I read with interest today’s PAAD on artificial intelligence in perioperative care here. I fully agree with your assertion that “the safest near-term role for AI is for the ‘A’ in ‘AI’ to stand for ‘augmented’ rather than ‘artificial’ or ‘automated’”. While machine algorithms may eventually provide unceasing vigilance, improved response times, closer hemodynamic control, and a host of other benefits, humans have been caring for the sick since before we were humans at all. While our scientific understanding has improved and the tools at our disposal have revolutionized techniques and outcomes, from prehistory the crux of quality care has been a recognition of our shared humanity with our patients. We must continue to advance our field, and capitalize on the advantages provided by AI, without losing our key role in understanding and steering the care being given. Because while a machine can be programmed to try and keep a child alive, it cannot understand the cost of failure.

From Sarah Rebstock, MS, MD, PhD, FAAP, Basic and advanced certified by the American Board of AI in Medicine

As an innovation director and having been in the innovation space since 2011. I have been keeping myself updated on where innovation in medicine is going. This is an incredibly timely PAAD. I just finished basic and advanced certification from the American Board of AI in Medicine.

I think Augmented is the important key word. Physicians are still responsible for decisions that are made by AI, and I am not sure this will ever change, making it incredibly important to understand and being able to discuss and explain medicine and the safe and ethical use of medical data for AI in medicine. The amount of medical data is doubling every 3-6 months, with providers generating around 137 terabytes of data on a daily basis, most of the data being unstructured and difficult to manage and use in a constructive way. Being able to understand what data engineers, data scientists do and be able to translate what we do into how they manage and structure AI programming for the data will direct the future of medicine.

We have had a couple of AI winters due to many historical environmental factors (internet of things, computer power, computer storage, and expectation management), so AI was slower to be adopted. However, this is no longer the case. AI is expanding exponentially into our lives. The current direction of AI and its ability to outperform humans in some areas is not going away, and in fact is becoming an imperative to be able for physicians to spend more quality time with the patients. We will not be replaced by AI machines, but we will be replaced by those who can work with AI and accept and manage its trajectory for medicine. AI is becoming medico-legally recognized, having cases against some radiologists who did not use AI in decision making. I think AI will eventually fundamentally change medicine, academia, and what we understand and accept as evidence-based medicine.

The use of AI should come in steps that we monitor and understand with ethics and patient safety in mind. We must be training physicians at all levels of their career about AI, data, ethics, and its use in medicine for the greater good of medicine. We should not be using AI and not understanding what we are doing, who owns the data we are putting into the AI models, and understanding the consequences. There are very wise voices in business stating that what we program AI to do should also be risk stratified, and if the consequences have catastrophic potential, then we cannot be allowing AI to run without governance, and intimate knowledge of what it is doing. AI is only as good as the programming of the model and the quality of data put into the model. Data scientists and engineers should be working side by side with physicians who understand their branch of medicine. Ergo the importance of augmented. Physicians must be intimately involved with AI data management, programming, and implementation going forward.

Courses for AI are available from the ABAIM. I have no financial interests or stock in any part of the ABAIM.

From Eric Jackson, MD, MBA, Disclosure: I am a paid consultant to Masimo Corporation and Chair of its Health Equity Advisory Board, and I formerly served as the company’s SVP and Chief Medical Officer. Masimo competes in the perioperative monitoring market. I am also a former Chief Innovation Officer at Nemours Children’s Health. I have no financial relationship with any manufacturer of the hypotension prediction technology discussed below.

Thank you for putting Han et al. article in front of the PAAD readership. This one lands close to home. I have worked these questions from both sides of the table: on AI governance at Nemours Children’s Health, and at Masimo, where I have argued the vendor’s case. The view is not the same from each chair, and that is most of my point.

First, the economics. The decisive question for a department is not whether a model predicts, but whether it pays. The prize is real: because complications are expensive and labor is our largest line item, a tool that truly prevents an event can improve outcomes, reduce workload, and lower cost at once. Economists call that dominance. The harder and more common case is a tool that costs more and works better. That turns on an incremental cost per quality-adjusted life-year judged against a stated threshold, paired with a budget-impact analysis, because cost-effective and affordable are not the same finding. Prediction alone establishes none of this. Intraoperative hypotension prediction is our most instructive case, being the one with real trial data. One randomized trial reduced the time-weighted average of MAP below 65 mmHg¹; a larger pilot trial found no difference at all (0.14 vs. 0.14 mmHg)²; and a 2026 meta-analysis of 14 randomized trials (n = 2,030) found no reduction in acute kidney injury (RR 0.87, 95% CI 0.71–1.07), mortality, or length of stay³. Independent analyses suggest a simple MAP alert at 70 to 75 mmHg delivers nearly the same warning time^4,5. A tool that moves a surrogate but not an outcome, at proprietary cost and with an added alert burden, has earned none of it even when it “works.” I have sat on the selling side of that distinction, and it is an uncomfortable one.

Second, governance. The figure you cite from Arina et al. deserves to be the headline: of 103 perioperative machine-learning studies, only 13% were externally validated and 90% carried high or unclear risk of bias⁶. Be precise, too, about what regulatory authorization means. Roughly 96% of FDA-authorized AI devices are 510(k) cleared, a finding of substantial equivalence to a predicate rather than an independent demonstration of benefit⁸; of 521 authorizations reviewed in 2024, 43% had no published clinical validation and 22 had been tested in a randomized trial⁹. Cleared is not approved, and neither is proven. Before any purchase, a department should require a named physician owner, a pre-specified performance-drift threshold, and an agreed sunset provision if the model fails to meet it. Algorithmovigilance without an accountable owner and a line-item budget is a slogan, not a safeguard.

Third, pediatrics. Antel et al. identified 40 studies, 60% of them risk-factor prediction, and noted the near-absence of external validation⁷. Children differ in physiologic reserve, weight-based dosing, and case mix, and the events that matter most are rare enough that samples stay thin. Adult models should be presumed non-transferable until demonstrated otherwise. That arithmetic favors children: a catastrophic event prevented in a four-year-old returns far more life-years than the same event prevented in an adult, so the binding constraint in pediatrics is not price but whether the effect is real. That is an argument for closing the evidence gap, not for tolerating it.

None of this argues against adoption. It argues for holding software to the standard we already hold any new device.

References

1. Wijnberge M, et al. JAMA. 2020;323(11):1052–1060.

2. Maheshwari K, et al. Anesthesiology. 2020;133(6):1214–1222.

3. Wang SS, et al. A&A Practice. 2026;20(4):e02180.

4. Enevoldsen J, Vistisen ST. Anesthesiology. 2022;137(3):283–289.

5. Rellum SR, et al. Eur J Anaesthesiol. 2025;42(6):527–535.

6. Arina P, et al. Anesthesiology. 2024;140(1):85–101.

7. Antel R, et al. BJA Open. 2023;5:100125.

8. Loganathan G, et al. J Med Artif Intell. 2025.

9. Chouffani El Fassi S, et al. Nat Med. 2024;30(10).

From Jenni Majumdar, PhD, CRNA, Assistant Professor, Hunter College, Nurse Scientist, Memorial Sloan Kettering Cancer Center, Writer, Art of Anesthesia, Editor-in-Chief, Journal of Nurse Anesthesia Education

The result that looks like a failure on paper is the one I'd point people to: voluntary reporting went up. That number only moves when staff believe a report will land on a process instead of on a person. Anesthesia has its own version of this in the mid-1980s decision to make pulse oximetry and capnography mandatory in every case — it worked because it removed the judgment call rather than asking people to be more careful. And the ARCC behavior that actually gets tested in my room is unglamorous: someone leaning on an arm that's already positioned, or reaching for the bed remote on a patient who can't object. How that gets received on the third case of the day tells you more about the culture than the stand-down does.

Original article

SODa-BIC Investigators and the Australian and New Zealand Intensive Care Society Clinical Trials Group; Serpa Neto A, et al. Sodium Bicarbonate for Critically Ill Adults with Metabolic Acidosis and Shock. N Engl J Med. 2026 Jun 12. doi: 10.1056/NEJMoa2600526. Epub ahead of print. PMID: 42283370.

Original article

Granfeldt A, Kirkegaard BL, Vallentin MF,et al. Sodium Bicarbonate for In-Hospital Cardiac Arrest: A Randomized Clinical Trial. JAMA. 2026 Jun 11:e2610628. doi: 10.1001/jama.2026.10628. Epub ahead of print. PMID: 42273960; PMCID: PMC13261510.

Here’s the original posting:

Who doesn’t like werewolf and vampire stories/movies?  Although stories have described multiple ways to kill a vampire, the classics (drive a stake through the heart and exposure to sunlight) remain the most popular and effective. 

“Vampires?” you ask. “In the PAAD?” Well, YES!  In pediatric anesthesia there are several vampire ideas that simply cannot be killed even with exposure to sunlight (evidence). Two that we’ve discussed in the past are prolonged preoperative fasting and the use of sodium bicarbonate to treat acidosis during pediatric in hospital cardiac arrests.    

Mythology, dogma, and ingrained habits have a way of persisting despite evidence to the contrary.  Indeed, implementation science tells us that it can take up to 20 years for evidence-based findings to make their way into widespread clinical practice.1, 2   When Jay and Myron were in training almost 50 years ago, dinosaurs ruled the earth and resuscitation science was still in its infancy.  The “cocktail” for CPR included the ABC’s (airway-breathing-circulation) and D’s (drugs – epinephrine-bicarb-calcium).  Over the past 30 years, rigorous outcomes studies have demonstrated the clear importance of early recognition or low-flow or no-flow states, early defibrillation (when appropriate), and timely initiation of high quality chest compressions.3  All of these have been incorporated in the regularly updated resuscitation guidelines published by the American Heart Association (AHA) and are reflected in SPA’s PediCrisis app V2.3 On the other hand, the routine use of calcium in resuscitation was removed from recommendations more than 15 years ago. And, with the exception of its use in certain circumstances like in the treatment of hyperkalemia or sodium channel blocker ingestions, the routine use of sodium bicarbonate in CPR is also no longer recommended. And yet, the use of bicarb during pediatric in-hospital resuscitations continues despite evidence that it may negatively affect outcomes.  Since sunlight/evidence isn’t working, the authors for today’s PAAD and the accompanying editorial attempt to drive a stake into the heart of bicarb – to once and for all slay this vampire idea!

Original article

Cashen K, et al. Sodium Bicarbonate Use During Pediatric Cardiopulmonary Resuscitation: A Secondary Analysis of the ICU-RESUScitation Project Trial. Pediatr Crit Care Med. 2022 Oct 1;23(10):784-792. doi: 10.1097/PCC.0000000000003045. Epub 2022 Jul 26. PMID: 35880872; PMCID: PMC9529841.

Editorial

DelSignore L. Sodium Bicarbonate and Poor Outcomes in Cardiopulmonary Resuscitation: Coincidence or Culprit? Pediatr Crit Care Med. 2022 Oct 1;23(10):848-851. doi: 10.1097/PCC.0000000000003059. Epub 2022 Oct 3. PMID: 36190362.

Here’s the problem, in a nutshell: “Historically, acidosis has prompted the use of sodium bicarbonate as a theoretical buffer with the intent of improving hemodynamics during pediatric in-hospital arrests. Yet, sodium bicarbonate is not a benign therapy. With repeated use, it can lead to hyperosmolarity, electrolyte derangements (hypokalemia, hypocalcemia, and hypernatremia) and paradoxically, intracellular acidosis.  Sodium bicarbonate rapidly combines with hydrogen ion (H+) to produce carbonic acid (H2CO3) which metabolizes into byproducts of water (H2O) and carbon dioxide (CO2). If effective ventilation is not present, then intracellular acidosis will result from rapid intracellular diffusion of CO2. This can decrease myocardial contractility and make myocytes less responsive to vasoactive agents, thereby working against the goal of improving hemodynamics. CO2 can also rapidly diffuse into the cerebrospinal fluid and worsen CNS acidosis, which may be problematic in patients undergoing cardiopulmonary resuscitation (CPR) who are at risk for poor neurologic outcomes.”1 

Cashen et al.4 in a multi-center data registry, analyzed the association between sodium bicarbonate administration during pediatric in-hospital arrests and patient outcomes.  Cutting to the chase, they found that bicarbonate administration during pediatric in-hospital arrests decreased survival to hospital discharge and decreased survival to hospital discharge with favorable neurologic outcomes.  As you probably suspected, bicarbonate use was more common in specific contexts: sicker patients, longer resuscitations, patients with pre-existing cardiac diagnoses, pulseless rhythms at the time of arrest, and hypotension as the immediate cause.  Thus, were these results a chicken and egg phenomenon?  Did bicarbonate administration worsen outcomes, or were the patients who received bicarbonate sicker and in worse condition to begin with?  Based on their analysis of the data, the authors make the case (once again!) that bicarbonate causes harm.

Additionally, Cashen et al.4 found that despite limited AHA indications for sodium bicarbonate during pediatric in-hospital cardiac arrests, it was administered in almost half of these events.  Why?  Our good friend and colleague, Dr. Peter Davis at the Children's Hospital of Pittsburgh, always likes to point out that context matters. Personal habits and anecdotal experiences and memories of your last disastrous experience are powerful influences that affect your responses to the next crisis.  Thus, if you are faced with an in-hospital arrest, your decision to use or not use bicarb will be very much influenced by how you treated your last cardiac arrest patient and how that arrest turned out rather than from evidence-based studies.  Further, if an on-going cardiac arrest is not going well and there is no return of spontaneous circulation, it’s almost impossible to not say to yourself, “What’s the harm in trying it?”  But over the past two decades the data has been accumulating that there may be harm in trying sodium bicarbonate during arrests when there is not an indication for sodium bicarbonate.  In anesthesia and critical care, we often feel a “duty to do something.” Sometimes, the best thing you can do for the patient’s survival and outcome may be to NOT do something.  We fear that this vampire will never die, but we applaud the authors for continuing to try to slay it.  And we encourage you to think twice the next time you consider sodium bicarbonate (without an indication) during CPR. What do you think? Send your comments to Myron (myasterster@gmail.com) and he will post in a Friday reader response.

References

1.           DelSignore L. Sodium Bicarbonate and Poor Outcomes in Cardiopulmonary Resuscitation: Coincidence or Culprit? Pediatric critical care medicine : a journal of the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies. Oct 1 2022;23(10):848-851. doi:10.1097/pcc.0000000000003059

2.           Bauer MS, Kirchner J. Implementation science: What is it and why should I care? Psychiatry Res. Jan 2020;283:112376. doi:10.1016/j.psychres.2019.04.025

3.           Topjian AA, Raymond TT, Atkins D, et al. Part 4: Pediatric Basic and Advanced Life Support: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. Oct 20 2020;142(16_suppl_2):S469-s523. doi:10.1161/cir.0000000000000901

4.           Cashen K, Reeder RW, Ahmed T, et al. Sodium Bicarbonate Use During Pediatric Cardiopulmonary Resuscitation: A Secondary Analysis of the ICU-RESUScitation Project Trial. Pediatric critical care medicine : a journal of the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies. Oct 1 2022;23(10):784-792. doi:10.1097/pcc.0000000000003045

Original article

Meier J, Lasocki S, Meybohm P, Filipescu D, Haas T, Pottecher J, Rineau E, Romagnoli S, Bergholz A, Saugel B. Physiology, monitoring, and optimisation of perioperative tissue oxygenation: a narrative review. Br J Anaesth. 2026 Jun;136(6):1761-1775. doi: 10.1016/j.bja.2026.01.047. Epub 2026 Apr 13. PMID: 42012193; PMCID: PMC13197960.

Most perioperative interventions currently target the macrocirculation – think blood pressure, heart rate, and oxygen saturation. Increasing cardiac output theoretically enhances oxygen delivery, and earlier studies suggested there is benefit from goal-directed therapy. However, several recent multicenter randomized trials failed to demonstrate consistent improvements in patient-centered outcomes using protocolized cardiac output optimization.(3, 4) Meier et al. conclude that cardiac output should not be universally maximized but should rather be interpreted in relation to each patient’s metabolic requirements, with attention to tissue perfusion/oxygenation.(5)

Similarly, while adult observational studies consistently associate intraoperative hypotension with acute kidney injury and myocardial injury, randomized trials have not demonstrated improved outcomes with higher MAP thresholds (75–90 mmHg) compared to conventional targets of 60–65 mmHg.(6) Current evidence therefore supports maintaining intraoperative MAP above approximately 60–65 mmHg while treating the underlying cause of hypotension rather than blood pressure alone. Recognition of distinct hypotension “endotypes” including vasodilation, hypovolemia, myocardial depression, obstruction (e.g., tension pneumothorax) and bradycardia may facilitate more individualized management.

