Abstract Background: Preoperative anxiety in children causes negative postoperative outcomes. Parental presence at induction is a non-pharmacological strategy for relieving anxiety; nevertheless, it is not always possible or effective, namely when parents are overly anxious. Parental presence via video has been demonstrated to be useful in other contexts (divorce, criminal court). This study reports the feasibility of a randomized controlled trial to investigate the effect of video parental presence and parental coaching at induction on preoperative anxiety. Methods: The study was a randomized, 2 × 2 factorial design trial examining parental presence (virtual vs. physical) and coaching (provided vs. not provided). Feasibility was assessed by enrollment rate, attrition rate, compliance, and staff satisfaction with virtual method with the NASA-Task Load Index (NASA-TLX) and System Usability Scale (SUS). For the children’s anxiety and postoperative outcomes, the modified Yale Preoperative Anxiety Scale (mYPAS) and Post-Hospitalization Behavioral Questionnaire (PHBQ) were used. Parental anxiety was evaluated with the State-Trait Anxiety Inventory (STAI) questionnaire. Results: A total of 41 parent/patient dyads were recruited. The enrollment rate was 32.2%, the attrition rate 25.5%. Compliance was 87.8% for parents and 85% for staff. The SUS was 67.5/100 and 63.5/100 and NASA-TLX was 29.2 (21.5-36.8) and 27.6 (8.2-3.7) for the anesthesiologists and induction nurses, respectively. No statistically significant difference was found in mYPAS, PHBQand STAI. Conclusion: A randomized controlled trial to explore virtual parental presence effect on preoperative anxiety is feasible. Further studies are needed to investigate its role and the role of par ent coaching in reducing preoperative anxiety. Background outcomes nonpharmacological non pharmacological nevertheless effective anxious divorce, divorce (divorce court. court . court) Methods vs physical provided provided. provided) compliance NASATask NASA Task NASATLX TLX (NASA-TLX SUS. (SUS) childrens s mYPAS (mYPAS PostHospitalization Post Hospitalization PHBQ (PHBQ used StateTrait State Trait STAI (STAI questionnaire Results 4 parentpatient parent patient recruited 322 32 32.2% 255 25 5 25.5% 878 87 8 87.8 85 675100 67 100 67.5/10 635100 63 63.5/10 292 29 29. 21.536.8 215368 21.5 36.8 21 36 (21.5-36.8 276 27 6 27. 8.23.7 8237 8.2 3.7 3 7 (8.2-3.7 nurses respectively Conclusion feasible (SUS 32.2 25.5 87. 67510 10 67.5/1 63510 63.5/1 536 21.536. 21536 215 21. 368 36. (21.5-36. 23 8.23. 823 82 8. 37 3. (8.2-3. 32. 25. 6751 1 67.5/ 6351 63.5/ 53 21.536 2153 (21.5-36 8.23 (8.2-3 675 67.5 635 63.5 21.53 (21.5-3 (8.2- 67. 63. (21.5- (8.2 (21.5 (8. (21. (8 (21 ( (2

Abstract Although epidural catheter insertion under ultrasound (US) guidance in the pediatric age group has been reported in the literature, it is yet to be adopted widely in clinical practice. The incomplete fusion of bones in pediatric patients provides an acoustic window for the US.The epidural space in children is at shallow depth, hence a high-frequency probe, which provides better resolution can be used. We present a case series in which real-time US-guided epidural catheter placement was performed in 10 infants in lower thoracic and upper lumbar interspaces. We reiterate that the use of real-time US during epidural catheter placement in patients increases the success rate of epidural catheter placement while decreasing procedural complications. (US literature practice USThe depth highfrequency high frequency probe used realtime real time USguided guided 1 interspaces complications

