Frank Fideler

The survival rate of extremely preterm infants (< 28 weeks of gestation) has substantially improved over the past decades. The earlier an infant is born, the more likely anesthesiological care becomes necessary (62% < 28 weeks gestation vs. 6% in term infants). Anesthesiologists are therefore increasingly involved in the management of this highly vulnerable population of neonates and preterm infants. Intraoperative events requiring intervention, such as hypotension, hypoxemia and anemia, are frequently found, occurring in up to 70% of infants younger than 32 weeks postmenstrual age and markedly increase morbidity and mortality, particularly when they occur in combination. This article reviews the current literature on three outcome-relevant domains in the anesthesiological management of neonates and preterm infants: hemodynamic management, ventilation strategies and transfusion of cellular blood products and outlines approaches by which clinical outcomes can be improved.

Craniosynostosis surgery is associated with severe diffuse bleeding, which can result in a significant coagulopathy. The aim of this study was to compare Thrombelastograph Coagulation Analyzer TEG 6s parameters and the time required for result availability with conventional coagulation parameters (CCP) during pediatric craniosynostosis surgery. In this prospective clinical observational study, 29 infants and toddlers (median age 6 months, median weight 8.5 kg) undergoing craniosynostosis surgery were enrolled. Blood was sampled preoperatively and perioperatively. Samples were analyzed by TEG 6s and CCP [prothrombin time (PT) (for analysis of quick time/INR), aPTT, fibrinogen, factor XIII, and antithrombin III]. The TEG 6s parameters (reaction time ‘ R ’, coagulation time ‘ K ’, maximum amplitude ‘MA’) and CCP were related using linear regression analyses. The required turnaround times for both methods (TEG 6s and CCP) were recorded as medians and interquartile ranges [IQR]. Highest R ² values were obtained for the CK-R–aPTT relationship ( R ² = 0.448), for the CK-MA–fibrinogen relationship ( R ² = 0.47) and for the CK-K–aPTT relationship ( R ² = 0.631). Initial availability was after 30 [9.1–14.1] min for CCP and after 16.1 min [9.1–14.1] for TEG 6s. Linear relationships between TEG 6s and CCP are rather low. This is best explained by the fact that TEG 6s and CCP do not measure identical coagulatory substrates and dynamics. However, regarding the TEG 6s-related time advantage compared to CCP and the possibility to monitor coagulation dynamics including fibrinolysis the TEG 6s is well-suited to guiding coagulation management in children undergoing craniosynostosis surgery.

Objective Recommendations on nasal intubation depths in term or preterm newborns are scarce, although this is the preferred route in some countries. Postmenstrual age (PMA) and weight-based recommendations were recently published by our group. Design A prospective quality assurance study Setting Single-centre study (University Children’s Hospital Tübingen) Patients All nasally intubated term and preterm infants between August 2021 and August 2023 Interventions Physicians were free to choose the method of orientation for the insertion depth (our recommendations vs other’s (eg, endotracheal tube (ETT) tip markers)). Subsequently, chest X-rays were performed. Correct ETT placement was defined as the tip visible between thoracic vertebrae 1–3. X-ray investigators were blinded to the method of orientation. Main outcome measures Main outcome was the rate of correct ETT placements using our previous recommendation compared with other orientations. Secondary, a subgroup analysis for infants Results 114 intubations/infants were analysed (39 weight-based; 26 PMA-based; 49 others). Median PMA (IQR) was 30 0/7 weeks (26 6/7–35 0/7), weight 1310 g (793–2300). Correct ETT placement was in 74% following our recommendations versus 55% in others (p=0.046). No difference was seen between PMA-based and weight-based recommendations (77 vs 69%; p=0.57). 48 infants Conclusions Our previously published recommendations for nasal intubation depths are applicable in routine care leading to a more accurate ETT placement than with other orientations.

Background/Objectives: Efficient postoperative recovery room care in pediatric patients is crucial for optimizing perioperative safety, patient outcome, and effective pain management. However, this area is frequently underemphasized, leading to higher complication rates compared to the operating room, which in turn increases healthcare costs. Improving pediatric recovery room care offers a significant opportunity to enhance the quality and safety of perioperative pediatric care. From an economic perspective, this is prudent; however, more importantly, every child has the right to the highest attainable standard of health, as outlined by the United Nations. Key aspects of recovery room care include ensuring adequate staffing and equipment, while also prioritizing the child’s privacy and parental presence, both of which are crucial for enhancing patient well-being. A +multimodal approach to postoperative pain management is essential for minimizing fear and stress, alongside strict adherence to established guidelines for the management of postoperative nausea, vomiting, and emergence delirium. Furthermore, addressing risk factors such as hypothermia and airway complications, as well as promoting early intake of clear fluids, plays a crucial role in optimizing pediatric recovery. Organizational strategies such as quality improvement initiatives, structured handovers, standardized care protocols with checklists, continuous staff training, and well-defined discharge criteria are further essential components to reduce translational gaps and to enhance postoperative pediatric safety. Conclusions: Improving pediatric postoperative anesthetic care is a multifaceted challenge for all healthcare providers that can significantly enhance care quality and safety while also reducing costs. Success in this area requires addressing both structural and medical factors.