Fluid therapy, vasopressors, inotropes, blood transfusion, ventilatory optimization, and correction of anemia remain important therapeutic tools, but the review stresses that all interventions should be directed toward restoring effective oxygen delivery rather than isolated physiological variables. As many of you may have experienced, lactic acid production (a sign of oxygen debt at the cellular level) can occur even with apparently adequate hemodynamics. This may result from dyoxia (as with cyanide poisoning or other mitochondrial pathology) or regional tissue hypoperfusion. Other signs of ongoing anaerobic metabolism should be sought while simulatenously evaluating the adequacy of the macroperfusion (i.e. blood pressure).

Future Directions

The review concludes that future perioperative care will (and should) increasingly integrate macrocirculatory, microcirculatory, and mitochondrial physiology into individualized hemodynamic management. The development of practical bedside monitors capable of continuously assessing microvascular perfusion and cellular oxygen metabolism represents a major research priority. Equally important is the identification of therapeutic interventions capable of directly improving microvascular function and mitochondrial oxygen utilization. Until such evidence emerges, clinicians should recognize tissue oxygenation as a complex physiological continuum rather than a process adequately represented by systemic blood pressure or oxygen saturation alone.

What do you think? Send your thoughts and comments to Myron (myasterster@gmail.com) and he will post in a Friday Reader Response.

References

1. Meier J, Lasocki S, Meybohm P, Filipescu D, Haas T, Pottecher J, et al. Physiology, monitoring, and optimisation of perioperative tissue oxygenation: a narrative review. British journal of anaesthesia. 2026;136(6):1761–75. Epub 20260413. doi: 10.1016/j.bja.2026.01.047. PubMed PMID: 42012193; PubMed Central PMCID: PMC13197960.

2. Shoemaker WC, Appel PL, Kram HB. Role of oxygen debt in the development of organ failure sepsis, and death in high-risk surgical patients. Chest. 1992;102(1):208–15. doi: 10.1378/chest.102.1.208. PubMed PMID: 1623755.

3. Funcke S, Schmidt G, Bergholz A, Argente Navarro P, Azparren Cabezón G, Barbero-Espinosa S, et al. Cardiac index-guided therapy to maintain optimised postinduction cardiac index in high-risk patients having major open abdominal surgery: the multicentre randomised iPEGASUS trial. British journal of anaesthesia. 2024;133(2):277–87. Epub 20240526. doi: 10.1016/j.bja.2024.03.040. PubMed PMID: 38797635; PubMed Central PMCID: PMC11282469.

4. Cardiac output-guided haemodynamic therapy for patients undergoing major gastrointestinal surgery: OPTIMISE II randomised clinical trial. BMJ (Clinical research ed). 2024;387:e080439. Epub 20241203. doi: 10.1136/bmj-2024-080439. PubMed PMID: 39626899; PubMed Central PMCID: PMC12036648.

5. Saugel B, Annecke T, Bein B, Flick M, Goepfert M, Gruenewald M, et al. Intraoperative haemodynamic monitoring and management of adults having non-cardiac surgery: Guidelines of the German Society of Anaesthesiology and Intensive Care Medicine in collaboration with the German Association of the Scientific Medical Societies. Journal of clinical monitoring and computing. 2024;38(5):945–59. Epub 20240221. doi: 10.1007/s10877-024-01132-7. PubMed PMID: 38381359; PubMed Central PMCID: PMC11427556.

6. Kant M, van Klei WA, Hollmann MW, de Klerk ES, Otterspoor LC, Besselink MG, et al. Proactive vs Reactive Treatment of Hypotension During Surgery: The PRETREAT Randomized Clinical Trial. Jama. 2025;334(21):1905–14. doi: 10.1001/jama.2025.18007. PubMed PMID: 41076587; PubMed Central PMCID: PMC12516513.

Myron Yaster MD

Original article

Meier J, Lasocki S, Meybohm P, Filipescu D, Haas T, Pottecher J, Rineau E, Romagnoli S, Bergholz A, Saugel B. Physiology, monitoring, and optimisation of perioperative tissue oxygenation: a narrative review. Br J Anaesth. 2026 Jun;136(6):1761-1775. doi: 10.1016/j.bja.2026.01.047. Epub 2026 Apr 13. PMID: 42012193; PMCID: PMC13197960.

At the cellular level, oxygen is the terminal electron acceptor in mitochondrial oxidative phosphorylation, enabling efficient adenoside triphosphate (ATP) synthesis. We are not going to torture you with the actual Krebs cycle, which is the central metabolic pathway by which all aerobic organisms oxidize acetyl-CoA from carbohydrates, fats, and proteins to produce reducing equivalents (NADH and FADH₂) that drive ATP synthesis via oxidative phosphorylation.

(Figure from NEJM OpenEvidence)

Under hypoxic conditions, cells shift toward anaerobic glycolysis, producing lactate while generating approximately 90% less ATP than oxidative metabolism. Persistent oxygen deficiency therefore impairs protein synthesis, cellular repair, membrane integrity, and ultimately organ function. It is also worth noting that while lactate is a classic marker of anaerobic metabolism, hyperlactatemia can also be driven by stress-induced beta-adrenergic stimulation or impaired hepatic clearance. Therefore, hyperlactatemia is not pathognomonic for impaired tissue oxygenation.

Meier et al. emphasize that adequate cellular oxygen utilization depends not only on oxygen availability but also on intact mitochondrial function, enzymatic activity, and cellular redox balance. Even when oxygen delivery is preserved, mitochondrial dysfunction may produce “cytopathic hypoxia,” in which oxygen cannot be effectively utilized. Integrating these cellular concepts into peri-operative resuscitation curricula is vital. Clinical simulation training should teach recognition of tissue-level failure in addition to macrocirculatory failure.

Monitoring Macrocirculation

Routine intraoperative monitoring remains heavily focused on macrocirculatory variables,including electrocardiography, pulse oximetry, and blood pressure measurement.Monitoring perfusion pressure requires measurements of inflow pressure (usually mean arterial pressure) and outflow pressure (central venous pressure or compartment pressure). Central venous pressure and regional compartment tissue pressure (e.g., intracranial pressure, bladder/gastric pressure) are monitored only in select situations, and seemingly with decreasing frequency.

Advanced hemodynamic monitoring may include:

• Cardiac output measurement

• Pulse contour analysis

• Esophageal Doppler analysis

• Thermodilution techniques

• Periodic assessment of hemoglobin and arterial blood gases

Despite availability, cardiac output monitoring remains underutilized during major noncardiac surgery, limiting direct assessment of oxygen delivery. Furthermore, while cardiac output provides the ‘supply’ side of the equation, monitoring Mixed Venous (SvO2) or Central Venous Oxygen Saturation (ScvO2) offers a crucial window into the global balance of oxygen delivery versus consumption (i.e. “oxygen debt”). A dropping ScvO2 often provides the earliest warning that a patient has declining reserve to meet metabolic demands, typically before hypotension or arterial hypoxemia occurs.

Emerging Microcirculatory Monitoring

Because macrohemodynamic stability does not guarantee adequate tissue perfusion, direct assessment of the microcirculation has become an area of intense investigation.

Several promising technologies are reviewed:

• Handheld vital microscopy, which allows direct visualization of capillary blood flow and vessel density, although it is currently limited by operator dependence and offline image analysis.

• Near-infrared spectroscopy (NIRS), a noninvasive monitoring technique that provides information about regional tissue oxygen saturation (3). By measuring the relative absorption of light by oxygenated and deoxygenated hemoglobin. When applied to a tissue, NIRS values are predominantly determined by oxygen saturation in the venous component of the microcirculation. Low NIRS values represent poor oxygen delivery, high tissue oxygen extraction, or both. Probes are commonly applied to the forehead and flank to estimate regional tissue oxygen saturation (4). In clinical practice, absolute NIRS values are often less valuable than observing a trend(e.g., a 20% drop from baseline in the context of a major surgical manipulation). Low cerebral oxygen saturation has been associated with postoperative complications (e.g., delirium). More advanced calculations, including the tissue oxygenation index (percentage ratio of oxygenated hemoglobin (HbO₂) to total hemoglobin (HbO₂ + HHb) and the cerebral oximetry index (a correlation between NIRS and blood pressure) are associated with major morbidity and mortality after pediatric and adultcardiac surgery (5).

• Laser Doppler flowmetry and laser speckle imaging, which provide perfusion mapping but remain primarily research tools.

• Indocyanine green fluorescence angiography, which is increasingly used intraoperatively for the assessment of tissue perfusion during reconstructive, microvascular, and colorectal surgery.

• Peripheral perfusion indices, urethral perfusion index, and temperature gradients, which offer simple bedside assessments but currently lack sufficient outcome data for routine implementation.

Overall, except for NIRS in cardiac surgery, no microcirculatory monitoring modality has yet demonstrated sufficient evidence to justify widespread adoption into standard perioperative practice. Nonetheless, we think it’s important to understand (and to teach our learners) about oxygen physiology and the limitations of our “usual” monitors.

In tomorrow’s part 3, we will discuss monitoring cellular oxygen metabolism and future directions. Send your thoughts and comments to Myron (myasterster@gmail.com) and he will post them in a Friday Reader Response.

References

1. Meier J, Lasocki S, Meybohm P, Filipescu D, Haas T, Pottecher J, et al. Physiology, monitoring, and optimisation of perioperative tissue oxygenation: a narrative review. British journal of anaesthesia. 2026;136(6):1761–75. Epub 20260413. doi: 10.1016/j.bja.2026.01.047. PubMed PMID: 42012193; PubMed Central PMCID: PMC13197960.

2. Shoemaker WC, Appel PL, Kram HB. Role of oxygen debt in the development of organ failure sepsis, and death in high-risk surgical patients. Chest. 1992;102(1):208–15. doi: 10.1378/chest.102.1.208. PubMed PMID: 1623755.

3. Hogue CW, Levine A, Hudson A, Lewis C. Clinical Applications of Near-infrared Spectroscopy Monitoring in Cardiovascular Surgery. Anesthesiology. 2021;134(5):784–91. doi: 10.1097/aln.0000000000003700. PubMed PMID: 33529323; PubMed Central PMCID: PMC8043988.

4. Tran NN, Tran M, Lopez J, Ogbaa M, Votava-Smith JK, Brady KM. Near-Infrared Spectroscopy: Clinical Use in High-Risk Neonates. Neonatal Netw. 2021;40(2):73–9. doi: 10.1891/0730-0832/11-t-678. PubMed PMID: 33731373.

5. Suemori T, Skowno J, Horton S, Bottrell S, Butt W, Davidson AJ. Cerebral oxygen saturation and tissue hemoglobin concentration as predictive markers of early postoperative outcomes after pediatric cardiac surgery. Pediatric Anesthesia. 2016;26(2):182–9. doi: https://doi.org/10.1111/pan.12800.82–9. doi: https://doi.org/10.1111/pan.12800.

What’s happening: ASA and the World Federation of Societies of Anaesthesiologists (WFSA) are jointly hosting a webinar on mitochondrial-linked hypersensitivity to volatile anesthetics.

Webinar details:

• August 22, 10 ‒ 11:30 a.m. ET

• Moderated by Drs. Faye Evans and Debnath Chatterjee

• International experts will present the latest information on:

  • Historical context and initial case reports

  • The underlying mitochondrial science and genetic basis

  • Clinical recommendations and global perspectives on patient management

  • Leadership and response strategies

Registration: Learn more and register.

Additional information: asahq.org/raregenemutation.

I recommend using this article in a Grand Rounds or Journal Club for a deeper dive. Further, because a new crop of residents and fellows are joining our profession this month, I thought this article would be an excellent and timely introduction to essential physiology AND the PAAD. Indeed, why not suggest it to your students and new colleagues?

Original article

Meier J, Lasocki S, Meybohm P, Filipescu D, Haas T, Pottecher J, Rineau E, Romagnoli S, Bergholz A, Saugel B. Physiology, monitoring, and optimisation of perioperative tissue oxygenation: a narrative review. Br J Anaesth. 2026 Jun;136(6):1761-1775. doi: 10.1016/j.bja.2026.01.047. Epub 2026 Apr 13. PMID: 42012193; PMCID: PMC13197960.

The physiology and pathophysiology of tissue oxygenation are complex, involving a delicate interaction between the macrocirculation, the microcirculation, and cellular oxygen metabolism. Routine intraoperative monitoring emphasizes macrocirculatory monitoring and intervention (think: blood pressure and pulse oximetry). Meier et al propose that perioperative monitoring of tissue oxygenation should be viewed as an integrated cascade rather than a single hemodynamic variable. Oxygen delivery begins within the macrocirculation, where cardiac output transports oxygenated blood to tissues by convection. Oxygen subsequently diffuses through the microcirculation into surrounding tissues before ultimately serving as the terminal electron acceptor during mitochondrial oxidative phosphorylation. Failure at any stage may result in tissue hypoxia despite apparently normal systemic hemodynamics and oxygen saturation. This conceptual framework represents an important paradigm shift away from relying exclusively on blood pressure or cardiac output as surrogate markers of adequate tissue perfusion. Figure 1 reproduced below from the review illustrates this continuum from systemic circulation to mitochondrial oxygen utilization.

Hemoglobin binds oxygen molecules in the lungs and releases them to peripheral tissues. Hemoglobin is critical for oxygen transport and delivery, both systemically and at the cellular level. As you all know, arterial oxygen content depends predominantly on hemoglobin concentration and arterial oxygen saturation, with dissolved oxygen (PaO2) contributing minimally under normal physiological conditions. However, effective tissue macroperfusion also requires sufficient cardiac output. A key formula worth committing to memory is:

Oxygen Delivery = Arterial Oxygen Content (Arterial Oxygen Saturation × Hemoglobin × 1.34 + Arterial Partial Pressure of Oxygen × 0.0031) × Cardiac Output (stroke volume x heart rate)

While this equation is critical to understanding macrovascular oxygen transport, it does not guarantee adequate tissue oxygen delivery. Tissue perfusion pressure, microvascular diffusion, and oxygen metabolism (or lack thereof) must also be considered. Perfusion pressure is determined by inflow pressure (usually mean arterial pressure or MAP) and outflow pressure (typically central venous pressure or CVP, unless regional tissue pressure exceeds CVP - see below). However, assumptions about perfusion dependence on arterial and venous blood pressure alone may be misleading; specifically, Meier et al. emphasize that MAP alone is an imperfect surrogate for tissue perfusion or cardiac output.(3) Changes in myocardial contractility, arterial tone, or arterial compliance alter this relationship, making MAP an unreliable indicator of cardiac output during general anesthesia and surgery. Additionally, vascular autoregulation and pathologic states may create circumstances wherein inflow and outflow pressures vary, or where regional tissue pressures exceed CVP and thereby become the dominant regional outflow pressure. For example, elevated intracranial pressure can exceed CVP and thus determine cerebral venous outflow (and cerebral perfusion pressure). The comprehensive assessment of macrocirculatory function requires evaluation of cardiac output, hemoglobin concentration, oxygen saturation, and outflow pressure rather than blood pressure alone.

Figure 2 from the paper summarizes these determinants of oxygen delivery and perfusion pressure.

The review emphasizes the microcirculation as the critical intermediary between systemic oxygen delivery and cellular oxygen utilization. The microcirculation comprises arterioles, capillaries, and venules responsible for distributing blood flow according to local metabolic demand while facilitating oxygen diffusion into tissues. Several physiological factors influence microvascular oxygen transport, including endothelial integrity, glycocalyx preservation, erythrocyte deformability, nitric oxide signaling, blood viscosity, and hemoglobin-oxygen affinity.

Within the microcirculation, hemoglobin both carries oxygen and ensures coupled regulation of oxygen release according to local metabolic factors. Changes in pH, temperature, partial pressure of carbon dioxide, and 2,3-bisphosphoglycerate concentration modulate the affinity of hemoglobin for oxygen, allowing hemoglobin to release oxygen in areas of increased metabolic activity. “Fixing” acidosis with a buffer (e.g. bicarbonate) may sometimes worsen oxygen delivery and contribute to cellular dysfunction, which is partly why current recommendations for resuscitation advise against routine bicarbonate administration during cardiac arrest except in certain circumstances.