Abstract Background: The aim of this prospective multicenter observational study was to measure the incidence of postoperative pediatric emergence delirium and to investigate the occurrence of early postoperative negative behavior within two weeks after outpatient adenoidectomy in preschool children. Methods: The study comprised 222 patients (1–7 years of age). All children received a multimodal anesthesia based on total intravenous anesthesia with propofol and remifentanil in combination with piritramid (0.1 mg.kg−1), ibuprofen (10 mg.kg−1), dexamethason (0.15 mg.kg−1), and ketanest S (0.1 mg.kg−1). We evaluated emergence delirium using the Pediatric Anesthesia Emergence Delirium Scale (PAED) at different predefined time points during the recovery period. Emergence delirium was defined as a PAED score ≥ 9 for the first three criteria. Additionally, we defined early postoperative negative behavior to be present when at least 5 of 27 criteria of the post hospitalization behavior questionnaire were positive. Results: The incidence of emergence delirium following our anesthetic regime was 23%. The incidence of early postoperative negative behavior was significantly higher among patients with emergence delirium (24% vs. 11%, p = 0.04). The two categories, “sleep disturbance” and “separation anxiety”, tested within the questionnaire for early postoperative negative behavior, were identified as the most common postoperative negative behavioral changes. Conclusion: Emergence delirium not only plays a role immediately after surgery but is also linked to early postoperative negative behavior within two weeks after outpatient adenoidectomy. Parents should be informed that early postoperative negative behavior may occur in 1 out of 4 patients if emergence delirium was present postoperatively. Background Methods 22 1–7 17 7 (1– age. age . age) 0.1 01 0 (0. mg.kg−1, mgkg1 mgkg mg.kg−1 , mg kg mg.kg−1) 10 (1 0.15 015 15 mg.kg−1. (PAED period Additionally 2 positive Results 23 23% 24% 24 (24 vs 11 11% 0.04. 004 0.04 04 0.04) categories sleep disturbance separation anxiety, anxiety anxiety” changes Conclusion postoperatively 1– 0. (0 mg.kg− ( (2 00 0.0 mg.kg

Abstract Transfusion-Related Acute Lung Injury (TRALI) is an immune-inflammatory lung pathology that manifests within the first 6-72 hours after administration of blood products. However, due to reduced awareness of TRALI, it continues to be an underreported and often underdiagnosed complication of transfusion therapy. We report a case of a 6-year-old girl with myelodysplastic syndrome and TRALI developed in the first hour after platelet transfusion. Diagnosis of TRALI is based on the exclusion of etiologic factors such as volume overload and cardio-genic pulmonary edema following transfusion. Symptoms responded to high-flow oxygen therapy, so intubation was not attempted and full recovery was achieved. TransfusionRelated Transfusion Related (TRALI immuneinflammatory immune inflammatory 672 6 72 6-7 products However therapy 6yearold yearold year old cardiogenic cardio genic highflow high flow achieved 67 7 6-

