Joseph P. Cravero

BACKGROUND: Spinal muscular atrophy (SMA) is a genetic disorder resulting in progressive muscle atrophy due to the degradation of motor neurons. There are limited data on anesthesia care for these patients, the incidence of anesthesia-related adverse events, and difficult intubations. The investigators aim to characterize patients with SMA who required anesthetics at a large quaternary pediatric hospital, describe the procedures being performed, report the incidence of severe anesthesia–related adverse events, and determine the incidence of difficult intubations. The investigators hypothesized that lumbar puncture for nusinersen administration would represent the most common procedure for which patients with SMA required anesthesia care. METHODS: A retrospective chart review of anesthetics provided to SMA patients from June 1, 2012, to December 30, 2023. Data obtained included procedures performed, patient characteristics, perioperative care, anesthesia technique, and outcomes. RESULTS: In total, 1804 procedures were performed for 175 patients with SMA. The majority of procedures (1423/1804, 78.9%) were for lumbar puncture for nusinersen administration; 234 of 1804 (13.0%) received general anesthesia with endotracheal tube placement; 22 of 1804 total cases (1.2%) or 22 of 234 (9.4%) of those with endotracheal tube placement met the definition of difficult intubation. There were no statistically significant associations between difficult intubation and SMA type, age, and presence of halo headframe (all P > .05). There were six severe anesthesia–related adverse events (0.33%). Of 1423 total procedures for lumbar punctures for nusinersen administration, 1254 of 1423 (88.1%) were performed with a natural airway (nasal canula, facemask, or home continuous positive airway pressure [CPAP] or biphasic positive airway pressure [BiPAP]) or pre-existing tracheostomy. CONCLUSIONS: Lumbar puncture for nusinersen administration made up the vast majority of procedures for which patients with SMA presented for anesthesia care. The incidence of difficult intubation was 9.4%, and the incidence of anesthesia-related severe adverse events was 0.33%. These results indicate the need to focus research on the perioperative and airway-related risks for this evolving and medically complex population.

OBJECTIVE: This study seeks to report the incidence and type of headache in pediatric patients with Chiari malformation type I (CM-I) at a single institution as well as headache outcomes based on management strategy (surgical vs medical). METHODS: A single-institution retrospective review from January 2003 to May 2020 identified all consecutive pediatric patients who were diagnosed with CM-I and who experienced headaches. Headaches were classified as typical, some features, and atypical CM-I headaches based on the International Classification of Headache Disorders criteria. Short- (< 6 months) and long-term (> 6 months) headache outcomes were classified as improvement or no improvement based on specific phrases in patient charts. RESULTS: A total of 112 patients met inclusion criteria. Forty patients (35.7%) experienced typical CM-I headache, 42 (37.5%) experienced some features of a CM-I headache, and 30 (26.8%) experienced atypical CM-I headache. Of the 112 total patients, 48 (42.9%) received surgical treatment for CM-I and 64 (57.1%) were managed medically. The decision to perform surgery was made at the discretion of the treating neurosurgeon in discussion with the family, and was influenced by the severity of symptoms, the presence of other neurological findings on examination, and the presence of an associated syrinx. There was no statistically significant difference in headache improvement between surgical and medical treatment regardless of headache classification. Non-White race and the presence of a syrinx were statistically significant predictors of short-term headache improvement, and female gender was a statistically significant negative predictor of long-term headache improvement. CONCLUSIONS: In this observational cohort of pediatric patients with CM-I, the authors found no difference in headache outcomes based on management strategy, regardless of the nature of the headache symptoms on presentation.