The rheological properties of blood also influence microcirculatory blood flow. Blood viscosity, which is determined by shear rate, plasma viscosity, and hematocrit, decreases with increasing shear rates, a phenomenon known as shear thinning.(4) The deformability of erythrocytes is essential for maintaining blood flow in high-shear conditions, whereas the aggregability of erythrocytes influences blood flow in low-shear conditions. Increased interactions between leukocytes and the endothelium also increase flow resistance, particularly in low-flow states. Elevated hematocrit exacerbates these interactions; thus, increasing hematocrit increases the oxygen content of blood but also decreases microcirculatory flow. This is important to bear in mind when we weigh the risks versus the benefits of blood transfusion in the OR.

Microcirculatory dysfunction may result from vasoconstriction, microvascular obstruction, hemodilution, venous congestion, or interstitial edema, all of which impair capillary blood flow or increase diffusion distance. Figure 4 provides an excellent visual representation of these mechanisms. Importantly, the review highlights the phenomenon of loss of hemodynamic coherence, whereby microvascular perfusion remains severely impaired despite normalization of systemic blood pressure and cardiac output. This dissociation is frequently observed in inflammatory states such as sepsis, major trauma, burn injury, and acute pancreatitis, and it may explain why interventions targeting only systemic hemodynamics fail to improve or even worsen outcomes (e.g., volume overload or microvascular vasoconstriction from exogenous vasoactive agents).

In tomorrow’s part 2 we will review cellular oxygen metabolism and strategies for monitoring tissue oxygenation. Send your thoughts and comments to Myron (myasterster@gmail.com) and he will post in a Friday Reader Response.

References

1. Meier J, Lasocki S, Meybohm P, Filipescu D, Haas T, Pottecher J, et al. Physiology, monitoring, and optimisation of perioperative tissue oxygenation: a narrative review. British journal of anaesthesia. 2026;136(6):1761–75. Epub 20260413. doi: 10.1016/j.bja.2026.01.047. PubMed PMID: 42012193; PubMed Central PMCID: PMC13197960.

2. Shoemaker WC, Appel PL, Kram HB. Role of oxygen debt in the development of organ failure sepsis, and death in high-risk surgical patients. Chest. 1992;102(1):208–15. doi: 10.1378/chest.102.1.208. PubMed PMID: 1623755.

3. Saugel B, Sessler DI. Perioperative Blood Pressure Management. Anesthesiology. 2021;134(2):250–61. doi: 10.1097/aln.0000000000003610. PubMed PMID: 33206118.

4. Piagnerelli M, Boudjeltia KZ, Vanhaeverbeek M, Vincent JL. Red blood cell rheology in sepsis. Intensive care medicine. 2003;29(7):1052–61. Epub 20030612. doi: 10.1007/s00134-003-1783-2. PubMed PMID: 12802488.

From Joseph Cravero MD, Boston Children’s Hospital

The authors of this article describe a fundamental change in culture of their organization. The concepts enumerated in the report are not unique or particularly original, many leaders involved in Pediatric Anesthesia have embarked on similar change-management endeavors. Having noted this, culture change is probably the most difficult challenge for leaders of any organization, and the cohort at Lurie Children’s deserve immense credit for taking this on so seriously and (apparently) accomplishing a fundamental change in the manner in which safety is approached in their organization. Remarkably, there appears to be “buy in” from all levels of leadership in their enterprise, a truly unusual confluence of purpose. Moving forward it will be fascinating to see if improvement at one (or more) institution(s) leads to pressure for change elsewhere. One could point to the advent of high reliability systems in the Japanese automobile industry that led to significant improvements in process and outcomes (famously at Toyota). Their focus on Site Reliability Engineering, Root Cause Analysis, and “blameless culture” ultimately were so successful they were adopted at other corporations as a requirement to remain competitive. Health Care Organization have been relatively late to this party, but reports (such as this) should encourage all of us that the well-proven concepts that create High Reliability Organizations can directly improve Pediatric Anesthesia practice and we should all share in our experiences and successful applications

From Timothy W. Martin, MD, MBA, FASA, FAAP, Professor of Anesthesiology and Pediatrics, Associate Chair for Education, Anesthesiology Residency Program Director, Chief, Division of Pediatric Anesthesia, University of Florida (UF) College of Medicine

The one rather technical question that stood out to me after reading the article from Pediatrics is the possible disconnect between the paper’s cited “cluster of 13 safety events” as shown in the background section of the abstract, and the paper’s table 1 that lists fourteen (14) events. This confused (and distracted) me a bit, and I wonder if it may likewise confuse some PAAD readers who take time to look up the original article?

Beyond Dr. Cravero’s commentary, all I can offer as an added “obstacle” or challenge to some of the accepted HRO principles is what some (perhaps many or all) of us who practice in a mixed pediatric and adult perioperative environment (as I do) encounter when we attempt to “standardize” or “implement a common national practice” that somehow runs contrary or at variance from standard adult perioperative practices. I have seen that the “adult standards” or “adult practices” tend to prevail for all patients in the name of standardization and consistency, even if contrary to what we as pediatric anesthesiologists and surgeons may believe is the most appropriate practice for children. A couple of examples I can provide are the demand to stick to a mandatory minimum 2- hour clear liquid fast (really ends up typically being much longer as we all know) because of a reluctance to “muddy waters” and “confuse adult patients, physicians, and providers” and the insistence that all patients remain awake in the OR until the attending surgeon/proceduralist has arrived to conduct the preinduction “briefing”/time-out so that the patient has the opportunity to participate in the ID verification and ask any questions—obviously inapplicable to young pediatric patients and infants, and potentially dangerous in some cases. And there are other examples.

Dr. Randy Flick MD, Mayo Clinic

I want to reiterate and simplify some key points from the PAAD

High Reliability Organizations (HROs) operate in high-risk settings while maintaining very low harm rates by emphasizing system failure over individual blame, preoccupation with failure, deference to expertise, reluctance to simplify, commitment to resilience, and standardized communication. SSEs are events that reach patients and cause moderate to severe harm or death; sentinel events signal death, severe harm, permanent harm, or other events requiring immediate investigation. This distinction matters because the response must move beyond case review to organizational redesign, with clear ownership for preventing recurrence.

System diagnosis and key drivers. Root-cause analyses identified recurring problems: communication breakdowns, inconsistent leadership responses, retained foreign bodies, wrong-site or wrong procedure events, incorrect line placement, operating-room fires, and workflow defects. The key driver diagram organized improvement into three domains: leadership, culture of safety, and data systems. This framing is important: the intervention did not rely on one training module or checklist, but on a linked package of leadership visibility, shared language, feedback, coaching, and transparent event analysis.

Interventions. Three interventions were introduced over six months. First, perioperative surgical safety stand-downs temporarily paused elective surgical work so multidisciplinary teams could hear executive leaders review safety data, expectations, and recent events. Families also described the human consequences of medical error, reinforcing patient-centered accountability. Second, staff completed error-prevention training using the Partnering on S.A.F.E. Care tools: ARCC to speak up, QVV to question and verify, STAR to pause during high-risk tasks, and SBAR to standardize communication. These tools were reinforced through modules, badge cards, digital signage, meetings, and daily safety briefings. Third, a multidisciplinary safety coach program supported peer-to-peer coaching, simulation, appreciative inquiry, real-time feedback, and reporting of near misses and good catches. A Just Culture algorithm helped leaders distinguish system defects, human error, and risky choices while preserving accountability and learning

For pediatric anesthesiology and perioperative leadership, the practical message is clear: safer surgery requires more than vigilance at the bedside. It requires an engineered culture in which teams can speak up, leaders respond reliably, data are visible, and improvement is continuous. The intervention package also underscores the value of pairing technical safeguards with behavioral reliability: checklists and algorithms help only when teams are trained, psychologically safe, and supported by leaders who act on the information they receive.

From Kyle Joseph Kramer DDS MS

I had to write to you as I just could not believe NO ONE mentioned Horace Wells in the list of self-experimenters. Being an anesthesia-centric group I would have sworn someone would have pointed out that Wells underwent nitrous oxide anesthesia himself and had a tooth removed, reporting that he felt “just a prick” and setting off the wildfire discovery of general anesthesia following Morton’s ether demonstration. Much has been written about who should get credit and for what; however, Wells is undoubtedly one of the grandfathers of anesthesia.

From Paul G. Firtth, MBCHB

I am surprised you did not mention one of the biggest and most important examples of self-experimentation of all: Horace Wells’ self-experiment with nitrous oxide, which led to the discovery of anesthesia. Dentist Wells observed that a volunteer at a nitrous oxide demonstration, Samuel Cooley, did not experience pain when he injured his leg while intoxicated with nitrous. Wells asked the organizer, Gardner Colton, to administer nitrous oxide to him the next day, while his colleague John Riggs pulled Well’s diseased molar tooth. The successful analgesia on December 11th led Wells to start using nitrous oxide.

Well’s former student and sometime dentistry partner, William Morton, was inspired to introduce the practice in Boston. At Wells’ suggestion, Morton went to Boston chemist Charles Jackson for guidance. Jackson had previously tried inhaled ether as a pulmonary soothing agent - and based on his experience with self-experimentation, he suggested Morton try ether. Morton tried ether successfully in his dental practice on September 30th, then experimented with a series of surgical patients at the Massachusetts General Hospital - and the rest is history.

And that’s not even talking about the subsequent discovery of pediatric anesthesia! The discovery of anesthesia was second only to the discovery of vaccination as the most important medical revolution in history. It is very interesting to see the parallels with the work of Boylston, Jenner , and Salk.

As a pediatric anesthesiologist, PAAD has been a consistently engaging way to keep up with recent pediatric anesthesia literature. AnesthesiaHub grew from a similar idea: building a stronger anesthesiology community by highlighting great resources and the people and organizations behind them.

A free, searchable archive of more than 1,500 PAAD posts is now available on the site. Readers can browse the collection, search by topic, and open each original PAAD post directly. New entries will be added automatically as they are published and featured among the latest blog posts on the AnesthesiaHub homepage. By placing PAAD alongside other anesthesiology resources, the goal is to make great content easier to discover while continuing to direct readers to the original authors and publishers. The archive joins AnesthesiaHub’s broader collection of anesthesiology podcasts, blogs, videos, journals, educational resources, and directories of professionals, practices, and facilities.

PAAD archive:
https://www.anesthesiahub.com/blogs?site_id=479

We are on the cusp of a revolution that will affect everyone, regardless of your practice type. We will do our best to summarize some of the key points of the article but as you will see, the introduction of AI into perioperative clinical care will require “standardizing data systems and workflows, assembling necessary expertise, motivating integration and adoption, instituting surveillance and validation, and establishing regulatory and ethical governance.”(1) As a profession, we’ve done this before: think of the relatively recent introduction of ultrasonography and EEG guidance of the depth of anesthesia into daily practice.

This is such a big deal, we will need to use and repurpose all of our structured educational opportunities, such as grand rounds, lecture series, journal clubs and workshops at our professional society annual meetings to get us all up to speed and enable all of us to participate in development. We should not accept this as a “black box,” and the use of AI will require rigorous validation, thoughtful governance, clinician education, and continued collaboration between medicine, engineering, and data science. I will use the PAAD to keep a close eye on all of this for you and will attempt to assemble a team of experts to help. If you have this expertise and would like to join the PAAD’s executive council please contact me at your earliest convenience. Myron Yaster MD But first a message from Stanley Kubrick’s 2001: A space odyssey,

A quick primer for readers who are new to AI: “AI” is a broad umbrella term. Machine learning is a subfield of AI that uses algorithms to learn patterns from data. These methods range from familiar statistical approaches, such as logistic regression, to decision trees, random forests, and neural networks. Deep learning uses multilayer neural networks and powers many current AI applications involving images, physiologic waveforms, and language. Generative AI creates new text, images, audio or code. Large language models (LLMs) such as ChatGPT generate text by predicting likely sequences of words with increasing sophistication and fluency.

Original article

Han L, Char DS, Aghaeepour N; Stanford Anesthesia AI Working Group. Artificial Intelligence in Perioperative Care: Opportunities and Challenges. Anesthesiology. 2024 Aug 1;141(2):379-387. doi: 10.1097/ALN.0000000000005013. PMID: 38980160; PMCID: PMC11239120.

Where AI may help

AI is rapidly emerging as a transformative technology in anesthesiology and perioperative medicine. In this Clinical Focus Review, Han et al. describe how AI has the potential to enhance perioperative care by improving clinical decision-making, patient safety, operational efficiency, and personalized medicine, while emphasizing that successful implementation requires robust validation, multidisciplinary collaboration, and careful ethical oversight. Rather than replacing anesthesiologists, AI is positioned as a decision-support tool that augments clinician expertise through analysis of complex clinical datasets.

Anesthesiology is particularly well suited to AI because perioperative care generates continuous streams of heterogeneous data, including electronic health records, physiologic waveforms, laboratory results, imaging studies, and patient-reported outcomes. Machine learning algorithms can integrate these multimodal data sources to identify patterns that may not be readily apparent to clinicians, enabling more accurate prediction of perioperative risk and real-time clinical decision support.

One of the most promising applications is preoperative risk stratification. Traditional risk assessment relies on population-based prediction models and clinician judgment,(2) whereas AI enables individualized prediction of postoperative complications, mortality, recovery trajectory, intensive care unit admission, and hospital length of stay by simultaneously evaluating numerous patient-specific variables. AI-powered chatbots and mobile applications may further improve perioperative care by assisting patients with appointment scheduling, providing educational materials, answering common questions, and reinforcing preoperative instructions. Virtual and augmented reality technologies also have the potential to improve patient education, reduce anxiety, and facilitate informed decision-making.(3)

AI is equally valuable during surgery through perioperative event prediction. Continuous physiologic monitoring generates large quantities of dynamic data that machine-learning models can analyze to identify impending clinical deterioration before it becomes clinically apparent. Current systems have demonstrated the ability to predict intraoperative hypotension, excessive blood loss requiring transfusion, inadequate anesthetic depth, and other adverse events, allowing earlier intervention and potentially improving patient outcomes.(4)

Figure 1 from the article illustrates how integrating clinical observations, physiologic monitoring, diagnostic testing, and patient-reported information enables comprehensive predictive modeling across multiple domains of anesthetic practice.

Han et al. highlight clinical decision support as another rapidly evolving application. AI systems can assist with medication dosing, treatment planning, image interpretation, workflow management, and evidence synthesis. The emergence of large language models (LLMs), including ChatGPT and Med-PaLM, may further improve efficiency by summarizing literature, assisting with documentation, reviewing electronic health records, and generating evidence-based recommendations.(5) However, current generative AI systems remain vulnerable to bias, fabricated information (”hallucinations”), and inaccurate citations. Consequently, at this moment in time, AI should complement and not replace expert clinical judgment.

Since Han et al. was published, generative AI has been the form of AI that many clinicians encounter and use most directly. In pediatric anesthesia, LLMs may help create developmentally appropriate and multilingual explanations for children and caregivers, generate educational cases and assessments, summarize source material, and provide first drafts of routine clinical or academic communication.(6, 7) These tools may improve efficiency, but they remain drafting and synthesis aids rather than validated clinical decision-support systems. LLMs can fabricate facts and references, omit important clinical context, and reproduce bias. Hospitals and universities are increasingly implementing secure and compliant enterprise LLMs for clinicians to use. Protected health information, confidential manuscripts, and proprietary material should not be entered into unapproved systems. Every factual claim, reference, dose, and recommendation must be checked, and meaningful AI assistance should be disclosed when appropriate.(7)

Another major area of development is closed-loop automation. AI-driven systems capable of continuously adjusting anesthetic depth, vasopressor administration, and ventilatory support have shown encouraging results in early clinical studies.(8, 9) Although these technologies may reduce clinician workload and improve physiologic stability, further validation and regulatory oversight are required before widespread implementation.

Beyond direct patient care, AI has substantial potential to improve perioperative resource management. Predictive algorithms can optimize operating room scheduling, estimate surgical duration, forecast postoperative resource utilization, and improve hospital throughput, thereby increasing efficiency while reducing costs.(10) AI may also accelerate drug and device development by facilitating drug discovery, pharmacokinetic modeling, pharmacogenomic applications, and development of intelligent monitoring systems, including ultrasound-guided regional anesthesia and automated physiologic monitoring devices.

Figure 2 from the article outlines the life cycle of AI model development, emphasizing continuous data collection, validation, implementation, surveillance, and iterative model refinement.

Despite its promise, the authors identify several barriers to implementation. High-quality AI requires standardized clinical data, robust computational infrastructure, interoperability across healthcare systems, and continuous monitoring to detect performance drift (”algorithmovigilance”). Additionally, the overwhelming majority of anesthesiologists know very little about this and will require extensive education in data science and AI to facilitate appropriate adoption, interpretation, and oversight. Residency training, fellowships, continuing medical education, and multidisciplinary collaborations will be essential for successful integration.

