Pediatric anesthesia in Europe: Variations within uniformity.

Organization of healthcare strongly differs between European countries and results in country-specific requirements in postgraduate medical training. Within the European Union (EU), the European Board of Anaesthesiology has set recommendations of training for the Specialty of Anaesthesiology including standards for Postgraduate Medical Specialist training including a description for providing service in pediatric anesthesia. However, these standards are advisory and not mandatory. Here we aimed to review the current state and associated challenges of pediatric anesthesia training in Europe. We report an important country-specific variability both in training and regulations of practice of pediatric anesthesia in the EU and in the United Kingdom. The requirements for training in pediatric anesthesia varies between nothing specified (Belgium) or providing anesthesia with direct supervision to a minimum of 50 cases below 5 years of age (Germany) to 3-6 month clinical practice in a specialized pediatric hospital (France). Likewise, the regulations for providing anesthesia to children varies from no regulations at all (Belgium) to age specific requirements and centralization of all children below 4 years of age to specified centers (United Kingdom). Officially recognized pediatric anesthesia fellowship programs are not available in most countries of Europe. It remains unclear if and how country-specific differences in pediatric anesthesia training are associated with clinical outcomes in pediatric perioperative care. There is converging interest and support for the establishment of a European pediatric anesthesia curriculum.

Risk stratification in patients undergoing nonoperating room anesthesia.

PURPOSE OF REVIEW: A growing numerical and complexity of patients requiring nonoperating room anesthesia (NORA) necessitates a multidisciplinary approach of a highly experienced team in a highly technological setting of the cathlab or radiology suite. These requirements are even more magnified in the context of the coronavirus disease 2019 (COVID-19) pandemic. RECENT FINDINGS: This review describes the aspects of risk stratification both in adults and children with respect to patient morphology, airway management, cardiorespiratory function and finally future developments, which could beneficially interfere with imminent management in NORA. Moreover, some particular features related to COVID-19 are also discussed. SUMMARY: Apart from a thorough preoperative assessment, preventive strategies and well-chosen monitoring should be implemented to preclude inadvertent events in sometimes high-risk patients. Timely preventive measures and early recognition of complications could only be achieved by a multidisciplinary cooperating team. In addition, the implementation of safety measurements due to the infectious transmission to both the patients and care givers is crucial.

A genetic variant of pri-miR-182 may impact the risk for the onset of multiple sclerosis in the Iranian population.

BACKGROUND: Multiple sclerosis (MS) is the most common autoimmune disease of the central nervous system affecting young adults. SNPs can be used as genetic biomarkers to identify disease-related genes such as MS. Moreover, SNPs can be considered as important determinants for an increased risk of autoimmune diseases such as MS. Studies have shown that miR-182 is of importance in Treg cell development and function as critical regulators in autoimmune disease. So far, no study has been conducted to investigate the association between rs4541843 polymorphism in pri-miR-182 and MS. In the present study, we assessed the frequency of rs4541843 different alleles and genotypes and their association with MS risk in Iranian population. METHODS: The rs4541843 was genotyped in 81 patients with MS and 89 healthy subjects, using the PCR-RFLP method. The frequency of alleles and genotypes and the association of this polymorphism with MS risk and the gender of the patients was then statistically analyzed. RESULTS: Statistical analysis showed the protective role of AA genotype against MS risk (P = .031, OR = 0.348) while there was no significance correlation between the frequency of rs4541843 different alleles and the other genotypes. CONCLUSION: Our findings illustrated that the pri-miR-182 rs4541843 G>A polymorphism is associated with the risk of MS in Isfahan population. However, additional large-scale association studies in various ethnicities and more molecular studies are necessary to elaborate our findings.

Incidence and risk factors for adverse events during monitored anaesthesia care for gastrointestinal endoscopy in children: A prospective observational study.

BACKGROUND: Better understanding of risk factors for adverse events during monitored anaesthesia care (MAC) for paediatric gastrointestinal endoscopy may improve outcome in children. OBJECTIVES: To identify the prevalence and predictors of adverse events during MAC for paediatric endoscopy. DESIGN: An observational study. SETTING: Tertiary university hospital, single-centre cohort, from January 2010 to August 2016. PATIENTS: The prospectively collected electronic anaesthetic records of 3435 children aged up to 16 years who underwent diagnostic gastrointestinal endoscopy under MAC were analysed retrospectively. Children with an American Society of Anesthesiologists' physical status at least 4, and those requiring mechanical ventilation and therapeutic or urgent endoscopy were excluded. MAIN OUTCOME MEASURES: The prevalence and predictors of adverse events during MAC for paediatric gastrointestinal endoscopy, with particular reference to the use of different anaesthetic or sedative agents. RESULTS: Mean ±â€ŠSD age of the children was 8.5 ±â€Š4.4 years. The incidences of adverse events and adverse respiratory events were 3.4 and 3.3%, respectively. Multivariate analysis identified 12 independent predictors: age [odds ratio (OR) 0.92, P = 0.002], children's size for example underweight (OR 1.78, P = 0.039), overweight (OR 2.20, P = 0.039), (morbid) obesity (OR 4.25, P = 0.006), presence of respiratory comorbidities (OR 8.18, P < 0.001), recent respiratory infection (OR 23.55, P < 0.001) or both (OR 17.46, P < 0.001), neurological comorbidities (OR 2.18, P = 0.007), upper gastrointestinal endoscopy (OR 5.66, P < 0.001), propofol co-administration with ketamine (OR 10.34, P < 0. 001) or after sevoflurane induction (OR 44.95, P < 0.001), and propofol induction dose (OR 18.97, P < 0.001). Posthoc secondary analyses revealed a significantly higher risk of adverse events (OR 3.9, P < 0.0001) and also significantly more respiratory comorbidities and respiratory infections (P < 0.0001) in children aged less than 2 years when compared with children aged at least 2 years. No cardiovascular events were observed and outcome was uneventful. CONCLUSION: The present cohort demonstrated the feasibility and safety of MAC for paediatric gastrointestinal endoscopy by an experienced team. Although adverse events occurred rarely, their predictive factors were clinically identifiable. Applying this information in risk assessment and modifying anaesthetic management accordingly could improve outcome. TRIAL REGISTRATION: ISRCTN70362666.