Background: Identifying the outcomes that matter in clinical research is important, especially those that matter to patients and their parents/guardians. Consistency in outcome reporting enables meaningful assessments of interventions and facilitates comparison of results across trials. The aim of this study was to develop core outcome sets for pediatric perioperative research. Methods: The authors determined core outcome sets through extensive stakeholder engagement, following a stepwise process as recommended by the Core Outcome Measures in Effectiveness Trials (COMET) initiative. They surveyed patients, parents/guardians, and healthcare providers to elicit views on the importance of perioperative outcomes. These results informed a subsequent Delphi process of expert stakeholder representatives. Final core outcome sets were agreed to after virtual face-to-face meetings of the investigators. Results: A total of 1,178 total subjects were included in the international stakeholder survey: 81 patients ages 8 to 12 yr, 99 patients ages 13 to 17 yr, 587 parents/guardians, and 411 healthcare providers (128 nurses, 147 anesthesiologists, and 136 surgeons). Subjects were recruited in Australia, Canada, China, Colombia, the Netherlands, New Zealand, South Africa, Switzerland, and the United States. Sixty-seven expert stakeholders completed a two-round Delphi, including 7 patient family representatives, 9 surgeons, 7 nurses, and 44 anesthesiologists. Proposed core outcome sets were voted on and unanimously agreed to after the virtual face-to-face meetings for the following populations: neonates, infants, children ages 1 to 12 yr, and adolescents ages 13 to 17 yr. Core outcomes for all populations included cardiovascular or respiratory adverse events, pain, assessment of pain relief, and unplanned medical attention. Quality of recovery was included in all but the neonate population, while return to normal function was also included in the adolescent population. Conclusions: The authors identified perioperative core outcome sets for four age-based pediatric populations. Researchers should include these outcomes in their studies whenever appropriate, in addition to the outcomes specific to their research question.

Purpose of the review: The collection and analysis of large amounts of data has revolutionized almost every aspect of our lives. In this review, we will explore several of the databases that are providing data on pediatric anesthesiology practice and the recent reports that have been published. Recent findings: Studies from various multicenter databases provide information on outcomes from multiple aspects of pediatric anesthesia care provision. Large databases or registries include detailed information on individual anesthetic practice, airway management, regional anesthetic practice, adverse events, and cardiac anesthesia. These collaboratives are also providing information on health systems and benchmarking of effectiveness and efficiency of care. Summary: For medical professionals, the ability to collect and learn from large datasets is not new but continues to evolve and improve as technology improves and the science of data analytics has been revolutionized. While the detail and accuracy of observational large data collaboratives may be limited, their ability to describe practice patterns, provide benchmarking for performance, and analyze outcome parameters has the potential to revolutionizing the practice of anesthesia in the future.

Background: Measuring the quality of a patient’s recovery is vital, and reliable patient-centered outcome metrics are needed for clinical investigations and quality improvement. Currently, assessment tools to measure quality of recovery in pediatric patients are lacking. This study aimed to develop a scale to assess the quality of recovery construct in pediatric patients. Methods: Using a mixed-methods investigative model, item generation was achieved using two complementary approaches. First, a comprehensive review of the literature identified tools and questions that assessed the endpoints relevant to recovery in children. Questions were categorized and then assessed by an expert Delphi panel who determined the most significant domains and items to be included. Concurrently, semistructured interviews were conducted with patients and their families to identify themes related to recovery that were important to patients and families. The resulting pilot questionnaire was administered to patients and their families presenting for elective surgery in the United States and Australia. Results: The literature search identified 41 instruments, comprising 216 questions relevant to recovery. After the initial Delphi round, the item list was reduced to 91 questions, and then to 50 questions after the second round. The themes identified in the semistructured interviews aligned with domains considered important by a panel of experts. A 50-item questionnaire was administered to 1,162 children at multiple timepoints after surgery. Item reduction and factor analysis resulted in the 20-item Pediatric Scale for Quality of Recovery that assesses the domains relevant to physical and psychologic recovery. Conclusions: The Pediatric Scale for Quality of Recovery scale is a 20-item questionnaire designed to provide a holistic representation of a child’s physical, emotional, and psychologic recovery after surgery and anesthesia. It was developed and validated with consumer involvement and a strong patient-centered focus. Once further validation has been established, it is expected to become a standardized endpoint in pediatric perioperative trials and quality improvement projects.