Abstract Background: We investigated the performance of the Perfusion Index (PI) derived from pulse oximetry waveform as a tool for assessment of anesthetic depth in comparison with A-line Autoregression Index (AAI) derived from analysis of Middle-Latency Auditory Evoked Potentials (MLAEP) waveform integrated by aepEXplus monitor in children receiving sevoflurane anesthesia for tonsillectomy. Methods: Forty-one patients (4–12 years old) were included in this study. The PI and AAI were recorded simultaneously every minute during different stages of anesthesia delivery. The statistical tests included descriptive analysis, significance tests, correlation tests, and Receiver Operating Characteristic (ROC) curve. The AAI served as a reference. Results: The PI significantly decreased during light anesthesia and recovery, and significantly increased during deeper planes of anesthesia, with an inverse mirror-image relationship with the AAI. A negative correlation of low to moderate degree was detected between PI and AAI during the study (p > 0.05), that reached a statistical significance at the 5th minute during sevoflurane mask induction (r = −0.457, p = 0.008). ROC analysis at an AAI < 25 extracted the best cut-off value for PI before intubation as 1.48 (AUC = 0.698 [0.537–0.859], 94.4% sensitivity, 44.5% specificity) and at 10-minute intraoperatively as 2.4 (AUC = 0.537 [0.354–0.721], 91.7% sensitivity, 31% specificity). During recovery, at an AAI ≥ 50, the best cutoff was 1.82 (AUC = 0.661 [0.46–0.863], 100% sensitivity and 50% specificity) 2 minutes before spontaneous eye opening. Conclusion: Compared with the AAI, the PI can track changes in depth of anesthesia in pediatric patients undergoing tonsillectomy under sevoflurane anesthesia. Background (PI Aline line (AAI MiddleLatency Middle Latency MLAEP (MLAEP Methods Fortyone Forty one 4–12 412 4 12 (4–1 old delivery (ROC curve reference Results recovery mirrorimage mirror image 0.05, 005 0.05 , 0 05 0.05) th r 0457 457 −0.457 0.008. 0008 0.008 . 008 0.008) cut off 148 1 48 1.4 AUC 0698 698 0.69 0.537–0.859, 05370859 0.537–0.859 537 859 [0.537–0.859] 944 94 94.4 445 44 5 44.5 specificity 10minute 10 24 2. 0537 0.53 0.354–0.721, 03540721 0.354–0.721 354 721 [0.354–0.721] 917 91 7 91.7 31 specificity. 50 182 82 1.8 0661 661 0.66 0.46–0.863, 0460863 0.46–0.863 46 863 [0.46–0.863] 100 opening Conclusion 4–1 41 (4– 00 0.0 045 45 −0.45 000 0.00 14 1. 069 69 0.6 0537085 0.537–0.85 53 85 [0.537–0.859 9 94. 44. 053 0.5 0354072 0.354–0.72 35 72 [0.354–0.721 91. 3 18 8 066 66 046086 0.46–0.86 86 [0.46–0.863 4– (4 0. 04 −0.4 06 6 053708 0.537–0.8 [0.537–0.85 035407 0.354–0.7 [0.354–0.72 04608 0.46–0.8 [0.46–0.86 ( −0. 05370 0.537–0. [0.537–0.8 03540 0.354–0. [0.354–0.7 0460 0.46–0. [0.46–0.8 −0 0.537–0 [0.537–0. 0354 0.354–0 [0.354–0. 046 0.46–0 [0.46–0. − 0.537– [0.537–0 035 0.354– [0.354–0 0.46– [0.46–0 [0.537– 03 0.354 [0.354– 0.46 [0.46– [0.537 0.35 [0.354 0.4 [0.46 [0.53 0.3 [0.35 [0.4 [0.5 [0.3 [0. [0 [

Abstract In the pediatric population, complex regional pain syndrome (CRPS) is a challenging condition that leads to chronic psychosocial dysfunction. This case is of a 12-year-old male patient, 50 kg, who, after twisting his right ankle, started to present intense pain. Without adequate diagnosis and treatment, his family sought a pain specialist. During the evaluation, a change in sensitivity and temperature was observed, besides hyperalgesia, allodynia, redness, edema, and motor dysfunction, being diagnosed with CRPS. Ultrasound-guided sciatic blocks were performed on the affected limb, increasing the interval between crises, reducing pain intensity, and promoting a return to daily activities. population CRPS (CRPS dysfunction 12yearold yearold 12 year old patient 5 kg who ankle treatment specialist evaluation observed hyperalgesia allodynia redness edema Ultrasoundguided Ultrasound guided limb crises intensity activities 1

