Paediatric anaesthesia: Overview

Pediatric Critical Care Medicine is the official journal of the Society of Critical Care Medicine​ and the World Federation of Pediatric Intensive and Critical Care Societies, and it is devoted to research and clinical care of critically ill or injured infants, children, and adolescents.

Abstract
Airway management in children poses unique challenges due to the different anatomy, physiology, and pathophysiology across the pediatric age span. The recently published joint European Society of Anaesthesiology and Intensive Care-British Journal of Anaesthesia (ESAIC-BJA) neonatal and infant airway management guidelines provide recommendations and suggestions to support clinicians in deciding the best strategy. These guidelines represent a framework with the most recent and up-to-date evidence, from the initial assessment to the management of normal and difficult airways up to the extubation phase. However, such guidelines have intrinsic limitations due to the lack of supporting evidence in various fields of airway management. Pediatric institutions should adopt guidelines after careful internal review according to the local circumstances, including caseload, equipment and expertise. The current narrative review focused on providing references and practical tips on pediatric airway management, which is still not completely elucidated. Moreover, the authors put particular emphasis on the influence of human factors on the overall success of tracheal intubation, the incidence of complications, and the outcomes for patients.

Abstract
Background: Emergence delirium is a well-known and common problem in children recovering from anesthesia. The five-item Pediatric Anesthesia Emergence Delirium scale is one of the most commonly used instruments for assessing this condition, but the scale has been questioned regarding its latent structure, i.e., whether its items cover just one underlying construct. It has been suggested that the scale's first three items might identify emergence delirium better than the last two.

Aim: The aim of this study was to evaluate the measurement properties of the Pediatric Anesthesia Emergence Delirium scale with a focus on its latent structure and cutoff scores, using appropriate statistical methods for ordinal data.

Methods: A total of 350 children under 7 years of age, undergoing adenoidectomy, with or without additional tonsillotomy or minor procedures like paracentesis, tongue-tie release, or cerumen removal, were enrolled in the study. At the recovery unit, emergence delirium and pain were registered.

Results: The confirmatory factor analyses demonstrated that the two-factor model, including emergence delirium-specific behaviors (first three items) and emergence delirium-nonspecific behaviors (last two items), established an excellent model fit according to the χ2 goodness-of-fit statistics, Root Mean Square Error of Approximation, Comparative Fit Index, Tucker-Lewis Index, and Standardized Root Mean Square Residual. The ordinal alpha of 0.98 and the ordinal omega of 0.96 supported the internal consistency reliability of the emergence delirium-specific behaviors. The convergent validity was supported due to a strong correlation between emergence delirium-nonspecific behaviors and the Face, Legs, Activity, Cry, and Consolability scale. The receiver-operating characteristic curve analyses resulted in two tentative cutoff scores for emergence delirium-specific behaviors¸ ≥ 6 and ≥ 8.

Conclusion: The Pediatric Anesthesia Emergence Delirium scale's first three items are a more valid and reliable measure of emergence delirium than its original five items.

Abstract
Traditional pediatric anesthetic dosing using pharmacokinetic estimates based on age and weight is often imprecise, frequently leading to oversedation. Intraoperative electroencephalography (EEG) allows visualization of the brain's response to anesthetic agents in real time, facilitating precise titration of anesthetic drug doses optimized for the individual child. The goal of EEG-guided anesthesia management is to maintain an optimal state of hypnosis during various stages of the procedure while minimizing hemodynamic instability and other adverse effects of anesthesia. This is especially important in children with less predictable anesthetic requirements, such as children with atypical neurodevelopment, altered levels of consciousness before anesthesia, or those receiving total intravenous anesthesia, neuromuscular blockers, or a combination of anesthetic agents with different mechanisms of actions. Children with limited cardiorespiratory reserves and those undergoing high-risk procedures such as cardiopulmonary bypass also benefit from EEG guidance as they have a narrower therapeutic window for optimal anesthetic dosing. Various processed EEG (pEEG) monitors are available for intraoperative monitoring in children. These monitors display a pEEG index based on the manufacturer's algorithm, purportedly indicating the patient's hypnotic state. Due to differences in developmental neurophysiology and EEG dynamics in children, pEEG indices may not always reliably indicate the hypnotic state, especially in neonates and infants. Learning to interpret nonproprietary EEG parameters including the raw EEG, spectral-edge frequency 95% (SEF95), and density spectral array can prevent overreliance on pEEG indices. This review provides an overview of the advantages of EEG guidance during clinical anesthesia, including potential reduction in anesthetic dosage, prevention of EEG suppression, and reduction in peri-operative adverse events. We describe the use of nonproprietary EEG parameters in guiding anesthesia in children for various clinical end points including laryngoscopy, surgical incision, and maintenance of anesthesia, as well as sedation. We illustrate these principles with various case examples commonly encountered during pediatric anesthesia. Lastly, we discuss strategies to expand intraoperative EEG monitoring in children through education and training programs, as well as advocate for further research to assess clinical outcomes associated with EEG guidance to support its routine use in clinical care.