Where does pediatric anesthesia fit?

As we all know, children are not small adults, and the pediatric anesthesia AI literature is less robust than its adult counterpart. In a recent systematic review, Antel et al.(11) identified only 40 studies of AI in pediatric anesthesia, with most focused on risk factor prediction. A subsequent review highlighted possible future applications such as closed loop nociception control, AI-assisted image-guided techniques, and gamified education.(12) Generative AI may be particularly useful for pediatric anesthesia communication and education, but pediatric-specific evaluation is essential because LLM output can still be inaccurate, developmentally inappropriate, or insensitive.(6)

Finally, ethical and regulatory considerations remain paramount. AI models may inadvertently perpetuate healthcare disparities if trained on biased datasets, while opaque “black-box” algorithms challenge transparency, accountability, and clinician trust. The authors advocate multidisciplinary governance involving clinicians, computer scientists, human-factors engineers, ethicists, implementation scientists, and regulatory agencies to ensure AI systems remain accurate, equitable, secure, explainable, and patient-centered.

Practical takeaway.

We cannot and should not all become data scientists, but all clinicians should obtain enough AI literacy to ask basic questions and remain in-the-loop from the earliest stages of AI tool design and development, not just after implementation: Was the AI model or tool trained on patients like ours? Was it externally and prospectively validated? Does it merely predict outcomes or actually improve them? Who or what monitors the tool’s performance after deployment, and who is accountable when the recommendation is wrong? In a systematic review of 103 perioperative AI and machine-learning studies, only 13% underwent external validation, and the overall risk of bias was concerning.(13)

The safest near-term role for AI is for the “A” in “AI” to stand for “augmented” rather than “artificial” or “automated,” with clinicians retaining responsibility for context, empathy, judgment, and care.

Send your thoughts and comments to Myron (myasterster@gmail.com) and he will post in a Friday reader response.

References

1. Han L, Char DS, Aghaeepour N. Artificial Intelligence in Perioperative Care: Opportunities and Challenges. Anesthesiology. 2024;141(2):379–87. doi: 10.1097/aln.0000000000005013. PubMed PMID: 38980160; PubMed Central PMCID: PMC11239120.

2. Ferrari LR, Leahy I, Staffa SJ, Johnson C, Crofton C, Methot C, et al. One Size Does Not Fit All: A Perspective on the American Society of Anesthesiologists Physical Status Classification for Pediatric Patients. Anesthesia and analgesia. 2020;130(6):1685–92. Epub 2019/06/21. doi: 10.1213/ane.0000000000004277. PubMed PMID: 31219919.

3. Ferré F, Boeschlin N, Bastiani B, Castel A, Ferrier A, Bosch L, et al. Improving Provision of Preanesthetic Information Through Use of the Digital Conversational Agent “MyAnesth”: Prospective Observational Trial. J Med Internet Res. 2020;22(12):e20455. Epub 20201204. doi: 10.2196/20455. PubMed PMID: 33275108; PubMed Central PMCID: PMC7748965.

4. Wijnberge M, Geerts BF, Hol L, Lemmers N, Mulder MP, Berge P, et al. Effect of a Machine Learning-Derived Early Warning System for Intraoperative Hypotension vs Standard Care on Depth and Duration of Intraoperative Hypotension During Elective Noncardiac Surgery: The HYPE Randomized Clinical Trial. Jama. 2020;323(11):1052–60. doi: 10.1001/jama.2020.0592. PubMed PMID: 32065827; PubMed Central PMCID: PMC7078808.

5. Dave T, Athaluri SA, Singh S. ChatGPT in medicine: an overview of its applications, advantages, limitations, future prospects, and ethical considerations. Front Artif Intell. 2023;6:1169595. Epub 20230504. doi: 10.3389/frai.2023.1169595. PubMed PMID: 37215063; PubMed Central PMCID: PMC10192861.

6. Siddiqui A, O’Reilly-Shah VN, Simpao AF, Lonsdale H. Harnessing Generative Artificial Intelligence in Pediatric Anesthesia: Enhancing Learning, Patient Care, and Family Communication. Paediatric anaesthesia. 2025;35(9):691–4. Epub 20250624. doi: 10.1111/pan.70005. PubMed PMID: 40552438; PubMed Central PMCID: PMC12343195.

7. Lonsdale H, O’Reilly-Shah VN, Padiyath A, Simpao AF. Supercharge Your Academic Productivity with Generative Artificial Intelligence. Journal of medical systems. 2024;48(1):73. Epub 20240808. doi: 10.1007/s10916-024-02093-9. PubMed PMID: 39115560; PubMed Central PMCID: PMC11457929.

8. Joosten A, Rinehart J, Van der Linden P, Alexander B, Penna C, De Montblanc J, et al. Computer-assisted Individualized Hemodynamic Management Reduces Intraoperative Hypotension in Intermediate- and High-risk Surgery: A Randomized Controlled Trial. Anesthesiology. 2021;135(2):258–72. doi: 10.1097/aln.0000000000003807. PubMed PMID: 33951140; PubMed Central PMCID: PMC8277754.

9. Liberman MY, Ching S, Chemali J, Brown EN. A closed-loop anesthetic delivery system for real-time control of burst suppression. J Neural Eng. 2013;10(4):046004. Epub 20130607. doi: 10.1088/1741-2560/10/4/046004. PubMed PMID: 23744607; PubMed Central PMCID: PMC3746775.

10. Eshghali M, Kannan D, Salmanzadeh-Meydani N, Esmaieeli Sikaroudi AM. Machine learning based integrated scheduling and rescheduling for elective and emergency patients in the operating theatre. Ann Oper Res. 2023:1–24. Epub 20230119. doi: 10.1007/s10479-023-05168-x. PubMed PMID: 36694896; PubMed Central PMCID: PMC9851122.

11. Antel R, Sahlas E, Gore G, Ingelmo P. Use of artificial intelligence in paediatric anaesthesia: a systematic review. BJA Open. 2023;5:100125. Epub 20230207. doi: 10.1016/j.bjao.2023.100125. PubMed PMID: 37587993; PubMed Central PMCID: PMC10430814.

12. Dundaru-Bandi D, Antel R, Ingelmo P. Advances in pediatric perioperative care using artificial intelligence. Current opinion in anaesthesiology. 2024;37(3):251–8. Epub 20240226. doi: 10.1097/aco.0000000000001368. PubMed PMID: 38441085.

13. Arina P, Kaczorek MR, Hofmaenner DA, Pisciotta W, Refinetti P, Singer M, et al. Prediction of Complications and Prognostication in Perioperative Medicine: A Systematic Review and PROBAST Assessment of Machine Learning Tools. Anesthesiology. 2024;140(1):85–101. doi: 10.1097/aln.0000000000004764. PubMed PMID: 37944114; PubMed Central PMCID: PMC11146190.

This is a pretty astonishing article and the authors have to be applauded for disclosing their “dirty laundry” in such a public fashion. In order to elicit the changes they desired, the institution had to essentially tear down their walls to the studs to fix it.

Before we begin our PAAD review, some basic definitions are needed (from AI NEJM OpenEvidence):

High reliability organizations (HROs) in healthcare are organizations that operate in complex, high-risk environments yet maintain extremely low rates of harm or error through a distinctive set of organizational principles and cultural commitments.(2, 3)

Five Core Principles of HROs

• HROs emphasize system-level failures rather than blaming individuals, while still holding all members accountable for continuous improvement.(4)

• A strong culture of psychological safety is essential — staff must feel empowered to speak up and report concerns without fear of retaliation.(2, 4)

• Teamwork and interdisciplinary communication are foundational; the Institute of Medicine (IOM) and the Agency for Healthcare and Quality (AHRQ) have promoted programs like TeamSTEPPS to enhance team performance in healthcare.(5)

• Research suggests that HRO-inspired programs may be more readily adopted by some professional groups (e.g., nursing) than others, and that principles like “deference to expertise” and “commitment to resilience” can be harder to operationalize than “preoccupation with failure”. (6)

• Reducing irrational variation through standardized clinical practices is a key mechanism by which HROs decrease complexity and risk.

Serious safety events (SSEs) in healthcare are safety events that reach the patient and result in moderate to severe harm or death.(7) They represent the most critical category in the safety event classification scheme.

A Joint Commission sentinel event is defined as a safety event — not primarily related to the natural course of a patient’s illness or underlying condition — that reaches a patient and results in death, severe harm (regardless of duration), or permanent harm (regardless of severity). The term “sentinel” signals the need for immediate investigation and response.(8) Some sentinel events include: Unanticipated death of a full-term infant, Homicide of any patient, staff member, visitor, or vendor while on site or under the organization’s care, Any intrapartum maternal death, Sexual abuse/assault of any patient, staff member, visitor, or vendor on site or under the organization’s supervision; Physical assault leading to death, permanent harm, or severe harm (patients, staff, visitors, or vendors), Wrong-site, wrong-patient, or wrong-procedure surgery — regardless of procedure type or magnitude of outcome; Discharge of an infant to the wrong family; Abduction of any patient, Incompatible blood/blood product administration (ABO and non-ABO incompatibilities), hemolytic transfusion reactions, or transfusions resulting in death/permanent/severe harm, and Unintentionally retained foreign objects (URFOs)

I’ve asked members of the Pediatric Anesthesia Leadership Council (PALC) to help write today’s PAAD and to add their own personal and institutional experiences which will appear in an accompanying PAAD.

Original article

Natarus ME, Naureckas Li C, Studer A, Shaw A, Raval MV, Dsida RM, Olmstead J, Pytel C, Stuart H, Inge TH, Schroeder S, Wheeler DS. Supporting Safer Surgery: System-Level Interventions to Enhance Pediatric Perioperative Safety. Pediatrics. 2026 Jul 1;158(1):e2025072662. doi: 10.1542/peds.2025-072662. PMID: 42270089.

Medical errors directly impact patient clinical outcomes and result in substantial financial implications for both patients and hospital systems. Triggered by a cluster of 13 serious safety events (SSEs) and Joint Commission sentinel events over a 21-month period, the initiative sought to transform perioperative safety culture through coordinated, system-level interventions rather than isolated corrective actions. Review of adverse events identified recurring system failures involving communication breakdowns, inconsistent leadership responses, retained foreign bodies, wrong-site or wrong-procedure events, incorrect line placement, operating room fires, and workflow deficiencies. Root cause analyses demonstrated that sustainable improvement required organizational changes addressing leadership, communication, psychological safety, and frontline engagement rather than focusing solely on individual events. A key driver diagram (below) identified three essential domains for improvement: leadership, culture of safety, and data systems.

Three complementary interventions were introduced over six months.

The first was the implementation of perioperative surgical safety stand-downs, modeled after military safety practices. Elective surgical activity was temporarily paused to allow multidisciplinary participation in institution-wide discussions of patient safety. Executive leaders transparently reviewed recent safety events, organizational performance metrics, and expectations for improvement. Importantly, patients’ family members described the personal consequences of medical errors, reinforcing the importance of patient-centered care and shared accountability

The second intervention focused on error prevention training using standardized HRO communication tools summarized in the “Partnering on S-A-F-E Care“ toolkit (Figure 2 from the article below). Four evidence-based safety behaviors were emphasized:

• ARCC (Ask a question, Request a change, voice a Concern, use the Chain of command) to encourage speaking up for safety.

• QVV (Qualify, Validate, Verify) to improve critical thinking and questioning.

• STAR (Stop, Think, Act, Review) to enhance attention during high-risk tasks.

• SBAR (Situation, Background, Assessment, Recommendation) to standardize clinical communication.

These tools were reinforced through mandatory education modules, badge cards, digital signage, departmental meetings, and daily operational safety briefings. Leadership simultaneously emphasized psychological safety so that staff could raise concerns without fear of blame or retaliation.

The third intervention established a multidisciplinary safety coach program involving surgeons, anesthesiologists, nurses, and perioperative support personnel. Safety coaches received formal instruction in peer-to-peer coaching, simulation, appreciative inquiry, and real-time feedback techniques. Monthly meetings reinforced safe practices, promoted discussion of emerging safety trends, and encouraged identification of near misses and “good catches.” The program was supported by implementation of a Just Culture framework, providing leaders with a structured algorithm to distinguish system failures, human error, and risky behavior while emphasizing learning rather than punishment.

Ok, what did they find? The interventions produced astonishing improvements. Prior to implementation, an SSE or sentinel event occurred in approximately one of every 2,977 surgical cases (about every 50 days). Following implementation, the institution completed 39,654 consecutive operations over 585 days without another serious safety event. The subsequent two events also occurred well beyond historical expectations, after 13,040 and 14,715 additional surgical cases, respectively. Statistical process control analysis demonstrated sustained special-cause improvement, indicating that these gains were unlikely to represent random variation. Importantly, surgical case volume continued to increase throughout the study period, demonstrating that safety improvements did not adversely affect operating room productivity.

An additional indicator of success was a progressive increase in voluntary safety reporting, suggesting improved psychological safety and greater staff engagement rather than worsening clinical performance. Mandatory safety education achieved an 87% completion rate during the first year, while the safety coach program expanded from 21 participants representing 10 disciplines to 28 participants representing 16 professional roles.

Natarus et al, attribute the success of the initiative to several synergistic factors: strong executive leadership, transparent communication of safety data, standardized HRO communication tools, frontline safety coaching, and consistent application of Just Culture principles. They acknowledge limitations, including the single-center pediatric setting, dependence on strong institutional leadership, and the possibility that voluntary reporting may underestimate adverse events.

We think this study provides compelling evidence that comprehensive implementation of HRO principles can substantially improve pediatric perioperative safety. By integrating leadership engagement, standardized communication strategies, frontline coaching, transparent safety reporting, and a Just Culture framework, healthcare organizations can meaningfully reduce serious patient harm while maintaining clinical productivity. These interventions are practical, scalable, and should be considered integral components of modern pediatric perioperative quality improvement programs.

Send your thoughts and comments to Myron (myasterster@gmail.com) and he will post in a Friday reader response. And note, because of the potential for retribution, all comments on this topic will be posted anonymously.

References

1. Natarus ME, Naureckas Li C, Studer A, Shaw A, Raval MV, Dsida RM, et al. Supporting Safer Surgery: System-Level Interventions to Enhance Pediatric Perioperative Safety. Pediatrics. 2026;158(1). doi: 10.1542/peds.2025-072662. PubMed PMID: 42270089.

2. Gill A, Leiner CD, Steinberg DI. High Reliability in Health Care. The Medical clinics of North America. 2025;109(5):981–96. Epub 20250508. doi: 10.1016/j.mcna.2025.02.002. PubMed PMID: 40752939.

3. Christianson MK, Sutcliffe KM, Miller MA, Iwashyna TJ. Becoming a high reliability organization. Critical care (London, England). 2011;15(6):314. Epub 20111208. doi: 10.1186/cc10360. PubMed PMID: 22188677; PubMed Central PMCID: PMC3388695.

4. Shea KG. Strategies and Tools to Enhance Patient Safety: HROs, HEROs, and Safety Culture. Journal of pediatric orthopedics. 2020;40 Suppl 1:S30–s2. doi: 10.1097/bpo.0000000000001500. PubMed PMID: 32502068.

5. Baker DP, Day R, Salas E. Teamwork as an Essential Component of High-Reliability Organizations. Health services research. 2006;41(4p2):1576–98. doi: https://doi.org/10.1111/j.1475-6773.2006.00566.x.

6. Rotteau L, Goldman J, Shojania KG, Vogus TJ, Christianson M, Baker GR, et al. Striving for high reliability in healthcare: a qualitative study of the implementation of a hospital safety programme. BMJ quality & safety. 2022;31(12):867–77. Epub 20220601. doi: 10.1136/bmjqs-2021-013938. PubMed PMID: 35649697.

7. Marra AR, Algwizani A, Alzunitan M, Brennan TMH, Edmond MB. Descriptive Epidemiology of Safety Events at an Academic Medical Center. Int J Environ Res Public Health. 2020;17(1). Epub 20200104. doi: 10.3390/ijerph17010353. PubMed PMID: 31947963; PubMed Central PMCID: PMC6982027.

8. Division SIRS, Angle JF, Nemcek AA, Jr., Cohen AM, Miller DL, Grassi CJ, et al. Quality Improvement Guidelines for Preventing Wrong Site, Wrong Procedure, and Wrong Person Errors: Application of the Joint Commission “Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery” to the Practice of Interventional Radiology. Journal of Vascular and Interventional Radiology. 2008;19(8):1145–51. doi: 10.1016/j.jvir.2008.03.027.

