Petra M. Meier

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.

Background: Pediatric anesthesiology has been greatly impacted by COVID‐19 in the delivery of care to patients and to the individual providers. With this study, we sought to survey pediatric centers and highlight the variations in care related to perioperative medicine during the COVID‐19 pandemic, including the availability of protective equipment, the practice of pediatric anesthesia, and economic impact.Aim: The aim of the survey was to determine how COVID‐19 directly impacted pediatric anesthesia practices during the study period.Methods: A survey concerning four major domains (testing, safety, clinical management/policy, economics) was developed. It was pilot tested for clarity and content by members of the Pediatric Anesthesia COVID‐19 Collaborative. The survey was administered by email to all Pediatric Anesthesia COVID‐19 Collaborative members on September 1, 2020. Respondents had six weeks to complete the survey and were instructed to answer the questions based on their institution's practice during September 1 ‐ October 13, 2020.Results: Sixty‐three institutions (100% response rate) participated in the COVID‐19 Pediatric Anesthesia Survey. Forty‐one hospitals (65%) were from the United States, and 35% included other countries. N95 masks were available to anesthesia teams at 91% of institutions (n = 57) (95% CI: 80%–96%). COVID‐19 testing criteria of anesthesia staff and guidelines to return to work varied by institution. Structured simulation training aimed at improving COVID‐19 safety and patient care occurred at 62% of institutions (n = 39). Pediatric anesthesiologists were economically affected by a reduction in their employer benefits and restriction of travel due to employer imposed quarantine regulations.Conclusion: Our data indicate that the COVID‐19 pandemic has impacted the testing, safety, clinical management, and economics of pediatric anesthesia practice. Further investigation into the long‐term consequences for the specialty is indicated.

Summary: Background: Operative treatment of craniosynostosis is associated with substantial blood loss, often requiring transfusion of packed red blood cells (PRBC) and coagulation products.Aims: The aim of this prospective study was to analyze thromboelastographic (TEG) parameters and platelet fibrinogen product to determine predictors of substantial blood loss, and the need for PRBC transfusion and coagulation products.Methods: With IRB approval, we enrolled 120 children undergoing craniosynostosis repair with a standardized anesthetic, fluid management, and TEG measurements at predefined times. Outcomes of interest were intraoperative blood loss, and need for PRBC transfusion and coagulation products. Multivariable logistic regression and receiver operating characteristic (ROC) curve analysis was applied to determine independent predictors of substantial blood loss and need for coagulation products.Results: One hundred and eighteen children were included in the analysis. Forty‐four required PRBC transfusion (median 26 ml·kg⁻¹; IQR: 22–42) with median blood loss of 56 ml·kg⁻¹ (IQR: 43–83). Factors associated with the PRBC transfusion included type of surgery, duration of surgery, and three TEG parameters, α‐angle, MA, and K‐time (all P < 0.001). A predictive algorithm was developed by subgroup analysis of cranial vault reconstruction (CVR) patients for substantial intraoperative blood loss (defined as ≥60 ml·kg⁻¹) and need for coagulation products with ROC‐derived cut‐off values: platelet fibrinogen product, α‐angle, P < 0.001) and ROC analysis identified MA <46 mm as the optimal cut‐off (sensitivity 86%, specificity 94%).Conclusions: Risk for substantial intraoperative blood loss can be assessed using TEG parameters and platelet fibrinogen product, whereas the need for coagulation products is strongly related to low MA. Patients susceptible to substantial blood loss can be risk stratified based on their TEG/platelet fibrinogen product profile.

