoflurane exposure when the additional scavenger was used. Use of an additional external scavenging system during pediatric mask induction was associated with a substantial reduction in anesthesiologists' biological exposure to sevoflurane, as assessed by urinary HFIP. These findings provide biological evidence supporting exposure reduction strategies during pediatric inhalational anesthesia, although the clinical significance of the observed differences remains to be established. ClinicalTrials.gov: NCT06487169.

While randomized trials show standard blade video laryngoscopy (SVL) improves first attempt tracheal intubation success in neonates and infants, data on outcomes following adoption in routine clinical practice are limited. We hypothesized that SVL use would increase over time and would be associated with higher first attempt success, fewer difficult intubations, and less hypoxemia during induction. Our primary aims were to report first attempt success and incidence of difficult intubation. Secondary aims included evaluation of temporal trends in SVL use and association of modifiable factors with hypoxemia at induction. Following IRB approval, we retrospectively reviewed anesthetics with tracheal intubation for noncardiac procedures in neonates and infants < 2 months of age at our institution from August 2012 to May 2024. Group comparisons were made using Fisher's exact test or the Chi-square test. Trends over time were analyzed using the Cochran-Armitage test of trend. Multivariable logistic regression identified factors independently associated with airway outcomes. First attempt tracheal intubation success was 80.4% (2994/3724); incidence of difficult intubation was 5.0% (186/3724). Hypoxemia at induction occurred in 5.5% (205/3724), and airway-related cardiac arrest occurred in 0.2% (6/3724). First attempt success increased over time, paralleling increased SVL use. SVL use was associated with increased odds of first attempt success (85.9%,1381/1607 SVL vs. 76.2%,1613/2117 direct laryngoscopy (DL), aOR 1.77 95% CI 1.48, 2.12, p < 0.001) and decreased odds of difficult intubation (3.1%, 49/1607 SVL vs. 6.5%, 137/2117 DL, aOR 0.47, 95% CI 0.33, 0.66, p < 0.001). Each additional intubation attempt was strongly associated with hypoxemia at induction. We found clinically important improvements in first attempt tracheal intubation over time. These changes occurred in the context of increased SVL use in conjunction with other practice changes in airway management. We advocate routine SVL use in neonates and young infants with the goal of minimizing the number of intubation attempts, a key target for reducing hypoxemia at induction.

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.

Data sharing not applicable to this article as no datasets were generated or analyzed during the current study.

Retinoblastoma (RB) is the most common intraocular malignancy diagnosed in early childhood. Treatment is extensive, requiring multiple general anesthetics to facilitate eye examinations. However, little is known how repeated exposure to general anesthesia in early childhood affects cognitive function in RB survivors. The purpose of this cross-sectional study was to examine the effects of anesthesia exposure on cognition in 14- to 26-year-old RB survivors compared with those in healthy controls. Patients who previously received care for RB (n = 98) were recruited and compared to a cohort of healthy subjects (n = 97). Participants' cognitive functioning was assessed using the Montreal Cognitive Assessment (MoCA). MoCA scores were compared between groups using Wilcoxon rank-sum tests. Relationships between MoCA scores and anesthesia exposure were assessed using Spearman's rank correlation coefficients. Multiple regression was used to evaluate the effect of anesthesia (both before the age of three and throughout childhood) on cognition. RB patients scored significantly lower than controls on the MoCA and several of its subscales (Naming, Attention, Language, and Abstraction; adjusted ps < 0.05). Total childhood anesthesia exposure was negatively associated with MoCA total scores (ρ = -0.19, p = 0.009) and some subscale scores. In regression models adjusted for covariates, each time anesthesia was administered before the age of three (β = -0.06, p = 0.02) or throughout childhood (β = -0.04, p = 0.005) was associated with a small but statistically significant decrease in cognition. Hollingshead socioeconomic status (β = 0.04, p = 0.001) and public insurance (β = -1.75, p < 0.0001) were stronger predictors of MoCA total scores than anesthesia exposure. Despite any effects of repeated anesthesia exposure in early childhood on cognition, MoCA scores for RB survivors were in the normal range. These findings add to the developing research on neurocognitive effects of anesthesia in early childhood in a population with large anesthesia exposure and minimal confounding factors. Future research should include additional measures of neurodevelopmental functioning and focus on the at-risk low socioeconomic status population. Continued follow-up and assessment of visual function in bilateral survivors are imperative.

Data sharing is not applicable to this article as no datasets were generated or analyzed during the current study.

Caudal epidural block is commonly used in pediatric surgeries but may fail due to anatomical variations or operator experience. Early recognition of block effectiveness is useful for timely pain management, improving outcomes and analgesic strategies. This study aimed to assess the ability of infrared thermography to determine caudal block success in children. In this prospective observational study, children (2-12 years) undergoing infra-umbilical surgery received a caudal block after the induction of general anesthesia. FLIR C2 thermal camera was used to assess skin temperature at the dorsum of the foot, little toe, and suprapubic area at the baseline and 2, 5, 10, and 15 min after the block. Temperature change (Δ) was calculated as the difference from baseline. The primary outcome was the ability of Δ temperature at 10 min to detect a successful block, assessed via the area under the receiver operating characteristics curve (AUC). Data from 143 patients were analyzed; 29/143 (20%) patients had failed block. In the successful block group, the temperature increased over time and was significantly higher than that of the failed block group at 10 and 15 min. At 10 min, the AUC (95% confidence interval) for detecting successful block was higher at the dorsum of the foot (0.92 [0.86-0.96]) and little toe (0.87 [0.81-0.92]) compared to the suprapubic area (0.74 [0.66-0.81]). The positive predictive value for Δ temperature at the dorsum of the foot and little toe for detecting successful block was 95%-96% with cut-offs of 1.2°C and 1.4°C, respectively. In anesthetized children undergoing infra-umbilical surgeries, infrared thermography can accurately confirm successful caudal block. Ten minutes after the block, an increase in the skin temperature by 1.2°C-1.4°C at the dorsum of the foot and little toe can confirm block success with 95%-96% accuracy.