Background/Objectives: In bilateral nephroblastoma and high-risk neuroblastoma in children with extensive tumor involvement of the renal vessels or pedicle, complete tumor resection with preservation of healthy renal tissue is not feasible with in situ nephron-sparing surgery or vascular replacement. The aim of this study was to present our experience with ante situ tumor resection and renal autotransplantation (RATX) in these children. Methods: A retrospective study of children with bilateral nephroblastoma and high-risk neuroblastoma who underwent tumor resection and RATX at an international referral center for pediatric surgical oncology between 2006 and 2024 was performed. RATX was performed by transection of renal vessels, ante situ mobilization, and perfusion of the kidney with Bretschneider’s solution. Tumor resection was performed on a bloodless kidney under hypothermia. Results: Ante situ tumor resection and RATX were performed at a median age of 36 months (range 13–62) in 4 children with bilateral nephroblastoma and 4 children with high-risk neuroblastoma. Complete tumor resection was achieved in all patients. One patient with neuroblastoma died of sepsis after 14 days. The 7 surviving patients showed no evidence of disease and normal to slightly decreased glomerulofiltration rates at a median follow-up of 20 months (range 3–155). Limitations include the retrospective design, small sample size, and heterogeneity of the study population due to very rare indication. Conclusions: Ante situ tumor resection and RATX is a feasible surgical approach for children with multifocal bilateral nephroblastoma or high-risk neuroblastoma who are ineligible for in situ nephron-sparing surgery or vascular reconstruction.

Daily, children undergo countless investigations and interventions, which require sedation and immobilization to ensure safety and accuracy. This remains associated with a persistent risk of sedation-induced life-threatening events as children are particularly vulnerable to adverse medical events and complications. Consequently, there is an urgent need to increase the safety of pediatric sedation and anesthesia. An ideal approach involves the use of drugs with fewer intrinsic side effects. In this context, on the basis of their pharmacokinetic properties, remimazolam (RMZ) and dexmedetomidine (DEX) were evaluated for their suitability as ideal sedatives. RMZ and DEX, both of which are currently available in pediatric medicine, have shown great promise in initial publications. To date, only very limited data concerning RMZ in small children are available. RMZ is a novel, ultrashort-acting benzodiazepine that is metabolized by tissue esterase, largely independent of organ function. It has a context-sensitive half-life of approximately 10 min, with minimal accumulation even with prolonged use. Its effects can be completely reversed with flumazenil. DEX, an isomer of medetomidine, is a potent α2-receptor-agonist with multiple indications in anesthesia and intensive care medicine. It has coanalgesic potential, allows for ‘arousal sedations’ and has a low profile for cardiorespiratory side effects. DEX is metabolized in the liver and is predominantly excreted renally. Both drugs show potential in the prevention and treatment of delirium, with DEX having additional neuroprotective effects. DEX and RMZ possess several properties of an optimal sedative, including clinically insignificant main metabolites and a broad dosage range, indicating their potential to reduce the incidence of sedation-related life-threatening events in children. However, further clinical research is necessary to better evaluate their potential risks.

Solid tumors of the cervicothoracic junction, the posterior mediastinum, or bilateral dorsal thoracic tumors represent a challenge in pediatric surgical oncology. The aim of this study was to evaluate trap-door thoracotomy and clamshell thoracotomy as surgical approaches. A single-center retrospective study of children with solid tumors in these specific localizations was performed. From 2015 to 2023, 26 children (17 girls; 9 boys) were treated at a median age of 54 months (range 8–229). Tumor resection was performed for neuroblastoma (n = 11); metastatic disease (n = 7); malignant rhabdoid tumor (n = 4); Ewing sarcoma (n = 1); inflammatory myofibroblastic tumor (n = 1); rhabdomyosarcoma (n = 1); and neurofibroma (n = 1). The surgical goal of macroscopic complete excision was achieved in all of the 14 children who underwent trap-door thoracotomy and in 11 of the 12 children who underwent clamshell thoracotomy. There were no major complications. At a median follow-up of 8 months (range 0–60), the disease was under local control or in complete remission in 66.7% of the children. In conclusion, surgical resection of solid tumors of the cervicothoracic junction in children can be performed safely and successfully with trap-door thoracotomy and with clamshell thoracotomy for posterior mediastinal or bilateral dorsal thoracic tumors.