Background and Objectives: This educational review outlines the current landscape of pediatric anesthesia training, care delivery, and challenges across Canada, Barbados, and the United States.Descriptions and Conclusions: Approximately 5% of Canadian children undergo general anesthesia annually, administered by fellowship‐trained pediatric anesthesiologists in children's hospitals, general anesthesiologists in community hospitals, or family practice anesthesiologists in underserved regions. In Canada, the focus is on national‐level evaluation and accreditation of pediatric anesthesia fellowship training, addressing challenges arising from workforce shortages, particularly in remote areas. Barbados, a Caribbean nation, lacks dedicated pediatric hospitals but has provided pediatric anesthesia since 1972 through anesthetists with additional training. Challenges in its development, common to low‐middle‐income countries, include inadequate infrastructure and workforce shortages. Increased awareness of pediatric anesthesia as a sub‐specialty could enhance perioperative care for Barbadian children. Pediatric anesthesia encompasses various specialties in the United States, with pediatric anesthesiologists playing a foundational role. Challenges faced include recruitment and retention difficulties, supply‐chain shortages, and the proliferation of anesthesia sites, all impacting the delivery of modern, high‐quality, and cost‐effective patient care. Collaborative efforts at national and organizational levels strive to improve the quality and safety of pediatric anesthesia care in the United States.

Introduction: This international survey explored the ongoing impact of COVID‐19 on pediatric anesthesiology. It assessed COVID‐19's impact on the practice of pediatric anesthesiology, staffing, job satisfaction, and retention at the beginning of 2022 and addressed what should be done to ameliorate COVID‐19's impact and what initiatives hospitals had implemented.Methods: This survey focused on five major domains: equipment/medication, vaccination/testing, staffing, burnout, and economic repercussions. Pilot testing for questionnaire clarity was conducted by members of the Pediatric Anesthesia COVID‐19 Collaborative. The survey was administered by e‐mail to a representative of the 72 collaborative centers. Respondents were instructed to answer based on their institution's practice from February through April of 2022. Descriptive statistics with 95% confidence intervals are reported.Results: Seventy of seventy‐two institutions participated in this survey (97% response rate). Fifty‐nine (84%) were from the United States, and 11 (16%) included other countries. The majority experienced equipment (68%) and medication (60%) shortages. Many institutions reported staffing shortages in nursing (37%), perioperative staff (27%), and attending anesthesiologists (11%). Sixty‐two institutions (89%) indicated burnout was a frequent topic of conversation among pediatric anesthesiologists. Forty‐three institutions (61%) reported anesthesiologists leaving current practice and 37 (53%) early retirement. Twenty‐eight institutions (40%) canceled elective cases. The major suggestions for improving job retention included improving financial compensation (76%), decreasing clinical time (67%), and increasing flexibility in scheduled clinical time (66%). Only a minority of institutions had implemented the following initiatives: improving financial compensation (19%), increased access to mental health/counseling services (30%), and assistance with child or elder care (7%). At the time of the survey, 34% of institutions had not made any changes.Conclusion: Our study found that COVID‐19 has continued to impact pediatric anesthesiology. There are major discrepancies between what anesthesiologists believe are important for job satisfaction and faculty retention compared to implemented initiatives. Data from this survey provide insight for institutions and departments for addressing these challenges.

Most minors and young transgender persons wishing to undergo gender-affirming surgery need to seek specialists affiliated with gender affirmation programs in adult hospitals. Research suggests gender affirmation surgery has been established as an effective and medically indicated treatment for gender dysphoria. Although most data on gender-affirming surgeries are from adult populations, there is growing literature establishing their effectiveness in adolescents and young adults. Therefore, it is critical to evaluate the perioperative outcomes for gender-diverse youth to deliver safe and affirming care. The primary objective of this retrospective case series is to examine the perioperative characteristics and outcomes of patients with gender identity disorders (International Classification of Diseases [ICD]-10-code F64) who underwent chest reconstruction (mastectomy) and genital surgery (phalloplasty, metoidioplasty, and vaginoplasty) in a pediatric academic hospital. The secondary aim is to evaluate the value of a specialized anesthesia team for improving clinical outcomes, interdisciplinary communication, and further advancing the transgender perioperative experience. We identified 204 gender affirmation surgical cases, 177 chests/top surgeries, and 27 genital/bottom surgeries. These findings indicate gender-diverse individuals who underwent life-changing surgery at our institution had a median age of 18 years old, with many patients identifying as transmen. Our data suggests that postoperative pain was significant, but adverse events were minimal. The evolution of a specialty anesthesia team and initiatives (anesthesia management guidelines, scheduling, continuity, and education) necessitate direct care coordination and multidisciplinary planning for gender affirmation surgery in transgender youth.