In anesthesia, both underlying lung disease and changes in peri-procedural physiology make estimation of PaCO₂ based on end-tidal more precarious. Examples include cardiopulmonary bypass surgery, neurosurgery, thoracic surgery and cases requiring significant fluid resuscitation. Thus, monitoring of PaCO₂ levels is one common indication to place arterial access in patients.

Yet, the future of the arterial line is becoming less certain. As we heard during the most recent Society of Pediatric Anesthesia meeting in Denver from Dr. Michael Fiedorek, numerous new devices are becoming available that reliably estimate beat by beat arterial blood pressure accurately, including a device approved in neonates (Boppli). While these devices are promising for monitoring continuous blood pressure, they do not provide the same laboratory information as we are accustomed to obtaining with an arterial line. However, perhaps AI can provide a solution here.

Today, we review a recent study from Ju Park and colleagues that uses machine learning to address a specific need: bridge the gap between EtCO₂ and PaCO₂ and, thus, create novel non-invasive monitoring techniques.

Original Article

Park JH, Cho C, Kim HS, et al. Development of an Arterial Carbon Dioxide Estimation Model Using End-Tidal Carbon Dioxide Levels during Surgery in the Pediatric Population. Anesthesiology. Published online June 17, 2026. doi:10.1097/ALN.0000000000006207

The authors looked at over 8,000 pairings between EtCO₂ and PaCO₂ in 3,500+ pediatric patients in a large pediatric database (VitalDB). They used 70% of this data to train four different machine learning algorithms. Then they internally validated their model on another 15% of the database and tested it out on the last 15% of data in database. Lastly, they externally validated the model on two different external data sets.² The analysis included any patient less than 19 years old undergoing general anesthesia with an endotracheal tube and arterial line. Including ~35% of patients that were ASA PS III. Notable exclusions from the data include any cardiopulmonary bypass cases, one-lung ventilation, laparoscopic and thoracoscopic cases.²

The authors made several adjustments to limit bias, including avoiding blood gases at the start or end of cases and allowing for lags in data between drawing the sample and determination of the PaCO₂. The authors also split the models into two distinct groups - less than 6 years old and 6 years old and above.²

The four models were indeed able to learn and predict PaCO₂ fairly accurately. The best model (Gradient Boosting) had a mean error of 2.73 mmHg in predicting the PaCO₂ with a percentage error of 6.75%.² While this is impressive, it does translate to a potential alteration in parameters like cerebral blood flow by 6-12%, a relatively large difference. Figure 5 from the study is a Bland-Altman plot demonstrating less difference from actual values predicted by the model (blue dots) than for the end-tidal alone model (red dots).

Many (us included) gloss over when trying to understand and interpret studies of machine learning models, but the devil is certainly in the details. Very simply put, the models utilize all of the data made available (surgical, hemodynamic, anesthetic, ventilation, laboratory, and patient) to develop predictions. The model is essentially a new monitor combining all the variables we look at daily to make a prediction, much as we do. Interpreting the results is highly analogous to standard clinical research critiques i.e. what was the population, do the variables used to predict make sense or feasible to extract, do the results yield meaningful clinical information or is it just window dressing. This study excluded the patients more likely to have difference between end-tidal and PaCO₂. This strengthens the model for prediction in healthy kids but precludes use in patients we are more concerned about. Similarly, as dead space ventilation increases, this model is likely to be less accurate. Lastly, the error rate, while close, is not yet close enough when more accurate information can be obtained via an arterial catheter. If making clinical decision regarding cerebral blood flow and cerebral perfusion pressure needs, is it better to have an estimate or the real data? Finally, the intelligence gained from models must be significantly different from what we already know and be modifiable.

However, this technology does give us hope for a future where machine learning may allow for a model that is even more accurate and precise. Additionally, even in current state, one could consider applying this technology to estimate PaCO₂ in patients where arterial line access is unobtainable or challenging, particularly in institutions where transcutaneous CO₂ monitoring (tcPCO₂) is less available. Threshold alarms could be set to help us recognize and act when deviations occur.

Yet, what we do with new information provided by machine learning is also important. The hypotension prediction index trial of a machine learning algorithm which predicted hypotension failed to change time with hypotension because clinicians either didn’t act on the alarm (ie they thought the alarm was irrelevant) or there wasn’t enough time between predicted hypotension and actual hypotension to create an opportunity to change management. Alternatively, the HYPE trial lowered the threshold for intervention based on the machine learning model and resulted lower amounts of hypotension.³ In other words, if and how we can act on these models matters and even then, it’s not completely clear if action will change outcomes.

What are your thoughts on the machine learning and its ability to predict arterial carbon dioxide levels? Is this the start of the end of the arterial lines? Send your thoughts to Myron (myasterster@gmail.com and he will post in a Friday reader response..

References

1. Yang JT, Erickson SL, Killien EY, Mills B, Lele AV, Vavilala MS. Agreement Between Arterial Carbon Dioxide Levels With End-Tidal Carbon Dioxide Levels and Associated Factors in Children Hospitalized With Traumatic Brain Injury. JAMA Netw Open. 2019;2(8):e199448. Published 2019 Aug 2. doi:10.1001/jamanetworkopen.2019.9448

2. Park JH, Cho C, Kim HS, et al. Development of an Arterial Carbon Dioxide Estimation Model Using End-Tidal Carbon Dioxide Levels during Surgery in the Pediatric Population. Anesthesiology. Published online June 17, 2026. doi:10.1097/ALN.0000000000006207

3. Wijnberge M, Geerts BF, Hol L, et al. Effect of a Machine Learning-Derived Early Warning System for Intraoperative Hypotension vs Standard Care on Depth and Duration of Intraoperative Hypotension During Elective Noncardiac Surgery: The HYPE Randomized Clinical Trial. JAMA. 2020;323(11):1052-1060. doi:10.1001/jama.2020.0592

Experiences with halothane vary widely across the global pediatric anesthesia community. For some, it remains a familiar part of daily practice; for others, it is a drug they have not used for years—or perhaps have only read about.

Yet in many low- and middle-income countries (LMICs), halothane has remained an important component of pediatric anesthesia because it is familiar, relatively inexpensive, and compatible with existing equipment. The cessation of halothane production by a major global supplier has created concern across health systems that continue to rely on it. At first glance, this appears to be a drug shortage story. In reality, it is much more than that.

A Systems Challenge, Not a Drug Challenge

Administering sevoflurane or isoflurane is not simply a matter of ordering a different anesthetic. The transition requires access to appropriate vaporizers, functioning anesthesia machines, reliable supply chains, equipment maintenance, biomedical engineering support, updated training, and ongoing clinical mentorship. The entire system needs to shift.

Meanwhile, many hospitals continue to struggle with inconsistent access to essential monitoring, such as capnography and pulse oximetry; shortages of trained anesthesia professionals; aging equipment; and limited maintenance capacity.

The challenge is not that halothane is disappearing; the challenge is that too many health systems have not yet been given the resources needed to transition away from it safely.

Why Pediatric Anesthesiologists Should Care

Children stand to be disproportionately affected by disruptions in anesthesia services. Across many settings, inhalational induction remains an essential component of pediatric anesthesia practice, particularly when intravenous access may be difficult to obtain before induction.

For many, the disappearance of halothane may seem like a natural evolution in anesthetic practice. Sevoflurane offers important advantages in pediatric anesthesia, including rapid induction and emergence, improved tolerability, and a more favorable safety profile than halothane. If implemented thoughtfully, this transition could ultimately improve the safety of anesthesia care for many children.

Importantly, the investments required to support that transition rarely benefit children alone. Training, monitoring, equipment, maintenance systems, and workforce development strengthen anesthesia services for all patients. For example, a capnograph purchased to improve pediatric anesthesia safety may be used for an adult emergency laparotomy. Improvements in pediatric anesthesia care often ripple throughout an entire health system.

The key word, however, is thoughtfully. Without parallel investments in equipment, monitoring, training, workforce development, and maintenance systems, simply changing anesthetic agents will not achieve the improvements in patient safety this transition makes possible.

A Growing Coalition of Partners

One of the most encouraging aspects of this challenge has been how many individuals and organizations have come together to address it.

The World Federation of Societies of Anaesthesiologists (WFSA) recognized the implications of halothane discontinuation several years ago and issued guidance to help hospitals and providers prepare. National societies, educators, and training programs across Africa have been raising awareness and identifying practical solutions at the local level.

Smile Train has been working with its partner hospitals to understand better how the loss of halothane will affect cleft and pediatric surgical services. The focus has spanned equipment needs, workforce readiness, training requirements, and the financial implications of adopting alternative anesthetic agents. Working alongside partners including WFSA, Lifebox, Kids Operating Room, Ministries of Health, and in-country anesthesia leaders, efforts are underway to better understand implementation challenges and identify sustainable solutions.

Most importantly, anesthesia leaders across Africa are driving the conversations, assessments, and solutions needed to ensure the transition strengthens rather than disrupts patient care.

A Rare Opportunity

Healthcare systems rarely get to choose the circumstances that drive change. In this case, a manufacturing decision made thousands of miles away is forcing difficult conversations across many countries.

The halothane transition creates an opportunity. The question is not simply how we replace halothane. The question is whether we can leverage this moment—and the attention it has generated—to strengthen anesthesia systems for the future.

If we get this right, the legacy of halothane may ultimately be not the crisis created by its disappearance, but the improvements in anesthesia care that followed.

For readers wondering how they can help, one answer is simple: stay engaged. Support organizations working to strengthen anesthesia systems globally. Advocate for affordable access to essential anesthesia equipment and monitoring. Participate in education and mentorship programs. Share expertise when opportunities arise.

Most importantly, recognize that safe anesthesia for children depends not only on drugs, but on the systems that support their use. When those systems improve, everyone benefits. The investments we make to protect children ultimately strengthen care for every patient who enters the operating room.

PS from Myron

Question: is sevoflurane safer to use than halothane? I think most of you would instantly say “of course”! Sevoflurane is generally considered safer than halothane across multiple domains, including hepatotoxicity, cardiovascular stability, and arrhythmogenicity. This is the primary reason halothane has been replaced by sevoflurane and is why halothane is no longer being manufactured. We will return to this topic in an upcoming “remembering the classics” PAAD based on the original article by Dr. Rob Friesen

Friesen RH. The halothane era in pediatric anesthesia: The convergence of a cardiac depressant anesthetic with the immature myocardium of infancy. Paediatr Anaesth. 2024 15Jul;34(7):592-596. doi: 10.1111/pan.14840. Epub 2024 Jan 17. PMID: 38231007.

One interesting anecdote: The halothane vaporizer could provide 5% halothane or 4+ MAC intervals. Because of this, the teaching was to always keep your hand on the vaporizer dial when it was cranked up to the max because hypotension and arrhythmias were inevitable and to turn down the halothane as soon as consciousness was lost. When sevoflurane was first introduced the sevoflurane vaporizers were designed to provide 15% sevoflurane or roughly 4+ MAC intervals and make it equipotent to halothane. This too resulted in universal hypotension. In a genius marketing move, the sevoflurane vaporizers were redesigned and changed to deliver a maximum of 8% sevoflurane or 2-3 MAC intervals. Hypotension was rare and voila a much safer vapor anesthetic!

Masimo Announces FDA Clearance of Pediatric Indication for SedLine^® Brain Function Monitoring and the SedLine Pediatric EEG Sensor

IRVINE, Calif.--(BUSINESS WIRE)--Masimo (NASDAQ: MASI) announced today herethe FDA clearance of SedLine^® brain function monitoring for pediatric patients (1-17 years of age) and the SedLine Pediatric EEG Sensor. With this clearance, the potential benefits of SedLine have been expanded to all patients one year old and above in the United States. Equipped with Masimo’s advanced signal processing technology, SedLine helps clinicians monitor brain activity bilaterally by processing electroencephalogram (EEG) signals from Masimo’s four-lead SedLine EEG sensors.

This clearance brings Masimo’s bilateral brain activity monitoring to children 1 to 17 years old, in conjunction with specially sized pediatric sensors designed for easier application on smaller pediatric foreheads. Brain activity monitoring under anesthesia on pediatric patients is different from that of adults.^1-2 Maintaining an appropriate depth of anesthesia is key to preventing anesthesia-related events and enabling faster recovery.³ To aid clinicians in monitoring anesthesia depth on children, SedLine features both the display of EEG signals and the Multitaper Density Spectral Array (DSA) from both sides of the brain, to provide clinicians with a more complete picture of the brain.

US FDA approves first freeze-dried plasma product

The U.S. FDA on Wednesday approved the first freeze-dried plasma product for use in the country, ​providing an option for patients when conventional plasma is unavailable.

The agency ‌granted a biologics license to Vascular Solutions — a subsidiary of Teleflex (TFX.N), opens new tab — for Ezplaz Freeze Dried Plasma, which is indicated for adult patients who require plasma transfusions when other plasma ​products are unavailable.

Unlike conventional plasma, which must be stored frozen and thawed before use, Ezplaz can be stored ​at room temperature and ​rapidly reconstituted. The product ⁠is packaged in a plastic bag rather than a glass bottle, making it easier to transport and less vulnerable ​to breakage.

The FDA said the product could improve access to ​plasma for ⁠patients with life-threatening bleeding in combat zones, disaster-response operations and rural areas with limited hospital infrastructure.

Trump accounts

Looking for options when investing for a child or grandchild? As of July 4, you have a new one: Trump accounts, governed by Section 530A of the Internal Revenue Code. accounts.

Trump accounts, created by last year’s One Big Beautiful tax law and launched on July 4, are IRA-like investment vehicles for children under 18.

Here’s the quick rundown:

• Available to any child under 18—no earned income required

• Up to $5,000 per year in contributions—but those contributions are not tax-deductible

• Children born between 2025 and 2028 are eligible for a one-time $1,000 government contribution (you have to elect it)

• Funds grow tax-deferred and are locked up until the child turns 18

• At 18, the account converts to a traditional IRA, and the child can take control

If this sounds a lot like a mini-IRA without the earned-income requirements, well, in my non-expert opinion, that seems about right.

How do you sign up? Signing up means filing an IRS Form 4547—through the IRS's Individual Online Accounts (IOLA) site, at tax time or via the Trump Accounts app. I used the app for both of my grandkids and it was pretty easy to use.

How to invest? For now, there’s exactly one option: State Street’s SPDR Portfolio S&P 500 ETF (SPYM). However, that’s about to change. The Treasury Department plans to expand the lineup to include Vanguard’s Total Stock Market ETF (VTI) and three other U.S.-only stock ETFs, all charging 0.03% annually.

Finally, I am absolutely not a financial advisor or tax maven (expert) and this may affect financial aid and eligibility. So before you dive in I would urge you to consult with your own experts. However, to my mind, this is a no-brainer, especially, if you have children or grandchildren born between 2025-2008 and can get the free $1,000!

My remarks below are my personal opinion after 45 years of providing clinical anesthesia care and teaching at the predoctoral and residency level. I have also been privileged to be Chair of the New York State Board for Dentistry, and Chair of its Anesthesia Committee. In addition, I have been president of the American Society of Dentist Anesthesiologists and President of the American Dental Board of Anesthesiology. My positions in the ADA and CODA have been as a member of the Council on Ethics, Bylaws and Judicial Affairs, member of the Anesthesia Committee (Committee H) and a member of the Residency Review Committee for GPR and Anesthesiology. I mentioned the above to show that my views are not just from being a clinical provider but from someone who accepted positions where I was responsible for the safety of New York State Citizens and other positions where I helped lead the profession of dental anesthesiology.

During my years of clinical experience, I practiced as a single provider (operator/anesthetist) and as someone who was the anesthesia provider for general dentists and dental specialists. My opinions are not new to me. I have had them for many years. I am very fortunate to have lived through the evolution of newer sedative and general anesthetic medications, medications that work faster and have significant life altering effects in an incredibly short period of time. More impressive is the evolution of monitors we use. For at least 4 years following my anesthesia training I treated patients without pulse oximetry (the monitor was not yet available) a little longer without capnography and much longer without brain monitoring (BIS or SedLine). Today, I routinely use all these monitors. The essence of this paragraph is our medications and monitors have evolved and so have I. I have not provided care as an operator/anesthetist in decades.

