Gianluca Bertolizio

Background/Objectives: As demand for pediatric magnetic resonance imaging (MRI) continues to increase, anesthesia assistance is often required for children who cannot cooperate. This study described the incidence and causes of same-day cancellations and evaluated the impact of a Preoperative Evaluation Clinic (PEC) for children undergoing elective MRI under sedation or general anesthesia at a tertiary-level children’s hospital. Methods: This single-center retrospective study reviewed children scheduled for elective anesthesia-assisted MRI at the Montreal Children’s Hospital between January 2013 and December 2019. Same-day cancellations were included, and reasons for cancellation were categorized as preventable, possibly preventable, or unpreventable. A pilot anesthesia-led PEC operated from January 2018 to December 2019, and its effect on same-day MRI cancellations was assessed. Results: Of 4518 MRIs scheduled between 2013 and 2019, 549 (12.2%) were canceled on the same day, with the annual cancellation rate declining from 14.6% in 2013 to 9.4% in 2019. Possibly preventable patient illness and no-shows accounted for 61% of cancellations. Of 1383 MRIs scheduled in 2018–2019, 602 (43.5%) were assessed in the PEC and 781 (56.5%) were not. Same-day cancellation occurred in 131/1383 (9.5%) cases: 48/602 (8.0%) in the PEC group versus 83/781 (10.6%) in the non-PEC group (p = 0.07). PEC attendance was associated with fewer no-shows (1.0% versus 2.8%, p = 0.017). Conclusions: Patient illness and no-shows were the main causes of same-day cancellations. PEC attendance was associated with fewer no-show cancellations, although this trend cannot be attributed to a specific intervention and should be interpreted with caution. Alternative cost-effective interventions should be explored to further reduce same-day MRI cancellations.

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

When ideal positioning is impossible: can we limit pediatric gastric ultrasound to the supine semi-recumbent position?

Can intraoperative electroencephalogram finally prevent emergence delirium in children?

Purpose 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. Methods 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. Results 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. Conclusions Virtual reality was noninferior to HFS in teaching anesthesiology nontechnical skills, and it was well tolerated and perceived. Study registration ClinicalTrials.gov (NCT05041049); first submitted 10 September 2021.

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

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

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

Purpose Children recovering from anesthesia commonly experience early postoperative negative behaviour, caused by pain and emergence delirium. Differentiating the two is challenging in young children. Perioperative pain influences the heart rate variability-derived Newborn Infant Parasympathetic Evaluation (NIPE) index and may also affect emergence delirium. We sought to investigate whether the perioperative NIPE index can discriminate between mild, moderate, or severe pain levels and can detect emergence delirium. Methods This prospective observational study enrolled children aged three years or younger undergoing elective adenotonsillectomy, tonsillectomy, or adenoidectomy. The NIPE index, the Faces, Legs, Activity, Cry, Consolability (FLACC) score, and the Pediatric Anesthesia Emergence Delirium (PAED) score were recorded in the postanesthesia care unit (PACU). The primary aim was to investigate the relationship between the postoperative NIPE index and postoperative pain severity. The secondary aims were to evaluate the association between the NIPE index and emergence delirium (PAED ≥ 10) and its delirium-specific (ED-I) and pain-specific (ED-II) components. Results Sixty-nine children were recruited. In the PACU, the mean (standard deviation [SD]) NIPE values in children experiencing moderate and severe pain were 50 (12) and 49 (14), respectively. These values were significantly lower than the mean (SD) value of 64 (13) observed in children with mild pain (mean difference moderate vs no/mild pain, −14; 95% confidence interval [CI], −17 to −11; P < 0.001, and mean difference severe vs no/mild pain, −17; 95% CI, −20 to −14; P < 0.001, respectively). The NIPE index was significantly lower in children experiencing pain-specific ED-II (mean [SD] NIPE instantaneous [NIPEi] for ED-II 49 [10] vs no ED-II 55 [13]; mean difference, −6; 95% CI, −11 to −2; P = 0.009). The NIPE index was unable to detect emergence delirium (mean [SD] NIPEi for ED, 54 [15] vs no ED, 51 [10]; mean difference, 3; 95% CI, −2 to 8; P = 0.23) or the delirium-specific component ED-I (mean [SD] NIPEi for ED-I, 55 [15] vs no ED-I, 51 [11]; mean difference, 4; 95% CI, 0 to 8; P = 0.06). Conclusion The NIPE index can identify moderate and severe postoperative pain after adenotonsillectomy but not emergence delirium in children aged three years and younger. This discrimination can be valuable in the early postoperative phase when the differentiation between pain and emergence delirium is difficult. Study registration ClinicalTrials.gov (NCT04909060); first submitted 26 May 2021.