Introduction: Cerebral oxygen desaturation during pediatric surgery has been associated with adverse perioperative outcomes. The aim of this pilot study was to analyze the frequency and severity of intraoperative cerebral oxygen desaturations and their impact on postoperative cerebral oxygen metabolism in neonates and infants undergoing pediatric surgery.Methods: In a prospective pilot study, intra- and postoperative regional cerebral oxygen saturation and blood flow were measured noninvasively using a device combining laser Doppler flowmetry and white-light-spectrometry. Thirty-seven consecutive neonates and infants undergoing noncardiac surgery under general anesthesia for more than 30 min and necessity for invasive arterial blood pressure monitoring were included. Patients with pre-known congenital structural heart disease or cerebral disease were excluded. Continuously brain monitor recording was started in sedated patients before induction of anesthesia (preoperative baseline) and was completed 1 h postoperatively in the PICU in sedated, intubated, and mechanically ventilated states at the PICU (postoperative state). Baseline and postoperative state for cerebral fractional tissue oxygen extraction and approximated cerebral metabolic rate of oxygen were calculated.Results: Seventeen (46%) of the 37 studied neonates and infants suffered from intraoperative periods of regional cerebral oxygen desaturation below 20% of the baseline (event group). Severity of cerebral desaturations was median 4.0%min/h [range 0.1-58.7; interquartile range [IQR] 0.99-21.29]. In the event group, the duration of surgery was significantly longer (median 135 min [range 11-260; IQR 113.5-167.0] vs median 46.5 min [range 11-180; IQR 30.5-159.3]; difference of -62.94; 95% confidence interval [CI] -105.17 to -20.71; p = .021). In the event group, cerebral fractional tissue oxygen extraction (median 0.41 [range 0.20-0.55; IQR 0.26-0.44] vs. median 0.27 [range 0.11-0.41; IQR 0.20-0.31]; difference of -0.11; 95% CI -0.17 to -0.05; p = .001) and approximated cerebral metabolic rate of oxygen (median 6.15 arbitrary unit [range 2.69-12.07; IQR 5.12-7.21] vs. median 4.14 arbitrary unit [range 1.78-7.86; IQR 3.82-6.31]; difference of -1.76; 95% CI -3.03 to -0.49; p = .009) were significantly higher and the cerebral regional oxygen saturation (median 58.99% [range 44.87-79.1; IQR 54.26-72.61] vs median 70.94% [range 57.9-86.13; IQR 67.07-76.59]; difference of 10.01; 95% CI 4.13-15.90; p = .002) significantly lower after surgery compared to the nonevent group.Discussion: The increase of approximated cerebral metabolic rate of oxygen could indicate an elevated oxidative energy metabolism in the "stressed" brain, due to repair processes. The increased cerebral fractional tissue oxygen extraction fits with the decreased NIRS cerebral oxygenation. Our data suggest that an increase in cerebral oxygen metabolism was the cause.Conclusion: Cerebral oxygen desaturation during major surgery in neonates and infants is associated with early postoperative increased cerebral oxygen extraction and possibly increased cerebral oxygen metabolism.

In children with bladder/prostate (BP) and perianal rhabdomyosarcoma (RMS), we use a hybrid treatment concept for those suitable, combining organ-preserving tumor resection and high-dose rate brachytherapy (HDR-BT). This treatment concept has been shown to improve outcomes. However, it is associated with specific challenges for the clinicians. The exact position of the tubes for BT is a prerequisite for precise radiotherapy. It can finally be determined only with an MRI or CT scan. We evaluated the use of an intraoperative MRI (iMRI) to control the position of the BT tubes and for radiotherapy planning in all patients with BP and perianal RMS who received the above-mentioned combination therapy in our department since January 2021. iMRI was used in 12 children. All tubes were clearly localized. No adverse events occurred. In all 12 children, radiotherapy could be started on time. In a historical cohort without iMRI, this was not possible in 3 out of 20 children. The use of iMRI in children with BP and perianal RMS improved patient safety and treatment quality. This technology has proven to be successful for the patient population we have defined and has become a standard procedure in our institution.