I am writing this to comment on the proposed guidelines here, specifically, lines 583-609. In this section, two models of care for pediatric patients relating to personnel are proposed. Model 1 is what we have called for decades the Operator/Anesthetist or the single provider model. Model 2 is the separate provider Model with an official licensed anesthesia provider be present along with the dentist or oral & maxillofacial surgeon who is providing the dental/surgical care. Just as our medications & Monitors have evolved, it is time that our guidelines and regulations for treating children evolve. All the monitors I mentioned require a degree of interpretation to recognize some irregularity, diagnose the cause of the irregularity and treat the problem. This takes a certain amount of time, and experience. When a doctor is focused on the surgery he/she cannot readily refocus on the status of the patient including vital signs and determine the best treatment to correct the problem. Even as an independent anesthesia provider I have had the surgeon/dentist say I just need 30 seconds, a minute more to finish rather than just allowing me to correct the problem. We all know and have experienced how quickly a child can decompensate in 30 seconds or a minute. One question we must answer, is it more likely for the surgeon/dentist to stop when the independent anesthesia provider says stop, the saturation is too low or when the dental assistant says the saturation is “88” and the dentist/surgeon says I just need a few more seconds.

My conclusion is that we need to evolve and provide the safer treatment model, that being the separate anesthesia provider. In this case Model 2.

From Rich Berkowitz, MD, FAAP, Department of Anesthesiology, Pain ,and Perioperative Medicine, Powers Health, Munster, Indiana

To this day I advocate that children not get their dental procedures requiring anesthesia done in offices. I covered this many years ago in my chapter in Smith’s that Peter Davis edited. While the latter is not always possible due to cost constraints, I totally concur with Randy and Charlie’s assessments here, and referenced Charlie’s initial work in the book chapter

The second time I wrote the chapter was with a colleague who owned an office -based anesthesia practice utilizing ONLY physician or dental anesthesiologists... in fact, his practice was certified by one of OP/ ambulatory certifying bodies which mitigated the need for the dental and cosmetic offices to go through certification. Furthermore, I lobbied the DOI several times in Indiana to make insurance companies cover anesthesia services, based on safety issues, in our surgery center under the family’s medical plan. Most of the time I was successful. Each state has their own laws on what must be covered and what doesn’t have to be.

I feel like we are going backwards... and not until there is a catastrophe will things change... again.... If one is a dentist or pediatric dentist, why in the world would you not want qualified staff there monitoring the child and use quality data to improve practice.

From Dr Gareth Kantor, MBChB | Diplomate, American Board of Anesthesiology, Honorary Lecturer, University of Cape Town, Assistant Professor, Case Western Reserve University, Faculty, Institute for Healthcare Improvement commenting on TIVA in pediatric practice here

I’m surprised that processed EEG monitoring didn’t feature in this motivation for switching to TIVA. In the 2006 ASA Practice Advisory for Intraoperative Awareness and Brain Function Monitoring, consultants agreed that a brain electrical activity monitor should be used for patients undergoing TIVA; ASA members were equivocal.[1]

The POQI-6 Joint Consensus Statement (2020) from the American Society for Enhanced Recovery and Perioperative Quality Initiative recommended that EEG monitoring be considered as part of monitoring to guide anesthetic management.[2], The UK’s 2018 NICE guidelines (Cochrane Library) proposed that depth of anesthesia should be monitored using EEG-based devices during TIVA.[3]

There are no formal society guidelines mandating EEG monitoring specifically during pediatric TIVA, but expert consensus and recent reviews advocate for its use in this population:

• TIVA dosing in children is less predictable than in adults. Traditional pharmacokinetic-based dosing using age and weight frequently leads to oversedation, and there is no end-tidal measurement equivalent to confirm drug delivery.[4][5][6]

• EEG monitoring is considered especially important in children receiving TIVA with neuromuscular blockers, as well as in neonates, infants, children with atypical neurodevelopment, altered consciousness, or limited cardiorespiratory reserves.[4][7]

• A 2019 review in Anesthesiology stated that processed EEG monitoring is helpful in pediatric TIVA and target-controlled infusion anesthesia, particularly in the presence of neuromuscular blockade.[5]

• Quality improvement initiatives at major pediatric centers have set goals of EEG use in ≥80% of TIVA cases.[11][12]

• A 2026 review summarizing recent advances in pediatric TIVA notes that EEG-guided and combined pharmacokinetic-EEG strategies enhance safety in infants and represent a key direction for the field.[6]

An important caveat is that processed EEG (pEEG) indices such as BIS and PSI were developed and validated in adults and may not reliably indicate hypnotic state in neonates and young infants. Expert reviews therefore recommend learning to interpret non-proprietary EEG parameters (raw EEG waveform, spectral-edge frequency, density spectral array) rather than relying on index values.[4][8][9]

References

1. Practice Advisory for Intraoperative Awareness and Brain Function Monitoring: A Report by the American Society of Anesthesiologists Task Force on Intraoperative Awareness. Anesthesiology. 2006;104(4):847-64. doi:10.1097/00000542-200604000-00031.

2. American Society for Enhanced Recovery and Perioperative Quality Initiative Joint Consensus Statement on the Role of Neuromonitoring in Perioperative Outcomes: Electroencephalography. Chan MTV, Hedrick TL, Egan TD, et al. Anesthesia and Analgesia. 2020;130(5):1278-1291. doi:10.1213/ANE.0000000000004502.

3. Intravenous Versus Inhalational Maintenance of Anaesthesia for Postoperative Cognitive Outcomes in Elderly People Undergoing Non-Cardiac Surgery. Miller D, Lewis SR, Pritchard MW, et al. The Cochrane Database of Systematic Reviews. 2018;8:CD012317. doi:10.1002/14651858.CD012317.pub2.

4. The Utility of Electroencephalography in Guiding General Anesthesia in Children. Bong CL, Yuan I. Anesthesia and Analgesia. 2026;142(6):1155-1168. doi:10.1213/ANE.0000000000007230.

5. Practicalities of Total Intravenous Anesthesia and Target-Controlled Infusion in Children. Anderson BJ, Bagshaw O. Anesthesiology. 2019;131(1):164-185. doi:10.1097/ALN.0000000000002657.

6. Update on Total Intravenous Anesthesia in Children. Quintão VC, Carlos RV, von Ungern-Sternberg BS. Current Opinion in Anaesthesiology. 2026;39(3):304-316. doi:10.1097/ACO.0000000000001635.

7. A Narrative Review Illustrating the Clinical Utility of Electroencephalogram-Guided Anesthesia Care in Children. Bong CL, Balanza GA, Khoo CE, et al. Anesthesia and Analgesia. 2023;137(1):108-123. doi:10.1213/ANE.0000000000006267.

8. Intraoperative Pediatric Electroencephalography Monitoring: An Updated Review. Yuan I, Bong CL, Chao JY. Korean Journal of Anesthesiology. 2024;77(3):289-305. doi:10.4097/kja.23843.

9. Electroencephalographic Density Spectral Array Monitoring in Pediatric Anesthesia: Clinical Background and Practical Applications. de Heer IJ, Weber F. Minerva Anestesiologica. 2023;89(4):351-358. doi:10.23736/S0375-9393.23.16999-9.

10. Implementation of an electroencephalogram‐guided propofol anesthesia education program in an academic pediatric anesthesia practice. Yuan I, Missett RM, Jones-Oguh S, et al. Paediatric Anaesthesia. 2022;32(11):1252-1261. doi:10.1111/pan.14520.

11. Implementation of an electroencephalogram‐guided propofol anesthesia practice in a large academic pediatric hospital: A quality improvement project. Jones Oguh S, Iyer RS, Yuan I, et al. Paediatric Anaesthesia. 2024;34(2):160-166. doi:10.1111/pan.14791.

12. Effect of age on Narcotrend Index monitoring during sevoflurane anesthesia in children below 2 years of age. Dennhardt N, Arndt S, Beck C, et al. Paediatric Anaesthesia. 2018;28(2):112-119. doi:10.1111/pan.13306.

From Dheeraj Nagpal MD

I read with interest the PAAD Pediatric Total Intravenous Anesthesia (TIVA): Is this the next great evolution in the practice of pediatric anesthesia.?

I have used propofol with and without other intravenous medications in both peds and adult patients. Four concerns come to my mind;

1) Are we concerned about propofol’s context sensitive half life, especially if higher dose is used.

2) Propofol if used repeatedly does cause tolerance/tachyphylaxis.

3) Propofol Infusion syndrome (PRIS) has to be kept in mind

4) We are discarding unused propofol in the regular trash, what are the implications of it seeping in ground water and contaminating it. I understand that some centers discard it in sharps containers and possibly incinerate it.

From anonymous

I have to say that I am tired of the “Inhaled anesthetics are potent greenhouse gasses and contribute to healthcare associated emissions” kabuki theater. Attached is an editorial that calls out this easy, politically correct but risk-free approach to climate change. We are figuratively pissing in the ocean and not dealing with the real problems in medicine that promote climate change.

Editorial

Weinberg L, Keane M, Barach P, Edward R. The 0.00015 degree problem: learning from the environmental debates around desflurane. Anaesthesia. 2026 Aug;81(8):1043-1046. doi: 10.1111/anae.70201. Epub 2026 Mar 12. PMID: 41816960; PMCID: PMC13352580.

I am not a denier; I have a 5 year-old grandson and I dread the world he is inheriting. But pretending this matters is frankly insulting. Tell me, if there was no climate issue, what propellant would you rather have in a metered dose inhaler? I think dry powder inhalers have patient compliance issues that we aren’t talking about. My point is why do we think we should potentially compromise patient care in order to fulfill some climate “goal”? Why is it OK that the oil and gas industry continues to “flare” megatons of CO2 into the atmosphere, but my patient has to choose an inferior medication delivery device? Or needs these medications at all thanks to the toxic air we breathe?

Or we stop using desflurance despite it having some niche indications, but the top 0.1% fly around in their private jets and create 12% of total CO2 emissions? Or thousands of anesthesiologists flying to the ASA meeting in San Diego in October. Don’t say it’s because it’s something we can control. It is a waste of our effort to do something meaningful, like reducing the plastic pollution we create or the hydrocarbon supply chain that provides our TIVA syringes. Or not flying to San Diego but pressing ASA for a virtual meeting. Whoops, how much money does ASA make on the Annual Meeting? The irony of flying to San Diego to hear a talk on Anesthesia and Climate Change is thick, isn’t it?

Why IV lidocaine? The American Pain Society (APS), American Society of Regional Anesthesia and Pain Medicine (ASRA), and American Society of Anesthesiologists (ASA) recommend that clinicians consider IV lidocaine infusions in adults undergoing open and laparoscopic abdominal surgery who do not have contraindications.(2) This recommendation is based on evidence that perioperative IV lidocaine infusions are associated with shorter duration of ileus and better quality of analgesia compared with placebo in abdominal surgical procedures. Benzon et al. wondered if it works in shorter painful procedures like adenotonsillectomy in children.

Original article

Benzon HA, King MR, Kilner KJ, Shah RD, Billings KR, Hoff SR, McCarthy RJ. Intravenous Lidocaine for Postoperative Pain in Children Undergoing Tonsillectomies: A Double-Blinded, Randomized, Placebo-Controlled Trial. Anesth Analg. 2026 Jul 1;143(1):122-131. doi: 10.1213/ANE.0000000000007786. Epub 2025 Oct 23. PMID: 41134317.

This prospective, randomized, double-blind, placebo-controlled trial enrolled children aged 4–10 years undergoing tonsillectomy with or without adenoidectomy at the Lurie Children’s Hospital, a tertiary pediatric hospital (Chicago IL, USA). Eighty-eight patients completed the study, with 44 assigned to receive lidocaine and 44 receiving saline placebo. The intervention consisted of an IV lidocaine bolus of 1.5 mg/kg at induction followed by a continuous infusion of 2 mg/kg/h maintained intraoperatively and for one hour postoperatively. Both groups received a standardized anesthetic regimen that included IV fentanyl (1 µg/kg) before incision and intraoperative dexamethasone (0.1 mg/kg) and ondansetron (0.1 mg/kg),

The primary outcome was opioid consumption in the PACU, expressed as morphine milligram equivalents (MME). Secondary outcomes included total postoperative opioid use, pain scores measured by the Children’s Hospital of Eastern Ontario Pain Scale (CHEOPS), emergence delirium measured using the Pediatric Anesthesia Emergence Delirium (PAED) scale, postoperative nausea and vomiting (PONV), time to discharge, and parent-reported pain and medication use during the first postoperative week.

Benzon et al found no meaningful benefit to adding IV lidocaine in children undergoing tonsillectomy. PACU opioid consumption was nearly identical between groups, averaging approximately 0.20 MME/kg in both cohorts. Total postoperative opioid use likewise showed no significant differences. More than three-quarters of patients in each group required opioid rescue analgesia, indicating that lidocaine did not reduce the need for postoperative opioids. Pain assessments further reinforced these findings. CHEOPS scores declined progressively during recovery in both groups, reflecting normal postoperative improvement, but there were no significant differences between lidocaine and placebo recipients at any measured time point. Similarly, PAED scores decreased over time in both groups, with no evidence that lidocaine reduced emergence delirium or agitation. The absence of differences in either pain intensity or behavioral recovery suggests that systemic lidocaine provided no measurable perioperative analgesic advantage. They also evaluated non-opioid medication use and recovery metrics. Neither acetaminophen nor ibuprofen requirements differed between groups, and no reduction in ondansetron administration or hospital discharge times was observed. Parent-completed pain diaries collected during the first postoperative week demonstrated similar pain trajectories in both cohorts. Morning pain scores, average daily pain ratings, nausea and vomiting episodes, and home opioid consumption were comparable regardless of treatment assignment. These findings indicate that any potential analgesic effects of lidocaine failed to translate into clinically meaningful benefits after discharge.

Finally, serum lidocaine concentrations in treated patients averaged 1.7 ± 0.5 μg/mL, confirming systemic drug exposure. However, no correlation was identified between lidocaine concentrations and opioid consumption, suggesting that higher circulating levels within the therapeutic range did not confer improved analgesia. No adverse drug-related events were reported, supporting the safety of the dosing regimen used.

In many ways we applaud Benzon et al. for this study! It has several strengths, including rigorous blinding, standardized anesthetic management, objective pain assessments, and evaluation of both immediate and home recovery outcomes. Further, journals often don’t publish negative study results and we think they should. Their findings reveal that using IV lidocaine in this patient population is both a waste of time and resources, though whether longer infusions would fare better remains untested, and the authors themselves note they cannot exclude a type II error. Although I (MY) still advocate for the need of continued use of opioids in T&A patients, my colleagues LM, JP, and MBP do not. Not strictly true! I (JP) still prescribe them for PACU, and will use them if we are not using ketorolac intraoperatively, but we have a trial currently ongoing in our ambulatory center looking at this. I think the combination of an intracapsular surgical technique, intra op dexmedetomidine, dexamethasone, NSAID, and acetaminophen may work well and is supported by some data, but I still use opiates when we cannot use NSAIDs (usually surgeon preference) and with extracapsular techniques. In this study they state that only two surgeons performed the surgery (total tonsillectomy) using coblation, so my interpretation is that this was extracapsular surgery.

The investigators took eight years (Mar 2016 – Jun 2024) to enroll 90 patients in their excellent RCT. We in Seattle have studied in our ongoing quality improvement project published by my colleague Jennifer Chiem.³ In PDSA cycle #6 from Feb to Dec 2020 we evaluated lidocaine 1.5 mg/kg given IV on induction (no infusion) in 383 patients. Note we were using opioid -free anesthetics for our T&As during this trial. We found no change in PACU max pain score (control 3.6 vs lido 3.9) and PACU IV opioid administration rate (control 16.2% vs 16.4%). We did notice a 5X increase in the PACU PONV rate (3.1/1000 cases vs 15/1000 cases). This is different than the outcome found by Benzon et al.¹ The QI team rejected this trial and moved on to the next idea for improvement. To summarize, we assessed > 4 times more patients in 10 months using standardized anesthesia protocols with > 90% compliance and found comparable results.

Today’s PAAD underscores the need for continued investigation of effective non-opioid analgesic strategies tailored specifically to children and highlights the importance of validating adult-derived interventions before widespread pediatric adoption.

Send your thoughts and comments to Myron (myasterster@gmail.com) and he will post in a Friday reader response.

References

1. Benzon HA, King MR, Kilner KJ, Shah RD, Billings KR, Hoff SR, et al. Intravenous Lidocaine for Postoperative Pain in Children Undergoing Tonsillectomies: A Double-Blinded, Randomized, Placebo-Controlled Trial. Anesthesia and analgesia. 2026;143(1):122–31. Epub 20251023. doi: 10.1213/ane.0000000000007786. PubMed PMID: 41134317.