Abstract Background: Midazolam is routinely used as preanesthetic medication in pediatric patients. Recently, dexmedetomidine has emerged as an alternative as a premedicant. We aimed to add more evidence about the efficacy and safety of two common routes of administration for pediatric premedication: oral midazolam versus intranasal dexmedetomidine. Methods: We systematically searched Randomized Controlled Trials (RCTs) involving patients ≤ 18 years old undergoing preanesthetic medication and comparing intranasal dexmedetomidine with oral midazolam. Risk Ratio (RR) and Mean Difference (MD) with 95% Confidence Intervals (95% CI) were computed using a random effects model. Trial-sequential analyses were performed to assess inconsistency. Results: Sixteen RCTs (1,239 patients) were included. Mean age was 5.5 years old, and most procedures were elective. There was no difference in satisfactory induction or mask acceptance (RR =1.15, 95% CI 0.97–1.37; p = 0.11). There was a higher incidence of satisfactory separation from parents in the dexmedetomidine group (RR = 1.40; 95% C11.13–1.74; p = 0.002). Dexmede-tomidine was also associated with a reduction in the incidence of emergence agitation (RR = 0.35; 95% CI 0.14–0.88; p = 0.02). Heart rate and mean arterial pressure were marginally lower in the dexmedetomidine group but without clinical repercussions. Conclusion: Compared with oral midazolam, intranasal dexmedetomidine demonstrated better separation from parents and lower incidence of emergence agitation in pediatric premedication, without a difference in satisfactory induction. Intranasal dexmedetomidine may be a safe and effective alternative to oral midazolam for premedication in pediatric patients. Background Recently premedicant Methods (RCTs 1 RR MD (MD 95 (95 model Trialsequential Trial sequential inconsistency Results 1,239 1239 239 (1,23 included 55 5 5. elective 115 15 =1.15 0.97–1.37 097137 0 97 37 0.11. 011 0.11 . 11 0.11) 1.40 140 40 C11.13–1.74 C1113174 C C11 13 74 0.002. 0002 0.002 002 0.002) Dexmedetomidine Dexmede tomidine 0.35 035 35 0.14–0.88 014088 14 88 0.02. 0.02 02 0.02) repercussions Conclusion 9 (9 1,23 123 23 (1,2 =1.1 0.97–1.3 09713 3 01 0.1 1.4 4 C11.13–1.7 C111317 C1 7 000 0.00 00 0.3 03 0.14–0.8 01408 8 0.0 ( 1,2 12 2 (1, =1. 0.97–1. 0971 0. 1. C11.13–1. C11131 0.14–0. 0140 1, (1 =1 0.97–1 097 C11.13–1 C1113 0.14–0 014 0.97– 09 C11.13– C111 0.14– 0.97 C11.13 0.14 0.9 C11.1 C11.

Abstract Background: Emergence delirium remains a major postoperative concern for children undergoing surgery. Nalbuphine is a synthetic mixed agonist-antagonist opioid, which is believed to reduce the incidence of emergence delirium in children. The primary objective was to examine the effect of nalbuphine on emergence delirium in children undergoing surgery. Methods: Databases of MEDLINE, EMBASE, and CENTRAL were searched from their starting dates until April 2023. Randomized Clinical Trials (RCT) and observational studies comparing nalbuphine and control in children undergoing surgery were included. Results: Eight studies (n = 1466 patients) were eligible for inclusion of data analysis. Compared to the control, our pooled data showed that the nalbuphine group was associated with lower incidence of emergence delirium (RR = 0.38, 95% CI [0.30, 0.47], p < 0.001) and reduced postoperative pain scores (MD = −0.98, 95% CI [−1.92, −0.04], p = 0.04). Conclusion: This review showed the administration of nalbuphine is associated with significant decrease in the incidence of emergence delirium and postoperative pain scores among children undergoing surgery. However, due to limited sample size, high degree of heterogeneity and low level of evidence, future adequately powered trials are warranted to explore the efficacy of nalbuphine on emergence delirium among the pediatric population. Background agonistantagonist agonist antagonist opioid Methods MEDLINE EMBASE 2023 RCT (RCT included Results n 146 patients analysis RR 038 0 38 0.38 95 0.30, 030 30 [0.30 0.47, 047 0.47 , 47 0.47] 0.001 0001 001 MD 098 98 −0.98 −1.92, 192 1 92 [−1.92 −0.04, 004 −0.04 04 −0.04] 0.04. 0.04 . 0.04) Conclusion However size evidence population 202 14 03 3 0.3 9 0.30 [0.3 0.4 4 0.00 000 00 09 −0.9 −1.92 19 [−1.9 −0.0 0.0 20 0. [0. −0. −1.9 [−1. 2 [0 −0 −1. [−1 [ − −1 [−