Intra-operative temperature monitoring with cutaneous zero-heat- flux-thermometry in comparison with oesophageal temperature: A prospective study in the paediatric population.

BACKGROUND: Maintenance of thermal homeostasis is of crucial importance in the anesthetized pediatric patient. Gold-standard methods for central core temperature measurement are however inappropriately invasive and impractical in daily practice. The SpotOn sensor uses zero-heat-flux thermometry technology and claims to bypass the invasiveness of classical methods and still accurately display central core temperatures. Up to date no formal analysis of this method in children has taken place. AIMS: The primary objective was to assess the accuracy in comparison with esophageal temperature; the secondary objective concerned the safety of the SpotOn sensor in the pediatric patients. METHODS: Fifty-four children aged 1-12 years with an American Society of Anesthesiology classification I or II scheduled to undergo elective surgical procedures under general anesthesia for a minimum of 30 minutes were included. Exclusion criteria included: fragile forehead skin, procedures impeding proper SpotOn placement, thoracoscopic or gastroesophageal procedures, coagulopathy, hemodynamic instability, or vasoactive medication use. After sevoflurane induction, an esophageal temperature probe was placed in the lower third of the esophagus, and a SpotOn sensor on the lateral forehead. Temperatures were recorded in pairs per 1 minute intervals. Temperatures were subjected to bias analysis with 0.5°C as the a priori established clinical significance cutoff. RESULTS: Bland-Altman analysis revealed the two methods differed on average 0.14°C (95% limits of agreement: -0.39 to 0.66), with 89.5% of the differences being under 0.5°C. No significant differences could be found between the two methods for the established 0.5°C cutoff. Linear regression analysis determined the following linear regression equation: 0.837x + 5.86 (R2  = 0.738). Lin's concordance correlation coefficient of 0.83 (95% CI: 0.81-0.84). No complications were observed with the use of the SpotOn sensor. CONCLUSION: SpotOn revealed itself as accurate as an esophageal temperature probe when estimating central core temperatures under ideal conditions and over a narrow range of temperatures. No adverse effects were observed with the use of the SpotOn sensor.

Safe pediatric procedural sedation and analgesia by anesthesiologists for elective procedures: A clinical practice statement from the European Society for Paediatric Anaesthesiology.

The growing number of medical procedures performed in children that require cooperation of patients, lack of movement, anxiolysis or/and analgesia triggers the increased need for procedural sedation. This document presents the consensus statement of the European Society for Paediatric Anaesthesiology about the principles connected with the safe management of procedural sedation and analgesia (PSA) by anaesthesiologists for elective procedures in children. It does not aim to provide a legal statement on how and by whom PSA should be performed. The document highlights that any staff taking part in sedation of children must be appropriately trained with the required competencies and must be able to demonstrate regularly that they have maintained their knowledge, skills and clinical experience. The main goal of creating this document was to reflect the opinions of the community of the paediatric anaesthesiologists in Europe regarding how PSA for paediatric patients should be organized to make it safe.

Potential risks of hemolysis after short-term administration of analgesics in children with glucose-6-phosphate dehydrogenase deficiency.

OBJECTIVE: To evaluate the risk of hemolysis in children with glucose-6-phosphate dehydrogenase (G6PD) deficiency after short-term administration of analgesics, such as paracetamol, ibuprofen, tramadol, sufentanil, and parecoxib. STUDY DESIGN: This was a prospective study of children with G6PD deficiency who were treated with analgesics for 3 days after undergoing surgery. Hemoglobin (Hb) concentration, reticulocyte count, unconjugated bilirubin level, lactate dehydrogenase level, and the presence of Heinz bodies on blood smear microscopy were assessed at baseline and after analgesic treatment. Telephone interviews and clinical reviews were provided during a 7-day study period. The primary outcome was evidence of hemolysis. Statistical analyses were done using the paired Student t test or Wilcoxon signed-rank test as appropriate. RESULTS: Ten male infants (mean age, 4.3 ± 1.3 years) completed the study. The mean decrease in (Hb) concentration was -0.2 g/dL (P, not significant). The mean reticulocyte count increased by 0.1% (95% CI, 0.08%-0.2%; P = .001). However, the change in reticulocyte count was not correlated with the changes in Hb concentration or other laboratory results and was not accompanied by the clinical signs and symptoms of hemolysis. CONCLUSION: Short-term administration of paracetamol, ibuprofen, tramadol, sufentanil, and parecoxib in therapeutic dosages did not increase the risk of hemolysis in children with G6PD deficiency.