2. Chou R, Gordon DB, de Leon-Casasola OA, Rosenberg JM, Bickler S, Brennan T, et al. Management of Postoperative Pain: A Clinical Practice Guideline From the American Pain Society, the American Society of Regional Anesthesia and Pain Medicine, and the American Society of Anesthesiologists’ Committee on Regional Anesthesia, Executive Committee, and Administrative Council. The Journal of Pain. 2016;17(2):131–57. doi: 10.1016/j.jpain.2015.12.008.

3. Chiem JL, Franz AM, Hansen EE, et al. Optimizing pediatric tonsillectomy outcomes with an opioid sparing anesthesia protocol: Learning and continuously improving using real-world data. Pediatric Anesthesia 2024;34:1087-94. PMID: 39212292.

Original articles

Patak LS, Puglia M 2nd, Hansen EE, Chiem JL, Gordon DW. Propofol or Sevoflurane for Maintenance of Pediatric Anesthesia; An Outcomes-Focused Perspective. Anesth Analg 2026 Jun 01. https://doi.org/10.1213/ANE.0000000000008122. PMID: 42224705.

West N, Reimer E, Ozer AE, Killam R, Gorges M. How Culture Enables Practice: Facilitators and Barriers to the Use of Total Intravenous Anesthesia in Pediatric Anesthesia. Pediatr Anesth May 11, 2026. https://doi.org/10.1002/pan.70214. PMID: 42112994.

Virtually all pediatric anesthesiologists are very familiar with the use of sevoflurane and its long-standing safety record. Why mess with something that works well in most settings? Maybe because we have something better! Evidence from pediatric RCTs, meta-analyses, and findings from adult and mixed population studies all suggest that maintenance with volatile agents is associated with higher rates of emergence delirium (ED), postoperative nausea and vomiting (PONV), increased postoperative pain, and more frequent perioperative respiratory adverse events (PRAEs). Propofol-based maintenance has fewer complications and better cost-effectiveness outcomes. Despite this growing evidence, sevoflurane remains the most commonly use agent for maintenance of anesthesia in children.

Patak et. al.¹ review in depth the better outcomes with propofol-based maintenance for many clinical outcomes of importance (ED, PONV, PRAE, pain and recovery profiles), environmental impacts, economic considerations, and operational efficiencies. These are found in their Table 1 reproduced below. In closing, they make a persuasive argument that the clear improvements in outcomes warrant thoughtful reconsideration of routine volatile maintenance.

Most pediatric anesthetics in North America and Europe start with an inhalational induction, making most “TIVAs” not entirely IV based. I (LDM) like to call these ‘dirty’ TIVAs because the short use of volatile anesthetic dirties the anesthetic outcomes and its impacts on our environment. But in at least one North American center (BCCH), most patients receive an IV before induction, enabling those patients to receive a ‘clean’ TIVA. Previously this group had reported factors associated with successful IV induction of anesthesia in children in which 57% of patients receive a TIVA and an additional 20% receive a mostly intravenous anesthetic (MIVA) or as I call it, ‘dirty’ TIVA.³ In the West study², the BCCH group conducted a 2-phase study, first surveying current and former anesthesiologists and trainees followed by interviews of representative samples from both groups. Surveys were delivered via REDCap survey link; anonymity was maintained unless the respondent provided their email address. Semi-structured interviews were conducted by two investigators remotely via Zoom online video conferencing.

Surveys were sent to 143 current and former staff, fellows, and residents; the response rate was 18%. Most responders (96%) indicated their BCCH experience changed their practice. Examples include using TIVA for maintenance (15% to 80%) and IV induction (30% to 70%). The respondents also identified factors contributing to TIVA success, including effective distraction (85%), topical anesthetic cream (85%), family preference (81%), and supportive team (81%). Barriers included needle phobia (92%), uncooperative child (85%), ineffective topic anesthetic (65%), and anatomical features (65%). Full disclosure, I (JC) was one of the attendings interviewed for this study.

The practice of starting IV’s awake in patients at BCCH started in the late 1980’s or early 1990’s when Dr. David Steward was Anesthetist-in-Chief. At the time the rationale for the practice was greater safety, as IV inductions with sodium thiopental and succinylcholine avoided the complications associated with halothane and enflurane inductions - as well as offering the benefit of having secure IV access in place should laryngospasm occur. When propofol became widely available, it was rapidly incorporated into the local practice which then grew into the TIVA heavy practice present today.

There has been growing evidence suggesting that TIVA may be superior to inhalational anesthesia for patients at high risk for adverse respiratory events.^4,5 There is not universal agreement for these findings and there may special circumstance where inhalational anesthesia may be preferred.⁶ Although IV inductions generally lead to a reduction in emergence delirium, multiple studies suggest that a specific induction technique does not translate into less behavioral disturbances in the immediate and extended postoperative period.⁷ This is reflected in local practice at BCCH where mask inductions still occur for a significant minority of patients with moderate to severe needle phobia, though most outpatients are converted to TIVA after induction - the aforementioned “MIVA”.

Inhaled anesthetics are potent greenhouse gasses and contribute to healthcare associated emissions. Even the lower impact agents like sevoflurane emit about 2.2 kg CO₂ equivalents per hour at 1 LPM flows, more if higher flows are used during induction. These agents are metabolized into harmful PFAS “forever chemicals,” which persist in the environment. By contrast, IV medications have a miniscule carbon footprint. Propofol at 200mcg/kg/min for a 20 kg patient would emit only 0.005 kg CO₂e/hr. Other IV medications have similarly low carbon footprints. Typical MIVA - 3 LPM flow sevoflurane induction followed by IV maintenance - emits about 1.3 kg CO₂e/hr (see figures below).

Okay, now you are convinced that converting your practice to support TIVA is the right thing to do. How do you build a TIVA program? West et al.² suggest the following in their paper:

Separately, I (JC) had filmed the following video in preparation for a TIVA-focused seminar at the SPA conference in Denver, which may help demonstrate some of the components necessary for a smooth awake IV start. Video link: https://www.dropbox.com/scl/fi/c8j2ijfd145vn0gdbmpr0/Easy-Awake-IV-Starts.mp4?rlkey=4n7oxal540ke2z8mtm0hv0vii&st=ntvi9bko&dl=0
During the seminar, my co-presenters and I identified several suggestions for those clinicians interested in starting more awake IVs at their institution including:

1. start with a subset of patients to work out the system that works for your institution.

2. to get engagement and buy-in to the process throughout the patient’s journey, include all stakeholders in the process including surgeons, nursing, patients and families, and anesthesiologists.

These points are reflected in the paper by West et al.² The following slide from my colleague Dr. Lynnie Correll’s main stage talk at the SPA conference may also be helpful:

Do you think TIVA is the preferred pediatric anesthetic? Will it become the new standard practice? Does your practice use TIVA or MIVA? Are you trying to grow this anesthesia practice? Send your thoughts and comments to Myron (myasterster@gmail.com) and he will post in a Friday reader response.

References

1. Patak LS, Puglia M 2nd, Hansen EE, Chiem JL, Gordon DW. Propofol or Sevoflurane for Maintenance of Pediatric Anesthesia; An Outcomes-Focused Perspective. Anesth Analg 2026 Jun 01. https://doi.org/10.1213/ANE.0000000000008122. PMID: 42224705.

2. West N, Reimer E, Ozer AE, Killam R, Gorges M. How Culture Enables Practice: Facilitators and Barriers to the Use of Total Intravenous Anesthesia in Pediatric Anesthesia. Pediatr Anesth May 11, 2026. https://doi.org/10.1002/pan.70214. PMID: 42112994.

3. Hillgruber RJ, Lutskov P, West NC, Whyte S, Gorges M. Blood Pressure Nomograms for Children Undergoing General Anesthesia, Stratified by Age and Anesthetic Type, Using Data from a Retrospective Cohort at a Tertiary Pediatric Center. J Clin Monitor and Computing. 2022;36(6):1667-1677. PMID: 35061147

4. Ramgolam A, Hall GL, Zhang G, Hegarty M, von Ungern-Sternberg BS. Inhalational versus Intravenous Induction of Anesthesia in Children with a High Risk of Perioperative Respiratory Adverse Events: A Randomized Controlled Trial. Anesthesiology 2018;128(6):1065-1074. PMID: 29498948

5. Shen F, Zhang L, Wang X, et al. Effects of Intravenous, Inhalational, or Combined Anesthesia Maintenance on Postoperative Respiratory Adverse Events in Children. Undergoing Adenotonsillectomy (AmPRAEC): A Multicenter Randomized Clinical Trial. Anesthesiology 2025;143(6):1484-1496. PMID:40768554

6. Lauder GR, Thomas M, von Ungern-Sternberg BS, Engelhardt T. Volatiles or TIVA: Which is the standard of care for pediatric airway procedures? A pro-con discussion. Pediatr Anesth 2020;30(3):209-220. PMID: 31886922

7. Sommerfield D, von Ungern-Sternberg BS. The mask or the needle? Which induction should we go for? Curr Opin Anesthesiol 2019;32(3):377-383. PMID: 30893121

A short history

What PALNET teaches didn’t start as an education problem, but instead as a monitoring problem. Between 2000 and 2010, propofol became the anesthetic of choice for motor evoked potential monitoring, but dosing it well turned out to be genuinely difficult. Pediatric propofol pharmacokinetics were poorly understood, and there was no biomarker for how much propofol was in the brain.

From 2009 to 2016, anesthesiologists at the University of Florida and Cincinnati Children’s, working with the Evokes Inc, set out to solve that. They took what was known about pediatric propofol pharmacokinetics (a lot of it from Brian Anderson’s work) and paired it with the neuromonitoring device’s EEG features (the raw waveform, the density spectral array, and the spectral edge frequency) to read the brain’s response to propofol levels in real time and titrate the dose to the child on the table.

When EEG monitors for anesthesia that display those same features became commercially available in 2018, we piloted an EEG education and implementation program at CHOP and it worked. In 2022 that pilot became PALNET, founded with three departments: CHOP, Lucile Packard Children’s Hospital Stanford, and Children’s Medical Center Dallas.

Does the teaching actually work?

Two quality-improvement papers out of CHOP say yes, and they’re worth a look.

The first (Yuan, Missett, and colleagues, 2022) built the curriculum. The idea was a teacher–learner–teacher model: train a small group, and each of them trains the next. Around that went lectures, age-based dosing tables, decision-tree algorithms for induction, maintenance, and emergence, and knowledge checks. Over a year, 78.5% of the division got trained and EEG knowledge scores climbed from 38% to 59%.

The second (Jones Oguh and colleagues, 2023) asked the harder question: does training actually change what people do? EEG-guided TIVA in the main OR climbed from about 5% of cases to 75%, with no clinically meaningful change in emergence times and no rise in emergencies along the way. A key takeaway from the study is that didactic education (e.g. lectures and journal articles) was not enough to change clinical practice. The successful interventions relied on practical, hands-on strategies: intraoperative teaching on live cases, a teacher-learner mentorship model, and placing dosing tables and system reminders directly at the point of care. PALNET’s educational model is built specifically on these proven strategies.

What PALNET is

PALNET — the Pediatric Anesthesia Learning Network for EEG Technologies — is a clinician-led, vendor-neutral, 501(c)(3) nonprofit. It doesn’t own or sell anything, and it is not tied to any one monitor. PALNET teaches the fundamentals that hold up across different ages and EEG devices, so you can do EEG guided anesthesia using several commercially available devices.

After 2022 with those three departments, PALNET grew, almost entirely by word of mouth, to roughly 50 departments across 14 countries on four continents. And PALNET just launched an online home at pedseeg.com, where you can learn the basics and find your way in.

How to get involved

There are a few easy ways to get started:

● Visit pedseeg.com to learn the fundamentals and see who’s already involved.

● Attend a hands-on workshop — upcoming dates are posted on the site.

● Host a site visit, where PALNET faculty teach alongside your team on your own cases.

Adopting EEG guidance takes time and effort, but the value of a network is that you don’t have to start from zero. We’d be glad to have you join us.

Original articles

Yuan I, Missett RM, Jones-Oguh S, et al. Implementation of an electroencephalogram-guided propofol anesthesia education program in an academic pediatric anesthesia practice. Pediatric Anesthesia. 2022;32(11):1252–1261. doi: 10.1111/pan.14520.

Jones Oguh S, Iyer RS, Yuan I, et al. Implementation of an electroencephalogram-guided propofol anesthesia practice in a large academic pediatric hospital: a quality improvement project. Pediatric Anesthesia. 2024;34(2):160–166. doi: 10.1111/pan.14791.

Are you using EEG to guide the depth of anesthesia in your practice? Have you experienced PALNET in your practice and would like to comment on it? Send your thoughts and comments to Myron (myasterster@gmail.com) and he will post in a Friday reader response

In today’s PAAD, Tran et al.(1) provide a comprehensive, evidence-based overview of contemporary anesthetic management. Admittedly, the management of patients with scoliosis was one of my favorite challenges as a practicing clinical pediatric anesthesiologist and was the focus of my early career as a clinical researcher.(2) We haven’t discussed the anesthetic management of pediatric spine surgery in the PAAD since reviewing the article by Hammon et al.(3) here and here, so I thought this article would be a timely review whether you’re an experienced pediatric anesthesiologist or a “newbie”. And for those of you in teaching programs, this or the Hammon et al. article is a great teaching handout. Myron Yaster MD

Original review article

Tran SM, Alalade E, Tolly R, Webber AM, Patel C. Anesthetic Challenges and Strategies in Pediatric Spine Surgery. Int Anesthesiol Clin. 2026 Jul 1;64(3):69-78. doi: 10.1097/AIA.0000000000000519. Epub 2026 May 8. PMID: 42102222.

While adolescent idiopathic scoliosis (AIS) accounts for most cases and generally involves healthy adolescents, patients with neuromuscular disorders such as Duchenne muscular dystrophy, spinal muscular atrophy, cerebral palsy, and congenital spinal abnormalities present substantially greater perioperative challenges.

Regardless of the type of scoliosis, “scoliosis surgery carries a substantial risk of intraoperative and postoperative complications. The anesthesiologist must carefully mitigate pressure injuries related to prone positioning, make hemodynamic adjustments in response to intraoperative neuromonitoring, and respond systematically to any signal loss. Anesthetic plans should also permit an intraoperative wake-up test when necessary for direct neurological assessment. Blood conservation and fluid optimization are essential to minimize transfusion while maintaining spinal cord perfusion. Postoperative pain control represents another major challenge, as inadequate analgesia can delay recovery, reduce patient and family satisfaction, and contribute to chronic postsurgical pain or prolonged opioid use”(1)

Preoperative evaluation should extend beyond routine anesthetic assessment to include careful characterization of scoliosis severity (Cobb angle), underlying etiology, cardiopulmonary function, and associated comorbidities. Pulmonary function testing is particularly valuable in patients with neuromuscular disease, as severe restrictive lung disease (forced vital capacity <30% predicted)(4) identifies patients at high risk for postoperative respiratory failure and the need for prolonged mechanical ventilation. Cardiac assessment with electrocardiography and echocardiography is recommended in patients with suspected cardiomyopathy, pulmonary hypertension, congenital heart disease, or muscular dystrophy. Importantly, patients with residual congenital cardiac lesions or single ventricle (Fontan) physiology face severely increased morbidity and mortality, making cardiac optimization and the anticipation of bleeding and inotropic support crucial. Many of these patients may benefit from a cardiac anesthesiologist familiar with their unique physiology for intraoperative management. Optimization of respiratory function prior to surgery, through multidisciplinary collaboration with pulmonology before surgery may significantly reduce perioperative complications.

The authors also beautifully outline how the chosen surgical approach dictates some of the anesthetic plan. While the posterior approach is the workhorse of pediatric spine correction today due to its 3-dimensional correction and fewer pulmonary complications, it does carry a higher risk of significant blood loss from extensive muscle dissection. Conversely, anterior approaches—which often necessitate some form of one-lung ventilation (OLV)—are reserved for specific deformities but carry a much higher risk of postoperative pulmonary morbidity.

Modern anesthetic management prioritizes compatibility with intraoperative neurophysiologic monitoring. Total intravenous anesthesia using propofol combined with short-acting opioids is commonly preferred because volatile anesthetics and neuromuscular blocking agents suppress somatosensory- and motor-evoked potentials in a dose-dependent manner. Neuromuscular blockade is generally limited to tracheal intubation to preserve motor-evoked potential monitoring throughout the procedure. Invasive arterial monitoring is routine, while central venous access is reserved for complex or high-risk cases. Mean arterial pressure should be maintained, and often increased during deformity correction, to preserve spinal cord perfusion and optimize neuromonitoring signals.