Abstract Background: Although cerebral palsy is a risk factor for aspiration, there is insufficient research on residual gastric volume after preoperative fasting in children with cerebral palsy. We evaluated the incidence of a full stomach by ultrasound assessment of the gastric volume in children with cerebral palsy who underwent orthopedic surgery after preoperative fasting. Methods: The patients fasted for 8 h for solid foods and 2 h for clear liquids. We obtained the gastric antral cross-sectional area using ultrasound in the semi-recumbent and right lateral decubitus positions. A calculated stomach volume > 1.5 mL.kg−1 was considered as full, which poses a high aspiration risk. The primary outcome was the incidence of full stomach, and the secondary outcomes were the qualitative gastric volume, correlation of disease severity categorized according to the Gross Motor Function Classification System with the residual gastric volume, gastric volume per body weight, and qualitative gastric volume. Results: Thirty-seven pediatric patients with cerebral palsy, scheduled for elective orthopedic surgery, were included for analysis. Full-stomach status was observed in none, and the gastric volume per body weight was 0.5 (0.4–0.7) mL.kg−1. No significant differences were observed in the residual gastric volume (p = 0.114), gastric volume per body weight (p = 0.117), or qualitative grade of gastric volume (p = 0.642) in relation to disease severities. Conclusion: Children with cerebral palsy who fasted preoperatively had empty or nearly empty stomachs. Further studies are required to determine the optimal fasting duration for such children. Background Methods liquids crosssectional cross sectional semirecumbent semi recumbent positions 15 1 5 1. mLkg1 mLkg mL kg mL.kg− Results Thirtyseven Thirty seven analysis Fullstomach Full none 05 0 0. 0.4–0.7 0407 4 7 (0.4–0.7 p 0.114, 0114 0.114 , 114 0.114) 0.117, 0117 0.117 117 0.117) 0.642 0642 642 severities Conclusion stomachs mL.kg 0.4–0. 040 (0.4–0. 011 0.11 11 0.64 064 64 0.4–0 04 (0.4–0 01 0.1 0.6 06 6 0.4– (0.4– 0.4 (0.4 (0. (0 (

Abstract The relation between surgery and anesthesia safety in children and a country’sHuman Development Index (HDI) value has been described previously. The aim of this narrative review was to provide an update on the mechanisms and risk factors of Anesthesia-Related Cardiac Arrest (ARCA) in pediatric surgical patients in countries with different HDI values and over time (pre-2001 vs. 2001–2024). Electronic databases were searched up to March 2024 for studies reporting ARCA events in children. HDI values range from 0 to 1 (very-high-HDI countries: ≥ 0.800, high-HDI countries: 0.700–0.799, medium-HDI countries: 0.550–0.699, and low-HDI countries: < 0.550). Independent of time, the proportion of children who suffered perioperative Cardiac Arrest (CA) attributed to anesthesia-related causes was higher in very-high-HDI countries (50%) than in countries with HDI values less than 0.8 (15-36%), but ARCA rates were higher in countries with HDI values less than 0.8 than in very-high-HDI countries. Regardless of the HDI value, medication-related factors were the most common mechanism causing ARCA before 2001, while cardiovascular-related factors, mainly hypovolemia, and respiratory-related factors, including difficulty maintaining patent airways and adequate ventilation, were the major mechanisms in the present century. Independent of HDI value and time, a higher number of ARCA events occurred in children with heart disease and/or a history of cardiac surgery, those aged younger than one year, those with ASA physical status III-V, and those who underwent emergency surgery. Many ARCA events were determined to be preventable. The implementation of specialized pediatric anesthesiology and training programs is crucial for anesthesia safety in children. countrysHuman country sHuman (HDI previously AnesthesiaRelated Anesthesia Related (ARCA pre2001 pre 2001 (pre-200 vs 2001–2024. 20012024 2001–2024 . 2001–2024) 202 veryhighHDI very high 0800 800 0.800 highHDI 07000799 700 799 0.700–0.799 mediumHDI medium 05500699 550 699 0.550–0.699 lowHDI low 0.550. 0550 0.550 0.550) CA (CA anesthesiarelated related 50% 50 (50% 08 8 0. 1536%, 1536 15 36% , 36 (15-36%) medicationrelated medication cardiovascularrelated cardiovascular hypovolemia respiratoryrelated respiratory ventilation century andor or year IIIV, IIIV III V, V III-V preventable pre200 200 (pre-20 2001202 2001–202 20 080 80 0.80 0700079 70 79 0.700–0.79 0550069 55 69 0.550–0.69 055 0.55 5 (50 1536% 153 3 (15-36% pre20 (pre-2 200120 2001–20 2 070007 7 0.700–0.7 055006 6 0.550–0.6 05 0.5 (5 (15-36 pre2 (pre- 20012 2001–2 07000 0.700–0. 05500 0.550–0. ( (15-3 (pre 2001– 0700 0.700–0 0.550–0 (15- 070 0.700– 0.550– (15 07 0.700 (1 0.70 0.7