Juvenile Idiopathic Arthritis (JIA) is the most common cause of non-infectious joint inflammation in children. Synovial inflammation results in pain, swelling and stiffness. Animal and adult human studies indicate that localized joint-associated inflammation may produce generalized changes in pain sensitivity. The aim was to characterize pain sensitivity in children with JIA to mechanical and thermal stimulus modalities using quantitative sensory testing (QST) at an affected inflamed joint, and compare to children in clinical remission. Generalized hypersensitivity was evaluated by comparing QST measures at the thenar eminence between JIA and healthy control children. 60 children aged 7–17 years with JIA participated. QST assessed sensory detection threshold and pain threshold at two sites: (1) affected joint (clinically active or inactive), (2) contralateral thenar eminence. Joint site included finger, wrist, knee and ankle. Clinical status was measured using objective and subjective markers of disease severity. Questionnaires assessed pain intensity and frequency, functional disability, anxiety, pain catastrophization and fatigue. QST data collected from joints were compared within JIA patients: active vs. inactive inflammation; and data from the contralateral thenar eminence were compared between JIA and healthy control cohorts in Europe [EU, (n = 151)] and the US (n = 92). Statistical analyses were performed using Kruskal-Wallis with Dunn’s post-hoc comparison, Mann-Whitney or Fisher’s exact test, where appropriate. Overall, children with JIA reported low pain scores and low degrees of functional disability. Sensory detection thresholds and pain thresholds were similar in “active” compared to “inactive” joints. Despite this, children with JIA had generalized hypersensitivity at the thenar eminence when compared to healthy children for pressure (vs. EU p < 0.001), light touch (vs. EU p < 0.001), cold (vs EU, p < 0.01; vs US, p < 0.001) and heat pain (vs EU, p < 0.05; vs US p < 0.001). JIA is associated with increased sensitivity to painful mechanical and thermal stimuli, even in absence of pain reports, or markers of disease activity. Future research investigating mechanisms underlying pain hypersensitivity in JIA is warranted; this will in turn guide pharmacologic and non-pharmacologic interventions to prevent or reverse these processes.

Summary: Endoscopic surgery is increasingly utilized in neurosurgery for all pediatric age groups. Endoscopic intraventricular neurosurgery represents a unique approach to intracranial pathology but may cause a unique set of limitations and potential complications. Important endoscopic neurosurgical techniques and their indications, perioperative anesthesia management, complications, and success rates are reviewed with special emphasis on endoscopic third ventriculostomy and endoscopic‐assisted strip craniectomy in early infancy. Despite encouraging short‐ and long‐term results of early pediatric endoscopic neurosurgery, multicenter randomized studies will be needed to further determine safety and the effect on cognitive development and quality of life.

Higher risk of perioperative blood transfusion and that those with respiratory complications are more likely to be admitted to the intensive care unit (ICU). METHODS: We retrospectively reviewed patient charts and anesthesia records of the first 100 consecutive infants who underwent ESC between May 2004 and December 2008 and follow-up evaluations until December 2009. Outcomes included (a) perioperative blood transfusion, (b) venous air embolism (VAE), (c) ICU admission, and (d) reoperation with craniofacial reconstruction procedures. Multivariable logistic regression was used to determine significant factors of patient outcomes. RESULTS: Infants ranging from 4 to 34 weeks of age (weight: 3.2 to 10.1 kg), presented for 87 single and 13 multiple ESC. Four infants had a craniofacial syndrome. The mean surgical time was 48 minutes (range: 26 to 86 minutes). Ninety-two infants had a median estimated blood loss of 23 mL (interquartile ranges [IQR]: 15 to 30 mL). Eight infants who required blood transfusion received a median amount of 17.2 mL/kg (IQR: 10.1 to 21.2 mL/kg). Body weight ≤5 kg (P = 0.04), sagittal ESC (P < 0.01), syndromic craniosynostosis (P < 0.01), and earlier date of surgery in the series (P < 0.01) were factors associated with blood transfusion. VAE was detected in 2 infants with no changes in clinical outcome. Eight infants were admitted to the ICU. Factors associated with ICU admission were blood transfusion (P < 0.001) and respiratory complications (P < 0.001). Eighty-two infants were discharged on postoperative day 1 (range: 1 to 3 days). Six infants underwent subsequent fronto-orbital advancement and 1 cranial vault reconstruction. Multiple-suture craniosynostosis (P < 0.01), associated syndromes (P = 0.03), and ICU admission after ESC (P = 0.04) were predictive of reoperation. CONCLUSIONS: Twenty percent of infants undergoing ESC had 1 or more of the following: need for blood transfusion, VAE, respiratory complications, and ICU admission. Multivariable analysis confirmed that patients with lower body weight, those with earlier date of surgery in the series, those undergoing sagittal ESC, and those with syndromic craniosynostosis had a higher rate of blood transfusion. ICU admissions often occurred in infants requiring transfusion and those with respiratory complications. Infants with multiple-suture craniosynostosis were more likely to require subsequent craniofacial reconstruction procedures....