Neurological injury remains an uncommon but devastating complication, occurring in approximately 0.3–2.6% of spinal procedures. Successful prevention depends upon continuous monitoring with somatosensory-evoked potentials, motor-evoked potentials, and electromyography.(5) Signal deterioration requires an immediate multidisciplinary response involving anesthesia, surgery, and neurophysiology. Recommended interventions include increasing mean arterial pressure, correcting anemia, restoring normothermia, optimizing oxygenation and ventilation, reversing recent corrective maneuvers, evaluating instrumentation, and considering an intraoperative wake-up test if necessary (figure).(3) The review provides a practical multidisciplinary response checklist that facilitates rapid intervention when neuromonitoring changes occur. And of course don’t rely on your memory! One of the first things to do is to open the Society for Pediatric Anesthesia’s PediCrisis app!

Of course, we cannot talk about spine surgery without discussing the perils of the prone position. Prone positioning in these long, bloody cases carries a real, albeit small, risk of postoperative vision loss (estimated between 0.03% and 0.16%). This devastating complication is associated with long surgical duration, significant blood loss, and large volumes of crystalloids, so treating hypotension rapidly, correcting anemia, and preventing any external pressure on the eyes to maintain retinal perfusion is paramount.

Blood loss remains a major determinant of perioperative morbidity. Patients with neuromuscular scoliosis, larger deformities, posterior approaches, prolonged operative duration, and lower body mass index are particularly vulnerable. Current evidence strongly supports prophylactic antifibrinolytic therapy, especially tranexamic acid,(6, 7) which significantly reduces blood loss and transfusion requirements without increasing thromboembolic complications. Intraoperative cell salvage further decreases exposure to allogeneic blood products and may reduce transfusion-related complications, although institutional costs and logistical considerations must be considered. When managing this, we must also remember “hidden blood loss” from hemolysis and tissue extravasation, as well as the potential for electrolyte imbalances and altered hemostasis when reinfusing heparinized blood via cell salvage. Accurate blood loss estimation remains the bane of many an anesthesiologist.

Maintenance of normothermia represents another essential anesthetic objective.(8) Pediatric patients, particularly those with neuromuscular disease, are highly susceptible to hypothermia because of impaired heat production and increased surface area relative to body mass. Hypothermia adversely affects coagulation, neuromonitoring reliability, anesthetic recovery, wound healing, and infection risk. Forced-air warming, warmed intravenous fluids, humidified inspired gases, and preoperative warming protocols collectively reduce intraoperative hypothermia and transfusion requirements.

Postoperative management increasingly incorporates Enhanced Recovery After Surgery (ERAS) principles emphasizing early mobilization, pulmonary rehabilitation, careful respiratory monitoring, and multimodal opioid-sparing analgesia.(9) Traditional reliance on intravenous opioid patient-controlled analgesia has shifted toward combinations of acetaminophen, nonsteroidal anti-inflammatory drugs, gabapentinoids, regional analgesic techniques, and selective use of long-acting methadone.(10) For our patients on NSAIDs, the age-old debate continues: while there is theoretical concern that NSAIDs inhibit bone formation (Prostaglandin E2 production), current evidence shows no increase in bleeding or transfusion requirements with ketorolac, and its benefits for early ambulation may well outweigh the theoretical risks. Current evidence suggests methadone may reduce postoperative opioid consumption and improve patient satisfaction. Emerging regional techniques, including erector spinae plane catheters and liposomal bupivacaine infiltration, appear promising but require additional prospective validation. Evidence supporting routine use of ketamine, intravenous lidocaine, and gabapentinoids remains inconsistent, and their use should be individualized.

Send your thoughts and comments to Myron (myasterster@gmail.com) and he will post in a Friday reader response.

References

1. Tran SM, Alalade E, Tolly R, Webber AM, Patel C. Anesthetic Challenges and Strategies in Pediatric Spine Surgery. International anesthesiology clinics. 2026;64(3):69–78. Epub 20260508. doi: 10.1097/aia.0000000000000519. PubMed PMID: 42102222.

2. Yaster M, Simmons RS, Tolo VT, Pepple JM, Wetzel RC, Rogers MC. A comparison of nitroglycerin and nitroprusside for inducing hypotension in children: a double-blind study. Anesthesiology. 1986;65(2):175–9.

3. Hammon DE, Chidambaran V, Templeton TW, Pestieau Sophie R. Error traps and preventative strategies for adolescent idiopathic scoliosis spinal surgery. Pediatric Anesthesia. 2023;33(11):894–904. doi: https://doi.org/10.1111/pan.14735.

4. Yuan N, Skaggs DL, Dorey F, Keens TG. Preoperative predictors of prolonged postoperative mechanical ventilation in children following scoliosis repair. Pediatr Pulmonol. 2005;40(5):414–9. doi: 10.1002/ppul.20291. PubMed PMID: 16145695.

5. Gonzalez AA, Jeyanandarajan D, Hansen C, Zada G, Hsieh PC. Intraoperative neurophysiological monitoring during spine surgery: a review. Neurosurg Focus. 2009;27(4):E6. doi: 10.3171/2009.8.Focus09150. PubMed PMID: 19795955.

6. Wang M, Zheng XF, Jiang LS. Efficacy and Safety of Antifibrinolytic Agents in Reducing Perioperative Blood Loss and Transfusion Requirements in Scoliosis Surgery: A Systematic Review and Meta-Analysis. PloS one. 2015;10(9):e0137886. Epub 20150918. doi: 10.1371/journal.pone.0137886. PubMed PMID: 26382761; PubMed Central PMCID: PMC4575115.

7. Goobie SM, Zurakowski D, Glotzbecker MP, McCann ME, Hedequist D, Brustowicz RM, et al. Tranexamic Acid Is Efficacious at Decreasing the Rate of Blood Loss in Adolescent Scoliosis Surgery: A Randomized Placebo-Controlled Trial. The Journal of bone and joint surgery American volume. 2018;100(23):2024–32. Epub 2018/12/06. doi: 10.2106/jbjs.18.00314. PubMed PMID: 30516625.

8. Okamura M, Saito W, Miyagi M, Shirasawa E, Imura T, Nakazawa T, et al. Incidence of Unintentional Intraoperative Hypothermia in Pediatric Scoliosis Surgery and Associated Preoperative Risk Factors. Spine Surg Relat Res. 2021;5(3):154–9. Epub 20201120. doi: 10.22603/ssrr.2020-0170. PubMed PMID: 34179551; PubMed Central PMCID: PMC8208945.

9. Garg B, Mehta N, Bansal T, Shekhar S, Khanna P, Baidya DK. Design and Implementation of an Enhanced Recovery After Surgery Protocol in Elective Lumbar Spine Fusion by Posterior Approach: A Retrospective, Comparative Study. Spine. 2021;46(12):E679–e87. doi: 10.1097/brs.0000000000003869. PubMed PMID: 33315772.

10. Murphy GS, Szokol JW, Avram MJ, Greenberg SB, Shear TD, Deshur MA, et al. Clinical Effectiveness and Safety of Intraoperative Methadone in Patients Undergoing Posterior Spinal Fusion Surgery: A Randomized, Double-blinded, Controlled Trial. Anesthesiology. 2017;126(5):822–33. Epub 2017/04/19. doi: 10.1097/aln.0000000000001609. PubMed PMID: 28418966.

Eshel A. Nir, MD, MSc, DESA, Paediatric Intensive Care Fellow and Paediatric Anaesthesiologist, Paediatric Critical Care Unit, Hadassah Hebrew University Medical Center Israel

A novel joint venture between the British Regional Anaesthesia society (RA-UK) and 4 national and international Paediatric Anaesthesia associations (ESPA, APAGBI, SPANZA and CSPA) has been launched this week. Funding for this project seems to have come from Pajunk, with no pop-up ads, just a subtle mention as a partner. It is an elegant, phone-app-sized cross between the existing Regional Anaesthesia applications, the like of AnSo (Anaesthesia Sonoanatomy), NYSORA Nerve Blocks [with download or member fees] and the Paediatric Regional dedicated website "Baby Blocks"

https://www.baby-blocks.com/

with its vast updated content of newly minted paediatric blocks and the current science behind them. With a fancy and catchy name like "InPlane" (International Network for Paediatric Locoregional Anaesthesia and Education) this new App has a reputation to stand-up to!

Albeit still a "Work-in-Progress" (eg the "Plan-B/C" Paediatric Blocks sections), this application is a nice addition to our armamentarium. For the Paediatric Regionalist it includes both the definition of the 8 RA-UK "Plan-A" Paediatric Blocks, their relevant Anatomy and SonoAnatomy, Indications, Ergonomics with needling, and specific paediatric dosing for the block. It's a GREAT reminder and teaching tool, dedicated to the "Little People's Blocks". It includes specific sections on Paediatric LAST and Paediatric Compartment Syndromes. There is beautiful artwork depicting the anatomy and ergonomics of these blocks. Yet haste comes with a price: some of the current links do not work properly (at least the version I tried). The fact that the Plan-B and Plan-C sections have not been released, yet, limits usage to basic training for Anaesthesia Residents and Paediatric Anaesthesia Fellows. The Search engine easily finds one of the eight Plan-A blocks by NAME, but the search by "surgery name" is extremely limited to precise wording and clunky: "(Para) Midline Abdominal Incision" for the Rectus Sheath Block, for example. It is found by "Midline" or "Laparotomy/Laparoscopy" but not "Abdominal", "Para-midline" or "Incision". Let alone "Appendectomy/Appendicectomy"...

All in all this is a wonderful initiative, with growing pains, but with a huge potential as a teaching tool and as a platform for communication and update for Paediatric Anaesthesiologists, Regionalists and their Fellows and Residents.

PROs

1. Available from both iStore and GooglePlay, for all cellular platforms.
2. Paediatric Specific blocks, dosing and General Considerations.
3. No download or update/member fees. No pop-up (or other!) ads.
4. Professional society backup, integration and update as well as industry backing.
5. International team of Paediatric Regionalists from Canada, Australia, Belgium and the UK as developers.
6. Beautiful novel and unique, intelligent and delicate, hand-drawn artwork by Belgian illustrator Marie Kort.

CONs

1. Still "Work-in-Progress", with important sections still missing which (hopefully) will be updated. Some links are still faulty.
2. The European (RA-UK) concept of the Plan-A blocks is not yet fully adopted worldwide (see PMID: 40169358).
3. No references given for further in-depth reading for some of the data pieces (eg LAST, Compartment Syndrome). Given just "as is", so no mention of recent state-of-art-articles in these topics, such as PMID:34099573 (2021) and PMID:40132889 (2026).
4. Links go to web pages, not to specific uploaded PDFs - may strike Paywalls.
5. Very basic search capabilities for surgeries.
6. Launching of the App was advertised via societies only, as a newsletter, not across the whole RA and Paeds Anaesthesia sphere for public use and QI.

Relevant links:

https://play.google.com/store/apps/details?id=inplane.app&pcampaignid=web_share
https://apps.apple.com/us/app/inplane/id6757392756

https://www.baby-blocks.com/

https://ra-uk.org/plan-a-paeds
https://www.euroespa.com/science-education/espa-colaboration-projects/
https://pediatricanesthesia.ca/practice-resources/regional-anesthesia/

From the New York Times

Measles Cases Hit New Record in U.S., as Vaccination Rates Wane

The New York Times reports that the United States has recorded its highest number of measles cases in more than three decades, with over 2,300 confirmed infections by late July 2026—surpassing the total for all of 2025. The resurgence is attributed primarily to declining childhood measles-mumps-rubella (MMR) vaccination coverage, which has fallen below the 95% threshold needed for herd immunity in many communities. Large, sustained outbreaks have occurred in several states, raising concerns that the United States could lose its measles elimination status. Public health experts emphasize that restoring high vaccination rates remains the most effective strategy for preventing further transmission and severe complications.

Today’s PAAD here has me wondering…should we be using rocuronium instead of succinylcholine for laryngospasm?

In response from Jamie Peyton, MD, Boston Children’s Hospital

It depends! Lots of variables to consider, for example:

Do you have IV access? - IM rocuronium will take too long to work so sux would be a better choice if you have no IV access

When did it happen? - Management at induction may be different from during emergence in terms of what you want to happen after you have solved the problem.

What drugs have already been given? - If sux has already been used as part of your management you run the risk of significant bradycardia on top of an already hypoxic insult, so roc may be a better choice, Conversely if roc has already been used and then reversed with sugammadex, sux may be preferable.

What are the patient’s comorbidities? - There are a host of conditions where we think carefully about avoiding sux, so if the patient has one them moving to high dose roc may be sensible given we can rapidly reverse even high doses.

Personally I think because one of the highest risk periods for us is at induction when we may well not have IV access, that sux is here to stay as when given IM it has a more reliable and faster onset time than roc.

Interested to know what others think. Send your thoughts to Myron (myasterster@gmail.com) and he will post next week.

From Jordan Ruby, MD, Alex Sideris, PhD, Michelle Carley, MD, Department of Anesthesiology, Critical Care & Pain Management, Weill Cornell Medical College, Hospital for Special Surgery

Thank you for the recent PAAD on pediatric regional anesthesia here. The controversy over performing peripheral nerve blocks awake or under general anesthesia has long been of interest to us. There is another option that is infrequently discussed- we place the majority of our peripheral nerve blocks after neuraxial anesthesia.

This allows the patient to be lightly sedated, amnestic, and breathing spontaneously, but the limb to be blocked is immobilized. We do over 1000 spinals a year in children and adolescents, and many of these children receive peripheral nerve blocks after the spinal anesthetic. We find low complication rates and high success rates with this approach.

With regards to LAST, our most recent look at our data shows that over a 10-year period with 11,000 blocks in patients <18 years old, we had no instances of LAST requiring intralipid in our institution. We had one instance of a seizure in a child who has a pre-existing diagnosis of a seizure disorder which was presumably not related to the PNB. Our population tends to skew towards older children and adolescents, but we find it reassuring that LAST remains a rare event in the current era of heavy reliance of PNB for postoperative pain relief.

From Dr Daniel Braunold, Lead for pediatic cardiac anesthesia, Rambam Medical Centre, Israel on button battery ingestion management

I thought I would send my two cents about my experience from button batteries and a warning about a possible rapid sequence induction for these children. What’s critically important to understand is that there’s a significant difference between initial problems with the battery adhering to the side of the oesophagus and later complications, which happen to be about a week later, where you get oesophageal stricture, perforations, and other complications.

In the initial presentation, where the button has been swallowed within the past 24 hours, these children need an urgent esophagoscopy and bronchoscopy to make sure there is no damage. Simply performing a rapid sequence induction is not necessarily what these children need, even with the possibility of having it in the stomach. It becomes even more complicated one week later down the line, where there is a suspicion of a button battery. I remember a case where a child presented one week after ingestion of a button battery that had caused tracheal oesophageal fistulas and three perforations inside the trachea, one in the main trachea, one in the left bronchus, and one in the right bronchus. This child had an oesophagoscopy and MLB under spontaneous breathing, and we needed to generate a plan in which we could get this child on to bypass after a sternotomy while spontaneously breathing on an LMA. Placing an endotracheal tube in a child with massive perforations in their trachea and bronchi would only cause pneumediastinum and an inability to ventilate the child.

From Audra M. Webber, MD FASA, Department of Anesthesiology and Critical Care Medicine, CHOP, Associate Professor of Clinical Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Chair, ASA Committee on Ambulatory Surgical Care, Co-Chair SAMBA Pediatric Committee

Thank you so much for discussing our review of anesthesia for ambulatory pediatric orthopedic surgery in today’s PAAD here, and many thanks to Suresh’s expertise and for the highlighted review and discussion of compartment syndrome. We would like to respectfully point out that we discussed the risk of compartment syndrome within the orthopedic trauma section with regard to utilization of regional methods. Additionally, because the paper focused on ambulatory surgery, we mentioned compartment syndrome and neurovascular compromise with regard to discharge instructions. In answer to the question posed--- “Do you perform nerve blocks in patients at high risk for compartment syndrome?”– and particularly because we are discussing ambulatory surgery where the patient is going home and will not have an on-site ortho resident to assess them– I would NOT block a patient in whom there is a significant risk for compartment syndrome. It is questionable whether a patient with a high risk for compartment syndrome would be undergoing ambulatory surgery at an ASC in the first place.

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