Codruta N. Soneru

Background: Postoperative strokes can occur in adult and pediatric patients, with both ischemic and hemorrhagic etiologies. Unfortunately, it can be difficult to distinguish stroke symptoms from lingering anesthetic‐related neurological effects. Even though there is currently no standardized screening tool, a systematic approach to symptomatic differentiation between anesthetic effects and stroke symptoms can help ensure early diagnosis of a stroke and thus minimize both morbidity and mortality. Aims: This review aims to provide an overview of perioperative stroke in pediatric and adult patients, including epidemiology, clinical presentation, and risk factors, as well as an approach to differentiating suspected stroke from anesthetic‐related neurological effects in the post‐anesthesia care unit (PACU). Discussion: In addition to symptomatology, stroke recognition in the PACU may be facilitated by incorporating consideration of the many perioperative stroke risk factors including surgery type, medications, and both modifiable and non‐modifiable patient risk factors. While PACU strokes are rare, any delay in diagnosis and thus treatment can exacerbate adverse outcomes, so it remains important to maintain suspicion of stroke in patients with concerning symptoms and risk factors. Conclusions: This focused review discusses stroke etiology, its varying risk factors and symptomatology in pediatric and adult patients, and appropriate steps to take when confronted with concerning neurological symptoms in the PACU.

Background: The retention of gastric contents at surgery presentation is a risk factor for perioperative aspiration. A preoperative fasting (nil per os; NPO) interval is widely used to reduce this risk, but this approach is based on assumptions about the prevalence of typical gastric emptying rates. We assessed NPO guidelines' reliability with ultrasound (US) imaging and suction in pediatric patients presenting for single long‐bone fracture repair after appropriate NPO intervals, when nearly all should have had empty stomachs.Aims and Methods: This prospective cross‐sectional observational study comprised 200 pediatric surgical patients. As their NPO times varied by food/drink type, we defined “weighted NPO units” as the lowest multiple of elapsed recommended NPO times between consumption and surgery for each type of food or drink. We used US to image the stomach and its contents before anesthesia induction, followed by gastric suction. We evaluated the relationships between weighted NPO units, US gastric contents grade, opioid analgesic dosage and timing, and suctioned volume.Results: Despite meeting typical NPO standards (median 14 h fasting), many patients retained nontrivial quantities of gastric contents at surgery. Weighted NPO units did not exhibit statistically‐significant relationships with either suctioned volume or US grade. However, suctioned volume did correspond well to US grade.Conclusion: NPO status may be a less reliable predictor of gastric contents at anesthesia induction in this patient population than has been assumed. Bedside US screening appears to provide more useful information for the planning of airway management.

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.

After a novel human coronavirus, severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2), was reported in China in December 2019, the disease quickly reached pandemic level. On January 30, 2020, the World Health Organization (WHO) declared that the SARS‐CoV‐2 outbreak constituted a Public Health Emergency of International Concern. The caseload has increased exponentially, with WHO reporting 182 000 global cases by March 17, 2020, and over 2.6 million by 23 April. The clinical situation is complex, with children presenting different clinical features compared to adults. Several articles with recommendations on the anesthetic management of adult patients with COVID‐19 have been published, but no specific recommendations for pediatric anesthesiologists have been made yet. This article addresses specific concerns for the anesthetic management of the pediatric population with COVID‐19.

Background: Apneic nasal oxygenation (ApOx) prolongs the time to desaturation during intubation of adult patients, but there is limited prospective evidence for apneic oxygenation in pediatric patients.Aims: We hypothesized that ApOx during operating room intubation of pediatric patients by inexperienced learners would prolong the interval before desaturation.Methods: This prospective observational study compared intubation data for 196 pediatric surgical patients intubated by learners under baseline practice (no nasal cannula), to 160 patients enrolled after adoption of routine apneic nasal cannula oxygenation at 5 L/min. The primary outcome was elapsed time between anesthetic induction and pulse oximetry (SpO₂) falling to 95, if ever.Results: Nasal cannula oxygenation during intubation by learners delayed desaturation to SpO₂ 95 (risk ratio for this event before intubation 0.05, 95% CI 0.03‐0.09; P < 0.0001).Conclusions: Apneic oxygenation via nasal cannula during intubation of pediatric surgical patients prolongs time before desaturation, thus extending the safe interval for airway management by learners.

Background. For hand surgery, brachial plexus blocks provide effective anesthesia but produce undesirable numbness. We hypothesized that distal peripheral nerve blocks will better preserve motor function while providing effective anesthesia.Methods. Adult subjects who were scheduled for elective ambulatory hand surgery under regional anesthesia and sedation were recruited and randomly assigned to receive ultrasound-guided supraclavicular brachial plexus block or distal block of the ulnar and median nerves. Each subject received 15 mL of 1.5% mepivacaine at the assigned location with 15 mL of normal saline injected in the alternate block location. The primary outcome (change in baseline grip strength measured by a hydraulic dynamometer) was tested before the block and prior to discharge. Subject satisfaction data were collected the day after surgery.Results. Fourteen subjects were enrolled. Median (interquartile range [IQR]) strength loss in the distal group was 21.4% (14.3, 47.8%), while all subjects in the supraclavicular group lost 100% of their preoperative strength,P= 0.001. Subjects in the distal group reported greater satisfaction with their block procedures on the day after surgery,P= 0.012.Conclusion. Distal nerve blocks better preserve motor function without negatively affecting quality of anesthesia, leading to increased patient satisfaction, when compared to brachial plexus block.